Frontispiece. Plate i. 1 ^ N V % j K\ i. Bacillus of Tetanus, with Spores. 2. Gonococci in Gonorrhceal Pus (aniline, methyl-violet). 3. Tubercle Bacilli in Sputum (Ziegler). 4. Hutchinson Teeth. 5, 6. Radial Pulse-tracings in Aneurysm of Right Brachial Artery: 5, left radial pulse; 6, right radial pulse. SaunSrrs' Xeto 9ili Scries A MANUAL OF MODERN S U R G K R Y GENERAL AND OPERATIVE BY JOHN CHALMERS DaCOSTA, M.D., DEMONSTRATOR OF SURGERY, JHFPERSON MEDICAL COLLEGE, PHILADELPHIA; CHIEF ASSISTANT SURGEON, JEFFERSON MEDICAL COLLEGE HOSPITAL, ETC. WITH 188 ILLUSTRATIONS IN THE TEXT AND 13 FULL-PAGE PLATES IN COLORS AND TINTS, AGGREGATING 276 SEPARATE FIGURES PHILADELPHIA W. B. SAUNDERS 925 Walnut Street. 1894. loo D\\Sv% \fe34 Copyright, 1894, by W. B. SAUNDERS. ELEOTROTYPED BY pRESS 0F WESTCOTT & THOMSON, PHILADA. w. B. SAUNDERS, PHILADA. THIS VOLUME IS DEDICATED, WITH AFFECTIONATE REGARDS, TO DR. ORVILLE HORWITZ, THE FELLOW-STUDENT, THE HOSPITAL ASSOCIATE, AND THE TRUSTED FRIEND OF THE AUTHOR. PREFACE. The aim of this Manual is to present in clear terms and in concise form the fundamental principles, the chief operations, and the accepted methods of modern surgery. The work seeks to stand between the complete but cumbrous text-book and the incomplete but concentrated compend. Obsolete and unessential methods have been excluded in favor of the living and the essential. There has been no attempt to exploit fanciful theories nor to defend unprovable hypotheses, but rather the effort has been to present the sub- ject in a form useful alike to the student and to the busy practitioner. The opening chapter is devoted to Bacteriology because the author profoundly believes that without some knowledge of the vital principles of this branch of science the vast im- portance of its truths will be ill-appreciated, and there will be inevitable failure in the application of aseptic and anti- septic methods. Ophthalmology, gynecology, rhinology, otology, and lar- yngology have not been considered, because of the obvious fact that in the advanced state of specialized science, only the specialist is competent to write upon each of these branches. In Orthopedic Surgery are discussed those conditions which must in the very nature of things often be cared for by the surgeon or the general practitioner (such as hip-joint disease, club-foot, Pott's disease of the spine, flat-foot, etc.). The limited space at command precluded the introduction of a special division on diseases of the female breast. A large amount of space has been devoted to Fractures and Dis- locations, the enormous practical importance of these sub- jects calling for their full discussion. Operative Surgery is 3 4 PREFACE. considered in separate sections, the most important pro- cedures being fully described, giving also the instruments necessary, and the positions assumed by patient and operator. This method has been adopted to fit the work for use in sur- gical laboratories. Many systems, manuals, monographs, lectures, and journal articles have been consulted, and credit has been given in the text for statements and quotations. Special acknowl- edgment is due to the American Text-Book of Surgery, edited by Keen and White; to the surgical works of Ashurst, Agnew, the elder Gross, Duplay and Reclus, Esmarch, Albert Koenig, Wyeth, and Bryant; to the Man- ual of Surgery edited by Treves ; to the International En- cyclopcedia of Surgery edited by Ashurst; to the Surgical Pathology of Billroth and of Bowlby; to the Diagnosis of E. Pearce Gould ; to the Surgical Dictionary of Heath ; to the Rest and Pain of Hilton; to the works on operative sur- gery of Barker, Jacobson, Treves, Stephen Smith, and Joseph Bell; to the Minor Surgery of Wharton; to the dictionary of Foster and of Gould ; to the Principles of Surgery of Senn; to the orthopedic writings of Sayre; to the work on Diseases of the Male Generative Organs of Jacobson; to the System of Genito-urinary Diseases edited by Morrow; and to the treatises on Fractures and Dislocations of Sir Astley Cooper, Malgaigne, Hamilton, Stimson, and T. Pickering Pick. The Author returns his thanks to the numerous writers who courteously authorized the reproduction of special illustrations, and particularly to Professors Keen and White for their free permission to draw upon the American Text- Book of Surgery, from which a number of pictures have been taken, distinctively those referring to Bandaging; to Mr. John Vansant for the great amount of labor so ably and cheerfully performed; and to Dr. Howard De Honey for the preparation of the Index. 2050 Locust Street, Philadelphia, October, 1894. CONTENTS. PAGE I. BACTERIOLOGY........................ 17 Micro-organisms, Microbes, or Bacteria, 17 : Forms of Bacteria, 19; Multiplication of Bacteria, 21; Life Conditions of Bacteria, 22; Effect of Heat and Cold on Bacteria, 23; Chemical Germicides, 24; Distribu- tion of Microbes, 24; Koch's Circuit, 25; Toxalbumins and Toxines, 26; Ptomaines, 27 ; Leucomaines, 27 ; Antitoxines, 27 ; Phagocytes, 28; Protective and Preventive Inoculations, 29; Antagonistic Microbes, 30; Mixed Infection, 30; Placental Transmission, 30. Special Sur- gical Microbes, 31 : Other Surgical Microbes, 32. II. Inflammation....................... 33 Definition, 33; Vascular and Circulatory Changes, 33; Active Hyper- emia, 33; Retardation of the Circulation, 34; Oscillation and Stagna- tion, 36; Exudation of Fluids, 36; Diapedesis or Migration, 37; Changes in the Perivascular Tissues, 38; Classification of Inflamma- tions, 39; Extension of Inflammation, 40; Terminations of Inflam- mation, 41; Causes of Inflammation, 41 ; Symptoms of Inflammation, 42; Constitutional Symptoms of Inflammation, 47 ; Treatment of In- flammation, 47; Local Treatment of Inflammation, 48; Constitu- tional Treatment of Inflammation, 60. III. Repair.......................... 73 Healing by First Intention, 73; Healing by Second Intention, 74; Heal- ing by Third Intention, 75 ; Cell-division, 76. IV. Surgical Fevers...................... 77 Types of Fever, 78: Sthenic, 78; Asthenic, 78; Nervous, 79. Trau- matic Fevers, 80 :—Primary Wound-fever: a, Aseptic Fever, b, Traumatic or Surgical Fever, 80; Secondary Wound-fever: Sup- purative Fever, 81. V. Terminations of Inflammation............... 81 Effusion of Serum, 81; Effusion of Lymph, 82 ; Suppuration, 84; Forms of Pus, 85. Abscesses, 88 : Forms of Abscesses, 90; Acute Abscess, 91. VI. Ulceration and Fistula..................101 Necrosis, 102; Classification of Ulcers, 102; Acute Ulcer of the Leg, 103; Chronic Ulcer of the Leg, 104; Complications of Ulcers, 105; Ulcers in any Region, 107; Fistula, 108; Sinus, 108. 5 6 CONTENTS. PAGB VII. Mortification or Gangrene...............109 Classification, 109; Dry or Chronic Gangrene (Pott's Gangrene), 110; Senile Gangrene, ill; Moist or Acute Gangrene, 113. Septic Gan- grene, 114: a, Traumatic Gangrene, 115, b, Hospital Gangrene, 115. Special Forms of Gangrene, 116: a, Symmetrical Gangrene, 116; b, Diabetic Gangrene, 117; c, Gangrene from Ergotism, 117; a", Gan- grene from Frost-bite, 118; e, Noma, or Cancrum Oris, 118; Slough- ing, 119; Phagedsena, 119; Decubital Gangrene, or Bed-sore (Decu- bitus), 120; Rules for Amputation in Gangrene, 121. VIII. Thrombosis and Embolism................122 IX. Septicemia and Pyaemia..................125 Septicemia, 125; Saprsemia, or Septic Intoxication, 125; Septic Infection, or True Septicaemia, 126. Pycemia, 127. X. Erysipelas (St. Anthony's Fire)..............129 Forms of Erysipelas, 130; Clinical Forms, 130; Cutaneous Erysipelas, 130; Cellulo-cutaneous or Phlegmonous Erysipelas, 131; Cellulitis, 132. XL Tetanus, or Lockjaw...................133 Acute, 133; Chronic, 134. XII. Tuberculosis and Scrofula...............137 Bacillus of Tubercle, 138; Tubercular Infection, 140; Scrofula, 141; Tuberculous Abscess, 142; Tuberculosis of the Skin, 142; Anatomi- cal Tubercle, 142; Scrofulodermata, or Scrofulous Gummata, 142; Tuberculosis of Subcutaneous Connective Tissue, 143 ; Tuberculosis of the Alimentary Canal, 143; Intestinal Tuberculosis, 143; Peritoneal Tuberculosis, 144; Tuberculosis of the Brain, 144; Tuberculous Dis- ease of the Joints, 144; Tuberculosis of Lymphatic Glands, 144; Diagnosis, Prognosis, and Treatment of Tuberculosis, 145; Koch's Tuberculin, 146. XIII. Rickets.........................147 XIV. Contusions and Wounds.................148 Contusions, 148; Wounds, 149; Local Phenomena of Wounds, 149; Con- stitutional Condition of Wounds, 150; Treatment of Wounds, 151; In- cised Wounds, 153 ; Lacerated and Contused Wounds, 153 ; Punctured Wounds, 154; Gunshot Wounds, 154; Poisoned Wounds, 156; Septic Wounds, 156; Dissection-wounds, 156; Malignant CEdema or Gan- grenous Emphysema, 157; Stings and Bites of Insects and Reptiles, 157; Anthrax, 160; Hydrophobia, Rabies, or Lyssa, 162; Glanders, Farcy, or Equinia, 163; Actinomycosis, 164. CONTENTS. 7 PAGE XV. Syphilis.........................165 Definition, 165; Transmission of Syphilis, 166; Syphilitic Stages, 167; Syphilitic Periods, 167; Primary Syphilis, 167; Initial Lesions, 168; Mixed Infection of Chancre and Chancroid, 168 ; Syphilitic Bubo, 171; General Syphilis, 172; Secondary Syphilis, 172. Syphilitic Skin Dis- eases, 172: Forms of Eruption, 173. Affections of the Mucous Mem- branes, 175; Affections of the Hair, 176; Affections of the Nails, 176; Affections of the Ear, 176; Affections of the Bones and Joints, 176; Affections of the Eye, 177; Affections of the Testes, 177 ; Intermediate Period, 177; Tertiary Syphilis, 178; Treatment of Primary Stage, 180; Treatment of Secondary Stage, 181 ; Acute Ptyalism, or Salivation, 184; Treatment of Tertiary Stage, 187; Hereditary Syphilis, 188. XVI. Tumors, or Morbid Growths...............191 Neoplasms, 191 ; Classes of Tumors, 192; Causes, 193; Malignant and Innocent or Benign Tumors, 194; Classification, 195. Innocent Con- nective-tissue Tumors, 196: Lipomata, 196; Fibromata, 197; Chon- dromata, 199; Osteomata, 200; Odontomata, 201; Myxomata, 202; Lyiuphomata, 203; Myomata, 204; Neuromata, 207; Angeiomata, 208; Lymphangeiomata, 209. Malignant Connective-tissue Tumors, or Sarcomata, 210. Innocent Epithelial Tumors, 215. Papillomata, or Warts, 215. Adenomata, 216. Malignant Epithelial Tumors, Carcinomata, or Cancers, 217: Epitheliomata, 219; Rodent Ulcer, 219; Spheroidal-celled Carcinomata, 220; Cylindrical-celled Carcino- mata, 221. Cysts, 222: Sebaceous Cysts, 222; Dermoid Cysts, 223; Hydatid Cysts, 223. XVII. Diseases and Injuries of the Heart and Vessels .... 224 Heart and Pericardium, 224: Wounds and Injuries, 224; Phlebitis, or Inflammation of a Vein, 225 ; Varicose Veins, or Varix, 225 ; Nsevus, 227; Arteritis, 227. Aneurysm, 229: Forms of Aneurysm, 230; Causes of Aneurysm, 233; Constituent Parts of Aneurysm, 233; Symp- toms of Aneurysm, 234; Diagnosis of Aneurysm, 234; Treatment of Aneurysm, 235 Arterio-venous Aneurysm, 241. Cirsoid Aneurysm, or Aneurysm by Anastomosis, 242. Wounds of Arteries, 243. (1) Hemorrhage, or Loss of Blood, 244: Hemorrhagic Fever, 245; Hemostatic Agents, 246; Golden Rules for Procedure in Primary Hemorrhage, 249; Reactionary or Recurrent Hemorrhage, 258; Sec- ondary Hemorrhage 258. (2) Operations on the Vascular Sys- tem, 260: Paracentesis Auriculi, 260; Paracentesis Pericardii, 260; Operation for Varix of Leg, 260; Open Operation for Varicocele, 261; Subcutaneous Ligature for Varicocele, 261 ; Phlebotomy, or Venesec- tion, 262; Transfusion of Blood, 263. (3) Ligation of Arteries 8 CONTENTS. IN Continuity, 265 : Radial Artery, 268; Ulnar Artery, 271; Brachial Artery, 272; Axillary Artery, 274; Subclavian Artery, 277; Region of the Neck, 278; Common Carotid Artery, 280; External Carotid Artery, 283; Internal Carotid Artery, 284; Lingual Artery, 285; Dorsalis Pedis Artery, 285; Anterior Tibial Artery, 287; Posterior Tibial Artery, 289; Popliteal Artery, 290; Femoral Artery, 290; Iliac Arteries, 293. XVIII. Diseases and Injuries of Bones and Joints....... (1) Diseases of the Bones, 295 : Atrophy of Bone, 295 ; Hypertrophy of Bone, 295 ; Osteitis, or Inflammation of Bone, 295 ; Chronic Periostitis, 298; Osteoplastic Periostitis, 298; Abscess of Bone, 298; Caries, 299; Necrosis, 301; Acute Diffuse Osteo-myelitis, 303; Acute Epiphysitis, 304; Chronic Osteo-myelitis, 305; Osteo-malacia, or Mollities Ossium, 305. (2) Fractures, 306: Definition, 306; Varieties, 306; Causes, 311; Symptoms, 314; Varieties of Displacement, 315; Diagnosis, 318; Complications and Consequences, 320; Repair of Fractures, 320; Non-union of Fractures, 322; Treatment of Fractures, 322. Special Fractures: Nasal Bones, 328. Superior Maxillary Fractures, 331. Fracture of Malar Bone, 333. Fracture of the Zygomatic Arch, 333. Fractures of Inferior Maxillary Bone, 333. Fractures of Hyoid Bone, 335. Fracture of Laryngeal Cartilages, 336. Fracture of the Ribs, 337 : Fracture of Costal Cartilages, 340. Fracture of Sternum, 341. Fractures of the Pelvis, 343: Fractures of False Pelvis, 343; Fractures of True Pelvis, 344. Fracture of Sacrum, 346. Fractures of Coccyx, 347. Fracture of Clavicle, 348: Fractures of Shaft of Clavicle, 348; Fracture of Acromial End of Clavicle, 351; Fracture of Sternal End of Clavicle, 352. Fracture of Scapula, 352: Frac- tures of Neck of Scapula, 353; Fractures of Glenoid Cavity of Scapula, 353; Fracture of Acromion Process of Scapula, 353; Fracture of Coracoid Process of Scapula, 354. Fractures of Humerus, 354: Fracture of Anatomical Neck of Humerus, 354; Fractures of Surgical Neck of Humerus, 356; Longitudinal and Oblique Fracture of Head of Humerus, 357; Separation of Upper Epiphysis of Humerus, 358; Fracture of Shaft of Humerus, 359; Fractures of Lower Extremity of Humerus, 360; Fracture of External Condyle of Humerus, 360; Fracture of Inner Epicondyle of Humerus, 360; Fracture of Internal Condyle of Humerus, 361; Fracture at Base of Condyles of Humerus, 361; T-Fracture of Humerus, 361; Fractures in or near Elbow-joint, 361; Epiphyseal Separation of Humerus, 362. Fractures of Ulna, 363: Fracture of Coronoid Process of Ulna, 363; Fracture of Olecranon Process of Ulna, 363; Fracture of Shaft of Ulna, 364; Fracture of Styloid Process of Ulna, 365. Fractures of Radius, 365 : CONTENTS. 9 PAGE Fracture of Head of Radius, 365; Fracture of Neck of Radius, 366; Fracture of Shaft of Radius, 366; Fracture of Radius above Insertion of Pronator Radii Teres Muscle, 366; Fracture of Radius below In- sertion of Pronator Radii Teres Muscle, 367; Fracture of Shafts of both Bones of Forearm, 367; Fracture of Lower Extremity of Radius, 368; Fracture of Both Radius and Ulna near Wrist, 370; Separation of Lower Radial Epiphysis, 370. Fractures of Carpus, 371 : Fracture of Metacarpal Bones, 371 ; Fractures of Phalanges, 372. Fracture of Femur, 372: Fractures of Upper Extremity of Femur, 372; Intra- capsular Fracture of Femur, 372; Extracapsular Fracture of Femur, 379; Fracture of Great Trochanter, 380; Separation of Upper Epiphy- sis of Femoral Head, 381; Separation of Epiphysis of Great Tro- chanter, 381; Fractures of Shaft of Femur, 381; Fracture of Femur above Condyles, 383; Fracture of Femur Separating either Condyle, 384; Longitudinal Fractures of Femur, 385; Separation of Lower Epiphysis of Femur, 385. Fracture of Patella, 385: Fracture of Patella by Muscular Action, 385 ; Transverse Fractures of Patella, 386; Fractures of Patella by Direct Force, 387. Fractures of Tibia, 388: Fractures of Upper End of Tibia, 388; Separation of Upper Epiphysis of Tibia, 389; Fractures of Shaft of Tibia, 389; Fractures of Lower End of Tibia: Fracture of Inner Malleolus, 389; Separation of Lower Epiphysis of Tibia, 390. Fracture of Fibula, 390 : Fractures of Upper Two-thirds of Fibula, 390; Fractures of Lower Third of Fibula, 390; Pott's Fracture of Fibula, 391; Fracture of Both Bones of Leg, 392. Fractures of Bones of Foot, 393: Fractures of Meta- tarsal Bones, 395; Fractures of Phalanges of Toes, 395. (3) Dis- eases OF THE Joints, 395 : Synovitis, 395 : Acute Synovitis, 395; Chronic Synovitis, 396. Arthritis, 397: Tubercular Arthritis, 398. Tuberculosis of Special Joints, 400: Hip-joint, 400; Knee-joint Dis- ease, 407; Ankle-joint Disease, 409; Shoulder-joint Disease, 409; Elbow-joint Disease, 410; Wrist-joint Disease, 410; Septic Arthritis, 411; Infective Arthritis, 411; Gonorrhoeal Arthritis, or Gonorrhoeal Rheumatism, 412; Rheumatic Arthritis, 414; Gouty Arthritis, 415; Arthritis Deformans, 416. Charcot's Disease, 419. Hysterical Joint, 420. Neuralgia of Joints, 421. Articular Wounds and Injuries, 422 : Sprains, 423. Ankylosis, 425 : False or Extra-articular Ankylosis, 428. Loose Bodies in Joints (Floating Cartilages), 428. (4) Luxations or Dislo- cations, 429 : Traumatic Dislocations, 430; Spontaneous, Pathological, and Consecutive Dislocations, 431; Congenital Dislocations, 431; Compound Traumatic Dislocations, 435 ; Old Traumatic Dislocations, 436. Special Traumatic Dislocations : Lower Jatv, 436. Dislocation of the Clavicle: Sternal End, 438; Forward Dislocation of the IO CONTENTS. t PAGE Clavicle, 438; Backward Dislocation of Clavicle, 439; Upward Dis- location of Clavicle, 439; Dislocation of Acromial End of Clavicle, 440. Dislocation of Lower Angle of Scapula, 440. Dislocations of Humerus {Shoulder-joint), 441. Dislocation of Elbow-joint, 448: Dislocation of Both Bones of Elbow Forward, 449; Lateral Disloca- tions of Both Bones of Elbow, 449. Dislocation of Ulna, 450. Dis- location of Radius Forward, 450: Dislocation of Radius Backward, 451; Dislocation of Radius Outward, 451; Subluxation of Head of Radius, 451. Dislocations of Wrist, 452: Backward Dislocation of Wrist, 453; Forward Dislocation of Wrist, 453; Dislocation at Infe- rior Radio-ulnar Articulation, 453. Dislocations of Individual Carpal Bones, 454. Dislocations of Metacarpal Bones, 454: Dislocation at Metacarpophalangeal Articulations, 454; Dislocation of Metacarpo- phalangeal Joint of Thumb, 454. Dislocations of Phalanges, 455. Dislocations of Ribs and Costal Cartilages, 456. Dislocations of Sternum, 456. Pelvic Dislocations, 456. Dislocations of Femur {Hip-joint), 457: Dislocation of Femur on Dorsum of Ilium, 457 ; Dislocation of Femur into Sciatic Notch, 460; Dislocation of Femur Downward into Obturator Foramen, 461; Dislocation of Femur into Pubes, 462 ; Anomalous Dislocation of Hip, 462. Dislocations of Knee, 463: Dislocation Forward of Knee-joint, 463; Dislocation Backward of Knee-joint, 463; Dislocation Outward of Knee-joint, 464; Dislocation Inward of Knee-joint, 464; Lateral Dislocations of Knee-joint, 464; Dislocation of Semilunar Cartilages of Knee, 464. Dislocations of Fibula : Dislocation at Superior Tibio-fibular Articula- tion, 465. Dislocations of Ankle-joint, 466: Lateral Dislocations of Ankle-joint, 466; Antero-posterior Dislocations of Ankle-joint, 467; Dislocation Upward of Ankle-joint, 467. Dislocation of Astragalus, 468: Dislocation of Astragalus Forward or Backward, 468; Lateral and Rotary Dislocations of Astragalus, 468; Subastragaloid Disloca- tion, 469. Dislocations of Other Tarsal Bones, 470. Dislocations of Metatarsal Bones, 470. Dislocations of Phalanges, 470. (5) OPERA- TIONS ON Bones, 470: Osteotomy 470: Osteotomy for Genu Valgum, or Knock-knee (Macewen's Operation), 471 ; Osteotomy for Bent Tibia, 473; Osteotomy for Faulty Ankylosis of Hip-joint, 473; Oste- otomy through Neck of Femur, 473; Osteotomy of Shaft of Femur below Trochanters (Gant's Operation), 475; Osteotomy for Faulty Ankylosis of Knee-joint, 475 ; Osteotomy for Vicious Union of Frac- ture, 476 ; Osteotomy for Hallux Valgus, 476; Osteotomy for Talipes Equino-varus, 476; Osteotomy for Talipes Equinus 477; Bone-graft- ing, or Transplantation (see p. 303); Osteotomy and Wiring for Ununited Fracture, 477. Treves' Operation for Caries of Lumbar CONTENTS. II and Last Dorsal Vertebra:, 479. Aspiration of Joints, 480. Ex- cision of Bones and Joints, 481 : Erasion, or Arthrectomy, 482; Ex- cision of Shoulder-joint, 483; Excision of Elbow-joint, 487; Excision of Wrist-joint, 488; Excision of Metacarpal Bones and of Phalanges, 490; Excision of Hip-joint, 491; Excision of Ankle-joint, 495; Excision of Os Calcis, 496; Excision of Astragalus, 497; Excision of Metatarsophalangeal Articulation of Big Toe, 497 ; Excision of Meta- tarsal Bone of Big Toe, 498; Excision of Clavicle, 498; Excision of Scapula, 498; Excision of Rib, 499; Complete Excision of One-half of Upper Jaw, 500; Excision of One-half of Lower Jaw, 502. XIX. Diseases and Injuries of Muscles, Tendons, and Burs^e . . . 503 Myalgia, or Muscular Rheumatism, 503; Myositis, 505 ; Hypertrophy of Muscles, 505; Atrophy of Muscles, 505; Degeneration of Muscles, 506; Local Ossification and Myositis Ossificans, 506; Tumors of Muscles, 506; Syphilis, 506; Trichinosis, 506; Wounds and Contu- sions of Muscles, 507; Strains and Ruptures of Muscles, 508; Hernia of Muscles, 509; Contractions of Muscles, 509; Dislocation of Ten- dons, 509; Wounds of Tendons, 510; Rupture of Tendons, 510. Thecilis, or Teno-synovitis, 510: Acute Thecitis, 510; Palmar Abscess, 511; Chronic Thecitis, 511. Ganglia, 512. Felon, Whitlow, or Paronychia, 512. Bursitis, 513. Housemaid's Knee, 514. Bunion, 514. Operations on Tendons: Tenotomy, 515: Tenotomy of Tendo Achillis, 515; Tendon-suture and Tendon-lengthening, 516. XX. Orthopedic Surgery...................517 Torticollis, 518; Dupuytren's Contraction, 519; Syndactylism (Webbed Fingers), 520; Polydactylism (Supernumerary Digits), 520; Genu Val- gum (Knock-knee), 520; Genu Varum (Bow-legs), 521 ; Talipes (Club-foot), 521; Pes Planus (Flat-foot), 523; Pes Cavus (Hollow- foot), 523; Hallux Valgus or Varus, 523; Hammer-toe, 523. XXI. Diseases and Injuries of Nerves.............524 (1) Diseases of Nerves: Neuritis, or Inflammation of a Nerve, 524; Neuralgia, 525. (2) Wounds and Injuries of Nerves: Section of Nerves, 525; Pressure upon Nerves, 526; Contusions of Nerves, 527; Punctured Wounds of Nerves, 527. (3) Operations upon Nerves : Neurorrhaphy, or Nerve-suture, 527; Neurectasy, Neurotomy, and Neurectomy, 52S; Stretching of Sciatic Nerve, 529; Neurectomy of Infraorbital Nerve, 529; Neurectomy of Supraorbital Nerve, 530. XXII. Diseases and Injuries of the Head...........530 (1) Diseases of the Head: Anatomical Regions of Head, 530; Dis- eases of Scalp, 534; Diseases of Bones of Skull (see p. 295 etsea.); 12 CONTENTS. Microcephalus, 535. Diseases and Malformations Involving Brain : Meningocele, 536; Encephalocele, 536; Hydrencephalocele, 536; Hydrocephalus, 537; Acute Hydrocephalus, 537; Chronic Hydro- cephalus, 537. (2) Injuries of Head : Cephalhsematoma, 537; Scalp- wounds, 537; Contusions of Head, 538; Concussion or Laceration of Brain, 538; Compression of Brain, 540. Intracranial Hemorrhage: 1, Extradural Hemorrhage, 542; 2, Subdural Hemorrhage, 543; 3, Cerebral Hemorrhage, 543. Rupture of a Sinus, 544. Fractures of Skull, 544: Fractures of Vault, 545 ; Fractures of Base, 546. Wounds of Brain, 549: Gunshot Wounds of Head, 550; Fungus Cerebri, 551; Traumatic Inflammation of Brain, 551; Pachymeningitis, 551; Pachy- meningitis Interna, 552; Leptomeningitis, 552; Tuberculous Menin- gitis, 553; Acute Traumatic Leptomeningitis, 554; Chronic Lepto- meningitis, 556; Abscess of Brain, 556; Brain Disease froni Suppu- rative Ear Disease, 558; Cerebral Abscess from Ear Disease, 559; Extradural Abscess, 559; Infective Sinus Thrombosis, 559; Intra- cranial Tumors, 560; Operative Treatment of Epilepsy, 561. Opera- tions on the Skull and Brain : Trephining, 562; Technique of Brain- operations, 564; Operation for Mastoid Suppuration, 565. XXIII. Surgery of the Spine................. Congenital Deformities, 566; Tumors of Spine, 567. Spinal Curvatures, 568: Lateral Curvature (Scoliosis), 569; Antero-posterior Curvature, 572; Angular Curvature, 573. Injuries of Spinal Ligaments and Muscles, 575 : Traumatic Hysteria, 577 ; Malingering, 578. Concus- sion of Spinal Cord, 579; Contusion of Spinal Cord, 579; Wounds of Spinal Cord, 579; Compression of Spinal Cord, 580; Fractures and Dislocations of Spine, 580. Operations on Spine: Treves' Operation for Vertebral Caries (see p. 479) ; Laminectomy, 582. XXIV. Surgery of Respiratory Organs............ (1) Diseases and Injuries of Nose and Antrum : Foreign Bodies in Nose, 583; Inflammation and Abscess of Antrum of Highmore (Max- illary Antrum), 583. (2) Diseases and Injuries of Larynx and Trachea: (Edema of Larynx (OLdema of Glottis), 584; Wounds and Injuries of Larynx, 585; Foreign Bodies in Air-passages, 585. (3) Operations on Larynx and Trachea: Tracheotomy, 588; High Tracheotomy, 590; Quick Laryngotomy, 591; Intubation of Larynx (O'Dwyer's Operation), 592. (4) Diseases and Injuries of Chest, Pleura, and Lungs : Pleuritic Effusion, 593; Empyema, 593; Contusions and Wounds of Chest, 594; Paracentesis Thoracis, 594; Thoracotomy, 595; Thoracoplasty, 596. CONTENTS. 13 PAGE XXV. Diseases and Injuries of the Digestive Tract......597 Diseases of Mouth, Tongue, and GZsophagus : Hare-lip and Cleft Palate, S97 ; Tongue-tie, 601; Ranula, 601 ; Excision of Tongue, 602; Stric- ture of Oesophagus, 603; Foreign Bodies in CEsophagus, 605. XXVI. Diseases and Injuries of the Abdomen.........606 Contusion of the Abdominal Wall, 606; Rupture of Stomach without External Wound, 606; Rupture of Intestine without External Wound, 607; Wounds of Abdominal Wall, 610; Foreign Bodies in Alimentary Canal, 611; Cancer of Stomach, 611; Cicatricial Stenosis of Orifices of Stomach, 612. Intestinal Obstrtiction, 613 : Symptoms of Acute Intes- tinal Obstruction, 615; Diagnosis, 616; Prognosis, 618; Treatment, 619. Appendicitis, 620. Peritonitis, 626: Plastic Peritonitis, 626; Sep- tic Peritonitis, 626; Fibrino-plastic Peritonitis, 627; Suppurative Perito- nitis, 627; Tubercular Peritonitis, 629. Operations upon the Abdomen : Abdominal Section, 629; Enterorrhaphy, or Suture of Intestines, 632; Pylorectomy (Excision of Pylorus), 634; Gastrostomy, 635 ; Gastro- enterostomy, 636. Enterectomy, or Resection of Intestine : Enterec- tomy with Circular Suturing, 636; Intestinal Anastomosis, 637 ; Ingui- nal Colostomy (Maydl's Operation), 639. Abdominal Hernia or Rup- ture, 640: Reducible Hernia,'641 ; Irreducible Hernia, 646; Incar- cerated or Obstructed Hernia, 647 ; Inflamed Hernia, 647 ; Strangu- lated Hernia, 648 ; Herniotomy, 651. XXVII. Diseases and Injuries of the Rectum and Anus.....654 Hemorrhoids, or Piles, 654: External Hemorrhoids, 655; Internal Hem- orrhoids, 655. Prolapse of Rectum, 658; Ulcer of Rectum, 659; Stricture of Rectum, 660; Cancer of Rectum, 661; Foreign Bodies in Rectum, 662; Wounds of Rectum, 662; Ischio-rectal Abscesses, 662; Fistula in Ano, 662; Pruritus of Anus, 665 ; Fissure of Anus, 665. XXyill. Anaesthesia and Anaesthetics.............666 General Anaesthesia, 666; Administration of Chloroform, 668; Adminis- tration of Ether, 669; Anaesthetic State from Ether or Chloroform, 670; Treatment of Complications, 671; Primary Anaesthesia, 673; Local Anaesthesia, 673; Cocaine Hydrochlorate, 674. XXIX. Burns and Scalds...................675 Scalds of Glottis, 676; Effects of Cold, 677; Chilblain, or Pernio, 677. XXX. Diseases of the Skin and Nails.............678 Dermatitis Venenata, 678; Furuncle, or Boil, 679; Carbuncle, 68oj Clavus, or Corn, 681; Warts (see p. 215); Onychia, 682. H CONTENTS. XXXI. Diseases and Injuries of the Lymphatics........683 Lymphangitis, 683. Lymphadenitis, 683: Acute Lymphadenitis, 683. Chronic Adenitis, 684; Lymphangiectasis, 684; Lymphangioma, 684 ; Elephantiasis, 684; Malignant Lymphoma, or Hodgkin's Disease (see p. 203). XXXII. Bandages.......................685 Spiral Reversed Bandage of Upper Extremity, 686; Spiral Bandage.of all the Fingers (Gauntlet), 686; Spiral Bandage of Palm or. Dorsum of Hand (Demi-gauntlet), 686; Spica of Thumb, 687; Spiral Re- » versed Bandage of Lower Extremity, 687; Bandage of Foot cover- ing Heel (American Bandage of Foot), 687; Bandage of Foot not covering Heel (French Method), 687; Spiral Bandage of Foot cover- ing Heel (Ribble's Bandage ; Spica of Instep), 688; Crossed Bandage of Both Eyes, 688; Borsch's Eye-bandage, 688; Barton's Bandage (Figure-of-8 of Jaw), 689; Gibson's Bandage, 689; Crossed Bandage of Angle of Jaw (Oblique Bandage of Jaw), 689; Spica of Groin (Figure-of-8 of Thigh and Pelvis), 690; Spica of Shoulder, 690; Velpeau's Bandage, 690; Desault's Apparatus, 691; Recurrent Band- age of Head, 692; Recurrent Bandage of a Stump, 692; T-Bandage of Perineum, 692; Handkerchief Bandages, 692. Fixed Dressings : Plaster-of-Paris Bandage, 692; Silicate-of-Soda Dressing, 693. XXXIII. Plastic Surgery..................693 Displacement, 693; Interpolation, 694; Retrenchment, 694. Skin- grafting, 694: Reverdin's Method, 694; Thiersch's Method, 695. XXXIV. Diseases and Injuries of the Genito-urinary Organs . . 696 Hsematuria, 696; Tests for Blood, 696; Bleeding from Kidney-substance, 697 ; Vesical Hemorrhage, including Hemorrhage from Prostate, 698; Urethral Hemorrhage, 698; Frequency of Micturition, 699; Mobile Kidney, 700. Injuries of Kidney: Laceration or Rupture, 702; Per- forating Wounds of Kidney, 703; Renal Calculus, 703; Abscess of J Kidney, 705; Pyelitis and Pyelonephritis, 706; Perinephritis, 706; Perinephric Abscesses, 706; Hydronephrosis, 707; Pyonephrosis, or Surgical Kidney, 708. Operations on the Kidnry: Nephrotomy, 709; Nephrolithotomy, 709; Nephrectomy, 710; Lumbar Nephrectomy, 710; Abdominal Nephrectomy, 710; Nephrorrhaphy, 711. Retention of Urine, 711. Injuries of the Bladder : Contusion of the Bladder, 714; Rupture of Bladder, 715 ; Atony of Bladder, 716; Vesical Calcu- lus, or Stone in Bladder, 717 ; Cystitis, 722 ; Tumors of Bladder, 725. & Operations on Bladder: Lateral Lithotomy, 726; Suprapubic Lithot- omy, 728.. Crushing of Vesical Calculi, 730. Litholapaxy (Bigelow's Operation), 730. Cystotomy, 735. Growths in Female Bladder, 736. CONTENTS. XXXV. Diseases and Injuries of the Urethra, Penis, Testicles, Prostate, Spermatic Cord, and Tunica Vaginalis..... Perineal Bruises, 736; Rupture of Urethra, 737; Foreign Bodies in the Urethra, 740. Urethritis, or Inflammation of the Urethra, 741 : Simple Urethritis, 741; Traumatic Urethritis, 742; Gouty Urethritis, 742; Eczematous Urethritis, 742; Tubercular Urethritis, 743. Gonor- rha-a, 743: Subacute or Catarrhal Gonorrhoea, 744; Irritative or Abortive Gonorrhoea, 745. Chronic Urethral Discharges : Chronic Urethral Catarrh, 745; Chronic Gonorrhoea, 745 ; Gleet, 745. Gonor- rhoea in the Female, 749. Stricture of Urethra, 750. Epispadias, 752; Hypospadias, 752. Chancroid, 752. Phimosis, 754. Fracture of Penis, 754; Gangrene of Penis, 754; Cancer of Penis, 754; Amputa- tion of Penis, 755. Hypertrophy of Prostate Gland, 755; Retained Testicle, 757; Orchitis, 757; Castration, 758; Epididymitis, 758. Hydrocele, 758: Congenital Hydrocele, 759; Infantile Hydrocele, 759; Encysted Hydrocele of Cord, 759; Funicular Hydrocele, 760. Ilaematocele, 760. Varicocele, 760. XXXVI. Amputations..................... Methods of Amputating: Circular Method, 764; Modified Circular Method, 765; Elliptical Method, 765; Oval or Racket Method, 766; Flap Method, 766. Special Amputations : Fingers and Hand, 767; Disarticulation of a Metacarpo-phalangeal Joint, 768; Amputation of Thumb, 768; Amputation at Wrist-joint, 768; Amputation through Forearm, 769; Disarticulation of Elbow joint, 769; Amputation of Arm, 770; Disarticulation at Shoulder-joint, 770; Amputation of Toes and Foot, 771; Amputation at Tarso-metatarsal Articulation, 771; Amputation through Middle Tarsal Joint, 773; Amputation at Ankle- joint, 773. Amputations of Leg, 774: Sedillot's Leg Amputation, 774; Modified Circular Amputation of Leg, 775 '■> Amputation of Leg by a Long Posterior and a Short Anterior Flap, 775 ; Amputation just below Knee, 776; Disarticulation of Knee, 776; Amputation through Femoral Condyles, 776; Amputation of Thigh, 777; Disarticulation of Hip-joint, 777. Bronchocele, or Goitre, 778: Exophthalmic or Pulsating Goitre, 780. XXXVII. Asepsis and Antisepsis................ Surgical Cleanliness, 780; Dry Antiseptic Method, 781. Preparations for an Operation, 781 : Disinfection of Instruments, 782; Antiseptic Preparation of Patient, 782; Antiseptic Ligatures, 782; Antiseptic Dressings, 783. Preparation of Marine Sponges, 784; Cleansing Vagina and Rectum, 785; Senn's Decalcified Bone-chips, 785. A Manual of Surgery. I. BACTERIOLOGY. Bacteriology is the science of micro-organisms. Though a science in the youth of its years, bacteriology has not only profoundly altered, but it has also revolutionized, pathology, and our views of surgery will be incomplete, misleading, and erroneous without its aid. Micro-organisms, microbes, or bacteria are minute vegetable cells of the class fungi, many of them being vis- ible only by means of a highly powerful microscope after they have been brightly stained. The contents of these cells is protoplasm enclosed by a structure like cellulose. The protoplasm can be stained by aniline colors, and the cell- wall is more readily detected after treating it with water, which causes it to swell. Many of these organisms are col- ored, others are colorless. Some move (motile bacteria), others do not move; among the motionless ones may be mentioned the bacilli of anthrax and tubercle. Definite knowledge of these minute bodies and of their actions dates from the study of fermentation by the cele- brated Frenchman, Pasteur, who in 1857 asserted that every fermentation has invariably its own specific ferment; that this ferment consists of living cells; that these cells produce fermentation by absorbing the oxygen of the substance acted upon; that putrefaction is caused by an organized ferment; 2 17 i8 A MANUAL OF SURGERY. that all organized ferments are carried about in the air; and that to entirely exclude air prevents putrefaction or fermenta- tion. These statements, which were radical departures from accepted belief, inaugurated a bitter controversy, and in that controversy were born the microbic theory of disease, the doctrine of preventive inoculation, and antiseptic surgery. The word microbe, which signifies a small living being, was introduced in 1878 by the late Professor Sedillot of Paris. At that time the nature of these bodies was in doubt; some thought them animal, and called them microzoaria; others thought them vegetable, and called them microphyta ; the designation "microbe" does not commit us to either view. We now know them to be vegetable, but the term " microbe " has remained in use. The fungi connected with disease in man are divided into three classes : 1. Yeasts, or Blastomycetes; 2. Moulds, or Hyphomycetes ; 3. Bacteria, or Schizomycetes. Yeasts are small cells which multiply by gemmation, these cells often sticking together and forming branches, and con- taining spores when nourishment is insufficient. They are thought to be vegetative forms of higher fungi (Green). The chief importance of these cells is that they cause fermenta- tions ; they never invade human tissues. Yeasts may dwell on mucous membranes, and even in the stomach. Oidium albicans is an yeast-fungus whose growth upon the mucous membranes of the mouth, pharynx, and oesophagus causes the disease known as " thrush." Moulds consist of filaments, each filament being com- posed of a single row of cells arranged end to end, and all filaments springing from a germinal tube which grows from a germinating spore. Moulds are largely connected with processes of decay. Some of them can grow upon inflamed BACTERIOLOGY. 19 mucous membrane; some invade the epidermis, producing certain skin diseases (favus, tinea tonsurans, tinea versic- olor, etc.). Actinomycosis and Madura-foot arise from the lodgment and growth of moulds (Fig. 1). Actinomycosis is a disease seen in cattle, and occasionally in men, es- pecially in drovers. Cattle become infected through their food, the fungus entering by a hollow tooth or by a breach in continuity. The Fig. 1.—Actinomyces (Ziegler). lower jaw is usually the seat of involvement (lumpy jaw). A tumor forms, which contains sero-pus, and after a time ruptures and discharges. The matter contains nodules of fungi. The bone may undergo extensive destruction. Other bones and various organs can be infected. Iodide of potassium will sometimes bring about a cure. Extensive operations may be demanded. Bacteria chiefly claim our attention. It is important to remember that the term " bacteria," though applied to the class schizomycctcs, has also a more restricted application— that is, to a division of the class; it may either mean schizo- mycetes in general, or rod-shaped schizomycctcs, whose length is not more than twice their breadth. Some of the schizomycctcs induce certain fermentations; others are productive of putrefaction, and are called sapro- phytes; still others, known as the pathogenic, cause various diseases. They vary much in shape, size, color, and arrange- ment. One form cannot be transformed into another, but each maintains its own specific identity. Every organism comes from a pre-existing organism, this being true of all forms, and spontaneous generation is impossible. Forms of Bacteria.—The three chief forms of bacteria are— 20 A MANUAL OF SURGERY. I. The Coccus—berry-shaped or round bacterium (Fig. 2); 2. The Bacillus—rod-shaped bacterium (Fig. 3); 3. The Spirillum—corkscrew-shaped bacterium (Fig. 4). Fig. 2.—Micrococcus. ✓-r Fig. 3.—Bacillus. JsjuF- Fig. 4.—Spirillum. De Bary compares these forms, respectively, with the billiard-ball, the lead-pencil, and the corkscrew. Cocci.—We only have to do with cocci and bacilli. Cocci may be named according to their arrangement with one 'AT"' 4) B ^■oaS^S^WS** . ■ . / Fig. 5.—Forms of Bacteria. Fig. 6.—Zooglcea (Ball). another, namely : in pairs they are called diplococci (Fig. 5 a); in a chain they are called streptococci (Fig. 5 c); in a cluster like a bunch of grapes they are called staphylococci (Fig. 5 b) ; and in an irregular mass, stuck together by a thick sub- stance, they constitute a zooglcea (Fig. 6). The cocci are often named according to their function, as, for example," pyogenic," or pus-forming. The name may BACTERIOLOGY. 21 embody the form, arrangement, color, and function; for instance, staphylococcus pyogenes aureus signifies a round, golden-yellow micro-organism, which arranges itself with its fellows into the form of a bunch of grapes, and which pro- duces pus. Multiplication of Bacteria.—Bacteria multiply with great rapidity when placed under suitable conditions. They can multiply by fission or by spore-formation. Some bacteria multiply by both methods. In fission, or segmentation, the cell elongates and about its middle a constriction begins, which deepens until the cell has divided into two parts, Fig. 7.—Divisions of a Micrococcus (after Mace). Fig. 8.—Divisions of a Bacillus (after Mace). each of which soon grows as large as its parent (Figs. 7, 8). All cocci and some bacilli multiply by this method. If segmentation of a single cell and the growth to maturity of its products require one hour (it really takes place in less time), a single cell in a single day will have sixteen million descendants (Cohn). Spores.—A spore is a germ, and corresponds with the seed of a plant. Most of the bacilli multiply by spore-formation. When spore-formation is about to occur in a bacillus, points 22 A MANUAL OF SURGERY. of cloudiness appear in the protoplasm, the cell generally elongates, and in twenty-four hours the cell is found to con- sist of a series of segments like a necklace of beads, each segment containing a full- grown spore (Fig. 9). The wall of the cell now liquefies, the segments separate, the spores are set free, and each spore, under favorable con- ditions, becomes a bacillus. When the initial cloudiness appears in the middle of the „ „ 1 .■ / a n n \ cell, it is called an " endo- Fig. 9.—Sporulation (after De Bary). ' spore;" when it appears at one or both extremities, it is christened an " endspore " or " endspores." When multiplication is by a single endospore, the bacillus does not elongate. Life-conditions of Bacteria.—In order to grow and to multiply, bacteria require suitable soil and the favoring influ- ences of heat and moisture. The soil demanded consists of highly-organized compounds rather than crude substances, and slight modifications in it may prove fatal to some forms of bacterial life, but highly advantageous to others. The fluids and tissues of the individual may or may not afford favorable soil for the germs of disease, or, in the same per- son, may afford it at one time, and not at another. Some individuals seem to possess indestructible immunity from, and others are especially prone to, certain contagious dis- eases. Impairment of health, by altering some subtle condi- tion of the soil, may make a person liable who previously was exempt. All organisms require water. If dried, no form will multiply, and many forms will die. The presence of oxygen effects microbic growth. Most BACTERIOLOGY. 23 organisms thrive best when exposed to the oxygen of the air, and they are known as " aerobic." The term " anaerobic " is employed to designate organisms that can live without free oxygen ; they require this gas, but are capable of extract- ing it from its combinations in tissues. An organism which can grow indifferently where oxygen is plenty or where free oxygen is absent is called a " facultative-aerobic " bacterium. A sensitive organism which dies when the amount of oxygen is even slightly diminished is called an " obligate-aerobic " bacterium. Most microbic diseases in man are due to facultative-aerobic bacteria. Effect of Heat and Cold.—Most fungi grow best when at rest; agitation retards the growth of some and kills others. Temperature is of importance to bacterial growth. Some organisms will only grow within narrow temperature limits, while others can sustain sweeping alterations, but most grow best between the limits of from 86° to 1040 Fahrenheit. Freezing renders bacteria motionless and incapable of multi- plication, but it does not kill them : they again become active when the temperature is raised. The absurdity of employ- ing cold as a germicide is evident when the fact is known that a temperature of 2000 F. below zero is not fatal to germ- life, its activities only being rendered dormant. High tem- peratures are fatal to bacteria; moist heat is more destructive than dry heat, and adult cells are more vulnerable than spores. A temperature less than 212° F. will kill many organisms, and boiling will kill every organism that does not form spores. Some spores are not destroyed after pro- longed boiling, and some will withstand a temperature of 1200 C. As a practical fact, however, boiling water kills, in a few minutes, all cocci, most bacilli, and many spores; though the spores of anthrax, tetanus, and malignant oedema are not with certainty destroyed. Sunlight antagonizes some forms of bacterial growth. 24 A MANUAL OF SURGERY. Chemical Germicides.—Many chemical agents will kill bacteria, the most certain of them all being corrosive sub- limate. Koch showed that corrosive sublimate is an efficient germicide when present in the proportion of only I part to 50,000. It is used in surgery in strengths of I part of the salt to 1000, 2000, 3000 or more parts of water. Because of the fact that contact with albumin precipitates from a solution of corrosive sublimate an insoluble albuminate of mercury, in surgical operations by the wet method consider- able quantities must be used; or the mercury is combined with tartaric acid in the proportion of I to 5, which com- bination prevents the insoluble albuminate from being formed. Carbolic acid is a valuable germicide in the strength of from 1:40 to 1 :20. It is certainly fatal to pus-germs. Unfortunately, this acid attacks the hands of the surgeon; consequently in the United States it is chiefly employed as an antiseptic medium in which to place the operating-instru- ments. Iodoform is largely used; it is not truly a germi- cide, as bacteria will grow upon it, but it hinders the devel- opment of bacteria and directly antagonizes the toxic prod- ucts of germ-life. Kreolin, which is a preparation made from coal, is a germicide without irritant or toxic effects. It is less powerful than carbolic acid, and is used in an emulsion of a strength of from 1 to 5 per cent. Peroxide of hydrogen is a most admirable agent for the destruction of pus cocci. It comes in a 15-volume solution, which is diluted one-half or two-thirds. It probably destroys the albuminous element upon which the bacteria live. The per- oxide of hydrogen is not fatal to tetanus bacilli. Distribution.—Microbes are very widely distributed in nature. They are found in all water except that which comes from very deep springs ; in all soil to a depth of 3 feet; and in air, except that of the desert, on the open sea, and on lofty mountains. » BACTERIOLOGY. 25 Microbes may be useful. Some of them are scavengers, and clean the surface of the earth of its dead by the process known as " putrefaction," in which complex organic matter is reduced to harmless gases and to a mineral condition, the gases being taken up from the air by vegetables, and the mineral matter dissolving in rain-water and passing again into the soil from which it came, there again to be food for • plants which become food for animals. Other organisms purify rivers; others again cause bread to rise; still others give rise to fermentation in liquors. Microbes may be harm- ful. They may poison rivers and soils ; they may be parasites on vegetable life; they cause disease of the grape and wine; they mould bread; they poison sausage and canned foods ; and they produce many diseases among men and the lower animals. With so universal a distribution of these fungi, man must constantly take them into his organism. They are upon the surface of his body, he inhales them with every breath, and he swallows them with his food and drink. Most of them, fortunately, are entirely harmless; others cannot act on the living tissues ; but some are virulent, and these are generally destroyed by the cells of the human body. The alimentary canal always contains bacteria of putrefaction, which act only upon the dead food, and not upon the living body; but when a man dies these organisms at once attack the tissues, and post-mortem putrefaction begins in the abdomen. Koch's Circuit.—To prove that a microbe is the cause of a disease it must fulfil Koch's circuit. It must always be found associated with the disease; it must be capable of forming pure cultures outside the body ; these cultures must be capable of reproducing the disease; and the microbe * must again be found associated with the morbid process. When disease-producing organisms enter the body, they are usually rapidly destroyed; they cannot dwell there 26 A MANUAL OF SURGERY. long without inducing disease, but spores can lie dormant in the system for years, only waking into activity when they come in contact with some damaged, weakened, or dis- eased part—a so-called point of least resistance (a locus minoris resistentice)—which affords a nest for them to develop and to multiply, the cellular activities of the weakened part being unable to cope with the organism. Even large doses of pathogenic organisms may induce no trouble in a healthy man; but let them reach a damaged spot, and mischief is apt to arise. Kocher established subcutaneous bone-injuries in dogs, and these injuries pursued a healthy course until the animal was fed upon putrid meat, whereupon suppura- tion took place. This experiment proves that an organism can reach a damaged area by means of the blood, and it enables us to understand how a knee-joint can suppurate when we merely break up adhesions, and how osteo-myelitis can follow trauma when the skin is intact. Toxalbumins and Toxines.—The action of pathogenic bacteria upon the tissues is of great importance. In the first place, they abstract from the blood, the lymph, and the cells certain elements necessary to the body—as water, oxy- gen, albumins, carbohydrates, etc.—and bring about body- wasting and exhaustion from want of food. In the second place, bacteria produce a series of compounds, some harm- less and others highly poisonous. These organisms contain and secrete ferments like pepsin or trypsin, and as albumoses are formed in the alimentary canal by the digestive ferments, which split up proteids, sugars, and starches, we have microbic albumoses. Just as the albumoses formed in digestion are poisonous when injected, so are the albumoses of microbic action, and they are called "toxalbumins." These albu- moses often operate as virulent poisons to the body-cells. Another assemblage of compounds formed by the microbic destruction of tissue is designated the group of " toxines." BACTERIOLOGY. 2J These toxines are poisonous alkaloids which are readily diffusible and, many of them, very virulent. It is probable that every pathogenic organism has its own special toxine which produces its own characteristic effects. The absorp- tion of toxines may be very rapid; for instance, the toxines of cholera may kill a man before the bacillus has migrated from the intestine. Ptomaines.—By many writers the term " ptomaine " is used to designate these toxines, but in reality a ptomaine is a form of toxine that is due to the action of saprophytic bacteria. A ptomaine is a putrefactive alkaloid, and a toxine is any poisonous alkaloid of microbic origin. Among these poisonous alkaloids may be mentioned tetanine, typhotoxine, sepsine, putrescine, muscarine, and spasmotoxine. Leucoma'ines must not be confounded with the above- mentioned bodies. Leucoma'ines are alkaloid substances existing normally in the tissues, and arising from physio- logical fermentations or retrograde chemical changes. They are natural body-constituents, in contrast to toxines, which are morbid. Leucoma'ines are found in expired air, saliva, urine, various tissues, and the venom of serpents. If not excreted, these bodies can induce illness, and when injected can act as poisons. Ordinary colds and some fevers result from leucoma'ines; they play a great part in uraemia, and when excretion is deficient and leucoma'ines are retained they make the system a hospitable host for pathogenic bacteria. Among leucoma'ines may be mentioned adenine, hypoxanthine, and xanthine, allied to uric acid, and other substances allied to creatine and creatinine. Antitoxines.—Another group of substances arising from microbic action are known as " antitoxines." It is a well- recognized fact in fermentation that after a time the process ceases, and the addition of more ferment is void of result. The same is true of specific maladies; thus, if a person 28 A MANUAL OF SURGERY. recovers, the organisms disappear, and the injection of more of them produces no result; in other words, immunity exists toward the disease. This immunity was long believed to arise from the exhaustion of some unknown constituent of tissue necessary to the life of the bacteria. It is now believed to be due partly to the capacity of the amoeboid cells to destroy germs, and partly to the production of anti- toxines which, when they have developed in sufficient amount, destroy the cells that made them. In other words, the fact seems to be established that bacteria not only produce poisons, but also the antidotes for them. Phagocytes.—The tendency of the white blood-cells and of the fixed tissue-cells to destroy organisms is undoubted. This process of destruction is known as " phagocytosis," and the destroying cells are called " phagocytes." These cells try to eat up and destroy the germs. A battle-royal occurs, Fig. io.—Phagocytosis : a, successful, b, unsuccessful (Senn). the microbe fighting the body-cells with most active ferments, the body-cells endeavoring to devour and engulf the bacteria (Fig. io). In some cases the bacteria win absolutely and the patient dies. In other cases they win for a time and overwhelm the organism, but presently the body-cells, whose BA CTERIOL OGY. 29 movements were inhibited by poison, regain their activity and successfully recur to the attack. After the attack is over the body-cells have been educated to withstand this poison, and their descendants retain this capacity; the weak cells were killed, the fittest survived, and the descendant cells of the survivors are born insusceptible. This is immu- nity, and lasts for a varying period. Some persons seem, from birth, immune to certain maladies. The theory of phagocytosis immunity assumes an educated white corpuscle and body-cell. This view originated with Sternberg, but it is usually accredited to Metschnikoff. Protective and Preventive Inoculations.—Our know- ledge of protective inoculations for contagious diseases dates from Jenner's discovery in 1768. Preventive inoculations with attenuated virus are due to the experiments of Pasteur. This observer discovered the cause of chicken-cholera, and he cultivated the micro-organism of this disease outside the body. He found that by keeping his cultures some time they became attenuated in virulence, and that these attenu- ated cultures, inoculated in fowls, caused a mild attack of the disease, which attack was protective, and rendered the fowl immune to the most virulent cultures. Cultures can be attenuated by keeping them for some time, by exposing them for a short period to a temperature just below that necessary to kill the organisms, and by treating them with certain antiseptics. It has further been shown that injection of the blood-serum of an animal rendered immune by inocu- lation is capable of making a susceptible animal also immune. A most important fact is that animals may be rendered immune by inoculating them with filtered cultures, the fil- trate containing microbic products, but not living microbes. By this method animals can be rendered immune to tetanus and diphtheria. Pasteur's protective inoculations against hydrophobia owe their power to microbic products, and 3Q A MANUAL OF SURGERY. Koch's lymph contains them as its active ingredients. The chief feature in acquired immunity is the presence in the blood of elements which can neutralize the toxic products of bacteria. These elements are called "antitoxines," or defensive proteids. The present knowledge of them arose from the discovery of Nuttall and Buchner that fresh blood- serum is germicidal, the power varying for different bacteria and being limited, for a fixed amount of serum is capable of « destroying a small dose of bacteria only. It has been shown that in tetanus injections of the serum of an immune ani- mal can cure the disease. The above facts are of immense importance, for on these lines will be solved the prevention and treatment of microbic maladies. Antagonistic Microbes.—Another observation of import- ance is that certain microbes are antagonistic to one another. The streptococcus of erysipelas attacks the organism of anthrax. We should note also that the growth of some microbes affects the soil favorably or otherwise for the growth of others, and the same may be true in the body. Mixed Infection.—A fact of practical importance to the surgeon is that an area infected by one form of pathogenic organism may be invaded by another form. This is known as a mixed infection, and consists of a primary infection with one organism, and a secondary infection with another. Koch found both bacilli and micrococci in the same lesion of tubercle. A soil filled with pneumococci is favorable to the growth of pus cocci and tubercle bacilli. Tuberculous and syphilitic lesions may be attacked by erysipelas. Chancre and chancroid can exist together. A syphilitic ulcer is a good culture for tubercle bacilli (Schnitzler). Suppuration in erysipelas or tuberculosis means a secondary infection with pus cocci. Placental Transmission.—The direct transmission of bac- teria from parents to foetus is a problem still in course of BACTERIOLOGY. 31 solution. Certain it is that some diseases (as syphilis) are due to the direct carrying of the microbes by sperm-cell to germ-cell, or to the transmission of the micro-organism through the septum of separation between the circulations of the mother and child. In many other diseases the microbe is not directly transmitted (as in phthisis), but a patient born with weakened tissue-cells is prone to fall a prey to the latter malady. Special Surgical Microbes.—Pus microbes, or pyogenic microbes, include the following forms: 1. Staphylococcus pyogenes aureus (Fig. 11), which is the commonest form, is killed by a few minutes' boiling, by cor- rosive sublimate, or by carbolic acid. These microbes are very widely distributed in the soil, air, and water, in the Fig. 11.—Staphylococcus Pyogenes Aureus Fig. 12.—Streptococcus Pyogenes in in Pus (X 1000) (Frankel and Pfeiffer). Pus (X 1000) (Frankel and Pfeiffer). superficial layers of the skin, especially the axillae and the region of the perineum, and are found in the mouth, phar- ynx, alimentary canal, and under the nails. 2. Staphylococcus pyogenes albus. 3. Staphylococcus pyogenes citreus. 4. Streptococcus pyogenes, which is found normally in the nose, saliva, vagina, and urethra (Fig. 12). 5. Bacillus pyocyaneus, which exists in blue pus. 32 A MANUAL OF SURGERY. These pyogenic cocci subsist in all acute abscesses. The staphylococci exist in circumscribed suppurations, as in boils and carbuncles; the streptococci, in spreading inflammations, as in erysipelas and cellulitis. Can suppuration exist without cocci ? It can, but prac- tically does not. The injection of irritants may form a thin fluid resembling pus, but containing no bacteria. The prod- ucts of bacterial action when injected will form pus. But practically in surgery to exclude cocci is to prevent the formation of pus. Cocci form pus by liquefying inflam- matory products or tissues. Cold abscesses are due to tubercle bacilli, and they do not contain pus cocci unless mixed infection exists. Other Surgical Microbes.—Streptococcus erysipelatis re- sembles streptococcus pyogenes, and they are thought by many to be identical. Their difference in action is consid- ered to be due to difference in virulence induced by external conditions and the state of the tissues.. The gonococcus, or Neisser's bacillus, is a diplo- coccus, and is the specific or- ganism of gonorrhoea (PI. i, Fig. 2). The tetanus bacillus, or the bacillus of Nicolaier, exists chiefly in the soii of gar- dens, in manures about stables, and in masonry (PI. 1, Fig- 1) Fig. 13.—Anthrax Bacilli in Blood TU , .,, . , . (Vierordt). A ne bacillus tuberculosis, or Koch's bacillus, the cause of all tuberculous processes, exists particularly in air infected by the dried sputum of tuberculous subjects. This infected air is the chief means of its transmission. It is found also IN FLA MM A TION. 33 in the milk of tuberculous cows. Such milk can spread the disease (PI. i, Fig. 3). The bacillus adcmatis maligni gives rise to malignant oedema. The bacillus of syphilis, or Lustgarten's bacillus, is not definitely determined to be the cause of syphilis. The bacillus mallei is the bacillus of glanders. The bacillus authracis is the bacillus of anthrax, splenic fever, wool-sorter's disease, or malignant pustule (F'g- 13)- The ray fungus causes actinomycosis. Strepto- cocci are found in noma. No specific organism has been isolated for traumatic spreading gangrene or hospital gangrene; only pus cocci have been found. The bac- terium coli communis is the supposed cause of peritonitis (a. v.). II. INFLAMMATION. Definition.—Inflammation is a nutritive disturbance aris- ing from tissue-damage, and is not an increase of nutrition. It is defined by Burden-Sanderson as " the succession of changes which occur in a living tissue when it is injured, provided that the injury is not of such a degree as at once to destroy its structure and vitality." The changes alluded to in this definition comprise—(1) changes in the vessels and the circulation; (2) exudation of fluids and solids from the vessels; and (3) changes in the perivascular tissues. Vascular and Circulatory Changes are essential to in- flammation in both vascular and non-vascular tissues. In the former they occur in the tissues; in the latter (cornea and cartilage) they are manifest in neighboring tissues from which the non-vascular area derives its nutritive material. Active Hyperaemia.—When an irritant is applied to tis- sue, there may be a momentary arterial contraction due to irritation of the nerves, but this contraction is transitory, and is not an inflammatory phenomenon. The first vascu- lar phenomenon is dilatation of all the vessels—capillaries, 3 34 A MANUAL OF SURGERY. venules, and arterioles—appearing first, and being most pro- nounced, in the small arteries. As a result of this dilatation there is increased rapidity of circulation and increased deter- mination of blood to the part. This condition of increased circulatory activity is known as " active hyperaemia " (Fig. 15). Retardation.—During active hyperaemia the capillaries are crowded with corpuscles and the blood in the veins is of a much brighter red than in health. The red blood-cells are swept along the centre of the current (in the axial stream), the white blood-cells float lazily along near the vessel-wall. After a variable time the blood-current begins to slow down until it becomes more tardy than in health. Fig. 14.—Normal Vessels and Blood-stream: a, artery; b, vein; c, capillary (Landerer). This is known as " retardation of the circulation." Retarda- tion is first noted in the capillaries, next in the venules Fig. i5.-Oilatation of the Vessels in Inflammation: a, artery; Fig. i6.-Stasis of Blood and Diapedesis of White Corpuscles in i, vein ; c, cap.llary (Landerer). Inflammation : „, artery ; b, vein , c, capillary (Landerer) 36 A MANUAL OF SURGERY. and last in the arterioles; but arterial pulsation continues. The white cells show a strong tendency to adhere to the vein-walls, and, as a result, accumulate against the inside of, and stick to, these walls and to one another until the veins are entirely lined with layers of leucocytes. In the capillaries some leucocytes gather, but not many. In the arteries they try to adhere during cardiac dilatation, but are swept away by the force of the heart's contraction. Oscillation and Stagnation.—By this accumulation of leucocytes the blood-stream is progressively narrowed and the axial current is impeded. The red blood-cells begin to stick to one another, forming aggregations like rouleaux of coin, which increase the difficulty the axial current has to contend with, until progressive movement ceases and the contents of the vessels sway to and fro with the pulse. This is the stage of oscillation. In a short time oscillation ceases and the vessels are filled with blood which does not move. This is known as " stasis " or " stagnation." If stasis per- sists, we get coagulation or thrombosis. We can then sum up the vascular changes of inflammation by stating that they consist in a dilatation of the vessel-walls, in a primary accele- ration, a secondary retardation, and a subsequent stagnation of the blood-current with adhesion of leucocytes to the walls of veins and capillaries, and in the aggregation into masses of the red blood-cells (Fig. 16). Exudation of Fluids.—It is to be remembered that in ordinary nutrition serum and white cells pass into the tis- sues through the walls of vein and capillary. In inflam- mation the same thing happens, but the exudation is vastly greater in amount and is different in composition. In any slight inflammation, and in the early stages of any inflam- mation, there is an increase in the serous exudate, and we speak of the condition as " serous inflammation." This fluid is really not serum, but is liquor sanguinis. We find serum I NFL A MM A TION. 37 in passive congestion, not in active hyperaemia. It contains very few white cells. If the inflammation goes no further, the exuded serum is drunk up by the lymphatics. A blister is an example of serous inflammation. If the inflammation continues to intensify, the exudation is altered in charac- ter—it becomes thicker, turbid, and very coagulable. It contains white cells and fibrin elements, and coagulates in the tissues. This fluid is known as "lymph" or plastic exudation, and when it is present we speak of the condi- tion as " plastic inflammation." The lymphatics endeavor to absorb the fluid, but it occludes them by coagulation, and the area they drain becomes swollen, hard, and " branny." This lymph can be seen in the anterior chamber of the eye in cases of plastic iritis. Diapedesis or Migration.— Even early in an inflammation some few white corpuscles pass through the vessel-walls; but when the inflammation is well established large numbers pass, and when it is severe, vast hordes. This process is known as "diapedesis" or "migration." The leucocytes throw out protoplasmic arms, insert themselves between the cells of the walls, and pull themselves through by their amoeboid movements. They do not pass through existing open doors, but form openings which close after them. This is readily accomplished, because the vessel-wall is itself damaged, weakened, and convoluted. This escape of leuco- cytes takes place chiefly from the venules, though some migrate through the capillaries and arterioles (Fig. 17). In very acute inflammation the vessel-walls are so dam- aged that red corpuscles also escape, making the tissue appear as if infiltrated with blood. The white corpuscles greatly increase in number in the blood of a person who has an acute inflammation, and the blood-making organs, such as the spleen and lymphatic glands, are often enlarged. The blood-plaques or third corpuscles are found to be pres- 38 A MANUAL OF SURGERY. ent in increased numbers. These blood-plaques are not seen in moving blood, but are found in blood-clot, their usual proportion to red cells being as i to 20, and they are espe- cially numerous at the height of fever processes and during convalescence from an extensive abscess. Changes in the Perivascular Tissues.—The exuded liquor sanguinis coagulates, and as a result of the exuda- 10.30 p. M. 10.40 11 11.15 11.40 12.20 Fig. 17—Stages of the Migration of a Single White Blood-corpuscle through the wall of a vein in two hours and ten minutes (mesentery of the frog) (Caton). tion of elements of the blood the tissues are softened, sep- arated, and overfed. The abundance of food causes them to multiply, and this is known as " cell-proliferation." To the proliferating cells of the perivascular tissues are added the migrated leucocytes, and we soon get a mass of small round or oval cells, held together by gelatinous intercellular material, called " embryonic tissue," inflammatory or organ- ized new formation, or plastic infiltration. The tissues have reverted to a condition identical with those of the embryo as the first step in repair. The above complicated processes are not accidents nor haphazard freaks, but are Nature's INFLAMMA TION. 39 efforts to bring about a cure. The acceleration of the circu- lation is an attempt to wash away offending material; when this fails, congestion is relieved by exudation and migration, the blood becoming albuminous and more corpuscular in order that foreign bodies may be encapsuled or extruded, so that damaged parts may be amply repaired and that vital structures may be protected and shielded. Dilatation is due to the direct effect of the injury upon the muscle or its nerve-elements, and not to reflex action, as it occurs even when the nerves have all been divided. Retardation and stasis are due primarily to an altered con- dition of the vessel-wall, which caused resistance to the passage of the blood-stream and adhesion of the cells to the vessel. It may be increased secondarily by the pressure of an enormous exudate, producing tension. This tension may be so great as to produce sloughing. Classification of Inflammations.—The various forms of inflammations are—(i) Simple or common, that which is due to any ordinary traumatic, chemical, or thermal cause, and not to bacteria, such as traumatic periostitis or sun dermatitis. It does not tend particularly to spread; (2) infective or specific, that which is due to micro-organisms, as erysipelas. An unsuccessful attempt has been made to charge all inflammations to bacteria. It is true that they can generally be found in inflammatory areas, but that they alone can be causative is accepted by but few. Infective inflammations tend to spread widely; (3) traumatic, which is due to a blow or an injury ; (4) idiopathic, which is without an ascertain- able cause. There is certainly a cause, however, even if it cannot be pointed out; (5) acute, which is rapid in course and violent in action; (6) chronic, which follows a pro- longed course ; (7) subacute, which is intermediate in violence and duration between acute and chronic; (8) sthenic, charac- terized by high action. Occurs in strong young subjects; 4° A MANUAL OF SURGER Y. (9) asthenic or adynamic, occurring in the old, the debili- tated, and the broken-down. It is unable to reach a suffi- cient degree to limit itself; (10) parenchymatous, affecting the "parenchyma," or active cells of an organ; (n) interstitial, affecting the connective-tissue stroma; (12) serous, character- ized by profuse serous exudation, as in pleuritis, or by marked inflammatory oedema; (13) plastic, adhesive, or fibrinous, characterized by an exudation which glues together adjacent surfaces, as in peritonitis; (14) purulent, phlegmonous, or suppurative, when the pus cocci are present and multiply; (15) hemorrhagic, when the exudate contains many red blood- cells, as in strangulated hernia and in black small-pox; (16) croupous, when an inflammation produces upon the surface of a membrane a fibrinous exudate which cannot be organized (aplastic lymph), and which is due to the action of micro-organisms, usually on mucous membrane; (17) diphtheritic, which differs from croupous in the fact that the false membrane is in the tissue rather than upon it; (18) gangrenous, or death of the part, which occurs from tension of the exudate or from violence of the poison; (19) healthy, when the tendency is to repair; (20) unhealthy, when the tendency is to destruction; (21) latent, one which for some time does not announce itself by any obvious symptoms, as the inflammation of Peyer's patches in typhoid fever; (22) contagious, when its own secretions can propagate it; (23) dry, without exudation; (24) hypostatic, arising in a region of passive congestion (as a bed-sore); (25) malignant, due to malignant growths; (26) catarrhal, affecting mucous membranes; (27) neuropathic, due to impairment of the trophic functions of the nervous system, as in perforating ulcer; and (28) sympathetic or reflex, due to injury of a distant part, as when duodenal ulcer follows a surface-burn. Extension of Inflammation.—Inflammation extends by- continuity of structure, by contiguity of structure, by the IN FLA MMA TION. 41 blood, and by the lymphatics. Extension by continuity is seen in phlebitis. Extension by contiguity is seen when a cutaneous inflammation advances and attacks deeper struc- tures. Extension by the blood is seen in the formation of the small-pox exanthem. Extension by the lymphatics is witnessed in a bubo following chancroid. Terminations of Inflammation.—Inflammation may ter- minate in a return of the tissues to health, and this return may take place by delitescence, by resolution, or by new growth. By delitescence is meant abrupt termination at an early stage, as when a quinsy is aborted by quinine, mor- phia, and a sweat; resolution means the gradual disappear- ance of the symptoms when inflammation has passed through its regular stages; and new grozvth means that an inflamma- tion has had fibrinous exudation, has lasted a considerable time, with ample blood-supply and without suppuration. Inflammation may terminate in death of the inflamed part, or necrosis. Death of the part may be due to suppuration, ulceration, or gangrene. The causes of inflammation are—predisposing, or those residing in the tissues, and rendering them liable to inflame; and exciting, or those which directly awake into activity. The first is the inflammable material, the second is the spark of fire. Predisposing causes are those which impair the general vigor, injure the blood, weaken the tissues, or lower nutri- tive activities. Among these causes are shock, hemorrhage, nervous irritation, gout, rheumatism, diabetes, Bright's disease, and syphilis. Plethora renders a person liable to sthenic inflam- mations (those characterized by high action). Tissue-debility renders one prone to adynamic or asthenic inflammations. Exciting Causes.—The exciting causes of inflammation are—traumatic, as blows, etc., and mechanical irritation; chemical, as the stings of insects, ivy poison, etc.; thermal, 42 A MANUAL OF SURGERY. heat and cold; and specific, the micro-organisms causing, for instance, tubercular peritonitis or erysipelas. Symptoms.—Inflammation announces its presence by symptoms which are local and constitutional. The local symptoms are heat, pain, discoloration, swelling, and dis- ordered function ; the chief constitutional symptom is fever. Local Symptoms of Inflammation.—The most promi- nent local symptoms were known centuries ago to the famous Roman Celsus, who stated them as " rubor, calor cum tumore et dolore "—redness and heat with swelling and pain. As set forth to-day, the local symptoms are—(i)heat; (2) pain; (3) discoloration; (4) swelling; and (5) disordered function. Heat is due to the passage of an increased quantity of blood through the damaged area and to increased cellular activity. Although an inflamed part may be, and usually is, warmer than the surrounding parts, its temperature is never greater than the temperature of the blood. This increase of heat is especially noticeable when we contrast the feeling of an arm affected with erysipelas with a well arm : the dis- eased arm feels much warmer, but still its temperature is not above the general body-temperature. The extremities in health, as is well known, show on the surface a temperature below that of the blood ; in an inflamed state their temper- ature may nearly equal that of the blood. Heat is always present in inflammation. Pain is a constant and a conspicuous symptom. It is due to stretching of or pressure upon nerves from exudate; to irritation of nerves; or to inflammation in the nerves them- selves, producing cellular changes. Pain varies in decree and in character. In serous membranes it is acute and lancinating, like dagger-thrusts; in connective tissue it is acute and throbbing; in large organs it is dull and heavy; in the bone it is gnawing or boring; in the skin it is itching INFLAMMA TION. 43 or stinging; in the urethra it is scalding; in the testicle it is sickening or nauseating; in the teeth it is throbbing; and in or under tense fascia it is pulsatile. Pain may alter its char- acter. If a pain becomes markedly throbbing, it often means suppuration. Pain does not always occur at the seat of trouble, but may be felt at some distant point. This is known as a "sympathetic" pain, and means nervous communication, trouble with a nerve-trunk referring pain to the peripheral distribution. Pain of hepatitis is often felt in the right shoulder. This pain at the point of the shoulder is felt also in gall-stones and in cancer of the liver. The pain arises in filaments of the pneumogastric from the hepatic plexus, which filaments reach the spinal accessory, pain being expressed in the branches of the spinal accessory which supply the trapezius and communicate with the third and fourth cervical nerves.1 Pain of coxalgia is often felt on the inside of the knee, because the obturator nerve, which sends a branch to the Iigamentum teres, sends a branch to the interior and to the inner side of the knee-joint. Inflammation of an eye with increased tension causes brow-ache. Inflammation of the neck of the bladder causes pain in the head of the penis. Inflammation of a testicle causes pain in the groin. Renal calculus causes pain in and retraction of the testicle, with pain in the thigh. If the covering of an organ is involved, pain becomes more violent; for instance, a hepatitis becomes much more painful when the perihepatic structures are attacked. Inflam- mation without pain is known as " latent" (as the inflamma- tion of Peyer's patches in typhoid). The sudden disappear- ance of inflammatory pain, when not due to opiates, means gangrene. The characteristics of inflammatory pain are that it comes on gradually, has a fixed seat, is attended by other 1 Enibleton's view in Hilton on Rest and Pain, a book every student should read. 44 A MANUAL OF SURGERY. inflammatory symptoms, and is increased by motion, by pressure, and by the hanging down of the part. If there be no tenderness in a part, the source of the pain is not local inflammation; but tenderness may exist when there is no local inflammation, as in pain referred from a distant part. Pain not corresponding to an exact nervous distribution is due to a local lesion. If pain corresponds exactly to parts supplied by a certain nerve, the cause of it is acting on the nerve-trunk or on its roots. If the cutaneous surface is involved, the lightest touch causes pain. If touching the skin produces no pain, but deep pressure does produce it, the deeper structures are the source. Pain in muscle and ligament is developed by motion: in muscle, by contraction, but not by passive movements with the muscle relaxed; in ligament pain is developed by active or passive move- ments. If, for example, a man with a stiff neck has pain on the right side of the back of his neck on voluntarily turning his face toward the left shoulder, but is without pain when his face is turned by the surgeon, who, conversely, induces pain by turning the patient's face far to the right, this con- dition indicates the trouble to be muscular. If, however, no pain arises on turning the face to the right, but it is manifest on turning the face actively or passively to the left, the pain is in those ligaments which stretch when the face is turned to the left (A. Pearce Gould). The pain of colic differs from that of inflammation. It is sudden in onset, intermits and recurs in paroxysms, and is relieved by pressure. The pain of inflammation is gradual in onset, is continuous, and is made worse by pressure. The pain of neuralgia is very paroxysmal, comes suddenly, darts through recognized nerve-areas, lasts some hours, and is apt to recur at a certain hour. It presents no general tenderness as does inflammation, but we may find several points which are acutely sensitive to pressure (Valleix's points douloureux). INFLAMMA TION. 45 Pain is of great value by calling attention to parts diseased, or is of great evil by racking the organism and even causing death. If pain continues, it becomes in itself formidable : it prevents sleep, it destroys appetite, and it disorders the mind, and one of the surgeon's highest duties is to relieve it. The expression of physical pain is one of heaviness, a fulness about the eyes and dropping of the angles of the mouth, added to appearances due to anaemia, tremor, etc. Discoloration arises from determination of blood to the part; hence the more vascular the tissue the greater the discoloration. A non-vascular tissue presents no discolora- tion, though we find it adjacent in the zone of blood-vessels which bring the tissue nutriment. Discoloration is most intense at the focus or centre of inflammatory action. Dis- coloration varies in tint and in character according to the tissue implicated and to the nature of the inflammation, and it may be circumscribed or diffuse. Arborescent redness means a distribution in dendritic lines. Linear discoloration runs in straight lines, as in phlebitis. Punctiform discolora- tion occurs in points, and means vascular rupture. Macu- liform redness means resembling an ecchymosis or blotch. Inflammation of the throat and skin produces scarlet dis- coloration ; inflammation of the sclerotic and fibrous coats of muscles produces lilac or bluish discoloration ; inflamma- tion of the iris produces brick-dust, grayish, or brown dis- coloration ; erysipelas causes a yellowish-red discoloration; secondary syphilis causes a copper-hued discoloration; and tonsillitis causes a livid discoloration. A scrofulous ulcer is of a purple color on the edge. Gangrene is shown by a blacky discoloration. Redness as a sign of inflammation must be permanent and joined with other symptoms. Redness due to inflam- mation disappears on pressure, but returns as soon as the pressure is removed. If redness is due to staining of the 46 A MANUAL OF SURGERY. 1 surface, pigmentation, or extravasation, pressure will not blanch the spot. If on taking off pressure the redness of inflammation rapidly returns, the circulation is active; if, on the contrary, it very slowly reappears, the circulation is very sluggish and gangrene may occur. Swelling or tumefaction arises in small part from vascular distention, but chiefly from effusion and cell-multiplication. The more loose cellular material a part contains, the more it swells; hence the eyelids, scrotum, vulva, tonsils, glottis, and conjunctiva swell very largely when inflamed. A swell- ing may be soft or ©edematous, due to serous effusion, or it may be hard and elastic, due to embryonic tissue. Swelling may do good by unloading the vessels and acting like a blister or local bleeding, or it may do great harm by press- ing upon the vessels and cutting off the blood-supply. Swelling of the conjunctiva, or chemosis, may cause slough- ing of the cornea, and swelling of the prepuce can cause gangrene. A swelling may do harm by obstruction, as in oedema of the glottis, or by compression, as of the urethra, by the swelling of the perineum. Disordered function is always present in inflammation. It may be manifested by increased tenderness or sensibility, a slight touch, it may be, producing torturing pain. Parts almost or entirely destitute of feeling when healthy (as ten- dons, ligaments, and bones) become highly sensitive when inflamed. In increased irritability in dysentery the colon constantly contracts and expels its contents; the stomach does likewise in gastritis; and the bladder also in cystitis. Spasmodic twitching of the eyelids occurs in conjunctivitis, and twitching of the muscles in fracture and after amputation. Impairment of Special Function.—In inflammations of the eye objects cannot be looked at, the lids closing spasmodi- ,v cally; even a little light causes great pain and lachrymation (photophobia). In inflammations of the ear noises cause INFLAMMATION. 47 great suffering, and even in quiet the patient has subjective buzzing and roaring sounds in his ears (tinnitus aurium). In coryza the sense of smell, and in glossitis the sense of taste, is lost; and in dermatitis the sense of touch, and in laryngitis the voice, may be lost. In inflammation of the brain the mind is lost; in arthritis the joints can scarcely if at all be used; and in myositis to employ the muscles is difficult and painful. Derangement of Secretionsr—In dermatitis the sweat is not thrown off; in hepatitis bile is not secreted; and in nephritis urine is not properly removed. The secretions may undergo important changes of composition. Pneumonia causes rusty sputum, and dysentery causes bloody mucus (Gross). Derangement of Absorbents.—In the height of an inflam- mation the absorbents are blocked and clogged by coagulable lymph, and they cannot perform their offices. Constitutional symptoms of inflammation may be ab- sent, and often are in moderate or limited inflammations, but in severe extensive or infective inflammations we get the compound symptom fever. This is known as symptomatic, sympathetic, or inflammatory fever, and it arises in non- septic cases from the absorption of pyogenous exudate. In inflammation with fever the proportion of fibrin in the blood rises from 4 in 1000 to at least 8 in 1000. The fibrin ferment is contained in the white corpuscles; it is liberated as the corpuscles break up in the exudate, and, acting on the liquor sanguinis, forms fibrin. Inflammatory blood con- tains an increased amount of albumen and salts. If a person with inflammatory fever is bled, the blood coagulates rapidly, the clot sinks, and there is found on the surface a cup-shaped coat, made up of liquor sanguinis and white cells, known as the "buffy coat." Treatment of Inflammation.—In treating an inflamma- tion there must first be removed the exciting cause. If this 4§ A MANUAL OF SURGERY. is from a splinter in the part, it must be taken out; if from a foreign body in the eye, it must be removed; if urine is extravasated, open and drain; take off pressure from a corn; and pull out an ingrown nail. After removing the cause, endeavor to bring about a cure by local and constitutional treatment. Local Treatment of Inflammation.—It must be remem- bered that the division of inflammation into stages is natural, and not artificial, and that a remedy which does good in one stage may do harm in another. Certain agents are suited to all stages of an inflammation, namely, rest and elevation. Rest is of infinite importance, and is always indicated in inflammation. Its principles were first thoroughly studied by Hilton.1 The means of securing rest differ with the structure or the organ diseased, but when rest is used, do not employ it too long. In cerebral concussion rest must be secured by quiet, by darkness, by the avoidance of stimu- lants and meat, by the application of ice to the head, and by the use of purgatives to prevent reflex disturbance and the circulation of poisons in the blood. In inflamed joints rest must be obtained by proper position coupled with splints, plaster, or extension. Muscular relaxation is a valuable form of rest. In pleurisy partial rest can be secured by strapping the affected side or by using a bandage or a binder to limit respiratory move- ments. In fractures Nature procures rest by a splint—the callus—and the surgeon procures rest by splints, immovable dressings, or extension. In fractures of the ribs, strap the chest on the injured side. In cancer of the rectum a colos- tomy secures rest for the damaged bowel. In enteritis opium gives rest to the bowel by stopping peristalsis. In cystitis rest is obtained by opium and belladonna, which paralyze the muscular fibres of the bladder. A cystotomy allows 1 Lectures upon Rest and Pain. » INFLAMMATION. 49 complete rest by permitting the bladder to suspend its function as a reservoir of urine. In vesical calculus rest is obtained by cutting or crushing the stone. In inflamed mucous membranes rest is secured (from the contact of irri- tants) by touching them with silver nitrate, which forms a protective coat of coagulated albumen. Opening an abscess gives its walls rest from tension. In inflammations • of the eye light should be excluded. In aneurism the opera- tion cuts off the blood-current and gives rest. In hernia the operation gives rest from pressure. Instances of the methods of using rest could indefinitely be multiplied. lllcvaiion partly restores circulatory equilibrium. A felon is less painful when the hand is held up in a sling than when it is dependent. A congestive headache is worse during re- cumbency. A gouty inflammation in the great toe is more painful with the foot lowered than with it raised. A tooth- ache becomes worse on lying down. Relaxation is in reality a form of rest, and consists in placing the part in an easy position. In synovitis of the knee semiflexion of the knee-joint lessens the pain. In muscular inflammations relaxation relieves the pain. Certain agents are suited to the stage of vascular engorge- ment, increased arterial tension, and beginning effusion. These agents are—(1) local bleeding or depletion ; (2) cutting m off the blood-supply ; and (3) cold. Local bleeding or depletion is the abstraction of blood from the inflamed area. This abstraction relieves circulatory re- tardation and causes the blood to move rapidly onward; the corpuscles clinging to the vessel-walls are washed away, the capillaries shrink to their natural size, and the exudate is absorbed. In other words, local blood-letting increases 9 the rate of the circulation, though not its force. The methods of bleeding locally are—(a) puncture; (b) scarification; (c) leeching; and (d) cupping. 50 A MANUAL OF SURGERY. Puncture is recommended in inflammation, not only because it abstracts blood locally, but also because it gives an exit to effusion under fibrous membranes. It is very use- ful in relieving tension, as in epididymitis. It is performed with a tenotome and with aseptic precautions. If punctures are made in numerous places, the procedure is termed " multiple puncture." This is very useful when applied to the inflamed area around a leg-ulcer. Scarification or Incision.—By means of scarification we bleed locally, evacuate exudates, and relieve tension. We may make one cut or many cuts, which may be deep or may not even go entirely through the skin, according to circumstances. Multiple incision is applied to inflamed ulcers, ulcers in danger of gangrene, and almost any con- dition of great tension. Leeching.—Leeches must not be applied to a region plen- tifully endowed with loose cellular tissue, as great swelling and discoloration are sure to ensue. These regions are the prepuce, labia majora, scrotum, and eyelids. Leeches should never be applied to the face (because of the scar), near specific scars or inflammations, nor over a superficial artery, a vein, or a nerve. A leech is best applied at the periphery of an inflammation or between an inflammation and the heart. To leech at the inflammatory focus only aggravates the case. Before applying leeches, wash the part and shave it if hairy. If the leeches will not bite, smear the part with milk or with a little blood. In using a leech, place it on the skin under a glass tube or an inverted wine-glass. Never pull off a leech : let it drop off; and if it refuses to do so, sprinkle it with salt. After removing a leech, employ warm fomentations if continued bleeding is desired. Sometimes the bleeding persists, but this may be arrested by styptic cotton and pressure. Leeching leaves permanent triangular scars. The Swedish leech, which is preferred to the Ameri- INFLAMMA TION. 51 can, draws from four to six drachms. Leeching has both a constitutional and a local effect. It is now used compara- tively rarely, but it is of value over the spermatic cord in epididymitis, and on the temple in ocular inflammation. Occasionally the neck of the womb is leeched by holding the leech against it in a test-tube. Cupping: Wet Cups.—In wet cupping, apply a cup for a moment, remove and incise or puncture, and apply it again to draw the requisite amount of blood. Baron Heur- teloup devised an instrument (Fig. 18) in which the incision Fig. 18.—Heurteloup's Artificial Leech (Tiemann). is made by a scarifier. The blood is drawn by a pump, the tube being placed upon the cut area and the withdrawal of the piston creating a vacuum. This instrument is known as the " artificial leech." Wet cupping is of value in pneu- monia, pleurisy, pericarditis, and nephritis. Cutting off the Blood-supply.—Onderdonk of New York in 1813 recommended ligation of the main artery of a limb for the cure of inflammation in important structures which it supplied. This procedure was warmly advocated by Campbell of Georgia for the treatment of gunshot wounds of joints. This plan of treatment is now not to be considered for a moment; antisepsis furnishes us with a safer and more 52 A MANUAL OF SURGERY. certain plan. Vanzetti of Padua advocates digital pressure to cut off the blood-supply to an inflamed part. Cold is a very powerful and an extremely useful agent. It constringes the vessels, prevents migration of corpuscles, favors the absorption of exudate, retards cell-proliferation, and relieves pain, swelling, and tension. Cold must not be applied to the old or to the feeble, as it may induce gan- grene. It is harmful in advanced inflammations or severe congestions (as strangulated her- nia). There are two forms of cold, the dry and the wet. Wet Cold.—To apply the wet cold, the part is wrapped in wet linen or muslin and laid upon a rubber sheet folded like a trough and emptying into a bucket. A Fig. 19.—Siphon (Esmarch). vessel filled with cold water is placed upon a higher level than the bed. A wet lamp-wick is now taken, one end is inserted into the water of the vessel, and the other end INFLAMMATION. 53 is laid upon the part. Capillary action and gravity combine to keep the part moist (Fig. 19). Ordinary water or iced water can be used. If the water be too warm, it can be reduced to about 45 ° F. by adding I part of alcohol to every 4 parts of water. A mixture of 5 parts of nitrate of potash, 5 parts of chloride of ammonium, and 16 parts of water produces great cold. If we use wet cold upon an open wound, the fluid should be antiseptic. Wet cold is now not often used to irrigate. It is applied in severe conjunctivitis by means of cloths soaked in ice-water and frequently changed. Evaporating lotions owe a portion of their efficacy to the cold they induce. Dry cold is applied by means of a rubber bag or a blad- der filled with ground or finely-cracked ice, several folds of Esmarch Cooling Coil (Esmarch). flannel being first laid over the part. A part can be encircled with a rubber tube through which ice-water is made to flow (Fig. 20). Leiter's tubes, which are made to fit various 54 A MANUAL OF SURGERY. regions and which carry a stream of cold water, can also be used. An ice-bag, if applied at once, is the best treatment for a strained joint. Ice-bags are very useful in acute myelitis, meningitis, joint-inflammations, epididymitis, and other acute inflammations in the early stage. Certain agents are suited to the stage of fully-developed inflammation, when we have a great deal of swelling due to effusion and cell-proliferation. The indication in this stage is to abate swelling by promoting absorption. This is accomplished by (i) compression ; (2) the local use of astrin- gents and sorbefacients; (3) the douche; (4) massage; and (5) intermittent heat. Compression is the agent especially used in fully-developed and in chronic inflammation, but it will do good as well in the first stage. Compression is of great usefulness: it sup- ports the vessels and causes them to drink up effusion, and strongly rouses the absorbents. This agent is valuable in most external inflammations with much swelling. In ery- sipelas of an extremity, besides the use of elevation and drugs, bandage the extremity from the periphery to the body. In ulcers, especially those with hard and blue edges, use the Martin elastic bandage or strap with plaster. In chronic inflammation of a joint elastic compression is of great value. In epididymitis, after the acute stage, strap the testicle with adhesive plaster. In lymphadenitis use com- pression by a weight or by a bandage. In fractures com- pression not only antagonizes spasm, but also combats the swelling and pain of inflammation. Compression must be judicious: it must never be too hard, and it must not be applied to a limb without including the extremity of it (never, for instance, strongly compress the elbow without including the hand, nor the palm without bandaging the fingers). Astringents and Sorbefacients: Solutions of Acetate of Lead.—Ammonium chloride was formerly employed in the INFLAMMATION. 55 strength of gj to 2 quarts of water, but if long used it pro- duces pustules and thus causes irritation and pain. A solu- tion of the acetate of lead is astringent and sorbefacient; it promotes the contraction of distended vessels, accelerates the blood-current, and urges the absorbents to increased activity. This agent, in practice, is usually mixed with lauda- num, as follows : Laudanum, f£j ; liquor plumbi subacetatis, f.$j; aquae. Oj. This solution, spoken of as lead-water and laudanum, is extensively used and is very soothing. It can be employed cold, the evaporation which it undergoes cool- ing the part. It is best applied by soaking a double layer of flannel in the lead-water, laying it on the affected part, and by means of a sponge squeezing more of the lotion upon it from time to time. If it is desired to have it very cold, an ice-bag can be placed upon the soaked flannel. Lead- water and laudanum may be used warm, the flannel being covered with oiled silk or waxed paper. If it is desired hot (veritably a poultice), lay upon the flannel a hot-water bag. Lead-water is not used in treating open wounds. Tincture of iodine acts like lead acetate. It must not be used pure, but diluted for adults with an equal part of alco- hol, and for children with 3 parts of alcohol. In using iodine, paint it on with a camel's-hair brush and fan it dry, applying one or more coats. The repeated application of iodine to the skin is of great benefit in inflammation of the glands, muscles, tendons, joints, and about ulcers and peri- osteal structures ; it is apt, after a time, to vesicate, and must not be used in treating open wounds. Nitrate of silver is a non-irritating astringent of great value in inflammation of mucous membranes. It forms a protective coat of coagulated albumen, and is much used in treating the throat, mouth, and genital organs. Ichthyol is a drug of wonderful efficacy in reducing in- flammatory swelling. It is usually employed in ointments 56 A MANUAL OF SURGERY. of a strength of from 25 to 50 per cent. It is best exhibited with lanolin. In acute rheumatism it can be rubbed upon the joints, and in lymphatic enlargements it is of great value. • In children a 25 per cent., and in adults a 50 per cent., oint- ment is well rubbed in twice a day. In inflammatory skin disease, synovitis, thecitis, frost-bite, bubo, chilblain, and in many other conditions it is indicated. The odor of ichthyol is highly disagreeable, and when ordered for a refined person it had better be deodorized. For this purpose Hare uses oil of citronella, Tftxx to .$j of ointment. Mercurials.—Blue ointment, pure or diluted to various strengths, is valuable to a high degree. It is spread upon lint and kept applied over inflamed joints, glands, tendons, etc. Blue ointment is strongly irritant, and will soon blister or excoriate a tender skin. It is very beneficial in perios- titis, and is employed largely in chronic inflammations. The douche consists of a stream of water falling upon a part from a height. The water may be poured from a receptacle or may run through a tube, and may either be hot or be cold. Alternating hot and cold streams are very popular in chronic inflammations of joints and tendons, and they constitute the "Scotch douche." In a strain of the knee, for instance, where, after a time, thickening has oc- curred, pour upon the part daily, from a height, first a pitcherful of very hot water, then a pitcherful of very cold water ; then use friction with a hand greased with cosmoline. The douche acts by restoring vascular tone and by promot- ing the action of the absorbents. Hot vaginal douches are largely employed in pelvic inflammations. Intermittent heat finds an example in the use of very hot water in a strained and badly-swollen ankle by plunging the foot in a bucket of hot water several times a day. Massage is a procedure not frequently enough employed. It is powerful for good in chronic inflammations at the INFLAMMATION. 57 period where rest is abandoned. It acts by promoting the movements of tissue-fluids (blood, lymph, and areolar fluid), stimulating the absorbents, strengthening local nervous con- trol, and thus improving nutrition. Passive motion in joints acts as massage. Heat.—Certain agents are indicated when suppuration is threatened, these agents being the various forms of heat. Heat increases the mobility of the white corpuscles, increases their migration, relieves stasis and thus tension, promotes tissue-change and microbic action, and favors suppuration. Continuous heat may be used earlier in an inflammation, as in the first stage of a pneumonia, but it is so used only in a deep-seated trouble, and acts purely as a revulsive, dilating the superficial vessels and helping to empty the deeper ones. The forms of heat are—(i) fomentations; (2) poultices; (3) water-bath ; and (4) dry heat. Fomentations.—A fomentation is the application of a liquid to the surface of the body on sponges or other material. To apply a fomentation, wring out a piece of flannel in hot water, lay it upon the part, and cover it with oiled silk or with waxed paper, changing it as soon as it begins to cool. The flannel which is dipped into the hot liquid is known as a " stupe." The turpentine stupe is made by wringing out the flannel as above and then putting upon it from 10 to 20 drops of turpentine. Instead of fomenting the part, steam may be thrown upon it. Fomentations are used chiefly for the reflex influence over deep congestions or inflammations. The liquid of a fomentation may, if desired, contain corrosive sublimate, carbolic acid, or other agents. Poultice or Cataplasm—A poultice is a soft mushy mass applied to a part to bring heat and moisture to bear upon it. Poultices are preferably made of ground flaxseed or of slippery-elm bark, but they can be made of arrowroot, 58 A MANUAL OF SURGERY. starch, bread and milk, potatoes, turnips, etc. To make a flaxseed poultice, scald a spoon and a tin basin, put the flaxseed into the dry hot basin, and pour upon it boiling water in sufficient quantity to form a thick paste. The proper consistence is found when the mass would stick to, if it were thrown against, a wall. It is now spread upon a piece of muslin to the thickness of a quarter of an inch, and covered with a bit of gauze or mosquito-net to prevent its adhesion to the skin. Flaxseed retains heat a long time, and it needs to be changed only every five or six hours. The poultice should be covered outside with oiled silk or with waxed paper. Spongiopiline is a good substitute poul- tice. Lint soaked with hot water and covered with some impermeable material does very well. The fermented poul- tice, which was once popular for gangrenous ulcers, was made by sprinkling yeast upon an ordinary cataplasm. The charcoal poultice is made by stirring charcoal into the usual poultice mass. A poultice containing opium is known as a "sedative." About gr. ij of opium to the ounce of poul- tice mass relieves pain. An antiseptic poultice is made by partly wringing out gauze in a hot solution of corrosive sub- limate (i : iooo), covering it with oiled silk, and placing a hot-water bag upon it to maintain the heat. Poultices must not be kept on too long, as they will then vesicate, especially in adynamic conditions. If a poultice is found to be vesicat- ing, sprinkle it with powdered oxide of zinc. A wound should never be poulticed except by the antiseptic method. Water-bath.—The continuous hot bath is now rarely em- ployed except in cases of phagedaena, when it often proves curative. The water should in these cases contain bichloride of mercury. Dry heat is applied by a metallic object dipped in hot water and laid upon the part; by Leiter's tubes, through which hot water flows; or by the hot-water bag. INFLAMMA TION. 50 Irritants and Counter-irritants in Inflammation.—Irritants cause an increased supply of blood to the part where they are applied; in other words, they are used for their local effects. Counter-irritants are used to affect by reflex influence some distant part. In chronic inflammation irritants may do good by promoting the blood-supply, thus favoring the removal of exudates (liniments in rheumatism and synovitis, and nitrate of silver in ulcers). Counter-irritants are power- ful pain relievers when used over an inflamed part; they bring blood to the surface and cause anaemia of internal parts, the site and area of anaemia depending on the site, the area, and the duration of the surface irritation. To strongly counter-irritate too near an inflammation is harmful instead of beneficial. (Do not blister for pericarditis directly over the pericardium.—Brunton). Counter-irritants not only re- lieve pain and congestion in the earlier stages of inflamma- tion, but they also promote absorption of exudate in the later stages. This is seen in blistering old thickened ulcers, and in painting the chest with iodine to relieve pleuritic effusion. Frictions, besides their pressure-effects, act as counter-irritants. Frictions may relieve skin-pain, and are associated with stimulating liniments in stiff joints. There is no more efficient method of relieving pleural effusion than by a succession of blisters. They are used in inflamed joints, pericarditis, pneumonic consolidation of the lung, acute and chronic rheumatism, etc., and back of the ears or at the nape of the neck in congestive coma or meningitis. A blister can be obtained in a few minutes by soaking a bit of lint in chloroform, and, after applying it to the surface, covering it first with oiled silk, and then with a watch-glass. Equal parts of lard and ammonia will blister in five minutes. It is more usual to blister with cantharidal collodion or blistering-paper. Before applying a blister, shave the part if it be hairy; then apply the plaster, which 6o A MANUAL OF SURGERY. is left on six hours in the case of an adult, but only two hours in the case of an old person or a child; the plaster is then removed, and if a blister is not formed, the part must be poulticed for a few hours. When a blister is obtained, open it with a clean needle. If it be desired to heal the blister, grease it with cosmoline or with zinc ointment. If it is to remain open, dress it with from 4 to 6 drops of nitric acid to the ounce of cosmoline after cutting away the stratum corneum. We can pustulate with tartar-emetic ointment, with the hot iron, or with Vienna paste. Tartar-emetic ointment was formerly used on the scalp in meningitis. To pustulate with the hot iron, use it at a white heat, lay it on the part, and, after using iced-water cloths for an hour or two, employ a poultice. The hot iron is the most powerful of counter-irritants, and is used for joint-inflammations, bone- diseases, and inflammations of the spinal cord. Vienna paste consists of 5 parts of caustic potash and 6 parts of lime made into a paste with alcohol. It is applied for five min- utes, and is then washed off with vinegar. Constitutional Treatment of Inflammation.—Certain remedies are used in inflammation for their general or con- stitutional effects; these remedies are—(1) general bleeding; (2) arterial sedatives; (3) cathartics; (4) diaphoretics; (5) diuretics; (6) anodynes; (7) antipyretics; (8) emetics; (9) mercury and iodides; (10) stimulants; and (11) tonics. General bleeding, venesection, or phlebotomy is suited to the early stages of an acute inflammation in a young and robust man. The indication for its employment is increased arterial tension, as shown by a strong, full, rapid, and incompressible pulse in a vigorous young patient. General blood-letting di- minishes blood-pressure and increases the speed of the blood- current, thus amending stasis, absorbing exudate, and wash- ing adherent corpuscles from the vessel-wall; furthermore, INFLAMMA TION. 6l it reduces the whole amount of body-blood, thus forcing a greater rapidity of circulation, decreases the amount of fibrin and albumen, lowers the temperature, arrests cell-pro- liferation, and stops the effusion of lymph. This procedure was in former days so highly esteemed that it settled into a routine formula to be applied to every condition from yellow fever to dislocation. The terrible mortality of the cholera epidemics from 1830 to 1835 led practitioners to question whether bleeding was or was not a general panacea, and from this doubt there was born in the next generation violent opposition to blood-letting in any disease. Like most reactions, opposition has gone too far, the pendulum of condemnation has swung beyond the line of truth and sense, and thus is universally neglected or broadly condemned one of the most powerful and valuable of resources. Many physicians of long experience have never seen a person bled; its performance is not demonstrated in most schools, and but few patients and families will permit it to be done. But when properly used it is invaluable. It is only applicable, however, to the young, strong, and robust, and not to the old, weak, or feeble. It is used in violent acute inflammations of important organs or tissues, and not for low inflammations or for slight affections of unimportant parts. It is used in the early, but not in the late, stages of an inflammation. It is used when the pulse is frequent, full, hard, and incompressible, but not when it is slow, small, soft, compressible, and irregular. It is used when the face is flushed, but not when it is pal- lid. It is not used in fat persons, drunkards, very nervous people, or the sufferers from adynamic, septic, or epidemic diseases. It is of infinite value in congestion of the lungs, pneumonia, pleurisy, meningitis, prostatitis, cystitis, and other acute inflammatory conditions. Blood is usually taken from the median cephalic vein, the 62 A MANUAL OF SURGERY. incision being made with a bistoury, which is manageable, rather than with a complicated lancet, which is not. The median cephalic vein crosses the tendon of the biceps and goes to the outer side of the arm, the external cutaneous nerve lying just beneath it. The median basilic is larger, shows clearer, and is often selected for venesection. This vein goes to the inner side, and lies just superficial to the brachial artery, being separated from it by the bicipital fascia. The internal cutaneous nerve may lie over or under it. The median cephalic is harder and safer to bleed from, as we can only damage a cutaneous nerve; the median basilic is easier and more dangerous to bleed from, as we not only may damage a cutaneous nerve, but also the brachial artery (see Phlebotomy, p. 60). The blood is allowed to flow into a basin, and the operator has his finger on the pulse to determine when to stop the flow. Bleeding is for effect, and not for quantity: the indi- cation being a hard, incompressible pulse, the blood should be allowed to flow until the pulse is soft and compressible. This will often require from 10 to 20 ounces. Syncope may occur, and its onset is heralded by weakness, dimness of vision, nausea, vertigo, and sweating. When muscular weak- ness begins the fillet is untied, the patient is placed recumbent, the arm is washed with corrosive-sublimate solution, a com- press of antiseptic gauze is put over the artery, a pad of gauze is laid over the compress, and a roller is run from the hand almost to the shoulder, the arm being hung in a sling. If the patient faints, he is placed with his head lower than the body; cold water is thrown in his face, mustard is put over the heart, and ammonia is passed under the nose. Caution must be observed in using ammonia, as it will cause spasm of the glottis if long held directly under the nostrils. After bleeding the patient should be put upon arterial sedatives, diuretics, diaphoretics, anodynes, and, if necessary, INFLAMMA TION. 63 purgatives. A favorite mixture of Prof. S. D. Gross was the antimonial and saline, consisting of gr. xl of Epsom salts, gr. y1^ of tartar emetic, 3 drops of tincture of aconite, 3'} of sweet spirits of nitre, in enough ginger syrup and water to make 3ss; given every four hours. When a person has apoplectiform cerebral congestion, he should be bled, whether he is fat or thin; if thin, he should be bled from the arm; if fat, the arm-veins are indistinct, and he should be bled from the external jugular, cutting across, and not with, the fibres of the platysma myoides muscle. Arterial sedatives are of great use before stasis is pro- nounced ; if used after it exists, they will increase it. If stasis exists, relieve it by bleeding before using the sedatives. Venesection abolishes stasis and lowers tension, and arterial sedatives maintain the effect and hold the ground which is gained. The arterial sedatives employed are aconite, vera- trum viride, gelsemium, and tartar emetic. These sedatives lessen the force and the frequency of the heart-beats, and thus slow and soften the pulse, and are suited to a robust person with an acute inflammation, but are not suited to a weak man in an adynamic state. Aconite is given in small doses, never in large amounts. One drop of the tincture in a little water is given every half hour until its effect is manifest on the pulse, when it may be given every two or three hours. Large doses of aconite produce nausea and vomiting, and are dangerous. Aconite lowers the temperature, slows the pulse, and produces dia- phoresis. Vcratrum viride is a powerful agent to slow the pulse and to lower blood-pressure; it produces moisture of the skin, and often nausea. It is given in i-drop doses of the tinc- ture every half hour until its physiological effects are mani- fested, when the period between doses is extended to two 64 A MANUAL OF SURGERY. or three hours. Ten drops of laudanum given a quarter of an hour before each dose of aconite or of veratrum viride will correct nausea. Gelsemium is an arterial sedative highly approved by Bartholow. It is given in doses of 10 drops of the tincture every three or four hours. Tartar emetic lowers arterial tension and lessens the pulse- rate. This drug is not largely employed; if it is used with the greatest care it is no better than some other agents, and if it is not so used it will cause dangerous depression. The dose is from gr. -^ to gr. -^ in water every three hours until the physiological effects are manifest. Cathartics.—The tongue affords the chief indication for the use of cathartics. Treatment in an inflammation can be inaugurated, if constipation exists, by giving a cathartic. Castor oil can be given in capsules, or the juice of half a lemon can be squeezed into a tumbler, 4 ounces of oil poured in, and the rest of the lemon squeezed on top, thus making a not unpalatable mixture. Aloin, podophyllum, the salines, and calomel in 5- or 10-grain doses, followed by a saline, have their advocates. In peritonitis the salines are of unquestionable value, a teaspoonful of Epsom salt and a teaspoonful of Rochelle salt being given hourly until a movement occurs. In the course of the case, from time to time, if there be constipation, coated tongue, and foul breath, there should be ordered gr. j of calomel with gr. xxiv of bicarbonate of sodium, made into twelve powders, one being given every hour; if the bowels are not moved by the time the powders are all taken, a saline should be given. If a violent purgative effect is desired, as in meningitis, croton oil or elaterium may be ordered. If constipation is persistent, give fluid extract of cascara sagrada daily (15 to 30 drops), or a pill at night containing gr. \ of extract of belladonna, gr. \ of extract of nux vomica, gr. -^ of aloin, gr. 1 of extract of INFLAMMA TION. 65 physostigma, and gr. ss of oil of cajuput. Enemas or clysters may be used in some cases. A very useful enema is com- posed of fsj of oil of turpentine, fgiss of olive oil, f^ss of mucilage of acacia, in fgx of water. Soap-suds and vinegar in equal parts make a serviceable clyster. A combination of oil of turpentine, castor oil, the yolk of an egg, and water can be used. Asafetida, gr. xxx to the yolk of one egg, makes a good enema to amend flatulence. Diaphoretics are very useful. A good sweat in the start of a tonsillitis may abort the disease. Dover's powder is commonly used, but pilocarpine is preferred by some. Camphor in doses of from 5 to 10 grains is diaphoretic, and so are antimony and ipecac. Acetate and citrate of ammonium, opium, alcohol, hot drinks, heat to the surface (baths, hot bricks, hot-water bags), serpentaria, and guaiac are diaphoretic agents. Diuretics are useful in fevers when the urine is scanty and high-colored, and are valuable aids in removing serous effu- sions and other exudates. Among the diuretics may be mentioned calomel in repeated doses, cocaine, caffeine, alco- hol, digitalis, the nitrites, squill, turpentine, copaiba, and cantharides. The liquor potassae and the acetate of potas- sium are the best agents to increase the solids in the urine. The liquor potassae citratis in doses of gr. xxx is efficient. Large draughts of water wash out the kidneys. In weak heart the citrate of caffeine is a good stimulant diuretic. Anodynes and hypnotics may be required. Dover's pow- der, besides being diaphoretic, is anodyne. Opium acts well after bleeding or purgation. If it causes nausea, it should be preceded one hour by gr. xxx of bromide of potassium. Opium is used by the mouth, by the rectum, or hypodermat- ically. It is used when there is pain, but its use is not to be long persisted in if it can be avoided. It is given in doses measured purely by the necessities of the case. If 5 66 A MANUAL OF SURGERY. opium disagrees, try the combination of morphia with atro- pine. After an operation antipyrine or phenacetine will often quiet pain and secure sleep. When a person feels " so tired he can't sleep," alcohol in the form of whiskey or brandy must be given. Sleeplessness not due to pain is met by chloral, the bromides, or sulphonal. Chloral is dangerous in conditions of weak heart or exhaustion. Bromides must be given in large doses. Sulphonal must be given about four or five hours before sleep is expected, in doses of from gr. x to gr. xv in hot milk. Antipyretics, as exemplified in diaphoretics, purgatives, and arterial sedatives, have previously been alluded to (p. 63). There are two great classes of febrifuges—those which lessen heat-production and those which increase heat- elimination. In the first group we find quinine, salicylic acid and the salicylates, kairine, alcohol, antimony, aconite, digitalis, cupping, and bleeding. In the second group we find alcohol, nitrous ether, antipyrine, antifebrine, phenace- tine, opium, ipecac, cold to the surface, and cold drinks. In surgical inflammations it is rarely necessary to employ heroic means to lower temperature. The use of such an agent as antipyrine is contraindicated in the weak and adynamic, and it is never to be thought of as a means of lowering temperature unless the latter goes above 1030. A good plan when compelled to use antipyretics is to start the reduction of temperature with antipyrine and to keep it down with gr. xx of quinine. Quinine, in doses of gr. xx to gr. xxx given at 4 p. m., may prevent an evening rise; salol or salicin can be given during the day. Inunctions of 30 minims of guaiacol lower the temperature in tubercular conditions and in septic fevers. These inunctions are made upon the abdomen, and often produce surprising results. Emetics.—An emetic does good when there are a parched, coated tongue, a dry and hot skin, nausea, and gastric INFLAMMATION. 67 oppression. There can be used 3j of alum in molasses, gr. xx of sulphate of zinc, or a tablespoonful of mustard and a teaspoonful of salt given in warm water, followed by large draughts of warm water. Ipecac in a dose of gr. xx can be employed. The emetic dose of tartar emetic is gr. ij, but it is too depressant. The sulphuret of antimony in doses of from I to 5 grains is safe. Apomorphia hypoder- matically, in a dose of from gr. jig- to gr. |-, will act in five minutes. F^metics are valuable in inflammatory conditions of the air-passages. Emetics are contraindicated in diseases of the heart, brain, and bowels, in hernia, in dislocations, in fractures, and. in aneurysms. Mercury and the Iodides.—Mercury is an alterative—that is, an agent which favorably affects body-nutrition without causing any recognizable change in the fluids or the solids of the body. Mercury lessens blood-plasticity, hinders the exudation of liquor sanguinis—thus furnishing less food to the cells in the perivascular tissues—and retards the for- mation of embryonic tissue. Further, by a stimulant action on the absorbents it promotes the breaking up of an exist- ing inflammatory exudate, and hence limits damage from excess of embryonic tissue. The time at which mercury is best given is when violent symptoms have abated, the guide being reduced temperature and moist skin. It is often given in conjunction with sorbefacients (as the acetate of lead), and is, when possible, associated with compression. It is usually given until the gums are slightly touched, but is not often given to salivation. When the breath becomes offensive and the,gums tender on snapping the teeth, the dose should be reduced. In iritis mercury is used to get rid of the plastic effusion which is causing pupillary fixation and opacity. In keratitis the gums should be touched lightly. In orchitis, after the subsidence of the acute symp- toms, mercury should be employed. In pericarditis, menin- 68 A MANUAL OF SURGERY. gitis, peritonitis, and in many chronic and lingering, and in all syphilitic, inflammations this drug may be used. Some persons will be salivated with very minute doses of mercury, either from idiosyncrasy or previous saturation. Others can take enormous doses without any appreciable constitutional effect, but its action can be favored by a com- bination with ipecac or with tartar emetic. Salivation, ptyalism, or mercurial stomatitis is made mani- fest by the excessive flow of saliva; white patches over the buccal surface ; purple, tender, spongy, ulcerating gums ; foul breath ; gray-coated tongue ; tenderness, loosening, and later dropping out, of the teeth ; enormous swelling of the tongue, jaws, face, the salivary and lymphatic glands; and great interference with audition, respiration, articulation, and deglu- tition. Gangrene may occur. Salivation is to be treated by astringent gargles, atropine, chlorate of potassium internally and locally, anodynes, and iodide of potassium. If suffoca- tion is impending, scarify the tongue. A very useful mouth- wash is prepared as follows : R. Acid, boracic, J^ij; Listerine, 5iv; Aquae, q. s. ad f^viij.—M. Sig. Locally p. r. n. A favorite prescription with the late Professor Gross con- sisted of 3j of liquor plumbi subacetatis (Goulard's extract) to .^viij of water, used as a mouth-wash every hour. The dental discoloration produced by Goulard's extract will after a time pass away. A very useful gargle consists of gr. xlviij of chlorate of potash, 3ss of tincture of myrrh, and sufficient elixir of calisaya to make fgiij. This can be given in 3j doses every three or four hours, or be used as a mouth-wash. The usual plan of treatment for salivation is to stop the mercury; place on a bland diet; if the swelling or pain interferes with feeding, push into the pharynx through the INFLAMMA TION. 69 nose a tube, and feed through it; after taking food clean out thoroughly and swab the mouth every two or three hours with a cotton pledget saturated with peroxide of hydrogen, and follow this by the use of one of the above-named mouth- washes. A hot bath should be ordered once a day, or a Turkish bath every third day. Give 10 grains of iodide of potassium three times a day, and gr. Ti-¥ of atropine at night. Sleep is secured by opiates if the pain is severe. Stimulants are indicated for exhaustion. When convalescence begins there should be ordered open-air exercise, nourishing food, red wines or malt liquors, and tonics. A mild case of salivation can be arrested in two or three days ; a severe case is of uncertain duration, and may prove fatal. In giving mercury, if a prompt effect is desired, give gr. iij of calomel every three hours until a metallic taste is noted in the mouth. If the case is not so urgent, gray powder is a good combination. If it is desired to give the drug for some time, corrosive sublimate is a suitable form, and small doses will actually increase the number of red blood-cor- puscles. Corrosive sublimate is to be given alone or com- bined only with iodide of potassium. In the prolonged use of mercury it will often be necessary to give at the same time a little opium to prevent diarrhoea and griping. A rapid effect can be obtained by rubbing with a gloved hand 3] of the oleatc of mercury or 3ss of the ointment into the groin, the axillae, or the inside of the thighs. Suppositories of mer- curial ointment induce rapid ptyalism. Hypodermic injec- tions of corrosive sublimate can be used, and must be thrown deepl)- into the muscles of the buttock. Old people, those who are exhausted, anaemic, and broken down, and the scrof- ulous, bear mercury badly. If it be given at all, it must only be given to them in small amounts and for a brief time. Alkaline iodides, which are useful in removing the prod- ucts of inflammation, can be given for a long time, and 70 A MANUAL OF SURGERY. they admirably supplement mercurials. Iodide of potassium can be prescribed in combination with corrosive sublimate, as follows: r& . Hydrarg. chlor. corros., gr. ij; Potass, iodidi, £v et ^j; Syr. sarsaparillse comp., q. s. ad f^jviij.—M. Sig. f^ij, in water, after meals. Iodide, well diluted, is given on a full stomach; it is never given concentrated nor before meals. A convenient mode of administration is to procure a concentrated solution of the iodide of potassium, remembering that every drop equals gr. j of the drug, and give as many drops as desired in half a glass of water after meals. If this disagrees, add to each dose, after it is put in water, 3j of the aromatic spirits of ammonia. Extract of licorice is a good vehicle for iodide. If the mixture in water disagrees, it should be tried in milk. Capsules are satisfactory, but a drink of water should be taken just before and again just after taking a capsule, to protect the stomach from the concentrated drug. Iodide of sodium may agree when iodide of potassium does not. When the iodides disagree they produce iodism. The first indications of iodism are a bad taste in the mouth, running of the eyes and nose, and sneezing, followed by a feeling of exhaustion, absolute loss of appetite, nausea, tremor, and skin-eruptions (acne, hemorrhages, blebs, hydroa, etc.) If iodism occurs, stop the drug and give the patient Fowler's solution in increasing doses, laxatives, diuretic waters, and also good food and stimulants if depression is great. Some- times belladonna does good in obstinate cutaneous disorders. Alcoholic stimulants are used for conditions, and not for diseases, their use being indicated by the state of the patient, rather than by the name of the malady. For a brief acute inflammation in a robust young person alcohol is not needed; but all who are weak or exhausted—the young, INFLAMMA TION, 7* the old, those accustomed to alcoholic beverages, those who have high temperatures or failure of circulation, and those who labor under septic inflammations or adynamic pro- cesses—require alcohol to be given with a free hand. Certain indications for alcohol in an acute malady are a feeble, com- pressible, rapid, and often irregular pulse and great weakness of the first sound of the heart. Low muttering delirium is a strong indication. There is no dose of alcohol in these states: it is given for its effect. Two ounces may be needed in a day, or perhaps twenty ounces. If the breath of the patient smells strongly of the alcohol, he is getting too much. If delirium increases after each dose, it is doing harm. Alcohol is contraindicated in acute meningitis. In acute ill- ness use whiskey, brandy, champagne, or alcohol and water. During convalescence there may be used a little spirit—port, claret, or sherry wine or malt liquor. These agents will promote appetite, digestion, and sleep. Tonics are indicated during convalescence from acute and throughout the course of chronic inflammations. There may be used iron, quinine, and strychnine in the form of elixir; iron alone, as in the tincture of the chloride ; quinine in tonic doses (gr. vj to gr. viij daily); or Fowler's solution of arsenic. An excellent pill consists of— I£ . Acid, arsenos, gr. j; Strychnini, gr. ss; Quinine, gr. xlviij; Fcrri redact., gr. vj. Ft. in pil. No. xxiv. Sig. One after each meal. Bitter tonics before meals improve the appetite. One of the best of these tonics is tincture of nux vomica. Antiphlogistic regimen includes all the facts relating to diet, ventilation, cleanliness, etc. Diet.—When, in the early stages of an acute inflammation, 72 A MANUAL OF SURGERY. the patient cannot eat, there must be administered a cathartic before food is given. Nausea is combated with calomel and soda, drop-doses of a 6 per cent, solution of cocaine, iced champagne, or cracked ice. When the process is depressive from the start, and in any case after the earliest stage, feed- ing is of vital moment. The great tissue-waste calls for much food, but the impaired digestion demands that it shall easily be assimilable; hence it is taken in liquid form, small quantities being frequently given. Milk contains all the elements required by the body, and is the food of foods. If it disagrees, it should be boiled and mixed with lime- water, or to each dose an equal amount of Vichy or soda- water may be added. Peptonized milk is a valuable agent. One part of milk, 2 parts of cream, and 2 parts of lime-water make a nutritious and digestible mixture. Milk punch is largely used. Whey may be used when milk cannot be taken. Eggs are highly nutritious, but are apt to disturb the stom- ach ; they may be given as egg-nog, or simply soft-boiled, or the yolk can be beaten up in a cup of tea. When con- siderable nausea exists the yolk of an egg may be added to .?j of lemon-juice and 3ij of sugar, the glass being filled with carbonated water. Beef tea is certainly a stimulant, but its food-powers are questionable. It is prepared by cut- ting up one pound of lean beef, adding to it a quart of water, and then simmering, but not boiling, down to a pint, and finally by filtering and skimming the liquid. The dose is a wineglassful seasoned to taste. Meat-juice, made by squeezing out partly-cooked meat with a lemon-squeezer, is also highly nutritious. Liquid-beef peptonoids are both agreeable and nutritious ; they are given in doses of 5ss to 5j". When noth- ing else will stay on the stomach koumiss will often be retained. This fermented milk is nutritious, stimulant, and very useful. Coffee is a valuable stimulant in febrile condi- tions. When the sufferer feels able to eat a little, any o-0od REPAIR. 73 soup, strained and skimmed, should be ordered. As the patient gets better he may be fed on sweetbreads, chops, etc. until he gradually reaches the ordinary diet; if his stomach rejects everything, he must be fed by the rectum. Ventilation and Cleanliness.—The ventilation of the apart- ment is of the greatest importance. Every day the windows should be opened widely for a time, the patient of course being protected. A constant access of fresh air must be secured, and the temperature kept at about 68°. The sick man must be cleaned and be sponged off with alcohol and water every day if high fever exists. It is important that the bed-clothing be clean and that the sheet be unwrinkled, as otherwise bed-sores may form. III. REPAIR. Repair is an active process by which destroyed tissues are replaced, and it is due to increased nutritive activity, rather than to inflammation. Inflammation may occur, or we may be obliged to induce it when the blood-supply is scanty or the exudation deficient; but certain it is that an aseptic wound heals without many of the evidences of inflammation. Healing by First Intention.—A wound may heal by " first intention." This mode of healing, which is known as " primary union," occurs without suppuration. If pus forms, primary union will not take place. When the edges of an incised wound are brought nicely in apposition, after stopping the hemorrhage and asepticizing thoroughly, slight swelling comes on, but no discoloration. Lymph and leucocytes are exuded from the vessels, fibrin forms in this lymph, and the edges of the wound are stuck together by a natural cement. In exten- sive wounds the exudation is in excess, and much of it must be drained away, for its retention means tension, inflamma- tion, and a warm nest for pus cocci. The exudation is con- 74 A MANUAL OF SURGERY. verted into embryonic tissue by multiplication of its own cells and multiplication of tissue-cells. Embryonic or gran- ulation-tissue consists of small round or oval cells held together by a jelly-like intercellular substance. In a few days some spindle-shaped cells can be found, and also large cells with one or more nuclei (epithelioid cells). Prolonga- tions of embryonic tissue are raised up by capillary loops, which prolongations fuse with one another end to end, or they fuse with other capillary loops, and are hollowed out and become endothelial tubes or capillaries. After vascu- larization or organization the embryonic tissue becomes fibrous (Figs. 21, 22). The final step in healing is the cover- t\\£m ill mm Fig. 21.—Nuclei developing into Fibres (Bennett). ing of the surface with epithelium, the cells springing from the epithelial cells upon the edges. This final process is called " cicatrization," and consists in the contraction of the wound and its skinning over. The " immediate union " of some writers never occurs. It means the union of micro- scopical parts to their counterparts without any effort at repair. A first union is effected always by fibrin, and next by embryonic tissue. Healing by Second Intention.—In a wound whose edges cannot be approximated a great gap has to be filled, which is accomplished by granulation. This process is known as " heal- Fig. 22.—Cells developing into Fibres (Bennett). « REPAIR. 75 ing by granulation " or " second intention." In an hour or so after the infliction of such a wound (it may be in less time) the raw surface is covered with a thin glazed layer of coagulated exudate. This glaze is fibrin, which soon becomes filled with leucocytes; underneath this fibrin-coat proliferation is pro- ceeding and embryonic tissue is forming. The wound-dis- charge is at first thin and red, but in a few days becomes purulent and so profuse as to wash away the discolored fibrin- coat. Granulations are now disclosed, the embryonic tissue being lifted up in countless points by capillary loops. When these loops approach the surface contraction begins, which brings the edges of the wound nearer together and gradually cuts off the excessive blood-supply which is no longer needed. When the granulations reach the surface, epithelium in a thin bluish film grows from the epithelial cells at the edge and covers the ulcer. Cicatrization is contraction plus skinning over with epithelium. Epithelium can only spring from the wound-edges, unless there be some epithelial structural remains in the wound, such as an undestroyed papilla, a sweat-duct, or a hair-follicle. If the granulations rise above the surface, constituting exuberant granulations or proud flesh, they must be cut off or burned away before epithelium will grow over the wound. Pale cedematous granulations are usual in tuberculous processes. The contraction of cicatrization results from the conversion of embryonic tissue into fibrous tissue (Figs. 21, 22). Contraction is so great after some wounds as to cause terrible deformities. This is notably the case after burns whose scars or cicatrices con- tain much elastic tissue. Coagulation necrosis of a super- ficial layer of granulation-tissue produces a diphtheritic membrane or aplastic lymph. This coagulation necrosis depends on capillary closure or lack of capillary develop- ment, the embryonic tissue dying for want of nutriment. Healing by Third Intention.—This consists in the union 76 A MANUAL OF SURGERY. of two granulating surfaces, as the union of collapsed abscess- walls. In subcutaneous wounds, if aseptic, healing occurs without suppuration. First a blood-clot fills the wound, exudate occurs, and embryonic tissue forms in the walls of the cavity; the new granulation-tissue grows into the clot, which is broken up and absorbed, and organization and con- traction of the embryonic tissue take place. If suppuration occurs, an abscess forms. Healing under an aseptic blood- clot is healing " by first intention." The fibrous tissue of a scar arises from connective tissue, which itself arose from embryonic tissue. The multiplication of connective-tissue cells may be by direct, but it is usually by indirect, division. Cell-Division.—Direct cell-division consists in division of the nucleus followed by division of the entire cell. Indirect cell-division, or karyokincsis, shows remarkable changes in the nucleus. The membrane of the nucleus dis- appears ; the nuclear network becomes first close and then more open, and the cells become round, if not so before. The network of the nucleus, now consisting of one long fibre, takes the shape of a rosette; next it takes a star- form—the aster stage; two sets of V's next form—the equa- torial stage ; an equatorial line appears and widens, and each set of V's retreats toward a pole. Thus two new nuclei are formed, each polar V passing in inverse order through the previous changes of shape, and the protoplasm of the original cell collects about each nucleus (Fig. 23). In non-vascular tissues, such as cornea or cartilage, the wound is glued together by fibrin, the exudate having come along the lymph-spaces from adjacent vascular areas. Organ- ization occurs by multiplication of fixed tissue-cells and leucocytes. Divided muscle unites by fibrous tissue. Divided nerve, when approximated, can regenerate. Tendon unites by fibrous tissue which after a time becomes truly tendinous. Bone first unites by embryonic tissue which becomes fibrous SURGICAL FEVERS. 77 and bony. When an artery is ligated, embryonic tissue forms in and around it, the walls soften and are converted into the same tissue, and the artery is organized into a fibrous cord. Fig. 23.—Forms Assumed by a Nucleus Dividing (Green, from Flemming). An ulcer heals in the same manner as does a wound—by second intention. An abscess heals by collapse of its sides and their adhesion. The sides are embryonic tissue which is formed into granulations, these granulations unite, and organization into fibrous tissue takes place. IV. SURGICAL FEVERS. The surgeon encounters fever as a result of an inflamma- tion or an aseptic wound, in consequence of infection, and in certain maladies of the nervous system. It is important to remember that, while elevated temperature is generally taken as a gauge of the intensity of fever, it is not a certain index. There may be fever with subnormal temperature (as in the collapse of typhoid or pneumonia), and there may be elevated temperature without true fever (as in certain brain diseases). It is true, however, that elevation of temperature is almost always noted. 78 A MANUAL OF SURGERY. The essential phenomena of fever, according to Maclagan, are—(i) wasting of nitrogenous tissue; (2) increased con- sumption of water; (3) increased elimination of urea; (4) increased rapidity of circulation; and (5) preternatural heat. Types of Fever.—Fevers, whatever their causation and special names, belong to one of three fundamental types, just as the diverse varieties of men belong to certain funda- mental races. These three types are—(1) sthenic fever; (2) asthenic fever; and (3) nervous fever. Sthenic Fever.—The sthenic or inflammatory type, found in the young and robust as a result of acute inflammation, is characterized by violent action at an early period. It is ushered in by malaise, chilly sensations or a moderate chill, want of appetite, nausea and often vomiting, and pain in the back and limbs. The pulse shows increased pressure, is fre- quent, full, hard, and incompressible (runs from 90 to 120); the face is flushed; the eyes are suffused and intolerant of light; the skin is dry; the respiration is accelerated; the mouth is dry, and the tongue is coated. There is thirst, anorexia, often nausea and bilious vomiting, and constipation ; headache; an insufficient amount of sleep, and disturbing dreams when the patient sleeps; he may show a delirium of an agreeable character. There is aching and soreness in the back and limbs, and emaciation. The temperature, which attains its height in from two to four days, rarely exceeds 1030. The urine is scanty, high-colored, offensive, and often contains albumin and casts. A fever may be sthenic in the beginning, but become asthenic later in the attack. The genuine sthenic type terminates by lysis. An acute pleuritis in a robust subject affords an example of the sthenic type of fever. Asthenic Fever.—The asthenic typhoid or adynamic type occurs in the weak, the sickly, the debilitated, and in those at the extremes of life. It is the fever of pyaemia, sep- SURGICAL FEVERS. 79 ticaemia, diphtheria, typhoid, etc., and it is often ushered in by a chill or chills and profound depression. The pulse is soft, tremulous, weak, compressible, frequent, and quick (no to 160). The temperature is elevated (ioo° to 1080), often for long periods, and oscillates greatly. Chills may recur; the respirations are rapid and shallow ; the skin is cold, clammy, often drenched with cold sweat; the face is lividly pale; the eyes sunken and partly closed; the tongue is dry, hard, and covered with a brown fur; sordes gather on the gums and teeth; the muscles and tendons twitch (subsultus tendinum); the patient picks at the bed-covers in a bad case (carphalogia); the appetite is absent, and the powers of assimilation at a low ebb; there are hiccough, great wasting, and diarrhoea; the urine is scanty, high-colored, often albuminous; the mental condition is one of torpor, apathy, or stupor, with low muttering delirium. Bad subsultus, persistent vomiting, carphalogia, or continued hiccough and a " Hippocratic" countenance usually indicate death, which is apt to happen in coma. The Hippocratic countenance presents the follow- ing elements : "A sharp nose, hollow eyes, collapsed temples; the ears are cold, contracted, and their lobes turned out; the skin about the forehead is rough, distended, and parched, the color of the whole face being brown, black, livid, or lead colored." Nervous Fever.—The irritative or nervous type is apt to attend the adynamic type, and is often met with following carbuncles, sloughing, and late eruptions of pox. The tem- perature is irregularly elevated (1010 to 1030). There are nervous chills, but not rigors. The mind is fretful, peevish, anxious, and despondent; pain is magnified; the pulse is quick, small, jerking, and often irregular; the skin is hot and dry; severe headache and pain in the back and limbs are complained of; insomnia is distressing, and the sleep obtained is disturbed by vivid dreams; restlessness is pro- 8o A MANUAL OF SURGERY. nounced, and loud noises or bright lights produce much annoyance. Traumatic fevers follow a traumatism and attend the heal- ing of a wound. The forms are—(i) primary wound-fever; and (2) secondary wound-fever. Primary tvound-fever is a result of the changes going on in a wound which does not contain pus. It is divided into two forms: (a) aseptic fever; and (b) traumatic or surgical fever. Aseptic fever appears after a thoroughly aseptic operation and after a simple fracture or a contusion. It may appear during the evening of the operation or not until the next day, and reaches its highest point by the evening of the second day (ioo° to 1020). This elevation is spoken of as the " post-operation rise." Besides the fever there are no obvious symptoms; the patient feels first-rate, and often wants to sit up ; there are no rigors and there is no delirium. This fever is due to absorption of pyrogenous material from the wound-area, where clot-tissue and exudate may be ab- sorbed. The pyrogenous element seems to be fibrin-ferment. In some cases an aseptic fever may appear after an opera- tion, and later be replaced by a septic fever. If the tem- perature remains high after a few days or if other symp- toms appear, the wound should be examined at once, as trouble certainly exists. Traumatic or surgical fever is seen in the healing of in- fected wounds where there is inflammation, but no pus. This fever is due to the presence of bacteria in the wound and the absorption of their ptomaines. It ceases as soon as free discharge occurs, and its appearance is an indication for instant drainage. The temperature rises pretty sharply in a day or so after the operation, ascends with evening exacer- bations and morning remissions, and reaches its height about the third or fourth day, when suppuration sets in; the tem- TERMINATIONS OF INFLAMMATION. 81 pcrature begins to drop if the pus has free exit, and reaches normal at the end of a week (see Suppurative Fever). When the fever begins the wound should be inspected, the stitches removed where stitch-abscesses exist, and the area drained and asepticized. The fact that this fever is apt to cease when suppuration begins led the older surgeons to hope for pus and to endeavor to cause it to form. Secondary Wound-fever: Suppurative Fever.—This fever, which is due to the absorption of the ptomaines of pyogenic cocci, occurs after suppuration has begun, and is found when the pus has not free exit. If the post-operation rise con- tinues, or if, after it has gone, a secondary rise occurs, look out for pus. Suppuration in a wound is indicated by a rapid rise of temperature—possibly first by a chill. The wound must at once be drained. In a chronic suppuration, such as occurs in a tubercular process, there exists a fever with marked morning remissions and vesperal exacerbations, attended with night-sweats, emaciation, diarrhoea, and exhaustion. This is known as " hectic fever;" it is really a chronic sup- purative fever. The treatment of hectic fever consists in draining or, if possible, excising the infected area, a nutri- tious diet, open air, stimulants, tonics, and in giving remedies for the exhausting sweats. V. TERMINATIONS OF INFLAMMATION. Inflammation can terminate in—(i) effusion of serum; (2) effusion of lymph; (3) formation of pus; (4) ulceration; and (5) mortification. Effusion of Serum.—The so-called " serum " of inflamma- tion is not serum at all, but is liquor sanguinis. We meet with true serum in passive congestions, but not in active hyperaemias. Effusion of serum into connective tissue con- stitutes (Edema ; and into a sac, like the peritoneum, dropsy; b 82 A MANUAL OF SURGERY. dropsy being designated by the prefix hydro-, as hydrothorax. Abdominal dropsy is ascites. Anasarca is general effusion of serum resulting from altered blood-pressure. CEdema is made manifest by the signs of inflammation, the swelling being soft, smooth, and inelastic, and the parts pitting on pressure. Effusion of serum may be beneficial, unloading the vessels and hence relieving pain, tension, and hyperaemia. It can do harm. In connective tissue it may exist in such « quantity as to cut off the circulation of certain areas, thus causing necrosis. Effusion into a cavity causes pressure on its contained parts; for instance, in a hydrothorax the lung is compressed. Treatment.—CEdema can be relieved by multiple punc- tures, but if it threatens necrosis free incisions must be made. If the dropsy be considerable, the fluid must be let out by tapping, aspiration, or incision. Tapping must be done aseptically, but it offers danger of infection, as air is bound to enter and be retained. In aspirating use full aseptic care. When it is wished to drain the abdomen, the latter should always be opened with a knife, because an intestine might happen to be glued to the abdominal wall; hence if a trocar or a needle were used perforation would take place. In a moderate oedema there is used locally compression, and tincture of iodine diluted with an equal bulk of alcohol. In persistent oedema employ frictions with a stimulating lini- ment. Internally, salines and diuretics are indicated. The compound jalap powder is well suited to dropsies. Mercu- rials can be used, and in severe cases also elaterium. Effusion of Lymph.—The term " lymph " is a synonym for fibrinous exudate, coagulable lymph, plastic infiltrate, solid inflammatory new formation, organized new formation, indifferent tissue, granulation-tissue, or embryonic tissue. « Here we have effusion of highly albuminous liquor san- guinis, with proliferation of the blood-corpuscles and the TERMINATIONS OF INFLAMMATION. 83 fixed connective-tissue cells (Fig. 24). Effusion of lymph means a more severe inflammation than does the effusion of serum. Lymph may be absorbed or it may be organized into tissue. If it becomes organized, capillaries form in it Fig. 24.—Recent Lymph, forming False Fig. 25.—Blood-vessels in Granula- Membrane (Gross). tion (Gross). by the extension from the surrounding tissue of capillary loops, which raise up the lymph and form granulations. A granulation may be defined as a small mass of lymph con- taining vessels (Fig. 25). Lymph is divided into two forms—plastic or formative lymph, that which can be converted into tissue, hence that which brings about repair; aplastic or croupous lymph, that which develops no fibres and cannot be converted into tissue, and which in consequence cannot bring about repair. Effusion of lymph may be beneficial. It repairs all injuries ; it surrounds and encapsules foreign bodies; it circumscribes abscesses; and it often prevents pus from evacuating into a cavity, gluing together structures to make a channel and leading the pus to the surface. It may be injurious. It forms adhesions of the brain, pleura, peritoneum, pericardium, and joints; it produces opacity in the cornea and adhesions of the iris; it constitutes the false membrane of the larynx or trachea; and it causes stricture of the urethra and thicken- ing of organs. Treatment.—Locally, employ compression, tincture of 84 A MANUAL OF SURGERY. iodine, lead-water and laudanum, alternating hot and cold douches, friction, and massage; also ichthyol and lanolin. Internally, use mercurials and iodide of potassium or tartar emetic. Prof. S. W. Gross recommended the following mix- ture for inflammatory thickening: R. Potassii iodidi, gr. x; Hydrarg. chloridum corros., gr. TJg; Antimonii et potassii tartras, gr. ^.—M. Sig. Three times a day, in half a glass of water, after meals. Suppuration is a process in which tissues and inflamma- tory exudates are liquefied by the action of pyogenic cocci, and it is a common termination of infective inflammation. Localized suppurations are due to staphylococci; spreading suppurations, to streptococci. Cocci liquefy exudates and tissues by peptonizing them. Suppuration can be induced by the injection of cocci, by their entry through a wound, and by rubbing them upon the skin. In some rare instances, especially when the diet has been putrid, they may enter through the blood. The entry of cocci does not necessarily mean suppuration, as the healthy human body can destroy a moderate dose, but a large dose in a healthy, or even a small dose in an unhealthy, organism almost certainly does. The pus of all acute abscesses contains cocci, but the pus of tubercular abscesses does not, unless there be a mixed in- fection ; in other words, pure tubercular pus is not pus at all. Can suppuration be induced without micro-organisms ? It is true that the injection of irritants can cause the forma- tion of a thin fluid which contains no organisms, but this non- bacterial pus is not pus. The same sort of fluid is formed by injecting cultures of cocci which have been rendered sterile by heat, the organisms being killed, their products being the active agent. Spurious or " aseptic " pus does not * concern us, as it is never found practically. Impaired health or an area of lowered vitality predisposes to suppuration. TERMINATIONS OF INFLAMMATION. 85 The lymphatic glands, medulla of bones, serous membranes, and connective tissue are especially prone to suppurate. When a medullary canal suppurates as a result of a blow that does not cause a wound, we know that the organisms must have arrived by means of the blood. Pus may form in twenty-four hours after an inflammation begins, or it may not form for days. The older surgeons claimed that pus could do good by protecting granulations and separating disorganized tissue. It is now held that it is absolutely harmful by melting down sound tissue and poison- ing the entire organism. Modern surgery has to a great degree abolished pus. If pus stands for a time, it separates into two portions— (1) a watery portion, the liquor puris or pus-serum, contain- ing peptone, fat, microbic products, osmazone, and salts, and not tending to coagulate ; (2) a solid portion, or sediment of pus cocci, pus-corpuscles (Fig. 26), and broken-down tissue. The pus-corpuscles are either white blood-cells or the fixed cells of connective tissue. Some of them are dead, some have amoeboid movements, some are fatty, others are granular and contain more than one nucleus, and all are degeneratino;. A pus-cell is waste matter, and it cannot aid in repair. Forms of Pus.—Laudable or healthy pus, a name long in vogue, is a contradiction, no pus being healthy. In former days fvee suppuration after an operation was regarded as a favorable indication, showing that there was no septicaemia, which disease dries up wound-discharges. At the present day suppuration after an operation is an evidence of previous infection, of unpardonable lack of care, or of infection by the blood. This form of pus is seen coming from a healing ulcer, and is a yellowish-white or a greenish fluid of the consistence of cream, opaque, with a very slight odor if it is not putrid, and has- a specific gravity of about 1.030. Malignant, watery, or ichorous pus is a thin, watery, putrid 86 A MANUAL OF SURGERY. fluid. It is pus rendered putrid by the organisms of putre- faction (bacterium termo). Sanious pus is a form of ichorous pus containing blood coloring-matter or blood. It is thin, of a reddish color, and Fig. 26.—Fragmentation of Nucleus in Leucocytes undergoing Transformation into Pus- corpuscles (Senn). very acrid, corroding the parts that it comes in contact with. It is found notably in caries and carcinoma. Concrete or fibrinous pus, which contains flakes of fibrin or coagulated fibro-purulent masses, is met with in serous cavities (joints, pleura, etc.). These masses are found in infective endocarditis (Bowditch). Blue pus.—The color of blue pus is due to the bacillus pyocyaneus. < Orange pus, which is due to haematoidin, follows violent inflammations in which red as well as white corpuscles are TERMINATIONS OF INFLAMMATION. 87 exuded, these corpuscles being broken up by the pyogenic cocci. Serous pus is a thin serous fluid containing a few flakes. Scrofulous or curdy pus is not pus at all, unless the tuber- cular area has undergone pyogenic infection. Gummy pus arises from the breaking down of a gumma which has outgrown its own blood-supply. It is not pus. Muco-pus is found in purulent catarrh, that is, in suppura- tive inflammation of an epithelial structure. It contains pus- elements and epithelial cells. Caseous pus comes from the fatty degeneration of pus- corpuscles or inflammatory exudations. This mass may calcify. It occurs in tuberculous processes. Contagious pus is that which contains and conveys the elements of some specific contagion, such as small-pox or a chancroid. Suppuration is announced by the intensification of all in- flammatory signs. Irregular chills and drenching sweats are very significant of suppuration in an important structure or of a wide area. The heat becomes intense, the discolora- tion becomes dusky, the swelling is much augmented, the pain becomes throbbing or pulsatile, and there is an increasing sense of tension. The skin at the focus of the inflammation becomes adherent to the parts beneath, and fluctuation soon appears. This adhesion of the skin is a preparation for a natural opening, and is what is known as " pointing." An important sign of pus beneath is oedema of the skin. This is noticeable in empyema or pyothorax and appendicitis. The above symptoms can be reinforced and their significance proved by the introduction of an exploring-needle and the discovery of pus. Diffused Cellulitis or Phlegmonous Suppuration; Purulent Infiltration.—This process may involve a small area or an entire limb. It is announced in severe cases by enormous 88 A MANUAL OF SURGERY. I swelling, the development of areas which feel boggy, a dusky-red discoloration, great burning pain, and probably chills, sweats, and fever. Gangrene of superficial areas is not unusual. The discharges of the wound, if a wound exists, dry up, and the wound becomes dry and brown. The adja- cent lymphatic glands are much enlarged. We find diffused suppuration in infected compound fractures, in extravasation of urine, and after the infliction of a wound upon a person * broken down in health. It is not unusual after scarlet fever, and is typical of phlegmonous erysipelas. The pus is sani- ous and offensive. This diffused suppuration may widely separate muscles, and even lay bare the bones. It is a very grave condition, and may cause death by exhaustion, septic intoxication, septic infection, pyaemia, or hemorrhage from a large vessel which has been corroded. Cellulitis of a mild degree may surround an infected wound or a stitch-abscess. Its spread is manifested by red lines of lymphangitis run- ning up to the adjacent lymphatic glands. Light cases may not suppurate, the lymphatics carrying off the poison. Any case of cellulitis is, however, a menace, and any severe case is highly dangerous (see Erysipelas). Abscesses.—An abscess is a circumscribed cavity of new formation containing pus. We emphasize the fact that it is a circumscribed cavity—circumscribed by embryonic tissue. A purulent infiltration is not circumscribed, hence it does not constitute an abscess. An essential part of the definition is the assertion that the pus is in a cavity of new formation, in an abnormal cavity ; hence pus in a natural cavity (pleural, pericardial, synovial, or peritoneal) constitutes a purulent effusion, and not an abscess. An acute abscess is due to the deposition and multiplica- tion of pyogenic cocci in the tissues or in inflammatory * exudates. These cocci attack exudates or tissues, form irri- tants which intensify the inflammation, and by exerting a Plate 2. 1. Infiltration of Connective Tissue of Cutis (X 500), with beginning suppuration in the centre (Senn). 2. Fmbolus Impacted at Bifurcation of a Branch of the Pulmonary Artery (Green). 3. Thrombus in the Saphenous Vein (Green). 4. Marasmic Rickets (Pye). 1 TERMINATIONS OF INFLAMMATION 89 peptonizing action on intercellular substance and fibrin of the exudate liquefy tissue and the products of inflammation and form pus. Within twenty-four hours after their lodgment the exudation increases in amount, the migrated leucocytes are found in enormous numbers, the fibres of tissue swell up, and the connective-tissue spaces are distended with cells and fluid. The connective-tissue cells, acted on by pus cocci, multiply by karyokinesis, develop many nuclei, lose their stellate projections, degenerate, and constitute one form of pus-corpuscle, leucocytes forming the rest. All the small vessels are choked with leucocytes, this blocking serving to cut off nourishment and tending to produce anaemic necrosis. Liquefaction occurs at many foci of the inflammation, drops of pus being formed, the amount of each being progres- sively added to and many foci coalescing (PI. 2, Fig. 1). The pus-cavity is circumscribed, not by a secreting pyogenic membrane, but by embryonic tissue whose cells and inter- cellular material have not as yet broken down, and this area of embryonic tissue is circumscribed by a zone of inflamma- tion. As an abscess increases in size the embryonic tissue from within outward liquefies into pus, and the zone of inflam- mation beyond continually enlarges and forms more lymph. After a time the inflammation reaches the surface, the embry- onic tissue glues the superficial to the deeper parts, liquefac- tion of this lymph occurs, a small elevation due to fluid pressure appears (pointing), and this elevation thins and breaks from tension and liquefaction (spontaneous evacua- tion). When an abscess forms in an internal organ or in some structure which is not loose like connective tissue— for instance, in a lymphatic gland—a mass of pus cocci, floating in the blood or lymph, lodges, and these cocci by means of irritant products cause coagulation necrosis of the adjacent tissue and inflammatory exudation around it. The area of coagulation necrosis becomes filled with white blood- 9o A MANUAL OF SURGERY. cells, and the dry necrosed part is liquefied by the cocci. Suppuration in dense structures causes considerable masses of tissue to die and to be cast off, and these masses float in the pus. Death of a mass with dissolution of its ele- ments is necrosis or inflammatory gangrene. Forms of Abscesses.—The following are the various forms of abscesses : acute or phlegmonous, which follows an acute inflammation; strumous, cold, lymphatic, tubercular, or chronic abscess is due to tubercle, and does not contain true pus without there is secondary infection. It presents no signs of inflammation. A lymphatic abscess may form in a week or two, and hence is not necessarily chronic, which term may mean a persistent non-tubercular abscess; caseous or cheesy abscess, a cavity containing thick cheesy masses, is due to the breaking down of tubercular matter; circumscribed abscess is one limited by embryonic tissue; diffused abscess is a collection of pus unlimited by lymph ; congestive, gravi- tative, wandering, or hypostatic abscess is a condition in which the pus travels from its formation-point and appears at some distant spot (as a psoas abscess); critical or consecutive abscess is one which arises during an acute disease ; diathetic abscess is due to a diathesis; embolic abscess is due to in- fected emboli; tympanitic or emphysematous abscess is one which contains the gases of putrefaction; encysted abscess, in which pus is circumscribed in a serous cavity; fecal or ster- coraccous abscess is one containing feces because of a com- munication with the bowel; follicular abscess is one arising in a follicle; hcematic abscess is that which arises around blood-clot, as a suppurating haematoma; marginal abscess, which appears upon the margin of the anus ; pycemic or metastatic abscess is the embolic abscess of pyaemia; milk abscess is an abscess of the breast in a nursing woman; ossifluent abscess, arising from diseased bone; psoas abscess, arising from vertebral caries, following the psoas muscle and TERMINATIONS OF INFLAMMATION. 91 usually pointing in the groin; sympathetic abscess, arising some distance from the exciting cause, such as a suppurating bubo from chancroid; thecal abscess is suppuration in a tendon-sheath; tropical abscess is an abscess of the liver, so named because it occurs in tropical countries. It usually follows dysentery; urinary abscess, caused by extravasated urine; verminous abscess, one which contains intestinal worms and communicates with the bowel; syphilitic abscess, which occurs in the bones during tertiary syphilis; Brodie's abscess is a chronic abscess of a bone, most common in the head of the tibia; superficial abscess, which occurs above the deep fascia ; deep abscess, occurring below the deep fascia; and residual or Paget's abscess, a recurrence of suppuration, it may be after years, about the residue of a former abscess. Acute Abscess.—In an acute abscess a part becomes in- flamed and embryonic tissue forms; this is liquefied (as above noted) and laudable pus is produced. If the abscess is in the brain, in the tonsils, or in the neighborhood of the rectum, the odor of the pus is apt to be offensive. An acute abscess can occur in a person of any constitution. Symptoms: Local Symptoms.—Locally there is intensifica- tion of inflammatory signs : swelling enormously increases, the discoloration becomes dusky, the pain becomes throbbing and the sense of tension increases, and the cutaneous surface is seen to be polished and oedematous. Constitutional Symptoms.—In cases of small collections of pus in unimportant structures there may be no obvious con- stitutional disturbance. If the abscess contains much pus or affects an important part, generally disturbances appear, from slight rigors or moderate fever to chills, high temperature, and drenching sweats. The constitutional condition typical of an abscess is due to the absorption of retained elements of pus, and this is known as " suppurative fever." When suppuration is long continued, there exists a fever which is 92 A MANUAL OF SURGERY. f markedly periodic: the temperature rises in the evening, attaining its highest point usually between 4 and 8 p. m., and then sinks to normal or nearly normal in the early morning (from 4 to 8 A. m.). When the temperature begins to fall profuse perspiration takes place. This fever is known as " hectic." The symptoms of an abscess are somewhat modified by location. Bone never suffers from acute abscess; sudden n and violent inflammations produce necrosis, and all bone- abscesses are chronic—that is, slow in format-ion and pro- longed in duration. Pain is continued, but not usually severe; it is boring in character and variable in intensity, being worse at night. Attacks of synovitis are apt to arise in the adjacent joint. In abscess of a silent region of the brain, symptoms may long be entirely absent. The usual symptoms are headache, vomiting, delirium, drowsiness, optic neuritis, and often a subnormal temperature. Localizing *" symptoms may be present. In but few cases are there fever and sweats. Appendicinal abscess results from ulceration and perfora- tion of the vermiform appendix, aplastic peritonitis circum- scribing the pus. Its signs are pain, tenderness, often swell- ing, dulness on percussion, and sometimes fluctuation and skin-oedema in the right iliac fossa, fever, vomiting, some- times constipation, and sometimes diarrhoea. Stercoraceous vomiting does not occur. Abscess of the liver may not be announced by symptoms until rupture. We may find fever of an intermittent type, profuse sweats, pain in the back, the shoulder, or the right hypochondriac region, enlargement of the area of liver- dulness, hepatic tenderness, and finally sepsis. Sometimes there is fluctuation and skin-cedema, the skin being a little «• jaundiced. The symptoms vary as the pus invades adjacent organs. TERMINATIONS OF INFLAMMATION. 93 Abscess of the lung gives the physical signs of a cavity; the expectoration is offensive and contains fragments of lung- tissue. Pyaemic abscesses may not be discovered. Abscess of the mediastinum causes throbbing retro-sternal pain, chills, fever, sweats, and often dyspnoea. A tumor may appear which pulsates and fluctuates. Perinephric abscess usually causes tenderness and pain in the lumbar region or about the hip-joint, running down the thigh and accompanied by retraction of the testicle. Indu- ration, fluctuation, or oedema of the skin may appear. The constitutional symptoms of suppuration usually exist. Retropharyngeal abscess causes cough, dyspnoea, pain on swallowing, dysphagia, and altered voice; an examination discloses a projection on the posterior wall. Abscess of the antrum of Highmore causes pain, cedema- tous swelling, and crepitation on pressure. Abscess of the larynx induces violent cough, pain, inter- ference with the voice, swallowing, and breathing, and is seen with a laryngoscope. Prostatic abscess is. manifested by chills, fever, and sweats, developing during an attack of acute prostatitis. Diagnosis.—The diagnosis of an abscess rests upon— (1) its history; (2) fluctuation; (3) pointing; (4) surface- ix'dcma; and (5) the use of the exploring-needle. A suspected abscess in a dangerous or important part under no circumstance should be opened by a bistoury without knowing that our diagnosis is certainly correct. This knowledge is obtained by inserting an exploring-needle and finding the nature of the fluid which exudes. An abscess made to move with the pulse by resting upon an artery may be confounded with an aneurysm. The pulse- movements of an abscess are in one direction only, it does not enlarge, and if a finger is laid upon either side of it the finders will be lifted, but not separated. The pulse-move- 94 A MANUAL OF SURGERY. ments of an aneurysm are in all directions; they are pul- satile, the tumor grows larger, and the fingers will not only be lifted, but will also be separated. The exploring-needle must be used : it will do no harm to an aneurysm if aseptic. A rapidly-growing, small-celled sarcoma feels not unlike an abscess; but the exploring-needle discovers blood, and not pus. A cystic tumor is separated from an abscess by the absence of inflammation, or, if it inflames, by the nature of the fluid it contains. Ordinary caution will prevent us from confounding an abscess and strangulated hernia. A cold abscess is separated from an acute abscess by the absence of inflammatory signs. Prognosis.—The prognosis varies according to the number of abscesses, their location and size, and the strength of the patient. Treatment.—In the treatment of an abscess there is one absolute rule which knows no exception, namely, that when- ever and wherever pus is found the abscess should be evacu- ated at once, and, after evacuating it, thorough drainage provided for. It should be opened early, if possible even before pointing or fluctuation, to prevent tissue-destruction, subfascial burrowing, and general contamination. In puru- lent effusion into the pleural cavity (empyema or pyothorax), resect a portion of a rib, cut away periosteum, incise the pleura, evacuate the pus, wash out the cavity first with a 14-volume solution of peroxide of hydrogen diluted with an equal bulk of water, then with a 1 : 3000 solution of cor- rosive sublimate, then with boiled water; insert a drainage- tube, dress antiseptically, and immobilize the chest with a binder, washing out afresh every day. If there be a large pus-cavity, resect a portion of each overlying rib to permit of sinking in of the chest-wall and approximation of the sides of the pus-cavity (Estlander's operation). Operations by the trocar or aspirator are rarely curative. In purulent perito- TERMINATIONS OF INFLAMMATION. 95 nitis, open the abdomen and flush well with boiled water, insert a drainage-tube, and wash out the abdomen every day. Abscess of the liver requires that an incision be made along the edge of the ribs down to the liver, which organ is then stitched to the edges of the wound, the abscess opened and washed out, and a tube inserted. Appendicular abscess, abscess of lung, of mediastinum, etc., like all other abscesses, require incision and drainage. In abscess of the brain the skull should be trephined, the membranes incised, and the abscess sought for, opened, and drained. In bone- abscess the bone must be trephined. In an ordinary super- ficial abscess, after cleansing the parts, make the skin tense, incise with a sharp-pointed curved bistoury, and let the pus run out itself, pressure being, as a rule, undesirable. If tis- sue-shreds block up the opening, they must be picked out with forceps. If the atmospheric pressure will not cause the pus to flow out, make light pressure with warm, moist, aseptic sponges. After the pus has come away, wash the cavity with peroxide of hydrogen and then with corrosive solution (1 : 1000), and pack with iodoform gauze for two or three days, when the discharge becomes serous. Pursue rigid antisepsis in dealing with pus. It is true we already have infection, but we can easily infect with organisms of putrefaction, making putrid pus. In a deep abscess always use a drainage-tube for several days. In a deep abscess or an abscess situated near important vessels, do not boldly plunge in a knife. Hilton says to "plunge in a knife is not courageous, as it is without danger to the surgeon, but may be fatal to the patient." Remember also that a large amount of pus displaces normal anatomical relations. Hilton's method of opening a deep abscess (as in the axilla or neck) is to cut through the deep fascia and then to push into the abscess a grooved director until pus shows in the groove; along this groove push a pair of dress- 96 A MANUAL OF SURGERY. ing-forceps, shut; after they reach the depths open them and withdraw, and so dilate the opening; then insert a tube and wash. In an abscess in the posterior part of the orbit, after incising transversely a portion of the upper lid, the abscess should be reached by this method. Always endeavor to open an abscess at its most dependent part, remembering that this may depend upon whether the patient is erect or recumbent. If we do not make the opening at the lowest point, all the pus will not run out and the walls will not completely collapse. In post-pharyngeal abscess opening through the mouth is dangerous, as pus may enter the larynx. In these cases it is better, as Hilton advised, to cut down through the sterno-cleido-mastoid muscle to the fascia below it and push the director and forceps through this into the abscess. When an abscess contains diverticula or pouches, the latter should be slit up or a counter-opening be made. A counter- opening is made by entering the dressing-forceps at our first incision, pushing them through the abscess to the point where we wish to make our counter-opening, opening the blades, and cutting between them from without inward. The blades are then closed and projected through the incision; they are opened to dilate the new door, and closed again upon a drainage-tube which is pulled through from opening to opening as the instrument is withdrawn. In empyema from a wound make a counter-opening by resecting a rib. When pus burrows, insert a grooved director in each channel and slit it up with a knife. Rest is of the first importance in the healing of an abscess, and we try to obtain it by bandages, splints, and pressure which will immobilize adjacent muscles and approximate the abscess-walls. If an abscess is slow to heal, use as a daily injection peroxide of hydrogen followed by I : 500 corrosive sublimate, or 3 drops of nitric acid to §j of water, TERMINATIONS OF INFLAMMATION. 97 or 3 grains of zinc sulphate to 3j of water, or a 5 per cent. solution of carbolic acid, or a solution of pyoktanin, 3j of the concentrated solution to Oj of water, or 20 drops of tincture of iodine to 5J of water. The constitutional treatment of an abscess depends upon its severity and upon the import- ance of the structures involved. In a bad case the patient should be put to bed, opiates given with a free hand, the bowels kept active by calomel and salines, skin-activity main- tained, nutritious food insisted on, and stimulants liberally employed. Tubercular abscess, called also chronic, cold, scrofulous, and lymphatic, is an abscess circumscribed by a distinct membrane. Ashurst says that the term " chronic " is a bad one. " It refers etymologically only to time. A phlegmon- ous abscess, if deeply seated, may be of slower development than a chronic or cold abscess which is superficial." A tuberculous abscess is most common in the lymphatic glands, bones, joints, and subcutaneous connective tissues, and is rare after the twentieth year. It may contain quarts of curdy pus. The bacilli of tubercle cause inflammation, and embryonic tissue is formed, which undergoes coagulation necrosis and caseation because of the irritation of ptomaines and anaemia due to the mass outgrowing its own blood-supply. First there forms from embryonic tissue a cheesy matter which is liquefied into scrofulous, curdy, or tubercular pus. This really is not pus, as the tubercle bacillus is not pyogenic; if true pus forms, it is because of a secondary infection with pus cocci—an accident, and not a part of the natural process of formation of a cold abscess. A cold abscess may be absorbed, or may become encapsuled by fibrous organization of its limiting lymph into the pyogenic membrane. Symptoms.—The term cold abscess is employed for a tubercular abscess because it presents no inflammatory signs. There is no local heat; no discoloration unless pointing 7 98 A MANUAL OF SURGERY. occurs; the parts look paler than natural; pain is absent in the abscess, though it may exist at the point of origin of the pus; the pus wanders from its point of origin under the influence of gravity; fluctuation is present unless thick walls mask it. Constitutional symptoms are absent unless secondary infection occurs. The tumor may suddenly appear in some spot—the groin, for instance. The abscess may last for years without producing pain or annoyance. The explor- ing-needle will settle the diagnosis. The constitution is in- variably below normal because of the tuberculous infection, and the temperature is a little above normal. A cold abscess which is infected with pus cocci exhibits great inflammation, and fever rapidly develops. In tubercular disease of the vertebra the fluid may find its way to the lumbar region, to the iliac region, or to the immediate neighborhood of Poupart's ligament, above or below it. Retro-pharyngeal or post-pharyngeal abscess is usually due to caries of the cervical vertebra. A tumor projects from the posterior pharyngeal wall, and there is great interference with respiration and deglutition. Pus from caries of the cervical vertebrae may reach the posterior mediastinum by following the oesophagus, or it may appear in front of or behind the sterno-mastoid muscle (Edmund Owen). Dorsal Abscess.—The pus in dorsal abscess arises from dorsal caries, flows into the posterior mediastinum, and reaches the surface by passing between the transverse pro- cesses. The pus from dorsal caries may run forward be- tween the intercostal muscles or between these muscles and the pleura, pointing in an intercostal space at the side of the sternum or by the rectus muscle. It may open into the gullet, windpipe, bronchus, pleura, or pericardium. It may descend to the diaphragm and travel under the inner arcuate ligament to form a psoas abscess, or under the outer arcuate ligament to form a lumbar abscess. A psoas abscess points TERMINATIONS OF INFLAMMATION. 99 external to the femoral vessels, and is thus distinguished from a femoral hernia. Iliac abscess comes from lumbar caries, the tumor lying in the iliac fossa and pointing above Poupart's ligament. Psoas abscess is usually due to lumbar caries, the pus pointing in Scarpa's triangle external to the femoral vessels. A psoas or iliac abscess by following the lumbo-sacral cord and great sciatic nerve forms a gluteal abscess. These abscesses may open into the bowel, bladder, ureter, or peri- toneal cavity. Lumbar Abscess.—In a lumbar abscess the pus from dorsal caries descends beneath the outer arcuate ligament, or the pus from lumbar caries which collected anterior to or in the quadratus lumborum muscle flows backward between the last rib and iliac crest in the triangle of Petit.1 Treatment.—If a small cold abscess exists in a superficial structure, open it with aseptic care, curette its walls, wash out with i : iooo mercurial solution, pack with iodoform gauze, and dress antiseptically. In a day or two remove the gauze, but continue mercurial dressings. If it be slow in healing, inject or swab out with a stimulating fluid as in acute abscess. Cold Abscess of Lymphatic Glands.—In non-exposed por- tions of the body the capsule should be incised, dissected and scraped away, and the cavity swabbed out with pure carbolic acid and packed with iodoform gauze. If the abscess is allowed to burst, it will make an ugly scar; there- fore in exposed portions of the body an effort should be made to prevent a scar. When only a little pus exists and the skin is not discolored, prepare the parts antiseptically and carry a silk thread by means of a needle through the skin, through the gland, and out at its lowest point. Dress 1 For a lucid description of these abscesses see Owen's Manual of Anatomy, from which the above is condensed. IOO A MANUAL OF SURGERY. with gauze. In three days the thread can be taken out and a firm compress applied. When the gland is almost entirely broken down and the skin above it is purple and thin, insert a hypodermatic needle through sound skin into the abscess, draw off the pus, and inject iodoform emulsion (io per cent. of iodoform, 90 per cent, of glycerin or olive oil). This pro- cedure is to be repeated when pus again accumulates. By this means we can often effect a cure in a week or so. When an abscess breaks or is at the point of breaking, cut away all purple skin, curette the abscess-walls (the abscess having become a scrofulous ulcer), remove all remains of gland and capsule, swab it with pure carbolic acid, and dress with iodoform and corrosive gauze. Large Cold Abscesses.—In view of the facts that these abscesses may cause no trouble for years and that an opera- tion may be fatal, some eminent surgeons are opposed to an operation unless the abscess is marching toward inevitable rupture or is disturbing the functions of organs by pressure. Most practitioners believe, however, that this mass of tuber- culous matter is a source of danger through being a depot of infective organisms which may overwhelm the system, and that death will not occur in the hands of the operator who employs with intelligence strict antisepsis. In no other cases is attention to every detail more important, as infection is very easy, and probably means death. In many cases aspiration can be employed to empty the cavity, after the pus runs out, injecting either a 10 per cent. iodoform emulsion to the amount of siij, or siij of a 5 per cent. ethereal solution of iodoform. After injecting the emulsion squeeze and manipulate the fluid into every nook and cranny. The American Text-book of Surgery advises the injection of from 1 to 3 ounces of the following preparation: Iodoform, 10 parts ; glycerin, 20 ; mucil. gum Arab., 5 ; carbolic acid, 1; water, 100. ULCERATION AND FISTULA. IOI Whatever fluid is chosen, the operation must be repeated three or four times at intervals of four weeks. It is danger- ous to inject large amounts of iodoform, as poisoning will be produced. When iodoform poisons, the patient has a metallic taste in his mouth, subjective foul odors in the nose, the nose and eyes water, and the stomach is disturbed. In bad cases we find insomnia, loss of memory, variable emo- tions, headache, and violent mania alternating with coma. If aspiration and injection fail, open, under rigid antisepsis, the most dependent portion of the abscess, scrape it well, and over-distend with a I : iooo solution of warm corrosive sublimate, which should be washed out with warm boiled water. With a long probe find the highest point of the cavity, and make a counter-opening, scrape well, search for and remove carious bone, flush out the whole area with corrosive sublimate, wash out this mercurial solution with boiled water, and either make tube-drainage from opening to counter-opening and from bone to counter-opening or pack the entire cavity with iodoform gauze. If hemorrhage is severe, after injecting with hot water the opening must be packed. When a large abscess breaks of itself, it should at once be drained and asepticized as above. In the treatment of a cold abscess give nutritious food, cod-liver oil, quinine, iron, and the mineral acids. Removal to the sea-side is often indicated, and mechanical appliances may be needed for dis- eases of the bones and joints. If secondary infection does occur, the patient develops hectic fever (q. v.). VI. ULCERATION AND FISTULA An ulcer is a loss of substance due to necrosis of a super- ficial structure. The action of the pus cocci is the same as in an abscess. A broken abscess becomes an ulcer, and an ulcer is a half-section of an abscess. The floor of an 102 A MANUAL OF SURGERY. ulcer consists of embryonic tissue and corresponds with the abscess-wall. An abscess arises from molecular death in the tissues; an ulcer, from molecular death of a free sur- face. An ulcer must not be confounded with an excoriation. In an ulcer the corium is always, and the subcutaneous tis- sue is generally, destroyed, and a scar is left after healing. In an excoriation the mucous layer of epithelium is exposed, or this is destroyed and the corium exposed. The corium is never destroyed, and no scar remains after healing. Necrosis can arise from—(i) Inflammation. The pressure of the exudate can cut off the circulation, or bacteria may directly destroy tissue. Suppuration occurs. (2) The action of pus cocci, causing primary cell-necrosis. (3) Bacteria of putrefaction and cocci of suppuration acting upon a wound. (4) Traumatism or irritants, producing at once stasis, which is added to by secondary inflammation, the exudate under- going purulent liquefaction. (5) Prolonged pressure. (6) Deficient blood-supply. (7) Faulty venous return. (8) De- generation of a neoplastic infiltration (gummatous, malig- nant, or tubercular). (9) Trophic disturbance. (10) Nutri- tional disturbances (as scurvy). Most ulcers are due to pus cocci, and even those that arise from something else (as gummatous degeneration) are apt to suppurate. Classification.—Ulcers are classified into groups accord- ing to the condition of the ulcer and the associated con- stitutional state. In the first group we find the varicose, hemorrhagic, acute, chronic, irritable, neuralgic, etc. In the second group are placed the strumous, syphilitic, senile, scorbutic, etc. All ulcers, whatever their origin, are either acute or chronic, and such conditions as great pain, hemor- rhage, oedema, exuberant granulations, phagedaena, slough- ing, struma, gout, syphilis, scurvy, etc. are to be looked upon *-■ as complications. The leg is so common a site of ulcers as to warrant special description. ULCERATLON AND FISTULA. 103 Acute ulcer of the leg may follow an acute inflammation and may be acute from the start, or may be first chronic and become acute. It is characterized by rapid progress and intense inflammation. In shape these ulcers are usually oval. The bottom of an acute ulcer is covered with a mass of gray aplastic lymph, or it may have upon it large green- ish sloughs. The edges are thin and undermined. The dis- charge is very profuse and ichorous, excoriating the sur- rounding parts. The adjacent surface is inflamed and cedem- atous. There is much burning pain. When the ulcer spreads with great rapidity and becomes deeper as well as larger in surface-area, it is called " phagedaenic." If sloughs form, this indicates that tissue-death is going on so rapidly that the dead portions have not time to break down and be cast off. Limited stasis produces molecular death ; more extensive stasis, a slough. Constitutionally, there is gastro- intestinal derangement, but rarely fever. Treatment.—In treating an acute ulcer of the leg, give a dose of blue mass or calomel, followed in eight or ten hours by a saline (sij each of Rochelle and Epsom salt). Order light diet. Deny stimulants except in diphtheritic ulcer. Administer opium if pain is severe. Use a spray of per- oxide and the scissors and forceps to get rid of sloughs, and after their removal wash the ulcer with corrosive sublimate. If the sloughs cannot be removed, use the antiseptic poultice. After asepticizing, local bleeding is of great value. Tie a fillet below the knee, make multiple punctures, and let the patient sit with his leg in tepid water until eight or ten ounces of blood have been lost; then untie the fillet and dress with antiseptic poultices, keeping the leg elevated. In two days paint around the ulcer with equal parts of tincture of iodine and alcohol, and repeat this treatment every day, dressing the ulcer with iodoform, covering it with gauze, and producing pressure by means of a roller. 104 A MANUAL OF SURGERY. Many cases do very well on the local use of lead-water and laudanum and the roller after bleeding. If the discharge is offensive, use gr. iij of chloral to every 3j of lead-water. The use around an acute ulcer of a 25 per cent, ointment of ichthyol is highly valuable. If sloughs continue to form, touch with a 1 :8 solution of acid nitrate of mercury or with a pure solution of carbolic acid and reapply antiseptic poul- tices. If an ulcer continues to spread, clean it up with per- ♦ oxide of hydrogen, dry with absorbent cotton, touch with nitrate-of-mercury solution (1 : 8), and apply a poultice. Do this every day until it ceases to extend and granulations begin to form. In an ulcer covered with a great mass of aplastic lymph, touch it daily with solution of silver nitrate (gr. xl to 5J) or with acid nitrate of mercury (1:15) and dress with iodo- form and gauze. Give internally tonics, stimulants, and good food. In any case, when granulations form we should dress * antiseptically with dry dressings, but we can employ a non- irritant ointment, such as cosmoline. If granulation is slow, touch every day with a solution of silver nitrate (gr. x to 3j) and dress antiseptically, or with a stimulating ointment (resin cerate or 3j of ung. hydrarg. nitratis to 3vij of ung. petrolii), or with an ointment of copper sulphate, gr. iij to §j, or with 3 drops of nitric acid to 3j of gum Arabic or cotton. Chronic ulcer of the leg is characterized by low action and slow progress. It may be chronic from the start, or it may result from acute ulcer. More usually it is found as a soli- tary ulcer two inches above the internal malleolus. Syphi- litic ulcers occur in a group, are often crescentic, and are fre- quent upon the front of the knee. A chronic ulcer is circu- lar or oval, and is surrounded by congested, discolored, and indurated skin, this induration being due to embryonic tissue, r and there is often eczema or a brown pigmentation of the neighboring skin. The bottom of the ulcer is uneven, and ULCERATION AND FISTULA. 105 usually possesses granulations each of which is the size of a pin-point, red, and which may be exuberant or may be cedematous. If granulations are absent, the ulcer has the appearance of a bit of liver. The edges are thick, turned out, and not sensitive to the touch. Occasionally they are thin and undermined. Some ulcers are thick, indurated, and adherent; this prevents healing by antagonizing contraction. Treatment.—In treating a chronic ulcer, give a saline every day or so. Treat any existing diathesis. Insist on rest-and, if possible, elevation. Asepticize the ulcer. Draw blood by shallow scarifications of the bottom of the ulcer and the skin. If the ulcer is adherent, make incisions like either of those shown in Figure 27, each cut going through the deep fascia. These incis- ions, besides permitting contraction, allow granulations to sprout in them, which eventuate in the absorption of the exudate. After incision keep the "H^^T^incisions for TcF- part elevated and dressed antiseptically herent Ulcer- for two days. In two days after scarification or incision, scrape the ulcer with a curette until sound tissue is reached, and make radiating incisions through its edge. Use anti- septic poultices for two days more, then paint around the ulcer with tincture of iodine and alcohol (1:3) and dress the leg with hot lead-water and laudanum. When healing begins, treat as outlined for healing acute ulcer (p. 103). Complications.