^*W^N*tf*WWW*? -H&^S. SS2SS8& ^sasgag 8i8K •Cv.x- ^ p xV • *******% NLfl DDSSSQSS d 5 SURG-EON GENERAL'S OFFICE || LIBRARY. I 1 aLn^ NLM005550552 THE PRINCIPLES OP SURGERY AND SURGICAL PATHOLOGY GENERAL RULES GOVERNING OPERATIONS AND THE APPLICATION OF DRESSLNGS BY Dr. HERMANN TILLMANNS PROFESSOR IN THE UNIVERSITY OF X.EIPZIG TRANSLATED FROM THE THIRD GERMAN EDITION BY JOHN ROGERS, M. I)., New York AND BENJAMIN TILTON, M. D., New York Edited by LEWIS A. STIMSON, M. D. PROFESSOR OF SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK, MEDICAL DEPARTMENT WITH 441 ILLUSTRATIONS D. NEW YORK APPLETON AND COMPANY 1895 TS77L ) $9S Copyright, 1894, By D. APPLETON AND COMPANY. Electrotyped and Printed at the appleton press, u. s. a, PREFACE. The great advances that have been made in recent years in our knowledge of the minute processes and tissue changes in disease, of the causes that underlie them, and of the principles of repair, have estab- lished the practice of surgery upon a much broader and more scientific foundation than it formerly had ; and the surgeon of to-day who wishes his work to be thorough, intelligent, and fruitful of good results must make this knowledge all his own and must build upon this foundation. Nowhere is this need more keenly appreciated than in our* medical schools, where it has long been recognised that the student must gain a thorough knowledge of surgical pathology before he can listen with advantage to didactic and clinical lectures upon special forms of sur- gical disease and injury. The makers of even the most recent surgical text-books in the English language have adhered, in the main, to the old division and arrange- ment of their subjects, and instead of adding to the general group of inflammations, surgical complications, and general surgical diseases, the kindred subjects of the general surgical injuries and diseases of the various tissues, they have separated the latter and combined them with the study of their numerous and varied local forms in regional surgery. Moreover, the general need of keeping the work within relatively nar- row limits has led to a correspondingly concise and restricted presen- tation of the general pathology of each subject, one unsuited to the needs of both the beginner and the practitioner who is in search of detailed information. On the other hand, the Germans, and to some extent the French, have divided their text-books into two distinct parts, the "general" and the " special " ; including in the former not only the general affec- tions and pathology, but also the pathology and principles of treatment of the injuries and diseases of the various tissues, and confining the latter to the consideration of their local manifestations in regional surgery; and the space given to general surgery in their best-known text-books is nearly or quite equal to that given to both subjects in ours. (Hi) IV PREFACE. A consideration of these facts and of the special needs of their students led some of the professors of surgery in New York to suggest the present translation, and as the project met with the approval of others similarly concerned with medical education it was undertaken. Tillmanns' Surgery was selected as the one best suited for the pur- pose, and it is hoped that it will receive in its present form the favour it has so widely enjoyed in the original. John Rogers, M. D. 14 West Twelfth Street. CONTENTS. FIRST SECTION. GENERAL PRINCIPLES GOVERNING SURGICAL OPERATIONS. I. The Preparations for an Aseptic Operation. SECTION PAGE 4. Definition of a surgical operation.........1 5. Indications and counter-indications for undertaking an operation ... 2 6. The preparations for an aseptic operation. Antisepsis and asepsis ... 2 II. The Alleviation ok Pain during Operations.—Narcosis.—Local Anaesthesia. 7. The alleviation of pain during the operation.......14 8. Chloroform narcosis............16 9. Technique of chloroform narcosis . ......18 10. Symptomatology of chloroform narcosis........23 11. Accidents occurring during chloroform narcosis......25 12. The occurrence and cause of death during narcosis ...... 27 13. Treatment of common accidents occurring during chloroform narcosis . . 33 14. Ether narcosis.............37 15. Laughing-gas narcosis............30 16. Mixed narcosis and other anaesthetics.........40 17. Local anaesthesia.............43 III. The Prevention of Loss of Blood during an Operation. 18. The prevention of loss of blood during an operation......47 19. Esmarch's artificial ischasmia . . ........48 IV. General Rules for performing an Aseptic Operation and for the After-treatment of the Patient. 20. Performance of an aseptic operation.........55 21. The accidents during an operation.........56 22. The post-operative treatment of patients........61 23. The most important causes of death after operation......62 V. The Different Ways of dividing the Tissues. 24. The division of the soft parts (accompanied by the loss of blood) ... 64 25. Bloodless division of the tissues without cutting, by tearing, twisting, etc. . 72 26. The division of bone............80 VI CONTENTS. VI. The Methods of arresting Hemorrhage. PAGE 27. The arrest of haemorrhage during operations.......86 28. Substitutes for the ligation of vessels ........90 29. Other methods of haemostasis..........92 30. Ligation of arteries in continuity.........95 VII. Drainage of Wounds. 31. The method of allowing the secretions of a wound to escape .... 98 VIII. The Method of uniting the Tissues.—Suture of the Wound. 32. Disinfection of the wound before inserting the sutures.....103 33. The method of uniting the soft parts—Suture of the wound .... 104 34. The method of uniting wound surfaces of bone . . . . . . 110 ' IX. Amputations, Disarticulations, and Resections.—General Considerations. 35. General considerations in performing amputations and disarticulations . . 112 36. General considerations in regard to amputations......114 37. The method of performing disarticulations.......123 38. The after-treatment of amputations and disarticulations.....124 39. Artificial limbs.............127 40. Operations on joints............128 X. Operations for Remedying Defects in the Tissues.—Plastic Operations.—Transplantation. 41. Plastic operations for cutaneous defects........135 42. Skin-grafting according to Reverdin and Thiersch......141 43. Plastic operations on other tissues.........144 SECOND SECTION. THE METHODS OF APPLYING SURGICAL DRESSINGS. I. The Antiseptic and Aseptic Protective Dressings. 44. General principles governing antiseptic or aseptic dressings .... 146 45. The most common antiseptic and aseptic dressings......148 46. The different antiseptics........... 152 47. Which antiseptics and which antiseptic or aseptic dressings are the best? . 170 48. The changing of an antiseptic or an aseptic dressing.....173 II. Other Methods of treating Wounds. 49. Other dressings for wounds..........177 III. General Rules for the Application of Bandages and Retention Appliances. 50. Application of bandages...........185 51. Application of suitably shaped pieces of cloth in place of bandages . . 194 IV. The Sick-bed of the Patient.—Immobilisation Appliances and Dressings. 52. The sick-bed of the patient...........200 53. Sick-bed appliances—Splints, cushions, etc....... 202 CONTENTS. vii V. The Application of Immobilising Dressings made of Materials which GRADUALLY HARDEN. PAGE 54. Immobilisation dressings of hardening substances......216 55. The method of applying extension by a weight........224 THIRD SECTION. SURGICAL PATHOLOGY AND THERAPY. I. Inflammation and Injuries. 56. Inflammation.............232 57. Causes of inflammation............239 58. Symptoms, diagnosis, and treatment of inflammation.....241 59. Morphology and general significance of micro-organisms.....252 60. General remarks concerning injuries.........277 61. The anatomical phenomena in the healing of a wound.....280 62. The general reaction which follows an injury and an inflammation.—Fever . 300 63. Shock...............313 64. Delirium tremens............316 65. Delirium nervosum and psychical disturbances which may follow injuries and operations.............317 66. The infectious-wound diseases..........318 67. Inflammation and suppuration of a wound—Etiology ..... 320 68. Lymphangitis, lymphadenitis..........326 69. Arteritis and phlebitis...........329 70. Cellulitis..............331 71. Erysipelas..............339 72. Hospital gangrene—Wound diphtheria........351 73. Traumatic tetanus............354 74. Septicaemia..............363 75. Pyaemia..............373 76. Infection by cadaveric poisoning.........379 77. Splenic fever, or anthrax...........381 78. Glanders, or farcy............390 79. Foot-and-mouth disease...........394 80. Hydrophobia.............395 81. Poisoning by insects, snakes, etc..........403 82. The poisoning of wounds by Indian arrow poison......405 Appendix. Chronic Mycoses: Tuberculosis (Scrofula), Syphilis, Leprosy, Actinomycosis. 83. Tuberculosis.............406 84. Syphilis..............425 85. Leprosy..............437 86. Actinomycosis.............441 II. Injuries and Surgical Diseases of the Soft Parts. 87. Wounds of soft parts...........448 88. The treatment of wounds of soft parts........464 89. Treatment of the conditions following severe haemorrhages—Blood and com- mon salt infusion...........478 viii CONTENTS. PAGE 90. Burns...............484 91. Effects of cold (freezing)...........494 92. Subcutaneous injuries of soft parts.........497 93. The diseases of the skin and cellular tissue.......510 94. The diseases of the mucous membranes........525 95. Inflammations and diseases of blood-vessels.......530 96. The diseases of the lymphatic system........543 97. The diseases of the peripheral nerves........545 98. The diseases of muscles, tendons, and tendon-sheaths.....549 99. The diseases of the bursa?...........558 100. Gangrene (necrosis) of the soft parts........561 III. Injuries and Surgical Diseases of L'one. 101. Fractures..............507 102. Contusions and wounds of bone.........607 103. The inflammations of bone..........609 104. Acute inflammations of bone—Acute periostitis and acute osteomyelitis . 609 105. The chronic inflammations of bone.........618 106. Necrosis of bone............630 107. Spontaneous (inflammatory) separations of the epiphyses .... 637 108. Rhachitis..............638 109. Osteomalacia.............644 110. Atrophy and hypertrophy of bone.........647 111. The tumours of bone............052 IV. Injuries and Diseases of Joints. 112. Review of the anatomy of the joints......... 655 113. The acute inflammations of joints.........658 114. The chronic inflammations of joints........667 115. Joint-bodies or joint-mice..........687 116. Neuroses of joints (neuralgias of joints; nervous, hysterical diseases of joints)..............690 117. Neuropathic diseases of bones and joints........693 118. Anchylosis..............696 119. Deformities of joints (contractures).........698 120. Injuries of joints............707 121. Sprains (distortions)............708 122. Dislocations of joints...........710 123. Wounds of joints............724 Appendix. Gunshot Wounds. Military Practice. 124. Gunshot injuries............727 V. Tumours. 125. Tumours in general—definition and classification......738 126. Etiology of tumours............739 127. Growth, course, diagnosis, and treatment of tumours.....742 128. The different varieties of tumours; connective-tissue tumours (fibroma, myxoma, lipoma, chondroma, osteoma, sarcoma, etc.) .... 746 129. The epithelial tumours (papilloma, epithelioma, adenoma, carcinoma, etc.) . 771 130. Cysts—Atheroma, teratoma, cyst-formation in different tumours . . . 784 TILLMANNS' PRINCIPLES OF SURGERY AND SURGICAL PATHOLOGY. FIRST SECTION. GENERAL PRINCIPLES GOVERNING SURGICAL OPERATIONS. CHAPTER I. THE PREPARATIONS FOR AN ASEPTIC OPERATION. a. Definition of a surgical operation, b. The indications and counter-indications for undertaking an operation, c. Antisepsis and asepsis, d. The preparations for an aseptic operation.—Operating room.—Operating table.—Preparation of the patient. —The operator and his assistants.—Sterilisation of the instruments.—Sponges.— Substitution for sponges of aseptic (sterilised) pads of gauze, etc.—Preparation of aseptic dressings. § 4. Definition of a Surgical Operation.—An " operation," in the broadest sense of the word, means any mechanical interference of the surgeon undertaken with a view to remedy disease, in which inter- ference surgical instruments are used. A distinction is made between an operation in which a loss of blood occurs and one in which it does not. To the bloodless opera- tions belong, for instance, the introduction of a catheter into the bladder, the crushing of a vesical calculus by the lithotrite, the re- moval of foreign bodies from the external auditory meatus, from the pharynx, etc. But, generally speaking, an operation is ordinarily understood to be of the kind that is accompanied by a loss of blood, and this is the kind that is meant here. " Operative surgery," says Diffenbach, " is, of all branches of the healing art, the most suited to arouse enthusiasm in its followers; it is a bloody fight with disease for life—a fight that means life or death." Every surgeon must have a certain amount of natural talent, and an enthusiastic devotion to his profession. A complete mastery of the 2 U) 2 THE PREPARATIONS FOR AN ASEPTIC OPERATION. technique, keen senses, a well-trained eye, a delicate touch, and a steady hand, are all indispensable. The plan of the operation must be clearly mapped out beforehand, and during the operation must be quietly and resolutely carried out. § 5. Indications and Counter-indications for an Operation.—A difficult problem which often confronts the surgeon is to correctly weigh the indications and counter-indications for undertaking an operation. It is often a hard question to decide whether a cure is not possible with- out an operation; and it is well to consider whether the proposed operation does not carry with it greater dangers than the disease itself, especially in those cases where the annoyances are but slight. The counter-indications for operation depend upon the particular organ which is diseased or upon the general condition of the patient (extreme youth or old age, general weakness, coexisting acute or chronic disease, etc.). Under all circumstances it is necessary to have the consent of the patient for the proposed operation. The question as to whether an operation should be performed against the will of the patient is answered differently by different sur- geons, though the majority of physicians consider that they are entitled, and indeed obliged, in exceptional cases, to perform an operation against the will of the patient—if, for instance, the danger from the operation is much less than that from the continuation of the disease, or if the patient can be saved by the operation from certain death. To gain the desired end in such cases—or, in other words, to per- form the operation—the patient is chloroformed, and upon recovering from the anaesthetic he is usually glad that the operation has been done, even though contrary to his will. § 6. Preparations for an Antiseptic or Aseptic Operation.—We operate, without exception, according to either antiseptic or aseptic principles— that is, we try to prevent entrance into the wound of substances that tend to cause inflammation and putrefaction. All the de- composing products of putrefaction come under the head of septic matter—sepsis (from 0771^49) meaning putrefaction. An antiseptic method of conducting an operation and of treating a wound is one that is directed against the entrance of sepsis, or of septic material, into the wound, or, in other words, prevents infection of the wound. An uninfected wound, a wound which runs the normal course in healing, without inflammation or suppuration, is called aseptic—that is, it is free from septic materials. By aseptic is meant that particular mode of operating and treating a wound in which an attempt is made to keep septic matters—i. e., bacteria and the poisonous products of their metabolism—out of the §6.J THE PREPARATIONS FOR AN ASEPTIC OPERATION. 3 wound, so that the process of healing may be without reaction, inflam- mation, suppuration, or fever. We know that all the processes of putrefaction, that every infection of the wound, that all inflammation and suppuration, are caused by micro-organisms (bacteria). The latter exist everywhere ; they float in the air, where they are mixed with the atmospheric dust, they cling to the clothes and the skin of the patient and the operator, they are found on the instruments, sponges, etc. Therefore, if we wish to protect those upon whom we operate from the noxious influence of bacteria, we must take the greatest pains to keep the latter out of the wound, or, if they have already found lodg- ment in the body, to check their further development, and to destroy them as soon as possible. The preparations for an aseptic operation must be so managed that every possibility of infecting the wound is avoided by careful anti- septic rules. Hence we must always take pains to most rigidly disin- fect the operating room, the table, the part to be operated upon, the hands and clothes of the operator and his assistants, the instruments, sponges, and dressings—in short, everything which comes into direct or indirect contact with the wound. Antisepsis and Asepis.—During operations in former times, anti- septics were employed much too freely—for instance, in the form of a mist, the so-called spray, or in the form of irrigations—and at the close of the operation the wound was once more energetically disin- fected. Our most effective antiseptics, especially carbolic acid and bichloride of mercury, are poisonous, and many patients have died after the operation of carbolic and bichloride poisoning. The too intense irri- tation of antiseptics endangers the vitality of the tissues with which they come in contact, and renders them less capable of withstanding bacteria; furthermore, serious parenchymatous lesions are thus produced in opera- tions on the organs in the thoracic and peritoneal cavities (Senger). It is right, therefore, to limit the use of antiseptics in operations; in fact, most surgeons aim to avoid them entirely. Disinfection and anti- septic treatment of a fresh wound which has been made by the surgeon is not necessary if the operation is conducted strictly aseptically—that is, if the field of operation, the hands of the surgeon, the instruments, the sponges or gauze pledgets, etc., have been sterilised—i. e., rendered free from micro-organisms. Under such conditions a sterilised solu- tion of common salt of a strength of five tenths to seven tenths per cent., or boiled water, can be substituted for the carbolic or bichloride solutions. If larger amounts of sterilised wrater are needed, the ap- paratus of Fritsch is useful. The employment of a six-tenths-per-cent, sterilised salt solution is especially useful in laparotomies (Fritsch). 4 THE PREPARATIONS FOR AN ASEPTIC OPERATION. Asepsis has taken the place of antisepsis in operations, for the rea- son that a wound which has not been irritated by antiseptics heals much more readily, the secretion is much less, and drainage can more frequently be entirely dispensed with. Furthermore, the process of repair in the wound is quicker with the aseptic than with the antiseptic method; the aseptic cicatrix forms sooner, and is more solid and durable than when the wound has been irritated by antiseptics. When the latter have been used the process of cell division is more sluggish, and begins later. In the case of wounds treated by the aseptic method, complete healing and the formation of the cicatrix usually occupies eight days; while in wounds in which bichloride of mercury has been used the change from granulation to cicatricial tissue has hardly begun in this time. Socin, Bergmann, Neuber, and others, were among the first to give up antisepsis for asepsis, though Lawson Tait, and Koberle had long furnished proof that beautiful operative results could be obtained without using antiseptic solutions. But for injuries and wounds already infected, the rules of rigorous antisepsis are to be carried out—i. e., the wound should be thoroughly disinfected with a three- to five-per-cent. solution of carbolic acid or a one tenth to one fiftieth per cent, of bi- chloride of mercury. At present, for the same reasons, there is a dis- position to avoid the use of dressings impregnated with antiseptic materials, such as carbolic acid and bichloride, as the dressings can be most easily and surely disinfected by subjecting them to the action of steam at a temperature of 100° to 130° C. (212° to 266° F.) for a half to three quarters of an hour. This method of disinfection is much surer than when the dressings are impregnated with antiseptic materials, as in dressings thus impregnated bacteria have been detected after a short time. Steam sterilising apparatus have now been uni- versally introduced in hospitals for the treatment of dressings, operat- ing gowns, beds, bed-clothing, etc., and small steam sterilising apparatus can easily be brought into every large surgical ward. The portable steam sterilisers of Straub, H. Settegast, Bubenberg, E. Hahn, and Schimmelbusch are especially adaptable for private practice. In Fig. 1 is illustrated the steriliser of Schimmelbusch, which has been intro- duced in Bergmann's clinic. As regards the mechanism of this apparatus, the following should be noted : W, the part which holds the water, is filled by a funnel through the tube T, up to a marked height. Whatever is to be sterilised is placed in the inner compartment of the apparatus, the latter having a double metallic wall. The cover D is screwed on tight. In the §6.] THE PREPARATIONS FOR AN ASEPTIC OPERATION. 5 centre of the cover is placed the thermometer, Th. The water is heated by a gas flame, and the steam, at a temperature of 100° to 130° C. (212° to 266° F.), enters the inner com- partment of the apparatus from above, and escapes through the opening R into a lead spiral in a condenser filled with water. The air between the double-walled water vessel and the metallic enclosure, which is protected by asbestos, escapes through the openings at 0. At the end of the sterilisation the water can be drawn off through the faucet II, the cover is removed, and the sterilised article taken out. In order that the sterilised dress- ings can be kept sterile, the tin vessel devised by Schimmelbusch (Fig. 2) is used. This is provided with a tight cover (d) and a great number of holes (a b); the latter can be opened and closed at will by a strip of tin. This tin vessel is filled with dressings and placed in the steriliser. We shall return again to the subject of sterilisation of the dressings, operation gowns, compresses, etc., and presently describe the sterilisation of the instru- ments by boiling for five minutes in a one-per-cent. soda solution, the cleansing of the hands, etc. For the disinfection of large articles, such as mattresses, clothes, etc., the disinfector of Kietschel Henneberg is particularly good. The cleanliness of the operating room and of everything it contains must always be rigorously enforced by the surgeon. Operating Room.—The operating room should be as light as possible, well ventilated, and plentifully sup- plied with arrangements for washing, receptacles for disinfecting solutions, especially three-to five-per-cent. solutions of carbolic and bichloride (1 to 1,000-5,000), etc. In larger hospitals it is well to have two operating rooms, one for aseptic operations and the other for in- fected cases; and it is advantageous to have on the floor of the operating room, which is best made of cement, a gutter arrangement for conducting off the water. The walls of the operating room must be so built as to be capable of being easily and thoroughly cleansed, and therefore should be cov- ered with oil or enamel paint, or with metal or glass plates. Kecesses Fig. 1.—Steam-sterilising appara- tus (Lautenschliiger.) and Fig. 2. — Sheet- iron vessel for dressing mate- rials (Schim- melbusch). 6 THE PREPARATIONS FOR AN ASEPTIC OPERATION. and corners which can harbour dust, etc., are to be avoided, on account of the microbes they contain, and pains should be taken not to stir up dust either before or during the operation. Before an operation the air in the room can be moistened by steam from a large spray or steam pipe, if there is one, and thus freed of dust. Operating Table.—The operating table should be as simple as pos- sible and absolutely clean. In order to facilitate the escape of soiled Fig. 3.—Author's operating table. liquids, operating tables are coming more and more into use which are provided with means to carry off these fluids. Juillard,* Sprengel,f Paul Schede,^: and Hagedorn # have invented excellent operating tables, with receptacles, buckets, etc., placed under the table to receive the overflow. I consider the operating tables used by Paul Schede, Hagedorn, and Bergmann worthy of recommendation in every way. Operating tables made with an iron frame and a glass plate are very good. My own operating table, illustrated in Fig. 3, has an iron frame with a plate of strong flint glass; the gutter placed around the table conducts away the overflow into a vessel underneath, and the whole table can be readily cleaned. The head-piece, which is easily adjusted, is fitted with a removable glass plate. For elevating the pelvis, a movable framework can be brought into use, made like the head-piece, of glass and iron, and leg-supporters can be very easily * Illust. Monatscht. d. Arz. Polytec, 1883, Heft 12. t Centrl. f. Chir., 1886, No. 8. t Centrl. f. Chir., 1884, No. 30. « Ibid., 1887, No. 28. §6.] THE PREPARATIONS FOR AN ASEPTIC OPERATION. 7 Fig. 4, -Author's transportable operating table for private and military prctice. Q attached. I have also devised a transportable table with folding legs for private practice and for army use (Figs. 4, 5, 6), which is made of wrought iron, weighs only twenty-five kilo- grammes, and is inex- pensive. Trendelenburg has constructed a table which allows the pa- tient to be brought into various positions. For protracted operations —laparotomies, for in- stance—it is advanta- geous to use operating tables which can be kept warm, such as me- tallic tables (Socin) filled with hot water. In this way the patient is kept from losing too much body tem- perature. Preparation of the Patient.—The prelimi- naries for an operation begin with the prepa- ration of the patient. In operations of any magnitude the whole body should be first thoroughly cleansed by means of a warm bath, £j. i • -u ^ ~™+ ^-F Fig. 6.—The transportable operating table: a, seen from be- after which the part 01 ^w. ^ the 'siae; c; the end. the body to be oper- ated on is scrubbed with soft soap, shaved, rubbed off with ether to remove the fat on the skin, and washed with a three-to five- per-cent. solution of carbolic acid, or an aqueous solution of bi- chloride of mercury of a strength of 1 to 1,000-1 to 5,000. The scrubbing and disinfecting of the hands and feet especially must be thoroughly and carefully carried out. Instead of brushes which are boiled and kept in a bichloride solution (1 to 1,000), I use swabs 8 THE PREPARATIONS FOR AN ASEPTIC OPERATION. of wood fibre or cotton which are sterilised by heat and burnt after use. In operations in the mouth the teeth should be thoroughly cleansed by a toothbrush, and the mouth frequently rinsed with a chlorate-of- potash solution of a strength of 5 or 6 to 100, or permanganate of potassium, boric acid, etc. Carious teeth and the tartar which swarms with bacteria, etc., are to be removed. If the operation is in the hypo- gastric region, in the neighbourhood of the anus, on the urinary and sexual organs, or in the peritoneal cavity, care should be taken to secure a movement of the bowels on the last day before the operation by a dose of castor oil, and about two hours before the operation the rectum should be washed out with lukewarm water injected from an irrigator. When necessary, the bladder should be emptied in advance by a catheter. The stomach of a patient about to be chloroformed should, if pos- sible, be empty, and in all cases the taking of solid food shortly before the operation should be forbidden, so that the respiratory movements of the diaphragm shall not be interfered with, and troublesome vomit- ing shall not occur. The entrance of vomited matter into the air-passages has repeatedly caused death during chloroform narcosis. After the cleansing and disinfecting of the portion of the body to be operated upon has been completed, the patient is then covered with rubber or linen protectives, leaving the field of operation exposed (Figs. 7-10). For this purpose protectives are provided with openings Fig. 7.—Preparation of the f°r tne arms, legs, and neck, or thev are suitably fettdTe^8011 fastened together with safety pins. The linen protectives should be sterilised by keeping them for half an hour in the steriliser at a temperature of 100° 0 In operations upon the face and neck the patient's hair should be covered by a rubber cap, which is made to fit tightly !>y means of an elastic band, so as to prevent the hair from coming i„ contact with the field of operation; or, better still, the head may be wrapped in an aseptic gauze bandage. For operations in the peritoneal cavity, it is better to provide two protectives, as is shown in Fig. 10. Fi^s. 7 to 10 illustrate sufficiently the excellent plan which has been recommended by Neuber I the neighbourhood of the field of operation with" lan-e septic'com presses (or towels) which have been sterilised in the steriliser bv heat so.] THE PREPARATIONS FOR AN ASEPTIC OPERATION. 9 -Position of the patient in operations on the upper ex- tremity. at a temperature of 100° to 130° C. (212° to 284° F.), and are then moistened with a one-tenth-per-cent. solution of bichloride. If an operation is protracted, especially in cold weather, care must be taken that the patient does not become chilled. If the patient be- comes badly chilled, a dangerous or even fa- tal collapse may be pro- duced, especially after operations in the peri- toneal cavity. For this reason it is wise to pro- tect the patient by flan- nel coverings, warm cloths, etc., and partic- ularly by warming the operating room to about lti°-lN°-19° R. (T*° to 75° F.). For protracted operations the warmed operating table of Socio, already Fig. 9.—Position of the patient in operations on the lower ex mentioned, is valuable. The best clothing for the operator and his assistants consists of a linen operating gown, the sleeves of which only reach to the middle of the up- per arm. Before every operation the fresh- tremity. Fig. 10.—Position of the patient in operations in the abdominal cavity. v washed operating gowns are sterilised for a half to three quarters of an hour in the steriliser by the action of hot steam at a temperature of loo° C. (212° F.). With a view to preserving thorough asepsis, the operator and his assistants must work with bare forearms. The hands and forearms are disinfected in the following manner I P. Furbringer): while dry, the nails are first cleansed of visible dirt by a nail cleaner and scissors which are always kept in a ten-per-cent. solution of carbolic acid in glycerine; then the hands and forearms are thoroughly scrubbed with a brush in soap and warm water, with special attention to the ends of the fingers and the part underlying the nails, then rubbed for one minute in seventy to eighty per cent. 10 THE PREPARATIONS FOR AN ASEPTIC OPERATION. alcohol, and before the alcohol has evaporated the hands and forearms are scrubbed with a brush for one minute in a 1 to 1,000 solution of bichloride or a three-per-cent. solution of carbolic. It is of the greatest importance in the disinfection of the hands to make the mechanical cleansing of the latter as thorough as possible. This is in accord with the researches of Landsberg. For keeping the hands in a good condition Pears's glycerine soap is particularly useful and if anything more is necessary, the inunction of a small amount of lanolin is excellent. The modern surgeon should give up wearing rings, and in any case always lay them aside before an operation, as they are invariably bearers of infection. A large basin containing a three-per-cent. solution of carbolic or a 1 to 1,000 solution of bichloride should be placed near the operator and his assistants, so that they may constantly keep their hands disinfected, even though they do not come in contact with unclean objects, such as pus, faeces, urine, etc.^ ^ Sterilisation of Instruments.—The instruments are best disinfected by boiling them for five to ten minutes in a one-per-cent. solution of soda, the latter substance rendering them less liable to rust than plain water. According to Davidsohn, five minutes is sufficient. The knives are wiped off with a piece of sterilised cotton wet in carbolic solution and placed for only one minute in the boiling soda solution, as they are easily dulled. As wood- en handles on instruments are soon damaged by boiling, nickel-plated metal handles are preferable. Instruments are not sufficiently disinfected by simply placing them in carbolic or other antiseptic solu- tion (Gartner, Kummel, Gutsch, Redard, Davidsohn). A sterilising apparatus for instruments can be made for a small price by any tin- man, in the following manner: a large box made of sheet copper, with a removable top. is provided instruments with a tray of tin plate which is punched full of holes; the trav holds the instruments, and has two handles attached to it so that it can be lifted out after the boiling and placed in a three-per-cent. solution of carbolic acid. A very excellent apparatus, devised by Schimmelbusch, is illustrated in Fig. 11, but it is much more expensive. The figure 1 ;;;:;-:..■ - ; —«■■•■:: /;" .??::::::;;;:r:;:: ._ Fig. 11.- -Apparatus for boilinc (Schimmelbusch). §6.] THE PREPARATIONS FOR AN ASEPTIC OPERATION. n needs no explanation. At the close of the process of sterilisation the wire tray E, which holds the instruments, is taken out and placed in a three-per-cent. carbolic solution contained in a glass dish or tray made of enamel-covered metal. Before using, I generally wipe off every knife carefully with a piece of sterilised cotton moistened in a three-per-cent. solution of carbolic acid. This is a mechanical means of disinfection which Gartner has shown to be particularly efficacious. During the operation the instruments should lie in an antiseptic solution, preferably a three-per- cent, solution of carbolic. For this purpose trays are used made of glass, porcelain, and metal. The non-breakable and easily cleaned vessels of enamelled metal which are used in the kitchen are very good for this purpose. After every operation the instruments are scrubbed with a brush and soap in a three-per-cent. solution of carbolic acid and then polished. Amongst the other sterilising apparatus, those devised by Braatz, Kronacher, Sternberg, and Mehler should be mentioned. For sponging the wound during the operation, sterilised pledgets of cotton wool or gauze pads should be used, and these are kept wrapped up in sterilised gauze ; they are made germ-free by sterilisation at a tem- perature of loo° to 130° C. (212° to 2()0° F.) for half an hour, and are decidedly preferable to the ordinary sponges which were formerly em- ployed, as the pads are only used to wipe out the wound once and are afterwards burnt. A large stock of such sterilised gauze pads can be always kept on hand in a bichloride solution (1 to 1,000), or only freshly sterilised pads can be used. Disinfection of Sponges.—Ordinary sponges very quickly become use- less after sterilisation in the hot steam of a steriliser, and they are best disinfected in the following way: After pounding them thoroughly, rinse them in a solution of potassium permanganate (1 to 500-1,000), then soak them for a quarter of an hour in a solution consisting of four fifths to one per cent, of hyposulphite of soda and from one fifth to eight per cent, of pure hydrochloric acid (Keller); then place them for a quarter of an hour more in boiling water or in a boiling soda solution of a strength of one per cent. The sponges are stored in a five-per-cent. solution of carbolic acid or one-tenth per-cent. solution of bichloride of mercury. Sterilisation of Dressings, Silk, Catgut.—Silk, catgut, drainage-tubes, dressings, and bandages should also be rendered perfectly sterile. Silk should be boiled for half an hour in a bichloride solution (2 to 1,000) or a five-per-cent. carbolic solution, and the other materials can be treated by dry sterilisation—i. e., by keeping them in the dry steril- 12 THE PREPARATIONS FOR AN ASEPTIC OPERATION. Fig. 12.—Hand-spraying apparatus. iser for half an hour at a temperature of 100° C. (212° F.). For the sterilisation of catgut, see page 88. The Spray.—Some years ago the operation and the application of the dressings were always carried out under the Lister spray—in other words, in a fine mist of carbolic acid. The man- agement of the hand spray can be un- derstood without further explanation from the illustration in Fig. 12. The steam spray apparatus consists of a vessel containing water, with a spirit lamp underneath. The boiler is filled through the opening at a and then closed by a stopper which is screwed in place. At b is placed a safety valve, which allows the steam collected in the kettle to escape in case the cock at c is turned off. The steam passes from the boiler through a tube closed and opened by the cock c, then into a glass containing three to five per cent. carbolic acid, and drives the latter out of the end of the tube in the form of a spray, the direction of which can be changed by means of the handle d. At present the spray, as has been said, is seldom employed, and I, person- ally, never use it. It has been proved that the results obtained without the spray are just as good as those obtained with it. The spray is troublesome, inconvenient for the operator, and not free from danger to the patient on account of the not unimportant chilling it may cause, and from the danger of carbolic or bichloride poisoning. I sometimes use the spray before a laparotomy when I wish to purify the air of the operat- ing room, and for this purpose I use a steam spray placed as high up as possible. In hospitals fitted with steam or water pipes a very effective spray apparatus can be contrived by connecting the st^am pipe with the boiler of the apparatus, and in this way the air in the operating room can be very easily and cheaply ren- dered germ free—in other words, disinfected. The disinfection of the air of the operating room is ordinarilv not neces- sary, since, in reality, wounds arc only infected by contact with the microbes on unclean and insufficiently disinfected hands, dressings, and instruments, but not by the bacteria in the air (Kiimmel, P. Furbringer). I lay great stress upon covering the neighbourhood of the field of operation with steril- ised towels, dipped in a one-tenth per cent, solution of bichloride of mercurv. Fig. 13.—Steam-spraying apparatus. §6.1 THE PREPARATIONS FOR AN ASEPTIC OPERATION. 13 0/ /"■ A hi ft Fig. 14.—Metallic or hard-rubber case with spool for aseptic catgut and silk. Preparation of the Dressings.—I should mention that the aseptic cov- erings of the wound, dressings, bandages, etc.—sterilised by heating them at a temperature of 100° C. (212° F.)—are made ready in advance. AVre shall speak of these in Chap- ter II. (The Technique of applying Dressings). Preparations for Operations in Private Practice.—If an operation is to be conducted aseptically outside of a clinic or hospital, as large and light a room as possible should be selected, and thoroughly cleaned and aired. The surest and simplest way of disinfecting a room is to rub down the walls and ceiling with bread (E. von Es- march), though infected rooms can also be disinfected by burning sulphur after the rooms have been tightly closed. A table, on which to place the patient, should be pro- vided, and covered with some water-tight material and then with sterilised linen; and two or three other tables should be near by, likewise covered with sterilised linen, to hold the instruments, dressings, and wash-basins. Several wash-basins, soap, absolute alcohol, brushes, towels, sterilised dishes for the instruments, and sponges should be within reach, as well as warm sterilised water in large quantities, chloroform or ether, concentrated car- bolic solution, tablets of bichloride, aseptic sponges or gauze pads, drains, silk, catgut, and the necessary instruments sterilised by boiling in a one per- cent, soda solution, and dressings and bandages. Silk and catgut can be carried about very easily in the simple apparatus pictured in Fig. 14. CHAPTER II. THE ALLEVIATION OF PAIN DURING OPERATIONS.--NARCOSIS.--LOCAL ANAESTHESIA. History.—Chloroform.—The physiological action and the method of administering chloroform.—Symptomatology of chloroform narcosis.—The possible accidents during chloroform narcosis: death from chloroform.—Treatment of the possible accidents during chloroform narcosis.—Other anaesthetics: methyl compounds.— Ether.—The phenomena of ether narcosis.—Method of administering ether.—The remaining ether compounds.—Nitrous oxide (laughing gas) as an anaesthetic- Other anaesthetics.—Mixed narcosis.—Local anaesthesia. § 7. The Alleviation of Pain during the Operation.—A distinction is made between general anaesthesia—i. e., narcosis which is caused by the inhalation of some sleep-producing vapour or gas—and the local anaesthe- sia which is limited to a particular portion of the body, and produced by the local application of a substance to the part of the body to be operated upon. Since the earliest times attempts have been made to perform opera- tions with the aid of some means for allaying pain, but the methods were invariably bad, and the action of the remedies which were tried was insufficient. It was not till the year 1846, with the introduction of ether as an anaesthetic, that the dream of the old surgeons was to come true—namely, the performance of even major operations without pain. As early as the year 1800, Humphry Davy, reasoning from his numerous physiological experiments, had recommended nitrous oxide (laughing gas) as an anaesthetic; and Horace AVells, a dentist in Hart- ford, tested the remedy in 1844 by extracting twelve or fifteen teeth ; but he was not able to introduce the drug as an anaesthetic into gen- eral surgical practice. In ancient times cannabis indica and opium were the chief remedies for controlling pain. Besides these, the pulverised stone of Memphis was used— a kind of marble which, when treated with acetic acid, gives off carbonic acid and in this way produces a certain amount of local anaesthesia. Mandrake root, made into a decoction with wine, was also given internally, and was used especially by the ancient Greek physicians, and in fact was employed (14) §7.] THE ALLEVIATION OP PAIN DURING THE OPERATION. 15 during the middle ages till the end of the sixteenth century. In the middle ages patients were often made to inhale vapours made from hemlock and from the juice of the mandrake leaf. Of interest in this connection are the experiments of Theodoric of Cervia, a learned Dominican, who at his death, in 1298. was Bishop of Bologna. A celebrated surgeon of Salerno, Mazzeo della Montagna (1309-1349), is said to have given the patients whom he was about to operate upon some sleep-producing potion. Porter also speaks of a remedy, without describing it more exactly, which, when inhaled, brought on a deep sleep. Besides these methods, excessive blood-letting till fainting occurred, com- pression of the vessels and nerves (Moore), enormous doses of tartar emetic, electricity, animal magnetism, and hypnotism have all been tried. On April 8, 1829, Cloquet is said to have removed without pain a cancer of the breast, together with the axillary glands, from a fourteen-year-old girl during the magnetic sleep, and in 1842 Ward amputated a thigh under the same conditions. Guerineau also performed a painless amputation of the leg while the patient was in the hypnotic slumber. Many other attempts were made to perform operations painlessly during the hypnotic state, but they were seldom successful; and Kappeler is certainly right when, in explaining the above-mentioned magnetic or hypnotic anaes- thesia, he calls to mind that there are individuals whose sensibilities are ab- normally blunted, and that insensibility can be simulated. Two Americans—the chemist Charles Jackson, and the dentist "W. L. G. Morton—introduced ether as an anaesthetic into general sur- gical use, after the inhalation of ether had already been used by others to allay pain and the physiological action of the vapour was known. Furthermore, in 1842 and 1843, W. C. Lang, a physician in Athens, had anaesthetised several patients with ether without publishing his ob- servations. Morton induced AVarren, the surgeon of the Massachusetts Hospital, to try the new remedy, and the latter, on October IT, 1846, removed without pain a tumour of the neck under ether narcosis. The knowledge of the new discovery spread quickly to Europe—first to England, then to France, Germany, and the other countries. In Eng- land, Robinson, Liston, and Simpson were the first to try it, and they were followed by Malgaigne in France. Schuh was the first in Ger- many, and on January 27, 1847, he removed, without pain, a telean- giectasis during ether narcosis. But the supremacy of ether as an anaesthetic was not to continue long. In Xovember, 1847, Simpson, as a result of some eighty obser- vations, including surgical and labour cases, recommended chloroform, which had already been discovered in 1831 by Soubeiran, in Paris, and had lain unnoticed on the apothecary's shelves for sixteen years. Ether was very quickly superseded by chloroform, and the enthusiasm for the new remedy was tremendous. But soon the first deaths from 16 THE ALLEVIATION OF PAIN DURING OPERATIONS. chloroform were reported, and the wish for a new anaesthetic became active. Numerous other drugs were tried, but at the present day chlo- roform and ether hold the field in triumph without rivals worthy of the name. In recent times ether has again gained ground, and is used especially in America, in Lyons, and lately also in England, in Switzer- land, and in Germany. In Austria and in Germany, chloroform, and a mixture of chloroform, ether, and alcohol, have the preference. I use ether narcosis in children almost exclusively when there is no disease of the air-passages and lungs, and I am very well satisfied with it. In adults I prefer chloroform narcosis, though neither is without danger, as there have been fatal cases from both; but it must be admitted that fatal cases occur more frequently from the use of chloroform than of ether. Both drugs, we shall see, have their advantages and dis- advantages, and the views of surgeons are much at variance as to which to give the preference. My own opinion is that ether should be used when the heart is diseased, and chloroform is preferable in cases with pulmonary lesions. The disadvantages of ether are its great inflam- mability and its volatility, the latter rendering necessary some special apparatus for its administration. Of the other anaesthetics, the most useful are nitrous oxide, or laughing gas, bromethyl, and recentlv pental, which is particularly valuable for short operations, and is quite extensively use by dentists. We shall first take up chloroform. §8. Chloroform Narcosis. The Chemical Reactions of Chloroform.— Trichlormethan (CHCL) is a clear, colourless, very volatile liquid, with a pleasant, aromatic odour, and a sweet and afterwards burning taste. It can be mixed with ether and alcohol in all proportions, and is soluble in two hun- dred parts of water. Chloroform is very slightly inflammable, and has at 15° C. (55° F.) a specific gravity of 1.502. It is decomposed by daylight into hydrochloric acid, chlorine, and free formic acid, and is therefore to be kept in the dark, preferably in glass bottles which are covered with pasteboard. By the addition of one half to one per cent, absolute alcohol the decomposi- tion of chloroform can be prevented. There are three different kinds of chloroform : The officinal German chloroform, chloral-chloroform, and the English chloroform, the latter bei-g purer than German chloroform and three times more expensive. Only such chloroform should be used as has been previously proved to be pure. The impurities of chloroform consist in adulterations with spirits of wine, ether, etc., in the very dangerous compounds of methyl formed during its preparation, and finally in the decomposition products which develop if the drug is long exposed to the action of light and air (free chlorine, com- pounds of the hydrocarbons with chlorine, aldehyde, hydrochloric acid, acetic acid, and formic acid). The testing of chloroform is a chemical procedure, which must be done by the chemist or the apothecary; but the surgeon should always make Hepp's smelling test, which is as simple as it is useful. Chem- §«■] CHLOROFORM NARCOSIS. 17 ically pure Swedish filter paper is dipped in chloroform, the latter allowed to evaporate, and the dry paper smelled of. If the chloroform is pure the paper has no odour; but if there is a peculiarly sharp and irritating odour the chloroform is impure, and it is either acid from decomposition or it contains the chlorine substitution products of the ethyl or methyl series. Chloroform can also be tested chemically by distillation over crude potash at a temperature of 60° to 61° C. (140° to 142° F.). Physiological Action of Chloroform.—By inhalation, chloroform vapour is carried to the lungs, or more particularly to the blood, and probably circu- lates in the blood in chemical combination with the haemoglobin of the red blood-corpuscles. Chloroform has the power in part of directly destroying the red blood-corpuscles, and in part of robbing them of their ability to take up oxygen and to drive out carbonic acid (Bottcher, Schmiedeberg, and others). The icterus—i. e., hematogenous icterus—which Nothnagel ob- served in animals is probably due to the power possessed by chloroform and ether of destroying the red blood-corpuscles. Hiiter and Witte erroneously ascribed the cause of the narcosis to the change in the blood, especially in the red blood-corpuscles, produced by the action of chloroform; the change in the form of the red blood-corpuscles to spheres with club-shaped processes leads, according to his theory, to the for- mation of coagula in the cerebral vessels, with a consequent paralysis of the nerve centres. But it is more probable that the blood is only the means of carrying the chloroform, and the chief cause of the narcosis is to be sought in the certain but not yet wholly understood changes in the central nervous apparatus. At any rate, it is certain that these changes do not depend upon disturbances of the circulation, such as a hyperaemia or anaemia in the nerve centres. The drug is carried to all the organs by the blood as it circulates, includ- ing the central nervous system, the brain, and the spinal cord. The ganglion cells are chiefly affected, while the nerve fibres suffer no loss of function, but retain their normal excitability (Bernstein). The sensory ganglion cells are first attacked by the poison, then the motor, as is evident from the final pa- ralysis of the automatic movements of the heart and respiration in a fatally ending narcosis. According to Flourens, the paralysis of the nerve centres begins in the great lobes of the brain; it then attacks the cerebellum, and finally the spinal cord, where first sensation and then motion are lost. The medulla oblongata retains its function the longest, then it also loses its ac- tivity, and life comes to an end. The loss of sensation and of the sense of pain is first noticeable in the back and extremities, and last in the cornea with its rich nerve supply. The changes in the blood pressure and the action of the heart have been carefully studied by Lenz, Scheinesson, Koch, Bowditch, Minot, and others. Chloroform acts upon the vaso-motor centre, and also, in all probability, directly upon the heart muscle and its ganglia. The arterial tension is re- duced, the blood pressure sinks, the energy of the heart's action is diminished, and the rapidity of the circulation is lessened. The blood of the whole body becomes more or less venous, and a decrease in oxidation with a sinking of the temperature of the body takes place as a result of the diminished heat production. 3 18 THE ALLEVIATION OF PAIN DURING OPERATIONS. Respiration is influenced in two ways by chloroform: in the first place, the direct action of the chloroform upon the terminal branches of the fifth nerve in the mucous membrane of the nose may cause a temporary reflex cessation of breathing, and a noticeable slowing of the heart (stimulation of the vagus), particularly at the outset of the narcosis. In the second place, chloroform acts directly upon the respiratory centre, and the changes thus brought about in respiration are independent of the changes in the circula- tion. The centre for breathing is first stimulated by chloroform, and later depressed, causing the breathing to become slower and more shallow. The behaviour of the pupils is of very great importance. The degree of dilatation depends not only upon the amount of light and the degree of ac- commodation, but also upon the psychical and sensory impressions from the outer world which are transmitted from the brain and cerebellum to the medulla oblongata and from this to the sympathetic, which supplies the dilator muscles of the iris. The dilatation of the pupils occurring at the out- set of the narcosis is dependent upon the mental excitement of the patient and upon the reflex stimulation of the fibres of the sympathetic nerve gov- erning the opening of the iris, brought about by the irritation of the branches of the trigeminal nerve in the throat. All these irritations which dilate the pupil cease when sleep or narcosis takes place, and the pupil is therefore contracted. The uterine contractions during childbirth are not stopped during chloro- form narcosis. The influence of the drug upon the muscular fibres of the intestine is not known. Chloroform produces a complete relaxation of the voluntary muscles. It is important to remember that chloroform is excreted in the milk of nursing women, and may be found in the blood of the foetus. Chloroform is excreted, according to Zeller, chiefly in the form of chlorides in the urine, and only about a third is excreted as unchanged chloroform by the lungs and kidneys. The excretion of the chlorine derived from the breaking up of the chloroform in the system is just as slow as the excretion of iodine after the external application of iodoform. Unchanged chloroform can be found in the urine of a patient who has been chloroformed, and if the urine is boiled with Fehling's solution the latter will be immediately reduced to the black copper oxide, and not the red (Hegar-Kaltenbach, C. Theim, P. Fischer). As a result of the destruction of the red blood cells by the action of chloroform, haemoglobinuria occasionally occurs, though bilirubinuria is more common, for the reason that, owing to the destruction of the red blood-cells, an increased formation of bile colouring matter takes place, which is excreted in the urine. § 9. Technique of Chloroform Narcosis. The Method of Administer- ing Chloroform.—If it has been decided to narcotise a patient for an operation, certain precautionary measures are to be observed. His general condition must be determined by a careful examination of the internal organs, especially the heart and lungs. In cases of extensive pulmonary disease, of pleurisy with effusion, of heart disease, particu- larly valvular insufficiency and fatty heart, of atheromatous defenera- tion of the arteries, of alcoholism, of great weakness from loss of §9-1 TECHNIQUE OF CHLOROFORM NARCOSIS. 19 blood, of uraemia, epilepsy, and many diseases of the brain, etc., one must be very careful in the use of anaesthetics, and one must decide in each case wdiether the narcosis is justifiable. Ether is to be preferred to chloroform for patients with heart disease, and in cases where an operation has to be performed by gas-light. If possible, the patient's stomach should be empty, since otherwise the vomiting which so easily occurs will disturb the quiet progress of the narcosis and of the operation; moreover, the movements of the diaphragm during the narcosis are interfered with when the stomach is distended. Therefore, without exception, patients should be for- bidden to take solid food for from three to four hours before the opera- tion. In England and America it is customary to give stimulants, es- pecially to weak patients, before the narcosis. In many operations, particularly those in the peritoneal cavity and about the region of the anus, etc., the intestine should be previously emptied by a laxative or enema. The patient should be clothed as lightly as possible, with no con- striction in the region of the neck, thorax, or abdomen which interferes with respiration, and the thorax should be uncovered so that the respira- tory movements can be watched. False teeth and plates must be re- moved from the mouth. During the stage of excitement, in the first part of the narcosis, I fasten the patient to the operating table by means of a leather strap passed over the thighs. The horizontal position is usually employed, with the head slightly raised; but for operations on the face, in the mouth, throat, or nose, it is better to place the patient in the sitting posture, with the head held forward to prevent the en- trance of blood into the trachea, though some operate with the head hanging back over the edge of the table (Rose). The other methods in use to meet this difficulty are discussed elsewhere (Plugging the Larynx after performing Tracheotomy ; see also § 16, Mixed Narcosis). If the operation must be performed with the patient lying upon his abdomen or side, it will be necessary to watch the respiration and heart action with great care. In order to have good control over the narcosis, and in case of accidents, one should never administer chloro- form without the presence of an assistant; in case death should occur from chloroform, as well as for other reasons, it is well to have a wit- ness present. AVhen the narcosis is to begin, the patient should be quieted by a few words, and told to count slowly and aloud while inhaling the chloroform vapour, and thus an even, quiet breathing is obtained, and the gradual effects of the chloroform can be observed. Chloroform used to be administered by pouring a few drops on a sponge or towel, 20 THE ALLEVIATION OF PAIN DURING OPERATIONS. which was held over the nose or mouth of the patient; but it is better to use Skinner's apparatus, as modified by Esmarch, with the accompany- ing flask for sprinkling chloroform in drops (Fig. 15). This appa- ratus has a wire frame wliich is covered with porous woollen cloth or thin flannel. Late- ly I have been using the excellent chloro- form mask which I saw Fig. 15.—Esmarch's apparatus for administering chloroform. used in Kocher's clinic. The wire frame, which is easily sterilised, is made of two pieces, A and B (Fig. 16), wliich fold together on a hinge inclosing between them a piece of compress which has been previously spread out on the frame A. In administering chloroform, care must be taken not to allow the patient to inhale the vapour in too concentrated a form, but to permit a suitable admixture with atmos- pheric air. In using the apparatus illustrated in Figs. 16 and IT, the patient cannot help getting the vapour suitably diluted, but the cloth covering of the frame must be as porous and wide-meshed as possible. Fur- thermore, the mask should never be pressed down so tightly on the face as to prevent the access of air from the sides, and the chloro- form should not be sprinkled on the apparatus too abundantly ; it should be administered in drops, but continuously. If it is pouredout too freely it not infrequently runs on to the neck and breast of the patient, and can cause a very troublesome erythema or burn I <-uv such a case as the result of the carelessness" of the chloroformer in which there occurred an extensive and verv painful erythema of the back, breast, and shoulders, with a loss of the epidermis as though from a burn. So it is best to lay a light compress on the neck ] DIVISION OF BONE. 83 divided with a knife. The short, strong resection knife is the best suited for this purpose.. For sawing bone we use bow-saws (Fig. 70), narrow- bladed (Fig. 71), and chain saws (Fig. 72). The broad, flat saws have now passed entirely out of use. Butcher's saw (Fig. 70, b) is a very good one ; its blade can be drawn tight or relaxed by means of the screw in the topmost crossbar, the latter being connected by a hinge joint, with the two bars running at right angles from its extremities. Thus these two bars, by means of the hinge joint, can exert traction in the line of the long axis of the saw blade, and the latter can make a curved cut in bone. For divid- ing small bones like the phalanges the so- called phalangeal (Fig. 70, c) or narrow- bladed saw is used (Fig. 71). The latter saw can be introduced through a punctured wound in the soft parts. The narrow-bladed saw is grasped in the closed fist and the index finger is extended so as to lie upon the back of the saw. For many operations Adams's narrow-bladed saw is one of the best (Fig. 71, b). Jeff ray's (1784) Fig. '0.—a, Bow saw; b, Butcher's saw ; c, metacarpal saw. Fig. 71.—Phalangeal or key-hole saws: a, b, Adams's. Fig. 72.—Chain saw. Fio. 73.—Flexible direc- tor l'or the chain saw. chain saw (Fig. 72) consists of numerous links connected by hinges, and each extremity of the chain is provided with a hook for connect- g-J. THE DIFFERENT WAYS OF DIVIDING THE TISSUES. ing it with the handles. The chain saw is carried around behind the bone either by the hand, or a ligature threaded on a blunt curved needle, or a curved probe with an eye at the end, or by an instru- ment like the one illustrated in Fig. 73. The guide in Fig. 73 is pro- vided with an eye for the thread, by means of which the chain saw is brought in position for use—for example, behind the neck of the femur. " The earlier instruments of this class were made of steel or iron ; but I have substituted for them a copper rod wliich can be bent and which has a steel handle, and thus I can give it any bend I desire. The chain saw should be handled gently, and with moderate traction exerted at the most obtuse angle possible. If too much force is used the chain may break, and if the tension upon the chain is uneven it may become jammed in the bone. The compound chain saw (Heine's osteotome) consists of a chain saw which is stretched in the form of an ellipse over a tongue-shaped metal plate and is made to revolve, or rather is set in motion, by means of a crank. Heine's osteotome and similar instruments are unnecessary. Rotation Saws.—Oilier, acting on the suggestion of the circular saw so widely used in the arts, has invented a " rotation saw " which is worked by a crank, and by means of which pieces of bone of any desired shape and size can be cut out. The circular or rotation saw of the dentist is also suitable for surgical operations; and mention should likewise be made of the different kinds of trephines made in the form of a round saw which are used for opening the skull. Among other instruments used in bone operations are the sharp spoons (see page 81) for scraping bone wliich has become inflamed and broken down; also the different kinds of drills for making holes in bone—for example, to insert a bone suture (see Fig. 93). The bone files for smoothing and rounding off the edges of a bone—for instance, after it has been sawed across—are no longer used, but their place has been taken by the sim- ple chisel or Liston's bone forceps. Osteoclasis.—Either the hands of the operator or special instruments (osteoclasts) are used to fracture a bone (osteoclasis) when, for example, a fracture has healed in a faulty position, or when there is a curvature of bone resulting from rha- chitis. Collin, Robin, Molliere, Ferrari, Beely, and Gratteau have each devised osteoclasts. Rizzoli's apparatus (Fig. 74) consists of two rings sliding on an iron bar, to which they can be made fast at any point by v.ieans of a thumb- FlG -Eizzoli's osteo- clast. 26.] DIVISION OF BONE. 85 screw, and in these rings the extremity is placed. The " stamp "—i. e., the lower end of the screw-pin—is applied at the point where it is desired to break the bone transversely. By turning the lever the pin is screwed down and the stamp fractures the bone. The skin should be carefully protected at the different points of pressure by means of cotton or jute pads. In spite of the manifold improvements in the osteoclasts the instruments cannot even yet be relied upon to do all that their inventors claim. Above all, it is very difficult to fracture a bone at exactly the desired spot, especially if it is in the neighbourhood of a joint, without doing some injury to the soft parts. CHAPTER VI. THE METHODS OF ARRESTING HEMORRHAGE. The tying of vessels (ligation).—Artery clamps.—The preparation of aseptic ligature material (catgut, silk, etc.).—The substitutes for ligation.—Torsion.—Deep suture. —Temporary occlusion of the lumen of the vessel by artery clamps.—Ligature of a part of a vessel's wall and suture of veins.—Pressure—Packing—Oauterisa- tion— Other methods of controlling haemorrhage — Irrigation with hot and cold water.—The suture of the wound, with application of pressure by the dressings as a means of stopping haemorrhage.—Old-fashioned and no-longer-used methods of stopping haemorrhage (acupressure, acutorsion, etc.).—Ligature of vessels in their continuity. See also §§ 18 and 19 (Prevention of Haemorrhage in Opera- tions, Esmarch's Artificial Ischaemia). § 27. The Arrest of Haemorrhage during Operations.—We distinguish between arterial, venous, and capillary or parenchymatous haemorrhage. We will here discuss, in the first place, the arrest of haemorrhage dur- ing an operation. The arrest of haemorrhage from a wound made in the course of an operation must be most carefully attended to, in order that no second- ary haemorrhage may interfere with the healing of the wound or en- danger the life of the patient. It is, in general, an indispensable requi- site for obtaining perfect primary union that all haemorrhage should be checked completely. In the presence of dangerous haemorrhage the qualities of a surgeon are revealed; coolness, presence of mind, and complete familiarity with the technique of operating are indis- pensable. We have already learned, in the consideration of Esmarch's bloodless method, in what way serious haemorrhages may be prevented in any operation. The first step in accurately checking haemorrhage consists in tying off (ligation of) the vessels, both veins and arteries, which have been wounded in the course of the operation. In the preantiseptic days of surgery there was great dread of ligating veins, on account of the fre- quency of the ensuing suppurative changes which took place in the thrombi, resulting in a general systemic infection (pyaemia) and death. Modern antiseptic surgery, however, has no fear of ligating veins and secures every bleeding vessel. If, for example, in a high amputation (86) §27.1 TIIE ARREST OF HAEMORRHAGE DURING OPERATIONS. S7 of the thigh, or disarticulation of the femur, the femoral vein is not ligated, it is perfectly possible for dangerous, recurrent, or secondary haemorrhages to take place; and as a matter of fact this has been observed. Attempts to diminish or prevent haemorrhage during an operation are as old as surgery itself. We recall with a shudder the times when amputation of a limb was performed with a red-hot knife, or when the amputation stump was plunged into melted pitch to check the bleeding. The skilful surgeons of the time of the Roman Empire understood the treatment of haemorrhage better than the physicians of the middle ages, were familiar with the liga- ture, and even used artery clamps. All this was entirely forgotten during the middle ages, and Ambrose Pare reintroduced the ligation of vessels in the sixteenth century. We tie off or ligate the vessels in the wound by seizing their open ends with so-called artery clamps or haemostatic forceps which are u b c d e Fig. 75.— Haemostatic forceps or clamps. closed and locked by a suitable contrivance. The clamps which I consider the best are illustrated in Fig. 75, some being open and some closed. The Fricke-Amussat clamp (Fig. 75, a, b), which is fastened by means of a small sliding piece the end of which fits into a ring in the other jaw of the forceps, and Pean and Koeberle's forceps, which have a ratchet lock on the handle, are the most useful forms of the in- strument. By means of the haemostatic forceps or clamps the isolated end of the vessel is seized, and, if necessary, the surrounding tissues are stripped back and the vessel is carefully encircled with catgut or silk, which is then tied beyond the clamp. In the case of large arteries the ligature should be tied in a double square or surgeon's knot; but small 68 THE METHODS OF ARRESTING HAEMORRHAGE. vessels only require the ordinary simple knot. The ends of the liga- ture are cut short after the clamp has been first removed to see whether the knot holds securely and whether there is any danger of its slipping. The surgeon's knot is made by twisting one end of the liga- ture around the other—not once, as in tying the ordinary knot, but twice. The application of ligatures en masse, as they are called, about the vessel and the surrounding tissue should be avoided as much as possible. Instead of haemostatic forceps or clamps, sharp-pointed hooks are sometimes used to draw out the end of the vessel. Liga- tures are made of catgut, which wras first recommended by Lister, and which is manufactured from the intestine of the cat or sheep, and silk which has been sterilised by boiling. Preparation of Aseptic Catgut.—Catgut can be prepared for use aseptic- ally in various ways. If the hot-air sterilisation plan of Doderlein, Kummel, and others is used, the raw catgut must first be soaked for twenty-four to forty-eight hours in absolute alcohol to remove all water. Then the catgut is put in a glass jar or between layers of blotting paper and placed in the sterilising apparatus, which is very gradually heated to a temperature of 130° C. After this it is placed for six to eight days in oil of juniper which has also been sterilised by beat, and then it is stored for use ,in a one-per-cent. alcoholic solution of bichloride of mercury or in a ten-per- cent, solution of carbolic acid in glycerin, or in a l-to-500 aqueous solution of bichloride of mercury. Brunner places the catgut in xylene in a closed vessel, and subjects this to the ac- tion of steam at a tempera- ture of 100° C. (212° F.) for three hours. The catgut is then washed in alco- hol and stored in an alcoholic solution of bichloride of mercury. According to my experience, the hot-air sterilisation of catgut is difficult and trouble- some, and I prefer the bichloride method of treating it devised by Schimmel- busch and Bergmann after the catgut has been previously rendered free of fat by soaking in ether. Tbe sterilisation is accomplished as follows : the glass vessel and the glass spools are sterilised by steam for three quarters of an hour; the raw catgut, which contains fat, is rolled on the spools and soaked for twenty-four hours in ether, which is then poured off and replaced by an alcoholic solution of bichloride of mercury (ten parts of bichloride, eight hun- dred parts of absolute alcohol, and two hundred parts of distilled water), which is renewed at the end of twenty-four hours. According to whether one'desires 1 2 3 Fig. 76.—Vessels for storing sterilised catgut and silk: 1, Glass case with glass spools for hospital"practice; 2 and 3, glass bottles with glass rollers and india-rubber pers for private practice (see also Fig. 14). ■ stop- §27.] THE ARREST OF HAEMORRHAGE DURING OPERATIONS. stiff or pliable catgut, the latter is stored in absolute alcohol, or in a twenty- per-cent. mixture of glycerin and alcohol, or in the alcoholic solution of bichloride just described. In this way a very strong, flexible catgut is ob- tained which is aseptic, and more desirable in every way than the carbolised catgut formerly used, which was not aseptic, and occasionally gave rise to suppuration, pyaemia, and septicaemia (Zweifel, Kocher). Chromicised Catgut, which is more slowly absorbed, is prepared from commercial raw catgut by subjecting it to a dry heat of 130° C. (266° F.), and keeping it for forty-eight hours in a ten-per-cent. solution of carbolic acid in glycerin, and then for five hours in a one-half-per-cent. solution of chromic acid. It is stored in a five- to ten-per-cent. solution of carbolic acid in glyc- erin, or in a one-per-cent. alcoholic solution of bichloride of mercury, and immediately before use it is placed in a three-per-cent. aqueous solution of carbolic acid or bichloride of mercury. Macewen keeps the raw catgut for two months in a mixture of twenty parts of glycerin and one part of a twen- ty-per-cent. aqueous solution of chromic acid. He then washes it and stores it in a twenty-per-cent. solution of carbolic acid in glycerin. Braatz uses the following method for sterilising catgut: the raw catgut is soaked in ether or chloroform for one or two days, to free it from fat; it is then placed for twenty-four hours in an aqueous solution of bichloride of mercury (1 to 1,000), or else sterilised by Reverdin's dry-heat method (page 88), and then stored in absolute alcohol. Many surgeons preserve their sterilised catgut in a dry state—for example, between layers of sterilised com- presses, or in a glass jar (Esmarch, Mikulicz). According to the investigations of Brunner, the catgut sterilised by treat- ment with bichloride of mercury, or by dry heat, is perfectly sterile, while the catgut treated with carbolic acid, chromic acid, and oil of juniper contains many fungi and bacteria. Brunner recommends the following method of sterilisation: the catgut is first washed with soft soap, and then, either im- mediately or after soaking for half an hour in ether, it is transferred to an aqueous solution of bichloride (1 to 1,000), where it is left for twelve hours. It is then stored in bichloride of mercury one part, absolute alcohol nine hundred parts, glycerin one hundred parts. Preparation of Carbolised and Bichloride Silk.—The carbolised and bi- chloride silk is prepared by winding the silk on hollow glass spools and then boiling it for half an hour in a five-per-cent. aqueous solution of carbolic acid, or a l-to-500 solution of bichloride of mercury. After this it is stored in a five-per-cent. aqueous solution of carbolic, or a l-to-2,000 solution of bi- chloride of mercury, or in absolute alcohol. An aseptic silk ligature remains in a wound as a foreign body, but without causing any reaction. Catgut has long been used for the ligation of vessels as well as for suture material, and for the latter purpose was used by Rhazes, while Hennen and Young (1813), Lawrence (1814), and A. Cooper (1817) used it for tying vessels. Ligatures of Other Materials.—Besides catgut and silk, ligatures are made of chamois leather or parchment, from the aorta of the ox, from horse-hair, and from the tendons of mammals like the kangaroo, whale, reindeer, etc. Catgut is absorbed and disappears without leaving a trace, while silk, on the other hand, remains unchanged. For ligation of the large 90 THE METHODS OF ARRESTING HEMORRHAGE. arteries and veins I prefer aseptic silk to catgut, as the latter may be absorbed too quickly before the cicatricial closure of the lumen of the vessel has become sufficiently firm. Moreover, silk can be sterilised by boiling with greater certainty than is possible in the case of catgut, and much finer ligatures of silk than of catgut can be used even for large arteries. § 28. Substitutes for the Ligation of Vessels.—Torsion of the End of the Artery (Amussat), and Deep Suturing.—Torsion of the cut end of a vessel is performed by seizing the end in a haemostatic clamp and twisting it several times on its long axis. The lumen of the vessel is thus closed by rolling up and tearing the walls of the vessel, especially the middle and inner coats. Torsion produces more accurate closure of the lumen of the vessel if the latter is grasped by two clamps—one at the end of the vessel and held in its long axis, the other clamp behind the first and at right angles to the vessel. The first clamp is then twisted till the portion of the vessel to which it is attached gives way. Arteries as large as the brachial can be so firmly closed by torsion that no bleeding will occur. But if branches are given off close above the bleeding end of the artery, the latter will not be sufficiently movable to make torsion safe, and on this account torsion—for instance, of the femoral artery—is usually impracticable. Torsion is, as a general thing, only used for small vessels. Stilling recommends drawing the end of the artery through a puncture made in the artery wall (Fig. 77). Deep Suture around a Vessel (" Umstechung").—A suture passed through the tissues around a vessel is similar to a ligature en masse, be- Fig. 77.—" Durchschlingung " of Fig. 78.—" Umstechung " 0f vessels. an artery (Stilling;. cause the surrounding tissues, as well as the vessel itself, are included in the ligature (Fig. 78). A sharply curved needle, carrying a ligature, is passed through the tissues so that the points where it enters and emerges lie close together. This method is applicable for those cases §28.] SUBSTITUTES FOR THE LIGATION OF VESSELS. 91 in which the bleeding end of the vessel lies, for instance, in stiff, un- yielding tissues, or, for one reason or another, cannot be sufficiently isolated for the application of a separate ligature. Haemostasis by passing a Suture through the Skin into the Parts around a Vessel.—Middledorpf's method of passing a suture through the skin and around a vessel is at best only a temporary expedient. For example, in bleeding from the temporal artery a curved needle carrying a ligature can be passed through the skin under the vessel and then knotted upon the skin. A similar plan is sometimes adopted to render operations on the tongue blood- less. At the end of the operation, when the wound in the tongue has been closed by sutures, this ligature en masse is removed. Temporary Occlusion of the Vessels by Clamps.—For cases in which the application of a ligature is difficult or impossible, it may be expedient to oc- clude the lumen of a vessel by a haemostatic clamp, which is left in place for some time. Koeberle and Pean have found the lumen of vessels per- fectly closed after the expiration of twenty-four hours with this method of haemostasis. Simple punctures or slits in the wall of a large vein have been closed by the application of a ligature to the side of the vessel. The injured portion of the vein is seized by a clamp, and, while slight traction is made upon it, a ligature is tied around the puncture beyond the jaws of the clamp, and thus the whole lumen of the vessel is not occluded. This lateral ligature is but little used, as it easily slips. If a large vein, like the common femoral, has been punctured, and there is fear of gangrene of the lower extremity if the whole vein is tied off, it is best to close the puncture temporarily with an artery clamp or by Schede's method of suturing with fine catgut. Schede has repeatedly sutured veins by means of the finest needles and catgut with excellent results. Under this heading come suture of the femoral, inferior vena cava, axillary, jugular, etc. Experimental Investigations on the Suture of Arteries and Veins.—The experiments of Horoch prove that suturing an artery, as well as ligating it, results in a perfect closure of the lumen of the vessel by means of a clot. But ligation causes immediate occlusion of the vessel, while suturing causes occlusion to take place slowly. Catgut is not suitable for sewing an artery, but only fine silk should be used. If a vein is sutured, the lumen persists to a greater or less degree, and consequently Horoch prefers suture to the appli- cation of a lateral ligature, as the experiments of Blasius show that lateral ligation of a vein regularly causes occlusion of the latter's lumen by a throm- bus. Jassinowsky, Burci, Muscatello, and others have also made experiments with suturing a partially divided artery in animals, and have obtained satis- factory results. With the aid of the sutures the wound in the artery unites by primary intention, and there is no haemorrhage following the operation. Secondary haemorrhage, thrombosis (contrary to Horoch's experience), and the formation of aneurisms, do not occur. The lumen of the vessel where the suture was applied remains entirely free. Suturing of the vessel's wall is particularly applicable in longitudinal, oblique, and " flap " wounds, provided that not more than half the circumference of the large vessel is involved in the wound. The most rigorous asepsis is absolutely essential for success in 92 THE METHODS OF ARRESTING HEMORRHAGE. suturing a portion of the wall of an artery, for which the finest silk is used in the form of a continuous suture passed gently through the adventitia and media. Hitherto suture of an artery in man has never been practically tested. § 29. Other Methods of Haemostasis.—Another most important meth- od of haemostasis is pressure, wliich we apply in many different ways, and wliich is evidently the simplest and most natural way of checking haemorrhage. "Whenever during the course of an operation blood gushes forth from a divided vessel, we immediately place our finger upon the bleeding point and so stop the haemorrhage. It is singular that this simple method of haemostasis is so little understood by the laity ; when they meet with dangerous bleeding, perhaps from a punc- tured wound of one of the larger arteries, they are very apt to employ the strangest remedies, such as, for example, the application of cobwebs and similar things. Pressure is also practised as a temporary means of haemostasis in the form of digital compression (mentioned in § 18, p. 47) of the afferent artery, and by means of rubber bandages, tourni- quets, etc. In suitable cases pressure can be combined with forced flexion of the neighbouring joint—as, for example, in bleeding in the popliteal space the knee joint is im- mobilised in extreme flexion (Fig. 79), or haemorrhage from near the elbow can be held in check by im- mobilisation of the elbow joint in a position of extreme flexion. Pressure is the ordinary method of haemostasis used for stopping pa- renchymatous bleeding. The wound is compressed for a time with aseptic sponges, or, if it occurs in a cavity, the latter is filled with some aseptic dressing material such as iodoform Fig. 79.-Forced flexion of the knee for tem- gauze (the WOUIld is packed), Or an porary arrest of haemorrhage in the ~wq.' „„,T a • • 1 i popliteal space. ordinary dressing is bound on so as to exert pressure. Packing.—A wound or a bleeding cavity, like the nose or rectum, is " packed " by filling it as tightly as possible with antiseptic dressing materials like iodoform gauze. In haemorrhage from the rectum, a large square piece of bichloride or iodoform gauze is seized in the centre with the fingers or blunt forceps and pushed up into the rectum in the form of a purse or empty bag, and into this strips of iodoform gauze are forced until the bag is full. The strips or pads of iodoform gauze can be fastened to a string and then packed in place. The col- §2»d . OTHER METHODS OF IEEMOSTAS1S. 93 peurynter can also be used in the rectum. It consists of a rubber blad- der to which a tube is connected, the former being introduced empty into the rectum and then filled by a syringe with warm water or air forced through the tube, which is finally closed by a compression for- ceps. The elastic bladder works in the same way as the gauze packing. Cautery.—Of the other methods for haemostasis the hot iron is the most important, the best form of wliich is Paquelin's thermocautery (Fig. 57, p. 74) or Middledorpf's galvano-cautery (p. T5). The firm eschar of the burn prevents the escape of blood. The hot iron is usually only suitable for bleeding from small vessels which cannot be ligated. It should be used at not more than a red heat, so as not to burn the tissues too rapidly, but simply to char them slowlv. Styptics.—Amongst the fluid remedies for checking haemorrhage mention should be made, in the first place, of the liquor ferri sesqui- chlorati, wliich makes a firm coagulum with blood. A pledget of cot- ton or gauze is soaked in it and applied to the bleeding spot as firmly as possible for one or two minutes. This procedure must usually be repeated one, two, or three times. Styptic cotton, as it is called, is simply cotton wliich has been soaked in liquor ferri sesquichlorati and dried. The material made from the Boletus igniarius and the Pengha- war djambi is very similar to styptic cotton, and consists of the light- brown hairs from the stem of the Cibotium cuminghii, an East Indian plant. If this is applied in sufficient amount to the wound surface and with enough pressure, it makes a very good styptic. JVoltenius has recommended a penghawar cotton consisting of a mixture of Pengha- war djambi with cotton and ten per cent, of iodoform. All styptics producing an eschar prevent primary union of the wound. Under fluid haemostatics there are still to be mentioned vinegar, solutions of alum, turpentine, and aqua Binelli. AY right recommends a solution of fibrin ferment with one per cent, of chloride of lime as a useful haemostatic, which does not produce an eschar. Cocaine has also a haemostatic action, and for this purpose can be used in operations on the gums, in bleeding from the nose, etc. For the latter purpose cot- ton tampons can be used after soaking them in a twenty- to thirty-per- cent, solution of cocaine (also adding a little glycerin). Saint-Germain and Henocque speak well of the haemostatic action of antipyrine (either in a twenty-per-cent. solution or in the form of a powder). In cases of haemorrhage from the genito-urinary tract Meisels has made successful use of cornutin (in doses of 0*01 gramme a day). Cold and Hot Irrigation.—AYe arrest capillary and parenchymatous haemorrhage by pressure applied for a short time, especially by means of aseptic sponges or pads, by irrigation with ice-water, or with water 94 THE METHODS OF ARRESTING HAEMORRHAGE. heated to about 45° C. (113° F.), and by suturing the wound and ap- plying an antiseptic dressing tight enough to exert pressure. Ice-water stops the bleeding by causing the capillaries and smallest vessels, to- gether with the surrounding tissues, to contract, while water at a tem- perature of about 45° C. (113° F.) acts by directly promoting coagula- tion of the blood. This explains how cold as well as hot water has a haemostatic action. As a rule, we employ antiseptic solutions of a medium temperature for irrigation of the wound. Suture of the Wound.—An important haemostatic measure, as already mentioned, is the exact coaptation of the edges of the wound by means of sutures, especially in the case of parenchymatous bleeding, and in haemorrhage from the smaller arteries, particularly those of the skin. Pressure from Dressings.—The application of an antiseptic dressing which exerts pressure likewise checks or prevents subsequent paren- chymatous oozing. Elevation.—In the case of the extremities we possess a valuable haemostatic measure in the form of elevation or suspension of the part, and in certain cases, particularly after the use of Esmarch's artificial ischaemia, which is apt at times to be followed by se- rious parenchymatous bleeding or oozing, this pro- cedure is invaluable. Ligature en Masse.—When large masses of tissue are tied off at once it is not infrequently found that the liga- ture has not been tied tight enough, and that, moreover, from tbe manipulation, the fingers become cracked, espe- cially if they come much in contact with carbolic acid; and so Thiersch has recommended that the ligature be threaded through the eye of a " spindle " made of ivory or nickel-plated iron three to four centimetres long. The point of the spindle is rather blunt, so that it can be pushed like a probe through dense masses of connective tissue. This method is especially adapted for the ligation of masses of tissue in ovariotomy, extirpation of the ute- rus, etc. To prevent injury being inflicted upon tbe sur- rounding parts in these operations by sharp-pointed nee- dles, particularly in vaginal extirpation of the uterus, Thiersch has constructed curved, blunt-pointed spindles with an eye for carrying tbe ligature. The spindle is held in a forceps and thus forced through the tissues (Fig. 80). Acupressure and Acufilopressure.—Acupressure and acufilopressure (Simp- son)—that is, compression of the vessels by long needles stuck through the soft parts (acupressure), or by needles thus inserted and having a thread wound around the projecting ends (acufilopressure)—are at present no longer used and will not be described. Acutorsion has also been abandoned. It Fig ).—Forceps with a small ligature hook for tyinir a lisrature en masse (Thiersch). g 30.] LIGATION OF ARTERIES IN THEIR CONTINUITY. *},-, consisted in drawing out the divided extremity of the artery and transfixing it with a needle, which was then given a half or complete turn until the bleeding ceased. After some forty-eight hours the needle was removed. £ 30. Ligation of Arteries in Continuity.—The ligation of arteries in their continuity is performed for injuries and for pathological condi- tions, notably aneurism. In case of severe haemorrhage from an artery as the result of a punctured, gunshot, or transverse wound, it used to be the custom to ligate the artery at its most accessible por- tion, in the so-called place of election, proximal to the site of injury. This is not the best plan, on account of the frequency of secondary haemorrhage from the unsecured wound in the artery after the collat- eral circulation becomes established. At present we search for the point where the artery has been wounded and tie the vessel on the proximal and distal sides of the wound, and then extirpate the injured portion of the vessel lying between the two ligatures and secure any branches which may be given off in the immediate neighbourhood. As described under § 18, the ligation of arteries in their con- tinuity is performed as a prophylactic measure, to diminish or con- trol haemorrhage during an operation upon the region supplied by the artery in question. Under this heading comes, for example, ligation of the lingual arteries in extirpation of the tongue, of the femoral in dis- articulation of the femur, of the axillary or subclavian in disarticula- tion of the humerus. Aloreover, the afferent arteries of a part are some- times ligated to check the growth of an inoperable tumour, and for elephantiasis—for instance, of an extremity, etc. The operation, which is performed with every aseptic precaution, consists of two parts: (1) The exposure and isolation of the artery, and (2) the application of the ligature. In general it is best to use Esmarch's artificial ischaemia in ligating an artery of an extremity. For instruments we use a medium-sized scalpel, a straight and curved pair of scissors, two toothed thumb forceps, two dissecting forceps, several artery clamps, two retractors, a director, and an aneurism needle, with aseptic silk and catgut ligatures. After carefully washing the field of operation in the usual way, shaving it, and disinfecting it with a three-per-cent. solution of car- bolic acid or of bichloride 1 to 1,000, and placing the part in a convenient position, an incision six to eight centimetres long is made through the skin along the course of the artery. The fingers of the left hand hold the skin firmly stretched, or a fold of skin is lifted up and divided from without inwards, or transfixed and cut from within outwards. The skin is divided by one stroke of the knife. Then the operator and his assistant seize the cellular tissue at two opposite points 96 THE METHODS OF ARRESTING HAEMORRHAGE. with toothed forceps, and while it is gently lifted up it is divided between the two forceps with the knife to the full extent of the cuta- neous incision. The remaining tissues are divided as in dissecting until the arterial sheath is reached. The sheath can also be reached very easily and quickly by pushing aside and tearing the tissues with a director, the handle of the knife, or the finger. It is advisable for the beginner to divide the connective tissue carefully upon the director. AYhen the sheath of the artery has been laid bare it is well to make certain, by palpation with the finger tip, that it is the artery which has been exposed. Even though there be no pulsation, one can easily distinguish the firm, thick arterial wall which can be made to roll under the finger from the soft, thin wall of a vein. A nerve feels like a round solid cord. The operator then grasps the sheath of the artery with a fine-toothed forceps or dissecting forceps, lifts it up from the artery, and opens it with a knife or Cooper's scissors or a director. Into the opening thus made in the sheath of the artery is inserted an aneurism needle or curved blunt hook (Fig. 81, a, b), in order to separate the artery itself on all sides from the sheath. One should never free the artery from its sheath to too great an extent, and one should carry out this step in the operation as gently as possible, to avoid unnecessary laceration of the artery and its sheath. AYhen the entire circumference of the artery has been separated from its sheath, an aneurism needle bearing an aseptic catgut or silk ligature is passed under the vessel, and after encircling the latter the ligature is tied fast around the artery (Fig. 82). Two surgeon's knots supple- mented by a simple knot are usually considered necessary for the larger arteries. A surgeon's knot is made by twisting the ends of the liga- ture twice about each other, and not once, as in forming a simple knot. Large arteries are usually secured by a double ligature, and the vessel is then divided between the central and peripheral ligatures. If an artery is to be tied double—i. e., on the central and peripheral side of Fig. 81.—Aneurism needles. Fig. 82.- -Ligation of an artery in its con- tinuity. §30.] LIGATION OF ARTERIES IN THEIR CONTINUITY. 97 the point of injury, perhaps a punctured wound—the aneurism needle is threaded with a doubled ligature, and the latter, after being placed around the artery, is cut at the loop, thus giving one ligature for the central and the other for the peripheral ligation of the artery. In passing the aneurism needle around the artery care must be taken to avoid injury to the neighbouring vein, and before drawing the ligature tight it must be ascertained that the artery alone is tied, and that a nerve is not included in the ligature. After tying the ligature its ends are cut short. If the operation has been performed with the aid of Esmarcirs artificial ischaemia, the rubber bandage is now carefully loosened and then slowly removed. AYhen the double ligature has been tied and the intervening wounded portion of the artery has been extirpated, the operator should always look out for branches arising from this intervening portion, which should be secured with the same care as the main vessel, because there is a possibility of secondary haemorrhage from these branches after the establishment of the collat- eral circulation. The wound is then drained from its deepest angle, when this is necessary (see § 31), and closed throughout its whole length with a continuous catgut suture, with or without silk tension sutures (page 106). An antiseptic dressing exerting a gentle pressure must then be applied, together with a splint in the case of the extremi- ties, so that the part which has been operated upon is immobilised as completely as possible. Immediately after the artery has been ligated a collateral circulation takes place through the channels formed by the branches given off above and below the ligature (see § 61). The ligation of particular arteries is taken up in the text-book on special surgery. The ligation of veins in their continuity is carried out in exactly the same manner as described for arteries. Ligation of Large Veins.—As a means of checking haemorrhage from large veins, Langenbeck has recommended ligation of the corresponding artery. In a case of a wound of the common femoral vein made during the extirpation of a tumour, Langenbeck arrested the haemorrhage by ligating the femoral artery. By ligation of the corresponding artery the amount of blood contained in the part of the body which it supplies is so diminished that the wound in the vein is able to close spontaneously. A simple dress- ing exerting slight pressure is then sufficient to stop the bleeding. But in other cases the method has entirely failed. It is always safer, when possible, to secure the wounded vein itself. 8 CHAPTER VII. DRAINAGE OF WOUNDS. Importance of drainage.-Different methods of draining a wound: leaving the wound open; aseptic packing ; drainage by rubber tubes.—Absorbable drams.—Drainage tubes of glass, metal, etc.—Capillary drainage with strands of catgut, horse-hair, and glass wool.—Formation of openings in the skin.—Secondary suture of Kocher. —Healing under a blood-clot without drainage (Schede). § 31. The Method of allowing the Secretions of a Wound to Escape.— Drainage.—In every fresh wound there is regularly an escape of a bloody, serous fluid, rich in albumin, from the divided tissues, the open capillaries, and lymph spaces, and it corresponds in amount with the size of the wound and the number of cavities and pockets. The forma- tion of these cavities in the wound should be prevented, as far as possi- ble, by sutures and by the application of a dressing exerting proper pressure. By means of the latter we try to promote the agglutination of the more deeply lying tissues which have been divided, and thus to diminish the ensuing secretion—a matter of much importance. In small wounds the pressure exerted by the dressings is sufficient to obtain rapid healing, and it is not necessary to use means for car- rying off the secretion except when suppuration is already present, and in the case of large fresh wounds. But if suppuration is present, we must provide suitable channels for the escape of the secretion in the shape of drainage in some form. Unless we do this the secretion is retained in the wound and prevents primary union. Moreover, opportunity is given for the secretion to decompose and for pus to form, and, as a result of the retention of the pus or decomposed secre- tion of the wound, spreading suppurative inflammation or general infection of the whole system takes place from absorption of the infec- tious material (pyaemia, septicaemia). The bloody, serous secretion present in the wound, and the blood which has escaped, are highly decomposable, on account of their albuminous character, and conse- quently it is a matter of great importance to provide careful drainage in large clean wounds and particularly in those which are already infected. At the present time attempts have been made to do away (98) £31.] METHOD OF ALLOWING WOUND SECRETIONS TO ESCAPE. 99 with drainage in wounds made in aseptic operations, but most surgeons still rely upon it. As a matter of fact, it is indispensable for the first twenty-four to forty-eight hours in large aseptic wounds, even after they have been closed by sutures—for example, after amputation of the breast, accompanied by cleaning out the axilla. The secretion from the wound and the effused blood can thus escape, and so do not pre- vent the edges of the wound from quickly uniting by primary inten- tion. There are various methods for enabling the secretion from the wound to escape. The simplest of these is to leave the wound open without suturing it, or only partially suturing it, leaving the angles of the wound un- closed. AATe combine with this open treatment the sprinkling of the wound with antiseptic powders (iodoform, boric acid, salicylic acid, etc.), or we fill deep wTounds or cavities with dressing materials which have a greater or less absorptive power—for example, with strips or wads of iodoform gauze. This aseptic packing of a wound is an excel- lent method of drainage, as it absorbs the secretion from the wound and causes it to remain aseptic. AYhen necessary, the packing can be fastened in place by sutures through the skin. A\Tounds which have been left open can then, after a few days, when the packing is removed, be closed by secondary suture, as it is called, which hastens the healing process. Gluck has recommended the use of an absorbable aseptic packing, consisting of rigorously disinfected sponges impregnated with iodoform, or a mixture of iodoform, ether, and alcohol, and also skeins or rolls of catgut, and bundles of silk with or without catgut of differ- ent shapes and sizes. He recommends their use particularly for intra- peritoneal drainage. Catgut alone is absorbable, and therefore only this material can be used as an absorbable packing. The absorbable aseptic packing becomes encapsulated, granulation tissue grows into it, and its place is. gradually taken by connective tissue. I do not con- sider this method desirable. If we wish to immediately close large and deep wounds, which have not been infected, so as to obtain rapid healing with primary union— i. e., direct agglutination of the tissues without the formation of pus, as in amputations, resection of joints, extirpation of tumours, etc.—we take proper steps for conducting off the secretions of the wound by drains inserted into the deepest portions of the wound. Drainage Tubes.—The ordinary drains are made of tubes of vulcan- ised rubber, provided with numerous lateral openings (Fig. 83). These rubber drainage tubes should have as large a calibre as possible, and, while not being too long, they must always be so inserted as to render easy the escape of the secretions from any part of the wound, and 100 DRAINAGE OF WOUNDS. Fig. 83. Fig. 84. Fig. 85.—Drain Kubber Glass forceps. drain. drain. therefore should reach into its deepest portions. AVhenever possible, I place the drain to one side of the suture line and not directly beneath it, so as not to separate the suture line from the underlying parts and thus render it impossible for primary union to take place. Drains are passed through a wound with the aid of dress- ing forceps (Fig. 85) after the skin has been first incised with a knife and the remaining soft parts have been pierced by the forceps. The drainage tube is secured in its position by a stitch tak- ing in a part of the end of the tube, or by a disinfected safety pin, and thus prevented from slipping into the wound. The drain is removed from fresh wounds at the same time that the stitches are, or by the second, third, fourth, or seventh day, according to the nature of the case and the size of the wound. If it is a suppurating wound the drain is taken out when the suppuration ceases, and under such conditions it is best not to remove the drainage altogether at one time, but first to shorten the tubes and then gradually take them out. I have recommended short drainage tubes of large calibre because they do not so easily become plugged up, and consequently there is no necessity for syringing them out with antiseptic solutions. This syring- ing out of drainage tubes should be avoided, especially in all fresh wounds produced in an operation. It can only do harm by irritating the wound and forcing apart again the already adherent wound surfaces. Even washing out a suppurating wound with antiseptic solutions by means of an irrigator (Fig. 8(1) is often entirely unnecessary, and may, indeed, do harm. Absorbable Drainage Tubes.—Besides rubber drainage tubes, other forms have been used, such as absorbable tubes made of decalcified bone (Trendelenburg, Neuber), glass tubes (Fig. 84), silver tubes, tubes made from a coil of wire, etc. The absorbable drainage tubes of decal- cified bone have not come into very general use, because they are liable to be absorbed too quickly before they have accomplished their pur- pose. Preparation of Absorbable Bone Drains.—Absorbable bone drainage tubes are made as follows: The long, bollow bones of fowls and other birds are freed from soft parts by boiling, and then placed for about ten or twelve §31.] METHOD OF ALLOWING WOUND SECRETIONS TO ESCAPE. IQI hours in a mixture of one part of hydrochloric acid and two parts of water; the ends of the bones are cut off with scissors and their interior cleaned out with a stout wire, after which they are boiled in a five-per-cent. carbolic solution, to wbicb Deakin adds some borax, and they are finally stored for use in tbe same solution. Hardening of Rubber Drains.—To prevent rubber tubes from becoming soft, it is a good plan to harden them by placing them in concentrated sul- phuric acid for about five minutes, the larger sizes a little longer; then wash the tubes in seventy-five-per-cent. alcohol and store them in a five-per-cent. carbolic solution or in a 1 to 2 to 1,000 bichloride solution. The orange-red colored rubber tubes are the best adapted to this process, the gray and black not being so good. After the rubber tubes have once been hardened this quality remains unchauged by the fluid in which they are kept stored. Strands of Catgut as a Drain.—The smallest drain which we use con- sists of strands of aseptic catgut or horse-hair, which are laid side by side in the form of a bundle of threads. This bundle, for example, of catgut is pushed through a small perforation in the skin, or through the open extremity of the suture line, down into the wound, thus sup- plying, in small wounds, an excellent form of capillary drainage. Kummel has recommended capillary glass drainage in the form of strands of spun glass. Attempts have been made to substitute drainage by means of holes made in the skin for the ordinary drainage with rubber tubes in case of wounds directly under the skin, and the canalisation of skin and mus- cular tissue in case of deeper wounds (Esmarch and Neuber). To make a canal of skin and muscular tissue for purposes of drainage, the cut edge of the skin on each side is attached by a catgut suture to the wound in the muscular tissue beneath it. Of all these different kinds of drainage, in my judgment the ordi- nary drainage supplied by rubber or glass tubes, or by packing the wound with sterilised gauze, is by far the best, and all other methods (strands of catgut, bundles of horse-hair, cutaneous punctures, canalisa- tion, and absorbable drains) are only suitable for small wounds, and are insufficient for large, deep wounds in which there are pockets. If the drainage by rubber tubes is properly managed and the drains removed at the right time, it is easy to prevent the evil consequences which the tubes sometimes cause, such as necrosis of the skin, persistent fistulae, etc. If an operation is performed in a rigorously aseptic manner, with carefully sterilised instruments and hands, and without leaving diseased tissues in the wound, often large wounds made during the operation may be closed without drainage. AVhen this is done it is best to main- tain moderate pressure upon the wound by means of the aseptic dress- ing. It is exceedingly important that the wound should be irritated as 102 DRAINAGE OF WOUNDS. little as possible, and hence antiseptic solutions should only be used when absolutely necessary. Kocher's Substitute for Drainage.—Kocher has tried to dispense with the drainage of the wound by covering it with a thin layer of subnitrate of bismuth. The latter is sprinkled over the wound in the form of a one-per- cent, mixture of bismuth in water, which is dropped out of a flask ; or, if there is bleeding, compresses impregnated with bismuth are applied to the wound. The wound surface is so much dried up by the bismuth that the secretion is almost nil. After twelve, twenty-four, or forty-eight hours the wound is closed by secondary suture. Schede's Method of healing under a Blood-Clot.—Schede has recently recommended "healing under a moist blood-clot "—e. g., he permits a cavity which has been hollowed out of a bone to fill with blood, closing the wound tight by suturing the skin and not inserting any drain. If the coagulum thus formed in the course of an aseptic operation remains aseptic, it will be gradually absorbed and its place taken by newly formed connective tissue or bone, and healing will occur without reaction. I think this method deserves a fair trial ; it has proved of service to me after operations for caries and necrosis. To prevent the coagulum from becoming too large, I leave the lower angle of the cutaneous wound open. The whole point in Schede's method is the doing away with tbe drains. As Lauenstein has correctly pointed out, this method is particularly suitable for all wounds with loss of substance in bones and soft parts, but it is not suitable for wounds in which the wound surfaces can be brought into apposition by primary or secondary sutures. Bad results are chiefly due to imperfect asepsis during the opera- tion or after treatment. CHAPTER VIII. THE METHOD OF UNITING THE TISSUES.--SUTURE OF THE WOUND. Disinfection of the wound and surrounding parts before inserting the sutures.—Suture of the soft parts.—Needles, needle-holders, and suture materials.—Different meth- ods of suturing the wound (interrupted, continuous, silver-wire suture, plate suture, twisted suture).—Removal of the sutures.—Secondary suture.—Bloodless suture.—Subcutaneous suture of nerves, tendons, muscles, etc.—Union of wound surfaces in bones (bone suture).—Periosteal suture.—Nailing and other methods of uniting the surfaces of a divided bone. § M2. Disinfection of the Wound before inserting the Sutures.—After arresting the haemorrhage very carefully and putting in the proper drain- age, the wound and the surrounding parts are washed with a three- per-cent. solution of carbolic acid or 1 to 1,000-5,000 solution of bichloride of mercury. The irrigator (Fig. 86) is best suited for this purpose ; it is made of metal—or, better, of glass—with a rubber tube provided with a removable tip made of glass or rubber, through which the solution flows. A warning must be given against too vigorous cleansing of the wound with antiseptics—ex- cepting in the case of already infected wounds—because too much irritation is produced, and the ensuing secretion from the wound will be increased. I irrigate wounds made during Fig. 86.—irrigator. an operation only in those cases in which there is the possibility of infection having occurred during the operation. In wounds already infected and when pus is present, etc., fairly strong antiseptic solutions should be employed (four-to-five-per- cent, carbolic or 1 to 1,000 bichloride), but the weaker antiseptic solu- tions should be used at the.end to again remove from the wound the concentrated and more or less caustic solutions which may easily produce symptoms of poisoning. If there are no irrigators at hand, clean, well- (103) 104 THE METHOD OF UNITING THE TISSUES. disinfected sponges, or aseptic gauze, or cotton tampons, may be soaked full of the antiseptic fluid, which is then squeezed out over the wound and adjoining parts, thus cleansing them. I use antiseptic solutions as little as possible, and avoid irrigating the wound with them after the operation, as the secretion from the wound is much less if the irriga- tion with irritant solutions is omitted. The main point is always to operate with perfectly aseptic hands and instruments. When the haemorrhage has been arrested and the wound treated on these general principles, we proceed to insert the sutures. § 33. The Uniting of the Soft Parts—Suture of the Wound.— In all -cases in which we wish to obtain as speedy union of the wound as pos- sible {per primam intentionem) we close the wound by suturing to- gether its edges. Suturing should .always be carried out with the same regard to asepsis as was had in the operation itself, and hence the needles and the sutures must be previously made aseptic. For introducing sutures we use straight and variously curved nee- dles with lance-shaped points. I use straight lance-shaped needles almost exclusively for the skin. Curved needles are suited particularly for deeply lying portions of the body and for introducing sutures in Fig. 87.—Needle holders. cavities (mouth, gums, throat, vagina, etc.). Hagedorn's needles, which are flattened on the sides, are very useful. The recently introduced platinum-iris needles possess the advantage of not oxidising, and they can be heated red-hot without losing their original temper. Besides the ordinary needles without handles, there are many provided with §33.] THE UNITING OF THE SOFT PARTS. 105 handles, though I never use them. AVhen the needle cannot be intro- duced by hand, as in the mouth or pharynx, the vagina, etc., we use a needle-holder. Of the numerous different kinds of needle-holders, those worthy of mention are the holders of Dieffenbach, Reiner (Fig. 87, a), Roux (Fig. 87, b), and Sims (Fig. 87, c). Hagedorn has recently in- vented a most excellent needle-holder, wliich I now use exclusively (Fig. 87, d). Suture Material.—Sutures are made of sterilised silk impregnated with carbolic acid or bichloride of mercury, of linen thread, catgut, horse-hair, sea-grass, silkworm gut (from the chrysalis of the silkworm), crin de Florence (from the intestine of the silkworm), and silver wire. Catgut has the great advantage over silk that it is absorbable, and is therefore preferable for subcutaneous or buried sutures—that is, suture of nerves, tendons, muscles, etc. Moreover, buried catgut sutures are the best for uniting a ruptured perinaeum ; for the radical cure of her- nia ; for operations on the uterus, bladder, or intestine; and for opera- tions on fistulae. If catgut is used for suturing the skin, the sutures will not need to be removed with scissors, but after about four to seven days the external portion lying over the line of the wound can be sim- ply picked off with forceps, as the part which lies buried in the tissues is absorbed, or is only very weakly attached to the rest of the suture. On account of this rapid absorption of catgut, it follows that under certain conditions catgut sutures will not hold the borders of the wound long enough in apposition, and so I do not use catgut alone for suturing the skin, but combine it with aseptic silk, especially if the skin is under considerable tension. The preparation of a satisfactory catgut has been described on page 88. The size of the catgut or silk suture required will, of course, depend upon the kind of tissues to be united and the amount of tension. AYhen there is great tension strong sutures are naturally required, because fine sutures would easily cut through. Silver wire should be made smooth before use by passing it through a flame till it becomes red-hot. Silkworm gut is excellent for tying off the pedicle in ovariotomy, for perineal operations, etc. In the place of expensive silk, Trendelenburg and Heyder recommend linen thread for ligatures and sutures. It is cheap, and easily obtained at any time (even in war). Sutures made from the Tendons of Reindeer, Horses, and Deer.—Rati] off uses the tendons of reindeer for suturing wounds. This material is used by the Siberian colonists for sewing. Putilow uses the tendons of horses and deer. The strips of tendon are soaked for twenty-four hours in ether, and for the same length of time in a five-per-cent. alcoholic solution of carbohc 106 THE METHOD OF UNITING THE TISSUES. acid. The strips of tendon tbus prepared are said to be stronger than catgut, as soft as silk, and completely absorbed in the wound. The Interrupted Suture.—The most common form of suture is the so-called interrupted suture (Fig. 88). This is introduced with straight or curved needles, the aseptic catgut or silk being simply knotted in the eye of the needle, or, better, threaded so as to leave two long ends. The knot, especially if the suture is of large size, interferes with draw- ing the eye portion of the needle through the skin. The border of the wound is seized with a toothed forceps, and the needle is pushed through first one edge of the wound and then the other. Both edges of the wound can be pierced at the same time, provided they are held together by an assistant. The knots should be placed to one side of the line of suture. If there is much tension on the edges of the wound the so-called surgeon's knot is occasionally used—that is, the ends of the suture are twisted not once, but twice about each other. It is best to begin the suture not at the ends of the wound, but in the middle, especially if it is a long one; and at the time of inserting the first suture care should be taken to have the borders of the wound in good apposition, as otherwise troublesome folds at the ex- tremities of the line of suture may result. Two different kinds of sutures are classed under the head of interrupted sutures—the tension suture and the coaptation suture. The first is inserted and brought out anywhere from 1-2 to 4—6 centimetres from the edges of the wound, whilst the second or Fig. 88.—interrupted coaptation suture is shorter, and the points where it suture. r ' r enters and emerges are only about half a centimetre distant from the edges of the wound (Fig. 88). Those sutures by which correct apposition of the borders of a long wound are obtained are called apposition sutures. In every suture line the greatest care is necessary to prevent the edges of the wound from becoming inverted, and the two borders must lie in good apposition with each other. The sutures must not be drawn too tight. It must constantly be borne in mind that the successful healing of a sutured wound depends upon the proper insertion of the sutures, and that sutures applied unskilfully and without antiseptic precautions may give rise to serious dangers. An erysipelas which may cause the death of the patient may start from a small spot of necrosis in the skin, aris- ing, perhaps, from a portion of the border of the wound which has got turned in, if the borders of the wound are not properly placed in appo- sition ; or it may start from a small stitch abscess produced by an §33.] THE UNITING OF THE SOFT PARTS. 107 imperfectly disinfected needle or suture. Tremendous results may follow from very small causes. Furthermore, no appreciable cavity should be allowed to remain; and hence the deeper-lying parts are sometimes united by special catgut sutures or are included in the cuta- neous sutures. " Good sutures, good results," was a favourite saying of Nussbaum. Continuous Suture.—Instead of the ordinary interrupted suture I frequently use the continuous suture, and usually in combination with tension sutures (Fig. 89). I use, whenever it is possible, needles with lance-shaped points, of the same size as the ordinary tailors' needles. The fine suture, which should not be too long, is simply / j knotted in the eye of the V ( needle. The number of ten- sion sutures required depends, of course, upon the length of the wound. The tension su- tures are inserted in the usual way, and then the continuous suture is begun at one end of the wound by making one ordinary interrupted suture; the thread, however, is not cut, but the suture is continued by transfixing at equal distances the opposed borders of the wound, which are held together by the fingers. When the other end of the wound is reached (Fig. 89, a) the suture is cut with scissors, and the three threads are knotted together like the ordinary interrupted suture, two threads being on one side of the wound and one upon the other. The suture can also be finished off by forming a loop through which the extremity of the suture is drawn. The con- tinuous suture has the advantage over every other kind of being capable of very rapid execution, and of rendering excellent coaptation of the borders of the wound. If the wound is very long and there is fear that a single continuous suture will not be strong enough, the suture can be interrupted at any desired part of the wound, and from this point a fresh continuous suture can be begun; or it can be given greater security by tying it at any point and then continuing. But when the precaution of inserting tension sutures is taken there need be no fear that the continu- ous suture will prove at all untrustworthy if it is carefully inserted. Catgut is ordinarily the best material for the continuous suture, and I use aseptic silk for the tension sutures. The continuous suture is par- ticularly adapted for operations on the peritonaeum and the gastro- Fig. 89.—Continuous suture. 108 THE METHOD OF UNITING THE TISSUES. Fig. 90. W ire su ture tight ener. intestinal tract, and for the buried catgut suture in operations on the vao-ina for prolapse and for rupture of the perinaeum. Silver-wire Sutures.—If silver wire is used for suturing, it is fast- ened to a straight or curved needle by simply bending over one end of the wire after it is threaded through the eye. The silver-wire suture is fastened in place by exerting suitable traction on the wire and then simply twisting together its crossed ends, or an instrument particularly designed for the purpose may be used (Fig. 90). The cross-piece of the " wire twister " contains two round openings into which the ends of the wire are passed after they have been crossed over the wound, and then by rotating the instrument the wires are twisted around each other. The Silver-wire Suture with the Lead Plate. —A form of tension suture which has at present somewhat gone out of use is the silver-wire lead- plate suture used for closing the wound after Fm. 91. abdominal section or amputatiotrof the breast. Lead plates. Small lead or glass plates are required which are perforated in the centre. The silver wire is either twisted around the plate (as in Fig. 91, a), or fastened to pins on its surface (Fig. 91, b), or else the silver wire is inserted in a small lead ring which is pinched together with forceps. Glass beads can also be used. The end of the wire is passed twice through tbe bead and drawn tight, then through the lead plate, and after attaching it to a needle the suture is inserted. Upon the other side of the wound the wire is first passed through the lead plate, then through one or more glass beads, and after obtaining tbe proper tension the wire is twisted around a sterilised match and the ends are cut short with scissors. It is a very good plan to use, instead of silver wire, a double silk suture having each end so fastened together over a glass bead that only one and not both threads pass through the bead. Pledgets of iodoform gauze can also be used for securing tbe ends of the silver-wire lead-plate suture. At present I have given up this kind of suture, and prefer a tension suture of stout sterilised silk inserted some distance from the edge of the wound. The latter, furthermore, is more quickly inserted. Other Methods of Suturing.—The old-fashioned continuous furrier's stitch, the fin stitch, and the looped suture are useless and out of date, and will not be described. The continuous suture which I have described differs materi- ally from the continuous furrier's stitch. The so-called " figure-of-8" or twisted suture (Fig. 92) I also consider unnecessary, and no longer use it. The interrupted suture answers the same purpose, and is more simply in- serted and is better for the tissues. It is applied in the following way: The edges of the wound are transfixed by long Carlsbad needles some distance apart. About tbe ends of the needles is twisted an aseptic silk suture in the $33.] THE UNITING OF TOE SOFT PARTS. 109 form of a circle or figure of 8, and the extremities of the thread are knotted together. The sharp ends of the needle are clipped off with a Luer's rongeur forceps. Deep Sutures attached to Beads.—Thiersch's method of inserting deep sutures with their ends attached to beads—for example, into the rectum or vagina—is a very good one. To the end of the silver wire a bead is fastened, as in the plate suture; a lead plate is then placed next on the wire, tbe other end Fig. 92.—Figure-of-8 suture. of which is threaded on a needle and passed through the borders of the wound. After removing the needle, the needle end of the wire is passed through ten to twenty glass beads and secured by pinching together a piece of lead upon it; by pushing tbe lead up or down on the beads the suture can be loosened or tightened. To remove the suture, the wire is cut on the proximal side of the piece of lead and pulled out by drawing on the other end. The Removal of Sutures.—The stitches are taken out, in the majority of cases, at any time from the third to the seventh day, according to the kind of wound. A\Te frequently—for instance, after plastic operations on the face—take out a stitch here and there at the end of twenty-four hours; but in other cases, on the contrary, as when the peritoneal cav- ity has been opened, we allow the stitches to remain till the eighth to the fourteenth day. In long wounds, and in those in which there is danger of the agglutinated borders of the wound separating after removal of the sutures, the latter should not all be taken out at the same time. The tension sutures, particularly at the extremities of the wound, when combined with the continuous suture, should be taken out first. If the tension sutures become buried in the skin—i. e., " cut out"—they should be removed immediately. Sutures are removed by seizing one end of the knot with dissecting forceps and, while slight traction is exerted, cutting off the suture close to the wound and care- fully drawing it out. Care must be taken that the whole suture is removed. If catgut has been used it is unnecessary to cut the stitches with scissors, as the portion buried in the tissues is absorbed, and only leaves the exposed loop of catgut to be picked off the skin with thumb forceps. Secondary Suture.—If the borders of the wound gape after removal of the stitches, the wound can be reunited by a fresh suture (secondary suture). This secondary suture is very much used—for example, in wounds which have been first packed, or in wounds which have been 110 THE METHOD OF UNITING THE TISSUES. left entirely open during the first few days, or in deep, granulating wounds, etc. To avoid a repetition of the anaesthesia when secondary sutures are applied, Xussbaum has advised that the secondary suture be put in place at the time of the first operation. For example, a mattress or continuous suture should be inserted in advance in each margin of the wound, and then, later, the loops of these sutures can be used to close the wound by passing a silk thread through them. Bloodless Suture.—Besides the above-described kinds of suture there is a bloodless or dry method of suture. The Arabs used, for closing a wound, an insect (Scarites pyraemon) whose maxilla terminated in a small hook. The borders of the wound were approximated by these hooks, the body of the insect being removed and leaving only the head with its hooks. Vidal de Cassis attempted to imitate this method of approximation with his serre-fine. This instrument is usually made of a round wire fashioned so as to have jaws closing by a spring, which are opened by pressure behind the point where the jaws cross. It has passed out of use, very properly, as the method is painful and unreliable. The suture of tendons, nerves, etc., is described in the third section (§ 88, Injuries, AVounds), and suture of the intestine, bladder, etc., is treated of in the text-book on special surgery. § 31. The Method of uniting Wound Surfaces of Bone. —The surfaces of a wound in a bone can be held in ap- position by periosteal sutures only when small bones are concerned. A suture passed through the bone itself is, of course, the best. The necessary holes are made in the bone by drills (Fig. 93) worked by pushing the wood or metal spool on the instrument up and down, and thus causing the needle attached to the instrument to rotate. Silver wire, which is allowed to remain in the wound, or stout catgut, are used as suture materials. J. Henequin (Rev. de Chir., August, 1892) and V. AVille (Centrbl. fur Chir., 1892, p. 46) have recommended a very good method of bone suture. Agile's plan con- sists in boring a hole through both walls of a hollow bone and dragging the silver wire through it by means of a peculiar " suture hook.'' Another excellent method of uniting the surfaces of a wound in bone is aseptic nailing. Long, four- cornered nails are used, which are first very carefully polished and then disinfected in a five-per-cent. carbolic-acid solution, after which they are placed in absolute alcohol and finally heated red- hot in the flame of a spirit lamp. After some three or four weeks §34.] THE METHOD OF UNITING WOUND SURFACES OF BONE, m the loosened nails can be easily drawn out with forceps or the fingers and without causing the patient pain. Of course, care must be taken that the nails project at least two centimetres beyond the level of the skin. Long ivory pegs are sometimes used instead of metal nails; but I have found that ivory pegs are not so easily removed as iron nails, as the outer surface becomes rough from contact with the tissues, especially bone. The ivory pegs become decalcified by the action of the carbonic acid in the tissues, and the remaining organic portion is dissolved, thus producing small pockets and cavities into wliich the surrounding bone grows. The aseptic nailing together of the surfaces of a wound in bone, as after resections, particularly of the knee and ankle, in fractures, separation of the epiphyses, etc., is entirely devoid of danger if the operation is performed with the strictest antiseptic precautions. For fastening together a divided bone, as in separation of the epiphysis at the upper end of the humerus, Helferich has recommended long, awl-like steel needles, fitted with a handle which unscrews. These are made to slowly bore their way into the bone. After eight to four- teen days the needles are removed. A clamp apparatus has been recommended for uniting the surfaces of a bone wound. Under fractures we shall become acquainted with Malgaigne's hooks and Langenbeck's screw. In cases of fracture Bircher has recently introduced the practice of inserting an ivory peg into the open ends of the medullary cavity of the diaphysis, and of using ivory clamps for holding in contact fractures involving the epiphyses. In part of the cases the wound healed up over the ivory peg; in sixteen cases (out Of thirty-five) the peff had Fig. 94.—Union of the ends of bones by implan- v J ' r ° tation. to be subsequently extracted. Another method of uniting a wound in bone is illustrated in Fig. 94. The somewhat pointed extremity of one fragment (the femur) is inserted, for instance after resection of the knee, into the medullary cavity of the other fragment of bone (in this case the tibia). Formation of Periosteal Flaps and Transplantation of Cartilage and Bone in Cases of Loss of Substance in Bone.—Loss of substance in bone can be remedied by periosteal flaps (Nussbaum) or by the transplanta- tion of cartilage or pieces of bone from young animals (rabbits and dogs). Cluck has attempted to supply loss of substance in bone by the implantation of dead bone and ivory (see § 101, Treatment of Frac- tures—Osteoplastic Method). The suture of bone or the holding of the 112 THE METHOD OF UNITING THE TISSUES. surfaces of a divided bone in apposition by one of these methods is especially indicated in compound fractures—for example, in compound transverse fracture of the patella or olecranon, in fractures of the lower jaw, etc. Besides these, it is indicated in resections of joints, such as the knee, in resections of bones in their continuity, after temporary division of bone, and in complicated harelip operations, etc. CHAPTER IX. AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. — GENERAL CONSIDERATIONS. Performance of amputations and disarticulations.—Subperiosteal amputations and dis- articulations.—History of the methods of amputations and disarticulations.—After treatment.—Bad sequelae.—Infection of the wound.—Muscular spasm.—Secondary haemorrhage.—Gangrene of the flaps.—Necrosis of the stump of the bone.—Coni- cal stump.—Neuralgia.—Neuromata.—Fatal results.—Mortality statistics.—Artifi- cial limbs.—The methods of performing resection. § 35. General Considerations in performing Amputations and Disartic- ulations.—By amputation (from amputare, to cut off) is understood the operative removal of an entire portion of an extremity. If a limb is severed through a joint the operation is called a disarticulation, in con- tradistinction to amputation, in which the portion of the limb removed is cut off by sawing through the bone in its continuity. Amputation is not confined to the extremities alone, but is used to designate the re- moval of certain portions of the trunk, like amputation of the breast, the penis, or the portio vaginalis. We shall discuss here only amputa- tions and disarticulations of the extremities. The Indications for Amputations and Disarticulations have markedly decreased in modern surgery, which leans more and more towards con- servative methods of treatment. With the aid of the antiseptic method we are now often able to save a limb which formerly, in the preanti- septic era, would have fallen a prey to the mutilating effects of amputa- tion and disarticulation. We shall entirely omit a detailed description at this point of the indications for amputation and disarticulation, as there will be opportunity enough for discussing this subject when we take up special diseases and injuries. It is sufficient to state here that these operations are indicated in all diseases and injuries of the extrem- ities which threaten to destroy the whole limb or the life of the pa- tient, and hence in (1) extensive injury to the soft parts and bone which precludes the possibility of saving the extremity in question, or renders the physical condition of the patient such that he cannot withstand a long confinement to bed, or in consequence of which the extremity, if 9 ("3) 114 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. spared, would be useless; or (2) in extensive inflammation or disease of the extremity which would render it completely incapable of perform- ing its functions, or which threatens the life of the patient. Under the latter heading come extensive gangrene, malignant new growths, irreparable injuries to bones and joints, large ulcers, spreading (sep- tic) intermuscular suppuration with threatening systemic infection, etc. Under the separate injuries and diseases we shall refer again to the indications for amputation and disarticulation. At present the general suggestions just made will be sufficient. When an amputation and when a disarticulation should be per- formed are questions which in general depend upon the nature of the case in hand and the location of the injury or disease. We shall dis- cuss this more fully in the Special Surgery. Formerly, in the preanti- septic days, disarticulation was performed more frequently, as it dis- pensed with the dreaded opening of the medullary cavity. In fact, there were surgeons who went so far as to give up amputations for this reason and performed only disarticulations. Since the introduc- tion of the aseptic method of operating this consideration is no longer thought of. At present the question whether amputation or disartic- ulation is better for any particular case is usually decided by practical considerations. Both forms of operation are practiced, and amputa- tion or disarticulation is decided upon according to the circumstances in each individual case. In general, amputations are performed much more frequently than disarticulations, because the former can be car- ried out at any part of the extremity, while the latter are confined to the joints. The method of dividing the soft parts, particularly the skin, is practically the same in both operations. The soft parts must be di- vided in such a way as to form a good covering for the bone stump. We distinguish three principal forms of incision—(1) the circular, (2) the flap, and (3) the racket-shaped incision. § 36. General Considerations in regard to Amputations.—The field of operation is carefully cleaned throughout its whole extent with soap and a brush, shaved, and then disinfected with a three- to five-per-cent. solution of carbolic acid or 1 to 1,000 bichloride. The patient is placed in a convenient position, and a particular duty is assigned to each assistant. The operator stands so that the limb to be operated upon will fall to his right. We operate in all cases, if possible, with the assistance of Esmarch's artificial ischaemia, described in § 19. Dur- ing the operation all the rules of antisepsis must be strictly observed by the operator and his assistants ; no unclean finger or instrument should come in contact with the wound. The knife as well as the saw §36.] GENERAL CONSIDERATIONS IN REGARD TO AMPUTATIONS. 115 should be used carefully and gently, and pains should be taken not to bear down too hard on the instruments. Violent manipulation and compression of the soft parts are to be avoided, as well as too vigorous rubbing of the wTound with sponges or compresses. In fact, sponging can be almost entirely dispensed with when Es- march's artificial ischaemia is used. I. Circular Division of the Soft Farts in a Single Stroke (Celsus, Louis).—The soft parts, having been drawn up by the hands of an assistant, are divided circularly down to the bone by a single stroke of the amputation knife (Fig. 95) held at right angles to the axis of the limb (Fig. 96). The size of the amputating knife should de- pend upon the diameter of the limb. The am- putating knife is grasped in the closed fist, the hand passed under the limb, and the incision is begun with the part of the edge nearest the han- dle, which is placed on that portion of the sur- face of the limb which faces the operator (Fig. 96). The blade is then drawn around the entire circumference of the limb, dividing all the soft parts down to the bone. I think it is easier and better to begin the incision with the knife in tbe right-angled position, point upwards, on tbe side of the limb which faces away from the operator. The knife is then carried with a sawing motion around about two thirds of the circumference of the limb, dividing all the soft parts down to the bone. Starting from the beginning of this in- cision, the knife is carried in the reverse direction, dividing the soft parts on the side of the limb fac- ing the operator. After division of the soft parts the bone is sawed through. Then the cylinder of soft parts is drawn up on the bone stump by an assistant, while the Fig. 96.—Circular method. Fig. 95.—Amputation knives. 116 AMPUTATIONS, DISARTICULATIONS. AND RESECTIONS. operator grasps the extremity of the bone stump with Luer's or Lang- en beck's bone forceps (Figs. 67, d, and 68), and elevates or pushes back the periosteum by means of a periosteal elevator (raspatory, Fig. 63) a distance equal to about half the diameter of the limb. At this point the bone is again sawed through, thus allowing the cylinder of soft parts to completely cover the stump of bone and the edges of the skin to be united, usually in a transverse line, without tension on the sutures. In amputations of ex- tremities containing two bones, such as the leg, the forearm, the metacarpus and metatarsus, the muscles and soft parts lying between the bones must be divided before sawing the bones. For this purpose a small, pointed, double-edged knife, sometimes called a catline, is best (Fig. 97). This knife is in- serted in the space between the bones and the soft parts di- vided by cutting first with one edge against one of the bones and then with the other edge against the other bone. This procedure is then repeated by inserting the knife from tbe opposite side into the space between the bones. Instead of the two-edged knife, a small scalpel can be used for this pur- pose. After dividing the soft parts in the space between the bones and laying the bones free, the latter are sawed in such a way that the division of both is completed at the same time. Thus, in amputations of the leg the tibia is first sawed about three quarters through before one begins to saw the fibula, and then both are completely sawed through at the same time. Fig. 97. Catline. Fig. 98.—Division of a bone by the saw. Fig. 99.—Split compresses. For sawing the bones in amputations it is best to use the bow-saw (see page 83, Fig. 70, b, c) in the way illustrated in Fig. 98—i. e., the saw is placed close to the soft parts, at right angles to the thumb of the left hand, which is placed upon them. To prevent injury to §36.] GENERAL CONSIDERATIONS IN REGARD TO AMPUTATIONS. H7 the soft parts they are retracted by a split aseptic compress (Fig. 99) or the hand of an assistant. The distal portion of the limb is held by an assistant, and allowed to drop a little as the sawing progresses, so that the saw does not become jammed. If projecting spicules of bone re- main after the sawing is completed they must be cut or smoothed off by bone shears or forceps, or the metacarpal saw or chisel may be used for this purpose, as for removing the anterior projecting border of the tibia. After amputation by the ordinary circular division of the soft parts three drainage tubes are generally inserted—one at each angle of the wound, and one in the centre of the posterior skin flap; but in small stumps the latter drain alone is sufficient. A continuous catgut suture with several interrupted silk tension sutures should be used to close the wound. Modifications of the Circular Division of Soft Parts in One Sweep.— After cutting the soft parts circularly in one sweep down to the bone, as just described, the cylinder of soft parts is drawn up or retracted by an assistant. The muscular fibres still adhering to the bone cause the surface of the wound to have the shape of a cone. A knife is then carried circularly through the base of this cone down to the bone at the point where the latter is to be divided. If the covering for the bone stump thus made out of the soft parts is not sufficient, the mus- cles are then freed from the bone by a scalpel. The bone can then be sawn through with or without first elevating the periosteum. By this method the surface of the relaxed wound is made to assume the shape of a short, hollow cone with its apex towards the trunk. The division of the soft parts in the form of a cone can be omitted, and the muscles simply freed from around the bone by means of a small scalpel and retracted by the fingers of the left hand. The Elevation of the Periosteum.—It is not always necessary to ele- vate the periosteum from the bone before sawing it through. I usu- ally omit it. According to my experience, the bone-forming power of the elevated periosteum does not affect the subsequent condition of the stump. On account of the rapidity with which it could be done, the circu- lar method, performed with one sweep, used to be much employed when operations were carried out without anaesthesia, but at the pres- ent time it is less often used. In fact, it is little suited for extremities having powerful muscles, for it provides a more or less insufficient covering of soft parts and of skin for the bone stump, and therefore is conducive to the formation of the so-called conical stump. But, on the other hand, this method is a perfectly proper one for performing 118 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. amputations on children and thin subjects, particularly in the case of limbs containing only one bone. II. Circular Method of dividing the Soft Parts at Two Different Levels.__An incision is carried circularly around the limb through the skin down to the fascia. The skin is then drawn up by an assistant, while it is freed from the subjacent parts by carrying a knife, held at right an- gles to the axis of the limb, circularly around the latter at the edge of the Fig. 100.—Formation of a cutaneous cuff in a circular amputation at g^jn cutting down two levels. ' , to the fascia (rig. 100), or by dissecting the skin and subcutaneous tissue from the deeper tissues by means of a scalpel. When the skin has been thus sufficient- ly freed from the fascia it is turned back in the form of a cuff, the length of which should equal about half the diameter of the limb. A circular incision through all the soft parts down to the bone is then made close to the attached edge of the cutaneous cuff, and the bone is then sawed in the manner already described. Here also it is a good plan to separate the muscular insertions from the bone for a short dis- tance to insure a sufficient covering for the stump. Funnel-shaped Method.—The so-called funnel-shaped method of dividing the soft parts (Alanson) is only a modification of the method just described. The skin is first divided circularly, and the knife is then applied at the margin of the retracted skin, having its edge directed obliquely upwards and at the same time towards the bone, in which direction it is carried through the muscles down' to the bone. In this way a conical-shaped wound surface is made, with its apex towards the upper end of the bone. III. The Flap Methods.—The flap methods vary in the thickness, shape, and length of the flaps. At the present time flaps are generally made to consist only of skin, or skin and subcutaneous tissue, as it is well known that the muscles in the flap covering the bone stump subsequently disappear entirely by fatty degeneration. But it is an excellent plan to fashion flaps of both cutaneous and muscular tissue whenever the skin is very thin and badly §36.] GENERAL CONSIDERATIONS IN REGARD TO AMPUTATIONS. H9 Fig. 101.—Formation of two semilunar skin flaps. nourished. The shape and position of the flaps vary very much, though anterior and posterior flaps are usually made either of equal length, or a long anterior and short posterior flap are made, in order that the suture line shall come to lie more posteriorly. The incision for the cutaneous flaps may be made in the same way as in the circular method of amputating in two stages just described, and then longitudinal incisions some five or six centimetres long are made on the inner and outer aspect of the ex- tremity, thus forming two cutaneous flaps of equal length, an ante- rior and a posterior. These are then freed from the fascia and turned back. The mus- cles are divided at the point where the cuta- neous flaps are turned back, just as in the circular method of amputa- ting in two stages. Another way is to form two semilunar-shaped skin flaps, either in front and behind or laterally, using a large scalpel with a blade convex on the edge. The flaps of skin are dissected from the fascia and turned back (Fig. 101). It is a very good plan to make a long, semilunar-shaped ante- rior flap of skin with a small posterior flap (Fig. 102). The form- er must be long enough to cover the entire cut surface like a curtain. Fig. 102.—Formation of a large anterior and small posterior skin flap. Fig, 103.—Anterior overhanging flap, and posterior semicir- cular incision. The overhanging anterior flap is made in the 120 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. Fig. 104.—Formation of a flap of skin and muscle by an in- cision from without inwards. simplest way, by cutting an anterior semilunar-shaped cutaneous flap and freeing it from the subjacent parts. The base of the flap should be equal to about half the circumference of the limb, and its length should equal its sagittal diameter. A similar but smaller cutaneous flap is then cut from the posterior half of the circumference of the limb and dissected from the fascia. A very simple way of carrying out this method of amputation by a long anterior flap, after the latter has been cut and turned back, is to divide the skin on the posterior portion of the circumference of the limb by a single circular sweep of the knife. The posterior flap is then dissected back from below upwards, as usual, by strokes of the knife held at right angles to the axis of the limb, and the muscles are then cut circularly by a single sweep of the knife (Fig. 103). Some surgeons prefer to include the fascia in the skin flaps, freeing skin and fascia together from the underlying muscles, as they believe that the skin flaps are better nourished in this way by the extensive network of vessels lying between the skin and fascia, particularly if the portion of skin in question is loosely attached and thin. I do not like these flaps of combined skin and fascia, and agree with Oberst that the fascia, on account of its poor blood supply, especially if the conditions Fig. 105.—Disarticulation for circulation are unfavorable, is liable to necrose tentn£rillZg-2, and so interfere with primary union. I think it flexor tendon and near better to form cutaneous flaps without the fascia. oy the two ligated dig- T~ . , r itai arteries and the It the skin is not suitable for making flaps on ac- nerves. In the center . j> i • ,, . T » , . of the wound is seen count ot being too thin, I prefer the circular £2S££rfaoeof method of amputation, carrying the knife to the bone in one sweep, or the method in which the flaps include both skin and muscular tissue. The formation of flaps consisting of both skin and muscular tissue is not at present so much in vogue as formerly. The wound surface §36.] GENERAL CONSIDERATIONS IN REGARD TO AMPUTATIONS. 121 is too large, the flaps are too heavy, and the vessels are usually cut obliquely. These flaps are formed either by cutting from without in- wards (Fig. 104), or in the reverse direction, from within outwards, by means of transfixion. In the latter method a double-edged knife is inserted close to the bone, at the base of the flap to be formed ; then the knife is carried with a sawing motion obliquely downwards and out- wards. All transfixion methods are bad, because the vessels are often wounded or divided in two different places. It was formerly used very often, when operations had to be performed rapidly without anaesthesia. IV. The Oval or Racket Incision (Fig. 105).—This is a compromise between the single circular sweep of the knife and the flap method. It is chiefly used for disarticulating fingers and toes, but it is seldom made use of in amputating. It is really an obliquely placed circular amputation—i. e., two lateral incisions are made, which meet at a sharp upward angle on the back of the limb, and in a slight downward curve on the front. The Treatment of Amputation Wounds.—Haemorrhage after ampu- tation is arrested by seizing separately all the divided vessels, both arteries and veins, in the bloodless stump with self-locking haemostatic clamps and then ligating them with catgut or aseptic silk (Fig. 106). To find the small muscular branches in the surface of the bloodless stump, one should follow the muscular in- terspaces, where the vessels can be discovered and grasped with clamps. If any vessel cannot be drawn out or isolated, it should be secured by passing a sharply-curved needle car- rying a catgut suture through the soft parts around the bleeding vessel (page 90, Fig. 78). The SUture is Fig. 106.—Ligation of the vessels in an am- iT . , • i -i i i- nutation stump. then tied so as to include the soft parts and the vessel. Small vessels can be closed by torsion, as de- scribed in § 2S. After all the vessels in sight have been ligated, the Esmarch elastic tourniquet is removed, while the amputation wound is elevated and pressure exerted upon it by aseptic sponges. Pressure lasting a couple of minutes is the best means of arresting the ensuing parenchymatous haemorrhage, which is very apt to be considerable im- mediately after the removal of the Esmarch tourniquet, on account of the vasomotor paralysis that it causes. 122 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. When the haemorrhage has been very carefully arrested the large nerve trunks are drawn out of the wound and cut off with scissors, to prevent the possibility of any subsequent neuralgia or the formation of amputation neuromata. After this the wound is disinfected, together with the parts surrounding it, by irrigation with a 1-to-l,000-5,000 bichloride solution, or a three-per-cent. solution of carbolic acid, and its margins are united by sutures and drainage tubes inserted. If the asepsis has been perfect throughout, there is no necessity of antiseptic irrigation of the wound, as this only causes irritation and increases the subsequent discharge from the wound. It is sufficient to wash out the wound with a sterilised seven-tenths-per-cent. solution of common salt or simple warm boiled water. The drainage tubes are fastened to the skin by a suture, one tube being generally placed in the posterior flap, and, when necessary, others are placed in the angles of the wound at each side (§ 31). The wound is closed (§ 33) by inserting several in- terrupted tension sutures and then a continuous catgut suture. Great pains must be taken in inserting the sutures. They should be even, and hold the margins of the wound in perfect apposition. All drawing and tension must be avoided. Neuber recommends the use of several rows of sutures for closing an amputation wound. He sutures first the periosteum, then the muscles, and finally the skin, and thus avoids the formation of any pockets. According to my ideas, this form of sutur- ing is unnecessary and even bad, and I have found that an aseptic dressing, applied so as to exert suitable pressure, is entirely sufficient to prevent the formation of pockets. An aseptic protective covering which exerts moderate pressure is the most suitable form of dressing for amputations. I usually moisten the wound with a 1 to 1,000 solution of bichloride of mercury, and then cover it with several layers of well-dried bichloride or iodoform gauze, or with gauze sterilised by dry heat at a temperature of 100° C. Over this I place sterilised cotton or my own wool dressing. Moss or jute cushions or pads are also good (see Dressing Materials, § 45). The dressings are held in position by mull or gauze bandages; the stump is placed in a slightly elevated position, and left for the time being un- covered, so that any secondary haemorrhage may be recognised at once. Subperiosteal Amputations.—Oilier, particularly, has upheld subperiosteal amputations, reasoning from the results obtained from experiments made on animals. He makes a flap from tbe periosteum to promote primary union of the deeply lying parts, and to prevent inflammatory complications from occurring in the medullary cavity. But when this method is used on man the results are not so good as the experiments on animals would seem to indicate. At present Oilier has himself given up periosteal flaps, and even §37.] THE METHOD OP PERFORMING DISARTICULATIONS. 123 considers them harmful in children, on account of the tendency to form osteophytes, and superfluous in adults since the introduction of Lister's method of antiseptic treatment of wounds. On the other band, Oilier is a very warm advocate of subperiosteal disarticulation (see Disarticulations). Amputation, with Scraping Out of the Diseased Medullary Cavity.—In diseases of the marrow of bone, such as suppurative osteomyelitis, Konig and Stoll have performed amputation accompanied by scraping out the marrow, and have obtained good results. In this way disarticulation at the adjoining joint above can be avoided. § 37. The Method of performing Disarticulations.—The technique is in the main the same as for amputations. The method by circular incisions at two levels, with turning back of a cutaneous cuff, can be used, or flaps may be cut of skin, or skin and muscular tissue combined. In disarticulations, a long anterior overhanging flap and a small posterior one are much used, and are made as described above (Figs. 102, 104). In disarticulations at the ankle or medio-tarsal joint, or of the fingers or toes, the posterior flap can be made the larger. For disarticulation at the small joints of the fingers or toes, especially the metatarso- and metacarpo-phalangeal joints, the racket incision is very often used (Fig. 105). After dividing the overlying soft parts in the form of skin flaps, or flaps of skin and muscular tissue combined, or after making the circular incision in two stages and turning back the cutaneous cuff, the ligaments of the joint are made tense and the joint opened. AVhen- ever it is necessary, any prominent part entering into the formation of the * joint can be cut away; and it is sometimes best to extirpate the synovial membrane completely, in order to obtain a wound surface to which the cutaneous flaps may unite more rapidly. The details for performing disarticulations are, in general, precisely similar to those for amputations. For the method of performing disarticulation on particular joints, as well as the various amputations, the reader is referred to the text- book on special surgery. Subperiosteal Disarticulation.—Oilier, especially, has recommended the regular use of subperiosteal disarticulation. Ollier's description is as fol- lows : The same incision is made as for resection of the particular joint in question (see § 40), dividing at the same time both capsule and periosteum. By means of a raspatory the periosteum is elevated from the bone and pushed aside from the joint, together with such muscular insertions as are present; the head of .the bone is then enucleated, and the soft parts cut trans- versely to tbe axis of the limb. Extensive new formation of bone has been observed after subperiosteal disarticulation, not only in animals, but also in man in early life. This is especially true of subperiosteal disarticulation 121 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. and amputation through the upper end of the metatarsus or metacarpus, and also after disarticulation at the tibio-tarsal joint with preservation of the periosteum of the os calcis. Oilier says that James Shuter of London has seen a new bone develop which was movable in the hip joint after subperios- teal disarticulation at this joint. The subperiosteal and subcapsular shelling out of the bone is probably of most use in case of disarticulations for gun- shot injuries. History.—During the middle ages and until the close of the sixteenth century amputations were done in the most horrible ways, on account of the inefficient methods then in vogue for arresting haemorrhage, and usually ended fatally. The bleeding was checked by encircling the member to be operated upon with a strong rope, or the red-hot iron was used; boiling oil was poured over the wound, or the operation was performed with red-hot knives. Permanent constriction of the limb and caustics were also some- times used. The technique was very greatly advanced by the introduction of the ligature of vessels by Ambrose Pare and his followers (1659-1692), and after this by the invention of the tourniquet by Morel (1674). The ligature of vessels for arresting haemorrhage had been well understood by the sur- geons of antiquity, and was in general use in the time of the Roman Empire. The ligature was afterwards entirely forgotten, as has been mentioned, and was later rediscovered by Pare. In more recent times amputation was occasionally performed by the ecraseur (Chassaignac), the galvano-cautery (Bruns), and the elastic ligature (Dittel). But now all these methods have become simply matters of history since tbe introduction of antiseptics. § 38. The After-treatment of Amputations and Disarticulations.—The after-treatment of amputations and disarticulations is veiw- simple if no fever occurs and the wound runs a normal course in healing. The first dressing should not be disturbed till the time arrives for removing the drains—i. e., till the second, third, or fourth day, according to the size of the wound. Some of the stitches are also taken out at the same time. Then the second dressing is applied, and it is often the last. If fever occurs, or if the patient complains of pain, the dressing should be changed earlier. For the details of treating the patient who has been operated upon, reference is made to § 22. Bad Results.—Since the introduction of the present antiseptic meth- od of operating and treating wounds the immediate bad results which have been observed to follow amputations and disarticulations are in- frequent. It is generally expected that healing will take place without any reaction. The occurrence of wound infection—such as suppura- tion, pyaemia, septicemia, erysipelas, and osteomyelitis, so frequently ob- served in the preantiseptic period—is now exceptional, and only takes place when an extremity is operated upon which is already infected, or when the rules of asepsis are not rigidly adhered to. For the treat- §38.] AFTER-TREATMENT OP AMPUTATIONS. 195 ment of these diseases of wounds resulting from infection, as well as for the treatment of shock, delirium tremens, etc., reference is made to § 62 to § 75. Amongst the other immediate bad results after amputation we may mention the occurrence of cramps or violent contractions of the mus- cles in the stump. These are liable to come on soon after the opera- tion, and are best treated by subcutaneous injections of morphine and by fixation of the stump by means of light sand-bags, etc. (See also § 64, Delirium Tremens.) Secondary haemorrhage also occurs much less frequently than it formerly did, because we have learned to take great pains to arrest all bleeding during the operation. Secondary haemorrhage starts either from an unsecured vessel which had retracted at the time that the bleeding from the stump was being stopped, or from a vessel which had been tied off but had opened again. In such cases of secondary haemorrhage from an artery often nothing but the reopening of the wound and the securing of the bleeding vessel will suffice to check it. The best way of treating parenchymatous secondary haemorrhage or oozing is to apply an aseptic dressing in such a manner as to exert proper pressure and to place the stump in an elevated position. At a later stage in the process of healing it is still possible for secondary haemorrhage to occur from a perforation in the wall of the vessel re- sulting from suppuration when the wound does not heal by primary union. The treatment of this is also practically the same—i. e., the haemorrhage should be stopped by applying a ligature to the point from which blood issues. If the skin is very thin, or if the skin flaps lie upon a non-vascular surface like cartilage, as is the case in disarticulations, or if the dress- ings are applied so as to exert too much pressure, there is apt to be a more or less extensive death or gangrene of the flaps. In such cases one must either await the separation of the damaged portion of the flap, or, if the gangrene is too extensive, a higher amputation must be performed. Sometimes necrosis occurs in the stump of the bone, especially if there has been suppuration. Under these circumstances one must wait until the sequestrum has become loosened, and then remove it. The bone stump does not necrose if the wound heals normally and without reaction. Another bad result after amputation is the so-called conical stump. This may be the fault of the method of operating—i. e., the cutaneous flaps were made too short for sufficiently covering the bone stump, or it may be due to the death of part of the cutaneous flaps, or to retrac- AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. tion of the soft parts as a result of suppuration. This latter cause was relatively common in the preantiseptic period of surgery. At present conical amputation stumps are rare, and are usually the result of an un- skilful performance of the operation. In a well-marked conical stump the end of the bone projects from the soft parts through the granulat- ing surface of the wound, and either cicatrisation does not take place, or^ the slowly forming, adherent scar is so tense and sensitive that the use of the stump and the wearing of an artificial limb are impossible. Under such conditions there is nothing to be done but to perform a reamputation or a subperiosteal resection of the bone. The latter is best carried out by making a longitudinal incision through the soft parts and periosteum down to the stump of bone, care being taken to avoid large vessels and nerves ; the periosteum with the overlying soft parts are then separated by means of the raspatory and periosteal elevator from the bone, and a sufficiently long piece of bone is removed with the saw or hammer and chisel. Since the era of aseptic surgery, the neuralgia of the amputation stump which used to occur after suppuration is seldom observed. The pain was usually caused by the stumps of the nerves becoming included in the contracting cicatrix which followed extensive suppuration. In other cases the pain is caused by a hyperplastic process occurring in the ends of the nerves and forming the so-called neuromata. The amputation neuroma is usually a club-shaped thickening of the extremity of the nerve, and consists of connective tissue with more or less numerous bundles of newly formed nerve fibres. Very severe neuralgic paroxysms are occasioned by these neuromata and are aroused by the slightest pressure. The neuralgia which results from cicatricial contraction, and from neuromata, is best prevented by keeping the am- putation wound aseptic, and by drawing out the ends of the large nerves with forceps after every amputation, and cutting off a considerable por- tion with scissors in order that the nerves may retract well between the muscles. Moreover, great care should be taken not to include nerves in the ligatures placed on the vessels. The treatment of neuralgia oc- curring in a stump consists in the excision of a long piece of the affected nerve trunk (neurectomy), and in the extirpation of any neuromata which may be present. During the first few days or weeks many patients who have under- gone an amputation complain of radiating pains of greater or less se- verity, which, however, gradually disappear in the great majority of cases. On account of irritation of the ends of the sensory nerve fibres which originally supplied the fingers or toes, these patients feel pain re- ferred to those parts though they no longer possess them. The sensa- §:w.] ARTIFICIAL LIMBS. 127 tions referred to the portions of the extremities which no longer exist last a variable length of time—often a year—and patients are very likely to dream that they still have their lost limb. Death following Amputation and Disarticulation.—A fatal result fol- lowing amputation or disarticulation is either caused by one of the forms of wound infection, such as septicaemia, pyaemia, erysipelas, or tetanus, or by collapse, by anaemia from great loss of blood, by second- ary haemorrhage, delirium tremens, fat emboli, or other intercurrent diseases. In general, age does not play so important a part in the prog- nosis of amputations and disarticulations as it formerly did, because we have learned how to avoid loss of blood, and healing is more rapid with the aseptic method of operating. It often happens in old people that there is marked atheromatous degeneration of the arteries, and yet the wound will heal satisfactorily. Furthermore, syphilis, tuberculosis, and kidney disease have no such deleterious effect on healing as was for- merly believed. In every case the prognosis after an amputation is favourable if there are no complications, and if there has been no trans- gression of the rules of antisepsis. Mortality of Amputations.—The mortality of aseptic amputations varies with the nature of the case and the presence or absence of complications. According to Oberst, of 2C0 uncomplicated amputations 14 died, a mortality of 5 4 per cent.; but, on the other hand, there were 39 deaths in 91 cases where complications were present, a mortality of 42'8 per cent. Of 57 am- putations in which sepsis was already present, 40 recovered, and, taking all cases without distinction, Oberst collected 351 amputations with 53 deaths, or a mortality of 15"1 per cent., and 84-9 per cent, recoveries. Wolfler has given the total mortality of amputations occurring in Billroth's clinic as 197 per cent In uncomplicated cases the mortality was 57 per cent., and in those in which complications occurred—i. e., in amputations where sepsis and pyaemia were already present—the mortality was 437 percent. Essen (in Wahl's clinic) gives the total death rate as 17"9 per cent., the mortality of uncompli- cated cases being 5 93 per cent., and of those with complications 42 8 per cent. The mortality of the 255 amputations performed in Czerny's clinic was only 2 7 per cent. (Schrade). The decrease in the mortality is to be ascribed solely to the aseptic method of treating wounds, and the mortality of amputations and disarticulations would be still less if all the operations could be performed immediately after tbe injury. § 39. Artificial Limbs.—The substitution of artificial limbs for lost extremities has become more and more common in recent years. In the case of the lower extremity, the prothetic apparatus need only ren- der standing and walking possible, and consequently it is conceivable that more satisfactory results can be obtained here than in the upper extremity, where the manifold movements of the hand and fingers can be only partially supplied; and not every one is in a position to pro- 128 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. vide himself with such costly apparatus as artificial arms and legs, with their complicated mechanism. As to the upper extremity, the move- ments of the fingers are usually imitated by spiral springs, or springs are placed in the apparatus in such a way as to make the latter movable when manipulated by the other hand or pressed against the thorax by the stump, etc. The simplest and cheapest prothetic apparatus for an amputated arm or forearm consists of a leather socket in which the stump is placed and retained by straps. At the other or lower end of the piece is fastened a hook, ring, or hand carved in wood and covered by a glove. It is remarkable how much some patients can sometimes accomplish with such a simple apparatus. After amputation or disarticulation of the lower extremity we make use either of the peg leg or the artificial limb. The peg leg is the cheaper and by far the simpler apparatus, and with it walking is generally easier and more comfortable than with the artificial limb. Many who have long been tormented by the latter turn finally to the use of the peg. And it is worth taking into consideration that the peg leg can be repaired by any mechanic, while the artificial limb requires a skilled instrument- maker. Trendelenburg and others have shown that the peg leg can be improvised very cheaply by fastening a stick of wood to a socket made of pasteboard by means of a water-glass bandage. The artificial leg is usually made of a leather pocket in which the stump is placed; to this is joined the leg, which is made of wood, having hinges for the knee and ankle joints. The foot can be extended, when pressing against the ground, by means of a strong spiral spring. The move- ment of the knee joint is accomplished by some elastic material placed inside the leg and simulating the function of the muscles. In a case of low amputation of the leg, A. Bier made an artificial foot from the end of the tibia with its overlying soft parts by dividing the bone again a little above the line of amputation and turning the piece so that it would unite with the tibia at right angles; the lower portion of the fibula was extirpated. If only a part of the foot is lost the defect can be concealed and walking rendered possible by padding an ordinary boot with cotton. These brief remarks will suffice for a general understanding of the principles of artificial limbs. § 40. Operations on Joints.—By resection of a joint is meant the partial or complete operative removal of the opposed bony surfaces forming the joint by means of the saw, sharp spoon, or chisel. A dis- tinction is made between partial and complete resection, depending upon whether the ends of the bone are completely or only in part removed. If the joint is extensively diseased, we do not satisfy our- selves with removal of the bony portion, but also extirpate the synovial §40.] OPERATIONS ON JOINTS. 129 membrane—i. e., we perform a complete extirpation of the joint. In all cases in which the periosteum is healthy we preserve it on account of its osteoplastic power, and call a resection of this kind subperiosteal. A distinction is made between early and late resection and between pri- mary, intermediate, and secondary resection. By primary resection is meant one which is performed immediately after the traumatism has occurred and before the onset of inflammatory reaction. The inter- mediate resection is performed after inflammatory symptoms appear. A secondary resection is one performed after the subsidence of the in- flammatory reaction, when the wound is granulating. Resection of Bones in Continuity.—Furthermore, we resect bones in their continuity when we remove greater or less amounts of diseased portions of them by means of the chisel or saw (Resection of Bones). The removal of diseased bone by the sharp spoon—for example, in tuberculosis—is designated as a scraping out, while the simple division of bone in its continuity is called osteotomy. Arthrectomy.—If the bony parts forming the joint are left intact, and only the diseased synovial membrane of the joint is removed, as in tuberculosis, the operation is an arthrectomy. The simple opening of the joint is called arthrotomy. We shall confine ourselves here to the general technique of joint resections, and shall take up the resections of particular joints in the Special Surgery. Indications for Resection of a Joint.—The indications for resecting a joint, especially for performing total resection, have become much fewer in number since the introduction of antiseptic surgery. At the present time we are often able to save a joint—one, for instance, which has been laid open by a wound—where formerly it would have been sacrificed. We now go on the principle of performing a resection as conservatively as possible—i. e., we try to preserve as much of the articular surfaces of the bone as we can. The complete resection of joints in children, which used to be so frequently performed for tuber- culosis, should be entirely given up. In these cases we should be satis- fied with removing the diseased portion of the bone with the sharp spoon or the chisel, with the single exception of the hip joint; and in adults the use of total resection should be restricted as much as possible, and as much bone saved as possible. If only the capsule of the joint is diseased—as, for example, in tuberculosis—only this should be extirpated (arthrectomy), and the bony portion of the joint should be left intact. When arthrectomy is performed—for instance, at the knee in a case of synovial disease—a movable joint may be obtained (Angerer, Sendler, myself, and others). On the other hand, it cannot be denied that a very good functional result is possible after an extensive atypical resec- 10 130 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. tion, as in the case of the foot, and amputation be thus avoided. I agree with Kappeler, Mikulicz, Kiister, and others in sanctioning extensive atypical resections, particularly of the foot. In general, resection of a joint is indicated after severe injuries (traumatic resection) and for pathological changes in the joint (patho- logical resection). Among injuries of a joint calling for resection are (1) compound fractures involving the joint, with considerable splinter- ing of the bones, especially gunshot fractures ; also dislocations accom- panied by rupture of the skin and overlying parts. Since the intro- duction of antisepsis it will often be found sufficient in these cases to drain the joint thoroughly after reducing the dislocation or removing whatever loose fragments are entirely detached. Resection of a joint is also called for (2) when there is very extensive suppuration or violent inflammation in the joint after an injury, and especially when there is (3) chronic disease of the joint, tuberculosis being the most common. Resections may also be performed for (4) loss of function in a joint caused by contractures or anchylosis, and in old dislocations in which there is a malposition of the bones which interferes with the functions of the joint, or in which the head of the bone presses on nerves and ves- sels, and finally (5) for new growths in the bones. Osteoclasis, or subcutaneous fracture of bones by the osteoclast (Molliere), has of late years been used very largely in place of the so- called orthopaedic resections for improving deformities of bone. But I agree with Oilier, that osteoclasis is not always as effective as its in- ventor claims; and, furthermore, it is not always possible to break the bones at precisely the desired point and without damaging the soft parts. Osteoclasis cannot usually be em- ployed in cases of anchylosis. General Rules for performing Re- I i I II I section.—The operation of resecting ra sm Ki ill mi a joint is divided into three stages: (1) The incision through the soft parts; (2) opening the joint; (3) division and removal of the injured or diseased ends of the bones with or without extirpation of the syno- vial membrane. "When possible, the operation should be performed with the aid of Esmarch's artificial ischae- mia, and of course with the strictest aseptic precautions. The soft parts are divided with a short, strong knife (Fig. 107). Resection knives are Fig. 107.—Resection knives. §40.] OPERATIONS ON JOINTS. 131 sometimes pointed, sometimes blunt, or fitted with a probe point. The incision through the soft parts is made preferably in the long axis of the limb, because this involves the least injury to muscles and tendons at their point of insertion, as well as to vessels and nerves. Only in the case of the knee—and, under certain conditions, the ankle—are trans- verse incisions allowable for affording a better view of the diseased joint. The joint is opened in the line of the cutaneous incision. It is very im- portant for the future function of the joint to preserve the tendinous insertions of the muscles about the joint and to keep intact their con- nection, as well as that of the capsule with the periosteum. In all cases where the periosteum is healthy, as in primary traumatic resections, it should be preserved—i. e., a subperiosteal resection should be performed. If it is diseased, it must of course be removed, as well as the bone. If the periosteum is to be retained—that is, if we are going to do a subperi- osteal resection—it is divided in the line of the cutaneous incision and raised by the raspatory (Fig. 63) and periosteal elevator (Fig. 64). At those places where the periosteum becomes continuous with the capsule, muscular insertions, and ligaments, it must be separated from the bone by perpendicular or horizontal strokes of the knife. Vogt and Konig have introduced an excellent plan for retaining the connection of the muscular insertions to the bony protuberances to which they are attached. These protuberances are separated from the shaft of the bone by the hammer and chisel, or, in the case of children, by the knife, and at the conclusion of the operation they are again brought back into place and secured by means of silver wire or nails. When there is a tubercular panarthritis, or when diseased, it would of course be a mistake to preserve the periosteum. In such cases the joint must be entirely extirpated—i. e., all diseased soft parts and bone must be removed. The periosteum having been removed, or left in place, as the case may be, the next step is the division of the bone (see § 26). The ends of the bone are forced out of the wound, while the soft parts are held aside by retractors, or the bony parts are divided in situ with the meta- carpal, bow, or chain saw, or with the chisel. The bones of children can be cut with the knife. After division of the bone all projecting angles are levelled off. If anchylosis is desired—for example, in the case of the knee—the ends of the bones are fastened together with catgut, silver wire, or four-cornered steel nails which have been carefully disinfected (see also § 34). Since partial resections give in general a better func- tional result than total ones, the former should be given, when possible, the preference in all joints in which we wish to obtain motion. The 132 AMPUTATIONS, DISARTICULATIONS, AND RESECTIONS. strictest asepsis must be maintained in all stages of the operation. At its conclusion the haemorrhage must be arrested with the utmost care, drainage of the joint must be provided for, and, after suturing the wound and applying an antiseptic dressing, the joint must be immo- bilised by a suitable splint. If the operation is performed with artifi- cial ischaemia, it is best to remove the elastic cord and arrest the bleed- ing before suturing. In case of extensive suppuration of a joint, or advanced tubercular disease, the wound should not be closed with sutures, but packed with iodoform gauze or sterilised compresses. When only a few interrupted sutures are inserted and the wound is left partially open, drainage may be dispensed with. If no reaction follows, a plaster dressing can be placed over the antiseptic dressing after a few days. For the method of dressing individual joints after resection, refer- ence is made to the text-book on special surgery. Outcome of Resections of Joints.—The results of joint resection are either anchylosis, or an actively movable joint, or a so-called flail-like joint. In the lower extremity, at the knee and ankle, anchylosis is the most desirable result. In the hip and upper extremity a movable joint is preferable. For restoring the function of a joint after the wound has healed, the after-treatment is of great importance. It is possible to obtain very excellent results by the methodical use of active and passive motion, by electricity, massage, and baths. If anchvlosis is desired, the joint should be immobilized in the position which is most suitable for subsequent use, by means of a plaster dressing or a splint left in place for a considerable length of time (see Methods of Dress- ing, and the special surgery). If a flail-like joint is obtained, it must be re-enforced by a suitable supporting apparatus, or another operation must be done to obtain anchylosis (see Arthrodesis, below). The causes of death following resection are the infectious wound diseases, such as sepsis or pyaemia, due to imperfect asepsis, or to their presence at the time of the operation. Patients who have undergone this operation sometimes die from fat emboli, especially when there is advanced fatty degeneration of the bone marrow. P. Vogt has very properly advised that bones in which there is this fatty degeneration should not be joined together too closely. History of Resections.—Eesections were performed in the flourishing days of surgery at the time of the Roman Empire, but were forgotten entire- ly during the middle ages, and were not again systematically practiced till near the close of the eighteenth century. In England, White was the first to use the operation, performing a resection of the humerus. In France the operation was employed by Moreau; later by Sabatier, Percy, Dupuytren, 40.] OPERATIONS ON JOINTS. 133 and Larry. Von Textor, B. von Jager, and Ried introduced the operation amongst German surgeons. Langenbeck has done more than anybody to advance the technique of joint resection. Arthrodesis.—By arthrodesis is understood the artificial anchylosis of a flail-like joint—in cases of paralysis, for example, in which it was first practiced by Albert, who operated with excellent results on both knee joints of a young girl suffering from paralysis of the lower extremities. The operation is very useful, especially for paralytic flail-like joints. At first arthrodesis was frequently performed by fastening the bones together with a wire suture after a typical resec- tion of their joint surfaces. But it is a better plan to pare off only the articular cartilages, and then unite the bones with long, perfectly sterilised steel nails instead of the silver-wire suture. The synovial membrane should be allowed to remain intact. If healing takes place with some slight amount of suppuration, the synostosis of the joint ends of the bones is more solid than if the wound unites by primary union (Zinsmeister). H. Euringer has collected from literature sixty- eight cases of arthrodesis (in fifty patients), of which the majority were successful, and enabled the patients to dispense with the heavy, uncom- fortable, and expensive splint apparatus. CHAPTER X. OPERATIONS FOR REMEDYING DEFECTS IN THE TISSUES.--PLASTIC OPERATIONS.--TRANSPLANTATION. Plastic operations for loss of substance in the skin.—General methods of plastic sur- gery in case of loss of substance in the skin: movability of skin; liberating incisions;, formation of flaps with pedicles; implantation of entirely separated portions of skin.—Skin-grafting by the methods of Reverdin and Thiersch.— Grafts of skin or mucous membrane taken from animals.—Hair-grafting.—Plastic operations for defects in other tissues (muscles, tendons, nerves, bones). § 41. Plastic Operations for Cutaneous Defects.—If the loss of sub- stance in the tissues is so great that it cannot be remedied by simply suturing together the borders of the wound, we perform what has been called by the general name of a plastic operation, for remedying the defect or bringing about a more rapid cicatrisation. We shall first take up the operative treatment of loss of substance in the skin. These defects are either fresh and the result of an injury or an operation, or they are old or congenital, or made up of a granu- lating wound surface. For treating such defects in the skin, or for hastening cicatrisation, there are in general two principal methods: 1. The closure of the defect by traction upon the skin in the neigh- bourhood, and by the formation of a cutaneous flap, which is freed from the underlying parts in such a way that it still possesses a bridge of skin at some portion of its circumference, called a pedicle, connect- ing it with the neighbouring skin. 2. The defect is also remedied by the transplantation or implanta- tion of an entirely detached portion of skin. This latter method has been perfected by Thiersch, and is now very frequently used for plac- ing an epidermic covering over a fresh or granulating defect in the skin or mucous membrane (see page 141). The first method, in which the defect is remedied by traction on the surrounding skin and by the formation of a movable flap with a pedicle, is what is ordinarily meant by a plastic operation, but it has been largely supplanted by Thiersch's method of skin transplantation or skin grafting. Defects not only in the skin, but also in muscles, tendons nerves (134) §41.] PLASTIC OPERATIONS FOR CUTANEOUS DEFECTS. 135 and bone, can be remedied by plastic operations—i. e., by the forma- tion of flaps with pedicles or by the transplantation of portions of tissue entirely separated from their original surroundings. Modern aseptic surgery has made great advances in plastic opera- tions and in the grafting of different tissues on others. Portions of tissue, such as bone, nerve, or skin, which have been completely severed from the body, will only unite in their new position when no suppu- ration occurs, and it is consequently of the greatest importance that there should be primary union. The cutaneous defects in which plastic operations are called for are caused by injuries and by diseases of every description (wounds from freezing, burning, inflammation causing necrosis, operations for tu- mours, malformations like harelip, ectopia vesicae, etc.). Plastic opera- tions are also indicated in cicatrices causing deformity or loss of func- tion in a part. German surgeons especially—Grafe, Dieffenbach, Lang- enbeck, Konig, Thiersch, and others—have devoted themselves to ad- vancing the methods for performing plastic operations. The ancient surgeons, particularly in India, were skilled in this branch, having plenty of opportunity for performing rhinoplasty and otoplasty, on ac- count of the frequency of the form of punishment wliich consisted in cutting off the nose or ears. The Healing in Place again of a Completely Severed Portion of Tissue. —If small portions of the body, like the tips of the fingers or the nose, are completely cut off, they will sometimes reunite in their proper posi- tion by primary union if they are carefully sutured in place with every antiseptic precaution, provided the piece of tissue is not too large and not too much crushed, and the sutures are applied immediately after the receipt of the injury. AVe shall return to the subject of the reuniting of small, completely severed portions of tissue in the chapters on Injuries and the Repair of Wounds. As to the time when plastic operations should be performed, we have stated that they may be done at once on a fresh wound, immedi- ately after the termination of an operation like the removal of a cancer from the lip, or as one of the steps in operating on harelip, etc.; or, on the other hand, on a granulating surface. If the loss of substance in the skin is due to a crushing wound, we should wait until it can be defi- nitely determined how much of the crushed tissue will survive. When a granulating wound is to be covered with a cutaneous flap having a pedicle, it is best to change the granulating surface into a fresh wound by scraping or cutting off the granulation tissue, and upon this surface to engraft the skin flap. On the other hand, granulating skin flaps can be safely transplanted, for example, on to a defect in the anterior wall 136 OPERATIONS FOR REMEDYING DEFECTS IN TIIE TISSUES. of the bladder (ectopia vesicae). It has already been mentioned that in other cases we are able to perform plastic operations after actual cica- trization of the wound has taken place, or after extirpation of a scar which is unsightly or interferes with the function of a part. General Principles of Plastic Surgery.—The following is a brief state- ment of the general principles governing plastic surgery, the details of which for special plastic operations—such as rhinoplasty, cheiloplasty, the operations for ectopia vesicae, etc.—will be considered in the text- book on special surgery. It is of the greatest importance for the success of any plastic opera. tion, or for the union of a skin flap in its new bed, that the operation should be conducted with the strictest attention to asepsis. The bor- ders of the wound should be as smooth and sharply outlined as possible, the flaps should be cut of adequate size, not too small or too thin, and the subcutaneous fatty tissue should be preserved in its connection with the flap. The sutures should be of catgut or fine aseptic silk, and should be so applied that the borders of the wound are held in exact apposition. Coaptation of the Borders of the Wound and Freeing of the Skin from Underlying Parts.—The simplest way of closing a defect in the skin consists in drawing together the borders of the wound and uniting them with sutures. To render the edges of skin more movable, they can be dissected free, together with the attached subcutaneous fat, from the underlying parts. Thus cutaneous defects of the most diverse shapes, if not too large, may be easily closed, as illustrated in Fig. 108. Julius Wolff ^ laHtTH , has recently I I I I I I I b elaborated this b method of clos- Fig. 108.—Union of the borders of an area where there has been a loss of incr rlpfeots bv substance in the skin; the edges of the skin are treed from the un- & uoj.ov,i,o uj derlying parts and united by sutures: a, before inserting the su- drawing over tures; b, after inserting the sutures. to them the ad- joining skin, which has first been freed from the subjacent parts, and then suturing the edges of the skin. He has in this way closed large areas where loss of substance has occurred in skin and in bone, and has also applied it to widely opened joints. The skin is loosened for some distance around the wound, partly with the hand and partly with a probe-pointedi knife or scissors, and then brought over the wound and sutured (Berlin, klin. Wochenschr., 1890, No. 6). In other cases it is best to make use of lateral liberating incisions ; i. e., before or after inserting the sutures in the approximated margins of the wound, an incision is made parallel to and at one side of the su- §41.] PLASTIC OPERATIONS FOR CUTANEOUS DEFECTS. Fig. 109.—Lateral liberating incisions: a, before inserting the sutures; b, after inserting the sutures. ture line, in order to lessen the tension on the suture line (Fio-. 109 a). As illustrated in Fig. 109, b, the liberating incisions cause slightly gap- ing wounds after the defect has been closed, but these usually heal rapidly by aseptic granulation. In a third category of cases the skin is drawn over a defect after mak- ing one or more incisions prolonged from the limit of the original defect in any required direction, and by this means forming a kind of flap. This is only a modification of the method of closing a defect by sliding the skin over it, and does not belong to the important method of plastic surgery about to be described—namely, the formation of a flap with a ped- t.|i.nTiMMI.<;________d x, f T TTTTTT^ icle. In Figs. 110, 111, and 112 are seen examples of the application of this method. In Fig. 110, the original incision has been prolonged in the line c d, and the portion of skin a c d is thus rendered capable of being moved, c being drawn over to b, and the two borders of the defect are united with sutures, giving the result illustrated in Fig. 110, b. In the same manner, under other circum- stances, a second incision can be prolonged from the original defect at b. When the three-cornered defect is closed by sutures there results some slight puckering of the skin at the sides. Burow remedies this by ex- Fig. 110.—Incision prolonged from one corner of a triangular wound : a, before, and b, after inserting the sutures. *VI ]\\\I Fig. Ill, -Curved incision from one corner of a triangular wound : a, before; J, after inserting the sutures. cising small three-cornered portions of skin in this region. This plan of excising a triangular-shaped portion of tissue, which Burow intro- 138 OPERATIONS FOR REMEDYING DEFECTS IN THE TISSUES. duced, is at present but little used. In Fig. Ill the liberating incision c d is prolonged from the edge of the defect in a curved direction, and 'H n m n v d 111 n 11U' Fig. 112.—Prolonged incisions for uniting a four-cornered wound: a, before; b, after inserting the sutures. here also a second curved incision from b can be employed with advan- tage for closing the defect by sliding over it a portion of the adjoining skin. In Fig. 112 four lateral incisions are made for closing a quadri- lateral defect. This principle of making lateral incisions or prolonging the original incisions, followed by drawing the skin over the defect, is capable of almost endless variations. Formation of Flaps with Pedicles.—The most important method used in plastic surgery consists in fashioning flaps which have a pedicle —i. e., cutaneous flaps which remain connected with their original local- ity in the skin by means of a bridge or pedicle through which they are nourished, but throughout all the rest of their extent they are com- pletely separated from their original bed. After this has been done Fig. 113.—Formation of two lateral flaps of skin: a, before; b, after inserting the sutures. the flap is laid in the defect, as illustrated in Fig. 113, b. In Fig. 113 two lateral flaps are fashioned (Fig. 113, a) and placed in the defect (Fig. 113), so that Fig. 113, c, results when the edges of the wound are united by sutures. In Fig. 114, a c, is illustrated the method of per- forming a complete rhinoplasty. For details and other methods of performing rhinoplasty reference is made to the Special Surgery. When flaps with pedicles are used care must be taken that the blood supply is good and that primary union is obtained. The pedicle must be so situated that as many vessels as possible enter the flap; and the pedicle must not be too narrow or too thin. The flap, particularly the portion constituting the pedicle, is freed with every precaution for §41.] PLASTIC OPERATIONS FOR CUTANEOUS DEFECTS. 139 preventing its becoming too thin. Moreover, it is important that the part representing the pedicle should not be subject to too much ten- Fig. 114.