BLACK-BOARD HEADINGS 
USED IN THE 
LECTURES ON SURGERY 
BY 
Robert F. Weir, M. D., 
Professor of Surgery in the College of Physicians and Surgeons 
of Columbia University. 
EDITED BY 
ABRAHAM L. WOLBARST, M. D., 
AND 
GEORGE ALEXANDER SAXE, M. D. 
NEW YORK 
1898. COPYRIGHT, 1898, 
BY 
\ R. F. WEIR. 
aIV rights reserved. 
EVENING POST JOB PRINT, N. Y. To Their 
FELLOW-STUDENTS 
AT THE 
COLLEGE OF PHYSICIANS AND SURGEONS 
OF 
COLUMBIA UNIVERSITY 
COLUMBIA UNIVERSITY 
These Notes Are Dedicated 
BY 
The Editors. PREFACE. 
The object of these notes is to save the student the 
time and trouble of copying the black-board tables 
given during the lectures, and thus to enable him to 
pay closer attention, to take better notes and to do 
more systematic reading. 
The notes are not intended to be a summary of 
facts and principles, but rather a series of headings, 
indicating the order of the topics discussed and the 
mode in which they are treated by the lecturer. 
They are therefore not offered as a substitute for 
notes upon the lectures themselves, but as a guide tor 
the student in his work. 
As few changes as possible have been introduced 
by the editors, as they believe the original form of 
these tables to be of more value than anything bear- 
ing their own emendations and additions. 
Exceptions, however, have been made, with Dr. 
Weir’s approval, in a few cases where a topic which 
has been spoken of in the lectures, receives no place 
in the black-board tables. 
To secure unity of the work, the editors have 
adopted a system of subdivisions which does not ob- 
tain on the black-boards. This has been done with- 
out altering the order of the topics. 
In conclusion, we take the opportunity of thank- 
ing Professor Weir for the interest which he has taken 
in our work, and for the courtesies which he has shown 
us while we were preparing this pamphlet. 
New York, October, 1898. GENERAL OUTLINE. 
PART I.—GENERAL SURGERY. 
SECTION I. 
I. Hemorrhage 9 
PAGE. 
11. Wounds 10 
111. Inflammation 10 
IV. Asepsis and antisepsis 12 
V. Abscess 16 
VI. Ulceration 16 
VII. Contused, lacerated and gunshot wounds 16 
VIII. Gangrene 17 
IX. Wound infection 18 
SECTION 11. 
I. Fractures—general considerations 18 
11. Special fractures 21 
111. Dislocations 26 
IV. Diseases of bone 27 
V. Bursitis 29 
VI. Diseases of lymphatics 30 
VII. Diseases of vessels 31 
VIII, Tumors 33 PART 11. REGIONAL SURGERY. 
I. Diseases and injuries of the breast 39 
SECTION I.—THE MAMMARY GLAND. 
PAGE. 
11. Amputation of the breast ' 42 
SECTION lI.—THE GENITO-URINARY ORGANS. 
I. The penis and urethra 43 
11. The bladder 45 
111. The prostate 48 
IV. Retention, cystitis and calculi 49 
V. The kidneys and the ureters 53 
VI. The scrotum and the testes 57 
SECTION lII.—THE HEAD. 
I. The scalp 61 
11. Concussion and compression of the brain 61 
HI. Foreign bodies in the brain 63 
IV. Fractures of the skull 63 
V. Cerebral abscess 65 
VI. Cerebellar abscess ■ 66 
VII. Lateral sinus abscess 66 
VIII. Rules for trephining 66 
IX. Tumors of the brain 67 
X. Applications of trephining 68 
XL Neuralgia of the fifth nerve 69 
SECTION IV.—THE THYROID GLAND. 
Diseases of the thyroid gland and their surgical treatment.. 70 
SECTION V.—THE LARYNX, PHARYNX AND 
TRACHEA. 
Pharyngotomy, laryngotomy, tracheotomy and laryngectomy. 71 PART 1-GENERAL SURGERY: 
EDITED BY 
GEORGE ALEXANDER SAXE, M.D. 
SECTION I—INTRODUCTORY LECTURES. 
I.—HEMORRHAGE. 
A. —A rrested by Nature: 
1. Contraction of arteries and capillaries, 
2. Mechanical entanglement of blood in tissues, 
3. Coagulation of blood, 
4. Decrease in blood pressure, 
5. Laceration of inner coats in larger vessels. 
B.—Arrested artificially by 
1. Mechanical pressure, 
2. Position, 
3. Flexion, 
4. Heat (cautery), 
5. Cold, 
6. Styptics, 
7. Ligature (a) Catgut, 
{b) Silk. 
(a) Pads, 
(b) Bandages, 
(c) Tourniquets, 
{d) Clamps, 
(e) Haemostatic forceps, 
(/) Torsion, 
(g) Acupressure. 
C.—Arrest retarded by : 
1. Haemophilia, 
2, A partial division of artery. 
A division of an artery or vein in muscle. Heart 
stimulants. Excitement. Movements of part. 10 
A.—lncised wounds are closed by : 
i. Plaster. Use gauze to protect wound. 
lI.—WOUNDS. 
{a) Continuous 
or 
ip) Interrupted, 
(c) Buried, 
{a) Catgut, 
(h) Silk, 
(.c) Silkworm gut, 
(d) Silver wire, 
{a) Catgut, 
{b) Kangaroo ten- 
don, 
(c) Silkworm gut, 
(d) Silk, 
(e) Silver wire. 
2. futures 
' (a) Reef or flat knot, 
(b) Grann}7’s knot (N. G.) 
(r) Surgeon’s knot, 
{d) Staffordshire knot. 
Surgical knots 
(a) Full curved, 
{b) Half curved, 
(y) Straight. 
Surgical needles 
B.—Healing of wounds: 
1. Immediate union (?), 
2. Primary union, 
3. Secondary union, 
4. Granulation. 
lII.—INFLAMMATION. 
A.-—Simple inflaimnation : 
1. Disturbed nutrition, 
2. Aseptic, 
3. Without suppuration, 
4. Includes : 
(a) Vascular changes: 
I. Diapedesis, 
11. Emigration of Leucocytes. 
{b) Cell changes: 
I. Multiplication, 
11. Chemotaxis, 
111. Phagocytosis. 
{c) Toxaemia. 11 
5. Signs, five in number: 
{a) Heat {calor), 
{b) Redness {rubor), 
(c) Swelling- {tumor), 
{d) Pain {dolor), 
{e) Impaired function {functio Icesa). 
6. Associated with : 
{a) Cell necrosis, 
{b) Cell changes, 
{c) Cell repair, 
{d) Cell heredity, 
{e) Cell degeneration. 
B.—lnfectious inflammation ; 
1. Of germ origin, 
2. Septic, 
3. Produces suppuration, 
4. Common pyogenic germs: 
{a) Staphylococcus pyogenes aureus, 
{b) “ “ citreus, 
{c) “ “ albus, 
{d) Streptococcus “ 
{e) “ “ erysipelatis, 
(/) Bacillus coli communis, 
{g) “ pyocyaneus. 
5. Rarer pyogenic germs : 
{a) Bacillus typhosus, 
{b) “ proteus, 
{c) “ diphtherim, 
{d) “ mallei (glanders), 
(e) “ pneumoniae (diplococcus), 
(/) “ of bubonic plague, 
{g) Gonococcus. 
6. Germs act in various ways: 
{a) Mechanically, 
{b) By starving cells, 
(c) By local poisoning, 
{d) By systemic poisoning, 
1. Ptomaines, 
2. Leucomaines, 
3. Toxins. 12 
7- Virulence of germs depends upon : 
{a) Quantity introduced, 
(b) Vitality of germs, 
(c) Associated germs (mixed infection), or 
ptomaines. 
{d) Locality of infection, 
(e) Predisposition of patient or resisting power 
of body. 
8. Park in 125 cases of suppuration found ; 
Staphylococcus pyogenes albus 41 times. 
“ “ aureus 38 “ 
“ “ cereus albus... 12 “ 
“ “ “ flavus 7 “ 
“ “ citreus 6 “ 
Streptococcus “ 11 “ 
“ “ foetidus 2 “ 
“ erysipelatis 2 “ 
Bacillus coli communis 2 “ 
pneumonias (diplococcus) 2 “ 
fluorescens liquidus once. 
“ putridus “ 
Micrococcus tetragenes “ 
IV.—ASEPSIS AND ANTISEPSIS. 
I.—Germs are killed by heat: 
Moist heat (steam) kills in 10 minutes: 
1. Bacillus anthracis at 120° Fahr. (490 Cent.). 
2. B. anthracis spores at 2120 Fahr. (ioo° Cent.). 
3. Bacillus tuberculosis at 2120 Fahr. (ioo° 
Cent.). 
4. Staphylococcus pyog. albus at 1430 Fahr. 
(62° Cent.). 
5. Staphylococcus pyog. aureus at 136° Fahr. 
(58° Cent.). 
6. Staphylococcus pyog. citreus at 1450 Fahr. 
(63° Cent.). 
7. Streptococcus pyogenes at 1290 Fahr. (540 
Cent.). 
S. Gonococcus at 140° Fahr. (6o° Cent.). 13 
11. Germs are killed by many chemical substances. 
1. Bichloride of mercury (corrosive sublimate): 
Solution i : 500 kills ordinary germs in 10 
seconds. 
Solution 1 : 1,000 kills ordinary germs in 45 
seconds. 
Solution 1 ; 2,000 kills ordinary germs in 
mins. 
Solution 1 : 5,000 kills ordinary germs in 3 
mins. 
Solution 1 ; 10,000 kills ordinary germs in 5 
mins. 
Solution 1 : 20,000 kills ordinary germs in 10 
mins. 
2. Carbolic acid : 
Solution 1 : 20 kills ordinary germs in 15 secs. 
1 ; 40 “ “ 20-60 
secs. 
1 : 60 kills ordinary germs in 4 mins. 
3. Salicylic acid: 
1 : 600 (Sat.) kills in 1 min. 
1 ; 1,000 (hot water cooled) kills in 
4-5 mins. 
4. Permanganate of potassium : 
Solution 1 ; 50 kills ordinary germs in 20 secs. 
“ 1 : 100 “ 1 min. 
“ 1 ; 200 “ “ 2 mins. 
5. Chlorine water 25 per cent., freshly prepared : 
Kills ordinary germs in i-J mins. 
6. Peroxide of hydrogen : 
1: 8 kills ordinary germs in mins. 
7. Alcohol 95 per cent.: Kills ordinary germs in 
20 secs. 
8. Argentic nitrate 1 : 5.000, or citrate 1 : 4,000, 
kills ordinary germs in 8 minutes. 
9. lodine: 
Saturated alcoholic solution kills ordinary 
germs in 48 hours. 14 
10. lodoform powder or ethereal solution : 
Kills ordinary germs in 12 hours. Ointment, 
no effect. 
11. Boric acid—any strength or form. No effect. 
12. Formaldehyde 1-2 percent.: Kills in 1 hour. 
lll.—Aseptic and antiseptic materials: 
{a) Moist heat I4o°-212° Fahr., by steam (Arnold’s 
sterilizer) or boiling, will sterilize in 10 
minutes; Cotton, gauze, pads, drainage tubes, 
silk, silkworm gut, horse-hair, towels, gowns, 
brushes, etc. Instruments sterilized by boil- 
ing for 10 minutes in water with sodium car- 
bonate § i to Oi. 
