THE 
PRINCIPLES AND PRACTICE 
m 
OF 
SURGERY, 
BEING 
A TREATISE ON SURGICAL DISEASES AND INJURIES. 
BY 
D. HAYES AGNEW, M.D., LL.D, 
/»l 
PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF PENNSYLVANIA. 
PROFUSELY ILLUSTRATED. 
SECOND EDITION—THOROUGHLY REVISED, WITH ADDITIONS. 
IN THREE VOLUMES, 
v VOL. I. 
/ PHILADELPHIA: 
—*" J. B. LIPPINCOTT COMPANY. 
LONDON: 10 HENRIETTA STREET, COVENT GARDEN. 
1 88 9. Copyright, 1878, by J. B. Lippincott & Co. 
Copyright, 1889, by J. B. Lippincott Company. PREFACE TO THE FIRST EDITION. 
The present volume is the first part of a work on the “Principles and 
Practice of Surgery.” 
For a quarter of a century I have been unceasingly occupied with the 
study of anatomy and surgery, and during most of that time have been 
actively engaged, as a public instructor, in communicating the great teach- 
ings of these closely-allied branches, in the hospitals of Philadelphia and 
in the halls of the University of Pennsylvania, to thousands of young men 
from all parts of the United States and to many from foreign countries. 
Most of the pages have been written, not in what may be termed moments 
of leisure, but during the hours of the night,—hours stolen from the time 
usually allotted to the repose of body and mind, and after the daily labors 
of an exacting public and private practice. 
In the composition of its pages, while I have expressed my own views 
independently on all subjects, I have also endeavored, as far as was con- 
sistent with the scope and limits of the work, to record those of other 
writers, not only that the student and the practitioner may be made 
familiar with the literature of their profession, but also that they may 
be able in their observation and practice to contrast different plans of 
treatment, and in this way draw their own conclusions in regard to the 
relative merits of the various modes of managing surgical disease. What- 
ever may be the defects of the work,—and none can be more sensible of 
these than myself,—I have endeavored most conscientiously to furnish a 
safe and reliable guide for the surgical practitioner. 
To Drs. Willard, Hunter, White, Muhlenberg, Haynes, Alison, Griffiths, 
Abel, and others, I am under obligations for valuable assistance rendered 
me in the collection of statistical information, and to Drs. Willard and 
\\ hite for a careful revision of the proof-sheets while the work was passing 
through the press, and for the preparation of the index. 
I have also to acknowledge the kindness of the Surgeon-General of the 
United States Army in allowing me the use of a number of wood-cuts. 
A large number of the illustrations have been executed from original 
drawings by Mr. Faber, while those which have been used from other 
writers I have, whenever able, referred to their proper source. I am also 
indebted to Mr. Gemrig and Mr. Kolbe, surgical cutlers of Philadelphia, for 
many cuts of instruments and other surgical appliances. 
D. HAYES AGKEW. 
1611 Chestnut Street, Philadelphia. PREFACE TO THE SECOND EDITION. 
The favorable reception accorded to the first issue of this work on the 
“ Principles and Practice of Surgery” has rendered it necessary to prepare 
a second edition, in doing which the order of subjects has been somewhat 
changed from that followed in the earlier work. Certain chapters have 
been transposed, others have been partly rewritten, and all have been care- 
fully revised and illustrated. During the last few years a spirit of extraor- 
dinary vitality has pervaded every department of medicine, and in none has 
it been more active than in that of surgery. The author, during these years, 
has not been an idle spectator, but has carefully watched all that was occur- 
ring within the domain of his own special study, and in the present treatise 
on surgery he has embodied whatever, by observation and experience, ap- 
peared to him worthy of professional confidence. The great advance, that 
which constitutes the most notable surgical feature of the century, is the 
doctrine of asepsis, based on the presence of micro-organisms as the leading 
causes of inflammation and its products. To this must be attributed the 
splendid achievements wrought in abdominal, pelvic, and cerebral surgery, 
as well as in the management of wounds in general. Early committed to 
the parasitic theory of disease, and adopting methods of practice in harmony 
with its acceptance, every year, with enlarging experience, has but served 
to strengthen the author’s faith in the value of germicidal agents. So com- 
pletely, indeed, has this doctrine revolutionized old plans of treatment, that 
the medical statistician must begin anew to collect and formulate surgical 
data in order to arrive at trustworthy conclusions. 