—Rhino-plasty : a, freshening of the borders of the defect in the skin, and formation of the pear-shaped flap on the forehead; b, after placing the flap over the defect in the skin; c, Langenbeck's method for performing rhino-plasty. sion when the flap is implanted on the defect, for otherwise the nutri- tion might be materially impaired. Plastic surgery performed with flaps having a pedicle was the form in which it was especially used by Indian surgeons, and they probably originated it. Flaps have also been fashioned from portions of the body widely separated from the defect, as we shall see when we take up rhinoplasty. Tagliacozzi (Taliacotius, 1597), a physician of Bologna living in the sixteenth century, was the first to use a flap fashioned from the skin in the biceps region of the arm, and after placing the arm over the nasal defect and allowing the flap to heal into the latter, he cut the flap loose by dividing its pedicle (Fig. 115). This Italian method, as it is called, is only applicable to those exceptional cases in which good material for making the flap cannot be obtained in the neighbourhood of the defect. The Italian method is usually performed in three stages: (1) The forma- tion of a flap which remains attached by two pedicles; the flap is sepa- rated from the underlying parts after making two lateral incisions, and its reunion prevented by iodoform gauze or oiled silk placed under Fig. 115.—Italian method of per- forming rhino-plasty (Taglia- cozzi and Graete). HO OPERATIONS FOR REMEDYING DEFECTS IN THE TISSUES. the flap. (2) After granulation has become well established one pedicle is divided, and the flap is sutured into the defect (Fig. 115). (3) After the flap has healed into its new bed, or after eight, ten, or fourteen days, the other bridge of skin or pedicle is divided. Graefe has per- formed the Italian method in one sitting by bringing the flap directly in contact with the defect (the German method). But the nutrition of the fresh flap is often poor, and it is likewise very apt to shrink. In recent times this method of remedying defects by transplanta- tion of pedunculated flaps from distant portions of the body has been revived, and fresh flaps of this kind, taken, for example, from the tho- rax, have been transplanted to fresh and granulating defects in the Fig. 116,—The manner of remedying losses of substance at the bend of the elbow, and on the forearm by pedunculated flaps of skin from the thorax: a, pedunculated flap of skin which still remains attached to the thorax, and which has been sutured into the defect; b, after it has healed in place. arm and forearm, and have thus prevented contractures of the elbow joint after burns, avulsion of the skin, etc. (Maas, Langenbeck's Archiv, Bd. xxxi; Wagner, ibid., Bd. xxxvi, 1887, S. 381; and V. Hacker, Bd. xxxvii). Granulating Skin Flaps.—NTot only fresh but also granulating skin flaps are used, as we have seen, especially for closing congenital defects in the bladder (ectopia vesicae). (See Special Surgery.) For closing a defect in the wall of a cavity, as in ectopia vesicae, and defects in the cavity of the mouth following, for example, the removal of a cancer, Plessing has recommended the use of flaps covered with epidermis. After fashioning a skin flap with a pedicle, its wound surface is pro- vided with epidermis by Thiersch skin grafts (see p. 141), and then the graft is allowed to heal into the defect. Skin Flaps with a Pedicle of Subcutaneous Tissue—Gersuny's Meth- §42.] SKIN-GRAFTING ACCORDING TO REVERDIN AND THIERSCH. Hi od.—Gersuny was the first to show that a skin flap which possessed only a pedicle of subcutaneous tissue would receive sufficient nourish- ment to enable it to be used for plastic purposes, particularly in reme- dying defects of mucous membrane. The flap is simply turned into the defect like a door on its hinges, or it is drawn into a more deep- ly lying region through a suitably placed slit or wide button-hole. Transplantation of entirely severed Pieces of Skin.—Moreover, pieces of skin which have been entirely separated from their original bed can be implanted in defects. Wecker and others have, in the case of defects of the lower eyelid (ectropion), successfully implanted a single flap of skin which did not even possess a pedicle. This method has been long practiced by the Indian surgeons, but, in spite of even the present aseptic way of doing this, it is still a matter of uncertainty whether a portion of skin which includes the entire thickness of the cutis will heal into its new position. To Reverdin and to Thiersch especially belong the credit of having given a practical surgical im- portance to the method of transplanting portions of skin entirely severed from their original bed. § 42. Skin-grafting according to Reverdin and Thiersch.—In 1870 Reverdin used his method of epidermic or, more correctly, skin-epider- mic grafting for causing a granulating wound to skin over more rap- idly than it otherwise could, as a granulating wound, in which the corium is entirely absent, can only become covered with skin by a very gradual ingrowth of the latter from the edges. It is only possible for skin to start to grow outwards from the middle of a granulating sur- face when there still remains in this area remnants of the rete Malpighii or of the sebaceous glands. By Reverdin's skin-grafting not only is the length of time required for a wound to skin over shortened, but the subsequent cicatricial contraction is considerably diminished. The way in which Reverdin originally practiced this was very imperfect, and Thiersch was the first to develop a useful and satisfactory method of skin-grafting or skin-transplantation. The skin is applied to a fresh defect after the bleeding has been thoroughly arrested ; but if the de- fect consists of an old granulating surface the granulation tissue must be first removed with the knife or sharp spoon. Nevertheless, skin can also be transplanted on to a granulating surface, especially in the case of a granulating area of bone. Moreover, skin for transplanting purposes can be taken from a fresh cadaver before the onset of rigor mortis, and from a part which has just been amputated, etc. Thiersch's Method of Skin-grafting.—The instruments to be used are sterilised by boiling them for about five minutes in a one-per-cent. soda solution and are then placed in a sterilised six-tenths-per-cent. solution t 112 OPERATIONS FOR REMEDYING DEFECTS IN THE TISSUES. of common salt. Antiseptic solutions like bichloride of mercury and carbolic acid should not be used, as they endanger the vitality of the cells in the pieces of skin to be transplanted. The latter are taken preferably from the arm or the lower extremity, etc. The area of skin in question is thoroughly washed with sterilised soap and warm water and shaved. As large a razor as possible, or a microtome, is covered with sterilised oil, and while the skin to be cut is put on the stretch, as thin flaps as possible are shaved off from it. To secure rapid healing, the pieces of skin should be laid upon a wound from which the blood has been removed as completely as possible (Garre). The very thin- nest piece of skin thus obtained contains, besides the entire thickness of the papillary layer, a part of the underlying stroma. In this way pieces of skin ten to twelve centimetres long and two centimetres broad can be made to heal into their new position. The larger grafts are carried upon an especially broad spatula and then spread out over the defect with a probe. Great care should be taken that the edges of the piece of skin do not roll up, and the separate pieces should be placed next one another with their edges just touching. This method is particularly valuable for fresh cutaneous defects caused by opera- tions or injuries, for burns in the stage of granulation, for ulcers of the leg, for broad and deep granulating areas following operations for necrosis, etc. After removing a large, soft fibroma, I successfully cov- ered with epidermis almost the entire hairy portion of the scalp in one sitting by Thiersch's method of skin-grafting; I also made a large per- manent opening into the left pleural cavity for empyema and tuber- culosis, and changed it into a gutter by use of the same method (see Special Surgery, § 126, p. 400, Fig. 296). In short, the method is an excellent one. Thiersch has also transplanted the skin of a negro upon a white man and the skin of a white man upon a negro. The negro's skin took root on the white man with exceptional rapidity, but the attempt failed in the majority of cases in which skin was transplanted from the white man on to the negro, no matter whether a granulating or a fresh wound surface was used. It is interesting to note that the portions of white skin implanted on the negro gradually turned black, and vice versa. The histological investigations of Karg showed that the pigment does not originate in the cells of the rete Malpighii, but is brought to them by the wandering cells which come from the deeper- lying portions of tissue laden with pigment and find lodgment amongst the cells of the rete. Consequently the white skin implanted on the negro becomes gradually black, and the negro's skin implanted on the white man becomes white from ceasing to receive deposits of pigment. The pigment particles are probably identical with the cell granules g42.] SKIN-GRAFTING ACCORDING TO REVERDIN AND THIERSCH. H3 discovered by Altmann and by him called bioblasts, and are probably formed from them by the help of the blood in some unknown way. According to Jarisch, the pigment of the negro's skin lies almost en- tirely in the deeper cells of the rete Malpighii and is entirely, or almost entirely, absent from the more superficial cells. Dressings after Skin-grafting.—The dressing for an area of trans- planted skin should be one wliich does not adhere to its surface, as the pieces of skin are easily torn off when the dressing is changed. It is best to cover the grafts with strips of sterilised tin or gold foil, or rubber tissue dipped in sterilised oil, and over these to place a dressing of sterilised compresses and cotton, which is bound on with a muslin and then a gauze bandage, exerting a slight amount of pressure. Anti- septics should be left out of the dressings altogether. The strips of tin foil, etc., are disinfected by a bichloride solution (1 to 1,000) and then placed in sterilised olive oil before they are applied to the wound. Excellent results can be obtained .in this way, and very large grafts will promptly become attached, provided only olive oil and a six- tenths-per-cent. salt solution are used, and the irritation of carbolic or bichloride solutions is avoided. I have also entirely given up covering the transplanted pieces of skin with iodoform. The first dressing- should be left in place for two, three, or four days, and then removed with great care. If the grafts have " taken," the area they cover pre- sents a mosaic appearance due to the separate pieces of skin used for the grafts. Later on the borders of the separate pieces of skin become less and less marked, and occasionally become quite indistinguishable. Until the grafts have become completely attached it is best to use the dressing of sterilised olive oil, with strips of tin foil or oiled silk. The epidermis generally comes off, and is liable to give the erroneous impres- sion that the grafting has failed. Success is easily prevented by suppura- tion or bleeding. E. Fischer has made the interesting observation that those skin grafts become attached the easiest which are taken from and transplanted upon parts which have previously been rendered anaemic by the use of Esmarch's rubber bandage. Wdlfler's Transplantation of Mucous Membrane.—Wolfler (see Lan- genbeck's Archiv, Bd. xxxvii) has successfully transplanted mucous membranes taken from man and animals upon defects in various mu- cous membranes. His method is to be greeted as a new and valuable advance in the treatment of defects in mucous membrane, such as strictures and defects in the urethra, conjunctiva, cheek, etc. Ger- suny, Witzel, and others have remedied defects in mucous membranes by turning in flaps of skin possessing a pedicle of subcutaneous tissue only (see page 140). HI OPERATIONS FOR REMEDYING DEFECTS IN THE TISSUES. Implantation of Hair.—SchWenninger and Nussbaum have at- tempted to implant hair by strewing it over a granulating area where there has been a loss of skin. If the root sheath still remained at- tached to the hair, it became adherent and formed a centre from which cicatrisation proceeded, but the hair itself fell out after a few days. Hairs without their root sheath did not become attached at all. Transplantation of Skin and Mucous Membrane from Animals (Rab- bits, Frogs).—The skin and mucous membranes of animals have also been successfully transplanted upon man. The conjunctiva of a rabbit has been successfully grafted in a defect of the human eyelid. Bara- tonx and Dubousquet-Laborderie have succeeded in implanting the skins of frogs upon granulating wounds in man. The pigment disap- peared after ten days, and the graft took on more and more the appear- ance of human skin. (For the minute anatomical changes concerned in the attachment of skin grafts, see § 61, The Healing of Wounds.) § 43. Plastic Operations on other Tissues (Tendons, Nerves, Mus- cles, Bones).—Plastic operations and graftings are performed not only upon the external cutaneous surface of the body, but also upon other tissues, such as tendons, muscles, nerves, and bones. We shall refer to this in detail later on. At present the following brief account will suffice: Defects or loss of substance in a tendon can be remedied by cutting flaps with pedicles from one or both divided ends of the tendon and bending them back and uniting them by means of sutures of catgut. In the same way I was able to repair a defect in the ulnar and median nerves by cutting flaps from the divided ends of the nerves to which the flaps remain attached by a pedicle. These flaps were turned down into the defects and united by catgut sutures. The result was completely successful. (See § 88, Injuries of Nerves and the Regeneration of Nerves.) Nussbaum likewise repaired a defect in the ulna by pieces of bone covered with periosteum, the graft, which had a pedicle, being taken from the end of the bone. Entirely detached portions of tissue have also been made to heal into defects. Philippeaux, Vulpian, Gluck, and others have thus ingrafted portions of a nerve taken from a rabbit into defects caused by loss of substance in a human nerve (see § 88). In the same way attempts have been made to remedy defects in muscles and bones by ingrafting corresponding kinds of tissue taken from animals. Loss of substance in bone—for example, in the skull or after total necrosis of one of the long bones—can be remedied by implanting small pieces of cartilage or bone taken from young animals or from an infant (Macewen, Oilier, etc.). The bone fragments should be small, about ten millimetres long and four to five millimetres thick, and, to obtain the best results, §43.] PLASTIC OPERATIONS ON OTHER TISSUES. 145 should be taken from infants or young animals, and preferably from near the joints, where ossification is most active—i. e., from the neigh- bourhood of the junction of the epiphysis with the diaphysis in long bones. It goes without saying that the strictest asepsis and immo- bilisation of the extremity afterwards are indispensable (see § 101). Macewen and Poncet have remedied defects in bone resulting from total necrosis—for instance, of the humerus and the tibia—by trans- plantation repeated many times. In cases of pseudarthrosis, Oilier and others have successfully implanted large fragments of bone taken from infants or young animals. Gluck has recommended the filling of cavities and defects with foreign bodies of the most varied descrip- tion, which are left permanently in place. He inserts, for example, ivory cylinders and ivory pegs in cases where there is a loss of substance involving the entire thickness of the bone, and he also makes use of pieces of ivory to form hinge or ball-and-socket joints. The experi- ence of others in Gluck's osteoplastic and arthroplasty methods has not been published, and his own results are open to doubt. Senn, Le Dentu, and others have filled in defects in bone by means of pieces of decalcified bone. Zahn, Fischer, etc., have performed very interesting transplantation experiments with materials of the most diverse sorts, which cannot be discussed more fully at present, as they will be brought up again in connection with injuries of the bones and soft parts (see § 88 and § 101). It need only be said that living bone having as large a pedicle as possible for supplying its nutrition is the best for osteo- plastic operations (the so-called homoeplasty or autoplasty). If a piece of dead bone (ivory) is ingrafted in the wound it remains a dead body, and only fills the space it occupies for a certain length of time (het- eroplasty). 11 SECOND SECTION THE METHODS OF APPLYING SURGICAL DRESSINGS. CHAPTER I. THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS FOR WOUNDS. General principles governing the antiseptic and aseptic dressing of wounds.—History. —The typical Lister dressing; its simplification.—Antisepsis and asepsis.—The most commonly used antiseptic or aseptic dressing materials (gauze, cotton, jute, lint, wood fibre, moss, etc.).—The different antiseptics; their uses and dangers (poisoning from carbolic acid, bichloride of mercury, iodoform, etc.).—Which anti- septics are of value ?—Which antiseptic and aseptic methods of dressing are the best ?—Antiseptic and aseptic change of dressings. § 44. General Principles governing Antiseptic or Aseptic Dressings.— After learning, in the previous section, the main principles governing the modern aseptic method of performing operations, we come to the question of what dressings should be used for covering the wound, and the discussion of the methods of applying surgical dressings. It is a part of surgical technique which requires indefatigable diligence and care. A correct application of the dressings, and a carefully con- ducted after-treatment of those who have been operated upon or wounded, are matters of the greatest importance. As we are aware that all infection of the wound is caused by micro- organisms, by the omnipresent bacteria, it follows that we should con- duct the after-treatment of the wound in such a way as to preserve it from the damaging effects produced by micro-organisms, and with the same care that is used in performing an aseptic operation. The surest and simplest way of preventing subsequent infection in a clean, aseptic wound—such as one resulting from an operation—is to cover it with a germ-free dressing which has been sterilised by hot steam (see pages 13, 14). In private practice, dressings are still much used which have been impregnated with antiseptics like carbolic acid and bichloride of mercury. That method of treating a wound is the best which offers the greatest security against subsequent infection and (146) §44J GENERAL PRINCIPLES GOVERNING ANTISEPTIC DRESSINGS. 147 most readily carries off and absorbs the discharge from the wound. We operate, without exception, according to the rules of asepsis, and consequently the same preventive measures should be carried out in the after-treatment of the wound until it has become entirely healed. In- fected wounds are to be cleaned as perfectly as possible from any dirt or foreign bodies which may be present, and are best disinfected by a 1 to 1,000 solution of bichloride of mercury. Historical Remarks on the Listerian Method of treating Wounds.—The antiseptic as well as tbe aseptic occlusive dressing for wounds has advanced very gradually to its present state of perfection. Lister began the use of his antiseptic occlusive dressing at the Glasgow hospital in 18G5, and published his first communication on the subject in 18(>7. Thiersch was the first Ger- man surgeon to bring into notice Lister's antiseptic method of treating wounds, describing it in his work on the repair of wounds.* Then followed the con- tributions of Schultz and Von Lesser, who had in Edinburgh itself made them- selves familiar with Lister's methods and praised them very highly. Even before Lister's discovery, antiseptics, especially carbolic acid, had been used for dressings, but to Lister belongs the immortal honour of having conceived and intelligently carried out the antiseptic method of operating and of applying dressings by the use of which it is possible to keep fresh wounds from infec- tion. In 1872-73 the first trials were made in Germany with the Lister dress- ing. In the German Surgical Congress of 1874 Volkmann reported his expe- riences with the Lister dressing, and in 1875 he published his " Beitrage zur Chirurgie," in which were described the remarkable and hitherto unheard-of successes obtained by the use of Lister's method of operating and applying dressings. In 1874-75 the Listerian method came into general use in Ger- many, and then started on its triumphant progress over the entire civilised world. Never was surgery so radically changed for the better as after the introduction of Lister's method for the treatment of wounds. In the very hospitals where the infectious wound diseases had raged the worst during the preantiseptic period, the severest operation wounds and injuries now healed up without suppuration and without secondary disease. After such remark- able success, the opponents of the method who arose here and there were forced to give up the contest. The Original Typical Lister Dressing-.—The typical Lister dressing used at first was applied in the following manner: Tbe disinfectant was carbolic acid, used in a two-and-a-half- to three-per-cent. solution for non-infected, and in a four- to five-per-cent. solution for infected wounds. Lister covered the wound, or, rather, the suture line, with carbolic acid and paraffine spread on oiled silk, the whole being called a '' protective " for keeping the irritating substances in tbe dressings away from the wound. The protective was made of green silk cloth, painted over with shellac, and covered on one side with a mixture of one part dextrin, two parts pulverised starch, and fifteen parts of a five-per-cent. carbolic acid solution. Before using, the protective was dis- infected by a three-per-cent. carbolic solution. The green colour of the pro- * Pitha-Billroth's Handbuch der Chir., Bd. i, p. 559. 148 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. tective was changed to black by decomposition of the wound-secretion, which was a matter of practical importance for determining whether tbe wound was perfectly aseptic or not. Besides the silk protective, a cotton protective was also in use. Over the protectives Lister placed eight or more layers of dry gauze impregnated with carbolic acid, and between the two outermost layers he inserted a water-tight material made of cotton and gutta-percha (mack- intosh). The layers of carbolised gauze extended some distance beyond the limits of tbe wound, particularly when considerable discbarge was expected. Lister used carbolised gauze bandages instead of the ordinary strong muslin bandages. He impregnated them with carbolic acid in the same way as the gauze compresses used in the dressing. The typical Lister dressing was always put on and changed in the early days under the carbolic spray (see page 12). Improvements in the Original Lister Dressing.—Very soon after its intro- duction, Lister's carbolised gauze dressing was materially simplified and im- proved, particularly by German surgeons. The carbolic spray used during tbe change of the dressings was done away with, also the protective and the mackintosh. The wound is now covered only with aseptic dressings, and stress is laid upon the importance of having the secretion from the wound dry quickly in the dressing. The instruments are sterilised by boiling them for five minutes in a one-per-cent. soda solution, and bichloride of mercury 1 to 1,000-5,000 is used as tbe antiseptic for the wound. Sterilised water, or a sterilised six-tenths-per cent, solution of common salt, is frequently used for operations on such parts of the body as the peritoneal cavity, etc. (see § 6). § 45. The Most Common Antiseptic and Aseptic Dressings for Wounds.—The modern surgeon uses particularly : 1. Antiseptic solutions for cleansing the wound and for disinfect- ing the materials used in the dressings. The most suitable are three- to five-per-cent. solutions of carbolic acid, and aqueous solutions of bi- chloride of mercury (1 to 1,000-5,000). He also uses antiseptic pow- ders, such as iodoform, boric acid, salicylic acid, and naphthaline, for dusting over wounds, especially if they have the form of a cavity or are not closed by sutures, or are already suppurating or granulating. 2. Absorbent materials, such as unstarched gauze, mull, jute, pre- pared moss, wood wool, my own specially prepared wool, and cotton from which all fatty matter has been extracted. These are sterilised by subjecting them to steam heat at a temperature of 100° C. ^212° F.) in a sterilising apparatus. The dressing materials impregnated with antiseptics, like carbol- ised and bichloride gauze, were formerly in very general use; but it is simpler and better to sterilise them all by heating them as just de- scribed, at a temperature of 100° C. (212° F.), in a sterilising apparatus. Moreover, it has been proved that dressing materials impregnated with antiseptics and kept in a dry condition do not remain sterile, but after a time all sorts of bacteria have been cultivated from them (Schlange, S45.] THE MOST COMMON ANTISEPTIC AND ASEPTIC DRESSINGS. 149 Ehlers, and others). Bergmann, Schlange, and Kocher were the first to oppose the use of these kinds of dressings; and in the surgical clinic of the Berlin University and in Copenhagen (Bloch), materials for dressings were first used which had been sterilised simply by passing through them steam at a temperature of 100° C. (212° F.). The modern surgeon no longer uses for dressing wounds the mate- rial called charpie, wliich was formerly much in vogue, and consisted of bundles of thread made by pulling to pieces bits of linen cloth. This charpie has caused much harm ; it was full of dirt and wound- poisons, and, consequently, has killed many a patient by exciting suppu- ration and infectious wound diseases (erysipelas, pjaemia, septicaemia). The dressing materials are fastened in place by mull bandages which have been soaked in a three-per-cent. carbolic or 1 to 1,000 bichloride solution, and gauze bandages are applied over these. The bandages subsequently dry and cause the whole dressing to form a firm, well-fitting support. When it is necessary to immobilise an extremity, the dressing may be strengthened by adding splints of wood, metal, wire, or thin pliable wooden hoops. Of the numerous materials used for making antiseptic dressings, the following are in most common use : Mull or Gauze.—The most extensively employed material is soft, unfin- ished gauze or mull. Mull is a most excellent substance for dressings, being soft and a good absorbent, but is somewhat expensive. It is impregnated with every kind of antiseptic, particularly bichloride of mercury, carbolic acid, and iodoform, but it is best sterilised by subjecting it to steam heat at 100° C. (212° F.), as we have described. For tbe method of preparing this or that particular kind of antiseptic mull—e. g., carbolised, or bichloride, or iodo- form gauze, etc.—reference is made to the description of the various anti- septics which is given further on. Other and cheaper materials are recommended as substitutes for the more expensive mull—these are jute, moss, prepared moss, wood wool, etc. Cotton.—Cotton is not suitable for placing directly upon the wound, as it does not sufficiently absorb the secretion from the wound, and allows it to collect underneath and decompose. But after covering the wound with a good thick layer of some absorbent material, like mull or the author's pre- pared wool, it is then a good plan to use dry cotton, which has been freed from fat, as the outermost covering of the dressing. Lint.—Lint has been manufactured, especially in England, since about the beginning of the present century. In combination with antiseptic sub- stances, especially boric acid (making boric lint), it is very much used as an antiseptic material for dressings. Jute.—Jute, also called Indian hemp, consists of the woody fibres of tbe different kinds of corchorus, particularly the Corchorus capsularis, a plant growing in the East Indies and China. It is an excellent substitute for cotton. Mosengeil was the first to use it for making dressings. It very 150 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. readily absorbs the secretions from the wound. Jute is often impregnated with antiseptics, such as carbolic, salicylic acid, and bichloride of mercury, and these forms of antiseptic jute are prepared practically in the same way as the corresponding kinds of antiseptic mull or gauze (see § 46). It is best used in the shape of jute pads - that is, jute sewed up in bags of sterilised gauze. Flax, hemp, seaweed, bran, tow, bark, etc., are used for dressings in the same way as jute, and impregnated with antiseptics or sterilised by subject- ing them to steam heat at a temperature of 100° C. (212° F.). Flax.—Flax is recommended by Medwedew, Makuschina, and others. It is usually made up into small bundles, which are boiled in lye for three hours and then left to stand in the same liquid for eight to ten hours longer. After washing it five to seven times in clean water, tbe flax is dried and combed, and finally becomes a completely white, soft, and delicate material which is very absorbent, and, like jute, is used in the form of small pads. Flax is about five or six times more expensive than cotton. Peat.—Neuber recommends peat, having, by chance, observed a compound fracture of the forearm which healed perfectly under softened peat which had been applied to it. Neuber soaks the peat in a 1 to 1,000 solution of bichloride, and fills bags of fine-meshed carbolised or bichloride gauze with it. These pads, made of different sizes, are then used for dressings. One or more layers of sterilised gauze are placed upon the wound ; then a small- sized pad of peat ; and next, a larger-sized pad. Peat can be easily impreg- nated with antiseptics, such as iodoform, salicylic acid, etc., and its antiseptic properties are thus increased. Peat also readily absorbs the secretions from the wound. The peat-gauze dressing can be left in place several weeks (four to six weeks) without giving rise to any disturbance. Peat Cotton.—Eedon has made from peat a material like cotton, or rather tow, which Lucas-Champoniere considers suitable as a dressing for wounds, on account of its softness, its great power of absorption, and its cheapness. Moss.—Leisrink recommends ordinary moss as a most excellent material for dressings, combining in itself all the advantages which a dressing should possess. It is soft, has great power of absorption, and is cheap. Neuber's peat gauze is, in fact, chiefly made up of moss. The di*ied moss should be soaked in a solution of bichloride (1 to 1,000-2,000), or made aseptic by sub- jecting it to steam heat at a temperature of 100° C, and then used as a dress- ing in a dry state, packed into sterilised gauze bags. The wound is covered with two layers of gauze which have been soaked in a 1 to 1,000-3,000 solu- tion of bichloride, or else sterilised by dry heat, and over these are laid a small and then a large moss cushion. Hagedorn has also recommended moss as a most appropriate dressing. The moss should be collected from the woods, picked apart, dried, and then heated in an oven for several hours at a temperature of 105°-110° C. (221°-230° F.). The dried material is then sewed up in sterilised gauze bags, and thus used for dressings in the form of moss cushions. These make an excellent dressing for one which has to be left long in place. The different species of moss were tbe materials used for dressings in ancient times. Moss Felt.—Leisrink has recommended tablets of moss felt in the place of moss cushions. The preparation of the felt is as follows : The freshly gath- §45.] THE MOST COMMON ANTISEPTIC AND ASEPTIC DRESSINGS. 151 ered moss is pulled apart, washed, and then steeped in water, after which it is made into felt and put in a press. According to the greater or less amount of moss used, thick or thin tablets are made which consist of hard or soft felt, depending upon the pressure exerted upon the pulp. The dried felt can be sewed up in gauze bags of different sizes and shapes. Before using, these dry gauze-moss tablets are soaked in a 1 to 1,000 solution of bichloride, and squeezed dry ; or else they are sterilised by steam at a temperature of 100° C, and then applied in the form of dressings. Leisrink also uses the thick, hard tablets as a splint material in compound fractures. Hagedorn's moss pulp and moss-gauze pulp, soaked immediately before use in sterilised salt solution, water, or bichloride, are excellent materials. Wood Wool.—P. Bruns and Walcher use for dressings wood wool or wood which has been rubbed into small particles by a grindstone. This material has great powers of absorption, is light, soft, and cheap. It can be impregnated with five to ten per cent, of glycerine and 0-5 per cent, bichlo- ride, or with any other desired antiseptic ; or it can be sterilised by steam at a temperature of 100° C. The best wood for the purpose is the Pinus picea. Wood wool is packed into gauze bags, and used for dressings in the shape of wood-wool cushions. This dressing is simplified by combining with the wood fibre a twenty-per-cent. admixture of ordinary cotton wool, thus rendering the preparation of wood-wool cushions superfluous. The wood wool dressings are remarkable for their great absorptive powers, and they can be left in place upon large wounds for two to three weeks, and the secretions from the wound will become dry during this time. Moreover, if the dressings on a large wound become saturated with the secretions at the expiration of two to three days, they need not be changed, but simply re-en- forced by the addition of wood-wool cushions applied externally. P. Bruns puts on the wood-wool dressing in the following way : The wound is cov- ered first with a layer of sterilised spun glass or gauze, to prevent the dress- ing from adhering. Over this is placed a small and then a large wood-wool or wood-cotton cushion, and tbe whole is firmly secured in place by a tight bandage. Wood Fibre.— Kiimmel has recommended wood fibre for an antiseptic dressing material. It is made from pine or fir needles, and forms a dry, green substance made up of fine fibres, and having a pleasant piny odor. Wood fibre is cheap, but does not absorb so readily as other materials. Like moss, it is best to sew it up in gauze bags, and after soaking in sterilised water and squeezing dry, it can be used for surgical dressing. Sawdust.—All other woody material in a finely divided state, like wood flour and sawdust, are used like wood wool. Mikulicz considers sawdust, particularly when free of sap, a most excellent material for dressings, it being a good absorbent and inexpensive. Sawdust is used for dressings in the shape of pads or cushions, like wood wool or moss. Wood Wadding.—Ronnberg recommends wood wadding, which is a sub- stance made during the process of manufacturing paper. It is pure cellulose, or a brown, woody material in a finely divided state, which can be readily impregnated with antiseptics. Powders like iodoform or salicylic acid, etc., can be easily mixed with it. Marly Scraps.—Tolmatscbew has recommended marly scraps as an ex- 152 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. tremely cheap material for dressings. It is a product in the manufacture of marly or Scotch gauze, and consists of thready scraps made in tearing off tangled threads. Ash Cushions.—Schede and Kiimmel have used pads made of ashes. Coal ashes are freed from the admixture of coarse particles, and, to increase their absorbent power, they are moistened with a little bichloride solution (one part of the bichloride solution to twenty-five hundred parts of the ashes). They are then packed in thin cotton bags which have been previously disin- fected by a one-half-per-cent. bichloride solution (with the addition of ten per cent, of glycerine), or sterilized by heating them at a temperature of 100° C. These soft ash cushions adapt themselves very well to the surface of the body, and are excellently suited for exerting pressure. Paper Wool.—I can recommend paper wool as an excellent absorbent ma- terial, and one which forms a soft dressing, very comfortable for the patient. It is made in the manufacture of paper from cloth and is cheaper than mull. Gedeke uses bichloride paper, or filter paper which has been soaked in a two-tenths-per-cent. solution of bichloride (with five per cent, of glycerine) and then dried. Maas claims that the absorbent powers of dressings can be increased very perceptibly by the addition to them of such hygroscopic substances as glyc- erine or common salt, and thus those dressings which have but little power of absorption, such as cotton, tow, jute, etc., can be materially improved, a consideration which would be of much value, particularly during war times. Glass Wool.—Schede, Kummel, and others have recommended glass wool as a substitute for Lister's protective. Tbe very delicate fibres of spun glass form a good absorbent, can be easily purified by concentrated acids, and are stored in small bundles in a one-tenth-per-cent. solution of bichloride, from which they are taken, and after gently squeezing them are laid upon the wound in a thin layer. This material keeps the wound, or the suture line, perfectly dry and free from irritation. § 46. The Different Antiseptics.—Of the various antiseptics which are employed in the treatment of wounds and for dressing purposes, carbolic acid and bichloride of mercury are the most widely used. Carbolic acid is the antiseptic which is most intimately connected with the reform in modern surgery, and was chosen by Joseph Lister from among all the antiseptic drugs known at that time as the best adapted for carrying out his new methods. Carbolic Acid.—Carbolic acid or phenol (C6H60) was isolated by Runge, in 1834, from coal tar. It forms colourless, hygroscopic crys- tals having a pronounced caustic action, which are soluble at ordinary temperatures in fifteen parts of water, and are very poisonous to plants and animals. J. K. Wolf, in 1840, seems to have been the first to recognise the disinfecting powers of carbolic acid, and he was cer- tainly the first to use the drug for medical or surgical purposes. In the fifth and sixth decades of this century carbolic acid was used in dressings by Cruveilhier, Rigault, Maisonneuve, and others, but to Lis §46.] THE DIFFERENT ANTISEPTICS. 153 ter belongs the honour of being the first to introduce the drug into general surgical use. Preparation of Carbolised Gauze.—Carbolised gauze, which was much used at one time, is best prepared by Paul Bruns's method : Five hundred grammes of soft gauze or mull are soaked in a mixture of one thousand parts of alcohol, two hundred parts of rosin, twentv parts of castor oil, and fifty parts of carbolic acid. At the present time carbolic acid, in spite of its poisonous character, is looked upon as one of the best of the antiseptics, particularly for the further disin- fection of instruments after they have been boiled for five minutes in a one-per-cent. soda solution. It is ordinarily used in the form of a two-and-a-half- to three-per-cent. aqueous solution for cleansing a wound, disinfecting instruments, for washing out pads or sponges dur- ing an operation, for a spray, or for the hands. Gartner and Plagge have established the fact that a three-per-cent. aqueous solution of car- bolic acid will render micro-organisms entirely innocuous. The stronger five-per-cent. solution is used for wounds already infected, but alwavs with caution on account of the danger of poisoning. The five-per- cent, solution should invariably be subsequently washed away by a three-per-cent. solution. Moreover, the five-per-cent. solution is serv- iceable for disinfecting the field of operation, and for storing sponges, silk, catgut, etc. Laplace has increased the solubility and the disin- fecting power of carbolic acid In7 the addition of crude sulphuric acid ; he forms a mixture consisting of twenty-five-per-cent. crude carbolic acid with an equal amount of crude sulphuric acid of a similar strength, and after heating it allows the mixture to cool off. The same result is obtained by the addition of a two-per-cent. solution of hydrochloric acid. At present we avoid washing out a wound with a three- to five-per-cent. solution of carbolic—a practice wliich was formerly much in vogue—as we now know that it is unnecessary and even dangerous in the case of large wounds. It should always be borne in mind that carbolic acid is a powerful irritant to the tissues, and is, further- more, poisonous. Children and anaemic and cachectic individuals are particularly prone to carbolic-acid poisoning. Carbolised Glycerine.—Carbolised glycerine is an excellent disin- fectant for instruments and the hands of the operator. It consists of glycerine containing ten to twenty per cent, of carbolic acid, and is useful for disinfecting catheters, sounds, or other blunt instruments, which should in the case of abdominal operations be immersed in it for several hours. We smear the finger with five-per-cent. carbolised glycerine or carbolised vaseline for making a rectal or vaginal exami- nation. 154 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. Carbolic-Acid Poisoning.—Carbolic acid is, as has been said, poisonous, and, even when used externally, can produce dangerous symptoms which may terminate in death. I once saw a very rapidly fatal case of poisoning in a student. A friend gave bim a teaspoonful of five-per-cent. carbolic acid by mistake, and unfortunately the stomach pump was not used by the physician called in. In another similar case the patient was saved by im- mediately washing out the stomach. The symptoms of carbolic-acid poisoning are headache, dizziness, nausea. and vomiting. The change in the colour of the urine to olive green or black is an important symptom in making the diagnosis. But the intensity of the poisoning bears no constant relationship to the intensity of the discolouration of the urine. With even strikingly dark urine the patient may feel very well. The carbolic acid is found in the urine in the form of phenol-sul- phuric acid. In the most severe cases there ensue bloody diarrhoea, haemo- globinuria, and symptoms of collapse, and convulsions caused by the in- creased reflex excitability of the spinal cord (Salkowsky, Gies.); then fol- lows a marked fall of temperature, the pupils react slowly or not at all, the respiration becomes superficial, consciousness is lost, and death takes place from paralysis of the vasomotor centre in the medulla. In the case of chil- dren and weakly individuals, the external application of carbolic acid should be used with great caution. Furthermore, many apparently strong indi- viduals are very susceptible to this drug. In 1878 I lost a woman thirty- nine years old from carbolic-acid poisoning, simply as tbe result of chang- ing the dressing under the spray ten days after tbe operation (a laparotomy for fibro-myoma of the uterus). An extensive carbolic erythema over the whole body, accompanied by intestinal haemorrhage, caused the death of this patient on the twenty-second day after the operation. The post-mortem ex amiuation showed perfect union of the operation wound and exceedingly hyperaemic intestines filled with blood. In the early days of the antiseptic treatment of wounds, cases of carbolic-acid poisoning were comparatively frequent. Billroth, Kiister, and Kocher were the first to point out the dangers in- volved in its external use. Clinically two distinct forms of phenol poison- ing are recognised—acute carbolic-acid poisoning, and the chronic, which takes the form of a marasmus (Falkson, Czerny, Kiister). The chronic poi- soning is characterised by headache, hiccough, debility, and loss of appetite- symptoms which were of frequent occurrence among surgeons who operated very much under the carbolic spray. Falkson assisted at an operation for two and a half hours where a two-per-cent. carbolic spray was used, and in the following twenty-four hours he found 2"06 grammes of carbolic acid in his urine, an amount fourteen times greater than the maximum dose of 0*15 gramme allowed by the Pharmacopoeia. Detection of Carbolic Acid in the Urine.—Millon's reagent (a solution of mercury in ordinary fuming nitric acid) and bromine water give a very useful reaction with carbolic acid after the urine has been previously acidu- lated with hydrochloric or sulphuric acid and then distilled. Carbolic urine assumes a violet colour upon tbe addition of chloride of iron, and if warmed with Millon's reagent it takes on a purplish-red colour, or with hypochlorite of sodium a dark-brown colour ; if treated with bromine water a precipitate 46.] THE DIFFERENT ANTISEPTICS. 155 of tribromopbenol results. A very good reaction for phenol is produced by a hydrochloric-acid solution (hydrochloric acid fifty centimetres, distilled water fifty centimetres, and calcium chloride 0"20 gramme) and a pine stick (Hoppe-Seyler, Tommasi). Tommasi describes it as follows : Equal quantities of urine and ether are shaken together, the supernatant liquid is then decanted and the piece of stick is soaked in it until saturated, when it is plunged quickly into the hydrochloric-acid solution and finally exposed to the sunlight. Tbe ensuing reaction consists in a blue colouration of the stick; but if carbolic acid was not present in the urine there will be no change in colour, or at the most a slight change to a faint green colour. This reaction will enable the slightest trace of carbolic acid to be recognised in urine or water. If the stick is exposed to the sunlight too long, the colour eventually disappears. The Presence of Carbolic Acid in the DiiFerent Organs after Poisoning.— Hoppe-Seyler has measured amounts of phenol contained in the separate or- gans after phenol poisoning, and he has found that the brain and kidneys hold more than the others, consequently investigation should be first directed to these organs in cases of suspected carbolic-acid poisoning. Treatment of Carbolic-Acid Poisoning.—The treatment of poisoning from this drug consists in stopping its use immediately—for example, by removing the carbolic dressing. Sonnenburg has recommended the internal admin- istration of Glauber's salts (sodium sulphate) to hasten its excretion through the kidneys in the form of the innocuous sulpho-carbolate of sodium. The sulphate of sodium should be given in large doses by the mouth or rectum, though its efficacy is somewhat doubtful. The rest of the treatment is symp- tomatic—i. e., the symptoms are treated as they arise, and stimulants and large amounts of water are given internally. If the poisoning is produced by swallowing carbolic acid, the stomach-pump should be used immediately. Bichloride of Mercury (corrosive sublimate, HgCla, Hydrargyrum bichloratum corrosivum) is one of the oldest drugs, and, according to Pearson, was known to the Chinese, who have made it from cinnabar from time immemorial. Paracelsus was the first to use it internally, but as an application to wounds it was first recommended by Bergmann and Schede, after Billroth, Buchholz, and R. Koch had found out and made known its excellent antiseptic properties. R. Koch showed that bichloride of mercury, even in the dilution of 1 to 330,000, completely arrested the growth of anthrax bacilli, and in a solution of a strength of 1 to 1,000-5,000 almost instantly killed the anthrax spores. As the bichloride is the most poisonous of all the salts of mercury, it was natu- ral that many surgeons at first would have nothing to do with it in the treatment of wounds. But now it is a great favourite among surgeons, and is almost always used for disinfecting the field of operation, the hands, and the wound, in aqueous solutions varying from 1 to 1,000- 5,000. Besides the positive antiseptic power of bichloride it has the advantage of being much cheaper than carbolic acid. I use a one-fifth- 156 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. per-cent. solution of bichloride for the storage of silk (after boiling it half an hour in a one-fifth-per-cent. bichloride solution) and of catgut which has been sterilised by the method already described. Bichloride is unsuitable for the disinfection of instruments, as we have seen, and for these I use a three-per-cent. solution of carbolic acid. Schede and I both use a one-tenth- to a one-twentieth-per-cent. solution of bichloride when we wish a powerful disinfectant, and a one-fiftieth-per-cent. solu- tion when a weak one. Stability of Bichloride Solutions.—If ordinary water, which has not been distilled, is used for making bichloride solutions, an insoluble compound of mercury will separate after a time, which, according to Furbringer, is a trioxychloride, or a dioxychloride, or a tetraoxychlo- ride, and is thrown down by the alkaline carbonates in the water. For preventing this precipitation of the bichloride wliich occurs in ordinary spring water, Furbringer recommends the addition of acids (salicylic, hydrochloric, and acetic acids, 0*5 to 1 gramme per litre); Laplace recommends tartaric acid (one part bichloride, five parts tartaric acid); while Bergmann and Angerer recommend common salt (one gramme sodium chloride to one gramme bichloride of mercury). These acid and common-salt solutions of bichloride of mercury are exceedingly good on account of their great stability, and are always to be pre- ferred to plain bichloride solutions. The bichloride tablets contain- ing bichloride and ordinary salt, and recommended by Angerer, are very useful for private and military practice. They consist of either one gramme or half a gramme of bichloride of mercury and chloride of sodium. Schillinger, Furbringer, and Y. Meyer have demonstrated that the stability of a bichloride solution depends especially upon whether the vessel in which it is contained is air-tight or not, and also upon the amount of exposure to light, as light and air tend to weaken the strength of the solution. Preparation of Bichloride Gauze.—Bichloride gauze, which has been used much more in the past than it is now, is made by saturating gauze with a mixture of ten parts of bichloride of mercury, five hundred parts of glycerine, ten hundred parts of alcohol, and fifteen hundred parts of water. This makes a mixture which is sufficient to saturate about sixty to seventy metres of gauze, which should be dipped into it and then dried. Ordinarily gauze containing one third per cent, of bichloride answers sufficiently the purposes of an antiseptic dressing. Cotton, jute, etc., can also be impregnated with bichloride in the same way. Instead of using dressings which have been impregnated with bichloride of mercury, we now employ materials which have been sterilised by steam heat at a temperature of 100° C, because it has been 46.] THE DIFFERENT ANTISEPTICS. 157 proved that dressings impregnated with antiseptics are, after a time, no longer sterile but contain bacteria (Laplace, Schlange, etc.). Bichloride Poisoning.—As we have previously remarked, bichloride of mercury is a dangerous poison, and must be used with very great caution, especially in the case of children and sickly individuals. The symptoms of poisoning manifested after the external exhibition of the drug consist in a feeling of dizziness, restlessness, general malaise, vomiting, salivation, ulcerative stomatitis of the gums, and toward the last there is a bloody diarrhoea and occasionally bleeding from the mouth and nose. The urine contains mercury and albumen. Locally, when the bichloride dressing has been applied, there is sometimes an eczema, with persistent itching and burning of the skin, particularly if the dressings have been put on too wet, and this should therefore be avoided. It is necessary, moreover, to use bichloride of mercury care- fully in the interests of the physician and of the assistants. Even then they will occasionally show signs of poisoning in the form of saliva- tion and inflammation of the gums, or mercury and albumen will be present in the urine. I have never yet seen dangerous symptoms of poisoning occur in patients whom 1 have treated myself, and only now and then slight stomatitis and eczema. Since asepsis has taken the place of antisepsis in operations, and we have limited the use of bichlo- ride, the cases of poisoning from this drug, like those from carbolic acid, have become much less common. One should operate as "' dry " as possible, and avoid irrigating and washing out the wound with bi- chloride solutions whenever this can be done, and use only dressings which have been sterilised by steam, etc. Operations in the thorax, peritoneal cavity, rectum, and vagina must be conducted with very great care as regards the use of bichloride, and the latter should not be employed for washing out the pleural cavity after an operation for empyema, nor for irrigating the uterus or rectum, etc. Bichloride Poisoning from very small Amounts of Bichloride.—Fatal cases of bichloride poisoning are sometimes caused by very small amounts of the salt. Thus Mikulicz lost a female patient fifty-six years old who otherwise was apparently sound, after amputating the breast and clearing the carci- nomatous glands out of the axilla. In this case the bichloride was only used in the dressings, which consisted of sawdust cushions containing one per cent, of bichloride of mercury. There was a severe dermatitis, followed after the second day by restlessness, vomiting, a thin, bloody diarrhoea, and bleeding from the nose and mouth accompanied by inflammation of tbe gums (gingivitis). No mercury was detected in the urine. Stadfeldt also lost a primipara twenty-three years old, from washing out the interior of the uterus with a 1 to 1,500 solution of bicldoride, which was done for fever occurring five clays after confinement. After about three hundred grammes 158 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. had been used the patient complained of headache and pain in the hypogas- trium. Two hours afterwards there was sweating, weakness, and vertigo, followed a few hours later by bloody diarrhoea, albumen in the urine, vomit- ing, ulceration of the tongue, etc. There was no abdominal pain. On the fourth day there was complete anuria and cyanosis, followed on the fifth day by death. The post mortem showed marked swelling of the cortex of both kidneys, ulcerations in the colon with a very hypersemic mucous mem- brane, and similar lesions in the small intestine. Microscopically the epi- thelium in the convoluted tubules of the kidneys was granular and swollen, and in many places showed marked fatty degeneration, and there were nu- merous hyaline casts. Similar lesions, though less pronounced, were found in the straight tubules. The spleen was small, tbe liver normal, and mer- cury was present in all the organs (liver, kidneys, brain;. Treatment of Bichloride Poisoning.—The treatment of poisoning by bichloride of mercury consists in immediately stopping its use; the rest is symptomatic—i. e., treatment of symptoms as they arise. Salicylic Acid.—Salicylic acid (CtHbOs) exists in the form of small needle- shaped crystals, which are odourless, and only slightly soluble in cold water (1 to 300-400), but readily soluble in hot water, alcohol, ether, or glycerine. Salicylic acid is not volatile like carbolic acid, from which it is made syn- thetically by treating carbolate of sodium with carbonic acid gas at a tem- perature of 150° C. By the absorption of carbonic acid the basic sodium salt of salicylic acid results, and the former treated with hydrochloric acid produces salicylic acid. Kolbe was the first to make salicylic acid in this way, and Thiersch then introduced it into surgery. Aside from its internal administration, salicylic acid is extensively used in surgery as a dusting powder for wounds (Schmidt), in solution (1 to 300) for the disinfection of wounds, and particularly for con- tinuous irrigation, and in disinfecting ointments (one part acid salicyl., six parts cera alba, twelve parts paraffme, twelve parts almond oil). As salicylic acid is not so poisonous as carbolic acid, it forms an excellent substitute for the latter in cases where there is reason to fear the use of carbolic or bichlo- ride. Salicylic acid should be used with caution as a dusting powder for wounds which are liable to absorb large quantities of it, since fatal poisoning has thus been produced. Schmidt saw two cases of death wdiere the powder had been employed very freely, and though death was not to be ascribed to the effects of salicylic acid alone, it nevertheless had certainly contributed towards the fatal termination. Boro-Salicylic Solution.—Bose has made the very practical suggestion of adding borax to the salicylic solutions, thus increasing the solubility of the salicylic acid without decreasing the effectiveness of its action. A very ex- cellent solution for the antiseptic irrigation of wounds consists of one part salicylic acid, six parts of borax, and five hundred of water—cotton and jute impregnated with three and ten per cent, of salicylic acid were formerly much in vogue, but at present they are being employed less and less, like all other materials saturated with antiseptics and used for dressings. Acetate of Aluminium—Acetate of aluminium, like all the salts of acetic S46.J THE DIFFERENT ANTISEPTICS. 159 acid, is a very good antiseptic (Pinner) ; Burow, senior (1857), was the first to use it with success. He prepared the substance from a mixture of eio-ht parts acetate of lead, five parts alum, and sixty-four parts water, the acetate of lead being slowly added to the cold alum solution. This precipitated sul- phate of lead, leaving the acetate of aluminium, though not chemically pure, in solution. The solution should then be filtered. Since his time acetate of aluminium has been used as an antiseptic with the best results by a great many surgeons, especially for continuous irrigation of wounds and for satu- rating wTet dressings (H. Maas). For continuous irrigation a one-half- to one- per-cent. aqueous solution is the best. Aceto-tartrate of Aluminium is an easily soluble double salt having a strong antiseptic action, and has been recommended by Schede and Kiimmel as an antiseptic in a one-half- to three-per-cent. solution for external antiseptic applications, and in a three- to five-per-cent. aqueous solution for the disin- fection of wounds, especially in cases where carbolic acid cannot be used on account of its poisonous properties. Thymol, a non-poisonous substance, is the active pinnciple of oil of thyme, which is obtained from various species of thyme, particularly tbe thymus vulgaris. In 1719, Neumann isolated from oil of thyme a crystalline, cam- phor-like body which he called thymol. The crystals are sparingly soluble in water, but readily soluble in alcohol and ether. Thymol has been recom- mended by Bouillon, Paquel, Ranke, and others as a suitable antiseptic for applying to wounds. Thymol is used in an aqueous solution in tbe strength of 1 to 1,000, con- taining, in addition to the water, ten parts of alcohol and twenty of glycerine to prevent the precipitation of the thymol. This solution can be used for the disinfection of instruments, sponges, hands, and particularly of the wound. Thymol gauze is prepared by mixing together sixteen parts of thymol, fifty parts of resin, five hundred parts of wax, and one thousand of gauze. Chloride of Zinc.—Chloride of zinc has been much used by Campbell, De Morgan, and Billroth, and lately by Kocher, for antiseptic dressiugs and for disinfecting wounds. Tbe experiences of different authors with the drug vary very much. Billroth thinks that only caustic solutions of chloride of zinc are of antiseptic value ; but Kocher, after a great many experiments, has reached the conclusion that even very weak solutions (2 or 2\ to 1,000) in dressings are sufficient for maintaining a wound aseptic ; other surgeons use chloride of zinc solutions in the strength of 1-3 to 100. In 1879. Bardeleben recommended dressings which were first soaked in such a solution and then dried before being applied ; thus, jute was saturated with a five- and ten-per- cent, solution of chloride of zinc and allowed to dry. But it has not come into anything like universal use in the treatment of wounds, and is chiefly employed as a caustic in about an eight- to ten-per-cent. solution to cleanse fistulous tracts, foul ulcers, etc. Boric Acid.—Boric acid (HsBOs) exists in the form of flat crystals, which are only slightly soluble in cold water (1 to 30), but readily soluble in hot water and in alcohol. It is usually employed in a two- to three-per-cent. solution, though for irrigation of wounds aqueous solutions of a strength of 5-10 to 100 may be employed. Boric acid is much used in the form of Lis- ter's boric lint, a dressing which is non-irritant and yet strongly antiseptic ; 160 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. it contains equal parts by weight of boric acid and lint, and is applied to the wound in a dry or wet state. Boric lint is very simply prepared by soaking lint in a hot concentrated boric-acid solution ; it is then allowed to dry, caus- ing the boric acid to adhere firmly to the lint in the form of crystals. Boric Ointment.—An excellent ointment is made with boric acid consist- ing of three parts boric acid, five parts vaseline, ten parts paraffine ; or three parts boric acid, four parts cera alba, and twenty parts olive oil. A simpler and more stable mixture is one of twenty parts of boric acid with one hun- dred parts of vaseline or ungt. glycerini (known as glyceritum boroglycerini). As a general thing boric acid is a mild antiseptic, but if used too freely it may not be devoid of danger. Molodenow used a five-per-cent. solution very freely for washing out the pleural cavity in one patient and a lumbar abscess in another, and in both cases uncontrollable vomiting resulted, followed by erythema of the face, and death from cardiac paralysis. He used an excess- ive amount (15 kilogrammes) of a five-per-cent. solution, continuing the irri- gation for as much as an hour. Aseptin.—The so-called aseptin used in Sweden is a mixture of two parts boric acid, one part alum, and eighteen parts of water ; it is less irritating than carbolic acid, is not poisonous, and has no unpleasant odour. Tetraboride of Sodium.—The tetraboride of sodium (Jaenicke) is more soluble and effective than boric acid, and on account of its non-irritant and non-poisonous character can be used in a fifteen- to seventy-per-cent. solution. Bismuth.—Bismuth (subnitrate of bismuth) is a white, crystalline powder of an acid reaction, which is only slightly soluble in water, and is recom- mended by Kocher for treating wounds and for antiseptic dressings. Its antiseptic properties had been already praised by Cloquet, Velpeau, etc. Bismuth lessens the secretion from a wound very perceptibly, but it is not an innocuous substance, as symptoms of poisoning have been produced when used in strong mixtures (ten per cent.) or in large amounts; these are acute stomatitis with marked swelling of the gums, tongue, and throat, and a dark discolouration of the edges of the gums, as in lead poisoning, diarrhoea, nephritis accompanied by albuminuria, and, finally, dark-coloured urine. On account of the possibility of poisoning, Kocher uses only a one-percent. bismuth mixture. When inflammatory processes develop about a fistulous tract I have found it a good practice, after first scraping out the fistula with a sharp spoon, to irrigate it thoroughly with a five-per-cent. bismuth mixture. Iodoform.—Iodoform (CHI3) is a bright yellow crystalline powder, almost insoluble in water, acids, and alkalies, but readily soluble in ether, chloroform, alcohol, volatile oils, and fats. About 2*5 to 3 grammes of iodoform are soluble in one hundred grammes of olive oil. It was first introduced in 1S53, and since 1860 has been highly recommended as a dressing for wounds, particularly in syphilitic cases; but to Moleschott, and especially to Mosetig-Moorhof, belong the honour of introducing iodoform, in 1880, into general surgical use, and thus enriching our methods of dressing wounds by a most valuable remedy. There is scarcely a material which is so extensively employed and § 40.] THE DIFFERENT ANTISEPTICS. 161 wliich gives such general satisfaction as iodoform. But the enthusiasm for iodoform waned somewhat when cases of poisoning terminating fatally had been recorded. I also, I am sorry to say, have had two cases of fatal iodoform poisoning following an extirpation of a goitre and removal of a carcinomatous larynx. Many surgeons then went to the opposite extreme, and expressed the hope that iodoform would disappear as soon as possible from all use in medicine on account of its very poisonous character. At present wre always employ iodo- form with great care, particularly if the patient is aged or anaemic or cachectic, or is a child, or has a diseased heart or kidneys. But even perfectly sound individuals may have an idiosyncrasy as regards iodoform, and very small amounts may produce symptoms of poi- soning. I very seldom use iodoform as a dusting powder for fresh wounds, and then only in small amounts. It should be applied by a brush or by a pulverising apparatus, or blown over the wound, or dusted over it through a piece of gauze, so that the surface in ques- tion is only lightly covered with iodoform. I consider it unnecessary to dust iodoform over a wound wliich has been sutured. It is very useful in injuries and operations affecting the nose, throat, mouth, vagina, and rectum, for syphilitic and tubercular ulcers, and for many cases of compound fracture. P. Bruns and myself have obtained ex- cellent results from the injection of a ten-per-cent. iodoform mixture in glycerine or oil, in cases of bone and joint tuberculosis and in cold (tubercular) abscesses. The drug has a marked antitubercular power, as proved by P. Bruns, ISauwerck, and B. Tilanus. Senger recommends the addition of formic acid to iodoform to increase the efficacy of the latter. The proportions are as follows: Iodoform 2'0, glycerine 20"0, sodium formate 0*5 to 1'5 (for adults, 3-0). According to Senger, iodo- form only derives its power from the formic and hydriodic acids and other decomposition products of iodoform set free by oxidation within the body. Iodoform gauze is exceedingly useful, consisting of iodo- form 50, ether 250, alcohol 750, and gauze 500 parts ; or iodoform 50, resin 20, glycerine 5, and alcohol 1,000 parts. It is particularly valu- able for packing cavities, but must be used with great care in the class of individuals mentioned above, as I have seen symptoms of poisoning after the use of iodoform gauze alone—for example, after extirpation of the rectum ; and particular care must be taken not to exert too much pressure in the bandages applied over a wound which has been packed with this gauze. Billroth's sticky iodoform gauze is best suited for cavities where mucous membrane exists, because it adheres firmly to the surface of the wound. It is made by wringing out six metres of gauze or mull in a solution consisting of 100 grammes of resin, 50 12 162 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. grammes of glycerine, and 1,200 grammes of alcohol (95 per cent.), and after the gauze has dried, 230 grammes of iodoform are rubbed into it. Iodoform Wicks.—Gersuny uses an iodoform wick instead of iodo- form gauze, and prepares it in the same wTay as the latter, which has the disadvantage of having many loose threads along its cut edge, which may be left in the wound and retard healing. The strand of wick is also more easily conducted out of the wound through an open- ing in the skin. An attempt may be made to conceal the very sharp, saffron-like odour of iodoform by the addition of tincture of musk, bergamot oil, tonka bean, or powdered coffee. The coarse crystal- line substance should always be employed, and not the fine powder. The iodoform dressing should be left in place, according to the nature of the case, from two to four to eight to fourteen days. Though iodo- form, particularly during the first years of its use, produced not in- frequently fatal intoxications, it has seldom been the cause of any poi- sonous symptoms worth mentioning since we have learned the necessity of using it with caution. Iodoform Drainage Tubes.—The impregnation of drainage tubes with iodoform has been recommended ; they are soaked for about an hour in a concentrated solution of iodoform in ether and then allowed to dry. Iodo- form is much used in the form of iodoform collodion (1 to 10), which is used in place of the ordinary sticking plaster. Sticks of iodoform gelatine are now used for fistula?, chronic gonorrhoea, and similar troubles. Mosetig recom- mends a fifty-per-cent. iodoform glycerine injection for goitre and for soft hyperplastic lymphomata. Iodoform sticks are prepared in the following way : Iodoform ten parts, gum arabic, glycerine, and pure starch each one part. This mass is then rolled into slender rods or sticks. They can be more simply made by mixing together one part of iodoform and two parts of cocoa butter. We shall return to this subject later on in its proper place. Effect of Iodoform upon Bacteria.—Kronecker, Heyn, Rovsing, and others, showed that the streptococcus and staphylococcus pyogenes aureus, as well as other bacteria, may live a week in iodoform powder unharmed, and that therefore [iodoform must be disinfected before it is used. But if we must admit that iodoform has no direct influence over tbe bacteria, we neverthe- less know that it renders harmless the ptomaines (toxine) of various bacteria, or rather that it decomposes the ptomaines into harmless compounds (De Ruyter, Behring). Neisser showed that iodoform is decomposed by bacteria, and that it then has an antiseptic action. Of these decomposition products free iodine and hydriodic acid are tbe most important. The more pronounced the putrefaction and decomposition in a wound, the more pronounced be- comes the antibacterial action of iodoform (Neisser). E. di Mattei and A. Scala also insist that iodoform and iodol only act through decomposition and the setting free of nascent iodine. Iodoform is. strictly speaking, not an antiseptic, as Schnirer has shown, but it still remains a valuable drug when combined with some antiseptic, on account of the power it possesses of dimin- 46.] THE DIFFERENT ANTISEPTICS. 163 ishing both pain and the secretion from a wound. According to De Ruyter the iodoform-ether-alcohol solution (1 to 2 to 8) is an excellent antiseptic. C. B. Tilanus has demonstrated that iodoform prevents, or at least checks, the development of tubercle bacilli, and even has a tendency to destroy them, though slowly and in no very active manner. Iodoform Poisoning.—Schede, Konig, Czerny, Kocher and others, have described the sy/nptoms of iodoform poisoning as usually taking the form of cardiac and cerebral disturbances, particularly in the more severe cases. Cardiac symptoms are usually the first to make their appearance. The milder cases of poisoning are characterized by a rapid, irregular, small pulse; by digestive and slight nervous disturb- ances, such as anorexia, nausea, and finally vomiting ; by headache, gen- eral malaise, sleeplessness, a depressed frame of mind, etc. In the more severe cases of iodoform poisoning the symptoms may correspond to either one of the two following descriptions, in wliich we agree with Konig: (a) The pulse suddenly becomes rapid and small; there is sleepless- ness, great restlessness, delirium, hallucinations, maniacal excitement, and melancholia, with refusal to take food. These symptoms of men- tal aberration can be quickly checked by removing the iodoform dress- ing, but they may be prolonged for weeks even after the iodoform has been stopped. Some of these cases terminate fatally from cardiac and respiratory paralysis. (b) After a brief period of excitement there follows a general paralysis of the central nervous system, giving the picture of a severe meningo-encephalitis (loss of consciousness, deep sleep, coma, involun- tary discharge of urine and faeces, accompanied by great muscular re- laxation). This is the more severe form, and nearly always terminates fatally. Occasionally there is observed a papular or, more commonly, an urticaria-like eruption on the skin. Observations upon the occur- rence of fever vary. Schede has seen it often, others (Konig, Kocher, and myself) have noticed it less frequently. The pulse is regularly greatly accelerated. The length of time that may elapse between the application of the iodoform dressing and the first symptoms of poison- ing varies very much. Sometimes marked symptoms come on during the very day of the operation ; in other cases three to five to six days, or even fourteen days, pass before they make their appearance. Iodoform poisoning is generally acute, but sometimes it takes a chronic or sub- acute course, and the symptoms may persist several weeks, although the drug is suspended at the very first appearance of intoxication. Miku- licz saw one case terminate fatally after the expiration of twenty-nine 164 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. days. Konig's statistics seem to show that, of all the cases of poison- ing that he could collect up to the present time, the greater number were in individuals advanced in years. Of thirteen severe and fatal cases, nine were in people over fifty years of age. In old people the strength of all the organs, particularly the heart and kidneys, is im- paired, and these organs in consequence succumb more readily to the influence of poisons. According to Konig, children are the least sus- ceptible to this danger. Explanation of Iodoform Poisoning.—To explain iodoform poisoning we must, of course, know in what form iodoform enters the body and in what form it is excreted. At the point where it comes in contact with the tissues iodine is split off and is absorbed into the blood as an alkaline iodide and an albuminate of iodine (Hogyes, Zeller, Harnack). The albuminate of iodine decomposes in the system, forming organic substances containing iodine, which are excreted in the urine together with the alkaline iodides. Ac- cording to Harnack and Ludwig, the general symptoms of iodine poisoning are, in fact, chiefly produced by the iodine in the form of an albuminate of iodine, or by the organic compounds of iodine. It is well known that the alkaline iodides can be introduced into the system in very large amounts without causing the general symptoms of iodine poisoning. Zeller claims that only a fractional part of the iodine is excreted in the urine and faeces while the rest remains in the system; and thus he explains how iodoform poisoning may sometimes first make its appearance after the expiration of two to three weeks. If iodine is already present in the system, iodine poison- ing is the more liable to occur when iodoform is applied externally at the same time. If this substance is then employed in too large amounts, and circumstances favour its absorption, and if there is diminished excretion of iodine on account of disease of the kidneys or heart, while the blood is both qualitatively and quantitatively deficient, under such circumstances poison- ing is apt to make its appearance rapidly and to run an acute course, termi- nating in death. As a means of preventing to a certain degree this general poisoning of the whole system, Harnack takes the precaution of applying with the iodoform some harmless alkali in the locality where the former is used, so as to favour the formation of an alkaline iodide from the free iodine which is split off from the iodoform. From the reasons just given it is plain how iodoform poisoning is pro- duced by dressings which exert pressure, or by those which, together with the iodoform, are frequently renewed, and especially by the use of large amounts of the substance when the kidneys are healthy, or small amounts when they are diseased. Mosetig-Moorhof, in his large experience, has never seen a single case of iodoform poisoning, attributing it to the fact that he never uses iodoform except in small amounts, never applies dress- ings in which it exists so as to exert pressure, and changes them as infre- quently as possible and without irrigation of the surface of the wound. He also considers it dangerous to use carbolic acid simultaneously with iodoform in dressings, because the carbolic acid may produce an inflam- mation of the kidneys amounting to an actual nephritis (nephritis carbolica), £46.] THE DIFFERENT ANTISEPTICS 165 and thus retard the excretion by the urine of the iodoform which has been absorbed, or, in other words, cause it to be retained in the blood. These statements of Mosetig-Moorhof are confirmed by the experiments of Holger Mygind, who found that in all cases in which iodoform and carbolic acid were used together the iodine reaction was given in the urine rather later than usual, the longest time necessary for it to appear being twenty-seven hours after ingestion, the shortest four hours, or the iodine was detected in the urine only after all traces of carbolic acid had vanished. Moreover, Holger Mygind claims that the albuminuria that appears during the use of iodoform is only produced by the simultaneous use of carbolic acid. It is of some practical value to note that the excretion of iodine is continued for a considerable length of time after tbe use of iodoform has been suspended ; for instance, one gramme of iodoform gave rise to a reaction for iodine for twenty-two days, and fifteen grammes gave the iodine reaction in the urine for thirty-eight days, etc. The size of the wound has a great influence upon the rapidity of the absorption of iodoform. Granulating wounds absorb it more quickly than fresh wounds, and wounds in which fat is abundant take it up very rapidly. According to Binz, the iodoform is dissolved by the small particles of fat. As we have before remarked, iodoform produces marked cerebral and cardiac disturbances, having a narcotic effect upon animals (dogs and cats), and causing death by paralysis of the heart and respiration (Binz, Hagyer). Aschenbrandt brought about a fatal pneumonia by causing animals to inhale iodoform vapour. The post-mortem examination in these cases revealed ad- vanced fatty degeneration of the heart, liver, and kidneys. Post-mortem examinations of the human subject dying from iodoform poisoning reveal a similar fatty degeneration of these organs, and in addition either no change in the brain or an oedema of the pia mater. Treatment of Iodoform Poisoning.-—Besides the immediate removal of the iodoform dressing, the treatment of iodoform poisoning is purely symptomatic. In the worst cases no treatment has proved of any avail. Very alarming symptoms are apt to make their ap- pearance suddenly without any prodromata. It is impossible to state the smallest amount of iodoform which may be used with impunity, as the dosage varies for each individual and depends on all the circum- stances above enumerated. One gramme of iodoform has been known to produce a transient delirium ; and Seeligmuller observed melancholia with hallucinations thirty days after the administration of six grammes of iodoform ; and five grammes caused the death of one of his cases, a woman thirty-six years of age. I lost one case in which a goitre was removed, and another in which a carcinomatous larynx was extir- pated, in each of which cases I employed about five grammes of the powdered drug together with the iodoform in the iodoform gauze used for packing the wound. In still another case, a strong man fifty years of age, I saw alarming symptoms follow a simple dusting of the suture 166 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. line which remained at the termination of the laparotomy, with four to six grammes of iodoform ; stupor, great restlessness, maniacal excite- ment, rapid, small pulse, etc., were present, but after four weeks com- plete recovery took place. Of course the dressings were removed at the very first appearance of the symptoms. The poisoning was doubt- less caused by the excessive sweating to which the patient was subject during the hot days in July. In general, five to ten grammes of iodo- form will produce no marked disturbances in patients between twenty and forty years of age who are otherwise healthy. The fine powder seems to be more readily absorbed and is therefore more dangerous than the coarse crystalline substance (Guterbock). Not infrequently, however, thirty to forty to eighty grammes of iodoform, and even more, have been employed. It is not to be wondered at that fatal poi- soning followed in some cases the use of such large amounts. Detection of Iodine in the Urine.—For detecting iodine in the urine there are the following four methods : 1. The fluid to be tested is mixed with a little starch paste, dilute sul- phuric acid, and a drop of fuming nitric acid, after which there results a bluish colour, which may change into dark blue according to the amount of iodine present. This colour disappears on warming the mixture, and re- appears when it has cooled off again. 2. The fluid is mixed with dilute sulphuric acid and a drop of fuming nitric acid, and then shaken with chloroform, in which the iodine is soluble, producing a violet colour. Chloride of lime can be used instead of the nitric acid, and bisulphide of carbon instead of chloroform. 3. Upon the addition of equal parts of oleum terebinthinae and guaiacol to an equal amount of urine there results a deep-blue colour if iodine is present. 4. To the fluid is added a little starch paste, dilute sulphuric acid, fuming nitric acid, and a few drops of bisulphide of carbon. Tbe fluid assumes a blue colour, and, if shaken, a part of the iodine is taken up by the bisulphide of carbon, producing a violet colour, and where the bisulphide of carbon touches the rest of the fluid a dark-blue ring of the iodide of starch gradually develops. According to Harnack, this last test is the most delicate; but all these re- actions are directly dependent upon the presence of iodine in the urine in the form of an alkaline iodide (iodide of sodium, etc.). He claims that iodine derived from the external use of iodoform occurs in the urine not only as an alkaline iodide, but also as a compound with organic substances, and in the latter state does not give the above reactions. Harnack noticed in two cases that tbe test for iodine in the urine was negative; but if the urine was evaporated and the residue burned, the ashes gave a very plain iodine re- action. His method is as follows : The urine is rendered alkaline by the addition of sodium somewhat in excess, and evaporated in a platinum crucible in which the residue is then burned by heating the crucible red-hot. The carbonised ash is then re- g46.] TnE DIFFERENT ANTISEPTICS. 167 peatedly treated with hot water and the resulting extracts are filtered. To the filtrate is then added a few drops of dilute starch paste and fuming nitric acid, together with a few drops of bisulphide of carbon. When the solution is acidulated with dilute sulphuric acid the presence of iodine is in- dicated by a blue colour ; when shaken, tbe bisulphide of carbon lying at the bottom takes on a violet tint, and just above it there forms a dark-blue rino- of the iodide of starch. To recognise the difference between the intensity of the reaction obtained from the ash and from the urine, tbe former must be mixed with a volume of water equal to the amount of the original un- evaporated urine, and then the reaction is carried out with equal quantities of this mixture and of urine. Ciamician, Mazzoni, Pick and others have recommended iodol as a substitute for iodoform; Perrier and Patin, salol made from carbolic and salicylic acids; Siebel and A. Petersen, europhen, which contains 28*1 per cent, of iodine; and Eichoff has recommended aristol, which is a compound of iodine with thymol. Aristol has no odour and is non- poisonous, and is particularly useful in the treatment of various skin diseases. Pallin saw a case of iodol poisoning after the use of five grammes of this substance in a sequestrotomy of the clavicle. Salol should be given internally with caution, on account of the phenol it contains; Hesselbach observed a death follow the administration of eight grammes of this drug, which parted with about 3-04 grammes of carbolic acid in the body. Dermatol is an excellent non-poisonous substitute for iodoform, and much used in the treatment of skin diseases. Those of the newer an- tiseptic powders which are worthy of mention are diiodthioresorcin, sulphaminol, and sozoidol (Hydrargyrum, sozoiodolicum, Tromsdorff). The latter non-poisonous powder is used in the form of a one-per cent. emulsion in glycerine, gum arabic, and water as an ointment for treat- ing catarrh, etc. Peroni and Bovus recommend euphorin in the place of iodoform. Of the remaining antiseptic substances, of which there are a great number of considerable merit, I shall briefly mention the following: Naphthalin.—Naphthalin (CioH8) was isolated from coal tar by Gardener in 1828. It forms large, shining, colourless, crystalline plates of a tarry odour and a burning taste. It is insoluble in water, readily soluble in hot alcohol, ether, volatile and fixed oils. It burns with a bright, sooty flame. E. Fischer especially has recommended it as an antiseptic for the treat- ment of wounds. Naphthalin is dusted over a wound in the same way as powdered iodoform. In my own experience I have found naphthalin a most excellent disinfectant. A foul wound will quickly clean up after dusting it with naphthalin, and the process of granulation is accelerated. Sometimes its use is accompanied by pain, which may be so great in suscep- tible persons that its further employment has to be discontinued. Naphtha- 168 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. lin possesses all the advantages of iodoform without having any poisonous action. Benzoic Acid.—Benzoic acid crystallises in the form of thin plates or needles, which are only slightly soluble in cold (1 to 500) but readily solu- ble in hot water (1 to 30), and in alcohol, ether, and concentrated sulphuric acid. Benzoic acid is usually employed in solution in the strength of 1 to 200. Sulpho-carbolate of Zinc.—Bottini (Pavia) has recommended sulpho-car- bolate of zinc as an antiseptic. It forms large, white, transparent, odourless, rhomboidal crystals, which are readily soluble in distilled water, alcohol, and other liquids. Bottini considers the sulpho-carbolate of zinc better than all other similar antiseptics. It has the great advantage of being absolutely non-poisonous. It is employed in two- to ten-per-cent. solutions. Alcohol.—Dressings of alcohol have been used since the most ancient times, and were in great repute even in Heister's day. In France, and per- haps in England, this liquid finds its most extensive use, but in Germany it is no longer employed. Fifteen- to twenty-per-cent. solutions have been used for washing out wounds and for disinfecting instruments, sponges, etc. According to Hack, it has the effect of rendering granulations which have been treated with it incapable of absorbing anything. Terebene.—Terebene (CaoHia) is a brownish, oily fluid with a pleasant, aromatic odour, insoluble in alcohol, ether, water, etc., but soluble in all pro- portions in oil. It is much used, particularly in England, for the treatment of wounds, either in the undiluted form for badly granulating, foul, gan- grenous wounds, or diluted with equal parts of oil for the saturation of dressings, or else it is mixed with water (30 to 500) and used for irrigation purposes. Eucalyptus.—Eucalyptus is a volatile oil having a strong antiseptic ac- tion, and is made from the leaves of the myrtaceae, a tree growing in Bel- gium, Italy, and the south of France (the Eucalyptus globulus). It has been recently recommended by Schultz as an excellent non-poisonous antiseptic. The commercial article is very variable in quality, and Schultz advises that the oil be treated with soda until its acid reaction becomes neutralised, and then be exposed in sunlight to the action of tbe oxygen in the air, which causes the oil to lose its pungent odour and become non-irritating when used in dressings. The oil of eucalyptus can be mixed with alcohol and water, 0-2 to 0'3 per cent., and then used as a fluid in which to wring out com- presses. Lint which has been soaked in a solution of one part oil of euca- lyptus and ten parts olive oil can be used for applying to wounds. Iodine.—The antiseptic properties of iodine, tincture of iodine, the solution of iodine in an aqueous iodide of potash solution and of iodine vapour, have been proved by countless experiments. In recent times, in England and America, the solution of iodine—i. e., iodine two parts, iodide of potassium three parts, and water forty-eight parts, has been much used for dressings, lint being steeped in this mixture. The combination of this iodine solution with laudanum is also highly spoken of. For cleansing wounds, Bryant recommends iodine water (one part tincture of iodine to 75 to 100 of water). Other Antiseptics.—There are still to be mentioned alum, quinine, chloral (1 to 4 per cent, in water), chloroform water (Salkowski), chloride of lime, carbonate, acetate, and chloride of lead, acetic acid, permanganate of potas- g46.] THE DIFFERENT ANTISEPTICS. 169 sium (from 1 to 100-1,000), camphor and the spirits of camphor, glycerine, sulphate of zinc, citric acid, trichlorphenol (Dianin, Popoff, etc., one- to ten- per-cent. solutions), turpentine, tar, peroxide of hydrogen (2 to 12 volume aqueous solution), sulphuric acid and the sulphates and subsulphates of the alkalies, picric acid, resorcin, balsam of Peru, common salt solutions, carbon, powdered coffee, naphthol (soluble in the proportions of 1 to 5,000 parts of water, but rendered more soluble by adding alcohol), tannic and chromic acids, bichromate of potassium, aseptol (two to ten per cent.), and aseptin acid (a five- to ten-per-cent. solution of aseptin acid), etc. Of the numerous other antiseptics recently brought to notice the follow- ing may be spoken of : Trichloriodine.—Langenbuch recommended trichloriodine (1 to 1,000-1,500) as practically devoid of danger, and as a suitable material for the disinfection of the instruments, hands, the field of operation, sponges, etc., and he tested it in a great number of cases. In germicidal power it stands next to bichlo- ride of mercury (Riedel). Creolin.—Jeyes, its discoverer (1875), Kortum, Frohner and others recom- mend creolin in a one- to two-per-cent. solution, which, according to Henle, is a mixture of soap, oil of creolin, phenol, and pyridin ; it combines the use- ful properties of bichloride of mercury^ and iodoform without their poisonous effects. Creolin is an oily, dark-brown fluid, smelling of tar, and is made by the dry distillation of coal tar, forming with water a milky emulsion which has a threefold more powerful action than carbolic acid, and is used in a one- to two-per-cent. solution. Esmarch has given fifty grammes of creo- lin to animals internally without causing any bad effects. Behring, Baum- garten, etc., maintain that creolin has no such germicidal properties as car- bolic acid or bichloride of mercury, and that it is more poisonous than has been hitherto supposed. In severe cases of creolin poisoning—for example, after the internal administration of large amounts—there occur loss of con- sciousness, albumen and blood and renal epithelium in the urine, enlarge- ment of the liver, and jaundice (van Ackeren). Peroxide of Hydrogen.—Love recommends peroxide of hydrogen (two- to three-percent, solution), but it is rather expensive, and on account of its unstable character it is unsuited for an antiseptic. Rotter's Antiseptic Solution.—Rotter has combined a great number of an- tiseptics in one solution. To one litre of water are added bichloride of mer- cury 0-05 gramme, sodium chloride 0"25 gramme, carbolic acid 2'0 grammes, chloride and sulpho-carbolate of zinc, each 5*0 grammes, boric acid 3'0 grammes, salicylic acid 0-6 gramme, thymol 0-l gramme, and citric acid 0.1 gramme. The ingredients of this solution are also combined in tablet form, and called " Rotterin." Rotter also left out of this solution bichloride of mercury and carbolic acid, and considers that the remaining ingredients have a stronger antiseptic action than one-tenth-per-cent. solution of bichloride alone. Von Baeyer has demonstrated that all these different antiseptics com- bined in the one solution do not undergo any change. Aniline Dyes.—Stilling recommends the aniline dyes for antiseptics in the form of an aqueous solution of (pyoktanin, Merk.) methyl violet (1 to 1,000), but its value has not been confirmed by others (Carl, Jaenicke, Petersen, etc.). Lysol.—Lysol in one fourth- to two-percent, aqueous solution, manufac- 170 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. tured by Schulke & Mayer, in Hamburg, is an excellent and relatively non- poisonous antiseptic, and is recommended by Engler, E. Schmidt, Gerlach, etc., and has been much used in operations. On account of its cheapness and its non-poisonous character lysol is very well adapted for disinfecting and cleansing purposes, instead of carbolic acid. Salveol.—Salveol (Hammer, A. Hiller), a cresol compound (neutral aque- ous solution of creosol) in 0 5-per-cent. solutions, has a more powerful anti- septic action than five-per-cent. carbolic solutions, and it is, furthermore, comparatively non-poisonous. Ichthyol.—Ichthyol is extensively used in the treatment of various skin diseases. Latteux commends the antiseptic effect of five- to ten-per-cent. solutions for irrigating purposes. Alumnol.—Alumnol (Heinz, Liebrecht) is a white powder which is highly recommended for the treatment of skin diseases and gonorrhoea, and in one- half- to five- to ten-per-cent. solutions for the disinfection of cavities, ab- scesses, infected wounds, ulcers, etc. § 47. Which Antiseptics and which Antiseptic or Aseptic Dressings are the Best?—Wliich antiseptic amongst the great number which are recommended is the most powerful and at the same time the best adapted to the treatment of wounds ? My own experience places car- bolic acid and bichloride of mercury at the head of the list for cer- tainty in action, and, if used with caution, particularly in the case of children and cachectic individuals, they are also devoid of danger. If one uses carbolic and bichloride in the proper way he will see no more cases of poisoning from their employment. For aseptic opera- tions common salt solutions or simply sterilised water may be used. Amongst the other antiseptics the ones which I consider the best are boric acid, acetate of aluminium, creolin, lysol, salicylic acid, iodo- form, oxide of zinc, naphthalin, chloride of. zinc, and bismuth. The method of their application has been sufficiently described above. Which antiseptic or aseptic material is the best for dressings? Their number is almost without limit, and the choice, as we have re- marked, is more or less a matter of taste. But the great principles involved remain the same, namely, that the operation must be con- ducted with the strictest attention to asepsis ; that the arrest of the haemorrhage, the drainage, and the suturing of the wounds should all be' carried out with the greatest care. The main point to be aimed at in the application of a dressing is that the secretion of the wound should be well provided for; and this is excellently fulfilled by the dry gauze or mull dressing, and also by the dressings made of moss, wood wool, jute, my own special wool prepared for dressings, and similar materials. Moss, wood wool or excelsior, jute, etc., are covered with sterilised gauze and applied in the shape of sterilised pads or cushions. All materials used for dressings should be sterilised by steam at a temperature of 100° C. M7-] THE CHOICE OF AN ANTISEPTIC. 171 for twenty to thirty minutes in a steam sterilising apparatus. Dressings wliich have been impregnated with antiseptics become after a time less aseptic, and, furthermore, produce irritation of the skin and cause an eczema (see pages 3, 4). My own method of applying a dressing is very simple, and is ordinarily done as follows: The wound, or the su- ture line, is covered with several layers of sterilised gauze ; over this is placed cotton, or pads or cushions of jute or moss which have been sterilised by steam at a temperature of 100° C. (212° ¥.). In private practice I cover the wound with gauze folded into several layers which has been dipped in a 1 to 1,000 solution of bichloride and wrung dry, and over this I apply a layer of cotton or of my prepared wool. The less the wound is irritated by antiseptics, or, in other words, the dryer the operation, so much the less is the subsequent secretion from the wound, and there is consequently less need of dress- ings having great absorptive powers like moss pulp, wood wool, etc.; gauze covered with absorbent cotton or jute cushions will be all that is required. To favour the drying of the secretion from the wound within the dressings the gutta-percha or mackintosh should be avoided, except in the case of young children, when some water-tight substance should be employed to prevent the dressings from becoming soiled by urine, faeces, etc. All the dry antiseptic dressings are much better than those of the wet antiseptic, occlusive variety, as the latter are apt to occasion an eczema frequently lasting a good while, and increase the danger of poisoning, particularly from carbolic acid and bichloride of mercury. But, as we shall see, wet dressings in the form of continuous irrigation are most excellent for cases of extensive suppuration (see pages ITS, 179). I never apply antiseptic dusting powders, like iodoform, bis- muth, salicylic or boric acids, to a wound which has been closed by sutures. This powder dressing is chiefly suited for wounds which have not been closed by sutures and for those which are granulating or suppurating. For these I always employ iodoform when possible, but only in very small amounts. But at present I very seldom use pow- der dressings, and content myself with packing the wound with iodo- form gauze. Open wounds—that is, those which have not been sutured, like one resulting from extirpation of the uterus and from a joint re- section for extensive tubercular inflammation, etc.—are best treated by packing with iodoform gauze, and after the expiration of two to four days the packing is taken out and the aseptic wound is closed by secondary sutures. 1 attach great importance to the use of a moderate amount of pressure upon the wound, particularly after the extirpation of tumours, by small moss cushions, or by gauze which has been shaken 172 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DllESSlNCS. out and crumpled up into pads. Antiseptic sponges have also been employed with good results for exerting pressure on wounds. For an ointment I prefer boric acid mixed with vaseline, or else plain vase- line alone. If it is necessary to disinfect an already infected wound, I use solutions of bichloride of mercury (1 to 1,000-5,000). The antiseptic and aseptic dressings should be as large as conven- ient, though I do not consider this now of as much importance as I used to. For applying the dressing the patient should be placed in the most suitable position. For bandaging the head, shoulder, and thorax the patient should be made to assume a sitting posture, while for the abdominal region a cushioned prop (Fig. 117) is placed under the patient's hips while the latter are held by an assistant. Splints of wood, sheet metal, plaster of Paris, or wire, etc., serve to immobilise an extremity (see § 53). For less serious cases thin, pliable -wooden hoops are exceedingly useful. One of the great advantages of the antiseptic and aseptic methods of treating wounds lies in the fact that the dressing requires much less frequent renewal than formerly, when the unsatisfactory occlusive dressing was employed. These general remarks on the technique of antiseptic or aseptic dress- ings will suffice at present, and the particular way of dressing this or that variety of operative or traumatic wound will be described in the Fig. 118.—Aseptic dressing for the Fig. 119.—Aseptic occlusive dressing for the head, scalp. neck and breast. Text-Book on Special Surgery. Figs. 118 and 119 illustrate two meth- ods for applying an aseptic dressing to the skull and the head, neck, and chest. The particulars are given in § 50. §48.] THE CHANGING OF AN ANTISEPTIC DRESSING. 173 § 48. The Changing of an Antiseptic or an Aseptic Dressing.—When shall an aseptic dressing be changed? In the first place, the nature of the case and the kind of operation or injury must be considered. In general it has been my experience that a change of the dressing is called for under the following conditions : 1. When the temperature rises above 3S-5° C. (101-3° F.). 2. When the dressing becomes soiled from without—for example, by urine or other excretory matter. 3. When the patient is suffering severe pain. 4. When the dressing becomes displaced or loosened, or when the secretion from the wound saturates the dressing to such an extent as to be apparent externally. Whenever fever occurs—and I make a regular practice of con- sidering any rise of temperature above 38*5° C. (101*3° F.) under this heading—I change the dressing, and am pretty sure to find that there is either some slight disturbance in the wound, a retention of the secretion, or a stitch which is too tight, etc. As a general thing, in my own operations I have very seldom observed any rise in tempera- ture above 3S'4° C. (101° F.). Other surgeons have noticed a rise of temperature of several degrees during the healing of a perfectly aseptic wound. Volkmann and Genzmer, especially, have made in- vestigations upon this fever and have called it the '-aseptic wound fever." I have very seldom seen the aseptic wound fever, and when a rise in temperature does occur while the healing process is going on it will usually be found to take its origin from some perceptible ab- normity in the wound. Opinions vary as to the cause of this aseptic wound fever, v'olkmann and Genzmer consider it an absorption fever produced by the entrance into the general system of the relatively homologous products of metabolism and disintegration which are formed in every wound. Sonnenburg and Kiister believe that aseptic wound fever is caused by carbolic-acid poisoning. Both of these views are of use in explaining the phenomena. My own view of the aseptic wound fever leads me to believe that it is caused by the absorption of lymph and the fibrin ferment from the blood lying in the wound. This fibrin ferment is formed the more abundantly the more the wound has been irritated by carbolic acid or other strong antiseptic solutions. I believe I am not mistaken in affirming that all surgeons who make free use of solutions of bichloride, carbolic, or other irritating antisep- tics in their treatment of wounds, will frequently notice aseptic rises in temperature, while those surgeons who are cautious in their use of antiseptics, and prefer asepsis to antisepsis, will only observe this phe- nomenon in a few exceptional cases. Many surgeons—Neuber, for in- 174 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. stance—have recommended that the dressing be allowed to remain un- disturbed in such instances of aseptic fever, claiming that a change of dressing only creates further disturbance in the wound and is conse- quently harmful. I cannot agree to this statement, though I sel- dom have to do with fever following an operation. If it does occur, I always change the dressing as a matter of course, if the temperature rises above 38*5° C. (101*3 F.), and I usually find, as I have said, some slight variation from the normal in the healing process. I prefer to change the dressing as infrequently as possible, and I am particularly careful to avoid irritating the wound by excessive irrigation, washing out, etc. It can only do harm. From what has been said so far, we can readily understand the im- portance of ascertaining a patient's temperature in the morning and evening, or, in more important cases, three to four times a day, or even every two hours, and it is best taken in the rectum. I prefer, if there is fever, to change the dressing too frequently rather than allow one to remain too long. If the discharge should soak through the dressings, they can still be left undisturbed, if only the external layers remain dry and no fever is present. My rules for changing an antiseptic dressing are as follows: If the wound is extensive, and'there is considerable discharge, I change the first dressing after the expiration of twenty-four to thirty-six hours, even though there is no rise in temperature; or I allow the first antiseptic dressing to remain undisturbed till the end of the third to the fourth to the eighth day, according to the nature of the case. Drains are removed at the end of the first twenty-four hours, or on the second to the third day, the stitches generally on the third to the fifth day. After a laparotomy which runs a normal course without reaction, I change the first dressing on the eighth to the twelfth day, according to the size of the abdominal wound, and at the same time I remove the stitches, though if the wound is under considerable ten- sion a stitch here and there is left in place for a little while longer. An aseptic dressing should be changed only with the strictest atten- tion to the rules of antisepsis, and everything which is required for the dressing, particularly the pieces of gauze, the bandages, etc., is to be prepared in advance in the proper manner. The instruments, such as scissors, probes, forceps, etc., should be boiled in a one-per-cent. soda solution and placed in a three-per-cent. solution of carbolic acid; the sponges or gauze pads should lie in a one-tenth-per-cent. solution of bichloride. The hands are to be disinfected with the greatest care (see page 9). The dressing is then slit up with strong bandage scissors (Fig. 120), or the bandage is unwound, and after it has been thor- §48.] THE CHANGING OF AN ANTISEPTIC DRESSING. 175 oughly washed, disinfected, and sterilised by steam at 100° C, it may be used again as a non-antiseptic bandage ; but it is a better plan to burn all dressings immediately after they have been taken off. I never use the spray now. After removing the bandages and superficial portions of the dressing, the hands are again disinfected by . ° Fig. 120.—Dressing scissors. dipping them into a three-per-cent. solution of carbolic or 1 to 1,000 bichloride, and after this the por- tion of the dressing lying in contact with the wound is removed as care- fully as possible. If it adheres to the skin or to the wound, it should be softened by squeezing out upon it a few drops of the antiseptic solution from a sponge. The wound is then examined by pressing here and there very lightly with the index and middle fingers to ascertain whether there is any retention of the secretion, and finally the drains, stitches, etc., are removed. If the healing process is progressing nor- mally in every respect, there should be no syringing out or washing off of the wound, and all that is necessary is simply the application of a fresh dressing. The forcing of antiseptic solutions through the drainage-tubes is particularly to be avoided, as it always does harm, and I never indulge in this practice except when suppuration is present, and then only rarely. If the drains become occluded by blood-clots and are to remain in the wound, they should be made pervious by passing a probe through them ; or, better still, they should be taken out of the wound, washed in a three-per-cent. solution of carbolic or 1 to 1,000 bichloride, and finally reinserted with a safety pin attached to them to prevent them from slipping into the wound, or else entirely new drainage-tubes may be employed. Very often a stitch which is cutting into the tissues or is drawn too tight must be removed at the end of twenty-four to thirty-six hours. The presence of swelling and redness indicates a retention of the secretion, which should then be let out by one or more incisions with the knife, with or without subse- quent drainage. If there is an appreciable .amount of suppuration it may be necessary in some cases to change the dressing every day for a time, or to substitute for the antiseptic occlusive dressing some other simpler kind. Should erysipelas occur, the antiseptic occlusive dress- ing can be maintained. Even when the wound remains uninterruptedly aseptic, bacteria are commonly found in the antiseptic or aseptic dressings. These bacteria belong chiefly to the non-pathogenic species of skin coccus, and do not interfere with the normal process of healing. If the staphylococcus 176 THE ANTISEPTIC AND ASEPTIC PROTECTIVE DRESSINGS. pyogenes aureus and the streptococcus are found, there will probably be a disturbance in the wound, but the presence of the staphylococcus pyogenes albus only exceptionally causes an infection of the wound (Tavel., O. Lang, A. Flach). Dressings which have been allowed to remain in place a long time will give off a bad odour not unlike old cheese, caused ordinarily by the decomposition of sweat and sebaceous matter. Xot infrequently there will be found an eczema, especially if wet carbolic or bichloride dressings have been used, and this is best treated by the application of vaseline or the ungt. lithargyr. Hebrae,* and by dusting it over wdth bismuth and starch (1 to 5-10), or oxide of zinc and starch (1 to 5-10), or by applying Lassar's paste (oxide of zinc and powdered starch aa 10, salicylic acid 1, vaseline 20). Such eczemas can be best avoided by the use of simple, sterilised, dry dressing materials. If the wound has healed there is generally no further need of any dressing. In other cases it may be necessary to cover granulating areas or drainage-holes with some ointment like boric-acid ointment, or by sticking plaster, iodoform collodion, or with iodoform, zinc oxide, or bismuth powder, or with a piece of simple dry gauze or cotton. I very often allow an aseptic material which has become dry to remain on the wound like a scab, with or without a protecting bandage. After a time the aseptic scab drops off and the wound is found to be healed. * Unguentum diachylon. CHAPTER II. OTHER METHODS OF TREATING WOUNDS. The old-fashioned protective dressing.—Open method of treating wounds.—Healing beneath a scab.—Antiseptic bathing.—Immersion.—The use of warm baths.—Cata- plasms.—Poultices.—Cold.—Ice.—Lister's cooling apparatus.—Adhesive substances (sticking plaster, gauze adhesive plaster, English plaster, collodion, photoxylin, traumaticin, gummi laccae).—Ointments. § 49. Other Dressings for Wounds.—The old-fashioned protective dressings of sticking plaster, charpie, ointments, etc., are no longer used at the present day, and after operations we now cover the wound, without exception, with antiseptic or aseptic dressings, though in the case of small fresh wounds, or those which are granulating, we occa- sionally employ adhesive plaster, collodion, iodoform collodion, and an- tiseptic salves, boric-acid ointment, for example. Open Method of treating Wounds.—The open method of treating wounds is the simplest one of all. Small superficial wounds are now allowed to go without any dressing, especially when the blood and secretion from the wound becomes dried and thus forms a protecting crust beneath which the wound heals. Healing beneath a Scab.—The healing under a scab, which occurs in small wounds, has been made the basis of a separate method of treat- ment, in which an attempt is made to form a scab artificially over wounds having an abundant secretion by the application of dry sub- stances, such as tinder and various kinds of powders, or a dry eschar is made by some strong caustic, like nitrate of silver, liq. ferri sesquichlor., the hot iron, etc. All these different ways of accomplishing the same result, if carried out with no antiseptic precautions, even though the wound be small, are not devoid of danger. But the modern surgeon never fails to treat every wound, including the very smallest, upon anti- septic principles, because we know that even the most insignificant lesion in the skin, under certain conditions, may cause a septic cellulitis or an erysipelas which can prove fatal. On the other hand, Schede's method of treating wounds by permitting a moist aseptic blood-clot to remain (see page 102) is to be looked upon as a real advance in this branch of 13 (177> 178 OTHER METHODS OF TREATING WOUNDS. surgery. As above stated, it is an excellent plan to permit the dried dressings to remain upon the wound like a dry aseptic scab, until they come away of their own accord when the wound has healed. This open method of treating wounds yielded relatively excellent results in the preantiseptic days of surgery, even when used for large wounds, such as amputations, disarticulations, compound fractures, etc., and was practised till supplanted by tbe antiseptic dressing. In the open method of treatment the wound was not provided with any dressing, but left entirely exposed, or only lightly covered with antiseptic compresses. It was not closed with sutures until later on, when a few coap- tation sutures were used. In this way the escape of the secretion from the wound was favoured. If the wound was situated on an extremity tbe latter was placed in a proper position to facilitate the escape of the discharges, which were received in a vessel or bowl placed beneath. The crusts which formed in the wound, from dried blood or secretions, were softened and re- moved by means of antiseptic solutions or by carbolised oil. The principal advantages in the treatment of a wound by the open method were a ready escape of the secretions, complete rest which was undisturbed by change of dressings, and finally absence of pressure. It bad the disadvantage that wounds healed slowly and only after suppuration. In cases where the antiseptic occlusive dressing is no longer advis- able on account of suppuration, or a threatening systemic infection, when it may even become dangerous from the pressure it exerts, the open method of treating wounds, particularly in conjunction with con- tinuous antiseptic irrigation, is now in very general use, and is an exceedingly valuable means of handling these cases. Antiseptic Bathing.—For continuous antiseptic bathing of a wound, or, in other words, for continuous irrigation, such antiseptic solutions should be used as involve no danger to the patient from their absorp- tion and produce no symptoms of poisoning. Of these, the best are three-tenths-per-cent. solutions of salicylic acid ; the boro-salicylic solu- tion (1 part of salicylic acid, 6 of borax, and 500 of water); or solutions of one tenth per cent, thymol, four per cent, boric acid, two per cent, acetate of aluminium, or, what is the best solution of all, viz., Burow's (described on page 159), consisting of ten per cent, sub- sulphate of sodium, one tenth per cent, permanganate of potassium, lysol, etc. The wound is covered with a light gauze compress. The patient is made to assume a suitable position, and protected by means of water- tight coverings and also by properly regulating the overflow of the irrigation fluid. The solution is made to drip from an Esmarch irri- gator placed in some elevated spot, or from an improvised irrigator, such as an inverted champagne bottle from which the bottom has been partly removed (Fig. 123), or the excellent apparatus of Starcke may §49.] OTHER DRESSINGS FOR WOUNDS. 179 be used (Fig. 122). Fig. 121 illustrates the proper position for the upper extremity when continuous antiseptic irrigation is employed. Starcke's apparatus consists of a vessel for holding fluid which is connected by a rubber tube with a lead or glass pipe; this is fitted with numerous outlets also connected with rubber tubes which can be opened or closed by stop- cocks or clamps, and by means of wires in their interior can be bent and turned in any desired direction. The lead or glass pipe is sus- pended from some beam or support by a couple of strings. If Esmarch's irri- gator or the inverted champagne bottle are used as in Fig. 123, the fluid is made to escape in drops or in any required amount by means of a stop- cock placed at the point of insertion of the rubber tube. If the tube is not fitted with one, the out- flow of fluid can be regulated by a clamp, or a piece of cotton, or a few strands of jute stuffed into the lumen of the tube, or by a straw, etc. Immersion.—Immersion, or bathing the whole body, or separate portions of it which have sustained an inju- ry, were endorsed principally by Langenbeck as a method of treating wounds. The con- tinuous immersion of a patient's whole body in a warm bath day and night is adapted especially for extensive burns, cellulitis, bedsores, and for the after-treatment of op- erations on the rectum, bladder, urethra, etc. The bath tub is usually made to con- tain a framework of wood or metal fitted with slats and a movable head-piece which can be raised or lowered Covers are laid over the frame and an air cushion on the head Fig. 121, -Position of the upper extremity during permanent antiseptic irrigation. Fig. 122.—Starcke's apparatus for the irrigation of a wound. 180 OTHER METHODS OF TREATING WOUNDS. piece, and thus the patient is made very comfortable. The patient can be placed on an ordinary sheet instead of a frame, and in this way can be raised or lowered in the tub. The tem- perature of the water must not be allowed to become too cool, and it is best to regulate it according to the wishes of the patient, and therefore it is a good plan for him to be able to regulate the temperature of the bath himself by turning on or letting out the water. The temperature of the water must usually be maintained at 37° to 38s C. (98-6° to 100-4° R), and perhaps more, and of course the patient, while asleep, should be watched very carefully by a nurse. Influence of a Continuous Bath on a Wound.—The influence of prolonged baths of this kind upon a wound is in general very favourable. The granula- tions usually swell considerably, and it occasionally happens for this reason that the escape of the dis- charges is rendered difficult, causing retention and burrowing of pus and phlegmonous inflammations. Nevertheless, the freely granulating surface is apt to become covered with skin very rapidly, and the parts surrounding the wound become soft and yielding. For regulating the growth of the granulations, irritant substances, like spirits of camphor, etc., have been added to the bath, or the wounds have been dressed with them. If the bath becomes too cold there is a possibility of necrosis taking place here and there in the skin ; and care should be taken in subjecting old people to prolonged baths on account of the danger of pulmonary, cardiac, or cerebral disturbances. The use of baths for separate portions of the body which have been injured needs no further description. The Use of Continuous Saths for Operative Cases and Long-Continued Suppuration.—At the present time, Sonnenburg is a prominent advocate of permanent baths for operative cases and for all patients who are afflicted with long-continued suppuration, and upon whom the ordinary form of anti- septic applications cannot be used, either on account of the peculiarities of the wound or other local conditions, or on account of some idiosyncrasy of the patient. Sonnenburg has practised this method in operations in the pelvic region, in lithotomies, extirpation of the rectum and uterus, urethrot- omy, intestinal operations, for bedsores, burns, extensive cellulitis, etc. Many patients can be kept for months in a bath at a temperature of about 30° C. (99*5° F.). The wound drains readily, and accidental wound diseases do not occur. Sonnenburg's description of this bath will be found in the Archiv. fur klin. Chirurgie, Bd. 28, p. 921. Fig. 123.—Improvised apparatus ^irrigator) for the irrigation of a wound. H»-J OTHER DRESSINGS FOR WOUNDS. 181 Cataplasms.—Warm poultices, either dry or wet, were much used in the treatment of wounds during the preantiseptic days. Fomentum, a hot, wet application, or a fomentation as it is called, is derived from foveo, to warm. Cataplasm, or poultice, comes from the Greek word Ka.Tcnfka, to lay on. Fomentations in a dry form are applied to the wound in the shape of hot cloths, or of finely powdered and chopped-up herbs or vegetable matter, such as bean meal, bran, flores sambucci, etc., either directly or after being sewed up in linen or flannel bags, etc. Cataplasms or poultices are made of boiled linseed meal, groats, etc., which are wrapped in gauze or linen cloth before applying. The ancients used a great number of herbs of various sorts as applications for wounds, and evinced a strong preference for cataplasms pre- pared in urine or from the excrement of different domestic animals. In the time of Aribasius a paste of figs and milk was much in vogue on account of its antiseptic action. At present, however, cataplasms are not considered proper for the treatment of wounds, and we only use them when we desire to promote suppuration in tissues which are infiltrated with inflammatory matter. The preparation of poultices is very tedious. The hot poultice is renewed by warming the wet cushion upon a hot plate, or in vessels made for the purpose with double walls between which the water is placed to sup- ply the moisture, and the vessel is then heated over a gas or spirit-lamp flame. For doing away with this slow process there have recently been invented artificial cataplasms about the weight of thin pasteboard. These are soaked in hot water and applied to the diseased portion of the body and covered over with some water-tight substance and then with cotton. They afterwards swell and assume a pulpy consistency. A mustard paper is also manufactured which has a very irritant effect upon the skin. Antiseptic Poultices.—The application to wounds of wet antiseptic poultices of mull, gauze, lint, linen, etc., in a cold or hot form is even at the present time much used in the treatment of suppurating wounds which are granulating. The lead-water poultice is also regarded with a good deal of favour, and I consider it a better application than the irritating one made with carbolic acid. The latter is sometimes used too strong by the laity, and also changed too frequently. I have re- peatedly seen gangrene of the skin on the tips of the fingers caused by carbolic acid applied in this form. If wet applications of this kind are to be left in place for some time, possibly one or two days, and the effect of moist heat is desired, the applications should be covered with rubber tissue over which cotton is laid, and the whole dressing is then fastened in position by a bandage (hydropathic poultice or Priessnitz's poultice). Wet dressings like these, particularly if made with lead-water, have a powerful stimulating action upon granulations, and the skinning-over process is occasionally very much hastened. If cold is aimed at in the wet applications, for reduction of the heat in any given portion of the body, the applications will need very frequent renewal. Cold—Ice.—In such cases it is best to use ice in rubber or ice bags, 182 OTHER METHODS OF TREATING WOUNDS. or to add ice or snow to the water used for wetting the poultices; or else make a cooling mixture consisting of one part ammonium chlo- ride, three parts of nitre, six parts of vinegar, and twelve to twenty-four parts of water (Schmucker). The effect of ice and cold applications upon the wound is both analgesic and haemostatic. Lately, Leiter, of Vienna, has invented an apparatus for obtaining in the most satisfactory manner the effect of cold and heat upon inflamed and injured portions of the body. It consists of a pliable metal tube through which water at any required temperature is allowed to flow. The metal tube can be made to as- sume any desired form, such as a cap for the head, or a coil for encir- cling an extremity, or a flat piece for the back, etc. A similar appa- ratus has been made of rubber tubing, and used as a cold coil for an extremity, an ice cap for the head, or an ice bag for the neck. Sticking Plaster.—We now treat small wounds, or those which are granulating, by means of a covering of sticking plaster, collodion, some ointment, etc. Adhesive plaster is made of some substance like linen, cotton, silk, leather, etc., covered upon one side with some such sticky material as litharge, olive oil, resin, or turpentine, etc.; lead plaster is made with certain hard substances—oil, wax, turpentine, etc. The ordinary German adhesive plaster is usually warmed over the flame of a spirit lamp before being applied, and then laid in strips upon the desired portion of skin, which has been previously dried. To prevent the plaster from adhering to the hairs, the latter must be first shaved off with a razor. American Adhesive Plaster.—A very good kind of sticking plaster, though somewhat expensive, is the American adhesive plaster (Ellis's adhesive plaster cloth), in which the sticky material is spread on muslin, linen, or silk. English Adhesive Plaster.—The English plaster adheres very well and is useful for small wounds; it consists of fine sarcenet having on one side a solution of isinglass and on the other tincture of benzoin (Emplastrum adhesivum anglicum). The sticky side should be mois- tened with some antiseptic solution and not with saliva, and then applied to the skin. Paris Plaster.—The Paris plaster is more flexible and adheres even better. The recently invented iodoform plaster consists of iodoform, glycerine, and mucilago gummi arabici, which is made into a solution and spread over linen. There are many other kinds of adhesive plaster which may be found in the Pharmacopoeia. Gauze Adhesive Plaster.—Unna has introduced a very excellent 8 4!).] OTHER DRESSINGS FOR WOUNDS. 183 gauze adhesive plaster, made of oxide of zinc or iodoform spread on gauze with some sticky substance, and it is often preferable to the ordi- nary adhesive plaster. Collodion.—Of the other adhering materials I should mention especially collodion, which is a solution of gun cotton in ether and alcohol. By the evaporation of the ether and alcohol the collodion dries in the form of a firm covering which adheres excellently to the skin. It is not suitable for apply- ing to fresh wounds on account of the irritation it causes. Iodoform collo- dion (1 to 10) is frequently used as a protective dressing, and it is far better than adhesive plaster in that it does not come off by contact with water. A cutaneous wound, after it has been sutured, is frequently painted over with iodoform collodion (Kiister, Zweifel, Hans Schmidt), and heals like any wound sutured aseptically, over which there forms a dry aseptic scab. Col- lodium elasticum (collodion 60, castor oil 2"5, turpentine 7*5) is particularly suited for chapped hands, frost-bites, etc. Substitutes for Collodion.—As a substitute for collodion I use a bismuth paste—i. e., a solution of bichloride to which bismuth has been added, or zinc glue (oxide of zinc and gelatine aa 20 parts with distilled water and glycer- ine aa 80'0 parts). These dry rapidly and form an excellent covering for sutured wounds, as well as for small, unsutured, fresh, or granulating wounds. Photoxylin.—Wahl has recommended pbotoxylin in place of collodion. It is a substance used in photography, and he employs it in a five-per-cent. solution in equal parts of alcohol and ether. Traumaticin.—Traumaticin, or a solution of gutta-percha in chloroform, is widely employed as an adhesive dressing in place of collodion. Gummi Laccae.—Gummi laccae (Mellez) is also much employed as a sub- stitute for collodion and English adhesive plaster. A solution of the con- sistency of jelly made by adding alcohol is warmed and spread on cloth, thus forming a cheap and serviceable adhesive plaster which is not attacked by water or fat, etc. Salves.—Ointments as dressings for granulating wounds do not en- joy the popularity which they once did, and I rarely use them. I prefer, even for granulating wounds, antiseptic dressings, such as sterilised gauze with or without the addition of antiseptic powders like bismuth, oxide of zinc, iodoform, or similar substances. There are a great number of ointments of which the principal ones are boric- acid ointment, boroglycerin lanolin (Graf), vaseline, salicylic vaseline, carbolised vaseline and glycerine, ointments either pure or mixed with various antiseptics, and, in addition, oxide of zinc, lead oint- ments, etc. An excellent base for making ointments is the lanolin recommended by Liebreich in which bacteria cannot grow. Glycerine fats, on the other hand, become easily rancid under the influence of light, and then become a good medium for the growth of micro-organ- isms (Frankel, Gottstein). 184 OTHER METHODS OF TREATING WOUNDS. Mollin.—Kirsten recommends mollin as an adjuvant to grey mer- curial and iodine ointments. Pasta cerata.—In conclusion, pasta cerata may be mentioned (Schleich), which can be used in a variety of ways as a dressing for wounds. CHAPTER III. GENERAL RULES FOR THE APPLICATION OF BANDAGES AND RETENTION APPLIANCES. The different kinds of bandages.—The application of the ordinary roller bandage.— The " reverse."—The removal of bandages.—The rolling of bandages.—The appli- cation of bandages to particular parts of the body (head, neck, trunk, upper and lower extremities).—The application of retention appliances to different portions of the body. § 50. Application of Bandages.—The ordinary bandages are made of linen, flannel, webbing, or gauze, etc. For bandaging wounds, as we have said before, we preferably employ sterilised mull or stout gauze, which are first soaked in a 1 to 1,000 solution of bichloride or a three- per-cent. carbolic solution, squeezed dry, and then applied to the se- lected portion of the body in a damp condition, thus making a well- fitting and strong permanent dressing, as illustrated in Figs. 118 and 119, on page 152. The rubber bandage, made from ordinary caoutchouc, or the band- age of elastic webbing is used when it is desired to apply a dressing to exert pressure. Elastic bandages are adapted for application about the thorax, the abdomen, etc., where other band- ages become easily displaced and loosened. There are both single and double roller band- ages, the latter being illustrated in Fig. 124; triple and quadruple rollers were formerly much in vogue, and can be easily made by FlG-124.—Double roller e ' '. bandage. fastening together a couple of ordinary band- ages. The many-tailed bandage, as it is called, consists of several strips of bandage overlapping laterally and joined in the centre by a single cross strip. Application of the Roller Bandage.—The ordinary roller bandage is applied by holding the end of the bandage upon the desired spot with the index finger or thumb of the left hand, while the roller is directed upward (Fig. 125). The first turn of the bandage is secured by a second, making two thicknesses of the bandage at the one place; then (185) 18G APPLICATION OF BANDAGES AND RETENTION APPLIANCES. the bandage is unrolled spirally upwards about the part, making each upper turn overlap about half of the width of the one next below. I usually wind the bandage from left to right. If it is desired to rapidly secure a dressing in place, each spiral turn may be separated by a considerable distance from the next lower turn (Fig. 120), and subsequently the bandage may be completed in the regular way. If one attempts to apply a linen or gauze bandage, for example, to the upper or lower ex- tremity, with circular or spiral turns, it will soon be noticed that the lower edge of each turn does not fit tightly to the extremity, and that its " set," particularly in the case of the forearm and leg, is uneven. For preventing this loose- ness of the lower margin of each turn, and to make the whole bandage fit evenly and firmly, it is customary to make what is called a " reverse," which is best done as follows (Fig. 127): 1. The roller is grasped by the right hand in such a way that one looks into the palm of the hand, the dorsal surface is directed downwards, and the bandage drawn tight and smooth obliquely upwards, while its lower edge is held firm by the left thumb (Fig. 127, a). 2. The traction on the obliquely directed portion of the bandage beyond the left thumb is then relaxed (Fig. Fig. 125.—Application of the ordinary roller bandage. Fig. 126.—Spiral bandage. Fig. 127.—Application of tbe reverse bandage. 127, b). 3. The upper edge of the bandage is then folded over down- wards (Fig. 127, c). The points of reverse should, as far as possible, be made at the same part of the circumference of the extremity, and lie one above the other. This method should be employed not only in §50.] APPLICATION OF BANDAGES. 187 bandaging an extremity, but any other portion of the body, so as to make the turns of the bandage fit into the inequalities of the particular locality. The bandage is usually completed by one or two circular turns. While making the reverses care should be taken that ridges and folds are not allowed to form. Considerable practice is necessary in order to be able to put one on quickly and accurately. The end of the bandage should be fastened in place with a safety-pin, or it may be slit up at the end with scissors, or simply torn lengthwise in the mid- dle, if it is a muslin or gauze bandage, and the split ends carried around the extremity in opposite directions and knotted together. A bandage is taken off by unwinding the turns in the reverse direc- tion to which they were put on—i. e., the turn last applied is the first to be taken off. At the same time the bandage is rolled up, and during the unwinding is quickly passed from one hand into the other. The removal of a mull or gauze bandage is generally accomplished by simply slitting it up with bandage scissors. In Fig. 12$ is illustrated the method of rolling a bandage. Mull and gauze bandage rolls are best and most rapidly made by means of a small rolling machine. Application of a Bandage to the Head.—The method of applying bandages to the head is illustrated in Figs. 129-132. Fig. 128.—Boiling a bandage. Fig. 129.—Fascia nodosa. Fig. 130.—Mitra Hippocratis. Fig. 129 represents the fascia nodosa or knotted bandage. The middle of a strip of bandage is laid, for example, on the left temple, and one end of the strip is carried over the crown, the other under the chin to the right temple, and at this point the two ends are crossed, the one which came from under the chin passing around the forehead, the other around the occipital region, and the two ends are then knotted together. The principle of this knotted bandage can be used with some variations for almost any desired portion of the body. Its chief use is for exerting pressure on some particular spot, which can be in- creased by inserting beneath the bandage a pad of cotton or gauze, etc. 188 APPLICATION OF BANDAGES AND RETENTION APPLIANCES. It is also used in the inguinal region (Fig. 157), as a temporary substi- tute for a hernia truss. Mitra Hippocratis.—The mitra Hippocratis (Fig. 130) is made with a double roller, or, what is simpler, with an ordinary roller bandage. When the double roller is employed its centre is applied in the middle of the forehead, one roller being carried horizontally around the head towards the right, the other towards the left, and at the occiput the two rollers are crossed in the manner of the fascia nodosa; then an assistant car- ries one roller over the crown to the forehead, while the operator, with the second roller, takes a circular turn horizontally around the head and crosses the roller, which has been carried over the crown, upon the forehead. This is continued, one roller being carried from the fore- head to the occiput and then back again to the forehead, first on the right side and then on the left of the original median strip carried sagittally over the crown, each circular turn of the other roller securing the strips passing over the crown. The entire skull is thus covered with strips of bandage running forwards and back in a sagittal direction. Finally, the ends of both rollers are carried circularly around the head and fastened in place with a safety-pin. The mitra Hippocratis is only occasionally applied with a double roller, but it is well to understand the principle of it in treating wounds of the head antiseptically (see page 152, Fig. 118). A mull or wet gauze bandage may be applied to the skull partly with circular turns and partly with turns passing back and forth in the sagittal direction over the top of the head. Capistrum. Duplex.—The capistrum duplex is not very often used now, but it was at one time in great repute for treating fractures of the lower jaw, as was also the capistrum simplex. The funda maxillae (Fig. 148) has the same effect as the capistrum simplex and duplex, and is, furthermore, much better and sim- pler. Some of the turns made in the capistrum duplex are used for applying antiseptic dressings to the head and neck, and hence it should be spoken of here. The description of the old-fashioned capistrum sim- plex will be omitted. The capistrum duplex is begun with the end of the roller on the vertex, then it passes Capisteumduplex. d°Wn ln fr0Ilt °f.the left eai>> Ullder the cllin> and T1P in front of the right ear to the vertex again; then from this point it passes around the occiput to the right side of the neck, under the chin, and up in front of the left ear, covering the first turn in great part, back to the vertex again ; then around the occiput to the left side of the neck, beneath the chin, and up in front of the right ear to the vertex. In this way three turns of the bandage are made in §50.] APPLICATION OF BANDAGES. 189 front of each ear, and then it is carried from the neck in front of the chin and the lower part of the under lip, and is finally terminated by a circular turn around the forehead and occiput. The circular turn around the front of the chin can be made between the second and third turns taken in front of the ear. In applying an anti- septic dressing the neck should also be included in the bandage. Monoculus and Binoculus.—Fig. 132 represents the method of applying the monoculus, which begins with a circular turn about the head, starting from the tem- poral region. The rest can be understood from Fig. 132. The so-called binoculus, or bandage over both eyes, is performed by first covering one eye with a circular turn of the bandage and then carrying the bandage with obliquely descending turns over the other eye. Application of a Bandage to Neck and Thorax.—The application of bandages to the neck is accomplished by making circular turns, to which, in the case of large wounds, are added cross turns under the ax- illa and over the shoulder (see page 152, Fig. 119). Bandages are ap- plied to the thorax by circular turns, with or without reverses. To keep the bandage from becoming displaced, every other turn can be carried from the back over the shoulder and secured with safety-pins at the points of meeting with the horizontal turns ; or the circular turns may be made to ascend from below upwards on the thorax, and finished by oblique turns about the shoulder and axilla like a spica humeri (Fig. 138, a and b). For bandaging a wound, after applying a thick cushion of dressings, we employ starch bandages, which, after drying, fit closely and do not become easily displaced. Elastic bandages are also to be recommended for the trunk, as they retain their position very well. Bandaging of the Mamma Suspensori- um Mammai Simplex (Fig. 133).—The bandage for the right mamma is begun by a circular turn about the lowermost portion of the thorax. The bandage is then car- ried obliquely so as to envelop the lower part of the gland, over the opposite shoulder, then across the axilla, over the shoulder and across the back, again to the right breast at its upper part, and then once more over the shoulder, etc. The upper and lower portion of the gland is crossed alternately, and then its middle Fig. 133.—Suspensorium mamma? duplex and small outer bandage for the mamma. 190 APPLICATION OF BANDAGES AND RETENTION APPLIANCES. part, and finally the bandaging is completed by a circular turn around the lowermost portion of the thorax covering the preliminary turns (Fig. 133). The suspensorium mammae duplex and a light supporting bandage for both breasts can be applied very simply by using the method illustrated in Fig. 133 on both sides. Antiseptic Retention Dressing after Amputation of the Breast and cleaning out the Axilla.—After amputation of the breast, accompanied by cleaning the carcinomatous lymphatic glands out of the axilla, I first put on a dressing of sev- eral layers of sterilised gauze placed in direct contact with the wound, then over this I apply absorbent cotton or pads of jute, covering in the shoulders and en- tire thorax. These materials are then bound on by a sterilised mull bandage encompassing the thorax, neck, and shoulders, the edges of the dressings, particular- ly in the axilla, neck, and at the lower border of the breast, be- ing very carefully filled in with absorbent cotton ; then the arm on the side which has been operated upon is placed in contact with the thorax and also covered with sterilised absorbent cotton. After this the arm is immobilised by a disinfected mull and finally a gauze bandage encircling the thorax, neck, and shoulder (Fig. 134). Application of Bandages to the Upper Extremity. — The methods of applying bandages to the fingers are illustrated in Fig. 135, a, b, c. They are begun with a circular turn around the wrist, and then carried across the dorsum of the hand to any particular finger, and, after encircling it, brought back again to the back of the wrist (Fig. 135, a). A finger can be bandaged, as illustrated for the Fig. 134.—Aseptic dressing for use after an am putatio m left axilla. putatio mammae with cleaning out of the le:" Fig. 135.—Application of bandages to the fingers. §50.] APPLICATION OF BANDAGES. 191 little finger in Fig. 135, c, by making oblique spiral turns down to its tip, and then covering in the finger by oblique or circular turns from tip to base. The finger bandage can also be carried in the reverse direction, beginning on the finger and terminating at the wrist. More- over, the thumb may be bandaged in the way pictured in Fig. 135, b ; beo-inninjr with a circular turn around the wrist, the bandage is carried to the tip of the thumb, and around this, over the back of the hand, and so on, with oblique turns till the base of the thumb is reached. If it is desired to bandage the tip of the finger, the roller is carried along the back or palmar surface of the finger over its tip and back on the other side opposite the starting-point, where it is retained while a cir- cular turn is made around the base of the finger, over the ends of the loop, securing it in its position. A bandage is applied to the whole hand according to the rules for the spica manus (Fig. 136). The bandage is started at the wrist by a circular turn, and then oblique or figure-of-eight turns are taken by the roller, grad- ually proceeding downwards till the finger ends Fig. 136. Spica manus. Fig. 137 the hand Bandage for Fig. 138.—a, Spica humeri ascendens. b, Spica humeri descendens. Fig. 139.- for the entire up- per extremity. are reached. It is concluded with a circular turn about the wrist. Another way of bandaging the hand is represented in Fig. 137, a and b. It is begun with a circular turn around the wrist (Fig. 137, a) 192 APPLICATION OF BANDAGES AND RETENTION APPLIANCES. or around the ends of the fingers, and proceeds up or down with figure- of-eight or oblique turns, half of the width of each upper turn overlap- ping a corresponding amount of the next lower turn, and finally termi- nating with a circular turn around the finger tips or the wrist. If it is desired to include the finger tips, as, for instance, in an antiseptic pro- tective dressing, the end of the bandage is secured while the roller is carried over and around the ends of the fingers and back on the oppo- site side in the form of a loop, and the extremities of the loop are then fastened in place by a circular turn. Application of a Bandage to the Shoulder.—The shoulder is bandaged by using the spica humeri ascendens (Fig. 138, a) or descendens (Fig. 138, b). The spica humeri ascendens (Fig. 138, a) begins with a circu- lar turn around the upper end of the arm, the bandage being then car- ried over the lower end of the shoulder from within outward, then over the back to the opposite axilla and back again across the breast over the shoulder through the axilla, and finally terminated by a circular turn around the thorax. The spica humeri descendens (Fig. 138, b) is applied in the reverse direction—i. e., it is begun with a couple of circular turns about the thorax, and finished with descending oblique or cross turns over the shoulder, terminating on the arm lower down, or with a circu- lar turn about the thorax again. Fig. 139 represents the method of applying a bandage to envelop the whole arm. The turns of the spica humeri around the thorax are omitted in the illustration in order to economise space, but the rest of the figure illustrates the bandage for the entire upper extremity. Application of Bandages to the Lower Extremity.—The bandage for the lower extremity is begun by enclosing the foot (Fig. 140, a and b) by a circular turn made back of the toes, as illustrated in Fig. 140, a • then two or three slightly oblique turns are taken, with or without the reverse (Fig. 127), and at about the fourth turn of the bandage the latter is carried ob- liquely over the anterior aspect of the ankle-joint toward the in- ternal malleolus, and from here over the heel and around the Fig. i40.-ApPiication of bandages to the foot. outer malleolus again to the inner side of the foot; thence across the sole, making two or three stirrup turns, and then ascending the leg with circular turns, followed by oblique turns and the reverse (Fig. 127). If the heel is to be included (Fig. 140, b), the bandage is begun §50.] APPLICATION OF BANDAGES. 193 as in Fig. 140, a / but after taking two or three turns, it is carried across the dorsum of the foot to the heel, around the latter, over the dorsum to the inner side of the foot, thence across the sole to the outer side of the foot, again over the dorsum to the heel, each preceding turn being covered by half the width of the following turn, and so on till above the ankle, when two circular turns are made, and then these are suc- ceeded by oblique turns with reverses ascending the leg. For applying a bandage to the region of the knee-joint the testudo inversa (Fig. 141, a and b) or reversa (Fig. 142, a and b) is used. In a b a b Fig. 141.—Testudo inversa genus. Fig. 142.—Testudo reversa genus. the testudo inversa (Fig. 141), after several circular turns are made around the leg, an oblique turn is carried across the popliteal space toward the thigh, passing around the latter back across the popliteal space to the leg and so on gradually covering in first the lower, then the upper part of the anterior aspect of the knee, the last turn crossing the centre of the anterior aspect of the knee transversely (Fig. 141, b). The testudo reversa is begun with a circular turn around the middle of the knee, and the remaining turns are made obliquely, first above and then below the original circular turn. The testudo bandage is also employed for the elbow. When it is desired to wrap the entire lower extremity in a bandage, the region of the knee may be covered simply by circular turns (Fig. 145). The hip, in the same way as the shoulder, may be bandaged by a spica coxae ascendens (Fig. 143) or descendens (Fig. 144). The spica coxae ascendens is begun with a circular turn around the upper part of the thigh, and then, in the case of the left hip, the bandage is carried across the gluteal and sacral region towards the opposite anterior supe- rior spine of the ilium, thence over the lower part of the abdomen and inguinal region back to the thigh. For the right thigh, the bandage is carried over the groin and abdomen to the anterior superior spine, 14 1 194 APPLICATION OF BANDAGES AND RETENTION APPLIANCES. turns around the abdomen, and is made to descend by oblique turns in a manner the reverse of the spica ascendens, and finally to come down the thigh by circular and oblique turns made with reverses. The method of bandaging the entire lower extremity will be understood from the previous remarks (Fig. 145). § 51. Application of suitably shaped Pieces of Cloth in place of Band- ages.—Properly shaped pieces of cloth as substitutes for bandages are Fig. 146.—Double piece of cloth : Fig. 147.—Handkerchief or impromptu bandage to support the jaw. cloth bandage for the jaw. not suitable for dressing wounds antiseptically, but under other cir- cumstances—viz., for applying a light protective dressing, or for the after-treatment of a wound, or in an emergency—they do very well, £51.] HANDKERCHIEF BANDAGES. 195 and possess the advantage that the material for making them can always be obtained in every household. These bandage substitutes are made of triangular or quadrilateral-shaped pieces of cloth. One of the most useful of these bandage substitutes is the sling bandage. The base or longest of the three sides of a triangular piece of cloth is cut in the manner indicated by the dotted lines in Fig. 146, thus mak- ing a five-tailed piece of cloth, which is excellent as a bandage for the inferior maxilla (Fig. 148). Another very good bandage substitute may be made by splitting the smaller sides of a long rectangular piece of cloth and applying it as a bandage for the head in the manner indi- cated in Fig. 147, a and b. These pieces of cloth used as bandage substitutes may either be folded up in the shape of a cravat and made to encircle any part of the body, or they may be used as simple unfolded pieces of cloth. The folded strips are applied like any ordinary roller bandage. For the sake of brevity I shall confine myself to the following short de- scription of the different methods of using these substitutes for roller bandages. As regards the head, a triangular piece of cloth folded into the shape of a cravat is an excellent substitute for the monoculus in band- aging the eye, and for making a horizontal bandage on the forehead like the fascia nodosa (Fig. 129). A very useful bandage as a tem- porary dressing for a fracture of the upper or lower jaw is the funda maxillae (Fig. 148), which is made from the five-tailed sling bandage represented in Fig. 146. The three-cornered piece is folded up like a cravat, the middle of which is placed under the chin of the patient, and the two ends are knotted together upon the top of the head. The point of meeting of the other two tails is held in front of the chin, and the ends of these tails carried around the back of the neck, where they are crossed and brought forward and knotted together on the forehead. Mention should also be made of the capitium parvum, magnum, and quadrangulare. The Small Head-dress (Capitium parvum, Fig. 149).— An ordinary triangular piece of cloth is laid over the head, with the centre of its longest side at the root of the nose, and its apex or angle opposite the longest side hanging down the neck. The lateral tails of the triangle are carried around the neck back to the forehead, where they are tied together. The tail hanging down the neck is turned back over the top of the head and secured with a safety-pin. The Large Head-dress (Capitium magnum, Fig. 150).—The triangu- 196 APPLICATION OF BANDAGES AND RETENTION APPLIANCES. lar sling bandage is cut in the manner represented in Fig. 146 and laid on the scalp, wdth the centre of its longest side at the root of the nose. Fig. 150.—Large handkerchief band- age for the head. Fig. 151.—Capitium quadrangulare. The two anterior tails hanging down on each side of the face are passed around the neck, as in the capitium parvum, and brought for- wards and knotted together on the forehead. The other two tails are tied under the chin, and the apex of the triangular piece of cloth is finally brought forwards, as in the capitium parvum, from beneath the tails, crossed behind the neck, and secured in front by a safety-pin. The Four-tailed Head-dress (Capitium quadrangulare, Fig. 151, a). —A quadrilateral piece of cloth is so folded over the top of the head that its under border overlaps the upper by about a handbreadth (Fig. 151, a). The two upper—or, rather, posterior—angles are knotted to- gether under the chin, while the other two corners are drawn some- what forwards and upwards. Then the projecting lower edge of the under portion of the cloth is turned up and back, and the two anterior corners are car- ried around be- hind the neck and tied, thus j forming the ij bandage repre- sented in Fig. 151, b. An ordinary three-cornered piece of cloth can be applied to the thorax in the manner illustrated in Fig. 152. The longest side of the triangle is placed around the lower portion of the thorax, while the Fig. 152.—Handkerchief bandage for the breast. Fig. 153.—Handkerchief bandage for the breast. §51.] HANDKERCHIEF BANDAGES. 197 apex or opposite angle of the triangle is carried over either the right or left shoulder and tied to the other two tails or angles of the triangle behind. In suitable cases a bandage may be applied as in Fig. 153—i. e., a folded piece of cloth is placed around the thorax and prevented from becoming displaced by a couple of retention straps carried over the shoulders and having their junctions with the breast-piece secured by safety-pins. The female mamma can be supported by an ordinary triangular piece of cloth, or one made double, as shown in Fig. 146. The sling is applied with the centre of the base of the triangle beneath the breast which it is desired to support. Then the lower tails or cor- ners at each side of this point are carried around the thorax, while the other three tails are conducted across the axilla and over both shoulders to the back, where they are tied together. Fig. 154.—Handkerchief bandage a for supporting the mamma. Fig. 155.—Mitella. The triangular piece of cloth is very frequently used for making the so-called mitella, or arm support (Fig. 155). The following is the method for applying the mitella: The three-cornered piece of cloth is grasped at each extremity of one of the shorter sides and placed be- tween the thorax and the arm bent at right angles, with one angle of the triangular cloth projecting around back of the elbow. The upper end of the longest side is then carried over the opposite shoulder and tied to the other end of the longest side behind the neck. The third corner or angle of the triangular cloth is carried around the back of the elbow to the front and secured in this place by a safety-pin (Fig. 155, a). Instead of bringing this third angle around in front of the elbow, it can be turned in, and then the two edges of the sling can be pinned be- hind the arm, as represented in Fig. 155, b. Moreover, it is a very good plan not to tie the ends of the sling around the neck, as the knot causes discomfort, but to bring the extremities to the front again, and either sew or pin them in that position. 198 APPLICATION OF BANDAGES AND RETENTION APPLIANCES. A four-tailed or four-cornered piece of cloth can be used for a sling, like the mitella, but the manner of its application is more complicated, without being any better. Fig. 156.—Handkerchief Fig. 157.—Knotted bandage Fig. 158.—Handkerchief bandage for the shoulder or about the inguinal region. bandage about the inguinal axilla. region. Strips of bandage can be used instead of the mitella. They are fastened to the coat or tied around the neck. An ordinary sling can be made for the arm, with a couple of suspensory strips attached to en- circle the neck, or the forearm can be bent at right angles and the hand inserted in the waistcoat or partially buttoned coat. In Figs. 156 to 160 are represented the methods for applying pieces of folded cloth around the axilla or the shoulder, about the in- guinal region, the hand, and foot, and they need no further explana- tion. In Fig. 157 the principle of the fascia nodosa is Fig. 159.—Hand- Fig. 160.—Handkerchief band- Fig. 161.—Hand- Fig. 162—Ilandker- kerchief band- age for the foot. kerchief bandage chief bandage for age for the hand. for the hand. the foot. about each other for exerting pressure upon some particular spot. By means of a pad of cotton, lead, rubber, or other material, the pressure can be increased. 51.] HANDKERCHIEF BANDAGES. 199 In Figs. 159 and 160 are represented the methods of applying a band- age substitute to the hand and foot. The hand is wrapped in a three- cornered piece of cloth in the following manner (Fig. 161) : The centre of the base of the triangle is placed at the wrist, while the angle oppo- site the base projects a little beyond the tips of the fingers. This pro- jecting angle is then turned back over the fingers and dorsum of the hand to the wrist, the lateral angles are given a turn around the wrist and made to cross each other on the dorsum of the hand, then brought back to the wrist and tied. The same idea is carried out on the foot, but instead of knotting the ends around the leg, they can be carried back from the leg and crossed over the dorsum of the foot, and finally tied after making a circular turn around the foot (Fig. 162). CHAPTER IV. THE SICK-BED OF THE PATIENT.--IMMOBILISATION APPLIANCES AND DRESSINGS. The siek-bed of the patient.—The bed.—Adjustable beds.—Bed fittings : Air-cushions; water-cushions.—Supports.—Wire cradles.—Appliances for lifting patients.—Ap- pliances for the siek-bed: Cushions; straw splints.—Planum inclinatum simplex and duplex.—Petit's leg splint.—Suspension.—Wire gutters and baskets.—Splints. —Materials for making splints (wood splints, paste splints, metal splints, glass splints, plaster splints, extension splints, articulated splints).—Complicated ap- pliances for the sick-bed. § 52. The Sick-bed of the Patient.—The greatest care must be exer- cised as regards the sick-bed of the surgical patient. The bed should be so arranged that the injured portion is easily accessible to the physician. In general, it is best to place the head of the bed towards the window, to prevent the patient from being blinded by the light. It should be as elastic as possible, and a spring or horse-hair mat- tress is far preferable to a feather bed. If the patient must be con- fined to bed for a long time, it is a very good plan to have a bedstead with contrivances for changing its shape, so that he can readily be brought into the horizontal or sitting position. A bedstead which the patient can adjust to suit himself with very little effort is particu- larly good. A water-tight rubber protective should be placed over the mattress to prevent it from getting wet. " Christia," a comparatively cheap, durable, and sterilisable preparation, has been recommended by Evens and Pistor, of Cassel, as a substitute for the ordinary water-tight substances hitherto used (rubber, oiled silk, gutta-percha, muslin, etc.). The greatest care must be used to keep the bed-linen perfectly clean, so that the dressings shall remain antiseptic. If the patient must lie for a long time upon his back, the sacral region particularly should be pro- tected from all injurious pressure by means of elastic cushions. For this purpose we use ring-shaped air-cushions, or, what is still better, large water-cushions filled with warm water. By means of a swinging crane placed over the head of the bed, or a sling attached to the foot of the bed, the patient is enabled to raise himself. By means of hoops joined together, or cradles (Fig. 163), (200) §52.] THE SICK-BED OF THE PATIENT. 201 Fig. 163.—Wire cradle for the limbs. the bed-clothes can be elevated from the diseased portion of the bodv upon which their pressure may be uncomfortable, or sometimes even painful. For lifting the patient or some portion of his body with as little disturbance as possible, we make use, when necessary, of special appli- ances called lifts. In the majority of instances they are not needed for changing the dressings or bed- clothes, or for enabling the patient to empty his bowels, and a nurse can render all the assistance required; but under many conditions—for ex- ample, when the dressings on a com- pound fracture have to be renewed, and the part must be held lifted up from the bedding for some time while it is being done—we employ windlasses, pulleys, belts, fenestrated scaffolds, etc. The portable fenestrated bed-lift, which is extensible and permits of defecation in the recumbent position, invented by Hamilton and Volkmann (Fig. 164), and Hase's apparatus (Illustr. Monatschrift d. iirzt. Polytech., Heft 6, 1883), are very useful contrivances. Yolk- mann's bed-lift is placed on the bed over the mattress and can be raised by two attendants, while the supports at each extremity can be automatically adjusted so that the apparatus can be re- tained at any desired elevation. Hase'sap- paratus consists of two steel rods with cross-bars in the re- gion of the shoulders and pelvis, and three straps for raising the head and legs; "from each one of these five parts a rope is carried over a roller on a crane projecting over the bed, and the patient is raised into an elevated position by turning a windlass. For elevating any single portion of the body, such as an extremity, the ordinary suspension ap- paratus will be found sufficient (Fig. 168). For enabling the patient to raise the upper portion of his body, cranes can be devised with two ropes and rings for him to grasp, or straps can be attached to the ceil- Fig. 164.- -Elevated frame for fractures of the vertebrae and pelvis (Hamilton, Volkmann). 202 THE SICK-BED OF THE PATIENT. ino- or to the foot of the bed. The pelvis of the patient may be lifted by a trestle on which is stretched a broad leather belt provided with a fenestrum for permitting evacuation of the bowels. But if it is impracticable to disturb the position of the patient at all, an opening can be provided in the mattress and bottom of the bed for enabling him to empty his bowels, or an arrangement can be made by which the mattress may be drawn from under him. The adjust- able bed of Hamilton and Volkmann is exceedingly well adapted for this purpose. § 53. Sick-bed Appliances—Splints, Cushions, etc.—There are numer- ous apparatus and contrivances for obtaining the necessary and secure position of a patient who is confined to bed, or of the particular part of the patient which has been operated upon. 1. Cushions.—The most useful cushions for retaining a diseased part in any required secure position are made of chaff, chopped straw, saw- dust, or sand. The cushions should be only partially filled, so that the contents may be shifted and the cushion given any desired shape for fitting the injured extremity and holding it securely. Sand bags or cushions are excellent on account of their weight, and the long, sausage-shaped bags are the best, as they can be placed along the whole Fio. 165.—straw splint for tem- length of each side of an extremity, espe- cially the leg. Chaff cushions are also very good, as their contents can be collected at each end of the bag, which may then be wrapped around an extremity and secured by a bandage, cloth, etc. Tbe same effect was obtained by the old-fashioned straw splint (Fig. 165), which can be made very simply by wrapping the two ends of a good-sized strip of cloth around bundles of straw or some similar material; the extremity is placed between two bundles, where it can be secured with a bandage. Tightly stuffed cushions of horse-hair or seaweed, the shape of which cannot be altered, are also used. In this class are Stromeyer's triangular axillary cushion with its rounded corners, and Middledorff's wedge cushion for fracture of the humerus. Large, wedge-shaped pads have been invented for the lower extremity also, having two plane surfaces inclined at an angle to each other. 2. The Single and Double Inclined Plane.—If it is desirable to ele- vate the peripheral end of an extremity either for inflammatory swell- ing, simple congestion, or for some injury or after an operation, it can be accomplished very readily by placing beneath the extremity chaff cushions arranged so as to form a simple inclined plane. The same re- §53.] SICK-BED APPLIANCES-SPLINTS, CUSHIONS, ETC. suit can be attained by placing under the leg an ordinary board with its distal end raised, and particularly by using Petit's box splint (Fig. 167). The double inclined plane is used chiefly for the lower ex- tremity. A large, wedge- shaped cushion will answer the purpose, or a couple of boards joined by a hinge and fastened with strings so as to maintain any de- sired angle. Esmarch's Fig. 166.—Planum inclinatum duplex. planum inclinatum duplex fitted with lateral retention pegs is exceedingly useful (Fig. 166). 3. Splints.—Leg splints are chiefly employed for fractures below the knee, and they may be used with advantage in all injuries of the leg. Petit's splint is a thoroughly good one (Fig. 167). Heister in- troduced it in Germany, and consequently it has been called by the lat- ter's name. By means of the wooden props attached to its bottom the splint can be raised or lowered, producing a greater or less amount of flexion at the knee, as the board under the thigh moves with the splint, to which it is attached by a hinge joint. This splint can be made into either a planum inclinatum simplex or duplex. The side- and foot- pieces can also be turned down, rendering frequent inspection of the extremity possible. The position of the extremity is represented in Fig. 167, with the pads which surround it. A long chaff cushion is laid on each side of the leg, and a greater or less amount of cotton or jute is stuffed into the in- ^ 167 _Petit,s D0X.splint for the leg. equalities to prevent any displacement of the fragments in the broken leg. Several turns of a bandage, or folded strips of cloth, are taken around the foot and foot- piece and around the leg and body of the splint to secure the limb in position. 4. Suspension.—All the old-fashioned suspension appliances for hold- ing the extremity in proper position are at present entirely superfluous, as we now combine all the various retention and extension dressings with suspension. Ketention dressings, particularly plaster bandages, will be again referred to later on. As will be seen, we now use, in 204 THE SICK-BED OF THE PATIENT. combination with suspension, retention dressings, which harden after their application, especially plaster-of-Paris bandages, with or without inserting splints or telegraph wire (Figs. 168, 169, 181, 182, 186, 196, 198, 199, 207, 208, 209). Amongst the various kinds of suspension splints in use those chiefly worthy of mention are Volkniann's (Fig. 177), Es- march's wood or telegraph wire splint for the upper and lower extremities (Figs. 169, 182), Smith's anterior wire splint (Fig. 186), Beely's gypsum-hemp splint (Fig. 200), Volkniann's wooden dorsal splint (Fig. 181), and Es- march's stirrup splint for the leg and foot, which consists of two splints, one for the sole of the foot, the other for the leg, the two being joined by a dorsal arch or bow. The special splints adapted to curvature of the spine will be described in the text-book on Special Surgery. Rauchfuss's Fig. 168.—The author's suspension apparatus. suspension appliance is represented in Fig. 218. The simplest way of suspending the lower extremity is illustrated in Fig. 196, where the limb is encased in a fenestrated plaster splint and hung from a wood or iron frame by a couple of strips of bandage. The point of support can also be arranged in the form of a gallows having a horizontal stick of wood attached at right angles to an up- right (Figs. 207, 208). I use an adjustable iron frame with rollers, as in Fig. 168. The cross-bar can be raised or lowered to any conven- ient height by means of the handle A. The rope for exerting the trac- tion with the weight G- runs over wheels, which can be moved to one side or the other and readily retained at any point by the notches in the cross-bar. Iron frames which can be fastened to the bed are very useful. 5. Wire Splints. Wire Gutters, Stockings, and Cases.—Wire gutter splints (Figs. 170, 172) are as simple as they are comfortable, and have supplanted to a large extent the contrivances just described. Wire gutters are usually made of wide-meshed wire gauze, padded with a thin layer of horse-hair or small cushions of cotton, jute, etc. They are §53.] SICK-BED APPLIANCES-SPLINTS, CUSHIONS, ETC. straight, or bent at an angle, and of various lengths and sizes. As they are flexible they can be made to fit the limb more or less accurately by means of straps. Roser's contrivance is very useful. It consists of a wire gutter for the entire lower extremity, and is made in two or three different parts, which can be telescoped together to any desired extent and fixed in the proper position with strings. For immobilising both lower extremities, together with the pelvis, for example, in fractures of the latter, Bonnet's wire stockings are widely used (Fig. 172). Bon- net has also invented an excellent wire frame or case for enclosing the whole body in fractures -^IG- If 2.—Bonnet's wire stocking for both lower extremities J and the pelvis. of the vertebras. 6. Splints and Splint Bandages.—Splints are generally employed in the treatment of fractures and in making dressings which harden after their application, as well as ordinary antiseptic dressings. Splints are made in an immense variety of shapes, either resembling more or less deep gutters, or only slightly concave or entirely flat; they may be straight, or bent at a right, acute, or obtuse angle. The particular kind of splint required for this or that portion of the body will be dealt with in the Special Surgery, and only a general review will be given here. Splints are made of wood pulp, metal, silica, felt, plaster, etc. Wooden Splints.—The stiff, unyielding wooden splints are usually made from the coarse heart wood of the tree; they are flat or slightly concave, or fashioned to fit the contour of a particular portion of the body, and they may be straight or bent at an angle. Fenestras are usu- ally cut in them to correspond to any projecting portions of the body, 206 THE SICK-BED OF THE PATIENT. such as the internal condyle of the humerus at the elbow, or the malleoli at the ankle, and thus the skin over these points is preserved from an Fig. 173.—Splints for the arm and hand. undue amount of pressure, which might cause it to become gangrenous. In Fig. 173 are represented various kinds of splints for the upper ex- tremity ; they are straight, or bent at an acute or obtuse angle, and made Fig. 174.—Esmarch's splint for the arm in Fig. 175. —Volkmann's supination splint. case of resection of the elbow. of wood or papier-mache. The splints (c tof) are padded with cotton, jute, or tow, and then covered with rubber tissue, the ends of which are stuck to the back of the splint with chloroform. These splints are used almost exclusively for inflammation, injuries, and fractures of the fingers, hand, and forearm. The splint d is somewhat modified from Xelaton's pistol splint for fracture of the radius. Wooden arm splints for the entire upper extremity can be made like the models represented in Fig. 173, e or f Esmarch's arm splints (Fig. 174) are also very useful, for example, after resection of the elbow- joint ; Volkmann's supination splint is likewise good, and enables the arm to be immobilised in a position between pronation and supination (Fig. 175). Esmarch's double splint (Fig. 176) is exceedingly good for a resected §53.] SICK-BED APPLIANCES—SPLINTS, CUSHIONS, ETC. 207 elbow-joint. It consists of two parts upon which the arm rests the upper portion being joined to the lower by a steel bow (Fig. 176, b). If it is desirable to place the forearm and hand in a vertical position, in cases of acute inflammation, in order to lessen the con- gestion, Volkmann's sus- pension splint is very use- ful (Fig. 177); the ring at the extremity of the splint is employed for suspending it in the ver- tical position; but an ar- rangement of cushions and bandages will ordi- narily be found sufficient for securing the forearm in position. The two excellent splints of Esmarch and Lister for resection of the wrist are represented in Fig. 178, a, b, and Fig. 179. Esmarch's bow splint is easily made from a piece of wood or sheet iron. Amongst the great number of wooden splints for the lower extremity, mention should be made particularly of Watson's splint (Fig. 180) for the posterior surface of the leg, with a notch for the heel, and of Bell's splint for the thigh or leg, made of two strips of wood buckled together by a strap. Volkmann's wooden dorsal splint is another good one (Fig. 181). Esmarch's wooden splint for resection of the ankle-joint is repre- sented in Fig. 182; it is applied to the posterior surface of the leg, Fig. 176.—Esmarch's double splint for resections of the elbow. Fig. 177.—Volkmann's suspension splint. 2;>S THE SICK-BED OF THE PATIENT. which is then wrapped in gypsum bandages and suspended from hooks made of telegraph wire. Fig. 178.—Esmarch's interrupted splint for Fig. 181.—Volkmann's dorsal splint (for resections of the wrist. ' suspension). Fig. 180.—Watson's splint for the lower ex- Fig. 182.—Esmarch's wooden splint for re- tremity. sections of the ankle. Pliable Wooden Splints.—In addition to these stiff wooden splints there have been recommended splints made of wood which is capable of bending, but they have not been received with as much favour as they deserve. They are always well suited for making an impromptu dressing, especially in transporting patients to the hospital. Even in ancient times, according to the assertion of E. Fischer, splints were manufactured from wood which could be bent into any desired shape. For this purpose there were used the stem of the Spanish broom, strips of wood cut very thin, pieces of veneer- ing, green twigs, palmetto leaves, and the bark of trees. According to Fig. 183.—Esmarch's materials for making the Same authority the Turks Use splints. '' moulded wooden splints made of the fibrous portions of palmetto leaves sewed to thin leather, thus obtaining a material which can be applied to an injured limb either circularly or in the form of a gutter. Martini and Grooch glue narrow, thin strips of wood taken from the linden tree close together upon soft leather, and §53.] SICK-BED APPLIANCES—SPLINTS. CUSHIONS ETC. 209 in this way a splint can be made which is an excellent temporary dress- ing for a fracture, particularly of the lower extremity. Esmarch's splint material, which can be cut into any required size, is very similar to this (Fig. 183). It consists of strips of wood three centimetres wide and one and a half centimetre thick, which are glued between two layers of cotton cloth. Herzenstein advises that splints be made after the fashion of the ordinary trellis work used for supporting vines. Keeds, willow withes, and straw made into mats have also been recommended as splints. Thin, pliable strips of wood about three to four centi- metres wide make a very good material for splints when combined with plaster bandages, and are also very useful for immobilising a joint after an antiseptic dressing has been applied. Wood Dressings.—Waltuch recommends wood dressings made of shav- ings, 4-5 centimetres wide and 05 to 1 millimetre thick, and any desired length, which are prepared by planing pine planks in a particular way. The wood shavings roll up spontaneously like a bandage, are more easily bandied than thin board splints, and much cheaper than the latter. This wood dress- ing, consisting of shavings bound togetber with glue, is suitable for corsets, for encasing a limb, etc. (Wien. klin. Wochensch., 1888, No. 10.) Papier-mache Splints.—Splints made of stout papier-mache, about three millimetres thick, are very frequently employed for immobilis- ing purposes. These splints are usually made with flat edges, which may be bent into any required shape, or else flat pieces are used of varying widths. After dipping this material in warm water just be- fore it is to be used, it becomes soft, and can be readily made to fit any part of the body when fastened on with a bandage. The small papier- mache splints are chiefly used for strengthening dressings in which starch is employed. Metal Splints.—Metal splints are generally made of iron, sheet iron, tin, zinc, telegraph wire, wire gauze, etc., and may be stiff and un- yielding or capable of being bent into any shape. Volkmann's sheet-iron splint (Fig. 184) is ex- ceedingly good, and in very gen- eral use for the lower extremity. It is a good plan to make this of two parts—an upper and lower— FlG- 184'_Volk^vnefsexsiemitr°n spUnt for the for lengthening and shortening the splint any necessary amount (Miigge). Metal splints which are cap- able of being bent into any shape are best made of telegraph wire, tin, zinc, or galvanised iron. Flat splints, made of thin tin plate, have been recommended by Solomon and introduced in the Danish army; they 15 210 THE SICK-BED OF THE PATIENT. are thirty-five centimetres long and ten centimetres wide, having at one end two small, three-pronged projections, which are hook-shaped and notched, and at the other two clefts, into which the projections are in- serted and secured, thus rendering it possible to make a splint of any desired length. Thin galvanised iron which is capable of being cut with shears has been recommended, especially by Schon and Weiss- bach, as a material suitable for splints. Schon gives directions for # A J ft 72 A ..:_____\ \. ®- IS 1 ? 21 t a - i / Fig. 185.—Pattern for cutting out a gutter for the arm or leg (Schon). making excellent splints in a very short time from this substance, and hinge joints, fenestra?, and interrupted spaces can be inserted. In Fig. 185 is represented a simple way of making a gutter splint for the arm and leg. The gutter splint for the arm (Fig. 185, a) is made by cutting out a splint of the desired size and bending it on its long axis so as to form a shallow groove, and then transversely so as to make an obtuse or right angle. Strings are passed through the punctures at a a, and tied to maintain tbe splint at the proper angle. The gutter splint for the leg is cut from galvanised sheet iron, as represented in Fig. 185, b ; it is then bent on its long axis into a half circle, and the foot-piece is formed by bringing the lateral parts a a around behind the middle part, and retaining them in this position by strings or wires. Wire Splints, made from properly bent telegraph wire or from wire netting, have recently come into considerable favour. Telegraph wire is chiefly used at present for making suspension splints, and in the prepa- ration of the interrupted plaster splint (Figs. 197-199). One of the best-known kinds of wire splint is Smith's (Fig. 186), which is espe- cially well suited for the treatment Tiri86.-Smith'B anterior wire splint. of compound fractures of the lower extremity. It is made of two nearly parallel bars joined at their extremities and in the intervening space by from two to four movable wire arches or hoops, to which are attached the ropes for suspending the splint. At three places—namely, over the ankle, knee, and hip joints—it is slightly bent, and is then applied to §53.] SICK-BED APPLIANCES—SPLINTS, CUSHIONS, ETC. 211 the anterior surface of the limb, to which it is secured generally by a plaster bandage. Fig. 187.—Esmarch's splint for the arm, made out of telegraph wire. Fig. 188. -Esmarch's wire sieve splint with strings. r 1 ^^SSV^VN^V^V^V. Esmarch has constructed a splint (Fig. 1st) of telegraph wire for the upper extremity, which approaches the character of the splints made of wire gauze gutters for the upper and lower extremities (Figs. 170,171). AVoven wire is also used for making splints which can be bent into different shapes. Esmarch has recommended the use of long strips of wire lattice for splints (Fig. 188), and from this material it is very easy to make a splint similar to Bonnet's stocking (Fig. 172). Cramer's lattice-work splint, made of iron wire tinned over, is exceed- ingly good both for ordinary practice and for army surgery. These splints can be bent into any shape, and can be made to fit over any dressing or any part of the body (Fig. 189), and they can be lengthened by fastening one or more together. By taking out some of the cross-pieces and bending the lateral bars the splint can be made interrupted, or can be bent at any angle (Fig. 1S9, d, e). Neuber has recommended splints made of glass (Figs. 190, 191), as particularly good for cases where an antiseptic dressing is left in place for a considerable time. They are transparent, and permit all parts of the dressing to be inspected without disturbing the limb. Glass splints Fig. 189.—Pliable splints made of iron wire tinned over (Cramer). 212 THE SICK-BED OF THE PATIENT. are comparatively cheap, very clean, and not so easily broken as one might imagine. Gluck has had splints made of glass, porcelain, and earthenware. Plastic Splints.—Moulded splints are prepared by wetting or heating the material of which they consist, and when it has become soft and Fig. 190.—Neuber's glass splint for the Fig. 191.—Neuber's glass splint for the upper extremity. lower extremity. plastic it is made to fit snugly over some particular portion of the body by the aid of a roller bandage. After the material becomes dry or cold, whichever the case may be, a hard, unyielding splint results which fits very closely. Such splints may be made in the shape of strips of from two to four finger breadths in width, or in the shape of a gutter which may surround a half or the entire circumference of a limb. Papier-mache.—In the preparation of these splints ordinary papier- mache can be used, though it only possesses a moderate amount of firm- ness when dry. The prepared papier-mache of P. Bruns is better, and consists of ordinary papier-mache which has been impregnated with some hardening substance, generally shellac. When this preparation is warmed in a hot oven, or wet in boiling water, it becomes soft, and capable of being moulded into any shape in a very few minutes, and subsequently becomes as hard as wood in from five to ten minutes. Plastic Felt.—Pliable felt can be used in a similar manner, and P. Bruns describes its preparation as follows: A sheet of ordinary felt, from five to eight millimetres thick, is soaked in a solution consisting of one part shellac to one and a half parts of alcohol until it has be- come completely saturated, or until the felt will absorb no more of the solution. (It takes up about four times its own weight.) It is then allowed to dry, and from this material excellent splints can be made in the shape of flat strips, or gutters, or cases. After cutting the piece of plastic felt into the proper shape, it is dipped into v/ater which is almost boiling, or stroked with a hot flat-iron or laid on a hot stove-lid, which causes it to become as soft as any ordinary unimpregnated felt. The softened felt is then applied with a roller bandage to the limb, which has been previously covered with a bandage or with cotton, and in a short time this splint becomes as hard as a board. F. Schwarz has used moulded felt in Billroth's clinic, as a substitute for more expensive §53.] SICK-BED APPLIANCES—SPLINTS, CUSHIONS, ETC. 213 and complicated contrivances, with the very best results (Wien. med. Wochensch., 1886, No. 37.) Gutta-percha.—Gutta-percha can be used in a similar manner for making straight, gutter, or case splints. Gutta-percha, or the dried sap of an East Indian tree (Isonandra gutta, Sapotacee), was introduced in Europe in 1843, and was first used for treating fractures in England in 1846, though it had been employed for this purpose in Borneo a long time previously. When gutta-percha is warmed in hot water it becomes soft and capable of receiving any shape, and then hardens when it cools off, in about fifteen minutes. For making straight, gutter, or case splints of gutta-percha, sheets of this material are cut into the proper form and softened by immersion in water at a temperature of 75° to 85° C. The splint is then allowed to cool off slightly, and after being modelled into the shape required to fit the particular extremity, which has been previously encased in a flannel bandage, it is kept in place by a wet roller bandage. By gluing together the edges of two gutters a circular splint may be made. Gutta-percha is not affected by water, blood, pus, or urine, but it is expensive, and on this account has not been very generally used. Caoutchouc Splints.—The black, stiff splints made of caoutchouc are also very good, and can be made to assume almost any form by warm- ing them in hot water. Leather.—Ordinary leather is an excellent material for making straight or case splints ; it should be soaked in water and applied to the limb with a roller bandage while in a wet condition, when it is capable of being moulded. Paraffin.—Paraffin has been recommended for splints, but it is hardly firm enough, and is very apt to cause an eczema. The plaster splint is referred to in § 54 (Plaster Dressings). The Author's Plastic Splint.—I have had made an excellent plastic material for the manufacture of splints; it is prepared from the fibres of an African plant, and can be had of the firm of F. Flinch, in Leip- sic. A piece of this material is cut of the proper shape and dipped in hot or boiling water, and is thus made so soft that it can be moulded into any form. After a short time this splint becomes very hard. Cellulose Splints.— R. de Fischer has advised the use of a hardening mate- rial for splints made of cellulose. Thick, flat plates of cellulose are manu- factured for this purpose having the outline of the different limbs, and strengthened on one side with water glass. This side of the splint is then. before use, painted over with nearly boiling water, which causes the material to become immediately soft and pliable. The splint is applied wet side out. and fastened in position with gauze bandages which have been saturated with 214 THE SICK BED OF THE PATIENT. cold water. These splints can be strengthened by impregnating them with water glass on both sides. They are said to possess tbe advantage of simplic- ity, rapidity in hardening, lightness and durability, and, furthermore, cost very little. They are manufactured by the apothecary in Triest, Karl Zanetti. Extension Splints.—Before the introduction of extension by weight, extension splints were employed, and they will be referred to in their proper place. Articulated Splints.—Jointed splints are those consisting of two or more ordinary splints united by a joint or some material capable of Fig. 193.—Adjustable clamp apparatus. Fig. 194.-Clamp apparatus pro- vided with a joint. soft parts, and for the after-treatment of resected joints as a supporting apparatus. §53.] SICK-BED APPLIANCES—SPLINTS, CUSHIONS, ETC. 215 Stillmann has also recommended an excellent adjustable brace, which permits motion in the joint to which it is applied, and which can be readily included in a plaster dressing (Figs. 193, 194). Be- sides all these appliances which have just been described, a great num- ber of complicated apparatus for securing parts in their proper position have been devised and recommended, but the majority of them can be easily dispensed with. Later on we shall become acquainted with sev- eral simple contrivances in the way of dressings and braces for treating particular diseases and injuries, but it has been intended at present to give only a brief review of the most useful appliances which are at our disposal. Improvised Dressings of the Battle-field.—In times of war it may become necessary to improvise dressings and splints out of whatever materials may be at hand. J. Port has written a book on this subject (Stuttgart, Ferd. Enke, 1892), in which are a number of illustrations and descriptions of materials which can be used as surgical dressings. Apparatus for Home Gymnastics.—Brief mention should be made in this place of the different kinds of apparatus used for gymnastic pur- poses which should always be found in every hospital. It would take too much space to describe them except in a very general way. L. Ewer has lately recommended a house-boat which is a very good substitute for rowing on the water. It forms an excellent addition to the number of contrivances for home gymnastics (see Illustr. Monatsch. fur artz. Poly- tech., Feb., 1889). The machines invented by Zander, of Stockholm, afford many kinds of gymnastic exercise which are exceedingly useful in some cases, and their place cannot be supplied by either massage or passive motion. CHAPTEE V. THE APPLICATION OF IMMOBILISING DRESSINGS MADE OF MATERIALS WHICH GRADUALLY HARDEN. The application of extension dressings.—Plaster dressings.—Dressings of tripolith, starch paste, gutta-percha, and felt.—The methods of applying extension dressings. § 54. Immobilisation Dressings of Hardening Substances.—Dressings for producing immobilisation are used for fractures, inflammations in joints, and after many operations—for example, in the after-treatment of resections and osteotomies, etc. ; they serve the purpose of prevent- ing movement in the part of the body under treatment. Even in ancient times attempts were made to form immobilisation dressings from substances which would subsequently harden, but the methods were imperfect. To Larrey, the distinguished army surgeon of Na- poleon I., belongs the honour of having generally introduced those immobilising dressings which were applied in the soft state and then allowed to harden. Larrey soaked the dressings for twenty-four to thirty-six hours in a mixture made of albumen, liquor plumbi subace- tatis, and spirits of camphor. This somewhat tedious procedure was supplanted by the starch dressing invented by Seutin in 1834. As the starch dressing took a long time to harden, attention was directed to some more rapidly hardening material, and gypsum was taken up, a substance which had been employed by the Arabian physicians. The honour of introducing the gypsum dressing and the methods of apply. ing it is due to the two Dutch physicians, Mathysen and Van der Loo. Numbers of other hardening substances, such as water glass, tripolith, etc., have also been used in the same way. The Gypsum Dressing.—Amongst all the materials employed for mak- ing an immobilising dressing there is none better than gypsum, pos- sessing, as it does, the power of rapidly becoming hard. Gypsum, or plaster of Paris, is hydrated sulphate of calcium (CaS04 -f- 2H!10). The gypsum used in dressings is burned or dehydrated, and after mix- ing it with water it hardens in a few minutes to a solid mass, forming with water a firm chemical combination. The plaster dressing can be (216) §54] IMMOBILISATION DRESSINGS OP HARDENING SUBSTANCES. 217 applied in many different ways, the best being in the form of plaster bandages. For this purpose bandages, preferably of gauze, are im- pregnated with dry gypsum powder by rolling them in the latter and working it into the meshes of the gauze. Soft mull bandages can also be treated in the same way. The application of the gypsum dressing is begun by smoothly enveloping the particular portion of the body with a soft mull or flannel bandage, or with a thin layer of cotton, over which is placed a soft mull bandage. In cases where it is necessary, the extremity may first be greased with oil, lard, or vaseline, to prevent the plaster from sticking to the hairs; bony projections should be cov- ered with a little cotton, to avoid pressure at these points ; and, above all, one must be careful to apply the bandages loosely, so that after drying they do not become too tight. Cotton hose can also be used beneath the gypsum; it is drawn over the extremity like tights; it is cheap, and fits exceedingly well without forming wrinkles. When necessary, two or three layrers of this material may be put on over each other. The roller gypsum bandages are then allowed to soak in water about a quarter of a minute, or until no more air bubbles are given off. The bandage is then squeezed dry and applied to the part in question as loosely as possible. It should never be drawn tight, as this will cause the bandage to become too narrow, and may subsequently impede the circulation in the limb. There is no need of making a reverse with the gypsum bandage, as a few wrinkles do no harm and can be smoothed out by rubbing the bandage with the hand, and thus causing the dress- ing to conform accurately to the shape of the limb. After about three or four layers of gypsum bandage have been applied, a thin layer of gypsum paste can be added; it is made by mixing together gypsum powder and water in about equal proportions. This layer is spread on and smoothed over with the palm of the hand, the smoothing process being continued until the dressing looks as though made in one piece. The gypsum paste should not be put on too thick, for fear of making the dressing very heavy, and I frequently do not use it at all. Plenty of bandage and not too much plaster is my maxim. The edges of the dressing are best treated by turning up the projecting underlying ma- terial (cotton or bandages) like a cuff and securing it to the outer surface of the splint with a turn of the plaster bandage or a little of the paste. Even while the bandages or outer layer of gypsum paste are being smoothed down with the hand, it will be noticed that the dressing has become firmer. In the next few minutes it becomes noticeably warm and at the same time perfectly hard, but not till two or three hours later will the dressing be completely dry. By the addition of some 218 THE APPLICATION OF IMMOBILISING DRESSINGS. crystalline substance, like chloride of sodium or alum, the hardening of the gypsum can be accelerated. If it is desired to make the plaster dressing water-tight, its external surface can be painted with a solution of resin in ether—one to four (Mitscherlich)—or a water-glass bandage may be placed over the gypsum; this latter method is the best. It makes the gypsum dressing, particularly when applied to children, exceedingly durable. For increasing the strength of the plaster dress- Fig. 195.—Thin splint of wood used for strengthening a plaster-of-Paris dressing. Fig. 196.—Fenestrated plaster dressing, sus- pended in a wooden frame. ing the latter is often made to include thin, pliable strips of wood (Fig. 195), or splints made of papier-mache, wood, zinc, or wire. If it is not desirable to cover in some portion of the body by the plaster dressing on account of wounds, fistulse, etc., a fenestrum (Fig. 196) can be cut out over this portion, the location of wliich may be previously indicated by placing over it a piece of cotton or a flat disk having a projecting nail. The edges of the fenestrum can be smoothed off with a little plaster paste or asphalt, to prevent fluids such as pus from gaining access to the under surface of the dressing. When a considerable portion of an ex- tremity, such as the knee- or elbow-joint, is to be left out of the splint, two plaster cases should be applied, one, for ex- ample, to the thigh, the other to the leg, joined together by an iron rod, which can also be cov- ered with plaster (Fig. 197); telegraph wire can be used in the same manner. Under other conditions, when, for instance, one wishes, at the same time, to suspend the extremity, another plan is carried out which is represented in Figs. 198 and 199. Two plaster cases are applied to the extremity while it lies upon a suitable splint, Fig. 197. -Interrupted plaster dressing knee). (for the Fig. 198.—Interrupted plaster dressing, suspended (upper extremity). §54.] IMMOBILISATION DRESSINGS OF HARDENING SUBSTANCES. Fig. 199, Interrupted plaster dressing, suspended (lower extremity). and a telegraph wire, having been bent into proper shape, connects the two separate bandages on the dorsal surface of the limb and is covered by plaster bandages (see Figs. 207, 208, 209).' In the same way two plaster cuffs can be provided with a hinge so as to form a joint, which is useful in the after- treatment of a resected elbow (Heine). Gradual stretching of Contracted Joints by the Plaster Dressing.— The plaster dressing can also be used for gradual extension of contracted joints. A plaster case is applied to the lower extremity and an oval-shaped fenestrum cut over the region of the anterior surface of the knee, and at the same time the splint is cut behind transversely across the popliteal space. Day by day continually larger pieces of cork are then wedged into the posterior line of division in tbe splint, and thus the knee-joint is gradually extended. Gypsum Dressing combined with an Antiseptic Dressing.—The great advances in modern aseptic surgery render possible the frequent combina- tion of plaster with antiseptic dressings. After osteotomy, for instance, of the femur, we cover the open wound with an aseptic protective dressing and then place over this a plaster splint, which is left undisturbed till the wound has healed, or from four to six weeks. We often adopt a similar practice in the after-treatment of resected joints, allowing the wound to remain par- tially open, or not sutured tight. In other cases of joint resection the plaster bandages are not placed over the antiseptic protective dress- ing till about three to five days after the operation, when the drains are taken out. In compound frac- tures the plaster splint is combined with the antiseptic dressing at the earliest possible moment. Berg- mann's and Reyher's experiences show that gypsum dressings will become of the greatest use in army surgery. These surgeons obtained most excellent results, during the Russo-Turkish war, from combined antiseptic and plaster dressing for the treatment of gunshot wounds of bone. In addition to the plaster bandage dressing, as it is ordinarily described, mention should be made of the follow- ing modifications: Modifications of the Gypsum Dressing.