—Remove by scissors and forceps any use- less tissue. Take out dead bone; slit sinuses ; trim over- hanging edges. Treat eczema by attention to the bowels and stomach, and locally by washing with Johnson's ethereal soap and by the use of powdered oxide of zinc or borated talcum, the leg being wrapped in cotton. Avoid ordinary soap, grease, and ointment. Varicose veins demand either ligation in several points, excision, obliteration with Vienna io6 A MANUAL OF SURGERY. « paste, or the continued use of a flannel roller or a Martin bandage. Inflammation is met by rest, elevation, and paint- ing the neighboring parts with dilute iodine, and by the use of a hot solution of lead-water and laudanum. For calloused edges employ radiating incisions or cut them away. Ordinary thick edges can be strapped. In strapping use adhe- sive plaster and do not completely encircle the limb. When the parts are adherent, completely or partly surround the sore r with a cut through the deep fascia. If the bottom of the ulcer is foul, dry it and touch with a solution of acid nitrate of mercury (i : 8) or with a solid stick of silver nitrate. Repeat this every third day and dress with an antiseptic poultice until granulations appear. Superfluous granulations (proud flesh) should be cut away or mowed down with silver nitrate. When a man having an ulcer must go out, use a firmly- applied roller, or, better still, a Martin bandage. This bandage, which is made of red rubber, limits the amount of arterial *' blood going to the ulcer and favors venous flow from the sore and its neighborhood. The bandage should be used as follows: Before getting out of bed, spray the sore with hydrogen peroxide by means of an atomizer, dry off the froth with cotton, wash the leg with soap and water, dry it, and put on the bandage—all of which should be done before putting a foot to the floor. At night, after getting in bed, take off the bandage, wash with soap and water, and dry it, and again cleanse the leg and ulcer. If these rules are not strictly observed, the Martin bandage will produce pain, suppuration, and eczema of the leg. Irritable ulcer is due to exposure of a nerve and destruction of its sheath. Find with a probe the painful granulation and divide it with a tenotome, or curette the ulcer or burn it with solid stick of silver nitrate. If healing entirely fails, skin-graft. There r are two methods of skin-grafting—(i) Reverdin's and (2) Thiersch's. (See Plastic Surgery.) ULCERATION AND FISTULA. 107 Ulcers in any Region.— The fungous or exuberant ulcer is especially common in burns and other injuries when cica- tricial contraction causes venous obstruction. These granu- lations bleed when touched. Burn or cut them off with a sharp knife, stop hemorrhage if there be any, and strap or use the rubber bandage. Erethistic, irritable, or painful ulcers, which are very sensi- tive, are due to the exposure of a nerve-filament. They are especially found near the ankle, over the tibia, in the anus (fissure), or in the matrix of the nail (in ingrowing nail). Curette an erethistic ulcer, and touch with pure carbolic acid or with the solid stick of silver. Chloral, gr. xx to the ounce, allays the pain; so does cocaine for a time. Phagedenic Ulcer.—The phagedaenic ulcer, which means the profound microbic infection of tissues debilitated by local or constitutional disease, is commonly venereal. This ulcer has no granulations and is covered with sloughs; its edges are thin and undermined, and it spreads rapidly in all directions. It requires the use of strong caustics or the Paquelin cautery followed by iodoform dressing. Internally, use tonics and stimulants. A rodent ox Jacob's ulcer is a superficial epithelioma devel- oping from sebaceous glands, sweat-glands, or hair-follicles. Decubital ulcer, or bed-sore, is due to pressure upon an area of feeble circulation. Neuro-paralytic or trophic ulcer is due to impairment of the trophic centres in the cord. The perforating ulcer, a name given by Vesigne, commonly affects the metatarso-phalangeal joint or the pulp of the great toe about a corn. The parts about the corn inflame, and pus forms which runs into the bone. A sinus evacuates the pus by the side of the corn.1 As this ulcer may be present in anaesthetic leprosy, paralyzed limbs, and tabes 1 See Treves in Lancet, Nov. 29, 1884. io8 A MANUAL OF SURGERY. • dorsalis, and as the part on which it occurs is apt to be sweaty, cold, and possessed of impaired sensation, and as the sore may be hereditary, it is usually set down as trophic in origin. Treatment of a perforating ulcer consists, accord- ing to Treves, in going to bed and poulticing. * Every time a poultice is removed the raised epithelium around the ulcer is cut away and then the poultice is reapplied. In about two weeks an ulcer remains surrounded by healthy tissue. r Treves treats this sore with glycerin made to a creamy con- sistency with salicylic acid to each ounce of which 1Tlx of carbolic acid have been added. He directs the patient to wear during the rest of his life some form of bunion-plaster to keep off pressure. If in a perforating ulcer the bone is diseased, it must be removed. This ulcer tends to recur in the same spot or in adjacent parts, and it may be necessary to amputate the toe or the foot. Epitheliomatous, sarcomatous, tuberculous, and syphilitic *" ulcers are considered "under their respective heads. Fistula.—A fistula is an abnormal communication between the surface and an internal part of the body, or between two natural cavities or canals. The first form is seen in a rectal fistula, a urethral fistula, or a biliary fistula, and the second form is seen in a vesico-vaginal fistula. Fistulae may result from congenital defect, as when there is failure in the closure of the branchial clefts, sloughing, traumatism, and suppura- tion. Fistulae are named from their situation and communi- cations. (Fig. 166). A sinus is a tortuous track opening usually upon a free surface and leading down into the cavity of an imperfectly- healed abscess. A sinus may be an unhealed portion of a wound. Many sinuses may be due to pus burrowing sub- cutaneously. A sinus fails to heal because of the presence «" of some fluid (as saliva, urine, or bile); because of the existence of a foreign body, as dead bone, a bit of wood, MORTIFICATION OR GANGRENE. IO9 a bullet, a septic ligature, etc.; or because of rigidity of the sinus-walls, which rigidity will not permit collapse. The walls of a tubercular sinus are lined with a material identical with the pyogenic membrane of a cold abscess. Sinuses may be due to the want of rest (muscular movements) and to general ill-health. Treatment.—In treating a fistula remove any foreign body, * lay the channel open, curette, swab with pure carbolic acid, and pack with iodoform gauze. Fresh air, good food, and tonics should be ordered. VII. MORTIFICATION OR GANGRENE. Mortification or gangrene is death in mass of a portion of the living body—the dead portions being visible—in con- trast to ulceration or molecular death, in which the dead 9 particles are too small to be seen and are cast away. In gangrene the dead portions may either desiccate or putrefy. Gangrene may be due to tissue-injury, either chemical or mechanical, to failure of the general health, to circulatory impairment, or to microbic infection. Molar death of bone is called " necrosis." When the gangrened portion is entirely dead, the process is spoken of as " sphacelus." Classification.—Gangrenes are divided into the following three great groups : (1) Dry gangrene, which is due to circulatory interference, the arterial supply being decreased or cut off. As venous return is still active, all fluid is taken up from the tissues, which shrivel up and mummify. (2) Moist gangrene, which is due to interference not only with arterial ingress, but also with venous return or capillary m circulation, the dead parts remaining moist. (3) Septic gangrene, arising from virulent septic matter coming from outside. 110 A MANUAL OF SURGERY. There are many gangrenous processes which belong under one or other of the above heads, namely: congenital gan- grene, a rare form existing at birth; constitutional gangrene, arising from a constitutional cause, as diabetes; cutaneous gangrene, which is limited to skin and subcutaneous tissue, as in phlegmonous erysipelas; gaseous or emphscmatous gangrene, in which the subcutaneous tissues are filled with putrefactive gases and crackle on pressure; diabetic or gly- ccemic, due to diabetes; hospital gangrene, which is defined by Foster as specific serpiginous necrosis, the tissues being pulpefied: some consider it a traumatic diphtheria; cold gangrene, a form in which the parts are entirely dead (sphacelus); hot gangrene, which presents some inflamma- tion, as shown by heat; idiopathic gangrene, which has no ascertainable cause; mixed, which is partly dry and partly moist; primary, in which the death of the part is direct, as from a burn ; secondary, which follows an acute inflamma- tion; multiple, a gangrenous ecthyma; pressure, which is due to long compression; purpuric or scorbutic, which is due to scurvy; Raynaud's or idiopathic symmetrical, which is due to vascular spasm from nerve-disorder; senile, the dry gan- grene of the aged ; venous or static, which is due to obstruc- tion of circulation, as in a strangulated hernia; trophic, which is due to nutritive failure by reason of disorder of the trophic nerves or centres; thrombotic, which is due to thrombus; embolic, which is due to embolus; and decubital gangrene, from bed-sores. Dry or chronic gangrene, Pott's gangrene (Fig. 28), arises from deficiency of arterial blood. In a person with healthy arteries dry gangrene can result by injury of the main trunk of an artery (lodging of an embolus, ligation, or laceration). Gangrene only follows injury when the anastomatic circu- lation fails to sustain the part. When, for instance, an em- bolus lodges and causes gangrene, the case runs the following t MORTIFICATION OR GANGRENE. Ill course: Sudden severe pain at the seat of impaction, and also tenderness; pulsation above, but not below, this point; the limb below the obstruction is blanched, cold, and an- aesthetic; within forty-eight hours, as a rule, the gangrene has mapped out its area; the limb becomes blue, reddish, greenish, and then black; the skin itself becomes shriveled and its outer layer stony or like horn. The entire part may •* become as dry as a mummy, but usually there are spots where some fluid remains, and these spots are soft and moist, and the dead tissue where it joins the living is sure to be moist. The contact of dead with living tissue causes Fig. 28.—Chronic Gangrene of the Feet (Gross). inflammation in the latter tissue, a bright-red line forms, and we have exudation, suppuration, and ulceration. This line of ulceration in the sound tissues is called the " line of demarcation," it being Nature's effort at amputation, which in time may get rid of a large portion of a limb, and then heal as any other ulcer. Senile gangrene is a form of dry gangrene due to feeble action of the heart plus obliterating endarteritis or atheroma of peripheral vessels. The vessels do not properly carry blood, and may at any time be occluded by thrombosis. Senile gangrene most often occurs in the toe or the foot. 112 A MANUAL OF SURGERY. Symptoms.—A man whose vessels are in the state above indicated is generally in feeble health and has a fatty heart and an arcus senilis (a red or white line of fatty degeneration around the cornea). His feet feel cold and numb, and they "go to sleep" very easily. The arteries are felt as rigid tubes like pipe-stems. A very slight injury of a toe will produce extensive inflammatory stasis, which completely cuts off the blood-supply and causes gangrene of the part. Gangrene is usually announced by a blue spot, followed by a vesicle which lets out bloody serum and has a dry floor. The tissues adjacent to the dead toe become victims to stasis and gangrene, and the process ascends until it reaches tissue whose circulation is sufficiently good to permit of ulcera- tion instead of gangrene, when a line of demarcation forms. Before the line of demarcation forms there is some burning pain; after it forms pain is rarely present. If embolism in a diseased vessel caused the gangrene, the pain is severe. In senile gangrene the periphery is always dry, the part nearer the body being generally somewhat moist. A line of demarcation may start, but prove abortive, the tissue mortifying above it. This proves that tissue near the line is in a state of low vitality. An entire leg can die. When a limited area is gangrenous, constitutional symptoms are trivial or are absent, but when a large area is involved we find the fever of septic absorption. Death may ensue from exhaustion caused by sleeplessness and pain, from septic infection, or from embolism of internal organs. Treatment of Senile Gangrene.—When injury of an artery causes us to fear dry gangrene, the patient should be placed in bed and the part relaxed, massage employed from time to time, and the part be kept wrapped up in cotton-wool and warmed with hot bottles or water-bags. If gangrene begins, wait for a line of demarcation and amputate well above it. While waiting for the line to form, dress the dead part antiseptically, MORTIFICATION OR GANGRENE. I 13 induce sleep, and give good food, tonics, and stimulants. If a person is of the type in which there is danger of senile gangrene, he should be cautioned against injuring his feet, especially cutting his corns carelessly, which is highly dan- gerous ; any wound, however slight, requires rest and anti- septic dressing. He must wear woollen stockings, put a hot-water bag to his feet on cold nights, and attend to his general health. A little whiskey after each meal is indicated. When gangrene occurs, if it shows a tendency to limit itself, we must wait for a line of demarcation and then amputate high up. If the gangrene shows no tendency to limit itself, or if the patient develops sepsis or exhaustion, at once amputate high up. The best point at which to amputate is above the knee, so that the deep femoral, which rarely occludes, will nourish the flap. Never amputate below the tubercle of the tibia. Some operators disarticulate at the knee-joint. Heidenhain affirms that so long as the gan- grene is limited to one or two toes we should merely treat it antiseptically, elevate the limb, and wait for the dead part to be cast off spontaneously; if, however, it extends to the dorsum or sole of the foot, amputate at once above the knee. He further states that gangrene of the flaps almost always occurs in amputation below the knee, and high amputation is indicated in advancing gangrene with or without fever.1 • In moist or acute gangrene (Fig. 29) the dead part remains moist and putrefies. It results from interference with venous return or capillary flow, as well as from arterial ingress. It is seen in a limb after ligature or destruction of its main artery and vein, after long constriction, and after crushes and lacerated wounds. Moist gangrene may follow acute inflam- mation, or may be due to local constriction (strangulated hernia), crushing, chemical irritants, heat, and cold. Moist gangrene of a limb is seen typically when both vein 1 Deutsche medicinische Wochenschrift, 1891, p. 1087. 8 U4 A MANUAL OF SURGERY. and artery are tied. The leg swells and is pulseless, the skin becomes cold and livid, and is raised up into blebs which contain sen>sanguineous fluid. The extremity swells enormously, there is pain at the seat of obstruction, and septic symptoms quickly develop. The bullae break and disclose the deeper structures, which are swollen and (Edem- atous. The fcetor is horrible. Portions of the extremity become emphysematous. A line of demarcation soon forms. Fig. 29.—Acute Mortification (Gross). Moist gangrene from inflammation is due to pressure of the exudate cutting off the blood-supply. It occurs in phlegmonous erysipelas. When an inflammation is about to terminate in gangrene, all the signs of inflammation, local and constitutional, increase; when gangrene occurs, they cease, bullae appear, emphysema is noted, with great swell- ing and all the other symptoms. Treatment of Moist Gangrene.—In moist gangrene of a limb we should wait for a line of demarcation and then amputate clear of and above it. Dress the dead parts anti- septically while waiting. Give opium, tonics, good food, and stimulants. In inflammatory gangrene relieve tension by incisions and then cut away the dead parts. Stimulate freely and feed well. Septic gangrene is divided into—(1) traumatic spreading gangrene ; (2) hospital gangrene; (3) phagedaena; (4) noma vulvae ; and (5) cancrum oris. MORTIFICATION OR GANGRENE. 115 Traumatic spreading gangrene results from a virulent infection of a severe wound. It is commonest after com- pound fractures, and begins within forty-eight hours after the accident. It does not begin at the periphery, as does ordinary traumatic moist gangrene, but at the wound-edges, which turn red, green, and finally black. The entire limb swells from oedema, the skin peels away, and emphysema , sets in. The gangrene spreads up and down from the wound, and in thirty-six hours may involve an entire limb. No line of demarcation forms. The system is soon over- whelmed with ptomaines, and the patient has septic intoxi- cation, or he passes into profound collapse with subnormal temperature. Treatment.—In treating traumatic spreading gangrene a line of demarcation need not be waited for, as none can form. Amputation should at once be performed high up and stimu- * lants must literally be poured into the patient. Hospital gangrene or sloughing phagedaena is a disease that has practically disappeared from civilized communities. It formerly occurred in crowded, ill-ventilated hospitals. Some consider it traumatic diphtheria. Koch thinks it is due to streptococci. Jonathan Hutchinson says, " Hospital gangrene is set up by admitting to the wards a case of syphilitic phagedaena." It may show itself as a diphtheritic condition of a wound, as a process in which form sloughs like masses of tow, or as a phagedenic ulceration. The surrounding parts are inflamed and painful, and buboes form in adjacent lymphatic glands. The system passes into a low septic state. Treatment.—In treating hospital gangrene ether should be given, the large sloughs removed with scissors and forceps, • the part dried with cotton and cauterized with bromine. Take a tumblerful of water and into it pour the bromine: this falls to the bottom; draw it up with a syringe and inject it into 116 A MANUAL OF SURGERY. the depths of the wound. Iodoform should be "shovelled " on and antiseptic poultices be used until the sloughs separate, when the sore is treated as an ordinary ulcer. If a limb is hopelessly damaged by this form of gangrene, we must wait for a line of demarcation and amputate. Special Forms of Gangrene.—Symmetrical or Raynaud's gangrene arises in severe cases of Raynaud's disease. It is a dry gangrene. Raynaud's disease, a vaso-motor neurosis seen in children and young adults, is characterized by attacks of cold, dead bloodlessness in the fingers or toes as a result of exposure to cold or of emotional excitement (local syn- cope). In the more severe cases we may have capillary congestion and livid swelling (local asphyxia). Chilblains belong in this group. The patient complains of pain, ting- ling, and stiffness. It is after local asphyxia that the gan- grene may appear. This gangrene is usually seen upon the ends of the fingers or the toes, but it may attack the lobes of the ears, the tip of the nose, or the skin of the arms or the legs. When gan- grene is about to occur, the local asphyxia at that point deepens, anaesthesia is complete, and the part blackens and becomes cold. The epidermis is now raised up into blebs, which rupture and expose dry surfaces. A line of demarca- tion forms, and the necrosed area is removed as a slough. Widespread gangrene from Raynaud's disease is rare; there is not often involved a large area—only a small superficial portion. Sometimes the disease is seen upon the trunk. These attacks recur again and again, are often accompanied by haemoglobinuria (Osier), and are sometimes excited by cold or by mental disturbance. The pathology is uncertain. Local syncope is thought to be due to vascular spasm, and local asphyxia to some contraction of the arterioles with dilatation of the capillaries and venules. Treatment of Raynaud's Disease.—When attacks of Ray- MORTIFICATION OR GANGRENE. WJ naud's disease are so severe as to threaten gangrene, the patient should be put to bed; if the feet are affected, elevate the legs, wrap the extremity in cotton-wool, and apply heat. If the hands are affected, they should be elevated, wrapped up, and the arm and hand be warmed. Massage is useful. When gangrene occurs, dress the part antiseptically until a line of demarcation forms, and then dispose of the dead parts by scissors, forceps, and antiseptic poultices. If amputation becomes necessary, which will rarely be the case, wait for a line of demarcation. Diabetic gangrene resembles in many points senile gan- grene, but the dead portions remain somewhat moist and putrefy. Diabetic gangrene is most usually met with upon the feet and legs, but it may attack the genital organs, thigh, lung, buttock, eye, back, finger, or neck (Hunt). It may begin in a perforating ulcer, or, as in senile gangrene, a trivial injury is apt to be the exciting cause. It spreads slowly, but more rapidly than senile gangrene. There is little tendency to the formation of any line of demarcation. Surgeons have become shy of amputating in such cases, but the experience of Kuster of Berlin proves conclusively that an amputation should be performed at once in diabetic gangrene, and should be done above the knee. If we operate below the knee, the flaps will become gangrenous. It has been noted that sugar will sometimes disappear from the urine after an amputation. Of eleven amputations by Kuster, six recovered and five died; and of these five, three had albumin in the urine as well as sugar.1 Gangrene from ergotism is a peripheral dry gangrene arising from tonic vascular contraction produced by the ergot in bread made from diseased rye. The gangrene is preceded by anaesthesia, muscular cramp, tingling pains, itching, and 1 See the convincing article of Chas. A. Powers in Amer. Journal of Med. Sciences, nth Nov., 1S92. n8 A MANUAL OF SURGERY. " gradual blood-stasis in certain vascular areas" (Osier). This form of gangrene occurs in epidemics where rye-bread is largely used, but is very rare in the United States. It usually affects the fingers or toes, but may involve an entire limb. In acute cases death occurs in from seven to ten days.1 In chronic cases await a line of demarcation and then amputate. Gangrene from Frost-bite.—When parts have been badly frozen, the peripheral parts dry up, being deprived of all blood because of contraction of the vessels. When a patient so afflicted is brought into a warm atmosphere, blood cannot run into the dead part, and the living tissues in contact with it inflame, forming a line of demarcation. Hence we note that severe frost-bite causes dry gangrene. If a part which is not so badly frozen is brought suddenly into a warm atmosphere, inflammation takes place when the blood runs into the deadened tissues, and moist gangrene results. A * frost-bite in which the skin is livid and not as yet gangrenous should be treated by frictions with snow or towels soaked in iced water. As the skin becomes warmer and congestion disappears the part should be wrapped up in cotton-wool. A sufferer from frost-bite should not suddenly be brought into a warm room. When the parts are dead or when gangrene follows, if only small areas be involved, allow the dead part to come away spontaneously, wrapping it up in the mean while with antiseptics; if removal be delayed by cartilage, ligament, or bone, cut through the retaining structure. If amputation is necessary, await a line of demarcation, as we are not sure how high tissue-damage extends, and to amputate through devitalized parts would mean renewed gangrene. Noma, or cancrum oris, is a gangrene beginning as a ** sloughing ulcer on the gums or cheeks, and affecting young 1 Pick, in Heath's Surgical Dictionary. MORTIFICATION OR GANGRENE. II9 children who live amid filth and squalor or who are conva- lescing from acute fevers. This disease may destroy large portions of the cheeks and jaws. The constitutional symp- toms are diarrhoea, fever, and great exhaustion. Death is the usual result, due frequently to septic broncho-pneumonia (Bowlby). Lingard has found a bacillus which he believes is causative of noma. The treatment of noma consists in destruction of the dis- eased tissue by nitric acid or the cautery, the use, locally and often, of peroxide of hydrogen and antiseptic washes, and, internally, the employment of good food, stimulants, and tonics. Sloughing is a process of ulceration by which visible por- tions of dead tissue are separated. These visible portions are called "sloughs;" if they were large they would be called " gangrenous masses." A large slough is a gangre- nous mass; a small gangrenous mass is a slough; there is no difference in the process, which corresponds to the forma- tion of a line of demarcation. Sloughing requires thorough cleansing, removal of the sloughs, and antiseptic treatment. Phagedaena is a process (most common in a venereal sore) in which the surrounding tissues are rapidly eaten up, the sore becoming jagged and irregular, with a sloughy base and thin edges ; the discharge is thin and reddish, and the encircling tissues are deeply congested. This ulcer has no tendency to heal. It is due to a specific poison which is not yet isolated. Noma vulvce is a form of phagedaena which attacks the genitals of little girls who are unhealthy, dirty, or convalescent from a specific fever. The treatment of phagedena consists in repeated touching with tincture of chloride of iron and the local use of iodo- form, the employment of continued irrigation, or the appli- cation of the cautery, chemical or actual. Whatever else is done, tonics, stimulants, and nutritious diet must be given. 120 A MANUAL OF SURGERY. Decubital Gangrene or Bed-sore; Decubitus.—A bed- sore is the result of local failure of nutrition in a person whose tissues are in a state of low vitality from disease or from injury. Such sores are due to pressure, aided by the presence of urine, of faeces, and of sweat, to wrinkling of the sheets, or to the dropping of foreign bodies (such as crumbs) in the bed. These ordinary pressure-sores arise like splint-sores due to the pressure of a splint upon the tissues over a bony prominence. They occur over the heels, elbows, scapulae, trochanters, sacrum, and nuchae. The pressure interferes with the blood-supply, the weakened tissues inflame, vesica- tion occurs, sloughs form, and an ugly ulcer is exposed. The acute bed-sore of Charcot is seen during certain dis- eases and after some injuries of the nervous system. These sores are usual over the sacrum in acute myelitis, and may appear in four or five days after the beginning of a disease or the infliction of an injury. The surgeon sees acute bed- sores upon the buttock of the paralyzed side after brain- injuries, and over the sacrum in spinal injuries. Some believe these sores are due to vaso-motor disorder, but others, notably Charcot, attribute them to disturbance of the trophic nerves or centres. Treatment of Bed-sores.—The " ounce of prevention " is here invaluable. From time to time, if possible, alter the position of the patient, keep him clean, maintain the blood- distribution of the skin by frequent rubbing with alcohol and a towel, and keep the sheet clean and smooth. When congestion appears (paratrimma, or beginning sore), at once use an air-cushion or a water-bed and redouble the care to frequently change the position of the patient. Not only protect, but also harden, the skin. Wash the part twice daily and apply spirits of camphor or glycerole of tannin; or rub with salt and whiskey (jij to Oj); or apply a mixture of gss of powdered alum, fgij of tincture of camphor, and MORTIFICATION OR GANGRENE. 121 the whites of four eggs; or paint with corrosive sublimate and alcohol (gr. ij to 3j); or apply tannate of lead or equal parts of oil of copaiba and castor oil; or paint on a protective coat of flexible collodion. When the skin seems on the verge of breaking, paint it with a solution of nitrate of silver (gr. xx to gj). When the skin breaks, a good plan of treatment is to touch once r a day with silver solution (gr. x to the ounce) and cover with zinc-ichthyol gelatin. We can wash the sores daily with I : 2000 corrosive-sublimate solution, dust with iodoform, and cover with soap plaster, with lint spread with zinc ointment, or with dry aseptic gauze. When sloughs form, cut most of them off with scissors after cleaning the parts. Slit up sinuses. Use antiseptic poultices. In sloughing Dupuytren employs pieces of lint wet with lime-juice and dusted with cinchona and charcoal. In obstinate cases use the continu- • ous hot bath or the intermittent ice poultice. When the sloughs separate, dress antiseptically or with equal parts of resin cerate and balsam of Peru. If healing is slow, touch occasionally with silver solution (gr. x to gj). Bed-sores, being expressive of lowered vitality, demand that the patient shall be stimulated, shall be well nourished, and shall have good sleep. Rules when to Amputate for Gangrene.—In dry gan- grene, due to embolus in a healthy artery, wait for a line of demarcation. In senile gangrene, if it affect only one or two toes, let the dead parts be cast off spontaneously. If a greater area is involved or the process spreads, amputate above the knee without waiting for the line. In ordinary moist gan- grene wait for a line of demarcation. In traumatic spreading gangrene amputate at once. In hospital gangrene and in m Raynaud's gangrene wait for a line of demarcation. In diabetic gangrene amputate at once, high up. In ergot gan- grene and in frost gangrene wait for a line of demarcation. 122 A MANUAL OF SURGERY. VIII. THROMBOSIS AND EMBOLISM. Thrombosis is the coagulation of blood in a vessel, which blood-clot remains at its point of origin and plugs up the vessel partially or completely. This process is an essential part in the arrest of hemorrhage; it occurs in phlebitis, and affords a frequent basis for embolism. We find thrombi in the veins, in arteries, and in the heart. Clotting is due to destruction of white blood-cells, a ferment being set free causing the union of the normal blood-albuminoids, fibrino- gen and fibrinoplastin. Figure 3 (PI. 2) shows a thrombosis. Causes of Thrombus.—Retarded circulation is a cause in consumption, influenza, and fevers, the blood clotting behind the vein-valves. The pressure of a bandage or of a splint or the presence of varicose veins may cause thrombosis. Liga- tion also causes it. It may be produced by injuries of a ves- sel ; by foreign bodies in a vessel; by atheroma in arteries; by sutures in a vessel; by certain diseases, such as gout, ty- phoid fever, pregnancy, and septic processes; by phlebitis or arteritis arising in the vessel or from extension of sur- rounding inflammation; and by entrance of specific organisms. It has been asserted that so long as the endothelium of a vessel is uninjured a clot does not form. Slowing of the blood-current in aseptic conditions, it is now taught, will not cause thrombosis. When moving blood coagulates, the third corpuscles first settle out, and then the leucocytes. This is known as the white or " ante-mortem " thrombus—the clot of moving blood. Thrombi from moving blood are rarely pure white : they contain some red corpuscles, forming mixed thrombi. The red thrombus plugs vessels which are cut across or ligated; it occurs in septic processes, and takes place after death. A thrombus may be absorbed, first embry- onic tissue and then fibrous tissue replacing it (organization). A thrombus may degenerate and break down (fatty degen- THROMBOSIS AND EMBOLISM. 123 eration), giving rise to emboli. A thrombus may undergo purulent liquefaction, infective emboli being set free. Symptoms.—The symptoms are dependent on the seat of the obstruction. An organ or a part of an organ may exhibit functional aberration. The local signs in a vessel accessible to touch or sight are the presence of a clot, and, if it be an artery, anaemia and the absence of pulse below it; r if it be a vein, swelling and oedema. There are usually pain and anaesthesia. Treatment.—If in a limb, raise the limb, keep it perfectly quiet to avoid detachment of fragments (emboli), apply a bandage and heat, and paint with iodine or rub with ichthyol. The great danger is the formation of emboli, so avoid move- ments and rough handling. Embolism signifies vascular plugging by a foreign body (usually a blood-clot) which has been brought from a dis- * tance. Emboli may arise either in the venous or in the arterial system, but lodge in an artery or in the veins of the liver. The initial thrombus may form upon diseased heart- valves or in a vein. It may be composed of fat, micro- organisms, air, or a portion of a tumor. An embolus is arrested when it reaches a vessel whose diameter is less than its own. It is usually caught just above a bifurcation. When an embolus lodges, it at once partially or entirely obstructs ( the circulation, and increases in size by thrombosis. A non- septic embolus usually organizes. A soft embolus may dis- integrate and permit of re-establishment of the circulation. An embolus may cause an aneurysm. A septic embolus breaks down, forms a metastatic abscess, and sends other emboli onward. Figure 2 (PI. 2) shows an impacted embolus. An embolus is more serious than a thrombus: it causes f sudden plugging which makes serious anaemia inevitable, and it may produce gangrene if the collateral circulation fails. In organs with terminal arteries (spleen, kidney, brain, 124 A MANUAL OF SURGERY. t and lung) there is no collateral circulation if embolism causes infarction. The embolus produces an area of anaemia; the removal of all propulsion upon the venous blood causes it to flow back and stagnate, and vascular elements exude, forming a wedge-shaped area of red tissue, the embolus being the apex of the wedge. This is known as the " red infarction," and is often seen in the lung. The white infarc- tion seen in the brain and kidney is not due to retrogression * of venous blood, but is due to anaemia and resulting coagu- lation necrosis. Symptoms.—The symptoms depend upon the organ in- volved. They are sudden in onset, and consist of loss of function which is permanent or is followed by inflammation or softening. Embolism of the cerebral arteries may cause aphasia, paralysis, or coma. Embolism of the pulmonary artery may cause almost instant death. Embolism of the central artery of the retina causes blindness. Embolism of r a large artery of a limb produces symptoms identical with thrombus, except more sudden and decided. Treatment.—The treatment depends upon the part involved. In a limb, rest, elevate, and keep it warm in order to stimu- late the collateral circulation. If gangrene ensues, await a line of demarcation and amputate. After an operation upon veins (as in varicocele), after a cutting operation, and after fracture, avoid as much as possible movements or handling, as fragments of thrombus may be detached. Fat-embolism is an accumulation in the capillaries of liquid fat, arising after injuries of adipose tissue, when we have high tension to force the fat into the open mouths of veins. Some fat may get into the blood by means of the lymphatics. Fat-embolism occurs in osteo-n^/elitis, after extensive bruises, crushes, or lacerations, and after amputa- » tions, fractures, resections, or rupture of the liver.1 This 1 G. H. Makins, in Heath's Dictionary. r SEPTICEMIA AND PYEMIA. 125 fluid fat accumulates especially in the capillaries of the lung and brain. Symptoms.—The symptoms are those of oedema of the lungs and exhaustion, often with coma or delirium. There are restlessness, dyspnoea, rapid pulse and respiration. If life is prolonged a day or two, oil is found in the urine. These symptoms never occur until at least twenty-four hours r after the accident, and rarely before the third day. The symptoms occur at a later period than those of shock, and at an earlier period than those of ordinary embolism of the lung. Severe cases are commonly fatal; milder cases are often recovered from. Treatment.—The treatment consists of the ordinary meth- ods used in shock—stimulants, heat, etc., with dry cupping of the chest, diuretics, strychnine, and, it may be, artificial respiration. See that drainage of the wound, if an external * wound exists, is good, and thoroughly immobilize the dam- aged part. IX. SEPTICAEMIA AND PYAEMIA. Septicaemia, or sepsis, is a febrile malady due to the intro- duction into the blood of septic organisms or their products. There is no one special causative organism, and any microbe which produces inflammatory and febrile products can cause it. Either streptococci or staphylococci are present. It arises by absorption of septic matter. Clinically we make two forms of septicaemia: (1) sapraemia, septic or putrid intoxication; and (2) septic infection, true or progressive septicaemia. Sapraemia, or septic intoxication, is due to the absorption of poisonous ptomaines from a putrefying area. The bacteria * do not enter the blood, but their toxines do, and, as these toxines are alkaloids, the condition is comparable to poison- ing by successive alkaloidal injections, the symptoms and 126 A MANUAL OF SURGERY. t prognosis depending upon the dose. Slight symptoms and recovery follow a small dose; grave symptoms and death follow a large one. The poison does not multiply in the blood, and a drop of the blood of a person laboring under putrid intoxication will not produce the disease when intro- duced into the blood of a well person; in other words, the disease is not infective. Sapraemia results from the absorp- tion of putrid matter from considerable areas which are under • high pressure. It may follow labor where putrid fluid is retained in the womb, or follow amputation where pus is pent up within the flaps. In this condition there always exist a considerable absorbing surface and a large amount of dead matter which has become putrid. Symptoms.—In twenty-four hours or more after the deliv- ery of a baby, after an injury, or after an operation there is a severe chill followed by high temperature, gastric dis- turbance, dry tongue, weak rapid pulse, great prostration, muscular twitching, restlessness, headache, often delirium, diarrhoea, drying up of wound-discharge, diminution or sup- pression of urine, and a strong tendency to congestion of vari- ous organs. Great elevation of temperature precedes death. Treatment.—The treatment is to at once drain and asep- ticize the putrid area and give enormous doses of alcohol. Strychnine and digitalis are useful. Establish the action of the skin and kidneys ; allay vomiting by champagne, cracked ice, calomel, cocaine, or carbolic acid with bismuth. Give food every three hours. Feed on milk, milk and lime-water, liquid beef-peptonoids, and other concentrated foods. Use quinine in stimulant doses. Antipyretics are useless. Watch out for any visceral congestion, and treat it at once. Septic infection, or true septicaemia, is a true infective process. Intoxication exists, due in part to toxines introduced f from the infected area, and also to toxines evolved by bac- teria which have been taken into the blood. In sapraemia ,, SEPTICEMIA AND PYEMIA. \2, the blood contains toxines, but not organisms. In septic infection the blood contains both toxines and organisms, the bacteria multiplying in it. The symptoms of sapraemia de- pend on the dose. In septic infection only a small number of organisms may get into the blood, but they multiply enormously. The pus microbes cause true septicaemia, and reach the blood chiefly through the lymphatics, but to some r degree by penetrating the walls of vessels. A drop of blood from a man with septic infection will reproduce the disease when injected into the blood of an animal; hence it is a true infective disease. The wound in such cases is often small. Symptoms.—The type of this condition is met with in puerperal septicaemia or a poisoned wound. It begins, in from four to seven days after labor or an injury, with a chill, which is followed by fever, at first moderate, but soon be- coming high. The fever presents morning remissions and evening exacerbations, and may occasionally show an inter- mission. The pulse is small, weak, very frequent, and com- pressible. The tongue is dry and brown with a red tip. The vomiting is frequent, and diarrhoea is the rule. Delirium alternates with stupor, and coma is usual before death. Prostration is very great. Toward the end the face often becomes Hippocratic (p. 79). Congestions occur. Ecchymo- ses and petechiae are noted, secretions dry up, urinary secre- tion is scanty or is suppressed, and the wound becomes dry and brown. Blood-examination detects disintegration of red globules. When a wound inaugurates septicaemia, red lines of lymphangitis are seen about it and there is enlargement of related lymphatic glands. No thrombi or emboli exist in septicaemia. The prognosis is bad, and death may occur within twenty-four hours. The treatment is the same as for <■ septic intoxication. Pyaemia.—Pyaemia, which is septicaemia plus metastatic abscesses, is characterized by fever of an intermittent type 128 A MANUAL OF SURGERY. and by recurring chills. It is not due to pus in the blood, but to the taking up of clots infected by streptococci and staphylococci. In an area of suppuration there are coagulation necrosis, thrombosis, and septic inflammation of the adjacent vessels, and the thrombi are infected. A vessel-thrombus reaches up to the first collateral branch, and the apex of the purulent clot is broken off by the blood-stream from that branch and is carried as an embolus into the circulation. Many of these poisonous emboli enter into the blood and lodge in some vessels which are too small to transmit them, and at their points of lodgment form embolic, secondary, or metastatic abscesses. Wounds of the superficial parts and bones pro- duce pyaemic infarctions or metastatic abscesses of the lungs. When these infarctions break into fragments particles may return to the heart and lodge there, or may be sent out through the arterial system to form another focus in the kidneys. Infected areas connected with the portal circula- tion (intestinal injuries or suppurating piles) produce abscess of the liver. Malignant endocarditis is called " arterial pyaemia," and is due to endocardial embolic infection. In this disorder infected emboli lodge in the kidneys, the spleen, the alimentary tract, the brain, or the skin (Osier). Idio- pathic pyaemia is a misnomer. Some primary focus of in- fection must exist (often in the ear). Symptoms.—The wound becomes dry, brown, and offen- sive. A severe and prolonged chill or a succession of chills usher in the disease; high fever follows, and a drenching sweat. These chills recur every other day, every day, or oftener. After the sweat the temperature falls and may become nearly normal. The general symptoms of vomiting, wasting, etc. resemble those of septicaemia. The skin be- comes jaundiced, and a profound adynamic state is rapidly established. The spleen is enlarged. The lodgment of em- f ER YSIPELAS. 129 boli produces symptoms whose nature depends upon the organ involved. Lodgment in the lungs causes shortness of breath and cough with slight physical signs. Lodgment in the pleura or pericardium gives pronounced physical evidence. Lodgment in the spleen produces severe pain and great enlargement. The parotid gland not unusually suppurates (as in the case of President Garfield). 9 In a suspected case of pyaemia always look for a wound, and if this does not exist, remember that the infection can arise from gonorrhoea, osteo-myelitis, suppuration of the middle ear, or abscess of the prostate. Chronic pyaemia may last for months; acute pyaemia may prove fatal in three days. The complications are joint-suppuration, broncho- pneumonia, pleuritis, endocarditis, pericarditis, peritonitis, venous thrombosis, and abscesses. Treatment is the same as for septicaemia. Open, drain, and • asepticize any wound and any accessible secondary abscess. X. ERYSIPELAS (ST. ANTHONY'S FIRE). Erysipelas is an acute, contagious, capillary lymphangitis due to the streptococcus of erysipelas, which grows and multiplies in the smaller lymph-channels of the skin and of serous and mucous membranes. It is characterized by a remittent fever and a tendency to recur. It is always due * to a wound. Idiopathic erysipelas is due to a small wound which escapes notice. It may or may not suppurate. Sup- puration, some say, does not require a mixed infection, as the streptococcus is identical with the streptococcus pyogenes (Osier, Koch); others think suppuration does require mixed infection, the streptococcus not being pyogenic. Erysipelas r is most common in the spring and fall, and is most usually met with among those who are crowded into dark, dirty, and ill-ventilated quarters; it attacks by preference the debil- 9 130 A MANUAL OF SURGERY. itated and broken-down (as alcoholics and sufferers from Bright's disease). The poison of erysipelas will produce puerperal fever in a lying-in woman. Forms of Erysipelas.—Ambulant, erratic, migratory, or ivandering erysipelas is a form which tends to spread widely over the body, leaving one part and going to another. Bullous erysipelas is attended by the formation of bullae. In diffused erysipelas the borders of the inflammation grad- ually merge into healthy skin. Erythematous erysipelas involves the skin superficially. Metastatic erysipelas appears in various parts of the body. Puerperal erysipelas begins in the genitals of lying-in women, producing puerperal fever. Erysipelas simplex is ordinarily cutaneous. Erysip- elas neonatorum begins in the unhealed navel of a new-born child and spreads from this point. Typhoid erysipelas occurs with profound adynamia. Universal erysipelas in- volves the entire body. Phlegmonous erysipelas involves the ' skin and subcutaneous tissues, with suppuration, and often with gangrene. (Edematous erysipelas is a variety of phleg- monous erysipelas with enormous subcutaneous oedema. Lymphatic erysipelas is characterized by rose-red lines of lymphangitis. Venous erysipelas is marked by the dark color of venous congestion. Mucous erysipelas involves a mucous membrane. Black tongue is erysipelas of the fauces. Clinical Forms.—The clinical forms are cutaneous ery- sipelas, cellulo-cutaneous or phlegmonous, and cellulitis. Cutaneous erysipelas is ushered in by a chill which is followed by fever and sweat. Any wound which exists becomes dry and unhealthy, and its edges redden and swell. This combination of redness and swelling extends, and its area is sharply defined from the healthy skin. In the hyper- aemic area vesicles or bullae form, and oedema affects the < subcutaneous tissues, producing great swelling in regions where they are lax (as in the eyelids). The anatomically r ER YSIPELAS. 131 related lymphatic glands become large and tender, and between them and a wound are seen the red lines of inflamed lymphatic vessels. Erysipelas spreads at its periphery and fades at its point of origin. When spreading stops the swell- ing and redness gradually abate, and after they disappear desquamation takes place. Cutaneous erysipelas rarely sup- purates, but may do so. The fever is remittent, and usually • terminates in four or five days by crisis. In strong subjects the symptoms are usually slight. In the old, debilitated, or alcoholic the symptoms are typhoid, delirium comes on, and death is apt to occur. Possible compli- cations are meningitis, pneumonia, septicaemia, endocarditis, and albuminuria. Erysipelas neonatorum is generally fatal. Treatment.—Isolate the patient and asepticize any wound. Cases of cutaneous erysipelas tend to get well without treatment. If a person is debilitated, stimulate freely. Tinc- ' ture of chloride of iron and quinine are usually administered. Nutritious food is important. For sleeplessness or delirium use chloral or the bromides; for high temperature, cold sponging and antipyretics. To prevent spreading, inject the healthy skin near the blush with a 2 per cent, carbolic solu- tion or with gr. y1^ of corrosive sublimate. Locally, paint the inflamed area with equal parts of iodine and alcohol and apply lead-water and laudanum. If an extremity be involved, bandage it. Another good treatment is a 50 per cent, ichthyol ointment with lanolin. Some use iced-water cloths. Others apply borated talc or salicylated starch. Ringer advised painting every three hours with a mixture composed of gr. xxx of tannic acid, gr. xxx of camphor, and 3iv of ether. Da Costa recommends pilocarpine. Cellulo-cutaneous or phlegmonous erysipelas is char- • acterized by high temperature (i04°-io6°), the rapid onset of grave prostration, irregular chills, sweats, and a strong tendency to delirium. The parts are not so red as in the pre- 132 A MANUAL OF SURGERY. vious form, but the tumefaction is vastly greater; it is branny, comes on early and with exceeding rapidity, inducing a high degree of tension and frequently producing sloughing or even cutaneous gangrene. The lymphatic glands are swol- len, but the inflamed vessels are hidden by the swelling. In most cases suppuration occurs, and when this happens the parts become boggy. When the disease abates sloughs form, which leave ulcers upon being thrown off. In bad cases muscles, vessels, tendons, and fascia may slough away The commonest complications are suppression of urine, broncho-pneumonia, congestion and oedema of the lungs, meningitis, and acute pleurisy. Treatment.—At once asepticize and drain any existing wound; apply iodine and blue ointment or ichthyol or lead- water and laudanum to the inflamed area, and if a limb is involved use a roller-bandage and a sling. Open the bowels with calomel and salines ; order quinine, iron, stimulants, and nourishing diet. If suppuration occurs, make many incisions near together, each cut being 2 or 3 inches long. Spray out by means of hydrogen peroxide in an atomizer, and then wash with corrosive-sublimate solution (1 : 1000). Drain by means of iodoform gauze in strips. Excise spots of gan- grene. Dress with many layers of wet gauze, which is to be enveloped in a rubber dam after application, or with dry gauze and iodoform. If sloughs form, cut them partly away and employ antiseptic poultices. Apply a bandage to an extremity which is attacked by this form of erysipelas. Change dressings often. When granulations begin to form, treat as a healing wound. Cellulitis.—In cellulitis redness of the skin is not very pronounced and is late in appearing, following swelling, and not preceding it. It is essentially the same condition as phlegmonous erysipelas. It is often mild in degree. Its spread is heralded by red lines of lymphangitis, swelling of TETANUS, OR LOCKJAW. 133 glands, and fever. In slight cases the lymphatics may dis- pose of the poison and suppuration fail to occur. Treatment.—The treatment is the same as that for phleg- monous erysipelas. XI. TETANUS, OR LOCKJAW. Tetanus is an infectious spasmodic disease invariably preceded by some injury. The wound may have been so slight as to have attracted no attention, or it may have been inflicted upon the alimentary canal by a fish-bone or other foreign body. Idiopathic tetanus is either not tetanus at all or is a term expressive of the fact that we have not found an injury which did exist. This disease is commonest after punctured or lacerated wounds of the hands or feet, and be- fore it appears a wound is apt to suppurate or slough ; but in some instances the wound is found soundly healed. Tetanus may appear twenty-four hours after an accident, but it may not arise until several weeks have elapsed. It prevails more in certain localities than in others. Colored people are very susceptible, and it may exist epidemically. • Tetanus is due to infection by a bacillus (first described by Nicolaier) whose toxic products, absorbed from the infected area, poison the ner- vous system precisely as would dosing with strychnine. This bacillus is found particularly in garden-soil, in the dust of walls, walks, and cellars, in street-dirt, and in the refuse of stables. Symptoms.—Acute tetanus usually begins within nine days of an accident. First the neck feels stiff, the patient think- ing he has taken cold, and next the jaws also become stiff. The neck becomes like an iron bar, and the jaws become as rigid as steel. The muscles of deglutition become rigid on attempts at swallowing. The muscles of the back, legs, and abdomen are thrown into tonic spasm, but the arms rarely suffer. Spasm of the face-muscles causes the risus 134 A MANUAL OF SURGERY. sardonicus, or sardonic smile (contraction particularly of the musculus sardonicus of Santorini). The contraction of the muscles of the back is often so powerful as to bend the patient back like a bow and allow him to rest only on his occiput and heels. This condition is known as " opisthot- onos." If he is bent forward so that the face is drawn to the legs, it is called " emprosthotonos." If his body is curved sideways, it is designated "pleurosthotonos." An upright position is " orthotonos." The state is one of widely-diffused tonic spasm, aggravated frequently by clonic spasms arising from peripheral irrita- tions. These irritations may be draughts, sounds, lights, shaking of the bed, attempts at swallowing, contact of the bed-clothing, the presence of urine in the bladder or of feces in the rectum, or various visceral actions. The agonizing " girdle-pain " so often met with means spasm of the dia- phragm. Each clonic spasm causes a hideous scream by the contraction of the chest forcing air through a contracted glottis. Constipation is persistent; retention of urine is the rule. The mind is entirely clear—one of the worst ele- ments of the disease. Swallowing is absolutely impossible. The temperature may be normal, but it is usually a little elevated. Hyperpyrexia sometimes occurs (io8°-i io°), and the temperature may even ascend for a time after death. Sleep is impossible. Death almost invariably occurs in acute tetanus in two or three days. It may be due to exhaustion or to carbonic-acid narcosis from spasm of the glottis or fixation of the respiratory muscles. Chronic tetanus comes on late after a wound (from ten days to several weeks). The symptoms are not so severe ■ the muscular spasm is widespread, but it may not be per- sistent, intervals of relaxation permitting sleep and the taking of food. It may last some weeks, and not infrequently the disease can be cured. Trismus is a mild form of tetanus TETANUS, OR LOCKJAW. !35 the contractions being limited to the face and jaw. Trismus neonatorum or trismus nascentium, which is lockjaw in the new-born, is due to infection of the stump of the umbilical cord, and is invariably fatal. Diagnosis.—Tetanus may be confounded with strychnine- poisoning or with hysteria. Wood's table makes the diagno- sis clear.1 Tetanus. Muscular symptoms usually commence with pain and stiffness in the back of the neck, sometimes with slight muscular twitch. ings ; come on gradu- ally. Jaw one of the earliest parts affected; rigidly and persistent- ly set. Persistent muscular rigidity very generally, with a greater or less degree of permanent opisthotonos, empros- thotonos, pleurosthot- onos, or orthotonos. Consciousness pre- served until near death,as in strychnine- poisoning. Hysterical Tetanus. Commences with blindness and weakness. Muscular symptoms commence with rigidity of the neck which creeps over the body, affecting the extremities last. Jaws rigidly set before a con- vulsion, and remain so between the paroxysms. Persistent opisthoto- nos and intense rigidity between the convulsions and after the convulsions have ceased, the opis- thotonos and intense rig- idity lasting for hours. Consciousness lost as the second convulsion comes on, and lost with every other convulsion, the disturbance of con- sciousness and motility being simultaneous. Strychnine-poisoning. Begins with exhilaration and restlessness, the special senses being usually much sharpened. Dimness of vision may in some cases be manifested later, after the development of other symp- toms, but even then it is rare. Muscular symptoms develop very rapidly, commencing in the extremities, or the convulsion when the dose is large seizes the whole body simultaneously. Jaw the last part of the body to be affected; its muscles re- lax first, and even when, during a severe convulsion, it is set, it drops as soon as the latter ceases. Muscular relaxation (rarely a slight rigidity) between the con- vulsions, the patient being ex- hausted and sweating. If re- covery occurs, the convulsions gradually cease, leaving merely muscular soreness, and some- times stiffness like that felt after violent exercise. Consciousness always pre- served during convulsions, ex- cept when the latter become so intense that death is imminent from suffocation, in which case sometimes the patient becomes insensible from asphyxia, which comes on during the latter part of a convulsion and is almost a certain precursor of death. lNe •rvous Diseases, by Prof. H. C. Wood. 136 A MANUAL OF SURGERY. Tetanus. Hysterical Tetanus. Strychnine-poisoning. Draughts, loud noises, etc. produce convulsions, as in strychnine-poisoning; may complain bitterly of pain. Eyes open and rig-idly fixed during the convulsion. Crying-spells alternat-ing with convulsions. Eyes closed. Partial spasm in the leg, producing in Wood's cases crossing of the feet and inversion of the toes. If all the muscles were involved eversion would occur, as the muscles of eversion are the stronger. The "slightest breath of air" produces convulsion. Patient may scream with pain or may express great apprehensions, but " crying-spells " would appear to be impossible. Eyes stretched wide open. Legs stiffly extended with feet everted, as the spasms affect all the muscles of the leg. Treatment.—Far better than even to treat tetanus well is to prevent it. Careful antisepsis will banish it as thoroughly as it has banished septicaemia. Every wound must be dis- infected with the most scrupulous care. Every punctured wound is to be incised to its depth and thoroughly cleaned and drained. Puerperal tetanus is prevented by antiseptic midwifery, and tetanus neonatorum is obviated by the anti- septic treatment of the stump of the cord. When tetanus exists, always look for a wound, and if one is found, open it, cut away sloughs, wash with peroxide of hydrogen and cor- rosive sublimate, swab it out with bromine, and secure drain- age by packing it with iodoform gauze. Isolate the patient, as the disease is infective; keep him in a darkened, well-ventilated, and quiet apartment, so as to exclude as far as possible peripheral irritation. Watch out for retention of urine, and use the catheter if it occurs. Secure movements of the bowels by salines, castor oil, croton oil, or enemas. Give plenty of concentrated liquid food, and stimulate freely with alcohol. If swallowing causes convul- sions, give an inhalation of nitrite of amyl before an attempt is made to swallow. If this treatment fails, partially anaes- TUBERCULOSIS AND SCROFULA. 137 thetize the patient and feed him through a pharyngeal tube passed through the nose. Large doses of the bromide of potassium or of this drug with chloral give the best results. Other drugs that have been used with some success are gelsemium, morphia, curare, injections and fomentations of tobacco, physostigma, anaesthetics, cocaine, and cannabis indica. An ice-bag to the spine somewhat relieves the girdle-pain. Hot baths have been advised. Yandell says, in summing up Cowling's report on tetanus :' " Recoveries from traumatic tetanus have been usually in cases in which the disease occurs subsequent to nine days after the injury. When the symptoms last fourteen days, recovery is the rule, apparently independent of treatment. The true test of a remedy is its influence on the history of the disease. Does it cure cases in which the disease has set in previous to the ninth day ? Does it fail in cases whose du- ration exceeds fourteen days ? No agent tried by these tests has yet established its claims as a true remedy for tetanus."2 It is now claimed by some observers that we have a rem- edy which fulfils the requirements of Yandell in the tetanus antitoxine of Tizzoni and Kitasato. To prepare this anti- toxine animals are rendered immune to tetanus by inocula- tions with mitigated cultivations of the microbe; the blood- serum is treated with alcohol and dried in a vacuum. This is used hypodermatically in doses of from 15 to 25 centi- grammes. Cures seem to have followed its use, and if it can be obtained it is our duty to try it in acute tetanus. XII. TUBERCULOSIS AND SCROFULA. Tuberculosis is an infective disease due to the deposition and multiplication of the bacilli of tubercle in the tissues 1 American Practitioner, Sept., 1870. 2 Quoted by Hammond in his Diseases of the Nervous System. 138 A MANUAL OF SURGERY. of the body. It is characterized either by the formation of tubercles or by a widespread infiltration, both of these con- ditions tending toward caseation, sclerosis, or ulceration. A tubercular lesion may undergo calcification. Bacillus of Tubercle.—A tubercle is an infective granu- loma, appearing to the unaided vision as a semi-transparent gray mass the size of a mustard-seed. The microscope shows that a gray tubercle consists of a number of cell-clusters, each cluster constituting a primitive tubercle. A typical primitive tubercle shows a centre consisting of one or of g^^S^sSiggs^afcawK!*. several polynucleated giant-cells sur- •&£&lgSg£^g&*0i8S^ rounded by a zone of epithelioid cells ^^SwSjS^J?®^* which are surrounded by an area of £^ffe|^$^& leucocytes. When the bacillus ob- ^^?^V«*£S8^Ah$ tains a lodgment the fixed connective- •/^■°'4 <^> q."<^*»"V6s^ tissue cells multiply by karyokinesis, p'^C''^^^S?^Jfell|^| forming a mass of n ucleated polygonal •J or round cells, called " epithelioid " from their resemblance to epithelial cells, and at the same time the blood- supply of the growth is limited by occlusion of surrounding vessels Fig. 30-SynoviaI Membrane, thrOUgh multiplication of their end0- showing giant-ceiu (Bowiby). thelial coats. Some of these epitheli- oid cells proliferate, and others attempt to, but fail for want of blood-supply. Those that fail succeed only in dividing their nuclei and enormously increasing their bulk (giant-cells). Giant-cells, which also form by a coalescence of epithelioid cells, are not always present. The presence of this mass of cells causes surrounding inflammation and the exudation of white blood-cells (Fig. 30). The bacillus, when found, exists in the epithelioid cells, and sometimes in the giant-cells; it may not be found, having once existed, but having been subsequently destroyed. It is often TUBERCULOSIS AND SCROFULA. 139 overlooked. In a lesion of active tubercle, even if the bacil- lus be not found, injection of the matter into a guinea-pig will produce lesions in which it can be demonstrated. A tubercle may caseate—a process that is destructive and dan- gerous to the organism. Caseation is due to a coagulation necrosis arising from direct microbic action upon a cellular area which contains no blood-vessels, and the nutrition is cut off by obliteration of surrounding vessels. This pro- cess starts at the centre, and the entire tubercle becomes converted into a soft yellowish-gray mass. Caseation forms cheesy masses which may soften into tuberculous pus, may calcify, and may become encapsuled by fibroid tissue. A tubercle may undergo sclerosis, which is an attempt on the part of Nature to heal and repair. Coagulation necrosis occurs in the centre of the tubercle; " hyaline transformation proceeds, together with a great increase in the fibroid ele- ments, so that the tubercle is converted into a firm, hard structure " (Osier). Infiltrated tubercle is due to the running together of many minute infective foci or to widespread infiltration without any foci. Infiltrated tubercle tends strongly to caseate. The bacillus of tubercle, discovered by Koch, is a little rod with a length equal to about half the diameter of a red blood-corpuscle. It can be stained by aniline, and this stain is not removable by acids (it being the only bacillus except leprosy which acts in this way.) In its growth the tubercle bacillus forms ptomaines, toxalbumins, and an antitoxine. These bacilli exist in all active lesions: the more active the process the greater is their number. They may be widely distributed, but are rarely identified in the blood. They exist in enormous numbers in phthisical sputum, but are not found in the breath of consumptives. Their great medium of distribution is dried sputum mixed with dust. They are 140 A MANUAL OF SURGERY. found in the milk of tuberculous cows, and sometimes in the meat of diseased animals. Infection may be due to hereditary transmission. Con- genital tuberculosis is occasionally, though rarely, seen. Tuberculosis is apt to appear in young children. Some think this is due to infection from without upon tissues whose resistance is lowered by hereditary predisposition; others think it is due to a tardy development of the germs * transmitted by heredity. That the disease may be present in a latent form is shown by the experiment in which the viscera of the foetus of a consumptive mother showed no tubercles, but produced the disease in guinea-pigs when inoculated.1 Tuberculosis may arise by inoculation, inocu- lation tuberculosis being seen in leather-workers and in those who dissect tuberculous bodies (butchers and doctors are liable to anatomical tubercle). Osier mentions as other causes of inoculation the bite of a tuberculous patient, the washing * of infected garments, and circumcision in which suction is employed. Infection through the air is very common. The bacteria of the dried sputum adhere to particles of dust and are carried into the lungs. Infection by meat, milk, and other foods may arise by this dust settling upon them in quantity. Commonly, however, it is due to disease of the animals. Milk is a common vehicle of contagion, and it can be in- fected even when an ulcerated udder does not exist. Infection is favored by hereditary predisposition—that is to say, by hereditary tissue-weakness, which, by maintaining a lowered momentum of nutritive processes, lessens the nor- mal resistance to infection. Two types of these predisposed persons are mentioned : (i) the sanguine type of scrofula, or those with oval faces, clear skin, large blue eyes, long lashes, a nervous manner, precocious minds, but little fat, and with *' long slender bones, these children being often graceful and 1 Quoted by Osier from Birch-Hirschfeld. , TUBERCULOSLS AND SCROFULA. 141 beautiful; and (2) those with stolid countenances, thick lips and noses, thick muddy skin, dark coarse hair, swollen necks, heavy bones, clumsy gait, and ungainly figure. The latter type is the phlegmatic form of scrofula. There is no doubt that an inflammatory area in a person can become infected when a sound area would escape, the process of phagocytosis being in this spot limited in power, • and the organisms, which are destroyed by healthy cell- activities, are victorious when those activities are diminished. Catarrhal inflammations of the air-passages favor phthisis, and traumatism is not unusually followed by a development of tubercle. Lowered health, impure air, and bad food all favor the development of tubercle. Any tuberculous pro- cess tends to spread locally and to produce inflammation. A tubercular area is always a danger to the system; from this as a focus dissemination may occur, tuberculous lesions • appearing in a distant part or general tuberculosis setting in. Tuberculous pus is not pus. True pus means a secondary infection (see Cold Abscess, p. 100). Scrofula is not a disease. It is a condition of tissues in which low resisting power makes them hospitable hosts to invading bacilli of tubercle. Some observers teach that scrofula is tuberculosis of bones, glands, and joints; others teach that it is latent tuberculosis until some cause lisrhts it o into activity; while still others say that it is a tendency rather than a disease. It is certain that some lesions of scrofula are not tuberculous (eczema capitis, facial eczema, corneal ulcers, granular lids, and chronic catarrhal inflam- mations), and that they result from ill-health, poor nutrition, bad air, and improper diet. A person who is recognized as of a scrofulous type may never develop tuberculous lesions. • It is unquestionable, however, that strumous subjects are peculiarly apt to develop true tuberculous lesions. These lesions often appear after a tissue or an organ has become 142 A MANUAL OF SURGERY. the seat of a primary non-tubercular inflammation; the bacilli, which could not live in the non-inflamed tissue, thrive in the inflamed tissue. Scrofula is generally of congenital origin, one or both parents being tuberculous, scrofulous, or in ill-health; it may, however, be acquired as a result of poor food, bad air, crowding, and general lack of sanitation. The scrofulous are very prone to develop tuberculous lesions of bones, joints, and lymphatic glands. Tuberculous Abscess.—For description of tuberculous abscess, see page 97. Tuberculosis of the Skin.—Lupus begins before the age of twenty-five, most usually upon the face, especially the nose. Three forms are recognized: (1) lupus vulgaris, in which nodules appear that after a time ulcerate and then cicatrize; (2) lupus exedens, in which ulceration is very great; and (3) lupus hypertrophicus, in which a very great amount of embryonic tissue is produced (large nodules or tubercles). Lupus may appear as a pimple, as a group of pimples, or as nodules of a larger size. The ulcer arises from desquamation, and is surrounded by inflammatory products which, by progressively breaking down, add to its size. The ulcer is often crusted over; it may be progress- ing at one point and healing at another; and it is slow in advancing, but often proves hideously destructive. The scars left by its healing are apt to break down. Clinically it is separated from a rodent ulcer by the absence of a hard base (W. Joseph Hearn). Anatomical tubercle, the verruca necrogenica of Wilks, is due to local inoculation with tuberculous matter. It is seen in surgeons, the makers of post-mortems, leather-workers, and butchers, usually upon the backs of the hands and fin- gers. It consists of a red mass of granulation tissue having the appearance of a group of inflamed warts. Pustules often form. Scrofulodermata or scrofulous gummata are chronic TUBERCULOSIS AND SCROFULA. 143 skin-inflammations from granulation tissue which breaks down to form small abscesses or sinuses. Tuberculosis of Subcutaneous Connective Tissue.—In this form of tuberculosis nodules of granulation tissue form and break down (tuberculous abscesses). In the deeper tis- sues these abscesses are usually associated with bone-, joint-, or lymphatic-gland disease. A large abscess is called " cold " (see Cold Abscess, p. ioo). Tuberculosis of the Alimentary Canal.—A tuberculous ulcer of the lip occasionally occurs, and is usually mistaken for a cancer or a chancre. A tuberculous ulcer of the tongue is commonly associated with other foci of disease. It is separated from cancer by the absence of glandular enlarge- ments, and from syphilitic processes by the therapeutic test. Confirmation of the diagnosis is obtained by cultivations and inoculations. Tubercle may affect the pharynx, palate, tonsils, and very rarely the stomach. Intestinal tuberculosis ordinarily follows pulmonary tu- bercle, but it may arise in the mucous membrane of the bowel or result from tuberculous peritonitis. Intestinal tuberculosis may cause diarrhoea and fever, may resemble appendicitis, and may cause abscess and perforation. Fistula in ano is very often tuberculous, and when it is the lungs are almost always involved, the pulmonary lesion being primary. Tuberculosis of the liver causes cold abscess and scir- rhosis. Tubercle may affect the kidneys, bladder, ureters, Fallopian tubes, prostate, urethra, seminal vesicles, ovaries, and uterus. Tuberculous testicle is not rare. Tuberculous orchitis affects one testicle at first, but the other usually becomes involved. It starts in the epididymis as a painless nodule. As the vaginal tunic and testicle become involved a hydrocele forms. The tuberculous mass softens, becomes adherent to the scrotum, and bursts. The cord is always more or less involved. 144 A MANUAL OF SURGERY. Peritoneal tuberculosis may be primary, may be part of a diffused process, or may follow intestinal tubercle. The germ may have entered by the Fallopian tube. It causes usually ascites, tympany, and tumor-like formations composed of adherent bunches of bowel or omentum or distended mesen- teric glands. Tubercles may attack the pleura or pericar- dium. Tuberculosis of the brain induces meningitis and hydro- cephalus. Tuberculous disease of the joints is called " white swell- ing " and pulpy degeneration of the synovial membrane. It may begin in the synovial membrane, but it usually starts in the head of a bone, dry caries resulting, necrosis ensuing, or an abscess forming which breaks into the joint. In the knee-joint the disease begins as a tuberculous synovitis, in the hip-joint as a tuberculous osteitis of the head of the bone. Tuberculosis of lymphatic glands is known as " tubercu- lous adenitis." It is the most typical lesion of scrofula. The common antecedent of a tuberculous adenitis of the neck is slight glandular enlargement as a result of catarrhal inflam- mation of the mucous membrane of the mouth. A man not of the scrofulous type can acquire tuberculosis of the glands, but adenitis is unquestionably of much greater frequency in the scrofulous. Tuberculous glands may get well and will often calcify. After healing they may break down and soften (residual abscess). They very frequently suppurate. Though at first a local disease, inflamed glands may be foci of infection, and may poison distant organs or the entire system. Glandular enlargement is in rare instances widely diffused, but it is far more commonly localized. Enlargement of the cervical glands is most common. Enlargement of the mesenteric glands causes tabes mesenterica. Cervical lymphadenitis may be confused with lymphade- noma. The former, as a rule, first appears in the sub- TUBERCULOSIS AND SCROFULA. 145 maxillary triangle, the latter in the occipital or inferior carotid triangles. Tuberculous glands weld together, they are apt to remain localized, and they tend to suppurate. They may be accompanied by other tuberculous manifestations. Lymphadenoma from the start affects many glands in several regions, shows no tendency to suppurate, and is accompanied by great debility and anaemia. Malignant gland-tumors infil- , trate adjacent glands and other structures, binding skin, muscles, and glands into one firm mass. Diagnosis.—The diagnosis may be determined by purely clinical facts. It may require the use of the microscope, cultivation experiments, or inoculations. In a suspected tuberculous lesion remove a portion of the tissue if it be accessible (by Mixter's canula) and make sections, stains, and cultivations. If no bacilli are found, inoculate a guinea-pig with the suspected material. If it be tubercular, the pig will ♦ have miliary tuberculosis in a few weeks. Prognosis.—The prognosis varies with age, sex, and the situation of the lesion. Prognosis is best in children, and is better in males than in females. Tuberculosis of the skin gives a fair prognosis. Tuberculous adenitis is often cured. Any tuberculous lesion is, however, a menace to the organ- ism, and tends strongly toward recurrence. Treatment.—Surgically, remove infected areas which are accessible. Never remove only part of a focus. Incomplete operations are apt to be followed by diffuse tuberculosis. Iodoform used locally upon or in tuberculous areas is of great value. Tuberculous glands before breaking down should be rubbed with ichthyol and lanolin or with mercurial ointment. When they break down they should be removed or opened, curetted, and packed. The rule must be to completely dis- • sect out lymphatic glands which fail to quickly respond to treatment. Climate is of very great importance. Osier sums up climatic necessities as " pure atmosphere, equable tem- 10 146 A MANUAL OF SURGERY. perature, and maximum amount of sunshine." Open-air life is imperative. The patient must have a well-ventilated sleep- ing-room, and his house should be free from dampness. Nourishing diet is essential. To gain in weight is a constant aim. Give meat, milk, and cod-liver oil, which can be admin- istered in capsules. The oil is poorly borne in hot weather, during which it should be discontinued. Advancing doses of creosote, arsenic, quinine, and stimulants have their uses. r Koch's Tuberculin.—The specific treatment by Koch's tuberculin or paratoloid has excited widespread interest. It has not fulfilled the expectations which many entertained, but does benefit some cases, notably lupus. The trouble with Koch's tuberculin is that it often causes fever and inflammation to a dangerous degree. In some cases, as Virchow showed, it produces acute miliary tuberculosis. Koch's lymph is a glycerin extract of a culture of tubercle bacilli, and the usual dose is 1 milligramme, given hypoder- * matically into the back by Koch's pistonless syringe. After it has been used for a time the dose may be increased to 10 milligrammes, or even much more. Bergmann gave 1 gram. Koch's lymph causes inflammation and necrosis of tubercu- lous tissue by the action of certain antitoxines. Many cases it improves. Some cases it apparently cures, but the disease is apt to return. In pulmonary tubercle it must not be given if there be much fever or extensive consolidation. Chevne •¥■■ used tuberculin by giving two or three doses a day and increasing the dose. It is best to associate other treatment with the lymph. Hunter of London declares that Koch's lymph contains one principle which causes fever, another which causes in- flammation, and a third which produces atrophy of tuber- culous foci without either fever or inflammation. This third *> desirable element he believes he has isolated in what is called a " derivative of tuberculin," a modified lymph. Some • RICKETS. H7 remarkable results have followed the use of this material; its administration seems entirely safe, and it should thoroughly and carefully be tried to ascertain its true rank as a remedy. XIII. RICKETS. Rickets is a constitutional disease arising during the early » years of life (the first two or three) as a result of insufficient or of improper diet and bad hygienic surroundings. A defi- ciency of fat and phosphate in the food or the use of a diet which, by inducing gastro-intestinal catarrh, prevents assimi- lation, causes rickets. The disease is never congenital, the so-called " congenital rickets" being sporadic cretinism (Bowlby). Figure 4 (PL 2) shows marasmic rickets. Evidences of Rickets.—The condition is one of general ill-health; the child is ill-nourished, pallid, flabby; it has • attacks of diarrhoea and a tumid belly; it is disinclined for exertion and has a capricious appetite; it is liable to night- sweats and night-terrors; enlarged glands are often noted, the teeth appear behind time, and the fontanelles close late. The long bones become much curved, the upper part of the chest sinks in, curvature of the spine appears, the head is large and the forehead bulges, and the pelvis is distorted. Swelling appears in the articular heads of long bones, beside the epiphyseal cartilages, and in the sternal end of the ribs, forming in the latter case rhachitic beads. The lesions of rickets are due to an imperfect ossification of the animal matter which is prepared for bone-formation, and conse- quently to softening of the bones which causes them to bend. The swellings at the articular heads are due to pres- sure forcing out the soft bone into rings. Rhachitic children > rarely grow to a full size, and the disease is responsible for many dwarfs. Most cases recover without deformity, but the time lost during the period when active development 148 A MANUAL OF SURGERY. should have gone on cannot be made up, and some slight deficiency is sure to remain. Treatment.—The treatment consists in open air, sunshine, salt-water baths, sea-air, fresh food (milk, cream, and meat- juice), cod-liver oil especially, syrup of the iodide of iron, arsenic, and some form of phosphorus. XIV. CONTUSIONS AND WOUNDS. Contusions.—A contusion or bruise is a subcutaneous laceration, the skin above it being uninjured (as in the abdomen) or damaged with a surface-breach (as in a part overlying bone), blood being effused. If a large vessel is damaged, the hemorrhage is large. An ecchymosis is diffuse hemorrhage over a large area; a hematoma is a blood-tumor or a circumscribed hemorrhage. In a diffuse hemorrhage the coagulation of fibrin induces induration; the serum and leucocytes are absorbed ; the red blood-cells disintegrate and the coloring matter is widely diffused (suggillation); and haemoglobin is changed into haematoidin, which crystallizes. In union with these chemical changes, color-changes ensue, the part being at first red and then becoming purple, black, green, lemon, and citron. A haematoma acts as an irritant, inflammation ensues around it, and it is encapsuled by em- bryonic tissue, which, by organizing into fibrous tissue, forms a blood-cyst and gradually absorbs the fluid blood, the cyst- contents becoming thicker and thicker. A fibrous scar may remain. If serum is not absorbed, haematoidin forms and the fluid becomes clear. A haematoma may suppurate, an abscess forming. Symptoms.—The symptoms are heat, tenderness, swell- ing, and numbness followed by pain. Discoloration appears quickly in superficial contusions, but days after in deep ones ; shock and loss of function are present after severe contusions. CONTUSIONS AND WOUNDS. 149 Treatment.—Obtain reaction from the shock. Local treat- ment consists of rest, elevation, and compression to arrest bleeding, antagonize inflammation, and control swelling. Cold is useful early in a case, but it is not suited to severe contusions or to contusions in the debilitated or aged, as in such cases it may cause gangrene. Lead-water and laudanum and iodine may be used. In very severe contusions employ heat and stimulation. When inflammation is subsiding after a contusion, massage and ichthyol should be ordered. A contusion should never be opened unless hemorrhage con- tinues, infection takes place, or a lump remains for some weeks. For persistent bleeding freely lay open the contu- sion, turn out clots, ligate vessels, irrigate with corrosive- sublimate solution, insert a tube, and close. If gangrene is feared, use iodine locally, and if a slough forms, employ antiseptic fomentations. Constitutional treatment for con- tusion is the same as that for inflammation. Wounds.—A wound is a breach of surface continuity by a sudden and violent mechanical force. Wounds are divided into open and subcutaneous, septic and aseptic, contused, incised, lacerated, punctured, gunshot, and poisoned. The local phenomena of wounds are pain, hemorrhage, loss of function, and gaping or retraction of edges. Pain is due to the injury of nerves, and it varies according to the situation and to the nature of the injury. It is influ- enced by temperament, excitement, and preoccupation. It may not be felt at all at the time of the injury. At first it is usually acute, becoming later dull and aching. In an asep- tic wound the pain is slight, but in an infected wound it is severe. Hemorrhage varies with the state of the system, the vas- cularity of the part, and the variety of injury. Loss of Function.—Depends on the situation and extent of the injury. 150 A MANUAL OF SURGERY. Gaping or Retraction of Edges.—Due to tissue-elasticity. The constitutional condition is that of shock, which is a sudden depression of the vital powers arising from an injury or a profound emotion acting on the nerve-centres and in- ducing vaso-motor paresis, the blood accumulating in the abdominal vessels. It may be slight and transient, it may be severe and prolonged, and it may even produce almost instant death. It is more severe in men than in women, in the nervous and sanguine than in the lymphatic, in those inured to suffering than in those who are strangers to illness. Injury of the abdomen produces great shock, and so does damage to the viscera, the urethra, and the testicles. Cere- bral concussion is a form of shock plus other conditions. Sudden and profuse hemorrhage causes shock; so, occa- sionally, does anaesthetization. Symptoms.—The symptoms are a temperature much below normal; weak, rapid, and compressible pulse; cold, clammy, or profusely-perspiring skin; shallow respiration; a tendency to urinary suppression; consciousness is usually maintained, but there is an absence of mental originating power, the injured person answering when spoken to, but volunteering no statements and lying with partly-closed lids in any position in which he may have been placed. If de- lirium arises, the condition is very grave (delirious shock). Pain is slightly or not at all appreciated. Vomiting may, as in concussion, presage reaction. Vomiting after a consider- able time in shock is regurgitation, and is a bad omen. Diagnosis.—Concealed hemorrhage is hard to separate from shock. It produces impairment of vision (retinal anaemia), irregular tossing, frequent yawning, nausea, and sometimes convulsions. In shock the haemoglobin is unal- tered ; in hemorrhage it is enormously reduced (Hare and Martin). In hemorrhage recurrent attacks of syncope are met with. Shock and hemorrhage are often associated. The CONTUSIONS AND WOUNDS. 151 essential characteristic of shock is sudden onset, which sep- arates it from exhaustion. Treatment.—In treating shock from a wound, lower the head, apply hot bottles and hot blankets, and give hypo- dermatic injections of ether, brandy, strychnine, digitalis, or atropia. A turpentine enema is useful. Hot coffee or other hot fluids should be given by the mouth and rectum, mustard be placed over the heart, spine, and shins, and the hypoder- moclysis of salines be practised. If shock comes on during operation, the proceedings must be hurried or even be stopped. Should we operate during shock ? Clearly, no, except for the purpose of arresting hemorrhage. Do not, for instance, perform an amputation in shock, but arrest hem- orrhage, asepticize, and bring about reaction before operating. Pat-embolism.—(See Embolism, p. 124.) Fever.—(See Fevers) Treatment of Wounds.—The rules for treating wounds are—(1) arrest hemorrhage; (2) bring about reaction; (3) remove foreign bodies ; (4) asepticize; (5) drain, coaptate the edges, and dress; and (6) secure rest to the part and combat inflammation. Constitutionally, allay pain, secure sleep, keep up the nutrition, and treat inflammatory conditions. Arrest of Hemorrhage.—To arrest hemorrhage the bleed- ing point must be controlled by digital pressure until ready to be grasped with forceps; it is then caught up and tied with catgut or aseptic silk. Slight hemorrhage stops spon- taneously on exposure to air, and moderate hemorrhage ceases after the vessels are clamped for a time; an injured vessel of some size must be ligated, even if it has ceased to bleed. Capillary oozing is checked by hot-water compresses. If a large artery is divided in a limb, apply a tourniquet before ligating (see Wounds of Vessels). Bringing About of Reaction.—(See Shock) Removal of Foreign Bodies.—Remove all foreign bodies 152 A MANUAL OF SURGERY. visible to the eye (splinters, bits of glass, portions of clothing, gun-wadding, grains of dirt, etc.) with forceps and a stream of corrosive-sublimate solution. In a lacerated or contused wound portions of tissue injured beyond repair should be regarded as foreign bodies and be removed with scissors. Cleaning the Wound.—To clean the wound scrub the area around it with Johnson's ethereal soap and then with cor- rosive-sublimate solution (i : iooo). If the surface is hairy, it must be shaved. The wound must be well washed out with an antiseptic solution, thus getting rid of blood-clots which would serve to separate the edges and favor infection. Drainage, Closure, and Dressing.—Superficial wounds re- quire no special drain, as some wound-fluid will find exit between the stitches and the rest will be absorbed. A large or deep wound requires free drainage for at least twenty-four hours by means of a tube, strands of horse-hair, silk, or catgut, or bits of iodoform gauze. An infected wound must invariably be drained. Good drainage almost compensates for imperfect antisepsis. If capillary drains be employed, apply a moist dressing. Divided nerves and tendons must be sutured. Close the edges with silk sutures or silkworm- gut if the wound is deep and tension is inevitable. Catgut is used for superficial wounds and for those where tension is slight. The interrupted suture is, as a rule, the best. If the wound is infected, dress with antiseptic gauze ; or with either aseptic or antiseptic gauze if it is not infected. Cover the gauze with a rubber dam to diffuse the fluids. Change the dressings in twenty-four hours, or sooner if they become soaked with discharge. After this, in an aseptic wound, the dressing need not be changed for days. If pus forms, open the wound at once. Rest.—Severe wounds require confinement in bed. Band- ages, splints, etc. are used to secure rest. The methods of combating inflammation have previously been set forth. CONTUSIONS AND WOUNDS. 153 Constitutional Treatment.—Bring about reaction from de- pression, but prevent undue reaction. Feed the patient well, stimulate him if necessary, and attend to the bowels and bladder. Watch the temperature as the danger-signal, secure sleep, and allay pain. Look out for complications, namely, inflammation, suppuration, gangrene, tetanus, and erysipelas. Incised Wounds.—An incised wound is a clean cut in- flicted by an edged instrument. Only a thin film of tissue is so devitalized that it must die. These wounds have a splendid chance of union by first intention. Symptoms.—The symptoms of incised wounds are sharp pain for a time, followed by smarting, profuse bleeding, and decided retraction of the edges. Treatment.—The treatment of incised wounds is accord- ing to general rules. Do not use styptics, as they cause a repugnant clot, produce irritation, and favor infection. Lacerated and Contused Wounds.—A lacerated wound is a tearing apart of the tissues; a contused wound is a crushing and pulpefying of tissues. These two forms are combined. They are irregular, contain masses of partially- detached tissue and blood-clots, and their edges are cold and discolored. Such wounds tend to necrosis. Symptoms.—The symptoms are excessive shock, slight hemorrhage, and only a moderately dull pain. Reactionary and secondary hemorrhages are common. Infection is liable to occur, and more or less sloughing is bound to ensue. Treatment.—Any damaged vessel, whether it bleeds or not, must be tied, the devitalized tissues cut away, and for- eign bodies removed. Asepticize with great care and secure thorough drainage, making very usually counter-openings. In dressing, put iodoform in the wound and close it par- tially. Watch for bleeding during reaction. When slough- ing begins, use antiseptic fomentations. A brush-burn, which is a contused-lacerated wound due to friction, requires the 154 A MANUAL OF SURGERY. use of an antiseptic poultice until the slough is cast off. In badly-lacerated wounds and crushes it is often necessary to amputate. Punctured wounds are wounds made by pointed instru- ments. A punctured wound is usually deep, it closes partly after withdrawal of the instrument, blood-clot and wound- fluids cannot get exit, and infection is certain if the instru- ment carries microbes. Large-sized foreign bodies may be driven in or a portion of the instrument may break off. Arrow-wounds are punctured and incised. Symptoms.—In punctured wounds the pain is rarely severe, but hemorrhage is slight unless a large vessel be wounded. Infection is apt to ensue. Varicose aneurysm may be caused. Treatment.—In treating punctured wounds incise to the depth of the puncture, stop the hemorrhage, asepticize, and drain. An arrow should never be pulled out, but should be pushed through or cut down to by enlarging the wound. Gunshot wounds are injuries inflicted by projectiles, such as shot and bullets, driven by explosives. If a bullet just grazes a surface, a friction-burn results; if it enters the tis- sues, it produces a punctured-contused-lacerated wound ; if it strikes the tissue, but fails to enter, it causes a contusion. If a bullet enters a cavity or an organ and does not emerge, it produces a penetrating wound; if it does emerge, it is a perforating wound. Bullets are very apt to carry a foreign body into the tissues (clothing, wadding, etc.). The wound of entrance is round, smooth, and depressed, and is smaller than the ball, because the skin stretches as the bullet strikes it and contracts again after it has passed. The skin around the wound of entrance is discolored by the ball, or, if the discharge took place near the victim, it is blackened by the gunpowder. A wound of entrance larger than the ball means the entrance with the projectile of some foreign body. The wound of CONTUSIONS AND WOUNDS. 155 exit, if one exists, is irregular, everted, and larger than the bullet (especially so if a round ball was used). Hemorrhage is slight unless a large vessel is opened, pain varies, and shock is severe. Dense fascia resists a ball strongly, often deflect- ing it, and is irregularly torn when the missile passes, pre- senting fringes which interfere with probing and drainage. Tendons are generally pushed away. Vessels are usually pushed aside, but they may be divided. If pushed aside, the damage done them is apt to produce sloughing and secondary hemorrhage or cause an aneurysm to develop. Diagnosis.—To diagnosticate the extent and nature of a gunshot wound, put the parts in the position they were in when injured; ascertain the direction of the ball's course, the size and nature of the weapon, and its distance away when fired. Examine the clothing to see if any part was carried in. Do not probe without a special indication. Treatment.—To treat a gunshot wound, bring about re- action. If hemorrhage be severe, take a knife and enlarge the wound, find the bleeding vessel, and secure it. Thor- oughly cleanse the wound and adjacent parts before handling. Do not explore for the ball unless sure that it has carried in with it septic foreign bodies, unless its presence interferes with repair, unless it is in or near a vital region (as the brain), or unless it is necessary to determine the position of the ball in order to decide the question of amputation or resection. The best probe is the finger. There may be used Fluhrer's aluminium probe, Nelaton's porcelain probe, the stem of a clay pipe, or a bit of pine wood, the last three of which stain with lead and will indicate whether the hard body is bone or a bullet. Girdner's telephonic probe can be tried if we wish to locate the ball. If any chance of success exists, try to get primary union by antisepsis and rest. This union will usually fail because of infec- tion at the time of the injury and the inevitable necrosis 156 A MANUAL OF SURGERY. of the compressed and damaged tissue. In any case use rigid antisepsis and watch for complications. Infection calls for enlargement of the wound and a counter-opening. For removing a ball numerous forceps have been devised. Resection.—Resection is sometimes demanded for the splintering of a joint. Amputation is sometimes demanded because of great injury to the soft parts (as by a shell-fragment), the splintering of a 4 bone, injury of a joint, damage to the chief vessels or nerves, or the destruction of a considerable part of a limb. Per- form a primary amputation if possible, and make the flaps through tissue that will not slough. In civil practice, with careful antisepsis, more questionable tissue can be admitted into a flap than in military practice, where transportation may be necessary and antisepsis be imperfect or wanting. Poisoned wounds are those in which a poison is intro- duced. This poison may be microbic and capable of self- * multiplication, or it may be chemical, and hence incapable of multiplication. There are three classes of poisoned wounds:l (1) mixed infection, as septic wounds, dissection-wounds, and malignant oedema; (2) chemical poison, such as snake-bites and insect-stings; and (3) microbic infection, such as rabies, glanders, etc. Septic wounds are those which suppurate or slough. Open septic wounds freely for drainage, curette or cut away hopelessly damaged tissue, wash with peroxide of hydrogen and then with corrosive sublimate, dust in iodoform, and either use a drainage-tube or pack with iodoform gauze. Watch the temperature for evidences of general infection or intoxication. Stimulate and secure good nourishment, rest, and sleep. Dissection-wounds are simple examples of infected « wounds, and they present nothing peculiar except virulence. 1 American Text-book of Surgery, « CONTUSIONS AND WOUNDS. 157 They affect butchers, cooks, surgeons who cut themselves in operating on a poisoned area, those who make post-mortems, and those who dissect. A dissection-wound inflicted while working on a body injected with chloride of zinc possesses but few elements of danger unless the health of the student is much broken down. Post-mortems are peculiarly danger- ous when the subject has died of some septic process. • When a wound is inflicted while dissecting, wash it under a strong stream of water, suck it to make the blood run, lay it open if it be a puncture, swab it out with pure carbolic acid, and dress it with iodoform and gauze. If infection shows itself, it must be treated as any other infected wound. Malignant oedema or gangrenous emphysema arises, as a rule, after punctures. It is due to a specific bacillus which produces great oedema, and to secondary infection with putre- factive organisms. ♦ Symptoms.—The symptoms are oedema, the fluid being dis- tinctly bloody, followed by rapidly-diffusing gangrene which is surrounded by a zone of cedematous tissue that crepitates under pressure because it contains gases of putrefaction. The zone of oedema is covered with blebs which contain thin, putrid, reddish matter. The constitutional condition is one of septicaemia. Death occurs, as a rule, in a few days. Treatment.—To treat malignant oedema, if it affect a limb, amputate at once, high up. If it affect some other part, excise, use the actual.cautery, and dress antiseptically. Stim- ulate very freely. Stings and Bites of Insects and Reptiles : Stings of Bees and Wasps.—A bee's sting consists of two long lances within a sheath with which a poison-bag is connected. The wound is made first by the sheath, the poison then passes in, and 't* the two lances, moving up and down, deepen the cut. The barbs on the lances make it difificult to rapidly withdraw the sting, which may be broken off and remain in the flesh. 158 A MANUAL OF SURGERY. Besides bees, hornets, yellow-jackets, and other wasps pro- duce painful stings. These stings rarely produce any trouble except pain and swelling. In some rare cases a bee-sting is fatal; persons have been stung to death by a great number of these insects. Symptoms.—If general symptoms ensue, they appear rap- idly and consist of great prostration, vomiting, purging, and delirium or unconsciousness. These symptoms may dis- « appear in a short time, or they may end in death from heart- failure. Stings of the mouth may cause oedema of the glottis. Treatment.—To treat a bee-sting, extract the sting if it be broken off, and apply locally a solution of washing-soda, tincture of arnica, iodine, or lead-water and laudanum. If constitutional symptoms appear, stimulate. Other Insect-bites and Stings.—The mandibles of a spider are terminated by a movable hook which has an opening for the emission of poison. The bite of large spiders is pro- * ductive of inflammation, swelling, weakness, and even death. The bite of the poisonous spider of New Zealand produces a large white swelling and great prostration; death may ensue, or the victim may remain in a depressed, enfeebled state for weeks or even for months. The tarantula is a much- dreaded spider. A scorpion has in its tail a sting, and a scorpion's sting produces great prostration, delirium, vomit- ing, diaphoresis, vertigo, headache, local swelling, and burning pain, followed often by suppuration, or even by gangrene and fever. Centipedes must be of large size to be formidable to man, and the symptoms arising from their stings are usu- ally only local. Treatment.—Tie a fillet above the bitten point; make a crucial incision, favor bleeding, and swab out the wound with pure carbolic acid or some caustic or antiseptic (if in the •' wilds, burn with fire or gunpowder); dress antiseptically if possible, and stimulate as constitutional symptoms appear, t CONTUSIONS AND WOUNDS. *59 slowly loosening the ligature. Chloroform stupes and ipecac poultices are recommended, also puncture with a needle and rubbing in 3 parts of chloral and 1 part of camphor.1 Snake-bites.—The poisonous snakes of America com- prise the copperheads, water-moccasins, rattlesnakes, and vipers. There is also a poisonous lizard. The symptoms of snake-bite are similar whether it is the bite of an Indian • cobra or of an American rattler, and they depend upon the dose of poison introduced. Poison injected into a vein may prove almost instantly fatal. The poison is not ab- sorbed by the sound mucous membranes. It is discharged through the hollow fangs of the reptile by contractions of the muscles of the poison-bag. In most varieties of snakes the teeth lie along the back of the mouth and are only erected when the reptile strikes. The poison contains proteid constituents, globulins, and peptones (Mitchell and Reichert), • and probably toxic animal alkaloids (Brieger). Symptoms.—The symptoms are—pain, soon becoming in- tense ; mottled swelling of the bitten part, which swelling may be enormous, and which is due to oedema and extrava- sation of blood, and assumes a purpuric discoloration. There may be complete consciousness, or there may be lethargy, stupor, or coma. Some cases present spasms. The general symptoms are those of profound shock, which may present delirium (delirious shock). Death may arise from paralysis of the heart, and may occur in about five hours, but as a rule it is postponed for a number of hours. If death is deferred many hours, profound sepsis comes upon the scene, with glandular enlargement, suppuration, and sometimes gangrene. Treatment.—Cases of snake-bite must, as a rule, be treated without proper appliances. Prof. Gross related that he had seen an army officer blow off his finger with a pistol the moment it was struck, and thus escape poisoning. For bit- 1 Bauerjie, in the Lancet. i6o A MANUAL OF SURGERY. ten fingers or toes this treatment would be wise. In general, the rules are to twist several fillets at different levels above the bite, to excise the bitten area, to suck or cup it if pos- sible, and to cauterize it by a pure acid or by heat. An expedient among hunters is to cauterize by pouring gun- powder on the excised area and applying a spark, or by lay- ing a hot ember on the wound. When a hot iron is available, use it. The fillets are not to be removed suddenly, and they had best be kept on for some time. Remove the highest constricting band first; if no symptoms come on after a time, remove the next, and so on; if symptoms appear, reapply the fillet. The constitutional treatment is expressed in one word: stimulate. Our only hope is in large doses of alcohol, and, if they can be obtained, ammonia, ether, strychnine, or digitalis hypodermatically administered. Mor- phia can be given for pain. There is no specific for snake- poison. Hypodermatic injections in the area adjacent to the bite of a I per cent, solution of the permanganate of potash are commended by some. Halford of Australia praises the intravenous injection of ammonia (io TTf of strong ammonia in 20 TTL of water). If a man is bitten by a large and deadly snake, the surgeon, if one is at hand, should at once ampu- tate well above the bite.1 Anthrax (malignant pustule, charbon, wool-sorters' dis- ease, Milzbrand, or splenic fever) is a term used by some as synonymous with carbuncle, but it is not here so employed. Anthrax, when seen among men, is a disease caught in some manner from an animal with splenic fever. It may be caught by working around diseased animals, by handling or tanning their hides, by sorting their hair or wool; it may be con- veyed by eating infected meat or by drinking infected milk. Flies may carry the poison. Forms of Anthrax.—There are two forms of the disease 1 Charters James Symonds, in HeaWs Dictionary. ♦ CONTUSIONS AND WOUNDS. 161 —anthrax carbuncle and anthrax oedema. The external form presents a papule with a red base; the papule becomes a vesicle which contains bloody serum ; the vesicle bursts and dries, the base of it swells and enlarges, other vesicles appear in circles around it, and there is developed an " anthrax car- buncle " which shows a black or purple elevation with a central depression surrounded by one or more rings of • vesicles. Pain is trivial. Lymphatic enlargements occur. In loose connective tissue the lesion may be anthrax oedema, a spreading livid oedema followed by blebs and even by gangrene. The constitutional symptoms may rapidly follow the local lesion, but may be deferred for a week or more. The patient feels depressed, has obscure aches and pains, and is feverish, but usually keeps about for a short period. After a time he is apt to develop rigors, high irregular fever, sweats, acute fugitive pains, diarrhoea, delirium, typhoid • exhaustion, dyspnoea, cough, and cyanosis. The local car- buncle of anthrax is distinguished from ordinary carbuncle by the central depression, the adherent eschar, the absence of tenderness, and the absence of suppuration of the first, as contrasted with the elevated centre, the multiple foci of suppuration and sloughing, and the acute pain of the second. Anthrax oedema differs from cellulitis in the absence of all tendency to form pus, and from malignant oedema by the greater tendency of the latter to result in gangrene. If anthrax has a visible lesion and the constitutional symptoms are slight or absent, the chance of cure is good. Treatment.—If a person is wounded by an object sus- pected of carrying the infection, cauterize the wound with the hot iron. A malignant pustule should be entirely ex- cised and the wound mopped out with pure carbolic acid, • or burnt with the hot iron and afterward dressed with wet bichloride-of-mercury gauze which is covered with an ice- bag. Another plan is to make crucial incisions through the n l62 A MANUAL OF SURGERY. lesion, to mop out with pure carbolic acid, and to inject around and in the pustule carbolic acid (i : io) every six hours until the disease abates or toxic symptoms appear. The adherent eschar is subsequently gotten away by anti- septic poultices. Constitutional treatment is sustaining and stimulating. Hydrophobia, Rabies, or Lyssa.—Hydrophobia is a spas- modic and paralytic disease due to infection through a wound with the virus from a rabid animal. The animal may be a dog, a cat, a wolf, a fox, or a horse. Roux estimates that about 14 per cent, of the people bitten by mad animals develop the disease. If the bite is on an exposed part, it is far more apt to cause rabies than if the teeth pass through clothing. Hydrophobia is always fatal. The saliva is the usual vehicle of contagion, but other fluids and tissues contain it, espe- cially the brain and cord. Symptoms.—The period of incubation of hydrophobia is from a few weeks to two years. The initial symptoms are mental depression, anxiety, headache, malaise, and often pain or even congestion in the cicatrix, which symptoms are quickly followed by a general hyperaesthesia, pharyngeal spasms, dyspnoea from laryngeal spasms, and constant attempts to expectorate thick mucus which forms because of congestion of the air-passages. Attempts at swallowing, as well as lights and noises, tend to bring on spasms, hence the fear of liquids (there is spasm from attempts at swallowing or from thinking of the act). The entire body may be thrown into clonic spasms, but there is no tonic spasm. The mind is usually clear, although during the periods of excitement there may be maniacal furor with hallucinations which pass away in the stage of relaxation. The temperature is moderately elevated (ioi° to 1030 or higher). This spasmodic stage lasts from one to three days, and the patient may die during this period from exhaustion or from asphyxia. If he lives through this CONTUSIONS AND WOUNDS. 163 period, the convulsions gradually cease, the power of swal- lowing returns, and the patient succumbs to exhaustion in less than twenty-four hours, or he develops ascending paral- ysis which soon causes cardiac and respiratory failure. In hydrophobia death is inevitable. Those cases in which it is alleged that recovery ensued were not true hydro- phobia, but hysteria. Wood says that in hysteria, especially among boys, "beast-mimicry" is common, the sufferer snarl- ing like a dog, and in the form known as " spurious hydro- phobia," in which there may or may not be convulsion, there is a dread of water, emotional excitement, snarling, and attempts to bite the bystanders (in genuine hydrophobia no attempts are made to bite and no such sounds are uttered as are made by a dog). Lyssa is separated from lockjaw by the spasms of the larynx and the absence of tonic spasms in the former, as contrasted with the spasms of muscles of mastication and the tonic spasms with clonic exacerbations of lockjaw. Treatment.—When a person is bitten by a supposed rabid animal, apply constriction above the wound if possible, ex- cise, and burn with the hot iron. Send the patient to a Pasteur institute at once, that he may be given preventive inoculations of an emulsion made from the dried spinal cords of hydrophobic rabbits (attenuated virus). The value of this plan seems definitely established. In the paroxysm the treat- ment is palliative, and cannot be curative. Keep the patient in a dark, quiet room, relieve thirst by enemata, saturate with morphia, and in the paroxysms anaesthetize. Glanders, Farcy, or Equinia.—Glanders is an infectious eruptive fever occurring in horses and communicable to man. If the nodules occur in a horse's nares, we call the disease "glanders;" if beneath his skin, it is termed "farcy." This disease is due to the bacillus of LofBer, and is communi- cated to man through an abraded surface or a mucous 164 A MANUAL OF SURGERY. membrane (Osier). The characteristic lesions are infective granulomata which in the nose form ulcers and under the skin develop abscesses. Acute and Chronic Glanders.—In acute glanders there is septic inflammation at the point of inoculation; nodules form in the nose, and ulcerate; there is profuse nasal dis- charge ; the glands of the neck enlarge; there are fever and an eruption like small-pox on the face and about the joints (Osier). Acute glanders is always fatal. Chronic glanders lasts for months, is rarely diagnosticated, being mistaken for catarrh, and is often recovered from. Diagnosis is made by injecting a guinea-pig with the nasal mucus. Acute and Chronic Farcy.—Acute farcy appears from a skin-inoculation; it begins as an intense inflammation, from which run out inflamed lymphatics that present nodules or " farcy-buds." Abscesses form. There are joint-pain and the constitutional symptoms of sepsis, but no involvement of the nares. Chronic farcy may last for months. In it nodules occur upon the extremities, which nodules break down into abscesses and eventuate in ulcers resembling those of tuberculosis. Treatment.—In treating this disease the point of infection is at once to be incised and cauterized. Open the abscesses, swab out with pure carbolic acid, and dress antiseptically. Give stimulants and nourishing diet. Diseased horses ought at once to be killed and their stalls torn out and purified. Actinomycosis is an infectious disorder characterized by chronic inflammation, and is due to the presence in the tis- sues of the actinomyces or ray-fungus. This disease occurs in cattle (lumpy jaw) and in pigs, and can be transmitted to man, apparently by the food. At the point of inoculation (which is usually about the mouth) arises an infective granu- loma, around which inflammation of connective tissue occurs, suppuration eventually taking place. SYPHILIS. 165 Symptoms.—The surgeon may see the lesion in the jaw (the enlargement resembling an abscess or sarcoma), on the tongue, and on the skin (resembling cutaneous tuberculosis). Pulmonary actinomycosis presents fever, cough, and wasting, the symptoms being usually one-sided and the fungus being found in the expectoration. Cerebral actinomycosis can occur. Osier says the disease is a chronic pyaemia with the fungus existing in the pus. Treatment.—The treatment consists in thoroughly extir- pating the growth as we would a malignant tumor. Open, curette, and cauterize abscesses and sinuses. Remove dead bone. Iodide of potash has cured cases. XV. SYPHILIS. Definition.—Syphilis is a chronic infectious, and some- times hereditary, constitutional disease. Its first lesion is an infecting area or chancre, which is followed by lym- phatic enlargements, eruptions upon the skin and mucous membranes, affections of the appendages of the skin (hair and nails), " chronic inflammation and infiltration of the cellulo-vascular tissue, bones, and periosteum " (White), and, later, often by gummata. This disease is probably due to a microbe, but Lustgarten's bacillus has not been proved to be the one. One fact against its being the cause is its pres- ence in the non-contagious late gummata. White quotes Finger in his assumption that syphilitic fever is due to absorption of ptomaines; that the eruptions of skin and mucous membranes in the secondary stage arise from local deposit and multiplication of the virus; that many secon- dary symptoms result from nutritive derangement caused by tissue-products passing into the circulation; that the virus exists in the body after the cessation of secondary symptoms; i66 A MANUAL OF SURGERY. and that it may die out or may awaken into activity, pro- ducing " reminders." During the primary and secondary stages fresh poison cannot infect, and this is true for a time after the disappear- ance of secondary symptoms. Immunity in the primary stage is due to products absorbed from the infected area. Colles's immunity is that acquired by mothers who have borne syphilitic children, but who themselves show no sign of the disease. Profeta's immunity is the immunity against infection possessed by many healthy children born of syph- ilitic parents. Tertiary syphilitic lesions are not due to the poison of syphilis, but to tissue-products from the action of that poison. Tertiary syphilis is not transmissible, but it secures immunity. Transmission of Syphilis.—This disease can be trans- mitted—(i) by contact with the tissue-elements or virus— acquired syphilis ; and (2) by hereditary transmission—hered- itary syphilis. The poison cannot enter through an intact epidermis or epithelial layer, and abrasion or solution of continuity is requisite for infection. Syphilis is usually, but not always, a venereal disease. It may be caught by infec- tion of the genitals during coition, by infection of the tongue or lips in kissing, by smoking poisoned pipes, by drinking out of infected vessels, or by beastly practices. The initial lesion of syphilis may be found on the finger, forehead, eye- lid, lip, tongue, cheek, palate, anus, nipple, etc. A person may be a host for syphilis, carry it, give it to another, and yet escape it himself (a surgeon may carry it under his nails, and a woman may lodge it in her vagina). Syphilis can be transmitted by vaccination with human lymph which con- tains the pus of a syphilitic eruption or the blood of a syphilitic person. Vaccine lymph, even after passage through a person with pox, will not convey syphilis if it is free from blood and the pus of specific lesions; it is not the lymph SYPHILIS. 167 that poisons, but some other substance which the lymph may carry. Syphilitic Stages.—Syphilis was divided by Ricord into three stages : (1) the primary stage—chancre and indolent bubo; (2) the secondary stage—disease of the upper layer of the skin and mucous membranes; and (3) the tertiary stage—affections of connective tissues, bones, fibrous and se- rous membranes, and parenchymatous organs. This division, which is useful clinically, is still largely employed, but it is not so sharp and distinct as was believed by Ricord; it is only artificial. For instance, ozcena may develop during a second- ary eruption, and bone disease may appear early in the case. Syphilitic Periods.—White divides the pox into the fol- lowing periods: (1) period of primary incubation—the time between exposure and the appearance of the chancre: from ten to ninety days, the average being three weeks; (2) period ' of primary symptoms—chancre and bubo of adjacent lymph- glands ; (3) period of secondary incubation—the time between the appearance of the chancre and the advent of secondary symptoms: about six weeks as a rule; (4) period of secon- dary symptoms—lasting from one to three years; (5) inter- mediate period—there may be no symptoms or may be light symptoms which are less symmetrical and more general than those of the secondary period: it lasts from two to four years, and ends in recovery or tertiary syphilis; and (6) period of tertiary symptoms—indefinite in duration. Primary Syphilis.—The primary stage comprises the chancre or infecting sore and bubo. A chancre or initial lesion is an infective granuloma resulting from the poison of syphilis. A chancre may be derived from the discharges of another chancre, from the secretion of mucous patches and moist < papules, from syphilitic blood, or from the pus or secretion of any secondary lesion. Tertiary lesions cannot cause chancre. It appears at the point of inoculation, and is the first lesion 168 A MANUAL OF SURGERY. of the disease. It is not a local lesion from which syphilis springs, but is a local manifestation of an existing constitu- tional disease, hence excision is entirely useless. If we take the discharge of a chancre and insert it at some indifferent point into the person from whom we took it, a new chancre will not be formed, because he already has syphilis. If we insert it into another person, a chancre is formed. Hence we say that primary syphilis is not auto-inoculable, but is hetero-inoculable. Initial Lesions.—An initial lesion, hard chancre, or infect- ing sore never appears until at least ten days after exposure; it may not appear for many weeks, but it usually arises in about three weeks. There are three chief forms of initial lesion: (i) a purple patch exposed by peeling epidermis, without induration and ulceration—a rare form ; (2) an indu- rated area under the epidermis, without ulceration—a very common form ; and (3) a round, indurated, cartilaginous area < with an elevated edge, which ulcerates, exposing a velvety surface looking like raw ham ; it bleeds easily, it rarely sup- purates, it does not spread, and the discharge is thin and watery. This is the " Hunterian chancre," which is rarer than the second variety, but commoner than the first, and which ulcerates because of dirt, caustic applications, or fric- tion. Mixed Infection of Chancre and Chancroid.—A chancre is rarely multiple, but if it is so all the sores appear together as a result of the primary inoculation : they do not follow one another because of auto-infection. A hard sore does not suppurate unless irritated by caustics, friction, or dirt, or unless there be mixed infection with chancroid; its nature is not to suppurate. The hardness may affect only the base and margins of an ulcer or it may affect considerable areas, 1 but it has well-defined margins and feels like cartilage encap- suled, so that it can be picked up in the fingers. This hard- • SYPHILIS. 169 ness or sclerosis is due to gradual inflammatory exudation into " the tissues at the base of the ulcer and to growth of the nodule" (Von Zeissl). A chancre untreated may last many months. The induration usually disappears soon after the appearance of secondary symptoms. A copper-colored spot remains, and does not disappear until the disease is cured. An induration may again appear before the outburst , of some distant lesion. Von Zeissl says: "If syphilitic contagion is mixed with pus, a chancre begins as a circumscribed area of hyperaemia and swelling, which undergoes ulceration, and does not de- velop hardness for a period of from ten days to several weeks, and may develop a nodule after the first ulce'r has entirely healed." We see this condition when mixed infection occurs, the chancroid poison being quick, and the syphilitic poison being slow, to act. If chancroid poison is deposited some • time after the syphilitic poison has been absorbed, the indu- ration may appear in a few days after the chancroid begins. A soft chancre may appear upon an existing syphilitic nodule and may eat out the induration. We must separate a chancre from a chancroid and from ulcerated herpes. A chancroid appears in from two to five days after contagion (always less than ten days); it may be multiple from the start, but, even if beginning as one sore, other sores appear by auto-inocu- lation ; it begins as a pustule, which bursts and exposes an ulcer; this ulcer is circular, has thin, sharp-cut or undermined edges, a sloughy, non-granulating base, and a thin, purulent, offensive discharge which is both auto- and hetero-inoculable. These soft sores have no true sclerotic area, do not bleed, produce no constitutional symptoms, and are apt to be fol- lowed by an acute inflammatory bubo which tends to suppu- * rate. A chancroid causes pain. A chancre appears in about three weeks after inoculation (never before ten days); it is generally single, but if multiple sores exist, they all appear 170 A MANUAL OF SURGERY. together, for their discharge is not auto-inoculable; it begins as an excoriation or as a nodule; if an ulcer forms, its base is covered with granulations and it is red and smooth; its discharge is thin and scanty and not offensive; its edges are thick and sloping; it is surrounded by an area of induration, and bleeds when touched; it is followed by secondary symp- toms, and there appear about the same time with it indolent multiple enlargements of the adjacent glands, which rarely suppurate. A chancre causes little pain. Herpetic ulceration has no period of incubation; it may follow fever, but usually arises from friction or the irritation of dirt or acrid discharges. It appears as a group of ves- icles, all of which may dry up, or some may dry up and others ulcerate, or they may run together and ulcerate. The edges of a herpetic ulcer are in " segments of small Circles " (White); the ulcer is superficial, has but little discharge, and does not have much tendency to spread; it has no indura- tion ; it is painful; it has no bubo unless suppuration is extensive, and there is no constitutional involvement. A urethral chancre appears after the usual period of incubation ; it is situated near the meatus, one lip of which is usually indurated; the discharge is slight, often bloody, and never purulent; indurated multiple buboes arise; the sore can be seen, and constitutional symptoms follow (White). "A chancre may be mistaken for cancer of the tongue. A chancre of this region is brownish-red, a cancer being bright red. A chancre is soft in the centre; a cancer presents uniformity of induration. A chancre has a thin, purulent discharge, free from blood; a cancer has a non-purulent, bloody discharge. A chancre is followed by indolent lymphatic enlargements under the jaw; a cancer is followed by painful enlarge- ments." A cancer is slower in evolution, is not followed by constitutional symptoms, and the lymphatic enlargements are much later in appearing than in chancre. • SYPHILIS. 171 Syphilitic Bubo.—In syphilitic bubo anatomically-related lymphatic glands enlarge about the same time as induration of the initial lesion begins. In the very beginning these glands may be a little painful, but they soon cease to be so. These enlargements are called "indolent buboes;" they may be as small as peas or as large as walnuts, are freely movable, and very rarely suppurate. The lesion of these glands is , hyperplasia of all the gland-elements and of their capsules, due to absorption of the virus. If a man is strumous, the bubo is apt to become enormous, lobulated, and persistent. If the chancre appears on the penis, the superficial inguinal and femoral glands enlarge, usually on the same side of the body as the sore; if the sore is on the fraenum, both groins are involved. These buboes may remain for many months; they do not suppurate unless the sore suppurates or there is some condition such as scrofula; and they finally disappear • by absorption or fatty degeneration. About six weeks after buboes have formed in the glands related to the lesion, all the lymphatics of the body enlarge. General lymphatic involvement arises about the same time as the secondary eruption. The enlargement of the post-cervical and epitroch- lear glands is diagnostically important. These glandular enlargements persist until after the eruptions have disappeared. The bubo of syphilis is always present, while the bubo exists in only one-third of the chancroid cases. The bubo * ... of syphilis is multiple, consisting of a chain of movable glands (the glandulae Pleiades of Ricord); the bubo of chan- croid is one inflamed and immovable mass. The bubo of syphilis is indurated, painless, small, and slow in growth ; the bubo of chancroid shows inflammatory hardness, is pain- ful, large, and rapid in growth; the first rarely suppurates, • the second often does. The skin over a syphilitic bubo is normal; that over a chancroidal bubo is red and adherent. A syphilitic bubo is not cured by local treatment, but is 172 A MANUAL OF SURGERY. cured by the internal use of mercury and is followed by secondary symptoms. A chancroidal bubo requires local treatment, is not cured by mercury, and is not followed by secondaries. Herpes, balanitis, and gonorrhoea rarely cause bubo, but when they do the bubo in each case is similar to that caused by chancroid. A positive diagnosis of syphilis can be made when an indurated sore is followed by multiple indolent buboes in the groin and by enlargement of distant glands. General Syphilis.—As the general lymphatic enlargement becomes manifest there is apt to appear a group of symp- toms known as " syphilitic fever." The patient usually thinks he has a bad cold and is feverish and restless; he complains of sleeplessness and anorexia; his face is pale; he has inter- mitting rheumatoid pains in the joints and muscles, especially of the shoulders, arms, chest, and back, which pains change their location constantly and prevent sleep; night-sweats occur, and the pulse is quite frequent. This fever usually reaches its height in forty-eight hours, and falls as the erup- tion develops. Syphilitic fever does not always arise; it may appear during the progress of the disease. Secondary Syphilis.—The phenomena of secondary syph- ilis arise from poisoned blood. They are characterized by plastic inflammation, by the formation of fibrous tissue, and by thickening of tissue. Ulcerations may occur. Structural overgrowths appear (warts). Syphilitic Skin Diseases.—Syphilodermata (syphilides), due to circumscribed inflammation, may be dry or purulent. There is no one eruption characteristic of syphilis. This dis- ease may counterfeit any skin disease, but it is an imitation which is not perfect and is never a counterpart. Syphilitic eruptions are often circumscribed; they terminate suddenly at their edges, and do not gradually shade into the sound skin. In color they are apt to be brownish-red, like tarnished cop- I SYPHILIS. 173 per; especially is this the case in late syphilides. Hutchinson cautions us to remember that an ordinary non-specific erup- tion may be copper-colored, especially in people with dark complexion and when it occurs on the legs. Eruptions are apt to leave a brownish stain. Early syphilitic eruptions are symmetrical. Syphilitic eruptions have an affection for par- ticular regions, such as the forehead, the abdomen and chest, • the neck and scalp, about the lips and the alae of the nose, the navel, anus, groins, between the toes, and upon the palms and soles. Early secondary eruptions rarely appear on the face or hands. Specific eruptions are polymorphous, various forms of eruption being often present at the same time, so that roseola is seen here, papules there, etc. These syphilides do not cause as much itching as do non-spe- cific eruptions, except when about the anus or between the toes. • Forms of Eruption.—The chief forms of eruption are (i) erythema, (2) papular syphilides, (3) pustular syphilides, and (4) tubercular syphilides. 1. Erythema {macula, roseola, or spots) presents round, cir- cumscribed, red, inflamed spots whose color does not entirely disappear on pressure. In the papular form of erythema the spots are a little elevated. It attacks especially the chest and belly, but appears often on the forehead, the bend of the elbow, and the inner portion of the thigh. Usually erythema follows syphilitic fever, about six weeks after the chancre appears, and the number and distinctness of these spots are in proportion to the violence of the fever. Absent or slight fever means few and transient spots. In rare cases the dis- ease is very transitory, lasting but a few hours, but it usually lasts for a long period if untreated. Mercury will cause it to # disappear in a couple of weeks. In examining for this form of eruption in a doubtful case, let cold air blow upon the chest and belly (Hearn); this blanches the sound skin and i74 A MANUAL OF SURGERY. makes clear any discoloration. Erythema means, as a rule, a mild and curable attack. 2. Papular syphilides, which are papules or elevations cov- ered with dry skin, may or may not have a crust. They are at first red, but become brownish. Papules upon the palms and soles constitute the so-called " palmar and plantar psori- asis," which appears about eight or nine weeks after the appearance of the chancre in an untreated case. These papules just below the line of the hair on the forehead con- stitute the corona venerea. This eruption affects especially the forehead, the neck, the abdomen, and the extremities. The papular or squamous syphilide of the palms and soles begins as a red spot which becomes elevated and brownish; the epidermis thickens and is cast off, and there then re- mains a central red spot surrounded by undermined skin. If papules are in regions where they are kept moist (as about the anus), they become covered with a sodden gray- film which comes off and leaves the papule without epidermis. These sodden papules are called " flat condylomata," moist or humid papules or plates. The papular syphilide gives a worse prognosis than roseola. 3. Pustular syphilides arise from papules. We have acne when the apex of a papule softens, impetigo when the whole papule suppurates, and ecthyma or rupia when the corium is also deeply involved. Vesicles often precede pustules, the pustular eruption coming out some months after infection (later than the papular). The pustular eruption gives a very bad prognosis. Rupia is formed by a pustule rupturing or a papule ulcerating, the secretion drying and forming a con- ical crust which continually increases in height and diameter, while the ulceration extends at the edges. When the crust is pulled off there is seen a foul ulcer with congested, jagged, and undermined edges. Rupia may be secondary or tertiary, and it invariably leaves scars. It appears only after at least • SYPHILIS. 175 six months have passed since the chancre began. Secondary rupia is symmetrical. 4. Tubercular syphilides are greatly enlarged papules inter- mediate between ordinary papules and gummata. Diagnosis between Secondary and Tertiary Syphilides.—A secondary eruption is distinguished from a tertiary eruption by the following: the first tends to disappear, the second tends to persist and to spread; the first is symmetrical, the second is asymmetrical; the first does not spread at its edge, the second tends to spread at its edge, and this tendency, which is designated " serpiginous," produces an ulcer shaped like a horse-shoe (Jonathan Hutchinson). Affections of the Mucous Membranes.—The chief lesions in syphilitic affections of the mucous membranes are mucous patches, warts, and condylomata. The first phenomena of secondary syphilis are, as a rule, symmetrical ulcers of the tonsils, painless and superficial (Hutchinson). The borders of the ulcers are gray, and the areas are reniform in shape. They rarely last long. Catarrhal inflammations often occur. Eruptions appear on the mucous membranes or upon the skin. Mucous patches are papules deprived of epithelium; they are gray in color, are moist, and give off an offensive and virulent discharge. They usually appear as areas of congestion, swelling, and abrasion of the epidermis upon the lips, palate, gums, tongue, cheeks, vagina, labiae, vulva, scrotum, anus, and under the prepuce. A moist papule of the skin is really a mucous patch. These patches, which are always circular or oval, are among the most constant lesions of the secondary stage, appearing from time to time during many months. If a patch has the papillae destroyed, it is called a " bald patch." If the papules present hypertrophied papillae fused together, there appear enlargements with flat tops termed "condylomata;" if the papillae of the papule hypertrophy and do not fuse, the growths are called " warts." 176 A MANUAL OF SURGERY. Mucous lesions of the mouth are commonest in smokers and in those with bad or neglected teeth. Hutchinson says that persistence in smoking during syphilis may cause leuco- mata, or persistent white patches. The larynx may suffer from inflammation, eruptions, and ulceration (hence the hoarse voice which is so usual). The nasal mucous mem- brane may also suffer. Affections of the Hair.—In syphilitic affections the hair is shed to a great extent. This loss may be widespread (beard, mustache, head, eyebrows, pubic hair, etc.) or it may be limited. Complete baldness sometimes ensues, but this is rarely permanent. The hairs are first noticed to come out on the comb; on pulling them they are found loose in their sheaths—so loose that Ricord has said " a man would drown if a rescuer could pull only upon the hair of the head." This falling out of the hair, which is known as " alopecia," begins soon after the fever or about the time of the eruption, but it may be postponed. The skin of a syphilitic bald spot is never smooth, but is scaly. The hair may thin generally, baldness may appear in twisting lines, or it may be complete only in limited areas. Alopecia results from shrinking of the hair-pulp, death of the hair, and casting off of the sheath. Affections of the Nails.—Paronychia is inflammation and ulceration of the skin in contact with a nail and extending to the matrix. The nail is cast off partially or entirely. Onychia is manifested by white spots, brittleness or extended opacity, twisting, and breaking off of the nail. The parts around are not affected. The damaged nail drops off and another diseased nail appears. Affections of the Ear.—Temporary impairment of hearing in one or both ears is not uncommon in syphilitic affections of the ear. Rarely, permanent symmetrical deafness is pro- duced. Meniere's disease is sometimes caused by syphilis. Affections of the Bones and Joints.—In syphilis there • SYPHILIS. 177 may be slight and temporary periostitis. Pain and tender- ness arise in various bones, the pain being worse at night (osteoscopic pains). The bones usually involved are the tibiae, clavicles, and skull. Pain like that of rheumatism affects the joints. Local periostitis may form a soft node which by ossification becomes a hard node. Affections of the Eye.—Iritis is the commonest trouble • of the eyes. It appears from three to six months after the chancre, and begins in one eye, the other eye soon becoming affected. The symptoms are a pink zone in the sclerotic, ciliary congestion, muddy iris, irregular pupil accentuated by atropine, pain and photophobia, and sometimes hazy or even blocked pupil. Rheumatic iritis causes much pain and photophobia, syphilitic iritis comparatively little; there is less swelling in the first than in the second; the former tends to recur, the latter does not. Iritis is usually recovered from, • good vision being retained. Diffuse retinitis and disseminated choroiditis never occur until a number of months have passed since the infection. The symptoms are failure of sight, mus- es volitantes, and very little photophobia. Diagnosis of retinitis and choroiditis is by the ophthalmoscope. Affections of the Testes.—Syphilitic Sarcocele.—The testes enlarge from plastic inflammation. Both glands usu- ally suffer, but not always. Fluid distends the tunica vagi- nalis. The epididymis escapes. The testicle is not the seat of pain, is troublesome because of its weight, and has very little of the proper sensation on squeezing. The plastic exudate is generally largely absorbed, but it may organize into fibrous tissue, the organ passing into atrophic cirrhosis. Intermediate Period.—In this period no symptoms may appear, but the disease is still for some time latent and is not * cured. Symptoms may appear from time to time. These symptoms, which are called " reminders," are not so severe as tertiary symptoms ; reminders are apt to be symmetrical, and 12 i78 A MANUAL OF SURGERY. they do not closely resemble secondary lesions. Among the reminders we may name palmar psoriasis, sarcocele, sores on the tongue, a papular skin-eruption, and choroiditis. Gum- mata occur in this stage, but they are apt to be symmetrical and non-persistent. Arteritis occurs, beginning in the intima or adventitia, and causing, it may be, aneurysm, embolism, or thrombosis. Obliterative endarteritis may cause gangrene. This vascular condition is frequent in the brain; thrombosis may occur, in which case a paralysis comes on gradually, preceded by numbness, although sudden paralysis may occur. These paralyses may be limited, extensive, transitory, or per- manent. The nervous system often suffers in this stage (anaesthetic areas and retinitis). The viscera are often con- gested and infiltrated (tonsils, liver, spleen, kidneys, and lungs). Tertiary Syphilis.—This stage is not often reached, the disease being cured before it has been attained. It is re- garded by many as not so much a stage of syphilis as a condition of impaired nutrition which results from the dis- ease. This view finds confirmation in the fact that tertiary lesions do not furnish the contagion. The primary stage disappears without treatment, the secondary stage tends ulti- timately to spontaneous disappearance, but tertiary lesions tend to persist and to recur. Tertiary lesions may be single or may be widely scattered; when multiple they are not symmetrical except by accident. These lesions may attack any tissue, even after many years of apparent cure; they all tend to spread locally, they all leave permanent atrophy or thickening, they all tend to relapse, and a local influence is often an exciting cause. Tertiary skin-eruptions are liable to ulcerate. The charac- teristic syphilide is rupia, which is formed by a pustule rup- turing or a papule ulcerating. A scab forms because of the drying of the discharge, ulceration continues under the scab, • SYPHILIS. 179 new scabs form, and, as the ulcer is constantly increasing peripherally, the new scabs are larger in diameter than the old ones, and the crust assumes the form of a cone. An ulcer is exposed by tearing off the scab, which ulcer has destroyed the deeper layers of the skin, and on healing always leaves a permanent scar. Ulcers are common in tertiary syphilis. They are frequent on the legs, especially about the knees. A syphilitic ulcer is usually crescentic, its edges are thin and sharp, its base is foul and sloughy, and its discharge is scanty and tenacious. Gumma.—The gumma is the typical tertiary lesion. A gumma arises from an inflammation the products of which cannot organize for want of sufficient blood-supply, and consequently they undergo fatty degeneration. A gumma presents a centre of gummy degeneration, a surrounding area of immature fibrous tissue, and an outer zone of embryonic tissue and leucocytes. A gumma, when it is spontaneously evacuated, exhibits a small opening with very thin under- mined edges ; the ulcer is slow to heal, and forms a depressed scar. A gumma in the internal organs may become a fibrous mass. These gummata form in the skin, subcutaneous tissues, muscles, tongue, joints, bursae, testes, spinal cord, brain, and internal organs. In tertiary syphilis an inflammation may not form a circumscribed gumma, but, instead, may produce a diffuse degenerating mass. This type of inflammation, which is seen in bones, is called " gummatous." A healing gumma in a mucous canal such as the rectum or larynx causes thickening and stricture. Tertiary syphilis is a most common cause of amyloid degenerations and arterial and nervous sclerosis. Various Lesions.—Hutchinson enumerates the lesions of tertiary syphilis as follows: Periostitis, forming nodes or causing sclerotic hypertrophy or suppuration or necrosis; gummata in various parts; disease of the skin of the type i8o A MANUAL OF SURGERY. of rupia or lupus; gumma or inflammation of tongue, causing sclerosis; structural changes in the nervous system, causing ataxia, ophthalmoplegia externa and interna, general paresis, optic atrophy, and paralyses of cerebral nerves; amyloid degenerations; and chronic inflammation of certain mucous membranes (of the mouth, pharynx, vagina, rectum, etc.), with thickening and ulceration. Visceral Syphilis.—In visceral syphilis the lungs may undergo fibroid induration (syphilitic phthisis). Syphilitic phthisis is a non-febrile malady. Gummata may form in the heart, liver, spleen, or kidneys ; the capsule and fibrous septa of the liver may thicken, the organ being puckered from con- traction. Amyloid changes may appear in any of the viscera. Nervous syphilis may be manifest in disorders of the brain, cord, or nerves. Much of our knowledge of these conditions is due to Wood. He says brain syphilis is usu- ally a late phenomena (from one to thirty years), and is more apt to appear after light secondaries. The lesion may be gumma of the membranes (tumor), gummatous meningitis, arterial atheroma, or obliterative endarteritis. A gumma may eventuate in a scar, a cyst, or a calcareous mass. The symp- toms of brain syphilis depend on the nature, seat, and rate of development of the lesions. It is to be noted that syphilitic palsy is apt to be limited, progressive, and incom- plete. Epilepsy appearing after the thirtieth year is very probably specific if alcohol can be ruled out. Persistent headache, insomnia or somnolence, transitory limited pal- sies, unnatural slowness of utterance, amnesia, vertigo, and epilepsy are very suggestive. The more usual type of in- sanity is a likeness or counterpart of general paralysis. Spinal syphilis may cause sclerosis, a condition like Landry's paralysis, softening, and tumor. Neuritis is not uncommon in syphilis. Treatment of Primary Stage.—A chancre should not be SYPHILIS. l8l excised. The disease is constitutional when the chancre appears, and excision and cauterization inflict needless pain and do no good. The initial lesion should never be burned unless it is phagedaenic or becoming so. Order the patient to soak the penis for five minutes twice daily in warm salt water (a teaspoonful of salt to a cupful of water), and then to spray the sore by an atomizer with peroxide of hydrogen (14-volume solution of peroxide diluted with an equal bulk of water). The ulcer is then dried with absorbent cotton and on it is dusted a powder of equal parts of bismuth and calomel. The buboes in the groin require no local treatment unless they tend to suppurate. If they persist or become large, paint them with iodine, smear blue oint- ment over them, and apply a spica bandage of the groin. Ichthyol and lanolin make an excellent application for the enlarged glands, and so does mercurial ointment. Some authorities give mercury in this stage, claiming that it pre- vents secondaries. The late S. W. Gross opposed this strongly, and affirmed a wish to see the secondary erup- tion—first, because it proves the diagnosis; and second, because it affords valuable prognostic indications (an ery- thematous eruption means a light case; an early pustular eruption means a grave case with serious complications). Dr. White will not order mercury until constitutional symp- toms develop. Treatment of Secondary Stage.—In the secondary stage the aim is to cure the disease. That it can be cured is known from the fact that reinfection occurs in some persons. The old axiom, " Syphilis once, syphilis ever," is not true. Mer- cury must be used, the form being a matter of choice. Fournier first advocated intermittent treatment. In this plan give gr. -J- of protiodide of mercury daily for six months, then stop a month ; then give mercury for three months, then stop two months. During the first year the patient is 182 A MANUAL OF SURGERY. «t under treatment nine months, and during the second year eight months. Some prefer the intermittent and others the continuous plan of treatment. Dr. White greatly prefers the continuous plan. The rule in most cases is to give mer- cury for two years. Find the patient's dose of tolerance, and keep him on this amount. Gross's rule for continuous treatment was to order pills of the green iodide of mer- cury, each pill containing gr. £. The patient was ordered * one pill after each meal to begin with; the next day he took two pills after breakfast; the following day, two after din- ner, and so on, adding one pill every day. This advance was continued until there was slight diarrhoea, griping, a metallic taste, or tenderness on snapping the teeth together, whereupon one pill was taken off each day until all unfavor- able symptoms disappeared. This experimentation gives a dose on which the patient can be kept with entire safety for a long time, but if it is found that colic or diarrhoea is apt ». to recur, there must be added to each pill gr. -^ of opium. The patient is given mercury in this way for two years. Every time new symptoms appear the dose is raised, and as soon as they disappear it is lowered to the standard. If the protiodide is not tolerated, give the bichloride: R. Hydrarg. chlor. corros., gr. iss; Syr. sarsaparillae conip., f^iy-—M. Sig. f^j in water after meals. Mercury with chalk in 1-grain doses four times a day, with or without Dover's powder in ^-grain doses, can be used. Mercurial inunctions produce a rapid effect, but irritate the skin. There can be used once a day j4 drachm of oleate of mercury (10 per cent.) or 1 drachm of mercurial ointment, rubbed in one day on the inside of one thigh and the next <* day on the inside of the other thigh ; next, the inside of one arm and then the other arm; next, one groin and then the t SYPHILIS. l83 other groin, and so on. After the rubbing the patient puts on underclothes and goes to bed, and in the morning takes a bath. The ointment may be smeared on a rag, which is then worn between the stocking and sole of the foot during the day. Fumigation is performed by volatilizing each night 3j of calomel. The patient sits naked on a cane-seat chair, the . calomel is heated by an alcohol lamp beneath the chair, and wrapped around the patient is a blanket which drops tent- like to the floor. The skin becomes coated with calomel, and the subject, after putting on woollen drawers and an undershirt, gets into bed. Hypodermatic injections of mer- cury are used by some physicians. They cause an eruption to disappear rapidly, but may produce abscesses, and relapses are prone to occur. The usual plan is to give daily a hypo- dermatic injection of corrosive sublimate deep into the back • or buttocks, the dose being gr. \ of the drug. Thirty such injections are used unless some indication points to their dis- continuance sooner. The treatment is then stopped. If the symptoms recur, however, the patient is given another course, the daily dosage being gr. \, the treatment being again stopped after thirty injections, but continued anew in ^-grain doses if the symptoms recur. Dr. Orville Horwitz has recently made thorough trial of this method, and arrives at the following conclusions: It will not abort the disease; it should never be a routine treatment; in suitable cases it is very valuable for symptomatic use, as when lesions on the face or in important structures make a rapid impression de- sirable or necessary ; in cases which obstinately relapse under other treatment, and in syphilis of the nervous system. Dr. J. William White, who has the right to speak authori- * tatively, says that hypodermatic injections of corrosive sub- limate are painful and are strongly objected to by many patients; that this method of treatment is occasionally danger- 184 A MANUAL OF SURGERY. ous and even fatal; that it is liable to be followed by local complications (erythema, nodosities, cellulitis, abscess, slough- ing) ; that it cannot be carried out by the patient, but requires the surgeon's constant intervention. This distinguished syph- ilographer concludes that hypodermatic medication does not offer advantages justifying its use as a systematic method of treatment, and that it encourages insufficient treatment— those " short heroic courses " which Hutchinson shows are followed by the gravest tertiary lesions. " The claim that by a few injections the time of treatment can be measured by months or even by weeks, instead of by years, would seem, as Mauriac has said, to involve the idea that mercury given hypodermatically acquires some new and powerful curative property which, given in other ways, it does not possess."1 In whatever way mercury is given, do not let it salivate (hydrargyrism). Acute Ptyalism, or Salivation.—In acute ptyalism the j saliva becomes thick and excessive in amount; the gums become tender (found first by snapping the teeth), spongy, and tend to bleed; a metallic taste is complained of; the breath becomes fetid; all the oral structures swell; the teeth loosen; the saliva is enormously increased; and there are purging, colic, and exhaustion. A chronic hydrargyrism may be shown by gastro-intestinal disorder, emaciation, mental depression, weakness, albuminuria, and tremor. To avoid salivation cautiously advance the dose and instruct the patient as to the first signs. He should use a soft tooth- brush and an astringent mouth-wash (gr. xlviij of boracic acid to §iv each of listerine and water). When ptyalism begins, stop the drug. Employ the above mouth-wash or one composed of a saturated solution of chlorate of potas- sium. Order gr. y^- of atropine twice a day, and in bad 1 Prof. J. William White, in Morrow's System of Genito-urinary Diseases, Syphilis, and Dermatology. I S YPHILIS. I85 cases spray the mouth with peroxide of hydrogen and use silver nitrate locally (gr. xx to §j). A weekly Turkish bath is of great use. In chronic hydrargyrism stop the drug, use tonics, stimulants, open-air exercise, Turkish baths, and good food. The chloride of gold and sodium forms a good sub- stitute drug. Treatment of Complications in Secondary Stage.—The com- plications of the secondary stage usually require local appli- cations in addition to general remedies. Mucous patches in the mouth should be touched with bluestone every day, an astringent mouth-wash being employed several times daily. If the patches ulcerate, they should be touched twice a day with lunar caustic ; if these areas proliferate, they should be excised and burned. Vegetations or growing papules on the skin must, if calomel powder fails to remove them, be cut away with scissors and be cauterized with chromic acid or with the Pacquelin cautery. Condylomata demand wash- ing with ethereal soap several times daily, thorough drying, dusting with equal parts of calomel and subnitrate of bis- muth or with borated talcum, and covering with dry bichlo- ride gauze. If these simple procedures fail, then excise and cauterize. For psoriasis of the palms and soles diachylon ointment, mercurial plaster, or painting with tincture of iodine should be employed. Ulcers of paronychia are dressed with iodo- form and corrosive-sublimate gauze. Deep cutaneous ulcers are cleaned once a day with Johnson's ethereal soap, then sprayed with peroxide of hydrogen, dressed with iodoform and corrosive-sublimate gauze, and bandaged. When granu- lation is well established dress with I part of unguent. hydrarg. nitratis to 7 parts of cosmoline. In sarcocele mercurial ointment should be used or the testicle be strapped. Alopecia requires that the hair be kept short and every night the scalp be cleaned with equal parts of 186 A MANUAL OF SURGERY. green soap and alcohol rubbed into a lather with water. After the soap is washed out some hair tonic should be rubbed into the scalp with a sponge. In treating persistent skin-lesions, inunctions, injections, or fumigations may be used; some prefer mercurial baths. Baths are suited to patients with delicate skins, to those whose digestion fails from mercury by the stomach, and to those whose lungs will not tolerate fumigations. Half an ounce of corrosive sublimate with 4 scruples of sal ammoniac are mixed in about 4 ounces of water; this is added to a bath at a temperature of 95°. The patient gets into this bath, covers the tub with a blanket, leaving only his head exposed, and remains in the bath an hour or so. These baths may easily cause salivation. In every case of syphilis, no matter what constitutional or local treatment is used, the general health of the patient must be watched and the use of tobacco be stopped, as the latter renders certain the arrival of mucous patches and causes them to persist. Alcohol as a beverage must be cut off: its use must only be as a medicine for debility and weakness of assimilation. An open-air life to a great degree must be insisted upon, and care be observed as to protection from damp and cold. Order flannels in winter. Have the patient sponge the chest and shoulders every morning with cold or with tepid water and then with alcohol, drying himself with a rough towel, and take a hot bath twice a week or a Turkish bath once a week. He should wash the anus and nates after every stool, and ought to dust the axillae, scrotum, perineum, and internatal region once a day with borated talc. The teeth are to be looked to and put in perfect order, a soft brush being used twice a day and an astringent mouth-wash being frequently employed. Meat and milk are largely to be used. The patient should be weighed weekly: any fall- ing off in weight is an indication for tonics, concentrated t SYPHLLIS. 187 food, and cod-liver oil. If a patient's health continues to fail on mercury, the drug should be stopped for some time and the patient be treated with iron, chloride of gold and sodium, baths, fresh air, cod-liver oil, and nourishing foods. Reminders require mixed treatment. Tertiary Stage.—If at any time during the case there appear tertiary symptoms, the patient should be put on # mixed treatment. In any case, after two years of mercury add iodide of potassium to the treatment. Dr. White's rule is to use this mixed treatment for at least six months (if any symptoms appear), the six-months course dating from their disappearance. This emphasizes the fact that the iodides alone will not cure tertiary syphilis. In obstinate tertiaries or in nervous syphilis the iodides should be run up to an enormous amount (from 30 to 250 grains per day). An easy way to give iodide is to order a saturated solution each drop » of which equals one grain of the drug. Each dose of the iodide is given one hour after meals and in at least half a glass of water. If the iodide disagrees, it may be given in water containing one drachm of aromatic spirits of ammonia or in milk. The iodide of sodium may be tolerated better than the potassium salt, or the iodides of sodium, potassium, and ammonium may be combined. In giving the iodides begin with a small dose. During a course of the iodide always give tonics and insist on plenty of fresh air. Arsenic tends to prevent skin-eruptions. The iodides when they disagree produce iodism—a condition which is first made manifest by running of the nose and the eyes. In some subjects there is an outbreak of acne, vesicular eruptions or even bullae, or hemorrhages. Iodism calls for a reduction in dosage, and, if severe or persistent, for the abandonment of « the drug. After the patient has been for six months under mixed treatment without a symptom, stop all treatment and await developments. If during one year no symptoms recur, i88 A MANUAL OF SURGERY. the patient is probably cured; if symptoms do recur, there must be six months more of treatment and another year of watching. Hereditary Syphilis.— Transmitted congenital syphilis is a hereditary syphilis manifest at birth. Acquired syphilis (except in the case of a woman who obtains the disease from a foetus) always presents the chancre as an initial lesion; hereditary syphilis never does. Hereditary syphilis may present itself at birth, and usually shows itself within, at most, the first six months of extra-uterine life. In rare cases (tardy hereditary syphilis) the disease does not become manifest until puberty. Rules of Inheritance.—According to Von Zeissl,1 the rules of inheritance are as follows : i. If one parent is syphilitic at the time of procreation, the child may be syphilitic. 2. Syphilitic parents may bring forth healthy children. 3. If a mother, healthy at procreation, bears a child syph- ilitic from the father, the mother must have latent pox or must be immune, having become infected through the pla- cental circulation. She often shows no symptoms, having received the poison gradually in the blood, and having thus received, it may be said, preventive inoculations. Certain it is that mothers are almost never infected by suckling their own syphilitic children (Colles's law). 4. If both parents were healthy at the time of procreation, and the mother afterward contracts syphilis, the child may become syphilitic, and the earlier in the pregnancy the mother is diseased, the more certain is the child to be tainted. This is known as " infection in utero." 5. The more recent the parental syphilis, the more certain is infection of the offspring. The children are often still- born. 1 Pathology and Treatment of Syphilis. • SYPHILIS. 189 6. When the disease is latent in the parents it is apt to be tardy in the children. 7. The longer the time which has passed since the dis- appearance of parental symptoms, the more improbable is infection of the children. 8. In most instances parental syphilis grows weaker, and after the parents beget some tainted children they bring forth healthy ones. Many women who labor under hereditary syphilis are sterile. Many syphilitic women abort, usually before the eighth month. The foetus very often dies at an early period of gestation. This may be due to a gummatous placenta or to a degeneration of placental follicles. Evidences of Hereditary Syphilis (manifest at, or oftener soon after, birth).—Hutchinson says that at birth the skin is almost invariably clear. In a few weeks " snuffles " begin, which are soon followed by a skin-eruption, by body-wasting, and by a chain of secondary symptoms (iritis, mucous patches, pains, condylomata, etc.). The child looks like a withered-up old man. Eruptions are met with on the palms and soles. Intertrigo is usual. Cracks occur at the angles of the mouth, and leave permanent radiating scars. The abdomen is tumid, and there is apt to be exhausting diarrhoea. Atrophic lesions may appear in the bones. In the skull the bone may be softened by removal of its salts or be thinned by the pressure of the brain. In the long bones the epiphyseal ends suffer, the attachment of epiphysis to shaft is weak, and separation is easily induced. Suppuration of the epiphysis is common. Osteophyte lesions of the skull are shown by symmetrical spots of thickening upon the parietal and frontal bones (nati- form skulls). In the long bones osteophytes are frequently formed. A child with precocious hereditary syphilis is apt to die, but if it lives from six months to one year the symp- toms for a time disappear and for years the disease may be 190 A MANUAL OF SURGERY. latent. When the disease begins again the symptoms are various, namely: noises in the ears, often followed by deaf- ness ; interstitial keratitis; dactylitis (specific inflammation of all the structures of a finger); synovitis in any joint; ossifying nodes ; developmental osseous defects ; suppurative periostitis; ulcerations; death of bone; falling in of nose; nervous maladies; occasionally sarcocele, etc. Diagnosis.—In the diagnosis of hereditary syphilis the condition of the teeth is of much importance : the temporary teeth decay soon, but present no characteristic defect. If the upper permanent central incisors are examined, other teeth may show defects, but in these alone are defects almost sure to appear. In hereditary syphilis they present an appearance of marked deviation from health, and are called " Hutchin- son teeth" (PI. 1, Fig. 4). If they are dwarfed, too short and too narrow, and if they display a single central cleft in their free edge, then the diagnosis of syphilis is almost cer- tain. If the cleft is present and the dwarfing absent, or if the peculiar form of dwarfing be present without any con- spicuous cleft, the diagnosis may still be made with much confidence. In early infancy the diagnosis is made by the snuffles, broad nose, skin-eruptions, wasted look, sores at the mouth-angles, tenderness over bones, condylomata, and history of the parents. The diagnosis at a later period is made by the existence of symmetrical interstitial keratitis, deafness which comes on without pain or running from the ear, ossifying nodes, white radiating scars about the mouth- angles, sunken nose, natiform skull, deformity of long bones, suppuration of epiphyses, and Hutchinson teeth. It must be remembered that a child apparently born healthy and pre- senting no secondary symptoms may show bone disease, keratitis, or syphilitic deafness at puberty. Treatment.—In infants inunctions are to be used until the symptoms disappear, but mercury must not be forced or TUMORS OR MORBLD GROWTHS. 191 continued too long after the symptoms are gone. There must be rubbed into the sole of each foot or the palm of each hand 5 grains of mercurial ointment every morning and night. Brodie advised spreading the ointment (in the strength of 3j to the ounce) upon flannel and fastening it around the child's belly. If the skin is so tender that mer- cury must be given by the mouth, White and Hearn advise that gr. -fa to gr. \ of mercury with chalk with I grain of sugar be taken three times a day after nursing. If tertiary symptoms appear, or in any case when the secondaries dis- appear, give gr. ss to gr. j or more of iodide of potassium several times a day in syrup. White advocates the continu- ance of the mixed treatment intermittently until puberty. Local lesions require local treatment as in the adult. A syphilitic child must be nursed by its mother, as it will poison a healthy nurse. If the mother cannot nurse the child, it must be brought up on the bottle. For the cachexia use cod-liver oil, iodide of iron, arsenic, and the phosphates. XVI. TUMORS OR MORBID GROWTHS. Division.—Morbid growths are divided into (1) neoplasms and (2) cysts. Neoplasms.—A neoplasm is a pathological new growth which tends to persist independently of the structures in which it lies, and which performs no physiological function. A hypertrophy is differentiated from a tumor by the facts that it is a result of increased physiological demands or of local nutritive changes and that it tends to subside after the withdrawal of the exciting stimulus. Further, a hypertrophy does not destroy the natural contour of a part, while a tumor does. Inflammation has marked symptoms: its swelling does not tend to persist, it terminates in resolution, organ- ization, or suppuration, and the microscope differentiates it from tumor. Inflammation, too, has an assignable exciting 192 A MANUAL OF SURGERY. cause. A new growth means a mass of new tissue; hence it is improper to designate as tumors those swellings due to extravasation of blood (as in haematocele) or of urine (from ruptured urethra), to displacement of parts (as in hernia, floating kidney, or dislocation of the liver), or to fluid dis- tention of a natural cavity (as in hydrocele or bursitis). Classes of Tumors.—There are two classes of tumors: the first class includes those derived from or composed of , ordinary connective tissue or of higher structures. These all originate from cells which are developed from the meso- blast. There are two groups of connective-tissue tumors: (a) the typical benign or innocent, which find their type in the healthy adult human body; and (b) the atypical or malig- nant, which find no counterpart in the healthy adult human body, but rather in the immature connective tissues of the embryo. The second class of tumors includes those which are * derived from or composed of epithelium: (a) the typical, composed of adult epithelium ; and (b) the atypical, com- posed of embryonic epithelium. Midler's Law.—Miiller's law is that the constituent ele- ments of neoplasms always have their types, counterparts, or close imitations in the tissues of a normal organism, either embryonic or mature. Virchow's Law.—Virchow's law is that the cells of a tumor spring from pre-existing cells (hence there is no special tumor-cell or cancer-cell). The term " heterologous " is no longer used to signify that the cellular elements of a tumor have no counterpart in the healthy organism, but is employed to signify that a tumor deviates from the type of the structure from which it takes its origin (as a chondroma arising from the parotid gland). 4 Tumors when once formed almost invariably increase and persist, though occasionally warts, exostoses, and fatty TUMORS OR MORBID GROWTHS. 193 tumors do disappear. Tumors may ulcerate, inflame, slough, be infiltrated with blood, or undergo mucoid, calcareous, or fatty degeneration. Causes.—The causes of tumors are not positively recog- nized, those alleged being but theories varying in probability and ingenuity. The inclusion theory of Cohnheim supposes that more embryonic cells exist than are needful to construct the fcetal tissues, that masses of them remain in the tissues, and that these may be stimulated later into active growth. This embryonic hypothesis seems to receive a certain force from the facts that exostoses do sometimes develop from portions of unossified epiphyseal cartilage, and that tumors often arise in regions where there was a suppression of a foetal part, closure of a cleft, or an involution of epithelium (epithelioma is usual at muco-cutaneous junctures). This theory, which does not explain the origin of most neoplasms, cannot suc- cessfully be maintained even as a common predisposing cause. Hereditation is extremely doubtful. S. W. Gross found hereditary influence by no means always apparent in cancer of the breast. It is affirmed by some, denied by others, and doubted by a number. At most, hereditary influence can only predispose. Injury and inflammation may undoubtedly prove exciting causes. A blow is not infrequently followed by sarcoma; the irritation of a hot pipe-stem may excite cancer of the lip ; the scratching of a jagged tooth may cause cancer of the tongue; chimney-sweeps' cancer arises from the irritation of dirt in the scrotal creases; and warts often arise from constant contact with acrid materials. Physiological activity favors the development of sarcoma, and physiological decline favors the development of cancer. Parasitic Influence.—This theory does not maintain that the tumor is the parasite, but that it contains the parasite. 13 194 A MANUAL OF SURGERY. Some facts render a parasitic origin of malignant growths not improbable; as, for instance, the likeness of some tumors to infective granulomata, their occasional secondary development in distant parts of the body, the resemblance of the secondary to the primary growths, and the tenacity of their persistence. It is only just to state, however, that tumors do not seem to be hetero-inoculable. A parasitic origin of cancer is pointed to by its geographical distribution, the disease being very common in low and marshy districts (Havilland). Actinomycosis, long thought to be a true tumor, is now known to arise from the ray-fungus. There can be no doubt that changes in the liver which practically constitute a new growth can arise from the growth of a cell called by Darier the " psorosperm." A disease due to psorosperms is called a "psorospermosis." It is affirmed by some that molluscum contagiosum, follicular keratosis, cancer, and Paget's disease are due to psorosperms. Some claim to find the parasite in all cases of cancer, while others can find it in only four or five per cent, of the cases. Heneage Gibbes affirmsx that dilatation of the bile-ducts of a rabbit's liver is caused by the chronic irritation arising from multiplication of the coccidium oviforme in them, and not in the columnar cells of the bile-ducts, as has been stated ; and, further, that the large majority of glandular cancers show nothing that can be considered parasitic, the suspicious appearances noted in some few cases being due to endoge- nous cell-formation. This coccidium oviforme is a genus of the sporozoa, class protozoa, the lowest division of the animal kingdom. To this class belong the monera and infusoria. Malignant and Innocent or Benign Tumors.—Malignant growths infiltrate the tissues as they grow; benign tumors only push the tissues away; hence malignant tumors are not thoroughly encapsuled, while innocent tumors are 1 The American Journal of Medical Sciences, July, 1893. TUMORS OR MORBID GROWTHS. 195 encapsuled. Malignant tumors grow rapidly; innocent tumors grow slowly. Malignant tumors become adherent to the skin and cause ulceration; innocent tumors rarely adhere and rarely cause ulceration. Many malignant tumors give rise to secondary growths in adjacent lymphatic glands (cancer, except in the stomach, gullet, and upper jaw, always so tends); sarcoma does not cause them, unless it be mel- anotic or unless it arises from the testicle or tonsil. Inno- cent tumors never cause secondary lymphatic involvement, although the glands near the tumor may enlarge from accidental inflammatory complications. The malignant tu- mors, especially certain sarcomata and soft cancers, may be followed by secondary growths in distant parts and various structures (bones, viscera, brain, muscles, etc.); innocent tumors are not followed by these secondary reproductions, although multiple fatty tumors or multiple lymphomata may exist. Malignant tumors destroy the general health; inno- cent tumors do not. Malignant tumors tend to recur after removal; innocent tumors do not if operation was thorough. Classification.—Tumors may be classified as follows: I. Connective-tissue tumors. 1. Innocent tumors, or those composed of mature con- nective tissue : Lipomata, or fatty tumors; fibromata, or fibrous tu- mors ; chondromata, or cartilaginous tumors; osteo- mata, or bony tumors ; odontomata, or tooth-tumors; myxomata, or mucous tumors ; myomata, or muscle- tumors ; neuromata, or tumors upon nerves ; angeio- mala, or tumors formed of blood-vessels ; lymphau- geiomata, or tumors formed of lymphatic vessels; and lymphomata, or tumors of lymphatic glands. 2. Malignant tumors, or those composed of embryonic connective-tissue: Sarcomata. 196 A MANUAL OF SURGERY. II. Epithelial tumors. 1. Innocent tumors, or those composed of mature epi- thelial tissue: Adenomata, or tumors whose type is a secreting gland ; and papillomata, or tumors whose type is found in the papillae of skin and mucous membranes. 2. Malignant tumors, or those composed of embryonic epithelial tissue: Carcinomata, or cancers. 1. Innocent Connective-tissue Tumors.—The growths mimic or imitate some connective tissue or higher tissue of the mature and healthy organism. Lipomata are tumors composed of fat contained in the cells of connective tissue, which cells are bound together by fibres. If the fibres are excessively abundant, the growth is spoken of as a " fibro-fatty tumor." A fatty tumor has a distinct capsule, tightly adherent to surrounding parts, but loosely attached to the tumor; hence enucleation is easy. Fibrous trabeculae run from the capsule of a subcutaneous lipoma to the skin; hence movement of the integument over the tumor or of the tumor itself causes dimpling of the skin. Lipomata are most frequent in middle life, and their com- monest situations are in the subcutaneous tissues of the back or of the dorsal surfaces of the limbs; they usually occur singly, but may be multiple and sometimes symmetrical. A lipoma is soft, doughy, mobile, lobulated, of uniform con- sistence, and may give on tapping a tremor or pseudo- fluctuation. The skin over a fatty tumor sometimes ulcerates from pressure ; the tumor itself may inflame or partly calcify. When a lipoma has once inflamed, it becomes immovable. The commonest situation for lipomata is in the subcutaneous layer of fat. Subcutaneous lipoma of the palm of the hand or sole of the foot resembles a compound ganglion, and it is apt to be congenital. Lipomata of the head and face are TUMORS OR MORBID GROWTHS. 197 rare. In the subcutaneous tissues of the groins, neck, pubes, axillae, or scrotum a mass of fat may form, unlimited by a capsule and known as a "diffuse lipoma." A naevo- lipoma is a naevus with much fibro-fatty tissue. Fatty tumors may arise in the subserous tissue, and when arising in either the femoral or inguinal canals or the linea alba they resemble omental hernias and are spoken of as " fat- herniae." In the retroperitoneal tissues enormous fibro-fatty tumors occasionally grow, and these neoplasms tend to become sarcomatous. Lipomata may arise from beneath synovial membranes and will project into the joints, being still covered by synovial membrane. Fatty tumors occa- sionally arise in submucous tissues, between or in muscles, from periosteum, and from the meninges of the spinal cord (Bland Sutton). Treatment.—A single subcutaneous lipoma is to be re- moved. Open the capsule, tear out or dissect out the mass, and always drain for twenty-four hours, or butyric fermenta- tion will be apt to occur. Multiple subcutaneous lipomata, if very numerous, should not be interfered with unless troublesome because of their size or situation, when they should be removed. Diffuse lipomata cannot be removed entirely, and operation is useless. Liquor potassae has been recommended to limit growth; it is to be taken internally for a considerable time, but it seems to be useless. Sub- peritoneal lipomata are never diagnosticated until the belly has been opened or the growth has been removed. Fibromata are tumors composed of wavy fibrous bundles. A fibroma has no distinct capsule, though surrounding tis- sues are so compressed as to simulate a capsule. Fibromata are most usual in young adults, but they may occur at any period of life, and are hard and movable. Pure fibromata, which are rare, are generally solitary, grow slowly, are of uniform consistence, and have not much circulation. Soft 198 A MANUAL OF SURGERY. fibromata grow more rapidly than do the hard, may become quite large, are apt to have distinct pedicles, and arise gen- erally from the scrotum, labia, uterus, and on the inner sur- face of the arm or the thigh. Hard fibromata grow slowly; they may form upon nerves, they may arise in the mammary gland, and they may spring from various fibrous membranes, from the periosteum of the nasal bones (fibrous polypi), and from the gums (fibrous epulides). Fibromata may become cystic, calcareous, osseous, or sarcomatous. A painful subcutaneous tubercle, which is a form of fibroma commonest in females, arises in the subcutaneous cellular tissue, usually of the extremities. It is firm, very tender, movable, rarely larger than a pea, and the skin over it seems healthy. Violent pain occurs in paroxysms and radiates over a considerable area of which the tubercle is the centre. These paroxysms may occur only once in many days or many times in one day. Nerve-fibrillae have never been found in these tubercles. Fibrous epulis is a fibroma arising from the gums or peri- odontal membrane (Bland Sutton) in connection with a carious tooth or retained snag; it is covered by mucous membrane, grows slowly, may attain a large size, and some- times has a stem, but is more often sessile. It may undergo myxomatous change or may become sarcomatous. Fibrous tumors may arise from the ovary, the intestine, and the lar- ynx. Pure fibromata of the uterus are very rare, but fibro- myomata are very common (see Myomata, p. 204); hence the term " uterine fibroid " should be abandoned. Molluscum fibrosum is an overgrowth of the fibrous tissue of both skin and subcutaneous structure. It may be limited or widely extended; it may appear as an infinite number of nodules scattered over the entire body or as hanging folds of fibrous tissue in certain areas. Keloid is a hard fibrous - growth arising in scar-tissue; it is crossed by pink, white, TUMORS OR MORBLD GROWTHS. 199 or discolored ridges, and is named from a fancied likeness to the crab. It is more common in negroes than in whites, and is most frequent in the cicatrices of burns, though it may arise in the scar of any injury, as the scar from piercing the ears, and in the scars of syphilitic lesions, small-pox, or vaccination. It is rare in early childhood and in old age. It grows slowly, lasts for many years, and may eventually , undergo involution and disappear. Morphea, or spontaneous keloid, is a name used to desig- nate a growth of this description which does not arise from a scar; but it seems certain that scar-tissue was present, though possibly in small amount from trivial injury. Treatment.—Enucleate fibromata; do not let them remain, as any fibrous tumor might become a sarcoma. Epulis requires the cutting away of the entire mass, the removal of the related snag or carious tooth, and sometimes the biting away • of a portion of the alveolus with a rongeur forceps. Keloid should not be operated upon: it will only return, and will also recur in the stitch-holes. Trust to time for involution, or use pressure with flexible collodion, by which method Prof. DaCosta cured a case following small-pox. Chondromata (enchondromata) are tumors formed either of hyaline cartilage, of fibro-cartilage, or of both. Chondro- mata are apt to occur in the long bones, the pelvis, the rib-car- tilages, and the bones of the hands or feet, and often spring from unossified portions of epiphyseal cartilage. They may be single or multiple, are often nodulated, and are most com- monly met with in the young. They have distinct adherent capsules ; they grow slowly, progressively hollowing out the bones by pressure; they cause no pain ; they impart a sen- sation of firmness to the touch, unless mucoid degeneration • forms zones of softness or fluctuation ; they are inelastic, smooth or nodular, immovable, and often ossify. Chondro- mata may grow to an enormous size. A chondroma of the 200 A MANUAL OF SURGERY. parotid gland or testicle always contains sarcomatous ele- ments, and any chondroma may become a sarcoma. Chon- dromata are notably frequent in persons who had rickets in early life. Ecchondroses, which are " small local overgrowths of cartilage " (Bland Sutton), arise from articular cartilages, especially of the knee-joint, and from the cartilages of the larynx and nose. Loose or floating cartilages in the joints may be broken-off ecchondroses or portions of hyaline car- tilage which are entirely loose or are held by a narrow stalk, and which arise by chondrification of villous processes of the synovial membrane; only one or vast numbers may exist; one joint may be involved, or several; they may produce no symptoms, but usually produce from time to time violent pain and immobility by acting as a joint-wedge. Treatment.—Remove chondromata whenever possible, for, if allowed to remain undisturbed, they are apt to resent this hospitality by becoming sarcomatous. Incise the cap- sule and take away the growth, using chisels and gouges if necessary. Incomplete removal means inevitable recur- rence. Amputation is very rarely demanded. Loose bodies in the joints, if productive of much annoyance, are to be removed, the joint being opened with the strictest antiseptic care. Osteomata.—Bland Sutton says that osteomata are ossify- ing chondromata. Compact osteomata, which are identical in structure with the compact tissue of bone, occur in the frontal sinus, mastoid process, external auditory meatus, and in other regions in those beyond middle life; they are small, capped with cartilage, smooth, round, with small, occasion- ally cartilaginous bases, and are densely hard. Cancellous osteomata, which comprise the great majority of bone-tumors, are similar in structure to cancellous bone. They spring from, and are crusted with, cartilage; they may have fibrous capsirles, and are often movable when recent, , TUMORS OR MORBID GROWTHS. 201 but soon become fixed; they have a broad base, are angled, nodular, firm (but not so hard as are the compact osteomata), painless except by pressure, occur particularly at the ends of long bones, may grow to large size, and are commonest in youth. Osteomata near joints become overlaid by bursas which in rare instances communicate with their related joints. The term exostosis has been used as being synonymous • with osteomata, but wrongly so, as an exostosis is an irregu- lar, local, bony growth which does not tend to progress beyond a certain point, and which is hence not a tumor. A true exostosis is seen in the ossification of a tendon-inser- tion, in a limited growth from the maxillary bones, and in a local growth from the last phalanx of the big toe, which growth is known as a " sub-ungual exostosis." The bony masses sometimes found in the brain, lungs, testicle, various glands, and tumors are not true osteomata. * Treatment. —Osteomata which are non-productive of pain or trouble do not demand removal. If they produce pain by pressure, if they press upon important structures, if they produce annoying deformities, or if they grow rapidly, then remove them by means of chisels, gouges, or by the surgical engine. Exostosis of the toe should always be removed, to do which the nail should be split and part of it taken away, and the bony mass be gouged away or be cut off with forceps. Odontomatax are tumors composed of tooth-tissue and springing from the germs of teeth or from developing teeth. Bland Sutton divides them into (i) those springing from the follicle; (2) those springing from the papilla; and (3) those springing from the whole germ. Epithelial odontomes, or multilocular cystic tumors, arise from the follicle, occur oftenest in the lower jaw, dilate the * bone, have capsules, and are made up of masses of cysts 1 This section is abridged from Bland Sutton's striking chapter upon odontomes in his recent work on Tumors. 202 A MANUAL OF SURGERY. n which are filled with brown fluid. These cysts are met with most frequently before the age of twenty. Follicular odontomes, or dentigerous cysts, oftenest spring from the follicles of the permanent molars. In a dentigerous cyst there exists an expanded follicle which distends the bone, the follicle being filled with thick fluid and containing a portion of a tooth. A fibrous odontome is due to thickening of the tooth-sac, thus preventing eruption of the tooth; fibrous * odontomes are usually multiple, and are apt to occur in rickety children. A cementome is due to enlargement, thickening, and ossification of the capsule, the developing tooth being encased in cement. A compound follicular odon- tome is due to ossification of portions only of an enlarged and thickened capsule, and the tumor contains bits of cementum, portions of dentine, or small misshapen teeth. A radicular odontome springs from the papilla and arises after the crown of the tooth is formed and while the roots are * forming; hence it contains dentine and cement, but no enamel. Composite odontomes are formed of irregular shape- less masses of dentine, cement, and enamel. All the above forms occur in man. They present themselves as hard tumors associated with teeth or in an area where teeth have not erupted. They may distend the jaw. Occasionally an odontome simulates necrosis; it is surrounded by pus, and a sinus forms. t Treatment.—The diagnosis is scarcely ever made until after incision; hence, be in no haste to excise large por- tions of bone for a doubtful growth ; incise first and see if it be an odontome, which requires only the removal of an implicated tooth, curetting with a sharp spoon, and packing with iodoform gauze. Myxomata are tumors composed of mucous tissue. The *' tissue type of these tumors is found in the vitreous humor of the eye and in the perivascular tissues of the umbilical TUMORS OR MORBID GROWTHS. 203 cord. Bowlby states that myxomata are in reality soft fibromata whose intercellular substance has been replaced by mucin. Myxomata may result from myxomatous degen- eration of cartilage, of muscle, or of fibrous tissue. These tumors are soft, elastic, usually pedunculated, tremulous, and vibratory. Cutting into them causes a straw-colored fluid to exude ; they grow slowly, have but little circulation, and their diagnosis may be impossible before removal. Some patholo- gists place myxomata among the malignant tumors, but most consider them as benign tumors, though they tend strongly to become sarcomatous (myxosarcomata). A sarcoma may undergo myxomatous degeneration. Myxomata may arise from the skin; from the mucous membrane of the nose, the frontal sinus, the antrum, the womb, and the tympanum (gelatinous polyps); from the parotid and mammary glands; from the subcutaneous tissue, the nerve-sheaths, the intermuscular septi, the rectum, and the bladder (polyps). Nasal polypi grow from the mucous membrane over the turbinated bones; they are soft and jelly-like, of a grayish color, and have stems or pedicles; they may be seen through the anterior nares, may project behind the veil of the palate, and may bulge out the passages of the nose; they may be, and usually are, multiple; they may be present in one nasal fossa or in both; and they occur most com- monly in young adults. Hydatid moles of pregnancy are due to myxomatous changes in the chorion. Treatment.—In treating myxomata, remove them when- ever possible. Nasal polyps may be twisted off or be re- moved by the wire snare or galvano-cautery. Lymphomata are tumors composed of lymphatic-gland structure, and are due to multiplication of pre-existing adenoid tissue. Lymphomata are most frequently encoun- 204 A MANUAL OF SURGERY. « tered in the neck and axillae, and one gland or many may be involved; they grow rapidly and attain a large size ; they are painless, are encapsuled, and are freely movable beneath the skin; they do not infiltrate surrounding tissues, and present no thickening from inflammation; they are com- monest between the ages of twenty and thirty-five, but they may occur in early life. Gross states that the enlarge- ment usually begins upon one side of the neck, gland after gland being successively attacked ; in from four to eighteen months the glands of both sides of the neck, the axillae, the bronchi, and the mesentery become involved, the patient's health fails, and death soon ensues. These tumors are said not to be malignant, but certain it is that they tend to recur after removal. It is impossible to distinctly separate this disease from lymphadenoma: they probably are related, or possibly are identical. Sarcoma of a lymphatic gland arises later in life than does lymphoma; it infiltrates surrounding structure, rendering the growth immovable, and implicates the related glands only, gluing them together; the tumor is painful and the skin ulcerates. Lymphoma differs from tubercular lymphadenitis in many ways. It originates in an apparently healthy person, it has no tendency to sup- puration, the growths do not infiltrate, they remain movable, and the overlying skin retains a healthy appearance. Treatment.—If possible, entirely extirpate a lymphoma; but if complete removal is impossible, perform no operation. In inoperable cases order cod-liver oil and nutritious diet, insist an open-air exercise, employ inunctions of ichthyol, give courses of arsenic in advancing doses, and from time to time administer iodide of potassium and iron in some form. Fowler's solution as an injection into the growth finds some advocates. Myomata are tumors composed of unstriped muscle-fibre mixed often with fibrous tissue (leiomyomata). Tumors TUMORS OR MORBID GROWTHS. 205 composed of striated muscle-fibre (rhabdomyomata) are very rare and are always sarcomatous. Leiomyomata are found in the womb, in the prostate gland, in the walls of the gullet, vagina, stomach, bladder, and bowel, in the broad ligament, ovary, and round ligament, in the scrotum, and in the skin. Myomata usually begin during or after middle age; they are encapsuled, they grow slowly, they are firm and hard, and they produce annoyance by their size and weight or by obstructing a viscus or channel. A leiomyoma of the posterior and middle of the prostate forms "a middle lobe." The so-called " uterine fibroid " is a myoma or fibromyoma. Uterine myomata may originate within the walls of the womb (intramural myomata), from the muscular structure of the mucous lining (submucous myomata), or from the muscular tissue of the serous covering (subserous myomata). Intra- mural uterine myomata may be single or be multiple and may grow to an enormous size. Submucous myomata pro- ject into the cavity of the womb (fleshy polyps). Sub- mucous myomata distend the uterus and are often accom- panied by menorrhagia or metrorrhagia; they may project into the vagina. In some rare cases the projecting tumor is detached by nature and the patient is cured; in other cases the myoma becomes gangrenous. This form of tumor may produce inversion of the fundus of the womb. Subserous uterine myomata cause trouble only by the inconvenience of weight or the discomfort of pressure. Uterine myomata may undergo fatty, calcareous, or myxomatous change, and may be infected by septic organisms as a result of the use of a uterine sound or of infection of the pedicle after oophorectomy. Infection of a uterine myoma causes great enlargement, elevated temperature, sweats, and exhaustion. Uterine myomata, which are commonest in single women (Bland Sutton), arise most frequently between the ages of 206 A MANUAL OF SURGERY. t twenty-five and forty-five. They may never produce any symptoms; some, by enlarging until they ascend above the pelvic brim, produce abdominal distention; some become jammed or impacted in the pelvis, and produce by pressure retention of urine, obstruction to passage of feces, or hydro- nephrosis. Impaction may occur temporarily at each men- strual period. Many myomata produce uterine hemorrhage ; some cause retroversion of the womb; some protrude from the cervical canal; some are so large that they cause dis- astrous pressure upon the colon (constipation), upon the iliac veins (intense oedema), or upon the ureters (hydro- nephrosis). Uterine myomata usually shrink after the meno- pause. Pregnancy in a myomatous womb usually ends in abortion. The symptoms of myomata of the alimentary canal are similar to or identical with the symptoms of malignant growths. Myomata of the skin are rare growths ; they are encapsuled, firm or elastic, and painless. Treatment.