{b) Dry heat of similar temperature will sterilize 
iodoform gauze, 10 per cent., with but slight 
loss of weight. 
(c) Pleat of boilmg alcohol, 170° Fahr. for hour will 
sterilize catgut and kangaroo tendon. Saul’s 
method: Boil ligatures in alcohol poparts, 
carbolic acid 50 parts, water 100 parts. 
/I. lodoform, ( Llodoform 3 iii, 
2. Bichloride i: i ,000. ] SoaP“dB; boilins- 
(d) Gauze:/3' Creolin 2 percent., ( 
Gauze 2\ yards. 
\ 4. Cyanide of Hg. and Zn. (Lister). 
(5. Balsam of Peru. 
{e) Cotton, plain and medicated, same as gauze ; 
sterilized by dry heat. 
(f) Lint, wool, wood-wool, jute, oakum, etc.; steril- 
ized by dry heat, or soaked in bichloride solu- 
tion. 
1. Beaten in a bag to get sand out, 
2. Soaked in acid water for few days, 
3. Washed in water, 
4. Soaked in solution of carbonate 
or of hyposulphite of soda, 
5. Soaked in oxalic acid, %iv to 
gallon. 
6. Washed in water io minutes. 
7. Kept in 6 per cent, carbolic, in 
glass jar. 
Rarely used in modern surgery. 
(<£■) Sponges i5 
(/?) Sublimate solution, i : 1,000: 
Bichloride of mercury grains, 
Chloride of sodium 15 grains, or 
Ammonium chloride 3 grains, or 
Tartaric acid 5 grains, 
Water up to one pint. 
3 
(t) Sublimate tablets; Hg Cl2 and tartaric acid, 
each grains (gm 0.5); one of these in a 
pint = 1 : 1,000. 
(j) Carbolic acid : 1 : 20 == 5 per cent. 
1 : 40 = 2\ per cent. 
{k) Potassium permanganate solution: 3 i to |i. 
A teaspoonful to a pint of water = 1 : 1,000. 
(/) Saline solution, T6ff per cent., or 3 grains to the 
ounce, or about a teaspoonful to a pint of 
water. 
{in) Boro-salicylic solution (Thiersch), salicylic 
acid 2 parts, boric acid 12 parts, water 
1,000 parts. 
(n) Aluminum acetate (Burow): Alum 24, lead 
acetate 38, water 1000, Let stand one day, 
filter. 
{0) Creolin, 2 per cent. 
{p) Peroxide of hydrogen, 3 per cent. Marchand or 
Oakland. 
{q) Chlorine water 25 per cent. 
IV.—Preparations for operation: 
1. Surgeon s and assistant's hands : 
{a) Scrub vigorously with green soap, 
{b) Use nascent chlorine, mixture (bleaching 
powder and washing soda), or alcohol 95 
per cent., 
(0) In special cases rubber gloves. 
2. Field of operation : 
{a) Soft or green soap for 8 to 10 hours, 
(b) Scrub well, 
(0) Apply 1-20 carbolic solution, or alcohol for 
1-2 hours. 16 
V.—ABSCESS. 
I. —Suppuration : 
1. Diffused, 
2. Circumscribed, 
3. From free surface. 
11. —Abscess :—Defined. 
1. Pathology,—acute and chronic, 
2. Fluctuation, 
3. Aspiration, 
4. Progress, 
5. Bursting, 
6. Treatment.—“ Übi pus ibi evacuo," 
7. Counter-opening and drainage. 
VI.—ULCERATION. 
I.— Ulcers:—l. Traumatic, 
2. Defective nutrition, varicose veins. 
3. Inflammatory, 
4. Specific 
Tubercular, 
Syphilitic, 
Cancerous, etc. 
II.—“ Diseases ”cf granulations : 
1. Exuberance, 
2. Indolence, 
3. Sensitiveness (hypenesthesia). 
lII. Treatment of ulcers, 
W .—Burns and scalds, 
(a) Varieties, 
ifi) Causes, 
([c) Treatment, 
(d) Shock, 
(e) Gastric ulcer. 
(a) Position, 
\b) Support, 
(V) Strapping, 
([d) Astringents, 
(e) Antiseptics, 
(/) Grafting, 
{g) Circular incision. 
VII.—CONTUSED, LACERATED AND GUN 
SHOT WOUNDS. 
I. —Definition and diagnosis. 
11. —Dangers and significance. 
111. Treatment and results. i7 
IV.—Gunshot wounds : 
A. —Dangers: 1. Clothing carried in with ball, 
2. Fascial penetration, 
3. Vessel “ 
4. Bone “ 
B. —Probe: 1. If wound is large and union hope- 
less, 
2. If union has failed, 
3. If septic, 
4. If in a cavity or a joint. 
VIII.—GANGRENE. 
I.—Definition: 
ll.—Synonyms : 
1. Death of living tissues. 
2. Mortification, 
3. Sphacelus, 
4. Necrosis, 
111. Varieties.—Dry and moist. 
IV. —Putrefaction.—Changes after death. 
V. —Causes: 
1. Pathological vessel changes : 
{a) Atheroma, 
{ib) Syphilis, 
(r) Alcoholism, 
id) Bright’s disease, 
(e) Gout, 
(/) Diabetes, 
{g) Raynaud’s disease, 
{h) Embolism or thrombosis, 
(0 Ergot, 
(/) Mercury, 
(,k) Nerve lesions. 
2. Traumatic and mechanical: 
(a) Arterial and venous occlusion : 
(b) Burns, caustics, frost, 
{c) Decubitus, 
3. Bacterial changes; 
(1a) Infectious fevers, e.g., measles, 
(b) Phagedsena, 18 
{ic) Sloughing. 
{d) Erysipelas, gangrene, oedema, 
(e) Boils and carbuncles, 
(/) Malaria, 
{g) Diabetes, senile gangrene, 
{h) Hospital gangrene. 
VI. —Boils.—Their treatment. 
VII. —Carbuncles.—Their treatment. 
VIII. Treatment of gangrene : 
1. If aseptic or dry—expectant. 
2. If septic or moist—wide and prompt surgical 
interference. 
IX.—WOUND INFECTIONS. 
1. Surgical fever, 
2. Sapraemia, 
3. Septicaemia, 
4. Pyaemia, 
5. Erysipelas, 
6. Erysipeloid, 
7. Tetanus, 
8. Malignant oedema, 
9. Hospital gangrene, 
10. Glanders. 
11. Actinomycosis, 
12. Malignant pustule, 
13. Insect bites and stings, 
14. Snake bites, 
15. Hydrophobia, 
16. Tuberculosis. 
(a) Simple, 
(b) Phlegmonous, 
(c) Gangrenous, 
id) Migrating, 
{e) Metastatic, 
{/) Facial (?) 
SECTION 11. 
I.—FRACTURES—GENERAL CONSIDERA- 
1 .—lmportant subdivisions: 
TIONS. 
r. Simple, 
2. Compound, 
3. Complicated, 
4. Gunshot. 
f {a) jQi 
Vessel 
Nerve 
W vfSCer’al lesion. 19 
ll. Unimportant but convenient subdivisions : 
1. Complete : 
(a) Direction of fracture, 
{b) Site “ “ 
(c) Number “ “ 
2. Incomplete : 
{a) Greenstick, 
{b) Fissured, 
(c) Depressed, 
{d) Impacted. 
lll.—Unclassified subdivisions : 
1. Spontaneous, 
2. Pathological, 
3. Recent, or old fractures, 
(a) Neoplasms, 
(b) Nerve disease, 
(c) Osteo-porosis, 
(.d) Osteomalacia. 
4. Diastasis, or epiphyseal separation, 
5. Ununited fracture. 
IV. —Mechanical Causes: 
1. Direct violence, 
2. Indirect “ 
3. Muscular action, 
4. In utero, or parturition. 
V. —Symptoms of fractures: 
1. Deformity, externally and by X-ray examina 
tion, 
2. False point of motion, 
3. Crepitus, 
4. Ecchymosis (late), 
5. Localized pain, 
6. Impaired function. 
VI. —Repair of fractures: 
1. Local lesions, aseptic fever, 
2. Periosteal bridge ; its influence, 
3. Fat embolism. 
4. Callus: 
{a) Exuberant, 
(р) Faulty, 
(с) Nerve entanglement. 20 
VII.—Diagnosis of fractures (Dr. E. Eliot, Jr.): 
(a) Swelling, 
(b) Ecchymosis, 
(c) Deformity. 
I.—lnspection ; 
(a) Local point of tenderness, 
(b) Bony irregularity, 
(c) False point of motion, 
(d) Crepitus. 
ll.—Palpation: 
111. —Motion—active and passive. 
IV. —Mensuration—comparison with opposite side 
VIII. Treatment of fractures: 
(a) Setting, 
(b) Rest, 
{c) Immobilization, 
{d) Extension, 
(e) Splints, 
(/) Muscular twitchings. 
IX. —Remote effects of fractures : 
(a) Joint stiffness, 
(b) Atrophy of limb, 
(c) Painful callus and paralysis, 
(d) Delayed union, 
(e) Vicious union, 
(/) Non-union or false joint. 
X. —False Joint due to: 
(a) Foreign bodies, 
(b) Necrosed bone, 
(c) Intervening soft parts, contraction of muscles 
(d) Defective nutrition of parts, 
(e) Constitutional disease, 
(f) Defective immobilization, 
{g) Separation of fragments— 
iff) Repeated fractures. 
olecranon 
patella. 
XL—Treatment of delayed union and non-union : 
(a) Motion, rubbing fragments together, 
{b) Venous stasis, 
(c) Drilling, 21 
(d) Resection, with or without wiring, pegs or 
screw plates, 
XII.— Treatment of vicious union : 
(a) Osteotomy, 
{&) Refracture (dysmorphosteodiaclasis!). 
lI.—FRACTURES, SPECIAL. 
I. —Nasal bones : 
{a) Recent: Replace thoroughly with instruments 
from within. 
(b) Ancient: Refracture by chiseling or special 
forceps. 
11. —Malar Bones'. 
Open into antrum, and push up with a sound, if 
depressed, 
111. —lnferior Maxilla : 
Usually compound. Wire together or use inter- 
dental splint, 
IV. —Clavicle: 
1. Site: Middle most common. 
2. Complications: 
{a) Vessels, 
{b) Nerves, 
([c) Pleura. 
3. Treatment: 
(a) Indications: Draw or push the shoulder 
outwards and upwards, 
(b) Decubitus, 
(r) Sayre’s Dressing, 
id) Elbow sling. 
V. —Sternum, ribs and cartilages : 
1. Symptoms and situation, 
2. Complications, 
(a) Emphysema, 
(b) Haemoptysis, 
(c) Pneumonia, 
(d) Hasmo-pneumo-thorax. 
3. Treatment: (a) Body bandage, 
(b) Adhesive plaster. 22 
VI. —Scapula : 
1. Complications: Thorax lesions, 
2. Treatment: None but immobilization by sling. 
VII. —Humerus: 
1. Site: (a) Anatomical neck, 
{b) Epiphyseal separation, 
(c) Head and tuberosities, 
(d) Surgical neck, 
(e) Shaft, 
(/) Condyles. 