—Compresses, pieces of cloth, or parts of the patient's clothing, are dipped in plaster paste and either laid Fig. 200.—Gypsum-hemp splint (Sehonborn and Beely). Fig. 201.—Case for the lower extremity, with straps, buckles, and a hinge-joint on the op- posite side. 220 THE APPLICATION OF IMMOBILISING DRESSINGS. around an extremity or fastened on with bandages after previously enveloping the limb in some buffer dressing. These gypsum cataplasms are highly rec- ommended by Pigoroff, Adelmann, Szymanowski and others for making a hasty dressing to suffice during transportation of the patient. Beely and Sehonborn dip strands of hemp in plaster paste, thus making gypsum-hemp splints to which buttons can be attached for purposes of suspension (Fig. 200). Splints which are made in a similar manner with cotton are more com- fortable, and are adapted especially for making Braatz's spiral splint for frac- ture of the radius (see Spec. Surg.). Cotton impregnated with gypsum, or the gypsum plates of Fickert, are dipped in hot water before they are applied to the limb. They harden after some eight to ten minutes. Gypsum powder is also sewed up in a sack, and when soaked in water it forms a mass which readily becomes moulded to the limb, and when dried makes a splint which can easily be taken off (Zsigmondy). By sewing together two of these sacks full of plaster longitudinally upon one side and laying them around an ex- tremity and then wetting them, a gypsum splint is formed having the sewed connection between the two bags as a hinge to facilitate its removal from the limb. In a similar manner immobilisation appliances can be made in two or more parts which can be fastened on a limb with bandages or secured with straps and buckles (Fig. 201). In this way most excellent splints can be fashioned of gypsum or other hardening material, such as waterglass, and also many kinds of supporting apparatus can be substituted for those manu- factured by instrument makers. Auschiitz advises that the straw splints which have long been employed by stretcher bearers as a transportation dressing be soaked in plaster paste and bound on with a wet gauze bandage. The plaster cast is the oldest method of applying the gypsum dressing, but is at present no longer used. It origi- nated in the Orient, was employed by the Arabians of ancient times, and was very generally used in Europe at the beginning of this century, especial- ly by Froriep and Dieffenbach. The skin of the extremity was first covered with oil and then enclosed in a wood or sheet metal case which was poured full of plaster paste. Finally, the limb was taken from the case surrounded by the plaster mould. Back Support.—For the application of the plaster dressing to the lower extremity, and particularly to the thigh and pelvis, extension and supporting appliances are of great utility. They render the pelvis accessible on all sides, and prevent a fractured femur from becoming shortened. The simplest form of pelvic support is represented in Fig. 117; it is Yolkmann's cushioned support, which is placed under the sacrum. A footstool used in the same way forms an excellent back rest. The patient is secured in the horizontal position, with extension applied to the leg and counter extension to the axilla. Billroth, Bar- deleben and others have invented excellent back rests. Extension ajjpliances are sometimes very useful accessories in ap- plying a plaster splint to the thigh, especially if the fracture is oblique and there is marked shortening. Liicke, Heine and Bruns have in- §54.] IMMOBILISATION DRESSINGS OF HARDENING SUBSTANCES. 221 par- ints. vented extension appliances for this purpose. Pulleys are used, ticularly for the lower extremity, in the application of plaster spl Special contrivances for extension are, as a rule, unnecessary, and the hands of an assistant will ordinarily be found suffi- cient. Plaster dressings are applied to the thorax chiefly in treating fractures of the upper end of the humerus (Fig. 202). A plentiful amount of cotton padding, with a wad of cotton in the axilla, is first applied and secured with a mull bandage, while the forearm is held across the thorax with the elbow bent at a right an- gle; then the plaster-splint dressing is placed over the padding, enveloping the thorax, the forearm, and the fractured arm. Removal of Plaster Splints.—Plaster ., 7 jr. .,i Fio. 20-2.—Gvpsum bandage around splints Or dressings are taken OJJ With the shoulder, thorax, and arm the assistance of a knife made especially ^^^°f the UN-*>art of for the purpose (Fig. 203), and with shears (Fiff. 204, a, b). Small ordinary saws, as well as circular saws, have also been recommended for this purpose. The plaster knife should be held with its edge somewhat at an angle to the splint, so as to cut it obliquely to the external surface; or two oblique longitudinal incisions are made in the plaster forming a Y-shaped gutter. The deeper layers of the splint should be cut with the plaster shears. By moist- ening the whole splint with water, or only along the line where it is to be cut, the cutting process is made much easier. After the plaster dressing has been cut through longitudinally, the edges of the incision are pulled apart and the limb is lifted out. Plas- ter splints which have been cut and taken off may, when desired, be replaced and used again. In such cases it is best to connect the f Fig. 203.— Knife for plaster dressings. Fig. 204—Scissors for plaster dressings. 222 THE APPLICATION OF IMMOBILISING DRESSINGS. edges with plaster paste or adhesive plaster, over which plaster paste is applied, and thus the edges of the splint are less likely to become sepa- rated. Tripolith Dressing.—Langenbeck has recommended tripolith as a sub- stitute for gypsum or plaster of Paris. Tripolith is a greyish, cement- like substance consisting of gypsum with a little silicate of aluminium and charcoal or coke. The properties of tripolith are in general the same as dehydrated gypsum, but tripolith, according to Langenbeck, is somewhat lighter and cheaper than gypsum; it also hardens a little more rapidly, and when hard will not absorb water. The tripolith dressing is applied with bandages, like plaster of Paris. The Starch Dressing.—Starch paste was recommended by Seutin, in 1834, for the manufacture of stiff dressings. A starch dressing is easily applied, agreeable to the patient, cheap and light, but it has the disad- vantage of requiring from one to three days to become dry, and for this reason starch dressings have been supplanted by plaster in the treatment of fractures. The starch bandage is frequently combined with pasteboard splints in fracture of the arm, and is also used alone in the later treatment of any fracture. The method of applying the starch bandage is briefly as follows: A padding is laid on the skin in the shape of a flannel bandage, and the bony prominences are protected from too much pressure from tbe starch dressing by a layer of cotton. A soft mull bandage is applied over the flannel, and then a layer of starch or bookbinders' paste is spread over the mull. Several strips of pasteboard of various sizes are rendered soft and pliable by soaking in warm water, and are included in the dressing in such a way as to encase the limb, leaving short inter- vals between each strip. The pasteboard is then covered evenly with the starch paste, and over this is placed a mull bandage, which receives another layer of starch paste. Some three to four layers are enough, and the strips of pasteboard can be used in a double layer, especially if they are narrow. Finally, a dry mull bandage is applied to prevent the starch paste from adhering to the clothes, or a bandage in the form of a bag may be used, as well as black silk, to improve the appearance of the dressing. The dressing is cut open with a stout pair of shears, and can then be used as a removable splint in the same way as described for the plaster splints (Fig. 201). Cotton-Starch and Paper-Starch Dressing.—The cotton-starch dressing of Burggraeve and the paper-starch dressing of Laugier and Heyfelder are modifications of the ordinary simple starch dressing. The latter is made by including strips of paper in the bandages and covering them with starch paste. In the cotton-starch dressing the limb is enveloped in from two to §54.] IMMOBILISATION DRESSINGS OF HARDENING SUBSTANCES. 223 four rather thick layers of cotton wool, over which is applied the starch- paste dressing, with strips of pasteboard softened in warm water, and made to fit the extremity by wrapping over them a mull bandage in the manner just described (page 222). The Water-Glass Dressing (Schrauth, Schuh, 1857) is very easily put on, is cheap, durable, hard, and light, and is also impervious to water, but has the disadvantage of requiring twelve to twenty-four hours to harden. It is best to use a freshly made solution of neutral silicate of potassium having a specific gravity of from 1-35 to 1*40. This dress- ing, like the plaster of Paris, is applied in prepared bandages which have been saturated with water glass having the consistency of syrup. About five to six layers of the water-glass bandages are sufficient. It is best to use a flannel bandage, or cotton and a mull bandage, as pad- ding to lie beneath the water-glass bandages. The skin should be care- fully protected from contact with the water glass, as the latter is liable to cause a very obstinate eczema, particularly when old solutions are used. Furthermore, the water-glass bandages should not be carried beyond the limits of the protective padding, as the sharp edges of the splint may cut into the skin. The water-glass splint can also be strengthened by including in it thin strips of wood or other material. It is an excellent plan to mix with the water glass, gypsum, chalk, cement, etc. These substances make the dressing harden more rapidly and render it very firm (Bohm, Konig, the author). Ban- dages are soaked in the thick paste and applied as in the plaster dressing, or the paste made from water-glass powder is applied with a brush to the bandages after they have been put in place. At the end the entire dressing can be dusted with the dry powder and painted over with alcohol, which gives it a hard, glassy covering. The water-glass splint is much used in the treatment of inflamed joints, fractures, etc., and can also be made into hinged, remov- , ■, -.. , -fT -, -i tt /-j i Fig. 205.—Bandaares, artificial limbs, and able splints. Kappeler and Haf ter have corsets, made of water glass. shown that a number of apparatus, arti- ficial limbs, corsets, articulated splints, etc., can be made of water glass * * For the further description of these appliances, see Kappeler and Haf ter, Deutsch. Zeitschr. fur Chir., Bd. vii., P. 129. 224 THE APPLICATION OF IMMOBILISING DRESSINGS. (Fig. 205). Fig. 205, a and b, represent water-glass splints for the lower extremity, provided with straps, buckles, strips of caoutchouc, and fenestras suitably placed for permitting movement of the joints. c is a contrivance of Taylor's for use in coxitis (see Spec. Surg.); d represents a prothetic apparatus for amputation of the arm ; e is a corset, andf is another of Taylor's devices for kyphosis; d and e are perforated with holes, to make the apparatus light and accessible to air. The manufacture of immobilisation appliances from moulded felt and gutta-percha has been described before (see pages 212, 213). Dextrine Dressing.—Amongst tbe other materials which have not found any very general use brief mention may be made of the dextrine dressing of Velpeau (1838). It is applied in the same manner as the starch dressing, one hundred parts of dextrine being mixed with sixty parts of spirits of camphor and fifty parts of water. This dressing takes from four to seven hours to dry. Glue Dressing.—The glue dressing (Vanzetti, 1846) hardens very slowly. Strips of linen or roller bandages of linen or muslin are spread on one side with joiner's glue, allowed to dry, and then rolled into bandages with the glue side out. The bandages immediately before use are dipped in hot water and applied to any desired region over a protective padding bandage. The same procedure can be adopted as in starch or water glass dressings, which consists in simply saturating bandages and splints with the glue after they have been applied. Thin wooden or pasteboard splints can be incorporated in the dressing to strengthen it. Magnesite Dressing.—The magnesite dressing is most excellent, firm, and durable. Finely powdered magnesite and water glass are mixed into a thick paste. The method of applying this dressing, which requires some twenty- four to thirty-six hours to dry, is practically the same as for the starch or water-glass dressing—i. e., either the magnesite water-glass paste is painted with a brush over the dry mull bandages, or else the mull or cotton bandages are first soaked in the paste and then applied to the extremity over a padding of flannel bandages. Cement Dressing.—In the application of the cement dressing a mixture of one part of cement to two to three parts of gypsum is employed, and this is then applied like the gypsum, or plaster-of-Paris dressing. Other Dressings.—The gum dressing (Lorinser) is made of lime or cement dissolved in casein, albumen, gum arabic, glue and other materials by the addition of water. The gum-chalk dressing of Bryant and Wolfler is made of a paste of gum arabic and chalk powder. There is also a collodion dressing, a resin dress- ing, with or without wax, a parafflne and stearine dressing, but so far all these have not come into general use. § 55. The Method of applying Extension by a Weight.—As we shall see later on, permanent extension is much used, for example, in chronic inflammations of joints and in fractures. The method of applying ex- §55.] THE METHOD OF APPLYING EXTENSION BY A WEIGHT. 225 Fig. 206.—Adhesive-plaster extension apparatus. tension by a weight is the most generally used of all, and for this we have to thank the American surgeons Buck, Crosby and others, as well as the German surgeons Volkmann and Bardenheuer. The pulling of the fragments apart by a weight is very fre- quently used for the lower extremity in fracture of the femur and for diseases of the hip and knee joints, and consequently we must describe it some- what at length. Extension by a Weight for the Lower Extremity.—The extension dressing for a fracture of the neck of the femur in the form of an adhesive-plaster extension contrivance is begun in the case of adults with the application of a strip of adhesive plaster, from three fingers to a hand-breadth in width, along the inner and outer side of the leg, in such a way that the mid- dle of the strip extends in the form of a loop about a hand- breadth beyond the sole of the foot. Before ap- plying the adhe- sive plaster it is a good plan to shave off the hairs, to prevent the latter from sticking to the plaster ; then strips of adhesive plaster (or a flannel bandage) are placed circularly around the leg over the lateral strips at intervals, or overlapping each other, beginning just above the malleoli and going to the head of the flbula. The free ends of the adhesive plaster, which should reach to the middle of the thigh. are then split longitudinally with scissors into two or three strips, 16 Fir, 207.—Extension with suspension by means of a gypsum-hemp splint or a telegraph-wire splint l'or fractures of the femur. 220 THE APPLICATION OF IMMOBILISING DRESSINGS. which are turned down from the thigh and also secured about the leg with several circular strips of adhesive plaster.* In this manner the lateral strips of adhesive plaster are secured to the leg very firmly. I avoid placing strips circularly around the leg in the region of the head of the fibula, as this practice sometimes has been known to cause a pressure paralysis of the external popliteal nerve. The adhesive plas- ter must be made of strong material, to withstand the strain put upon it, and consequently it may be advisable to make the lateral strips of two or three thicknesses. In the loop made by the adhesive plaster below the foot a small piece of board is fastened in place to prevent chafing of the skin over the malleoli. Through a hole in the centre of this board is passed the rope to which the extension weight is at- tached. The rope is fastened to the board by knotting it on the side next the foot, or it may simply be attached by a hook (Figs. 206, 209). The rope to which the weight is fastened for making the exten- sion runs over two rollers fastened to the patient's bed (Fig. 206). This dressing can be made more firm and durable by applying over it a layer of mull bandage, and over this a gauze bandage, or, better still, a water-glass or chalk-water-glass dressing. To lessen the amount of the chafing to which the limb is subjected, and to regulate the position of the foot, it is a good plan to use Yolkmann's sliding foot rest (Fig. Fig. 208.—Vertical suspension with a plaster dressing, the knee being bent at a right angle. 206), which consists of a tin gutter splint for the leg, padded with cot- ton or jute, and having a removable foot-piece attached to a wooden cross-bar. The cross-bar slides on two longitudinal strips of wood. * In this country the strips are not turned down, but left applied to at least half the length of the thigh above the knee, to lessen the traction on the ligaments of the knee-joint.—[ Trans.] §55.] THE METHOD OF APPLYING EXTENSION BY A WEIGHT. 227 Other sliding foot rests have been invented by Riedel and Wahl. If Volkmann's contrivance is employed, any hardening dressing, such as Fig. 209.—Vertical extension for fractures of the femur Fig. 210.—Extension at in children. the shoulder by a weight. Fig. 211.—Extension by a weight applied to the upper arm (Lossen); a, gutter splint. the patient's perinasum, thence to the head of the bed, and attached to a weight by a cord running over a couple of rollers. As adhesive plaster is sometimes uncomfortable, and may cause a THE APPLICATION OF IMMOBILISING DRESSINGS. troublesome eczema, emplastrum cerussge may be used in its place; or perhaps a better plan is to enclose the limb in a flannel bandage, and to attach to this extension strips made of pieces of linen cloth; or a strong and not too elastic rubber bandage may be sewed laterally to the turns of the flannel bandage. Exten- sion may also be combined with some one of the various kinds of immobilising dressings, such as plaster of Paris. Recently the cord for exerting the trac- tion has been attached by means of hooks and cross-bars to rub- ber tubing filled with air ap- plied around the region just above the malleoli. In the after-treatment of cases, such as a hip-joint resec- tion, where extension is only required at night, gaiters are applied reaching to the middle of the thigh and having a leather foot-piece to which is fastened the cord for exerting the traction. If it is desired to apply ex- tension to the thigh in a somewhat abducted position, as after resection of the head of the femur, rollers can be attached to a board, which Fig. 212.—Extension by a weight applied to the upper extremity (Hofmokl). In extension by weight of the upper arm the loops 1 and 3 are not used; in case of the forearm 2 is not used; the extension is then made at 3 and counter- extension at 1. Fig. 213.—Extension of the forearm and hand (Langenbeck). may be fastened with screws to any desired part of the bed, while the cord for exerting the traction is carried over a wooden frame placed in the neighbourhood. Frequently, in cases of fracture of the lower extremity, extension is combined with suspension, as illustrated in Figs. 207, 208, and 209. It requires no further explanation. §55.] THE METHOD OF APPLYING EXTENSION BY A WEIGHT. 229 Extension by a Weight for the Upper Extremity is carried out by means of adhesive plaster applied to the shoulder-joint and arm, accord- Fig. 214.—Permanent extension by weight by means of Glisson's sling for cases of spondylitis. ins to the methods of Bardenheuer and Hamilton, or of Lossen or Hofmokl. Extension upon the upper extremity has by no means the importance that it has upon the lower. Hamilton's extension at the shoulder-joint (Fig. 210) is applied by means of adhesive plaster and a column. (Sayre). weight, while counter extension is made with a crutch in the axilla, the crutch being supported by a belt around the waist. Lossen's extension for the arm (Fig. 211) is applied by laying the arm on a splint which is �9999995355� THE APPLICATION OF IMMOBILISING DRESSINGS. fastened to the patient's bed. The way in which the traction is ex- erted by adhesive-plaster strips is represented in the figure and needs no further description. Hofmokl has also devised an excellent apparatus for applying extension by a weight to the upper extremity (Fig. 212). There is seldom any need of applying extension at the elbow-joint, but for the forearm and wrist-joint Langenbeck's method (Fig. 213) can be used. Extension by a weight can also be employed for the metacarpus and fingers by means of loops of adhesive plaster. Extension by suspending the arm is illustrated in Fig. 168. Extension by a Weight for the Vertebrae.—The fol- lowing is a brief description of the methods of using extension for the vertebrae: For fractures and tuber- cular inflammation of the vertebrae, Glisson's leather Fig. 217-Felt-corset sling with a metal arch (Fig- 2M) is employed, Or with jury mast for Falkson's chin-neck sling; of emplastrum cerussae (Fie;. fixation oi the head . in spondylitis ccr- 215). E, Fischer's suggestion is excellent: A four- cornered piece of cloth is provided with openings for the face and neck ; it is then padded in the region of the chin and back of the neck, and the four corners of the cloth are brought together over the top of the head and connected with the cord used for exerting the traction. Counter extension is furnished by the weight of the body— i. e., the head of the bed is raised, or extension is applied to the legs. Fig. 218.—Position of the patient in Eauchfuss's hammock in cases of spondylitis tuberculosa. In cases of tubercular inflammation, for example, of the cervical vertebrae, the latter may be fixed and extended by means of the jury mast corset (Sayre, Figs. 216, 217). For extension of the lumbar and dorsal vertebrae it is best to use the weight of the patient's body by placing him either in a Rauchfuss hammock (Fig. 218) or in a Bar- §55.] THE METHOD OF APPLYING EXTENSION BY A WEIGHT. 231 well's sling. The methods of applying these different dressings will be described in the Text-Book on Special Surgery. The Amount of Force to be used in Extension.—The amount of trac- tion which may be employed in the different extension appliances varies with the age of the patient and the nature of the disease or injury. For fractures of the femur and hip-joint inflammations in small chil- dren, one to two to three kilogrammes are used; for children from ten to twelve years old, somewhat more; while in adults ten to fifteen kilo- grammes may be needed. Extension by Splints.—Extension by splints is much less used now than was formerly the case. Reference will be made in the text-book on special surgery to the splints used for extension purposes, especially under the treatment of diseases of the hip-joint. THIRD SECTION. SURGICAL PATHOLOGY AND THERAPY. CHAPTER I. INFLAMMATION AND INJURIES. The phenomena of inflammation.—The histological changes which take place in in- flammation.—Causes of inflammation.—Symptoms of inflammation.—Termina- tions.—Diagnosis.—Treatment.—Morphology and significance of micro-organisms (microbes).—Injuries in general.—The histological changes which occur in the healing of a wound.—The reaction following wounds and inflammations.—Fever.— Shock.—Delirium tremens.—Delirium nervosum.—Disturbances which may arise during the healing of a wound.—Infection of wounds.—Inflammation.—Suppura- tion of the wound.—Lymphangitis.—Arteritis.—Phlebitis.—Cellulitis.—Erysipe- las.—Wound diphtheria (hospital gangrene).—Tetanus.—Septicaemia.—Pyaemia.— Infection by cadaveric poison.—Other kinds of infection.—(Anthrax; symptomatic anthrax.—Glanders.—Hoof and mouth disease.—Hydrophobia.)—Poisoning by in- sects, snakes, etc.—Curare poisoning.—Appendix: Chronic microbic diseases.— Tuberculosis.—Leprosy.—Actinomycosis.—Syphilis. § 56. Inflammation.—The physicians of antiquity recognised the four cardinal symptoms of inflammation : Redness (rubor), heat (calor), swelling (tumour), and pain (dolor). But these outward manifestations do not throw light upon the source and essence of inflammation. The question, where the origin of the process is to be found, has always been a subject of discussion, and the principal part in the production of inflammation has been ascribed in turn to the blood, to the tissues, to the blood-vessels, and to the nerves. Numberless experiments have been performed and the most diverse theories have been advanced to account for the phenomena of inflammation. Virchow founded the cellular-pathology theory, according to which an " inflammatory irrita- tion " leads to definite changes in the cells. Cohnheim ascribed it to a probable molecular change in the walls of the vessels, while Reck- linghausen and Thoma laid stress upon the vasomotor nerves, and par- ticularly upon their centres located in the inflamed region. Of the various inflammatory irritants or causes of inflammation, micro-organ- (232) §56.] INFLAMMATION. 233 isms and the products of their metabolism should be looked upon as the most important. Changes in the Circulation in an Inflamed District.—In order to un- derstand the nature of inflammation, it is best first to study what takes place in the circulatory system. Cohnheim has shown how these processes may be watched under the microscope. The intestine of an etherised or curarised frog is drawn out through an opening made in the side of the abdominal wall, and the mesentery is spread out on a slide beneath a microscope. In this way the mesentery, with its ves- sels, is subjected to the influence of the air and the irritating substances in it. After a short interval an inflammation begins, all the various manifestations of which can be observed from beginning to end, and all the more exactly if the preparation is protected from all bruising, drying, or soiling, etc. The webbing between the toes or the tongue of the frog can be used in the same manner: the tongue is drawn out and fastened with insect pins to a cork rim around a slide, and then by cauterising or scratching the papillae an inflammation can be pro- duced and the various phenomena studied. There is first seen a dilatation of the exposed vessels of the mesen- tery, if that is employed, beginning in the arteries and extending to the veins, and to a less extent involving the capillaries. Simultaneously with the dil- atation of the vessels the blood stream begins to flow more rapidly, and this is followed sooner or later, in from half an hour to an hour, by a marked slowing of the current. As a result of this slowing the separate corpuscles can be distin- guished in the veins and cap- illaries, and even in the arteries; and they will be found to accumulate, espe- cially in the veins and cap- illaries. In the veins, par- ticularly, there will be large numbers of colourless blood- corpuscles in the peripheral portions of the current, and occasionally they will stick to the inner walls of the veins (peripheral stasis of the Fig. 219. . Inflamed mesentery of a frog; I', vein; A, small artery and capillaries. The vessels contain white blood corpuscles on their inner walls, some being in the process of emigration; the surround- ing tissues contain numerous leucocytes which have already emigrated from the vessels. 234 INFLAMMATION AND INJURIES. white corpuscles or leucocytes, Fig. 219). The red cells, on the con- trary, continue to flow along with diminished rapidity in the centre of the stream. Presently, following the peripheral stasis of the white cells, there will be observed a new phenomenon : a point will be seen to project from the external contour of some vein or capillary, and then gradually become larger and more and more prominent (Fig. 220, a); and finally this bit of protoplasm will only remain attached to the wall of the vessel by one or more processes, and at last becomes entirely separated, which means that a white corpuscle has made its way out of the vein or capillary (Fig. 220, b). Six or eight hours later this process has continued to such an extent that the veins and capilla- ries are surrounded by these migrated white cells. In addition to these cells, which are usually polynuclear, there will be found small round mononuclear cells (lymphocytes), which, according to Grawitz and Ribbert, are to be regarded as derived from the fixed connective tissue cells, though Baumgarten claims that they are likewise white corpuscles which have mi- grated from the vessels of the same region (leucocytes). According to Baumgarten, the small mononucleated lymphocyte form of leucocyte is the predominant element in chronic inflammations. Waller was the first (1846) to note the migration of the leucocytes from the interior of the vessels, but his observations had been entirely for- gotten when Cohnheim rediscovered this phenomenon in 1867. Red blood disks also pass through the walls of the capillaries, but not of the veins, for in the capillaries both classes of cells come in con- tact with the walls, and are not, as in the veins, confined to separate parts of the blood current. The proportion of red cells contained in the exudate varies; some lie here and there on the outer wall of the capillaries, some collect in tiny punctate haemorrhages, and some are washed away in the stream of transuded serum. No blood-corpuscles migrate through the walls of the arteries. The time required for a white cell to pass through the wall of a capillary or vein varies, and the same holds true as to the passage (diapedesis) of a red cell through the wall of a capillary. Sometimes the movement is slow, while at others a few minutes are enough for Fig. 220.—Emigration of leucocytes: a, Incomplete, b, complete emi- gration (schematic). §56.] INFLAMMATION. 235 three, four, or more cells to escape one after the other at the same spot; and immediately thereafter the blood stream, with its corpuscles, flows on normally past the point where they have escaped. Significance of the escape of the Leucocytes.—As Leber has demon- strated, the escape of the leucocytes from the vessels is not unregu- lated, but they obey an attraction towards the place of irritation similar to that observed by Pfeffer, O. LTertwig and Engelmann in vegetable cells and bacteria upon which certain chemical substances exert a peculiar power of attraction (chemotaxis). The substances which act in this manner on bacteria are the salts of potassium, peptones, and especially all nutritive substances ; while other substances, such as free acids and alkalies or alcohol, have a repellent power (negative chemo- taxis). These facts, which Pfeffer has demonstrated experimentally for the fungi, have a most important bearing upon the subject of in- flammation. This power to attract, or chemotaxis, influences or even controls the movements of the leucocytes in the tissues towards the focus of inflammation, also the actual migration of the cells from the vessels and later the formation of new vessels at the same point. The leucocytes are especially attracted by the bacteria, or rather by the products of their metabolism. According to Buchner, the protoplasm of bacterial cells contains substances which exert this attraction upon the leucocytes, the so-called bacterial proteins which Nencki studied as early as 1880 in certain kinds of bacteria, from a purely chemical standpoint. These proteins will produce inflammation or suppuration only after they have become separated from the bacterial cell, con- sequently only after the latter has died or become diseased. The as- sembling of cells at the seat of inflammation is to be regarded as essentially a protective measure taken by the organism for the purpose of defending itself against external noxious influences. The leucocytes serve, perhaps, to eliminate, to liquefy, and to separate the inflam- matory focus from the healthy living tissues (Leber). Increased Exudation.—Accompanying the migration or extravasa- tion of blood-cells there is an increased transudation of the liquid elements which infiltrate all the surrounding tissues. This increases the amount of the lymph current until the lymph channels become inadequate for carrying away the transuded liquid, and then results a swelling of the part of the body which is inflamed. Partly as a result of their own power of locomotion, and partly carried along by the transuded fluid, the white blood-corpuscles become distributed through the tissues at ever-increasing distances from the vessels out of which they have wandered. Finally, both the corpuscles and the exudate make their way to the surface of the mesentery, and there the exudate 236 INFLAMMATION AND INJURIES. coagulates, forming a so-called false membrane, which is filled with numberless white blood-corpuscles and a few red ones. Corresponding to the great number of leucocytes which it contains, the inflammatory exudate is very rich in albumen, while the exudate which follows passive congestion is not (Hoppe-Seyler, Lassar). Only in cases of mild inflammation, or in the early stages of others, does the exudate contain a small number of cells. According to the character of the inflammatory exudate, we dis- tinguish it as serous, fibrinous, croupous, diphtheritic, suppurative, hsemorrhagic, and ichorous. Proliferation of Connective-tissue Cells in Inflammation.—Not all of the cells wliich are found in inflamed parts are migrated leucocytes. The fixed connective-tissue cells proliferate by rapid division, and con- tribute notably to the cellular infiltration of the inflammatory focus. According to Strieker and Grawitz, the intercellular substance of the tissues undergoes a cellular metamorphosis when inflamed, revert- ing to its embryonic cellular state. The cells also which have hitherto lain dormant in the stroma (dormant cells, Grawitz) are said to awake to renewed activity. The views which Grawitz has expressed con- cerning the process of inflammation are of great scientific interest, but they greatly lack the support of observed facts, and have not yet met with general acceptance. Inflammation from Croton Oil.—The manifestations of inflammation just described can also be produced by irritating the frog's tongue with very dilute croton oil (1'50 of olive oil), by cauterising it with a stick of nitrate of silver, or by applying a ligature to temporarily shut off the blood from tbe vessels of the tongue. Precisely similar phenomena can be observed in warm- blooded animals—for instance, in the mesentery of a small rabbit. All the gross changes which take place in an inflammation can be produced iu a rabbit's ear by painting it with croton oil, cauterising it, applying a ligature, or by subjecting it to heat or cold, as by dipping it in hot water or lightly freezing it with a cooling mixture. An ear which has been subjected for even a few minutes to a temperature of 56° to 60° C. (140° to 147° F.), or -18° to —20° C. (—1° to —4° F.), will inevitably necrose. After a rabbit's ear has recovered from the effects of croton oil, it gains, according to Samuel, a kind of immunity as regards this drug—i. e., it reacts to a subsequent appli- cation of the oil much less violently than an ear which has not been so treated. The phenomena thus described—viz., the simple congestive hyper- semia, the extravasation of the corpuscular elements from the capilla- ries and veins, the increased exudation terminating in stasis and later in death of tissue, and also the proliferation of the fixed connective- tissue cells—form a group of symptoms which we are accustomed to designate by the name of inflammation. §56] INFLAMMATION. 237 Cause of Inflammation.—Cohnheim ascribed the cause of all these phenomena and the essence of inflammation to molecular changes in the walls of the vessels. According to him, these molecular changes increase the adhesiveness, and consequently the friction, between the blood and the walls ; hence the slowing of the stream. Exactly what kind of a change is produced in the vessel walls in inflammation is not clearly understood; it cannot be detected with the microscope, and we can only say that the walls become more pervious, enough so to occa- sion the increase in exudation notwithstanding the diminution of the blood pressure which takes place especially in the capillaries. Wini- warter has shown that a colloid liquid, such as a solution of glue, can pass through the inflamed walls of blood-vessels even when the pres- sure is subnormal. A rupture, an interruption of continuity in the wall of the vessel, permitting the escape of the leucocytes and of a few red corpuscles, certainly does not take place. Likewise, Arnold's theory that in inflammation the natural stomata between the endothelial cells become enlarged and that new ones form, is, as Cohnheim always main- tained, incorrect. Cohnheim's comparison of inflammatory exudation with filtration seems very appropriate. Under normal conditions only a small amount of a thin liquid can pass through the filter of the vessel wall; but when inflammation sets in the filter becomes coarser and permits not only denser solutions to pass through, but also formed ele- ments, the blood-corpuscles. The change produced in the vessel wall by inflammation is, according to Cohnheim, probably chemical. But all the manifestations of inflammation cannot be explained by the condition of the vessel walls, which Cohnheim thought was sufficient. The investigations recently made by Recklinghausen, Arnold and others go to show that Cohnheim's theory needs certain limitations in view of the fact that a distinction must be made between the exudation of fluid constituents of the blood and the emigration of white corpuscles. Thoma's researches have shown that a primary alteration in the walls of the vessels is not always the cause of the emi- gration. A simple disturbance of circulation following an irritation of the local vasomotor centres produces a peripheral stasis and an emigration of leucocytes. But the latter phenomenon will only last a brief time in those cases in which there is no other influence at work; the vasomotor nerves resume their function, and the peripheral slow- ing of the current and the escape of the leucocytes cease. If the dis- turbances in innervation are more marked, and if the emigration is allowed to go on for a longer time, a secondary change in the walls of the vessels takes place. But in these cases the disturbance in the innervation of the vessels is the primary event, and not the alter- 238 INFLAMMATION AND INJURIES. ation in their walls. Thus Recklinghausen seems to be correct in ascribing to the vasomotor nerves, and particularly to their ter- minal local centres, an important part in the inflammatory process, and especially in the emigration of the leucocytes. Herpes zoster and other diseases resulting from disturbances in innervation go to prove the truth of this theory. Samuel has shown that the inflammatory process becomes more severe when there is vasomotor paralysis. Moreover, the emigration of leucocytes is affected in both a positive and negative way by the above-mentioned chemotaxis. On the other hand, the exudation of the fluid elements of the blood during an in- flammation can only be explained by a change in the permeability of the walls of the vessels, located in either the endothelial cells or the cement substance between them. According then, to our present knowledge, we must look for an explanation of the phenomena of inflammation (1) in vasomotor changes in the vessels, or, rather, in disturbances within the vasomotor centres in the walls of the vessels; (2) in an increased permeability of these walls; (3) in the positive (attracting) and negative (repelling) chemotaxis of the inflammatory focus, and finally (4) in the reactionary proliferation of the cells in the inflamed tissues. It is an exceedingly difficult matter to give an exhaustive and satisfactory definition of in- flammation. Other Theories of Inflammation.—Before Cohnheim, Kecklfnghausen, and Thoma had established the above explanation of inflammation, a great va- riety of theories had been advanced, the most important being the neuro- humoral (Cullen, Henle) and the cellular (Virchow). According to the for- mer, the nature of inflammation or the disturbances in the circulation are explained either by a contraction or dilatation of the afferent arteries, pro- duced reflexly through stimulation of the sensory nerves. We have seen that nervous influences really do play an active part in the process of inflam- mation. Vircbow's cellular theory of inflammation is based upon tbe changes in the life of the cells brought about by the primary causes of inflammation. Virchow regarded the cells of the tissues as the essential elements in the in- flammatory process. As a result of the inflammatory irritation they were caused to swell and proliferate and form pus corpuscles. These altered cells are supposed by Virchow to exei'cise a kind of attractive power for the con- tents of the vessels, producing increased exudation. Samuel thinks that inflammation is due to a changed relationship of the blood, the walls of the vessels, and the tissues to each other. Recklinghau- sen agrees with him in general. Landerer thinks that the inflammatory changes in the circulation depend upon a disturbance of the normal balance between tbe blood pressure and the tension of the tissues, caused by a change in the elastic properties of the tis- sues and the walls of the vessels. This change in elasticity, he is inclined to §57.] INFLAMMATION. 239 believe, is the primary factor, though he admits that the walls of the vessels may become primarily diseased. No one of these theories can by itself explain the nature of inflammation especially if that theory is based upon only a single manifestation of tbe in- flammatory process and attempts to solve tbe problem from this standpoint alone. Consequently, it is evident why Cohnheim's attempt to explain in- flammation by a change in the walls of the vessels is to-day regarded as inadequate. No value can be attached to any theory which does not include a correct explanation of the changes produced under the stimulus of inflam- mation in both the solid and fluid elements of the tissues (cells, nerves, and walls of the vessels), and does not consider these in their causal relationship to one another. § 57. Causes of Inflammation.—The causes of inflammation are very numerous. Any influence which produces a change in the walls of the vessels in any particular part of the body, in the manner above described, may give rise to inflammation. "We recognise principally the following classes of inflammation which differ in point of etiology : 1. Inflammation from mechanical causes (every kind of trau- matism). 2. Inflammation following the action of extremes of temperature (thermal inflammation ; burning, freezing). 3. Inflammation due to chemical causes (toxic bacterial infection). Under the heading of toxic inflammations belong not only those which are produced by the action of some particular chemical such as mercury, sulphuric acid, etc., but it includes all inflammations caused by the absorption of chemically changed, decomposed, or putrid sub- stances of a gaseous or liquid nature. Inflammations following the stings of insects, such as bees, and those from the bites of serpents, all come within the class of toxic inflammations. Advancing a step fur- ther, we come to the infections inflammations, or those which are pro- duced by the ingress of a low order of organism or fungi—for exam- ple, after an injury to the tissues from some traumatism. Significance of Micro-organisms.—Micro-organisms, especially the fungi schizomycetes or bacteria, are the worst enemies of the surgeon, interfering with the normal healing process of a wround and causing the secondary wound diseases. ITallier, Pasteur, Billroth, Klebs, Eberth, and particularly Robert Koch and his followers, have made great ad- vances in the study of micro-organisms. The honour of having estab- lished the etiology of parasitic infectious diseases by means of new methods of investigation belongs chiefly to Robert Koch. At the time when Lister established his antiseptic and aseptic methods of oper- ating on the principle that all infection was due to bacteria, which, though not then proved, nevertheless seemed probable, surgery made 240 INFLAMMATION AND INJURIES. the greatest advance in its history. Every inflammatory process in a wound, especially all suppuration, is due principally to the presence of micro-organisms, while the injury itself plays only a subordinate part. Causes of Acute Suppurative Inflammation—Significance of Bacteria.—The investigations of Ogston, Strauss, etc., prove that chemical irritants, no matter of what kind, do not excite suppurative inflammation, but that the latter can only be caused by micro-organisms. These authorities performed their ex- periments with the most rigid antiseptic precautions. Strauss, for example, to prevent accidental infection from the wound, made an eschar over the selected area of skin with the Pacquelin, then through this made his incision with a red-hot knife, and introduced the long tip of a glass tube containing the sterilised fluid into the subcutaneous cellular tissue, the upper end of the tube meanwhile being closed with a cotton plug. The glass tip was then broken off beneath the skin, and the fluid was forced out of the tube and under the skin by blowing with the mouth over the cotton plug. After tak- ing away the tube the injured area of skin was again cauterised. After the introduction in this manner of such chemical irritants as sulphuric acid, tur- pentine, croton oil, mercury, etc., only a serous, sero-fibrinous, or fibrino- diphtheritic inflammation resulted, but never acute suppuration. If acute suppuration did occur, it was always possible to demonstrate the presence of micro-organisms. These authorities experimented on rabbits, in which, to be sure, a suppurative inflammation is seldom caused by chemical irritation. But it has recently been proved that these statements are incorrect. Orth- mann, Grawitz, and De Barry have demonstrated that sterilised chemical sub- stances, such as nitrate of silver, oil of turpentine, liq. ammonii caustici, digi- toxin, etc., can produce acute suppuration in the subcutaneous tissue; and according to Scheuerlen and Grawitz. sterilised cultures of various micro- organisms—in other words, products of bacterial metabolism, such as putres- cin, cadaverin, penthamethylendiamin, etc.—act in the same way. A similar conclusion has been reached by Krynski, who experimented on dogs and rab- bits with tbe greatest care, partly by Strauss's and partly by Councilman's methods, using germ-free (aseptic) chemical substances, the microbes which cause suppuration and the products of their metabolism. Krynski asserts, in opposition to Strauss and others, but agreeing with Brewing and Dubler, that oil of turpentine or mercury produces in dogs and rabbits a suppuration which is free from bacteria. A one-to-five-per cent, solution of nitrate of silver ex- cites the formation of pus in dogs, but only an inflammatory oedema in rab- bits. Croton oil, bromine, mineral acids (hydrochloric, sulphuric, nitric, and chromic), organic acids (acetic, carbolic, lactic, etc.) do not cause pus. In dogs it is produced by creolin and petroleum. Clean, mechanically acting agents, such as glass splinters, do not excite pus formation. The bacteria of suppuration (tbe staphylococci and streptococci), according to Kiwnski, will only excite the formation of pus in tissues which have become pathologically changed, and they will not develop in healthy tissues, but become destroyed, while the bacillus pyogenes fcetidus will excite suppuration even in perfectly healthy tissue. Krynski maintains that the pneumococcus Friedlanderi and the micrococcus prodigiosus are not pyogenic; but Grawitz and De Barry have established the latter's pyogenic character in the case of dogs, cats, rabbits, and §58.] INFLAMMATION. 241 rats. Sterilised cultures of the staphylococci and streptococci, or the sterilised solutions of the products of their metabolism, will produce pus, while steril- ised cultures of the prodigiosus and decomposition extracts have no such power. Although there can be no doubt as to the possibility of exciting sup- puration in the subcutaneous tissue of animals by the experimental introduc- tion of germ-free chemical substances, yet it is just as true that suppuration in man under ordinary circumstances is caused by the presence and activity of micro-organisms, usually of a specific variety—viz., pyogenic cocci. Immunity against Virulent Staphylococci.—The investigations of Eoux, Eronacher and others are of great interest as regards the acquirement of immunity against virulent staphylococci. By the inoculation of sterilised cultures of the staphylococcus pyogenes aureus white mice can be made un- susceptible to cultures containing virulent cocci. Bouchard, Gley and others have shown that the injection of the soluble products of certain micro-organisms such as the bacillus pyocyaneus has an antiphlogistic effect from paralysis of the vasodilator nerves, which prevents dilatation of the vessels and emigration of tbe leucocytes. Leber's Phlogosin—Buchner's Bacterial Protein.—Leber's investigations are extremely interesting.* He showed that the micro-organisms, in virtue of the diffusible products of their metabolism, can excite an inflammatory reaction at a distant part of the body, and from liquids containing staphylo- cocci he isolated a crystallisable body, phlogosin, capable of producing in- tense inflammatory and necrotic processes. Buchner demonstrated that the protoplasmic contents of the bacterial cells, the so-called bacterial protein, has a similar power of exciting inflammation and suppuration when separated from the bacterial cells—in other words, when these die or become diseased. Buchner has so far isolated this protein from seven kinds of bacteria, and proved its pyogenic action. Inflammatory Leucocytosis.—After invasion of the blood-vessels with the fungi of suppuration there is an increase in the number of leucocytes in the blood (inflammatory leucocytosis), originating in the spleen, the lympb glands, and bone marrow. According to Limbeck, this is not so much a new formation of leucocytes as a result of the flushing out of the above organs. This inflammatory leucocytosis has an intimate connection with the exuda- tion accompanying inflammation, and with the peptonuria (Leber, Hof- meister, Maixner, etc.). As to the influence of micro-organisms upon the production of wound diseases, etc., we shall see later (§ 66) that each separate wound disease is caused by a particular and clearly distinguishable micro- organism. A short review of the morphology and general significance of these will be found in § 59. § 58. Symptoms, Diagnosis, and Treatment of Inflammation.—The symptoms of inflammation—redness, swelling, increased warmth, and pain—are easily explained by the disturbances of circulation wdiich have been described. The redness and increased warmth are due to the * Fortschritte der Med., 1888, No. 12. 17 242 INFLAMMATION AND INJURIES. distention of the blood-vessels; the swelling is likewise the result of this, and also of increased exudation. The pain is caused by the pres- sure of the over-filled vessels and of the exuded fluid upon the sensory nerves. A fifth symptom is the disturbance of function, and is pro- duced by the change in the circulation and the pressure of the exuded fluid upon the motor nerves, and upon those governing secretion, or upon the cells themselves. The separate symptoms naturally vary con- siderably in intensity, depending upon the severity of the inflammation, and particularly upon its location. The pain in inflammation depends upon the richness of the sensory nerve supply in the inflamed part, and upon the amount of the exu- date, or rather of the pressure which the exudate produces on the sen- sory nerves. Furthermore, the amount of expansion that the inflamed part is capable of is an important factor. For all these reasons, an acute inflammation located under the fascia, or in the tips of the fingers, under the nails, is particularly painful, while one involving mucous membrane is much less so. The increased warmth is the result of an increased amount of blood. As Cohnheim has shown, nearly double the normal amount of blood flows through a dog's paw when inflamed. There is an increased amount of warmth brought to the part, but the diminished rapidity of the current causes an increase in the loss of heat by radiation. There has been an erroneous belief that the inflammatory focus was in itself productive of heat, and that the temperature at this point was higher than the general body temperature. But ordinarily it is certain that the temperature of the inflamed spot never exceeds that of the blood, and generally is not as high. Hunter's law still holds true to this day —viz., that the local temperature of an inflamed part cannot rise above that at the source of the circulation, the heart. The redness is usually dependent upon the richness in blood supply of the inflamed tissues. The swelling or inflammatory tumefaction resulting from the exuda. tion which takes place varies, of course, with the anatomical structure of the inflamed region. In general, the exudation takes place in the same way, but it may manifest itself in many different ways, depend- ing upon whether it occurs in firm tissues like bone or cartilage, or in wide-meshed connective tissue, or in a glandular organ, or in a cav- ity, such as the pleural cavity. As regards the location of the inflammation, we distinguish between a superficial and a deep or parenchymatous inflammation in the interior of an organ. To the superficial inflammations belong those situated in the superficial portions of the body, in the mucous membranes, or the surfaces of the great serous cavities. In a superficial inflammation the §58.] INFLAMMATION. 243 inflammatory exudate appears superficially, and forms an exudate in the narrow sense, while in a parenchymatous inflammation the exudate is spread out in the tissue in question in the form of a so-called infiltra- tion. For distinguishing the location of the parenchymatous inflam- mations more exactly—as, for example, those which occur in the glands or muscles—a distinction is made between a parenchymatous inflamma- tion in its narrow sense and an interstitial inflammation, according as the inflammatory process affects more the gland cells, such as those making up the parenchyma of the liver, or the connective-tissue stroma. The Varying Constitution of the Inflammatory Exudate.—The com- position of the exudate is of the greatest importance in determining the character of the inflammation. If the latter belongs to the lower grades of the process, or if, in other words, there is but a slight change in the walls of the vessels, the exudate is serous—that is, there is only a small amount of albumen and formed elements (blood-corpuscles) con- tained in it. On the other hand, we speak of a fibrinous or croupous inflammation when the exudate is rich in spontaneously coagulating albu- men and in white blood-corpuscles. In a fibrinous inflammation the diseased part, such as, for instance, the serous membrane or the inner surface of a joint capsule, becomes covered with a more or less thick layer of soft fibrin, which gives it sometimes a smooth and sometimes a shaggy appearance. The microscopic examination of such a fibrin- ous pseudo-membrane reveals the presence of an immense number of white blood-corpuscles scattered amongst threads of fibrin and granular matter. This same croupous or fibrinous covering is found on the sur- faces of mucous membranes. Between the two main types of serous and fibrinous inflammations there are, of course, a number of interme- diate forms -which are designated as sero-fibrinous exudates. Suppurative Exudate.—The third kind of exudate is the suppura- tive or purulent, consisting of a thick, milky or cream-like, non-coagu- lable fluid, generally without odour, and briefly designated by the name of pus. Microscopically, this is a colourless fluid containing a vast quan- tity of cells, " pus-cells," and a few red blood-corpuscles. According to Grawitz, the suppurative inflammation is only a more advanced grade of inflammation, while AVeigert, on the other hand, maintains that it represents qualitatively a particular kind. Strieker and Reck- linghausen think that suppuration is not exclusively a melting-down process of the tissues without coagulation, produced by means of emi- grated leucocytes, but rather that a proliferation of the fixed connec- tive-tissue elements also plays an important part. By the proliferation of the fixed cells a large number of young cells are formed which cor- respond in appearance to the mononuclear white blood-corpuscles. 244 INFLAMMATION AND INJURIES. Pus is a product composed of emigrated leucocytes and the altered offspring of the connective-tissue cells. Every suppurative inflamma- tion is to be considered as a severe inflammation, and, as we have indi- cated, it is in the main of an infectious nature—that is, it is the result of an infection by bacteria. But we have seen that sometimes even germ-free chemical substances may produce suppuration (Grawitz, De Barry, Krynski, etc.). Between the extreme types of purulent and fibrinous inflammation there are also many intermediate gradations of the process which are known as fibrino-purulent inflammations. If the suppurative process is sharply defined in the tissues, there results what is called an abscess; but if the process is more diffuse, it is spoken of as suppurative infil- tration. An abscess—i. e., a cavity filled with pus—results from a sup- purative infiltration which liquefies and dissolves the affected tissues. A loss of substance in the superficial portions of the body, accom- panied by the formation of pus and breaking down of the granulation tissue, constitutes an ulcer. A collection of pus in a cavity is called a purulent effusion, while a purulent secretion from a mucous membrane is called a purulent catarrh. Hsemorrhagic Exudate.—The fourth kind of exudate is the hasmor- rhagic—i. e., the serous, fibrinous, or purulent exudate contains such an amount of red blood-corpuscles that it becomes red in colour. The hsemorrhagic exudate is a symptom of serious alterations in the walls of the capillaries, such as takes place in certain constitutional diseases, or as the result of a systemic infection through bacteria. Ichorous Exudate.—The decomposed, foul-smelling exudate accom- panying putrefaction is designated as ichorous or putrid. It has a grey or greyish-green, brown, or dirty yellow colour. Croupous or Diphtheritic Inflammation.—The so-called croupous or diphtheritic inflammation, or the croupous or diphtheritic exudate, is the result of the combination of an inflammatory process with another of a different nature. Croupous inflammation of a mucous membrane is characterised by the formation of a skin-like, fibrinous exudate (croup- ous membrane) clinging to its surface and taking the place of the origi- nal epithelial covering which has perished. This croupous membrane consists of a network of fibrin fibres containing leucocytes and the re- mains of the epithelium. In diphtheria the death of tissue extends deeper, and the process is a combination of necrosis and fibrinous in- flammation. The affected portion of the mucous membrane is changed into a peculiar greyish-white, tough mass, which comes away in mem- brane-like layers (diphtheritic pseudo-membrane), and produces corre- sponding losses of substance (diphtheritic ulcers). The tissues de- §58.] INFLAMMATION. 245 stroyed by the inflammatory process coagulate in flaky or stringy masses, which signifies serious structural changes involving the blood- vessels and surrounding tissue, with here and there stasis and throm- bosis. Cohnheim and AVeigert have given to this form of localised tissue death the name of coagulation necrosis (Neumann's fibrinoid de- generation). Weigert's investigations show that coagulation necrosis is a death by coagulation of the tissue or cells in a necrotic area through which a small amount of lymph flows. The lymph, with its fibrinogen, penetrates the cells and coagulates with the fibrino-plastin within the cells. Coagulation necrosis is a frequent accompaniment of inflamma- tory processes, of embolic infarcts, and of the so-called waxy degenera- tion of muscles. Extension of an Inflammation.—The inflammatory process spreads by infiltration of the connective-tissue spaces, the muscular sheaths, and the vascular channels with the inflammatory exudate—in other words, from a circumscribed spot of suppuration (abscess) there may develop a spreading cellulitis. The inflammation also spreads through the lymph spaces, the main lymphatics, and the blood-vessels. When the exciting cause of the inflammation gets into the circulatory system, the original local disturbance becomes a general systemic disease in- volving the whole organism. The poison—so to designate briefly the noxious element—passes through the lymph channels to the nearest lymphatic glands, exciting there also inflammation, and finally sup- puration. These diseased glands then become a fresh source of in- flammation, wliich in this manner spreads farther and farther through the body and progressively affects more of its organs. Such a meta- static inflammatory and suppurative process will be again referred to under the heading of pyaemia, by which we mean a poisoning of the blood by the microbes of suppuration and the products of their meta- bolism. By the spreading of the micro-organisms and the products of their metabolism throughout the circulation, and the production of cir- cumscribed foci of inflammation in different organs, a general systemic infection accompanied by fever results (see § 62, Fever). AVe shall learn later how prominently the fungi are concerned in the extension of the inflammation and in the occurrence of the systemic infection. Clinical observations and experiments on animals seem to show that local metastatic foci of suppuration are particularly liable to occur when there exists a general weakness or impairment of vitality of the whole organism (Rinne). The soil for the lodgment of the micro- organisms is made ready for them in advance by the products of their metabolism which get into the circulating blood. Duration of the Inflammation.—According as the inflammation lasts 246 INFLAMMATION AND INJURIES. a shorter or longer time it is spoken of as acute or chronic. The manifestations of an acute inflammation have been sufficiently de- scribed above. The acute inflammation often becomes a chronic one, or the latter begins from the first as such. The transition or inter- mediate types between an acute and chronic inflammation are known as subacute inflammations. Tubercular and syphilitic inflammations are the most important forms of the chronic class. The true type of chronic inflammation is the productive or adhesive inflammation, -which leads to new formation of* tissue, to adhesions and thickenings of every description, depending upon the anatomical structure of the affected organ, such as a joint, bone, periosteum, or connective tissue. We shall describe in their proper place the special symptoms of inflamma- tions involving the different organs. Origin of the Pus-corpuscles.—The so-called pus-corpuscles which are found in the inflammatory effusion are made up, in part at least, of the white blood-corpuscles which have wandered out from tbe interior of the vessels. Whether all the pus-corpuscles are emigrated blood-cells, or whether pus- cells may originate otherwise—as, for instance, from the fixed tissue cells—or whether pus-cells may multiply by fission or division, are all questions to which various answers have been given. Some have considered it impos- sible that tbe enormous number of pus-corpuscles found in a large inflam- matory process, like a pblegmon or a large granulating wound, should all be derived from the blood. Cohnheim was right in directing attention to the fact that the veins and capillaries contain comparatively large numbers of white blood-corpuscles, and that the number of these white cells is much increased during inflammatory diseases. The white blood-corpuscles which go to form pus-cells are constantly replaced by an increased activity of the spleen and lymphatic glands. Bottcher, Strieker and his followers, Beck- lingbausen, Grawitz and others differ from Cohnheim in his view that the blood is the sole source of the pus-cells, and affirm that the latter originate in far greater proportion from the fixed tissue cells. These authors believe that the cellular elements of pus consist partly of emigrated leucocytes and partly of the offspring of the fixed connective-tissue cells. Grawitz affirms that the stroma or fibrous portion of tbe tissues takes on a cellular change and becomes a third source of the pus-corpuscles. Recklinghausen has dem- onstrated that pus-cells, if kept in a warm and moist medium while being examined, will change their form and go through the same amoeboid move- ments as the white blood-cells. Number of Pus-cells in Pus.—Chelchowski determined the number of pus- corpuscles by means of Mallassey-Verick's apparatus in twenty different cases of suppuration. For diluting the pus, he employed a weak solution of common salt or Toisson's fluid (methvlviolet). The number of pus-cells in one cubic millimetre of pus, according to Chelchowski, varied between four hundred thousand and one million six hundred thousand. The exudate con- tained from ten to fifteen times more leucocytes than the transudate.* The * In the sense of a passive effusion, as in cardiac dropsy. g "'*] INFLAMMATION. 247 suppurative character of a fluid, drawn off by aspiration, can only be recog- nised macroscopically when it contains at least from forty to sixty thousand pus-cells to the cubic millimetre, and consequently it is very possible for a comparatively large amount of pus to be present in a fluid without its being noticed. Composition of Pus.—Pus consists of the above-mentioned cellular ele- ments, which are called pus-corpuscles, and, in addition, of pus serum. If pus is allowed to stand for a time in a test tube, it separates into two layers the upper bright yellow layer being the pus serum, and the lower forming a thick deposit made up principally of pus-corpuscles. The pus serum cor- responds to the plasma of the blood which is its source, but often differs from it chemically very materially. There are ten to sixteen per cent, of solid elements in pus, and five to six per cent, of ash. The gases consist of nitrogen and carbonic acid ; ordinarily there is no oxygen or hydrogen. There is generally a somewhat greater amount of sodium and potassium than in blood serum. The albuminous substances in pus consist chiefly of para- globulin, albuminate of potassium, serum albumen, myosin, leucin, and tyrosin. The formed constituents, in addition to the pus-corpuscles, include micro-organisms, and often red blood-cells, fibrin, fat droplets, fat and cholesterin crystals, particles of necrotic tissue, etc. Pus which contains fungi usually does not coagulate, althougb large numbers of leucocytes may be present. This is due to the fact that there is no fibrinogen in the pus, or rather that the micro-organisms change the fibrinogen in the exuded plasma into peptone. Growth of Bacteria in Germ-free Pus.—According to Eichel, germ-free pus contains a substance which is deleterious for many kinds of bacteria, and small quantities of the staphylococcus pyogenes aureus and the anthrax bacillus will perish after about five days, but tbe streptococci are not harmed. By the addition of putrefactive bacteria or the products of their metabolism this deleterious property is increased. The reaction of pus which bas re- cently been taken from the body is alkaline, but it becomes acid after long exposure to the air. Coloured Pus.—Green or blue pus is sometimes found instead of the usual creamy, more or less yellow-coloured variety. This discoloui-ation is usually* brought about by the presence of the bacillus pyocyaneus (see pages 313, 314). 0. Grube and Ferchmin have seen fourteen cases of bright red pus. The cinnabar colour is due to a specific bacillus (see page 314). Orange-coloured pus occurs as tbe result of tbe admixture with crystals of haematoidin. Outcome of an Inflammation.—In considering the outcome of an in- flammation, the secondary conditions that follow must be distinguished from the purely local processes at the seat of the inflammation. As regards the system at large, the main purpose of inflammation is to do away with the causes which give rise to the inflammation, accomplish- ing this by increased metabolism, rapidity of circulation, and transuda- tion. The processes which take place in an inflammation combat its causes in an efficient way, and try to make reparation for the damaging effects that it produces (Leber, Arnold). In many cases the inflamma- 218 INFLAMMATION AND INJURIES. tion is not capable of removing the causation of the disease. Death may occur at any stage of the inflammation, but especially when the inflammatory process is at its height, as a result of a general systemic infection with fever, due to the primary local inflammation. AVe shall learn in § 62 about the significance of fever and its dangers for the organism. From a prognostic standpoint, the location of the inflam- mation is of the greatest importance. A subcutaneous abscess is by no means as dangerous to life as a very minute collection of pus in the bones of the skull, the meninges, or in the brain, the medulla oblongata, etc. The age and constitution of the patient is likewise an important factor. If we take a purely local view of the outcome of an inflammation, the worst that can occur is gangrene or necrosis—i. e., death of the affected tissues. In its various gradations this is a very frequent re- sult of an inflammation, and is due either to complete stasis in the ves- sels, followed by coagulation of the blood which they contain, or to pressure of the exudate on the surrounding tissue. Furthermore, in a localised death of tissue, constitutional conditions, such as diabetes or old age, play a very important part. We shall return to the discussion of localised death of tissue (gangrene, necrosis, or mortification) in an- other chapter. It will only be stated now, that in general the extent of the inflammatory necrosis varies greatly, depending upon the in- tensity and extent of the inflammation. AVe shall see that the influ- ence of micro-organisms, such as single groups of bacteria, is a promi- nent factor in the production of gangrene. The capability on the part of the tissues, and especially of the vessels, of withstanding gangrene varies greatly with the portion of the body which is affected and with the individual. The most favourable outcome of an inflammation is a -complete restitutio ad integrum—a perfect restoration to the original condition—which of course is most frequently observed after an inflam- mation of a mild type in which the exudate has been scanty and chiefly serous. The disappearance of the phenomena of inflammation begins as soon as the circulating blood has restored the walls of the blood- vessels to their normal condition, and when this has taken place the exudation ceases. The fluid portion of the exudate is absorbed by the lymph vessels, likewise the white blood-corpuscles and fibrin, after they have in part undergone a fatty degeneration. The red blood-cells lose their colouring matter, and gradually become disintegrated. The fixed tissue cells which have been damaged by the inflammatory irritation recover after the restoration of their normal nutrition, and by degrees a complete restitution takes place. Sometimes, however, after absorp- tion of the fluid the formed or solid elements of the exudate remain §"*.] INFLAMMATION. 219 behind as a light yellow, caseous mass, wliich, by a reactive inflamma- tion, becomes encapsulated as a cheesy nodule, like a foreign body. Under such conditions complete absorption often does not occur, and finally a deposition of salts of lime takes place, forming a firm, calcare- ous concretion. If the inflammatory process is more severe, and if there is localised death of tissue, the absorption of the exudate and the necrotic soft parts takes place in a similar manner—i. e., by absorption of the fluid and fatty emulsion of the solid elements. Small portions and granules of tissue, in case they are not taken up by the lymph channels, are seized by the cells which have wandered out of the vessels, and wliich in this way become granular cells. If, as the result of an inflammation, a portion of bone has become necrotic, the dead piece of bone or sequestrum is separated from the living bone by a suppurating line of demarcation (see § 106). The pus formed during an inflammatory pro- cess near the surface of the body may break through spontaneously, or be removed artificially by operative measures, such as incision, etc. There is the danger in all infectious inflammations, or those cases of suppuration which are due to micro-organisms, that the inflamma- tion may become the starting-point for a general infection. There- fore, whenever it is possible, operative measures should be undertaken at an early period to provide a way of escape for the exudate, for otherwise the inflammation and suppuration may spread, resulting in an extensive infiltration or phlegmon, which may break through into an important organ, such as a joint, the cranial cavity, abdominal cav- itv, etc. Moreover, the micro-organisms that cause the inflammation are scattered about by the lymph- and blood-vessels. It must always be borne in mind that products are constantly being formed in an infectious inflammation which are capable of producing further inflam- mation in the surrounding parts and in widely separated organs. The bacteria, and the products of metabolism and decomposition which they cause, are here again the causes of the secondary inflammatory processes. As a result, then, of infectious inflammations, bacteria may be deposited in large numbers in different internal organs, causing sec- ondary so-called metastatic abscesses. Scar Formation.—If a defect or loss of substance results from a severe inflammation with necrosis, this is remedied to a greater or less extent by a new production of connective tissue, which is then called cicatricial tissue. Scar formation is to be looked upon as an inflam- matory process which is productive in character. A germinal or granu- lation tissue, as it is called, develops, consisting only of round cells with a very small amount of interstitial substance; this granulation tis- 250 INFLAMMATION AND INJURIES. sue then gradually changes into fibrous connective tissue, which makes up the cicatrix. I used to believe, as Cohnheim did, that the new- formed connective tissue, the granulation and cicatricial tissue, was chiefly derived from the emigrated leucocytes, which increased in size when the new blood-vessels developed amongst them and became large, irregular-shaped cells (fibroblasts). But some recent investigations have made me conclude that the leucocytes at the inflammatory focus are unfit for making new connective tissue and healing up the wound, and I am now convinced that they gradually disappear, partly by wan- dering into the lymphatic vessels and being carried off in the lymph current, and partly by wandering into other localities and disintegrat- ing and being taken up by the fixed cells of the part (Baumgarten, Zahn, Marchand, etc.). Ziegler has also expressed the same view. The newly formed connective tissue, therefore, is in reality produced by a growth of the fixed connective-tissue cells (Baumgarten, Marchand, etc.). Marchand has proposed to designate the leucocytes originating from the blood and lymphatics as exudation cells, in contradistinction to the granulation or true formative cells which are derived from the tissues. The formative cells get their nourishment from the protoplasm of the leucocytes, as I have mentioned above. Sherrington, Ballance, Shattock and others maintain that the plasma cells are the ones chiefly concerned in the formation of cicatricial tissue (see also § 61). Regeneration of the Tissues.—Simultaneously with the formation of the granulation or cicatricial tissue there is a proliferation of the fixed (specific) cells in the neighbourhood for the purpose of restoring the cells that make up the particular organ. Epithelium gives rise to epithelium; muscle cells form muscular fibres, though in a very limited amount; periosteal and medullary cells make bone, etc. The power of regeneration possessed by the different tissues varies very greatly, as we shall see. The skinning over or covering of a loss of substance in the skin with epidermis is brought about by the cells of the rete Mal- pighii and sebaceous glands. Reference is made to § 61 for the de- scription of the various phenomena in scar formation and regeneration in the different tissues (microscopic phenomena in the healing of a wound), and to §§ 87 and 88, (Injuries of Soft Parts). For the process of healing of fractures see § 101. The healing of a Foreign Body into a Wound.—If the inflammation is caused by the entrance into the tissues of a solid foreign body, the latter may completely heal into the tissues, as we shall often have the opportunity of observing ; and this will occur the more readily the more free the body is from dirt, dust, bacteria, products of decomposition, etc. We know that silk sutures, silver wire, bullets, etc., heal up in a wound in this way without giv- ^ 38.] INFLAMMATION. 251 ing rise to any reaction. Foreign bodies which have thus become enclosed often change their location later on, and in their wanderings may make their appearance beneath the skin in another portion of the body. Large, soft foreign bodies are completely absorbed in the way described above. I implanted, under antiseptic precautions, large fresh pieces of liver, spleen, lung, and even entire kidneys of rabbits, in the peritoneal cavities of other rabbits, and found that they became absorbed without producing peritonitis. I also used similar specimens which had been hardened in absolute alcohol, and with the same results. The portions of tissue were invaded by vast num- bers of wandering cells and slowly liquefied. Hallwachs, Rosenberger. Salzer and others have recently studied the sub- ject of the encapsulation of foreign bodies, and Salzer says that those which are smooth and solid become enclosed in a delicate connective-tissue capsule, while the porous, fibrous, rough foreign bodies are most apt to heal into the scar tissue with the formation of very thick layers of connective tissue. Diagnosis of Inflammation.—In the diagnosis of inflammation—i. e., of the four above-described cardinal symptoms, redness, swelling, heat, and pain—we make special use of inspection and palpation of the affected part in case it can be seen and touched. If the inflammation is located on the outer surface of the .body the diagnosis is simple, but it is more difficult if the inflammation is situated more deeply. By palpation of the inflamed tissues we attempt to determine whether the inflammatory focus contains pus—i. e., whether it " fluctuates " or not. Every fluid, and consequently pus or serum, contained in a cavity hav- ing yielding, elastic walls will give fluctuation or a wave movement when the fluid in this cavity is set in motion by intermittent pressure with the index or middle finger. The detection of fluctuation is of the greatest practical importance. If the pus is contained within firm, unyielding walls, such as bone, or in deeply situated tissue with thick- ened rigid walls, fluctuation cannot be made out. Furthermore, it must not be confused with the pseudo-fluctuation manifested upon pal- pation of soft elastic parts ; but a little experience will soon teach the distinction between the fluctuation of an elastic cavity filled with fluid and the pseudo-fluctuation of soft elastic tissues such as the muscles of the thenar eminence, soft fatty tumours, etc. Puncture with a hypo- dermic syringe is an exceedingly useful diagnostic measure for de- termining the nature of the contents of an inflammatory focus (see page 71). A\re also employ the sense of hearing in the diagnosis of an inflam- mation by noting, for example, whether any friction sound is produced by the rubbing together of two opposed inflamed surfaces. Hueter has constructed instruments analogous to the stethoscope used in the diagnosis of diseases of the thoracic viscera; they are a dermatophon, 252 INFLAMMATION AND INJURIES. an osteophon, and a myophon, for the diagnosis of surgical diseases of the skin, bones, and muscles respectively, and they consist of an elastic tube fitted to an ear-piece. We shall refer to this apparatus in diseases of bone, but it may be said here that hitherto it has not been brought into general use. The febrile disturbance accompanying an inflammation is deter- mined by accurate measurement of the body heat by means of a ther- mometer placed in the axilla, or, better, in the rectum (see § 62, Fever). Amongst other aids to diagnosis I should mention the probe, which is used to ascertain the direction and length of a fistulous tract, or the presence of a foreign body. There are also instruments designed for snecial organs, such as the urethra, bladder, stomach, etc., and a great number of contrivances for inspection of the nose, larynx, bladder, eye, etc. These general remarks will be sufficient until we return to the diag- nosis of inflammations of the separate parts of the body. Treatment of Inflammation.—At present we can only deal briefly with the treatment of inflammation, as we shall have to come back to the subject in detail for each separate part of the body. From a pro- phylactic standpoint it is best to treat every injury, no matter how trifling it may be, on antiseptic principles, after the manner described in a former chapter. In general, the treatment of an acute inflamma- tion consists in the use of suitable antiphlogistic measures, particularly the proper position of the inflamed part, such as elevation in the case of an extremity, in the application of ice, and in the prompt evacuation of the pus or infiltrating exudate by incision. Blood-letting by leeches, cupping, and scarification used to be much in vogue for diminishing the amount of blood contained in an in- flamed portion of the body, but now this practice has very properly been given up. The counter-irritation method of treatment by cutane- ous irritants, such as the moxa, issue, red-hot iron, painting with tinc- ture of iodine, and the application of vesicants, is also old-fashioned. It would require too much space to give the outlines of treatment for inflammation according to the location and causes of the latter, and it can be done more satisfactorily in the discussion of the treatment of inflammations of the separate organs. The treatment of the general febrile disturbance due to inflammation will be considered in the treat- ment of fever (§ 62). § 59. Morphology and General Significance of Micro-organisms.—By micro-organisms or microbes is understood a class of minute living organisms which belong to the lowest forms of plant life or stand on the border line between plants and animals. The majority of the mi- §59.] MICRO-ORGANISMS. 253 cro-organisms have a diameter of only about one micromillimetre or less. They multiply with extreme rapidity, and 'are able to live in widely differing degrees of temperature, some in acid and others in alkaline solutions of simple compounds (with the exception of carbon dioxide), as well as of more complex nourishing substances. The micro-organisms play a very important part in the economy of nature. They excite fermentation and decomposition, and are parasites in living plants, animals, and man, causing in some cases disease and death. By fermentation and decomposition the micro-organisms dis- integrate considerable amounts of organic material in a short period of time with the evolution of gas. The change of sugar into lactic acid (sour milk), the lactic into butyric acid, and alcohol into acetic acid, are all processes of fermentation caused by micro-organisms. We make use of micro-organisms in the preparation of many alimentary sub- stances, such as bread, cheese, beer, wine, etc., while on the other hand, as a result of the fermentative and putrefactive action of these low orders of organisms, our food may be rendered unfit to eat. Micro-organisms also produce poisonous matters (ptomaines, tox- ines) which are dangerous to the health and life of man. Numerous acute and chronic inflammations, particularly the surgical diseases of wounds, are due to the presence of micro-organisms. Evidence of the Bacterial Origin of many Infectious Diseases, especially the Diseases of Wounds.—Under normal conditions we find no micro-organ- isms in the blood and internal organs of healthy human beings and animals; this has been proved beyond a doubt by Meissner and many other investi- gators. On tbe other hand, we observe in the various infectious diseases, particularly the surgical-wound diseases, certain micro-organisms in the blood and internal organs, and we know that every infectious disease is due to some specific, plainly distinguished class of micro-organism. These gain access to the body from without by means of the inspired air, the food, water, or by contact with the surface of the body, especially if there is an interrup- tion of continuity in the skin or mucous membranes. The striking results obtained by antisepsis and the aseptic method of operating and treating wounds demonstrate that the infectious-wound diseases are caused by the entrance of micro-organisms into the wound from without. If we perform an operation, taking every precaution not to introduce microbes by our hands or instruments, or from the patient's own skin, into the wound, or, briefly, if we operate aseptically, as we have learned in a previous chapter, with everything germ-free and sterile, and then dress the wound with germ- free (sterilised) materials, such a wound will invariably heal without inflam- mation and suppuration per primam intentionem, or, in other words, by immediate agglutination of its borders, and without giving rise to fever. If there is a transgression of the rules of asepsis or antisepsis in performing an operation or treating a wound, and if micro-organisms get into the wound, inflammation and suppuration and other wound diseases, accompanied by a 251 INFLAMMATION AND INJURIES. corresponding febrile disturbance, will result. If an infected wound is treated with disinfecting substances, such as bichloride (1 to 1,000 - 5,000) or three- per-cent. carbolic solutions, the micro-organisms are prevented from further development and the existing inflammation or suppuration is modified or checked, provided it has not already become too far advanced and no general systemic poisoning has taken place. A further proof of the microbic origin of the infectious diseases is furnished by the successful results of transmis- sion from animal to animal. Cultures of a particular kind of bacteria which had caused a certain infectious disease, were introduced into the body of an animal and here produced the same disease, and the same kind of bacteria could be isolated from the diseased tissues. The micro-organisms damage the human organism in a double manner—viz., by the formation of the poison- ous products of their metabolism, and by multiplying very rapidly and invad- ing new portions of tissue. The Different Kinds of Micro-organisms.—AVe recognise four large classes of micro-organisms: I. The fungi or moulds. II. The sprout- ing or yeast fungi (saccharomycetes, blastomycetes). III. The fission fungi, bacteria (schizomycetes). IV. Mycetozoa and protozoa. I. Fungi—Moulds form the well-known green, yellow, whitish, or black skin-like covering found upon all sorts of dead organic substances. They usually consist of two functionally distinct parts, the mycelium and the germinal hypha or zy- gospore. The mycelium consists of branching, usually jointed threads, which anastomose with one another and proliferate in the nutrient substrata. The zygospores spring from the my- celium and produce and carry on their ends the seeds or spores (Fig. 221). The latter are round or elongated cells generally having a dense en- veloping membrane, and after separation from the zygospore are capable of forming another fungus with its zygospore. The spores can re- tain their vitality in a dry state for from two to ten years. Numerous species of fungi are distinguished by the manner in which the spores form upon the zygospores. Occasionally the spores undergo segmentation by transverse di- vision of the terminal cells at the extremity of the zygospore (conidia). In other fungi the terminal cell develops into the so-called sporan- gium or ascus, in the interior of which the spores form by division of the plasma (ascospores). In still others two zygospores grow one within the other, and the so-called oospores develop at the point of junction of the two spore carriers. The same fungus will occasionally form its spores in several different ways, depending upon the conditions in which it exists (conidia and ascospores). Conditions suitable for the Life of the Fungi.—The fungi are found upon Fig. 221, -Penicillium glaucum, x 500. t«59.] MICRO-ORGANISMS. 255 every description of dead substance, and upon substances which contain a relatively small amount of water and have an acid reaction, thus differing from the bacteria. For making pure cultures of fungi, the best materials are boiled potatoes, bread pulp, and gelatine, or the agar mixture rendered acid by the addition of two to five per cent, of tartaric acid, to prevent bacteria from taking root along with the fungi. The temperature is an important matter, some species thriving best at +15° C. (59° F.), and another at +40° C. (101° F.). The spores will only form when there is plenty of air, oxygen being essential, and consequently most of the fungi will not multiply in the interior of animal tissues nor in blood; they ordinarily exist only upon such portions of the body as are freely exposed to the atmospheric air. Penicillium.—The commonest fungus is the penicillium glaucum (Fig. 221). It groAvs in distilled water and many kinds of medicine, best at a tem- perature of from 15° to 20° C. (59° to 68° F.), while at 38° C. (101° F.) it gradually dies. The mycelium has a flocculent, white appearance, turning green after the formation of the spores. Tbe latter do not grow when intro- duced into warm-blooded animals by injection into the blood or by inhala- tion, and they may remain for weeks in the liver and spleen. Oidium.—There are numerous species of the oidium which flourish partly upon a dead substratum and partly (like mildew) upon living plants. They are regularly present upon sour milk. Mycelium and spores are white. They thrive best at a temperature between 19° to 30° C. (50° to 86° F.). They have plain, upright zygospores, bearing chains of cylindrical spores. Fungi of the oidium class are found in favus, pityriasis versicolor, and herpes tonsurans. Monilia.—The monilia is distinguished from the oidium by its zygospore, which takes a bushy-shaped, branching form as it springs from the myce- lium. It causes thrush. Mucor.—There are many species of mucor, some of which thrive best at a temperature of 37° C. (98'6° F.), and cause death in rabbits when their spores are injected into the blood-vessels in large amounts. There are then found in the internal organs, particularly the kidney, a great number of small fungi which do not fructify. They are chiefly found in man, in the external auditory meatus. The spores are developed in sporangia. Aspergillus.—They generally germinate like the conidia, less frequently having ascospores. The aspergillus glaucus is greenish yellow, is harmless as regards warm-blooded animals, and is generally found in damp wTalls, fruits which have been stored away, etc. The aspergillus niger, fumigatus, flavescens, and subfuscus are pathogenic, and tbe maximum temperature compatible with their existence is about 37° C. (98*6° F.). The injection of large numbers of the spores will kill rabbits, numerous foci of the fungus being found in the heart, liver, and kidneys. Spores of aspei*gillus fumi- gatus exist chiefly in the air-passages of birds. In man, colonies of this species of aspergillus have been observed in the bronchi, lungs, external auditory meatus, upon the cornea, etc. Actinomyces.—The actinomyces or ray fungus is found in cattle and man chiefly in the tongue, jaw, and lungs, where it causes abscess and suppurat- ing growths. Harz, De Barry and others placed the actinomyces amongst the fungi, but the recent investigations of Israel, Ponfick and Bostroem seem to prove it to be a branched form of cladotbrix (see § 86, Actinomycosis). 256 INFLAMMATION AND INJURIES. Pathological Importance of the Fungi in Man.—The pathological bearing of the fungi upon man, as ascertained by experimental and clinical observa- tions, is briefly as follows: It is well known that the fungi occasionally find lodgement in the epithelium of the skin and mucous membranes, and in the former situation give rise to favus, herpes tonsurans, and pityriasis versi- color, and in the latter to thrush. E. Wagner has noticed that the threads of the thrush fungus penetrate into the blood-vessels of the mucous membrane; and Zenker found in the brain of a child affected with thrush multiple abscesses with sprouting spores of the thrush fungus in their centres. Fungi are capable of growing in the tissues of warm-blooded animals through which blood is circulating. Grohe at first denied this, but it was subse- quently affirmed by Grawitz, though the fungus has to undergo an " accom- modative cultivation " before it can live in the alkaline blood at a temperature of 39° C. (102,2° F.). Experiments made by Koch and others have demon- strated that there are pathogenic fungi which are capable of development in the tissues of warm-blooded animals without having undergone any pre- vious particular kind of cultivation, while the non-pathogenic fungi never possess this power even though they have first been subjected to cultivation. The non-pathogenic fungi include the penicillium glaucum, the aspergillus glaucus and niger, the mucor mucedo, and stolonifer. The species which are certainly pathogenic include: 1. The aspergillus fumigatus, distinguished from the aspergillus glaucus by its very small size and that of its spores, its dirty green colour, tbe manner of its growth, its poor development at ordi- nary temperatures, and the very rapid growth manifested in temperatures equal to blood heat. The aspergillus fumigatus is present in bread, and is readily cultivated on dough kept at a temperature of 39° to 40° C. (102'2° to 104° F.), as a dark-green fungous covering. 2. The aspergillus flavescens is similar to the aspergillus fumigatus, and is characterised by its yellowish- green colour. 3. The mucor rhizopodo-formis is distinguished from the non- pathogenic mucor (Rhizopus) by the greyish-brown colour of its mycelium, the large size of its individual parts, its small, round, colourless spores, and by the egg-shaped columella dilated at its top. 4. The mucor corymbifer is known by the snow-white colour of its mycelium and its characteristic form. Internal fungous diseases arising spontaneously in, for instance, the lungs and intestinal tract, are seldom seen in man, as the pathogenic fungi (of the aspergillus and mucor varieties) will only thrive at a high temperature, and consequently are not very plentiful in the air, water, or alimentary sub- stances. Furthermore, the fungi are only pathogenic when they exist in great numbers, while the system is capable of overcoming a few of them without itself suffering harm (Grawitz), and their increase by means of spores does not take place in living tissue. Fungous diseases are most easily excited by intravenous injection of tbe organisms. Lichtheim's mucor injections proved fatal in rabbits in every case, while dogs were not affected at all. Morse, Kaufmann and Schulz caused animals to inhale and swallow large amounts of pathogenic fungi without producing any ill effect ; Lichtheim noted only a scanty and stunted vegetation in tbe lungs after inhalation. In man there is occasionally observed a pneumomycosis aspergillina (aspergillus fumigatus) and a pneumomycosis mucorina, secondary to already existing pulmonary disease. There is also a keratomycosis aspergillina, a corneal §59.] MICRO-ORGANISMS. 257 lesion, and an aspergillus mycosis of the external auditory meatus (oto- or myringo-mycosis aspergillina), produced by the aspergillus fumigatus, fla- vescens, and nigrescens. According to Carter, the Madura foot, a disease like elephantiasis, endemic in India, and characterised by the formation of wartv lumps, suppurating in their interior and terminating in death after about a year, is caused by a fungus, the chionyphe Carteri, related to the mucor sto- lonifer; but other investigators have disputed this. As a general thing, man may be said to be immune to the pathogenic fungi hitherto identified ; but under conditions not yet understood these fungi may take on a fatal activity, as exemplified by the above-mentioned case of Zenker's, and a recently de- scribed and interesting case of Paltauf, in which a man died in coma after what appeared to be an enteritis and peritonitis. In the brain, lungs, and intestine were found inflammatory foci, or abscesses, containing mycelia of the mucor variety (mucor corymbifer). It is by no means impossible that still other new forms of fungous disease may be found to have their existence in man. All the facts which are known as regards the pathogenic fungi are of great surgical interest. The fungi play a very important part in the pro- duction of diseases in plants and low orders of animal life, such as the grape disease, the potato disease, the " rot" of grain, the muscardine disease of silk- worms, and various diseases in insects, etc. II. The Yeast Fungi (Blastomycetes).—-The yeast fungi (Fig. 222) are round, oval cells of different sizes, varying from two to fifteen micromillime- tres in diameter, having a thin enveloping membrane and granular protoplasm, in which there are frequently vacu- oles (Fig. 222). They multiply by budding or putting forth daughter cells, which finally become separated from the mother cells by a partition, and either remain in contact with their parent cell for a considerable time, forming more or less long chains, or they become entirely separated. Many, though not all of the yeast fungi produce in solu- FlG- 222- — Yeast ,. ' , , . ,. , ... . . fungus. Saecha- tions of sugar alcoholic fermentation, changing grape sug- romyces cerrevi- ar into carbonic acid and alcohol. The true yeast-fungi sise- Vacuoles are which cause fermentation (saccharomycetes) must be dis- of the larger cells. tinguished from the other fungi of the same class. The mycelia of the typical mould fungus—for instance, the mucor species—can form chains and can cause alcoholic fermentation in a solution of sugar. Macroscopically the yeast plant forms a white cloudy sediment in a ferment- ing fluid, or a white scum over the surface of alcoholic fluids which are spoil- ing. In solid nutritive media (gelatine) the yeast fungus makes spores by developing free cells within the enlarged mother cell (ascospores). Beer-wort and decoctions of malt or prunes, to which sugar is afterwards added, form the best culture media, but they must be mixed with one per cent, of tartaric acid to keep out the bacteria. The pathological interest of tbe yeast fungi is limited ; they occasionally give rise to fermentation in the stomach. Some writers think that thrush is caused by a variety of the yeast fungus (mycoderma). III. The Bacteria (Schizomycetes).—The bacteria (from to fZaKTrjpiov, a small rod, from the rod shape which many of them have) are very 18 258 INFLAMMATION AND INJURIES. -\ ys it Fig. 223.—Different varieties of cocci: a, Small- er and larger cocci; b, diplococci; c, chain coccus (streptococcus); d e, clusters of cocci in the form of a bunch of grapes (staphylo- cocci );/, sarcina (packet coccus); g, micro- coccus tetragonus. small, simple cells of a low order of vegetable life related to the lower orders of algae. They are divided into several distinct classes, according to their shape and the effects which they produce. Never- theless, under altered conditions in their life the bacteria of one class change their shape and function to a greater or less degree. There are chiefly to be distinguished— 1. The micrococci. 2. The ba- cilli. 3. The spirilli. 1. The Spherical Bacterium (Micrococcus or Coccus).—The micrococci are small, round or oval cells, which by division or fission always produce in turn the same round cells. The micro- cocci exist either as isolated sphe- rules (Fig. 223, a), or they remain in pairs after dividing (diplococ- cus, Fig. 223, b), or the spherules cling together in chains (strep- tococcus, Fig. 223, c). In other instances they form irregular groups (staphylococcus, Fig. 223, d, e). Large groups or colonies bound to- gether by some sticky material such as mucus are called zoogloa. Sometimes the micrococci develop in groups of four (merismopaedia, merista, Fig. 223, g), or they are joined together in cubes (sarcina, Fig. 223, f). The sarcina is found in the stomach of man, as sarcina ventriculi, when decomposition of the gastric juice is present. 2. Rod-shaped Bacte- ria (the Bacillus).—In all bacilli the longitudinal di- ameter exceeds the trans- verse, and their size varies very greatly (Figs. 221, 225, 22, that the micro-organisms which are everywhere present outside the body may, by their admission to any wound, give rise to the gravest dangers. This cannot occur in subcutaneous injuries where the protect- ing skin and mucous membrane remain intact and ordinarily prevent the entrance of these noxious bodies into the system. The aim of the modern method of treating wounds is directed, as it should be, towards keeping out of the wound all injurious substances, including bacteria, and towards rendering them innocuous in case they have gained en- trance. For this purpose we employ, in treating wounds, fluids which, like three-per-cent. solutions of carbolic acid and 1 to 1,000 to 1 to 5,000 solutions of bichloride of mercury, are capable of killing the micro-organisms; and, furthermore, we only bring in contact with the wound such objects as have been made perfectly sterile. A probe or a finger which has not been disinfected may cost the patient's life. In the chapter on fractures we shall see that in the pre-antiseptic periods of surgery the course of subcutaneous fractures was entirely different from that of fractures complicated by wounds of the skin. It was in the treatment of this latter class of injuries that Joseph Lister, the great reformer of modern surgery, began the practical application of his antiseptic, or we might say his antibacterial, method of treating wounds. Now we are enabled to keep a fresh wound free from all injurious substances—in other words, to prevent all infectious wound diseases—and to bring about a cure of a great number of injuries which in the pre-antiseptic days would undoubtedly have proved fatal. According to the causation of the injury, we distinguish between injuries due to mechanical violence and those due to thermal (burning, freezing) or chemical influences (cauterisation). Subcutaneous injuries are produced by blows with blunt instruments, or falls, while open wounds are caused by blows with more or less sharp instruments, and take the form of punctured, lacerated, incised, contused, or gunshot wounds, etc. All wounds due to blows with blunt instruments are more or less contused wounds—that is, the borders of the wounds suffer a more or less extensive necrosis as a result of the violence used. The pure incised, stab, and punctured wounds are simple wounds, while the lacerated and contused wounds are, as we shall see, complicat- ed wounds. The condition of the borders and the depth of the wound £60.] GENERAL REMARKS CONCERNING INJURIES. 970. are matters of great practical importance. If a wound penetrates into a joint or into one of the large cavities of the body, such as the cranial, thoracic, or peritoneal cavities, we call it a penetrating wound. If a portion of tissue is completely cut or torn from its connections by violence, a wound is formed with loss of substance; but if the portion of tissue still retains some of its connections with the surrounding parts, there results what is called a flap or peel wound. A wound which is clean, not poisoned and not infected, is distinguished from one which is unclean, poisoned, and infected. AVe count amongst unclean wounds all those in which there is present any foreign body whatsoever, such as dust, sand, dirt of every description, portions of clothing, bullets, pow- der grains, etc. Wounds affected with any one of the infectious wound diseases belong to the class of infected wounds (inflammation, suppu- ration, erysipelas, wound diphtheria, septicaemia, etc.). The wounds pro- duced by bites of snakes, insects, etc., are wounds poisoned by animal poisons. The symptomatology and treatment of injuries vary greatly, accord- ing to the portion of the body involved and the anatomical peculiari- ties of the injured tissues. Consequently we divide injuries of the human body into injuries of soft parts, of bones, and of joints, and their symptomatology and treatment will be discussed later on. "We shall first give a general outline of the anatomical changes occurring in the healing of a wound. Railway Injuries.—A very severe and numerous class of injuries are in- curred from collisions between railway trains. Tardieu, Vibert and others have recorded their valuable experiences on this subject, particularly Vi- bert, who gave a report of four hundred persons injured in a railroad acci- dent at Charenton. The occupants of the train which moves the most rap- idly suffer the worst and most numerous injuries. Upon those who die instantly without exhibiting any external injury many punctiform haemor- rhages are found, mostly about the head and upper portions of the body, similar to those which occur in fracture of the base of the skull. Bad fractures and injuries to the soft parts are found chiefly in the lower ex- tremities, unless the victims protect themselves in time by rising from their seats. Not infrequently the lungs are injured (haemoptysis) by contusion or crushing of the thorax, and there may also be injuries of the abdominal vis- cera. Very often the patients suffer grave disturbances of the central nervous system—loss of sleep, headache, alterations in their mental condition of a partly excitable, partly melancholic, depressed type, disturbances of digestion, loss of memory, easily excited intellectual fatigue, great susceptibility towards stimulants (alcohol, tobacco), maniacal conditions, auditory sensations of a subjective character, photophobia, paralysis of accommodation, disturbances of smell and taste, paraestbesia of the sensory nerves, anaesthetic areas, particu- larly when there is an organic lesion of the brain, muscular twitchings, motor weakness, especially in the legs, paralysis, disturbances of circulation and res- 280 INFLAMMATION AND INJURIES. piration (increasing cachexia). The patient exhibits, in some cases, every symp- tom of dementia paralytica. All these nervous phenomena are grouped to- gether under the name of traumatic neuroses. They are particularly liable to make their appearance after concussion of the brain and spinal cord, and sometimes are caused by relatively slight accidents. In the majority of cases it is a psychosis and neurosis, similar to hysteria, without actual changes in the central nervous system (Charcot, Striimpell). Albin Hoffmann has cor- rectly pointed out that a traumatic neurosis is of much less frequent occur- rence in individuals previously perfectly healthy than has hitherto been sup- posed ; the number of malingerers is large, and is steadily increasing since the accident law went into effect. In the minority of the cases there do occur progressive pathological changes in the central nervous system as a direct result of the accident. The prognosis of these cases is very unfavourable ; they often lead to chronic disease of the cortex of the brain; less frequently it is located in the spinal cord. The English physicians have given the name of railway spine to the secondary diseases of the central nervous system fol- lowing railway accidents. § 61. The Anatomical Phenomena in the Healing of a Wound.—The anatomical phenomena manifested in the healing of wounds were first studied exhaustively by Thiersch, and all the recent investigations have been based upon the correct statements which he made. AVe ordinarily distinguish two kinds of repair in a wound: (1) the direct primary agglutination of the divided parts, called healing per primam inten- tionem / and (2) the repair of a wound by the formation of granulation tissue, or, in other words, repair accompanied by suppuration, called healing per secundam intentionem. Healing per Primam Intentionem.—Healing by primary intention takes place in all fresh aseptic wounds, particularly in those produced in the course of an operation, the borders of the latter class (operation wounds) being held by the stitches in continual contact until they ad- here together. Those wounds which are treated aseptically heal more rapidly than those treated antiseptically—that is, than the wounds irri- tated by antiseptic solutions (bichloride, carbolic acid, etc.). Macroscopic Phenomena in Healing by Primary Intention.—The macro- scopic phenomena manifested in the healing of wounds per primam intentionem are briefly as follows: AVe ordinarily find, in the first place, that the borders of the wound become agglutinated by a coagu- lum made up of blood and lymph. During the next four, six, or eight days the union of the wound is definitely established, the coagulum in and around the wound space becoming replaced by new cells and blood-vessels, the former of which gradually change into the fibrillar connective tissue making up the cicatrix. In the case of small wounds, or slight losses of substance, there is usually developed as a result of the coagulation of the blood and lymph a crust, beneath §61.] ANATOMICAL PHENOMENA IN THE HEALING OP A WOUND. 281 which the complete healing of the wound is accomplished (called healing under a scab (see page 177). The skinning over of the wound proceeds from its borders by proliferation of the cells of the rete Malpighii and of the sebaceous glands, if the latter still exist in the surface of the wound. The young cicatrix at first forms a fine red line, which subsequently becomes gradually whiter and softer. The cicatrices of many wTounds which unite by primary intention disap- pear in course of time more or less completely. Healing by Secondary Intention.—The healing per secundum inten- tionem, with the formation of granulation tissue and pus, takes place in badly contused wounds, or where there has been a loss of substance and it has been impossible to obtain direct adhesion of the divided tis- sues with the aid of stitches, and also in wounds which have been neg- lected and not treated aseptically, and in wounds wdiich have been infected by micro-organisms. Macroscopic Phenomena in the Healing of Wounds by Secondary In- tention.—Alacroscopically, the phenomena which take place in this form of healing of a wound, involving, for example, vascular soft parts, are somewhat as follows: Until the expiration of about twenty-four hours after the reception of the injury the various tissues exposed in the surface of the wound are clearly distinguishable from one another. Later on the outlines of the various tissues in the wound are obscured by a jelly-like covering consisting of a reddish-yellow fluid, a mixture of blood serum and lymph which has been poured out from the wound. After about two to three days the grejdsh-red gelatinous wound surface begins to take on a granular, red appearance, and the wound begins to granulate, or to form vascular cellular germinal tissue called granula- tion tissue, from which there is ordinarily produced an exudate con- taining a great quantity of round cells—in other words, pus. If the wound heals aseptically as a result of most careful disinfection and most rigorous aseptic treatment, the secretion will be slight, and fre- quently actual pus formation will not take place. Profuse suppura- tion will only occur in a wound which is not aseptic. In contused wounds with destruction, or rather necrosis, of the tis- sues, the dead portion of the tissues is first cast off by the process of granulation; the wound " purifies itself." Under these conditions it is possible to obtain with aseptic dressings a more rapid healing, unac- companied by profuse secretion, suppuration, or decomposition. The Skinning Over of a Granulating Wound.—The covering over of a granulating surface with skin proceeds gradually from the margins of the wound, and is accompanied by a simultaneous shrinkage of the granulation tissue. If the cutis has not been entirely destroyed, if 282 INFLAMMATION AND INJURIES. there are still traces of the Malpighian stratum present, or if the epi- thelium of the sebaceous glands is intact, the remains of these struc- tures will form the starting points within the granulating area from which skin will spread outwards over the granulating surface. All cicatrices which are accompanied during their formation by suppura- tion are thicker, more extensive and unsightly than the small linear cicatrices resulting from primary union. Histological Phenomena in the Healing of Wounds.—The minute phe- nomena which take place in the repair of a wound involving vascular Fig. 236.—Wound in the liver (cuneiform Fig. 237.—Immigrated white blood-corpuscles excision), tvventy-1'our hours old. a, in a four-cornered defect in the middle of Border of the liver; b, coagulum of a dead, hardened piece of liver substance, blood in the defect. Commencing col- which had been implanted with antiseptic lection of wandering cells in the bor- precautions in the abdominal cavity of a ders of the wound. rabbit twenty-four hours. tissue is practically the same whether the w7ound heals with the forma- tion of pus or without it. Healing by primary intention is character- ised by the formation of a minimum amount of germinal tissue unit- ing the borders of the wound, while in healing by secondary intention the amount of germinal tissue is much more considerable. After every wound, no matter howr free the healing may be from reaction, there follows an inflammation in the sense described in § 56, and as a result of this there is a cellular infiltration of the borders of the wound with wandering cells (Fig. 236). This cellular infiltration of the borders of the wound steadily progresses, advancing by degrees into the wound, and taking the place of the blood coagulum which is present (Fig. 237). In cases of pronounced inflammatory infiltration of the borders of the 61.] ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 283 wound the old tissues in the immediate neighbourhood are more or less completely destroyed by fatty degeneration. On about the third day the wound, or the wound cleft, will be found filled with a tissue consisting almost exclusively of round cells, with a very small amount of inter- mediate substance, I used to believe that these formative cells were direct descendants of the emigrated white blood-corpuscles, but recent discoveries have forced me to abandon this view as incorrect, and I have come to the conclu- sion that Thiersch, Recklinghausen and others are right in stating that the original fixed connective-tissue cells and the endothelium of the vessels are the essential factors in the formation of the cicatrix. Zieg- ler has also recently adopted this view. The numerous nuclei in differ- ent stages of division which can be demonstrated in the fixed connec- tive-tissue cells and the endothelium of the vessels as the latter undergo rapid proliferation are proofs of the correctness of this theory. The newly formed tissue cells can also become wandering cells. The regen- erative processes within the injured organs are likewise carried on by the fixed tissue cells. The connective-tissue cell always gives rise to a new connective-tissue cell, an epithelial cell to an epithelial cell, but a connective-tissue cell is never formed from an epithelial cell, or vice versa. The leucocytes present either perish—i. e., are either absorbed by the growing tissue cells, particularly the polynuclear leucocytes—or they wander back into the circulation as in inflammation. On the other hand, I believe that some of the protoplasm of the wandering cells is 284 INFLAMMATION AND INJURIES. 'i%a^4W^'-@> ,■■■ ■g>M$L employed as cell material in both the scar formation and the regenera tive processes carried on in the original fixed tissue cells of the neigh- bourhood. I am unable to say whether the white blood-corpuscles can themselves form fibrillar connective tissue when the circulation is suffi- ciently active, for example, in a l™ ---'J granulating wound of granula- / .."'"O1?! h tions, but their importance in this respect is much less than that of the fixed tissue cells—i. e., the cells of the connective tissue and the endothelium of the vessels which have been demonstrated to be the real producers of the scar and are called fibroblasts. Reinke and others believe that further development is possible in those wandering cells which make their appearance after the proliferation of the fixed cells has begun, and which exhibit great vital energy. Ribbert considers it probable that the lymphogenic leucocytes with a single nucleus are capable of taking part in the construction of new connective tissue by helping to cover over the lymph cavities and spaces with endothelium. New Formation of Tissue accord- ing to Ziegler, Marchand, Tillmanns. —Ziegler was the first to make an exhaustive study of the manner in which new tissue—the fibrillary con- nective tissue—is formed. He fitted together two pieces of glass, about ten to twenty millimetres long and ten millimetres broad, and made them ad- herent to each other at the corners with porcelain cement, leaving an emp- ty space, accessible by capillarity from the sides, into which the white blood- corpuscles and the lymphatic fluid could penetrate after the glass plates had been placed beneath the skin or periosteum or inside one of the cavi- ties of the body of an animal. The plates were left in place inside the animal from ten to twenty-five to fifty days, and when removed were gent- ly washed, and then placed for two days in a O'l per-cent. solution of hy- perosmic acid, after this in spirits of glycerine, and finally in pure glyc- erine. My own method consists in hardening in absolute alcohol pieces of lung, liver, and kidney, measuring about one cubic centimetre, and mak- /'J v'v §JXf ' / ft, /■/.✓ Fig. 239.—Fifth day; a piece of hardened liver with a defect in the middle; large formative cells which have developed from fixed tissue cells; a, clearly defined fibrillary connective tissue formed from cells; b, masses of proto- plasmic formative material with commencing differentiation seen by the appearance of larger nuclei; c, solid sprouts from the ves- sels ; d, blood-vessel. g6I.] ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 285 ing holes and notches in them, and then placing them with every anti- septic precaution in the peritoneal cavity of a rabbit. Sections are after- wards cut from these specimens, and when examined under the microscope will give a very beautiful picture of the new formation of tissues. Ziegler came to the conclusion that the emigrated white blood-corpuscles undergo further development, and form fibrillar connective tissue if there is a suffi- cient circulation of lymphatic fluid, and especially if enougb nutrition is supplied by the development of new vessels. Ziegler has also, like myself, modified this view. We now know that in Ziegler's glass plates, and in my pieces of dead tissue, the new tissue is chiefly developed from the cells of the newly formed vessels. Salzer has also made recent investigations upon the healing up in a wound of foreign bodies, and Marchand particular^ has made some very valuable experiments both in the healing in of foreign bodies and in the new formation of tissue. Marchand employed chiefly bits of sponge, cork, elder-wood pith, and pieces of lung and liver injected with blue gela- tine, which he buried in tbe peritoneal cavities of guinea-pigs and rabbits. After four to seven hours a development of a network of fibrin and an emi- gration of numerous leucocytes took place. After twenty-four to thirty hours, and later, the foreign body became intimately connected with the peri- tonaeum, and within it were found new cell-forms derived from the fixed ele- ments in the neighbourhood, these cells being mostly spindle-shaped, with large, elongated nuclei, though round cells are also present. All these cells spring from the endothelium of the peritonaeum, tbe fixed connective-tissue cells, and the cells of tbe walls of the vessels, etc., in which the nuclei are seen forming variously shaped figures in the process of their segmentation. There are also present giant cells, often having an extraordinary number of nuclei. The giant cells are formed by the fusing together of fixed tissue cells, and possess the power of absorbing leucocytes ; but they exhibit no progressive development, and later on perish by fatty degeneration. Giant cells are only found in those foreign bodies (bits of sponge, elder pith) whose absorption presents difficulties; and Marchand did not discover them in the pieces of lung, as the tissue of which it consists is readily destroyed, and can be absorbed by the leucocytes. The granulation cells are likewise the off- spring of the fixed tissue cells, and not of the single or polynucleated leuco- cytes. Moreover, the offspring of the fixed tissue cells very often become wandering cells. Marchand saw segmentation figures in the nuclei of the mononuclear leucocytes. The polynucleated leucocytes develop from those with a single nucleus, and are retrogressive in nature. The leucocytes take no part in the formation of new tissues, but they do take part in the forma- tion of fibrin which, according to Marchand, is produced by substances liber- ated by the death of the white blood-corpuscles. (See also page 250.) Sherrington and Ballance maintain that the cicatrix is formed from the cells of the plasma, these cells being supplied with nourishment by the proto- plasm of the white blood-corpuscles. The Formation of Fibrillar Connective Tissue.—Ziegler's and my own experiments show that the fibrillar connective tissue—or, in other words,-the cicatrix—is formed from the fibroblasts in the following way : The formative cells are at first round, and then enlarge, and .look 286 INFLAMMATION AND INJURIES. '" ,¥ #»&*/!* .JB' vl w Si 1. ( '« !M *,«) 4 •>■•. 'It ■$---w Hi Fig. 240.—Wound in the liver in the stage of cicatrisation, tenth day. a, Youiilt cicatricial tissue; b, liver tissue which has par- tially undergone fatty degeneration in the neighbourhood of the cicatrix, and contains many red and white blood-corpuscles. like large, round epithelium ; or they are more elongated, or possess one or more processes, some becoming spindle-shaped, others club-shaped; or they may form branching cells or polynuclear giant cells. The processes repeated- ly anastomose with one another. The number of the large formative cells then rapidly increases, and in certain lo- calities they lie close together. The fibrillar tissue is formed in part di- rectly from the pro- toplasm of the formative cells, and is consequently intracellular in its origin, or it comes from a homogeneous intercellular ground substance or stroma which has previously developed from the formative cells. In the intracellu- lar fibre-formation fibres make their appearance on one or both sides of a cell, or at one ex- tremity of it, or in a process, and unite with the fibres of the adjoining cells. The nucleus, to- gether with a por- tion of the proto- plasm of the form- ative cell, persists as a fixed connect- ive - tissue cell (Figs. 239, a, 240). The direction taken by the fibres is usually the same over a considerable area, the formative cells playing no part in determining the direction of the fibres. As illustrated in Fig. 240, the cicatrix is in the beginning rich in large elongated cells, the remains of the earlier formative cells, which in part become changed u ,; ' ■' at >' i ' •• V\H Fig. 241.—Fourteenth day ; cicatrised defect (a) in a piece of dead, hardened lung (5); the latter is tilled with numerous wander- ing and formative cells, especially in the neighbourhood of the defect, or rather the cicatrix. § 61.] ANATOMICAL PI1ENOMENA IN THE HEALING OF A WOUND. 287 into fibres. The size of these cellular remains subsequently diminishes, the fibrous tissue becomes thicker, and the cicatrix is complete (Figs. 241, 242, 243). New Formation of Vessels.—The formation of new vessels proceeds hand in hand with the above-described tissue formation. In fact it is n'rXiv':t''Rt "■". ■'"'tj'i'iiwi' ■!:i!,f,M,|,i',vn,'|,ir!r!!i'/rf-BT| Fig. 243.—Twenty-eighth day; healed wound in the liver, cicatrix (a) containing blood pigment. this that renders possible the further development of the accumulated formative cells; and the cells of the newly formed vessels also contribute very essentially to the formation of the new tissue which makes up the cicatrix. In the earliest stages in the repair of a wound, the formative cells, or the cells of the granulation tissue, receive their nutriment from the stream of plasma escaping from the vessels in the neighbourhood. As Thiersch has shown, this intercellular circulatory system can be injected through the blood-vessels. But this arrangement for supply- ing nutrition to the cells is only temporary, and the formation of new blood-vessels is required for the further process of repair in a wound. The development of new blood-vessels is the result of an actual sprouting from the walls of pre-existing vessels (Figs. 239, 244, 245). There is first noticed on the external surface of a capillary loop a gran- ular accumulation of protoplasm, which gradually enlarges (Fig. 244, a, J, c) and grows into a solid protoplasmic filament, which contains a nucleus. This protoplasmic filament, simple (Fig. 244./) or branched (Fig. 244, d, e, g), joins either with the wall of another vessel, or unites with another similar sprout advancing in the opposite direction and springing from another similar capillary loop (Fig. 244, d,f g). There are also formed, not infrequently, protoplasmic filaments wliich turn Fig. 242.—Seventeenth day; cicatrised de- fect (a) in a piece of a dead, hardened liver (b). 288 INFLAMMATION AND INJURIES. back in an arch to the same vessels from which they started. Further- more, processes from the spindle- or club-shaped or branching forma- tive cells of the intercapillary tissue join with the sprouts from the walls of the vessels, and thus the material in the formative cells helps in the formation of the new blood-vessels. After a certain length of time Fig. 244.—Development of blood-vessels by budding; different forms of buds, a, b, c. First stages; d,f, g, simple and branching solid buds; e, vascular bud which is being made hol- low and which already contains blood-corpuscles. while the daughter vessels become more and more hollowed out and gradually filled with blood from the mother vessels. Not infrequently an open pouch (Fig. 244, b) develops at the very outset from the wall of the vessel, gradually tapering off into a filament of protoplasm. The walls of the daughter vessel, the newly developed capillary, are at first homogeneous, later on nuclei are added, and they take on a plain- ly recognisable cellular structure, consisting of flat cells (endothelial cells). Subsequently the walls of the vessel are strengthened materi- ally by the formative cells in the neighbourhood. The above-mentioned protoplasmic filaments shooting out from the walls of the vessels are made up partly of the cells of the vessel walls, and partly, as I believe I have observed, of white blood-corpuscles which have passed through the capillary wall. At a later period a shrinkage takes place in the newly formed connective tissue of the §61.] ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 289 cicatrix, and a portion of the vessels disappear, causing the original red scar to become pale. The manner in which the wound, or rather the granulating surface, is covered with skin, has been briefly stated above. For the purpose of healing up large granulating surfaces, Reverdin employed the transplantation of small particles of skin. This method of skin transplantation was, however, first made a useful procedure by Thiersch (see § 42). The adhesion, or rather the union, of a piece of skin on to its new bed takes place, according to Thiersch, by the vessels in the granulations and in the bit of skin be- coming connected through the intercel- lular passages ; these passages conduct the blood circulating in the gran- ulation vessels directly into and back from the vessels in the pieces of skin. There is subsequently a formation of permanent vessels which supplants this provisional circulation. My own experiments, and those of Ziegler, show that there is at the outset a rapid emigration of white blood-cells accompanying the union or adhesion of the transplanted bit of skin. But the leucocytes are of no importance in the final taking root of the transplanted skin, the actual accomplishment of which is brought about by the fixed tissue cells, the newly formed vessels, and their cells. The minute phenomena wliich take place during the taking root of a Thiersch skin graft are practically the same as in any union by primary intention. The surface of the wound and the adhering layer of skin are filled with round cells. This round-celled infiltrate is then gradually changed into granulation tissue, accompanied by the sprouting of the vessels on the surface of the wound, and finally the granulation tissue becomes fibrillar connective tissue. The transplanted skin flap is at the outset passive, but from the third day on it becomes vascularised by sprouts from the vessels on the surface of the wound. Fig. 245.—Development of new blood-vessels by budding. Seventeenth day. Wound in the liver. 290 INFLAMMATION AND INJURIES. In spite, of this two days' interruption in the circulation of the blood, the majority of the tissue elements in the cutaneous graft retain their function and vitality, and only the epidermal layer, with a portion of the rete Malpighii, and the greater part of the vessels, will be found to perish, the latter by atrophy and hyaline degeneration. From the third or fourth day on the graft takes an active part in the process of healing into its new bed, as the epithelial cells (in the transversely cut hair follicles and excretory ducts) which lie upon the exudate prolif- erate and make their way into the bed. Garre says that fourteen days after the transplantation all the granulation tissue has become replaced by connective tissue, and the healing is complete. Reunion of Entirely Severed Portions of the Body.—Parts which have been completely severed from all their connections with the body may again become united in the same manner as the skin grafts of Rever- din and Thiersch. But this is only possible in the case of small por- tions of tissue, such as the tip of the nose or of the fingers. To these phenomena belong the reposition of teeth which have been extracted, the transplantation of living or dead bone or cartilage into defects in bone, etc. The success of all these operations is dependent upon the strictest observance of the rules of asepsis. The transplantation of the various tissues above mentioned has been described on page 143. The Formation of a Cicatrix in a Vessel, or the Organisation of a Thrombus.—The formation of a cicatrix in a vessel which has been wounded or ligated, or, in other words, the organisation of a throm- bus, is of special importance. The following is a brief description of the manner in which the thrombus forms in a vessel : Since Briicke made his famous experiments, we know that tbe blood is kept fluid within the walls of the vessels because of its contact with a normal endothelium, and because of its constant movement. If either one of these two conditions is lacking, if the integrity of the endothelium of the vessels is altered in any way by an inflammation or traumatism, if the blood escapes from the walls of the vessels, or if its circulation is interrupted —for example, by ligation of the vessel—the blood will then coagulate; it will form a thrombus. The thrombus which develops after ligation of an artery, for example, extends from the point at which the ligature has been applied to the nearest lateral branch above and below. The same holds true as regards the veins. We know, however, that in a vein extensive thrombi form much more readily than in an artery, and this is the case not only when the lumen is occluded by a ligature or an injury, but also when there occurs a pronounced stasis and obstruction to the forward movement of the blood. If two ligatures are applied to a vessel with a moderate interval between them, the blood will coagulate between these ligatures; but a thrombus does not always develop after the ligation of a vessel. Baumgarten demonstrated that the blood §61.1 ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 291 lying between two ligatures may remain fluid for three, four, or even twelve to fifteen days if the ligation is carefully performed, and particularly if the wall of the vessel is not isolated from its connections with the adjoining tissues, and if its nutrition from the vasa vasorum is not interfered with. Under such conditions the endothelium appears to remain intact and per- forms its functions normally, and consequently the blood, though not mov- ing, retains its fluid character. In wounds or injuries involving only a portion of the circumference of a vessel there is not always the formation of a thrombus filling the entire lumen of the vessel. The rent in the wall is often completely filled by a thrombus which organises, leaving only a thickening of the vessel at the site of the injury. This method of repair may take place in vessels of any size whatsoever. Again, a thrombus which at the outset only partially fills tbe lumen may finally cause its total occlusion by the addition to it of one layer of coagulum after another. We have to deal mainly with thrombi occurring after an injury or the ligation of a vessel. Mention should also be made of the so-called compres- sion thrombi, which form when the blood is brought to a standstill as a re- sult of compression from without, as by tumours; of the dilatation thrombi in aneurysms and varices; of the thrombi caused by inflammatory processes in the walls of the vessels accompanied by destruction of the endothelium, etc. But changes in the walls of the vessels and primary disturbances in the circulation are not always sufficient in themselves to produce coagulation of the blood; the cause for the thrombosis must be sought for not infrequently in a general alteration in the composition of the blood. Silberman has seen multiple coagula form during life from acute poisoning by the salts of hydro- chloric acid, arsenic, phosphorus, and several other blood poisons. On the other hand, Arthus proved that by depriving the blood of its calcium it loses its power of coagulation. Red, White, and Mixed Thrombi.—There are red, white, and mixed thrombi. The formation of a white thrombus by an accumulation of white blood-cells can be watched under the microscope by irritating with a crystal of common salt placed in its neighbourhood, some large artery or vein lying in the spread-out mesentery or tongue of a curarised frog. At the point of irritation the inner wall of the vessel becomes covered with white blood-cor- puscles, and a white immovable plug gradually develops, filling tbe entire lumen of the vessel by a constant addition of new white corpuscles to those already in place. Some investigators claim that the white thrombi described by Zahn are not formed from white blood-corpuscles, but from the blood plaques discovered by Bizzozero, those very small, delicate, colourless, disk- shaped bodies which constitute the third formed ingredient of the blood. The origin of the blood plaques, which can be stained with methyl violet while in a neutral common-salt solution, is still obscure, and their signifi- cance is still a matter of controversy. Eberth and Schimmelbusch make a sharp distinction between the white tbrombi of blood plaques and the red blood-clots; the blood plaques, according to these authorities, having nothing to do with tbe formation of fibrin, and simply adhere together at some in- jured point of the intima as a result of their peripheral location in the blood stream when there is any marked retardation in the flow of the current. 20 292 INFLAMMATION AND INJURIES. They also hold that a thrombus is not identical with a blood coagulum, the thrombi being not red, like the ordinary coagulum, but either entirely, or for the most part, white. Coagulation of the Blood.—There are many views as to the manner in which coagulation of the blood takes place. Alexander Schmidt and his fol- lowers, reasoning from numerous experiments, explain coagulation of the blood in tbe following manner : The fibrin results from the union of two fibrin generators, the fibrinogen and the paraglobulin, brought about by the action of the fibrin ferment. The fibrinogen exists in solution in the blood plasma; the fibrin ferment and the paraglobulin are first liberated by the disintegration of the white blood-corpuscles, and then have the power of acting upon the fibrinogen. As long as the white blood-corpuscles circulate uninjured in the blood a coagulum cannot form. In the blood of birds and amphibia tbe disintegrated red (nucleated) corpuscles furnish the fibrin-mak- ing substances. The blood in immediate contact with the living and normal walls of a vessel, as we have said, does not coagulate; but if the walls are altered by pathological processes or mechanical injury—if, for example, the intima becomes changed by inflammation, if it becomes roughened, uneven, swollen, torn, etc.—a blood-clot will form at these points even while the cir- culation still continues. Blood which has escaped from a wounded vessel will immediately coagulate, as will blood within the heart or a vessel after death. Moreover, by the disintegration of white blood-cells which takes place under normal circumstances in healthy, circulating blood, some fibrin ferment develops (Schmidt, Jakowicki, Birk); this is the case especially in venous blood. It is furthermore an interesting fact that in septicaemia and pyaemia the amount of the fibrin ferment resulting from the disintegration of the white blood-corpuscles can be so increased as to give rise to the spon- taneous formation of coagula (Kohler and others). On the other hand, fever is produced (Wahl, Bergmann, Angerer) by the absorption of the fibrin fer ment from the extravasated blood after operations or subcutaneous injuries (fractures). Bizzozero, on the other hand, ascribes the formation of fibrin solely to the dissolution of the blood plaques and their derivatives (Zimmermann's cor- puscles), and he denies that the white blood corpuscles have any part in the process. Haym also claims that the cause of the coagulation of the blood when a vessel is injured is to be sought for in what he calls the " hsemato- blasts" (Bizzozero's "blood plaques"). These small, very easily altered cellular elements in the blood become immediately changed, according to Haym, when a foreign body comes into contact with them, or when the in- tima of the vessel loses its integrity by pathological pi-ocesses or mechanical influences. Wooldridge made some very exhaustive experiments upon the subject of coagulation of the blood, under Ludwig's guidance, in the Physiological Insti- tute at Leipsic, and he states that Alexander Schmidt's explanation of coagu- lation of the blood is correct only to a very limited extent, if at all. Wool- dridge disputes the necessity of the co-operation of the formed elements of the blood in the process of coagulation, and asserts that the blood plasma itself, free from all formed elements, contains everything which is necessary for the production of coagulation. The plasma is caused to coagulate by two §61.1 ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 293 bodies contained in it, which are a combination or mixture of albumen and lecithin, and are called by Wooldridge A- and B-fibrinogen. He states that certain substances (albuminous bodies containing a very large percentage of lecithin) which have a marked power of producing coagulation can be iso- lated from the testicle, lymph glands, the chyle, brain, thymus, and stroma of the red blood-corpuscles. He does not attach any importance to the fibrin ferment as a cause of coagulation. Our knowledge of the coagulation of the blood has been recently en- riched by some exceedingly interesting facts discovered by the important investigations made by Marcus Arthus.* Arthus found that by the addition to the blood of oxalate of ammonia—i. e., by decalcification of the blood— the latter loses its power to coagulate; but if chloride of calcium is again added in excess the blood then immediately coagulates. From this it follows that the calcium in the blood has a fibrinoplastic action, and that the fibrin ferment and the fibrinogen only act in the presence of calcium salts. Arthus states that the salts of strontium have the same effect as those of calcium, and consequently there is also a strontium fibrin. This makes it necessary for us to recognise many different kinds of fibrin. Arthus maintains that the teachings of Schmidt and Hammerstein should be modified to the extent of making three factors necessary for the coagulation of blood, viz., the fibrin ferment, fibrinogen, and a lime salt. According to Arthus, the coagulation of the blood is analogous to the coagulation of cheese from milk, the caseine corresponding to the fibrinogen, the curdling ferment to the fibrin ferment, and the cheese to the fibrin. Freund maintains that the coagulation of the blood is brought about by the undissolved phosphate of calcium. The phosphates and potassium salts preponderate in the blood-corpuscles, the sodium and calcium salts in the serum. When the blood comes in contact with a foreign body and ceases to touch the walls of the vessel, the phosphates in the blood-corpuscles unite with the calcium salts in the serum, forming a large amount of phosphate of calcium, which does not all remain in solution. The Varying Reaction of the Leucocytes to Staining Substances.—The colourless blood-corpuscles (leucocytes) vary in their reaction to staining materials—a matter of great diagnostic importance (Ehrlich). While the nuclei of all leucocytes are coloured by the well-known aniline dyes used for staining nuclei, the protoplasm of the cells behaves differently, possessing for particular dye stuffs a greater or less affinity. The leucocytes differ also in size and in the number of their nuclei (mono- or polynucleated). The ma- jority of the leucocytes (about seventy per cent, of the colourless blood-corpus- cles) form the polynucleated leucocytes, the granules in which are neutral (neutrophilar)—i. e.. their protoplasm is only susceptible of being stained by neutral dyes, such as, for example, a neutral mixture of a basic and acid ani- line dye (methylene blue and the so-called acid fuchsin). A smaller number of the leucocytes (about five per cent, to eight per cent.) in the blood are eosino- philar or acidophilar cells—in other words, the granules of their protoplasm are capable of being stained bright red by the acid dye eosin. The acidophilar * Marcus Arthus. Theses presentees a la faculte des sciences de Paris. Paris : H. Jouve, rue Racine, 15, 094 INFLAMMATION AND INJURIES. or eosinophilar granules are coarser than the neutropbilar ; the cells also are perceptibly larger than the neutrophilar, and for the most part possess one or two nuclei of 'considerable size. The third class of leucocytes, which are rare —mostly mononucleated cells—possess a protoplasm which is only capable of being stained by basic aniline dyes (basophilar leucocytes). The fourth class of leucocytes, mostly small mononucleated cells with a narrow or broad enveloping band of protoplasm, are partly neutrophilar and partly capable of being stained by acid as well as basic aniline dyes (amphophilar). Mosso * has made an exhaustive study upon the change of the red blood-corpuscles into leucocytes and tbe necrobiosis of the red blood-corpuscles in coagulation and suppuration. Changes in the Thrombus.—After a thrombus has formed, the fur- ther points in its history which are of interest are (1) its organisation into solid connective tissue containing blood-vessels, or, in other words, the formation of a cicatrix, and (2) the softening of the thrombus. The organisation of the thrombus into connective tissue containing vessels is the most desirable termination ; but softening of the throm- bus, particularly its suppurative breaking down, brought about by the action of bacteria and accompanied by subsequent embolic processes, is always dreaded by the sur- geon. Thanks to the aseptic method of operating and treat- ing wounds, this infectious soft- ening or breaking down of a thrombus is of infrequent oc- currence in modern surgery. AVe shall treat of the infectious softening of thrombi more in detail when we come to diseases of wounds. The calcification of a thrombus from deposition of lime salts is another compara- tively satisfactory change which a thrombus may undergo. The so-called phleboliths are calcified thrombi which have formed in veins. Organisation of the Thrombus, or rather the formation of a Vascular Cicatrix.—We are here concerned with the question of the organisation of the thrombus into connective tissue containing vessels, and in the formation of a vascular cicatrix. Fig. 246.—Organisation of a thrombus; M, me- dia infiltrated with cells; J, intima infiltrated with cells; B, various shaped formative cells resulting from the proliferation of the en- dothelial cells of the vessels and employed in the organisation of the thrombus (formation of the cicatrix in the vessel); Th, thrombus. x 300. * Virch. Arch., Bd. 109, 1887. §61.] ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 295 The minute changes are practically the same as we have described above, and they apply to the arteries as well as the veins. According to Thiersch, Thoma, and others, the closure of a vessel, the so-called organ- isation of the thrombus, or, more correctly, the substitution for the thrombus of connective tissue, is mainly brought about by a prolifera- tion of the endothelium of tlie intima. All the authorities agree that the thrombus itself plays no part in the formation of a cicatrix in a ves- sel ; it is gradually supplanted by the cellular infiltration, which then forms fibrillar connective tissue. At first variously shaped formative cells (Fig. 246) develop by the proliferation of the endothelium of the vessels, and these subsequently change into fibrillar connective tissue. These cells penetrate the thrombus in all directions ; the connective tis- sue developing from them becomes steadily stronger, and finally takes the place of the thrombus throughout its whole extent. At the conclu- sion of the process there only remains of the thrombus a few granular masses of brown pigment—hematogenous pigment, probably hydroxide of iron. Simultaneously with this endothelial proliferation and growth of cells into and throughout the thrombus the latter becomes vascula- rised by the formation of new vessels. If a thrombus does not com- pletely occlude the lumen of a vessel, its organisation takes a longer time than when the vessel is completely plugged by the thrombus (Baumgarten). The cicatrix is formed from the cellular germinal tis- sue in the manner we have described on page 286. The vascularisation of the thrombus—i. e., the formation of new vessels within it—takes its start chiefly from the point at which the intima has been broken or torn. The vasa-vasorum, on account of the diminution of the pressure in the interior of the vessel, grow through the relaxed walls into the lumen of the vessel (Benecke, Ackermann). The minute changes which take place in the organisation of a thrombus can be studied very satisfactorily by placing, with every antiseptic precau- tion, a segment of a vessel which has been previously hardened in absolute alcohol inside the peritoneal cavity of a rabbit (Seuf tleben, Tillmanns). There will be observed a steadily increasing emigration of colourless blood-corpus- cles into the wall and interior of the vessel, or rather into the thrombus ; at tbe same time there will be a corresponding new formation of vessels from the germinal cellular tissue, which is developed from the endothelium of the newly formed vessels and not from the white blood-corpuscles, and finally the thrombus becomes supplanted, in the manner already described, by vas- cular fibrillar connective tissue, and the vessel is closed by a cicatrix (Fig. 247). The length of time required for the cicatricial closure of a vessel to take place by the organisation of a thrombus varies very much. In young subjects the reparative process is in general more rapid than in 296 INFLAMMATION AND INJURIES. old individuals, and it is slowest in the case of patients afflicted with chronic (atheromatous) degeneration of the intima of the vessels. In animals which have been experimented upon, vascular tissue will be found at the site of the thrombus, or rather where the ligature has been applied to the vessel, at the end of the second week, and possibly even earlier, by the seventh to the eighth day. During the third to the fifth week the cicatrix in the vessel becomes completely formed, though in some cases the process takes much longer. In course of time the cicatrix in a vessel shrinks like any other scar. If the cicatrix shrinks in the centre, the scar, or rather the vessel, may again become pervious, so that the final result may be merely a diminution in the lumen of the vessel, with a thickening of its wall. In still other cases the cicatrix, as a result of dilatation of the vessel in which it lies, may become per- forated by several small isolated vessels connecting the central and peripheral ends of the artery (Fig. 249). The so-called -sinus degen- eration (Rokitansky), in which the thrombus is changed into a network of connective-tissue strands having spaces between them, is particularly liable to occur in thrombi which develop in veins. Collateral Circulation.—If a blood-vessel—an artery, for example—is occluded at some point by a ligature or a thrombus, a collateral circula- tion is immediately developed by dilatation of the vasa vasorum and of the branches given off on the proximal and distal side of the thrombus. This restores the circulation, and ensures the nutrition of the portion of the body supplied by the occluded artery (Fig. 248). It is interest- ing to note the manner in which the collateral circulation becomes established after ligation of an artery in its continuity, as illustrated in a specimen obtained by Luigi Porta, showing the collateral cir- culation eight months after ligation of the abdominal aorta in a dog (Fig. 249). It is plain that the collateral circulation took place in this instance both through the dilated vasa-vasorum lying between the two stumps of the ligated aorta and the adjacent lumbar arteries, and branches made up partly of old and partly of newly formed vessels. Fig. 247.—Organised vascular thrombus in a piece of dead kidney. Nineteenth day. In the centre are a newly formed blood-vessel and a giant cell. The adventitia of the wall of the vessel con- tains many leucocytes, but the muscu- lar coat not so many. Gentian, Cana- da balsam. §61.] ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 297 Recently Xothnagel has made some very exhaustive experiments on rabbits relating to the establishment of the collateral circulation, and he found that six days after applying the ligature there occurred a hypertrophy and hyperplasia of the muscular fibres in the dilated col- lateral arteries. Tsothnagel and Recklinghausen explain the growth of these vessels by the increased rapidity of the blood current within them and the increased amount of nutrition which this brings about. The Fig. 248.—Collateral circulation (after Fig. 249.—Collateral circulation eight months ligation of an artery in its conti- after ligation of the aorta of a dog (Porta). nuity) through the central and peripheral branches. more blood that passes through a vessel in a given time, the greater is tbe amount of nutritive material supplied to the wall of the vessel. The pressure theory, which many authorities think sufficient to account for the establishment of a collateral circulation, is, according to Xoth- nagel, of no value. The repair of a Wound in Non-vascular Tissues.—The process of re- pair in a wound, or the formation of a cicatrix in tissues which do not contain vessels (cornea, cartilage, etc.), is practically the same as for vascular tissue. We know that non-vascular tissues—the cornea, for example—contain an intricate communicating system of canals, in which, under normal conditions, wandering cells are present here and there. 298 INFLAMMATION AND INJURIES. If the cornea is injured there occurs an abundant emigration of white blood-corpuscles from the adjoining sclera and conjunctiva and from the conjunctival sac. The tissue developed from the .inflamma- tion—in other words, the cicatrix—is here also formed from the origi- nal fixed cells of the cornea. A cicatrix is formed in cartilage in precisely the same way from the cartilage cells in the neighbourhood. The cicatrix resulting from an aseptic wound—i. e., from one which has healed without reaction—will retain its fibrillar character for a great length of time. Gies claims that it retains this character permanently ; but if a severe inflammatory reaction takes place the cicatrix will rapidly become hyaline, like nor- mal hyaline cartilage (see Injuries of Joints). Regeneration of Injured Tissues.—In every injured organ there is always an attempt to bring about, as far as possible, a complete restitutio ad integrum. The regeneration of the damaged tissues will take place the more rapidly and completely the more delicate the cicatrix is—in other words, the stricter the asepsis and the more the wound is made to heal by primary union without reaction, and the less the cells peculiar to the organ are damaged. But the more highly organised tissues have relatively slight powers of regen- erating themselves after they have been damaged. The epidermis, the epithelium of the mucous membranes, bones, cartilage, periosteum, tendons, and other connective-tissue structures, are capable of regen- erating themselves completely, while, on the other hand, losses of sub- stance in the various glands and in muscle are not restored, but their place is supplied solely by scar tissue, in the manner described above. Consequently, a cicatrix which includes the more deeply lying sub- cutaneous cellular tissue contains no sweat or sebaceous glands and no hair follicles or hairs, and a correspondingly extensive cicatrix in the intestine contains no follicles and no glands of Lieberkuhn. Moreover, defects or losses of substance in muscular tissue are only made good, as already stated, by scar tissue, and are not replaced by newly formed muscular fibres; the fibrous cicatrix is interposed like a tendinous intersection in the course of the muscle and enables it to contract. Regeneration of muscular fibre takes place only in the neighbourhood of the cicatrix, and in those cases in which the injury to the muscle has been trifling—a contusion, for example. Ponfick, however, has demon- strated that losses of substance in highly organised tissues, such as the liver and kidneys of animals, can be made good in a relatively brief time by a new development of the tissues characteristic of the organ. Of the more highly organised tissues the peripheral nerves are ex- ceptional as regards their capability of regenerating themselves. After §61.] ANATOMICAL PHENOMENA IN THE HEALING OF A WOUND. 299 a nerve has been divided and neurorrhaphy performed, there will often be a complete regeneration of the nerve even when the neurorrhaphy has been performed several months, or even a year, after the reception of tbe injury. Regeneration has been brought about in a nerve in which there has been a loss of substance several centimetres in length by suturing together the divided ends of the nerve, or by adopting other suitable measures, and now and then even spontaneously. I performed a successful neuroplasty upon the median and ulnar nerves for a loss of substance which they had suffered several months previously (see §88). Regeneration of the tissues of the brain and spinal cord never takes place in man, though Brown-Sequard has seen regeneration occur in the divided spinal cord of a pigeon. The proper treatment for promoting regeneration in the various tissues will be discussed in §§ 87, 88, 101. Subsequent Pathological Changes in the Cicatrix—Cicatricial Contraction. — Cicatricial contractures are the most important of the later pathological changes which scars undergo. The contraction is, of course, proportionate to the size of the defect or tbe amount of granulation tissue. All cicatrices replacing losses of substance in the skin and the underlying tissues are espe- cially liable to shrink. According to the depth to which the loss of sub- stance extends, the cicatricial contracture involves only the skin, or, besides this, the deeper parts, especially the fascia, muscles, and tendons. The cica- tricial contractions following extensive burns are especially dreaded. The sequelae of such contractures vary with the locality which is affected. If one is situated on the flexor aspect of a joint, the latter will become fixed in a certain degree of flexion and cannot be completely extended. Cicatricial shortening of the sterno-mastoid muscle causes wry-neck (caput obstipum); a scar involving the under eyelid will roll the latter outward (ectopion); cica- tricial contracture of the cheek will interfere with the opening of the mouth. The chin and neck are sometimes fastened firmly together as a result of burns. This is not the place to describe the treatment for these conditions, and it is only necessary to state that they are now treated with excellent results by methods of gradual extension, or by excision of the scar, followed by implantation of Thiersch skin grafts, or of flaps with pedicles taken, per- haps, from a widely removed portion of the body. Keloids.—Occasionally the cicatrix becomes the seat of a tumour-like fibrous induration called a keloid. A thick elevation develops at the site of the scar, usually with outgrowths extending into the adjoining healthy tissues. This is really a hypertrophy of the cicatrix. The cause of this keloid, which is rather rare, is not understood. After its extirpation there is usually a re- currence. I saw one case of cicatricial keloid the size of a plum, following a perforation made in the lobule of the ear, which resisted every kind of treatment with the knife and red-hot iron. Sometimes a keloid disappears by degrees spontaneously. Malignant New Growths.—Occasionally malignant new growths, like car- 300 INFLAMMATION AND INJURIES. cinomata, may originate in cicatrices. We shall discuss this possibility when we come to the etiology of tumours. Cicatricial Ulcers.—Now and then cicatricial tissue breaks down and sup- purates, giving rise to a cicatricial ulcer, which ordinarily is covered with large fungous granulations having no tendency to become covered with skin. This usually occurs in weak and sometimes in tubercular individuals, and is apt to start from some slight injury, such as the friction produced by clothes might bring about. Pressure Paralysis of Nerves from Pressure of the Scar.—A large cicatrix may exert injurious pressure upon the blood-vessels in its immediate neigh- bourhood, and may also cause a pressure paralysis of the nerves. It is well known that these pressure paralyses due to cicatrices have, as a general thing, a favourable prognosis, and will ordinarily quickly disappear with removal of the cause. § 62. The General Reaction which follows an Injury and an Inflamma- tion—Fever.—The general condition of those who have been injured or operated upon bears a most intimate causal relationship to the be- haviour of the wound. If the latter heals normally—i. e., aseptically— and if no injurious substances gain access from the wound to the cir- culating fluids of the body, there will usually be no fever. From the fact that a wound which heals aseptically, as a rule, ensures freedom to the patient from a general febrile disturbance, it follows that the febrile disturbance involving the whole system of those who have been injured or operated upon is mainly caused by the absorption from the wound of injurious substances, the most important of which are the micro-organisms and the poisonous products of their metabolism held in solution by the fluids of the body. The so-called wround fever is really an absorption fever—an alteration of the blood. The fever which accompanies the so-called internal diseases is also in part an absorption fever, and the changes wliich are present in the blood and produced by the bacteria, or rather the products of their meta- bolism (ptomaines, toxines), play a most important part in the causation of the phenomenon. On the other hand, we must look for the cause of what is called the essential fevers in the central nervous system. In this latter class belong the febrile disturbances following a violent fright, the periodic stages of excitement in mental disorders, epileptic fits, injuries of the spinal cord, etc. These " nervous fevers " are per- haps caused by an increased metabolism in the tissues due to the ex- cessive nerve irritation, which raises the temperature of the body, or to diminished loss of heat by radiation as a result of the lessened rapidity of the circulation (Murri). The fever which follows phlebotomy and the administration of cocaine is, according to Mosso, also dependent upon the nervous system. Though recent investigations have made §62.] REACTION WHICH FOLLOWS INJURY AND INFLAMMATION. 3Q1 the etiology of wound fever so plain to us, we unfortunately are still much in the dark as regards the nature of the febrile process. The symptoms of fever are perfectly simple, but their explanation still pre- sents many insurmountable difficulties, and allows plenty of room for many hypotheses. We shall confine ourselves to the discussion of the fever which accompanies surgical diseases. Symptoms of Fever.—The most important manifestations of any fever are (1) the increase in the temperature of the body, (2) the cir- culatory disturbances, and (3) the changed products of the metabolism of the body. The Increase in the Temperature of the Body.—The most constant symptom of fever, and the one which is proportionate to its intensity, is the increase in specific heat. For ascertaining the temperature of the body, we use in Germany a thermometer having a scale divided into one hundred parts, and each of the one hundred parts subdivided into ten parts. The most useful is the so-called maximum thermometer, in which the column of mercury maintains its altitude after the instru- ment has been removed from the axilla or rectum, and readily permits at any time the reading off of the highest temperature registered. The temperature of patients who have been injured or operated upon is or- dinarily taken in the axilla or rectum two to three times a day—morn- ing, noon, and evening. But not infrequently it is important that it should be ascertained hourly, or every two hours, especially in cases with high fever, in which the height of the fever decides the kind of therapeutic measures that should be undertaken. If the fever is slight the temperature in the axilla may amount to 38-5° to 39° C. (101-3° to 102° F.); if severe, to 40° C. (101° F.) ; while temperatures above 11° C. (104-1° F.) or 42° C. (106-5° F.) are called by Wunderlich hyperpyretic. Unusual rises of temperatures like this, to 42° C. (106-5° F.) and higher, are ordinarily the precursors of a rapidly approaching death. Temperatures higher than 44-5° C. (113° F.) are very rarely observed, though Phillipson has recorded the case of a girl twenty-five years old in whom the temperature reached 47'2° C. (116-6° F.). Occasionally the temperature continues rising several hours after the death of the patient (post-mortem rise of temperature). The initial stage of fever is usually characterised by a more or less pronounced feeling of chilliness or a rigour. This is the more pro- nounced the more rapidly the fever rises and the shorter the initial stage of the fever. A chill is usually absent if the body temperature rises gradually during several days. During the cold stage the tem- perature of the body is already elevated. The cold feeling is the ex- 302 INFLAMMATION AND INJURIES. pression of a nervous excitation caused by the difference in tempera- ture existing between the internal and the external or superficial por- Puis Tage: 1 2 3 4 5 6 1 8 9 10 11 ___180 ___170 ___160 ___ISO ___140 ___130 ___120 ___110 ___100 ___ 90 ___ 80 ___ 70 f a f CL f a /"'a r CL f a f\ a r a r a f a F a 41,5 ___4l,o ___40,5 ___40,0 39,5 39,0 38,5 ___38,o 37,5 37,o 36,5 ' 1 i A t ! 1 A \, ' " ✓ V / i I I Fig. 250.—Febris continua. Death on the eighth day. tions of the body. After the stage of cold there follows the climax— i. e., the fever reaches its maximum point. The subsequent course of the fever varies. The temperature either remains more or less con- tinuously elevated (Febris continua, Fig. 250), or it fluctuates (Febris remittens, Fig. 251). If the fever is a continued one, the difference between the maximum and minimum rises of temperature taken in Puis Tage: 1 2 3 4 5 6 7 8 9 10 11 ___180 ___170 ___160 ___ ISO ___140 ___ 130 ___ 120 ___ 110 ___100 ___ 90 ___ 80 ____ 70 f a f u f a f u /'a f a f a f a f a f a f a _ 41,5 4l,o h 40,5 ,___40,0 39,5 ___39,0 38,5 38,0 ___37,5 ___37,o ___36,5 'A \\ vt~ V »» Fig. 251.—Remittent type of fever with gradual fall of temperature (lysis) from the eighth day on. the course of the day, or morning and evening, will be at the most but a few tenths of a degree (Fig. 250). In a remittent fever there will be a daily fall of about 1° C. (1-8° F.) or more. A third type of fever 62.] REACTION WHICH FOLLOWS INJURY AND INFLAMMATION. 303 is the intermittent, in which brief marked rises in temperature alter- nate with normal or even subnormal temperatures (Fig. 252). After Puis Tage: 1 1 2 3 4 5 6 1 8 9 10 11 ___180 ___170 ___160 1___150 ___140 ___130 ___120 ___110 ___100 ____ 90 ____80 ____70 f a r a /' a f a f CL r a f CL f a f a. f a f a. U 41,5 ___4l,o 40,5 40,0 39, s 39,0 38,5 ___38,0 ___37,5 ___37,0 ___36,5 A A A w j\ A A A i/\ A '\ A A r 1 1 \\ f \ A , U \j \ 1 /' 1 1/ \ 1 \ \l \ V V /^ *. y ^s J V v \ /^ v ^ V V Fig. 252.—Intermittent type of fever with temporary sudden fall of temperature (crisis) on the fifth day; fresh rise of temperature on the seventh day, and then on the tenth day a sudden fall of temperature followed by convalescence. each fall the temperature rises again in the course of the day, regularly registering higher in the evening than in the morning, or the exacer- bations may occur less frequently than this. As we shall see when we come to diseases of wounds, the course of the fever is typical for many diseases, especially the way that defervescence takes place. The decline of the temperature may take place rapidly in the form of a crisis, fall- ing 2° to 3° to 1° C. (3-6° to 7-2° F.), and even more in a few hours on a single day (Fig. 252). In such cases the temperature may drop below normal and become subnormal, sometimes accompanied by symptoms of collapse and nervous excitement (delirium of collapse). In other cases the defervescence comes on more gradually (by lysis), being for several days continuous or remittent, with transient rises (Fig. 251). The defervescence is usually accompanied by sweating. After the fall in the fever there ensues the stage of convalescence, which is fre- quently only simulated, as a new outbreak of the fever may take place with a set of symptoms exactly the same as those which occurred in the beginning (Fig. 252). Thus, in a protracted fever like chronic pyaemia, the fever may alternate with an apparent period of convales- cence, until death or true convalescence make their appearance. AYhen the fever has a fatal termination, death may come on during the hot stage, and is then often the direct result of the high temperature; or the cause of death is to be sought for in the general weakening of the body brought about by the fever, particularly in the degeneration of the muscles of the heart and the muscular coat of the blood-vessels, 304 INFLAMMATION AND INJURIES. and, above all, in the general systemic poisoning which is due to bac- teria. The behaviour of the temperature curve is a most important diagnostic guide for the surgeon in his estimation of the condition of the reparative process going on in the wound, and it enables him to judge whether the dressing requires changing or not. Moreover, the surgical wound diseases, as we shall see, are characterised by a typical fever curve. From these facts it is easy to understand the importance of care- fully ascertaining the body heat in those who have been operated upon or injured. The other symptoms of fever consist of disturbances in the circula- tion, the breathing, the digestion, and the nervous system. They occur as the result of the elevated temperature or of the primary disease. Behaviour of the Pulse in Fever.—Great importance attaches to the condition of the pulse, as regards its frequency, ten- sion, and regulari- ty. Its frequen- cy, in general, cor- responds to the height of the fe- ver, but exceptions to this rule are not infrequent ; thus, for example, as the result of stimulat- ing the vagus or its centre in the medulla, there occurs a slowing of the pulse with an elevation of the temperature. In cases of iodoform pois- oning the temperature may be 38° C. (100-4° F.), while the pulse is very markedly accelerated. The state of the blood pressure is not constant in fever; ordinarily it is somewhat lower than normal (Lud- wig, Hiiter). If the fever remains high for any great length of time, the blood pressure becomes very decidedly lessened, and may give rise to dangerous symptoms. The pulse is often dicrotic (Fig. 252, 2)—i. e., it shows in the place of a single beat a double one, caused by a dimi- nution of the arterial tension. A dicrotic pulse can be produced artifi- cially in animals by injection of atropine subcutaneously or by adminis- tering amyl nitrite by inhalation (Fig. 253, 3). The rapidity with which the blood current flows, according to the measurements taken by Ludwig and Hiiter with the sphygmograph, is reduced during fever about one third. Fig. 253.—1, Normal pulse with well-marked arterial tension; 2, dicrotic, rapid pulse in fever; 3, very rapid dicrotic pulse after injection of atropine (Meuriot-Marey). §62.] REACTION WHICH FOLLOWS INJURY AND INFLAMMATION. 305 Condition of the Vessels during Fever.—Maragliano has demonstrated, with the aid of Mosso's plethysmograph, that the cutaneous blood-vessels are contracted during fever before any rise in temperature can be detected ; that, as the contraction of the vessels advances, the temperature begins to rise, and reaches its highest altitude simultaneously with the maximum of contraction in the vessels ; and that the fall of temperature is preceded by a dilatation of the blood-vessels. Cheilo-angioscopy.—Hiiter has attempted to make a microscopic investi- gation of the circulation of the blood in the lip of a man suffering from fever. The cheilo-angioscope, as it is called, which is used for this purpose, is described in Part I, of Hiiter's Principles of Surgery. By means of this instrument he noted that in fever the circulation in the smaller vessels was retarded, and finally that the blood in them came to a standstill. Condition of the Respiration during Fever.—During fever the respi- ration is more active; there is a greater consumption of oxygen, and as fever increases, or, in other words, metabolism becomes more active, there is a larger amount of carbonic acid produced. According to Kraus, twenty per cent, more oxygen is consumed during fever than when the body is in a normal condition. The respiration, particularly at the beginning of the fever, is deeper than it ordinarily is; but later on, after the fever has persisted some time, it becomes shallower, on account of the weakening of the respiratory muscles. If the fever lasts for a long time, an increase in the amount of gaseous interchange in the lungs may not take place, owing to the accompanying inanition of the patient. Disturbances of the Nervous System.—The disturbances of the nerv- ous system during fever vary with the height to which the temperature rises, and with the location of the injury. They consist in a feeling of general lassitude and debility, and, if the fever is high, in a dulling of the patient's intellect, accompanied by all kinds of symptoms denoting irritation and depression of the central nervous system. Digestion.—The digestion is impaired during fever; there is pro- nounced loss of appetite; there is a diminution in the amount of the digestive juices secreted, and the peristalsis of the gastrointestinal canal is lessened. Thirst is usually increased, and the tongue is apt to be dry. Urine — The amount of urine secreted is diminished, chiefly as the result of the lessened absorption of nutritive matter and the increased excretion of water by the skin and lungs. The urine of a patient in fever has a high specific gravity ; it is rich in nitrogenous substances, particularly urea, and in the calcium salts, and it is poor in sodium chloride. The large percentage of calcium salts and colouring matter is due to the increased disintegration of the red blood-corpuscles which 306 INFLAMMATION AND INJURIES. takes place during fever. Not infrequently the urine in fever con- tains albumen and hyaline casts. Muscular System.—The symptoms referable to the muscular system, consisting of weakness and pain, are partly nervous in their nature, being caused, in all probability, by an altered innervation, and partly are directly dependent upon changes in the muscles consisting of a parenchymatous degeneration of their contractile substance. Body Weight.—The weight of the body diminishes during fever, as a result of the increased metabolism or destruction of albumen. Tbe weight which a patient loses in fever would be much greater if the de- struction of fat were in the same ratio as that of albumen. According to Kraus, the fat is not destroyed in the same proportion as the albu- men. Leyden has demonstrated by many systematic measurements that the loss of weight is greatest during the crisis of the fever, and in twenty-four hours at this stage the average weight lost amounts to 10-6 parts in 1,000. Prognosis—Outcome of the Fever.—As Cohnheim has correctly stated, the body makes use of fever to destroy as rapidly as possible the noxious substances which have gained access to it. In this sense fever is advantageous to the organism. It was formerly thought that the danger in a febrile disease lay mainly in the elevation of the tem- perature—in other words, that death was caused principally by tbe abnormally great specific heat. This view is being more and more suc- cessfully contested. AYe know now, as regards the febrile diseases, es- pecially those following wounds, that the species of pathogenic bacteria which may be present, or the products of their metabolism, are the prin- cipal factors in determining the prognosis of the febrile infection. The length of time which a febrile disease lasts may, aside from the severity and nature of the infection, become dangerous to the patient as a result of the increasing inanition. According to Leyden, the daily loss dur- ing fever amounts to about seven tenths per cent, of the total weight. Chossat states that all the higher animals die when they have lost forty per cent, of their weight through deprivation of nourishment; conse- quently a moderately severe fever would be sufficient to kill a man in about eight weeks. The Pathological Changes during Fever.—The pathological changes in fever will be described under the infectious-wound diseases, and when we come to discuss those subjects we shall learn about the changes in the composition of the blood brought about by micro-organ- isms. It is sufficient to note here that the cloudy swelling, or paren- chymatous degeneration, as it is called, of the glands and muscles, varying from a granular cloudiness and swelling to pronounced fatty degenera- §(>2.] REACTION WHICH FOLLOWS INJURY AND INFLAMMATION. 307 tion, used to be erroneously looked upon as the result of the high tempera- ture. Furthermore, the loss of weight which accompanies a fever of any considerable duration is not the direct result of the fever, but of the in- fection or intoxication which has occurred. It is more exact to ascribe all these changes not to the increased heat of the body, but to the nature of the infection or poisoning. Etiology and Character of Fever, particularly of Wound Fever.—If we would understand the etiology and nature of fever, we must at- tempt to give an explanation of the principal symptom of fever—viz., the rise of temperature. AYe have already emphasised the fact that fever is mainly the result of absorption. Billroth and C. O. AYeber were the first to add materially to our knowledge of the etiology of fever, and they demonstrated that fever can be caused in animals by introducing into the subcutaneous cellular tissue, or directly into the blood, decomposing animal or vegetable matter. But not only are actually decomposing and putrid substances capable of causing fever— i. e., pyrogenous—but also every kind of pus due to bacterial infec- tion, including the so-called j)us bonum et laudabile, has the same pyro- genous effect. The micro-organisms (the bacteria) are the most impor- tant of the causes of fever, giving rise to it as soon as they, or the dis- solved poisonous products of their metabolism (ptomaines, toxines), gain access to the circulation (see § 59). The bacteria act by decomposing their nutritive media, consisting of the animal tissues, the blood, and the lymph, giving rise to fermentative and decomposition processes, and destroying the blood-corpuscles, particularly the white ones, etc. AYe learned in § 59 that the poisonous products of their metabolism which have been isolated from the bacteria are also capable of exciting a gen- eral febrile intoxication. Mention should also be made of the rise of temperature occurring in conjunction with constipation, particularly tbat following an operation, for instance. This fever is probably due to the absorption of soluble decomposing substances which are formed either with or without the co-operation of bacteria. Every intoxication fever is not by any means to be ascribed to bacteria, as we know that substances capable of exciting fever, such as ferments, can be formed in extravasated blood and in the undecomposed secretion of a wound, without the co-operation of bacteria. AYe are already familiar with several ferments of this kind which have the power of producing fever, notably the fibrin ferment (Alexander Schmidt), wliich causes a rise of temperature to take place in the animal into which blood has been transfused, particularly when the blood is taken from an animal of another species. Iiammerstein investigated the blood of fifteen patients during fever, and found fibrin ferment existing in a free state 21 308 INFLAMMATION AND INJURIES. in the blood of twelve. He also found it free in the blood of two patients who did not have fever. The presence of the fibrin ferment in the blood during fever is not constant, consequently no satisfactory theory of fever based upon the fibrin ferment can be established. Solutions of hemoglobin also have a pyrogenous action—i. e., they are capable of exciting fever. Schmiedeberg has isolated from the blood another ferment, histocym, and has demonstrated that this body, which is a product of the normal metabolism, when introduced into the circu- lation in sufficient quantities can give rise to high fever. Bergmann and Angerer have shown that other ferments, such as pepsine, pan- creatine, etc., have the same power. This non-bacterial ferment fever, as we may call it, is observed after subcutaneous injuries of bones which are accompanied by con- siderable extravasation of blood. This is the explanation of a rise in temperature, which may reach 39° to 40° C. (102-2° to 104° F.), and which makes its appearance after a subcutaneous fracture, a severe con- tusion of a joint, or a subcutaneous injury of soft parts. In the same category belongs, perhaps, the fever following absorption of the unde- composed primary secretion of a wound, called aseptic wound fever, and which may cause the temperature to rise as high as 10° C. (101° F.), even when the repair of the wound runs a perfectly aseptic course (Yolkmann and Genzmer). Nevertheless, I believe, at present, that this aseptic wound fever is mainly the result of a too free use of carbolic acid during the operation. If the wound is much irritated, especially by such an antiseptic as carbolic acid, there will follow, not infrequently, extravasations of blood into the wound, there will be a considerable amount of secretion, and the above-mentioned ferments will develop in the stagnant blood, and, even though the wound remains aseptic, these ferments will give rise to the so-called aseptic wound fever. Since I began to use bichloride of mercury instead of carbolic acid, and par- ticularly since I began to make less free use of the poisonous antisep- tics, I have no longer observed this aseptic wound fever. Chronic Ferment Intoxication.—Langenbeck and Cramer have recorded an interesting case of chronic ferment intoxication with continuous high fever, cough, and occasional diarrhoea in a young woman who had a blood cyst the size of a goose-egg on the thigh. The blood cyst had probably de- veloped from a pre-existing cavernous angioma. After its operative re- moval all disagreeable symptoms immediately vanished. Within the cyst, as in all blood which is not in contact with the normal walls of the vessels, or which becomes stagnant, there had developed different ferments, amongst them Schmidt's fibrin ferment, which had then gained access to the general circulation, as the cyst, from the cavernous structure of its walls, was in direct communication with the vascular system. The febrile symptoms, and g 62.] REACTION WHICH FOLLOWS INJURY AND INFLAMMATION. 309 the coagulation processes in the capillaries of the lungs and intestines, were caused in this way, corresponding in every respect to the facts which had been noted by Kohler, Bergmann and others in their experiments on ferment intoxication. AYe are able, then, to distinguish two classes of absorption fever, the first being the fever caused by micro-organisms and the poisonous products of their metabolism (ptomaines, toxines) which have gained access to the circulation, and the second being the fever which follows the absorption of the disintegrated products of the body, these products differing but little from the substances formed in the physiological metabolism of the body (non-bacterial ferment fever). The part played by the nervous system in the production of any one of the various kinds of fevers is briefly spoken of on page 300. Explanation of the Febrile Process.—How do the factors so far known to be capable of causing fever, the bacteria and the products of their meta- bolism, the non-bacterial ferments and the central nervous system, how do these factors act ? in other words, in what way does the principal symptom of fever, the rise in temperature, come about ? It is well known that the body temperature normally regulates itself within moderate fluctuations, and that the amount of heat formed and lost occasionally changes even in health—it increases and diminishes. The amount of heat given off by the body is influenced by the clothing or coverings of the body, by the perspira- tion, by tbe circulation of blood in the skin, and, finally, by the increased or diminished excretion of warmth and moisture through the lungs. The amount of heat developed is altered by the voluntary or involuntary increase of muscular activity, by the processes going on in the glands and tissues, by the ingestion of nutritive material, or, in other words, by the increased or diminished supply of fuel. The nervous system, through its reflexes, regu- lates these various portions of the apparatus, causing each to assume its proper activity, and thus is explained tbe constancy of the temperature of the body. During fever the amount of heat produced is, in the first place, increased, and the substances which excite fever must somehow affect those parts of the body which regulate the production of heat. We are ignorant of the exact manner in which this takes place during the febrile process. We can only say that the physiological warmth of the body is the product of the biochem- ical metabolism of the tissues, and the febrile agent causes an increased meta- bolism, and consequently an increased production of heat. It can be proved that the metabolism or combustion is actually increased during fever. The increased consumption of oxygen, the increased excretion of carbonic acid and nitrogenous substances, particularly urea, are all evidences of the truth of this. The increase in urea corresponds in general to the severity of the fever, and, according to Cohnheim, no matter bow little food is administered, there may be three times more urea excreted than normally, and it may amount to forty to fifty grammes per diem. This increased secretion of urea means that a greater disintegration of albumen is taking place within the 310 INFLAMMATION AND INJURIES. body. Leyden gives the excretion of carbonic acid as one and a half to two and a half times more than in a state of health. Are there certain tissues in which the increased production of heat is more marked than in others ? This question has not as yet been answered. We only know that muscular tissue, particularly that of the heart, nerve tissue, and the glands, are important factors in the generation of heat. Mosso was unable to demonstrate in the cortex of a dog's brain any circumscribed cen- tre regulating the heat of the body, but he conjectured that the regulating power was widely distributed throughout the brain and spinal cord. Aron- son, Sachs and Gottlieb affirm that the heat centre for rabbits exists in the corpus striatum. The blood is certainly one of the most important sources in which a rise of temperature in fever takes place, and this is particularly true in wound fevers, where it contains bacteria and the dissolved poisonous products of their metabolism. By the latter's presence in the circulation we know that the blood becomes altered and that the white blood-corpuscles are destroyed. It is probable that the increased metabolism and tbe rise of temperature are the results of the alteration in the blood, since the heart and the walls of the vessels are directly affected by the noxious substances, particularly the dis- solved poisonous products of bacterial metabolism. Consequently Bergmann has advanced the view, and it seems to me to be the correct one, that the cause of the febrile rise of temperature is to be sought for in an increased metabolism in the blood. The alterations in the blood, according to Berg- mann, are the most essential of all the accompaniments of fever. In order to retain the constancy of the composition of the blood, all the machinery in the body designed for this purpose exhibits a more intense activity, and in this way is explained the increased metabolism and rise in temperature which occurs in fever. On account of the elevated temperature of the blood the further development and spread of certain species of pathogenic bacteria are prevented. It is a fact that in anthrax infection, for example, the animal affected has only to be repeatedly cooled off to make the bacilli appear imme- diately in the blood. The fever or elevation of the temperature of the body and the greater activity of its metabolism is all a conservative process which the body makes use of to more rapidly get rid of the injurious substances which have gained access to it. In other cases, where there is no intoxication or infection of the blood or tissues, the rise in temperature is due to influences connected with the nerv- ous system, as we have before remarked. Loss of Heat during Fever.—What are the conditions as regards the amount of heat lost during fever ? Ordinarily the amount of heat lost dur- ing the chill is less than normal, but during the height of the fever, ac- cording to Leyden's measurements, it is greater, being for temperatures above 40° C. (104° F.) double the normal, and even triple when there is an abun- dant secretion of sweat. Nevertheless tbe body is unable to get rid of its ex- cess of warmth, because the amount of heat produced is continuously increased during fever, whilst the amount lost fluctuates, at one time being greater than normal, and at another less. Tbe diminution in the amount of heat lost is due to the contraction of the cutaneous blood-vessels, which, as we saw on page 301, begins before tbe rise in temperature. §C2.] REACTION WHICH FOLLOWS INJURY AND INFLAMMATION. 3H Traube, particularly, taught that the cause of fever was to be found in the diminished amount of heat lost, or rather in the pathological changes con- nected with the loss of heat. It is more correct to ascribe the cause of fever to the increased production of heat resulting from the more active metabolism in conjunction with a pathological alteration in the amount of heat lost. The amount of heat lost is not constant, as Traube thought, but it is patho- logically altered, being at one moment increased and at another decreased. Traube was wrong in denying an increased production of heat in fever. Definition of the Febrile Process.—If we should wish to formulate a definition of the febrile process, we can say, with Recklinghausen, that fever is a disturbance which increases the metabolism of the materials of the body, especially the tissues which are rich in albuminous sub- stances. This increased metabolism may have its cause in the nervous system or in the blood. Recklinghausen considers that the part of the system principally affected by fever is the motor apparatus of the vas- cular system, consisting of the heart and muscular coat of tbe vessels which are regulated by the vasomotor nervous system. The latter plays, according to Recklinghausen, one of the most important parts in the production of fever. The typical symptoms of fever result from a combination of excitation of the nervous and vasomotor apparatus, with an increase in the biochemical processes carried on by the tissues of the body, due to certain causes. The exciting cause of the fever leads to molecular changes in the body substances, but how this comes about still baffles us. Treatment of Fever.—AVe shall confine ourselves to the treatment of wound fever. It is mainly surgical, and consists, in the first place, in properly treating the existing injury. The best prophylactic measures in the treatment of wound fever consist in carrying out strictly the rules of antisepsis and asepsis. It is very important to provide for the escape of secretions from the wound by means of careful drainage. If fever makes its appearance in a patient who has been wounded or op- erated upon, it is advisable to examine the wound carefully to deter- mine whether there is a retention of the secretion or some other ab- normity. In wounds which have been sutured, which involve the scalp, for instance, it may be sufficient to remove the sutures and permit a free escape of the retained secretion, and the fever will thus often dis- appear very promptly. In other cases deep incisions may have to be made on account of the retention of secretions, and abundant drainage may be necessary. I make it a rule to change the dressings on patients who have been injured or operated upon if the temperature rises above oS\>° C. (10r3o F.). If the wound is really aseptic, as in fresh in- juries, or after operations, healing without fever is usually assured. 312 INFLAMMATION AND INJURIES. The different wound diseases due to infection must receive their special treatment (see §§ 66-82). If the temperature becomes too much ele- vated, or if the duration of the fever threatens to cause serious weak- ness of the patient, in addition to the above briefly outlined local treat- ment of the wound, it is advisable to adopt other suitable means of treating the fever, just as in ordinary febrile diseases. The best way of reducing the temperature when there is no contraindication consists in the employment of cool baths, cold packs, and sponging off with cold water. The cold-water treatment of fever is considered by many physicians the best means at our disposal for reducing the temperature. It is used either in the form of baths at a temperature of 20° C. (08° F.), in which the patient is immersed for ten minutes, or baths at a tempera- ture of 21° C. (75-2° F.), which are gradually cooled down during fifteen to twenty minutes to a temperature of 22° C. (71'8° F.). At the same time, in proper cases cold water is poured over the patient, or even ice water, as he lies in the tub. This serves as an excellent stimulant to respiration and the psychical functions. The patient is then brought back to bed without being previously dried off, as in this way the cooling off will continue longer. Wine should be admin- istered freely as a stimulant while the patient is being subjected to this treatment. The reduction of temperature by medicaments, such as quinine, digitalis, veratrum viride, sodium salicylate, antipyrine, etc., should be employed when the patient cannot stand cold baths, or when, for some reason or other, their use is not practicable. The action of the antifebrile medicaments, such as antipyrine, has been repeatedly tested in recent times, and it has been proved that they act principally through the nervous system, particularly the vasomotor part of it, and the heat centres in the brain ; they increase the amount of heat lost, or they diminish the amount of heat produced, or they do both. Maragliano demonstrated that kairine, antipyrine, thalline, qui- nine, and salicylate of sodium, whether administered during fever or in health, caused dilatation of the cutaneous vessels, and thus increased the amount of heat lost by radiation. The best treatment by the surgeon of wound fever consists in a careful investigation of the wound, and, as far as possible, in remedying any abnormity which may exist. The treatment of the rise in tem- perature, if present, is next to be considered, though it will generally not be necessary to do more than to rectify any abnormal condition which may be found in the wound. At present antipyresis—i. e., the reduction of elevated temperatures—is not so energetically carried out as it used to be even in medical cases. Lately we have been giving up §0:S.] SHOCK. 