—Cutaneous myomata are removed in the same manner as fatty tumors. Uterine myomata are treated by rest, ergot, barium chloride, and dilute sulphuric acid. If this treatment fails to arrest serious bleeding due to a fleshy polyp, dilate the cervical canal and remove the growth. If there be dangerous bleeding in a woman who has some years to wait for the menopause and who has not a remov- able polyp as the cause, perform oophorectomy in order to bring on an artificial menopause. When a myoma becomes impacted at each menstrual period, remove the ovaries and Fallopian tubes. Hysterectomy is indicated for some very large tumors, for tumors that grow after the menopause, and for infected myomata. If the abdomen be opened to perform oophorectomy, and the tubes and ovaries are found so im- plicated in the growth that they cannot be removed com- pletely, or the broad ligament is found so drawn out that a TUMORS OR MORBLD GROWTHS. 207* safe pedicle cannot be secured, perform a hysterectomy.1 A recent suggestion for the shrinkage of uterine myomata is to ligate both the uterine and ovarian arteries. If a myoma of the prostate causes severe obstruction, effect a suprapubic cystotomy and remove the major portion of the enlarged gland. Neuromata.—A true neuroma springs from nerve-tissue » (brain, cord, or nerve-trunks); it is composed of medullated or non-medullated nerve-fibres which form a plexus or net- work and which are not continuous with the fibres of the nerve-trunk or other area from which the tumor grows. True neuromata, which are rare growths, arise during mid- dle life; they are small in size, are due to injury or hered- itary tendency, and they may be single or multiple. There is usually around the tumor, rather than in it, severe neuralgic pain, which is greatly intensified by dampness, by * blows, or by rough handling. The parts below a neuroma are cold, swollen, often anaesthetic, and frequently present motor paralysis or trophic disorder. A false neuroma or neuro-fibroma is a tumor growing from a nerve-sheath, and is identical in structure with the sheath. False neuromata may be single, but they are often multiple; they may be as small as peas or as large as oranges ; they are smooth and movable, and may cause great pain or may only hurt when » pressed or struck; they may spring from roots, trunks, or branches, and they may be linked with the disease known as " molluscum fibrosum." In plexiform neuroma some branches of a nerve enlarge and lengthen like an artery in a cirsoid aneurysm ; the mass feels like beads or like a bag of worms; it is mobile, and no pain is felt on moving it; and it is generally congenital. In plexiform neuroma the nerve-sheath undergoes myxomatous change. Malignant 1 See Bland Sutton's admirable article on " Uterine Myomata" in his work on Tumors. •208 A MANUAL OF SURGERY. neuroma means primary sarcoma of a nerve-sheath, though any neuroma may become sarcomatous. Traumatic neuromata are occasionally well exhibited after nerve-section or amputation. On nerve-section the distal end shrinks and atrophies, the proximal end enlarges and becomes bulbous. These traumatic neuromata are composed of fibrous tissue which contains nerve-fibres ; they are usually, but not always, painful on pressure or during dampness, and they are commonest in stumps which did not heal by first intention. Painful subcutaneous tubercle is considered under the head of Fibromata. Treatment.—A false neuroma is to be removed, if possible, without destroying the nerve-trunk. If, in removing a neur- oma, it is necessary to exsect a portion of a nerve-trunk, always endeavor to suture the ends so as to facilitate resto- ration of function. For multiple neuromata—at least should the number be large or should molluscum fibrosum exist— surgery can do nothing. Plexiform neuromata may often be removed, but amputation may be required. Painful neuro- mata in stumps should be excised. Angeiomata.—These vascular or erectile tumors are growths composed of blood-vessels. Simple or capillary angeiomata, or "mother's marks," which affect the skin or subcutaneous tissue, are composed of enlarged and twisted capillaries and of anastomosing vessels surrounded by fat. These growths are congenital or appear in the first few weeks of life ; they are of a bright-pink color if composed chiefly of arterioles, and are bluish if com- posed mainly of venules ; they are but little elevated ; they can be almost completely emptied by pressure; they occasion- ally pass away spontaneously, but usually grow constantly and may become cavernous ; they may ulcerate and occasion violent or fatal hemorrhage. One or several large vessels join a naevus to adjacent blood-vessels. Port-wine or claret TUMORS OR MORBID GROWTHS. 209 stains are pink or blue discolorations due to superficial naevi of the skin; they may be small in extent or they may involve a very large area, and are not elevated. Teleangi- ectasis is a form of naevus involving the skin and subcu- taneous tissue in which many arterioles and venules exist. Simple angeiomata are common on the forehead, the scalp, the face, the neck, the back, and the extremities. They may • appear on the labiae, the tongue, or the lips. Cavernous angeiomata resemble in structure the corpora cavernosa of the penis; there are large spaces with thin walls carrying blood, and there may be distinct vessels as well. Arteries send blood into the spaces, and veins receive it from the spaces. These channels and sinuses are enor- mously distended capillaries. Cavernous angeiomata arise in the skin and subcutaneous tissues ; they are usually congeni- tal, but may develop from simple angeiomata. These cav- * ernous angeiomata are purple or blue in color, are distinctly elevated, and are apt to pulsate; they may be emptied by pressure, and often look like cysts with very thin walls. Cavernous angeiomata may arise in the breast, the tongue, or the muscles. If an angeioma contains an excess of fat, the growth is called a " naevoid lipoma." Plexiform angeiomata are known as "cirsoid aneurysms" or aneurysms by anastomosis (see p. 231). t Treatment.—Small port-wine stains can be removed by electrolysis, but extensive stains are ineffaceable. Small naevi may be ligated under hare-lip pins ; larger naevi may be strangulated with the Erichsen suture or may be completely excised. Excision is the best plan for the cure of the cav- ernous variety of angeiomata. Do not use astringent in- jections. Lymphangeiomata are tumors composed of dilated lymph- vessels, and are usually, though not invariably, congenital. The lymphatic naevus is a colorless or faintly pink elevation; 14 210 A MANUAL OF SURGERY. if it is punctured with a needle, lymph flows from the punc- ture. One or several naevi may be present in the same individual. Local lymphangeioma of the tongue is mani- fested by a cluster of papillary projections containing lymph. Macroglossia is a congenital enlargement of the anterior portion of the tongue, which enlargement grows more and more marked until finally the tongue is forced far out of the mouth. This condition of tongue-enlargement is due to lymphangeioma of the mucous membrane. Just as there occur cavernous angeiomata among blood-vessel tumors, there occur cavernous lymphangeiomata among lymph- vessel tumors, and the spaces are filled with lymph instead of with blood. Treatment.—Lymphatic naevus requires excision. In ma- croglossia remove the bulk of the mass by a V-shaped cut and so stitch the mucous membrane as to close the stump. Malignant Connective-tissue Tumors, or Sarcomata.— The sarcomata are composed of embryonic tissue. They develop from connective tissue, have no definite stroma, and contain no lymphatics. The rapidly-growing forms are very vascular, the blood flowing in vessels whose walls are very thin or running in canals whose boundaries are sarcom- atous cells. These tumors may pulsate and have a bruit, and hemorrhages often take place in their substance. Slow- growing sarcomata have but few vessels. Sarcoma dissem- inates by means of the blood and the vessel-walls, particles of sarcoma being carried by the venous blood to the heart and from this organ to the lungs, where they lodge and form secondary growths. Emboli from this secondary focus are sent out by the arterial blood to various portions of the body, as the bones, kidneys, brain, liver, etc. This process is known as " metastasis." Sarcoma follows the vein-walls for considerable distances and builds elongated masses inside the veins. Sarcoma tends strongly to infiltrate adjacent TUMORS OR MORBID GROWTHS. 211 parts. The tumor may possess a capsule when it is in an early stage, but soon loses this except in very slow-growing or mixed forms growing by central proliferation. Sarcomata may arise at any age from birth to extreme senility, but they are commonest during youth and early middle age. They are not hereditary, and often follow contusion. They may arise from malignant change in an innocent connective-tissue growth (chondrosarcoma, fibrosarcoma, etc.). A sarcoma does not tend to affect lymphatic glands except by the accident of its position, and if it does implicate them, the sarcomatous elements are carried rather by the vein-walls and blood than by the lymph (melanotic sarcoma implicates adjacent glands, and so does sarcoma of the tonsil or of the testicle). The skin over the tumor may give way, a bleeding fungus-mass protruding (fungus hematoides), and suppura- tion may cause septic enlargement of adjacent glands. After removal of a sarcoma the growth tends to recur, and the recurrent tumor may be either more or less malignant than its predecessor, the degree of malignancy being in direct ratio to the number and smallness of the cells. A sarcoma is malignant by local tissue-infection and by dis- semination. Sarcomata rarely cause pain when they are not ulcerated. Sarcomata are commonest in the skin and con- nective tissue of the extremities, but they arise also from bone, neuroglia, periosteum, in the lymphatic glands, the breast, the testicle, the eye, the parotid, and in other parts. Hemorrhages into a sarcoma often occur, with the result of suddenly increasing its size and forming blood-cysts. Sarcomata are subject to partial fatty degeneration, to myxomatous changes which produce cavities filled with fluid, to calcification, and occasionally to necrosis of large masses. Species of Sarcomata.—The following species of sarcomata are recognized: 212 A MANUAL OF SURGERY. I. Round-celled, in which the matrix is soft and vascular. The cells may be small or may be large. The smaller the cell the more malignant the growth. A small round-celled sarcoma is the most malignant variety of sarcoma and is soft in consistence. 2. Spindle-celled, which are composed of bundles of spindle- cells lying in a matrix which may be homogeneous, but which may show some attempt at fibre-formation. Rhabdomyoma is a variety of spindle-celled sarcoma containing striated muscle-cells. These spindle-celled sarcomata often contain cartilage. 3. Mixed-celled sarcoma, containing both of the above varieties of cells. 4. Giant-celled or myeloid, which contains some round cells, some spindle-cells, and large cells with many nuclei, like the cells of bone-marrow. It is maroon colored on section. This is the least malignant form of sarcoma, and it sometimes admits of complete extirpation and cure. It tends to occur in the long bones as a central sarcoma. 5. Alveolar, in which the cells are collected in alveoli as are the cells of cancer. It arises usually from a mole. 6. Melanotic, which may be composed of either round cells or spindle-cells containing a black pigment. 7. Lympho-sarcoma, which is composed of small round cells held in a delicate network, the tissue somewhat resem- bling that of a lymphatic gland. Clinical Varieties of Sarcoma.—The following are the clinical varieties of sarcoma: Melanotic or black sarcoma, the color of which is due to pigment in the cells or matrix. These growths are usually round-celled, but may be spindle-celled; they are sometimes alveolar, and spring from parts which contain pigment (skin and choroid coat of the eye); they are apt to arise from pigmented moles ; they are very malignant; TUMORS OR MORBID GROWTHS. 213 they implicate related lymphatic glands, and during their existence the urine contains pigment. Glio-sarcoma is a sarcoma of neuroglia. A pure glioma is composed of adult connective tissue ; but, as a matter of fact, pure glioma almost never arises, and the growth practically always contains numerous small round cells and is properly a sarcoma. It springs from the neuroglia of the central ner- vous system, and is usually of about the consistence of the cortex of the brain; it is generally single, and does not cause secondary growths. A gliomatosis of the cord produces that remarkable disease known as " syringomyelia." The symptoms of glioma of the brain depend upon its situation. Hemorrhagic sarcoma is a sarcoma containing blood- cysts, the results of parenchymatous hemorrhages. Cylindroma, or Plexiform Sarcoma.—In this variety the cells adjacent to vessels have undergone hyaline degenera- tion ; cells distant from vessels are unchanged. Section shows the norjnal cells apparently contained in spaces with hyaline walls. Mixed tumors consist partly of mature and partly of embryonic tissue, the cellular elements exceeding the adult elements in amount. Among these mixed tumors are fibro- sarcoma or the recurrent fibroid tumor, myxo-sarcoma, chondro-sarcoma, and osteo-sarcoma. Treatment of Sarcomata.—Remove a sarcoma at once if it is in an accessible spot. Never delay removal. Cut well clear of it. The rapidly-growing soft sarcomata will almost inevitably return, and the very malignant variety, if uninter- fered with, may terminate life in six months; but operation postpones the evil day and renders it possible that death will occur from metastasis in an organ, and that the patient will escape the horrors of ulceration and hemorrhage from the original tumor. Slowly-growing and hard tumors offer some prospects of cure. The mixed tumor (as a recurrent 214 A MANUAL OF SURGERY. fibroid) may repeatedly recur, and yet the patient may be cured at last by a sixth, an eighth, or a tenth operation. In sarcomata of the long bones amputation should, as a rule, be performed, though in some cases of giant-celled sarcomata excision can be employed. In sarcomata of the jaw-bones, excision ; of the eye, enucleation ; and of the testicle, castra- tion, are demanded. Sarcoma of the ovary in adults demands ovariotomy, but in children the operation is useless. Sar- coma of the kidney in adults calls for nephrectomy, but in children the operation is of no avail. In melanotic sarcoma remove the growth and adjacent lymph-glands, or in some cases amputate. Removal of a sarcoma when there is no hope of a cure is often justifiable to prolong life, to relieve the patient of a foul, offensive, bleeding mass, and to permit of an easier road to death by means of metastasis to an internal organ. Wright advocates internal treatment for sar- coma and for cancer. He advises that bromide of arsenic be given for a long period of time, the dose being gr. -fa to gr. fa after each meal. Before meals gr. x of carbonate of lime are advised. This treatment, Wright holds, should be used before, and for many months after, operation, as an aid to surgery. In inoperable cases it may be tried.1 It has been observed that an attack of erysipelas occasion- ally greatly benefits a sarcoma, causing large masses of the growth to soften or to slough and expose a granulating sur- face. It has been suggested that in inoperable cases of sarcoma this condition might be established artificially. A bouillon culture is made of the streptococci; this culture is filtered through porcelain and is injected once a day into and about the sarcoma. The first dose is Vf[x, and it is increased ; it should cause a febrile reaction, and sometimes establishes softening or suppuration. The exact status of this plan is not determined; it has improved or possibly 1 Annals of Surgery, April, 1893. TUMORS OR MORBID GROWTHS. 215 cured some cases, but is not free from danger.1 The injec- tion of aniline products into the sarcoma, which has received a qualified commendation from some observers, has been abandoned by Profs. Keen and White after careful trial. Innocent Epithelial Tumors.—These growths imitate an epithelial tissue of the mature and healthy organism. Papillomata, or Warts.—These growths are formed upon the type of cutaneous and mucous papillae. A papilloma consists of a fibrous stroma which contains blood-vessels and lymphatics and which is covered by epithelium of the variety appertaining to the diseased part. Warts grow from the skin and from mucous membranes; they may be single or multiple; they may be painless or may be ulcerated and bleeding; great masses may gather around the anus, the vagina, or the penis during the existence of" a filthy dis- charge, and crops appear on the hands of those who work in irritant material (as petroleum). A large crop of warts may disappear in a single night; hence the popular belief in the efficacy of charms. A single wart may reach a large size and become pigmented. The squamous epithelium covering a skin-wart may become horny (a wart-horn). Other cutaneous horns arise from the nails, from the scars of burns, or from ruptured sebaceous cysts. Villous papillomata grow chiefly from the bladder; they form tufts like the villous processes of the chorion ; they may be single or multiple, and may be sessile or pedunculated ; they are very vascular, and are apt to bleed freely. Papillo- mata may arise in cysts of the paroophoron, in cysts of the mammary gland, and from the choroid plexuses of the ventricles of the brain. A villous papilloma of the choroid plexus early calcifies and becomes converted into a psam- moma. Psammomata of the spinal membranes may arise. Any papilloma may become a cancer. 1 See Coley, in American Journal of Medical Sciences for May, 1893. 2l6 A MANUAL OF SURGERY. Treatment.—Venereal warts are treated by repeatedly washing with peroxide of hydrogen, drying with cotton, and dusting with a powder composed of equal parts of calomel and subnitrate of bismuth, or oxide of zinc and iodoform, or borated talcum. If they do not soon dry up, cut them off with scissors and burn with the Pacquelin cautery. Ordinary warts may usually be destroyed in a short time by daily applications of lactic or chromic acid. Keeping a wart constantly moist with castor oil will often cause it to drop off. Warts, and even extensive callosities, may be removed by painting once a day for five days with pure carbolic acid and covering with lint kept wet with boracic acid. A convenient plan is to paint a wart daily with a solution containing I part of corrosive sublimate to 30 parts of collodion (hydrarg. chlor. corros., 3ss ; collodion, 3vij et ss). Large warts should be freely excised. Villous papillomata of the bladder demand the performance of a suprapubic cystotomy in order to remove them. Psammo- mata cannot be diagnosticated until the growth is exposed. Adenomata.—These glandular tumors are composed of tissue identical with that of normal glands, and they may contain acini and ducts like racemose glands or tubes like tubular glands. They grow from secreting glands, but can- not produce the secretion of the glands from which they spring, or, if they do secrete, the fluid is retained, and not discharged by the gland-duct. Adenomata occur in the mammary gland, the parotid, the ovary, the thyroid gland, the liver, the sweat-glands, and the prostate, and as pedun- culated growths from the mucous lining of the intestine and uterus. They are encapsuled, are usually single, but may be multiple, are of slow growth, but may attain a great size; they do not tend to recur after thorough removal, do not involve adjacent glands, and do not disseminate; they are firm to the touch; they tend to become cystic (especially in TUMORS OR MORBID GROWTHS. 217 the thyroid), the fluid which distends the ducts being due to mucoid liquefaction of the proliferating epithelium. In the breast a fibro-adenoma has a distinct capsule; it is elastic and movable, is usually superficial, and one occasion- ally exists in each gland. They are most common before the age of thirty, and are often painful, especially during men- struation. Cystic adenomata of the breast attain a large size; they are encapsuled and grow slowly, are most common after the thirtieth year, and are rarely painful. Both fibro- adenoma and cystic adenoma may arise in the male breast. Young unmarried women not unusually develop in the breast small, very tender, and painful bodies, most usually around the edge of the areola, which bodies increase in size and become more tender during menstruation, and which are only cysts of the mammary tissue. Adenomata of the thyroid gland begin before the fifteenth year (Gross). Adenomata may arise in the prostate if that gland be already the seat of senile hypertrophy. Adenoma of mucous glands may arise in the young or the middle- aged. Treatment.—Adenomata require extirpation. By confus- ing adenomata of the mammary gland with small cysts of that structure an erroneous belief has arisen that the former, as well as the latter, may sometimes be cured by the local use of iodine, mercury, and ichthyol and the internal use of iodide of potassium. The treatment is excision. It would be as easy to dissolve off a rooster's comb by iodide of potassium as by it to absorb an adenoma. Malignant Epithelial Tumors, Carcinomata, or Cancers. —Cancers are tumors growing from epithelial surfaces, and are composed of epithelial cells which are clustered in spaces, nests, or alveoli of fibrous tissue. The cells of a cluster are not separated by any stroma, and the walls of the alveoli carry blood-vessels and lymphatics. Cancers are always 218 A MANUAL OF SURGERY. derived from epithelium (of glands, of skin, of mucous mem- brane, etc.), and if found in a non-epithelial tissue must be secondary. They have no capsules, rapidly infiltrate sur- rounding tissues, are firmly anchored and immovable. In the beginning a cancer is a local lesion, but it soon attacks related lymph-glands and by means of the lymph is disseminated throughout the system, secondary growths arising which are identical with the parent growth. Cancer is rare before the age of forty, and never occurs before puberty; seems occa- sionally to be hereditary; is sometimes linked with continued irritation as a cause (cancer of the penis in phimosis; cancer of the lip from the hot stem of a clay pipe; chimney- sweeps' cancer from soot in the scrotal folds); is often the seat of pricking pain ; tends strongly to recur after removal; is prone to ulcerate, causing pain, hemorrhage,and cachexia; makes rapid progress, and is often fatal in from one to two and a half years. It is more common in women than in men, and rarely exists with tubercle. After a cancer has existed for a time in an important structure, or after a super- ficial cancer has ulcerated and become hemorrhagic, there is noted in the individual evidences of illness and exhaustion. We speak of this condition as the " cancerous cachexia," and in it the muscles are wasted, the body-weight is constantly diminishing, the complexion is sallow, the face is sunken, pearly white conjunctivae contrast strongly with the yellow skin, the pulse is weak and rapid, and night-sweats add to the exhaustion. The above condition is due to pain, loss of sleep, bleeding, deprivation of exercise, mal-assimilation of food, and anxiety. Cancer may kill by obstructing a canal, by destroying the functions of a viscus or organ, by hemorrhage, by anaemia, by sepsis, or by exhaustion. Classification of Carcinomata.—Carcinomata are classified as follows: I. Squamous-celled cancer, or epithelioma- 2. Rodent ulcer, or Jacob's ulcer; 3. Spheroidal-celled cancer TUMORS OR MORBID GROWTHS. 219 (a, scirrhus; b, encephaloid; c, colloid); and 4. Cylindrical- celled cancer. Epitheliomata.—An epithelioma may arise wherever there is pavement epithelium, and it is especially apt to appear at the junctions of skin and mucous membrane (as the lips) or the point of juxtaposition of different kinds of epithelium. In epithelioma there is an ingrowth of surface epithelium into the sub-epithelial connective tissue, colonies of cells growing inward and forming epithelial nests. It may arise without discoverable cause, it may follow prolonged irrita- tion, or it may arise in a wart or fissure. In the nipple it is often preceded by a persistent eczema, due probably to psorosperms and known as Paget's disease. Epithelioma generally begins as a warty protuberance which soon ulcer- ates. The malignant ulcer has a hard, irregular base, uneven edges, a foul, fungus-like bottom, and it gives off a sanious or ichorous discharge. This ulcer is the seat of sharp prick- ing pain, sometimes bleeds, and extends over a considerable area, embracing and destroying all structures. Epithelioma affects lymphatic glands, usually early, but its action may be delayed for eight or ten months. These glands break down in ulceration, making frightful gaps and often causing fatal hemorrhage. Dissemination is not nearly so common as in other forms of cancer, but it does sometimes occur. A rodent or Jacob's ulcer is scarcely ever met with except upon the face, it being especially common upon the nose and forehead. It begins after the age of forty as a little warty prominence which ulcerates in the centre, the ulceration pro- gressing at a rate equal to the new growth, and sometimes healing temporarily at one spot while it extends at another. Jacob's ulcer grows slowly, may last for years, does not involve the lymphatics, produces no constitutional cachexia, and is rarely fatal. It is an ulcer with irregular edges and a smooth base of a grayish color, its discharge being thin and 220 A MANUAL OF SURGERY. acrid, and is considered to be a malignant epithelial growth which springs from a sweat-gland, a sebaceous gland, or a hair-follicle. The base of the ulcer is hard, which differen- tiates it from lupus (Hearn.) From lupus the bacilli of tubercle may be cultivated. Spheroidal-celled Carcinomata.—(a) Scirrhous cancer is a white and fibrous mass which has no capsule, which infil- trates tissues, and which draws in toward it, by the contrac- tion of its outlying processes, adjacent soft parts, thus producing dimpling, or, as in the breast, retraction of the nipple. It is composed of spheroidal cells in alveoli formed of connective-tissue bands. The commonest seat of scirrhus is the female breast. It occurs also in the skin, vagina, rectum, prostate, uterus, stomach, and oesophagus. It is most frequent in women after'forty. It begins as a hard lump which is at first painless, but soon becomes the seat of an acute localized pricking pain. This lump grows and becomes irregular and adherent, causing puckering of the soft parts. After the skin or mucous membrane above it has become infiltrated ulceration takes place and a fungous mass protrudes to bleed and to suppurate. The adjacent lymphatics soon become involved, and the constitutional involvement is rapid and certain. (b) Encephaloid cancer is a soft gray or brain-like mass. It is a rare growth, it has no capsule, and it may appear in the kidney, liver, ovary, testicle, mammary gland, stom- ach, bladder, and antrum. An encephaloid often contains cavities filled with blood, and this variety is known as a " hematoid " or a " telangiectatic " carcinoma. These growths are soft and semi-fluctuating, they infiltrate rapidly and soon fungate, and they terminate life in from a year to a year and a half. If the cells of encephaloid become filled with mel- anin, we have the condition known as " melanosis" or " melanotic cancer." , TUMORS OR MORBLD GROWTHS. 221 (c) Colloid cancer arises from either a scirrhus or an en- cephaloid cancer when the cells or stroma undergo colloid degeneration. On section we see in the centre of the growth a series of cavities filled with a material resembling honey or jelly; the periphery often shows an ordinary scirrhus or encephaloid cancer. Colloid degeneration is most prone to attack cancers of the stomach, mammary gland, and intes- • tine. Cylindrical-celled carcinomata which occur in the rec- tum are known as "adenoid " or "glandular" cancers. They may occur in this region at a much earlier age than do can- cers elsewhere, being not uncommon between the ages of twenty-eight and forty. At first covered by mucous mem- brane, they soon ulcerate and involve the submucous and muscular coats in the growth. They grow rather slowly, and take usually from four to six years to kill. They usu- * ally, but not always, cause lymphatic involvement and con- stitutional infection. They are composed of a stroma of fibres between which lie tubular glands lined with columnar epithelium and masses of epithelial cells. Treatment.—Carcinomata demand early and free excision with removal of implicated glands. A certain proportion can be cured. Recurrent growths may be removed as a palliative measure, to lessen pain and to relieve the patient from ulceration and hemorrhage. If a growth does not recur within five years after removal, a cure has probably been attained. A rodent ulcer should be excised or else be curetted and cauterized with the hot iron or the Pacquelin cautery. In cancer of the lip, remove a V-shaped piece; in cancer of the tongue, excise this organ; in cancer of the breast, remove the breast and pectoral fascia and take away ' the fat and glands of the axilla; in cancer of the rectum, if near the surface, excise the rectum from below; if above five inches from the anus, do the sacral resection of Kraske; in 222 A MANUAL OF SURGERY. cancer of the esophagus, perform gastrostomy; in cancer of the pylorus, perform pylorectomy or gastro-enterostomy; in cancer of the bowel, do resection with anastomosis, side-track the diseased area by an anastomosis, or make an artificial anus; in cancer of the penis, amputate. Cysts.—A cyst is a sac containing a fluid or a semi-fluid. Division of Cysts.—Cysts are divided into (i) Retention-cysts, which are due to blocking up of the excretory ducts of glands and accumulation of the glandular secretions. These comprise sebaceous cysts or wens, serous cysts, mucous cysts, salivary cysts, milk-cysts, oil-cysts, and seminal cysts. (2) Exudation-cysts, which are due to accumulations in closed cavities. These comprise synovial cysts (ganglions and bursas) and dentigerous cysts. (3) Dermoid cysts, which are congenital and arise from inversion of the cutis and im- perfectly closed foetal clefts. (4) Cystomas, which are cysts of new formation due to cystic degeneration of connective tissue. These cysts are found in the neck (hygroma), in the arm-pit, and in the perineum. An example of a cystoma is found in the bursa which will develop from pressure. (5) Ex- travasation-cysts, that form around blood-extravasations. (6) Hydatid cysts, or cysts due to the echinococcus or tapeworm of the dog. A mother-cyst is formed, which becomes filled with daughter-cysts floating in a saline liquor containing hooklets. Sebaceous cysts arise when the excretory duct of a sebaceous gland is blocked by dirt or occluded by inflam- mation. The orifice of the duct is often visible as a black speck over the centre of the cyst. They are very common in the scalp, where they are known as " wens," and upon the face, neck, shoulders, and back. Arising in the skin, and not under it, the skin cannot be freely moved over them, though a large cyst must extend into the deeper tissues. A sebaceous cyst is lined by epithelium and is filled with TUMORS OR MORBID GROWTHS. 223 foul-smelling sebaceous material. A sebaceous cyst may suppurate. Treatment.—To treat a sebaceous cyst, dissect it entirely away with scissors or an Allis dissector, trying not to rupture the sac. If even a small particle of it is left, the cyst will return. If it ruptures during removal and it is feared that some portion may remain, swab out the wound with pure . carbolic acid. If acid is not used, close without drainage, but if acid is used, drain for twenty-four hours. If an abscess has formed, open it. Grasp the edges of the cyst- lining with forceps, dissect out this lining with scissors curved on the flat, cauterize with pure carbolic acid, and drain for twenty-four hours. Dermoid cysts are lined with true skin. They contain sebaceous matter, hair, teeth, or other epiblastic products. They are always congenital, but may be so small at birth as • to escape notice for years. They may be distinguished from sebaceous cysts by the fact that they always lie below the deep fascia, and hence the skin is freely movable over them. They are met with at the root of the nose, at the orbital angles, in the eyelids, upon the floor of the mouth, over the sacrum or coccyx, and in the ovaries, the testicles, the brain, the eyes, the mediastinum, the lungs, the omentum, the mesentery, and the carotid sheaths. They are due to imper- fect closure of foetal clefts and inclusion of epiblast. If a dermoid cyst contains bones, it shows that mesoblast was included as well as epiblast. Treatment.—To treat a dermoid cyst, excise, if accessible, the same as in the case of a sebaceous cyst. If it lies over bone, go down to the bone: the growth will be found ad- herent, so remove a portion of periosteum with the cyst (Hearn). Hydatid cysts occur particularly among people who live shut up with dogs, as is the case in Iceland. The parasite is 224 A MANUAL OF SURGERY. swallowed with the food and is taken up by the stomach- veins, and penetrates the intestine and peritoneum to find a nest in some neighboring or distant organ or tissue. Open these cysts, scrape, asepticize, and pack with iodoform gauze. XVII. DISEASES AND INJURIES OF THE HEART AND VESSELS. Heart and Pericardium.—In an acute pulmonary conges- tion the venous side of the heart is over-distended with blood, and the surgeon in desperate cases may tap the right auricle (see Paracentesis auriculi). Pericardial effusion, if severe, calls for tapping or aspiration, and purulent peri- carditis demands incision and drainage. Wounds and Injuries.—The heart may rupture and cause instant death, but slight wounds may not prove fatal. A wound of the heart causes hemorrhage, usually copious, but, owing to the interlocking of muscular fibres, the hemorrhage is often slight. If bleeding into the pericardal sac takes place, the signs of a pericardial effusion become manifest. Pain is constant, and attacks of syncope are the rule. Death is apt to occur suddenly from shock, hemorrhage, and inability of the heart to contract because of the severed fibres, or inability of the heart to dilate because of the pressure of blood in the pericardial sac. If a wound of the pericardium or heart does not cause death in the first day or two, inflammation follows (traumatic pericarditis or carditis). Treatment.—The treatment of heart-wounds consists of recumbency and the lowering of the head. The body is surrounded with hot bottles, opium is given in small doses, and stimulants are applied in moderation, but never to ex- cess. Traumatic carditis or pericarditis is treated in the same way as idiopathic cases. DISEASES AND INJURIES OF HEART AND VESSELS. 22 5 Phlebitis, or Inflammation of a Vein.—Phlebitis may be plastic or it may be purulent. Plastic phlebitis, while occa- sionally due to gout, to a febrile malady, or to some other constitutional condition, usually takes its origin from an injury, from the extension to the vein of a perivascular inflammation, or from a thrombus or an embolism. When phlebitis begins ^ thrombus forms because of the destruction of the endothelial coat, and this clot may be absorbed or organized. Suppurative phlebitis is a suppurative inflamma- tion of a vein, arising by infection from suppurating peri- vascular tissues. It is most frequently met with in cellulitis or phlegmonous erysipelas, and may arise in the lateral sinus as a result of mastoid suppuration. A thrombus forms, the vein-wall suppurates, is softened and in part destroyed, and the clot becomes purulent. No bleeding occurs when the vein ruptures, as a barrier of clot keeps back the blood- stream. The clot of suppurative phlebitis cannot be absorbed and cannot organize. Septic phlebitis may cause pyaemia, and the infected clots of pyaemia may cause phlebitis. Symptoms.—The symptoms of phlebitis are pain, tender- ness in and around a vein, discoloration over it, and solid oedema below the seat of the disease. Suppurative phlebitis causes the constitutional symptoms of infection. Treatment.—The treatment of phlebitis comprises rest in bed, elevation of the part, the administration of tincture of iron, and, locally, lead-water and laudanum. Hot fomenta- tions are used later in the case. Abscesses are opened, asep- ticized, and drained. Internal treatment is symptomatic (opium, stimulants, etc.). When a vein is involved in this process, ligate, if possible, above and below the clot, open the vessel, and wash out the purulent mass. This is always to be done in infective thrombo-phlebitis of the lateral sinus. Varicose Veins, or Varix.—Definition and Causes.—Vari- cose veins are unnaturally and permanently dilated veins 15 226 A MANUAL OF SURGERY. which elongate and pursue a tortuous course. The causes of varicose veins are obstruction to venous return and weak- ness of cardiac action, which lessens the propulsion of the blood-stream. Varicose veins are chiefly met with on the inner side of the lower extremity, in the spermatic cord, and in the rectum. Varix in the leg is met with during and after pregnancy and in persons who stand upon their feet for long periods. It especially appears in the long saphenous, which, being subcutaneous, has no muscular aid in supporting the blood- column and in urging it on. The deep as well as the super- ficial veins may become varicose. Varix of the spermatic cord is known as " varicocele." It is apt to appear about the time of puberty, and most adult men have at least a slight varicocele. Varix is more likely to appear in the left spermatic vein than in the vein of the right side, because the left spermatic vein has no valves (Brinton). Varix of the veins of the rectum is known as " hemor- rhoids " or " piles," which are caused by obstruction to the upward flow in the hemorrhoidal veins, either by obstructive liver disease, enlargement of the uterus or prostate, or the presence in the rectum of fecal masses in a person habitually constipated. A vein under pressure usually dilates more at one spot than at another, the distention being greatest back of a valve or near the mouth of a tributary. The valves become incom- petent and the dilatation becomes still greater. The vein- wall may become fibrous, but usually it is thin and often ruptures. The veins not only dilate, but they also become longer, and hence do not remain straight, but twist and turn into a characteristic form. Varicose veins are apt to cause oedema, and the watery elements in the tissues cause eczema of the skin. When eczema is once inaugurated, excoriation DISEASES AND INJURIES OF HEART AND VESSELS. 227 is to be expected. Infection of an excoriated area produces inflammation, suppuration, and an ulcer. The skin over varicose veins in the leg is often discolored by pigmentation due to the red blood-cells having escaped from the vessel and broken up. The tissues around a vari- cose vein become atrophied from pressure, and there is often met with a very large vein whose thin walls are in close contact with skin. In this condition rupture and hemorrhage are probable. Varicose veins are apt to inflame, and thrombosis frequently occurs. Treatment.—The treatment of varix may be palliative or curative. In palliative treatment, attend to the general health, keep up the force and activity of the circulation, and prevent constipation. Recommend the patient to exercise in the open air and to lie down, if possible, every afternoon. Locally, in varix of the leg, order a flannel roller or a Martin rubber band- age to support the veins and drive the blood into the deeper vessels which have muscular support. Locally, in varicocele, pour cold water upon the scrotum twice a day and order the patient to wear a suspensory bandage. Locally, in haemor- rhoids, use astringent suppositories. The curative or radical treatment of varix of the leg comprises ligation with excision of part of the vein, exposure and ligation of the vein, multiple subcutaneous ligatures of catgut, acupressure-pins with twisted sutures, or injection of pure carbolic acid into the perivascular structures (see Operations upon Vessels). Naevus.—(See Tumors) Arteritis, or inflammation of an artery, is acute or is chronic. Acute arteritis may result from injury or from extension of inflammation from the perivascular tissues. This latter mode of origin is uncommon, as arteries are very resistant to the spread of inflammation, but we meet with it sometimes in suppurating areas. In a suppurating acute arteritis the 228 A MANUAL OF SURGERY. coats ulcerate through, but hemorrhage rarely occurs unless a considerable portion of the vessel sloughs. Septic emboli lodging in the arterial system produce acute arteritis. This is seen during the progress of ulcerative endocarditis. Chronic arteritis produces " atheroma." It is due to increase of blood-pressure from hard work, strains, heart disease, or contracted kidney. It is especially common in drunkards and in the larger arteries. It is commonest in the aged, but may be met with in young drunkards. It is a true saying that "A man is as old as his arteries." In chronic arteritis exudation of serum and leucocytes takes place beneath the intima, which coat, in consequence, is swelled out, and a like exudation soon becomes manifest in the media, in the adventitia, and even in the sheath. Embryonic tissue is formed, which may undergo resolution, may become fibrous tissue (arterial sclerosis), or may undergo fatty degen- eration (atheroma). When fatty degeneration occurs the en- dothelium is destroyed, the vessel-wall is damaged, and the blood obtains access to the deeper coats. Calcareous change may follow fatty degeneration. An atheromatous artery is rigid and inelastic, and the parts it supplies are cold, congested, and ill-nourished. Atheroma is a frequent cause of thrombosis, aneurysm, senile gangrene, and apoplexy. Syphilitic arteritis is characterized by an enormous growth of granulation tissue from the inner coats (obliterative arteritis) of arteries of small size. Calci- fication of an artery may be secondary to fatty change or may occur primarily from deposit of lime salts in the middle coat. Periarteritis is inflammation of the sheath and outer coat. An acute arteritis is always local, but a chronic arteritis may be general. Treatment of acute arteritis consists of rest, elevation and relaxation, the application of tincture of iodine, and the use of lead-water and laudanum. Hot fomentations are applied DISEASES AND INJURIES OF HEART AND VESSELS. 229 later. Abscesses are opened and drained. Internally, treat any diathesis (rheumatic, gouty, or syphilitic), maintain kidney secretion, quiet the circulation, and employ a non- stimulating diet. The part must be kept quiet, as rough movement would tend to rupture the vessel. Treatment of Chronic Arteritis.—In treating chronic arteritis, endeavor to antagonize the dangers to which the patient is obviously liable. Stop alcohol as a beverage, though a little whiskey may be taken at meals to aid digestion. Maintain the activity of the skin by daily baths, and of the kidneys by diuretic waters. The contents of the bowels are to be kept soft. The diet is to be plain and is to contain a mini- mum of nitrogen. If syphilis has existed, occasional courses of iodide are to be urged. If the arterial tension at any time becomes inordinately high, give nitroglycerin. One danger is apoplexy ; hence excitement and violent exercise are to be avoided. Another danger is senile gangrene; hence the patient should wear woollen stockings, put a hot bottle to his feet at night, and be careful to avoid injuring his toes or feet, especially when cutting his corns. When a patient with atheroma has dyspnoea and is of a livid color, or when the arterial tension is very high, a moderate blood-letting (six- teen to eighteen ounces) does good. Still another danger is aneurysm, which may appear suddenly from rupture or gradually from progressive distention. Aneurysm.—An aneurysm is a pulsating sac containing blood and communicating with the cavity of an artery. Some restrict the term " true aneurysm " to a condition of glilatation involving all the coats of the vessel. We shall consider, with Heath, a true aneurysm to be that in which the blood is included in one or more of the arterial coats, and a false aneurysm to be that in which the vessel has ruptured or has atrophied and the aneurysmal wall is formed by a condensation of the perivascular tissues. 23O A MANUAL OF SURGERY. Forms of Aneurysm.—The following forms of aneurysm are recognized: 1. True aneurysm—one whose sac is formed of one or more arterial coats. 2. False aneurysm—one whose sac is formed of condensed perivascular tissues and contains no arterial coat. 3. Traumatic aneurysm—a false aneurysm due to traumatic rupture some time before, the blood being in a sac of tissue and all wound being healed. 4. Fusiform aneurysm—a variety of true aneurysm, the sac being spindle-shaped. 5. Consecutive aneurysm—a sacculated aneurysm diffused by rupture, or a false aneurysm due to gradual destruction or atrophy of a true aneurysmal sac or to vascular rup- ture. 6. Sacculated aneurysm—a common form of aneurysm, in which the dilatation is like a pouch, arising from a part of the arterial circumference and joining the lumen of the vessel by an aperture. 7. Dissecting aneurysm—a pouch-like dilatation, due to the blood which, passing through an aperture in the intima, enters between the media and adventitia and dissects them apart. It may or may not join the lumen of the artery at another point by a fresh aperture in the intima. 8. Arterio-venous aneurysm, which is divided into aneurys- mal varix, or Pott's aneurysm, where there is direct commu- nication between a vein and an artery, and varicose aneurysm, where there is communication between an artery and a vein by means of an interposed sac. 9. Acute aneurysm—a cavity in the walls of the heart, which cavity communicates with the interior of this organ, and which is due to suppuration in the course of acute endo- carditis or myocarditis. 10. Aneurysm by anastomosis.—(See Angeiomata) DISEASES AND INJURIES OF HEART AND VESSELS. 231 11. Aneurysm of bone—a clinical term to designate a pulsatile tumor of bone. 12. Circumscribed aneurysm—when the blood is circum- scribed by distinct walls. 13. Cirsoid aneurysm—-a mass of dilated and elongated arteries shaped like varicose veins and pulsating with each heart-beat. 14. Cylindrical aneurysm—a dilatation of the same dimen- sions for a considerable space. 15. Embolic or capillary aneurysm—dilatation of terminal arteries due to emboli. 16. Spontaneous aneurys?n—non-traumatic in origin. 17. Miliary aneurysm—a minute dilatation of an arteriole. 18. Secondary aneurysm—one which, after apparent cure, again pulsates, the blood entering by means of the anasto- motic circulation. 19. Verminous aneurysm—one containing a parasite. This form of aneurysm is met with in the mesenteric artery of the horse. The sac of a sacculated aneurysm is at first composed of at least two of the arterial coats, reinforced by the sheath and perivascular tissues. After a time the blood-pressure distends the sac, and the inner and middle coats either stretch with interstitial growth or—what is more common—are worn away and lost. When all the coats are lost, and the blood is sustained only by the sheath and surrounding tissue, a true aneurysm becomes a diffused or consecutive aneurysm, the limiting tissues and sheath being condensed, thickened, and glued together. This limiting process is deficient in the brain; hence cerebral aneurysms break soon after their formation. When all the arterial coats are lost, the blood- pressure, acting on the tissues, finds some spots less resistant than others, the blood follows the lines of least resistance, the aneurysm grows with great rapidity, and soon ruptures. 232 A MANUAL OF SURGERY. An aneurysm may rupture into a cavity (pleura, pericar- dium, or peritoneum), into the perivascular tissues, or through the skin. Rupture into the tissues may produce pressure-gangrene. When rupture occurs through the skin, the hemorrhage is not often instantly fatal, but is during days constantly recurrent in larger and larger amounts. The pressure of an aneurysmal sac causes atrophy of tissues, hard and soft, bones and cartilages being as easily destroyed as muscles and fat. Sometimes the perivascular tissues inflame and suppurate, and the sac is opened rapidly by sloughing. An aneurysm usually progresses toward rupture, the slowest in this progression being the fusiform dilatations, which may exist for many years, but which finally eventuate in the sacculated variety. In some rare instances there takes place spontaneous cure, which may result from laminated fibrin being deposited upon the walls of the sac as the blood circulates through it. This laminated fibrin is known as an "active clot," and eventually fills the sac. The weaker and slower the blood-stream, the greater is the tendency to the formation of an active clot; hence any agent impeding, but not abolishing, the circula- tion aids in the deposition. This weakening and slow- ing of circulation may be brought about by great activity of the collateral circulation deviating most of the blood away from the area of disease. Sometimes a clot breaks off from the sac-wall and plugs the artery beyond the dilatation, and the anastomotic vessels, enlarging, divert the blood-stream. A large aneurysm, falling over by its own weight upon the vessel above the mouth of the sac, may diminish the blood-stream. The development of another aneurysm upon the same vessel weakens the circulation in the older one. Inflammation occasionally forms a clot. The tissues about an aneurysm tend to contract when arterial force is lessened; hence tissue-pressure may more DISEASES AND INJURIES OF HEART AND VESSELS. 233 than counteract blood-pressure when the circulation is feeble. Clotting of the blood contained within a sac, circulation through the aneurysm having ceased, causes a passive clot. A passive clot, which occasionally cures, may arise from a twisting .of the neck of the sac, preventing the passage of blood; from the lodgment of a clot in the mouth of the sac; and from inflammation. Spontaneous cure is, unfortu- nately, very rare. Causes of Aneurysm.—Gradual distention of arterial coats which are in a condition of arterial sclerosis, or local loss of resisting power due to atheroma, may cause aneurysm. Hence the causes of sclerosis and atheroma are also causes of aneurysm. The principal cause of aneurysm is increased blood-pressure. This increase may be brought about by severe labor; by sudden strains, as in lifting; by violent efforts, as in rowing in a boat-race; by chronic interstitial nephritis; by hypertrophy of the heart; by alcoholic in- ebriety ; and by syphilis. Arterial disease is commonest in the larger vessels and in the aged, but it may occur in youth. When an aneurysm follows a strain, it may be due to laceration of the media and loss of resistance at a narrow point. The intima may lacerate, permitting the blood to come in contact with the media or causing it to diffuse between the coats (dissecting aneurysm). An embolus may cause an aneurysm on its proximal side. The embolus, if in- fective, causes softening, and if calcareous causes laceration (Osier). Colonies of micrococci may cause aneurysm.1 The parasite strongylus armatus causes aneurysm of the mesenteric arteries in horses. Suppuration around a vessel weakens its coats and tends to aneurysm by inducing acute arteritis and softening. Some people develop many aneurysms the origins of which are lost in mystery. The constituent parts of an aneurysm are (1) the wall of 1 See Osier on Malignant Endocarditis. 234 A MANUAL OF SURGERY. the sac; (2) the cavity; (3) the mouth; and (4) the con- tents. Symptoms of Aneurysm.—A pulsatile tumor exists, which instantly ceases to pulsate and almost or entirely disappears on making firm pressure on the artery above. On relaxing the pressure the pulsatile enlargement at once reappears. Direct pressure upon the tumor causes it to almost or entirely disap- pear. Pressure upon the artery below causes the tumor to en- large. The pulsation is expansile—that is, it expands in all directions—and if an index finger be laid on each side of the tumor so that their points nearly touch, each pulsation not only lifts the fingers, but it also separates them. On placing a stethoscope over the aneurysm there is imparted to the ear a distinct bruit which travels in the direction of the blood-stream and is systolic in time. In internal aneurysms pressure-symptoms are marked. Thoracic aneurysm causes intercostal pain; iliac aneurysm causes pain in the thigh. Aneurysm of the aorta presses upon the pneumogastric nerve, causing spasmodic dyspnoea, and upon the recurrent laryn- geal, causing loss of voice and paralysis of all the muscles of the larynx except the crico-thyroid. The pulse below an aneurysm is weaker than the pulse of a corresponding part of the opposite limb. This is well shown by the sphygmo- graph, the tracings being rounded without a sudden rise or an abrupt fall (PI. I, Figs. 5, 6). Diagnosis.—A cyst or abscess over a vessel may show transmitted pulsation which is not expansile, and the tumor does not disappear on pressure above it. There is no true bruit, and the history is widely different. A growth under a vessel may lift the vessel and simulate an aneurysm, but the pulsation is not noted in the entire growth, the growth does not disappear on proximal pressure, and there is only a false, and never a true, bruit. The larger the growth the less is the pulsation due to pressure upon the vessel. A DISEASES AND INJURIES OF HEART AND VESSELS. 235 sarcoma, especially a soft sarcoma attached to the bone, pulsates and often has a bruit; it never disappears from proximal pressure, though it may slowly diminish in size, to gradually enlarge again when pressure is withdrawn. An aneurysm may cease to pulsate from consolidation leading to cure, or from rupture. Rupture of a large aneurysm into a cavity induces deadly pallor, syncope, and rapid death. Rupture of an aneurysm of an extremity into the tissues is made manifest by a sensation of something breaking, by pain, by sudden increase in size, by absence of bruit and pulsation, by absence of pulse below the aneurysm, by swelling and coldness of the limb, and by shock. Treatment.—In inoperable aneurysms general, medical, and dietetic treatment must be tried. It consists chiefly in rest in bed to diminish the rapidity and force of the circulation and favor fibrinous deposit. Tufnell's plan is to reduce the heart-beats by rest and mental quiet, and to rigidly restrict the diet so as to diminish the total amount of blood and render it more fibrinous. Liquids are restricted in amount, and the patient lives for twenty-four hours upon four ounces of bread, a very little butter, eight ounces of milk, and three ounces of meat. Pursue this plan for several months if pos- sible, or employ it for several weeks at a time over and over again. There can be no doubt that Tufnell's treatment sometimes cures by decidedly lowering the blood-pressure. Valsalva long ago suggested rest, occasional bleeding, and a diet just above the point of starvation. In many cases of aneurysm the patient may be permitted to go about, taking his time about everything and avoiding work, worry, and excitement. The diet is low and non-stimulating, and the bowels must be maintained in a loose condition. Iodide of potassium in doses of 20 grains undoubtedly does good, and not only in syphilitic cases. It seems to lower the blood-pressure. Balfour taught that it thickened 236 A MANUAL OF SURGERY. the sac. Osier says it relieves the pain. Iron, acetate of lead, and ergotine are prescribed by some, f Digitalis is contraindicated, as it raises the blood-pressureJ Morphia and bromide of potassium are occasionally useful to tran- quillize the circulation, allay pain, or secure sleep. Aconite and veratrum viride have long been employed. Other expe- dients are: the kneading of the sac to release a clot, in the hope that it will plug the mouth of the sac or the artery beyond it—this is dangerous ; electricity; electrolysis; the injection of an astringent liquid; the insertion of a fine aspirating-needle and the pushing through it into the sac of a large quantity of silver wire, in the hope that it will aid in whipping out fibrin. Some physicians have inserted needles and horse-hair. Even in an operable case diet and rest are of importance. The patient should be in bed for a number of days before operation, the daily diet consisting of ten or twelve ounces of solid food with a pint of milk. If the circulation is very active, use aconite and allay pain by morphia. Treatment by Pressure.—Instrumental pressure is made by applying two Signorini tourniquets or some specially-devised apparatus to limit the flow of blood through an aneurysm without entirely stopping it, the aneurysmal sac being felt to still slightly pulsate. These instruments can be worn for from twelve to sixteen hours at a time, usually removing them to permit sleep and reapplying them the next day, and so on for several days. This method may cure, but it is very painful. It aids in the formation of an active clot. Digital pressure, made with the thumb aided by a weight, and maintained for many hours by a relay of assistants, has cured many cases. It entirely cuts off the blood and pro- motes the formation of a passive clot. Direct pressure upon the sac has been used in aneurysm of the popliteal artery, the pressure being obtained by flexing DISEASES AND INJURIES OF HEART AND VESSELS. 237 the leg; and in aneurysm of the brachial artery pressure has been obtained at the bend of the elbow by flexing the elbow. The pressure of a hollow rubber ball has been used in aneur- ysm of the subclavian. Rapid pressure completely arrests the passage of blood through the sac for a limited time, and is applied while the patient is under the influence of an anaesthetic. Take, for example, a case of popliteal aneurysm: the patient is placed under ether; two Esmarch bandages are used, one being put on the limb from the toes to the lower limit of the aneurysm, and the other from the groin down to the upper limit of the sac, and the Esmarch band is fastened above the upper bandage. This procedure stagnates the blood both in the veins and in the arteries, the sac remaining full of blood. Pressure is thus maintained for three or four hours, and on removing the Esmarch apparatus a tourniquet is put on the artery above the aneurysm and partly tightened to limit the amount of blood passing through and thus prevent the washing away of clot. This method of rapid pressure sometimes cures by forming a passive clot, but it sometimes results in gangrene. Operative Treatment: By the Ligature.—Ligation of the main artery is, as a rule, the best procedure. The methods of ligation are—(1) the method of Antyllus ; (2) the method of Anel; (3) the method of Hunter; (4) the method of War- drop ; and (5) the method of Brasdor. In the method of Antyllus the sac itself is attacked. Hemorrhage is controlled by the Esmarch bandage, the sac is opened, its contents turned out, and the artery ligated immediately above and below the sac. This method is only employed for traumatic aneurysms, as its use in aneurysms from diseased vessel-walls would mean that the ligatures were almost surely applied upon diseased areas (Fig. 31). The Method of Anel.—In Anel's method the artery is 238 A MANUAL OF SURGERY. ligated close to and above the sac (Fig. 32). It is only used for traumatic aneurysms, and is never employed when the vessel is diseased. The Method of Hunter.—This operation, which is the modern method of ligation, was devised by the illustrious Fig. 31.—Old Operation of Antyllus for Aneurysm (Am. Text-Book of Surgery). Fig. 32.—Anel's Operation for Aneurysm (Am. Text-Book of Surgery). John Hunter. He recognized the fact that the vessel adjacent to an aneurysm was apt to be diseased, and he discovered the anastomotic circulation. Putting together these two facts, he devised the operation which goes by his name. It con- sists in applying a ligature between the heart and the aneurysm, but so far above the sac that collateral branches are given off between it and the point of ligation (Fig. 33). This operation, which is done upon a healthy area, does not (Q5=EEI Fig. 33.—Hunter's Operation for Aneurysm (American Text-Book of Surgery). at once cut off all blood, but so diminishes the force and frequency of the circulation that an active clot forms within the sac. Thus is lessened the danger of secondary hemor- rhage and of gangrene. It is, as a rule, the proper opera- tion for aneurysm. In some cases pulsation does not return after tightening the ligature; in most cases, however, it reappears for a time after about thirty-six hours, but is weak and constantly diminishing. Previous prolonged compres- DISEASES AND INJURIES OF HEART AND VESSELS. 239 sion by enlarging the collateral branches permits strong pulsation to soon recur after ligation, and thus militates against cure; hence it is a bad plan to use pressure in cases where its success is very uncertain. Distal Ligation.—When an aneurysm is so near the trunk that Hunter's operation is impracticable, or when the artery on the cardiac side of the tumor is greatly diseased, distal ligation can be employed. Distal ligation forms a barrier to the onflow of blood, collateral branches above the aneur- ysm enlarge, the blood-current is gradually diverted, and a clot is formed. Distal ligation is used in some aneurysms of the aorta, iliacs, innominate, carotids, and subclavians. Fig. 34.—Brasdor's Operation (Holmes). Fig. 35.—Wardrop's Operation (Holmes). The operation of Brasdor consists in tying the main trunk some little distance below the aneurysm (Fig. 34). The operation of Wardrop consists in tying one of the branches of the artery below the aneurysm (Fig. 35). After ligating for aneurysm by any of these methods, elevate the limb, keep it warm, and subdue arterial excite- ment. When moist gangrene follows ligation, amputate early, above the ligature. When dry gangrene takes place, await a line of demarcation. Rupture of the sac after liga- 240 A MANUAL OF SURGERY. tion may produce gangrene or suppuration, the first condition demanding amputation, and the second incision for drainage. Amputation for aneurysm is performed in some perilous cases of subclavian aneurysm instead of distal ligation. Electrolysis.—An attempt may be made to coagulate the blood at once, or from time to time an endeavor may be made to produce fibrinous deposits, but the first method is the better. It is, however, rarely possible to at once occlude a sac, and pulsation, which is for a time abolished, recurs as the gas present is absorbed. Use the constant current. Take from three to six cells which stand in point of size between those used for cautery and those used for ordinary medical purposes. A platinum needle is attached to the positive pole and a steel needle to the negative pole, both needles being insulated by vulcanite at the points where the skin will touch them. The asepticized needles are plunged into the sac where it is thick and they are kept near together. The current is passed for a variable period (from half an hour to an hour and a half). This operation is not dangerous. Pressure stops the bleeding. Electrolysis sometimes cures, and often ameliorates, aortic aneurysms.1 Acupressure consists of the partial introduction of a num- ber of ordinary sewing-needles into an aneurysmal sac and leaving them in it for five or six days or more. Introduction of Wire.—Insert into the sac a hypodermatic or small aspirating-needle, and push through the needle or canula a considerable quantity of aseptic silver wire, which is allowed to remain permanently. Loreta combines elec- trolysis with the introduction of wire. Traumatic aneurysm is a condition in which, after punc- ture or rupture of an artery, a sac has formed of tissue, and if any wound previously existed, it has healed. The treat- ment consists in ligation by the method of Antyllus. When 1 See John Duncan, in Heath's Dictionary. DISEASES AND INJURIES OF HEART AND VESSELS. 241 an artery ruptures and a large mass of blood is extravasated, no sac exists, and it is an error to designate this condition as a diffuse traumatic aneurysm. There is no pulsation in the tumor nor in the arteries below it, and the limb is cold and swollen. If the main vein is also ruptured, or if the rupture has occurred into a large joint, amputate ; otherwise perform the operation of Antyllus. Arterio-venous aneurysm is an unnatural passage-way between a vein and an artery, through which passage blood circulates. There are two forms: (a) aneurysmal varix, where a vein and an artery directly communicate; and {b) varicose aneurysm, where vein and artery communicate through an intervening sac. These conditions arise usually from punctured wounds, the instrument passing through one vessel and into the other, blood flowing into the vein, the Fig. 36.—Plan of an Aneurysmal Varix Fig. 37.—Varicose Aneurysm (Spence). (American Text-Book of Surgery). subsequent inflammation gluing the two vessels together, and the aperture failing to close (aneurysmal varix, Fig. 36). After the infliction of the wound the two vessels may sepa- rate, the blood still flows from artery into vein, and the blood-pressure, by consolidating tissue, forms a sac of junction (varicose aneurysm, Fig. 37). Aneurysmal varix is a far less grave disorder than varicose aneurysm. Symptoms.—In aneurysmal varix a swelling exists with the characteristic pulsation and a loud whirring bruit is transmitted along the veins. The veins above and below the tumor are enlarged, tortuous, and pulsating. A distinct thrill is felt. Pressure over the tumor stops the thrill and 16 242 A MANUAL OF SURGERY. greatly lessens the bruit. The extremity is apt to be swollen and the parts are usually painful. When pressure on the main artery causes the entire disappearance of the tumor, the case is one of aneurysmal varix; but if on applying this pressure the veins collapse and a distinct tumor remains which can be emptied by direct pressure, the case is one of varicose aneurysm. If light pressure on one spot stops both murmur and thrill, it is aneurysmal varix. The diagnosis between the two is often impossible. Treatment.—Aneurysmal varix often requires only palli- ative measures, as it does not tend to rupture, the veins becoming thick and resistant and after a time ceasing to enlarge. Some form of support is used. If the part is painful or the veins promise rupture, tie the artery above and below the opening. Varicose aneurysm requires the use of the plans ordinarily adopted in treating aneurysm (com- pression, etc.). If these fail, tie the artery above and below the opening, but do not open the sac. Cirsoid aneurysm, or aneurysm by anastomosis, con- sists in great dilatation with pouching and lengthening of one or several arteries. The disease progresses and after a time involves the veins and capillaries. The walls of the arteries thin and the vessels tend to rupture. Cirsoid aneurysm is met with upon the forehead and scalp of young people, where it sometimes takes origin from a nasvus. Symptoms.—A pulsating mass, irregular in outline, com- posed of dilated, elongated, and tortuous vessels that empty into one another. The mass is soft, can be much reduced by direct pressure, and is diminished by compression of the main artery of supply. A thrill and a bruit exist. Pregnancy and puberty cause a rapid growth of a cirsoid aneurysm. Treatment.—In treating a cirsoid aneurysm the ligation of the larger arteries of supply is a wretched failure. Sub- DISEASES AND INJURIES OF HEART AND VESSELS. 243 cutaneous ligation at many points of the diseased area has effected a cure in some cases, but it has failed in most. Direct pressure is also entirely useless. Ligature in mass has been successful. Destruction by caustic has its advo- cates. Electro-puncture with circular compression of the arteries of supply has once or twice effected a cure. Injec- tion of astringents has been recommended. Verneuil ligated the afferent arteries, incised the tissues around the tumor, and sunk a constricting ligature into the cut. The proper method of treatment is excision after the subcutaneous liga- tion of every accessible tributary of supply.1 Wounds of arteries are divided into contused, incised, lacerated, punctured, and gunshot wounds, and vascular ruptures. Contused and Incised Wounds.—A contusion may destroy vitality and be followed by sloughing and hemorrhage. A contused wound may do little damage, or it may produce gangrene from thrombus, or it may cause secondary hemor- rhage. In an incised wound there is profuse hemorrhage. The artery after a time is apt to contract and retract, and thus arrest bleeding. A transverse wound causes profuse bleeding, but there is a better chance for natural arrest than in an oblique or in a longitudinal wound. In a partially- divided artery, cut it entirely through and tie both ends. The clot which forms in a cut artery is known as the " in- ternal clot;" it reaches as high as the first collateral branch, and subsequently becomes organized permanently, obliter- ates the vessel, and converts it into a shrunken fibrous cord. Between the vessel and its sheath, over the end of the vessel, and in the surrounding perivascular tissues is the " external clot." Lacerated wounds cause little 'primary hemorrhage. The internal coat curls up, the circular muscular fibres of the 1 Anderson, in Heath's Dictionary. 244 A MANUAL OF SURGERY. media contract upon it, and the external coat is so pulled out as to cap the orifice of the vessel—all of which con- ditions favor clotting. The vessel-wall is so damaged that secondary hemorrhage is usual. Punctured Wounds.—In punctured wounds primary hem- orrhage is slight. Secondary hemorrhage is not usual. Dif- fuse aneurysm and arterio-venous aneurysm are not unusual results. Gunshot wounds are apt to be contusions which may eventuate in sloughing and secondary hemorrhage or throm- bosis and gangrene. A shell-fragment makes a lacerated wound. A rifle-bullet may make a clean-cut division of an artery. Secondary hemorrhage after gunshot wounds tends to occur during the third week. Partial rupture of an artery may cause sloughing and secondary hemorrhage, thrombosis and gangrene, and aneurysm. Complete rupture is a lacer- ated wound, and is a condition accompanied by diffuse trau- matic aneurysm. Wounds of veins are classified as are wounds of arteries. The symptom of any vascular wound is hemorrhage. i. Hemorrhage, or Loss of Blood. Hemorrhage may arise from wounds of arteries^ veins, or capillaries, or from wounds of the three combined. In arte- rial hemorrhage the blood is scarlet and appears in jets from the proximal end of the vessel, which jets are synchronous with the pulse-beats; the stream, however, never intermits. The stream from the distal end is darker and is not pulsa- tile. Venous hemorrhage is denoted by the dark hue of the blood and by the continuous stream. In capillary hem- orrhage red blood wells up like water from a sponge. In subcutaneous hemorrhage from vascular rupture (dif- fuse aneurysm) there are great swelling, cutaneous discolora- tion, and systemic signs of hemorrhage. If an artery rup- DISEASES AND INJURIES OF HEART AND VESSELS. 245 tures in an extremity, there is no pulse below the rupture. If a vein ruptures in an extremity, intense oedema occurs. Pro- fuse hemorrhage induces constitutional symptoms, and death may occur in a few seconds. Generally, after the bleeding has gone on for a time syncope occurs, which is Nature's effort to arrest hemorrhage, for during this state the feeble circulation and the increased coagulability of the blood give time for the formation of a clot. When reaction occurs the clot may hold, or it may be washed away with a renewal of bleeding and syncope. These episodes may be repeated until death supervenes. Nausea and vertigo exist, black specks float before the eyes (muscas volitantes), tinnitus aurium exists, delirium is not unusual, and convulsions often occur. After a profuse hemorrhage an individual is intensely pale and of a sort of greenish tinge; the eyes are fixed in a glassy stare and the pupils are widely dilated; the respirations are shallow and sighing; the skin is covered with a cold sweat; the legs and arms are extremely cold; the pulse is soft, small, compressible, fluttering, or often cannot be detected; the heart is very weak and fluttering ; and there is musular tremor. When such a dangerous con- dition is due to a visible hemorrhage, temporarily arrest bleeding by digital pressure in the wound, lower the head, and have compression made upon the femorals and sub- clavians, so as to divert more blood to the brain. Apply artificial heat. Inject by hypodermoclysis the normal salt solution (10 to 16 ounces) into the cellular tissue of the buttock; inject ether hypodermatically, then brandy, and then strychnia in doses of gr. fa. Atropia, digitalis, and morphia are recommended. Give enemata of hot coffee and brandy. Apply mustard over the heart and spine. As soon as -reaction begins, arrest the bleeding permanently by the ligature. Hemorrhagic Fever.—A profuse bleeding is apt to be fol- 246 A MANUAL OF SURGER Y. lowed by fever—hemorrhagic fever—due to the absorption of fibrin ferment from extravasated blood and its action upon a profoundly debilitated system. In this form of fever there are most intense thirst, violent headache, dimness of vision, great restlessness, often mental wandering, with a very fre- quent, weak, and fluttering heart. Treatment.—In treating a patient after a severe hemor- rhage, apply cold to the head to prevent serous effusion into the brain. Aconite, morphia, and neutral mixture are given by the mouth. Fluids and ice are grateful. Frequently sponge the skin with alcohol and water (S. W. Gross). Milk punch, koumiss, and beef-peptonoids are given at frequent intervals. If the hemorrhage is from some spot inac- cessible to ligation, such as the lung, give the patient 3 grains of gallic acid, I grain of powdered digitalis, 1 grain of ergotine, and y2 grain of powdered opium every three or four hours. Hemostatic agents comprise (1) the ligature ; (2) torsion ; (3) acupressure; (4) compression; (5) styptics ; (6) the actual cautery; and (7) forced flexion of limbs. The ligature may be made of silk, floss-silk, or catgut, but it must be aseptic. The ligatures should be about ten inches long. The vessel is drawn out with forceps and separated from surrounding tissues. The forceps are better than the tenaculum in most cases, because the tenaculum makes a hole through which blood may subsequently exude. When the artery lies in hard tissues or is retracted deeply in muscle or fascia, the tenaculum is best. Tie with a reef-knot. The tightening of the first knot cuts the internal and middle coats ; the second knot must not be tied too tightly, or it will cut the ligature. Do not jerk the ligature in tying, and cut it off close. Both ends of the vessel are tied. If an artery is incompletely divided, tie on each side of the cut and entirely sever the vessel between the liga- tures. If a large vein is slightly torn, try pinching up DISEASES AND INJURIES OF HEART AND VESSELS. 2tf the vein-walls around the rent and apply a ligature (lateral ligature). If the bleeding comes from an artery very close to its point of origin, tie the main trunk as well as the bleed- ing branch, otherwise the clot formed will be too short and secondary hemorrhage will be inevitable. When the parts about an artery are so thickened that the artery cannot be drawn out, arm a Hagedorn needle (Fig. 38) with catgut and so pass the latter around the vessel that the catgut will include t Fig. 38.—Hagedorn Needles. Fig. 39.—Torsion in Continuity (Bernard and Huette). the vessel with some of the surrounding tissue, and tie the ligature. This method is pursued in necrosis, atheroma, scar-tissue, sloughing, etc. Never include a nerve. If this mode of ligation fails, try acupressure. Torsion.—By means of torsion the internal and middle coats are ruptured and the external coat is twisted. It is a safe procedure, and is practised by many surgeons of high standing upon vessels as large as the femoral. Torsion has the signal merit of not introducing possible infection in liga- tures. The vessel is drawn out by one pair of forceps, and another pair is applied transversely half an inch above the cut end and twisted six or eight times. Figure 39 a, b shows torsion in continuity. 248 A MANUAL OF SURGERY. Acupressure is pressure with a pin. A pin is simply passed under a vessel (transfixion), leaving a little tissue on each side between the pin and vessel. A needle can be passed under a vessel, and a wire be thrown over the needle and twisted (circumclusion). The needle can be inserted upon one side, passed through half an inch of tissues up to the vessel, be given a quarter-twist, and be driven into the tissues across the artery (torsoclusion). Some tissue is picked up on the needle, folded over the vessel, and pinned to the other side (retroclusion). Acupressure is used for inflamed or atheromatous vessels, in sloughing wounds, and where a ligature will not hold. Compression is either direct or indirect—that is, in the wound or upon its artery of supply. In the removal of the upper jaw, arrest bleeding by plugging. In injury of a cere- bral sinus, plug with gauze. Compression and hot water (1200) will stop capillary bleeding. A graduated compress is often used in hemorrhage from the palmar arch. A com- press will arrest bleeding from superficial veins. The knotted bandage of the scalp will arrest bleeding from the temporal artery. Long-continued pressure causes pain and inflam- mation. Styptics.—Chemicals are now rarely used. In epistaxis we may pack with plugs of gauze saturated in antipyrine. In bleeding from a tooth-socket, pack with styptic cotton (absorbent cotton soaked in Monsel's solution and dried). In bleeding from an incised urinary meatus, pack with styptic cotton. Cold water or ice acts as a styptic by pro- ducing reflex vascular contraction. Hot water produces contraction and coagulates the albumen. The temperature should be from 1150 to 1200 F. A mixture of equal parts of alcohol and water stops capillary oozing. The actual cautery is a most ancient hemostatic. It is still used in some cases after excising the upper jaw, in DISEASES AND INJURIES OF HEART AND VESSELS. 249 bleeding after the removal of some malignant growths, in continued hemorrhage from the prostatic plexus of veins, after lateral lithotomy, and to stop oozing after the excision of venereal warts. We are driven to it in " bleeders "—that is, those persons who have a hemorrhagic diathesis, and who may die from having a tooth pulled or from receiving a scratch. It will arrest hemorrhage, but sloughing is bound to occur, and when the slough separates secondary hemor- rhage is apt to set in. The iron for hemostatic purposes must be at a black heat. Forced flexion is a variety of indirect compression. It will stop bleeding, but soon becomes intensely painful. Golden Rules for Procedure in Primary Hemorrhage.— 1. In arterial hemorrhage, tie the artery in the wound, enlarging the wound if necessary. In tying the main artery of the limb in continuity we fail to cut off the bleeding from the distal extremity, and hemorrhage is bound to recur. If we fail to look into the wound, we cannot know what is cut: it may be only a branch, and not a main trunk. The same rule obtains in secondary hemorrhage (Guthrie's rule). 2. Ligate veins as we would arteries. 3. In a wound of the superficial palmar arch, tie both ends of the divided vessel. 4. In a wound of the deep palmar arch, enlarge the wound, if necessary, in the direction of the flexor tendons, at the same time maintaining pressure upon the brachial artery. Catch the ends of the arch with hemostatic forceps and tie both ends. If the artery can be caught by, but cannot be tied over the point of, the forceps, leave the instrument on for four days. If the artery cannot be caught with forceps, try a tenaculum. If these means fail, insert a small piece of gauze in the depth of the wound, put over this a larger piece, and keep on adding bit after bit, each one larger than its predecessor, until there is constructed a conical pad the 250 A MANUAL OF SURGERY. apex of which is against the extremities of the cut arch and the base of which is well external to the palm. Bandage each finger and the thumb, put a piece of metal over the pad, put a compress in front of the elbow, flex the forearm upon the arm, wrap the hand in gauze, place the arm upon a straight splint, apply firmly an ascending spiral reverse bandage of the arm, starting as a figure-of-8 of the wrist, and hang the hand in a sling. The pad is left in place for six or seven days unless bleeding keeps on or recurs. If bleeding is maintained or begins again, ligate the radial and ulnar. If this manoeuvre fails, we know that the interosseous artery is furnishing the blood and that the brachial must be tied at the bend of the elbow. If this fails, amputate the hand. 5. In primary hemorrhage, if the bleeding ceases, do not disturb the parts to look for the vessel. If the vessel is clearly seen in the wound, tie it; otherwise do not, as the bleeding may not recur. This rule does not hold good when a large artery is probably cut, when the subject will require transportation (as on the battle-field), when a man has delirium tremens, mania, or delirium, or when he is a heavy drinker. In these cases always look for an artery and tie it. 6. When a person is bleeding to death, arrest hemorrhage temporarily by digital pressure in the wound and apply above the wound a tourniquet or Esmarch bandage. Bring about reaction and then ligate, but do not operate during collapse if the bleeding can be controlled by pressure. 7. If an artery be divided incompletely, put a ligature on each side of the vessel-wound and then sever the artery so as to permit of complete retraction. 8. If a branch comes off just below the ligature, tie the branch as well as the main trunk. 9. If a branch of an artery is divided very close to a main trunk, tie the branch and also the main trunk. If the DISEASES AND INJURIES OF HEART AND VESSELS. 251 branch alone be tied, the internal clot, being very short, will be washed away by the blood-current of the larger vessel. 10. If a large vein is slightly torn, put a lateral ligature upon its wall. Gather the rent and the tissue around it in a forceps and tie the pursed-up mass of vein-wall. 11. When a branch of a large vein is torn close to the main trunk, tie the branch, and not the main trunk. Apply practically a lateral ligature. 12. If, after tying the cardial extremity of a cut artery, the distal extremity cannot be found even by a careful search after enlarging the wound, firmly pack the wound. 13. In bleeding from diploe or cancellous bone, use Horsley's antiseptic wax. 14. In bleeding from a vessel in a bony canal, plug the canal with an antiseptic stick and break the wood, or fill up the orifice of the canal with antiseptic wax; or, if this fails, ligate the artery of supply. 15. In bleeding from the internal mammary artery, pass a large curved needle holding a piece of silk into the chest, under the vessel and out again, and tie the thread tightly. 16. In bleeding from an intercostal artery, make pressure upward and outward, or throw a ligature by means of a curved needle entirely over a rib, tying it externally, or resect a rib and tie the artery. 17. In collapse due to puncture of a deep vessel, the bleed- ing having ceased, do not hurry reaction by stimulants. Give the clot a chance to hold. Wrap the sufferer in hot blankets. If the condition is dangerous, however, stimulate to save life. 18. In punctured wounds, as a rule, try pressure before using ligation. 19. After a severe hemorrhage always put the patient to bed and elevate the damaged part (if it be an extremity or the head). 20. A clot which holds for twelve hours after a primary 252 A MANUAL OF SURGERY. hemorrhage will probably hold permanently; but even after twelve hours be watchful and insist on rest. 21. If recurrence of a hemorrhage from a limb is feared, mark with aniline or iodine the spot on the main artery where compression is to be applied, put on a tourniquet loosely, and order the nurse to screw it up and to send for the physician at the first sign of renewed bleeding. This must often be done in gunshot wounds. 22. In extra-dural hemorrhage, trephine. The side to be trephined is determined by the symptoms, and not by the situ- ation of the injury. The opening is made on a level with the upper orbital border and one and a quarter inches behind the external angular process. This opening exposes the middle meningeal and its anterior branch (Keen). If this does not expose a clot, trephine over the posterior branch, on the same level and just below the parietal eminence. When the clot is found, enlarge the opening with the rongeur, scoop out the clot, and stop the bleeding by passing a catgut ligature through the dura, under the artery and out again, and then tying it. 23. In hemorrhage from a cerebral sinus, catch the edges of the opening with forceps if possible and ligate ; apply a lateral ligature, or leave the forceps on for forty-eight hours, or compress firmly with one large piece of iodoform gauze. 24. In extra-medullary spinal hemorrhage rapidly advanc- ing and threatening life, perform a laminectomy and arrest the hemorrhage. 25. In bleeding from a tooth-socket, use ice. If this treat- ment fails, plug with gauze infiltrated with tannin, close the jaws upon the plug, and hold them with Barton's bandage. If this expedient fails, soak the plug in Monsel's solution, and if this is futile, use the cautery. Pressure on the carotid and ice over the jaw and neck are indicated. It may be necessary to tie the common carotid. DISEASES AND INJURIES OF HEART AND VESSELS. 253 26. In intra-abdominal hemorrhage, open the belly. If the blood accumulates so rapidly as to prevent the location of the bleeding point, compress the aorta or pack the abdomi- nal cavity with large sponges. In parenchymatous hemor- rhage, try packing with iodoform gauze. In the liver, if this fails, suture the torn edge or use the cautery. Severe wounds of the spleen demand splenectomy; those of the kidney, nephrectomy. Mesenteric vessels are ligated en masse with silk (Senn). Wounds of stomach and intestines causing hemorrhage require stitching of their edges. When there arc an infinite number of points of bleeding, take a number of sponges, tie a piece of iodoform gauze firmly to each one, pack many places in the belly with the sponges, bring the gauze out of the wound, and remove the sponges from below upward one at a time, securing the bleeding points as they come into view. 27. In abdominal section for disease of the female pelvic organs, bleeding is limited by the clamp or by pressure-for- ceps. Ligation en masse is often practised. Use silk. A large mass can be transfixed and tied in sections. Bleeding edges are stitched. Areas of oozing are treated with tem- porary pressure and hot water, or, if this fails, by the cautery. Packing can be used as a tamponade, which is a gauze pouch, pieces of gauze being packed into this pouch after its inser- tion into the belly. 28. A ruptured varicose vein requires a compress, a band- age from the periphery up, and elevation. 29. For capillary hemorrhage use hot water and com- pression, or, if this fails, the cautery. Understand that cap- illary bleeding does not so much mean bleeding from genu- ine capillaries as it does bleeding from arterioles and venules. 30. Pressure above a wound stops arterial hemorrhage, but aggravates venous bleeding. Pressure below a wound stops venous hemorrhage, but increases arterial bleeding. 254 A MANUAL OF SURGERY. 31. In severe epistaxis, or bleeding from the nose, pack the nares. Pass a Bellocq canula (Fig. 40) along the floor of one nostril into the pharynx, project the stem into the mouth, tie a plug of lint or gauze to the stem, and with- draw it. Carry out the same procedure upon the other nostril, pull the strings firmly forward, pack the nostrils from before backward, and tie the strings around the head. Soaking the lint or gauze in antipyrine solution is a good Fig. 40.—Plugging the Nares for Epistaxis (Guerin). plan. Do not use subsulphate of iron, as it forms a disgust- ing, clotty, adherent mass. If a Bellocq canula is not obtainable, push a soft catheter into the pharynx, catch it with a finger, pull it forward, and tie the plug to it. 32. In gunshot wounds the primary hemorrhage is slight unless a large vessel is cut. The bleeding may be visible or may be internal (concealed), the blood running into a natu- ral cavity or among the muscles. Capillary oozing is arrested DISEASES AND INJURIES OF HEART AND VESSELS. 255 by very hot water and compression. Venous bleeding is usually arrested by compression. If a large vessel is the source of bleeding, enlarge the wound and tie the vessel. If the artery cannot be found in the wound, tie the main trunk. 33. In prolonged bleeding from a leech-bite, try compres- sion over a plug saturated with alum or with tannin. If this fails, pass under the wound a hare-lip pin and encircle it with a piece of silk. If this fails, use the actual cautery. 34. In severe bleeding from the ear, elevate the head, put an ice-bag over the mastoid, give opium and acetate of lead, and, if blood runs into the mouth, plug the Eustachian tube with a piece of catheter. 35. Umbilical hemorrhage in infants requires pressure over a plug containing tannin or alum. If this fails, pass hare-lip pins under the navel and apply a twisted suture. If this fails, use the actual cautery. 36. Rectal bleeding requires elevation of the buttocks, insertion of plugs of ice, ice to the anus and perineum, astringent injections (alum), and the internal use of opium, ergot, and acetate of lead. If these means fail, plug the bowel over a catheter, or insert and inflate a Peterson bag or a colpeurynter, or tampon and use a T-bandge. If the bleed- ing persists or if a considerable vessel is bleeding, stretch the sphincter, catch the bowel and draw it down, seize the vessel, and tie it if possible; if not, leave the forceps in place. Failing in this, the actual cautery must be used. 37. Subcutaneous hemorrhage, if severe, demands that an incision be made and ligation be performed. 38. Bleeding from a cut urethral meatus requires the insertion of styptic cotton and the application of pressure. Moderate bleeding from the urethra can usually be arrested by a hot bougie, by hot injections, or by tying a condom over a catheter, and, after inserting it, inflating the condom 256 A MANUAL OF SURGERY. by blowing through the catheter and plugging the orifice of the instrument, thus using pressure. Sitting with the perineum on a thickly-folded towel is useful. Ice to the perineum does good. If these means are futile, perform an external urethrotomy and reach the bleeding point. 39. Hemorrhage from the prostate requires hot injec- tions, the introduction of a large bougie first dipped in very warm water, and the retention of a catheter for two days. Perineal section may be required, or suprapubic cyst- otomy with packing which does not occlude the ureteral orifices. 40. Vesical hemorrhage usually ceases spontaneously, in which case the urine must be drawn off and the viscus be washed out frequently with a solution of boric acid to pre- vent septic cystitis. If blood-clots prevent the flow of urine, break them up with a catheter and inject vinegar and water. Perfect quiet is to be maintained, cold acid drinks to be given, ice-bags to be put to the perineum and hypogastric region, and opium with acetate of lead, ergot, or gallic acid to be given by the mouth. If the hemorrhage is severe or persistent, perform a suprapubic cystotomy. 41. In hemorrhage after lateral lithotomy, ligate if pos- sible. If the vessel can be caught but cannot be ligated, leave the forceps in place. If we cannot catch the vessel with forceps, try a tenaculum. If the tenaculum fails, pass a threaded curved needle through the tissues around the ves- sel and tie the ligature. Plugs of ice and injections of hot water may be tried. These means failing, pressure is indi- cated. Take a canula, fasten to it a chemise (Fig. 41), empty clots from the bladder, insert the instrument into the viscus, and pack gauze between the sides of the canula and the chemise. The chemise is bulged out and pressure is made. Tie the canula by means of tapes to a T-bandage. Pressure is thus combined with vesical drainage. Buckstone DISEASES AND INJURIES OF HEART AND VESSELS. 257 Brown makes pressure by inflating a rubber bag with air. The hot iron may occasionally be demanded. 42. Renal bleeding requires ice to the loin, tannic acid and opium, gallic acid and sulphuric acid, ergot, and perfect quiet. If the bleeding threatens life and the dis- eased organ is identified, perform a lumbar nephrectomy; if not sure which organ is diseased, perform an abdom- inal nephrectomy. 43. Vaginal hemorrhage requires the ligature or the tampon. 44. Severe uterine hemorrhage (un- connected with pregnancy) requires the tampon. Persistent hemorrhage due to morbid growths may require removal of the tubes and appendages, ligation of the uterine and ovarian arteries, or hysterectomy. 45. Haematemesis, or bleeding from the stomach, is treated by the swallowing of ice, giving tannic acid (dose, 20 or 30 grains) or Monsel's solution (3 drops). Never give tannic acid and Monsel's solution at the same time, as they mix and form ink. Opium is usually ordered. Acetate of lead and opium and gallic acid are favorite remedies, and ergot is used by many. Give no food. 46. In bleeding from the small bowel, give acetate of lead and opium, sulphuric acid, ergot, or Monsel's salt in pill form (3 grains), allow no food for a time, and insist on liquid diet for a considerable period. 47. In bleeding from the large bowel, use styptic injections (10 grains of alum or 5 grains of bluestone to 5] of water). If bleeding is low down, use small amounts of the solution; if high up, large amounts. Do not use absorbable poisons. 17 Fig. 41.—Canula k Chemise. 258 A MANUAL OF SURGERY. 48. Haemoptysis, or bleeding from the lung, is treated by morphia hypodermatically, by perfect rest, by dry cups or ice over the affected spot if it can be located, by ergot, and by gallic acid. Gallic acid aids coagulation.1 Reactionary or Recurrent Hemorrhage (called also Consecutive, Intermediate, or Intercurrent).—This form of hemorrhage comes on during reaction from an accident or an operation—that is, during the first forty-eight hours. It is usually due to badly-applied ligatures, or may result from vascular excitement or from hypertrophied heart, the jump- ing arteries loosening the ligature. The Esmarch apparatus is not unusually the cause. The constricting band paralyzes the smaller arteries, which do not bleed during shock and do not contract as shock departs; hence bleeding comes on with reaction. To lessen the danger of the Esmarch appa- ratus, use a broad constricting band rather than a rubber tube. During reaction after an amputation, if slight hemor- rhage occurs, elevate the stump and compress the flaps. If the hemorrhage persists or at any time becomes severe, make pressure on the main artery of the limb, open the flaps, turn out the clots, find the bleeding point, ligate, asep- ticize, close, and dress. In any severe reactionary hemor- rhage, open the wound at once and ligate. Secondary hemorrhage may occur at any time in the period between forty-eight hours after the accident or opera- tion and the complete cicatrization of the wound. Secondary hemorrhage may be due to atheroma, to slipping of a liga- ture, to inclusion of nerve, fascia, or muscle in the ligature, to sloughing, to erysipelas, to septicaemia, to pyaemia, to gangrene, and to overaction of the heart. If during' an 1 The use of ergot is a general but questionable practice. Bartholow and others hold that this drug does harm; it contracts all the arterioles, and hence more blood flows from an area where there is damage. Purgatives do good in bleed- ing from the lung by taking blood to the abdomen and lowering blood-pressure. DISEASES AND INJURIES OF HEART AND VESSELS. 259 operation the vessels are found atheromatous, acupressure had best be used, or pass a thread, by means of a Hagedorn needle, around the vessel, including a cushion of tissue in the loop of the ligature (this prevents cutting through). One great trouble with atheromatous arteries is that their coats cannot retract; another trouble is that the ligature cuts entirely through them. If after an operation the pulse is found to be forcible, rapid, and jerking, give aconite, opium, and low diet. Treatment of Secondary Hemorrhage.—The method of treatment, supposing a case of leg-amputation in which, several days after the operation, a little oozing is detected, is to elevate the stump, apply two compresses over the flaps, and carry a firm bandage up the leg. If the bleeding is pro- fuse or becomes so, make pressure on the main artery, open and tear the flaps apart with the fingers, find the bleeding vessel and tie it, turn out the clots, asepticize, close, and dress. If the bleeding begins at a period when the stump is nearly healed, cut down on the main artery just above the stump and ligate. In secondary hemorrhage from a blood- vessel in nodular tissue, throw a ligature around the vessel by a curved needle and tie higher up, or, if this fails, ampu- tate. When secondary hemorrhage arises in a sloughing wound, apply a tourniquet or an Esmarch bandage, tear the wound open to the bottom with a grooved director, look for the orifice of the vessel, dissect the artery up and down until a healthy point is reached, and tie both ends. If this fails, include tissue in the ligature or use acupressure. In sec- ondary hemorrhage from atheromatous vessels, use acupres- sure or include surrounding tissue in the ligature. Secondary hemorrhage may occur after ligation in con- tinuity, the blood usually coming from the distal side. If the dressings are slightly stained with blood, put on a gradu- ated compress. If the bleeding continues or is severe, make 260 A MANUAL OF SURGERY. pressure on the main artery of the limb, open the wound and ligate, wrap the part in cotton, elevate, and surround with hot bottles. If this re-ligation is done on the femoral and fails, do not ligate higher up, as gangrene will certainly occur, but amputate at once, above the point of hemorrhage. If dealing with the brachial artery, do not amputate, but ligate higher up and make compression in the wound. In a secondary hemorrhage from the innominate, tie the vertebral. The best way to deal with secondary hemorrhage is not to have it, and thorough antisepsis is the greatest possible safeguard. 2. Operations on the Vascular System. Paracentesis auriculi, or tapping the heart-cavity, has been suggested for the relief of an over-distended heart from pulmonary congestion. The right auricle should be tapped. Push the aspirator-needle directly backward at the right edge of the sternum, in the third interspace. This operation is not recommended, as it is highly dangerous and is of questionable value. Paracentesis pericardii, or tapping the pericardial sac, is only done when life is endangered. Introduce the needle two inches to the left of the left edge of the sternum, in the fifth interspace, and push it directly backward (thus avoiding the internal mammary artery). Operation for Varix of Leg.—In this operation, make, at several points in the course of the long saphenous vein, skin incisions each two inches long and in the long axis of the vessel. Clear the vessel at each incision, apply two liga- tures an inch apart, and excise the vein between them. Never operate if the slightest phlebitis exists (Barker). Another method is as follows: The patient stands for a time before a fire to enlarge the veins. A hare-lip pin is pushed into the tissues an inch from the vein, at the upper end of its varicose portion; the pin is passed under the vein and emerges an DISEASES AND INJURIES OF HEART AND VESSELS. 261 inch outside of it. A bit of catheter wrapped in gauze is laid over the vein, and a twisted suture is carried around the pin and over the pad. This operation is done lower down in one or two positions. Open Operation for Varicocele.—The open operation is by far the best procedure for varicocele. The instruments used are a scalpel, an aneurysm-needle, a Reverdin needle, a grooved director, a dissecting-forceps, an Allis dry dis- sector, haemostatic forceps, and scissors. Operation.—The patient is recumbent and anaesthetized. The operator stands on the diseased side. The assistant stands on the sound side and makes pressure over the inguinal ring of the affected side. A fold of skin is pinched up on the scrotum, and the surgeon transfixes it in the line of the cord, so that he will have an incision about one and a half inches long running downward from below the external ring. The veins are reached by means of an Allis dissector and the cord is located and held aside. A double ligature of silk is passed under the veins by an aneurysm-needle. The threads are separated three-quarters of an inch, tied tightly, and cut. The veins between the ligatures are divided or excised. The scrotum is sewed up with silk- worm gut, a small drainage-tube being used for twenty-four hours. Healing is complete in one week. Dr. Hearn, after resecting a portion of the vein-mass, ties the cut ends together and thus shortens the veins. Subcutaneous Ligature for Varicocele.—In this opera- tion, employ every antiseptic precaution. The patient stands, and the operator, sitting in front of him, holds the veins in a fold of skin away from the vas deferens by means of the thumb and index finger of the left hand. A large straight needle earning a double piece of strong silk is passed entirely through the scrotum, between the veins and the vas. The needle is again inserted at the puncture from 262 A MANUAL OF SURGERY. which it emerged, is carried around under the skin and in front of the veins, and emerges at its original point of entry. The veins are thus surrounded by the silk. .The patient, who now lies down, is placed under the first stage of ether, and the double ligatures are separated as far as possible from each other, tied, and cut off, the knots slipping in through the puncture. This operation presents certain dangers. The veins may be wounded and the vas or other structures may be included. In an operation it is always best to be able to see what we are doing; hence the open operation is preferred to the subcutaneous. Phlebotomy, or Venesection.—The instruments used in venesection are a lancet or bistoury, a broom-handle, a fillet or tape, an antiseptic pad, and a bandage. Operation.—The patient sits on a chair " with the arm abducted, extended, and inclined outward " (Barker). The surgeon stands to the right of the arm, holds the elbow with his left hand, and puts his thumb upon the vein below the intended point of puncture. Asepticize the parts and tie the tape above the elbow. The patient grasps the stick firmly and works his fingers to swell the veins. Either the median cephalic or median basilic can be punctured (Fig. 43). The median basilic is the more distinct, and is the vein usually selected. In puncturing it, do not go too deep, as nothing but the bicipital fascia separates it from the brachial artery. The median cephalic may be selected (we thus avoid en- dangering the brachial artery), but remember that under this vein lies the external cutaneous nerve (Fig. 42). Steady the Fig. 42.—Superficial Fig. 43.—Incisions Veins in Front of the for Venesection. Elbow. (Bernard and Huette.) DISEASES AND INJURIES OF HEART AND VESSELS. 263 vein with the thumb and open it by transfixion, making an oblique cut which divides two-thirds of it. Remove the thumb and allow bleeding to go on, instructing the patient to work his fingers. When faintness begins, remove the fillet, put an antiseptic pad over the puncture, apply a spiral reverse bandage of the hand and arm and a figure-of-8 bandage of the elbow, and place the arm in a sling for several days. Transfusion of Blood.—This operation has been a recog- nized procedure since 1824, though it has certainly been known since 1492, when transfusion in the case of Pope Innocent VIII. was made. Its chief use is in severe hemor- rhage, especially post-partum, in which it replaces the blood lost and supplies something for the heart to con- tract upon until new blood is formed. That it saves life is unquestionable, but the procedure falls short, in per- manent result, of what was anticipated for it. The old view was that blood must come from the same animal, but Brown-Sequard demonstrated that the blood of various animals could be used, and Panum proved that defibrinated blood is as efficient as pure blood. This discovery of Panum indicates that the saline elements are those which are required ; hence at the present day a saline fluid is more often transfused than blood. This fluid is generally thrown into the cellular tissue rather than into the veins. In saline injection by hypodermoclysis, which is so useful in col- lapse, from ten to sixteen ounces of warm normal salt-solu- tion are gradually passed into the cellular tissue by means of a fountain-syringe and a large aspirating-needle, the region of injection being rubbed and kneaded. Some physicians inject a solution consisting of boiled water and phosphate of soda. Transfusion of blood may be mediate. A thoroughly health)' man is bled from the median basilic vein, the blood being caught in an aseptic tumbler which stands in a basin of water at ioo° F. The heat prevents coagulation of the 264 A MANUAL OF SURGERY. blood, which is defibrinated by whipping with a clean fork. The median basilic vein of the sufferer is exposed by an in- cision, and is lifted up from its bed by a probe and opened. There are sucked up in an aseptic syringe two ounces of blood, which is at once injected into the vein of the patient; two ounces more are allowed to run from the donor and are defibrinated, and two ounces more are thrown into the veins of the recipient, in the interval pressure being used to prevent bleeding. There are thus introduced ten, twelve, or sixteen ounces. The chief dangers are embolism, sepsis, and the entrance of air. Transfusion of blood may be immediate. Expose with antiseptic care a vein of the donor at the bend of the elbow Fig. 44.—Aveling's Apparatus for Immediate Transfusion. and a vein of the recipient in the same situation, fillets being tied above each elbow. The veins must be thoroughly bared to the extent of three-quarters of an inch. Open the veins and introduce the canulae of an Aveling syringe (Fig. 44), which instrument is filled with normal salt-solution. The opening is small and transverse. The canula in the vein of the donor is pushed toward the hand, that in the vein of the recipient being pushed toward the shoulder, the arms of giver and receiver resting upon a table. Remove the fillets. Compress the tube between the bulb and the giver, open the clips, squeeze the bulb to drive the salt-solution into the LIGATIONS. Plate 3. 1. Opening the Sheath for Ligation of an Artery (Guerin). 2. Sheath of Artery Open (Guerin). 3. Tightening the Knot in Ligation (Guerin). 4. Anatomy of the Iliac Arteries, and showing the lines of incision for their ligation : 1, Abernethy's incision (Guerin). 5, 6. Ballance and Ed- mund's Stay-knots. DISEASES AND INJURIES OF HEART AND VESSELS. 265 giver, remove the pressure from the tube between the bulb and the donor, compress the tube between the bulb and the recipient, and allow the bulb to expand and fill with blood ; force this blood out by the same plan, and thus continue until six, eight, or ten ounces are transferred. Dress each patient as after phlebotomy. Saline transfusion is sometimes performed. Arterial Transfusion.—Hueter prefers the arterial method of transfusion, in order to send the blood more gradually to the heart, and thus prevent sudden disturbance of the circula- tion. A little air in an artery will do no harm, and the danger of venous embolism is avoided. The radial artery is exposed and surrounded by three ligatures, and the thread toward the heart is at once tied. The distal ligature is slightly tightened to cut off anastomotic blood-supply. The artery is cut transversely half through; the syringe is inserted, pointed toward the periphery, and fastened by the third ligature; the second ligature is loosened and the blood is in- jected. On finishing, the peripheral thread is tied tightly and that portion of the artery which held the canula is excised. 3. Ligation of Arteries in Continuity. The instruments used in this operation are two scalpels (one small, one medium), two dissecting-forceps, several haemo- static forceps, toothed forceps, blunt hooks or broad metal retractors, an Allis dissector, an aneurysm-needle, for super- ficial arteries the instrument of Saviard, for deep vessels the needle of Dupuytren, ligatures of catgut, of chromicized gut, or of silk, and the reflector or electric forehead-lamp for deep vessels. The position varies according to the vessel, though the body is supine except when ligation is to be performed on the gluteal, sciatic, or popliteal. The operator, as a rule, stands upon the affected side, cutting from above downward on the right side and from below upward on the left side. 266 A MANUAL OF SURGERY. Operation.—Accurately determine the line of the artery, and make an incision at an angle of five degrees to this line, avoiding subcutaneous veins, and holding the scalpel like a fiddle-bow or a dinner-knife while cutting the superficial parts, and like a pen while incising, the deeper parts. On reaching the deep fascia, make out the required muscular gap by the eye and finger, so moving the extremity as to bring individual muscles into action. Treves cautions us not to depend upon the yellow line of fat, which often cannot be seen in emaciated people or'when an Esmarch bandage is employed; nor upon the white line due to attachment to the fascia of an intermuscular septum. In opening the deep portion of the wound, relax the bounding muscles by altering the posture. Open a muscular interspace with the knife or the Allis dissector. Make the depths of the wound as long as the superficial incision. Do not tear structures apart with a grooved director (Treves). Arrest hemorrhage as it occurs. Try to find the situation of the artery with the finger. Pulsation is present, but it may be very feeble and hard to detect. The artery feels like a very thin rubber tube; it is compressible, though not so easily as a vein, and when compressed feels like a flat band which is thinner in the centre than at the edges (Treves). A nerve feels like a hard round cord. The veins are soft, larger than their related arteries, and so very compressible that they can scarcely be felt when pressed upon, compression causing distal distention. If the wound can be seen well into, it will be noted, as Treves asserts, that " the nerves stand out as clear, rounded, white cords; that the veins are of a purple color and of somewhat uneven and wavy contour; that the artery is regular in outline and of a pale-pink or pinkish- yellow tint, the large vessels being of lighter color than the small." All the arteries of the upper extremity and all the arteries below the knee are accompanied by two veins known DISEASES AND INJURIES OF HEART AND VESSELS. 267 as " venae comites." The arteries of the head and neck have each a single attending vein, except the lingual, which has venae comites. Most of the smaller arteries of the trunk (pudic, internal mammary, etc.) have venae comites. These companion veins may lie on each side of the artery or in front and back of it, and they communicate with one another by transverse branches crossing the artery. On reaching the sheath, pick up this structure with toothed forceps so as to make a transverse fold, and thus avoid catching the artery or vein ; lift the fold to see that it is free, and open the sheath by cutting toward the edge of the forceps with a scalpel held obliquely with its back toward the vessel, thus making a small longitudinal incision (PI. 3, Figs. I, 2). Hold the edge of the incised sheath with the forceps; pass an aneurysm-needle under the vessel and from the forceps; this clears one-half of the vessel. Grasp the other edge of the sheath and pass the aneurysm-needle all the way around the vessel, threading the needle when it emerges and withdrawing it. In passing the needle this last time, carry it away from its most dan- gerous neighbor. If venae comites are in the way, try and separate them, but if this proves difficult, include them in the ligature. In small vessels always include them if they are in the way, as this saves trouble. If, in passing the needle, a large vein is severely wounded (such as the femoral), Jacobson advises the employment of digital pressure in the lower portion of the wound while the artery is being tied on a level above or below that of the vein- . . . r ... . Fig. 45.—Reef-knot. injury, and after ligation the maintenance of pressure on the wound for a couple of days. A slight puncture in a vein merely requires a lateral liga- ture. After getting a ligature under an artery, press for a moment upon the artery over the ligature, which is held taut; 268 A MANUAL OF SURGERY. this pressure will show that pulsation below is arrested. Tie the thread at right angles to the vessel with a reef-knot (Fig. 45), rupturing the internal and middle coats. As the ligature is tightened place the extended index fingers along the liga- ture up to the artery (PL 3, Fig. 3), using the middle joints as the fulcrum of a lever by placing them against each other. Ballance and Edmunds have recently claimed, as Scarpa and Sir Philip Crampton did long since, that it is not neces- sary to divide the internal and middle coats to ensure oblit- eration. If this claim be true, the danger of secondary hemorrhage can be greatly lessened. Holmes, however, thinks the older method the more certain of the two. Ballance and Edmunds recommend that the artery be sur- rounded with a doubled ligature of floss-silk, that each ligature be tied with one turn of a reef-knot, and that the final turn be made by gathering together as single pieces both ends of each ligature and tying them to each other. This knot is known as the "stay-knot" (PI. 3, Figs. 5, 6). The chief dangers after ligation are secondary hemorrhage and gangrene. Rigid asepsis usually prevents the first; rest, elevation, and heat antagonize the second. Radial Artery.—The line of the radial artery is from the middle of the front of the elbow-joint to the front of the styloid process of the radius. The line in the tabatiere is from the apex of the styloid process to the posterior angle of the first interosseous space. Anatomy (PI. 4, Fig. 5).—The radial artery, though smaller than the ulnar, is the direct continuation of the brachial. It arises from the bifurcation of the brachial, half an inch below the bend of the elbow, runs down the radial side of the forearm to the front of the styloid process of the radius, passes beneath the extensor muscles of the first metacarpal bone and of the first phalanx of the thumb, and over the car- pus to the first interosseous space, where it is crossed by the ligations. Plate 4. < "2 S 6 33 Z V < 5 -a ■ - c J •- ■a £ -I n o < C DISEASES AND INJURIES OF HEART AND VESSELS. 269 extensor secundi internodii pollicis, and enters into the palm between the heads of the first dorsal interosseous muscle to form the deep palmar arch. The artery in the upper part of its course is somewhat overlaid by the supinator longus muscle; throughout the rest of the forearm it is superficial. In the upper third of the forearm it lies between the supi- nator longus on the outside and the pronator radii teres on the inside; in the lower two-thirds of the forearm it lies between the supinator longus on the outside and the flexor carpi radialis on the inside. The radial nerve is to the outer or radial side of the artery, well removed from the artery in the upper third, nearer to the artery in the middle third, far external to the artery in the lower third, the nerve at this point passing beneath the supinator longus muscle. The radial artery, from above downward, rests upon the biceps tendon, the short supinator muscle, the pronator radii teres muscle, the flexor sublimis, the flexor longus pollicis, the pronator quadratus muscles, and the radius. It has two venae comites. The best guide to the radial artery in the forearm is the outer edge of the flexor carpi radialis muscle or the inner edge of the supinator longus muscle. The tabatiere, or snuff-box, is an anatomical triangle whose base is the lower edge of the posterior annular ligament, one side being formed by the extensor secundi internodii pollicis tendon, the other by the extensor ossis metacarpi and the extensor primi internodii pollicis tendons; the floor consists of the trapezium, scaphoid, and base of the first metacarpal bone. Operations: Ligation in the tabatiere is a dissecting-room operation of but little practical use. Ligation in the Lozver Third.—In this operation (PI. 4, Fig. 6) the forearm is supinated and held by an assistant. The surgeon stands on the side operated upon, and cuts from above downward on the right arm and from below 270 A MANUAL OF SURGERY. upward on the left arm. The line of the vessel is laid down and marked with iodine or aniline. An incision one and a half inches long is made at an angle of five degrees to this line and midway between the supinator longus and the flexor carpi radialis muscles, which incision must not extend below the level of the tuberosity of the scaphoid bone. In the superficial fascia watch for the superficial radial vein, and if it comes into view, push it aside. Incise the superficial fascia and locate each guide-tendon. Open the deep fascia in the length of the first cut; try and separate the veins, but if they strongly adhere, include them in the ligature. There is no special fascial sheath. The radial nerve will not be seen, but a division of the anterior cutaneous is frequently found in relation with the vessel. The needle can be passed in either direction. A high origin of the superficialis volae artery is confusing. Ligation in the Middle Third.—In this operation the posi- tion is the same as in the preceding. A two-inch incision • is made. Veins of the subcutaneous tissues are avoided. Lying upon the deep fascia is the anterior division of the musculo-cutaneous nerve. Open the fascia; find the inner edge of the supinator longus muscle and draw it outward, flexing the elbow if necessary. Be sure not to get external to this muscle. Find the vessel where it is bound down by connective tissue to the pronator radii teres muscle, separate the veins, and pass the ligature from without in. The nerve is external. Ligation in the Upper Third.—In this operation the incision is like the last, only higher up. The artery is between the supinator longus and the pronator radii teres, which muscles are at once differentiated by the different direction of their fibres. The artery is usually covered by the supinator longus muscle, which must be retracted externally. The nerve is not seen. The ligature is passed in either direction. DISEASES AND INJURIES OF HEART AND VESSELS. 271 Ulnar Artery.—No one line will overlie the entire ulnar artery. The line of the upper third runs from the middle of the front of the elbow-joint to the point of junction of the upper and middle thirds of the ulna. The line of the lower two-thirds runs from the tip of the internal condyle of the humerus to the radial side of the pisiform bone (PI. 4, Figs. 5, 6). Anatomy.—(PI. 4, Fig. 5.) The ulnar artery arises from the brachial bifurcation and runs obliquely inward under the median nerve and a group of muscles from the internal condyle; it turns down the arm, being covered in the middle third of its course by the flexor carpi ulnaris muscle. In the lower third it is superficial, between the tendons of the flexor carpi ulnaris on the inside and the flexor sublimis digitorum on the outside, the vessel being a little overlapped by the flexor carpi ulnaris. This vessel rests first upon the brachialis anticus muscle, next upon the flexor profundus, to which it is bound by a distinct process of fascia, and next upon the annular ligament, which structure it crosses to become the superficial palmar arch. Two venae comites attend the vessel. In the upper third the nerve is well in- ternal, but in the lower two-thirds the nerve lies near the artery and to its ulnar side. The guide is the outer edge of the flexor carpi ulnaris. Operations (PI. 4, Fig. 6): Ligation in the Lower Third.—The position in this operation is the same as for the radial artery. Make a two-inch incision to the radial side of the tendon of the flexor carpi ulnaris, which incision is not taken lower than a point one inch above the pisiform bone. Avoid the superficial ulnar vein in the subcutaneous tissue. Open the deep fascia, find the tendon of the flexor carpi ulnaris, flex the wrist and draw the tendon inward, open the sheath of fascia, separate veins if possible, and pass the ligature from within outward to avoid the nerve. On the artery is the palmar 272 A MANUAL OF SURGERY. cutaneous branch of the ulnar nerve, and this branch must not be included in the ligature. Ligation in the Middle Third.—In this operation the posi- tion is the same as in the preceding one, the incision being three inches long. Avoid the anterior ulnar vein and the branches of the internal cutaneous nerve in the superficial fascia. Open the deep fascia a little external to the super- ficial cut (Treves). Find the space between the flexor carpi ulnaris and the superficial flexor, feeling with the index finger, and when the space is discovered, flex the wrist, retract the flexor carpi ulnaris inward and the flexor sublimis digitorum outward, open the fascia, find the ulnar nerve, look external to it for the artery, clear the vessel, separate the venae comites, and pass the needle from within outward. Brachial Artery.—The line of the brachial artery is from the junction of the anterior and middle thirds of the outlet of the axilla, the arm being abducted and the forearm supi- nated, to the middle of the front of the elbow-joint. Anatomy (PI. 4, Fig. 1).—The brachial artery is the pro- longation of the axillary, and extends from the lower edge of the teres major muscle to half an inch below the bend of the elbow, where it divides into the radial and ulnar. It lies first to the inner side of the arm, but passes to the front of the elbow. It is crossed by no muscle, and is in fact superficial, barring its being somewhat overlaid in part of its course by the edge of the biceps muscle. The median nerve is outside above, crosses over or under it about the middle of the arm, and reaches the inside. The coraco-brachialis and biceps mus- cles are external, and both often overlap the vessel. The ulnar nerve is internal above, and the median nerve below, the mid- dle. The basilic vein is internal to the artery, being outside the deep fascia to the upper third, at which point it pierces it. The artery above is separated from the long head of the triceps by the musculo-spiral nerve and superior profunda i, Anatomy, 2, Ligation, of the Subclavian Artery and First Part of the Axillary Artery. 3, Anatomy of the Neck. 4, Ligation of the Carulid, Lingual and Facial Arteries. 5, Anatomy, 6, Ligation, of the Anterior Tibial and Peroneal Arteries. (From Bernard.) DISEASES AND INJURIES OF HEART AND VESSELS. 273 artery and vein; it rests from above down on the inner head of the triceps, the coraco-brachialis, and the brachialis anticus. The artery is covered by skin and by superficial and deep fascia. The internal cutaneous nerve lies in front of the artery, upon the deep fascia, until it pierces the fascia along with the basilic vein. The artery has venae comites, and in its upper third has also the basilic vein to its inner side. The guide to the brachial is the inner edge of the biceps. Just in front of the elbow-joint the artery lies in a triangle the base of which is formed by an imaginary transverse line above the condyles, the apex by the junction of the pronator radii teres and the supinator longus. The outer line is the supinator longus, the inner is the pronator radii teres, and the floor is formed by the brachialis anticus and the supinator brevis. From within outward the triangle contains the median nerve, brachial artery, tendon of the biceps, anasto- mosis of the superior profunda and radial recurrent arteries, and the musculo-spiral nerve. Operations : Ligation at the Bend of the Elbozv.—In this operation (PI. 4, Fig. 2) extend the arm moderately and abduct, and allow it to lie upon its posterior aspect. The forearm is supinated. The surgeon stands upon the side operated upon, and cuts from above downward on the right side and from below upward on the left side. Accurately locate the tendon of the biceps and the median basilic vein. An incision is made parallel with the inner edge of the biceps tendon and two inches in length, the centre of this cut being in the crease of the elbow. On exposing the median basilic vein, retract it inward, open the bicipital fascia, clear the artery of fat, separate the venae comites, and pass the ligature from within outward to avoid the median nerve. The above operation is not frequently per- formed. Ligation in the Middle of the Arm.—In this operation ex- 18 274 A MANUAL OF SURGERY. tension and abduction of the arm and supination of the fore- arm are made. An assistant holds the forearm, but the arm should not rest upon the table, because, if it be allowed to do so, the inner head of the triceps will be forced forward and may overlie the artery, and thus complicate the opera- tion. Locate the inner edge of the biceps, which is the guide. Make an incision three inches long in the line of the artery. Incise the skin and fascia, flex the elbow slightly, retract the biceps outward, feel for the artery, open its sheath, separate its venae comites, and, having located the median nerve, pass the ligature from it. In the middle of the arm the nerve is in front of or behind the vessel, above the middle it is external, and below the middle internal. High up the arm the inner edge of the coraco-brachialis is the guide, rather than the biceps, and at this point the basilic vein perforates the deep fascia and runs along to the inner side of the artery; hence, high up, the artery has three companion veins, and there is seen the ulnar nerve to the inside of the artery. Axillary Artery.—To determine the line of the axillary artery, place the arm at right angles to the body and lay down a line from the middle of the clavicle to the humerus near the inner border of the coraco-brachialis. The line of the third portion can easily be approximated by projecting the line of the brachial upward. Anatomy (PI. 4, Fig. 3 ; PI. 5, Fig. 1).—-The axillary artery is the continuation of the subclavian, and runs from the lower margin of the first rib to the inferior border of the teres major muscle. It is divided into three portions by the pectoralis minor muscle. The first portion is above, the second portion is behind, and the third portion is below, the pectoralis minor. The position of the artery varies with the position of the limb. When the arm is parallel with the body the artery is far from the surface and forms a curve DISEASES AND INJURIES OF HEART AND VESSELS. 27$ whose convexity is upward and outward. When the arm is at right angles to the body the vessel is nearer the surface and straight. When the arm is raised above a right angle the artery comes near the surface and forms a curve with the convexity downward. The first portion of the axillary artery is occasionally ligated. It lies upon the first intercostal muscle and the first serration of the great serratus muscle, and has behind it the posterior thoracic nerve; on the outer side of the artery is the brachial plexus ; on its inner side is the axillary vein ; in front of it are the clavicle, the great pectoral muscle, the subclavius muscle, the costo-coracoid membrane, the cephalic and acromio-thoracic veins, and the external anterior thoracic nerve. The branches of the first part of the axillary artery are the superior thoracic and the acromio-thoracic. The brachial plexus is external and posterior. The second part of the artery is not ligated. The third part is covered in front, above, by the great pectoral, but is covered below by skin and fascia; behind, it has the tendon of the sub- scapulars, the latissimus dorsi, and the teres major; the coraco-brachialis is on the outer side; the axillary vein is on the inner side. It is important to remember that there may be three veins, one external and two internal. The axillary vein is formed by the venae comites of the brachial artery joining, and this new vein effecting a junction with the basilic vein. The median nerve lies upon the axillary artery in the upper part of the third portion of the vessel's course, and passes to the outer side. The musculo-cutane- ous nerve is external, but it is only seen high up; the ulnar nerve is internal; the lesser internal and the internal cutaneous nerves are internal; the musculo-spiral and the circumflex nerves are behind. The branches of the third portion of the axillary artery are the subscapular and the anterior and posterior circumflex. 276 A MANUAL OF SURGERY. Operations : Ligation of the Third Portion (PI. 4, Fig. 4).— The position in this operation is supine with the shoulders raised and the arm abducted to a right angle. The surgeon stands between the patient's arm and side. An incision is made three inches in length. It begins at the junction of the anterior and middle thirds of the outlet of the axilla and curves downward along the inner margin of the coraco- brachialis muscle, which is the guide. Incise the integu- ments and fascia, find the coraco-brachialis muscle, and draw it outward. The vein or veins will be prominent and may overlie the vessel. Feel for the pulsations of the artery, find the median nerve and draw it outward, draw the internal cutaneous nerve inward, clear the artery from the venae comites, and pass the ligature from within outward. Apply the ligature well below the circumflex branches. Ligation of the First Part.—This operation (PI. 5, Fig. 2) was first performed in 1815 by Chamberlaine of Jamaica. The position is supine, the upper part of the body being raised, a sand-pillow being placed between the scapulae to ensure carrying back of the point of the shoulder, and the arm being brought down along the side. In operating on the left side the surgeon stands on the outer side of the left arm; in operating on the right side he stands to the right of the subject's head and leans over his shoulder. The incision, which is slightly curved downward, begins external to the sterno-clavicular joint and ends external to the coracoid process. The incision is half an inch below the clavicle. Incise skin, platysma myoides muscle, superficial nerves, and deep fascia. In the outer angle of the wound watch out for the acromio-thoracic artery and the cephalic vein. Incise the pectoralis major; find the pectoralis minor and draw it down; open the costo-coracoid membrane by a vertical in- cision near the coracoid process. The cephalic vein points out the situation of the axillary vein. Find the brachial DISEASES AND INJURIES OF HEART AND VESSELS. 277 plexus, feel for the artery internal to it, clear the vessel, draw the vein internally, and pass the needle from within outward. This avoids the dangerous neighbor, which is the axillary vein. This operation is difficult, dangerous, and unusual, and in its performance the axillary vein, which has a close attachment to the costo-coracoid membrane, is apt to be torn. Subclavian Artery.—There is no line for this vessel. Anatomy (PI. 5, Fig. 1).—The subclavian artery of the right side arises from the innominate; of the left side, from the arch of the aorta. The subclavian is divided into three parts. The first part runs from the origin of the vessel to the inner border of the scalenus anticus muscle; the second part lies behind the scalenus anticus muscle; and the third part runs from the outer edge of the muscle to the lower border of the first rib. At the present day the first and second portions are not ligated. The third portion is contained in the subclavian triangle (Fig. 46), and is superficial. It rises, as a rule, to half an inch above the clavicle. The subclavian vein is below the artery, being separated from it by the scalenus anticus muscle. The brachial plexus is above and external to the artery. The vessel rests upon the first rib, and behind it is the scalenus medius muscle. The suprascapular and trans- versalis colli arteries and veins and branches of the cervical plexus lie in front of the artery, and the external jugular vein crosses it at its inner side. The third portion gives off no branches. Ligation of the Third Part.—This operation (PL 5, Fig. 2) was first successfully performed in 1817 by Post of New York. The position is as follows : place the patient upon his back, raise the shoulders, extend and turn the head toward the opposite side, pull down the arm, and hold it by pushing the forearm under the patient's back (Treves). 278 A MANUAL OF SURGERY. This pulls down the clavicle, thus increasing the size of the subclavian triangle. The operator stands facing the shoulder, with his back toward the patient's feet. Draw the skin over the subclavian triangle, half an inch above the clavicle, down upon this bone, and incise. This manoeuvre avoids the exter- nal jugular vein and gives an incision half an inch above the collar-bone. The incision reaches from the anterior edge of the trapezius to the posterior border of the sterno-cleido mas- toid (Fig. 46), and is about three inches long. By this in- cision are divided the skin, the superficial fascia, the platysma myoides, the vein running from the cephalic to the external jugular, and some superficial nerves. Open the deep fascia. Draw the external jugular vein into the outer angle of the wound, and do not divide it unnecessarily; if forced to do so, tie the vein with two ligatures and cut between them. Find the outer edge of the anterior scalene muscle, and run the finger down along it to the tubercle on the first rib. Draw up the posterior belly of the omo-hyoid muscle. With the finger on the tubercle recall the fact that the vein is in front of the finger and the artery is behind it, and that the subclavian vein is on a lower plane than the artery. The artery is felt beating as it lies upon the rib. Clear the artery and expose the lower cord of the brachial plexus. Guard the vein with the finger and pass the needle from above down- ward, as the plexus, which is in more danger than the vein, is to be avoided. In this operation never cut the transversa- lis colli or suprascapular arteries, as they are necessary to the future anastomotic circulation. If the field of operation is too small, incise the trapezius or sterno-cleido-mastoid or both. Region of the Neck.—Anatomy.—The side of the neck is that space between the median line in front and the anterior edge of the trapezius behind, which space is limited below by the clavicle and above by the body of the jaw and an DISEASES AND INJURIES OF HEART AND VESSELS. 279 imaginary line running from the angle of the jaw to the mas- toid process. The sterno-cleido-mastoid muscle divides this space into an anterior and a pos- a______Lower jaw.______B terior triangle, and each of the triangles is subdivided by other structures, the anterior into three spaces and the posterior into two 5 (Fig. 46). \ Anterior Triangle.—The anterior « o triangle is bounded in front by the h median line of the neck, behind by | the anterior margin of the sterno- f cleido-mastoid, and above by the body of the lower jaw and an J J c Clavicle. u imaginary line from the angle of fig. 46.—The Triangles of the . . Neck, right-sided view (after Keen): the jaW tO the mastoid prOCeSS. 1- Submaxillary triangle; 2. triangle . of election, or superior carotid tri- Tllis Space is Subdivided intO three angle; 3-Triangle of necessity, or in- L fenor carotid triangle; 4. Occipital smaller triangles, namely, the in- triar,gle; s- Subclavian triangle. ferior carotid, the superior carotid, and the submaxillary. The inferior carotid triangle is called the " triangle of necessity," because the common carotid in it is ligated, not from choice, but through force of necessity. It is bounded in front by the median line, above by the anterior belly of the omo-hyoid, and below by the anterior edge of the sterno-mastoid. The floor of this triangle is composed of the longus colli, the scalenus anticus, and the rectus capitis anticus major muscles. The superior carotid triangle is known as the " triangle of election," because, whenever possible, it is elected to tie the carotid in this situation. In this region the carotid is super- ficial, and there can be tied either the external, the internal, or the common carotid, as may be desired. The triangle is bounded behind by the anterior edge of the sterno-mastoid, above by the posterior belly of the digastric, and below by 280 A MANUAL OF SURGERY. the anterior belly of the omo-hyoid. Its floor is composed of the inferior and middle constrictors of the pharynx and the thyro-hyoid and hyoglossus muscles. The submaxillary triangle is bounded above by the body of the jaw and an imaginary line from the angle of the jaw to the mastoid process, behind by the posterior belly of the digastric and the stylo-hyoid muscle, and in front by the middle line of the neck. Its floor is composed of the digastric, mylo-hyoid, and hyoglossus muscles. The posterior triangle is bounded in front by the posterior border of the sterno-mastoid, behind by the anterior edge of the trapezius, and below by the clavicle. The posterior belly of the omo-hyoid subdivides it into two smaller spaces, the occipital and subclavian triangles. The subclavian triangle is bounded above by the posterior belly of the omo-hyoid, below by the clavicle, and in front by the posterior border of the sterno-mastoid. Its floor is formed by the first rib and the first serration of the serratus magnus muscle. The occipital triangle is bounded in front by the posterior edge of the sterno-mastoid, behind by the anterior border of the trapezius, and below by the posterior belly of the omo-hyoid muscle. Common Carotid Artery.—The line of the common carotid artery is from the sterno-clavicular articulation to midway between the angle of the jaw and the mastoid pro- cess, the head being turned toward the opposite side. Anatomy (PI. 5, Figs. 1, 3).—The right common carotid arises from the innominate opposite the sterno-clavicular joint; the left common carotid arises from the arch of the aorta. In the neck the two carotids possess identical relations. The common carotid runs upward and outward from behind the sterno-clavicular articulation to a level with the upper border of the thyroid cartilage, at which DISEASES AND INJURIES OF HEART AND VESSELS. 281 point it divides into the external and internal carotids. The common carotid is contained in a sheath from the cervical fascia, which sheath also holds, though in separate compart- ments, the internal jugular vein on the outer side of the artery and the pneumogastric nerve between the vein and artery and behind them. The anterior edge of the sterno- mastoid muscle lies over the artery and is a guide. Low in the neck the common carotid is deep, being covered by skin, superficial fascia, platysma, deep fascia, and the sterno-mas- toid, sterno-hyoid, and sterno-thyroid muscles. Above the omo-hyoid the vessel is more superficial, being covered by the skin, superficial fascia, platysma, deep fascia, and the an- terior edge of the sterno-mastoid. Upon the sheath (occa- sionally within it), above the crossing of the omo-hyoid muscle, lies the descendens noni nerve—the descending branch of the ninth pair of Willis (the hypoglossal). This nerve is a valuable guide to the sheath in the triangle of election. The sterno-mastoid branch of the superior thyroid artery crosses the carotid a little below its bifurcation, and the superior thyroid veins cross it in this region; the middle thyroid vein crosses the middle of the line of the artery, and the anterior jugular vein crosses low down. The carotid rests upon the longus colli and rectus capitis anticus major muscles, the sympathetic nerve lying between the last-named muscle and the vessel, outside the carotid sheath. The recurrent laryngeal nerve passes behind the carotid below the omo-hyoid muscle, and the inferior thyroid artery passes behind the carotid just above the omo-hyoid muscle. The carotid is in relation internally with the trachea, thyroid gland, larynx, and pharynx. On its outer side are the pneumogastric nerve (which is on a posterior plane) and the jugular vein. On the left-hand side, low down in the neck, the jugular vein often lies in front, or partly in front, 282 A MANUAL OF SURGERY. of the artery. Ligation of the common carotid was first successfully performed in 1806 by Sir Astley Cooper. Ligation in the Triangle of Necessity.—In this operation the position is supine with the shoulders raised, a sand- pillow under the neck, and the head turned to the opposite side with the chin raised. The operator stands upon the side operated upon. The incision,.three inches long, at an angle of five degrees to the arterial line, runs from the level of the cricoid cartilage downward and inward toward the sterno-clavicular joint, following the inner border of the sterno-cleido-mastoid. Avoid cutting the external jugular vein, the course of which should be outlined before making the incision. Open the deep fascia, draw the sterno-cleido- mastoid outward, retract the sterno-hyoid and sterno-thyroid muscles inward, and feel for the carotid tubercle of Chassaignac. This tubercle is the costal process of the sixth cervical verte- bra, and lies directly under the artery. The tubercle is found about the point at which the omo-hyoid crosses the carotid. When the tubercle is found we know the situation of the artery, and that the triangle of necessity is below, and the triangle of election above, the finger. Pull the omo-hyoid muscle upward. Open the sheath on its inner side, clear it, and pass the needle from without inward to avoid the internal jugular vein, remembering that the pneumogastric nerve is in the same sheath as the artery and vein, posterior and external to the artery. In this operation the inferior thyroid veins are much in the way, the anterior jugular vein crosses low down, and on the left side, at the root of the neck, the internal jugular vein may be in front of the carotid artery. If the incision is not sufficiently wide, incise the sterno-cleido-mastoid or the sterno-hyoid and thyroid. In the triangle of necessity the descendens noni nerve does not serve as a guide to the sheath. Ligation in the Triangle of Election.—In this operation DISEASES AND INJURIES OF HEART AND VESSELS. 283 the position is the same as in the preceding one. An incis- ion, three inches in length, is made along the anterior edge of the sterno-mastoid in the line of the artery, the middle of this incision being opposite the cricoid cartilage. In cut- ting the superficial fascia, avoid the external jugular vein. Open the deep fascia, retract the sterno-cleido-mastoid out- ward, feel for the carotid tubercle, draw the omo-hyoid down- ward, find the descendens noni nerve upon the sheath, open the sheath at its inner side, and pass the needle from without inward. This incision permits ligation of either the superior thyroid or the external, internal, or common carotid, and if it be extended up a little there can be tied through it the lingual, and even the facial and occipital, arteries. External Carotid Artery.—The line of the external carotid artery is the upper portion of the common carotid line. Anatomy.—The external carotid artery, which is one of the terminal branches of the common carotid, arises on a level with the upper border of the thyroid cartilage and runs to the level of the neck of the condyle of the lower jaw. At its point of origin it is covered only by skin, platysma and fascia, and the edge of the sterno-mastoid, but as it ascends it passes beneath the digastric and stylo-hyoid muscles and into the parotid gland. The glosso-pharyngeal nerve, sty- loid process, and stylo-pharyngeus muscle lie between the external and internal carotid arteries. The hypoglossal nerve crosses the vessel just below the digastric muscle, and the facial and lingual veins cross it a little below the nerve. The first branch is the superior thyroid, which arises from the very beginning of the trunk. The lingual arises on a level with the greater cornu of the hyoid bone. The facial and occipital take origin above the lingual. Each of them can be ligated through the incision of this operation. Operation.—The position is the same as that for the com- mon carotid. The spot of election is between the superior 284 A MANUAL OF SURGERY. thyroid and the lingual. Make an incision three inches long in the arterial line, from near the angle of the jaw to oppo- site the middle of the thyroid cartilage, cut through skin, platysma, and deep fascia, and retract the sterno-cleido mas- toid outward. Look for the digastric muscle, find the hypo- glossal nerve, and feel for the greater cornu of the hyoid bone. Open the sheath a little below the hyoid cornu and pass the needle from without inward, being certain not to include in the ligature the superior laryngeal nerve. Internal Carotid Artery.—The line of the internal carotid is parallel with and half an inch external to the line for the external carotid. Anatomy.—The internal carotid artery, the other terminal branch of the common carotid, arises on a level with the upper border of the thyroid cartilage and enters the carotid canal. The first inch of the artery is the only point where a ligature is ever applied, this point being covered only by skin, platysma, fascia, and sterno-mastoid; higher up it is more deeply placed. It rests upon the vertebrae and the rectus capitis anticus major muscle. The internal jugular vein is in the same sheath and external to the artery; the pneumo- gastric is in the same sheath, between the artery and the vein, but posterior to both. The superior cervical ganglion of the sympathetic lies behind the origin of the internal carotid, and between the ganglion and the artery is the superior laryngeal nerve. Operation.—In this operation the position is the same as in ligation of the external carotid. Incision as for the external carotid, except that it is half an inch external. The sterno-cleido-mastoid is drawn outward, the external carotid artery is found and drawn inward, the internal carotid is found and drawn outward, and the needle is passed from without inward. The internal carotid is known by its more external position and by the fact that it gives off no branches. i, Anatomy, 2> Ligation, of the Dorsalis Pedis Artery. 3, Anatomy, 4, Ligation, of the Femoral Artery. 5, Anatomy, 6, Ligation, of the Posterior Tibial Artery. (From Bernard.) DISEASES AND INJURIES OF HEART AND VESSELS. 285 Lingual Artery.—Anatomy (PI. 5, Fig. 3).—The lingual artery arises from the external carotid opposite the greater cornu of the hyoid bone, passes beneath the digastric and stylo-hyoid muscles, reaches the margin of the hyoglossus, passes under that muscle, and emerges from under it to run along the under surface of the tongue. The place of elec- tion for ligation is where the artery is beneath the hyoglossus muscle and rests upon the genio-glossus. Its guide is the hypoglossal nerve, which lies upon the muscle, but at a slightly higher level than the artery. Operation.—In this operation (PI. 5, Fig. 4) the position is recumbent with the shoulders raised and the face turned away from the side to be operated upon. The surgeon should stand upon the affected side. A curved incision is made from a little external to the symphysis of the lower jaw, downward and outward, to just above the greater cornu of the hyoid bone, and upward and outward to just in front of the facial artery at the lower edge of the lower jaw. Incise the skin, the superficial fascia and platysma, and the deep fascia. Clear the submaxillary gland and retract it well upward. Divide the fascia below the gland by a trans- verse incision. Find the posterior edge of the mylo-hyoid and the bellies of the digastric. Catch one of the digastric tendons and have it hooked down and out (Treves). Clear the hyoglossus muscle with a director; find the hypoglossal nerve and ranine vein and draw them a little upward. Divide the hyoglossus muscle transversely a little above the hyoid bone and below the level of the hypoglossal nerve, find the artery, and pass the needle from above downward. Dorsalis Pedis Artery.—The line of the dorsalis pedis artery is from the middle of the front of the ankle-joint to the middle of the base of the first interosseous space. Anatomy (PL 6, Fig. 1).—The dorsalis pedis is a continua- tion of the anterior tibial artery, and it runs from the bend of 286 A MANUAL OF SURGERY. the ankle to the proximal extremity of the first interosseous space, where it divides into the dorsalis hallucis and the communicating arteries. The artery rests, from above down- ward, upon the astragalus, scaphoid, and internal cuneiform bones, and at its point of bifurcation lies between the heads of the first dorsal interosseous muscle. It may lie in some persons a little external to this course. It is held upon the bones by a distinct layer derived from the deep fascia. This artery is covered by skin, by superficial and deep fascia, and by the annular ligament above, and is sometimes partly overlaid by the extensor proprius pollicis muscle, and is crossed, just before its bifurcation, by the innermost tendon of the extensor brevis muscle. The inner tendon of the extensor communis digitorum is to the outer side of the vessel; the tendon of the extensor proprius pollicis is to the inner side and is a guide. The artery is ligated in the dorsal triangle of the foot—a space which is bounded above by the lower edge of the annular ligament, externally by the inner tendon of the extensor brevis, and internally by the tendon of the extensor proprius pollicis. The artery has venae comites; the anterior tibial nerve lies, as a rule, to its inner side, and the inner division of the musculo-cutaneous nerve to its outer side in the superficial parts. The anterior tibial nerve may be found upon the artery or to its outer side. Operation (PI. 6, Fig. 2).—In this operation the position of the patient is supine with the legs and feet extended. The surgeon stands below the extremity, cutting from above downward. Make an incision two inches in length along the arterial line, beginning opposite the lower edge of the annular ligament and running along by the tendon of the extensor proprius pollicis; cut through the skin, superficial fascia, and deep fascia; have the toes extended; retract the tendon of the extensor proprius pollicis inward and the tendon of the extensor communis outward; clear the artery, find the nerve, DISEASES AND INJURIES OF HEART AND VESSELS. 287 try and separate the venae comites, and pass the needle from the nerve. Anterior Tibial Artery.—To locate the line of the anterior tibial, find a point midway between the head of the fibula and the tuberosity of the tibia, drop one inch, and draw a line from the second point to the middle of the front of the ankle-joint. Anatomy.—The anterior tibial artery is one of the terminal branches of the popliteal; it arises opposite the lower border of the popliteus muscle, passes forward between the two heads of the posterior tibial muscle, comes to the front of the leg through an opening in the interosseous membrane, and runs down to the middle of the front of the ankle-joint. In the upper two-thirds of its course it rests upon the inter- osseous membrane, to which it is fastened by firm fascia; in the lower third it lies first upon the front of the tibia and then upon the anterior ligament of the ankle-joint. For its upper two-thirds the artery has the tibialis anticus muscle just internal to it; at the junction of the middle and lower thirds the extensor proprius pollicis comes from the outside and lies either upon the artery or to its inner side for the rest of its course. Externally in its upper third is the ex- tensor communis digitorum, in the middle third is the extensor proprius pollicis; in the lower third, the proprius pollicis having crossed, the extensor communis again. The artery is covered by skin and by superficial and deep fascia. In its upper third it is deeply set between the muscles; in its middle third it is less overlaid by muscle; in its lower third it is superficial except where it is crossed by the extensor proprius and where it is covered by the annular ligament. The artery has venae comites. In the lower three- fourths of its course it is accompanied by the anterior tibial nerve, which in its course in the upper third of the leg is external to the artery; in the middle third it is external and 288 A MANUAL OF SURGERY. a little in front of the artery; and in the lower third it is ex- ternal to or upon the artery (PI. 5, Fig. 5). Operations.—The ligations of the anterior tibial (PI. 5, Fig. 6) are (1) in the lower third ; (2) in the middle third; and (3) in the upper third. In all these ligations the sur- geon stands outside of the extremity, cutting from above downward on the right side and from below upward on the left side. Ligation in the Lower Third.—This operation is prac- tically the same as that for the dorsalis pedis. Make an incision three inches long in the line of the artery and over the annular ligament. This incision is external to the tibi- alis anticus muscle and half an inch from the outer border of the tibia (Barker). Divide the skin and fascia, retract the tendon of the tibialis anticus inward, and the tendon of the extensor proprius pollicis, along with the tendons of the extensor communis, outward. Flex the ankle-joint and clear the artery. Draw the nerve external and pass the ligature from without inward. In order to recognize the muscles in this as in other ligations, rely largely upon the finger while the muscles are being moved. Ligation in the Middle Third.—In this operation the pro- cedure is similar to the above. Remember that the nerve lies upon the vessel and that the extensor proprius pollicis muscle is external. The nerve is retracted outward and the needle is passed from the nerve. A good rule for detecting the artery is to find the outer edge of the tibia and by this locate the interosseous membrane, and then, by passing out along this membrane, discover the artery. Ligation in the Upper Third.—In this operation the position is the same as in the above. Make an incision three inches long in the arterial line. On opening the deep fascia, do not rely on the eye for finding the muscular interspace, as often the latter cannot be seen, and neither a white nor a yellow DISEASES AND INJURIES OF HEART AND VESSELS. 289 line is reliable. Place the index finger deep in the wound and have the tibialis anticus and extensor communis muscles successively rendered tense by an assistant. In opening the interspace, use the handle of the knife. Relax the muscles, retract the tibialis anticus inward, and draw the extensor communis outward. Find the interosseous membrane where it is attached to the edge of the tibia, and the artery will be found upon this membrane, between the tibia and the nerve. Clear the vessel and pass the ligature from without inward to avoid the nerve. Posterior Tibial Artery.—The line of the posterior tibial is from the middle of the popliteal space to a point midway between the tip of the inner malleolus and the point of the heel (PI. 6, Figs. 5,6). Anatomy.—The posterior tibial is the larger of the two terminal branches of the popliteal. It arises opposite the lower border of the popliteus muscle, runs down between the deep and superficial flexor muscles to midway between the tip of the malleolus and the point of the heel, and divides into the external and internal plantar vessels. In its upper third it is very deep and midway between the tibia and fibula; in its middle third it is less deep, having passed inward; and in its lower third it is superficial. At the ankle the artery is beneath the annular ligament. From above down- ward the posterior tibial artery rests upon the posterior tibial muscle, the flexor longus digitorum muscle, the posterior surface of the tibia, and the internal lateral ligament of the ankle-joint. For the first inch or two of the course of the artery the posterior tibial nerve is internal; the nerve then crosses to the outer side, and remains on that side through- out the rest of its course. When the knee is partly flexed and the leg is laid upon its outer surface the artery is between the operator and the nerve and the nerve is between the artery and the table. Back of the malleolus, in the first 19 290 A MANUAL OF SURGERY. compartment, lies the posterior tibial muscle; in the next compartment is the flexor longus digitorum muscle; in the next are the artery and nerve; and in the most posterior is the flexor longus pollicis muscle. Operations: Ligation back of the Malleolus.—In this opera- tion the position of the patient is recumbent with the thigh abducted and the leg flexed and resting upon its outer sur- face. The surgeon stands to the outside. Make a two-inch semilunar incision corresponding in its curve to the malle- olus and half an inch posterior to its margin. Cut down to the annular ligament, incise it, and find the artery and venae comites. Clear the vessel and pass the needle from behind forward (to avoid the nerve, which is here posterior and external). Do not make the preliminary incision nearer the malleolus than half an inch, as the sheath of the tibialis posticus muscle would then surely be opened. In sewing up, suture the ligament (PI. 6, Fig. 6). Ligation in the Middle of the Leg.—In this operation the position is the same as in the above. Feel for the inner border of the tibia, and make an incision four inches long one inch behind the border and parallel with it, and extend- ing through skin and superficial and deep fascia. Draw the gastrocnemius outward. Incise the soleus, but not the fascia beneath the soleus; cut this fascia, dropping the handle of the knife so that the blade will be at right angles with the plane of the tibia. Clear the artery; pass the needle from without inward (PI. 6, Fig. 6). The popliteal artery is now never ligated in continuity; hence the methods that may be used will not be discussed. Femoral Artery.—The line of the femoral artery is from midway between the anterior superior spine of the ilium and the symphysis pubis to the adductor tubercle on the inner condyle of the femur, the thigh being abducted and resting upon its outer surface (PI. 6, Fig. 3). DISEASES AND INJURIES OF HEART AND VESSELS. 291 Anatomy.—The femoral artery is the continuation of the external iliac trunk; it extends from the lower border of Poupart's ligament to the opening in the adductor magnus muscle, and hence occupies the upper two-thirds of the thigh. The artery for its first five inches is superficial, lying in Scarpa's triangle, which is bounded externally by the sartorius muscle and internally by the adductor longus, its base being Poupart's ligament and its floor being composed of the psoas, iliacus, pectineus, and often the adductor brevis. The artery enters the triangle as the common femoral, but after a two-inch course it divides into the profunda, which passes deeply, and the superficial femoral. The latter vessel \s the one alluded to in this section. At the base of Scarpa's triangle the vein is internal, the artery is between, and the nerve is external (v. a. n.). At the apex of the triangle the vein is posterior and a little internal. At the apex of the triangle the superficial femoral passes under the sartorius muscle and enters into Hunter's canal, which occupies the middle third of the thigh and which terminates at the opening in the adductor magnus muscle. Hunter's canal is bounded externally by the vastus interims, internally by the adductors longus and magnus, and its roof is fascia which stretches from the adductor longus to the vastus. In Hunter's canal the vein is behind the artery above, but external to it in the lower part of the canal, and is firmly attached to the artery. There may be two veins. Inside Hunter's canal, but outside the femoral sheath, is the long saphenous nerve, which crosses the artery from without inward. A good way to remember the relation of the femoral vein with the femoral artery is to recall the fact that the relation of the vein to the artery is always contrary to the relation of the sartorius muscle with the artery: when the sartorius muscle is external to the artery the vein is internal, as at the 292 A MANUAL OF SURGERY. base of Scarpa's triangle; when the sartorius muscle is cross- ing in front toward the inside of the artery the vein is pass- ing at the back to the outside, as at the apex of Scarpa's triangle ; when the muscle is over the artery the vein is back of it, as in the upper third of Hunter's canal; and when the muscle is to the inside of the artery the vein is to the out- side, as in the lower two-thirds of Hunter's canal. In a ligation at the apex of Scarpa's triangle the inner edge of the sartorius is the guide. In a ligation in Hunter's canal the long saphenous nerve is the guide. Operations: Ligation of the Superficial Femoral at the Apex of Scarpa's Triangle.—In this operation the position is supine with the thigh and leg a little flexed, the thigh abducted, everted, and rested upon its outer surface on a pillow The operator stands to the outside of the leg. From a point cor- responding to the middle of the triangle, and two and a half inches below Poupart's ligament, make a three-inch incision in the arterial line. Cut the skin and superficial fascia. The saphenous vein will not be seen unless the incision is internal to the arterial line; if this vein is seen, draw it inward. Open the fascia lata, find the inner border of the sartorius muscle, and draw it outward. The fibres of this muscle run downward and inward, thus distinguishing it from the ad- ductor longus, whose fibres run downward and outward. Open the common sheath for the artery and vein, and then incise the individual arterial sheath. Clear the artery and pass the ligature from within outward (PI. 6, Fig. 4). Ligation of the Superficial Femoral in Hunter's Canal.—In this operation the position is the same as in the above. Make a three-inch incision in the middle third, but above the middle of the thigh, parallel with the arterial line and half an inch internal to it (Barker). Incise the skin and superficial fascia, look out for the internal saphenous vein, open the fascia lata, and find the sartorius and retract it DISEASES AND INJURIES OF HEART AND VESSELS. 293 inward, thus exposing the roof of Hunter's canal, which is to be opened for an inch or more. Within the canal is seen the long saphenous nerve, usually upon the sheath. Open the sheath of the artery, clear the vessel, and pass the needle from without inward. Iliac Arteries.—The line of the common and external iliac is from half an inch below and half an inch to the left of the umbilicus to midway between the anterior superior spine of the ilium and the pubic symphysis. The upper third of this line represents the common iliac, and the lower two-thirds the external iliac (PI. 3, Fig. 4). Anatomy.—The common iliac arteries arise from the aorta opposite the left side and lower border of the fourth lumbar vertebra, and extend to the upper margin of the right and left sacro-iliac joints, where they each bifurcate into an external and an internal iliac. The common iliac arteries lie upon the fifth lumbar vertebra, are covered with peritoneum, and are crossed by the ureters. In women the ovarian arteries cross the common iliacs. The common iliac veins lie to the right side of their respective arteries. The right common iliac artery has in front of it, besides the peritoneum and ureter (in women also the ovarian artery), the ileum, branches of the superior mesenteric artery, and branches of the sympathetic nerve. The left common iliac artery has in front of it, in addition to structures common to both sides (ureter, ovarian artery, sympathetic branches), branches of the inferior mes- enteric artery and the sigmoid flexure with its mesocolon. The internal iliac artery runs from the sacro-iliac joint to the upper margin of the great sacro-sciatic foramen. It is very rarely ligated (only in uncontrollable hemorrhage from the gluteal or sciatic arteries). The external iliac runs from the sacro-iliac joint along the pelvic brim, upon the inner edge of the psoas muscle, to Poupart's ligament. The external iliac vein is internal to the artery. On the' right side, high 294 A MANUAL OF SURGERY. up, it passes behind the artery. The external iliac has in front of it peritoneum and subserous tissue (Abernethy's fascia). The ilium crosses the right, and the sigmoid flexure the left, external iliac. The genital branch of the genito- crural nerve crosses the artery low down, and the circumflex iliac vein crosses it just before it terminates in the femoral. The spermatic vessels and the vas deferens in the male, the ovarian vessels in the female, lie upon it, low down. Some- times the ureter crosses it high up. We find the spermatic vessels in the male and the ovarian in the female lying for a time upon the inner side of the artery. Ligation of the Iliacs by Abdominal Section.—The best method for ligating either iliac is by abdominal section, pack- ing away the intestines with gauze, opening the peritoneum posteriorly, and selecting the vessel to be tied and the exact spot where it is desired to apply a ligature (Hearn and other operators). In ligating either common iliac, pass the needle from right to left. In ligating the external iliac, pass the ligature from within outward. Ligation of the External Iliac by Abernethy's Extra-perito- neal Method.—In this operation the position of the patient is recumbent with the thighs extended during the first incisions, but in the latter stages of the operation they are flexed a little to relax the abdominal structures, the operator standing to the outside. The surgeon will find the artery along the psoas muscle. Mark a point one inch above and one inch external to the middle of Poupart's ligament, and another point one inch above and one inch internal to the anterior superior iliac spine (Barker). Join these two points by a curved incision four inches long and convex downward. Cut the skin, the fat, the two oblique and the transversalis mus- cles; open the transversalis fascia, draw the peritoneum inward by a broad retractor, and look for the artery along the pelvic brim. The anterior crural nerve is seen internal DISEASES AND INJURIES OF BONES AND JOINTS. 295 to the artery, the vein is internal to the artery, and the genito-crural nerve is upon the artery. Clear the artery near its middle and pass the ligature from within outward. In Sir Astley Cooper's ligation the inguinal canal is laid open. XVIII. DISEASES AND INJURIES OF BONES AND JOINTS. 1. Diseases of the Bones. Atrophy of bone is a diminution in the amount of bony matter without change in osseous structure. It arises from want of use (as seen in the wasting of the bone of a stump) or from pressure (as seen in the destruction of the sternum by an aneurysm of the aorta). Eccentric atrophy is the thinning of a long bone from within, the outer surface being un- changed—usually a senile change. Concentric atrophy means a thinning of the outer surface of the shaft, causing a lessened diameter. It is usually linked with eccentric atrophy. Hypertrophy of bone may be due to increased blood-sup- ply (as is seen in chronic epiphyseal inflammation), the bone growing much more than does its fellow. It may arise from excessive use or from strain, as is seen in the increased size of the fibula when the tibia is congenitally absent (Bowlby). Osteitis, or inflammation of bone, may be due to trauma- tism, to a constitutional malady or diathesis, to the extension of inflammation from some other structure, or to infection. In inflammation of bone the exudation flows into the Haver- sian canals and spaces and the canaliculi, the corpuscles of the exudate and the bone-corpuscles proliferate, embryonic tissue forms, the bone undergoing thinning (rarefaction), not because of pressure, but because of absorption by voracious leucocytes and osteoclasts. This process of rarefaction enlarges all the bony spaces, and by destroying septa throws two or more spaces into one. If the surface of a 296 A MANUAL OF SURGERY. bone inflames, the periosteum will more or less be separated by the exudation and the bone will be covered with little pits or erosions. Inflamed bone is so soft that it can readily be cut with a knife. Osteitis may terminate in resolution or it may terminate in sclerosis, the exudate being converted first into fibrous tissue and next into dense bone with only a kw small cancellous spaces. If the exudation is under the periosteum, the bone will be thickened at this point, bone stalactites marking the point of passage of the vessels. Osteitis may terminate in suppuration, this condition being known as " caries." In strumous osteitis caseation of the inflammatory products is very apt to arise (strumous caries). Acute osteitis may ter- minate in necrosis. Symptoms of Osteitis and Osteo-periostitis.—As a chronic process the symptoms of osteitis are commonest in the femur. Its history usually exhibits a record of a cold or an injury. Pain is severe, boring or aching in character, deep-seated, worse at night, and aggravated by a dependent position of the part. The symptoms closely resemble those of periostitis, with which disease it is almost sure to be linked. Tenderness ex- ists on percussion, and sometimes on pressure. Subperiosteal swelling, fusiform in shape, is noted; cutaneous oedema and discoloration are observed if a superficial bone be involved. In syphilis atrophic osteitis may attack the cranial bones and produce softening or even perforation, or osteophytic osteitis may arise, exostoses being formed. Osteo-periostitis may be acute or chronic, circumscribed or diffused, and may termi- nate in resolution, organization, or suppuration. It arises from cold, blows, wounds, strains, the spread of adjacent inflammation, pyogenic infection, syphilis, rheumatism, or tubercle. The symptoms are pain (which is worse at night and which is aggravated by motion, pressure, and a depend- ent position), swelling, oedema, and discoloration of the DISEASES AND INJURIES OF BONES AND JOINTS. 297 soft parts. Pain in the syphilitic form is not so severe as in other varieties. Acute necrosis or diffuse periostitis, a septic inflammation of bone and periosteum, is commonest in boys about the age of puberty. It is usually due to cold, a specific fever, or injury, and generally affects the tibia or femur; the symptoms locally are severe; redness, swelling, and pain are marked ; constitutionally, rigors, fever, often convulsions. Necrosis is apt to result. Pyaemia is common. Some fever always exists. Treatment of Osteitis and Osteo-periostitis.—In syphilitic forms the treatment consists of rest, elevation of the part, the local use of iodine and mercurial ointment, and bandag- ing. Specific treatment is by the stomach or hypodermati- cally. Operation is rarely justifiable. In other forms, if the case be recent and severe, put the patient to bed, place the limb in a splint and elevate it, apply leeches, cold, and lead- water and laudanum, use a bandage, and order salines and iodide of potassium. Morphia is used for pain. If these means fail, order counter-irritation by iodine and blue oint- ment or blisters, and use heat locally. In severe cases take a tenotome and slit the periosteum subcutaneously to relieve tension; this procedure often instantly relieves the pain. Some cases demand a longitudinal osteotomy, which is per- formed by taking a Hey saw and dividing the bone longitu- dinally into the medullary canal. If pus forms, drain at once. Diffuse osteo-periostitis requires early and free incisions, antiseptics, drainage, rest and elevation of the limb, and strong supporting and stimulating treatment. Amputation is sometimes demanded, as when the patient grows weaker and weaker even after incision, and when a joint is seriously involved. If the necrosis affects the entire shaft, which separates from its epiphyses, and new bone has not yet formed from the periosteum, make a subperiosteal resection of the shaft. 298 A MANUAL OF SURGERY. Chronic periostitis is usually syphilitic. A node is a chronic inflammation of the deep periosteal layers. Nodes occurring early in the secondary stage remain soft and soon pass away, but those occurring two years or more after infec- tion are apt to cause a bony deposit. A node may suppurate, leaving a sinus at the bottom of which is a piece of dead bone. Gumma of the periosteum is one form of node which is apt to produce caries or necrosis. Osteoplastic periostitis accompanies chronic osteitis and causes the deposit of new bone which undergoes sclerosis. The chief symptom is aching pain, which is worse when warm in bed and is aggravated by damp and wet. A swelling is found at the seat of pain (often over the tibia, ulna, clavicle, or sternum). The soft parts are uninflamed and move freely unless softening or suppuration has occurred. Tenderness is manifest. Treatment.—For the nodes of early syphilis use mixed treatment; for the nodes of late syphilis give mercury and large advancing doses of iodide of potassium. Blisters, blue ointment, and iodine used locally, and subcutaneous division of periosteum, are of value. If suppuration occurs, open antiseptically. Abscess of bone is always chronic, never acute. It was first described by Sir Benjamin Brodie, and is often called " Brodie's abscess." It occurs in the cancellous structure of the ends of bones—usually in the head of the tibia, some- times in the femur or humerus. The cause of bone-abscess is injury which induces osteitis; bone-rarefaction forms a cavity, the inflammatory products suppurate or caseate, and the surrounding bone thickens and hardens because of growth from the periosteum. Pus is apt to break into a joint, as the joint-surface is not covered by periosteum and no barrier of bone is there formed. Suppuration of bone may induce necrosis. DISEASES AND INJURIES OF BONES AND JOINTS. 299 Symptoms.—The symptoms are like those of osteo-perios- titis, only they are localized and persistent. These symp- toms are thickening of bone and soft parts, oedema and discoloration of skin, tenderness, constant pain (subject to violent exacerbations and made worse by motion, pressure, and a dependent position), and attack after attack of syno- vitis in the nearest joint. Fever and sweats may be noted. Treatment.—In treating bone-abscess, trephine the bone at the point of the greatest tenderness, and if the abscess is missed, follow the advice of Holmes and perforate the wall of bone with the trephine, opening in several directions to discover the pus. If the abscess opens into a joint, trephine the bone and open and drain the joint. Caries is a suppurative osteitis with molecular osseous de- struction, though some surgeons limit the term to strumous osteitis, and others include under it all forms of osteitis with bone-destruction. Osteitis is apt to become purulent when the bone is exposed to the air, when rest is not secured, when the health of the individual is below normal, when a foreign body such as a bullet is in the bone, and when struma or syphilis exists. In this condition the embryonic tissue becomes pus, which is discharged from the softened and granulating bone, and after drainage is secured organiza- tion, sclerosis, and healing result. In these cases new bone usually forms, and a cure results. Strumous caries, due to caseation of the product of an osteitis in a scrofulous subject, shows no tendency to self- cure, no organization or sclerosis taking place and no new bone being formed, the interior of bones, especially of the carpus and tarsus, being entirely softened and destroyed, thin shells only being left. Caries nccrotica is a condition in which small but visible portions of soft and dead bone come away in the pus; caries sicca is molecular death of bone without suppuration. 300 A MANUAL OF SURGERY. The caseating masses in strumous caries contain the tubercle bacillus. If a strumous collection is evacuated and infection with pus cocci occurs, genuine suppuration takes place, and constitutional infection means suppurative fever, and may mean death. Purulent osteitis may affect any bone, but caseous osteitis (strumous caries) tends to arise in cancellous structure (heads of long bones, vertebral bodies, and bones of the carpus and tarsus). Strumous oste- itis is apt to cause tubercular disease in an adjacent joint. Symptoms.—In the start the symptoms of caries are usu- ally those of osteitis, but the first symptom noted may be a fluctuating swelling due to pus or to caseated tubercle. After a time, if not opened, the abscess breaks, voids its con- tents, and leaves a sinus from which runs a purulent matter which after a time becomes thin, reddish, and irritant to the skin, contains small portions of gritty bone, and has a foul smell. The opening of the sinus becomes filled with cedematous granulations. A probe introduced to the bot- tom of the sinus finds bone which on being struck gives a muffled note rather than the clear, sharp note of necrosis; the bone is rough, is bared, and is so soft that the probe can usually be stuck into it. Treatment.—If syphilis exists, give iodide of potassium in advancing doses and a mild mercurial course. If tubercle exists, give iodide of iron, arsenic, cod-liver oil, and nour- ishing foods, and recommend a change of air. Locally, insist on rest and at once secure drainage, enlarging the opening if necessary and inserting a tube, and even making additional openings; syringe often with antiseptic fluids and dress anti- septically. If the case is seen before the abscess has opened, open it under strict antiseptic precautions. When the case is found to be chronic there arises the question of operation. Incomplete operations are worse than useless, for they may cause pyaemia, and if the case be tubercular may inaugurate DISEASES AND INJURIES OF BONES AND JOINTS. 30I systemic diffusion of the infection. If the gouge is used, try to remove all carious bone. The diseased bone is white, crumbles up, and does not bleed; the non-carious bone is pink and vascular. Scrape away all granulations; swab out the cavity with pure carbolic acid and pack it with iodoform gauze. Instead of gouging away bone, there may be used the actual cautery or sulphuric acid (Pollock). In severe cases excision is required, and in some very rare cases amputation may be necessary. Caries of the spine is con- sidered under Diseases of the Spine (p. 573). Necrosis is the death of visible portions of bone from cir- culatory impediment. It is analogous to gangrene. The cause of necrosis is injury (such as the tearing off of perios- teum) which deprives the bone of blood. Inflammation of the periosteum further lessens the nutrition. Acute inflam- mation in bone causes necrosis, the excessive exudation in the canals and spaces obliterating the blood-vessels by pres- sure. A thin shell of bone only may necrose from periosteal separation, or an entire shaft may die from acute osteo- myelitis or diffuse infective periostitis. A fragment of dead bone is a foreign body; the healthy bone adjacent to it inflames, softens, and granulates, and this line of granulations, like the line of demarcation of gangrene, separates the dead part from the living, the white dead bone being surrounded by the red zone of granulation tissue. A bit of dead bone is called a " sequestrum," and Nature tries to cast it off. A superficial sequestrum is known as an " exfoliation." Nature's method of casting off a sequestrum is as follows : Suppuration takes place at the line of demarcation, osteitis extends for a considerable distance around this line, the periosteum shares in the inflammation, and new bone forms. A cavity thus forms within by suppuration, and a box or case forms without by ossification, the now entirely loosened sequestrum being so encased that it cannot escape. The pus 302 A MANUAL OF SURGERY. finds its way through the new bone, and there is presented the condition so often seen by the surgeon—namely, a case of new bone known as the " involucrum," a cavity contain- ing pus and the dead fragment or sequestrum, and a dis- charging sinus or " cloaca." Nature may eventually get rid of the fragment, but the surgeon should not wait. When a portion of the bone surrounding the medullary canal dies, the condition is called " central necrosis." In some rare cases necrosis occurs without apparent suppuration, a painless swelling of bone simulating sarcoma. Mercury is a cause of necrosis. The fumes of phosphorus may cause necrosis of the lower jaw in those with decayed teeth. Traumatisms are usual causes of necrosis, but it may be produced by frost-bites and burns. Many fevers (measles, typhoid, scarlet fever, etc.) are followed by necrosis. Syphilis and tubercle are occasional causes. Symptoms.—The symptoms of necrosis are at first those of osteitis. The abscess, when formed, opens of itself or is opened by the surgeon, and a sinus or sinuses exist as in caries. A probe introduced into the sinus strikes upon hard bone with a clear, ringing note. In superficial necrosis the discharge is slight and the probe shows the limitations of the disease. In extensive necrosis the discharge is profuse, much new bone forms, several sinuses form far apart, and the probe must pass a considerable thickness of new bone before it finds the bit of dead bone. The surgeon should not operate until the dead bone is separated from the living, until a line of demarcation forms, and until the sequestrum is loose. In youth dead bone loosens quickly, but in old age slowly. An exfoliation becomes loose sooner than a deep or a central necrosis. In diffuse periostitis the necrosed shaft loosens quickly. Necrosed particles of the upper extremity loosen more rapidly than those of the lower. Chilton states1 that 1 Heath's Dictionary. DISEASES AND INJURIES OF BONES AND JOINTS. 303 in the young adult two or three months will be required to loosen a necrosed fragment in the lower extremity, and from six weeks to two months in the upper extremity. A loose sequestrum may be moved by the probe, and when struck gives a hollow note. In old cases of necrosis and caries amyloid disease may arise. Treatment.—The treatment of necrosis comprises free in- cisions for drainage, antiseptic dressing, frequent cleansing, rest, good food, stimulants, and tonics. When the seques- trum becomes loose, enlarge the cloaca with the chisel, gouge, and rongeur, remove the dead bone with the forceps, and pack the cavity with iodoform gauze. This operation is known as " sequestrotomy." If much of a gap is left by the operation, try and fill this gap by taking flaps of skin and fastening them to the bottom, by breaking the edges of the involucrum and turning them in, or by inserting bone-chips. These chips, which are obtained from the compact part of the tibia or femur of an ox, are decalcified by being placed for a couple of weeks in a 10 per cent, aqueous solution of hydrochloric acid (which is renewed every day); they are well washed in a weak alkali and then in water, are cut into strips, are soaked for two days in a I : 1000 sublimate solu- tion, and are kept in a saturated ethereal solution of iodo- form. The cavity is made sterile and is well dusted with iodoform, the bone-chips are dried and inserted into the involucrum, a capillary drain is employed, the periosteum is stitched over the opening, and so are the soft parts; but if this cannot be done, iodoform packing is used to keep the chips in place. This method is due to the genius of Senn. Acute diffuse osteo-myelitis, a diffuse inflammation of bone and marrow, is due to infection with pyogenic cocci (staphylococcus pyogenes aureus and streptococcus pyoge- nes; Figs. 11,12). It may arise from a wound, such as a com- pound fracture, a gunshot injury, or an amputation. It may 3n Apparatus in Fracture of the Femur. 15, 16. Adhesive Strips for Extension Apparatus. DISEASES AND INJURIES OF BONES AND JOINTS. 333 simple fractures, except that the mouth is washed more frequently. The malar bone is rarely broken alone. Hamilton says no uncomplicated case is on record. The malar is a strong bone resting on a fragile support, and hence it can be used as a wedge to break other bones and yet itself be unfrac- tured. The cause of fracture is violent direct force. A fracture of the orbital surface of this bone causes subcon- junctival hemorrhage like that encountered in fracture of the base of the skull. Protrusion of the eye may result either from hemorrhage or from crushing in of the malar bone. Chewing is apt to cause pain. Treatment.—If no deformity exists, there is practically nothing to be done. If deformity exists, try to correct it as in fractures of the superior maxillary. As these cases are almost invariably complicated by breaks of the upper jaw, they are treated in the same manner as the latter injury. The union is complete in three weeks. Fracture of the zygomatic arch is very rare. The causes are (i) direct violence; (2) indirect force (from depres- sion of the malar); and (3) forcing of foreign bodies through the mouth. Direct violence causes inward displacement, and indirect force causes outward displacement. The symptoms are pain, ecchymosis, swelling, displacement, and difficulty in moving the jaw (because of injury to the masscter). Treatment.—In simple fracture, give ether and try to push the arch in place. Make no incision, as depression will do no harm and the functions of the jaw will be restored. Dress with compress, adhesive strips, and crossed bandage of the angle of the jaw (PI. 10, Fig. 1). Union will take place in three weeks. Fractures of the inferior maxillary bone may, and most usually do, affect the body, although they occasionally occur in the rami. Any part of the body may be fractured, the most 334 A MANUAL OF SURGERY. usual seat being near the canine tooth or a little external to the symphysis (Pick). A portion of alveolus may be broken off In fractures of the ramus either the angle, the condyloid neck, or the coronoid process may be broken. In fractures of the body the posterior fragment generally overrides the anterior. Fractures of the lower jaw are often multiple and are almost always compound, because the oral mucous mem- brane and alveolar periosteum are torn. The cause is usually direct violence. Indirect violence (lateral pressure) may frac- ture the body anteriorly. Fractures near the angle are always due to direct violence. Indirect violence may frac- ture the condyle (falls on the chin), and so may direct violence. Fractures of the coronoid are very rare, and they arise from great direct violence (usually gunshot wound or some other penetrating force). Symptoms.—In fracture of the body preternatural mobility and crepitus generally exist. There is bleeding because of laceration of the gums; saliva dribbles constantly; the jaw is supported by the hand; great pain exists (possibly from injury of the nerve); and deformity is present, shown by inequality of the teeth if fracture is anterior to masseter, the anterior fragment going downward and backward and the posterior fragment going upward and forward. The down- ward displacement is due to muscular action (action of the digastric, geniohyoid, and genio-hyoglossus). The backward displacement is due to the violence. The temporal muscle draws the posterior fragment up and to the front. In frac- ture of the neck of the condyle the jaw is drawn toward the injured side and the condyle goes inward and forward by the action of the external pterygoid. In fracture of the coronoid process the temporal pulls the small fragment up. Complications.—The complications are—digestive disorders and diarrhoea from swallowing foul discharges; loosenjng of the teeth; loosened teeth between fragments; bleeding DISEASES AND INJURIES OF BONES AND JOINTS. 335 (usually only oozing from the gums, but there may be hem- orrhage from the inferior dental); and suppuration. Necrosis may follow these fractures. Treatment.—Remove a tooth if between fragments, but replace it in its socket after reducing the fracture. Correct deformity. Push in loose teeth and put back detached ones. Wash out the mouth with hot water to clean it and to check bleeding. If bleeding is very severe, compress the carotid for a time. The fracture can be dressed with a pad of lint over the chin and a four-tailed bandage ; or put on a splint of paste- board, felt, or gutta-percha (cut as shown on PI. 7, Figs. 3, 4) moulded to the part, padded with cotton, and held in place by a Barton or a Gibson bandage (PL 10, Figs. 2, 5). If appo- sition of the fragments cannot be maintained by the above methods, fasten the teeth together with wire, wire the frag- ments themselves together, or employ inter-dental splints. The patient is to be fed on liquid food (see Fracture of the Upper Jaiv, p. 332), the mouth is to be washed out frequently, and the dressings are to be changed every second day. The union is complete in five weeks. Though these fractures are usually compound, they do not endanger life. If they are compound, wash the mouth often with a solution of boracic acid or of chlorate of potash. Fractures of the Hyoid Bone.—These fractures are rare injuries, and are caused by hanging, by the throat being grasped by an antagonist, and by falls in which the neck strikes some obstacle. If the bone breaks by throttling, it is its body which fractures (indirect force). Fractures by mus- cular action are most unusual. Symptoms.