2. Fractures of the Head—Note: 
{a) Direction of shaft, 
(b) Whether head is under acromion, 
(c) Whether head rotates with shaft, 
id) Altered shape of shoulder. 
3. Epiphyseal separation—Note: 
{a) Age under eighteen years, 
{b) Head does not rotate with shaft, 
Shoulder socket is not empty, 
(1d) Crepitus subdued, 
(e) Shaft felt as a transverse surface, 
(/) Recurs after reduction. 
4. Surgical neck of humerus; 
(a) Head is felt in socket, 
(b) Peculiar displacement, 
(r) Head does not rotate, 
(d) Shoulder often is much broadened, 
5. Anatomical neck of humerus : 
(a) Exclude all other fractures, 
(b) Peculiar to old age, 
(c) Subsequent necrosis and suppuration. 
VIII. Treatment of all varieties; 
(a) Give ether, 
{b) Reduce displacement, 
(r) Use body as principal splint, 
(<d) Let forearm act as counter-extension, 
{e) Do not put pad in axilla, as it compresses 
vessels and nerves. 23 
IX. —Elbow : 
(a) Supra-condyloid, 
(b) Diastasis (through epiphysis), 
(e) Through condyles, 
(d) Fractures involving the joint, 
A. Shaped like a T, 
B. Through external condyle, 
C. Through internal condyle, with radius dis- 
location. 
X. Forearm : 
1. Kinds : (a) Single bone, 
(b) Both bones. 
2. Treatment: 
{a) Special indication is to prevent approxima- 
tion of both bones by supination and splints, 
(b) Prevent wrong union of fragments, by care- 
ful adjustment. 
XI. —Lower end of radius (Colies’): 
(a) Produced by fall on palm of hand, 
((b) Treatment: 
1. Reduction : A. Twisting hand, 
B. Pressure, 
C. Flexion and extension. 
D. Use ether or gas. 
2. Fixation: 
(a) Plaster of Paris, 
(b) Adhesive plaster (Willard Parker), 
(e) Palmar and dorsal splints. 
3. Avoid early passive motion, but start finger 
movements early. 
XII. —Pelvis : 
(1) False pelvis, 
(2) True pelvis, 
Treatment: Body bandage, 
Adhesive plaster. 
Complications : 
Rupture of bladder or urethra. 24 
XIII.—Femur: 
I. Fractures of neck: 
{a) Intracapsular, 
(b) Extracapsular, 
(c) Complete, 
(d) Impacted with or without splitting trochanter. 
N.B.—Fracture of acetabulum : 
If upper lip broken, may simulate dorsal 
dislocation or fracture of neck. 
Fractures of neck may be : 
Close to anterior surface, 
Close to trochanter. 
Principal symptoms, fracture of neck of femur : 
(a) Flattening of hip, 
(b) Trochanter drawn up or sunken in, (Nela- 
ton’s, Bryant’s, Morris’, tests). 
(c) Rotation changed : 
1. Eversion, 
2. Helplessness. 
(d) Shortening (a) intracapsular, \to I inch. 
(b) extracapsular, to 3 “ 
Both overcome by traction. 
{e) Crepitus—often subdued or absent, but 
elicited by traction, 
(/) Pain. 
Risks, (a) Immediate : 
1. Bedsores, 
2. Hypostatic pneumonia, 
(b) Later: 
1. Non-union, 
2. Deformity. 
Results, {a) Bony union, 
(b) Fibrous union, 
{c) Eburnation, 
Treatment; Sand or salt bags, avoid much motion 
or handling. 
Extension, 
Plaster of Paris (alone), 
“ “ (Senn’s method). 25 
2. Upper third of femur: 
{a) Note tilting of fragments (upper, upward 
and outward), 
{ib) Put the lower fragment into the axis of the 
upper, 
ic) Treatment—j {a) Hodgen’s splint, 
( {b) Allis’ plan, 
3. Middle third and lower third ; 
(a) Vertical extension in children, 
(b) Buck’s extension, Volkmann’s splint. 
4. Condyles: 
Note influence of gastrocnemius, 
Theory vs. practice. Tenotomy in rare cases. 
Hodgen’s splint. Double inclined planes. 
XlV.—Patella: 
1. —Causes of usual fibrous union: 
{a) Action of quadriceps extensor, 
{b) Inversion of fibrous tissues between frag- 
ments. 
2. Risks of ordinary treatment: 
(a) Uncertain gait, 
{b) Refracture, 
(,c) Fracture of other patella. 
3. Risks of operative treatment: 
{a) More or less ankylosis, 
(b) Suppuration of joint, 
(r) Amputation, 
{d) Death. 
4. Ordinary treatment (old method): 
{a) Compression of joint, 
(1b) Approximation of fragments, 
(c) Immobilization of limb, 
(d) Duration, six weeks to three months. 
5. Operative treatment: 
(a) Aspiration of blood from joint, 
{b) Suturing fragments, 
(r) Traction sutures, 
{d) Duration, three to six weeks, 
{e) Advantages—bony union, restored function, 26 
XV. —Fibula—Upper end : 
Note possible injury to the external popliteal nerve 
XVI. —Ankle joint: 
1. Pott’s fracture, 
2. Sprains, 
3. Fracture of os calcis. 
I. —Kinds: 
1. Complete, 
2. Simple, or compound, or complicated : 
(a) Nerve, 
(b) Vessel, 
(c) Visceral lesion, 
{d) Fractured bone. 
3. Bilateral or double, 
4. Traumatic or pathological, 
5. Congenital or acquired, 
6. Recurrent or habitual. 
11. —Signs: 
1. Deformity, 
2. Loss of motion, 
3. Impairment of function, 
4. Crepitus, soft. 
111. —Reduction impeded by: 
1. Interposition of capsule, muscles, tendons, 
2. Contraction of muscles, 
3. Swelling of soft parts, 
4. Overriding of joint ends, 
5. Complication of fracture. 
IV. —lndications for treatment: 
1. Draw or twist dislocated end of bone towards 
the normal position, 
2. Overcome muscular contractions (anaesthesia), 
3. Overcome overriding by position and manipu- 
lation. 
111.—DISLOCATIONS. 27 
V.—Risks of reduction: 
1. Skin damage, 
2. Vessel and nerve damage, 
3. Fracture by twisting, etc., 
4. Joint inflammation and ankylosis. 
IV.—DISEASES OF BONE. 
I.—Periostitis: 
1. Non-pyogenic: 
2. Pyogenic; 
(a) Traumatic, 
(b) Syphilitic, 
(c) Gouty, 
{d) Gonorrhoeal, 
(e) Rheumatic, 
(/) Drugs. 
(a) Of similar origin, 
(b) Formation of abscess, 
{c) Concurrent osteomyelitis. 
ll. Osteomyelitis: 
1. Acute: 
(ia) Often confounded with (a) Ac. rheumatism, 
ib) Typhoid fever. 
1. Simple, 
2. Multiple, 
3. Recurring. 
1. Early bone section, 
2. Drainage. 
1. Internal or external ab- 
scess (Pott’s puffy tumor), 
2. Necrosis, 
3. Caries, 
4. Epiphysitis, 
5. Joint and visceral involve- 
ment. 
(1b) Varieties: 
(c) Treatment: 
(d) Results: 
2. Chronic—usually non-pyogenic : 
' I. Syphilis, 
2. Gout, 
3. Rheumatism, 
4. Irritation, repeated or 
chronic, 
5. Obscure forms: Charcot’s 
Joint, Arthritis Deformans. 
1. Deformity, 
2. Chronic ulceration, 
3. Necrosis. 
(,a) Causes : 
(b) Results: 28 
111.—Irregularities of growth : 
1. Defective nutrition : 
(a) Bone atrophy, 
{b) Malacostia, 
(e) Rickets, 
(d) Contracted pelvis, 
{e) Bow-legs, etc., 
(/) Pigeon breast, etc. 
2. Excessive nutrition : 
{a) Bony hypertrophy, 
(b) Bow-legs, 
(r) Knock-knee, 
{d) Exostosis, 
{e) Osteophytes, 
(/) Enchondrosis, 
(g) Leontiasis, 
{h) Acromegalia. 
3. Treatment: 
(a) Bow-legs: 
{a) Manual reposition, 
(b) Simple osteotomy, 
(c) Cuneiform osteotomy. 
(<b) Knock-knees: Condyloid osteotomy, 
(Macewen). 
(c) Exostoses and enchondromata : 
(1) Frontal sinus, cerebral risk in removal, 
(2) Nose, 
(3) Ear, 
(4) Ivory exostoses, 
(5) Under toe-nail. 
Treatment, extirpation. 
IV.—Suppurative Osteomyelitis ; 
1. Terms : 
(a) Cloaca, 
(b) Sequestrum, 
(c) Involucrum. 
2. Necrosis and chronic abscess : 
{a) Of compact structures of shaft: 
1. Exfoliation, 
2. Total necrosis, 
3. Frequent after amputation. 29 
{b) Of cancellous structures and epiphysis : 
1. Bone abscess, 
2. Arrest of growth, 
3. Joint involvement. 
3. Diagnosis.—Detection of dead and separated 
bone by probing. 
4. Treatment of bone abscess and necrosis; 
{a) Early subperiosteal resection, 
{b) Bone solvents (?) 
(t) Sequestrotomy, 
(<d) Osteotomy. 
5. Filling up of bone cavity after operation : 
[a) Skin depression and tacking down, 
(1h) Blood clot, 
{c) Decalcified bone or bone depression, 
(d) Fresh bone grafting, 
((e) Gutta percha, 
(/) Plaster of Paris. 
V. —Nonsuppurative necroses : 
(a) Phosphorus, 
(b) Mercury, 
(p) Caries sicca, 
VI. Tumors of Bone : 
1. Myelo-sarcomata, 
2. Sarcoma, 
{a) Small round cells, 
{b) Spindle cells, 
(c) Giant cells. 
3. Chondromata, 
4. Chondro-sarcomata, 
5. Carcinomata, 
6. Hydatids, 
7. Aneurisms and angeiomata. 
V.—BURSITIS, ETC.: 
1. Fleischmann’s bursa (Ranula), 
2. Subhyoid, 
3. Subacromial, 
4. Olecranon, 30 
5. Trochanteric, 
6. Prepatellar, 
7. Subligamental-patellae, 
8. Ham, 
9. Bunion, 
10. Teno-synovitis, 
(a) Simple, 
{b) Compound, 
(c) Tubercular. 
11. Palmar and digital abscess, 
12. Dupuytren’s contraction, 
13. Webbed fingers. 
VI.—DISEASES OF LYMPHATICS, 
I.—Lymphangitis: 
1. In patches—reticular, 
2. In lines—tubular, 
3. Superficial—easily recognized, 
4. Deep—often simulates cellulitis. 
11. —Lymphadenitis: 
{a) Axilla, 
{d) Neck; 
(c) Groin. 
1. Acute: 
2, Chronic,—tubercular, 
3. Treatment. 
(ia) Injection of iodine or iodoform, 
1$ lodoform, 3 i, 
Ether sulph., 3 v, 
01. olivas, 3 x. 