313 more and more the idea that the temperature curve is the only consid- eration which determines our treatment of fevers. Repeated observa- tions have demonstrated that there is no truth in the idea that man can- not survive an elevation of the specific heat of his body above 42° C. (107"6o F.). Striimpell and others have declared that the reduction of the increased body temperature should not form the only part of our treatment of fevers. A routine treatment of fever is not a good plan. Every case must be treated symptomatically, according to the condi- tions which may arise. Too energetic antipyresis—i. e., the adoption of too active measures for reducing temperature—can frequently do more harm than good, from the fact which we mentioned before, viz., that the temperature of the body must be higher than normal to render possible the sudden or gradual destruction of many species of bacteria ; and if the temperature of the body is lowered, infection of the blood is favoured. It is wise to give patients who have fever easily digestible food, and to restrict its amount and variety. Cool, effervescing waters with citric acid, fruit juices, and wines should be allowed as drinks. If an indi- vidual has been accustomed to the use of alcohol, the latter should not be denied him entirely, as otherwise nervous complications, or even de- lirium tremens, may make their appearance (see § 01). Furthermore, it is known that alcohol has the power of directly reducing temperature. § 63. Shock.—By shock is understood a peculiar state of depression of the nervous system, which is apt to be excited reflexly by injuries involving a shaking up or contusion of the sensory nerves. Etiology of Shock.—Fischer, Goltz, and Seabrook consider the es- sence of shock to be a paralysis of the vasomotor centre in the medulla oblongata, produced reflexly by a contusion or violent disturbance of the sensory nerves in the manner illustrated by Goltz's well-known experiment on the frog. By repeatedly striking the abdomen of a frog there is produced a peculiar state of collapse, which can terminate fatally by cardiac paralysis, the heart stopping in diastole. The cause of these phenomena lies in the fact that by mechanical irritation of the intestines, or the irritation of any sensory nerves, the activity of the brain and, above all, of the vasomotor centre in the medulla ob- longata, becomes reflexly altered, weakened, or paralysed. As a result of this there follows a diminution or paralysis of the vascular tone, par- ticularly in the arteries. There is a weakening in the propelling force driving on the stream of blood, the speed of the current lessens, and the blood pressure diminishes; the blood is unequally distributed, the arterial system is less full, the lungs and brain are anaemic, while, on the other hand, the blood collects in the veins, particularly those in the 314 INFLAMMATION AND INJURIES. abdomen. Eventually the disturbances in the circulation may become so pronounced that the heart's action ceases. Seabrook attempted to determine the nature of shock by experiments on animals, making contusions of the tissues in both warm- and cold-blooded species, and he reached the same conclusion that has been given above. He determined by his experiments that external violence, acting through the sensory nerve trunks, so affected the medulla, and the vasomotor centre in particular, that after a brief period of irritation a condition of depression followed which resulted in a permanent dilatation of the blood-vessels. The inhibitory nervous system of the heart plays only an unimportant part in shock, except when the terminal branches of the vagus, as in Goltz's beating experiment, are directly acted upon by the violence causing the shock. The paralysis of the vasomotor centre is sufficient for explaining all the symp- toms which are manifested by patients in a condition of shock. By the pa- ralysis of tbe muscular coat of the smaller arteries the blood current loses part of the force by which it is propelled, the blood flows more slowly, and, following the law of gravitation, sinks into the vessels which are most de- pendent, particularly the large abdominal veins. Thus not only do these become distended with blood, but, in addition, the right heart soon becomes overloaded ; the heart's action is interfered with, the pulse grows weak, fre- quent, and small. The abnormal distribution of the blood, the anaemia of the skin and the brain, due to the overfilling of the abdominal veins, cause tbe paleness, the coolness of the superficial portions of the body, and the cere- bral symptoms, somnolence, and motor weakness. Symptoms of Shock.—The sum-total of the symptoms of shock in man correspond exactly to the facts which have been determined ex- perimentally. All the manifestations of shock can be traced back to the paralysis of the vasomotor nerves produced reflexly by the con- tusion of the sensory nerves. The characteristic symptoms of shock are a marked pallor and coolness of the skin and visible mucous membranes; the face is with- out expression; the eyes are dull and staring, the pupils are dilated, and react slowly. The heart's action is plainly delayed, irregular, and weak ; the pulse is thready or imperceptible ; the respiration is irregu- lar and long; deep breaths alternate with shallow inspiratory efforts. The mind is dull and reacts slowly; the patients are completely apa- thetic, and will only answer questions tardily and unwillingly. The sensibility of the superficial portions of the body is impaired, and the energy of muscular movement is diminished. Not infrequently there is nausea or actual vomiting. The temperature is about 1° to 1£° C. (1"8° to 2*7° F.) below the normal. In other cases, instead of the above-described torpid form of shock, there will be a more active set of symptoms—in other words, the patients are more excited, they fling themselves about, cry out, shriek, and act like maniacs. §63.] SHOCK. 315 It is undoubtedly true that shock occasionally changes gradually into deep syncope and ends in death, particularly in the case of neuro- pathic, anaemic individuals. In such cases there will usually be found complicated injuries with severe loss of blood, and the post-mortem examinations will frequently show that there are also severe internal injuries, perhaps, of the brain. As a general rule, patients suffering from uncomplicated shock will recover after the lapse of a longer or shorter time, ordinarily after a few hours. Sometimes a psychical change persists for a certain length of time, but eventually perfect re- covery will take place. All nervous manifestations, syncope, etc., which follow severe losses of blood and which may look very much like shock, should be carefully distinguished from true shock (see §§ 87-89). The individual symptoms of shock, particularly cerebral shock, will be described in the Special Surgery under Concussion of the Brain. The latter injury may cause the patient to lose more or less completely all recollection of the accident. He may not be able to remember how he was hurt, he may have no idea of distance and time, and may even forget everything he did, saw, or heard for several days before the time of his injury. As the circulation in the brain becomes in time gradually restored and regulated, the patient may recover some of his lost memories, but a part of his experiences, recollections, and conceptions will remain lost forever. The Treatment of Shock.—The treatment of shock consists, in the main, in overcoming as soon as possible the existing paralysis of the vasomotor nerves, together with the accompanying disturbances which the paralysis gives rise to. To combat effectively the cerebral anaemia, the head of the patient should be placed low down ; but if venous con- gestion of the face becomes marked this position of the head must be immediately given up. Fischer and Konig are right in recommend- ing vigorous stimulation of the skin by sinapisms, electricity, rubbing the extremities, applying dry heat, etc. In fact, Goltz's beating ex- periment fails if combined with vigorous irritation of the sensory nerves of the extremities. Internally warm stimulating drinks, strong coffee, hot wine, whiskey, etc., should be administered ; there should also be given subcutaneous injections of camphor or calabar extract, digitalin, and atropin. Tincture of digitalis can be tried by mouth instead of subcutaneous injections of digitalin. Dercum has highly recommended the rectal use of a musk emulsion (0*9 to 125 gramme), with fifteen drops of the tincture of opium or an enema of strong, black coffee. The respiration must be carefully watched, and, if neces- sary, kept up artificially, as described in § 13. One must avoid under- 316 INFLAMMATION AND INJURIES. taking an operation with chloroform narcosis upon a patient in a state of shock. The chloroform narcosis may alone be sufficient to cause the weakly contracting heart to come to a complete standstill. Patients who are suffering from shock should, as a rule, not be operated upon; but if it is absolutely necessary to adopt some operative measures, such as checking haemorrhage or the like, the operation should be done without chloroform. § 61. Delirium Tremens.—By delirium tremens (drunkard's delirium) is understood an acute outbreak of chronic alcoholic poisoning, which is particularly liable to occur when a habitual drinker is compelled, by some injury or acute internal disease, to remain for some time in bed. Delirium tremens, owing to the increase in the misuse of alcohol, has been observed in youthful subjects, and even in five- to eight-year- old children. These children, whose parents had, as a rule, been ad- dicted to drink, had for a long time been taking daily increasing amounts of alcohol. The delirium usually breaks out very soon after the injury or operation. According to Krugenberg, in about fifty per cent, of the cases there exists, besides the alcohol habit, a tendency to some nerv- ous disease such as epilepsy. Krugenberg, basing his opinion on three hundred and one cases of alcoholism which he observed, amongst which there were one hundred and sixty-one cases of delirium tremens, denies that the sudden stoppage of alcohol plays a causative part in the pro- duction of delirium tremens. The first symptoms manifested are loss of sleep, great restlessness, and constant talking. The trembling movements are characteristic, and particularly evident when the patient is told to hold out his arm or to show his tongue. The patients see animals of every description, and they are very apt to complain that their rest is disturbed by mice, rats, etc., crawling about them. The delirium is generally connected with marked hallucinations, and not infrequently there is pronounced maniacal excitement. They try to get up, and they may even walk about without pain though they have a fracture of the leg. They make frequent attempts to run away, and consequently must be carefully watched. Arery often they will have to be put in a strait-jacket and tied in bed. The prognosis of the delirium is in general favourable, though it frequently happens that old people, in particular, die rather suddenly with symptoms of collapse. It must also be borne in mind that the original injury from which such a patient may be suffering— a subcutaneous fracture, for example—may easily run an unfavourable (complicated) course if his violent movements are not carefully enough guarded against, and he is not properly treated. The post-mortem ex- amination will usually reveal the ordinary changes which occur in the S r,.-).] DELIRIUM NERVOSUM AND PSYCHICAL DISTURBANCES. 317 organs of drunkards, particularly chronic gastritis, atheromatous degen- eration of the arteries, fatty liver, the kidneys of Bright's disease, thickening of the cerebral membranes, etc. Treatment of Delirium Tremens.—The treatment of delirium tremens consists, in the first place, of vigorous prophylactic measures. It is exceedingly important that the daily amount of alcohol wliich the patient has been accustomed to should not be stopped, and even more alcohol should be given during his illness than he is accustomed to take normally. In this way an outbreak of delirium tremens can often be avoided. Considerable amounts of alcohol should be administered, best in the form of strong wine or cognac—about one half to three quarters to one litre in twenty-four hours; and, in addition, the patient should be given an easily digestible diet—meat, bouillon with eggs, etc. Furthermore, it is a good plan to administer opium in large doses (O'lO to O'lO gramme every two hours), with or without combining it with Rochelle salts, or opium with chloral hydrate, or morphine subcu- taneously, to combat the restlessness and loss of sleep from which the patient suffers. I do not, as a general thing, like these narcotics in the treatment of delirium tremens, and prefer large doses of alcohol, which will often bring on, without the assistance of narcotics, the sleep which is the precursor of a speedy convalescence. I employ opium or mor- phine only in bad cases of great restlessness or mania. When the latter condition is present, it is an excellent plan to use cold douches, continued for a considerable length of time, until the patient is put to bed in an exhausted condition. Sawadskje praises the action of strychnine, which he exhibits in doses of 0*003 gramme for a week, to counteract the desire for drink, and as a treatment of the delirium tremens and the conditions which it gives rise to. § 65. Delirium Nervosum and Psychical Disturbances which may fol- low Injuries and Operations.—By delirium nervosum is understood a condition of nervous excitement without fever (Billroth), which is sometimes observed in hysterical persons, following injuries and opera- tions. The delirium may be of the wild, maniacal type, or it may be melancholic. Some cases have the character of hysteria, or dementia senilis. The delirium of sepsis, alcoholism, and poisoning from iodo- form, morphine, chloroform, and of uraemic states, etc., of course do not belong to this class. Le Dentu has noted over twelve cases of delirium nervosum following operations, and he has collected sixty- eight cases from the literature on the subject, thirty-eight of which were observed after operations on the female genitalia. Delirium ner- vosum generally makes its appearance two to five days after the opera- 318 INFLAMMATION AND INJURIES. tion, and lasts several days or a week, and in exceptional cases niav terminate in death (Le Dentu). In the majority of instances the psy- chical disturbances occurring in connection with operations upon the male and female sexual organs, or following operations upon the face, etc., are of a transient nature. Mention should also be made of tbe delirium of collapse, which is occasionally observed after a sudden fall of a high temperature—for instance, after the defervescence in ery- sipelas, and in hysterical individuals with a subnormal temperature. This delirium of collapse is usually accompanied by transient psychical disturbances. The prognosis of collapse delirium is generally favour- able, and the acute mental aberration often disappears in a few days, or even in a few hours. § 66. The Infectious-Wound Diseases.—The existence of infectious diseases of wounds has been established beyond a question by tbe labours of Pasteur, Billroth, Klebs, Eberth, and, above all, by Koch and his followers. Thanks to their careful researches, we now know that the infectious diseases of wounds are caused by micro-organisms, or by the products of their metabolism (ptomaines, toxines). (See § 59.) Koch, experimenting upon animals, excited infectious-wound dis- eases which possessed many similarities to corresponding diseases in man. However, the facts which are experimentally ascertained as regards animals cannot be directly applied to man, as we know that different species of animals are affected differently by the same poisons. A poison or a certain species of bacteria may not be injurious for one kind of animal, while this same poison may immediately excite danger- ous symptoms in another. Furthermore, totally different classes of micro-organisms may produce in different animals diseases which are very similar. The bacillus of mouse sepsis is totally different from the bacillus which causes sepsis in rabbits, and it does not cause sepsis in the latter. The sepsis which occurs in mice from infection by a bacillus has only been observed in house-mice, while field-mice are immune from its effects, etc. Koch was the first to develop an exact method for investigating the infectious diseases of wounds. He introduced improved methods of illuminating and staining preparations, and thus made it possible for us to study the shape, distribution, and number of the bacteria in the body. He, moreover, made cultures of the bacteria which he had found upon solid nutritive media, so as to observe the characteristics of their growth and the immutability of their species. These pure cultures were then reinoculated upon animals, for the purpose of ex- citing the same disease which they had first caused. AVe have these exact methods of his to thank for our knowledge of the etiology of the Ij 06.] THE INFECTIOUS-WOUND DISEASES. 319 infectious diseases of wounds, and the facts ascertained by experiments upon animals conform very closely to what we have observed in man. Every inflammatory or suppurative process which occurs in the wound, such as circumscribed and diffuse cellulitis, acute inflamma- tions of the lymph and blood-vessels (lymphangitis, phlebitis, arteritis), erysipelas, hospital gangrene (wound diphtheria), pyaemia, septicaemia, and tetanus, are all included amongst the secondary infectious diseases of wounds which may make their appearance in man. These infec- tious-wound diseases are all caused by bacteria. This class of diseases also includes anthrax, hydrophobia, glanders, etc., which are diseases communicated from animals to man. Actinomycosis, tuberculosis, and syphilis are also due to infection by micro-organisms, and there are still other diseases of a like character which we shall learn about later. The bacteria are capable of gaining access to the tissues or the fluids of the body through any wound, even the smallest interruption in the con- tinuity of the skin or mucous membranes. The trauma in itself plays no part in the origin of the infectious-wound disease, and the gravest injuries, the most extensive operations, will run their course without inflammation and without suppuration, provided only the bac- teria are kept out of the wound. The best way of preventing an in- fectious-wound disease is to employ the most careful asepsis or anti- sepsis in every operation or injury and in the application of every dressing. The possibilities of surgery since the introduction of anti- septic and aseptic methods have increased to a most wonderful degree, and our responsibility towards our patients has become correspondingly greater. Every physician should constantly bear in mind that he may cause the death of his patient by a single transgression of the rules of asepsis—by an unsterilised and non-aseptic instrument, or by an unclean finger. The infectious diseases of wounds have, corresponding to the action of the bacteria, partly a local and partly a general systemic character. As was stated in § 62, the general disturbances, the fever, and the gen- eral poisoning are caused by the absorption of the metabolic products of the fungi, which, as we shall see when we come to septicaemia, can give rise to systemic poisoning even after they have become separated from the fungi. Their metabolic products thus give rise to an intoxi- cation which, like every kind of poisoning by chemical substances, can- not be transmitted by inoculation. Infectious diseases caused by the bacteria themselves are, on the contrary, capable of being transmitted from one individual to another. AVe shall see that each one of the in- fectious-wound diseases to which man is subject is excited by a specific micro-organism. There are cases, howTever, which are not due to in- 320 INFLAMMATION AND INJURIES. fection by any single species of bacteria, but are mixed infections—in other words, they are caused by several different species acting together. The questions concerning the significance of the micro-organisms in the causation of the infectious-wound diseases and the various methods for investigating them have been described in § 59. In all febrile infectious diseases of bacterial origin the cause of tbe fever is to be ascribed to the changes in the blood brought about by the bacteria, or rather the products of their metabolism. Furthermore, in the fevers due to unformed ferments, or non-bacterial solutions, such as fibrin ferment, pepsin, trypsin, or haemaglobin, it is principally, as described in § 62, the change in the composition of the blood which gives rise to the increased oxidation processes going on in the blood, and to the rise of temperature. § 67. Inflammation and Suppuration of a Wound—Etiology.—Though it was once believed that all suppuration was caused by micro-organisms, we learned on page 210 that Grawitz, De Barry and others have dem- onstrated that suppuration can also be excited without bacteria in dogs and rabbits by aseptic (germ-free) chemical substances, such as turpen- tine, nitrate of silver, mercury, etc. Moreover, sterilised cultures of various micro-organisms, or the sterilised products of their metabolism (cadaverine, putrescine, penta- methylendiamine), have a similar (pyogenic) power of exciting suppu- ration. When Behring added iodoform to the cadaverine the latter never produced suppuration. Though it is undoubtedly true that suppuration can be excited by a whole series of germ-free chemical substances, it is just as certain that suppuration is produced in man, under ordinary conditions, by tbe presence and life of certain distinct micro-organisms, no matter whether the suppuration takes the form of a simple felon, a furuncle, or a dan- gerous phlegmon. The question does not involve two opposing prin- ciples, since the bacteria themselves give rise to suppuration mainly through the chemical products of their metabolism. Ogston, Rosen- bach and others have studied the micro-organisms which are present in acute suppuration, and they have frequently found only a single species, but at other times several. Suppuration in man is mainly due to cocci, which are found either in irregular masses arranged in groups (the staphylococcus, Fig. 251), or in the form of chains (the strepto. coccus, Fig. 256). The streptococcus is more apt to give rise to spreading erysipelatous inflammations, the staphylococcus to localised inflammation and suppuration, and the latter is the true pus coccus. The lodgment of pus cocci, or rather the starting up of suppuration, is favoured by local lesions as well as by weakness of the whole organism. §67.] INFLAMMATION AND SUPPURATION OF A WOUND. 321 Different Kinds of Pus Microbes.—Ogston, Eosenbacb and Passet have made pure cultures of the various bacteria found in acute suppuration upon solid nutritive media (peptone-gelatine-meat extract, meat-peptone-agar, hard- ened blood serum, potatoes). Rosenbach has cultivated five different spe- cies of microbes which he obtained from thirty acute abscesses, leaving out the abscesses which contained decomposing matter and were rilled with bacilli, spirilla, and various kinds of cocci in addition to the pus cocci. Amongst these five kinds of microbes Rosenbach found one species only once, an oval coccus (bacterium). The others were the staphylococcus pyo- genes aureus, the staphylococcus pyogenes albus, the micrococcus pyogenes tenuis (rare), and the streptococcus pyogenes. Passet cultivated eight differ- ent kinds of pus microbes—the staphylococcus aureus, albus, and citreus; the streptococcus pyogenes, a micro-organism resembling tbe pneumococcus; the bacillus pyogenes fcetidus (Fig. 259) ; the staphylococcus cereus, and flavus. They are all capable of exciting acute suppuration. The cultures of the chain cocci of pus cannot be distinguished from the cocci of ery- sipelas (see § 71). From Passet's experiments it appears that the effect upon animals of the pus streptococci is almost exactly the same as the effect pro- duced by the cocci of erysipelas. All the microbes found in foci of suppu- ration, when transplanted into milk will cause the latter to coagulate. The fact that pyogenic microbes may in one instance cause only trifling suppura- tion, in another a dangerous diffuse phlegmon, which may threaten life, and in still another an acute inflammation of the bone marrow (osteomyelitis), or pyaemia with its metastases, is explainable partly by the differences in tbe points of invasion and partly by the variability in tbe numbers and virulence of the micro-organisms which gain access to the system. While suppura- tion is going on, pus cocci can frequently be demonstrated in the blood, urine, and sweat (Brunner, Tizzoni, etc.). Artificially obtained Immunity from the Poison of Pus Cocci.—In excep- tional cases the pus of acute suppuration does not contain any microbes, though this does not necessarily mean that none have been present at an earlier period, since we know from Rosenbach's experiments that there are bacilli which cause suppuration and then perish very soon afterwards. Lindwurm and Pazet, sixty years ago, recorded a temporary immunity from poisoning by pus cocci in animals, brought about by the injection of pus. P. Reichel has obtained temporary immunity in dogs from the virus of pus cocci by injecting into their peritoneal cavities pure cultures of the staphylococcus pyogenes aureus or by inoculating them with the germ-free infiltrate, or products of the metabolism of tbe staphylococcus pyogenes au- reus. This immunity was of very brief duration, lasting only a few weeks. Effects of Bichloride upon Pus Cocci.—According to Abbot, bichloride of mercury is capable of rendering harmless only a certain number of pus cocci (staphylococcus pyogenes aureus)—sometimes more and sometimes less—de- pending upon the virulence, or rather the resisting powers, of the cocci. The Most Important, Pus Microbes.—1. The staphylococcus pyogenes aureus (Figs. 254, 255), so designated because of its golden or orange-yellow colouring matter, is the species of micrococcus which is most frequently found in suppuration. (According to Frankel, it is found in eighty per cent. of all the cases examined). These cocci are incapable of motion, vary in size, 322 INFLAMMATION AND INJURIES. and are arranged in clusters, often in the form of diplococci. It is present in pus, in the air, in dish-water, and in the earth. The staphylococcus pyo- genes aureus can be grown in pure cultures upon gelatine, agar-agar, potatoes, and blood- serum. In gelatine plate cultures, at the end of the second day, small punctiform colonies appear, having a yellow colour and a sharp, slightly depressed border, separating them from the non-fluid gelatine. Puncture cul- tures in gelatine at first reveal a dim, greyish point, which after about three days becomes yellowish, and then orange-coloured ; then the gelatine becomes liquefied, and the culture Fig. 254,-Pus with staphylococcus sinks to the bottom- Linear cultures upon (Fliigge). x«oo. agar-agar (Fig. 255) give an opaque yellow culture which has a crooked outline. Upon potatoes there first forms a thin, whitish layer, which gradually becomes orange-yellow, and smells like paste. The staphylococcus pyogenes aureus grows in blood serum in the same way as upon agar-agar. All cultures de- velop pretty rapidly—most so at temperatures between 30° and 37° C. (98"6° F.), and more slowly at ordinary room temperatures. They have not hitherto been seen to form spores. This coccus possesses great powers of retaining its vitality, and is exceedingly resistant, for instance, to drying, chemical substances, and boiling water. To tbe latter it has to be subjected for several minutes before it is killed. The staphylococcus pyogenes aureus can exist a great while without atmospheric air, is facultative aerobic, and gives rise to the formation of no gas or stinking decomposition; it peptonises albumen and liquefies gelatine. Gram's method is excellent for staining the staphy- lococcus pyogenes aureus. The pathogenic effect of the staphylococcus pyogenes aureus, when used experimentally upon animals, varies with the manner in which it is em- ployed. Inoculations have been made upon man by various experimenters. Grarre inoculated himself by inserting a pure culture in a small wound at the root of his finger-nail, and obtained an extensive suppuration ; by rubbing a great number of the cocci upon the healthy, unbroken skin of his forearm he produced a large carbuncle. Subcutaneous inoculations in mice, guinea-pigs and rabbits are without any result, though subcutaneous injections in the two latter classes of animals give rise to the formation of abscesses. Injec- tions made into the peritoneal cavity cause a violent suppurative inflamma- tion, which usually kills the animal in a few days. Injections of the cocci into the blood-vessels give rise to inflammations of joints and to diseases of the kidneys, and metastatic abscesses develop in the muscles of the heart and in the kidneys. If the valves of the heart are first wounded, a typical endo- carditis ulcerosa results. If, before injecting the cocci into a blood-vessel, a subcutaneous fracture or crush of one of the long hollow bones is artificially produced, the point at which the injury is situated becomes " predisposed" to suppurative inflammation of the medullary portion and periosteum. The staphylococcus pyogenes aureus is the most frequent excitant of acute osteo- myelitis (see § 104). Frequently tbe staphylococcus pyogenes aureus is §67.] INFLAMMATION AND SUPPURATION OF A WOUND. 323 found combined with other micro-organisms h^-.cases of suppuration. Arti- ficially acquired immunity from the poison of :the staphylococcus pyogenes aureus is described on page 321. > 2. The staphylococcus pyogenes albus is in all respects similar to the staphylococcus pyogenes aureus, except in not having the latter's yellow col- ouring matter. It also appears to be somewhat less harmful, and is of less frequent occurrence than the aureus. 3. The staphylococcus pyogenes citreus was discovered by Passet, and is seldom found in suppurative processes in man. The staphylococcus pyogenes citreus is distinguished by its beautiful lemon-yellow pig- ment (Fig. 232), but is otherwise exactly like the aureus and albus, except that it takes longer to liquefy gelatine. f Streptococcus Pyogenes.—4. The streptococcus pyo- ^tr^,;;: .^^ genes (Fig. 256) plays a very important part in the causa- tion of suppuration. It is frequently found alone in ab- scesses, rarely in combination with the staphylococci. This coccus causes, for the most part, progressive suppura- tion, and from recent discoveries is thought to be identi- cal with Fehleisen's streptococcus of erysipelas. In tbe latter disease the streptococcus is found principally in the ' lymph channels of the skin. The streptococci form chains generally consisting of six to ten to twenty cocci arranged in a row like links, though there may be hun- dreds of these cocci, or links, in a single chain. The chains are often made up of two parts, or they may be twisted together in thick masses, or arranged in slender bundles. The following are the principal facts as regards the development of pure cultures : Gelatine plate cultures take the form of fine, round, granular dots. Linear cul- tures upon gelatine plates are thickest at the centre of the line, of a faint brown colour, with tbe edges of the line plainly punctate, and later becoming graded off in terraces. Puncture, or stab cultures, in gelatine, have a delicate areola at the point where the puncture enters the gelatine, the line of puncture itself being finely granular (Fig. 257). The streptococcus does not multiply upon potatoes, though some individual cocci increase in size, and, when examined by the microscope, chains are seen made up of some large and some small cocci or links. The streptococcus pyogenes grows best at a temperature of .35° to 37° C. (98*6° F.), ordinary room temperatures be- ing less favourable to them. The cultures grow slowly, linear cultures requiring two to three weeks to spread a couple of millimetres. After the lapse of four months the cultures will be found, for the most part, to have perished. Gelatine is not liquefied ; it decomposes albumen in a vacuum; it is facultative aerobic, and is not particularly affected by the absence of oxygen. It is best stained by Gram's method. The streptococcus pyogenes can be found almost any- where, and its pathogenic effects may be manifested in various ways, accord- Fig. 255.—Linear cul- ture in agar-agar— Staphylococcus py- rogenes aureus. 324 INFLAMMATION AND INJURIES. i.^** Fig. 256.- \y Streptococcus, x 950 coccus. b, pus with strepto- in°* to the manner and the region in which it gains access to the body. It is found in saliva, nasal and vaginal mucus, and in tbe urethra of man in health. It is often found in tissues which have undergone morbid changes —for example, in typhoid fever, pneumonia, tuberculo- sis, pleurisy, and scarlet fever, and under such condi- tions it may give rise to se- vere inflammatory complica- tions. Upon the valves of the heart it excites typical endocarditis. When grow- ing in the lymph channels of the skin and mucous mem- branes it causes cutaneous erysipelas and destructive inflammation of the mu- cous membranes, and when lodged in the subcutaneous tissue it gives rise to cellulitis, etc. Bacillus Pyocyaneus.—5. The bacillus pyocyaneus a, Gessard, or the ba- cillus of green or blue pus, is a small slender rod (Fig. 258) sometimes found in a non-suppurating, serous wound secretion and in ordinary [7---Sg| sweat. This bacillus gives to pus or dressings a blue or green I Mi colour without causing complications to arise in the reparative | process in the wound, and is similar to the bacillus of blue I' fi4\ milk. Though somewhat narrower, it is capable of active mo- | | tion, and frequently takes the form of a string with four to six joints, and less often forms long filaments. It has not been observed to undergo spore formation. When cultivated on gelatine plates, small white points or dots make their appear- ance within the gelatine, gradually rising to the surface, upon which they spread out. The nutritive medium very soon takes on a greenish, fluorescent colour all around the culture, and after the lapse of about five days the gelatine becomes com- pletely liquefied. In a test tube the bacillus develops almost exclusively in the deeper parts of a stab culture. The gelatine becomes rapidly liquefied, and assumes a beautiful green col- our. Upon agar-agar there forms a moist, rather thick yellow covering, which colours the nutritive medium green. Upon potatoes there is developed a dirty yellowish-green scum, with a green discolouration of the adjoining parts. The colouring matter (pyocyanine) is for the most part seen at the free bor- ders of the clusters, and, according to Ledderhose, is an aro- matic crystalline compound having no pathogenic properties. According to C Frankel, the colouring matter is white when first formed from the bacteria, only assuming its peculiar tinge when brought in contact with the oxygen of the air. The bacilli themselves, and the products of their metabolism, are undoubtedly injurious to animals. If about one cubic centimetre of a fresh bouillon culture is injected into the Fig. 257.—Star or puncture culture of streptococcus pyogenes. £67.] ' INFLAMMATION AND SUPPURATION OF A WOUND. 325 subcutaneous tissue of a guinea-pig or rabbit there will result a rapidly spreading oedema and suppurative inflammation, causing the death of the animal in a short time. The bacilli wdll be found at the point of inoculation in the blood and internal organs. jfiwiit^ Bouchard and Charrin have demonstrated the vei-y inter- >V ^m&^i s^ esting fact that it is possible, with the aid of the bacillus '', VA'iW, ^ pyocyaneus, to check an advancing anthrax infection and **, ^« ' \^ to cause it entirely to disappear. ' •'1^ Bacillus Pyocyaneus 0 Ernst—Ernst has described a FlG- 258.—Bacilli of variety of the bacillus pyocyaneus as the /3 bacillus pyocy- ^700!" ' U6 PUS aneus. It forms a blue colouring matter, or rather blue pus, while the other (a) bacillus forms the green pigment. Ledderhose has designated the a bacillus the bacillus pyofluorescens, and /3 bacillus the ba- cillus pyocyaneus 0. Generally the two kinds of bacilli occur together and produce a mixed colour. Other Colouring Matters Produced by Bacillus Pyocyaneus.—Schimmel- busch states that the bacillus pyocyaneus forms, in addition to the green or blue colouring matter, brown and a whole series of colour- ing matters ranging all the way from brown to green. ( * i,*g|>i_" The production of the colouring depends upon the presence »•; , $' »?4,sS?^£«' of sufficient air, proper nutritive media, and upon the struc- •' *X£, '!j- il'r-'" ture of the bacilli. The latter may assume different forms .jSj v'^r,'-^ ""-':^ in different nutritive media, and may even be unable to '---X-is/f/.H. " lose their property of producing colouring matters under 1 l-c • i j-i.- Fig. 259.—Bacillus natural or artificial conditions. pyogenes fcetidus Red Pus.—There is occasionally observed a red cinna- (Passet). xToo. bar-coloured pus. Ferchmin found that the causation of this red pus was to be ascribed to a special form of bacillus with evenly rounded ends, which could be cultivated best at a temperature of 36° to 37° C. in various nutritive media—agar-agar, gelatine, blood serum, potatoes. The red colouring matter is easily soluble in alcohol, and is insoluble in water, ether, and chloroform. In man, the red colour of the pus has nothing to do with the reparative process in a wound. In rabbits especially tbe ba- cillus has pathogenic properties. Other Pus Microbes.—Amongst the other pus microbes mention should be made of the micrococcus pyogenes tenuis, the bacillus pyogenes fcetidus Pas- set (Fig. 259), and the staphylococcus cereus, albus, and flavus. These bac- teria are of subordinate importance as regards man. Recently the bacillus pyogenes fcetidus has been carefully studied by Burci. He proved that it possessed not only pyogenic but even septic properties for rabbits and mice. Neumann and Haegler maintain that tbe micrococcus pyogenes tenuis is identical with the pneumococcus of Frankel and Weichselbaum. Pneumococci and Typhoid Bacilli as Excitants of Suppuration.—There are still other micro-organisms which excite suppuration. It is occasionally pro- duced by pneumococci (Schwartz, Malgaigne) in the form of secondary sup- puration in joints during pneumonia, and similar phenomena, due to the typhoid bacillus, may occur during typhoid fever, etc. The suppurative pro- cesses occurring in the course of the acute infectious diseases—for example, in diphtheria—are due to the presence of pus cocci. The micrococcus which 326 INFLAMMATION AND INJURIES. causes suppurative inflammation of the urethra, the vagina, etc.—in other words, the gonococcus Neisser—is discussed in the Special Surgery. Chronic abscesses, apart from those due to syphilis, glanders, and actino- mycosis, are for the most part tubercular, and are caused by a characteristic bacillus (Koch). Clinical Forms of Inflammation and Suppuration as we meet them in Surgery.—Clinically, inflammation and suppuration may exist in various forms, either as an ordinary superficial suppuration limited to the wound, or the inflammation may extend to the parts in the neighbour- hood of the injury and result in a cellulitis. This inflammation may lead to more or less circumscribed suppuration and abscess, or to dif- fuse and often rapidly spreading inflammatory and suppurative pro- cesses. The worst form of spreading inflammation and suppuration is the diffuse, foul-smelling inflammation of the cellular tissue, to which is given the name of septic phlegmon. Inflammation of the lymph vessels is called lymphangitis. Inflammations of the vessels, especially the veins (phlebitis), are very important, particularly as regards their dangerous sequela?, due to the so-called emboli. The spreading inflam- mation which involves the skin and subcutaneous cellular tissue, the so- called erysipelas, is caused by an inflammation of the smaller lymph chan- nels, due to the streptococcus pyogenes. The gangrenous breaking down of a granulating wound is called hospital gangrene, or wound diphtheria. Accompanying the inflammation and suppuration caused by micro-or- ganisms, there is more or less fever, due to secondary infection or poisoning of the lymph and blood by the bacteria and the products of their metabolism. This may finally terminate in a fatal general sys- temic poisoning, which we shall learn about more particularly under the heading of Pyaemia and Septicsemia. We shall first discuss acute inflammation of the lymph vessels (lymphangitis) and lymph glands (lymphadenitis). § 68. Lymphangitis, Lymphadenitis. Acute Inflammation of the Lymph Vessels—Lymphangitis.—Acute lymphangitis is characterised partly by a change in the lymph and walls of the lymph vessels, and partly by a perilymphangitis—i. e., an inflammation of the connective tissue surrounding the lymph vessels. The starting-point of a lym- phangitis is usually some focus of infection ; in other words, it is par- ticularly apt to originate from an infected wound. The interruption of continuity in the skin is frequently most insignificant. The inflam- matory irritant, the bacteria—and these are generally pus cocci—are taken up by the lymph vessels, and then they spread into the larger lymph channels, and wherever the bacteria become lodged they give rise to inflammation or thrombosis. As a result of the inflammation, §68.] LYMPHANGITIS, LYMPHADENITIS. 327 the walls of the lymph vessels undergo a change, the endothelium may perish, and the entire wall may necrose, suppurate, etc. The lvmphan- gitis may terminate in either a restitutio ad integrum, with absorption of the exudate and regeneration of the destroyed endothelium, or in abscess formation and necrosis of the walls of the lymph vessels and surrounding parts. Chronic inflammation of the lymph vessels leads to hyperplasia of the connective tissue, with induration of the lymph vessels and the tissue surrounding them. Histological and Experimental Investigations upon the Movement of the Lymph during Inflammation.—The lymphatic system plays both a passive and an active part in inflammation. As long as the lymphatic vessels remain free from the inflammatory process, they carry off the products of the in- flammation, the emigrated leucocytes, and red blood-corpuscles, and the in- flammatory process may resolve without going on to the formation of an abscess. An abscess is particularly apt to develop when the walls of the blood- and lymph-vessels become affected to a marked degree by tbe inflam- matory agent, causing a retardation of the lymph current and insufficient removal of the inflammatory products. The slowing of the lymph current may eventually become a complete stasis, with emigration of the leucocytes from the lymph channels and a corresponding infiltration of the tissues, re- sulting in abscess or gangrene of tbe affected parts. The changes which occur in lymph-vessels during inflammation are the same as those that occur in the blood-vessels. Clinical Course of Acute Lymphangitis and Lymphadenitis.—Acute lymphangitis presents the following clinical picture: After the reception of a wound which is not treated aseptically, possibly a superficial abra- sion of the skin on the fingers, the patient complains of pain in his entire arm, particularly when it is moved. When the patient is care- fully examined there will usually be found a painful swelling of the epitrochlear and axillary glands, and from the still visible wound, or from the site where it existed, there will be seen red stripes leading up to the axilla. There will ordinarily be fever at the same time. The subsequent course of the disease varies. There either occurs, when proper treatment is adopted (rest, elevated position, ice), a complete restitutio ad integrum, or there is a continuation of the fever, with an increase of the local inflammatory symptoms leading to suppuration, generally in the form of circumscribed abscesses in the lymphatic glands of the axilla and its neighbourhood. If the inflammation in- volves the more deeply lying lymph channels, there will be none of the above-mentioned red stripes in the skin. Acute inflammation may then suddenly develop in the corresponding lymphatic glands, wdiich may either entirely resolve or go on to the formation of an abscess. Any lymphangitis is capable of giving rise to extensive inflammation 323 INFLAMMATION AND INJURIES. and suppuration, to cellulitis, erysipelas, suppurative periostitis, gener- ally accompanied by superficial necrosis of the neighbouring bone; also to general systemic infection, pyaemia, or septicaemia, terminating in death. All these possibilities depend upon the nature of the poison which is absorbed, or upon the virulence of the bacteria. Occasionally a severe phlegmon (§ 70), or a general systemic poisoning—particu- larly pyaemia—makes its appearance at a rather late period, long after the lymphangitis has entirely disappeared. In such cases the bacteria, which were first admitted through an interruption of the continuity of the skin, lie dormant in a lymph gland, and after the lapse of a cer- tain length of time, either spontaneously or as the result of some cause which gives rise to inflammation (a blow, violent muscular movements, etc.), they may suddenly excite dangerous suppuration, and even cause death from pyaemia or general septic poisoning of the whole system. The study of the clinical course of lymphangitis, caused by bacterial infection, teaches us very plainly the necessity of treating with anti- septic principles even the most insignificant wound on the surface of the body. The Treatment of Acute Lymphangitis and Lymphadenitis.—The treat- ment of acute lymphangitis and lymphadenitis in fresh cases consists in placing the affected portion of the body in a proper (elevated) position and giving it complete rest. For lymphangitis of the hand the arm should be fixed in the vertical position, upon Yolkmann's suspension splint, for instance, which is very serviceable for this purpose (Fig. 177, page 207); the circulation is thus regulated, the afferent arterial current is checked, while the efferent current in the veins and lymphatics is made to flow off more readily, and the inflammatory swelling goes down, usually very rapidly. Ice should be applied in combination with the elevated position, or, if cold is not well borne, moist applications covered over with rubber tissue are excellent. In addition, grey mer- curial ointment, very gently rubbed in, serves a useful purpose. The course of the disease must be carefully watched for the appearance of any localised redness and swelling indicating suppuration. Whenever suppuration can be demonstrated by fluctuation, the pus should be let out by incision at the earliest possible moment. Occasionally there will be noticed a great tendency to recurrence, especially after infection by cadaver poisoning (§ 76), and this recurring lymphangitis requires the most careful treatment. In such cases the warm baths recommended by Billroth and others are exceedingly useful. But search should always be carefully made for the possible presence of some focus of infection —some small wound, ulcer, pustule, etc.—and this, when found, should be treated upon antiseptic principles. §69.] ARTERITIS AND PHLEBITIS. 329 § 69. Arteritis and Phlebitis. Inflammation of the Walls of the Blood-vessels (Arteritis, Periarteritis, Phlebitis, Periphlebitis).—AVe referred to inflammation of the walls of the vessels in the chapters on inflammation (§ 56) and the repair of wounds (§ 61). AVe saw that in every inflammation there occurred an alteration in the walls of the ves- sels, and that in every injury to a vessel and in the organisation of the thrombus an inflammation took place for the purpose of forming a cicatrix in the vessel. Every reparative process which takes place in a wound, even though aseptic in its nature, is an inflammatory change; but the aseptic repair of the injured vessels in a wound and the organ- isation of the thrombi into vascular connective tissue take place with- out any disturbance. AYhen an injury, however, becomes infected by bacteria, the inflammation wliich then develops in the walls of the vessels becomes a matter of great importance. AVe shall concern ourselves here principally with the inflammation of the walls of the vessels which results in suppuration—acute suppura- tive arteritis and phlebitis. Both of these inflammatory processes are very apt to be observed in conjunction with a suppurating wound or ulcer, and are caused by micro-organisms, particularly those micrococci which excite suppuration (staphylococcus, streptococcus, etc.). The suppurative necrotic arteritis may be secondary to already ex- isting disease of the surrounding tissues. In such cases the inflamma- tion first attacks the adventitia, and then extends to the inner coats of the artery. If the artery contains a thrombus, as is the case after liga- tion, the thrombus may, from the influence of the bacteria wliich have entered it, undergo a suppurative breaking down (thrombo-arteritis purulenta), and as a result of the sloughing of the arterial wall a hemorrhage may result which can endanger the life of the patient. In other cases the suppurative thrombo-arteritis is developed by em- boli, which carry the infectious material from some focus of infection into the blood-vessels, and, finding lodgment at some point, produce there suppurative changes (metastatic abscesses). In suppurative inflammation of the veins (phlebitis) practically the same phenomena are observed. It is caused either by the direct en- trance of bacteria into the blood-vessels or by the extension to the latter of an infectious inflammation in the surrounding parts; for instance, an acute suppurative inflammation of the cellular tissue may extend and involve the walls of a vein. The inflammation in the wall of a vein, particularly the alteration which it produces in the intima, the endothelium, gives rise to the formation of a thrombus and thrombo- phlebitis ; or else this order is reversed, and the thrombus forms before there is an inflammation of the walls of the vein. In the veins thrombi 330 INFLAMMATION AND INJURIES. Fig. 260.—Throm- bus in the valve of a vein (sche- matic). Fig. 261.—Purulent thrombus of a vein (schemat- ic). are particularly liable to develop in the region of the valves (Fig. 260), as the blood current flows more slowly at these points than at others, and the micro-organisms can thus more easily find lodgment (Fig. 260). If in a suppurative throm- bophlebitis the suppurating masses containing micrococci are swept off in the blood current to other parts of the body, wherever they are deposited they form the above- mentioned metastatic abscesses re- sulting in pyaemia (§ 75). Buday maintains that the lodgment of emboli made up of large particles of tissue or masses of cocci is by no means necessary for the pro- duction of metastatic suppuration; the micro-organisms circulating in the blood may become lodged in the endothelium of the vessels, and, growing very rapidly, break through their walls and give rise to phlebitis, thrombosis, and secondary phleg- monous processes. From what has just been said, it follows that every infection of the blood by micro-organisms, every suppurative inflamma- tion, as soon as it extends to the walls of a vessel and reaches its lumen, is an exceedingly grave event on account of the spreading of the pus, or rather the bacteria, through the circulation. Other inflammatory conditions, affecting the walls of the vessels, which concern the surgeon, are the acute inflammations which are particularly liable to occur in the intima of the aorta and the other arteries in pyaemic and septic infections of the general system, and which are due to the bacteria or the products of their metabolism circulating in the blood. Anatomically, these inflammations are char- acterised by the formation of groups of small cells in the intima and the other coats of the arteries, and by a fibrinous exudation into the intima, the latter being sometimes covered by a tough layer of fibrin. It is important for the surgeon to bear in mind that the acute in- flammations occurring in the walls of the vessels in conjunction with injuries to the soft parts are, after all, only partial manifestations of other local and general bacterial infections, such as a circumscribed or spreading cellulitis, erysipelas, pyaemia, or septicaemia. AVe shall therefore abstain from going into the diagnosis and treatment of in- flammation of the walls of the vessels separately at present, as this §70.] CELLULITIS. 331 subject will be brought up again in connection with the diagnosis and treatment of the inflammations or infections of the surrounding parts. The phlebitis and the periphlebitis which sometimes occur in a more or less isolated form like a lymphangitis, and often originate from some insignificant injury, are diagnosed and treated briefly as follows: The subcutaneous veins feel like cords on account of the inflammatory thickening of their walls and the thrombosis which takes place in their interior. The process is essentially a periphlebitis with inflammatory infiltration of the sheaths of the vessels, and the veins are not always thrombosed. If, however, thrombi do exist in the veins, there is usu- ally a corresponding cedematous swelling from the disturbance in the circulation. The treatment, particularly when the disease occurs in the lower extremity—and it sometimes occurs spontaneously in individ- uals with varicose dilatation of the veins—consists in placing the ex- tremity in a properly elevated position, enveloping it in a moist dress- ing covered with rubber tissue, and, in addition, rubbing in mercurial ointment. This rubbing in or, more correctly, inunction of mercurial ointment for phlebitis must be done with the greatest caution and by gentle strokes of the hand, so as not to loosen any thrombi and have them carried off into the general circulation, as sudden death may result from cerebral embolism, or from the lodgment of an embolus in the pulmonary artery. By this treatment the local disease and the fever, when the latter exists, are caused to disappear; the cord-like veins becoming softer after the lapse of about six to eight days, and finally assuming, by degrees, a perfectly normal character. In such cases the phlebitis or the periphlebitis, whether there has been a thrombus formation or not, resolves to a complete restitutio ad inte- grum. If an abscess develops, the pus should be let out as soon as possible by an incision. A permanent occlusion of the vessel some- times follows the organisation of a thrombus in a vein; this is particu- larly apt to happen in varicose veins of the leg. The so-called phlebo- liths (vein stones) result from calcification of venous thrombi. The manner in which thrombi develop, and the changes which occur in them, have been described on pages 290-294. § 70. Cellulitis.—By cellulitis is meant an inflammation of the soft parts, which has a tendency to go on to suppuration, and is particu- larly liable to be located in the subcutaneous cellular tissue, or more deeply in the intermuscular cellular tissue, or beneath fascia, in the sheaths of tendons, in the periosteum, etc. AVe distinguish clinically two principal classes—the circumscribed and the diffuse. The former remains more or less limited to the neighbourhood of the original start- 332 INFLAMMATION AND INJURIES. ing-point of the inflammation, while the latter has a marked tendency to spread and become a progressive process, the worst form of which is the very acute septic phlegmon; the inflammation sometimes mani- fests a tendency to spread with incredible rapidity. It is not always plainly visible open wounds, or large recent inju- ries, which give rise to the cellulitis. Often enough it is an insignifi- cant, perhaps already healed, abrasion of the epidermis near the nail such as a scratch or a needle prick, which forms the starting-point for a spreading inflammation. Not infrequently, the cellulitis develops at some spot widely removed from the point of inoculation, from which the bacteria have been carried off in the lymph channels, finally lodg- ing in some suitable locality, a lymph gland, for instance, where they grow and develop. The cellulitis which used to be called spontaneous in its origin does not exist. There is always an infection by bacteria,, a.......... Fig. 263.—Intermuscular phlegmon of Fig. 262.—Streptococcus of progressive tissue necro- the forearm: streptococcus pyogenes sis in mice (Koch); a, cells of the cartilage in the between the muscle bundles; stained ear; b, streptococci, x 700. with gentian violet (after Gram). x 250. or by the products of their metabolism (staphylococcus pyogenes au- reus, streptococcus pyogenes, the bacillus of malignant oedema, less often other pus cocci). The Micro-organisms found in the Different Forms of Cellulitis; Pus Cocci. -Cellulitis is most frequently excited by the staphylococcus pyogenes aureus and the streptococcus pyogenes, though there are sometimes found other pus cocci, such as the staphylococcus pyogenes albus, the micrococcus pyogenes tenuis, the bacillus pyogenes foetidus, tbe bacillus pyocyaneus, etc. Occa- gTO.] CELLULITIS. 333 sionally there will be found only a relatively small number of cocci in the inflammatory collections, the tissues being caused to necrose extensively by the chemical products of the bacterial metabolism (Fig. 262). Again, in other cases, the cocci will be present in vast numbers (Fig. 263). The cellulitis excited by the streptococcus is characterised generally by a marked tendency to spread with great rapidity. Bacillus of Malignant (Edema.—The worst forms of cellulitis, the so-called acute malignant oedema, progressive gangrenous emphysema (Pirogoffs acute purulent oedema, Maisonneuve's gangrene foudroyante), are excited by a specific bacillus first identified by Robert Koch. These little rods are prob- ably identical with the vibrions sejjtiques found by Pasteur in septicaemia. In man, malignant oedema occurs, for instance, in conjunction with a com- pound (open) fracture which does not receive aseptic treatment, or from any wound not aseptically treated. It is characterised by an extensive em- physema (evolution of gas) and by decomposition of the soft parts, and it almost always terminates in death after the lapse of a few days. The bacillus of malignant oedema is very apt to be found in the superficial strata of garden earth, in the dust collecting in the cracks of a floor, in all sorts of decomposing matter, in dirty water, etc. It is more slender than the Fig. 264.—A, bacillus of malignant oedema. B, spore-formation. anthrax bacillus, being 3"0 to 3"5 n long and about 1*0 p broad; it has pointed or rounded ends, and often forms long filaments which may have different crooks or bends (Fig. 264, A). These bacilli are capable of very active movement, and possess cilia on the sides, which can be demonstrated by means of Loffler's method of staining. Spores make their appearance in the cultures by the end of the first day, forming best at a temperature of 37° C. (98-6° F.), (body temperature), in which they grow very rapidly, more slowly at ordinary room temperatures. When developing spores, the bacilli enlarge at one end or in the middle (Fig. 264. B). The oedema bacilli are strictly anaerobic, and can only be cultivated in an atmosphere free from oxygen. On gelatine plates the colonies form small shining knobs contain- ing fluid, and the gelatine is liquefied. On agar plates they form rough, matted clusters with an ill-defined border. Puncture cultures in agar-agar, to which should be added one to two per cent, of grape sugar, develop in diffuse cloudy groups (Fig. 265). Cultures in blood serum show a homogeneous 334 INFLAMMATION AND INJURIES. cloudiness in the line of the puncture. In the interior of a boiled potato the bacilli can be made to grow at a temperature of 38° C. (1004° F.), and after several days the potato will be found riddled with a network of bacilli. The bacilli can be stained by all the aniline dyes, and will then frequently present a granular appearance. Gram's double stain cannot be used. If 01 to 0'3 cubic centimetres of a bouillon culture is injected into the subcutaneous tissue of mice and guinea-pigs, the animal thus inoculated will die in eight to fifteen hours. Upon post-mortem examination there will be found starting from the point of inoculation an extensive subcutaneous oede- ma, the fluid of which it consists being of a reddish colour and full of bacilli, with bubbles of gas scattered here and there. The bacilli will be found located principally in the serous cavities and in the fluids contained in the different or- gans. Guinea-pigs inoculated with tbe peritoneal fluid taken from such an animal will die very quickly. The bacilli can only be demonstrated in tbe blood several days after death. If bouillon cultures are kept for ten minutes at a temperature of 115° C. (239° F.), or if they are filtered first through porce- lain, and then about 100 cubic centimetres of the fluid ren- dered germ-free in either way are injected at three successive periods into the peritoneal cavity of a guinea-pig, the animal will be rendered immune from subsequent inoculations with the bacilli themselves. In other words, by injecting the prod ucts of the metabolism of the bacilli, the animals can be made unsusceptible to the bacilli. Septic Emphysema due to the Bacillus Coli Communis — In a case of fatal septic emphysema in Gussenbauer's clinic, Chiari found that the bacillus coli communis was the cause of the disease. Chiari attempted to excite a disease analogous to the " septic emphysema" in man with its gas formation, by injecting these bacilli into animals, but all bis attempts failed. He could not bring about gas formation, though he made in- travenous, intraperitoneal, and subcutaneous injections. The animals died from septicaemia, and the bacilli taken from their dead bodies and isolated in pure cultures evolved gas in con- siderable quantities. Symptoms of a Circumscribed Cellulitis.—The symp- toms of a more or less circumscribed cellulitis vary with the latter's situation; the more superficial the inflammation is, the plainer are the manifestations of the beginning cellulitis. In a superfi- cial cellulitis, involving the skin and subcutaneous cellular tissue, the affected skin area is red and swollen, it feels hot, and is painful upon pressure. The skin is tense with oedema and cannot be lifted from the underlying parts. The infiltration feels hard at first, but subsequently, with the onset of suppuration, it becomes soft and doughy. Kesolu- tion of the inflammation without suppuration is a very rare occurrence. AVhen the transition to pus has taken place, when an abscess is present, Fig. 265.-Pure culture of the bacilli of ma- lignant oede- ma. Agar-in- digo - sodium sulphate. §70.] CELLULITIS. 335 the affected area fluctuates—i. e., by alternating pressure made with both index fingers, the pus is caused to " fluctuate " or take on a wave motion, as any fluid will do when set in motion in a cavity with yield- ing walls. The pus either forces its way to the surface through the skin, which undergoes a gradual thinning process, or it is evacuated by an incision. The longer the suppuration is allowed to continue before being permitted to escape externally the more apt is the pus to burrow or extend to the parts in the neighbourhood of the abscess. In this way a spreading cellulitis dangerous to life may originate from a cir- cumscribed cellulitis or suppuration. If a circumscribed cellulitis is deeply situated at the outset, there is but little change in the skin, and neither swelling nor redness will be present, and only when the deep process draws near to the surface of the body will any of the above-described manifestations of its presence be revealed, the first being pain on pressure and oedema of the skin. In the neighbourhood of the circumscribed cellulitis there will be necrosis of the skin, and particularly of the fascia, tendons, tendon sheaths, muscles, and bones, in proportion to the amount of inflammatory infiltration and the ensuing suppurative breaking down. This death of tissue will be the more easily prevented or limited the earlier incisions are made, and the cavity washed out with antiseptic solutions of bi- chloride of mercury (1 to 1,000-2,000) or of carbolic acid (three per cent.). Every cellulitis which is not recognised early in its course may not only lead to extensive suppuration, with a proportionate destruction of tissue, but may even cause the death of the patient from a fatal gen- eral systemic infection—pysemia, for instance—if the inflammatory ele- ments are carried off and spread throughout the body by the blood- vessels. Under such conditions inflammation of the lymph channels (lymphangitis) and inflammation of the arteries and veins (arteritis, phlebitis) may be excited, with the formation of suppurating thrombi in the veins, also swellings and abscesses of the lymph glands, and meta- static abscesses in the internal organs, etc. Accompanying every cir- cumscribed cellulitis there will be fever, the intensity of which will vary according to the virulence of the poison. Whitlow or Paronychia.—Paronychia or whitlow is, for the most part, at the outset a circumscribed inflammation of the subcutaneous cellular tissue of a finger, particularly on its palmar aspect, though it may begin in the palm of the hand. Paronychia may appear to begin spontaneously, but usually results from some injury, which may be only a very small abrasion of the epidermis. It is most apt to occur in individuals who are con- stantly receiving superficial injuries of the skin on their fingers, or in those who, like physicians and anatomists, frequently handle decomposing sub- stances and thus infect themselves. The inflammation is more likely to 336 INFLAMMATION AND INJURIES. spread into the deeper parts than to come to the surface; but there are also superficial forms of paronychia which spread very rapidly. The pain is usually very severe, as great pressure is exerted upon tbe nerves in the tense tissues. Death of tissue is a common occurrence as a result of the closure of the capillaries and small veins and arteries by pressure. If the paronychia extends to the tendon sheath, it usually spreads rapidly on account of the looseness of the tissue. From a neglected paronychia or whitlow, resulting in a spreading cellulitis, many a patient has suffered a serious loss of func- tion of the hand, or the hand itself, or the forearm, or the whole arm, while the lives of some patients have not been saved even by an amputation. Symptoms of the Diffuse Spreading Cellulitis.—The diffuse spreading cellulitis, formerly called diphtheritis of the cellular tissue, is usually very acute and much worse than the circumscribed variety. Like the latter, it is sometimes caused by very trifling injuries, such as a needle prick, or by a wound of the soft parts of a bone, or of a joint, which is not brought soon enough under the protection of an antiseptic treat- ment. The local manifestations are at the outset the same as those of a circumscribed cellulitis. In many instances the disease begins with a severe chill and a proportionately high fever. The changes in the overlying skin may at first be very slight, and in fact it is not even reddened in the very dangerous deep forms of cellulitis which spread very rapidly. Just these cases are the ones so often unrecognised by the beginner. The process spreads quickly in the deep subfascial cellu- lar tissue, and may terminate in a relatively short time in a fatal sys- temic infection. But in a spreading diffuse cellulitis, the skin is gen- erally involved, and has a dark or bluish-red colour, and not infrequently the epidermis is elevated by blebs; there is also an inflammatory in- filtration of the skin which may make it as hard as a board. If the cellulitis is deeply situated, the skin feels more doughy and oedematous. The pain is very marked and usually there is a high fever. Not rarely the course of the disease is so acute that even after the expiration of four to five days disarticulation of the extremity may be necessary, or it may even then be too late to prevent the death of the patient from the general systemic poisoning. This form of septic, spreading cellulitis with high fever, extensive gangrenous destruction of tissue, and death by general systemic poisoning, has a very unfavourable prognosis, and has received the names of malignant oedema, progressive gangrenous em- physema, acute purulent oedema (Pirogoff), and gangrene fondroyante (Maisonneuve). These dangerous forms of septic cellulitis are excited by the bacillus pictured in Fig. 20-1. If the diffuse inflammatory infiltrate in the subcutaneous cellular tissue, in the subfascial and intermuscular tissue, the sheaths of the tendons, and in the periosteum, is changed into pus and softens, the §70.] CELLULITIS. 337 pain decreases, and there follows an extensive necrosis of the infiltrated tissues, including the skin, subcutaneous cellular tissue, fascia, muscles, tendons, and bone. Large sacs are formed filled with pus, the skin is lifted from the underlying parts, and joints are opened. As a result of the decomposition of the pus, emphysema, or the formation of gas. takes place, and this may be so marked that a peculiar crackling can be obtained on palpation, and a more or less tympanitic resonance will be elicited on percussion. If the diffuse cellulitis does not carry off the patient by general sepsis, the subsequent course of the disease is often very tedious, consisting in the gradual sloughing away of the gangre- nous parts, and the proportionate formation of cicatricial contractures in the skin, tendons, muscles, joints, etc. The patient may also die in this stage from pyaemia, marasmus, parenchymatous degeneration of the internal organs, or from extension of the inflammation to vital parts—for example, from the skull to the meninges. Death may also result from haemorrhage following suppurative perforation of the arte- ries or large veins, etc. Prognosis of Cellulitis.—The prognosis of cellulitis varies greatly, depending upon the situation of the disease, the extent of the inflam- mation, and the kind of bacteria which excites the process. A cellu- litis of the scalp, for instance, is a serious matter, from the danger of the inflammation spreading to the cranial cavity. In general, the super- ficial forms of cellulitis are not dangerous, while the deeper, subfascial, spreading forms, by causing general systemic infection, involve the greater risk to life the longer they remain unrecognised. The worst forms are those with progressive emphysema, caused by infection with the bacillus of malignant oedema; they often terminate fatally within a few days, before the local manifestations of the process become plainly marked. The prognosis of the others may be inferred from what has been said of them. Treatment of a Cellulitis.—The treatment of every cellulitis is prac- tically the same, whether the inflammation is circumscribed or spread- ing. Much time used to be lost by the employment of cataplasms to obtain resolution of the inflammation. The knife should be used as soon as possible, and free incisions made to diminish the inflammatory tension of the tissues and to allow the pus to escape, after which the entire focus of the inflammation should be disinfected by one-tenth-per- cent, solutions of bichloride of mercury, or by three- to five-per-cent. solutions of carbolic acid. AVe do not wait till suppuration and break- ing down of the tissues have taken place, but we immediately make an incision into the region where there is the most pain or the most pro- nounced swelling and inflammatory infiltration, even though there may 338 INFLAMMATION AND INJUIRES. be as yet no pus present. If early incisions are thus made it may be possible to prevent death of tissue from taking place, particularly in the tendon sheaths, bones, etc., or at least to limit the amount of it, and cases treated in this manner will heal comparatively the most rapidly. The incisions should not be too small; it is better to make them too free rather than not large enough. The collection of pus should be laid bare throughout its whole extent by long incisions, and any pockets that may be present opened up. If the cellulitis is deep, the incision should be carried through the skin and fascia with the knife, and then the incision should be deepened with a blunt instrument—a closed dressing-forceps, for instance—till finally the bone is reached. In an extensive cellulitis the parts which appear sound must be examined very carefully, to determine whether pus may not have burrowed into or beneath them. After making the incisions the region in which there have been large collections of pus should be washed out vigorously with a 1 to 1,000 solution of bichloride of mercury, or three to five per cent, of carbolic acid. The incisions should be so placed as to facilitate the escape of the pus, which is then provided for by proper drainage (§ 31), or by packing with iodoform gauze, sterilised mull, etc. The best dressing for a circumscribed cellulitis is one which is antiseptic and absorbent—for example, iodoform gauze, sterilised mull and cotton, or pads of moss, jute, etc. Of course, the dressings should not exert any more than moderate pressure, to prevent pus from being forced into the connective-tissue spaces. In cellulitis of the fingers, I prefer to have the first dressings moist rather than dry, and to make use of frequent antiseptic baths, and then, later, to use as dressings ointments of iodoform and boric acid. Poultices, which used to be so much in vogue, should be condemned. Their use has caused much harm. To be able to determine whether there is any burrowing or retention of pus, the dressings must at first be frequently changed, possibly every day, or every second or third day; and not until the wound begins to granulate and suppuration ceases can the dressings be left undisturbed for a longer period. If the suppuration has been extensive, secondary sutures may be of service in hastening the repair after the packing has been removed. In diffuse cellulitis, with extensive destruction of tissue, long in- cisions, followed by packing the wounds, are particularly valuable, and this may be subsequently supplemented with advantage by antiseptic washings or permanent irrigation (pages 179, 180). After the gangre- nous tissues are cast off and the granulating stage has begun, a return may be made to antiseptic protective dressings of iodoform, oxide of zinc, etc. To shorten the time required by a large granulating wound §71.1 ERYSIPELAS. 339 to become covered with skin, Thiersch's skin grafts are very useful (see £ 42). In the treatment of every cellulitis, it is exceedingly im- portant to secure for the inflamed part a proper position upon splints (§ 53), or in a mitella (Fig. 155), etc. Elevation of an inflamed lower extremity, or vertical suspension of an inflamed hand, has an excellent eft'ect, and sometimes works wonders. In the worst cases of septic cellulitis, amputation or disarticulation of the affected extremity will sometimes be found necessary in order to save the life of the patient. Unfortunately, the operation is sometimes performed too late, when general sepsis is already present. The after-treatment of the sequelae of cellulitis, the cicatricial con- tractures, necrosis of bone, etc., is conducted on the lines laid down for these conditions in another chapter (Contractures, Necrosis of Bones). Phlegmasia Alba Rolens is an inflammation of the leg, rarely of both legs, running a slow course, with oedema and pain, principally due to venous thrombosis and occurring mostly in lying-in women and in cachectic pa- tients (tuberculosis, carcinoma, etc.). The phlegmasia alba dolens of puer- peral women is usually caused by the extension of an infectious inflamma- tion of the pelvic connective tissue (parametritis), which ordinarily takes place in the second week after confinement. It terminates either in absorp- tion of tbe inflammatory infiltrate, or in suppuration or gangrene, and rarely in death, which is then apt to be due to embolism or sepsis. The phlegmasia alba dolens of cachexia is mainly the result of venous stasis, caused by defective cardiac and pulmonary activity. It rarely goes on to suppuration. § 71. Erysipelas.—By erysipelas (from ipvOpos, red, and 7re'XXa, skin) is meant a spreading inflammation of the external cutaneous covering of the body, or rather of its smaller lymph channels, and of those of the subcutaneous cellular layer, caused by bacteria (strep- tococcus). It is a specific dermatitis, characterised (1) by a more or less rapid, for the most part, continuous extension along the surface, less often into the deeper parts; (2) by a toxic diseased state of the general system (intoxication fever) going hand in hand with the local inflammatory disease ; and (3) generally by a complete restitutio ad integrum of the local inflammation, at least in the typical and uncom- plicated cases. Gangrenous destructive processes, abscess formation, etc., take place in exceptional cases, and are then complications of the local disease. Etiology of Erysipelas—Streptococcus of Erysipelas.—The micro-or- ganism of erysipelas is generally a streptococcus (Figs. 256, 257, and 266) which was first obtained in pure cultures by Fehleisen. If man or animals are inoculated with this streptococcus true erysipelas will result. I have produced in animals (rabbits) true erysipelas by inocu- 310 INFLAMMATION AND INJURIES. Fig lating them with the contents of erysipelas blebs. The streptococcus erysipelatis is found almost everywhere, particularly in the air of sur- gical wards (Eiselsberg). Tissues affected by this disease, when examined by the microscope, reveal the erysipelas coccus, especially in the lymph spaces of the skin and subcutaneous cellular tissue, but it is usually not to be found in the blood-vessels. Not infrequently there will be large groups of the streptococ- cus present. Recent investigations have demonstrated that Fehleisen's erysipelas coccus is identical with the streptococcus pyogenes described on page 323, and neither coccus can be distinguished from the other in any way. The description of the erysipe- las coccus is given on page 323 (strep- tococcus pyogenes). In erysipelas, as mentioned before, the streptococcus grows mainly in the smaller lymphat- ics of the skin and subcutaneous cell- ular tissue, while in circumscribed suppurative processes the coccus is found more in the tissues them- selves. Suppuration and abscess occur in erysipelas, in all probability, when the streptococci develop in large numbers in the tissues out- side of the lymph channels, or when there is a mixed infection—in other words, when the staphylococcus pyogenes aureus or other pus cocci are present in addition to the streptococcus pyogenes. The ery- sipelas which is complicated by gangrenous destructive processes is also probably caused by a mixed infection. Jordan and others maintain that erysipelas can also be caused by the staphylococcus, thus making erysipelas, from a bacteriological standpoint, a non-specific disease as regards its etiology. Kaltenbach and others have made the interesting observation that erysipelas or the erysipelas coccus can be transmitted from the mother to the foetus in ulero. Bostroem has also demon- strated the fact that erysipelas cocci may enter the blood. He saw an acute catarrhal pneumonia develop in conjunction with a facial ery- sipelas, and after death the lymphatic vessels in the lungs were found filled with streptococci. The systemic intoxication, the fever in ery- sipelas, is, in the main, the result of the entrance into the circulation of the metabolic products of the streptococci. The streptococci them- selves cannot, as a rule, be demonstrated in the blood. 266.—Streptococci of erysipelas, x 700. Section through a lymph vessel of the skin ^Flug^cj. s?l.] ERYSIPELAS. 311 Erysipelas of Mucous Membranes.—Erysipelatous inflammations occur not only in the external cutaneous coverings of the body but also in mucous membranes, especially the adjoining mucous membranes of the nose, mouth, and their adnexa, the trachea, the female genital tract, and the rectum. A cutaneous erysipelas may have involved these mucous membranes in its course, or, on the other hand, an erysipelatous in- flammation may originate in the mucous membranes and extend from them to the skin in the form of a true erysipelas. Erysipelas is a true infectious disease of wounds—i. e., it originates from some inter- ruption of continuity which may be of the most insignificant character. Erysipelas does not originate spontaneously in the sense that used to be understood by the term. But there are forms of erysipelas—for in- stance, in systemic pyaemic poisoning—which have a metastatic origin. From any cellulitis a capillary lymphangitis, in other words, an erysipe- las, may begin if the streptococci find lodgment and undergo subse- quent development in the lymphatics of the skin and subcutaneous cellular tissue. Location of Erysipelas.—As regards the localities affected by ery- sipelas, it occurs most frequently upon the face, often starting from some superficial abrasion of the skin, an ulcer in the nose, etc. Some- times erysipelas cases occur in such numbers in some particular locality or in some hospital that the disease becomes epidemic, or, rather, en- demic. Like every infectious-wound disease, erysipelas has become less common since the general use of antiseptic methods, and by strict asepsis it is possible to absolutely prevent an outbreak of erysipelas in a recent non-infected wound. Symptomatology of Erysipelas.—The clinical picture of true, uncom- plicated, cutaneous erysipelas is in the majority of instances character- ised by the sudden occurrence of a rapidly rising, generally severe febrile movement which goes hand in hand with the erysipelatous in- flammation of the skin. Subsequently there is just as rapid a defer- vescence, the temperature falling to the normal or below it when the local erysipelatous inflammation approaches its termination. At the beginning of a true cutaneous erysipelas there will be noted the gradual appearance of a diffuse, somewhat elevated reddening of the skin in immediate proximity to some small or large, recent or old, granulating or ulcerated wound of the skin. Frequently no wound of the skin can be made out at all ; a slight cutaneous abrasion may have already healed. In other cases the point at which the streptococci of erysipelas have entered may be found in some adjoining mucous mem- brane or in some widely removed region. The redness is at the outset apt to be in spots, which often appear as though the lymphatic network 342 INFLAMMATION AND INJURIES. had been injected with some red material. It was mentioned before that the streptococci of erysipelas spread mainly in the lymph channels of the skin and subcutaneous cellular tissue. The original spots very soon coalesce, forming an even, diffuse redness. Sometimes the redden- in o- of the skin may start, as has been said, at a greater or less distance from a wound or interruption of continuity in the epidermis, and under such conditions the red stripes of a lymphangitis will connect the wound, on the fingers or toes, for instance, with the commencing red spot on the arm or on the leg or thigh (see Lymphangitis, § OS). The erysipelatous redness and swelling extend steadily now in this and now in that direction; they migrate, and may involve large areas of skin, or even the entire body, depending upon the intensity of the disease. The areas of skin first affected begin to turn pale again after the lapse of about two to four days, and sometimes earlier. In the regions where the skin is firmly attached to the underlying parts, to the bones or fascia, the erysipelas is apt to come to a standstill. Erysipelas gen- erally extends progressively, though in cases of rapid, wandering ery- sipelas the disease may sometimes skip over an area of skin—for in- stance, in erysipelas of the foot—a large erysipelatous patch may sud- denly appear in the region of the knee or thigh, and then soon after- wards coalesce with the patch on the foot. Under these conditions the two foc^ 0f erysipelas are usually connected by red stripes (lymphangit- is). Occasionally, especially when occurring as a complication of pyaemia, there will be observed the so-called erratic, or, better, multiple erysipelas, wliich makes its appearance by metastasis upon different parts of the body. The erysipelatous reddening of the skin ordinarily exhibits different tinges, varying from a bright to a dark red colour. In weak individu- als, or when complicating pulmonary or cardiac affections (disturbances of circulation), or just before death or as the first stage of local death of tissue, the erysipelas has more of a bluish colour. If there are gastric complications, or if occurring in drunkards, the cutaneous redness occasionally assumes a yellowish shade. The swelling in an area affected by erysipelas is usually uniform, and the pain in the majority of cases is slight, but is increased on pressure with the finger. Wherever the skin is superimposed upon distensible loose tissue there will be a marked erysipelatous exudation, as in the scrotum, penis, the female genitals, the eyelids, or the lips. As a result of the saturation of the superficial layers of the cutis with serum during the course of an erysipelas there will often develop smaller or larger blebs, at the outset containing a clear serous fluid, and later, for the most part, pus. The blebs, as a usual thing, very soon dry up and form crusts. §71.1 ERYSIPELAS. 343 The extension of the erysipelas takes place now from this and now from that border; it strides forward like a fire ; it wanders, and hence the name erysipelas migrans or ambulans. For several days the ery- sipelas may spread in some particular direction, and then the process ceases and begins to spread from another border. It acts like a fire whieh cannot be controlled and which continues to burn wherever there is food for it, and the flame may suddenly again break out in a region where it seemed quenched. Pfleger thinks that the spread of erysipelas in a particular direction depends upon the course of the linear furrows of the skin. The rapidity with which the erysipelatous inflammation extends varies greatly, moving forward sometimes one to two centimetres within twenty-four hours, again four to eight or fifteen to twenty centimetres and more. Eventually, in the great majority of cases, the inflammatory redness and swelling terminate in a complete restitutio ad integrum • but suppuration may occasionally take place and multiple abscesses may form, or as a result of very pronounced swelling or from the extension of the disease to the deeper parts the erysipelas may become complicated by phlegmonous changes, with ex- tensive or limited death of tissue (erysipelas phlegmonosum, erysipelas gangrenosum). A process the reverse of this sometimes takes place— i. e., a deep-spreading cellulitis may come to the surface and run its Puis Tatje: 1 2 3 4 5 6 7 8 9 1 10 n 180 ___170 ___160 ___ISO ___140 ___130 ___120 ___110 ---100 ___- 90 ---- 80 ____70 r a f CL f a f CL f CL f a f\a f a f u f U f\a ___41,5 ___4l,o i___40,5 ___40,0 ___39,5 ___39,o ___38,s ___38,0 ___37,5 ___37,o _36,5 1 -K- , i h S- y\ 1 — / \ \ 1 { i \ \ 1 c \ \ * \> n^ R ec/o iv V ' 1 2 Fig. 267- 1, Temperature-curve of an erysipelas lasting two days with a sudden typical fall of temperature; 2, temperature-curve of an erysipelas "with temporary fall of the temperature followed by a relapse of the erysipelas ; recovery. course as an erysipelas of the skin. It has already been stated that in the complicated cases of erysipelas there is usually a mixed infection, due to the streptococcus and other bacteria. The general constitutional symptoms correspond to the intensity and extent of the local process. The rise of temperature begins, as a 23 344 INFLAMMATION AND INJURIES. rule, suddenly and rather violently, with one or more chills, and sub- sequently, when the erysipelas ceases, the temperature returns to the normal with equal rapidity. At the height of the disease the tem- perature generally rises to about 40° C. (104° F.) or more, and in ex- ceptional cases it may reach 42° C. (107"6° F.). The fever may have either a continuous, a remittent, or an intermittent type (see pages 258 260). Yery often there will be pronounced gastric symptoms ; the re- gions over the liver and stomach are tender on pressure, there is total loss of appetite, with nausea or vomiting, the thirst is ordinarily exces- sive, the tongue is heavily coated, dry, etc. The spleen is frequently much swollen ; sometimes there is pain in the region of the kidneys, the urine is generally dark coloured, and may contain albumen, blood, bile pigment, and micrococci, and its quantity is diminished. If the erysipelas has a fatal termination, death is either the result of the gen- eral systemic poisoning by the products of the metabolism of the bacteria, or it is caused by some local complication, such as the exten- sion of the erysipelas to some vital organ, to the cranial cavity, for example. Occasionally, if the erysipelas is protracted for a great length of time, the gradually increasing exhaustion of the patient may be the direct cause of death, which may take place suddenly after convales- cence has begun. There is no typical time of duration for an erysipelas, and recur- rences are very common. The erysipelas may appear to have come to an end and then it will suddenly start up again. Its duration varies between hours and weeks. There are well-marked cases of erysipelas lasting twenty-four hours, and even a less time, and others which con- tinue for a week, with now greater and now less intensity, and which may eventually involve the entire body, and possibly attack the same locality several times. The average duration of erysipelas amounts to about six to eight to ten days, but, as Billroth says, it is, as a general thing, unusual for the disease to continue more than fourteen days. Habitual Erysipelas.—Many individuals are subject to what is called habitual erysipelas, a form of the disease recurring more or less period- ically upon some particular portion of the body, most commonly the face, and resulting very often from a chronic nasal catarrh which is accompanied by ulceration. Complications of Erysipelas.—As complications of erysipelas, there may be marked disturbances of the central nervous system due to the high fever or general systemic poisoning, particularly in an erysipelas of the head, which gives rise to meningitis. When the latter con- dition arises, there will be at the outset very marked symptoms of irritation, headache, vomiting, delirium, stupour, and finally convul- §71.] ERYSIPELAS. 345 sions. Exceptionally, even when convalescence has begun, and after the erysipelas and the fever have almost completely vanished, there will be observed in excitable persons a state of collapse with delirium of a more or less maniacal nature, accompanied by illusions and halluci- nations of sight and hearing, the so-called collapse delirium. This tem- porary aberration of mind lasts usually only a few days. More rarely there are paralyses of the peripheral nerves as a result of central dis* turbance, or from peripheral neuritis caused by the erysipelatous in- flammation. Leyden and Renvers observed an ataxia of the lower extremities which lasted a considerable time and followed the exten- sion of an erysipelas of the head on to the back. The most important of the local complications which may arise are suppuration and gangrene, and the combination with an inflammation of a phlegmonous character. The number of multiple abscesses which may make their appearance in the stage of convalescence is compara- tively large—twenty to thirty or more. Landouzy saw as a result of an erysipelas involving the face, hairy portion of the scalp, the neck and back, sixty-nine abscesses, and some of them in areas which had not been affected by the erysipelas^ Occasionally the suppurative process is more diffuse in its nature, and extends inwards, leading to suppuration of the muscles, tendon sheaths, joints, etc. (erysipelas phlegmonosum). The erysipelatous joint suppurations appear either at the outset and run a very acute course, or they first make their ap- pearance during convalescence. Mention should also be made of phle- bitis, lymphadenitis, and abscesses of the lymph glands. The lymph glands are usually swollen at an early stage of the disease. Gangre- nous processes occurring in a true erysipelas are rare and generally of limited extent, and only extensive and severe when the erysipelas is complicated by changes of a phlegmonous character (E. gangrenosum). Amongst the other local complications which may arise, the diseases which may affect the eye should be included, such as impaired vision, rarely temporary blindness, panophthalmia with atrophy or suppura- tion of the eyeball, particularly when a facial erysipelas spreads to the cellular tissue of the orbit, iritis, ulcerative processes of the cornea, retinitis, and optic neuritis with atrophy of the optic nerves. There may also be catarrhal and suppurative processes affecting the ear, inflammation and suppuration of the parotid gland, dysphagia, and sometimes changes in the pharynx simulating diphtheria. Occasion- ally an inflammation of the lungs is produced (erysipelatous pneu- monia). Pleurisy and cardiac affections (pericarditis, endocarditis, and myocarditis) are not common. Amongst the gastro-intestinal compli- cations which may arise are ulcerations of the small intestine, and 316 INFLAMMATION AND INJURIES. transitory hypersemia of the intestinal mucous membrane accom- panied by bloody diarrhoea. A similar condition may occur in patients who have received burns, and I have seen it in con- junction with extensive carbolic erythema (see page 154). The liver and spleen only exceptionally give rise to complications. Jaundice due to gastritis may occasionally be present, but haematogenous jaun- dice can also occur in severe cases of erysipelas as a result of the poisoning of the blood by the products of the bacterial metabolism, and this is usually a precursor of speedy death. Nephritis is often pres- ent as a complication, but it is generally of a temporary nature; only in very exceptional cases is the acute erysipelatous nephritis so marked as to cause uraemia. The latter is particularly dangerous when occur- ring in individuals already affected by kidney disease before they were attacked by erysipelas. Erysipelas is sometimes complicated by pyae- mia and septicaemia (see §§ 74 and 75), and occasionally, as has been stated, erysipelas will occur in the course of a pyaemia. Behaviour of the Wound in Erysipelas.—The interruption of con- tinuity from which the erysipelas has sprung seldom manifests any complications. The healing of the wound per primam intentionem is not often disturbed ; but the healing may sometimes be only apparent, and the wound may only unite superficially, while in its deeper parts there will be a retention of the secretion or of pus. A granulating wound will often exhibit a dry or dirty appearance, and may be cov- ered by a peculiar croupous diphtheritic membrane. Erysipelas has occasionally been complicated by hospital gangrene (§ 72), especially before antisepsis was introduced. The Healing Effect of Erysipelas (Curative Erysipelas).—Great inter- est attaches to the influence exerted by an intercurrent erysipelas of the skin upon new growths, particularly those of a lupoid or syphilitic nature, with or without ulceration, and also upon tumours, such as sar- coma and carcinoma. It has been noticed that the above-mentioned formations may permanently disappear, and that ulcers of long standing and chronic skin diseases, which resisted every kind of treatment, have improved and were healed after an erysipelas had passed over them. The French have given the appropriate name of erysipele salutaire to an erysipelas which acts in this way, and numerous observations are recorded in literature upon the healing powers of erysipelas for all sorts of diseases. W. Busch, in particular, has recorded some very remark- able facts relating to the curative effect of erysipelas upon large tumours (sarcomata, lymphosarcomata), and he showed that the tumours under- went a rapid and extensive fatty metamorphosis, and could thus be absorbed and completely disappear. The curative power of erysipelas §71-1 ERYSIPELAS. 347 over tumours has been repeatedly made use of artificially for the pur- pose of destroying inoperable new growths. If inoculation of erysip- elas is to be practised on any patient, it must be borne in mind that the course of this disease cannot always be held under control, and that there is a possibility of a fatal termination, as many cases testify. And although it is certainly justifiable to produce erysipelas artificially for the purpose of curing an inoperable tumour, the patient should always be informed beforehand of the danger of the treatment. P. Bruns has recently made a critical investigation of the curative effects of erysipe- las upon tumours, and succeeded in collecting twenty-two cases from literature. There was a complete and permanent cure in three cases of sarcoma, in two cicatricial keloids, and in a few lymphomata. In Bruns's own case a perfect recovery was brought about from a recur- ring melano-sarcoma of the mamma. In one case, observed by Janicke and Wisser, in which erysipelas inoculation was practised for an in- operable carcinoma of the breast, it could be demonstrated with the microscope that the erysipelas cocci actually destroyed the cancerous cells. Consequently it is possible for erysipelas to cure a carcinoma. Ferret observed the complete absorption within six days of the callus surrounding an already united fracture of the thigh, so that the fragments again became as freely movable as at the time of fracture. There is one other curious fact ascertained by Emmerich, Pawlowsky and Di Mattei which should be mentioned in this connection. If rab- bits and guinea-pigs are inoculated with erysipelas, during the ensuing three to ten days they will be unsusceptible to (immune from) anthrax ; but after the lapse of this period the system is so weakened by its con- flict with the erysipelas cocci that when the animal is infected by anthrax for the second time it succumbs more easily and rapidly than it normally would; in other words, after the lapse of this period the animal is no longer immune from anthrax. Erysipelatous Inflammations of the Mucous Membranes.—Inflamma- tions analogous to cutaneous erysipelas occur, as has been stated, in the mucous membranes which adjoin the skin, and consequently in the oral cavity and its adnexa (nose, pharynx, larynx), in the female genital tract, and in the rectum. Erysipelatous wandering pneumonia is de- scribed in books on internal medicine. Diagnosis of Erysipelas.—The diagnosis of the ordinary cutaneous erysipelas is very simple in typical cases, and can hardly cause any trouble. The gradually spreading local redness and swelling of the skin and the accompanying fever are so characteristic that there can scarcely be any confusion, even with the exanthemata. Erythema bears the closest resemblance to erysipelas, but in erythema there is 348 INFLAMMATION AND INJURIES. usually no fever, and the swelling and pain are not nearly so pro- nounced as in erysipelas. Prognosis.—In general, the prognosis of erysipelas is not unfavour- able, but in no case of this disease, no matter how mild it may seem, can we be certain of a satisfactory termination. There are many cir- cumstances which affect the prognosis of an erysipelas, particularly its location, the constitution and age of the patient, the complications which may arise, the intensity and duration of the local disease, and of the fever, etc. The more extensive the inflammation the higher the fever, and the longer it lasts so much the worse is the prognosis. The mortality given by various authors differs very much, the average being about eleven per cent. Treatment of Erysipelas. —A great number of remedies have been employed for erysipelas, and the fact that the treatment varies so much shows that nothing is entirely satisfactory ;' and it is my opinion that, as yet, we have no very reliable and effective method of treatment. Since the disease has no typical duration, it is very natural that mistakes should be made in regard to the curative power of this or that remedy, The best way of preventing erysipelas consists in treating every in- terruption of continuity, whether recent or old, large or small, upon antiseptic or aseptic principles ; and whenever a dressing is changed it should be done with a careful observance of the rules of antisepsis. I believe—and my opinion is sustained by the experiments of Robert Koch—that bichloride of mercury is the most reliable antiseptic for use in dirty infected wounds, to prevent infectious-wound diseases. Fehl- eisen states that cultures of the erysipelas coccus are completely de- stroyed when subjected for ten to fifteen seconds to the action of a 1 to 1,000 solution of bichloride. Erysipelas never occurs after opera- tions which have been performed with the strictest attention to asepsis. We avoid the free use of poisonous antiseptics in performing aseptic operations; though they were formerly much in vogue. They are not necessary if the rules of asepsis are understood and followed—in other words, if everything which comes in contact with the wound is made absolutely germ free (sterilised). When the erysipelas has broken out, the treatment should be directed against the general febrile disturb- ance and the local disease. The treatment of the fever has been dis- cussed in § 02. The treatment of the local disease consists in placing the affected portion of the body in a suitable position, and in the application of ice, particularly if the erysipelas involves the head. By painting the ery- sipelatous area with oil and covering it with cotton the tension and pain will be lessened. , . g71.] ERYSIPELAS. 349 It is an excellent plan to use the parenchymatous injections of a two- to three-per-cent. solution of carbolic acid at the margins of the inflamed district, which Hue ter has recommended, particularly in the heo-inning of the erysipelas. The contents of three to five hypodermic syringes filled with this solution are injected into the sound skin imme- diately adjoining the erysipelatous area; and after the acute stage of the inflammation has passed, or while the disease is spreading, these injections are repeated once or twice. Subcutaneous injections of bi- chloride of mercury are also exceedingly good. Petersen has employed salicylic acid injections with successful results; others have done the same with cocaine, and Zuelzer has used ergotine (five to eight centi- grammes to equal parts of alcohol and glycerine). Estlander recom- mends subcutaneous injections of morphine, particularly when com- bined with a daily painting of the diseased area with tincture of iodine. Liicke and others have used inunctions of turpentine with success; it is rubbed into the diseased area of skin two to three to five times a day with a brush or piece of cotton. Strong tincture of iodine can be ap- plied with a brush seven to eight times a day; nitrate of silver (one to four, or eight, or ten) is highly praised ; also the application of com- presses wet in a three- to five-per-cent. solution of carbolic acid, or in a five- to ten-per-cent. solution of trichlorphenol; fifty to eighty per cent. resorcin ointment may be spread over the affected part, etc. Heppel recommends painting the borders of the erysipelatous area with a ten- per-cent. alcoholic solution of carbolic acid, covering a portion of skin about two inches wide all around the diseased spot. The following methods have also been recommended for treating the disease locally : Covering the erysipelatous area of skin with ammonium sulpho-ichthy- olicum mixed with equal parts of lard, or with ichthyol and vaseline (equal parts), and placing over this absorbent cotton ; covering the ery- sipelatous area close up to the surrounding healthy skin with an oint- ment of one part creolin, four of iodoform, and ten of lanoline (Koch and Mracek), or with white lead, or with a varnish of linseed oil, over which some water-tight material is applied, etc. Kuhnast, from his experiments in Kraske's clinic, recommends multiple scarifications and incisions, followed by irrigation with a five-per-cent. solution of carbolic acid ; also the application to the erysipelatous area of compresses wet with a two-and-a-half-per-cent. solution of carbolic acid, the compresses to be changed once or twice a day. Riedel and Classen recommend scarification, particularly at the advancing margins of the erysipelas. Scarifications are exceedingly effective,'especially when made chiefly or exclusively in the healthy adjoining skin. Madelung, W. Meyer and others have obtained satisfactory results from scarification and 350 INFLAMMATION AND INJURIES. application of compresses wet in a three- to five-per-cent. solution of carbolic acid or in a 1 to 1,000-3,000 solution of bichloride of mercury. This latter method of treatment is coming more and more into favour at present. Larrey preferred to make linear or punctate cauterisa- tions with the red-hot iron, aiming at retaining the erysipelas within the barriers made by the eschars. Wolfler has prevented the spread of an erysipelas by means of the mechanical compression produced by placing strips of adhesive plaster around its borders. For the same purpose Niehans employed collodion, applying the latter around an extremity over a space about two handbreadths in Avidth, thus encircling the extremity with the collodion as with a bandage. Kroell recom- mends strips of caoutchouc for the same purpose. Winiwarter and Fraipont speak well of the following method of treatment: The part affected by the erysipelas and the wound are soaked for ten minutes in a bath of 1 to 3,000 bichloride, or the latter is used in the form of an irrigation for a longer period of time; the erysipelatous area is then dried, and it and the adjoining healthy skin are covered with tar, over which is applied a dressing wet with Burow's solution (see page 159); then iodoform gauze which has been dipped in a bichloride solution is placed on the wound, and the whole dressing is bandaged lightly in position. It has been attempted to combat the erysipelatous inflammation by the internal administration of drugs. English surgeons, in particular, give iron internally (liq. ferri chlorat., in large doses, fifteen to twenty drops every hour, or even 2"0 grammes or more); others use liq. ferri sesquichlorati., ten to fifteen drops every two to three hours; ergotine, iodide of potassium, and belladonna have been used for the same pur- pose. Haberkorn has recently employed with success benzoate of sodi- um in mucilaginous solutions, or in some effervescing water, in doses of fifteen to twenty grammes a day; -no local treatment is made use of. The effectiveness of all internal medication is exceedingly doubtful. Camphor (internally or in the form of subcutaneous injections) has but little value, though it was highly recommended by Pirogoff. The treatment of the complications, particularly the abscesses, gan- grenous processes, and the inflammations of joints, should be con- ducted on the principles laid down for these conditions. At the time of the outbreak of the erysipelas, or when the case is met with in a later stage, the wound from which the disease starts should be carefully ex- amined and treated antiseptically, and if any blood or pus is held in retention it should be let out by removing a few sutures, by separating the agglutinated margins of the wound, by making incisions, etc. If it is desired to inoculate an erysipelas for therapeutic purposes §72.] HOSPITAL GANGRENE—WOUND DIPHTHERIA. 351 upon an inoperable tumour or other diseases of the skin, it should al- ways be borne in mind that infection by the streptococcus of erysipelas may cause the death of the patient. Zoonotic Erysipelas—Wandering Erythema (Erythema migrans).— The so-called erysipeloid or wandering erythema occurs almost exclu- sively on the hands, and attacks most commonly individuals who handle all sorts of dead animal substances, dealers in game or fish, cooks, restaurant keepers, butchers, tanners, oyster openers, and those who come much in contact with cheese, herring, etc. The erysipeloid is a disease of wounds which is not very infectious in character, and affects the hands almost exclusively, some infectious substance being inoculated into small wounds. After inoculation there ensues a mod- erate infiltration of the skin, giving the latter a dark-red discolouration ; there is no fever, and the disease spreads very slowly, with an itching, prickling sensation, and it may take eight days to extend, for instance, from the finger-tip to the metacarpus. The reddening of the skin more often occurs in spots; less frequently it is of a diffuse character. It is only very exceptionally that the erysipeloid extends as far as the wrist, and it never reaches the forearm. The disease is often very stubborn and persistent, lasting sometimes three to four to six w^eeks unless proper treatment is adopted; but in other cases it may disappear spontane- ously in one to two to three weeks. Rosenbach found that a coccus-like body was the cause of the erysipeloid; it is larger than the staphylo- coccus, grows best in gelatine at a temperature of 20° C, forms twisted filaments of varying length, and bears a remarkable resemblance to a form of microbe described by Cohn under the name of cladothrix dichotoma. Rosenbach and Cordua have produced this erysipeloid by inoculations practised on themselves. The best method of treating the zoonotic erysipeloid consists in cutaneous injections of a three-per-cent. solution of carbolic acid into the inflamed area of skin, and into the healthy skin immediately adjoin- ing its outer borders. § 72. Hospital Gangrene—Wound Diphtheria.—Hospital gangrene (Gangrama nosocomialis), or wound diphtheria, used to be, in the pre- antiseptic era, a very common disease, but if antiseptic treatment is used it never occurs. Hospital gangrene is a local wound disease, al- ways bacterial in its origin, and consists essentially of a gangrenous destruction of the granulations and adjoining tissues. In the days before the dawn of antisepsis it was of very frequent occurrence in many hospitals with bad hygienic arrangements, and was particularly common in conjunction with contused wounds or those in which there was considerable extravasation of blood, as well as in gunshot wounds. 352 INFLAMMATION AND INJURIES. Since the introduction of antisepsis hospital gangrene has almost en- tirely disappeared. Etiology of Hospital Gangrene.—The micro-organism of hospital gangrene has not as yet been discovered ; but reasoning from the whole course of the disease, there can be no doubt that we have to deal with an infectious-wound disease caused by some one of the fungi. Rosenbach, in his last monograph on hospital gangrene, could give no information upon the exciting cause of the disease. The identity of hospital gan- grene and diphtheria of the pharynx is still an open question, and many arguments pro and con have been advanced by different authors. W. Roser and Rosenbach have been the most outspoken against the identity of the two diseases. The pathological changes in hospital gan- grene, like those in diphtheria of the pharynx, consist in an infarct of the infected wound, or in a coagulation necrosis, as it is called by Cohnheim and Weigert, in which are present great numbers of micro- cocci and bacteria of decomposition. Clinical Cause of Hospital Gangrene.—Clinically the disease occurs in one of three forms: 1, The superficial croupous and diphtheritic; 2, the ulcerative diphtheritic, and, 3, the pulpy, the latter being the most ma- lignant form. These different forms of the disease may run into each other, and clinically cannot always be sharply distinguished. The croupous or diphtheritic form of hospital gangrene is characterised by the development of haemorrhagic foci accompanied by swelling, the foci subsequently breaking down and forming a foul, suppurating, jelly- like mass. By immediate treatment of the diphtheritic area with a con- centrated chloride-of-zinc solution, or with the Paquelin thermo- cautery, the spread of this lowest grade of hospital gangrene can gen- erally be arrested. The ulcerative form of the disease also begins with the development of haemorrhagic spots having a grey or greyish-yellow colour, and at the outset is of limited extent; but in a relatively short space of time it spreads over the granulating surface and changes the latter into a grey or greyish-yellow mass, which subsequently breaks down into a gangrenous pulp. This gangrenous destruction of tissue may steadily advance inwards, and superficially may involve the skin adjoining the granulating surface by a spreading of the ulcerative pro- cess. The ulcerative form of hospital gangrene.may change into the pulpy or most dangerous kind of wound diphtheria. In the pulpy form, according to Konig, there occurs, as a general rule, a rapid swell- ing of the tissues in consequence of the extensive haemorrhages into the granulations, followed by putrefaction of the entire mass and the evolution of gases of decomposition. The borders of the wound are red and very painful. The swollen, grey, or greyish-red wound §72.] HOSPITAL GANGRENE—WOUND DIPHTHERIA. 353 looks, as Konig says, like a soft, decomposing spleen or mass of brain tissue. The course of hospital gangrene depends, in general, upon whether the gangrene of the wound remains superficial or extends into the more deeply lying parts. Every form of hospital gangrene may destroy the skin and spread into the subjacent tissues, particularly if it is of the pulpy variety. The gangrenous changes advance very rapidly, and within twenty-four hours cause the wound to become double its origi- nal size, or even larger, but in other cases the changes take a much longer time. The general symptoms correspond to the severity of the local dis- ease. The fever may be continuous or remittent, with intercurrent chills. Very frequently the local disease begins with a rigour and a fever of 40° to 41° C. (104° to 105-8° F.). Prognosis of Hospital Gangrene.—The prognosis of hospital gangrene depends upon the form of the gangrene and the nature of the treat- ment. The pulpy form of hospital gangrene has the most unfavour- able prognosis of all. The strength of the patient and the conditions under which he has lived must be taken into account. The milder forms of hospital gangrene will often get well spontaneously, while the more severe forms will frequently cause death by general' septic poi- soning, unless the spread of the .gangrenous process is combated suffi- ciently early and energetically by proper treatment.- Recurrences of the disease take place not infrequently. Treatment of Hospital Gangrene.—The treatment of hospital gan- grene consists in the energetic use of the Paquelin thermo-cautery and of caustics, particularly nitric acid or chloride of zinc, to check the spread of the gangrene. Deeply placed gangrenous foci must be laid open with the knife, to permit the pus to escape and to enable the sup- purating region to be energetically disinfected with a 1 to 1,000 solu- tion of bichloride of mercury. Iodoform or naphthaline are excellent substances to apply in the dressings; or, if the gangrene is very exten- sive, antiseptic irrigation may be practised, as described on pages 178 and 179. If it becomes necessary to amputate a gangrenous limb, the operation should be performed with the strictest antiseptic precautions, after first' energetically disinfecting the gangrenous focus, or burning it with the Paquelin thermo-cautery and covering it with an antiseptic dressing wet with bichloride. Every patient with wound diphtheria should be isolated with the greatest possible care, as a protective measure for the other patients. Hospital gangrene, as has been said, does not occur at present with the antiseptic niethod of treating wounds; but in the time of war, 354 INFLAMMATION AND INJURIES. where the rules of antisepsis cannot always be strictly observed, hospi- tal gangrene invariably makes its appearance. § 73. Traumatic Tetanus (Trismus).—Tetanus is an infectious-wound disease characterised by cramp-like contractions of the muscles of the lower jaw alone (trismus), or by contractions of certain other groups of muscles, or of the muscles of the whole body (tetanus). The cramps may affect at one time the muscles of the extremities, and at another the muscles of the anterior or posterior aspect of the trunk. Etiology of Tetanus.—There used to be a great many theories con- cerning the nature and etiology of tetanus, but they did not account satisfactorily for its occurrence in the injured, and they are to be looked upon at present as untenable. Amongst them was the reflex theory, which supposed that tetanus was excited reflexly from irrita- tion of the peripheral nerve trunks by an injury, a foreign body, or by the application of a ligature, or that the disease was due to changes in temperature, or to catching cold, etc. Verneuil, Roser and Heiberg were the first to affirm the infectious nature of tetanus and its causation by absorption of a poison from the wound. The recent investigations of Nicolaier, Brieger and Kitasato have proved v / . beyond a doubt that tetanus is produced by a ^vV specific bacillus discovered by Nicolaier, and V^^w first obtained in pure cultures by Kitasato ^\Z * (Fig. 268). *^ -^c jr^ The injuries which may be followed by tet- \ *^ anus are of every description. Sometimes £ ^ they are severe, and involve both soft parts and f.g. 268,-Tetanus bacilli with bones, such as compound fractures, and some- snores from an agar culture times less severe, such as burns, frost-bites, or (Kitasato). x 1000. ' ' ' insignificant wounds of the skin or a granu- lating surface, or perhaps only a small punctured wound, etc. Tetanus has been known to come from a blister and the sting of a bee. We can easily understand, from the analogous origin of other infectious-wound diseases, particularly anthrax, how tetanus may follow the very slightest interruption of continuity in the skin. The disease is particularly apt to occur as a result of injuries to the hands or feet, in which are lodged foreign bodies, such as bits of earth or splinters of wood. Animals, such as horses, may often be the means of transmitting the tetanus bacillus to man. Occasionally the disease appears to break out after the lapse of a certain period of incubation, and consequently it is possible for tetanus to occur after the wound has entirely healed. The disease may become endemic under certain conditions—for instance, in hospitals where the rules of antisepsis and asepsis are not strictly observed. In 3 73.] TRAUMATIC TETANUS. 355 order to get a clear idea of the nature of tetanus, attempts were made to excite the disease experimentally in animals; but all attempts at in- oculation failed until Kitasato and others finally succeeded quite re- cently, thus making it certain that tetanus is infectious in nature. Experimental Inoculation of Tetanus upon Animals.—Carle and Rattone excised from a man who had died of tetanus the inflamed area of skin sur- rounding an acne pustule from which the disease had probably originated; an emulsion was prepared from the excised pustule and injected into the perineurium of the great sciatic nerve, the spinal cord, and back muscles of different rabbits. Of the twelve rabbits inoculated, eleven were seized with true tetanus and died within four days at the latest. Blood taken from the diseased animals and inoculated upon healthy animals did not excite the disease, but an emulsion made from material taken from the point at which the inoculation was made in the sciatic nerve produced fatal tetanus. Rosen- bach and others succeeded in transmitting the disease from man to animals (guinea-pigs), and from the latter to other animals (guinea-pigs and rabbits). Nicolaier's Earth Tetanus.—Nicolaier performed some very interesting experiments in Fliigge's laboratory. While carefully studying the micro- organisms in surface soil, he was surprised to find that a disease similar to human tetanus was produced in a considerable number of cases (sixty- nine times in one hundred and forty experimental inoculations) by inocu- lating animals with earth taken from widely separated sources (Berlin, Wiesbaden, Leipsic and Gottingen). The inoculations with the earth were practised at the root of the tail in white and yellow mice, and beneath the skin in rabbits and guinea-pigs. In mice after the lapse of one and a half to two and a half days, or four to five days in rabbits, cramps occurred in tbe muscles in the neighbourhood of the region inoculated, and later the tetanus extended to the muscles of the other extremities and to those of the back and the nape of the neck. In rabbits, the muscles of the jaw became rigid in a state of tonic spasm, and death occurred after the lapse of one and a half to two days. Mice died twelve to twenty hours after the first symptoms of poi- soning made their appearance. Dogs did not react at all when inoculated. The post-mortem examination revealed, as in man, very little which was distinctive. Microscopically, in the slight amount of pus at the point of in- oculation, micrococci were found, and particularly a peculiar bristle-shaped rod carrying spores. Nicolaier was not able to obtain pure cultures of this bacillus; he could not separate them from other bacilli, and consequently it was believed that tetanus was caused by a kind of symbiosis of different bac- teria. The bacillus in question was found by itself in tbe subcutaneous tis- sues, but Nicolaier was almost never able to demonstrate microscopically the presence of the bacillus in the more deeply lying muscles and nerves, includ- ing the blood. Only in a few cases was he able to find the bacilli in the sheath of tbe sciatic nerve and in the spinal cord. When the earth was heated for an hour the inoculations were unsuccessful. Attempts at pro- ducing infection by pus taken from animals at the point where they were inoculated succeeded in sixty-four out of eighty-eight experiments, the dis- ease running a more rapid course than when earth was employed. Inocula- tions with pieces of the infected tissues succeeded only fourteen times in 35(3 INFLAMMATION AND INJURIES. fifty-two cases. Nicolaier concluded, from his experiments, that tetanus was produced by the bacillus in question, which acted by producing a poison like strychnine, and not by simply increasing in numbers. Socin has also excited true tetanus by making inoculations with garden earth. I saw one fatal case of tetanus following a compound fracture which had become befouled with earth. The patient came under my care after well-marked tetanus had developed. Description of the Tetanus Bacillus.—Kitasato was the first to isolate Nicolaier's tetanus bacillus from the other bacteria found accompanying it; he cultivated it and excited tetanus in animals by inoculating them with the pure culture, and thus established the correctness of the suppositions which had existed about the disease. Kitasato placed in the necessary culture me- dium a small piece of tissue taken from the immediate neighbourhood of a suppurating wound in a man who bad died of tetanus. The culture when placed in the incubator revealed a luxuriant growth of bacteria; but the kind which carried spores at one extremity developed tbe most rapidly, while the others only began to grow after the lapse of a certain length of time. Before these latter could develop Kitasato heated tbe mixed culture to a temperature of 80° C. and destroyed all the bacilli which had not taken on their perma-. nent form, leaving only those which were capable of forming spores. From these be made a pure culture, which, when inoculated upon animals, estab- lished the fact that the bacillus containing spores in one of its extremities, and first discovered by Nicolaier, was actually tbe true bacillus of tetanus. Pathogenesis of Tetanus.—The tetanus bacillus is a slender rod, somewhat longer though not as large in diameter as the bacillus of mouse septicaemia (Koch), and is found in the surface layers of ordinary earth, in decaying masonry, decomposing fluids, manure, or splinters of wood found in wounds, and in the pus from a wound upon a person who has died of tetanus. The rods sometimes form long filaments, upon which the divisions between the segments (bacilli) are almost indistinguishable. The bacilli, for the most part, collect in irregular groups. The tetanus bacillus possesses a recognisable though slight power of movement, and grows rather slowly, best at a tem- perature of 36° to 38" C. (96-8° to 100'4° F.), while below 16^0. no develop- ment takes place. It is obligate anaerobic—i. e., it grows only when atmos- pheric air is absent. In the presence of oxygen, the bacillus quickly died. In an atmosphere of pure hydrogen, small ray-like colonies develop slowly upon gelatine plates after the lapse of some days; they liquefy the nutritive medium with the evolution of gas, and present an appearance similar to the hay bacillus (a rather thick, solid centre, with radiating filaments). Stab cultures in a test tube containing a considerable amount of grape sugar gelatine, or in gelatine to which has been added 0*1 per cent, of indigo-sulphate of sodium, give a culture at the bottom of the tube having the appearance illustrated in Fig. 269. At the end of the first week it looks something like a fir-tree—i. e., numerous fine processes radiate outwards from the line of puncture, simulating the bacillus figurans. Subsequently the gelatine sur- rounding the colony is liquefied and there is an evolution of gas. In a test tube containing agar, to which has been added one to two per cent, of grape sugar or indigo-sulphate of sodium, the growth at the proper incubation tem- perature is more rapid and luxuriant, and after the first or second twenty- S73.J TRAUMATIC TETANUS. 357 four hours the culture causes an evolution of gas which has a characteristic unpleasant odour. In grape-sugar bouillon the growth of the culture is ex- ceedingly vigorous, and is accompanied by the formation of a large amount of gas. In blood serum, at a temperature of 34° to 38° C, after the lapse of one to three days, small round cavities develop, which gradually coalesce. Spore formation, at a temperature of 37° C, takes place in thirty hours, and occurs at one end of tbe bacillus, this por- tion of the cell swelling, and giving it the appearance of a drum-stick (Fig. 268). The spores have great vitality, and .will remain alive when exposed in a moist state to a tem- perature of 80° C. for one hour, but are destroyed in five minutes when exposed to steam at a temperature of 100° C. Dried pus containing spores retains its virulence after the ex- piration of sixteen months. The tetanus bacillus is readily stained by tbe ordinary aniline dyes. Gram's method can also be employed. If a small amount of a pure culture is inoculated upon mice, rats, guinea-pigs, or rabbits, the former two kinds of an- imals will manifest the first symptoms of the disease in twen- ty to twenty-four hours, the latter two in two to three days. If horses, sheep, or dogs are inoculated with the pure culture they will develop typical tetanus. The manifestations of the disease are at first local, and confined to tbe parts immediate- ly adjoining the point of infection, from which they gradu- ally spread, and the animal then dies in a short time. At the point of infection there is infiltration of the tissues and hyperaemia, but no suppuration, and sometimes it may be possible to demonstrate the presence of the bacilli; but they are never found in the different organs or in the blood. The latter fact is explainable on tbe ground that the bacilli form an extremely active poison, which spreads rapidly throughout the body. Brieger has ob- tained from tetanus cultures four toxines in a chemically pure state: teta- nine C13H30N2O4, tetanotoxine CsHuN, spasmotoxin^, and a toxine hydro- chlorate. Very small amounts of these toxines produce in animals tetanic symptoms, but Weyl states that it is not typical tetanus. The Tetanus Poison.—Weyl and Kitasato have also attempted to isolate the poisonous substances from pure cultures of the tetanus bacillus. They considered that Brieger worked with impure cultures. Weyl and Kitasato found a very poisonous substance closely allied to the albuminoid bodies, which produced, after the lapse of a certain period of incubation, tbe symptoms of tetanus, though they were not so typical as after an infection by the tetanus bacillus. Brieger, working with E. Frankel, has also discovered the same body (tetanotoxalbumen). The toxine, isolated at an earlier date by Brieger, produced very acute tetanic symptoms, but not tbe typical picture of tetanus. The toxic substance obtained from different kinds of pure cultures of tbe tetanus bacillus varies—a fact which corresponds to wThat we know of other bacteriological investigations. By subcutaneous injection in mice, guinea- pigs, and rabbits, of the germ-free filtrate from bouillon cultures of the Fig. 269.—Tetan- us culture. Stab culture in gela- tine with indi- go-sulphate of sodium. Seven days old. 353 INFLAMMATION AND INJURIES. tetanus bacillus, Kitasato obtained a typical tetanus which terminated fatally. Consequently intoxication by the tetanus bacillus seems to be caused by sev- eral different poisonous substances. The poison exists in the serum of the blood, and after circulating through the system in this medium, it is excreted by the kidneys, which accounts for the particularly toxic powers of the latter organs. Bruschettini wTas able to excite tetanus in healthy animals by injecting into them subcutaneously the urine taken from animals suffering from this disease. Testana, on the other hand, was unable to demonstrate in the liver, spleen and kidneys tbe toxic substance of the tetanus bacilli. Tetanus Immunity in Animals.—Great interest attaches to tbe experi- ments of Behring and Kitasato relating to the production in animals of im- munity from tetanus. These authors succeeded in curing infected animals, and in so treating healthy ones that they were never afterwards affected by tbe tetanus bacillus. The blood and serum of rabbits which have been rendered immune from tetanus possess the power of destroying the tetanus poison. They are both prophylactic and curative. By transfusion of blood or serum remarkable therapeutic effects can be obtained—that is, infected animals can be cured, and healthy ones—mice, for example—can be rendered permanently immune. The artificially acquired immunity is transmitted from the animal to the foetus in utero, and persists in the young for some time after birth. Tizzoni and Cattani have made white mice immune by the serum of the blood taken from frogs and pigeons which are unsusceptible to tetanus ; but Kitasato, experimenting with the blood of chickens, has con- tested their assertions. Kitasato has rendered rabbits immune from tetanus by injections of iodoform. Tizzoni and Cattani state that rabbits from which the spleen has been removed cannot be made immune. The future must de- cide whether the facts established about the action of blood serum in curing animals affected wdth tetanus is of therapeutic value for man in a similar condition. Vaillard's experiments seem to make tbe hope of success in this line rather doubtful. Tizzoni, Cattani and others have prepared curative serum (antitoxine) from animals which have been made immune from the disease, and have recommended it for use in man. As yet no definite con- clusion has been reached upon the success which may be obtained by the subcutaneous injection of this remedy. Sormani gave pure cultures of tetanus bacilli and tbe flesh of animals dying of tetanus to herbivora and carnivora, and both classes of animals re- mained healthy ; but in the faeces of these animals, particularly the herbiv- ora, he found an active tetanus poison which was capable of communicating the disease. Disinfection of Objects Infected with the Tetanus Poison.—The disinfection of all objects infected with the tetanus poison is best carried out by subject- ing them to the action of steam at a temperature of 100° C. to 130° C. (212° to 266° F.), or by boiling them in a one-per-cent. aqueous solution of soda. For the disinfection of hospital wards, rooms, etc., Bombicci recommends nascent chlorine, while a ten-per-cent. solution of chloride of lime can be used for stone walls, or, better, a mixture of ten parts of chloride of lime, twenty-five parts of quicklime, and one hundred of water. Fluid coal tar is excellent for wooden walls. Tizzoni and Cattani recommend a mixture of §73.] TRAUMATIC TETANUS. 359 one per cent, bichloride of mercury, five per cent, carbolic acid, and five tenths per cent, hydrochloric acid for disinfecting the hands of the surgeon. Tetany after Extirpation of Goitre.—It is well known that tetany may follow total extirpation of the thyroid gland. It is characterised by a peculiar condition of irritation of the anterior horns of the grey matter of the spinal cord. The tonic spasm, which chiefly affects the hands and feet, used to be thought to be due either to irritation of the peripheral sympathetic nerves, caused, for instance, by ligation of a great number of vessels, or to the division of the numerous nerves of the thyroid gland. Horsley and others state that tetany only occurs after total extirpation of the thyroid, and never after a partial extirpation or removal of half the gland. But Eiselsberg produced tetany in cats by removing four fifths of the thyroid ; the dis- ease, however, was not always fatal, while the tetany following total extir- pation was invariably so. Consequently it follows that the thyroid gland is functionally a very important organ, and its total removal will cause death. Horsley, Wagner and Eiselsberg consider that the function of the thyroid is to render mucoid substances innocuous. After its total extirpation there results an accumulation of mucin in the tissues (myxcedema), and death is caused by mucin poisoning with tetanic symptoms. Herbivora, such as rabbits, stand total extirpation of the thyroid gland better than carnivora, such as dogs or foxes. The Clinical Course of Tetanus.—The clinical picture presented by tetanus in man is briefly as follows: About the third or fourth day after infection, or still later, it is noticed that the patient cannot open his mouth properly, and complains of pain in the muscles of mastication. At the same time there is usually a high fever, though in the less acute cases the fever may be absent. As a result of the cramp-like contraction of the facial muscles, the countenance assumes a peculiar rigidity. There soon follows a certain amount of stiffness of the neck, with tetanic spasms lasting a few or several minutes, and affecting at one time the trunk and at another the extremities; they are very painful, and are excited by the slightest external irritation—for example, by touching the patient, by a draught of air, a noise, etc. Many of the muscles become firmly and permanently contracted. Tetanus does not always begin with a cramp- like contraction of the muscles of mastication (trismus). If the patient is carefully watched, it may be noticed that there is at first a peculiar stiffness and contraction of the muscles in the neighbourhood of the injury or point of inoculation, occurring perhaps in the upper or lower extremity, and subsequently tetanus will develop in the other groups of muscles. These facts were observed by Nicolaier and Kita- sato in their experiments upon animals, which have already been de- scribed. The fever in tetanus is usually high, the rise in temperature not infrequently reaching 41° to 42° d* (105-8° to 107-6° F.), or even 43° to 44° C. (109-4° to 111-2° F.), while after death there is some- 360 INFLAMMATION AND INJURIES. times a further rise to about 45° C. (113° F.). This excessive increase in body heat is essentially the result of muscular contraction, as was also proved by Leyden's experiment, in which, within two hours, the temperature of a dog was made to rise from 39-6° C. (103-2° F.) to 44.8° C. (112-6° F.), simply from the frequently repeated muscular contraction caused by powerful electrical stimulation of the spinal cord. The patients usually retain perfect consciousness, and are bathed in sweat. The urine contains albumen, probably as a result of the tetanic contraction of the renal arteries. There are also cases which may run a rapidly fatal course and yet be unaccom- panied by fever. In these there is an extensive muscular rigidity, particularly about the head and trunk, the patients hold themselves perfectly stiff, and there are none of the above-described muscular con- tractions alternating with a momentary abatement of the rigidity. Acute tetanus is usually fatal. Death may occur within twenty- four hours from the beginning of the disease, or after the lapse of four to five days. There is also a subacute or chronic form of trismus or tetanus which ordinarily is not accompanied by fever. Sometimes the tetanus remains limited to the muscles in the neighbourhood of the injury, affecting perhaps the arm alone, or the injured leg, or the mus- cles of the head. Head Tetanus.—Rose, Bernhardt and Guterbock state that the so- called head tetanus occurs after injuries in the region of the distribu- tion of one of the twelve cranial nerves. It is distinguished particu- larly by tetanic contractions of the muscles of mastication—by trismus, as it is called—which is combined with facial paralysis and spasm of the muscles of the pharynx, as in hydrophobia, and hence is sometimes given the name of tetanus hydrophobicus. The paralysis of the facial nerve, according to Rose's view, is caused by compression of the swoll- en nerve in the aqueductus Fallopii, but this cannot always be demon- strated in the post-mortem examination. Brunner has excited head tetanus in guinea-pigs and rabbits by inoculating into the heads of these animals a pure culture of the bacillus; and he found that there was no paralysis of the affected half of the face, but that the asym- metry of the sides of the face, apparently due to facial paralysis, was really due to tetanic contracture. When inoculation was practised in the median line, both halves of the face became tetanised. If the facial nerve was divided upon the inoculated or diseased side of the head, real paralysis appeared for the first time, and the rigidly contracted muscles became relaxed. Brunner thinks that the supposed facial paralysis in head tetanus, in man, is probably an error in observation, though P. Klemm, basing his opinion §73.] TRAUMATIC TETANUS. 361 upon an analysis of thirty-eight published cases, has contested this con- clusion. Head tetanus is not always fatal, particularly chronic cases, which Klemm's statistics show may last from four to twelve weeks, and are much more apt to terminate favourably than the acute form of the disease. Guterbock and Bernhardt collected fourteen cases with four recoveries. Klemm had one case of chronic tetanus hydrophobicus, and collected the reports of twenty-four others, seven of which re- covered, six of these being chronic. Pathology of Tetanus.—The anatomical changes in tetanus are slight. The microscopical examination of the spinal cord and the neighbouring peripheral nerves shows an extensive proliferation of the cells. Monastyrski found half-moon-shaped extravasations of blood in the interstitial connective tissue of the spinal cord and peripheral nerves, and a granular infiltration of the nerve cells. Prognosis of Tetanus.—The prognosis of tetanus, as may be gath- ered from what has been said above, is for the most part unfavour- able. Acute tetanus generally terminates fatally, while the subacute and the rare chronic forms of the disease have a more favourable prognosis. In those cases in which the tetanus is confined to the mus- cles of one limb, or to the head (tetanus hydrophobicus), the disease does not always terminate fatally. Treatment of Tetanus.—Treatment in acute tetanus has little effect. In the first place, the injury or wound should always receive proper surgical treatment according to antiseptic rules. It is very important that every wound which has become soiled with earth, or similar sub- stances, should be thoroughly cleaned and disinfected as soon as possible. Tizzoni and Cattani recommend, for the disinfection of wounds in which there is fear of the development of tetanus, a one-per-cent. solu- tion of nitrate of silver, which destroys the bacilli and the spores very rapidly and certainly—in one minute. If tetanus already exists when the case comes under observation, we are, as a general thing, powerless to hold it in check, and almost all the patients die after a very short time. Very rarely, and then only when the case is seen immediately after the reception of the injury, can tetanus be checked by burning the wound with the thermo-cautery. Recovery may often be obtained by amputating the injured limb, though even this is sometimes unsuc- cessful. Especially in tetanus following injuries of the extremities, attempts have been made to arrest the disease by exposing and stretch- ing the principal nerve trunks—the sciatic, for instance—which supply the injured portion of the body, and Verneuil, Kocher and others have reported cures by this treatment. The good obtained from nerve- stretching in infectious tetanus is certainly open to doubt (§ 97). 362 INFLAMMATION AND INJURIES. The remainder of the treatment for tetanus is purely symptomatic. Subcutaneous injections of morphine are often used, accompanied by the administration of chloral hydrate (three to five grammes pro die) by the rectum, or large doses of chloral hydrate or bromide of potassium may be given internally, two grammes of chloral hydrate being alternated with the same amount of bromide of potassium every two hours. Kane states that, of two hundred and twenty-eight cases treated with chloral hydrate, one hundred and thirty-four recovered and ninety-four died. Of ninety-three treated with chloral hydrate in combination with other remedies, thirty-three died. The most efficient means for quieting a patient during a paroxysm is to administer chloro- form by inhalation; but after the cessation of the narcosis the muscular spasm immediately recurs. Curare, the Indian arrow poison, which has the power of paralysing voluntary muscles, is an exceedingly valuable remedy, though very inconstant in its effects on account of its variable chemical composition. The success of the curare treatment has not, however, been very encouraging. Its concentration varies within wide limits. Curare can be injected in the dose of about 0*015 to 0-05 grammes every quarter to half to one hour. Karg has curarised patients (by subcutaneous injection) till respiration became paralysed, after previously performing a prophylactic tracheotomy for facilitating artificial respiration ; but all the cases treated in this way terminated fatally. It is a better plan to combine the administration of narcotics with injections of curare. Bacelli has obtained satisfactory results by injections of carbolic acid (O'Ol gramme every hour). Sormani recom- mends iodoform. According to the latter's experiments, the tetanus poison is neutralised by iodoform, or by the iodine derived from it; and by treating the wound with iodoform during the period of its in- cubation tetanus can be prevented. He states that mice inoculated simply with earth died of tetanus in less than three days; but if the earth used in the inoculations was first mixed with iodoform the animals remained unaffected by the disease. Pure cultures are not changed when iodoform is added to them, but are killed in one minute by the addition of a one-per-cent. solution of nitrate of silver (Tizzoni, Cattani). Sormani also recommends iodol and a two-per-cent. acid solution of bichloride of mercury, or chloral with camphor. The further treatment of the disease consists in careful isolation of the patient, and in keeping away from him every sort of external irritation or disturbance, particularly during the stage when the muscular spasms are a prominent symptom. De Renzi has succeeded in curing four out of a total of five cases of tetanus by securing to the patient absolute rest, which is the very §74-] SEPTICEMIA. 363 best curative agent at our disposal. De Renzi places the patient with tetanus—the ears having been plugged—in a room which is completely isolated, absolutely quiet, and without windows. All the necessary manipulations in the care of the patient are performed, as far as pos- sible, in the dark. The nourishment is entirely fluid. When the pain is severe De Renzi gives belladonna and ergot internally. Value of "Curative Serum" (Antitoxine).—It has been mentioned before that Behring, Tizzoni, and Cattani have prepared and recom- mended a curative serum (antitoxine) for treating tetanus in man. It is made from the blood serum of dogs, less often of rabbits which have been rendered immune from the disease, and when injected subcutane- ously in man is said to have cured a number of cases of tetanus : but as yet it is impossible to come to any definite conclusion upon the the- rapeutic value of this serum. § 74. Septicaemia.—The term septiccemia is given to a poisoning of the body (intoxication) which, as a rule, rapidly terminates in death, and is not characterised by the formation of such metastatic suppura- tive processes as occur in the disease called pyaemia (pus poisoning), which is closely related to it. Septicaemia is usually found in conjunc- tion with putrefactive (gangrenous) changes in a wound or inflamma- tory focus, though it may sometimes have an intestinal or pulmonary origin. It is often perfectly impossible to make a sharp distinction be- tween pyaemia and sepsis, as the two diseases are frequently found in combination, both clinically and anatomically, and hence the term sep- ticopycemia. Cryptogenetic Septicaemia.—Oftentimes the point at which the infec- tion gains access to the system cannot be found, and we then speak of a cryptogenetic septicaemia. Etiology of Septicaemia in Man.—Virchow, Billroth and others produced septicaemia by injecting decomposing substances into the vascular system and tissues of animals, and the discoveries in fermentation and decomposi- tion which were made about the same time helped to shed light upon the importance of lower organisms in the production of sepsis. Then Panum demonstrated that analogous septic diseases could be excited by using de- composing fluids which had been boiled after the fungi existing in them were removed. This theory of the origin of septicaemia, partly from bacteria and partly from fluids free of bacteria, is now being still further elaborated, so that at present we distinguish two principal forms of septicaemia, one caused by fungi and the other by soluble chemical poisons. The septicaemia due to the presence of bacteria is an infectious disease capable of transmis- sion to other animals ; in other words, the blood of animals having this kind of sepsis will produce the same disease when inoculated into healthy animals. The virulence of the blood increases each time it is taken from an animal having the disease and inoculated into a healthy one—that is, its virulence 364 INFLAMMATION AND INJURIES. bears a direct proportion to the frequency of its transmission from one animal to another. In the second form of septicaemia, the blood contains dissolved in it chemical poisons or gases, the poisonous products of the metabolism of the fungi, and it is not infectious any more than tbe blood of an individual suf- fering from strychnine or prussic-acid poisoning. Between the two forms of septicaemia, the one due to toxines and the other to bacteria, there are numerous transition and combined forms ; in other words, bacteria of every description are sometimes found in the blood of those suffering from poisoning by the chemical products of bacterial metabolism. The changes which take place in decomposition are of great importance for an understanding of the etiology of septicaemia. It has been mentioned that in the decomposition excited in albuminous bodies by bacteria, various substances are formed, the chief of which are peptones and similar bodies, nitrogenous bases /leucine, tyrosine, amine), organic fatty acids, aromatic products, colouring matters, and particularly poisonous toxalbumens, and certain alkaloids to which have been given the name of cadaver alkaloids or ptomaines. The latter possess intensely poisonous properties. It had long been known that toxic bodies were present in the products of decomposition, as Panum, in 1863, had isolated from putrefying substances his putrid poison. Bergmann and Schmiedeberg obtained a crystalline body, sepsine, Billroth discovered another, etc. Selmi was the first to recognise the nature of these bodies, and he gave them the name of cadaver alkaloids or ptomaines. Brieger and others have obtained several ptomaines in a pure state, such as collidine, peptoxine, neurine, neuridine, choline, etc., and have investigated their action upon animals. Paterno, Spica and others found that ptomaines are also a product of normal metabolism, though, of course, they are formed in small amounts. Bergmann and Angerer have proved that febrile diseases similar to septicae- mia can be produced by non-bacterial poisons such as ferments. In a case of septic (putrefactive) intoxication occurring without the presence of micro- organisms in the blood, there will somewhere be found a focus of suppura- tion or some decomposing pus or blood, the decomposition being due to micro-organisms, particularly the various kinds of bacilli. If the focus of suppuration is removed early enough recovery may take place. In these foci of suppuration or gangrene there will be not only tbe bacteria of decom- position, but many others, such as pyogenic staphylococci, streptococci, and different bacilli. Septicaemia in man is caused sometimes by bacilli and sometimes by cocci (streptococcus pyogenes, streptococcus septicus Fliigge, staphylococcus aure- us). Ogston and Rosenbach identified the streptococcus pyogenes as the cause of the septicaemia in a case of progressive gangrenous phlegmon which produced fatal sepsis. In the septicaemia following progressive gangrenous emphysema, Rosenbach and others found the very bacillus which Koch proved to be the cause of malignant oedema—a disease running a rapidly fatal course in mice, guinea-pigs, and rabbits. These oedema bacilli (Fig. 270), which Pasteur formerly designated as vibrions septiques, are morphologically similar to the anthrax bacilli (Figs. 8T4.] SEPTICAEMIA. 365 l\ 264, 265). It is interesting to note that tbe symptomatic anthrax occur- ring endemically in cattle is produced by similar bacilli, and that their multiplication in the subcutaneous cellular tissue causes inflammatory swelling with the evolution of gas. Furthermore, in haemor- rhagic septicaemia many kinds of bacilli have been found. Lubarsch observed a case of septic pneumonia in a newborn child which died two days after birth. Experimental Septicaemia in Animals.— Thanks to Robert Koch, we possess a more accurate knowledge of human septicaemia on account of this investigator's experiments upon animals. There is a toxic septicaemia (septic intoxication), and a septicaemia which is bacterial in its nature (trans- missible septic infection). Toxic septicaemia occurs after the injection of large amounts of decomposing substances into the subcutaneous cellular tissues. Immediately, or soon after the injection, there ensue restlessness, weakness, cramps, often vomiting, finally paralysis, and not infrequently death fol- lows in a few hours from paralysis of respiration. No bacteria are found in the blood or internal organs. If decomposing fluids, with the bacteria of de- composition, are kept for twenty-four hours in the incubator at a temperature of 40° to 41° C. (104° to 105-8° F.) and then used for injection, the poisonous effects are very pronounced ; but if tbe fluid is treated in the same way for forty-eight hours, no effects follow its injection. \ B Fig. 270.—Bacillus of malignant oede- ma (vibrion septique Pasteur): A, from the spleen of a guinea-pig; 2>, from the lung of a mouse (Koch). ■d Fig V Tl ,■* *> ■-•* -■■--■ i^- r*>' 283.—Anthrax ba- cilli from a malignant pustule of the skin. The bacilli are stained with gentian violet, and the tissues with Bismarck-brown. x 300. pustule), less often through the lungs and intestine. The anthrax bacilli multiply very rapidly in the animal body, and are found not only at the point of infection—the malignant pustule, for example (Fig. ^ N 283)—but also in the blood-vessels, where they exist in vast numbers. They are also present, immediately after the infection takes place, in the lymph and the chyle when the infection occurs through the intestine. In the malignant pustule the anthrax bacilli will be fre- quently found enclosed within cells, a fact which can- not be considered as supporting Metschnikoff's theory of phagocytosis (see pages 272, 273), as the bacilli were probably dead before they were taken up by the cells. The infected organism usually succumbs very soon in consequence of the rapid multiplication of the bacilli and the poisonous products of their metabolism. The toxic products (albumoses and bases) of the anthrax bacilli have been studied by Hankin, Lando Landi, and others. Natural Immunity of certain Animals from Anthrax.—Dogs, pigs, and the majority of birds, are immune from anthrax; also rats, for the most part, and frogs under ordinary conditions. But if a frog, in whose lymph sack are placed anthrax spores, is put in an incubation apparatus, he will quickly die of anthrax. Accord- ing to Rohrschneider, 28° C. is the lowest limit of temperature at which anthrax bacilli will devel- op within a frog's body. Accord- ing to Crookshank, pigs may ac- quire anthrax. Ssawtschenko stated that after the spinal cord is divided in doves they are no longer immune from anthrax. In general, the immunity which va- rious animals possess towards an- thrax does not appear to be com- rr » plete, as tbe bacilli can gradually ;r:; become accustomed to develop in ^ media which are unsuitable for them. It has been proved by Birch- Hirschfield and others that an- thrax bacilli can be transmitted Fig from the mother to the foetus in utero. The bacilli, as it were, grow into the foetal placenta, aided by changes in the walls of the vessels, in the tissues surrounding the vessels, and in the epithelium of the villi. The healthy placenta does not normally permit the passage into and through it of micro-or- ganisms or other formed elements, and the filter only becomes pervious 26 284.—Anthrax bacilli in the capillaries of an intestinal villus (rabbit), stained with methy- lene violet, and then treated with potassium carbonate, x 700 (Koch). 386 INFLAMMATION AND INJURIES. when affected by pathogenic bacteria which have gained access to the pla- centa. Staining of Anthrax Bacilli.—The anthrax bacillus can be rapidly stained by aqueous solutions of the aniline dyes, and also by Gram's method. The spores are best stained at a high temperature by means of Ehrlich's aniline- water-fuchsin solution or Ziehl's solution containing carbolic acid. Instead of Ehrlich's fuchsin solution, a correspondingly made solution of gentian violet can be employed for staining the spores. After decolouration of the substance of tbe bacilli the spores are stained with Bismarck brown. The Course of Anthrax in Animals.—Anthrax in domestic animals may take one of three courses: 1, The apoplectiform anthrax (anthrax acutis- simus), which lasts from a few minutes to several hours ; 2, the acute an- thrax (anthrax acutus), lasting from a few hours to several days ; and, 3, the subacute form of anthrax (anthrax subacutus), of longer duration. There is no period of incubation, or it may occupy three to five days. In the more common apoplectiform variety of anthrax (cattle, sheep) the animals which previously had apparently been in perfect health fall down as though struck with a blow, and die often in a few minutes with convulsions, cyanosis, and dyspnoea. According to Bollinger, acute anthrax in cattle and horses begins with loss of appetite and a chill, followed by a remittent or inter- mittent high fever (41° C.—105'8° F.—and higher) ; there are almost always spasms, particularly clonic spasms of the extremities. These symptoms come on in the form of paroxysms. The subacute form of anthrax, the anthrax carbuncle, is characterised by carbunculous and erysipelatous swelling oc- curring in different places in the skin, particularly in the region of the hind feet, while there is only a slight constitutional disturbance. The carbuncle begins to be absorbed frequently after the lapse of a few days, and an eschar and ulceration develop only exceptionally. In about sixty to seventy per cent, of the subacute cases (in cattle and horses, for example) death follows with dyspnoea and convulsions. Anthrax in Man.—Anthrax occurs in man mainly by transmission of the anthrax bacilli or their spores from a diseased animal, and hence those persons are particularly liable to the disease who in their occu- pation come in contact with infected animals or parts of animals. Such persons are shepherds, farmers, butchers, veterinary surgeons, workers in leather (furriers, and those who handle skins), and people who are employed in the preparation of horse-hair, wool, and paper. The so-called rag-sorters' disease, wliich runs a rapidly fatal course, presenting the appearance of pneumonia with typhoid or septic symp- toms, and attacks people who sort and tear rags in the manufacture of paper, is occasionally primary anthrax of the lungs caused by inhaling anthrax spores. Kraunhals states that the disease is also caused by the bacillus of malignant oedema. There are naturally various micro-or- ganisms in rags. O. Roth describes three kinds of pathogenic bacilli: Bacillus I is like the bacterium coli, Bacillus II like the proteus homi- nis, and Bacillus III like Hauser's proteus vulgaris (see page 366). §77.] SPLENIC FEVER OR ANTHRAX. 387 Enderlen's experiments in the Pathological Institute at Munich show that breathing in the spores of anthrax is much more dangerous than their ingestion in food. All " inhalation animals" perished of anthrax, while of the auimals infected through food some remained alive. Anthrax is also caused in man by eating the flesh, milk or but- ter obtained from animals affected with this disease. It may also be transmitted by insects (flies) which come in contact with animals having anthrax, and the poison may be communicated from man to man—for example, at an autopsy. The disease starts either by inoculation of the bacilli or of their spores into the skin (it may be a very small interrup- tion of continuity), or by inhalation of the poison, or by its introduction with the food into the alimentary canal. The cases of so-called intes- tinal mycosis recorded by E. Wagner and others are really cases of true anthrax disease. In general man is not very disposed towards an- thrax. Marchand observed anthrax in a pregnant woman with fatal infection of the child. Lingard, experimenting with pregnant rabbits, caused an infection of the foetus, and found that in some cases the foetus alone became diseased, in others the mother also. Sections through the placenta plainly showed the passage of the anthrax bacilli from the foetal to the maternal blood-vessels. Birch-Hirschfeld's re- cent observations, which were mentioned before, are very interesting, proving, as they do, the transmission of the anthrax bacilli from the maternal into the foetal circulation. If an abundant development of anthrax bacilli takes place in the placenta, the bacteria actually grow into and through the foetal portion of the placenta in a manner similar to that in which, after inhalation of anthrax spores, the bacilli enter the pulmonary vessels, as was demonstrated by Buchner's experiments. The course which anthrax takes in man varies according to whether the infection takes place externally or internally. AVhen infection oc- curs through the skin there is an incubation period of three to six days, and then at the point of entrance there develops a burning or itching red nodule with a reddish or bluish bleb, which soon breaks and dries up, forming a scab. The skin in the neighbourhood of the scab then usually becomes swollen, and sometimes more blebs form. The primary nodule at the point of infection varies from the size of a pea to that of a nut. Ordinarily the induration and cedematous swell- ing extend very rapidly in all directions from the primary nodule, and the adjoining lymphatic glands become enlarged. After the local symptoms have continued some forty-eight to sixty hours the constitu- tional manifestations of the disease begin (high fever, great weakness, delirium, diarrhoea, severe vague pains, etc.). If there is a fatal termi- nation, death occurs very often with symptoms of collapse, generally 388 INFLAMMATION AND INJURES. after the disease has lasted five to eight days. If there is a favourable termination the scab is sometimes cast off by a process of suppuration. In other cases there is observed a diffuse, erysipelatous form of car- buncle (Virchow, Bollinger)—for example, after infection by a fly-bite, and also when the infection has taken place internally. According to E. Wagner, the course of anthrax when the infection lias taken place from the intestine is characterised by the suddenness of the onset and its rapid progress, with vomiting, diarrhoea, cyanosis, and subsequent collapse. AYhen the infection takes place through the lungs, as in the above-mentioned rag-sorters' disease, there is observed a pneumonia, with typhoid or septic symptoms, and for the most part a rapidly fatal course. The autopsy in man reveals essentially the same changes as in animals. There are immense numbers of anthrax bacilli in the blood- vessels, and particularly in the capillaries (Fig. 284). The Diagnosis of Anthrax, when infection has occurred through the skin, is made chiefly from the characteristic appearance of the malig- nant pustule, and from the patient's statements concerning his occupa- tion, the origin of the pustule, etc. If necessary, the diagnosis can be cleared up by microscopical examination of the carbuncle. For mak- ing the diagnosis when the infection takes place from within, we must refer the reader to the text-books on internal medicine. Prognosis.—The prognosis of anthrax in man, when infection takes place externally, depends mainly upon whether energetic surgical treat- ment is undertaken early enough. Lengyel and Koranyi, by adopting suitable local treatment, lost only thirteen out of one hundred and forty-two cases of anthrax. Patients with anthrax resulting from in- ternal infection (intestinal, pulmonary) very rarely recover. The Treatment of Anthrax.—In the treatment of anthrax in man the fact that the disease remains local a longer time than in animals is of the greatest importance. If the patient comes under observation early enough, it is our duty to destroy the point of infection as rapidly and thoroughly as possible—for instance, by extirpation, by making an eschar with the Paquelin, by cauterisation with nitric acid, etc. According to Koch, bichloride of mercury is the most effective poison for anthrax bacilli, being capable of killing them when used as dilute as 1 part to 300,000 of water. Consequently it is an excellent plan to use in and around the point of infection injections of one-tenth-per- cent. bichloride, or two to five per cent, carbolic acid (liaimbert and others), or dilute tincture of iodine (one to two of water, Davaine). In suitable cases, which come under treatment at an early stage, with an- thrax infection located in an extremity, the latter can be tied off by an elastic tourniquet (Nissen). When general infection has occurred, as g77.] SPLENIC FEVER OR ANTHRAX. 389 shown by the presence of bacilli in the blood, little success can be ex- pected from any effective internal treatment, such as with iodine, quinine, carbolic acid, etc., though Russian authors in particular have obtained very satisfactory results by the energetic subcutaneous and internal administration of carbolic acid (0*5 gramme of carbolic acid internally and energetic injections into the pustule). The future must decide whether it is possible in man, as in animals, to prevent anthrax or to cure it, by the inoculation of other kinds of bacteria (see page 384). Symptomatic Anthrax.—Symptomatic anthrax (charbon symptomatique of the French) is a disease similar to anthrax, affecting cattle, which occurs endemically and mostly during the warm months of the year in many re- gions, notably the Bavarian Alps, Baden, Schleswig-Holstein, etc., and has long been confused with anthrax. Symptomatic anthrax has not hitherto been known to occur in man. The disease has been studied by Bollinger, Kitasato, and others. It is character- ised by the formation of irregularly v • * * outlined, emphysematous, crackling ^^^4V Vk * '^ swellings of the skin and muscular ✓!•**! A tissue, particularly on the thigh, and ^ I f 9 w by a peculiar reddish-black discolour- fe *& © ^^^ i ation of the diseased muscles. In the ^ bloody serous fluid at the focus of the ® . |^ g % disease there is found a characteristic ^^ , % " bacillus, which Kitasato was the first &p A • • . » ^ q ^& to obtain in pure cultures upon a solid fv ^, ^f, ' nutritive medium. By inoculating * j^ Q animals with this bacillus Kitasato > • • tf^ excited typical symptomatic anthrax. FiG 285._Bacilli of symptomatif anthrax. The bacillus of symptomatic an- Spore-bearing rods from a culture in agar. ii /Tn- oof> • ±i_ i _ Cover - glass preparation, stained with thrax (Fig. 285) is a rather large, fuchsin.0 x 1000 (Frankel and Pfeifter). slim, actively moving rod with plain- ly rounded ends, generally occurring singly, occasionally in pairs, but never in long filaments. It is strictly anaerobic, and when brought in contact with the oxygen of the air soon perishes. It grows at ordinary temperatures above 18° C, but best in the incubator. The spores form large, strongly re- fracting bodies, rather long, and are placed eccentrically at the end of the rod (Fig. 285). When the spores become free the rest of the bacillus speedily dies. The spores, which have great powers of resistance, do not form in living animals, but do so in dead bodies and in artificial cultures. It is worth noting that the older cells, or those which have grown in media un- suitable for them, have a tendency to develop involution forms, which some- times take the shape of large, plump, spindle-like segments enlarged in the centre, and revealing a granular cloudiness and an irregular contour. In gelatine to which has been added grape sugar or some other reducing substance there develop within a few days spherical masses, which rapidly liquefy the nutritive medium (Fig. 286). In stab cultures, made in a large amount of gelatine, a cloudy, grey liquefaction takes place in the most deeply 390 INFLAMMATION AND INJURIES. placed parts, with the evolution of gas having a characteristic acid odour. Agar, at the temperature of the incubator, becomes filled with bubblec of gas even after the lapse of twenty-four hours. In bouillon, white flakes develop at the bottom of the vessel, accompanied by the formation of gas. When culti- vated at a temperature of 42° to 43° C, the virulence of tbe bacilli is rapidly caused to disappear. The spores, particularly when subjected to high tempera- tures, lose their virulence; but if placed in a twenty-percent, solution of lactic ucid, and then injected into susceptible animals, they can be made to regain their virulence, and that, too, in an increased amount. By inoculating sus ceptible animals with pure cultures the animals quickly die of symptomatic anthrax with the above-described symptoms. Under natural conditions, the disease occurs, in the majority of cases, from infection of small wounds, particularly of the extremities, less often from infection through the lungs or intestine. The poison is conveyed especially by the spores, as the bacilli quickly perish when exposed to the air. It is possible in va- rious ways to obtain immunity from symptomatic anthrax, and for this purpose " vaccination " with suitable " vaccine " is very worthy of recommendation. The bacilli of symptomatic anthrax are stained in the or- dinary way. The little rods, when subjected to Gram's meth- od, lose their stain again. The spores cannot be stained by aqueous solutions of the aniline dyes, but readily take the double stain. § 78. Glanders or Farcy (Malleus).—Glanders is an infectious disease due to bacilli, primarily occurring, by preference, in horses and asses, and is transmissible to man and all domestic animals, with the single excep- tion of cattle. The disease is characterised by the presence of peculiar small and large nodules, particu- larly in the mucous membrane of the respiratory tract, and in the skin, with secondary metastatic nodules in the internal organs (spleen, liver, kidneys, testicle, bones, etc.). Loftier and Schiitz demonstrated four years ago the presence of the characteristic bacilli in the glanders nod- ules, and made pure cultures of the bacilli upon artifi- cial nutritive media, and produced typical glanders by inoculating various animals with these cultures. Israel, Kitt and Weichselbaum have also found the same bacilli in glanders, and have successfully inoculated other ani- mals with them, so that there can be no doubt that these bacilli are the cause of the disease. Glanders Bacilli.—The glanders bacilli (Fig. 287) are slim rods similar to tubercle bacilli, but more regular as regards their size, and somewhat broader Fio. 286.—Bacilli of symptomatic anthrax. Pure culture four days old, after scattering the inoculating ma- terial about in grape-sugar gelatine ; un- stained ; natu- ral size (Frankel and Pfeitfer). §78.] GLANDERS OR FARCY. 391 than the latter. They possess no inherent power of motion. The bacilli, like most of the pathogenic bacteria, are facultative anaerobic, and can be culti- vated in the necessary nutritive medium at temperatures ranging between 25° and 40° C, and in the presence of oxygen. Upon potatoes there forms, at the ordinary incubator temperature, in the course of about two days, a yellowish, honey-like layer, which afterwards gradually becomes darker, varying from brownish to dark red. Upon agar the colonies form a whitish shining layer, and upon blood serum, which does not become liquefied, a clear, transparent covering in the form of drops, which later coalesce. The formation of spores by the glanders bacillus has not yet been demonstrated, but is considered probable by Loffler, Baumgarten and Rosenthal. Prolonged cultivation upon artificial nutritive media causes the glanders bacillus soon to lose its virulence. By inoculation of pure cultures of glanders bacilli upon sus- ceptible animals (horse, ass, goat, cat, \ field mouse, house mouse, guinea- pig), the typical form of glanders is produced, the glanders bacilli being /J ^ "if mainly found in the centre of the specific glanders nodules. Less sus- ceptibility to glanders is evinced by hogs, sheep, rabbits, and dogs, with the exception of young dogs, wbich according to Fliigge, are very sus- ceptible to the disease. Cattle, house mice, white mice and rats are entire- ly unsusceptible. Field mice die in from three to four days after an arti- Fig. 287.—Bacillus of glanders. Pure cultures ficial subcutaneous infection with upon glycerine-agar, teased specimen stained with carbolic-fuchsin. x 100(iran- glanders ; guinea-pigs only in the kel and Pfeiffer). course of several weeks. Leo states that white mice lose their natural immunity and become susceptible to glanders if they are made artificially diabetic by feeding them with phlori- zin. The richer the blood of a particular animal in oxygen, the less able is the glanders poison to dovelop (Sanarelli). By continuous transmission of glanders bacilli from one animal to another it is possible to cause a remark- able increase in their virulence (Gamaleia). Babes has obtained from glan- ders cultures a toxalbumen (" mallein ") which causes no local disease, but does cause symptoms of poisoning (fever, cramps, nephritis, marasmus). The bacilli exist in the specific new tissue formations partly singly and partly in irregular collections or bunches of several parallel rods. The glan- ders preparations, or rather the glanders bacilli, are stained with concentrated alkaline solutions of methyl blue. They are then treated with greatly diluted acetic acid, washed in alcohol, and embedded in oil of cedar. Glanders bacilli cannot be stained by Gram's method. Amongst the recent methods of stain- ing the following are particularly good : Weigert's aniline method, Unna's dry method, and the method of R. Kiihne (sections placed for six to eight hours in carbolised methylene blue, then decolourised in acetic acid, and again in distilled water, dried upon the slide, clarified with xylol and em- bedded in Canada balsam). 392 INFLAMMATION AND INJURIES. Noniewicz recommends the following combination of Loffler's and Unna's staining methods : 1. Place the section taken from alcohol in Loffler's solu- tion of methylene blue for from two to five minutes. 2. Wash in distilled water, and stain for from two to five seconds in seventy five parts of one- half-per-cent. acetic acid and twenty-five parts of one-half-per-cent. tropaeo- lin. 3. Wash in distilled water. 4. Dry upon the slide, apply a drop of xylol, and examine in xylol and Canada balsam. According to Noniewicz, glanders is caused partly by bacilli and partly by a coccus form. The round bodies are found particularly in subacute and chronic glanders. Glanders infection, under natural conditions, generally occurs through some small injury of the skin or mucous membranes, and by inhalation. Babes has produced glanders in guinea-pigs by rubbing very virulent glan- ders bacilli into the sound skin; whence it follows that glanders bacilli are also able to penetrate into the hair follicles of the uninjured skin. Glanders in Animals.—Glanders occurs in horses and other animals in the form of small or large nodules, or as a diffuse infiltration. The glanders nodules appear especially upon the mucous membrane of tbe respiratory tract and upon the skin. The nodules occurring in the mucous membrane of the respiratory tract, especially that of the nose, the larynx, and trachea, vary between the size of a grain of sand and a pea. At the outset they have a greyish-white or greyish yellow colour, and appear singly or in groups and are surrounded by a red areola. From a suppurative breaking down, often within a few days, there result proportionately large ulcers, which usually enlarge rapidly by necrosis of the surrounding parts, extending also deeply into the subjacent tissues. In the lungs the glanders nodules are similar to tubercular nodules, appearing partly as lobular foci of inflammation and partly as interstitial nodules. The pulmonary glanders nodules occur, ac- cording to Bollinger and others, partly from direct aspiration of the glanders poison and partly as a result of embolism. In addition to the circumscribed glanders nodules, there are also found in the lungs diffuse infiltrations. Upon the skin there occur, in tbe cutaneous form of glanders, small (miliary) or large nodules, accompanied by a rapid suppurative breaking down, and tbe formation of ulcers which quickly extend and also lead to in- flammation of the lymphatic vessels and glands. Cutaneous glanders in rare cases may also occur, by an embolic process, secondarily to primary glanders of the respiratory mucous membrane. As wTus mentioned before, secondary glanders may also be found in the spleen and liver and in the bones, less often in tbe kidneys and testes, as a result of embolism. The course of glanders may be acute or chronic, in the former terminat- ing in death in six to twelve days ; the latter, the more common form, may last for years. Glanders in Man.—The transmission of glanders to man does not take place very frequently. Individuals—such as butchers, hostlers, cavalry soldiers, veterinary surgeons, etc.—who come in contact with animals, especially horses, which have glanders, are particularly apt to contract the disease. In man the disease takes the form of glanders of the conjunctiva, less often of the nasal mucous membrane, and particu- §78.] GLANDERS OR FARCY. 393 Fig. 288.—Acute glanders in man eights days old.' Well-developecTuk-erations oF*fn"e skin of the face (Birch-llirseli- feld). larly glanders of the skin, originating in some insignificant injury, espe- cially about the face and on the hands. In man also, as in animals glanders may run an acute or chronic course, and there may develop the above-described glanders nodules and ulcerations at the point of infection, and secondary nodules in the internal organs as a result of embolism. Acute glanders runs a course marked by severe tvphoid, septic manifestations, and sometimes it may resemble acute articular rheu- matism. The disease not infrequent- ly begins with a general feeling of malaise, and pains in all the limbs, in the joints and in the back. In conjunction with a high fever there develop at the point of infection typ- ical glanders nodes which break down and ulcerate. Upon the skin pustular eruptions appear, which change into phagedsenic ulcers having a dirty, lar- daceous base. Birch-Hirschfeld saw pemphigus-like blebs upon the skin of the nose and cheeks, with rapid destruction of the greater part of the skin of the face (Fig. 2SS). In cutaneous glanders there are also not infrequently observed diffuse erysipelatous inflammations, and particularly lymphangitis and phleg- monous infiltrations of the subcutaneous cellular tissue, terminating in suppuration or ulcerative destructive processes. The secondary foci of glanders, particularly those in the internal organs, bear in acute glan- ders a close resemblance in every respect to pyaemic foci of pus, in chronic glanders to cheesy formations. The above-described affection of the nose so characteristic of glan- ders in the horse, is not so frequently observed in man, and occasion- ally it first makes its appearance rather late in the disease. Acute glanders is accompanied by high fever, and runs a regularly fatal course within days or weeks, in consequence of the increasing systemic infection, with the formation of secondar}7 nodes or abscesses in the internal organs as well as in the muscles and subcutaneous cellular tis- sue. Chronic glanders in man has hitherto been less accurately observed. Konig gives its average duration as four months. It runs a course essentially analogous to the above-described chronic glanders in the horse. Birch-Hirschfeld calls attention to the resemblance of chronic glanders to syphilitic and tubercular disease. According to Konig, the mortality of chronic glanders is about fifty per cent. 394 INFLAMMATION AND INJURIES. Diagnosis of Glanders.—The diagnosis of glanders in primary infec- tion of the skin and nasal mucous membrane is usually not difficult, in consequence of the characteristic behaviour of the glanders nodes taken in conjunction with the occupation of the patient. Internal glanders of the trachea and lungs may often be first recognised when secondary affections of the skin occur, or when the characteristic glanders bacilli are demonstrated in the sputum. The demonstration of the bacilli in every case is, of course, of the greatest diagnostic importance. A good method for quickly diagnosing glanders consists in mixing the suspected secretion with water, and then injecting it intraperitoneally into male guinea-pigs. If it is really glanders, after the lapse of two to three days there occurs a swelling of the testicles, which increases during the next few days. In glanders it is of the greatest importance for the patient and his surroundings that the disease should be recognised as early as possible and energetically treated. Treatment of Glanders.—The treatment of glanders can only be suc- cessful when the point of infection can be destroyed at a very early pe- riod by surgical means—either by extirpation, by the Paquelin or gal- vano-cautery, or by strong caustics (nitric acid, chloride of zinc), etc. The remainder of the treatment is symptomatic, and consists mainly in an energetic local treatment of the glanders focus by incision. Inunctions of mercurial ointment (two to three grammes a day) have been repeatedly used with success. Iodine and arsenic have been recommended internally. § 79. Foot-and-Mouth Disease (Aphthae EpizoUticce).—The foot-and- mouth disease is, according to Bollinger, an acute infectious disease which is transmitted exclusively by infection from one animal to an- other. This disease, which is observed particularly in cattle, sheep, swine, and goats, less often in horses and dogs, is characterised by moderate febrile constitutional symptoms, and by the formation of blebs and ulcers upon the mucous membrane of the mouth (stomatitis aph- thosa), in the clefts of the hoofs, and on the udder. The means of in- fection—that is, the variety of micro-organism—is not yet known. Bender and Bollinger found in the ulcers and aphthae micrococci and small rods. For the poison to enter the body, an injury, according to Bollinger, is not necessary; it clings to the uninjured epithelial layer of the cavity of the mouth or enters the system through the lungs, and probably also with the food. The disease is very contagious. The course of the foot-and-mouth disease is, as a rule, favourable, its dura- tion, according to Bollinger, being usually twelve to fourteen days, rarely less. It generally terminates in recovery, and only young and cachectic old animals occasionally succumb to the disease if surrounded by unfavourable conditions. §80.] HYDROPHOBIA. 395 Occurrence of the Mouth-and-Hoof Disease in Man.—The transmission of the disease to man occurs, according to Bollinger, most frequently by drinking the uncooked milk of diseased cows (Hertwig, Jacob), or by infection of a wound, particularly on the hands of butchers, or as a. result of milking cows with a vesicular eruption on their udders, or by contact with the saliva of animals having the disease. Man is only moderately susceptible to the poison. The symptoms of the disease in man—for example, after infection through milk—consist in an ulcerative stomatitis, a catarrhal gastro- enteritis, accompanied by fever, and frequently in a vesicular eruption upon the hands, the face, and other portions of the body. If the poison is transferred through a wound—for instance, in slaughtering or milking an infected animal—the hand and forearm become swollen, vesicles form, and the patients complain at the same time of pain in the mouth and dysphagia; and later vesicles or pustules make their appearance on other portions of the skin, particularly on the face. The disease lasts five to eight days; and only when the ulcers in the mouth and on the hands take on a virulent character and heal slowly does the affection continue for two to four weeks. Secondary phlegmonous- suppurative inflammations occasionally make their appearance. In a great majority of the cases, according to Bollinger, the disease terminates in recovery, and only rarely, particularly in weak infants, causes death. Treatment.—The treatment is essentially dietetic. Care should be taken to use only healthy milk. If the stomatitis is intense, it is an excellent plan to swab the mouth out repeatedly with a borax solution, and to employ mild cauterisation of the erosions and ulcers with silver nitrate in the form of a stick. The vesicular eruptions on the skin should be treated with ungt. lithargvr. Hebrae,* vaseline, boro-glycerine ointment, and particularly by dusting them with bismuth, iodoform, or oxide of zinc with starch (one to five to ten). § 80. Hydrophobia (Lyssa, rabies).—Hydrophobia is an acute infec- tious disease which occurs chiefly in the dog ami related species of animals —wolf, fox, jackal, hyena. It consists essentially in a disease of the central nervous system, and is characterised by a long and extremely variable period of incubation. Etiology of Rabies.—Babies originates in a manner similar to syphi- lis—that is, by direct transference of the poison from the bearer to the receiver. The poison only takes root when inoculated into an injury of the skin or mucous membranes. 26 * Unguentum diachylon. 396 INFLAMMATION AND INJURIES. Rabies is almost always transmitted through the bite of a rabid ani- mal, by which the poison is directly inoculated into the wound. The experiments of Roux and Xocard show that infection may even re- sult from a dog which at the time when he bites or licks an individ- ual is entirely healthy, but later becomes mad. According to Novi, the poison of rabies may also be transferred to animals by midges and flies. Decomposition does not seem to destroy its virulence very soon. In dead animals decomposing in the air, the virulence, accord- ing to Travali and Brancaleone, could not be found after twenty-one days. In buried animals, the nervous centres were, in some instances, found virulent even after the lapse of forty-eight days; in other cases every trace of virulence had disappeared thirty-eight days after burial. The poison of rabies is destroyed by the digestive fluids. Zagari states that the virus of rabies loses its virulence very quickly when in con- tact with oxygen or air, as it also does in a dry medium and when the temperature is somewhat elevated ; but in a space devoid of air, in carbonic acid, in a damp medium, and at low temperatures, it remains active for a long time. The poison of rabies, according to Pasteur, is always present in the fresh saliva, the blood, the spinal cord, and in the brain, salivary and lachrymal glands, the pancreas, and perhaps the mamma of animals affected with hydrophobia. Bombicci has also found that the suprarenal capsules are always virulent. Di Yestea, Zagari, and Schaffer have shown that the rabies poison is spread throughout the body by the nerves, in addition to the blood and lymphatic vessels, and this nervous distribution of the poison is the essential factor in caus- ing the diffuse myelitis of the central nervous system. The views upon the microbe of rabies are still divided. Gibier, Brigidi and Bianchi think that a micrococcus is the cause of hydrophobia, whilst Pasteur has found a characteristic bacillus which he attempted to breed in pure cultures, and which for a long time he considered to be the exciting cause of hydrophobia. As yet the micro-organism of rabies is not known, all attempts at artificial cultivation having been hitherto unsuc- cessful. The poison of rabies acts like strychnine. Transference Experiments.—Eaynaud, Lannelongue, Pasteur and others have transferred the disease to rabbits by inoculating them with the saliva of persons affected with rabies. Pasteur obtained from the blood of these rabbits a micro-organism which he cultivated in veal broth; it was a bacillus somewhat contracted in the centre, and surrounded by a gelatinous sub- stance. Pasteur at first believed, as we have said, that he had found in this bacillus the excitant of rabies; but he then produced the same disease by in- oculating healthy human saliva, and he found the same micro-organisms in the inoculated rabbits. Vulpian and Frankel obtained the same results by inoculating rabbits with normal saliva. Brigidi and Bianchi found in the §80.] HYDROPHOBIA. 397 saliva, and particularly in the blood of three individuals with rabies, before and after death, micrococci occurring singly or in pairs (diplococci). Only one of the attempts at inoculation in a rabbit was successful. Making use of Pasteur's method, brain substance was used for inoculation in this case. A portion of the brain substance taken from a child which had just died of rabies was placed in a wound in a rabbit's brain which had been exposed through a small opening in the skull and dura. The wound healed without reaction; the rabies began after the lapse of thirty-two days, and in two days the animal was dead. Tbe autopsy revealed complete cicatrisation at the point of operation, intact meninges, intact brain and spinal cord, and no suppuration. In the brain, spinal cord and blood numerous micrococci were found. An attempt at inoculation with the brain matter of this animal gave no results. Contrary to the views hitherto held upon the subject, L. Gibier has suc- cessfully inoculated birds (chickens) with hydrophobia, and from these he again transmitted the disease to rats by inoculation, which then died with the characteristic symptoms of rabies. Sometimes the inoculated birds withstood the disease. Microscopical examination of the brain of the diseased animals always revealed the presence of the above-described micrococcus of Gibier. Transmission of rabies from the maternal animal to the foetus in utero has been observed by Perroncito and Carita in rabbits and guinea-pigs. Strengthening and Attenuation of the Rabies Poison according to Pasteur. —It is well known that Pasteur has artificially strengthened and weakened the virulence of the poison of hydrophobia. By continued transference of the poison in rabbits Pasteur obtained a very pure rabies poison which is constant in its effects. The fresh spinal cord and the medullary portion of the brain of such animals contain the strongest virus. If portions of the spinal cord and brain are dried, the virulence gradually diminishes propor- tionately to tbe length of time tbat the drying is continued. Pasteur has been able, by means of systematic inoculations with rabies poison of increas- ing virulence, to make dogs immune from the bite of mad dogs and from the artificially transferred rabies poison in its most potent form. In conjunction with these experiments on animals, Pasteur undertook, for therapeutic pur- poses, protective inoculation in individuals who had been bitten by dogs pre- sumably mad (see pages 401-403, Treatment of Rabies). According to Tizzoni and Schwarz, the immunising substance, as in tetanus and diphtheria, is only found in the blood serum of the inoculated animals ; it behaves like globu- line, and probably balongs to the enzymes. Therefore they recommend that, as in tetanus and diphtheria, the blood serum of animals which have been rendered immune from rabies by inoculation should also be employed in man for prophylactic and curative purposes. Action of the Rabies Poison.—The action of the still unknown rabies poison is probably similar to that of the tetanus bacillus. AVe saw in the chapter on tetanus, which is so closely related to rabies, that the number of the bacilli in the system capable of demonstration is very small, and that the tetanus bacilli are destructive not by their num- bers but by the formation of the poisonous products of their meta- 398 INFLAMMATION AND INJURIES. bolism (toxine). The poison of rabies acts, as we have stated, similarly to strychnine. Rabies in the Dog.—The symptomatology of rabies in the dog is briefly as follows: A stage of incubation precedes the disease, and lasts generally three to five weeks, seldom less or more. The longest duration of the incubation stage, according to Bollinger, is eight months. During the incubation the wound from the bite usually heals very rapidly, without any particular in- flammatory manifestations. In dogs, two forms of rabies are distinguished —the raging madness, or rabies, and the still rabies. The symptoms of rabies vary in other respects, according to the race, sex, the state of nutrition, etc., of the animal. The raging madness usually begins with a stage of melan- cholia, which is characterised by great irritability of the animal, a peculiar restlessness, loss of appetite, dysphagia, and nausea. The dog shows a re- markable preference for all sorts of indigestible things, such as hair, earth, straw, dung, etc. The danger for man is the greatest during this stage, and is so much the more so since the first manifestations are often very insignifi- cant. The initial stage, according to Bollinger, lasts one half to two to three days ; then follows the stage of real madness—the irritation or maniacal stage—lasting three to four days. The characteristic manifestations of this stage, which only occur in paroxysms, are the change in the disposition, the continued loss of appetite, a peculiar change in the voice, an impulse to escape and run about, disturbances of consciousness, a marked passion for biting, and a rapidly increasing emaciation. A noticeable aversion to water is lack- ing, according to Bollinger, and only in exceptional instances does spasm occur in the muscles of deglutition. In the last or paralytic stage there is a constantly increasing weakness. The entire picture presented by the bris- tling animal is frightful to look at. The voice becomes constantly hoarser, the dyspnoea increases, and death generally occurs on the third, fifth, or sixth day, occasionally with partial or general convulsions. The termination, according to Bollinger, is always fatal ; recovery has not yet been observed. The quiet or melancholic form of rabies, which, according to Bollinger, makes up about fifteen to twenty per cent, of the total number of cases of madness, runs a more rapid course, as there is no maniacal stage. In the first stage the manifestations are the same as in the wild variety ; then there soon follows a paralysis of the lower jaw, the mouth remains wide open, the voice becomes hoarse, disturbances of consciousness, rapid emacia- tion, and paralysis of the hind quarters follow, with death in two to three days. The results of the autopsy reveal little which is positive. The most im- portant changes, according to Bollinger, are a dark, thick condition of the blood, oedema of the brain, more or less pronounced catarrhal changes in all the mucous membranes, particularly in the respiratory and digestive tracts, frequently combined with hyperaemia and ecchymoses, hypersemia and cya- nosis of the parenchyma of various organs, and a high grade of emaciation. In the stomach and intestine there are usually found, instead of the normal food stuffs, indigestible foreign bodies of various kinds. Hydrophobia in Man.—In man, rabies occurs by far the most fre- quently as the result of the bite of a mad dog (ninety per cent.), less §80.] HYDROPHOBIA. 399 often of cats (four per cent.), wolves (four per cent.), and foxes (two per cent.), and it always terminates fatally. Children, especially, often fall victims to the disease. According to the French statistics, one third to one fourth of all the cases of the disease occur in children under fifteen years of age (Ollivier). The question as to how many of those who are bitten by mad dogs are attacked afterwards by the disease, has received very diverse answers. Bollinger is right in maintaining that the percentage of those attacked by the disease depends upon whether one only takes into account the bites of really mad animals, or also of those which are supposed to be mad ; and finally upon whether, and when, energetic prophylactic treatment of the wound made by the bite is adopted. This explains the discrepancies in the records, some of which state that a half, others a third, or even not more than five per cent., of those who are bitten become affected with hydrophobia. The cases of death from rabies in animals and in man have diminished remarkably in states such as Prussia, where there are stringent laws levied against all dogs found running about loose, or those thought to have hydrophobia, and wdiere the muzzling of dogs is compulsory; indeed, in such states, as Fliigge has stated, rabies in man has as good as entirely disappeared. As yet no undisputed case has been observed of the transmission of rabies from man to man. In man, also, rabies is marked by a stage of incubation, generally of eighteen to sixty days, and occasionally of three to six months. An incubation of less than fourteen days is rare, and only in exceptional instances are there incubations lasting from six to twelve months. After the termination of the incubation j>eriod, during which the per- son who has been bitten feels perfectly well, and the wound has healed, usually with exceptional rapidity, the rabies begins with psychical disturbances (a melancholic frame of mind, excitability, restlessness, loss of sleep), loss of appetite, and occasionally, even at this stage, an antipathy towards liquids. The local manifestations at the point of the bite, which has generally healed, are not constant; occasionally there is observed an inflammatory swelling of the cicatrix, or the patient complains of pain, burning or itching. Fever is usually not present. The prodromal stage lasts, for the most part, about twenty- four hours, rarely longer. The first symptom of true hydrophobia in man is a spasm of the pharynx resulting in an inability to swallow. There now occur, in the form of paroxysms, severe respiratory and pharyngeal spasms caused by any kind of irritation, and especially by the sight of liquids—hence the name " hydrophobia." At the same time there are observed reflex spasms, for the most part general clonic spasms, less often tetanic. There is also a characteristic increased reflex 400 INFLAMMATION AND INJURIES. excitability of the nerves of special sense; the patients suffer from a perverted sense of smell; they are over-sensitive to any noise, any draught of air, etc. They are usually afflicted with a nameless dread, which does not allow them to get any rest; the salivary secretion is in- creased; the mind remains, in the intervals, for the most part clear, but from time to time there are maniacal seizures, partly as a result of the terrible dread and the oppression in the chest due to the feeling of suffocation, and partly as a result of the attempts of others to re- strain them. The pulse, which is at the outset full, gradually becomes weaker and more frequent, particularly after the paroxysms, when it reaches 120 to 160 or more. The temperature is generally only slightly elevated— 38° to 38-5° C. (100*4° to 101'3° F.)