The author desires to express his indebtedness to Mr. Joseph McCreery 
for his very careful and critical revision of the proof-sheets of the work 
while passing through the press. 
If these volumes, on a branch of medicine to which the author has fondly 
devoted his life, shall prove useful to his professional brethren, or serve to 
enlighten and instruct the student of medicine, his highest ambition will 
have been realized. 
D. HAYES AGNEW. 
1601 Walnut Street, Philadelphia. CONTENTS OF VOLUME I. 
CHAPTER I. 
SURGICAL DIAGNOSIS. 
PAGE 
The Ground-Work of Diagnosis—Factors concerned—Modes of investigating Disease 
—General Inquiries—Age—Sex—Occupation—Habits—Mental and Moral States— 
Antecedent History—Individual or Personal History—Temperament—Social Con- 
dition—Residence—Personal Knowledge of the Patient by others—Duration of 
Symptoms—Knowledge acquired by the Senses—Attitude—Surface Expression— 
Mensuration — Form — Color — Translucency — Muscular Movement — Sounds— 
Touch—Consistence—Movement—Weight—Exact Form—Temperature—Smell— 
Examination of the Internal Organs—Circulation—Thermometry—Respiration— 
Nervous System — Intelligence — Sensation—Pain — Motility—Loss of Power— 
Digestive Apparatus—Genito-Urinary Apparatus 25 
CHAPTER II. 
ANTISEPSIS. 
The Seminal Thought of Antisepsis—Early Observations—Occlusion of Air—Ex- 
periments—Relation of Micro-Organisms to Fermentation — Modus Operandi of 
Micro-Organisms—Permanant Position of Antiseptic Surgery—General Description 
of Bacteria in Surgical Diseases—Micro-Organisms in the Arts—Manner of entering 
the Body—Sepsin—Relation between Bacteria and Disease—Germicides—Prepara- 
tion of Materials generally used in Aseptic Surgery—Carbolic Acid—Bichloride of 
Mercury—Sterilized Water—Chloride of Zinc—Sponges—Basins—Towels—Car- 
bolized Catgut—Silver Wire and Silk-Worm Gut—Carbolized Silk Thread—Car- 
bolized Gauze—Corrosive Sublimate Gauze—Sawdust, Moss, and Peat Dressings— 
Protective—Mackintosh Cloth —Absorbent or Salicylized Cotton — Iodoform— 
Rollers—Nail-Brush—Pins—Alcohol, Turpentine, and Ether—Spray-Apparatus— 
Application of Antiseptic Methods to Operation—Surgeon and Assistants—Guard- 
ing the Person of the Patient—Disinfection and Arrangement of Instruments . 43 
CHAPTER III. 
SURGICAL DRESSINGS. 
Lint — Patent Lint — Charpie — Pellets — Tents — Bullets — The Mesh—Pledget— 
Oakum—Paper Lint—Waxed Paper—Oiled Silk—Rubber Cloth—Compresses—Re- 
tractors—T Bandages—Slings—The Roller Bandage—Special Rollers—Spiral Re- 
versed—The Spica—Head Bandages—Recurrent Bandage for Amputations—Breast 
Bandages—Velpeau’s Bandage—Provisional or Handkerchief Dressings . . 62 
CHAPTER IV. 
INFLAMMATION. 
Varieties of Inflammation—Healthy—Unhealthy—Acute—Chronic—Causes of In- 
flammation—Predisposing Causes—Exciting Causes—External—Internal—Exten- 
sion of Inflammation—Acute Inflammation—Local Symptoms—Change of Color— 8 
CONTENTS OF VOLUME I. 