—The symptoms are—a sensation of something breaking; bleeding from the mouth if the mucous mem- brane be lacerated ; pain, which is worse on opening the jaws or on moving the head or tongue; difficult}7 in swal- lowing (dysphagia); muffled, hoarse, or absent voice; .swell- 336 A MANUAL OF SURGERY. ing, and frequently ecchymosis, of the neck. There are observed occasionally, though rarely, harsh cough and dysp- noea, irregularity of bony contour, and crepitus. Always look into the mouth and see if there can be detected mucous ecchymosis or laceration or projection of a bony fragment. The displacement is due to the middle constrictor of the pharynx contracting. This fracture may destroy life. Treatment.—For dyspnoea be ready to perform trache- otomy at a moment's notice. CEdema of the glottis is a great danger. Try to restore the fragments with one hand externally and with a finger in the mouth. Put the patient to bed and have him lie back upon a firm rest so that his shoulders are elevated. His head is to be thrown between extension and flexion, a pasteboard splint or collar is moulded on the neck, and a bandage is applied around forehead, neck, and shoulders to keep the head immobile. The patient must not utter a word for a week; he must at first be fed by enemata, and then for some time on liquid diet which is given through a tube early in the case. Endeavor to con- trol the cough by opiates. A fractured hyoid bone requires about four weeks to unite. Fracture of laryngeal cartilages is caused by direct violence, as throttling, blows, or kicks. It is rare in young persons, and is commonest when the cartilages have begun to ossify. It is a very grave injury (80 per cent, die), death arising from obstruction to the entrance of air. Symptoms.—The symptoms, which are severe, are pain, aggravated by attempts at swallowing or speaking; swelling, ecchymosis it may be, and emphysema of the neck ; cough ; aphonia; intense dyspnoea; and bloody expectoration if the mucous membrane is ruptured. There can be detected in- equality of outline (flattening or projection) and perhaps moist crepitus. The usual seat of the injury is the thyroid cartilage. DISEASES AND INJURIES OF BONES AND JOINTS. 337 Treatment.—Cases without dyspnoea require quiet, avoid- ance of all talking, feeding with a stomach-tube, compresses and adhesive strips over the fracture, remedies to quiet cough, and a readiness to operate at any moment. In most cases dyspnoea exists, due to projection of the fragments or submucous extravasation. When there is dyspnoea, emphy- sema, or spitting of blood, at once practise intubation (p. 592), or, if unable to do this, open the larynx or trachea below the seat of fracture. If laryngotomy or tracheotomy is done, try and restore displaced fragments. If the fragments will not stay reduced, introduce a Trendelenburg canula or a tracheotomy-tube around which gauze is packed. Take out the packing in four days, and remove the tube as soon as the patient breathes well, when the opening is allowed to close. In these fractures feed with a stomach-tube and keep the patient absolutely quiet. Union takes place in four weeks. Fracture of the Ribs.—The ribs, owing to their shape, elasticity, and mode of attachment, readily bend and as readily recover their shape, thus standing considerable force without breaking. Notwithstanding these facts, the situation of the ribs so exposes them that in sixteen per cent, of all cases of fractures noted by Gurth these bones were involved. In children this injury is rare and is most usually incom- plete ; it is common in adults and the aged, and in them is generally complete. It is more frequent among men than among women. The ribs most commonly broken are from the fifth to the ninth, the seventh being the most usual sufferer. The eleventh and twelfth ribs are seldom broken. A rib may be broken in several places, and several ribs are often broken at the same time. These fractures may be compound either through the skin or through the pleura, a damaged lung permitting pneumothorax; but compound fractures are very rare except from bullet-wounds. 22 338 A MANUAL OF SURGERY. Causes.—Direct force, as buffer accidents, blows with heavy instruments, or being jumped on while recumbent, may produce these injuries. A fracture from direct violence occurs at the point struck, and the ends, projecting inward, are apt to damage the viscera. Indirect force, as great pres- sure or blows which exaggerate the natural bony curves, tends to produce fractures near the middle of the ribs or in front of their angles and to force the ends outward. A number of ribs are apt to be broken. Muscular action, as in cough- ing or parturition, occasionally, but very rarely, is a cause. Symptoms.—In connection with the history of the accident the symptoms are—acute localized pain (a stitch) on breathing, increased by pressure over the injury, pressure backward over the sternum, cough, and forcible inspiration or expiration; respiration is largely diaphragmatic, the patient endeavoring to immobilize the injured side ; cough is frequent and is sup- pressed because of pain. Crepitus is often but not invariably found. It is sought, first, by resting the palm over the seat of pain while the patient takes long breaths; second, by placing a thumb before and behind the seat of pain and making alternate pressure; and third, by auscultation. It should be remembered that incomplete fractures are the rule in children ; hence in them do not expect crepitus. Deform- ity is usually trivial unless several ribs are broken, because shortening cannot occur and the intercostal attachments prevent vertical displacement. Preternatural mobility may occasionally be elicited, when the region is not deeply cov- ered with muscles, by pressing on one side of the supposed break and observing that a part of, and not the entire, rib moves. Cellular emphysema without a surface-wound is proof of rib-fracture. Bloody expectoration and emphysema mean injury of the lung. A simple uncomplicated case in a young person gives a good prognosis. The complications are—additional injury, making the frac- DISEASES AND INJURIES OF BONES AND JOINTS. 339 ture externally or internally compound ; laceration of pleura, pericardium, heart, lung, diaphragm, liver, spleen, or colon ; rupture of an intercostal artery; haemothorax; cellular em- physema ; pulmonary emphysema; pneumothorax and pyo- thorax; traumatic pleurisy; pneumonia; bronchitis; con- gestion or cedema of the lungs. Treatment.—In an uncomplicated case the patient is not put to bed, as breathing is easier when erect than when recumbent. Angular displacement outward is corrected by direct pressure. Displacement inward is soon corrected, as a rule, by the expansion of ordinary respiratory action, but if it is not thus corrected, etherize, the deep breathing of the anaesthetic state almost always succeeding. If ether fails and dangerous symptoms come on, incise under strict anti- septic guardianship, elevate, and drain. After correcting any existing deformity, immobilize the injured side. Direct the patient to raise his arms above his head, to empty his chest by a forced expiration, and to keep it empty until a piece of rubber plaster (two inches wide) is forcibly applied seven or eight inches below the fracture and reaching from the spine to the sternum. The patient is now allowed to take a breath and is directed to empty the chest again, another piece of plaster being applied, covering the upper two-thirds of the width of the previous strip. This process is continued until the side is strapped well above and well below the fracture (PI. 7, Fig. 13). Over the plaster light turns of an inelastic spiral bandage are carried, or pref- erably a figure-of-8 bandage of the chest, the turns crossing over the seat of injury. About once a week the plaster is removed and fresh pieces applied after rubbing off the chest with soap liniment, drying, and anointing excoriations with an ointment of oxide of zinc. The dressing is worn for three or four weeks. The patient avoids cold, damp, and draughts. The diet is to be nutritious but non-stimulating, and any 34O A MANUAL OF SURGERY. cough is at once attacked by opiates and expectorants. A person with this injury who has reached the age of sixty must take stimulant expectorants (ammonii carb., grs. x, in infus. senegas, 5ss, t. in d.) or employ a steam-tent several times a day. The old method of treatment, in which the chest was included in a forcibly-applied broad rib roller, is not to be used except as a temporary expedient; it com- presses the entire chest, causes pain and dyspnoea, and tends to loosen and slip. Fracture of the ribs complicated with visceral injury is highly dangerous, and requires confinement to bed. The treatment is that of the visceral injury. If there be bloody expectoration, apply adhesive strips as above indicated, put the patient to bed reclining on a bed-rest, keep him quiet, subdue the circulation, and employ opium, diaphoretics, and expectorants (a good mixture consists of squill, ipecac, ammonium acetate, and chloroform ; opium is given sepa- rately). Inflammations of the lung or the pleura, fortunately, are apt to be localized, and are treated as are ordinary in- flammations of these parts. In laceration of an intercostal artery, incise and try to ligate; if unable to ligate, resect a rib and apply a ligature. If the signs point to internal bleeding, resect a rib, search for the bleeding point, and ligate. Emphysema usually soon disappears, but if it does not, open the cellular tissue, dress antiseptically, and employ pressure. When there arises a sudden attack of dyspnoea, which is prone to happen in these cases, and in which there are a blue face and a laboring pulse and suffocation seems imminent, bleed the patient almost to syncope. Fracture of the costal cartilages is not a common occurrence, even in the aged. Such fractures occur either through the cartilages or through their points of junction with the ribs. These injuries generally arise from direct violence, the cartilage of the eighth rib being most prone DISEASES AND INJURIES OF BONES AND JOINTS. 341 to suffer. Indirect force (such as a blow upon the shoulder) is occasionally the cause, but when it is the cause some other injury is apt to be noted. Muscular action is a pos- sible cause. Symptoms.—Displacement is often absent, but if present it is forward or backward of either fragment, and is due chiefly to the force of the injury, but partly, it may be, to muscular action. When displacement is absent crepitus will not often be found ; in fact, crepitus is usually absent in these injuries. Localized pain, swelling, and ecchymosis are noted. Preter- natural mobility may or may not be detected. Union by bone is to be expected. Treatment.—If displacement exists, try to reduce it. If the fragment is displaced backward, reduce by deep inspira- tions ; if the fragment is displaced forward, reduce by pull- ing back the shoulders. In this attempt failure is the rule, and the surgeon should then adopt Malgaigne's expedient of applying a truss over the projection for a day or two. Dress and treat the case as if a rib were broken, removing the dressings in four weeks. Fracture of the Sternum.—The sternum may be broken, along with the ribs and spine, from great violence. Frac- tures of the sternum alone are infrequent, because the bone rests on a spring-bed of ribs. Fractures of the sternum may be simple or compound, complete or incomplete, single or multiple. The most usual injury is a simple transverse frac- ture at or near the gladio-manubrial junction, at which point dislocation may also occur. Both fracture and separation of the ensiform cartilage are very rare. The sternum may be broken along with the ribs or clavicle. Causes.—The causes of fracture of the sternum are— direct force, as by falls of embankments or of walls, by car- crushes, or by the passing of a cart-wheel over the body; indirect force, as by falls upon the head, thus driving the 342 A MANUAL OF SURGERY. chin against the chest; by falls upon the feet, the buttocks, or the shoulder; by forced flexion or extension of the body over an edge or angle (as may occur during labor-pains). Symptoms.—In fracture of the sternum displacement is not always present, but when it does occur the lower fragment is apt to go forward; displacement may, however, be trans- verse or angular, or there may be overriding. The posterior periosteum, which rarely tears, limits displacement, but some deformity can, as a rule, be detected. The history of the nature of the accident has a valuable bearing upon the ques- tion of diagnosis. The position assumed by the patient is with the head and body bent forward, as attempts to straighten up cause much suffering. There is fixed and localized pain, increased by deep respiratory action, by body-movements, or by cough. Crepitus is sought for by auscultation and by placing the hand over the injury and directing the patient to make quick respirations. Mobility may become manifest on external pressure, during respiration, or while attempts are being made to bring the body erect. Respiration in these cases is usually much interfered with. It is not important to separate diastasis from fracture. Complications.—Other fractures generally complicate frac- ture of the sternum, and laceration of the pleura or peri- cardium and hemorrhage into the anterior mediastinum may exist. Abscess of the mediastinum and necrosis of the sternum may appear as late consequences. The prog- nosis is good in uncomplicated cases. Treatment.—The deformity attending fracture of the ster- num is to be corrected, if possible, by external pressure. If overriding is found, effect reduction by bending the body back over a firm pillow and ordering deep respiration; if this method fails, give ether and then bend the patient back. The deformity, if reduced, tends to recur, but the bones unite well in deformity and no great harm results. The DISEASES AND INJURIES OF BONES AND JOINTS. 343 fragments should not be cut down on or hooked up unless there be internal injury. After reducing the deformity, cover the front of the chest with adhesive strips extending laterally from one axillary line to the other and vertically from well above the fracture down to the ensiform cartilage. Place over this covering an anterior figure-of-8 of the chest. In some cases, where deformity recurs after reduction, a cir- cular bandage of the chest is applied and the shoulders are pulled strongly back with a posterior figure-of-8 bandage. The plaster is to be renewed once a week. Some surgeons treat these cases by means of a large compress held by adhesive plaster and a broad tight roller. The patient, however dressed, is put to bed and reposes erect or semi-erect on a bed-rest. This position favors easy respiration and antagonizes the tendency to displacement. The diet should be light, nutritious, and non-stimulating. The patient is convalescent in four weeks, and the plaster is permanently taken off in five weeks. When the ensiform cartilage is so bent in as to cause intense pain or to injure the stomach, it should be incised and resected. CEdema of the skin and fever, if they appear, indicate pus, in which case an incision is made at the edge of the sternum and the pus- cavity is irrigated, drained, and dressed antiseptically. Fractures of the Pelvis.—In some of the indicated frac- tures serious injury of the pelvic contents is apt to be found. Fracture of the False Pelvis.—Fractures of this region are seldom dangerous unless comminuted. There may be fracture of the iliac crest or of the anterior superior spine, or the line of fracture may traverse the entire length of the flanged-out ilium, or the bone may be comminuted with the association of grave visceral damage. The anterior superior and posterior superior spines may be broken off. Causes.—The cause of fracture of the false pelvis is gen- erally violent direct force, as the passage of a wagon-wheel, 344 A MANUAL OF SURGERY. the fall of a wall, the kick of a mule, or the force of car- crushes. Violent contraction of the rectus muscle may tear off the anterior inferior spine of the ilium. Symptoms.—In fracture of the false pelvis the history of violent force is noted. The patient leans toward the injured side. Pain exists, which is aggravated by movements (par- ticularly by bending forward), by coughing, or by straining to empty the bowels or the bladder. Ecchymosis and swelling are manifest. Crepitus and preternatural mobility are de- tected by moving the crest. Deformity is very rarely present. Cases uncomplicated by visceral injury make good recoveries. Complications.—The fracture may be, but rarely is, com- pound, as the parts are well protected with muscles. The colon may be injured when comminution has taken place. Treatment.—In treating fracture of the false pelvis, put the patient on a fracture-bed, raise the shoulders, and put a binder about the pelvis, or encase the pelvis with broad pieces of rubber plaster, or employ the belt or girdle. Place the knees over two pillows so as to semiflex the legs and thighs, and tie the knees together. To restrain thigh-movements it may be necessary to encase a restless patient with splints or bind him to sand-bags. If the binder displaces the fragments or causes pain, abandon it and trust to position. The dress- ings can be removed in six weeks, and the patient is allowed to get up in eight weeks. In compound fractures of the false pelvis, asepticize, drain and dress, put on a binder, and direct the same position to be maintained as for simple fractures. Fractures of the True Pelvis.—The most usual seat of these fractures is through the obturator foramen, the ascend- ing ischial and horizontal pubic rami being broken. A frac- ture may occur near the symphysis pubis, the symphysis may be separated, a break may run near to or into the sacro- iliac joint, the same fracture may occur on each side of the body of the pubis, and the fracture may be multiple. Frac- DISEASES AND INJURIES OF BONES AND JOINTS. 345 tures of the acetabulum and of the tuberosity of the ischium may occur. Before the seventeenth year the innominate bone may be broken into its three anatomical segments. These injuries are highly dangerous because of the damage which is apt to be inflicted on the pelvic contents. There may be rupture of the bladder or membranous urethra and injury of the vagina, the rectum, the uterus, or the small gut. The cause of pelvic fracture is violent force, direct or indirect. Front force tends to produce direct, and side force indirect, fracture. Symptoms.—In pelvic fracture there is a history of violent force. There are great shock, ecchymosis which is possibly linear, swelling, and intense pain increased by attempts at motion, coughing, and straining. There is also inability to sit or to stand. Mobility becomes obvious on grasping an ilium in each hand and moving them. Crepitus may be noticed by this manoeuvre or by moving an ilium with one hand, a finger of the other hand being inserted in the rectum or in the vagina. In making movements for diagnostic pur- poses, be very gentle, as rough manipulation permits of injury by sharp fragments. There may be doubt as to whether crepi- tus is to be referred to pelvic fracture or to fracture of the neck of the femur; in this case follow the rule of Mr. John Wood :' " The surgeon grasps the femur with one hand and places the other firmly upon the anterior superior iliac spine or crest or upon the pubes; then, on moving the femur and abducting it freely, if a crepitus be detected, it will be felt the more distinctly by that hand which rests on or grasps the fractured bone." Injury of the bladder or urethra is made manifest by retention of urine, extravasation of urine, haematuria, etc. Bleeding from the vagina or the rectum points to a lacera- tion of the part by a fragment. Intestinal injury induces 1 Lancet, 1865, vol. ii. p. 347. 346 A MANUAL OF SURGERY. septic peritonitis. Fractures of the brim of the acetabulum permit dorsal dislocation of the femur to occur, which dis- location will not remain reduced. The acetabulum may be broken by falls upon the feet, and when its base is broken the injury can only be guessed at if displacement does not take place. If the head of the femur be driven through the acetabulum into the pelvis, the injury is very grave; there is then found shortening, adduction, and semiflexion of the thigh, absence of the prominence of the great trochanter, and more capacity for movement than is noted in dislocation. Fracture of the ischium rarely occurs alone. Treatment.—In treating pelvic fractures, endeavor to re- store the parts to a normal position, employing external manipulation and inserting a finger in the rectum or in the vagina. If reduction is difficult, give ether. Use a catheter before dressing, to detect any bladder-injury. Treat as in fractures of the false pelvis, attending carefully to visceral injuries. If urinary extravasation occurs, effect a perineal section. If peritonitis develops, perform a laparotomy. All visceral injuries are treated by general rules. Remove the dressings in six weeks, and allow the patient to be about in twelve weeks. In fracture of the acetabulum, if the limb be shortened, give ether and reduce. Treat these fractures in the same way as intracapsular fractures of the femur (p. 372). Fractures of the ischium are best treated by position, the pad, and adhesive plaster. Fracture of the Sacrum.—This injury may arise from direct force, such as a kick, but it is very rare. The sacral plexus is usually injured, and then there is paralysis in the territory of its branches. Symptoms.—The symptoms in fracture of the sacrum are pain, frequently incontinence of feces and retention of urine, irregularity of the sacral- spines, ecchymosis, and crepitus. Crepitus may be sought for with one hand externally and a DLSEASES AND INJURIES OF BONES AND JOINTS. 2,47 finger of the other hand in the rectum. The lower fragment goes forward and may obstruct or may tear the rectum. Paralysis may be found in the area of distribution of the sacral plexus. Treatment.—In treating fracture of the sacrum, press the fragments into place with a hand externally and a finger in the rectum. Do not plug the rectum. Put a pad over the upper fragment, hold it with plaster or a binder, place the patient recumbent on a fracture-bed, and insert a large cushion underneath the pad. Give opium to induce consti- pation, which allows a fecal support to accumulate in the rectum. Use a clean catheter regularly and guard against bed-sores. Union occurs in about four weeks, when the dressing can be removed. The patient can get about again in six weeks. If urinary retention persists or if intractable bed-sores form, after eight or ten weeks cut down on the seat of injury and elevate or remove the portion of bone causing pressure. Fractures of the Coccyx.—The coccyx may be broken or be separated from the sacrum by a fall, a blow, a kick, or the straining of parturition. Its mobility is so great, however, that it does not often break. Symptoms.—The chief symptom of fracture of the coccyx is pain, which is much aggravated by sitting, walking, or straining at stool. If the index finger is inserted in the rectum, the displaced bone is felt; if the thumb of the same hand is also placed externally, a rocking motion will develop crepitus and preternatural mobility. Treatment.—In treating fracture of the coccyx, reduce by external pressure and by the manipulations of a finger in the rectum. Put the patient to bed and obstruct the bowels by opium for a number of days. In four weeks the fracture should be united. If union does not take place, defecation and all movements of the coccyx will cause excruciating 348 A MANUAL OF SURGERY. pain by pressure on the last sacral nerve. This condition, known as " coccygodynia," demands a subcutaneous division of the nerve or of the muscles which move the coccyx, or a resection of the bone. Fracture of the Clavicle.—The clavicle is more often fractured than any other bone. This fracture may occur at any age, but is notably common before the sixth year (Hulke says one-half of the recorded cases). It may be simple, multiple, comminuted, oblique, transverse, incomplete, or, very rarely, compound. Both clavicles may be broken. Fractures are most apt to occur just external to the middle, at the point where the inner or large curve meets the outer or small curve, at which junction the bone is at its smallest diameter. Fractures of the acromial end are more frequent than fractures of the sternal end and less frequent than frac- tures of the shaft. The causes of clavicle-fractures are direct violence, indirect violence, and, very rarely, the contractions of " the deltoid and clavicular fibres of the great pectoral" (Treves, from Poaillon). Fractures of the shaft are usually due to indirect vio- lence, as falls upon the shoulder or upon the hand of the outstretched arm. In the latter, which is the usual mode of origin, the concussion of the fall travels up and the body-weight travels down, and these two forces compress the bone, which snaps at its weakest point. Fractures from indirect force are oblique, and in children are of the green- stick form. Fractures from direct force are usually trans- verse and are occasionally comminuted. Fractures from muscular action have been recorded (Rubini the tenor, recorded by Melay). Symptoms.—In fractures of the shaft the attitude of the patient is peculiar. He supports the elbow or wrist of the injured side with the hand of the sound side, and also pulls the extremity against the chest; the head is turned down DISEASES AND INJURIES OF BONES AND JOINTS. 349 toward the shoulder of the damaged side, as if trying to listen to something in the joint, thus relaxing the pull of the sterno-cleido-mastoid muscle upon the inner fragment. The shoulder is nearer the sternum, on a lower level, and farther front than that of the sound side. Loss of func- tion is shown by inability to abduct the arm. Considerable pain exists, which is increased by motion, by pressure, and by the extremity hanging down without support. The deformity above noted is described by stating that the shoulder goes downward, inward, and forward (d. 1. f.). The dowmuard deformity is chiefly due to the weight of the arm, which pulls down the unsupported outer fragment, and is contributed to by the action of the pectoralis minor muscle. The iinvard deformity is chiefly due to the con- traction of the pectoralis minor and subclavius muscles assisted by the action of the pectoralis major. The fonvard deformity is due to rotation of the outer fragment, which is brought about by the serratus magnus muscle carrying the acromion forward. In this deformity the inner end of the outer fragment is below and behind the outer end of the inner fragment, which overrides it. The inner fragment, though pulled on by the sterno-mastoid and relatively higher than the outer fragment, is really but little, if at all, elevated, marked elevation being prevented by the attachment of the rhomboid ligament. After noting the deformity, detect with the finger the irregularity of bony contour. Examine for preternatural mobility and crepitus by raising and throwing back the shoulder. In looking for these signs in children it is to be remembered that the fracture is probably incomplete. The prognosis is good, the bone uniting, but always with some shortening and inequality. Complications.—Fractures of the shaft are rarely com- pound, because the sharp end of the outer fragment goes back and because of the free play the skin makes over the 35° A MANUAL OF SURGERY. bone (Pickering Pick). Both clavicles may be broken. In fractures from direct force deeper structures may be injured by fragments. Thus, injury of the brachial plexus will induce paralysis. Ribs may be broken at the same time. Treatment.—In treating fractures of the shaft, reduce the fracture as soon as possible by throwing the shoulder upward, outward, and backward. If the patient is a girl, it is desirable to minimize the deformity. Place her upon her back on a hard bed, with a small pillow under her head, a firm and narrow cushion between the shoulders, a bag of shot resting over the seat of fracture, and the forearm lying on the front of the chest, the arm being held to the side by a sand-bag. In three weeks there will be union, practically without deformity. In a child with an incomplete fracture a handkerchief sling for the forearm, worn three weeks, is all that is needed. In complete fracture the Velpeau bandage is efficient (PI. 13, Fig. 4). Before applying it, place lint around the chest and cotton over the elbow. Change the bandage every day for the first week, and after that period every third day. Each time it is changed, rub the skin with alcohol, ethereal soap, or soap liniment, then dry it and examine for excoriations, which, if any are found, are anointed with zinc ointment before the dressing is reap- plied. The dressing is permanently removed at the end of four weeks, the arm being worn in a sling for another week. The classical apparatus of Desault is now rarely used (PI. 13, Figs. 1-3). The posterior figure-of-8 bandage associated with the second roller of Desault, some turns being made from the elbow of the injured side to the shoulder of the well side, can be used in cases in which the forward deformity is apt to return. The apparatus of Fox, which is very useful, consists of a pad for the axilla, a sling for the forearm, and a ring for the opposite shoulder, to which ring are tied the tapes from both the pad and the sling. DISEASES AND INJURIES OF BONES AND JOINTS. 35 I The dressing of Moore of Rochester is valuable in an emergency. The four-tailed bandage is preferred by Pick. Sayre's dressing has many advocates (Fig. 50). For this there are required two pieces of rubber plaster, each piece being three inches wide and sufficiently long to go around the chest one and a half times. The end of one piece encircles the arm of the injured side just below the arm-pit; the plaster strip is pulled across the back tO the Other Side, F,g. 5°.-Sayre's Adhesive-Plaster Dressing tO the front Of the Chest f°r Fracture of the Clavicle (Stimson): A, first ' piece; B, second piece. and returns again to the middle of the back. This procedure pulls the elbow back and throws the shoulder out. The hand of the injured side is placed on the breast of the opposite side, cotton being interposed, and the second strip of plaster runs from the elbow of the injured side and the opposite shoulder, front, around, and back, pressing the elbow forward, upward, and inward. In any fracture, if signs indicate pressure upon vessels or nerves, the patient must be put to bed and the arm be abducted. After removing the dressings, if the shoulder is stiff, make passive movements daily; if these fail, break up the stiffness under ether or nitrous oxide. Fracture of the acromial end of the clavicle is due to direct force. If the fracture is between the two coraco- clavicular ligaments, deformity is very slight, crepitus is elicited by manipulating with the fingers, and pain exists, but loss of function is not markedly manifest unless it is due to pain. These fractures are treated by binding the 352 A MANUAL OF SURGERY. arm to the side with the second roller of Desault, inter- posing cotton between the arm and the side, and hanging the hand in a sling. In fractures external to the liga- ments crepitus is manifest on moving the shoulder, the out- line of the bone is irregular, severe pain exists on move- ment, and deformity is pronounced. The deformity is due to the serratus magnus muscle rotating the scapula forward, the inner end of the outer fragment of the clavicle often coming in contact with the anterior surface of the outer portion of the inner fragment. This fracture is reduced by pulling the shoulders back over the knee, and it is kept reduced by a posterior figure-of-8 bandage. In either frac- ture the dressings are worn for four weeks. Fracture of the sternal end of the clavicle is very rare. It is caused by both direct and indirect force. There are found crepitus, projection at the seat of fracture, rigidity of the sterno-mastoid muscle, and shortening of the clavicle. The inner end of the outer fragment always goes forward, and often also downward and inward. Reduce these frac- tures by pulling the shoulders back, and treat them by means of the posterior figure-of-8 bandage worn for four weeks. Fracture of the Scapula.—This bone is not often broken, as it rests upon thick muscles and elastic ribs; it is freely movable, and it has attached to it a bone which easily breaks. Fractures of the body of the bone are due to direct violence. The symptoms are pain (which becomes agonizing on attempting to rotate the shoulder-blade), ecchymosis, and swelling. Crepitus is sought for by placing the hand over the bone and making movements of the arm ; also by hold- ing the point of the shoulder and lifting up the lower angle of the bone. The latter plan may display mobility. The spine of the scapula is uneven only when it itself is fractured. Examine for unevenness of the vertebral border. In frac- DISEASES AND INJURIES OF BONES AND JOINTS. 353 tures of the body of the scapula a shoulder-cap should be applied, a gutta-percha splint must be moulded over the scapula, the arm is bound to the side, and the hand is carried in a sling. The apparatus is worn for four weeks. Fractures of the spine of the scapula are treated as are frac- tures of the body of the bone, and for the same time. Fractures of the Neck.—Fracture of the anatomical neck has not been proved to exist. Fracture of the surgical neck is evinced by flattening of the shoulder, prominence of the acromion, and a lump in the axilla which gives crepitus on pressure upward and backward. The deformity is reduced with ease, but it at once recurs. It is treated by placing a pad in the axilla, a shoulden-cap on the shoulder, applying the second roller of Desault, and supporting the forearm and elbow in a sling. A Velpeau dressing can be used, associated with a folded towel in the axilla. The dressing is to be worn for five weeks. Fracture of the glenoid cavity, which is not very unu- sual, may occur with dislocation. It arises from direct force applied to the shoulder. The existence of this fracture is determined by excluding fractures of other bones and by detecting crepitus when the arm is at right angles to the body and the humerus is pushed against the glenoid cavity, the crepitus not being found when the arm hangs by the side. Treatment here is by the second roller of Desault and a forearm sling for four weeks ; then by careful passive move- ments limit ankylosis, which, if it occurs, will have to be broken up under ether or nitrous oxide. Fracture of the acromion is often met with as the result of direct violence. Its existence is indicated by pain, by in- ability to abduct the arm, by flattening of the shoulder, by sudden lowering of the point of the shoulder, by mobility, and by crepitus. To treat a case of this kind, put a large pad in the axilla with the base down, bind the arm over 23 354 A MANUAL OF SURGERY. the pad with the second roller of Desault, lifting the elbow with turns of the roller carried over it and the opposite shoulder, thus splinting the bone in place by the head of the humerus pushing against the coraco-acromial ligaments. The dressing is to be worn for four weeks. Fracture of the coracoid, which rarely happens alone, may arise from direct force or from muscular action. But little displacement is found. Crepitus and mobility are usu- ally detected. Inability to shrug the shoulder inward was pointed out as a symptom by Wellington Byers. These cases are well treated by the Velpeau bandage, which is to be worn for four weeks. Fractures of the humerus .are divided into (i) fractures of the upper extremity; (2) fractures of the shaft; and (3J fractures of the lower extremity. In examining any fracture of the humerus, feel at once for the pulse, so as to ascertain if the artery has been torn; in any fracture near the head of the humerus, be certain that there is no dislocation. 1. Fractures of the upper extremity include (a) frac- tures of the anatomical neck; (b) fractures of the surgical neck; [c) fractures of the head, oblique and longitudinal; and (d) separation of the upper epiphysis. Fractures of the Anatomical Neck of the Humerus.— The anatomical neck is the constricted circumference of the articular surface, and fractures of it, though rare, do occur, especially in the aged. The line of fracture in some cases follows the insertion of the capsule, in others it is entirely within the capsule, but in most it is without the capsule above and within the capsule below; hence the term " intra- capsular " is rarely correct as a designation. The cause is direct violence. Symptoms.—The symptoms in fracture of the anatomical neck are pain, swelling, ecchymosis, slight irregularity of the shoulder (which is soon hidden by tumefaction), and DISEASES AND INJURIES OF BONES AND JOINTS. 355 inability to abduct the arm voluntarily. Deformity, as a rule, is slight or is absent, because the capsule is rarely entirely torn from the lower fragment. If deformity exists, it is due to the muscles inserted on the bicipital groove and to the coraco-brachialis, which pull the lower fragment inward and forward. Treves says that a tear of the reflected fibres of the capsule means subsequent necrosis, because this joint has no ligamentum teres. In some cases impaction occurs, the upper fragment impacting in the lower. In this con- dition there is very slight shortening and shoulder-flattening, no crepitus unless the tuberosity is broken off, and, as Erich- sen says, the head of the bone, while it can be felt through the axilla, is not in the axis of the limb. The prognosis of this fracture is good for bony union (Hamilton, Pick, and R. W. Smith). A stiff joint is apt to result. Treatment.—In the treatment of fracture of the anatomical neck, flex the arm to a right angle with the body, and carry up from the base of the fingers to above the elbow the turns of a spiral reverse bandage. Interpose lint between the arm and the side, and place a folded towel or a small pad in the axilla, tying the tapes over the opposite shoulder. Mould a shoulder-cap (PI. 7, Fig. 8) upon the outer aspect of the arm and upon the shoulder. This cap, which is made of pasteboard or of felt, should reach below the insertion of the deltoid, cover one-half the circumference of the arm, and is to be padded with cotton. The arm with the shoulder-cap is fixed to the side by the second roller of Desault, and the hand is hung in a sling. The edges of the bandage had best be stitched. This apparatus is changed daily for the first few days, the body and arm being rubbed at each change with alcohol, soap liniment, or ethereal soap. After this period a change every third or fourth day is often enough. Passive motion is started at the end of four weeks, and the dressings are removed at the end of six weeks. In impacted 356 A MANUAL OF SURGERY. fracture do not pull apart the impaction, but apply a cap to the shoulder and fix the arm to the side for five weeks. No pad is used. The fracture unites in deformity. Fractures of the Surgical Neck of the Humerus.—The surgical neck is the constricted portion of bone between the tuberosities and the upper line of the insertion of the muscles on the bicipital groove. Fractures in this region are usually transverse, but they may be oblique. The causes are—direct force almost always; indirect force occasionally; and mus- cular action in rare instances. Symptoms.—The symptoms in fracture of the surgical neck are—pain running into the fingers from pressure upon the brachial plexus; crepitus and mobility on extension; and flattening, which differs from the flattening of disloca- tion in that it occurs farther below the acromion and that this process is not so prominent. Shortening to the ex- tent of an inch is noted. The head of the bone can be felt in the glenoid cavity, but it does not move on rotating the arm. The upper end of the lower fragment is felt beneath the acromion, and moves on rotating the arm. The displacement is pronounced. The lower fragment is pulled upward by the deltoid, biceps, coraco-brachialis, and triceps; inward by the muscles of the bicipital groove ; and forward by the great pectoral; thus, the upper end of the lower fragment projects into the axilla, and the elbow lies from the side and backward. Penn holds that the violence sends the lower fragment forward. The upper fragment is abducted and rotated outward, which is due, it is generally taught, to the action of the supraspinatus, infraspinatus, and teres minor muscles. In some cases displacement is forward, and in other cases it is not obvious. The lower fragment may impact into the upper, in which case the symptoms are obscure and the diagnosis is made by exclusion. If the impaction is solid and complete, there are the history of SPLINTS. Plate 8. i Bond's Splint in Colles's Fracture; 2, Two Straight Splints in Fracture of both Bones of the Forearm ; 3, Anterior Angular Splint in Fractures in or near the Elbow-joint; 4, Internal Angu- lar Splint and Shoulder-cap in Fracture of the Surgical Neck of the Humerus; 5, Internal Angu- lar Splnu^n^r^cj^uj^jfjJj^SJj^yjfjhj^yumerus; 6, Fracture-box in Fractures of the Bones of thf LegW^ Hnmpi DISEASES AND INJURIES OF BONES AND JOINTS. 357 direct force, the impaired movements, the slight deformity, and the absence of crepitus. In all fractures of the upper end of the humerus the distinction can be made from dis- location by feeling the head of the bone under the acromion and by noting that it does not move on rotating the arm. The prognosis of these fractures is good. Treatment—In treating a case of fracture of the surgical neck, take an internal angular splint (PI. 7, Fig. 6) and pad it well, putting on extra padding at the points that are to rest against the palm, the inner condyle, and the axillary folds. Lay the arm and pronated forearm upon the splint. Apply a padded shoulder-cap. Fix the splint and cap in place with a spiral reverse bandage terminating as a spica of the shoulder, and hang the hand or forearm in a sling (PI. 8, Fig. 4). The dressing is to be worn for five weeks, and the rules to be followed in changing it are the same as in fractures of the anatomical neck. Motions are to be made after four weeks to keep the shoulder from stiffening. Another plan of treatment is the same as for fracture of the anatomical neck, supporting the hand only in a sling, so as to get the extending weight of the elbow, increasing this weight in some cases by hanging to the elbow a bag of shot. In rare cases—those with strong anterior projection of the upper end of the lower fragment—apply an anterior angular splint (Brinton). Longitudinal and Oblique Fracture of the Head of the Humerus.—By this term may be designated separation of the great tuberosity, or separation of a portion of the articular surface, together with the great tuberosity, from the shaft and lesser tuberosity (Pickering Pick, Guthrie, and Ogston). The cause is direct violence to the front of the shoulder. Symptoms.—The symptoms in longitudinal and oblique fracture of the head are broadening and flattening of the shoulder with projection of the acromion. The upper frag- 358 A MANUAL OF SURGERY. ment passes up and out, and the lower fragment passes up and in to rest on the margin of the glenoid cavity below the coracoid. The elbow is drawn from the side, there is some shortening, and the patient cannot abduct his arm. If the elbow be grasped and held to the side and the arm be rotated while the other hand grasps the upper fragment, crepitus is very positive. Examination develops wide sepa- ration of the fragments. The deformity cannot be entirely corrected, because the biceps tendon gets between the fragments (Ogston), but a useful limb can usually be obtained. Treatment.—The plan which gives the best result in treat- ing longitudinal and oblique fracture of the head is to place the patient on his back upon a hard bed with a small firm pillow under his head, and to abduct the arm above the head, rotate it outward so that the back of the hand rests on the bed, and hold it in place by sand-bags. This position should be maintained for three weeks, at the end of which period the fracture can be dressed for three weeks more as a fracture of the anatomical neck. If the patient refuses to go to bed, treat the injury as a fracture of the anatomical neck, padding well over the tuberosities. The dressings should be worn for six weeks, passive motion being made after four weeks. In all the above injuries—in fact, in all fractures of the humerus—feel at once for the pulse, to see if the artery has been torn. Separation of the Upper Epiphysis.—The epiphysis is united during the twentieth year, its separation being a rare accident and being produced by direct force. Symptoms.—The chief symptom in separation of the upper epiphysis is projection of the upper end of the lower frag- ment inward, forward, and upward beneath the coracoid, and consequently a projection of the elbow backward and from the side. If only the lower fragment passes forward, the DISEASES AND INJURIES OF BONES AND JOINTS. 359 elbow simply passes back. The upper end of the lower frag- ment is smooth and convex. Rotation of the shaft develops soft crepitus. The prognosis is good for bony union, though the future growth of the limb may be impaired. Treatment.—The treatment for separation of the upper epiphysis is a pad in the axilla, a shoulder-cap, binding the arm to the side, and hanging the hand in a sling. 2. Fracture of the Shaft of the Humerus.—Fracture of the shaft of the humerus is a very common accident. The cause is usually direct violence, such as a blow. The fracture may arise from indirect violence, such as a fall upon the elbow. Muscular action is not rarely also a cause, as in throwing a ball, in catching a tree-limb while falling, or in turning another's wrist as a test of strength (Treves). Symptoms.—The symptoms of a fractured shaft are pain, swelling, ecchymosis, inability to move the arm, mobility, and distinct crepitus. Shortening to the extent of three-fourths of an inch occurs. The displacement varies with the situation of the fracture and the direction of the force. If the fracture is above the insertion of the deltoid, the lower fragment is pulled up by the triceps, biceps, and deltoid, and pulled out by the deltoid, and the upper fragment is pulled inward by the arm-pit muscles. In fracture below the deltoid this muscle is apt to pull the lower end of the upper fragment outward, while the lower fragment passes inward and upward because of the action of the biceps and triceps. The prognosis is good, but the fact should always be remembered that ununited fractures are commoner in the humerus than in any other bone. Treves believes this to be due to entanglement of muscle between the fragments, lack of fixation of the shoulder-joint, and imperfect elbow- support. Hamilton believes that it is due to the facts that the elbow soon becomes fixed at a right angle, and that any 360 A MANUAL OF SURGERY. movement of the forearm moves the seat of fracture, and not the elbow. Treatment.—The treatment for fracture of the humerus is an internal angular splint without the shoulder-cap. If deformity is not corrected, associate with this splint three short humeral splints instead of the shoulder-cap used in fractures near the shoulder-joint. Splints are to be worn for six weeks. Passive movements are not to be made until the fracture is well united (after six weeks), for, if made too soon, they predispose to non-union, and, as no joint is in- volved, ankylosis will not occur (PI. 8, Fig. 5). 3. Fractures of the Lower Extremity of the Humerus. —These fractures are spoken of as fractures in, or in the neighborhood of, the elbow-joint, and they include (a) frac- ture of the external condyle; [b) fracture of the internal condyle; (c) fracture of the internal epicondyle; [d) frac- ture at the base of the condyles; (e) T-fracture; and (/) epiphyseal separation. In all injuries of the elbow-joint, give ether in making the diagnosis (Brinton). Fracture of the External Condyle of the Humerus.— A fracture of the external condyle runs into the joint and the capitellum is usually broken off. This injury occurs oftenest in children by falling on the hand, but it may occur from direct force, and may happen to adults. Symptoms.—The symptoms of fracture of the external condyle are pain, great swelling, impaired function, and crepitus (found on pressing or moving the condyle). Mobil- ity may also be discovered. Fracture of the Inner Epicondyle of the Humerus.— The inner epicondyle is an epiphysis which unites during the seventeenth year. It not infrequently breaks from mus- cular action or from direct violence, the fracture not in- volving the joint. Displacement is slight. The outer epi- condyle does not break. DISEASES AND INJURIES OF BONES AND JOINTS. 361 Fracture of the Internal Condyle of the Humerus.— The line of fracture of the internal condyle runs into the joint, to the trochlear surface of the humerus. The cause is always direct violence. Symptoms.—In fracture of the internal condyle the frag- ment, accompanied by the ulna, goes upward and backward, and when the forearm is extended the ulna projects posteri- orly, the lower end of the humerus being felt in front. Crepitus and preternatural mobility can be found if swelling is not too great. The space between the condyles is broader than normal and the forearm takes a bend toward the ulnar side, the carrying function of the forearm being lost (Brin- ton); that is, if a bucket be held in the hand, it would strike the leg. Fracture at the Base of the Condyles of the Humerus. —This fracture is just above the olecranon and is on a higher level behind than in front. The cause is direct force upon the olecranon. The symptoms are loss of function and pain from injury of the median or ulnar nerves. Crepitus and mobility are readily found. The lower fragment goes backward and upward by the action of the triceps, biceps, and brachialis anticus. The lower end of the upper fragment projects in front of the joint. T-fracture of the Humerus.—This fracture is a trans- verse fracture above the condyles plus a vertical fracture between them. The cause is violent direct force applied posteriorly. Symptoms.—The symptoms are increase in breadth of the joint, preternatural mobility, crepitus, pain, and swelling. Fractures In or Near the Elbow-j'oint.—Prognosis and Treatment.—The prognosis for complete restoration of func- tion is bad, and in most of these fractures some deformity and considerable stiffness are inevitable. Callus poured into 362 A MANUAL OF SURGERY. a joint acts like a stone pushed into the crack of a door: it limits or prevents motion. Give ether for diagnosis and the first dressing. If swelling is so great that the surgeon dare not apply a splint, let him rest the arm, semiflexed, upon a pillow and apply lead-water and laudanum for a day or two. The position for splinting is to be full supina- tion, which is obtained by so placing the hand of the patient that he could easily spit into the palm (Brinton). Apply a well-padded anterior angular splint (a right-angled splint; PI. 7, Fig. 5 ; PI. 8, Fig. 3). If posterior projection exists, mould a pasteboard cup over the elbow or apply a trough. In applying the anterior angular splint, first fasten the upper end to the arm, then make extension of the elbow, and fasten the lower end of the splint to the extended forearm. This splint is to be worn for four or five weeks, removing it carefully every third day. Begin passive motion at the end of the second week. After the dressings are removed employ passive motion, massage, hot and cold douches, in- unctions of ichthyol or mercurial ointment, iodine locally, corrosive sublimate and iodide of potassium internally, and direct the patient to systematically use the arm. Many surgeons at the end of the second week apply a Stromeyer splint which permits the patient and the surgeon to make some motion by means of the screw (Fig. 67). In children or in very stout people an anterior angular splint will not stay in place, in which case the arm should be put at a right angle and plaster of Paris be used. If, on removing an angular splint from any case after four weeks, non-union exists, put up the arm in an immovable splint for three or four weeks more. Epiphyseal separation of the humerus is a not unusual accident. The inferior extremity of the humerus may be separated, or the condyles may be separated from each other and from the shaft of the bone. DISEASES AND INJURIES OF BONES AND JOINTS. 363 Symptoms.—The symptoms are—prominence in front of the joint, caused by the lower end of the shaft of the humerus ; projection backward of the olecranon ; hand mid- way between pronation and supination. Epiphyseal separa- tion may retard growth and produce deformity. Fractures of the ulna comprise the following varieties: (1) fracture of the coronoid process; (2) fracture of the olec- ranon process ; (3) fracture of the shaft; and (4) fracture of the styloid process. Fracture of the coronoid process of the ulna occurs only as a complication of a backward dislocation or in associa- tion with other fractures. Symptoms.—When fracture of the coronoid process is associated with a dislocation there is produced crepitus on reduction, and it is found that the deformity of the disloca- tion promptly returns on cessation of extension. The upper fragment may be pulled up by the brachialis anticus, and there exists an inability to flex the forearm completely. The position is one of extension with posterior projection of the olecranon. The broken piece is felt in front of the joint. Treatment.—The treatment is by an anterior splint whose angle is less than a right angle; the splint is to be worn for four weeks, and passive motion is to be begun in the third week. A stiff joint is probable. Fracture of the olecranon process of the ulna is not an uncommon injury in adults. Hulke states that it never occurs before the age of fifteen, but the writer has seen in the Jeffer- son Hospital a girl aged fourteen with a fractured olecranon. The cause is direct violence or muscular action. Only a small fragment may be torn away or the greater part of the olecranon may be broken off, and the break may be com- minuted or even be compound. Symptoms.—The symptoms of fracture of the olecranon arc—swelling ; partial flexion of forearm ; separation of frag- 364 A MANUAL OF SURGERY. ments, the upper piece being pulled up from half an inch to two inches by the triceps; the space between the frag- ments is increased by forearm flexion and lessened by fore- arm extension ; there is inability to extend the arm. Bulging of the triceps above the fragments and crepitus on approxi- mating the fragments are observed. The prognosis is fair, fibrous union being the rule. Some joint-stiffness usually occurs, and much ankylosis may be unavoidable. Treatment.—The treatment calls for a well-padded anterior splint, almost but not quite straight. A perfectly straight splint is uncomfortable, and, by opening a retiring angle between the fragments and into the joint, favors non-union and ankylosis. The splint should reach from a level with the axillary margin to below the fingers. If the upper frag- ment does not come in contact with the lower, pull it down by adhesive plaster and fasten the strips to the splint. The author in one case employed a glove to which strings from the adhesive plaster were attached. The danger of anky- losis in this fracture is very great, and, in case it occurs in the position of extension, means an almost useless arm. Pickering Pick at the end of three weeks anaesthetizes the patient, presses his thumb firmly down upon the top of the olecranon, puts the forearm at a right angle, and applies an anterior angular splint and directs it to be worn for two weeks, passive motion being made every other day. When the splint is removed, try to obtain motion as previously directed. Non-union requires wiring of the fragments. Fracture of the shaft of the ulna is most apt to be near the middle, is always due to direct violence, and is not un- usually compound. The radius may also be broken. Symptoms.—By running the finger along the inner sur- face of the bone there are detected inequality and depression ; crepitus and mobility are developed; there are pain and the evidences of direct violence. The long axis of the hand is DISEASES AND INJURIES OF BONES AND JOINTS. 365 not in a line with the long axis of the forearm, but is internal to it. If deformity exists, it is due to the lower fragment passing into the interosseous space because of the action of the pronator quadratus muscle; the upper fragment, acted on by the brachialis anticus, passes a little forward. The forearm at and below the seat of fracture is narrower and thicker than normal. Treatment.—In treating fracture of the shaft, place the forearm midway between pronation and supination, so as to bring the fragments together and to obtain the widest pos- sible interrosseous space; this limits the danger of ankylosis in this space. The position midway between pronation and supination is marked by flexing the forearm to a right angle with the arm and pointing the thumb to the nose. Take two well-padded straight splints, one long enough to reach from the inner condyle to below the fingers, the other from the outer condyle to below the wrist; place a long pad over the interosseous space on the flexor side of the limb, and another on the extensor side ; apply the splints and hang the arm in a triangular sling (PI. 8, Fig. 2). Passive motion is to be made in the third week, and the splints are to be worn for four weeks. Fracture of the styloid process of the ulna is due to direct force. The displacement is obvious. Treatment.—In treating fracture of the styloid process, push the fragment back into place and use a Bond splint with a compress for four weeks. Fractures of the radius include the following varieties: [a) fractures of its head ; [b) fractures of its neck; (c) frac- tures of its shaft; and [d) fractures of its lower extremity. Fracture of the head of the radius very rarely occurs alone, but it may complicate backward dislocation of the radius and the ulna. Symptoms.—The symptoms of fracture of the head of the 366 A MANUAL OF SURGERY. radius are crepitus on making pronation and supination, and loss of voluntary pronation and supination. Treatment.—The treatment of fracture of the head of the radius is the same as for a fracture in or near the elbow- joint—namely, an anterior angular splint for four or five weeks, with passive motion in the third week (PI. 8, Fig. 3). Fracture of the neck of the radius rarely occurs alone. Symptoms. — In this fracture the forearm is pronated and the patient is found to have lost the power of voluntary pro- nation and supination. Under forced pronation and supina- tion it will be noted that the head of the radius does not move and crepitus is felt. The lower fragment, being pulled up and forward by the biceps, can be felt in front of the elbow-joint. Treatment.—The treatment for fracture of the neck of the radius is the same as for fracture of the elbow-joint—namely, an anterior angular splint for four or five weeks (PI. 8, Fig. 3). Fracture of the shaft of the radius is far commoner than fracture of the shaft of the ulna. It may occur above or below the insertion of the pronator radii teres muscle. It may arise from either direct or indirect force. Fracture of the Radius above the Insertion of the Pronator Radii Teres Muscle.—Symptoms.—The upper fragment is drawn forward by the biceps and is fully supi- nated by the supinator brevis. The lower fragment is fully pronated by the pronator quadratus and pronator radii teres, and its upper end is pulled into the interosseous space. There are crepitus, mobility, pain, narrowing and thickening of the forearm below the seat of fracture, and loss of the power of pronation and supination. The head of the bone is motionless during these movements, and the hand is prone. Treatment.—In treating this fracture, do not put the forearm midway between pronation and supination, as this position will not bring the fragments into contact, the upper DISEASES AND INJURIES OF BONES AND JOINTS. 367 fragment remaining flexed and supinated. To bring the lower fragment in contact with the upper, flex and fully supinate the forearm. Put the arm upon an anterior angular splint for four weeks (PI. 8, Fig. 3), and make passive motion in the third week. Fracture of the Radius below the Insertion of the Pronator Radii Teres Muscle.—In this variety of fracture the upper fragment is acted on by the biceps, the supinator brevis, and the pronator radii teres, and it remains about midway between pronation and supination, passing forward and also into the interosseous space. The lower fragment is acted on by the supinator longus and the pronator quad- ratus, the latter being the more powerful of the two, and the lower fragment is moderately pronated, its upper extremity being thrown into the interosseous space. Other symptoms are identical with those of fracture above the insertion of the pronator radii teres. Treatment.—In treating fracture below the pronator radii teres, the forearm is flexed and is placed midway between pronation and supination; interosseous pads and two straight splints are applied as for fracture of the ulna (PI. 8, Fig. 2). The splints are worn for four weeks, and passive motion is made in the third week. Fracture of the shafts of both bones of the forearm is not frequently seen. It is caused by direct or indirect force. Symptoms.—In fractures of both bones of the forearm the hand is pronated and the two lower fragments come together and are drawn upward and backward or upward and forward by the combined force of flexor and extensor muscles, short- ening being manifest and a projection being detected on either the dorsal or the flexor surface of the forearm. The upper fragment of the ulna is somewhat flexed by the brachialis anticus; the upper fragment of the radius is flexed by the biceps and is pronated and drawn toward the ulna by 368 A MANUAL OF SURGERY. the pronator radii teres. The forearm is narrower than it should be (the ends of the fragments having passed into the interosseous space) and is thicker than normal (the contents of the interosseous space having been forced out). Crepitus, mobility, pain, and inequality exist, the power of rotation is lost, and on passive rotation the head of the radius does not move. The forearm is prone and semiflexed. Treatment.—The treatment requires two straight splints and two interosseous pads, the forearm flexed to a right angle and placed midway between pronation and supination (PI. 8, Fig. 2). The splints are worn for four weeks, and passive motion is made in the third week. Fracture of the Lower Extremity of the Radius.—Bar- ton's fracture is oblique and runs into the joint. Colics's fracture is a transverse or moderately oblique fracture of the lower end of the radius, between the limits of one-quarter of an inch and one and a half inches above the wrist-joint, the lower fragment mounting upon the dorsum of the upper piece. Colles's fracture, a very common injury, is met with more frequently in those beyond the age of forty, and oftener in women than in men. It is due to transmitted force (a fall upon the palm of the pronated hand), the force being received by the ball of the thumb and passing to the carpal bones and the edge of the radius ; a fracture begins posteriorly rather than anteriorly, the force driving the fragment upon the dorsal surface of the radius. Some hold that this fracture is due to sudden traction upon the anterior ligaments, which drag upon the bone and break it at the point where the cancellous end of the radius joins the compact shaft. Symptoms.—In Colles's fracture the hand is abducted (drawn to the radial side of the forearm) and pronated, the head of the ulna is prominent, the styloid process of the radius is raised, and the lower fragment, which mounts on the back of the lower end of the upper fragment, causes DISEASES AND INJURIES OF BONES AND JOINTS. 369 a dorsal projection termed by Liston the "silver-fork de- formity." The lower end of the upper fragment can be felt beneath the flexor tendons above the wrist. The position in deformity is produced by the force and is maintained by the action of the supinator longus and the flexor and exten- sor muscles, but particularly by the extensors of the thumb. Pronation and supination are lost. Crepitus, which is best obtained by alternate hyperextension and flexion, can be secured unless swelling is great or impaction exists. Crepi- tus on side movements is rarely obtainable. Impaction may greatly modify the deformity, though displacement generally exists to some extent, and the fragments do not ride easily on each other. The styloid process of the ulna may be broken, or the inferior radio-ulnar articulation may be sepa- rated. This latter complication allows the lower fragment to roll freely upon the upper, and the characteristic silver- fork deformity does not appear. If the styloid process of the ulna is broken, pressure over it causes great pain. If a person in falling strikes the back of the hand and a fracture of the radius occurs, the lower fragment is driven upon the front surface of the upper fragment and is felt under the flexor tendons at the wrist. Treatment.—In treating Colles's fracture, reduce the de- formity by hyperextension to unlock the fragments, by lon- gitudinal traction, and by forced flexion. The extremity can be placed upon a Levis splint, the position maintaining reduc- tion and the tense extensor tendons giving dorsal support. The favorite splint in Philadelphia practice is Bond's. It places the hand in a natural position of rest (semiflexion of the fingers, semi-extension of the wrist, and deviation of the hand toward the ulna). Two pads are used : a dorsal pad which overlies the lower fragment, and a pad for the flexor surface which overlies the upper fragment. A bandage is applied, the thumb and fingers being left free (PI. 8, Fig. 1 ; PI. 7, Fig. 7). 24 37° A MANUAL OF SURGERY. Passive motion is begun upon the fingers in three or four days, and upon the wrist during the second week. The splint is removed in three weeks, and a bandage is worn for a week or two more because of the swelling. In applying the Bond splint, do not pull the hand too much up on the block, or the fracture will unite with a projection upon the flexor surface of the extremity and the tendons of the wrist will be apt to be caught in the callus. If a stiff joint and limited tendon-motion eventuate from the fracture, use massage, frictions, sorbefacient ointments, tincture of iodine, electricity, and hot and cold douches, or give ether and forcibly break up adhesions. Some surgeons dress Colles's fracture with a band of adhesive plaster around the wrist and support the extremity in a sling (Pilcher). Fracture of both the Radius and Ulna near the Wrist. —Colles's fracture may be complicated by a fracture of the ulna other than of its styloid process. Symptoms.—In fracture of the radius and ulna near the wrist the lower ends of the upper fragments come together, the upper fragment of the radius is pronated, and the lower fragment of the radius is drawn up. Pain, crepitus, mobility, shortening, and loss of function exist. Treatment.—A fracture of the radius and ulna requires the use of the Bond splint, as for Colles's fracture. Separation of the Lower Radial Epiphysis.—This acci- dent occurs in children from falling upon the palm of the hand. It never happens after the twentieth year. Symptoms.—In separation of the lower radial epiphysis the lower fragment mounts upon the upper and produces a dorsal projection like Colles's fracture, but the hand does not deviate to the radial side. The deformity resembles that of a backward carpal dislocation, but is differentiated from dis- location by the unaltered relation in the fracture between the styloid processes and the carpal bones. DISEASES AND INJURIES OF BONES AND JOINTS. 371 Treatment.—The treatment in separation of the lower radial epiphysis consists of the use of a Bond splint, as in Colles's fracture. Fractures of the carpus are not frequent, and they are usually compound. The cause is violent direct force. Symptoms.—Fractures of the carpus are indicated by pain, swelling, evidences of direct force, sometimes crepitus, loss of power in the hand, and a very little displacement. Treatment.—Many compound comminuted fractures of the carpus require amputation. In an ordinary com- pound fracture, asepticize, drain, dress with antiseptic gauze and a plaster-of-Paris bandage, cutting trap-doors in the plaster over the ends of the drainage-tube. In a simple fracture, use lead-water and laudanum for a few days. Dress the hand upon a well-padded straight palmar splint (PI. 7, Fig. 10) reaching from beyond the fingers to the mid- dle of the forearm, and place the hand and forearm in a sling. The splint is worn for four weeks, and passive motion of the wrist is begun in the second week. Fracture of the Metacarpal Bones.—Metacarpal frac- ture is very common. One or more bones may be broken. The first metacarpal bone is oftenest broken; the third is rarely broken (Hulke). The cause is direct or indirect force. Symptoms.—The signs of a metacarpal fracture are— dorsal projection of the upper end of the lower fragment, the head of the bone being felt in the palm ; pain; crepitus ; and often evidences of direct violence. Treatment.—To treat a fracture of the metacarpal bones, reduce by extension; place a large ball of oakum, cotton, or lint in the palm to maintain the natural rotundity, and apply a straight palmar splint like that used in fractures of the carpus (PI. 7, Fig. 10). It may be necessary to apply a com- press over the dorsal projection. The duration of treatment is three weeks, and passive motion is begun after two weeks. 372 A MANUAL OF SURGERY. Fractures of the Phalanges.—The phalanges are often broken. The fracture may be compound. The cause usually is direct force. Symptoms.—Fracture of the phalanges is indicated by pain, bruising, crepitus, and mobility, with very little or no displacement. Treatment.—If the middle or distal phalanx is broken, mould on a trough-like splint of gutta-percha or of paste- board, which splint need not run into the palm. If the proximal phalanx is broken, run the splint into the palm of the hand. Make the splint of gutta-percha, pasteboard, wood, or leather. The splint is worn three weeks. A sling must be worn, otherwise the finger will constantly be knocked and hurt. Some cases require a dorsal as well as a palmar splint. Fracture of the femur is a very common injury. The divisions of the femur are (i) the upper extremity; (2) the shaft; and (3) the lower extremity. 1. Fractures of the upper extremity of the femur are divided into [a) intracapsular; (b) extracapsular; [c) of the great trochanter; and [d) epiphyseal separation (either of great trochanter or head). Intracapsular Fracture of the Femur.—This fracture of the neck is transverse or only slightly oblique, and is not unusually impacted. The cause is slight indirect force, of the nature of a twist, acting upon a person of advanced years (more often a woman than a man). A fall upon the knees, a trip, or an attempt to prevent a fall may produce this frac- ture. Intracapsular fracture is never caused by direct force unless it is due to gunshot violence. The aged are more liable to intracapsular fracture than the young or the middle- aged, because, first, the angle which the neck forms to the axis of the femur becomes less obtuse with advancing years, and may even form a right angle; this change is more pro- nounced in women than in men; secondly, the compact DISEASES AND INJURIES OF BONES AND JOINTS. 373 tissue becomes thinned by absorption, the cancelli diminish, the spaces between them enlarge, the bony partitions of the cancellous portion are thinned or destroyed, and the cancel- lous structure becomes fatty and degenerated. Symptoms.—In intracapsular fracture there is usually shortening to the extent of from half an inch to an inch. Shortening of a quarter of an inch does not count in diag- nosis, for, as Hunt shows, one limb is often naturally a little shorter than the other. If the reflected portion of the capsule is not torn, the shortening is trivial in amount or is entirely absent. In some cases shortening gradually or suddenly increases some little time after the accident. This is due to separation of an impaction, tearing of the previously unlac- erated capsular reflection, restoration of muscular strength after a paresis, or absorption of the head of the bone. Short- ening is due chiefly to pulling up of the lower fragment by the hamstrings, the glutei, and the rectus. Eversion exists, spoken of as " helpless eversion," though in a very few instances the patient can still invert the leg. This eversion is due to the force of gravity, the limb rolling outward because the line of gravity has moved externally. That eversion is not due to the action of the external rotator muscles, as was taught by Astley Cooper, is proved by the fact that when a fracture happens in the shaft below the insertion of these muscles the lower fragment still rotates outward. This is further demonstrated by the considera- tions that the internal rotators are more powerful than the external, that some patients can still invert the limb, and that eversion persists during anaesthesia.1 In some unusual cases inversion attends the fracture. Besides shortening and eversion, the leg is somewhat flexed on the thigh and the thigh on the pelvis, the extremity when rolled out resting upon its outer surface. 1 Edmund Owens : A Manual of Anatomy. 374 A MANUAL OF SURGERY. Loss of power is a prominent symptom : the limb can rarely be raised or inverted. Pain is trivial except upon motion, when it can be localized in the joint. Crepitus often cannot be found, either because the fragments cannot be approximated or because they are greatly softened by fatty change. To obtain crepitus the front of the joint must be examined while the limb is extended and rotated inward. But why try to obtain crepitus ? The diagnosis is readily made without it, in many cases it cannot be found, and the endeavor to obtain it inflicts pain and may effect damage. These fractures offer a not very flattering chance of repair, and efforts to find crepitus may injure the capsule or pull apart an impaction (Allis). Altered Arc of Rotation of the Great Trochanter (Desault's sign).—The pivot on which the great trochanter revolves is no longer the acetabulum, and the great trochanter no longer describes the segment of a circle, but rotates only as the apex of the femur, which rotates around its own axis. Relaxation of the fascia lata (Allis's sign) simply means shortening. The fascia lata is attached to the ilium and the tibia (ilio-tibial band), and when shortening brings the tibia nearer to the ilium this band relaxes and permits one to push more deeply inward on the injured side, between the great trochanter and the iliac crest, than on the sound side. Ascent of the Great Trochanter above Nelaton's Line.—This line is taken from the anterior superior iliac spine to the most prominent part of the ischial tuberosity (Fig. 51). In health the great trochanter is below, and in intracapsular fracture it is above, this line. Ascent of the Trochanter into Bryant's Triangle (Fig. 51). —Place the patient recumbent, carry a line around the body on a level with the anterior superior spines, lay down Nela- ton's line, and measure the base of the triangle from the DISEASES AND INJURIES OF BONES AND JOINTS. $7$ great trochanter to the perpendicular line from the spine to determine the amount of ascent. Morris's measurement shows the extent of inward displace- ment. Measure from the median line of the body to a perpendicular line drawn through the trochanter on each side of the body. Diagnosis.— Intracapsular fracture without separation of the fragments may be mistaken for a mere contu- . iii- • Fig. si.—A CD, Bryant's Ilio- SlOn, and the diagnosis may Continue femoral Triangle; AB, Nelaton's obscure unless the fragments sepa- rate. Loss of function in contusion is rarely complete or prolonged, although occasionally the head of the bone is absorbed. Intracapsular fracture may be confused with extracapsular fracture or with a dislocation of the hip-joint. Extracapsular fracture, which is commonest in young adults, results from direct violence over the great trochanter; if non-impacted, there are noted shortening of from one and a half to over three inches, crepitus over the great trochanter, and usually, but not invariably, eversion; if impacted, there is less eversion, crepitus is almost or entirely absent, and the shortening is limited to about an inch. Great tenderness exists over the great trochanter in both impacted and non- impacted fractures. In dislocation on the dorsum of the ilium the patient is usually a strong young adult. There are inversion (the ball of the great toe resting on the instep of the sound foot), rigidity, ascent of the bone above Nela- ton's line, and shortening of from one to three inches. In dislocation into the thyroid notch there is possibly eversion, but it is linked with lengthening. Prognosis.—The prognosis is not very favorable. Old people not unusually die. In impacted fracture bony union may occur; in non-impacted fracture fibrous union is the best 376 A MANUAL OF SURGERY. that can be expected. Non-union is not unusual. Perma- nent shortening to some degree is inevitable, and the function of the joint is sure to be more or less impaired. It will be found necessary in many cases for the patient to always employ support in walking. Treatment.—In treating a very old or a feeble person for intracapsular fracture, make no attempt to obtain union. Keep the patient in bed for two weeks, give lateral support by sand-bags, tie around the ankle a fillet, to which attach a weight of a few pounds, and hang the weight over the foot-board of the bed. When pain and tenderness abate, order the patient to get into a reclining chair, and permit him very soon to get about on crutches. If hypostatic con- gestion of the lungs sets in, if bed-sores appear, if the appe- tite and digestion utterly fail, or if diarrhoea persists, abandon attempts at cure in any case and secure for the sufferer sunshine and fresh air. Immobilize the fracture as thor- oughly as possible by means of pasteboard splints. If it is determined to treat the case, combine extension with lateral support by means of sand-bags and the extension apparatus originally devised by Gurdon Buck. Place the subject on a firm mattress, and if the patient be a man, shave the leg. Cut a foot-piece out of a cigar-box, perforate it for a cord, wrap it with adhesive plaster as shown on Plate 7, Figures 15, 16, run the weight-cord through the opening in the wood, and fasten a piece of plaster on each side of the leg, from just below the seat of fracture to above the malleolus (PI. 7, Fig. 14). The plaster is guarded from sticking to the malleoli by having another piece stuck to it at each of these points. Apply an ascending spiral reverse bandage over the plaster to the groin (Fig. 52), and finish the band- age by a spica of the groin. Slightly abduct the extremity. Put a brick under each leg of the bed at its foot, thus obtaining counter-extension by the weight of the body. DISEASES AND INJURIES OF BONES AND JOINTS. 377 Run a cord over a pulley at the foot of the bed, and get extension by the use of weights. From ten to fifteen pounds will probably be necessary at first, but after a day or two from six to eight pounds will be found sufficient (remember that a brick weighs about five pounds). Make a bird's-nest pad of oakum for the heel. Take two canvas bags, one long Fig. 52.—Adhesive Plaster Applied to Extension. enough to reach from the crest of the ilium to the malleolus, the other long enough to reach from the perineum to the malleolus. Fill the bags three-quarters full of dry sand, sew up their ends, cover the bags with slips, and put the bags in place in order to correct eversion. The slips may be changed every third or fourth day. The bowels are to be emptied and the urine is to be voided into a bed-pan, unless using a fracture-bed. Maintain extension for five or six weeks, then mould pasteboard splints upon the part, and keep the patient in bed for three or four weeks more. In from eight to ten weeks after the accident the patient may get about on crutches. Union, if it takes place, is cartilagi- nous, and not bony, and there is bound to be some shorten- ing and some stiffness of the joint. Passive motion is not made until after eight weeks have elapsed. Professor Senn claims that by his method of " immediate reduction and permanent fixation" bony union is obtained in fractures of the neck of the femur within the capsule. He " places the patient in the erect position, causing him to stand with his sound leg upon a stool or a box about two feet in height; 378 A MANUAL OF SURGERY. in this position he is supported by a person on each side until the dressing has been applied and the plaster has set. "Another person takes care of the fractured limb, which in impacted fractures is gently supported and immovably held until permanent fixation has been secured by the dress- ing. In non-impacted fractures the weight of the fractured limb makes auto-extension, which is often quite sufficient to restore the normal length of the limb; if this is not the case, the person who has charge of the limb makes traction until all shortening has been overcome as far as possible, at the same time holding the limb in position, so that the great toe is on a straight line with the inner margin of the patella and the anterior superior spinous process of the ilium. In applying the plaster-of-Paris bandage over the seat of fracture a fenestrum, corresponding in size to the dimensions of the com- press with which the lateral pressure is to be made, is left open over the great trochanter. " To secure perfect im- mobility at the seat of fractures, it is not only necessary to include in the dressing the fractured limb and the entire pelvis, but it is absolutely neces- sary to also include the opposite limb as far as the knee and to extend the dressing as far as the cartilage of the eighth rib. "The splint (Fig. 53) is incorporated in the plaster-of-Paris dressing, and it must carefully be applied, so that the com- press, composed of a well-cushioned pad with a stiff, unyield- Fig. 53.—Senn's Apparatus (Senn). Fig. 54.—Senn's Appa- ratus Applied (Senn). DISEASES AND INJURIES OF BONES AND JOINTS. 379 ing back, rests directly upon the trochanter major, and the pressure, which is made by a set-screw, is directed in the axis of the femoral neck. Lateral pressure is not applied until the plaster has completely set. Syncope should be guarded against by the administration of stimulants. "As soon as the plaster has sufficiently hardened to retain the limb in proper position, the patient should be laid upon a smooth, even mattress, without pillows under the head, and in non-impacted fractures the foot is held in a straight position and extension is kept up until lateral pressure can be applied. " No matter how snugly a plaster-of-Paris dressing is applied, as the result of shrinkage it becomes loose, and without some means of making lateral pressure it would become necessary to change it from time to time in order to render it efficient. But by incorporating a splint in the plaster dressing (Fig. 54) this is obviated, and the lateral pressure is regulated, day by day, by moving the screw, the proximal end of which rests on an oval depression in the centre of the pad." Extracapsular Fracture.—The line of extracapsular frac- ture is at the junction of the neck with the great trochanter, and is partly within and partly without the capsule, the fracture being generally comminuted and often impacted. The cause is violent direct force over the great trochanter (as by falling upon the side of the hip). This fracture is most usual in strong young adults. Symptoms.—When impaction is absent there is marked crepitus, which is manifested most when the fingers are put over the great trochanter; there are great pain, swelling, and ecchymosis; there is absolute inability on the part of the patient to move the limb, and passive movements cause great pain ; there is shortening to the extent of at least one and a half inches, and often three inches; and there is abso- 38o A MANUAL OF SURGERY. lute eversion with slight flexion both of the leg and the thigh. All these symptoms follow violent direct lateral force. In the impacted form of extracapsular fracture, in addition to the aid given the surgeon by the history, there is severe pain which is intensified by movement or pressure; shorten- ing exists to the extent of one inch at least, which is not corrected by extension; there is also great loss of function; and whereas the limb may be straight or even inverted, it is usually everted. Crepitus cannot be obtained without improper violence, and the trochanter moves in a large arc of rotation, although it is in Bryant's triangle and above Nelaton's line. Treatment.—In treating extracapsular fracture, make ex- tension, raise the foot of the bed, and apply the extension apparatus with sand-bags for four weeks; then apply a plaster dressing and get the patient up on crutches. Remove the plaster at the end of four weeks. In impacted fracture use a moderate force in extending, but never violently pull the bones apart. Fracture of the Great Trochanter.—This process may be (i) broken off without any other injury, but in most cases (2) the line of fracture runs through the trochanter, and leaves one portion of the trochanter attached to the head and neck and the other part attached to the shaft. The cause is violent direct force over the great trochanter. Symptoms and Treatment.—The symptoms of the second form are similar to those of extracapsular fracture. On rotating the femur the lower part of the trochanter moves with it, but not the upper. The lower fragment goes upward and backward and projects by the side of the sciatic notch. There are shortening, eversion, crepitus, and altered position of the trochanter. The symptoms of the first form resemble those of epiphyseal separation. The treatment of the second form is like that in extracapsular fracture, and the first DISEASES AND INJURIES OF BONES AND JOINTS. 381 form is treated like separation of the epiphysis of the trochanter. Separation of the upper epiphysis of the femoral head is a very rare result of accident; it occurs most often from disease and in youth. Symptoms and Treatment.—The symptoms are like those of fracture of the neck, except that the crepitus is soft. The treatment is extension as above directed. Separation of the epiphysis of the great trochanter is a very rare accident. The cause is direct violence, and the injury occurs only in youth. Symptoms.—The trochanter is found to have ascended and passed posteriorly; there is no shortening; all the motions of the hip-joint can be obtained; if the thigh is flexed, abducted, and rotated externally, and the fragment pushed down and forward, crepitus is obtained—soft in epiphyseal separation, hard in fracture. Treatment.—In treating separation of the epiphysis of the great trochanter, flex the leg on the thigh and the thigh on the pelvis, place the extremity upon its outer surface, keep it fixed by some form of retentive apparatus, and try to draw the trochanter downward and forward by adhesive strips or by a pad and bandage. Some degree of lameness is inevi- table, even after Bryant's extension. Bryant's extension directly upward may admit of the trochanter being pulled downward upon the bone. Dressing must be applied for six weeks, and crutches and pasteboard splints are used for four weeks more. 2. Fractures of the shaft of the femur may affect any portion of the shaft, but especially the middle third, and may occur at any age. The cause of fractures in the upper third is usually indirect force; fractures in the lower third are due to direct force; and in fractures of the middle third these two causes are about equally potential. Fracture from muscular 382 A MANUAL OF SURGERY. action occasionally occurs. Oblique fracture is the usual variety. Symptoms.—The chief symptom in fracture of the shaft of the femur is great displacement, except when impaction occurs or when the break is in a child and the periosteum is untorn. As a rule, the lower fragment is drawn up and is posterior and somewhat to the inside of the upper fragment, and undergoes external rotation (the drawing up is due to the rectus and hamstrings; the passing in is due to the adductor muscles; the rotation outward arises from the weight of the limb). In fracture of the upper third the upper fragment is apt to be thrown strongly forward and outward. Some attribute this to the action of the psoas, iliacus, and external rotator muscles, but Dr. Allis thinks it is due to the lower fragment pushing the upper fragment into this position. There is complete loss of function, the thigh and leg being semiflexed and everted. There are shortening to the extent of two or three inches, pain on movement, preternatural mobility, crepitus, and obvious deformity, and the ends of the fragments can be felt. In impaction there is shortening with altered axis of the limb. Fig. 55.—Dressing of Fracture of the Femur in the Upper Third with Extension upon a Double Inclined Plane (Agnew). Treatment.—In fractures of the shaft of the femur some amount of permanent shortening is almost inevitable. In frac- tures of the upper third, use Agnew's plan—namely, a double DISEASES AND INJURIES OF BONES AND JOINTS. 383 inclined plane with extension in the axis of the partly-flexed thigh (Fig. 55). If, notwithstanding position and extension, the upper fragment projects, push it into place and bind short splints upon the limb. Extension is continued for four weeks, a plaster-of-Paris bandage being used for four weeks more, the patient being then allowed to get about on crutches. Some surgeons, in fractures of the upper third, apply a plaster-of- Paris bandage to the leg, thigh, and pelvis, extension being made from the foot while the dressing is being applied. The anterior splint of Nathan R. Smith is much used in the South in treating fractures of the shaft and the upper extremity (Fig. 56). In fractures of the middle third and upper part of the lower third of the shaft, use the extension appara- tus (PI. 7, Fig. 14) with the sand-bags, running the plaster to just below the seat of the fracture, and the roller bandage to a little above this point. Ex- tension is to be continued for four weeks, and the plaster-of-Paris bandage is used for four weeks more. In fractures of the lower part of the lower third of the shaft, use a double inclined plane (PI. 7, Fig. 2) alone. A Mclntyre splint (Fig. 57) is a useful form of double inclined plane. At the end of four weeks apply plaster, which is to be worn for four weeks. Fracture just above the Condyles.—The line of this fracture is well above the epiphyseal line. The femoral artery is in danger from the fragments. The cause, as a rule, is direct violence. Indirect force is sometimes re- Fig 56.—Smith Anterior Splint. 384 A MANUAL OF SURGERY. sponsible (falls upon the feet). The knee-joint may be opened. Symptoms.—The upper end of the lower fragment passes back into the popliteal space and is drawn upward (rectus, Fig. 57.—Mclntyre Splint (Tiemann). the knee is broadened and crepitus is got by moving the condyles, one up and the other down. Treatment.—In treating a fracture above the condyles, place the limb on a double inclined plane for five weeks, then start passive motion once every other day, restoring the limb to the splint after the movements are completed. At the end of eight weeks after the accident, remove the dressings, and, if the knee-joint be stiff, use for some time massage, motions, hot and cold douches, ichthyol inunctions, etc. Bryant treats this fracture in extension, cutting the tendo Achillis, if necessary, to amend deformity. Fracture Separating Either Condyle.—The cause of this fracture is direct force. Symptoms and Treatment.—The broken piece is drawn upward, the leg bends toward the injury, crepitus exists, the DISEASES AND INJURIES OF BONES AND JOINTS. 385 knee is much broadened, there is no shortening, and consider- able swelling is sure to arise. In treating a fracture separating either condyle, use a double inclined plane as directed above. Longitudinal fractures run up from the knee-joint. The cause is a fall upon the feet or the knees. Symptoms and Treatment.—The symptoms of longitudinal fracture are often obscure. The femur is broadened when the knee is flexed. The split is detected between the con- dyles. The treatment is the straight position in plaster for eight weeks. Separation of the lower epiphysis occurs only before the twenty-first year. Symptoms.—The symptoms in separation of the lower epiphysis are like those of fracture, but crepitus is moist. The danger is that the growth of bone will be stunted. Treatment.—The treatment for separation of the lower epiphysis is a double inclined plane as above directed. Fracture of the patella is a very common accident. The cause is direct force (producing vertical, star-shaped, or oblique lines of fracture) or muscular action (producing a transverse line of fracture). Fractures of the Patella by Muscular Action.—The knee-cap is more often broken by muscular action than is any other bone. When the knee is partly ---- flexed the middle third of the patella rests upon the condyles of the femur and the upper third of the knee-cap projects above them; when in this position a contraction of the quadriceps may easily cause a fracture near the centre of the bone (Fig. 58). Both FiG.58.-Fractureof . the Patella by Muscu- patellae may be broken at once. In this form iar Action (Treves). of fracture the joint, and often the prepatellar bursa, is opened. Symptoms.—The symptoms in fractures by muscular action are—rapid and enormous swelling, due to the effusion first of 2b 386 A MANUAL OF SURGERY. blood and then of synovia and inflammatory products into and around the joint; absolute inability to raise the limb from the bed. The fragments are widely separated, this separation being distinctly manifest to the touch unless swelling is great. The separation is accentuated by flexion of the leg. Crepitus is detected if the upper fragment can be pushed down until it touches the lower piece, but if swelling is great this cannot be done. Union, if it occurs, will be ligamentous, and not bony, and if the patient gets about too soon, apparently well-united fragments will by degrees stretch far asunder. Transverse Fractures of the Patella.—Treatment.—If the swelling in transverse fracture of the patella be so great as to prevent approximation of the fragments, reduce it by bandaging for a day or two, by using ice-bags and lead- water and laudanum, or by aspirating the joint. When the swelling diminishes, bring the two fragments into apposition, pull them together by adhesive plaster, and put on a well- padded posterior splint. Run a piece of adhesive plaster over the upper end of the upper fragment, draw the bone down, and fasten the plaster behind and below the joint. Run another piece of plaster over the lower end of the lower fragment, draw the bone up, and fasten the plaster behind and above the joint. A third piece is run over the junction of the fragments to prevent tilting. Agnew's splint admirably accomplishes this approximation (PI. 7, Figs. 11, 12). A bandage holds the splint in place, and may be carried around the knee by figure-of-8 turns. The heel is sometimes raised upon a pillow so as to extend the leg and to semiflex the thigh, but this is not essential. Remove and reapply the dressing every few days, as it inevitably becomes loose. At the end of three weeks remove the splint permanently and apply a plaster-of-Paris dressing from just above the ankle to the middle of the thigh. The dressing is to be worn DISEASES AND INJURIES OF BONES AND JOINTS. 387 for five weeks. At the end of eight weeks let the patient walk with canes, the joint being kept fixed for four weeks more by pasteboard splints or by a light plaster-of-Paris bandage. For one year after removing the splints and plaster a lacing knee-cap and a posterior splint should be worn to support the joint. The plan of prolonged retention renders more or less joint-stiffness a certain occurrence, but this is less of an impediment than the wide separation of the fragments that inevitably attends an early use of the joint. Malgaigne's hooks (Fig. 59), if employed to treat these fractures, are to be inserted with the full antiseptic care of an ordinary surgical opera- tion. Insert the lower hooks just below the point of the patella, entering them under its edge, press the fragments together, draw up the skin over the upper fragment to prevent puckering, and insert the upper hooks with force just above the upper fragment, letting the points of the hooks bear upon the bone. Lock or screw the hooks together, dress with antiseptic gauze, and apply a posterior splint. Remove the hooks in three weeks, and treat with plaster as in the preceding case when the special splint was removed. Among other plans of treatment may be mentioned wiring the fragments (see Operations upon Bones); encircling the fragments with a subcutaneous silk ligature; passing a pin through the tendon of the quadriceps, another through the ligament of the patella, and approximating the two by figure-of-8 turns with a silk cord, thus drawing together the fragments. Fractures of the patella by direct force are vertical, stellate, oblique, or V-shaped, and are often incomplete. Fig. 59.—Malgaigne's Hooks. 388 A MANUAL OF SURGERY. Symptoms.—Fractures of the patella by direct force are indicated by discoloration, swelling, great difficulty in move- ment, and much pain. There may or may not be crepitus, and rarely is there separation of the fragments. Bony union occurs in these fractures. Treatment.—Fracture by direct force requires a posterior splint, the local use of lead-water and laudanum, and the application of a bandage. If there is any separation, approx- imate the fragments by bandages and compresses. The danger in these cases is not non-union, but is ankylosis ; hence, begin passive motion of the knee-joint in the fourth week after the accident. Remove the dressings at the end of six weeks, and let the patient at once get about. Fractures of the Leg.—In leg-fractures both bones or only one bone may be broken. Fractures of the tibia are divided into (i) fractures of the upper end ; (2) separation of the upper epiphysis; (3) frac- tures of the shaft; (4) fractures of the lower end; and (5) separation of the lower epiphysis. Fractures of the upper end of the tibia are uncommon. They may be transverse, oblique, or vertical running into the joint. The cause is direct violence. Symptoms.—In fracture of the upper end of the tibia there is contusion of the soft parts. In a transverse fracture there are mobility and crepitus, but there is little displacement. In oblique fracture crepitus and mobility are marked and the axis of the limb is altered. In vertical fractures enter- ing the joint there is great swelling of the knee-joint. In comminuted fractures, which exhibit marked signs, union is readily obtained, but if the joint has been damaged stiffness is sure to ensue. Treatment.—In treating fractures of the upper end of the tibia, employ a double inclined plane in the form of a Mclntyre splint (Fig. 57) or in the form of a fracture-box DISEASES AND INJURIES OF BONES AND JOINTS. 389 (PI. 7, Fig. 1). Lead-water and laudanum and cold are applied about the knee-joint. At the end of the fourth week begin passive motion, reapplying the splint after each daily seance. In six weeks let the patient get about, first with crutches, then with a cane, then without any artificial support. Separation of the Upper Epiphysis of the Tibia.—There is only one recorded case (Pick). Fractures of the Shaft of the Tibia.—The cause of these fractures is direct force. The fracture is generally trans- verse in the upper part of the bone and oblique in the lower part (Pickering Pick). Symptoms.—In transverse fracture of the shaft of the tibia there is no deformity, and the support of the fibula may even permit of walking; there is fixed pain; there may or may not be inequality of fragments felt by the finger; and there are crepitus, mobility, and often linear ecchymosis. In oblique fractures there usually exist crepitus, a little mobility, and some deformity. The deformity depends on the direction of the line of fracture, and, as this line is usually from above downward, inward, and a little forward, the lower fragment usually passes behind the upper fragment and rotates inward. Treatment.—In treating fractures of the shaft of the tibia, if there be much swelling, put the limb in a fracture-box (PI. 7, Fig. 1 ; PI. 8, Fig. 6) and apply lead-water and lauda- num. A silicate-of-soda or a plaster-of-Paris dressing is applied when the swelling subsides, or the dressing is used at once if swelling is slight. The patient gets about on crutches. The dressing is removed in six weeks, and the patient goes about for one week on crutches, lightly using the foot, and then for one week with a cane. At the end of eight weeks the leg may be used, but not too much at first. Fractures of the Lower End of the Tibia: Fracture of the Inner Malleolus.—The cause of fracture of the inner malleolus is direct force. 39° A MANUAL OF SURGERY. Symptoms and Treatment.—The symptoms of fracture of the inner malleolus are some downward displacement, depression above the fragment, mobility, and crepitus. The treatment is to push the fragment into place and use side- splints or a fracture-box for two weeks, when a plaster-of- Paris or a silicate dressing may be substituted and the patient be ordered to use crutches. Remove the plaster four weeks after it is applied, and direct the patient to grad- ually bear his weight upon the leg, as outlined above. Separation of the lower epiphysis of the tibia is a very rare accident. The treatment is a fixed dressing for six weeks. Fracture of the fibula alone is commoner by far than is fracture of the tibia alone. Fractures in the upper two- thirds, which are rare, are usually due to direct force. Frac- tures in the lower third are frequent, and they arise from indirect force. Fractures of the Upper Two-thirds of the Fibula.—In these fractures the cause is direct force. Symptoms.—In fracture of the upper two-thirds of the fibula the patient can often walk. The bone is deeply situ- ated, and displacement cannot often be made out. There is a fixed pain which is intensified by movement and by pressure. Pressure upon the lower fragment does not move the uppei fragment. Crepitus is sometimes felt, and a linear ecchy- mosis is apt to appear. The bone bends normally, hence slight mobility is of no value diagnostically. Treatment.—In treating a fracture of the upper two-thirds of the fibula, apply a plaster-of-Paris or a silicate bandage and direct that it be worn for six weeks. Weight is not to be put upon the foot for eight weeks after the accident. Fractures of the Lower Third of the Fibula.—In these fractures the cause is indirect force, especially twists of the foot. P'orcible inversion of the foot pulls upon the external lateral ligament and the external malleolus, forces the fibula DISEASES AND INJURIES OF BONES AND JOINTS. 391 outward, and tends to break it, the lower fragment being dis- placed outward. Forcible eversion pulls the internal lateral ligament off from the inner malleolus (often breaks the mal- leolus) and fractures the fibula above the ankle, the bone being displaced inward. Symptoms.—In the lower third of the fibula the bone is superficial, and the irregularity of a fracture is manifest to the touch. There is localized pain which is increased by pressure or by motion. Crepitus may exist. Deformity is often exhibited by the position of the foot. Pott's fracture, which is a fracture of the lower fifth of the fibula accompanied by outward dislocation of the foot, is due to powerful eversion of the foot. This outward dislocation is rendered possible by rupture of the deltoid ligament or—what is far commoner—by the tearing off of a portion of the internal malleolus. Treatment.—In fractures of the lower third of the fibula, after reducing displacement, place the limb in a fracture-box containing a soft pillow. A bird's-nest pad of cotton or oakum is made for the heel (PI. 8, Fig. 6). A fillet around the ankle fastens the foot to the foot-piece of the box; a pad of oakum rests between the foot-piece and the sole. If dressing Pott's fracture, put a compress above the inner malleolus and another compress below the outer malleolus. Close the sides of the box and tie them together with a bandage. Swing the box, if desired, on a gallows. Every day let down the sides of the box and rub the leg, the ankle, and the foot with alcohol. In ten days apply a plaster-of- Paris bandage and let the patient get about on crutches. Remove the plaster at the end of the fifth week after the accident, and Jet the patient go about with crutches for one week and with a cane for a week longer. Some surgeons dress Pott's fracture with a Dupuytren splint. This is a straight splint (PI. 7, Fig. 9) which reaches 392 A MANUAL OF SURGERY. from the head of the tibia to or below the toes. This splint is padded, and a pyramidal pad with the base down is laid upon the inner surface of the leg, above the inner malleolus, the splint being put upon the inner surface of the leg, over the pad. The splint is fastened as shown on Plate 7 (Fig. 9), and the leg is semiflexed upon the thigh and is laid upon its outer surface on a pillow. After ten days apply the plaster- of-Paris bandage, which is to be worn as above directed. Fracture of both bones of the leg, a very common in- jury, is often compound, and is not unusually comminuted. Fractures by direct force, such as blows or kicks, are com- monest in the upper half of the leg. Fractures by indirect force, as by falls, are commonest in the lower half of the leg. In fractures from indirect force the tibia breaks first, and then the fibula breaks at a higher level. The point of greatest liability to fracture from indirect force is the junction of the lower and middle thirds. Fractures of the leg are usually oblique, but they may be transverse if arising from direct force. Spiral, torsion, or V-shaped fractures and longitudinal breaks sometimes occur. In oblique fractures, as a rule, the line of fracture runs downward, inward, and a little forward. Symptoms.—Fracture of both bones of the leg is easy of recognition. By running the finger along the crest of the tibia displacement will be found, except in transverse frac- tures, when it may not occur. The common displacement is for the lower fragment to ascend and pass behind the lower end of the upper fragment and to rotate a little out- ward, and for the upper fragment to project in front. This ascent is due to the action of the gastrocnemius and soleus muscles. If the line of fracture is in a direction the reverse of that which is usual, the lower fragment ascends in front of the lower end of the upper fragment. In fracture of both bones there are mobility, crepitus, pain, and inability to walk. In fractures from direct force there is more or less damage DISEASES AND INJURIES OF BONES AND JOINTS. 393 to the soft parts. A fracture near the ankle is distinguished from a dislocation by the fact that the deformity is easily reduced, but it tends to recur in the fracture, and, further, that in a fracture the relations of the malleoli to the tarsus are unaltered. Treatment.—In treating a simple fracture, reduce by ex- tension and counter-extension, and use a fracture-box (PI. 7, Fig. 1) as in Pott's fracture (p. 391), though the compresses are not required. If the soft parts are bruised, use lead-water and laudanum ; if they are lacerated, apply antiseptic dress- ings. The fracture-box may be swung upon a gallows. After three weeks apply plaster-of-Paris or silicate-of-soda dress- ing and let the patient sit up in a chair daily for one week; at the end of this time the patient may get about with crutches. At the end of six weeks after the accident, remove the plaster, and let the sufferer get about with crutches for two weeks and with a cane for two weeks more. Dr. Brin- ton dresses a fracture of both bones of the leg for two weeks in a fracture-box, for two weeks in side-splints, and for two weeks in an immovable dressing. If the fracture is com- pound, asepticize thoroughly, make a counter-opening, insert a drainage-tube, dress with bichloride gauze, apply a plaster bandage, and cut trap-doors over the openings of the tube (see Fig. 47). Remove the tube, as a rule, in about forty- eight hours; but the patient's temperature is a better guide than time. Fractures of the bones of the foot are rather rare acci- dents. Owing to the number of the bones and to the elasticity of their connections, the force of blows and falls is spread and dissipated. Fractures from direct force are often compound. The cause of fracture of either the scaph- oid, the cuboid, or any of the cuneiform bones is direct force. Fractures of the os calcis and astragalus arise, as a rule, from indirect force, such as falls, but the calcaneum 394 A MANUAL OF SURGERY. may be broken by direct violence. In rare instances the os calcis has been broken by contraction of the great calf- muscles. Symptoms.—In fracture of the os calcis there are severe pain, swelling, crepitus, mobility, often an apparent widening of the bone, not unusually a loss of the arch of the foot (Pick). In some cases the posterior fragment is drawn up by the calf-muscles, and in other cases there is deformity. In fracture of the astragalus displacement may occur which resembles that of a dislocation. Crepitus may or may not be detected. If crepitus cannot be found, it is not certain that a fracture is present, though the patient may be unable to stand and there may be swelling and pain on pressure. Fractures of the other bones are hard to detect. There may or may not be crepitus, which, if it exists, is hard to localize; there are pain on standing and on pressure and bruising of the soft parts. Treatment.—To treat a fracture of the os calcis when no deformity exists, use a fracture-box for two weeks ; maintain the foot at a right angle to the leg; apply lead-water and laudanum ; then put on an immovable dressing, and let it be worn for four weeks. In fracture of the os calcis with drawing up of the posterior fragment, flex the leg upon the thigh, extend the foot, and maintain this position by means of a band around the thigh, the band being fastened by means of a cord to a slipper (PI. 9, Fig. 5), the leg resting upon its outer side. At the end of two weeks apply plaster, and let it be worn for four weeks. If the projecting fragment of the os calcis cannot be forced into place, and if it makes dangerous pressure upon the skin, excise it; if it does not make pressure which threatens sloughing, place the joint in a position favorable for ankylosis, and immobilize. In a frac- ture of the astragalus, use a fracture-box and then an im- movable dressing, as in fracture of the os calcis without DISEASES AND INJURIES OF BONES AND JOINTS. 395 deformity. Fractures of the other bones of the tarsus are almost invariably compound, and the injury may require drainage and immovable dressing, excision, or even ampu- tation. Fractures of the metatarsal bones are due to direct force and are almost always compound. Fractures from crushes usually demand excision or amputation. When only one bone is broken displacement is slight, there is severe pain on motion and pressure, and crepitus can gener- ally be obtained. A simple fracture of a metatarsal bone is dressed in a fracture-box for one week and in immovable dressings for three weeks. Fractures of the phalanges of the toes are due to direct force and are often compound. They may require imme- diate amputation. Treatment.—In a compound fracture where amputation is unnecessary, drain with strands of catgut for forty-eight hours and dress antiseptically; at the end of this time apply over the bichloride gauze a gutta-percha or a pasteboard splint extending from beyond the end of the toe to well up upon the sole of the foot, and fix the splint in place with a spiral bandage of the toe and instep. The splint is to be worn for four weeks. In a simple fracture, use a splint of gutta-percha, pasteboard, or binder's board, and let it be worn for three weeks. 3. Diseases of the Joints. Synovitis is an inflammation of the synovial membrane alone. If other structures besides the synovial membrane are involved, the condition is known as " arthritis." Most cases of acute joint-inflammation begin as synovitis. Two forms of synovitis exist—namely, acute and chronic. Acute Synovitis.—The causes of acute synovitis are con- tusions, sprains, twists, exposure to cold or damp, wounds, 396 A MANUAL OF SURGERY infection, and rheumatism. The membrane is red and swollen and the joint contains an excess of turbid fibrinous fluid. If the inflammation advances, arthritis arises and sometimes blood is effused. Symptoms.—The symptoms of acute synovitis are—pain, which is increased by motion of the joint, by pressure upon the articulation, and by a dependent position of the limb, and which is worse at night; a fluctuating swelling is noted, most marked between the ligaments, which swelling bulges out the synovial area and hides or obscures the articular heads of the bones (the patella floats up above the condyles); the skin over the joint is not reddened, but feels hot to the hand of the observer; the joint is partly flexed ; fever exists, varying in degree with the size of the joint, the acuteness of the attack, and the nature of the cause. In septic cases rigors occur, there is a septic temperature, and the joint soon gives evidence of containing pus (periarticular oedema). Traumatic synovitis without infection tends toward cure with- out suppuration if the patient is healthy, and ankylosis is rare. Rheumatic synovitis proceeds to arthritis. Treatment.—In treating acute synovitis, immobilize the joint in the position of rest (semiflexion), apply leeches, use the ice-bag or the Leiter coil, and follow the cold by lead-water and laudanum. After a day or two apply gentle pressure, intermittent heat, and iodine and ichthyol. If the effusion is very great and persistent, and pressure, astringents, and sorbefacients fail, aspirate with antiseptic care. If effu- sion recurs, apply a plaster-of Paris dressing or use flying blisters and massage. Chronic Synovitis.—Chronic synovitis follows acute synovitis or it may be chronic from the start. The syno- vial membrane looks nearly natural, but is cedematous, and the joint contains an excess of fluid. If the quantity of fluid is large, the patella floats up and the disease is called DISEASES AND INJURIES OF BONES AND JOINTS. 397 " hydrops articuli " or " dropsy." In prolonged cases the synovial membrane is thickened in some places, softened in others, and is often adherent, and the villous processes of the synovial membrane are hypertrophied. If the membrane becomes extensively softened (pulpy degeneration), the soft- ened areas bulge and suppuration eventually occurs. Symptoms.—In chronic synovitis pain is absent or is only present through exercise or from pressure, and is slight even then; there is some limitation of movement; passive motion may develop creaking or crepitus; fluctuation is apparent; there is atrophy in the muscles about the joint; and the hypodermatic needle will draw out a viscid, straw-colored or bloody fluid. Treatment.—For hydrops use rest and pressure (a Martin rubber bandage or, better, a plaster dressing), massage, douches, frictions, passive movements, and flying blisters. Painting the joint with iodine and spreading over it blue ointment, and inunctions with ichthyol, may do good. The actual cautery is a valuable expedient. Aspiration and the subsequent use of a plaster-of-Paris bandage may be tried in some cases. Many surgeons advise aspiration, wash- ing out with boiled water, injecting a 5 per cent, solution of carbolic acid, and immobilizing. Incision and drainage is a radical but proper plan. If pulpy degeneration exists, perform an excision or an erasion. If pus forms, incise at once and drain. Internally, treat any existing diathesis and crive eood food, tonics, and stimulants. Arthritis.—By this term is meant not only inflammation of a synovial membrane, but also of other structures com- posing and surrounding a joint. It may follow a traumatic synovitis; it may be due to pus cocci, to tubercle bacilli, to infectious diseases (gonorrhoea and typhoid fever), to rheu- matism, to gout, to syphilis, and to lesions of the spinal cord. Arthritis may be either acute or chronic. 398 A MANUAL OF SURGERY. Tubercular Arthritis (White swelling; Strumous joint; Pulpy degeneration).—Pathology a?id Symptoms.—The ex- citing cause of tubercular arthritis may be strains, blows, twists, or cold. The primary infection with tubercle bacilli is usually in the bone, though it may be in the synovial membrane, the joint-capsule, or the structures about the joint. If the primary infective focus is in the bone, a portion of the cartilage is destroyed and the joint is opened, or a sinus forms and perforates the synovial membrane. When tubercular inflammation attacks the synovial mem- brane granulation tissue is formed, and the capsule and periarticular structures soon become involved in the process; the parts thicken and soften from caseation, and they may be covered with tubercles, though but little fluid is usually effused into the joint. Some few cases present large joint- effusions. In the ordinary form of arthritis there occurs what is known as " gelatiniform degeneration;" the embry- onic tissue is formed in large amount as fungous growths; the structures are markedly cedematous and softened; the relaxed ligaments yield under pressure; the natural contour of the joint is lost, and it becomes spindle-shaped; all the structures, articular and periarticular, are glued into one mass; the skin about the joint is white, thick, and adherent, and in it one or more large veins are seen; fluctuation or pseudo-fluctuation is noted when caseation has occurred; pain is not often severe, but it can usually be elicited by certain motions or by firm pressure (but the pain will always be severe when the epiphysis is involved); the temperature of the part is somewhat elevated; deformity results from destruction of bone, cartilage, and ligament, from muscular spasms, and from the habitual assumption of certain attitudes to secure relief from pain ; there is soon impairment of joint- motions. When the products of a tubercular arthritis caseate, the thick liquid seeks exit by forming sinuses from which DISEASES AND INJURIES OF BONES AND JOINTS. 399 caseous pus runs. If a sinus becomes infected with pyo- genic cocci, and the joint itself becomes their prey, acute suppuration arises in the joint, and constitutional involvement is pronounced and perilous to life. In pannous synovitis a large effusion is formed, there is but little granulation tissue, though the tubercles are present in large numbers, and the ligaments and structures about the joint are slightly or not at all implicated. The diagnosis early in a case is difficult, often impossible, and the prognosis is grave. In only a very few cases, even when recognized early, is a cure obtained without impairment of joint-function. The best that can usually be accomplished is a cure with more or less ankylosis, fibrous or bony; but often ankylosis is complete. Long after the disease is apparently cured, it may break forth anew. Tubercular lesions may arise in a distant organ, or general tuberculosis may occur. Caseation is apt to produce severe constitutional disorder. Infection by pus organisms gives rise to grave danger of septicaemia. Death is not unusual from exhaustion, from septicaemia, from disseminated tuberculosis, from tubercle in an import- ant organ, or from amyloid disease. Treatment.—Constitutionally, the treatment is directed against the tubercular diathesis. Locally, rest is of the first importance, and it is maintained for many weeks, it being obtained by splints, by a plaster-of-Paris bandage, or by extension appliances. Aspiration can be used for fluid accumulations. Caseous masses are often let alone, or an aspirator is used and the joint drained, washed out with boiled water, and injected with an emulsion of iodoform and glycerin (10 per cent.). Injections of balsam of Peru or of iodoform emulsion about the joint once a week are efficient in some cases. If these means fail, if the patient gets worse, or if the condition of the sufferer renders dangerous the pro- longed conservative course, then operate, removing the 400 A MANUAL OF SURGERY. entire diseased area by erasion, by excision, or by ampu- tation. Always remember that an incomplete operation, a partial removal, is worse than no operation, as it opens the portals to systemic infection, and may be responsible for a general tuberculosis, septicaemia, or pyaemia. Tuberculosis of Special Joints.—Tuberculosis of the hip-joint (hip disease; morbus coxarius; morbus coxae; hip-joint disease) usually begins in the epiphysis. It is com- monest in children, but it may arise in adults. Traumatism and cold may be exciting causes. Symptoms.—In tuberculosis of the hip-joint there are three stages: (i) the stage of microbic deposition and multiplication, the products of the bacilli causing irritation and new growth; (2) the stage of progression, with forma- tion of embryonic-tissue masses and effusion into the joint; and (3) the stage of caseation, with destruction of the joint and often of the structures about it. The symptoms of the first stage are slight and may be overlooked entirely. In a child there are night-terrors; on getting about in the morning the child shows some lameness, which wears off during the day, and it soon grows tired while playing and lies down to rest. There may be a slight limp ; a slight adductor spasm may often be noted; some pain may occur in the hip on tapping the sole of the foot while the patient is recumbent with the leg extended; pain may be complained of at night in the hip, in the front of the thigh, or at the inside of the knee. The diagnosis in this stage is more or less problematical. In the second stage, or the stage of apparent lengthening, the symptoms are positive. The child limps ; the adductor muscles are rigid; the hip is broadened by an effusion in the joint, and fluctuation may possibly be detected; the thigh-muscles are atrophied; the extremity is pushed for- ward, abducted, and everted (the patient tilts the pelvis so as HIP-JOINT DISEASE. Plate 9. 1 2. Effects on the Lumbar Spine of Flexing and Extending the Diseased Leg in Hip Disease (Albert). 3,4. Positions in Coxalgia (Albert). 5. Strap-and-slipper Apparatus for Fracture of Pos- terior Portion of the Calcaneum (after Hamilton). 6. Extension in Hip Disease (Treves). 7. Exten- sion of the Limb in a Flexed and Adducted Position (Treves). 8. Extension of the Limb in a Flexed and Abducted Joint (Treves). DISEASES AND INJURIES OF BONES AND JOINTS. 40I to rest his weight on the sound limb); the thigh is some- what flexed; in very rare instances adduction is present; pain exists, often sudden or starting, and is located in the joint, on the front of the thigh, and to the inner side of the knee in the course of the obturator nerve; the pain is aggravated at night; and full extension and complete abduc- tion are not possible. The gluteal muscles waste, and the gluteal crease is on a lower level than is that of the sound side. Jarring of the heel when the extremity is in extension causes pain in the hip. The above symptoms arise chiefly from joint-effusion, reflex irritation, and involuntary or spas- modic muscular contractions. Lengthening in the second stage is apparent, not real, but this stage is spoken of as the " stage of lengthening." The position is shown on Plate 9 (Fig. 4). The fluid effusion may be absorbed or may find its way externally by means of sinuses. The latter condi- tion is known as " abscess of the hip." The absorption of the exudate or the rupture of the capsule permits the con- tracting muscles to bring the head of the femur into firm contact with the acetabulum or its brim; the bones are worn away and destroyed, shortening results, abduction and flexion are increased, and the third stage is established. In the third stage the head of the femur goes upward and outward upon the rim of the acetabulum, the thigh is flexed and fixed, and attempts at extension when the patient is recumbent cause the pelvis to tilt forward and occasion a marked lumbar curve (PI. 9, Fig. 3), which is due to the pelvis moving with the femur as if ankylosed, and which disappears on flexion. In the third stage adduction occurs because of the ascent and movement outward of the head of the bone. Shortening is marked. After a hip-abscess finds an external outlet pyogenic infection is very apt to take place and inflammation is liable to arise, followed by that state which is designated as " hectic." If a cure follows 2ti 402 A MANUAL OF SURGERY. the third stage, partial or complete ankylosis takes place; if death ensues, it may be due to septicaemia, tuberculosis of the viscera, exhaustion, or amyloid degeneration. Diagnosis is very easy in well-established cases of hip dis- ease, but very difficult when the disease is incipient. Always make a systematic and thorough examination. Undress the patient and place him recumbent upon a table or a hard mattress, with the legs extended, and note if the heels are level and if the iliac spines are on the same level (depressed spine on the affected side means abducted extremity, the degree of which is determined by carrying the limb out until the spines are horizontal; elevation of the iliac spine on the affected side means adduction, the amount of which is deter- Fig. 60.—Positions in Hip-joint Disease (after the plan of Howard Marsh and Treves). A.—e f lumbar spine ; b d, limb fixed in flexion and abduction—useless for walking, b.—e f, lumbar spine. Patient corrects the condition in Figure a by curving the lumbar spine for- ward and rotating the pelvis on its transverse axis, thus making the femur point downward. The lumbar spine is curved laterally, the pelvis ascending on the sound side and descending on the affected side (apparent lengthening), c.—b d, limb fixed in flexion and adduction. D.—e f, curve of lumbar spine to correct condition in Figure c (apparent shortening). mined by adducting the limb until the spines are horizontal; Fig. 60); try all the movements belonging to the joint, to detect any limitations; try if bringing down the knee pro- duces lordosis (PL 9, Figs. 1, 2); look for swelling and for muscular wasting; feel if the head of the bone is enlarged; observe if motion produces pain or if pressure causes tender- ness ; and always carefully elicit the history of the attack, of the person, and of the family. DISEASES AND INJURIES OF BONES AND JOINTS. 403 Hip disease may be confounded with spinal caries in which a psoas or a lumbar abscess has formed, with sacro-iliac disease, with infantile paralysis, with congenital dislocation, with lordosis from rickets, and with gluteal abscess. In hip disease there is always some lameness; pain may be severe or may be absent entirely, and may be in the hip or be referred to the front of the thigh or to the inner side of the knee. Always remember that the pain is not characteristic, and that pain in the same localities may arise from aneurysm of the femoral or iliac arteries, from abscess in Scarpa's triangle, from caries of the lumbar vertebrae, from sacro-iliac disease, and from cancer of the rectum. Altered position of the limb, limitation of movement in the hip-joint, muscular wasting, and swelling soon arise in hip-joint disease. In disease of the sacro-iliac joint, examination shows that the movements of the hip-joint are unlimited and produce no pain, and that pain is developed by pressure over the sacro-iliac articulation and by pressing the ilia together. In infantile paralysis there is no pain, but paralysis with great muscular atrophy, which comes on with considerable rapidity. In spinal caries with psoas abscess the evidences of disease of the vertebr.e are clear and the pus is located in the groin external to the femoral vessels. The pus of hip-abscess generally gathers under the tensor vaginae femoris muscle, but it may reach Scarpa's triangle by pass- ing through the cotyloid notch or through the bursa under the psoas muscle; it may appear under the glutei. Matter from a caseating acetabulum may reach the inside of the pelvis and appear above Poupart's ligament. Prognosis.—If the case of hip disease is seen early, the chances of cure are excellent in children, in whom the dis- ease may be arrested at any stage. The longer the duration of the disease and the older the subject, the more unfavor- able is the prognosis. The cure takes many months, and 404 A MANUAL OF SURGERY. advanced cases only get well by means of ankylosis with shortening and deformity. Hip disease may recur years after apparent cure, and a person who has had hip disease runs a strong chance of developing visceral tuberculosis. Complications.—The complications that may accompany hip disease are the following: Abscess, as above noted. Tuberculous meningitis, or the condition known as " acute hydrocephalus," or water on the brain, may arise during the progress of the case or after apparent cure, and is apt to ensue upon incomplete operations. It is almost inevitably fatal. Amyloid, lardaceous, or ivaxy degeneration of viscera, which condition follows upon profuse and long-continued suppura- tions, and which is apt to arise in the liver, spleen, kidneys, or intestinal mucous membrane. Tuberculosis is not the only cause, syphilis being responsible for at least thirty per cent. of all cases. In amyloid disease of the liver this organ is much enlarged, smooth, painless, and of increased consist- ency, there is no jaundice, the spleen is apt to be enlarged, and albuminuria is the rule. In amyloid kidney large amounts of pale urine of low specific gravity are voided; albumin is usually present in large amount, but may be absent; globulin may often be found, as may also hyaline, fatty, or granular casts; the patient is anaemic, and dropsy usually exists. Test the hyaline casts with iodine for amyl- oid material. Amyloid changes are usually slow in onset, but they may be rapid; they are commoner in men than in women, and are most frequently encountered in individuals between the ages of ten and thirty. Slight amyloid change may be recovered from, but an extensive degeneration brings about a fatal result. Dr. Dickson's famous theory of how this tissue-change is caused is that the flow of pus drains off from the body the alkaline salts, especially the salts of potassium, which drainage results in visceral depositions of de-alkalinized fibrin. Phthisis pulmonalis is a rare compli- DISEASES AND INJURIES OF BONES AND JOINTS. 405 cation, but is a common sequence, often arising, sooner or later, after the hip disease is cured. Treatment.—-In the early stage of hip disease the treat- ment consists of rest. Place the patient upon a solid mat- tress and apply extension. In children under ten years of age, use a weight of from three to five pounds; in children between ten and twenty, use a weight of from five to eight pounds. A long splint is often applied to the sound side to keep the patient recumbent and horizontal. Apply the exten- sion in the long axis of the limb, the extremity being placed in the line of the deformity due to disease and being supported by pillows. In lordosis from thigh-flexion, raise the limb until the iliac spine is straight (PL 9, Fig. 6). If the spine is depressed on the affected side, abduct the limb (PL 9, Fig. 7); if the spine is elevated, adduct the limb until the spines are horizontal (PL 9, Fig. 8). The object in taking these precau- tions is to enable the extension to separate the femoral head and the acetabulum. Extension will remove flexion in two weeks in a recent case and in the course of some months in an older case. As flexion is relieved remove the pillows and lower the leg so as to keep up extension in the long axis of the thigh. Abduction and adduction cannot be removed by extension. Always use a cradle to hold up the bed- clothing. Abduction demands no special treatment. In a movable joint it will disappear, and in an ankylosed joint it is an ad- vantage, compensating by apparent lengthening for the short- ening due to bone-absorption or to stunted growth of the limb. Adduction requires an addition of several pounds to the ex- tension weight, the use of a long splint on the sound limb, and the drawing up of the sound limb by a rope and pulley toward the head of the bed. The weight used to pull the sound side toward the head of the bed is equal to that used to pull the damaged side to the foot of the bed. This expedient is 406 A MANUAL OF SURGERY. used for a month or six weeks. In old cases where the weight will not bring about extension, anaesthetize the patient, gently straighten the limb a very little, and re- apply the weight. Thomas's splint is used by many, and it may be combined with weight extension (Fig. 61); or Sayre's splint (Fig. 62) may be em- ployed. Wyeth's apparatus (Fig. 63) is a favorite with many American surgeons. Extension in a mild case must be continued for three months after the symptoms have disappeared, and in a severe case the period must be six months. The weight is gradually taken off; if symptoms recur, the weight is reapplied; if they do not recur, apply a traction splint or a plaster dressing, put a high-heeled boot on the sound limb, and send the patient out on crutches. In young children Fig. 61.—Thomas's Posterior extension can be made in a wheeled carriage, thus enabling the patient to go out in the fresh air and sunlight. The general treat- ment is tonic and restorative. If an abscess forms, incise it with the most thorough anti- septic care, let the fluid drain away, wash out with corrosive- sublimate solution and then with boiled water, inject with iodoform emulsion, insert a tube, and dress antiseptically. The old plan of not operating until rupture was seen to be inevitable was bad. To open early and antiseptically often means rapid healing, the prevention of burrowing, a lessened danger of visceral infection, and an earlier cure. Hectic will not arise if the abscess is opened with antiseptic care. Excision of the hip is to be performed when the head of DISEASES AND INJURIES OF BONES AND JOINTS. 407 the femur is detached and lies loose in the joint; when pro- fuse suppuration continues for a long time, and other methods fail to arrest it; when amyloid disease is beginning; or when very faulty position is inevitable without operation. Excision is an operation of considerable danger, and the older the person the greater the danger. When there is extensive Fig. 62.—Sayre's Long Splint. Fig. 63.—Wyeth's Combination Method. disease of the femur, when excision has been tried and has failed, and when the patient has not the recuperative power to stand the long siege following excision, amputate.1 Knee-joint Disease (White swelling).—After the hip, the knee is, of all joints, the commonest site for tuberculous dis- ease. Knee-joint disease begins as a synovitis, or oftener as 1 See the admirable article of Howard Marsh in Treves's Manual. 408 A MANUAL OF SURGERY. an inflammation of the femoral or the tibial epiphysis. If an acute synovitis ushers in the case, there may be large effusion into the knee-joint and partial flexion. Swelling is usually slight in knee-joint disease. Pulpy degeneration of the synovial membrane occurs; the joint enlarges; the liga- ments soften; the skin is cedematous; muscular spasm is marked; the leg is flexed; the bones are displaced back- ward and outward, the foot being everted; lameness exists, due chiefly to deformity; pain may be absent, is often slight, and is rarely severe. When the disease begins in the bone or an epiphysis there are pain, tenderness, lameness, swelling, inability to ex- tend the limb completely, sudden spasmodic muscu- lar contractions, and final involvement of the joint. When an abscess forms, it may destroy the joint very rapidly or it may break ex- ternally. Treatment.—In treating Fig. 64.-Sayre's Fig. 6S.-Hutchinson's kliee-joint disease, emploV Knee-splint Applied. Knee-joint Splint. general antitubercular treat- ment. Apply splints (Figs. 64, 65), extension (Fig. 66), or a plaster-of-Paris bandage, and keep the patient in bed for a few weeks; then permit him to go out with crutches, with a high-heeled shoe upon the sound foot. In cases in which treatment was begun early the disease can often be arrested in from eight to twelve months. If the symptoms do not abate after a number of weeks, or if the condition grows worse and an abscess arises, aspirate, and inject iodoform emulsion. If these means fail, DISEASES AND INJURIES OF BONES AND JOINTS. 409 open the joint and perform an excision or an erasion. Some cases demand amputation, which, if the patient's health is much impaired, is to be preferred to excision. Ankle-joint disease begins usually as a chronic synovitis, but it may arise in the tibial epiphysis. The symptoms are Fig. 66.—Sayre's Double Extension of the Knee-joint (Tiemann). pain, swelling, lameness, limitation of joint-movements, and atrophy of the calf-muscles. Suppuration often occurs, and sinuses form. Treatment.—The treatment of ankle-joint disease consists .in the employment of antitubercular remedies, and of rest by means of splints or plaster. Caution the patient to avoid standing upon the diseased extremity. When suppuration occurs, open, drain, wash out with corrosive-sublimate solu- tion and with iodoform emulsion, and put up the ankle-joint in plaster. When joint-disorganization occurs, perform an excision or an erasion. Some cases demand amputation (Syme's amputation being preferred by some, amputation above the ankle being approved by many). Osteoplastic resection is sometimes advised (Wladimiroff-Mikulicz opera- tion). Shoulder-joint disease, which is rare in children and is commonest in adults, begins either in the synovial mem- brane or in the epiphysis. Pain is slight, atrophy of the 410 A MANUAL OF SURGERY. deltoid and other muscles is noted, the joint is stiff, and the scapula follows the motions of the humerus. Suppuration is rare. Treatment.—In treating shoulder-joint disease, employ antitubercular remedies and iodoform ointment. Put on a shoulder-cap, apply the second roller of Desault, and hang the hand in a sling. Maintain rest for at least four months. If an abscess forms, open and drain it. In rare instances dead bone will have to be gouged away. Caries sicca may occur. Excision is sometimes required. Elbow-joint disease may begin in the humerus or the ulna. The joint is swollen, its movements are somewhat limited, the skin is usually hot, muscular wasting is pro- nounced, and pain is generally slight. Pus may form. Treatment.—In treating elbow-joint disease, employ anti- tubercular foods, drugs, and hygienic measures ; iodoform ointment locally; rest by means of an anterior angular splint (Fig. 67) and a triangular sling. If matter forms, open the —\ Fig. 67.—Stromeyer's Anterior Angular Splint. joint and drain. Splints are to be worn for from four months to a year. If any considerable area becomes carious, perform an erasion or an excision. Wrist-joint disease may arise at any age. The joint presents a puffy swelling, loses its normal contour, and becomes spindle-shaped. Hand-movements are impaired, pronation and supination cannot completely or satisfactorily DISEASES AND INJURIES OF BONES AND JOINTS. 411 be performed, the joint is stiff and partly flexed, the grasp is enfeebled, pain may be severe or slight, the skin is usually hot, and muscular atrophy is marked. Treatment.—The essential treatment in wrist-joint disease comprises cod-liver oil, tonics, good food and fresh air, and iodoform ointment locally. Apply a Bond splint and sling or put on a plaster bandage, and maintain rigid rest for from four to six months. Suppuration demands incision and drainage with the maintenance of rest. A moderate amount of caries is treated by drainage and rest. Necrosis demands removal of the sequestra. Extensive caries requires excision. Septic Arthritis.—This infection is usually due to the staphylococcus pyogenes aureus or to the streptococcus pyogenes which find entrance by means of a wound, by the spontaneous evacuation into a joint of the products of an osteomyelitis, by extension of suppurative inflammation through contiguous structures, or by the blood-stream, as in pyaemia and other conditions. Symptoms.—The symptoms of septic arthritis are—severe pain, which is aggravated by motion and is worse at night; discoloration, heat, and cedema of the skin; partial flexion of the joint; fluctuation; and marked constitutional symp- toms of sepsis. The joint tends to rapid disorganization, and fatal septicaemia is very apt to occur. In pyaemic arthri- tis several joints become infected. Treatment.—The treatment in septic arthritis consists in prompt incision, evacuation, antiseptic irrigation, drainage, antiseptic dressing, and immobilization. Cure is followed, as a rule, by ankylosis, but in cases treated early the joint may be preserved. Infective arthritis arises in the course of an acute infec- tious disease (such as erysipelas, typhoid fever, measles, scarlatina, variola), and may be due to pyogenic cocci or to the specific micro-organism of the acute infectious disease. 412 A MANUAL OF SURGERY. Joint-inflammation arising in the course, or as a sequel, of an acute infectious disease may or may not suppurate. Symptoms and Treatment.—If no suppuration takes place, the symptoms of the attack resemble those of rheumatism; if suppuration occurs, the symptoms are identical with those of septic arthritis. The treatment in a non-suppurative case is the same as in ordinary synovitis (p. 395). In a suppurative case, treat as in septic arthritis (p. 411). Gonorrhoeal Arthritis, or Gonorrhoeal Rheumatism.— During the progress of gonorrhoea every rheumatic attack is not gonorrhoeal rheumatism, for ordinary rheumatism may just as likely arise when a man has clap as when he has not this malady. Furthermore, the term is bad, as gonorrhoeal rheumatism is not rheumatism at all, but is a septic or an infective disorder of the joints or of the synovial membranes, the infective material being contained primarily in the urethral discharge. This infective arthritis sometimes, though rarely, arises during the height of a gonorrhoea, but is more fre- quently met with in chronic cases or when the intensity of the inflammation is abating in acute cases. Men suffer from gonorrhoeal rheumatism far more frequently than do women, and the seizure is very apt to recur again and again. In some cases many joints are involved, but in most cases only a few joints suffer. Osier states that the knees and ankles are most apt to be involved in a gonorrhoeal rheumatism, and that this form of arthritis is peculiar in often attacking joints which are apt to be exempt in acute rheumatism (" the sterno-clavicular, the intervertebral, the temporo-maxillary, and the sacro-iliac "). Changes in and about the Joint.—The inflammation of gonorrhoeal arthritis may be located around rather than in the joint, and especially in the tendon-sheaths. Suppuration is unusual, but it does occur in joints and in tendon- sheaths. Cultivation of the exudate may or may not show DISEASES AND INJURIES OF BONES AND JOINTS. 413 the gonococci. These organisms die quickly in cultivations, and it requires a most expert bacteriologist to deny or affirm positively their presence. Osier suggests that the non-sup- purative cases are due to the action of ptomaines taken up from the area of primary infection, and that the suppurative cases are due to infection with pus cocci. Symptoms.—In gonorrhoeal arthritis there may be transi- tory, intermittent, and wandering pains in and about the joint, without any other symptom; one or more joints may become swollen and painful, and moderate fever may develop. An acute inflammation with intense pain and great swelling may attack a single joint, in which case fever will be mod- erate unless suppuration follows. One joint, especially the knee, may swell up to an enormous extent, pain, periarticular oedema, redness, and fever being absent (hydrarthrosis, or dropsy of a joint). Suppuration in this form is rare. The tendons, the tendon-sheaths, the bursae, and the periosteum may inflame. A case of gonorrhoeal rheumatism is often very hard to check. It may last for long periods, and tends to recur again and again. Iritis, pleuritis, endocarditis, and pericarditis have been observed as complications. The diagnosis between gonorrhoeal rheumatism and acute rheumatism rests chiefly on the great chronicity, the slight degree of fever, the excessive tendency to recurrence, and the absence of profuse acid sweats in gonorrhoeal rheuma- tism ; and on the shorter course, the higher fever, the pro- fuse acid sweats, the lesser tendency to rapid recurrence, the greater proneness to symmetrical involvement, and the greater frequency of cardiac and visceral complications in rheumatic fever. Furthermore, in gonorrhoeal rheumatism a urethral discharge certainly exists or recently existed; in ordinary rheumatism a urethral discharge may, of course, happen to be present. Gonorrhoeal rheumatism is apt to affect certain joints which acute rheumatism rarely attacks. 414 A MANUAL OF SURGERY. Treatment.—Internally, in treating gonorrhoeal rheuma- tism, the salicylates, the alkalies, salol, and iodide of potas- sium are useless; iron, arsenic, strychnine, and quinine are of some benefit. In suppurative cases, incise and drain (see Septic Arthritis, p. 411). In non-suppurative cases, treat as in synovitis (p. 395). In lingering cases, employ massage, passive motion, flying blisters, and the hot iron; if these means fail, open the joint, wash it out with some antiseptic fluid, and dress antiseptically (or aspirate and inject). Rheumatic Arthritis.—Acute rheumatism is a self-limited febrile malady whose characteristic features are polyarthritis, profuse acid sweats, and a tendency to heart-involvement. Symptoms of Acute Rheumatism.—In acute rheumatism the case begins with malaise and fever, and one or more joints become affected. The inflammation spreads from joint to joint, is apt to be symmetrical, and when it arises in fresh joints it is apt to disappear quickly in those previously affected. The temperature is high, the skin sweats profusely, the joints are red, swollen, hot, and excruciatingly painful, and the structures about the joint are cedematous. After a short time the inflammation subsides in one joint and passes into another, the joint first attacked regaining its functions. Suppuration does not take place. Anaemia is pronounced, exhaustion is profound, the sweat is sour, the saliva is acid, the urine is acid, scanty, high-colored, often contains albumin, and is deficient in chlorides. Cardiac disease is apt to be caused (endocarditis, pericarditis, or myocarditis). Nodules may form upon fibrous structures, hyperpyrexia is not unu- sual, and cerebral or pulmonary complications may occur. Chronic rheumatism rarely follows repeated attacks of acute rheumatism, but arises insidiously in people who have been exposed to cold and damp, who have suffered from poverty, hardship, and privation, or who have had much worry. The capsule and the tendon-sheaths thicken, and there is usually DISEASES AND INJURIES OF BONES AND JOINTS. 415 but little effusion in the joint, but the articulation becomes stiff and painful. The joint-cartilages are occasionally eroded. Muscular atrophy occurs. Symptoms of Chronic Rheumatism.—Chronic rheumatism is indicated when the affected joints are stiff and painful and are a little swollen, but not red. Dampness and cold aggra- vate the symptoms. One joint or many may be affected, but usually many are involved. Passive movements cause the joint to creak and develop crepitus in the tendon-sheaths. The muscles are wasted. The joint may ankylose. Anaemia is usually pronounced. There is no fever and no tendency to suppuration, and the disease is incurable. The treatment in acute rheumatism comprises the use of alkalies, salicylates, etc. (See a book upon medicine, as acute rheumatism is in the physician's province.) In chronic rheumatism, maintain the general health of the patient, give courses of iron, arsenic, and strychnine, and an occasional course of iodide of potassium or a salt of lithium, and, if possible, send him every winter to a warm climate. Turkish baths give the greatest possible relief. The waters and regimen of Carlsbad and Vichy are of immense though temporary benefit. The patient will obtain relief at the hot springs of Virginia. The patient must avoid damp and must wear woollens. Frictions, the douche, massage, flying blisters, counter-irritation with the hot iron, ichthyol oint- ment, and mercurial ointment are of benefit. In partial ankylosis, give ether and break up the adhesions. Gouty arthritis, which appears especially in the smaller joints (as the fingers and the metatarso-phalangeal joint of the big toe), is due to a deposition of urate of sodium in the joint and in the periarticular structures. This irritant urate of sodium causes inflammation, inflammation forms embry- onic tissue, embryonic tissue is converted into fibrous tissue, and the fibrous tissue contracts and thus deforms the joint 416 A MANUAL OF SURGERY. and limits its mobility. A great mass of urates in a joint constitutes a " chalk-stone." Symptoms.—The premonitory symptoms may be observed for a day or so, but the acute seizure occurs early in the morning, the patient, as a rule, being aroused by excruciat- ing pain in the metatarso-phalangeal articulation of the great toe. The joint swells, and the skin over it feels hot to the hand and becomes shiny. There is considerable fever. After a few hours the ferocity of the seizure abates, recurring again with renewed violence early the next morning, these remissions and recurrences taking place for six or eight days, when the attack subsides. In patients with chronic gout many joints are stiffened and deformed as a result of repeated attacks. Chalk-stones form, and the skin above them may ulcerate. Such patients are chronic dyspeptics, have high-tension pulses, their hearts are hypertrophied, and their urine contains albumin and casts. The treatment of gouty arthritis belongs to the physician, and not to the surgeon, although to the latter the disease should be known, so that it can be diagnosticated from other maladies. Arthritis Deformans (Rheumatoid arthritis; Osteoar- thritis ; Rheumatic gout).—In this disease, which is not a combination of gout and rheumatism, the synovial mem- brane is affected, the cartilages are diseased, the periarticular structures are involved, and masses of new bone are formed. Arthritis deformans has, as Prof. John K. Mitchell pointed out, a probable nervous origin. It arises especially in per- sons who have been worried, driven, and harassed. There is apt to be muscular atrophy; trophic lesions of the hair and nails are likely to occur, and the symptoms are dis- posed to be symmetrical. The causative lesion has not been determined. Rheumatic gout is commoner in women than in men. The greatest liability exists between the ages of DISEASES AND INJURIES OF BONES AND JOINTS. 417 twenty and thirty, but children may acquire the disease, and it may also be developed in people beyond middle life. Arthritis deformans may attack the rich or the poor; it does not result from gout nor follow rheumatism, it is not caused by damp and cold, and it does not arise from traumatism. Apes in captivity may develop it. Arthritis deformans differs from gout in the entire absence of urate deposit, and it differs from chronic rheumatism in the extensive alterations in the joint-structures. The changes begin in the cartilage; the cartilage-cells multiply, the inter- cellular substance degenerates, the pressure of the bone causes thinning, and at length the cartilage is entirely destroyed and the bone is exposed. The exposed bone is altered in shape, is hardened, and is worn away in the centre, the periphery increasing in thickness by ossific deposit; thus the centre becomes deepened by absorption and the periphery bulged and lengthened by deposit. The fringes of the syno- vial membrane hypertrophy and multiply, and some of them are apt to break off (loose cartilages). The capsule and the ligaments of the joint, as a rule, become fibrous and con- tract, but they may soften, relax, and permit of dislocation. The joint usually contains no effusion, but in some cases there is great effusion (hydrarthrosis). The tendons about the joint may become fibrous and contracted, they may ossify, they may be separated from the bone, or they may be destroyed entirely. Deformity is marked and motion is limited. The fingers, when involved, show nodules on the sides of the joints (Heberden's nodules). The vertebrae may be involved. Almost all the joints may suffer. Sup- puration does not occur. Symptoms.—Charcot classifies arthritis deformans into three forms, and gives their symptoms as follows : (1) Heberden's nodosities, which condition is commoner in women than in men, comes on between the ages of thirty 418 A MANUAL OF SURGERY. and forty, and is especially common in neurotic subjects. The interphalangeal joints become the victims of attacks of moderate swelling and of some tenderness, which attacks are not severe, but recur again and again. After a time small hard swellings (nodosities) appear upon the sides of the dorsal surfaces of the second and third phalanges, re- main permanently, and slowly increase in size. The joints become stiff and creak on movement, the cartilage is de- stroyed, and contractions and rigidity develop, but there is no fever and the larger joints are not involved. The malady is incurable. (2) Progressive rheumatic gout, which may be acute or chronic. The acute form begins as does rheumatic fever. There are moderate fever, and swelling, but no redness, of a number of joints, of bursas, and of tendon-sheaths; the joints are stiff and crepitate, and are apt to be symmetrically in- volved ; muscular atrophy begins early and rapidly becomes decided; pain is slight. This acute form is apt to arise in young women after pregnancy, but is not unusual at the climacteric and in children. Anaemia always exists. The case is apt to advance progressively until a number of joints are firmly locked, when it may become stationary. A fresh pregnancy will develop anew the acute symptoms. In the chronic form swelling and pain on movement are noted in certain joints. The involvement is apt to be symmetrical. Attacks of swelling and pain alternate with periods of quies- cence, but the disease does not cease its advance. Articu- lation after articulation is attacked by the malady until almost all the joints are involved; deformity and stiffness become pronounced, and pain may or may not be severe. There is no fever. Muscular atrophy is marked. (3) Partial rheumatic gout attacks one articulation, and it is most often met with in old men. It may fix itself on the vertebral column, on the knee, on the shoulder, on the DISEASES AND INJURIES OF BONES AND JOINTS. 419 elbow, or on the hip. The joint grates and becomes stiff, swollen, and deformed; the muscles atrophy; there is usually pain, but fever is absent. Partial rheumatic gout of the hip-joint in an old person is known as " morbus coxae senilis," and partial rheumatic gout of the vertebral articu- lations causing fixation is called " spondylitis deformans." Treatment.—Rheumatic gout cannot be cured, but in some cases it remains stationary for many years. Treat the anaemia by iron, arsenic, good food, and fresh air. Debility is met by strychnia. Hot baths of mineral water do good. Massage retards the progress of the case, relieves the pain, helps the absorption of the effusion, and delays fixation. During an acute exacerbation the joint should be put at rest for a day or two, and there should be used lead-water and laudanum, cold water, or tincture of arnica. Douches and hot baths improve these cases, but electricity is entirely useless. Counter-irritants do no good. The patient is unfortunately liable to develop the opium habit. In dropsy of a joint, if it arises, try compression with a Martin bandage, and if this fails, aspirate and inject carbolic acid. Patients with rheu- matic gout do best in a warm dry climate. Cod-liver oil does good, as it improves nutrition and hence retards the progress of the disease. Do not be tempted to immobilize the joints beyond a day or two: fixation only hastens ankylosis. Charcot's Disease (Tabetic arthropathy; Charcot's joint; Neuropathic arthritis).—This condition is an osteo-arthritis due to trophic disturbance, arising in a sufferer from loco- motor ataxia, and is anatomically identical with rheumatic gout. The knee is most apt to be attacked. The disease begins acutely, often as a sudden effusion which after a time disap- pears. Pain is slight or is absent, there is no constitutional involvement, and the condition is unconnected with injury. The bones and cartilages are rapidly destroyed; fracture is 420 A MANUAL OF SURGERY. apt to occur; the joint creaks and grates; the softening and relaxation of ligaments permit an extensive range of move- ment ; great deformity ensues; dislocation is apt to occur; muscular atrophy is decided ; and pus occasionally, though very rarely, forms. Treatment.—The treatment of Charcot's disease consists in the wearing of an apparatus to sustain the joint. Re- section is recommended by some, but most surgeons do not advise its performance. Hysterical joint (Brodie's joint) is a condition mostly encountered in young women. The disease occurs in the knee and the hip, and often follows a slight injury which acts as an auto-suggestion, a latent hysteria being awakened into action and localized, though severity of the injury does not determine the severity of the symptoms. The disease may ensue upon an arthritis or may arise without apparent cause. The patient resists passive motion strenuously and claims that it causes much pain. There is occasionally some mus- cular atrophy from want of use, and the joint is a little swollen. The skin is hyperaesthetic, and a light, touch causes more pain than does deep pressure. The muscles may be rigid. The joint may be maintained either in flexion or in extension, but it is rarely in the exact degree of flexion assumed for ease in a true joint-inflammation, and the position is apt to be changed from day to day or from hour to hour. The skin is usually cool, but may be hot, and a periodically developed heat may be observed, especially at night, accom- panied apparently by much pain. The pain in some cases is a neuralgia, but in most cases is a pain hallucination. In some rare cases organic disease arises in a hysterical joint. Hysterical phenomena are seldom isolated, but are asso- ciated with certain stigmata which may be latent. These stigmata are concentric contraction of the visual fields, pharyngeal anaesthesia, convulsions, hysterogenic zones, DISEASES AND INJURIES OF BONES AND JOINTS. 421 globus hystericus, clavus hystericus, zones of anaesthesia, especially hemianaesthesia and hyperaesthetic areas. Such patients are predisposed by inheritance, and have previously, as a rule, had nervous troubles. Hysterical phenomena, be it remembered, lack regularity of evolution, and are pro- duced, altered, or abolished by mental influences and physi- cal sensations which are without effect in causing, modifying, or curing organic disease. The general health, as a rule, is good, but neurasthenia may coexist. In examining these patients the observer will note that the symptoms disappear when the attention is diverted, that they are out of all proportion to the local evidences of the disease, that there is no evidence of joint-destruction, and that light touching causes more pain than does firm pressure. If the patient is anaesthetized, perfect joint-mobility will be found. Treatment.—The treatment in hysterical joints comprises attention to the general health, the employment of nourishing and easily-digested food, the prevention of constipation, and the administration of tonics if they are needed. The sur- geon must dominate his patient's mind and make her realize that he is master of the case. He is to be an inexorable but just ruler—never a brutal or a cruel one. If possible, send the patient away from the sympathies of her home and let her have the rest treatment of Weir Mitchell. Local rem- edies applied to the joint do harm, as a rule, by concentrating afresh the patient's attention upon the articulation, although the hot iron sometimes does good. Suggestion in the hyp- notic state may be tried. The use of morphia should be avoided as being the worst of enemies. Never immobilize the joint, and always use massage, passive motions, and frictions. Neuralgia of the joints as an independent, isolated affec- tion is extremely rare, though as a complication of other dis- eases it is by no means uncommon. The neuralgia is more 422 A MANUAL OF SURGERY. often around the joints than in them, and is especially frequent in the knee and the ankle. Joint-neuralgia may arise in any person, but it is more commonly present in young neurotic females. The pain may be persistent or it may occur in periodic storms, and it is often linked with neuralgia in other parts. The pain may be dull and aching, but it is more often sharp and shooting. Joint-neuralgia is associated with tenderness on pressure, soreness on motion, often with transitory swelling without redness, and sometimes with numbness of the extremity. The diagnosis depends on the temperament of the patient, the sudden onset of the pain, the absence of constitutional symptoms, and the free mobility of the joint, especially under ether. Articular neuralgia may depend upon disease or injury of the central nervous system, upon malaria, syphilis, neurasthenia, rheumatism, gout, hysteria, and neuritis, and may be due to reflected irritation, especially from the ovaries, the womb, and the rectum. Treatment.—The treatment to be observed in joint-neural- gia is to maintain the general health ; examine for a possible exciting cause, and, if found, remove it; give a long course of iron, quinine, and strychnine or of arsenic. In rheumatic or gouty subjects give suitable drugs and insist upon proper diet. During the attack use phenacetin. Morphia must occasionally be used in severe cases, but be careful of it, and never tell the patients they are taking it, as there is a liability of their forming the opium habit. Locally, employ frictions, ointment of aconite, and heat, and keep upon the part a piece of flannel soaked in a mixture of soap liniment, laudanum, and chloroform (Gross). Never let a joint stiffen ; any tendency to do so should be met by daily massage, fric- tions, passive motion, and the hot and cold douche. In some rare cases nerve-stretching or neurectomy becomes necessary. Articular Wounds and Injuries.—A non-penetrating DISEASES AND INJURIES OF BONES AND JOINTS. 423 wound requires antiseptic irrigation, stitching, and antiseptic dressing upon a splint. A penetrating wound is very serious, and it may be due to compound fracture (p. 307), to com- pound dislocation (p. 435), to gunshot wounds, or to stabs. If a bursa near a joint be injured, secondary penetration may occur as a result of suppuration. In a penetrating wound, besides pain, hemorrhage, and swelling, there is a flow of synovial fluid. A small amount of synovia flows from an injured bursa, a large amount from an open joint. Treatment.—If a joint is opened aseptically (as when incised by the surgeon), it gets well nicely under rest and antisepsis. If a joint is opened by a septic body, suppurative arthritis is apt to arise, and the indications are to irrigate, drain, dress antiseptically, and secure rest. In gunshot wounds, if antisepsis is not employed, suppuration is inevitable; hence military surgeons, as a rule, have advocated amputation or excision in gunshot splinterings of large joints. In these injuries the wound is enlarged, the finger is introduced to discover and remove foreign bodies, through-and-through drainage is secured, a tube is inserted, the joint is irrigated, antiseptic dressings are applied, and the extremity is placed upon a splint. Very severe cases demand resection or even amputation. Ankylosis more or less complete follows a gunshot wound of a joint. If the joint suppurates, the drainage must be made more free, sinuses must be slit up and packed, sloughs must be cut away, dead bone must be gouged out, and the patient must be placed upon a stimu- lant and tonic plan of treatment. Sprains.—A sprain is a joint-wrench due to a sudden twist or traction, the ligaments being pulled upon or lace- rated and the surrounding parts being more or less damaged. A sprain is often a self-reduced dislocation. The joints most liable to sprains are the knee, the elbow, and the ankle. The smaller joints are also often sprained, but the ball-and- 424 A MANUAL OF SURGERY. socket joints are infrequently sprained, their normal range of free movement saving them; they do occasionally suffer severely, however, as a result of abduction. In a bad sprain the ligaments are torn; the synovial membrane is contused or crushed; hemorrhage takes place into and about the joint; muscles and tendons are stretched, displaced, or lacerated; vessels and nerves are damaged; the skin is often contused ; and portions of bone or cartilage may be detached from their proper habitat, though still adhering to a liga- ment (sprain-fractures). Sprains are commonest in young persons and in adults. A joint once sprained is very liable to a repetition of the damage from slight force. Sprains are common in a limb with weak muscles, in a deformed extrem- ity in which the muscles act in unnatural lines, and in a joint with relaxed ligaments. Symptoms.—The symptoms manifested in sprains are as follows: severe pain in the joint, accompanied by weak- ness, nausea, often by vomiting, and sometimes by syncope. Impairment or loss of motion is present. This condition is succeeded by a season of relief from pain while at rest, numbness being complained of, and pain on motion being severe. Very soon swelling begins if hemorrhage is severe. In any case swelling begins in a few hours. Movement of the joint becomes difficult or impossible; the tear in the ligament may be distinctly felt; pain and tenderness become intense; joint-crepitus will be detected ; and in a day or two discoloration becomes marked. Diagnosis and Prognosis.—Sprain-fractures cannot be diag- nosticated with certainty. The diagnosis must be made from fracture and dislocation. In fracture, crepitus and mobility exist; in dislocation, rigidity. The diagnosis should be made by a consideration of the joint involved, of the age, of the nature of the force, by the length of the limb, by the fact that the patient could use the joint for at least a short DISEASES AND INJURIES OF BONES AND JOINTS. 425 time after the accident, and by the local feel and movements of the part. The prognosis depends on the size of the joint, on the extent of laceration, and on the amount of intra- articular hemorrhage. The danger is ankylosis. Treatment.—The indications are, first, to limit inflamma- tion, and, secondly, to restore the functions of the joint. In a mild sprain use lead-water and laudanum or apply at once a silicate dressing. In a severe sprain place the extrem- ity upon a splint and to the joint apply flannel kept wet with lead-water and laudanum, iced water, tincture of arnica, alcohol and water, or a solution of chloride of ammonium. The ice-bag should from time to time be laid upon the flannel for periods of twenty or thirty minutes. Leeches around the joint do good. Constitutionally, employ the rem- edies for inflammation (p. 60). Morphia or Dover's powder is given for the pain. Judicious bandaging limits the swell- ing. After a day or two, if the symptoms continue or if they grow worse, use hot fomentations, hot lead-water and lauda- num, the hot-water bag, plunge the extremity frequently in very hot water, or apply heat by Leiter's tubes. When the acute symptoms begin to subside, rub stimulating liniments upon the joint once or twice a day and employ firm com- pression by means of a bandage. Many cases do well at this stage under the local use of ichthyol and lanolin (50 per cent.), tincture of iodine, or blue ointment. Later in the case, use the hot and cold douche, massage, frictions, passive motion, and the bandage. Give iodide of potassium, often use tonics internally, and insist on open-air exercise. Many sprains may be put up in an immovable dressing about the first day or two after the accident. If the joint contains much blood, aspiration should be practised before the dressing is applied. Ankylosis.—When a joint-inflammation eventuates in 426 A MANUAL OF SURGERY. the formation of new tissue in and about the joint, contrac- tion of this tissue limits or destroys joint-mobility, producing the condition known as " ankylosis." Ankylosis may be complete (bony) or incomplete (fibrous); it may arise from contractures in the joint (true or intra-articular ankylosis) or from contractures in the structures external to the joint (false or extra-articular ankylosis). True or intra-articular ankylosis may arise from any cause which produces joint-inflammation with formation of new tissue, and may be due to wounds, contusions, sprains, dis- locations, fractures in or near a joint, movable bodies in a joint, tubercle, gout, rheumatism, or syphilis. Want of use of the joints causes partial ankylosis, though this has been denied. Ankylosis is more apt to take place in a hinge- joint than in a ball-and-socket joint. In ankylosis from a general cause (as rheumatic gout) many joints are apt to suffer. Ankylosis may be due to fibrous tissue, and is then usually partial; it may be due to chondrification of fibrous tissue, and is then incomplete; it may be due to ossification of fibrous tissue, and is then complete, the joint being entirely immobile (osseous or bony ankylosis). The entire joint may be converted into bone. Only one small joint- surface may contain adhesions (limited adhesion), or the entire joint-surface may be bound up in them (diffused ad- hesion). Fibrous ankylosis follows aseptic inflammations; bony ankylosis is apt to follow infections. Though some motion is usually possible in fibrous ankylosis, in some cases it may be impossible. A joint immovable from fibrous ankvlosis is distinguished from a joint immovable from bony ankylosis by the fact that in the former attempts at motion are pro- ductive of pain, and subsequently of inflammation. The incapacity resulting from ankylosis is due, first, to the impairment or destruction of joint-function, and, secondly, DISEASES AND INJURIES OF BONES AND JOINTS. 427 to the fixation at an inconvenient angle (a fixed flexed knee is worse than a fixed extended knee ; a fixed extended elbow is worse than a fixed flexed elbow). Treatment.—The effort should always be made to pre- vent an ankylosis by treating carefully any joint-inflamma- tion and by beginning passive motion at the earliest safe period. To limit inflammation is to prevent ankylosis. Many cases of fibrous ankylosis are improved by passive movements, massage, frictions, stimulating liniments, inunc- tions of ichthyol" or mercurial ointment, hot and cold douches, and electricity. Some cases may be straightened out slowly by screw-splints or by weights and pulleys. Fibrous ankylosis of the elbow is best treated by using the joint. Fibrous ankylosis is often corrected by forcible straightening. If the tendons are much contracted, tenot- omy should be performed two or three days before forcible straightening is attempted. In order to straighten, always give ether. Suppose a case of ankylosis of the knee: put the patient upon his back, bring the leg over the end of the operating-table, grasp the ankle with one hand and the lower portion of the leg with the other hand, and make stron«- steady movements of flexion and extension until the limb can be straightened. The adhesions will be felt to break, the snapping often being audible. At once apply a plaster-of-Paris dressing, and keep the limb immobile for two weeks. This procedure is not free from danger. Vessels may be ruptured, nerves may be torn, skin and fascia may be lacerated, suppuration may ensue from the admission into the joint of encapsuled cocci, or organisms in the blood may find this area a point of least resistance. Because of the danger of opening up depots of encapsuled bacilli and cocci, do not forcibly break up an ankylosis that results from a tubercular or a septic arthritis, but use gradual extension by weights or by screw-splints. Ankylosis of the 428 A MANUAL OF SURGERY. knee following fracture of the patella is almost sure to recur after forcible breaking up. The best treatment for knee- ankylosis is use of the joint. In bony ankylosis of any joint other than the elbow-joint, do nothing if the joint is in a useful position. If the joint is in an unfortunate position, resort to excision or an osteotomy. In the elbow, excision should be performed, no matter what the position, in the hope of obtaining a movable joint. False or Extra-articular Ankylosis.—In this disease the joint is intact, but the contractures are in surrounding parts. The causes are muscular and tendinous contractures, cicatrices (especially from burns), deposits of bone, muscular paralysis, tumors, and aneurysm. Contractions of muscles or tendons may be due to gout, rheumatism, injury, thecitis, fractures, and dislocations. False ankylosis is seen in club- foot and in Dupuytren's contraction. Treatment.—The treatment of false ankylosis depends upon the cause. Recently-contracted muscles or tendons require motions, massage, frictions with stimulating liniments, and the hot and cold douche. Old contractions require division. Whenever possible, excise a cicatrix that causes false ankylosis, and fill the gap with good tissue. Bony deposits are gouged away and tumors are removed. Paralysis requires electricity, passive motion, frictions with stimulating liniments, and general treatment. Loose Bodies in Joints (Floating- Cartilages).—In this affection the knee is the joint oftenest affected. These bodies may be free, may have a stalk or pedicle, may move about and occasionally block the joint, or may lie quietly in a joint-recess or diverticulum. They may be single or multiple, flat or ovoid, smooth or irregular, as small as peas or as large as plums, and may be composed of fibrous tissue, of bone, or of cartilage. There are numerous differ- ent modes of origin of these bodies, many being " detached DISEASES AND INJURIES OF BONES AND JOINTS. 429 ecchondroses or pieces of hyaline cartilage hanging by narrow pedicles " (Bland Sutton), and they result from en- largement and chondrification of the villi of the synovial membrane. Some loose bodies are broken-off osteophytes; some arise from blood-clots ; some by projection or hernia- tion of the synovial membrane, which protrusion is broken off; others are detached fringes of tubercular synovial mem- brane. Traumatism is usually an exciting cause. Loose cartilages are commonest in adult men. Symptoms.—Many small bodies give rise to no symptoms other than those of synovitis. A large body produces pain and interferes with joint-function. The joint is weak and a little swollen, and the patient can feel the body and often can push it into a superficial area of the joint, where it can be felt by the surgeon. From time to time the body may get caught, thus suddenly locking the joint and producing intense and sickening pain, extension and flexion being impossible until the body slips out, and inflammation and effusion following the accident. Treatment.—To relieve locking, employ forced flexion and sudden extension. Cure can be obtained only by operation. Let the patient bring the foreign body to a point where it can be felt; the surgeon then fixes it with a pin or holds it with the fingers, ether being given or cocaine being used. The joint is now opened, the foreign body extracted, and an exploration is made to see that no other bodies are present. The wound is now stitched and the leg is placed upon a splint. Antisepsis must be most rigid. The operation does not cure the causative lesion, and these bodies are apt to form again. 4. Luxations or Dislocations. A dislocation is the persistent separation from each other, partially or completely, of two articular surfaces. A sprain 430 A MANUAL OF SURGERY. is a self-reduced dislocation. There are three forms of dis- location : (i) traumatic; (2) spontaneous or pathological; and (3) congenital. 1. Traumatic dislocations are due to injury. They are divided into—complete dislocation, in which the two articular surfaces are entirely separated and the ligaments are torn ; incomplete or partial dislocation, in which the two articular surfaces are not completely separated and the ligaments are rarely lacerated ; simple dislocation, in which the articular surfaces are not brought into contact with the external air; compound dislocation, in which the external air has access to the articular surfaces; complicated dislocation, in which, besides the dislocation, there is a fracture, extensive drainage of the soft parts, an opening admitting air to the soft parts, or damage of a nerve or blood-vessel; primitive dislocation, in which the bones remain as originally displaced; secondary dislocation, in which the bone assumes a new position: for instance, a subglenoid luxation of the humerus is primary, and it may become secondarily a subcoracoid luxation because of muscular contraction or attempts at reduction; recent dislocation, in which the displaced bone is not firmly fastened by tissue-changes in its new situa- tion, and its old socket is not obliterated ; old dislocation, in which the displaced bone is firmly fastened by tissue-changes in its new habitat, and the old socket is to a great extent obliterated (whether a dislocation is old or new depends on the state of the parts rather than on the time which has elapsed since the accident); double dislocation, in which corresponding bones on each side are dislocated ; single dis- location, in which only one joint is dislocated ; unilateral dis- location, in which one articulation of one bone is out of place; bilateral dislocation, in which symmetrical articula- tions are dislocated; and relapsing or habitual dislocation, which recurs constantly from slight force because of relaxed DISEASES AND INJURIES OF BONES AND JOINTS. 431 ligaments or lack of complete repair after the ligamentous rupture of a first dislocation. 2. Spontaneous, Pathological, or Consecutive Disloca- tions.—Spontaneous dislocation arises from such very slight force that it often cannot be identified, and it acts on a joint rendered lax by disease. It may arise in the course of chronic synovitis and during tubercular joint-disease. In Charcot's joint [arthropathie des ataxiques) this form of dis- location constantly appears. This condition comes on in a few hours, during the progress of locomotor ataxia, and is without apparent reason. The knee, the shoulder, or some other joint becomes greatly swollen, fluid gathers in large amount, the ligaments relax, the joint is destroyed and becomes excessively mobile, but there is no pain, no fever, and no sign of inflammation. 3. Congenital Dislocations.—The third form, or congen- ital dislocation, is due to a congenital joint-malformation which renders it impossible for the bone to maintain a nor- mal position, or is due to external violence during the period of uterine gestation. Congenital dislocations should not be confounded with dislocations produced during delivery. Traumatic Dislocations.—In the succeeding pages the traumatic form of dislocations will particularly be considered. The causes of traumatic dislocations are divided into predis- posing and exciting. Predisposing causes are (1) Age—dislocations are com- monest in middle life the usual lesion of the young being green-stick fracture, and that of the old being fracture. Dislocations of the radius are not uncommon in youth. (2) Muscular development—dislocations being commonest in those with powerful muscles. (3) Sex— males being more predisposed than females, because of their occupations and muscular strength. (4) Occupation predisposes as a cause according as it demands the employment of muscular force, 432 / MANUAL OF SURGERY. as in the carrying of burdens. (5) Nature of the joint— ball-and-socket joints being more liable to luxation than are ginglymus joints, because of their wide range of motion. (6) Joint disease predisposes by relaxing the ligaments. (7) Situation of the joint—some joints being more exposed to injury than others. Exciting causes are classified into (1) external violence and (2) muscular action. External violence may be direct, as when a blow upon one of the bones forces it directly away from the other; or it may be indirect, as when a blow at a distant part of a bone transmits force to its end and drives the bone out of its socket. Muscular action is a cause when sudden and violent muscular contraction occurs during the existence of a position of the joint which gives the muscles full sway, and throws the head of the bone against the weakest part of its retaining ligaments. Pathological Conditions.—In a recent complete traumatic dislocation the ligaments are damaged, and may perhaps show extensive laceration, or may show only a button-hole laceration through which a bone projects. External force produces much laceration and little stretching of the liga- ments ; muscular action produces little laceration and much stretching of the ligaments (Mears). In some cases of dis- location due to external violence the structures about the joint are bruised or otherwise damaged; the old socket is filled with blood, and the bone in its new situation lies in a bloody area. Large vessels and nerves are rarely torn, though they may be compressed. If a dislocation is not soon reduced, inflammation arises in the old joint and about the displaced bone, and the whole area is glued together, first by coagulated exudate, and next by embryonic tissue. After a time, in ball-and-socket joints, the old socket fills with fibrous tissue, contracts, becomes irregular, and may even be obliterated; the head of the dis- DISEASES AND INJURIES OF BONES AND JOINTS. 433 located bone alters its shape, its cartilage is destroyed or converted into fibrous tissue, and the pressure of the head of the bone forms a hollow in its new situation, which hol- low becomes surrounded by fibrous tissue or even by bone. A new joint may form, the surrounding tissue becoming a compact capsule, and a bursa forming between the head of the bone and its new socket. In a dislocated hinge-joint the ends of the bone alter greatly in shape and their carti- lage is converted into fibrous tissue. In an unreduced dislo- cation the muscles shorten or lengthen or undergo atrophy or fatty degeneration, as the case may be. An unreduced dislocation of a ball-and-socket joint may give a fairly mov- able new joint, but an unreduced dislocation of a hinge- joint rarely allows of much motion. General Symptoms of Traumatic Dislocations.—In general, traumatic dislocations are indicated (1) by pain of a sicken- ing, nauseating character; (2) by rigidity (voluntary motion is impossible except to a slight extent in the direction of the deformity. For instance, in dislocation of the inferior max- illary the jaw can be opened a little more, but it cannot be closed. This rigidity brings about loss of function. When the surgeon attempts to move the joint he finds it very rigid); (3) by change in the shape of the joint (as flattening of the shoulder after dislocation of the humerus); (4) by alteration in the mutual relations of bony prominences about a joint (alteration of the relation between the olecranon and humeral condyles in dislocation of the elbow backward); (5) by feeling the displaced bone in its new situation; (6) by missing the head of the bone from its proper situation; (7) by alteration in the length of the limb (in dislocation of the femur into the thyroid foramen the leg is lengthened, but in dislocation into the dorsum of the ilium it is shortened); and (8) by alteration in the axis of the bone (in dislocation upon the dorsum of the ilium the axis of the injured thigh 28 434 A MANUAL OF SURGERY. would, if prolonged, pass through the lower third of the sound thigh). Diagnosis of Traumatic Dislocation.—A dislocation may be mistaken for a fracture. In dislocation there is rigidity, in fracture there is preternatural mobility ; in dislocation there is no true crepitus (may get tendon- or joint-crepitus), in frac- ture there usually is crepitus; in dislocation the deformity does not tend to recur after reduction, in fracture it does recur after extension is relaxed. In a sprain the movements of the joint are only limited, not abolished by an almost com- plete rigidity. The change which a sprain may cause in the shape of a joint is due to effusion or to bleeding; there is no alteration in the relation of the bony prominences to one another; there is no notable alteration in the length of the limb (a slight increase in length may arise from joint-effusion, or the head of the bone may subsequently be absorbed, and thus produce shortening after some weeks); there is no alteration in the axis of the bone; the head is not felt in a new position, it being found in its normal place. Always remember that a fracture may exist with a dislocation. In any doubtful case—in fact, in most cases—give ether, for a dislocation should be reduced while the patient is anaesthe- tized (except in dislocation of the jaw, of the fingers, of the carpus, etc.). In some cases swelling renders the diagnosis difficult or impossible. Always compare the injured joint with the corresponding joint of the sound side. Treatment of Traumatic Dislocations: Recent Simple Dis- locations.—Reduce simple dislocations under ether, as a rule. Try manipulation, a procedure in which it is sought to make the bone retrace its own pathway. If this procedure fails, employ extension and counter-extension. If considerable force is needed, an assistant makes counter-extension, and the surgeon fastens to the extremity a clove-hitch which he ties about his waist, and thus secures powerful extension. DISEASES AND INJURIES OF BONES AND JOINTS. 435 Counter-extension may be obtained by bands or, in some instances, by the foot of the surgeon. The clove-hitch is used because it will not tighten by traction, as a tighten- ing band would lacerate the soft parts (Fig. 68). If great power is needed, compound pulleys may be employed, such as the Jarvis adjuster or some similar appliance (see pages 447, 459). If these means fail, cut down upon the bone and restore it to position. After reducing a dislocation, immobilize the joint for a time (time varies with different joints), and for the first few days combat swelling and inflammation with evaporat- ing lotions. If there exists a fracture of the dislocated bone, apply splints and then try to reduce by manipulations, grasping the limb and the splint with one hand below and, if possible, with the other hand above the seat of the fracture. In some cases with fracture reduction can be much aided by screwing a gimlet into the head of the bone and using this tool as a handle. If the fracture is near the joint and the fragments cannot be fixed, try to reduce the dislocation, first striving to press the bone into place. Compound Traumatic Dislocations.—The opening in the soft parts may be due to external violence or to projec- tion of a bone. Compound dislocations are very serious. Hinge-joints are more often victims to these injuries than are ball-and-socket joints. Many cases require excision and amputation; all that do not demand excision or amputation are treated by counter-opening, by careful antisepsis, by drainage, and by immobilization, ankylosis generally ensu- ing, except sometimes in the small joints. It is scarcely ever necessary to cut away any portion of the protruding bone to effect reduction. If a joint is badly splintered or if the soft parts are extensively damaged, excise or amputate; if the main vessels or the nerves are seriously injured, or if the patient is so old or so feeble that it is perilous to force him to combat a long illness, then amputate. 436 A MANUAL OF SURGERY. Old Traumatic Dislocations.—The problem always pre- sented in old dislocations is, Shall reduction be tried, or shall the bones be left alone ? Sir Astley Cooper laid down this rule: " Do not attempt to reduce a shoulder-dislocation after three months, nor a hip-dislocation after two months;" but this rule was laid down before the days of ether. Do not select any fixed period of time to determine the action. In dislocation of a ball-and-socket joint considerable motion may become possible and a new joint may form. If move- ment does not produce pain, a good new joint may eventu- ally be obtained by faithful passive movements ; if movement of the limb does produce pain, enough motion will not be attempted by the patient to produce a useful joint. In the former case try to obtain a useful new joint, and in the latter case try to reduce the old dislocation. In trying to reduce an old dislocation, give ether, make movements to break up adhesions, and persist in making these motions until the head of the bone is felt to move; then try at once to reduce by manipulation, extension, or the pulleys, not waiting for two days, as some suggest. If the head of the bone cannot be made to move, there may be followed the Dieffenbach plan, which is to cut the tense restraining bands with a tenotome. Always remember that dislocations of a hinge-joint, if left unreduced, will never eventuate in a useful artificial joint. Sir Joseph Lister, being much impressed with the danger inevitably linked with for- cibly dragging old dislocations into place, prefers to cut down and restore the bone, employing, of course, the fullest antisepsis. Special Traumatic Dislocations : Lower Jaw.—With- out fracture the lower jaw can only be dislocated forward. There are two forms of dislocation—the unilateral, which is rare, and the bilateral, which is common. Dislocations of the jaw are commonest in women and during middle life. DISEASES AND INJURIES OF BONES A.VD JOINTS. 437 When the mouth is open contraction of the external ptery- goid can pull the condyle over the articular eminence; this contraction may be brought about by yawning, vomiting, scolding, etc. When the mouth is open dislocation of the lower jaw can be caused by a blow upon the chin; it can also be caused by forcing the mouth more widely open by pushing a bulky body between the teeth. Symptoms of Lower-jaw Dislocations.