—seldom'reach- ing 40° C. (104° F.) or more. After the above-described manifesta- tions of the second stage have lasted for one to two to three days, there occurs, with an abatement of the spasms and the difficulty in breathing and swallowing, a general exhaustion ; death then follows within the next few hours, with convulsions, or even perfectly quietly, or less often during a recurrence of one of the attacks of spasm. The con- sciousness is usually unclouded up to the last. The duration of rabies in man is, in the majority of cases, two to four days, rarely more or less; the termination, as in animals, is regu- larly fatal. Result of Autopsy.—The results of the autopsy in man are similar to what we have briefly described for rabies in animals—that is, the autopsy shows practically no characteristic changes. Schaffer called attention to an acute diffuse myelitis of the central nervous system in both the grey and the white matter, with marked degeneration of the nerve fibres and ganglia. Popoff often found in the nerve fibres of the central nervous system a very high grade of hypertrophy of the axis cylinder and an atrophic condition of the nerve cells, with conspicuous pigmentation. Popoff saw these changes chiefly in the motor centres. At all events, there is a pronounced parenchymatous myelitis, which affects principally the nuclei of the motor nerves (Charcot, Leyden, Erb). Diagnosis.—In the diagnosis of rabies in man, the pharyngeal and respiratory spasms, the increased reflex excitability, and the paroxysmal nature of the manifestations of the disease are characteristic. Rabies can only be confused with tetanus of the head, the so-called tetanus hydrophobicus, which occurs in conjunction with wounds in the region supplied by the cranial nerves (§ 73), as in this also there are pharyn- geal spasms. In such cases the patient's statements may point to the correct diagnosis. Tetanus, for the most part, occurs between the third §80.] HYDROPHOBIA. 401 to the eighth to the tenth day after the injury, and hydrophobia in the fourth to the seventh week after the reception of a bite from a rabid animal. Prognosis.—The prognosis of rabies in man is regularly fatal. Tso certain cases of recovery from true hydrophobia have been observed. Treatment of Rabies in Man.—Prophylaxis is of the first impor- tance in the treatment. Strictly enforced police laws against allowing dogs to run about loose without their masters, also a high dog-tax, and laws compelling the use of muzzles, are of the greatest importance in lessening the occurrence and the spread of hydrophobia. As we men- tioned before, it has been possible in this way to very materially diminish the frequency of the disease. If a person is bitten by a mad dog, or by one supposed to be mad, the poison at the point of infection—that is, in the wound—must be de- stroyed as soon and as energetically as possible by careful disinfection with a one-fifth-per-cent. solution of bichloride of mercury or a five- per-cent. solution of carbolic acid, followed by energetic cauterisation with the red-hot iron, the Paquelin, or with chemical caustics (caustic potash, sulphuric and nitric acids). It is also a very good plan to im- mediately suck out the fresh wound. Excision of the wound or cica- trix, with subsequent cauterisation, may be efficacious, even though done several days or weeks after the injury was received. Pasteur's Protective Inoculation.—It is well known that Pasteur has undertaken protective inoculations upon people who have been bitten by mad dogs, after he had made the discovery, as stated above, that dogs become gradually unsusceptible to hydrophobia when inoculated with rabies poison the virulence of which is gradually increased. Bor- doni-Uffreduzzi has successfully practised Pasteur's preventive inocula- tion on dogs and on one horse. Tizzoni and Schwarz recommend the use of blood serum taken from animals (rabbits, dogs) rendered arti- ficially immune, for prophylactic and curative purposes in man, since the immunising or curative substance is, as in tetanus, chiefly found in the blood serum. Technique of Pasteur's Protective Inoculation.—Pasteur's manner of per- forming protective inoculation is as follows : A suitable amount of the dried spinal cord of an animal which has had rabies is pulverised with sterilised instruments, and to it is added sterilised veal bouillon. Lymph is thus obtained of varying virulence, according to the relative amounts of the con- stituents and the length of time that the cord has been dried. The material for inoculation is now injected with a hypodermic needle beneath the skin of the abdomen a little below the ribs, three fourths of a cubic centimetre being used for full-grown men and a little less for women, and half a cubic centimetre for children. Pasteur usually begins with a spinal cord 402 INFLAMMATION AND INJURIES. which has been dried for fourteen days, then on the following day an injec- tion is made of one dried for thirteen days, etc., until for the tenth inocula- tion a spinal cord is employed which has only been dried five days ; the patients are then discharged. Sometimes, especially in bad cases—for ex- ample, in Russians bitten by mad wolves—according to Uffelmann's report, inoculations are made two to three times a day with rabies poison of increas- ing virulence. In this manner Pasteur has inoculated a great nnmberof people who had presumably been bitten by mad dogs ; of these people some died of rabies a short time after the treatment, and others later, and it is not impossible that death from hydrophobia may have occurred in some of the cases in consequence of the inoculation. But in a great number of cases the protective inoculation may have given the wished-for result. At all events, Pasteur's experiments are of the greatest scientific interest; but we must acknowledge, with Koch and Fliigge, that Pasteur's protective inoculation for man has been used, for practical purposes, much too soon. A more thorough scientific investigation of the method should have been made before it was put to practical use. According to the results hitherto recorded, the success of protective inoculation is uncertain ; and, on the other hand, there is the danger that people who would otherwise have remained healthy may, in consequence of the inoculation, become infected with rabies and die. Bordoni-Uffreduzzi has likewise employed Pasteur's method of treatment with the best success, and in his statistics during the years 1886-88 he re- ports : Two hundred and forty-one persons were bitten by animals which were experimentally proved to have rabies ; in tbe case of two hundred and forty-five more, treated by Pasteur's method, the hydrophobia of the animals which bit them was rendered certain by physicians' certificates or by clinical observation ; in forty-five persons the diagnosis of rabies was doubtful. Only six of the first group died ; of the second, four ; of the third, none ; and consequently the mortality of the whole list was 1.88 per cent. "When the disease has once broken out, usually no treatment is of avail. We are then forced to limit ourselves to easing the great suffer- ings of the patient by symptomatic treatment. First of all, and as soon as possible, large doses of curare should be injected subcutane- ously. Pensoldt, in one case occurring in an eleven-year-old boy, employed without success very large doses of curare, injecting on an average 0*01 to 0*02 gramme every half hour, and in the course of one to two and a half hours the full fatal amount of curare was administered. Curare is very valuable in all cases as a symptomatic remedy for modifying the pharyngeal and respiratory spasms, but it does not possess an actual curative effect upon the disease. Remedies like chloral and chloroform are indispensable. For the severe convulsive and maniacal seizures of the patient the continuous administration of chloroform by inhalation is probably the best treatment. Recently various remedies have been recommended for rabies. For example, Kartschewskji speaks wTell of the internal use of cantharides 81.] POISONING BY INSECTS, SNAKES, ETC. 403 powder (0*06 gramme pro die) for a week, and at the same time the application of emplastrum cantharidum to the wound made by the bite. According to the experiments of De Blasi and Russo Travali, the poison of rabies has little power of resistance against the ordinary antiseptics and caustics, and they recommend creolin and succus citri. The latter, as is well known, has a great reputation as a popular remedy. § 81. Poisoning by Insects, Snakes, Etc.—From the bites of certain insects and snakes, poisoning, sometimes mild and sometimes severe, may result, the nature of which we do not as yet fully understand. Amongst the injuries caused by the stings of insects belong the bites of gnats, fleas, bugs, etc., after which, as a result of the introduction of some irritating substance, there ensue local inflammatory manifesta- tions in the form of redness and wheals, with itching and burning. Severer inflammation follows the wound inflicted by the sting wdiich is situated in the posterior end of the bodies of bees and wasps. Their sting involves a decided poisoning of the wound, which occasionally presents itself as a very extensive, painful inflammation, with redness and swelling, and not rarely there may even be alarming constitutional symptoms. Many individuals are exceedingly susceptible to the stings of bees and wasps. The local inflammatory manifestations usually sub- side very soon. The constitutional symptoms which now and then occur—for instance, after the direct injury of a small cutaneous vein or a lymphatic vessel—consist sometimes in a peculiar state of collapse ; the skin is cool, and covered with a clammy sweat, the pulse is small and rapid, and occasionally a condition of coma is observed. These threatening constitutional symptoms last usually only a few hours, but the patients generally feel remarkably feeble for several days. There are also many examples known of men and animals dying in a short time after being attacked by a swarm of bees or wasps. The nature of the wasp and bee poison is as yet unknown. Injuries from Tarantulas and Scorpions.—I should also mention in- juries produced by the tarantulas and scorpions of southern countries, with the subsequent extensive local inflammations, wliich never termi- nate fatally. The treatment of the above-mentioned injuries, particularly the stings of bees, wasps, tarantulas, and scorpions, is best carried out with ammonia and antiphlogistic remedies. As Billroth says, bee-tenders employ scorpion oil as a kind of antidote for bee stings—that is, olive oil in which some scorpions have been kept. Injuries from Venomous Snakes.—The injuries due to poisonous snakes are relatively rare in our zones as compared with the tropics. 404 INFLAMMATION AND INJURIES. The nature of the snake poison is as yet unknown to us; it is probably a poisonous alkaloid which is contained in the secretion of the poison glands. In Europe there are ordinarily found only three kinds of poisonous snakes—the vipera berus, the vipera redii, and the vipera aspis. These poisonous snakes have two hook-shaped poison teeth, in which the excretory ducts of small glands empty. At the time of the bite the glands empty their poisonous juices into the wound. By drying the secretion from the poison glands of forty asps, Karlinski obtained fifteen grammes of a white amorphous mass, easily soluble in water and alcohol, a twenty-per-cent. aqueous solution of which cor- responded in its action to the fresh poison coming from the poison glands of the adder. The bites of the above-mentioned poisonous snakes are in general not very dangerous; according to Billroth, about two die out of a total of sixty bitten. The manifestations after the bite of these poisonous snakes consist in a very painful local inflammation, in coagulation of the blood in the parts immediately adjoining the wound, in thrombosis of the blood- vessels, not infrequently in gangrene, vomiting, high fever, a feeling of anxiety, cramps, great weakness, etc. The affected portion of the body is subsequently often remarkably devoid of sensation. Occasion- ally death occurs in a relatively short time, preceded by an increasing state of collapse. If a person bitten by a viper redii survives the first two days, the prognosis is in general favourable. The best treatment for these snake-bites is to immediately suck the wound—a procedure entirely free from danger—then to wash out the wound with bichloride of mercury, carbolic acid, absolute alcohol, etc., and, when possible, to cauterise the wound with some energetic liquid caustic or with the hot iron. To prevent the rapid absorption of the poison, it is a very good plan to employ the popular remedy of tying off the injured portion of the body—an extremity, for instance—as soon as possible, close above the bite. Energetic antiphlogistic meas- ures are adopted for the local inflammation. Finally, the internal and subcutaneous administration of liquor ammonii fortior has been recom- mended, a hypodermic syringe full (one part liq. ammon. fort, with one to two to three parts water) being used as a subcutaneous injec- tion ; internally ten to twelve drops of the same mixture should be given many times each day. Karlinski praises the injection of one per cent, chromic acid and of chlorine water (Lenz) into the wound made by the bite and the surrounding parts. Large doses of alcohol (whiskey) and energetic active motion of the muscles are in great re- pute amongst the laity. The most dangerous poisonous serpents are the American rattle- §83.1 THE POISONING OF WOUNDS BY INDIAN ARROW POISON. 405 snakes and the cobra species of Asia and Africa. After injuries in- flicted by the bite of these snakes there ensue extremely severe local inflammations which terminate in gangrene. The constitutional mani- festations are like those in hydrocyanic-acid poisoning, consisting in a feelino- of dread, oppression of the chest, cyanosis, delirium, convul- sions, and stupor. Death follows, occasionally in a few hours, with svmptoms of collapse ; in fact, death not infrequently occurs before any local symptoms make their appearance. It is of practical importance to note that the poison may even have a fatal effect when in a dried condition or in an alcoholic preparation. According to Cohnheim, death from a poisonous snake-bite is in all probability caused essen- tially by the disintegration of the red blood-corpuscles. The treatment is in general like that for the bite of a vipera berus. Richards and De Lacerda, basing their opinion upon experiments with the poison of the cobra, recommend the subcutaneous injection of a five-per-cent. aqueous solution of permanganate of potassium (eight to twelve grammes of the solution). Immediately after the reception of the bite a ligature should be placed on the proximal side of the wound, the ligature not being removed until several minutes after making the injection. In one case potassium permanganate was in- jected with success twenty-five minutes after the reception of the bite. The length of time within which a subcutaneous injection of potas- sium permanganate is attended with success becomes proportionately prolonged when a ligature is applied above the poisoned wound. If the poison has already caused constitutional symptoms, Richards's ob- servations show that the injection of permanganate of potassium has no effect. § 82. The Poisoning of Wounds by Indian Arrow Poison.—This is perhaps the best place briefly to consider the wound infections pro- duced, for instance, by the poisoned points of arrows used by the Indians. According to ^V. T. Parker, the arrow-points of the American Indians are poisoned with a devilish cunning, and the process is frequently kept secret. Vegetable poisons, especially curare or urari, or decomposing putrid substances (decomposing meat and blood, for instance, of dead enemies, decomposing liver, etc.), or snake poisons, made, for ex- ample, from the crushed heads of serpents, are employed. There is also a partiality for using the liver of an ox, which is pierced with arrows and allowed to decompose in the sun; crushed ants are also added to the mixture. The symptoms of poisoning differ according to whether a vegetable poison like curare, or putrid substances, or animal poisons like those of snakes, or mixed poisons are employed. The action of curare, the real arrow poison of the Indians, is, as is well 406 INFLAMMATION AND INJURIES. known, to paralyse voluntary muscles, except those of the heart and respiration. The cardiac and respiratory activity only succumb after poisoning with very large doses of curare. The American Indians still commonly use the arrow, in addition to firearms, for war and the chase. The point of the war arrow, according to W. T. Parker, is short and broad, and so formed as to enter easily between the ribs of a man. The hunting arrow is the weapon to be most feared. The Indiana can shoot this about one hundred metres, and with as great accuracy as the best modern revolver. The arrow penetrates the tissues with great force, and can perforate the stoutest bones. Gutters are made in the shaft to permit the blood to escape from the wound. The point of the arrow is fastened to the shaft in such a manner that when it becomes wet, and consequently when it is in a wound, or when at- tempts are made at extraction, it easily becomes loosened and remains in the wound. The arrow-points are made of iron, pebbles, bones, glass, wood, etc. The Indians are greatly skilled in removing the points of arrows from wounds in which they have stuck. A counter opening is often made through which, after cutting off the shaft, the arrow-point is withdrawn. Appendix. Chronic mycoses: Tuberculosis (scrofula), syphilis, leprosy, actinomycosis. § 83. Tuberculosis.—Of the chronic infectious diseases of bacterial origin which are of importance for the surgeon, tuberculosis is very prominent. By tuberculosis (from tuberculum, a nodule) we under- stand an infectious disease due to a rod-shaped micro-organism, the bacillus tuberculosus (Koch), and characterised anatomically by the formation of nodules, the so-called tubercles. On the 24th of March, 1882, Robert Koch announced to the Physiological Society at Berlin that he had found the cause of tuberculosis, and that the disease was alone produced by a single specific bacillus which he had made grow in pure cultures. The sensation created by Koch's discovery was exceed- ingly great, and his classical experiments in tuberculosis will always excite the profoundest admiration. We shall here discuss mainly surgical tuberculosis—that is, the tuberculosis coming within the jurisdiction of surgical therapy, and so particularly the very common tuberculosis of the skin, mucous mem- branes, lymphatic glands, sheaths of tendons, bones and joints, etc. In whatever part of the body the tubercle bacilli develop and multiply, they always give rise to the formation of characteristic tubercles—that is, to cellular nodules devoid of vessels, which, after the lapse of a defi- §83.] TUBERCULOSIS. 407 nite length of time and in a certain stage in their development, die, usually by a process of cheesy degeneration. Origin and Structure of the Tubercles.—These tubercles (Fig. 289) originate, according to the very careful investigations of Baumgarten, Cornil, and others, in the following manner: In consequence of the growth of the bacilli in any particular tissue, there occurs, in the first place, a proliferation of the fixed tissue cells, which begins with the process of caryomitosis and leads to the formation of protoplasmic, epithelial-like or epithelioid cells. The tubercles are consequently at first made up essentially of groups of epithelioid cells which lie within the connective-tissue stroma of the original tissue, which has been partly absorbed and partly pushed aside—the so-called reticulum of the tubercle. Some epithelioid cells have one nucleus, others two, while still others are polynu- r clear—so-called giant cells- which there are often very great number of large nuclei. The giant cells prof bly originate not by the of several epithelioid celh by the proliferation of ciei of a single cell. of the vigorous growth of the ^gig^^^^ fixed-tissue cells (connective-tts ^^m^i^^^ sue cells: cells of the walls of _,/>«^«&*[«)A,V»l^v,*.^,*, m~@% the vessels, epithelium) no new e^^^(f)f^^ ^iWW formation of capillaries takes *" <*>■*<9 ^ place within the nodules. After FlQ 289.—Tuberculosis of lymph glands : T, tu- fl^ n,.Ai;fovQ^ATi n-f +1ip nrio-innl bercle with £iant cells in the contre> avd larSe the prollteration 01 tlie Ollglliai cdled tissU(T between the separate tubercles; tissue Cells there OCCUr, SOOner v f, cheesy tubercle; A tissue of the lymph- gland, stained with hsemato.x) In. x iW. or later, inflammatory changes in the vessels of the diseased region which lead to an emigration of the colourless blood-corpuscles, first in the periphery and then later in the centre of the nodules. The nodules, which are at the outset made up of large cells, thus come to be made up more and more of small round cells. If the emigration of leucocytes occurs at a very early stage and masks the growth of the fixed cells, it is possible for the nodules to ap- pear to be made up of small cells from the very beginning. When the grey transparent nodules, which are about the size of millet seeds, have reached the stage of the small-celled tubercles they are no longer capa- ble of further development, and there now occurs a retrograde meta- morphosis, the cells perishing by fatty or cheesy degeneration or by 408 INFLAMMATION AND INJURIES. coagulation necrosis, and forming homogeneous masses. Frequently the tubercular foci become permeated with lime salts, and finally form mortar-like concretions. The typical death of the tubercle is by casea- tion or cheesy degeneration (Fig. 289, v. T). The cause of these tu- bercles__that is, the cause of tuberculosis —is the above-mentioned rod-shaped bacillus discovered by R. Koch (bacillus tuberculosus, Fig. 224, page 258). Tubercle Bacilli.—The characteristic bacilli present in the nodules are found either in the interior of the cells—for instance, within the giant cells (Fig. 290)—or between the cells; also in the blood of those suffering from general tu- berculosis, in the sputum of those with tuberculosis of the respiratory tract, in the urine in genito-urinary tu- berculosis, in pus, etc. To Koch alone is due the great credit of having proved, by inoculations with pure cul- tures of his bacillus, that the bacilli present in tuberculo- sis are the sole cause of the disease. Fig. 290.—Giant cell with tubercle bacilli. x 700 (Koch). Robert Koch's Tubercle Ba- cilli—The tubercle bacilli are fine, generally slightly curved rods from 1*6 to 3*5 p in length, incapable of spontaneous movement. They usually occur singly, rarely in pairs, and sometimes filaments are seen made up of five to six segments. Whether or not tbe bacilli form spores has not hitherto been determined. When the ba- cilli are stained there are occasionally seen bright vacuoles having a regular arrangement, which are suggestive of spores. The bacilli are extremely re- sistant, probably as a result of their very firm membrane or envelope ; hence they do not lose their virulence, though dried for a month, or subjected to high temperatures nearly reaching the boiling-point, or when subjected to decomposition or the acid gastric juice. The cultivation of the facultative anaerobic, strictly parasitic bacteria out- side of the animal body is accompanied with difficulties. They thrive best of all upon the hardened blood serum of sheep, cattle, and calves in the incuba- tion apparatus, at a temperature of 37° to 38° C. (98-6° to 100-4° F.). A tubercle containing bacilli or some similar substance taken from a slightly caseous lymph gland can be used for tbe seed. Below 29° C. and above 42° C. tu- bercle bacilli cease to grow. At an incubator temperature of 37° to 38° C, if the culture is very carefully protected from impurities and from becoming mixed with other bacteria, there develop upon the blood serum characteristic §83.] TUBERCULOSIS. 409 greyish-white, small dry scales or crumbs, which become visible through the microscope within five to six days, but to the naked eye only after the lapse of ten to fifteen days. From the end of the third week on, the appearance is very characteristic. In a test tube the tubercle bacilli thrive exceedingly well upon meat-peptone agar to which has been added three to five per cent, of glycerine (No- card, Eoux). This glycerine agar is at present almost exclusively used for making pure cultures, and is displac- ing more and more the blood serum which is so difficult to sterilise. When tubercle bacilli are inoculated witb the platinum wire upon glycerine agar, the first colonies will be observed along the line where the wire was drawn about fourteen days subsequently. If the culture is al- lowed to remain in the incubator for one and a half to two weeks longer the typical picture of a tubercle-bacilli culture will be obtained—that is, there will be seen upon the agar an uneven, greyish-white, dry, lustreless mass, which is made up of flakes, nodules, and small scales (Fig. 291). The colonies consist of variously interlacing strings of bacteria clinging together (Fig. 292). Tubercle bacilli also thrive in bouillon to which three to five per cent, of glycerine has been added, and they have even been cul- tivated upon slices of potato (made alkaline) which were kept from drying by fusing together the open end of the glass tube containing them (Globig, Roux). Tbe tubercle bacilli retain their virulence, though cul- tivated in artificial nutritive media, for a long time. \ ; Koch has made pure cultures of these bacilli grow in a test tube for more than nine years, and he has observed only a slight diminution of their virulence. The tuber- ! , cle bacilli must be kept from the light, as in direct sun- i \. j: light they perish in a few minutes or hours, according 4^^fi to the thickness of the culture. The dispersed daylight V ,J: )$} acts more slowly. ^k^^" Toxine of Tubercle Bacilli.—Koch, Prudden and oth- Fm. 291.—Linear cul- ers have attempted to find in the pure cultures of the t}}™ of tubercle ba- ^ r cilh upon glycerine- tubercle bacillus obtained from man the active principle agar 5 weeks old. (toxine) which causes the morbid conditions associated wtih tuberculosis. According to the discoveries of Prudden and Hodenpyl, the poisonous substances are not found, as in many other species of fungi, in the nutritive medium, but they are, analogous to Buchner's bacterial protein, fixed to the bodies of the bacilli in an extremely resistant form. Their sojourn in the living body does not change them for a long time. Complete recovery from tuberculosis is not obtained by the death of the tubercle bacilli, but the tubercular foci containing the dead bacilli must likewise be done away with or the tubercular poison itself rendered harmless. Thomas Weyl has isolated a highly poisonous substance—toxomucin —from cultures of tubercle bacilli. According to Maffucci, the toxic sub- stance formed by tubercle bacilli only acts after the lapse of a long period 410 INFLAMMATION AND INJURIES. of time, and animals, such as guinea-pigs, inoculated with this poison die of marasmus. Richet and Hericourt have obtained from tubercular cultures a toxine which has a toxic effect upon tubercular rabbits, but none at all upon healthy ones. Certain metabolic products which are dissolved in the nutritive media, in a glycerine-peptone solution, for instance, have, according to Scholl, a cura- tive effect upon the tubercular process when injected subcutaneous]y. The tuberculin isolated by Robert Koch is described on page 421. Staining of Tubercle Bacilli.—Different methods have been recommended for staining tubercle bacilli. The examination of sputum for tubercle bacilli is as follows : A portion of one of the ordinary yellow, tenacious lumps is taken from a mass of sputum, transferred to a cover glass, upon which is then placed a second cover glass, and the material to be examined is pressed between them. The cover glasses are then removed from one another, al- lowed to dry in the air, and passed three times through a flame. While the cover glass is held by thumb forceps, a drop of carbolised fuchsin is placed upon it, the preparation is held a moment over the flame, and this procedure is repeated several times, fresh stain- ing solution being added if necessary. Then the stain is washed off with distilled water. The parts surround- ing the bacteria are decol- ourised with fifteen to twen- ty per cent, nitric acid by moving the cover glass back and forth a few moments in the latter until the deep-red preparation becomes greenish blue. Then the dissolved fuchsin is washed away in seventy-per-cent. alcohol, and the prep- aration is rinsed in distilled water and re-stained with methylene blue, by which everything is coloured blue except the bacilli, which still remain red. After washing in water the preparation can be examined immediately, or it may be dried, and mounted in Canada balsam. Of the other methods of staining I should mention particularly B. Frankel's, which is the best of the remaining ones, and can be quickly car- ried out (staining with hot carbolised fuchsin, then decolourising and counter- staining in a solution of fifty parts water, thirty parts alcohol, twenty parts nitric acid, and methylene blue to saturation, washing in water). Gram's method is also useful. By the above-mentioned rules a stain can be given to sputum, faeces, pus from a wound, samples of pure cultures, etc. The stain- ing of a section, and consequently of the tubercle bacilli in the tissues, is done in essentially the same manner (for instance, immersion for one hour in carbolised fuchsin, decolourising in dilute [ten-per-cent.] nitric acid for about one half to one minute, washing in seventy-per-cent. alcohol, counter- staining in methylene blue for two to three minutes, dehydrating in absolute Fig. 292.—Colonies of tubercle bacilli upon coagulated blood-serum. §83.] TUBERCULOSIS. 411 alcohol, clarifying in oil, and mounting in Canada balsam). Ehrlich's aque- ous aniline-dye solutions are also much used for sections and cover-glass preparations (at ordinary temperatures the object is immersed for at least twelve hours in Ehrlich's solution [aniline-water, fuchsin, or gentian violet], at higher temperatures for a shorter time, then for a few seconds it is washed in twenty-five-per-cent, nitric acid, and for several minutes in sixty-per-cent. alcohol, then double stained in Bismarck-brown or a methylene-blue solu- tion, depending upon whether it was first stained with violet or fuschin then washed in sixty-per-cent. alcohol and dehydrated in absolute alcohol, clari- fied in oil of cedar, and mounted in Canada balsam). Transmission of Tuberculosis to Animals.—The transmissibility of tubercu- losis to animals by inoculation, by intravenous injection, and by allowing them to eat and inhale tuberculous substances bad been proved by Klencke in 1843, before Koch's epoch-making experiments had been made. Villemin (1865-'68j was the first to demonstrate by systematic experiments that tuber- culosis can be transmitted from man to animals, and from animal to animal. These experiments were then repeated with positive results, particularly by Chauveau, Cohnheim, Klebs, and others. Then Robert Koch showed that tuberculosis could only be transmitted to animals by inoculation, by intra- venous injection, and by inhalation when the material employed contained tubercle bacilli. In the first place, Robert Koch repeated many times success- fully the inoculation experiments which had been performed upon guinea- pigs, rabbits, etc., with portions of tubercular tissue (nodules of miliary tuberculosis, tubercular pus, phthisical sputum, fungous matter from joints, lupus, portions of scrofulous glands, nodules of bone tuberculosis). He then employed in a great number of transmission experiments pure cultures of tubercle bacilli, and by inoculating these into the subcutaneous tissue, into the anterior chamber of the eye, and by injecting them into the peritoneal cavity and into the veins, and by causing them to be inhaled, he produced true tuberculosis, with its characteristic bacilli, which could be again and again successfully transmitted to other animals. So Koch has furnished in the most convincing manner the indisputable proof that tuberculosis is caused by specific bacilli. Koch's admirable work will be found in the Mittheilungen des Kaiserlichen Gesundheitsamtes, 1884. Almost at tbe very same time that Koch published his work upon the etiology of tuberculosis, Baumgarten, independently of Koch, had likewise found bacilli in the tubercles produced in rabbits by inoculation, but he did not make cultures and inoculations with them. All animals are not equally susceptible to tubercle bacilli. Guinea-pigs, rabbits, and ruminants have a pronounced predisposition for tuberculosis, while dogs, rats, and white mice are immune from it. It is well known that man shows great variations in susceptibility to the poison of tuberculosis. Tuberculosis of Cattle.—The tuberculosis of cattle, in which small and large nodules are formed even reaching the size of a walnut or potato, is, according to recent investigations, identical with the tuberculosis of man, and the presence of tubercle bacilli has likewise been demonstrated. Inocu- lation experiments have also given corresponding results. By the ingestion of meat and milk containing tubercle bacilli from tubercular cows (particu- larly those with local tubercular disease of the udder), tuberculosis may easily 412 INFLAMMATION AND INJUIRES. be caused in man. If boiled, the virulence of infected milk is destroyed ; its poisonous character may be weakened by diluting it with milk which is free from bacteria (Bollinger). Pseudo-Tuberculosis.—Eberth has described a pseudo-tuberculosis of guinea-pigs. Changes simulating tuberculosis are found particularly in the abdominal organs, especially in the liver, and to a less extent in the lungs. Some of the nodules present the appearance of miliary tubercles, others of small abscesses. In tbe centre of the nodules collections of micrococci are found, and the nodules themselves appear microscopically either as spots of coagulation necrosis, surrounded by a zone of leucocytes, or as collections of pus. The tuberculose zoogloeique of Malassez and Vignal is probably iden- tical with this pseudo-tuberculosis. Eberth also observed a tubercle-like dis- ease—a pseudo-tuberculosis—in rabbits, and he found the micro-organisms to be small, short rods, double the width of tubercle bacilli and rounded at the ends, forming chains made up of shorter or longer segments, which were either placed side by side or twisted together in groups and collected in thick clusters. Eppinger found a cladotbrix form to be the excitant of pseudo- tuberculosis in man. The Tubercle Bacillus of Birds.—The weakened (attenuated) or virulent tubercle bacillus of birds, cultivated in a liquid of slight nutritive powers, furnishes substances, according to Courmont and Dor, by means of which rabbits can be made immune from tbe effects of inoculation with the tubercle bacillus of man. Combination of Tuberculosis with Carcinoma and Syphilis.—In rare cases there has been observed the simultaneous occurrence of carcinoma and tuber- culosis in the same portion of the body; for instance, an eruption of tubercles may be found in the neighbourhood of a carcinoma of the stomach or larynx. In such instances the tubercle bacilli have gained access to the surrounding tissues through the carcinomatous ulceration (Zenkel, Hofmokl, and others). The simultaneous occurrence of syphilis and tuberculosis is also interesting ; tbe syphilitic product, for example, may gradually take on a tubercular char- acter from the lodgement of tubercle bacilli (Eisenberg, Leloir). In conse- quence of such a mixed tubercular-syphilitic infection, there will be observed corresponding affections—for instance, of the lymphatic glands and skin— which will only partially disappear under antisyphilitic treatment. Origin of Tuberculosis in Man.—In the first place, individual pre- disposition, which may be congenital or acquired, is of particular im- portance in the acquirement of tuberculosis by man. This predisposi- tion is due to general constitutional conditions and to local changes in the tissues, and especially to variations in the metabolism of the tis- sues exhibited by some individuals, as well as a change in the ir- ritability of the cells. Foremost in this category stands scrofula, a congenital or acquired constitutional disturbance of nutrition. Cli- matic and other conditions peculiar to certain regions are also of great importance. In many places, such as certain high resorts or regions where lime industries exist, tuberculosis is almost unknown. § 83. J TUBERCULOSIS. 413 The tubercle bacilli or their spores, whose existence is still doubt- ful, are contained in the atmospheric air, into which they get from the excretions, or the sputum, etc. of animals or man affected with tuber- cular disease. Tubercle bacilli are found particularly in the dust or the air in which phthisical sputum has opportunity to dry and be- come dispersed. They are also carried about by flies (Spillmann, Haushalter). To put a prophylactic restraint upon tuberculosis it is advisable first of all to introduce cuspidors into more general use, pro- vided with a solution of bichloride of mercury (Cornet). Healthy people can very easily become infected with tuberculosis by constant contact with unclean phthisical individuals. Tubercle bacilli are taken into the body chiefly by the lungs; they also are taken into the intes- tine with the food, or they find entrance through an interruption in the continuity of the skin, through fresh wounds, etc. Tuberculosis pro- duced by inoculation into very small wounds or cutaneous abrasions is observed particularly on the hands of physicians, students, nurses,. dead-house attendants, washerwomen, etc. According to Baumgarten, Tangl, and others, the bacilli, as the result of their growth and multi- plication, always form at the point where they were absorbed, a local tubercular focus of inflammation. They may also gain access to the circulation, and by it be carried into the internal organs, particularly the lymph glands and bones (the marrow). The tubercular affection is, at the outset, always purely local (Baumgarten, Ponfick), but if the poison gets into the general circulation and so is distributed through- out the system, general miliary tuberculosis, or a flooding of the body as it were with bacilli, can take place. Local tubercular disease originates with preference in the places where the tubercle bacilli easily find lodgement and are not mechanic- ally swept away, as in the lungs, the lymph glands, in the capillaries of the bone marrow which have no walls, in terminal vessels, and espe- cially in blood extravasations. According to Robert Koch, tuberculosis in man originates most frequently in the lungs. It is a matter of im- portance for the surgeon to know that tuberculosis of the skin and lymph glands can result from scratches, cutaneous eruptions, and ulcers in the skin. Czerny saw two cases which had been inoculated with tuberculosis by skin transplantation. Embolic tuberculosis of different organs, particularly the bones and joints, frequently originates from tubercular bronchial glands. Extension of Tubercular Inflammation.—The extension of the tubercu- lar inflammation, which, as we have said, is at the outset purely local, is dependent upon the multiplication of the bacilli. The extension either proceeds steadily by contiguitv, or the wandering cells carry the bacilli ■27 414 INFLAMMATION AND INJURIES. into the adjoining parts and there form new foci, wliich either re- main isolated or gradually coalesce with the primary focus. By the entrance of living bacilli into the circulation (blood, lymph) the tuber- cular inflammation may be distributed throughout the entire body. We observe an extension of the tubercular inflammation by contiguity when, for example, a tubercular inflammation of the bone marrow breaks through the bone and infects a neighbouring joint. In a simi- lar manner the large serous cavities become diseased, usually by direct extension of the tubercular inflammation from one of the organs that form their walls (Weigert). Thus tubercular pleurisy originates, in the majority of instances, from a small pulmonary focus extending to the pleura, or from tubercular disease of the vertebrae, ribs, or lymph glands. Tuberculosis of the peritoneum is most frequently observed in conjunction with a tuberculosis of the intestine, the female organs of generation, etc. Deposition of the poison directly from the blood into the serous cavities seldom takes place. Occasionally the extension of the tuberculosis can be traced along the lymph channels. In such cases there will be observed a corresponding formation of nodules in the course of the lymphatic vessels. From the lymph channels the poison passes into the lymph glands, then through the thoracic duct into the blood-vessels; or it may break into a vein directly, and in such cases cause a general distribution of the bacilli all through the system, so that nodules occur everywhere (general miliary tuberculosis), and then death usually follows in a short time. Tubercular Systemic Poisoning.—In fourteen cases of general miliary tuberculosis, Weigert, by carefully examining the veins, was able thir- teen times to demonstrate the place where the poison broke through into the veins, or into the thoracic duct, in the form of tubercular thrombi. Not infrequently there is an extensive formation of tuber- cles in the walls of the vessels. The bacilli occasionally lodge in the intima of the thoracic duct itself. In such cases there is observed a cheesy ulceration of the intima of the duct (Ponfick). Demonstration of Tubercle Bacilli.—The demonstration of the tubercle bacilli is, as we have remarked, of the greatest importance for diagnostic pur- poses, particularly when found in the blood in general tuberculosis, in the sputum in tuberculosis of the respiratory tract, in the evacuations from the bowel in intestinal tuberculosis, in the urine in genito-urinary tuberculosis, and in the pus in tubercular disease of bones, joints, and soft parts. The bacilli can be most easily demonstrated in the sputum when they find a medium favourable for their nutrition, and can keep on multiplying second- arily. According to Robert Koch, the bacilli are particularly apt to be found where the tubercular process is in its inception, the cheesy, suppurating products, as a general rule, containing but few bacilli. Very often the tu- £83.] TUBERCULOSIS. 415 bercle bacilli cannot be demonstrated in tubercular pus; nevertheless guinea- piv this cauterisation with argent, nitrat., we make the shrinkage of the granulation tissue more rapid and prevent it from growing too luxuri- antly. We cover extensive losses of substance in the skin with trans- planted skin (§ 42), or by plastic operations (§ 41), etc. The formation of cicatricial contractures is always, as far as possible, to be prevented; but if contractures do nevertheless develop, they should be treated in the manner described on pages 140, 299, 487, and in § 119. For finding metallic foreign bodies which have become healed up in a wound the magnetic needle has been used with success. By its deviations it can indicate, for example, the location of a needle which has become healed up in the wound (Kocher, etc.). Also for finding bullets which have healed in, the magnetic needle can be used with advantage, particularly in army surgery (see § 124). § 89. Treatment of the Conditions Following Severe Haemorrhages- Blood and Common Salt Infusion.—If, after an injury to large arteries or veins, the haemorrhage has been considerable, the general weak con- dition of the patient very often demands, after arrest of the bleeding, the adoption of special measures which must be carried out rapidly and energetically. In the milder cases of swooning after loss of blood. the head should be placed as low as possible, the face of the patient sprinkled with water, olfactory stimulants, such as ammonia, adminis- tered, as well as several hypodermic injections of ether; the patient should be placed as soon as possible under warm coverings and sur- rounded by hot bottles, sand-bags, and the like, besides being rubbed with towels and stimulated with strong wine, cognac, black coffee, etc. It is also a very excellent plan to supply a patient who has lost a large amount of blood with great quantities of heated fluids; they are ab- sorbed from the gastro-intestinal tract more rapidly than under normal conditions, and are a direct means of making good the blood deficiency. In severe cases the lowering of the head should be combined with elevation of the legs, or, better, with the envelopment of the legs in an elastic bandage, in order to prevent the threatening cerebral anaemia and to drive the blood out of the extremities towards the heart, the lungs, and the brain (autotransfusion). In the cases of very extreme §89.] TREATMENT OF HEMORRHAGES. 479 anaemia all the above-mentioned remedies will be of no avail in keep- ing the patient alive, and the only other remedy that offers any hope is the transfusion or infusion of blood or a sterilised physiological solution of sodium chloride. Transfusion of Blood used to be very frequently practised for threatening death from haemorrhage, for poisoning by illuminating gas, carbonic oxide, carbonic acid, for septicaemia, and for various internal diseases. At present the belief in the capabilities of transfusion has been given up, and the operation is but rarely performed. With the increasing knowledge of the physiology and pathology of the blood, we have found that the earlier views and presumptions which lay at the foundation of blood transfusion were false. I fully agree with Berg- mann and others who, reasoning from physiological facts, consider transfusion not only a useless, but also, as we shall see, a dangerous operation. Causes of Death from Haemorrhage.—The cause of death from haemorrhage used to be ascribed to the loss of red blood-corpuscles, and hence to the impoverishment of the blood in haemoglobin, or rather in oxygen. But now we know that death from haemorrhage is dependent upon purely mechanical conditions. It is caused by the insufficient filling of the vascular system, by the fall of the arterial blood pressure, or, in other words, by the purely mechanical dispropor- tion between the capacity of the vascular system and the amount of its contents. For this reason the movement of the contents of the vessels ceases; the heart, which at first continues to beat, is, like an empty pump, no longer able to raise the column of blood and drive it onwards. Hence in such cases the indication is to increase the con- tents of the vascular system by infusion of some liquid, and for this purpose the blood of man or animals, in its entirety, or defibrinated human blood, used to be employed ; but recently fhe infusion of an alkaline seven-tenths per-cent. solution of common salt has been largely substituted for blood transfusion (Kronecker, Sander, etc.). Infusion of a Common Salt Solution.—As a matter of fact, infusion of common salt is better than blood transfusion, and I should always use it in cases of acute anaemia. The recent reports of Cavazzani, Pors- tempski, and others, which favour blood transfusion, do not influence my views in the least. Landerer, at the suggestion of C. Ludwig and Gaule, has proposed the addition of three to five per cent, of sugar to the alkaline (0'7 per cent.) solution of common salt. The advantage of the salt-sugar solution over the plain salt solution consists, according to Ludwig, in the fact that the former is to be regarded as a nutritive solu- tion, and that, in consequence of its high endosmotic equivalent, blood 480 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. which contains sugar takes up the parenchymatous fluids more ener- getically ; moreover, the blood pressure rises more rapidly, and the red blood-corpuscles are more apt to remain intact than when a pure salt solution is employed. It is simplest to infuse the salt solution subcu- taneously (pages 483, 484.) Dangers of Blood Transfusion.—That the transfusion of blood in any form is not only a useless but also a dangerous operation, the following statements prove. In the first place, we know from the experiments made by Muller and Lesser, under the guidance of C. Ludwig, that all the red blood-corpuscles injected with the blood are destroyed in a few days. The corresponding hemoglobinuria which accompanies this process is caused by the disintegra- tion of the red corpuscles, or, rather, by the separation of the haemoglobin from the stroma of the red corpuscles, allowing free haemoglobin to circulate in tbe blood. According to Sacbsendahl, the dissolved haemoglobin is the most powerful agent for bringing about a rapid destruction of the colourless blood-corpuscles and a very sudden and marked accumulation of the fibrin ferment in tbe circulating blood, so that death may occur from ferment intoxication. Magendie uttered a warning against the use of defibrinated blood, because its injection was followed by very definite disorders, such as rapid respira- tion, diarrhoea, bloody transudations into the peritonaeum, the pleura and pericardium, and even by death. The interesting investigations of Armin Kohler show the possibility of ferment intoxication after blood transfusion. He demonstrated that blood taken from another species, as well as blood from the same species, had a poisonous action. If only ten to twelve cubic centimetres of blood were drawn from the carotid of a strong rabbit, allowed to coagulate, and the blood coagulum then chopped up, pressed between pieces of linen, filtered, and of this defibrinated blood only five to six cubic centimetres were injected slowly into the internal jugular vein of the same animal, it usually died during the injection, from extensive coagulation in the right heart and in all the branches of the pulmonary artery in both lungs. These facts are explainable upon Schmidt's theory of coagulation. The fibrino-plastic substance, and particularly the fibrin ferment, are found free in blood defibrinated in the above manner, and being carried in this state into the circulating blood they excite within the blood channels exten- sive thromboses. The animal dies in consequence of the ferment intoxica- tion. Pepsin and pancreatin have an effect analogous to the blood ferment (Bergmann, Angerer). Blood defibrinated by beating or shaking, according to the old method of blood transfusion, is not by any means as rich in the fibrino-plastic substance and in the fibrin ferment as blood which has been pressed in the manner just described, but it is only a difference in quantity; consequently Kohler is right in considering blood which has been defibrin- ated by whipping not so harmless as has been hitherto supposed. As regards the histocym isolated from the blood by Schmiedeberg, see page 307. Transfusion of Animal Blood.—In the transfusion of blood taken from another species of animal still other conditions come into consideration. Partly as a result of chemical action and partly as a result of the above- g89.] TREATMENT OF HEMORRHAGES. 481 mentioned disintegration of the red blood-corpuscles, the blood of a sheep, for example, is a fatal poison for a dog if injected in sufficient amount into the vascular system of the latter ; and again, a dog's blood is just as poison- ous for a sheep. After the direct introduction of lamb's or dog's blood into the veins of a man, dangerous symptoms had been observed more than two hundred years ago, and yet about fourteen years ago an attempt was made to reintroduce the transfusion into man of lamb's blood. Chills, fever, haemo- globinuria, as a result of the disintegration of the red coimuscles in the circu- lating blood, and not infrequently death, were the consequences. Panum, Lan- dois and Ponfick have proved by numerous experiments the clangers of the transfusion of animal blood into man, and, in fact, the danger of transfusion of blood in any form which has been taken from another species. We shall now always be on our guard against a return to the transfusion of animal blood. Direct Blood Transfusion.—It would be most advantageous if the blood in its entirety could be conducted from the artery of a man into the vein of tbe receiver. But all kinds of difficulties stand in the way of employing this direct transfusion. It is not so easy to find any one who will give blood directly from an artery as one who will give it from a vein. Then, the pos- sibility of tbe blood coagulating in the conducting tube must be taken into consideration. Furthermore, it is always questionable whether the corpus- cles retain their vitality in the blood of the receiver. Wright and Hertig have recommended decalcified blood for transfusion, as Arthus and Pages found that it did not coagulate (see page 293). As a substitute for tbe introduction of blood into the vascular system, Ponfick has recommended intra-peritoneal transfusion—i. e., the infusion of defibrinated blood into the peritoneal cavity. The clinical and experimental investigations of Angerer, Edelberg and others have taught that this method should be condemned. Ziemssen has employed with advantage in chronic anaemia the subcu- taneous injection of defibrinated blood at a temperature of 37° to 40° C. into the subcutaneous tissue of the thigh, using, for example, three hundred and fifty grains in about fourteen injections. For acute anasmia Ziemssen and others recommend the subcutaneous injection of a sterilised, physiological, seven-tenths per-cent. solution of common salt. Indications for Infusion of Blood and Sodium Chloride.—The indications for undertaking blood or common-salt infusion are most frequently a high grade of anaemia after loss of blood, and poisoning by, for example, carbonic- oxide gas and illuminating gas, in which common salt infusion has also repeatedly proved efficacious. The operation is no longer employed for sep- ticaemia or chronic diseases of the blood (chlorosis, leucocythaemia, pernicious anaemia, etc.), nor for chronic marasmus. General Technique of Blood and Common Salt Infusion.—The transfusion is carried out without an anaesthetic, in order that the behaviour of the patient during the infusion can be more accurately observed. The operation is not painful, and very often the patients are unconscious. During the transfu- sion of blood a greater or less amount of dyspnoea and cyanosis is usually observed, and both manifestations not infrequently become so pronounced that the operation has to be suspended. Furthermore, if fainting-fits super- vene, the infusion should be immediately stopped. 31 482 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. Technique of the Transfusion of Venous Blood.—In venous transfusion with defibrinated human blood, about two hundred to four hundred grammes of blood are drawn from a vein of a strong man into a carefully disinfected glass vessel. The blood is heated on a water bath to about 39° to 40u C. (102-2° to 104° F.), defibrinated by whipping with a clean glass rod, then fil- tered through clean linen in a glass funnel into another glass vessel kept at about 39° to 40° C. (102-2° to 104° F.) over a water bath. While an assistant attends to the defibrination and filtration of the blood, a large cutaneous vein —usually at the elbow—is picked out. The finding of the vein can be facili- tated by causing it to become distended with a phlebotomy bandage wound around the (upper) arm. After exposing the vein and isolating some 23 centimetres of its extent, two catgut ligatures are passed under it, and the vein is gently lifted with the peripheral ligature and opened by scissors. A disinfected glass cannula is pushed into the opened vein in the direction of the blood current and secured by the other ligature. The bleeding from the vein is checked simply by lifting the vein by the peripheral ligature, or the latter may be knotted. The glass cannula is filled with blood, and then the warm defibrinated blood is injected by a glass syringe, which is not too large, or a glass jar is used with a rubber tube like an irrigator. About two hun- dred to three hundred grammes are injected slowly ; Hueter recommends the injection of four hundred grammes or more. The entrance of air into the vein and the formation of coagula are especially to be avoided. The strict- est asepsis as regards the giver and receiver of the blood must always be observed. Technique of Arterial Blood Transfusion.—In arterial transfusion (Grafe, Hueter) the radial or ulnar artery is exposed and sufficiently isolated above the wrist joint. Three catgut ligatures are then pushed under the artery. The centrally located ligature is knotted and occludes the artery, while a simple knot or sling is made with the peripheral ligature, or the vessel is closed temporarily with a small artery clamp. The artery is then opened with scissors between the two ligatures or on the proximal side of the periph- erally placed artery clamp, a glass tube is pushed into the hole in the artery towards tbe periphery and firmly secured with the third ligature. The fur- ther course of the operation is the same as above. After the termination of the transfusion tbe artery and vein are tied cen- trally and peripherally, the intervening portion used for the infusion is ex- tirpated, and the glass cannula removed. Hueter claims that the advantage of arterial transfusion lies in the fact that the blood is first driven into the capillaries, and the latter act as a filter for any clot that may be injected; there is, moreover, no danger of the entrance of air. Technique of Direct Blood Transfusion.—In the direct conduction of blood from an artery into a vein the above rules are followed—i. e., a glass cannula is tied into the vein of the receiver and one into tbe artery of the giver of the blood, and both are connected by a rigorously disinfected rubber tube in which a glass tube is sometimes interposed to control any coagulation. Technique of Sodium-Chloride Infusion.—In the sodium-chloride infusion, which should be undertaken as soon as possible after tbe haemorrhage and with the strictest asepsis, a sterilised seven-tenths-per-cent. solution of com- mon salt warmed to about 39° C. (102-2° F.) is used, which is rendered alka- §89.] TREATMENT OF HAEMORRHAGES. 483 line by the addition of sodium hydroxide or potassium carbonate. Szuman recommends aq. destil. 1,000, sod. chloral. 6'0, sod. carb. 10. For one to one and a half litres of a seven-tenths-per-cent. solution of common salt about three drops of sodium hydrate are sufficient. According to Kixxnecker, tbe solution of salt should be 073 percent, and neutral—alkaline liquids may prove dangerous—or the above-mentioned salt-sugar solution of Ludwig's may be used. For infusion, a glass funnel is employed, or a glass flask with a tube at the bottom connecting it with a rubber tube and a glass cannula. The infusion should take place under no higher pressure than exists in the large veins. Jacobson states that this is represented at tbe most by one centi- metre of mercury or thirteen centimetres of the sodium-chlo- ride solution—i. e., the infusion flask should not be held higher than 013 to 0'25 millimetre above the opening in the vein. During the infusion the body, especially the abdominal visce- ra, should be vigorously mas- saged. Five hundred cubic cen- timetres at the least are injected, and in severe cases of haemor- rhage about one thousand to fifteen hundred cubic centime- tres. The infusion should not be carried on too rapidly, about sixty to ninety cubic centime- tres being injected in a minute. The success of sodium-chloride infusion has so far been very encouraging. The venous salt infusion, according to the ex- perience we have had with it, should be preferred to the arte- rial. The arterial salt infusion has also been made into the central end of an artery, the radial, for example ; but this method has no advantage over the venous infusion. Kummel likewise warns against infusing salt solution into an artery. After tbe infu- sion with a glass syringe of about five hundred grammes of a six-tenths-per-cent. alkaline salt solution into the radial artery, gangrene of the skin followed, rendering it necessary to amputate the forearm between the lower and middle thirds. Subcutaneous Salt Infusion.—According to my own experience, the subcu- Fig. 308.—Apparatus for the transfusion of a salim solution, consisting of a glass vessel with a rubber stopper having three holes; a thermometer ( Th), a rubber tube with an interposed glass tune, a stop-cock (Q), and a hollow needle. 484 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. taneous infusion of a sterilised seven-tenths-per-cent. solution of common salt is exceedingly good. The investigations of Ziemssen, Samuel, etc., have dem- onstrated that the system, even when the activity of the heart is impaired, is still able to take up into its circulation great quantities of salt solution in- jected subcutaneously. It is injected through a hollow needle into various parts of the body, particularly beneath the skin over the abdomen, by means of some apparatus like that of Sahli's, illustrated in Fig. 308; five hundred to one thousand cubic centimetres, warmed to 39° C. (102-2° F.), are injected during five to ten to fifteen to twenty to thirty minutes, according to the nature of the case, and absorption is hastened by gentle rubbing (massage). I have seen remarkable results in acute anaemia, and in collapse after pro- longed operations on weak individuals. In proper cases several litres of salt solution can be injected subcutaneously on several different days. In one patient with chronic mercurial poisoning, Sahli washed out the body, as it were, with twenty-one litres of salt solution in eight sittings; each time two and a half to four litres were infused subcutaneously. However, a therapeu- tic success was not obtained, since the mercury could not be demonstrated in the urine.* Infusion of Warm Water.—In one case Coates made a successful injection of six hundred and fifty grammes of pure warm water into the cephalic vein. Milk Infusion.—At tbe end of the eighteenth century Muralto recom- mended the injection of milk instead of blood. American physicians in par- ticular are said to have used milk infusions into the veins with success. But Landois and others have shown by animal experimentation that the proce- dure is to be condemned as directly dangerous to life; its results are marked disturbances of circulation, coagulations, and emboli. Yigezzi has recently tested experimentally tbe infusion of milk into veins, and be states that acidified milk brings about the above-mentioned dangerous manifestations, but that milk mixed with an alkaline solution is entirely harmless. § 90. Burns.—Burns originate in a great many different ways—e.g., by direct contact of the affected portion of the body with a flame, or by the explosion of powder, illuminating gas, " fire-damp," etc. Fire- damp occurs in coal mines in particular, and causes an explosion if mixed with a double volume of oxygen or a tenfold volume of air and brought in contact with a flame. Burns are very often due to the action of hot gases, steam, liquids, hot solid bodies, such as metals, etc. In this class of cases belong the injuries caused by caustic substances such as concentrated acids (sulphuric acid, nitric acid, etc.), and by caustic alkalies. Comparatively mild burns of the skin are caused by the sun's rays. Symptoms and Course of Burns.—The clinical course of a burn de- pends upon its intensity and extent. The intensity of the burn is con- ditional upon the degree of the heat and the duration of its action. The purely local manifestations may occur in three different degrees of * Sahli, Samml. klin. Vortr., N. F., No. 11. §90.] BURNS. 485 severity: First degree, hyperemia; second degree, bleb formation; third degree, eschar formation. Burns of the First Degree.—The first degree is characterised by a painful redness and slight swelling of the skin—i. e., by a dilatation of the capillaries, with a slight exudation of serum, as in erythema, or in a mild inflammation. In the mildest cases the redness disappears in a short time and nothing follows. Aery frequently the horny layer of epidermis is cast off in the form of small scales or patches. In the second degree of burn we observe, in addition to the manifestations of the first degree, the development of small and large blebs, which are filled with a watery, transparent, or slightly yellow serum, and here and there with serum mixed with blood. These blebs either develop immediately or in the course of the next few hours after the reception of the burn. The blebs are usually located in the epidermis, and their contents raise the horny layer from the underlying layer of the rete Malpighii. The rapid development of the blebs in a burn has not yet been clearly explained. In burns of this second degree the swelling and pain are usually very considerable, especially at those points where there is much tension, or when the blebs are removed and the very sensitive reddened corium is exposed to the air. If the blebs break or are artificially opened, the epidermis beneath the portion that has been lifted up forms a new horny layer within three to six to eight days, and from this the shreds of the old horny layer can be easily removed. If the true cutis is exposed, or if the latter is involved in the burn, suppuration often ensues; but it can be entirely prevented by antiseptic dressings, after previously carefully disinfecting the parts. These latter cases form the tran- sition to burns of the third degree, in which, as a result of the action of very severe heat, an eschar is formed. The appearance of the eschar varies greatly, being ashy grey, brown, yellow or black in colour, and either moist or dry. The separation of the eschar is brought about by the ensuing suppura- tion, which can be limited or prevented by antiseptic treatment. In burns of the third degree the difference between individual cases is very great, and they include burns varying from a partial destruction of the cutis to a complete carbonisation of an entire extremity. Hence Fkj. 309.—Cicatrix resulting from a burn with boiling -water, observed in a boy five years old. 486 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. it follows that the division of burns into three degrees is somewhat illusory, and there have been surgeons who have distinguished seven to ten degrees of burns. But the division of burns into three degrees is, on the whole, the best. The casting off of the burned tissue occasionally takes a very long time, especially when bones are involved. AVhen the eschar has been removed, and a correspondingly large granulating wound surface has taken its place, the skin gradually forms over it, as described in § 61. A very extensive destruction of skin is often observed after burns, causing great obstacles to repair. The cicatrix not infrequently gives rise to various disturbances of function and to deformities, amongst which mention should be made of ectropion of the eyelids, adhesion of the chin to the chest, contractures of joints in the extremities, etc. (Fig. 309). These cicatricial contractures are best prevented by the transplantation of large, fresh cutaneous flaps with pedicles, or by skin grafting. Constitutional Symptoms after a Burn.—The constitutional symp- toms observed after the reception of a burn depend in the first place upon the extent of the burn. It is generally accepted that when more than half the surface of the body is burned even to a slight extent death is certain to follow ; in many cases death ensues when the burn involves only a third of the body. The carbonisation of an extremity is, in general, better borne than an extensive slight burn of the surface of the body. After extensive burns death ensues either immediately after the injury or in the course of the first or second day, or after several days or weeks—i. e., either in the stage of inflammatory reaction, or in that of suppuration and exhaustion. Immediately after the reception of an extensive burn the patient is usually in a state of great excitement, he complains of severe pain in the injured part, and often cries and screams. The mind is at first entirely clear. In the cases running a rapidly fatal course the patients are very restless and toss about in bed; delirium and cramps come on, the thready pulse is extremely rapid, the temperature of the body is below normal—sometimes as much as 3° to 5° F.—the respiration is superficial and rapid, the extremities are cool, and death usually follows with in- creasing symptoms of collapse and coma. The lowering of the tempera- ture occurring, as a rule, in extensive burns of the skin is due to the abnormally increased radiation of heat from the dilated vessels in the affected parts which have been robbed of their protecting epidermic covering. In a number of cases of burns very pronounced excitement is present until shortly before death, while other patients lie quietly in a state of apathy. There is often vomiting and great thirst. The 890.] BURNS. 487 urine, in the majority of instances, is very scanty, and occasionally there may be more or less complete anuria, and not infrequently hsemoglobinuria. The latter is a result of the destruction of the red blood-corpuscles which were in the vessels of the affected part at the time of the burning. If the patient survives the first two days much has been gained, but after the lapse of five to six days, in the stage of the inflammatory reaction, the above-described group of symptoms may suddenly make their appearance and cause death within a few hours. In the later stages the cause of death is due essentially, as we have said, to the increasing exhaustion; a violent diarrhoea begins, with now and then the formation of ulcers in the duodenum, usually in the neighbourhood of the pylorus. Causes of Death after Extensive Burns.—How is the death which quickly ensues after extensive burns to be explained ? The opinions of various au- thorities differ greatly upon this subject, and as yet no generally satisfac- tory explanation has been advanced. According to Wertbeim, Ponfick, and others, the above-mentioned destruction of the red blood-corpuscles is the main cause of death. The marked diminution in the number of red blood- corpuscles which are necessary for respiration and for metabolism, produces, according to this view, death, with symptoms similar to those in carbonic- acid-gas poisoning; or the sudden death of the red blood-corpuscles has in itself a deleterious effect. In consequence of the destruction of the red cells, the haemoglobin is dissolved in the blood, and this, as we know, is also a means of rapidly destroying the white blood-corpuscles, and of favouring tbe development of the fibrin ferment, and of extensive coagula in the vessels. As a matter of fact, extensive thrombi, originating intra vitam, are found in the vessels of all the different organs; this has been recently demonstrated in man and animals by Silbermann and Welti. Furthermore, larger or smaller amounts of haemoglobin are frequently found in the kidneys, it be- ing most plentiful in the straight uriniferous tubules, though occurring also in the convoluted tubules and within Bowman's capsule. From tbe presence of haemoglobin such kidneys have a dark, brownish-red colour, which used to be erroneously ascribed to excessive hyperaemia. In addition, the kidneys are more or less hyperaemic, and, like tbe stomach and liver, full of necrotic foci. These necroses become more extensive with the prolongation of life after the reception of the burn (Welti). The diminished excretion of urine is explained by the changes in the kidneys. Eeasoning from bis experi- ments and observations, Sonnenburg has come to the conclusion that death after extensive burns is caused either by the overheating of the blood with subsequent cardiac paralysis (in such cases it immediately follows the in- jury), or that the characteristic manifestations of collapse are to be regarded as the effect of an excessive irritation of the nervous system, which has, as its reflex result, a lowering of the tone of the vessels. The hyperaemia and ecchymoses of the internal organs so frequently found in autopsies upon people who have been burned, Sonnenburg ascribes to the diminution of the vascular tone which has been brought about reflexly. 488 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. According to Salvioli, the cause of death from burns is to be sought for mainly in the formation of numerous thrombi and emboli made up of blood- plaques. In consequence of these blood-plaque thrombi, and in consequence of the increased adhesiveness of the blood-corpuscles, the circulation finally comes to a complete stand-still. After animals have been, as far as possi- ble, deprived of the blood-plaques by venesection and injection of defibri- nated blood, they endure severe burns much better, for the reason that the above-mentioned thrombi do not develop. According to Lustgarten, death from burning is due to ptomaine poison- ing. Tbe intoxication is caused by the metabolic products of the organisms of decomposition which, lying in the depths of the cutaneous follicles, have escaped the effects of the burn. The other theories about the causes of death after extensive burns lack a foundation in fact, and have found but few adherents. I will mention only the stoppage of the activity of the skin as a result of extensive burns, the accumulation in the blood of certain poisonous substances like ammonia {ammoncemia), and the loss of blood serum with the consequent thickening of the blood. Eecently Catiano has again adopted the theory that death after extensive burns is caused by noxious chemical substances. He has raised the question whether, in extensive burns, a substance found mostly in the skin is not changed, by being rapidly heated, into a poison, the absorption of which gives rise to the disturbances in question. The sweat of the skin has an acid re- action from formic acid (CH2O2). If this is gradually neutralised on the skin by ammonium hydroxide there forms the very easily soluble formate of ammonium. If this salt is rapidly heated it loses water and changes into hydrocyanic acid. The symptoms of hydrocyanic-acid poisoning are said to be in every respect similar to those following burns. The causes of death in the later stages of the inflammatory reaction, as well as during the period of suppuration and exhaustion, vary greatly in their nature. The intensity of the burn and the subsequent suppuration, the fever, and the individual peculiarities of the injured person are here the most important factors. Amongst the inflammations of the internal organs the most frequently observed are inflammations of the intestines, the kidneys, the lungs, the pleurae, and the meninges; they are rarely caused by the action of the heat during the reception of the burn, but are much more frequently a result of tbe gradual alteration in the blood that occurs after the burn. Duodenitis after Burns.—The origin of the duodenal ulceration after burns, mentioned on page 487, has not as yet been clearly explained. Catiano believes that the duodenal ulcers and the intestinal catarrh originate from the destruction of the epithelial layer and the action of the intestinal juice upon the exposed parts. The epithelial destruction is said to be produced by for- mate of ammonium, which is formed by the decomposition of the hydrocyanic acid in the organism. Hunter also is of the opinion, reasoning from his experiments upon dogs with toluylendiamin, that analogously to the way this substance acts, certain similar products of decomposition in the tissues are produced in cases of burns which are excreted in the bile and are capable of exciting inflammation and ulceration in the duodenal mucous membrane. Since the time that we have been able, with the help of the modern §90.] BURNS. 489 method of treating wounds, to control suppuration and its accompanying fever and prostration, as well as the accidental-wound diseases, cases of death from suppuration and other wound infections after burns bave become less common. Prognosis of Burns.—The prognosis of burns may be inferred from what has been said. The more extensive a burn is, so much the more unfavourable is the prognosis, quoad vitam. In addition, the location and depth of the burn, as well as the age and constitution of the pa- tient, play an important part. Quoad functione?n, burns of the third degree, involving the entire thickness of the cutis, are alone to be feared, on account of the cicatricial contractures which may result. Contractures of the joints, abnormal adhesions, such as adhesion of the chin to the neck, adhesions between the two jaws, contractures of the eyelids, etc., result in this wTay. Treatment of Burns.—Leaving for the present the treatment of exten- sive burns endangering life out of consideration, the local treatment of burns of the first degree is mainly directed towards the alleviation of the pain. This is best accomplished by the local use of cold in the form of ice bags and ice compresses ; by the use of liquor plumbi subacetatis dilutus with ice ; by cold baths ; by painting with flexible collodium, un- guentum cerussge or unguentum lithargyri Ilebrse (unguentum diachy- lon) after dusting on starch, or starch with oxide of zinc, dermatol, etc., with or without an occlusive dressing of cotton wool. Protective dress- ings, according to my own experience, are the best for alleviating the pain. By placing the parts in a proper position—if an extremity, by ele- vating it—the analgesic effects of the above remedies are materially pro- moted. In some instances it is proper to give subcutaneous injections of morphine. In burns of the second degree, when blebs are present, it is advantageous to evacuate the blebs through punctures, but not to remove the elevated epidermis, to cleanse the burned area in the usual way with antiseptic solutions (1 to 1,000 bichloride, or three-per-cent. carbolic-acid solutions), and then to apply an antiseptic powder dress- ing—for example, zinc oxide, bismuth, iodoform, boric acid, etc. As materials for dressings it is a good plan to use iodoform gauze or steril- ised mull covered wdth cotton, or some other aseptic material, which allows drying to take place. These antiseptic or aseptic dry powder dressings I consider far better for burns than the other kinds of dress- ings with salves (unguentum simpl., cerussse, diachylon, vaseline, etc.), or washes (lime-water and linseed oil, equal parts), or solutions of ni- trate of silver (arg. nitr., 1 to 100 of water). The dressing dries into a firm aseptic scab, which can be left uncovered by bandages until it falls off of its own accord from the healed wound. In mild burns the 490 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. formation of simple aseptic scabs, by means of iodoform, dermatol, bismuth, or zinc oxide, without any other dressing, is a very excellent treatment. After careful disinfection of the burn, Nitzsche recom- mends covering it with linseed oil varnish (1 part oxide of lead dis- solved in 25 parts of boiled linseed oil, to which is then added five to ten per cent, of salicylic acid while the oil is hot); over this a layer of cotton is placed, and pressed down as firmly as possible by an elastic bandage. Healing generally follows under a single dressing. The antiseptic powder dressings are particularly good for burns of the th ird degree. In this way the decomposition of the burned tissues is most easily prevented, and the secretion or suppuration is kept as small as possible. The treatment of burns, like any other wound, should always be conducted with the strictest attention to antiseptic rules, and the less often the dressings are changed the better. A. Bidder recom- mends painting the burned area with thiolum liquidum or powdering it with thiolum siccum, one of the remedies belonging to the unsatu- rated sulphur compounds of the hydrocarbons. In extensive burns the patient should be placed, when feasible, in a permanent warm bath (see page 179). The covering of large granulating surfaces with skin can be hastened by the transplantation of Thiersch skin grafts (§ 42). or by the transplantation of large, fresh skin flaps with pedicles (§ 41). This is the best way of preventing the development of cicatricial con- tractures or abnormal adhesions. If cicatricial contractures or disfig- uring strips of scar tissue have developed after a burn, the cicatrix should be excised and the defect closed by skin flaps with pedicles or Thiersch skin grafts. In the milder cases of contractures following burns, systematic movements and massage are sufficient. The indica- tions for the amputation of extremities which have been extensively burned are, in general, the same as for crushings and severe contusions of an extremity. The amputation should be performed as early as pos- sible after the first symptoms of shock have subsided. In very extensive burns involving a large portion of the body, the treatment of the general condition of the patient is the first thing to be considered. For the collapse which occurs in conjunction with the burn, the patient should be placed on his back, wrapped up as warmly as possible, and stimulants (wine, whiskey, grog, black coffee, or any warm stimulating drink)'should be administered. The subcutaneous injection of ether or camphor is also advantageous, as is the temporary envelopment of the extremities in elastic bandages to drive more blood to the heart (autotransfusion). Kestless patients should be given mor- phine subcutaneously. Blood-letting, which used to be frequently prac- tised, or blood transfusion, should be condemned. On the other hand, §00.] BURNS. 491 subcutaneous salt infusion (see pages 483, 484) in proper cases of anae- mia or of collapse are worth recommending. Burns from Lightning.—According to Sonnenburg, lightning pro- duces the effect of an electrical shock and has a tearing and burning action. Sometimes the one and sometimes the other of these effects is the more prominent. If people and animals are directly struck bv lightning, death occurs immediately in many cases, probably as a result of the violent electrical shock to the nerve centres, especially those governing respiration and circulation. The condition of a person struck by lightning is often precisely similar to one who has suffered a commotio cerebri. Paralyses, dysphagia, disturbances of sight, and other nervous phenomena, are also observed. Lightning paralysis has, in general, a favourable prognosis. When considering the paralyses due to strokes of lightning, the true or direct strokes, according to Lim- beck, must be carefully distinguished from those occurring indirectly from haemorrhage—in the brain, for instance. In the true lightning paralysis two stages are to be recognised: In the first, we have to deal with a direct injury to the nerves and muscles caused by the lightning, while in the second we have the picture of a traumatic neurosis (see page 280). Occasionally large vessels are ruptured, followed by death, and now and then extremities are completely severed from the body. The effects of lightning upon the skin are manifested by all sorts of changes, varying from a simple drying of the epidermis to the severest burns. The so-called lightning-marks upon the skin are well known. They consist of branching, brownish-red, zigzag lines, the formation of which is probably connected with the action of the lightning upon the blood. The colouring matter is set free from the red blood-corpuscles by the electrical action of the lightning, and in transuding through the walls of the capillaries or vessels forms marks which correspond to the distribution of the affected vessels (Rollet). Occurrence of Lightning Strokes in Man.—Sonnenburg states that in Prus- sia, from 1854 to 1857, according to the official statistics, five hundred and eleven individuals were struck by lightning, and 72 "25 per cent, of the cases were fatal. The great majority of the individuals affected were struck while at work in tbe fields. The statistics of Boudin show that in France from 1835 to 1864, 2,324 people were struck by lightning. During the American civil war, in the summer of 1864, the lightning struck amongst the Eighteenth Missouri Regiment, which was encamped on a hill, and knocked down the en- tire troop. Almost all the horses and eighteen men were killed, and all the rest were more or less injured. When a row of men or animals is struck by lightning the first and last in the row appear to be the most endangered. It is noticeable, as Sonnenburg has correctly remarked, that bodies of troops on the march have only seldom been struck by lightning. 492 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. Treatment.—The treatment of lightning strokes, particularly of the constitutional symptoms, is purely symptomatic. The treatment of the burns is just the same as described above. If any paralyses are left they usually disappear entirely under electrical treatment. Sun-burn Erythema and Eczema Solare.—In consequence of the action of the sun's rays upon the uncovered skin superficial burns are produced. These occur in summer time, especially in tourists and mountaineers. The skin becomes red and swollen, feels hot, and is more or less painful {erythema solare). After a few days the burned layer of epidermis comes off in shreds from the underlying parts. Other cases present a more eczematous appear- ance, with the formation of blebs {eczema solare). For prophylaxis against sun-burns, sun-shades should be carried or veils worn, etc. People with irri- table skins when going on mountain tours should cover the exposed parts of their bodies with vaseline, or ungt. litharg. Hebrae, or with starch powder. The burns themselves, as long as severe pain exists, should be treated with applications of liq. plumbi subacetatis dil. and ice, or with ungt. litharg. Hebrae or vaseline, and then powdered with zinc oxide and starch (1 to 5 to 10). Sun-stroke or Heat-Stroke.—^^Te have yet to consider the so-called sun-stroke or heat-stroke (insolation). This is essentially an overheat- ing of the body, and often terminates very quickly in death, particu- larly in hot climates; but the affection is frequently seen in summer, even in our latitudes, particularly amongst young soldiers who have to take long marches in very hot weather. From the experiments of Krishaber, Schleich, and others, we know that the temperature of a man's body, by immersion of the latter in a hot medium, can be made to rise very rapidly, reaching, for example, 40° to 41° C. (104° to 105'8° F.) in thirty to sixty minutes. Individuals thus treated become restless, the respiration gets very frequent, the pulse rises to 160 or 180, the production of urea is increased, etc. The marked rise in tempera- ture observed in individuals who have been sun-struck coincides with these experiments. In a case which terminated fatally, Baumler found the temperature of the patient to be 42-9° C. (109*4° F.) one hour after his reception into the hospital. The symptoms exhibited in sun-stroke or heat-stroke are very char- acteristic. The face is red, the respiration rapid and sighing, the heart's action is very rapid, and the pupils are dilated. The patient is unconscious, delirious, and convulsions often occur. Death takes place in collapse, sometimes very suddenly. In other cases the course is not so acute; symptoms of collapse are then especially prominent, from which the patient may recover entirely. The decreased secretion of sweat which is noticeable in insolation is important, especially as re- gards the treatment. At first the secretion of sweat is very much S»0.] BURNS. 493 increased in individuals who work or inarch in very hot weather, or with the sun beating directly upon the head ; but later it is diminished, probably as a result of the diminution of the amount of water in the blood, and then the above-described symptoms of sun-stroke make their appearance. As a result of the diminution in the production of sweat, the loss of heat by evaporation becomes so much diminished that the heat balance is disturbed, and, in consequence of the increased reten- tion of heat, the temperature of the body rises more or less rapidly above the normal, even to a fatal height (Cohnheim). The albuminuria as well as the hemoglobinuria sometimes coming on in horses, for ex- ample, after severe sweating, are ascribed by Maas to the changes in the blood, especially in the serum albumen and the red blood-corpus- cles, due to the great loss of water. The cause of death in sun-stroke or heat-stroke is partly the over- heating of the body and partly the great loss of water from the body, or the alteration in the composition of the blood. Occurrence of Sun-stroke.—Meyer has recently reported a great number of sun-strokes affecting harvest labourers almost like an epidemic in the sum- mers of 1873 and 1880. He ascribes death to cardiac paralysis, due to the in- creased temperature of the body and to an alteration in the blood which he considers uraemic. He distinguishes three stages of the disease—a prodromal stage, a stage of excitement, and a stage of depression. Amongst the numer- ous cases, only one terminated fatally from meningitis and bilateral pneu- monia. American physicians have also described regular epidemics of sun- stroke. In many campaigns sun-strokes bave formed a considerable part of the diseases and deaths. As Sonnenburg mentions, the Crusaders appear to have suffered especially large losses by sun-stroke and heat-stroke. On the march through Bithynia and Phrygia, in July, 1099, five hundred men often perished on a single day from sun-stroke. During the American war of secession (1861-64) there were seventy-two hundred sun-strokes, with three hundred and nineteen deaths. As a result of a forced march during very hot weather in 1848, Sonnenburg states that in the Nineteenth Infantry Regiment of the German army twenty-nine men died. It is a particularly fatal mistake to keep soldiers, while manoeuvring or on the march, from drinking. Treatment of Sun-stroke.—It is my belief that the treatment of sun- stroke or heat-stroke is dependent upon the last-mentioned facts. For prophylactic reasons, it should be stated that the withholding of drink increases the danger of insolation. Hence a regular supply of water to individuals while at work or on the march is to be regarded, to a certain extent, as a protection against sun-stroke. When the dreaded accident of sun-stroke has occurred, our efforts should be di- rected towards lowering the temperature of the body, stimulating the 494 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. secretion of sweat, and combating the weakness of the heart. AVe try to meet these indications by cold applications and cold baths; by introducing large quantities of w7ater into the stomach and intestinal canal; by the administration internally of stimulants, particularly alco- hol ; by subcutaneous injection of ether and camphor, and by keeping the patient as quiet as possible. Many authorities have opposed the energetic use of cold applications, cool baths, etc., and advocate warm baths and warm rubbing. I believe that in sun strokes as vigorous an attempt as possible should be made to lower the temperature of the body by cold applications, and, when feasible, by cool baths. Venesec- tion should not be employed; it is useless, and, in fact, usually causes marked collapse. § 91. Effects of Cold (Freezing).—There are usually distinguished, as in burns, three different degrees in the effects of cold upon the skin. The first degree is characterised by a superficial, erythematous inflam- mation, the second by the formation of blebs, and the third by eschar formation. The peripheral portions of the body—the toes and fin- gers, the feet and hands, the nose and ears—are especially exposed to the danger of freezing. Symptoms of Freezing.—In cases of freezing there usually occurs, in the first place, a contraction of the cutaneous vessels, in consequence of which the affected skin area appears pale, and in many individu- als corpse-like, particularly when the fingers are involved; this is often a result of the action of a very slight amount of cold. After the first contraction of the vessels there follows a dilatation throughout the affected area; the latter takes on a deep red colour, and a more or less pronounced swelling develops, which causes an itching or burn- ing sensation. Severe pains may also occur, especially when the frozen parts are rapidly warmed. In the first degree of freezing this inflam- matory redness and swelling disappear permanently within a few days. But not infrequently the frozen area of skin has a tendency to become affected by a constantly recurring redness, particularly the skin of the nose, ears, toes, and fingers. It may even happen that such cutaneous areas, especially the point of the nose, may, in consequence of a sort of vascular paralysis, remain red throughout life. The so-called chil- blains (perniones) come from a repeated slight freezing of the fingers and toes. The extensor surfaces especially become the seat, in such cases, of a dark or bluish-red swelling, which has a tendency to ulcer- ate, and the patient is annoyed by severe itching and burning, particu- larly in bed, during the change from cold to thawing weather, and in summer. Individuals who have to change constantly from cold to hot atmospheres are very apt to suffer from chilblains. Women, and, as §91.] EFFECTS OF COLD. 495 a general thing, anaemic people, appear to be most susceptible to these mild degrees of freezing. In a frost-bite of the second degree the affected area of skin assumes a deep red or bluish colour and is covered with blebs. In such cases it is a matter of great uncertainty as to whether there will finally occur a complete restitutio ad integrum, or whether we do not have to deal with a frost-bite of the third degree, with its termination in eschar formation or in gangrene. Speaking generally, the prognosis of the second degree of frost-bite is much more unfavourable than is the case with burns. Whenever blebs develop after a frost-bite there will follow in the majority of cases a gangrene of greater or less depth. It is very suspicious, in such cases, when the absence of sensibility persists for several days, and when the area of skin—apart from the blebs—ap- pears to be almost normal. In the pronounced cases of freezing of the third degree terminating in mortification of the affected tissues, the parts involved are usually entirely devoid of sensation, of a dark blue colour, and covered with blebs and scabs; there is no circulation, as the prick of a needle draws no blood. I saw a case of freezing like this, involv- ing both feet and legs, in a deserter who had wandered many days in the forest during extreme cold with insufficient clothing; both legs were amputated and the patient recovered. When extremities are entirely frozen like this, parts of the toes can be broken off through the joints like glass. Effect of Cold upon the Body.—The constitutional effects of cold upon the human organism is a matter of great interest. If an individual is placed in a cold medium, he will lose heat the more rapidly the lower the temperature of the medium and the quieter he remains. As long as a person is in a position to perform active movements he can suc- cessfully withstand severe degrees of cold, such as — 42° to — 45° C. (_ 430 to — 49° F.). When the muscles become quiet the danger of freezing is particularly great. Experiments in the Reduction of the Temperature of Animals.—Walther, Howarth, and Cohnheim, experimenting with animals, have studied the consequences of cooling off the organism. If a rabbit or a small dog is im- mersed to the neck in water at a temperature of about 0° C, or placed in a small vessel surrounded by a cooling mixture, in which movement is impos- sible, the temperature gradually sinks. If the animal is kept in the cold medium until the rectal temperature becomes 18° to 20° C. (68° F.), as a result of this cooling off a general paralytic condition becomes evident. The ani- mal is no longer able to stand on its legs, and lies as though dead, the con- tractions of the heart are weak and slow (16 to 20 beats in the minute), tbe frequency of respiration is also diminished, peristalsis of the intestine ceases, and the urinary bladder, though filled to distention, is not emptied. The eyes 496 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. are widely opened, tbe cornea shows almost no reaction, and the pupils are very widely dilated and almost entirely insensitive to light. If, after the ani- mal has been cooled down to a temperature of 18° C. (64 4° F.), he is allowed to remain in the cold medium still longer, death usually soon occurs in the majority of cases from cardiac paralysis. Animals whose temperature has been reduced to 18° C. ordinarily die when allowed to lie quietly at room temperatures ; but their temperature will again rise to the normal if they are placed in a hot medium—for example, in a vessel at a temperature of 40° C. (104° F.). At first the temperature rises very slowly to about 30° C. (86° F.), and then more rapidly; within about two to three hours tbe temperature of the animal rises from 18° to 39° C. (64-4° to 102° F.). The chilled animal can also be made to become warm again by artificial respiration. As the temperature of the body rises tbe general paralytic condition disappears, the activity of the heart and lungs increases, intestinal peristalsis reappears, the urinary bladder is emptied, and finally the brain regains its function and the animal is a° F.). It is often necessary and always very useful to perform artificial respiration. Ether and cam- phor are given subcutaneously, and, as soon as the patient can swallow, alcoholic stimulants are freely administered. Wrapping the extremi- ties in cold wet cloths is excellent for the severe pains in the limbs which occur as the patient returns to life. Bergmann and Eeyher rec- ommend suspension of the frozen extremities at the earliest possible moment, to limit the gangrene. There should be no hesitation in ap- plying vertical extension to all four extremities. § 92. Subcutaneous Injuries of Soft Parts.—The most common and important subcutaneous injury which the soft parts suffer is contusion. It usually results from a bruising or crushing produced by some blunt object, by a thrust, blow, or fall. The soft parts are either squeezed 32 498 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. together as a whole, or pressed against a neighbouring bone. The de- gree of the crush, of course, varies all the way from a slight bloody discolouration, a bloody suffusion or suggillation, to a crushing of the bones and soft parts into a pulpy mass. In many individuals, such as the so-called bleeders (see page 57), a comparatively large effusion of blood not infrequently follows a trifling contusion of the tissues. Fur- thermore, spontaneous subcutaneous haemorrhages are not uncommon in bleeders. The different soft tissues of the body possess a very unequal power of resisting a contusing force. As Gussenbauer's experiments teach, and as daily experience proves, the loose connective tissue and the small vessels and capillaries it contains have the least powers of resist- ance. The skin, the fascia, the tendons and larger vessels exhibit a remarkable resistance to the effects of a contusing force. In general, two degrees of contusion can be distinguished, the first being the con- tusion with preservation of the affected parts, and the second with their destruction (mortification, necrosis). Symptoms of Contusion.—The most important of the symptoms of a contusion of the subcutaneous tissues is haemorrhage. In the majority of cases the extravasated blood comes from the capillaries and veins, the arteries possessing great powers of resistance to violence inflicted by a blunt object. As a result of the laceration of the lymph vessels, there is also an extravasation of lymph, and it sometimes happens that the extravasation is made up mostly of lymph. This lymph ex- travasate may form a fluctuating tumour, and usually is made up of a citron-yellow or a slightly reddish-coloured fluid having the composi- tion of lymph or blood serum. According to Gussenbauer, these lymph effusions are particularly apt to occur when the skin is more or less displaced by a traumatism from its position in relation to the underlying parts. This displacement causes a laceration of the lym- phatic vessels which permeate the subcutaneous cellular tissue. The lymph effusions are consequently usually located in the subcutaneous cellular tissue. As a general thing, the haemorrhage in subcutaneous injuries, even when large vessels are ruptured, is not dangerous, and, for the most part, soon stops in consequence of the rapid coagulation which usually follows contusions. The extravasated blood is either evenly distributed throughout the contused tissues as a haemorrhagic infiltration, or it forms small, circumscribed collections which are called ecchymoses or suggillations. The larger collections of blood are called haematomata; suffusions, on the other hand, designate more superficial, large, spread-out collections of blood. The extravasated blood distributes itself through the tissues in the direction of least §«J2.] SUBCUTANEOUS INJURIES OF SOFT PARTS. 499 resistance, especially between the fasciculi of connective tissue, be- tween the muscles, in the subcutaneous cellular tissue, etc. If the bleeding takes place into a free cavity, a bursa or a joint, or into one of the cavities of the body, a large collection of blood may result. The collections of blood in the cavities of the body have their special nomenclature, an effusion of blood into a joint being called haemar- thros; into the pleura, haemothorax or haematothorax, etc. Other blood effusions have likewise received particular names, according to the locality in which they occur—for example, the blood tumour on the head of a newborn infant is called a cephalo-luematoma; a haemor- rhage into the brain, an apoplexy, etc. The haemorrhages into the large cavities of the body are, of course, dangerous, and are not infrequently fatal, partly because of the amount of blood poured out, which has been able to escape freely, and partly because of the pressure of the extravasation upon organs such as the heart or brain, which are necessary for the preservation of life. It is well known that no less danger attaches to haemorrhages into the brain itself, the so-called apoplexies by which, apart from other disturbances, the substance of the brain is partially destroyed, and rapidly develop- ing paralyses and death are produced. As the larger arteries are in general deeply located in the soft parts, and their tough, elastic walls are not easily torn, it but rarely happens that they suffer a subcutaneous rupture. But if it does happen as a result of unusual violence, a pulsating tumour may be formed—a so- called traumatic aneurysm (§ 95, Aneurysm). When the extravasated blood comes from an artery or from the larger veins the hydrostatic pressure in the connective-tissue spaces usually soon rises to such an extent as to arrest the bleeding, the rupture in the artery being closed by a coagulum. But the presence of pulsation in an extravasation of blood does not in all cases indicate a subcutaneous injury to an artery. The pulsation may be only apparent, and due to the rise and fall of the more or less tense extravasation caused by the pulsation of the under- lying uninjured artery. If the apparent pulsation of a tumour is com- municated from an adjoining artery, the tumour shows no increase in all dimensions with each systole, but only in a direction at right angles to the underlying artery. On the other hand, an artery may have re- ceived an injury, and yet, on account of the thickness of the overlying layers of tissue, it will be impossible to detect pulsation. The recognition of extravasated blood when the haemorrhage is superficial presents no difficulties. The haemorrhages into the skin and subcutaneous cellular tissue are usually seen immediately. In such cases the skin has a dark-red or violet colour and the greater the 500 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. haemorrhage the more extensive is the doughy and fluctuating tumour. As a result of the distribution of the colouring matter of the blood in the tissues of the cutis, there occur within the first few days following the injury various shades of discolouration, of which green, dark green and yellow usually predominate; they often persist a week or so as a symptom of the contusion which the skin has suffered. The larger the swelling the greater is the subcutaneous extravasation of blood. The more deeply situated extravasations in the extremities cannot be recognised solely by inspection ; it is usually necessary to make use of palpation of the contused soft parts. As a general thing, crushed soft parts are rendered hard by the bloody infiltration; they are thick- ened and give a feeling of resistance. In the worst degree of contu- sions, on the other hand, such as those in which the soft parts and the bones are crushed to a pulp by the wheel of a heavy -waggon, the affected parts are changed into a shapeless mass devoid of circulation, with or without preservation of the cutaneous coverings. The comparatively rare extravasations of pure lymph are distin- guished from blood extravasations by their slower increase in volume, by the absence of discolouration of the skin, and of all the other symp- toms which occur as a result of the coagulation of blood and of the presence of the colouring matter of blood in the tissues. Fever in Subcutaneous Injuries.—Following subcutaneous injuries of tissue there will sometimes be fever, and yet there will be no symp- toms worth speaking of which indicate either inflammation or sup- puration ; thus in subcutaneous extravasations of blood or subcutaneous fractures there wdll sometimes be an elevation of temperature to 101° to 102° F., or even as high as 104° F. The cause of this fever is to be ascribed, in these cases, to the taking up of the products of destruc- tion in the tissues by the circulating fluids of the body (see § 62, Fever). In addition to the elements of the blood and lymph, ingredients of the contused tissues are also taken up into the circulation, especially fat, wliich may enter the blood and lymph vessels, thus causing exten- sive fat emboli in the lungs and brain. Fat emboli are particularly apt to occur when the marrow of a bone is injured, as in a fracture. When we come to the latter subject these emboli will be discussed more fully. Disturbance of Function.—The disturbance of function exhibited by the contused soft parts varies greatly according to the portion of the body affected and the degree of the contusion. A contused joint in which there is a large intra-articular extravasation of blood naturally has its mobility affected. A crushed muscle wliich has suffered com- plete rupture will be unable to contract, and the rupture of a nerve, 92.] SUBCUTANEOUS INJURIES OF SOFT PARTS. 501 such as a mixed nerve in an extremity, will give rise to a paralysis of the muscles which it supplies. The pain which is felt in a contusion at the moment the violence is exhibited varies greatly, according to the richness of the nerve supply in the affected portion of the body, and according to the amount of crushing sustained by the nerves. If from the effects of the violence a large sensory nerve is injured, the pain at the moment the injury is received is very severe, and the person who has been injured feels the pain of the contusion not only at the point where the injury was re- ceived, but usually all along the course of the nerve, and so at points widely removed from the injury. Results of the Contusion of a Nerve.—Concussion of the nerve sub- stance is particularly apt to occur in contusions of the skull. When a blow is received on the head, the symptoms of concussion of the brain [commotio cerebri) are very plain, and eventually may be combined with so-called focal symptoms indicating an injury to some particular part of the brain, or with symptoms of compression from extravasated blood which may collect between the brain and the skull (see Special Surgery). In other cases the symptoms of concussion of the brain and spinal cord are produced indirectly, as by falls upon the feet. In the same way a concussion of the nervous system or a contusion of a nerve due to an injury to any part of the body can reflexly affect the central nervous system to such a degree as to give rise to the set of symptoms known as shock (see § 63). The severity of the injury to the skin is of the greatest importance as regards the subsequent course of the contusion, but the extent of this injury cannot always be determined from the first. The severity of the injury to the skin depends upon the shape of the body inflicting the contusion and the force with wliich it acts, and upon the elasticity and thickness of the skin, which vary in different portions of the body and in different individuals. If the skin is contused to such an extent that all the vessels are ruptured and the circulation in the affected area is stopped, the natural consequence is death or necrosis of the tissues thus deprived of nutri- tion. An area of skin like this contains no blood, and none flows when an incision is made into it, and no pain from the incision will be felt by the patient. Sometimes an apparently dead portion of skin re- covers, the circulation becomes established here and there, and then the entire thickness or the entire area of contused skin, does not per- ish. The subcutaneous soft parts and the bones, like the skin, may also suffer a primary necrosis in consequence of a crushing injury. There is another kind of death of tissue which is secondary in its 502 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. nature and caused by the inflammation that takes place after the injury. If the integrity of the skin has been preserved, absorption of the subcutaneous extravasation of blood usually takes place without any particular disturbance. During the first few days following the injury the con- tused skin exhibits the characteristic changes which take place in the colour- ing matter of the blood. The discoloura- tion, which at the outset is dark blue or bluish red, becomes brownish, dark green, green, and finally yellow ; the yellow stain often persists for weeks or months. Occasionally the areas of discoloured skin are very extensive. Absorption of the Blood Extravasation. —The extravasated blood is absorbed as fol- lows: First the fluid portion of the coagulum is taken up and carried off by the lymphatic vessels, and then the fibrinous portion be- comes liquefied and is likewise absorbed by the lymphatics. Some of the colourless blood-corpuscles disintegrate when coagula- tion takes place, while others are forced out of tbe clot as it coagulates, or leave it, accord- ing to Cohnheim, by spontaneous locomotion. The chief interest in the resorption of extravasated blood centres upon the fate of the red blood corpuscles. Many of them get into the lymph channels and are carried by the lymph current to tbe nearest lymphatic glands, where they occasionally accumulate in such numbers as to cause marked swelling of the glands and to make a section of their parenchyma present an evenly dis- tributed dark-red appearance. I found in a case of a fractured pelvis, with a subcutaneous rupture and contusion of the psoas muscle, a very extensive col- lection of red blood-cells in tbe retro- peritoneal lymph glands. Similar ac- cumulations of red blood-corpuscles or of blood pigment (Fig. 311) were also present in other organs, particularly the liver. These observations show that red blood-corpuscles are taken up in great numbers by the lymph channels and enter the circulation. Another portion of the red corpuscles disappear in loco by granular degeneration after they Fig. 310.—Collection of blood in a retro-peritoneal lymph gland re- sulting from a subcutaneous lac- eration and contusion of the psoas muscle with fracture of the pelvis, x 30. Fig. 311.—Collection of blood in the liver after subcutaneous laceration and con- tusion of the psoas muscle with frac- ture of the pelvis, x 80. S92.] SUBCUTANEOUS INJURIES OF SOFT PARTS. 503 have previously become decolourised by loss of their colouring matter. The colouring matter of the blood is diffused through the surrounding parts and a portion of it is simply absorbed, while another portion is changed into crystalline haematoidin—i. e., mto oblique rhomboid crystals about O'l milli- metre long, of a yellowish-red to brick-red colour. Together with these crys- talline forms there also occur orange-yellow needles and small angular or indentated rust-coloured particles. The haematoidin is not formed solely by direct transformation of tree red blood-corpuscles, but also originates intra- cellularly—that is, the red corpuscles are taken up by the lymph corpuscles and the colourless blood corpuscles and are here changed into pigment (Langhans). Other Terminations of Extravasations of Blood.—The most satisfac- tory termination for an extravasation of blood is its complete ab- sorption in the manner described above. AVhen the extravasation is diffuse, absorption is the commonest termination. The particles of pig- ment and crystals of haematoidin gradually disappear in the course of months, leaving nothing wliich recalls the hemorrhage that has oc- curred or the injury which the tissues have suffered. In severer con- tusions with larger, more circumscribed extravasations of blood, the extravasation is gradually displaced by new-formed connective tissue, as in the so-called organisation of a thrombus in a vessel (see page 294). Organisation of the Extravasated Blood.—In contusions of perios- teum, or of bone or its marrow, the product of the organisation is not connective tissue but bone. Sometimes the organisation of the extravasated blood into connect- ive tissue is confined to the outer layers of the extravasation, as, for example, in cerebral haemorrhages or in hemorrhages into the sub- stance of the thyroid gland or of a tumour. In this way there devel- ops at the point where the extravasation occurred a cyst—that is, a space filled usually with a yellowish-red fluid and enclosed by a con- nective-tissue capsule. After the liquid in the cyst has been absorbed a true connective-tissue cicatrix may eventually develop. Drying, Calcification, Suppuration, and Gangrene of the Extravasated Blood.—In rare cases the extravasated blood becomes dried, or calcare- ous concretions are formed by deposition of lime salts. The unfavour- able changes which the extravasation may undergo are suppuration, and particularly putrefactive decomposition and gangrene. These ter- minations are only brought about, as mentioned in § 57, by bacterial infection through a cutaneous injury, or, in rare instances, through the circulation, and are seldom observed in subcutaneous extravasations of blood. AVhen infection does occur it is usually due to a superficial cutaneous injury or to necrosis of the skin caused by the injury. It is also to be borne in mind that bacteria may be forced into the skin 504: INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. when the latter is subjected to violence, and they will then find a favourable medium for their development in the extravasated blood and the contused skin. Absorption of Extravasated Lymph.—The more or less pure lymph extravasations are ordinarily absorbed very slowly, and they sometimes persist for months as a soft fluctuating tumour; it is an exceedingly rare occurrence for them to undergo suppuration or putrefactive change. The repair of a wound and the regeneration of injured tis- sues are described in § 61. Treatment of Contusions.—The treatment of a contusion is, in the first place, directed towards as rapid an absorption as possible of the extravasation. A great number of the slighter contusions get well without assistance in a comparatively short time. If a contusion of soft parts—on an extremity, for instance—comes under observation immediately after it has been received, and if a fracture has been'posi- tively excluded, the injured extremity should be placed in an elevated position to diminish the pain and check the subcutaneous haemorrhage. With the same object in view ice is employed locally, or cold applica- tions, to which may also be added substances like acetate of lead, chlo- ride of ammonium, spirits of camphor, etc. It is always advantageous for arresting subcutaneous haemorrhage to apply a dressing which ex- erts a slight pressure. If the skin is intact and there is a considerable extravasation of blood, the latter should be mechanically forced into the interstices of the tissues and into the lymph channels by being gently kneaded and rubbed in a centripetal direction by the thumbs, fingers, or palms. In this manner the absorption of the extravasation is hastened. After the massage, it is often advantageous to wrap the injured portion of the extremity in a flannel, mull, or cotton bandage to prevent a recurrence of the subcutaneous haemorrhage and swelling. As a general thing, it is a good plan, immediately after the massage, to make the patient move his contused muscles or joint. This increases the effect of the massage and materially hastens the absorption of the extravasation. Massage is suitable for subcutaneous ruptures and con- tusions like sprains of joints, which can often be cured by this method within a few days; in fact, the effects of massage upon a sprain often seem perfectly wonderful to the laity. The patient may have suffered the severest kind of pain when making the least attempt to stand upon his contused foot or ankle, and yet after massage has been practised but once he will be able to get about with very slight pain, or practical- ly none at all. The massage must be repeated daily, and in the most favourable cases three to five sittings will be enough to effect a cure, while in §92.J SUBCUTANEOUS INJURIES OF SOFT PARTS. 505 others the massage must be continued for a longer time. The sooner the massage can be undertaken after the injury the more rapid will be the success. Technique of Massage. —The technique of massage is not as simple as it appears. It has recently been employed with success for all sorts of troubles. Before beginning the treatment upon the injured portion of the body, it is very often advisable to start with an introductory massage of the healthy parts on the proximal side of the injury, using centripetally directed strokes of the hand to empty the veins and lymphatic vessels and thus promote the absorption from the injured portion of the body. Massage of the healthy parts on the proximal side of the injury should be employed in all cases where massage of the actually inflamed or injured portion of the body is impossible on account of a cutaneous injury or too great pain. The parts to be massaged and the hands of the masseur should first be smeared with lard or vaseline, to facilitate the strokes given by the band. There are in general four methods of employing massage: 1. Effleurage, or centripetally directed strokes of varying strength made with the palm of the hand or its radial border. 2. Massage a friction, or vigorous circular rubs with the hand or finger tips, and particularly with the thumbs, to break up and scatter pathological products. 3. Petrissage, or elevation of a portion of tissue with both hands, or with the fingers of one hand, followed by squeezing and kneading the parts thus lifted. 4. Tapotement, or beating and striking the part under treatment with the band, or with some instrument made of wood, rubber, etc., specially constructed for the purpose. The length of time occupied at each sitting varies greatly; it may be two to three minutes, or as much as five to fifteen minutes or longer, depending upon the extent of surface to be covered. Of course, a great number of contusions are not suited for massage. In this category belong all cases in which the skin has been severely damaged by mechanical violence, or where large vessels have been rup- tured, in consequence of which considerable extravasations of blood have occurred, or where, in addition to an extensive contusion and crushing of soft parts, there is also a fracture of a bone. Every cuta- neous abrasion, no matter how superficial it may be, must be care- fully treated upon antiseptic principles. The subcutaneous extravasa- tion of blood will also be diminished by an antiseptic dressing which exerts pressure. In other cases there may be a scab of dried blood wliich will protect the cutaneous injury from infection. If suppura. tion occurs—i. e., if the skin becomes hot, red, and tender, and fluctua- tion is detected—incisions should be made in the most dependent parts, drainage inserted, and antiseptic dressings applied. Should putrefac- tion of the extravasated blood set in—i. e., should there be a rapid in- crease in the size of the inflammatory tumour, with high fever and chills—vigorous treatment must be adopted. Incisions should be made 50G INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. as large and numerous as possible in order that the secretion from the wound may freely escape. The wound should then be disinfected with a 1 to 1,000 solution of bichloride of mercury, or with a three- to five- per-cent. solution of carbolic acid, and all gangrenous shreds of tissue removed. Early amputation is sometimes indicated when there are extensive gangrenous changes, but, as a rule, such interference is verv rarely called for. When large extravasations of blood are absorbed very slowly, or at best but incompletely, it is allowable to open them up, scrape them out, and drain the cavity thus formed. This applies especially to the above-mentioned purely lymph extravasations. They neither coagulate nor become absorbed, and are rather more apt to increase in size ; consequently the majority of these cases should be treated by operation. They should be opened as much as is necessary by an incision and scraped out. Furthermore, when a large vessel is ruptured subcutaneously, unless the haemorrhage ceases, the vessel must eventually be sought for at the point of the injury and ligated on the proximal and distal side of the injured spot, and the intervening con- tused portion of the vessel extirpated. The special treatment for con- tusions of joints and bones is described in the paragraphs upon these subjects. Muscular paralyses following contusions of nerves, if the continuity of the nerve is not interrupted, usually disappear under electrical treat- ment. If the nerve has been completely divided, neurorrhaphy should be performed in the ordinary way (see page 469). Subcutaneous Rupture of Healthy Muscles and Tendons.—The subcu- taneous rupture of healthy muscles and tendons ordinarilv only occurs as a result of the action of great force, such as a violent muscular effort or an excessive strain at the time of the dislocation of a joint, or from direct violence, such as a blow, etc. As a result of excessive muscular exertion, as in jumping, there may occur a rupture of the gastroc- nemius or of the tendo Achillis. In a similar manner there may fol- low a rupture of the tendon of the quadriceps extensor when an indi- vidual is in danger of falling and tries to hold himself on his feet by vigorously contracting the extensor muscles of the leg. The ruptures may be partial or complete, and occur either in the muscle or the tendon. Purely muscular ruptures are most common in long-bellied muscles possessing either a very short tendon or none at all, such as the rectus abdominis or the stern o-cleido-mastoid. Tsot infrequently tendons are torn from their points of insertion with or without a tear- ing away of bone substance (so-called torn fractures). The tear takes place where there is the least resistance. If muscles and tendons en- dure the increased amount of strain, their points of insertion, the bony §92.] SUBCUTANEOUS INJURIES OF SOFT PARTS. 507 prominences, may break off, and thus there may result transverse frac- tures of the patella, or fractures of the processus calcanei posterior, in consequence of excessive strain from the quadriceps femoris or gastroc- nemius with its tendo Achillis. The tearing away of the muscles or tendons at their points of in- sertion on the bones, with or without laceration of bone substance, is particularly apt to occur in traumatic dislocations of joints such as the shoulder or hip. r Very rarely ruptures of muscles or tendons are produced by direct violence—a blowr or a thrust. If muscles or tendons have suffered a loss in their powers of resist- ance as a result of inflammation or degenerative processes, such as fatty or waxy degeneration accompanying constitutional febrile dis- eases, a very moderate amount of mechanical violence may prove suf- ficient to cause a rupture. These ruptures of diseased muscles and tendons are called spontaneous, in contradistinction to the ruptures of healthy muscles and tendons. The symptoms of subcutaneous rupture of a tendon or muscle—an accident which is most commonly observed in military practice—consist first of all in the inability to perform those movements of which the ruptured muscle is ordinarily capable. At the injured point it is usu- ally evident that the ruptured ends of the muscles or tendons are sepa- rated by a greater or less interval, and that in this gap in the tissues there is a correspondingly large fluctuating extravasation of blood. If the latter is considerable, it may render the diagnosis difficult. The patients themselves often direct the attention of the physician to the nature of their injury by positively stating that they have plainly felt or heard a rupture of the tissues. The subcutaneous muscular and tendinous ruptures usually heal readily under proper treatment, without being followed by any disturb- ance whatsoever; suppuration is scarcely ever observed. Even when no suitable treatment is adopted, the muscular and tendinous stumps very often heal together by the formation of an interposed connective- tissue cicatrix, such as takes place, for example, after the subcutaneous division of the tendons and muscles undertaken for the cure of club- foot or other joint or muscular contractures. The connective-tissue cicatrix interposed between the muscular and tendinous stumps is at the outset adherent on all sides to the surrounding parts. These ad- hesions are gradually torn or stretched as soon as the patient again begins to use his muscles. Even after loss of muscular substance such as follows suppuration, the two stumps of the muscle can become bound together by a con- 508 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. nective-tissue cicatrix, a kind of inscriptio tendinea, and the muscle be rendered capable of performing its functions. It sometimes happens after subcutaneous rupture of a tendon that, in consequence of the retraction of the central end of the tendon, the two stumps do not directly unite with one another but with the over- lying skin. Both tendon stumps in such cases then become adherent to the skin, and the latter may become so mobile that it follows the movements of the tendon, and the latter performs its normal functions. After muscular ruptures subsequent contractures sometimes de- velop. In this class of cases belongs the so-called congenital form of wry-neck (caput obstipum), which is due generally to a partial rupture of the sterno-mastoid muscle, usually the result of operative interfer- ence during birth. According to Stromeyer and A'olkmann, the con- tracture is produced in part by a cicatricial shrinkage of the muscular substance, and in part by the oblique position of the head instinctively assumed from the time of birth. According to Petersen, the sternomas- toid muscle involved in caput obstipum is congenitally shortened. In other cases a contracture after muscular and tendinous rupture is caused by the action of the antagonistic groups. But it is certain, as the divis- ion of tendons for contractures also proves, that these so-called antago- nistic muscular contractures are not by any means so severe nor so com- mon as was formerly believed to be the case. AVe shall discuss this ques- tion more fully under the subject of contractures of the hand and foot. Treatment of Subcutaneous Muscular and Tendinous Ruptures.—This consists essentially in approximating as closely as possible the divided and separated ends of the muscles and tendons, and preventing the use of the muscles or tendons, whenever possible, by immobilisation of the affected portion of the body. AVherever it is feasible, an attempt should be made, after division of the skin under antiseptic precautions, to obtain primary union by sutures connecting the muscular or tendinous stumps (see Tenorrhaphy). Occurrence of Subcutaneous Muscular and Tendinous Ruptures.—Recently Maydl, in particular, has written a very exhaustive treatise upon this subject, and, by collecting a great number of cases of rupture of muscles and tendons on the trunk and extremities, be has demonstrated that the injury is not so rare as was formerly believed. He has collected sixty-one cases of rupture of the quadriceps extensor muscle or of its tendon, and fifty-seven cases of rupture of the ligamentum patellae. He states that one hundred and three cases of rupture of the muscles of the upper extremity and of the muscles and tendons of the trunk, including the muscles attached to the pelvis, have been published ; of these, the most common ruptures were those of the ster- no-cleido-mastoid, the rectus abdominis, the biceps brachii, the psoas and biceps femoris muscles. 3 92.] SUBCUTANEOUS INJURIES OF SOFT PARTS. 509 Fig. 312.—Muscular hernia (adductor loncms) resulting from a rupture of the fascia, due to a fall from a horse. (Eawitz.) Muscular Hernia.—The protrusion of a portion of a muscle through an unhealed rupture in its overlying fascia or sheath is called a mus- cular hernia. In cases of this description, during the contraction of the affected muscle, a portion of its belly pushes itself through the gaping tear in the fascia or sheath of the muscle and forms an elastic fluctuating tumour (Fig. 312). Herniae of the straight abdominal mus- cles and of the muscles of the thigh seem to be the most common, occurring par- ticularly in the soldiers of cavalry and artillery regiments. As Baudin has re- cently demonstrated, the affection is not so rare as was formerly believed. In the thigh the development of muscular herniae after subcutaneous rupture of the fascia is favoured by the very slight distensibility of the fascia, by its tense arrangement on the inner side of the leg, and by a frequently repeated, excessive stretching of the adductors such as oc- curs in riding. The observations of Bau- din show that a sudden rupture of the fascia does not necessarily occur. Much more commonly there is a gradual forcing asunder and tearing apart of the fibres of the fascia. On account of the poor nerve supply in the fascia, a tear in the latter is not ordinarily accompanied by pain. As regards the diagnosis, it is characteristic for tumours due to muscular herniae to disappear or be- come prominent as the points of origin and insertion of the affected muscle are separated from or approximated to one another. If the discomfort caused by such a muscular hernia is considerable, an operation should be undertaken for its cure. The skin is incised, the ruptured fascia exposed, and the edges of the rent freshened and drawn together by catgut sutures. After healing is complete, an elas- tic dressing which exerts pressure in the form of an elastic girdle, pos- sibly with a flat pad, should be worn for some time. In mild cases, and when patients are afraid of the knife, we are forced to confine ourselves to a purely palliative treatment of the affection by an elastic girdle with a flat pad. Dislocations of Muscles and Tendons.—Displacements of muscles and tendons after laceration of their fasciae and synovial sheaths have re- ceived the name of dislocations. In general they are very rarely ob- served, and mainly occur when the muscle or tendon in question by some violent movement slips over a bony prominence where it is held 510 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. fast. Displacement of the tendons of the peronei muscles on to the outer surface of the external malleolus may occur in severe sprains of the ankle joint. There is a division of opinion as to the frequency with which dislocation of the biceps tendon occurs from the bicipital groove over the lesser tuberosity of the humerus. According to Cow- per, the dislocation is particularly apt to occur in forced elevation of the arm, and the accident is characterised by severe pain in the region of the lesser tuberosity, and by inability to move the shoulder joint. Jarjavay, Pitha and others doubt the occurrence of simple dislocations of the biceps tendon unaccompanied by dislocation or fracture of the upper end of the humerus. The reposition of the dislocated tendons—of the peronei, for ex- ample—is an easy matter in recent cases. To keep the tendons in ~ their proper position after they have been replaced, a suitable retentive dressing should be applied so as to exert pressure upon the point where the dislocation has occurred, while the joint is made to assume a suitable position, which in dislocation of the peronei consists in supinating the foot. As dislocations of tendons are particularly apt to occur when the bony grooves are not deep enough, and as this con- dition also favours their recurrence, it is occasional^ advantageous to make use of Albert's method, and deepen the groove subperiosteal^ with a gouge and then reunite the elevated periosteum by catgut sutures. Maydl also recommends freshening and suturing together the lacerated edges of the tendon sheath. If there is atrophy of the tendon sheath, a portion of the periosteum may be turned over the ten- don and sutured to its sheath. Dislocations of Nerves.—These occur under conditions similar to those described for dislocations of the tendons and muscles. Disloca- tion of the ulnar nerve from its groove behind the internal condyle of the humerus is a particularly familiar accident. In obstinate cases the bony groove should be deepened subperiosteally with a gouge, or the nerve should be secured in position by suturing its sheath to the fascia or inner border of the triceps tendon and covering in the nerve by suturing the fascia over it to the periosteum (Stabb). Subcutaneous stretching, tearing, or laceration of the capsules of joints and their ligaments—the so-called sprains—will be discussed under the subject of Injuries of Joints (§ 121). § 93. The Diseases of the Skin and Cellular Tissue.—The diseases of the skin are very numerous, since it is so much exposed to injurious influences from without, and since it bears such an intimate relation- ship to the whole oi'ganism. This relationship to the rest of the system explains why the skin presents secondary symptomatic changes §93.] THE DISEASES OF THE SKIN AND CELLULAR TISSUE. 511 in diseased conditions of the nervous system, the blood, the lymphatic system, and the internal organs. The trophoneurotic cutaneous affections are extremely interesting. AVe know that, as a result of long-continued irritation of peripheral nerves, there may occur not only degenerative changes in the periph- eral portions of these nerves, accompanied by trophic disturbances, but that also the peripheral changes may advance in the form of an ascending neuritis to the spinal cord and brain. These secondary dis- eases of the central nervous system may then in turn give rise to trophic disturbances of the skin, to inflammation, gangrene, ulcers, vasomotor disturbances, etc. I should also mention at this place the reflex angioneuroses, in which, as a result of various kinds of irritation such as may proceed from the sexual organs, manifold polymorphous exanthemata including wheals, papular efflorescences, erythema nodosum, etc., may occur. AVe shall confine ourselves here to only the most important dis- eases of the skin in so far as they come under the treatment of the surgeon. Acute Inflammations of the Skin.—The principal acute inflammations of the skin of interest to the surgeon are erythema, eczema, furuncle, carbuncle, and erysipelas; the latter is described in § 71. 1. Erythema.—By erythema (dermatitis erythematosa) is understood an acute, circumscribed inflammation mainly involving the papillary layer of the skin. In consequence of the inflammatory hyperaemia the skin is reddened and somewhat swollen. The temperature of the af- fected area is elevated, and there is usually a sharp, burning pain. The anatomical changes in erythema consist in a serous exudation into the space between the most superficial layer of the cutis and the rete Mal- pighii, and in a more or less pronounced infiltration with leucocytes. The cells of the rete Alalpighii are generally somewhat enlarged and swollen. As a result of the exudation, the epidermis is often elevated in the form of small blebs which are filled with serum or pus. Ery- thema usually terminates in a complete restitutio ad integrum, without leaving any visible cicatrix. The epidermis comes off mostly in the form of scales or large flakes. If the irritation continues long enough, small ulcers may occasionally develop from the blebs, but these, too, as a rule, heal very rapidly. The causes of erythema are very varied. Ordinarily the disease originates from a local mechanical, thermal, or chemical irritation ; it may thus come from superficial burns or frost- bites, from continued irritation of the skin by wet bichloride or car- bolic dressings, or it may be caused by sweat, urine, or pus, particularly in localities where areas of skin rub together, as at the anus, the vulva, 512 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. in the axilla, or after the ingestion of various kinds of food or medica- ments (quinine), etc. Erythema Multiforme, Erythema Nodosum.—In endocarditis, as a result of infection by micro-organisms, and in all cases of acute and chronic infectious diseases, various forms of erythema sometimes oc- cur, particularly erythema multiforme and erythema nodosum. The etiology of erythema multiforme is extremely varied. In addition to the toxic influences which bacteria exert, a very important part is played by alterations in the nervous system, including both the pe- ripheral nerves and the central nervous system, and by irritations of the skin when the nervous system is normal. The Treatment of Erythema consists in the use of washings and baths. For pure hyperaemia ice and lead-water should be employed, and the parts should be covered with unguentum lithargyri Hebrae (unguentum diachylon), or vaseline, and afterwards dusted with starch or oxide of zinc and starch (1 to 5 to 10), and then covered with cot- ton. The latter treatment is particularly good when blebs are present; they rapidly disappear under the application of desiccating substances such as unguentum diachylon or vaseline, or when dusted with starch and zinc oxide. But the cause of the erythema should always be taken into account, especially if it is a bacterial erythema—i. e., an erythema occurring in the course of an infectious disease. 2. Eczema.—Amongst the inflammations of the skin in which there is a formation of blebs special mention should be made of eczema, which is sometimes acute and sometimes chronic, and consists in the development of papules, vesicles, and pustules which dry and form crusts. The skin in the neighbourhood of the vesicles is usually more or less inflamed. Eczema, too, is particularly apt to be excited by all sorts of external irritation, such as wTet antiseptic dressings of bichlo- ride, carbolic acid, etc. A large number of very different skin diseases are included etiologically under the term eczema which should really be separated. An important type of eczema is the eczema seborrhoicum, in which there is a formation of scales and crusts on those parts of the body which are richly supplied with sebaceous glands, such as the hairy por- tion of the scalp, the edges of the eyelid, the axilla, etc. (Unna). Treatment of Eczema.—The treatment of acute eczema consists in removing the cause, such as the wet dressings, and then in the applica- tion of desiccating remedies—unguentum diachylon or vaseline, dusting with zinc oxide and starch, and covering with cotton, but without gutta percha over it, since the drier the eczematous area is kept the better. If success is not obtained by these methods, a trial should be made §93.] THE DISEASES OF THE SKIN AND CELLULAR TISSUE. 513 with zinc glue (oxide of zinc and gelatine, each one part, glycerine and aq. destil., each four parts), Unna's ointment of benzoate of zinc spread on gauze, Pick's salicylic-soap plaster, Lassar's zinc paste, etc. Chronic eczema is treated in essentially the same way. In addition wre use animal preparations—ichthyol (internally and externally), liniments which are allowed to dry on, etc. Pick's bichloride gelatine, the sali- cylic-soap plaster, Lassar's salicylic paste, Unna's salicylic-plaster mull, two to ten per cent, of chrysarobin or pyrogallic acid in vaseline, are all useful preparations. Arsenic should be administered internally, and in children oftentimes cod-liver oil. Any constitutional dyscrasiae, such as gout, diabetes, scrofula, etc., should receive special treatment. The diet should be carefully regulated. Other Skin Diseases.—According to the different forms and causes of erythema and the skin inflammations in which blebs develop, many vari- eties of these diseases are distinguished, such as erythema exudativum multi- forme, erythema nodosum, urticaria tuberosa, impetigo (pustules drying and forming crusts), etc. We cannot discuss at this place other cutaneous affec- tions like psoriasis (development of dry. white scales), prurigo (inflammation accompanied by the formation of papules), and the various manifestations of syphilis. By miliaria is understood an eruption of small, transparent vesicles; by herpes, vesicles arranged in groups —for instance, upon the lips (herpes labialis) or prepuce (herpes preputialis), and on tbe back (herpes zoster). Herpes zester occurs along the distribution of some particular nerve, and is sometimes present when changes have taken place in the spinal ganglia and the Gasserian ganglion. The infectious character of herpes zoster is becom- ing more and more insisted upon; epidemics of this affection have repeatedly been observed (Pick, Kaposi). By pemphigus is understood a cutaneous eruption with the formation of blebs which vary in size from that of a pea to that of a hen's or goose's egg. All moist cutaneous affections accompanied by the formation Jof blebs are best treated in the manner described above for eczema—viz., by desiccating dressings with oxide of zinc, or ointment dressings, such as unguentum diachylon. 3. The Furuncle.—By a furuncle is understood an acute inflamma- tion of the sebaceous glands and hair follicles, wliich is always due to micro-organisms, especially the staphylococcus pyogenes aureus and albus (Garre). By the penetration of the micro-organisms into the mouths of the sebaceous glands there is first developed a pustule (acne) about the size of a pin-head, which soon enlarges into a very painful nodule the size of a pea or bean. After a few days suppurative sof- tening usually develops in the centre of the nodule. Occasionally the inflammation extends more deeply and spreads into the surrounding parts, giving rise to a cellulitis with extensive suppuration or necro- 514 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. sis of the underlying fascia. Many people are very subject to furun- cles. They sometimes develop simultaneously in various parts of the body in individuals who are otherwise perfectly healthy; the same thing also happens in diabetes, during the convalescence from typhoid fever, etc. It is interesting to note that during the furunculosis occur- ring in perfectly healthy people, sugar sometimes appears in the urine and vanishes after the recovery from the furunculosis. In hospitals where the antisepsis is defective furuncle epidemics sometimes arise. Treatment of a Furuncle.—The best treatment of a furuncle is early incision under local anaesthesia with cocaine and the ether spray, to alleviate the painful tension and to provide an escape for the pus. Very often it is possible to prevent a furuncle from developing by opening the small acne pustule as soon as it forms and disinfecting it with a one-tenth-per-cent. solution of bichloride of mercury. In large, fully developed furuncles a cruciform incision should be made and the purulent masses carefully scraped out. Ointment dressings of boric- acid ointment or vaseline with iodoform are better than dry dressings. Much time used to be lost in the treatment of furunculosis by a purely symptomatic procedure, such as the employment of ice and warm, moist applications. When there is an extensive infiltration of the parts surrounding the furuncle, the moist, warm applications are no doubt serviceable; but the main point is always to lessen the tension by an incision at the earliest possible moment, and to provide a means of escape for the pus, in order to prevent the development of a cellu- litis with extensive necrosis of tissue. Bidder has recommended as an abortive treatment for furuncles the parenchymatous injection of three per cent, carbolic acid. The treatment for general furunculosis consists in the use of luke- warm baths, in regulating the diet, and in the internal administration of arsenic. The local treatment is in general the same as that given above. In diabetes, regulation of the diet is particularly important (meat, wine). It is well known that in diabetes extensive gangrenous processes sometimes occur in conjunction with a furuncle; in this con- dition the knife should be used with caution. 4. Carbuncle.—By carbuncle is understood a collection of furuncles lying close together, giving the skin the appearance of being perfo- rated like a sieve by separate foci of inflammation. In this condition we generally have to do with infection by the staphylococcus pyogenes aureus and albus. The carbuncle has a more pronounced tendency than the furuncle to extend peripherally. It occurs particularly on the neck, back, buttocks, cheeks and lips. The carbuncle in healthy people, as a general thing, is not dangerous; but it can become com- §93.] THE DISEASES OF THE SKIN AND CELLULAR TISSUE. 515 plicated with extensive phlegmonous suppuration and necrosis of the skin and deeper tissues, with venous thromboses, and may terminate fatally from septicaemia or pyaemia. In a carbuncle involving the lips, cheeks, or neck, there is reason for fearing an extension of the inflam- mation to the cranial cavity, as cases in which this happens often run a rapidly fatal course. AVhen the patient has diabetes the gangrenous destruction of tissue is often very considerable, and not infrequently, as a result of the extensive gangrene, and in spite of energetic and suit- able local surgical treatment, death will occur from sepsis or pyaemia. The Treatment of a Carbuncle is essentially the same as for a fu- runcle, and the incisions should be made as early as possible. Their number will depend upon the extent of the inflammation, though in small carbuncles it is sufficient to make one longitudinal or cruciform incision down to healthy tissue. If the suppuration and necrosis of the tissues are sufficiently far advanced, I remove the softened gan- grenous and suppurating parts with a sharp spoon, scissors, and for- ceps, and disinfect the focus most carefully with a one-tenth-per-cent. solution of bichloride of mercury. For dressings I prefer iodoform, dermatol, or zinc oxide with boric ointment or vaseline. Moist warm applications are excellent for softening areas containing an inflam- matory infiltration. Later on we should always be on the alert to pre- vent any burrowing of pus, any retention of the discharges, etc. Ac- cording to the extent of the inflammation, the antiseptic dressing should be changed once or twice a day, or every two to three days. This energetic operative treatment of a carbuncle is better than the old- fashioned symptomatic method, which avoided the use of the knife. The strength of old people, in particular, should be sustained by nu- tritious food, by wine, etc. Cutaneous defects—loss of skin substance on the face, for example—should be remedied by plastic operations. The anthrax carbuncle (pustula maligna) is described in § 77, and acute inflammation of the skin and cellular tissue (Cellulitis) in § 70. 5. The Chronic Inflammations of the Skin and Subcutaneous Cellular Tissue—Lupus.—Of the chronic inflammations of the skin I shall first take up lupus, a disease which is to be regarded, in the main, as a tuberculosis of the skin (see § $?>). As a proof of this, tubercle bacilli are found in the lupus foci (see page 408). By the inoculation of lup- ous tissue into the peritonaeum or the anterior chamber of the eye of guinea-pigs and rabbits unquestionable typical tuberculosis is pro- duced. As regards the pathological changes in lupus, I must refer the reader to the detailed description of tuberculosis in § So ; we shall discuss here only the following clinical aspects of the disease. Lupus is particularly apt to occur on the face, though it also appears on 516 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. other portions of the body, such as the extremities. Lupus originates by the tubercle bacilli finding lodgement in the normal pores of the skin, or in some wound which may be a very small cutaneous in- jury or an abrasion. Not infrequently it may be proved to have originated by inoculation or by contact with people having tubercu- losis. This lupus coming from inoculation, as a result of a direct in- fection, and occurring in individuals otherwise perfectly healthy, I believe to be much more common than has hitherto been supposed. In lupus of the skin the pathological changes consist in the formation of small nodules made up of typical tubercles. The nodules may dis- appear by absorption, or break down and suppurate, giving rise to cor- responding losses of substance in the skin—i. e., ulcers. In combina- tion with the nodules and ulcers a diffuse infiltration and hyperplasia of the tissues is frequently observed. The epithelium often proliferates in an atypical form growing into the sub- cutaneous cellular tissue and giving rise to formations similar to carcino- ma. As regards further pathological changes in lupus, I must refer the reader, as I have before remarked, to the detailed description of tuberculo- sis in § S3. We shall confine our- selves here to its clinical and thera- peutic aspects. Clinically, three forms are distin- F.o.313.-Lupusofthe face (Esmarch). g™hed: lupus maClllosUS (or lupUS exfoliativus), lupus exulcerans, and lupus hypertrophicus. In lupus maculosus, red or yellowish-brown smooth spots are formed, with a cracked, exfoliating, epidermic cov- ering (lupus exfoliativus). If there is destruction of tissue, corre- sponding ulcers result, generally covered with crusts (lupus exulce- rans), which may lead to extensive destruction of the skin and adjoin- ing parts, especially upon the nose, cheeks, lips, etc. (Fig. 313). Very often the process extends at the peripheral portion of the diseased area, while in the centre a smooth or seamed cicatricial tissue develops. In lupus exulcerans there will be found, in addition to the tubercle bacilli, pus cocci, especially the staphylococcus pyogenes aureus. Ac- cording to Leloir and Tavernier, the ulcerative changes occurring in lupus are mainly due to the pus cocci which come from without. Ca- zin describes hyaline flakes in the connective tissue of ulcerating lupus. §93.] THE DISEASES OF THE SKIN AND CELLULAR TISSUE. 517 Fig. 314.- Lupus hypertrophicus of the hand (Busch). They take on a deep stain, with crystal violet (according to Kiihne), and are similar to the bodies found by Russel in epitheliomata. The nodular form of lupus is called lupus hypertrophicus (Fig. 314). Be- tween these different classes there are numerous transition forms, which often occur close beside one another in the same lupous collection. The clinical course of lupus is usually very chronic. It generally begins in children from four to twelve years of age, or later, and often lasts for many years. In consequence of the losses of substance and marked cicatricial shrinkage or diffuse cic- atricial thickening, bad deformi- ties result, particularly on the face (Fig. 315,) the treatment of which will be discussed in the Special Surgery. ]STot infrequently pa- tients with lupus die of tuberculosis of the internal organs—of the lungs, for example. Sometimes epitheliomata originate in lupous foci and cicatrices. Treatment of Lupus.—The treatment of lupus consists, in addition to a suitably invigorating mode of life (see § 83, Tuberculosis), mainly in adopting energetic local surgical measures, such as excision of the lupous disease or its destruction with the sharp spoon (Yolkmann, page 72), the Paque- lin thermo-cautery (see page 74), or the galvano-cautery (see page 76). The earlier a lupus is removed by extirpa- tion with the knife the sooner may per- manent recovery be expected. The wound from the excision is either sim- ply closed by sutures, or, if this is im- possible on account of too great a loss of substance, the cutaneous defect is remedied by plastic, operations (see page 134), or by Thiersch skin grafts (see page 141). The plastic operation or transplantation of skin prevents the troublesome consequences produced by cicatricial contraction, and is especially valuable in preventing recurrences. By excision of the lupus and making use of Thiersch skin grafts, particu- Fig. 315.—Lupus (Esmarch). 518 INJURIES AND SURGICAL DISEASES OF THE SOFT PARTS. larly on the face, I have obtained very satisfactory results and have prevented or overcome bad deformities. Punctures made with a gal- vano-cautery curved at the end, or with the fine tip of the Paquelin cautery, are exceedingly serviceable for the pure macular or exfoliating lupus, such as occurs upon the face. We destroy lupus exulcerans or hypertrophicus by vigorous scraping with the sharp spoon, or by using the Paquelin thermo-cautery, in case excision is impossible. I have given up the use of caustics altogether (caustic potash, copper sulphate, nitric or chromic acid, etc.). Liebreich recommends the subcutaneous injection of cantharidic acid or of the cantharidate of potassium. It is my opinion that the treatment of lupus by ointments is entirely with- out effect. The constitutional treatment by strengthening food, good air, sea baths, proper climate, etc., is, next to the energetic local treat- ment, of the greatest importance, especially for preventing any recur- rence of the disease. The treatment of lupus by Koch's tuberculin is described on page 421. Actual cures by tuberculin are rarely ob- tained ; I have never seen one. In the course of the treatment, after apparent improvement has occurred in the affected portion of skin, I have excised a piece of the latter and found in the deeper parts, under the healed external cutaneous covering, eruptions of new tu- bercles. 6. Ulcers of the Skin.—By ulceration is understood a granulating defect in the skin accompanied by a suppurative breaking down of the granulations, which shows no tendency to heal. Ulcers present great differences as regards their size, character, and course. The causes of an ulcer, its location, and the general condition of the patient, have a most important bearing upon its clinical course. According to the intensity of the reactive inflammation, we make a distinction between atonic or torpid ulcers and inflammatory ulcers. There are great dif- ferences in the shapes of ulcers, some being round, others half-moon shaped, circular, or irregular in outline. The surface of an ulcer may be smooth or sunken, or more or less prominent. According to the character of the surface of the ulcer or its base we distinguish oedematous, haemorrhagic, gangrenous, sloughing, and fungous ulcers; the latter are marked by prominent, spongy, inflamed granulations. Very often a canal, or fistula, as it is called, extends from the ulcer to a greater or less depth into the adjoining parts. The fistulae (from fistula, a pipe), as a general thing, originate from some deeply placed focus of inflammation which has gradually made its way to the surface. The edges of an ulcer may be either more or less normal, flat or swoll- en, or hard and like a wall (callous ulcer), or undermined (sinuous ulcer). Phagedenic ulcers (.'5:3, and of the femur to 694 kilogrammes per square millimetre. He found that the compression strength of the individual bones decreased in the following order: Tibia, femur, humerus, radius, ulna, clavicle, fibula. Compression directed through the longitudinal axis caused fracture of the shaft, the tibia being the strongest and breaking under a pressure of 1,650 kilogrammes, the femur on the aver- age in man requiring a pressure of 756 kilogrammes, the radius in man 334 kilogrammes, in women 220 kilogrammes. Frequently the break does not take place at the point most endangered—the middle of the bone—but at one or other articular extremity by compression. A great number of fractures are, as is well known, the result of bending (Bruns). The limit of bending possessed by bones varies in different years of life, and, according to Messerer, it amounts to between 1,040 and 1,980, and reaches its maximum at middle age. In men 400 kilogrammes, and in women 263 kilogrammes, will cause a fracture of the femur from bending. The torsion elasticity amounts to about a third of the bending elasticity. A fracture of the femur by torsion, according to Messerer, is produced by 89 kilogrammes, of the clavicle by 8 kilogrammes. The femur possesses the greatest torsion strength, the clavicle, ulna and fibula the least. Messerer's experiments on the skull show that the diameter, which is not subjected to pressure, becomes, in the majority of instances, gradually though very slightly lengthened in proportion as the pressure increases. The de- crease of the diameter in the direction of the pressure is not evenly distributed over the whole skull, as only the part directly subjected to pressure bends in- wards. The skull withstands a greater amount of force in a sagittal than in a transverse direction. The average pressure required to produce a longi- tudinal fracture averaged 650 kilogrammes ; for a transverse fracture, 520 kilogrammes. In most instances the base of the skull proved to be the weak- est spot, that portion of it bursting which was under the greatest tension; transverse pressure caused a transverse fracture, and longitudinal pressure a longitudinal fracture. The average pressure, acting through the vertebral column, which was required to produce a fracture of the base amounted to 270 kilogrammes. In young persons tbe sternum could be driven completely back to the vertebral column by sagittal pressure upon the thorax without producing a fracture. A pressure of 250 kilogrammes exerted in a sagittal direction upon the pelvis generally caused a symmetrical fracture of the os pubis ; a trans- verse pressure of 180 kilogrammes exerted upon the crest of the ilium, caused a diastasis of the sacro-iliac joint. According to Rauber, the strength of bones is, as a general thing, dimin- ished by heat. Changes in the Strength of the Bones.—The normal strength of bones is affected very materially by various circumstances, such as their shape, their length and thickness, the direction of their longitudinal axes, §101.] FRACTURES. 571 whether the latter approach the perpendicular or show deviations from it, etc. There are also various pathological conditions which lessen the resisting powers of bones and produce an abnormal fragility (osteopsathyrosis), causing- the bones to break spontaneously or upon the application of a very slight amount of violence. In this category belongs the atrophy of bone which occurs in advanced age, or in the course of chronic diseases, or after paralysis, etc. The strength of the bones usually increases till middle life, and from then on gradually decreases (senile atrophy). The bones also atrophy when they are not used, as in the course of chronic diseases, in paralysis, etc. (atrophy of disuse). Neurotic or Trophoneurotic Atrophy.—In addition to the atrophies of senility and disuse, Weir Mitchell, Charcot, and P. Bruns have di- rected attention to the occurrence of neurotic or tropho-neurotic atro- phies of bone which are due to affections of the central nervous system. In this class of cases belongs the fragility of bone which accompanies tabes dorsalis and chronic cerebral disease, such as progressive paralysis, and in fact all forms of mental disease and paralysis. Pauber found that the tibia of a paralysed extremity supported a weight of 198 grammes, while the bone on the non-paralysed side held a weight of 281 grammes. No further explanation is required for the fragility which is the result of disease of bone with subsequent loss of substance, such as occurs, for example, in tubercular and syphilitic diseases, suppuration, or necrosis; tumours, such as cysts, sarcoma, or carcinoma ; from the presence of echinococcus; or abnormal softness of structure (rhachitis and osteomalacia). An abnormal weakness and fragility of the bones is also present in scurvy, a disease which was at one time very common. Idiopathic Osteopsathyrosis.—But in addition to these various kinds of fragility of bone due to this or that cause, there is also an idiopathic form, the etiology of which is as yet completely unknown. In such patients, who in all other respects seem perfectly well, the slightest ex- hibition of violence, such as a sudden movement, a slight thrust, or even turning over in bed, suffices to produce a fracture of bones which ex- ternally appear entirely normal. The malady is congenital in a num- ber of cases, and sometimes a pronounced hereditary taint runs through many generations. In other cases the disease develops in early youth or later, and then usually persists throughout life. In this idiopathic form of fragility no gross changes are found in the bones. The most probable cause of this disturbance of the nutrition of the bones is a change in the composition of their ground substance. The observa- tions of Blanchard, in particular, show the frequency of fractures in 572 INJURIES AND SURGICAL DISEASES OF BONE. individuals with idiopathic fragilitas ossium. He had one case of a twelve-and-a-half-year-old girl who had had, since the second month of her existence, forty-one fractures from the effects of very slight violence; she had had fourteen fractures of the right and eleven of the left leg. Arnott had a patient fourteen years old who since the third year of life had had thirty-one fractures, of which seven were of the right thigh and nine of the right leg below the knee. It is rather remarkable that the repair of fractures in idiopathic osteopsathyrosis usually takes place easily and quickly. Strength of the Epiphyses.—As long as the diaphysis and the epiph- ysis, during the period in which the bones are growing, are con- nected by a cartilaginous symphysis, the resistance at this point may be diminished by various processes, especially those of an inflammatory nature, and a spontaneous separation of the epiphysis may thus be pro- duced. Under this heading came the epiphyseal separations due to syphilitic processes, to scurvy, and to the primary infectious inflamma- tions of the bone marrow (osteomyelitis). The Various Kinds of Fractures—Incomplete Fractures, Depressions, Fissures.—AYe distinguish complete and incomplete fractures according to the extent to which the bone is divided. To the incomplete fractures belong the green-stick fractures and the fissures. A green-stick frac- ture occurs in the bending of a bone, by which the cortical substance on the convex side is broken while on the concave side it is only pressed in (Fig. 331). The depressions oc- curring on the skull, for example, as a result of pressure or a blow, can Fia. 33i.-TncomPiete fracture (green stick be regarded as incomplete fractures fracture) or the clavicle. & r (Fig. 340). The fissures (Fig. 332) are comparable to a crack in a glass or a plate, and occur especially in the brittle bones of adults, less often in those of children, and are fre- quently combined with complete fractures which are received at the same time. They are particularly common on the skull. In gunshot fractures the bones involved often sustain numerous fissures. It is of great practical importance to note that fissures of this description, especially when the fracture is near a joint, sometimes run through the articular extremity of the bone and penetrate into the neighbouring joint. If after a gunshot fracture, for example, suppuration should take place at the point where the bone has been broken, this suppura- tion may travel along the fissure into the joint. Complete Fractures.—A fracture is complete when the bone breaks into two or more pieces which are completely separated from one another; division of the bone into two fragments takes place most S 101.] FRACTURES. 573 commonly. According to the direction of the line of fracture with reference to the longitudinal axis of the bone we recognise transverse, oblique, spiral, and longitudinal fractures. The pure transverse fractures are generally produced by direct violence, and are not very common if we disregard the separations of the epiphyses. The most common fractures are the oblique, which are almost always the result of indirect violence or forcible bending. The fracture hav- ing the form of a clarinet mouthpiece, and first described by French writers (fracture en bee de flute), is a pronounced oblique fracture which occurs especially in the tibia and femur, and was produced by W. Koch by rotation combined with a vertically directed blow (Fig. 333). The spiral or torsion fracture (Figs. 334, 335) is produced, according to the experiments of Koch and Bruns, exclusively by twisting, the line of fracture having the shape of a spiral curve. The prognosis of a spiral fracture is more un- favourable than an oblique one, for the reason that the fractured surfaces are very extensive and the points of one of the fragments may readily penetrate the skin or be driven into the other fragment and cause considerable crushing of the bone marrow Longitudinal Fractures.—Longitud- inal fractures, or the division of a bone into two fragments with the line of fracture running its entire length, are very rare in the long, hollow bones, and most longitudinal fractures are merely extreme forms of oblique frac- tures. Kronlein has described a longi- tudinal fracture of the humerus and three longitudinal fractures of the phalanges of the fingers, and he could find in literature only one longitudinal fracture through the whole length of the tibia, which was recorded by Ga- diicke. Longitudinal fractures have been noted somewhat more frequently in the short bones (patella, ver- tebrae). Fig. 332.—Fissures femur. the Fig. 333.—Fracture having the shape of the mouth-piece of a flute {fracture en bee de flute). 574 INJURIES AND SURGICAL DISEASES OF BONE. A Multiple Fracture.—In a multiple fracture (fractura multiplex) the bone is either broken at two or three different points (double, three- fold fracture), or the bone is shattered at one point into many fragments (commi- nuted fracture—frac- tura comminuta.) The term multiple fracture also includes fractures sustained simultaneously by several bones, partic- ularly those wliich are placed parallel to one another in the fore- arm and leg. The shape of the multiple breaks in the same bone varies, of course, very much, but a few typical forms are fre- quently observed. These typical forms include especially the T- and Y-shaped frac- tures, occurring at the epiphyseal extremities of the long bones (Figs. 336, 337). In the T fracture (Fig. 336) there is a transverse and a longitudinal break; in the Y fracture two oblique breaks, the pro- duction of which has been studied experimentally by Gurlt, Madelung, and Marcuse. In fractures from bending and from torsion a cuneiform or rhombic piece is sometimes broken out of the continuity of the bone (Bruns). The outward appearance of a comminuted or splintered frac- ture (Fig. 338) presents great variations in regard to the number, shape, and size of the individual fragments. In the worst cases there will be found at the point of fracture a peculiar soft bag of skin like a sack filled with crepitating fragments of bone, or the bones and soft parts are crushed into a bloody pulp, as is the case, for example, in " run- over " accidents. Condition of the Soft Parts in the Neighbourhood of a Fracture.— The condition of the soft parts in the neighbourhood of a fracture is exceedingly important for the prognosis. All fractures in wliich there Fig. 334.—Spiral fracture of the tibia (W. Koch). Fig. 335.—Spiral fracture of tho femur (W, Koch). § 101-1 FRACTURES. 575 is a wound of the soft parts penetrating to the line of fracture are called compound or open fractures, and must be carefully distinguished from Fig. 336.—T-shaped fracture Fig. 337.—Y-shaped fracture Fig. 338.—Comminuted frac- of the lower end of the of the condyles of the hu- ture of the lower end ot femur, caused by a fall merus, caused by a fall the humerus, caused by upon the knee (Bruns). upon the elbow (Bruns). a fall upon the elbow. the subcutaneous or simple fractures—i. e., those in which the outer covering of the soft parts has not been opened. In the days before antisepsis the compound or open fractures very often terminated fatally from pyaemia and septicaemia. The extent of the wound of the soft parts varies from an insignificant puncture to an extensive crushing and laceration of the tissues. The wound is produced either by the same violence that produces the fracture, as in gunshot or run-over injuries, or the skin is opened afterwards by injudicious movement of the fractured extremity—in transportation of the patient, for example —or as a result of gangrene, etc. The open, comminuted fractures, the compound fractures of joints, particularly those found in gunshot wounds, and extensive mangling of the bones and soft parts in run-over accidents, are the most unfavourable compound fractures. Separations of the Epiphyses.—In young subjects, as long as the diaphysis and epiphysis are connected by a cartilaginous symphysis, traumatic separations of the epiphyses may occur, which, according to Bruns, are most common in the case of the lower epiphysis of the femur, then in the lower epiphysis of the radius and in the upper epiphysis of the humerus. The spontaneous separations of the epiphy- ses in consequence of inflammatory or suppurative processes must be carefully distinguished from the traumatic separations. The traumatic separations are mainly the result of exaggerated movements in joints. As a result of these exaggerated movements in adults, dislocations of the joints take place, but in children fractures through the fragile epiphyseal cartilage or in its neighbourhood. This is the reason why traumatic dislocations are so very rare in young children. In infants, 576 INJURIES AND SURGICAL DISEASES OF BONE. separations of the epiphyses, particularly inter j^rtum, are brought about by violent or unskilfully performed obstetrical operations (turn- ing, extraction). The age limit within which epiphyseal separations may occur varies with the different epiphyses. The observations hith- erto recorded, for example, show that the twenty-fifth year of life is the latest period at which a traumatic separation occurs in the upper epiphysis of the humerus. Symptomatology and Clinical Course of Fractures.—The symptoms of fractures are partly objective and partly subjective. The most impor- tant objective symptoms are: 1. The abnormal mobility of the bone. 2. Crepitation—i. e., the rubbing sound which is heard, or, more cor- Fig. 339.—The different varieties of displacements of the frag- +-]ie neighbourhood of ments. » the line of fracture and moving them in opposite directions. Rotary movements may also be tried in cases of fractures of the articular ends of bones. Abnor- mal mobility and crepitation are absent in impacted fractures, in frac- tures with sharp, toothed fragments which interlock, and in incom- plete fractures. Crepitation will also be absent when the fractured surfaces are not in immediate contact with one another. The soft friction sound wliich is sometimes emitted by dried extravasations of blood or by inflammatory7 processes—of the tendon sheaths, for ex- ample—must be carefully distinguished from the harder bony crepi- tus. Deformity is caused by the displacement of the fragments. We recognise the following four principal kinds of displacement, which sometimes occur separately and sometimes combined in various ways: 1, Angular displacement (dislocatio ad axin, Fig. 339, a); 2, lateral displacement (dislocatio ad latus, Fig. 339, b); 3, displacement of the fragments in a longitudinal direction (dislocatio ad longitudinem, Fig. g 101.1 FRACTURES. 577 Fig. 340 a, Fracture of the skull with depression, seen from the out- side (caused by a fall upon a pointed stone); b, the same fracture seen from within (Bergmann). 339, c); and, 4, rotation of the fragments on their longitudinal axis (dislocatio ad peripheriam). The so-called overriding of the fragments —the pushing of one over the other (Fig. 339, d)—is a combination of the dislocatio ad latus and ad axin, sometimes with the addition of a dislocatio ad lon- gitudinem. The so-called diastasis of the fragments (Fig. 339, e) and the reverse or im- paction of the fragments are to be regarded as a dislocatio ad lon- gitudinem. There is a variety of displacement, oc- curring mainly in fractures of the skull, which is called depression of the fragments (Fig. 340, a, b). The different displacements are sometimes primary and produced by the fracturing force, and at other times secondary, occurring sooner or later after the injury as a result of voluntary or involuntary muscu- lar contractions, of transportation, examination, the position the injured member is caused to assume, of defective dressings, etc. Subjective Symptoms of Fracture—Pain and Disturbance of Function. —The subjective symptoms of fracture are pain and disturbed function. By pain is understood primarily the great tenderness of the bone at the line of fracture, especially when pressure is applied at this point. Above and below the line of fracture the bone is not at all tender on pressure. This linear character of the pain, so to speak, is of diagnostic impor- tance in doubtful cases. The disturbance of function which occurs in fractures needs no fur- ther explanation. In consequence of the division of the bone, an ex- tremity, for example, loses its bony support, and the muscles their fixed points of attachment. The amount of functional disturbance depends principally upon the amount of the abnormal mobility, displacement, and deformity, and also upon the nature and location of the fracture. If, for instance, only one bone is broken in a limb which contains two, the functional disturbance may be very slight, varying with the impor- tance of the broken bone. Thus in fractures of the fibula the patient will still be able to walk, and in fractures of the ulna use of the fore- arm is possible, especially pronation and supination. The disturbance 37 578 INJURIES AND SURGICAL DISEASES OF BONE. of function is also slight in the case of impacted fractures, and patients with an impacted fracture of the neck of the femur can stand and walk. Moreover, in impacted fractures of the articular extremities of other bones the mobility of the joint involved is often very little or not at all disturbed. Fever in Subcutaneous Fractures.—Apart from these local symptoms at the point of fracture, we sometimes observe fever following the re- ception of subcutaneous fractures. The thermometrical measurements made by Arolkmann, P. Bruns, Grundler, and myself, show that, as a rule, more or less fever exists, particularly during the first few days after the injury. The height of the fever varies between 101"3o and 102-2° F., though in rare instances the temperature may rise to 1<>4° F. In twenty-five out of twenty-six cases of subcutaneous fracture Grundler observed a rise of temperature to 99'1° F. The cause of this febrile movement is ascribed by Bergmann, "Wahl, and Angerer to the ab- sorption of dead tissue elements, and especially of fibrin ferment and other ferments which are formed in the extravasated blood near the point of fracture, as described in § 62. The fever is essentially a fer- ment intoxication. Suppuration in Subcutaneous Fractures.—As a rule, subcutaneous frac- tures heal without suppuration, and the latter only occurs when micro- organisms gain access to the point of fracture through some small cuta- neous wound or through the blood ; the extravasated blood and the injured (necrotic) tissues furnish a favourable nutritive medium for their development. Course of Compound Fractures.—The course of compound fractures varies greatly7, according to the size of the wound in the soft parts, the condition of the fragments, and the treatment. The favourable cases are those with a small cutaneous wound, which, before infection occurs, heals by immediate adhesion of the opposed wound surfaces, or beneath a scab per primam intentionem. Under these conditions they run a course like that of a subcutaneous fracture. The worst cases of compound fractures are those in which the soft parts are so extensively destroyed that the preservation of the limb is entirely out of the question. To these may be added the cases in which there is extensive splintering of the bones or a perforation into a joint or one of the cavities of the body. But as a general thing it is more the extent of the injury to the soft parts than the nature of the injury sus- tained by the bones which determines the severity of the case. Any simple division of the bone which is accompanied by great destruc- tion of soft parts is to be regarded, in point of prognosis, as a more severe injury than a splintering of bone which is in itself considera- § 101.] FRACTURES. 579 ble but is not accompanied by any great amount of injury to the soft parts. The clinical course of a compound fracture is, moreover, affected in a very marked degree by the way in which it is treated. The sooner a compound fracture is placed under the protection of antiseptic treat- ment—i. e., the sooner the wounded soft parts and the seat of the frac- ture are thoroughly disinfected, the drainage of the wound attended to, and an antiseptic dressing applied—the sooner is a satisfactory course of repair guaranteed. If we leave out of consideration the compound fractures which heal antiseptically, the local symptoms, in the majority of cases, consist in a more or less severe inflammatory swelling in the parts surrounding the wound and point of fracture. The discharge from the wound is at first thin and discoloured by blood. In the aseptic cases it is limited in amount and does not become suppurative. In the cases which do not run an aseptic course the discharge is plainly purulent or even sanious— in other words, it undergoes decomposition in consequence of infec- tion by micro-organisms. The production of suppuration and putre- faction is favoured by extensive destruction of the soft parts at the time of the injury. This putrefactive suppuration can, if the escape of the discharge is prevented, readily take on a spreading character in the shape of a progressive gangrenous cellulitis, which may endanger the preservation of the limb and of life. If the suppuration or putrefac- tion runs a favourable course, the surface of the wound gradually " purifies " itself—i. e., the superficial gangrenous portion of the wound is slowly cast off by a demarcating suppuration, red granulations make their appearance, and the wound fills with germinal tissue which then ossifies. The suppuration around the ends of the fragments which have become necrotic, or around splinters, is sometimes very tedious, and there is always the possibility of the pus burrowing or giving rise to infectious suppuration in the periosteum or the bone marrow, or causing lymphangitis, phlebitis, etc., and thus death from septicaemia or pyaemia. By long confinement to bed, or from protracted fever or profuse suppuration, the patient may become so exhausted and such serious degenerations of the internal organs may occur, that life is im- perilled. Throughout the entire period occupied by the process of repair, the temperature of the patient should be taken two or three times a day, and at every new rise of temperature the wound should be care- fully examined to determine the presence of any disturbance, such as a burrowing of pus, a deeply located spreading inflammation and suppu- ration, etc. 580 INJURIES AND SURGICAL DISEASES OF BONE. Not infrequently, after a compound comminuted fracture has healed fistulae will persist for a long time; they indicate the presence of some encapsulated, necrotic piece of bone—a so-called sequestrum. Condition of the Urine in Fractures.—As a result of the absorption of blood from the point of fracture, the urine very frequently contains urobilin a derivative of the colouring matter of blood, which, on shaking the urine with a solution of chloride of zinc and ammonia, causes the urine to assume a yellowish-green fluorescence. Fat is also very often found in the urine; it is derived as fluid fat from the crushed medullary portion of the bone and the fat in the neighbouring soft parts, and, passing through the circulation, is excreted by the kidneys. We shall learn further on that it can sometimes accumulate to a dangerous degree in the lungs and brain. Tbe amount of fat in the urine varies greatly, depending upon the severity of the injury to the marrow and soft parts; in some cases it is found only in traces, while in others there may be large quantities of it. Occasionally it is so abundant that it is visible in the form of smaller or larger drops on the surface of the urine. Most commonly the fat is mixed with the urine in the form of an emulsion, and Scriba maintains that this occurs in almost every case of frac- ture. After the urine has been allowed to stand for some time a white layer develops on its surface, which the microscope shows is made up of small and minute fat drops. According to Scriba, tbe excretion of fat by the kidneys takes place periodically, corresponding to the sweeping away of the fat emboli in the lungs. This is tbe reason why tbe urine during the repair of a frac- ture changes so much, containing fat for several days and then being free from it for five to six to ten days. The excretion of fat begins on the second to the fourth day after the injury, and usually ceases on the twentieth to the twenty-fourth day. In addition to fat, the urine of patients with fractures sometimes contains albumen and casts. The amount of albumen and casts is greatest in the first twenty-four to forty-eight hours, and the condition lasts about four to six days. Besides hyaline casts Riedel found other casts studded with numerous brown granules like those which occur in bilious pneumonia and other dis- eases accompanied by degenerative changes in the blood. These brown casts are irregular in their occurrence in fractures and are frequently entirely ab- sent, while in other instances they appear in great numbers. Riedel ascribes tbe origin of these brown casts to the absorption of red blood-corpuscles at the point of fracture. They are obtained experimentally by producing frac tures artificially, by injecting blood into the peritoneal cavity, and by inject- ing Kohler's fibrin ferment. Both Orth and myself have occasionally found very large collections of red corpuscles and of the colouring matter of blood in the lymph glands and in the internal organs. The haematogenous jaun- dice which sometimes occurs is similarly explained by the presence of disin- tegrated red corpuscles and blood-colouring matter in the circulation. Repair of Fractures.—Fractures either heal per primam or per se- cundum intentionem, in the same way as described in § 61 for wounds of soft parts. Subcutaneous fractures, as a rule, heal per primam in- tentionem, while compound fractures heal per secundam intentionem. §101.] FRACTURES. 581 As we remarked above, suppuration takes place in exceptional cases of subcutaneous fractures from the entrance of micro-organisms through an abrasion in the skin or by means of the blood-vessels. Whether a fracture heals with or without suppuration, the anatom- ical changes are essentially the same, and consist, briefly speaking, in the formation at the point of fracture of cellular tissue, which is at first soft, and later is gradually changed into bone by the ossifying action of the pe- riosteum and marrow. The ossifying tissue at the point of fracture is called the callus. Anatomical Changes in the Formation of the Callus.—The anatomical changes which take place in the formation of the callus are histologically an ossify- ing periostitis and osteomyelitis. The extravasated blood at the point of frac- ture plays no active part in the forma- tion of the callus, and is gradually sup- planted by a germinal tissue rich in cells and vessels. The outer or periosteal callus originates from the inner layer of periosteum, which contains osteo- blasts, while the marrow forms the in- ner or medullary callus (Fig. 341). The callus between the broken ends of the bone is called the intermediary callus, and is mainly produced by proliferation of the periosteal germinal tissue be- tween the fractured surfaces; the tissue of the opened Haversian canals and the marrow only shares to a slight extent in the formation of the interme- diary callus. The view which formerly prevailed—namely, that the surrounding soft parts were capable of contributing to the formation of the outer callus—is untenable in the light of our present knowledge of the normal development of bone. The Normal Formation of Bone—The Development of Bone.—It is now generally believed that the normal development of bone is mainly the result of successive appositions of bone substance due to the activ- ity of the medullary tissue, the cells of which change into specific bone- forming cells—the so-called osteoblasts (Gegenbaur, Fig. 342). x M Fig. 341.—Longitudinal section through a fracture of the femur three weeks old : P= periosteum ; K = bone; M— medulla. Periosteal callus and medullary callus. The intermedi- ary callus consisting of periosteal granulation-tissue, which is ossitied only in some places and is partly cartilaginous. 582 INJURIES AND SURGICAL DISEASES OF BONE. The medullary tissue may spring either from the periosteum or from cartilage. The periosteum or perichondrium (in the cartilagi- nous bones of the embryo) is made up of two layers, an outer fibrous layer and an inner layer of osteoblastic cells. In this latter layer med- ullary spaces develop, and in '„•-■ ~~-- them the osteoblasts from an S^^ti--—' active formation of cells and growth of vessels. In addition to the periosteal or perichon- drial bone formation we recog- nise an endochondrial bone for- mation in the cartilage of em- "-Z "^CS^H---""^ ~ ~" TJ^___^~I bryonic bone ; this takes place F.o. 342.-Periosteal formation of bone from osteo- especially in the growth of the blasts a; b, newly formed bone; c, old bone. ]onor bones at the epiphyseal x 300. . n . r r . . junction. Medullary cavities develop here also, and a portion of the medullary cells change into osteoblasts. Opinion differs as regards the importance of the car- tilage cells in the endochondrial formation of bone, Virchow and oth- ers believing that the cartilage cells change into medullary cells and osteoblasts, while Gegenbaur and Strelzoff maintain that the cartilage cells, as such, perish, and take no part in the formation of bone. The latter authorities hold the view that the osteoblasts are always derived from the marrow or the osteoblastic layer of the periosteum. Maas's view that the colourless blood-corpuscles are capable of forming the cal- lus seems to me untenable. The transformation of the osteoblasts into bone tissue is brought about by a change of the greater part of the protoplasmic material into a tissue which appears homogeneous, but is really made up of fine fibrils, which, after taking up bone salts, forms a lamellated ground substance. Here and there cells persist as bone cells, which are enclosed by the newly formed bone in serrated cavities, having fine processes radiating from them. These are the so-called bone-corpuscles. Meyer and the mathematician Cullmann were the first to show that the bony structure and trabeculse are arranged according to mechanical laws. Interstitial Growth of Bone.—In addition to this appositional growth of bone from the periosteum and medulla, Oilier, Virchow, and others have called attention to the occurrence of an interstitial growth—i. e., an expansion of the bone substance already formed. This was dem- onstrated by driving pegs and boring holes into growing bone. Artificially Increased Growth of Bone.—Under such pathological con- ditions as necrosis, chronic inflammatory processes, compound fractures, s' lOi-J FRACTURES. 583 chronic joint inflammations, etc., as a result of irritation of the epiph- yses, an increased growth of bone is observed, especially in the long axis. The longitudinal growth can be artificially increased and short- ening compensated for by driving ivory pegs into the bone, or tying off the extremity with an elastic tourniquet, or by other forms of irrita- tion acting upon the diaphysis in the neighbourhood of the epiphysis, from which the effects are transmitted to the epiphyseal cartilage (Oilier, Langenbeck, etc.). In the case of a compound fracture which healed slowly with suppuration, I saw a shortening of eight centimetres in the beginning changed to three centimetres in the course of about one to one and a half year as a result of an abnormal stimulation of the growth. Sometimes, even in subcutaneous fractures, the shortening which may exist at first disappears after a year or two by augmented longitudinal growth. Absorption of Bone Substance.—Simultaneously with the new forma- tion of bone there is constantly taking place, on both the outer and inner surface of the bone, an absorption of bone substance which is brought about by special cells called osteoclasts (Kolliker). These osteoclasts (Fig. 343) usually and Recklinghausen, that they originate from white blood-corpuscles. According to Fommer, the cells of the adventitia of the blood-vessels, the endothelial cells of the perivascular lymph spaces, and of the Haversian blood-vessels themselves—in short, the protoplasm of all the cells lying near the bone substance—are capable, under certain conditions, of taking on osteoclastic functions. Pommer states that the subsequent history of the osteoclasts, as well as their derivation, varies, and that osteoblasts or other cells may be made from them. He ascribes the cause of the production of the osteoclasts to the in- crease in the local blood pressure. The action of the osteoclasts is entirely local, the bone disappearing in the form of small pits or lacunas (Howship's lacunae, lacunar bone resorption, Fig. 343). The 584 INJURIES AND SURGICAL DISEASES OF BONE. osteoclasts probably form carbonic acid, by which the lime salts are dissolved, and the rest of the ground substance is assimilated by the osteoclasts or absorbed by the blood or lymph current. The Ossification of the Callus.—The ossification of the callus takes place in precisely the same way as in the development of bone. The germinal tissue either ossifies as such, or there is first a production of hyaline or fibrous cartilage. In the deepest layers of the periosteal germinal tissue, and hence close to the bone, at a little distance from the broken ends and in the neighbourhood of the normal intact periosteum, there appear by the third or fourth day small collections of bone-like, " osteoid " tissue. A network of bony trabecular, with enclosed medullary spaces, gradually develops. During the second week the formation of the periosteal callus is so far advanced that it consists of a great number of osteoid and osteal trabecular—in other words, the two fragments are bound together by a young osteophyte made of wide-meshed bone tissue. At the end of the third week (Fig. 341) the periosteal callus usually consists of fairly firm, spongy bone. Simultaneously with the formation of the periosteal callus the internal (myelogenic) callus develops in the medulla of the bone in the same way. On the inner surface of the cortex a trabecular system of osteoid tissue is formed, which gradually changes into true bone by the deposition of bone salts. The size of the medullary callus va- ries greatly, oftentimes filling the entire medullary cavity, while in other instances it may only develop to a slight extent. In the me- dullary callus also, particularly7 in the neighbourhood of the point of fracture, hyaline and fibrous cartilage is found, though not so con- stantly nor in so large amounts as in the periosteal callus. The so-called intermediary portion of the callus, which lies between the broken ends, develops, as we remarked before, principally from the periosteum. Retrogressive Metamorphosis of the Callus.—At the outset the callus is made up of spongy bone rich in marrow. This so-called provisional callus is then transformed into the permanent bone cicatrix by be- coming more compact, decreasing in circumference, and becoming smooth on its surface. This involution of the callus may reach such completeness that the bone cicatrix is later on scarcely visible. If the medullary cavity was closed by the medullary callus it may again be- come free by absorption of bone. AVherever the bone substance formed in the ossification of the callus is not functionally necessary it is ab- sorbed ; while, on the other hand, apposition of bone substance takes place in those parts of the callus where they are necessary for the firmness of the bone cicatrix. In this way the structure of the bone g 101.] FRACTURES. 585 at the point of fracture is regenerated as completely as possible and as the laws of statics demand. Billroth, Volkmann, Oilier, Bruns and others have been instru- mental in elucidating the subject of the formation of the callus, but the real founder of the experimental study of callus formation is Du- hamel (1740), who showed by his classical investigations that the callus is not produced by any particular fluid of the body, but by a formation of bone from the periosteum and marrow. The size and circumference of a callus varies greatly, according to the condition and position of the broken pieces, the location of the fracture, and the size of the bone. Constitutional conditions also exert an influence. The strongest callus, as a general thing, develops in fractures through the diaphysis of the long bones, which heal with dis- placement, especially7 if the fracture has been com- pound. Considerable disturbance of function may be produced by fractures like these which heal in a position of deformity with such a callus luxurians, as it is called (Fig. 344). The callus is generally slight in flat bones like the scapula or those of the pelvis. After fractures of two par- allel bones which lie next one another, as is the case in the forearm, it is possible for a synostosis of the two bones to occur. After fractures in the neighbourhood of joints the callus sometimes extends in the form of processes into the capsule of the joint, or bridges of callus develop, extend- ing from the articular end of one bone to that of the other, and producing anchylosis of the joint. Occasionally true tumours (callus tumours) form from the callus at the point of fracture ; these are sometimes benign osteomata, or enchondromata, and sometimes malignant periosteal or myelogenic sarcomata (Haberen). Effect of Division of the Nerves upon the Callus Formation.