. . . PAGE 
Swelling—Heat—Pain—Alteration of Function—Constitutional Symptoms—In- 
flammatory Fever and its Effects—Nature of Inflammation—History of the Causes 
and Nature of Inflammation—Nerve-Agency in Inflammation—Terminations of 
Inflammation—Treatment of Inflammation—Local Treatment—Position—Cold— 
Heat—Fomentations—Steaming—Blood-Letting—Compression—Counter-Irritants 
—Antiseptics—Constitutional Treatment—Blood-Letting—Depressants—Diapho- 
retics—Diuretics—Cathartics—Mercurials—Anodynes—Tonics^—Stimulants—Diet 
—Hygiene—Chronic Inflammation—Symptoms—Causes—Pathology—Treatment 
—Effects or Results of Inflammation—Liquor Sanguinis—Serous Exudation— 
Fibrinous Exudation—Transudation of Blood — Suppuration—Pus—Varieties— 
Diagnosis of Pus—Origin of Pus—Theories of Suppuration—Causes of Suppuration 
—Tissues involved—Absorption of Pus—Signs of Suppuration—Pointing—Fluc- 
tuation—Constitutional Signs of Suppuration—Differential Diagnosis of an Abscess 
—Divisions of Suppuration—Superficial—Diffused—Circumscribed—Treatment of 
Diffused Suppuration—Circumscribed Suppuration—Acute or Phlegmonous Ab- 
scess—Symptoms—Pathology—Treatment—Chronic or Tuberculous Abscess—Con- 
stitutional Symptoms—Prognosis—Treatment—Aspiration—Ulceration—Causes— 
Pathology—Location—Repair in an Ulcer—Cicatrization—Ulcers—Simple Ulcer— 
Complicated Ulcers—Ulcers with Excess of New Formation—Ulcers with Deficient 
New Formation—Chronic or Indolent Ulcers—Treatment—Skin-Grafting—Man- 
ner of Performing—Ulcers from Internal or Constitutional Causes—Ulcers from 
Defective Innervation—Perforating Ulcer—Mortification—Synonymes—External 
Causes—Internal Causes—Inflammatory Obstruction—Thrombosis—Circular Gan- 
grene—Diseased Conditions—Venous Obstruction—Varieties of Mortification— 
Acute Mortification—Separation of the Dead from the Living—Amputation— 
Chronic Mortification—Senile Mortification—Hospital Mortification—History of 
Hospital Mortification 89 
CHAPTER Y. 
WOUNDS. 
General Considerations—Varieties of Wounds—Indications in the Treatment of 
Wounds—Hemorrhage—Nature’s Method for the Control of Hemorrhage—Closure 
of Vessels — Formation of the Thrombus — Changes in the Thrombus—Treat- 
ment of Hemorrhage from Wounds—Haemostatics—Vital Haemostatics—Chemico- 
Vital Haemostatics—Mechanical Means—Position—Digital Compression—Com- 
presses—Tourniquet—The Actual Cautery—Galvano-Cautery—Paquelin’s Thermo- 
Cautery—Torsion—Arterio-Version—Acupressure—Circumclusion — Torsoelusion 
—Retroclusion—Forci-Pressure—Artery Forceps—Ligatures—Materials used— 
Form of Knot—Animal Ligatures—Metallic Ligatures—Comparison of Haemo- 
statics—General Treatment of Hemorrhage—Transfusion—Removal of Foreign 
Bodies from Wounds—Drainage—The Approximation of Wounds—Position— 
Rollers—Compresses—Plasters—Collodion — Sutures — Interrupted—Continued— 
Twisted—Quilled—Button or Relaxing—Rubber—External Dressings—Renewal 
of Dressings—Open Treatment of Wounds—Pneumatic Aspiration—Constitutional 
Treatment—Complications—Inflammation—Persistent—Suppuration—Erysipelas 
—Diphtheritic Deposits—Mortification—Hemorrhage—Muscular Spasms—Sinuses 
—Maggots—Incised Wounds—Lacerated Wounds—Contused Wounds—Results of 
Contusions—Punctured Wounds—Poisoned Wounds—Dissection or Post-Mortem 
Wounds—Varieties — Local—Constitutional — Anatomical Tubercle — Malignant 
Pustule—Occurrence in Man—Pathology—Foot and Mouth Disease—Glanders, or 
Farcy—In Animals—In Man—Equinia Mitis—Hydrophobia—In Animals—Causes 
—Symptoms—Varieties—In Man—Incubation Period—Symptoms—Pathology— 
Diagnosis—Treatment—Poisons derived from Arachnidans and Reptiles—Spiders— 
Scorpions—Tarantulas—Centipedes—Snake-Bites—Poisons derived from Insects— 
Gunshot Wounds—Character of Arms and Projectiles—Rifle-Balls—Cannon-Balls 
—Shells—Grape-Shot—Canister-Shot—The Effect of a Change of Form of the Ball 
and the Momentum on the Tissues—Openings of Entrance and Exit—Change 
which the Ball undergoes after leaving the Gun—Character of Gunshot Wounds— 
Local Symptoms—Primary and Secondary Hemorrhage—Constitutional Symptoms 
—Prognosis—Provisional and Permanent Treatment—Relief of Shock—Arrest of 
Hemorrhage—Removal of Foreign Bodies—Local and Constitutional Treatment— 
Secondary Hemorrhage—Amputation and Excision in Gunshot Wounds—General 
Rules—The Shoulder-Joint—The Arm—The Elbow-Joint—The Forearm—The 
Wrist-Joint—The Hand—The Thigh—The Hip-Joint—The Knee-Joint—The 
Ankle-Joint—Gunshot Fractures of the Bones—Excisions in the Continuity of the 
Bones of the Leg—Sabre Wounds—Healing of Wounds—Immediate Union—Ad- CONTENTS OF VOLUME I. 