—In the bilateral form the mouth is open and fixed, and it cannot be closed, though it can be opened a little more. The condyles are in front of the articular eminences, and are fixed by the action of the masseters and internal pterygoids, the coronoid processes being wedged against the malar bones. The lower jaw is advanced in front of the upper and the face looks longer than natural. The lips cannot close, the saliva over- flows, swallowing and speech are difficult, there is a depres- sion in front of the ear, the condyle is recognizable in its new abode, the coronoid process is detected by a finger in the mouth, and the masseters and temporals stand out in a state of rigidity. Pain may be severe or be absent. In the uni- lateral form the chin goes toward the sound side, and the mouth is not so widely open as in the bilateral form, neither is the jaw so fixed. The symptoms are similar to those of a bilateral luxation, but are not so pronounced. The hollow in front of the ear and the condyle in an abnormal situation are only detected upon one side. In an unreduced disloca- tion the patient may after a time establish some movement of the jaw, but the power of mastication will always be im- paired seriously. Treatment of Lower-jaw Dislocations.—In treating dislo- cations of the lower jaw the patient is placed with his head against the back of a chair or against the body of an assist- ant. The surgeon, after wrapping up his thumbs to save them from being bitten, stands in front of the patient, puts 438 A MANUAL OF SURGERY. his thumbs upon the last molar teeth, and grasps the chin with his free fingers. He now presses downward and back- ward on the jaw, and as soon as the condyle is loosened closes the jaw over the condyle by pushing up the chin, using his thumbs as levers. If this procedure fails, wedges should be put between the molar teeth and the chin should be pushed up either by the hands or by a tourniquet whose band is round the head and chin. In a unilateral disloca- tion the wedge should only be used on the injured side. In difficult cases Sir Astley Cooper took a round wooden ruler and pushed it between the molar teeth, using the upper teeth as a fulcrum and raising the end of the ruler as the handle of a lever. The forceps used by an anaesthetizer may depress the condyle from its point of fixation, whereupon the chin may be pushed up and back. Nelaton's plan was to put the thumbs in the mouth and push the coronoid pro- cesses backward. In an old dislocation always try reduc- tion, at least up to a period of six or seven months. After reduction apply a Barton bandage for over two weeks, taking it off once a day, and begin passive motion in the second week; discard the bandage in the third week. Liquid diet is advisable for three weeks after the accident. Dislocation of the Clavicle: Sternal End.—There are three forms of dislocation of the sternal end of the clavicle, namely: (i) forward; (2) backward; and (3) upward. Forward Dislocation of the Clavicle.—The causes of forward dislocation of the clavicle are blows, falls, or pulls which drive or draw the shoulder backward. Symptoms and Treatment of Dislocation of the Clavicle.— * The symptoms manifest in dislocation of the clavicle are —prominence in front of the sternum ; the acromion is nearer to the sternum on the injured than on the sound side; the ( clavicular origin of the sterno-cleido-mastoid is rigid ; move- ment is difficult and painful. To treat a dislocation of the DISEASES AND INJURIES OF BONES AND JOINTS. 439 clavicle, pull the shoulders back against, the knee placed between the scapulae. Dress with a posterior figure-of-8 bandage (PL I 2, Fig. 5) or a Velpeau bandage (PL 13, Fig. 4), the dressing to be worn for three weeks. After removal of the dressing apply a truss the pad of which is put over the head of the clavicle, and which instrument is to be worn for a month. Dislocation of the clavicle is difificult to keep reduced, but even if it becomes fixed in deformity the motions of the arm will not be impaired permanently. Backward dislocation of the clavicle is very rare. The causes are direct violence and indirect force, such as falls or blows which drive the shoulder forward and inward. Symptoms and Treatment of Backzvard Dislocation of the Clavicle.—The symptoms are—pain ; loss of function in the arm ; inclination of head toward the injured side ; stiffness of the neck ; the shoulder passes forward and inward, and often falls downward ; a depression exists over the sterno-clavicular joint; the head of the clavicle cannot be felt, or is found back of the sternum. The displaced clavicle may press upon the trachea, the oesophagus, or the great vessels, inducing dyspnoea, dysphagia, obliteration of pulse in the arm of the injured side, or great venous congestion of the head (see Pick). To treat a backward dislocation, pull the shoulders backward and apply a posterior figure-of-8 band- age (PL 12, Fig. 5), which must be worn for three weeks. If pressure-symptoms are urgent, resect the displaced head. Upward dislocation of the clavicle is very rare. The cause is indirect force which carries the shoulder downward, inward, and backward (Smith). Symptoms and Treatment of Upward Dislocation of the Clavicle.—The chief symptom is impaired function of the arm; the shoulder passes downward and inward, the clavic- ular axis is altered, and the displaced head is felt. Dyspnoea may or may not exist. To treat this dislocation, put a pad 440 A MANUAL OF SURGERY. *• in the axilla and press the elbow to the side in order to throw the bone outward, and try to push the head into place. Apply a Desault bandage (PL 13, Figs. 1-3) and place a firm pad over the sterno-clavicular joint. The deformity is apt to recur, but a useful limb will nevertheless be obtained. Dislocation of the acromial end of the clavicle is almost always upward, but it may be below the acromion. The cause is violent force, which, if so applied to the scapula as to drive the shoulder forward, may produce a dislocation upward. A dislocation downward is due to blows upon the upper surface of the outer end of the clavicle. Symptoms and Treatment.—The symptoms of dislocation of the acromial end of the clavicle are—prominence of the clavicle upon the top of the acromion ; impaired function of the arm (cannot be lifted over the head); the shoulder falls downward and passes inward ; there is apparent length- ening of the arm; the head is bent toward the injured side, and the clavicular origin of the trapezius is strongly out- lined (Pick). In dislocation downward both the acromion and the coracoid are very prominent, the clavicular axis is altered, and there is depression over the sterno-clavicular joint. A dislocation upward is reduced by pulling the shoulder back and pushing the bone into place. Apply a Desault bandage, which must be kept on for three weeks. More or less deformity is inevitable. Dislocation downward is reduced and treated the same as dislocation upward. Dislocation of the lower angle of the scapula is not, as it was long thought to be, a dislocation at all. The lower angle and vertebral border deviate from the chest. This condition was thought to be due to the bone slip- ping from under the latissimus dorsi muscle, but it is now known to be due to paralysis of the serratus magnus muscle, the bone being acted upon by the trapezius, pectoralis minor, levator anguli scapulae, and rhomboid muscles. Examina- DISEASES AND INJURIES OF BONES AND JOINTS. 441 tion shows that the scapula will not rotate normally forward. This is demonstrated by extending the arms in front to a right angle, the gliding forward of the scapula upon the sound side being marked and upon the diseased side being slight or absent. Treatment of dislocation of the lower angle of the scapula comprises massage, electricity, passive motion, and deep in- jections of strychnine. Dislocations of the Humerus (Shoulder-joint).—These injuries are most frequent because of the free mobility of the shoulder-joint, its anatomical insecurity, and its exposed situation. These dislocations are rare in the very young and in the aged, being oftenest encountered in muscular young adults. Four forms of shoulder-joint dislocation exist, namely: (1) forward, inward, and downward, under the coracoid process—subcoracoid ; (2) downward, forward, and inward, beneath the glenoid cavity—subglenoid; (3) backward, inward, and downward, under the spine of the scapula—subspinous ; and (4) forward, inward, and upward, under the clavicle—subclavicular. A very rare form of shoulder-joint dislocation has been described, which is known as the " supracoracoid." Subcoracoid Luxation.—The subcoracoid variety of dislo- cation embraces three-fourths of all the shoulder-joint luxa- tions. It may be caused by direct force driving the head of the humerus forward and inward, or by indirect force, such as falls upon the hand or the elbow. In this dislocation the anatomical neck of the humerus lies upon the anterior margin of the glenoid cavity, just beneath the coracoid process, and is above the tendon of the subscapulars muscle. Subglenoid or axillary luxation may be produced by con- traction of the great pectoral and latassimus dorsi muscles when the arm is at a right angle to the body, but it is usually due to falls upon the hand or the elbow when the arm is 442 A MANUAL OF SURGERY. raised and the head of the bone is against the lower portion of the capsule. In this dislocation the head of the bone rests upon the border of the scapula, below the tendon of the subscapulars, in front of the long head of the triceps, and above the teres muscles. Some observers hold that most dislocations of the shoulder are primarily subglenoid, the position having been altered by muscular action. Subspinous luxation is a rare injury. Pick met with this accident in a man who, while having his hands in his pockets, fell upon the front of the point of the shoulder. The head of the bone reposes beneath the scapular spine, between the infraspinatus and teres minor muscles. Subclavicular luxation is very rare. It is caused by the same sort of violence which produces subcoracoid luxation. The head of the bone rests upon the thorax, below the clavicle and underneath the pectoralis major muscle. In the rare form known as the " supracoracoid " the head of the humerus rests upon the coraco-acromial ligament or upon the acromion process. The acromion or the coracoid is always fractured. Symptoms of Dislocation of the Shoulder-joint.—Disloca- tion is diagnosticated by (i) pain of a sickening character; (2) flattening of the shoulder, the head of the bone having ceased to bulge out the deltoid muscle; (3) apparent projec- tion of the acromion through sinking in of the deltoid; (4) hollow beneath the acromion, over the empty glenoid cavity, and the bone missed from its normal habitat; (5) rigidity (some movement is possible, in the direction especially of an existing deformity, but mobility is strictly limited and attempts at motion produce great pain); (6) the elbow can- not touch the side when the hand is placed upon the sound shoulder—Dugas's sign (this is due to the rotundity of the chest. In a dislocation the head of the bone is already touching the chest, and the bone, being approximately DISEASES AND INJURIES OF BONES AND JOINTS. 443 straight, cannot touch it in two places at the same time. If the elbow can be placed against the chest with the hand on the sound shoulder, there can be no dislocation; if it cannot be so placed, there must be dislocation); and (7) finding the head of the bone in a new situation. Symptoms 1 to 5 may be grouped as Erichsen's list of signs. The form of disloca- tion is made out by a study of the direction of the axis of the limb, the existence and extent of lengthening or of shortening, and the situation of the head of the bone. The following table from T. Pickering Pick's work on Fractures and Dislocations makes the above points clear : Direction of the Axis of the Limb. Alteration in the Length of the Limb. Presence of the Head of the Bone in New Situation. Subcoracoid. Subglenoid. Subspinous. Subclavicular. The elbow is car-ried backward and slightly away from the side. The elbow is car-ried away from the trunk and slightly backward. The elbow is raised from the side and carried for-ward. The elbow is car-ried outward and backward. Very slight lengthening. Very consider-able lengthening. Lengthening in-termediate in de-gree between the subglenoid and the subcoracoid. Shortening. The head of the bone cannot easily be felt; if it can, it is found at the upper and inner part of the axilla. The head of the bone can easily be felt in the axilla. The head of the bone can be felt and be grasped beneath the spine of the scapula. The head of the bone can readily be seen and be felt be-neath the clavicle. In a shoulder-joint dislocation the head of the bone may press upon the brachial plexus and produce pain and numb- ness, and sometimes a traumatic neuritis or paralysis; some- times pressure upon the axillary vein causes intense oedema, and pressure upon the axillary artery diminishes or obliter- ates the pulse. The axillary vessels may be torn and the muscles may be lacerated badly. The capsule is torn and 444 A MANUAL OF SURGERY. considerable blood is usually effused. Swelling is due first to hemorrhage and secondly to inflammation. Partial dis- locations sometimes, though rarely, occur. What is usually spoken of as " partial dislocation " is a condition in which the head of the humerus passes forward under the coracoid because of rupture of the long head of the biceps or because this tendon slips out of its groove, the ligaments being intact. Diagnosis of Shoulder-joint Dislocation.—In fracture of the neck of the scapula there is prominence of the acromion and a hollow below it, a hard body being felt in the axilla; but the coracoid process descends with the head of the bone, which it does not do in dislocation. Furthermore, in frac- ture there is rigidity; in dislocation mobility. In fracture crepitus is present; in dislocation it is absent. In fracture the deformity is easily reduced, but it at once recurs; in dis- location the deformity is with difficulty reduced, but does not recur. In fracture the elbow can be made to touch the side when the hand is upon the sound shoulder; in disloca- tion it cannot be so manipulated. In fracture of the anatomi- cal neck of the humerus deformity is slight; the head of the humerus is found in place, and does not move when the shaft is rotated ; and the head is not in line with the axis of the bone. Crepitus exists in fracture if impaction is absent. In paralysis of the deltoid there is distinct flattening, but the bone is felt in place and there is no rigidity. Treatment of Shoulder-joint Dislocation.—Reduction by manipulation is usually readily obtained in recent cases of shoulder-joint dislocation. Always give ether. Forward dis- locations (subcoracoid, subclavicular, and axillary) are re- duced by Kocher's method (Fig. 73): Put the arm against the side, flex the forearm to a right angle with the arm, perform external rotation of the arm until the forearm is at a right angle with the body, raise the elbow, make internal rotation, and place the hand on the opposite shoulder. The formula DISEASES AND INJURIES OF BONES AND JOINTS. 445 is, flexion of the forearm, external rotation, abduction, and internal circumduction of the arm. If in trying Kocher's plan external rotation of the humerus does not take place, abandon the method. Another method of manipulation is as follows : If the right shoulder is dislocated, the surgeon stands behind the patient (whose shoulders are raised); if the left shoulder is dislocated, he stands in front of the patient. The surgeon holds the arm flexed upon the forearm with his right hand and makes external traction and rotation, and with the fingers of his left hand he tries to force the bone into place. In Henry II. Smith's method for forward dislocations the surgeon stands in front of the patient. If the left shoulder is dislocated, the surgeon grasps it with his left hand; if the right shoulder is dislocated, he grasps it with his right hand, the thumb resting on the head of the bone. With his disengaged hand the surgeon grasps the elbow, abducts it, makes traction and external rotation, and suddenly sweeps the elbow inward, aiming it at the sternum, and tries with his thumb to push the bone into place. In subspinous luxations the surgeon stands behind the patient, makes abduction, traction, and internal rotation, sweeps the elbow inward toward the spine, and with the thumb aids the bone in its return into position. Raising the elbow far above the head and sweeping it inward will reduce some dislocations. As the head of the bone slips back a distinct jar is felt and a snap is heard, the motions of the joint are again obtainable, and with the hand on the opposite shoulder the elbow may be made to touch the side. Reduction by Extension.—In reduction of shoulder-joint dislocation by extension the patient is anaesthetized and placed upon a low bed or upon the floor. The surgeon then places his foot, covered only by a stocking, in the axilla. Place the sole of the foot, not the heel, against the chest 446 A MANUAL OF SURGERY * high up, the instep being made to touch the humerus and the heel the border of the shoulder-blade, a towel being first put into the axilla to rest the foot against (Fig. 70). If the left arm is dislocated, use the left foot, or vice versa. The elder Gross approved of sitting between the patient's limbs. Make steady extension, which will in many cases bring about the reduction. If it fails to cause reduction, bring the patient's arm across the chest and use the foot as the fulcrum of a lever. If the humerus is pretty firmly fixed in its abnormal position, make counter-extension with a foot in the axilla and make extension by fixing a clove-hitch (Fig. 68) above the elbow and fastening to it bands which go over one shoulder and under the other shoulder of the surgeon. The back may be used for extension, the hands being left free for manipulation (Allis's and Pick's plan). The late Prof. Pancoast favored Sir Astley Cooper's method of placing the unanaesthetized patient in a chair and using the knee as a fulcrum, pushing the elbow to the side (Fig. 69). A good method is that in which the surgeon stands behind the patient, steadies the scapula with his foot or hand, and carries the patient's arm above his head, making exten- sion and external rotation (Fig. 71). Cock advises, when reduction fails, that an air-pad be placed in the axilla and the arm be bound to the side—a method by which reduction will often take place after two or three days. The pulleys are very rarely used, as they develop a dangerous force, antiseptic incision being a safer and a better expedient. If the pulleys are used, break up adhesions by repeated and forcible movements; fix the scapula by a collar and band fastened to the wall; attach the pulleys by one end to a clove-hitch fastened above the elbow, and by the other end to the wall; extension is made until the head of the bone moves, whereupon attempts are made to push and manipu- late it into the glenoid cavity (Fig. 72). DISEASES AND INJURIES OF BONES AND JOINTS. 447 Fig. 68.—Clove-hitch Knot applied above the Wrist (after Erichsen). Fig.69.—Reduction of Shoulder- joint Dislocation by the Knee in the Axilla (Cooper). Fig. 70.—Reduction of Shoulder-joint Dislo cation by the Foot in the Axilla (Cooper). Fig. 71.—Reduction of Shoulder-joint Dislo- Fig. 72.—Reduction of Shoulder-joint cation by Extension Upward (Cooper). Dislocation by the Pulleys (Cooper). j,-IG ?3.__Kocher's Method of Reduction by Manipulation (Ceppi) : A, first movement, outward rotation; B, second movement, elevation of elbow ; c, third movement, inward rotation and lowering of the elbow. 448 A MANUAL OF SURGERY. In reducing a dislocation the axillary artery or vein may be ruptured, fracture of the neck of the humerus may take place, injury to the brachial artery may occur, or the soft parts may be badly damaged. After reducing a dislocation, apply a Velpeau bandage, keep the shoulder immobile for one week, then make passive motion daily; the patient may wear a sling alone during the third week, after which period he may use the arm. (For old dislocations and compound dislocations see page 435). Reduction of old dislocations may some- times be effected by manipulation. Extension may have to be used, and ether may be required. In old dislocations try to reduce, after breaking up adhesions, by forced flexion and strong extension. After reduction immobilize for three weeks, and start passive motion after seven days. Dislocations of the Elbow-joint.—Injuries of the elbow- joint are not rare, and they are commonest in children. Both bones or only one bone may be dislocated, and the dislocation may be partial or be complete. Dislocation of Both Bones Backward.—The causes of backward dislocation of both bones of the elbow-joint are falls upon the extended hand or twists inward of the ulna (Malgaigne). The coronoid process lodges in the olecranon fossa. Symptoms of Backward Dislocation.—In complete dislo- cation of both bones of the elbow-joint the olecranon is very prominent; the distance between the point of the olec- ranon and the apex of the inner condyle is notably greater than on the sound side; the forearm is flexed, supinated, and shortened; the lower end of the humerus projects in front of the joint, below the skin-crease; the head of the radius is found back of the outer condyle; and there are the general symptoms of dislocation. Fracture of the coronoid rarely occurs with backward dislocation, but if it does occur there will be crepitus and mobility. In fracture DISEASES AND INJURIES OF BONES AND JOINTS. 449 above the condyles there are found the ordinary symptoms of a fracture; measurement from condyles to styloid processes does not show shortening; there is no alteration of normal relation between olecranon process and condyles; and the projection in front of the joint is above the crease of the bend of the elbow. Treatment of Backward Dislocation.—Reduction must be made early in dislocation of both bones of the elbow-joint, or it will be found impossible, and an unreduced dislocation means a limb without the powers of flexion, pronation, and supination. The surgeon places his knee in front of the el- bow-joint, grasps the patient's wrist, presses upon the radius and ulna with his knee, and bends the forearm with consider- able force, the muscles pulling the bones into place (Sir Astley Cooper's plan). Forced flexion, traction, and extension may be tried (Fig. 74). Apply an anterior angular splint, and have it worn for two weeks. Make passive motion after a few days. Dislocation of Both Bones Forward.—The cause of for- ward dislocation of both bones of the elbow-joint is a blow on the olecranon when the arm is flexed. It is a rare accident. Symptoms and Treatment.—The symptoms of forward dis- location of both bones of the elbow-joint are—forearm is flexed and lengthened; some slight motion is possible; olecranon is on a level with the condyles if unfractured, hence its prominence is gone; the humeral condyles are felt posteriorly, and the radius and ulna are felt anteriorly. The treatment of this injury is the same as that for disloca- tion backward. Forced flexion and pressure may be em- ployed for reduction. Lateral dislocations of-both bones of the elbow-joint are usually incomplete. Symptoms and Treatment of Outward Dislocation.—The symptoms of outward dislocation of both bones of the 29 450 A MANUAL OF SURGERY. Fig. 74.—Reduction of Elbow-joint Dislocation (Tiemann). elbow-joint are—forearm is flexed, fixed, and pronated; joint is widened; the head of the radius projects externally and has a depression above it; the inner condyle projects internally and has a depression below it; the olecranon is nearer than normal to the external condyle and further than normal from the internal condyle. Reduc- tion is effected by exten- sion of the forearm and pressure upon the head of the radius. Apply an ascending spiral reverse bandage of the forearm, a figure-of-8 bandage of the elbow-joint, and a sling. Make passive motion after a few days. The bandages must be worn for two weeks. Symptoms and Treatment of Imvard Dislocation.—In dislo- cation inward of both bones of the elbow-joint the position of the forearm is the same as that in dislocation outward; the sigmoid cavity of the ulna projects internally, and the external condyle projects externally. The treatment of this form of elbow-joint dislocation is the same as that employed in the preceding form. Dislocation of the ulna alone is very rare, and can only take place backward. Symptoms and Treatment.—Dislocation of the ulna alone is indicated by the forearm being flexed and pronated. The head of the radius is found in place, and the olecranon pro- jects posteriorly. The treatment of this injury is the same as that of the preceding dislocation. Dislocations of the Radius Forward.—Dislocation of the radius forward is the commonest form. This injury is caused by a fall upon the hand with the forearm in pronation and DISEASES AND INJURIES OF BONES AND JOINTS. 451 extension, or is produced by blows on the back of the joint; forced pronation alone will not cause it. Symptoms and Treatment.—The symptoms in dislocation of the radius forward are—forearm midway between prona- tion and supination, and semiflexed; attempts to increase flexion cause the radius to strike against the humerus with a distinct blow; the head of the radius is felt in front of the outer condyle and is missed from its proper abode. Reduc- tion is effected by extension and manipulation. A splint is used as in dislocation of both bones. Deformity is apt to recur after reduction, because of rupture of the orbicular ligament. Dislocation of the radius backward is caused by falls on the hand or by blows on the front of the joint. Symptoms and Treatment.—Backward dislocation of the radius is indicated by the forearm being slightly flexed and fixed in pronation, by some impairment of flexion and extension, and by the radius being felt behind the outer condyle. The treatment in this injury is the same as that given in the preceding dislocation. Dislocation of the radius outward is very rare. In this injury the head of the radius is distinctly felt. The treatment is the same as that of the above-mentioned dis- locations. Subluxation of the Head of the Radius.—This name is given to an injury which is very frequent in children between two and four years of age. It results from traction upon the hand or the forearm, and often arises when the nurse or the mother pulls upon a child's arm to save it from a fall or to lift it over a gutter. Some writers hold that pronation is re- quired, as well as extension, to produce the injury; many surgeons claim that extension and adduction are the causative forces. Hutchinson maintains that supination may cause subluxation. Bardenheuer assigned falls as causes. 452 A MANUAL OF SURGERY. The symptoms are very characteristic. The history points to the injury. Pain, and often a click, may be felt in the wrist at the time of the accident. The arm hangs by the side, with the elbow-joint slightly flexed and the forearm midway between pronation and supination. Flexion to a less angle than 6o° and complete extension are resisted and are very painful, but movements between 6o° and 1300 are free and painless.1 The movements of the wrist-joint are free and painless. The elbow-joint presents no deformity. Pressure over the head of the radius causes pain. Strong pronation is painful; strong supination is very painful, and there seems to be a mechanical obstacle to its performance. Forced supination develops a distinct click at the head of the radius, and causes pronation and supination to become natural and free from pain. The condition will be reproduced if a splint is not used. The nature of the lesion is not understood, and various conditions have been thought to exist by different observers. Among them may be mentioned the following: a slight anterior displacement of the head of the radius; a slight posterior displacement; locking of the tuberosity of the radius behind the inner edge of the ulna; dislocation of the triangular cartilage of the wrist; intracapsular fracture of the radial head; painful paralysis from nerve-injury; dis- placement by elongation, the return of the bone being pre- vented by collapse of the capsule; and the slipping up of the margin of the orbicular ligament over the rim of the head of the radius. Treatment—Place the forearm at a right angle to the arm and make forcible supination; apply an anterior angular • splint, and have it worn for four or five days. Dislocations of the wrist, which are very rare, are caused by falls upon the hand. t 1 See the able and learned article of W. W. Van Arsdale in the Annals of Surgery, vol. ix., 1889. DISEASES AND INJURIES OF BONES AND JOINTS. 453 Backward Dislocation of the Wrist.—Symptoms.—The deformity in backward dislocation of the wrist (Fig. 75, a) resembles that of Colles's fracture (Fig. 75, b). The fingers are flexed, the wrist is bent backward, the radius projects on the front of the wrist, the carpus projects on the dorsal surface of the arm, the relation of the styloid process of the radius to the styloid process of the ulna is unaltered (it is altered in Colles's fracture), there is rigidity, and crepitus is absent (Fig. 75). Fig. 75.—Deformity in Dislocation of the Wrist Backward (a) and in Colle's Fracture (b) (Stimson). Forward dislocation of the wrist, which is very unusual, is caused by a fall upon the back of the hand. Symptoms and Treatment.—In forward dislocation of the wrist the radius and ulna project posteriorly and the carpus projects in front. The treatment in both of these dislocations is extension and manipulation, a Bond splint for ten days, and passive motion after five or six days. Dislocation at the inferior radio-ulnar articulation, which is also very rare, is caused by twists. Symptoms and Treatment.—In forward dislocation at the inferior radio-ulnar articulation the forearm is pronated, the space between the styloid processes is diminished, and the ulna forms a projection posteriorly. In backward disloca- tion the forearm is supinated, the space between the styloid processes is diminished, and the ulna projects in front. The treatment is extension and manipulation. Two straight splints (as in fracture of both bones) are to be applied for four weeks, and passive motion is to be made in the third week. 454 A MANUAL OF SURGERY. Dislocation of Individual Carpal Bones.—Pick says there is one weak spot, which is " between the head of the os magnum and the scaphoid and semilunar bones," and the os magnum may be forced up. The os magnum is the only bone dislocated with any frequency, and the injury is caused by forced flexion of the wrist. Symptoms and Treatment.—The symptom of dislocation of the carpal bones is a firm projection which becomes more prominent during flexion of the wrist. The treatment is extension and manipulation, a Bond splint being worn for three weeks. Dislocations of metacarpal bones are rare. The first metacarpal bone is most liable to dislocation. Symptoms and Treatment.—Dislocations of the metacarpal bones are obvious because of projection. The treatment is extension and manipulation, a straight splint and large pad for the palm (as in fracture of the metacarpus), the splint to be worn for three weeks. Dislocations at the metacarpophalangeal articulations are rare, and backward dislocation is the rule. The cause is a fall upon the hand. Symptoms and Treatment.—Dislocated metacarpo-phalan- geal articulations are obvious. Reduction is easily effected, except in the case of the thumb. A splint must be worn for three weeks. Dislocation of the Metacarpo-phalangeal Joint of the Thumb.—In this dislocation the phalanx usually passes backward. Symptoms.—Symptoms of backward dislocation are—the base of the first phalanx rests upon the metacarpal bone; the head of the metacarpal bone projects forward and button- holes the muscles of the thumb ; the first phalanx of the thumb is strongly extended, and the terminal phalanx is semiflexed. The symptoms oi forward dislocation are—the DISEASES AND INJURIES OF BONES AND JOINTS. 455 base of the first phalanx is felt in the palm, and the head of the metacarpal bone is felt posteriorly. Treatment.—In treating backward dislocation of the meta- carpo-phalangeal joint of the thumb, reduction is difficult because of the head of the bone being caught in the perfora- tion of the flexor muscle. Always give ether. Keetley's directions are to adduct the metacarpal bone into the palm (to relax the muscles) and to have an assistant hold it; bend the thumb strongly back, extend, pull the thumb Fig. 76.—Levis Splint for Reducing Dislocation of Phalanges. Fig. 77.—Levis Splint Applied. toward the fingers, and suddenly flex. To get a firm enough grasp for these manipulations, use the apparatus of Charriere or of Levis (Figs. 76, 77). If the above manoeuvres fail, perform tenotomy or incise freely and reduce. After reduction of this dislocation a splint must be worn for three weeks. In forward dislocation reduction is easily effected by strong extension and forced flexion. A splint is to be worn for three weeks. Dislocations of the phalanges may be complete or may be partial. They are commonest between the first and second phalanges. 456 A MANUAL OF SURGERY. Symptoms and Treatment.—Dislocations of the phalanges are obvious. In treating such dislocations, employ extension and manipulation, and a splint for one week. Dislocations of the Ribs and Costal Cartilages.—The ribs may be dislocated from the vertebrae. This accident is rarely uncomplicated, and cannot be differentiated from frac- ture. The diagnosis is rarely made, and the injury is treated as a fracture. The ribs may be dislocated from their carti- lages, one or more ribs being displaced. The end of the rib forms an anterior projection, there is a depression over the cartilage, and crepitus is absent. Treatment is the same as that employed for fractured ribs. The costal cartilages may be displaced from the sternum, forming an anterior projec- tion upon this bone. Reduction is brought about by placing the patient upon a table with a sand pillow between the scapulae, pushing back the shoulders and chest, and forcing the cartilage into place. The dressings are the same as those used in fractured sternum. The cartilages of the lower ribs (sixth, seventh, eighth, ninth, and tenth) may be separated. The inferior cartilage goes forward and can be felt. Pick states that reduction is brought about by causing the patient to hold the chest full of air while efforts are made to push the cartilage into place. Dress as for fractured ribs. Dislocations of the Sternum.—In dislocations of the sternum the manubrium may be separated from the gladio- lus in young subjects. The symptoms and treatment are the same as those in fracture (p. 342). Pelvic dislocations are almost always complicated with fracture. A pubic bone can be dislocated by falls from a • height or by applying violent force to the acetabula. The dislocation may be up or down, front or back, and it may damage the urethra or the bladder. The patient cannot t stand; there are great pain and recognizable deformity. Treat by moulding the bones into place, by applying a pelvic belt, DISEASES AND INJURIES OF BONES AND JOINTS. 457 and by rest in bed for four weeks. Dislocations of the sacro-iliac joint are produced by falls. Movement on the part of the patient is difficult or impossible; there is violent pain, and often paralysis (from pressure upon nerves). In » dislocation backward there is an apparent shortening of the leg, eversion of the foot exists, and the ilium moves poste- riorly and upward. In dislocation forward the anterior supe- rior iliac spine projects and the pelvis is broadened. Sacro- iliac dislocations are reduced by holding the pelvis firm and making extension with a pulley. The patient stays in bed for four weeks and wears a pelvic belt as in fracture. Dislocations of the Femur (Hip-joint).—These injuries are rare, as the hip-joint is very strong. They occur in young adults. In forcible extension the head of the femur presses against the capsule, but the capsule here is very thick, and certain muscles, the rectus, psoas, and iliacus, are pulled tight and serve to strengthen the capsule. The head of the bone cannot go directly upward, because of the ace- tabulum (Edmund Owen). The weak point of the acetabular rim is below; the weak part of the capsule is also below; hence forced abduction is apt to take the head of the bone through the lower part of the capsule, a dislocation occur- ring primarily into the thyroid foramen. Four forms of hip-joint dislocation exist: (1) upward and backward, on the dorsum of the ilium; (2) backward, into the sciatic ► notch ; (3) downward, into the obturator foramen ; and (4) inward, on the pubes. Dislocation on to the dorsum of the ilium comprises one- ♦ half of all hip-dislocations. It is caused by a fall or a blow when the limb is flexed and abducted (as in carrying a weight upon the shoulder), by a fall upon the knees or feet, by a weight striking the back while bending, etc. In this dislocation the head of the femur goes upward and back- ward, rests upon the ilium, and is always above the tendon 458 A MANUAL OF SURGERY. of the obturator internus muscle. This dislocation is sec- ondary to a thyroid dislocation, because of muscular action shifting the bone from its initial seat of displacement. Symptoms.—Dislocation on to the dorsum of the ilium is indicated by the following symptoms : The buttock looks flat and broad; the great trochanter is above Nelaton's line and is deeply placed; the head of the bone can be detected in its new situation; deep pressure in front of the joint finds a hollow; the leg is shortened by about two or three inches, as a rule; the knee is slightly flexed; the thigh is slightly flexed, inwardly rotated, and adducted (Fig. 78) (this is shown by the fact that the "axis of the thigh of the injured side, if prolonged, would pass through the lower third of the sound thigh); the heel is raised, and the great toe of the foot of the injured side rests upon the front of the instep or the ankle of the sound side; the fascia lata is relaxed; rigidity exists; voluntary movement is impossible, though some pas- sive motion is possible in the direction of the deformity (the deformity can be made more marked). The diagnosis from intracapsular fracture is obtained by noting the inversion, the great shortening, the absence of crepitus, the age of the subject, and the nature of the force. The nature of the force, the inversion, and the absence of crepitus mark the diagnosis from extracapsular fracture. Treatment.—The chief obstacle to reduction in dislocation on to the dorsum of the ilium, Bigelow states, is the untorn portion of the capsule, especially the Y-ligament. The ilio- femoral, Y, or Bigelow's ligament resembles an inverted Y, arises from the anterior inferior spine of the ilium, is inserted into the anterior intertrochanteric line, and is incorporated into the front of the capsule. To reduce a dislocation this ligament must be relaxed by manipulation or be torn by extension. Manipulation makes the head of the bone re- trace its steps over the same route it took in emerging. Give DISEASES AND INJURIES OF BONES AND JOINTS. 459 Fig. 79. — Reduction of Dislocation on the Dorsum of the ilium by the Pulleys (Cooper). Fig. 78. —Hip- joint Dislocation : Upward, or on the dorsum of the ilium (Cooper). Fig. 81.—Reduction of Dislocation into the Sciatic Notch by the Pulleys (Cooper). Fig. 82. —Hip- joint Dislocation : Downward, into the obturator or thyroid foramen (Cooper). Fig. 80.— Hip-joint Dislocation: Back- ward, or into the sci- atic notch (Cooper). p1G 83.—Reduction of Dislocation into the Obturator Foramen by the Pulleys (Cooper). Fig. 84. — Disloca- Fig 8s -Reduction of Dislocation on the Pubes by the Pulleys tion on the Pubes (Cooper). (Cooper). 460 A MANUAL OF SURGERY. ether; place the patient supine upon a mattress on the floor ; flex the leg on the thigh (to relax the hamstrings), the thigh on the pelvis; increase the adduction over the middle line; strongly abduct; perform external rotation and extension. This treatment may be summed up as flexion, adduction, external cirumduction, and extension ; or, as Pick puts it, " bend up, roll out, turn out, and extend." If manipula- tion fails, try extension. A perineal band is fastened to the wall, and extension by pulleys is made in the axis of the de- formed limb—that is, across the lower third of the other thigh (Fig. 79), or at a right angle to the body while the patient lies upon the sound side. After reduction put the patient to bed and use sand-bags (as in fracture of the hip) for four weeks. Passive motion is made in the third week. Dislocation into the Sciatic Notch.—In this dislocation the head of the bone passes backward and a little upward, and rests upon the ischium at the margin of the sciatic notch (not in the notch), below the tendon of the obturator internus muscle. The causes are the same as those given for the previous dislocation. Symptoms.—The signs in dislocation into the sciatic notch are like those of dislocation upon the dorsum of the ilium, but they are not so marked. There are flattening and broadening of the hip; ascent of the trochanter above Nela- ton's line; shortening to the extent of an inch. Flexion, inward rotation, and adduction exist, but the axis of the femur of the injured side passes through the knee of the sound side, and the ball of the great toe of the injured * side rests upon the great toe of the sound side (Fig. 80). Other symptoms are identical with dislocation upon the dorsum of the ilium, but are less pronounced. Allis's signs , of this dislocation are of value: if, with the patient recum- bent, the thighs are brought to a right angle with the body, DISEASES AND INJURIES OF BONES AND JOINTS. 461 shortening on the affected side is materially increased; if the dislocated thigh is extended, the back arches as in hip disease. Diagnosis and Treatment.—The symptoms of dislocation into the sciatic notch are similar to, but are less marked than, those of dorsal dislocation, and, being a backward dislocation, the reduction and treatment are the same as for dislocation backward upon the dorsum of the ilium (Fig. 81). Dislocation Downward into the Obturator Foramen.— Downward dislocation is the primary position of most dislo- cations of the hip, the bone rarely remaining in the thyroid foramen, but usually mounting up as a result of muscular action or of the initial violence. The cause is violent abduc- tion by falls or by stepping from a moving car. Symptoms.—Dislocation downward into the obturator fora- men is indicated by flattening of the hip; the head of the bone is felt in its new position and is missed from the acetabulum ; rigidity except in the direction of deformity; a hollow over the great trochanter, which process is well below Nelaton's line and nearer than normal to the middle line ; the gluteal crease is lower than is the crease of the opposite side; lengthening to the extent of one to two inches; the body is bent forward by the traction upon the psoas and iliacus muscles, and is also deviated to the side, thus causing great apparent length- ening ; the limb is advanced and abducted, and the foot is pointed straight ahead or is a little everted (Fig. 82); when the patient is recumbent extension is impossible, the knees cannot be pushed together without great pain, and the adduc- tor muscles are hard and rigid. Unreduced dislocations do well, the patient obtaining a very useful hip-joint (Sedillot). Treatment.—In treating dislocation downward into the obturator foramen, effect reduction if possible by manipula- tion, and if this fails by extension. To reduce by manipu- lation, flex the leg on the thigh and the thigh on the pelvis, and then perform, in the following order, abduction, internal 462 A MANUAL OF SURGERY. circumduction, and extension. If extension is used, employ a pelvic band to pull the pelvis toward the sound side, and a perineal band beneath the pelvic band, having pulleys to maintain force upward and outward from the injured hip. The surgeon, grasping the leg and ankle, drags the member inward and pries the femur into place (Keetley; Fig. 83). The after-treatment is the same as that for the previous forms. Dislocation into the pubes is very rare. The head of the bone usually rests just internal to the anterior inferior spine of the ilium. The primary position of the bone is in the thyroid foramen; the pubic dislocation, when it occurs, is always secondary, and is due to the initial force and to muscular action. Symptoms.—In pubic dislocation the head of the bone can be felt and seen in its new position; the hip is flattened ; there is a hollow over the great trochanter, this process being found below the anterior superior spine of the ilium; there is shortening to the extent of an inch; the limb is in abduction with eversion (Fig. 84), and the knees cannot be approximated without great pain. Treatment.—The treatment of pubic dislocation is manip- ulation as performed for thyroid dislocation. If this fails, employ extension. The limb is well abducted, extension is made downward and backward, and the head of the femur is pulled outward " by a towel around the thigh, just beneath the groin " (Keetley; Fig. 85). The after-treatment is the same as that for the previous forms. Anomalous Dislocations of the Hip.—In supraspinous dislocation the dislocation of the hip is backward, the head of the femur resting upon the ilium above or even anterior to the anterior superior spine. In ischial dislocation the dis- location is downward and backward, the head of the femur resting on the ischial tuberosity or in the lesser sciatic notch. Montcggia's dislocation is a supraspinous dislocation with DISEASES AND INJURIES OF BONES AND JOINTS. 463 eversion of the limb. In perineal dislocation the head of the femur is in the perineum. In suprapubic dislocation the head of the femur passes above the pubes. In subspinous disloca- tion the femoral head rests on the horizontal ramus of the pubes. Dislocations of the Knee.—These dislocations are rare. There are four forms—forward, backward, inward, and out- ward. They may be complete or be incomplete; the com- monest dislocations are lateral. The cause is violent force, such as a fall, or in jumping from a moving train, or in being caught by the foot and dragged. Dislocation Forward of the Knee-joint.—In the com- plete form of forward dislocation the deformity is obvious. The limb is usually extended, but it may be flexed. Much shortening exists ; the condyles are felt posterior and below; the head of the tibia is felt anterior and above; the patella is movable and the quadriceps is lax; pressure of the condyles upon the contents of the popliteal space stops the tibial pulse and causes oedema and intense pain. In incomplete dislocation the symptoms are identical in kind, but are less pronounced. Treatment.—Compound dislocation of the knee-joint often demands excision or amputation. In simple dislocation give ether. One assistant extends the leg, another makes coun- ter-extension on the thigh, and the surgeon pushes the bone into place. Reduction is easy because of ligamentous lacera- tion. Place the limb on a double inclined plane, and combat inflammation by the usual methods (see Synovitis, p. 395). Begin passive motion in the third week. The patient must wear a knee-support for months. If the popliteal vessels are much damaged, gangrene will supervene and amputa- tion will be demanded. Dislocation Backward of the Knee-joint.—In the com- plete form of knee-joint dislocation backward displacement 464 A MANUAL OF SURGERY. is not so great as in dislocation forward. The head of the tibia projects posteriorly and above, the femoral condyles anteriorly and below; the leg is, as a rule, partly flexed, but it may be extended, and there is moderate shortening. In incomplete dislocation the symptoms are less marked. Treatment.—The treatment of backward dislocation of the knee-joint is the same as for forward dislocation. Dislocation Outward of the Knee-joint.—The inner tuberosity of the tibia in outward dislocation lies upon the outer condyle of the femur (Pick); the inner condyle of the femur projects internally; the outer tibial tuberosity and fibular head project externally, the former having a depres- sion below it, and the latter above it; the leg is semiflexed, but shortening is absent. Dislocation Inward of the Knee-joint.—The outer tuber- osity of the tibia in inward dislocation lies upon the inner condyle of the femur; the outer condyle of the femur forms an external prominence, and the inner tuberosity of the tibia forms an internal prominence. Pick cautions us not to mis- take a separation of the lower femoral epiphysis for lateral dislocation (the former is reduced easily, the deformity tends to recur, and there is soft crepitus). Treatment.—In treating lateral dislocation of the knee- joint, effect extension and counter-extension as in antero- posterior dislocations. The leg is moved from side to side and attempts are made at rotation. The after-treatment is the same as that for antero-posterior luxations. Lateral dislocations of the knee-joint are usually incom- plete. Dislocation of the Semilunar Cartilages of the Knee (the Internal Derangement of Mr. Hey; Subluxation).—These interarticular cartilages are attached in front of and behind the tibial spine, and their convexity is attached to the edge of the tibial tuberosities by the coronary ligament. The DISEASES AND INJURIES OF BONES AND JOINTS. 465 inner cartilage is connected with the internal lateral liga- ment, and it has a moderate freedom of movement; the outer cartilage is not connected with the external lateral ligament, and is not freely movable, yet the outer is more often dislocated than is the inner cartilage. The cause is a twist when the knee is flexed, as in stubbing the toe. Symptoms.—The indications of interarticular-cartilage dis- location are a sudden violent, sickening pain in the knee, that may cause the patient to fall; the position is one of fixed semiflexion, voluntary motion being impossible and passive motion causing fierce pain ; a displacement of either cartilage away from the tibial spine produces a prominence on one or the other side of the knee-joint, and a displacement toward the tibial spine makes a prominence on one side of the liga- ment of the patella. Subluxation is soon followed by in- flammation, and swelling rapidly masks the projection. This accident is usually mistaken for blocking of a joint by a floating cartilage. Treatment.—In treating dislocation of the semilunar carti- lages of the knee, reduce by forced flexion and sudden exten- sion with rotation, at the same time endeavoring to push the projecting cartilage into place. After reduction combat inflammation, apply a splint, and use the proper remedies for one week (see Synovitis), then begin passive motion. As recurrence of the displacement is usual, the patient should wear a knee-cap for a year or more. If reduction is impos- sible, persistent passive motion will secure a useful joint. Dislocations of the Fibula: Dislocation at the Supe- rior Tibio-fibular Articulation.—This injury is rare. The head of the fibula may go forward or backward. The causes are direct force and violent adduction of the foot with abduc- tion of the knee (Bryant). Symptoms.—In dislocation of the fibula the position is one of semiflexion, voluntary extension and flexion being 30 466 A MANUAL OF SURGERY. impaired or lost. A distinct movable projection is readily noticed in front or behind, which is found to be continuous with the fibula. There is a depression over the normal posi- tion of the head of the fibula. Treatment.—In treating dislocation of the fibula, bend the knee to relax the biceps, and proceed to push the bone into place. Put a compress over the head of the fibula, apply a bandage, and put the limb on a double inclined plane for three weeks. At the end of this time put a lacing knee- support upon the knee and let the patient up. Displacement being liable to recur, a knee-cap must be worn for a year. Dislocations of the Ankle-joint.—These injuries are not unusual. Fracture is a frequent complication. There are five forms of ankle-joint dislocation—outward, inward, for- ward, backward, and upward. Lateral dislocations of the ankle-joint are either out- ward and inward, and may be complete or incomplete. In these dislocations the astragalus rotates. In incomplete dis- locations " there is no great separation of the trochlear sur- face of the astragalus from the under surface of the tibia, but the outer or inner margin of this surface is brought into contact with the articular surface of the tibia, and the whole foot presents a lateral twist" (Pick). The causes of these dislocations are twists of the joint. Symptoms.—Incomplete outward dislocation of the ankle- joint is known as Pott's fracture (see p. 391), and complete outward dislocation, in which the articular surface of the astragalus is completely displaced from the articular surface of the tibia, is known as Dupuytren's fracture. In incom- plete dislocation the foot goes outward and upward, the fibula is fractured, and the tibio-fibular ligaments are torn off. In Dupuytren's fracture the ankle is broad, the inner malleolus projects and looks lower than natural, the outer malleolus ascends with the foot, the foot rotates outward, DISEASES AND INJURIES OF BONES AND JOINTS. 467 and crepitus can be found. In inward dislocation which is associated with fracture of the inner malleolus there is inversion, the outer malleolus projects, and crepitus can be found. In incomplete separation the symptoms are similar, but are not so marked. Treatment.—In treating outward dislocation of the ankle- joint the deformity is reduced by flexing the leg on the thigh and the thigh on the pelvis; an assistant makes coun- ter-extension from the knee; the surgeon makes extension from the foot, and at the same time rocks the astragalus into place. Dupuytren's fracture is treated in the same manner as Pott's fracture (p. 391). Dislocation inward is treated in a fracture-box for the same period as Pott's fracture. Antero-posterior dislocations of the ankle-joint are rare. The cause is the catching of the foot in jumping or falling—direct violence. In dislocation forward the foot is lengthened, the heel is not conspicuous, the tibia and fibula project against the tendo Achillis, and the relation of the malleoli to the tarsus is altered. In incomplete dislocation the symptoms are similar, but less pronounced. In disloca- tion backward the foot is shortened, the tibia and fibula project in front, the heel is prominent, and the relation between the malleoli and the tarsus is altered. In incom- plete dislocation the symptoms are similar, but less marked. Treatment.—In antero-posterior dislocation of the ankle- joint, reduce as in lateral dislocations. Sometimes the tendo Achillis must be cut. Apply a silicate-of-soda dress- ing, and let it be worn for two weeks; then begin passive motion, and let the patient wear side-splints for a week longer. Dislocation upward of the ankle-joint is a very rare injury. The astragalus wedges in between the widely-sepa- rated tibia and fibula. This dislocation is usually associated 468 A MANUAL OF SURGERY with fracture. The cause is a fall upon the feet from a great height. Symptoms.—Upward dislocation of the ankle-joint is indi- cated by the widening of the ankle and by the flattening of the foot. The malleoli are nearly on a level with the plantar surface of the foot, and there is absolute rigidity. Treatment.—In treating upward dislocation of the ankle- joint, give ether and try to reduce by powerful extension and counter-extension. Treat the injury afterward as in antero-posterior luxation. Dislocation of the Astragalus.—The astragalus may be displaced from the bones of the leg and at the same time be separated from the rest of the tarsus. The displacement may be forward, backward, outward, inward, or rotary. Dislocation of the astragalus forward or backward is caused by falls or twists. Symptoms.—In forward dislocation the astragalus projects strongly; there is shortening of the foot, and the malleoli approach the plantar aspect of the foot; the foot is deviated to one side or to the other, and there is absolute rigidity of the ankle-joint. In incomplete luxations the symptoms are similar, but less marked. This dislocation may be obliquely forward. In backward dislocation of the astraga- lus the foot is not deviated to either side; the astragalus projects between the malleoli and above the os calcis, and the tendo Achillis is stretched over the projection. Rigidity is absolute. This dislocation may be obliquely backward. Lateral and Rotary Dislocations of the Astragalus.— Lateral dislocations of the astragalus are rare, are always * compound, and are always associated with fracture. In rotary dislocation the astragalus remains in its normal habitat after rotating on its own axis, either horizontal or vertical. The causes of rotary dislocation are twists of the foot when at a right angle to the leg (Barwell). The symp- DISEASES AND INJURIES OF BONES AND JOINTS. 469 toms of rotary dislocation are obscure. There is rigidity, but sometimes portions of the astragalus may be made out. Treatment of Dislocations of the Astragalus.—In treating astragalus dislocation, reduce under ether by flexing the » knee to relax the gastrocnemius, extending the foot, and pushing the bone into place. It may be necessary to cut the tendo Achillis. After reduction put up the foot and leg in silicate-of-soda dressing for two weeks, and then begin passive motion and apply side-splints, which are to be worn for one week more. If reduction fails, support the limb on splints, combat inflammation, and endeavor to bring about union between the dislocated bone and the tissues. Often, in unreduced dislocation, the skin sloughs over the project- ing bone. Excision is demanded the moment sloughing is seen to be inevitable. Cases of compound dislocation of the astragalus require immediate excision. Subastragaloid Dislocation.—This condition is a separa- tion of the astragalus from the os calcis and scaphoid, with- out separation of the astragalus from the bones of the leg. Pick states that the usual classification for these dislocations is forward, backward, inward, and outward, but that the dis- placement is, as a rule, oblique, the foot passing backward and outward or backward and inward. The causes are twists. Symptoms.—In subastragaloid dislocation the astragalus projects on the dorsum ; the foot is everted in outward dis- location and inverted in inward dislocation; the relation of the malleoli to the astragalus is unaltered ; the ankle-joint is not absolutely rigid ; the foot " is shortened in front and is • elongated behind " (Pick). Treatment.—To treat subastragaloid dislocation, make extension in the direction opposite to that of the displace- ment. In dislocation of the tarsus backward, fix a bandage around the foot, on a level with the heads of the metatarsal bones, which bandage the surgeon ties around his shoulders. 470 A MANUAL OF SURGERY. The surgeon puts one knee in front of the ankle and thus fixes the leg, raises himself up to make extension upon the tarsus, and moulds the bone into position. Tenotomy may be necessary. After reduction apply a silicate dressing for three weeks. The ankle-joint, fortunately, is not involved, and stiffness of this articulation need not be apprehended. If reduction is impossible, take the same course as in luxa- tions of the astragalus. Dislocations of the other tarsal bones are very rare. Single bones may be dislocated, or the luxation may occur at the medio-tarsal articulation. Symptoms and Treatment.—Projection is an obvious symptom in dislocation of the other tarsal bones. The treatment is to reduce by extension and moulding, the part being put up in silicate-of-soda dressing for two weeks. Dislocations of the metatarsal bones are rare. Symptoms and Treatment.—Shortening of the toes and projection of the dislocated bone are symptoms of disloca- tion of the metatarsal bones. To treat these dislocations, reduce by extension under ether and put' up in a silicate dressing for two weeks. If reduction fails, the functions of the foot will not be much impaired. Dislocations of the phalanges are very rare. The first phalanx of the big toe is the one most liable to dislocation. Symptoms and Treatment.—Dislocations of the phalanges are obvious. The treatment is by reduction as in disloca- tions of the thumb. Immobilize for two weeks. 5. Operations upon Bones. Osteotomy.—By the term osteotomy the modern surgeon means literally the sectioning of a bone for the purpose of straightening a limb ankylosed in a bad position, correcting a bony deformity, or amending a vicious union of a fracture. In a linear osteotomy the bone is transversely divided in one DISEASES AND INJURIES OF BONES AND JOINTS. 471 spot; in a cuneiform osteotomy a wedge-shaped portion of bone is removed. The operation of osteotomy may be per- formed with a saw (Fig. 86) or with an osteotome. The saw creates dust, draws much air into the wound, and lacerates the tissues to a considerable degree. Most surgeons prefer the chisel or the osteotome. The osteotome (Fig. 88) differs from a chisel in having two bevels instead of one. Osteotomy for Genu Valgum, or Knock-knee (Macewen's Operation).—In'this operation the instruments required are Fig. 87.—Rawhide Mallet. Fig. 88.—Osteotome. the scalpel, haemostatic forceps, osteotomes of several sizes, a mallet (Fig. 87), and a sand-bag wrapped in an aseptic towel. Operation.—The patient lies upon his back, being rolled a little toward the diseased side. The leg of the diseased side is partly flexed upon the thigh and the thigh upon the pelvis, and the extremity is laid upon its outer surface, the sand-bag being pushed between the extremity and the bed, opposite to the site of section. The flexion of the knee relaxes the popliteal vessels and saves them from injury. The surgeon, 472 A MANUAL OF SURGERY. if operating on the right leg, stands outside of that ex- tremity ; if operating on the left leg, he stands opposite the left hip (Barker). Enter the knife at the inner side of the knee, just in front of the adductor tubercle of the inner con- dyle and on a level with the upper border of " the patellar articular surface of the femur" (Barker); cut down to the bone, and make an incision upward one inch in length, in the direction of the axis of the femur. At the lower angle of this wound insert an oste- otome and turn it to a right Fig. 89.—Osteotomy of the Right Femur in a Case of Knock-knee: All, epiphyseal line; c, section of Macewen; de, section of Ogston. Fig. go.—Macewen's Operation for Genu Val- gum : the chisel is held in the line for striking with a mallet; the arrow shows the direction in which the chisel is levered up and down so as to make a wide gap in the bone (after Barker). angle with the shaft, half an inch above the epiphysis (Fig. 89); strike the osteotome several times with a mallet; move the handle several times toward and from the body, so as to widen the cut in the bone (Fig. 90); strike the osteotome again several times, move it again, and continue this process until the bone is cut one-third through. If the osteotome becomes tightly fixed, withdraw it and introduce a smaller one. When the bone is cut two-thirds through, withdraw the osteotome, hold a piece of wet antiseptic gauze over the opening, and fracture the femur by strong adduction. Do DISEASES AND INJURIES OF BONES AND JOINTS. 473 not suture nor drain the wound, but dress it antiseptically, wrap the entire extremity in cotton, and apply a plaster-of- Paris dressing up to the groin. This dressing may be re- moved in two weeks, and the patient may subsequently be treated with sand-bags, but without extension, as for an ordinary fracture of the thigh. This operation is scarcely ever fatal. Ogston's Operation (Fig. 89).—In this operation the inter- nal condyle is sawed off obliquely with an Adams saw—a proceeding which permits the straightening of the knee. The objection to this operation is that it opens the knee- joint, and that this cavity fills up more or less with a mixture of blood and bone-dust. Macewen's operation is decidedly the safer. Osteotomy for a Bent Tibia.—In this operation the in- struments required are the same as those indicated in the above operation. The tibia is divided transversely or obliquely (linear osteotomy), or a wedge-shaped piece is removed (cuneiform osteotomy). The oblique incision is the best. If the convexity of the tibial curve is inward, cut the bone from above downward and from in front backward; if the curve is forward, section the bone from above down- ward and from within outward. The fibula need rarely be interfered with. Osteotomy for Faulty Ankylosis of the Hip-joint.— This operation is performed in order to allow straightening of a limb which has undergone bony ankylosis in a faulty or an inconvenient position. In some cases an attempt is made to obtain a movable joint, but in most cases the sur- geon must be satisfied with an ankylosis in extension. Osteotomy may be performed through the neck of the femur or through the shaft of the femur below the tro- chanters. Osteotomy through the neck of the femur is performed 474 A MANUAL OF SURGERY. (i) with a saw (Adams's operation) or (2) with an osteo- tome. 1. Adams's Operation (Fig. 91).—In this operation the instruments required are a scalpel, haemostatic forceps, a long, blunt-pointed tenotome, and an Adams saw. Operation.—The patient lies upon his sound hip; the sur- geon stands upon the side to be operated upon, and back of the patient. The knife is entered a finger's breadth above the great trochanter, is pushed in until it strikes the neck of the bone, is then carried across the front of and at a right angle to the neck, and is withdrawn, enlarging the wound in the soft parts, as it emerges, to the extent of an inch. The saw is now intro- duced and the neck is entirely divided. After the osteotomy dress the wound anti- septically and place the extremity straight. To straighten the limb it may be found Fig. 91.—Osteotomy ° J through the Neck of necessary to cut contracted tendons and the Femur: A, Adams s -' operation.' B' Gant's fascial bands. Apply the weight-extension apparatus and the sand-bags. Begin passive movements from the start if a movable joint is desired; few patients can tolerate the pain necessary to bring this about. If it is determined to aim for a stiff joint, treat the case as an intracapsular fracture would be treated. 2. With an Osteotome.—The instruments required in this operation are the same as those used for genu valgum. No sand-bag is required. The position of the patient is the same as that in Adams's operation. An incision one inch long is made, starting just above the great trochanter, ascending in the axis of the femoral neck, and reaching to the bone. An osteotome is introduced, is turned to a right angle with the bone, and is struck with a mallet until the bone is completely divided. (It is not to be divided partially and then broken.) DISEASES AND INJURIES OF BONES AND JOINTS. 475 The after-treatment is the same as that for Adams's opera- tion. The operation with the osteotome is to be preferred to that by the saw. Osteotomy of the Shaft of the Femur below the Tro- * chanters (Gant's Operation).—In this operation (Fig. 91) the saw may be used, but the osteotome is to be preferred. The instruments employed are the same as those used for Adams's operation, plus an osteotome. Operation.—The position in Gant's is like that in Adams's operation. A longitudinal incision one inch long is made upon the outer aspect of the femur and on a level with the lesser trochanter. The osteotome is inserted and the bone is completely divided below the lesser trochanter. The after-treatment is the same as that for Adams's operation. Gant's operation is the best method for correcting faulty position in bony ankylosis, and Adams's operation can only be employed in those cases where the femur still has a neck which practically is unchanged. Osteotomy for Faulty Ankylosis of the Knee-joint.— This operation is performed for bony ankylosis of a knee in a position of flexion. The instruments employed are the same as those used for genu valgum. Operation.—The patient lies upon his back with his thighs flat upon the bed, the legs hanging over the end of the bed. The surgeon stands on the patient's right side. Just above the patellar articular surface upon the femur a transverse incision is made, one inch in length and reaching to the bone. The osteotome is introduced and the bone is cut * nearly through. The leg is then forcibly extended. Do not extend too violently, or the popliteal vessels may be injured. In cases where the structures of the popliteal space are , tense, do not at once bring the leg into extension, but do so gradually by means of weights. The wound is dressed , antiseptically, and the extremity is placed upon a double 476 A MANUAL OF SURGERY. inclined plane and is treated as for fracture near the knee- joint. Osteotomy for vicious union of a fracture is performed in case of angular deformity, and is carried out in the same manner as are the above procedures. It is best, when pos- sible, to enter the osteotome upon the concavity of the bent bone, so as not to rupture the periosteum when extension is made, and to thus enable one to gain a longer limb. Osteotomy for Hallux Valgus.—In this operation a linear osteotomy is made through the neck of the metatarsal bone of the great toe, the toe is forcibly adducted, and a splint is applied to the inside of the foot and the toe. Osteotomy for Talipes Equino-varus.—The instruments required in this operation are a scalpel, haemostatic forceps, a narrow, blunt-pointed saw, special directors, bone-cutting forceps, sequestrum forceps, and scissors. Operation (after Barker).—The patient lies upon his back, the thigh is semiflexed, the knee is bent, and the sole of the foot rests upon the table. The surgeon stands to the right side if it is the right limb operated upon, or to the left side if it is the left limb. Feel for the outer surface of the cuboid bone, and cut away from over the latter a piece of skin corresponding in size with the bone-wedge intended to be removed (this piece of skin must include the bursa which forms in these cases). Turn the foot outward, find the astragalo-scaphoid articulation, over which make an incision " from the lower to the upper dorsal border of the scaphoid bone " (Barker), reaching through the skin only; place the foot again in the first position, raise all the soft parts from off the superior surface of the tarsus, and clear a triangular surface corresponding with the base of the wedge to be removed ; pass a " kite-shaped " director (Fig. 92) from the external wound, and cause it to project from the internal wound; push the saw through the groove of the director DISEASES AND INJURIES OF BONES AND JOINTS. 477 nearest the toes, and saw through the tarsus, from the dor- sum to the sole, at right angles to the metatarsal bones; push the saw through the groove of the director nearest the ankle, and saw from the dorsum to the sole, at right angles to the long axis of the calcaneum ; grasp the wedge- shaped piece of bone with sequestrum forceps, and cut it out with scissors, with bone-for- ceps, or with a blunt bistoury. The wound is well irrigated, the foot is straightened, the internal wound is sewed up, the external wound is sutured except at its lowest portion, where a drain- age-tube is to be retained for twenty-four hours, and the wound is dressed antiseptically. The foot is put up in plaster or is put upon a Davy splint. Osteotomy for Talipes Equinus.—This operation is de- scribed by Mr. Davy, who devised it, as follows :l " Taking the line of the transverse tarsal joint as a guide, on the outer and inner sides of the foot, and immediately over the joint, two wedge-shaped pieces of skin are removed, equal in extent to the amount of bone demanded. The soft structures are freed on the dorsum of the foot in the way previously described; but, as the base of the osseous wedge for equinus cases is at the dorsum and its apex at the sole, the parallel wire director, instead of the kite-shaped varus one, is used. The saw is successively inserted in its grooves, and by keeping in mind the idea of a keystone a clean wedge of bone is cut out from the dorsum to the sole of the foot." The wedge is extracted, and the foot is straight- ened and is put in plaster or in a Davy splint. Bone-grafting, or Transplantation (see p. 303). Osteotomy and Wiring for Ununited Fracture.—The instruments required in this operation are a scalpel, haemo- 1 Barker's Manual of Surgical Operations. 478 A MANUAL OF SURGERY. static forceps, dissecting-forceps, retractors, Allis's dissector, an awl or special drill (Figs. 93, 94), chisels, a mallet, a fine saw, lion-jaw forceps, and silver wire. In operating, incise longitudinally down to the seat of fracture, retract the periosteum from the bone, drill the bones before cutting them, chisel away the material of imperfect union, saw through each end far enough from the seat of fracture to reach sound tissue, pass large silver wires through the holes (this wire should be one-tenth inch in diameter for the femur, one-sixteenth inch for the patella, etc.), twist the Fig. 93.—Hamilton's Improved Bone-drills. Fig. 94.—Wyeth's Drills, with Adjustable Handle. wires a fixed number of times (two) in the direction that the hands of a watch move (this is Keen's direction in case removal of the wires should be demanded), sever the ends of the wires, and hammer their stems against the bone. The wires may never require removal. Dress the part as a recent fracture. In fracture of the patella an incision is made in the long axis of the limb, above the middle of the space between the fragments, from well above the upper fragment to well below the lower piece; this incision divides all the soft parts. The soft parts are retracted, but the peri- osteum is undisturbed; each fragment is bored (Fig. 95, a) DISEASES AND INJURIES OF BONES AND JOINTS. 479 in one or two places ; the surfaces of the fragments are cut square through sound bone with a saw; all old reparative material is cut away; the wires are passed through the per- foration, twisted, cut off, and hammered down as before (Fig. 95, b). A small drain is inserted, the wound is sutured, antiseptic dressings are applied, and the limb is put upon a Mac- ewen splint. Treves's Operation for Caries of the Lumbar and Last Dorsal Vertebrae.—In this operation the right loin is chosen for incision, as a rule. The instruments required are a scalpel, haemostatic forceps, grooved director, an Allis dissector, sequestrum forceps, curette spoons, and a sand-bag. Operation.—The patient lies up- on his left side, with the knees drawn up and a sand-bag under him. The surgeon stands behind the patient (Barker). An incision is made at the outer border of the erector spinae mass, reaching from the last rib to the iliac crest and going down at once to the lumbar fascia. The lumbar aponeurosis is opened, the erector spinae is retracted inward, and the anterior portion of the erector spinae sheath is incised. The quadratus lumborum muscle is next cut, and then the ante- rior leaflet of the lumbar aponeurosis is slit. Loose pieces of bone are removed with forceps, and cavities are thor- oughly curetted. The wound is irrigated with corrosive sublimate and is dusted with iodoform; a large tube is inserted; the wound is packed with iodoform gauze, is partly closed by sutures of silkworm gut, and is dressed antiseptically. Fig. 95.—Wiring of the Patella (after Barker): A, fragments cut and cleaned and the wires passed ; u, wires twisted and hammered down upon the bone. 480 A MANUAL OF SURGERY. Aspiration of Joints.—In certain cases of joint-effusion from inflammation, tubercular or otherwise, and sometimes in hemorrhage into a joint, it is desirable to remove the fluid by aspiration. The pneumatic aspirator is used (Fig. 96). The trocar and canula are thoroughly asepticized and the joint is prepared as for a set operation. The needle is entered at a surface free from vessels. The directions for using an aspirator are as follows: Insert the stopper firmly into a strong bottle (a clear glass one preferred), then attach the short elastic hose to the stop-cock b of the tube projecting from the stopper, and attach the other end of the same elastic hose to the exhausting or inward-flowing cham- Fig. 96.—Aspirator and Injector. ber of the pump. Next attach one end of the longer elastic hose to the stop-cock a projecting from the stopper, and the other end to the needle. Care should be taken that all the fittings or attachments are placed firmly into their respective places. Now close the stop-cock a and open stop-cock b, and by giving from thirty-five to fifty strokes of the pump a sufficient vacuum can be produced to fill with the fluid from the joint a bottle holding from a pint to a quart. DISEASES AND INJURIES OF BONES AND JOINTS. 481 After having formed the vacuum, close the stop-cock b, and the instrument is ready for use. The trocar may be used to inject corrosive-sublimate solution, 1 : 1000 (Halstead), or carbolic-acid solution, 1 : 20. The joint is dressed antisep- tically and is put at rest upon splints. Excisions of Bones and Joints.—Excision or resection of a joint is the removal of the articular portions of the bones of the joint, and also the cartilage and synovial membrane. In the hip-joint and shoulder-joint the head of the long bone only may be removed, and not the articular surfaces of both bones. In excision enough bone is known to have been re- moved only when the remaining bone bleeds. Excision of a bone is the removal of an entire bone or of a portion of it. Excision is a conservative operation which often averts amputation. Excision may be performed by the open method, in which the periosteum is not preserved, or it may be performed by the subperiosteal method, in which the periosteum is carefully separated by a rugine and the capsular ligament is preserved. Arthrectomy, or erasion, is the excision of the synovial mem- brane of a joint. Excision may be employed for compound dislocation, and it is usually performed in compound dislocations of the elbow and the shoulder. Excisions for compound disloca- tions in other large joints are very dangerous; they should not be attempted in battle-field practice, and are to be avoided even in civil practice unless the patient is young and vigorous and every advantage can be given him during * the operation and convalescence. Excision for deformity is rarely performed except upon the hip, the knee, and the shoulder, and these excisions must not be employed if the patient's condition leads one to fear the result of a protracted convalescence. Excision of the elbow, however, is usually a safe operation. In excising for deformity, always consider 31 482 A MANUAL OF SURGERY. the patient's trade and the demands of habitual position which it makes upon him.1 Excision is largely employed for joint disease, especially for tubercular joints. Bell states that attempts to preserve the limb without excision are more largely justifiable in the lower than in the upper limbs, because operation in the lower extremity is more dangerous than in the upper, and because a cure without operation in the lower limbs, if this cure can be brought about, gives as good a result as a cure by ex- cision. In the upper extremities the danger from operation is less than is th^e danger from waiting. In a young subject an excision may remove the epiphysis, and thus lead to per- manent shortening, which is productive of less inconvenience , and deformity in the arm than in the leg. The great danger of excision operations is that the section may be made through cancellous bony tissue; hence suppuration, phlebitis, myelitis, septicaemia, or pyaemia may follow; further, in ex- cision the cut is through diseased tissue, and a protracted convalescence is often inevitable. Amputation is effected through healthy tissue, and the convalescence is short. Excision, however, when successful, gives the patient a very useful limb. Erasion, or Arthrectomy.—Erasion is the complete ex- cision of diseased synovial membrane. This operation seeks to remove a depot of infection in an early stage of tubercular synovitis, and it possesses the conspicuous merit of not interfering with the epiphysis. Erasion is oftenest practised upon the knee-joint. The instruments required are a scalpel, haemostatic forceps, dissecting forceps, toothed forceps, volsellum, scissors, bone-gouges, curettes, and an Esmarch apparatus. Operation upon the Knee.—The patient lies upon his back ; • the limb is flexed with the sole of the foot planted upon the 1 Joseph Bell, in his Manual of Surgical Operations. DISEASES AND INJURIES OF BONES AND JOINTS. 483 table, and an Esmarch bandage is applied to a point well up on the thigh. The surgeon stands to the right of the patient. The incision starts in the mid-line of the thigh (on the side opposite to that occupied by the surgeon), about three inches above the patella ; it is carried down across the ligament of the patella and up to a corresponding point on the opposite side of the thigh. This incision is made down to the bone; the flap is turned up and the joint exposed; the knee-joint is strongly flexed, and the synovial membrane and diseased ligaments are dissected away with scissors and forceps, great care being taken that the posterior ligaments (which, fortu- nately, are rarely implicated early in the case) are not divided and that the contents of the popliteal space remain intact. After removing the diseased ligaments and synovial mem- brane, examine the cartilage and remove any diseased por- tion, and then examine the bone and gouge away any tubercular foci. Ligate any exposed vessels, irrigate the wound and dust in iodoform, straighten the extremity, suture together the ends of the ligamentum patellae, suture the skin after inserting a drainage-tube in each angle, dust iodoform over the wound, and dress antiseptically. Put the limb upon a posterior splint for a few days, then take out the drainage-tubes, re-dress antiseptically, and put up in a plaster-of-Paris dressing, cutting trap-doors upon each side and keeping the joint immobile for two or three weeks. This operation is only suited to early cases, in which it gives a good result, some capacity for motion being not unusually preserved. Excision of the Shoulder-joint.—In the shoulder-joint partial excision is often performed, the head of the humerus being removed and the glenoid being undisturbed ; but some patients require complete excision, the entire glenoid depres- sion, as well as the head of the humerus, being removed by the surgeon. Excision of the shoulder-joint is made, if 484 A MANUAL OF SURGERY. possible, an intracapsular operation, the capsule being opened, but the capsular attachment to the anatomical neck not being interfered with. In bad cases, however, the capsular attachment must be destroyed. This operation is rare in civil, but is common in military practice; it is per- formed in gunshot wounds, in compound dislocations, in tubercular disease, and in tumors of the head and upper por- tion of the humerus. The instruments required are a scalpel, an Adams saw, an osteotome or chisel, a mallet, an Allis dissector, a periosteum-elevator, haemostatic forceps, dissect- ing-forceps, toothed forceps, lion-jawed forceps, sequestrum forceps, metal retractors, curettes, and cutting bone-forceps. Operation by Anterior Incision.—The patient lies supine; a pillow is placed beneath the shoulders, and a sand pillow is put beneath the shoulder to be operated upon. The arm is held to the side with the outer condyle forward and the bicipital groove inward (Barker's directions). The surgeon stands upon the affected side. An incision three or four inches in length is made from just external to the cora- Fig. 97.—i-io, Amputations: i, of lower third of forearm (Teale's); 2, at shoulder-joint by large postero-external flap (second method); 3, at shoulder-joint by triangular flap from deltoid (third method); 4, 5, through tarsus (Chopart's); 6, 7, at knee-joint; 8, by single flap (Carden's); 9, 10, of thigh (Teale's). A, excision of hip; b, of ankle-joint (Hancock's incision). Fig. 98.—1-18, Amputations : 1, amputation at wrist-joint (dorsal incision); 2, at wrist- joint (palmar incision); 3, at forearm (dorsal incision); 4, at forearm (palmar incision); 5, at elbow-joint (anterior flap); 6, at arm (Teale's); 7, at shoulder-joint (first method); 8,9, of metatarsus (Hey's); 10, n, at ankle (Syme's) ; 12, 13, of leg, posterior flap (Lee's) ; 14, at knee-joint (Carden's); 15, of thigh (B. Bell's); 16, of thigh (Spei.ce'sl ; 17, of thigh in mid- dle third; 18, at hip-joint. A, excision of wrist (radial incision); B, of wrist (ulnar incision). Fig. 99.—1-9, Amputations : 1, of arm by double flaps ; 2, at shoulder-joint; 3, at ankle- joint by internal flap (Mackenzie's); 4, 5, of leg just above the ankle-joint (Syme's) ; 6, 7, 1 below the knee (modified circular); 8, through condyles of femur (Syme); 9, at lower third of thigh (Syme). a, excision of head of humerus; B, of knee-joint (semilunar incision). Fig. 100.—1-8, Amputations : 1, at elbow-joint (posterior flap); 2, at shoulder-joint, pos- terior incision (first method); 3, at ankle-joint (Mackenzie's); 4, through condyles of femur (Syme); 5, at lower third of thigh (Syme); 6, at knee (posterior incision); 7, of thigh t (Spence's); 8, at hip-joint, a-g, Excisions : a, excision of shoulder-joint (deltoid flap); b, of shoulder-joint (posterior incision); c, of elbow-joint (H-shaped incision); d, of elbow-joint (linear incision); e, of hip-joinl (Gross's); f, of os calcis; G, of scapula. DISEASES AND INJURIES OF BONES AND JOINTS. 485 Fig. 99. FlG- IO°- Amputations and Excisions (Joseph Bell; see p. 484). 486 A MANUAL OF SURGERY. coid process, running straight down the humerus (Fig. 99, a). This incision divides the border of the deltoid muscle and brings into sight the long head of the biceps. The tendon of the biceps is retracted inward, unless it is dis- eased, in which case it is resected. The knife is carried up the groove and opens the capsule of the joint. The peri- osteum is lifted from the neck of the bone while an assistant rotates the elbow to make the muscles tense. In some places, if the periosteum tears, muscular insertions must be cut with a knife. The head of the bone is sawn off while the bone is in place, or the elbow is strongly pulled back, the head of the bone is forced out of the wound, and is then sawn off at the point required. In ordinary cases, remove only the articular head; in other cases make the section just above the surgical neck ; in yet others remove a portion of the shaft. If the glenoid cavity is found diseased, any dead bone must be removed by the chisel and mallet or by the cutting-forceps. Scrape away all damaged tissue; ligate bleeding points; irrigate the wound with corrosive-sub- limate solution; swab it out with a solution of chloride of zinc (gr. xx to 3j); dust with iodoform ; close the upper portion of the wound and insert a drainage-tube in the lower angle; dress the wound antiseptically; place a small pad in the axilla; apply the second roller of Desault; and put the patient in bed with a pillow under the affected shoulder. In seven days the hand-sling is substituted for the bandage, and with the elbow hanging free the patient is permitted to get up and is advised to move his arm fre- quently. Drainage is maintained until the wound is well healed from the bottom. Excision by the deltoid flap is performed when the head of the bone is much enlarged (as by a tumor) or when the tissues are thick and indurated. The deltoid flap is in the shape of a V or is semilunar (Fig. ioo, a). Raising this DISEASES AND INJURIES OF BONES AND JOINTS. 487 flap exposes the head of the bone most satisfactorily. Bell states that when the glenoid cavity is chiefly involved the incision should be posterior (Fig. 100, a). Excision of the Elbow-joint.—This operation is per- formed for wounds, faulty ankylosis, and chronic articular disease. Excision must be complete. Endeavor to make a subperiosteal resection; this maintains the shape of the articulation and gives the best chance for a movable joint. The instruments used are the same as those for the shoulder, plus a Butcher saw. Operation.—The patient is " supine, but inclining to the sound side, the affected arm being held almost vertical, with the forearm flexed and nearly horizontal " (Barker). The incision is made on the posterior surface of the joint. A single posterior incision is usually employed (Fig. 100). An incision is made a little internal to the long axis of the olecranon, and reaching two inches above and two inches below the tip of the olecranon. This incision goes down to the bone, and throughout the entire operation the surgeon must guard and shield the ulnar nerve. The periosteum and soft parts are well separated ; the olecranon is sawn off; forced flexion exposes the joint-cavity freely, and enables the surgeon to lift the periosteum and soft parts from the humerus; the humerus is sawed through at the beginning of its condyloid processes; the radius and ulna are cleared and are sawn at a level below that of the base of the coro- noid process of the ulna. Cut and spoon away diseased tissues, the wound being irrigated, closed, drained, and dressed. In some cases an H-shaped incision is employed (Fig. 100, c), but the cicatrix of a transverse cut will limit flexion of the limb. After excision of the elbow the patient is put to bed and the arm is laid upon a pillow, the elbow being placed mid- way between a right angle and complete extension, the fore- 488 A MANUAL OF SURGERY. arm being placed midway between pronation and supination. No splint is used, as a rule. The aim in treatment is to obtain a freely-movable joint. Passive motion is begun in one week, Fig. ioi.—Esmarch's Splint for Excision of Elbow. when the patient gets up. The hand is carried for a time in a sling. Esmarch used the splint shown in Figure ioi. Excision of the Wrist-joint.—Bell states that, whatever method of excision is chosen, three cardinal rules must be borne in mind : (i) Remove all the diseased bone, including the portions of the radius, ulna, carpus, and metacarpus which are covered with cartilage; (2) interfere with the tendons to the least possible degree ; and (3) begin passive motion of the fingers very early. Many surgeons prefer the simple gouging away of diseased foci and the scraping of sinuses instead of a formal resection of the wrist, amputation being employed in severe cases or when scraping fails after several trials. Formal excision is not very often done, and the results cannot often be considered as very favorable. Lister's Open Method of Excision.—The instruments re- quired in this operation are the same as those used for any resection. Break up adhesions as completely as possible by forcible movements. Apply a tourniquet or an Esmarch appa- ratus. The patient lies upon his back, the arm and the fore- arm being brought, from stage to stage, into the most desirable positions. Begin an incision over the middle of the dorsum DISEASES AND INJURIES OF BONES AND JOINTS. 489 of the radius, on a level with the styloid process; carry it downward in the direction of the inner edge of the articula- tion of the thumb with its metacarpal bone, and when the knife reaches the radial side of the second metacarpal bone, alter the direction of the incision and carry it downward in the long axis of the metacarpal bone to about its middle (Fig. 98, a). This is known as the radial incision, and the only tendon divided is that of the extensor carpi radialis brevior muscle. The tissues upon the radial aspect of the incision are dissected up, the tendon of the extensor carpi radialis longior muscle is divided at its point of insertion (Bell), and all the soft structures are retracted outward, exposing the trapezium, which is cut off from the rest of the carpus, but which is left in place, as its removal at this stage endangers the radial artery (Barker). By extending the hand the tendons are loosened and the carpus is cleared in the direction of the ulnar border of the hand. Another incision is made, starting upon the inner surface of the wrist, two inches above the articular surface of the ulna, and midway between the ulna and the flexor carpi ulnaris tendon. This incision, which is known as the ulnar incision, is carried down until it is opposite the middle of the fifth metacarpal bone in the palm (Fig. 98, b). "The dorsal lip of this incision is raised " (Bell), and the extensor carpi ulnaris tendon is divided and dissected from its depres- sion, but is not separated from the integument. The extensor tendons are lifted up; the ligaments upon the dorsum and sides of the wrist-joint are cut; the flexor tendofis are lifted from the carpal bones; the pisiform bone is cut from the carpus, but is not yet removed; and the unciform process of the unciform bone is cut with forceps. The anterior radio- carpal ligament is divided, the carpo-metacarpal articulations are cut through, and the carpus is pulled out with bone- forceps. The ends of the radius and ulna are forced out of 49O A MANUAL OF SURGERY the ulnar incision. All that portion of the ulna which is crusted with cartilage is to be removed, the saw-cut is to be oblique, and the base of the styloid process is to be left behind. A thin section is to be sawn from the radius, and the tendon-grooves are not to be impinged upon. The artic- ular surface of the ulna is cut away with pliers (Bell). If foci of disease are discovered beyond these points, they are to be gouged out. The ends of the metacarpal bones are sawn off, and their articular facets are cut away by means of pliers. The trapezium is dissected out, the end of the first metacarpal bone is sawn off and its facet is cut away with pliers, and a portion of the pisiform bone is removed (the entire bone being removed if it be diseased). The wound is irrigated, vessels are tied, the radial incision is closed, the ulnar incision is partly closed, a drainage-tube is inserted by way of the ulnar incision, the wounds are dressed antiseptically, and the Esmarch apparatus is taken off. The forearm and hand are placed upon a splint which immobilizes the wrist and leaves the fingers semiflexed. The Fig. 102.—Esmarch's Interrupted Splint Applied. splint is worn for many months, until the wrist-joint is immo- bile and solid. Esmarch uses the splint shown in Figure 102. Passive motion of the fingers is begun after thirty-six hours. Excision of Metacarpal Bones and of Phalanges.— Excision of a metacarpal bone, except in cases of necro- DISEASES AND INJURIES OF BONES AND JOINTS. 491 SIS with the formation of large quantities of new bone, usually leaves a useless finger; hence amputation is pre- ferred usually to excision. This rule does not apply to the metacarpal bone of the thumb, which is occasionally resected. The incision for this operation is made upon the dorsum, and is straight. Excision of the proximal phalanx of the thumb is sometimes performed. Excision for disease is rarely performed upon the finger-joints, amputation being preferred, though the operation is sometimes undertaken for compound dislocation. In the metacarpo-phalangeal joint of the thumb, excision, if it can be performed, is preferred to amputation. The incision for resection of this joint is placed upon the radial aspect. Excision of the Hip-joint.— Some surgeons advocate this op- eration; others, notably Marsh, are emphatically opposed to it. Ex- cision should be performed in the early stage of tubercular disease if less radical treatment has failed, and in this stage the usual position of the limb is one of flexion, ab- duction, and eversion. In cases of long duration, especially where dis- cation exists, excision is an easy and a comparatively safe operation; in recent cases it is difficult and carries with it decided dangers, but the peril cf delay is greater than is the peril of an early resection. In cases of hip disease with involvement of the acetabulum the mortality is fifty per cent., whether operation is or is not attempted. Excision is performed especially for tubercular disease and Fig. 103.—Excision of the Hip-joint: A, gluteus muscle ; B, tensor vaginae femoris muscle; c, sartorius muscle ; d, anterior incision. 492 A MANUAL OF SURGERY. for gunshot injuries (Fig. 103). The instruments required are those used for other excisions. Operation by Anterior Incision (Parker's Operation).—In this operation the patient is supine, with the thighs extended as thoroughly as circumstances permit. The surgeon stands to the right of the patient. An incision is begun half an inch below and half an inch external to the anterior superior iliac spine, and it is carried downward and a little inward for about three inches (Fig. 103, d). If dislocation exists, the incision must not be so long. This incision is carried at once deeply between the muscles, and the capsule of the joint is opened. The neclc of the bone is divided from its upper surface downward with a saw or an osteotome, and without dislocating the bone through the wound by forcible extension and eversion. The head of the bone is removed. All tubercular foci are scraped away, and the gouge is used upon tubercular areas of the acetabulum. All sinuses are most thoroughly scraped. Bleeding is arrested, the wound is irrigated with corrosive-sublimate solution, mopped out with chloride-of-zinc solution, and dusted with iodoform. A drainage-tube is inserted at the lower angle of the incision, and the upper portion of the cut is closed. The wound is dressed antiseptically. Extension is made with the extension apparatus until healing has obtained a good headway, when a double Thomas splint is applied, so that the patient can be taken out daily in the air and sunlight. Seek to obtain a movable joint by passive motions. This joint will, how- ever, rarely be very firm. Operation by Lateral Incision.—In this operation a straight incision two inches long is made in the direction of the axis of the femur, and runs downward from the apex of the great trochanter. From the beginning of this incision a curved incision is carried toward the head of the bone, the convex- ity of the curve being backward (Fig. 97, a). Bell advises DISEASES AND INJURIES OF BONES AND JOINTS. 493 the use of the saw after bringing the head of the bone into the wound by adduction and eversion of the thigh. Barker applies the saw with the bone in situ, and strongly opposes wrenching the bone out of the incision, because of the danger of peeling off the periosteum, which peeling, if it takes place, favors necrosis. Incision of Gross.—In Gross's operation a semilunar flap is made with the convexity backward (Fig. 100, e). Excision of the Knee-joint.—In this operation a com- plete excision should be performed, and the patella ought to be removed. This operation is performed in tubercular dis- ease, in some compound fractures and compound dislocations, and in some cases of angular ankylosis, but it is not suitable for gunshot injuries, amputation being advisable (Ashurst). The instruments required are the same as those for the shoulder, plus Butcher's saw. Operation by Anterior Semilunar Flap.—The patient lies upon his back, and the joint, if not ankylosed in extension, is semiflexed. The surgeon stands to the right side. An incision is made, at once opening the joint, starting from one condyle and reaching the other condyle by a downward curve which passes through the ligamentum patella midway between the tuberosity of the tibia and the inferior margin of the patella (Fig. 99, b). The flap is dissected up, the knee is thrown into forced flexion, the lateral ligaments and crucial ligaments are cut, and the end of the femur is well cleared. The blade of Butcher's saw is passed beneath the bone, which is sawn from below upward (Ashurst). The end of the tibia is cleared and a portion is sawn off. If, after sawing, diseased foci are discovered, another section can be sawn off or the foci can be gouged away. Prof. Ashurst, who is one of the highest of authorities, insists that in sawing through the femur the natural obliquity of the bone must be borne in mind and the section must be 494 A MANUAL OF SURGERY. made in " a line parallel to that of the free surface of the condyles." If the section is made transverse to the axis of the femur, "the limb, after adjustment, will be found to be markedly bowed outward." Ashurst says that the epi- physeal line is somewhat higher on the front than it is on the back of the femur, and in consequence the following rule is formulated for section of the condyles: The section of the condyles should be " in a plane which, as regards the axis of the femur, is oblique from behind forward, from below upward, and from within outward." Ashurst advo- cates section of the tibia " in a plane transverse to the long axis of the bone, with a slight antero-posterior obliquity, so as to correspond with that of the section of the condyles." Ashurst says also that the patella must be removed, whether it is diseased or not, and he quotes Peniere's observations to the effect that excision of the patella diminishes the risk of death one-third, and its retention doubles the chance of re- covery without a future amputation. After removing the patella the diseased synovial membrane is clipped away with scissors and all sinuses and diseased territories are well curetted. The posterior ligament of the joint is not removed unless it is diseased; its retention pre- vents displacement and guards the popliteal space. In chil- dren the fragments should be wired together; in adults this need not be done. After haemostasis irrigate, dust with iodo- form, insert a drainage-tube, suture, dress antiseptically, and adjust the limb upon Price's splint or Ashurst's bracketed wire splint. In some cases tenotomy is required to permit exten- sion. If the bracketed splint is used, place it in a fracture-box. If the femur tends to project anteriorly, use an anterior splint. If there be a tendency to outward bowing, adopt Ashurst's expedient of carrying a strip of adhesive plaster around the outside of the limb and fastening it to the inner side of the splint. The splint is kept on until bony union is complete, DISEASES AND INJURIES OF BONES AND JOINTS. 495 as in this operation a movable joint is never sought. Many surgeons use a plaster-of-Paris splint which is applied when healing is well advanced (Fig. 104). Fig. 104.—Watson's Plaster-of-Paris Swing-splint. Excision of the Ankle-joint.—This operation is performed chiefly in gunshot wounds, in compound dislocations, and in early cases of chronic joint disease. Complete resection is employed for chronic joint disease. Excision of the ankle is a rare operation. The instruments used are the same as those employed for any resection. Operation (Hancock's Method).—In this operation the pa- tient lies upon his back and the foot rests upon its inner side. The surgeon stands on the outer side of the damaged limb. Begin an incision just behind and two inches above the external malleolus, and carry it across the front of the joint to a corresponding point above and behind the internal malleolus (Fig. 97, b) ; this incision goes only through the skin, and the flap thus marked out is reflected. " Cut down upon the external malleolus, carrying the knife close to the edge of the bone both behind and below the process, dislodge the peronei tendons, and divide the external lateral ligaments " (Joseph Bell). Cut the fibula one inch above the malleolus by means of pliers; divide the tibio-fibular liga- 49<5 A MANUAL OF SURGERY. ment; turn the foot upon its outer side; dissect from their habitat back of the inner malleolus the tendons of the pos- terior tibial and the common flexor of the toes; carry the knife around the inner malleolus, close to the bony edge; separate the internal lateral ligament, and dislocate the lower end of the tibia through the wound by turning the sole of the foot downward; saw off the lower end of the tibia and the articular process of the astragalus, sawing away from the tendo Achillis, and remove the fragments with bone-forceps. Cut away diseased synovial membrane, and curette all sinuses and tubercular areas. Arrest bleeding, irrigate, Fig. 105.—Volkmann's Dorsal Splint for Excision of the Ankle. and drain. Sew up the wound, insert a tube at its outer angle, and pull it out at the inner angle. Apply antiseptic dressings, and put up the foot in fixed dressing or in splints at a right angle to the leg (Fig. 105). In Langenbeck's operation the excision is subperiosteal. If, in an excision of the ankle-joint, the astragalus is found extensively dis- eased, remove the entire bone. Excision of the Os Calcis.—In caries limited to the os cal- cis most surgeons prefer to gouge away the dead bone, leav- ing the periosteum and, if possible, a shell of healthy bone, and draining thoroughly. Others advocate excision in some DISEASES AND INJURIES OF BONES AND JOINTS. 497 cases. Extensive disease limited purely to the os calcis is rare, and most surgeons advise gouging for limited caries, and Syme's amputation in event of the disease extending beyond the periosteum or reaching adjacent bones. Operation by Subperiosteal Method.—In this operation the position assumed by the patient is supine with the leg extended and the foot resting on its inner side. The incision, which cuts the tendo Achillis and reaches the bone at once, is begun at the up'per border of the os calcis and the inner margin of the tendo Achillis, and is taken outward and horizontally forward to a point in front of the calcaneo- cuboid articulation. A vertical incision is begun near the forward termination of the initial incision, is carried across the outer edge and plantar surface of the foot, and terminates at the external margin of the inner surface of the os calcis. Some surgeons carry the vertical incision a little upward, toward the dorsum (Fig. IOO, f). The periosteum is entirely stripped with an elevator, the os calcis is removed, the cavity is packed with iodoform gauze, the wound is stitched, a drain is inserted posteriorly, and the foot is dressed antiseptically and put up in plaster at a right angle to the leg, trap-doors being cut for drainage. Excision of the astragalus is a rare operation. Operation by the Subperiosteal Plan.—Barker advises an incision going at once to the bone, from the " tip of the ex- ternal malleolus forward and a little inward, curving toward the dorsum of the foot." The foot is extended and turned inward, the periosteum is lifted, the bone is removed, and the wound is treated and the foot is dressed as is done in excision of the os calcis. Excision of the Metatarso-phalansreal Articulation of the Big- Toe.—In this operation, make a lateral incision and cut off or saw off the proximal end of the first phalanx and the distal third of the first metatarsal bone. 32 498 A MANUAL OF SURGERY. Excision of the Metatarsal Bone of the Big Toe (Butcher's Method).—In this operation a lateral straight incision is made, the periosteum is elevated, and the shaft is sawn from each extremity and removed. Excision of the clavicle may be required in dislocation, in caries, in necrosis, for gunshot wounds, in tumor of this bone, as a preliminary to ligation of the artery and vein in certain cases of amputation at the shoulder-joint, or in cases of removal of the entire upper extremity. In excision of the clavicle the position of the patient is the same as that for ligation of the third part of the subclavian artery (p. 277). An incision is made down to the bone, from the sterno-clavicular joint to the acromio-clavicular articulation. If the case is suitable, the periosteum is stripped and the bone is sawn and removed ; if not, the bone is sawn and each half is separately disarticulated. The wound is sutured and dressed, and the limb is put up in a Velpeau bandage. Excision of the Scapula.—Complete excision of the scapula is most usually performed for tumors. Partial ex- cision requires no detailed description, as it resembles the operation of sequestrotomy. In excision of the scapula the patient lies upon his sound side. Treves suggests the following incisions: One outside the vertebral border of the scapula, from its superior to its inferior angle; another from over the acromio-clavicular joint, along the acromion process and spine of the scapula to meet the first incision. Syme used an incision carried transversely inward from the acromion process to the vertebral border of the scapula, and another cut directly downward from « the centre of the first incision (Fig. 100, g). In the method of Treves1 the upper flap is reflected and the trapezius muscle is divided; the lower flap is reflected and 1 Treves's Manual of Operative Surgery, one of the very best books now before the profession. DISEASES AND INJURIES OF BONES AND JOINTS. 499 the deltoid muscle is divided. The patient's hand is placed on the sound shoulder; the muscles of the vertebral border are divided, the posterior scapular artery is tied, and while the vertebral border of the scapula is pulled toward the surgeon the serratus magnus muscle is cut, the upper border of the shoulder-blade is cleared, and the suprascapular artery is tied. The hand is now brought down to the side; the acromio-clavicular joint is disarticulated; the conoid and trapezoid ligaments are divided; the muscles of the coracoid process are cut; the capsule is incised, with the supraspinatus and infraspinatus, the subscapulars muscles, and the scapular origins of the biceps and triceps ; and finally the teres major and minor muscles are divided, the subscapular artery is tied, and the bone is removed. The wound is stitched, a drain is introduced, and antiseptic dressings are applied. The patient lies upon his back until healing is well under way, when the arm is placed in a sling. The drainage-tube may be removed in twenty-four hours. Excision of a Rib.—In caries the gouge and rongeur may remove the disease. In other cases excision is performed. In this operation the patient lies upon his sound side. The surgeon faces the patient. Make an incision down to the bone, in the long axis of the rib. The periosteum, if not diseased, is lifted from the bone, and the intercostal artery is thus saved from being cut. After sawing the bone beyond the limits of disease, remove it. During the sawing a metal retractor is held beneath the rib, between the rib and the periosteum. If the periosteum is diseased, remove it after tying the inter- costal artery. Curette sinuses. Pack with iodoform gauze for some days. Sew up the wound except at one end. Dress antiseptically and apply a binder. If a rib is re- sected in order to drain the pleural cavity, remove it by the subperiosteal section, ligate the artery after one-half of the rib has been removed, cut away the periosteum to 500 A MANUAL OF SURGERY. prevent re-formation of bone, and open the pleura. (See Operations upon the Chest and Estlander's Operation) Complete Excision of One-half of the Upper Jaw.— The whole upper jaw has been removed, but in what fol- lows only resection of one-half the jaw will be described. This operation is performed for malignant tumors of the superior maxillary bone or its antrum. Up to 1826, at which time Lizars of Edinburgh suggested the operation, tumors of the antrum were treated by scraping them away with a sharp spoon. Gensoul of Lyons in 1827 performed the first operation for resection of the upper jaw. This operation is not justifiable, except as a palliative measure, if the orbit is invaded, if the skin and subcutaneous tissues are infiltrated, or if the disease extends beyond the superior maxillary and palate bones. The instruments required are a mouth-gag; scalpels; strong scissors; dissecting, toothed, and haemo- static forceps ; bone-cutting forceps ; lion-jawed and seques- trum forceps; tooth-extracting forceps; a volsella; a narrow- bladed saw; a chisel and mallet; a periosteum-elevator; a spatula or metal retractor; a Pacquelin cautery; sponges which are tied to sticks; needles, curved and straight; silk and catgut ligatures; silkworm-gut sutures; a Rever- din needle; and Horsley's anti- septic bone-wax. Operation by Median Incision.— The patient, whose face is shaved, is placed upon a Trendelenburg chair, and the head is lowered, thus avoiding the possible need of instant tracheotomy. The surgeon stands upon the right side of, and faces, the patient. The incisor tooth on Fig. 106.—ab, Excision of the Upper Jaw ;cde, Excision of the Lower Jaw. DISEASES AND INJURIES OF BONES AND JOINTS. 501 the diseased side is pulled out. The incision (Fig. 106, line ab) is begun half an inch below the inner canthus of the eye, and is carried along the side of the nose, around the ala of the nose, by the margin of the nostril, and through the middle of the lip. While the lip is being incised the assistant arrests hemorrhage by grasping the corners of the mouth, and after the lip is divided the coronary arteries are at once ligated. Some operators approach the mucous membrane cautiously and ligate the vessels before opening the cavity of the mouth. The upper portion of the wound having been compressed by another assistant during these manipulations, pressure is now removed and bleeding points are ligated. Another incision is now carried outward from the beginning of the first incision, along the orbital margin to well over the malar bone. The flap is lifted from the periosteum, and the bleeding from the infraorbital artery and the small vessels is re- strained by pressure. The nasal car- tilage is separated from the bone, and the nasal process of the superior maxillary is sawn (line a b, Fig. 107). The orbital periosteum is lifted up, and the orbital plate is cut with for- ceps from the saw-cut in the superior maxillary bone to the sphenomax- illary fissure (line b c, Fig. 107). The malar bone is sawn or is bitten through about its centre, the cut running into the spheno-maxillary fissure and taking a downward and outward direction (line c d, Fig. 107). The soft parts covering the hard palate are incised in the median line, a corresponding incision is made along the floor of the nose near the septum, and the Fig. 107.—1. Excision of the Upper Jaw: ab, section of the nasal process ; bc, section of the orbital plate; D, section of the malar bone and orbital plate ; e, section of the alveolus and hard palate. 2. Excision of the Lower Jaw: G, section of the inferior maxillary; H, section of the ramus in partial resection. 502 A MANUAL OF SURGERY. soft palate is separated from the hard palate by a trans- verse cut. The saw is introduced through the nose, and the palate is sawn (line E, Fig. 107). The upper jaw-bone is grasped with Fergusson's lion-jaw forceps and removed, the removal being aided by the use of the scissors and bone- cutters ; the latter are used to separate the upper jaw and the pterygoid process (Treves). Every vessel that can be seen is tied, and severe bleeding from bone is arrested by antiseptic wax. Oozing is controlled by hot water and pressure or by the Pacquelin cautery. Examine carefully to see if all the diseased area is removed ; if it is not, use the gouge, scissors, chisel, and saw until healthy tissue is reached. The wound is packed with iodoform gauze, and the end of the strip is so placed as to be accessible through the mouth. The wound is sutured (the mucous membrane of the lip must be stitched, as well as the skin) and is dressed antiseptically (the eye being protected by aseptic gauze), and a crossed bandage of the angle of the jaw is applied. Excision of One-half of the Lower Jaw.—In some rare instances the entire bone is removed. The lesions necessi- tating removal of the lower jaw are the same as in the case with the upper jaw. The instruments required are those used for excision of the upper jaw, plus a metacarpal saw (having a movable back) and a large curved needle. In this operation the patient is placed in the same position as that for excision of the upper jaw, the chin being shaved. A vertical cut is made through the chin-tissue, starting below the margin of the lip and reaching to below the border of the jaw (c d, Fig. 106). From the point d an incision is car- ried outward below the border of the jaw and then back of the ramus, as shown in the line d e (Fig. 106). Treves's ad- vice is to carry this incision down to the bone, except at the line of the facial artery, at which point it must only go through the skin. The facial artery is now to be sought DISEASES AND INJURIES OF MUSCLES, ETC. 503 for, tied in two places, and divided. The periosteum is lifted from the external surface of the bone, from the symphysis outward. Hemorrhage is arrested. The buccal mucous membrane is cut from the alveolus. A lateral incisor tooth is pulled, and the bone is sawn in the line g (Fig. 107). The bone is grasped in a lion-jaw forceps and is drawn out- ward. The mylo-hyoid insertion is cut; the internal ptery- goid muscle is cut or the periosteum at this spot is lifted; the inferior dental artery is cut and tied ; the jaw is pulled down ; the insertion of the temporal muscle upon the coronoid pro- cess is cut away; and the external pterygoid muscle is divided. The capsule of the joint is opened, and the bone is separated from the ligaments which still hold it in place. Bleeding is arrested, the wound is sutured, a tube is introduced in the posterior portion of the wound and retained for twenty-four hours, and antiseptic dressings and a Gibson or a Barton band- age are applied. Partial excisions of the alveolus may be performed through the mouth by means of chisels and rongeur forceps ; but if any considerable part of the body of the jaw is to be removed, an incision should be made below the jaw. XIX. DISEASES AND INJURIES OF MUSCLES, TENDONS, AND BURS^. Myalgia, or muscular rheumatism, is a painful disorder of the voluntary muscles and of the fibrous and periosteal areas where they are attached. The term " muscular rheu- matism " is not strictly correct. It is possible that in some cases the muscular structure is inflamed, but it is certain that in many cases the pain is distinctly neuralgic. Muscular rheumatism may be due to cold and wet, to over-exertion and strain, to acute infectious disorders, to syphilis, to chronic intoxications (lead, mercury, and alcohol), and to disturb- ances of the circulation. Gouty and rheumatic persons are 504 A MANUAL OF SURGERY. especially predisposed, men being more liable to the disease than women. The disease is usually acute, but it may be chronic. Symptoms.—Muscular rheumatism is apt to come on sud- denly. The pain, which may be very acute and lancinating or may be dull and aching, is in some cases constantly present; in other cases it is awakened only by muscular con- traction. The pain is frequently relieved by pressure, though there is often some soreness. The disease usually lasts for a few days, but it tends to recur. There is little, if any, fever. Lumbago is myalgia of the muscles of the loins. Rheu- matic torticollis is myalgia of the muscles of the neck. Usually one side of the neck is attacked. The chin is turned from the affected side and the neck is stiff. Pleurodynia is myalgia of the intercostal muscles. The pain is very severe, is aggravated by deep respiration, by coughing, and by yawning, there may be tenderness, and the patient tries to limit chest-movement. In intercostal neuralgia the pain is limited, is not constant, but occurs in distinct paroxysms, and is linked with the tender spots of Valleix. Pleurodynia lacks the physical signs of pleurisy. Myalgia must not be confused with the pains of locomotor ataxia. Cephalodynia is myalgia of the muscles of the scalp. The muscles of the shoulder, upper dorsal region, abdomen, and extremities may also be attacked by myalgia. Treatment.—Remove any obvious cause. Treat any exist- ing diathesis, such as gout or rheumatism. Rest is of the first importance. For lumbago, put the person to bed. For pleurodynia, strap the side of the chest. A hypodermatic injection of morphia and atropia into the affected muscles at once allays the pain, and a deep injection of water is often curative. The introduction of four or five aseptic needles into the muscles, and their retention for a few minutes, often acts like magic. Ironing the muscles is a good domestic DISEASES AND INJURIES OF MUSCLES, ETC. 505 remedy. Vigorous rubbing of the area with a piece of ice allays the pain. Hot poultices do good. If the pain is widely diffused, alters its seat, or is very obstinate, order hot baths or a Turkish bath and diuretics. In chronic cases employ blisters or counter-irritation by the cautery and give iodide of potash and nux vomica. The constant electric current finds advocates. In an ordinary severe case order a hot bath, put the patient to bed with a hot poultice over the part, and order 10 grains of Dover's powder; the next day give him four times daily a capsule containing 5 grains of salol and 3 grains of phenacetin. Myositis may be a widespread inflammation of the volun- tary muscles, due to an unknown infective cause. It is a disorder accompanied by pain and stiffness, by cutaneous oedema, and by various paraesthesiae. Myositis resembles trichinosis, and is distinguished from it only by spearing out a bit of muscle and examining it microscopically. Occasion- ally diffuse suppuration occurs. Ordinary myositis arises from injuries, from syphilis, or from rheumatism, and it pre- sents the usual inflammatory symptoms. Contraction and adhesion may follow. Treatment.—Infective myositis is treated by anodynes, stimulants, nutritious food, hot applications, and rest. If pus forms, it should be evacuated. Rheumatic myositis calls for the salicylates, the alkalies, or salol. Syphilitic myositis is treated with mercury and iodide of potassium. The rem- edies employed for myalgia are used in traumatic myositis. Hypertrophy of the muscles may arise from their in- « creased use. In pseudo-hypertrophic paralysis the bulk of the muscle is greatly augmented, but it contains less muscle- structure and more fat or connective tissue. Hypertrophy of the tongue, which is due to lymphangioma, is called ' " macroglossia " (see p. 209). Atrophy of the muscles arises from want of use, from 506 A MANUAL OF SURGERY. injury, from continuous pressure, from interference with the blood-supply, from disease of the nerves or their centres, or from lead-poisoning. Degeneration of Muscles.—The muscles may undergo granular degeneration, waxy degeneration, fatty degenera- ^ tion, and calcareous degeneration, and may become pig- mented. Local Ossification and Myositis Ossificans.—It is not un- usual for a small portion of bone to form in the bony inser- tion of a muscle which is subjected to frequent strain. In persons who ride many hours a day there not unusually develops the " rider's bone," which is an area of ossification in the adductor muscles of the thigh. Myositis ossificans, a widespread ossification of the muscles, is a rare disorder the cause of which is unknown, and which, if not congenital, begins at least in early life. Tumors of the Muscles.—Primary tumors of the muscles are rare. Among those which may occur are sarcoma, fibroma, lipoma, osteoma, angeioma, myxoma, and enchon- droma. Syphilis may cause inflammation. Gummata may form, or gummatous infiltration may take place. * Trichinosis or trichiniasis is a disease due to the embryos of the trichinae spiralis. The disease originates from eating insufficiently cooked meat which contains the trichinae. These nematodes are thus carried into the intestine, there to develop and to multiply. In from seven to nine days a / horde of embryos have developed in the intestines, and they leave the intestine by passing through the peritoneum or by » means of the blood, and finally reach the connective tissue of the muscles. From the connective tissue the embryos migrate into the primitive muscle-fibres, where they dwell and enlarge. Myositis develops, and in the course of five or six weeks the parasites become encapsuled and develop DLSEASES AND INJURIES OF MUSCLES, ETC. S°7 no further. The cyst-wall may calcify, and the worm ma)' become calcified or it may live for years. Because infected meat is eaten the disease does not inevitably develop, and a few embryos lodged in muscle may cause no symptoms. Symptoms.—The symptoms of trichinosis often appear in a day or two after eating infected meat. The symptoms of acute gastro-intestinal catarrh or of cholera morbus are com- mon, but in some cases no gastro-intestinal manifestations usher in the disease. In from seven to fourteen days after the infected meat is eaten the migration of the parasites develops obvious symptoms. A chill may be noted ; there is usually fever; muscular pain, tenderness, swelling, and stiffness are complained of. This condition may be widespread. Involve- ment of the muscles of mastication interferes with chewing; of the larynx, with audition and respiration; of the inter- costals and diaphragm, with respiration. Skin-oedema and itching are marked. In some cases delirium exists. The writer saw in the Philadelphia Hospital one fatal case which was mistaken for erysipelas because of the high fever, the delirium, and the cedematous redness of the face and neck. Dyspnoea is frequent. Mild cases get well in a week or two ; severe cases may last many weeks. The mortality varies in different epidemics from I to 30 per cent. (Osier). The diagnosis is made by spearing out a piece of muscle which is then examined for trichinae under a microscope; or the worm may be detected in the feces by means of a pocket- lens. Treatment.—To treat trichinosis, employ purgatives (senna and calomel) early in the case, and give glycerin, and also santonin or filix mas. When muscular invasion has taken place, sedatives, hypnotics, nourishing diet, and stimulants are indicated. Wounds and Contusions of the Muscles.— Wounds of muscles may be either open or subcutaneous. In a longitudinal 508 A MANUAL OF SURGERY. wound the edges lie close together, and hence drainage must be thorough. In a transverse wound the edges separate widely, and catgut stitches must be inserted. Contusions of muscles, like contusions of other tissues, vary in extent and in severity. There are pain (which is increased by attempts # i to use the muscle), loss of function, swelling beneath the deep fascia, and discoloration, which may appear at once because of superficial damage from the initial injury, or which may appear in dependent parts after many days by gravitation of the blood and the blood-stained serum. As a result of contusion, suppuration, inflammation, or atrophy may arise. Treatment.—The indications in wounds and contusions of muscles are to obtain rest by means of splints and to secure relaxation. Limitation of swelling is secured by bandaging. Inflammation is combated first by cold and lead-water and laudanum, later by iodine, blue ointment, ichthyol, and inter- mittent heat. To prevent loss of function, employ, as soon as the acute symptoms subside, massage, passive motion, and stimulating liniments, and, later in the case, electricity (galvanism if the reactions of degeneration exist, faradism if they are absent). » Strains and Ruptures.—A strain is a stretching of a muscle with a small amount of rupture. The muscle is swollen, tender, stiff, weak, and sore, and attempts at motion produce sharp pain. Strains are common in the deltoid, the hamstring muscles, the back, the calf, the biceps, and the great pectoral. " Lawn-tennis arm " is a strain of the pro- nator radii teres muscle. " Rider's leg " is a strain of the * adductor muscles of the thigh. Treatment.—A strain is treated in the same way as is a contusion. Rupture of a muscle is announced by a sudden and vio- lent pain and by loss of function during powerful muscular DISEASES AND INJURIES OF MUSCLES, ETC. 509 contraction or strong traction on a muscle. The rupture may be announced by a distinctly audible snap (A. Pearce Gould). A distinct gap is felt between the ends ; great pain develops on movement; there are tenderness and swelling. Strains and ruptures may be followed by atrophy, as are contusions. Treatment.—In treating rupture of an important muscle, when the ends are widely separated, incise with every aseptic care, unite the divided ends by catgut sutures, and sew up the skin with silkworm gut. Treat the part in any case by rest and relaxation, and combat inflammation by appropriate means. Passive motion and massage are employed as soon as union is firm. Hernia of Muscles.—When a breach exists in a muscular sheath, a portion of the muscle protrudes. The treatment is incision and the stitching of the fascia. Contractions of muscles may result from injury, from joint-disease, from malposition of parts (as in old disloca- tion or torticollis), or from diseases of the nervous system. The treatment in some cases is sudden extension, in other cases gradual extension, tenotomy, or myotomy. Macewen recommends the making of a number of V-shaped incisions in the muscle. In some cases of spasmodic contraction nerve-stretching is of value. Dislocation of Tendons.—The long head of the biceps is oftenest displaced. The flexor carpi ulnaris and the pero- neus brevis may be dislocated. Most of these accidents are associated with chronic joint disease or with fracture, but displacement may exist as a solitary injury. Symptoms.—In dislocations of the tendons the muscle will contract, but it acts at a disadvantage; thus the correspond- ing joint exhibits partial loss of function. The displaced tendon can be felt, and a hollow exists where it used to reside. 5io A MANUAL OF SURGERY. Treatment.—In tendon-dislocation reduction is easy, but the displacement is apt to recur because of laceration of the sheath. The treatment is by splints and by lead-water and laudanum. Passive movements are begun at the end of the first week. Even if the tendon will not stay reduced, a use- m ful joint will be obtained. Wood of New York advised in obstinate cases tenotomy and immobilization. Open incision may be necessary. Wounds of Tendons.—Subcutaneous wounds of tendons are usually inflicted by the surgeon, and they heal well. Open wounds require rigid antisepsis and the suturing of the tendon. In wounds of the wrist especially always suture the tendons (Figs. 109 to 112), and be sure to bring the proper ends into apposition. Rupture of Tendons.—A violent muscular effort may rupture a tendon, and a snap can often be heard. The symp- toms are sudden pain and loss of power, fulness of the asso- ciated muscle from retraction, and absolute inability to bring the tendon into action. A gap can often be felt in the tendon. Treatment.—The best procedure in treating rupture of a tendon is incision and tendon-suture. Some surgeons relax * the parts and apply splints. Thecitis or teno-synovitis is inflammation of the sheath of a tendon. Acute thecitis may arise from a contusion, from a wound, from repeated over-action in working, from rheumatism, from gonorrhoea, or from syphilis. Symptoms.—In nonsuppurative cases of thecitis the symp- » toms are pain, swelling, tenderness, and moist crepitus along the tendon-sheath, due to inflammatory roughening. The crepitus disappears as the swelling increases, but it reappears as the swelling diminishes. In suppurative cases the symp- toms are great swelling, pulsatile pain, dusky discoloration, DISEASES AND INJURIES OF MUSCLES, ETC. 5 11 inflammation spreading up the tendon-sheaths, and the con- stitutional symptoms of sepsis. Treatment.—In treating non-suppurative thecitis, employ splints and apply locally iodine, blue ointment, or ichthyol. Treat any causative constitutional state. In the suppurative form make free incisions, irrigate, and drain. Palmar Abscess.—A suppurative thecitis of the flexor tendons of the fingers travels rapidly upward and is apt to produce a palmar abscess. Thecitis of one of the three middle fingers is usually arrested at the lower end of the palm, but suppurative thecitis of the thumb or the little finger diffuses pus over a large surface of the palm and also up the arm. Palmar abscess is a most serious affection. The pus may dissect up all the structures of the palm, may reach the dorsum, or may pass beneath the anterior annular ligament into the connective-tissue planes of the forearm. Treatment.—A palmar abscess demands free incision and drainage at the earliest possible moment. The incision is made in the line of the metacarpal bone. A line transverse with the web of the thumb is below the palmar arches. In an incision above this line, try not to cut the arch, but if it be cut, ligate at once. Chronic thecitis is usually a tubercular inflammation of a tendon-sheath. The swelling is firm or doughy when due to granulation tissue, but is fluctuating when due to fluid. Grating is marked. The tendon-sheath may contain numer- ous small bodies which are either free or are attached (rice, riziform, or melon-seed bodies). Tubercle bacilli are present in the fluid or in the granulation tissue. Chronic thecitis is commonest in the tendons of the fingers, the ankle, and the knee; it may spread to a joint or it may arise from a tuber- cular joint. This condition causes very little pain. Treatment.—In cases of fluid effusion, make a small in- 512 A MANUAL OF SURGER Y. cision, wash out with iodoform emulsion, and close the wound. In cases of rice bodies, open the sheath, evacuate the contents, scrape the walls thoroughly, inject with iodo- form emulsion, and close the wound. (If the annular liga- ment is divided, stitch it together; Fig. 112.) In cases with extensive formation of embryonic tissue, apply an Esmarch bandage, make a large incision, and remove all infected tis- sue from the sheath, around the sheath, and from the tendon. Ganglia.—In connection with tendon-sheaths simple ganglia may develop. They are small, tense, round swell- ings, which are firm, grow progressively though slowly, are painless when uninflamed, and contain a fluid of the appearance and consistence of glycerin jelly (Bowlby). These ganglia are commonest upon the dorsum of the wrist, and they occur especially in those who constantly use the wrist-muscles. Paget states that a simple ganglion is due to cystic degeneration of a synovial fringe inside a tendon- sheath, and that the fluid of the ganglion does not communi- cate with the fluid of the tendon-sheath. Other pathologists believe a simple ganglion to be a hernia of synovial mem- brane through a rent in a tendon-sheath, all way of com- munication being soon obliterated. Compound ganglion is an old name for tubercular thecitis. Treatment.—Ganglia are treated by aseptic puncture with a tenotome, evacuation, scarification of the walls, antisep- tic dressing, and pressure. An old-time method of treat- ment was subcutaneous rupture brought about by striking with a heavy book. Recurrent ganglia, very large ganglia, and ganglia with very thick contents should be dissected , out. Felon, whitlow, or paronychia is a suppuration of a finger or a toe due to abrasion which may be very slight, pus organisms being carried inward. The commonest seat of a felon is the last digit of a finger, because the superficial DISEASES AND INJURIES OF MUSCLES, ETC. 5 13 lymphatics run directly inward. Superficial felon usually occurs in children and in persons broken down in health. More than one finger is apt to be attacked, and the felon usually appears as a suppuration around the nail (a ring- around). The symptoms are pain, suppuration, and, in bad cases, loss of the nail. In deep felon (bone-felon) the finger is very hot, tense, and painful, the pain being pulsatile and much increased by motion, by pressure, or by a dependent position. Pus soon forms. An abscess may form in the superficial tissues as well as in the depths. Treatment.—A superficial felon demands instant incision in all cases, and the patient should subsequently be ordered tonics and a change of air. A bone-felon should be incised at once to the bone alongside the tendon. Do not wait for pus to form, but allay tension and prevent pus-formation by early incision. Do not waste time with poultices: to wait means agonizing pain, sleepless nights, constitutional involvement, and perhaps sloughing of tendons or death of the bone. Incision and drainage constitute the treatment, followed by irrigation, antiseptic dressing, and splinting of the extremity. If the patient cannot sleep, give morphia. See that the bowels are moved once a day. Give quinine, iron, and milk punch. Opening a felon is exquisitely pain- ful ; hence ether should be given to the first stage, nitrous oxide should be administered, or the superficial parts should be frozen by a spray of chloride of ethyl. Bursitis is the inflammation of a bursa. Acute bursitis arises from strain or from traumatism. The symptoms of acute bursitis are pain, limited swelling, moist crepitus, fluc- tuation, and discoloration in the anatomical position of a bursa. Bursitis of a deep bursa is hard to separate from synovitis ; indeed, the joint is apt to become secondarily affected. Suppuration may take place. Chronic bursitis may follow acute bursitis, or the disease may be chronic from 33 514 A MANUAL OF SURGERY. the start. Its symptom is swelling with little or no pain unless acute inflammation arises. Treatment.—Acute bursitis is treated at first by rest and pressure and with lead-water and laudanum; later with iodine, blue ointment, or ichthyol. If the swelling persists, aspirate. If pus forms, incise, swab out the sac with pure carbolic acid, and pack it with iodoform gauze. If some causative diathesis exists, it should be treated. Housemaid's knee is thickening and enlargement of the prepatellar bursa due to intermittent pressure. In effusion into the knee-joint the fluid is behind the patella and the bone floats up; in housemaid's knee the fluid is above the bone and the osseous surface can be felt beneath it. " Miner's elbow," which is a condition similar to housemaid's knee, affects the olecranon bursa. Treatment.—Housemaid's knee is treated by incision and packing with iodoform gauze. In bursitis of the bursa be- neath the ligamentum patellae, if rest and blistering fail to cure, aspirate or incise. In bursitis below the tendon of the semimembranosus, incise or aspirate. Bunion.—A bunion is a bursa due to pressure, and it is most commonly found above the metatarso-phalangeal articu- lation of the great toe, but occasionally over the joint of another toe. When the big toe is pushed inward by ill- fitting boots a bunion forms. When a bunion is not in- flamed it may cause but little trouble, but when it is inflamed the bursa enlarges and the parts become hot, tender, and excessively painful. Suppuration may occur and pus may invade the joint, and the bone not unusually becomes dis- eased. Treatment.—In treating a bunion the patient must wear shoes that are not pointed, that have the inner borders straight, and that have rounded toes (Jacobson). For a mild case a bunion-plaster gives comfort. Dr. Sayre advises DISEASES AND INJURIES OF MUSCLES, ETC. 515 the use of a linen glove over the phalanges, which are to be drawn inward by a piece of elastic webbing one end of which is fastened to the glove and the other end to a piece of strap- ping from the heel. A special apparatus may be worn (Fig. 108). In many cases osteotomy of the first phalanx or of the first metatarsal bone is required; in some cases excision of the joint is necessary; in others amputation must be performed. When the bursa is not inflamed, but only thickened, blisters should be employed over it, or there should be ap- plied tincture of iodine, ichthyol, or mercurial ointment. When the bursa inflames, lead- water and laudanum is applied, and intermit- tent heat by foot-baths gives relief. Suppura- tion demands immediate incision and antiseptic Apparatus for Bun- dressing. If an ulcerated bunion does not heal Ions by antiseptic dressing, stimulate it with silver and dress it with unguent, hydrarg. nitrat. (1 part to 7 of cosmoline). Jacobson recommends skin-grafting for some cases. Operations upon Tendons.—Tenotomy is the cutting of a tendon. It may be open or subcutaneous, the open opera- tion being preferred in dangerous regions, and the method of its performance being obvious. The subcutaneous method will here be described. Tenotomy of the Tendo Achillis.—In this operation the tendon is cut about one inch above its point of insertion. The instrument used is a sharp tenotome. The patient lies upon his back " with his body rolled a little toward the affected side " (Treves), the foot being placed upon its outer side on a sand pillow. The surgeon stands to the outside. The tendon is rendered moderately rigid, and the sharp tenotome, with its blade upward, is carried inward along the anterior border of the tendon until the surgeon's finger feels the knife on the outer side. The tendon is now drawn 5i6 A MANUAL OF SURGERY. into rigidity, and the surgeon turns the blade of his knife toward the tendon, places his finger over the skin, and saws toward his finger. The tendon gives way with a snap. Treves states that a beginner is apt not to push his knife far enough toward the outside or he may push his knife through the tendon; in either case the tendon is not completely cut. The little wound, which is covered with a bit of gauze, will be entirely closed in forty-eight hours. In club-foot cases after tenotomy some surgeons at once correct the deformity and immobilize the limb in plaster; some partially correct the deformity and apply plaster for one week, at which time they remove the plaster, partly correct the deformity, reapply the plaster, and so on; other surgeons do not attempt cor- rection of the deformity until the cut tendon has begun to unite, when they gradually stretch the new material. Tendon-suture and Tendon-lengthening.—The instru- ments required in these operations are an Esmarch apparatus; L 1 Fig. no.—Anderson's Method of Ten- don-lengthening. Fig. 109.—Tendon-sutures : a, of Le Fort; B, of Le Dentu; c, of Lejars. curved needles and needle-holder; chromicized gut, kangaroo tendon, or silk for an ordinary case, silver wire for a sup- purating wound. In performing tendon-suture, make the part aseptic and bloodless ; find the ends of the tendon, and be sure the proper ends are brought into contact; stitch them together with a continuous suture or with one of the sutures shown in Figure 109, A, b, and c. In a suppurating wound ORTHOPEDIC SURGERY. 517 suture by silver wire should be tried, though it usually fails. After suturing, remove the Esmarch apparatus, arrest bleed- ing, suture the wound and dress it antiseptically, relax the parts, and place the limb on a splint. If a flexor tendon of the wrist is cut, approximate the ends by flexing the finger of the cut tendon and extending the other fingers. If, after suturing, there is much tension, stitch the cut tendon above the sutures to an adjacent tendon. Dress with plaster, the finger of the cut tendon being flexed, the others being ex- tended. Begin passive motion after one week. If only one end of the tendon can be found, graft it upon the nearest tendon with a like anatomical course and function. In old injuries, when the ends cannot be brought into apposition, lengthen one end or both ends either by the method of Czerny (Fig. in) or by the method of Anderson (Fig. 110). N— l V Fig. 112.—Method of Suturing ' the Annular Ligament of the Fig. in.— Czerny's Method of Tendon-lengthening. Wrist. These methods of lengthening may be used in cases of de- formity from a contracted tendon. If the tendon cannot be lengthened sufficiently, make a bridge of catgut from one end of it to the other, or graft in another tendon from the same person or from one of the lower animals. The annular ligament is sutured as shown in Figure 112. XX. ORTHOPEDIC SURGERY. This branch of surgery formerly dealt only with the treat- ment of deformities by means of mechanical appliances, but of recent years its domain has been enlarged to include the treatment, surgical and mechanical, of deformities, contrac- tures, and many joint diseases* 5 l8 A MANUAL OF SURGERY. Torticollis (wry-neck) is a condition in which contraction of certain of the neck-muscles causes an alteration in the position of the head. The disease is one-sided ; the sterno- cleido-mastoid is the muscle chiefly involved, though the trapezius, splenius, and other muscles sometimes suffer. « Acute torticollis, which is rare, results from cold or from injury (see Myalgia). Chronic torticollis may be congenital, it may be due to nerve-irritation, or it may be due to an assumed attitude because of eye-defect. Chronic torticollis may be intermittent, but is usually spastic. The muscie stands out in bold outline, the head is turned to the oppo- site side, the ear of the disordered side is turned toward the shoulder, and the chin is thrown forward. There is no pain. Spinal curvature may arise. The head can often be restored to its normal position by passive movement or by voluntary effort, but it at once returns to its habitual position. The corresponding side of the face atrophies. Symptoms.—Congenital wry-neck is due to central nervous disease, to spinal deformity, or to injury during delivery, and in this form the sterno-mastoid is shortened, hardened, and atrophied. It may not be noticed for some years because of the short neck of infancy, and it is associated with asymmet- rical development of the face. It is almost invariably upon the right side. Spasmodic wry-neck may present tonic spasm only, intermittent spasm alone, or both may appear alter- nately. It is a disease especially of adults; in women it is often linked with hysteria. The exciting cause may be a cold, a blow, or a mental storm; the predisposing cause is the neurotic temperament. In some rare cases bilateral * spasm occurs, the head being pulled backward and the face being turned upward. Clonic spasms may come on unan- nounced, or they may be preceded by pain and stiffness; g the head can be held still for a moment only; there is sometimes pain, always fatigue, but during sleep the contrac- ORTHOPEDIC SURGERY. 519 tions cease. The attack will probably pass away, but will almost certainly recur. Treatment.—Congenital wry-neck is treated by tenotomy (through an open wound) and the use of proper braces and supports. The old subcutaneous tenotomy should be abandoned, as aseptic incision enables the surgeon to see and to feel all the contracted bands of fascia, muscle, and tendon, and to avoid dangerous structures. In spas- modic wry-neck treat the neurotic temperament; in per- sistent cases stretch, or divide and exsect a part of the spinal accessory nerve. To reach this nerve, make an in- cision along the posterior edge of the sterno-cleido-mastoid, find the nerve as it emerges from under the middle of the muscle, and retract the muscle at this point. For the treat- ment of rheumatic wry-neck see Myalgia (p. 504). Dupuytren's contraction is a contraction of the palmar fascia, of its digital prolongations, and of the fibres joining the fascia and skin. Fixed contraction of one or of more fingers occurs. The ring-finger and the little finger most often suffer. The disease arises oftenest in men beyond middle age. The cause of this disease is unknown: some think it is gout or rheumatism, others that it is trauma- tism, reflex irritation, or neuritis. Symptoms.—Dupuytren's contraction is indicated by a small hard lump or crease which appears over the palmar surface of the metacarpophalangeal joint. This nodule grows and the corresponding .finger is pulled down. In some cases the tip of the finger is forced against the palm. The skin becomes dimpled or puckered. Treatment.—In treating Dupuytren's contraction subcu- taneous multiple incisions may be made, the tense fascia and the fascio-cutaneous fibres being cut. The finger is straight- ened and is placed upon a straight splint, which is worn continuously for a week or ten days and is worn at night * 520 A MANUAL OF SURGERY. for at least a month. Dr. Keen divides the skin by a V-shaped cut, the base of the V being down, and dissects out the contracted tissue. Syndactylism (webbed fingers) is always congenital, and may persist through several generations. Simple incision of the web is useless; the operation to be performed is that of Agnew or of Diday (Figs. 113, 114). Fig. 113.—Agnew's Operation for Webbed Fingers (Pye). Fig. 114.—Diday's Operation for Webbed Fingers (Pye). Polydactylism (supernumerary digits) is always con- genital, is often hereditary, and is usually symmetrical. There may be an incomplete digit, or there may be an entire and well-developed finger or toe with a metacarpal or meta- tarsal bone. The connection to the metatarsus or metacar- pus may be by a fibrous pedicle only. If the digit is com- plete, with a metacarpal bone, no operation is required; if it is incomplete or is ill-developed, it should be removed. Genu valgum (knock-knee) results from an unnatural growth of the internal condyle, causing the shaft of the femur to curve inward and the internal lateral ligament of the knee-joint to stretch, the knees coming close together and the feet being widely separated. This deformity is usu- ally noted when the child begins to walk, but it may not appear until puberty or even long after. Knock-knee may arise from rickets, from an occupation demanding prolonged standing, or from flat-foot. It may be noted in one knee or in both knees. ORTHOPEDIC SURGERY. 521 Treatment.—Mild rhachitic cases of knock-knee may re- main in slight deformity or may get well from improvement of the general health. In ordinary cases, simply treat the rickety condition. The patient is forbidden to stand or to walk, and the limb, after being put as straight as it can be, is fixed on an external splint and a pad is put over the inner condyle. Later in the case plaster-of-Paris is used. Some surgeons prefer to immobilize, in which case the leg is flexed to a right angle with the thigh. In a severe case the surgeon can immobilize after forcibly straightening (causing an epiphyseal separation) or after the performance of osteotomy (Fig. 90). Osteotomy is preferable to fracture by a mechanical appliance (osteoclasis). Genu varum (bow-legs) is the opposite of knock-knee. Usually both legs are bowed out, the knees being widely separated, the tibiae and femurs, as a rule, being curved, and the feet being turned in. This disease is due to rickets, the weight of the body producing the deformity in early life. In older people incurable bow-legs may arise from ar- thritis deformans. Treatment. — Some mild cases of genu varum recover from improvement of the health. Ordinary cases are treated by braces, by plaster- of-Paris bandages, and by attention to the general Fig. us-—Talipes fig. n6.-TaiiPes , , „.. ,, , Equinus (Albert). Calcaneus (Albert). health. When the bones have hardened, osteotomy or osteoclasis is indicated. Talipes (club-foot) is a deviation of the foot not due to traumatism. Talipes equinus (Fig. 115) is a confirmed ex- tension; talipes calcaneus (Fig. 116) is a confirmed flexion; talipes varus is a confirmed adduction ; and talipes valgus is 522 A MANUAL OF SURGERY. a confirmed abduction. Two of these forms may be com- bined, as in equino-varus (Fig. 117). The causes of talipes are under-action of some muscles, over-action of other muscles, or abnormality of bony form or position ; it may be congeni- tal or it may be ac- ^.; -« quired. The acquired H 1 form arises from infan- i|| - % tile paralysis; the con- W: m genital form is due to '^%i-'--W persistence of the foetal Jf form of the foot. sa&esi^^ Symptoms and Treat- Fig. 117.—Double Equino-varus {Am. Text-book ment__In club-foot the of Surgery). ..... , » position is obvious. In congenital cases the condition is usually manifest on both sides, and is nearly always talipes equino-varus. Congenital club-foot, where a restoration to position can take place, is treated by plaster-of-Paris bandages. If a child has begun to walk, it may still be possible to correct the deform- ity eventually by manipulations, by plaster-of-Paris bandages, or by club-foot shoes, but most cases require tenotomy of the tendo Achillis before the application of the shoe or the plaster. The club-foot shoe may do good service, but in many instances it is painful and is not so efficient as plaster. In severe cases, before applying the plaster, the patient is given ether; the surgeon cuts the tendo Achillis, the ten- dons of the anterior and posterior tibial muscles, and the plantar fascia, and forcibly corrects the deformity. In old cases with alteration in the shape of the bones, cuneiform • osteotomy (p. 474), or the removal of the cuboid or other tarsal bones, is indicated. In these cases Phelps advises a transverse incision through all the plantar soft parts. In talipes due to infantile paralysis the operative treatment is the same. Do not immobilize in plaster, but rather in some ORTHOPEDIC SURGERY. 523 Fig. 118.—Print of a Normal Foot-sole (a) and of a Flat Foot-sole (b) (Albert). apparatus which can easily be removed to permit the use of massage and electricity. In some cases of talipes calcaneus the surgeon may be forced to shorten the tendo Achillis. Pes planus (flat-foot) is the loss of the arch of the foot, due to ligamentous weakness and to prolonged standing. This condition is productive of much pain on standing. Flat-foot can at once be recognized by wetting the sole of the patient's foot with a colored fluid and causing him to step firmly upon a piece of paper (Fig. 118, a, b). Treatment.—To treat flat-foot deformity a shoe should be made containing a piece of steel so arranged as to raise the arch of the foot. The patient's general health must also be looked to. Pes cavus (hollow-foot) is an increase in the arch of the foot, due to contraction of the peroneus longus muscle or to paralysis of the muscles of the calf. It is the opposite of flat-foot. Treatment.—A shoe is worn containing a plate of steel in the sole, and pressure is applied over the instep. Tenotomy, cutting of the plantar fascia, or excision of bone may be required. Hallux valgus or varus, a displacement of the great toe outward or inward, may occur in the young, but it is most frequent in old men ; it may be due to rheu- matic gout. In hallux valgus a bunion is apt to form. Treatment.—An arrangement may be worn to straighten the toe and to protect the bun- ion, osteotomy may be performed upon the metatarsal bone, the joint may be excised, or amputation may be required. Hammer-toe (Fig. 119) is the flexion of one or more toes at the first interphalangeal joint. Shattuck shows that this » 524 A MANUAL OF SURGERY. condition is due to contraction of " the plantar fibres of the lateral ligaments of the joint."1 This disease usually begins in youth. A bunion is apt to form, and the joint may be dislocated. The treatment is excision of the joint or ampu- tation, i XXI. DISEASES AND INJURIES OF NERVES. i. Diseases of Nerves. Neuritis, or inflammation of a nerve, may be limited or be widely distributed (multiple neuritis). The first-men- tioned form will here be considered. The causes of neuritis are traumatism, wounds, over-action of muscles, gout, rheu- 4 matism, syphilis, fevers, and alcohol. Symptoms.—The symptoms of neuritis are as follows: Excessive pain, usually intermittent, in the area of nerve- distribution. The pain is worse at night, is aggravated by motion and pressure, and occasionally diffuses to adjacent nerve-areas or awakens sympathetic pains in the opposite side of the body. The nerve is very tender. The area of nerve-distribution feels numb and is often swollen. Early in the case the skin is hyperaesthetic; later it may become anaesthetic. The muscles atrophy and present the reactions of degeneration; that is, the muscles first ceases to respond to rapidly-interrupted, and next to slowly-interrupted, faradic currents ; faradic excitability diminishes, but galvanic excita- bility increases. When, in neuritis, faradism produces no contraction, a slowly-interrupted galvanic current which is so weak that it would produce no movement in the healthy * muscles causes marked response in the degenerated muscles. In health the most vigorous contraction is obtained by clos- ing with the — pole; in degenerated muscles the most * vigorous contraction is obtained by closing with the + pole. 1 American Text-book of Surgery. DISEASES AND INJURIES OF NERVES. 525 When voluntary power returns galvanic excitability declines, but power is often nearly restored before faradic excitability becomes manifest (Buzzard). Treatment.—The treatment of neuritis consists of rest upon splints, ice-bags early in the case, and hot-water bags later. Massage and electricity must be used to antagonize degeneration. Deep injections of chloroform may allay pain. Treat the patient's general health, especially any constitu- tional disease or causative diathesis. In some cases nerve- .stretching is advisable. Neuralgia is manifested by violent paroxysmal pain in the trajectory of a nerve. This disease belongs chiefly to the physician, except in very bad cases. Neuralgia of stumps and scars belongs to the surgeon, and is due to neuromata, or entanglement of nerve-filaments in a cicatrix. Tic douloureux and other intractable neuralgias may require severe operations. Treatment of Neuralgia of Stumps.—Excise the scar; find the bulbous end of the nerve and cut it off. In some cases re-amputation is performed. In entanglement of a nerve in a scar, remove a portion of the nerve above the scar. 2. Wounds and Injuries of Nerves. Section of Nerves (as from an incised wound).—In nerve- section the entire peripheral portion of the nerve degenerates and ceases structurally to be a nerve in a few weeks, but after many months, or even after years, the nerve again regenerates —with difficulty, if union of the ends has not taken place, with • much greater ease if the ends have united. The proximal end only suffers in the portion immediately adjacent to the section ; it degenerates, but rapidly regenerates, and a bulb or enlargement composed of fibrous tissue and small nerve- fibres forms just above the line of section ; this bulb adheres to the perineural tissues. Union of a divided nerve is brought 526 A MANUAL OF SURGERY. about by the projection of an axis-cylinder from each end and the fusion of these cylinders. The nearer the two ends are to each other, the better is the chance of union. Symptoms.—Pronounced changes occur in the trajectory of a divided nerve. The muscles degenerate, atrophy and shorten, and show the reactions of degeneration. When union of the nerve occurs the muscles are restored to a normal condition. If the nerve contains sensory fibres, com- plete anaesthesia (to touch, pain, and temperature) usually follows its division, but if a part is supplied by another nerve as well as by the divided one, anaesthesia may not be com- plete. Trophic changes arise in the paralyzed parts. Among these changes are muscular atrophy, glossy skin, cutaneous eruptions, ulcers, dry gangrene, painless felons, falling of the hair, brittleness, furrowing, or casting off of the nails, joint- inflammations, and ankylosis. Immediately after nerve-sec- tion vaso-motof paralysis comes on, and for a few days the paralyzed part presents a temperature higher than normal. The diagnosis as to which nerve is cut depends upon a study of the distribution of paralysis and anaesthesia.1 Treatment.—In all recent cases of nerve-section, suture the ends. If the patient is not seen until long after the accident, incise and apply sutures (secondary sutures); if the .nerve cannot be found, extend the incision, find the trunk above and trace it down, and find the trunk below and follow it up. Even after primary suture loss of function is bound to occur for a time. After secondary suture sensa- tion may return in a few days, but it may not return until after a much longer period ; in any case muscular function is • not restored for months. In partial section of a nerve the ends should be sutured. Pressure upon nerves may arise from callus, scars, pres- sure of a dislocated bone or a tumor, or pressure from an 1 See Bowlby on Lnjuries of Nerves. DISEASES AND INJURIES OF NERVES. 527 external body. The symptoms may be anaesthetic, paralytic, and trophic. The treatment is as follows: Remove the cause (reduce a dislocated bone, chisel away callus, excise a scar, etc.); then employ massage, douches, and electricity. Contusion of Nerves.—The symptoms of contusion of nerves may be identical with those of section. Sensation or motion, or both, may be lost. The case may get well in a short time, or the nerve may degenerate as after section. The treatment at first is rest, and later electricity, massage, frictions, and the douche. Punctured Wounds of Nerves.—The symptoms of punc- tured wounds of nerves may be partly irritative (hyperaesthe- sia, acute pain, and muscular spasm) and partly paralytic (anaesthesia, muscular wasting, and paralysis). The treat- ment is the same as that for contusion. 3. Operations upon Nerves. Neurorrhaphy, or Nerve-suture.—When a nerve is com- pletely or partially divided by accident, it should be sutured. The instruments required are an Esmarch apparatus, a scalpel, blunt hooks, dissecting-forceps, haemostatic forceps, curved needles or sewing-needles, a needle-holder, and cat- gut or kangaroo tendon. In primary suture render the part bloodless and aseptic. Enlarge the incision if neces- sary. If the ends can readily be approx- imated, pass two or three sutures through both the nerve and its sheath and tie them (Fig. 120). If the ends cannot be approximated, stretch each end and then suture. Remove the Esmarch band, arrest bleeding, suture the wound, dress antiseptically, and put the part in a relaxed position on a splint. After union of the wound remove the splint and use massage, frictions, electricity, and the douche. The operation in some instances fails, Q 528 A MANUAL OF SURGERY. jP^c but in many cases succeeds. In some few cases sensation returns in a few days, but in most cases does not return for many weeks or months. Sensation is restored before motor power. Secondary suture is performed upon cases long after division of a nerve. The part is rendered aseptic and bloodless; an incision is made; the bulbous proximal end is easily found and loosened from its adhesions; the shrunken distal end is sought for and loosened up (it may be necessary to expose the nerve below the wound and trace its trunk upward); the entire bulb of the proximal end is cut off; about one-quarter of an inch of the distal end is removed (Keen) ; each end is stretched, and the ends are approximated and sewn together. If even stretching does not permit >isp. of approximation, adopt one of Fig. 121.—Suture of a Nerve by Bowlby's expedients (Fig. I2l) Or Splitting the Ends (Beach). . . graft a bit of nerve from a recently- amputated limb or from a lower animal (it makes no dif- ference as to whether the grafted nerve were motor, sensory, or mixed). Von Bergmann suggests shortening the limb by excising a piece of bone. Neurectasy, Neurotomy, and Neurectomy.—Neurectasy, or nerve-stretching, may be applied to motor, sensory, or mixed nerves. A nerve can be stretched about one-twentieth of its length (Vogt). Neurectasy has been employed for neuralgia, neuritis, muscular spasm, hyperaesthesia, anaes- thesia, painful ulcer, and the pains of locomotor ataxia. The operation, which was once the fashion, seems to benefit some cases, but it is not now thought so highly of as formerly. The incision for neurectasy is identical with the incision for neurectomy or neurotomy of the same nerve. Neurotomy, or section of a nerve, is only performed upon small and purely sensory nerves. It is performed chiefly for peripheral DISEASES AND INJURIES OF NERVES. 529 neuralgia or for some other painful malady. Neurectomy, or excision of a portion of a nerve-trunk, is only applicable to sensory nerves and to painful affections. Stretching of the Sciatic Nerve.—Some surgeons stretch the sciatic nerve by anaesthetizing the patient and holding the leg and thigh in line, strong flexion being made upon the hip, the entire lower extremity being used as a lever (Keen). This method, which has caused death, inflicts needless damage, and the operative plan is safer and better. The instruments required are a scalpel, haemostatic forceps, dis- secting forceps, an Allis dissector, retractors, and a scale with a handle and a hook. The patient lies prone, the thighs and legs being extended. An incision four inches in length is made a little external to the middle of the thigh, and going at once through the deep fascia; the biceps is found and is drawn outward; the nerve is found between the retracted biceps on the outside and the semitendinosus on the inside, resting upon the adductor magnus muscle. The nerve, which is caught up by the finger, is first pulled down from the spine and then up from the periphery, and finally the hook of the scale is inserted beneath the trunk and the nerve is stretched to the extent of forty pounds. Very rarely is a single ligature needed. The wound is sutured and dressed. If the incision is made higher up, just below the gluteo-femoral crease, the sciatic nerve will be found just by the outer border of the biceps. Neurectomy of the Infraorbital Nerve.—The instru- ments required in this operation are a scalpel, dissecting-for- vt ceps, aneurysm-needle, haemostatic forceps, blunt hooks, an Allis dissector, and metal retractors. The patient lies upon his back, the head being a little raised by pillows. The , surgeon stands to the outside of, and faces, the patient. A curved incision one and a half inches long is made below the lower border of the orbit. The nerve lies in a line 34 530 A MANUAL OF SURGERY. dropped from the supraorbital notch to between the two lower bicuspid teeth. The nerve is found upon the levator labii superioris muscle, and a piece of silk is passed under the nerve by an aneurysm-needle and firmly fastened. The upper border of the incision is drawn upward ; the periosteum < of the floor of the orbit is elevated and held by a retractor; the roof of the infraorbital canal is broken through ; the nerve is picked up far back with the blunt hook and is divided with scissors, and the entire nerve is drawn out by making traction upon the silk. The bleeding in the orbit is checked by pres- sure. The wound is stitched without drainage. Neurectomy of the Supraorbital Nerve.—In this opera- tion, shave off the eyebrow. The instruments required and the position of the patient are as for the operation upon the infraorbital nerve. A curved incision one inch long discloses the nerve as it emerges from the supraorbital notch or fora- men at the junction of the inner and middle thirds of the eyebrow. The nerve is pulled forward and cut off above and below. XXII. DISEASES AND INJURIES OF THE HEAD. i. Diseases of the Head. < In approaching cases of brain disorder, first endeavor to locate the seat of the trouble; next, to ascertain the nature of the lesion; and finally, to determine the best plan of treatment, operative or otherwise. In all operations upon the brain the surgeon must be able to determine accurately the situations of certain fissures and convolutions, the find- ing of the situations of these convolutions and fissures com- * prising the science of cranio-cerebral topography. The regional terms used in cranio-cerebral topography are derived from Broca (Fig. 122). The fissures and convo- . lutions of the brain are shown in Figures 123, 124, and 125. The fissure of Bichat is marked by a line on each side drawn DISEASES AND INJURIES OF THE HEAD. 531 from the inion to the external auditory process. A line from the glabella to the inion overlies the median fissure and the superior longitudinal sinus. The fissure of Rolando begins in the median line, half an inch posterior to the middle of the distance between the inion and glabella (Keen). This fissure runs downward and forward at an angle of 670 for a distance of three and three-eighths inches. Chiene finds the fissure of Rolando by the following method : He takes Fig. 122.—Skull showing the Points named by Broca : As, asterion (junc- tion of the occipital, parietal, and temporal bones); Basion, middle of anterior wall of foramen magnum; B, bregma (junction of the sagittal and coronal sutures) ; G, ophryon (on a level with the superior border of the eyebrows, and corresponding nearly to the glabella, the smooth swelling between the eyebrows); g, gonion (angle of the lower jaw); /, inion (external occipital protuber- ance) ; L, lambda (junction of sagit- tal and lambdoidal sutures); N, na- sion (junction of the nasal and frontal); Ob, obelion (the sagittal suture between the parietal foram- ina); P, pterion (point of junction of great wing of sphenoid and the frontal, parietal, and squamous bones. This may be H-shaped or K-shaped, or " retourne," in which the frontal and temporal just touch); S, ste- phanion (or, better, the superior ste- phanion, intersection of ridge for temporal fascia and coronal suture); S', inferior stephanion (intersection of ridge for temporal muscle and coronal suture). Fig. 123.—View of the Brain from Above (Ecker). a square piece of paper and folds it into a triangle (Fig. 126, 1); the angle bac of this triangle is 450 ; the edge da is folded back on the dotted line ae; the angle dae equals half of 450, or 22.50, and the angle cae equals the same (Fig. 126, 2); unfold the paper in the line ca; in the 532 A MANUAL OF SURGERY. figure thus formed bac=45° and eac —22.50; eab^67.5°, which is the angle desired. Place the point a in the mid- line of the head, over the point of origin of the Ro- landic fissure; the side a b is laid along the middle line of the head, and the line a e corresponds to the fissure of Rolando.1 Horsley determines the situation of the Rolandic fissure by the use of his metal cyrtometer (Fig. 127). He places the point marked zero over the inio-glabellar line and mid- way between the inion and the glabella. To find the Fig. 124.—Outer Surface of the Left Hemisphere of the Brain (Ecker). Fig. 125.—Inner Surface of the Right Hemisphere of the Brain (Ecker). fissure of Sylvius (Fig. 124, S,s',s"), draw a line from the external angular process to the occipital protuberance. The fissure of Sylvius begins on this line one and one-eighth 1 American Text-book of Surgery. DISEASES AND INJURIES OF THE HEAD. 533 inches behind the external angular process; the main branch of the fissure runs toward the parietal eminence; the ascending branch of the fissure corresponds to the squamoso-sphenoidal suture, and continues upward in the same line half an inch above the suture. The preccntral sulcus (Fig. 124, f) limits anteriorly the ascending frontal c Fig, E B C E 6.—Chiene's Method of Fixing Position of the Rolandic Fissure {Am. Text-book of Surgery) convolution; it runs parallel with and just behind the coronal suture, and a finger's breadth in front of the fissure of Rolando. The intraparietal fissure (Figs. 123, 124, ip) limits the motor region posteriorly. It begins opposite the junc- tion of the lower and middle thirds of the fissure of Rolando, l>, ■■*l...6|...5|.,.«|,,.3|.,?|, ,.'l.,°l » ■ . l». ■ ■ I* ■ ■ H . ■ l«. . ■ \'. , A Fig. 127.—Horsley's Cyrtometer. passes upward in a line parallel with the longitudinal fissure and midway between the Rolandic fissure and the parietal emi- nence, passes by the parieto-occipital fissure, and downward and backward into the occipital lobe (Keen). The motor 534 A MANUAL OF SURGERY. areas, which on the outer surface are adjacent to the fissure of Rolando, are shown in Figures 123 and 124. The supe- rior longitudinal sinus is overlaid by a line from the inion to the glabella. The lateral sinus is indicated by a line run- ning from the occipital protuberance horizontally outward to a point one inch posterior to the external auditory meatus, and from this point by a second line dropped to the mastoid process. The supra-meatal triangle of Mac- ewen is bounded by the posterior root of the zygoma, the poste- rior bony wall of the auditory meatus, and a line joining the two. Figure 128 shows clearly the main points of cranio-cerebral topography, obtained by methods approved by many scientists. Diseases of the Scalp.—The scalp is composed of skin, sub- cutaneous fat, and the occipito- frontalis muscle and aponeurosis. The scalp is liable to inflammation from various causes, and to other diseases, namely: tumors, cysts, warts, moles (local cutaneous hypertrophies), cirsoid aneurysm (p. 231), naevi, and lupus. Abscesses of the scalp are com- mon. If an abscess forms beneath the pericranium, the pus diffuses over the area of one bone, being limited by • the attachment of the pericranium in the sutures. If an abscess forms in the tissue between the occipito-frontalis and the pericranium, it is widely diffused. Treves calls this subaponeurotic connective tissue "the dangerous area." Abscess of the subcutaneous tissue is apt to be limited Fig. 128.—Head, Skull, and Cere- bral Fissures (adapted from Marshall by Hare) : B corresponds to Broca's convolution; EAP, external angular process; FR, fissure of Rolando ; IF, inferior frontal sulcus; IPF, intrapari- etal sulcus ; MMA, middle meningeal artery; OPr, occipital protuberance; PE, parietal eminence ; POF, parieto- occipital fissure; SF, Sylvian fissure; A, its ascending limb; TS, tip of tem- poro-sphenoidal lobe. The pterion (to the left of B) is the region where three sutures meet, viz., those bounding the great wing of the sphenoid where it joins the frontal, parietal, and tem- poral bones. DISEASES AND INJURIES OF THE HEAD. 535 because of the great amount of fibrous tissue. Abscess is treated by instant incision at the most dependent part, anti- septic irrigation, and drainage. Diseases and Malformations of the Bones of the Skull. —The bones of the skull are liable to caries, necrosis, oste- itis, periostitis, atrophy, hypertrophy, tumors, etc. (See Dis- eases of Bones.) Microcephalus.—By microcephalus is meant unnatural smallness of the head due to imperfect development. It is a cause or a frequent associate of idiocy. A child may be born with a skull completely ossified even at the fontanelles, or the ossification may become complete soon after birth. In microcephalus the face is apt to be fairly well developed; the jaws are prominent; the forehead is flat; the cranium and brain are small; the convolutions of the brain are simpler than is natural; there is apt to be marked asym- metry of the two sides of the brain; internal hydrocephalus may exist; areas of sclerosis and atrophy are common; porencephaly is not unusual. Some patients have perfect motor power; others are slow and inco-ordinate. Epilepsy, chorea, and athetosis frequently complicate the case. Treatment.—Skilled training in a school for the feeble- minded or in an institution for idiots is necessary in treating microcephalus. Some surgeons advise that first a craniec- tomy be performed (see Operations on Skull and Brain). The late Prof. Agnew, taking the view that the growth of soft parts moulds hard parts, and that the fault is with the brain, and not with the skull, maintained that the surgeon might as well cut a piece out of a turtle's shell to permit growth of the turtle as to cut a piece out of the skull to permit growth of the brain. Prof. Keen says, " While there is no doubt that, as a rule, the growth of the encasing hard parts is dominated by the growth of the contained soft parts, yet it is very possible that while a healthy brain may over- 536 A MANUAL OF SURGERY. come the normal resistance of the skull, a brain with feeble powers of development may be arrested in its growth by the slight resistance offered by the skull." Prof. Keen further says, " Whether the operation will stand the test of time cannot yet be determined, but considerable initial improve- ment has followed in a number of cases." Diseases and Malformations Involving the Brain.— Meningocele is a congenital protrusion of the cerebral membranes through a bony aperture, the sac containing some extra-cerebral fluid. Meningocele feels and looks like a cyst (is translucent and fluctuates); it does not usually pulsate, it has a small base, it becomes tense on forcible expiration, and it may be reduced. Encephalocele is a congenital protrusion not only of membranes, but also of a portion of the brain as well, the sac containing some extra-cerebral fluid. Encephalocele is small, opaque, does not fluctuate, has a broad base, does pulsate, becomes tense on forced expiration, and attempts at reduction cause pressure-symptoms. Hydrencephalocele is a congenital protrusion of mem- branes and brain-substance, the interior of the mass com- municating with the ventricles and containing ventricular »• fluid. This is the most frequent and the most dangerous form. Hydrencephalocele is larger than a meningocele, is translucent, fluctuates, rarely pulsates, is pedunculated, is rendered a little tense on forced expiration, and cannot be reduced.1 Treatment.—For hydrencephalocele nothing can be done, and early death is inevitable. In rare instances an enceph- # alocele is converted into a meningocele, and the bony aperture closes, thus bringing about a cure. Among the expedients for treating meningocele and encephalocele are electrolysis, injection of Morton's fluid (gr. x of iodine, 1 American Text-book of Surgery. DISEASES AND INJURIES OF THE HEAD. 537 gr. xxx of iodide of potassium, §j of glycerin), pressure, and excision. Hydrocephalus.—In external hydrocephalus the fluid is between the membranes and the brain; in internal hydro- cephalus the fluid is in the ventricles. Hydrocephalus may be acute or chronic, congenital or acquired. Acute hydrocephalus, which results from meningitis (usually from tubercular meningitis), is usually internal, but may be external. The symptoms are headache, elevated temperature, delirium, stupor, convulsions, paralysis, and choked disk. Treatment of acute hydrocephalus is of no avail. Tapping of the ventricles may be tried. Chronic hydrocephalus is usually congenital. The cra- nium enlarges enormously and the bones of the skull are widely separated. The broad forehead overhangs the eyes. The child is an idiot, and very often does not learn to walk or to talk. Convulsions and palsies are common, and blind- ness is frequent. Such children usually die young. The treatment of chronic hydrocephalus is rarely of much avail. Pressure by strapping with adhesive plaster has been tried. Tapping through a fontanelle may be performed by means of a trocar (only gij or giij being drawn at a time). If much fluid is drawn, the head must be strapped afterward. If the skull ossifies, the lateral ventricles may be tapped. It has been proposed to drain by tapping the theca of the spinal cord (Quincke). 2. Injuries of the Head. Cephalhematoma (caput succedaneum), which is a col- lection of bloody serum under the scalp of a new-born child, results from the pressure of labor. No treatment is required. Scalp-wounds are treated as are other wounds. A large 538 A MANUAL OF SURGERY. piece of scalp with only a narrow pedicle may not slough; hence try to save any piece that has an attachment. Always shave a wide area and disinfect the wound thoroughly. Stitch the wound with silkworm gut. If drainage is required, use a few strands of horsehair. Contusions of the Head.—Scalp-swelling from hemor- rhage is usually considerable. The patient may be stunned or dazed. The swelling of haematoma must not be mistaken for fracture with depression. In haematoma there is a cen- tral depression, hard pressure finds bone on a level with the general contour of the bone, and the margin of a haematoma is circular, is not quite hard, and is elevated above the gen- eral contour. In depressed fracture the edge is on a level with or below the level of the general bony contour, and the margin is sharp and irregular. The treatment is by means of pressure and the use of lead-water and laudanum. If suppuration arises, at once incise. Concussion or Laceration of the Brain.—Prof. Keen says that there may be slight brain-injuries which may properly be called " concussions," but it is better to consider concussion as synonymous with laceration of the brain. The cause of concussion is violent force, either direct (as a blow upon the head) or indirect (as a fall upon the buttocks). This force shakes, oscillates, or jars the brain and ruptures vascular twigs, large vessels, or even the membranes. In the slighter ruptures concussion only exists; in the severe ruptures compression soon arises. Symptoms.—In a mild case of brain-concussion the patient may or may not fall; his face is pale ; he feels weak, giddy, nauseated, and confused; he often vomits, but soon reacts. In a severe case he lies with complete muscular relaxation, cold extremities, pale and cold skin, shallow and quiet respiration, frequent, small, soft, and irregular pulse (pulse may not be detectable), and fluttering heart. He seems DISEASES AND INJURIES OF THE HEAD. 539 unconscious, but can be roused to monosyllabic response by shouting, pinching, or holding a bright light near his face. The urine and feces are often passed involuntarily. The pupils may be unaltered, may be dilated or contracted, or may be equal or unequal, but in any case they will react to light. No paralysis exists/ The temperature at first is subnormal. In a severe cortical laceration there will be twitchings or even general convulsions, or the patient will lie curled up with limbs flexed and eyelids shut, and will resist all attempts to open his eyes or mouth or to move his limbs (A. Pearce Gould). Erichsen called this condition " cerebral irritability." As the patient reacts he will most probably vomit. Within twenty-four hours he usually im- proves, but is feverish and complains of headache and lassi- tude. After concussion a man's whole nature may change: he may develop hysteria, insanity, or epilepsy, and in many cases there is complaint for a long time of headache, insom- nia, low spirits, and lassitude. If the patient in concussion recedes from, instead of advancing toward, recovery, coma will set in or inflammation will develop. Dr. Keen states that the prognosis is always uncertain. Any concussion producing unconsciousness is a serious injury, because con- siderable laceration must have occurred. Treatment.—In treating brain-concussion, bring about reaction by the administration of aromatic spirits of ammo- nia (no alcohol), by surrounding the patient (who lies in bed without a pillow) with hot bottles, by the application of mustard over the heart, and by the administration of hot coffee. Place the patient in bed in a quiet room, and watch him. For some -days or for some weeks, according to the case, insist on an easy life. Give a plain diet containing a minimum of meat, administer an occasional purgative, and secure sleep. If inflammation arises, some surgeons will not trephine, but others, especially if the damage seems to 540 A MANUAL OF SURGERY. * be localized, incise the scalp and inspect the bone. If a fracture is discovered and the symptoms are serious, they perform an exploratory trephining, open the dura, and secure drainage for inflammatory products. In many severe contusions the surgeon should at once incise the scalp and inspect the bone. For many weeks after a severe concussion a patient must be kept away from business and be watched because of the possibility of an abscess of the brain arising. Compression of the Brain.—The causes of brain-com- pression are hemorrhage, depressed fracture, tumor, inflam- matory exudate, pus, and foreign bodies. Symptoms.—In brain-compression complete coma exists without voluntary movement. The skin is hot and per- spiring; the respirations are slow and stertorous and the cheeks flap during expiration; the pulse is slow and full, and may be irregular; the pupils are dilated, and do not respond to light; there is usually retention of urine, and often incontinence of feces ; paralysis exists, which may be very limited (monoplegia), may be of one side (hemiplegia), or may be general. In hemorrhage into the interior of the brain the unconsciousness is immediate or nearly so. In bleeding from the middle meningeal artery a period of con- sciousness intervenes between the injury and the coma, in which period blood collects. In compression from depressed fracture or from a foreign body the symptoms usually come on at once, but they may be deferred for some hours. Com- pression from inflammation or pus begins gradually after a considerable time has elapsed. A diagnosis must be made between coma due to brain- injury and the comatose conditions of apoplexy, uraemia, opium-poisoning, and alcoholic intoxication. In hospital practice cases of unconsciousness without a known history are frequent. In attempting this diagnosis, examine care- DISEASES AND INJURIES OF THE HEAD. 541 fully for any evidence of traumatism, and inquire as to how and where the patient was found, if any fit occurred, and if a bottle or a pill-box was found near by or in the pockets, which also examine. Smell the breath to notice alcohol or opium, but always remember that a man may be stricken with apoplexy while being drunk, and may fracture his skull by falling when under the influence of opium or of alcohol. Draw the urine with the catheter if any water is in the bladder, examine the urine for albumin and alcohol, and take the specific gravity. In doubtful cases of coma, use the ophthalmoscope. In post-epileptic coma the tempera- ture is never below normal, there are no unilateral symptoms, the condition resembles sleep, and the patient can be aroused. Hysterical coma occurs in boys and women ; there are no ob- jective symptoms, and the patient, though swallowing what is put into his mouth, cannot be roused (Gowers). In urcemia, besides the condition of the urine (and always remember that a person with albuminuria is apt to develop apoplexy), there is a persistent subnormal temperature, and convulsions are prone to occur. There is oedema of the legs, and paralysis and stertor are absent. In apoplexy hemiplegia exists, and the initial temperature is for a short time sub- normal. A single convulsion may have ushered in the case. Alcoholic unconsciousness is often diagnosticated when apo- plexy really exists. A man will smell of alcohol who has had one drink, but one drink will not produce coma; hence the smell of alcohol is not conclusive. In any case of doubt some hours of watching will clear up the diagnosis. Regard a doubtful case as serious until the truth is clear. In opium-poisoning the pupils are contracted to a pin-point, the respirations are usually slow, shallow, and quiet, but may be stertorous, but there is no paralysis.. Always remember that hemorrhage into the pons will produce pin-point pupils, but it also causes paralysis (crossed paralysis if in the lower 542 A MANUAL OF SURGERY. half of the pons) and high temperature with sweating. In opium-poisoning the temperature is subnormal. In diabetic coma the pupils will react to a very bright light, the tempera- ture is subnormal, and the breath and the urine smell like chloroform. Treatment.—The treatment of brain-compression depends on the cause. Hemorrhage (extradural or subdural) requires trephining and arrest of bleeding ; coma from depressed frac- ture demands trephining and elevation; foreign bodies must be removed; abscesses must be evacuated; some tumors are to be removed. Intracranial hemorrhage may be either spontaneous or traumatic. In the vast majority of instances spontaneous hemorrhage comes from the lenticulo-striate artery (Char- cot's artery of cerebral hemorrhage), and produces apoplexy, a disease belonging to the physician except in some ingra- vescent cases, for which ligation of the carotid on the same side as the rupture is indicated. Traumatism during delivery is a not unusual cause of hemorrhage from the middle men- ingeal artery (Richardiere). A traumatic hemorrhage may take place (i) between the bone and the dura [extradural); (2) between the dura and the brain [subdural); and (3) in the brain-substance [cerebral). (1) Extradural hemorrhage arises from the middle meningeal or, more often, from one of its branches. It is usually, but not always, accompanied by fracture; in fact, in some cases not even a bruise can be found. The accident may or may not cause temporary unconsciousness, but even if it does, from this unconsciousness the patient almost always » reacts, and there is a distinct period of consciousness between the accident and the lasting coma, the coma being due to pressure from a continually increasing mass of extravasated blood. If the main trunk or a large branch is ruptured, the period of consciousness is short; if a small branch is rup- DLSEASES AND INJURIES OF THE HEAD. 543 tured, the period of consciousness is prolonged for hours or perhaps for days. The other signs of this condition are paralysis of the side opposite the blood-clot (not necessarily of the side opposite the injury, for the artery may rupture from contre-coup on the uninjured side); this paralysis is apt at first to be localized, but it gradually and progressively widens its domain. If the clot extends toward the base, the pupil on the same side as the clot ceases to react and dilate, and if it be the left side, aphasia is noted. The pulse becomes frequent; the breathing becomes stertorous; the tempera- ture rises, that of the paralyzed side exceeding that of the sound side; and in a compound fracture the pressure of escaping blood may force brain-matter out of the wound (Keen). Treatment.—In treating extradural hemorrhage, localize the clot, not by the seat of the wound or contusion, but entirely by the symptoms. Trephine one and one-fourth inches back of the external angular process, at the level of the upper border of the orbit (Kronlein). If this incision does not show the clot, trephine again at the level of the upper border of the orbit and just below the parietal emi- nence. The first incision gives access to the trunk and to the anterior branch; the second incision exposes the poste- rior branch. If signs indicate that the clot is travelling to the base, the trephine should be used half an inch lower than the first indicated point. Proceed to arrest bleeding as directed on page 252, and always drain. (2) Subdural hemorrhage is usually due to depressed fracture and rupture of the middle cerebral artery or of a number of small vessels. The symptoms are identical with those of extradural bleeding. The treatment is trephining at the first hemorrhagic point, enlarging the opening with a rongeur upward and back- ward, opening the dura, turning out the clot, ligating the 544 A MANUAL OF SURGERY. bleeding point, elevating any depression of bone, draining, and stitching the dura with catgut. Hemorrhage from internal pachymeningitis requires the same treatment. (3) Cerebral Hemorrhage.