([b) Scraping, 
(c) Extirpation. 
111.—Lymphangeioma and Lymphangiectasis : 
1. Kinds: {a) Cutaneous 
1. Tumors, 
2. Elephantiasis, 
3. Pachydermatocele, 
{b) Submucous, e.g., chyluria, 
(c) Subcutaneous, 
{d) With angeioma. 
1. Filaria Sanguinis Hominis, 
2. Mosquitoes. 
2. Causes ; 
IV, —Lymphosarcoma : Hodgkin’s disease. 
V, —Lympho-carcinoma. 31 
VII.—DISEASES OF VESSELS. 
I.— Wounds of veins and arteries 
Methods of repair. 
Dangers. 
Treatment : 
Murphy’s suture. 
{a) Punctured 
{b) Contused 
{c) Lacerated 
{d) Gunshot 
(e) Incised 
(/) Ruptured 
11. —Accidents during certain operations: 
(1) Wound of carotid in tonsillotomy. 
(2) Wound of palmar arch in operations on the hand. 
(3) Wound of thyroid isthmus, or of a vein in 
tracheotomy. 
(4) Entrance of air into veins. 
(5) Wound of intercostal in thoracotomy. 
(6) Wound of epigastric in laparotomy, etc. 
111. A neurism: 
1. Classes: 
{a) Spontaneous or Idiopathic (previous arte- 
rial disease). 
(Ib) Traumatic: 
1. Rupture, 
2. Ulceration, 
3. Puncture. 
(c) According to shape, etc.: 
1. Fusiform (tubular), or true, 
2. Saccular, or false, 
3. Circumscribed, 
4. Diffused, 
5. Dissecting. 
(d) According to site : 
1. External, 
2. Internal. 
2. Symptoms: 
(a) Pulsation, 
(b) Compressibility, 
{c) Situation along the artery, 
{d) Expands after compression, 
(<?) Bruit. 32 
3. Differential diagnosis: 
(1a) Abscess or tumor over an artery, 
(b) Angeio-sarcoma, 
(r) Enlarged aorta, 
{d) Pulsating liver, 
(e) Goitre. 
4. Destroys life; 
{a) By rupture, internally, externally. 
{b) By pressure on trachea, etc. 
5. Spontaneous cure : 
{a) How effected, 
{b) Factors favoring. 
6. Treatment of external aneurism : 
(1) Antyllus A. D. 200-300, 
(2) Anel 1710, 
(3) Hunter 1785, 
(4) Brasdor 1780, 
(5) Wardrop 1815, 
(6) Ballance’s knot. 
(a\ Lip-ature 
{a) lgature 
(b) Flexion. 
(r) Esmarch bandage. 
(d) Digital or instrumental compression. 
{e) Extirpation. 
(/) Manipulation (Ferguson, 1852). 
{g) Amputation if: gangrene sets in, sac rup- 
tures, sac suppurates ; joint or bone com- 
plication. 
7. Treatment of internal aneurism : 
(a) Tuffnell’s (1864): Diet, position, quiet. 
(b) Balfour’s: potassium iodide. 
(c) Acupuncture (Simpson). 
(d) Galvanopuncture (Phillips, 1829). 
(e) Insertion of wire or catgut (Loreta). 
(/) Macewen’s plan—needling. 
8. Arterio venous aneurism: 
(a) With tumor = varicose aneurism. 
(b) Without tumor = aneurismal varix. 
(c) Treatment: 
1. Ligature artery above and below tumor, 
2, Extirpation, 33 
g. Orbital aneurism. 
io. Cirsoid “ 
ii. Naevus—Treatment: 
i (a) Cautery, 
(b) Electrolysis, 
(c) Multiple incision. 
VIII—TUMORS. 
1. Definitions: 
{a) A tumor is a new formation not inflamma- 
tory in origin, and is more or less in con- 
formity with the tissue in which it has 
originated, but having no physiological 
function. 
[b) All true tumors are formed from previously un- 
developed cells. 
(r) Cysts are formed from pre-existing sacs or lo- 
bules by accumulation of secretions or excre- 
tions. 
2, Causes of true tumors: 
1. Heredity, n percent., 
2. Trauma, 11 per cent., 
3. Inflammation and prolonged irritations, 
4. Anomalous embryonic arrangement, 
5. Parasites and germs. 
3, Classification: 
{a) Malignant and innocent, 
(,b) Homologous and heterologous, 
(,c) Homoplastic and heteroplastic. 
(d) Formed from 
1. Epiblast, 
2, Hypoblast, 
| 3. Mesoblast. 
{e) Morphological division : 
I. Connective tissue tumors, 
11. Epithelial tumors, 
111. Dermoids, 
IV. Cysts—only for convenience. 34 
4- Frequency and sites: 
According to Weber in 1013 cases: 
Mouth and maxillae 217, 
Glands 174, 
Bones (excl. maxillae) 161, 
Skin 93, 
Genitals (male) 86, 
Lungs : 64, 
Nose and pharynx 56, 
Eyes and orbits 41, 
Genitals (female) 31, 
Intestine and anus 13, 
Urinary organs 13. 
5. Benign or innocent tumors: 
{a) Are of slow growth, 
{d) Usually encapsulated, 
{c) Do not contaminate adjacent glands, 
(d) Do not infiltrate, 
{e) Do not recur after complete removal, 
(f) Do not disseminate, 
{g) Do not imperil life except mechanically. 
6. Malignant tumors : 
(a) Are of rapid growth, 
(,b) Usually not encapsulated, 
(c) Affect adjacent glands generally, 
(d) Infiltrate, 
(e) Return after removal, 
(/) Disseminate, 
(g) Destroy life, 
(h) The connective tissue group contains one malig- 
nant genus, viz., sarcoma. 
(i) The epithelial group contains two malignant 
genera, epithelioma and carcinoma. 
{j) All other tumors are benign. 
7. Group I.—Connective tissue tumors : 
1. Lipomata, 
2. Chondromata, 
3. Osteomata, 35 
4. Odontomata, 
K. Fibromata 
’(a) Simple, 
(b) Molluscum fibrosum, 
(c) Neuro-fibroma, 
(d) Keloid. 
6. Myxomata, 
7. Gliomata, 
8. Neuromata, 
9. Angeiomata, 
10. Lymphangeiomata, 
11. Sarcomata, 
Tissues of immature connective-tissue with 
cells preponderating. 
{a) Round-celled sarcoma, occurs everywhere, 
at all ages. 
(,b) Spindle-celled sarcoma, 
{a) Often with hyaline cartilage, 
{b) Often of slow growth, 
(c) Prognosis more favorable. 
(c) Lympho-sarcoma, 
Cells resemble lymph-gland cells. 
(d) Myeloid-sarcoma, 
{a) Like marrow of young bone, 
{b) Often capsulated, 
(r) Prognosis more favorable. 
(e) Sarcoma disseminates, 
{a) Usually by venous channels, 
{b) Rarely by lymph channels. 
(/) Treatment of sarcoma, 
{a) Removal in accessible positions, 
{b) In bone, amputation above adjoining 
joint. 
Group ll.—Epithelial tumors : 
(a) Skin warts, 
(b) Cutaneous horns, 
(r) Villous papillomata, 
id) Intracystic warts, 
(e) Psammomata. 
i. Papillomata, 
2, Epitheliomata, 
Differ from warts in not being limited by a 
basement membrane, but its cells pass into the 
connective tissue. 36 
Treatment: 
{a) A wide and early removal, including en- 
larged adjacent glands. 
{b) Look out for crossed gland—infection, in 
case of tongue especially. 
(c) Operation makes life easier and prolongs it. 
{d) In a moderate but increasing percentage a 
cure is effected,—i. e., no recurrence for 
3 years or more. 
{e) Recurrence, except in special cases, means 
uselessness of further operations. 
3. Adenoma : 
Constructed on the type of, and grows in connec- 
tion with, a secreting gland. Does not produce 
secretion of the gland it mimics. Is usually a 
benign growth. 
4. Carcinoma: 
Grows from pre-existing gland, and mimics it, but, 
unlike adenoma, the mimicry is incomplete. Ir 
regular epithelial clusters fill the acini. 
Old terms : (a) Scirrhus, 
{b) Encephaloid, medullary, 
{c) Colloid. 
9. Group lll.—Dermoid tumors: Containing skin or 
mucous membrane where such are not normally 
found. 
Divided into : 
1, Sequestral Dermoids : 
Where in embryonic life coalescence occurs 
between skin and corresponding surfaces, 
e.g., along line of union. (1) Face, (2) scalp 
and dura mater, (3) median line of body. 
2. Tubulo-dermoids : From obsolete canals, 
1. Thyroglossal, 
2. Lingual, 
3. Lateral cervical (branchial clefts), 
4. Median cervical (Subhyoid bursa), 
5. Infundibulum and pituitary gland, in 
pharynx, 37 
6. Median and lateral accessory thyroid, 
7. Posterior and anterior rectal. 
3. Dermoid patches, moles, etc., 
4. Implantation dermoids. 
10. Group IV.—Cysts : 
Not true tumors. 
Derived from dilatation of pre-existing tubules 
or cavities. 
1. Retention cysts : 
From dilatation of obstructed gland-duct. 
(a) Hydrometra, 
(3) Hydrosalpinx, 
(1c) Hydrocholecyst, 
{d) Galactocele, etc. 
Obstruction due to : 
(«) Inflammation, 
{&) Cicatrices and stenoses, 
(r) Tumor pressure, 
(,d) Flexions of duct (intermittence), 
(.e) Valvular closure, 
(/) Altered secretion, 
{g) Foreign body, concretion, etc. 
2. Tubulo Cysts :or dilatation of functionless ducts. 
(a) Vitello-intestinal, 
{b) Parovarian, 
{c) Gaertner’s, 
{e) Testes 
(d) Urachus, 
Cystic adenoma, 
Organ of Giraldes, 
Kobelt’s tubes, 
Hydatid of Morgagni. 
3. Hydrocele: 
Collection of fluid in : 
(a) Tunica vaginalis, 
(b) Canal of Nuck, 
{e) Ovary, etc. 
4. Gland cysts : 
Ranula, 
Pancreatic cysts, 38 
Chyle cysts, 
Lachrymal cysts, 
Renal cysts, single and multiple, 
Galactocele, 
5. Pseudo-cysts : 
Diverticula, 
Bursas, 
Neurocysts (spina bifida), 
Hydatids. PART lI—REGIONAL SURGERY. 
ABRAHAM L. WOLBARST, M.D. 
EDITED BY 
SECTION I—THE MAMMARY GLANDS. 
I.—DISEASES OF THE BREASTS. 
1. Polymastia—{a) In normal lines, 
{b) Abnormal sites, e.g., thighs. 
Allied conditions : 
(a) Accessory mammas, 
{b) Champney’s axillary plaque. 
2. Hypertrophy of mamma : 
{a) Infantile, 
{b) Adult, 
1. Pregnancy, 
2. Lactation, 
3. Menstruation. 
1. Temporary 
2. Permanent, 14-30 years. 
3. Usually general, sometimes localized. 
3. Gyncecomastia: 
Hypertrophied mamma in male adult. No 
change in other sexual characteristics. 