9 
PAGE 
hesive Inflammation—Granulation—Union of Granulations—Scabbing—Union 
through Granulation-Tissue—Ulceration of Cicatrices—Keloid—Unhealthy Cica- 
trization—Contraction of Cicatrices *" . 214 
CHAPTER VI. 
INJURIES OF THE HEAD. 
General Considerations—Injuries of the Scalp—Surgical Anatomy of the Scalp— 
Contusions—Wounds—Gunshot Wounds—Complications—Injuries of the Bones 
of the Cranium—Contusions—Exostosis—Hypertrophy—Atrophy—Caries and Ne- 
crosis—Symptoms of Inflammation in the Cranial Bones—Treatment—Intracranial 
Abscess—Fractures of the Skull—Anatomical Considerations—Classification of 
Cranial Fractures—Contre-Coup—Causes—Repair—Prognosis—Simple Fracture of 
the Skull—Complicated Fractures and their Signs—Fractures of the Base of the 
Skull—Causes—Symptoms—Anterior Fossa—Middle Fossa — Posterior Fossa— 
Prognosis — Fractures with Depression — Varieties—External Table — Internal 
Table—Both Tables with Depression—Depression without Fracture of the Skull— 
Diagnosis—Rules for the Treatment of Simple and Complicated Fractures of the 
Skull—Separation of the Sutures—Punctured Fractures—Concussion of the Brain— 
Varieties—Cerebral Vibration without Visible Lesion—Vibration followed by the 
Transudation of a Sero-Sanguinolent Fluid—Morbid Changes—Vibration followed 
by Extravasation of Blood—Morbid Appearances—Vibration followed by Lacera- 
tion—Prognosis in Concussion—Treatment of Concussion—Compression of the 
Brain—Symptoms—Diagnosis—Intracranial Extravasation of Blood—Extravasa- 
tions between the Bone and the Dura Mater—Extravasations into the Cavity of the 
Arachnoid—Extravasation of Blood from the Vessels of the Pia Mater—Wounds 
of the Sinuses—Gunshot Wounds of the Head—Mortality—Gunshot Injuries of 
the Scalp—Gunshot Wounds of the Cranial Bones—Contusions—Fractures without 
Depression—Fractures with Depression—Penetrating and Perforating Fractures— 
Crushing Fractures—Treatment—Arrow Wounds—Injury of the Cranial Nerves 
—Sequels of Head-Injuries—Fungus Cerebri—Morbid Anatomy—Diagnosis—Tre- 
phining—Operation—Cerebral Topography—Rules to be observed in Operating on 
the Brain—Injuries of the Face—Anatomical Peculiarities—Contusions or Un- 
opened Wounds of the Face—Open Wounds of the Face—Gunshot Wounds of the 
Face—Secondary Effects—Salivary Fistula—Necrosis—Neuralgia—Facial Paraly- 
sis—Lachrymal Fistula—Deformities—Wounds of the Neck—Middle Cervical 
Region—Lateral Cervical Region—Posterior Cervical Region—Gunshot Wounds 
of the Neck—Secondary Complications ......... 322 
CHAPTER VII. 
INJURIES OF THE CHEST. 