—The symptoms of cerebral hemorrhage are identical with those of apoplexy. The treat- ment is the same as that for apoplexy, except in ingravescent cases, when the common carotid on the same side as the clot should be ligated. Rupture of a sinus usually arises from compound frac- ture or during a brain-operation. The treatment, if the rupture happens from fracture, is trephining. Enlarge the opening by the rongeur, pack with one large piece of iodo- form gauze, or catch the rent with haemostatic forceps, leav- ing them in place for three or four days, or apply a lateral ligature. Elevate depressed bone. In rupture during an operation, control hemorrhage by packing. Fractures of the skull may be simple, compound, depressed, non-depressed, or punctured. They are divided into frac- tures of the vault, usually due to direct force, and fractures of the base, due to extension of fractures of the vault, to indirect violence (a fall upon the feet, the buttocks, or the vault), to forcing of the condyles of the lower jaw against or through the base, or to foreign bodies breaking through the orbit or the roof of the nostrils. Fracture by contre-coup, which occurs on the side opposite the application of the violence, is very rare. Fractures of the skull are uncommon in early youth, but they are much more frequent in the aged. Usually the entire thickness of the bone is fractured, but either the outer or the inner table may be broken alone. In complete fractures the inner table is broken more exten- sively than is the outer table, because the inner table is the more brittle, because the force diffuses, and also, as Agnew taught, because the inner table is part of a smaller curve than is the outer table, and violence forces bone-elements DISEASES AND INJURIES OF THE HEAD. 545 together at the outer table, but tears them asunder at the inner table (Figs. 129, 130). Pig. 129.—Section of Outer and Inner Fig. 130.—Greater Yielding of the Inner Tables, with two parallel lines (after Ag- Table than of the Outer after the Applica- new). tion of Violence (after Agnew). Fractures of the Vault.—A fracture of the vault of the skull may be simple and undepressed, or may be depressed, compound, or comminuted. A mere crack may exist in a bone, and if a rent exists in the soft parts, a bit of dirt or a hair may be caught in the crack. Fractures of the vault arise from direct force. A fissure may escape recognition, although in some cases percussion gives a " cracked-pot" sound. Any considerable depression can be detected. In a simple fracture occasionally the cerebro-spinal fluid collects under the scalp and forms a tumor which pulsates and becomes tense on forcible expiration. Compound fractures can be readily recognized, but Keen cautions the surgeon not to mistake a suture, a Wormian bone, or a tear in the peri- cranium for a fracture. A fissured fracture is marked by a dark line of blood which sponging zvill not remove. Fracture of the inner table alone can be suspected only (Keen). The prognosis of fractures of the vault depends upon the extent of brain-injury rather than upon the extent of bone-injury. Simple fractures unite by bone; compound fractures with loss of bone, by fibrous tissue. The dangers may be immediate (brain-injury and septic inflammation) or be distant (epilepsy, insanity, and persistent headache). Treatment.—A simple fracture without depression and 35 546 A MANUAL OF SURGERY. without brain-symptoms is treated expectantly (by rest, quiet, low diet, purgation, moderate elevation of and cold to the head, and arterial sedatives). A simple fracture with mod- erate depression and without cerebral symptoms is treated expectantly, and so also is a simple fracture in which symp- toms existed but are abating. Simple fracture with marked depression requires immediate trephining, even when brain- symptoms are absent. Trephining in these cases often pre- vents disastrous consequences, and is known as " preventive trephining " (Agnew, Keen, White, Horsley, Macewen). In all compound fractures, shave and asepticize the entire scalp, enlarge the incision, and explore the bone. If a fissure exists, it must be asepticized, and if a hair or other foreign body is found in it, in order to effect removal and secure asepsis the outer table of the skull must be cut away with a chisel, the fissure being thus converted into a broad groove. In a compound fracture with much depression, trephine, elevate, and irrigate. In any fracture, trephine if distinct symptoms exist. In punctured wounds of the brain (punctured frac- tures), always trephine, open the dura, and disinfect (Keen). In any case of fracture of the vault where trephining has been performed, do not hesitate, if it seems expedient, to open the dura and examine the brain. Fractures of the Base.—A fracture of the base of the skull may exist in only one of the three fossae, in two of them, or it may involve all. The middle fossa is oftenest involved. Fracture of the posterior fossa is the most fatal. These fractures may be due to direct violence, to indirect force, and to extension of a fracture of the vault. Extension from the vault is always by the shortest route. Fracture by direct violence may arise from the penetration of the nasal roof, the orbital roof, or the pharyngeal roof by a foreign body. The posterior fossa may suffer from a fracture by direct violence applied to the neck. Fractures by indirect DISEASES AND INJURIES OF THE HEAD. 547 force may arise from blows upon the frontal bone (the orbital portion of the frontal or the cribriform process of the eth- moid breaking), from falls upon the chin (the condyle of the jaw breaking the middle fossa), or from falls upon the but- tocks, the knees, or the feet (fracture occurring in the poste- rior fossa). The base is very rarely broken by contre-coup (Treves). Symptoms.—In fractures of the base of the skull blood and cerebro-spinal fluid are apt to flow externally. In frac- tures of the anterior fossa blood may run from the nose, its source being the laceration of the mucous membrane or the vessels of the dura, the fracture being compound. Cerebro- spinal fluid only appears when the mucous membrane, the dura, and the arachnoid are each lacerated (Treves). In fractures of the anterior fossa blood is apt to flow into the orbit, producing subconjunctival ecchymosis, and some blood is often swallowed and vomited. In fractures of the middle fossa blood flows from the ear through a tear in the tympa- num, its source being the vessels of the tympanum, the meningeal vessels, or a sinus. Blood may flow through the Eustachian tube and come from the nose, may be spit up, or may be swallowed and vomited. In many cases a quantity of cerebro-spinal fluid flows from the ear, the discharge being increased by expiratory effort and a position which favors gravity. The cerebro-spinal fluid must not be confused with either blood-serum or liquor Cotunnii. The cerebro- spinal fluid is always present in large amount; the liquor Cotunnii can only be present in minute amount. Blood-serum is highly albuminous ; cerebro-spinal fluid is a serous fluid of very low specific gravity, never shows more than a trace of albumin, and contains considerable chloride of sodium and in some instances sugar, which, when present, reacts to Trommer's and to Moore's test, but does not reflect polarized light nor ferment with yeast (Keetley, from Collins). Treves 548 A MANUAL OF SURGERY. statesl that cerebro-spinal fluid cannot flow from the ear in fractures of the middle fossa unless (i) the line of fracture crosses the internal meatus, (2) unless the prolongation of the membranes into the meatus is torn, (3) unless a com- munication exists between the internal ear and tympanum, and (4) unless the drum-membrane is torn. Profuse serous discharge may flow from the ear after an injury without frac- ture when the drum is ruptured, the fluid coming from the cells of the mastoid. It must be understood that fracture of the base may exist when there is no flow of blood or of serous fluid (when the drum is not lacerated). A fracture of the middle fossa is usually compound, made so, even when the drum is not ruptured, by the Eustachian tube. In fracture of the posterior fossa blood accumulates beneath the deep fascia and produces discoloration in the line of the posterior auricular artery (Battle's sign), the discoloration first appear- ing near the tip of the mastoid. Fractures of the base are apt to be associated with paralysis of cranial nerves. Optic neuritis often arises after the first week. Dr. Keen says that in fractures of the base the temperature is subnormal during the shock, rises to ioo° or 1010, falls again to a little below normal, and remains normal or subnormal unless there be inflammation or sepsis. Treatment.—In treating a fracture of the base of the skull, collect any serous discharge and analyze it, and disinfect any cavity involved. In fractures of the middle fossa with rup- tured drum, clean the ear mechanically, wash it out with hydrogen peroxide and with a stream of warm corrosive- sublimate solution of a strength of 1 : 2000 (turn the head toward the affected side, so that the mercurial solution will not run down the Eustachian tube), pack with iodoform gauze, and apply an antiseptic dressing. The naso-pharynx must be cleaned and insufflated with iodoform. In fracture 1 Applied Anatomy. DISEASES AND INJURIES OF THE HEAD. . 549 of the orbit the surgeon must disinfect, and if the fracture is punctured, the roof of the orbit must be trephined or be chiseled to permit of disinfection and drainage. In fractures of the middle and anterior fossae the naso-pharynx must be cleaned. Wash out these cavities often with hot water, next with peroxide of hydrogen, and finally with boracic-acid solu- tion. Insufflate the naso-pharynx with iodoform, and pack the nose with iodoform gauze (Keen, Dennis). In some cases drainage has been obtained from the anterior fossa bv breaking down the cribriform plate and introducing a tube through the nostril (Allis), and from the middle fossa by trephining above and behind the external auditory meatus. In a very extensive fracture of the base, besides use of the methods set forth above, the entire head should be shaved and a plaster cap be applied. Cases of fracture of the base must be put into a quiet and darkened room and be kept upon a low diet, sleep being secured and the bowels and bladder being attended to. Wounds of the brain are produced by violence and by foreign bodies (knives, bullets, etc.). Except when due to penetration of a fontanelle in a child or of a parietal foramen in adults, wounds of the brain are accompanied by fracture of the skull. These wounds are very dangerous: foreign bodies (bone, hair, clothing, etc.) are often lodged in the brain, hemorrhage is usually severe, and sepsis is almost inevitable without proper treatment. These cases are very fatal, though some astonishing recoveries are on record.1 The symptoms of brain-wounds may be slight and long- deferred or may be immediate and overwhelming; they depend upon the site and extent of the injury. Localizing symptoms may exist, and encephalitis with coma is apt to arise. Abscess not unusually follows. In treating wounds 1 See a most interesting and instructive paper by Dr. Wm. J. Taylor, read before the Academy of Surgery of Philadelphia, and reporting a number of cases. 55O A MANUAL OF SURGERY. of the brain, always shave the entire scalp and examine the weapon to see if a piece were broken off. Asepticize, enlarge the wound, trephine, arrest bleeding, elevate any depression, remove foreign bodies, irrigate the wound, suture the dura, drain, and dress. Gunshot Wounds of the Head.—A penetrating wound is one in which the bullet enters the head, but does not emerge ; a perforating wound is one in which the bullet passes through the head and emerges. The wound of entrance is small; the wound of exit is large. At the wound of entrance the inner table is more extensively fractured; at the wound of exit, the outer table. The symptoms of gun- shot wounds of the head are similar to those of any other brain-wound, but, as a rule, are more widely diffused. Treatment.—In treating gunshot wounds of the head, shave and asepticize the whole scalp, disinfect the entire track of the ball, and arrest hemorrhage at the wounds of entrance and exit, using the rongeur to expose the bleeding points. The bullet, if retained, is to be sought for. So place the head that the track of the ball will be vertical, then in- troduce Fluhrer's aluminium probe and let it find its way by gravity. The probe may find the ball near the wound of entrance, in which case extract the ball with forceps; or the probe may find the ball near the opposite side of the head, in which case make a counter-opening through the bone, at a point the probe would touch if it were pushed entirely across. Take a new and clean rubber catheter (No. 9, French), insert a stylet, and carry the catheter through the wound (Keen). Knowing the depth of the ball, it is * searched for around the catheter tube as an axis, and when found it is extracted. After extraction, drain the wound by means of a tube. When a counter-opening exists, drain through and through. Girdner's induction-balance may be employed to locate a ball. If the ball cannot be detected, DISEASES AND INJURIES OF THE HEAD. 55 I drain by a tube carried to the depths of the wound. After dressing, always place the head in a position favorable to drainage. Fungus cerebri (hernia of the brain) rarely contains true brain-substance. It is in most instances a growth from the neuroglia. Hernia cerebri cannot occur if the dura is not opened ; it is rare in any case unless the brain was damaged, and is most frequent after septic wounds. In any brain- operation where the dura is opened, suture it; or, if there be a great gap in the dura, cut off a piece of pericranium from the flap, turn its bone-forming surface upward, and stitch this membrane to the dura (Keen). The evidence of brain- hernia is a protruding mass which is soft, lobulated, of a dirty- white color, pulsating, painless to the touch, often bleeding) and sometimes discharging cerebro-spinal fluid. In treating brain-hernia, employ antiseptic dressings. Skin-grafting benefits some cases. Pressure is dangerous. Excision by the knife or cautery does no good. After healing, a depres- sion marks the site of the hernia. Traumatic inflammation of the brain and its mem- branes is divided into encephalitis or cerebritis, inflammation of the cerebrum ; cercbellitis, inflammation of the cerebellum; meningitis, inflammation of the meninges; arachnitis, inflam- mation of the arachnoid; pachymeningitis, inflammation of the dura; and leptomeningitis, inflammation of the arachnoid and pia. Pachymeningitis.—Inflammation of the external layer of the dura is rare (pachymeningitis externa). It may arise from tumor, caries, necrosis, middle-ear disease, sunstroke, or traumatism. Syphilis is a not unusual cause. The other membranes may become involved. Suppuration may arise, having extended by contiguity from neighboring parts. The symptoms of pachymeningitis externa are uncertain. They resemble often those of leptomeningitis. Pressure-symptoms 552 A MANUAL OF SURGERY. may arise. Paralysis may or may not exist. If pus forms, the ordinary constitutional symptoms of suppuration arise (high temperature and sweats), not the symptoms of abscess in the brain. In a severe case other membranes become in- volved. The treatment consists in removing the cause (cari- ous bone, pus, middle-ear disease). In pachymeningitis from traumatism, trephine to drain inflammatory products; in a case with localizing symptoms, trephine; in an ordinary case, without pus and with no evidences of traumatism, use wet cups back of the mastoid processes, apply an ice-bag to the head, and purge by means of calomel. Use iodide of potas- sium in most cases. If sunstroke is the cause, treat accord- ingly. Pachymeningitis interna may extend from the pia. The form known as heematoma of the dura mater, or pachymenin- gitis interna haemorrhagica, may arise during infectious dis- eases (typhoid fever and rheumatism), in persons of the hem- orrhagic diathesis, in diseases causing atrophy of the brain, and in chronic diseases of the heart and kidneys. Among the exciting causes are traumatism, inflammation in adjacent parts, and, especially, the abuse of alcohol. In this disease blood is extravasated on the inner surface of the dura. Many observers do not class hemorrhagic pachymeningitis as in- flammation, but regard the hemorrhage as primary. The symptoms of internal pachymeningitis are very chronic, are not characteristic, and may be absent. They consist usually of persistent headache and apoplectiform attacks with con- traction of the pupil, slow pulse, and vomiting. Choked disk is not infrequent, localizing symptoms may be made out, and coma is apt to arise. The treatment is the same as that of external pachymeningitis. Leptomeningitis is a purulent inflammation of the soft membranes of the brain. The pathological changes can be noted in the pia and in the brain-substance. The brain is DISEASES AND INJURIES OF THE HEAD. 553 cedematous, the pia purulent, the convolutions are flattened, the ventricles are distended with fluid, and hemorrhages occur into the brain-substance. Pus may be localized upon the pia, but it is usually diffused over one hemisphere or over both. This disease may be acute or be chronic, and a severe case is spoken of as encephalitis. One form is tubercular, another is syphilitic. Secondary leptomeningitis is apt to affect the convexity; primary leptomeningitis is apt to affect the base (Hirt). The causes of leptomeningitis are epidemic cerebro- spinal fever, tuberculosis, acute general diseases (pneu- monia, typhoid, erysipelas, and rheumatism), bone diseases, traumatisms, middle-ear disease, syphilis, and sunstroke. The tissues of the pia and the cerebro-spinal fluid con- tain diplococci identical with pneumococci. Hirt suggests that these cocci, when no wound exists, effect an entrance through the nose and the ethmoid foramina. In fractures at the base the organisms enter by way of the pharynx and the Eustachian tube, or the ear. The symptoms of acute lepto- meningitis are violent headache persisting during delirium, rigidity of the neck, cerebral vomiting, a slow pulse, ele- vated temperature, contraction of the pupils, hyperaesthesia of the skin and muscles, and delirium passing into stupor and coma. Choked disk, strabismus, and nystagmus are not unusual. Convulsions or paralyses may occur. Death is the rule within one week. The treatment is purgation with calomel; bleeding behind the mastoid processes; cold to the head; warm baths with cold affusions to the head; iodide of potassium, bromide of potassium, or morphia for vomiting and headache. Some surgeons trephine. Tuberculous Meningitis (Acute Hydrocephalus; Water on the Brain).—In a child affected with meningitis there is often a record of a fall. Prodromal symptoms are common (restlessness, irritability, anorexia, change of character). The 554 A MANUAL OF SURGERY. disease begins with a convulsion or with headache, fever, and vomiting (Osier), the child cries out from pain (the hydrocephalic cry), and the bowels are constipated. The pulse is rapid, but becomes slow and irregular. The pupils are contracted, there is muscular twitching, and the sleep is impaired. The temperature is about 1030. In the sec- ond period of the disease the vomiting ceases, constipation becomes more marked, the belly retracts, headache is not so marked, and the patient lies in a soporose condition with episodes of delirium. In this stage the pupils dilate and are often unequal, the head is retracted, convulsions occur or limited rigidity is noted, the respiration is sighing, and if a finger-nail is drawn along the skin, a red line develops (the tdche cerebrale, due to vaso-motor paresis). Squint and consequent double vision are usual. In the last stage coma becomes absolute and general convulsions or limited spasms are apt to occur. Optic neuritis exists, and the child passes to death along a road identical with that of typhoid collapse. In children the base is usually involved, and the disease is apt to last from two to four weeks ; in adults the convexity of the brain is usually involved, and death is apt to occur in a few days. The treatment is like that for traumatic meningitis. Acute Traumatic Leptomeningitis (Acute Encephalitis). —A day or so after the injury there appear severe general headache, photophobia, fever (i02°-i04°), a flushing of the face, intolerance of sound, contracted pupils, a full and bounding pulse (Keen), constipation, insomnia, and restless- ness. A chill or chills may occur. Delirium soon sets in, linked with muscular twitching and strabismus, and followed by stupor, coma, rigidity, paralysis of sphincters, and a typhoid condition. Choked disk is sometimes found, though not often. In this condition all the membranes and the brain-substance suffer. Acute encephalitis should not be confused with uraemia. DISEASES AND INJURIES OF THE HEAD. 555 Treatment.—Before coma arises, give from five to ten drops of Lugol's solution three times a day (Bartholow); during the stage of excitement give aconite and opium (Bartholow), and restrain convulsions with bromide of potassium. Mercury does no good. In acute traumatic encephalitis interrogate every organ. If a wound ex- ists, asepticize it. Give a calomel purge and keep the bowels loose; shave the head; place the patient with the head raised in a cool, quiet, and darkened room; use the catheter whenever necessary; apply cold to the head by means of tubes or the ice-cap; in vigorous subjects employ venesection; leeches or wet cups over the mastoid and nape of the neck may be preferred to phlebotomy. Two drops of tincture of aconite and 5 drops of deodorized tincture of opium should be given every two or three hours during the stage of excitement (Bartholow), and TTfj of tincture of gelsemium may be given with each dose. Large doses of bromide are given to restrain convulsions and to secure sleep. Among the hypnotics that may be used are the hydro- bromate of hyoscine, chloral, and paraldehyde. During the stage of excitement apply mustard plasters to the fore- head and neck for a short period several times a day. When pressure-symptoms become evident, blister the nape of the neck, the vertex, or the mastoid region. If great depression comes on, give aromatic spirits of ammonia, or even wine (champagne or sherry). The diet is to consist of milk. If, during coma, constipation exists, give croton oil and glycerin. Never give much opium, as it constipates and adds to the congestion. It does no good to touch the gums with mercury: ptyalism will not check the inflamma- tion, and will enhance the danger (Bartholow). If localizing symptoms of suppuration arise, at once trephine and drain. Many surgeons are approaching the belief that in this most fatal disease trephining should be performed to let out the 556 A MANUAL OF SURGERY. products of inflammation, thus relieving tension, even when pus has not formed and when distinct localizing symptoms do not exist. Should the patient recover, physical and mental exertion are forbidden for a long time, and he is guarded from excitement, worry, irritation, constipation, indi- gestion, and insomnia. Chronic Leptomeningitis (or Encephalitis).—The causes of chronic leptomeningitis are the same as those of the acute form. If traumatism is the cause, the inflammation arises at a later period than it would in acute encephalitis. The symptoms of concussion follow a head-injury. Days, or even weeks, after the accident, a series of symptoms occur, namely: localized pain at the seat of injury, often accentuated by tapping; listlessness; irritability; apathy regarding business affairs and home obligations, or profound depression and hypochondria with inability to attend to business. Choked disk exists. Soon acute encephalitis arises, with or without a chill. The treatment of this disease is the same as that for acute encephalitis. Always operate if localizing symptoms are found. Intense local pain justi- fies trephining. Abscess of the brain is a localized collection of pus. The causes are suppurative otitis media (in half of all the cases), fracture of the skull, concussion of the brain, and general septic diseases. A tubercular mass may caseate (tubercular abscess). The abscess may be between the dura and skull (extradural), between the dura and brain (subdural), or in the brain-substance (cerebral or cerebellar). A traumatic abscess is generally beneath the injured area, but it may be on the opposite side. Symptoms of Abscess of the Cerebral Substance.—The symptoms due to pus-formation are as follows: There may be an initial rise of temperature, but (except in extradural abscess) the temperature becomes normal or DISEASES AND INJURIES OF THE HEAD. 557 subnormal. Toward the end of the case the temperature may rise and the fever is linked with delirium. The local temperature over the abscess may be elevated. A chill may or may not occur. Anorexia and vomiting are pres- ent. Urinary chlorides are diminished and the phosphates are increased (Somerville). Symptoms due to pressure are —headache (which at first is general, then local, and grows worse later in the case, when fever arises and exists even in delirium: this fact distinguishes it from the headache of fever, which ceases in delirium); pulse is very slow; respiration tends to the Cheyne-Stokes type; stupor passes into coma; paralysis of the sphincters takes place; con- vulsions are common; sensation is rarely impaired; and paralysis of the basal nerves may occur (third and sixth especially). The pupil on the same side as the abscess is dilated and fixed. Choked disk is not invariably found; if it is unilateral, it is on the same side as the abscess; if it is bilateral, it is more marked on the same side as* the abscess. In cerebellar abscess there are vertigo, vomiting, occipital headache, rigidity of the post-cervical muscles, and inco-ordination. Choked disk is often absent. Localizing symptoms depend upon the centre which is irritated or destroyed. Meningitis arises soon after an accident; an abscess, more than a week, often many weeks, after an accident. Menin^- gitis presents high temperature and the general symptoms before outlined. Mastoid disease may occasion cerebral symptoms without abscess, or it may cause abscess. In • sinus thrombosis there is septic temperature, the veins of the face and neck are enlarged, and a clot can usually be felt in the jugular. A tumor grows slowly, usually presents almost from the start distant localizing symptoms, and double choked disk is frequently present. In tumor the temperature is apt to be normal. 558 A MANUAL OF SURGERY. Treatment.—If localizing symptoms exist, trephine the skull at once, and, if no pus is found between the bone and dura, open the membrane. When the dura is opened, if the abscess is subdural, pus will be evacuated; if the abscess is in the brain-substance, the brain will bulge very much and will not be seen to pulsate. A grooved director is plunged into the brain, in the direction of the abscess, for two or two and a half inches (Keen). If pus is not found, withdraw the director and introduce it at another point. When pus is found, incise the brain with a knife, enlarge the opening by expanding the blades of a pair of forceps, scrape away the granulation tissue lining the abscess-cavity, irrigate with boiled water, and introduce a rubber drainage-tube; stitch the dura, bring the tube out through a button-hole in the scalp, and after the first two days pull the tube out a little every day and cut off a piece. If the first trephining does not find pus, trephine again at another point. In cerebellar abscess, make a flap with the base up, and trephine or gouge away the bone just below a line drawn from the inion to the external auditory meatus (to avoid the lateral sinus). Puncture the brain as for cerebral abscess. Brain Disease from Suppurative Ear Disease.—Chronic disease of the middle ear is apt to destroy the bone between the tympanum and the middle fossa of the skull, and thus produce meningitis, thrombosis of the petrosal or lateral sinuses, abscess of the temporo-sphenoidal lobe or of the cerebellum, or extradural abscess. This teaches the surgeon that chronic ear disease should never be neglected, but should receive the closest attention of the specialist if pos- sible. In ordinary cases cleanliness and antisepsis are sufficient, the ear being syringed every day with a warm 2 per cent, solution of common salt. If only a small drum- perforation exists, io drops of pure alcohol or of corrosive- sublimate solution (i : 5000) are dropped into the ear, but DISEASES AND INJURIES OF THE HEAD. 559 if a large drum-perforation exists, boric acid and iodoform (7 to i) are insufflated. Never inject alum. A strong silver solution is not safe; if it is used, wash the ear out afterward with warm salt water. If granulations or polypi exist, they must be removed (Burnett). Some cases require the removal of the drum-membrane and the ossicles of the ear. If head- ache, vomiting, and mastoid tenderness exist, open the mas- toid at once (see Operations) to prevent abscess of the brain. Cerebral abscess from ear disease is almost always in the temporo-sphenoidal lobe. The symptoms are—sudden disappearance of the ear-discharge; a transient rise of tem- perature followed by a subnormal temperature; vomiting; mastoid, frontal, and temporal pain; the mind is dull, and stupor arises which passes into coma; the bowels are con- stipated ; choked disk may be present; and convulsions or spasms or paralyses may exist. Trephine and clean out the mastoid antrum, and asepticize (see Operations upon the Skull and Brain). Trephine at Barker's point, one and one- fourth inches behind, and the same distance above, the middle of the external auditory meatus. If pus is not found, open the cerebellum. Extradural Abscess.—The eye symptoms and pain are the same in this as in cerebral or subdural abscess, but the temperature is different, rising to 1030 or 1040. There is often considerable tenderness above and behind the mastoid. Trephine and clean out the mastoid; follow up a sinus to the abscess, rongeur away the bone, avoiding the lateral sinus, curette, irrigate, and drain. Infective Sinus Thrombosis (a form of Pyaemia).—The symptoms of this disease present a history of chronic ear disease; general headache and pain over the sinus arise; violent rigors occur; and the temperature rises and fluctu- ates o-reatly. Tenderness and marked cedema are detected over the mastoid. A clot may be felt in the neck, in the 560 A MANUAL OF SURGERY. internal jugular vein. The veins of the face swell. Choked disk usually exists. The mind is generally clear, at least for a time. Treatment.—Infective sinus thrombosis is treated as fol- lows : Open and clean out the mastoid, and expose the sinus ; irrigate; open the sinus, which, if full of clot, will not bleed ; introduce a small spoon in the sinus, carry it toward the torcular Herophili, and scrape away the clot until blood flows. When bleeding begins, arrest it by packing the side of the sinus toward the occiput. Incise the neck, expose the internal jugular vein, ligate the vein below the clot, divide the vein above the ligature, and wash out the clot by running a stream of corrosive sublimate in at the lateral sinus and out at the cut jugular. Suture the neck-wound, drain the mastoid, and apply sutures in the soft parts. Intracranial tumors may be true neoplasms, may be of parasitic origin, may result from injury, or may be tubercular or syphilitic. Among these tumors are papillomata, gliomata, sarcomata, fibromata, psammomata, myxomata, osteomata, etc. (see Tumors). Cysts sometimes occur. The symptoms are diffuse and local, and are similar in many particulars to the symptoms of some other lesions. Among the symptoms are headache, pain on percussion, vertigo, vomiting, epileptic convulsions, double choked disk, partial or complete blind- ness, paralyses of eye-muscles, paralysis of face or of limb, anaesthesia and aphasia, word-deafness, word-blindness, agra- phia, inco-ordination, and mental disturbances. The situation of a tumor is fixed from localizing symptoms, their mode of onset and manner of combination. The nature of the tumor, its size, its depth, and whether it is single or other tumors exist, is, if possible, determined. Treatment.—If the tumor is located in an accessible region and operation is indicated, trephine the skull, enlarge the opening with the rongeur, open the dura, and turn out the DISEASES AND INJURIES OF THE HEAD. 561 tumor by means of the finger, or, if this is impossible, by using an Allis dissector, a knife, the scissors, or a sharp spoon. If the tumor is beneath the cortex, incise the brain with a knife. Arrest bleeding, stitch the dura, drain, and close the wound. Operative Treatment of Epilepsy.—When epilepsy has followed traumatism and a scar exists upon the scalp, excise the scar, especially if it is tender or is the seat of an aura. If, on lifting the scalp, a depression of bone or a disease of the bone is manifest, trephine for exploration, even over a silent area. Remember that epilepsy, as shown by Sachs, may follow a long-forgotten injury. Where the injury is over a known centre, trephine. This operation is especially indicated when the convulsions begin in the muscles of this centre, in which case remove the centre after trephining. Remove all sources of peripheral irritation (Briggs reported a case of epilepsy in which there was distinct skull-depres- sion and necrosis of the tibia, but the cure of the necrosis stopped the fits). Trephining in epilepsy may disclose a cyst, a dural scar, a brain-scar, a depressed portion of bone, or eburnation of bone from osteitis (Keen). In exploratory operations for epilepsy, always open the dura. If epilepsy arises notwithstanding a primary trephining, open the flap, round the bony edges with a rongeur, and cut out. the scar.1 These operations often seem to cure, but sometimes so does any operation. Dr. White records2 ninety trephinings in which, though nothing was found, great relief followed, and two cases were apparently cured; he mentions benefit or apparent cure following tracheotomy, ligation of the carotid, incision of the scalp, etc. The fact seems to be that any operation, by means of nervous shock, may interrupt 1The author, in Hare's System of Practical Therapeutics. 2" The Supposed Curative Effects of Operations per se," Annals of Surgery, August and September, 1891. 36 562 A MANUAL OF SURGERY. the epileptic habit; but in ordinary operations the fits tend to recur, and soon reach their old standard of frequency. In the special brain-operations with excision of obvious lesions or discharging centres, the fits often recur, but they will rarely reach the old standard of frequency, and will ^ be more amenable to medical treatment. In non-traumatic epilepsy the fits are to be studied by a competent observer (Keen), and, if focal epilepsy or Jacksonian epilepsy exists, trephining is to be performed over the diseased centre and the explosive focus is to be located by an electric current and removed. In favor of this procedure is the high author- ity of Keen, Horsley, and Macewen. This operation causes paralysis, but the paralysis is rarely permanent except, per- haps, to the finer movements. In non-traumatic chronic epilepsy without localizing symp- toms trephining is not justifiable unless persistent headache calls for it as a means of relief from intracranial pressure. After trephining for epilepsy five years should elapse without a convulsion before cure is reasonably assured, and if con- vulsions arise, they must at once be met by medical treat- ment. A man having once had a convulsion may at any time have more ; hence he should always be watched. It is , not unusual for a few convulsions to occur soon after an operation, and then to cease. These early fits result from habit. Among the operative procedures suggested for the treatment of epilepsy may be mentioned circumcision, clito- ridectomy, ocular tenotomy, ligation of the vertebral arteries, removal of the cervical ganglia of the sympathetic (Alex- ander), and the actual cautery to the head (Fere). u Operations on the Skull and Brain.—Trephining (for a fractured skull).—Shave the scalp, wash it with ethereal soap, then with ether, scrub with a brush wet with corro- sive-sublimate solution (1 : 1000), and wrap up the scalp in wet corrosive-sublimate gauze (1 : 2000). The instruments DISEASES AND INJURIES OF THE HEAD. 563 required are a scalpel, an Allis dissector, haemostatic, dissect- ing, and toothed forceps, trephines of several sizes, a perios- teum-elevator, a Hey saw, rongeur forceps, a bone-elevator, a dural separator, a tenaculum, small curved Hagedorn needles, and a needle-holder. Provide a sand pillow. The patient lies upon his back, the shoulders are a little raised, the sand pillow is placed under the neck, and his head is turned away from the side to be operated upon. The posi- tion of the surgeon is such that the patient's head is a little to his left. A large semilunar incision is made with the base down, which incision goes through the periosteum, and the flap is lifted. The bleeding vessels of the flap are caught with forceps. The pin of the trephine is projected beyond the crown and is set upon sound bone, the crown overhang- ing the line or edge of the fracture. A gutter is cut in the bone, the pin is withdrawn, and the trephining is completed. In going through the diploe bleeding is copious and the inner table feels very dense. Stop from time to time, clean out the gutter with the dissector, and try the bone with an elevator to see if it is loose. When the fragment is loose enough, pry it out and hand it to an assistant, who places it at once in a bowl of solution of corrosive sublimate (1 : 2000) kept warm by standing in a basin of water at 1050, or who puts it in warm carbolized towels or in warm normal salt- solution. The edges of the opening are rounded with a rongeur and the bone is elevated. Sometimes it may be necessary to remove splinters and fragments of bone. The dura is examined to see if injury exists, hemorrhage is , arrested, the wound is cleansed, the button of bone is re- introduced, or some chips are cut from it and scattered upon the dura. The scalp is sutured and horse-hair drainage is employed for a day or two. Sterilized gauze dressings are put on, a rubber dam is laid over them, and a gauze bandage wet with bichloride-of-mercury solution is applied. 564 A MANUAL OF SURGERY. Technique of Brain-operations (after Horsley and Keen). —Always shave the scalp, and always antisepticize it. In localizations, mark out the fissure upon the scalp with an aniline pencil or with iodine. Have the patient semi-recum- bent. Mark three points upon the bone with the centre-pin ^ of the trephine before incising the scalp (both ends of the Rolandic fissure and the point at which the trephine will be applied). Make a semilunar flap three inches in diameter, with the base below. Control bleeding in the flap by forceps pressure. The one and a half inch trephine is used, but, if a smaller trephine is employed, the opening must be enlarged with a rongeur. Before enlarging the opening, separate the dura from the bone by a dural separator. As a rule, open the dura and examine the brain. The dura is lifted by rat- toothed forceps and is opened with scissors along a line a quarter of an inch from the bone-edge. Hemorrhage is arrested by pressure and hot water or by passing a curved needle threaded with catgut around any bleeding vessel. In some cases packing must be left in or forceps must be kept on. In packing, never use more than one piece of gauze, so as to avoid leaving in a forgotten piece. Upon opening the dura, cerebro-spinal fluid flows out, the stream being increased with » each expiration. Absence of pulsation of the brain points to tumor, and a livid color indicates subcortical growth. An old laceration is brownish. If the brain bulges through the opening, it means increased pressure (tumor, abscess, effusion into the ventricles, etc.). After opening the dura, employ no antiseptics except boiled water, especially when the surgeon intends using electricity to locate a centre. Re- , move any abnormal brain-tissue which is found. In electri- fying the brain, faradism is employed of a strength about sufficient to move the thenar muscles when applied to them. After an aseptic cerebral operation, as a rule, do not drain. In many cases replace the bone, but not when the bone is DISEASES AND INJURIES OF THE HEAD. 565 diseased, is infected, or is very compact, or if it is desired to alter pressure. The dura is sutured by a continuous catgut suture (Fig. 131); the scalp is sutured by interrupted silk- worm gut (Fig. 132). , \%; V" ' '■ *\ -■ ■ ■ ■ *' * Fig. 131.—Continuous Suture. Fig. 132.—Interrupted Suture. Operation for Mastoid Suppuration.—The instruments required in this operation are a scalpel, a gouge, a chisel, a mallet, curettes, a probe, a dissector, dissecting and haemo- static forceps, and needles. Provide a sand-bag to place under the neck. An incision is made one-quarter of an inch posterior to the auricle and down to the bone. The bone is bared and examined especially at a point in the line of the incision which is on a level with the roof of the meatus. The bone will usually be found softened. Gouge it away and thus open the mastoid antrum. This bone-opening is within the limits of Macewen's suprameatal triangle, a space bounded by the posterior root of the zygoma, the posterior bony wall of the meatus, and a line joining the two. If, in the adult, pus is not found, gouge downward and backward, but with great care, so as to avoid the lateral sinus. After evacuating the pus, scrape out the cavities with the curette, enlarge the opening between the mastoid and the middle ear t with the gouge, turn the head toward the side operated upon, and irrigate the mastoid with corrosive-sublimate solution I (1 : 2000); dust in iodoform, pack with iodoform gauze for a few days, and then introduce a silver drainage-tube. Treat the causative ear disease. If mastoid suppuration has established abscess in the 566 A MANUAL OF SURGERY. temporo-sphenoidal lobe, trephine one and a quarter inches behind and one and a quarter inches above the middle of the external meatus (Barker's point), and search for pus as directed on p. 559. If abscess of the cerebellum exists, tre- phine below the line of the lateral sinus—that is, below a line running from the inion to a point on a horizontal line from the roof of the meatus, one inch posterior to the middle of the meatus. If infective sinus thrombosis exists, break into the lateral sinus through the mastoid opening and proceed as directed on p. 560. XXIII. SURGERY OF THE SPINE. Congenital Deformities.—Spina bifida, or hydrorrha- * chitis, is a congenital cystic tumor due to vertebral deficiency, permitting protrusion of the contents of the spinal canal in the median line. The laminae or spines of one vertebra or of several vertebrae may be deficient, most frequently in the lumbo-sacral region. Meningocele is a protrusion of dura mater and arachnoid, the sac containing cerebro-spinal fluid, but no nerves and no cord-substance. Meningo-myelocele (the commonest form) is a protrusion of dura mater and » arachnoid, the sac containing cerebro-spinal fluid, nerves, and cord-substance. The cord may spread out upon the sac- wall or it may pass through the sac and re-enter the canal. Syringo-myelocele is great distention of the central canal, the sac-wall being formed of the thinned cord. A hydror- rhachis varies in size from that of a walnut to that of a child's head; it grows rapidly during the early weeks of « life; it is usually sessile, but may present where it joins the body a definite constriction, or even a pedicle ; the base of the sac is covered with healthy skin, and the fundus is covered only by thin epidermis or by the spinal membranes themselves. Pressure upon the tumor is found to diminish SURGERY OF THE SPINE. 567 its size and to increase the tension of the anterior fontanelle, and possibly to cause convulsions or stupor. The cyst is translucent, and the margins of the bony aperture are dis- tinct. Crying, coughing, or pressure upon the anterior fontanelle makes the tumor more tense. Spina bifida is apt to be associated with club-foot, with hydrocephalus, and with rectal or vesical paralysis. Spina bifida usually causes death. A few meningoceles and a very few meningo myeloceles undergo spontaneous cure by the shrinking of the sac. Syringo-myelocele is invariably fatal. The cause of death may be rupture of the sac or marasmus. Treatment.—Very small protrusions which grow slowly and are covered with sound skin may be treated by the use of a compress and bandage, by an elastic bandage, or by applications of contractile collodion. Some surgeons tap and drain the sac. Injection is used by many. The sac being cleaned, the child is placed on its side and a little chloroform is given. A fine trocar is plunged obliquely in at the side through sound skin, little or no fluid being drawn off, and 3j of Morton's fluid is injected (iodine, gr. x; iodide of potassium, gr. xxx ; glycerin, 3j). The trocar is withdrawn and the puncture is sealed with a bit of gauze and iodoform collodion. The child is put to bed. If the injection proves successful, the sac shrinks; if the injection fails, it may be repeated at intervals of from seven to ten days (Jacobson, White). Many surgeons prefer excision of the sac. Bayer treats it as he would a hernia. Tumors of the Spine.—Among congenital tumors are lipomata and cysts (dermoid, congenital, sacral, and fcetal). Tubercle, gumma, psammoma, and fibroma may arise from the cord or its membranes. Glioma is the most usual growth. Primary sarcoma is rare. Angeioma may occur. * Carcinoma is never primary. A tumor rarely produces obvi- ous symptoms until it is as large as a hazel-nut. 568 A MANUAL OF SURGERY. Symptoms and Treatment.—Pain, stiffness of the back, areas of anaesthesia, and progressively advancing motor paralysis are symptoms of spinal tumors. A tumor may produce the symptoms of compression-myelitis, locomotor ataxia, or myelitis. In glioma there are apt to be loss of ability to recognize variations of temperature (or even to distinguish between heat and cold), loss of the sense of pain, and paresis and atrophy of muscles. Contractures or paraplegia may arise. The location of the tumor can be inferred by a study of the territory of paralysis and the zone of sensory disturbance. The tumor is always somewhat above the upper limit of anaesthesia. In many cases the diagnosis is impossible. Gradually increasing painful para- plegia, with pain in the back or with sensory paralysis after a time appearing and ascending from the feet toward the trunk, points to tumor as a cause. The reflexes are at first increased, but are finally lost from below upward. Spasms may develop, and spinal curvature may arise. Growths out- side the membranes produce more pain and spasm ; growths within the membranes produce more motor paralysis and anaesthesia. If syphilis is suspected, give the patient a heroic course of iodide of potassium. In a focal lesion not due to dissemination of a known malignant growth, perform the operation of laminectomy to permit of exploration and pos- sibly of removal. Spinal Curvatures.—There are four chief forms of spinal curvature: (i) lateral curvature (the scoliosis of the older surgeons); (2) posterior curvature (the excurvation, gib- bosity, or kyphosis of the older surgeons); (3) anterior curvature (the lordosis of the older surgeons); and (4) angular curvature (from spinal caries). The normal spine has four curves: the cervical curve, the convexity of which is forward ; the dorsal curve, the concavity of which is for- ward ; the lumbar curve, which is convex anteriorly; and SURGERY OF THE SPINE. 569 the pelvic curve, which is concave anteriorly. The dorsal and the pelvic curves, which are primary, are due to the formation of the cavities of the chest and pelvis, and depend upon the shape of the bones (Treves). The cervical and lumbar curves, which are compensatory, depend upon the shape of the intervertebral disks, and only appear after birth when the erect position is assumed. Lateral curvature (scoliosis) is a lateral deviation of the spinal column, often accompanied with rotation of the vertebrae and associated with increase or with diminution of the normal curves. Lateral curvature is predisposed to by weak muscles and ligaments, by the habitual assumption of strained and unnatural attitudes, by unequal length of the legs, and by paralysis of one leg. This distortion, which is commonest in girls, is apt to arise at the age of puberty (it is usually corrected in boys by outdoor exercise). The bones are soft and the muscles are weak, and this con- dition is often hereditary. Rickets is very commonly asso- ciated with lateral curvature. Any condition of ill-health weakens the muscles ; hence lateral curvature may arise after an acute sickness or in a person who outgrows his strength. An empyema with adhesions, by pulling on the chest-wall, may produce a curvature the concavity of which is toward the diseased side. The weak muscles cease to sustain the spinal column, and the ligaments stretch, relax, or lengthen. The commonest curve is toward the right in the dorsal region (because most people use the right hand more than the left). As soon as a dorsal curve to the right arises, a compensatory lumbar curve (Fig. 133) takes place to the left, thus enabling the patient still to sit or to stand erect. In almost all cases the vertebrae soon rotate, the bodies turning to the convexity and the spines turning to the concavity of the curve; hence the transverse processes toward the convexity project. The 570 A MANUAL OF SURGERY. ribs follow the spinal rotation; the shoulder is elevated on the side of the convexity, and the hip on the same side is raised (Bowlby). The intervertebral disks are apt to flatten out on the concavity of the curve. In very rare instances lateral curvature results from caries of a half of one or of several vertebrae. In a spinal tumor lateral curvature may occur, the concavity of the bend being on the side of the growth. Symptoms.—An ordinary case of spinal curvature from weak muscles comes on gradually with stooping, and after a time with pain in the dorsal and lumbar regions and weakness in the back. The pain is made more severe by walking or by sitting long in one atti- tude. Anaemia is manifest, and walking is awkward and ungraceful. When the shoes and clothing are removed, and the child stands with its back toward the surgeon and the feet symmetrically together, the lower angle of the right scapula (in a dorsal curvature to the right) is unduly prominent and is Fig. 133.— elevated above the left; the normal prominence of Lateral Dor- fae left iliac crest is lost; the right iliac crest is sal Curvature to the Right, unduly distinct; on marking the spinous processes satory^Lum- with an aniline pencil the curve becomes manifest; b*r £urve t0 tenderness is often developed on pressing the spines; the normal dorsal antero-posterior curve is exag- gerated ; the abdomen is protuberant; the chest is flat- tened; the neck juts forward; and the breast on the same side as the concavity of the curve is more prominent and on a lower level than the other breast. Always observe if the anterior iliac spines are on a level or not, and always measure the length of the legs. The patient, with the knees extended, bends forward with the arms hanging loosely : the erector spinae muscle between the iliac crest and the last rib is seen to be more prominent on the convexity of the lumbar curve than on its concavity (Bernard Roth), and SURGERY OF THE SPINE. 571 the angles of the ribs on the side of the convexity of the dorsal curve are on a higher level than are those on its concavity. Have the child assume what it sup- poses to be an erect attitude, and let the surgeon correct this into the best possible position (Roth), and see how long it can voluntarily be maintained. A large percentage of these patients labor under pes planus. When there is no osseous deformity (that is, when the surgeon can correct the deformity), and when the spinal muscles are not paralyzed, the prognosis is good for complete cure. Roth states that cases without osseous deformity can practically be cured in one month, but the treatment must be continued for one year to prevent relapse.1 In cases of moderate osseous de- formity the patient can be improved vastly by three months' daily treatment (Roth). Even in severe cases of bony deform- ity the pain may be relieved and the deformity be modified. Treatment.—If one leg is too short, let the patient wear a thick-soled shoe. No treatment for weak muscles has ever been devised so utterly irrational and absurd as the prevention of all movement; and neglect of all treatment for lateral curvature does less harm than immobilizing the spinal muscles by braces and supports. The muscular nutrition in these cases is to be restored, as is muscular nutrition in any other region, by scientific gymnastics, electricity, the douche, salt baths, frictions, and massage. Roth's advice is to so re-educate the muscular sense that a patient can again know whether she is or is not standing straight; to maintain an improved position in sitting and standing; to use such clothing as will not interfere with the assumption of a normal attitude; to enforce systematic training of the muscles of the spine and thorax; and to give attention to the general health. In those rare lateral curvatures due to caries a supporting apparatus must of course be applied. 1 Heath's Dictionary of Practical Surgery. 572 A MANUAL OF SURGERY. Antero-posterior curvature (not from spinal caries or from hip-joint disease) is an increase of the normal antero- posterior curves. Increase of the dorsal curve is posterior curvature, kyphosis, or excurvation (Fig. 134, a) ; increase of the lumbar curve is anterior curvature, lordosis, or saddle- back (Fig. 134, b). Both lordosis and kypho- \ sis are apt to be present. Scoliosis has / nearly always some antero-posterior curva- ' ture associated with it. Lordosis is apt to be compensatory, to prevent the centre of ^>. gravity going too far forward. Lordosis is ^A found in pregnant women and in very fat ^) men. In an old man kyphosis arises from Fig. 134.—Kyphosis flattening out of the vertebra] disks from (a) an or osis (b). pressure< Rheumatic gout may cause it. Antero-posterior curvature is often due to paralysis of the erector spinae mass (from infantile paralysis). Pseudo- hypertrophic paralysis causes lordosis. Symptoms and Treatment.—The symptoms of antero-pos- terior curvature are as follows: The thorax is flattened or pigeon-breasted; the shoulder-blades are widely separated and the scapular angles project; the abdomen is protuberant; the patient complains of backache and soon tires. A recent kyphosis disappears when the patient" lies upon his stomach. The fact that the erector spinae muscles are soft, and the absence of pain on concussion transmitted from the heels separate kyphosis from caries. Lordosis is unmistakable. When the spine is movable, employ the same plan of treat- ment as that in lateral curvature, suiting the gymnastics to the deformity (Roth). In painful kyphosis with partial ankylosis, endeavor to make the ankylosis complete to pre- vent pain, obtaining this result by applying a plaster jacket which laces up and letting the patient wear it for several years. ft SURGERY OF THE SPLNE. 573 Angular curvature (spinal caries, Pott's disease), which is strumous caries of the vertebral bodies, occurs particularly in children who are scrofulous, but it may arise at any age. The dorso-lumbar region is most prone to suffer. The causes are struma and syphilis. Blows or strains are often exciting causes. It may develop after an exanthematous fever. The cancellous tissue of the anterior portion of a verte- bral body becomes primarily carious, or the inflammation may begin in an intervertebral disk. (The changes of strumous osteitis have previously been set forth.) The body of the vertebrae and the adjacent vertebral disks are destroyed, and the process extends to adjacent vertebrae. The weight which rests upon the spinal column crumbles down softened bone, compresses the diseased vertebrae and disks, and produces angular deformity (the anterior part of the spine formed by the vertebral bodies is shortened, the posterior part is not, and hence the spines project). In some cases the disease is spontaneously arrested by organization of inflammatory products, and ankylosis (fibrous or bony) in deformity is Nature's cure. In most cases, however, the dis- ease spreads and caseous pus is formed, which, according to the route it takes, causes lumbar abscess, dorsal abscess, psoas abscess, or post-pharyngeal abscess (pp. 98, 99). In some cases the spinal cord is compressed, but in most cases it is not, and even when it is compressed, paraplegia is rare and is usually temporary. Pachymeningitis is apt to arise. Caries of the cervical region constitutes a more dangerous disease than caries of either the dorsal or the lumbar regions (dangerous pressure occurs more easily). Death may be caused by exhaustion, sepsis, hemorrhage, amyloid disease, pneumonia, peritonitis, pleuritis, tubercular dissemination, and pressure upon the cord. Symptoms.—The first symptom of angular curvature is pain in the back, which is increased by motion, by pressure, 574 A MANUAL OF SURGERY. and by vertebral jars. Neuralgic pains pass into distant parts (sciatica, intercostal neuralgia) and are often linked with muscular spasm. In cervical caries there is often wry-neck. Cramp in the legs occurs in dorsal or lumbar caries. The patient, if a child, grows tired easily, shows alteration of dis- position, becomes moody and irritable, complains of vague pains in many places, constantly leans, rests, or lies down, and walks with the back rigid, which produces a peculiar gait. If asked to pick up something from the ground, the child will not bend the back, but bends the knees or gets upon the knees instead. A painful spot is found by pressing upon the spines, and the same spot is painful on pressing the head downward or upon jarring the entire spine. Spasm of the erector spinae is detected (C. Hilton, Golding-Bird). The pain is relieved by lifting the shoulders. When angular deformity begins, it is easily recognized. Paralysis may exist, and it is due to pachymeningitis more often than to pressure from bone. Cervical caries causes dyspncea and torticollis, the head requiring support with the hand. Dys- phagia indicates abscess. In adults the first signs of Pott's disease to attract attention are backache, neuralgia, girdle- pain, cramp, or even paralysis. Treatment of Caries of the Spine.—When recent caries of the spine is active and affects a child, when it is accom- panied with pain and fever, and when paralysis threatens, insist upon perfect rest. Place the child supine on a hard mattress, and, if possible, take it, while still in bed, out of doors daily. Leeches, blisters, or the hot iron over the area of pain may do good. When the disease is not active or when it arises in an adult, apply Sayre's plaster-of-Plaster jacket (Fig. 135). When "all subjective signs cease" (Golding- Bird), substitute for Sayre's jacket a felt jacket which laces. In diseases at or near the vertebro-occipital articulation, as long as dyspncea persists, keep the patient supine with a SURGERY OF THE SPLNE. 575 small hard pillow under the nape of the neck (Hilton) and a sand-bag on each side of the head and neck. After sev- eral months mechanical support can be given by Furneaux Jordan's apparatus. In disease of the cervical region below the axis, or in cervico-dorsal disease, use Sayre's jury-mast '.—l'laster-of-Paris Jacket Fig. 135.—Plaster-of-Paris Jacket (Sayre). and Jury-mast Applied (Sayre). (Fig. 136). Treat abscesses as indicated on pages 98 and 99. Treves's operation for caries will be found upon page 479. Paralysis, if due to cord-inflammation, is treated by iodide of potassium, absolute rest, and counter-irritation. During the course of caries of the spine, give oleum morrhuse, tonics, and nutritious food, and try to get the patient out often into the fresh air. Sea-air is very beneficial. When all active disease ceases, and angular curvature only remains, use an apparatus to combine extension with mechanical support, the plaster jacket being generally employed. Injuries of spinal ligaments and muscles, which may complicate more serious injuries or may exist alone, are caused by wrenches, twists, and violent muscular efforts (as in lifting). Railway accidents may be responsible for these ir.^ v,t 57^ A MANUAL OF SURGERY. sprains and strains. The symptoms soon after the accident are—considerable shock, as a rule, even hysterical excite- ment ; pain, which is felt in the back and often shoots into the extremities, and which is much increased by moving the muscles; tenderness; muscular rigidity, which in one-sided lesions is unilateral (unilateral rigidity cannot be simulated); and often, but not always, swelling and discoloration. The vertebral spines are regular and are not mobile. There is no distant paralysis or hyperaesthesia unless the cord is damaged (though in some rare cases the bladder and the rectum are paralyzed when no cord-lesion can be detected), and hyper- aesthesia may exist over the spines. The treatment of recent injuries comprises rest; the ice-bag and leeching over the painful area; in a day or two hot fomentations, tincture of iodine, and inunctions of ichthyol and lanolin; and, later, massage, the douche, and frictions with a stimulating oint- ment. Phenacetin relieves pain, though in some cases opium is necessary. The injury is called "railway spine" when it is caused by a railway accident. After the immediate effects of the accident subside, trau- matic neurasthenia is apt to arise. In this condition the patient grows tired easily and complains of pains and aches in the back and loins, interfering with or preventing work; paraesthesia and numbness exist in the extremities; in many cases sexual intercourse is impossible because of premature ejaculation or of incapacity for erection ; there are dyspepsia, eye-strain, insomnia, loss of memory, rapid and irregular pulse, cardiac palpitation, and mental depression or con- fusion. The reflexes are usually exaggerated, but they can be exhausted more easily than can the exaggerated reflexes of organic cord disease (because of irritable weakness). Some rigidity and tenderness exist in the back, and the skin over this region is often hyperaesthetic. Attacks of retention of urine may occur. Hypochondria is not unusual. SURGERY OF THE SPINE. $77 Treatment of Traumatic Neurasthenia.—Rest, tonics, mas- sage, douches, and frictions to the back. Secure sleep, and endeavor to bring about a gain in weight. If sexual inca- pacity or seminal emissions worry the patient, dilate the urethra with steel bougies. Traumatic hysteria develops only in those predisposed by a neuropathic hereditary tendency; traumatic neurasthenia may arise in anybody. In the first disease the accident is only the exciting cause; in the second disorder it is the cause. Many cases of so-called " railway spine " are really examples of traumatic hysteria. Traumatic hysteria and neurasthenia may be associated. Neurasthenia is a con- dition of exhaustion associated with a number of chronic disorders; it forms a foundation on which hysteria loves to build its structure of morbid impressionability, hyper- aesthetic centres, lowered self-control, and sensitive peripheral nervous system. The accident plays a double part in pro- ducing traumatic hysteria: first, by its effect on the mind (psychical traumatism); second, by its effect on the body, which anchors the attention at one point, and this area of pain or stiffness often serves as an auto-suggestion which undergoes morbid magnification when viewed through the distorting medium of hysteria. Erichsen used to teach that the varied symptoms of what he named " railway spine " arose from inflammation of the cord and its mem- branes. A blow given to a hysterical person causes a feeling of numbness, and this negative sensation from local shock may establish the idea of paralysis, or the traumatism, acting as a suggestion, inhibits motor representations and destroys the normal ideas of motion and feeling (Charcot and Pitre). Terror always causes a feeling of loss of power in the legs, and the terror of the accident may thus develop ' the idea of paraplegia. The site of a traumatism may localize symptoms; for instance, a blow upon the eye may 37 578 A MANUAL OF SURGERY. cause amaurosis or blepharospasm. It is important to re- member Charcot's saying that a hysteria, long latent and unrecognized, may be awakened into obvious activity by a blow or an accident. Pitre shows the same to be true of epilepsy. A not unusual lesion is hysterical traumatic monoplegia, not coming on at once after the accident, but usually some days afterward, and presenting flaccid muscles, the electrical reactions and reflexes remaining normal, but the muscular sense being lost (Pitre). The muscles usually waste. The skin of the paralyzed limb is anaesthetic or analgesic. There may be anaesthesia limited to a limb, hemianaesthesia, or general anaesthesia.1 Hysterical paraly- sis is usually associated with the permanent stigmata of hysteria—concentric contraction of the visual field, pharyn- geal anaesthesia, convulsive seizures, and hysterogenic zones (Clarke and Pitre). The permanent stigmata may be latent. Hysterical phenomena lack regularity of evolution, and they can be produced, altered, or abolished by mental influences or by physical forces which produce no effect on organic disease. In most hysterical conditions the general health is not profoundly impaired.2 Treatment.—By moral means chiefly. Gain the confidence of the patient. In many cases separation from family and friends is necessary and isolation is desirable. The Weir Mitchell rest-cure is the best plan of treatment, and all its details should be carried out faithfully. Malingering.—Persons injured in accidents are often apt to pretend to maladies which do not exist. Some get well upon the rendering of a favorable verdict by a jury. In any case always examine carefully, so as to be able to exclude malingering. Note the patient's behavior and motions when his attention is diverted from his disease. Meningo-myelitis can be excluded if there be no spasm nor .l J. Michell Clarke in Brain. 2 Read the works of Thorburn and Pitre. SURGERY OF THE SPINE. 579 paralysis, hyperaesthesia, paraesthesia, or anaesthesia at a distance (A. Pearce Gould). If pain has lasted for months, if pressure downward upon the head or shoulders does not increase pain, if the vertebrae are movable and there is no angular displacement, exclude caries. Gould states that when there are wasted muscles, when moderate spine-move- ment is painless, but effort in bringing the body erect causes pain in the erector spinae region, the trouble is a sprain of the erector spinae muscle. If the muscle is not wasted, and the pain is in bending forward rather than in straightening up, the vertebral ligaments are the seat of trouble. Unilateral spasm cannot be simulated. The administration of ether may dispose of a pretended paralysis. Concussion of the Spinal Cord.—This term has no def- inite pathological meaning. It is probable that the condition is one of laceration. The symptom is shock, with intense pallor, nausea, often vomiting, and sometimes syncope. To this condition special symptoms may be linked—as tempo- rary paralysis, a girdle-sensation, numbness and loss of power in the limbs, hiccough, torticollis, coarse tremors, pains in the back and limbs, areas of anaesthesia and anal- gesia—depending on the portion of cord lacerated. Treatment.—The treatment in concussion of the spinal cord is the same as that for sprains. Traumatic neurasthenia and hysteria or organic cord disease may follow this injury. Contusion of the spinal cord may arise from a sprain, but it is usually due to extreme flexion of the spine. It causes hemorrhage into the gray matter of the cord (haema- tomyelia). The symptoms are motor and sensory palsy and diminished reflexes. Some cases recover, but others end in myelitis. Wounds of the spinal cord, which are rare, are usually fatal. Wounds above the origin of the phrenic nerves cause almost instant death. Gunshot wounds are the most usual 580 A MANUAL OF SURGERY. form, the cord being damaged by the bullet and by bone- fragments. A knife is sometimes thrust in between the occiput and atlas. Compression of the spinal cord may be due to blood or to lymph. Compression from blood may be due to extra- medullary hemorrhage or to intramedullary hemorrhage. Extramedullary hemorrhage causes sudden pain in the back, the pain radiating from compressed nerve-roots; hyperaes- thesia and paraesthesia in the area of the radiated pain; spasm of vertebral muscles supplied by the compressed nerves, sometimes of muscles whose nervous supply is below the lesion; tremors; convulsions; retention of urine; para- lytic symptoms following the signs of irritation, but no absolute paralysis (Mills). A girdle-sensation is usual. Intramedullary hemorrhage causes pain, a girdle-sensation, abolition of reflexes, and paralysis. Spasms, rigidity, and paralysis come on early. Bed-sores, retention of urine, and incontinence of feces may occur. Treatment.—If paralysis from spinal-cord bleeding ex- tends rapidly, and life is endangered through the probable involvement of a vital centre, perform a laminectomy (White). In some cases with persistent paraplegia the operation should be undertaken. If operation is not undertaken, cause the patient to lie upon his side and give morphia hypodermat- ically. If hemorrhage continues in the cord and if the patient be plethoric, perform venesection. Some surgeons advise hypodermatic injections of ergotin. To promote absorption of the clot and exudate, give a combination of carbonate and acetate of ammonium, order pilocarpine, and employ spinal galvanism and the hot douche (Bartholow). Fractures and dislocations of the spine are very rare. The spinal regions most liable to injury are the atlo-axial, the cervico-dorsal, and the dorso-lumbar (Treves). A verte- bra may be fractured alone, but dislocation without fracture, SURGERY OF THE SPLNE. 581 except in the upper cervical region, very rarely occurs. These two lesions, dislocation and fracture, are so often associated that the term fracture-dislocation is used by many surgeons to include them both. The causes of fracture and dislocation are direct force (rarely) and indirect violence (commonly). Fracture-dislocation from direct force may occur at any part of the column, and in this accident the posterior vertebral segments are driven together. The cord, as a rule, escapes. Direct force may damage the bones only. Fracture-dislocations from indirect force most com- monly happen in the cervical and dorsal regions. In the cervical region reduction can usually be secured, but in the lumbar region reduction is impossible. In fractures from indirect force the cord generally suffers. Symptoms.—In fracture-dislocations much displacement is rare, but some is almost always recognizable (irregularity of spines or angular deformity). In fractures there are pain (which is increased on motion), tenderness, ecchymosis, and motor and sensory paralysis. Priapism, cystitis, and reten- tion of urine often occur. The extent of paralysis depends on the seat of the cord-injury. The prognosis depends on the amount of damage done to the cord. Fracture-disloca- tions in the cervical region produce obvious deformity, stiff- ness of the neck, and irregularity of the spines, and a dis- placed vertebra may occasionally be detected by a finger in the pharynx. Crepitus can rarely be detected unless a spinous process is fractured. Treatment of Fracture-dislocations.—When dislocation ob- viously exists, attempt reduction by extension and rotation (White). This manoeuvre is very dangerous in the cervical region, and, as deaths have happened, some eminent sur- geons advise against reduction when the injury affects that region. In fracture-dislocation the traditional plan is to straighten the spine gently if possible and to put the patient 582 A MANUAL OF SURGERY. upon his back upon a water-bed or upon air-cushions. In fractures in the cervical region, support the head and neck with sand-bags. Empty the bladder four times every twenty- four hours with a soft catheter which is kept strictly aseptic. Take every precaution to prevent bed-sores. Some sur- geons advocate reduction of the deformity by extension and counter-extension, and by the application of a firm-fitting but removable jacket with the suspension collar (as used in Pott's disease). The head of the bed is raised and the collar is fastened to it. Every day extend gently from the shoulders in dorso-lumbar fracture, and from the chin and occiput in cervical fractures. Extension may be maintained perma- nently until cure. Prof. White says laminectomy should be performed for fracture or for dislocation when there is obvious depression of the vertebral arches; in all cases of pressure upon the cauda equina; when there are character- istic symptoms of spinal hemorrhage; and in some cases where rapid degeneration becomes manifest. Operations on the Spine : Treves's Operation for Verte- bral Caries.—(See p. 479.) Laminectomy.—The instruments required in laminectomy are dissecting-, rat-toothed, and haemostatic forceps; scalpels; bone-cutting forceps; rongeur forceps; a trephine; a dry dissector; a periosteum-elevator; sequestrum forceps ; small scissors, straight and curved on the flat; a chisel and mallet; retractors; blunt hooks; a probe; tenaculum forceps; a spoon-curette; a sand pillow; fine needles, curved and straight, large needles, and a needle-holder. In the operation of laminectomy the patient lies prone and a sand pillow is placed under the lower ribs. Make an incision down the vertebral spines, the middle of the incision corresponding to the seat of fracture. The sides of the spinous process and the laminae are cleared. The perios- teum is incised in the angle between the laminae and spines, SURGERY OF THE RESPIRATORY ORGANS. 583 and it is lifted away from the arch. The spinous processes are cut off with forceps close to their bases, the laminae are divided on each side with the rongeur, and the dura is exposed. In some cases the fragments will be found on exposing the vertebrae, or the blood-clot will be seen between the dura and the bone ; in other cases the dura must be opened with scissors vertically in the middle line while it is grasped with rat-toothed forceps. After reaching and removing the compressing cause, or after failing to find or remove it, close the dura with catgut, drain the length of the wound with a tube, stitch the superficial parts with silk- worm gut, and dress antiseptically.1 XXIV. SURGERY OF THE RESPIRATORY ORGANS. 1. Diseases and Injuries of the Nose and Antrum. Foreign bodies in the nose are usually introduced through the anterior nares, but in rare instances they enter by way of the posterior nares. Small particles are often expelled spontaneously; larger pieces gather mucus and become fixed. Some materials swell after lodgment. Treatment.—Illuminate the nostril, and, if the foreign body can be seen, insert a hook back of it and effect its removal by means of forceps. In many cases anaesthesia is required. Some foreign bodies require to be pushed back into the naso-pharynx. Occasionally expulsion may be effected by inserting a rubber tube into the unblocked nos- tril and telling the patient to blow forcibly through it. In serious cases a specialist should be summoned to remove a portion of the turbinated bone or to perform whatever operation he thinks best. • Inflammation and Abscess of the Antrum of High- 1 See J. W. White's admirable description in the Annals of Surgery, July, 1889. 584 A MANUAL OF SURGERY. more (Maxillary Antrum).—The source of this disease may be inflammation of the nose or periostitis around the roots of the teeth. The symptoms are pain, cedematous swelling of the face, and thinning of the bone so that it crepitates under pressure. When pus exists, certain posi- tions of the head will cause a purulent flow from the nose, and pus may be seen by a speculum as it flows into the nose. In severe cases the jaw expands, the eye protrudes, and great tenderness of the alveolus exists. Percussion exhibits a dull note. In the diagnosis it may be well to employ an electric light in the closed mouth and note the limitations of light-transmission. Treatment.—Before pus forms, leech and use hot fomen- tations. When pus has formed, evacuate it at once. If the disease arises from a carious tooth, pull the tooth and push a trocar through its socket into the antrum. If the teeth are sound, bore a hole with a large gimlet or with a bone- drill above the root of the second bicuspid tooth and one inch above the edge of the gum. A counter-opening should be made into the inferior nasal meatus. A drainage-tube is pulled from the first opening into the nose and is allowed to protrude from the nostril. Irrigate daily with peroxide of hydrogen. In three or four days discontinue through-and- through drainage, but prevent the first opening from closing until the discharge ceases to be purulent. 2. Diseases and Injuries of the Larynx and Trachea. CEdema of the Larynx (CEdema of the Glottis).—The causes of oedema of the larynx are—acute laryngitis ; chronic diseases, such as tuberculosis or syphilis; inflammatory dis- orders, such as diphtheria and erysipelas; acute infectious diseases; Bright's disease; aneurysm ; whooping-cough ; pneumonia; quinsy; wounds of the larynx ; wounds of the neck; scalds and burns of the larynx. The symptoms are SURGERY OF THE RESPIRATORY ORGANS. $8$ sudden and rapidly increasing dyspncea, respiratory stridor, huskiness of the voice, and finally aphonia. The epiglottis may be felt with the finger and may be seen with a mirror. Treatment.—In cases of oedema of the larynx which are not excessively acute, make multiple punctures into the epiglottis and favor bleeding by the inhalation of steam. In severe cases perform intubation or tracheotomy. Wounds and Injuries of the Larynx.—The larynx may be injured internally by foreign bodies, and externally by blows and cuts. A condition often met with is cut throat, the result usually of a suicidal attempt on the part of the patient or a homicidal effort on the part of an assailant. The cut of the suicide is usually in front; it misses the great vessels, but divides the crico-thyroid or thyro-hyoid mem- brane. The epiglottis may be incised, or even be cut off. If a large vessel is cut, death rapidly occurs. The immediate dangers of cut throat are hemorrhage, suffocation by blood, entrance of air into veins, and suffocation by displacement of parts. The secondary dangers are pneumonia, infection and sepsis, exhaustion, and secondary hemorrhage. The remote dangers are stricture and fistula (Keetley). Treatment.—In wounds of the throat, arrest hemorrhage, remove clots from the larynx and trachea, bring about reaction, asepticize the parts as well as possible, suture the deeper structures with catgut and the superficial parts with silkworm gut, dress antiseptically, and place a bandage around the head and chest, so as to pull the chin toward the sternum. If laryngeal breathing is much interfered with, perform tracheotomy. Feed the patient through a tube until union has well advanced. The old method of leaving the wound open is to be condemned. When sutures are used, primary union may be obtained. Foreign Bodies in the Air-passages.—The lodgement of foreign bodies in the air-passages is a frequent accident. 586 A MANUAL OF SURGERY. Small solid bodies are usually expelled by coughing. Liquids and solids rarely pass beyond the larynx (except in laryngeal disease or palsy, wounds of the floor of the mouth, cut throat, and in people unconscious or comatose). In post-ether vomiting or in the vomiting of drunkards the vomited matter may find its way into the larynx. In most instances of foreign bodies lodged in the air-passages it will be found that the object was being held in the mouth when a sudden deep inspiration was taken (often from laughter). The symptoms are immediate, due to obstruction by the body and to spasm, and secondary, due to the situa- tion of the body and the changes it undergoes or induces. Lodgement in the pharynx causes violent dyspncea. The body can be seen or felt. Lodgement in the Larynx.—In a severe case the patient fights madly for air; his face becomes livid and cyanotic; his veins stand out prominently; speech is impossible, though he may make noises and utter harsh cries; violent coughing begins, and then vomiting; he tries to force a finger down his throat and clutches at his neck; sweat pours from him ; he feels a sense of impending dissolution, and he falls down unconscious, with incontinence of feces and urine.1 In a less severe case violent dyspncea gradually departs and the patient lies exhausted, but dyspnoea and cough are liable to recur suddenly at any time because of spasm, and they may be induced by a change of position. These attacks of fierce spasmodic cough are not at first linked with expectoration, but after inflammation begins there is a profuse and often bloody expectoration. Inflam- mation follows more rapidly the lodgement of a sharp or irregular body than it does that of a round or smooth body. Inflammation is apt to produce cedema of the glottis, broncho-pneumonia, or ulceration and necrosis of the larynx. 1 See C. Mansell Moullin's graphic description. SURGERY OF THE RESPIRATORY ORGANS. 587 Any foreign body in the larynx may at any moment produce spasmodic dyspncea, and it is always very liable to cause cedema of the glottis. Lodgement in the Trachea.—The immediate symptoms of foreign bodies in the trachea depend on the shape and weight of the body, and whether it becomes fixed in the mucous membrane or moves to and fro with the air-cur- rent. A smooth heavy body falls to the bifurcation, and, if it does not enter a bronchus, moves with every breath, and by its movement causes violent laryngeal spasm, cough, and whooping inspiration without aphonia. The patient is often conscious of the movements of the foreign body, and the surgeon may detect them with the stethoscope. A foreign body in the trachea is liable to cause death by dyspnoea, or it may ascend so as to be caught in the larynx, or may even be expelled. Irregular or sharp bodies lodge in the mucous membrane, produce inflammation, frequent cough, and ex- pectoration, and finally lead to ulceration. Bodies which swell up from heat and moisture tend to lodge and to become fixed (seeds may sprout). Lodgement in a Bronchus.—Foreign bodies in the bronchi usually lodge in the right bronchus. When a small lung- area is obstructed, the obstructed side shows diminished respiratory movement and murmur with occasional whistling sounds and large moist rales; percussion note is normal. When an entire lobe is obstructed, all respiratory sounds are absent over it, and over the unobstructed lung respira- tion is exaggerated; the percussion note, at first resonant, becomes dull. Lodgement in a bronchus may cause broncho- pneumonia, abscess, hemorrhage, and even gangrene. Treatment.—If a foreign body lodges in the pharynx, try to pull it forward; if this fails, push it back into the oesoph- agus. In lodgement in the larynx or below, if the symptoms are very urgent, at once perform a quick laryngotomy. If 588 A MANUAL OF SURGERY. the symptoms are not so urgent, get a complete history of the accident and find out the nature of the foreign body. Be sure a foreign body is retained in the respiratory tract, and determine what its situation may be. Often a skilful man can remove a foreign body from the larynx by means of forceps, a mirror being used for illumination. The fauces and upper portion of the larynx should have cocaine applied to them to lessen pain and spasm. If the surgeon fails in extraction by forceps, and laryngotomy has been performed, continue the search through the opening in the crico-thyroid qaembrane; if laryngotomy has not been performed, let it be done in the form known as thyrotomy (a vertical incision between the alae of the thyroid cartilage, and the separation of these alae to permit of exploration). After a thyrotomy suture the perichondrium with catgut. If the foreign body is in the trachea or in a bronchus, perform tracheotomy: this prevents suffocation from laryngeal spasm or cedema. The foreign body may be expelled; if it is not expelled, search the trachea and bronchi with Gross's forceps, with probes, with hooks, or with the finger. If the foreign body cannot be found, insert a tube, put the patient to bed, and maintain a moist atmosphere. If the foreign body be ex- tracted, do not insert a tube (unless cedema of the glottis exists or is likely to come on), do not suture the wound, but cover it with moist gauze and let it heal by granulation. Morphia and sedative cough-mixtures are given. Gross says that, even when a foreign body has long been retained, an operation should be performed so long as the air-passages are not seriously diseased. 3. Operations on the Larynx and Trachea. Tracheotomy.—The instruments required in this opera- tion are the scalpel, dissecting-forceps, a dry dissector, haemostatic forceps, scissors, a tenaculum, aneurysm-needle, SURGERY OF THE RESPIRATORY ORGANS. 589 tubes, tapes, Pacquelin cautery, needles, needle-holder, a mouth-gag, tongue-forceps, foreign-body forceps, retractors, and, if membrane is present, feathers and a solution of bicar- bonate of sodium. In a formal operation give chloroform, but in an emergency case this cannot be done. The patient may be placed supine with a sand pillow under the neck and with the head thrown over the end of the table. In a child, Liston would wrap it up to the neck in a sheet to prevent movements of the limbs, would seat himself on a chair, place the child upon the nurse's lap, and take its head between his knees. If bleeding is profuse when the surgeon Fig. 137.—Blood-supply of the Larynx and Fig. 138.—Parts Exposed in Tracheotomy Trachea (Esmarch and Kowalzig). (Esmarch and Kowalzig). is ready to open the trachea, place the patient in the Trendel- enburg position with the neck extended. The head must be exactly in the middle line, and extended (in an adult this , gives two and three-quarter inches of trachea above the manubrium ; in a child of ten, two and a quarter inches ; in a child of six, about two inches). The operator stands upon the right side when the patient is supine. The trachea may be opened above or below the isthmus of the thyroid gland. The isthmus in an adult usually lies over the second and 59° A MANUAL OF SURGERY. third rings (Fig. 137). The isthmus in a child usually lies over the first ring or even over the space between the cricoid cartilage and the first ring. The high operation is always performed except in cases where it is desired to search for a foreign body in a bronchus. High Tracheotomy.—This operation is preferred because in this region the muscles are distinctly separated (Fig. 138), the main vessels of the neck and the inferior thyroid vessels are not encountered, the anterior jugular veins are small and have very few transverse branches, and the trachea is near the surface (Treves). Accurately locate the cricoid and thyroid cartilages. An incision is begun at the upper border of the cricoid cartilage, and is carried down precisely in the middle line for about one and a half inches. Treves advises the operator to steady the skin of the neck with the fingers of the left hand and to cut with the unsupported right hand (if the hand be supported the respirations will interfere with the operation). Incise the skin, the superficial fascia, and the anterior layer of the cervical fascia, separate the sterno- hyoid and sterno-thyroid muscles, and divide the fascia over the trachea. This fascia is attached above to the thyroid cartilage, and it divides below into two layers to invest the thyroid body and its isthmus. If veins are in the line of the incision, push them aside, but do not stop to apply a double ligature. Even if bleeding is profuse, as soon as the trachea is opened and air enters freely into the lungs venous conges- tion is relieved and bleeding is apt to cease. If hemorrhage be violent and the veins are not at once caught by forceps, it may be well to place the patient in the Trendelenburg • position. Before opening the trachea, push the isthmus of the thyroid gland down; if it cannot be pushed down suf- ficiently, make a transverse incision through the fascia at the upper border of the cricoid cartilage, and lift the fascia, and the isthmus with it, off the trachea. Insert a tenaculum SURGERY OF THE RESPIRATORY ORGANS. 591 into the cricoid cartilage in order to steady the tube. Turn the back of the knife toward the sternum, hold a finger on the blade to prevent too deep a cut being made, plunge the knife, like a trocar, into the mid-line of the trachea above the isthmus, and divide two or three rings. Do not remove the hook at this time. If a foreign body is present, try to re- move it; if success attends the effort, no tube need be worn, but if the body is not found, use a tube. In croup or in diphtheria, remove membrane (by means of a feather and a solution of bicarbonate of sodium |ij, glycerin 3j, water §x__ Parke) and insert a tube. Grasp an edge of the cut with the dissecting-forceps, include the mucous membrane in the bite, bring the head erect, introduce the tube, and remove the tenaculum. Secure the tube by tapes, and suture the wound below the tube. Remove the tube at the first moment con- sistent with safety. In croup or diphtheria, put a screen around the bed; have the air moist by steam; remove the inner tube and clean every two or three hours at first; clean the outer tube, and the larynx and trachea whenever re- quired, by means of a feather and Parke's solution. A steam spray-atomizer may very often be used with advantage.1 Quick laryngotomy must never be attempted upon a child under thirteen years of age, because of the small size of the crico-thyroid space before this age (Treves). In view of the difficulty of introducing a tube and of wearing it so near the vocal cords, laryngotomy should not be per- formed for croup, diphtheria, or for any condition in which a tube must be worn long. An incision an inch and a quarter long is made in the middle line, from above the lower edge of the thyroid cartilage to below the lower border of the cricoid. Divide the skin, superficial fascia, and deep fascia, separate the crico-thyroid and sterno-thy- 1 See Mr. Jacobson's admirable comments upon the croup-tent and the after- treatment of tracheotomy. 592 A MANUAL OF SURGERY. roid muscles, divide the deep layer of fascia, and divide the crico-thyroid membrane horizontally just above the cricoid cartilage. The tube must be shorter than is the tracheotomy- tube. An operation which opens vertically the crico-thyroid membrane, the cricoid cartilage, and the upper rings of the trachea is called " laryngo-tracheotomy." Intubation of the Larynx (O'Dwyer's Operation).—The instruments required in this operation are a mouth-gag, an instrument to hold the tube and introduce it, an instrument for extracting the tube, and a graduated scale. The collar of the tube has a perforation through which a piece of silk is fastened to draw out the tube. The child is wrapped in a sheet to secure the limbs, is seated in a nurse's lap, and its head is held by an assistant. Open the jaws and insert the self-retaining mouth-gag. The surgeon sits in front of the patient, wraps the index finger of his left hand with plaster, and passes it into the child's mouth until his finger touches the epiglottis. Introduce the holder and tube (observing if the silk is free) along the surface of the tongue until the obturator touches the epiglottis; raise the epiglottis with the left index finger, and pass the tube into the larynx; place the left index finger against the tube, and withdraw the holder with the right hand. Tie the silken thread to the ear, and direct the nurse to employ it to remove the obturator if it becomes obstructed or is coughed up. Remove the tube in two or three days; if breathing is easy, do not reintroduce it, but if dyspncea recurs, replace the tube for two or three days more. If, in introducing the tube, a mass of false membrane is pushed before it into the trachea, breathing ceases, and, if the mass is not at once coughed up, tracheotomy must be performed. Wharton feeds these patients on semi-solids rather than upon liquids (mush, soft eggs, and corn-starch), and if trouble occurs in swallowing these articles, he feeds ' by the rectum or by means of a tube (Wharton). SURGERY OF THE RESPIRATORY ORGANS. 593 4. Diseases and Injuries of the Chest, Pleura, and Lungs. Pleuritic effusion may arise from foreign bodies, from injury by fragments of a broken rib, from tumors, and from inflammation of the lung, but most usually from pleuritis. Inflammatory effusion is nearly always unilateral (except in tubercular pleurisy, which is one-sided at the start). The signs of pleuritic effusion are—dulness on percussion over the effusion, this dulness, when the patient is erect, being at the lower part of the chest and ascending higher posteriorly than anteriorly (alteration of position alters the situation of the dulness); the intercostal spaces are widened and the intercostal depressions are obliterated; no breath- sounds can be detected in the area of flatness when the col- lection of fluid is large, but in small effusions deeply situated the breath-sounds are often audible; the percussion note above the liquid is hyper-resonant or tympanitic, and is often associated, at the edge of the liquid, with a friction sound; posteriorly, high up and near the spine, there is bronchial respiration and bronchophony (Prof. DaCosta). In these cases pain disappears with the advent of effusion, dyspncea comes on, and the patient lies upon the diseased side. Cough and fever always exist. In serous effusions the diagnosis may be confirmed by the introduction of an asepticized hypoder- matic needle. The treatment in this stage is to discontinue arterial sedatives and to stimulate if the circulation calls for it. The exudation is removed by salines, by compound jalap powder, or by elaterium. If these means fail, if the effusion is excessive, if it is producing dyspncea, or if pus forms, at once aspirate. Empyema is a collection of pus in the pleural cavity. Among the causes of empyema are those of serous effusion. The signs are dulness on percussion, as in serous effusion, 33 594 A MANUAL OF SURGERY. fever, chills, bulging of the intercostal spaces, and cedema of the skin of the chest. The treatment is aspiration or incision and drainage. Contusions and Wounds of the Chest.—The symptoms of contusions of the chest are pain and soreness, and, as a consequence, abdominal respiration and decubitus upon the back inclining to the injured side. In severe contusions the viscera may be injured. The treatment is by strapping the chest as for fractured ribs (PI. 7, Fig. 13). Non-penetrat- ing wounds of the chest, which are not especially grave, are treated according to general rules, the chest being immo- bilized. Penetrating wounds are very grave and serious. Visceral injury may be inflicted. Emphysema is apt to occur. Haemoptysis indicates a wound of the lung. In examin- ing chest-wounds, feel with a finger, not with a probe. In wounds of the pleura, cleanse, stitch the pleura with catgut or fine silk, suture the skin, dress with gauze, and immo- bilize the chest. Wounds of the lung demand absolute rest. Always arrest hemorrhage. In haemothorax, if the effusion causes intense dyspnoea, turn out the clots and drain. If emphysema of the chest-walls is moderate, strapping or a bandage will control it; if it is great, make multiple punc- tures and then apply pressure. In hernia of the lung, try to restore the protrusion, but if restoration is impossible or if gangrene seems highly probable, ligate the base with silk and cut away the mass. If foreign bodies in the thorax can be felt, remove them ; if they cannot be felt, do not conduct a prolonged search, but leave them to Nature. Paracentesis Thoracis.—The trocar must not be used except in an emergency; the aspirator (Fig. 96) is greatly to be preferred. The aspirator evacuates the fluid, and, as air does not enter, the lung expands and infection does not occur. The skin, the instruments, and the surgeon's hands must be asepticized. Give the patient a little whiskey, and, SURGERY OF THE RESPIRATORY ORGANS. 595 unless he is very weak, make him sit up in bed. The arm hangs by the side, and the surgeon introduces the needle in the fifth interspace, just in front of the angle of the scapula. The surgeon marks the upper border of the sixth rib with the index finger, and plunges in the needle just above the finger, thus avoiding the intercostal artery, which lies along the lower border of the rib above. Always guard the needle with a finger to prevent its going in too far. After withdrawing the needle, place iodoform collodion over the opening in the chest. When the fluid is purulent, tapping rarely proves curative except in the empyemas which follow pneumonia in children. In pleuritic effusion, if the lungs will not expand after tappings, perform thoracot- omy. Thoracotomy is an incision into the cavity of an empyema. The instruments required are a scalpel, a grooved dissector, forceps (haemostatic and dissecting), scissors, a dry dissector, retractors, bone-instruments (in case rib-excision is required), drainage-tubes, and needles. Chloroform is given the pa- tient, who lies supine at the edge of the table, with the arm elevated to a right angle with the body. Make an incision about three inches in length along the upper border of the lower rib bounding the space it is proposed to penetrate. This space is either the sixth or the sev- enth, and the desired site is in front of the posterior axillary fold. Incise the FlG I39._ReSection of skin divide the intercostal muscles near Rib (Esmarchand Kowai- zig). the rib, push a grooved director through the pleura, and enlarge the opening by means of forceps and the finger. The finger removes all masses of tuber- cular material or aplastic lymph within reach. Against washing the cavity at once on operation is the great author- 59^ A MANUAL OF SURGERY. ity of Treves, but many able surgeons advocate immediate irrigation. In some cases a counter-opening is made by cutting down upon the long probe which is pushed against the chest-wall after being introduced through the incision; in other cases it is necessary to resect a rib (p. 499; Fig. 139). A short drainage-tube is introduced and stitched in place. If a counter-opening has been made, introduce another short tube, but do not pull a tube through both openings. Arrest bleeding, suture the skin, dust with iodo- form, dress with gauze, wood-wool, and a binder, and have the dressings changed as soon as they become soaked at one point. After a day or so has passed, wash out the cavity once every twenty-four hours. Use a fountain-syringe. Irri- gate first with warm diluted peroxide of hydrogen, and then with hot corrosive-sublimate solution (1 : 1000) or with a hot solution of tincture of iodine (1 : 1000). Thoracoplasty (Estlander's operation) is employed in old cases of empyema in which drainage has failed, and in cases with retracted chest-walls, collapsed lungs, thickened pleura, and cavities whose rigid walls will not collapse. This opera- tion causes the obliteration of the cavity by collapsing that portion of the chest-wall overlying it. The cavity is in the upper or central part of the pleural space (Treves). The instruments required are the same as those for resection of a rib. The position is the same as that for rib-resec- tion. The length of the incision depends on the size of the cavity. The surgeon usually removes portions of the second, third, fourth, fifth, sixth, and seventh ribs. Make a transverse incision along the centre of an intercostal space, and through this incision remove the ribs above and below by the method set forth on page 499 (the removal of six ribs will require three incisions). Always take away the periosteum. Treves recommends that the cavity be at once washed out with corrosive sublimate (1 : 1000); that, if small DISEASES AND INJURIES OF DIGESTIVE TRACT. 597 it be packed with iodoform gauze and allowed to granulate; that, if large, it be drained by a large tube, the skin being sutured by silkworm gut. XXV. DISEASES AND INJURIES OF THE DIGES- TIVE TRACT. Diseases of the Mouth, Tongue, and (Esophagus: Hare-lip and Cleft Palate.—Hare-lip is a congenital cleft in the upper lip. Cleft palate is a congenital fissure in the soft palate or in both the hard and soft palates. In hare-lip the cleft is usually complete, through the entire lip into the nostril, but in rare cases it may only show as a furrow in the mucous edge or as a split from the nostril partly into the lips. In double hare-lip the central portion of the lip is often adherent to the tip of the nose (Bowlby). Median hare-lip is exceedingly rare. In cleft palate the septum of the nose is usually adherent to the palatine process opposite to the side upon which the fissure exists. In those rare cases of cleft palate double in front the nasal septum is attached only to the premaxillary bone, and the premaxil- lary bone is not attached at all to the superior maxillae. In hare-lip there is often a cleft in the alveolus, and almost always flattening of the corresponding side of the nose. Hare-lip is often associated with cleft palate, talipes, and other deformities. It is a great deformity, and interferes with suckling, swallowing, and articulation. Operation for hare-lip should be performed between the third and sixth months of life in a child in good health, free from stomach trouble, cough, or coryza, but operation is not advisable in the early weeks of life. Always, if possible, operate before dentition begins (seventh month). If the child is in poor health, postpone the operation until restora- tion has so far advanced as to render operation safe. If a 59^ A MANUAL OF SURGERY. cleft exists in the palate, operate first upon the lip, because the pressure of the parts after the edges of the gap are approximated aids in the closure of the bony cleft. Cleft palate interferes with suckling, deglutition, mastication, and articulation. In severe cases the food passes into the nose and excites inflammation. Loss of control of the palate- muscles always exists, and liquids and solids are liable to pass into the windpipe. Clefts in the hard palate should not be operated on until the tenth or twelfth year unless the child is unable to take sufficient nourishment. In most cases the passage of food and drink into the nose can largely be prevented by the use of a diaphragm. The patient at the period of operation should be well and free from cough (the elder Gross). Operation for Hare-lip.—The instruments required are a tenotome, hare-lip clamps, toothed forceps, haemostatic forceps, scissors curved on the flat and pointed, straight blunt-pointed scissors, needles (straight and curved), silk- worm-gut and silk sutures, a mouth-gag and tongue-forceps, a needle-holder, and sequestrum forceps, each blade pro- tected by a rubber tube. Wrap the child in a sheet; place it supine; raise the head and rest it upon a sand pillow. 0 The surgeon stands to the right-hand Fig. 140.—Operation for side. Ether or chloroform is given. For Hare"lip' single hare-lip, separate with the scissors the upper lip from the bone on each side of the cleft until approximation of the cleft can be effected without tension. If the maxillary bone of one side projects more than its fellow, grasp it with sequestrum forceps and bend it back (Jacobson and Treves). Put a compressor in each angle of the mouth. Grasp the lower angle of one flap with dissect- ing-forceps and pare the edge; carry out the same procedure DISEASES AND INJURIES OF DIGESTIVE TRACT. 599 upon the other flap (Fig. 140). The edges are approximated by an assistant, and silkworm-gut sutures are passed by means of a straight needle. Each suture goes down to the mucous membrane. The first suture is passed through the middle of the lip, one-third of an inch from the cleft. Three or four main sutures are passed through the thickness of the lip, and are tied and cut off. Two or three fine silk sutures are passed by curved needles through the vermilion border of the lip and its mucous membrane, and are tied and cut off. A small piece of gauze is placed over the lip and is held in place by straps of rubber plaster. About the sixth day one-half the sutures are taken out, and on the eighth or ninth day the remaining ones are removed. Hare- lip pins are rarely used at the present time, and are not needed if the lip is well separated from the bone. In double hare-lip the operation is similar to that for single hare-lip. If the intervening piece is vertical and is covered with healthy skin, complete each operation as for single hare-lip, closing both fissures at once in a strong, healthy child, closing them at intervals of three weeks in one not so lusty. Excise the septum if it is deformed. The premaxillary bone should in most in- stances be removed, the skin over it being preserved. Sir. Wm. Fergusson Fig.i4i.-incisions for Double was accustomed to incise the mucous h«-"p (*"»«* and Kowai- membrane and shell out this bone. The premaxillary bone can be forced back into line, being held, if necessary, by catgut suture of the periosteum ; but if saved it is liable to necrose and its teeth soon decay. Figure 141 shows incisions for double hare-lip. ^Operation for Cleft Palate.—Early operations are very dangerous in bony clefts, and during the early years of 6oO A MANUAL OF SURGERY. growth the clefts diminish in size. Bony clefts should be operated upon about the twelfth year. Clefts of the soft palate only may be operated upon in the third year (Thomas Smith). For closure of the soft palate [staphylorrhaphy) Treves says the following instruments are essential: Two sharp-pointed tenotomes, a blunt-pointed tenotome, a rect- angular knife, two pairs of long forceps (one with tenaculum points, one serrated), a fine hook, a pair of sharp-pointed curved scissors, scissors curved on the flat, periosteum-ele- vators, two long-handled needles with eyes at their points, a suture-catcher, a tubular needle for wire sutures, haemo- static forceps, Whitehead's gag and retractors, silver wire, silkworm gut, and sponge-holders; also an electric forehead light. The patient's body is raised, and his head is elevated and rested upon a sand-bag. A better position would be that of Trendelenburg, thus avoiding the blood trickling into the windpipe. Chloroform is given. The gag is intro- duced ; the edges of the fissure are pared with the tenotome; the sutures are introduced from below upward, silkworm gut being used for the uvula and lower part of the velum, silver wire for the remainder of the cleft; each suture, as it is passed, is tied or twisted, but is not cut until the next suture is inserted, thus serving as a handle. If there is too much tension to allow of the sutures being tied as they are inserted, all the sutures are passed and loosely twisted; a longitudinal incision is made upon each side, internal to the hamular process, the mucous membrane being cut with the sharp teno- tome, the deeper structures being divided with a blunt teno- tome; the sutures are tied or twisted and cut (Fig. 142). In Fergusson's operation for clefts in the hard palate [uranoplasty) the mucous edges are pared and the sutures inserted but not tied. Make an incision upon each side down to the bone, the incision being midway between the cleft and the alveolus. Divide the bone on each side, by means of a chisel, to the DISEASES AND INJURIES OF DIGESTIVE TRACT. 6oi full length of the incision, and, using the chisel as a lever, force each half of the bone toward the gap. Tie the sutures, and plug each lateral incision with a piece of iodoform gauze (Fig- 143)- After the operation for cleft palate, put the pa- tient to bed for one week; forbid talking; give fluid or semi- solid food for three weeks at intervals of two or three hours; Fig. 142.—Staphylorrhaphy (Esmarch and Fig. 143.—Uranoplasty (Esmarch and Kowalzig). Kowalzig). wash out the mouth very often (always after eating) with a carbolic solution (i : ioo) or a solution of boracic acid and listerine. Sutures are removed in from two to three weeks. Tongue-tie is a congenital shortness of the fraenum. The tongue cannot be protruded beyond the incisor teeth. Swal- lowing is interfered with, and later in life articulation is impeded. To treat tongue-tie, tear up the fraenum with the thumb-nail. If this fails, catch the fraenum in the slit in the handle of a grooved director, push the director toward the floor of the mouth, and divide the fraenum with scissors curved on the flat and pointed toward the director. Ranula is a dilatation of one of the ducts of the mucous glands of Nuhn and Blandin. These glands lie on each side of the fraenum of the tongue. It was long thought that a ranula arose from obstruction in the duct of the sublingual gland. A ranula appears upon the floor of the mouth on one side and pushes the tongue toward the opposite side. The contents of a ranula resemble mucus or saliva. The 602 A MANUAL OF SURGERY. treatment of ranula is by the seton; by excision of a por- tion of the cyst-wall and cauterization of the interior with pure carbolic acid or with 15 minims of a solution consisting of 10 parts of tincture of iodine, 10 parts of water, and I part of iodide of potassium ; or by cutting a flap from the cyst-wall and stitching it aside so as to keep a permanent opening. Excision of Tongue (Kocher's Method).—Kocher used to employ a preliminary tracheotomy in tongue-excision, but the Trendelenburg chair renders this procedure unneces- sary so far as hemorrhage is concerned. Always clean the mouth well. The instruments required are a scalpel, retrac- tors, a dry dissector, haemostatic and dissecting-forceps, a tenacu- lum, aneurysm-needle, tenaculum forceps, needles, sutures, and scis- sors. In this operation the pa- tient is placed in the Trendelen- burg position, the surgeon being on the affected side. Chloroform is given. An incision is made from behind the lobe of the ear, along the anterior edge of the sterno-cleido-mastoid to about the middle of the margin of this muscle. From this point the incision is carried to the hyoid bone and then to the symphysis menti, along the anterior belly of the digastric muscle (Fig. 144). The flap is dissected and turned up; the facial and lingual arteries are ligated; " the submaxil- lary fossa is evacuated " (Treves); the sublingual and sub- maxillary glands are removed; the mylo-hyoid muscle is divided; the mucous membrane is incised close to the jaw, and the tongue, caught with tenaculum forceps, is drawn through the opening. Split the tongue in the middle with scissors, and remove the near half. If the whole Fig. 144.—Excision of Tongue (Es march and Kowalzig). DISEASES AND INJURIES OF DIGESTIVE TRACT. 603 tongue requires removal, perform a set ligation of the lingual artery of the opposite side. Arrest bleeding. Some sur- geons stitch the mucous membrane of the stump to the mucous membrane of the floor of the mouth; others em- t ploy no sutures. Kocher does not suture his skin-wound; other surgeons do, and employ drainage-tubes. Keen ad- vises closing the floor of the mouth if possible. Some hours after the operation, when oozing has ceased, dust the mouth- wound with iodoform. The patient, as soon as possible, is propped up in bed, and he must not swallow the dis- charges if it can be avoided. The mouth, every half hour, is sprayed out with peroxide of hydrogen and washed with a carbolic solution (1 :60); every three hours, after a washing, the floor of the mouth and the stump are dried with absorb- ent cotton and dusted with iodoform. For twenty-four hours after the operation nothing is given by the mouth except a little cracked ice, the patient being fed per rectum. At the end of twenty-four or forty-eight hours some liquid food is given by a feeding-cup. The patient will soon learn to swal- low, but if he cannot swallow, feed him with a tube. Treves, in his clear and positive directions for after-treatment, states * that nutrient enemata are to be continued until sufficient nourishment is taken by the mouth; that the mouth should be flushed out by irrigation, and must be washed imme- diately after taking food; that morphia is to be avoided; and that the patient can usually leave the hospital in from seven to ten days. Stricture of the (Esophagus.—Fibrous or cicatricial # stricture is due to a wound, to swallowing a corrosive sub- stance, or to syphilis. It is commonest in the young, and is apt to be situated opposite the cricoid cartilage. Malig- nant or cancerous stricture, which arises in those beyond middle life, is more common in men than in women. It is usually due to epithelioma, and its most usual site is on a 604 A MANUAL OF SURGERY. level with the cricoid cartilage. It is invariably fatal, usually by means of septic pneumonia or starvation. Spasmodic or hysterical stricture, which is commonest in women, is asso- ciated with the stigmata of hysteria, and especially with globus (a sense as of a ball rising in the throat); a bougie held against it is only temporarily obstructed. The contrac- tion arises suddenly, and one passage of a bougie often causes it to disappear. Symptoms and Treatment of Organic Stricture. — Difficulty of swallowing, emaci- ation, regurgitation of food which was appar- ently swallowed (be- cause of dilatation above the stricture). Auscultation as fluid is being swallowed will locate the ob- struction. The bougie makes the diagnosis (Fig. 145, e). In fi- brous stricture, feed the patient on liquid food and on food cut up into very small pieces. Pass a bougie every day, gradually increasing the size. In cancer- ous stricture bougies are dangerous; if they are passed, it must be very gently. The passage daily of a soft-rubber catheter maintains an open way. Feed upon liquids, through a tube if necessary, and when this becomes difficult or impos- sible, perform gastrostomy. Symonds advocates permanent Fig. 145.—Operating Instruments: A, B, forceps; C horsehair probang ; d, coin-catcher; e, oesophageal bou gie (Esmarch and Kowalzig). DISEASES AND INJURIES OF DIGESTIVE TRACT. 60$ tubage of strictures. The younger Gross advocated a course of iodide of potassium in stricture, because of the possibility of syphilis. The operation of cesophagostomy has been undertaken, but with poor success. Excision of the dis- eased portion of the oesophagus has been practised. Foreign Bodies in the (Esophagus.—A large foreign body in the oesophagus is apt to be arrested at the smallest part of the tube, opposite the cricoid cartilage. Foreign bodies are frequently caught where the gullet is crossed by the left bronchus and also where it passes through the diaphragm. Small and sharp bodies may lodge any- where. Symptoms and Treatment.—If the body is large, there will be pain and difficulty in swallowing, and, in some cases, dyspnoea. If the body is sharp, there will be hemorrhage and severe pain. A patient may grow accustomed to a foreign body, and cease to notice it; but, on the contrary, the for- eign body may produce inflammation, and even may ulcerate into the windpipe, the pleura, the pericardium, or the aorta. Even after a foreign body has been removed by swallowing or otherwise, a sensation is apt to remain as if it were still lodged. The diagnosis in children or lunatics is made by the detection of the body by external manipulation and by feeling it with an oesophageal bougie. A round smooth body is grasped with forceps and pulled out, or, if this is impossible, it is pushed down with a probang. Sharp bodies are removed with a horsehair probang (Fig. 145, c). Coins are removed with a coin-catcher (Fig. 145, d). Various forceps are employed (Fig. 145. A, B)- Vomiting sometimes displaces a foreign body. In rare instances cesophagotomy is demanded, the cut being made on the left side, between the trachea and the larynx in front and the carotid sheath behind, the centre of the incision being opposite the cricoid cartilage. After removing the foreign body, suture the 606 A MANUAL OF SURGERY. oesophagus with catgut and feed the patient through a tube for one week. XXVI. DISEASES AND INJURIES OF THE ABDOMEN. Contusion of the Abdominal Wall.—In some cases of contusion of the abdominal wall only the parietes are con- tused ; in other cases the viscera or the abdominal tissues are injured. In simple cutaneous contusion there is con- siderable shock if the injury is severe; there is pain, in- creased by respiration, and ecchymosis soon appears. In treating simple contusion, place the patient at rest in a supine position; obtain reaction from the shock; give morphia for pain; place an ice-bag over the injury from time to time, and in the intervals of its application use lead- water and laudanum locally. If much blood is extravasated, aspirate and apply a binder. After twenty-four hours apply intermittent heat by poultice, employ an ointment of ichthyol, and move the bowels, if necessary, by salines. Muscular Rupture from Contusion.—In this injury there are severe shock and pain (increased by respiration and movement). Separation between the fibres of the muscle is distinct at first, but it is soon masked by effusion of blood. Such injuries may cause death, or they may lead to hernia. The treatment is the same as for simple contusion. Always apply a binder. A hernia is returned and a compress is applied over the opening through which it emerged. If strangulation occurs, operate at once. Rupture of the Stomach without External Wound.— The symptoms of this injury are—excessive shock; pain over the entire abdomen, especially over the epigastric region; and vomiting of blood if the mucous membrane is DISEASES AND INJURIES OF THE ABDOMEN. 607 torn. After incomplete rupture local peritonitis is frequent; in complete rupture the escape of food into the peritoneal cavity causes septic peritonitis. To diagnosticate between complete and incomplete ruptures, endeavor to distend the viscus with hydrogen gas : in incomplete rupture the contour of the dilated stomach can be made out upon the surface; in complete rupture the viscus cannot be distended and the gas passes into the peritoneal cavity, producing the physical signs of tympanites (Senn). The treatment in complete rup- ture is as follows: React from shock and at once open the abdomen; if the rent is not visible, find it by inflating with hydrogen; flush out the stomach and the peritoneal cavity; sew up the stomach-wound with a double row of silk sutures, the first row being buried and including the muscular coat and mucous coat, the second row being Lem- bert sutures; drain; close the wound in the parietes with silkworm gut; feed by the rectum for four days, and then begin the administration of a very little food by the mouth. In incomplete rupture the danger is perforation. The patient is put to bed, is reacted, is fed by the rectum for several days, and morphia is given hypodermatically. Rupture of the Intestine without External Wound.— The symptoms of this injury are profound shock, tympani- tes, and pain, rapidly followed by peritonitis. Vomiting comes on soon after the accident, the vomited matters being at first bloody and then stercoraceous. The respiration is thoracic, the tongue is dry, and great thirst exists. The pulse, which is slow at first, becomes small and rapid. A high-tension pulse goes with tympanites, because the disten- tion of the bowel greatly decreases the amount of blood in its coats, and thus increases the amount of blood in the rest of the system. Any portion of the intestine may rupture, but the ileum is most liable to this accident. Blood in the stools rarely appears early enough to be of diagnostic value. The 608 A MANUAL OF SURGERY. escape of gas into the peritoneal cavity may cause disappear- ance of normal liver-dulness. By anaesthetizing the patient hydrogen gas insufflated into the rectum will come from the mouth if there is no perforation in the stomach or the intes- tine ; if a perforation exists, tympanites is much increased. To apply rectal insufflation of hydrogen, generate the gas in a bottle by means of zinc and sulphuric acid, catch the gas in a large rubber bag, and attach the tube from the gas reservoir to a tip which is inserted in the rectum. Give the patient ether to relax the abdominal muscles, direct an assistant to press the anal margins against the rectal tip, and when the patient is unconscious turn on the stopcock and press upon the reservoir (Senn). Treatment.—Give stimulants by the rectum, and a hypo- dermatic injection of morphia and atropia; asepticize and anaesthetize. Perform a laparotomy; check hemorrhage; find the rent, and close it by Lembert sutures if possible. It may be necessary to perform an end-to-end approxima- tion or an intestinal anastomosis. Flush out the abdominal cavity with cooled boiled water. The hydrogen-gas test will discover perforations. " In abdominal operations it is frequently imperatively necessary that the large intestine be recognized with cer- tainty or the small bowel be positively identified. The size of the tube will not always aid in this recognition, as a small intestine may be distended enormously and a large intestine may be contracted to the size of a finger because of obstruc- tion above. The longitudinal muscular fibres of the large bowel are accentuated in three portions; these accentuations constitute the three longitudinal bands which begin at the caecum and terminate at the end of the sigmoid flexure of the colon. Each band is composed of a number of shorter bands, the shortness of these constituent bands permitting the sacculation of the large intestine. Longitudinal bands DISEASES AND INJURIES OF THE ABDOMEN. 609 and sacculation are not met with in the small gut, their pres- ence or absence being a means of identification in many cases; but when the colon is much distended the bands cannot be seen distinctly and the sacculation disappears. From the large intestine only spring the appendices epiplo- icae (small overgrowths of fat in pouches of peritoneum), but they are sometimes not well marked except upon the transverse colon, and when emaciation exists they may almost entirely disappear. The relatively fixed position of the large intestine and the free mobility of the small bowel are important points of distinction. The foregoing indicates that it is not always easy to distinguish between colon and small gut, and that, according to old rules, it may often be necessary to make large incisions, to see as well as feel, and to handle a large extent of the bowel. Any scrap of knowledge that will shorten an abdominal operation, that will permit of as certain work through a smaller incision, and that will diminish handling of intraperitoneal structures, tends to in- crease the chances of recovery. For these reasons the writer suggests a method of bowel-identification which rests upon the facts that each bowel has a posterior attachment, that the origin of the attachment differs according to the bowel it supports, that a single finger can detect the origin of the peritoneal support of any section of the bowel, and, this origin being known, the portion of bowel it supports is with certainty deducible. In an exploratory operation, for instance, the finger comes in contact with the bowel: to de- termine whether it is a large or a small bowel, note first if 4 the structure is movable or is firmly fixed ; next, pass the finger over the bowel and let it find its way posteriorly. If dealing with a small bowel, the finger will reach the origin of the mesentery between the left side of the second lumbar * vertebra and the right sacro-iliac joint; if dealing with the large bowel, the finger will reach the origin of the meso- 6lO A MANUAL OF SURGERY. colon, or the point where the colon is fixed posteriorly and to the side." 1 After flushing out the abdomen a drainage-tube is inserted and the wound is closed. Wounds of the Abdominal Wall.—Non-penetrating wounds are to be treated on general principles. Suture with great care and apply external support. Ventral hernia may follow a large wound. Penetrating Wounds.—The symptoms of penetrating wounds of the abdominal wall are usually those of shock and hem- orrhage* and later of septic peritonitis. Emphysema is apt to occur. Viscera may protrude. In an incised or a lacerated wound some of the contents of the abdomen may protrude. If protruding viscera are uninjured, they are cleansed with cooled boiled water and returned into the abdomen, the wound being enlarged if necessary. The belly is flushed out with hot sterilized water to remove blood-clots, a drainage-tube is inserted, the peritoneum is sutured with catgut, and the muscles and integument are approximated with silkworm gut. If the viscera are injured, treat them appropriately. In punctured and in gunshot wounds, when the intestine has been perforated, rectal insufflation of hydro- gen will often disclose the fact, but evisceration may be neces- sary. Always arrest bleeding. In punctured wounds enlarge the wound of entrance, examine for injury of viscera, close perforations if any are found, flush out the belly, drain, and close the wound. In gunshot wounds examine for a wound of exit; follow the track of entrance by means of a knife and a grooved director; open the peritoneum; arrest hemor- t rhage; look for perforations and close them; examine viscera; search for the ball, but not long, and if it is found, remove it; flush out the belly with hot sterilized water; dry with sponges; drain; and close the wound. In some 1 The author, in Medical News, June 9, 1894. DISEASES AND INJURIES OF THE ABDOMEN. 6ll cases of penetrating wounds of the abdomen enterectomy will be required, and also enterorrhaphy. Irrigation of the cavity is only required when the contents of the stomach or the bowel have escaped or when a considerable hemorrhage t has taken place. The surgeon should drain when the con- tents of the stomach or the intestines have escaped, when hemorrhage is severe, or when the liver, pancreas, kidney, or spleen is damaged. Active stimulation and artificial heat are needed immediately after the operation, to combat shock. The after-treatment consists of rest, opium in small amounts to arrest peristaltic action, avoidance of food by the stomach for forty-eight hours, and the administration of brandy and water from time to time. Feed by the rectum for two days. On the appearance of the first sign of peritonitis forty-eight hours or more after the operation, give a saline cathartic. It will not do to purge during the first forty-eight hours after the operation. When there is no sign of peritonitis, do not purge until the fourth day. After forty-eight hours liquid food can usually be given by the stomach. Solid food may be given after seven or eight days, but the patient must not leave his bed until the wound is solidly united, because of the danger » of ventral hernia. A support should be worn for a long time. Foreign Bodies in the Alimentary Canal.—Most foreign bodies are passed with the feces. A purgative should never be given to expedite the passage of a foreign body, because increased peristalsis means increased danger of impaction or of perforation. Endeavor to encrust the foreign body, and thus lessen the danger of perforation, by feeding with bread , and milk only for several days, and at the end of this period give a mild laxative. An exclusive diet of mush or of mashed potatoes has been suggested. If a foreign body lodges in the stomach, perform a gastrotomy. Cancer of the Stomach.—Surgical treatment may aim at the excision of the growth, or may seek to remove the 6l2 A MANUAL OF SURGERY. mechanical impediment to the entrance of food into, or the emergence of food from, the stomach. In stricture of the cardiac orifice of the stomach the surgeon usually keeps the passage open as long as possible by the frequent passage of a tube, and through this tube introduces liquid food. Some- times a small tube is introduced and permanently retained. If a tube cannot be introduced, gastrostomy is performed, and through this artificial opening the patient is fed (p. 635). In cancer of the pylorus limited in extent and without lymphatic involvement, pylorectomy may be performed ; but in cancer which has widely infiltrated the coats of the stom- ach and has involved the lymphatic glands, gastroenteros- tomy is performed as a palliative measure, the patient during the balance of his life subsisting upon liquid or semi-liquid foods and submitting to frequent irrigation of the stomach to remove food-residue. In cases of ineradicable cancer it is usually best to create the opium-habit. Cicatricial stenosis of the orifices of the stomach results from the healing of an ulcer, the swallowing of a corrosive substance, or a traumatism from a foreign body. Constric- tion of the cardiac orifice is indicated by gradually increasing difficulty in swallowing. After a time the oesophagus above the stricture dilates or pouches; the fluid food passes into the stomach, but the solid food lodges in the oesophageal pouch and is soon regurgitated. The site of the stricture is located by a bougie. If the constriction be malignant, the patient will be found to be beyond middle life, a tumor may possibly be felt, the vomit is occasionally bloody, and emacia- tion is rapid and decided. If the constriction be cicatricial, , the history will exhibit the cause. Constriction of the pyloric orifice causes retention of food and dilatation of the stomach. Dyspeptic symptoms will be found to have been long present. A tube passed into the stomach permits of the injection of fluid so as to fill the stomach. When the fluid runs out it DISEASES AND INJURIES OF THE ABDOMEN. 613 contains portions of undigested food eaten days before, and measurement of the liquid shows that the capacity of the stomach is enormously increased. If air be forced through the tube, the outline of the distended stomach is at once made clear. The usual method of distending the stomach is by a Seidlitz powder: two solutions are made; the bicar- bonate solution is swallowed at once, and the tartaric solu- tion is taken afterward in small amounts at a time. Treatment.—Cardiac stenosis requires dilatation with bougies and the maintenance of the restored calibre. If this dilatation is unsatisfactory, perform a gastrotomy, push a small bougie from the mouth into the stomach, tie a string to the bougie, draw the string through the stricture, use the string as a saw to cut the fibrous bands, pass a full-sized bougie, close the wound in the stomach, and maintain the calibre by the repeated passage of dilating instruments. If no instrument can be passed through the stricture, perform a gastrotomy, introduce an instrument from below, and use Abbe's string saw. If no instrument can be passed from below, convert the gastrotomy into a gastrostomy. Pyloric stenosis is treated by a gastrotomy and digital divulsion of the stricture (Loreta's operation), by pyloroplasty (Heineke- Mikulicz operation), or by gastro-enterostomy. Intestinal Obstruction (Ileus or Entero-stenosis).—Intes- tinal obstruction is a condition in which fecal movement is mechanically impeded or prevented. It may be either partial or complete. Acute obstruction is due to a sudden narrowing or occlusion of the lumen of a portion of the intestine. Chronic obstruction is due to a gradual narrowing of the lumen of a portion of the intestine, and it may at any time become acute. If obstruction to circulation in the wall of the bowel occurs, the condition becomes one of strangula- tion. Intestinal obstructions are classified l as follows : 1 After Treves, in Heath's Dictionary. 614 A MANUAL OF SURGERY. I. Strangulation by bands or in apertures, the commonest form, is due to peritoneal adhesions, but the band may come from the omentum. Strangulation may take place by Meckel's diverticulum, a structure due to persistence of the vitelline duct, and coming off from the ileum from twelve to thirty-six inches above the ileo-caecal valve. Strangulation may take place beneath an adherent appendix, a Fallopian tube, a portion of mesentery, or the pedicle of an ovarian tumor, or it may take place in an omental or a mesenteric aperture. Strangulation by bands or apertures usually in- volves the ileum, and sometimes the colon. This form of obstruction is identical with hernia excepting in the absence of an external protrusion. 2. Volvulus, or twisting of the bowel. The twist may be about the mesenteric axis or on the axis of the bowel itself, or two intestinal coils may be twisted together. Volvulus is commonest in the sigmoid flexure. 3. Intussusception is the invagination of a portion of bowel- wall into the lumen of an adjacent part. One-third of all cases of obstruction are due to this cause (Treves). There are four varieties: the ileo-ccecal, in which the ileum and the ileo-caecal valve pass into the caecum and colon; the colic, * in which the large intestine is prolapsed into itself; the ileal, in which the small intestine alone is involved ; and the ileo- colic, in which the ileum prolapses through the ileo-caecal valve. The first variety is the commonest. Intussusception is due to active peristalsis. 4. Stricture of the intestine, which stricture may be either cicatricial or cancerous. M 5. Obstruction by Tumors of the Bowel and by Foreign Bodies.—Tumors may be innocent or malignant. Foreign bodies include certain substances that have been swallowed, gall-stones, and enteroliths, or intestinal calculi. Foreign bodies are apt to lodge in the lower portion of the ileum or DISEASES AND INJURIES OF THE ABDOMEN. 6\$ in the caecum, and they may cause ulceration at the seat of lodgement. If a gall-stone is sufficiently large to cause obstruction, it cannot have passed the duct, but must have ulcerated into the bowel from the gall-bladder (Treves). 6. Obstruction by tumors, etc. outside the bowel, among the causes of which are retroflexion or retroversion of the womb, especially in pregnancy, cysts or tumors of the kidneys, ovaries, uterus, etc., and enlarged spleen. Obstruction from any of the above causes takes place in the rectum or the sigmoid flexure. 7. Obstruction from fecal accumulation is due to paresis or paralysis of the bowel and the diminution or abolition of peristalsis. Paresis or paralysis arises in the colon. Treves mentions among the rare forms of obstruction kinking of the bowel, adhesions matting the bowels together or com- pressing the gut, and shrinking of the mesentery. Symptoms of Acute Obstruction.—Severe colic comes on suddenly, the pain varying in intensity, but at no time entirely ceasing; there is constipation which soon becomes absolute, not even wind being passed; vomiting is early— first of the contents of the stomach, next of bilious matter, and finally of feces (stercoraceous); the abdomen becomes distended and tender; some fever may be found at the start, but collapse soon arises ; the temperature is subnormal; the face is Hippocratic; the pulse is rapid and feeble; and the amount of urine passed is very small. In obstruction of the upper third of the ileum true fecal vomiting cannot occur. The tongue is dry, the mind is clear, and muscular cramp may occur. Intestinal peristalsis above the obstruction may be detected through the abdominal wall. If obstruction is high up in the small intestine, tympanites does not occur. Symptoms of Chronic Obstruction.—At intervals there arise attacks of pain which become gradually more frequent and severe and are linked with vomiting and constipation, 6l6 A MANUAL OF SURGERY. the vomiting not being stercoraceous and the constipation not being absolute. Between the painful seizures the patient complains of constipation alternating with fluid diarrhoea, distention of the belly, some abdominal uneasiness, anorexia, and dyspepsia. The attacks recur with increasing frequency and severity, and acute obstruction may arise or the patient may be worn out by pain, vomiting, and want of food. Diagnosis.—The determination of the seat of lesion re- quires rectal examination. An intussusception may some- times be felt. Vaginal examination may be demanded. Pain is apt to arise at the seat of obstruction or to radiate from there. Palpation may detect a tumor. Rectal insufflation of hydrogen may locate the obstruction by causing great distention below it. Entire suppression of urine, early vomit- ing which is not truly stercoraceous, absence of abdominal distention, and rapid collapse, mean obstruction in the duo- denum or in the jejunum. Early vomiting, which is often stercoraceous in a rapidly progressive case with great dis- tention of the umbilical region, means obstruction of the ileum or the caecum (Pepper). Distention of the entire abdomen and of the flanks, linked with tenesmus, with less intensity of symptoms, less rapidity of progress, and less diminution of urine than in the above-cited forms, means obstruction low down in the colon or in the rectum (Pepper). A test for obstruction in the adult large intestine is an injec- tion by a fountain syringe: if six quarts can be introduced, there is no obstruction in the large intestine ; if less than four quarts can be introduced, there is probably obstruction in the large intestine. " The passage of a sound in the rectum is generally useless and is often unsafe. The determination of the causative condition is always diffi- cult and is often impossible. Intussusception is the common cause in children. A tumor can usually be felt in the right iliac fossa, tenesmus exists, and bloody mucus is passed DISEASES AND INJURIES OF THE ABDOMEN. 617 The abdomen is rarely distended or tender. Vomiting occurs, but it is seldom stercoraceous. The prolapse may be detected by a finger in the rectum. In obstruction from bands, internal hernia, etc. there is a record of peritonitis, of a traumatism, of a violent effort, or of pelvic pain. The attack is sudden in onset, is fierce in character, and is usually excited by violent exercise or the taking of food. Vomiting is early and intractable, and it soon becomes stercoraceous; pain is violent; tympanites and abdominal tenderness appear after the attack has lasted for some little time; obstruction is complete, no wind even being passed; collapse soon appears; no tumor can be detected, and rectal examination is negative. Volvulus, which is usually located in the sigmoid flexure, is preceded by constipation. The symptoms come on with explosive suddenness, and rapidly attain great severity. Constipation is absolute; vomiting is late and is rarely stercoraceous; no tumor can be detected; rectal examination is negative; abdominal distention and tenderness are early and pronounced; collapse is not so rapid or so grave as in the previously-considered forms. Obstruction by a foreign body may sometimes be inferred by the history of some such body having been swallowed. The obstructing body can occasionally be felt during palpa- tion. Abdominal distress may exist for days or weeks before obstruction occurs. Vomiting is late and is rarely severe, but pain, tenderness, and distention are marked. In obstruc- tion from gall-stones there will be a record of one or more attacks of hepatic colic. Pain is early and acute, and vomit- ing is invariable and usually becomes stercoraceous. In obstruction from fecal accumulation chronic obstruction evolves into acute obstruction, pain and vomiting are late or even absent, and the mass of feces can often be felt by rectal examination or by abdominal palpation. In some cases the fluid elements of the feces pass, but the solid elements 6l8 A MANUAL OF SURGERY. agglutinate on the walls of the bowel (the diarrhoea of consti- pation). Obstruction from strictures or from pressure comes on acutely after a prolonged period of disturbance, during which period occurred attack after attack of temporary obstruction, complete or partial. A history of blood or pus in the stools would indicate tumor of the bowel; a history of blood or pus having been absent would indicate pressure from without (Pepper). In functional obstruction there is no local pain, no tenderness, no tumor, no tendency to collapse, but simply distention and absolute constipation, and pos- sibly non-fecal vomiting occurring in a neurotic or hysterical subject. A phantom tumor due to a local distention of the intestine from limited muscular spasm disappears under ether. * Separation of Intestinal Obstruction from Other Diseases.— Always examine for a strangulated hernia at every hernial outlet. If obstruction is complicated with an irreducible hernia above the seat of lesion, the hernia will always enlarge and become tender because of accumulation of feces (Pepper). Functional obstruction may attend peritonitis or may fol- low the reduction of a hernia. Appendicitis with peritonitis may cause symptoms similar to those of obstruction, but there is fever, a history of trouble in the right iliac fossa, and the vomiting is not stercoraceous. Pepper says that acute hemorrhagic pancreatitis produces symptoms so nearly identical with those of intestinal obstruction that a diagnosis cannot be made. Poisoning by arsenic or by corrosive sub- limate should not be confounded with intestinal obstruction. Prognosis.—Without surgical interference most cases of acute intestinal obstruction die within ten days, usually within seven days. Death may be due to shock, to ex- haustion, to perforation, to peritonitis, or to obstruction of respiration and circulation by tympanites. Recovery occa- • sionally happens by the formation of a fistula externally or DISEASES AND INJURIES OF THE ABDOMEN. 619 into another portion of the bowel. In acute obstruction from foreign bodies the obstructing body occasionally passes. Volvulus and strangulation by bands are almost invariably fatal unless an operation is performed. In intussusception recovery occasionally follows the sloughing away of the pro- lapsed gut, but stricture almost inevitably follows this rare event. Functional obstruction gives a good prognosis. The prognosis of chronic obstruction depends upon the causa- tive lesion, and is not nearly so grave as is that of acute obstruction. Treatment.—In acute obstruction it is usually customary to empty the stomach by lavage and to evacuate the rectum by means of copious injections given while the patient is in the knee-chest position. Hutchinson's method of taxis and massage is uncertain, and is more liable to inflict harm than to confer benefit. Some surgeons apply constant compres- sion to the abdomen by means of straps of adhesive plaster. Puncture of the intestine with an aseptic hypodermatic needle introduced obliquely will relieve gaseous distention. The passage of a small tube from the anus to the sigmoid flexure will empty the colon of gas if no obstruction intervene. In intussusception, give no food by the stomach, give opium and belladonna to stop peristalsis, and distend the bowel below the obstruction with hydrogen gas. Wash out the rectum with copius injections, give an anaesthetic, and insufflate the gas. If this fails, and the condition of the patient is good, perform laparotomy. In obstruction from fecal impaction, use large rectal injections and give small repeated doses of salines or a mixture of castor oil and oil of turpentine. If there are signs of inflammation, do not give cathartics, even in small doses, but give opium and belladonna to arrest vomiting and to relax spasm. Impactions in the rectum can be spooned away. In acute intestinal obstruction, if the symptoms grow worse, do not wait, but open the abdomen 620 A MANUAL OF SURGERY. before collapse comes on and find the cause of the obstruc- tion. If it is a gall-stone or enterolith, try to crush it without opening the intestine; if this fails, push it up a little distance, incise the bowel, remove the stone, and close the incision with Lembert sutures. If there be fecal obstruction, break up the masses by pressure and push the fecal plug down. If there be intussusception, reduce the prolapse and shorten the mesentery, but if reduction is impossible perform an anastomosis, or a resection and enterorrhaphy, or make an artificial anus. In volvulus untwist and shorten the mesen- tery, but if this is impossible treat as an irreducible invagi- nation. In obstruction from adhesions, try to separate them and straighten out the bowel, stitching healthy peritoneum over each raw spot to prevent recurrence. Anastomosis may be necessary. In flexion, separate the intestine, remove the flexion by a V-shaped incision, and suture the wound in the bowel (Senn). In chronic obstruction it is often advisable to perform an exploratory laparotomy and deter- mine by the condition what is to be done. Some tumors external to the bowel are removed. Growths in the bowel- wall may be removed by resection of the involved portion of intestine. Anastomosis may be performed, or an artificial anus may be necessary. Appendicitis.—Appendicitis, which is an inflammation of the vermiform appendix of the caecum, is almost in- variably the primary lesion of all of those various con- ditions known as typhlitis, perityphlitis, paratyphlitis, etc.— terms which no longer imply pathological entities, and are in most instances well relegated to obscurity. The appendix is a diverticulum (musculo-membranous in struc- ture) which comes from the posterior and internal part of the head of the colon, and which has no physiological function (in herbivora and rodents it is a functionally active { organ). The structure of the appendix is identical with the DISEASES AND INJURIES OF THE ABDOMEN. 621 structure of the colon. The appendix averages about four and a half inches in length, and its diameter is, as a rule, about equal to that of a No. 9 English bougie; its canal is narrow and is partly closed by the valve of Gerlach (Tala- mon). The appendix enters the caecum at its posterior in- ternal part, which part is usually the seat of the most intense pain in inflammation; it is known as " McBurney's point," and corresponds to a point on the surface two inches from the spine, on a line drawn from the umbilicus to the anterior superior iliac spine. The free part of the appendix in one- third of all persons is in relation with the posterior surface of the caecum; in almost one-third of all persons it is fixed in the iliac fossa, so that if perforation occurs the contents will be voided in the retroperitoneal tissue (iliac abscess). In some cases it is external to the caecum; in some it passes downward, and in some inward. In about two-thirds of all cases the appendix is completely covered with peritoneum ; in one-third of all cases it is in contact, in some part of its length, with cellular tissue (Talamon). Etiology and Pathology.—Appendicitis is very rare in in- fants, but is common at any period beyond childhood. Non- traumatic catarrhal or ulcerative inflammation may arise, prob- ably from the action of the bacterium coli commune of Escherich. When non-traumatic inflammation occurs, swell- ing of the mucous membranes occludes the opening into the colon, and the lumen of the appendix increases and fills up with a thick or muco-purulent fluid. Ulcers sometimes form, which may only involve the mucous membrane, may pass deeply into the coats, or may even perforate. A com- mon cause of appendicitis is the presence of scybala, which are little masses of hardened feces that are at first moist and soft, but soon become dry and hard. They are usually formed in the caecum, and not in the appendix. This fact is proved by their outline rarely being that of the appendix (Talamon). 622 A MANUAL OF SURGER Y. These scybala are formed by small portions of feces lodging in depressions found between the longitudinal muscular fibres of the colon, taking the shape of the depressions, and being forced out by peristalsis. Talamon states that a concretion may form in a very large appendix. When a concretion enters the appendix and becomes impacted, the appendix strives to expel it by muscular contraction, and violent symptoms are produced (appendicular colic). For- eign bodies, such as pins, fish-bones, and grape-seeds, may enter the appendix, but they do so far less often than is gen- erally supposed, most alleged grape-seeds from the appendix being only fecal concretions. Appendicitis due to a foreign body, such as a grape-seed or a pin, is known as traumatic ; appendicitis due to a concretion is known as stercoral. A foreign body may produce instant perforation at the site of the body. If impaction of a foreign body or concretion occurs, the orifice of the appendix is closed, the circulation is soon cut off, the secretions are retained, the coats become congested, the diverticulum enlarges enormously, microbes multiply with great rapidity, and the wall of the congested appendix inflames and ulcerates and is finally perforated. Some hold that catarrhal appendicitis can result from exten- sion of a catarrh of the colon and can arise from external traumatism. If before a perforation the appendix adheres to the cellular tissue behind the caecum, cellulitis or abscess without peritonitis may result. When appendicitis goes on to perforation, there is almost always some peritonitis; but if the steps to perforation are gradual, the peritonitis may be local, and will sometimes by effusion of lymph make a barrier between the appendix and the peritoneal cavity before perforation occurs. When perforation takes place at all suddenly, septic peritonitis is inevitable. Peritonitis can arise without perforation by contiguity of structure or ( by migration of the bacterium coli commune through the DISEASES AND INJURIES OF THE ABDOMEN. 623 congested walls of an obstructed appendix. In some cases perforation takes place into the peritoneal cavity, but pus is circumscribed by matting together of the intestines with plastic exudate. The appendix may become gangrenous very rapidly or after some time. In some cases, if the per- foration is very small and the appendix is swathed in lymph, or if perforation does not occur, the inflammation may sub- side. Perforation rarely occurs from liquid pressure or from the pressure of concretion; it is generally due to ulceration or to the action of micro-organisms. Appendicitis which subsides may at any time recur, and the life of the patient is under constant menace. An enormous number of people have had appendicitis. Toft recorded five hundred autopsies, and in thirty-six per cent, of them there were positive signs of past attacks. The disease is often unsuspected in life. These facts prove that the disease may subside without the aid of surgery. Forms of Appendicitis.—Simple parietal or catarrhal ap- pendicitis is not limited to the mucous membrane; hence the term catarrhal is not strictly correct. Forty-eight hours after the mucous coat begins to inflame, the peritoneal coat will be involved. In simple appendicitis the diverticulum enlarges, fills up with mucus, and its coats become infiltrated with inflammatory exudate. This inflammation may undergo resolution or suppuration, or may become chronic. In a catarrhal inflammation secondary to catarrh of the colon the case may be chronic from its origin. If inflammation obliterates the lumen of the appendix, the condition is de- > nominated obliterativc appendicitis (Senn). In appendicitis from a concretion the attack may subside, the fluid elements may be absorbed or flow back into the bowel, and resolution of the exudate may take place, but if the concretion remains in the appendix recurrence is probable. Recurrent ap- pendicitis may be due to inordinate size of the mouth of 624 A MANUAL OF SURGERY. the appendix, making of this diverticulum a drag-net for foreign bodies. Suppurative appendicitis is due to puru- lent infiltration of the walls. Pus in the lumen is not purulent appendicitis. Gangrenous appendicitis is a moist or septic gangrene, due to interference with the circulation by an impaction near the base and to tissue-destruction by the action of micro-organisms. Perforations occur, and they are often multiple. Symptoms.—The disease is often ushered in by appen- dicular colic, which is apt to arise after partaking of an in- digestible meal or after indulging in violent exertion. Pain of a colicky nature begins in the right iliac fossa and radiates to the umbilicus; tenderness does not at first exist in the fossa. Nausea and vomiting occur; constipation is usual, but it may alternate with diarrhoea. This condition may pass away or may go on to inflammation. Appendicitis may follow colic or may appear without a preceding colic, and it is mani- fested by violent abdominal pain which is aggravated by move- ment, by pressure, and by breathing. This pain is usually intense in the right iliac fossa, but radiates to the umbilicus or even over the entire abdomen. The patient lies upon the right side and draws up the right leg. The abdomen is dis- tended and rigid. Tenderness exists in the right iliac fossa, and the point of greatest tenderness, which is known as " McBurney's point," is apt to be about two inches from the anterior superior spine, on a line drawn from the spine to the umbilicus. Irregular fever arises. The pulse becomes fre- quent and hard. The respiration is shallow and thoracic. Occasionally a chill occurs. Vomiting is common. Great thirst, anorexia, and obstinate constipation exist. Hiccough is not unusual. The urine is scanty and high colored. The face is anxious and expressive of pain. If the inflammation continues, in from one to two days a swelling may often be detected in the right iliac fossa. This swelling may be small DISEASES AND INJURIES OF THE ABDOMEN. 625 or large, distinct or obscure; it may be detected by palpation of the abdomen alone or by palpation with a finger in the rectum. If the tenderness is great and the abdomen tense, ether may be required to determine the nature and extent of the swelling. In perforative appendicitis an initial chill may occur, and the pain is very violent; there are fever, coated tongue, vomiting, excessive tenderness, and frequent pulse. Tympanites is the rule, but the belly may be flat, and collapse rapidly arises. If abscess forms, there may be cedema of the skin or even fluctuation. In sudden perforation there is collapse and, if reaction occurs, septic peritonitis. In gangrenous appendicitis there are sepsis and collapse. It is often impossible to distinguish the form of an appendicitis, but remember that sudden pain and local tenderness in the iliac fossa, with fever, mean ap- pendicitis, whether a swelling is found or not. In a mild case resolution occurs, pain diminishes, the bowels move, fever disappears, and in a week or so the patient feels all right. In more severe cases local peritonitis arises, or suppuration occurs with irregular fever, or perforation takes place, or the appendix becomes gangrenous. Pus may be evacuated into the bowel, into a cavity formed by lymph (appendicular abscess), into the cellular tissue back of the colon, or into the peritoneal cavity. Evacuation of pus into the peritoneal cavity causes collapse and septic peritonitis. Catarrhal appendicitis is apt to be mild, but not of necessity, as it may cause the gravest symptoms. The pains of colic are due to appendicinal contractions attempting to force out t a foreign body or imprisoned mucus. The pains of begin- ning perforation are localized, intense, and accompanied by the tenderness of a local peritonitis. Treatment.—In appendicular colic a saline is to be given, followed, after a movement occurs, by opium. If tenderness exists, do not give a purgative, because in appendicitis to 626 A MANUAL OF SURGERY. violent peristalsis may produce perforation. The old theory of fecal impaction in the head of the colon has been ex- ploded by Weir, Bull, Dever, Keen, and others, who have never seen it. In an appendicitis even with slight symptoms many surgeons maintain that an operation should be per- formed, because slight symptoms are no sign that even in an hour or two gangrene or perforation will not occur. Early operation is comparatively safe; operation after perforation, gangrene, or septic peritonitis arises must be done, but it is usually futile. Other surgeons, in a first attack, if the symp- toms are mild, wait and temporize, apply a hot-water bag over the right iliac fossa to favor plastic exudation, and give opium in full doses. Some open the case with salines, apply an ice-bag over McBurney's point, and after a free movement of the bowels give opium and keep the patient on liquid diet. If the symptoms become worse, they recommend operation. In recurrent appendicitis, after the attack passes away, operate. In any severe case, in a case with distinct swelling, and in any case where suppuration, gangrene, or perforation are thought to have occurred or to be liable to occur, operate at once. (See Operation for Appendicitis) Peritonitis.—In rare instances peritonitis is said to be primary, following a cold; but most surgeons doubt this. Plastic peritonitis is due to an aseptic cause (traumatism or chemical irritation); it remains limited, and is really a process of repair rather than of inflammation. The symp- toms of plastic peritonitis are local pain, tenderness, and rigidity. Fever exists, due to the absorption of fibrin-ferment and the products of tissue-change; adhesions form, which may be either temporary or permanent. Recovery is the rule. The treatment comprises saline purgatives followed by rest, opiates, a liquid diet, and local heat (hot-water bag or fomentations). Septic peritonitis is apt to destroy life even before the DISEASES AND INJURIES OF THE ABDOMEN. 627 peritoneum presents any marked change. Death ensues from the absorption of toxic alkaloids. Septic peritonitis may arise during puerperality, through lymphatic infection; it may be due to infection from without by an operation or an accident, to perforation of an ulcer, to gangrene of a portion of the intestine, to rupture of an abscess into the peritoneal cavity, or to migration of micro-organisms through a damaged wall of the bowel. It is made manifest by a chill, a shock, or rapid collapse, very rapid pulse, tempera- ture which is apt to be subnormal or to soon become so, dry tongue, delirium, persistent vomiting, and often, but not invariably, distention. In puerperal peritonitis or septic peritonitis from operation there is often no pain; in perfora- tive peritonitis there is acute pain. Patients usually die within five or six days. Treatment is rarely successful. The abdomen is opened, flushed out, and drained, and any per- foration is closed. Stimulants are strongly pushed. The patient is fed upon liquids (koumiss especially). In fibrino-plastic peritonitis the septic organisms are fewer or less virulent, the products of germ-action are lim- ited and surrounded by adhesions, and circumscribed sup- purative peritonitis is apt to arise. Suppurative peritonitis differs clinically from septic peri- tonitis in the fact that it is more apt to be circumscribed and less apt to be fatal. The causes of both are identical. In septic peritonitis death occurs from absorption of pto- maines before obvious pathological changes occur in the peritoneum; in suppurative peritonitis the microbes are fewer, are less virulent, or vital resistance is more decided, and suppuration follows marked changes in the peritoneum. In suppurative appendicitis the pyogenic bacteria are always present, and there exists in the peritoneum a wound or damaged area to constitute a point of least resistance. Symptoms.—Chilliness or a rigor is common, followed by 628 A MANUAL OF SURGERY. fever, the temperature rising to 1020 or 1040 ; pain is intense, and is accentuated by motion and pressure; the attitude of the patient is assumed to relieve pain (he lies upon his back, with the shoulders raised and the thighs drawn up); there are vomiting, obstinate constipation, and distention and rigidity of the abdominal walls. The constipation may be due either to tympanitic distention or to the shock of a perforation inhibiting intestinal peristalsis. In perforation gas often passes into the peritoneal cavity and obscures the liver-dulness; in tympanites without perforation the liver is pushed up and its dulness remains, but on a higher level. Pus unconfined by adhesions will gravitate to the most dependent part of the peritoneal cavity. Circumscribed sup- purative peritonitis presents the signs of a deep abscess. In some cases of suppurative peritonitis there is no tym- panitic distention or rigidity; in some cases there is no fever, and a subnormal temperature may even exist. The high-tension pulse of peritonitis is due to the tympanitic dis- tention emptying the bowel-walls of blood, and thus increas- ing the amount of fluid in the other vessels of the body. Treatment.—In the beginning of ordinary peritonitis with- out perforation, give a saline cathartic, which will empty the peritoneal cavity of fluid, will favor the elimination of mi- crobes, and will combat inflammation. The old-time remedy was opium, but Tait proved its inefficiency, and showed that it masked the symptoms and often created a false sense of security in the very midst of imminent dangers. The usual method of administering salines is to give 3j of Rochelle salt and 3j of Epsom salt every hour until a free movement occurs. This treatment will often cut short a beginning peritonitis. Give an enema of turpentine at the same time as the saline. After the bowels move, give opium for pain. If this treatment fails, open the belly, explore for the causa- tive condition, remedy it, flush, and drain. In perforative DISEASES AND INJURIES OF THE ABDOMEN. 629 peritonitis do not give cathartics: they will only increase the extravasation and prevent its limitation by lymph. In per- forative peritonitis perform a laparotomy, suture the perfora- tion, flush out the belly, and drain. A circumscribed abscess is to be opened and the primary lesion sought for and, if found, removed. Do not tear up the lymph barriers in an attempt to find the primary lesion ; rather let it go undiscovered. Pack iodoform gauze against the intestines to reinforce the barrier of lymph, and insert a tube. Every patient with peritonitis requires stimulants and frequent feeding with liquid food. Tubercular peritonitis is seen by the surgeon as a primary local tuberculosis, though it occurs also as an associate of phthisis and as a part of a general tuberculosis. Abdominal section with drainage cures not a few cases. Operations upon the Abdomen: Abdominal Section (Cceliotomy ; Laparotomy).—In opening the abdominal cav- ity for exploratory purposes or to gain access to some area of abdominal or pelvic disease, the patient is carefully prepared as for any operation. The instruments required depend upon the nature of the case. As a rule, there are required scalpels, scissors, a dry dissector, two pairs of dissect- ing-forceps, haemostatic forceps, pedicle-forceps, Hagedorn needles, a needle-holder, drainage-tubes, gauze pads, sponges, silk, catgut, silkworm gut, Pacquelin cautery, an electric light, a bag, a tube, and a solution for hypodermoclysis. Always count the instruments, sponges, and pads, and write down the number. Operation.—In some cases the patient is placed recumbent, , in others is put in the position of Trendelenburg (Fig. 145). The patient is placed near the right side of the table, the extremities and the chest are covered with blankets, and sterilized sheets are placed well around the field of opera- tion. The surgeon steadies the skin of the belly with the fingers of his left hand, and, holding the knife in the right 63O A MANUAL OF SURGERY. hand, makes an incision about two inches long. This incision is often made in the middle line, but not invariably, and is placed midway between the pubes and umbilicus. The first cut goes to the aponeurosis. Clamp the vessels. Do not hunt for the linea alba below the umbilicus, but go right through or between the recti muscles. Divide the transversalis fascia, beneath which is a little fat, and expose the peritoneum. The latter structure is recognized by its glistening appear- ance, by the ease with which it can be pinched up between the finger and thumb, and by the readiness with which its opposed surfaces can be made to glide over Fig. i46.-The Trendelenburg Po- each other. On identifying the Sltl0n' peritoneum, catch it at each side of the incision with forceps, lift it up, nick it with a knife, and open it with scissors to the length of the external wound. To prevent the stripping of the peritoneum, a good plan is to anchor it to the belly-wall with a stitch on each side of the incision. Through the wound thus made the abdomen and its contents are explored, the trouble located, and de- termination made as to whether or not operation is advis- able, and, if it is advisable, what form it shall take. It may be necessary to enlarge the wound. This is done by placing the index and middle fingers of the left hand in the belly, with their pulps against the peritoneum, in the line where the surgeon will cut, to serve as supports to the scissors and as guards to intraperitoneal structures. The scissors are introduced and the wound is enlarged upward around the umbilicus if necessary. As soon as the incision is complete, Treves pushes a large sponge into Douglas's pouch and leaves it there until the operation is completed. Slender adhesions are broken off with the finger or are pushed off with gauze; firm adhesions are tied and cut. DISEASES AND INJURIES QF THE ABDOMEN. 631 The toilet of the peritoneum is important after the opera- tion is completed. Following a clean laparotomy, when but little blood has flowed into the cavity, flushing out is not required; if much blood has flowed or if any septic matter has passed into the peritoneal cavity, after removing the sponge from Douglas's pouch flush out the belly thor- oughly with warm boiled water, and sponge out the fluid which will not run out by gravity. Flushing is continued until the fluid runs clear. Before closing the wound, stop hemorrhage and count the instruments and sponges. In most instances drainage is not needed, but it must be used in septic cases and when hemorrhage has been severe. The best tube is the glass drain, which is introduced at the lower angle of the wound and reaches the bottom of the pouch of Douglas. This tube is repeatedly emptied during the prog- ress of the case by means of a syringe. In closing the wound some surgeons close the peritoneum with a continuous cat- gut suture and close the belly-wall with interrupted sutures of silkworm gut; some operators close with interrupted silkworm-gut sutures, including peritoneum, muscles, and skin in each stitch. Dress with antiseptic gauze and wood- wool, and apply a flannel binder. In section for appendicitis, make a vertical incision two inches in length and two inches internal to the anterior supe- rior spine of the ilium. After opening the peritoneum, find the appendix by the following method : Follow the parietal peri- toneum outward with the finger, then backward, then inward; the first obstruction it encounters is the colon. Pass the fin- ger down to the head of the colon, find the appendix, usually posterior and internal, and lift it into the wound. In most cases the neck of the appendix is tied with strong silk, gauze is packed around it to prevent septic matter entering the abdomen, the appendix is cut off, and the stump is cauter- ized with pure carbolic acid and is inverted into the colon by 632 A MANUAL OF SURGERY. Lembert sutures. If there is no abscess, perforation, or gan- grene, drainage is unnecessary; otherwise it is necessary. Always irrigate. In opening an abscess following perfora- tion, explore very carefully for the appendix. When it is found, try and lift it up; if this is feasible, remove it. If lifting it up is liable to rupture the barrier of lymph, leave the appendix in place, irrigate gently, pack iodoform gauze around to sustain the barrier, and put a tube deep in the centre. Partially suture the wound. Remove the gauze about the fourth day, but leave the tube some days longer (Barton). Enterorrhaphy, or suture of the intestine, is to be per- formed with fine silk, a small, round, calyx-eyed needle (Fig. 147) being employed. Lembert's suture (Fig. 148, a) is at right angles to the wound. It goes down to, but not through, the mucous membrane. It is formed by picking up a fold of the intestine (one-twelfth to one-eighth of an inch wide) one-eighth of an inch from the edge on one side of the wound, passing the needle through, picking up a fold on the opposite side of the wound, and passing the needle through. Eye of the On tying the threads the serous membrane is Calyx - eyed inverted and peritoneum is brought into contact Needle. ° with peritoneum. Dupuytren's suture (Fig. 148, b) is a continuous Lembert suture. The Czerny-Lembert suture (Fig. 149) is a suture passed through the serous membrane on one side of the wound and brought out in the wound without perforating the mucous membrane. It is re-entered at a corresponding point of the wound-surface of the opposite side, and emerges at a corresponding point of the serous membrane. A Lembert suture is added. Halstead's suture includes not only the muscular coat, but also a portion of the tough submucous coat. Cushing's right-angled suture (Fig. 148, c) is a continuous suture going through the mus- cular coat and serving to invert the serous layer. Joberfs M DISEASES AND INJURIES OF THE ABDOMEN. 633 i\i.fc , Kig. 148 — Enterorrhaphy : a, Lembert's suture; B, Dupuytren's suture; c, Cushing's suture. Fig. 152.—Excision of Bowel with Enterorrhaphy and Stitch- ing of the Redundant Mesentery : second step. Fig. 151.—Pylorectomy. Fig. 154.—Gastroenterostomy Fig. 155.—Gastro-enter- (after Wolfler). ostomy (after Kocher). Fig. 156.—Senn's Entero-anastomosis : a, Senn's bone Fig. 157.—Inguinal Colos- plate; b, intestinal anastomosis ; c, operation complete. tomy (after Maydl). (From Esmarch and Kowalzig.) 634 A MANUAL OF SURGERY. suture invaginates serous membrane against serous mem- brane. Senn modifies this by the use of a ring. Wolfler s suture unites the broad layers of the serous coat, the knots being tied internally (Fig. 150). Senn says that after suturing a large wound of the stomach or of intestine a strip of omen- tum ought to be laid over the wound and fastened by catgut sutures (omental graft). These grafts adhere and are a safe- guard against leakage. Pylorectomy (Excision of the Pylorus).—For one week before any operation upon the stomach, feed the patient upon peptonized milk by the stomach and by nutritive enemata, and during this period wash out the stomach once a day with warm water introduced and withdrawn by a siphon- tube. A few hours before the operation, wash out the stomach again. The best incision through the abdominal wall is transverse over the middle of the tumor. A small incision is made first to permit of exploration, and if the growth is found to be removable, the incision is enlarged. The centre of the incision is over the most prominent part of the tumor, and the direction of the incision corresponds with the long axis of the pylorus. Draw the tumor into the wound, and tuck pads about the stomach and the pylorus to catch extravasated fluids. Free the pylorus; incise between forceps the great omentum near the greater curvature of the stomach, and ligate each end in segments; treat the lesser omentum in the same manner. The greater and the lesser omentum are divided only to an extent sufficient to permit removal of the growth. Repack the gauze pads and tie a rubber tube around the duodenum below the growth. In making the excision remember that the stomach-wound will be much larger than the duodenal wound, and a special method of suturing will be required to approximate the two wounds in size. The lines of incision are shown in Figure 151. The stomach is cut with scissors until two-thirds of DISEASES AND INJURIES OF THE ABDOMEN. 635 its depth is divided, and the organ is washed out. After stopping hemorrhage this cut is closed by a continuous suture for the mucous membrane and by interrupted Lem- bert sutures for the serous coat. The remaining portion of the stomach is cut through. The duodenum is cut through its upper half below the growth, and is fastened to the stomach by Lembert sutures at the upper border and Wolf- ler's sutures at the posterior borders. Wolfler's sutures are applied from inside, pierce all the coats, and bring broad layers of the serous coat into apposition. The remainder of the duodenum is cut through, and its anterior and inferior parts are united to the stomach by a double row of sutures, as set forth above (Fig. 151). Stitch the edges of the cut omenta to the stomach, cleanse the parts, replace the stom- ach, close the abdominal incision, and dress the wound. Give nothing by the mouth for twenty-four hours. Thirst can be relieved by enemata of water or by the hypodermatic injection of boiled water. After twenty-four hours begin with stomach-feeding, starting with dessertspoonful-doses of peptonized milk every hour. Gastrostomy.—In Witzel's method an incision is made four inches long, running to the left from the middle line, just below the border of the ribs. After opening the peri- toneal cavity seize the stomach, bring it out of the wound, and pack gauze around it. Introduce a rubber tube into the stomach and enfold it by a double row of Lembert sutures. This tube should be five inches long and of the same diameter as a No. 25 French bougie. The opening in the stomach is toward the cardiac extremity, the tube is placed parallel with the belly-wound, and the outer end of the tube emerges in the median line. The stomach is returned, and is stitched by three sutures to the abdominal wall. The tube is retained in place by a catgut stitch through the wall of the tube and the stomach-wall. The 636 A MANUAL OF SURGERY. r abdominal incision is sutured and a clamp is placed on the tube. Gastro-enterostomy (Senn's method) is the establish- ment of a permanent fistula between the stomach and the small intestine, in order to side-track the pylorus. The stomach is irrigated as before pylorectomy. In the operation of gastro-enterostomy a median incision is made through the abdominal wall, from below the xiphoid cartilage to the umbilicus. An opening is made in the stomach, in the direc- tion of the long axis of the viscus, and its edges are stitched with a continuous catgut suture. The contents of the bowel are forced along to below the point where an incision is to be made; a rubber tube is fastened around the bowel above this point, and another below it; an incision is made in the long axis of the bowel, and the margins of the wound are sutured in the same manner as the stomach-wound. Bone plates are introduced into the stomach and intestine, and the ligatures are tied as in intestinal anastomosis (p. 637). Cat- gut rings or rubber rings may be used. Figure 154 shows the result of a gastro-enterostomy, and Figure 155 shows Kocher's method of gastro-enterostomy without rings. Enterectomy, or Resection of the Intestine: Enterec- tomy with Circular Suturing.—After opening the abdomen, isolate the loop of intestine it is intended to resect. Push a rub- ber tube through the mesentery, close to the bowel, above the seat of operation, and pass a rubber tube through the mesen- tery below the seat of operation. Empty this segment of bowel by squeezing and stroking, tighten the rubber tubes, and clamp them to keep the bowel empty. Instead of tubes, strips of iodoform gauze may be used to encircle the bowel. The diseased intestine is resected, each incision being carried through a healthy segment. The lumen of each end of the divided gut is irrigated with boiled water. The divided sur- faces are approximated by a double row of sutures—a con- DISEASES AND INJURIES OF THE ABDOMEN. 637 tinuous suture for the mucous membrane, and Lembert's, Dupuytren's, or Cushing's suture for the serous coat. If a redundant fold of mesentery is left, it can be stitched at its raw edge. Many surgeons remove a V-shaped piece of mes- entery and tie the mesenteric vessels. The tubes are removed and the wound is cleansed, closed, and dressed. Figure 153 shows the tubes fastened for excision of the bowel, and Figure 152 shows enterorrhaphy with stitching of the re- dundant mesentery. If the two segments of bowel are unequal in size, the narrower part of the bowel should be cut obliquely and the larger part should be cut transversely. To meet this complication Billroth devised lateral implantation. Suppose the caecum has been resected: its lower end is closed by Lembert sutures, an opening is made in the long axis of the periphery of the colon opposite the mesocolon attachment, and the end of the ileum is sutured into this incision. Senn advises the insertion of an anastomosis-ring in the ileum, the invagination of the colon as the ring is pulled into place, and the firm suturing of the ring. By Senn's method the ileum may be implanted into the end of the colon or into a slit in the wall of a large bowel after the end of the colon has been closed. In some cases, where one portion of bowel is larger than the other, intestinal anastomosis is the prefer- able method. For a full week after an intestinal resection the patient is fed chiefly by nutrient enemata. During the first twenty-four hours nothing is given by the stomach but bits of ice, and for the next six days but a very little liquid food is allowed to be swallowed. Intestinal Anastomosis.—Operation with Rings.—In this operation a portion of bowel above the obstruction and a loop below the obstruction are brought into the wound. These segments are emptied, and are kept empty by the fastening around them of rubber tubes or of iodoform strips. 638 A MANUAL OF SURGERY. Two tubes are needed for each loop of bowel. Pack in gauze pads. Make an incision in one loop, in the long axis of the bowel, on the surface away from the mesentery; per- mit the contents to escape externally; irrigate this segment with boiled water; and introduce the bone plate of Senn (Fig. 156, a) or Abbe's catgut ring. A calyx-eyed needle is used (Fig. 147), and the threads of the ring are carried through the coats of the bowel and are gathered together in the bite of a pair of forceps. The other loop of intestine is treated in a similar; manner. The intestines are so brought together that the two wounds are opposite each other, the posterior sutures being first tied, next the upper, next the lower, and finally the ante- rior threads. The ends of the threads are cut off and the entire anastomosis is sur- rounded by a layer of Lem- bert sutures or is encircled by Cushing's SUture. Figure *'ig. 158.—Method of Passing the Silk Su- ,. , ... tures in Inserting the Rings of Abbe. 156, b, shows an intestinal anastomosis partly finished, and Figure 156, c, shows an anas- tomosis complete. Figure 158 shows the passing of the sutures when the catgut ring of Abbe is employed. Many surgeons are returning to anastomosis without rings in cases of resection. Abbe's method is as follows : After # closing the ends he places them side by side and applies two rows of a Dupuytren suture, one-quarter of an inch apart. These rows of sutures are an inch longer than the slit in the bowel will be (Fig. 159), the thread at the end of each row being left long. An incision is made in the bowel, one- DISEASES AND INJURIES OF THE ABDOMEN. 639 quarter of an inch from the sutures, both rows of threads being on the same side of the cut. This incision is four inches long. The other portion of bowel is then incised in the same way. The adjacent cut-edges are united by a whip-stitch which goes through all the coats, and the free cut-edges are stitched in the same manner ****** S 1£J£l™ long threads of the first sutures, and brings the serous surfaces of the opposite sides together Fig. 159.—Suturing Intestines in Apposition before by means Of Dupuy- indsion (Abbe). tren's suture. Murphy's button is a mechanical arrange- ment by which an anas- tomosis is rapidly per- formed, the two seg- ments being clamped together. For anasto- mosis below the ileo- Fig. 160.—Showing the Four-inch Incision and the .„p„j valve a IsiT^e Sewing of the Edges (Abbe). fa Murphy button does admirably, but for anastomosis higher up so small a button must be used that the result is unsatisfactory. Inguinal Colostomy.—Maydl's Operation.—In this opera- tion a vertical incision four inches long is made over the por- tion of colon to be incised. The colon usually bulges into the wound, but if it does not it may easily be found by follow- ing with the finger the parietal peritoneum outward, back- ward, and inward, the first obstruction it encounters being the mesocolon. Draw the colon out of the wound until its 540 A MANUAL OF SURGERY. mesenteric attachment is level with the abdominal incision. Push a glass bar through a slit in the mesocolon near the bowel, and wrap the ends of the bar with iodoform gauze to prevent slipping. The two parts of the flexure are stitched together by sutures which penetrate the serous and muscular coats (Fig. 157). If the colon has to be opened immediately, stitch the serous coat of the bowel to the parietal peritoneum before opening. Whenever possible, wait from twelve to twenty-four hours before opening. The colon is opened by the cautery or by scissors. If the artificial anus is to be permanent, make a transverse incision three-quarters of the way through the bowel. The bar is withdrawn in a few days, and the bowel retracts. If the artificial anus is to be temporary, the incision is longitudinal. This operation has great advantages: it is quick, certain, reasonably safe, and entirely prevents fecal accumulation below the opening. The old operation of lumbar colostomy is now rarely per- formed. Some surgeons cut one-fourth way through the colon when it is first opened, and entirely across in two or three weeks. Abdominal Hernia or Rupture.—This condition is the protrusion of a viscus or part of a viscus from the abdominal cavity. MacCormac says the term implies that the pro- truded viscus is covered with integument; hence a protrusion of viscera through a wound does not constitute a hernia. A hernia has three parts—the sac, the sac-contents, and the sac-coverings. The sac is formed of peritoneum. A con- genital sac is due to developmental defect, and is found only in the inguinal region or in the umbilicus. An acquired sac is due to intra-abdominal pressure bulging the peritoneal covering of the internal abdominal ring and converting it into a pouch. The sac comprises a body, a neck, and a mouth. A sac once formed is almost certain to persist, because it adheres by its outer surface to surrounding parts, DISEASES AND INJURIES OF THE ABDOMEN. 64I and hence the sac of a hernia is irreducible even when the con- tents are reducible. The neck of the sac is due to the con- striction through which the sac passes; it becomes furrowed and folded, and the adhesion of these folds causes thickening and rigidity. Hernia of the bladder or of the caecum has no sac or but a partial sac. The contents of the sac depend chiefly on the situation, a portion of the ileum being the usual con- tents. The colon, the stomach, the great omentum, and other structures may enter the hernial sac. An enterocele contains only intestine ; an cpiplocele contains only omentum ; an entero-epiplocele contains both omentum and intestine; a cystocele contains a portion of the bladder. The coverings of the sac, which vary with its situation, will be set forth during the consideration of special herniae. In old herniae the layers are never distinct, fat and muscle waste, tissues adhere, and the skin stretches and atrophies. Causes of Hernia.—The male sex is more liable to hernia. It occurs at all periods of life, and hereditary predisposition sometimes seems to exist. Excessive length of the mesen- tery has been assigned as a cause. Any laborious occupa- tion predisposes to rupture. Any condition which weakens the abdominal wall predisposes (muscular relaxation from ill-health, relaxation of abdominal walls following the termi- nation of pregnancy, the removal of a large tumor, or the tapping of an ascites, and wounds or abscesses of the ab- dominal wall). The exciting cause is muscular effort (strain- ing at stool, coughing, lifting weights, jumping, straining to make water, and the sexual act). All congenital herniae are due to structural defects. Hernia is divided clinically into reducible, irreducible, incarcerated, inflamed, and strangulated. Reducible Hernia.—In this form of hernia the contents of the sac can be reduced into the abdominal cavity. At a known hernial opening the patient has a smooth enlargement (narrower above than below) which began to grow from -ii 642 A MANUAL OF SURGERY. above and extended downward. A distinct neck can often be felt. In enterocele, straining, lifting, or standing enlarges the mass; the tumor becomes smaller and may disappear on lying down; cough causes impulse or succussion ; the tumor is elastic, and on reduction there is a gurgling sound. In epiplocele the mass is often irregular and compressible, and feels boggy rather than elastic; muscular effort does not have much influence in enlarging it; impulse on coughing is slight; percussion gives a dull note, and reduction pro- duces no gurgling sound. In entero-epiplocele some parts of the tumor are smooth, elastic, and tympanitic, others are dull on percussion, irregular, and flabby; but the diagnosis of this especial form is uncertain. The victims of reducible hernia complain of some pain on exertion, of dyspepsia, and often of constipation. Treatment of Reducible Hernia: Palliative Treatment.— Prevent constipation, forbid sudden strains and violent exer- cise, and order a truss. The continued employment of a truss, especially in young persons, may bring about a cure. The day truss should be applied before rising in the morn- ing and be removed after lying down at night, when a light truss should be substituted. A special truss is applied for bathing. In very fat people there is always trouble in adjusting a truss. A femoral hernia is more difficult to keep reduced than an inguinal hernia. In those cases in which the gut is replaceable, but a portion of omentum is irre- ducible, it is difficult to maintain reduction with a truss. In an oblique inguinal hernia the pad of the truss fits over the internal abdominal ring; in a direct inguinal hernia, t over the external abdominal ring; in a femoral hernia, over the femoral ring at the level of Gimbernat's ligament. MacCormac's rule to measure for a truss is as follows: In either inguinal or femoral hernia, start the tape from the lower part of the hernial opening, carry it up to the anterior DISEASES AND INJURIES OF THE ABDOMEN. 643 superior iliac spine of the same side, then take it around the body, one inch below the crest of the ilium, to the other anterior superior iliac spine, and then to the upper part of the hernial opening."1 A well-fitting truss will keep up the hernia even when the patient sits in a position to relax the abdominal walls and then coughs and strains. A truss is always uncomfortable at first, but a person soon grows used to it. It should be kept scrupulously clean, and it is well to dust borated-talc powder upon the skin under the pad at least once a day. A truss which does not keep up the hernia or which causes pain does harm. Too strong a spring tends to enlarge the hernial orifice, and thus aggravates the case. Bryant insists that even after an apparent cure with a truss the instrument must be worn for a long time. Radical treatment seeks to permanently cure by plugging the mouth of the sac or by obliterating the canal of descent. Radical operations should be performed when strangulation is operated for, in ordinary cases of reducible hernia in which a truss is very painful or does not keep up the bowel, in most cases of irreducible hernia, and in any case which has occasional attacks of obstruction. Radical cures fail if the subject is under three years of age. Macewen's Operation for Inguinal Hernia.—The instru- ments required in this operation are scalpels, a blunt straight bistoury, a dry dissector, a grooved director, scissors, a hernia-director, hernia-needles (Fig. 164), dissecting-forceps, toothed forceps, haemostatic forceps, an aneurysm-needle, blunt hooks, half-curved needles, needle-holder, and catgut sutures. The patient lies recumbent, the thigh being ab- ducted and partly flexed and resting on a pillow beneath the knee. The bowel is reduced, and an incision three inches long is made in the direction of the inguinal canal, the centre of the incision corresponding to the external ring. 1 Treves's Manual of Surgery, " Hernia." 644 A MANUAL OF SURGERY. The sac is freed from its attachments below and is lifted up. The surgeon introduces a finger into the inguinal canal and separates the sac from the cord and from the walls of the canal, and then carries the finger through the internal ring and separates the peritoneum for one inch about the periph- ery of this aperture (Fig. i6i,a). A catgut stitch is fastened to the lowest portion of the sac, and is passed through the sac several times, so that pulling on the stitch will purse up the sac (Fig. i6i,b). The free end of this stitch is carried through the internal ring into the belly, and is pushed out through abdominal muscles one inch above the internal ring, the skin being pushed aside so as to escape perforation by the needle. The thread is tightened so as to fold up the sac and pull it into the belly. This plugs the ring (Fig. i6i,c, d). The thread is handed to an assistant to keep tight until the sutures are introduced into the ring, when the sac is perma- nently anchored by taking several stitches in the external oblique muscle. A strong catgut suture is passed with a Macewen needle through the conjoined tendon from below upward, the ends of this suture being carried through Poupart's ligament and the outer borders of the internal ring from within outward. This suture is tightened and closes the internal ring. The external ring is sutured and the skin is stitched together (Fig. 161, e). In congenital hernia the sac is divided in its middle and the lower part is closed by stitches, forming a tunica vagi- nalis. The upper part of the sac is slit posteriorly to per- mit the escape of the cord, and is closed by stitches. The operation is finished as in the acquired form (Fig. 162). After this operation the patient should stay in bed for six or seven weeks, and must not walk for eight or nine weeks. Workmen after this operation should always wear a pad and a spica bandage. Children require no pad. Never apply a truss, as strong pressure will atrophy the curative scar. DISEASES AND INJURIES OF THE ABDOMEN. 645 \ C' A f > - / / Fig. 161, a-e.—Macewen's Operation for the Radical Cure Fig. 162.—Macewen's Ope- of Inguinal Hernia: a, Stripping of the sac; b, Purse-string ration for the Radical Cure suture; c, Fastening the purse-string suture; d, Passing, of Congenital Hernia. and K, tying, the sutures for the internal ring. Fig. 163.