—\V. Kusmin, experimenting upon the posterior extremities of rabbits, has studied the effect on the callus of dividing the nerves, and he observed that after nerve division the callus is larger and stronger in all its stages than calluses made without neurotomy, and the deposit of lime salts and ossification takes place at an earlier period and more exten- sively than is the case under normal conditions. Behaviour of Bone Splinters.—It is of special interest to note what happens to small fragments of bone. Those which remain attached Fig. 344.—Fracture healed with deformity (callus luxurians). 586 INJURIES AND SURGICAL DISEASES OF BONE. to the periosteum or bone heal in place the most readily. Smaller splinters are occasionally absorbed. If bone fragments do not become united to the rest of the bone, if they die and remain near the point of fracture, consolidation of the fracture may, in the case of large frag- ments, be very much delayed, or even entirely prevented, unless the dead portion of bone—the sequestrum, as it is called—is removed (see § 106, Necrosis of Bone). But it has been frequently noted, and even proved experimentally by Oilier, Bergmann, and others, that fragments which have been completely separated from the bone may heal in place perfectly in the case of subcutaneous fractures and of compound frac- tures in which the wound heals aseptically. Transplantation of Pieces of Bone into Defects in Bone.—The many experiments with transplantation of portions of bone into defects in bone have an important bearing upon the subject of the behaviour of fragments of bone which have been entirely separated from the bone and periosteum. All the experiments of Oilier, Bergmann, and others show that transplanted portions of bone with or without periosteum heal in place if the wround runs an aseptic course and if no suppuration takes place. Bergmann and Jakimowitsch performed twelve experi- ments, in ten of which portions of bone twenty millimetres long with and without periosteum and marrow were successfully transplanted; suppuration occurred twice, and in both instances the transplanted pieces of bone failed to unite. Jakimowitsch succeeded in healing a portion of a rabbit's phalanx into the skull of a dog. As a general thing, a loss of bone substance, particularly in the skull, should be re- paired by the implantation of a pedunculated flap consisting of bone, periosteum, and soft parts. On the skull the pedunculated skin-perios- teum-bone flap is taken from the vicinity of the defect, the surface of the bone being chiselled through, leaving the inner tablet intact. Nussbaum was the first to successfully repair loss of bone substance by peduncu- lated periosteum-bone flaps, which remained connected to the periosteum by a periosteal bridge at one end of the fragment. MacEwen successfully repaired a loss of bone substance 11*4 centi- metres long in the diaphysis of the humerus by transplantation of small pieces of bone about 0-3 to 0*5 centimetre in diameter. The pieces of bone, including periosteum and marrow, were obtained from osteoto- mies for rhachitic curvatures in small children. Oilier has successfully repaired losses of bone substance by the transplantation of small hollow bones, such as the first phalanx of the great toe. If the transplanta- tion of bone is to succeed, the strictest asepsis must be employed to prevent suppuration, the extremity must be carefully immobilised, and the transplanted material, including, if possible, the medulla and perios- §1011 FRACTURES. 587 teum, should be taken while it is in process of vigorous growth, and consequently from young subjects or newborn children. Gluck has repaired losses of bone substance by pieces of ivory (see § 43), but, as Bergmann found in one instance, the cure was only temporary, and he was obliged to remove the ivory peg on account of the pain and con- tinued uselessness of the hand. Senn and others have successfully employed decalcified bone. In ten cases in which he had good results with pieces of decalcified bone Le Dentu proceeded as follows: He freed the bone to be used, which was generally the femur or tibia of an ox. from periosteum and medulla, decalcified it by immersion for eight days in a sixteen-per-cent. solution of hydrochloric acid; he then washed the pieces of bone, placed them for twenty-four hours in a solution of bichloride of mercury, and stored them in iodoform ether. These implanted decalcified pieces of bone, placed like an internal splint inside the bone, are eventually completely absorbed, but they atimulate the formation of bone. Dead pieces of bone which have not been de- calcified and are below a certain size, as proved by the experiments of Ochotin, can be made to heal in place. The dead pieces of bone, like any foreign body, are first surrounded by young connective tissue, and are then permanently enclosed by newly formed bone tissue. Vigor- ous processes of absorption take place within the encapsulated dead tissue, by which small pieces of bone may be entirely absorbed. The dead piece of bone, as Bergmann has correctly stated, is either encap- sulated by bone or its place is taken by living bone tissue. If a large dead piece of bone is made use of for the functions of motion or sup- port, the implanted material does not usually7 heal in place, and inflam- matory (carious) processes take place in the adjoining living bone (Bergmann). Repair of Fractures of Cartilage.—The process of repair in fractures of cartilage, such as the ossifying costal cartilages or laryngeal carti- lages which are covered with perichondrium, is mainly carried on by the perichondrium, and a fibrous cartilage is formed, which then gradu- ally ossifies. Regressive changes usually take place at the broken ends, and the cartilage undergoes fatty degeneration, but at a distance a little further removed from the broken ends of the cartilage there occurs a vigorous proliferation of cartilage cells and a formation of new carti- lage tissue (Tizzoni, and others). In cases of interruption of continu- ity and loss of substance in the cartilage of joints which is not pro- vided with perichondrium, a fibrous connective-tissue cicatrix ordinarily develops, which Tizzoni states is capable in time of changing into hyaline cartilage tissue. Portions of cartilage which have been com- pletely broken off do not regain their attachments, and either become 588 INJURIES AND SURGICAL DISEASES OF BONE. free bodies in the joint or are encapsulated by new connective tissue formed from the inner surface of the capsule. The Time required for Fractures to Heal.—The time wliich is re- quired for the callus formation to reach completion and render the affected bone again capable of performing its function, depends upon the size of the bone which is involved, the nature of the fracture, and not infrequently also upon constitutional conditions. A simple subcu- taneous fracture, as a general thing, heals more rapidly than a com- minuted or a compound fracture with considerable injury to soft parts. In childhood, healing takes place more rapidly than in adult life. The healing of a fracture may be prolonged by constitutional anomalies, such as the occurrence at the same time of severe acute constitutional infectious diseases, or by syphilis, scurvy, diabetes mel- litus, and not infrequently by pregnancy. Gurlt has given the follow- ing periods as those required for the healing of simple subcutaneous fractures: A broken phalanx needs about two weeks, the metacarpus, metatarsus and ribs three, the clavicle four, the forearm five, the hu- merus and fibula six, the neck of the humerus and the tibia seven, both bones of the leg eight, the femur ten, and the neck of the femur twelve weeks before consolidation is complete. Condition of the Soft Parts and Joints after Healing of a Fracture.— After consolidation of a fracture the full usefulness of the joint is not immediately restored, and the muscles very frequently have become atrophic as a result of their long inactivity. From long-continued immobilisation or too tight dressings this atrophy of the muscles, par- ticularly in anaemic individuals, may give rise to the ischsemic paraly- ses and contractures mentioned on page 549. Sometimes the functions of the muscles are disturbed by cicatricial shrinkage as a direct result of the injury, or by their insertion having been torn away, or by paralysis in consequence of a complicating injury to the nerves, or from compression of the nerves, for instance, by the callus. The skin very often exhibits slight disturbances of nutrition; it is dry and rough, and the epidermis comes off in scales. Very frequently there are varying degrees of oedema of the skin and subcutaneous soft parts. The rest which the healing of a fracture enjoins also exerts a disad- vantageous influence upon the condition of the joints (Menzel, Reyher). In consequence of the shrinkage of the capsule of joints immobilised by the fracture dressing, the joints are more or less stiff after the splint is removed, and sometimes inflammatory effusions occur. Ordi- narily, with the increasing use of the joint and under proper treatment (by massage and passive motion) these disturbances very soon disap- pear. In other cases joint inflammations have their foundation in a §101.] FRACTURES. 589 direct injury of the joint, and under these circumstances it is possible for permanent joint disturbances, inflammation giving rise to deformity, anchylosis, etc., to occur (see Diseases of Joints). Course of the Epiphyseal Separations.—The separations of the epiph- yses run essentially the same course as fractures of the bone. AVe still lack precise anatomical knowledge upon the phenomena of their healing. Great interest attaches to the question of how much dis- turbance after epiphyseal separations has been observed in the growth of the affected bone on account of ossification of the epiphyseal carti- lage. Unfortunately, only a few observations have been recorded on this subject. Bruns's statistics show that a consequent arrest of devel- opment only occurs in rare and ex- ceptional instances to any marked degree. Vogt has recorded obser- vations of this kind. In Fig. 345 is represented a shortening of the humerus amounting to twelve and one half centimetres in a thirty- year-old woman which was proba- bly the result of a traumatic separa- tion of the epiphysis sustained in childhood, with subsequent anchy- losis of the shoulder joint. Short- ening develops especially when the diaphysis and epiphysis are driven into one another and heal together in this position. Disturbances during the Healing of Fractures.—The most important disturbances which may arise while a fracture is healing are briefly as follows : 1. Shock. See § 63. 2. Delirium Tremens. See § 64. 3. Infectious Diseases of Wounds. See §§ 66-75.—These are par- ticularly liable to occur in the case of compound fractures which have not been treated antiseptically. 4. Gangrene. See § 100.—This may be caused by severe injury of the soft parts, by injury to the larger vessels, by pressure of the frag- ments upon the main artery, by improper treatment, such as too tight dressings, etc. 5. Necrosis of the Ends of the Fragments—-This is especially apt to occur in compound fractures when the broken ends lie in the wound Fig. 345.—Impeded growth of the right hu- merus, probably resulting from a trau- matic separation of the epiphysis (Bryant). 590 INJURIES AND SURGICAL DISEASES OF BONE. stripped of their periosteum, or when they are badly crushed or splin- tered into several fragments, or when the periosteum and medulla are to a great extent destroyed by suppuration and sloughing. The dead bone—or sequestrum, as it is called—is then separated from the living bone by a demarcating suppuration (see § 106, Necrosis of Bone). 6. Fat Emboli.—Probably in every fracture, as a result of the laceration of the bone marrow and subcutaneous adipose tissue, fluid fat gains access to the blood and lymph vessels which are opened at the point of fracture. Wherever the lumen of the vessels is too small for the passage of the fat drops circulating in the blood at this point, these drops lodge and occlude the vessel. Fat emboli of this kind following fractures are observed particularly in the pulmonary capilla- ries, and they also frequently occur in the smallest vessels of the brain, kidneys, liver, intestinal villi, etc. As long as the fat emboli are scat- tered and not extensive their occurrence is entirely unimportant; the fat produces no symptoms worth mentioning of either a local or consti- tutional nature, beyond causing a temporary occlusionof the lumen of the vessel in question. But sometimes the fat emboli in the lungs or brain are so numerous and so extensive as to cause death, not only in those weakened by age, but now and then in those who are in the prime of life. Death is due to a pronounced accumulation of fat in the capillaries of either the lungs or the brain. Scriba has performed experiments to determine the manner in which fat emboli act, and he maintains that death is mainly the result of their lodgement in the brain. As a rule, death occurs about three to four days after the frac- ture, and in such cases there is a continual accumulation of fat, during several days, in the capillaries of the lungs and brain, which finally causes a more or less sudden functional incapacity of these organs. It is comparatively seldom that death is the result of fat emboli alone; there are generally other complications. 1. Embolism of the Pulmonary Artery following Thrombosis of the Larger Veins at the Pond of Fracture.—This serious complication may occur particularly after thrombosis of the deep veins in fractures of the lower extremity. The thrombus in the vein may break loose either while the patient is lying quietly in bed, or because of some movement of the body, from massage, or from a change of the dress- ing, and death may follow within a few seconds from embolism of the pulmonary artery. Ivonig observed death from embolism of the pul- monary artery on the eighteenth day after a subcutaneous fracture of the leg in a strong man thirty years of age. AVhen the patient was laid upon the operating table preparatory to changing the dressings, he was suddenly seized with cramps and opisthotonus, the pupils be- 8 101-1 FRACTURES. 591 came dilated, and he died in a few moments. The autopsy revealed a large clot lodged in the pulmonary artery, and it was only with diffi- culty that the point was found in the vena tibialis antica where the thrombus had originated. 8. 1 hemorrhage.—In compound and subcutaneous fractures haemor- rhage may occur as a result of the violence which has been brought to bear upon the part, or it may be produced by pointed fragments, splinters of bone, etc. (see §§ 87-89). 9. Constitutional anomalies play an important part in respect to the prognosis in the case of any fracture. A fracture sustained by a very old person and entailing a long confinement in bed is a serious accident, for the reason that life may readily become endangered by hypostatic pneumonia. 10. Delay in the formation of the callus is particularly apt to occur when constitutional anomalies exist, or in acute and chronic infectious diseases (typhoid fever, syphilis, scurvy), in diabetes mellitus, in diseases of the peripheral nerves and central nervous system, such as progressive paralysis, or during preg- nancy, etc. 11. Pseudarthrosis.— If bony union does not take place between the frag- ments, the resulting condi- tion is called a pseudarthro- sis—i. e., a false joint (see Fig. 346). In a case of pseudarthrosis, the frag- ments are either entirely free from connection with one another, or they are joined together by a connective-tissue or cartilaginous intervening substance of varying strength. In rare instances a kind of true joint is observed at the point of fracture—i. e., the ends of the fragments are covered with a layer of hyaline cartilage, and a shallow cavity is hollowed out of one fragment, while the other is rounded to fit it; the periosteum and neighbouring connective tissue surrounds and encloses the broken pieces in the form of a capsule, and in some cases there will be found in the joint-like cavity a fluid which resembles synovia. In pseudar- throses such as this, even synovial villi and loose bodies have been found, the latter sometimes in great numbers. Occurrence of Pseudarthrosis.—In general, pseudarthrosis is not of Fig. 346. -Pseudarthrosis of the humerus twelve yearc old in a fifty-three-old man. 592 INJURIES AND SURGICAL DISEASES OF BONE. common occurrence. Karmilow states that a pseudarthrosis takes place once in about three hundred or four hundred fractures. The pseudarthroses following fracture of the neck of the femur and frac- ture of the patella are the most frequent. Bruns's statistics seem to show that childhood and old age predispose less to pseudarthrosis than middle life. Causes of Pseudarthrosis.—The causes of pseudarthrosis are usually local in their nature, being principally those which prevent exact coap- tation of the wounded bone surfaces. A pseudarthrosis may result, for example, from a diastasis of the fragments, such as often occurs after transverse fracture of the patella or after loss of a large portion of a bone, owing to its becoming extensively crushed; or the affection mav result from displacement of the fragments, or from interposition of muscles, tendons, fascia, foreign bodies (bullets), pieces of dead bone, etc., between the fractured surfaces. In other cases—for instance, after intracapsular fractures of the neck of the femur, or intracapsular fractures of the neck of the humerus—the pseudarthrosis is caused by the insufficient nourishment of one of the fragments. Pseudarthrosis may also originate in consequence of insufficient coaptation of the frac- tured surfaces due to defective dressings, particularly if the fracture is oblique; under these conditions the fragments are permitted to move and become separated. An influence is sometimes exerted in this di- rection by a paralysis which may exist at the time of the fracture, or by too little inflammatory reaction in consequence, for example, of the wound healing aseptically in the case of compound fractures. Consti- tutional disturbances, especially7 the general weak condition which fol- lows severe febrile diseases, loss of blood, prolonged lactation, preg- nancy, etc., have in rare instances given rise to pseudarthroses. Under these circumstances it has also happened that an already ossified callus has softened and been completely absorbed. The degree of functional disturbance resulting from a pseudar- throsis depends mainly upon the location of the latter, the function of the bone which is involved, and especially upon the amount of motion possessed by the false joint. In a pronounced pseudarthrosis of a long bone, like the femur or humerus, the affected portion of the limb or the entire extremity is quite useless, unless some supporting apparatus is worn. Diagnosis of Fractures.—The diagnosis of fractures is made from the above-described symptoms. In order to make out the latter, a system- atic and careful examination of the injury should be undertaken. This examination consists: 1. In a thorough inspection of the injured por- tion of the body7, noting, for example, changes in its shape and disturb- § 101.] FRACTURES. 593 ances of function. 2. In palpation of the place where the fracture is presumed to be, combined with passive motion. 3. In an exact meas- urement of the length of the injured bone, or, rather, the extremity, to determine the presence and amount of shortening. Simple inspection will often be sufficient for the immediate recognition of a fracture. En- tirely apart from the crepitation and abnormal mobility, the character- istic linear pain obtained by palpation of the line of fracture will fre- quently betray the existence of a fracture. In order to palpate the line of fracture more readily, the extravasation at the point of fracture should, when practicable, be removed, or at least diminished in amount, l>y gentle massage. The corresponding sound portion of the body should always be compared with the injured part, with a view to determining how far the normal position of the constituent parts has been altered by the injury. Not infrequently we have to make the examination during narcosis to find out the exact nature of the fracture, especially when it is compound. In all cases where the diagnosis of fracture is doubtful, the injury should always be treated, for the first at least, according to the rules which govern the treatment of fractures. Percussion and Auscultation of Bones.—Lucke and Hueter have recom- mended percussion and auscultation of the bone as an aid in the diagnosis of fractures, particularly when it is desired to determine the presence of fissures in the skull, which can be recognised by the pain the patient feels during the percussion. If soft parts are interposed between the ends of the fragments, Hueter states that auscultation (osteophony) will show a diminution or com- plete cessation of the conduction of sound. The Prognosis of Fractures.—The prognosis of subcutaneous fractures without much injury of,the surrounding soft parts is, in general, favour- able. Transverse fractures heal more rapidly and are less apt to cause lasting deformity than oblique fractures. The location of the fracture is an exceedingly important matter as regards the prognosis. The latter is more favourable in fractures of the extremities than in those of the bones of the skull, trunk, and pelvis, in which the concomitant in- juries of neighbouring organs of vital importance, such as the brain, spinal cord, lungs, heart, bladder, etc.. may readily give rise to very serious disturbances or death. In other cases injury to a neighbouring large vessel may cause fatal haemorrhage, or, when the middle meningeal artery is wounded, cerebral compression, with possibly fatal results. Fractures of the lower extremities in old people, necessitating their confinement to bed for weeks, are always to be looked upon as severe injuries. As a result of the long-continued dorsal decubitus, general disturbances of nutrition, bronchitis, and hypostatic processes in the lungs readily develop, which very often terminate fatally. This fact 38 594 INJURIES AND SURGICAL DISEASES OF BONE. is of therapeutic importance, as it teaches us in proper cases to permit patients with fracture of the neck of the femur, for example, to get about on crutches as soon as possible. The prognosis of fractures involving the articular ends of bones of the extremities is very frequently unfavourable, particularly as regards restoration of the functions of the joint. The character of the fracture exerts a very important influence upon the prognosis as regards the preservation of the patient's life and tin- saving of the injured limb, as well as its complete restitutio ad integrum. Compound fractures, in particular, are always to be looked upon as severe injuries, and ones which threaten both the limb and life itself, but, thanks to Lister's antiseptic method of treating wounds, we are no longer powerless to combat infectious-wound diseases. In the pre-anti- septic times the mortality of compound fractures amounted to thirtv- five to forty per cent, and in especially infected hospitals even to sixty to seventy per cent, and more. Three quarters of the fatal cases were due to septicaemia and pyaemia. At present the mortality of compound fractures, when timely and proper antiseptic treatment is bestowed upon the wound, is extremely small, for the reason that we have learned to prevent infectious-wound diseases. During four years and a half Volk- mann cured seventy-five compound fractures without having a single death. From this it is plain that the prognosis of a compound frac- ture is, in general, more favourable the earlier it is placed under the protection of antiseptic treatment. Frequently it may be impossible to preserve the broken limb, so that either immediately after the injury, or later, amputation of the ex- tremity must be undertaken. The extent to which the prognosis of any fracture, subcutaneous as well as compound, may be affected by various accidental circumstances, has been described on pages 589-592. Treatment of Fractures.—The first aid to the person who has just sustained a fracture often falls to the share of the laity who happen to be present at the accident. Unfortunately, their assistance frequently does more harm than good. In fractures of the upper extremity the patient usually instinctively places the broken limb in a proper position. But the conditions are entirely different in all fractures of the pelvis, vertebme, and lower extremity, in consequence of which the injured person is unable to walk. Under these conditions the patient must he lifted cautiously after securely supporting the point of fracture. If an individual who has received an injury of this kind has to be transported to his home or to a hospital, the fractured part should be placed in the most secure position possible, a suitable temporary dressing applied to s' 101.] FRACTURES. 595 prevent unnecessary pain and displacement of the ends of the frag- ments, as well as serious injuries, such as perforation of the skin and severe wounds of the soft parts, particularly of the vessels, with dan- gerous haemorrhage, etc. Great care should be used in removing the patient's clothes, portions of the latter—his boots, etc.—when necessary, being slit up with a knife or scissors. The technique of applying an impromptu dressing, the various splints, the arrangement of the bed, the position of the patient, etc., are described in §§ 52-55. The proper treatment for fractures, particularly those which are subcutaneous, consists in correcting the deformity as soon as possible— i. e., in reposition or reduction of the fragments, and in retention or fixation of the broken pieces after they have been placed in apposition by a suitable retentive dressing until bony union is complete. Reposition of the Fragments.—The reposition or reduction of the dis- placed fragments into their normal position is usually brought about by extension (traction) and counter-extension in the longitudinal axis of the broken bone. The extension and counter-extension of the broken limb are usually cautiously performed by two assistants, while the sur- geon grasps the point of fracture and brings the fragments into their normal position (coaptation). Manual reposition or reduction will al- most always be sufficient. If great force has to be used, or if the pain is intense, narcosis may have to be employed. Extension apparatus, such as the pulley or Schneider-Mennel's frame, which were at one time very much used, have become antiquated. The reduction of many frac- tures, such as those of the bones of the face or through the condyles in the immediate neighbourhood of a joint, etc., can be accomplished sim- ply by direct manipulation, without extension and counter-extension. Obstacles to Reduction.—()ccasionally various obstacles stand in the way of the successful reduction of a fracture. These include the inter- position of splinters of bone or of soft parts between the fragments, impaction of the broken ends in fractures of the articular extremities of bones, and the impossibility of bringing sufficient power to bear upon the fragments. Impaction of the broken ends, such as may occur in fractures of the neck of the femur, should be let alone, for the reason that the impaction favours consolidation of the fracture. Application of Retentive Dressings.—There are a great number of splints and dressings described in £§ 53-55 for holding the fragments in their normal position after they have been brought into apposition. The ordinary dressing for a fracture is the rapidly hardening retentive appliance made of plaster of Paris (page 216). Extension apparatus are generally used for fractures of the thigh, and can also be employed for the upper extremity (see § 55, page 229), while special splints are 596 INJURIES AND SURGICAL DISEASES OF BOXE. recommended for many fractures, such as those of the lower end of the radius. The hardening retentive dressings should be applied as soon as possible, and it very often happens that subcutaneous fractures will heal under a single dressing. If the swelling at the point of fracture is considerable, ice can be applied to the surface for several days with advantage, and then, after the inflammatory swelling has been reduced the limb can be placed in the hardening dressing. Even though the swelling is marked the plaster-of-Paris dressing can be immediately ap- plied, if the parts are first carefully padded with cotton. In such cases the hardening dressing has an antiphlogistic effect from its gentle and even pressure—i. e., it prevents an increase in the swelling. After a certain length of time this dressing becomes loose and does not suffi- ciently immobilise the point of fracture, and hence it must be taken off and replaced by a new one. In putting on the hardening dressing great care must be taken not to apply it too tightly. Subsequently the fingers and toes should be carefully watched, and if they swell or become blu- ish-red or oedematous, if pain or a feeling of numbness occur, the band- age has been applied too tightly and must be immediately removed. Every plaster-of-Paris dressing, whenever it is possible, should be again carefully inspected some hours afterwards to determine whether it has not been applied too tightly. Incurable ischaemic muscular contractures may readily develop within a few hours after the application of a plas- ter-of-Paris dressing which is too tight (see page 549), and for these the attending physician can be held legally responsible. A warning should be given against the too prolonged use of re- tentive dressings and the rest in bed which this entails, because of the bad effect produced upon the general health, the atrophy of the mus- cles, the enforced disuse of the joints, etc. On account of these serious possibilities, and particularly on account of the danger of hypostasis, old people with fractures of the lower extremities must often be allowed to leave their bed and go about on crutches with a suitable splint, and with a raised sole on the shoe of the sound leg. Recently successful results have been obtained by allowing all patients with fractures to walk about with suitable splint dressings, and by avoiding, for the above-mentioned reasons, the treatment with dressings which require a long confinement to bed. Within five to seven days the patients are allowed to move around on crutches in a proper retentive apparatus, such as a Thomas splint, with a raised sole under the foot of the sound side (see second edition Special Surgery, vol. ii, Fig. 723, p. 623). The results are very satisfactory, and the time required for healing to be accomplished is shortened. Treatment of Subcutaneous Fractures involving a Joint.—In sub- § ioi.] FRACTURES. 597 cutaneous fractures involving a joint special care must be taken to pre- vent the development of anchylosis or a partially stiff joint (contrac- tures). This is best accomplished by the use of suitable splints or a plaster-of-Paris dressing, which should be frequently changed—every five to eight days, for example—and reapplied after altering the posi- tion of the joint. Massage and passive motion may be combined with this—for example, at every change of dressing. Extension appliances are also very useful, and may be employed, as Bardenheuer has recently recommended, even for fractures of the upper extremity which involve joints. If it is difficult to maintain the fragments in position after they have been reduced, they may be fastened together by7 aseptic steel nails or pins (see page 111). Treatment of Traumatic Separation of the Epiphysis.—For securing bony union after traumatic separations of the epiphyses, the fragments should be directly united by long aseptic steel nails or pins (Trendelen- burg, Bruns, etc.). Helferich has recommended long steel pins attached to a removable handle, by which they can be slowly screwed into a bone; they can be used for both subcutaneous and compound epiphy- seal separations. Direct Fixation of the Fragments in Subcutaneous and Open (Com- pound) Fractures, Suturing, Nailing, etc.—In all subcutaneous or com- pound fractures, where it is difficult to maintain the fragments in proper position, the wounded bone surfaces can be held in contact by directly suturing them together, by driving nails into them, or ivory pegs, or Helferich's steel pins, or by placing bone or ivory pegs in the medullary cavity, as described in § 34 (Union of Wounded Bone Surfaces). In this category belong Malgaigne's hooks for fracture of the patella and Malgaigne's pin for fracture of the tibia—instruments which are scarcely ever used at present. If nails are to be used to secure fixation of the bones, long four-cornered steel ones should be employed. These are polished, boiled for fifteen minutes in a one-per- cent, soda solution, heated red-hot, and placed in a ten-per-cent. solution of carbolic acid in glycerine, after which they are perfectly sterile. After the bones have been nailed together they are securely immobilised. The wounds in compound fractures are not sutured, but packed with sterilised gauze. The nails are removed about the beginning of the fourth week. The Treatment of Open (Compound) Fractures.—The treatment of open (compound) fractures has been totally changed by the antiseptic method of treating wounds, and the results which we now obtain are very satisfactory. Typical cases of compound fracture which run an aseptic course heal without pain and without fever ; the discharge from 598 INJURIES AND SURGICAL DISEASES OF BONE. the wound is slight, and we are certain of being able to prevent sup- puration. The technique of the antiseptic treatment of the wound varies with the kind of case. For this reason we distinguish three classes of cases: 1. The perfectly fresh fractures in which the wound is the result of a perforation of the skin by a fragment. 2. The ordinary severe cases of compound fracture. 3. The compound fractures which are not recent and have already become infected. 1. Treatment of Fresh Fractures with Transfixion of the Skin by a Frag- ment.—The antiseptic management of a perfectly fresh fracture com- plicated with a perforation of the skin by a fragment is as follows: We will suppose that we have to deal with a fracture accompanied by only a small, still bleeding cutaneous wound, similar to a punctured wound; that the case comes under observation immediately or within a few hours after the reception of the injury; that there is no large ex- travasation of blood present; that the bone is simply broken, and not splintered ; and that no infectious-wound disease can be made out. In such cases enlargement of the wound and drainage can be omitted. After disinfection of the wound and surrounding parts, as described in § 6 and § 32, the wound is covered with an antiseptic dressing, such as sterilised gauze, folded together into several layers, and cotton, wool, or pads filled with moss.. Should the wound have become closed by a dried blood-clot and no indications of infection be present, this scab can be left undisturbed and the fracture allowed to heal under it. A plaster-of-Paris dressing can then be immediately applied over the anti- septic dressing. This antiseptic plaster-of-Paris occlusive dressing is left in place, if no fever or pain in the wound occurs, for two or three weeks longer, until the w7ound has healed, and is then, if necessary, re- placed by a simple plaster-of-Paris dressing until complete consolida- tion of the fracture has taken place. This antiseptic plaster-of-Paris occlusive dressing has been recently very much employed for fresh compound fractures with small wounds, and also in the treatment fol- lowing osteotomies of the rhachitic extremities of children. Bergmann, Reyher and others obtained brilliant results in the Turko-Russian War with this same form of dressing, even in such injuries as gunshot wounds of the knee. The method is not suitable for severe compound fractures with extensive wounds of the soft parts, nor for cases which are not perfectly fresh when they come for treatment. The opinions of surgeons still differ as to whether the antiseptic occlusion carried out in the manner above described should likewise be used for fresh comminuted fractures with a small cutaneous wound, or whether the wound should be enlarged and the splinters extracted. 8101] FRACTURES. 599 At all events, the brilliant results obtained by Bergmann and Reyher in the Turko-Russian War show that the primary extraction of the fragments, formerly so much insisted upon in comminuted fractures, is not always necessary ; that the above-described simple antiseptic occlu- sion, without enlarging the wound and without extraction of the frag- ments, gives even here excellent results; and that the splinters, though very numerous, are capable of healing up completely in the wound, provided the wound runs an antiseptic course. 2. The Antiseptic Management of Severe Compound Fractures, with extensive injury to the soft parts, likewise consists in a thorough disin- fection of every portion of the wounded surface and of the surround- ing parts to a considerable distance from the wound. If the opening into the wound is not large enough to permit of careful examination or disinfection of the entire wound cavity, it should be enlarged with the knife, using for the extremities Esmarch's artificial ischaemia. The point of fracture is inspected, and the entire cavity of the wound is energetically irrigated with a one-tenth-per-cent. solution of bichloride of mercury, crushed shreds of tissue are cut off with the scissors and for- ceps, the haemorrhage carefully arrested, foreign bodies, bullets, etc., are removed, and long, deep pockets under the skin or deeper parts are split open. If necessary, the fragments may be drawn out of the wound with sharp hooks or bone forceps, to render it possible to sys- tematically examine and disinfect them and the soft parts lying behind them. Counter-openings are made for the admission of short, large- sized drainage tubes to the most deeply lying parts, and every niche, every recess in the wound, and every pocket, should be carefully drained or split open. The deep drains should always extend to the cleft in the bone, but should not lie between the fragments. Tamponing the wound with iodoform gauze or sterilised mull supplies excellent drain- age. If splinters are present, all those which are entirely loose and dead should be removed, while those, on the other hand, which are still alive and attached to the periosteum should be retained, and, if displaced, returned to their normal position. Projecting points on the fragments which interfere with reduction should be removed with the bone forceps or saw. If it is difficult to maintain the fragments in position after their reduction, they may be secured in their normal sit- uation by sutures through the ends of the bone, or by nailing them together aseptically (see page 597). After the wound, with all its recesses, has been very carefully dis- infected and drained, we proceed to insert the sutures, provided the case is one suited for primary union. I believe it is wiser not to suture wounds of this kind, but to leave them open and pack them with iodo- 600 INJURIES AND SURGICAL DISEASES OF BONE. form gauze or sterilised mull, over which is placed an antiseptic protective dressing. Resection of the Broken Ends.—Formerly, in the case of compound comminuted fractures of the long hollow bones, the splintered ends of the bone were frequently removed (so-called resection in continuity). This primary resection immediately after the injury is only applicable for the most severe cases. If, during the subsequent course of com- pound comminuted fractures, necrosis of the broken ends takes place, then secondary resection of the fragments is indicated to obtain more rapid healing. Treatment of Compound Fractures of Joints.—If we have to deal with a compound fracture of a joint, we proceed according to the same prin- ciples—i. e., the joint is exposed by a sufficiently long incision, carefully disinfected, and drainage provided for. When necessary, we also re- move any crushed fragments of bone, extract the free splinters, or, in the severest cases, perform total resection of the articular ends of the bones. Speaking generally, resection in compound fractures of a joint is gov- erned by7 the following principles (see § 40): Primary resection is in- dicated in fresh, non-infected, extensive comminuted fractures of the articular ends of the bones, accompanied by great injury to the soft parts. Compound fractures involving a joint with only a small cuta- neous wound, after careful disinfection of the latter, should be treated at first as though the fracture were subcutaneous. If the attempt fails, and inflammation or suppuration of the joint with fever comes on, then arthrotomy should be performed—i. e., the joint is opened freely, the fracture exposed, carefully disinfected, and drained. Not infrequently, under these conditions, fixation of the fragments by sutures or nails renders excellent service. Whether a typical resection of the broken articular extremities should be performed depends upon the character and severity of the injury to the bone and the extent of suppuration or infection. At all events, resection is indicated wdien fever and local inflammation continue after arthrotomy and drainage of the joint, and when there is a probability7 of a severe infection of the wound of the bone having taken place. Subsequent Treatment of Compound Fractures.—The rest of the treat- ment of compound fractures depends upon their subsequent behaviour. In the most favourable cases, running a course free from fever, the first dressing is left in place six to eight to ten to fourteen days and then changed, and at the same time any drains, sutures, or tampons are removed. If, on the other hand, fever should occur, or the patient complain of pain in the wound, the dressing should be immediately changed and the wound and parts surrounding it carefully examined g 101.] FRACTURES. 601 for the presence of retained discharges, which should be immediately let out by an incision. The granulating wound should also be treated strictly according to antiseptic principles, and a closed or fenestrated plaster splint, or one of the modifications given under § 54, applied until the wound has become covered with skin. We cover large granulating surfaces with skin by Thiersch's method of skin grafting. When the wound has healed, a closed plaster splint is applied, if neces- sary, until consolidation of the fracture is complete. 3. Treatment of Fractures which are not Fresh and have become Septic.—We count all cases as not " fresh " wliich come under obser- vation twenty-four to forty-eight hours after the injury, with already existing local inflammatory changes in the wound. Of course, the character of these cases varies greatly, according to the severity and nature of the reaction which is present in the wound. If the reaction in the wound is slight, an aseptic course of repair may not infre- quently be obtained by energetically disinfecting, enlarging, and drain- ing the wound and then applying an antiseptic occlusive dressing. Tamponing the cavity of the wound with iodoform gauze or sterilised mull, and omitting all sutures, is a procedure particularly applicable for such cases. In other instances, again, the reaction in the wound will have al- ready become very marked. There is pronounced decomposition and putrefaction of the discharges, and the crushed soft parts and cellular tissue are gangrenous, and saturated with the products of decomposi- tion. The suppuration and putrefaction which are present are no longer limited to the wound, but have begun to spread progressively. Xot infrequently there is such a large accumulation of putrefactive gases that a pronounced gaseous infiltration (emphysema) takes place. Even in such unfavourable cases of pronounced sepsis a vigorous dis- infection of all the septic tissues should be undertaken and incisions made in great numbers. We, of course, avoid applying the ordinary closed protective dressings which exert pressure, and content ourselves with energetic disinfection of the wound, covering it with sterilised gauze or iodoform gauze, or employing permanent antiseptic irrigation (see page ITS). As long as the treatment lasts it is exceedingly impor- tant to keep the extremity in an elevated position and the fragments as securely immobilised as possible. When the wound has become aseptic and is granulating, we cover it with iodoform gauze and cotton and immobilise the fragments by a suitable splint, or by a fenestrated or interrupted plaster-of-Paris dressing. The treatment of compound fractures which have become infected demands much patience and care, and, above all, experience. It is very important to note the be- 602 INJURIES AND SURGICAL DISEASES OF BONE. haviour of the temperature by means of the constant use of the ther- mometer, and to recognise any retention of discharges at the earliest possible moment and to let them out by incisions. Indications for Amputation and Disarticulation.—In which cases of com- pound fracture should amputation or disarticulation of the injured limb be performed ? Immediate amputation or disarticulation of the injured limb directly after the reception of the injury, or within the first twenty-four to forty-eight hours, before the reaction in the wound sets in, is only indicated in cases of very severe crushing of the bone with extensive injury to the soft parts (primary amputation). With the aid of the antiseptic method of treating wounds we are enabled to carry out conservative treatment success- fully in cases where formerly preservation of the injured limb would have been impossible. Tbe opening of a large joint or injury of large arteries and nerves do not in themselves indicate primary amputation, though it should be immediately performed if the soft parts, muscles, vessels and nerves are so extensively lacerated and crushed that preservation of the limb is impossible or gangrene is sure to follow. The decision as to whether amputation should be immediately performed or not is not always easy. After having deter- mined upon amputation, we perform it through sound tissues which have not been crushed, and take the greatest care to avoid fashioning the flaps which are to cover the amputation wound, from the contused portions of skin or those portions that have been torn loose from the underlying parts. Amputation is also indicated in the case of many infected compound frac- tures when the local wound infection, the suppuration, putrefaction, etc., have become so extensive as to render preservation of the limb impossible, or when severe manifestations of general septic infection make their appearance. In such cases we amputate—in other words, we remove the source of infection in order to save the life of the patient. Delay in such cases is dangerous, and the sooner amputation is performed in the presence of high, septic fever, the better is tbe prospect of recovery. In the later stages of compound frac- tures amputation is indicated, especially when there is extensive suppurative inflammation of the medulla of the bone or of the joints, or when the patient is in danger of exhaustion from severe suppuration, etc. Briefly speaking, we amputate when the condition of the extremity is such that healing can- not be expected from conservative treatment. After-treatment of Fractures.—The after-treatment is directed prin- cipally towards the joints and the disturbances in nutrition which oc- cur in the soft parts, particularly the skin and muscles. Very often no special after-treatment is necessary when consolidation of the fracture is completed. Massage, diligent exercise of the muscles, and active and passive motion of the joints will usually soon remedy the muscular weakness and the stiffness of the joints, and the sooner these measures are adopted the better. A warning should be given against the too protracted use of retentive dressings for fractures, on account of the atrophy of the muscles and the disturbances in the functions of the §101.] FRACTURES. 603 joints which they cause. In the case of old people particularly it is often necessary to give up the confinement to bed because of the threat- ening hypostasis or disturbance of the general health, and to permit them to move about, even with fractures of the lower extremity, on crutches, and with suitable splints and a raised sole under the foot of the sound leg (see page 596). In proper cases, such as in fractures of the radius with the ulna intact, or of the fibula with the tibia intact, massage can be begun at a very7 early period—within the first or sec- ond week, for instance—and a more rapid recovery will thus be ob- tained. Of course, the above-mentioned fractures must be immobilised a long enough time—two to three weeks at least—by proper splints. Baths and rubbing with alcohol are also of use. If there is much oedema, particularly, for example, in the case of the lower extremity, the latter should be enveloped in a tight flannel bandage, or retentive dressings which can be readily removed should be applied (Figs. 201, 205). If a long time has elapsed since consolidation of a fracture in the extremities, and if the stiffness of the joints and atrophy of the muscles, owing to lack of energy on the part of the patient or physician, has become very pronounced, it is all the more difficult to restore the nor- mal function. In such cases it is sometimes best to repeatedly anaes- thetise the patients for the purpose of moving the joints and performing vigorous massage. It is in just these cases that massage not infre- quently yields most brilliant results. In these old cases, where motion is impaired and there are contractures and muscular atrophy, method- ical exercises by means of the mechanical appliances in the orthopaedic institutes are exceedingly valuable. If we have to deal with ischaemic contractures and paralyses, they should be treated according to the rules mentioned on page 550. Treatment of the Complications.—The treatment of the above-men- tioned complications is described in previous paragraphs — shock in § 63, delirium tremens in § 64, infectious diseases of wounds in §§ 66- 75, and gangrene in § 100, etc. Treatment of Delayed Callus Formation and Pseudarthrosis.—For these conditions the following methods are particularly valuable: 1. Rubbing together the ends of the bones (Celsus), according to Karmi- low, was successful only forty times in four hundred and thirty cases. In this method, which is suited more for cases with delayed callus for- mation, the fragments are rubbed together daily until a sufficient local reaction has set in and the point of fracture is tender on pressure. A plaster-of-Paris dressing is then applied. Patients with fracture of the low7er extremity can be allowed to move about in a retentive dressing for the purpose of maintaining an inflammatory irritation at the point 604 INJURIES AND SURGICAL DISEASES OF BONE. of fracture. 2. Artificial increase of bone formation by the production of a venous hyperaemia at the point of fracture by tying off the extrem- ity on the proximal side of the fracture with a rubber tourniquet drawn moderately tight. In order that the hyperaemia may be localised at the point of fracture the extremity above and below it can be enveloped in a bandage (Dumreicher, IIelferich, etc.). The procedure can be com- bined with the application of a plaster or other kind of splint, and it is here also a good plan to permit patients with fracture of the lower ex- tremity to move about in a proper dressing. 3. Le Fort has success- fully employed electrolysis—i. e., two platinum needles connected with a constant battery are stuck into the false joint. The needle fastened to the positive pole is kept in one place, while that fastened to the nega. tive pole is introduced repeatedly at several different points. 4. The employment of various other means of irritation has been abandoned (irritation of the skin, subcutaneous injections of irritating chemical liquids, etc.). Nevertheless, Mikulicz has used oil of turpentine with excellent results. After making a longitudinal incision through the soft parts and periosteum, the latter is freed from almost the entire cir- cumference of the bone with the raspatory to a distance of about ten centimetres from the point of fracture, and gauze saturated with oil of turpentine is placed between the bone and periosteum and changed every three to five days until the wound has healed. As yet, Berg- mann has seen no case of pseudarthrosis cured by the oil-of-turpentine treatment. 5. Irritation of the ends of the bones by driving ivory pegs into them (Dieffenbach) is performed in the following manner: After the soft parts above and below the point of fracture have been divided with the knife, holes are bored in the bone with a drill, and one or two ivory7 pegs, according to the size of the bone, are driven into each fragment. The extremity is then encased in a plaster dressing, which may be fenestrated or not. The ivory pegs are allowed to remain two to three weeks or longer. Karmilow states that the procedure when applied to the thigh and arm has been successful in 43*5 per cent, of the cases, while for the leg and forearm the number of cures have amounted to eighty per cent. Instead of ivory pegs, Riedinger has recommended bone pegs, which are capable of becoming firmly adher- ent to the bones. If the procedures hitherto described do not prove successful, there is nothing left but to expose the false joint with the knife, to freshen the ends of the bones, to resect them, and then, when necessary, to fasten them together by sutures of catgut, sterilised silver wire, iron wire, or silkworm gut, or by nails. The ends of the bones can be freshened by resecting them in the form of steps and thus fitting 3 101-] FRACTURES. 605 them together; or the pointed end of one fragment can be introduced into the medullary cavity of the other (see page 111, Fig. 94). Expo- sure of the false joint, followed by freshening the ends of the bones and uniting them with sutures or nails, is the safest method of treating all false joints of long standing, and if carried out with antiseptic pre- cautions it is entirely free from danger. For nailing the bones, we use, as was said before, long, four-cornered steel nails, which are ren- dered perfectly sterile by polishing, boiling for fifteen minutes in a one-per-cent. soda solution, heating red-hot, and storing in a ten-per- cent, solution of carbolic acid in glycerine. After nailing the bones together, an antiseptic protective dressing is placed over the wound, which is left open, and a gypsum dressing is applied on the outside. The nails are removed at the end of the third or beginning of the fourth week. Treatment of Losses of Bone Substance—Transplantation of Bone.—If a considerable loss of substance has occurred in one of the two bones of the forearm or leg, we may either chisel out of the other bone a piece corresponding in size to the defect, and cause the ends of the bones to unite, with a corresponding amount of shortening, or we may adopt Nussbaum's plan, and, after freshening the ends of the bone, fill up the defect caused by the loss of substance with one or two pedunculated bone-periosteal flaps. In proper cases, as, for example, on the skull, a loss of bone substance is repaired by pedunculated skin- bone flaps taken from the vicinity of the defect, the bone being cut from the outer tablet (see Special Surgery). We can also transplant into the defect, as MacEwen, Oilier, Bergmann, and others do, several free pieces of bone, from 0*3 centimetre to 0"5 centimetre in length, retaining their periosteum and medulla; or we can use for this pur- pose a small hollow bone like the first phalanx of the great toe, as described on page 586. The bone material used for transplantation must be taken while it is still undergoing active growth, and, conse- quently, from young subjects or newborn infants, and suppuration must be prevented by the strictest asepsis. Losses of bone substance have also been successfully repaired by pieces of decalcified bone (see pages 586, 587, Transplantation of Bone). In one case where there was a loss of substance in the tibia, Halm successfully implanted the fibula into the tibia. The internal administration of lime, or, what is better, of phos- phorus (Wegner), has been recommended for pseudarthrosis. Any constitutional or local anomaly which may be present must always, of course, be taken into consideration. If all methods of treatment prove unsuccessful, care must be taken 606 INJURIES AND SURGICAL DISEASES OF BONE. Fig. 347.—Erosion {a) of an ivory peg by the action of carbonic acid. to alleviate the disturbance of function, as far as possible, by a suitable splint apparatus. If the peripheral portion of the limb has become so atrophic and flail-like as to render the wearing of a supporting appli- ance scarcely possible, amputation, particularly if it is the lower extremity which is involved, is indicated. The Erosion of an Ivory Peg which has been driven into a Bone.—It is well known that ivory pegs which have been driven into a bone become roughened and appear as though portions of their sur- face had been gnawed away (Fig. 347). Polynuclear giant cells are found in the small cavities, and the same oste- oclasts which are present dur- ing the normal process of bone absorption. The cause of this lacunar-bone absorp- tion is partly to be ascribed to the action of an acid and partly to the pressure of the vessels and the cells of the surrounding tissues. I have shown that it is probably the carbonic acid which, in statu nascendi, during the metabolism of the tissues, sets free the lime in the ivory peg, and that then the decalcified ground substance which is left behind is dissolved by the alk- aline fluids in the tissues (see page 583). The Treatment of Fractures which have healed with Deformity.— Deformity in the healing of a fracture should be prevented by careful supervision of the point of fracture, or, in other words, of the position of the fragments while the process of healing is going on. The reten- tive dressing should be changed too often rather than too infrequently. If a fracture heals with so marked a displacement as to produce serious disturbance of function, the bones should either be refractured or the point of fracture exposed, chiselled through, and the ends of the bones then reunited in a good position. Those cases, as a general thing, are least amenable to treatment which have healed with considerable dis- locatio ad longitudinem. The bones are broken under chloroform an- aesthesia either by hand or by some special apparatus. The machines used for directly fracturing the bones are called osteoclasts; the ones invented by7 Rizzoli and by Collin and Robin are very useful (see page 84). The open division of fractures which have healed with deformity is carried out by making an incision through the soft parts, thus expos- ing the point of fracture, and then dividing the bone with the hammer and chisel (osteotomy). The bone is not chiselled entirely through, w §102.] CONTUSIONS AND WOUNDS OF BONE. 607 but a small portion is left, wliich is broken by hand. When necessary, a wedge-shaped piece must be chiselled out of the deformed bone. Os- teotomy of the bone is absolutely free from danger if the rules of asep- sis are carefully observed. The wound is not sutured, but left open and packed with sterilised gauze, and directly over the protective dress- ing a plaster splint is applied, which is left in place until the wround has healed, though it is changed earlier if there is need of doing so. In cases of considerable shortening from mal-union of a fracture, the use of extension by a weight, after performing osteotomy, is very much to be recommended. Badly united fractures, of the femur for instance, occurring in adults and accompanied by much shortening, sometimes require powerful extension (by a weight amounting to twenty to twenty-five to thirty pounds), and surprisingly good results may be ob- tained, as both Schede and myself have observed. Under certain cir- cumstances Schede recommends increasing the weight used for exten- sion in the case of adults to as much as forty pounds. Moritz and Meyer have used the electric current with success for exuberant callus (callus luxurians). § 102. Contusions and Wounds of Bone.—If a bone is crushed by a blow from a blunt object, we have especially to consider, in addition to the contusion of the bone substance, the injury to the overlying soft parts, the skin, the subcutaneous cellular tissue, and the periosteum. The course of contusions of the soft parts is described in § !>2. Con- tusions of periosteum lead to a greater or less extravasation of blood into and particularly beneath the periosteum, which is called a haema- toma of the periosteum. These periosteal and subperiosteal extravasa- tions of blood usually terminate by being gradually absorbed. JS^ot infrequently there develops, at the point where the periosteum has been contused, a traumatic, ossifying periostitis, in consequence of which the bone becomes only temporarily thickened. The anatomical changes which occur in contusions of bone tissue proper consist in a more or less pronounced compression or splintering of the bone substance, such as happens after a thrust or blow, and to a marked degree in every fracture. In the medullary cavity an extrava- sation of blood is found proportionate in size to the amount of violence exhibited. As is the case with fractures, the course of contusions of the periosteum, bone, and medullary tissue depends mainly upon whether an external wound is present or not. Only in the most ex- ceptional instances of subcutaneous contusions of bone do inflammatory or suppurative processes occur, and when they do, it is owing to the deposit of micro-organisms from the blood in the contused portions of bone and medullary tissue, or to the extension to the deeper parts of 608 INJURIES AND SURGICAL DISEASES OF BONE. inflammatory processes existing in the contused skin. Primary acute infectious osteomyelitis is probably sometimes caused by such a con- tusion of the medullary and cortical tissue. It is a well-known fact that tuberculosis may originate from some slight contusion of the bone, particularly in the case of children, for the reason that the tuber- cle bacillus finds in contused tissues and extravasations of blood condi- tions which are favourable to its development. The vascular arrange- ment in the medulla is such that solid impurities in the blood readily become deposited. The inflammation of bone to which mother-of-pearl turners are subject is an instance of this (see page 618). The treatment of subcutaneous contusions of periosteum and bone consists at first in placing the injured part in a suitable (elevated) posi- tion, in the application of ice, and later in employing massage to pro- mote absorption of the blood extravasated in the periosteum and soft parts. Inflammatory complications, suppuration, etc., are treated ac- cording to the general rules laid down in §§ 68-71. Open Wounds of Bone.—The open wounds of bone have lost the danger that used to attend them before the introduction of the antisep- tic method of treating wounds. By the latter means all infection is avoided, and even deep wounds which penetrate into the medullary cavity heal without complications. The most common wounds of bone are those occurring in fractures. True wounds of bone are such as are caused by a blow, or a thrust with a sabre, knife, axe, etc. In con- sequence of this violence there may be produced in the skull for ex- ample, the fissures or cracks, mentioned under Incomplete Fractures, which divide the bone either partially or completely. On the extremi- ties, particularly the fingers, complete division of the bone and soft parts is frequently observed. JS"ow and then, by paying strict atten- tion to antisepsis, phalanges or finger tips which have been entirely severed may be sutured in place and caused to reunite. Careful sub- cutaneous suturing of the periosteum with catgut and absolute immo- bilisation of the affected part are of chief importance. I once saw a terminal phalanx wdiich had reunited in this way come off again four weeks later in consequence of a violent blow, and then it could not be made to heal on a second time. If a piece has been taken out of the continuity of a bone by a sabre cut, for example, and there is no peri- osteum left at the spot in question, the bone will granulate very soon, and skin will gradually form over the granulating surface. Very often the loss of substance in a bone of the skull is not completely replaced by new bone, and persists as a more or less appreciable gap. The repair of a wound in bone is essentially the same as that which takes place in fractures, and is described on page 580. Gunshot wounds rr §104.J ACUTE INFLAMMATIONS OF BONE. DQ9 of bone and soft parts will be discussed in conjunction with injuries of joints (see § 121). § 103. The Inflammations of Bone.—The inflammations of bone gen- erally begin in the periosteum and in the medulla in the form of a periostitis and osteomyelitis. From these regions the inflammation extends to the bone substance proper and to the epiphyseal or articular cartilages, giving rise to a true ostitis or chondritis. The ostitis mani- fests itself either as an absorption of bone (rarefying ostitis) or as a new formation of bone (condensing ostitis). The inflammatory changes in the bone proper take place in the parts surrounding the vessels and in the medullary spaces. The pathological absorption of bone is, as a rule, analogous to the normal absorption—i. e., it takes place in the form of pit-like depressions, the so-called Howship's lacunae (lacunar absorption of bone), which are hollowed out of the bone by the action of polynuclear cells—the osteoclasts, as they are called (Kolliker, Fig. 313). In this lacunar absorption of bone the lime salts and the ground substances are always dissolved more or less simultaneously. In a second form of absorption of bone—in halisteresis ossium—the lime salts become at first dissolved, the decalcified ground substance of the bone persisting for some time longer. The latter kind of absorp- tion of bone takes place especially in osteomalacia (see § 109). The changes which occur in inflammation of cartilage consist mainly in a proliferation of the cartilage cells and in a fibrillary degeneration and ' necrosis of the ground substance of the cartilage. § 101. Acute Inflammations of Bone, Acute Periostitis, and Acute Osteomyelitis.—The acute inflammations of bone, in the form of an acute inflammation of the periosteum and medulla (acute periostitis and acute osteomyelitis), have been studied in their simplest form in § 101, under the subject of Callus Formation after subcutaneous frac- tures. In every instance where a suppurative periostitis and osteo- myelitis occurs it is due, like any acute suppuration, to infection by micro-organisms. The infection has either taken place at the point where the injury was received, as in the case of compound fractures wliich are not treated antiseptically and open wounds of the perios- teum, or it has spread from a suppurative inflammation of the sur- rounding parts, or, thirdly, it originates by infectious matter being brought from another portion of the body by the blood-vessels and deposited in the bone (haematogenous infection). The latter kind includes the metastatic inflammations of the periosteum and medulla occurring in pyaemia, typhoid and scarlet fevers, etc. Such acute in- flammations of the periosteum and medulla not only develop in the course of acute infectious diseases from metastasis of their poisons, but 39 610 INJURIES AND SURGICAL DISEASES OF BONE. also occur in perfectly healthy individuals, and are due to micro-organ- isms which are carried to the bone in the blood from the external cutaneous covering, the intestinal tract, the lungs, etc., and there excite the various kinds of inflammation. Acute Infectious Osteomyelitis.—The severest acute inflammation of bone is the primary acute infectious osteomyelitis and periostitis (Liicke) first described by Chassaignac as osteomyelite spontanee diffuse des os or typhus des os or des membres. This is chiefly observed in young people. Young growing bones, as a general thing, possess a more or less pronounced tendency towards inflammatory processes. An active development of new vessels takes place in growing bone, and the ter- minal loops of the vessels with their dilatations lie close to the epi- physeal cartilage ; consequently solid impurities, especially micro-organ- isms, can be deposited in the cartilage from the retarded blood stream. Moreover, the filtration and deposition of micro-organisms and all solid impurities contained in the blood is rendered easy in the medulla of every bone, for the reason that the blood stream is not confined by walls as it passes through the sacculated medullary spaces. Osteomyelitis oc- curs most commonly in the femur of young subjects, possibly because this bone grows the most rapidly. According to Haaga's statistics, cov- ering forty years' experience in the clinic at Tubingen, the disease oc- curs more frequently in men than in women, the proportion being 3*38 to 1. Acute osteomyelitis is particularly common in certain regions, such as Switzerland, the mountainous parts of South Germany, and the coast of North Germany. Epidemics of very severe cases occur in these places. In other instances acute osteomyelitis is secondary, and occurs, for example, in the course of acute infectious diseases such as measles, scarlet fever, small-pox, or typhoid fever (see page 617). We shall con- fine ourselves at present mainly to the primary acute osteomyelitis. Etiology of Primary Acute Osteomyelitis.—Our knowledge of the eti- ology of primary acute infectious osteomyelitis has recently been advanced, particularly by Kocher, Rosenbach, Kraske, and others. It has been found that in the majority of cases it is caused by the yellow pus coccus, the staphy- lococcus pyogenes aureus, less often by the staphylococcus pyogenes albus (see pages 321-325). Occasionally there is a mixed infection—i. e., in addi- tion to the staphylococcus pyogenes aureus other pus cocci will be present, especially the staphylococcus pyogenes albus or the streptococcus pyogenes. In fifteen cases of acute osteomyelitis, Rosenbach found the staphvlococcus pyogenes aureus fourteen times, once with the chain coccus of collulitis, and once with the white pus coccus (staphylococcus pyogenes albus). In only one case of osteomyelitis was the yellow coccus absent, and in this the white coc- cus alone was found. In nine cases out of twelve Colzi found only the staphy- lococcus pyogenes aureus, and in three instances the staphylococcus albus was §104.] ACUTE INFLAMMATIONS OF BONE. 611 also present. In forty-five cases of osteomyelitis, Lannelongue and Achard found the staphylococcus pyogenes albus twenty-eight times, the staphylo- coccus albus seven times, the staphylococcus aureus and albus together once, the staphylococcus citreus once, the streptococcus four times, the pneumococ- cus twice, and twice a micro-organism which could not be positively identified (pneumococcus [?]). The staphylococcus pyogenes aureus, and particularly the streptococcus pyogenes, are more virulent than the staphylococcus pyo- genes albus. Osteomyelitis can also be produced by the intravenous injection of the bacterium which produces lactic acid, by typhoid bacilli, pneumococci, etc. Like any other acute inflammation and suppuration, osteomyelitis can be excited experimentally in animals by agents having a purely chemical ac- tion, such as turpentine or sterilised cultures, the latter producing their effect through the chemical products resulting from the metabolism of the pus cocci (Ullmann). In short, osteomyelitis can be excited by many varieties of mi- cro-organisms and chemical agents, but tbe ordinary pus cocci are tbe most common cause of the disease. Consequently osteomyelitis is not due to a specific poison, as was believed to be the case for a long time, but it may be caused by any kind of micro-organism which excites acute inflammation and suppuration. Acute infectious osteomyelitis is essentially a phlegmon, so to speak, of the medullary cavity. By transferring osteomyelitic pus, or the above-mentioned micro-organisms, to the soft parts, a cellulitic inflammation and suppuration is produced. Tbe experiments of Becker and others show that after the introduction of pus cocci into the circulatory system or peri- toneal cavity, typical acute osteomyelitis is particularly likely to develop if the affected bones have been previously contused or broken, for the reason that broken or contused bone offers a favourable medium for the growth of the pus cocci. As Kocher first stated, the origin of acute infectious osteomyelitis is to be explained on the supposition that the above-mentioned micro-organisms enter the circulation from some point in tbe skin, or in the lungs or intestinal tract, for example, particularly when at this point there is an inflammation, such as a f uruncle, or even a slight interruption of continuity, and are carried off in the blood, from which they are deposited in the medullary portion of the bones of youthful subjects for the anatomical reasons mentioned before; here they develop, and give rise to severe suppurative or gangrenous inflamma- tion with secondary involvement of the bone, periosteum, and frequently the joints. Colzi's experiments seem to show that the bacteria in osteomyelitis enter the body most frequently from the skin, less often from the lungs or intestinal tract. Inflammations of other organs, such as the spontaneous acute inflammation of tbe thyroid gland occurring in rapidly growing goitre, originate in a similar way from infection through the blood (Kocher). As we remarked before, traumatic lesions of bone favour the development of acute infectious osteomyelitis. How7 far catching cold conduces to its occur- rence is a matter which cannot be determined, but the majority of surgeons believe that it exerts some influence. Acute infectious osteomyelitis is also occasionally observed as one of the sequelae of acute infectious diseases (measles, scarlet fever, typhoid fever, diphtheria), and may follow suppura- tive inflammation of various organs. It can originate from an acute inflam- mation or collection of pus in any organ of the body if the virulent micro- 612 INJURIES AND SURGICAL DISEASES OF BONE. organisms mentioned above, particularly the pus cocci, are carried off and lodged in the marrow. Mikulicz found the staphylococcus pyogenes aureus and albus occasionally in the discharges from aseptic wounds which healed by perfect primary union, and Frankel demonstrated both kinds of cocci in the discharges accompanying inflammations of the pharyngeal cavity, and almost constantly in the normal pharynx. Anatomical Changes in Acute Infectious Osteomyelitis.—The anatom- ical changes in acute infectious osteomyelitis are in the main the follow- ing : At the outset there is a diffuse hyperaemia of the medulla, and, later, yellowish or greyish-coloured foci of suppuration appear in it which not infrequently coalesce and form a single large collection of pus. In the severest cases there is observed a general suppuration of the medulla of the entire diaphysis—most commonly7 of the femur or tibia—with secondary collections of pus in the Haversian canals, be- tween the periosteum and bone, in the periosteum, and in the adjoin- ing soft parts. The periosteum probably becomes involved for the most part secondarily7, and is the seat of an inflammatory infiltration and swelling (serous, sero-fibrinous periostitis). In this serous perios- titis the exudate is usually very rich in albumen, and hence was called by Oilier periostitis albuminosa. Suppurative periostitis only occurs in the severer cases. As a rule, the pus in acute infectious osteomye- litis is rich in fat, in consequence of the acute degeneration of the me- dullary cells. Not infrequently the infectious matter—the cocci and the products of their metabolism—enter the circulation, causing death from septicaemia or pyaemia. The suppurative separation of the epi- physes at their junction with the diaphyses is a pathological change of considerable importance, as well as the secondary7 development of in- flammations of the neighbouring joints either in the form of a transi- tory mild serous or sero-fibrinous inflammation, or of a severe suppu- rative arthritis. Haaga states that in four hundred and seventy cases, permanent, slight, or pronounced changes remained in the joints one hundred and eighty-nine times. Curvatures or angular deformities of bones sometimes develop after osteomyelitis (see page 611). Necrosis varying in amount even up to total necrosis of an entire diaphysis very often occurs in the diseased bone. Acute infectious osteomyelitis ter- minates either in a complete restitutio ad integrum, with or without suppuration, or in a varying amount of necrosis of the bone, or in death, particularly from pyaemia and septicaemia. Not infrequently encapsulated central bone abscesses are left behind which persist for years. Osteomyelitis occurs either in a single bone, involving most com- monly the diaphysis of the long hollow bones (femur, tibia), or as a §104.] ACUTE INFLAMMATIONS OF BONE. 613 multiple affection in different bones. In the latter instance there is a simultaneous infection of several bones, or the primary disease in one bone gives rise to metastases in other bones. The short, flat bones most commonly affected are the clavicle, the ileum, and the scapula. After total necrosis of the clavicle the bone may be completely regen- erated, its shape restored, and the function of the arm undisturbed. Clinical Course of Acute Infectious Osteomyelitis.—The clinical course of acute infectious osteomyelitis varies greatly. The worst cases pre- sent the symptoms of a very severe constitutional disease, with high fever, delirium, rapid swelling of the affected bone, and death within a few days. In the mildest cases the local and constitutional manifes- tations are slight. The cases of moderate severity are probably the most common. The amount of constitutional infection does not always correspond to the extent of the local disease. The fever in the severe cases is, as a rule, very high, reaching 11° C. (101-1° F.). The disease generally begins with a chill two "to three days after a traumatism, for example, or exposure to cold, and during the days immediately follow- ing the local disease can usually be readily made out in one bone, less often in several bones. The intense pain, the even swelling, the absence at first of any fluctuation or inflammation of the soft parts, and the pronounced disturbance of function are in general characteristic of the local disease of the bone. Many cases do not begin so acutely; on the contrary, they often commence very gradually. Occasionally the dis- ease runs a course wliich presents the picture of an acute articular rheu- matism with inflammation of the large joints. In these cases the osteo- myelitis is alway7s multiple, and the inflammation of the joints (secondary to disease of the neighbouring epiphyses) often goes on to suppuration. The subsequent course of acute infectious osteomyelitis is in the majority of instances favourable. In the mildest cases complete resti- tutio ad integrum takes place in two to three to four weeks without any noticeable suppuration. In the severest cases the suppuration of the medulla runs a very7 rapid course, accompanied by secondary7 sup- puration of the periosteum and phlegmonous sloughing of the soft parts, sometimes with the evolution of gas. Death in such cases generally occurs from what looks like septicaemia with severe typhoid symptoms, or from pyaemia with secondary abscesses in the internal organs. Prob- ably the most common termination is recovery, with necrosis correspond- ing to the amount of bone which has been affected. The necrosis is usually a central one—i. e., it is limited to the bone substance adjoin- ing the medulla. But if there is extensive suppuration in the medulla and periosteum the entire diaphysis of a long bone may die. Not in- frequently circumscribed collections of pus in the medullary cavity be- 614 INJURIES AND SURGICAL DISEASES OF BONE. come encapsulated and form abscesses running a chronic course with- out necrosis, and leading to a characteristic diffuse thickening of the affected bone. The suppurative separation of the epiphyses is another complication occurring in young subjects when the suppuration invades these parts. The epiphyseal separation, as in fractures or traumatic separations, is recognised by the abnormal mobility. Usually there is only separation of one epiphyses, which in the femur, for example, is the lower ; only in rare instances are both involved. The separation of both epiphyses of a single bone appears to have occurred most com- monly in the tibia. The secondary inflammations of the joints wliich accompany acute infectious osteomyelitis are either acute or subacute serous inflamma- tions, or severe suppurative forms, wThich may even be attended by the evolution of gas. Sometimes, after an acute osteomyelitis has run its course, even when no extensive necrosis has taken place, the bone may be left ab- normally soft. It may lose its strength to such an extent that curva- ture, angular deformity, or axial rotation of the diaphysis of a bone, like the femur, may be produced by muscular action and by the super- imposed weight of the body (Stahl, Oberst, and others). In such cases of curvature or deformity the bones involved are remarkably porous, and at the point where the disease is located a fistula will generally be found which leads to a focus of rarefied bone with a sequestrum. As Krause has correctly stated, the osteomyelitic cocci appear to possess great powers of resistance, since renewed formation of pus has been observed in old osteomyelitic areas even after the lapse of years. This is the explanation for those cases of multiple osteomyelitis in which the foci of the process have apparently completely disappeared, but in which, nevertheless, suppuration and necrosis subsequently de- velop. Diagnosis and Prognosis of Acute Osteomyelitis.—The diagnosis of acute infectious osteomyelitis can be made from what has been stated about the anatomical changes and the symptomatology. The prognosis, in the majority of cases, is favourable quoad vitam. But it must be borne in mind that the disease may cause death at any stage, so long as an escape is not provided for the pus by chiselling open the medullary cavity. Many cases, especially those caused by the streptococcus, run a rapidly fatal course. After the suppuration has subsided, it is mainly the extent of the necrosis, the amount of inflam- mation which has occurred in the joints, the condition of the epiphyses, etc., which determine the character of the case. The Treatment of Acute Infectious Osteomyelitis.—The treatment of § 104.] ACUTE INFLAMMATIONS OF BONE. 615 acute primary osteomyelitis has gained in efficacy with our knowledge of the etiology of the disease. In the treatment, a distinction must be made between the severe cases, which run a very acute course, and those which are mild and subacute. In the severest cases with high fever, a means of escape should be provided for the pus as soon as possible by making, under antiseptic precautions, a long incision down to the bone, at the point of greatest tenderness, or wdiere the perios- teum is swollen, and then cutting with the hammer and chisel a large enough opening into the medullary cavity in the shape of a gutter. If operative measures are adopted early enough, the otherwise un- avoidable necrosis of the bone and the breaking through of pus into a neighbouring joint may sometimes be prevented, and the course of the disease will thus be rendered milder and shorter than it otherwise would be. To avoid recurrences and to obtain speedy recovery, it will often be found a better plan, instead of making a gutter-shaped open- ing into the medullary cavity of a long, hollow bone, to remove all of the bone except a wall of cortex (Riedel). This early scraping out of the infected medulla has recently been energetically supported by Tscherning (Copenhagen), Thelen, and others, and is in every respect a rational procedure, when it is remembered that we have to deal essentially with a cellulitis of the medulla ; and in the case of any cellulitis it should be our aim to evacuate the pus at the earliest pos- sible moment. It is not always easy to decide in what cases the aseptic opening of the diseased bone with the chisel should be attempted ; moreover, many7 cases run such a rapidly fatal course that the correct diagnosis cannot be made at an early enough period. The evacuation of pus from bones, such as those of the pelvis, is difficult, and I have seen very severe cases involving just these bones where death occurred quickly. After opening the medullary cavity of a long hollow bone, the suppurative focus should be scraped out, and, if necessary, the en- tire medullary cavity. The periosteum and soft parts should likewise be carefully examined for the presence of pus, and, if found, it should be let out by incision and drainage. Finally, the medullary cavity should be disinfected as carefully as possible with a one-tenth-per-cent. solution of bichloride of mercury or a three-per-cent. solution of carbolic acid, and then filled with iodoform gauze, over which is placed an antiseptic protective dressing. Permanent antiseptic irrigation (see page 178) can be used with advantage for severe cases, instead of the antiseptic protective dressing. Immobilisation of the extremity in the best pos- sible position by splints, etc., cannot be emphasised too strongly. Un- fortunately, in spite of energetic and early operative local treatment, some of the severe cases will die in consequence of the systemic intoxi- 616 INJURIES AND SURGICAL DISEASES OF BONE. cation already present, wliich even an amputation or a total subperios- teal resection of the diseased bone will not always prevent. Complete resection of the bone—i. e., the removal of the diseased bone in toto__ seems to me very inadvisable, as its efficacy has as yet not been suffi- ciently established. Amputation in the acute stage is rarely indicated though it may be in the later stages, when suppuration becomes so excessive as to threaten to carry off the patient from exhaustion. In the moderately severe and the mild cases the local treatment con- sists in the energetic application of ice, in placing the extremity in an elevated position, and in immobilising it as much as possible with a splint. Others prefer moist heat to ice for alleviating the pain. I con- sider that the application of iodine, which was formerly so much used, has but little effect. If there is marked swelling of the periosteum and the pain due to this is severe, even though no pus can be obtained by a test puncture, I nevertheless advocate early incisions to lessen the ten- sion, and thus ease the patient's pain. Furthermore, it is possible by this means to prevent, or at any rate to lessen, a subsequent necrosis of the bone. Not infrequently cases which were at the outset mild, be- come so severe that it may be necessary to chisel a groove into the medullary cavity and drain or pack the latter with iodoform gauze. As regards the treatment of complications the following should be noted : Inflammations of joints are treated according to the general principles applicable to these affections (see Diseases of Joints). If sup- puration occurs, the joint should be opened and drained as soon as pos- sible. Separations of the epiphyses are treated in the same way as a fracture. Curvatures of bone following osteomyelitis can sometimes be overcome, after scraping out the osteomyelitic focus and removing the sequestrum which may be present, by extension with a heavy weight (five to ten kilogrammes). The treatment of the necrosis which is so common a result of osteomyelitis is described in § 106. Amputation accompanied by Scraping out the Bone Stump.—Perkowsky practised amputation in eight severe cases of osteomyelitis, and then scraped out the medullary cavity of the diseased bone stump, removing in three cases the medulla of the entire stump with the sharp spoon, so that only a thin shell of bone was left. Necrosis did not take place in a single case, and a rapid recovery followed in all eight cases under iodoform dressings. Per- kowsky thus avoided disarticulation or amputation of the limb at a higher point. The treatment of acute periostitis occurring by itself is conducted according to the general rules which apply to inflammation. If the acute periostitis is suppurative, incision is employed ; if not suppurative, anti- phi ogesis. §104.] ACUTE INFLAMMATIONS OF BONE. 617 The Acute Traumatic Inflammations of the Periosteum and Medulla.— Acute traumatic inflammations of the periosteum and medulla are ob- served after injuries of various kinds, such as contusions, wounds of the periosteum, subcutaneous and compound fractures, wounds of bone, etc. Acute non-suppurative periostitis and osteomyelitis traumatica take place after every contusion and subcutaneous fracture. The suppurative form is always caused by infection with bacteria which enter through some wound or circulate in the blood. This includes, moreover, the acute osteomyelitis of the amputation stump which, especially in the days before antisepsis, terminated in death from pyaemia. At present we have learned to avoid this form of osteomyelitis with certainty in our amputations by employing antisepsis and asepsis. The anatomical changes and the cause of the acute (traumatic) periostitis and osteomye- litis are essentially the same as in the above-described spontaneous acute infectious osteomyelitis and periostitis. Metastatic Inflammations of Bone.—The metastatic inflammations of bone in pyaemia, typhoid and scarlet fevers, measles, small-pox, etc., are either analogous to the spontaneous acute infectious osteomyelitis and periostitis, or they run a chronic course with the formation of circum- scribed cold abscesses. The inflammations of bone occurring in the course of typhoid fever are mainly observed in the ribs, where they be- come localised as a chondritis or perichondritis, having a very chronic course ; typhoid bacilli have repeatedly been demonstrated in the in- flammatory foci (Bergmann, Potter, etc.). In the cases of metastatic bone inflammation from plugging of the vessels by emboli, a corre- sponding necrosis of bone occurs which is called an " embolic necrosis.'' Such embolic necroses from obstruction to the afferent flow of blood are occasionally observed in endocarditic processes, when blood-clots with or without micro-organisms break loose from the growths on the endocardium and are swept away and lodge in the bones. Epiphyseal separations and secondary joint diseases, which were described above, may also accompany metastatic periostitis and osteomyelitis. Growth Fever.—In young subjects there is occasionally observed a marked temporary tenderness to pressure in the epiphyses of the long bones, espe- cially the femur, humerus, and tibia, accompanied by inflammatory irritation of the neighbouring joints, with the manifestations of fever and a correspond- ing disturbance of the general health. Bouilly and Juillier have designated this condition as growth fever. It is a question whether in such cases there may not sometimes be present a true acute infectious osteomyelitis of the mild- est kind, which terminates in restitutio ad integrum. Embolic Foreign-Body Inflammations of Bone.—Great interest attaches to the embolic foreign-body inflammations of bone which are observed 618 INJURIES AND SURGICAL DISEASES OF BONE. in mother-of-pearl turners and workers in woollen and jute mills. Peo- ple employed in these occupations breathe in the particles of mother- of-pearl dust, wool, or jute, which then pass from the lungs into the circulation and lodge in the small arteries of the medullary portion of the bones, particularly the terminal arteries at the extremities of the diaphysis, and here excite embolic inflammation of the medulla with secondary involvement of the periosteum. As is the case with acute infectious osteomyelitis and periostitis, youthful individuals are the ones who are principally affected by these inflammations of the me- dulla in the diaphyseal ends of the bones and in the epiphyses. Gussenbaur, Englisch and Levy have given accurate descriptions of the inflammations of bone to which mother-of-pearl turners are sub- ject. The symptoms consist in very7 painful swellings, which usually appear suddenly at the ends of the diaphyses with marked swelling of the periosteum. The course of the affection is generally subacute, and suppuration has as yet never been observed. Restitutio ad integrum ordinarily follows, the worst that happens being a thickening of the periosteum, which persists for a greater or less length of time. But if the turners resume their occupation, recurrences of the inflammation are frequently observed, which run a chronic course, with thickening of the spongy bones of the carpus or tarsus, or of the diaphyseal ends of the long bones. Klein has described the bone disease of jute spinners. In this, too, there is an inflammation of the medulla and periosteum in the region of the epiphyseal cartilages, accompanied by severe pain. A consid- erable growth of epiphyseal cartilage usually takes place, giving rise to secondary curvature of the bones, particularly the tibia. In this affec- tion also suppuration or necrosis never occurs. § 105. The Chronic Inflammations of Bone (Chronic Periostitis, Os- titis, and Osteomyelitis).—The most important chronic diseases of bone are the mycotic, of which the tubercular, syphilitic and actinomycotic inflammations of bone are prominent examples. Furthermore, acute infectious diseases, such as measles, scarlatina, typhoid fever, etc., may be followed not only by acute inflammations of bone, as mentioned above, but also by inflammations which are at first latent, and then subsequently manifest themselves as affections running a chronic course. The chronic inflammation of the ribs which follows typhoid fever is an example of this class of cases (see page 617). The other chronic in- flammations of bone are mostly secondary to preceding acute inflam- mations, and include, as a terminal stage of the latter, necrosis. Chronic inflammations of bone are also sometimes the result of the extension to the latter of chronic inflammation in the surrounding parts. The §105.] THE CHRONIC INFLAMMATIONS OF BONE. 619 changes which occur in bone in consequence of chronic inflammation consist either in a destruction of the bone substance (caries, necrosis) or in a reactive new formation of bone. Chronic Periostitis.—Amongst the various forms of chronic perios- titis, mention should first be made of the periostitis chronica fibrosa. In this variety tough, fibrous thickenings of the periosteum develop, sometimes with absorption of the superficial portions of the bone (caries superficialis), and sometimes with new formation of bone. In the latter instance the process is an ossifying periostitis. Periostitis Albuminosa or Mucinosa (Non-purulenta).—Poncet and Oilier were the first to describe a peculiar form of periostitis under the name of periostitis albuminosa (ganglion periostale), concerning the nature of which different authorities hold very divergent views. The affection attacks almost exclusively the ends of the diaphysis of the long, hollow bones in young sub- jects from fifteen to twenty years of age, and involves not only the periosteum but frequently the bone also (ostitis albuminosa). Schlange has proposed calling it periostitis and ostitis non-purulenta, and Riedinger periostitis mu- cinosa. As a rule, the disease begins with severe pain, swelling at the lower end of the diaphysis in the neighbourhood of the epiphyseal line, and fever, as is the case in acute primary osteomyelitis. After a few days the fever and pain disappear, and the swelling of the periosteum and bone becomes more and more prominent. There will be found at the diseased point, instead of pus, either a bloody serous or a hydrocele- or synovial-like fluid which has the consistency of tenacious mucus. The fluid lies either beneath the peri- osteum, or within it in the form of a cyst, or on its outer surface, and in the latter instance there is also a diffuse cedematous swelling of tbe surround- ing soft parts. The periostitis and ostitis albuminosa, or non-purulenta, or mucinosa, is not tubercular in its nature, but is possibly a non-suppurative osteomyelitis and periostitis caused by weakened, attenuated pus cocci; it resembles an inflammation which has not passed beyond the serous stage. Pus cocci, including the staphylococcus pyogenes albus and also the aureus, have been repeatedly demonstrated in periostitis albuminosa. Vollert states that a mucoid metamorphosis of the leucocytes takes place in this affection. Fig. 348.—Osteophyte (Pathological museum at Leipsic). Iti course is very chronic, and necrosis of tbe bone is often present. The disease is very rebellious to therapeutic measures, and recurrences frequently 620 INJURIES AND SURGICAL DISEASES OF BONE. take place, or fistulae may persist for months or years. The best treatment consists in incision and energetic scraping out of the underlying diseased bone, with or without chiselling an open- ing into the medullary cavity. Cystic formations should be carefully extir- pated. In the periostitis chronica ossifi- cans the new formation of bone is either limited to a circumscribed por- tion of the bone, giving rise to what is called an osteophyte (Fig. 348), or diffuse hypertrophies—hyperostoses, as they are called—are developed, in consequence of which thickenings of the bone resembling elephantiasis re- sult (Fig. 319). In addition to chronic fibrous and chronic ossifying periostitis, we rec- ognise a chronic suppurative perios- titis, which sometimes is the terminal stage of an acute periostitis and some- times develops gradually as a disease by itself, and chiefly comes into con- sideration as a concomitant phenom- enon of necrosis or caries of bone. In chronic suppurative periostitis we have to deal, for the most part, with specific processes, such as tuberculo- sis, syphilis, or actinomycosis, and also with necrosis of bone from vari- ous causes. Tubercular periostitis is either primary or secondary to tuberculosis of bone or its medulla, or of the surrounding soft parts. Treatment of Chronic Periostitis.—Chronic nonsuppurative perios- titis should be treated briefly as follows: First of all its cause should be determined and proper steps taken to remedy it. To relieve the tension, pain, and local inflammatory symptoms, incisions and hydro- pathic applications can be used with advantage. It is also an excellent plan to paint the parts with tinct. iodi fortior alcoh. (five parts iod. pur. to 30*0 of alcohol). Compression by the elastic bandage is of use for the fibrous thickening and osteophytes ; but troublesome osteophytes, occurring, for example, in connection with an ulcer of the leg or some other disease of the soft parts, should be removed with the hammer and chisel. Fig. 349.—Hyperostosis (elephantiasis) of the femur (Pathological museum at Leipsic). §105.] THE CHRONIC INFLAMMATIONS OF BONE. 621 The treatment of chronic suppurative periostitis is likewise mainly determined by the cause, and we shall discuss this disease more fully under Tuberculosis, Caries, and Necrosis, etc. (see also Syphilis, § SI, and page 626). Tuberculosis of Bone.—One of the most important and by far the most common of chronic bone diseases is tuberculosis (ostitis tubercu- losa, caries tuberculosa or fungosa), which occurs chiefly as tubercular periostitis and osteomyelitis, and leads to extensive destruction of bone —to caries, as it is called (Fig. 350)—and to necrosis. Volkmann in particular has won lasting honours by7 his studies upon the subject of tuberculosis of bones and joints, and Robert Koch has greatly advanced our knowledge upon the etiology of tubercular inflammation by demon- strating and obtaining in pure cultures the tubercle bacillus (§ 83). We now know that all those forms of inflammation which affect bone, and have been designated as caries, spina ventosa, scrofulous or fun- gous inflammation of bones and joints, tumor albus, etc., are in the main true tubercular inflammations. Tubercular inflammation of bone occurs most commonly in young individuals—i. e., in growing bone—for the reason mentioned before, namely, that the formed foreign elements circulating in the blood, par- ticularly the tubercle bacilli, are more readily deposited in the branches of the vessels in growing bone, although tuberculosis also occurs dur- ing the later years of life, and may be met with even in extreme old age. The poison of tuberculosis, the tubercle bacilli, are generally carried to the bones by means of the blood-vessels, as can be easily proved by experiments on animals. Traumatic injuries of bone, as we remarked before, favour the development of tuberculosis. Tuber- culosis of bone may, moreover, be due to the direct extension to the latter of a tubercular process in the surrounding tissues, such as the skin, subcutaneous tissue, tendon sheaths, synovial membrane, etc. Tubercular inflammations of the vertebrae and of the bones of the hands and feet are the most common. Anatomical Changes in Tuberculosis of Bone.—Tuberculosis of bone almost always begins with the formation of circumscribed foci in the periosteum, in the epiphyses of the long bones, or in the medulla, particularly in the spongiosa of the short bones (Fig. 351); less com- monly the disease is more diffuse. The tubercular focus often remains for a long time the size of a pea or a hazel-nut, and then enlarges In- direct extension from its edges or by the development of new foci in the region surrounding the primary one. The individual foci then coalesce, and thus large tubercular foci or diffuse processes originate. Xot infrequently several distinct foci are observed in one and the same 622 INJURIES AND SURGICAL DISEASES OF BONE. bone, or tubercular inflammations occur in different bones at the same time or one after the other. The tubercular focus is made up of tbe characteristic tubercles which originate from the lodgement and growth of the tubercle bacilli, and have been minutely described on page 408. Wherever a tubercular focus develops in bone (Fig. 351) caries results—i. e., the bone disappears in the form of lacunar absorp- tion (see Fig. 343)—wdiile the focus itself sooner or later becomes the seat of a cheesy degeneration beginning in its centre. If the bone has not been destroyed at the time that caseation of the tuber- cular focus occurs, mortification of the bone then takes place in toto__ i. e., a so-called tubercular sequestrum forms which becomes sepa- rated from the surrounding parts by a demarcating suppuration. In the later stages the tubercular sequestrum lies completely free in a cavity of greater or less size, containing cheesy, flocculent pus, with or Fig. 350.—Tuberculosis of the lower epi- Fig. 351.—Fungous granulations with tubercles physis of the femur, with two seques- ( Tv) in the cancellous portion of the talus: tra («). The process has broken K, intact trabecula of bone. through into the knee-joint (Weber). without fistulae opening externally (Fig. 350). In general the charac- teristic tubercular sequestrum is a larger or smaller caseated concretion of bone through which has grown tubercular or caseous granulation tissue. Yery often the entire tubercular focus becomes softened and liquefied in toto without the formation of a sequestrum. The central abscesses of bone, which exist for years, are partly due to tubercular processes, partly to a preceding primary acute infectious osteomye- litis, and. partly to metastasis in the course of acute infectious diseases. A reactive deposit of bone often takes place around the tubercular focus in the bone or its medulla, causing it to become more or less completely enclosed by thickened, sclerotic bone tissue. In the pro- nounced cases of sclerosis of bone the bony structure becomes as dense §105] THE CHRONIC INFLAMMATIONS OF BONE. 623 as ivory (so-called eburnatio ossis), and the medullary cavity may be completely obliterated. But in other instances all traces of reactive hyperplasia of bone are absent, even though the tubercular inflamma- tion has existed for years. In the tuberculosis of bone there are also formed sacculated collec- tions of pus—cold abscesses—which are enclosed in a characteristic so-called pyogenic membrane consisting of connective tissue and granu- lation tissue containing tubercles. The abscesses either rupture exter- nally in the region where they originated, or the force of gravity7 causes them to sink lower. In the case of tubercular inflammation of the cervical and thoracic vertebras, for example, they descend along the anterior surface of the vertebne, following the course of the psoas muscle, and appear beneath Poupart's ligament (so-called congestion abscesses). These congestion abscesses extend in a perfectly typical manner, which is governed by the anatomical conditions—i.e., they follow the natural spaces between the tissues corresponding to the ar- rangement of the fasciae and aponeuroses. The caries which accompanies tuberculosis is often—in the case of the vertebrae, for example—very considerable. In consequence of this there develops in the back the so-called kyphosis or Pott's hump, named after the English surgeon Percival Pott, who first described this disease. Marked destructive changes also take place in the small bones and articu- lar ends of the long ones, leading to deformities of various kinds, with subluxations and complete dislocations of the deformed articular extremi- ties of the bones. In the fingers and toes tuberculosis usually occurs as a tubercular osteomyelitis, with a spindle-shaped enlargement of the bone (spina ventosa). In this condition the cortex of the bone becomes con- stantly thinner in consequence of the tubercular osteomyelitis, while at the same time, as a result of the reactive periostitis, osteophytes are formed. Spina ventosa often heals without suppuration or necrosis having taken place, and with a spontaneous and complete restitutio ad integrum. ' The same form of tuberculosis also occurs in the long bones, such as the tibia and femur. The most common site of bone tuberculosis in the long, hollow bones, whether located in the periosteum or in the interior of the bone, is in the region of the epiphyses. This is the reason why secondary tuberculosis of the joints is so common (see § 114, Tuberculosis of Joints). Tuberculosis of the diaphysis of a bone is comparatively rare —a fact of great diagnostic importance, especially in the case of adults. Consequently, if the shaft of a bone is diseased, particularly in an adult, we think of syphilitic or some other bone disease before tuberculosis. As regards other bones, tuberculosis is especially common in the 624 INJURIES AND SURGICAL DISEASES OF BONE. bones of the skull, in the orbital portion of the superior maxilla, in the ribs, and particularly in the spinal column and the bones of the carpus and tarsus. Under the microscope, tuberculosis of bone presents a picture which corresponds to the tubercular inflammation described in § 83. Koch's tubercle bacilli will be found most abundantlyT where the tubercular pro- cess is beginning, the best method of staining being that of Ehrlich's, with fuchsin or gentian violet. Nevertheless, their demonstration in tuberculosis of bone is sometimes very difficult, or even impossible—a fact which has been commented upon before. In tuberculosis of bones and joints Miiller frequently found peculiar bodies resembling fat drops, which not uncommonly were surrounded by minute granules, and, like these, were characterised by taking on a deep red or violet stain. These bodies probably bear some relationship to the bacilli. The Clinical Course of Bone Tuberculosis.—The clinical course of tuberculosis of bone is usually very chronic. There are often symp- toms of tuberculosis in other organs—the lungs, for instance—at the same time. Heredity is important—i. e., tuberculosis of the parents or grandparents or other near relatives. Quite often it happens that for a long time symptoms peculiar to tuberculosis of bone are absent; severe pain especially may long be missed, unless a neighbouring joint, the peri- osteum, or overlying parts are attacked by the tubercular inflammation. In the majority7 of instances the symptoms pointing to tubercular in- flammation will not make their appearance till after the disease has existed for months, the development of an appreciable tumour, par- ticularly if the tuberculosis is periosteal, being the first intimation of the process. But even if the tuberculosis is located in the bone or medullary cavity, an appreciable tumour will sometimes be formed after several months in consequence of a thickening of the bone, while in other instances, though the tuberculosis may have existed for years, all swelling will be absent. Under these conditions the diagnosis can often only be made when the periosteum begins to become involved in the inflammation, and there is tenderness on pressure over the area in ques- tion, or when oedema of the skin is present. As the tuberculosis ad- vances the symptoms become more pronounced, especially the swelling at the diseased spot, the pain, particularly if the tuberculosis is located in the medulla, the disturbance of function, the development of fistula?, burrowing of pus, etc. The disturbance of function is most pronounced in tuberculosis of the epiphysis in the neighbourhood of a large joint like the hip or knee. The tumefaction accompanying tubercular infil- tration of the periosteum or medulla is either due to osteophyte forma- tion, or the bone is puffed out, as it were, by tubercular osteomyelitis, §105.] THE CHRONIC INFLAMMATIONS OF BONE. 625 in the manner which we described as occurring in spina ventosa of the phalanges of the fingers. In this spina ventosa of the fingers the bone may feel firm, or elastic and thin. After a certain length of time the tubercular pus works its way outwards and breaks spontaneously through the skin, and the thin liquid, usually mixed with cheesy floc- culi, is discharged. ' Fistulous ulcers with a cheesy base and under- mined edges then develop from the fistulae. If a probe is passed through the fistula it either immediately comes in contact with the bone, or penetrates into the medullary cavity. The other secondary manifestations of tuberculosis, the cold or congestion abscesses, etc., have been sufficiently described, and we need only call attention to the fact that the latter do not heal up until the original focus which gave rise to them has disappeared. Their course is usually very tedious, especially in the case of tubercular inflammation of the spine. The tubercular inflammations of joints are discussed in § 114. A tubercular deposit in the periosteum or medulla of an epiphysis, lying in imme- diate proximity to a joint, often works its way to the surface extra- articularly, and leaves the joint intact. The general health in tuberculosis of bone is very often but little or not at all affected. There is frequently a slight fever, varying with the extent of the process. It is a common occurrence to find that the general health is only slightly disturbed even when extensive multiple tuberculosis is present. In general the fever is most pronounced before the tubercular inflammation has extended beyond the bone, but it is usually slight, and, as a rule, disappears more or less completely when the inflammation has worked its way to the surface of the body. Diagnosis of Bone Tuberculosis.—The diagnosis of tuberculosis of bone is easy in the case of primary tubercular periostitis, particularly if the bone is superficial, and the characteristic swelling, tenderness on pressure, etc., are present. The diagnosis of bone tuberculosis may occasionally be doubtful for some time, but still its beginning and sub- sequent course in different parts of the body, as we shall see in the Spe- cial Surgery, is generally so typical that the diagnosis is not very diffi- cult (see also § 83, Tuberculosis). Prognosis of Bone Tuberculosis.—As regards the termination and the prognosis of tuberculosis of bone, I must refer the reader to what has been stated in § 83. Suffice it to say that the location of tuber- culosis of bone plays a very important part as regards prognosis—i. e., in so far as it determines whether the existing focus can be completely removed by operative measures at the earliest possible stage, or whether other local treatment, such as iodoform injections, can be employed. If the latter is impracticable, as may often be the case in tuberculosis 40 626 INJURIES AND SURGICAL DISEASES OF BONE. of the vertebras, spontaneous recovery can probably only take place when the focus is not too large. In the majority of instances the tuber- cular disease steadily progresses or very often leads to tubercular sys- temic infection. Recurrences in tuberculosis are pretty common and permanent cures do not occur so frequently as many enthusiasts believe (see § 83). The Treatment of Tuberculosis of Bone.—In the first stages of a de- veloping tuberculosis of bone the treatment is purely symptomatic (rest, immobilising dressings, ice, good food, fresh air, etc.). As soon as possible I then begin in suitable cases with parenchymatous injec- tions of sterilised ten per cent, iodoform oil, or the iodoform glycerine of Bruns, which I can most heartily recommend (two to eight grammes every two to four weeks). At present I always use ten-per-cent. iodo- form oil. The iodoform and oil are sterilised separately by heating them in a sterilising apparatus to 100° C. (212° F.); the sterilised materials are then cooled and made into a ten-per-cent. iodoform mix- ture in a sterilised vessel. Instead of ol. olivae, Bohm recommends ol. amygd. dulc, in which is dissolved fifty per cent, of iodoform. If the iodoform oil is prepared in the manner described above, we avoid the injurious effects or poisonous manifestations of the iodoform, which are mainly caused by the liberation of iodine. The latter is particularly apt to be set free if the iodoform and oil are sterilised together at high temperatures when in the form of an emulsion. Lannelongue praises the results obtained by the injection of strong solutions of chloride of zinc into the periphery of the tubercular focus; a contracting, cicatrix- like tissue is thus produced, which forms an obstruction to the spread of the tubercular process and causes the death of the tubercular focus. I have little to say7 in favour of parenchymatous injections of three- per-cent. solutions of carbolic acid or arsenic. Balsam of Peru and cinnamic acid are spoken of on page 420. Isannotti recommends oil of cloves (ten per cent., with olive oil); Reboul, naphthol camphre ob- tained by mixing and heating one hundred parts of finely powdered y3 naphthol with two hundred parts of finely powdered Japan camphor. The oily liquid of naphthol camphre is insoluble in water, but miscible with fats, ether, alcohol, and chloroform, and must be kept in a dark bottle. The remedy can be employed in various ways—as a wash, an injection, etc. Bouchard states that its toxic dose for adults is about two hundred and fifty grammes. If treatment by drugs proves unsuccessful, and a marked focus of disease or of pus is present, operative treatment should be undertaken— i. e., the tubercular deposit should be removed as soon as possible, with strict regard to antisepsis. Operations on the extremities are performed §105.] THE CHRONIC INFLAMMATIONS OF BONE. 627 under Esmarch's artificial ischaemia, which renders it possible to easily distinguish the healthy from the diseased parts. Free incisions should always be made, in order that the focus may be inspected throughout its entire extent. Mosetig-Moorhof finds an electric lamp useful for this purpose. If the tuberculosis is in the medulla, the bone should be opened sufficiently with the chisel and hammer, and the tubercular focus should be energetically removed with the sharp spoon. The scraping-out process must be continued until healthy, firm bone is reached. Even when the entire medullary cavity7 of a long bone has to be thus scraped out, necrosis will not occur if only the wound in the bone heals aseptically. To prevent recurrences and to render speedy recovery possible, Riedel recommends extensive removal of the bone, leaving only a thin wall of cortex intact. Free sequestra should be ex- tracted ; infected soft parts in the neighbourhood of the diseased bone, abscess membranes, etc., should likewise be removed with the greatest care by scissors and forceps. After having scraped out the tubercular deposit in the bone, the resulting cavity should be filled with ten per cent, iodoform oil and packed with iodoform gauze. Billroth's method is most excellent and efficacious. The tubercular cavity, in case it has not opened externally before the operation, is immediately filled with ten per cent, iodoform oil or iodoform glycerine, and hermetically closed after all tubercular tissue has been removed with the sharp spoon. The iodoform acts more effectively in the absence of air. If any recurrences take place, they are soon recognised by the per- sistence of fistulae with fungous tissue. The secondary operation should not be delayed too long. Operations must often be performed two, three, or more times, with short intervals, before a complete cure is obtained. The cold abscess, which used to be a noli me tangere to the old surgeons on account of the pyaemia which so frequently followed the operation, must always be opened at the earliest possible moment, scraped out and drained. The treatment of tubercular inflammations of joints will be discussed under the subject of Diseases of Joints (§ 114). The indications for amputation and resection are described on pages 113 and 129. All operations in cases of tuberculosis should be performed with the greatest care and most rigid asepsis. We men- tioned, in first speaking of tuberculosis, that general miliary tubercu- losis may occasionally follow operations on tubercular foci, as well as vigorous movements of joints affected with tubercular disease. Iodoform and iodoform gauze are the best materials for dressings in cases of tuberculosis, and large wounds may be packed with them. Instead of packing with iodoform gauze, Schede's plan of obtaining healing under an aseptic blood-clot without drainage is 628 INJURIES AND SURGICAL DISEASES OF BONE. also very serviceable after scraping out the tubercular deposit (see page 102). The treatment of tuberculosis of bone with Koch's tuberculin is discussed on page 421. I have obtained no permanent cures by this means, and sometimes matters have been made decidedly worse. Kraske, among others, has had the same experience. In tuberculosis it is very important that the constitution of the patient should be strengthened by energetic general treatment, in the manner described on pages 421 and 424. The Syphilitic Diseases of Bone.—Syphilis of bone occurs in the later stages of syphilis (§ 84), either in the form of death of bone, as caries and necrosis, or as an ossifying inflammation of bone. The in- flammation of bone characteristic of syphilis is the gummatous perios- titis and osteomyelitis—i. e., the formation of gummata or syphilo- mata in the periosteum or medulla. The periosteal gummata take the form of flat, elastic swellings, which on section reveal a gelatinous con- sistency. In the later stages a fatty, cheesy, or a suppurative degeneration takes place, writh or without shrinkage to firm fibrous thickenings. The periosteal gumma is very apt to occur on the skull, and also not infrequently in the periosteum inside the cranial cavity, less often on the clavicle, and rarely on the diaphyses of the long bones. The epiph- yses of the latter and the short bones are, almost without exception, exempt from gummata. The osteomy7elitic gummatous nodes are soft or more fibrous gelat- inous formations, varying from about the size of a pea to that of a nut, and usually cheesy in the centre. They are sometimes multiple, being found, for example, on the skull, on the phalanges, and, accord- ing to Chiari, also on the long bones, the femur and tibia being the most frequently affected. Both periosteal and osteomyelitic gummata destroy the bone to a greater or less extent, and lead to a varying amount of superficial or central caries with necrosis. In consequence of this death of bone fractures readily occur, and not infrequently are followed by pseudar- throsis. The syphilitic caries with necrosis is particularly apt to make its appearance on the skull, and sometimes is very extensive (see Spe- cial Surgery). A reactive new formation of bone also occurs as a re- sult of the gummatous periostitis and osteomyelitis ; it leads to the development of osteophytes of varying dimensions, and also to hyper- trophy and sclerosis of the bone. The gummata either disappear under appropriate antisyphilitic treatment by becoming gradually7 absorbed and replaced by dense cica- §105.] THE CHRONIC INFLAMMATIONS OF BONE. 629 tricial tissue or newly formed bone tissue, or else a spreading destruc- tion and necrosis of bone develops, the gummata open externally7, etc. Apart from the reactive development of new bone with the forma- tion of osteophytes and diffuse hyperostoses accompanying gummata, there is also an independent ossifying syphilitic ostitis, a periostitis and osteomyelitis, which occur alone. In congenital syphilis there is observed a characteristic disease of the bones in the neighbourhood of the epiphyses, consisting in some cases in an abnormity in the deposit of lime, and in the formation of medullary spaces such as occurs in rhachitis. This syphilitic rhachitis is not very common. But in other cases of congenital syphilis a very characteristic localised disease is present in the epiphyses, particularly in the part near the articular and epiphyseal cartilages. This syphilitic osteochondritis of infants, first described by Wegner, is in fact a com- mon though not a constant manifestation of hereditary syphilis. The disease consists in the formation of greyish-red or yellowish-grey foci in the medulla of the epiphyses in the neighbourhood of the articular and epiphyseal cartilages. The bone becomes replaced by a soft granu- lation tissue, and the cartilage itself is in a state of inflammatory growth. Separation of the epiphysis sometimes occurs in syphilitic osteochondritis, as it does after acute infectious osteomyelitis. Kasso- witz found this condition nine times in thirty-three cases. Epiphyseal separations have also not infrequently been observed in still-born syphi- litic children (Haab, Veraguth, etc.), but under these circumstances the separations may possibly have been caused by putrefactive changes as well as by the syphilitic osteochondritis. The course of the syphilitic inflammations of bone, which occur especially in the later so-called tertiary period of the disease and in the cases which have been improperly treated, is for the most part very chronic and marked by frequent relapses. They have been wrongly ascribed to the effects of mercury. Ostitis due to mercury is only ob- served as a result of salivation ulcers on the jaws. Traumatism appears to play an important part in the syphilitic inflammations of bone. The severe pains (dolores osteocopi), which occur principally at night, are often characteristic. The treatment of the syphilitic inflammations of bone consists in the adoption of a general antisyphilitic regimen (see § 84). The local treatment of the syphilitic metastases is conducted according to general principles, and is similar to that briefly described for tuberculosis of bone. The So-called Bone Abscess.—We have made repeated mention of the so-called chronic bone abscess which occurs, for example, after 630 INJURIES AND SURGICAL DISEASES OF BONE. acute infectious osteomyelitis and tuberculosis of bone. It is always infectious in its nature and arises in various diseases, and is not, as was once believed, an independent disease, but always a symptom or a result of a pre-existing specific disease. Hence it follows that the causes of abscess of bone vary very greatly. The acute suppurative inflamma- tions of the periosteum and medulla, the tubercular and svphilitic in- flammations of bone, etc., are especially conducive to the development of chronic bone abscesses. The so-called acute bone abscesses are essentially metastatic in their nature or originate as a primary acute infectious osteomyelitis. The symptomatology and treatment of abscess of bone can be inferred from what has been said concerning acute and chronic suppu- ration of bone. Other Bone Diseases: Actinomycosis; Glanders.—Amongst other chronic diseases of bone, I should mention actinomycosis and the cir- cumscribed cheesy or suppurative inflammations which occur in the periosteum and medulla in the course of glanders. Both diseases have been described in § 78 and § 86. § 106. Necrosis of Bone.—We have repeatedly spoken of the death of bone or of a certain portion of bone—the so-called necrosis of bone —when discussing the subject of Injuries and Inflammations of Bone. The causes of necrosis of bone are sometimes inflammatory and sometimes traumatic in their nature. In typical necrosis of bone there is almost always an interruption of the afferent flow of blood, less often a direct death of the bone substance. Amongst the special causes of necrosis the diseases of the periosteum and medulla are the most im- portant. It is principally the suppurative form of periostitis which very frequently leads to necrosis; but any suppurative periostitis, as such, will not cause necrosis of bone until it has existed a long time and has extended to the contents of the Haversian canals. The suppu- rative periostitis is frequently the result of a necrosis due to other causes. Necrosis is also produced by the various forms of ostitis and osteo- myelitis when the bone tissue becomes unable to obtain nourishment, owing to the destruction of the medulla and the contents of the Haver- sian canals. In this class of cases comes, for example, the necrosis from suppurative osteomyelitis and tuberculosis of bone, mentioned in a previous chapter. Suppurative inflammations of the surrounding parts and ulcerative processes which extend to and destroy the periosteum likewise lead to necrosis. In this manner is caused, for example, the necrosis of the nasal bones, which occurs in the course of syphilis from the extension § 106.] NECROSIS OF BONE. 631 of ulceration in the nasal mucous membrane to the deeper parts (ozaena syphilitica). The necrosis occurring in the course of typhoid fever and the acute exanthemata is due in some instances to metastatic periostitis and osteo- myelitis, while in others it is probably a kind of inanition necrosis which is the result of the general disturbance of nutrition. As a matter of fact the state of the nutrition of such individuals is generally extremely bad, and they suffer for the same reason from gangrene of the ears and nose. In rare instances necrotic foci in bone originate from emboli. Volk- mann saw a multiple necrosis of the astragalus and tibia which followed the formation of coagula on the mitral valve in endocarditis. In these cases we generally have to do with multiple capillary emboli, and in the case of infectious processes these emboli may consist of micro-organisms which have entered the circulation. Embolism of a single nutrient artery of the bone would probably never be followed by appreciable con- sequences, for the reason that a collateral circulation readily develops, and the blood is carried to the bone by very many and for the most part very small vessels. The phosphorus necrosis, first described by Lorinser, of Vienna, in 1845, is extremely- interesting. It is observed in people employed in the manufacture of phosphorus matches, and is due to the injurious effects of the vapour of phosphorus. Phosphorus necrosis only affects the bones of the face, and selects the jaw almost always—the inferior maxilla more frequently7 than the superior. The disease regularly be- gins with inflammatory disturbances in the periosteum (phosphorus periostitis, Wegner), especially where there are diseased (carious) teeth. At first a chronic ossifying periostitis usually develops, then, as a result of infection by bacteria in the oral cavity, suppuration and gangrene follow between the periosteum and new bone, or between the new and old bone. Sometimes, though rarely, the disease begins immediately with suppuration and necrosis without a preceding ossifying periostitis. The entire lower jaw may become necrotic, especially if the process is not arrested by early removal of the focus of disease. Hack el states that the average duration of the disease from the time the periostitis begins till the suppuration and necrosis of the under jaw, for example, ceases, is, when the disease is left to itself—for the inferior maxilla two years nine and a half months, and for the superior maxilla one year and two months. Since the manufacture of phosphorus matches has become less extensive, and strict hygienic regulations have been enforced in the factories, phosphorus necrosis has become rare; but it still occurs in regions such as the Thuringian Forest, where the making of phos- phorus matches is carried on as a family industry. 632 INJURIES AND SURGICAL DISEASES OF BONE. Necrosis develops after a traumatism, particularly if portions of the bone are completely torn off or separated from their attachments—a fact wliich we learned when discussing fractures (see § 101). AVe stated at that time that in fractures which heal aseptically and in those which are subcutaneous, pieces of bone which have been completely detached may again heal in place and not undergo necrosis. After subcutaneous dislocation of the astragalus, Winiwarter observed total necrosis of the bone occur in two instances in spite of its having been carefully re- placed. Furthermore, wdien a bone has been severely splintered and crushed, circumscribed necrosis is particularly apt to develop if the arterial vessels in the medullary space or narrow Haversian canals are compressed—by an ex- travasation of blood, for example. Traumatic separa- tion of the periosteum laying bare the bone does not of itself lead to necrosis, but the latter will develop if the bone becomes dry from long contact with the air, or if suppuration takes place. Anatomical Changes in Necrosis; Separation of the Sequestrum (Demarcation).—When a portion of a bone has perished it is gradually separated or set free from the surrounding living bone by a demarcating inflam- mation. The separation of the dead bone—the demar- cation, as it is called—is designated anatomically as a granulating, rarefying ostitis, the bone disappearing by lacunar absorption (see Fig. 343) along the line of de- marcation. The piece of bone, after it has become completely separated, is called a sequestrum (Fig. 352, a, and Fig. 353, *). The outer, periosteal, cortical sur- face of the sequestrum ordinarily remains smooth, while the other portions of the sequestrum, where it is gradually set free from the living bone by the demarcation, appear rough and uneven, Fig. 352.—Necro- sis of bone (fe- mur) : a, se- questrum. Fig. 353.—Complete necrosis of the diaphysis of the tibia : .S\ sequestrum ; a a, fistulse (cloacae); b, newly formed bone or involucrum (schematic). just like the ivory pegs which have been driven into a bone for pseu- darthrosis (see Fig. 347). The size of every sequestrum is rendered §106.] NECROSIS OF BONE. 633 less by this corrosion or abrasion, and, in fact, small sequestra, like small splinters of bone in fractures, may be completely absorbed if there is no suppuration and the granulating germinal tissue surrounds them closely. As is the case in the corrosion of the ivory pegs, so also in the separation of the sequestra and the absorption of small sequestra it is mainly the carbonic acid, resulting from the metabolism of the tissues, which in the free state, together with the osteoclasts, dissolves the lime salts. The length of time occupied by the process of demarcation till the sequestrum has been completely separated varies greatly, and depends upon the size of the sequestrum and its location. The activity of the separating process in different individuals is also very variable. In general it may be said that extensive necroses, such as the total necrosis of a diaplrysis, require in some instances from three to five months, and in others from eight to ten to twelve months, be- fore they are completely separated. Separation of the sequestrum takes place more rapidly in young than in old patients. Hand in hand with the separation of the dead portion of bone its regeneration proceeds by reactive bone formation—i. e., by an ossifying periostitis and osteomyelitis—as in the repair of fractures. Through the action of the periosteum a cap- sule of bone—the involucrum, as it is called—is formed around the se- questrum, as in the case of necrosis of the entire diaphysis (Fig. 353, b, and Fig. 354, b). The fistulae which lead from the involucrum to the surface of the body are Pflllprl clnflffp an pxnrpssion wbifb Flg-^—Partial necrosis of a hollow bone : caiiea Cloacae, an expression Wllicn 77, cavil v in the bone after removal of the has passed OUt of USe at the present sequestrum; «, fistula: 4, newly formed r r bone or involucrum (schematic). time. Through these cloacae, or, better, fistulae, the pus escapes from the cavity containing the seques- trum (Fig. 353, a, and Fig. 354, a). Large defects develop especially in those parts of the involucrum where the periosteum has perished in consequence of suppuration or a traumatism. In cases of central necrosis—i. e., necrosis in the interior of a bone—the innermost layers of the involucrum are, of course, formed from portions of the old in- tact bone. But even in these central necroses there usually occurs a reactive ossifying periostitis with the formation of fresh layers of bone. The capabilities of regeneration possessed by bones (a subject which has been thoroughly investigated by Oilier) are in general very great, and a necrosis which involves the whole of a long bone can be so com- pletely compensated for that no variations from the normal will be 634 INJURIES AND SURGICAL DISEASES OF RONE. noticed. But occasionally the regeneration is defective, or may even be entirely absent and permit the defect to persist. Not infrequently in the case of a necrosis involving the diaphysis of a long bone in a young subject, there will be observed, in consequence of the irritation of the epiphyseal cartilages, an increased longitudinal growth causing the bone in question to become two to three centimetres longer than the corresponding one on the sound side. Various Kinds of Necrosis Distinguished by their Location and Extent. —According to the situation and extent of the necrosis we recognise a superficial, external, or peripheral necrosis in contradistinction to the above-mentioned central necrosis occurring in the interior of a bone. We also recognise a partial and a total necrosis, and a multiple necro- sis occurring in different portions of the same bone or in several bones of the same skeleton. The necrosis tubulata (Blasius) with a tubular- shaped sequestrum is very rare ; the internal axis of the sequestrum is formed of living bone substance which is firmly connected with the old bone. Consequently we have to deal with tubular sequestra in which there is a preservation of the innermost layers of bone or a consider- able regeneration of the latter by an ossifying periostitis. Symptomatology and Diagnosis of Necrosis.—The symptoms caused by necrosis have already been partly described. They are mainly due to the demarcating inflammation and regenerative new formation of bone for casting off and replacing the dead portion, which come more and more into prominence after the subsidence of the primary disease (periostitis, osteomyelitis). If there has been a loss of substance in the overlying soft parts the dead bone will be plainly visible; but if the necrotic bone is covered by soft parts, and if the sequestrum is deeply situated, the bone will ordinarily be found to be evenly thickened at the affected point, as a result of the ossifying periostitis (Figs. 353, 354). The presence of fistulous tracts, which usually discharge only a little pus, is another symptom of necrosis of bone. If a metal probe is passed through these fistulous passages it will usually strike the surface of the sequestrum. The latter feels hard, and if percussed with the probe emits a tympanitic sound. In the case of superficial or total necrosis the surface of the sequestrum is smooth; if the necrosis is central the surface is rough. The dead bone is also recognisable by its lack of blood, and by its white colour when com- pared to the rosy appearance of the living bone. It is very impor- tant, both for diagnosis and treatment, to determine whether the se- questrum has become movable. The mobility of the sequestrum can be ascertained by pressing the probe firmly against it, or by pass- ing two probes through two different fistulae down to the sequestrum, § 106.] NECROSIS OF BONE. 635 or finally by attempting to move it back and forth by means of a dressing forceps. Occasionally a sequestrum which has become en- tirely free is so tightly enclosed that it is impossible to demonstrate its mobility. In such cases the separation of the sequestrum is deter- mined by the duration of the disease. Necrosis may be mistaken for those central bone diseases which lead to enlargement of the bone with the formation of fistulae, such as central bone abscesses and tumours of bone, and then particularly for caries. The typical caries, with few exceptions, as we saw, is a tubercular process, and is very often com- bined with necrosis. The tubercular sequestra usually contain cheesy tissue and have a soft feeling, while the sequestra of ordinary necrosis appear white and hard, like normal bone. The pus in necrosis is scanty and more mucoid, but in caries it is a thin liquid mixed with cheesy masses. The fistulous tracts of tuberculosis generally have a pale, lardaceous appearance, and if a probe is introduced through them it strikes against soft, crumbling bone ; while in necrosis the granulations usually have a vigorous, healthy appearance and bleed easily, and the sequestrum when touched by the probe feels hard. Furthermore, the development of the two diseases is different. The tubercular caries begins gradually, and mainly affects the epiphyses and the spongy bones, while the typical necrosis ordinarily develops after acute or sub- acute inflammation of bone, especially the long, hollow bones (femur, tibia, humerus). Treatment of Necrosis.—The treatment of necrosis before the se- questrum has separated is purely symptomatic, and consists mainly in keeping the fistulae clean. AVhen the sequestrum has become com- pletely free it must be removed by operation, if it has not already been spontaneously cast off or out. Even large, deeply located se- questra can work their way outwards through the cloacae and come to lie beneath the skin, which they then gradually penetrate. I extracted simply with the fingers, in the case of a twelve-year-old boy, a large, completely separated sequestrum consisting of the entire thickness of the femur. During many months it had projected several centimetres from the soft parts, and no one had dared remove it. As a rule, only those sequestra which are completely free should be removed, but there are a few exceptions to this. In the case of phosphorus necrosis, for instance, the foul suppuration compels us to adopt operative meas- ures before the sequestrum has become completely separated, and early resection—i. e., early removal of the primary focus of disease—should be undertaken to shorten the process and to prevent it from extending further. If the disease is left to itself, the entire lower jaw perishes, according to Hiickel, in seventy-nine per cent, of the cases. In ordinary 636 INJURIES AND SURGICAL DISEASES OF BONE. necrosis we must wait for the separation of the sequestrum to become complete, for the reason that the loss of substance will have been re- placed by a new formation of bone, and that if we operate before the separation is complete we are liable to remove too much of the healthy bone, or possibly too little of that which is dead. In doubtful cases, where the mobility of the sequestrum cannot be determined, the length of time the process has lasted must be taken into consideration in de- ciding whether or not operative removal of the sequestrum should be undertaken. On the other hand, when the necrosis is extensive, though the sequestrum be free, the operation should be postponed if the new formation of bone is too scanty. The Operative removal of the Sequestrum (Sequestrotomy).—If the necrosis is not encapsulated, the fistulae are simply enlarged to the necessary amount with the knife and the sequestrum extracted with suitable forceps, such as a dressing forceps. If the sequestrum is en- capsulated by an involucrum, the latter must be opened with the ham- mer and chisel after freely dividing the soft parts and elevating the periosteum. Esmarch's artificial ischaemia should be used for the ex- tremities. After extraction of the sequestrum the cavity in the bone should be thoroughly scraped out, and then either packed with iodo- form gauze, or the wound in the soft parts closed almost entirely by sutures, after providing for drainage. If the wound is left to granu- late, the skinning-over process can be hastened later on by the trans- plantation of skin. Schede's method of obtaining healing under an aseptic blood-clot (see page 102) is also good—i. e., the wound in the soft parts is closed by sutures without drainage, though I leave one angle open as a means of escape for any surplus accumulation of fluid. To prevent recurrences and to obtain speedy recovery, the involucrum should be removed, as Riedel rightly says, until only a wall of cortex remains in the form of a flat trough. If the operation has been per- formed under Esmarch's artificial ischaemia, antiseptic dressings exert- ing pressure should be applied, and the extremity elevated, before the rubber tourniquet is removed ; the limb should then be kept elevated for the next twelve to twenty-four hours. It is very important that the extremity which has been operated upon should be immobilised as much as possible by a splint. If fistulae persist, they must be thoroughly scraped out, and the sequestrotomy, when necessary, repeated for the extraction of any other sequestra which may be present. Sequestrot- omy is a very beneficent and not at all a dangerous operation if per- formed with antiseptic precautions. Liicke and Bier have recommended an excellent new method for sequestrotomy which is called osteoplastic necrotomy (Fig. 355). In §107.] SPONTANEOUS SEPARATIONS OF THE EPIPHYSES. 637 V I the first place, the incisions a c, a b and c d are made through the soft parts, then the bone, which in Fig. 355 is the tibia, is cut half through transversely with a keyhole saw and divided with the chisel in the line of the lon- gitudinal incision. By de- pressing the handle of the chisel the skin-periosteal-bone flap thus fashioned is broken through along the line where it still remains joined to the rest of the cortex, and is turned back like the lid of a box, exposing the cavity con- taining the sequestrum (see Fig. 355). After removing the sequestrum and scraping out and disinfecting the cavi- ty, the cover is replaced, and the wound in the soft parts closed immediately or by sec- ondary sutures applied after the wound has first been packed. Recovery usually takes place with slight sup- puration. § 107. Spontaneous (In- flammatory) Separations of the Epiphyses.—The spontaneous (inflammatory) separations of the epiphy- ses which occur in the bones of young subjects at the cartilaginous junctions wdth the diaphyses have already been discussed under the sub- ject of Suppurative Periostitis and Osteomyelitis. As a matter of fact, the spontaneous separation of an epiphysis from the bone is almost always secondary to suppurative inflammation of the periosteum, the marrow of the bone, or the joint. But occasionally the epiphyseal separation is due to primary inflammation at the cartilaginous sym- physis, as, for example, is the case in the osteochondritis luetica occur- ring in the course of syphilis. Multiple epiphyseal separations affect- ing several bones have been observed in pyaemia. The non-suppura- tive, spontaneous epiphyseal separation is very rare, and when it does take place may be due, according to Poupart, Petit, and Volkmann, to a haemorrhagic malacia of the epiphyseal cartilages occurring in scurvy. Fig. 355.—Osteoplastic necrotomy. 638 INJURIES AND SURGICAL DISEASES OF BONE. The osteochondritis dissecans described by Konig, the nature of which is obscure, also sometimes leads to complete separation, for example, of the head of the femur from its neck, without any traumatism hav- ing been received, and even occurs in people from thirty to forty years of age. According to Volkmann, the typical spontaneous separation of the epiphysis is generally observed before the fifteenth year, and no case has been recorded where it happened later than the twentieth year. It is well known that the cartilage between the epiphyses and diaphyses persists till about the twentieth to twenty7-second to twenty fourth year of life, the epiphyses joining with the diaphyses somewhat earlier in women than in men. Separation of the epiphysis is most common at the lower end of the femur and the upper end of the tibia. Traumatic separations of the epiphysis are described on pages 575 and 589. The symptoms of epiphyseal separation are in the main those of a fracture, and repair takes place in precisely the same way. We have discussed on page 589 the occurrence of disturbances of growth after bony consolidation of the epiphyseal line. It need only be briefly stated here that in two cases of suppurative separation of the upper epiphysis of the tibia in comparatively young children, Blasius and Volkmann were able subsequently to demonstrate no shortening after the growth of the body had been completed. The treatment of separations of the epiphyses is conducted accord- ing to the rules which govern the treatment of simple and compound fractures, and is the same as that for traumatic separations, which was given in § 101. § 108. Rhachitis.—Rhachitis (from pd%i<;, the spine) is a general dis- turbance of nutrition which occurs in early childhood, and anatomically is characterised mainly by the formation of bone which is deficient in lime, and by an increased absorption of bone. Therefore the bones affected by rickets are abnormally soft and have a tendency to bend, to suffer infractions ; and the epiphyseal cartilages are remarkably thick—a peculiarity which has given the disease the name of doppelte Glieder (double limbs). Rhachitis is a disease affecting the develop- ment of bone, and a true disease of childhood, most commonly begin- ning in the first or second year of life, very rarely after the fifth or sixth. According to Schwartz, pronounced rickets is often observed in infants, and the investigations of Kassowitz show that it frequently begins during the latter months of foetal life, in consequence of the transmission of morbid stimuli, or as a result of deficient absorption of lime from the maternal circulation, and then during the months imme- § 108.] RHACHITIS. 639 Riiii diately following birth the symptoms of the affection become more and more marked. In the Vienna obstetrical clinic, among five hundred children, Schwartz found 80*6 per cent, to be rhachitic, and the great majority of the mothers of these rhachitic children had lived under improper dietetic and hygienic condi- tions, and during their pregnancy had done hard work. Rhachitis was first accurately described by the English surgeon Glisson in the middle of the eighteenth century—hence the name " English disease"—but it was known to the ancients. Anatomical Changes in Rhachitis.—The anatomical changes in rickets have recently been studied by Virchow, Kassowitz, Ba- ginsky, and others. Kassowitz ascribes all the manifestations of rhachitis to chronic in- flammatory changes at the boundary line be- tween the foetal and infant bone—i. e., to an abnormally increased vascularisation of the tissues which go to form bone. As a result of this hyperaemia, and the numerous, chiefly new-formed vessels at the epiphyses in the periosteum and medulla, there occurs a growth of the epiphyseal cartilages, a dimin- ished deposit of lime salts, and an increased resorption of the fully formed bone. The bone undergoes a lacunar absorption (Fig. 343), osteoclasts being present, and, as I have stated before, is probably dissolved by car- bonic acid. Rhachitic bone is poor in lime, and the newly formed bone remains for a long time in the uncalcified state. Not till the rhachitis has run its course does the ground substance of the bone become com- pletely calcified, and then usually to an ex- treme degree, so that the affected bone ap- pears thickened and very hard—sclerosed. The changes at the epiphyses are very characteristic. Under normal conditions the epiphysis is defined by a plain white line, cartilage and bone being sharply differentiated from one another. But in rhachitis this sharply defined linear boundary is absent, and the different tissues, Fig. 356.—Rhachitis. Longitudi- nal section through the upper epiphysis of the tibia near the boundary of ossification; a, zone of the proliferating columns of cartilage; b, vas- cular medullary spaces in the cartilage; c, calcified cartilag- inous tissue; d, osteoid un- calcified or only slightly cal- cified tissue with remnants of cartilaginous tissue; e, fully formed bone. 640 INJURIES AND SURGICAL DISEASES OF BONE. the cartilage, bone and medulla, appear as though blended together without any system (Fig. 356). The cartilaginous epiphyseal line is broadened and irregular, the boundary between cartilage, bone, and medullary tissue is not well marked, and the zone of calcification at the points of ossification is absent or deficient. The most important fac- tors in the process are always the insufficient deposit of lime salts and the increased absorption of the bone already present. Baginsky states that rhachitic bone has lost more than three fourths of the lime it contains. Rhachitic bones are so soft that they can easily be cut with a knife, and, in consequence of this softness, deformities of the skeleton occur. In older children the changes in the thorax, the vertebrae and extremities are more prom- inent than those in the skull. Bow-shaped curves develop in the bones of the extremi- ties, or, more commonly, angular deformi- ties at the ends of the diaphyses (Fig. 357) with thickening of the epiphyses. The joints are loose, abnormally movable, and painful. At the knee joint, for instance, there is very often a considerable abduction or adduction and rotation of the leg in con- sequence of the relaxation of the ligaments Fig. 357.—Rhachitic deformities of the joint and the rliachitic curvature which exists in the tibia and femur (genu valgum and genu varum rhachiticum). At the hip joint the rhachitic bending of the neck of the femur is to be noted. In the foot the so- called "flat foot" develops, etc. This relaxation of the joints and softness of the bones are the reasons why rhachitic children take so long to stand and walk, and why they lose their ability to perform these acts in recurrent rhachitis or rhachitis of late development. The pelvic walls fall together, causing the cavity to become contracted, the promontory of the sacrum projects downwards and forwards, the acetabular region is pushed inwards, the symphysis forwards. Curva- tures develop in the vertebrae (scoliosis, kyphosis), and the thorax, par- ticularly at the points where the ribs join the costal cartilages, becomes depressed, so that in severe cases the sternum is pushed forwards (the so-called " chicken breast," or pectus carinatum). In the skull, espe- cially in the occipital region, the bones remain for a very long time soft and yielding to pressure, and, as a result of the loss of bone sub- stance, some portions may again become membranous (cranio-tabes rha- s 10S.J RHACHITIS. 641 chitica). The cutting of the teeth is delayed, and after the disease has been cured they often come through precipitately7. The longitudinal growth and body weight are less than they normally should be. Bou- chat states that rhachitic children only grow about two to three centi- metres in a year, while the average longitudinal growth in health amounts to about seven to eight centimetres. Under anomalies of internal organs are to be mentioned disturb- ances of the central nervous system and of the circulatory and digest- ive organs, such as, for example, hypertrophy or sclerosis of the brain, and chronic hydrocephalus. The spasm of the glottis, which is so common in rhachitic children, is probably caused by a general or a reflex anaemia. Disturbances of digestion (dyspepsia, diarrhoea, alter- nating with constipation), chronic bronchitis, lobular pneumonia, etc., are very common. The liver is very often decreased in size; the spleen, on the other hand, is usually but not always enlarged, and sometimes attains enormous dimensions. The skin, mucous mem- branes, lymph glands, etc., often show the same disturbances of nutri- tion as in scrofula (see page 423). In the form of rhachitis appearing somewhat later in life (rhachitis tarda), Levrat (Lyon) very often ob- served goitre. Analyses of the urine show, according to Baginsky, that (1) a healthy child retains more nitrogen in its system than a rhachitic one, and excretes phosphoric acid more freely in the urine; (2) that under the influence of dyspeptic conditions the rhachitic child excretes nitrogen in the urine more readily than the healthy child, and retains phosphoric acid; (3) that no difference can be made out between healthy and rhachitic children as regards the excretion in the urine of lime and magnesium; (4) that the relative amount of chlorine excreted in the urine of healthy children is greater than in that of rhachitic children. As regards the excretion of phosphorus or phosphoric acid in the urine of rhachitic children, the statements of authorities vary very greatly; but as a general thing the majority of German authorities declare that there is a diminution of the phosphoric acid in the urine (hypophosphouria) in rickets; while the majority of French authori- ties maintain that there is an increase (hyperphosphouria). The analysis of the ash of the faeces shows that more lime is excreted in the stools of rhachitic children (to one kilogramme of body- weight) than is normally the case, and that the excretion of phosphoric acid, as compared with that in health, is not increased. The Etiology of Rhachitis.—The cause of rickets—which we have learned to recognise as a general disturbance of nutrition in children, mainlv localised in the bony system—has been made the object of 41 6-t2 INJURIES AND SURGICAL DISEASES OF BONE. much experimental investigation. The majority of the authorities ascribe the cause of rhachitis to malnutrition. As a matter of fact, we know that a proper supply of the salts of the alkalies and of the earthy salts is of the greatest importance for the nutrition of all the tissues. Chossat and others have demonstrated by experiments on young grow- ing animals that by feeding them with food deficient in lime, young birds and dogs, for example, show changes which are analogous to those in rhachitis. Baginsky, whose careful investigations include 627 cases of rickets (347 boys and 280 girls), also states that the disease is a result of unfavourable conditions of life, especially deficient nourish- ment, bad dwellings, etc. Rhachitis is, in fact, a disease of the poor, particularly in large cities, and occurs less often in the country, as Morgan and Baxter have recently proved by extensive statistics. Bill- roth and Winiwarter maintain that in Vienna about eighty per cent, of the children of the poorer classes show symptoms of rickets. Children who are brought up by bad artificial feeding without being nursed at the breast, and who have disorders of digestion, are particularly apt to be affected with rickets. According to R. L. Lee, preceding respira- tory disturbances due to bronchitis, pneumonia, whooping-cough, etc., are also of great etiological importance. Furthermore, we saw on page 629 that the syphilitic poison, and possibly also other haematoge- nous dyscrasiae, excite changes at the epiphyseal junctions which are similar to those of true rhachitis; and doubtless rickety children suffer from hereditary syphilis more often than is generally7 supposed. The Course of Rhachitis is for the most part chronic, more rarely acute, and the earlier the rhachitis occurs the more rapid, as a general thing, is its course. Thus the rare cases of congenital rickets run a very rapid course; and of the children affected by the disease during the months immediately7 following birth, a large part perish from in- creasing inanition due to unfavourable hygienic conditions. But if the causative factors are removed, and the children properly fed and their surroundings improved, the disease usually disappears rapidly— in the milder cases within five to six months, and in the more severe ones within two to three years. Occasionally the disease drags on till the fifth or sixth year ; cases lasting longer than this are very rare. In the cases of acute rhachitis there are sometimes complicating disturb- ances of nutrition, particularly scurvy, which may occur simultaneously with the rickets (Th. Smith, Barlow, etc.). The Diagnosis of Rhachitis, as a rule, is very easy, for the reason that the above-described anatomical changes in the skeleton are pathogno- monic. It should be a rule, in making an examination, to undress com- pletely all children suffering from chronic disease. S108.] RHACHITIS. 643 The Prognosis, if proper treatment is adopted, is favourable, as we have said before. But if the unfavourable conditions continue, a large proportion of rhachitic children perish from diseases of the intestinal tract, of the respiratory organs, from hydrocephalus, general inanition, etc. The Treatment of Rhachitis consists, in the first place, in the ad- ministration of proper food to the child, and in doing away as soon as possible with all unfavourable hygienic conditions. Inasmuch as recent investigations show that rhachitis is of such common occurrence in young infants, they must always be carefully examined for its presence, and in cases where the disease is found the proper treatment must be begun early. The best food for suckling children is mothers' milk or good cows' milk sterilised by Soxhlet's apparatus. Nursing the child longer than the first year of its life, Baginsky states, is just as apt to cause rickets as is the administration at too early a period of starchy or indigestible food. All disorders of digestion and other complications in rhachitic children should be carefully treated according to the gen- eral rules which apply to them. Internally, cod-liver oil, iron, lime, phosphorus, arsenic, and pyrogallic acid have been recommended for rhachitis, but in their administration the state of the digestive organs must be taken into consideration. Cod-liver oil, which may be com- bined with extract of malt, is useful for children who are not fat, espe- cially in winter. Lime is given in the form of liquor calcis added to milk, or in a mixture made of carbonate and phosphate of calcium with ferri oxyd. sacch. (ferri carb. sacch.), equal parts of each, enough to cover the point of a knife, three times a day. On account of its osteo- plastic action the administration of phosphorus has recently been recommended for rhachitis by Wegner and Kassowitz. It is given (1 milligramme pro die) in cod-liver oil (0*01 gramme phosphor., 1000- cubic centimetres ol. morrhuae, one to two teaspoonfuls a day), or in pill form with oil of phosphorus and some indifferent powder enclosed in gelatine capsules. Maas and others maintain that arsenic and pyro- gallic acid have also an osteoplastic action like phosphorus. Three per cent, brine baths, sea baths, health resorts situated on high land, and proper climate have as valuable an influence upon rickets as they have upon scrofula (see page 424). To prevent as far as possible the curva- tures and angular deformities which may occur in the extremities, for example, rhachitic children should not be encouraged to stand and walk at too early a period. Braces and similar apparatus should be used to support the lower extremities, and the application of light water-glass or starch dressings is also advantageous. After the rhachitis has sub- sided, the bony deformities, particularly those in the leg, often have to t',44 INJURIES AND SURGICAL DISEASES OF BONE. be corrected, the crooked bones either being broken by hand or by Riz. zoli's osteoclast (Fig. 74, page 84), and then when they have been ren- dered straight treated like a subcutaneous fracture. In other cases when the strength and sclerosis of the bone is considerable, it will be impossible to break the bone subcutaneously, and subcutaneous oste- otomy, combined possibly with an excision of a wedge-shaped piece of bone, must be undertaken. To perform osteotomy, the proper incision is made through the skin, and through this the bone is divided with the hammer and chisel, with the exception of a small portion of the cor- tex, which is then usually broken by hand. The wound is not sutured and after covering it with an antiseptic protective dressing a plaster-of- Paris splint is immediately applied. If the operation is carried out with antiseptic precautions it is entirely devoid of danger. Macewen's oste- otomy at the lower end of the diaphysis of the femur is also very ap- propriate in cases of genu valgum rhachiticum. Tenotomy of the tendo Achilles must sometimes be added when the curvature of the tibia is convex anteriorly. But frequently7 braces will be sufficient to overcome deformity, the bones gradually becoming straight of their own accord. I must refer the reader to my Special Surgery for the particulars of the treatment for the various sequelae of rhachitis in the different portions of the body7, such as the vertebrae, the extremi- ties, etc. § 109. Osteomalacia.—By osteomalacia we understand a peculiar softening and resorption of bone substance which is observed most commonly in women during pregnancy and the puerperium, less often Fig. 358.—< )steomalacia (pelvis). Trabeeulae of decalcified bone with remnants of calcified bone. The enlarged medullary spaces (J/) have arisen from absorption of the trabeeulae. x 75. in men, and in women who are not pregnant. The disease not in- frequently occurs in pregnant and milch cows. In osteomalacia the normal, strong bones of adults become soft, while in rhachitis, on the other hand, we have to deal with a disease of development affecting §109.] OSTEOMALACIA. 645 young bone, in consequence of which the latter remain soft and do not become firm. Anatomical Changes in Osteomalacia.—The puerperal form of osteoma- lacia probably always begins in the pelvis, and either remains limited to the latter or attacks other bones, and may even involve most of the skeleton, particularly if the woman passes through several pregnancies after the ap- pearance of the disease. The non-puerperal form begins most commonly in the vertebras and thorax, and then extends to the extremities and finally to the bones of the head. The softening, the absorption of bone substance (Fig1. 358), is an halisteresis—i. e., tbe lime salts are first dissolved, but the decalcified ground substance persists a little while longer, then it also gradu- ally disintegrates, and is finally absorbed. The absorption of the lime salts always begins in the periphery of the bone and advances steadily towards the centre. In this manner a considerable loss of bone may be brought about, and the cortex of the long bones may become as thin as paper, or the diseased bone may even entirely disappear, leaving only the periosteum and medulla to persist as an elastic tube. Morand observed a very pro- nounced degree of osteomalacia in a woman who possessed in the place of most of her bones only membranous cylinders or very thin tubes of bone. In the milder cases, which recover quickly, tbe decalcified bone substance can be very rapidly changed to normal bone by a fresh deposit of the salts of lime. As long as tbe disease is advancing the medulla is usually very richly supplied with blood, contains numerous haemorrhagic foci scattered through it, has an abundance of cells, and is poor in fat. In rare instances of osteomalacic softening of bone there have been noted multiple cystic for- mations with tumour-like enlargement of the softened portions of bone (Al- bertin). There are, moreover, cases which present the clinical picture of osteomalacia, and anatomically are due to the development of multiple true tumours, especially sarcomata (Recklinghausen). As a result of the softening of the bones there of course arise corresponding curved or angular deformi- ties, and fractures. Changes of shape in the osteomalacic pelvis are particu- larly common. Recklinghausen and Rehn have recently described an in- fantile osteomalacia, but this is probably in the main a severe rhachitis. The Etiology of Osteomalacia.—The precise cause of osteomalacia is still but little understood, though various theories have been advanced. We only know that it occurs chiefly in pregnant or nursing women and animals, and is common in certain regions which in Germany lie along the Khine, while other places, like the valley of the Oder, appear to be free from it. Damp, unhealthy dwellings, malaria, anaemia, and other constitutional anomalies connected with disturbances of nutrition, are said to be of importance. Cohnheim maintains that osteomalacia, like rhachitis, is a disturbance of nutrition, and he believes that the maternal organism during pregnancy and the nursing period contains too little lime, because a very large amount of lime salts are necessary for the development of the foetal skeleton as well as for the milk. For 646 INJURIES AND SURGICAL DISEASES OF BONE. this reason only osteoid tissue, which is deficient or entirely lackino- in lime, is formed in the maternal organism. Consequently, according to Cohnheim's theory, the uncalcified or deficiently calcified bone tissue is not decalcified old bone tissue, but new-formed osteoid tissue. I be- lieve, however, that the old idea is correct, viz., that the bone tissue which is poor in lime or in which the lime is absent is the decalcified ground substance of the old bone. It is natural that the cause for the decalcification in this condition should also be ascribed to an acid such as lactic acid, or, more correctly, carbonic acid ; but as yet no proof of this has been obtained. Heiss and others have fed animals with lactic acid for months (three hundred and eight days, for example), and yet have not been able to produce osteomalacia. It seems more probable that the decalcification is due to the action of carbonic acid ; it is pos- sible, and the hyperaemia of the medulla favours this view, that in osteomalacia we have to deal with an inflammatory process accom- panied by an increased vascularity and an abnormal formation of car- bonic acid. Examination of the urine, however, does not always show an increased excretion of earthy phosphates, a thing which the acid theory would lead us to expect. Petrone calls attention to the in- creased amount of nitric acid contained in the urine, and believes that osteomalacia is caused by the micro-organism described by Schlossing and Miinz, which produces nitric acid. In one case of non-puerperal osteomalacia observed by Kohler, with pronounced changes in almost all the bones, examination of the ash obtained from the blood revealed a considerable increase of sulphuric acid and a diminution of the so- dium to less than half the normal quantity. The rare osteomalacia of men, and of women who are not pregnant or nursing, depends, accord- ing to Cohnheim, in the main upon disorders of digestion or of as- similation, combined with a lessened absorption of lime. We have practically given the symptomatology of osteomalacia in the above description. The disease almost always begins, as we have said, during pregnancy or during the puerperium, with severe shooting pains in the affected bones. Consequently the disease, at the outset, is often confused with rheumatism, until the changes in the shape of the bones enable the correct diagnosis to be made. The affection may be- come very pronounced during a single pregnancy or a single puer- perium. The milder cases will get entirely well; but very frequently the disease makes pauses in its progress, and then, in conjunction with another pregnancy, though apparently cured, it will break out again with fresh intensity. Recklinghausen observed osteomalacia in young subjects in combination with Basedow's disease. The prognosis of osteomalacia is very unfavourable, and actual cures §110.] ATROPHY AND HYPERTROPHY OF BONE. 647 are exceedingly rare. Nevertheless, the operative removal of the ovaries in puerperal osteomalacia, recently recommended by Fehling, yields surprisingly good results. The treatment of osteomalacia is like that of rickets (see pages 643, 644), and consists primarily in the administration of good nutritious food, also cod-liver oil, iron, lime, quinine, phosphorus, and arsenic. All unfavourable hygienic conditions, disturbances of nutrition, and constitutional anomalies are, as far as possible, to be done away with. If the woman is nursing her child, she must be forbidden to do so, and made aware of the danger that in a new pregnancy the disease may recur with increased severity. Great interest attaches to the cures of osteomalacia recently obtained by the removal of the ovaries. The castration, which was first recommended by Fehling, is either per- formed by itself, or combined with Porro's supravaginal removal of the gravid uterus. The success of this procedure is so remarkable that pa- tients with a very pronounced form of the disease can be cured and allowed to attend to their employment after the lapse of from three to four to five weeks. Petrone believes that the success is mainly to be ascribed to the narcosis and not to the operation, as he has cured one case of osteomalacia in three weeks by the daily administration of two grammes of chloral hydrate, the nitric acid which was present in the urine disappearing on the fifth day of the treatment. The castration recommended by Fehling for osteomalacia, with or without supravaginal removal of the uterus, deserves the most general consideration because of the success which has already been obtained. AVe must not omit to state that in rare instances the osteomalacia of women also gets well spontaneously. § 110. Atrophy and Hypertrophy of Bone.—Atrophy of bone is due to various causes. Every resorption of fully formed bone substance, which, as we have seen, occurs so frequently under pathological condi- tions, is to be looked upon as an atrophy of bone. The resorption of bone substance either takes place on the external surface of the bone or it starts in the medulla and advances outwards. In the outer (concen- tric) atrophy the bone becomes smaller and thinner, while in the case of the internal (excentric) atrophy the medullary cavity and the Haver- sian canals grow larger and the bone becomes porous (osteoporosis). The senile atrophy which affects the bones of the skull (the cranial vault, the inferior maxilla, etc.) and of the extremities, especially their articular ends, is a special form of bone atrophy. The senile osteo- porosis of the neck of the femur is of practical importance, as the neck gradually becomes depressed and may be broken by a very slight traumatism. 648 INJURIES AND SURGICAL DISEASES OF BONE. A common cause of the atrophy of a bone is disuse of the latter (atrophy of disuse). We have said that this follows paralyses, inflam- mations of joints, temporary immobilisation of an extremity by a plas- ter-of-Paris dressing, etc. The disappearance of the acetabulum, wliich occurs when a dislocation of the hip is not re- duced, also belongs to the atrophies of disuse. This form of atrophy may take place in cer- tain limited portions of a bone, as in the callus formed after a fracture, those portions of the bone substance gradually disappearing which have become useless for the function of the bone. Another form of atrophy of bone is the neuroparalytic and trophoneurotic, which oc- curs in conjunction with diseases of the nerv- ous system, such as tabes, or as a result of changes in the trophic nerve fibres or afferent nerves, or in the trophic centres in the anterior horns of grey matter in the spinal cord (Fig. 359). A careful description of the trophoneu- rotic diseases of the bones and joints is given in § 117. Local arrest of longitudinal growth is caused by diseases of the epiphyseal cartilages, such as inflammation or suppuration, or it may follow their ossification at too early a period or their removal in too extensive a resection, etc. Pressure, inflammation, and the development of a tumour may also lead to localised atrophy, to wearing away of bone, or to caries. Hypertrophy of Bone is either limited to some particular portion of a bone, as in the formation of osteophytes, or it affects the en- tire bone, the whole volume of the latter being increased or only its length or thickness. The hypertrophies include the hyperostoses men- tioned on a previous page—i. e., the increase in volume following peri- osteal and endosteal formation of bone, and the osteosclerosis or thick- ening of bone tissue, which is also called eburneatio ossis. Helferich and others have, as we remarked before, increased the development of bone at a given point by artificial hyperaemia, pro- duced, for example, by tying off the extremity with an elastic tourni- Fio. 359.—Partial (tropho-neu- rotic ?) atrophy of the skele- ton (upper part of the body) ; pelvis and lower extremities are well-devel- oped; thirty-flve-year-old unmarried woman (Mosen- geil). suio.] ATROPHY AND HYPERTROPHY OF BONE. 641) Fig. 360.—Partial giant growth on the hand (Curling and Bohm). quet drawn moderately tight on the proximal side of the point in the bone wliich is diseased. This procedure is worth trying in the case of fractures where the callus formation is de- layed and insufficient, and in pseudarthrosis, and also to diminish shortening, etc. (see page 603). The lengthening which bones may under- go in conjunction with irritation of the epi- physeal cartilages due to injuries and diseases of the diaphysis or neighbouring joints and soft parts, is also a matter of practical impor- tance. As Oilier has demonstrated experi- mentally, an increase in the longitudinal growth of young bones is very easily brought about by stimuli of various kinds. This ex- plains the occurrence of the increased longi- tudinal growth which takes place in conjunction with fractures, espe- cially those which are compound and heal with marked inflammatory reaction, or which follows necrosis, osteomyelitis, large ulcers of the foot, and diseases of joints. Young bones which have been dislocated and not replaced take on increased longi- tudinal growth if they are freed from the pressure of the superimposed bone. Thus, for example, increased longitudinal growth of the radius takes place after dislocation of its head. Congenital hypertrophy7 of bone makes its appearance in the form of giant growth of the fingers and toes (Fig. 360, macro- dactylia), and also as giant growth of an entire extremity (Figs. 361, 362). Ac- cording to Wittelshofer's statistics, all the cases of true giant growth hitherto re- corded are congenital in origin, and origi- nate, as in the case of the very considera- ble monstrosity illustrated in Figs. 361 and 362, from an abnormal increase of growth involving all the tissues of one part of the body. Giant growth is possibly a congenital trophoneurotic disturbance. The cases of acquired hypertrophy of the bones and soft parts (compensatory hypertrophy) are, of course, to be distinguished from Fig. 361.—Giant growth of the upper extremity and the right side of the thorax (Wagner). 650 INJURIES AND SURGICAL DISEASES OF BONE. this congenital giant growth. P. Wagner has recently collected several cases of congenital and acquired giant growth, and has given the litera- ture on this subject (Zeitschrift fur Chir., Bd. xxvi, page 216). Bessel- Hagen has called attention to the various anomalies of the bones and joints wliich occur in giant growth. As regards the treatment of partial giant growth, elastic bandaging, massage, and Weir Mitchell's cure have been used with success in the Fie;. 362.—Giant growth of the lower extremity on the right side, and the upper extremity on the left side. milder forms of the affection. In severe cases, wliich cause much trou- ble in consequence of the awkwardness and weight of the affected extremity, operative measures will sometimes be necessary, and the enlarged member should be removed (see also Treatment of Elephan- tiasis). Acromegaly, a disease to which Marie, in 1S86, first directed atten- tion, must be carefully distinguished from the congenital giant growth. In acromegaly, which begins about the tenth to the twentieth to the thirtieth year of life, and lasts ten to twenty years or longer, there is a hypertrophy of all parts of the body, involving both the bones and the soft parts, especially of the head and extremities. The hands and feet have the appearance of paws. In the head the hypertrophy af- fects most commonly the lower jaw, tongue, under lip, and nose. The power of vision may be completely lost, owing to the pressure exerted by the enlarged sphenoid bone on the optic nerve. Hadden and Ballame state that the disturbance of sight is caused by compression of the optic chiasm or medullary striae of the optic nerve brought about by the hypertrophy of the pituitary body. The vertebrae, ster- num, and ribs are symmetrically enlarged; there are kyphotic curv- atures of the spinal column ; the joints are deformed ; the internal organs, brain, muscles, nerves, etc., hypertrophy. The subjective §no.] ATROPHY AND HYPERTROPHY OF BONE. 651 symptoms presented are pains in the head and joints, a feeling of weakness, and paraesthesia. A steadily increasing cachexia finally makes its appearance. The precise cause of acromegaly is still ob- scure. According to W. A. Freund, the affection is an anomaly of growth, and he believes that its immediate cause must be ascribed to an increased flow of blood to the dilated vessels. Inherited predisposi- tion to the disease is contested by some authorities and accepted by others. It probably has a complex etiology, and occurs after various kinds of disorders, including tumours of the brain, for example. Great psychical excitement has frequently been thought to be the primary cause of the affection. Acromicria.—The condition the reverse of acromegaly is called acromicria (Stembo, Reidel). In this there is a striking atrophy, especially of the ter- minal portions of the body (head, fingers, toes), together with a process of shiinkage, which attacks different organs and sometimes the entire body. The etiology of the affection is very obscure, and the disease must be care- fully differentiated from syringomyelia, Morvan's disease, tbe anaesthetic form of leprosy, Raynaud's disease, and from analogous syphilitic or dia- betic affections of the fingers. According to Stembo, the disease begins on the fingers. On the latter there is often a development of blebs or ulcers, which heal slowly, and are accompanied by intermittent pain. The skin on the fingers grows more and more thin, cicatricial, and tense; all the nails perish, the fingers become shorter and less movable, and tbe entire body grows smaller, from atrophy of the skin and the soft parts, including the tongue and oesophagus. The face assumes a peculiar stiff, immovable, and bird-like expression. There are no disturbances of sensibility, the cutaneous reflexes are normal, the tendon reflexes diminished, and the electrical ex- citability of the muscles and nerves is slightly increased. Daily Variations in Height.—As regards the well-known fact that, man becomes shorter in the course of the day. Merkel has made some accurate measurements (mostly upon himself), and has found that the length of the body in the morning in the recumbent position, immediately after awaken- ing, is some five centimetres more than in the evening in the erect position. The loss in size is partly gradual and partly sudden. The former is due to the gradually increasing compression of the sole of the foot and the inter- vertebral fibro-cartilages; while the latter, or sudden diminution of stature on rising from the horizontal to the perpendicular position, is brought about by compression of the joints of the lower extremity, a shortening of eight millimetres taking place in the region of the ankle joint, of two to three millimetres at the knee, and of one centimetre at the hip. This lessening of the length of the lower exti'emities is mainly caused by compression of the elastic articular cartilages and by tbe sinking of tbe caput femoris into the cavity of the acetabulum, which occurs upon standing in the erect position. Lymphadenia Ossium (Nothnagel).—A peculiar kind of pernicious bone disease, which has been described by Nothnagel, requires mention at this point. It was observed in a man twenty-four years of age, and terminated 652 INJURIES AND SURGICAL DISEASES OF BONE. fatally in a year and a half, the patient having been afflicted with severe pains, thickening of the bones, and steadily increasing cachexia. The autopsy revealed a very extensive development of a lymphadenoid tissue, with a great number of Charcot-Neumann crystals iu the bones, and at the same time a periosteal and medullary new formation of bone. The medulla had almost completely disappeared. Nearly all the bones were diseased the phalanges of the hands and feet and the bones of the face alone remaining unaffected. The lymph glands and the spleen were enlarged, probably to compensate for the lack of medullary tissue, with its power of making blood. § 111. The Tumours of Bone.—The tumours peculiar to bone (os- teoma, exostosis, osteosarcoma, enchondroma, soft-bone tumours, cyst etc.) will be described in §§ 125-130, where we shall take up the sub- ject of tumours in general. At present we shall only briefly discuss the parasitic tumours of bone. Of animal parasites there occur in bone the echinococcus and the cysticercus celluloses, the latter being very rarely met with. Yolk- mann mentions one case of Froriep's, in which this parasite was found in the first phalanx of the middle finger, the symptoms being those of a panaritium periostale. Of echinococcus of bone there are fifty known cases. Echinococcus of Bone.—The taenia echinococcus, as is well known, is a four-jointed parasite about four millimetres long, which lives in the intesti- nal canal of the dog; and only tbe cysticercus of this taenia, after the intro- duction of the taenia eggs into the intestinal canal, occurs in man. In whatever organs the embryo lodges, the liver being the one most commonly affected, characteristic cystic tumours develop. The cyst is made up of a lamellar, very elastic cuticular layer (ectocyst), on the inner surface of which is a granular parenchymatous layer. From this inner layer the so-called brood-capsules develop, and upon these are formed the scolices in great numbers. The echinococcus cyst either remains single—unilocular—or it goes on to form daughter cysts by exogenous and endogenous proliferation. The size of the cysts, especially in the liver, is often very considerable. The echinococcus mul til ocularis is another form of the echinococcus. which forms in the liver only small cysts in great numbers, varying from the size of a millet grain to that of a pea, which are surrounded by a thick, tough, diffuse mass of connective tissue. The echinococcus cysts excite a local inflammation which leads to the formation of a connective-tissue capsule. The cysts, after attaining the size of a walnut or apple, often die, and their fluid contents become absorbed, a cheesy, fatty detritus or calcification being then found inside the shrunken sac. In other instances the cysts grow so large as to become dangerous, and by penetrating or bursting into some cavity of the body give rise to severe inflammations. The echinococcus develops in bone, especially in the medulla (Fig. 363), and occasionally forms at some point where the bone has been sub- §111.] THE TUMOURS OF BONE. 653 jected to a traumatism. The echinococcus cysts of bone are of slow, indolent growth, and after the lapse of years sometimes give rise to painful tumours, which at the outset present the appearance of a central bone tumour and subsequently of a bone cyst. The affection occasion- ally remains latent for several years. Echino- coccus cysts usually vary in size from that of the head of a pin to that of a pea, or they form large cysts (Fig. 363, a) which commonly break through the cortex after they have existed a long time, and invade the surrounding soft parts, muscles, vessels, and nerves, or neighbour- ing joint (see below). As Bergmann has re- marked, there is sometimes a formation of ab- scesses in the tissues around the bone, which after being incised show no tendency to heal, and may lead one to suppose that there is a ne- crosis present. The pus at times is remarkably rich in cholesterin crystals, a fact which is of importance for the diagnosis. The atrophy of bone is not infrequently very considerable (Fig. 361). It is worth noting that, as Gangolphe says, the multilocular form of echinococcus of bone is by far the most common ; it was found thirty-two times in thirty-seven cases, and only in five instances was encysted echinococcus pres- ent (which is much the more common form in the soft parts, especially in the liver). Of fifty- two cases, twenty-six were of the hollow bones (eleven humerus, eight tibia, six femur, one phalanx) and eighteen of the flat bones (eleven pelvis, four each involving the skull, scapula, and sternum, and the ribs once). The diagnosis can only be made with certainty when the soft, fluc- tuating tumours have broken through the bone, or when a portion of their contents can be withdrawn by an exploratory puncture. In the case of the long hollow bones the nature of the disease is occasionally revealed by the occurrence of a spontaneous fracture. The prognosis is governed by the location of the disease, echi- nococcus of the bones of the skull and of the vertebrae and pelvis being the most unfavourable, while the echinococcus of the extrem- ities is less so. Gangolphe states that out of seven cases of echino- coccus of the vertebrae, six died of sepsis after the operation, while Fig. 363.—Echinococcus of the femur and tibia of a fifty-two-year-old wom- an : a, large echinococ- cus cyst. Amputatio fe- moris (Hahn). 651 INJURIES AND SURGICAL DISEASES OF BONE. of nineteen patients with echinococcus of the extremities only four died. The treatment consists in as complete a removal as possible of the cyst as well as of the diseased bone, or, when this cannot be done, in in- cision, with destruc- tion of the mem- brane by means of the sharp spoon, Paquelin thermo- cautery, etc. In the case of the ex- tremities, amputa- tion or disarticula- tion will often be necessary. Of the thirty-six cases of echinococcus of bone collected by Reszey and Hahn, twenty were ope- rated upon, and of these fourteen were cured (two by incision, twelve by amputation). At all events the treatment should be as energetic as possible so as to prevent recurrences. Echinococcus in Joints.—Occasionally, as we have remarked before, an echinococcus of bone breaks through into the neighbouring joint (Fischer found ten such cases in literature); but it is extremely rare for the parasite to lodge primarily in the joints. Of the above-mentioned ten cases, eight affected the hip joint, one the knee, and one an inter- phalangeal joint. Of echinococcus cysts of the pelvic bones with per- foration into the hip joint, only one case has been cured by operation (Bardeleben). The treatment of this affection of the joints demands very energetic procedures (resection, or even amputation). Fig. 364.—Echinococcus of the pelvic bones on the right side, with well-marked resorption of the bones of the pelvis and head of the femur of a twenty-five-year-old peasant woman (Viertel). CHAPTER IV. INJURIES AND DISEASES OF JOINTS. Review of the anatomy of joints.—The acute inflammations of joints: Arthritis or syno- vitis serosa, sero-fibrinosa. and purulenta.—The acute polyarticular rheumatism.— The secondary inflammations of joints occurring in the course of acute infectious diseases (metastatic inflammations of joints).—Gonorrhoeal arthrites.—The acute arthrites occurring in the course of syphilis.—Arthritis urica (gout).—Gout of lead poisoning.—Treatment of acute inflammations of joints.—The chronic inflamma- tions of joints: Hydarthros chronicus.—Chronic articular rheumatism.—Chronic suppuration of joints. — The fungous (tubercular) arthrites, joint caries. — The syphilitic arthrites.—Arthritis deformans.—Diseases of joints in bleeders (hemo- philia).—Joint bodies.—articular neuralgias, articular neuroses (hysterical joint affec- tions).—Neuropathic inflammations of bones and joints.—Anchyloses.—Deformi- ties of joints (contractures). — Echinococcus in the joints (see page 654). — The injuries of joints: Subcutaneous injuries (contusions, sprains).—Dislocations (luxa- tions) of joints.—Wounds of joints.—Appendix: Gunshot wounds.—Remarks upon military surgery. § 112. Review of the Anatomy of the Joints.—It is well known that the cavities of the joints of the cartilaginous skeleton of the foetus are made by7 dehiscence, or softening and liquefaction of the formative tissue remaining between the cartilaginous layers. They develop later than the ligaments of the capsule, which, as processes of the perichon- drium, stretch across the space lying between the ends of the cartilages. The articulations between the bones are commonly divided into two classes: the synarthroses and the diarthroses. The synarthroses are characterised by having a cartilaginous or fibrous layer interposed be- tween the bone surfaces, which is connected to the periosteum, the latter extending from one bone to the other. In the diarthroses the continuity is completely interrupted, and they are provided with a loose capsule, which is generally strengthened by accessory ligaments. The inner surface of the capsule of a joint, or the so-called synovial membrane, is covered usually by a single layer of endothelium, which, as my investigations show, very often extends over the synovial fringes and interarticular ligaments as far as they lie free in the cavity of the joint, but under normal conditions does not, as a rule, cover the point of orio-in of the synovial membrane at the articular cartilage. In the (655) 656 INJURIES AND DISEASES OF JOINTS. foetus the cartilage is ordinarily partially covered by endothelium, and after birth, if a joint remains quiet for any length of time, the endo- thelium will grow over por- tions of the articular carti- lages and other parts of the joint which present free sur- faces. On the inside of the synovial membrane there are found thread-like out- growths, the synovial villi (Figs. 365, 366), which can be seen especially well as floating structures when a joint like the knee is opened under water. Some of the villi contain vessels (Fig. 366), others do not ; and some of them are single filaments, while others are branched and are provided with daughter villi. According to the na- ture of the tissue, cartilage villi, fibrous villi, fat villi and mucous villi can be distinguished, while between these individual kinds there are Fig. 365. -Synovial villi (knee-joint). acid, x 30. Gl\ cerin-osmic- Fig. 366.—Vascular synovial villi. Five per cent, bichromate of potassium. Knee-joint of man. x 30. §112.] REVIEW OF THE ANATOMY OF THE JOINTS. 657 numerous transition forms. Cartilage cells are very often found in the fibrous villi. Fig. 367.—Lymphatics of the synovial membrane (knee-joint of an ox), x 20. The joint capsules are, as Fig. 367 shows, very7 richly supplied with lymph vessels—a matter of great practical importance. It is supposed that there are open communications—stomata, as they are called—between the lymph channels and the joint cavity on the inner surface of the articular capsule, as there are in other serous membranes; but as yet I believe no one has been able to demonstrate them. The hyaline cartilage is only apparently ho- mogeneous. As I was the first to show (Archiv fur Anat. und Phys., 1877), it can be demon- strated by means of trypsin, or the prolonged action of permanganate of potassium, that hya- line cartilage is really made up of fibres which are bound together by a cement substance. The latter is dissolved by the above-mentioned materials, especially7 by the action of trypsin at a temperature of 38°' to 10° C. (lOl'l0 to 101° F.) in the incubating oven, and the fibres are then made evident (Figs. 368, 369, 370). They may have a lamellar arrangement, as in Fig. 369, or form a network, a reticulated structure (Figs. 368, 370). Through our knowledge that 42 Fig. 368.—Hyaline cartilage treated in an incubator with trypsin. Network arrangement of the fibres, x 150. 658 INJURIES AND DISEASES OF JOINTS. even hyaline cartilage is constructed of fibres, we can more readily under- stand the various changes wliich occur, for example, in the calcification Fig. 369.—Hyaline cartilage treated in an incu- Fig. 370.—Hyaline cartilage treated in a bator with trypsin. Arrangement of the hatching oven with trypsin. Network fibres in the form of lamellae, x 240. arrangement of the fibres, x 240. of the callus or in the repair of wounds of cartilage, also the fibrillation of hyaline cartilage which takes place in chronic joint disease, etc. AVe have Budge to thank for his beautiful investigations upon the circula- tory channels in cartilage. The views of authorities vary as to the origin of the synovia, but my own investigations have led me to believe that it is mainly formed by the mucous and fat villi, partly by secretion and partly by a break- ing up of their cellular elements. However, this is not the place to discuss any more fully the anatomy and physiology of joints, and I must refer the reader to the text-books on these subjects; but I have thought it wise to briefly touch upon some of the questions wliich are particularly important as regards the subject of diseases of joints. The mucous bursas are described in § 99. § 113. The Acute Inflammations of Joints.—We distinguish, accord- ing to the nature of the exudate in the acute inflammations of joints, two general classes : the serous and the suppurative arthritis. 1. The arthritis or synovitis serosa (hydrops artictdorum acutus or hydarthros acutus) is usually characterised by the presence of a cloudy, serous liquid containing a greater or less number of fine flakes of fibrin. If there is a considerable quantity of the latter present the arthritis is also called sero-fibrinosa. The other pathological changes which occur in a serous synovitis consist in a varying amount of hyper- aemia and swelling, and upon microscopical examination there are usually found here and there small focus-like collections of leucocytes or extravasations of blood. § 113.] THE ACUTE INFLAMMATIONS OF JOINTS. 659 The clinical course of a serous synovitis is briefly as follows: If we suppose, for example, that the knee joint is the one affected, it is usually swollen and feels hot, is tender to the touch, and on palpation fluctuation is plainly made out, and the patella is lifted from its normal position—it " floats." Active and passive movements of the joint are possible, but cause pain. There is either no fever at all or only a very slight amount of it. The further course of the disease is in the main dependent upon the cause, but it is ordinarily favourable, and if proper treatment is adopted recovery will very speedily ensue. Occasionally an acute serous synovitis will change into the suppurative form or into a chronic hydarthros. Not infrequently after recovery from the acute hydarthros there is a pronounced tendency to relapses. 