Wounds of the Chest—Non-Penetrating—Penetrating—Wounds of the Diaphragm— 
Wounds of the Contents of the Chest—Symptoms of Lung-Wounds—Complica- 
tions—Prognosis—Treatment—Immediate Complications—Hemorrhage— Hemo- 
thorax—Emphysema — Pneumothorax — Hernia of the Lung, or Pneumocele— 
Pleurisy and Pneumonia—Hydrothorax and Empyema—Operation of Thoracen- 
tesis—Fistulse of the Thorax—Mediastinal Wounds—Wounds of the Pericardium, 
the Heart and its Vessels—Hydrops Pericardii—Tapping the Pericardium—Wounds 
of the Vessels of the Thorax—Wounds of the (Esophagus—Wounds of the 
Thoracic Duct 404 
CHAPTER VIII. 
i 
WOUNDS AND INJURIES OF THE ABDOMINO-PELVIC CAVITIES AND THEIR 
CONTENTS. 
General Directions in Laparotomy—Wounds of the Abdomen—Non-Penetrating— 
Contused, Incised, and Punctured Wounds—Penetrating Wounds—Penetrating 
Wounds with Protrusion—Rupture of the Abdominal Walls without the Integu- 
ment being Broken—Foreign Bodies in the Stomach—Operation of Gastrotomy— 10 
CONTENTS OF VOLUME I. 
PASS 
Pyloric Stenosis—Treatment—Digital Dilatation—Partial Gastrectomy or Pylorec- 
tomy—Gastro-Enterostomy—Gastrorrhaphy—Gastrostomy—Penetrating Wounds 
implicating the Viscera—Wounds of the Stomach—Rupture of the Stomach—Of 
the Omentum and Mesentery—Of the Intestines—Penetrating Wounds of the In- 
testines without Protrusion—Wounds of the Intestines and Omentum with Pro- 
trusion—Enterectomy and Enterorrhaphy—Wounds of the Liver and Gall-Bladder 
—Abscess of the Liver—Hydatids of the Liver—Rupture, Wounds, and Distention 
of the Gall-Bladder — Gall-Stones — Cholecystotomy—Oholocystectomy— Entero- 
Cholecystotomy or Cholecystenterostomy—Wounds of the Spleen—Abscess of the 
Spleen—Splenectomy—Wounds of the Pancreas—Cysts of the Pancreas—Excision 
and Drainage—Wounds of the Kidney and Supra-renal Capsules—Wounds of the 
Ureter—Sequels of Abdominal Wounds—Perinephritic Abscess—Fistulse—Fistula 
of the Stomach—Fistulae of the Gall-Bladder—Faecal Fistula—Artificial Anus— 
Resection of the Intestine—Wounds of the Pelvis—Soft Parts—Pelvic Bones— 
Bladder—Rupture of Bladder—Operation—Wounds of the Prostate Body—Wounds 
of the Anus and Rectum—Gunshot Wounds of the Rectum .... 429 
CHAPTER IX. 
DISEASES OP THE ABDOMEN. 