4. Diseases of nipples : 
{a) Fissure, 
{li) Sebaceous cyst, 
if) Papilloma, 
(d) Chancre, 
{e) Chancroid, 
(/) Eczema, chronic, 
{g) Paget’s disease. 40 
5. Tumors of the breast: 
(a) Lipoma—rare, generally outside of the gland, 
(b) Chondroma—rare, 
(y) Galactocele—infrequent; with or subsequent to 
lactation, 
*(d) Fibroma, or cystic fibroma, under puberty and 
upwards, 
(e) Cystoma, 30-50 years. 
*(/) Adenoma, 15-40 years ; fibro-cyst-adenoma (20- 
40 years). 
{g) Myxoma—very rare (40-50). 
*{h) Sarcoma—20-30 years. 
*(*') Carcinoma—3s-60 years. 
1. Tubular, 
2. Acinous. 
* = common. 
(_/) Tumors and ulcers of infectious origin, 
(1) Syphilitic gumma, 
(2) Tubercular mastitis and ulceration. 
6. Malignant growths : 
A. —Sarcoma, 
Occurs 4 per cent, of all breast tumors, 
(a) Pure sarcoma, not large, 20 per cent, of all sar- 
comata. 
{b) Adeno-sarcoma 80 per cent., often cystic and 
quite large. 
Signs : No adhesion to skin and subjacent parts. 
Glands sometimes involved and ulcerate. 
When ulcers present, they are fungating, 
edges not infiltrated, grow rapidly, veins en- 
larged ; 20-50 years. 
B. —Carcinoma: 
{a) Tubular, 
(b) Acinous, 
Frequency of breast tumors; 
Carcinoma 79 per cent. 
Sarcoma 4 “ “ 
Benign 15 “ “ 
Cysts 2 “ “ 4i 
C. —Differential diagnosis of breast tumors : 
(a) Benign : 
Age, 20 to 40, 
Circumscribed, 
Mobile, 
Non-adherent to skin and deep parts, 
No gland infection, 
No retracted nipple. 
(,b) Malignant: 
Age, average 48 years, 
Possible 20-70 years, 
Hard, irregular, 
Fixed, adherent to skin (“ pigskin ”), 
Retraction of nipple 52 per cent., 
Not very rapid growth, 
Glands infected, 
Late ulceration with fungation, cachexia and 
metastases. 
D. Treatment of Carcinoma Mamma ; 
I.—Caustics (inadvisable). 
ll.—Surgical operation : . 
(a) Average duration of life, in unoperated 
cases is 44 months; in operated cases 
with recurrence, 60 months. 
{b) Average prolongation of life, 16 months. 
(r) Recurrence: 
Within 6 months after operation in 60 per 
cent, cases. 
From 6 months to 2 years after operation 
in 32 per cent, cases. 
General rule: (Volkmann) 
If no recurrence in 1 year, a cure is pos- 
sible ; 
If no recurrence in 2 years, a cure is prob- 
able ; 
If no recurrence in 3 years, a cure is almost 
certain. 42 
II.—AMPUTATION OF THE BREAST. 
Operation memoranda : 
{a) In 47 per cent of cases where no glands are 
felt through the skin, infected axillary 
glands are found. 
(<b) Infected glands are also found in Mohren- 
heim’s space, and also above the clavicle, 
(r) Infection of supra-clavicular glands is some- 
times considered a contra-indication. 
Cd) Besides the axillary routes of gland infec- 
tion, it can also occur via pectoral fascias 
and muscles (Haidenhain). 
{/) Avoid nerve damage, and especially the 
two subscapular nerves, the long 
thoracic, etc. 
(/) Skin-grafting can be used if wound cannot 
be closed. Better as a secondary opera- 
tion. 
{g) Technique: 
1. Run incision below and above breast, I 
to inches from tumor and prolong 
above anterior axillary fold to below 
attachment of the pectoralis major. 
2. Make the lower incision first, so as to 
avoid obscuring by blood from above. 
3. Dissect off skin in upper flap up to 
clavicle. 
4. Do not fasten arm too much upward, 
lest paralysis follow. 
5. Remove whole gland at once, not piece- 
meal. 
6. Expose axillary vein early to avoid its 
injury. 
7. Ligate small veins early, and at a dis- 
tance from parent trunk. 
8. Remove the pectoralis major, except the 
clavicular portion, the pectoralis minor 
and axillary fat and glands. 43 
SECTION II —THE GENITOURINARY 
ORGANS. 
I.—THE PENIS AND URETHRA. 
I. —Malformations of the penis : 
{a) Absence of the penis, 
{b) Double penis, 
(r) Abnormal size of penis, 
d) Curvature and scrotal adhesions, 
(e) Epispadias, 
(/) Hypospadias, 
{g) Phimosis and preputial complications, 
{h) Shortened frsenum, 
(i) Hermaphroditism, true and false. 
11. —Malformations of the urethra : 
{a) Atresia and narrowing of meatus, 
(£) Meatus with “ four lips,” 
(c) Congenital strictures, 
(d) Valves, 
(.e) Dilatations and pouches. 
Hl.—Phimosis may produce : 
1. Urinary troubles (mechanical), 
2. Dilatation of prepuce, 
3. Formation of and arrest of calculus* 
4. Balanitis, 
5. Hernia (especially in children), 
6. Prolapsus ani, 
7. Premature sexual excitement, 
{e.g. masturbation ; reflex neuroses) ; 
8. Intensified venereal troubles, 
9. Impaired coitus, 
10. Paraphimosis, 
11. Epithelioma of penis. 
IV.—lnjuries and diseases of penis : 
(a) Wounds and contusions, 
{b) Strangulation and gangrene, 
(■c) Fracture (?), 
{d) Luxation (?), 
{e) Gouty or calcareous plaques, 44 
(/) Skin affections | Eczema, 
(g) Growths : 
1. Vegetations, 
2. Sebaceous tumors, 
3. Elephantiasis, true and false, 
4. Epithelioma, 
5. Sarcoma, 
6. Fibroma, 
7. Angeioma and aneurism. 
V.—lnjuries and diseases of urethra inon-venereal): 
(a) Contusions and abrasions (sounds and catheters), 
(b) Wounds and lacerations, 
(e) Urinary and urethral fever, 
(d) Urinary abscess and extravasation, 
(e) Fistula, 
(/) Polypus, 
1. Balanitic, 
2. Penile, 
3. Perineal, 
(g) Calculus, 
(h) Foreign bodies. 
Vl.—Lacerations and wounds of urethra : 
Urethral Traumatism may produce 
{a) Hemorrhage, 
[b) Extravasation of urine, 
(r) Retention “ “ , 
{d) False passage, 
{e) Urethritis, 
(/) Pus infection and abscess, 
{g) Urinary fistula, 
(h) Curvature of penis, 
(i) Intractable stricture. 
Treatment : 
(1) For hemorrhage— 
Pressure—external or internal. 
(2) For retention of urine— 
Aspiration (?), catheter, perineal incision. 
(3) For extravasation of urine— 
Incision—irrigate. 45 
(4) For laceration— 
Incision, suture and drainage. 
Results—Stricture—(sounds). 
Fistula 
early, 
late. 
II.—THE BLADDER. 
I.—Extravasation of urine may be due to : 
{a) Strictured urethra, 
(b) Dilated follicles, 
(c) Wounded urethra, 
(d) Ulceration or rupture of urethra, 
if) External injury, 
1. Wounds, 
2. Contusions, 
in perineum, 
3. Fractures of pelvis. 
ll.—Malformations, malpositions and injuries of the 
bladder: 
1. Double bladder, 
2. Exstrophy (sacro-iliac suture), 
3. Patent urachus 
Umbilical fistula, 
Allantoic cysts, 
4. Hernia of bladder, 
Gunshot, 
Incised and punctured (catheter), 
5. Wounds 
6. Rupture of bladder. 
Causes: 
A. Traumatic, injuries with or without frac- 
ture of pelvis ; 
{a) Surgical instruments, 
(b) “ over distension, 
{c) Parturition. 
B. —Pathological: 
{a) Diseased bladder (foetal rupture), 
(ih) Sacculated “ 
Ulcerated “ 
{d) Retention from obstruction. 
Site of rupture : Dangers: 
1. Intraperitoneal— Peritonitis, 
2. Extraperitoneal— Urinary extravasation. 46 
Diagnosis : 
1. By testing bladder capacity, 
2. “ “ “ distensibility (Weir, 1887), 
3. “ exploratory incision. 
Treatment: 
For intraperitoneal, 
Laparotomy and drainage. 
For extraperitoneal, 
Incision and perineal drainage. 
111. —Foreign bodies in the bladder; 
Introduced in (a) Masturbation, 
{b) Defective catheters, 
(c) Wounds and abscesses. 
To be removed by (a) Lithotrite or Guyon’s hook, 
{b) Lithotomy. 
IV. Tumors of the bladder: 
1. Benign : {a) Papilloma, 
(b) Myxoma (polyp), 
(c) Myoma, 
{d) Angeioma, 
{/) Cysts 
Hydatid 
Dermoid 
rare. 
2. Malignant: 
A. —Sarcoma, {a) Fibro-sarcoma, 
{b) Lympho-sarcoma, 
(c) Myo-sarcoma, 
{d) Round and spindle sarcoma. 
B. Carcinoma, (a) Epithelioma, 
(b) Alveolar. 
Forty-three per cent, of vesical tumors are at or 
near left urethral orifice, 
Twenty-six percent, of vesical tumors are at or near 
right urethral orifice. 
Symptoms of tumor of the bladder: 
i. Hemorrhage (Guyon’s 3 glass test, also rectal 
pressure test. Note, most blood in urine last 
passed.), 47 
2. Cystitis, 
3. Gelatinous urine, 
4. Tumor—determined by 
{a) Sounding, 
{b) Bimanual examination, 
(e) Cystoscope, 
(id) Lithotrite, 
(<?) Exploratory incision. 
5. Urinary shreds. 
Differential diagnosis: 
Hematuria=\)r'\x\c\\)2L\ symptom ; may also be found 
with: 
1. Hypertrophy of prostate, 
2. Stone in bladder, 
3. Acute cystitis, 
4. Tubercular cystitis, 
5. Ulceration and fissure of neck of bladder, 
6. Bilharzia Hematobia (Egypt), 
7. Filaria Sanguinis Hominis 
South America, 
India, 
China. 
8. Renal neoplasms and calculi. 
For cystoscopic examination : 
1. Have medium clear, 
2. Avoid bladder wall, 
3. Examine base first. 
Treatment: 
{a) Hot water irrigations, 
{b) Aspiration, 
(f) Internal medication. 
For hemorrhage, 
(a) Extirpation 
(use glass vaginal speculum 
. for vesical exploration), 
{6) Extirpation with resection of 
bladder, 
“ tumor, 
(a) partial, 
[b) complete. 
Disposition of Ureters, if involved. 
Palliative operation on unremovable tumors. 48 
lII.—THE PROSTATE. 
I. —Prostatic Abscess: 
{a) From the urethra: 
Acute—i. Gonorrhoea, 
2. Infectious instrumentation 
(catheters). 
(Ib) From the bladder: 
Chronic—i. Stone, 
2. Cystitis from hyper- 
trophy of the prostate. 