2. The arthritis or synovitis acuta purulenta (empyema of the joint) is characterised anatomically by the formation of a purulent or fibrino-purulent exudation. It either follows a serous or sero-fibrinous inflammation or begins as such. In addition to the pure or flocculent pus which is found in the joint, there is also usually7 present a marked swelling and hyperaemia of the synovial membrane and ligaments upon which a fibrino-purulent material is deposited, sometimes containing foci of pus. Furthermore, the articular cartilages become dull in ap- pearance, and there is an even extension of the synovial membrane over their edges in the form of vascular, newly developed, delicate connect- ive tissue. The milder grades of suppurative arthritis, without deep destruction of the synovial membrane, we shall designate as catarrhal suppuration of a joint. In the cases of longer duration, or in the more severe forms of suppuration, a suppurative panarthritis develops—i. e., all portions of the joint are attacked by the suppuration, the cartilage undergoes fibrillation and here and there becomes necrotic. The sup- puration may extend to the bones and the medulla, and, after breaking through the capsule of the joint, give rise to periarticular abscesses, etc. In the worst forms of acute suppurative arthritis putrefactive changes take place, sometimes accompanied by a marked evolution of gas. Sup- purative inflammation of a joint may terminate in a restitutio ad in- tegrum, in recovery with partial or total stiifness of the joint (anchylo- sis), or in death. The clinical course of an acute suppurative inflammation of a joint like the knee, is characterised by severe pain, by high fever, which often begins suddenly with a chill, by great swelling, and by pronounced disturbance of function. The knee is usually slightly flexed, and the least attempt at passive motion causes the most intense pain. The skin generally feels very hot, and is reddened. At the outset fluctuation is ordinarily not present, but becomes capable of 660 INJURIES AND DISEASES OF JOINTS. detection as the amount of pus increases. A characteristic feature of suppuration of a joint is the oedematous swelling of the parts surround- ing it or of the entire extremity. The subsequent course of the dis- ease depends upon the nature of the infection, and especially upon whether the suppurative arthritis receives early antiseptic treatment. If the joint is opened and drained antiseptically at an early stage, recovery with a movable joint may still be obtained; and even in neglected cases a restitutio ad integrum is possible with the help of antiseptics. In other instances the acute suppuration becomes chronic. Very often recovery takes place with more or less stiffness, or with partial or complete obliteration of the joint. When the joint is ob- literated the granulation tissue which is present changes into cica- tricial tissue—i. e., a cicatricial connective-tissue anchylosis develops, though sometimes the stiffness is due to bony union of the articular ends of the bones (anchylosis ossica ; see § 118, Anchylosis). The worst cases terminate in death from pyaemia or septicaemia, the latter coming on with great rapidity in the case of putrefaction of a joint, unless operative measures are very speedily and energetically adopted. Suppuration of joints in arthropathies is described in § 117, and the spontaneous dislocations which occur in acute inflammations of joints in § 122 (Luxations). The contractures which take place in the course of acute joint dis- eases are mainly reflex in their nature (see pages 549 and 551). The Primary Acute Suppurative Synovitis of Small Children.—Krausc has recently described a primary acute suppurative synovitis of small children on the basis of observations made in Volkmann's clinic. Tiie affection occurs not infrequently in the form of catarrhal suppurative arthritis in children from one to four years of age, is always non-articu- lar, and attacks most commonly the shoulder, ankle, elbow, and hip joints. The course is very acute, and is accompanied by the symp- toms of a phlegmon ; but after freely opening the joint recovery usu- ally takes place rapidly without disturbance of function. Satisfactory results are often obtained even in the cases where the pus has spon- taneously ruptured externally, and in neglected cases. Not infre- quently spontaneous luxations occur. Krause found the streptococcus pyogenes in the pus. Sometimes suppurative inflammations of joints are observed during early childhood in conjunction with injuries or the acute exanthemata; they are generally caused by the staphylo- coccus pyogenes aureus or albus, and have a pronounced pyaemic character. Synovitis Crouposa.—Many authorities, including Bonnet, have recog- nised, in addition to the serous and suppurative synovitis, a croupous §113.] THE ACUTE INFLAMMATIONS OF JOINTS. 661 synovitis wliich is analogous to the croupous inflammation of mucous membranes. In the croupous synovitis there are found in the cavity of the joint large amounts of coagulated fibrin; the affected joints are very painful, but only slightly swollen, and fluctuation is absent. The course of this more or less dry arthritis is unfavourable, inasmuch as the joint becomes obliterated in the majority of instances, and firm anchylosis results. As a matter of fact, there are inflammations of joints which run a very dry course; but Volkmann considers it ques- tionable whether in these cases there is really a croupous inflammation of the joint. Etiology of Acute Inflammations of Joints.—The causes of acute pri- mary inflammations of joints are in the main traumatic, and are chiefly to be ascribed to infection of some injury by micro-organisms. Every suppurative arthritis is due to the presence of bacteria. In the case of a serous synovitis, however, taking cold cannot be left out of ac- count as a primary or exciting cause. Primary acute inflammations of joints very often originate secondarily—i. e., they are either the result of disease of the adjoining tissues, such as the medulla, perios- teum, etc., or they are the local expression of a general systemic in- fection—in other words, they7 are metastatic inflammations which gen- erally develop simultaneously in several joints. In the latter category belong, for example, the inflammations of joints occurring in the course of pyaemia, typhoid fever, the acute exanthemata, and of pneumonia in consequence of infection by Frankel's pneumococcus, also polyarticu- lar rheumatism, arthritis urica (gout), gonorrhoeal rheumatism, the in- flammations of joints arising in the course of syphilis, chronic lead poi- soninor, etc. We must refer the reader to the text-books on internal medicine for the description of acute polyarticular rheumatism. It will suffice to say here that the entire course of this disease suggests an in- fection by micro-organisms with localisation in the joints and other se- rous cavities (the endocardium, for example). The inflammation of the joints is generally serous, but it may occasionally be suppurative in its nature. A. Monti found the diplococcus pneumoniae of Frankel and Weichselbaum in the pus of acute articular rheumatism. At all events there are many different kinds of micro-organisms concerned in the so- called acute polyarticular rheumatism. The Secondary Inflammations of Joints which Occur in the Course of Acute Infectious Diseases (Pyaemia, Acute Exanthemata, etc.).—The in- flammations of joints which occur in the course of acute infectious dis- eases (pyaemia, erysipelas, puerperal fever, measles, scarlatina, small-pox, typhoid fever, diphtheria, pneumonia, mumps, glanders, dysentery, etc.) are mostly of the suppurative variety, and the bacterial forms which are 662 INJURIES AND DISEASES OF JOINTS. characteristic of the primary disease are usually found in the exudate contained in the joint. In the case of pneumonia the suppurative ar- thritis following infection by Frankel's pneumococcus may develop be- fore or after the pneumonia itself. The pyaemic inflammations of joints run the course of an acute suppurative catarrh or of an acute pyaemic gangrenous arthritis, and the disease is almost always multiple. If the patient recovers from the pyaemia the inflammation of the joints will ordinarily subside with great rapidity, and not infrequently the joints will regain perfect motion where one would expect stiffness. Other cases run a very chronic course, like cold abscesses. The inflammations of joints which occur in the course of the acute ex- anthemata (scarlatina, measles, small-pox, typhoid fever, diphtheria, dys- entery, etc.) present the picture either of acute polyarticular rheuma- tism or of suppurative pyaemic arthritis. During convalescence from the acute infectious diseases, however, we meet with pronounced, se- rous, monarticular exudations into the joints which only cause a slight amount of pain ; this is particularly apt to happen in typhoid fever. O. Witzel has recently called attention to the frequent occurrence of inflammations of bones and joints during acute infectious diseases.* Suppuration in Neuropathic Bone and Joint Disease.—Suppuration in neuropathic bone and joint disease is discussed in § 117. The analgesia which is the result of disease of the spinal cord (tabes, syringomyelia. etc.) and peripheral nerves is an important etiological factor in the pro- duction of this kind of suppurative arthritis, for the reason that the pa- tients, in consequence of the absence of their sense of pain, neglect inju- ries which they receive, and this allows suppurative infection to take place. Gonorrhoeal Arthritis.—Great interest also attaches to the gonor- rhoeal inflammations of joints—gonorrhoeal gout or rheumatism, as it is called. This form of arthritis is rendered thoroughly intelligible to us since we know that the specific catarrh of the urethra is excited by the gonococcus first described by Neisser. Petrone, Bornemann and others maintain that, as a result of the systemic infection which may occur from a gonorrhoea, not only the joints may become diseased, but also the ten- dons and tendon sheaths, the mucous bursae, the nerves, the eyes, the endocardium and pericardium, etc. This gonorrhoeal inflammation attacks by preference the knee joint, though the affection often occurs in a multiple form involving several joints, and as a rule is serous or sero-fibrinous, very rarely7 suppurative, in its nature. Quite often there is a very considerable exudation into the joint. In three hundred * Bonn, Max Cohen & Son, 1890, p. 146. 113.] THE ACUTE INFLAMMATIONS OF JOINTS. 663 and eight cases Nolan states that the knee was affected eighty-six times, the ankle fifty-two, the shoulder twenty-nine, the wrist twenty-six, the hip fifteen, the fingers and toes seventeen, etc. Out of one hundred and eighteen cases, only twenty-three were monarticular, and in fifteen cases many joints were involved. The course of gonorrhoeal rheuma- tism in the majority of instances is favourable, and after the joint has been punctured once or twice the effusion disappears entirely, but re- currences of the affection are rather common. There are also cases which run a very chronic course, like tumor albus or arthritis deform- ans, and occasionally we encounter cases which are very malignant and rapidly pass on to suppuration. In these, as a rule, there is a mixed infection, and the cocci of suppuration will generally be found in the pus. But it is sometimes impossible, as Guyon, Janet and others have remarked, to demonstrate the presence of gonococci (see Special Sur- gery) even in a typical gonorrhoeal rheumatism which does not suppu- rate. Bornemann maintains that gonorrhoeal rheumatism should be looked upon as an ordinary infectious-wound disease due to an invasion of staphylococci and streptococci. The typical form of the disease gen- erally makes its appearance during the first month which follows the gonorrhoea ; according to Nolan, it developed sixty-four times within this period, eleven times in the course of the second month after the urethritis broke out, and twelve times after a still longer interval. The Acute Inflammations of Joints which occur in the Course of Syphi- lis.—In the course of syphilis there are likewise observed monarticular and polyarticular inflammations of joints which are like a monarticular hydarthros of the knee, or, when polyarticular, like acute rheumatism. The chronic syphilitic inflammations of joints are discussed in § 114. Gout (Arthritis Urica).—Gout is an expression of the uric-acid dys- crasia. The blood contains an excess of the salts of uric acid, which are deposited especially in the articular cartilage (Fig. 371), the capsule, the liga- ments, and in the parts surrounding the joints. Erbstein, to whose pains- taking study of gout we are greatly indebted, has produced the disease ex- perimentally in cocks by tying off the ureters and destroying the secreting parenchymatous portion of the kidneys. This very painful inflammation occurs in the form of paroxysms, and most Fig. 371.—Deposition of needle-shaped crystals of urate of sodium in the articular cartilage in a case of gout. x 250. 664 INJURIES AND DISEASES OF JOINTS. commonly attacks the joints of the toes (podagra), less often those of the fingers or wrists (chiragra), for the reason that disturbances of cir- culation more readily take place in the terminal parts of the body. Arthritis urica is mainly a disease of the higher classes, and is more common in England than on the Continent, making its appearance at the earliest about the thirtieth to the thirty-fifth year of life. Gout begins with a serous effusion into the affected joint, which is very apt to be the one between the metatarsus and first phalanx of the great toe. Then follows the deposition in and around the joint of crystals consist- ing of urate of sodium and compounds of uric acid with calcium, mag- nesium, ammonia, and hippuric acid. The skin is very much reddened, and is exceedingly tender upon the slightest pressure. Usually a com- plete restitutio ad integrum ensues, but inasmuch as the attacks are frequently repeated, deforming inflammations of the joints may eventu- ally develop, which consist in a fibrillation and abrasion of the cartilage, thickening of the eynovial membrane, periarticular tissues, etc. There is also a formation of circumscribed nodules, gout nodes (tophi) as they are called, containing chalky deposits. Furthermore, patients with gout suffer from progressive degenerative changes in the internal organs, especially in the kidneys and walls of the vessels (atheroma of the ves- sels). The post-mortem examination of individuals who have had this disease reveals with remarkable frequency pulmonary emphysema and chronic interstitial nephritis; also calcification and degeneration of the valves of the heart, particularly those of the aorta, apoplexies of the brain in consequence of atheroma of the walls of the vessels, etc. Acute inflammations of joints occurring in attacks and presenting a clinical picture which is like arthritis urica, are also sometimes observed in the course of chronic lead poisoning. The Diagnosis of Acute Inflammation of a Joint.—The diagnosis of acute arthritis can in the majority of instances be made with ease from the description given above. In making the examination the diseased side should always be compared with the healthy one. Any exudate which may be contained in the joint adapts itself to the form of the latter. A test puncture with a hypodermic needle—which, of course, must be carried out with every antiseptic precaution—will give accurate information as to the nature of the exudate in the joint, whether it is serous or purulent. For the rest, I must refer the reader to what we have said as regards diagnosis in the chapter on Inflammation (see pages 251-252). The Treatment of Acute Inflammation of a Joint.—The treatment of acute serous synovitis, acute hydarthros, consists, at the outset, in main- taining the part in a quiet (elevated) position, possibly with the aid of §113.] THE ACUTE INFLAMMATIONS OF JOINTS. 665 splints, and in the application of ice. As soon as the inflammatory manifestations, especially the pain, have subsided, the serous exudate which may be present should be caused to disappear by compression with elastic bandages—the ordinary rubber bandage, for example—and by massage practised once or twice daily, and the patient then per- mitted to walk about. The treatment by rest should not be continued too long a time in acute hydarthros, for the reason that the affection may then easily take on a chronic character. If the effusion is under great tension, if absorption is delayed, or if the hydrops has become chronic, the joint should be punctured aseptic- ally. The area of skin over the joint is carefully scrubbed with soap, shaved, and washed with a five-per-cent. solution of carbolic acid or a one-tenth-per cent, solution of bichloride of mercury. The effusion in the joint is then compressed with the left hand, and the joint opened with a trocar which has been sterilised by boiling it for five to ten min- utes in a one-per-cent. solution of soda (see page 69, Fig. 50), or by heating it red-hot, or with a large hollow needle of an aspirator simi- larly sterilised, or simply by puncture or incision with the knife. After the exudate has been evacuated the joint can be washed out with a three-per-cent. solution of carbolic or a one-tenth-per-cent. solution of bichloride. In pure serous effusions I usually avoid this washing out, but perform the operation if the effusion is sero-fibrinous and contains a slight amount of pus. After puncturing it the joint is immobilised by splints and an antiseptic dressing which exerts pressure. The aseptic puncture of a joint with the trocar, aspirator, or knife is entirely devoid of danger if the rules of asepsis are carefully observed and if pains are taken to prevent the entrance of air into the joint—in short, if the operation is performed with the utmost possible caution. Schede, in particular, has obtained satisfactory results by antiseptic puncture and washing out the joints in hydrops, haemarthros, etc. Treatment of Acute Suppurative Arthritis.—If there is pronounced suppuration in a joint, aseptic puncture followed by irrigation of the joint with a three-per-cent. carbolic or one-tenth-per-cent. bichloride solution may be practised in those cases in which the suppuration is still in its inception; but if the suppuration is well marked and there is high fever, the joint must be immediately opened by a free incision and drained (§ 31), and, if necessary, resection of the joint (§ 40) must be performed. If the test puncture (with the hypodermic needle) reveals acute suppuration, the expectant treatment by elevation, ice, and immo- bilising dressings, which used to be employed, should be discarded, and operative treatment by incision and drainage or resection should be straightway adopted in its place. Ubi pus ibi evacua! After the 666 INJURIES AND DISEASES OF JOINTS. « operation the joint is placed in a suitable position and carefully immo- bilised by splints and antiseptic dressings. When the arthritis is sup- purative a careful examination should always be made to determine whether periarticular collections of pus are present. In cases where the suppuration is severe, permanent antiseptic irrigation should be used (page 17S). In the worst forms of suppurative arthritis with putrefactive changes it is often necessary to perform an amputation in order to save the patient's life. If after suppuration of a joint recov- ery takes place, with motion in the latter, we improve the motility as much as possible, after the inflammation has completely subsided, by passive motion, massage, and electricity. If recovery takes place with anchylosis, the joint must be made to assume a position which will be as useful as possible for the patient. The ankle and the elbow, for example, should be kept in a right-angled position, but the other joints must be extended. The treatment of the secondary, metastatic inflammations of joints is precisely the same as for those which are primary. If many joints are attacked by suppuration, and there is a severe or hopeless constitu- tional disease, one would probably relinquish all idea of adopting ener- getic operative measures, and simply provide an escape for the pus by incision and drainage, and alleviate any pain which the patient may suffer. Treatment of Acute Polyarticular Rheumatism.—Acute polyarticular rheumatism is treated by immobilisation of the joints with splints of wood, pasteboard (see page 223), or water-glass; by placing the limb in an elevated position, and by administering internally diaphoretics and diuretics, particularly salicylic acid or salicylate of sodium (3-0 to 6-0 grammes pro die). I ordinarily give to adults four to six grammes of salicylate of sodium in wafers or a mucilaginous mixture (with aq. dest. and mucilag. gummi mimos., aa 50*0 grammes) about every two to three hours. If 0*50 to TO gramme of salicylic acid are given in wafers, or the above-described mixture, one should not neglect to make the patient drink a glass of water after each dose, as otherwise the stomach may easily become disordered. I must refer the reader to the text-books on internal medicine for the rest of the treatment of acute polyarticular rheumatism, including any cardiac complications which may arise. Treatment of Gout.—The local treatment of gout consists in allevi- ating the pain by placing the part in a proper (elevated) position and in enclosing the inflamed joint in cotton, so as to exert pressure. The joint in question is painted over with fat or vaseline and enveloped with dry cotton, or a hydropathic dressing is applied around it. Lithium, §114.] THE CHRONIC INFLAMMATIONS OF JOINTS. 667 salicylate of sodium, etc., are given internally7. Diaphoretic remedies are supposed to shorten the attacks. The patient is put upon a light diet, and Moselle wine with seltzer, or some such beverage, is given him to drink. The morbid diathesis is treated by a moderation in the patient's mode of living, especially as regards alcohol, by a meat diet, which must not be too excessive, and by the use of Carlsbad, Kissin- gen, Marienbad, Wiesbaden, Levico, Vichy, and other saline-spring waters; the hot baths of Gastein, Teplitz, Wiesbaden, etc., are also worthy of recommendation. Treatment of Gonorrhoeal Rheumatism.—The milder cases of gonor- rhosal inflammations of joints are treated by rest in bed, by ice, by immobilising dressings, and by a simple diet. Internally we occasion- ally give four to six grammes of salicylate of sodium pro die. In the case of large effusions puncture and antiseptic irrigation of the joint, as described above, should not be too long delayed. In the rare in- stances of suppuration of the joint the rules given on page 665 should be followed. For gonorrhoeal rheumatism Vogt recommends the in- jection of a bichloride-of-mercury solution into the joint (O'l gramme bichloride, 1"0 gramme sod. chlor., and aq. destil. 50"0 cubic centime- tres ; three to five hypodermic syringes to be injected into the joint each time at intervals of three days). Konig praises injections of a five-per-cent. carbolic-acid solution. During the acute inflammatory stage of the arthritis the treatment of the gonorrhoea which is present should be deferred, but later, under all circumstances, it must be cured as soon as possible (see Special Surgery). After the inflammation of the joint has subsided it will often be advantageous to wear an elastic bandage, and a splint apparatus may7 possibly be necessary, particularly in the case of the knee, if the latter has been inflamed for some time. I do not think that massage should be used after the subsidence of a gonorrhoeal arthritis, for the reason that recurrences of the affection may thus be lighted up, the micro-organisms being again introduced into the circulation and carried off to other portions of the body. I have seen very satisfactory and permanent cures brought about in pro- tracted and malignant cases by a residence in southern climates— Riviera, Sicily, Egypt, Tunis. The symptomatology and treatment of the acute inflammations of individual joints is described in the Text-Book on Special Surgery. § 111. The Chronic Inflammations of Joints.—The chronic inflamma- tions of joints are divided, according to differences in pathology, into two main groups, namely, the dry (arthritis sicca) and the exudative inflammations of joints (arthritis exudativa, with or without a forma- tion of new tissue or of granulations). The subject of chronic arthritis 668 INJURIES AND DISEASES OF JOINTS. is of very great practical importance, and, among others, Billroth, Bonnet, Volkmann, Oilier, C. Hueter and Konig have done much to advance our knowledge of it. I. Arthritis, or Synovitis Chronica Serosa (Hydarthros, Chronic Hydrops of a Joint, Chronic Dropsy of a Joint).—Hydarthros, or chronic articular hydrops, either begins very gradually as such, or it follows an acute serous synovitis. The pathological changes which occur in a synovitis chronica serosa (hydarthros) are essentially as follows : The fluid which collects in the joint is either thin and watery7, or it is thick, gelatinous, or colloid. The exudate is sometimes remarkably rich in endothelium (Volkmann's endothelial catarrh). The secondary changes in the cartilage and cap- sule of the joint are usually slight; but after the process has lasted a long time the synovial membrane becomes thickened, the villi are increased in size and numbers, t\e joint cartilage becomes thickened and fibrillated, and the symovial membrane grows over the free sur- faces of the cartilage (Hueter's synovitis hyperplastica laevis or pannosa). The synovial membrane occasionally projects through the stretched external fibres of the capsule in the form of a symovial hernia. After the hydarthros has existed a long time the ligaments and capsules of the joint become stretched, sometimes to such a degree that the joint loses its normal firmness and becomes flail-like, and displacements, sub- luxations, or complete luxations of the articular ends of the bones fol- low. If a rupture of the capsule of the joint takes place spontaneously, or as a result of a traumatism, a periarticular effusion will make its ap- pearance. The neighbouring mucous bursae which communicate with the joint are often similarly diseased. The causes of hydarthros are traumatisms (contusions and sprains), infection, such as syphilis or gonorrhoea, taking cold, and the presence of loose bodies in the joint. The symptoms are in the main the same as those of an acute serous arthritis, with the single difference that inflammatory manifestations are usually absent. Hydarthros, or chronic serous synovitis, most commonly occurs in the knee, and in this situation the effusion into the joint can best be demonstrated by placing the leg in the extended position. Very often, if the affected joint is moved, a creaking and rubbing can be felt and heard, and is mainly caused by a thickening of the synovial membrane, by hypertrophy of the villi, together with an increase in their number, and by fibrillation of the cartilage, or by the formation of loose joint bodies. The tendency to the formation of free joint bodies (see § 115) in hydarthros occasionally exists in a marked degree. The course of chronic serous svnovitis or hydarthros § 114] THE CHRONIC INFLAMMATIONS OF JOINTS. 669 is generally favourable if the disease receives proper treatment, and only in rare instances do we meet with the above-mentioned deforming changes in the synovial membrane, the articular cartilages, or in the entire articular apparatus. The best treatment for chronic serous synovitis consists in the use of massage (see page 505) and of compression of the effusion by means of rubber or elastic bandages. It is of the utmost importance that the patient should not protect his joint—should not keep it quiet—but rather should use it industriously. If this does not bring about a cure and cause the effusion to disappear, the latter should be removed in the manner described above, by aseptic puncture, with or without a subsequent washing out of the joint with a three-per-cent. solution of carbolic acid or with a one-tenth-per-cent. solution of bichloride of mercury. After the puncture the joint must of course be immobilised in a suitable (elevated) position during the next few days by an anti- septic dressing applied so as to exert pressure. If the reaction follow- ing the irrigation is too severe, it should be combated with ice. As a general thing, simple evacuation of the effusion by puncture, without antiseptic irrigation, will suffice in the majority of cases of hydarthros. A few days after removing the effusion the joint should be massaged and vigorously moved, and from time to time enveloped in an elastic bandage. Any recurrences which may take place can be speedily cured by massage, elastic compression, and movement of the joint. The treatment at one time much in vogue, by irritation of the skin (tinct. of iodine) and by the administration of internal remedies (tartar, stibiat,), has very properly been abandoned, and keeping the joint quiet is actually7 injurious. I never make use of the injection of tincture of iodine into the joint—a procedure by no means devoid of danger. II. Chronic Articular Rheumatism (Bheumatismus Chronicus Ar- ticulorum, Polyarthritis Rheumatica Chronica).—By chronic articular rheumatism we understand an inflammation of the synovial membrane running an exceedingly slow course, which occurs almost exclusively in adults, generally after the thirtieth to the fortieth year, and always attacks several joints. There is generally a gradually increasing dis- turbance in the function of the joints, which ordinarily in the end leads to complete stiffness or anchylosis of the joint. The anatomical changes which occur in chronic articular rheu- matism consist essentially in a chronic inflammatory formation of new connective tissue in the synovial membrane and surrounding parts which have a tendency to shrink and become hard and dense, in a fibrillation of the cartilage, and in a substitution for the latter of vascu- 670 INJURIES AND DISEASES OF JOINTS. lar connective tissue. The connective-tissue metaplasia of the cartilage is brought about mainly by growth on the part of the synovial mem- brane, though it is very largely promoted by the increased formation of medullary spaces in the deeper layers of cartilage, and by inflamma- tory changes with a formation of new vessels in the subchondral medulla. As the new formation of connective tissue increases, the cavity of the joint grows steadily smaller. The stiffness of the joint, the anchylosis, is at the outset due to connective-tissue adhesions which may eventually ossify, the process spreading from the spongiosa until the entire joint may become filled with bone. Chronic articular rheu- matism never leads to suppuration, and never to true caries, the patho- logical changes presenting more of a similarity to arthritis deformans, except that in the latter disease there is more an increased growth of cartilage, while in the former the cartilage is replaced by vascular con- nective tissue. But deformities of the joints, subluxations and luxa- tions develop in chronic articular rheumatism as they do in arthritis deformans. Chronic articular rheumatism either follows an acute rheumatism, or it begins insidiously as a chronic disease which lasts many years, and is very frequently—in fact, as a rule—incurable. Gradually many different joints become affected, and, in rare instances, all the joints of the body7. The disease is most common in the lower walks of life, and hence the name arthritis pauperum. The causes wliich are given for it are particularly taking cold, getting wet through, damp dwell- ings, etc. It is observed almost exclusively in adults; and only in exceptional instances are severe cases with deformities of the joints, resembling arthritis deformans, met with during childhood (Wagner). As in acute rheumatism, it is still uncertain as to how much of a part is played by micro-organisms in the production of the chronic poly- articular rheumatism. The subjective symptoms consist in sharp, severe pains felt now in this and now in that joint. The movements of the joints, particularly in the morning, after the night's rest, are limited and cause pain; but during the day, after the patient has used his limbs somewhat, the mobility of the joints improves. In other instances the joints are so painful that no movements at all can be performed. The joints are usually somewhat swollen; and in many cases—i. e., in the so-called fungous form of articular rheumatism—the growth of connective tissue is so considerable that the joints present the appearance of tumor albus. If the joints are moved, a creaking or crackling friction sound, due to the newly formed connective tissue and to the fibrillation of the cartilage, can very frequently be made out. As a rule, subacute §114] THE CHRONIC INFLAMMATIONS OF JOINTS. 671 exacerbations of the subjective and objective symptoms take place at irregular intervals, the joints become steadily stiffer, and the muscles atrophy more and more, so that these pitiable individuals grow con- stantly more helpless, and death often occurs from general marasmus or some intercurrent disease. In other cases the disease gets well with partial or total anchylosis of the affected joints. I saw a divinity student who had complete anchylosis of both hips, both knees, the right elbow, and the left wrist; and Percy found anchylosis of all the joints of the body in a French officer who died in his fiftieth year. The skeleton of this officer, who had suffered from chronic articular rheumatism contracted in his campaigns, has been preserved in the Ecole de Medecine, and forms, to all appearances, a single piece of bone. The diagnosis of chronic polyarticular rheumatism can, in all probability, be readily7 made from what has been said above ; but the milder cases are often difficult to differentiate from gout and arthritis deformans. We have also made the prognosis sufficiently clear. The treatment of chronic polyarticular rheumatism generally de- mands a great deal of patience, and even then, I am sorry to say, is often entirely unsuccessful. In cases which are not of long standing, massage and methodical exercise of the joints should be tried in com- bination with hydrotherapy (baths, steaming, douches, etc.). The joint should not be kept quiet in the early stages of a chronic rheumatism. If massage and movement of the joint are too painful, they must be carried out occasionally under chloroform anaesthesia. I have seen very satisfactory and permanent cures obtained by this treatment in cases which had not existed too long a time. Furthermore, the use of hot springs, such as Gastein, Teplitz, Wiesbaden, Wildbad, and Eagatz- Pfaffers, and a residence in warm climates, are very valuable. Volk- mann recommends the internal administration of cod-liver oil and iron, and iodide of potash or vinum semin. colchici. The use from time to time of salicylic acid or salicylate of sodium is exceedingly serviceable. But often on account of the severe pain massage cannot be carried out, or the joints may already have undergone too extensive changes. In such cases, which are generally of long standing, we are often com- pelled to confine ourselves to orthopaedic treatment, placing the dis- eased joints in a good position, under chloroform anaesthesia, and immobilising them by plaster-of-Paris splints. As a result of the rest given the joints by the plaster of Paris, the pain ordinarily becomes less, but at the same time the occurrence of anchylosis is favoured. After having kept the diseased joints quiet by splints for a long time, 072 INJURIES AND DISEASES OF JOINTS. it has been my experience that all hopes of the possibility of obtaining a cure with a movable joint must generally be given up, and a recovery with anchylosis be striven for. Sonnenburg has recently obtained very surprising success in chronic articular rheumatism by laying the joint widely open (arthrotomy) and then washing it out antiseptically and packing the cavity with iodoform gauze. Schuller recommends injec- tions of a sterilised two-per-cent. boro-salicylic solution or a three- to five-per-cent. iodoform-glycerin solution ; but in the severe chronic cases he also advises operative treatment, such as arthrectomy (see page 129). I have not seen any success from intra-articular injections in chronic rheumatism, but I believe, with Sonnenburg and Schuller, that chronic articular rheumatism in its later stages, especially if there is great pain, should receive operative treatment more frequently and earlier than it ordinarily does. Sonnenburg's method of freely open- ing the joint, washing it out antiseptically and packing it with iodoform gauze will generally suffice, though if the disease is severe arthrectomy may be indicated. III. Chronic Suppuration of Joints.—Every suppuration of a joint is the result of infection by micro-organisms. The infection takes place in conjunction with a traumatism, for example, or by way of the cir- culation, or in consequence of the extension to the joint of a suppura- tive inflammation in the surrounding parts (medulla, periosteum, soft parts). In chronic suppuration of a joint the synovial membrane is usually the seat of an inflammatory infiltration and is covered with fibro-purulent masses, the cartilage is cloudy and fibrillated, and losses of substance develop in it (cartilage ulcers); occasionally large portions of the cartilage necrose and separate from the underlying parts, or the cartilage is completely destroyed. The suppuration very often spreads to the medulla, the periosteum, and the periarticular tissues. The joint becomes more or less altered according to the severity and duration of the suppuration, and in pronounced cases which have existed for a long time fibrous or bony anchylosis usually develops when recovery takes place, as we remarked before in discussing the subject of acute suppurative arthritis. We shall first take up that form of chronic suppuration of joints which is due to tuberculosis. IV. The Chronic Fungous and Suppurative (Tubercular) Inflammations of Joints—Tuberculosis of Joints—Tumor Albus—Tubercular Caries of Joints—Fungus of Joints.—All these terms indicate one and the same disease, viz., tuberculosis of joints or tubercular arthritis. Tubercular arthritis is generally a secondary inflammation—i. e., it originates most commonly in conjunction with a tubercular focus in §114.] THE CHRONIC INFLAMMATIONS OF JOINTS. 673 the medulla (in the epiphyses of the long bones, for example, or in the periosteum); less frequently the tuberculosis is primary in the joint. Primary tuberculosis of a joint may begin in any part of it, particu- larly in the bone and synovial membrane; but, as far as I know, no case of primary tuberculosis has hitherto been observed which origi- nated in the ground substance of the cartilage. Muller's statistics, ob- tained from Konig's clinic, show that in two hundred and thirty-two cases of tubercular arthritis one hundred and fifty-eight started in the bones, forty-six in the synovial membrane, and in twenty-eight cases the point of origin was uncertain. We remarked on page 610 that the anatomical structure of the medulla is especially favourable to a deposition from the blood of the tubercle bacilli, and we likewise em- phasised the fact that tubercular arthritis develops very often after the reception of some traumatism. The general subject of tuberculosis and of tuberculosis of bone is described in § 83 and § 105, and there- fore we shall confine ourselves here to the presentation of the tubercu- losis which is peculiar to joints. The Pathological Changes which Occur in Tubercular Arthritis.—The pathological changes which occur when a joint is infected by tubercle bacilli, no matter whether the infection is primary in the joint or secondary to similar disease in the medulla, periosteum, or periarticular soft parts, are as follows: The bacilli enter by one or more points of infection, and are, so to speak, planted in different parts of the joint, where they give rise to the development of tubercles which have the structure that wre described on a previous page (407). The synovial membrane undergoes inflammatory changes, and is filled with charac- teristic greyish-white nodules, and as the tuberculosis advances it is possible to distinguish three different forms of the disease, which, to be sure, merge into one another: (1) The pure miliary form, without the formation of a spongy, so-called fungous tissue, (2) the fungous form, and (3) the fibrous, with the formation of lardaceous thickenings. The fungous form of tubercular arthritis is the most common, and in it the synovial membrane becomes changed into a spongy, red granulation tissue filled with tubercles, while during the early stages the joint con- tains a serous or sero-fibrinous exudate (hydrops tuberculosus), and later on pus in which there are generally small particles of cheesy matter (cold, tubercular, suppurative arthritis). The tubercular granulation tissue in course of time grows into all parts of the joint, pushes its way over the cartilage and ligaments, and penetrates into the bone and medulla, etc.; in short, wherever the tubercular granulation tissue de- velops the original tissue is destroyed. In the case of tuberculosis of bone the portion of the latter which is affected by the disease either 43 674 INJURIES AND DISEASES OF JOINTS. necroses in toto (Fig. 372), or several isolated sequestra are formed (Fig. 373). In the caput femoris, for example, very characteristic cuneiform sequestra are frequently observed (Fig. 372) which are similar to the Fig. 372.—Larsre infarct-shaped sub- chondral tubercular focus in the head of the femur, which is in an advanced stage of demarcation ; the articular cartilage is lifted up like a pustule. Early resection, five-year-old girl. Eecovery. Fig. 373.—Tuberculosis of the neck of the femur with three sequestra. Secondary tuberculosis of the hip-joint; the cartilage of the head of the femur is destroyed. Eesection of the hip. Eight-year-old boy (Volkmann). so-called infarcts—i. e., the necrosis of tissue resulting from occlusion of the terminal, afferent arterial vessel. These infarcts have the form of a wedge which corresponds to the distribution of the terminal branches of the affected vessels. The cuneiform sequestra which are met with in tuberculosis of bone are probably due in the same way to the plugging of the terminal artery at the apex of the wedge with tu- bercle bacilli. If the tuber- culosis begins in the bone the articular cartilage either be- comes perforated like a sieve by the tubercular inflamma- tion, or it is raised from the underlying parts more or less in toto, as in Fig. 372. In the later stages large portions of articular cartilage may be Fig. 374.—So-called wandering of the acetabulum in , -, • , , £ „, xiiri coxitis (•'intraacetabuliire Luxation"). separated tn WtO trom tlie § 114.] THE CHRONIC INFLAMMATIONS OF JOINTS. 675 Fig. 375.—Tubercular kyphosis of the vertebral column (Sayre). bone, or the cartilage may be completely destroyed, as in Fig. 373. It is very fortunate for the patient if the tubercular process, for exam- ple, in the epiphysis of a long, hollow bone does not attack the joint but breaks through externally to it. This extra - articular breaking through of bone tu- berculosis in the neighbourhood of a joint is a rather common occurrence. After the tuber- cular inflammation of the joint has broken through the joint capsule there follows a develop- ment of periarticular tubercular inflammation and suppuration with extensive collections of pus—the so-called congestion, cold, or gravitation abscesses which we have spoken of in a previous chapter. Not infre- quently the extra-articular tu- bercular abscesses originate by infection through the lymph channels without a rupture of the capsule having taken place, and without the existence of any visible communi- cation between the intra- and extra-articular suppurative processes. If the lymph glands connected with the joint become infected by tuber- culosis, the danger of the tubercle bacilli being carried further—in other words, the danger of a general tuberculosis—becomes more im- minent. Very often the tubercular inflammation works its way7 out- wards through the skin spontaneously, and gives rise to fistulae which frequently pass a long distance through soft parts and bone. The destruction of tissue which takes place in tubercular arthritis, and is the result of the progressive change of bone, cartilage, and soft parts into tubercular granulation tissue, which breaks down and undergoes cheesy degeneration and suppuration, is sometimes very considerable. The entire head and neck of the femur may thus be destroyed by caries and necrosis, and not infrequently extensive ulcerative processes lead to perforation of the acetabulum. Very often the latter becomes enlarged in an upward direction, and the head of the femur, following the change in the shape of the acetabulum, is caused to assume a higher position— a phenomenon which is called " wandering of the acetabulum " (Fig. 374). In the spinal column entire vertebras may be destroyed, giving rise to corresponding deformities, especially kyphosis or Pott's hump 676 INJURIES AND DISEASES OF JOINTS. (Fig. 375). Furthermore, in tuberculosis of the vertebras, the cold, con- gestion abscesses which gradually burrow downwards may attain a considerable size ; they usually follow the course of the ilio-psoas muscle, and may eventually come to the surface in the thigh beneath Poupart's ligament. If left to itself a tubercular focus may heal up at any stage of its exist- ence. Recovery often takes place only after the joint has become completely obliterated or anchylosed, but not in- frequently the cure is only apparent and temporary. If the joint has not been immobilised in a proper position while the tubercular disease was in progress, contractures are very liable to take place ; and if these affect the knee or hip, the use of the leg may be seri- ously' interfered with or rendered im- possible (see Fig. 376). The Development of Tubercular Ar- thritis after the Injection of Tubercle Ba- cilli into the Joints of Animals.—If pure cultures of tubercle bacilli are injected into the joints of guinea-pigs there will be ob- served, after the lapse of four to six days, an increasing inflammatory swelling and exudation into the joints under consider- ation, and towards the end of the third week the presence of tubercle bacilli can be plainly made out, and pus will be found in the joints. Pawlowsky states that the tubercle bacilli are located mainly in the lymph passages and connective-tissue cells. If intravenous injections of attenuated (weakened) cultures of tubercle bacilli are practised in rabbits, the typical picture of tu- bercular disease of joints will sometimes be obtained only after four to five to six months, while the other organs will remain healthy (Courmont, L. Dor). Fig. 376.—Tubercular contracture and anchylosis of the knee of a six-year- old boy. Cuneiform resection fol- lowed by healing in the extended position. Tubercular arthritis runs an exceedingly chronic course, as a rule, and often lasts many years. The disease most commonly attacks chil- dren, though adults of all ages are not exempt from it. The joints most frequently affected are the knee, the hip, the astragalo-tibial joint, and the joints of the tarsus. Tubercular arthritis generally be- gins very gradually, but in rare instances is more or less acute in its onset. The first symptoms of tuberculosis involving the knee joint §114.] THE CHRONIC INFLAMMATIONS OF JOINTS. 677 of a child, for example, are a proneness to fatigue and a slight limp or dragging of the leg in walking, and after having been on its feet for some time; or, if pressure be made, the child will complain of pain in the joint. The first objective symptom is generally a moderate amount of swelling, which causes the furrows beside the patella to become less plainly marked than upon a healthy knee. The ini- tial symptoms manifested by joints which are more deeply placed are not so apparent as they are in the knee. As the disease progresses the swelling of the knee gradually increases, and the normal contour of the joint disappears to a greater and greater extent. The swell- ing feels rather hard, or it is more soft and spongy, and is caused either by a thickening of the synovial membrane and periarticular connective tissue, or, as in primary osseous tuberculosis, by enlarge- ment of the articular ends of the bones. The skin is ordinarily more or less tense, and presents a white, waxy appearance, which gave rise to the term tumor albus, formerly used to designate this condition. As the swelling becomes greater the pain in the joint increases, and is made worse by pressure and attempts at motion. The pain, however, is not always felt in the diseased joint, as in tubercular inflammation of the hip (coxitis), for example, the children very often complain of pain in the knee, which might lead an inexperienced person to search for the disease in the wrong place. This pain in the knee accom- panying tubercular coxitis is particularly apt to be present when there is tubercular disease of the medulla, the pain shooting through the latter down to the lower epiphysis; the phenomenon used to be looked upon as a reflex manifestation. Standing and walking eventually become im- possible, and the tubercular inflammation causes the joint to grow more and more immovable. The knee and elbow are usually flexed to a greater or less extent, and the hip assumes a position in flexion, abduc- tion, and outward rotation. At the outset the abnormal position of the joints can be corrected under chloroform anaesthesia, but later this can- not be accomplished without operative interference. The distorted positions of the joints—the contractures—may sometimes, as a result of improper treatment, become very7 excessive, as illustrated in Fig. 376 ; but contractures like this can always be easily prevented by the use of retentive dressings applied at the right time. Attempts have been made to explain this abnormal position as- sumed by inflamed joints by (1) the mechanical theory advanced by Bonnet, and (2) by the reflex theory. Bonnet demonstrated by intra- articular injection of a liquid that the joint thus treated assumes a position in which its capacity is greatest—i. e., increasing its contents forces a joint like the knee to become flexed. According to the second 678 INJURIES AND DISEASES OF JOINTS. theory, a reflex muscular contracture is produced by the irritation of the synovial membrane. Both theories are right as far as they go but by themselves are not sufficient to answer the question—a fact which Volkmann has correctly insisted upon. It must be borne in mind that the patient instinctively places his joint in a position which diminishes the pressure on the joint surfaces and causes him the least pain. More- over, the mechanical conditions connected with the use of the diseased extremity, the longitudinal growth of the bone, and subsequently the changes which take place in the shape of the articular ends of the bones, have an influence upon contractures (see pages 549 and 554). The further course of tubercular arthritis—sometimes called the second stage of the affection—is characterised by an increase of all the pre-existing symptoms, especially the swelling, fixation, and pain, and, in addition, there are very often manifestations of suppuration in the joint; in other words, a high fever develops, the joint becomes very painful at some particular point, and, finally, fluctuation can be detected. Suppuration in the joint is either accompanied by7 inflammatory mani- festations of variable intensity, or it runs its course as a cold abscess. The amount of pus which is present is by no means constant, being in some instances very considerable, while in others the formation of pus is slight, although the destruction of the articular ends of the bones may be very marked. Permanent deformities develop in consequence of these changes in the bones, as well as the so-called pathological or spontaneous dislocations. The anatomical changes which follow suppuration in a joint, the development of periarticular abscesses from rupture of the pus in the joint through the capsule or from infection through the lymphatics, the occurrence of extensive gravita- tion abscesses, etc., have all been described above. The patients' general condition is ordinarily very much altered for the worse ; they are emaciated, anaemic, without appetite, and not infre- quently have diarrhoea and more or less fever. Tubercular arthritis terminates either in recovery, or in death from systemic tubercular infection, from tuberculosis of the internal organs, especially the lungs and intestine, from increasing marasmus, from amyloid degeneration, or from some intercurrent disease. Tubercu- losis is the most common cause of death. Of one hundred and thirty- five cases of tubercular arthritis which ended fatally, Albrecht states that sixty-four were due to tuberculosis, twenty-three to marasmus, and fourteen to amyloid changes ; while in thirty-four the cause of death was unknown. Billroth maintains that the danger of pulmonary tuberculosis is greater after tubercular arthritis occurring in the upper extremity than when the disease affects the lower. §114.] THE CHRONIC INFLAMMATIONS OF JOINTS. 679 As a general thing it requires a very long time, often years, for recovery to take place spontaneously from tubercular arthritis. In such cases there is a gradual abatement of the local manifestations, the general health improves, and any fistulas which may be present close up. AVhen spontaneous recovery takes place from a pronounced tuber- cular arthritis with fistulae, the joint which has been affected always becomes stiff. If no appreciable suppuration has occurred, recovery not infrequently follows without operative interference and with per- fect motion in the joint in question. It is scarcely possible to say with certainty when joints which have been affected by tuberculosis have gotten entirely well, for relapses have taken place even after anchylosis has existed for years. AVith the modern methods of per- forming surgical operations we are able to give a more favourable prognosis, both as regards the preservation of the joint and the life of the patient. Nevertheless, the prognosis of tubercular arthritis, as Billroth has remarked, is in so far unfavourable as such individuals do not reach an advanced age. There are, for example, only compara- tively few people with anchylosis due to tuberculosis who live to be more than forty or fifty years old; and Billroth says that only the minority of children who have been operated upon for tubercular caries of a joint, and cured, attain adolescence. Treatment of Tubercular Arthritis.—The therapy of tubercular ar- thritis comprises local treatment of the diseased joint, and measures de- signed to improve the general health and render the system capable of successfully carrying on the struggle for existence with the tubercle ba- cilli. This constitutional treatment is described on pages 420 and 424 (Constitutional Treatment of Tuberculosis and Scrofula). Inasmuch as tubercular arthritis gets well, though very slowly, under proper local and constitutional treatment without operative interfer- ence, it would be entirely wrong to immediately subject every case of tuberculosis of joints to operation. Therefore, at the beginning of the tubercular arthritis, the local treatment should be directed towards se- curing absolute rest for the joint by means of hardening dressings (see § 54, plaster of Paris, water-glass), or some of the various kinds of splints (see § 53), or by permanent extension (see § 55), the latter being par- ticularly applicable for the hip. Sayre and Taylor have invented in- genious extension appliances for the lower extremity which enable the patient to w7alk about. It is also very advantageous in the case of cox- itis to place a raised sole under the foot of the sound side, and, by using crutches to walk with, thus keep in suspension the diseased leg, which should be maintained in a fixed position by Thomas's splint (see Spec. Chir. Bd. II, p. 623). Hydropathic applications or ice may also be 6S0 INJURIES AND DISEASES OF JOINTS. employed for acute or subacute exacerbations which are accompanied by pain. If contractures of the joints are already present when the case comes under observation, they must be gradually overcome by re-' tentive (see page 218) or extension dressings, often with the aid of chlo- roform anaesthesia. Great care must be taken in correcting the posi- tion of a joint which has become distorted ; it will often be impossible to remedy matters all at once, and the desired result will have to be ac- complished gradually in several sittings. Each time that the contrac- ture is improved the joint should be immediately fixed in its new posi- tion by a plaster-of-Paris dressing. Massage should never be practised at the beginning of a tubercular arthritis, as I have repeatedly seen se- vere constitutional tubercular infection caused by quacks who have pre- scribed it. Injections of sterilised ten-percent, iodoform oil or ten-per-cent. iodoform glycerin (Bruns) are exceedingly valuable at the commence- ment of the tubercular inflammation of a joint, and later on when fistulae have developed. The manner of preparing and sterilising the iodoform- oil emulsion is described on page 626. According to the age of the patient and the size of the affected joint, about every two to four weeks from two to five to ten grammes of the above mentioned mixture are injected into the joint and scattered through the latter as far as pos- sible by careful motion and gentle massage. I have seen very remark- able success obtained by these iodoform injections. Injections of car- bolic acid, of a strong solution of chloride of zinc (Lannelongue), and of arsenic (acid, arsen. 1 to 1,000, and of this one to two hypodermic syringefuls each day, combined with the internal administration of 0-004 to 0*012 gramme arsenic pro die), of iodoform ether, balsam of Peru, cinnamic acid (see page 420), etc., have also been recommended. The treatment of tubercular arthritis by Koch's tuberculin has been discussed on page 421. I have not seen any satisfactory results from its use. Bier's treatment by constriction for the purpose of causing stasis is described on page 421, and the other methods for treating tu- berculosis in § 83. It is not always an easy matter to decide whether operative meas- ures are necessary, for the simple reason that one cannot always be sure of the exact nature of the pathological changes which are present—a matter which Konig is right in calling attention to. In former times, when the antiseptic method of treating wounds was first introduced, surgeons went too far and performed resections of joints too often, par- ticularly in the case of children who suffered from tubercular arthritis. But at present conservative treatment is employed as much as possible. and many joints, which would formerly have been sacrificed by per- £114.] THE CHRONIC INFLAMMATIONS OF JOINTS. 681 forming total resection, are now saved by iodoform injections, by exci- sion of the synovial membrane, or by7 scraping away the diseased tissue. Richet, Kocher and Vincent have recommended ignipuncture or punctiform ustion made with the fistula tip of the Paquelin cautery or with the galvano-cautery. I believe that this procedure is suitable for tuberculosis of the synovial membrane which has not become too extensive; but after the fungous granulations have passed into the stage of suppuration energetic operative measures are required. The joint, after being artificially made bloodless, is opened and the diseased parts then removed with great care by means of scissors, forceps, and the sharp spoon ; but typical resection of the articular ends of the bones should be performed only in extreme cases (see § 40). If the tubercu- losis is purely of the synovial variety, and the bones are healthy, we should, of course, preserve the latter and content ourselves with exci- sion of the diseased membrane (arthrectomy). Early as well as late resection of all children's joints, with the exception of the hip, should be confined to as small a number of cases as possible; energetic scrap- ing away of the diseased bone with the sharp spoon, but sparing the epiphysis, or extirpation of the diseased synovial membrane, but leav- ing the bone untouched or removing some of the cartilage, will almost always be found sufficient. By performing early arthrectomy with preservation of the articular ends of the bones in their entirety, or as much of them as possible, a permanent cure can often be obtained, and that, too, with a movable joint, a fact which is attested by Angerer's numerous cases. Amputation is only permissible in cases where the saving of life comes into the question, where the destructive processes have become very extensive, or where the patient cannot survive the long period of time required for a resection to heal. Other compli- cations are treated according to the general principles which apply to them. Cold abscesses can with impunity be freely opened, thor- oughly scraped out and drained. It is very important to recognise a tubercular focus in the neighbourhood of a joint before it breaks through into the latter, and to remove it with the sharp spoon. After every operation for tubercular arthritis the wound should be disin- fected as carefully as possible to prevent infection with bacilli from the wound. Iodoform and iodoform gauze seem to be the most suitable dressing materials, especially for packing the joint. When a tubercular inflammation of a joint has got well, some suitable splint apparatus, such as one of those devised by Say re, Taylor, or Thomas, should be worn, especially on the lower extremity, to support the limb, which, will still be weak. If any abnormal conditions, such as con- tractures, follow a tubercular arthritis, they may have to be treated by 682 INJURIES AND DISEASES OF JOINTS. tenotomy of the shortened muscles—or, rather, tendons—by resection, arthrotomy, or by a wedge-shaped osteotomy, below the trochanter, for example, when the contracture involves the hip, unless they can be stretched under anaesthesia or gradually overcome by extension or re- tentive appliances (see page 216). The treatment of tuberculosis of the individual joints will be de- scribed in the Special Surgery. V. The Syphilitic Diseases of Joints (see also § 84, Syphilis, and page 628, Syphilis of Bone).—The syphilitic diseases of joints have lately been frequently and accurately described by such men as Schuller, G-ies, Falkson, etc., and their occurrence can be readily understood if we bear in mind that syphilis is a specific infectious disease. The joints become affected in the course of syphilis, sometimes primarily and sometimes secondarily, after syphilitic disease in the surrounding parts, particularly the periosteum and medulla. The syphilitic inflam- mations of joints may be met with during the early stages of the dis- ease at the time of the febrile eruption, or during the later periods. The early forms are, in the main, serous synovites, wliich occasionally make their appearance in a manner analogous to acute polyarticular rheumatism. The inflammations of joints which occur in the later stages of syphilis have, as a rule, a pronounced chronic character, and are generally connected with the formation of gummatous deposits in the periosteum, the medulla, and the synovial membrane. After the gummatous nodules have come to the surface and ruptured externally characteristic ulcerations occasionally develop. In these late syphi- litic inflammations of joints there will frequently be found in the joint a gummatous or carious destruction of the bones and sharply defined circumscribed losses of substance, or radiating, glistening white cica- trices in the cartilage, together with fibrillation of the latter, while in other instances a connective-tissue growth in the synovial membrane, taking the form of indurations or of villi, may be more prominent. The pathological changes at the first glance sometimes look like those which occur in arthritis deformans. Many cases run a course with a very gradual increase in the amount of swelling, and resemble clinic- ally tumor albus, but the pathological changes are very different from those of tubercular arthritis. In rare instances the gummatous nodes occur in the synovial membrane in a miliary form and may be macro- scopically mistaken for tubercles, and then only a microscopic exam- ination and other manifestations of syphilis which may be present will clear up the diagnosis. The indurated, villous connective-tissue growths, the losses of substance and the cicatrices in the cartilage, and the gummatous, carious destruction of bone are characteristic of §114] THE CHRONIC INFLAMMATIONS OF JOINTS. 683 syphilitic disease of joints. An acute, subacute, or chronic serous ar- thritis may also occur in the later stages of syphilis, and primary sup- purative inflammation of a joint will be encountered in rare instances —for example, when syphilis is complicated with gonorrhoea, etc. The therapy of the syphilitic inflammations of joints consists, in the first place, in a proper local treatment conducted according to the rules which have been given for diseases of joints, and, secondly, in a general antisyphilitic treatment, the best being inunctions of ungt. hydrarg. ciner. (see § 84, Treatment of Syphilis). VI. Arthritis Deformans or Malum Senile.—This affection is in every respect the opposite of tubercular arthritis. Suppuration or caries never occurs. The disease attacks individuals who are old or past the prime of life, and almost always involves several joints. As a rule, it causes deformities in the joints, which very gradually become more marked, while recovery—i. e., a complete restitutio ad integrum—never occurs, and arrest of the process only rarely. The pathological changes which take place in arthritis deformans consist (1) in degenerative processes in the cartilage and bones, and (2) in hyperplasia of the bones, cartilage, and soft parts. A fibrillation occurs in the more superficial layers of the ground substance of the hyaline cartilage, while a localised cracking and softening are produced in the deeper layers by the vascular me- dullary spaces of the underlying bone pushing their way into the cartilage. At the same time, particularly at the free borders, a growth of cartilage oc- curs taking the form of knob-like tube- rosities, which subsequently, for the most part, ossify (Figs. 377, 379). In consequence of the degenerative fibril- lation and softening of the cartilage (arthritis chronica ulcerosa sicca) the latter may completely disappear, expos- ing the uncovered bone, which then, by the friction produced in the movements of the joint, develops a smooth, polished surface (Fig. 379, a). The degenerative changes which take place in the bone consist in a lacunar absorption and inflammatory atrophy of the bone tissue, for the most part subchondral. The atro- phy of bone is occasionally very considerable, and may lead to the dis appearance of the head or entire neck of the femur (Figs. 3"' Fig. 377.—Coxitis deformans: head ot the femur below the tip of the great trochanter; neck of the fe- mur no lonsjer present (Path, col- lection in Zurich—Volkmann). 378) 684 INJURIES AND DISEASES OF JOINTS. Just as in the case of cartilage, there will be encountered in addition to the atrophy a new formation of bone which is sometimes very marked (Figs. 378, 379). In some cases the atrophy of the bone predominates (Fig. 377), in others the new for- mation of bone (Fig. 379). These degenerative and hyperplastic changes in the cartilage and bone are very characteristic of arthritis deformans. The capsule and lig- aments of the joints also become thickened and afterwards con- tracted, and the synovial villi be- come the seat of an active process of proliferation. Loose-joint bod- ies (see § 115) are very frequently found in the joint, but adhesions between the articular surfaces of the bones or obliteration of the joint by newly-formed connective tissue almost never occur. The joints gradually become so deformed by these changes in the articular ends of the bones and by the thickening and shrink- ing of the capsule, which is some- times the seat of a new formation of bone, that motion becomes more or less limited or entirely lost. If the atrophic changes in the bones predominate the joint may become abnormally mobile or even loose and flail-like, with a tendency towards subluxation or complete dislocation (luxations of deformity, as they are called). These dislocations cannot, as a rule, be kept permanently reduced owing to the deformities of the head of the bone and the socket, and in the case of dislocations of the head of the femur a new acetabulum may be formed on the ilium (Fig. 380). Arthritis deformans is most commonly observed in the hip, knee, elbow, and shoulder, and less often in joints of the fingers and verte- brae. In the vertebrae the atrophy of bone may cause the development of spinal curvatures, especially7 kyphosis, while the new formation of bone may give rise to osseous union between the different vertebrae. Arthritis deformans is either monarticular or polyarticular. If monar- ticular, it is usually located in a large joint, while the polyarticular form more commonly occurs in the small joints, such as those of the fingers or toes, etc. Fig. 378.—Arthritis deformans of the hip joint: the greatly enlarged head of the femur lies very near the trochanter owing to the dis- appearance of the neck (Path." Institute at Leipsic). §114.] THE CHRONIC INFLAMMATIONS OF JOINTS. 685 bf-— a------ AVe still know little about the etiology of this disease, though its anatomical peculiarities are so characteristic. It may begin spontane- ously, or follow the re- ception of some trau- matism, such as a frac- ture which involves the joint, or come on after some such infectious inflammation as a gon- orrhoeal arthritis, or after acute polyarticu- lar rheumatism. The patient's occupation or position in life plays no part in the causation of arthritis deformans, but his age probably does. I look upon this affec- tion as essentially a senile disorder which, as a rule, can be traced to some exciting cause, such as a traumatism or an infection—it is rare- ly spontaneous — and gives rise to character- istic atrophy and to hyperplasia of the cartilage and bone, and to thick- ening and contraction of the capsule. The clinical course of both the monarticular and polyarticular form of arthritis deformans is exceedingly chronic, and it is not an uncom- mon thing for the disease to last twenty to thirty years. The initial symptoms are those of a chronic arthritis running a course without fever, and consist in stiffness of the j'oint, particularly in the morning bours, in slight pains, and in the occurrence of crepitating or creaking sounds. Later on the deformities of the articular ends of the bones or of the entire joint become prominent. The movements of which the joints are capable become more and more restricted, or the opposite condition may exist, the joints becoming loose and flail-like. Occa- sionally acute inflammatory symptoms make their appearance, consist- ing of fever, increased tenderness and inflammatory swelling of the joint, and an acute effusion of serum. The pain may be excessive. Recovery7 is extremely rare, the disease ordinarily growing worse very condyl. ext. condyl. int. Fig. 379.—Arthritis deformans of the right knee-joint: a, pol- ished and smooth articular surface; b, growth of bone and cartilage; c, fibrillation of the cartilage; unequal length of the femoral condyles, giving rise to pronounced genu valgum ; the transverse diameter of the internal con- dyle and the longitudinal diameter of the external con- dyle are shortened (Path. Institute at Leipsic). 686 INJURIES AND DISEASES OF JOINTS. gradually until it is terminated by death from some intercurrent affec- tion. Diagnosis.—The very chronic course of the disease, the absence of suppuration and caries, the characteristic deformity of the joints, the advanced age of the patient, and the history of some predisposing cause, are important factors in the diagnosis of arthritis deformans. The Treatment of Arthritis De- formans.—The sooner arthritis de- formans is subjected to systematic treatment by massage and active and passive movements of the joint, the greater is the possibility, par- ticularly in the case of the monar- ticular form, of arresting the fur- ther development of the disease. In addition to massage and me- thodical exercise of the joint, baths in which the entire body is im- mersed in lukewarm water, or sand baths, mud baths, or steam baths, combined with cold douches—in short, hydrotherapeutic measures— are especially to be recommended. The use of hot springs, such as Gastein, AYildbad, Wiesbaden, Teplitz, Ragatz, etc., and a residence in southern climates, are also exceedingly serviceable. Marked disturb- ances of function, especially in the upper extremity, can be improved by performing resection, but amputation is only indicated in the rarest instances, where the changes are very pronounced. Resection of the joint has been repeatedly practised for severe pain, the results in some cases being excellent, and in others entirely negative (Fock, Kiister, Riedel, etc.). The other complications, such as the acute exacerbations, dislocations, or flail-like joints, which sometimes occur, are treated ac. cording to the general rules which apply to these conditions. The in- ternal administration of drugs, such as iodide of potassium, aconite, quinine, iron, etc., is of little use, but a strengthening mode of life with nourishing food, fresh air, etc., is very important. The Diseases of Joints which occur in Bleeders {Haemophilia; see page 57). —Individuals who suffer from haemophilia are sometimes affected by various kinds of joint diseases, which generally take on a serious character owing to the presence of the constitutional dyscrasia. Leaving out of consideration the different forms of inflammation of joints which occasionally occur in Fig. 380.—Formation of a new acetabulum (A) on the os ileum after a dislocation from arthritis deformans in a woman seventy years old; B, remains of the original acetabulum (Gutsch). 115.] JOINT BODIES OR JOINT MICE. 687 bleeders as well as in other people, there is left a certain definite group of joint diseases which are clinically and pathologically peculiar to haemophilia, and which are to be regarded, so to speak, as a symptom of this disease. Konig has recently described "bleeder joints " very much at length, and I can fully confirm his statements. These typical joint diseases which are met with in haemophilia are characterised by the presence in the joint of an effu- sion of blood, which may persist in an unaltered state for weeks and then gradually grow smaller, and, if the conditions are favourable and compres- sion is employed, may eventually entirely disappear. But in other instances, particularly if the disease is not properly treated, the effusion of blood is added to by fresh haemorrhages, the joint becomes gradually more and more damaged, the articular cartilages undergo erosion and fibrillation, and the joint grows constantly stiffer, finally becoming obliterated. If the unfavour- able conditions continue, contractures and deformities of the joints develop. It is a very easy matter to mistake a bleeder joint, particularly during the early stages, for hydrops tuberculosus. Konig lost two patients from haemor- rhage because he had thought the articular disease was tubercular and conse- quently undertook extensive operations. In making the diagnosis of a bleeder joint the personal history of the patient is of the utmost importance, for the reason that the patients or their parents are generally aware of their bleeder disease. It should be noted that it almost always occurs in young subjects, the large effusion of blood usually develops suddenly from some slight traumatism, pain is generally absent, and several joints are commonly affected, some being in the early and others in the advanced stages. The treatment of recent cases consists in placing the limb in an elevated position, in immobilisation and compression of the joint, and subsequently in gentle massage and passive motion. In some instances the joint should be punctured for the purpose of removing the effused blood. Massage should be used cautiously and as an experiment. § 115. Joint Bodies or Joint Mice (Mures Articulares).—By joint bodies or the so-called joint mice (mures articulares) we mean bodies varying in structure which are formed within joints and are either free or attached by pedicles. Joint bodies anatomically consist of cartilage or of bone, or of bone with a cartilaginous covering, of fibrous connect- ive tissue, of fatty tissue, or of masses of fibrin. AATe are able to distinguish etiologically three principal kinds of joint bodies: (1) Concretions made up of fibrin, (2) joint bodies result- ing from the breaking off of cartilaginous or bony portions of the articular ends of the bones or intra-articular ligaments by some trauma- tism, and (3) growths of connective tissue, cartilage, or bone which originally are pedunculated, but later, as a result of atrophy or sudden rupture of the pedicle, become free joint bodies. The fibrin concretions—i. e., the fibrin precipitated from the synovia in cases of chronic hydarthros, for example—take the form of round, smooth, or irregularly shaped concrements, usually about the size of a 688 INJURIES AND DISEASES OF JOINTS. melon seed or grain of rice, which often occur in great numbers. These concrements, from their similarity to grains of rice, are also called rice bodies (corpora oryzoidea). Schuchardt maintains that the rice bodies are not " fibrinous " products of coagulation formed from the thickened contents of a joint or tendon sheath, but are portions of the synovial membrane or tendon sheath which have undergone coagu- lation necrosis (Weigert) or fibrinoid degeneration (Neumann). Occa- sionally the concrements attain a considerable size—that of a hen's egg, for example, or larger. Small foreign bodies, such as needle points, broken-off synovial villi, a blood-clot, etc., have been found in the in- terior of the concretions, just as in vesical calculi. In the second category of cases the free joint bodies are formed from bony or cartilaginous portions of the articular ends of the bones or intra-articular ligaments wliich are torn from their attachments by some traumatism, such as a blow, a fall, or some other violence. These may be increased in size, partly by deposits of fibrin from the synovia and partly by the independent growth of the cartilage or medullary cells which they contain. Occasionally the detachment is not complete, and then at some later period there takes place a gradual or sudden separation of the partially detached piece of bone or cartilage. Krage- lund was able only by using a great amount of force to partially or completely break off from the femur—generally the internal condyle— but not' from the tibia, portions of bone which presented a close simi- larity to mures articulares, and Poncet saw small fragments of bone torn from the points where the ligaments were attached. Furthermore, without the reception of any traumatism or injury, larger or small pieces may become separated from the articular ends of the bones as a result of some process which is not as yet understood ; these pieces are then covered on their bony surfaces with dense connect- ive tissue which contains cartilage cells, and the loss of substance in the bone from which they came is repaired in a similar manner. Konig has given the name of osteochondritis dissecans to this genetically obscure and circumscribed disease of the articular ends of the bones. The third way in which joint bodies may originate—i. e., in the form of steadily enlarging growths of tissue attached by a pedicle to some part of the articulation, such as the villi, the synovial membrane, or the articular cartilages—is met with especially in chronic joint diseases, such as arthritis deformans, or hydarthros chronicus, or after fractures which involve the joint. The growths are made up, according to the point from which they spring, of connective tissue, cartilage, or bone, or bone with a cartilaginous covering, and then by gradual atrophy or by sudden rupture of the pedicle these growths become free joint §115.] JOINT BODIES OR JOINT MICE. 689 bodies. In this category belong the free joint bodies formed by growth of the synovial villi or by fibrillation of the cartilage, as well as those which result from the detachment of tumours of cartilage or bone (enchondroma osteoma), or of the cartilaginous or bony plates in the synovial membrane which may develop in the course of hydarthros and arthritis deformans. As a result of the fibrillation of the articular cartilage occurring in a chronic arthritis, there is often a very excessive formation of cartilaginous villi in which a vigorous circumscribed growth of cartilage cells sometimes takes place. If these formations become loose, hyaline rice bodies analogous to the above-mentioned fibrinous rice bodies develop, having exactly the same form as the latter, and likewise existing in very great numbers. The condition in which there is an excessive growth of fat in the villi is called lipoma arbores- cens, and may give rise to the formation of free joint bodies which are soft and made up of fat. The cartilaginous and bony joint bodies vary greatly in size, some being not larger than a bean or almond, while others are as large as the patella. Billroth states that a joint body has been preserved in the museum at Vienna as large as the os calcis, which was found attached by a pedicle to the capsule of the joint. Symptomatology and Diagnosis of Free Joint Bodies.—As we stated before, joint bodies are found in joints which are either otherwise per- fectly healthy or are the seat of chronic inflammation, particularly chronic hydarthros and arthritis deformans. The knee joint is the most common location in which they are encountered, while of the other joints the elbow comes next. The symptoms caused by free joint bodies are, first of all, a sudden, severe, darting pain, experienced during some particular movement of the joint, often causing the patient to appear as though paralysed and to fall to the ground in a faint. These pains, which reappear with more or less frequency, are particularly likely to occur when a moderate-sized, freely movable joint body becomes caught in a synovial pouch or between the articular ends of the bones. The attacks of pain are usually followed by inflammatory manifestations in the joint of greater or less severity, which take the form of an acute serous synovitis. Diagnosis.—These characteristic, paroxysmal pains are of the great- est importance for making the diagnosis of free joint bodies. In some instances the latter can be felt. Nevertheless, one can be deceived even in this, and I once mistook a commencing circumscribed tubercu- losis of the capsule of the knee joint for a free joint body. After opening the joint and extirpating the diseased portion of the capsule, recovery took place, with perfect motion in the joint. The most diffi- cult cases to recognise are those in which the joint bodies exist in 44 690 INJURIES AND DISEASES OF JOINTS. an articulation which has undergone changes due to arthritis de- formans. Treatment.—The best treatment for free joint bodies consists in their operative removal by aseptic arthrotomy. The body having been located by palpation, an incision is made directly down upon it, where- upon it is pressed through the opening thus made and the borders of the wound are immediately closed by sutures. The joint is then im- mobilised as completely as possible with an antiseptic protective dress- ing, over which splints are placed. If the patient is afraid of the knife, or if the condition does not cause him much trouble, we recom- mend the wearing of an elastic cap around the joint, to afford the latter a certain amount of support and prevent too free motion. In those cases where the symptoms indicate beyond a doubt the presence of a joint body, but where, as in the elbow, it cannot be reached by an in- cision made directly down upon it, in case the patient's discomfort is great enough, the joint should be laid freely open with the strictest aseptic precautions, and, if necessary, a partial (temporary) resection undertaken to render it possible to remove the joint body. Exostosis Bursata with Joint Bodies.—Bergmann operated upon an exos- tosis on tbe outer aspect of the lower end of the femur, just above the knee, which was surrounded by a capsule containing upwards of five hundred rice bodies made up of hyaline cartilage. The exostosis probably originated intra-articularly as an ecchondrosis of the articular cartilage, and derived a true synovial sac by pushing before it the capsule of the joint, the divertic- ulum thus formed becoming afterwards completely shut off from the joint. In other instances the exostosis has been found still in the joint, as in a case of Volkmann's, where it was attached to the portion of the semilunar carti- lage which adjoins the capsule. In this case there were in addition three bodies lying free in the joint (see Exostoses, § 128). § 116. Neuroses of Joints (Neuralgias of Joints; Nervous, Hysterical Diseases of Joints).—The nervous or hysterical affections of joints, the neuroses or neuralgias of joints, were first described by the celebrated English surgeon Brodie, and his statements have been confirmed by such German surgeons as Stromeyer, Esmarch, and Erb ; while quite recently Newton M. Shaffer has written an exhaustive treatise on the subject. No pathological changes can be made out in joints which are the seat of neuralgias. The knee and hip are the ones most commonly affected, and usually one joint at a time, rarely two or more. Females with an over-excitable nervous system, or who are markedly hysterical, especially young girls of the better classes of society, are particularly apt to suffer from these troubles, and hence the term hysterical joint affection. But the disease is occasionally met with even in perfectly §116.] NEUROSES OF JOINTS. 691 healthy men and women. Among the exciting causes may be mentioned traumatisms, such as bruises and sprains of the joints, irritation of or pressure upon the nerves in the neighbourhood, excessive emotional disturbances, and taking cold. Joint neuralgias also occur reflexly from diseases of the abdominal viscera, especially the female sexual organs, and from diseases of the central nervous system, such as tabes. Symptoms and Course of Joint Neuroses.—The chief symptom of a joint neuralgia or neurosis is the pronounced pain and tenderness in the joint, while objectively nothing abnormal can be made out. The pain is felt especially when pressure is made at some particular point, or when the joint is moved. In addition to these tender points, there is generally a pronounced diffuse hyperaesthesia of the skin over the joint; but in rare instances there may be anaesthesia. Moreover, the function of the joint in question is disturbed—i. e., the patient avoids moving the joint because of the pain, and keeps it rigid. There are also observed a state of muscular spasm, with secondary distortions of the joints (contractures); vasomotor disturbances (urticaria-like wheals, alternate flushing and blanching, etc.); tremor; a marked feeling of weakness; atrophy of the extremity7 which is involved, and now and then paralyses. The stiffness and contractures of the joints, which may take the form of nervous club-foot or stiffness of the hip, will immediately disappear under chloroform anaesthesia, and while the patient is in this state the joint will be freely movable, The verte- bral column, especially the spinous processes, are also sometimes tender on pressure. The course of the nervous joint affections is usually rather tedious and very variable. If the nervous system is otherwise normal, recovery generally takes place after the lapse of a longer or shorter time, though it may occur suddenly after some emotional excitement or after some energetic movements have been made with the joint. In cases of pronounced hysteria, or diseases of the nervous system, the patients are occasionally doomed to be confined to bed for years, and in such instances the affection is often incurable. In making the diagnosis of a hysterical joint, we should note par- ticularly that certain symptoms which indicate an inflammation of the joint are absent, and that the contractures, the stiffness, etc., disappear completely under chloroform anaesthesia. The above-mentioned mani- festations of the disease are so characteristic that they are generally sufficient to establish the diagnosis. Old sprains with slight intra- articular adhesions have sometimes been mistaken for joint neuralgias; but cases of this kind can be cured in a very short time by massage combined with forced movements of the joint. The prognosis is favourable in the case of individuals who are 692 INJURIES AND DISEASES OF JOINTS. otherwise healthy ; but if they are excessively neurotic and hysterical, it is uncertain, and is the more unfavourable the severer the nervous complications. Treatment.—The treatment of nervous joint affections is directed first of all towards the cause. If there is pronounced neurasthenia, hysteria, or other nervous anomalies, or disease of certain organs (of the sexual organs, constipation, etc.), these conditions must receive careful attention. In every case a general tonic treatment for the nervous system by cold-water cures, sea-bathing, a sojourn in the mountains, and removal of the patient from his business and family, are very much to be recommended. Treatment of a psychical nature is also very valuable; while unexpected joy or sorrow has often caused hysterical joint neuroses to disappear suddenly and permanently. The local treatment of the diseased joint comprises massage and methodical exercise, rubbing with cold water, and electricity (the strong faradic or galvanic current passed transversely through the joint). Morphine or atropine is occasionally given in the form of subcutaneous injections if the patient is otherwise healthy and robust. Quinine and arsenic, given internally, are also of use. For the contractures and the weak- ness of the muscles and joints we employ suitable braces or splints which will enable the patient to move his limbs. Other Joint and Bone Neuralgias.—The neuralgias sometimes occurring in joints and bones which have previously been tbe seat of a disease like tubercular arthritis, or which make their appearance in the course of syphi lis, or after recovery from caries and necrosis, or in general occur in old bone cicatrices, are of a totally different nature. Pain of this description is very apt to occur in syphilis, or in ossifying osteomyelitis and periostitis, or in sclerosis of bone. The treatment of these joint .and bone neuralgias depends upon the cause. Warm baths and the bathing cures given at Teplitz, Wies- baden and Gastein are generally very useful. The pain occurring in bones and joints which have been at one time diseased may sometimes become so severe that amputation or disarticulation is performed at the patient's own request. Close examination of the bone in such cases reveals nothing which can account for the great suffering, but we do find that individuals thus affected are usually neurotic (Poncet, Auday). Quite often, however, these neuralgias are due to circumscribed, inflam- matory foci concealed in the bone or joint, and if this is the case the disease should receive its appropriate treatment. Abnormal adhesions in a joint, such as may occur, for example, in old dislocations which have been im- properly treated, may give rise to violent pains, which can be quickly stopped by massage and exercise. In general, neuralgias of joints and bones follow- ing a pre-existing disease are most commonly the result of syphilis or some nervous disease; and these must be the first things to be considered in the treatment. Sometimes violent pain also occurs in bones which are otherwise ap- §117.] NEUROPATHIC DISEASES OF BONES AND JOINTS. 693 parently healthy and have not previously been diseased, coming on espe- cially after taking cold, and in neurotic individuals. Warm baths and the use of the above mentioned hot springs, as well as an antineurotic treat- ment, should be employed. § 117. Neuropathic Diseases of Bones and Joints.—Peculiar neuro- pathic affections of the bones and joints, of great clinical interest, oc- cur in the course of diseases of the nerves and spinal cord, especially tabes. Charcot was the first to describe accurately the arthropathies which make their appearance during the course of the grey degenera- tion of the posterior columns of the cord; and while Charcot, Erb, Buzzard and other neurologists ascribe the arthropathia tabidorum to direct nervous influences—in other words, to trophoneurotic disturb- ances—Arolkmann, Leyden and Virchow maintain that the tabes merely brings about unfavourable conditions, in consequence of which certain diseases of the joints occur more easily and frequently than they do in a state of health, and run an unusual and malignant course. The main predisposing causes in tabes of inflammations and injuries of the bones are the loss of sensibility—i. e., the anaesthesia or anal- gesia of the joints, the ataxia, and the fragility of the bones. These factors also influence very materially any deforming or traumatic, acute or chronic inflammation occurring in a person suffering from tabes dorsalis. The softness and brittleness of the bones in tabes are well known, and account for the frequency with which spontaneous fractures take place in patients with this disease. The fragility of the bones is due to a trophoneurotic change in their organic ground sub- stance, and may be encountered even in bones which are apparently very strong and compact. The bones may also become remarkably brittle in people with various mental diseases, or with infantile spinal paralysis, progressive muscular atrophy, leprosy, etc., and Neumann has ascribed the changes that occur to an affection of the vasomotor system. Czerny, Rotter and others have lately made exhaustive studies of arthropathia tabidorum and neuropathic bone and joint affections in general. The question of the relationship between these affections and the sclerosis of the posterior columns of the cord and other diseases of the spinal cord and peripheral nerves has recently been the subject of animated discussion, but as yet it has not been positively decided whether spinal diseases, such as tabes, syringomyelia, etc., should be regarded as direct causes of these troubles, which Char- cot believes them to be, or only as predisposing. Charcot has lately adopted the view that they are due to certain localised processes of disease in the diaphyses and epiphyses. Cause of Arthropathia Tabidorum.—As before stated, the anaesthesia 694 INJURIES AND DISEASES OF JOINTS. or analgesia of the joints plays a most important part in the produc- tion and course of arthropathia tabidorum. The neuropathic affections of the joints which occur in tabes begin either without any external cause, or they follow the reception of some traumatism ; and as the patients feel no pain, they walk about while their joints are inflamed and thus make matters worse; they wear off the brittle articular ends of the bones, as it were, so that the entire astragalus, for example, may by degrees completely disappear. A tabetic individual with a fracture of the leg, who came under Volkmann's care, could produce a very marked displacement of the fragments without suffering any pain. The analgesia cannot always be easily recognised, it being occasionally limited to the more deeply situated nerves alone, while the skin is even over-sensitive to the slightest irritation. The chronic arthropathies which occur in tabes and do not go on to suppuration, run, as a rule, a course similar to arthritis deformans (see page 683), but differ from the latter in the fact that the different parts of the joints are very rapidly destroyed, and dislocations and spontaneous fractures are of frequent occurrence. One can distinguish, as in arthritis deformans, an atrophic and a hypertrophic form of arthropathies as well as a monarticular and a polyarticular form. If the specific excitants of inflammation— micro-organisms—gain entrance to a joint of this kind which is the seat of a chronic inflammation, septic or even gangrenous inflammation running a very rapid course often develops. Hence it can be seen that in the course of tabes various forms of arthritis may be en- countered, some acute and others chronic, and either suppurative or non-suppurative ; but the characteristic feature of the inflammation is that it is always greatly modified and influenced by the analgesia and ataxia which are present, and by the weakness and fragility of the bones. The knee is the joint most commonly affected, although the articulations of the upper extremity do not always escape. Rotter has collected 112 cases of joint disease occurring in 74 patients with tabes; of these, 49 were of the knee, 24 of the hip, 12 of the shoulder, 12 of the tarsal joints, 6 of the elbow, 4 of the ankle, 3 of the hand and fingers, and 2 of the temporo-maxillary joint. Both knee joints were diseased in 11 cases, both hips in 7, the tarsal joints in 3, and the shoulder, wrist, and finger joints were symmetrically affected twice. In Weizsacker's statistics of 109 cases, 72 occurred in men and 37 in women. The knee joint was affected 78 times, the hip 31, the shoulder 21, the tarsus 13, the elbow 10, the ankle 9, the carpal and temporo-maxillary joints twice, and the vertebral column once. The observations of Leyden, Oppenheim and others show that affec- tions of the joints and weakness and fragility of the bones may § 117.] NEUROPATHIC DISEASES OF BONES AND JOINTS. 695 occur in both the earliest and the most advanced stages of tabes dor- salis. In making the diagnosis of neuropathic bone and joint affections, the characteristic features in chronic cases are the existing nervous dis- orders, which in the case of arthropathies of the lower extremity is most commonly tabes, and of the upper extremity syringomyelia, the analgesia, the pronounced exudation, and the marked destruction of the articular surfaces of the bones ; the acute cases become rapidly worse. Czerny is right in calling attention to the fact that the predisposition to nervous disorders is an important matter from a medico-legal stand- point—in other words, should be taken into account in a plaintiff who brings suit for damages. The prognosis of the tabetic arthropathies is very uncertain, and depends largely upon whether the joints are used or protected and properly treated, whether ataxia exists, etc. If proper treatment is received (fixation, orthopaedic appliances, etc.), it is possible for the arthropathy to be improved or arrested. Similar neuropathic affections of the bones and joints are also noted in the course of other cerebral and spinal diseases and are due to analogous disturbances of innervation. In six cases of neuropathic joint disease described by Czerny, two of the patients suffered from tabes and four from syringomyelia (see below). If the upper extremity is the seat of paresis and analgesia, affections of its joints may occur which run the same course as the arthropathies of tabes; there may also be a grind- ing away of the head of the humerus in the shoulder joint, spontaneous fracture of the bones of the forearm, osteophyte growths, trophic dis- turbances in the skin (ulcers), etc. Neuropathic contractures are dis- cussed on page 701. The Arthropathies of Syringomyelia.—The arthropathies coming on in the course of syringomyelia mainly attack joints of the upper extremity, for the reason that the primary disease is for tbe most part localised in tbe cervical portion of the spinal cord, and they occur in the great majority of instances in men of advanced age. Traumatisms play a predisposing part in their pro- duction. The course of the arthropathies is always chronic, not infrequently lasting for years. There will occasionally be observed an acute exudation in the joint, or even suppuration, especially if there has been some injury which on account of the analgesia has been neglected ; but there seldom occurs such a marked destruction of the joint in a comparatively short time as in tabes. The changes in the joints are more like those of arthritis deformans, with tbe formation of intra-articular and periarticular osteophytes, with ossification of the periarticular soft parts, degeneration of tbe muscles, and thickening, dilatation and relaxation of the capsule, with secondary spontaneous disloca- tions. The joints are analgesic, and sometimes to such a pronounced degree that large joints can be resected without chloroform (Czerny, Sokoloff). This 696 INJURIES AND DISEASES OF JOINTS. analgesia is, moreover, the chief factor in furthering the development of the disturbances of nutrition which are present in the joints and bones. The bones are in some instances abnormally weak (hence the spontaneous frac- tures) and in others remarkably sclerotic. The termination of the arthrop- athies which occur in syringomyelia is governed mainly by the primary disease in tbe spinal cord, and also by the amount of care the patient takes to protect his joints from injuries that may readily give rise to complicating periarticular and intra-articular suppuration. Under favourable conditions the joint affections are usually very protracted. The diagnosis can be read- ily made if the pathological changes and the clinical course are taken into consideration together with the analgesia and the location of the arthro- pathies in the upper extremity. The treatment, particularly in the early stages, consists in immobilising the joint, though later on suitable operative measures may be necessary, as they are in tabes. The treatment of the neuropathic inflammations of joints, particu- larly the arthropathies which occur in tabes and syringomyelia, com- prises proper local treatment of the affected joint and general treatment of the neuropathy which is the primary cause of the trouble. We con- sider, as Czerny does, that firm anchylosis in a good position is prefer- able to a loose joint which is rapidly ground to pieces by friction, and in the early stages it would be proper to bring about artificial anchylo- sis by performing arthrodesis (see page 133). If patients with the above-mentioned diseases of the spinal cord receive a sprain, the joint must be treated by immobilisation and subsequently by a supporting apparatus. Should extensive destruction or suppuration of the joint occur, the question of arthrotomy, resection or amputation would arise. § 118. Anchylosis.—-By anchylosis (from cfy/ciAo?, angular, crooked) is understood an immovable, stiff joint, such as results from an inflam- mation of a joint which has run its course. The word anchylosis sig- nifies properly an angular position of the joint; but this conception of the term has in course of time been entirely given up, so that when we speak of anchylosis of a joint we mean that its power of motion has been lost, irrespective of whether the joint has become fixed at an angle or in a straight, extended position. If a joint is in an angular position we speak of it as a contracture (see § 119). Anchylosis—in other words, stiffness of the joint—and contracture very frequently occur in com- bination. If we wish to differentiate these two terms more exactly, we may say that anchylosis signifies a complete cessation of the motility of a joint brought about by intra-articular causes, while contracture is a limitation of motion generally due to pathological changes in the extra- articular soft parts (see all § 97 and § 98, Diseases of the Nerves and Muscles). We also recognise a false and a true anchylosis (anchylosis spuria and anchylosis vera). The term false anchylosis applies to those §118.] ANCHYLOSIS. 697 cases in which apparently immovable joints can be caused to move under chloroform anaesthesia, and is a condition which is observed in the course of acute or chronic inflammations of joints, or as a result of inflammatory or voluntary muscular contraction, or in hysterical joint disorders, etc. The Causes of True Anchylosis.—True anchylosis is most commonly due to the development of a firm union between the different parts of the joint, and according to the nature of the tissue forming the union between these parts we recognise a connective tissue (anchylosis fibrosa), a cartilaginous (anchylosis cartilaginea), and a bony anchylosis (anchy- losis ossea). The cicatricial connective tissue which develops between the opposed articular surfaces in the healing, for example, of an arthri- tis with fungous granulations, either takes the form of adhesions which resemble ligaments, or they7 more or less completely fill the joint. If ossification of the connective tissue takes place it is possible for a bony anchylosis to occur, in which case the articular ends of the bones are joined together by an osseous bridge, or united by bone throughout their entire extent. Bony anchylosis may7 develop from the cartilag- inous form, or it may arise from the direct coalescence of joint sur- faces which have lost their covering of cartilage. Cartilaginous anchy- losis is brought about by a growth of vascular connective tissue be- tween the opposed surfaces of the articular cartilages, and if, then, this connective tissue disappears, the surfaces of the cartilage are found to have coalesced into a single cartilaginous mass. Other causes of stiff- ness in joints are cicatricial shrinkage of the capsule and ligaments of the joint, and adhesions between two opposed portions of the synovial membrane, so that the latter can no longer adapt itself to the move- ments of the different portions of the joint. Anchylosis may also be caused by the growth of bone or cartilage in a joint, as in arthritis deformans, or by the development of bone in the capsule or parts sur- rounding the joint, which sometimes occurs after fractures in the neigh- bourhood of or extending into a joint. Furthermore, the articular ends of bones may be so altered by changes such as occur in caries and ar- thritis deformans that they do not fit together, and so are not capable of performing their function of gliding over each other (anchylosis of deformity). AVe learned in a previous chapter that joints may become fixed in a faulty position by muscular contractures, or by cicatricial processes in the muscles, tendons, tendon sheaths, bones, etc. It is generally an easy matter to make the diagnosis of anchylosis, but in doubtful cases chloroform anaesthesia may be required to deter- mine whether the anchylosis is false or true; it is also the best way of finding out how much motion, if any, exists. 698 INJURIES AND DISEASES OF JOINTS. Treatment of Anchylosis.—The treatment of a stiff joint includes both an attempt at restoration of its motion and at overcoming the ab- normal position in which the joint may have become anchylosed; in other words, one should strive to place the joint in such a position that the limb may be more or less useful to the patient. Only in rare instances is it possible to restore motion in a joint which has become fixed by true anchylosis, and then it is generally accomplished by re- section. But we can very often prevent an anchylosis from taking place by employing proper treatment for the diseases and injuries of the joints and the parts which surround them, particularly by causing wounds to heal aseptically, and after the subsidence of inflammation, by using massage and active and passive motion. If in the course of an injury or inflammation of a joint we are unable to prevent an anchylosis from developing, we must always place the joint in that position which will render it most useful for the patient—the knee, for example, in extension, the ankle and elbow at a right angle, etc. If the joint has already become fixed in a distorted position, it may be possible to gradually overcome the latter by massage and passive motion, by manual correction under anaesthesia, by permanent exten- sion by a weight, by the use of frequently applied plaster-of-Paris dressings or splints which exert pressure or traction, or by operative division of the contracted periarticular soft parts, especially the mus- cles, tendons, and fascia (see Tenotomy, Myotomy, page 558), by oste- otomy of the bone in the neighbourhood of the joint, or by resection of the joint, combined possibly with the removal of a wedge of bone. Osteotomy is performed either in the form of simple division of the bone (see § 26), or division combined with the removal of a wedge- shaped piece from the continuity of the bone. Volkmann's method of performing linear or wedge-shaped osteotomy below the trochanter of a hip which has become anchylosed has yielded excellent results, im- proving both the position and the usefulness of this joint. Resection of the joint (§ 40), and in desperate cases amputation or disarticulation (§ 36 and § 37), are also operations which may have to be resorted to. When there is a firm anchylosis due to fibrous, cartilaginous or bony union between the articular ends of the bones, combined with a dis- torted position of the joint, resection of the latter is generally called for, the object being the formation of a movable joint, or one fixed in a position which will render use of the limb possible. The opera- tion of arthrodesis for obtaining artificially anchylosis of a paralytic, flail-like joint is described in § 40. § 119. Deformities of Joints (Contractures).—The deformities of joints which we shall speak of here are faulty positions in which joints §119.] DEFORMITIES OF JOINTS. 699 may have become more or less fixed, and are sometimes congenital and sometimes acquired, and when acquired are called contractures. In discussing the subjects of inflammation and anchylosis of joints we learned how contractures might develop, and consequently we shall confine ourselves at present merely to a brief account of the individual forms of this affection, the reader being referred to the Special Sur- gery for a more detailed description of each, especially as regards the treatment. The congenital deformities of joints are mainly due to disturb- ances of development wdiich occur in the foetal stage of life. The con- genital club-foot (pes varus, Fig. 381)—i. e., the supination-contracture of the foot—is an example of this. The supination is almost always combined with plantar flexion (pes equino-varus). It might be said that a slight amount of club-foot is physiological, inasmuch as every infant at birth has some suggestion of it. Pronounced club-foot is, briefly speaking, a disturbance of development in the astragalo-crural, the calcaneo-astragaloid, or the astragalo-scaphoid joints, which is brought about principally by the foot being kept in continuous supina- tion owing to lack of space in the uterus. The bone which undergoes the most pronounced change of form in consequence of this continual supination of the foot in utero is the astragalus, the neck of which becomes longer than it normally should be, and somewhat bent; in other words, the growth of the astrag- alus adapts itself to the abnormal posi- tion which the foot assumes in utero. The rare cases of congenital flat - foot (pes valgus or pla- nus, Fig. 385) and of pes calcaneo-valgus originate in a similar manner, being due to the pressure exerted by the walls of the uterus. By pes cal- caneo-valgus is un- derstood a foot which is dorsally flexed to such an extent that its dorsum comes nearly or quite in contact with the leg, and is at the same time abducted (Fig. 388). Scoliotic or kyphotic curvatures of Fig. 381.—Club-foot {pu> varus). Fig. 382.—Club-foot caused by a congenital absence of the entire tibia. 700 INJURIES AND DISEASES OF JOINTS. the spinal column, or club-hand or club-foot, may also have their ori- gin in congenital defects occurring in the vertebrae or in the bones of the forearm or (lower) leg (see Fig. 382). The acquired deformities of joints are due first of all to disturb- ances occurring during the growth of articular surfaces previously normal, in children and young subjects. Thus deformities of the joints develop in the lower extremities and vertebral column as a result of the pressure exerted by the weight of the body. Their origin is to be ascribed to pressure on the joint surfaces, which is either too protracted or too excessive, or unevenly distrib- uted. This class of cases includes the lateral curvatures of the spinal column or scoliosis (Fig. 383), genu valgum (Fig. 384), and flat-foot (pes planus or pes valgus, Fig. 385). Rhachitic bones are particularly7 apt to suffer from these pressure deformities; the pressure causes a grad- ual change in the shape of the bones, their growth being diminished in the parts where the pressure is greatest and increased where the pressure is least. The diaphyses or epiphyses of the long hollow bones, especially if they are soft (see Rhachitis), are thus bent and curved by the weight which they have to sustain. This is also the explanation of the change in the shape of the vertebrae encountered in a case of scoliosis which has existed for a long time, and of the curvatures of the femur and tibia in the neighbourhood of the junction of the epiphysis with the diaphysis; of the obliquity of the condyles in genu valgum (Mikulicz) ; and of the depression of the arch of the foot and change in shape of the tarsal bones in pes valgus. Stretching or shortening of the soft parts, especially the muscles, fascia, and the ligaments of the joint, may then develop secondarily. As a result of primary disease of the muscles, or, more commonly, of the nervous system, myopathic and neuropathic deformities, or, in other words, true contractures of joints, are produced. Primary mus- cular contractures used to be thought very common, and were wrongly looked upon as the cause of scoliosis and flat-foot. Neuropathic contractures are divided into the spastic and the para- lytic. Spastic contractures are the result of diseases of the central nervous system, and hence belong more properly to the province of § 119.] DEFORMITIES OF JOINTS. 701 Fig. 384.—Genu valgum. internal medicine, so that we shall confine ourselves here to merely a brief description of them in so far as they are of surgical importance. Little and Erb have recently made a special study of this form of con- tracture, and have shown that it is not by any means as rare as has hitherto been supposed. Little has also given a description of a con- genital spastic paralysis, of which Rupprecht has published some typ- ical cases. Spastic contractures (Fig. 386) are due in the main to a hyperin- nervation of the muscles, and are either congenital, or acquired in the course of numerous diseases of the brain and spinal cord, such as tumours, embolism, localised infec- tious processes, injuries, spondylitis with compression of the spinal cord, chronic meningitis, hydro- cephalus, syphilis of the brain, mul- tiple sclerosis, and finally as a result of reflex action from simple irrita- tion of the brain. Heusinger observed spastic contractures of the foot in the form of equino-varus during an epidemic of ergotism. The congenital form of spastic contracture (Erb's spastic spinal paralysis of children) is, according to Erb, due to pathological lesions which con- sist, as Little thinks, of interpartum haemorrhages into the brain and spinal cord, resulting in sclerosis, chronic meningitis, and cerebro- medullary hyperaemia. The symptoms of spastic con- tractures are very characteristic. The muscles are not paralysed, but, on the contrary, possess an in- creased amount of innervation. As illustrated in Fig. 386, the tightly contracted muscles of the lower ex- tremity compel the limb to assume a position of flexion, adduction, and inward rotation. The resistance which the muscles offer to an attempt at passive extension is usually very considerable. If, however, the patient sits or lies down, placing his body completely at rest, and if the points of origin and insertion Fig. 385.—Pes valgus. 702 INJURIES AND DISEASES OF JOINTS. of the flexor muscles are approximated, the muscles immediately be- come relaxed. But every effort to use the muscles actively or to extend them passively, or any application of electricity, straightway gives rise to a tetanic, contraction which renders co-ordinated move- ments impossible. Under chloroform the muscles of young persons become completely limp, and all movements can be easily made; but the muscles and ligaments on the flexor aspects of the limbs of older patients, as illustrated in Fig. 386, are ordinarily so shrunken that complete exten- sion will no longer be possible. The paralytic contractures —i. e., those which are the re- sult of paralytic conditions and follow injuries and diseases of the central nervous system and peripheral nerves — are ex- tremely common (see Figs. 387, 388, 389). They include the paralytic contractures which occur so frequently with the partial or total paralyses following meningitis and en- cephalitis in children, and the Fig. 386.—Spastic contracture of the lower extrem- spinal (sO-Called essential) in- fantile paralyses which affect almost exclusively the lower extremity. Of the paralytic contractures of the foot the most common are the pes equinus paralyticus (Fig. 387) and the paralytic club-foot which very often takes the form of pes equino-varus paralyticus. In the paralytic club-foot the equinus posi- tion predominates, but in the congenital form the varus contracture— i. e., the adduction and supination—is the most noticeable feature (Fig. 381). The pes calcaneus paralyticus (Fig. 388) and the pes valgus par- alyticus (Fig. 3S5) are much rarer. Paralytic contractures of the knee, the hip, and especially of the hand, where they may follow injuries of the ulnar, median, or musculo-spiral nerves, are comparatively com- mon. Fig. 389 illustrates the typical main en griffe, or claw position, assumed by the fingers after paralysis of the ulnar nerve. In the re- gion of the spinal column paralytic contractures take the form of later- al curvatures (paralytic scoliosis) or of flexion or extension contractures (paralytic kyphosis and lordosis). In all cases paralysis of any one §119.] DEFORMITIES OF JOINTS. 703 particular group of muscles, or rather of the nerves which supply them, invariably gives rise to a characteristic contracture (see Special Surgery, Fig. 387.—Pes equinus Fig. 388.—Pes calcaneus paralyt- Fig. 389.—" CI aw position" (main paralyticus. icus. en griffe) ol the fingers follow- ing paralysis of the ulnar nerve. Infantile Spinal Paralysis.—As the spinal paralysis of children often leads to paralytic contractures, it should be briefly described at this point. The disease usually attacks children between one and four years of age. The acute infectious diseases and rheumatism have an important etiological bearing upon it, and heredity is sometimes to be taken into consideration. Pathologically it is an acute inflammatory process situated in the anterior grey horns of the spinal cord (polio- myelitis acuta), and is most commonly located in the lumbar, less often in the cervical, enlargement; it is either unilateral or bilateral, and is characterised by hyperaemia, by haemorrhages, and by red softening with degeneration of the ganglion cells and nerve fibres. This inflam- matory process, which at the outset is acute, results in the development of a circumscribed or diffuse sclerosis (connective-tissue growth) with secondary atrophy of the nerve fibres, and a subsequent secondary de- scending degeneration of the nerves. The muscles supplied by these nerves likewise undergo a degenerative atrophy, and in addition be- come the seat of a secondary interstitial growth of connective tissue or fat. The atrophy of the nerves and their roots is a secondary change, and that of the muscles is a result of the loss of their trophic centres in the anterior columns of grey matter. Leyden states that the affection may also result from a peripheral multiple neuritis, the latter in part remaining peripheral and in part leading to localised disease of the spinal cord. 704 INJURIES AND DISEASES OF JOINTS. I must refer the reader to the text-books on nervous diseases for a full description of the symptomatology of infantile spinal paralysis, as only the following brief outline will be given here. The disease usu- ally begins suddenly without prodromata, with a high-fever, 40° to 41° C. (104° to 105-8° F.), and corresponding acute manifestations accom- panied by stupor, convulsions, etc. Occasionally this acute febrile onset is absent. After one or two days the acute manifestations gen- erally disappear. The paralysis develops during the time that the tem- perature is elevated, but is usually not noticed till later.. It spreads at first very rapidly, and may affect all the muscles of the limbs and even those of the trunk. It then ordinarily diminishes, leaving a perma- nent paralysis which varies greatly in extent, but is generally mono- plegic and confined to one leg, less often paraplegic, and still more in- frequently takes the form of spinal hemiplegia or of crossed spinal hemiplegia (leg and arm of different sides). Often only parts of a limb, or, more exactly, only certain groups of muscles, are affected. The permanent paralysis is purely motor, and is characterised by a rapidly progressing atrophy of the muscles. Within one or two weeks the faradic excitability is lost, though at the outset there is a temporary increased response to the galvanic current, especially to the positive pole. There are to be noted, in addition to the reaction of degenera- tion, the absence of the cutaneous and tendon reflexes in the region where the muscles are paralysed, the not uncommon hyperalgesia of the latter on pressure, and their steadily increasing atrophy, and, above all, the previously mentioned contractures which most frequently occur in the foot. The treatment is given on page 706. The Manner in which Contractures Develop.—How do the various paralytic contractures which occur in such typical forms come to take place ? Delpech was of the opinion that they were produced by active shortening of the non-paralysed antagonistic groups of muscles, and that for this reason the contracture took place towards the side of the antagonists. But Volkmann and Hueter have shown that this antago- nistic theory is not in itself sufficient to explain the manner in which paralytic contractures develop; that, in fact, the contracture of the an- tagonists is quite commonly absent, and that, in addition, the contrac- ture really forms in the direction of the paralysed group. They proved that the weight of the limb, and, in the case of the lower extremity, the superimposed weight of the body, play very important parts in the production of the paralytic contractures. This is the way in which the pes equinus paralyticus (Fig. 387) develops, since the foot drops down of its own weight—in other words, assumes a position in plantar flex- ion, no matter whether all the muscles of the leg below the knee or §1190 DEFORMITIES OF JOINTS. 705 only the extensors are paralysed. This equinus position of the foot may also result from a paralysis which is limited to the muscles of the calf alone, for the reason that the paralysed muscles undergo a short- ening from lack of nutrition. The weight of the paralysed limb can likewise be shown to have an effect upon the development of contrac- tures in other joints of the upper and lower extremity. The pressure exerted upon the paralysed part by the weight of the body is a matter of importance in the production of the various con- tractures which may occur in the spinal column and in the lower ex- tremity when the affected limb is used for standing and walking. This partially explains the way in which the paralytic scoliosis and paralytic flat-foot develop. The rare deformity known as pes calcaneus (Fig. 388), which is usually combined with a valgus position—i. e., a drop- ping of the inner border of the foot—is, according to Volkmann, caused by a tipping forward of the os calcis, due to the latter not being held firmly enough in position by the muscles of the calf. The diagnosis of paralytic contractures is usually easy, and can be made from their general appearance, without an electrical examination (see Injuries of Nerves, Diseases of Nerves, § 87, § 88, and § 97). The pure myopathic contractures due to primary disease of muscles are much rarer than the neuropathic, and result from certain forms of atrophy, injury, and inflammation of muscle (see § 98). The cicatricial contractures, especially those due to loss of substance in the skin and subcutaneous soft parts following acute and chronic inflammations of the soft parts and joints, have already been sufficiently described in the chapters on Healing of Wounds (§ 61) and on injuries and Inflammations of the Soft Parts (§§ 87-100). AVe have thus gained an understanding of the numerous causes which give rise to contractures, and can now distinguish two main groups of those which involve joints, basing the classification upon the manner in which they originate. These are, (1) arthrogenic contrac- tures resulting from congenital or acquired changes in the parts wliich constitute the joint, and (2) non-arthrogenic contractures due to patho- logical changes in the neighbourhood of the joint, or to other diseases, especially those of the nervous system. The neurogenic, myogenic, and tendoerenic contractures which follow diseases or injuries of the nerves, muscles, or tendons, or are brought about by shrinkage of fascia, etc., belong to the non-arthrogenic class. The cicatricial con- tractures which follow losses of substance from traumatism or inflam- mation, or are the result of adhesions, may occur in any part of the body. Contractures of joints are sometimes produced by causes which are partly arthrogenic and partly non-arthrogenic, as, for example, in 45 706 INJURIES AND DISEASES OF JOINTS. chronic inflammations of the hip (coxitis), where there develops alone with the inflammation a progressive shrinkage of the fascia lata, unless this is prevented by proper treatment (Fig. 390). Muscular contrac- Fig. 390.—Contracture of the hip-joint in coxitis from shrinkage of the fascia lata. tures in diseases of joints are also very frequently caused by reflex action, as described on pages 549 and 554. Treatment of Deformities and Contractures of Joints.—The treatment of very many of the deformities and contractures of joints belongs really to the province of orthopaedic surgery, which has made great progress in the last few years. It would require too much space to describe at length the treatment of each separate deformity, but it will suffice to say here that in general the treatment consists in the use of immobilising dressings (plaster of Paris, extension), supporting appara- tus, operative measures (osteotomy, tenotomy, myotomy), electricity, massage, and gymnastics. The treatment of cicatricial contractures which have resulted from inflammation and injury of the soft parts has already been spoken of in connection with Injuries and Inflamma- tions of the Soft Parts (§§ 87-100), and the treatment of arthrogenic contractures has been given in connection with inflammations and anchylosis of joints (§§ 113-118). The treatment of infantile spinal paralysis consists in the use of massage, electricity, and a strengthening mode of life. A weak con- stant current should be applied to the spinal cord as early as possible, by placing one of the large, flat electrodes over the portion which is supposed to be the seat of the disease, and the other electrode on the anterior surface of the trunk, and then alternating the action of the anode with that of the cathode. In addition, the muscles themselves are treated with weak faradic or constant currents, and massaged, or rubbed with alcohol. Baths (hot baths, salt baths, sea baths, etc.) are § 120.] INJURIES OF JOINTS. 707 useful, as well as other hydrotherapeutic measures; also the internal administration of the iodide of potassium, nitrate of silver, ergotine, iron, strychnine, cod-liver oil, and finally good air and nourishing food. Supporting apparatus or immobilising dressings should be used to pre- vent the occurrence of deformities, especially in the lower extremities. The congenital spastic contractures are treated at first by passive movements of the joints, and later by lukewarm baths, galvanisation of the spinal cord, and irritation of the skin along the spinal column. In order to prevent or correct deformities, it is a good plan to use plaster- of-Paris dressings or suitable orthopaedic contrivances. Tenotomy is often of great value ; it not only corrects deformity, but acts directly as an antispasmodic measure. § 120. Injuries of Joints.—Injuries of joints are divisible into two main groups, (1) subcutaneous and (2) open. The latter are also called penetrating, as they enter the joint-cavity. We shall first take up con- tusions of joints. Joint Contusions.—Contusions resulting from a blow with some blunt instrument, or from a fall, are the mildest form of injury to a joint. The contusions may be direct or indirect, depending upon whether the violence which causes the injury acts directly upon the joint, or indirectly by7 contre coup. Indirect contusions of the hip, for example, are caused by a fall upon the feet or upon the trochanter. In indirect contusions the principal injury is a greater or less amount of crushing of the articular surfaces brought about by the latter being forced against one another, and in the worst cases a fracture may occur with impaction of the fragments; but in direct contusions it is mainly the surrounding soft parts and the synovial membrane which are injured. The most important symptom of a contusion of a joint is the ef- fusion of blood into the latter—the Inemarthros—which is in some cases slight, in others very marked, so that the joint feels tense. If the joint is filled to its utmost limits it becomes slightly flexed, as this position renders it most relaxed and gives it its greatest capacity. The effusion of blood is, of course, most easily made out in joints like the knee, which are superficially situated. In haemophilia and scurvy an effusion sometimes occurs spontaneously, or as a result of very slight injuries. Other symptoms of joint contusions are an infiltration of the skin and the subcutaneous soft parts with blood, especially if the contusion is direct; pain in the joint, which is usually slight, and made worse by movement; and disturbance of function, varying with the amount of blood which is effused. For the symptoms caused by a fracture of the bony parts of a joint the reader is referred to § 101 (Fractures). 708 INJURIES AND DISEASES OF JOINTS. The subsequent course of a contusion of a joint which is not com- plicated by a fracture is, as a rule, favourable, and complete recovery usually follows in a short time, though occasionally slight inflammatory symptoms, or hydarthros, persist for a good while. It is only in very exceptional instances that suppuration takes place within the joint, from a suppurative process which originates in a laceration of the skin, gradually extends to the deeper parts and finally involves the articula- tion. Suppuration of the effusion of blood, due to micro-organisms which are deposited by the circulating blood, is extremely rare, but in a tubercular or scrofulous person a tubercular inflammation not in- frequently results from a contusion or sprain of a joint. The diagnosis of contusion can usually be easily made from the swelling of the joint coming on after a traumatism, from the fluctua- tion, the pain on movement, and the more or less marked loss of func- tion. The effusion, if sufficient in amount, assumes the outward con- figuration of the joint. The possibility of haemophilia, as well as of fracture, should always be thought of, and as careful an examination as possible made with these in view. The treatment of joint contusions consists in the employment of massage at an early period, in order to get rid of the effusion by press- ing it into the interstices between the tissues and by causing it to be absorbed by the lymphatics. Pressure applied to the joint by means of elastic bandages, and, above all, repeated movements of the joint, also promote the resorption of the blood. In this way joint contusions are made to get well very rapidly, and even very large effusions will dis- appear in a few days if massage is begun as soon as possible after the accident. Contusions of joints used to be treated by keeping the joint at rest and by applying ice. Ice is seldom necessary7, and then only in the first stages, to soothe the pain ; but keeping the joint at rest is ac- tually harmful in typical cases uncomplicated by a fracture, as the or- ganisation of the effusion into connective tissue is thus materially helped. Puncture and antiseptic irrigation of the joint (see page 665) are only necessary when the joint is distended to its utmost capacity. For the treatment of a hydarthros or suppuration of a joint which may follow a contusion, the reader is referred to §§ 113, 114. A sub- cutaneous fracture within a joint is treated according to the rules laid down on page 596. § 121. Sprains (Distortions).—By a sprain or distortion we mean a momentary, forcible stretching and twisting of a joint, usually combined with a laceration of certain portions of its capsule and ligaments. At present we shall omit all mention of the severe, complicated lacerations which are accompanied by opening of the interior of the joint, as we §1210 SPRAINS. 709 shall return to these injuries under the subject of Penetrating AVounds of Joints, and shall confine ourselves here simply to a description of the typical subcutaneous sprains or distortions which occur with such great frequency. Besides the stretching and tearing of the capsule and ligaments of the joint and the periarticular soft parts which we have just men- tioned, there also occurs a temporary change in the normal position of the articular ends of the bones—a momentary partial dislocation, as it were—but as soon as the force has ceased to act they return to their proper position. Sprains are usually caused by the same sort of vio- lence as dislocations (see § 122)—i. e., by forced movements which are carried beyond the physiological limits, or which are at variance with the normal mechanism of the joint. The amount of force ap- plied in causing sprains is, however, not sufficient to bring about a more than temporary separation of the articular ends of the bones, and only a stretching or partial tearing of the capsule and ligaments takes place, though in the severest cases these structures may be completely ruptured. Sprains of the wrist are usually the result of hyperexten- sion, hyperflexion, or torsion of the hand, and those of the ankle of forced pronation or supination of the foot. Simultaneously witli sprains of the joint the neighbouring muscles and tendons are of course often stretched and lacerated, but a partial or complete rup- ture of the muscles and tendons or dislocation of the latter is only observed in rare instances. Injuries of bones, consisting in contusions of their articular ends, or in tearing or chipping off portions of them, are common occurrences in distortions. Examples of such injuries are fractures of the fibula or internal malleolus in sprains of the ankle, fractures of the lower end of the radius in sprains of the wrist, and cortical tear-fractures (Rissfracturen)—i. e., the tearing away of pieces of bone which form the points of insertion of ligaments and tendons. I should not omit mentioning the dislocations of interarticular carti- lages which may take place—the semilunar fibro-cartilages of the knee, for example—in sprains of the latter joint. The symptoms of a sprain consist mostly in a very intense pain, in consequence of which the active function of the joint is disturbed, the joint becoming completely powerless and as though paralysed. There is usually a diffuse swelling of the joint, caused by the intra-articular and periarticular effusion of blood, and if a fracture is present at the same time this effusion is very marked. Later, owing to changes in the colouring matter of the blood situated in the skin and subcutaneous tissue, bluish-red, bluish-green, dark yellow or yellow discolourations make their appearance. The subsequent course of sprains in typical 710 INJURIES AND DISEASES OF JOINTS. cases is usually favourable, and as a rule, if proper treatment is adopted, thev get well very rapidly. In cases complicated with a fracture, the final outcome, especially as regards restoration of the function of the joint, is dependent upon the nature and location of the break in the bone. Complicated cases of sprain may occasionally give rise to chronic deforming inflammations of the joint, which obstinately resist every form of treatment. In other instances anchylosis may develop, or the opposite conditions may be encountered, the articulation becom- ing loose and flail-like from the stretching and displacement of its various constituents, so that subluxations, or partial dislocations of joints, like the wrist, knee (genu valgum), or ankle (flat-foot), may result. The consequences which may ensue from an unrecognised rupture of a tendon or separation of the latter from its point of attach- ment are also worthy of consideration. Sprains, like contusions, are only followed by acute suppuration of the joint in very exceptional instances; but not infrequently predisposed individuals may subse- quently acquire a tubercular arthritis in a joint which has been the seat of a distortion. The diagnosis of sprains can be easily made from what has been said ; but the joint should always be carefully examined for fracture, especially when the injury is near the hand or foot. The treatment of subcutaneous sprains which are not complicated by a fracture is essentially the same as that of a contusion of a joint, and consists in early massage, intermittent bandaging of the joint with an elastic bandage, and the use of methodical movements. Antiphlogesis is very frequently not necessary, or at most only in the first few hours or days. Massage, in cases not complicated by a fracture, frequently seems to act in a marvellous way, and a joint which is still perfectly stiff and without function may again be made capable of active mo- tion and of performing all its functions by massaging it only once. The sooner massage is begun the better. Rest and immobilisation in uncomplicated cases are to be condemned. If a fracture is present, it should of course be treated according to the general principles which apply to it. In the rare cases of complete rupture of the tendons or capsule, the joint must likewise at first be immobilised until the tears in these structures have united. If tendons have been ruptured, their ends may ultimately have to be joined together by catgut sutures. Other complications, such as suppurative arthritis—which very rarely occurs—are to be treated in the usual way. Puncture and antiseptic irrigation of the joint, on account of extreme distention of the latter with blood, are called for only in exceptional instances. § 122. Dislocations (Luxations) of Joints.—By a dislocation is meant §122.] DISLOCATIONS OF JOINTS. 711 a permanent displacement of the articular ends of two or more of the bones making up the joint. Dislocations are complete or incomplete, the latter also being called subluxations. In complete dislocations the op- posed joint surfaces are entirely separated from one another, while in the incomplete variety the articular ends are still in contact, having merely changed their relative positions in regard to each other. The dislocations of amphiarthroses like the symphysis pubis are usually called diastases. A distinction is also made between recent and old, and between simple and complicated or compound dislocations. The latter include those especially which are associated with open wounds in the soft parts, with ruptures of large vessels or nerves, or with fractures. As regards the causation of dislocations, we distinguish (1) the trau- matic, due to external violence, (2) the spontaneous, pathological, or inflammatory dislocations which occur in the course of an inflamma- tion in a joint, and (3) the congenital dislocations. I. Traumatic Dislocations.—Traumatic dislocations are almost al- ways the result of external violence, rarely of excessive muscular ac- tion. The force is usually applied indirectly, so that the bones are separated from one another by leverage, the power being exerted at a greater or less distance from the joint. Thus, as a rule, forced move- ments are caused to take place wliich go beyond the physiological limits of flexion, extension, abduction, adduction, pronation, or supi- nation, or movements are produced which are at variance with the normal mechanism of the joint, particularly forced rotation. In every joint there exists a mechanism for checking its motion; this is gener- ally made up of bone, less often of the ligaments or capsule of the articulation. When a dislocation takes place this natural inhibitory mechanism is overcome, and the articular end of the bone is pressed against this check to its further movement, which then becomes the fulcrum. If the force ceases to act at this stage, the articular ends of the bones return to their normal position of contact with one another, and only a sprain is the result; but if the force keeps on acting, one of the articular surfaces is lifted from the other, the capsule ruptures, the ligaments and muscular insertions which resist are stretched or likewise ruptured, and the articular end of the bone escapes either partially or completely from the capsule. In a dislocation of the elbow from over-extension, the olecranon fossa acts as the fulcrum against which presses the tip of the olec- ranon process. At the hip the rim of the acetabulum is the fulcrum. The point where the displaced articular end of the bone finally comes to rest depends upon the nature of the movement and the amount of force brought to bear. After the force which produces the injury has 712 INJURIES AND DISEASES OF JOINTS. ceased to act, the dislocated articular end of the bone is made to as- sume some particular position by a so-called secondary movement, brought about by the elasticity of the soft parts—skin, ligaments, cap- sule, and muscles. In this the weight of the limb and the movements made by the injured person or by others are also to be taken into con- sideration. The dislocated articular end of the bone is held in its new position mainly by means of the uninjured portions of the capsule and accessory ligaments. The dislocations caused by direct violence, such as a blow or fall upon the joint, are much rarer. Occasionally dislocations result from muscular action, especially at the shoulder (Cooper, Streubel, etc.), where they have been caused by making attempts to seize an object placed above the head, or by pull- ing with the hand elevated. The dislocations of the lower jaw due to opening the mouth too wide, as in yawning, are also produced by mus- cular action ; and dislocations following general muscular contractions, as in epilepsy or eclampsia, belong to the same category. Many persons can dislocate their joints voluntarily ; but these dis- locations—that of the first phalanx of the thumb being a common ex- ample—are not ordinarily complete, though in some instances they may be. The well-known athlete Warren was able at will to com- pletely dislocate most of his joints, including the shoulder and hip, and, in the case of the latter, to cause the head of the femur to lie two inches above Nelaton's line. Then, when he wished, he could re- duce it again, causing a loud, snapping sound. Acrobats and so-called " snake men " bring about by constant practice such a lengthening and loosening of the capsule and ligaments of their joints that they can finally dislocate the latter and bring them back into place again volun- tarily. Occurrence of Traumatic Dislocations.—Dislocations are most common in middle life, but are very rare in old people and young children, for the reason that external violence is more likely to cause their bones to break. Young children are very apt to sustain separations of the epiphyses owing to the slight powers of resistance which the latter possess. Dislocations of the upper extremity are the most common, amounting, according to Kronlein, to 92"3 per cent, of all luxations, while dislocations of the lower extremity amount to only 5 per cent., and those of the trunk to only 2'8 per cent. Dis- location of the shoulder, on account of the freedom of motion in this joint, are the most common, constituting about one half of all the dislocations which are encountered (51-7 per cent., Kronlein). Dislocations occur from three to five times more frequently in men than in women, because the for- mer are more exposed to injuries on account of their occupations. Disloca- tions of the lower jaw are, however, according to Kronlein, about four times more common in women than they are in men. g 122.] DISLOCATIONS OF JOINTS. 713 The anatomical changes—i. e., the amount of injury to the tissues— depend in general upon the nature and intensity of the force which is brought to bear and the anatomical structure of the joint in question. As a rule, however, the following injuries to the tissues are more or less constant: The rent in the capsule, which is always present in a complete traumatic dislocation, is sometimes slit-shaped and sometimes irregular in form ; not infrequently the capsule is torn from its inser- tion, and may or may not carry with it at the same time a portion of the bone to wliich it is attached. The accessory ligaments are either stretched, lacerated, completely ruptured, or torn from their point of insertion on the bone. Similar changes take place in the muscles. The intra-articular and periarticu- lar effusion of blood is usually not very large, and when it is, a frac- ture may be suspected. The most important complications of trau- matic dislocations are extensive in- jury to the skin and subcutaneous soft parts, the simultaneous pres- ence of a fracture, and injuries to large vessels, nerves, and internal organs. In the majority of cases of un- complicated dislocations, after re- duction of the displaced articular surfaces has been accomplished, a complete restitutio ad integrum usually follows, the rent in the capsule appearing to heal with es- pecial rapidity. But if the dislo- cated articular end of the bone re- mains in its abnormal position a new more or less perfect joint is formed—a so-called nearthrosis (see Figs. 391, 380). These nearthroses are sometimes very perfectly de- veloped, especially at the hip and shoulder. As illustrated in Fig. 391, a new socket is formed at the hip by growth of the periosteum, which becomes covered with hyaline or fibrous cartilage. The capsule is con- structed by an inflammatory new formation of tissue in the surround- ing soft parts, and its inner surface is gradually made smooth by the movements of the head of the bone, so that it may finally come to re- semble a synovial membrane. The dislocated end of the bone usually Fig. 391.—Luxatio femoris supracotyloidea in- veterata with a very perfectly formed new acetabulum (preparation from the collec- tion in the surgical clinic at Bonn—Kron- lein). 714 INJURIES AND DISEASES OF JOINTS. atrophies somewhat, and changes take place in its articular surface cor- responding to the new conditions of friction ; these changes are some- times similar to those of arthritis deformans. Symptoms and Diagnosis of Uncomplicated Traumatic Dislocations.— The symptoms of traumatic dislocations are partly objective and partly subjective. The objective symptoms are : (1) A change in the contour of the joint; (2) a change in the relative positions of the articular ends of the bones ; (3) a change in the axis of the bone or limb thought to be dislocated; (4) a lengthening or shortening of the dislocated limb (Figs. 392, 393). The change in the contour of the joint is often evident to an experienced eye at the first glance. The patient should always be sufficiently undressed to render a comparison between the sound and damaged side possible; one can then note the normal con- figuration of the uninjured joint, the normal position of the bony prominences, the relationship of the folds of the skin and soft parts on the healthy and the abnormal de- pressions and elevations on the dis- eased side resulting from the changed situation of the head of the dislocated bone. The most im- portant symptom—viz., the abnor- mal position of the head of the dislocated bone—can be recognised by palpation or by making move- ments with the dislocated limb. The altered direction in wliich the latter points is usually such that the long axis of the luxated bone does not strike the articular cavity of the other, but passes outside of it; in the case of the shoulder, for exam- ple, the long axis of the humerus passes outside of the glenoid cavity (Figs. 392, 393). The dislocated limb, in the majority of instances, is shortened, rarely lengthened, and assumes a position which is perfectly characteristic in every dislocation. The subjective symptoms are pain, and inability to perform normal movements with the injured limb. The disturbances of function usu- ally consist of a loss of active motion, while passive movements are possible to some extent. The latter are often very easily carried out in a certain direction, while in others they may be quite impossible. Fig. 392.—Luxatio humeri subcoracoidea sinistra. §122.] DISLOCATIONS OF JOINTS. 715 From what we have just said, it follows that the diagnosis of dislo- cations, especially soon after the accident, is usually not difficult. If the swelling due to the effusion of blood is very large, it can be reduced in size by gentle mas- sage, possibly under an anaesthetic. Disloca- tions are most likely to be confused with frac- tures of the articular ends of the bones. The latter may be suspected if the dislocation, or, rather, the deformity, is easily reduced by slight traction applied to the injured limb, but returns again immediately when extension is discon- tinued. In dislocations, on the other hand, spe- cial manoeuvres are necessary to cause a disap- pearance of the deformity, and when reduction has once taken place the change of contour does not again recur spontaneously. In fractures, abnormal mobility and crepitus are usually pres- ent, while in dislocations there is an abnormal fixation of the limb, and certain movements are quite impossible. A kind of crepitus is also some times met with in dislocations, but it is softer than bone crepitus, and is due to blood coagula and to the tearing of the ligaments of the capsule or of the tendons. Complications of Dislocations.—The most im- portant complications of dislocations are: (1) Fig. 393.—Dislocation of the Extensive injury to the skin and subcutaneous m^f^1^ ^^ soft parts over the joint; (2) fracture occurring simultaneously with the dislocation; (3) rupture of large vessels and nerves; (4) injury to internal organs. Division of the skin and subcutaneous soft parts with exposure of the head of the dislocated bone is not common ; it is observed most often at the elbow, in the fingers, at the knee, and at the ankle. Such compound dislocations are always to be looked upon as serious injuries, especially when they are combined at the same time with fracture. The sooner a compound dislocation is subjected to antiseptic treatment the better will be the prospect of preventing infection and a serious suppu- rative arthritis (see § 123, Wounds of Joints). The most common complication of a dislocation is a fracture occur- ring at the same time. The fracture may either involve the cortex, a portion of bone being torn off at the point of attachment of some liga- ment or tendon, or the fulcrum, or the dislocated bone itself, or the 716 INJURIES AND DISEASES OF JOINTS. non-dislocated parallel bone, such as the ulna, which may be broken below the elbow in forward dislocations of the head of the radius. The fractures of least importance are those of the cortex and of bony promi- nences like the tuberosities of the liumerus or the malleoli. Fractures of the rim of the acetabulum at the hip, and of the glenoid cavity at the shoulder, are, on the other hand, more serious, since they increase the difficulty of reduction or favour a recurrence of the dislocation. If a fracture occurs in a dislocated bone, the dislocation usually takes place first and then the fracture. Rupture of large vessels or nerves is very rare, and is sometimes the result of unskilful reduction of an old dislocation. Stretching and crushing of the vessels and nerves are, however, more common. Crush- ing of the vessels occasionally gives rise to extensive thrombosis fol- lowed by gangrene, especially if the dislocation is not promptly reduced. Of the injuries of nerves, those of the circumflex, with paralysis of the deltoid muscle, are the most frequent. Of the injuries of internal organs, I should mention injury of the spinal cord in dislocation of the vertebrae, of the bladder, intestine, and pelvic organs in luxatio femoris centralis—i. e., dislocation of the femur inwards through the acetabulum, also compression of the tra- chea and oesophagus in dislocation of the sternal end of the clavicle, etc. Prochaska saw a case in which the head of the humerus pene- trated the thorax between the second and third ribs. Prognosis of Traumatic Dislocations.—As regards the prognosis, it is important for us to consider (1) whether we have to deal with a simple or a compound dislocation, (2) whether complications are present, and, if so, their nature, and (3) the region of the body and the particular joint where the dislocation has occurred. We usually expect perfect recovery to take place in the case of simple uncomplicated dislocations which have been successfully reduced. Should the dislocation not be reduced, a new joint or nearthrosis is formed, as we saw above, in the abnormal situation occupied by the articular end of the dislocated bone, particularly if the dislocation were one of the shoulder or hip. Occasionally a dislocation will recur from even a very slight amount of violence, and particularly if extensive movements are made with the joint at too early a period. We sometimes meet with individuals who in this way suffer from very frequent recurrences of the same dislocation, especially that of the shoulder, jaw, or the hip, and there are people who have dislocated their shoulder or jaw more than fifty or one hundred times. These " habit- ual dislocations," as they are called, have many different causes, but they are usually due to a lax condition of the capsule and its accessory liga- § 122.] DISLOCATIONS OF JOINTS. 717 ments, which have become stretched and torn to such an extent that the cavity of the joint is enlarged, and a dislocation can take place without the occurrence of any fresh laceration. Treatment of Traumatic Dislocations.—The treatment of recent un- complicated dislocations consists in bringing the displaced articular end of the bone back into its socket by special methods of reposition, and then immobilising the joint until the rent in the capsule has healed. The reposition was at one time carried out in a very .forcible and rough way, and not infrequently with the aid of mechanical con- trivances, pulleys, etc.; so that sometimes disastrous consequences— such as severe injuries to the skin, vessels, nerves, and muscles, or fractures—followed, and in some instances even entire extremities were torn away. At present we have in chloroform anaesthesia an excellent means of rendering the reduction of dislocations easy and painless. An attempt should first be made to reduce a recent dislocation without an anaesthetic, and if this is found to be impossible chloroform should be administered, but with great caution, because a collapse resulting in death may easily take place, especially in habitual drinkers, who are much excited by the accident. The sooner after the accident reduction is performed the more easily it is accomplished. The movements employed for reducing a dislocation must be carried out according to certain rules, which vary with the nature of the case, and in making them one should always take into consideration the shape of the joint and the nature and location of the rent in the capsule. Impediments to the reduction of recent dislocations are furnished by active contrac- tion of the muscles, by the narrowmess or unfavourable location of the rent in the capsule, by portions of capsule which still remain intact though stretched and abnormally situated, and by interposition of por- tions of the capsule, tendons, muscles, and fragments of bone. Active contraction of the muscles and the elastic tension of the soft parts are overcome by chloroform anaesthesia. It is evident that the movements made in accomplishing reduction must differ very greatly according to the nature of the case and the site of the dislocation ; that sometimes rotation, sometimes flexion or extension, and sometimes abduction or adduction must be performed ; and Kronlein is right in saying that it is not so much the etiology of a dislocation as it is its anatomy which determines our method of treatment. By means of the movements or manipulations aimed at reduction the head of the dislocated bone is brought opposite the rent in the capsule or the socket, and then, with a snapping sound or perceptible jolt, caused to enter the cavity of the joint. As a rule, it is well to combine with the above-mentioned manipulations a direct pressure upon the articular end of the dislocated 718 INJURIES AND DISEASES OF JOINTS. bone. For the methods of reducing the various dislocations of the different joints I must refer the reader to my Special Surgery. The restoration of the normal contour and functions of the joint will show at once that the reduction of the dislocation has been successful. The after-treatment consists in keeping the replaced portions of the articulation at rest by means of light, immobilising dressings. In dislocations of the shoulder, for example, it will suffice if the arm is held firmly fixed by a mitella (see Fig. 155), which is secured in posi- tion by a few turns of a bandage around the arm and thorax. In dis- locations of the hip the patient should be kept in bed, a spica coxae (see Fig. 143) applied about the joint, and the limb immobilised by a cloth passed around the leg in the region of the knee. It is difficult to keep some joints reduced, as is the case with forward dislocations of the head of the radius and dislocations of the acromio-clavicular and sterno-clavicular articulations. In such instances an attempt must be made to hold the bone in place by dressings which exert pressure, by pads, or, when necessary, by the use of nails or bone sutures. After the lapse of some eight, ten, or fourteen days—depending upon the nature of the case—passive motion of the dislocated joint should be begun in order to prevent subsequent stiffness. Forced movements of the joint should, however, not be attempted during the next few weeks, because the healing of the lacerations in the capsule and ligaments may be interfered with, or the cicatrices of these structures may be so stretched that the dislocation easily recurs, or even becomes ha- bitual. The treatment of habitual dislocations, as a rule, is very difficult, particularly in marked cases. Long-continued rest of the joint in one position is usually unsuccessful, because the injured person has not the required patience. Yery often nothing remains but to restrict the movements of the joint by means of a suitable bandage. In bad cases it may be well to expose the joint under antiseptic precautions, and either suture the rent in the capsule or resect the head of the bone. Genzmer successfully treated two cases of habitual dislocation—one of the shoulder and the other of the jaw—by the subcutaneous injec- tion of pure tincture of iodine (0*5 to 0*75 cubic centimetres tinct. iodi injected by a hypodermic syringe at intervals of three to four days, until six to eight injections have been made). Subcutaneous injections of absolute alcohol might also be tried. In fresh dislocations which are irreducible an aseptic arthrotomy should be performed—i. e., the site of the dislocation should be ex- posed by an incision and the head of the bone then brought back into place, or resected if reduction is otherwise impossible. But recent § 122.] DISLOCATIONS OF JOINTS. 719 simple dislocations seldom require operative interference, since reduc- tion can generally be accomplished, especially if chloroform is used. One should first try to reduce even old dislocations by the usual method, though they may have existed for weeks, months, or years ; luxations of the shoulder and also of the hip have thus been success- fully brought back into place two years after the accident. The possi- bility of reduction in these cases depends mainly upon the extent of the injuries which the soft parts have suffered, upon the greater or less degree of fixation of the dislocated articular end of the bone in its new position, and, finally, upon whether the joint cavity is much diminished in size or quite obliterated. After thoroughly anaesthetising the patient with chloroform, the same manipulations are employed for the reduction of old dislocations as for those which are recent, the articular end of the bone being first freed by rotatory movements. The manipu- lations aimed at reduction should be made with great care so as not to injure the bones or soft parts. The mechanical contrivances once so extensively used, such as pulleys, windlasses, etc., have become obsolete and have only a historic interest. Even though the reduction is suc- cessfully accomplished a good result is not always assured, as the joint often remains stiff in spite of massage, electricity, and active and pas- sive motion. If reduction is impossible, the dislocation should be ex- posed by an incision—i. e., arthrotomy should be performed and the head of the bone returned to its normal position, especially in those cases in which the limb has become useless owing to malposition, or in which the dislocated articular end of the bone causes pain and paralysis by pressing upon the nerves. In such instances resection of the articular end of the bone will often be necessary as a preliminary step in per- forming reduction. At the hip the position of the limb is sometimes best corrected by osteoclasis or subtrochanteric osteotomy. In other cases of old irreducible dislocations one may try to make as good a nearthrosis as possible by means of massage, passive motion, electricity, and warm baths. Dislocations in which there is an opening at the same time into the joint are treated by the same rules that apply to wounds of joints (see page 723). Under these circumstances, also, reduction should be per- formed as promptly as possible, taking every antiseptic precaution and providing for drainage of the joint. According to Drewitz, reduction without resection of the head of the bone gave, even in preantiseptic times, movable joints in forty per cent, of the cases. If difficulties are met with in performing reduction the knife should be made use of, and when reduction has been accomplished the joint should be care- fully drained and immobilised. If the soft parts have been very much 720 INJURIES AND DISEASES OF JOINTS. injured permanent irrigation should be employed. Kesection of the head of the dislocated bone is indicated in cases complicated by com- minuted fractures, extensive injury to the soft parts, suppuration within the joint, or where reduction is impossible by other means. If sepsis has already made its appearance prompt amputation or disarticu- lation may be necessary. If both dislocation and fracture occur together, it should be our first aim to reduce the dislocation when this is possible, using, for ex- ample, direct pressure upon the articular fragment in the case of dislo- cation and fracture of the humerus at the shoulder joint. In other instances reduction of the dislocation may be impossible, and the frac- ture must first be allowed to heal before the dislocation is attended to. In suitable cases operative measures must be undertaken—i. e., the seat of injury should be exposed, and whatever measures the condition calls for adopted. The prognosis of all dislocations which are complicated by fracture should be looked upon as doubtful as regards restoration of the normal mobility of the joint. The other complications, such as injuries to vessels and nerves, are to be treated in the usual way (see § 88). Dislocation of the semilunar cartilages of the knee rarely occurs inde- pendently of other changes in the joint. Habitual dislocation of these car- tilages has been observed, tbe most common variety being a displacement of the inner cartilage forwards, due to forced flexion of the knee joint combined with outward rotation of the foot, or, rather, leg. The displaced cartilage can be felt on the anterior border of the joint, the knee is somewhat flexed, and complete extension is impossible. For a description of dislocations of tendons and nerves see pages 509, 510. II. Pathological or Spontaneous Dislocations are observed in the course of diseases of joints either as a result of an abnormal stretch- ing or lax condition of the capsule and ligaments, or of changes within the joint such as those caused by arthritis deformans or caries. Under such circumstances either an incomplete or a complete dislocation takes place, coming on gradually and brought about by the weight of the limb, or suddenly from some slight traumatism, muscular action, etc. We distinguish: 1. Distention Dislocations, due to a stretching or lax condition of the capsule and ligaments of the joint caused by a serous, sero-fibrinous, or more rarely suppurative effusion. Complete and incomplete dislocations of this kind are especially common in the course of metastatic inflammations of joints with large collections of fluid, such as occur in typhoid fever, small-pox, measles, scar- let fever, diphtheria, puerperal fever, and pyaemia. The capsule and ligaments of a joint—the shoulder, for example—may also become g 122.] DISLOCATIONS OF JOINTS. '21 stretched in cases of muscular atrophy and paralysis. Under these conditions the muscles are not capable of supporting the extremity, and thus allow displacements of the joint surfaces to take place either Gradu- ally or suddenly. The voluntary dislocations mentioned on pao-e 712 are likewise looked upon by some authors as distention dislocations. Quite recently Verneuil has called attention to dislocations which occur during acute articular rheumatism and run a course exactly like that of traumatic dislocations. In all cases the luxations took place suddenly and spontaneously, and could be reduced very easily under an ansesthetic. Ver- neuil thinks that these dislocations are caused by muscular action and a lax condition of the ligaments. 2. Destruction Dislocations.—The most common form of patho- logical dislocation is due to a carious destruction of the joint surfaces combined with corresponding changes in the capsule and ligaments. In this category belong the so-called " wandering of the acetabulum " in coxitis (page 674, Fig. 374) and the spondylolisthesis—i. e., the slipping down of the last lumbar vertebra into the pelvis in cases of tubercular destruction of the corresponding intervertebral ligaments (see § 114). 3. Deformity Dislocations, which are the result of changes in the shape of the bony parts of the joint due to an atrophy of bone with- out suppuration and without the production of granula- tions. They most commonly occur in connection with ar- thritis deformans (see page 6S6, Fig. 380). For the course, diagnosis, and treatment of pathological dislocations see § 113, § 114, ^ 119 (Inflammations and De- formities of Joints), and the above description of traumat- ic dislocations. III. Congenital Disloca- tions. — Congenital disloca- tions are mainly the result of anomalous or arrested foetal development. They are most common at the hip (Fig. 394), being very rarely found in the rest of the joints, and are occasionally combined with other anomalies of development, such as club-foot, spina bifida, and ectropion vesicae. These congenital dis- locations, which take place in utero, should not be confused with the traumatic ones which take place during delivery and are due to extrac- 46 Fig. 394. - Congenital dislocation of the left hip in a six-months-old jrirl: a, remains of the capsule wliich has been dissected away; b, undeveloped acetabulum. INJURIES AND DISEASES OF JOINTS. tion of the child. This latter form of dislocation is, however, extreme- ly rare, fractures, especially at the epiphysis, on account of the latter's slight power of resistance, being much more common. Investigations relating to the Pathology and Etiology of Congenital Dislo- cations.—These investigations have to do almost exclusively with congenital dislocations of tbe hip. I had an opportunity at one time of examining a dislocation of this kind in a female child six months old (Fig. 394). I found that the acetabulum was very imperfectly developed, that the neck of the femur formed an obtuse angle with the shaft, and that the ligamentum teres was so much thickened and lengthened that tbe head of the femur, which was situated near the anterior superior spine, did not have sufficient room in the shallow acetabulum. The pelvis was, moreover, asymmetrical, but the capsule of the joint was normal. The congenital dislocation of tbe hip usually belongs to the iliac variety, the head being in contact with the ilium. Lordosis of the vertebral column is present, especially in bilateral dislocations, and the pa- tients have a very characteristic gait, like that of a duck. The main cause of congenital dislocation of the hip is probably to be found in an imperfect development of the acetabulum or the cotyloid ligament, and its occurrence is favoured by extreme flexion and adduction of the thighs of the foetus (Fig. 395, Dupuytren, Eoser). A very small uterus, which exerts abnormal pressure upon the foetus, thus causing the latter to assume a cramped position, may possibly have a deleterious influence upon the develop- ment of the hip joint. The obtuse angle which the neck of the femur makes with the shaft (Fig. 394) should also be noted, as this is probably not always a secondary condition, but one which may sometimes develop primarily from the above-mentioned cramped position of the foetus brought about by a uterus which is deficient in size. Owing to the obtuse angle which tbe neck of the femur forms with the shaft (Fig. 394), the head, as it were, grows past the acetab- ulum instead of into it. Other cases of congenital dislo- cation are probably the result of an abnormally long and thick ligamentum teres, which, as in the case I examined, does not give the head sufficient room in the acetabulum. Another important fact, from an etiological point of view, is that congenital dislocations of the hip are much more common in females than in males, 87"6 per cent, of all cases occurring in the former sex. From careful examinations which I have made of the fcetal pelvis, I be- lieve that this latter fact can be explained by the comparatively vertical posi- tion of the ilium in females, which, in conjunction with the abnormal angle formed by the neck of the femur with the shaft, readily allows the head to leave the shallow acetabulum and glide up on to the ilium. It follows from what has been said that the congenital dislocations of the hip are undoubtedly to be ascribed to anomalies in the development of the foetus due to various causes. Fig. 395.—The man- ner in which a congenital dislo- cation of the hip is produced: the leg of the foetus is forced to assume an abnormally adducted position by a uterus wliich is too small (W. Roser). 122.] DISLOCATIONS OF JOINTS. 723 The rare cases of congenital dislocations of other joints of the body are probably also due to foetal anomalies of development. Congenital subcoracoid, subacromial, and infraspinous dislocations of the shoulder have been reported, as well as congenital dislocations of the elbow wrist, knee, and ankle. At the elbow, congenital dislocation of the head of the radius—backward, outward, forward, or inward—is the most common. The symptoms, diagnosis, and treatment of congenital dislocations of the different joints are taken up at length in the Special Surgery, and I will only briefly state here that the prognosis is usually unfavour- able, although fairly good results have been obtained in dislocations at the knee. Effective treatment is generally very difficult, as the dislocations are ordinarily not rec- ognised until too late. Patients do not, as a rule, come under observa- tion until the joint has undergone such changes that a reduction is no longer possible. Little or no bene- fit results from immobilisation car- ried out for a long time, or from extension or supporting apparatus. Eecently Konig and others have tried to expose the head of the fe- mur in cases of congenital disloca- tion of the hip by Langenbeck's in- cision, and then to free the head sufficiently7 by subperiosteal divis- ion of the muscular insertions and soft parts to enable it to be drawn down into the region of the acetab- ulum. If there is no acetabulum, or if, as is usual, it is only rudimen- tary, it must be chiselled out, or an artificial one made by means of a flap of periosteum and bone. I have found it very difficult, especially in older children, to keep the head in the neighbourhood of the acetab- ulum, either immediately after the operation or later, when the wound has healed, on account of the obtuse angle made by the neck of the fe- mur with the shaft. I obtained, however, an excellent result in the case of a boy three years old with a unilateral dislocation, because the Fig. 396. -Double congenital dislocation of the hip. 724 INJURIES AND DISEASES OF JOINTS. acetabulum was abnormally deep, so that the head found sufficient sup- port, even without enlarging the acetabulum artificially. This was the deepest acetabulum that I have ever seen in a congenital dislocation ; and as the ligamentum teres had ruptured, I doubt if this was, after all, a true congenital dislocation. It was, more likely, a traumatic disloca- tion, acquired at a very early period—an injury which, as is well known, is extremely rare in the first years of life. § 123. Wounds of Joints.—Wounds of joints consist of punctured, incised, and contused wounds, and wounds which are complicated with fracture, including gunshot wounds (see § 124). Any wound which opens a joint—a so-called penetrating wound—even though extremely small, should be looked upon as a very serious injury, since it may- more or less completely destroy the function of the joint, and even imperil the life of the patient. The escape of synovial fluid is a symp- tom which indicates beyond a doubt that the joint has been opened. The prognosis of penetrating wounds of joints is, however, much more favourable than it was before the introduction of the antiseptic method of treating wounds, and we now have no fear of opening a joint aseptically with the knife or trocar. But the conditions are entirely different in the case of accidental wounds made with an unsterilised instrument, or of gunshot wounds into which dirty pieces of clothing have perhaps entered. Under such circumstances germs of infection can readily make their way into the joint, and with great rapidity cause violent inflammation. The course of a penetrating wound of a joint depends very largely upon whether or not germs of infection have gained access to the joint at the time of the accident, or afterwards. We shall first discuss the cases in which everything is most favour- able—i. e., in which no infection of the wound, a punctured one, for example, has taken place. The course of such a wound will then be as follows: The synovia makes its appearance at the time of the acci- dent, but soon ceases to flow out, and the wound becomes agglutinated and heals up without causing any inflammation or disturbance of func- tion in the joint. In other cases a mild inflammation occurs, taking the form of a synovitis serosa or serofibrinosa. The course of an infected wound of a joint is quite different. In- fection may take place at the time of the accident or later, and is then due to improper treatment or dirty probes, or to the fact that the patient pays no attention to the wound, and walks about, thus, by his movement of the parts, permitting air and infectious germs to have free access to the joint. In some cases the wound has already united, and then on the third to the fifth day manifestations of inflam- s5123-1 WOUNDS OF JOINTS. 725 mation suddenly make their appearance, and rapidly increase in sever- ity. The joint is swollen, tense, and very painful, the skin is red and feels hot, and there is high fever. If the agglutinated borders of the wound are separated by a probe, or if the sutures are removed, pus immediately makes its appearance. Other cases, especially those in which there is a large effusion of blood, run a more acute course, and the local and general symptoms of suppuration in the joint come on within twenty-four hours after the injury. These are the most unfavourable ones, and unless the infected contents are promptly removed by freely opening up the joint, followed by drainage and antiseptic irrigation, or, if necessary, by resection, acute gan- grene of the joint may rapidly follow, with, perhaps, constitutional sepsis. In another group of cases the course is more subacute, and though the exudate within the joint is very large it is not noticeably suppu- rative in character, but looks like cloudy synovia mixed with flakes con- taining pus-cells (see § 113). The final outcome of an infected wound of a joint varies, though if it receives antiseptic treatment early enough recovery is assured. In some cases, after a longer or shorter time, the suppurative inflam- mation gradually gets well spontaneously without any particular anti- septic treatment, but in others which are not properly attended to the suppuration becomes progressive, breaks through the capsule of the joint, and gives rise to suppuration in the neighbourhood, while the inflammation in the joint itself apparently diminishes in intensity. Such suppurative processes not infrequently run a very tedious course, gradually going on to pyaemia, to which or to extreme exhaustion the patient succumbs. The worst cases are those in which death occurs from acute septicaemia within a few days. These septic or gangrenous inflammations of joints may be caused by a very slight injury, such as puncture of the joint with a sewing needle, and they may run such a rapid course that even on the fourth or fifth day death from septicaemia cannot be prevented even by amputation or disarticulation. We have already described the course and outcome of the different varieties of acute inflammations of joints in the chapters devoted to Joint Inflam- mations. The Repair of Wounds in Cartilage.—Gies has made experiments on young dogs with reference to the repair of wounds made in cartilage and has come to the conclusion that clean aseptic wounds in this tissue never heal, but remain permanently unchanged, while wounds which are made in the presence of micro-organisms heal up so completely as not to leave any or scarcely any traces behind them. 726 INJURIES AND DISEASES OF JOINTS. The escape of synovial fluid in all recent cases which come under observation immediately after the reception of the injury has, as we remarked before, a very important bearing upon the diagnosis of pene- trating wounds of a joint. In some instances in which the joint is laid wide open the exposed articular cartilages may be recognized at the first glance. But not infrequently the puncture or other wound is already closed, so that it is doubtful whether the joint has been opened or not, and under these circumstances we must quietly wait for further developments. A warning should be given here against probing wounds too freely in the neighbourhood of a joint. Treatment of Wounds of Joints.—Every wound of a joint, even the most trivial, should be treated with the greatest care. We shall not discuss the treatment of gunshot wTounds of joints, as they will be taken up later in § 124. Absolutely fresh cases without much effusion into the joint, and without apparent infection, are treated by disinfection of the wound and its neighbourhood. I do not, as a rule, suture such wounds, but merely dust them with iodoform, cover them with iodoform or bichlo- ride gauze which has been moistened in a l-to-1,000 solution of bichlo- ride of mercury, and over this place sterilised cotton. Large wounds should be packed with iodoform or sterilised gauze. The antiseptic occlusive dressing should be as large as possible, and the joint must be carefully immobilised by splints. The time for changing the dressings depends upon the subsequent course of the injury, and very often asep- tic healing takes place without changing the dressing at all. But should fever make its appearance, and the patient complain of pain, the dress- ing must be changed immediately. If, upon taking off the dressing, it is evident that the joint has become infected and that an acute suppu- rative inflammation has developed, thorough disinfection and drainage of the joint must be begun at once. The joint should be freely opened, all pockets within it disinfected with a 1-to-l,000 bichloride solution, and any blood-coagula that may be present carefully removed. Short and thick drainage tubes—preferably of glass—must be inserted in those places where they can most effectually help to carry off the dis- charges. In suitable cases the wound is packed with iodoform gauze or sterilised mull, and it is also of the greatest importance to secure immobilisation of the joint. The dressings must be changed often, de- pending upon the height of the temperature. Xot infrequently one has the pleasure of seeing that this treatment is followed by excellent results, that the inflammation of the joint is averted, and that, even in cases where one could hardly have expected it, perfect mobility of the joint is regained despite the fact that suppurative arthritis has occurred. g 124.] GUNSHOT INJURIES. 7^7 If, in spite of disinfection and drainage of the joint, severe consti- tutional symptoms make their appearance, or if the suppuration that is present is very7 extensive, so that drainage of the joint presents great difficulties, resection is then indicated ; or, if general systemic infection threatens, the focus of infection must be removed by amputation or disarticulation. If the patient comes under treatment after suppuration lias already- begun, antiseptic incision and drainage, or packing of the joint with or without resection, or even amputation are indicated, depending upon the amount of suppuration and the length of time the disease has lasted. In opening up old infected cases of this kind one should not be afraid of making too many incisions into the different parts of the joint. Continuous antiseptic irrigation will often be found a most excellent aid in the subsequent treatment (see page 17s). Any complications that may be encountered—fractures, for instance—are to be treated in the usual way7. (See page 600, Treatment of Compound Fractures.) Al'l'KNDIX. Gunshot wounds. Military practice. § 124. Gunshot Injuries.—In connection with wounds of joints, we shall give a short description of the gunshot wounds which have already been referred to several times in speaking of injuries to the different tissues. We must, of course, confine ourselves here merely to a brief sketch, and whoever cares to become better acquainted with this ex- tremelv interesting subject should read the excellent works of Stro- meyer, Pirogoff, Langenbeck, Billroth, Esmarch, etc. The literature of gunshot wounds and military surgery is very extensive. Of the older books, I should speak especially of the memoirs of Larrey, the famous army surgeon of Xapoleon I, and, amongst English works, of The Principles of Military Surgery, by John Ilennen. Gunshot wounds are essentially contused and lacerated wounds, and are most commonly caused by hand firearms. The projectiles of the latter (shot-guns, revolvers, pistols) are generally cylindrical or shaped like an acorn, and are usually made of lead. The bullets used in mod- ern weapons—i. e., those of small calibre (eight millimetres), at present employed by the European armies—are long and cylindrical, and con- sist of a lead core encased in steel. Owing to this steel covering the bullets have great strength and retain their shape when they strike a bone or pass through the body. The penetrating power of these bullets is as we shall see, very extraordinary, but they are nevertheless more 728 INJURIES AND DISEASES OF JOINTS. humane than the lead bullets. The latter become so soft from friction as they pass through the barrel of the gun and the air that they change their shape very materially and break up into single pieces, so that a sort of explosion results. When they strike bone, for example, they become flattened out, split, shattered, or broken up into irregular, pointed fragments of lead. In the case of shots fired from a short dis- tance the bullet is heated to a very high temperature, and, as we shall see, it is under these circumstances that its explosive action is most likely to take place. Bullets cause the following injuries : 1. The mildest form of gun- shot injury is contusion of the soft parts, with suggillation and without a wound. These contusions of the skin or soft parts are usually made by spent balls coming from a great distance. In rare cases subcutane- ous fractures are also produced in this manner. Occasionally the con- tused, undivided skin is pressed inwards like a pouch, thus causing, when the bullet strikes upon the abdomen, contusion and laceration of internal organs, of which the liver may be one. Moreover, bullets which have a great velocity can be so checked by striking a watch, purse, pocketbook, pieces of leather on the uniform, etc., that only a contusion without any wound results. Bullets of small calibre with a covering of nickel or steel cannot be stopped in this way, as they have an extraordinary penetrating power. 2. Furrowed wounds are caused by bullets which graze the surface of the body and carry with them a portion of the skin, so that a more or less deep furrow is formed. 3. The most common gunshot injuries are tubular wounds—i. e., the bail passes through the skin and enters the soft parts, where it either remains lodged (so-called blind shot canal) or comes out again at another part of the body (" seton shot"), thus making an opening where it entered and one where it emerged. The differentiation of the points of entrance and exit is of importance notably from a medico- legal point of view. The point of entrance is usually more or less in- dented, depending upon the size of the bullet, and is coloured bluish- black, while the exit opening is generally smaller, and looks more like a tear. These points of difference do not, however, always hold good, as the opening of exit is sometimes larger than that of entrance, partic- ularly when a bone is splintered or when the ball changes its shape or becomes broken into pieces. Occasionally several points of exit are found, especially if the bullet has been fired at short range—a thing which produces an effect like an explosion, shattering the bone into separate splinters, which perforate the skin. The burning of the integu- ment is often very extensive when the revolver or pistol has been dis- § 124.] GUNSHOT INJURIES. 729 charged close to the body, as in attempts at suicide, and then, owing to the healing into the tissues of small particles of powder, the skin often remains of a greyish-black colour for the rest of life. The same is true of small shot, wliich, when fired from near at hand, can also cause very extensive destruction of the region where they strike, and particularly severe shock, giving rise to such marked symptoms of collapse that the patient may die soon after the injury. Quite recently I saw a bad case of collapse occasioned in this way, in a hunter who was struck by fifty- two pieces of shot; but in spite of having sustained wounds of his lungs, pericardium, and intestine, the patient recovered. The direction of the canal formed by the ball in its passage through the body is sometimes very peculiar, and instances are recorded where it encircled the thorax close to the ribs without injuring the pleura or the lungs. The entrance into a gunshot wound of unclean foreign bodies, such as bits of cloth, leather, or linen from the clothing, has a very important bearing upon the subsequent course of the injury, as substances like these are extremely apt to give rise to infection pro- vided the micro-organisms they contain are not killed by the intense heat of the bullet. The modern artillery projectiles, such as grenades, cannon balls, shells, etc., often give rise to severe injuries similar to those caused by machinery in times of peace; en- tire extremities may be torn from the body, and death can be instan- taneous. But slight wounds, such as contusions and superficial lace- rated wounds, are likewise fre- quently caused by the same mis. siles. The gunshot injuries of bone are, as a rule, (1) compound com- minuted fractures. The number of fragments is sometimes very large, and, in addition, there are many fissures, as illustrated in Figs. 332, 336-338, 397. The splinters of bone are often driven into the soft parts or even through the skin, forming, as we stated before, sev- eral exit openings. Not infrequently the bone is crushed to a pulp. There are also found in bone (2) tubular gunshot wottnds or punched-out wounds, with or without splinters or fissures. The latter, Fig. 397.—Gunshot injury of the skull (in a Russian soldier killed Aug. 30th, before Plewna), with numerous fissures which run from one opening (a) to the other (b) (Berg- mann). 730 INJURIES AND DISEASES OF JOINTS. in Fig. 397, unite the points a and b of entrance and exit of the mis- sile. (3) Subcutaneous fractures caused by a spent ball have already been spoken of. The mildest form of injury to bone is (1) contusion, with an extravasation of blood into the periosteum and bruising of the bone substance. Sometimes hollows or depressions, together with fis- sures, are formed in the bone against which the bullet is flattened out, or the latter is found impacted, being in some cases split in two and seated astride of the broken edge of a fragment (Fig. 398). In rare instances a gunshot fracture takes place not directly at the point where the bullet strikes the bone, but at some distance from it, and either exists by itself or is combined with a fracture at the point where the bullet struck (Lacronique). These indirect gunshot fractures may result from a bend, a twist, or concussion of the bone in question, and occasionally by a union of several of the fissures which radiate from the point where the bone has been struck by the bullet. Gunshot injuries of joints are in the main complicated wounds with or without injury of bone. The most severe gunshot injuries of the joints are those with splintering of the articular ends of the bones. The Effects produced by Modern Projectiles.—Bush, Kocher and others have made some interesting experiments pertaining to the action of projec- tiles constructed of lead and the kind of damage they cause in the tissues; and Reger has recently studied the action of such projectiles upon bone, and has come to some practically important conclusions. In the case of injuries made by soft lead within a range of four hundred metres, an effect is pro- duced which is like an explosion; the wound is funnel-shaped, and the bone is crushed to fragments, which penetrate the soft parts posteriorly, making tbe opening where tbe projectile emerges ten to twenty times as large as tbe opening where it entered. In the case of gunshot wounds made at a range of five hundred to one thousand metres, a clean-cut, penetrating wound is made, with or without radiating fissures. If the projectile traverses the lon- gitudinal axis of the bone, extensive splintering of the latter may be pro- duced. In the case of wounds made at a range of one thousand to fifteen hundred metres, comminuted fractures with considerable shattering of bone not infrequently occur in spite of tbe diminished momentum of the projec- tile. At longer ranges there is a slight splintering or contusion of the bone, in which the bullet will often be found impacted (Fig. 398). The Action of Projectiles of Small Calibre (Eight Millimetres in Diameter) with a Steel Coating.—Cbauvel, Bovet and others have made experiments with the new small calibre (eight millimetres in diameter) projectiles covered with nickel or steel, which have lately been introduced into the European armies. All the experiments show that these new projectiles have a great penetrating power on account of their tremendous velocity, and this has been still further increased by the use of the new smokeless powder. The projec- tiles which are coated with steel retain their shape, while those made of lead become flattened on account of their comparative softness, and when dis- §124] GUNSHOT INJURIES. 731 charged at a short range show a considerable explosive effect. At short ranges, however, the action of the projectiles which are covered with steel and those made entirely of lead is very much the same, except that the penetrat- ing power of the former is greater, being sufficient to pass through several cada- vers placed one behind the other. Ac- cording to Bruns, these steel-coated pro- jectiles can pass through iron plates twelve millimetres in thickness, or pine wood one hundred and ten centimetres F,G- ^.-Impaction and splitting of lead bullets in bone (Bergmann). thick, at a range of twelve metres. At a range of four hundred metres Bruns found that they produced an effect like an explosion upon the skull only, the long hollow bones not suffer- ing such extensive injury; at a range of eight hundred metres perforating wounds occurred ; and even at a range of twelve hundred metres two or three parts of a body placed one behind the other were completely shot through. The projectiles rarely remain in the body, as Hobart and Chauvel have noted by experiments made at ranges as long as fifteen hundred to two thousand metres. In general, the modern projectiles of small calibre which are covered with steel are more humane than those made entirely of lead, and, except at the ranges where explosion of the projectile takes place, the wounds they make have a more favourable prognosis, since the bullets do not become shattered, but make a smooth puncture with small openings. The firearm of small calibre is the most powerful weapon of modern times, on account of its great velocity, long range, and tremendous penetrating power. The observations made upon living men with projectiles of eight millime- tres diameter correspond very closely with those mentioned above (Stitt). Up to certain ranges (twelve hundred to two thousand metres) projectiles which strike the body directly pass entirely through it, forming small open- ings at their points of entrance and exit; but if, before entering the body, they rebound from a rock or piece of iron, they rarely do this. In these rebounding shots the steel-covered bullets lose their shape and become bent, the steel covering bursts, etc., and. accordingly, the wounds they make are torn and mangled, and the openings they form on entering and coming out are much larger. The Course of Gunshot Wounds.—The course of gunshot wounds may be inferred from what we have already said of injuries to the soft parts, bones, and joints, and the reader is referred to the paragraphs which treat of these subjects. The pain is usually trifling, as the wound is made so quickly, and often a person does not know that he has been hurt until he notices the blood. The haemorrhage may be very slight even when large, deep-seated arteries have been injured, and it ceases spontaneously by the formation of a thrombus and by the pressure of the surrounding parts. In other cases the wounded person dies in a few minutes, or even sooner, if a large artery such as the femoral or the carotid has been divided. 732 INJURIES AND DISEASES OF JOINTS. The subsequent course of a gunshot wound depends upon whether at the time of the injury or afterwards, infectious substances (bacteria) have gained access to the wound by means of dirt of various kinds pieces of clothing, or unclean fingers, instruments, etc. The tempera- ture of the projectile at the moment when it struck .the body is another matter which has an important bearing upon the course of the wound as the micro-organisms are often killed by the heat of the ball, espe- cially if it is of small calibre and has a nickel or steel covering. Hence infection of gunshot wounds on the battle-field is almost always due to the fact that immediately after the injury, or not until later, micro- organisms gain access with the dirt, or from insufficiently disinfected fingers and instruments. This infection may give rise to the various diseases of wounds, such as progressive inflammation and suppuration, sepsis, and pyaemia. Tetanus is also not infrequently observed, espe- cially if earthy materials have come in contact with the wound. If, however, infection does not take place, even very extensive injuries to bones and joints heal readily. Gunshot wounds inflicted at a short range, in which both soft parts and bone are badly mangled, have the worst prognosis, and in many cases, especially in wounds involving the trunk, head, or abdomen, death is instantaneous. If a patient with a gunshot wound of an ex- tremity remains alive, a conservative plan of treatment is usually hope- less, and amputation or disarticulation is indicated. It has already been remarked that the modern steel-coated projectile of small calibre, in spite of its great penetrating power—leaving out of consideration the range within which it explodes—makes a cleaner wound than the old-fashioned soft lead projectile, wliich mangles and lacerates both bone and soft parts. Treatment of Gunshot Wounds.