—Herniotomy in inguinal Hernia. A Fig. 164.—a, Hernia-needles; b, Hinged Fig. 165, a-c.—Bassini's Operation for the Hernia-director. Cure of Inguinal Hernia. {From Esmarch and Kowalzig.) 646 A MANUAL OF SURGERY. Bassini's Operation for Inguinal Hernia.—This operation forms a new inguinal canal. The instruments employed are the same as for Macewen's operation, excepting special needles, which are not needed. The position is the same as in Macewen's operation. An incision is made from the external ring to a point external to the internal ring. The sac is exposed and twisted, its neck is ligated, and it is cut off in front of the ligature. The spermatic cord is lifted (Fig. 165, a); the border of the rectus muscle, the edges of the internal oblique and the transversalis muscles, and the transversalis fascia, are sutured to Poupart's liga- ment below the cord (Fig. 165, b). The border of the external oblique is sutured to Poupart's ligament above the cord (Fig. 165, c). The skin is sutured. Halstead makes a new inguinal canal and a new ring, and places the cord between the external oblique muscle and the integument in preference to placing it, as does Bassini, below the external oblique. Radical Cure of Umbilical Hernia.—Cut out the umbilicus (omphalectomy) and approximate the edges. Radical Cure of Femoral Hernia.—Salzer stitches Pou- part's ligament to the pectineal fascia. Cheyne ligates the neck of the sac, stitches the stump to the abdominal wall, dissects out a flap from the pectineus muscle, stitches this flap to Poupart's ligament and to the abdominal wall, and thus fills up the crural canal. Bassini makes an incision parallel with Poupart's ligament, ties the neck of the sac, cuts below the ligature, and returns the stump into the belly. He attaches by deep sutures Poupart's ligament to the pecti- neal aponeurosis as high up as the pectineal eminence, the cord or round ligament being drawn out of the way. Super- ficial sutures are passed between the pubic portion and the iliac portion of the fascia lata. Irreducible Hernia.—The tumor in irreducible rupture presents the usual evidences of hernia, shows an impulse on DISEASES AND INJURIES OF THE ABDOMEN 647 coughing, but cannot be replaced in the abdomen. Some- times a portion is reducible and a portion is irreducible. A hernia may become irreducible because of the size of the mass, because of adhesions, or because of a great growth of omental fat. An irreducible hernia is liable to be bruised and to cause much distress and pain, and is always a menace to life because of the danger of obstruction and strangulation. A small irreducible hernia can be supported by a hollow padded truss; a large hernia of this variety is carried in a bag-truss. The patient must not take very active exer- cise, must keep the bowels regular, and must live upon a plain diet. Most of these cases should be treated by operation. Incarcerated or Obstructed Hernia.—Obstruction takes place by the damming up of feces or of undigested food, the fecal current being arrested, but the blood-current in the walls of the bowel being undisturbed. Incarceration is commonest in irreducible hernia, umbilical hernia, and during the existence of constipation. The tumor enlarges and becomes tender, painful, and dull on percussion; pres- sure diminishes it in size; it is irreducible, but still pre- sents impulse on coughing. The abdomen is somewhat distended and painful; there are nausea, constipation, and not unusually slight vomiting. Constitutional disturbance is slight and constipation is not absolute, wind at least usually passing. Vomiting is not fecal. The treatment is rest in bed in a position to relax the belly, an ice-ba'g over the hernia, and a little opium for pain. Do not give a particle of food for twenty-four hours; when the active symptoms subside give an enema, and after this acts a dose of castor oil. Do not employ taxis, as bruising the bowel may produce strangulation. Inflamed Hernia.—Inflammation of a hernia is local peri- tonitis due to injury of an irreducible hernia. The mass 648 A MANUAL OF SURGERY. * becomes tender, painful, and hot. In enterocele much fluid forms; in epiplocele the mass becomes hard. The hernia cannot be reduced; there is constipation, often vomiting, usually fever, but the mass still shows impulse on coughing. Vomiting is not fecal. Some wind is usually passed by the bowels. Constitutional symptoms are slight. The treatment is rest in bed with abdominal relaxation, an ice-bag to the tumor, a small amount of opium by the mouth if pain is severe, an enema, and when this acts a saline. If pus forms, incise and drain. Strangulated hernia is a condition in which not only is the fecal circulation arrested, but the circulation of blood in the bowel-wall is also arrested. The bowel is irreducible and obstructed, and the blood ceases to circulate. Strangulation is commonest in old inguinal ruptures in active, middle-aged men, and is more frequent in enteroceles than in epiploceles. It may be due to entry into the sac of more intestine or omentum, which has been forced down by sudden movement or violent effort. It may be due to active peristalsis or to congestion, and it may arise from inflammation or from in- carceration. The constriction is usually at the neck of the sac, in the outside tissues, or even in the sac itself. In an hour-glass hernia the constriction is in the body of the sac. Adhesions within the sac may cause strangulation. Spas- modic contraction of the tissues about the neck of the sac is an exploded hypothesis. When strangulation once begins the hernia swells, a furrow forms at the seat of constriction, the bowel and omentum below the constriction become deeply congested and cedematous, and, finally, the rupture passes into a state of moist gangrene. The sac is apt to inflame, and inflammation produces fluid and lymph ; serum accumulates in the sac, being first clear, then bloody, and finally brown and foul. When gangrene is once established the bowel is in danger of rupturing. A strangulated femoral hernia DISEASES AND INJURIES OF THE ABDOMEN. 649 becomes gangrenous more rapidly than does a strangulated inguinal hernia. Symptoms.—The hernia is found to be irreducible; it becomes larger, tender, painful, and dull on percussion, and gives no impulse on coughing. Abdominal pains, uncontrollable vomiting, and prostration come on. The vomiting is first of the contents of the stomach, next of bilious matter, but finally of feces. Constipation is abso- lute, no wind even being passed, though in the very begin- ning there may be some diarrhceal passages from below the constriction. The urine is scanty and high-colored, and contains only a small amount of the chlorides; the tongue becomes dry and brown; the thirst is torturing; the pulse is small and very rapid. Pains in the abdomen and in the hernia become violent, and collapse rapidly develops. When gangrene begins, the symptoms apparently lessen in violence : there is a "delusive calm." Vomiting usually ceases, though regurgitation may take its place ; hiccough begins ; the pain abates or disappears; the pulse becomes very feeble and intermittent; collapse deepens, and delirium is usual. It is a safe clinical rule that in strangulated hernia cessation of pain without the relief of constriction or the use of opiates means that gangrene has begun. In a pure omental hernia strangulation produces similar but less decided symptoms. In Littre's hernia only a portion of the circumference of the bowel is constricted, usually in the femoral ring. In a strangulated Littre hernia constipation is rarely absolute and the tumor is often undiscovered. Treatment.—In treating strangulated hernia, place the patient upon his back, bend the knees over a pillow, and rigidly interdict the administration of food. An attempt is to be made to effect reduction by gentle manipulation or taxis. In applying taxis to a femoral or inguinal hernia, flex and adduct the thigh of the affected side. In applying taxis 650 A MANUAL OF SURGERY. to an umbilical hernia both thighs should be flexed upon the abdomen. Always lower the shoulders and head and raise the pelvis, and accomplish this by lifting the foot of the bed and placing pillows under the pelvis. Grasp the neck of the sac with the fingers and thumb of one hand, and employ the other hand to squeeze the hernia and urge it toward the belly. In direct inguinal hernia the pressure should be backward and a little upward; in umbil- ical hernia it should be backward ; in oblique inguinal hernia it should be upward, outward, and backward; in femoral hernia it should be downward until the hernia enters the saphenous opening, and then " backward toward the pubic spine " (Sir Win. MacCormac). If the bowel is reduced, it passes from the hand with a sudden slip and enters the belly with an audible gurgle; omentum, when reduced slowly, glides back without gurgling. Taxis is never to be con- tinued long, and it is not even to be attempted in cases of great acuteness, in cases where strangulation has lasted for several days, in cases known to have previously been irre- ducible, in cases associated with stercoraceous vomiting, or in an inflamed or gangrenous hernia. If taxis fails, obtain the patient's permission to operate. Anaesthetize; try taxis again while ether is being dropped upon the hernia to cause cold; if it fails, at once perform herniotomy. Taxis possesses certain dangers: it may rup- ture the bowel; it may rupture the neck of the sac and force the bowel through the rent; it may strip the peri- toneum from around the hernial orifice and force the bowel between the detached peritoneum and the abdominal wall; it may reduce a hernia into the belly when the bowel is still strangulated by adhesions; it may reduce the hernia en masse or en bloc, the sac and strictured bowel being forced together into the abdomen. By reduction en bissac is meant the forcing of a congenital hernia into a congenital DISEASES AND INJURIES OF THE ABDOMEN. 6$\ pouch or diverticulum. In any of the above accidents strangulation may persist after apparent reduction by taxis, and this condition calls for instant laparotomy—in most instances through the hernial aperture. If taxis is success- ful, put the patient to bed, apply a pad and bandage, allow the patient to take no food until vomiting ceases, merely permitting him to suck bits of ice, keep him on a liquid diet for several days, and stop peristalsis by opium. At the end of the first week give solid food; if the bowels have not acted by this time, administer an enema, following it by a dose of Epsom salt if there is no pain or no disposition to vomit. Some surgeons advocate inversion as a valuable aid to taxis. Herniotomy.—The instruments required in herniotomy are a scalpel, a hernia-knife and director, haemostatic and dis- secting forceps, blunt hooks, scissors, a dry dissector, partly- curved needles, and a needle-holder. Drainage-tubes should be ready. In the operation the patient lies upon his back with the shoulders raised, the surgeon standing upon the patient's ri'i-ht side. In oblique inguinal hernia a fold of skin is raised at right angles to the axis of the external ring and is trans- fixed, and the wound which results is extended until it becomes three inches in length. The tissues are divided until the sac is reached, and no attempt is made to specially identify them. The sac is known by the fat which usually covers it, by the arborescent arrangement of its vessels, by the fact that it can be pinched up between the finger and thumb and the layers rolled over each other, and by the fluid within the sac. Should the sac be opened ? In very recent cases it is usually unnecessary, but if there is any doubt as to the condition of the bowel, or if a radical cure is to be attempted, open the sac and be certain as to the con- dition of its contents. The general rule should be to open the sac. The sac is opened and the contents examined for fecal odor (which is not unusual) and for gangrenous smell; the 652 A MANUAL OF SURGERY. thickness of the bowel is estimated, and the color and lustre are determined. Always pull down the bowel and examine the seat of constriction. If the bowel is healthy, restore it and do a radical cure. If there is a gangrenous or a strongly fecal smell, wash the sac and bowel with corrosive-sublimate solu- tion and fasten the bowel to the skin by a couple of stitches. In oblique inguinal hernia nick the constriction upward and outward, as shown in Figure 163. In direct inguinal hernia the cut is made upward and inward. Do not open the bowel at this time, but dust the parts with iodoform and dress. The bowel may recover in a day or two, when it can be restored to the belly ; or it may slough and form an artificial anus. If gangrene of the bowel is pronounced, resect the gangre- nous bowel, and either make an artificial anus or perform an end-to-end approximation or an anastomosis. Gangrenous omentum requires ligation and resection. If the bowel is fit to reduce, push it just inside the ring, irrigate the parts, insert a drain, and stitch. In many cases perform a radical cure. In femoral hernia, make the incision one inch internal to, and parallel with, the femoral vessels, and crossing the tumor and ligament (Barker). Divide the constriction by cutting upward and a little inward. In umbilical hernia make a slightly curved incision a little to one side of the middle of the tumor, open the sac, separate adhesions, and divide the constriction by cutting upward or downward, and sometimes also laterally. After an operation for strangulated hernia, put the patient to bed; bend the knees over a pillow; give no food by the mouth for thirty-six hours (MacCormac), only allowing the patient bits of ice to suck; give nutrient enemata containing brandy; and use morphia hypodermatically. If the bowels have not acted by the end of the first week, give an enema and follow this by a saline. Remove the drainage-tube on the third day. At the end of about three weeks, if a radical DISEASES AND INJURIES OF THE ABDOMEN. 653 cure has not been attempted, get the patient up, first apply- ing a pad and a spica of the groin. A truss cannot be worn for five or six weeks. Anatomical Varieties of Hernia.—In direct inguinal hernia the bowel passes out through Hesselbach's triangle internal to the deep epigastric artery. It enters the inguinal canal low down, and passes outside the conjoined tendon or forces the conjoined tendon before it or splits through the tendon. The neck of the sac is internal to the deep epigastric artery. The coverings of this hernia when it passes external to the conjoined tendon are the same as for indirect inguinal hernia; when a direct hernia pushes before it the conjoined tendon, its coverings are skin, superficial fascia, intercolumnar fascia, conjoined tendon, transversalis fascia, subserous tissue, and peritoneum. In indirect inguinal hernia the bowel passes through the internal abdominal ring external to Hesselbach's triangle and external to the deep epigastric artery. It passes down the inguinal canal and emerges from the external ring; it may enter the scrotum or labium (scrotal or labial hernia), or it may not. The neck of the sac is external to the deep epigastric artery. Its coverings are—skin, superficial fascia, intercolumnar fascia, cremaster muscle, infundibuliform fascia, subserous tissue, and peritoneum. Congenital or encysted inguinal hernia is a hernia into an unclosed vaginal process. The bowel in congenital hernia has one layer of peritoneum in front of it. The testicle is posterior. In funicular hernia the vaginal process is closed below and open above, and a hernia takes place into the un- closed funicular process. The bowel has one layer of peri- toneum in front of it. The testicle is posterior. In infantile hernia the vaginal process is occluded above, and not below, and the septum of occlusion is pushed down by the hernia. In infantile hernia the bowel has three layers of peritoneum in front of it. The testicle is in front. Always remember 654 A MANUAL OF SURGERY. that congenital hernia may not appear for several months after birth. Congenital hernia conceals or buries the testicle ; acquired hernia does not. In femoral hernia the bowel de- scends along the femoral canal, and the neck of the sac is at the femoral ring. A femoral rupture is always external to the pubic spine; an inguinal rupture is always internal to the pubic spine. Femoral hernia is never congenital. Its coverings are—skin, superficial fascia, cribriform fascia, crural sheath, septum crurale, subserous tissue, and peritoneum. Umbilical hernia may be congenital (the ventral plates having closed incompletely), infantile (the cicatrix of the umbilicus having stretched), or acquired. Ventral hernia is a protru- sion at any part of the anterior abdominal wall except at the umbilicus. Obturator hernia passes through the obturator membrane or the obturator canal, and is felt below the hori- zontal ramus of the pubes, internal to the femoral vessels. Lumbar hernia occurs at the edge of, or through, the quad- ratus lumborum muscle. Sciatic hernia passes through the great sacro-sciatic foramen. In diaphragmatic hernia some viscera of the abdomen pass through a natural or an acci- dental opening into the thorax. Pudendal hernia protrudes into the lower part of the labium. Perineal hernia presents in the perineum, between the rectum and the prostate gland or between the rectum and the vagina. Hernia into the fora- men of Winslow is very rare. XXVII. DISEASES AND INJURIES OF THE RECTUM AND ANUS. Hemorrhoids, or Piles.—There are three varieties of varicose tumors of the rectum, namely: internal, which take origin within the external sphincter; external, which take origin without the external sphincter; and mixed hemor- rhoids, which are a combination of the two. DISEASES AND INJURIES OF RECTUM AND ANUS. 6$$ External Hemorrhoids.—A livid, soft enlargement ap- pears near the edge of the anus, due to rupture of a dis- tended vein, and accompanied by decided pain and other evidences of inflammation. These blood-tumors may get well if let alone, or they may suppurate. External piles are covered with skin, are apt to be multiple, and cause no pain except when inflamed. When the superfluous tags of skin around the anus enlarge, they give rise to much pain and inflammation. These cutaneous outgrowths are often spoken of as a form of external piles. Symptoms and Treatment.—An inflammatory enlargement is detected, which enlargement is tender and painful. Pain is increased by defecation. These piles do not bleed. In treating external hemorrhoids some surgeons merely use remedies to combat the inflammation. An old plan of treat- ment is to incise the blood-tumor, turn out the clot, and pack with a bit of iodoform gauze. Matthews freezes the part or injects cocaine, catches up the blood-tumor with a volsellum, excises the tumor and the tabs of inflamed skin, dusts the part with iodoform, and dresses it with anti- septic gauze. The bowels should be tied up for two days. Never inject external piles with carbolic acid: it causes great inflammation, excessive pain, and is not free from danger. If the patient declines operation, order rest, a non-stimulating diet, avoidance of tobacco (Matthews), a saline purgative, injections into the rectum of cold water several times a day, sponging of the anus frequently with hot water, and the application of hot poultices. As the acute symptoms begin , to disappear use lead-water and laudanum ; when they have nearly subsided, apply zinc ointment. Extract of hamamelis is a valuable application to external piles. Internal hemorrhoids are internal to the external sphinc- ter, just within the anus, and they prolapse easily. They are covered by mucous membrane. Capillary piles are 656 A MANUAL OF SURGERY. small, sessile, with a surface like a mulberry, and bleed freely. Children are, as a rule, not very liable to develop piles, but they not infrequently have this capillary form. Venous piles are the ones commonly met with. They extend from just above the anal margin of the rectum for an inch or more. They are purple in color, soft, irregular in outline, and are usually multiple. They bleed, but not so easily as the capillary pile, when irritated by hard fecal masses. Each pile is composed of a varicose vein, some little fibrous tissue, and a few arterial twigs. Arterial piles are very unusual. They are large, smooth, pedunculated, and bleed easily and freely. Each pile contains, besides a distended vein, arteries of some size. Anything producing venous congestion in the rectum— constipation, diseases of the rectum, enlargement of the prostate, pregnancy, tumors of the womb, congestion of the liver, cirrhosis of the liver, certain diseases of the heart and lungs, sedentary occupations, relaxing climate, and stric- ture of the urethra—will cause hemorrhoids. Symptoms and Treatment.—If there is no bleeding and no protrusion, the piles give no trouble. The first symptom is usually hemorrhage, and rectal examination by the spec- ulum will make clear the condition. After a time, during defecation, the piles protrude; they may reduce themselves when the patient stands up, or it may be necessary to push them in. Pain does not exist in uncomplicated cases, and pain during or after protrusion means " abrasion, fissure, or ulceration" (Matthews). Palliative treatment will not cure, but it will give great comfort. Some people only suffer at rare times when the liver is congested, and such subjects will not submit to operation. Remove, if possible, the cause (alco- hol, irritating foods, want of exercise, etc.) ; restrict the diet; insist on regular exercise; give a course of Carlsbad salt, and follow this by the stomach use of bichloride of mercury DISEASES AND INJURIES OF RECTUM AND ANUS. 657 (gr. Jjj- after each meal). Prevent constipation by a nightly dose of fluid extract of cascara sagrada. After each move- ment wash off the parts and syringe out the rectum with cold water, and dry with a soft rag. If the hemorrhoids prolapse, after restoring them and injecting water, insert a suppository containing gr. v of the extract of hamamelis, and use another suppository at bed-time. When the piles prolapse and inflame, rub Allingham's ointment on the parts (oij each of ext. of conium and ext. of hyoscyamus, sj of ext. of belladonna, and sj of cosmoline). Matthews uses gr. xij of cocaine, 3j of iodoform, 3ss of ext. of opium, s"j of cosmoline. If the piles are protruding and reduction cannot be effected, put the patient to bed, give a hypodermatic injec- tion of morphia, and apply hot poultices. If reduction can- not soon be effected, operate. Operative Treatment.—Give a saline the morning before, and an enema the evening before, the operation, and wash out the rectum well the morning of the operation. In treating by injection of carbolic acid the tumors are drawn out or the patient strains them out, an injection is given by a hypoder- matic syringe into the centre of the pile, and as each pile is injected it is pushed into the rectum. The dose for each pile is 10 drops of a solution containing 3 parts of glycerin, 3 of water, and 1 of pure carbolic acid. The injection is rarely curative, is very painful, and may produce hemorrhage, phlebitis, pyaemia, stricture, and even death (W. T. Bull). The clamp and cautery are used in interno-external piles. The pile is caught with forceps and drawn outside. Smith's # clamp is applied with the ivory surface against the mucous membrane of the bowel, the pile is cut off, and the stump is seared with the Pacquelin cautery at a dull-red heat. Excision is preferred by Allingham. He stretches the sphinc- ter, holds it open with a retractor, catches up the pile, cuts it off, and twists the bleeding vessels. Some prefer to pass 42 658 A MANUAL OF SURGERY. a ligature, cut off the tumor, and tie the thread (Fig. 166). Whitehead's operation is suited to severe cases, and only a surgeon who can master violent hemorrhage should venture to perform it. The entire pile-bearing area of mucous membrane is dissected out, and the cut margin of mucous membrane is pulled down and stitched to the surface. The sphincter must be dilated as a preliminary. The ligature is the easiest and most gen- erally useful method. In this operation stretch the sphincter and treat each haemorrhoid: sep- arately. Catch a pile with a pair of forceps or a volsellum, pull it down, and cut a gutter fig. i66.—Extir- through the skin-margin ; tie the small piles pation of Hemor- ° rhoids(Esmarchand without transfixing (transfix the large piles); tie with silk (coarse silk for the large piles, finer silk for the small piles); cut off the tumor, and cut the ligatures short. Treat the other piles in the same manner. Irrigate with corrosive-sublimate solution, dust with iodoform, pack a piece of iodoform gauze into the rectum, and apply a gauze pad and a T-bandage. Give some morphia to lock up the bowels, and keep the patient on a light diet for three days, at the end of which time a saline may be given. Just before the bowels act remove the dressings and give an enema of warm water. After the movement wash out the rectum with 1 :5000 corrosive- sublimate solution and apply a gauze pad over the anus. Irrigate daily until healing is complete. After the tenth day examine with a speculum to see that the ligatures have come away; if any are found in place, remove them. Prolapse of Rectum.—If the mucous membrane alone is prolapsed, the condition is called " prolapsus ani;" if the entire thickness of the rectal wall is prolapsed, it is called " prolapsus recti." Prolapse, which is apt to occur from DISEASES AND INJURIES OF RECTUM AND ANUS. 659 excessive straining at stool, is commonest in feeble, ill- nourished children. Piles and worms may be complicated with prolapse. Straining from phimosis, stone in the blad- der, or stricture may be causative. Prolapse may be either large or small, but it tends to recur again and again, and eventually the mucous membrane inflames, ulcerates, or sloughs. Strangulation of the prolapsed part may occur. Treatment.—In palliative treatment the patient must not strain at stool; if prolapse occurs, the parts are bathed in cold water and restored. Constipation must be prevented (enemata of water or glycerin may be used). If a prolapse is caught firmly, place the patient upon his knees and chest, wash the mass with cold water, grease it with cosmoline, insert a finger into the rectum, and apply taxis around the finger (Matthews). If this fails, cover a finger with a hand- kerchief and insert the wrapped digit into the rectum ; if this prove futile, invert the patient. Severe cases require ether. After reduction apply a compress, direct it to be worn except when at stool, and before each act of defecation give an injection of cold water containing an astringent (tannin or fluid hydrastis). Some bad cases require excision of the mucous membrane, the divided edge of this membrane being stitched to the skin. Ulcer of the Rectum.—Simple ulcer is due to abrasion with fecal masses, and is apt to be single. Its base and edges are neither prominent nor hard. Syphilitic ulcer is a tertiary lesion commonest in women. There are numerous small ulcers, but little indurated, with sharp-cut edges which are not undermined. These ulcers fuse together and consti- tute one large irregular ulcer; fibrous tissue forms in the wall of the bowel, induration becomes noticeable, and stric- ture follows. There is profuse discharge, and fistulae are apt to form. In syphilis there may be a breaking down of a huge gummy mass. Tubercular ulceration presents a conical 660 A MANUAL OF SURGERY. ulcer with overhanging edges and a pale-red base. There is some mucous discharge, some tenesmus, and a little pain. Dysentery, catarrh, neoplasms, and foreign bodies produce ulceration. The symptoms are constipation, burning pain on defecation, straining at stool, and blood and mucus in the stools. The diagnosis is made by the finger and the specu- lum. Treatment.—In simple ulcer, empty the bowel with a saline, wash it out with hot water, introduce a speculum, touch the ulcer with pure carbolic acid or silver nitrate (gr. xl to 3j), place the patient in bed, restrict to a liquid diet, and every day inject iodoform and olive oil or insufflate iodoform. In tubercular ulcer, improve the general health, send the patient to a genial climate or at least into the sun- light and fresh air, prevent constipation, give cod-liver oil, and wash out the rectum every day with hot water and insufflate iodoform. Touch the ulcer once a week with silver nitrate (gr. x to §j). In syphilitic ulcer, give antisyphilitic treatment and treat the ulcer locally as is done in tubercular ulcer. Dysenteric ulcer requires injections of hot water and the touching of the ulcer with pure carbolic acid and insuffla- tions of iodoform. Stricture of the rectum may arise from syphilitic tissue, from ordinary inflammatory tissue, from cicatrices of opera- tions, from sloughing, from tubercular or dysenteric ulcera- tion, and from cancer. The usual seat of simple stricture is from one inch to one and a half inches above the anus. The deposit may be limited to the submucous coat or all the coats may be involved. Symptoms and Treatment.—The symptoms of rectal stricture are constipation, pain on defecation, straining at stool, blood and mucus in the stools, an open anus, and stools flattened out into ribbons. The stricture is found by the finger or by the bougie. Complete obstruction may come on, and dis- DISEASES AND INJURIES OF RECTUM AND ANUS. 661 tended abdomen with colic is very usual. The treatment is rest, non-stimulating diet, warm-water injections, mild laxa- tives, and hot hip-baths. Cocaine suppositories may be needed. Any existing disease is treated. Bougies are passed every other day. Use a soft-rubber bougie, warmed and oiled, and introduce it gently. If this method of gradual dilatation is employed the bougie must be used always. For fibrous strictures forcible dilation (divulsion) by a special instrument is employed or incision is practised. Incision (proctotomy) may be either external or internal. In in- ternal proctotomy one or more incisions are made through the stricture down to healthy tissue, the first cut being in the middle line posteriorly. External proctotomy, which divides the sphincters, is apt to leave incontinence as a legacy. Electrolysis finds some advocates, but on what grounds it is difficult to see. In some cases the rectum should be re- moved. Complete obstruction calls for inguinal colostomy. Cancer of the rectum may be epithelioma, but it is often scirrhus. It not unusually occurs before the thirty-fifth year. The retroperitoneal and inguinal glands are involved late or not at all. Extensive ulceration occurs. A hard ring is apt to encircle the rectum. Symptoms and Treatment.—The symptoms of rectal cancer are like those of simple ulcer except that the pain is greater, the hemorrhage more severe, and constipation is apt to alter- nate with diarrhoea. The finger and the speculum make the diagnosis. Palliative treatment is as follows : Every day in- troduce a tube through the stricture, wash out the rectum with warm water, and after washing inject emulsion of iodoform (grs. x to sj of sweet oil). Injections of chloride of zinc (gr. j to si of water) lessen the foulness of the dis- charge. In operative treatment internal proctotomy does some good. Excision of the rectum from below (Cripp's operation) is practised if not more than three inches require 662 A MANUAL OF SURGERY. removal, if the peritoneum is not invaded, and if the adjacent organs are free from disease. The peritoneum must not be opened in Cripp's operation. Excision of the rectum after excising a portion of the sacrum (Kraske's operation) is an operation which permits removal of the entire tube, and even of adjacent parts. If the peritoneum is opened, it is closed with sutures. It is well to precede a Kraske opera- tion several weeks by an inguinal colostomy, which per- mits of cleansing the lower bowel from feces and allows the surgeon to operate with a fair chance of escaping infection. In obstruction from cancer, or in cases that do not permit of removal, inguinal colostomy is performed. It intercepts the feces from the cancerous region, allays pain, and pro- longs life. Foreign bodies in the rectum, if small, are extracted with forceps and the fingers ; if large, ether must first be given and the sphincter must be dilated. Wounds of the rectum require free drainage, antiseptic irrigation, and antiseptic dressing. Ischio-rectal abscesses are situated in the ischio-rectal fossa. They travel in the line of least resistance, which is upward, and more often burst into the bowel than externally. They are caused by cold, by external traumatisms, or by perforations of the rectum by hard fecal masses. They may be tubercular. The symptoms are the same as those of abscess anywhere, the swelling, however, being brawny and fluctuation being hard to detect. The treatment is instant incision, irrigation, and packing with iodoform gauze or the insertion of a drainage-tube. Fistula in ano is the track of an unhealed abscess. An abscess in the anal region is apt to refuse to heal because of the constant movement of the parts (respiration, coughing, passage of wind, defecation). The passage of feces will keep a fistula open. If a tubercular ulcer perforates, a DISEASES AND INJURIES OF RECTUM AND ANUS. 663 tubercular sinus forms. Fistula is often associated with phthisis pulmonalis, and is not unusually linked with piles, cancer, or stricture. There are three varieties of fistula—the blind external (Fig. 167, a), the blind internal (Fig. 167, b), and the com- plete (Fig. 167, c). The external opening is usually near the anus, but may be far away, and there may be only one path- way or there may be several sinuses. In a healthy individual the external orifice is small and a mass of granulations sprout from it. In tuberculous fistula the external orifice is large and irregular, with thin and undermined edges, shows no Fig. 167.—Fistula in Ano : A, blind external; B, blind internal; c, complete (Esmarch and Kowalzig). granulations, extrudes small quantities of sanious pus, and the skin about it is purple and congested (Bowlby). In a fistula following an anal abscess the internal opening is just above the anus, between the two sphincters. In fistula fol- lowing an ischio-rectal abscess the internal opening is above the internal sphincter. In an old fistula the track becomes fibrous and cannot collapse. The symptoms of fistula are passage of feces and wind through the opening and of a dis- charge which stains the clothing. A probe can be carried from the external opening into the bowel. After a time in- continence of feces is apt to come on, repeated attacks of inflammation thickening the rectum and destroying its sensi- 664 A MANUAL OF SURGERY. bility. From time to time the opening will block, and new abscesses may then form. In examining a fistula, use Brodie's probe, as its flat handle enables one to locate the direction a bent probe has taken. Treatment.—In treating a fistula prepare the parts antisep- tically, as antiseptic work, though it will not prevent pus, will limit suppuration. Pass a grooved director through the sinus, bring its point out externally, and lift up the tissues between the sinus and the surface. Incise the tissues (Fig. 168). Push the finger to the depth of the wound, to deter- mine that the sinus does not ascend above the internal opening. Slit up the sinuses and scrape them. Curette the sinus, and if it is very fibrous clip it away with scis- sors and forceps. Cut away diseased skin ; irrigate with corrosive-sublimate solution (i : iooo) ; pack with iodoform gauze ; and dress with gauze and a T-bandage. In forty-eight hours remove the dressings, irrigate with peroxide of hydrogen and then with corrosive sublimate (i : 5000), dust in iodoform, insert lightly to the depths of the wound a piece of iodoform gauze, and reapply the dressings. Dress the wound thus every day until healing is almost complete. It is unnecessary to confine the bowels beyond forty-eight hours, at which period, if they have not moved, an enema is given. If the dressing be stained with feces, re-dress at once. Get the patient out of bed as soon as possible. Should an operation be undertaken if phthisis exists ? Many of the old masters said no. Matthews sums up the modern view: In incipient phthisis, operate; in rapidly progressive fistula, operate whether cough exists or not; if much cough exists, do not operate unless the fistula is rapidly progressive; in the last stages of phthisis, do not operate. Fig. 168.—Operation for Fistula in Ano (Es- march and Kowalzig). DISEASES AND INJURIES OF RECTUM AND ANUS. 665 Pruritus of the anus is a symptom, and not a disease. It may be due to piles, fissure, seat-worms, eczema, nerve-dis- turbance, kidney-disease, jaundice, constipation, opium-habit, torpid liver, dyspepsia, alcohol, tea, vesical calculus, smoking, urethral stricture, uterine disease, ovarian trouble, and men- tal disorder. The itching, which is fearful, is worse at night. Treatment.—Remove the cause. Further, before going to bed wash the parts with very hot water, dry them, and apply at frequent intervals a mixture containing 3J of campho- phenique and sj of water (Matthews). Matthews commends the following mixture: Chloral, 3J; gum-camphor, 3ss ; glycerin and water, each gj.1 In this disease a " scarf- skin" forms, which must be made to peel off by iodine, pure carbolic acid, corrosive sublimate (grs. iv to |j of cosmoline), calomel (sij to sj of cosmoline), or campho-phenique. Fissure of the anus is a crack at the anal orifice pro- ducing spasm of the sphincter. The pain is due to twigs of nerves upon the floor of the crack. Fissure is caused by constipation or traumatism. The symptom is violent burning pain, sometimes beginning during defecation, but usually at the end of the act, and lasting for some time. Constipation exists, and often pruritus. Examination discloses a fissure, usually at the posterior margin, running up the bowel one- quarter to one-half an inch. Piles often exist with fissure. Treatment.—In palliative treatment prevent constipation, wash out the rectum with cold water, and apply an ointment made by evaporating sij of the juice of conium to Sfij and adding it to sj of lanolin and grs. xij of persulphate of iron. In operative treatment stretch the sphincter, incise the floor of the fissure, and scrape it with a curette. 1 Diseases of the Rectum. 666 A MANUAL OF SURGERY. XXVIII. ANESTHESIA AND ANESTHETICS. Anaesthesia is a condition of insensibility or loss of feeling artificially produced. An anaesthetic is an agent which pro- duces insensibility or loss of feeling. Anaesthetics are divided into—(i) General anaesthetics, as amylene, chloro- form, ethylene chloride, ether, bromide of ethyl, nitrous oxide, and bichloride of methylene; (2) Local anaesthetics, as alco- hol, bisulphide of carbon, chloride of ethyl, carbolic acid, ether spray, cocaine, ice and salt, and rhigolene spray. General anaesthesia may be required to prevent the pain of labor and of surgical procedures; to produce muscular relaxation in herniae, dislocations, and fractures; and to aid in diagnosticating abdominal tumors, joint diseases, and malingering. Heart disease is not a positive contraindication to surgical anaesthesia. It is quite true that anaesthetics are dangerous in people with fatty hearts, but shock is equally dangerous, and the surgeon stands between the Scylla of anaesthesia and the Charybdis of shock. Whenever possible, prepare a patient for anaesthesia. Always examine the urine if the nature of the case allows time. If albumin exists, operation is not contraindicated; but the peril of anaesthesia is greater, and certain dangers are to be watched for and guarded against. If much albumin is present, postpone operation except in emergency cases. Give a purgative the night before. In the morning, allow no breakfast if the operation is early, but if the patient is very weak order a little brandy and beef-tea. If the operation is to be about noon, give a breakfast of some beaf-tea and toast or a little consomme; * never give any food within three hours of the operation, but brandy is admissible if it is required. If the stomach is not empty at the time of operation, vomiting is inevitable and « portions of food may enter the windpipe; if the stomach ANAESTHESIA AND ANAESTHETICS. 667 contains no food, vomiting is less likely to happen, and even if the vomited matter enters the windpipe it will do little harm, as it consists chiefly of liquid mucus. Vomiting is dangerous also because of the great cardiac weakness which precedes and follows it. Before giving the anaesthetic see that artificial teeth are removed and that the patient does not have a piece of candy or a chew of tobacco in the mouth. Always have a third party present as a witness, because in the anaesthetic sleep vivid dreams often occur, and erotic dreams in women may lead to damaging accusa- tions against the surgeon. Place the patient recumbent, and see that the clothing is loose, particularly that there is no constriction about the neck and abdomen. Do not have the head high unless this position is demanded by the exigencies of the operation. The anaesthetizer must have a mouth-gag, a pair of tongue-forceps, a hypodermic needle in working order, and solutions of strychnia, atropia, digitalis, and brandy. It is always well to have an electric battery at hand. Accidents, it is true, are rare, but they may happen at any time, and hence the surgeon should always be pre- pared for them. Any danger which arises must be met with promptness and decision, or action will be of no avail. Many surgeons give a hypodermatic injection of morphia a short time before operation, to steady the heart, prevent vomiting, and aid the bringing about of insensibility with very little of the anaesthetic. The two favorite anaesthetics are ether and chloroform. Chloroform is more dangerous than ether in general cases, though it is more agreeable, less irritant to the lungs and kidneys, and quicker in its action. Recovery from chloro- form is quicker and quieter than that from ether, but chloro- form vomiting lasts longer than ether vomiting. Chloroform may induce sudden and even fatal syncope. Dr. Hare's experiments on animals show that chloroform may kill 668 A MANUAL OF SURGERY. through the respiration; but certain it is that clinically the danger of chloroform is paralysis of the heart, and this condition may come on so rapidly that death can occur almost before an attempt can be made to save life. If ether kills, it does so through the respiration, and not the heart, and there is usually time to undertake means of resuscitation, which means are apt to be successful. Chloroform is to be preferred to ether in the following cases: for children under ten years of age, in whom ether causes a great outflow of bronchial mucus which may asphyxiate; for people over sixty, at which age most persons have some bronchitis, and ether fills them up with mucus (ether irritates kidneys, which at the latter age are apt to be weak or diseased); for labor cases, when moderate anaesthesia only is required; for operations on the mouth and nose (unless the Trendelen- burg chair is used, when ether can be employed). In cleft palate chloroform should always be used to limit cough and to minimize salivary flow. In ligation of a large artery which is overlaid by a vein ether must not be used, as it greatly enlarges the veins. Chloroform is preferred for patients with difficult respiration from any cause; for patients with kidney disease; for patients with diabetes; and in ovariotomy, be- cause of a belief by many surgeons that ether causes oozing of blood. Ether is safer in patients with heart disease. Administration of Chloroform.—In administering chloro- form, have at hand a mouth-gag, tongue-forceps, a clean towel, a hypodermatic syringe, solutions of strychnine, atropine, and brandy, and, if possible, an electric battery. Use only pure chloroform (Squibb's). The patient must be recumbent. No special inhaler is required, but the drug can be given upon a thin towel, a napkin, or a piece of lint. The chloroform vapor must be well mixed with air. The chloroform is sprinkled on the fabric with a drop-bottle. Put the napkin well above the mouth, add five drops of ANAESTHESIA AND ANAESTHETICS. 669 chloroform, and tell the patient to take deep and regular breaths. Add a few more drops of chloroform, and when the patient grows so accustomed to it as not to choke, turn the wet part of the fabric toward the face and place it near the mouth ; do not touch the mouth with the wet lint, because it will blister. It is a good plan to smear the lips with cos- moline to prevent blistering. If the drug is given gradually, struggling is not usually violent or prolonged. Never pour on a large amount at one time. During the stage of excite- ment do not suspend the administration of chloroform unless respiration becomes difficult, in which case suspend it until the patient gets one or two respira- tions. Chloroform vapor is not in- flammable, hence it is safer than ether when a hot iron is to be used about the face and when there is a lighted lamp or a stove in a small room. Administration of Ether.—Ether is given by means of an Allis in- haler (Fig. 169). Have at hand the same instruments as for chloroform. Place the dry appliance over the mouth and nose, let the patient take several breaths to gain confidence, pour a few drops of ether into the cone, let the patient take several more breaths, and so on, gradually increasing the amount of ether. Never sud- denly add a large amount of the anaesthetic: it causes coughing and often vomiting. When the patient becomes thoroughly anaesthetized, diminish the amount of ether; when bleeding is profuse, do the same. If a hot iron is used about the face, take away the cone and fan away the ether before bringing the iron near. Have any light set hicrh up, as ether vapor is heavier than air, and no explosion 99999999 670 A MANUAL OF SURGERY. is possible until it reaches the level of the flame. If the vapor takes fire, cover the patient's mouth and nose with a towel. Anaesthetic State from Ether or Chloroform.—The in- halation of an anaesthetic produces irritation of the fauces, some cough, a profuse secretion of mucus, acts of swallow- ing, dilatation of the pupil, flushed face, and sometimes struggling (especially in children and in drunkards). The cough soon ceases, the respirations become rapid and often convulsive, the pulse becomes frequent, and the patient passes into a condition of active intoxication with preserva- tion of sight and touch, loss of hearing and smell, diminu- tion of pain and sensibility, and often with illusions or hal- lucinations. From this state many subjects (strong men and drunkards) pass into a stage of rigidity in which the muscles become rigidly fixed, the breathing impeded, the respirations stertorous, and the face bluish and congested. Too rapid forcing of the anaesthetic tends to cause rigidity, and a skilled anaesthetizer endeavors to avoid its production, because it is dangerous. The next stage is one of insensi- bility : the pupils are contracted, but may react slightly to light; the conjunctival reflex is gone; the lids are closed; if the arm is lifted and allowed to fall, it drops as a dead weight; the skin is cool and moist, and often wet with sweat; the respirations are easy and shallow; the pulse is slow; and there is complete unconsciousness to pain. If anaesthesia is deep, the contracted pupils will not react to light; if anaesthesia is profound, the pupils dilate, but will not react to light. Always bear in mind that a dilated pupil reacting to light and associated with preserved conjunctival reflex means that anaesthesia is not complete; that a contracted pupil reacting to light and without conjunctival reflex means moderate anaesthesia; that a contracted pupil not reacting to light ANAESTHESIA AND ANAESTHETICS. 67 I and without conjunctival reflex means deep anaesthesia; that a dilated pupil not reacting to light and associated with lost conjunctival reflex means dangerously profound anaes- thesia ; that weak pulse and pallor may be due to nausea, but always require instant attention; that vomiting may be due to forcing strong vapor upon the patient, but that it may be due to his partially emerging from a state of insen- sibility. Watch the pulse carefully to see if it becomes very weak, irregular, abnormally slow, or abnormally fast. Syncope may be due to nausea, shock, hemorrhage, or the giving of too much of the drug. Watch the respiration, and do not forget that the chest-walls and belly may move when no air is entering the lung; hence always listen to the breathing. Obstruction of the air-passages may be due to some foreign matter, as blood or vomit, lodging in the brachial tubes, windpipe, larynx, or pharynx; to falling back of the tongue (swallowing of the tongue); to closure of the epiglottis; or to the glottis being pushed against the pharyngeal wall by bending forward of the head. Some patients with occluded nostrils may fail to get enough air because of closure of the y lips. A patient may appear to forget to breathe. Shock is manifested by deadly pallor, weak and irregular pulse, slow respiration, cold extremities, and a drenching sweat. Treatment of Complications.—In rare cases cedema of the lungs occurs. This condition is treated by instant vene- section, the inhalation of nitrite of amyl, and the adminis- tration of stimulants and nitro-glycerin. Vomiting due to # too much anaesthetic is corrected by giving a few breaths of air; vomiting due to incomplete anaesthesia is amended by giving more of the vapor. When the patient vomits, hang the head over the edge of the bed, separate the jaws with the gag, and wipe out the vomited matter, mucus, and saliva. Shock is treated by diminishing the 672 A MANUAL OF SURGERY. amount of the anaesthetic given, by the hypodermatic in- jection of brandy, strychnine, or atropine (the last-named drug is very useful when there is a profuse sweat), by sur- rounding the patient with hot bottles, or by wrapping him in hot blankets and lowering the head of the bed. A tendency to syncope requires lowering of the head of the bed, suspension of the anaesthetic, and hypodermatic injection of strychnine. In extreme syncope, which is most apt to occur from chloroform, suspend the anaesthetic, open the mouth with the gag, draw the tongue forward, make slow artificial respiration, not waiting for breathing to cease (which it tends rapidly to do), and lower the head of the bed. If the patient does not at once improve, invert him completely, holding him by the legs and continuing artificial respira- tion by compressing the sternum (Nelaton). By continuing artificial respiration the blood is urged on through the heart. Give hypodermatic injections of ether, brandy, strychnine, or even of ammonia. Put mustard over the heart and spine. Employ faradism to the phrenic nerve (one pole to the epigastric region, the other to the right side of the root of the neck). Let fresh air into the room, put hot-water bottles around the legs, apply friction to the extremities, wrap the patient in hot blankets, give an enema of brandy, and hold ammonia or nitrite of amyl to the nose. " Forgetting to breathe " is met by removing the inhaler and waiting a moment; a breath will usually be taken now, but if it is not taken open the mouth and pull forward the tongue; this causes a reflex inspiration. Obstruction to breathing from bending forward of the head may be amended by changing the position of the head or by pulling forward the tongue. Cyanosis, if slight, is met by continuing the anaesthetic and by carrying the patient quickly into the stage of relaxation; but if the condition grows worse suspend the drug, dash cold water in the face, force open the jaws, pull ANAESTHESIA AND ANAESTHETICS. 673 forward the tongue, and make artificial respiration until a breath is taken. " Swallowing the tongue " is corrected by pulling the tongue forward. If it tends to recur, lay the head upon its side or keep the tongue anchored with forceps. Closure of the epiglottis is corrected by pulling the patient's head beyond the end of the table and pushing strongly back upon his forehead. This manoeuvre lifts the hyoid bone, and with it the epiglottis. The epiglottis can be lifted by passing a spoon-handle over the dorsum to the base of the tongue and pressing forward. If, in obstruction to res- piration, the above means fail, make artificial respiration at once ; if obstruction continues, perform tracheotomy. After stopping the anaesthetic in an ordinary case have the patient carefully watched until consciousness and intelli- gence are entirely restored. The face is washed with cold water; the patient is kept recumbent; if vomiting occurs, his head is hung over the edge of the bed and the mouth is subsequently wiped out. No food should be taken for at least eight hours. If vomiting occurs, draughts of hot water will relieve it by washing out the mucus from the stomach. Primary Anaesthesia.—Instruct the patient to count out aloud and to hold one arm above his head. Give the anaes- thetic. In a short time he becomes mixed in his count and his arm sways or drops to the side. There is now a period of insensibility to pain lasting only about half a minute, and during this period a minor operation can be performed. The patient quickly reacts without vomiting from primary anaes- thesia (Packard). Local Anaesthesia.—Freezing with Ice and Salt.—Take one-quarter of a pound of ice, wrap it in a towel, and break it into fine bits; add one-eighth of a pound of salt; then place the mixture in a gauze bag and lay it upon the part. The surface becomes pallid and numb, and in about fifteen minutes is decidedly analgesic. Spray of rhigolene freezes 43 074 A MANUAL OF SURGERY. in about ten seconds. It is highly inflammable. Chloride of ethyl comes in hermetically-sealed glass tubes. Break the end of the tip of the tube and hold the bulb in the palm : the warmth of the hand causes the fluid to spray out. Hold the tube some little distance from the part and let the fine spray strike the surface. The skin blanches and whitens, and is ready for the operation in about thirty seconds. Ether-spray anaesthesia was suggested by Benja- min Ward Richardson. Cocaine Hydrochlorate.—Always bear in mind that cocaine is more dangerous than ether (Richardiere made eleven autopsies in deaths from cocaine). Never use over two-thirds of a grain upon a mucous surface, and never inject hypodermatically more than one-third of a grain. The urethra is a particularly dangerous region, and so is the face. Mild cases of cocaine-poisoning are character- ized by great tremor, restlessness, pallor, dry mouth, talka- tiveness, and weak pulse. In severe cases there is syncope or delirium. Death may arise from paralysis or from fixation of the respiratory muscles (Mosso). Cases with a tendency to respiratory failure require the hypodermatic injection of strychnine. In cases with tetanic rigidity of muscles give enemata of chloral, hypodermatic injections of nitro- glycerin, or inhalations of the nitrite of amyl. In cases marked by delirium, if the circulation is good give chloral or hyoscine. In any case give stimulants, employ a catheter, and favor diuresis. Cocaine-poisoning is always followed by a wakeful night. Cocaine should not be used if the kidneys are inefficient. In using cocaine try to prevent poisoning. Have the patient recumbent. One minute before giving the cocaine, administer one drop of a I per cent, alcoholic solution of trinitrine, repeating the dose once or twice during the operation. In operation on a finger, after making the part anaemic tie a tube around the root of the digit before inject- BURNS AND SCALDS. 675 ing cocaine, and after the operation gradually loosen the tube. Merck prepares a far safer agent than the hydro- chlorate, and that is the phenate of cocaine. This is a honey-like material, soluble in alcohol. It is used locally in from 5 to 10 per cent, solutions. It takes longer to act than does the hydrochlorate, and it coagulates the tissue- albumin, and thus absorption is lessened. It causes anaemia, anaesthesia, and retards germ-growth (Kyle). Gluck and Bartholow some time ago advised a mixture composed of cocaine hydrochlorate and carbolic acid. XXIX. BURNS AND SCALDS. Burns and scalds are injuries due to the action of caloric. Scalds are due to heated fluids or vapors. There is no true pathological difference between burns and scalds. Dupuy- tren classifies burns into six degrees, as follows: (1) charac- terized by erythema; (2) characterized by dermatitis with the formation of vesicles ; (3) characterized by partial destruction of the skin, which structure is not, however, entirely burnt through; (4) characterized by destruction of the skin to the subcutaneous tissue; (5) characterized by destruction of all superficial structures and of part of the muscular layer; (6) characterized by " carbonization " of the whole thickness of the muscles. The symptoms are local and constitutional. Local symp- toms are pain and inflammation, which vary in nature, in intensity, or in degree according to the extent of damage done. Constitutional symptoms are shock, followed by a severe reactionary fever, with a strong tendency to con- gestion of internal parts. Sepsis is not infrequent. The stages arc often designated as prostration, reaction, and sup- puration. Death may be due to shock, to sepsis, to exhaus- 676 A MANUAL OF SURGERY. tion, to congestion of the brain, lungs, or kidneys, or to Curling's ulcer of the duodenum. Treatment.—The local treatment of slight burns (as sun- burn) is to wrap up the parts in a saturated solution of bicarbonate of soda, a strong solution of Epsom salt, or a 1 : 8 solution of phenol sodique. In burns of moderate degree a mixture of zinc ointment with iodoform, though not antiseptic, is a comfortable dressing; but all severe burns should be treated antiseptically. In a severe burn, cut away the clothing, avoid exposure to cold, wash the part with a solution of peroxide of hydrogen and then with a warm solution of boracic acid, open the vesicles with an aseptic needle, dust on iodoform, and dress with aseptic cotton. Change the dressings no oftener than is required, and at each change wash the burn with peroxide of hydro- gen and boracic acid, take away sloughs, and reapply iodo- form and cotton. Where extensive destruction of tissue has taken place, use splints and extension to limit contractures, and skin-graft as soon as possible. If granulation is slow, stimulate with copper-sulphate or mild silver-nitrate solu- tions. Exuberant granulations require burning down. Flabby granulations require pressure. Carron oil, which consists of linseed oil and lime-water, allays the pain of a burn, but it is a foul and dirty preparation. When an extremity has been carbonized amputation must be performed. In constitu- tional treatment, react from shock; combat pain with opium; keep the bowels and kidneys active. If suppuration occurs, give tonics, stimulants, and concentrated foods. Complica- tions are treated according to general rules. Scalds of the glottis are due to the inhalation of steam or of ignited gas. A child may scald the glottis by trying to drink from the spout of a kettle (Moullin). The symptoms are pain, dysphagia, and dyspnoea. CEdema of the glottis quickly comes on. The treatment is tracheotomy or intuba- BURNS AND SCALDS. 677 tion of the larynx in severe cases; in mild cases, scarifica- tion of the larynx. Effects of Cold.—Local Effects.—Cold produces numb- ness, prickling, a feeling of weight, redness of the surface followed by stiffness, local insensibility, and mottling or pal- lor. Sudden intense cold causes the formation of blebs, the coagulation of blood in the superficial veins, and violent pain in- the limb. Cold locally produces frost-bite (p. 118). The constitutional effects of cold are at first stimulating, then depressing, and are exhibited by uneasiness, pain, and an intense drowsiness which, if yielded to, is the road to death by way of internal congestion. Death from prolonged cold resembles in appearance death from apoplexy. Death from sudden and overwhelming cold is caused by anaemia of the brain from weak circulation and capillary embolism. To bring a partly-frozen person into a warm room will cause death by embolism. Treatment.—Frost-bite is treated as outlined on page 118. When a person is nearly frozen to death, place him in a cool room, but under no circumstance in a cold bath, make arti- ficial respiration, rub him down with flannel soaked in alcohol or in whiskey, and follow this by rubbing with dry hands. After a time wrap the patient in warm blankets and give an enema of brandy. Mustard plasters are to be applied over the heart and spine. As soon as swallowing is possible brandy is administered by the mouth. As the condition improves gradually raise the temperature of the room and give hot drinks. Chilblain, or pernio, is the secondary effect of cold. It usually appears as a local congestion upon the toes, the fingers, or the nose, and it is apt now and then to inflame and ulcerate. A chilblain is apt to become congested by approaching a fire or by taking exercise, and when con- gested it itches, tingles, and stings. Frequent attacks of 678 A MANUAL OF SURGERY. congestion produce crops of vesicles; these vesicles rupture and expose an ulcer which in rare instances sloughs. Treatment.—Prevent congestion of the legs and feet if chilblain affects the toes. Order large shoes and woollen stockings and forbid tight garters. The patient with pernio must take regular outdoor exercise and must not loiter around a hot fire. Every morning and evening he should take a general cold sponge bath followed by rubbing with alcohol and frictions with a coarse towel, and he should sleep with warm stockings on or with his feet upon a hot- water bag. When a chilblain is only a congested spot it should be washed twice a day in cold salt water, rubbed dry with flannel, and subjected to applications of tincture of iodine and soap liniment (i : 2), tincture of cantharides and soap liniment (1 : 6), or equal parts of turpentine and olive oil (W. H. A. Jacobson). Jacobson says itching is relieved by painting belladonna liniment upon the part and allowing it to dry. If vesicles form, paint with contractile collodion ; if ulcers form, dress antiseptically. If ulcers are sluggish, use equal parts of resin cerate and spirits of turpentine. A good antiseptic and protective is the following: Oxide of zinc, grs. vj; chloride of zinc, gr. xx; gelatin, Iij ; Dis- tilled water, 3j. XXX. DISEASES OF THE SKIN AND NAILS. Dermatitis venenata results from irritants and from gar- ments containing arsenic, but is generally due to rhus-poi- soning. Rhus-poisoning arises from the poison-oak, the poison-ash, the poison-ivy, and other species of sumach. Actual touching of the plants is not always necessary. The symptoms are burning and itching, redness and cedema of the face and hands. A vesicular eruption begins between the fingers, and the eruption and the inflammation spread DISEASES OF THE SKIN AND NAILS. 679 widely over the body. There may be some slight fever. The treatment, when a moderate area is involved, com- prises the application of cloths wet with black wash or lead- water and laudanum. If an extensive area is involved, apply grindelia robusta (3iv to Oj of water) or moisten the surface frequently with sweet spirits of nitre. For the face use borated-talc powder. Oxide-of-zinc ointment containing 10 grs. of carbolic acid to ^j gives great relief. A 1 : 8 solu- tion of phenol sodique allays pain and itching. Furuncle, or boil, is an acute and circumscribed inflam- mation and suppuration of a hair-follicle, a sebaceous gland, and the adjacent connective tissue. A boil is caused by in- fection of a hair-follicle, through a slight wound (by scratch- * ing, shaving, etc.), with the staphylococcus pyogenes aureus. Boils are very common during Bright's disease, diabetes, gout, tuberculosis, and disorders of menstruation and diges- tion. Boils are commonest in the spring, and sometimes an epidemic of furunculosis appears in a hospital, a jail, or an asylum. The symptoms of a boil are as follows: A red elevation appears, which stings and itches; this elevation enlarges and becomes dusky in color; a pustule forms, that ruptures and gives out a very little discharge which forms a crust. Inflammatory infiltration of adjacent connective tissue advances rapidly, and the boil in about three days consists of a large, red, tender, and painful base capped by a pustule and some crusted discharge. In rare instances, at this stage, absorption occurs, but in most cases the swelling increases, the discoloration becomes dusky, the skin becomes oedematous, the pain becomes fierce and pulsatile, and the centre of the boil becomes lifted up. About the seventh day rupture occurs, pus runs out, and a " core " of necrosed tissue is found in the centre of a ragged opening. In a day • or two more the core will be discharged and healing by granulation will occur. A blind boil lasts only three or four 680 A MANUAL OF SURGERY. days and has no core. The constitution often shows reaction during the progress of a boil. Boils may be either single or multiple. The development of boil after boil is known as " furunculosis." Boils are commonest upon the neck and the back. The treatment consists of crucial incision, re- moval of necrotic tissue, irrigation with peroxide of hydro- gen and corrosive sublimate, and antiseptic dressing. Aleppo boils (endemic boils of the tropics) are papules appearing upon the exposed parts of the body. These papules, which ulcerate and do not cicatrize for at least a year, are due to a pathogenic bacterium and leave ineradi- cable scars. Carbuncle (benign anthrax) is a circumscribed infectious inflammation of the deeper layer of the true skin and of the subcutaneous tissue, with fibrinous exudation in which multiple foci of necrosis arise and the tissue adjacent to each necrotic plug becomes gangrenous. The infection takes place through a hair-follicle. It is really a boil with extensive infiltration of adjacent tissues. A boil can become a carbuncle, and pus from a carbuncle inoculated into a healthy person may cause either a boil or a carbuncle. The causative organism seems to be the staphylococcus pyogenes aureus. The local symptoms in the start resemble those of a boil, but the constitution sympathizes from the beginning (a chill and a septic fever) and the pain is agoniz- ing. The inflammatory area enlarges enormously, is boggy to the touch, is dusky in color, is oedematous, and the skin is not freely movable over the deeper parts. In a few days many pustules appear, each pustule marking the site of a focus of necrosis. Large vesicles filled with bloody serum are frequently met with. In some cases, about the tenth day, the pustules rupture, the necrotic plugs are discharged, and the case slowly progresses toward cure; but in many cases the carbuncle spreads at the periphery while pustules DISEASES OF THE SKIN AND NAILS. 681 are rupturing near the centre of inflammation, and pus forms in the deeper tissues, reaching the surface through many small openings each of which is partly blocked by a plug of dead tissue. A carbuncle in this stage resembles a honeycomb, discharges bloody pus, and large masses of skin and subcutaneous tissue are destroyed. The entire carbuncular mass may become gangrenous, and a sudden and almost complete cessation of pain points to this compli- cation. An ordinary carbuncle remains acute for about three weeks, but healing requires a month more. The most dangerous positions for a carbuncle are the face and neck (tends to pjroduce septic phlebitis, septic clots in the cerebral sinus, or infective emboli). The most usual positions for carbuncle are the neck, the back, and the buttocks. The diagnosis of carbuncle is made by noting the multiple foci of necrosis and the profound constitutional involvement. Treatment.—Give ether, make free crucial incisions, re- move dead and necrosing tissue with the scissors and forceps, curette pockets, stop hemorrhage by pressure and hot water, cauterize with pure carbolic acid, dust with iodo- form, pack with iodoform gauze, and dress with corrosive- , sublimate gauze. Every day, or several times a day, remove the dressings, wash with peroxide of hydrogen, irrigate with corrosive-sublimate solution, dust in iodoform, and reapply the iodoform gauze and antiseptic gauze. Secure sleep by morphia, give quinine, milk punch, and nourishing diet, and attend to the bowels and kidneys. Clavus, or Corn.—A corn is a tender, painful, and cir- cumscribed thickening of the epidermis, and is commonest over one of the joints of the toes. Hard corns are situated on exposed parts of the digits ; soft corns appear between the digits and are kept constantly moist. Corns are caused by pressure. Treatment.—-By wearing well-fitting boots corns upon the 682 A MANUAL OF SURGERY. toes will usually disappear. Soak the feet often in water containing bicarbonate of soda, dry them, and apply circular corn-plasters to the corn, to take off the pressure of the boot. Another method is to touch the corn with iodine every night and pare away the hard tissue every morning. An old and valuable plan is to paint the corn every night with a mixture composed of salicylic acid, 3iss; extract of cannabis indica, grs. x; and collodion, Ij, and to scrape this mixture away every morning. Soft corns are treated by washing the feet often with ethereal soap, drying, gently removing the soft epithelium, dusting with borated talc, and placing absorbent cotton between the toes. Incurable soft corns re- quire the freshening of the adjacent sides of the two toes and suturing them together (thus converting two toes into one). In inflamed corns employ rest and lead-water and laudanum, and let out pus when it forms. Remember that in old per- sons the cutting of a corn may cause senile gangrene. In the inflamed and painful feet of a person who has corns, nothing gives so much relief as washing them with ethereal soap, soaking in hot water, and wrapping the feet for half an hour in cloths wet with a mixture composed of linseed oil and lime-water, each, Iij, and spirits of camphor, 3j. Warts.—(See p. 215.) Onychia is inflammation of the matrix of the nail. A " run-around " is suppuration of the matrix and the root of the nail, of traumatic origin. It requires incision, trimming away of the buried edge of the nail, and packing with iodo- form gauze. Malignant onychia, which is inflammation and ulceration of the entire matrix, occurs in persons with di- lapidated constitutions. This condition requires removal of the entire nail, cauterization of the matrix, dressing with iodoform gauze, and the internal use of stimulants, tonics, and nourishing diet. Ingrown toe-nail is due either to lateral hypertrophy of the edge of the nail or to the forcing DISEASES AND INJURIES OF THE LYMPHATICS. 683 of the soft tissues over the margin of the nail. The con- dition is treated by splitting the nail, removing the piece of nail, the soft tissue, and the adjacent matrix, and dressing antiseptically. XXXI. DISEASES AND INJURIES OF THE LYMPHATICS. Lymphangitis is inflammation of lymphatic vessels. Re- ticular lymphangitis, which is inflammation of lymphatic radicals, is seen in some circumscribed inflammations of the skin. It is apt to attack the hands, causing redness and swelling, fading at the point of initial trouble while it spreads at the periphery; it is caused by micro-organisms derived from decomposing animal matter (Rosenbach). Erysipelas also causes it (see Erysipelas). Tubular lymphangitis, which is due to the entry into the lymphatic ducts of virulent micro- organisms or their products, is seen in dissection-wounds, septic wounds, snake-bites, etc. It is announced by cedema and by minute hard red streaks running from the wound up the extremity. Suppuration may occur. Lymphadenitis, or inflammation of the glands, may follow lymphangitis or may be due to the deposition of infective material, the lymph-vessels not being inflamed. In septic lymphadenitis there are pain, tenderness, and swelling. In severe cases there are chill and septic fever. Suppuration may arise. The treatment is to drain and asepticize the wound, to apply over the glands and vessels iodine and blue ointment or ichthyol, and to employ rest and compression. Internally, milk punch, quinine, and nourishing diet are required. If suppuration occurs, incise and drain. Acute lymphadenitis, or acute inflammation of lymphatic Hands, may follow lymphangitis or may be due to tubercle, syphilis, glanders, cold, or traumatism. Suppuration may or 684 A MANUAL OF SURGERY. may not occur. In inflammatory lymphadenitis there are pain, heat, and nodular swelling. In severe cases there is fever. The treatment is to asepticize any area of infection, place the glands at rest, apply cold and lead-water and lauda- num, or inject into the gland every day 5 m. of a 3 per cent. solution of carbolic acid to prevent suppuration. If pus forms, evacuate, drain, and asepticize. Chronic adenitis is almost invariably syphilitic or tuber- cular. It requires constitutional treatment and the local use of ichthyol, iodine, or blue ointment. Lymphangiectasis (varicose lymphatics), or dilatation of the lymphatic vessels, is due to obstruction. It results, as a rule, from chronic lymphangitis or the pressure of a tumor, and is most usually situated in the pubic, the inguinal, or the scrotal regions or on the inner side of the thigh. There are two forms: the varicose, in which the vessels have a tortuous outline, like varicose veins, but are covered only by surface epithelium; and lymphatic warts (lymphangioma circum- scriptum), in which wart-like masses spring up, these masses being covered with epithelium and filled with lymph. In most cases of lymphangiectasis there is considerable hard cedema. Rupture of the dilated vessel causes a flow of lymph (lymphorrhcea). Lymphangioma is an advanced stage of lymphangiectasis (p. 209). The treatment in mild cases is to pierce each ves- icle with the minus pole of a galvanic battery and pass a current. In severe cases destroy the mass with the Pacque- lin cautery or excise it with a knife or with scissors. Elephantiasis.— True elephantiasis (elephantiasis Arabum) is chronic hypertrophy of the skin and subcutaneous tissues following upon a lymphangiectasis produced by a nematode worm (the filaria sanguinis hominis). Spurious elephantiasis is hypertrophy of the skin and subcutaneous tissue due to chronic inflammation (in a leg which possesses an ancient BANDAGES. 685 ulcer, or in the scrotum of a man with urinary fistula). The treatment is massage and bandaging, sometimes ligation of the artery of supply, extirpation, or amputation. Malignant Lymphoma, or Hodgkin's Disease.—(See p. 203). XXXII. BANDAGES. A bandage is a fibrous material which is rolled up and is then employed to retain dressings, applications, or appliances to a part, to make pressure, or to correct deformity. It may be made of plain gauze, of gauze infiltrated with plaster of Paris or soaked in silicate of sodium, of gauze wet with corrosive-sublimate solution, of flannel, of calico, or of un- * bleached muslin. Unbleached muslin, which is the best material for general use, is washed to remove the sizing, is torn into strips, and the edges are stripped of selvage. One end is folded to the extent of six inches, this is folded upon itself again and again until a firm centre is formed, and over this centre the bandage is rolled. In a well-rolled bandage the centre cannot be pushed out of the roll. A cylindrical part of the body may be covered by a cir- t cular bandage, each turn exactly covering the previous turns. A conical part may be covered by a spiral bandage, each turn ascending a little higher than the previous turn. As each turn of a spiral bandage is tight at its upper and loose at its lower edge, the reverse was devised to correct this inequality; hence a conical part should be covered by a spiral reversed bandage. To make a reverse hold the roller in the right hand (do not have more than six inches of slack), place the thumb across the fresh turn, fold the bandage down without traction, and do not make traction until the turn has been carried well around the limb. A projecting point is covered with ' figure-of-8 turns. The groin, shoulder, breast, or axilla can be covered by figure-of-8 turns, each succeeding turn ascend- 686 A MANUAL OF SURGERY. ing and covering two-thirds of the previous turn and form- ing a figure like "the leaves on an ear of corn." Such a figure is called a " spica." In bandaging an extremity the peripheral turns should be tighter than the turns nearer the body. Never apply a tight bandage to the leg or the arm without including the foot or the hand. In firm dressings ' leave the fingers exposed, and use them as an index of the condition of the circulation in the part. Spiral Reversed Bandage of the Upper Extremity.—In making this form of bandage, use a roller two and a half inches wide and eight yards long. Take a circular turn about the wrist, and a second turn to hold the first; pass obliquely across the back of the hand to the extremities of the fingers; ascend the hand to the root of the thumb by * several spiral turns; cover the wrist by a figure-of-8 ; ascend the forearm by spiral reversed turns; cover the elbow by a figure-of-8, and the arm by spiral reversed turns; end the bandage by two circular turns, and pin them (PI. 11, Fig. 4). Spiral Bandage of All the Fingers (Gauntlet).—The gauntlet bandage requires a roller one inch wide and one and a half yards long. Take two circular turns around the wrist, pass obliquely across the wrist to the root of the thumb, » and descend to its tip by spiral turns; cover in the thumb by spiral reverses, and return to the wrist. Cover in each successive finger in the same manner, and terminate by two circular turns around the wrist (PI. 11, Fig. 2). Spiral Bandage of the Palm or Dorsum of the Hand (Demi-gauntlet).—The demi-gauntlet requires a roller one inch wide and four yards long. This bandage has only a limited value; it must not be applied tightly, as it makes much pressure at the finger-roots, but leaves the fingers free. If it is desired to cover the palm, supinate the hand; if to cover the dorsum, pronate the hand. Take two circular turns * around the wrist, sweep around the root of the thumb, and BANDAGING. Platk io. i. Oblique or Crossed Bandage of the Angle of the Jaw ; 2, Gibson's Bandage ; 3, Recurrent K.ndage of the He..,! ; 4, Crossed Fignre-of-8 Bandage of both Eyes; 5, Barton's Bandage or Figure-of-8 of the Jaw : 6, Figure-of-8 Bandage of the Elbow. • t > BANDAGES. 687 return to the point of origin. Treat each finger in the same way. End by circular turns around the wrist (PI. 11, Fig. 1). Spica of the Thumb.—For this bandage use a roller one inch wide and three yards long. Start at the wrist, and reach the tip of the thumb as in applying a spiral bandage of a finger. Make a series of ascending figure-of-8 turns between thumb and wrist, each ascending turn overlying two-thirds of the previous turn; terminate with a circular of the wrist (PI. 11, Fig. 3). Spiral Reversed Bandage of the Lower Extremity.— Take a roller two and a half inches wide and seven yards long, and make two circular turns just above the malleoli, and an oblique turn across the dorsum of the foot to the metatarso-phalangeal articulation ; make a circular turn, and cover the foot with spiral reversed turns ; return to the ankle by a figure-of-8; ascend the leg by spiral reverses; cover the knee by a figure-of-8, and the thigh by spiral reverses; terminate by two circular turns (PI. 11, Fig. 6). Bandage of the Foot covering the Heel (American Bandage of the Foot).—Take a roller two and a half inches wide and seven yards long. The bandage is begun as is , a spiral reversed bandage of the lower extremity. After the foot is well covered by ascending spiral reversed turns, carry the bandage directly around the point of the heel and return to the instep; from this point carry it around the back of the ankle, down the side of the heel, under the heel to the instep, around the ankle in the opposite direction, down the opposite side of the heel, and under the heel to the instep; take the roller to above the malleoli, and end by a circular turn (PI. 12, Fig. 2). Bandage of the Foot not covering the Heel (French Method).—Take a roller two and a half inches wide and 1 six yards long. Make a spiral reversed bandage of the foot and a figure-of-8 of the ankle-joint (PI. 12, Fig. 1). 688 A MANUAL OF SURGERY. % Spiral Bandage of the Foot covering the Heel (Ribble's Bandage; Spica of the Instep).—Take a roller two and a half inches wide and six yards long. Apply as a spiral reversed bandage of the lower extremity until the meta- tarsus is well covered. Carry the bandage, parallel with the margin of the foot (the inner or outer margin, according as to whether it is the left foot or the right), around the poste- rior aspect of the heel, along the opposite margin of the foot to cross the original turn at the median line of the dorsum. Make a number of these ascending turns, each turn covering in three-fourths of the previous turn; terminate by circular turns above the ankle (PI. 12, Fig. 3). Crossed Bandage of Both Eyes (Figure-of-8 of Both Eyes).—Take a roller two inches wide and six yards long. Make a circular turn around the forehead from right to left, a second turn to hold the first, a turn downward over the left eye, under the left ear, around the back of the neck, Fig. 170.—Borsch's Eye-bandage: a, first step; b, second step. M and upward under the right ear and over the right eye; repeat these turns, and terminate by a circular turn of the forehead (PI. 10, Fig. 4). Borsch's eye-bandage is convenient and useful (Fig. 170). BANDAGING. Plate h. i. Demi-gauntlet Bandage; 2, Gauntlet Bandage; 3, Spica of the Thumb; 4, Spiral Reverse Bandage of the Upper Extremity ; 5, Recurrent Bandage of Stumps; 6, Spiral Reverse Bandage of the Lower Extremity. • • « BANDAGES. 689 Barton's Bandage (Figure-of-8 of the Jaw).—Take a roller two inches wide and five yards long. Place the initial extremity of the bandage behind the inion; pass over the right parietal bone, across the vertex, down the left side in front of the ear, under the chin, up the right side in front of the ear, across the vertex, and across the left parietal bone to the point of origin. A turn is now taken forward along the right side of the jaw to the chin, and backward along the left side of the jaw, from the chin to the nape of the neck; repeat these turns, and pin the points of junction (PI. 10, Fig. 5). In Barton's bandage the ear lies in a tri- angle. The bandage may be finished by circular turns around the forehead. Barton's bandage is used for fracture of the lower jaw. Gibson's Bandage.—Take a roller two inches wide and six yards long. Make three vertical turns around the head and the jaw in front of the ear; reverse the bandage above the level of the ear, and carry it horizontally around the forehead and head three times; drop the bandage to the nape of the neck, and take three turns around the neck and jaw; terminate by taking from the nape of the neck a half > turn upward, carrying the bandage forward to the forehead, and pinning it over the neck and over the forehead. Pin each point of junction (PI. 10, Fig. 2). Gibson's bandage is used for fracture of the lower jaw. Crossed Bandage of the Angle of the Jaw (Oblique Bandage of the Jaw).—Take a roller two inches wide and six yards long. Make a circular turn around the forehead r toward the affected side, and a second turn to hold the first; drop to the back of the neck ; come forward on the sound side, under the ear and chin ; now make a series of turns around the head and jaw, in front of the ear on the injured side, but back of the ear on the sound side : these turns successively advance on the sound side only; terminate by 44 690 A MANUAL OF SURGERY. going backward under the ear of the sound side to the nape of the neck, and then by taking two circular turns around the forehead (PI. 10, Fig. 1). This bandage is used for frac- tures of the ramus of the jaw and for holding dressings upon the face and the cranium. Spica of the Groin (Figure-of-8 of the Thigh and Pelvis). —For one groin the roller is three inches wide and seven yards long ; for both groins, three inches wide and ten yards long. Take two circular turns, from right to left, around the waist, then down over the front of the right groin, around the back of the thigh, up over the front of the right thigh, around the waist, down over the front of the left groin, around the back of the thigh, up over the left groin, and around the waist. The map being thus laid out, the turns are continued and ascended, each turn overlying one-third of the previous turn, and the bandage is completed by a circular turn around the waist (PI. 12, Fig. 4). Pin the crossed pieces. Spica of the Shoulder.—Take a roller two and a half inches wide and seven yards long. Make a circular turn and several spiral reversed turns around the upper arm; then, coming from behind forward, carry the bandage over the shoulder, across the front of the chest, through the opposite arm-pit, and return across the back to the shoulder. Make successive and advancing turns (PI. 13, Fig. 6). Figure-of-8 bandages of the breast, the elbow, the neck and axilla, and of both shoulders (posterior figure-of-8) are shown on Plate 10 (Fig. 6), Plate 12 (Figs. 5, 6), and Plate 13 (Figs. 1-6). Velpeau's Bandage.—Take a roller two and a half inches wide and ten yards long. Place the palm of the hand of the injured side upon the shoulder of the sound side, inter- posing cotton between the arm and the side. Start at the axilla of the sound side posteriorly, cross the back to the BANDAGING. Plate 12 , Figure-of-8 Bandage of the Ankle ; 2. Method of Covering the Heel; 3> Spica of the Instep : 4. Spica of the Groin; 5, Posterior Figure-of-8 of both Shoulders; 6, Figure-of-8 of Neck and Axilla. • • ► • BANDAGES. 691 shoulder of the injured side, down the front of the arm and under the arm just above the elbow, returning to the point of origin; repeat this turn, but, on reaching the axilla the second time, cross the back and pass around the chest, in- cluding the arm ; keep on with these turns, each alternate turn going over the injured clavicle, each alternate turn encircling the arm and the body, the first turns advancing and the second turns ascending (PI. 13, Fig. 4). Pin the crossed pieces. This bandage is used for fracture of the clavicle. Desault's Apparatus.—This apparatus consists of three rollers, a pad, and a sling. Each roller is two and a half inches wide and seven yards long. The pad, which is wedge-shaped, is inserted into the axilla with the base up. The first roller is used to hold the pad (PI. 13, Fig. 1). The second roller binds the arm to the side over the pad. This pad is a fulcrum, the shoulder is the weight, the arm is the lever, and the second roller of Desault corrects the inward deformity of a fractured clavicle (PI. 13, Fig. 2). The third roller corrects the downward and forward displacement. It starts in the axilla of the sound side anteriorly, crosses the chest to the shoulder of the injured side, runs down the back of the arm, around the elbow, and crosses the chest to the point of origin, forming the anterior triangle; it is now carried through the axilla of the sound side to the back, crosses the back to the shoulder of the injured side, runs down the front of the arm, around the elbow, and across the back to the axilla of the sound side, forming the posterior triangle (PI. 13, Fig. 3). The formula for the Desault bandage is: Start in the axilla of the sound side anteriorly, run from the axilla to the shoulder, from the shoulder to the elbow, from the elbow to the axilla, and pass to the back; from the axilla to the shoulder, from the shoulder to the elbow, from the elbow to the axilla, and pass 692 A MANUAL OF SURGERY. to the front. Pin the crossed pieces and hang the hand in a sling (PI. 13, Fig. 3). Recurrent Bandage of the Head.—Take a roller two inches wide and six yards long. Make two circular turns horizontally around the forehead and head ; when the middle of the forehead is reached, catch the bandage, take a half turn, carry the bandage to the occiput, let an assistant catch it, take a half turn, bring the roller forward to the forehead, covering a portion of the preceding turn; continue this pro- cess until the scalp is well covered; terminate with two cir- cular turns around the forehead and head (PI. 10, Fig. 3). It is often advisable to take a turn around the head and chin. Pin the crossed pieces. Recurrent Bandage of a Stump.—Take a roller two inches wide and six yards long. Make two light circular turns around the root of the stump; make recurrent turns covering the stump as is done in covering the head; take a circular turn around the root of the stump, oblique turns to the top of the stump, circular turns around the tip, and apply an ascending spiral reversed bandage (PI. 11, Fig. 5). T-Bandage of the Perineum.—Pass the transverse part around the body above the iliac crests, and pin it in front; bring one of the tails over the dressing and up between the thigh and the genitals of one side, and the other tail over the dressing and up between the thigh and the genitals of the opposite side; secure these tails to the horizontal band. Handkerchief Bandages.—Take unbleached muslin one yard square. The muslin folded once makes an oblong bandage; bringing its diagonal angles together makes a triangle bandage; a cravat is formed by folding a triangle bandage from summit to base; a cord is a twisted cravat. The triangle makes an admirable sling. Fixed Dressings: Plaster-of-Paris Bandage.—Cover the BANDAGING. Plate 13. ,_3. Desault's Bandage: i, First Roller: 2, Second Roller; 3, Third Roller; 4, Velpeau's Bandage; 5, Figure-of-S Bandage of the Breast; 6, Spica of the Shoulder. • • « 4 ♦ PLASTIC SURGERY. 693 extremity with a cotton or flannel bandage or with a woollen stocking. Take a gauze roller infiltrated with plaster, and place it endwise in a basin of cold water, the water covering the plaster. When bubbles cease to come off, squeeze the bandage and apply it without much tension, smoothing out each turn with a moistened hand. As each bandage is taken from the basin, drop a fresh one into the water. Apply four thicknesses of bandage, and finish the dressing by sprinkling dry plaster over the bandage and smoothing it with wet hands. The ordinary plaster will set in from fifteen to thirty minutes. If it is desired to have it set more rapidly, put salt or alum in the water; if to have it set more slowly, pour stale beer into the water. The plaster bandage is re- moved by sawing it down the front or by moistening with dilute hydrochloric acid and then cutting through the moist- ened line with a strong knife. Silicate-of-soda Dressing.—Protect the part as is done for a plaster bandage. Bandage the limb loosely with an ordinary muslin bandage, paint this bandage with silicate of soda, apply another bandage and paint it, and so on until six layers are applied. Gauze bandages soaked in silicate are better than ordinary bandages. Silicate dressings require from twelve to eighteen hours to dry, and they are removed by softening with water and cutting. XXXIII. PLASTIC SURGERY. Plastic surgery includes operations for the repair of de- ficiencies, for the replacement of lost parts, for the restora- tion of functions in parts tied down by scars, and for the cor- rection of disfiguring projections. The following are the methods used:l Displacement is the method of stretching or of sliding: 1 American Text-Book of Surgery. 694 A MANUAL OF SURGERY. • (i) approximation after freshening the edges (as in hare- lip ; (2) sliding into position after transferring tension to other localities (linear incisions to allow of stretching of the skin after large wounds). Interpolation is the method of borrowing material from an adjacent or a distant region or from another person: (1) transferring a flap with a pedicle, which flap is put in place at once or is gradually gotten into place by a series of partial operations; (2) trans- planting without a pedicle, which is performed by placing in position and by fixing there portions of tissue recently removed from the part, from another part of the same indi- vidual, or from a lower animal (as the button of bone after tre- phining, or in nerve-grafting), or by skin-grafting. Retrench- ment is the removal of redundant material and the produc- tion of cicatricial contraction. Skin-grafting.—In Reverdin's method the surface to be grafted should possess healthy granulations which are at the skin level. The grafts may come from the person to be grafted or from another person. Cleanse the skin from which the grafts are to come, the ulcer, and the skin about it, and, if corrosive sublimate is used, wash it away with a stream of warm normal salt-solution. Thrust a sewing- needle under the epidermis to lift it up, cut off the graft with a pair of scissors, and place the cut surface of the graft upon the ulcer. After applying a number of grafts place thin pieces of gutta-percha tissue over the grafts and extend- ing on each side of the ulcer, and so placed as to allow drainage. This tissue, after being asepticized, is moistened with warm normal salt-solution (^ of 1 per cent.). Dress with a pad of aseptic gauze moistened with salt-solution; place over this gauze a rubber dam, and over the latter absorbent cotton and a bandage. In the case of children apply a light silicate bandage. Put the patient in bed. In forty-eight hours remove all the dressings except the gutta- PLASTIC SURGERY. 695 percha tissue, irrigate with normal salt-solution, and reapply the dressings. All signs of the grafts will often have disap- peared. In a day or two, at the site of grafting, bluish- white spots should appear, which are islands of epidermis. Each graft is capable of forming about half an inch of cicatrix. Grafting stimulates the edges of the ulcer to cicatrize and contract. The spot from which the grafts are taken is dressed antiseptically. Reverdin's method does not limit cicatricial contraction to any great degree, and the new skin is apt to break down. At the end of seven days the special dressings can be dispensed with. Thiersch's Method.—Thoroughly asepticize the ulcer, the surrounding skin, and the site from which the graft is to come (the inner side of the arm or the thigh), and wash away the mercurial preparation with normal salt-solution. Apply dressings wet with salt-solution. On bringing the patient into the operating-room, remove the dressings from the ulcer, scrape the ulcer and its edges, irrigate with salt- solution, and compress to arrest hemorrhage. Grafts are then obtained by putting the prepared skin upon the stretch and cutting strips with a razor. While the razor is being used the part is constantly irrigated with salt-solution. The grafts are pressed into place, and each graft overlaps a little the edges of the wound and the adjacent grafts. Mixter's apparatus enables one to perform this operation with great neatness and speed. The skin-wound is dressed antisep- tically, and the grafted area is dressed as in Reverdin's method. Recently it has been suggested that a ring of aseptic gauze be made to encircle the limb below the grafted area, and another ring above the grafted area; on these pads little strips of wood wrapped in aseptic gauze are so laid as to make a cage, and around this cage the dressings are applied (moist chamber plan). 696 A MANUAL OF SURGERY. • XXXIV. DISEASES AND INJURIES OF THE GENITO-URINARY ORGANS. Hsematuria.—By this term is meant the voiding of bloody urine or pure blood, the blood arising from any portion of the urinary apparatus, and the condition being a symptom, and not a disease. Hsematuria may be a symptom of disease or of injury of some part of the urinary system, of blood-dis- organizations (purpura, scurvy, or variola), or of metallic poisoning (mercury, lead, or arsenic). The color of the urine in hematuria may be anything between a light-red and a decided black, but these colors may be produced by agents other than blood. Senna and rhubarb make urine red; carbolic and salicylic acids, brown; beet-root and sorrel, the color of blood. In jaundice, melanosis, and splenic fever the urine becomes brown. Be sure that bloody urine in the female is not due to admixture with menstrual blood. Tests for Blood.—Spectroscope Test.—Fresh urine diluted with water shows the two absorption bands of oxyhemo- globin. The addition of ammonium sulphide causes the two bands to give place to the band of reduced haemoglobin. If bloody urine stands for some time the four bands of methsemo- globin are discovered (Von Jaksch). Heller's Test.—Add to the urine potassium hydrate, and boil: a red precipitate of earthy phosphates and haematin forms. Throw the precipitate upon a filter and treat with acetic acid: a red solution is produced, which soon fades. Rosenthal's Test.—Take the precipitate from caustic pot- ash, dry it, and test it for haematin; put some of the dry sediment on a slide, add a crystal of common salt, apply a cover-glass, and cause a few drops of glacial acetic acid to flow under the glass; warm, but do not boil. Teich- mann's crystals will appear on cooling. DISEASES OF THE GENITOURINARY ORGANS. 697 Struve's Test.—Test the urine with hydrate of potassium, and add acetic acid in excess : a dark precipitate forms, which will yield crystals of haematin when treated with sal ammo- niac and glacial acetic acid. Almen's Test.—Take 10 cc. of urine, and pour upon its surface a mixture of equal parts of tincture of guaiac and old oil of turpentine: at the point of junction of this fluid with the urine there forms a white ring which turns blue. Microscope Test.—The microscope shows numerous cor- puscles except in a very alkaline urine, when but few cor- puscles may be found. In haemoglobinuria—a condition sometimes occurring in burns, acute maladies, and metallic poisoning—there is pres- ent blood coloring matter, which is shown by Heller's test and by Almen's test. The spectroscope shows methaemo- globin. The microscope shows no corpuscles or only a few, but discloses masses of pigment. Bleeding from the Kidney-substance.—Bleeding from the pelvis of the kidney and from the ureter may be due to inflam- mation, congestion, contusion, stone, vicarious menstruation, hemorrhagic diathesis, powerful diuretics, fevers, purpura, tumors, catheterization of the bladder, etc. Blood is thor- oughly mixed with the urine, and no sediment forms (smoky urine). The corpuscles are profoundly altered, are devoid of coloring matter, and show pale-yellow rings. The severity of the hemorrhage is measured by the number of the cor- puscles. Von Jaksch states that the diagnosis between renal and ureteral hemorrhage rests on the nature of the casts and the epithelium present. From the pelvis of the kidney and from the ureter comes small epithelium, the cells from the superficial layers being polygonal or elliptical, those from the deeper layers being oval or irregular. In hemorrhage from the ureter the cells are few; in hemorrhage from the pelvis they are plentiful and rest upon one another like 698 A MANUAL OF SURGERY. "tiles on a roof" (Von Jaksch). Cells from the tubules of the kidney are small, granular, and polyhedral, have large nuclei, and are often so arranged as to form cylinders (epithelial casts). The urine of renal hemorrhage is apt to be acid unless alkalies have been administered, unless the bleeding has been severe, or unless pus is present in the urine. A very large renal hemorrhage may cause the passage of almost pure blood. In renal haematuria there are aching in the loin, numbness of the corresponding leg, and often renal colic. Vesical hemorrhage, including hemorrhage from the prostate, may follow the relief of retention of urine, may be due to stone, inflammation, tumor, etc., or may arise from traumatisms, instrumental or otherwise. The color of the urine is usually bright-red, but if long retained in the blad- der it becomes black and often tarry. The reaction is alka- line. The clots, when floated out, are large and without definite shape. In micturition the urine is clear or only a little colored at the beginning, but becomes darker and darker as micturition ends, at which time the flow may consist of almost pure blood. In very small vesical hemorrhages the urine may be smoky. Crystals of triple phosphate indicate bladder disorder. The microscope shows colorless and swollen corpuscles and many polygonal cells. Symptoms of bladder mischief usually exist, but cystoscopic examina- tions or exploratory suprapubic cystotomy may be demanded for the diagnosis. Urethral Hemorrhage.—In urethral bleeding blood comes independently of micturition, or blood comes out first and is followed by pure water. Urethral hemorrhage arises from an acute urethritis, from an inflamed stricture, from the pas- sage of an instrument, or from some other traumatism. Pain in Genito-urinary Diseases.—Pain as a symptom of genito-urinary disease may be found at some point dis- DISEASES OF THE GENITO-URINARY ORGANS. 699 tant from the seat of lesion. A stone in the bladder causes pain in the head of the penis just back of the meatus ; stone in the kidney induces pain in the loin, the groin, the thigh, and the testicle; inflammation of the testicle causes pain in the line of the cord in the groin. In other cases of genito-urinary disease pain is felt at the seat of lesion, as in urethritis and prostatitis. Pain felt before micturition, and being relieved by the act, is found in cystitis and in retention of urine. Pain is felt during micturition in inflammation of the bladder, prostate, and urethra and in the passage of gravel or stone. Pain which is acute at the end of micturition is noted in stone in the bladder, in inflammation of the neck of the bladder, and in inflammation of the prostate gland. The pain of stone in the bladder, it may be observed, is amelior- ated by rest and is aggravated by exercise. The pain of acute prostatitis is intensified by defecation. Frequency of Micturition.—Frequent micturition arises from irritation of the sensory nerves, from phimosis, con- tracted meatus, inflammations, very acid urine, calculi, ure- thral stricture, and hyperaesthesia of the urethra. Frequency of micturition may be due to spinal irritability from concus- sion or from sexual excess, from contraction of the bladder rendering the viscus unable to hold much, or from excessive urinary secretion, as in diabetes or in the first stage of con- tracted kidney. Frequent micturition exists in obstruction by enlarged prostate and in atony of the bladder-walls. Hypersecretion of urine plus bladder intolerance is known as " nervousness," and is found in hysteria. Frequency of micturition increased by movement is observed in stone and tumor of the bladder; increased by rest, is found in enlarged prostate and atony of the muscular walls of the viscus. Frequency of micturition with diminution of stream- calibre suggests a constriction of the urethral diameter; fre- quency of micturition with diminished force suggests a pos- 700 A MANUAL OF SURGERY. terior stricture, enlarged prostate, or bladder atony. Slow- ness of micturition hints at enlarged prostate, atony, or urethral stricture. Thompson's diagnostic questions are as follows : " i. Have you any, and, if so, what, frequency in passing water? Is frequency more manifest during the night or the day ? Is frequency more manifest during motion or rest ? Does any other circumstance affect it? " 2. Is there pain on passing urine, and, if so, is it before, during, or after the act? What is its character—acute, smarting, dull, transitory, or continuous? What is its seat? Is it felt at other times, and is it produced or intensified by sudden movements ? " 3. What is the character of the stream ? Is it small or large; twisted or irregular; strong or weak; continuous, re- mitting, or intermitting? Does it come by the meatus, or partly or entirely through fistulae ? " 4. Is the character of the urine altered ? What is its appearance, color, odor, reaction, and specific gravity ? Is it clear or turbid, and if turbid, is it so at the time of pass- ing ? Does it vary in quantity ? Are the normal constitu- ents increased or diminished ? Does it contain abnormal elements, as albumin or sugar? What inorganic deposits are found ? What organic materials are met with ? "5. Has the urine ever contained blood? If so, was the color brown or bright red; were the blood and urine thoroughly mixed; was the blood passed at the end or at the beginning of micturition, or did it come only with the last drops of urine; or was it passed independently of micturition ? " 6. Inquire as to pain in the back, loins, and hips, perma- nent or transitory, or for the occurrence of severe paroxysms of pain there." Mobile Kidney.—There are two forms of this condition : DISEASES OF THE GENITOURINARY ORGANS. 7OI (1) Movable kidney, a kidney freely moving back of the peritoneum, either within the cavity of its fibro-fatty capsule or entirely without its capsule (this condition is acquired); and (2) floating or wandering kidney, a kidney having a mesonephron and lying within the peritoneal cavity (this rare condition is always congenital). Keen states that there may be drawn a clear theoretical distinction between movable and floating kidney, but practically there is no rigid line of demarcation, as a movable kidney may have as large a range of movement as a floating one. When a movable kidney becomes fixed in an abnormal situation the organ is spoken of as dislocated. The organ may drop below the brim of the pelvis, may cross the vertebral column, or may* reach the anterior abdominal wall. Women more often suffer from movable kidney than do men, and it is found in the great majority of cases upon the right side. Floating kidney is always congenital. Among the assigned causes of the movable condition are to be named traumatisms, strains, abdominal-wall laxity from pregnancy, absorption of peritoneal fat from wasting disease (Edebohls) and tight lacing. Symptoms of Both Forms.—There may be no discomfort whatever, or the patient may be a confirmed invalid. The usual symptoms are epigastric pain (just to the left of the middle line) which disappears when the kidney is replaced, drao-cring pain in the loin, and paroxysms like nephritic colic. There is a sense of a moving body in the abdomen, and the patient has aggravated indigestion, often accompanied by vomiting. Constipation is the rule, and violent attacks of cardiac palpitation are common. Most subjects of this kidney-mobility are extremely nervous, many of them hys- terical or hypochondriacal. In women the sexual organs are almost invariably deranged, and menstruation aggravates the pain and discomfort. All the symptoms are intensified 702 A MANUAL OF SURGERY. by exertion and are modified by rest. The urine is normal. The proof of the existence of movable kidney is the finding of a tumor (movable on respiration, change of position, and palpation) shaped like that organ, pressure upon which oc- casions no sensation or causes pain or a sickening feeling. A " lumbar recess " (Morris) may be found, and percussion over the loin gives resonance. A movable kidney must not be mistaken for a distended gall-bladder, a tumor of the mesentery, stomach, or omentum, a phantom tumor, an ovarian tumor, or a cancer of the pancreas. Sometimes a movable kidney endangers life, rupture of the kidney or twisting or rupture of the ureter occurring, the ultimate cause of death being albuminuria, uraemia, or hydronephrosis. Treatment.—Mobile kidney is treated as follows: (i) The rest-treatment of Weir Mitchell may be tried; it often markedly mitigates the symptoms, but does not seem to cure. (2) Bandage and pad should always be tried, using the pad of Dunning or Newman: this will cure not a few cases. Edebohls uses only a bandage of elastic webbing or a well- fitting corset. (3) Nephrorrhaphy is the proper procedure in most instances (p. 711). (4) Nephrectomy in rare cases is necessary; it may be done for dislocated kidney, when kidney disease exists, or when nephrorrhaphy has failed in a case of severity. Injuries of the Kidney.—Laceration or rupture is caused by falls and by bldws upon the back and the belly. The blood may or may not extravasate into surrounding structures. The symptoms are—pain in the loin, shooting into the testicle or the thigh ; frequent and painful passage of bloody urine or suppression of urine; the loin is full and is dull on percussion, and collapse or evidences of internal hemorrhage exist. Bloody urine is not proof of renal injury, and kidney damage may occur without haematuria. Treatment.—If the shock is profound with increasing ful- DISEASES OF THE GENITOAJRINARY ORGANS. 703 ness of the loin, whether haematuria exists or not, or if blood comes profusely from the urethra, make an exploratory lumbar incision and, if necessary, remove the organ. Ordi- narily the cases are treated by rest in bed and by feeding with liquid food or by nutritive enemata to prevent vomiting. Ergot, opium, or gallic acid may be used. Apply ice-bags to the loin and the side of the abdomen, and after bleeding ceases strap the loin and apply a binder. If large blood-clots cause pain or retention, introduce a catheter and inject the bladder with boracic acid, or use the tube and evacuator of a Bigelow apparatus. If this procedure fails, open the bladder. Perforating wounds of the kidneys, if posterior, do not involve the peritoneum ; if anterior, they do. The symptoms are—escape of blood and urine by the wound ; haematuria is usual, but not invariable; pain as in rupture; the patient may be unable to micturate; and nausea, vomiting, and con- stitutional signs of hemorrhage exist. Traumatic peritonitis, perinephric abscess, or general sepsis may ensue. Confirm the diagnosis by exploration with the finger. Extraperi- toneal injuries give a good, and intraperitoneal a bad, prognosis. Treatment.—If the wound in perforated kidney is extra- peritoneal, enlarge it to permit of drainage, and arrest hem- orrhage by packing and hot water. Asepticize the wound, insert a drainage-tube down to the kidney, dress often with bichloride gauze, keep the patient in bed on a low diet, and give ergot and opium. In intraperitoneal wounds, perform an abdominal section and remove the damaged organ (see Nephrectomy). Renal Calculus.—A stone in the kidney is formed by the precipitation of urinary salts into the renal epithelial cells and the gluing together of these salts and cells by material from mucus or blood-clot, this mass serving as a nucleus on which accretion takes place. Most calculi escape when 704 A MANUAL OF SURGERY. small as gravel. The cause is a highly acid urine which induces catarrh of the renal tubes. This high concentration of urine is favored by a sedentary life, by the ingestion of much alcohol or nitrogenous food, by constipation, by an inactive skin, and by a torpid liver. The children of poverty are liable to calculi because of the use of unsuitable foods and the formation of great amounts of nitrogenous waste. Males more often suffer than do females, certain locations favor the development of the malady, and a family liability sometimes exists. Symptoms.—The symptoms of stone in the kidney may not appear for years, but usually they are manifested early. Nephritic colic is due to the washing of a calculus into the orifice of the ureter, which it blocks, tears, or distends. The pain is either sudden or gradual in onset, is fearful in intensity, and runs from the lumbar region down the corresponding thigh and spermatic cord (the testicle being retracted) and into the abdomen and shoulder-blade. There are nausea, vomiting, collapse, sometimes unconsciousness or convul- sions. Frequent attempts at making water are productive of pain, but of little urine. The urine is usually, but not always, smoky from blood. After a time the pain vanishes, the stone having passed into the bladder or having fallen back into the pelvis of the kidney. A calculus retained in the kidney eventually excites pyelitis. There is pus in the urine, and soreness or pain in the loin exists. Attacks of colic occur from the passage of small stones or of plugs of mucus. Entire obstruction of the ureter induces hydro- nephrosis or pyonephrosis. Nephrolithiasis may cause death by exhaustion, by sepsis, by rupture of a hydronephrosis, or by amyloid degeneration. Treatment.—In the gravel of uric-acid diathesis, use alkalies, especially the liquor potassii citratis, and reduce the amount of nitrogen in the diet to a minimum, at the DISEASES OF THE GENITO-URINARY ORGANS. 705 same time washing out the organs by copious draughts of Poland water or Londonderry lithia. Piperazine, in doses of grs. v to grs. viij three times a day, is highly commended. Exercise is to be insisted on. When gravel is phosphatic, order strychnine, the mineral acids, and rest at the sea- side. When oxalate of lime is found, restrict diet, use the mineral acids, recommend travel or rest amid new sur- roundings, and give an occasional course of sodii phos- phas, 3ss three times a day, drunk in Buffalo lithia water. Nephritic colic is relieved by hypodermatic injection of morphia and atropia, the hot bath, diluent drinks, or the inhalation of ether. After the attack wash out the bladder with an evacuator. If a stone impacts in the ureter, perform * the operation of ureterolithotomy. The diagnosis of this impaction is often possible only by exploratory laparotomy. If the symptoms point to stone in the kidney, medical treat- ment having been used without avail, and there being no evi- dence of organic disease of the other kidney, make an ex- ploratory lumbar incision; feel the surface of the kidney with the finger, sound the inside of the organ with a needle, and if a stone is detected remove it (see Nephrolithotomy, p. 709). Dr. Keen is of the opinion that operation should not be performed if the urea is below I per cent. If, after nephrolithotomy, suppression of urine occurs, cut into the other kidney, as in half of all cases a stone will be found lodged there. Abscess of the kidney is caused by traumatism, by calcu- lus, by stricture of the urethra, by disease of the bladder, by the union of miliary abscesses, or by pyaemia. The symptoms are pus in the urine (this is usual, but not invariable), haema- turia in traumatic cases, and pain running into the groin. Constitutional symptoms of suppuration exist. The treat- ment in the early stage is rest, morphia, purgation, ano- dynes, and ice-bags to the loin, followed in forty-eight hours 45 706 A MANUAL OF SURGERY. by hot fomentations. When the diagnosis is clear, incise the loin, open and stitch the kidney to the abdominal wall, or, if the organ be badly damaged, remove it. Pyelitis and pyelonephritis, which affect usually only one gland, are caused by urethral stricture, by stopping of the ureter by blood-clot, by vesical paralysis, by stone in the bladder or in the kidney, and by enlargement of the prostate gland. Symptoms.—A patient who has, or who has had, retention of urine develops high fever often preceded by a chill; headache, stupor, and dry tongue are noted. Unlike acute Bright's disease, there is neither cedema nor dry skin, con- vulsions do not occur, and the urine is plentiful and contains pus and, but rarely, blood. The prognosis is very bad. The treatment is to remove the obstruction if possible. If the urine be acid, give liquor potassii citratis; if alkaline, give benzoic-acid. Gallic acid, eucalyptol, and small doses of copa- iba or cubebs are recommended. Quinine is used to stimulate the patient and to lower fever. The bladder is to be washed out every day with boracic-acid solution (gr. iij to §j). Cups, dry or moist, and hot sand-bags or bran-bags are to be applied to the loin. Alcohol may be sparingly administered. Perinephritis.—The symptoms of this condition are rigidity of the spine, the inclination being toward the affected side, flexion of the foot, and often pain in the knee. The symp- toms resemble those of hip-joint disease in the second stage. Suppuration may or may not take place. The treatment is wet cups to the loin, ice-bags to the loin, rest, purgation by salines, morphia for pain, and, after the acute stage, potas- sium iodide internally and ichthyol locally. Perinephric Abscesses.—Primary abscess is caused by chills, traumatism, acute febrile disturbances, or by pus flow- ing from some other part, as the spine. Consecutive abscess is secondary to kidney inflammation, suppuration, calculus, DISEASES OF THE GENITOAJRINARY ORGANS. 707 tuberculosis, or cyst. In the consecutive form the symp- toms may be masked by the malady to which perinephric abscess is secondary. As a rule, in perinephric abscess there are found the constitutional symptoms of suppuration. The local symptoms are a deep aching and paroxysmal pain intensified by lumbar pressure. CEdema of the correspond- ing foot and lameness are not unusual. CEdema of the skin is usual, but fluctuation is rare. The exploratory incision will settle a doubtful diagnosis. The treatment is to lay open the abscess, wash it out, and drain. Hydronephrosis is a condition of the kidney in which* an impediment to the outflow of urine is caused by obstruction in the ureter, the bladder, or the urethra, the calyces of the kidney becoming over-distended with urine and the glandu- lar tissue being absorbed by pressure. This condition may be congenital, and is due usually to twisting of the ureter or to imperforate meatus, both kidneys being involved. The causes of the acquired form are the pressure of pelvic growths or pregnancy, inflammation or tumor of the blad- der, stone in the bladder, kidney, or ureter, twisting of the ureter of a movable kidney, enlargement of the prostate gland, and stricture of the urethra. This acquired hydro- nephrosis may involve both kidneys, all of one kidney, or only a part of a single gland. Symptoms and Treatment.—Hydronephrosis is most fre- quent in females. When tumor is absent there may be no symptoms, or there may be pain in the back and abdomen, frequent micturition, a persistent or intermittent diminution in urine, or even occasional anuria. A tumor may be found in the loin, which growth is dull on percussion and may come and go, a large urinary flow being noted when it dis- appears. Hydronephrosis may last a long while if only one kidney be involved, but death is not far distant if both glands suffer. Death occurs from anaemia, from pressure on 708 A MANUAL OF SURGERY. adjacent organs, or from rupture into the peritoneal cavity. Treatment by aspiration may cure, but the operation may have to be done repeatedly. Tapping on the left side is performed just below the last intercostal space ; on the right side the tap is made midway between the last rib and the crest of the ilium. If repeated aspirations fail, perform a nephrotomy, stitching the edges of the cut kidney to the surface and irrigating. If a permanent suppurating fistula ensues or if the organ is found extensively damaged, neph- rectomy is to be performed, provided the other kidney is in reasonably good condition. Pyonephrosis, or surgical kidney, is a condition in which the pelvis and the calyces of the kidney are distended with pus or with pus and urine. The whole kidney may be de- stroyed. This condition has the same causes as has hydro- nephrosis, for it is in reality usually an infected hydrone- phrosis. In some cases the inaugural malady is pyelitis which causes blocking of a ureter. Symptoms and Treatment.—At first the symptoms are those due to the obstructing cause, plus pyelitis. Pus may appear in the urine in incomplete obstruction, or it may in- termittently come and go. Constitutional symptoms of sup- puration are soon manifest. A tumor may appear in the loin, like the tumor of hydronephrosis. If only one kidney be involved, and if the disease is due to blocking of a ureter, recovery is to be expected. The treatment in the early stages comprises removal, if possible, of the cause of ob- struction and the employment of measures directed to the cure of the pyelitis. If obstruction is not complete, pallia- tive measures may be employed for the tumor. If fever is continued, if there is great visceral derangement, if pain is severe and constant, and if the tumor continually grows, perform a nephrotomy, stitching the organ to the surface if possible, or removing it if it is hopelessly disorganized. DISEASES OF THE GENITO-URINARY ORGANS. 709 Operations on the Kidney.—Nephrotomy means incision of a kidney, but the term is also applied to the exploratory exposure of the kidney without incision. The instruments required are scalpels, a blunt-pointed bistoury, dissecting- forceps, toothed forceps, a grooved director, haemostatic forceps, spatulae, metal retractors, a fountain syringe, an Allis dissector, Hagedorn needles, and an Abbe needle- holder. If looking for a stone, have a large hare-lip pin to sound with, forceps and a scoop to remove the stone, and a periosteum-elevator to scrape away adherent calculi. The patient lies upon the sound side, a sand pillow being placed under the loin. The incision is made half an inch below the last rib and close to the outer border of the erector spinae mass, and runs obliquely downward and forward toward the iliac crest for three inches, the incision being enlarged later if required. Divide the skin, the superficial fascia, the fat, the external oblique, the posterior border of the external oblique, and the outer edge of the latissimus dorsi. This incision ex- poses the lumbar fascia. Push aside the last dorsal nerve and incise the lumbar fascia, when the perirenal fat will bulge into the wound. Two distinct layers of fat exist. Tear this fat through with dissecting-forceps or with an Allis dissector to expose the kidney, which can now be opened while it is forced into the wound by the hand of an assistant making abdominal pressure. Nephrolithotomy.—In this operation the incision is the same as in nephrotomy. Feel the kidney for a stone, or, if this procedure fails, explore with a needle or a pin. Morris suggests that first the organ be well drawn out. If no stone be found, open the pelvis and explore with the finger. If a stone be detected, open the kidney-tissue, loosen the calculus with the nail, and remove it with the finger, with a scoop, or with forceps. After removing the stone, stop renal hemorrhage by pressure and hot water, or in some cases 710 A MANUAL OF SURGER Y. plug with iodoform gauze for twenty-four hours. When hemorrhage ceases put a large drainage-tube down to the kidney. Close the wound in the muscles and integument, and dress antiseptically. The dressings must be changed frequently and the tube should be shortened daily. Nephrectomy is the removal of a kidney. The mortality for cancer is io per cent, for tubercle 36 per cent. There are two methods of nephrectomy, the lumbar and the ab- dominal. Lumbar Nephrectomy.—The instruments required for this operation are scalpels, a blunt-pointed bistoury, forceps as used in the preceding operation, a clamp, retractors, spatulae, blunt hooks, an aneurysm-needle, a pedicle-needle, a grooved director, stout silk, an Allis dissector, sharp spoons, and a Pacquelin cautery. The position of the patient and the incision are the same as those for the pre- ceding operation. When the kidney is exposed the incision, if necessary, may be enlarged in its existing directions, or, as Morris advises, it may be enlarged by cutting with a blunt bistoury a vertical incision from a point one inch in front of the posterior extremity of the first cut downward and from within outward. Lift the kidney, and separate it, if possible, with the finger; clamp the pedicle; pass an armed aneurysm- needle between the vessels of the pedicle; ligate in two places; cut between the threads; and arrest hemorrhage by ligature or by the cautery. If the ureter be healthy, drop it back; if it be foul and purulent, scrape it with a spoon, wash it with corrosive sublimate, and touch it with pure carbolic acid, and then either drop it back or sew it into the wound. If hemorrhage persists from the wound, plug. Put in a drainage-tube and close the wound. If the peritoneum be accidentally opened, close it with Lembert's suture. Abdominal nephrectomy is more dangerous than the lumbar operation. The same instruments are required as DISEASES OF THE GENITOAJRINARY ORGANS. 71I are used in the preceding operation. The position is supine. The incision is that of Langenbeck—four inches long in the linea semilunaris, its centre corresponding to the umbilicus. Open the abdomen, introduce a hand, feel the kidneys, and if both show serious disease do not perform nephrectomy. Keep the small intestines away by sponges, push the colon toward the umbilicus, incise the outer layer of the meso- colon, and bare the kidney. Strip off the peritoneum from the kidney and its vessels, and ligate the vessels by pass- ing strong silk through the centre of the pedicle with an aneurysm-needle. Ligate the ureter if healthy, and cut. If the ureter is septic, fasten it to an opening made in the loin by cutting on to forceps pushed to the outer edge of the quadratus lumborum. Stop bleeding, irrigate the belly- cavity, and dress as usual, employing drainage only when septic matter has gotten into the peritoneal cavity or when oozing is persistent. Nephrorrhaphy is fixation of a mobile kidney. The kid- ney is exposed in the loin as above detailed, and is forced into the wound by abdominal pressure. Insert sutures of chromicized gut, kangaroo tendon, or silkworm gut, by means of curved Hagedorn needles, through the renal sub- stance, and thus fix the organ to the lumbar fascia. Use drainage-tubes until inflammation appears. The mortality is about 3 per cent. Retention of Urine.—By this term is meant an inability to empty the bladder. The retention may be complete, not a drop emerging, or it may have been complete, a dribbling setting in after a time, due to paralysis of the bladder, which cannot, contain more fluid, expulsion of the overflow from the ureters being produced by atmospheric pressure. This con- dition is known as the engorgement, the overflow, or the in- continence of retention. There may be a partial retention from enlarged prostate, a portion only of the urine being 712 A MANUAL OF SURGERY. voided. Retention may be caused by—(i) obstruction, result- ing from urethral stricture, enlarged prostate, inflamed pros- tate, occluded meatus, impacted calculus, urethral tumors, complete phimosis, fecal impaction, and pressure from gravid tumors, or by (2) defective expulsion, resulting from paralysis, disease or injury, atony, reflex inhibition, shock, muscular weakness of fevers, and the action of drugs such as bella- donna, opium, or cantharides. Symptoms.—In acute retention there is an agony of desire to urinate, the patient making acutely painful straining efforts during which feces are often passed. There are severe pain and aching in the abdomen, thighs, .perineum, and penis. All the symptoms rapidly increase, a typhoid state is inaug- urated, and death closes the drama unless relief be given. If retention is from time to time alleviated by the passage of a little water, the symptoms are slower in evolution and are less intense, and the case is said to be chronic. Some cases of gradual onset, due to atony, are very insidious, the patient feeling no particular pain, and complaining only of the dribbling, which is really the overflow of retention, and is not a sign that the bladder is successfully emptying itself. In any case of retention the bladder rises above the pubes, and there is found a pyriform, elastic, fluctuating tumor (dull on percussion) in the hypogastrium, which tumor enlarges until the bladder is evacuated or incontinence sets in. The flanks of the patient give a clear percussion note, and the tumor is more prominent when he is erect than when recum- bent. Long continuation of obstructive disease, producing partial retention with or without attacks of complete reten- tion, disorganizes the kidneys. Acute and complete retention may induce rupture of the urethra or urinary suppression. Treatment.—In organic stricture try to pass a soft catheter ; if this fails, a hard catheter; if this fails, a filiform bougie; but if the stricture is known to be organic from previous DISEASES OF THE GENITO-URINARY ORGANS. 713 history, at once insert a filiform bougie, leave it in place, and fasten it. The filiform bougie will act as a capillary drain, and in a few hours will empty the bladder. Then insert another bougie beside the first, and so on for several days, using also opium, ordering rest in bed, and making no attempt to dilate the stricture forcibly until retention is passed and inflammation has subsided. If no bougie can be passed, aspirate or perform cystotomy (suprapubic or peri- neal). In spasmodic stricture hold a good-sized metal catheter firmly against the face of the spasmed area: relaxation will occur and the instrument will eventually pass. In inflam- mations give a hot hip-bath and suppositories of opium and belladonna, and then use a hot sand-bag to the perineum • and hot poultices to the hypogastrium. If these fail or if the symptoms are urgent, pass a soft catheter. In the oc- cluded meatus of the new-born incise with a tenotome. In a congenital cyst of the sinus pocularis pass a steel bougie, which will rupture the cyst. In complete phimosis split up the prepuce. In impacted stone try to pull it out with ure- thral forceps ; if this fails, push it in or cut. In fecal impac- tion scrape out with a spoon. In enlarged prostate insert a Coude catheter strengthened by the insertion of a filiform bougie nearly to the beak (Brinton), or pass a silver instru- ment with a large curve. In retention from expulsive defect use a soft catheter. Cases of retention require warmth, con- finement to bed, the administration of laxatives, free action of the skin, and the use of such drugs as salol, boracic acid, and quinine to asepticize the urine. In some few cases no instru- ment can be inserted in the bladder. In most of such cases aspirate—which may be done several times if necessary— and in a day or two, when swelling and congestion abate, an instrument can be passed. A small trocar or an aspirator- • needle is pushed into the bladder, the trocar or needle being inserted in the median line, just above the pubes, and taking 714 A MANUAL OF SURGERY. a course downward and backward. The parts are first pre- pared antiseptically, and the puncture is dressed with iodo- form and collodion. Rectal puncture is now obsolete. The perineal incision is not advocated for retention unless rupture of the urethra has taken place. When a catheter is used for retention the patient must be recumbent to minimize shock. Withdraw only half the urine retained, as complete emptying of an over-distended bladder, by suddenly relieving pressure, renders the sufferer liable to venous rupture and to severe hemorrhage. The same rule maintains in tapping. Injuries of the Bladder.—This viscus is so deeply situ- ated, and the abdominal walls are so elastic, that it is rarely injured when empty. If the bladder be full and the abdomen be tense—which is common in alcoholic intoxication—force applied upon the abdomen may contuse the bladder. Contusion of the Bladder.—In this condition there are noted vesical haematuria, tenesmus, an impediment to the flow of water because of clots, and severe cystitis. Hemor- rhage may be very severe, and sepsis may arise, even causing death. When contusion exists retention is relieved by a clean soft catheter; if this fails because of occlusion of the eye of the catheter with blood-clot, there must, from time to time, be forced through the catheter by an irrigator a solu- tion of sodium bicarbonate in cooled boiled water. Gross's blood catheter can be used, or the evacuator of Bigelow may be employed. The patient is put to bed, a hot-water bag is applied to the hypogastrium, morphia is administered in moderate doses, the bladder is washed out several times a day with boracic-acid solution to disintegrate and remove blood-clots, and the urine is diluted and rendered aseptic by the stomach administration of salol, boracic acid, and liquor potassii citratis. Hemorrhage usually ceases on relieving distention; if it does not, some more radical measure must be employed (see Hematuria). DISEASES OF THE GENITO-URINARY ORGANS. 715 Besides contusions, the bladder may be injured by bullets; by stabs or punctures through the abdomen, the vagina, or the uterus; or by penetration by a fragment of a fractured pelvic bone. The symptoms of such conditions are those of rupture of the bladder (q. v.). In any intraperitoneal wound, at once open the abdomen, suture the wound in the bladder-wall, irrigate the peritoneal cavity, and drain the bladder by means of a retained catheter, a perineal section, or a suprapubic cystotomy. In an extraperitoneal wound, drain the wound by a tube, and drain the bladder by a re- tained catheter, a perineal section, or a suprapubic opening. Rupture of the bladder occurs in three forms : (1) intra- peritoneal—a rupture involving the peritoneal coat; (2) ex- traperitoneal—a rupture of a portion of the bladder not covered by peritoneum; and (3) subperitoneal—a rupture of the mucous and muscular coats, the urine diffusing under the peritoneal investment. The causes are of two kinds, predisposing and exciting. Predisposing causes are— distention of bladder; drunkenness ; ulceration ; degenera- tion or atony of the bladder-coats. Exciting causes are— obstruction to outflow of urine (by stricture or enlarged prostate); external violence; falls upon the feet and the buttocks, as well as upon the abdomen; lifting; straining at stool, in micturition, or during parturition ; and the forcing of injections into the bladder. This accident is commoner in men than in women (10 to 1), and is rare in children. Symptoms, Diagnosis, and Treatment.—The symptoms are not always definite, and every characteristic one may be for a time absent, the patient seeming in some rare instances to possess the power of retaining his urine and of voiding it. As a rule, however, there are found some or all of the follow- ing symptoms, following an accident or occurring during the progress of a causative disease: collapse; excessive desire to urinate; inability to do so; a catheter, when used, brings 716 A MANUAL OF SURGERY. away pure blood or a very little bloody urine; the catheter occasionally slips through the tear into a cavity, and more bloody water comes away; severe hypogastric pain comes on after a temporary sense of relief from retention; shock is so severe that death may ensue; if reaction follows, there is delirium, often septicaemia and peritonitis; extensive infil- trations of urine may occur. In intraperitoneal rupture gen- eral peritonitis is certain to arise, but its appearance may be postponed for several days if the urine is healthy. In these cases the extravasation is noted as a simple swelling, probably on one side only. In extraperitoneal rupture the urine may infiltrate the perineum, the scrotum, the thighs, and under the integuments of the abdomen and the back, and may soon induce sloughing. In subperitoneal rupture peritonitis is apt to arise. Injecting fluid fails to lift up the bladder into the hypogastric region so as to be recognizable on percussion. If there is injected a measured amount of fluid, less will run out than went in. In all doubtful cases take a Davidson syringe, tie a piece of cotton over its outer end, fasten its other end to a soft catheter which is inserted into the bladder, and pump in air filtered to prevent infection: an unruptured bladder will rise above the pubes as a pyriform tumor, tympanitic on percus- sion ; a ruptured bladder will not so rise. In intraperitoneal rupture the general peritoneal cavity will be distended with the air. In extraperitoneal rupture injection produces emphy- sema of the extravesical connective tissues. On removing the syringe the air rushes out again if the bladder is unrup- tured, but little if any comes away if it is ruptured. Senn recommends injecting hydrogen gas instead of air. The treatment is the same as that for wounds of the bladder. Atony of the bladder is a condition in which the expul- sive power of the bladder is diminished or lost because of impairment of muscular tone. The bladder is very thin, DISEASES OF THE GENITOAJRINARY ORGANS. 717 and the muscles ace flaccid and often the seat of fatty degen- eration. Sometimes the bladder is very large and sometimes it is very small. A slight degree of atony is physiological after middle age. The causes are senility, distention from true paralysis, chronic over-distention from obstruction, and acute over-distention. Symptoms and Treatjnent.—In atony of the bladder the patient passes water frequently (a symptom probably exist- ing for some years), and especially at night; he may even do so while asleep. The stream, when voluntarily passed, has no projection, but drops at once from the end of the penis. Retention is apt to occur with incontinence, and residual urine exists for years, and may at any time set up cystitis. This condition is not vesical paralysis resulting from a lesion of the nervous system. In treating atony of the bladder, measure the residual urine : if it amounts to four ounces, use a soft catheter night and morning; if it amounts to six ounces, use the catheter every eight hours; if it amounts to eight ounces, use the catheter every six hours (J. W. White). The patient should be taught how to use the catheter. After using it, it is washed with soap and water, a stream of water is run through it, it is soaked in a I : IOOO solution of corrosive sublimate, is kept until again wanted in a I : 40 carbolic solu- tion, and when again needed is anointed with glycerin. The bladder is from time to time washed out with gr. iij to the ounce of boracic-acid solution at a temperature of ioo° F. Strychnine, electricity, ergot, and cantharides maybe ordered. Vesical Calculus, or Stone in the Bladder.—The salts normally in solution in the urine may deposit as calculi and may be imprisoned in any portion of the urinary tract. The commonest calculi are those composed of uric acid, urates, calcium oxalate, and fusible phosphates. The formation of uric-acid and urate calculi is explained under Renal Calcu- lus (p. 703). Vesical calculi are usually renal calculi that 7i8 A MANUAL OF SURGERY. • have passed the ureter and become enlarged by new accre- tions. Phosphatic calculi may be formed in the bladder when chronic cystitis causes and maintains an alkaline urine. Uric-acid calculi are smooth, round or oval, and hard, but easily broken. On section they present the color of brick-dust and are marked by concentric rings. Their nu- clei are dark by comparison. They are soluble in dilute potassium hydrate, and with effervescence in nitric acid. They are combustible, and leave scarcely any ash. Urate of sodium and urate of ammonium often occur together in stones, and these calculi are not in rings, are not so hard as the uric-acid stones, and are fawn-colored on section. Oxalate-of-lime stones are round with many projecting nodes like the mulberry, hence the term " mulberry calculus." They are very hard, and section shows the color to be brown or green, and that they possess wavy concentric rings. This form of calculus is soluble in hydrochloric acid. Fusible calculus, which is composed of magnesic ammonic phos- phate with phosphate of lime, constitutes the commonest form of phosphatic stones and of large stones. It is light, soft, smooth, and white, and shows no laminae on section. Some rare forms of stone are composed of xanthic oxide, cystic oxide, calcium phosphate or carbonate, and magnesic ammonic phosphate (triple phosphate). A stone may be formed having layers of different sub- tances; for instance, there is often found a uric-acid nucleus surrounded by phosphates, the latter surrounded by uric acid or urates, and these again by phosphates. In some cases oxalate of lime alternates with uric acid, urates, or phosphates (Bowlby). Bowlby states that the alternating uric-acid and phosphatic layers are due to the altering reac- tions of the urine; that when the urine is acid, uric acid is deposited on the stone, but when cystitis makes the urine alkaline the stone receives a phosphatic coat. DISEASES OF THE GENITOAJRINARY ORGANS. 719 Anything that favors the formation of an excessive uri- nary deposit may cause vesical calculus, such as defective digestion, failure in processes of oxidation, excess of solids and nitrogenous elements in the diet, deficient exercise, etc. If to the urinary condition established by the above condi- tions a catarrh of the genito-urinary tract occurs, pus or muco-pus in concentrated urine may induce stone. Children are predisposed to uric-acid stones, and old people to phos- phatic stones. In an old man with enlarged prostate and chronic cystitis a stone forms easily about any accidental nucleus. The nucleus may be some phosphate-crystals glued up by mucus, may be a blood-clot, some uric-acid gravel, or some foreign body. Stone is rare in females, y because of the shortness, the large diameter, and the ready dilatability of the urethra. Stone is very rare in the negro. Gout, rheumatism, lithaemia, enlarged prostate, vesical atony, urethral stricture, and catarrhal inflammation of the kidney, the ureter, and the bladder, are predisposing causes. Symptoms.—In not a few cases the vesical symptoms are antedated by an attack of nephritic colic. The severity of the symptoms depends more on the .roughness of the stone than on its size. Small rough calculus will produce intoler- able anguish, whereas several large smooth stones will cause but moderate pain. A patient with stone in the bladder complains of frequency of micturition, particularly in the day-time, the desire being sudden, uncontrollable, and invoked or aggravated by exercise. This symptom is more positive in youth than in old age. Pain of a sharp, burning charac- ter is experienced at the end of micturition, due to the con- traction of the empty bladder upon the stone. The usual seat of this pain is the under surface of the head of the penis, a little behind the meatus, and the pain may continue for some time. By pulling on the penis to relieve this pain the prepuce often becomes pendulous. This pain varies in 720 A MANUAL OF SURGERY. % severity, being worse during cystitis and after exercise; it may be absent in encysted stone, it may even almost disap- pear, and it is always worse in the young than in the old. Stone in chronic cases of atony and in cases of vesical paralysis causes neither marked pain nor frequency of micturition.1 Attacks of cystitis in a man with calculus are spoken of as attacks of stone. When a stone is small it may during micturition roll into the urethral orifice, and so cause a sudden interruption of the flow of water, the stream again starting when the patient changes his position. This symptom is rare in the old, the stone in them dropping into the sac back of the prostate and below the urethral orifice. Haematuria may or may not be noted ; it is most usual after exercise, and is noted at the end of the urinary act. Pus or muco-pus will be noted if cystitis occurs. Priapism occurs in some cases. Pain of a reflex nature may be felt in the rectum, in the perineum, or in some distant part. The above symptoms, even if all are present, do not prove the individual to have a stone in the bladder. To prove the presence of a stone, it must be touched with a sound and the contact must be felt and heard. To sound a patient, have the bladder well filled with water, and place him recumbent with the knees drawn up. Never sound a person while he is standing, because of the danger of syncope. In an ordi- nary case use a sound with a very slight curve; in a man with hypertrophied prostate use a sound with a short and decided curve. The calibre of a stone-sound is a No. 13 French. Examine the entire bladder systematically, and never operate unless a stone be both heard and felt. The stone may be hard to find, or it may elude the instrument entirely when it is encysted, when it rests in a diverticulum, when it is fixed to the roof or anterior wall of the viscus, or when it is crusted with lymph or blood-clot. In doubtful 1 American Text-Book of Surgery. DISEASES OF THE GENITO-URINARY ORGANS. J21 cases always insist on a second examination, giving ether if the first was very painful. Occasionally a small stone will be found by using a Bigelow evacuator, the current causing the calculus to knock against the tube. A stone, when it is detected, should always be measured by an arrangement like a lithotrite. The composition of the stone is assumed from an examination of fragments which pass by the urethra or which adhere to the measure. Remember that the outer rind of a calculus may be soft phosphate and the inner por- tion may be hard uric acid, urates, or oxalates. Examine for stone in females with a straight sound, and in cases of uncertainty dilate the urethra and explore the bladder with the little finger. Treatment.—In people predisposed to stone (for instance, by lithaemia) the surgeon should foresee the danger and essay to antagonize it. Insist on the urine being kept dilute by the freest use of water and of milk, and reduce to a minimum alcohol, meat, sugar, and fat. Let the patient live on green vegetables, salads, bread, fruit, eggs, fish, poultry, weak tea or coffee, water, milk, and, if desired, a little red wine. Con- tinued purging does harm by concentrating the urine, though • a laxative may be employed when indicated. Moderate open-air exercise is of immense importance, sunshine and fresh air being Nature's correctives for a condition of imper- fect oxidation power. If the urine be very acid, use piper- azine, grs. xv to grs. xxiv daily, liquor potassii citratis, phos- phate of sodium, or borocitrate of magnesium. If the urine be phosphatic, order mineral acids and strychnine. If the urine , be filled with oxalate, use the mineral acids with an occasional course of phosphate of sodium. Travel and rest at the sea- side or at some spa are often of service in all forms. Always endeavor to prevent cystitis, and treat it at once when it does occur. When a stone is once formed, it is an idle dream to think of dissolving it. An operation must be done. The 46 722 A MANUAL OF SURGERY. operation selected depends upon the age, the state of the bladder and the prostate, the dilatability of the urethra, the kidney condition, and the size and composition of the stone (see Operations on the Bladder). Cystitis.—Inflammation of the bladder is, as a rule, a . complication of some other disease of the genito-urinary tract, but it can arise from cold and wet. Traumatism from a catheter, the presence of a stone, the spread of a urethral inflammation, pus infection, the existence of tuberculosis or cancer, and the use of such a drug as cantharides, can pro- duce it. It appears not unusually during an exanthematous fever or in conditions of vesical paralysis; it often follows retention, frequently accompanies enlarged prostate and # urethral stricture, and sometimes arises from concentration of urine or accompanies growths. Acute cystitis causes discoloration and swelling of the bladder-walls, and there is present a catarrhal discharge which is mixed with urinary elements, serum, mucus, often pus and epithelial debris. Ul- ceration, sloughing, or false-membrane formation may occur. In chronic cystitis there is an enormous production of thick, sticky mucus and the urine becomes alkaline. The exces- sive secretion of mucus and the great number of bacteria con- * vert the urea into carbonate of ammonia, and this production, being irritant to the bladder-walls, makes the inflammation worse. In chronic cystitis the bladder is contracted and has very thick walls, and the mucous membrane is thick, oedem- atous, congested, and filled with large veins. The bladder may be ulcerated or be encrusted with urinary salt. The urine contains triple phosphate, pus, blood, and mucus, the » blood emerging with the last drops of water. Symptoms of Acute Cystitis.—Great frequency of micturi- tion, with the passage at each act of very small quantities of ( urine; the desire to urinate is almost constant, and there is intensely painful straining (tenesmu.s). The pain is acute DISEASES OF THE GEAUTO-URINARY ORGANS. 723 and scalding, and may be felt above the pubes or in the perineum; the pain often runs into the loins and the thighs and radiates over the sacrum. Pain above the pubes indi- cates involvement of the fundus, and pain in the perineum and the head of the penis points to inflammation of the bladder-neck. The urine, at first clear, loses its transparency, becomes full of thick mucus, and often contains a little blood or pus. The patient not unusually has some fever. A rectal examination causes fearful pain. If ischuria takes place there will be a chill and high fever, and anaemia may appear or vesical rupture may ensue. Treatment.—In treating acute cystitis, try to remove the cause. If cystitis arises from the administration of canthar- ides, put the patient in bed and give him liquor potassii citratis. If it comes from the use of a clean sound, order rest in bed, suppositories of opium and belladonna, diluent drinks, and the use of ammonii benzoas or of lupulin. If the inflammation is septic (as from the use of a dirty sound) or is very acute, put the patient in bed, keep him warm, and use a hot sand-bag to the perineum and hot fomentations or poultices to the hypogastrium. Hot hip-baths may be used. The hips had best be elevated and the bowels be emptied by salines and glycerin enemata. An exclusive milk diet is desirable. The patient should drink copiously of sweetened water containing a few drops of aromatic sulphuric acid or of milk of almonds. An excellent remedy is the combina- tion of equal parts of the infusion of herba herniariae and chenopodium ambrosioides, three glassfuls, sweetened with sugar, being given every day (Von Zeissl). If the pain and straining still continue, order— R. Ext. sem. hyoscyamin., grs. viij; Ext. cannabis indicae, grs. viij; Sacchar. alba, grs. xlviij.—M. Div. in pulv. No. xx. Sig. One powder every three hours. (Von Zeissl.) 724 A MANUAL OF SURGERY. < Or, R. Camphora, Ext. cannabis indicae, Sacchar. alba, Div. in pulv. No. xx. Sig. One powder every three hours Suppositories of extract of belladonna are of great value. If these remedies fail, the surgeon will be driven to opium, which, unfortunately constipates; when it is used, secure evacuations by glycerin suppositories or by enemata. Give a suppository containing gr. j of powdered opium and gr. \ of the extract of belladonna every three or four hours. Hypodermatic injections of morphia may be required. If retention occurs, use a soft catheter. If much blood is passed, give internally the tinctura ferri chloridi and blister the perineum. A very acute cystitis is rarely arrested within a week or ten days. Symptoms of Chronic Cystitis.—This condition may be a legacy from acute cystitis, or it may appear without any acute precursory phenomena. There will be found frequency of micturition, but not so great as in the acute form; there will be slight tenesmus, and moderate pain from time to time, running toward the head of the penis. Constitutional symp- toms arise only when kidney-damage has become pronounced or sepsis has occurred from absorption. The urine is ammo- niacal, fetid, and turbid; it is filled with viscid, tenacious mucus or with muco-pus; it contains a great excess of phosphates, and occasionally clots of blood. This condition of chronic cystitis with the production of immense quanti- ties of thick mucus is often called " chronic catarrh of the bladder." This state of the bladder may eventuate in the formation of stone or in the production of serious diseases of the bladder, the ureters, and the kidneys. It often occa- sions retention. grs. viij; grs. viij; grs. xl viij.—M. (Von Zeissl.) DISEASES OF THE GENITO-URINARY ORGANS. 725 Treatment.—In treating chronic cystitis, remove the cause if possible, get rid of a stone, frequently evacuate residual urine, dilate a stricture, and remove a tumor. For chronic cystitis there are used certain remedies by the mouth. Water is drunk in large amounts, also iron spring-water (Marienbad, etc.). Salol and boracic acid, gr. v of each four times a day, are very valuable. Salol in fluid extract of triticum repens does good; so does chlorate of potassium, gr. x daily. Astringents such as alum, tannic acid, and uvse-ursi leaves arrest mucus-formation. Copaiba, cubebs, buchu, uva ursi, and turpentine have all been recommended. Whatever remedy is used, see that the bladder is emptied of residual urine, using a soft instrument several times a day. Cham- pagne and beer must be avoided in chronic cystitis. If the above plan fails, irrigate the bladder daily with peroxide of hydrogen (25 to 40 per cent, solution), nitrate of silver (2 per cent.), boric acid (5 to 10 per cent.), carbolic acid (1 : 500), corrosive sublimate (from 1 : 5000 to 1 : 20,000), or permanganate of potassium (1 to 4 per cent). If silver or permanganate of potassium is used, first rinse out the blad- der with distilled water. If any other agent is used, first wash out the bladder with boiled water. Some surgeons occasionally use, at intervals of a number of days, strong silver solutions (30 or 40 grains to the ounce). If this solu- tion is used, after the drug runs out, wash out the bladder with a solution of common salt. The bladder is washed out by attaching to a soft catheter a tube which is connected with a graduated bottle, the force being obtained by elevating the reservoir (fountain irrigation). If these methods fail and the patient's health is breaking down, drain by perineal or suprapubic cystotomy (see Perineal Section, p. 736) and wash the bladder through the incision frequently and thoroughly. Tumors of the Bladder.—These tumors may be either innocent or malignant, the latter being the commonest. 726 A MANUAL OF SURGERY. Innocent tumors are papillomata or villous tumors, mucous polypi, and fibrous polypi; malignant tumors are sarcoma (rare) and carcinoma (encephaloid, rare, epithelioma, com- mon). Symptoms and Treatment.—The innocent tumors rarely % cause cystitis or irritation, though by obstructing the ureters or the urethra they may induce disease of the kidneys. Often hemorrhage is the only phenomenon produced by a papilloma or a mucous polyp. Malignant tumors cause cystitis, and the urine contains mucus, blood, and pus. Innocent tumors are hard to feel with the sound, but ma- lignant tumors are easily felt. The bleeding in bladder- growths is apt to be profuse, and it occurs intermittently. # Bleeding follows the use of a sound. The urine should be examined microscopically to see if it contains villi, portions of fibroma, colonies of cancer-cells, or fragments of epitheli- oma (White). The use of Leiter's cystoscope may aid the surgeon, but it is scarcely yet a perfected instrument. In doubtful cases exploratory suprapubic cystotomy is advisable. The treatment is by suprapubic cystotomy and removal of the growth. The perineal operation only enables the sur- geon to reach and remove growths of small size, peduncu- * lated growths, and growths near the neck of the bladder (see Operations on the Bladder). Operations on the Bladder: Lateral Lithotomy.—Lith- otomy is the removal of a stone from the bladder. Lateral lithotomy is an operation which is every year becoming less popular, but which is still employed by many famous sur- geons, especially for stone in children. This operation should • not be performed if the stone is over two inches in its short diameter; it is rarely justifiable if the stone weighs three ounces or over (Cage); and it must not be performed for en- t cysted stone, or on a person with a deep perineum, a narrow pelvic outlet, or an enlarged prostate. For one week before « DISEASES OF THE GENITO-URINARY ORGANS. 727 the operation keep the patient in bed, wash out the bladder daily with hot boracic-acid solution, and administer salol and boracic acid by the mouth, gr. v of each four times a day. The night before the operation, give a saline, order a hot bath, and have the perineum, the scrotum, the buttocks, and the inner sides of the thighs cleansed and dressed antisep- tically. In the morning an enema is to be given. At the time of operation the bladder should contain some ounces of urine. The instruments required are a lithotomy-knife, a straight probe-pointed bistoury, a grooved staff, a stone- sound, scoops and stone-forceps, a tenaculum, an aneurysm- needle, a fountain syringe, curved needles and a needle- holder, haemostatic forceps, a tube with chemise (Fig. 41), a Pacquelin cautery, a Clover crutch, and a lithotrite. In performing the operation, place the patient upon his back and find the stone by sounding. If the stone is not dis- covered by the sound, do not operate. Pull the buttocks over the end of the table, introduce the staff, flex the legs and thighs, and fasten the patient in the lithotomy position with a crutch. During the first incision the handle of the staff is held toward the belly; after the first cut the staff is set perpendicularly and is hooked up under the pubes. An in- cision is made, starting just to the left of the raphe and one and a quarter inches in front of the edge of the anus, and passing downward and outward to between the anus and the ischial tuberosity, but one-third nearer the former than the latter. In the adult this incision is three inches long. The first incision is superficial and does not reach the staff, but it is this incision which may cut the rectum. After making the first cut the nail of the left index finger feels for the groove of the staff, the staff is hooked up, the knife is entered into the groove and is pushed into the bladder, and as it is withdrawn the wound is enlarged. As the knife enters the bladder there is a gush of fluid. The finger 728 A MANUAL OF SURGERY. follows the knife and stretches the wound, the staff is with- drawn, and the stone is felt for and extracted. In with- drawing the stone, make traction in the axis of the pelvis, and do not rotate the calculus until it is entirely out of the prostatic urethra. Wash or scrape away debris or in- crustation, see that no other stone is present, syringe out the bladder with hot corrosive-sublimate solution (i : 5000), insert a tube, apply antiseptic dressings around the tube, and put on a T-bandage. The end of the tube which is external to the dressings is fastened to the tails of the T-bandage. A rubber cloth is put on the bed, under the body and legs, and the patient's buttocks rest upon a mass of old linen, the scrotum being raised on a pad. The knees are bent over pillows. Change the linen as soon as it becomes wet. Remove the tube in forty-eight hours. The urine begins to come by the urethra from the eighth to the twelfth day. In children the incision is not so long and is dilated with forceps instead of with the finger; no tube is required. In lateral lithotomy the prostatic and membranous urethra are opened, the prostate gland is partly divided with the knife, and the wound is dilated with the finger. Suprapubic Lithotomy.—This operation is the removal of a stone through an opening over the pubes. It is in many instances the preferable operation. It is used for the removal of multiple calculi, for very hard stones, for stones above one and a half inches in diameter, for calculi in men with enlargement of the prostate, for foreign bodies incrusted with sediment, when the perineum is deep, when the pelvic out- let is narrow, and when the urethra will not permit the use of a lithotrite. The patient is prepared as for lateral lithotomy, except that the pubes are shaved and the lower part of the abdomen and the upper part of the thighs are disinfected. During the operation the penis is covered with an antiseptic cloth. The instruments required are a scalpel, a probe- DLSEASES OF THE GENITO-URINARY ORGANS. 729 pointed bistoury, scissors, a tenaculum, blunt hooks, haemo- static forceps, retractors, dissecting-forceps, a dry dissector, an electric forehead-light, a rectal bag, a brass syringe, a sound, rubber tubing, rubber catheters, stone-forceps and scoops, a bladder-tube, curved needles and a needle-holder, and a graduated glass jar for injecting the bladder. In performing the operation, place the patient in the Tren- delenburg position (Fig. 146). Have an assistant oil the rectal bag and push it above the sphincters. Draw off the urine with a soft catheter, wash out the bladder with warm_ boracic-acid solution (1:32), and inject the bladder with the same solution. In a child under the age of five inject three to four ounces; in an adult inject ten to twelve ounces. Withdraw the catheter, and tie a tube around the penis to prevent the escape of fluid. Some surgeons simply inject air by means of a catheter and a brass syringe or a Davidson syringe. After injecting the bladder, if the viscus is not well lifted up, inject the rectal bag and clamp its tube with forceps. In a child inject from two to four ounces of warm water; in an adult inject ten ounces. Make a three-inch incision in the median line of the hypogastric region, terminating over the symphysis. When the peri- vesicular connective tissue is reached, cut it. If the peri- toneum should appear, push it up. Hold the wound- edges apart by retractors. The large veins are seen, giv- ing the bladder a blue color. Avoid these veins if pos- sible, but even if they should be cut bleeding will stop when the bladder is opened and the rectal bag is removed. Clamp bleeding vessels ; catch the bladder transversely with a tenaculum at the upper angle of the wound; open the viscus in the middle line above, and cut toward the pubes; catch the edges of the cut with haemostatic forceps, and remove the tenaculum. Explore the bladder, remove the stone or stones, scrape away incrustations, ligate bleeding 73O A MANUAL OF SURGERY. vessels outside the bladder, and irrigate the viscus with hot bichloride-of-mercury solution (i : 5000). Introduce a tube into the bladder, and attach to its external end a long tube to siphon off the urine. Suture the muscles and fascia at the upper part of the wound, but, as a rule, do not suture the bladder. Bladder-sutures rarely hold, and become in- crusted with urinary salts. Dress with dry antiseptic gauze and a rubber dam, the dressings and binder being split to go around the tube. Catch the urine which siphons over in a bottle containing some antiseptic fluid. Change the dress- ings as often as they become wet. Take out the tube in four or five days, and allow the wound to heal by granulation. Crushing of Vesical Calculi.—This is now done in one sitting, the old operation of Civiale, requiring repeated crush- ings, being obsolete. Litholapaxy (Bigelow's operation, or rapid lithotrity) is the operation for removing a stone in the bladder in one sit- ting by thoroughly crushing the stone and completely wash- ing away the fragments. Sir H. Thompson says this method is suited to twenty-nine cases out of thirty. Litholapaxy should be employed if the bladder will hold at least six ounces of fluid and is in a fairly healthy condition; if the urethra is tolerant and penetrable by instruments; if the stone is not too hard, does not weigh over two and three- quarter ounces, and is not over two inches in diameter. It is not suited for multiple calculi, for large and hard calculi, for encysted stones, or for a patient with enlarged prostate, with vesical atony, or with cystitis. An easily dilatable stric- ture need not prevent the surgeon from doing litholapaxy. The stricture can first be dilated, and later Bigelow's opera- tion can be performed, but firm, gristly strictures demand a cutting operation. If the urethra is intolerant of instrumen- tation, the patient being prone to febrile attacks when it is attempted, cut instead of crushing. People with kidney DISEASES OF THE GENITO-URINARY ORGANS. 731 disease will do better after this operation than after cutting (Cage). In diabetes, locomotor ataxia, and conditions of exhaustion patients are best treated by Bigelow's operation, unless cystitis exists. The preparation of the bladder is the same as for lithotomy. Be sure to measure the stone, and to ascertain also whether a lithotrite can readily be introduced and manipulated. The instruments required are a stone-sound, lithotrites (several sizes), an evacuating-bulb and tubes (straight and curved), soft catheters, a glass irrigator to inject the bladder, and instru- ments in case the surgeon is forced to cut. The patient is anaesthetized and is placed upon his back, a pillow is inserted under the pelvis, and he is well wrapped up. The urine is drawn and a measured amount of warm boracic acid is allowed to flow into the bladder. This plan is better than having the patient retain his urine, as in the latter case there is no certainty as to the amount of fluid in the viscus. It is well to introduce at least five or six ounces of fluid if pos- sible. If the bladder will not hold four ounces, the operation is unsafe (Thompson). The lithotrite is now introduced, the handle being gradually raised to a vertical position as the penis is drawn up on the shaft, but not being depressed until the instrument has passed by its own weight into the prostatic urethra. Thompson's plan for catching the stone is as follows : After introducing the lithotrite, let its lower end rest for a few seconds on the bottom of the bladder, so that currents will subside; then draw back the male blade, wait a second, close it again, and in almost every instance the stone is caught. If the stone is caught, press firmly to see that the calculus is well held, lock the instrument, and break the foreign body by screwing. When resistance suddenly ceases the stone has either slipped or has been crushed; if crushed the blades should have been felt forcing through the stone and the calculus should have been heard to break. When 732 A MANUAL OF SURGERY. resistance ceases catch and crush again as above directed. Rapid movements with the lithotrite are improper, as they establish currents which are apt to push away the stone. If the above manoeuvre does not catch the stone, see if the cal- culus be near the neck of the bladder. Pull the instrument % close to the vesical neck, and open it, not by pulling the male blade, but by pushing the female blade. If the operator still fails to catch the stone, or if, after crushing, a large frag- ment knocks against the evacuator, which fragment cannot pass, conduct a careful search: turn the blades to the right side, open, and close; then to the left side, open, and close ; next turn the point around behind the prostate, open, and close. In these side turns of the lithotrite, in order to crush, turn the instrument very slowly, so as to detect the catching of the bladder-wall if it has occurred, and crush the stone in the middle of the bladder with the blades up. After crush- ing several times, proceed to evacuate. Fill the aspirator with warm boiled water or with warm solution of carbolic acid (io m. to the pint). Insert an evacuating catheter, its point being in the centre of the bladder, let the fluid and fragments run out, and attach to the catheter the aspirator ; turn the valve, and compress and relax the bulb so that an • ounce or more of fluid is forced in at each squeeze, the com- pression coinciding with expirations. The debris falls into a bulb, and the pumping is continued until fragments cease to pass, whereupon the point of the catheter is pushed against the floor of the bladder and another trial is made. If fragments which cannot gain exit are felt knocking against the tube, withdraw the evacuator, crush again, and again use « the aspirator. When no more debris comes away and no more fragments are felt, withdraw the tube and carefully sound the bladder. Keyes advises the operator to seek for a final fragment by listening with a stethoscope while pumping at the bulb and searching the bladder with the tube. This opera- DISEASES OF THE GENITO-URINARY ORGANS. 733 tion will rarely occupy over forty minutes, though Bigelow has protracted it for three hours, the patient recovering. A serious complication is severe bleeding, due to damage done with the instrument or to the presence of a tumor which easily bleeds. The injection of moderately hot water usually checks hemorrhage, but if bleeding is dangerous in amount the operation of litholapaxy should be abandoned, and a suprapubic lithotomy be performed instead. If clogging of the instrument with fragments occurs, forcible pushing of the blades together repeatedly will probably amend it; but it should never happen, as the occurrence indicts the operator of carelessness or of ignor- ance in using an improper tool. A lithotrite with a fenes- ' trated blade will not lock. If the blades become forcibly and hopelessly locked, make a perineal section, clear out the blades, and then withdraw the instrument. Forbes's lithotrite is a very powerful tool. After-treatment.—Put the patient to bed, apply a bag of hot water to the hypogastrium, and give him a hypodermatic injection of morphia as he recovers from ether. Give a hot hip-bath every night, and administer every day liquor potassii , citratis in moderate doses. If urethral fever occurs, use quinine and morphia, wash the bladder several times daily with warm boracic-acid solution, and tie in a rubber catheter. If retention occurs, use the catheter. If cystitis appears, treat as in an ordinary case. The urine ceases to be bloody in two or three days, and the patient may get up in a week. Litholapaxy in Male Children.—It was considered until quite recently that a child, because of the small size of its bladder, the small diameter of the urethra, and the readiness with which the mucous membrane is ruptured by even slight violence, was a bad subject for crushing. Lateral lithotomy is known to be eminently successful when per- formed upon children. The elder Gross did this opera- 734 A MANUAL OF SURGERY. tion upon 72 children with only 2 deaths. Dr. Keegan, however, has persuaded the profession that rapid lithotrity is perfectly applicable to children: he shows that the bladder of a child even less than two years of age is quite large enough to allow the surgeon to manipulate an instrument, that the mucous membrane is in no danger if the operator be careful, and that the urethra is by no means so small as was supposed. The urinary meatus must often be incised, and after doing this, Keegan states, there can be passed in a boy of from three to six years a No. 7 or 8 lithotrite (English), and in a boy of from eight to ten years a No. 10 or even a No. 14. It is, however, just to state that the operation is more delicate than a like procedure on older persons, and that no one is justified in doing it who has not had considerable experience in adult cases. Further- more, it should be noted that Keegan's mortality by this operation has been 4.3 per cent., while Gross's mortality from lateral lithotomy on children was 2.67 per cent. Special points of litholapaxy on male children are as fol- lows : Use well-fenestrated lithotrites; have a stylet to punch out the fragments blocking the evacuator; and crush the stone to a fine mass. There can usually be employed a No. 8 lithotrite and a No. 8 evacuating-tube. Operation for Stone in Women.—If the stone be small, give the patient ether, place her in the lithotomy position, dilate the urethra with a uterine dilator until it admits the index finger, and remove the stone with the finger, the scoop, or the forceps. If the stone is found to be too large to pass, crush it with a lithrotrite and get rid of the debris by the evacuator. Large stones (two ounces) may require a suprapubic lithotomy. Vaginal lithotomy is never required. If done, it is very likely to leave as a legacy a vesico-vaginal fistula. In female children dilate the urethra, crush the stone, and evacuate. DISEASES OF THE GENITO-URINARY ORGANS. 735 Cystotomy.—This term means the opening of the bladder, and it is usually applied to an opening made for drainage, for diagnosis, for the removal of stones and tumors, and for the treatment of ulcers. This opening may be done by (i) a suprapubic cut (as in suprapubic lithotomy), (2) a lateral perineal cut (as in lateral lithotomy), or (3) a median perineal cut (as in median lithotomy). Suprapubic Cystotomy.—To explore the bladder, to treat an ulcer, or to remove a tumor, perform suprapubic cystotomy and illuminate the interior of the bladder by the rays of an electric lamp, which appliance is fastened with a mirror to the forehead of the operator. The inflation of the rectum is a decided advantage. If an ulcer is found, it is scraped with a curette or a spoon. Most cases of tumor require suprapubic cystotomy. It is true that a small single growth at the vesical neck is accessible by median cyst- otomy, but the area for manipulation is very narrow and the growth cannot be seen. Every large growth, all cases of multiple tumors, and all cases of tumor with great depth of perineum or with enlarged prostate require suprapubic cyst- otomy, an operation which allows one to feel and to see the growth, which gives room for manipulation, and which permits thorough exploration of the entire bladder. The patient is put in the Trendelenburg position (Fig. 146). After opening the bladder as for stone, hold the edges of the incision apart by specula (specula of Keen or Watson) or by retractors and throw in the electric rays. Growths when seen can be twisted off, a pair of forceps holding the base and another pair being used to twist. Broad growths are transfixed, ligatured, and severed. Some growths (as cancer) are removed piece by piece with Thompson's forceps, the base being scraped. Soft growths are scraped away with a curette, a spoon, or a finger-nail. If bleeding is severe, check it by pressure, by iced water, or even by the actual cautery. 736 A MANUAL OF SURGERY. Median Cystotomy.—The same incision is made in the perineal raphe in median cystotomy as for median lithot- omy. A grooved staff is introduced and is hooked up under the pubes; an incision is made into the membranous urethra and is extended backward for three-quarters of an inch, and a finger is carried into the bladder. If searching for a growth, find it with the finger, catch it in Thompson for- ceps, and twist it off Soft growths can be scraped away. Stop bleeding by digital pressure or by injections of iced water. If median cystotomy does not allow access to the tumor, perform suprapubic cystotomy. Growths in the Female Bladder.—Dilate the urethra as in a case of stone, and scrape, twist, pull, or ligature the growth away. If the growth is large or if there are multiple growths, perform suprapubic cystotomy. XXXV. DISEASES AND INJURIES OF THE URE- THRA, PENIS, TESTICLES, PROSTATE, SPER- MATIC CORD, AND TUNICA VAGINALIS. Injuries may arise from traumatism to the perineum or the penis, from cuts and twists of the penis, from the pop- ular "breaking" of a chordee, from tying strings around the organ, from forcing rings over it, from the passage of instruments, or from the impaction of calculi. The writer saw one man with a glass rod broken off in the canal, he having been in the habit of introducing it at the dictate of morbid sexual excitement. A patient in the Insane Depart- ment of the Philadelphia Hospital had a ring around his penis, which organ was lacerated into the urethra. These injuries are treated on general principles. Perineal Bruises.—If the perineum be bruised without rupture of the urethra, the perineum and scrotum swell and become discolored; water is passed with difficulty because DISEASES AND INJURIES OF THE URETHRA, ETC. 717 of the extravasation in the periurethral tissues occluding more or less the canal; the water is not bloody; and there are pain and profound shock. Some authors designate as rupture those cases in which laceration of the spongy tissue occurs, without involvement of the mucous membrane or of the fibrous coat, but they are properly contusions. Treatment of Perineal Bruises.—Place the patient in bed and establish reaction, and when reaction is complete em- ploy opiates for the relief of pain. Place lint, wet and kept wet with lead-water and laudanum, upon the perineum, alter- nating every two hours with a fifteen-minute application of the ice-bag. If, notwithstanding these measures, swelling continues, introduce a silver catheter (No. 12 E.), tie it in, ' and make firm pressure upon the perineum by a firmly- applied T-bandage or by a crutch braced against the thighs or the foot-board of the bed. Even when swelling is slight retention may occur from projection into the canal of the urethra of a submucous blood-clot. Punctured wounds of the urethra require ordinary dressings. Incised wounds of the urethra, when longitudinal, are closed by suture. Healing is rapid, and ill consequences are not to be feared. Stricture does not follow. When the wound is transverse, introduce a catheter, suture the wound over the instrument, and remove the catheter at the end of the third day. If a catheter can- not be introduced, employ sutures, but at the first evidence of extravasation open the wound, and if drainage is not free perform an external perineal urethrotomy. Rupture of the Urethra.—By this term is meant a lace- rated or a contused wound of the urethra, destroying par- tially or entirely the integrity of the canal. A lacerated wound can be induced by fracture of the cavernous bodies during erection, the symptoms being severe hemorrhage, intense pain, retention of urine, and inability to pass an instrument; infiltration of urine occurs, and gangrene is a 47 738 A MANUAL OF SURGERY. common result. The writer has seen one case of rupture of the penile urethra due to a man's slipping while shaving, the penis being caught in a partially open drawer, the drawer being shut by his body coming against it. Rupture, however, is almost invariably located in the perineum, and it arises when the urethra is suddenly and forcibly pressed against the ramus of the pubes by a blow, by a kick, or by falling astride a beam or a fence-rail. The lesion of urethral rupture consists in some cases of laceration of the spongy tissue and the mucous membrane, a cavity being formed which communicates with the canal, and which fills with urine during micturition. In other cases not only the spongy tissue and the urethral mucous membrane are rent asunder, but the fibrous coat is also torn, the canal opening directly into the perineal tissues, among which a huge cavity forms, that fills with blood and later with clot, urine, and pus. The urethra may be torn entirely across, but in most cases a small portion at least of its circumference is unin- jured. Rupture never occurs primarily and alone in the prostatic urethra; it is extremely rare in the membranous urethra unless due to pelvic fracture; and it is very unusual in the penile urethra. The seat of rupture in the great majority of cases is in the region of the bulb. Very rarely is the skin broken. Symptoms.—The symptoms of rupture of the urethra are—considerable pain, aggravated by motion, pressure, and attempts to pass the water ; great shock ; in some cases mic- turition is still possible, blood preceding and discoloring the stream, for some blood usually runs into the bladder; reten- tion soon comes on ; in a vast majority of the cases retention is absolute from the very first, and it is due to the interrup- tion in the integrity of the canal and to the occlusion of the channel by blood-clots. Bleeding, which is usually free, lasts for several hours, some little blood generally appearing exter- 1 DISEASES AND INJURIES OF THE URETHRA, ETC. 739 nally and much being retained in the. perineum, inducing progressive swelling. The presence of blood is regarded as evidence of urethral rupture. The perineal swelling is due to blood which may extend under the fascia to the penis and scrotum ; the swelling soon becomes reddish, purple, or even • black, and pressure upon it is apt to cause blood to run from the meatus. This swelling enlarges when attempts are made to urinate. After a time, if the surgeon does not act, the urine fills the perineal cavity and. widely infiltrates, and there ensue gangrene, sloughing, and sepsis, life being endangered or fistulae being left as legacies. In rupture of the urethra the course of the extravasated urine will often enable one to locate the seat. In rupture of the membranous urethra, » if uncomplicated, the urine remains between the two layers of the triangular ligament until a channel is opened for it by sloughing or by the knife. When extravasation occurs behind the posterior layer of the ligament the urine finds its way to the perineum in the neighborhood of the anus. When the rupture is in front of the anterior layer the urine, directed by the deep layer of the superficial fascia, finds its way into the scrotum and up on the belly, but does not pass into the thighs. A contusion is distinguished from a rupture by the facts that in the former the perineal swell- ing does not enlarge on attempting micturition, while in the latter it does; and contusion does not cause urethral hemor- rhage, while rupture does. A contusion sometimes, but not often, prevents the passage of a catheter; a rupture almost always, but not invariably, does so. The mortality from severe rupture with extravasation is grave. Massing * together all cases, the mortality is 14 per cent. (Kaufman). Treatment.—In recent cases of ruptured urethra the treat- ment is as follows: immediate perineal section with turning « out of the clot; trimming off of lacerated edges; finding the proximal end of the urethra, passing a catheter from the 74O A MANUAL OF SURGERY. meatus into the bladder, and leaving it in situ until healing has begun around it. In cases with extravasation, lay open freely all pockets of urine and proceed as above. If the proximal end of the urethra cannot be found, either open the bladder by Cock's method of perineal section without a guide, cutting toward the apex of the prostate gland and carrying the * incision forward into the rent, or perform a suprapubic cyst- otomy with retrograde catheterization ; that is, push an instru- ment from the bladder into the wound, and use it to guide a catheter passed from the meatus into the bladder. It is always well to attempt to suture together the divided ends of the canal. The wound is packed with iodoform gauze, and the bowels are tied up with opium for a few days. Many surgeons strongly disapprove of the custom of retaining the « catheter, and merely stuff the wound with gauze, the patient urinating through the wound for the first few days, after which time a catheter is used. When the rupture is in the bulb perineal section is performed to permit drainage, the rent is sutured, and a catheter is retained as a support. Whatever method is employed, healing will require from six to eight weeks, and the patient must ever after frequently introduce large-sized bougies. Foreign Bodies in the Urethra.—These bodies may be * calculi, bodies introduced by injury, as shot, bone, etc., bodies entering from a morbid opening into the rectum, or bodies introduced from the meatus, as broken bits of cathe- ters, straws, pins, etc. The symptoms vary with the size and the nature of the body. Sometimes there are almost no symptoms ; at other times there are found great pain, reten- tion of urine, and hemorrhage. Examination is made by feel- • ing externally with a finger in the rectum and by searching very gently with a sound, taking care not to push the body back. If the bladder is well filled with water when the body becomes impacted, inject a little oil into the meatus, close DISEASES AND INJURIES OF THE URETHRA, ETC. 741 the lips with the fingers, and direct the patient to forcibly attempt urination, the surgeon opening the meatus when the urethra is widely distended, the foreign body being often forced out. If this manoeuvre fails, and the foreign body is impacted in the pendulous urethra, prevent its backward passage by at once tying a rubber tube around the penis. Try to squeeze the body out, and, if unsuccessful, endeavor to catch it with a wire loop, with a scoop, or with the long urethral forceps. If these methods fail, cut down upon the body and remove it, dividing any existing stricture. If a hair-pin is in the canal, the feet of the pin are almost always pointing to the meatus; to prevent them catching on at- tempted withdrawal, the penis must be squeezed to approxi- • mate the feet, and when they are adjacent a part of a silver catheter is slipped over to retain them in this position, when the pin can be extracted. If this fails, drag the penis against the belly, by rectal touch force the sharp ends out through the integument, cut one end off, and then withdraw the other. An ordinary large-headed pin is forced out in the same way, and when the head is turned externally it is extracted from the meatus. If a lithotrite loaded with fragments be caught in the urethra, the surgeon must perform a perineal section, clean and close the blades, and withdraw the instrument. Urethritis, or Inflammation of the Urethra.—Urethral inflammations can be divided into two classes : (1) Simple, in which infection is due alone to pyogenic cocci, and (2) specific, in which the gonococcus is present. Simple urethritis may be due to several causes, such as traumatism; great acidity of the urine; chancre in the urethra; contact with menstrual fluid, leucorrhceal discharge, the dis- charge from malignant disease of the uterus, ordinary pus, or acid vaginal discharge; the passage of instruments; • irritant diuretics; strong injections ; worms in the rectum ; and the passage or impaction of foreign bodies. A tern- 742 A MANUAL OF SURGERY. * porary and mild urethritis sometimes accompanies early syphilitic eruptions. Simple urethritis is usually less severe and prolonged than specific urethritis, though clinically the surgeon cannot invariably distinguish between the two forms. Professor Coplin is persuaded that the gonococcus is never found in the discharge of simple urethritis. In the non- specific inflammation pus is not always present, many cases stopping short of it after a varying period of catarrh, but any catarrh can become purulent. Traumatic Urethritis.—The pain in traumatic urethritis is coincident with the introduction of the foreign body. The discharge, which may be bloody, mucous, muco-purulent, or purulent, comes on within twenty-four hours. Treatment.—If the inflammation is slight, prescribe diluent • drinks, paregoric, and a saline. If severe, put the patient to bed, apply warm fomentations to the perineum, give diluent drinks, employ suppositories of opium and belladonna, and watch for fever and other complications. G-outy Urethritis.—This condition first manifests itself in the posterior urethra, not in the anterior, as does clap. Its symptoms are—great vesical irritability; pain on urina- tion ; discharge, usually scanty, associated with uric acid in the urine or other symptoms of gout. The treatment com- prises dieting and the usual remedies for gout. Purgatives are given freely, and full doses of colchicum, piperazine, or the alkalies ; hot baths, low diet, diluent drinks, and diapho- retics are indicated. A chronic discharge from the prostatic region is apt to linger; for this there is nothing better than the usual gouty remedies and saline waters with copaiba, cubebs, or sandalwood oil. Eczematous Urethritis.—Berkeley Hill states that this disease is very obstinate, is probably associated with gout, and is met with in adults of full habit or who are beer- • drinkers and who have eczema of the surface of the body. DISEASES AND INJURIES OF THE URETHRA, ETC. 743 He states also that the glans penis near the meatus is red and tender, and that the interior of the urethra is in the same condition. Pain is constant, and it is aggravated on micturition. The discharge is scanty. The treatment com- prises injections of cold water or irrigation with ice-water, and internally the administration of arsenic with the alkalies. Tubercular urethritis is due to a tubercular ulcer which is most apt to be seated near the vesical neck. There is a little pain on micturition, but there is intense pain at one spot on passing a bougie. The discharge is slight and at times bloody. The bladder is very irritable, and severe cystitis arises and persists. The treatment includes fresh air, sunlight, warmth, good food, and cod-liver oil. The bladder is washed out once a day with boracic-acid solution, but after a time the surgeon will be forced to drain by peri- neal or suprapubic cystotomy. Gonorrhoea (Clap; Specific Urethritis; Tripper; Venereal Catarrh).—Gonorrhoea is an acute inflammation of the genital mucous membrane, of venereal origin, due to the deposition and multiplication of gonococci in the cells of the mem- brane and a mixed infection with the cocci of suppuration. In the male, clap begins within the meatus and fossa navicu- laris and extends backward throughout the length of the urethra. The mucous membrane swells and becomes hyper- aemic, and there is a discharge, first of mucus and serum, and then of pus. In severe cases the discharge is bloody (black gonorrhoea). For a week or more the inflammation increases, then becomes stationary for a time, and then declines, the discharge growing less profuse and thinner, a watery discharge lasting for some little time. During the acute stage the entire penis swells and the corpus spongiosum becomes infiltrated with inflammatory exudate. Chordee is a painful erection in which the penis bends because of the rigid infiltration of the corpus spongiosum. 744 A MANUAL OF SURGERY. Symptoms of Acute Inflammatory Gonorrhoea.—The period of incubation is from a few hours to two weeks. The patient notices on arising a drop of thin fluid which glues together the lips of the meatus, and he feels some pain on urination. The meatus is red and swollen. Within forty-eight hours the first stage, or the stage of increase, becomes established. The meatus is now red, swollen, and everted (fish-mouth meatus); micturition causes severe pain (ardor urinae); chordee occurs, especially when the patient is warm in bed; there is frequent micturition with tenesmus, and a profuse discharge which is yellow, greenish, or even bloody. The complications of this stage are balanitis (inflammation of the mucous membrane of the glans penis), balano-postlutis (in-. flammation of the surface of the glans and the mucous membrane of the prepuce), phimosis (thickening and contrac- tion of the foreskin so that the glans cannot be uncovered), and paraphimosis (catching and fixation of the retracted prepuce behind the corona glandis). In the second or sta- tionary stage, which lasts from the end of the first week to the end of the second (White), the acute symptoms of the first stage continue. The complications of this stage are periurethral abscess, lymphangitis, solitary and painful bubo of the groin which may suppurate, inflammation of Cowper's glands, inflammation of the prostate or of the bladder, and gonorrhoeal ophthalmia. In the third or subsiding stage the symptoms gradually abate, the discharge becoming scantier and thinner and finally drying up. This stage is of uncer- tain duration, and in it there may occur epididymitis, or inflammation of the epididymis. Subacute or catarrhal gonorrhoea develops in men who have previously had gonorrhoea, as a result of prolonged or repeated coition or of contact with menstrual fluid or leucor- rhceal discharge. There is profuse muco-purulent discharge, very little pain on micturition, rarely chordee or marked DISEASES AND INJURIES OF THE URETHRA, ETC. 745 irritability of the bladder. In this condition, according to White, gonorrhoeal rheumatism (p. 412) is most apt to occur. Irritative or Abortive Gonorrhoea.