May evacuate into 
1. Urethra, 
2. Rectum, 
3. Perineum. 
11. —Hypertrophy of the Prostate : 
1. Produces: 
(a) Dilatation and elongation of prostatic 
urethra, 
(,b) Elevation of vesical outlet, 
(c) Obstruction of venous circulation. 
2. Results in: 
(a) Residual urine; Decomposition, 
(b) Hypertrophy of vesical wall, 
(f) Dilatation of the bladder, 
1. Atony (a flabby bag), 
2. Incontinence, 
3. Overflow (retention), 
(d) Sacculation of bladder, 
{e) Dilatation of ureters and pelves. 
3. Infection begets : 
{a) Cystitis, 
ib) Epididymitis, 
{c) Surgical kidney, 
(d) Prostatic abscess. 
4. Treatment: 
As to bladder : 
1. Empty bladder (catheter), 
2. Correct the infection, 
3. Permanent drainage. 49 
As to prostate itself : 
i. Prostatic dilatation, 
i. Excision, 
{a) Internal (McGill, Bottini), 
{b) External (Alexander), 
3. Castration, 
4. Excision of vas deferens, 
5. Prostatic dilatation (Harrison). 
IV.—RETENTION OF URINE, CYSTITIS 
AND CALCULI. 
I. —Retention of urine : 
A. From paralysis and atony : 
(a) Lesion of cerebro-spinal system, 
(<h) Shock from distant injuries, 
(r) Certain medicines, as opium, etc., 
(d) Debility from exhausting disease, 
[e) Hemorrhoids, peritonitis, etc. 
B. —From Obstruction : 
(a) Phimosis or priapism, 
(,b) Urethral stricture, (a) Spasmodic (hysteria), 
(b) Organic. 
(e) Laceration of urethra, 
id) Acute prostatitis, 
(e) Hypertrophy of prostate, 
(/) Tumors of prostate, 
{g) Stone, (a) In prostate, 
{b) In urethra, 
(r) In bladder, 
(-h) Hemorrhage in bladder, 
(z) Extra-vesical tumor (Englisch), 
(J) Hernia of the bladder. 
11. —Cystitis; 
A.—From the prostate : 
{a) Violence, 
{b) Urethral infection. 50 
B. —From the bladder : 
{a) Violence, 
(b) Purulent inflammation, 
From {a) Prostate, 
{b) Rectum, direct or in- 
direct. 
{c) Tubercular infection. 
C. —From the kidney : 
{a) Gravel, 
(b) Purulent infection, 
(c) Tubercular infection. 
Varieties: 
1. Simple, 
( Diabetes, 
■< Vesico-intestinal 
i fistula, 
2. Ammoniacal; Pneumaturia, 
3. Gangrenous, 
4. Diphtheritic, 
5. Tubercular. 
lll.—Stone in the bladder: 
I. —Origin : 
1. Renal, 
2. Bladder, 
3. Prostate. 
11. —Retrograde changes from : 
Albumin.C72H112N18022S 
Tyrosin _C7 H41 NOs 
Hippuric Acid..C9 H9 NOa 
Leucin C 6 Hl3 N02 
Cystin C 6 H6 N02 S 
Xanthin C 5 H4 N4 02 
Uric Acid .C5H4N40 
Oxalic Acid_C2H204 
Urea CH4NsO 
Ammonia NH3 
Carbonic Acid Coo 
Water HsO 
lll.—Kinds of Deposit; C = common, R ===== rare. 
1. —Due to defective nitrogen elimination : 
{a) Uric acid (C), 
(b) Urates—ammonia principally (C), 
(c) Uric oxide or xanthin (R). 
2. —Due to defective starchy and saccharine elimina- 
tion : 
Oxalate of lime (mulberry calculus) (Q. 
3. —Due to defective sulphur elimination : 
Cystin (R). 5i 
4. —Due to non-inflammatory changes in the urine : 
(a) Carbonate of lime (R), 
lb) Phosphate “ (R). 
5. —Due to inflammatory changes in the urine; 
Phosphates of ammonia, magnesia and lime (C). 
Mixed or fusible calculus. 
6. Other Forms of concretions (Rarer) ; 
(a) Fibrinous, 
(b) Urostealith, 
(c) Blood, 
(<d) Siliceous, 
{e) Foreign nuclei, 
7. Compound stones— 
Size, number, facets, 
Spontaneous fracture. 
IV. —Symptoms—Stone in the bladder: 
1. Pain—when absent, aggravated by motion, 
2. Frequency—diminished by rest, 
3. Arrest of stream, 
4. Hematuria, aggravated by motion, 
5. Reflex pains, along sciatic, 
(even felt in tips of fingers—Cavendish). 
V. —Diagnosis—Made by : 
1. Sounding with, 
{a) Metallic sound or lithotrite for size and 
double stone, 
{b) Metal-tipped flexible catheter, 
(c) Litholapaxy, . 
Aspiration (Bigelow’s). 
2. Bi-manual examination, through rectum above 
pubes (most serviceable in children). 
3. Cystoscope. 
4. Digital examination (through dilated urethra, in 
women). 
5. Digital and ocular exploration, preferably by 
suprapubic section (in women by Kelly’s 
tubes, knee and elbow position). 
In sounding, bladder should be moderately full. 52 
VI. —Errors in sounding: 
{a) Sound is yet in elongated prostatic urethra, 
{b) Stone too light or covered with blood or 
mucus, 
(*:) Stone hidden in a sacculus or by an interure- 
teral bar, 
{d) Striking promontory of the sacrum, 
(e) Rubbing through stricture occasionally simu- 
lates stone, 
(/) Encrusted vesical tumor, suspicious if fixed 
and above line of gravity, 
{g) Stone too large to permit excursions of sound, 
hence simulating cancer. 
VII. Treatment: Stone in the bladder: 
{a) By crushing and removal of fragments : 
Litholapaxy, | Urethral or perineal. 
(1b) By cutting out the calculus; 
Lithotomy. 1. Median, 
2. Lateral and modifications, 
3. Suprapubic. 
Vlll.—Mortalities (Cabot) in 602 cases: 
Litholapaxy. 
Perineal Lithotomy. 
Suprapubic Lithot- 
omy. 
Children 
1-70% 
3-oi% 
•3- 1% 
A dults 
4-05% 
9-07% 
11-03% 
Old men 
7 %• 
19 % 
CO 
IX. -—Post-operation damage from 
1. Lithotrity, 
{a) Cystitis, 
{b) Failure to evacuate all fragments. 
(a) Sterility, 
(b) Incontinence of urine, 
(ic) Permanent urinary fistula, 
(d) Stricture (median operation), 
(e) Rectal fistula. 
2. Lithotomy 
(perineal), 53 
X. —Contraindications to litholapaxy: 
(a) Calculi too large, too many or too hard, 
(1b) Calculus with known foreign body or too hard 
or too soft to be well crushed, 
{c) Calculus encysted, 
{d) Stricture of the urethra, 
(e) False passage in urethra preventing necessary 
instrumentation, 
(/) Hip ankylosed in position impracticable for 
operation. 
XI. —Diseases concurrent contraindicating lithotomy: 
{a) The shock of a cutting operation or its anaes- 
thesia. 
(b) Disease of heart, diabetes, advanced Bright’s, 
polyurias with low specific gravity, gout, 
Litholapaxy is better, or the old lithotrity. 
XII. —Operations advised for stone are: 
(<2) In childhood— Lithotomy (median or supra- 
pubic) or Litholapaxy. For large stones 
suprapubic section, thus avoiding sterility. 
(b) In adult life—Litholapaxy. If stone resists 
crushing use suprapubic lithotomy. 
(c) In old age—Suprapubic section, in two stages 
(p. r. n.). 
XIII. —Possible accidents in litholapaxy: 
{a) Rupture of bladder, 
(b) Nipping of bladder, 
(r) Fastening of one jaw in a pocket or sacculus, 
id) Laceration of urethra, 
(e) Impaction of fragments in urethra, 
(/) Clogging or breaking of lithotrite. 
V.—THE KIDNEYS AND URETERS. 
I. —Malformations: 
(a) Single kidney 1-4,000. 
(Ib) Horseshoe kidney, 
(r) Floating kidney, 
(d) Movable=result of traumatism, e.g., tight 
lacing, parturition. 54 
11. —Examination of the kidneys. Bimanual best. 
1. Position. If felt below ribs, it is either movable 
or enlarged. 
2. Ballottement. If present, indicates enlarged or 
movable kidney. 
3. Cystoscope and exploratory incision sometimes 
necessary. 
4. Thompson’s method of examination, (good). 
5. Relations to colon. Determined by distending 
it by air. 
111. —lnjuries of kidney and ureter: 
1. Contusions, 
2. Lacerations, 
3. Gunshot and other wounds = urinary fistula, 
4. Division of ureter (e.g., in gynecology. Suture 
of ureter), 
5. Movable kidney (enteroptosis). 
IV. —Suppuration in the kidney: 
1. Synonyms —l. Pyelitis, 
2. Pyelo-nephritis, 
3. Pyonephrosis. 
2. Due principally to: 
(a) Injury, 
\ / J J 7 
Cb) Stone and 
other ob- 
structions 
' 1. Urethral stricture, 
2. Prostatic hypertrophy, 
3. Ureteral kinking, 
4. “ stricture. 
(1c) Infection 
1. Common, 
2. Special, e.g., tuberculosis. 
(Multiple abscess of kidney=interstitial 
suppurative nephritis). 
V.—Stone in the kidney: 
I. Results in—l. Pyelitis, 
2. Pyelonephritis, 
3. Hydronephrosis, 
4. Perinephritis. 55 
2. Symptoms—l. Unilateral pain, 
2. Renal (kidney) colic, 
3. Hemorrhage, 
4. Changed urine | test> 
5. Renal tenderness, 
6. Renal crepitus (?) 
7. X-ray examination, 
8. Pus (pyuria), 
3. Diagnose in exploratory examination by 
1. Palpation of kidney and exposed 
ureter. 
2. Needle, 
3. Incision, 
4. Sounding of ureter. 
3. Surgical treatment of stone: 
1. Nephrotomy, 
2. Nephrolithotomy, 
3. Nephrectomy, 
4. Ureterotomy. 
VI. —Renal abscess: 
Symptoms: 
1. Enlargement of kidney—Aspiration (?) 
2. Purulent urine, 
3. Constitutional effects. 
Treatment: Nephrotomy. 
Hunt for multiple nephritic abscess. Primary 
or if possible secondary nephrectomy. 
VII. —Hydronephrosis: 
Due to obstruction, always mechanical and usually 
without septic inflammation. 
Caused by: 1. Kinking of ureter from movable kid- 
ney, 
2. Stone or stricture in ureter, 
3. Pressure on ureter, e.g., tumor in 
bladder or pelvis, 
4. Congenital or acquired stenoses or 
valves. 56 
Symptoms: 
1. Unilateral, painless tumor, 
2. Contents under aspiration either urinary or 
free from urinary salts, 
3. Don’t seriously effect health. 
Treatment: 
1. If small, and obstruction is accessible, uret- 
eral anastomosis. 
2. If large, remaining kidney substance is use- 
less, hence nephrectomy. 