—Gunshot wounds are treated, in general, according to the same principles which we have already given for the treatment of injuries to the soft parts, bones, and joints. Nevertheless, 1 shall discuss the treatment of gunshot wounds some- what more at length, with particular reference to their treatment in times of war. For the special treatment of penetrating wounds of the head, thorax and abdomen the reader is referred to the Special Sur- gery. We think with a shudder of that period of the middle ages when gunshot wounds were wrongly looked upon as poisoned wounds, and were therefore burned out with boiling oil in order to destroy the venom of the powder. Ambroise Pare and Maggi successfully com- bated this method of treatment in 1551 and 1552. The story is told that when the army of King Francis of France stormed the little castle § 124.] GUNSHOT INJURIES. 733 of Villane, near Susa, Ambroise Pare did not have sufficient hot oil at hand to burn out all the gunshot injuries in accordance with the treat- ment then in vogue. On the next day all those wounds which had not been burned out with oil were free from pain and inflammatory swell- ing, while those which had been thus treated were very painful and much swollen. After this experience Pare always denounced this cruel method. Every gunshot injury should, of course, be treated according to antiseptic principles, although this is quite a different thing in times of peace from what it is in war, when, on account of the great numbers of the wounded, it is not possible to attend to every case as carefully as we are ordinarily accustomed to. It is hence very natural that the expectant treatment of gunshot injuries has again been recommended for military practice. It is especially important to check the haemorrhage and remove all foreign bodies that may have gotten into the wound, such as bullets, unclean pieces of clothing, etc. But it is a bad plan to hunt for the bullet too industriously or too long, as they subsequently become healed up in the tissues, just like other foreign bodies. Dement jew and Berg- mann saw in the Russo-Turkish AVar eighteen cases in which the ball healed up within the knee joint. Subsequently the projectiles some- times leave their original position and wander about, like needles or other similar bodies. Bergmann and Reyher made very successful use of the expectant treatment during the Russo-Turkish War, even in cases of injuries involving joints. They confined themselves to a disinfec- tion of the wound and its neighbourhood, and then immobilised the extremity in plaster of Paris with or without an antiseptic occlusive dressing. The parts often united per primam intentionem, the bullet becoming enclosed, while in other instances suppuration took place, and yet the bullet remained where it was. The expectant plan of treat- ment may be accompanied by dangers when there are pieces of cloth- ing in the wound ; but these form the minority of cases, and there are usually no such sources of infection present. If one decides to adopt operative measures and enlarge the wound, in order to check haemor- rhage, for example, or on account of inflammation or suppuration, one must, of course, proceed according to general antiseptic principles. In civil practice one will not make so much use of the expectant form of treatment for gunshot fractures, but will follow the ordinary rules which govern the management of compound fractures. In cases of wounds inflicted at short ranges with extensive mangling of the soft parts and bone, conservative treatment is usually hopeless, and ampu- tation is in general indicated ; while for wounds inflicted at long ranges 734 INJURIES AND DISEASES OF JOINTS. the conservative method should first be tried, as it is in such cases that it has been shown to be most useful. It is especially important that the wound should not be examined with fingers or instruments wliich have not been disinfected, except, perhaps, in the face of serious haemorrhage which threatens the pa- tient's life. Many a wounded person has lost his life through exam- ination of his injury with a finger or a probe which had not been properly disinfected. Reyher is right in discriminating between " fin- gered " wounds—i. e., those which have already been examined by a physician—and " unfingered " wounds—i.e., those which come directly under the surgeon's care. Out of eight patients with " fingered " in- juries of the knee, six died and one was in great peril, while of seven ''unfingered " injuries of the knee six recovered. The primary antiseptic treatment consists either of antiseptic occlu- sion of the wound in the skin or antiseptic drainage. In the former— i. e., in healing under a scab—all exploration of the wound with a probe or the finger should as far as possible be avoided. If, however, an ex- ploration of the wound is absolutely necessary on account of dangerous haemorrhage, infection of the wound, etc., drainage must at the same time be provided for, and any operative measures wdiich may be neces- sary, such as removal of splinters of bone, resection, or amputation, must be undertaken at once. An excellent method of drainage in case of large gunshot wounds is to pack the latter with iodoform gauze or sterilised mull; the best antiseptic for military practice is probably bichloride of mercury. The drainage should be as simple as possible. It has been suggested that each soldier be supplied with the material for the first dressing in the form of a small bundle which can be sewed into his coat or carried in the breast pocket or knapsack, and that he should also have with him some antiseptic powder, such as iodoform. I think this plan of letting each soldier apply the first dressing with the materials which he carries wdth him is a bad one, since these dressings are anything but antiseptic—in fact, they are usually full of dirt. It is much better that there should be a large number of surgeons and well- trained assistants upon the field furnished with sufficient antiseptic dress- ing materials, and that the dressings which the soldiers carry with them should only be used in an emergency. These consist of two pieces of compress impregnated with bichloride, one bandage, a safety pin, and a three-cornered piece of cloth, all of which are wrapped up in some rubber material. In order that antisepsis may be properly observed in time of war all persons entrusted with the care of the wounded should be previously instructed in the general principles of antiseptic treatment and in the technique of applying simple antiseptic dressings. The vol- 124.] GUNSHOT INJURIES. 735 untary assistance of persons in the higher walks of life, especially stu- dents, is very desirable in this connection. The sterilisation of dressings can be carried out in times of war ac- cording to the same principles as in times of peace, and hence it is not a good plan to make a collection beforehand of dressing materials wliich have been impregnated with antiseptics, as they will be subsequently found to contain bacteria in spite of the best of packing. The most suitable kind of dressings are those wliich can be transported in the smallest possible bulk, such as mull, hemp, and cotton. The common salt-bichloride tablets which Angerer has recently recommended for military practice are very useful, and greatly facilitate the preparation of permanent bichloride solutions. Instead of sponges, aseptic gauze pads impregnated with bichloride of mercury may be used. On the battle-field the wounded are first carried to a protected spot, marked by a white flag with a red cross, where temporary dressings are applied, so that they can be transported to the field hospital situated near by. At the first place only the operations necessary to save life should be performed, such as arrest of haemorrhage and amputation. The most seriously wounded, especially those who cannot get to this place by themselves, should be attended to first. In future battles the dispro- portion between the number of the injured and that of the surgeons will be even more evident than it has been in the past, as the rapid- firing guns now used, on account of the greater accuracy of their aim, will probably increase the numbers of the wounded, while the number of surgeons will remain about the same. Hence only those operations will be performed which are absolutely necessary. Billroth likewise expressed the fear that the number of wounded in coming battles will be so great that there will not be sufficient help at hand to render them the necessary assistance while the battle is going on. Haase states that the organisation for the care of the wounded which the German army possesses will amount in future wars to forty-five thousand well-trained men (hospital orderlies, carriers of the wounded, etc.). Thus we can see that a liberal provision has been made. At the field hospitals, which are usually churches, school-houses, or other large buildings, or tents and barracks, the wounded who are brought in with temporary dressings on are examined with antiseptic precautions and permanent dressings then applied, and, when necessary, the wounds are enlarged, drained, and disinfected. Those who have thus been dressed antisep- tically are then transported to a permanent hospital. During trans- portation injured portions of the body, especially gunshot fractures, must be immobilised as thoroughly as possible (see § 53 and page 219). In addition to tents, Docker's barracks are particularly well adapted 736 INJURIES AND DISEASES OF JOINTS. for quarters for the wounded. Haase states that an army of 100,000 men need 601 movable and 167 stationary barracks to furnish room for from 15,000 to 18,000 wounded. Some of the barracks used for war purposes are made of felt (Docker's barracks), while others are tents or wooden sheds. Haase is right in recommending that these tents and barracks be put in position by bodies of men organised for that purpose and under the command of special officers. We have not space to take up more in detail the first treatment of the wounded on the battlefield, but whoever is interested in this subject should consult the books which have been written upon it by Esmarch and Port. A very excellent and exhaustive treatise on military surgery will be found in Fischer's Handbuch der Kriegschirurgie (Deutsche Chirurgie, Stuttgart, 1882). For a descrip- tion of the easily transportable operating table which I have devised for military practice, see page 7, Figs. 4 to 6. Search for a Ball.—In searching for a ball one may use the finger or an ordinary probe, and in the case of very deep wounds, long, curved or straight dressing forceps, silver catheters, etc. Graham Bell has invented an electric probe for finding bullets. A needle which has been insulated by coating all but its point with varnish is inserted into the region where the presence of the projectile is suspected and then connected with the end of a telephone wire. A metallic plate of the same material as the needle is fastened to the end of the other wire and applied to the skin in tbe neigh- bourhood of the bullet. If the point of the needle comes in contact with the ball tbe circuit is closed, and every time they come together a distinct noise is heard in the telephone. Klein has constructed a similar electro-microphonic searcher (see Aerztl. Polytechnik, March, 1892). The magnetic needle can also be used in suitable cases for finding a ball even after it has become healed up in the tissues, and is especially Ameri- applicable to the search for the modern steel-coated projec- tiles. Gartner recommends that the steel-covered bullet which has entered the body be first magnetised by stroking the area in question with a powerful magnet. By means of a sensitive magnetic needle—i. e., a pair of astatic needles suspended by a silk thread, or Lamont's magnetoscope—the point on the skin is determined to which the ball or iron splinter lies nearest (Kocher, Gartner, Sachs). Gartner constructed an astatic magnetic needle out of a magnetised sewing needle which he broke in two, a straw, and a piece of silk thread, and made successful use of it in finding projectiles after having first magnetised them. The old-fashioned probe invented by Nelaton has a knob made of porcelain which is made black by contact with the bullet. Projectiles are extracted by means of forceps, or spoon-shaped instru- Fio. 399 can forcep; extracting let. for a bul- g 124.] GUNSHOT INJURIES. 737 ments. The most simple kind are the long, curved or straight dressing forceps, or long, narrow forceps with sharp-pointed teeth which cover one another when closed (Fig. 393), so that they do not injure the tissues but be- come inserted into the lead when they seize tbe ball. The best-known spoon-shaped instruments are Thomassin's and Langenbeck's. Elevators can also be employed for this purpose. Formerly, if tbe ball were firmly em- bedded in the bone, it was extracted by screws or augers, which were bored into the lead like corkscrews. These augers and screws, and the forceps with the sharp-pointed teeth, are no longer used for the modern steel-coated projectiles, having been superseded by narrow, straight, or curved forceps. The steel covered projectiles, however, remain lodged in the body much more rarely than the lead bullets; they usually pass entirely through it and emerge externally. 47 CHAPTER V. TUMOURS. Tumours in general.—Definition and classification of tumours.—Etiology of tu- mours.— Clinical features, diagnosis, prognosis, and treatment.—The ana- tomical structure and clinical course of the different varieties of tumours, with their treatment. § 125. Tumours in General—Definition and Classification.—The study of tumours forms one of the most interesting chapters of pathology; but it would require too much space to discuss this vast subject with anything like completeness, and so we must satisfy our- selves with merely a superficial account of such tumours and growths as are amenable to surgical treatment. I must refer the reader to the excellent text-books of Virchow, Waldeyer, Cohnheim and others for a description of the general pathology and anatomy of neoplasms. The question, What is a tumour? has received various answers. In fact, it is difficult to give a suitable definition which includes all tumours, as they present marked differences anatomically, etiologically, and clinically. Liicke's definition has been the most widely accepted. According to him, we mean by a tumour an increase in the volume of some portion of the body, due to a new formation of tissue which reaches no physiological limit, and which—to add Cohnheim's words— differs from the morphologico-anatomical type of the locality where it occurs. We distinguish from true tumours the hyperplastic, inflam- matory formations, all the infectious granulation tumours of tubercu- losis, syphilis, leprosy, etc., and certain collections of fluid and cells in preformed cavities, such as aneurysm, hygroma of tendon sheaths and mucous bursae, hydrocele of the tunica vaginalis testis, and all reten- tion cysts. We recognise, as Cohnheim does: 1. Tumours the main portion of which is of the connective-tissue type; these include fibroma, lipoma, myxoma, cliondroma, osteoma, angeioma, lymphangeioma, endothelioma, lymphoma, and sarcoma, together with mixed or combination tumours made up of simpler forms. 2. Tumours having the type of muscular tissue : Myoma lsevicellu- lare and myoma striocellulare. (738) §126.] ETIOLOGY OF TUMOURS. 739 3. Tumours made up of nerve tissue : Neuroma and glioma. 4. Tumours of the epithelial type—viz., epithelioma, onychoma, adenoma, cystoma, and carcinoma. There remains as a subdivision of this group the teratoma of Virchow, in which many different kinds of tissue—such as hair, skin, bone, teeth, parts of intestine and brain—are found. In this class belong the dermoid cysts. Birch-Kirschfeld makes the following classification : 1. Connective- tissue tumours; 2, muscle tumours; 3, nerve tumours; 1, epithelial tumours; 5, mixed or combination forms of tumours; 6, cystic tumours, consisting of a closed sac containing more or less fluid. This group includes tumours which are etiologically and histologically very different; some of them (retention cysts) do not belong to the prolifer- ating tumours at all, while others are due to abnormities of develop- ment (teratoma-dermoid cysts), or originate secondarily from different tumours (cystoma glandulare, cystosarcoma). 7. Infectious tumours (granulation tumours) which are related histologically and etiologically to the inflammatory formations, and do not belong amongst the true tumours (products of tuberculosis, syphilis, leprosy, etc.). § 126. Etiology of Tumours.—The etiology of tumours, meaning thereby neoplasms, still remains obscure, although many theories have been advanced upon this subject. Their causes are partly direct and partly indirect or predisposing, the latter including the effects of age, sex, occupation, etc. Esmarch thinks that inherited predisposition plays an important part in their causation, and in many cases—notably of sarcomata—he believes that their development depends upon a pre- disposition inherited from syphilitic ancestors. As direct causes of tumours, local irritations—mechanical, chemical, or inflammatory in nature—have been thought especially important. Thus we know that a sarcoma, for instance, occasionally forms after a severe contusion, or that an epithelioma of the lower lip or of the mucous membrane of the mouth develops in immoderate smokers, or as a result of frequently repeated traumatic irritations caused by a sharp tooth, frequent shav- ing with dull razors, etc. A similar explanation is given for the origin of the epithelioma which is met with upon the scrotum of chimney sweeps and people employed in the manufacture of tar and paraffin. Sometimes after fractures benign (osteoma, chondroma) and malignant tumours (sarcoma) develop in the callus—the so-called callus tumours. According to Rapok, one hundred and twenty-eight out of six hundred and sixty-nine tumours' followed injuries. But the number due to this cause alone is, as Ball and Winiwarter state, not large, nor is mechanical or chemical irritation sufficient in itself to produce one ; first of all there must be present a predisposition of the part in qnes- 740 TUMOURS. tion to the development of a tumour, and it is this that is really the determining cause of tumour formation. Sometimes disturbances of the nervous system—trophoneuroses—play an important part in their causation. Buchterkirch and Bumke saw a case of multiple, sym- metrical lipomata which followed a contusion of the spinal cord. A preceding inflammation has a very important influence upon the development of neoplasms, as is shown in those cases of carcinoma of the breast which follow a. mastitis. Malignant tumours, both carcinoma and sarcoma, often originate from simple warts, and me- lanomata from small patches of pigment in the skin. Rapok states that one hundred and eighty-two out of three hundred and ninety- nine carcinomata started in warts, and indeed one third of all the instances of tumours collected by him (six hundred and ninety-nine) had this origin. According to Woodhead, tumours are due to a de- ficiency— not a superfluity — of nourishment; even though there is actually an increased amount of food taken into the system, this is not able to supply the needs of the tissues in question. He holds the view that tumours develop when, as a result of irritations from dif- ferent sources—such as injuries, parasites, microbes, long-continued action of an irritating organic or inorganic substance, or a simple chronic catarrh—so great an increase in the activity of the tissue ele- ments is demanded that the food brought into the system is insufficient to supply these demands. Schleich looks upon tumour-formation as a kind of infection originating within the organism, a cell at a certain stage of its physiological development becoming infectious as a result of irritations of various sorts. Analogously to the development of an impregnated ovum, tumours are considered by him as products of a pathological conception and impregnation ; the pathological spermato- zoon is represented by the cell that has become infectious. Many authorities think that tumours are caused by micro-organisms, and we shall consider this question when we take up carcinomata. Cohnheim developed a very ingenious theory as to the ultimate cause of new growths. He thought this to be an abnormity or irregularity in the embryonic rudiment of the part of the body in question—in short, that neoplasms originate from the growth of embryonic germs or ger- minal cells which have been, as it were, shut up in the normal tissues. In many individuals these tumour germs do not become developed, but in others traumatisms, mechanical and chemical irritation, or the dimin- ished powers of resistance possessed by the surrounding normal parts, increased blood supply, etc., may arouse them to activity. This theory of Cohnheim's seems very plausible for many cases, but it lacks ana- tomical foundation ; in fact, as Birch-Hirschfeld says, a positive proof § 126]. ETIOLOGY OF TUMOURS. 741 of the correctness of Cohnheim's hypothesis, as applied to tumours in general, is quite impossible. It is, however, unquestionable that some tumours spring from embryonic germs, and certain facts are very well explained by Cohnheim's theory—viz., the transmission of tumours by inheritance, the occurrence of congenital tumours, and of certain tumours in particular portions of the body, such as epithelial tumours, carcinomata of the lip, tongue, cardiac or pyloric orifices of the stomach, glans penis, portio vaginalis, cervicis, etc.; in other w7ords, in localities where inversions of the epiblast in the form of groups of epithelial cells, which have strayed away during the embryonic period, may easily take place. Cohnheim's hypothesis also furnishes the best means of explaining the heterologous origin of primary epithelial tumours in organs which do not contain epithelium. We know, for instance, that the dermoid cysts are a result of stray embryonic germs. But tumours probably do not have an unvarying etiology. As Ziegler has said, new growths arise from different tissues, these being (1) em- bryonic tissue, (2) growing tissue, (3) fully formed tissue, and (4) tissue in the stage of retrogression. In early life, connective-tissue tumours predominate, as a rule; in old age epitheliomata and carci- nomata. Transmissibility of Tumours.—Great importance attaches to the question whether or not tumours, especially malignant ones (carcinoma, sarcoma), are transmissible in the sense that living tumour-cells, when transplanted, can give rise to the development of the same kind of malignant tumour in that part of a body to which they are transferred. Such a transmissibility of tumours has in fact been sufficiently proved in the case of both animals and man by experimental and clinical obser- vations. Eiselsberg successfully inoculated rats with a fibro-sarcoma. In regard to the transmissibility of carcinoma see page 781; of mela- noma, page 770. Etiology of Tumours in Animals.—Plicque has published, in regard to the origin of tumours in animals, some interesting facts which show many analo- gies to tumour-formation in man. The real cause of tumours in animals is, to be sure, unknown, as far as the predisposition of tbe bearer is concerned. But as regards the direct cause, the following has been noted : The carcino- ma of the lip in horses generally develops in the corners of the mouth from pressure of the bit, while in cats the upper lip is ordinarily affected as a re- sult of the repeated bites of small animals. The subcutaneous fibroma which is often seen in horses is caused by the pressure of the harness. Constant or frequently repeated traumatisms play an important part in the origin of tu- mours in animals, as do also preceding inflammations. Bitches suffer from carcinoma of the mammary glands much oftener than male dogs, and the hindermost glands are the ones most commonly affected, as they are particu- 742 TUMOURS. larly likely to be tbe seat of a mastitis. The melanosis of horses is thought to be transmissible by inheritance, so that mares or stallions which have it cannot be used for breeding; heredity is also said to play a part in the origin of the mammary cancer of bitches. The influence of age is very noticeable in animals. In old dogs carcino- ma is very frequent, while young ones are practically immune. Whether tbe nutrition of the animal plays a part in the tumour-formation, as has been thought to be the case in carcinoma in man, cannot, as Plicque says, be easily decided. Amongst pronounced carnivora like the dog, carcinoma is very common, and herbivora like the horse are not exempt when they reach an advanced age. § 127. Growth, Course, Diagnosis, and Treatment of Tumours.—The growth of tumours takes place in exactly the same way as that of other tissues—by cell proliferation. The rapidity of growth is very variable, depending upon the locality, the blood supply, and the structure of the tumour. The more cells the latter has, the more rapidly it grows. Localised or more diffuse disturbances of nutrition, such as fatty de- generation, calcification, and colloid degeneration or necrosis, resulting, perhaps, in a complete spontaneous cure of the tumour very frequently occur. Necrosis wThich takes the form of ulceration is exceedingly common, especially in carcinomata which have broken through the skin or mucous membrane. According to Nepveu and Verneuil, the softening of tumours is caused in some instances by bacteria. A true tumour does not disappear spontaneously; some remain stationary, while others keep on growing at a faster or slower rate. The most important distinction between tumours is presented by their clinical course, and this allows us to divide them into benign and malignant growths. The former remain local, but the latter penetrate into the neighbouring tissues and destroy them, and the tumour germs, being carried off in the blood and lymph, give rise to metastatic or secondary neoplasms in all parts of the system, especially the liver and lungs. Cartilage is the only tissue in which, so far as I know, no metastases have been found. The metastases have essentially the same structure as the primary tumours, and are found either in the vicinity of the lat- ter—that is, in the region supplied by the lymph and blood which come directly from the tumour—or in distant organs after the tumour germs have passed through the heart. Metastases due to capillary emboli are most commonly caused by the tumour cells which pass through the lungs in the venous blood without being retained there (ZahnV Should the germs be carried through the lympli vessels, they usually become implanted in the nearest lymph glands and here lead to the develop- ment of tumour tissue which is identical with that of the original neo- plasm. In this way the infected lymph glands become new foci for §127.] GROWTH, COURSE, DIAGNOSIS, TREATMENT OF TUMOURS. 743 further infection and development of metastases. The tumour germs also enter the vascular system by a direct ingrowth of the mother tumour into the walls of the vessels. I once saw a metastasis in a valve of the femoral vein in a case of sarcoma of the leg. Tumours which in other respects are benign—such as fibroma, lipoma, cystic goitre, chondroma, myoma, etc.—may also, in exceptional instances, give rise to metastases. It is characteristic of tumour metastases—especially those from the really malignant tumours—to go on growing indefinitely. Normal tissue germs do not have this peculiarity, as is shown by the experiments of Cohnheim, Maas, etc. Small pieces of periosteum and embryonic cartilage implanted in the circulation, the peritoneal cavity, or in the anterior chamber of the eye, grow for a time and can thus give rise to very small osteomata or enchondromata; but these soon disappear without leaving any traces. If, on the other hand, living tumour cells from a carcinoma or sarcoma, for example, are inoculated upon animals, they go on developing, and give rise to tumours which are the same as the original ones. Man also may become infected with the germs of tumours, and this has occurred during operations for their extirpation. Carcinoma and sarcoma are the typical malig- nant tumours ; they lead to local destruction of tissue and to general infection of the body by the formation of metastases. They are espe- cially the ones which so commonly reappear at the original site after they have been extirpated. These recurrences are, according to Thiersch, due partly to tumour germs which were not removed, though in other instances we have to deal with a new tumour—a so-called regional re- currence—similar to the one that was removed, wdiich makes its ap- pearance in the cicatrix or near by, months or even years afterwards. Then, again, recurrences may be due to the inoculation at some point of living tumour cells during the extirpation of the primary tumour. It can easily be understood that a benign tumour may also prove fatal to the bearer on account of its position, as exemplified by an osteoma on the inner tablet of the skull. The evil effects of tumours upon the organism are partly local and partly constitutional in character. Those in particular which grow rapidly are a great drain upon the system. The part which is affected may be entirely destroyed, and the formation of metastases, together with the necrosis and ulceration undergone by the tumour, may involve different organs and eventually lead to an increasing general cachexia, to which the patient will succumb. This cachexia, manifesting itself in the form of general disturbances of nutrition, loss of flesh, and marasmus, appears in malignant tumours which are accompanied by local destruction of tissue and metastases. Rommelaire and Ranzier 744 TUMOURS. have found that the excretion of urea is diminished in all malignant tumours, and may ultimately become less than twelve grammes pro die. The degree and rapidity of development of the cachexia depends upon the location of the tumour, its condition (ulceration, necrosis, haemor- rhage), and the age and constitution of the patient. The malignancy of the infectious tumours varies very considerably. Some, like epithelioma of the lip and the flat skin cancer (ulcus rodens), spread but slowly to the nearest lymph glands, while others—carcinomata and sarcomata, for instance—go on very rapidly to the formation of metastases in in- ternal organs. The above-mentioned gradual diminution in the excre- tion of nitrogen, which is met with in malignant tumours, may occa- sionally have great value in determining the need and prognosis of surgical interference, especially if the decrease in the amount of urea is marked, in which case operative procedures are contraindicated. The Possibility of curing Malignant Tumours (Carcinoma and Sar- coma).—A variety of statements, based upon statistics, have been pub- lished relating to the curability of the malignant tumours. Fischer and Meyer have written an especially interesting article on this subject. Of two hundred and ninety-eight cases of malignant tumours operated upon by Rose in the hospital at Zurich between 1867 and 1S78, Meyer was able to get reliable returns from sixty-four. Of these sixty-four, twenty-two were alive in 1887 without recurrence, and showed a period of exemption varying from nine years and seven months to twenty years and three months. Nineteen died without recurrence, the period of exemption varying from one and a half to sixteen years. In the remaining five patients the cause of death could not be ascertained. Amongst the cases of cure were some exceedingly serious ones, involv- ing very extensive operations, with removal of recurrent tumours and diseased lymphatic glands. Sarcoma, cysto-sarcoma, and fibro-sarcoma showed the longest period of exemption, while carcinoma showed the fewest instances of permanent cure. In rare cases of sarcoma of the skin and multiple melanosarcoma, spontaneous retrograde changes have been observed which have resulted in the complete and perma- nent disappearance of the tumours (Hardaway). Diagnosis of Tumours.—The diagnosis of tumours is not always easy. By means of inspection, palpation, and examination of the subjective symptoms we try to form as correct an idea as possible of the location and structure of the tumour. The location of a neoplasm often enables us to determine its nature. Very often a differential diagnosis must be made between an inflammatory process and a new growth (see page 251, Diagnosis of Inflammation). In doubtful cases puncture with a hypodermic needle may be necessary. It is often very important to § 127.] GROWTH, COURSE, DIAGNOSIS, TREATMENT OF TUMOURS. 745 determine before the operation whether the tumour is benign or malig- nant, in order to decide upon the kind of operation to pursue. In suitable cases—for example, in growths within the larynx probably carcinomatous in nature—parts of the tumour are removed and exam- ined microscopically. Syphilis, tuberculosis, and other chronic infec- tious diseases must always be considered in making a differential diag- nosis, as a large number of the connective-tissue tumours—such as cer- tain so-called sarcomata of muscle, many spindle-celled sarcomata, neuromata, keloids, and malignant lymphoinata (Esmarch)—are gum- mata, and can be cured by an antisyphilitic treatment. General Treatment of Tumours.—The general rule in regard to the treatment of tumours—which we shall later discuss more fully in speak- ing of the individual tumours—is that they should be removed as quickly and as thoroughly as possible. The sooner a malignant tumour is radi- cally excised the better is the prospect of a complete and permanent cure. The possibility of the total removal of a tumour depends upon its location and the kind of organ involved. In malignant tumours, especially carcinoma, the neighbouring lympli glands should also be re- moved, even though they are not diseased, and after every amputatio mammae for carcinoma the lymphatic glands and surrounding fat in the axilla must likewise be extirpated. The removal of tumours is ac- complished usually by the knife, though occasionally by the galvano- or thermo-cautery, red-hot iron, ligature, ecrasement, etc., methods all of which have been sufficiently described in §§ 24-44. In proper cases Pean recommends the removal of the tumour in pieces (morcellement). The method consists mainly in first rendering the tumour as bloodless as possible by the use of differently formed clamps applied around its circumference, after which the growth is ex- cised in portions, and, if possible, the wound is sutured while the for- ceps are still in place. The latter can then usually be taken off and the wound dressed. In other cases Pean leaves the forceps in position for twelve to forty-eight hours. An almost bloodless operation can thus be performed even in the case of very vascular tumours. The encapsulated, myelogenic, giant-celled sarcoma of bone can in suitable cases be removed by cutting away only the anterior half of the bony capsule by means of the chisel and hammer, or the saw. and then carefully scraping out the tumour mass with a sharp spoon. Nussbaum has lately made use of the thermo-cautery for the destruction of malig- nant tumours like cancers. By circumcision with the thermo-cautery in cases of inoperable, malignant neoplasms, the patient can be helped very materially; the growth of the tumours is thus diminished, the pain caused to disappear, and any carcinomatous ulcerations are im- 710 TUMOURS. proved and their decomposition checked. In cases of sloughing, in- operable carcinomata, the removal of the softened portions with the sharp spoon and the subsequent application of the thermo-cautery give good results. Many attempts have been made to destroy tumours, especially in- operable sarcoma and carcinoma, lymphoma and myoma, by means of parenchymatous injections of absolute alcohol, tincture of iodone, ergot- ine, acetic acid, nitrate of silver, arsenic, turpentine, osmic acid, phos- phorus, etc. Turpentine is injected with equal parts of absolute alco- hol, or one part of turpentine to two parts of alcohol, from a half to a whole hypodermic syringeful about every ten to fourteen days. This is usually followed by the formation of abscesses which cause a variable amount of shrinkage in the size of the tumour. Some three drops of a one-per-cent. solution of osmic acid is injected every day. Arsenic can be given in the form of Fowler's solution, either internally or sub- cutaneously. Internally one begins with ten drops daily, and increases the dose two to three drops every third day. About two drops of Fowler's solution, undiluted, are injected into the tumour daily, or ten drops of the undiluted solution once a week. The solution may be di- luted two or three times for susceptible patients. The arsenic treat- ment was recommended by Billroth, especially for malignant lympho- ma. Mosetig-Moorhof finds the parenchymatous injection of aniline dyes (pyoktannin, methyl violet, 1 to 500) very useful in malignant tu- mours (carcinoma and sarcoma), but the success which he has reported has not been experienced by other surgeons (Billroth); on the con- trary, bad results, such as premature softening, rupture of the tumours through the skin, sloughing, etc., were obtained. The treatment of tu- mours by parenchymatous injections was first introduced by Thiersch. In cases of inoperable tumours erysipelas has been inoculated by means of cultures of the erysipelas coccus, after Busch had observed that, as a result of erysipelatous inflammation, tumours, such as sarcoma of the face or neck, disappeared by fatty degeneration. Janicke and Neisser were able to demonstrate by microscopic examination, in a case of car- cinoma with fatal erysipelas due to inoculation, that the cancer cells are actually destroyed by the erysipelas cocci. One should, however, take into account that such an inoculation may cause death, and hence one should warn the patient of the danger of the treatment. The man who succeeds in discovering a really successful method of treating malignant tumours—carcinomata, for example—would deserve to be honoured by humanity for all time as being its greatest bene- factor. 8 128. The Different Varieties of Tumours. Connective-tissue Tu- § 128.] THE DIFFERENT VARIETIES OF TUMOURS. 747 Fig. 400.—Hard fibroma of the skin of the nose (Bill- roth). mours; Fibroma.— Of the different varieties of connective-tissue tumours, we shall first take up the fibroma, which is made up almost entirely of this kind of tissue. We distinguish ordinarily a hard (Fig. 400) and a soft (Figs. 401, 402) form. The hard fibroma is made up, as a rule, of bundles of tough, coarse fibres with few cells, while the soft form consists of loose connective tissue having a great number of cells. There are, of course, numerous transition forms. The soft fibroma (fibroma molle) is also called fibroma molluscum by Virchow (Figs. 401, 402). The vascularity of the fibromata varies greatly, being sometimes very slight, and again so marked as to give rise to large dilatations of the blood and lymph vessels, as in the diffuse hyperplasia of tissue found in elephantiasis. Fibroma mol- luscum must not be confounded with the so- called molluscum contagiosum (see page 773). The retrograde changes that take place in fibromata are fatty degeneration, calcification, softening, the formation of cavities and cysts, and a perforation of the skin with the formation of ulcers as a result of long-continued traumatic irritation from without, and of in- flammation leading to the formation of abscesses. The fibroma only becomes dangerous from its location and size, the latter being sometimes very great, par- ticularly in the case of fibroma of the skin or uterus (Fig. 402). In other re- spects the fibroma is a perfectly benign neoplasm, giving rise to no metastases, although it is found multiple, especially in the skin, where it may appear in vast numbers. The multiple fibromata of the skin (Fig. 4<>2) may be the size of a pea or walnut, or they may grow and form very large soft tumors; they are some- times accompanied by disturbances of the general nutrition (so-called leontiasis, Vir- chow). I cannot discuss here the question (see § 85) whether in such cases we do not really have to do with leprosy. According to the investigations of Recklinghausen, the multiple soft fibromata of the skin develop particularly from the connective-tissue sheaths of the sebaceous glands, vessels, and nerves (neuro-fibroma). Fig. 401.—Soft fibroma of the face (elephantiasis faciei) of a twenty- four-year-old woman (Schuller, Greifswald clinic). 748 TUMOURS. Many soft fibromata are diffuse, hyperplastic formations, and represent a transition to elephantiasis, as seen in Fig. 401. These formations are sometimes called cutis pendula or elephantiasis of the skin. There Keloid.—In speaking of the hard fibromata, mention should be made of the keloid, i. e., a tumour-like, fibrous degeneration of the skin and subcutaneous tissue in the form of a tough swelling wliich sends out cord-like processes into the healthy surrounding parts. In by far the majority of cases the keloid develops within a cicatrix (cicatricial keloid). We distinguish, as do Warren, Kaposi, Deneriaz, and others, three forms of keloid : (1) a spontaneous, (2) a cicatricial keloid, and (3) the hypertrophied cicatrix. Scrofulous, tubercular and syphilitic individuals seem especially prone to keloid. Deneriaz is disposed to think that keloid is caused by infection with microbes. It is char- acteristic of keloid to recur almost invariably after extirpation. Leloir and Vidal recommend, in true keloid, multiple scarifica- tions, which should be made in different directions during several sittings, and followed by the application of a moist dressing with compresses wet in boric-acid solution, and on the next day of a mer- curial plaster. Fibromata are most commonly found in the skin and subcutaneous §128.] THE DIFFERENT VARIETIES OF TUMOURS. 749 tissue, in the nerves, periosteum, bone, uterus, and ovaries. Some of the polyps which form in the facial cavities—many nasal polyps, for ex- ample—are periosteal fibromata. There are sometimes seen, especially n the pharynx, polyps which are covered with hairs and possess an epidermis, rete Malpighii, and corium, and, according to Arnold, origi- nate from strayed embryonic cells. They belong, probably, to the tera- tomata (see page 787). Combination or mixed fibrous tumours include fibro-myxoma, fibro- myoma, fibro-sarcoma, fibro-neuroma, fibro-angeioma, fibro-cavernoma, fibro-lymphangeioma. The diagnosis of fibroma can be easily made from what we have stated in describing the neoplasm. Treatment of Fibroma.—The treatment of a fibroma consists in its re- moval by the knife, the galvano-cautery or the thermo-cautery. Large diffuse fibromata of the skin are to be extirpated in several sittings by cuneiform excisions followed by deep sutures. Billroth once re- moved a large tumour in twenty sittings. I removed an extensive dif- fuse fibroma involving almost the entire scalp in one sitting, and cov- ered the surface of the wound with Thiersch skin grafts. In cases of very large fibromata of the uterus one must often give up all idea of extirpation, and treat with injections of ergotine, or, in order to stop the frequent haemorrhages, remove both ovaries (Hegar). The de- scription of operations for fibro- ma of the uterus, etc., is found in the Special Surgery. Fibromata of nerves can usually be removed and the continuity of the nerve pre- served (see Neuroma). If the nerve cannot be saved, the nerve stumps can sometimes be . „ l . ,. ,. c Fig. 403.—Cells from a myxoma of the cervical united after the extirpation ot fa8cia. x 350. the tumour by suture, or by the use of the neuroplastic methods described on pages 470-472. Myxoma.—The myxoma is made up of a soft, gelatinous tissue. The microscopic examination shows the presence of a mucoid ground substance with a fibrillar framework and round, spindle-shaped or star-shaped cells. The latter have usually many branches and pro- cesses which interlace with one another (Fig. 403). Koster has denied that the myxoma is a special form of tumour, and, as a matter of fact, it is possible'to look upon it as in the main a softened, (Edematous fibroma 750 TUMOURS. or lipoma (myxo-fibroma, myxo-lipoma). Myxomatous, softened areas are often found in cartilaginous tumours. The myxomata are met with most commonly in the skin and sub- cutaneous tissue, in the periosteum, medulla of bone, fasciae, muscular sheaths, nerves, and in the brain and its coverings. They sometimes attain a very large size. The treatment of a myxoma consists in its removal according to the above rules. Lipoma.—The lipoma (fatty tumour) is a lobulated tumour made up of fatty tissue, sometimes soft and sometimes firm in consistency. The lipomata are either circumscribed or diffuse growths, and frequently possess a pedicle. According to their location, there may be distin- guished cutaneous and subcutaneous, subserous (subperitoneal), sub- synovial, submucous, inter- and intramuscular (subfascial, peritendi- nous) and periosteal lipomata. The lobes of fat of which the lipoma is made up are usually held together by bands of connective tissue. Increased development of the stroma gives rise to the lipoma fibro- 6um. In some instances, especially in the region of the neck and shoul- der, very diffuse lipomata are found. Growth of the fatty villi in the joints, of which the knee is a prominent example, gives rise to the lipoma arborescens. Similar diffuse lipomata are found on the ten- don sheaths. The articular lipomata probably develop as a result of traumatic ruptures of the synovial membrane, causing a prolapse of the retrosynovial fat into the joint; they are also encountered in ar- thritis deformans. The subperitoneal and submucous lipomata which develop upon the stomach and intestine are of special clinical impor- tance. The lipomata of the intestine occasionally give rise to intesti- nal obstruction. According to Sutton, two forms of lipoma are found attached to the spinal cord. In most cases they are the result of the change of the sack of a spina bifida into fatty tissue; less frequently they are intradural lipomata which grow around the spinal cord. The lipomata, as we remarked before, sometimes change into fibromata, myxomata, sarcomata, and cavernous tumours. They may attain a considerable size, especially when situated on the back, and growths of this kind, weighing twenty to twenty-five pounds, have been success- fully removed (Billroth, Halm, and others). Pick published an account of a subserous lipoma of the abdomen weighing twenty-nine pounds. The lipoma is a benign tumour, and does not give rise to metastases, though it is sometimes multiple. They are most likely to develop in individuals from thirty to fifty years of age, but are sometimes con- genital, in which case they are usually diffuse, often combined with teleangeiectases, dermoid cysts, and fibromata, and occur principally in §128.] THE DIFFERENT VARIETIES OF TUMOURS ^1 i 0 J. the lumbar region and on the buttocks. The so-called " false tail" is merely a congenital lipoma pendulum which is situated above the anus, and may occasionally be combined with spina bifida (Bartels). Quite recently Grosch has published the results of very exhaustive studies on this subject, which place the seemingly simple lipomata in a new light. He has attempted to show that certain tumours are prone to develop upon particular parts of the body, mainly on account of definite anatomical conditions and structural peculiarities which these parts possess. The lipomata appear to have a specially marked tendency to grow in certain localities, being most common on the front and back of the neck, on the posterior aspect of the trunk, about the shoulder, and on the upper and lower extremities. They are sel- dom encountered on the head, and then more often on the face than on the scalp, being rarest in the latter region (Konig, Gussenbauer). Grosch states that they occur most commonly in the integument of those parts of the body which have a scanty covering of hair and a small number of sweat and sebaceous glands] These glands eliminate fats and their derivatives in addition to disintegrated products of meta- bolism, and hence the amount of their secretion is an important index of the amount of the subcutaneous fat. Obesity and lipoma formation are, according to Grosch, quite identical. In many cases, particularly in thin individuals, the lipomata are neuropathic in nature, and pos- sibly are the result of a diminution in the secretion of the sebaceous and sweat glands due to disturbances in the central nervous system. Symmetrical lipomata, in particular, result in this way. The diagnosis of a lipoma is made chiefly from its soft, movable, lobulated character. If pressure is exerted upon the tumour, as a rule there will be felt a distinct crepitation caused by the >^J<^-*^^j^^<\i crushing of single lobes $& »' i* p~2 r^^^TY^J^ vv"' of fat. The skin over &-M(lJ[ii. J?(^£/:*t$i':*& the lipoma shows little J* (Sr-ftQw ' ^rX^^'^^^f^f^ shallow depressions which O'Q ~''v*$3- fe ^^>fi;*\ (^P « K are particularly plain when ;;■' (:) ^lij \*> (»j -| ^^'^'''•■*JJi * .'C.|^V the tumour is encircled Ki .^ ''c^'f- •"*"> "^ *^>aV^xV5;-v: T<[y*\ by the hand. K^S^ ^W^^ The extirpation of li- ^f^g Sjf ^^SX^*£r\ r J _ Fig. 404.—Small - celled Fig. 405.—Large-celled chon- SCisSOrS is very easy even in chondroma of the tin- droma of the pelvis very „ ger. x 80. rich in cells, x 80. the case of large tumours. Chondroma or Enchondroma.—The chondroma consists essentially of cartilage, most commonly hyaline, less often fibrous or reticular. The 752 TUMOURS. cells which this kind of tumour contains may be small (Fig. 404) or laro-e (Fig. 405), and their quantity varies within wide limits. The enchondromata are most often encountered in places where cartilage normally exists — hence, upon the skeleton (epiphyses, periosteum, medulla of bones)—though they are also met with in the parotid and thyroid glands, mamma, and testicle. The enchondromata of the skin and internal organs develop partly from stray cartilage cells and partly from transformed connective-tissue cells, especially the endothelia of the connective-tissue sheaths and of the blood and lymph vessels. Thus chondro-endotheliomata are sometimes seen. The enchondromata which grow directly from cartilage—that of the epiphyseal line, for example—are also called ecchondroses. Like the exostoses, the enchon- dromata are often multiple, and appear in great numbers. Very remarkable cases of multiple enchondromata of different bones, com- bined with venous angeiomata of the soft parts, have been described by Kast, Recklinghausen, and others. Probably both kinds of tumours were the result of disturbances of circulation. Enchondromata are comparatively often the seat of degenerative changes, such as myxoma- tous softening and cyst formation. The most important mixed forms of chondroma are the osteochondroma and chondrosarcoma. Chon- dromata may eventually become entirely ossified. I have also seen a cliondroma combined with a melanosarcoma— on the hand, for example. Not infrequently enchondromata are found multiple in different parts of the body. The simple enchondroma is in general a benign neoplasm, but malignant forms with metastases do occur. It is most often found in young subjects. The tumours attain at times a very considerable size, espe- cially when situated upon the pelvis or the femur. A favourite locality for enchondromata is the fingers, where they form characteristic nodular tumours (see Fig. 406). They may also originate from cartilage cells in the ethmoid bone, and grow as an osteochondroma or car- tilaginous exostosis into the frontal sinus and nasal cavity. These osteochondromata or ex- ostoses of the frontal sinuses and nasal cavity can become detached, and are then found in these cavities in the form of free bodies or dead osteochondromata or osteomata. I once published a typical case of this kind. The frequency with which enchondromata or ossified clion- Fig. 406 Enchondroma of the fingers of the left hand of a twenty-year- old spinner (Leo). §128.] THE DIFFERENT VARIETIES OF TUMOURS. 753 dromata (exostoses) of the ethmoid bone occur can be explained by the fact that remnants of the cartilaginous cranium remain in this locality for a comparatively long time. The location and the hard nodular consistency of the tumours are important factors in making the diagnosis. The treatment consists in their prompt removal with the hammer and chisel. Osteoma.—The osteoma is a tumour made up of bone, and occurs not only upon the skeleton, but also in the skin, muscles, tendons, lungs, parotid gland, and brain. A\Te have already spoken of diffuse and circumscribed osteomata—the hyperostoses and osteophytes—in con- nection with inflammations of bone (see page 620), and of the so-called " riding " or " exercise " bones which develop in the muscles (see page 551), and of the diffuse formation of bone which takes place in myo- sitis ossificans progressiva (see page 552). The development of bone in tissues where bone is usually not present is best explained by Cohn- heim's theory—i. e., by supposing that strayed embryonic cartilage, periosteal or medullary cells have led to the production of osseous tissue. Osteomata also frequently appear upon bones after fractures. I once successfully removed such a one, almost as large as a fist, from the horizontal and descending ramus of the pubic bone, where it had followed a fracture. The osteomata situated on the surface of bones are also called exos- toses (Fig. 407), and those in the interior of bones enostoses. The exos- toses which are developed in the periosteum are sometimes very mov- able, and do not have a direct con- nection with the bone. Their struc- ture is in some cases as compact as ivory (osteoma eburneum), and in other cases spongy (osteoma spon- giosum). Many osteomata have a covering of cartilage (exostosis car- tilaginea), and this is especially true of the exostoses in the neighbour- Flo 407__Exostoslsof thefemur(Busch). hood of the epiphyseal cartilage, wliich are really ossified enchondromata or ecchondroses (ecchondrosis ossificans). The cartilaginous exostoses (osteomata with a covering of hyaline cartilage) are sometimes styloid or finger-shaped, and resemble a' metacarpal or metatarsal bone. These cartilaginous exostoses, or rather ossified chondromata, are often multiple, occurring in the neigh- bourhood of the epiphyses of many different bones in the same individ- ual. Occasionally the influence of heredity is very noticeable. Hey- 48 754 TUMOURS. mann observed multiple cartilaginous exostoses on many of the bones of a phthisical patient whose mother and four brothers, as well as his three children, all had a similar peculiarity. Reinecke collected thirty-six cases of multiple exostoses from literature, in which the hereditary predisposition could be traced back in one case five generations, in fifteen cases three generations, and in twelve cases two generations. In such instances the development of the exostoses is due to an inherited predisposition, and begins usually in the third or fourth year of life. By exostosis bursata is meant an exostosis which is covered by a bursa. It develops principally in the joints, from the articular car- tilage, and pushes the synovial membrane before it. The pocket thus made in the capsule of the joint either remains open, so that the bursa retains its connection with the joint, or it becomes entirely cut off from the latter (see page 690). These bursal or synovial exostoses generally contain a fluid resem- bling synovia, and several free-joint bodies usually made up of hyaline cartilage. This form of exostosis may also occur at some distance from a joint, and even upon the bones of the trunk and ribs; in these cases the enveloping sack forms, after the fashion of an accessory, mucous bursa. The exostoses can become gradually or suddenly detached by traumatisms, for example, and then persist as dead pieces of bone, like the free dead osteomata in the frontal sinuses and nasal cavity. Osteomata of the teeth and alveolar processes are comparatively common. The tumours of the teeth, the so-called odontomata, which consist of dentine and enamel, arise from the pulp or degenerated embryonic tooth cells as a result of anomalies during the period of development of the teeth, and sometimes in young subjects after inju- ries. The true odontomata are rare, and are found, according to Heath, almost exclusively on the lower jaw. Lloyd saw an odontoma of the upper jaw, and Metnitz has published an account of five cases of this rare form of tumour, and thinks that want of room, abnormal posi- tion of the neighbouring teeth, and inflammatory processes, especially chronic periostitis, are important factors in their etiology. In general, two forms of odontoma can be distinguished—soft and hard—or, better, those with dentine and those without (Partsch). The exostoses which form on teeth are, of course, not to be counted amongst the odontomata, but amongst the osteomata. The osteomata are, on the whole, benign tumours, and usually grow slowly, but sometimes are found multiple, occurring, for example, on numerous epiphyses, where they are capable of causing disturbances of growth. In cases of multiple exostoses of the bones of the cranium § 128.] THE DIFFERENT VARIETIES OF TUMOURS. 755 Fig. 408.—Osteosarcoma (osteoid, ma- lignant exostosis) of the superior maxilla (Busch). and face, atrophy of the latter has been observed as a result of inter- ference with its development. The malignant osteomata include the osteosarcoma, also called osteoids (see Fig. 40S), which give rise to extensive local destruction of tissue and to metas- tases (see sarcoma). In this category belongs also the very vascular (pulsa- ting) osteosarcoma. For cysts of bone see page 785. Pointed exostoses can sometimes cause injuries to large arteries and veins, and thus lead to the formation of aneu- rysms, as in the instances observed by Boling, Kiister, and others. In Kiis- ter's case a pointed osteophyte wounded the popliteal artery and led to the formation of an aneurysm. After removal of the osteophyte by a chisel, and double ligation of the popliteal artery, a rapid recovery was made. Kronlein observed, on the other hand, that a traumatic aneurysm of the popliteal artery which had lasted ten years caused an erosion and formation of osteophytes on the lower end of the femur. The diagnosis of osteomata can usually be made from their location and hard, bony consistency. Osteomata are usually removed by the chisel or saw, or when in the soft parts, by extirpation with the knife. In cases of exostoses in the vicinity of a joint one should always think of the pos- sibility of their communicating with the joint. In such cases the tumour is only removed when it causes serious trouble. Angeioma (Blood-vessel Tumour).— The angeioma is made up principally of newly formed and old, dilated, hypertro- phied blood-vessels. Three varieties are distinguished : 1. The angeioma simplex (teleangiec- tasis, nsevus vasculosus, plexiform angei- oma), consists of dilated, tortuous, and newly formed capillaries and small ves- sels. Macroscopically, the teleangeiectases are mostly soft swellings, bright- to dark-red in colour, which are only slightly elevated above the surface of the skin, where they are usually found. They are very Fig. 409.—Congenital telangiecta- sis (birth - mark) with hairs (Mason). 756 TUMOURS. often congenital, forming the so-called birth-mark. These birth-marks are often associated with hypertrophy and pigmentation of the skin, and very frequently with hair-formation (see Figs. 409 and 411). Many of these hairy birth-marks are diffuse, soft fibromata, others more like teleangeiectases. The hair-formation often resembles the hide of animals, such as rats, monkeys, or rabbits. The mothers of such children often say—as in the cases illus- trated in Figs. 400, 410—that they were frightened during pregnancy by the sud- den appearance of the animal whose skin resembles that of the birth-mark. The marked heteroplastic development of hair on certain parts of the body which are cov- ered with an otherwise normal skin—the growth of a beard in women, for exam- ple (hypertrichosis circumscripta)—and the growth of hair over the entire body (hy- pertrichosis universalis), have nothing to do with tumour-formation; it is mostly a hereditary malformation which is found in certain families. Several families of hairy people are known in which the complete covering of the body with hair was inherited by the children. Fig. 411 represents Schwe-Maong, the father of an Asiatic hairy family, and Fig. 412 the Russian liairy man Andrian, whose son had the same pe- culiarity. Treatment by the galvano-cau- tery may be used for this abnormity. The angeiomata also include the an- eurysma anastomoti- cum or racemosum, which is best called angeioma arteriale racemosum or cir- soid aneurysm, and has been described in a previous chapter (Fig. 413). The cirsoid aneu- rysm, as we saw on page 535, is the result of a pampiniform dilatation, tortuosity, and thickening of the arteries supplying a certain region, FiO. 410.—Very large congenital hairy birth-mark on the back, neck, and upper extremity of a twelve-year-old girl (Beigel and Paget). Fig. 411. — Shwe-Maong, ancestor of an Asiatic hairy-family. Fig. 412.—Andrian, a Russian hairy man (Virchow and Eartels). § 12«.] THE DIFFERENT VARIETIES OF TUMOURS. 757 and is due partly to the formation of new vessels and partly to hyper- trophy of the old ones. 2. The cavernous angeioma (tumor cavernosa) resembles in struc- ture the corpus cavernosum —i. e., it consists of cavities lined with endothelium, which are filled with fluid or coagu- lated blood, and separated by connective-tissue septa. It is most commonly found in old people in the liver, skin, sub- cutaneous tissue ; less often in the brain, spleen, kidneys, uterus, or bone. The views as to its origin do not agree. According to Rokitanski, the cavernous spaces are first formed from the connective tissue, and then secondarily become joined with the blood- vessels and thus filled wdth blood. Another explanation seems to me the more prob- able—viz., that a dilatation of the capillaries first takes place, and subsequently the walls of the dilated capillaries which lie next one another gradually disappear, resulting in the formation of large cavities filled with blood. Angeioma is not infrequently combined with fibroma, lipoma, and sarcoma (angiosarcoma). The treatment of angeiomata consists in their extirpation with the knife, if possible, or with the galvano-cautery or thermo-cautery (so- called ignipuncture or punctiform ustion). In order to operate with- out loss of blood, tlie base of the angeioma may in appropriate cases be transfixed and tied off in two or more parts, or portions of the tumour may be seized by clamps before they are divided. Large, diffuse angeiomata, like cirsoid aneurysms, may, if removal is impossible, be treated by ligation of the afferent arteries combined with ignipuncture. Cirsoid aneurysm occurs most commonly on the scalp, and in this situation might require ligation of the external carotid. If the main artery is too short, each of its branches should be secured. It is dan- Fig. 413.—Angeioma arteriale racemosum (cirsoid aneurysm) of the art. angularis and frontalis dextra et sinistra of a twenty-year-old man (Brunsl. Ligation of the right'external carotid and left common carotid. Death due to cere- bral embolism. 758 TUMOURS. gerous to ligate the common carotid on account of the changes wliich may thus be produced in the cerebral circulation. For the purpose of preventing recurrences it is often advisable to apply to the diseased part for a considerable time dressings which exert pressure or to paint it with iodoform collodion. Amongst other methods which have been recommended are electrolysis, parenchymatous injections of the tinc- ture of iron, liquor ferri (Monsell's solution), absolute alcohol, liquor Piazza (sodii chlor. 15'0 grammes; liq. ferri sesquichlorati [thirty per cent.], 20'0 cubic centimetres; aq. destil, 60#0 cubic centimetres [St. Germain]). Great care should be taken not to make the injection into healthy subcutaneous tissue. Gunn and Haven speak well of the injec- tion of carbolic acid (ninety-five per cent. acid, carbol. and glycerine, aa) into the peripheral parts of the angeioma (a few drops in from five to fourteen different places). Setons made of threads saturated in liquor ferri, and then dried and passed through the growth, used to be em- ployed, as were also the ligature (see page 72), cauterisation with fum- ing nitric acid, etc. These are all methods of treatment which have now become obsolete. Lymphangeioma (Angeioma Lymphaticum, Lymphangeiectasis).— The lymphangeioma corresponds to the angeioma of the blood-ves- sels, and consists essentially of dilated and hypertrophied lymph vessels (Fig. 414). The following varieties may be distinguished: 1, lymphangei- oma simplex (teleangiecta- sia lymphatica); 2, cavernous (lymphangeioma cavernosum [Fig. 414]) ; and 3, cystic lymphangeioma (lymphangei- oma cysticum). Some lym- phangeiectascs are acquired and others are congenital. The great majority of lym- phangeiomata are probably due to disturbances of em- bryonic development; a simple lymph stasis would not be sufficient to explain them, although it can favour the growth of a lymphangeioma which already exists. They usually communicate directly with the lymph vessels, and in one case Tsasse was able to demonstrate an open connection between a cavernous lympliangeioma of the neck and the subclavian vein and thoracic duct—a circumstance which can only be Fig. 414.—Lymphangeioma cavernosum of the sub- cutaneous cellular tissue of the neck, consisting of enlarged lymph vessels with hypertrophic walls, x 30. § 128.] THE DIFFERENT VARIETIES OF TUMOURS. 759 Fig. 415.—Leiomyoma of the uterus; some of the nuclei of the muscle fibres have been cut longitudinally, and others transversely, x 200. Lymphangeiectases are very explained on the grounds of a disturbance of embryonic development, as mentioned above. In consequence of this communication of a lymphangeioma with veins caused by abnormities in foetal development, large blood - cysts are formed, especially on the neck (Bayer). The congenital lymphangeiectatic hy- pertrophy of tlie tongue (macroglos- sia) and of tlie lips (macrocheilia) be- long to the congenital lymphangeio- mata. Lymphangeiomata sometimes reach a very considerable size. The fluid which they contain is, as a rule, clear, but sometimes milky. If one bursts, a lymphorrhcea or lymph fistula results, through which large amounts of this fiuid may escape (see page 543) often found in connection with the diffuse hyperplasia of connective tissue forming the so-called ele- phantiasis (elephantiasis lymphan- geiectatica, see page 523). The treatment of lymphangei- oma has already been spoken of. When possible, it consists in extir- pation of the growth—a procedure which is sometimes very difficult. Simple incision and drainage, or packing with iodoform gauze, may prove effective in cystic tumours; but this method should not be used when numerous small cavities are present. Bergmann has obtained very good results from extirpation, and Rehn successfully removed a lymphangeioma cavernosum of the sacral canal wliich pressed upon the cauda equina. Myoma (Muscle Tumour). — The myoma is made up essential- ly of muscle fibres, which may be either striated (rhabdomyoma, my- oma strio-cellulare) or non-striated Fig. 416.—Plexiform neuroma of the lumbar plexus (Czerny). 760 TUMOURS. (leiomyoma, myoma lsevicellulare, Fig. 415). Simple rhabdomyomata are very rare, the myosarcoma being the most common tumour of stri- ated muscle. Striated muscle fibres and spindle cells with striations are often seen in sarcomata of the testicle, kidney, and in tumours of the ovary (myosarcoma). Probably in such cases strayed embryonic muscle cells have become deposited in these organs. The leiomyoma is most common in the uterus and intestinal tract, where it takes the form of nodu- lar tumours, which are more or less pure myomata or fibro-myomata. Mi- croscopically, the non-striated muscle fibres are recognised on longitudinal sec- tion by the rod-like nuclei and their reg- ular arrangement. On cross section the characteristic con- tours of the fibres are seen, together with the transverse section of the nu- clei, in their interi- or (Fig. 415). The leiomyomata of the uterus often take on secondary changes, such as extensive fat- ty degeneration, calcification, cyst formation, and suppuration. They are occasionally combined with sarcoma and carcinoma. The treatment of myomata of the uterus, for example, is in tlie main the same as that of fibroma (see page 740). Neuroma (Nerve-fibre Tumour).—Tlie neuroma is made up essen- tially of newly formed nerve fibres. A distinction is made between true and false neuroma. Most neuromata are false—that is, they are fibromata or myxomata of the connective-tissue portion of nerves, with displacement and atrophy of the nerve fibres. They generally form flask-like swellings of the nerves, or cylindrical or spherical tumours, about the size of a bean, cherry, or plum, and, in rare cases, the size of Fig. 417.—Plexiform neuroma of the lower part of the face and neck on the right side in a boy ten years old (Bruns). 128.] THE DIFFERENT VARIETIES OF TUMOURS. 16I a lien's egg. The false neuromata are often multiple. Bergmann, for instance, observed more than a hundred neuro-fibromata of the skin in a man fifty-four years old. The so-called amputation-neuromata, which are club-shaped swellings of the ends of the nerves in amputa- tion-stumps, are, as a rule, made up mostly of newly formed connective tis- / "~\ sue, with more or less numerous col- lections of newly formed nerve fibres. The so-called plexiform neuroma also belongs to the false neuromata or fibro- neuromata. It is essentially a nodu- lar, fibrous degeneration of the branch- es of a particular nerve, the trunk of which becomes twisted and tortuous (Figs. 416, 419). These plexiform neu- romata, of whicli the rudiments were present in the embryo, are very much like soft fibromata of the skin and sub- cutaneous cellular tissue, in which they form flabby, lobulated folds and ele- vations (Fig. 417), sometimes uneven and nodulated, usually containing dark pigment and covered with hair, as in elephantiasis (Fig. 401). Very large tumours sometimes result from this elephantiasis-like hyperplasia of the skin and subcutaneous tissue. The plexiform neuroma is, according to Bruns, almost always situated in the subcutaneous tissue, and only exceptionally in the deeper parts, as in a case seen by Pomorski, in which a plexiform neuroma of the intercostal nerves had grown into the pleura. Bruns collected from literature a large number of instances of plexiform neuroma, and found that its most common location is on the temples and upper eyelid (fifteen cases). It was found eight times in that part of the neck wliich lies posterior to the ears, three times on the nose and cheek, four times near the lower jaw and front of the neck, seven times on the breast and back, and three times on the extremities. The true neuromata consist for the most part of newly formed nerve fibres, which develop in one or more peripheral nerves. Some cases of amputation neuromata also belong to this class of tumours. Depending upon whether the neuroma is made up of medullated or non-medullated nerve fibres, we make a distinction, as Virchow does, between a neuroma myelinicum and a neuroma amyelinicum. The brain and certain neoplasms of the testicle and ovary are sometimes the, Fig. 418.—Neuroma amyelinicum mul- tiplex recurrens ulcerosum anti- braehii. Most of the nodules lie beneath the skin : a, ulcerating nod- ule ; b, scar from a previous extirpa- tion of the primary neuroma (Vir- chow). 762 TUMOURS. seat of a cellular (ganglionic) neuroma. The neuroma is in general a benign tumour, though it is sometimes multiple in the nerves of the brain and spinal cord. In rare cases neuromata are found to be malignant, giving rise to local recurrences after extirpation, and even to metastases (Fig. 418). Benign neuromata can sometimes rapidly become malignant by chang- ing into sarcoma. Krause has collected from literature twenty-four such cases. Microscopically, the malignant neuromata are usually myxomata or lipomatous myxomata, or medullary, round, or spindle- Fig. 419.—Plexiform neuroma; specimen taken from the case illustrated in Fig. 417 (Bruns). celled sarcomata, or coarse fibrous neuromata, which nevertheless run a very malignant course. Softening and cyst formation in the centre of the tumour are common. The malignant neuromata usually spring, according to Krause, from the nerve sheaths, especially the intra-fascic- ular tissue. They can develop rapidly to tumours the size of a man's head, and are especially common on tlie large nerves of the extremities, such as the median and great sciatic, but are not infrequently met with in the small cutaneous nerves. Newly formed medullated nerve fibres are occasionally found in the neuromata—a fact which is not remark- able, as we know that degeneration and regeneration of nerve fibres take place in normal nerves. The so-called tubercula dolorosa, which appear as small, movable, painful, subcutaneous tumours, are, according to Virchow, in some in- stances true neuromata, while in others it has not been possible to demonstrate nerve fibres. § 128.] THE DIFFERENT VARIETIES OF TUMOURS. 763 As regards the treatment of neuroma, I may say that neuro-fibro- mata and neuro-myxomata can usually be removed and the continuity of the nerve be preserved. If extirpation is not possible, as in the case of large nerves of the extremities, for example, and the removal of tlie tumour is indicated on account of great pain, rapid growth, etc., the continuity of the nerve must be restored, after the extirpation of the neuroma, by means of sutures or a plastic operation. The treatment of a plexiform neuroma, which involves the whole region of distribu- tion of a nerve, is merely palliative in case an extirpation is impossible. The treatment of amputation neuromata was described on page 126. Glioma.—Gliomata occur especially in the brain, less often in the spinal cord, and result from the growth of the neuroglia cells of the central nervous system. They form pale-grey, greyish-white, or, when very vascular, reddish or dark-red tumours, wliich are usually not sharply defined. They are not infrequently the seat of retrograde metamor- phoses, such as fatty degeneration, caseation, and softening. Under the microscope the gliomata are seen to be made up of a network of fine, translucent fibres, which contain branching cells resembling those of the neuroglia. According to Klebs, Heller, and others, many gliomata con- sist of growing ganglionic cells and newly formed nerve fibres. Ziegler is right in separating these from the gliomata, and calls them neurogli- oma ganglionare. Lymphoma.—By lymphoma we understand a true neoplasm as well as a chronic inflammatory or infectious hypertrophy of lymph glands. The latter may originate as a result of local and constitutional causes. In this category belong, for example, tlie lymphomata of the neck fol- lowing chronic inflammation of the skin or mucous membrane in the region supplied by the lymphatic vessels which lead to the enlarged glands, also the lymphomata due to local or general tuberculosis, or which occur in the course of leucaemia, and the progressive lymphoma- tous formations encountered in anomalies of the organs producing the blood (malignant lymphoma, Hodgkin's disease, pseudo-leucaemia). Tlie word lymphoma signifies, in general, hyperplasia of lymph glands, but if the enlargement is caused by a true neoplasm, we call it, according to its structure, a lympho-sarcoma, lympho-adenoma, etc. The above- mentioned progressive formation of lymphomata, the so-called malig- nant lymphoma, is exceedingly interesting. The disease usually begins with a large, nodular swelling of the lympli glands of the neck (see Fi°\ 420) wliich is entirely free from pain. As a rule, the nearest lymph glands become successively swollen, then the glands of the other side, and, finally, in many cases the mediastinal and the retroperitoneal o-lands. The microscope shows a simple hyperplasia of the lymph 764 TUMOURS. glands, though Goldmann observed in them a marked increase in the number of cells which can be readily stained by eosin (eosinophilous cells). Metastases in the internal organs are of frequent occurrence (lungs, spleen, liver, kidneys, bone), and the enlargement of the spleen mav become very marked. The general health can remain undisturbed for a comparatively long time, but ordinarily a steadily increasing loss of flesh and strength soon sets in and is followed by death. Occasion- ally, as in goitre, the end comes suddenly from suffocation in conse- quence of softening of the laryngeal cartilages or of paralysis of the vocal cords due to bilateral pressure on the recurrent nerve. The eti- ology of malignant lymphoma has not been thoroughly investigated. The white blood-corpuscles are not increased in numbers as in leucaemic lymphoma, hence the name pseudo-leucaemia. Malignant lymphoma or pseudo-leucaemia is probably the result of some as yet unknown in- fection. The treatment of lymphoma va- ries according to its cause. Neo- plasms of the lymph glands should be extirpated as soon as possible. Tubercular lymphomata should also be treated in the same way, or scraped out with the sharp spoon, or treated by ignipuncture with the galvano-cautery, or parenchymatous injections of ten-per-cent. iodoform oil or iodoform glycerine, etc. I also excise simple, non-tubercular, so-called scrofulous hypertrophies in case they do not disappear under a general tonic regimen, a thing which is of great importance in the man- agement of all lymphomata. The arsenic treatment is sometimes suc- cessful, both internally and in the form of parenchymatous injections. Billroth begins with ten drops of Fowler's solution pro die internally, and injects at first two, subsequently four to six drops a day into the substance of the tumour. The internal dosage may be raised two drops every third day, but if symptoms of poisoning make their appearance the doses must be diminished. A cure is not obtained in this way, but the patient improves and the course of the disease is checked or ren- dered less severe. The operative removal of malignant lymphomata is probably always unsuccessful, as recurrences appear, as a rule, very promptly. But they should be removed sufficiently to relieve at least the urgent symptoms, such as those caused by obstruction to respiration. Fig. 420.—Soft malignant lymphoma of the cervical glands of a boy eight years old (W iniwarter). §128.] THE DIFFERENT VARIETIES OF TUMOURS. 765 Sarcoma.—The sarcoma (Figs. 421, 422) is a neoplasm which springs from connective tissue, and is formed, in general, after the type of embryonic connective tissue with abnormal and luxuriant cell forma- Fig. 4"21.—Sarcoma (osteo-sarcoma) of the left (upper) arm (Es- march). Fig. 422.—Sarcoma'(myxo-sar- coraa) of the dura mater in a twenty-eight-year-old man (Heineke). tion. Tlie sarcomata originate in all varieties of connective tissue (car- tilage, bone, periosteum, ordinary connective tissue, fat tissue, etc.), and are particularly likely to start from the cells of the walls of the blood- vessels. Benign tumours, as we remarked before, not infrequently Fig. 423.—Marginal portion of an inter- muscular sarcoma of the arm : 8, sar- coma tissue consisting of round cells; M, transversely divided muscular tissue. . 424.—Portion of a sarcoma of the fascia of the thigh containing cells of various shapes (small and large round cells, spindle cells, polynucleated giant cells, etc.'). x 250. become sarcomatous, thus giving rise to mixed tumours, such as fibro- sarcoma, myxo-sarcoma, osteo-sarcoma, etc. Sarcomata in the skin, peri- osteum and marrow of bone occasionally appear in a multiple form. 766 TUMOURS. The size and shape of the cells in a sarcoma vary within wide limits (Figs. 423-428), many being round cells, which are often contractile, like white blood-corpuscles, while others are spindle cells, endothelial cells, stellate cells, or giant cells. Between each of these there are nu- merous intermediate cell forms, and different shaped cells are often Fig. 425.—Small-celled alveolar sar- coma of the lymph glands of the neck. The alveoli between the connective tissue bands are filled with sarcomatous round cells. x 150. found lying next one another. There is a greater or less amount of intercellular substance which may be fibrous, homogeneous, reticu- lated, granular, mucoid, etc. The vascularity of sarcomata also varies very much, being occasionally so marked that the tumours pulsate like aneurysms. They likewise show great differences in consistency and colour. The very malignant, soft, rapidly growing sarcomata, made up largely of cells, are especially to be dreaded (medullary sarcoma). The pigmented varieties, the melano-sarcomata, are also very malignant. The formation of metastases takes place, as Billroth showed, principally through the veins, and to a less extent through the lymphatics. I once found in a case of medullary sarcoma of the lower extremity a meta- static deposit the size of a small pea in a valve of the femoral vein. The retrograde metamorphoses which take place are fatty degeneration, case- ation, softening, cyst formation, haemorrhage, and, after the disease has broken through the skin, ulceration and sloughing. Sarcoma of bone originates either from the periosteum or from the medullary cavity. The latter, or myelogenic sarcoma, is characterised by having a greater number of giant cells. As long as the central (myelogenic) sarcoma of bone possesses a closed capsule the prognosis is favourable, but otherwise it is extremely bad. Out of twelve pa- tients with sarcomata of the long bones which were removed with the knife, six died from recurrences, which in two of the remaining six Fig. 426.—Giant-celled sarcoma of the breast, x 300. § 128.] THE DIFFERENT VARIETIES OF TUMOURS. 767 cases soon afterwards necessitated secondary operations. According to the shape of the cells and tlie structure of the sarcoma the follow- ing different forms are distinguished, which of course often merge into and combine with one another to a greater or less extent: 1. The round-celled variety occurs as the small- and large-celled sarcoma. The small round-celled sarcoma (Fig. 423) is made up of cells which resemble white blood-corpuscles, and as a rule grows rapidly, forming a soft tumour, which on section appears white, and when squeezed gives out a milky fluid. It consists of round cells, blood-vessels, and generally of a very small amount of a fibrous, granular, or homogeneous stroma. In some cases it has a pro- nounced alveolar structure, and then resembles gland tissue or carcinoma— i. e., the cells, or rather groups of cells, are divided off by connective-tissue septa (alveolar sarcoma, Fig. 425). The small round-celled sarcomata are usually very malignant in character; tbey destroy the surrounding tissues, forming metastases and running a course similar to carcinoma (§ 129). Tbe most common locations for this sarcoma are connective tissue, muscle, fascia, periosteum, bone, lymph glands, etc. The large round-celled sarcoma (Fig. 426), although it is not quite so malignant as the small-celled and does not grow as rapidly, is very similar to the latter in its clinical course. It also occasion- ally possesses an alveolar structure. 2. The spindle-celled sar- coma usually consists of cells which are for tbe most part long, thin, and spindle- shaped, lying close together (Fig. 427), with or without a variable amount of homo- geneous or fibrous inter- cellular substance. If the latter is fibrous and abun- dant, the tumour is called a fibro-sarcoma. 3. The giant-celled sar- coma is characterised by the presence of a great number of very large, polynuclear, round, or polymorphous cells (Fig. 428), and origi- nates most commonly in bone marrow (myelogenic osteo-sarcoma). Giant cells are also occasionally found in the round and spindle-celled sarcomata, but not by any means in such quantities as in the true giant-celled neoplasm 4 Stellate or reticular-celled sarcomata are most commonly encountered in mvxomata and myxo-chondromata which are combined with sarcoma. The stellate or reticular cells, with their interlocking processes, are usually embedded in a soft, gelatinous, mucoid intermediary substance. 5. In many sarcomata cells of all varieties of shapes are found together (sarcoma with polymorphous cells, Fig. 424). Fig. 427. — Cells from a spindle - celled sarcoma of the thigh, x 300. Fig. 428.—Cells from a myelogenic giant-celled sarcoma of the lower jaw. x 300. 768 TUMOURS. 6. The alveolar sarcoma (Fig. 425) which was mentioned above is made up of mononuclear and polynuclear cells, as a rule about as large as average- sized pavement epithelial cells, which lie singly or in groups in a fibrous, less often in a homogeneous intermediary substance. A characteristic feature of this variety is that the cells, contrary to carcinoma, are closely united to the connective-tissue stroma, and cannot be easily separated from the fibrous meshes. Although this forms the means of distinguishing the alveolar sar- coma from carcinoma, yet sections of the two tumours under the microscope often present such similar pictures that it is very difficult to recognise one from the other. 7. The plexiform angeio-sarcoma (Waldeyer) is to be looked upon as an angeioma with a sarcomatous growth of the walls of the vessels; it originates mainly by growth of the endothelial cells which lie next the adventitia of both the lymph and blood-vessels (Fig. 429). These cell growths surround the walls of the vessels like a sheath, Vvx -^l\'-^~p^r^^^M^'^^ and, as a growth of the inner en- .•^^•^^(jVii^S'-T-V. -''''^;- dothelial cells also takes place, the v x >'\ '\ lumen of the blood or lymph ves- .•*.""..'. °. ^--x-"-.--" 'v"--''..- 'v«v sel in question may finally become ^V-ii^p^ entirely occluded. The reticulated ". ' - V" ^ - ■ anastomosing filaments and tubules * 7 ' '" ^ of the cells usually lie in fibrillar 4^^V.vJ;^ connective tissue, and as a result of '. J:--^ hyaline degeneration of the Avails of --"-*- \ - ' i ^ \ y>^ _''- *' the vessel hyaline tubules are formed ?;i:->;:v:^v.;5 ^iv.^, ''■-■' < '-\M0?Kc V i"^|$K having cells in their interiors, or the v.;'-' •■ '." " -, A'v.^y-'''■'• '}';-■.-?'-. latter are so narrowed by the hya- v;:^^'M';V:'>;"^^ line degeneration that only hvaline y^^z'~-^-'i'iC^'^:;<^^/Ay^^SW0' branching cords, bulbs, or spherules '*'fr^'■•' ^' without cells are found. Occasion- Fig. 429.—Plexiform angeio-sarcoma, or rather, ally the hyaline degeneration attacks endothelioma, of the thigh The annate- primarily the cells in the tubules, so mosing groups of cells are derived in this ■, ■, . instance from proliferation of the endo- that the hyaline cords are surrouud- thelium of the lymph vessels; they sur- d fc jj faj h h t t b round the latter like a sheath. In some J J places the groups of cells, or rather en- come degenerated. The plexiform dothelium, are in solid masses, while in o,10-in-omfl i«s rpallv nn Pnrlnf hp- others they have undergone degeneration. an£10 sarcoraa 1S really an endOtne- x 30. liosarcoma or endothelioma, and on account of the hyaline cylinders this tumour was once called a cylindroma. The endothelioma arises in some cases from the endothelium of the blood-vessels, and in others from the endo- thelioma of the lymphatics or connective tissue. Kiister rightly called atten- tion to the fact that there are haemorrhagic sarcomata or angeio-sarcomata (endotheliomata) which show extensive degeneration of the walls of vessels —i. e., growth of endothelial cells and hyaline degeneration—before a tumour nodule has become developed; they lead to haematomata without macroscop- ically visible sarcoma tissue. In other cases such haematomata are followed, months after, perhaps, by remarkably malignant sarcomata. The plexiform angeiosarcoma or endothelioma is anatomically easily mistaken for carci- noma, and runs a similar course—i. e., it is a markedly malignant tumour, §128.] THE DIFFERENT VARIETIES OF TUMOURS. 7G9 recurs after extirpation, and causes at a comparatively early period an infec- tion of the nearest lymph glands and metastases. Hence some authors have designated the malignant endothelioma as endothelial cancer. Some of the endotheliomata should, however, not be counted among true neoplasms on account of their diffuse development, but should rather be assigned to the infectious tumours. The xanthoma or xanthelasma, a sulphur-yellow or brownish-yellow pig- mentation of the skin, is, according to De Vincentiis, Touton and others, an endothelioma in which fat has been deposited (endothelioma lipomatodes); it grows from the endothelium of the lymphatic vessels, and occurs in a flat (xanthoma planum) and nodular (xanthoma tuberosum) form, especially on the eyelids, though occasionally it has a multiple character, appearing on different parts of the body, particularly where there are folds of skin (flexor side of joints, axilla, neck, etc.). Now and then the eruption occurs more or less suddenly—in the course of diabetes, for example (xanthoma diabeticum) —at other times symmetrically, probably from tropho-neurotic disturbances. Occasionally it changes into sarcoma or fibroma (sarco-xanthoma, fibro- xanthoma). The villous sarcoma, the so-called cholesteatoma, which may be encoun- tered on the meninges of the brain, probably owes its origin likewise to growth of the endothelial cells of the vessels, or rather of the cells of their sheaths. Perhaps the psammoma of the brain and orbit described by Virchow also belongs to the endotheliomata. They are characterised by the presence of large amounts of lime concretions similar to the " brain sand " normally present in tbe hypophysis cerebri. Such concretions are met with in sar- coma, fibroma, and myxoma, and, according to Billroth, are to be regarded as calcified bundles of endothelial cells which are attached to the blood- vessels, though Virchow thinks they are also the result of the calcification of connective tissue. The melanosarcoma (pigmented sarcoma) is characterised by the presence of a brown or black pigment which is almost always deposited in the cells. less often in the intercellular substance and walls of tbe vessels. On section the melanomata are brown, or, if the pigmentation is excessive, black in colour. They are among the most malignant tumours, their growth being sometimes very rapid and tbe number of metastases considerable (see Fig. 430). They are most likely to develop in places where pigment is already present—as in freckles or pigmented warts, for example (Fig. 430)—and most commonly begin on the extremities. The origin of the pigment is doubtful. According to Gussenbauer, it is formed from the red blood-corpuscles of the thrombosed vessels, while others think that it is not identical with the pig- ment resulting from haemorrhages, but may be due to a special activity of the cells (Birch-Hirschfeld). Schmidt considers tbe pigment to be haema- togenous in nature, having passed the haemosiderin stage and parted with its iron reaction. Terrillon observed, in a case of melanosis which ran a rapidly fatal course, an increase in the number of white corpuscles in the blood and a large num- ber of " black bodies." Melanuria is encountered in rare instances of multi- ple melanoma, and Zeller found variable amounts of bydrobilirubin and 49 770 TUMOURS. melanin in the dark-brown but otherwise perfectly clear urine. The urine in melanosis, when first passed, is clear, but if allowed to stand becomes black, and at times almost the colour of ink. The question of the transmissibility of melanoma, which has been experi- mentally studied by Lanz, has not yet been definitely settled, but I, person- Fig. 430.—Melanoma of the skin (man seventy-four years old) originating in a pigmented wart upon the back; within six months over one hundred pigmented spots and tumors formed upon tlie skin. Numerous melanosarcomata of the pleura, lungs, pericardium, liver, kid- neys, and retroperitoneal glands were found (Liicke). ally, do not doubt that it, like sarcoma and carcinoma, is capable of develop- ing from inoculation, as shown by the following remarkable instance of this which was observed by Lanz: Tbe latter injected into a guinea-pig a certain amount of an infusion of melanotic cutaneous nodules, melanotic brain, liver, and spleen. The animal died a month and a half after the injection, and the autopsy showed collections of pigment in many different parts of the body (skin, subcutaneous tissue, muscles, peritoneum, spleen, liver, kidneys, etc.). In this case the pigment must have been formed within the body, as only very little of the colouring matter was injected. The chloroma is a pale, grass, or brownish green round-celled sarcoma, which, according to tbe observations that have been made up to the present time, originates in the periosteum of the bones of the face and cranium, and gives rise to metastatic green nodules in various organs, especially the liver and kidneys. According to Huber, the green colour is due to small, very refractive granules, which are found in the cells and which give the micro- chemical reaction of fat. The chloroma is also characterised by the presence of an abnormally large amount of chlorine. We have already dwelt sufficiently upon the course and prognosis of sarcoma when discussing its different varieties. The duration of the disease depends in general upon the importance of the organ in- volved. The sarcoma of the brain is the most rapidly fatal, and may § 129.] THE EPITHELIAL TUMOURS. 771 cause death in one and a half to two months. Sarcomata of the medi- astinum are likewise very malignant, and may prove fatal in a few months by suffocation or paralysis of the heart. The prognosis is most favourable in the sarcomata of the skin, wliich can be easily extir- pated, and of the extremities in case the tumours are removed early enough by operative means. We have already mentioned that sarco- ma, especially of the skin, can be made to disappear permanently by the inoculation of erysipelas. Among important diagnostic factors, besides the above-described general characteristics of sarcoma, are its location and the age of the patient. Its favourite location is in mus- cle, periosteum, bone, nerves, glands (lymph glands, parotid, testicle, mamma), and it not infrequently develops after an injury. As regards age, sarcoma is most common in middle life, and less so in childhood and old age. It is usually a painless tumour. The general rule for treatment is to remove the neoplasm as soon as possible. In suitable cases of encapsulated, myelogenic giant-celled sarcoma of bone the anterior half only of the bony capsule may be removed by means of the hammer and chisel or the saw, and the tu- mour carefully' scraped out with a sharp spoon. In inoperable cases the inoculation of erysipelas may be tried. Burns has observed three permanent cures in five cases of this kind, and Coley published an account of nine cases with four cures. Among the latter was a very remarkable case of Bull's : Kound-celled sarcoma of the neck, with five recurrences in three years ; the entire removal was impossible in the last operation, and a wound twelve and a half by five centimetres re- sulted, which soon became filled up with masses of sarcoma tissue. Fourteen days later two attacks of erysipelas took place, whereupon the wound rapidly cicatrised. Seven years afterwards the cure was found by Bull and Coley to be perfect. Langenbuch has also published an instance of a great number of recurrent sarcomata of the skin which were caused to disappear by this means. One must, however, con- stantly bear in mind that the patient may die as a result of the inocu- lation of erysipelas, and hence it is one's duty to warn the patient or his friends of the danger before this procedure is adopted. The various other methods of treatment of sarcoma are described in the Special Surgery, and in connection with the treatment of tumours in general. § 129. The Epithelial Tumours.—The epithelial tumours include the papilloma, the epithelioma, the adenoma, and the carcinoma. I. Papilloma.—The papilloma results from hyperplasia of the epi- thelial layer of the skin and mucous membranes, with a corresponding new growth of connective tissue and blood-vessels. It is really a mixed 772 TUMOURS. Fig. 431.—Warty hyper- trophy of the scalp oc- curring in a woman twenty years of age (Billroth). tumour consisting of newly formed connective tissue and epithelium. A distinction is made between a hard and a soft papilloma. The hard, horny papillomata include, in the first place, warts (ver- rucas), which are the well-known growths of the papillae of the skin and epidermis, about the size of a bean or a pea. They are essentially a product of an overgrowth of the epidermis, which becomes horny, and often occur in great numbers without any known cause, especially on the hands, though in rare instances a diffuse warty hypertrophy of the cutis has been observed on the scalp (see Fig. 431). Mention should also be made of the onychoma (hyper- trophy of the nails), calluses (clavi) resulting from a circumscribed hyperplasia of the epidermis, and tlie cutaneous horns (cornea cutanea), which are excrescences on the skin due to a new growth of horny epithelial cells (true epitheliomata). The cutaneous horns occasionally originate from tlie sebaceous glands or from open atlieromata (sebaceous cysts). They are most common on the forehead and nose in old people. Brinton has collected fifteen cases of cutaneous horn of the penis, besides one that came under his own ob- servation. They sometimes occur in great num- bers (Fig. 432), not infrequently being curved, and may attain a length of from twelve to sixteen centimetres or more (see Special Surgery). It should be noted that occasionally benign cutane- ous horns which consist only of horny epithelial cells change into carcinomata. In this category belong also the tumour-like thickenings of the epidermis called keratomata, wliich are most commonly found on the sole of the foot and the palm of the hand, and are not infrequently inherited by all the branches of a family for many generations (Unna). They re- sult from a thickening of tlie epidermis, though the whole cutis also takes part in the hyperplasia. They often change,into real cutaneous horns or become combined with other new growths like an- geiomata (angeio-keratoma). Unna recommends for their treatment the use of a ten-per-cent. ethereal solution of salicylic acid, or the latter made into a plaster. Fig. 432.—Multiple cutane- ous horns, from twelve to sixteen centimetres in length, on various portions of the body of a seventeen - year - old girl (Bathge). § 129.] THE EPITHELIAL TUMOURS. 773 Ichthyosis (from lx6vs, fish) is a scaly thickening of the epidermis, usually congenital, over the entire surface of the body. Hystricismus (from vaTpi%, hedgehog) is a disease in wliich there is a formation of thorn-like excrescences on the skin, due to hypertrophy of the papillae and the epidermis. It is likewise, as a rule, congenital in origin. The soft papilloma is characterised by a soft stroma, a marked vas- cularity, and a very moderate growth of epithelium, which does not become horny. They occur on the skin and mucous membranes, gen- erally of the bladder, rectum, and uterus. The cauliflower excrescence of the vaginal portion of the cervix is a soft papilloma. In the rec- tum, uterus, and in other mucous membranes, the soft papilloma forms growths wliich are analogous to the above-mentioned mucous polyps. The polyps wliich are covered with epidermis, rete Malpighii, cutis, and hair, and occur in the pharynx, for example, originate, according to Arnold, from strayed embryonic cells and probably belong to the tera- tomata. The soft papillomata not infrequently change into sarcoma and carcinoma. The condyloma acuminatum found on the mucous membrane of the vulva, vagina and penis is also a soft papilloma; the broad condyloma (condyloma latum) is a papillary growth with a broad base, and often occurs about the anus in syphilis. The various kinds of papilloma should be treated according to the general rules already laid down. Warts should be removed by cauter isation with red, fuming nitric acid (not chemically pure), after paring off the epidermis with a knife. They are then usually cast off on the fifth or sixth day, or, if not, they may have to be cauterised again. Repeated applications of salicylic or iodoform collodion with a brush, as well as of a paste made with arsenic, are also exceedingly serviceable. By the use of these medicaments the wart gradually drops off in the form of a dried-up eschar. The same treatment may be used for cal- luses and corns, though they can be removed more simply by the knife after softening them in salt water. Molluscum Contagiosum or Epithelioma Molluscum.—Authorities differ widely in their views as to the nature of molluscum contagiosum. It is a peculiar skin disease in which there is a development of numerous nodules, varying in size from that of a pea to that of a hazel-nut or larger, generally located on the uncovered parts of the body and on the genitals. The small tumours are epithelial in character, and are said by Hebra to be caused by an accumulation of cells in a sebaceous gland, while Virchow thinks the growth of epithelial cells begins in the hair follicles, and Bizzozero, in the interpapil- lary portions of the rete Malpighii. They contain characteristic bodies, partly free and partly enclosed in cells which resemble swollen starch, and which, according to Leber, are degenerated epithelial cells, although Klebs and Bol- linger maintain that they are parasitic (psorosperms, coccidia). The disease 774 TUMOURS. is contagious, and not infrequently occurs in the form of epidemics, especially in children's asylums. Isolated cases are rarely met with. The treatment consists in simply pressing out the small tumours with the finger nail; the larger ones may require tbe use of tbe sharp spoon. Healing takes place without the formation of a cicatrix. II. Adenoma (Glandular Tumour).—The adenomata correspond in their structure to that of glands (Fig. 433), but the term does not in- clude simple hypertrophy of the latter, being used to designate only the true new growths which are separated from the surrounding tissues in the form of circumscribed nodular tumours. Even adenomatous de- generation of an entire organ can be easily distinguished from a general glandular hyperplasia. The adenomata form both hard and soft tumours. Microscopically, a distinction is made between tubulous and acinous or alveolar adenoma. They are very often combined with the formation of cysts. The adenoma is in itself not malignant, but it fre- quently changes into a destructive form—i. e., it becomes a carcinoma, in that the growing tubules penetrate the surrounding parts, take on an atypical growth, destroy the neighbouring tissues, and, by involving the lymphatics and blood-vessels, give rise -. .^\\';:::V-' ':;■•,(.'^ O.-'V" .-^"-^v^ f° metastases. The commencement )- x • ' ' ~ - \ of a change like this from adenoma •' '' ■ i ':-;'; •- ''•••• - to carcinoma has been called adenoid. • '<-, There are, however, malignant adeno- 1 , • - -, ^ '.,' !' ^ mata, which remain true adenomata, ;.- ■; . . }vHr with a distinct separation of the glan- v>\ \\ .!' ';f:::-^ dular epithelium from the stroma, but i ,,'{ " ^ J which nevertheless cause local destruc- <•*■ ' 111 ^( i- ' . '"'' '■■■■-, -. N tases. The adenoma of the rectum is k f' • • J an example of this variety. The ' -^^i&^ adenoma is found in various glandular Fig. 433.—Adenoma mamma? alveolare or ,*,»„.„~„ .'„ j.i,„ i • / 1 i j acmosum. x 30. organs, in the skm (sebaceous glands, sweat glands), in the respiratory and digestive tracts, in the genital organs, the mamma, thyroid, and salivary glands, liver, kidneys, etc. The treatment of adenoma consists in prompt extirpation of the tumour, as it is to be looked upon as an early stage of carcinoma, into which it frequently develops. With reference to the technique of the operation for removal of adenoma of the thyroid (goitre) and of lapa- rotomy for removal of ovarian adenoma, particulars will be found in the Special Surgery. III. Carcinoma (Cancer).—A carcinoma originates from the atyp- § 129.] THE EPITHELIAL TUMOURS. 775 ical growth of epithelial cells, the latter forming the main part of the tumour, though every atypical growth of epithelium is not cancer. In inflammatory processes and in the healing of wounds, an atypical growth of epithelial cells takes place in the form of cylinders or bulbs, but their growth is limited and they do not infiltrate and destroy the surround- ing tissues. It is quite different with carcinoma. Here the epithelial cells keep on growing unhindered; they infiltrate the surrounding tis- sues in the form of cell nests, displacing and destroying them. The cellular cylinders and nests, wliich are made up of proliferating epi- thelial cells, lie embedded in a partly old and partly new formed con- nective-tissue stroma (Fig. 434). As a result of the unimpeded growTth Fig. 434.—Carcinoma mammae simplex. x 200. of the carcinoma, or rather of the groups of epithelial cells, the latter invade the lymph and blood vessels and produce, by means of trans- ported living cancer cells, secondary nodules in the nearest lymph glands, and later in the various internal organs (Fig. 435). This power of forming metastases—in other words, of causing a general infection of the body—is characteristic of cancer. As regards the development of metastases in the lymph glands, it has been shown that the epithe- lial cells which make their way through the afferent lymphatics into the lymph sinuses multiply by caryocinesis; that they, by their con- tinuous growth, mechanically displace the glandular tissue ; and that endothelial cells and lymph cells do not change into cancer cells. The general cancerous infection can lead to such extreme exhaustion that the patient succumbs to the cancerous cachexia. In the skin the carcinoma arises from the cells of the rete Mal- pio-hii or from the cutaneous glands; an infiltration of the corium with Fig. 435.—Section through a com- mencing embolic cancer in a liver capillary resulting from an adeno - carcinoma of the stomach (Ziegler). x 300. 776 TUMOURS. epithelial cells gradually takes place, the cells being collected in single groups, cylinders, or nests which lie in a partly old and partly new formed connective-tissue stroma. In the glands a proliferation of the glandular epithelium first takes place, forming an adenoma ; then these proliferated cells invade the tissue surrounding the lobes of the glands, where they continue to grow unimpeded. The shape of the proliferated epithelial or cancer cells is not constant, but depends upon the location of the cancer. The cells of an epithelioma of the skin correspond in general to those of the rete Malpighii, while in a carcinoma of the stomach they have a cylindrical form, etc. Retrograde metamorphoses are very common in carcinoma because the nutrition of the great num- bers of cancer cells is insufficient. Hence fatty, mucoid, colloid, or cystic degeneration as well as calcification are of frequent occurrence. The degenerative changes in the central portions of a carcinoma and tlie adhesion of the integument often give rise to an umbilicated draw- ing in or depression of the skin. Superficial carcinomata, especially those which involve the skin, mucous membranes, or mamma, are extremely apt to break down and form extensive sloughing, punched- Fig. 436.—Large ulcerating carcinoma of the Fig. 437.—Pronounced destruction lower jaw and cheek occurring in a pa- of the face bv an epithelioma of tient suffering from lupus (Esmarch). the skin (Billroth). out cancerous ulcers (Figs. 436, 437). Bleeding not infrequently takes place, manifesting itself in the form of circumscribed haemorrhages or blood cysts, or, in other cases, a carcinoma may by degrees erode a large vessel, and thus suddenly lead to a profuse loss of blood, which may prove fatal. Occasionally a primary carcinoma is found in a multiple form. § 129.] THE EPITHELIAL TUMOURS. 777 Schimmelbusch has collected these rare cases from literature showing that multiple carcinomata of the skin are the most common, and may develop from a soot or tar eczema, from senile seborrhoea and xero- derma pigmentosum, ulcer of the leg, etc. In some instances they probably originate by inoculation from one part of the body to an- other, though in addition to these multiple carcinomata of inocula- tion others occur which, according to Schimmelbusch, are to be re- garded as independent tumours appearing simultaneously. Mandy has reported a carcinoma of both ears which came under observation in Bruns's clinic. The following different varieties of carcinoma have been described. 1. Flat Epithelial Cancer or Epithelioma.—The epithelioma of the skin, or cancroid, appears in the form of diffuse thickenings or nodular, warty, often ulcerating, elevations. On section, the alveolar structure can usually be seen with the naked eye and the epithelial nests or cylinders can be squeezed out or scraped from the cut surface with the knife. Some epitheliomata remain superficial, while others grow into the deeper parts-. The superficial variety, the cancroid or ulcus rodens, as it is called, which is more flat than the other, arises mainly from the rete Malpighii, while the growth having deeper at- tachments take its origin to a greater extent from the sebaceous glands. Epitheliomata also develop on mucous membranes that have a pavement epithelium (mouth, pharynx, oesophagus, vagina, uterus, bladder). 2. Cylindrical-celled Carcinoma.—The carcinoma with cylindrical cells is found particularly in the mucous membrane of the digestive tract and uterus; it has a soft consistency and is very likely to undergo a mucoid degenera- tion. 3. Carcinoma icith Gland Cells {Carcinoma Glandulare).—This is found in various glandular organs (mamma, liver, salivary glands, kidneys, testicles, etc.), and varies microscopically according to the organ affected. 4. Other Varieties of Carcinoma.— According to the shape, consistency, and other properties of the cancer the following varieties may be differen- tiated. The scirrhus is a very hard, tough carcinoma with small and few cancer cell nests lying in a dense stroma. The soft carcinoma (carcinoma medullare) is the opposite of the scirrhus, being rich in cells and having a soft stroma. The pigmented or melano-carcinoma, like tbe melano-sarcoma, is a brown or black tumour, which is. however, much less common than the latter. The pigment is likewise situated in the cells. The so-called giant-celled carcinoma is in some instances made up of true giant cells, while in others, the increase in the size of the cells is due to mucoid or dropsical degeneration. The colloid cancer (carcinoma gelatinosum) occurs especially in the intes- tine and breast, where it forms a transparent gelatinous tumour as a result of the mucoid or gelatinous degeneration of tbe cell-nests. The carcinoma myxomatodes originates either from the mucoid degeneration of the stroma and often of the cancer cells, or from the combination of a myxoma with a carcinoma (myxo-carcinoma). Occasionally colloid degeneration of the 778 TUMOURS. cancer cells gives rise to homogeneous spherical bodies which are found in the cancer nests. The external appearance of carcinoma is variable. Most commonly there is a formation of circumscribed nodules; less often the disease takes the form of a more diffuse, superficial infiltration and induration, or of papillary growths with large, branching papillae (villous cancer—e. g., of the bladder). Occasionally the skin, as in the region of the mamma, becomes diffusely diseased, as hard as a board, and infiltrated by a great number of small and large nodules (cancer en cuirasse). Etiology of Carcinoma.—Local irritations of a mechanical and chem- ical character are very important factors in the production of a carcino- ma. Hence one is most likely to develop in those parts of the body where mechanical and chemical irritations most commonly occur, as in the skin, lips, mouth, oesophagus, and in other parts of the digestive tract where normally narrow places exist, such as, for example, the oesophagus at the point where it passes through the diaphragm, the cardiac and pyloric regions of the stomach, the flexura sigmoidea, the rectum near the sphincter tertius, and the anus. In men, cancers of the skin, lips (almost always the lower lip), mouth, and rectum are the most com- mon ; while in women the glandular carcinomata predominate, and those of the mamma and the uterus are especially frequent. Carci- noma of the stomach is equally common in women and men, and is very likely to develop from a cicatrised gastric ulcer. The epitheli- omata of the lips, especially the lower lip in men, have been ascribed to smoking, to frequent irritation from unskilful shaving, etc., and tlie epitheliomata of the tongue and mucous membrane of the inside of the mouth to the irritation produced by smoking and chewing tobacco, or by the sharp edges of tlie teeth. The epitheliomata of the scrotum, observed in chimney-sweeps and workers in tar and paraffine, are ex- plainable on the same principle. Analogous irritating chemical sub- stances are present in soot, tar, and paraffine, just as in tobacco-smoke, tobacco-juice, and tobacco-ashes—i. e., various products of dry distilla- tion, especially carbolic acid. These irritating substances become de- posited in the skin of the scrotum, and sometimes give rise to cancer. I observed in a worker in paraffine who had a characteristic chronic paraffine dermatitis with the formation of scabs and pustules on the hands and forearms, the development of a typical carcinoma with metastases at the site of one of the scabs. Fig. 438 shows the hand of this patient, who finally died of general carcinosis. Two years pre- viously I had removed from the same man a paraffine epithelioma of the scrotum, which did not recur. Chronic inflammations in various parts of the body often give rise to carcinoma. Cancer will also be §129.] THE EPITHELIAL TUMOURS. 779 found in conjunction with benign neoplasms, like fibroma, atheroma, cutaneous horns, etc., and in cicatrices. According to different authors, its development is favoured by a too plentiful meat diet, as the inhab- itants of soutliern countries, who live largely on vegetable food, and the herbivorous animals are said, as compared with the carnivora, to suffer very seldom from this disease. A predisposition to carcinoma often appears to be inherited. It is essentially a disease of advanced life. At this period a slowly increasing atrophy of the stroma, in a certain sense, takes place, causing the skin, for instance, to be- come shrivelled and thin, and rendering it easier for the epithelium to make its way into the stroma as a result of mechanical or chemical irritations. A " boundary war," as it were, begins between epithelium and connective tissue, which in carcinoma ends in a victorious entrance of the epithe- lium into the less resistant stroma. What is the cause of the unlimited energy and power of growth possessed by carcinoma ? Hansemann attempted to an- swer this question in the following way: While it is an established fact under nor- mal conditions that in the indirect nuclear division the chromatin or nuclear fibrils divide into exactly equal-sized groups, Hansemann found that in malignant epi- thelial tumours (carcinoma) a division often took place into two unequal groups; and he thinks that this asymmetrical nuclear division, which belongs only to the malignant epithelial growths, is due to the fact that the cell eliminates certain parts of its protoplasm in the same way that the ovum, by expelling the directing or polar globules, frees itself of certain elements that are present in too large quantities. In this way the cancer cells attain an independence like that of the ovum, and to this is due their energy of growth and power of further development as metastases in different parts of the body. Importance of Micro-organisms in the Etiology of Carcinoma.—Scheuer- len (Deutsche med. Wochenschrift, 1887, No. 48) attempted to make pure cultures of specific bacilli and spores from a carcinoma, and inoculate them Fig. 438.—Hand of a worker in par- affine, showing chronic derma- titis with a formation of pus- tules and crusts and papillary- growths ; carcinoma of the fore- arm starting from one of these inflamed spots; amputatio an- tibrachii and death from gen- eral carcinosis. 780 TUMOURS. into animals. He used for his experiments ten mammary carcinomata, and made on the average twenty inoculations for each case, among which there were always at least seven successful ones. The microscopic examination of the pure cultures showed, in addition to bacilli from 15 to 2'5 micromilli- metres in length and 0"5 micromillimetre in breadth, a number of almost as large ovoid, translucent, and greenish-coloured bodies (spores). The bacilli and spores have a special kind of self-locomotion; the former can be stained by all methods and immediately decolourised by alcohol. The spores can be stained in the same way as tubercle bacilli. Scheuerlen could not find with certainty bacilli or spores in sections of carcinomatous organs, but he did find them in the cancer juice, mostly outside the cancer cells. Pure cultures of cancer bacilli grow best upon agar, potato, infusion of meat peptone, or cabbage, and more slowly upon gelatine. In agar a streaky cloud is de- veloped along the line of puncture, similar to the one caused by the bacilli of mouse septicaemia. By injection of media containing cancer bacilli into the mammary glands of six bitches, hard cancer nodules were produced from which pure cultures of characteristic bacilli and spores could be obtained. Other authorities, such as Pfeiffer and Sanarelli, have also found Scheu- erlen's bacilli in carcinoma, but attempts at inoculation proved entirely unsuccessful, and the majority of winters are of the opinion that there is at present no ground for considering the questionable bacilli to be the cause of cancer. They are much more inclined to think that it is merely an innocent, accidental saprophyte. Pfeiffer maintains that the bacillus is identical with the proteus mirabilis. Schill found in sections and in the juice of carcinoma and sarcoma little rods containing two dots, both ends of which appeared, after staining by Gram's method, as small points of a deep violet colour, which were joined by a transparent thread. Besides these a mould-fungus was present. Some interesting investigations have been made by Thoma, who found in carcinomata of the rectum, the stomach, and the breast peculiar unicellu- lar structures within the cell nuclei, having a diameter of from four to fifteen micromillimetres, spherical or oval in shape, or more like a whetstone, and consisting of protoplasm and a nucleus. He is inclined to think that these bodies are encapsulated coccidia. Whether they are to be looked upon as the cause of carcinoma cannot, as Thoma himself says, be decided until further exact tests have been made. Many other investigators have seen similar bodies in the nuclei or protoplasm of epithelial cells in carcinoma, some looking upon them as psorosperms, and others as altered and degenerated epithelial cells. The question whether protozoa really are present in carci- noma has been discussed very fully of late, and the matter is one of great interest. But the occurrence of coccidia in carcinoma has become more and more doubtful recently, and they are thought by many to be products of the degeneration of cells (Le Dentu, Karg, author). Schiitz thinks it very prob- able that some of the bodies originate from the red blood-cells. It is evident that we have to deal here with morphologically and genetically different forms of cells as well as of cellular and nuclear changes, including Altmann's cell gran u la. The fuchsine bodies described by Russell and others as characteristic of carcinoma and thought to be blastomycetes are, according to Klein, Altmann, 129.] THE EPITHELIAL TUMOURS. 781 and Karg very large cell granules. The parasitic nature of carcinoma is at present still an open question. The Transmissibility of Carcinoma.—The question whether carcinoma is transmissible or not is of tbe greatest importance as regards its etiology. That it is has, in fact, been experimentally proved in the case of mice and rats by Novinsky and Morau, who also succeeded in causing metastases in the internal organs of the former animal. It has also been noted that carci- noma is occasionally transferred from one part to another of the same body, or from one person to another. Hahn cut skin grafts from some of tbe nu- merous disseminated cutaneous nodules of a cancer existing on the thorax of a woman and planted them on other portions of her body, and found that they went on growing and developed into similar cancers. Cornil and Frank have likewise seen successful inoculations of carcinoma in man. It has repeatedly been observed that malignant tumours (carcinoma and sarco- ma) have resulted from a simple transference of living tumour cells during an operation, and hence this means of infection may occasionally be tbe cause of recurrences after tbe extirpation of such a neoplasm. Billroth saw an isolated carcinoma form in the cicatrix in the overlying abdominal wall after extirpation of a similar growth (which was not adherent to tbe sur- rounding parts) from the pylorus. Becker and Czerny have also noticed in- stances of cancerous inoculation of a cicatrix following an operation. Berg- mann saw a carcinoma of the upper and lower lips at exactly opposite points, a circumstance which made it probable that one was the cause of the other. There are many similar cases recorded, all of which indicate that carcinoma originates from infection by contact, and may develop in a person who comes into close relations with another who has the disease; husbands, for exam- ple, have been known to acquire one of the penis from wives with a cancer of the uterus (Czerny, Tross, etc.). This transmissibility possessed by carci- noma does not prove, of course, that the poison of cancer depends upon mi- cro-organisms; on the contrary, it seems very probable that the transmission, like the metastases, is accomplished by the living cancer cells. Course, Prognosis, and Diagnosis of Carcinoma.—Carcinoma runs a chronic course extending over months and years. Its varying energy of growth and its location are factors of great importance in determin- ing how rapidly or slowly the disease will progress. In rare instances a more or less acute general carcinosis takes place, causing, in a few weeks, metastases and marked cancerous cachexia. The latter is very much increased by rapid growth of the primary and secondary cancer nodules, by ulceration and sloughing, by stenoses that interfere with the entrance of air or food, by disturbances of digestion, etc. Ulcera- tion is especially prominent in epitheliomata of the skin. Cancerous ulcers are, as a rule, irregular in form, and their edges and bases, as well as the surrounding tissue, are hard and indurated. The superficial ulcerating epithelioma of the skin, the so-called cancroid or ulcus rodens, runs comparatively the most favourable course, in that it spreads slowly over the surface, has less tendency to involve the 782 TUMOURS. deeper parts, and only leads late in its course to infection of the near- est lymph glands. According to Klemperer, the metabolism of cancerous individuals is characterised by a pronounced destruction of albumen, the viscera undergoing fatty degeneration and the blood showing a marked diminu- tion in its percentage of carbonic acid; and hence he infers that carci- noma causes a systemic intoxication by means of certain poisonous sub- stances—a conclusion which is not accepted by Minkowski. According to Miiller, the cancerous cachexia resulting from the increased destruc- tion of albumen, the diminution of the chlorides in the urine, and the loss of weight, is similar to the febrile processes and cachexies present in long-continued malaria, leucaemia, and pernicious anaemia. The cause of the abnormal destruction of albumen in cancerous individuals prob- ably lies in the poisonous action of the products of metabolism of the carcinoma. As a result of the accumulation of these products of me- tabolism and of the insufficiency of the kidneys, symptoms of coma carcinomatosum and death may supervene (see pages 743, 744). The prognosis of cancer is, as we have already clearly stated, very unfavourable. Complete cures are rare, even when the carcinomata are extirpated very early in their course. As a rule, one recurrence fol- lows another until the patient succumbs to general carcinosis or exhaus- tion. We make a distinction, based upon their mode of origin, between continuous and regional recurrences; tlie former spring from portions of the primary tumour which were left behind at the time of the opera- tion, while the latter (regional recurrences) are to be looked upon as independent new tumours in the cicatrix or its vicinity. The second kind sometimes make their appearance only after the lapse of years. All recurrences which occur later than two years after the operation should be considered, according to Snow, new independent tumours resulting from new injurious agencies. The diagnosis of carcinoma is in general not difficult if what has been said be borne in mind. A differential diagnosis may have to be made from tubercular and syphilitic growths. A careful microscopic examination of an excised portion of the tumour will usually clear up any uncertainty. If syphilis is suspected, antisyphilitic treatment should be begun (iodide of potassium, mercury, etc.), and when the latter dis- ease is present such a method of treatment will be successful, but not in cases of carcinoma. Treatment of Carcinoma.—The treatment of carcinoma consists in as early an extirpation as possible. During the later stages an attempt should at least be made to check its course and improve the general condition of the patient. In extirpation with the knife as much of the 129.] THE EPITHELIAL TUMOURS. 783 healthy tissue as can be spared sliould be included, so as to leave no tumour cells behind. The nearest lymph glands must always be thought of; thus, in every amputation of the breast, for example, the axilla should be opened and the glands and all the fat removed, even though no enlargement of the former can be felt from without. After the axilla has been cut into, slightly enlarged lymph glands are often found in cases where they were not suspected. Complete cures some- times result from an early, careful extirpation of a carcinoma, and if no recurrence appears within one and a half to two years the patient is to be regarded as probably entirely freed from his disease. I have, however, occasionally seen recurrence take place three years after the first operation. One generally occurs sooner or later, and after extir- pation of this, the carcinoma very frequently reappears in a still shorter time, making it seem in many cases as though recurrences were hastened and increased in virulency by each succeeding operation. The different methods of operation for carcinoma with the knife, gal- vano-cautery, thermo-cautery, etc., are described in the chapters on gen- eral surgical technique, and the extirpation of carcinomata in different parts of the body—the skin, breast, mouth, stomach, intestine, uterus, etc.—is described in the Special Surgery. The treatment of inoperable carcinomata is symptomatic. Accord- ing to the nature of the case, a trial may be made of the various methods already mentioned in connection with the treatment of tumours in gen- eral. These include, in addition to a general strengthening regimen, parenchymatous injections, the arsenic treatment, and circumcision with the thermo-cautery in order to diminish the growth, pain, and final sloughing of tlie carcinoma. In sloughing cancers, use may be made of the sharp spoon, thermo-cautery, and dressings filled with deo- dorizing substances, such as acetate of aluminium, carbolic acid, bichlo- ride of mercury, iodoform, and naphthaline. Narcotics in the form of subcutaneous injections of morphine are often indispensable. The inoculation of erysipelas has already been spoken of on page 771. It is frequently necessary to perform an operation for the treatment of the sequelae of an inoperable carcinoma; a tracheotomy may be required, for example, in carcinomatous stenoses of the larynx, or the formation of an artificial anus in carcinoma of the intestine. Whether the growth of the disease is influenced by the transplantation upon it of healthy skin (Goldmann) cannot as yet be definitely decided. Amongst the medicinal preparations that have recently been well spoken of, the following should be mentioned: Mosetig-Moorhof recommended parenchymatous injections of aniline dyes (methyl violet or pyoktannin 1 to 500 aq. dest.), but I have seen no good results from 784 TUMOURS. its use. Clay (Birmingham) speaks well of the action of turpentine (in the form of the essence made by Southall and Barclay in Birmingham, two teaspoonfuls three or four times a day, with pills of sulphur and sulphate of copper, etc. ; also local injections into the tumour). Stroh- binder uses parenchymatous injections of tannic acid into the carcino- matous growths (one hypodermic syringeful a day). Glycerine and resorcin have also been used locally, decoctum Zittmanni (decoctum sarsaparillae compositum) internally, and chalk, powdered oyster-shells, and condurango-bark both internally and locally—all of which are prob- ably useless. Esmarch and others have recommended for cancer pa- tients a diet consisting of but little nitrogenous matter. § 130. Cysts—Atheromata, Teratomata, Cyst-formation in Different Tumours.—The formation of cysts takes place, as we have already said, Fig. 439.—Cysto-sarcoma of the Fig. 440.— Proliferating follicular dental cyst femur (Busch). of the lower jaw in a peasant thirty-two years of age (Bryk). in many different kinds of tumours, especially adenoma (cysto-adeno- ma), fibroma (cysto-fibroma), and sarcoma (cysto-sarcoma), as a result of softening. The proliferating cystoma of the ovaries, kidneys, or mammae, in which a new production of cysts takes place, belongs to the class of the true cystic tumours. But, in the main, these proliferating cysts are adenomata; a proliferation of cells first occurs, and, secondarily, the formation of cysts as a result of mucoid and colloid degeneration of the cells. This continues, until finally very large tumours are de- § 130.] CYSTS—ATHEROMATA, TERATOMATA. 785 veloped, particularly in the ovaries. Cystic goitres also begin as adenomata. Bone cysts are, as a rule, either enchondromata, fibromata, or sarco- mata, which have undergone cystic degeneration (Fig. 439), or true proliferating cystic tumours. To the latter belongs that cystic degen- eration which often simultaneously attacks all the bones of the body, and is perhaps to be regarded as a constitutional disease. Bramann found a multiple formation of cysts in a great number of the bones of a woman thirty-four years old, who had osteomalacia. Many bone cysts are probably due to inflammatory processes or haemorrhages (Schlange). Tlie cysts of the jaw and teeth (Fig. 440) arise either from the periosteum or from the dental follicles as a result of disturb- ances of development. Here, also, the proliferation of cells takes place first, and then a progressive formation of cysts follows. A large num- ber of cysts, originating in a great variety of ways, are congenital; these have been described very fully by Lannelongue and Archard. Other cysts are due to parasites, such as echinococcus and cysticercus cellulosge, and are found in various organs of the body. The contents of the cysts are serous, mucous, or bloody. A dis- tinction is made between simple and compound or multilocular cysts. The interior of the latter is divided off by septa, and, in some in- stances, new cysts form in the walls of the old ones. The retention cysts do not belong to the true tumours, as in these cases an abnormal new growth of cells does not occur, but only an accumulation of secretion. With Virchow, we divide the retention cysts into (I) mucous cysts, (2) follicular cysts, and (3) retention cysts, starting in the excretory duct or the acini of large glands. Mucous cysts, which result from the retention of the secretion of the mucous glands, are found especially in the mucous membrane of the lips, the cheeks, the antrum Highmori, the respiratory and digestive tract, the vagina, the uterus, etc. Tlie follicular cysts include the comedones, those well-known little spots in the skin, often of a black colour, which are plugs or secretion in the hair follicles, and the milium resulting from a similar accumulation of secretion in the sebaceous glands. The atlieromata or sebaceous cysts are retention cysts of the hair follicles. The latter continue to form their secretion, and consequently the sac becomes more and more tense; and thus are developed in the skin the well-known tumours wliich vary in size from that of a small pea to that of a fist or a child's head, and contain epidermis, fat, and crystals of cholesterin. A second variety of atheroma is situated not in the skin, but deeper down in the subcutaneous tissue. These deep subcutaneous atheromata are probably the result of separated embryonic remnants 50 786 TUMOURS. of skin tissue which contain sebaceous glands or groups of epithelium belonging to the epidermis. In the latter case they might be called epidermoids (Franke). Franke thinks that atlieromata are not reten- tion cysts of the skin follicles, but represent true new growths which have sprung from embryonic cells. The atlieromata sometimes grad- ually break through the integument, and become complicated by in- flammation, suppuration, or even epithelioma (Fig. 441). Hence ex- tirpation of atheromata is always indicated. Cutaneous horns occa- sionally develop from open atlieromata with fistulae. Among the retention cysts which arise from the excretory ducts or acini of large glands may be mentioned the retention cysts of the liver, the mamma, and the kidney; also the so- called ranula under the tongue near the frenulum resulting from the closure of the excretory ducts of the submaxillary and sublingual glands, and particularly of the Blandin-ISTuhn glands—two mucous glands situated near the tip of the tongue. Cysts are, moreover, found in structures which do not persist after the birth of the foetus ; examples of these are branchiogenic cysts of the neck, cysts of the urachus, etc. We have already mentioned the occur- rence of blood and lymph cysts due to a gradual dilatation of blood- and lymph- vessels. By cholesteatoma is meant either an atheroma or a dermoid cyst, with charac- teristic, often silky white contents which are made up of fat, cholesterin, and groups of cells which shine like mother- of-pearl. The cholesteatomata are found especially in the brain and its meninges; also in the ovaries, in the subcutaneous cellular tissue, and in bone (petrous portion of the temporal). According to Eppinger and others, the cholesteatomata are essentially endotheliomata (see page 768). Glaeser examined one wliich was found on the base of the brain, and came to the conclusion that the cells of the cholesteatoma develop from the endothelia of the lymph spaces of tlie arachnoid by growth and concentric division. Kuhn is disposed to think that the cholestea- tomata of the ear are principally congenital in origin. Politzer found small roundish bodies in the mucous membrane of the ear wdiich in- crease in size and lead to the formation of these tumours. Tlie sup- puration and sloughing which accompany cholesteatomata of the ear Fig. 441.—Woman fifty-nine years of age with atheromata of the hairy portion of the scalp; a typical carcinoma developed in a cyst which suppurated on the top of her head. § 130.] CYSTS—ATHEROMATA. TERATOMATA. 787 are secondary conditions, and not, as Ilabermann thinks, the cause of their development. These sequelae lead not infrequently in cholestea- tomata of the ear to death of the patient; and hence Kuhn emphasises the necessity of a radical removal by osteotomy, if it is required, of the portion of the bone in question (mastoid process). The etiology of cholesteatomata of the middle ear and the meatus is probably com- plex ; some of the cases are certainly endotheliomata, while others are the result of a simple proliferation of epithelial cells, or a change of epithelial cells into epidermis. Tlie etiology of cholesteatomata has an extremely interesting bearing upon the etiology of tumours in general, showing, as it does, that tumours can arise from the cells of the meso- derm which correspond exactly to those that originate from epithelium. The treatment of cysts depends largely upon their location and their cause; it consists in extirpation, puncture, incision, parenchyma- tous injection of various fluids, such as absolute alcohol with or with- out tincture of iodine (see page 745, Treatment of Tumours in Gen- eral), etc. The treatment of cysts of the different parts of the body is described in the Text-Book on Special Surgery. The extirpation of smaller atheromata is best accomplished by introducing a probe or a small instrument shaped like a spatula, or a pair of Cooper's scissors, into the cutaneous incision, freeing the atheroma on all sides, and finally taking out the uninjured cyst with its capsule in toto. Care must be taken to always remove the whole of the atheroma, which should not be opened at the time the cutaneous incision is made; this may be done by cutting through the skin first at the base of the tu- mour, and after separating the latter from the surrounding parts with a probe, enlarging the original incision with scissors sufficiently to permit the loosened cyst to be enucleated. Teratomata are congenital tumours or malformations which are made up of a great variety of tissues. They include both the double monstrosities, in which one embryo is rudimentary and united to the other, and malformations which have taken place in a single foetus. All sorts of structures have been found in congenital tumours and' cysts. Kummel discovered in a congenital coccygeal neoplasm a body that resembled an eye which was similar to one found by Marchand and Baumgarten in an ovarian cyst, The dermoid cysts also belong in this class ; they have an inner wall which is analogous to the skin, and may occur in organs where skin is not normally present. They are most commonly found in the ovary, and also in the peritonaeum, neck, orbits, nose, and in the sacral and coccygeal regions. The wall of the cyst consists, as we have said, of epidermis and corium, with sebaceous glands, hair follicles, and less 788 TUMOURS. often sweat glands. The contents usually consist of a fatty, yellowish or whitish, greasy mass, together with hairs, cartilage, bone, and even teeth. In very rare cases, brain, nerve, and muscle tissue or structures resembling extremities have been found. Occasionally the contents are oily (oil cysts). Kocher and Streit have laid emphasis upon a pecul- iarity possessed by these tumours—when not filled too full—of retain- ing for a considerable length of time any change of form which is given them. This is due to their homogeneous cement-like contents. If epi- thelial cells and masses of fat are mixed with a large amount of hair, a peculiar crepitation may be felt on palpation of the tumour (Kocher). The dermoid tumours develop from stray cutaneous cells which have been inverted, as in the closure of embryonic clefts. At the same time cells of the entoderm may become displaced or separated. Polypous appendages are sometimes found upon different parts of the surface of the body. They are to be looked upon as abnormal dis- placements of tissue or malformations depending upon an imperfect closure of embryonic clefts. Such tumours or cutaneous appendages, occasionally containing cartilage, are found in the vicinity of the lines of closure of the dorsal or ventral clefts, or near the face, ears, neck, anal region, or the rhaphe of the perinaeum (Chiari). INDEX. Acetabulum, wandering of the, G74, 675. Acetal as anaesthetic, 42. Acetate of aluminium, 158. Acetic ether, 39. Aceto-tartrate of aluminium, 159. Acne, 513. Acromegaly, 650. Acromicria, 651. Actinomyces, 255. Actinomycosis, 441. diagnosis and prognosis of, 446. occurrence in animals, 443. occurrence in man, 444. treatment of, 447. Acufilopressure, !)4. Acupressure. 94. Adenoid, 774. Adenoma, 774. Air cushions, 202. Air, entrance of, into veins, 60, 453. Alcohol dressings, 168. Aldehyde, 39. Alkaloids, cadaver, 264. Alumnol, 170. Amoebae, 277. Amputation, general technique of, and in- dications for, 113, 476. after-treatment of, 124. artificial limbs after, 127. mortality of, 127. sequelae of, 124. subperiosteal, 122. Amputation in cases of fracture, 602. Amputation knives, 115. Amputation neuroma, 126. Amputation stump, conical, 125. Amputation with scraping out the medulla, 616. Anaemia, artificial, 48. (See also Ischae- mia.) Anaesthesia, 15. local, 43. Anaesthetics, 15-45. Anatomical tubercle, 380. Anchylosis, 696. Aneurysms, 532. diagnosis and prognosis of, 537. symptoms of, 536. treatment of, 537. varieties of, 533-535. Angeioma, 755. Angeio-keratoma, 772. Angeio-sarcoma, 757. Aniline dyes as antiseptic, 169. Anomalies of granulating wounds, 521. Anthrax, 381. in animals, 386. attenuation of virulence of bacilli of, 384. bacillus of, 382. etiology of, 382. immunity from, 385. in man, 386. occurrence and origin of, 384. stain of bacilli of, 386. Antisepsis, 3. Antiseptic dressings, 146. Antiseptics, 152. Aorta, congenital stenosis of, 531. ligation of, 296. Aphthae epizooticae, 394. Apparatus for gymnastics. 215. Apparatus for permanent irrigation, 179. Argentum nitricum, 79. Aristol, 167. Arm, bandages for, 190. Army surgery, 727. Arrow poison of Indians, 405. Arsenic paste, 80. Arteries, 530. aneurysms of, 542. digital compression of, 47. diseases of, 530. haemorrhage from, 86. inflammation of, 329. ligation of, 87, 95. punctured wounds of, 457. suture of, 91. Umstechung, 90. Arteritis, 329. Artery clamps, 87. Arthrectomy, 129. Arthritis, acute, 658. chronic, 668. deformans, 683. luetica, 682. tubercular, 672. urica, 663. (See also Joints.) Arthrodesis, 133. Arthropathia tabidorum, 695. 790 INDEX. Arthrospores, 261. Arthrotomy, 129. Articular rheumatism, 658. acute polyarticular, 658. chronic, 669. Aseptin, 160. Aspergillus, 256. Asphyxia, 26. .Aspiration, 70. Aspirators, 70, 71. Atheroma, 785. Atrophy of skin, idiopathic, 524. Auscultation of bone, 593. .Auto-transfusion, 52, 478. :Bacilli, 258 (see also the separate infec- tious diseases). of diphtheria, 527. of glanders,'390. of malignant oedema, 333. of symptomatic anthrax, 389. Bacillus of anthrax, 382. coli communis, 334. of Ernst, 325. of leprosy, 438. of mouse septicaemia, 365. pyocyaneus, 324. of rabbit septicaemia, 365. Bacteria, action of pathogenic. 269. attenuation of virulence of, 270. conditions suited to life of, 262. culture media for, 267. of decomposition, 366. experimental transmission of, 274. formation of pigment by, 265. immunity from effects of, 272. infectious, 321. influence of constant electric current upon, 263. influence of light upon, 263. influence of oxygen upon, 263. influence of temperature upon, 263. intra-uterine transmission of, 275. linear cultures of, 268. methods of studying, 267. movements of, 260. needle-point cultivation of, 268. non-pathogenic, 275. pathogenic, 275. phosphorescence of, 265. power of organism to protect itself against, 271. products of metabolism of, 263, 265. restraint upon growth of, 266. structure and reproduction of, 259. toxic, 269. Bacterial proteins, 235, 241. Bandages, application of, 185. handkerchief, 194. for the head, 187. for the lower extremity, 192. for the mamma, 189. for the neck and thorax, 189. for the shoulder, 192. for the upper extremity, 190. Barracks in war, 735. Docker's, 735. Baths, permanent, after injuries, 179. Batteries, electric, 77. Beds, movable, 200. Bee stings, 403. Benzoic acid, 168. Bichloride of mercury, 155. effects upon pus cocci, 321. poisoning by, 157. stability of, 156. Bichloride gauze, preparation of, 156. Binoculus, 189. Birth-mark, 755. Bismuth, 160. Bistoury, 64. Blastomycetes, 257. Blood, coagulation of, 292. regeneration of, 453. treatment of loss of, 478. Blood - corpuscles, white, emigration of, 234. reaction of, to staining reagents, 293. Blood cysts, 757. (See also Angeioma, Lymphangeioma, and Cysts.) Bloodless operation, 1. Blood transfusion, 479, 482. Blood-vessels, 530. aneurysms of, 532. diseases of, 530. injuries of, 449. ligation of, 87. punctured wounds of, 456. suture of, 91. torsion of, 90. Umstechung, 90. varices, 540. Boiler for sterilisation of instruments, 4. Bones, abnormal fragility of, 571. abscess of, 629. absorbable drains of, 100. absorption of, 583. acromegaly, 650. acromicria, 651. acute inflammation of, 609. acute osteomyelitis, 610. atrophy and hvpertrophv of, 647. caries of, 621, 628. chronic inflammations of, 618. crushing of, 607. cysticercus cellulosae. 652. division of, 80. echinococcus of, 652. formation of, 581. giant growth, 649. gunshot injuries of, 730. implantation of, 144. increased growth of, 582, 649. inflammations and diseases of, 609. inflammation of marrow of, 610. injuries and fracture of, 567. metastatic inflammations of, 617, 618. necrosis of, 630. neuralgia of, 692. INDEX. 791 Bones, neuropathies of. 693. in syringomyelia, 695. tabetic, 693. operations upon, 80. osteomalacia, 644. percussion and auscultation of, 593. plastic surgery upon, 111. resection of, in continuity, 129. rhachitis, 638. sawing of, 83. strength of, 569. suture of, 110. syphilis of, 628. transplantation of, 586. tuberculosis of, 621. tumours of, 652. uniting, by nails, 110. wounds of, 607 Bone forceps, 82. Bone screws, 111. Bone shears, 82. Borated lint, 159. Borax, 158. Boric acid, 159. Boric-acid ointment, 160 Boro-glycerine lanolin, 160. Boro-salicylic solution, 158. Box splint, Heister's, 203. Branchiogenic cvsts, 786. Bromethyl, 42. Bromethylene, 43. Bromoform, 43. Bullet forceps, 736. Bullets, discovery by magnet of, 736. extraction of, 736. healing in of, 733. impaction of, 730. Burns, 484. causes of death from, 487. from lightning, 491. prognosis of, 489. symptoms of, 486. treatment of, 489. Bursae, diseases of, 558. Carbolised gauze, 153. Carbolised glycerine, 153. Carbolised silk, 89. Carbonic acid as an anaesthetic, 43. Carbuncle, 514. Carcinoma, 774. curability of, 783. etiology of, 778. histology of, 777. micro-organisms of, 779. transmission of, 781. treatment of, 782. Caries of bone, 621, 628. Caro luxurians, 521. Cartilage, fibrillation of, 683. fractures of, 575, 587. histology of, 656. inflammation of, 683. injuries of, 575, 587. repair of fractures of, 587. repair of wounds of, 725. Cataplasm, 181. Catgut, capillary drain of, 101. ligatures of, 87. preparation of, 88. sterilisation of, 11. sutures of, 105. Caustic pastes, 80. Caustics, different kinds of, 79. use of, 79. Cauterisation en fleches, 80. Cavernoma, 757. Cellulitis, 331. prognosis of, 337. symptoms of, 334. treatment of, 337. Cellulose splints, 213. Cement dressing, 224. Chain saw, 83. Cheilo-angioscopy, 305. Chemotaxis, 235. Chin bandage, 188. Chionyphe Carteri, 257 Chisels, 81. Chloral-chloroform narcosis. 42. Chloral methyl (local anaesthetic), 46. Chloride of zinc, 159. Chloride-of-zinc paste, 80. Chloroform, 16. accidents during narcosis of, 25. apparatus for administering, 21. chemical composition of, 16. death from, 27. decomposition of, by gas flame, 23. narcosis of, 18. physiological action of, 17. poisoning by drinking, 30. statistics of death from, 27 symptomatology of narcosis of, 23. treatment of accidents during narcosis of, 33. Chloroform-morphine narcosis, 41. Chloroform-oxygen narcosis, 32. Cholesteatoma, 786. Chondrioderma difforma, 276. Cadaver alkaloids, infection by, 379. Cadaver infection, treatment of, 381. Cadaver tuberculosis, 381. Callosities of skin, 772. Callus, formation of, 581. delayed formation of, 591. treatment ol delayed formation of, 603. Callus luxurians, 585. Cancer (see Carcinoma), 774. Cancroid, 776. Canquoin's paste, 80. Caoutchouc splints, 213. Capistrum duplex, 188. Capitium parvum, 195. magnum, 196. quadrangulare, 196. Caput obstipum (congenital), 508. Carbolic acid, 152. demonstration of. in urine, 154. poisoning by, 154. 792 INDEX. Chondroma, 751. Chondrostitis dissecans, 638. luetica, 629. Christia, 200. Cicatrix, formation of, 249. malignant neoplasms of, 299. paralysis from, 300. subsequent changes in, 299. tumours of, 299, 748. ulcers of, 300. Cladothrix, 255. Clamp apparatus for uniting bones, 111. Clavi, 772. Clostridium, 259. Club-foot, 699. Coagulation necrosis, 526. Cocaine (as anaesthetic), 45. Cocci, various kinds of, 258. Coccidia, 277. Coccus of gonorrhoea, 433. Coccus of sputum septicaemia of dogs, 366. Cold, effects of, 494. use of, 181. Cold abscess, 623, 675. Collateral circulation after ligation of ar- teries, 296. Collodion, dressings of, 183. Comedones, 785. Compresses, split, 116. Compression (as method of haemostasis), 92. Condyloma acuminatum, 773. Condyloma latum, 430. Congestion abscess, 623, 675. Conidia, 254. Connective tissue, growth of, 284. Continuous suture, 107. Contractures, cicatricial, 299, 485, 705. inflammatory, 549. ischemic, 549. of joints, 698. myopathic, 705. neuropathic, 700. paralytic, 702. spastic, 701. Contusions, 497. symptoms of, 498. treatment of, 504. Contusions of bones, 607. Contusions of joints, 707. Cooper's knife, 05. Corpora oryzoidea, 559. Corsets, 223. Cotton-starch dressing, 222. Creolin, 169. Croton oil as an irritant, 236. Croup, 526. Curare, 405. Curative serum. 363. Cushions for sick-bed, 202. Cutaneous horns, 772. Cylindroma, 768. Cystoma, 784. Cysto-sarcoma, 784. Cysts, 784. Decomposition, 264. Decubitus, 562. Deformities (contractures) of joints, 698. Delirium nervosum, 317. Delirium of collapse, 318. Delirium tremens, 316. treatment of, 317. Dermatitis, 511. Dermatol, 167. Dermatolysis, 524. Dermoid cysts, 737. Devouring cells, 272. Dextrine dressing, 224. Digital compression of arteries, 47. Diiodthioresorcin, 1G7. Dimethylacetal-chloroform narcosis, 42. Diphtheria, bacilli of, 527. etiology of, 527. Diplococci, 258. Director, 66. Disarticulations, 123. after-treatment of, 124. artificial limbs for, 127. diseases following, 124. mortality of, 127. performance of, 123. subperiosteal, 123. Disinfection of catgut, 11. of the dressings, 11. of the field of operation, 8. of the instruments. 10. of the operator and his assistants, 9. of silk, 11. of sponges, 11. Dislocations of joints, 710. complicated, 715. congenital, 721. of deformity. 721. of destruction, 721. from distention, 721. habitual, 716. inflammatory (pathological), 720. of the interarticular cartilages, 720. intra-aeetabi.lar, 674. irreducible, 719. of muscles, 509. of nerves, 510. old, 719. of tendons, 509. voluntary, 712. Distortion of joints, 708. Division of the soft parts, 64. Drainage, 98. Drainage forceps, 100. Drains, 99. of rubber tubing, 100. Dressings, antiseptic and aseptic, 146. change of, 173. for the head. 187. impromptu or temporary, 215. Dressing forceps, 07. Earth tetanus, 355. Eburnatio ossis, 623. Ecchondroses, 752. INDEX. 793 Ecchymoses, 498. Echinococcus, 652. of bone, 652. in the joints, 654. Ecrasement, 73. Eoraseur, 73. Eczema, 512. following use of antiseptics, 512. solare, 492. Electric batteries, 77. Electro-puncture of the heart, 36. Elephantiasis, 522. Elevators, 81. Emboli, fat, 590. Emphysema, gangrenous or septic, 333. traumatic, 460. Enchondroma, 751. Endarteritis, 530. Endothelial cancer, 769. Endothelioma, 768. Enostoses, 753. Epiphyses, spontaneous separations of, 637. strength of, 572. syphilitic separations of, 629. traumatic separations of, 589. Epithelial tumours. 771. Epithelioma, 777. Epithelioma molluscum, 773. Ergotine gangrene, 563. Ergotism, 563. Erysipelas, 339. cocci of, 339. complications of, 344. curative, 346. diagnosis of, 347. habitual, 344. of mucous membranes, 341. prognosis of, 348. symptoms of, 341. treatment of, 348. zoonotic, 351. Erythema, 511. migrans, 351. solare, 492. various kinds of, 511, 513. Erythrophlaeine as an anaesthetic, 46. Esmarch's artificial ischaemia, 48. chloroform apparatus, 20. rubber bandage, 4!>. rubber tourniquet, 49. Ether, 37. Ethyl acetate, 39. Ethyl chloride as local anaesthestic, 45. Eucalyptus, 168. Euphorin, 167. Europhen, 167. Exercise bones, 552. Exostosis, 753. Exostosis bursata, 690, 754. Extension by a weight. 224. Extension dressings, technique of apply- ing, 224. modifications of, 224. Extension splints, 214. Extravasation of blood, 498. Extravasation of blood, absorption of, 502. changes in, 502. of lymph, 498. Extremity, upper, dressings for, 190. lower, dressings for, 191. Exudate, various kinds of, 243. Farcy (see Glanders), 390. Fascia lata, shrinkage of, 706. Fascia nodosa, 187. Fat emboli, 590. Favus, 256. Felt, plastic, 212. Fermentation, 257. Ferment intoxication, 366. Ferrum candens, 74. Fever, 300. body weight in. 306. condition of respiration in, 305. condition of vessels during, 305. definition of, 311. digestion during, 305. disturbances of nervous system in, 305. etiology of, 307. explanation of, 309. loss of heat during, 310. muscular system in, 306. pathological changes in, 306. prognosis of, 306. pulse in, 304. symptoms of, 303. treatment of, 311. Fever in subcutaneous injuries, 500. Fibroma. 747. molluscum, 747. Field hospitals, 735. improvisation of, 735. Filopressure, 94. Filter paper for dressings, 152. Finger bandages, 191. Fistula, 518. Flax. 150. Flexion, forced, as a method of checking haemorrhage, 92. Foot, dressings for, 192. Foot and mouth disease, 394. occurrence of, 395. treatment of, 395. Forceps, toothed, 67. Foreign bodies, healing in of, 250. behaviour in the wound. 461. Formation of new tissue, 284. of a cicatrix in a vessel, 2!M). of fibrillar connective tissue, 285. of new vessels, 287. Fractures. 567. causes of, 567. condition of urine in, 580. diagnosis of, 592. direct fixation of fragments by nails, su- tures, etc., 597. disturbances during healing of, 589. gunshot, 729. prognosis of, 593. repair of, 580. 794 INDEX. Fractures, symptomatology of, 576. treatment of, 594. treatment of malunited, 605. various kinds of, 572. Fractures involving joints, 596, 599, 715. Freezing, 494. Frost-bite, 494. blebs, 495. Funda maxilla?, 194. Fungi, 254. pathological importance of, 256. Furuncle, 513. Galvano-cautery. 75. instruments, 76. Galvano-puncture, 78. Ganglion, 561. periostale, 619. Gangraena senilis, 562. Gangrene foudroyante. Gangrene of the soft parts, 561. of bone, 630. Genu valgum, 701. varum rhachiticum, 640. Germicides, tests and comparisons of, 266. Glanders, 390. in animals, 392. bacilli of, 390. diagnosis of, 394. in man, 392. treatment of, 394. Glass splints, 211. Glass wool, 152. Glioma, 763. Glisson's sling for extension, 230. Glue dressing, 224. Glycerine-salt dressing material, 152. Gonococcus, 433. Gonorrhoea, 433. Gonorrhoeal rheumatism, 662. Gout, 663. Gout of lead poisoning, 664. Granulations, formation of, 280. anomalies of, 521. Gregarines, 277. Gum and chalk dressing, 224. Gummata, 430. Gummi lacca\ 183. Gutta-percha splints, 213. Gymnastics. 215. Gvpsum dressing, 216. "knife for, 221. scissors for, 221. various methods of applying, 217. Gypsum splints, 220. Haemarthros, 707. Haematoma, 498. absorption of, 502. changes in, 503. Haemophilia, 57. joint diseases complicating, 686. Haemorrhage, arrest of, 86. arterial, 449. capillary, 450. Haemorrhage, causes of death from, 452. death from, 452. effects of, 451. prevention of, during operations, 47. regeneration of blood after, 453. secondary, 477. treatment of, 478. venous, 450. Haemostasis, 86.' temporary, 465. Hairy people, 756. Hammer, surgical, 81. Hand, bandages for, 191. Hand spray, 12. Healing beneath a scab, 177. microscopic phenomena in the healing of a wound, 282. per primam intentionem, 280. per secundam intentionem, 281. Heister's cradle or box splint, 203. Hip, bandages for, 193. Histocym, 308. Hollow needles, 69. Hollow probes, 66. Hospital gangrene, 351. clinical course of, 352. etiology of, 352. prognosis of, 353. treatment of, 353. Howship's lacunae, 583. Hydarthros, acute, 658. chronic. 667. Hydrophobia, 395. action of poison of, 397. attenuation of the poison of, 397. diagnosis of, 400. in dogs, 398. etiology of, 395. experiments upon, 396. in man, 398. prognosis of, 401. protective inoculation with, 401. results of autopsy in, 400. treatment of, 401. Hygroma of bursae, 559. of tendon sheaths, 558. Hyperostoses, 620. Hypertrichoses circumscripta, 756. universalis, 756. Hypodermic needle, 71. Hysteria after injuries, 279. 546. Hysterical joint diseases, 690. Hystricismus, 773. Ice. use of, 181. Ice bags, 181. Ichthyol, 170. Icthyosis, 773. Immersion, 179. Immunity, natural and artificial, 321. Impromptu dressings, 194. Indian arrow poison, 405. Infantile spinal paralysis, 703. Infection from cadaver alkaloids, 379. intra-uterine, 416, 427. INDEX. 795 Infectious wound diseases, 318. origin of, by microbes, 318. various kinds of, 320-405. Inflammation, 232. causes of, 237. croupous and diphtheritic, 244. diagnosis and treatment of, 251. of joints, 658. acute, 658. chronic, 667. movements of lymph in, 235. nature of, 238. symptomatology of, 241. Inflammation and suppuration of wounds, 320. Infusion of salt solution, 478. indications for, 481. technique of, 481. Initial sclerosis of syphilis, 428. Injections, parenchymatous, 71. Injuries, general remarks upon, 277. Insects, injuries inflicted by, 403. Insolation, 492. Instruments, sterilisation of, 10. Iodine, 168. as an antiseptic. 168. demonstration in urine of, 166. Iodine, trichloride of, 169. Iodoform, 160. behaviour of, towards bacteria, 162. with formic acid, 161. poisoning by, 163. Iodoform collodion, 183. Iodoform gauze, 161. Iodoform wick, 162. Iodol, 167. Iron, red-hot, 74. Irrigation, permanent, of wounds, 178. Irrigator, 179. Ischaemia, artificial, 48. Ischaemic contractures, 549. Ivory pegs, insertion in bone of, 111. Joints, anatomy of, 655. anchylosis of, 696. cartilage of, 657. contractures, of, 698. deformities of, 698. diseases of, in bleeders (haemophilia), 686. echinococcus of, 654. endothelium of, 655. histology of articular cartilages of, 657. inflammations of, 658. acute, 658. chronic, 667. arthritis deformans, 683. gout, 663. syphilis, 682. tuberculosis. 672. gonorrhoeal, 662. metastatic, 661. rheumatic, 669. injuries of, 707. contusions, 707. dislocations, 710. Joints, gunshot injuries of, 727. punctured wounds, 724. sprains or distortions, 708. wounds, 724. lymph vessels of, 657. neuropathic inflammations of, 693. neuroses of, 690. resection of, 129. synovia of, 658. synovial villi of, 656. Junker's chloroform apparatus, 21. Jury mast, 229. Jute, 149. Kappeler's chloroform apparatus, 21. Keloid. 299, 748. Keratoma, 772. Knee, bandages for, 193. Knife, forms of, 64. methods of holding, 65. Kyphosis, 675. Lacerated wounds, 463. Lancets, 64. Lanoline, 183. Laryngeal mucous membrane, anaesthesia of, by irritation of, with chloroform or carbonic acid, 43. Laughing gas, narcosis of, 39. combined with oxygen, 40. Lead plates for suturing, 108. Leather splints and bandages, 213. Leg, bandages for, 192. Leontiasis, 747. Leprosy, 437. bacilli of, 438. diagnosis and prognosis of, 441. occurrence of, 439. symptoms of, 439. treatment of. 441. Leptothrix, 259. Leucocytes, different reactions towards staining materials, 293. emigration of, 235. Leucocytosis, inflammatory, 241. Lifts for sick-bed, 201. Ligature en masse, 72. of vessels, 87. Lightning, action of, 491. Lint, 149. Lipoma. 750. Lipoma arborescens, 689. Lister's method of treating wounds, 147. Liver, collection of blood in the, 502. Lues, 425. Lupus, 515. Lymph, movements of, during inflamma- tion, 235. Lymphadenia ossium, 651. Lymphadenitis, 326. Lymphangiectasis, 543. Lymphangieoma, 758. Lymphangitis, 326. Lymphatics, acute inflammation of, 326. diseases of, 543. 796 in Lymph fistula, 544. Lymph glands, acute inflammation of, 326. collection of blood in, 502. diseases of, 326. Lymphoma, 763. Lymphorrhagia, 544. Lymphorrhcea, 544. Lysol, 169. Lyssa, 395. Madura foot, 257. Magnesite dressing, 224. Magnetic needle for extraction of metallic foreign bodies, 66, 478. for extraction of bullets, 736. Malaria, protozoa in, 277. Malformations, 649. Malleus, 390. Malum perforans pedis, 564. Malum senile, 683. Mamma, dressings for the, 189. Marly scraps for dressings, 151. Marrow of bone, actinomycosis of, 630. chronic inflammations of, 618. echinococcus of, 652. metastatic inflammations of, 617. scraping out of, 615. syphilis of, 628. traumatic inflammations of, 617. tuberculosis of, 621. Massage, technique of, 505. Melanoma, 769. Menthol as anaesthetic, 45. Mercurial cachexia, 436. Metal splints, 209. Methylol. 36. Methyl chloride, 36. Methylene bichloride, 36. Methylene compounds, 36. Methylene ether, 36. Methyl ether, 36. Microbes, importance of, in inflammation, 257. importance of, in fever, 309. methods of examining, 267. morphology of, 259. of suppuration, 321. Micrococci, 258. Micrococcus pyogenes tenuis, 325. tetragonus, 258. Miliaria, 513. Milium, 785. Milk infusion, 484. Mitella, 197. Mitra Hippocratis, 188. Mollin, 184. Molluscum contagiosum, 773. Monilia, 255. Monoculus. 189. Morphine-chloroform narcosis, 41. -ether narcosis, 42. Moss, 150. Moss-felt pads, 150. Moss pulp, 151. Mouse septicaemia, bacilli of, 365. Mouth-and-hoof disease, 394. Mouth-gag, 22. Mouth speculum, 22. Mucin poisoning, 359, 523. Mucor corymbifer, 256. rhizopodoformis, 256. Mucous membrane, inflammations of, 525. transplantation of, 143. Mull, 149. sterilised pledgets of, 11. Mures articulares, 687. Muscles, diseases of, 549, 553. hernia of, 509. injuries of, 506. luxations of, 509. regeneration of, 468. suture of, 468. transplantation of, 468. Muscular rheumatism, 553. Mycetozoa, 276. Myoma, 759. Myositis serosa, 550. fibrosa, 551. ossificans, 551. Myxoedema, 523. Myxoma, 749. Myxomycetes, 276. Naevus vasculosus, 755. Naphthaline, 167. Narcosis with chloroform-air mixture, 29. chloroform-morphine, 41. chloroform-oxvgen, 32. ether, 37. by irritation of laryngeal mucous mem- brane, 43. laughing gas, 39. mixed, 40. Nearthrosis, formation of, 686, 713. Neck, dressings for, 189. Necrosis of bone, 630. of soft parts (gangrene), 561. streptococci in, 332. Necrotomy, 636. Needle-holder, 104. Needles, 104. Nephritis carbolica, 164. Nerves, defects of, 471. degeneration of, after injuries of, 454. diseases of, 545. grafting. 470. injuries of, 453, 459. luxations of, 510. neurectomy, 548. regeneration of, 454, 473, 474. stretching of, 470, 547. suture of, 469. transplantation of, 471. treatment of defects of, 470. Nervus phrenicus, electrical stimulation of, in asphyxia, 35. Neuralgia, 547. of bones, 692. of joints, 690-692. INDEX. 797 Neurectomy, 548. Neuritis, 545. Neurofibroma, 747. Neuroglioma ganglionare, 763. Neuroma, 760. malignant, 762. plexiform, 761. Neuropathic inflammations of bones and joints, 693. Neurorrhaphy, 469. after-treatment of, 472. histological changes after, 475. results of, 473. secondary, 470. Neuroses, traumatic, 279, 546. following operations, 63. New formation of tissue, 284. New formation of vessels, 287. Noma, 525. Occlusion, antiseptic, in army surgery, 733. Occlusive dressings, antiseptic, 146. Odontoma, 754. CEdema, malignant, 333. bacilli of, 333. Oidium, 255. Oil-cysts, 788. Onychoma, 772. Operating tables, 6, 7. Operation, 1. accidents in the course of. 56. after-treatment of, 61. alleviation of pain in, 14. aseptic, 2. causes of death in, 62. definition of, 1. healing of wounds made in the course of. 61,280. indications and contra-indications, 2. neuroses following, 63. preparations for, 2. preparations for, in private practice, 13. saving of blood during, 47. Operator, clothing of, 9. disinfection of clothing of, 9. Organisation of a thrombus, 290. Osteoblasts. 582. Osteochondritis, 629, 638. dissecans, 638. luetica, 629. Osteoclasis, 84. Osteoclastic cells, 583. Osteoclasts, 84, 583. Osteoma, 753. Osteomalacia, 644. anatomical changes in. 645. Osteomyelitis, acute primary. 610. anatomical changes in, 612. clinical course of, 613. diagnosis and prognosis of, 614. etiology of, 610. treatment of, 614. Osteomyelitis, chronic, 618. syphilitic, 628. tubercular, 621. Osteomyelitis, tubercular, anatomical changes in, 621. clinical course of, 624. diagnosis and prognosis of, 625. treatment of, 626. Osteophonia, 593. Osteophyte, 619. Osteoplasty, 586. Osteoporosis, 647. Osteopsathyrosis, 571. Osteosarcoma, 755. Osteosclerosis, 648. Osteotome, 84. Ostitis, 514. Paper-starch dressing, 222. Papier-mache splints, 209. Papilloma, 771. Paquelin's thermo-cautery, 74. Paraffine splints, 213. Paralysis of heart from chloroform, 26. electro-puncture for, 36. Paralysis, infantile spinal, 703. Parenchymatous injections, 71. Paronychia, 335. Pasta cerata, 184. Peat, 150. Pelvis, bandages for, 193. Pemphigus, 513. Penghwaer djambi, 93. Penicillium glaucum, 255. Pental narcosis, 43. Percussion of bone, 593. Percutaneous ligation (of vessels), 90. Periarteritis, 329. Periosteum, inflammations of, 609. Periostitis, albuminoid or mucinoid, 619. chronic ossifying, 620. syphilitic, 628. tubercular, 621. Periphlebitis, 329. Peroxide of hydrogen, 169. Pes calcaneus paralyticus, 702. equino paralvticus, 702. valgus, 700, 701. varus, 699. 700. Petit's leg splint, 203. Phagocytes, 272. Phenol, 152. Phlebectasia\ 540. Phlebitis, 329. Phlebotomy, 458. Phlegmasia alba dolens, 339. Phlogosin, 241. Phosphorus necrosis, 631. Photoxylin, 183. Pityriasis versicolor, 255. Plasmodia, 276. Plasmodiophora Brassicae, 276. Plasmodium malariae, 277. Plaster of Paris, splints of, 216. Plastic operations, 134. Plexiform neuroma, 761. Pneumococcus, 325. Poison, cadaveric, 379. 793 INDEX. Poisoning by insects and snakes, 403. Poultice, antiseptic, 181. Pressure paralysis from cicatrix, 300. Projectiles from firearms, effects of, 727. Protozoa, 277. Pseudarthrosis, 591. Pseudo-tuberculosis, 412. Ptomaines, 264. Pulse in fever, 304. Punctured wounds, 456. of cavities, 459. of joints, 459, 724. of nerves, 459. of vessels, 457. Pus, 247. blue, 247. green, 247. red, 247. Pus-corpuscles, origin of, 246. Pus microbes, 321. Putrefaction, bacteria of, 366. Pyaemia, 373. clinical course of, 376. diagnosis of, 378. etiology of, 373. occurrence of, 376. pathology of, 374. prognosis of, 378. treatment of, 378. Rabies, 395. Rag-sorter's disease, 836. Railway injuries, 279. Reaction following injury or inflamma- tion, 300. Red-hot iron, 74. for haemostasis. 93. Red pus, 325. Regeneration of tissues, 250-298. of nerves, 454. of tendons, 469. Reproduction of bacteria, 259. Respiration, artificial, 34. Retentive dressings, 216. Retractors, 68. Reunion of entirely severed parts, 290. Rhachitis. 638. anatomical changes in, 639. the course of, 642. the diagnosis of, 642. the etiology of, 641. the treatment of, 643. Saccharomyces, 257. Salicvlic acid, 158. Salveol, 170. Salves, 183. Scab, healing under a, 177. Scissors, 68. Scleroderma, 524. Scrofula, treatment of, 424. Scurvy or scorbutus, 521. Secondary haemorrhage, 47 Septicaemia, 363. of animals, 365. Septicaemia, clinical course of, 368. cryptogenetic, 363. diagnosis of, 371. etiology of, 363. occurrence of, 367. pathological changes in, 367. prognosis of, 371. treatment of, 372. Sequestrum, separation of, 632. Sequestrotomy, 636. Shock, 313. etiology of, 313. symptoms of, 314. treatment of, 315. Shot-suture. 109. Sick-bed of the patient, 200. Silk, preparation of, 89. Size, daily variations in, 651. Skin, burns of, 484. callosities of. 772. contusions of, 461. diseases of, 510. frost-bites of, 494. horns of, 772. injuries of, 448. opening for drainage, 101. plastic operations upon, 134. polypus growths of, 788. transplantation of, 141. Skin-grafting, 141. Skin-muscle canalisation, 101. Skinning over of granulation wounds, 281. Snake-bites. 403. - Sodium chloride, addition to bichloride solution of, 156. impregnation of dressings with, 152. for treatment of wounds, 170. Sodium chloride infusion, 482. Sodium tetraboricum, 160. Soft chancre, 432. Spastic stiffness of joints, 701. Spirillum, 259. Splints of plaster of Paris, 216. Spoon, sharp, 72. Sprains of joints, 708. Spray, 12. Starch dressing, 222. Steam spray, 12. Steam sterilising apparatus, 4. Stenocarpine, 46. Sterilisation of catgut, 11. of dressings, 11. of instruments, 10. of silk. 11. Sticking plaster, extension by, 225. various kinds of, 182. Sticking-plaster, mull, 182. Streptococcus pyogenes, 323. Structure and reproduction of bacteria, 259. Subcutaneous rupture of muscles and ten- dons, 506. treatment of, 508. Subcutaneous salt infusion, 484. Sulphocarbolate of zinc, 168. Sun-burn, 492. INDEX. 799 Sun-stroke, 492. treatment of, 493. Suppuration, causes of, 240. importance of microbes in, 257. various kinds of, 243. various kinds of microbes of, 321. Suspension apparatus, 204. Suture, continuous, 107. interrupted, 106. of nerves, 469. secondary, 109. of tendons, 466. of vessels, 91. Suture materials, 105. Syncope, 27. Syphilis, 425. changes in blood in, 421. course of, 432. immunity from, 432. inheritance of, 427. origin of, 427. symptoms of, 428. transmission of, to animals, 426. treatment of, 433. Syphilis maligna, 437. Syphilitic albuminuria, 432. dental deformities, 432. pseudo-paralysis, 432. Temperature of body in fever, 301. Temporary dressings, 194. Tenoplasty, 467. Tenorrhaphy, 466. Tenosynovitis. 566. Tenotome, 67. Tenotomy, 558. Teratoma, 787. Terebene, 168. Tetanus, bacillus of, 356. clinical course of, 359. etiology of, 354. of the head, 360. hydrophobicus, 400. immunity from, 358. pathogenesis of, 356. poison of, 357. prognosis of, 361. traumatic, 354. treatment of, 361. Tetany, 359. Tetraboride of sodium, 160. Thermo-cautery, Paquelin's, 74. Thrombus, organisation of, 290-294. red, white, and mixed, 291. subsequent changes in, 294. Thymol, 159. Tissue, division of. 64. formation of, 284. regeneration of, 250, 298. Toothed forceps, 67. Tourniquets, 48. Toxines, 264. Transfusion of blood, 479-482. dangers of, 480. indications for, 481. Transfusion of blood, technique of, 481. Traumatism, 183. Trichloride of iodine, 169. Tripolith dressing, 222. Trismus, 354. Trocar, 69. Tubercle, anatomical, 380. Tubercles, origin and structure of, 407. Tubercle bacilli, 408. of birds, 412. demonstration of, 414. staining of, 410. toxine of, 409. Tuberculosis, 406. of bones and joints, 419. of cattle, 411. combined with syphilis and cancer, 412. diagnosis of, 420. extension of, 413. inheritance of, 415. of lips, rectum, etc., 418. of lymph glands, 420. of mucous membranes, 417. of nose, 418. origin of, in man, 412. of pharynx, palate, etc., 418. prognosis of, 420. of subcutaneous tissue, 416. termination of, 415. of tongue, 417. transmission of, to animals, 411. transmission of, to foetus, 416. treatment of, 420. treatment of, with tuberculin, 421. Tumours, 738. in animals, 741. clinical course of. 742. curability of malignant, 744. diagnosis of, 744. etiology of, 739. growth of, 742. transmissibility of, 741. treatment of, 745. various kinds of, with their treatment, 744. Ulcers, cicatricial, 300. irritable, 522. of skin, 518. Urine, condition of, in fractures, 580. condition of, in rhachitis, 641. Vaccination lancet, 64. Varices, 540. Venesection, 458. Verruca necrogenica, 380. Vessels, behaviour of, in fever, 305. formation of, cicatrix in, 294. formation of new, 287. ligation of, 87. ligation of. en masse, 90. other methods of haemostasis, 92. suture of, 91. Vibrio. 259. Villi, synovial, 656. SOO INDEX. Wandering of the acetabulum, 674, 675. Water-glass dressing, 223. Whitlow, 335. Wire splints and gutters, 210. Wire stocking, Bonnet's, 211. Wood-fibre dressing, 151. Wood-fibre pads, 151. Wooden splints, 205. Wood wool, 151. Wounds, foreign bodies in, 461. gaping of, 449. haemorrhage from, 449. healing of, 280. Wounds, infectious diseases of, 318. inflammation and suppuration of, 320. of muscles and tendons, 453. of nerves, 453. repair of, in non-vascular tissues, 297. of soft parts, 448. suture of, 104. symptomatology of, 448. treatment of. 464. Wound pain, 448. Xanthoma, 769. THE END. September, 1895. MEDICAL ANT) HYGIENIC WOEKS PUBLISHED BT D. APPLETON & CO., 72 Fifth Avenue, New York. AMERICAN GYNECOLOGICAL AND OBSTETRICAL JOURNAL. (Monthly.) Edited by J. Duncan Emmet, M.D. $4.00 per annum ; single copy, 35 cents. AULDE (JOHN). The Pocket Pharmacy, with Therapeutic Index. A resvme of the Clinical Applications of Remedies adapted to the Pocket-case, for the Treatment of Emergencies and Acute Diseases. 12mo. Cloth, $2.00. BARKER (FORDYCE). On Sea-Sickness. A Popular Treatise for Travelers and the General Reader. Small 12mo. Cloth, 75 cents. BARKER (FORDY'CE). On Puerperal Disease. Clinical Lectures delivered at Bellevue Hospital. A Course of Lectures valuable alike to the Student and the Practitioner. Third edition. 8vo. Cloth, $5.00; sheep, $6.00. BARTHOLOW (ROBERTS). A Treatise on Materia Medica and Therapeutics. Eighth edition. Revised, enlarged, aDd adapted to "The New Pharmacopoeia." 8vo. Cloth, $5.00; sheep, $6.00. BARTHOLOW (ROBERTS). A Treatise on the Practice of Medicine, for the Use of Students and Practitioners. Seventh edition, revised and enlarged. 8vo. Cloth, $5.00; sheep, $6.00. BARTHOLOW (ROBERTS). On the Antagonism between Medicines aiid be- tween Remedies and Diseases. Being the Cartwright Lectures for the Year 1880. 8vo. Cloth, $1.25. BASTIAN (H. CHARLTON). Paralyses: Cerebral, Bulbar, and Spinal. A Manual of Diagnosis for Students and Practitioners. With 136 Illustra- tions. Small 8vo, 671 pages. Cloth, $4.50. BASTrAN (H. CHARLTON). Paralysis from Brain Disease in its Common Forms. With Illustrations. 12mo, 340 pages. Cloth, $1.75. BILLINGS (F. S.). The Relation of Animal Diseases to the Public Health, and their Prevention. 8vo. Cloth, $4.00. BILLROTH (THEODOR). General Surgical Pathology and Therapeutics. A Text-Book for Students and Physicians. Translated from the tenth German edition, by special permission of the author, by Charles E. Hackley, M. D. Fifth American edition, revised and enlarged. 8vo. Cloth, $5.00; sheep, $6.00. BOYCE (RUBERT). A Text-Book of Morbid Histology. For Students and Practitioners. With 130 Colored Illustrations. Cloth, $7.50. . BRAMWELL (BYROM). Diseases of tbe Heart and Thoracic Aorta. Illus- trated with 226 Wood-Engravings and 68 Lithograph Plates—showing 91 Figures—in all 317 Illustrations. 8vo. Cloth, $8.00; sheep, $9.00. BRYANT (JOSEPH D.). A Manual of Operative Surgery. New edition, revised and enlarged. 793 Illustrations. 8vo. Cloth, $5.00; sheep, $6.00. 2 BURT (STEPHEN S.). Exploration of the Chest in Health and Disease. 8vo. 210 pages. With Illustrations. Cloth, $1.50. CAMPBELL (F. R.). The Language of Medicine. A Manual giving the Origin, Etymology, Pronunciation, and Meaning of the Technical Terms found in Medical Literature. 8vo. Cloth, $3.00. CARMICHAEL (JAMES). Disease in Oliildren. A Manual for Students and Practitioners. Illustrated with Thirty-one Charts. 12mo, 591 pages. (Students' Series.) Cloth, $3.00. CASTRO (D'OLIVEIRA). Elements of Therapeutics and Practice according to the Dosimetric System. 8vo. Cloth, $4.00. CHAUVEAU (A.). The Comparative Anatomy of the Domesticated Animals. Revised and enlarged, with the co-operation of S. Arloing, Director of the Lyons Veterinary School. Second English edition. Translated and edited by George Fleming, C. B., LL. D., F. R. C. V. S., late Principal Veterinary Surgeon of the British Army; Foreign Corresponding Member of the Societe Royale de Medecine, and of the Societe Royale de Medecine Pub- lique, of Belgium, etc. 8vo, 1084 pages,with 585 Illustrations. Cloth, $7.00. CORNING (J. L.). Brain Exhaustion, with some Preliminary Considerations on Cerebral Dynamics. Crown 8vo. Cloth, $2.00. CORNING (J. L.). Local Anaesthesia in General Medicine and Surgery. Being the Practical Application of the Author's Recent Discoveries. With Illus- trations. Small 8vo. Cloth, $1.25. DAVIDSON (ANDREW). Geographical Pathology : An Inquiry into the Geographical Distribution of Infective and Climatic Diseases. 2 vols. 8vo. Cloth, $7.00. DENCH (E. B.). Diseases of the Ear. A Text-Book for Practitioners and Students of Medicine. With 8 Colored Plates and 152 Illustrations in the text. 8vo. Cloth, $5.00; sheep, $6.00. DEXTER (FRANKLIN). The Anatomy of the Peritonaeum. 12mo. With 39 colored Illustrations. Cloth, $1.50. DOTY (ALVA 11 H.). A Manual of Instruction in the Principles of Prompt Aid to the Injured. Including a Chapter on Hygiene and the Drill Regula- tions for the Hospital Corps, U. S. A. Designtd for Military and Civil Use. 12mo. 124 Illustrations. Cloth, $1.50. ELLIOT (GEORGE T.). Obstetric Clinic: A Practical Contribution to the Study of Obstetrics and the Diseases of Women and Children. 8vo. Cloth, $4.50. EVANS (GEORGE A.). Hand-Book of Historical and Geographical Phthisi- ology. With Special Reference to the Distribution of Consumption in the United States. 8vo. Cloth, $2.00. EWALD (C. A.). Lectures on the Diseases of the Stomach. By Dr. C. A. Ewald, Professor of Pathology and Therapeutics in the University of Berlin, etc. Translated from the German by special permission of the author, by Morris Manges, A. M., M. D. Cloth, $5.00 ; sheep, $6.00. FLINT (AUSTIN). Medical Ethics and Etiquette. Commentaries on the National Code of Ethics. 12mo. Cloth, 60 cents. FLINT (AUSTIN). Medicine of the Future. ' An Address prepared for the Annual Meeting of the British Medical Association in 1886. With Portrait of Dr. Flint. 12mo. Cloth, $1.00. FLINT (AUSTIN, Jr.). Text-Book of Human Physiology; designed for the Use of Practitioners and Students of Medicine. Illustrated with three hundred and sixteen Woodcuts and Two Plates. Fourth edition, revised. [tcperial 8vo. Cloth, $6.00; sheep, $7.00. FLINT (AUSTIN, Jr.). The Physiological Effects of Severe and Protracted Muscular Exercise; with Special Reference to its Influence upon the Excre- tion of Nitrogen. 12mo. Cloth, $1.00 3 FLINT (AUSTIN, Jr.). The Source of Muscular Power. Arguments and Con- clusions drawn from Observation upon the Human Subject under Conditions of Rest and of Muscular Exercise. 12mo. Cloth, $1.00. FLINT (AUSTIN Jr.). Physiology of Man. Designed to represent the Exist mg State of Physiological Science as applied to the Functions of the Unman Body. Complete in 5 vols., 8vo. Per vol., cloth, $4.50; sheep, $5.50. *** Vols. 1 and II can be had in cloth and sheep binding; Vol. Ill in sheep only. Vol. IV is at present out of print. FLINT (AUSTIN, Jr.). Manual of Chemical Examinations of the Urine in Disease; with Brief Directions for the Examination of the most Common Varieties of Urinary Calculi. Revised edition. 12mo. Cloth, $1.00. FOSTER (FRANK P.). Illustrated Encyclopaedic Medical Dictionary : Being a Dictionary of the Technical Terras used by Writers on Medicine and the Collateral Sciences in the Latin, English, French, and German Languages. The work consists of Four Volumes, and is sold in Parts; Three Parts to a Volume. (Sold only by subscription.) FOURNIER (ALFRED). Syphilis and Marriage. Translated by P. Albert Morrow, M. D. 8vo. Cloth, $2.00; sheep, $3.00. FRET (HE1NRICH). The Histology and Histochemistry of Man. A Treatise on the Elements of Composition and Structure of the Human Body. Trans- lated from the fourth German edition by Arthur E. J. Barker, M. D. and revised by the author. With 608 Engravings on Wood. 8vo. Cloth, $5 00 ■ sheep, $6.00. ' ' . ' FRIEDLANDER (CARL). The Use of the Microscope in Clinical and Patho- logical Examinations. Second edition, enlarged and impioved, with a Chromolithograph Plate. Translated, with the permission of the author by Henry C. Coe, M. D. 8vo. Cloth, $1.00. FUCHS (ERNEST). Text-Book of Ophthalmology. By Dr. Ernest Fuchs, Professor of Ophthalmology in the University of Vienna. With 178 Wood- cuts. Authorized translation from the second enlarged and improved Ger- man edition, by A. Duane, M. D. Cloth, $5.00; sheep, $6.00. GARMANY (JASPER J.). Operative Surgery on the Cadaver. With Two Colored Diagrams showing the Collateral Circulation after Ligatures of Arteries of Arm, Abdomen, and Lower Extremity. Small 8vo. Cloth $2.00. GERSTER (ARPAD G.). The Rules of Aseptic and Antiseptic Surgery. A Practical Treatise for the Use of Students and the General Practitioner. Illustrated with over two hundred fine Engravings. 8vo. Cloth, $5 00 • sheep, $6.00. GIBSON-RUSSELL. Physical Diagnosis: A Guide to Methods of Clinical In- vestigation. By G. A. Gibson, M. D., and William Russell, M. D. With 101 Illustrations. 12mo. (Student's Series.) Cloth, $2.50. GOULEY (JOHN W. S.). Diseases of the Urinary Apparatus. Part I. Phleg- masic Affections. Being a Series of Twelve Lectures delivered during the autumn of 1891. With an Addendum on Retention of Urine from Pros- tatic Obstruction in Elderly Men. Cloth, $1.50. GROSS (SAMUEL W.). 4 Practical Treatise on Tumors of the Mammary Gland. Illustrated. 8vo. Cloth, $2.50. GRUBER (JOSEF). A Text-Book of the Diseases of the Ear. Translated from the second German edition by special permission of the author, and edited by Edward Law, M. D., and Coleman Jewell, M. D. With 165 Illus- trations and 70 Colored Figures on Two Lithographic Plates. 8vo. Cloth- $6.50; sheep, $7.50. 4 GUTMANN (EDWARD). The Watering-Places and Mineral Springs of Ger- many, Austria, and Switzerland. Illustrated. 12mo. Cloth, $2.50. HAMMOND (W. A.). A Treatise on Diseases of the Nervous System. With the Collaboration of Graeme M. Hammond, M. D. With One Hundred and Eighteen Illustrations. Ninth edition, with corrections and additions. 8vo. Cloth, $5.00; sheep, $6.00. HAMMOND (W. A.). A Treatise on Insanity, in its Medical Relations. 8vo Cloth, $5.00; sheep, $6.00. HAMMOND (W. A.). Clinical Lectures on Diseases of the Nervous System. Delivered at Bellevue Hospital Medical College. Edited by T. M. B. Cross, M. D. 8vo. Cloth, $3.50. HARVEY (A.). First Lines of Therapeutics. 12mo. Cloth. $1.50. HIRT (LUDWIG). The Diseases of the Nervous System. A Text-Book for Physicians and Students. Translated, with permission of the Author, by August Hoch, M. D., assisted by Frank R. Smith, A. M. (Cantab.), M. D., Assistant Physicians to the Johns Hopkins Hospital. With an Introduc- tion by William Osier, M. D., F. R. C. P., Professor of Medicine in the Johns Hopkins University, and Physician-in-Chief to the Johns Hopkins Hospital, Baltimore. 8vo, 671 pages. With 178 Illustrations. Cloth, $5.00 ; sheep, $6.00. HOFFMANN-ULTZMANN. Analysis of the Urine, with Special Reference to Diseases of the Urinary Apparatus. By M. B. Hoffmann, Professor in the University of Gratz, and R. Ultzmann, Tutor in the University of Vienna. Third edition, revised and enlarged. 8vo. Cloth, $2.00. HOLT (L. EMMETT). The Care and Feeding of Children. A Catechism for the Use of Mothers and Children's Nurses. 16mo. Cloth, 50 cents. HOWE (JOSEPH W.). Emergencies, and how to treat them. Fourth edition, revised. 8vo. Cloth, $2.50. HOWE (JOSEPH W.). The Breath, and the Diseases which give it a Fetid Odor. With Directions for Treatment. Second edition, revised and corrected. 12mo. Cloth, $1.00. HUEPPE (FERDINAND). The Methods of Bacteriological Investigation. Written at the request of Dr. Robert Koch. Translated by Hermann M. Biggs, M.D. Illustrated. 8vo. Cloth, $2.50. JACCOUD (S.). The Curability and Treatment of Pulmonary Phthisis. Trans- lated and edited by Montagu Lubbock, M. D. 8vo. Cloth, $4.00. JOHNSTONE (ALEX.). Botany : A Concise Manual for Students of Medicine and Science. With 164 Illustrations and a Series of Floral Diagrams. 12mo. (Student's Series.) Cloth, $1.75. JONES (H. MACNAUGHTON, Practical Manual of Diseases of Women and Uterine Therapeutics. For Students and Practitioners. 188 Illustrations. 12mo. Cloth, $3.00. JOURNAL OF CUTANEOUS AND GENITO-URINARY DISEASES.* Published Monthly. Edited by John A. Fordyce, M. D. Terms, $2.50 per annum. KEYES (E. L.). A Practical Treatise on Genito-Urinary Diseases, including Syphilis. Being a new edition of a work with the same title by Van Buren and Keyes. Almost entirely rewritten. 8vo. With Illustrations. Cloth, $5.00; sheep, $6.00. KEYES (E. L.). The Tonic Treatment of Syphilis, including Local Treatment of Lesions. 8vo. Cloth, $1.00. 5 KINGSLEY (N. W.). A Treatise on Oral Deformities as a Branch of Mechan- ical Surgery. With over 350 Illustrations. 8vo. Cloth, $5.00; sheep, $6.00. LEGG (J. WICKHAM). On the Bile, Jaundice, and Bilious Diseases. With Illustrations in Chromolithography. 8vo. Cloth, $6.00; sheep, $7.00. LITTLE (W. J.). Medical and Surgical Aspects of In-Knee (Genu-Valgum): Its Relation to Rickets, its Prevention, and its Treatment, with and without Surgical Operation. Illustrated by upward of Fifty Figures and Diagrams. 8vo. Cloth, $2.00. LORING (EDWARD G.). A Text-Book of Ophthalmoscopy. Part I. The Normal Eye, Determination of Refraction, and Diseases of the Media. With 131 Illustrations, and 4 Chromolithographs. 8vo. Buck- ram, $5.00. Part II. Diseases of the Retina, Optic Nerve, and Choroid: their Varie- ties and Complications. The manuscript of this volume, which the. author finished just prior to his death, has been thoroughly edited and revised by F. B. Loring, M.D., of Washington, D. C, and is now issued in the same style as the first volume. Profusely illustrated. Part II, buckram, $5.00. Two Parts, buckram, $10.00. LUSK (WILLIAM T.). The Science and Art of Midwifery. With 246 Illustra- tions. Fourth edition, revised and enlarged. 8vo. Cloth, $5.00; sheep, $6.00. MARCY (HENRY O.). The Anatomy and Surgical Treatment of Hernia. 4to, with about Sixty full-page Heliotype and Lithographic Reproductions from the Old Masters, and numerous Illustrations in the Text. {Sold only by subscription.) MARKOE (T. M.). A Treatise on Diseases of the Bones. With Illustrations. 8vo. Cloth, $4.50. MATHEWS (JOSEPH M.). A Treatise on Diseases of the Rectum, Anus, and Sigmoid Flexure. 8vo. With Six Chromolithographs, and Illustra- tions in the text. (Sold only by subscription.) MILLS (WESLEY). A Text-Book of Animal Physiology, with Introductory Chapters on General Biology and a full Treatment of Reproduction for Students of Human and Comparative Medicine. 8vo. With 505 Illustra- tions. Cloth, $5.00; sheep, $6.00. MILLS (WESLEY). A Text-Book of Comparative Physiology. For Students and Practitioners of Veterinary Medicine. Small 8vo. Cloth, $3.00. MORROW (PRINCE A.). A System of Genito-Urinary Diseases, Syphilology, and Dermatology. By various Authors. In Three Volumes, beautifully illustrated. Vol. I. Genito-urinary Diseases. Vol. II. Syphilography. Vol. III. Dermatology. (Sold only by subscription.) THE NEW YORK MEDICAL JOURNAL (Weekly). Edited by Frank P. Foster, M. D. Terms, $5.00 per annum. Binding Cases, cloth, 50 cents each. "Self-Binder" (this is used for temporary binding only), 90 cents. General Index, from April, 1865, to June. 1876 (23 vols.). 8vo. Cloth, 75 cts. NIEMEYER (FELIX VON). A Text-Book of Practical Medicine, with particu- lar reference to Physiology and Pathological Anatomy. Containing all the author's Additions and Revisions in the eighth and last German edition. Translated by George H. Humphreys, M. D., and Charles E. Hackley, M. D. 2 vols., 8vo. Cloth, $9.00; sheep, $11.00. NIGHTINGALE'S (FLORENCE) Notes on Nursing. 12mo. Cloth, 75 cents. 6 OSLER (WILLIAM). Lectures on the Diagnosis of Abdominal Tumors. Small 8vo. Illustrated. Cloth, $1.50. OSLER (WILLIAM). The Principles and Practice of Medicine. Designed for the Use of Practitioners and'Students of Medicine. Cloth, $5.50; sheep, $6.50; half morocco, $7.00. (Sold only by subscription.) PELLEW (C. E.). A Manual of Practical Medical Chemistry. 12mo. With Illustrations. Cloth, $2.50. PEYER (ALEXANDER). An Atlas of Clinical Microscopy. Translated and edited by Alfred C. Girard, M.D. First American, from the manuscript of the second German edition, with Additions. Ninety Plates, with 105 Illustrations, Chromolithographs. Square 8vo. Cloth. $6.00. PIFFARD (HENRY G.). A Practical Treatise on Diseases of the Skin. By Henry G. Piffard, A.M., M.D., assisted by Robert M. Fuller, M.D. With Fifty full-page Original Plates and Thirty-three Illustrations in the Text. 4to. (Sold only by subscription.) POMEROY (OREN D.). The Diagnosis and Treatment of Diseases of the Ear. With One Hundred Illustrations. Second edition, revised and enlarged. 8vo. Cloth, $3.00. POORE (C. T.). Osteotomy and Osteoclasis, for the Correction of Deformities of the Lower Limbs. 50 Illustrations. 8vo. Cloth, $2.50. QUA1N (RICHARD). A Dictionary of Medicine, including General Pathology, General Therapeutics, Hygiene, and the Diseases peculiar to Women and Children. By Various Writers. Edited by Sir Richard Quain, Bart., M. D., LL. 1)., etc. Assisted by Frederick Ihomas Roberts, M. D., B. Sc, and J. Mitchell Bruce, M. A., M. D. With an American Appendix by Samuel Treat Armstrong, Ph.D., M.D. In two volumes. {Sold only by subscription.) RANNEYr (AMBROSE L.). Applied Anatomy of the Nervous System, being a Study of this Portion of the Human Body from a Standpoint of its General Interest and Practical Utility, designed for Use as a Text-Book and as a Work of Reference. Second edition, revised and enlarged. Profusely illustrated. 8vo. Cloth, $5.00; sheep, $6.00. ROBINSON (A. R.). A Manual of Dermatology. Revised and corrected. 8vo. Cloth, $5.00. ROSCOE-SCHORLEMMER. Treatise on Chemistry. Vol. 1. Non-Metallic Elements. 8vo. Cloth, $5.00. Vol. 2. Part I. Metals. 8vo. Cloth, $3.00. Vol. 2. Part II. Metals. 8vo. Cloth, $3.00. Vol. 3. Part I. The Chemistry of the Hydrocarbons and their Derivatives. 8vo. Cloth, $5.00. Vol. 3. Part II. The Chemistry of the Hydrocarbons and their Derivatives. 8vo. Cloth, $5.00. Vol. 3. Part III. The Chemistry of the Hydrocarbons and their Deriva- tives. 8vo. Cloth, $3.00. Vol. 3. Part IV. The Chemistry of the Hydrocarbons and their Deriva- tives. 8vo. Cloth, $3.00. Vol. 3. Part V. The Chemistry of the Hydrocarbons and their Deriva- tives. 8vo. Cloth, $3.00. ROSENTHAL (I.). General Physiology of Muscles and Nerves. With 75 Wood- outs. 12mo. Cloth, $1.50. 7 SAYRE (LEWIS A.). Practical Manual ol the Treatment of Club-Foot. Fourth edition, enlarged and corrected. 12mo. Cloth, $1.25. SAYRE (LEWIS A.). Lectures on Orthopedic Surgery and Diseases of the Joints delivered at Bellevue Hospital Medical College. New edition, illus- trated'with 324 Engravings on Wood. 8vo. Cloth, $5.00; sheep, $6.00. SCHULTZE (B. S.). The Pathology and Treatment of Displacements of the Uterus Translated from the German by Jameson J. Macan, M. A., etc.; and edited by Arthur V. Macan, M. B., etc. With one hundred and twenty Illustrations. 8vo. Cloth, $3.50. SHIELD (A. MARMADUKE). Surgical Anatomy for Students. 12mo. (Student's Series.) Cloth, $1.75. SHOEMAKER (JOHN V.). A Text-Book of Diseases of the Skin. Six Chromolithographs and numerous Engravings. Second edition, revised and enlarged. 8vo. Cloth, $5.00; sheep, $6.00. SIMPSON (JAMES Y.). Selected Works: Anaesthesia, Diseases of Women. 3 vols., 8vo. Per volume. Cloth, $3.00; sheep, $4.00. SIMS (J. MARION). The Story of my Life. Edited by his Son, H. Marion- Sims, M. D. With Portrait. 12mo. Cloth, $1.50. SKENE (ALEXANDER J. C). A Text-Book on the Diseases of Women. Illustrated with two hundred and fifty-four Illustrations, of which one hundred and sixty-five are original, and nine chromolithographs. Second edition. 8vo. (Sold only by subscription.) SKENE (ALEXANDER J. C). Medical Gynecology. A Treatise on the Diseases of Women from the Standpoint of the Physician. 8vo. With Illustrations. (In press.) STEINER (JOHANN). Compendium of Children's Diseases: a Hand-Book " for Practitioners and Students. Translated from the second German edition, by Law son Tait. 8vo. Cloth, $3.50 ; sheep, $4.50. ^TFVFNS CGEORGE T.) Functional Nervous Diseases: their Causes and their Treatment. Memoir for the Concourse of 1881-1883 Academie Royal de Medecine de Belgique. With a Supplement on the Anomalies of Re- fraction and Accommodation of the Eye, and of the Ocular Muscles. Small 8vo. With six Photographic Plates and twelve Illustrations. Cloth, $2.50. STONF fR FRENCH). Elements of Modern Medicine, including Principles of Pathology and of Therapeutics, with many Useful Memoranda and Valuable Tables of Reference. Accompanied by Pocket Fever Charts Designed for the Use of Students and Practitioners of Medicine. In wallet-book form, with pockets on each cover for Memoranda, Temperature Charts, etc. Roan, tuck, $2.50. QTRFniTFR rADOLPH). Short Text-Book of Organic Chemistry. By Dr. Johannes Wislicenus. Translated and edited, with Extensive Addntions, by W. H. Hodgkinson and A. J. Greenaway. 8vo. Cloth, $5.00. STRUMPELL (ADOLPH). A Text-Book of Medicine, for Students and Prac- tiUoners Translated, by permission, from the sixth German edition v! wlrn «n E Vickerv A B., M. D., Instructor in Clinical Medicine, Har- Jjrd^SSJ'B^^ -d Philip Coombs Knapp, Physician to Out- natients with Diseases of the Nervous System, Boston City Hospital etc. With Edrtorial Notes by Frederick C. Shattuck, A. M, M D., Jackson Pro- fessor of ClmTcal Medicine, Harvard Medical School, etc Second American edition With 111 Illustrations. 8vo. 981 pages. Cloth, $6.00; sheep, $7.00. 8 THOMAS (T. GAILLARD). Abortion and its Treatment, from the Stand- point of Practical Experience. A Special Course of Lectures delivered be- fore the College of Physicians and Surgeons, New York, Session of 1889-'90. From Notes by P. Brynberg Porter, M.D. Revised by the Author. 12mo. Cloth, $1.00. THOMSON (J. ARTHUR). Outlines of Zoology. With thirty-two full-page Illustrations. 12mo. (Students' Series.) Cloth, $3.00. TILLMANNS (HERMANN). The Principles of Surgery and Surgical Pathology. Translated by John Rogers, M.D., and Benjamin Tilton, M. D., New York. 8vo. With 441 Illustrations. Cloth, $5.00; sheep, $6.00. TYNDALL (JOHN). Essays on the Floating Matter of the Air, in Relation to Putrefaction and Infection. 12mo. Cloth, $1.50. ULTZMANN (ROBERT). Pyuria, or Pus in the Urine, and its Treatment. Translated by permission, by Dr. Walter B. Piatt. 12mo. Cloth, $1.00. VAN BUREN (W. 11.). Lectures upon Diseases of the Rectum, and the Sur- gery of the Lower Bowel, delivered at Bellevue Hospital Medical College. Second edition, revised and enlarged. 8vo. Cloth, $3.00; sheep, $4.00. VAN BUREN (W. H.). Lectures on the Principles and Practice of Surgery. Delivered at Bellevue Hospital Medical College. Edited by Lewis A. Stim- son, M. D. 8vo. Cloth, $4.00; sheep, $5.00. VOGEL (A.). A Practical Treatise on the Diseases of Children. Translated and edited by H. Raphael, M.D. Third American from the eighth German edi- tion, revised and enlarged. Illustrated by six Lithographic Plates. 8vo. Cloth, $4.50 ; sheep, $5.50. VON ZEISSL (HERMANN). Outlines ot the Pathology and Treatment of Syphilis and Allied Venereal Diseases. Second edition, revised by Maximil- ian von Zeissl. Authorized edition. Translated, with Notes, by H. Ra- phael, M.D. 8vo. Cloth, $4.00; sheep, $5.00. WAGNER (RUDOLF). Iland-Book of Chemical Technology. Translated and edited from the eighth German edition, with extensive Additions, by William Crookes. With 336 Illustrations. 8vo. Cloth, $5.00. WALTON (GEORGE E.). Mineral Springs of the United States and Canadas. Containing the latest Analyses, with full Description of Localities, Routes, etc. Second edition, revised and enlarged. 12mo. Cloth, $2.00. WEBBER (S. G.). A Treatise on Nervous Diseases: Their Symptoms and Treatment. A Text-Book for Students and Practitioners. 8vo. Cloth, $8.00. WEEKS-SHAW (CLARA S.). A Text-Book of Nursing. For the Use of Training-Schools, Families, and Private Students. Second edition, revised and enlarged. 12mo. With Illustrations, Questions for Review and Ex- amination, and Vocabulary of Medical Terms. 12mo. Cloth, $1.75. WELLS (T. SPENCER). Diseases of the Ovaries. 8vo. Cloth, $4.50. WORCESTER (A.). Monthly Nursing. Second edition, revised. Cloth, $1.25. WYETH (JOHN A.). A Text-Book on Surgery: General, Operative, and Me- chanical. Profusely illustrated. Second edition, revised and enlarged. 8vo. (Sold only by subscription.) NATIONAL LIBRARY OF MEDICINE NLfl 0D555D55 2 W&& ,:>&&* -V^' .. ;\ik4t>&>x \ <::i' NLM005550552