—In this disease the symptoms, which are identical with those of beginning clap, do not increase, but are apt to disappear within ten days. Chronic Urethral Discharges.—Chronic urethral catarrh, which may follow gonorrhoea, is characterized by the occa- sional presence of a drop of clear tenacious liquid. This discharge becomes more profuse as a result of sexual ex- citement or the abuse of alcohol. Chronic Gonorrhoea.—The persistence of a small amount of milky discharge, because of localization of inflammation in one spot or the production of a granular patch or a super- ficial ulcer, characterizes chronic gonorrhoea. There is some scalding on urination; erections produce aching pain; there are pain in the back and redness and swelling of the meatus. All the symptoms are intensified by sexual excitement, by coitus, by violent exercise, or by alcoholic excess. Gleet.—In gleet the lips of the meatus are stuck together in the morning, and squeezing them discloses a drop of opalescent muco-purulent fluid. During the day the dis- charge is rarely found. There are frequency of micturition, pains in the back, and dribbling of urine, and a bougie will find a stricture of large calibre. A discharge may be main- tained by chronic prostatitis. In this condition there are fre- quency of micturition ; a sense of weight or dull pain in the perineum ; diminished projectile force of the stream of urine; the first portion of urine, if collected in a glass, is more turbid than the second portion (Ultzmann); the sediment consists of " prostatic epithelium, muco-pus, and mucous shreds " (White) ; there is often a tendency to sexual excite- ment and premature emission. Treatment of Acute Gonorrhoea.—Abortive treatment should be tried if the case is seen early. The writer's plan is to 746 A MANUAL OF SURGERY. cleanse the urethra several times a day by injecting peroxide of hydrogen (15-volume solution diluted with an equal amount of water). After each injection of peroxide intro- duce oil of cinnamon into the urethra by means of a metal- nozzled atomizer or even an ordinary syringe (the oil is mixed with benzoinol, three solutions being used, the strength being respectively 1 drop, 2 drops, and 3 drops to the ounce). The mild solution of oil of cinnamon is used the first day, the 2-drop solution the second day, the 3-drop solution the third day if the urethra will tolerate it.1 Other abortive methods are the use of hot retro-injections of cor- rosive-sublimate solution (1 :20,000), two pints being run through the urethra once a day, strong injections of nitrate of silver or of tannin, scraping the meatus and the urethra adjacent with cotton, and injecting 15 drops of a 3 per cent, solution of nitrate of silver. If in seventy-two hours the symptoms are not greatly improved, abortive treatment should be abandoned (Horwitz). In treating a developed case, order plain, non-stimulating diet and the avoidance of alcohol, sexual excitement, wet, and violent or prolonged exercise. The patient should sleep under light covers and drink much water daily (Seltzer, Apollinaris, or ordinary water containing bicarbonate of soda). If the foreskin is long, the discharge should be caught by placing bits of absorbent cotton over the meatus and within the prepuce. If the fore- skin is short, cut a small opening in a square piece of old linen, slip this linen over the glans, catch it back of the corona, and bring the ends forward with the prepuce. If the glans is completely naked, pin an old stocking-foot upon the undershirt and in it hang the penis. Irritative gonorrhoea will subside in a few days. The above treatment should be applied, and the urethra should be washed out several times daily with peroxide of hydrogen. 1 Medical News, Oct. 21, 1893. DISEASES AND INJURIES OF THE URETHRA, ETC. 7\7 In catarrhal gonorrhoea at once order injections (1 grain to the ounce of sulphate of zinc; or zinci sulphas gr. viij, plumbi acetas gr. xv, water gviij; or gr. v of sulphocarbolate of zinc to gj of water; or White's prescription of 3j each of acetate of zinc and tannic acid, 3iij of boric acid, 3vj of liq. hydrogen. peroxid.). Use for injecting a blunt-pointed hard-rubber syr- inge of a capacity of three drachms. Let the patient sit on a chair, his buttocks hanging over the edge; throw in a syringeful and let it at once run out; throw in another syr- ingeful and hold it in from three to five minutes. In acute gonorrhoea order two capsules three times a day, each cap- sule containing 5 grains of salol, 5 grains of oleoresin of cubebs, 10 grains of balsam of copaiba, and 1 grain of pepsin. After the patient micturates he should employ a mild astringent injection. If an astringent injection causes much pain, use a sedative injection—3ij of boracic acid, gr. viij of aqueous extract of opium, and |viij of liquor plumbi sub- acetatis dilutus. As the inflammation subsides increase the strength of the injection. A good plan is to order an eight- ounce bottle and eight half-grain powders of sulphate of zinc. Direct the patient to fill the bottle with water, in which one powder is dissolved; when this is used dissolve two powders in a bottleful of water, and so progressively increase the strength. When the discharge ceases stop the injections gradually. Whenever a syringeful is taken from the bottle a syringeful of water is put into the bottle, and thus pure water is soon obtained, at which point injection is discontinued. Ardor urinoe is relieved by urinating while the penis lies in hot water and by administering an alkaline diuretic. Chordee requires a bowel-movement in the evening and sleeping in a cool room, under light covers, and on a hard mattress; bromide is given several times daily, and a con- siderable dose is given at night; it may be necessary to use 748 A MANUAL OF SURGERY. suppositories of opium and camphor or to give hyoscine. Balanitis requires frequent washing with warm water, drying with cotton, and dusting with borated talc or with boric acid and subnitrate of bismuth (i : 6). Balano-posthitis requires lead-water and laudanum and injections of black wash under the prepuce until cedema of the foreskin subsides, and then cleanliness externally and a powder. Phimosis requires soak- ing the penis in hot water, injections beneath the foreskin of hot water, followed by black wash and lead-water and lauda- num externally. If this fails, circumcise. For paraphimosis, grasp the head of the penis with the left hand, squeeze the blood out, and try to push the head back while with the right hand effort is made as if to lift the individual by his penis. If this fails, cut the collar on the dorsum with scissors. Bubo requires iodine, blue ointment, a spica bandage, and rest. If a bubo suppurates, it must be opened. Acute prostatitis and cystitis require confinement to bed, a milk diet, the use of alkaline diuretics, hot sand-bags to the perineum and hypo- gastrium, suppositories of opium and belladonna, leeching the perineum, and the discontinuance of the balsams and injections. Abscess of the prostate requires instant opening. In retention of urine the patient should try to pass the urine while in a hot bath ; if this fails, use a soft catheter. After relieving the bladder put the patient to bed and use hot sand- bags as for prostatitis. Chronic prostatitis requires cold hip- baths, cold-water enemata, deep urethral injections, plain diet, avoidance of alcohol and over-exertion, counter-irritation of the perineum, and the relief of stricture or phimosis. In epididymitis, put the patient to bed, stop injections, shave the hair from the groin and leech over the cord, elevate the testicles, keep the parts covered with lint wet with lead-water and laudanum, and from time to time apply an ice-bag. Give a cathartic, a fever-mixture, and suitable doses of bromide of potash and morphia. When tenderness DISEASES AND INJURIES OF THE URETHRA, ETC. 749 subsides strap the testicle. In gonorrhoeal ophthalmia, place a watch-crystal over the unaffected eye, put the patient in a darkened room, wash out the affected eye often with hot boracic-acid solution, keep the pupil dilated with atropine, leech the temple, give purgatives, and employ hot mustard foot-baths. Always send for an ophthalmologist. Treatment of Chronic Gonorrhoea.—In chronic gonorrhoea, try to locate any existing granular or ulcerated patch with a bulbous bougie. When the point is discovered apply to it, by a deep urethral syringe, a few drops of a 2 per cent, solu- tion of nitrate of silver. The strength of the silver solution can gradually be increased, or other solutions can be substi- tuted (sulphate of copper or sulphocarbolate of zinc). Pass a large bougie every other day. Copious retro-irrigation with hot solutions of corrosive sublimate (1:20,000) does good. Horwitz injects into the bladder once a day a pint of water containing 3J grains of permanganate of potash, and the patient voids it by an act of micturition. The treat- ment of gleet is the same as that of stricture. Gonorrhoea in the female may affect the vulva, the vagina, the urethra, or the uterus. The treatment for vulvitis is to place the patient upon a low diet and put her at rest with the pelvis elevated; every two or three hours spray the parts with peroxide of hydrogen, dry them with absorbent cotton, and dust them with equal parts of starch and oxide of zinc. In severe cases purge, use hot baths, apply lead- water and laudanum locally or paint the vulva with silver solution (gr. xl to 3j)» and leech the groins. If the vulvo- vaginal gland suppurates, open it. For vaginitis, follow the same general directions. Syringe out the vagina every two hours, first with Oj of hot solution of bicarbonate of soda, next with Oj of hot water, and finally with Oj of astringent solu- tion (a teaspoonful of lead acetate, a teaspoonful of zinc sul- phate, a teaspoonful of alum, or four teaspoonfuls of tannin 750 A MANUAL OF SURGERY. * to the pint of hot water) (White). Peroxide of hydrogen followed by oil of cinnamon does good. As the attack sub- sides use vaginal suppositories each containing gr. v of tannic acid. For urethritis, use astringent injections locally and copaiba and cubebs by the mouth. In chronic cases, use strong solutions of silver nitrate. For uterine gonorrhoea, • observe the same general management. Sw.ib out the uterus with tincture of iodine; use tampons of iodoform gauze and injections of peroxide of hydrogen and oil of cinnamon. Stricture of the urethra, or narrowing of the urethral calibre, is divided into inflammatory, spasmodic, and organic. Inflammatory or congestive stricture is not a stricture, but is an inflammatory swelling of the mucous membrane. Spas- modic stricture does not exist alone, but complicates organic , stricture, a hyperaesthetic urethra, or an inflamed bladder. Organic stricture is a fibrous narrowing of the urethra, due, as a rule, to chronic gonorrhoeal inflammation or to trau- matism. Traumatic strictures occur in the bulbous or mem- branous urethra; gonorrhoeal strictures occur in the penile, bulbous, or membranous urethra. Stricture never forms in the prostatic urethra. The more fibrous a stricture is, the more it narrows the urethra and the less dilatable it is. A stricture may be annular (forming a ring around the urethra), * tubular (surrounding the urethra for a considerable distance), or bridle (when a band crosses the urethra from wall to wall). The nearer a stricture is to the meatus, the more fibrous it is. Results of Stricture.—The urethra back of the stricture dilates, a pouch forms, drops of urine collect and decompose, and a chronic inflammation results in the mucous membrane or the parts adjacent, which inflammation may go on to • ulceration or to periurethral abscess. A urinary fistula results from the opening of a periurethral abscess. In stricture the stream of water is small, twisted, often forked, and it dribbles % long after the conclusion of micturition. A chronic dis DISEASES AND INJURIES OF THE URETHRA, ETC. 751 charge is apt to exist, varying in amount. Retention of urine may occur, not from obliteration of the tube by the growth of the stricture, but by swelling in the neighborhood of the stricture, due to some complication (cold, wet, venereal excitement, the use of alcohol, over-exertion, etc.). Spasm of the muscles results, and contact of the urine increases the spasm and closes the urethra. Spasm may exist in the urethra itself and in the muscles of the neck of the bladder, but is only a temporary condition. In old strictures the bladder is hypertrophied and often fasciculated, and is very liable to cystitis. The diagnosis of stricture and of its location is made by the use of exploratory bougies. Treatment of Stricture.—Strictures of large calibre in the deep urethra require gradual dilatation with conical steel bougies. A bougie is introduced every third or fourth day, the size being gradually increased. Never anoint a bougie with cosmoline, as it may become a nucleus for a stone in the bladder; use oil or glycerin. If the meatus is too small to admit a full-sized bougie, cut it with a knife. Strictures of large calibre in the pendulous urethra, if elastic, are treated by gradual dilatation ; if fibrous and contractile, by internal urethrotomy. In performing internal urethrotomy, prepare the patient carefully; for several days before the operation give salol and boracic acid by the mouth, and wash out the bladder repeatedly with boracic-acid solution. Be thoroughly aseptic. Before cutting irrigate the urethra with corrosive sublimate (1 : 5000), and after cutting irrigate again and tie in a rubber catheter. These precautions will prevent urethral fever. In cutting, insert Gross's urethrotome back of the stricture, spring out the blade, cut the stricture on the roof of the urethra, close the blade, withdraw the instrument, and introduce a full-sized bougie. Strictures of the meatus require incision with a knife and the use of a meatus bougie until healing is complete. 752 A MANUAL OF SURGERY. Strictures of small calibre in front of the membranous urethra require gradual dilatation and, if this fails, internal urethrotomy or divulsion. For divulsion the patient is pre- pared as for internal urethrotomy. The divulsor of Gross or of Sir Henry Thompson is introduced, the blades are separated, the instrument is withdrawn, a large bougie is passed, and a catheter is tied in the bladder. Strictures of small calibre in the deep urethra require gradual dilatation; if this fails, employ external urethrotomy. In strictures of the deep urethra, if only a filiform bougie can be introduced, the bougie can be left in place and in a day or two another can be slipped in beside it, until in a few days the channel is permeable by a metal bougie. A tunnelled catheter can be slipped over the bougie, both be withdrawn, and a metal bougie be passed. A tunnelled and grooved staff can be carried in over the bougie and external urethrotomy be per- formed. Thompson's dilator can be carried over the bougie and the stricture be divulsed. Maisonneuve's urethrotome can be carried over the bougie and internal urethrotomy be performed (White mentions four of these plans, but disap- proves of divulsion). In impassable stricture of the deep urethra, perform external perineal urethrotomy without a guide (the operation of Cock or of Wheelhouse). Epispadias is a congenital cleft in the corpora cavernosa, the roof of the urethra being absent. Hypospadias is a congenital cleft on the floor of the urethra, this channel being a gutter instead of a canal. Chancroid (Soft Chancre; the Local Venereal Sore).—A chancroid appears soon after intercourse, usually within five days, always within ten days. It is first manifested by a pustule which ruptures and discloses an ulcer. This ulcer has sharply-defined and undermined margins; it looks "punched out;" the base is gray and sloughy; the dis- charge is profuse, purulent, foul, and auto-inoculable, and DISEASES AND INJURIES OF THE URETHRA, ETC. 753 causes fresh chancroids by flowing over the parts. The area around a chancroid is red and inflamed, and considerable pain is apt to be complained of. The original chancroid spreads and new sores appear. The edge of a chancroid is not indurated unless caustics have been used or there is mixed infection with syphilis. Inflammatory induration fades gradually into the tissues, but the induration of a hard chancre is sharply defined. When a chancroid after a time displays marked and sharply-outlined induration, it means a mixed infection of chancroid and syphilis. Chancroids are not followed by constitutional symptoms, but are apt to be accompanied by painful inflammatory buboes which are prone to suppurate. When inflammation in chancroids is high a rapidly destructive ulceration known as phagedena may arise. Treatment.—Ordinary cases of chancroids are treated by spraying with peroxide of hydrogen, drying with cotton, touching each sore first with pure carbolic acid and then with pure nitric acid, and dusting with iodoform or with calomel. Every few hours after this application the patient soaks the penis in hot salt water (a teaspoonful to half a pint), sprays the sores with peroxide of hydrogen, dries with cotton, and dusts with iodoform or with calomel. As soon as granulation begins, dress with 1 part of ointment of nitrate of mercury to 7 parts of cosmoline. Mild cases do well without cauterizing, peroxide of hydrogen being frequently used and a drying powder being employed. In chancroids with phimosis, slit up the foreskin, burn the edges of the wound with pure carbolic acid, and treat the sore by cauterization. A set circumcision often fails because of infection of the stitch-holes. Phagedena requires the in- ternal use of iron, quinine, and milk punch, and the local use of powerful caustics (bromine or nitric acid) or even of the actual cautery. In some cases continuous antiseptic irrigation is valuable. When a bubo first begins, order rest, 4S 754 A MANUAL OF SURGERY. ion apply iodine and ichthyol, and make pressure by a spica bandage of the groin. If pus forms, incise, curette, cauter- ize with pure carbolic acid, cut away hopelessly infiltrated skin, and pack the wound with iodoform gauze. Phimosis is a condition of the prepuce that renders retrac- tion over the glans impossible. It is usually congenital, but it may arise from inflammation. Congenital phimosis causes retention of sebaceous matter, which decomposes and lights up inflammation. The prepuce is apt to grow fast to the glans. Congenital phimosis may induce irritability of the bladder, incontinence of urine, prolapse of the rectum, and various nervous symptoms. The treatment is circumcision. Grasp the foreskin and the mucous membrane with two forceps, draw them forward, catch the BFSm7ietedC(Srch skin (at the point it is desired to cut) hori- and Kowalzig). zontally between the handles of a pair of scissors, and cut off the redundant prepuce. Retrench the excess of mucous membrane by cutting around with scissors one-quarter of an inch from the glans, stitch the skin to the mucous membrane, and dress antiseptically (Fig. 171). Fracture of the penis, which is a laceration of the cav- ernous bodies with extravasation of blood, occurs occasion- ally during coition. The treatment requires cold and band- aging to arrest bleeding, and occasionally incisions to let out clot. Gangrene of the penis arises from phagedena, from tying constricting bands around the organ, from fracture with excessive hemorrhage, and from paraphimosis. If extensive, it requires amputation. Cancer of the penis is commonest in persons with phi- mosis. In a limited epithelioma of the foreskin circumcision is employed; if cancer affects the glans, amputation is re- quired. DISEASES AND INJURIES OF THE URETHRA, ETC. 755 Amputation of the Penis.—Ricord advises cutting off the organ with a single stroke of the knife, making four slits in the mucous membrane of the urethra, and stitching each of these flaps to the skin. Treves splits the skin of the scrotum along the raphe, separates the halves of the scrotum down to the corpus spongiosum, passes a metal catheter down to the triangular ligament, inserts a knife between the corpus spongiosum and the corpora cavernosa, withdraws the cathe- ter, cuts the urethra across, detaches the urethra from the penis back to the triangular ligament, cuts around the root of the penis, divides the suspensory ligament, detaches each crus from the pubes, slits up the corpus spongiosum half an inch, stitches its edges to the rear end of the scrotal incision, introduces a drainage-tube, ligates the vessels, and sutures the wound. Hypertrophy of the prostate gland is a senile change occurring only after the age of fifty, and being most apt to occur after the age of sixty. All the lobes maybe enlarged equally, all may be enlarged but unequally, or only one lobe may be enlarged. Prostatic hypertrophy causes narrowing and lengthening of the urethra, and gives this tube a tor- tuous course. The opening of the urethra into the bladder is pushed to a higher level, and there forms behind it a pouch in which urine collects. This urine, which is known as residual urine, may collect in large quantity; it cannot be voluntarily expelled, and it is apt to decompose, producing cystitis. The bladder enlarges, thickens, and becomes fas- ciculated, micturition becoming very difficult and sometimes impossible. An enlarged middle lobe will effectually block the urine until the bladder becomes greatly distended. The ureters distend, so do the renal pelves and calyces, and surgi- cal kidney may develop. Symptoms.—In 80 per cent, of all cases there is only slight inconvenience. The stream of urine is slow to start and falls 756 A MANUAL OF SURGERY. i feebly from the end of the penis. The last drops fall entirely without control, and there are occasional episodes of noc- turnal frequency of micturition. In 20 per cent, of all cases the bladder cannot entirely be emptied and residual urine collects in the bladder. Frequency of micturition comes on, particularly at night; the patient has to get up often; the bladder never feels empty; and cystitis is apt to arise. The urine, at first acid and clear, becomes neutral and cloudy, and finally ammoniacal and turbid, and contains bacteria, muco- pus, precipitates of phosphate, and blood. Above the pubes there is aching pain soon spreading to the perineum, which pain is increased when the bladder is distended and during micturition. The rectum becomes irritable, and piles form or prolapse of the mucous membrane occurs. Retention of urine may take place. The bladder becomes thin and dis- tended or hypertrophied, rigid, and fasciculated. In rare cases true incontinence is caused by the median lobe growing toward the neck of the bladder and preventing closure. The health breaks down because of pain, restless nights, indigestion, and disorder of the bowels. The kidneys may become involved (inflammation of the pelves or calyces, or surgical kidney) and suppression may occur. Calculi may form in the blad- der. Death is due to exhaustion, suppression of urine, or septic cystitis. If a foul catheter is used, septic cystitis is certain to occur; but micro-organisms sometimes enter by passing along the urethral mucous membrane. Treatment.—Prevent cystitis by emptying the bladder each evening with a Coude catheter which is strengthened by a filiform bougie as a stylet (Brinton). Teach the patient to use the instrument himself. The catheter should be kept in corrosive-sublimate solution (1 : 5000), and before using it should be washed with ethereal soap and water and then with corrosive sublimate (1 : 1000); after using it should be again cleansed and replaced in the solution. If there is a DISEASES AND INJURIES OF THE URETHRA, ETC. 757 great amount of residual urine, withdraw only a portion of it at a time. Tell the patient to avoid violent exercise, cold, damp, sexual excitement, and the use of alcoholic liquor, prevent constipation and indigestion, and direct him to drink plenty of Poland water. If much residual urine exists or if cystitis begins, wash out the bladder twice a week with boracic-acid solution and give salol or boracic acid by the mouth. If the suffering becomes severe, if the patient can- not urinate without the use of an instrument, and if catheteri- zation is painful, perform prostatectomy by suprapubic or perineal incision, according to the case, or drain by perineal section. Retained Testicle.—The testicle may be arrested in its passage to the scrotum : it may remain in the lumbar region; it may reach only the internal abdominal ring; it may lodge in the inguinal canal; it may emerge from the external ring, but fail to enter the scrotum ; or it may pass into unnatural positions, as into the perineum or the crural canal. It may or may not be functionally active. A retained testicle is sub- ject to repeated attacks of orchitis, and it is apt to become sarcomatous. Sometimes a testicle descends after being re- tained for months. Treatment.—If one testicle is undescended one year after birth, and the other testicle is sound, the former should be removed. In some rare cases it is possible to draw the gland into the scrotum and fasten it. Orchitis is inflammation of the testicle. Acute orchitis may be due to cold, wet, traumatism or epididymitis, gout, mumps, rheumatism, or fever. The testicle is round, swollen, tender, and very painful, the scrotum is red and swollen, the tunica vaginalis fills with fluid, and there is fever. Chronic orchitis results from the acute form or from a chronic urethral inflammation, and is almost always combined with epididymitis. Syphilis or tubercle may be responsible for 758 A MANUAL OF SURGERY. chronic orchitis. The treatment of the acute form requires rest in bed and applications as for epididymitis (see below). The chronic form requires the removal of the causative lesion, a suspensory bandage, inunctions of ichthyol or mercurial ointment, and iodide of potassium by the mouth. Strapping may do good. Castration may be required. Castration (Excision of the Testicle).—In this operation an incision is made over the cord, commencing just outside the external ring and running down over the base of the tumor. Divide the cord near to the tumor, remove the tes- ticle, ligate the spermatic artery alone, and then ligate the entire thickness of the cord. It is often advisable to remove a considerable amount of scrotal skin. Epididymitis, or inflammation of the epididymis, is due to inflammation of the urethra. It is apt to occur in the stage of decline of a gonorrhoea, and is announced by a complete cessation of the discharge. Acute epididymitis is character- ized by swelling about the testicle, pain in the groin, and tenderness over the posterior part of the testicle. The pain becomes acute, swelling rapidly increases, and the constitu- tion sympathizes. The swelling is due partly to engorge- ment of the epididymis and partly to fluid in the tunica vaginalis (acute hydrocele). Chronic epididymitis is usually linked with orchitis, and it follows an acute attack or a chronic urethral inflammation. Treatment by puncture with an aseptic tenotome, if fluctuation is marked, relieves tension and pain. Leeching, the ice-bag, elevation, lead-water and laudanum, laxatives, and opium are used in the acute stage, and strapping is employed as .the inflammation subsides. The treatment of the chronic form is the same as that for chronic orchitis. Hydrocele (chronic hydrocele) is a collection of fluid in the tunica vaginalis testis. An enlargement of the testis can cause it, but in most instances the cause is unknown and no DISEASES AND INJURIES OF THE URETHRA, ETC. 759 signs of inflammation exist. The fluid is albuminous, but it does not coagulate spontaneously; it is thin, straw-colored, and may contain crystals of cholesterin. The testicle is at the lower and back part of the sac. The pyriform mass fluctuates, is translucent, grows from below upward, and the introduction of an exploring-needle causes the yellow fluid to flow out. Treatment.—Simply tapping the sac with a trocar is only palliative, and, as air must run in as fluid runs out, suppura- tion may occur, which will be dangerous without drainage. Never tap a rigid sac. The injection of irritants should be abandoned, as it exposes the patient to serious danger because of inflammation occurring without provision for drainage. Hearn incises the sac, dries its interior with bits of gauze, swabs it out with pure carbolic acid, packs it with iodoform gauze, and dresses it antiseptically. The packing is removed in twenty-four hours and the wound is allowed to close. If the sac is rigid and will not collapse, either stitch it to the skin and pack it or excise a large portion of its parietal layer and insert a drainage-tube (Volkmann's operation). It has recently been proposed to tap the sac with a trocar and canula, to leave the canula in place as a drain for some days, and to dress antiseptically. Congenital hydrocele is hydrocele through an unclosed funicular process into the tunica vaginalis. If the pelvis is raised the fluid runs back into the peritoneal cavity, from which it originally came. The treatment is a truss to oblit- erate the funicular process. Infantile hydrocele is a collection of fluid in a funicular process and the tunica vaginalis, the funicular process being closed above, but not below. The treatment is to puncture the sac and to scarify the sac-wall with a needle. Encysted Hydrocele of the Cord.-In this variety the funicular process is obliterated above and below, but it is 760 A MANUAL OF SURGERY. patent between these two points, and fluid collects. The treatment is the same as that for infantile hernia. If this fails, incise and pack. Funicular Hydrocele.—The funicular process is closed below, but is open atiove. Raising the pelvis causes the fluid to trickle back into the peritoneal cavity. The treat- ment is a truss. Encysted hydroceles of the testicles and of the epididymis can occur. Diffused hydrocele of the cord is simply cedema of the cord. Hydrocele of a hernia is the distention of a hernial sac with peritoneal fluid. Haematocele.— Vaginal hematocele is blood in the tunica vaginalis, the result of traumatism, a tumor, or the tapping of a hydrocele. There is a pyriform tumor, which fluctu- ates, but which gradually becomes firmer; the scrotum is livid, and the testicle is below and posterior to the tumor. The encysted form of hematocele of the cord is a hydrocele of the cord into which bleeding has occurred. The diffused form is due to extravasation of blood into the cellular sub- stance of the cord. Encysted haematocele of the testicle is due to effusion of blood into an encysted hydrocele of the testicle. Parenchymatous haematocele is extravasation of blood into the substance of the testicle. The treatment of a recent case of vaginal haematocele is to put the patient to bed, support the scrotum, and apply an ice-bag over the testicle. If the swelling does not soon abate, incise, irrigate, and pack. Varicocele is varicose enlargement of the veins of the pampiniform plexus. An irregular swelling exists in the scro- tum and extends up the cord. This swelling feels like " a bag of earth-worms;" it exhibits a slight impulse on coughing; the scrotal skin and cremaster muscle are attenuated; the testicle lies at the bottom of the swelling and is softer and smaller than normal; the swelling diminishes on lying down and increases on standing or on making pressure over the AMPUTATIONS. 761 external ring. There is usually some discomfort, aching, or dragging in the testcle or the groin, and even neuralgic pain in the cord. There is sometimes mental depression and hypochondria. In treating varicocele, reassure the patient: tell him there is no real danger of impotence; order cold shower-baths, correct constipation and indigestion, give occa- sional tonics, and order the patient to wear a suspensory bandage. If the testicle becomes much atrophied, if the pain and the dragging are annoying, or if the mind is much depressed, operate (see p. 261). XXXVI. AMPUTATIONS. An amputation is the cutting off of a limb or a portion of a limb. Removal of a limb or a portion of a limb at a joint is known as "disarticulation." Amputation may be necessary because of the existence of severe injury, of gan- grene, of tumors, of intractable disease of bones or joints, of ulcers which will not heal, of traumatic aneurysm, etc. A re-amputation may be required because of the existence of a defect or disease in the stump. Classification.—Amputations are classified as follows: (1) As to time after the injury of operation : a primary amputa- tion is performed soon after the occurrence of the accident— as soon as the sufferer reacts from shock, and before he develops fever; a secondary amputation is performed some time after the accident, suppuration having supervened (Stokes); and an intermediate amputation is performed during the existence of fever, but before the development of sup- puration. (2) As to the situation, where the bone is divided or according to which joint is cut through. (3) As to the form and situation of the flap. In performing an amputation, maintain rigid asepsis ; com- pletely remove the hopelessly-damaged portion ; sacrifice as ro2 A MANUAL OF SURGERY. little of the sound tissue as possible; prevent hemorrhage during the amputation, and carefully arrest it after the opera- tion ; have enough sound tissue in the flap to cover the bone, and enough skin to cover the muscles; and secure drainage at a dependent point. Hemorrhage is prevented by the elastic bandage of Esmarch. In an ordinary case apply this bandage from the periphery to well above the line of the prospective incision, encircle the limb with the elastic band (not a thin tube), and remove the bandage. The bandage and band, which are asepticized before using, are applied to a limb wrapped with antiseptic towels. After the band has been applied the limb should not freely or forcibly be moved, because of the danger of tearing muscles which are firmly set by the compressing • band. When elastic compression is used in an operation the surgeon should be very careful to tie every visible vessel. The paralysis of the small vessels induced by pressure often prevents bleeding, and unless their mouths be found and the vessels be tied secondary hemorrhage will occur. Secondary hemorrhage is the great danger from the Esmarch bandage, and paralysis or sloughing may also follow its use. If there be an area of suppuration or of gangrene or an extra-osseous malignant growth, do not apply the bandage as directed above. One bandage can be applied from the periphery to near the lower border of the area of growth or infection, and another, from near the upper border of this area, up the limb. The contents of the area (tumor-cells and fluids or septic products) are not squeezed into the circulation. In cases like the above many surgeons hold the extremity in a ver- tical position for five minutes, lightly stroking it toward the * body with the hand, and at once apply the constricting band. Some surgeons prefer the tourniquet. To apply Petit's tourniquet, place the plates in contact, apply a small firm » compress over the artery and a broad thick compress over AMPUTATIONS. 763 Fig. 172.—Catlin, Knife, and Saws for Amputations. Fig. 173.—Modified Circular Amputa- tion of the Forearm (Bryant). f~\ f Fig. 174.—Amputation of Arm by the Circular Method (Druitt). Fig. 175.—Amputation of the Thigh by Transfixion (Gross). Fig. 17O.—Amputation of the Leg by a Long Posterior Flap (Gross). Fig. 177.—Sedillot's Amputation of Fig. 179.—Lisfranc's Amputation: second step 177 the Leg (Wyeth). (Guerin). 764 A MANUAL OF SURGERY. the outer surface of the limb, buckle the tapes around the limb so that the plate is over the broad pad, and tighten the tourniquet by separating the plates with the screw. When a tourniquet is applied to arrest bleeding during transporta- tion, bandage the limb, sew the compress pad to the band- age, and place the plates of the instrument over the pad. Signorini's horseshoe tourniquet may be used upon the brachial artery. In hip-joint and shoulder-joint amputations Wyeth's pins are passed, and after the limb is emptied of blood the band is fastened above them. These pins prevent the bands from slipping. The instruments and appliances required are Esmarch's apparatus or tourniquet, amputating-knives, a bone-knife, scalpels, saws, a lion-jawed forceps, bone-cutting forceps, a periosteum-elevator, retractors of linen, dissecting, haemo- static, and toothed forceps, a tenaculum, an aneurysm-needle, a probe, scissors, needles, ligatures, sutures of silkworm gut, dressings, bandages, and solutions. A retractor has two tails for the thigh and arm and three tails for the leg and fore- arm ; it is made by taking a piece of muslin eight inches wide and twelve inches long and cutting tails on one side eight inches in length. Methods of Amputating : Circular Method (Fig. 174).— The surgeon should stand to the right of the limb and use a long amputating-knife which cuts from heel to point. After an assistant has retracted the skin the operator divides the soft parts by a series of circular cuts. Do not cut at once to the bone, but divide the skin and subcutaneous tissues. At the retracted edge of the first cut divide the superficial muscles, and after these muscles retract divide the deep muscles. Incise the periosteum with a bone-knife, push up the periosteum with an elevator, and after the application of the retractors saw the bone. A periosteal flap can be made to cover the end of the bone, but it is unnecessary. AMPUTA TIONS. 765 Fig. 180. — Circular Amputation: up the skin-flap (Esmarch). dissecting In this amputation is formed a cone whose apex is the bone and whose base is the skin-edge. In one form of cir- cular amputation {ampu- tation a la manchelte) the retracted skin is cut by a circular sweep of the knife, a cuff of skin and subcu- taneous tissue is freed and turned up, and the muscles are cut circularly at the edge of the turned-up cut (Fig. 180). The pure cir- cular amputation is per- formed on the arm and the thigh ; the amputation a la manchctte is performed chiefly through the wrist and the lower forearm. Modified Circular Method.—In this operation the cir- cular skin-cut may be modified by making a vertical incision to join the first wound, the muscles being cut by a circular sweep or by making two vertical skin- incisions. Liston's modi- fication consists in dis- secting up two short semi- lunar integumentary flaps and in dividing the mus- cles circularly This is known as the " mixed method" (Fig. 181). The modified circular can be used upon the thigh, the leg, the arm, and the forearm. Elliptical Method.—This method stands midway between the circular operation and the operation by a single flap. An elliptical incision is made through the skin and subcu- Fig. 181.—Modified Circular Amputation: skin- flaps and circular through muscles (Esmarch) 766 A MANUAL OF SURGERY. 9 taneous tissues, the tissues are pushed up or turned back, and the muscles are divided circularly or cut partly by trans- fixion. This method is employed in certain disarticulations. Oval or Racket Method.—In an oval amputation the incision through the skin and subcutaneous tissue is an oval with a pointed end or a triangle, and the other parts down to the bone are cut from without inward. When a longi- tudinal incision down to the bone (Fig. 184, a, b) extends from the point of the oval {a, b), the operation is called the "racket" amputation. If the longitudinal cut joins a cir- cular cut, the operation is known as a "T" amputation. The oval or racket operation is performed at the metacarpo- phalangeal, metatarso-phalangeal, and shoulder-joints; the T operation may be performed at the hip-joint. Flap Method.—A flap may be composed of skin only or of both skin and muscle, but the skin must always be cut longer than the muscle, so that the latter will be covered by it. A flap containing much muscle heals badly, but the best flap has a moderate amount of muscle (enough skin to cover the muscle and enough muscle to cover the bone). Flaps may be single or double. Double flaps may be lateral or antero-posterior, square or ^-shaped, equal or unequal, and they may be cut by transfixion (Fig. 175), by cutting from without inward, by dissection, or by cutting the skin from without inward and the muscles by transfixion. When an amputation is completed, irrigate, tie the main vessels, pull down the nerves and cut them off, smooth the flaps, take off the constricting band, and after arresting hemorrhage apply sutures. In some cases the deep parts are stitched with a continuous catgut ligature and the superficial parts are closed with silkworm gut; in other cases the deep parts are not stitched at all, the skin alone being sutured with silkworm gut. Drainage-tubes should be used except in amputations of the fingers and toes. AMPUTATIONS. 767 Special Amputations: Fingers and Hand.—In ampu- tating the thumb and index finger, save every possible scrap of tissue. In either of the other fingers, if it be necessary to amputate above the middle of the middle phalanx, the attachment of the flexor tendons will be cut off and the finger will be liable to project directly backward, so that it is better with these fingers either to disarticulate at the meta- carpal joints or to stitch the flexor tendons to the perios- teum. The flexor tendons have fibrous sheaths extending from the proximal end of the distal phalanx to the meta- carpo-phalangeal articulations, these sheaths being thin and collapsible opposite the joints, but being thick and rigid opposite the shafts of the bone. The fibrous sheath is known as the theca, and when it is cut in an amputation it should be closed, otherwise it may carry infection to the palm of the hand. The theca does not exist over the distal phalanx, and it is not distinctly visible over the joint between the distal and middle phalanges. To effect closure over the shaft of a bone, strip up the periosteum and pass catgut sutures vertically through the theca and the periosteum (Treves). In amputation of the fingers and the thumb an Esmarch bandage is unnecessary, though pressure may be made upon the arteries in the wrist. Ligatures are often unnecessary. Close with a very few sutures, so as to favor drainage between the threads. The distal phalanx is best removed by a long palmar flap (Fig. 182, a). The palmar flap (a) is marked out by cutting through the skin and subcutaneous tissue. The incisions are next carried to the bone, the flap is dissected from the bone, the finger is strongly flexed, a transverse in- Fig. 182—Amputation cision (b) is carried across the dorsum on a level with the base of the third phalanx, the soft parts are pushed back, the joint is opened, the lateral ligaments are 768 A MANUAL OF SURGERY. cut from within outward, the third phalanx is forcibly ex- tended, and the remaining structures are cut from below upward. The middle phalanx can be removed by the same method (c). The proximal phalanx can be removed by a long palmar flap or by a long palmar and a short dorsal flap (d, e). Disarticulation of a metacarpo-phalangeal joint is best performed by the oval or racket method. The incision upon the dorsum (a) is begun just above the head of the meta- carpal bone, is carried down to beyond the base of the phalanx, and involves the skin only (Fig. 183). One incision sweeps around the finger at the level of the web, going only through the skin (b) ; the finger is extended and the palmar cut is carried to the bone; each lateral incision is car- ried to the bone while the finger is bent in the opposite direction, the flaps are Fig. 183.—Disanicuia- dissected back to the joint, the finger is ;:0nnge0a!jaoi^taCarP°"pha" strongly extended, the joint is opened from the palmar side, and disarticulation is effected. Cutting off the head of the metacarpal bone improves the appearance of the stump but weakens the hand, hence in a working-man it must not be done. If it is neces- sary to remove a metacarpal bone, the incision (c) is made from the carpo-metacarpal joint. Amputation of the thumb through its distal or proximal phalanx is performed identically as is an amputation of a finger. Amputation of the thumb with a portion or the whole of its metacarpal bone is performed by the oval or racket incision. Amputation at the wrist-joint can be done by the circu- lar method or by a double flap. In the double-flap amputa- tion (Fig. 98, 1, 2) a dorsal flap is made by carrying a semi- AMPUTA TIONS. 769 lunar skin-incision between the styloid processes; the skin is lifted up, the wrist is forcibly flexed, the joint is opened by a transverse cut, and a long semilunar palmar flap is made by dissection, which flap includes only the skin and fascia. Amputation through the forearm may be done as a circular (Fig. 174), a modified circular, or a flap operation. An excellent plan is to make a semilunar dorsal skin-flap (Fig. 98, 3) and a semilunar skin-flap on the flexor surface (Fig. 98, 4). The flaps are raised, the muscles are cut circu- larly (Fig. 173), the interosseous space is cleared with the knife, a three-tailed retractor is applied, the periosteum is pushed up, and the bones are sawn half an inch above the flap. In sawing the bones, start the saw upon the radius, draw it from heel to point, make a furrow on the radius and ulna, and saw both bones together. After sawing, cut away any irregular edge with bone-pliers. In the lower third Teale's amputation may be done, the dorsal flap being the long one (Fig. 97, 1). In Teale's amputation rectangular flaps are made. The long flap is equal in width and length to one-half the circumference of the limb at the point where it is to be sawn. The short flap is equal in width to the long flap, but is only one-fourth its length. The two longi- tudinal cuts are at first taken only through the skin, but the two transverse cuts go at once to the bone. The flaps are dissected up from the interosseous membrane and the bone. In the middle or the upper third of a fleshy arm two semi- lunar skin-flaps can be cut from without inward, and the muscle can be cut by transfixion. Disarticulation of the elbow-joint can be done by the elliptical method or by a long anterior flap and a short poste- rior flap. In the latter operation the forearm is partly flexed and a skin-cut marks out a long anterior flap, the knife being entered opposite the external condyle and being with- drawn one inch below the internal condyle (Fig. 98, 5). 49 770 A MANUAL OF SURGERY. The muscles, which are bunched forward, are cut by trans- fixion. A posterior semilunar flap is made (Pig. ioo, i), which separates the attachments of the radius, the ulna is cleared, and the triceps is cut at its insertion (Bell). Gross advocated sawing through the olecranon and the inner troch- lear surface. Amputation of the arm is best performed by marking out with a knife two equal semilunar antero-posterior flaps, the knife cutting through the skin, the muscles then being transfixed with a long knife (Fig. 99, 1). Teale's method is shown in Figure 98 (6). The circular or the modified circu- lar amputation may be performed. Disarticulation at the Shoulder-joint.—In this operation Wyeth's pins must be passed to prevent hemorrhage. The anterior pin is entered at the middle of the lower margin of the anterior axillary fold, and emerges one inch within the tip of the acromion. The posterior pin is entered at a cor- responding point on the posterior axillary fold, and emerges more posteriorly than the first pin and an inch within the tip of the acromion. Larrey's Operation.—In this method of shoulder-joint dis- articulation the limb is held from the side and an incision is made down to the bone, the in- cision beginning just below and in front of the acromion and running vertically for four inches down the outer surface of the arm (Fig. 184, a, b). From the centre of this incision an oval incision is carried around the arm, the inner Fig. 184.—Ampu- tation at the shoui- aspect of the oval reaching as low as the lower der-joint:A B,Lar- end of thg vertical cut U £). The OVal in- rey s operation; i, v » / 2, Dupuytren's op- cision at first involves only the skin and sub- cutaneous tissues. The anterior structures are divided close to the bone, and the posterior structures are next cut. To disarticulate, cut the capsule transversely upon AMPUTATIONS. 771 the head of the bone; while the arm is rotated outward cut the subscapularis, and while the arm is rotated inward cut the supraspinatus and infraspinatus and the teres minor. Cut away any tissue holding the humerus to the body, cut away hanging nerves, capsule-fragments, and tissue-shreds, and sew up the wound vertically. Bell advises an oval in- cision without a racket handle (Fig. 98, 7). Spence used an anterior racket incision. Dupuytren's Method.—In Dupuytren's shoulder-joint dis- articulation a U-shaped flap is marked out by a skin-incision (Fig. 184, I, 2; Fig. 97, 3). In the right shoulder the arm is carried across the chest; the knife is entered at the root of the acromion, follows the margin of the deltoid, and is withdrawn at the coracoid process, the arm being gradually abducted and pulled off from the chest. In the left shoulder the procedure is reversed (Treves). The knife now cuts through the deltoid and raises a flap composed of this mus- cle, the shoulder-joint is exposed, and disarticulation is ef- fected as in Larrey's method. The knife is passed down back of the bone and a short internal flap is cut. , > Lisfranc's amputation is by transfixion with I j the formation of an anterior and a posterior ( \ flap, and can be performed very rapidly, but j only a most skilful surgeon should attempt it. \ Amputation of the Toes and the Foot.— A Only in the great toe is partial amputation i— \ j performed, and it is performed by a long { / . hi plantar flap as is done in the finger. Am- jA^Jw/r' putation at the metatarso-phalangeal joints is \qJ yoT performed by an oval or racket incision (Fig. FlG. l85.-AmPu- 185). Amputation of a toe with removal of udon of Metatarsal its metatarsal bone is shown in Figure 185. Amputation at the Tarso-metatarsal Articulation.— Lisfranc's Method (right foot, after Treves).—-Begin an incis- 772 A MANUAL OF SURGERY. ion on the outer border of the foot, behind the tubercle of the fifth metatarsal bone; carry the incision forward one inch and sweep it across the foot half an inch below the tarso- metatarsal articulations; bring the incision to the inner edge of the foot, half an inch in front of the tarsal articulation of the big toe, and carry the cut straight along the inner margin of the foot until it reaches a point three-fourths of an inch above the articulation of the metatarsal bone of the great toe. A semilunar dorsal skin-flap is thus formed (Figs. 178, 179). After the skin-flap is dissected back for a quarter of an inch the tendons are divided, and the flap, which now contains all the soft parts, is dissected back to above the joint. A long plantar flap is cut, reaching from the origin of the first flap to the necks of the metatarsal bones. The skin-flap is dissected up until the hollow behind the heads of the metacarpal bones is reached, when, with the toes in extension, the tendons are cut across and a flap composed of all the soft parts is dissected up to above the tarso-meta- § tarsal joint. The joint is opened from the outer side according to the following rule : In separating the fifth metatarsal, direct the edge of the knife toward the distal end of fume ° the first metatarsal; in separating the fourth metatarsal, direct the knife toward the middle of the first metatarsal; in separat- ing the third metatarsal, carry the knife almost directly across. Figure 186 shows the line of Lisfranc at the tarso-metatarsal . A articulation. The separation is facilitated Fig. 186.—Lines in Am- x putations of the Foot by bending down the front of the foot, and at the same time the tendons of the pero- neus brevis and tertius are divided. Open the joint between the first metatarsal and the inner cuneiform bone, turning the knife toward the middle of the shaft of the fifth metatarsal, AMPUTA TIONS. 771 and at the same time divide the tibialis anticus muscle. Treves says that in disarticulation of the second metatarsal the knife is to be held as a trocar, it is to be thrust between the base of the first and second metatarsal bones until the point strikes bone (Fig. 178), and is then to be raised to a perpen- dicular and the cut is to be made toward the external malle- olus to sever the ligament of Lisfranc (Fig. 179). Divide, any remaining ligaments, and also the tendon of the peroneus longus muscle. The skin-incisions in the left foot are begun on the inner side, and in disarticulating the tarsal joint of the great toe is first opened. Hey's Method.—In Hey's method the incision is practically the same as that for Lisfranc's amputation (Fig. 98, 8, 9). The four external metacarpal bones are disarticulated, but the first metatarsal is removed by sawing a portion of the internal cuneiform bone. Guerin advised sawing all the bones across. Skey advised the division of the head of the second metatarsal. Figure 186 shows the line of Hey. Amputation through the Middle Tarsal Joint.—Chopart's Amputation.—Make a transverse incision through the skin of the instep, two inches below the ankle-joint; cut the ten- dons and muscles, expose the tarsus (Fig. 97, 4, 5), and make on each side a small longitudinal incision reaching to below and in front of the corresponding malleolus. The flap thus formed is retracted. The plantar flap is made as in Lisfranc's amputation. Open the astragalo-scaphoid joint, then the calcaneo-cuboid joint, and disarticulate. Figure 186 shows the line of Chopart. In amputation through the tarsus Forbes of Toledo advises making flaps as in Chopart's am- putation, disarticulating the scaphoid from the cuboid bones, and sawing through the cuboid. Figure 186 shows the line of Forbes. Amputation at the Ankle-joint.—Syme's Method.—The foot is held at a right angle to the leg, and a skin-incision is 774 A MANUAL OF SURGERY. t carried, from just below the external malleolus, straight across or a little backward across the sole to a correspond- ing point on the opposite side (Fig. 98, 10, 11). Do not take this incision near to the inner malleolus, as to do so will en- danger the posterior tibial artery. The incision is carried to the bone, the flap being pushed back and separated from the bone by means of a strong knife and the thumb-nail until the tuberosity of the os calcis has been reached. The foot is now extended and a transverse cut is made across the dorsum, joining the two ends of the first incision (Fig. 98, 10, 11); the ankle-joint is opened, the lateral ligaments are cut, disarticulation is effected, and the foot is finally com- pletely removed by severing the tendo Achillis. A thin piece of bone including both malleoli is sawn from the tibia and fibula. The flap is perforated posteriorly to secure drainage. Pirogoff's Method.—In this method of ankle-joint ampu- tation the incisions are the same as those for Syme's amputa- tion. Do not dissect the flap from the posterior portion of the os calcis, but saw off this bony projection obliquely and leave it adherent to the tissues. The saw is used after disarticula- tion of the ankle-joint; it is passed behind the astragalus, cutting downward and forward. The ends of the tibia and fibula are sawn off, and the sawn os calcis is brought into contact with the sawn tibia and fibula. Amputations of the Leg.—In amputations of the leg by the long anterior fiap, cut through the skin (Fig. 99, 4, 5), dissect up the anterior muscles with the flap, and cut all the posterior tissues with a single transverse sweep. In ampu- tation by rectangular flap Teale's method is very useful (Fig. 98, 12, 13). Sedillot's leg-amputation (Fig. 177) is by a long exter- nal flap. A longitudinal incision is made along the inner edge of the tibia, the tissues are drawn toward the fibula, 1 AMPUTATIONS. 77S a knife is introduced and passed to the outer edge of the tibia, just touching the fibula, and is brought out posteriorly, thus transfixing the calf-muscles and cutting an external flap. A convex incision is made on the inner side, the bones are cleared and are sawn one inch above the flaps, half an inch 1 more being taken from the fibula than from the tibia, and the tibia being bevelled anteriorly. Modified Circular Amputation of the Leg.—Cut semi- lunar skin-flaps (Fig. 99, 6, 7), lay them back, and cut circu- larly to the bone at the edge of the turned-up flap. Another method of modified circular amputation is by adding to the circular cut a vertical incision down the front of the leg. In sawing the bones of the leg, the surgeon, who stands on the • outer side of the right leg or on the inner side of the left leg, divides the fibula first, and at a higher level than the tibia, and bevels the anterior surface of the tibia. In sawing the left fibula the saw points to the floor; in sawing the right fibula it points to the ceiling. Amputation of the Leg by a Long Posterior and a Short Anterior Flap.—In this operation a posterior U-shaped flap is made, equal in length and breadth to the diameter of the limb. The skin-incision is begun one inch below the point where the bone is to be sawn, and behind the inner edge of the tibia, and is carried to a point posterior to the peronei muscles. The gastrocnemius muscle is divided trans- versely at the level of the flap, the soft parts on either side in the line of the flap being cut to the bone. Through these vertical cuts the muscles are lifted from the bones and are divided through their lower part by cutting from within 1 outward. The anterior flap is formed by making a semi- lunar skin-flap and by cutting the muscles across at its retracted edge (Fig. 176). Amputation of the leg by lateral flaps is not a popular operation, as it offers too much en- couragement to subsequent protrusion of the bone. «76 A MANUAL OF SURGERY. Amputation just below the Knee.—The seat of election is one inch below the tuberosities. No muscle is needed in the flap. Cut two flaps of skin, equal in size and semilunar in shape, these flaps beginning anteriorly two inches below the tuberosity of the tibia. One flap is antero-external and the other is postero-internal (Fig. 99, 6, 7). The flaps are pulled up, the anterior muscles are cut as high up as pos- sible, and the posterior muscles are cut through the middle of the portion exposed (Bell). The bone is sawn one inch below the tuberosity. Disarticulation of the Knee.—In disarticulation by the long anterior flap (Carden's amputation; Fig. 97, 8), make a long anterior skin-flap, incise the ligament of the patella, turn up the flap with the patella, open the joint, and make a short posterior flap by cutting from within outward and downward. The knee may be disarticulated by means of a long anterior and a short posterior flap (Fig. 97, 6, 7). Amputation through the Femoral Condyles.—Syme's Method by a Long Posterior Flap (Figs. 99, 100, 4, 8).—Carry a skin-incision with a very slight downward curve from one condyle to the other, across the middle of the patella. Cut down to the bone, retract the flap, and cut the quadriceps above the patella. Insert a long knife at one angle of the wound, pass it back of the femur, and make it emerge at the opposite angle, cutting a posterior flap eight inches long. Retract the posterior flap, clear for sawing, and section the condyles horizontally. Amputation of the Thigh.—In thigh-amputation in the lower third either a flap or a circular operation may be per- formed. In a double-flap operation a semilunar skin-incision should be made from without inward and the muscles should be cut by transfixion (Fig. 187). In the lower third Teale's flap (Fig. 97,9, 10) or the long anterior flap may be employed. The amputation by a long anterior flap consists in making AMPUTATIONS. 777 a lengthy skin-flap, reflecting it, cutting the anterior struc- tures to the bone, again entering the long knife at one angle of the incision, pushing it back of the femur, bringing it out at the other angle, and cutting the struc- s' ^ tures back of the bone directly backward (Fig. 98,16). Bell amputates by a long anterior semi- lunar flap and a short posterior flap. In am- putations in the upper two-thirds of the thigh the best plan is to mark out equal anterior and .. „ " . r , _.. . .„ * tiG. 187.—Amputation of the Ihigh (Bryant). posterior semilunar skin-flaps, enter the long knife at one angle of the anterior flap, bring it out at the other angle, and cut the muscles by transfixion (Fig. 175). Cut the posterior flap in the same manner. Some surgeons prefer a long anterior semilunar flap and a short posterior semilunar flap. The pure circular is not adapted to the thigh. Disarticulation of the Hip-joint.—In the bloodless method of Wycth (Fig. 188) the band of the Esmarch apparatus is held up by Wyeth's pins, the outer pin being inserted one and a half inches below and a little internal to the anterior superior spine of the ilium, and brought out just back of the great trochanter. The inner pin is entered one inch below the level of the crotch, internal to the saphenous opening, and it emerges one and a half inches in front of the tuberosity of the ischium. The hip is brought well over the edge of the table, a circular incision is made down to the deep fascia six inches below the constricting band, and joined by a longitudinal skin-cut reaching from the incision to the level 778 A MANUAL OF SURGERY. of the circular incision, and the cuff is reflected to the level of the lesser trochanter. Cut the muscles by a circular sweep at the level of the retracted cuff, open the capsule freely, cut the cotyloid ligament posteriorly, have the thigh bent upward, forward, and inward to dislocate the head of the bone, and, using the thigh as a handle, incise the round ligament and remove the limb. After ligating the vessels and introducing tubes the flaps are sewn together vertically. Fig. 188.—Amputation at the Hip-joint: Wyeth's bloodless method. The old transfixion operation is practically extinct. A T'-amputation may be employed. It consists of an external straight incision down to the bone, starting over the great trochanter, down the outer side of the limb, and a circular incision through the skin five inches below the constricting band, the muscles being cut by a circular sweep at the level of the retracted skin. This method affords easy access to the joint. The bloodless method of Wyeth, as applied to the hip-joints and shoulder-joints, is one of the most notable modern advances in the art of surgery. BRONCHOCELE. 77g Broxchocele, or Goitre. A goitre is an enlargement of the thyroid gland not due to malignant tumor or to inflammation. Goitre may affect a por- tion of one lobe, both lobes, or both lobes and the isthmus, • and it may occur sporadically or endemically. In Switzerland it is very common. Among the alleged causes are the playing of wind-instruments, the drinking of snow-water, and the use of water impregnated with the salts of. lime. Hereditary influ- ence is frequently noted. The forms of goitre are as follows : Simple hypertrophy, a hypertrophy of the gland-tissue, usually symmetrical; cystic goitre, in which cysts form in hypertro- phied glands, or rarely in non-hypertrophied thyroids, the • cysts being either single or multiple, being due to mucoid or colloid degeneration, and containing a fluid sometimes clear and thin, sometimes viscid, and often coffee-ground in charac- ter ; and fibrous goitre, a fibrous induration which is apt to arise in old bronchoceles, and which may pass into a calca- reous condition. The symptoms are—congestion of the head and neck from enlargement of veins; occasionally cerebral symptoms (anae- mia, syncope, even convulsions) from pressure on carotids; irritation of recurrent laryngeal nerve (causing spasm of the glottis or laryngeal paralysis); compression of the trachea (dyspncea). Rapidly-growing goitres (acute goitres) are often fatal; slow-growing goitres are rarely fatal. A goitre moves with the gullet in swallowing. Treatment.—Medical treatment of goitre is of little use. Iodide of potassium and arsenic internally have been ad- vised ; ointment of red oxide of mercury locally is advocated by some writers. The only hopeful methods are surgical. Cystic goitres may be aspirated and injected with a solution of iodine. Electrolysis may benefit a soft goitre, the negative pole being pushed into the growth, the positive pole being 780 A MANUAL OF SURGERY. applied to its surface. Ligation of the thyroid arteries has been recommended by some surgeons. The radical opera- tion is the removal of the mass (thyroidectomy). It is a bloody and dangerous operation, and during its performance and for a time after its completion the patient is liable to sudden and fatal collapse. The entire gland must not be removed: a bit of it is always allowed to remain, otherwise cachexia strumipriva (or myxcedema) may arise. Exophthalmic or Pulsating Goitre.—In this condition there are palpitation of the heart, rapid pulse, protrusion of the eyeballs, and enlargement of the thyroid gland. It is a vaso-motor ataxia (Cohen) resulting from disease of the sympathetic system. Von Graefe's sign is retraction of the upper lids and a failure of the lids to follow the eyes when looking down. A systolic bruit can be heard over the goitre. The goitre is usually bilateral, but may be unilateral, and it may be intermittent or persistent. Emo- tional causes are influential in its production. Nystagmus, tremor, flashes, haemoptysis, haematemesis, and mental dis- turbances are apt to occur. Exophthalmic goitre may be treated by aconite, belladonna, digitalis, or strophanthus. Electricity may be used. Extirpation has been tried, but it is scarcely considered advisable. XXXVII. ASEPSIS AND ANTISEPSIS. Surgical cleanliness may be obtained by either the aseptic or the antiseptic method. In the aseptic method heat, chemical germicides, or both are used to cleanse the instru- ments, the field of operation, and the hands of the surgeon and his assistants. After the incision has been made no chemical germicide is used, the wound being simply sponged with gauze sterilized by heat; if irrigation is necessary, boiled water is used, and the wound is dressed with P-auze ASEPSIS AND ANTISEPSIS. 781 which has been rendered sterile by heat. The aseptic method should be used only in non-infected areas. The elimination of chemical germicides lessens serous flow and often enables the surgeon to dispense with drainage- tubes. If irrigation is not practised and the wound is dressed with dry gauze, the procedure is said to be by the " dry" method. In the antiseptic method the same preparations are made for the operation as in the aseptic method, but during the operation sponges impregnated with a chemical germicide are used, and the wound is dressed with gauze containing corrosive sublimate. If the wound is not flushed with a chemical germicide, and is dressed with dry gauze, the operation is said to be by the " dry " antisep- tic method. The antiseptic method is always preferred in infected areas. Dry dressings are usually preferable to moist dressings, because they are more absorbent and do not act as poultices, and dry dressings may be used even when the wound has been flushed. Preparations for an Operation.—The surgeon and his assistants remove their coats, roll up their sleeves, and envelop their bodies in aseptic or antiseptic sheets to pro- tect the patient and themselves. The hands and forearms are scrubbed with soap and hot water. There is nothing equal to the ethereal soap of Johnson, which is a solution of castile soap in ether. The brush employed is kept constantly in a 1 : IOOO solution of corrosive sublimate. The nails are cut short, are cleansed with a knife, and the hands are again scrubbed. The hands are dipped in a hot solution of corrosive sublimate, and with the fore- arms are scrubbed for at least a minute, the nails receiving especial care; they are then dipped for one minute into pure alcohol and are again bathed with .the mercurial solution. Kelly disinfects the hands by washing them with soap and water, dipping them in a solution of permanganate of potas- 782 A MANUAL OF SURGERY. sium (a saturated solution in boiling distilled water), and decolorizing them in a saturated solution of oxalic acid. Instruments are disinfected by boiling for fifteen minutes in a I per cent, solution of carbonate of sodium and then rinsing them in a 5 per cent, solution of carbolic acid. They are kept in trays containing boiled water. Instruments can be disinfected satisfactorily by keeping them for fifteen minutes in a 5 per cent, solution of carbolic acid. Instruments with handles of wood must not be boiled, but they are disinfected by carbolic acid. After the completion of the operation the instruments should be scrubbed with soap and water, boiled, and dried. Marine sponges are rarely used, small pieces of sterilized or antiseptic gauze being.preferred. In the abdo- men Ashton's aseptic gauze pads are employed. These pads are about ten inches square, and are made of a number of folds of gauze stitched loosely at the edges. Whenever possible, give the patient some days' rest in bed before a severe operation, and place him on a diet nutritious but not bulky. The night before the operation give a saline cathartic, and the morning of the operation employ an enema. When- ever possible, give a general warm bath the day before. The evening before the operation scrub the entire field and well clear of it with soap and water, shave if necessary, wash with ether, scrub well with hot corrosive-sublimate solution (1 : 1000), apply a layer of moist corrosive-sublimate gauze, and place over this dry antiseptic gauze, a rubber dam, and a bandage. On removing the dressings to perform the operation, scrub the part again with hot mercurial solution. In emergency cases disinfection must be practised just pre- vious to the operation. The favorite ligature material is catgut, which is well pre- pared by boiling in alcohol. Another method is to take the raw catgut, soak it in ether for twenty-four hours, soak it for twenty-four hours in an alcoholic solution of corrosive ASEPSIS AND ANTISEPSIS. 783 sublimate (1 : 500), wind it on sterilized glass rods, and place it for keeping in ether or in alcohol. Fowler's cat- gut is carried in tubes of alcohol hermetically sealed, each tube holding twelve ligatures. Johnson's quick method of preparing catgut is as follows : Place it for twenty-four hours in ether; at the end of this period place it in a solution con- taining 20 grains of corrosive sublimate, 100 grains of tartaric acid, and 6 ounces of alcohol. The small gut is kept in this for ten or fifteen minutes, the larger gut from twenty to thirty minutes, but never longer. It is placed for keeping in a mix- ture containing 1 drop of chloride of palladium to 8 ounces of alcohol. This gut is strong and reliable. At the time of operation the gut is placed in a solution two-thirds of which • is 5 per cent, carbolic-acid solution and one-third of which is alcohol. Chromicized gut will not be absorbed so readily as other gut. It is prepared by adding 200 parts by weight of catgut to 200 parts of carbolic acid, 2000 parts of water, and 1 part of chromic acid. After remaining in this solution twenty-four hours it is transferred for permanent keeping to ether or to alcohol. Sutures of silk should be well boiled before using. A convenient method of preparation is to wind the silk on a glass spool, place the spool in a large test-tube, close the mouth of the tube with absorbent cotton, introduce the tube into a steam sterilizer, and keep it there for one hour. These tubes are carried in wooden boxes sealed with rubber corks. Silk- worm gut is prepared by. placing it in ether for forty-eight hours and in a solution of corrosive sublimate (1 : 1000) for one hour. It is carried in a long tube filled with alcohol. A few minutes before using, the gut is placed in carbolic acid and alcohol (two-thirds of a 5 per cent, solution of acid, one-third of alcohol). Silver wire is prepared by boiling. • Dressings are made of cheese-cloth. This cloth is boiled in a solution of carbonate of soda, rinsed out, and dried; 784 A MANUAL OF SURGERY. it is then soaked for twenty-four hours in a solution contain- ing 1 part of corrosive sublimate, 2 parts of table-salt, and 500 parts of water. It is kept in jars, and it may be main- tained moist or dry. Sterilized gauze is prepared by boiling the material in soda, rinsing, and either boiling it for fifteen minutes or placing it in the steam sterilizer for the same time. Iodoform gauze is useful for packing and for dressing foul wounds. It is prepared as follows: Make an emulsion com- posed of equal quantities by weight of iodoform, glycerin, and alcohol, and add corrosive sublimate in the proportion of 1 part to the iOOO of the mixture. This mixture stands for three days. Take moist bichloride gauze, saturate it with the emulsion, let it drip for a time, and keep it in sterilized and covered glass jars (Johnson). Lister's cyanide gauze (double cyanide of zinc and mercury) must be dipped into a corrosive-sublimate solution (1 : 2000) before using. All antiseptic appliances can be bought ready prepared from reliable firms. Small wounds in which drainage is not em- ployed may often be dressed by laying a film of aseptic ab- sorbent cotton over the wound and applying, by means of a clean camel's-hair brush, iodoform collodion (grs. xlviij to ,$j). When a wound is dressed with gauze a rubber dam must always be laid over the dressings, so as to diffuse the dis- charge and prevent it from coming rapidly to the surface. Drainage is obtained when needed by rubber tubes or by strands of horsehair, silkworm gut, or catgut, but these three last-named materials will not drain off pus. Dressings must be changed as soon as soaking is apparent. Stitches may usually come out about the sixth day. In large wounds only a portion of them are taken out at one time, the balance being allowed to remain for a couple of days longer. When a stitch begins to cut it is doing no good, and it should be removed, no matter how short a time it has been in place. ASEPSIS AND ANTISEPSIS. 785 Preparation of Marine Sponges.—Beat out the dust; place them for forty-eight hours in a solution of hydrochloric acid (15 per cent.); wash them out with water; place them for one hour in a solution of permanganate of potassium (3iij to 5 pints of water); soak for four hours in a solution contain- ing 10 ounces of hyposulphite of sodium, 5 ounces of hydro- chloric acid, and 3 pints of water; wash with running water for six hours. Keep the sponges in a jar containing corro- sive-sublimate solution (1 : 1000). After using, wash in hot water, soak for half an hour in a solution of sodium carbonate (1 : 32), wash in hot water, and replace in corrosive sublimate. A marine sponge inevitably becomes foul in its interior, and should not be used. To clean the vagina or rectum, use a sponge soaked with creolin and Johnson's ethereal soap (1 : 16), and subsequently irrigate with corrosive-sublimate solution. Senn's Decalcified Bone-chips.—Take the shaft of the tibia or femur of a recently killed ox, saw it into portions two inches in length, remove the marrow and periosteum, and place the bits of bone in a 15 per cent, solution of hydro- chloric acid. Change the solution every twenty-four hours. In from two to four weeks the bone will be decalcified. Wash in distilled water, place the bone in a dilute solution of potash to neutralize the acid, and then immerse for twenty-four hours in distilled water. The portions of bone are now cut into strips in the direction of the long axis of the segments, each strip being three-quarters of an inch wide and being sliced up into bits one millimetre thick. These chips are kept in an alcoholic solution of corrosive sublimate (1 : 500). 50 « • • • I INDEX. Abbe's catgut ring, 638 method of intestinal anastomosis, string saw, 613 Abdomen, diseases of, 606 injuries of, 606 operations upon, 629 Abdominal section, 629 bleeding in, 253 for appendicitis, 631 wall, contusion of, 606 gunshot wound of, 610 penetrating wound of, 610 wounds of, 610 Abscess, acute, 90, 91 appendicinal, 92, 622, 625 Brodie's, 298 cerebral, from ear disease, 559 chronic, 97 cold, 97 of lymphatic glands, 99 dorsal, 98 extradural, 559 * forms of, 90 gluteal, 403 iliac, 99 ischio-rectal, 662 lumbar, 99, 403 lymphatic, 97 mediastinal, 93 metastatic, 123, 128 of antrum of Highmore, 93, 583, of bone, 298 of the brain, 556 » of the cerebellum, 566 of the hip, 403 of the kidney, 705 of the larynx, 93 of the liver, 92 of the lung, 93 of the maxillary antrum, 584 of the prostate gland, 93, 748 Abscess of the scalp, 534 of the temporo-sphenoidal lobe, 565 Paget's, 91 palmar, 511 perinephric, 93, 706 psoas, 99, 403 residual, 91, 144 retro-pharyngeal, 93, 98 scrofulous, 97 tubercular, 90, 97, 142 Abscesses, 88 Acid, carbolic, as an antiseptic, 782 Actinomyces, 164 Actinomycosis, 19, 164 Acupressure in aneurysm, 240 Adams's operation, 474 Adenitis, chronic, 684 tuberculous, 144 Adenomata, 216 cystic, 217 Adhesions, 426 Agnew's operation for webbed fingers, 520 Air-passages, foreign bodies in, 585 Alcoholic unconsciousness, 541 Aleppo boils, 680 Alimentary canal, foreign bodies in, 611 Allis's ether-inhaler, 669 signs, 374 Alopecia of syphilis, 176 Amputation, 761 a la manchette, 765 at ankle-joint, 773 Pirogoff 's method, 774 Syme's method, 773 at elbow-joint, 769 at hip-joint, 777 Wyeth's method, 777 at metacarpophalangeal joints, 768 at shoulder-joint, 770 Dupuytren's method, 771 787 788 INDEX. Amputation at shoulder-joint, Larrey's method, 770 Lisfranc's method, 771 at wrist-joint, 768 Chopart's, 773 circular, 764 modified, 765 elliptical method, 765 flap method, 766 for aneurysm, 240 for gangrene, 121 intermediate, 761 methods of, 764 modified circular method, 765 of arm, 770 of fingers, 767 distal phalanx of, 767 middle phalanx of, 768 proximal phalanx of, 768 of foot, 771 Chopart's method, 773 Forbes's method, 773 Hey's method, 773 Lisfranc's method, 771 of forearm, 769 Teale's operation, 769 of hand, 767 of leg, 774 below the knee, 776 Carden's method, 776 lateral flaps, 775 long anterior flap, 774 long posterior and short anterior flap, 775 modified circular, 775 rectangular flaps, 774 Sedillot's method, 774 Syme's method, 776 through the femoral condyles, 776 through the knee-joint, 776 of penis, 755 of thigh, 776 Teale's flaps in, 776 of toes, 771 oval method, 766 primary, 761 racket method, 776 secondary, 761 T-shape of, 766 through middle tarsal joint, 773 Wyeth's bloodless, of hip-joint, 777 Wyeth's pins in, 764 Amputations, special, 767 Amylene, 666 Amyloid degeneration, 404 Anaesthesia, 666 general, 666 local, 673 preparations for, 666, 667 primary, 673 treatment of complications in, 671 Anaesthetic state from chloroform, 670 from ether, 670 Anaesthetics, 666 genera], 666 local, 666 Anastomosis, intestinal, 637 with rings, 637 without rings, 638 Anastomosis-rings, 637 Anderson's method of tendon-lengthen- ing, 5X7 Aneurysm, 229 acupressure in, 240 acute, 230 amputation for, 240 arterio-venous, 230, 241 by anastomosis, 230, 242 capillary, 231 circumscribed, 231 cirsoid, 209, 231, 242 consecutive, 230 cylindrical, 231 diffused, 244 dissecting, 230 distal ligation in, 239 embolic, 231 false, 229 forms of, 230 fusiform, 230 miliary, 231 of bone, 231 operation for, Anel's, 237 Antyllus's, 237 Brasdor's, 239 Hunter's, 238 Wardrop's, 239 operative treatment of, 237 sacculated, 230 secondary, 231 spontaneous, 231 traumatic, 230-240 treatment of, by ligature, 237 true, 229 verminous, 231 Angeiomata, 208 INDEX. 789 Angeiomata, capillary, 208 cavernous, 209 plexiform, 209 simple, 208 Ankle-joint disease, 409 osteoplastic resection in, 409 Syme's amputation in, 409 Ankylosis, 425 bony, 426 extra-articular, 428 false, 428 fibrous, 426 intra-articular, 425 osseous, 426 true, 426 Antagonistic microbes, 30 Anthrax, 160 benign, 680 forms of, 160 Antisepsis, 780 Antiseptic surgical cleanliness, 780 Antitoxine of tetanus, 137 Antitoxines, 27 Antrum of Highmore, inflammation of, 5»3 injuries of, 583 Anus, diseases of, 654 fissure of, 665 injuries of, 654 prolapse of, 658 pruritus of, 665 Apoplexy, 540 Appendicitis, 620 abdominal section for, 631 bacterium coli commune a cause of, 621, 622 catarrhal, 622, 623 caused by foreign bodies, 622 by scybalae, 621, 622 cellulitis in, 622 etiology of, 621 gangrenous, 623, 624 local, peritonitis in, 622 obliterative, 623 operation for, 631 pathology of, 621 perforation in, 622-624 recurrent, 623 septic peritonitis in, 622 simple parietal, 623 stercoral, 622 suppurative, 624 symptoms of, 624 Appendicitis, traumatic, 622 treatment of, 625 Appendicular abscess, 92, 622-625 colic, 622-624 Arachnitis, 551 Ardor urinae, 747 Areas, motor, 533, 534 Arterial piles, 656 rupture with fracture, 326 sclerosis, 228 transfusion, 265 Arteries, calcification of, 228 inflammation of, 227 ligation of. See Ligation. wounds of, 243 Arteritis, acute, 227 chronic, 228 obliterative, 228 syphilitic, 178, 228 Arthrectomy, 481, 482 of knee-joint, 482 Arthritis, 397 deformans, 416 gonorrhoeal, 412 gouty, 415 infective, 411 neuropathic, 419 rheumatic, 414 septic, 411 tubercular, 398 Arthropathie des ataxiques, 431 Arthropathy, tabetic, 419 Articular injuries, 422 wounds, 422 Artificial respiration in anaesthesia, 672 Asepsis, 780 Aseptic gauze, 784 surgical cleanliness, 780 wounds, 149 Aspiration of bladder, 713 of joints, 480 Aspirator, pneumatic, 480 Atheroma, 228 Atony of bladder, 716 Atrophy of bone, 295 of muscles, 505 Auto-suggestion, 577 Bacillus, 20 mallei, 33 of anthrax, 33 of glanders, 33 of gonorrhoea, 32 /9° INDEX. Bacillus of Koch, 32 of Lustgarten, 33 of malignant cedema, 33 of Neisser, 32 of Nicolaier, 32 of syphilis, 33 of tetanus, 32 of tubercle, 32, 138, 139 pyocyaneus, 31 Bacteria, 17-19 distribution of, 24 effects of heat and cold upon, 23 life-conditions of, 22 motile, 17 multiplication of, 21 pathogenic, 19 Bacteriology, 17 Bacterium coli commune of Escherich, 621, 622 Balanitis, 748 Balano-posthitis, 748 Bandage, anterior figure-of-8, of shoul- ders, 690 Barton's, 689 Borsch's, of eye, 688 circular, 685 crossed, of angle of jaw, 689 of eye, 688 demi-gauntlet, 686 Desault's, 691 Esmarch's, 762 gauntlet, 686 Gibson's, 689 handkerchief, 692 oblique, of jaw, 689 of elbow, 690 of foot covering heel, 687 not covering heel, 687 of neck and axilla, 690 posterior figure-of-8, of the shoulder, 690 recurrent, of head, 692 of stump, 692 Ribble's, 688 spica, of groin, 690 of instep, 688 of shoulder, 690 spiral, 685 of fingers, 686 reversed, 685 of lower extremity, 687 of upper extremity, 686 T, of perineum, 692 Bandage, Velpeau's, 350, 390 Bandages, 685 Barton's bandage, 689 Bassini's operation for femoral hernia, 646 for inguinal hernia, 646 Bed-sores, 107, 120 Bees, stings of, 157 Bent tibia, osteotomy for, 473 Bichat's fissure, 530 Bigelow's operation for vesical calculi, 73° Bigg's apparatus for bunions, 515 Bites of insects and reptiles, 157, 158 of snakes, 159 Bladder, aspiration of, 713 atony of, 716 contusion of, 714 extraperitoneal rupture of, 715, 716 female, growths in, 736 injuries of, 714 intraperitoneal rupture of, 715, 716 operations on, 726 rupture of, 715, 716 stone in, 717 tumors of, 725 Blastomycetes, 18 Bleeding from kidney-substance, 697 from pelvis of kidney, 697 from ureter, 697 to death, 250 Blind boil, 679 Blood, tests for, 696 transfusion of, 263 Boils, 679 endemic, of tropics, 680 Bond's splint, 369 Bone, abscess of, 298 aneurysm, 231 atrophy of, 295 hypertrophy of, 295 inflammation of, 295 plates of Senn, 638 transplantation of, 477 Bone-chips, Senn's decalcified, 785 in treatment of necrosis, 303 Bone-felon, 512 Bone-grafting, 477 Bones, diseases of, 295 excision of, 481 open method, 481 subperiosteal method, 481 injuries of, 295 INDEX. 791 Bones of skull, diseases of, 535 malformations of, 535 operations on, 470 Borsch's eye-bandage, 688 Bougie, filiform, 752 oesophageal, 604 Bowel-obstruction, 613 Bow-legs, 521 Brain, abscess of, 556 compression of, 540 concussion of, 538 disease of, from ear disease, 558 hernia of, 551 inflammation of, 551 lacerations of, 538 malformations of, 536 operations on, 562 technique of, 564 traumatic inflammation of, 551 tuberculosis of, 144 tumor of, 557 water on, 553 wounds of, 549 Broca's regional terms, 530 Brodie's abscess, 298 joint, 420 Bromide of ethyl, 666 Bronchocele, 779 Bruises. See Contusions. perineal, 736 Bryant's triangle, 375 Bubo of chancroid, 753 of gonorrhoea, 748 syphilitic, 171 Bunion, 514 Burns, 675 Bursae, diseases of, 503 injuries of, 503 Bursitis, 513 Button, Murphy's, 639 Calculi, renal, 703 Calculus, vesical, 717 crushing of, 730 lateral lithotomy for, 726 suprapubic lithotomy for, 728 Calyx-eyed needle, 632, 638 Cancer. See Carcinomata. Cancrum oris, 118 Caput succedaneum, 527 Carbuncle, 680 Carcinoma of stomach, 611 Carcinomata, 217 Carcinomata, adenoid, 221 classification of, 218 colloid, 221 cylindrical-celled, 219, 221 encephaloid, 219,220 glandular, 221 hematoid, 220 melanotic, 220 of oesophagus, 603 of penis, 754 of rectum, 661 scirrhous, 661 spheroidal-celled, 218, 220 squamous-celled, 218 telangiectatic, 220 Carden's amputation, 776 Caries, 296, 299, 579 cervical dyspncea in, 574 in wrist-joint disease, 411 necrotica, 299 sicca in shoulder-joint disease, 410 spinal, 403 strumous, 296-299 torticollis in, 574 Cartilages, floating, 200, 428 Castration, 758 Catarrh, venereal, 743 Catgut, chromicized, preparation of, 783 preparation of, 782 Cautery, actual, in treatment of hemor- rhage, 248 Cell-division, 76 Cellulitis, 132 diffused, 87 Cementome, 202 Cephalhaematoma, 537 Cephalodynia, 504 Cerebellitis, 551 Cerebellum, abscess of, 566 Cerebral abscess, 556 fungus, 551 hemorrhage, 542, 544 irritability, 539 Cerebritis, 551 Cerebro-spinal fluid, flow of, in fracture of base of skull, 547 Chalk-stone, 416 Chancre, hard, 168 mixed infection of, 168 soft, 752 Chancroid, 752 mixed infection of, 168 Charcot's disease, 419 792 INDEX. Charcot's joint, 419, 431 Chest, contusions of, 594 diseases of, 593 injuries of, 593 wounds of, 594 Cheyne's operation for femoral hernia, 646 Chiene's method for finding fissure of Rolando, 531, 533 Chilblain, 677 Choked disk, 677 Chloroform, 666 administration of, 668 Chondromata, 199, 200 Chondrosarcoma, 211 Chopart's amputation, 773 line of amputation of foot, 772, 773 Chordee, 743 Choroiditis, disseminated, in syphilis, 177 Chromicized catgut, 783 Chronic arteritis, 228 Cicatricial stenosis of orifices of stom- ach, 612 Circumcision, 754 Cirsoid aneurysms, 209, 231, 242 Clap, 743 " Claret-stains " of skin, 208, 209 Clavus, 681 Cleansing of rectum, 785 of vagina, 785 Cleft palate, 597 operation for, 599 Cloaca, 302 Clove-hitch, 435 Clover crutch, 727 Club-foot, 521 Coagulation necrosis, 128 in tubercle, 139 Cocaine hydrochlorate, 666, 674 Cocaine-poisoning, 674 Cocci, 20 of suppuration, 31 pyogenic, 20 Coccidium oviforme, 194 Cock's method of perineal section, 740, 752 Cceliotomy, 629 Cohnheim's theory of tumors, 193 Coin-catcher, 605 Cold, effects of, 677 Colic, appendicular, 622, 624 Collapse from hemorrhage, 251 Colles's fracture, 368 law, 188 Coma, diabetic, 542 due to brain injury, 540 hysterical, 541 of alcoholic intoxication, 540 of opium-poisoning, 540 post-epileptic, 541 uraemic, 540 Compression of brain, 540 of spinal cord, 580 Concussion of brain, 538 of spinal cord, 579 Condylomata, 175 Congenital hernia, 653, 654 hydrocele, 759 phimosis, 754 wry-neck, 518 Constriction of cardiac orifice of stom- ach, 612 of pyloric orifice, 612 Contraction, Dupuytren's, 519 of muscles, 509 Contused wounds, 149 of arteries, 243 Contusions, 148 of abdominal wall, 606 of bladder, 714 of chest, 594 of head, 538 of muscles, 507 of nerves, 527 of spinal cord, 579 Corns, 681 Coxalgia, 400 Coxarius, morbus, 400 Craniectomy, 535 Cranio-cerebral topography, 530, 534 Cripp's operation, 661 Crushing of vesical calculi, 730 Cuneiform osteotomy, 471 Curvature of spine, 568 Cushing's suture, 632 Cutaneous horns, 215 Cyrtometer, 532 Horsley's, 533 Cystic adenomata, 217 multilocular tumors, 201 Cystitis, 722 Cystocele, 641 Cystotomy, 735 Cysts, 191 dentigerous, 202 INDEX. 793 Cysts of spine, 567 Czerny-Lembert suture, 632 Czerny's method of tendon-lengthen- ing, 5*7 Dactylitis, 190 Deafness, syphilitic, 190 Decubitus, 120 Deformities of spine, congenital, 566 Degeneration of muscles, 506 reactions of, 524 Dentigerous cysts, 202 Derangement, internal, of knee-joint, 464 Dermatitis venenata, 678 Desault's apparatus, 350, 691 sign of fracture of hip, 374 Diapedesis, 37 Diaphragmatic hernia, 654 Diarrhoea of constipation, 618 Diastasis, 310 Dickson's theory of amyloid degenera- tion, 404 Diday's operation for webbed fingers, 520 Digestive tract, diseases of, 597 injuries of, 597 Digits, supernumerary, 520 Diphtheria, tracheotomy in, 591 Diplococci, 20 Direct cell-division, 76 Disarticulation at ankle-joint, 773 at elbow-joint, 769 at hip-joint, 777 at knee-joint, 776 at metacarpo-phalangeal joint, 768 at shoulder-joint, 769 at wrist-joint, 768 Disinfection of hands, 781 of instruments, 782 of patient, 782 Dislocation, 429 anomalous, of hip, 462 axillary, 441 bilateral, 430 complete, 430 complicated, 430 compound, 430 traumatic, 435 congenital, 431 consecutive, 431 deformity in, 433 double, 430 Dislocation, habitual, 430 incomplete, 430 of ankle-joint, 466 of astragalus, 468 of carpus, 454 of clavicle, 438-440 acromial end, 440 sternal end, 438 of costal cartilages, 456 of elbow-joint, 448 of femur, 457 downward into obturator foramen, 461 into pubes, 462 into sciatic notch, 460 on to dorsum of ilium, 457 supraspinous, 462 of fibula, 465 of hip, anomalous, 462 of humerus, 441 of inferior radio-ulnar articulation, 453 of knee, 463 of knee-joint, 463, 464 of lower jaw, 436 of metacarpal bones, 454 of metacarpo-phalangeal articulation, 454 joint of the thumb, 454 of metatarsal bones, 470 of Monteggia, 462 of pelvis, 456 of phalanges of fingers, 455 of toes, 470 of radius, 451 of ribs, 456 of semilunar cartilages of knee, 464 of shoulder-joint, 441 reduction of, by manipulation, 444 by extension, 445 of spine, 580 of sternum, 456 of superior tibio-fibular articulation, 465 of tarsal bones, 470 of tendons, 509 of ulna, 450 of wrist, 452 old, 430 traumatic, 436 partial, 430 pathological, 430, 431 primitive, 430 794 INDEX. Dislocation, recent, 430 relapsing, 430 secondary, 430 simple, 430 single, 430 spontaneous, 430, 431 subastragaloid, 469 subclavicular, 442 subcoracoid, 441 subglenoid, 441 subspinous, 442 traumatic, 430, 431, 436 special, 436 unilateral, 430 with fracture, 325 Displacement in plastic surgery, 693 Dugas's sign, 442 Dupuytren's amputation of shoulder- joint, 771 classification of burns, 675 contraction, 519 fracture, 466 splint, 391 suture, 632, 638 Ear disease as a cause of cerebral ab- scess, 559 Ecchondroses, 200 Ecchymosis, 148 Eczematous urethritis, 742 Effusion of lymph, 82 pleuritic, 593 Elbow, miner's, 514 Elbow-joint, disarticulation at, 769 disease, 410 Elephantiasis, 684 Embolic aneurysm, 231 Embolism, 122, 123 fat, 124 Emphysema, gangrenous, 157 Empyema, 593 Encephalitis, 551, 556 Encephalocele, 536 Encephaloid cancer, 219, 220 Enchrondromata, 199 Encysted hydrocele of cord, 759 inguinal hernia, 653 Endarteritis, obliterative, in syphilis, I78 Engorgement of retention of urine, 711 Enterectomy, 611, 636 with circular suturing, 636 Enterocele, 641 Entero-epiplocele, 641 Enteroliths in obstructed bowel, 614 Enterorrhaphy, 632 Entero-stenosis, 613 Epididymitis, 748, 758 Epilepsy, operative treatment of, 561 Epiphyseal separation, 310 of great trochanter, 381 of humerus, 358, 362 of lower end of femur, 385 of lower end of tibia, 390 of radius, 370 of upper end of tibia, 389 Epiphysitis, acute, 304 Epiplocele, 641 Epispadias, 752 Epistaxis, 254 Epithelial odontomes, 201 Epithelioma, 218, 219 Epulides, fibrous, 198 sarcomatous, 198 Epulis, fibrous, 198 Equinia, 163 Equino-varus, 522 Erasion of joints, 481, 482 of knee-joint, 482 Erysipelas, 129 cellulo-cutaneous, 131 clinical forms of, 130 cutaneous, 130 phlegmonous, 131 streptococcus pyogenes in, 129 Erythema of syphilis, 173 Esmarch's bandage, 762 interrupted splint, 490 Estlander's operation, 500, 596 Ether, administration of, 669 and chloroform, relative merits of, 667, 668 Ether-spray, 666 Ethyl bromide, 666 chloride, 666 Excision in shoulder-joint disease, 410 in wrist-joint disease, 411 of ankle-joint, 495 Hancock's method in, 495 of astragalus, 497 operation for, by subperiosteal method, 497 of bones, open method, 481 subperiosteal method, 481 of clavicle, 498 of elbow-joint, 487 INDEX. 795 Excision of hip-joint, 491 anterior excision in, 492 incision of Gross in, 493 lateral operation, 492 of internal hemorrhoids, 657 of joints, 481 open method, 481 subperiosteal method, 481 of knee-joint, 493 anterior semilunar flap, 493 of metacarpal bones, 490 of metatarsal bone of the big toe, 498 of metatarso-phalangeal articulation of big toe, 497 of oesophagus, 605 of one-half of lower jaw, 502 of os calcis, 394, 496 of phalanges, 490 of pylorus, 634 of rectum, 661 of ribs, 499 of shoulder-joint, 483-486 of testicle, 758 of tongue, 602 of upper jaw, complete, 500 of wrist-joint, 487 Lister's open method, 488 Exfoliation, 301 Exophthalmic goitre, 780 Exostosis, 201 Exploratory laparotomy, 620 Extradural abscess, 559 Extramedullar hemorrhage, 580 Extravasation of urine, 716 Farcy, 163 Fatty tumor, 196 Felon, 512 bone-, 513 deep, 513 superficial, 513 Femoral hernia, 646, 654 Femur, osteotomy through neck of, 473 Fergusson's operation for cleft palate, 600 Fever, 151 aseptic, 80 asthenic, 78 hemorrhagic, 245 nervous, 79 primary wound-, 80 secondary wound-, 81 Fever, sthenic, 78 suppurative, 81 surgical, 77, 80 traumatic, 80 types of, 78 urethral, 751 Fibroid tumor of uterus, 205 recurrent, 213, 214 Fibro-adenoma, 217 Fibromata, soft, 197 Fibromyoma, 205 Fibro-myomata, 198 Fibro-sarcoma, 211 Fibrosum, molluscum, 198, 207 Filaria sanguinis hominis, 684 Filiform bougie, 752 Fingers, amputation of, 767 webbed, 520 Fission of cells, 21 Fissure, intraparietal, 533 of anus, 665 of Bichat, 530 of Rolando, 531 Chiene's method of locating, 531 Horsley's method of locating, 532 of Sylvius, 532 Fistula, 101, 108 in ano, 662 Fixed dressings, 692 Flat-foot, 523 Floating kidney, 701 Foot, amputation of, 771 Forearm, amputation of, 769 Foreign bodies in air-passages, 585 in alimentary canal, 611 in larynx, 586 in nose, 583 in oesophagus, 605 in pharynx, 586 in rectum, 662 in trachea, 587 in urethra, 740 Fox's apparatus, 350 Fracture-sprains, 424 Fractures, 306 Barton's, 368 by contre-coup, 310 causes of, 311 Colles's, 368 comminuted, 310 complete, 307 complicated, 307 I compound, 307 796 INDEX. < Fractures, compound, treatment of, 326 crepitus in, 317 deformity in, 314 diagnosis of, 318 direct, 310 displacement in, varieties of, 315 extravasation of blood in, 316 "green-stick," 308 impacted, 310 incomplete, 307 indirect, 310 in elbow-joint, 361 intra-uterine, 311 loss of function in, 316 multiple, 310 near elbow-joint, 361 non-union of, 322 oedema in, 325 of acetabulum, 346 of bones of foot, 393 of carpus, 371 of clavicle, 348 acromial end of, 351 shaft of, 348 sternal end of, 352 of coccyx, 347 of costal cartilages, 340 of false pelvis, 343 of femur, 372 above condyles, 383 extracapsular, 372-379 great trochanter of, 380 intracapsular, 372 longitudinal up from knee, 385 separating either condyle, 384 shaft of, 381 upper extremity of, 372 of fibula, 390 lower third of, 390 upper two-thirds of, 390 of forearm, both bones, 370 of humerus, 354 anatomical neck of, 354 at base of the condyles, 361 epicondyle of, 360 external condyle of, 360 head of, 357 internal condyle of, 361 lower extremity of, 360 shaft of, 359 surgical neck of, 354-356 T-fracture, 361 upper extremity, 354 Fractures of hyoid bone, 335 of inferior maxillary bone, 333 of laryngeal cartilages, 336 of leg, 388, 392 of malar bone, 333 of metacarpal bones, 371 of metatarsal bones, 395 of nasal bones, 328 of os calcis, 393 of patella, 385 transverse, 386 of pelvis, 343 of penis, 754 of phalanges, 372 of toes, 395 of radius, 365 above insertion of pronator radii teres muscle, 366 below insertion of pronator radii teres muscle, 367 head of, 365 lower extremity, 368 neck of, 366 shaft of, 366 of ribs, 337 of sacrum, 346 of scapula, 352 acromion process of, 353 coracoid process of, 354 glenoid cavity of, 353 neck of, 353 of skull, 544 compound, 544 depressed, 544 non-depressed, 544 of inner table of, 544 of outer table of, 544 punctured, 544 simple, 544 trephining for, 562 vault of, 544 of spine, 580 of sternum, 341 of superior maxillary bone, 331 of tibia, 388 inner malleolus of, 389 of ulna, 363 coronoid process of, 363 olecranon process of, 363 styloid process of, 365 of zygomatic arch, 333 pain in, 314 pathological, 310 INDEX. Fractures, Pott's, 391 preternatural mobility in, 316 repair of, 320 simple, 306 spontaneous, 310 stellate, 310 strain-, 308 symptoms of, 314 treatment of, 322 ununited, 310 varieties of, 306 vicious union in, 328 with dislocation, 325 Freezing, death by, 677 Frost-bite, 677 Fumigation in syphilis, 183 Fungus cerebri, 551 Funicular hernia, 653 hydrocle, 760 Furuncle, 679 Genu valgum, osteotomy for, 471 varum, 521 Germicides, chemical, 24 Gibson's bandage, 689 Girdner's induction-balance, 550 Glanders, 163 Gleet, 745 Glio-sarcoma, 213 Globus hystericus, 604 Glottis, cedema of, 584 Goitre, 779 cystic, 779 exophthalmic, 780 fibrous, 780 pulsating, 780 Gonococcus, 32 Gonorrhoea, 743, 745 bacillus of, 32 ' in female, 749 Gonorrhoeal arthritis, 412 Gout, rheumatic, 416 Gouty urethritis, 742 Grafts, omental, 634 " Green-stick" fracture, 308 Growths in female bladder, 736 Gummata of syphilis, 179 scrofulous, 142 Gunshot wounds, 149 of abdominal wall, 610 of arteries, 244 of head, 550 primary hemorrhage of, 254 HjEMATEMESIS, 257 Haematocele, 760 Haematoma, 148 of dura mater, 552 Haematuria, 696 vesical, 714 Haemoglobinuria, 697 Haemoptysis, 258 Hallux valgus, 523 varus, 523 Halstead's suture, 632 "Hammer-toe," 523 Hare-lip, 597 Head, contusions of, 538 diseases of, 530 gunshot wounds of, 550 injuries of, 537 Healing by first intention, 73 by granulation, 75 by second intention, 74 Gall-stones in obstructed bowel, 614 Ganglia, 512 Gangrene, 109 acute, 113 amputation for, 121 chronic, no classification of, 109 decubital, 120 diabetic. 117 dry, 109, HO forms of, 109, no from ergotism, 117 from frost-bite, 118 hospital, 115 moist, 109-113 of penis, 754 Pott's, no Raynaud's, 116 senile, III septic, 109-114 symmetrical, 116 traumatic spreading, 115 Gangrenous appendicitis, 623 Gant's operation, 475 Gastro-enterostomy, 612, 636 Gastrostomy, 635 Gauze, antiseptic, preparation of, 783 aseptic, preparation of, 784 iodoform, preparation of, 784 Genito-urinary organs, diseases of, 696 injuries of, 696 Genu valgum, 520 614 798 INDEX. Healing by third intention, 75 Heart, diseases and injuries of, 224 Heberden's nodosities, 417 Heineke-Mikulicz operation, 613 Hemorrhage, 244 arrest of, 151 capillary, treatment of, 253 cerebral, 542 consecutive, 258 constitutional symptoms of, 244, 245 extradural, 542 extramedullary, 580 following amputation, 762 lateral lithotomy, 256 from bladder, 256 from cerebral sinus, 252 from deep palmar arch, 249 from diploe, 251 from ear, 255 from incomplete division of artery, 250 from intercostal artery, 251 from internal mammary artery, 251 from large bowel, 257 from leech-bite, 255 from lung, 258 from palmar arch, 249 from prostate gland, 256, 698 from punctured wounds, 251 from small bowel, 257 from stomach, 257 from tooth-socket, 252 from urethra, 255 from vessels in bony canal, 251 in abdominal section, 253 intercurrent, 258 intermediate, 258 intra-abdominal, 253 intracranial, 542 intramedullary, 580 primary, golden rules for procedure in, 249 reactionary, 258 rectal, 255 recurrent, 258 renal, 257 secondary, 258 subcutaneous, 255 subdural, 543 umbilical, 255 urethral, 698 uterine, 257 Hemorrhagic fever, 245 Hemorrhagic infarction, 124 sarcoma, 213 Hemorrhoids, 654 excision of, 658 operative treatment of, 657 Hepatitis, pain in, 43 Hereditary syphilis, 188 treatment of, 190 Hernia, abdominal, 640 acquired, 654 anatomical varieties of, 653 causes of, 641 cerebri, 551 congenital, 653 diaphragmatic, 654 direct inguinal, 653 femoral, 654 Bassini's operation for radical cure of, 646 Cheyne's operation for radical cure of, 646 Salzer's operation for radical cure of, 646 funicular, 653 incarcerated, 641, 647 infantile, 653 inflamed, 641, 647 inguinal, Bassini's operation for, 646 Macewen's operation for, 643 into foramen of Winslow, 654 irreducible, 641, 646 Littrd's, 649 lumbar, 654 obstructed, 647 obturator, 654 of brain, 551 of muscles, 509 perineal, 654 pudendal, 654 reducible, 641 radical treatment of, 643 sciatic, 654 strangulated, 641, 648 umbilical, 654 radical cure for, 646 ventral, 654 Hernial sac, 640 Herniotomy, 651-653 Hesselbach's triangle, 653 Hey's amputation of foot, 773 internal derangement of knee, 464 line of amputation of foot, 772 Hip-joint, disarticulation at, 777 INDEX. 799 Hip-joint, excision of, 491 tuberculosis of, 400 Hippocratic countenance, 615 Hodgkin's disease, 203, 685 Hollow-foot, 523 Horns, cutaneous, 215 Horsley's cyrtometer, 533 Housemaid's knee, 514 Hutchinson's teeth, 190 Hydatid moles of pregnancy, 203 Hydrargyrism, 184 Hydrencephalocele, 536 Hydrocele, 758-760 Hydrocephalic cry, 554 Hydrocephalus, 537, 553 Hydrogen, rectal insufflation of, 608, 616 Hydronephrosis, 707 Hydrophobia, 162 Hydrorrhachitis, 566 Hyphomycetes, 18 Hypodermatic injections of mercury in syphilis, 183 Hypospadias, 752 Hysteria, permanent stigmata of, 578 traumatic, 577 Hysterical joint, 420 paralysis, 578 stricture of oesophagus, 604 Ileus (intestinal obstruction), 613 Iliac abscess, 99 Ilio-femoral triangle of Bryant, 375 Immunity, 29 Incontinence of retention, 711 Indirect cell-division, 76 Induction-balance of Girdner, 550 Infarction, 124 Infection, mixed, 30 secondary, 30 septic, 125 syphilitic, mixed, 168 Infective sinus thrombosis, 559, 566 Inflammation, 33 causes of, 41 changes in perivascular tissues in, 38 circulatory changes in, 33 classification of, 39 constitutional symptoms of, 47 treatment of, 60 derangement of absorbents in, 47 of secretions in, 47 diapedesis in, 37 Inflammation, discoloration in, 45 disordered functions in, 46 effusion of lymph in, 82 of serum in, 81 extension of, 40 exudation of fluids in, 36 impairment of special functions in, 46 local symptoms of, 42 treatment of, 48 migration of blood-corpuscles in, 37 of antrum of Highmore, 583 of arteries, 227 of bone, 295 of brain, traumatic, 551 of nerves, 524 of urethra, 741 of veins, 225 oscillation of circulation in, 36 pain in, 42 purulent infiltration in, 87 repair in, 73 retardation of the circulation in, 34 stagnation of the circulation in, 36 . swelling in, 46 symptoms of, 42 terminations of, 41 treatment of, 47 vascular changes in, 33 Inflammatory stricture of urethra, 750 Ingrown toe-nail, 682 Inguinal colostomy, 639 Inoculations, protective and preventive, 29 Insects, bites and stings of, 157 Instruments, disinfection of, 782 Insufflation of air in rupture of bladder, 716 of hydrogen gas in rupture of blad- der, 716 in rupture of intestine, 608 in rupture of stomach, 607 Intercostal neuralgia, 504 Interdental splints, 335 Internal derangement of knee, Hey's, 464 Interpolation in plastic surgery, 694 Intestinal anastomosis, 637 with rings (Senn's), 637 without rings (Abbe's), 638 implantation, 637 8oo INDEX. Intestinal obstruction, 613 calculi in, 614 caused by fecal accumulations, 615 by foreign bodies, 617 by gall-stones, 617 by tumors outside of the bowel, 615. classification of, 613 complete, 613 intussusception, 614 partial, 613 passage of a tube in, 619 seat of, 616 strangulation caused by volvulus, 614 by bands, 614 in apertures, 614 stricture of, 614 treatment of, 619 tuberculosis, 143 Intestine, resection of, 636 suture of, 632 Intoxication, putrid, 125 septic, 125 Intracranial hemorrhage, 542 Intubation of larynx, 585, 592 Intussusception, 614, 616 Involucrum, 302 Iodoform gauze, 784 Iritis, rheumatic, 177 syphilitic, 177 Ischio-rectal abscess, 662 Isthmus of thyroid gland, position of, 590 Jacket, plaster of Paris, and jury-mast, 575 Jacob's ulcer, 107, 218 Jarvis's adjuster, 435 Jobert's suture, 632-634 Johnson's method of preparing catgut, 783. Joint, Brodie's (hysterical), 420 Charcot's, 419 shoulder-, dislocation of, 441 Joints, aspiration of, 480 diseases and injuries of, 295 excision of, 481 loose bodies in, 428 neuralgia of, 421 • strumous, 398 tuberculosis of, 144 Jones's nasal splint, 331 Karyokinesis, 76 Keen's method of operation for Du- puytren's contraction, 520 Keloid growths, 198 Kidney, abscess of, 705 dislocated, 701 floating, 701 laceration of, 702 movable, 701 operation on, 709 perforating wound of, 703 rupture of, 702 surgical, 708 Knee, housemaid's, 514 operations upon, 482 Knee-joint, arthrectomy of, 482 disease, 407 excision of, 493 Knock-knee, 520 osteotomy for, 471 Kocher's method of excising tongue, 602 of gastro-enterostomy, 636 of reducing shoulder-joint disloca- tions, 444 Koch's circuit, 25 tuberculin, 146 Kraske's operation, 662 Kyphosis, 568, 572 Laminectomy, 582 Laparotomy, 629 exploratory, 705 in intestinal obstruction, 620 Lardaceous degeneration, 404 Large intestine, identification of, 608 Laryngotomy, quick, 591 Laryngo-tracheotomy, 592 Larynx, anatomy of, 589 diseases and injuries of, 584, 585 intubation of, 592 Law of Colles, 188 of Miiller, 192 of Virchow, 192 " Lawn-tennis arm," 508 Leiomyomata, 204 Leiter's coil, 396 tubes, 425 Lembert's suture, 632, 635, 638 Leptomeningitis, 551, 554, 556 Leucomaines, 27 Ligation in tabatiere, 269 in triangle of election, 282 INDEX. 801 Ligation in triangle of necessity, 282 of arteries in continuity, 265 of axillary artery, 274 of brachial artery, 272 of carotid artery, common, 280 external, 283 internal, 284 of dorsalis pedis artery, 285 of femoral artery, 290 of iliac arteries, 293 of lingual artery, 285 of popliteal artery, 290 of radial artery, 268 of subclavian artery, 277 of tibial artery, anterior, 287 posterior, 289 of ulnar artery, 271 Line of Nelaton in intracapsular fracture of femur, 375 Lines of amputation of foot, 772, 773 Lipomata, 196 Liquor Cotunnii, 547 Lisfranc's amputation of foot, 771 Lister's cyanide gauze, 784 Liston's modified circular amputation, 765 Litholapaxy 730 in male children, 733 Lithotomy, 726, 728, 735 Lithotrity, rapid, 730 Littre's hernia, 649 Local anaesthetics, 666 shock, 577 venereal sore, 752 Lockjaw, 133 Lordosis, 403, 568, 572 Loreta's operation, 613 Lumbago, 504 Lumbar abscess, 403 hernia, 654 nephrectomy, 710 Lumpy-jaw, 19 Lungs, diseases and injuries of, 593 Lupus, 142 in tertiary syphilis, 180 Luxations. See Dislocations. Lymph, 83 Lymphadenitis, 683 Lymphangeiomata, 209 cavernous, 210 Lymphangiectasis, 684 Lymphangioma, 684 Lymphangitis, 683 51 Lymphatic glands, tuberculosis of, 144 warts, 684 Lymphatics, diseases and injuries of, 683 varicose, 684 Lymphoma, malignant, 685 Lymphomata, 203 Lymphorrhoea, 684 Lympho-sarcoma, 212 Lyssa, 162 Macewen's operation for congenital hernia, 644 for inguinal hernia, 643 for knock-knee, 471 supra-meatal triangle, 534 Macroglossia, 210 Macula eruption of syphilis, 173 Madura-foot, 19 Maisonneuve's urethrotome, 752 Malignant oedema, 157 tumors, 194 Malingering, 578 Marine sponges, preparation of, 782 Mason's pins, 330 Mastoid disease, 557 suppuration, operation for, 565 Maxillary antrum, abscess of, 584 Maydl's operation, 639 McBurney's point, 621, 624, 626 Mclntyre splint, 383 Meatotomy, 751 Meatus, stricture of, 751 Meckel's diverticulum, 614 Meniere's disease, 176 Meningitis, 557 traumatic, 551 tuberculous, 553 Meningocele, 536, 566 Meningo-myelitis, 578 Meningo-myelocele, 566 Mercurial inunctions in syphilis, 182 Metacarpal bones, excision of, 490 Metastatic abscess, 128 Methods of distinguishing between large and small bowel, 609 Microbes, 17 antagonistic, 30 of suppuration, 31 placental transmission of, 30 Microcephalus, 535 Micro-organisms, 17 Microphyta, 18 Microzoaria, 18 802 INDEX. i Micturition, frequency of, 699 Miliary aneurysm, 231 Miner's elbow, 514 Mixed infection, 30 of syphilis, 168 tumors, 213 Moles, hydatid, of pregnancy, 203 Mollities ossium, 305 Molluscum fibrosum, 198, 207 Monoplegia, traumatic hysterical, 578 Monteggia's dislocation, 462 Moore's dressings, 351 Morbid growths, 191 Morbus coxarius, 400 Morphcea, 199 Mortification, 109 Morton's fluid, 536, 567 Mothers' marks, 208 Motor areas, 533, 534 Moulds, 18 Mouth, diseases of, 597 Mucous patches of syphilis, 175 Multilocular cystic tumors, 201 Murphy's button, 639 Muscles, atrophy of, 505 contractions of, 509 contusions of, 507 degeneration of, 506 diseases and injuries of, 503 hernia of, 509 hypertrophy of, 505 rupture of, 508 strains of, 508 tumors of, 506 wounds of, 507 Muscular rheumatism (myalgia), 503 Myoma, 205 Myomata, 204 uterine intramural, 205 Myositis, 505 ossificans, 506 Myxomata, 202 Myxo-sarcomata, 203 Nevoid lipoma, 209 Naevo lipoma, 197 Naevus, 227 Nails, diseases of, 678 Natiform skull, 189 Neck, triangles of, 278 Necrosis, 301 coagulation, 128 Needle, calyx-eyed, 632, 638 Neisser's bacillus, 32 Nelaton's line, 374 Neoplasms, 191 Nephrectomy, abdominal, 710 lumbar, 710 Nephritic colic, 705 Nephrolithotomy, 709 Nephrorrhaphy, 711 Nephrotomy, 709 Nerve, infraorbital, neurectomy of, 529 pressure upon, 526 sciatic, stretching of, 529 supraorbital, neurectomy of, 530 Nerve-division, trophic changes in, 526 Nerve-suture, 527 Nerves, contusion of, 527 degeneration of, 525 diseases and injuries of, 524, 525 inflammation of, 524 operations on, 527 punctured wounds of, 527 regeneration of, 525 section of, 525 Nervous fever, 79 Neuralgia, 525 intercostal, 504 of joints, 421 of stumps, treatment of, 525 Neurasthenia, traumatic, 576 Neurectasy, 528 Neuritis, 524 multiple, 524 Neuroma, 207 Neuromata, 207 traumatic, 208 Neuropathic arthritis, 419 Neurorrhaphy, 527 Neurotomy, 528 Nitrous oxide, 666 Nodosities, Heberden's, 417 Noma, 118 Normal salt-solution in skin-grafting, 694 Nose, foreign bodies in, 583 injuries of, 583 Obstruction, intestinal, 613-615 Obturator hernia, 654 Odontomata, 201 O'Dwyer's operation of intubation of larynx, 592 GEdema, malignant, 157 of glottis, 584 INDi CEdema of larynx, 584 Oesophageal bougie, 604 CEsophagostomy, 605 Cfisophagus, diseases of, 597 excision of, 605 foreign bodies in, 605 stricture of, 603, 604 Ogston's operation, 473 Omental graft, 634 Onychia, 682 malignant, 682 Operations for hare-lip, 598 for mastoid suppuration, 565 for stone in women, 734 for varix of leg, 260 Maydl's, 639 on abdomen, 629 on bladder, 726 on bones, 470 on brain, 562 on kidney, 709 on nerves, 527 on skull, 562 on spine, 582 on vascular system, 260 preparation for, 781 technique of, 564 Opium-poisoning, 541 Optic neuritis in fracture of base of skull, 548 Orchitis, 757 Os calcis, excision of, 394 Ossificans, myositis, 506 Osteitis, 295 * strumous, 296 Osteo-arthritis, 416 Osteoclasis, 521 Osteo-malacia, 305 Osteomata, 200 Osteo-myelitis, acute diffuse, 303 chronic, 305 Osteo-periostitis, 296 diffuse, 297 Osteoplastic periostitis, 298 resection in ankle-joint disease, 409 Osteoscopic pains of syphilis, 177 Osteotome, 471 Osteotomy, 470, 515 cuneiform, 471 for bent tibia, 473 for faulty ankylosis of hip-joint, 473 of knee-joint, 475 for genu valgum, 471 EX. 803 Osteotomy for hallux valgus, 476 for talipes equino-varus, 476 for talipes equinus, 477 for ununited fracture, 477 for vicious union of fracture, 476 linear, 470 longitudinal, 297 of shaft of femur below trochanters, 475 through neck of femur, 473 Overflow of retention, 711 Pachymeningitis, 551, 552 Pacquelin's cautery, 727 Palate, cleft, 597 Palmar arch, hemorrhage of, 249 psoriasis in syphilis, 178 Pancreatitis, acute hemorrhagic, 618 Papillomata, 215 Papular syphilides, 174 Paracentesis auriculi, 260 pericardii, 260 thoracis, 594 Paralysis, hysterical, 578 in syphilis, 178-180 Paraphimosis, 748 Paraplegia, idea of, 577 Parke's solution, 591 Paronychia, 512 Penis, amputation of, 755 cancer of, 754 diseases and injuries of, 736 fracture of, 754 gangrene of, 754 Perforating ulcer of foot, 107 Pericardium, 224 Perineal bruises, 736 cystotomy, lateral, 735 median, 735 hernia, 654 section, Cock's method of, 740 Perinephric abscess, 706 Perinephritis, 706 Periostitis, chronic, 298 in syphilis, 177-179 Peritoneum, toilet of, tuberculosis of, 144 Peritonitis, 626 fibrino-plastic, 627 plastic, 626 primary, 626 saline cathartics in treatment of, 611, 628 804 INDEX. Peritonitis, septic, 626 suppurative, 627 tubercular, 629 Pernio, 677 Pes cavus, 523 planus, 523 Petit's tourniquet, 762 Phagedaena, 119 Phagocytes, 28 Phagocytosis, 28 Phalanges, excision of, 490 Phantom tumor, 618 Phimosis, 754 Phlebitis, 225 Phlebotomy, 262 Piles, 654 PirogofPs amputation of foot, 774 Placental transmission of microbes, 30 Plaster bandage, removal of, 692 Plaster of Paris in compound fracture, 327 Plaster-of-Paris bandage, 693 Plastic surgery, 693 Pleura, diseases and injuries of, 593 Pleuritic effusion, 593 Pleurodynia, 504 Pneumatic aspirator, 480 Poison-ash, 678 Poison-ivy, 678 Poison-oak, 675 Poisoned wounds, 149 Poly dactyl ism, 520 Polyps, 203 fibrous, 198 fleshy, 205 gelatinous, 203 nasal, 203 "Port-wine stains" of skin, 209 Pott's disease, 573 fracture, 391, 466 Preventive inoculations, 29 trephining, 546 Primary amputation, 761 anaesthesia, 673 peritonitis, 626 Probang, horse-hair, 604, 605 Proctotomy, 661 Prostate gland, diseases and injuries of, 736 hypertrophy of, 755 Prostatic abscess, 748 Prostatitis, 748 Protective inoculations, 29 Pruritus of anus, 665 Psammomata, 215 Psoas abscess, 403 Psorospermosis, 194 Psorosperms, 194 Psychical traumatism, 577 Ptomaines, 27 Ptyalism, acute, 184 Pudendal hernia, 654 Pulsating goitre, 780 Pus, 84, 85 microbes, 31 Pustular syphilides, 174 Putrid intoxication, 125 Pyaemia, 125-127 Pyelitis, 706 Pyelonephritis, 706 Pylorectomy, 612, 634 Pyloroplasty, 613 Pylorus, excision of, 634 Pyogenic cocci, 31 Pyonephrosis, 708 Rabies, 162 Railway spine, 575-577 Ranula, 601 Ray fungus, 19, 33, 164 Reaction of degeneration, 524 Reactionary hemorrhage, 258 Rectal insufflation of hydrogen, 608, 616 Rectum, cancer of, 661 cleansing of, 785 diseases and injuries of, 654 excision of, 661 foreign bodies in, 662 prolapse of, 658 stricture of, 660 ulcer of, 659 wounds of, 662 Recurrent hemorrhage, 258 Reduction of hernia en bloc, 650 en masse, 650 Reef-knot, 268 Renal calculus, 703 Repair, 73 Reptiles, bites of, 157 Resection of bones. See Excision. of intestine, 636 of joints. See Excision. Residual abscess, 144 Respiratory organs, surgery of, 583 Retained testicle, 757 INDEX. 805 Retention of urine, 711, 748 incontinence of, 711 Retinitis, diffused, of syphilis, 177 Retrenchment in plastic surgery, 694 Reverdin's method of skin-grafting, 694 Rhabdomyomata, 205 Rheumatic arthritis, 414 gout, 416 iritis, 177 torticollis, 504 Rheumatism, acute, 414 chronic, 415 gonorrhoeal, 412 muscular, 503 Rheumatoid arthritis, 416 Rhus-poisoning, 678 Rib, resection of, 595 Ribble's bandage, 688 Rickets, 147 Rider's leg, 508 Rodent ulcer, 218 Rolando's fissure, 531 Roseola of syphilis, 173 Rules of inheritance of syphilis, 188 " Run around," 682 Rupia, 178, 180 Rupture, 640 Sacro-iliac joint, disease of, 403 "Saddle-back," 572 Salivation, 184 Salzer's operation for femoral hernia, 646 Sapraemia, 125 Sarcocele in syphilis, 177 Sarcoma, alveolar, 212 black, 212 erysipelas in treatment of, 214 giant-celled, 212 glio-, 213 hemorrhagic, 213 lympho-, 212 melanotic, 212 mixed-celled, 212 myeloid, 212 plexiform, 213 Sarcomata, 210 round-celled, 212 spindle-celled, 212 Sayre's knee-joint splint, 408 plaster-of-Paris jacket, 574, 575 Scalds, 675 of glottis, 676 Scalp, abscess of, 534 cirsoid aneurysm of, 534 cysts of, 534 diseases of, 534 local cutaneous hypertrophies of, 534 lupus of, 534 moles of, 534 naevi of, 534 tumors of, 534 warts of, 534 wounds of, 537 Schizomycetes, 18 Scirrhus, 219 Scoliosis, 568 Scrofula, 137, 141 Scrofulodermata, 142 Scrofulous gummata, 142 Scybala as a cause of appendicitis, 621 Secondary amputation, 761 Sedillot's amputation of leg, 774 Segmentation of cells, 21 Senn's apparatus for intracapsular frac- ture of femur, 377 bone plates, 638 decalcified bone-chips, 785 method for gastro-enterostomy, 636 Septic arthritis, 411 infection, 125 intoxication, 125 peritonitis, 626 wounds, 149 Septicaemia, 125 Sequestrum, 301 Serum, effusion of, 81 Shock, 150 local, 577 of anaesthesia, 671 Shoulder-joint disease, 409 excision of, 483 Signorini's horseshoe tourniquet, 764 Silicate-of-soda dressings, 693 Silk sutures, preparation of, 783 Silkworm gut, preparation of, 783 Sinus, 108 rupture of, 544 thrombosis, 557 infective, 559 Skin, diseases of, 678 syphilitic, 172 tuberculosis of, 142 Skin-grafting, 694 Reverdin's method, 694 Thiersch's method, 695 8o6 INDEX. Skull, fracture of, 544. Sloughing, 119 Small intestine, identification of, 608 Smith's (Nathan R.) splint, 383 Snakes, bites of, 159 Snuffles in hereditary syphilis, 189 Spermatic cord, diseases and injuries of, 736 Sphacelus, 109 Spina bifida, 566 Spinal caries, 403, 573 cord, compression of, 580 concussion of, 579 contusion of, 579 wounds of, 579 curvature, 568 ligament, injuries of, 575 muscles, injuries of, 575 Spine, angular curvature of, 568, 573 anterior curvature of, 568, 572 antero-posterior curvature of, 572 cervical curve of, 568 congenital deformities of, 566 dislocation of, 580 dorsal curve of, 568 fracture of, 424, 580 fracture-dislocation of, 581 lateral curvature of, 569 lumbar curve of, 568 operations upon, 582 pelvic curve of, 569 posterior curvature of, 568 primary curve of, 569 railway, 575, 577 surgery of, 566 tumors of, 567 Spirillum, 20 Spores, 21 Sprains, 423 St. Anthony's fire, 129 Staphylococci, 20 Staphylococcus pyogenes albus, 31 aureus, 21, 31 citreus, 31 Staphylorrhaphy, 600 Stay-knot, 268 Stercoraceous vomiting, 615 Stercoral appendicitis, 622 Sthenic fever, 78 Stings of insects, 157 Stomach, cancer of, 611 cicatricial stenosis of orifices of, 612 rupture of, 607 Stone in bladder, 717 Strain, 508 Strain-fracture, 308 Strangulation, intestinal, 614 Streptococci, 20 Streptococcus erysipelatis, 32 pyogenes, 31, 32 Stricture of intestine, 614 of meatus, 751 of oesophagus, 603 of rectum, 660 of urethra, 750 Stromeyer's anterior angular splint, 410 Strumous caries, 296, 299 joint, 398 osteitis, 296 Subcutaneous painful tubercle, 198,208 Suggillation, 148 Sulcus, precentral, 533 Suppuration, 84, 87 of mastoid, operation for, 565 organisms of, 31, 88 without organisms, 32, 84 Surgical cleanliness, antiseptic, 780 aseptic, 780 dressings, preparation of, 783 fevers, 77 kidney, 708 Suture, Cushing's, 632, 638 Czerny-Lembert, 632 Dupuytren's, 632 Halstead's, 632 Jobert's, 632 Lembert's, 632 of intestine, 632 Wolfler's, 634 Sylvius, fissure of, 532 Syme's amputation at ankle-joint, 773 of leg, 776 Syndactylism, 520 Synovial membrane, pulpy degenera- tion of, 144 Synovitis, 395-399 Syphilides, 172-175 Syphilis, 165 acquired, 166 affections of bones in, 176 of ear in, 176 of eye in, 177 of hair in, 176 of joints in, 176 of mucous membrane in, 175 of nails in, 176 INDEX. 807 Syphilis, affections of testes in, 177 alopecia in, 176 arteritis in, 178 bubo of, 171 catarrhal inflammations in, 175 chancre of, 168 choroiditis, disseminated, in, 177 condylomata of, 175 continuous treatment of, 182 dactylitis in, 190 deafness of, 190 erythema of, 173 fumigation in, 183 general, 172 gummata in, 179 hereditary, 166, 188 hypodermatic injections of mercury for, 183 infection in utero, 188 inflammation of tongue in, 180 initial lesion of, 168 intermediate period of, 177 intermittent treatment of, 181 iritis in, 177 macular eruption of, 173 mercurial inunctions in, 182 mucous patches of, 175 natiform skull in, 189 obliterative endarteritis in, 178 of mucous membranes, 175 osteoscopic pain in, 177 palmar psoriasis in, 178 paralysis in, 178-180 periods of, 167 periostitis of, 177-179 primary, 167 reminders of, 177 retinitis, diffused, in, 177 roseola of, 173 rules of inheritance of, 188 secondary, 172 snuffles in hereditary, 189 tertiary, 178 tonsils in, 175 transmission of, 166 treatment of primary stage of, 180 of secondary stage of, 181 of tertiary stage of, 187 ulcers of, 179 warts of, 175 Syphilitic sarcocele, 177 Syphilodermata, 172 Syringo-myelocele, 566 Tabetic arthropathy, 419 Talipes, 521 calcaneus, 521 equino-varus, osteotomy for, 476 equinus, 521 osteotomy for, 477 valgus, 521 varus, 521 Taxis, 649 Teleangiectasis, 209 Temporo-sphenoidal lobe, abscess in, 559 Tendo Achillis, tenotomy of, 515 Tendon-lengthening, 516 Tendon-suture, 516 Tendons, diseases and injuries of, 503 dislocation of, 509 operations upon, 515 rupture of, 510 wounds of, 510 Teno-synovitis, 510 Tenotome, 515 Tenotomy, 515 in torticollis, 519 of tendo Achillis, 515 Testicles, diseases and injuries of, 736 excision of, 758 retained, 757 Tetanus, 133 antitoxine of, 137 bacillus of, 32 Thecitis, 510 Theory of Cohnheim, 193 Thiersch's method of skin-grafting, 695 Thompson's diagnostic questions, 700 Thoracoplasty, 596 Thoracotomy, 595 Thrombosis, 122 Thyroidectomy, 780 Toe-nail, ingrown, 682 Toes, amputation of, 771 Toilet of peritoneum, 631 Tongue, diseases of, 597 excision of, 602 Tongue-tie, 601 Topography, cranio-cerebral, 530, 534 Torcular Herophili, 560 Torticollis, 504, 518 Toxalbumins, 26 Toxines, 26 Trachea, anatomy of, 589 diseases and injuries of, 584 Tracheotomy, 588 8o8 INDEX. Tracheotomy, high, 590 Transfusion, arterial, 265 of blood, 263 Traumatic fever, 80 hysteria, 577 neurasthenia, 576, 577 Traumatism, psychical, 577 Trendelenburg's canula, 337 position, 589, 630, 729 Trephining, 562 in fracture of skull, 545 preventive, 546 Treves's operation for vertebral caries, 582 Triangle of election, ligation in, 282 of Hesselbach, 653 of necessity, ligation in, 282 of neck, 278 Trichinosis, 505 Trophic changes from nerve-division, 526 Truss, measurements for a, 642 Tubercle, 138 painful subcutaneous, 198, 208 Tubercular adenitis, 144 arthritis, 398 orchitis, 757 peritonitis, 144, 629 syphilides, 175 ulceration of rectum, 659 Tuberculin, Koch's, 146 Tuberculosis, 137 diagnosis of, 145 of alimentary canal, 143 of brain, 144 of hip-joint, 400 of intestines, 143 of lymphatic glands, 144 of peritoneum, 144, 629 of skin, 142 of special joints, 144,400 of subcutaneous connective tissue, 143 prognosis of, 145 Tuberculous abscess, 90, 97, 142 disease of joints, 144,400 meningitis, 553 urethritis, 743 Tubes, Leiter's, 425 Tubular lymphangitis, 683 Tumors, 191 benign, 194 causes of, 193 classes of, 192 Tumors, classification of, 195 cystic multilocular, 201 fatty, 196 hereditation in, 193 heterologous, 192 innocent connective-tissue, 196 epithelial, 215 intracranial, 560 malignant, 194 connective-tissue, 210 epithelial, 217 mixed, 213 of bladder, 725 of brain, 557,560 of muscles, 506 . of spine, 567 parasitic influence in, 193 phantom, 618 psorosperm, 194 Tunica vaginalis, diseases and injuries of, 736 Ulcers, ioi acute, 103 chronic, of leg, 104 classification of, 102 forms of, 107 Jacob's, 107, 218, 219 of the rectum, 659 proud flesh in, 106 rodent, 107, 218 superfluous granulations in, 106 symmetrical, of tonsil, 175 syphilitic, 179 Ulceration, 101 Uraemia, 541 Uranoplasty, 600 Ureter, bleeding from, 697 Ureterolithotomy, 705 Urethra, diseases and injuries of, 736 foreign bodies in, 740 inflammation of, 741 rupture of, 737 stricture of, 750 Urethral discharges, chronic, 745 fever, 751 hemorrhage, 698 rupture, 737 Urethritis, 741 Urethrotomy, 751,752 Urine, extravasation of, 739 retention of, 711, 748 Uterus, fibroid tumors of, 205 INDEX. 809 Vagina, cleansing of, 785 Vaginal haematocele, 760 Varicocele, 760 open operation for, 261 subcutaneous ligature for, 261 Varicose veins, 225, 253 Varix, 225 of leg, operations for, 260 Vascular system, operations on, 260 Veins, inflammation of, 225-227 varicose, 225 wounds of, 244 Velpeau's bandage, 350, 690 Venereal catarrh, 743 sore, local, 752 warts, 216 Venesection, 262 Venous piles, 656 Vermiform appendix of caecum, 620 Verruca necrogenica of Wilks, 142 Vesical haematuria, 714 hemorrhage, including hemorrhage from prostate, 698 Virchow's law, 192 Volkmann's dorsal splint for excision of ankle, 496 Volvulus, 614, 617 Von Graefe's sign, 780 Wart-horn, 215 Warts, 215 of syphilis, 175 Wasps, stings of, 157 Water on brain, 553 Waxy degeneration, 404 Webbed fingers, 520 Agnew's operation for, 520 Diday's operation for, 520 White swelling, 144, 398, 407 White's rule of syphilitic stages, 197 Whitehead's operation for piles, 658 Whitlow, 512 Wire, introduction of, in aneurysm, 240 Wiring for ununited fracture, 477 Witzel's method of gastrostomy, 635 Wolfler's suture, 634 Wound-fever, primary, 80 secondary, 81 Wounds, 148 Wounds, articular, 422 penetrating, 423 aseptic, 149 cleansing of, 152 closure of, 152 constitutional treatment of, 153 contused, 149-153 dissecting, 156 drainage of, 152 dressing of, 152 gunshot, 149, I53» 244 of arteries, 244 incised, 149, 153 lacerated, 149, 153 of arteries, 243 non-penetrating, 422 of abdominal wall, 610 contused, 243 incised, 243 of brain, 549 of chest, 594 of head, penetrating, 550 of larynx, 585 of muscles, 507 of nerves, 525 of scalp, 537 of spinal cord, 579 of tendons, 510 of veins, 244 open, 149 poisoned, 149, 156 punctured, 149, 154 of arteries, 244 septic, 149, 156 subcutaneous, 149 treatment of, 151 Wrist-joint, amputation at, 768 disease, 410 excision in, 411 Wry-neck, 518 Wyeth's bloodless amputation at hip- joint, 777 pins in hip- and shoulder-joint am- putations, 764, 777 Yeasts, 18 Zooglcea, 20 Womm published by W. B. SAUNDERS, 925 Walnut Street, Philadelphia, Pa. PAGE 'American Text-Book of Applied Thera- peutics................8 ♦American Text-Book of Diseases of Chil- dren .................3 ♦American Text-Book of Gynecology . 4 ♦American Text-Book of Nursing .... 8 ♦American Text-Book of Obstetrics ... 8 ♦American Text-Book of Physiology ... 8 ♦American Text-Book of Practice .... 2 ♦American Text-Book of Surgery . . . . 1 Ashton's Obstetrics...........23 Ball's Bacteriology...........27 Bastin's Laboratory Exercises in Botany . 18 Beck's Surgical Asepsis.........12 Brockway's Physics...........27 Burr's Nervous Diseases ........12 Cerna's Notes on the Newer Remedies . . 18 Chapman's Medical Jurisprudence and Toxicology..............14 Cohen and Eshner's Diagnosis......26 Cragin's Gynaecology..........24 DaCosta's Manual of Surgery......13 ♦De Schweinitz's Diseases of the Eye . . 5 Dorland's Obstetrics ..........13 Frothingham's Guide to Bacteriological Laboratory .............14 Garrigues' Diseases of Women......10 Gleason's Diseases of the Ear......28 Griffin's Materia Medica and Therapeutics 12 ♦Gross's Autobiography.........7 Hare's Physiology............22 Hampton's Nursing: its Principles and Practice...............15 Hyde's Syphilis and Venereal Diseases . . 12 Jacksonand Gleason's Diseases of the Eye, Nose, and Throat ..........25 Jewett's Outlines of Obstetrics......18 *Keating's Pronouncing Dictionary of Medicine ..............7 Keating's How to Examine for Life In- surance ...............20 Keen's Operation Blanks........16 Kyle's Diseases of Nose and Throat ... 12 Laine's Temperature Charts.......g Lockwood's Practice of Medicine .... 12 Long's Syllabus of Gynecology......g Martin's Surgery............22 Martin's Minor Surgery, Bandaging, and Venereal Diseases..........25 Morris' Materia Medica and Therapeutics 23 Morris' Practice of Medicine......24 Morton's Nurses' Dictionary......g Nancrede's Anatomy and Manual of Dis- section ................16 Nancrede's Anatomy..........22 No'rris' Syllabus of Obstetrical Lectures . 17 Powell's Diseases of Children......26 Raymond's Physiology.........13 Saunders' Pocket Medical Formulary . . ig Saunders' Pocket Medical Lexicon . . . . ig Saunders' New Aid Series of Manuals . n, 12 Saunders' Series of Question Compends . 21 Sayre's Practice of Pharmacy......26 Semple's Pathology and Morbid Anatomy 23 Semple's Legal Medicine, Toxicology, and Hygiene..............25 Senn's Syllabus of Lectures on Surgery . .17 Shaw's Nervous Diseases and Insanity . . 27 Stelwagon's Diseases of the Skin .... 24 Stevens' Materia Medica and Therapeu- tics .................20 Stevens' Practice of Medicine......17 Stewart and Lawrance's Medical Elec- tricity ................28 Thornton's Dose-Book and Manual of Pre- scription-Writing ...........14 ♦Vierordt and Stuart's Medical Diagno- sis ..................6 Warren's Surgical Pathology......10 Wilson's Orthopaedic Surgery......15 Wolff's Chemistry........... 23 Wolff's Examination of Urine......26 Mr. Saunders, in presenting to the profession the following list of his publications, begs to state that the aim has been to make them worthy of the confidence of medical book-buyers by the high standard of authorship and by the excellence of typography,paper,printing, and binding. The works indicated thus (*) are sold by subscription (not by booksellers), usually through travelling solicitors, but they can be obtained direct from the office of publication (charges of shipment prepaid) by remitting the quoted prices. Full descriptive cirulars of such works will be sent to any address upon application. All the other books advertised in this catalogue are commonly for sale by booksellers in all parts of the United States ; but any book will be sent by the publisher to any address (post-paid) on receipt of the price herein given. [For Announcement of Forthcoming Publications see next page.) announcement ot jfortbeomino publications. AN AMERICAN TEXT-BOOK OF OBSTETRICS. By Amer- ican Teachers. (See page 8.) AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By Amer- ican Teachers. (See page 8.) AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- TICS. By American Teachers. AN AMERICAN TEXT-BOOK OF NURSING. By American Teachers. 4 SURGICAL PATHOLOGY AND THERAPEUTICS. By J. Col- lins Warren, M. D., Professor of Surgery, Harvard Medical School, etc. (See page io.) A SYLLABUS OF GYNECOLOGY, arranged in conformity with The American Text-Book of Gynecology. By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. (See page 9.) TEMPERATURE CHART. Prepared by D. T. Laine, M. D. (See page 9.) LABORATORY EXERCISES IN BOTANY. By Edson S. Bas- tin, M. A., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. (See page 18.) A GUIDE TO THE BACTERIOLOGICAL LABORATORY. By Langdon Frothingham, M. D (See page 14.) SAUNDERS' NEW AID SERIES OF MANUALS. New volumes in active preparation. See pages //, 12. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam \V. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal-octavo volume of over 1200 pages (10x7 inches), with nearly 500 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Prices: Cloth, #7.00 net; Sheep, #8.00 net; Half Russia, $9.00 net. The want of a text-book which could be used by the practitioner and at'the same time be recommended to the medical student has been deeply felt, espe- cially by teachers of surgery; hence, when it was suggested to a number of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. While there is no distinctive Amer- ican Surgery, yet America has contributed very largely to the progress of modern surgery, and among the foremost of those who have aided in developing this art and science will be found the authors of the present volume. All of tbem are teachers of surgery in leading medical schools and hospitals in the United States and Canada. Especial prominence has been given to Surgical Bacteriology, a feature which is believed to be unique in a surgical text-book in the English language. Asep- sis and Antisepsis have received particular attention. The text is brought well up to date in such important branches as cerebral, spinal, intestinal, and pelvic surgery, the most important and newest operations in these departments being described and illustrated. The text of the entire book has been submitted to all the authors' for their mutual criticism and revision—an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the important sur- gical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens, and the modern improvements in the art of engraving have enabled the publisher to produce illustrations which it is believed are superior to those in any similar work. CONTRIBUTORS: Dr. Charles H. Burnett, Philadelphia. Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York. William W. Keen, Philadelphia. Charles B. Nancrede, Ann Arbor, Mich. Roswell Park, Buffalo, N. Y. Lewis S. Pilcher, New York. Dr. Nicholas Senn, Chicago. Francis J. Shepherd, Montreal, Canada. Lewis A. Stimson, New York. William Thomson, Philadelphia. J. Collins Warren, Boston. J. William White, Philadelphia. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet. " The soundness of the teachings contained in this work needs no stronger guarantee than is afforded by the names of its authors."—Medical News, Philadelphia. 2 IV. B. SAUNDERS For Sale by Subscription. AN AMERICAN TEXT-BOOK ON THE THEORY AND PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal-octavo volumes of about 1000 pages each, with illustrations to elucidate the text wherever necessary. Price per Volume : Cloth, $5.00 net; Sheep, #6.00 net; Half Russia, $7.00 net. VOLIIJIE I. CONTAINS: Hygiene.—Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing).—Scarla- tina, Measles, Rotheln, Variola, Varioloid, Vaccinia,Varicella, Mumps,Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus.— Tubercu- losis, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever.— Nervous, Muscular, and Mental Diseases etc. VOLUME II. CONTAINS: Urine (Chemistry and Microscopy).—Kid- I —Peritoneum, Liver,and Pancreas—Diathet ney and Lungs.—Air-passages (Larynx and Bronchi) and Pleura.—Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithaemia, and Diabetes.)— Blood and Spleen.—Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. The articles are not written as though addressed to students in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causa- tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formulas. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the knowledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without consulting works specially devoted to the subject. CONTRIBUTORS: Dr. J. S. Billings, Philadelphia. Francis Delafield, New York. Reginald H. Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. William Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Gilman Thompson, New York. W. H. Welch, Baltimore. James T. Whittaker, Cincinnati. James C. Wilson, Philadelphia. Horatio C. Wood, Philadelphia. " We reviewed the first volume of this work, and said: ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is, in our opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be."—New York Medical Journal. " A library upon modern medical art. The work must promote the wider diffusion of sound knowledge."—American Lancet. "A trusty counsellor for the practitioner or senior student, on which he may implicitly rely."—Edinburgh Medical Journal. CATALOGUE OF MEDICAL WQRKS. 3 For Sale by Subscription. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M.D., assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo volume of 1190 pages, profusely illustrated with wood-cuts, half-tone and colored plates. Net Prices : Cloth, $7.00; Sheep, #8.00; Half Russia, $9.00. The plan of this work embraces a series of original articles written by some sixty well-known psediatrists, representing collectively the teachings of the most prominent medical schools and colleges of America. The work is intended to be a practical book, suitable for constant and handy reference by the practi- tioner and the advanced student. One decided innovation is the large number of authors, nearly every article being contributed by a specialist in the line on which he writes. This, while entailing considerable labor upon the editors, has resulted in the publication of a work thoroughly new and abreast of the times. Especial attention has been given to the latest accepted teachings upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- dren, with the introduction of many special formula; and therapeutic procedures. Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose and Throat, and the Skin ; while the introductory chapters cover fully the important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro- cedures coming within the province of the medical practitioner are carefully considered. CONTRIBUTORS: Dr. S. S. Adams, Washington. John Ashhurst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada. Dillon Brown, New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. W. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald Church, Chicago Floyd M. Crandall, New York. Andrew F. Currier, New York. 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Frederick Peterson, New York. W. T. Plant, Syracuse, New York. William M. Powell, Atlantic City. I!. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia. F. C. Shattuck, Boston. J. Lewis Smith, New York, Louis Starr, Philadelphia. M. Allen Starr, New York. J. Madison Taylor, Philadelphia. Charles W. Townsend, Boston. James Tyson, Philadelphia. W. S. Thayer, Baltimore. Victor C. Vaughan, Ann Arbor, Mich. Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J. William White, Philadelphia. J. C. Wilson, Philadelphia. 4 W. B. SAUNDERS For Sale by Subscription. AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume, with 360 illustrations in text and 37 colored and half-tone plates. Prices: Cloth, $6.00 net; Sheep, $7.00 net; Half Russia, $8.00 net. In this volume all anatomical descriptions, excepting those essential to a clear understanding of the text, have been omitted, the illustrations being largely de- pended upon to elucidate the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to dis- cuss mooted points, still the most important of these have been noted and ex- plained. The operations recommended are fully illustrated, so that the reader, having a picture of the procedure described in the text under his eye, cannot fail to grasp the idea. All extraneous matter and discussions have been carefully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who figure as the authors. The work is well illustrated throughout with wood-cuts, half-tone and colored plates, mostly selected from the authors' private collections. CONTRIBUTORS l Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. J. H. Etheridge. William Goodell. Dr. Howard A. Kelly. Florian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. "The most notable contribution to gynecological literature since 1887.....and the most complete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book surpasses anything we have seen."—Boston Medical and Surgical Journal. "A valuable addition to the literature of Gynecology. The writers are progressive aggressive, and earnest in their convictions."—Medical News, Philadelphia. "A thoroughly modern text-book, and gives reliable and well-tempered advice and in- struction. —Edinburgh Medical Journal. " The harmony of its conclusions and the homogeneity of its stvle give it an individuality which suggests a single rather than a multiple authorship."—Annuls of Surgery. " It must command attention and respect as a worthy representation of our advanced clinical teaching."—American Journal 0/ Medical Sciences CATALOGUE OF MEDICAL WORKS. 5 For Sale by Subscription. DISEASES OF THE EYE. A Handbook of Ophthalmic Prac- tice. By G. E. de Schweinitz, M. D., Professor of Diseases of the Eye, Philadelphia Polyclinic; Professor of Clinical Ophthalmology, Jefferson Medical College, Philadelphia, etc. Forming a handsome royal-octavo volume of more than 600 pages, with over 200 fine wood-cuts, many of which are original, and 2 chromo-lithographic plates. Prices: Cloth, $4.00 net; Sheep, $5.00 net; Half Russia, $5.50 net. The object of this work is to present to the student and practitioner who is beginning work in the fields of ophthalmology a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question ; and the method of examination, the symp- tomatology leading to a diagnosis, and the treatment of the various ocular defects have been brought into special prominence. The general plan of the book is eminently practical. Attention is called to the large number of illustrations (nearly one-third of which are new), which will materially facilitate the thorough understanding of the subject. "For the student and practitioner it is the best single volume at present published."— Medical News, Philadelphia. "A most complete and sterling presentation of the present status of modern knowledge concerning diseases of the eye."—Medical Age. " Pre-eminently a book for those wishing a clear yet comprehensive and full knowledge of the fundamental truths which underlie and govern the practice of ophthalmology."—Med- ical and Surgical Reporter. " At once comprehensive and thoroughly up to date."—Hospital Gazette (London). PROFESSIONAL OPINIONS. "A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D., Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. " Contains in concise and reliable form the accepted views of Ophthalmic Science." William Thomson, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia, Pa. " Contains in the most attractive and easily understood form just the sort of knowledge which is necessary to the intelligent practice of general medicine and surgery." J. William White, M. D., Professor of Clinical Surgery in the University of Pennsylvania. " A very reliable guide to the study of eye diseases, presenting the latest facts and newest ,dcas Swan M. Burnett, M. D., Professor of Ophthalmology and Otology, Medical Department Univ. of Georgetown, J J Washington, L>. L. 6 W. B. SAUNDERS' For Sale by Subscription. MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Second Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Third and Revised Edition. In one handsome royal-octavo volume of 700 pages, 178 fine wood-cuts in text, many of which are in colors Prices : Cloth, #4.00 net; Sheep, $5.00 net; Half Russia, $5.50 net. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the'bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. This valuable work, is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. "Rarely is a book published with which a reviewer can find so little fault as with the volume before us. All the chapters are full, and leave little to be desired by the reader. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. Notwithstanding a few minor errors in translating, which are of small importance to the accuracy of the rest of the volume, the reviewer would repeat that the book is one of the best—probably the best—which has fallen into his hands. An excel- lent and comprehensive index of nearly one hundred pages closes the volume."—University Medical Magazine, Philadelphia. "Thorough and exact.....The author has rendered no mean service to medicine in having prepared a work which proves as useful to the teacher as to the student and prac- titioner."— The Lancet (London). PROFESSIONAL OPINIONS. "One of the most valuable and useful works in medical literature." Alexander J. C. Skene, M. D., Dean of the Long Island College Hospital, and Professor of the Medical and Surgical Diseases of Women. " Indispensable to both ' students and practitioners.' " F. Minot, M. D., Hersey Professor of Theory and Practice of Medicine, Harvard University. " It is very well arranged and very complete, and contains valuable features not usually found in the ordinary books." J. H. Musser, M. D., Assistant Professor Clinical Medicine, University of Pennsylvania. " One of the most valuable works now before the profession, both for study and reference." N. S. Davis, M. D., Professor qf Principles and Practice of Medicine and Clinical Medicine, Chicago Medical College. > CATALOGUE OF MEDICAL WORKS. 7 For Sale by Subscription. A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia; Vice-President of the American Paediatric Society; Ex-President of the Association of Life Insurance Medical Directors; Editor " Cyclo- paedia of the Diseases of Children," etc.; and Henry Hamilton, author of " A New Translation of Virgil's ^Eneid into English Rhyme;" co- author of " Saunders' Medical Lexicon," etc.; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix containing important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- gery, Poisons and their Antidotes, Weights and Measures, Thermometric Scales, New Official and Unofficial Drugs, etc. Forming one very attractive volume of over 800 pages. Second Revised Edition. Prices: Cloth, $5.00 net; Sheep, #6.00 net; Half Russia, $6.50 net. With , Denison's Patent Index for Ready Reference. PROFESSIONAL OPINIONS. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Henry M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. Lindsley, M. D., Professor of Theory and Practice of Medicine, Medical Dept. Yale University; Secretary Connecticut State Board of Health, New Haven, Conn " I will point out to my classes the many good features of this book as compared with others, which will, I am sure, make it very popular with students." John Cronyn, M. D., LL.D., Professor of Principles and Practice of Medicine and Clinical Medicine ; President of the Faculty, Medical Dept. Niagara University, Buffalo, N. Y. AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price, $5.00 net. % This autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men—surgeons, physicians, divines, lawyers, states- men, scientists, etc.—with whom he was brought in contact in America and in Europe ; the whole forming a retrospect of more than three-quarters of a century. r W. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. By American Teachers. By Richard C. Norris, A. M., M. D.; James H. Etheridge, M. D.; Chauncey D. Palmer, M. D.; Howard A. Kelly, M. D.; Charles Jewett, M.D.; Henry J. Garrigues, M. D.; Barton Cooke Hirst, M.D.; Theophilus Parvin, M. D.; George A. Piersol, M. D.; Edward P. Davis, M. D.; Charles Warrington Earle, M. D.; Robert L. Dickinson, M. D.; Edward Reynolds, M. D.; Henry Schwarz, M. D.; and James C. Cam- eron, M. D. In one very handsome imperial-octavo volume, with a large number of original illustrations, including full-page plates, and uniform with " The American Text-Book of Gynecology." (In active preparation.) Such an array of well-known teachers is a sufficient guarantee of the high character of the work, and it gives the assurance that this work will have the same measure of success awarded it as has attended the recent publication of its companion volume, " The American Text-Book of Gynecology." The illus- trations will receive the most minute attention; the cuts interspersed throughout the text, and the full-page plates, which will reflect the highest attainments of the artist and engraver, will appeal at once to the eye as well as to the mind of the student and practitioner. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By American Teachers. Edited by William H. Howell, Ph. D., M. D., Professor of Physiology, Johns Hopkins University. With the collaboration of such eminent specialists as Henry P. Bowditch, M. D.; John G. Curtis, M. D.; Henry H. Donaldson, M. D.; Frederick S. Lee, M. D.; Warren P. Lom- bard, A. B., M. D.; Graham Lusk, Ph. D.; Henry Sewall, M. D.; Edward T. Reichert, M. D.; Joseph W. Warren, M. D. In one imperial-octavo volume (with a large number of original illustrations), uniform with The American Text-Books of " Surgery," " Practice," " Gynecology," etc. (In preparation for early publication.) This will be the most notable attempt yet made in this country to combine in one volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they will write. The completed work will represent the present status of the science of Physiology, and in particular from the standpoint of the student of medicine and the medical practitioner. Illustrations largely drawn from original sources will be used freely throughout the text. AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS. By American Teachers. (In preparation.) AN AMERICAN TEXT-BOOK OF NURSING. By American Teachers. (In preparation.) CATALOGUE OF MEDICAL WORKS. Q A SYLLABUS OF GYNECOLOGY, arranged in conformity with The American Text-Book of Gynecology. By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. (Preparing.) Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- room, as the subject is presented in a manner at once systematic, clear, succinct, and practical. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x 13 j^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Fxcretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. Compiled for the use of nurses. By Honnor Morten, author of " How to Become a Nurse," " Sketches of Hospital Life," etc. Second and enlarged edi- tion. i6mo, 140 pages. Price, Cloth, $1.00. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. " Should be at the disposal of every nurse."—Birmingham Medical Review. " Maintains its reputation for brevity and simplicity."—Hahnemannian Monthly. "Though ostensibly for professional nurses, contains in a compact form just such infor- mation as almost every intelligent man would like to have at hand in these days when the interest in all matters of sanitation and medicine has become so great. -Medual Examiner. " A book which every progressive nurse must have."—Medical World. " This little volume is almost indispensable in the training school and in the library of the nurse.""— New York Medical Times. IO W. B. SAUNDERS' SURGICAL PATHOLOGY AND THERAPEUTICS. By J. Col- lins Warren, M. D., Professor of Surgery, Harvard Medical School, etc. In one very handsome octavo volume of over 800 pages, with 135 illus- trations, 33 of which are chromo-lithographs, and all of which are drawn from original specimens. (Passing through the press.) Covering as it does the entire field of Surgical Pathology and Surgical Thera- peutics by an acknowledged authority, the publisher is confident that the. work will rank as a standard authority on the subject of which it treats. Particular attention has been paid to Bacteriology and Surgical Bacteria from the stand- point of recent investigations, and the chromo-lithographic plates in their fidelity to nature and in scientific accuracy have hitherto been unapproached. DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., Professor of Obstetrics in the New York Post-Graduate Medical School and Hospital; Gynecologist to St. Mark's Hospital and to the German Dispensary, etc., New York City. In one very handsome octavo volume of about 700 pages, illustrated by numerous wood-cuts and colored plates. Prices : Cloth, $4.00 net; Sheep, $5.00 net. A practical work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fullv recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of the female genitalia, besides exemplifying, whenever' needed, morbid condi- tions, instruments, apparatus, and operations. EXCERPT OF (OXTEXTS. ;„l™eVel0pP1!en,t °f mC Female Gen'ta's-Anatomy of the Female Pelvic Organs.-Phys- ^?Pl:^,|berty--~rMenSt,|Uati-0n & "d 9vulatI°n—Copulation.-Fecundation.-The Climac- teric.-Ltiology m General.-Lxaminat.ons m General.-Treatment in General—Abnormal Menstruation and Metrorrhagia.-Leucorrhea.-Diseases of the Vulva.-Diseases of the T?ZeUmfT 'SeaSef ?£ 'A* V.ag.na^-Diseases of the Uterus.-Diseases of the Fallot, an lubes—Diseases of the Ovaries.—Diseases of the Pelvis.—Sterility. P The reception accorded to this work has been most flattering. In the short period which has elapsed since its issue it has been adopted and recommended as a text-book by more than 60 of the Medical Schools and Universities of the United States and Canada. ►iJ'f'VI^i16 beSt texf-b.ooks f°r students and practitioners which has been published in the English language; ,t is condensed, clear, and comprehensive. The profoundI learning mo^at^ ?,lth0r find expression^ this book in a ^^^yi^M\tlVX JTg P1?"^0"^. t° whom experienced consultants may not De available, will find in this book invaluable counsel and help." Thad. A. Reamy, M. D., LL D Professor of Clinical Gynecology, Medical College of Ohio; Gynecologist to the Good Samaritan and Cincinnati Hospitals. Practical, Exhaustive, Authoritative. SAUNDERS' • NEW AID SERIES OF MANUALS FOR Students and Practitioners. Mr. Saunders is pleased to announce as in active preparation his NEW AID SERIES OF MANUALS for Students and Practitioners. As publisher of the Standard Series of Question Compends, and through in- timate relations with leading members of the medical profession, Mr. Saunders has been enabled to study progressively the essential desiderata in practical "self-helps" for students and physicians. This study has manifested that, while the published " Question Compends'' earn the highest appreciation of students, whom they serve in reviewing their studies preparatory to examination, there is special need of thoroughly reliable handbooks on the leading branches of Medicine and Surgery, each subject being compactly and authoritatively written, and exhaustive in detail, without the introduction of cases and foreign subject-matter which so largely expand ordinary text-books. The Saunders Aid Series will not merely be condensations from present literature, but will be ably written by well-known authors and practitioners, most of them being teachers in representative American Colleges. This new series, therefore, will form an admirable collection of advanced lectures, which will be invaluable aids to students in reading and in comprehending the contents of "recommended" works. Each Manual will further be distinguished by the beauty of the new type; by the quality of the paper and printing; by the copious use of illustrations; by the attractive binding in cloth ; and by the extremely low price, which will uniformly be $1.25 per volume. 11 SAUNDERS' NEW AID SERIES OF MANUALS. VOLUMES NOW READY. PHYSIOLOGY. By Joseph Howard Raymond, A. M , M. D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital, etc. Price, $1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M. D,, Demonstrator of Surgery, Jefferson Medical College, Philadelphia, etc. Double number. Price, $2.50 net. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Price, $1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- fessor of Institules of Medicine and Medical Jurisprudence in the Jeffer- son Medical College of Philadelphia, etc Price, $1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the German Poliklinik ; Instructor in Surgety, New York Post-Graduate Medical School, etc. Price, $1.25 net. VOLUMES IN PREPARATION FOR EARLY PUBLICATION. OBSTETRICS. By W. A. Newman Dorland, M. D., Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispen- sary, Pennsylvania Hospital; Member of Philadelphia Obstetrical Society, etc. Price, $1.25 net. MATERIA MEDICA AND THERAPEUTICS. By Henry A. Griffin, A. B., M. D., Assistant Physician to the Roosevelt Hospital, Out-patient Department, New York City. Price, $1.25 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nkvins Hyde, M. D., Professor of Skin and Venereal Diseases in Rush Medical College, Chicago. Double number. Price, $2.50 net. NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Pro- fessor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. Price, $1.25 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College and in the New York Infirmary, etc. Double number. Price, $2.50 net. NOSE AND THROAT. By D. Braden Kyle, M. D., Chief Laryngol- ogist to St. Agnes' Hospital, Philadelphia; Instructor in Clinical Micros- copy and Assistant Demonstrator of Pathology in the Jefferson Medical College, etc. Price, $1.25 net. *** There will be published in the same series, at close intervals, carefully-pre- pared works on the subjects of Anatomy, Gynecology. Pathology, Hygiene, etc., by prominent specialists. 12 CATALOGUE OF MEDICAL WORKS. 13 Saunders' New Aid Series of Manuals. A MANUAL OF PHYSIOLOGY. By Joseph H. Raymond, A. M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; Director of Physiology in the Hoag- land Laboratory; formerly Lecturer on Physiology and Hygiene in the Brooklyn Normal School for Physical Education; Ex-Vice-President of the American Public Health Association; Ex-Health Commissioner City of Brooklyn, etc. Illustrated. Price, Cloth, $1.25 net. (Just ready.) In this manual the author has endeavored to put into a concrete and avail- able form the results of twenty years' experience as a teacher of Physiology to medical students, and has produced a work for the student and practitioner, representing in a concise form the existing state of Physiology and its methods of investigation, based upon Comparative and Pathological Anatomy, Clinical Medicine, Physics, and Chemistry, as well as upon experimental research. A MANUAL OF SURGERY, General and Operative. By John Chalmers DaCosta, M. D., Demonstrator of Surgery, Jefferson Medical College, Philadelphia; Chief Assistant Surgeon, Jefferson Medical College Hospital; Surgical Registrar, Philadelphia Hospital, etc. One very hand- some volume of over 700 pages, with a large number of illustrations. (Double number.) Price, Cloth, $2.50 net. A new manual of the Principles and Practice of Surgery, intended to meet the demands of students and working practitioners for a medium-sized work which will embody all the newer methods of procedure detailed in the larger text-books. The work has been written in a concise, practical manner, and especial attention has been given to the most recent methods of treatment. Illustrations are freely used to elucidate the text. A MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M. D., Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispensary, Pennsylvania Hospital; Member of Phila- delphia Obstetrical Society, etc. Profusely illustrated. Price, Cloth, $1.25 net. (Preparing.) This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for the student and of value to the practitioner as a convenient handbook of reference. Although concisely writ- ten, nothing of importance is omitted that will give a clear and succinct know- ledge of the subject as it stands to-day. Illustrations are freely used throughout the text. [4 W. B. SAUNDERS' Saunders' New Aid Series of Manuals. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Illustrated. Price, Cloth, #1.25 net. But little attention is generally given, in works on Materia Medica and Thera- peutics, to the methods of combining remedies in the form of prescriptions, and this manual has been written especially for students in the hope that it may serve to give a thorough and comprehensive knowledge of the subject. The work, which is based upon the last (1890) edition of the Pharmacopoeia, fully covers the subjects of Weights and Measures, Prescriptions (form of writing, general directions to pharmacist, grammatical construction, etc.), Dosage, Incompatibles, Poisons, etc. MEDICAL JURISPRUDENCE AND TOXICOLOGY. By Henry C. Chapman, M. D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia; Member of the College of Physicians of Philadelphia, of the Academy of Natural Sciences of Philadelphia, of the American Philosophical Society, and of the Zoological Society of Philadelphia. 232 pages, with 36 illustrations, some of which are in colors. Price, #1.25 net. For many years there has been a demand from members of the medical and legal professions for a medium-sized work on this most important branch of medicine. The necessarily proscribed limits of the work permit the considera- tion only of those parts of this extensive subject which the experience of the author as coroner's physician of the city of Philadelphia for a period of six years leads him to regard as the most material for practical purposes. Particular attention is drawn to the illustrations, many being produced in colors, thus conveying to the layman a far clearer idea of the more intricate cases. "The salient points are clearly defined, and ascertained facts are laid down with a clear- ness that is unequivocal."—St. Louis Medical and Surgical Journal. "The presentation is always thorough, the text is liberally interspersed with illustrations, and the style of the author is at once pleasing and interesting."—Therapeutic Gazette. " One that is not overloaded with an unnecessary detail of a large amount of literature on the subject, requiring hours of research for the essential points in the decision of a question; that contains the most lucid symptomatology of questionable conditions, tests of poisons, and the readiest means of making them—such is the new book before us."—The Sanitarian. A GUIDE TO THE BACTERIOLOGICAL LABORATORY. By Langdon Frothingham, M. D. Illustrated. (In preparation.) The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work. CATALOGUE OF MEDICAL WORKS. 15 NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md.; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 i pages, profusely illustrated. Price, Cloth, $2.00 net. This entirely new work on the important subject of nursing is at once com- prehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desideratum with those intrusted with the management of hospitals and the instruction of nurses in training schools. It is also of especial value to the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. The author, who has had considerable experience as superintendent of training schools for nurses and hospital management, brings to her task a mind thoroughly equipped to make the subject attractive as well as scientific and instructive. Thoroughly attested and approved processes in practical nursing only have been given, particularly in antiseptic surgery, and the minutest details regard- ing the nurse's technique have been explained. Illustrations to elucidate the text have been used freely throughout the book, and they will be found of material help in showing the forms of modern appli- ances for the hospital ward and sick-room, the registration of temperature, daily records, etc. METHODS OF PREVENTING AND CORRECTING DEFORM- ITIES OF THE BONES AND JOINTS : A Handbook of Prac- tical Orthopedic Surgery. By H. Augustus Wilson, M. D , Professor of General and Orthopedic Surgery, Philadelphia Polyclinic; Clinical Pro- fessor of Orthopedic Surgery, Jefferson Medical College, Philadelphia, etc. (In preparation.) The aim of the author is to provide a book of moderate size, containing comprehensive details that will enable general practitioners to understand thor- oughly the mechanical features of the many forms of congenital and acquired deformities of the bones and joints. The mechanical functions that are impaired will be considered first as to pre- vention as of primary importance, and following this will be described the methods of correction that have been proved practical by the author. Ope- rative procedures will be considered from a mechanical as well as a surgical standpoint. Prominence will be given to the mechanical requirements for braces and artificial limbs, etc., with description of the methods for construct- ing the simplest forms, whether made of plaster of Paris, felt, leather, paper, steel, or other materials, together with the methods of readjustment to suit the changes occurring during the progress of the case. A very large number of original illustrations will be used. I 16 W. B. SAUNDERS' AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. A convenient blank, suitable for all operations, giving complete instructions \ regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. , At the back of pad is a list of instruments used—viz. general instruments, etc., required for all operations; and special instruments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito- urinary organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur geon's office or in the hospital operating-room. " Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed "—New York Medical Record " Covers about all that can be needed in any operation."—American Lancet. " The plan is a capital one."— Boston Medical and Surgical Journal. ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection " By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. * Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy, and forming a handsome post 8vo volume of over 500 pages. • " The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting-room."—fournal of American Medical Association. "Should be in the hands of every medical student."— Cleveland Medical Gazette. " A concise and judicious work."—Buffalo Medical and Surgical Journal. • • CATALOGUE OF MEDICAL WORKS. 17 A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Penn- sylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations, and includes the following sections: General Diseases, Diseases of the Digestive Organs, Diseases of the Respiratory System, Diseases of the Circulatory System, Diseases of the Nervous Sys- tem, Diseases of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each section is prefaced by a chapter on General Symptomatology. Third edition. Post 8vo, 502 pages. Numerous illustrations and selected formulae. Price, $2.50. Contributions to the science of medicine have poured in so rapidly during the ast quarter of a century that it is well-nigh impossible for the student, with the limited lime at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enabled, by classification, to group allied symp- toms, and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the prac- tice of medicine. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with The American Text-Book of Surgery. By Nicholas Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This, the latest work of its eminent author, himself one of the contributors to the "American Text-Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome or supplement to the larger work. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Demonstrator of Obstetrics in the University of Pennsyl- vania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, $2.00 net. " This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant; no minor matters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise."—New York Medical Record. 18 W. B. SAUNDERS' OUTLINES OF OBSTETRICS : A Syllabus of Lectures Deliv- ered at Long Island College Hospital. By Charles Jewett, A. M., M. D., Professor of Obstetrics and Pediatrics in the College, and Obstetri- cian to the Hospital. Edited by Harold F. Jewett, M. D. Post 8vo, 264 pages. Price, $2.00. This book treats only of the general facts and principles of obstetrics : these are stated in concise terms and in a systematic and natural order of sequence, theoretical discussion being as far as possible avoided; the subject is thus presented in a form most easily grasped and remembered by the student. Special attention has been devoted to practical questions of diagnosis and treatment, and in general particular prominence is given to facts which the stu- dent most needs to know. The condensed form of statement and the orderly arrangement of topics adapt it to the wants of the busy practitioner as a means of refreshing his knowledge of the subject and as a handy manual for daily reference. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 175 pages. Price, $1.25. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that, if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical importance of the new agents. " Especially valuable because of its completeness, its accuracy, its systematic consider- ation of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner."—Chicago Clinical Review. "A timely and needful book .... which physicians who avail themselves of the use of the newer remedies cannot afford to do without."—The Sanitarian. LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. With over 75 plates. (In preparation.) This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. The folding charts which supplement the subjects will be found useful in connection with the study of the text. CATALOGUE OF MEDLCAL WORKS. 19 SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M. D., editor of "Cyclopaedia of Diseases of Children," etc.; author of the " New Pronouncing Dictionary of Medicine; and Henry Hamilton, author of " A New Translation of Virgil's .-Eneid into Eng- lish Verse;" co-author of a " New Pronouncing Dictionaiy of Medicine." A new and revised edition. 321110, 282 pages. Prices: Cloth, 75 cents; Leather Tucks, $1.00. This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market, which, dating as they do from 1855 to 1884, are of but trifling use to the student by their not containing the hundreds of new words now used in current litera- ture, especially those relating to Electricity and Bacteriology. " Remarkably accurate in terminology, accentuation, and definition."—Journal of Amer- ican Medical Association. " Brief, yet complete .... it contains the very latest nomenclature in even the newest departments of medicine."—New York Medical Record. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1750 Formulas, selected from several hundred of the best-known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions; with an Appendix containing Posological Table, Formulae and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Third edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, $1.75 net. A concise, clear, and correct record of the many hundreds of famous formulae which are found scattered through the works of the most eminent physicians and surgeons of the world. The work is helpful to the student and practitioner alike, as through it they become acquainted with numerous formulae which are not found in text-books, but have been collected from among the rising genera- tion of the profession, college professors, and hospital physicians and surgeons. "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given is unusually reliable."—New York Medical Record. " Designed to be of immense help to the general practitioner in the exercise of his daily calling."—Boston Medical and Surgical Journal. 20 W. B. SAUNDERS' HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Paediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large phototype illustrations, and a plate pre- pared by Dr. McClellan from special dissections; also, numerous cuts to elucidate the text. Second edition. Price, in Cloth, 32.00 net. Part I., which has been carefully prepared from the best works on Physical Diagnosis, is a short and succinct account of the methods used to make examinations; a description of the normal condition and of the earliest evidences of disease. Part II. contains the Instructions of twenty-four Life Insurance Companies to their medical examiners. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science."—The Medical News, Philadelphia. MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 435 pages. Price, Cloth, #2.25. This wholly new volume, which is based on the 1890 edition of the Pharma- copeia, comprehends the following sections : Physiological Action of Drugs; Drugs; Remedial Measures other than Drugs; Applied Therapeutics ; Incom- patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of Diseases; the treatment being elucidated by more than two hundred formulae. " The author is to be congratulated upon having presented the medical student with as accurate a manual of therapeutics as it is possible to prepare."—Therapeutic Gazette. " Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable and accurate."—New York Medical Journal. "The author has faithfully presented modern therapeutics in a comprehensive work, . . . and it will be found a reliable guide."—University Medical Magazine. "Will be of immense service to the busy practitioner."—Medical Reporter (Calcutta). " Reliable and timely."—North American Practitioner. "Concise, up to date, and withal comprehensive."—Pacific Medical Journal. SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form, THE LATEST, CHEAPEST, and BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature WITH Students and Practitioners in every City of the United States and Canada. THE REASON WHY. They are the advance guard of " Student's Helps "—that DO help; they are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-four subjects, has been kept thoroughly revised and enlarged when necessary, many of them being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence: 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. *** Any of these Compends will be mailed on receipt of price. 21 22 W. B. SAUNDERS i. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M. D., Pro- fessor of Therapeutics and Materia Medica in the Jefferson Medical Col- lege of Philadelphia; Physician to St. Agnes' Hospital and to the Medical Dispensary of the Children's Hospital; Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc. Third edition, revised and enlarged by the addition of a series of handsome plate illustrations taken from the celebrated " Icones Nervorum Capitis "' of Arnold. Crown 8vo, 230 pages, numerous illustrations. Price, Cloth, $1.00 net; interleaved for notes, $1.25 net. "An exceedingly useful little compend. The author has done his work thoroughly and well. The plates of the cranial nerves from Arnold are superb."—Journal of American Medical Association. 2. ESSENTIALS OF SURGERY, containing also Venereal Diseases, Surgical Landmarks, Minor and Operative Surgery, and a Complete De- scription, together with full Illustrations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, Instructor in Operative Surgery, and Lecturer on Minor Surgery, University of Pennsylvania; Surgeon to the Howard Hos- pital ; Assistant Surgeon to the University Hospital, etc. Fifth edition. Crown 8vo, 334 pages, profusely illustrated. Considerably enlarged by an Appendix containing full directions and prescriptions for the prepara- tion of the various materials used in Antiseptic Surgery; also several hundred recipes covering the medical treatment of surgical affections. Price, Cloth, $1.00; interleaved for notes, $1.25. "Written to assist the student, it will be of undoubted value to the practitioner, contain- ing as it does the essence of surgical work."—Boston Medical and Surgical Journal. " Cleverly combines all the merits of condensation, while avoiding the errors of super- ficiality and inaccuracy."—University Medical Magazine. 3. ESSENTIALS OF ANATOMY, including the Anatomy of the Viscera. By Charles B. Nancrede, M. D., Professor of Surgery and of Clinical Surgery in the University of Michigan, Ann Arbor; Cor- responding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon to the Jefferson Medical College, etc. Fifth edition. Crown 8vo, 380 pages, 180 illustrations. Enlarged by an Appendix containing over sixty illustrations of the Osteology of the Human Body. The whole based upon the last (eleventh) edition of Gray's Anatomy. Price, Cloth, $1.00; interleaved for notes, $1.25. " Truly such a book as no student can afford to be without."—American Practitioner and News. " The questions have been wisely selected and the answers accurately and concisely given."—University Medical Magazine. I CATALOGUE OF MEDICAL WORKS. 23 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC, containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Law- rence Wolff. M D., Demonstrator of Chemistry, Jefferson Medical Col- lege ; Visiting Physician to the German Hospital of Philadelphia; Member of Philadelphia College of Pharmacy, etc. Fourth and revised edition, with an Appendix. Crown 8vo, 212 pages. Price, Cloth, $1.00; inter- leaved for notes, $1.25. " The scope of this work is certainly equal to that of the best course of lectures on Med- ical Chemistry."—Pharmaceutical Era. " We could wish that more books like this would be written, in order that medical students might thus early become interested in what is often a difficult and uninteresting branch of medical study."—Medical and Surgical Reporter. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M. D., Professor of Gynecology in the Medico-Chirurgical College of Philadelphia; Obstetrician to the Philadelphia Hospital. Third edition, thoroughly revised and enlarged. Crown 8vo, 244 pages, 75 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. " An excellent little volume containing correct and practical knowledge. An admirable compend, and the best condensation we have seen."—Southern Practitioner. " Of extreme value to students, and an excellent little book to freshen up the memory of the practitioner."—Chicago Medical Times. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANAT- OMY. By C. E. Armand Semple, B. A., M. B., Cantab. L. S. A., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney; Professor of Vocal and Aural Physiology and Examiner in Acoustics at Trinity College, London, etc. Crown 8vo, 174 pages, illus- trated. Sixth thousand. Price, Cloth, $r.oo; interleaved for notes, $1.25. "A valuable little volume—truly a multum in parvo."—Cincinnati Medical News. " The volume is very comprehensive, covering the entire field of pathology."—St. Joseph Medical Herald. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION-WRITING. By Henry Morris, M. D., late Demonstrator, Jefferson Medical College; Fellow of the College of Physicians, Philadelphia; co-editor Biddle's Materia Medica; Visiting Physician to St. Joseph's Hospital, etc. Fourth edition. Crown 8vo, 250 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. " One of the best compends in this series. Concise, pithy, and clear, well suited to the purpose for which it is prepared."—Medical and Surgical Reporter. " The subjects are treated in such a unique and attractive manner that they cannot fail to impress the mind and instruct in a lasting manner."—Buffalo Medical and Surgical Journal. 24 W. B. SAUNDERS' 8, 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D., author of " Essentials of Materia Medica," etc., with an Appendix on the Clinical and Microscopical Examination of Urine, by Lawrence Wolff, M. D., author of " Essentials of Medical Chemistry," etc. Colored (Vogel) urine scale and numerous fine illustrations. Third edition, enlarged by some three hundred essential formulae, selected from the writings of the most eminent authorities of the medical profession, collected and arranged by William M. Powell, M. D., author of " Essentials of Diseases of Children." Crown 8vo, 460 pages. Price, Cloth, #2.00. '* The teaching is sound, the presentation graphic, matter as full as might be desired, and the style attractive."—American Practitioner and News. "A first-class practice of medicine boiled down, and giving the real essentials in as few words as is consistent with a thorough understanding of the subject."—Medical Brief. " Especially full, and an excellent illustration of what the best of the compends can be made to be."—Gaillards Medical Journal. 10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M. D., Attending Gynaecologist, Roosevelt Hospital, Out-Patients' Depart- ment; Assistant Surgeon, New York Cancer Hospital, etc. Fourth edi- tion, revised. Crown 8vo, 198 pages, 62 fine illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. " This is a most excellent addition to this series of question compends. The style is con- cise, and at the same time the sentences are well rounded. This renders the book far more easy to read than most compends, and adds distinctly to its value."—Medical and Surgical Reporter. " Useful not only to the student who is barely at the threshold of professional life but to the busy practitioner as well."— New York Medical Journal. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M. D., Clinical Lecturer on Dermatology in the Jefferson Medical College, Philadelphia; Physician to the Skin Service of the Northern Dispensary; Dermatologist to Philadelphia Hospital; Physician to Skin Department of the Howard Hospital; Clinical Professor of Der- matology in the Woman's Medical College, Philadelphia, etc. Third edi- tion. Crown 8vo, 270 pages, 86 illustrations, many of which are original. Price, Cloth, $1 00; interleaved for notes, $1.25 net. " An immense amount of literature has been gone over and judiciously condensed by the writer s skill and expenence."—AVw York Medical Record. " The book admirably answers the purpose for which it is written. The experience of the rev.ewer has taught him that just such a book is needed."-A^w York Medical Journal. CATALOGUE OF MEDICAL WORKS. 2$ 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, A.M., M. D., author of " Essentials of Surgery," etc. Second edition. Crown 8vo, thoroughly revised and enlarged, 78 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. , "Characterized by the same literary excellence that has distinguished previous numbers of this series of compends."— American Practitioner and News. "The best condensation of the subjects of which it treats yet placed before the pro- fession. -Medical News, Philadelphia. " A capital little book. The illustrations are remarkably clear and intelligible "— Aus- tralian Medical Gazette. " We have nothing but praise for the subject-matter of this book."—Bristol Medico-Chi- rurgicalJournal. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M. D., author of " Es- sentials of Pathology and Morbid Anatomy." Crown 8vo, 212 pages, 130 illustrations. Price, Cloth, $1.00 ; interleaved for notes, #1.25. " The leading points, the essentials of this too much neglected portion of medical science, are here summed up systematically and clearly."—Southern Practitioner. " But for the author's judicious condensation of facts, the information it contains would be sufficient to fill an ordinary octavo volume."—College and Clinical Record. 14. ESSENTIALS OF REFRACTION AND DISEASES OF THE EYE. By Edward Jackson, A.M., M. D., Professor of Dis- eases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine ; Member of the American Ophthalmological Society; Fel- low of the College of Physicians of Philadelphia ; Fellow of the American Academy of Medicine, etc.; and ESSENTIALS OF DISEASES OF THE NOSE AND THROAT. By E. Baldwin Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila- delphia ; Surgeon in charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia; formerly Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylvania, and Assistant in the Nose and Throat Department of the Union Dispen- sary, etc. Two volumes in one. Second edition. Crown 8vo, 294 pages, 124 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. "A valuable book to the beginner in these branches, to the student, to the busy prac- titioner, and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers, know what a student most needs."—New York Medical Record. " Very valuable, since in both sections is given about all that a candidate for examination is required to know."—Medical Times and Hospital Gazette. 26 W. B. SAUNDERS' 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N.J.; late Physician to the Clinic for the Dis- eases of Children in the Hospital of the University of Pennsylvania and St. Clement's Hospital; Instructor in Physical Diagnosis in the Medical Department of the University of Pennsylvania. Crown 8vo, 216 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. " This work is gotten up in the clear and attractive style that characterizes the Saunders Series. It contains in appropriate form the gist of all the best works in the department to which it relates."—American Practitioner and News. " The book contains a series of important questions and answers, which the student will find of great utility in the examination of children."—Annals of Gynecology. 16. ESSENTIALS OF EXAMINATION OF URINE. By Law- rence Wolff, M. D., author of " Essentials of Medical Chemistry," etc. Colored (Vogel) urine scale and numerous illustrations. Crown 8vo. Price, Cloth, 75 cents. " A little work of decided value."—University Medical Magazine. " A good manual for students, well written, and answers, categorically, many questions beginners are sure to ask."—New York Medical Record. " The questions have been well chosen, and the answers are clear and brief. The book cannot fail to be useful to students."—Medical and Surgical Reporter. 17. ESSENTIALS OF DIAGNOSIS. By Solomon Solis-Cohen, M. D., Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic, and Augustus A. Eshner, M. D., Instructor in Clinical Medicine, Jefferson Medical College, Philadelphia. Crown 8vo, 382 pages, 55 illustrations, some of which are colored, and a frontispiece. Price, $1.50 net. " A good book for the student, properly written from their standpoint, and confines itself well to its text."—New York Medical Record. 4 "Concise in the treatment of the subject, terse in expression of fact. . . . The work is reliable, and represents the accepted views of clinicians of to-day."—American Journal of Medical Sciences. "The subjects are explained in a few well-selected words, and the required ground has been thoroughly gone over."—International Medical Magazine. 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre, M. D., Professor of Pharmacy and Materia Medica in the Uni- versity of Kansas. Second edition, revised and enlarged. Crown 8vo, 200 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. "Covers a great deal of ground in small compass. The matter is well digested and arranged. The research questions are a valuable feature of the book."— Albany Medical Annals. " The best quiz on Pharmacy we have yet examined."—National Drug Register. " The veteran pharmacist can peruse it with pleasure, because it emphasizes his grasp upon knowledge already gleaned."— Western Drug Record. CATALOGUE OF MEDICAL WORKS. 27 20. ESSENTIALS OF BACTERIOLOGY: A Concise and Syste- matic Introduction to the Study of Micro-organisms. By M. V. Ball, M. D., Assistant in Microscopy, Niagara University, Buffalo, N. Y.; late Resident Physician, German Hospital, Philadelphia, etc. Second edi- tion, revised. Crown 8vo, 200 pages, 81 illustrations, some in colors, and 5 plates. Price, Cloth, $1.00; interleaved for notes, $1.25. " The amount of material condensed in this little book is so great, and so accurate are the formulae and methods, that it will be found useful as a laboratory handbook."—Medical News. " Bacteriology is the keynote of future medicine, and every physician who expects success must familiarize himself with a knowledge of germ-life—the agents of disease. This little book, with its beautiful illustrations, will give the students, in brief, the results of years of study and research unaided."—Pacific Record of Medicine and Surgery. "Thoroughly practical, very concise, clear, well-written, and sufficiently illustrated. . . . The best book of the kind in the English language."—Medical and Surgical Reporter. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY, their Symptoms and Treatment. By John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island Col- lege Hospital Medical School; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital; formerly Medical Super- intendent King's County Insane Asylum. Second edition. Crown 8vo, 186 pages, 48 original illustrations, mostly selected from the Author's private practice. Price, Cloth, $1.00; interleaved for notes, $1.25. " Clearly and intelligently written."—Boston Medical and Surgical Journal. "A valuable addition to this series of compends, and one that cannot fail to be appreciated by all physicians and students."—Medical Brief. " Dr. Shaw's Primer is excellent. The engravings are well executed and very interest- ing.''—Medical Times and Register. " Written with great clearness, devoid of verbosity, it encompasses in a brief space a vast amount of valuable information."—Pacific Medical Record. 22. ESSENTIALS OF PHYSICS. By Fred J. Brockway, M. D., Assistant Demonstrator of Anatomy in the College of Physicians and Sur- geons, New York. Second edition. Crown 8vo, 320 pages, 155 fine illus- trations. Price, Cloth, $1.00 net; interleaved for notes, #1.25 net. " The publisher has again shown himself as fortunate in his editor as he ever has been in the attractive style and make-up of his compends."—American Practitioner and News. "Contains all that one need know of the subject, is well written, and is copiously illus- trated."—New York Medical Record. " The author has dealt with the subject in a manner that will make the theme not only comparatively easy, but also of interest."—Medical News, Philadelphia. " Deserving of close investigation at the hands of students and physicians."—American Gynecological Journal. 28 W. B. SAUNDERS' CATALOGUE. 23. ESSENTIALS OF MEDICAL ELECTRICITY. By D. D. Stewart, M. D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College; Phy- sician to St. Mary's Hospital and to St. Christopher's Hospital for Chil- dren, etc.; and E. S. Lawrance, M. D., Chief of the Electrical Clinic, and Assistant Demonstrator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown 8vo, 148 pages, 65 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. " Clearly written, and affords a safe guide to the beginner in this subject."—Boston Med- ical and Surgical Journal. " The subject is presented in a lucid and pleasing manner."—New York Medical Record. " A little work on an important subject, which will prove of great value to medical students and trained nurses who wish to study the scientific as well as the practical points of elec- tricity."— The Hospital, London. " The selection and arrangement of material are done in a skilful manner. It gives, in a condensed form, the principles and science of electricity and their application in the practice of medicine."—Annals of Surgery. " The compilation is a good one, and will be found useful both to students and to men in practice."—New Zealand Medical Journal. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia; Surgeon in Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia; formerly As- sistant in the Nose and Throat Dispensary of the Hospital of the Univer- sity of Pennsylvania, and Assistant in the Nose and Throat Department of the Union Dispensary. 89 illustrations. Price, Cloth, $1.00; inter- leaved for notes, $1.25. This latest addition to the Saunders Compend Series accurately represents the modern aspect of otological science. The effort has been made to state the Essentials of Otology concisely, without sacrificing accuracy to brevity, and the book, while small in compass, is logically and capably written; it comprises up- ward of 150 pages, with 89 illustrations, most of which are from original sources. • • < tIBRARY OF MEDICINE NATIONAl tIBRARY OF ME w jo Asvaan ivnoiwn snoiqsw jo Aavaan ivnoiivn 3noio3w jo xavagn tvnoiivi* \JK/ \ V\i/V s V* US. Department 5 USDeportmen WO 100 DH8m 46110010R ^7 5 NATIONAL LIBRARY OF MEDICINE