VIII. Tumors of kidney: 
A. Congenital —l. Sarcoma, 
2. Cystic disease, 
3. Hydronephrosis, 
4. Cavernous tumors—rare. 
B. Extra renal —l. Abscess—secondary, 
2. Cysts, 
3. Myxolipoma—rare, 
4. Adrenal tumors. 
C. Renal pelvis —l. Hydronephrosis, 
2. Villous growths, 
3. Carcinoma. 
1. Hydatid cyst, 
2. Tuberculosis, 
3. Lymphadenoma—rare, 
4. Syphilis—rare, 
5. Lipoma—rare, 
6. Sarcoma, 
7. Adenoma, 
8. Carcinoma, 
9. Secondary growths. 
D.—Glandular or from 
renal substance. 
Special symptoms : 
1. Capricious hemorrhage, 
2. Rapid growth of tumor, 
3. Unusual general deterioration, 
4. No temperature elevation. 
Treatment : 
Nephrectomy, except for multiple cystoma. 57 
IX. —Symptoms generally common to : 
I. Calculus, 2, chronic suppurative inflammation, and 
3, tumors, are 
{a) Hemorrhage, 
{b) Purulent urine, 
(c) Renal enlargement in 2) or 3). 
Conjoin to this history of 
{a) Renal colic = calculus. 
{b) Chills and fever = pus. 
ic) Presence of tubercle bacilli 
Without these = cyst or neoplasm. 
X, Operations on the kidney : 
1. Nephrorrhaphy = stitching to abdominal wall. 
For movable kidney ; 30 percent, mortality ; 
20 per cent, failures. 
2. Nephrotomy = incision and suture. For injury, 
calculus, hydronephrosis (?), cysts, abscess, 
exploratory incision. 
3. Nephrectomy = removal of kidney. For tumors, 
persistent renal disorganization, renal or 
ureteral fistulas, abscess, calculi (?), large 
hydronephrosis. 
Mortalities:—3B per cent, Newman, in 324 
nephrectomies. 
28 per cent. Weir; in 25 cases, 10 per cent, mor- 
tality ; in last 6 cases, no deaths, 
4. Ureteral anastomosis : 
For wounds, strictures or valves, kinkings 
and in hydronephrosis with moderate dilata- 
tion. 
Methods of nephrectomy : 
By incision, 1. Lumbar, 
2, Abdominal, 
Direct or transperitoneal. 
VI.—THE SCROTUM AND TESTES. 
I.—Surgical diseases of the scrotum : 
1. Sebaceous cyst, 
2. Erysipelas, 58 
3. Gangrene (urinary infiltration), 
4, Elephantiasis, 
5. Tumors, (a) Cysts, 
Simple. 
Dermoid. 
(b) Lipomata, or fatt}r tumors. 
from soot, 
“ paraffin, 
“ coal-tar prod- 
ucts. 
(c) Epithelioma, 
11. —lnjuries of testes and cord; 
1. Hematocele, 
2. Rupture (?) of vas deferens, 
3. Spasm of cremaster muscle. 
111. —Anomalies of the testes : 
1. Absence of testes, 
2. Supernumerary testes, 
3. Hypertrophy of testes, 
4. Atrophy of testes (from injury or metastatic in- 
flammation, e.g., mumps), 
5. Maldescent of testes, 
One absent = monorchid, 
Both absent = cryptorchid. 
Varieties ; In abdomen, 
In canal, 
At external ring, 
In perineum, 
With or without 
hernia. 
IV.—Diseases of testes and cord : 
1. Epididymitis, 
2. Epididymo-orchitis, 
Simple, 
Gonorrhoeal, 
Tubercular. 
3- Orchitis (hernia of testis), 
4. Hydrocele, 
5. Spermatocele, 
6. Varicocele, 
7. Neuralgia of testis (irritable testis), 
8. Rotation and strangulation of testis. 
9. Tumors, 
(a) Cystic, 
{b) Dermoid, 59 
(c) Enchondroma, 
{d) Lipoma, 
(i?) Fibroma, 
(/) Sarcoma, 
{g) Carcinoma. 
V. —Hydrocele : 
{a) Of the cord, 
(b) With congenital hernia, 
(c) Encysted, 
{d) Of the scrotum. 
Treatment : 
By i. Acupuncture, 
2. Tapping, 
3. Injection (tinct. iodine or carbolic acid), 
4. Incision (Volkmann’s method), 
5. Excision of tunica vaginalis (Bramann’s 
method), 
6. Ligation of funicular portion of peritoneum in 
congenital hydrocele. 
VI. —Spermatocele: 
From foctal relics: 
1. Organ of Giraldes, 
2. Hydatids of Morgagni, 
3. Vasa aberrantia, 
4. Epididymal cysts. 
1, 3, 4 derived from Wolffian body and 2 from 
Muller’s duct. 
Treatment: 
1. Injection (half full syringe, tincture of 
iodine), 
2. Extirpation (when large). 
VII. Varicocele: 
Treatment: 
1. Palliative, by (1) Suspensory bandage, 
(2) Truss, 
2. Operative, (1) Ligature of veins, 
(2) Excision (leave veins of vas), 
(3) Ablation of scrotum, with 
excision. 60 
VIII,—Impotence and sterility in the male: 
A. —lmpotence: 
1. Organic = malformations or injuries of the 
penis and testes. 
(a) Radical amputation, 
{b) Castration (double), 
{c) Malformations or atrophy of testes, 
(d) Double hernia, 
{e) “ hydrocele, 
{/) Old cryptorchids. 
2. Symptomatic = due to drugs, etc, 
{a) Tobacco, 
(b) Bromides, 
{c) lodides, 
{d) Camphor, 
(e) Conium, 
(/) Opium, 
(g) Alcohol, etc. 
3. Atonic = impaired genital spinal center, or 
impaired cerebral nerve cells. 
Due to (a) Age, 
(b) Sexual excess, 
(c) Prostatorrhea, 
{d) Masturbation, 
{/) Stricture. 
4. False or psychical impotence: 
Due to (a) Doubt, 
(b) Emotions, 
(c) Irregular conditions. 
B. —Sterility: 
1. Azoospermia ===== absence of spermatozoids. 
{a) Stricture of urethra, 
{b) Phimosis. 
2. Dyspermia = abnormal condition of semen. 
3. Aspermia = absence of semen. 
(a) Obstruction of ejaculatory duct, 
{b) Failure of seminal vesicles to contract, 
(c) Anaesthesia of glans penis, 
4. Mal-emission, 
5. Hypochondriasis. 61 
IX.—Spermatorrhea=involuntary discharge of semen. 
1. Azoospermia = emission but no spermatozoids. 
{a) Spermatozoids inactive or dead, 
(b) “ not formed, in old cryptor- 
chids, 
(c) “ formed, but not ejaculated 
from vas owing to epidi- 
dymitis, traumatism or 
double hydrocele, 
(.d) “ not formed in diseased 
testes, 
{e) Advanced spermatorrhea or vesiculitis. 
2. Mai-emission : 
(a) Hypospadias or epispadias, 
(b) Radical amputation of penis. 
SECTION lII.—THE HEAD. 
I—THE SCALP. 
1. Diseases, etc.; 
(a) Sebaceous tumors, 
(b) Fatty tumors, 
{c) Warts, wens and horns, 
{d) Wounds (erysipelas and necrosis). 
2. Contusions of the head : 
1. Affecting scalp and cranium, 
(a) Hematoma, 
ib) Osteomyelitis (Pott’s puffy tumor). 
2. Complicated with cerebral injury. 
II.—CONCUSSION AND COMPRESSION OF 
THE BRAIN. 
I. Concussion of the brain : 
(a) Contusion of the brain, 
(b) Laceration of the brain, 
if) Cerebral hemorrhage, 
id) Lesions local or remote—“ Centre coup.” 62 
2. Compression of the brain : 
{a) Immediate, e.g., 
) Depressed bone, 
[ Foreign bodies. 
Ib) Early and progressing=Extravasated blood. 
(c) Late=Pus. 
(d) Tumors, 
Symptoms: 
Concussion, 
Stupor, partial and di- 
minishing 
Pulse, feeble, often rapid 
Breathing, natural or 
sighing 
Surface, cold 
Muscles, relaxed 
Restlessness 
Vomiting 
Compression, 
Complete and increasing, 
Full and slow, 
Stertorous, 
Warm, 
Natural, 
Paralysis, 
Convulsions. 
Treatment of Concusssion: Rest, cold to head, warmth 
to extremities, Bromides, etc. 
Treatment of Compression : Trephining, 
Compression from fracture, immediate (always ex- 
plore). 
“ “ foreign bodies, immediate. 
“ “ blood, early and progressive. 
“ “ pus, localized or diffused, late. 
“ “ tumors (pathogenic) slowly pro- 
gressing. 
“ otitic abscess, usually slow, oc- 
casionally rapid. 
Traumatic coma differentiated from : 
I. Alcoholic stupor by 
{a) Temporary dilatation of pupils on being 
aroused (reliable, Macewen), 
(h) Alcohol in urine, 
(r) Effects on pressure over supra-orbital nerve 
(alcoholic will respond), 63 
(d) Pulse not retarded, 
[e) (General appearance, dress, odor of breath?) 
2. Opium stupor by 
(a) Slow respiration, 
{b) Persistently contracted pupil. 
3. Urcemic stupor by 
(a) Albumin and casts in the urine, 
{b) Ophthalmoscope, 
Often difficult between 1 and 3. 
lII.—FOREIGN BODIES IN THE BRAIN. 
Orbital wounds most fatal. 
Gunshot wounds of the brain : 
Auditory meatus, 5 cases, all dead. 
Bullet left in =54 per cent, mortality. 
Sixteen subsequently had brain symptoms. 
Bullet removed =33 per cent, mortality. 
Determined by 
Fluhrer’s probe, Bryant’s method, 
Electric probe, 
X rays—2 pictures at different angles. Good for 
metals, not for bone. 
0/316 cases ( Wharton): 
210 bodies not removed, 88 recovered. 
106 bodies removed, 72 recovered. 
10 per cent, of recoveries died 3 to 15 years later 
with brain symptoms. 
IV.—FRACTURES OF THE SKULL. 
A. Varieties : 
1. At vault or base, 
2. Direct or indirect, 
3. Simple or compound, 
4. Fissured or depressed, 
5. Punctured and gunshot. 
B. Complications : 
1. Concussion of brain, 
2. Laceration “ 
3. Compression “ 64 
4- Meningitis, 
5. Encephalitis, 
6. Hernia cerebri, 
7. Septicemia, 
8. Pyemia, 
9. Sinus thrombosis. 
RULES. Remember! 
When in doubt with brain symptoms, explore ! 
In every compound fracture with depression, 
trephine ! 
C. Mechanism of basal fractures : 
1, In direct violence the fissure usually runs from 
trauma to base by the nearest route, e.g., 
1. In frontal region, to anterior fossa (subcon- 
junctival ecchymosis), 
2. In parieto-temporal region, to middle fossa, 
3. In occipital region, towards foramen mag- 
num (mastoid ecchymosis), 
2. In indirect violence, e.g., from a fall or crush, note 
that when compressed antero-posteriorly, 
skull alters shape most and determines 
usually a transverse fracture, and vice versa. 