Diseases of the Umbilicus—Hemorrhage—Ulceration—Morbid Growths—Cysts— 
Carcinoma—Urinary Fistula—Stercoraceous Fistula—Ovarian Fistula—Ascites— 
Paracentesis Abdominis—Intestinal Obstruction—Chronic or Slow Obstruction— 
Typhlitis and Appendicitis—Perforation of Appendix or Caecum—Colotomy— 
Colectomy—Laparotomy—Diseases of Anus and Rectum—Congenital Malforma- 
tions—Condylomata—Pruritus Ani—Sphincterismus—Loss of Co-ordination in 
the Muscles of Defecation—Fissure in the Anus—Foreign Bodies in the Rectum— 
Irritable Rectum—Dilatation of the Rectal Pouches—Prolapsus Ani et Recti— 
Polypus of the Rectum—Inflammation and Ulceration of the Anus and Rectum— 
Stricture: Non-Malignant and Malignant—Epithelioma, Scirrhus, Sarcoma, and 
Encephaloid of the Rectum—Excision of the Rectum—Peri-Anal and Peri-Rectal 
Abscess—Perineo-Anal and Perineo-Rectal Fistula—Complete and Incomplete 
Fistula—Diagnosis—Operation for Fistula—Hemorrhoids—External—Internal— 
Causes—Symptom—Treatment—Palliative Treatment—Radical Treatment—Oper- 
ation by Ligature—Operation by the Clamp and Cautery—Injections—Crushing 
—Treatment by Caustics—By the Ecraseur—Excision—Dilatation—Complications 
—Rectal Chemise—Hernia—Defined—Divisions—Varieties—Anatomical Compo- 
nents—Sac—Contents—Coverings—Causes—Occupation in—Sex in—Age in— 
Tabular Statistics—Symptoms—Treatment—Trusses—The Application of a Truss 
—Radical Cure of Hernia—Invagination—Gerdy’s Method—Signorini’s Method 
—Wutzer’s Method—Agnew’s Method—Wood’s Method—Dowell’s Method— 
Retroclusion—Baker’s Method—Macewen’s Method—Radical Cure of Femoral 
Hernia—Radical Cure of Umbilical Hernia—Transplantation—Local Irritation 
conjoined with Compression—Irreducible Hernia—Causes—Symptoms—Treat- 
ment—Permanently Irreducible Hernia—Strangulated Hernia—Definition—Seat 
of Stricture—Effects of Strangulation on the Contents of the Sac—Symptoms— 
Diagnosis—Taxis—Reduction of Hernia—Intraparietal Hernia—Rupture of the 
Intestine—Herniotomy—Opening the Sac—Description of Instruments and Oper- 
ations—Causes of Difficulty in Reductions—Spica for the Groin—Complications— 
Adhesions—Fsecal Accumulations—Volvulus—Congestion—Mortification—Par- 
tial Mortification—Complications affecting the Omentum—Hemorrhage—Prog- 
nosis in Strangulated Hernia—Statistics of Recovery—Special Hernise—Inguinal 
Hernia—Surgical Anatomy of Inguinal Hernia—Varieties—Complete Oblique— 
Incomplete—Concealed Hernia—Intraparietal Hernia—Scrotal Hernia—Its Vari- 
eties—Hernia in Females—Diagnosis of Inguinal Hernia—From Varicocele— 
From Hydrocele—From Hematocele—Sarcocele—Undescended Testicle—En- 
larged Inguinal Glands—Abscess—Fatty Tumors—Treatment of Inguinal Hernia 
—Trusses—Strangulated Inguinal Hernia—Dropsy of the Hernial Sac—Femoral 
Hernia—Surgical Anatomy—Symptoms—Diagnosis of Femoral Hernia from In- 
complete Inguinal Hernia—Enlarged Inguinal Glands—Psoas Abscess—Varix of 
the Saphena Magna—Adipose Tumor—Sarcomatous and other Malignant Tumors 
—Treatment of Femoral Hernia—Strangulated Femoral Hernia—Operation— 
Umbilical Hernia—Varieties—Treatment—Trusses for Umbilical Hernia—Stran- 
gulated Umbilical Hernia—Operation—Ventral Hernia—Obturator Hernia—Her- 
nia of the Foetal Cord—Ischiatic Hernia—Diaphragmatic Hernia—Pudendal 
Hernia—Vaginal Hernia—Perineal Hernia—Sacro-Rectal Hernia—Properitoneal 
Hernia—Cvstocele—Diverticular Hernia ........ 475 CONTENTS OF VOLUME J. 
11 
CHAPTER X. 
WOUNDS OP THE EXTREMITIES. 
PAGE 
General Considerations—Situation of Principal Blood-Vessels in the Extremities— 
Wounds of the Upper Extremity—Vital Points in the Upper Extremity— 
Wounds of the Arm—Their Treatment—Wounds of the Hand—The Palmar 
Arch—Lacerated, Punctured, Poisoned, and Contused Wounds—Palmar Ab- 
scesses—Topography of the Vessels of the Hand—Wounds of the Nerves—Con- 
tusion of Ulnar Nerve—Punctures of Nerves—Digital Pseudo-Neuralgia— 
Wounds of the Lower Extremity 609 
CHAPTER XI. 
DISEASES AND INJURIES OP THE BLOOD-VESSELS. 