D. Symptoms: Like laceration of the brain. 
1. More or less unconsciousness, with or without 
severe paralysis, 
2. Argyll-Robertson or Hutchinson’s unilateral 
pupil, 
3. Altered respiration, 
4. Hemorrhage or fluid from ear, nose or pharynx. 
Bleeding (if found) may be due to : 
(a) Ruptured membrana tympani, 
{b) Fracture through petrous bone (generally due 
to oblique or antero-posterior fracture). 
Serum may arise from : 
(a) Cerebro-spinal fluid (rich in chlorides, some- 
times sugar, no albumin), 
([b) Serum from clot, 
(r) Mucous membrane of the middle ear. 65 
E. Treatment of basal fractures: 
1. Mainly expectant and as far as possible aseptic• 
occasionally surgical, with removal. 
(Usual treatment for ordinary cases, wash out 
with antiseptic, then H2 Os, then loosely 
pack with iodoform gauze for drainage and 
to give blood room to escape). 
V.—CEREBRAL ABSCESS. 
A. Etiology: 
1. Acute or chronic purulent ear inflammation (50 
per cent.), 
2. Traumatism, 
3. Tubercular foci, etc., 
4. Localized meningitis, 
5. Metastasis, e.g., pneumonia, etc. 
B. Site in g8 cases: 
1, In temporal lobe 40 times, 
2, “ cerebellum 31 “ 
3, Elsewhere 27 “ 
Result of operations: 30 cases = 15 recoveries. 
Macewen; 11 cases = 10 recoveries. 
C. Symptoms: 
From —l, Suppuration: 
{a) Diminished otorrhea, 
{b) Rigors and moderate temperature eleva- 
tion. 
From—2. Pressure: 
{a) Headache and pain, 
{b) Localized tenderness, 
(c) Nausea and vomiting, 
{d) Nerve (111, VI, VII) paralysis (aphasia 
mono- and hemi-plegia ; late), 
(e) Hebetude, stupor, mild delirium, 
{/) Pulse and respiration changes; late. 
In 10 abscesses in temporo-sphenoidal lobe, 9 re- 
covered (Macewen), 66 
VI—CEREBELLAR ABSCESS. 
Symptoms— O bscu re. 
(a) Occipital headache, 
{b) Rigidity of neck muscles, 
(e) Expulsive vomiting, 
(d) Vertigo, muscular incoordination if middle lobe 
is involved. 
In 8 operations, 4 recoveries (Macewen); 
VII.—LATERAL SINUS ABSCESS. 
Symptoms ; 
{a) Rapid pulse, 
(b) High fluctuating temperature, 
(c) Repeated chills, 
(d) Delirium, 
(e) Suppuration at mastoid foramen, 
(/) Thrombosis of jugular vein, 
(g) Pleuritic and pulmonary complications. 
Operations : 
1. Trephining to open sinus and abscess (Lane, 
1889), 
2. Also to ligate jugular vein to prevent lung infec- 
tion (Ballance, 1890), 
17 cases, 13 deaths (Macewen). 
VIII RULES FOR TREPHINING. 
1. For meningeal hemorrhage : 
(a) Two inches above middle of zygoma, 
(b) Intersecting line from posterior edge of 
mastoid and from upper edge of orbit. 
2. For mastoid suppuration : 
One-quarter inch behind and \ inch above audi- 
tory opening. Note : Keep close to auditory 
canal for antrum. 
3. For otitic extra-diiral abscess: 
Enlarge No. 2 upwards and forwards (by for- 
ceps or trephine). 67 
4. For otitic cerebral abscess : 
One and one-quarter inches behind and ip 
inches above auditory opening. 
Note; Explore in the line of the opposite ala 
nasi. 
5. For otitic cerebellar abscess : 
One and one-half inches behind auditory open- 
ing and \ inch below it. Note: Explore for- 
wards, upwards and inwards. 
6. For sinus abscess and infectious suppurative menin- 
gitis ; 
One inch behind and \ inch above auditory 
opening. 
7. For tapping the ventricles : 
Same as No. 4. Note: Explore to the depth of 
2 to 2\ inches in aline 2\ to 3 inches above 
opposite aural opening. 
IX.—BRAIN TUMORS. 
A. Varieties— (580 cases collected by Drs. Weir 
and Seguin). 
Sarcoma or glioma 28 per cent., 
Tubercular (multiple or consecutive).. 23 per cent., 
Hydatid or other cystoma 9 per cent., 
Carcinomata and consecutive 4 per cent., 
Gummata .--82 Per cent., 
Fibromata 1 per cent. 
Only 10 per cent, could have been removed. 
Only 5 per cent. (Dana) or 6 per cent. (Starr) could 
be diagnosed. 
B. Symptoms:— 
{a) Headache, 
(0 Increasing stupor, 
(r) Convulsions, 
(,d) Choked (optic) discs, 
(e) Slow pulse, 
(/) Aphasia, 
(g) Hemianopsia, 
(/'1) Apraxia, 
{i) Alexia, 68 
C. Diagnosis should include 
(a) Existence of tumor, 
{&) Location, 
(r) Depth, 
{d) Numbers, 
{e) Nature, 
(/) Size. 
D. Surgical treatment : 
In 87 operations = per cent, mortality. 
Of 74 cerebral, 45 recovered. 
In 57 tumor found and removed, 38 recovered, 19 
died = 33 per cent, mortality. 
Of 13 cerebellar, n died == 84 per cent, mortality. 
E. Medical treatment : 
If tumor be syphilitic or supposed to be so, give 
enormous doses of KI. 
F. Localizing symptoms : 
(a) Invading paralysis, spreading from part to 
part, and constantly increasing, is an im- 
portant sign. 
(b) Jacksonian epilepsy is very important, if con- 
nected with signal symptoms. 
(c) Slow pulse, aphasia and hemianopsia are not 
infallible. 
{d) Hemianopsia generally points to a lesion be- 
hind the chiasm. 
X.—APPLICATIONS OF TREPHINING. 
1. Traumatism ; 
{a) Depressed fractures of the skull, 
if) Meningeal and intracranial hemorrhage, 
{c) Extra-dural and sub-dural abscess, 
{d) Epilepsy (?) (note dural sensitiveness), 
{e) Suppurative meningitis. 
2. Disease: 
{a) Ear suppuration, 
1. Mastoid abscess, 
2. Extra-dural abscess, 69 
3. Cerebral or cerebellar abscess, 
4. Lateral sinus abscess, 
5. Lepto-meningitis. 
{b) Tumors (removable and non-removable), 
(c) Jacksonian epilepsy (10 percent, mortality), 
(d) Inveterate localized headache, 
(e) Pachymeningitis hemorrhagica, 
{/) Hydrocephalus and distension of ventricles, 
(y) Microcephalus and idiocy (?), 
{h) Insanity and general paralysis (?), 
(i) Severe and progressive apoplexy (?). 
XI.—NEURALGIA OF THE FIFTH NERVE. 
(Neurotomy of the trigeminal nerve). 
1. Second branch : 
(a) Carnochan’s method, 
[b) Linhart’s “ 
(r) Langenbeck’s “ 
2. Third Brandi: 
(a) In the mouth (Paravicini), 
(b) At angle of jaw (Gross), 
(c) Above zygoma (Salzer), 
{d) In cranium (Hartley and Horsley). 
A. Carnochan s operation: 
Make an opening in and at back part of an- 
trum. Break through the wall, and cut 
nerve at foramen rotundum. 
B. —Langenhcck's operation: 
Pass a tenotomy knife above floor of orbit, fol- 
lowing the nerve backwards, and cut at fora- 
men rotundum. (This is a blind method and 
is not advisable.) 
C. —Paravicini’s operation: 
Aims to cut inferior dental nerve at dental 
foramen, conducting the operation through 
the mouth. 70 
D. —Salzer s operation : 
Cut through and depress zygoma. Divide 
nerve at foramen rotundum and foramen 
ovale. 
E. —Hartley s operation : 
Trephine an oval bone flap in zygomatic region, 
remove Gasserian ganglion outside of dura. 
Horsley goes inside dura. 
SECTION IV.—DISEASES OF THE 
THYROID GLAND. 
I. Circulatory Disturbances: 
(a) From venous compression, 
menstruation, 
lactation. 
/7\ T7* 
(i) From neuroses, g., 
2. Inflammations: 
Abscess, local or distant infection. 
3. Tubercle 
4. Hydatids 
rare—usually secondary, 
5, Hyperplasia or true goitre: 
(a) Parenchymatous, 
{b) Follicular, 
(c) Vascular; Basedow’s or Grave’s disease. 
6, Neoplasms with or without hyperplasia: 
(a) Fibroma, 
(b) Cystoma, 
{c) Adenoma, 
(d) Sarcoma, 
{e) Carcinoma. 
Unusual forms: 
1. In accessory thyroids (tongue), 
2. Around trachea, 
3. Retro-sternal, 
4. Within trachea. 
Effects on trachea, oesophagus, nerves and veins. 
Diagnosis, movement in deglutition. 71 
Treatment: 
1. Non-operative: 
(a) Thyroid feeding and 
(b) Electricity. 
2. Operative: 
{a) Repeated injection of iodoform (emulsion) 
or iodine, 
(b) Partial resection, 
{c) Enucleation for cysts (avoid hypodermic 
puncture), 
(d) Ligation of superior and inferior thyroid 
arteries, 
(e) Thyroidechthesis, 
(/) Removal of cervical ganglia of sympathetic. 
For hyperplasia: 
Use 1. Thyroid feeding, 
2. Injections of iodoform or iodine, 
3. Partial resection, or 
4. Ligation of thyroid arteries ? 
For tumors: 
Use 1. Enucleation or 
2. Partial resection. 
SECTION V—THE LARYNX AND 
TRACHEA. 
1. Sub-hyoidpharyngotomy : 
(.a) For small neoplasms in pharynx and larynx. 
{b) For fixed foreign bodies in pharynx and larynx. 
2. For sub-hyoid bursitis {?). Better to inject with 
melted paraffin and dissect out when hardened. 
3. Thyrotomy, or laryngo-fissure : 
For intra-laryngeal growths and fixed foreign 
bodies (notch thyroid to insure exact repo- 
sition). 72 
4. Tracheotomy, including laryngotomy : 
(a) For obstruction in acute injiammmation, 
as i. CEdema of glottis, 
2. Acute laryngitis, burns and scalds, 
3. Croup, diphtheria, 
(b) For non-inflammatory obstruction : 
1. Foreign bodies in larynx, trachea and 
bronchus, 
2. For malignant disease, 
3. “ cicatrical stenosis, 
4. “ stenosis from external pressure, tumor 
or abscess. 
(c) For obstruction of nerve origin : 
1. Spasms of larynx, 
2. Double adductor paralysis, 
(a) Cervical tumors, 
if) Thoracic aneurism, 
(d) For pain fid ulceration of larynx : 
E.g., syphilis or tuberculosis; to give relief or 
rest to the parts. 
(e) Preliminary to other operations in or near upper 
air-passages, e.g., tongue extirpation etc. 
(/) For fracture of the larynx. 
Tracheotomy is divided into 
1. Crico-thyroid laryngotorny, 
2. Supra-thyroid tracheotomy, 
3. Infra- “ “ 
5. Laryngectomy or extirpation of the larynx. (Avoid 
cardiac nerves, shutoff pharynx ; artificial larynx).