Angeiomata—Arterial—Capillary—Venous—Cirsoid Aneurism—Aneurism by Anas- 
tomosis—Arterial Varix—Ligation of the Carotids in the Treatment of Arterial 
Varix—Capillary Varix—Venous Angeiomata—Diagnosis—Anatomy—Treatment 
of Angeiomata—Strangulation—Excision—Acupressure—Moles—Angeioma of the 
Tongue—Angeioma of the Labium—Injuries and Diseases of the Veins—Wounds 
—Air in Veins—Ligation of Veins—Phlebitis—Causes—Acute—Diffuse—Chronic 
Phlebitis — Hypertrophy— Atrophy — Phleboliths —V arix — Pathology— Elastic 
Stockings—Caustics—Electro-Galvanism—Injection—Ligation—Injuries and Dis- 
eases of the Arteries—Contusions—Lacerations—Incised Wounds—Arteritis— 
Results—Atheroma—Anatomical Characteristics—Calcification—Consequences of 
Atheroma—Amyloid Degeneration—Aneurism — Divisions — True—False—Fusi- 
form—Sacculated—The Aneurismal Sac—Form—Opening into Sac—Contents— 
Effect of Aneurism on Adjoining Structures—Causes of Aneurism—Vessels af- 
fected—Phenomena arising from Pressure of the Tumor—Circumstances which 
modify Pulsation and Auscultation Sounds—Diagnosis of Aneurism from Abscess 
—Encephaloid Disease—Solid Tumors—Erectile Growths—Cysts—Rheumatism— 
Results of Aneurism—Treatment of Aneurism—Constitutional Treatment—Incis- 
ion and Ligation—Causes which render the Ligature Ineffectual—Opening of the 
Sac—Sloughing—Suppuration—Treatment—Mortification—Treatment of Morti- 
fication—Ligation of the Artery on the Distal Side—Compression—Preparation 
for Compression—Means of Applying—Acupressure—Digital Compression—Gen- 
eral Compression—Esmarch’s Bandage—Flexion—Manipulation—Galvano-Punc- 
ture—Introduction of Substances into the Sac, and also Subcutaneously—Ergotin 
—Solid Substances introduced into the Sac—Acupuncture Needles—Comparison 
of Methods of Treatment of Aneurism—False Aneurism—Dissecting Aneurism— 
Traumatic Aneurism—Diffused Traumatic Aneurism—False Circumscribed Aneu- 
rism—Arterio-Venous Aneurism—Direct Aneurism, or Aneurismal Varix—Inter- 
mediate or Varicose Aneurism—Aneurism of Special Vessels—Thoracic and Cer- 
vical Aneurism—Aneurism of the Thoracic Aorta—Signs and Symptoms—Treat- 
ment—Aneurism of the Innominate—Diagnosis from Aneurism of the Arch of 
the Aorta—Tabular Statements of the Results of Operations—Aneurism of the 
Carotid — Differential Diagnosis — Treatment — Results of Ligation — External 
Carotid — Its Branches — Internal Carotid — Subclavian —Vertebral—Transverse 
Cervical — Intracranial Aneurism of the Carotid, the Vertebral, and their 
Branches — Intraorbital Aneurism — Arterio-Venous Aneurism of the Carotid 
Artery and Internal Jugular Vein—Aneurism of the Axillary Artery—Brachial 
Artery and its Branches—Superficial Palmar Arch—Superficial Volar—Abdom- 
inal Aorta—Certain Branches of the Abdominal Aorta—Primitive Iliac—Internal 
Iliac and its Branches—External Iliac—Femoral—Profunda Femoris—Popliteal 
—Tibial—Dorsalis Pedis—Plantar 615 
CHAPTER XII. 
LIGATION OP ARTERIES. 
General Observations and Rules—Instruments—Recognition of the Position and 
Course of the Artery—The Exposure of the Artery—Opening the Sheath—The 
Recognition and Deligation of the Artery—Special Arteries—Innominate—Prim- 12 
CONTENTS OF VOLUME I. 
PAGE 
itive Carotid—Surgical Anatomy—Operations—Collateral Circulation—Tables of 
Ligations of Common Carotid—Table of Ligations of both Primitive Carotids— 
External Carotid—Superior Thyroid—Lingual—Facial—Occipital—Temporal— 
Internal Carotid—Subclavian—Table of Ligations of the Subclavian within the 
Scalenus Anticus—General Statistics—Complications—Vertebral—Inferior Thy- 
roid—Internal Mammary—Axillary—Anatomy—Operation—Brachial—Radial— 
Ulnar—External Iliac—Epigastric—Internal Iliac—Gluteal and Ischiatic—Prim- 
itive Iliac—Table of Ligations of Primitive Iliac—Abdominal Aorta—Femoral 
—Popliteal—Posterior Tibial—Peroneal—Anterior Tibial—Dorsalis Pedis . . 734 
CHAPTER XIII. 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Fractures—Definition—Causes—Age—Diathesis—Exciting Causes—Varieties—Sim- 
ple—Complicated—Compound—Comminuted—Direction of Fracture—Oblique— 
Transverse—Longitudinal—Signs of Fracture—Displacement—Deformity—Pre- 
ternatural Mobility—Crepitation—Loss of Function—Pain—Discoloration—Dis- 
ordered Sensibility—Time to examine Fractures—Repair of Fractured Bones— 
Extravasation of Blood—Callus—Provisional Callus—Definitive Callus—Conclu- 
sions derived from Observations on Lower Animals—Process of Repair—Treat- 
ment of Fractures—Removal of the Patient—Preparation of the Bed—Fracture- 
Bed—Removal of the Clothing—Retentive Dressings—Material for Splints—Im- 
movable Dressings—Setting a Fracture—Extension—Counter-Extension—Coapta- 
tion—The Time to set a Fracture—After-Treatment—Removal of Dressings— 
Time to lay aside the Dressings—Restoration of Functions—Compound Fractures 
—Comminuted Fractures—Hemorrhage after Simple Fractures—Hemorrhage 
after Compound Fractures—Primary—Secondary—Injuries to Nerves—Com- 
pound Fractures of Joints—Fractures not Compound extending into a Joint— 
Fracture with Dislocation—Necrosis—Mania a Potu—Epilepsy—Anchylosis— 
Atrophy—Embolism—Fat-Embolism—Pyaemia—Ununited Fracture, or Pseud- 
arthrosis—Causes—Changes which take place in Bones—Various Methods of 
Treatment of Ununited Fracture—Apparatus—Friction—Irritation—Subcutane- 
ous Irritation—The Seton, Drill, and Gimlet—Irritation with Open Wound— 
Caustics—Tables of Cases of Pseudarthrosis—Tables showing Results of Different 
Methods of Treatment—Non-Union of Special Bones—Inferior Maxillary— 
Humerus—Radius and Ulna—Radius—Ulna—Femur—Tibia and Fibula—Tibia 
—Fibula—Patella—Summary, with Conclusions derived from Study of Tables— 
Deformed or Vicious Union—Shortening and Rotatory Displacement—Angular 
Union—Treatment of Vicious Union—Instruments employed—Union of Adja- 
cent Bones by a Bridge of Callus—General Rules for the Treatment of Cases of 
Deformed Union—Morbid Changes of Callus—Table of Fractures treated at the 
Pennsylvania Hospital from January 1, 1850, to January 1, 1874—General Sum- 
mary—Special Fractures—Fractures of the Vertebrae—Spinous Process—Trans- 
verse Process—Vertebral Arches—Body—Fractures of the Dorso-Lumbar and 
Lumbar Regions—Dorsal Vertebrae—Cervico-Dorsal and Cervical Regions—The 
Upper Cervical Vertebrae—Odontoid Process— Treatment of Fractures of the Ver- 
tebrae—Fractures of the Bones of the Face—Ossa Nasi—Complications—Superior 
Maxilla—Malar Bone and Zygomatic Arch—Inferior Maxilla—Bandages em- 
ployed—Barton’s—Gibson’s—Hamilton’s—Garretson’s, and others—Splints—In- 
terdental—Delayed Union—Gunshot Wounds of the Bones of the Face—Fracture 
of the Hyoid Bone—Cartilages of the Larynx and Trachea—Bones of the Chest— 
Ribs—Complications — Treatment — Costal Cartilages — Sternum—Bones of the 
Upper Extremity—Clavicle—Various Bandages and Appliances for Treatment of 
Fractures of the Clavicle — Treatment — Erect Position — Mayor’s, Velpeau’s, 
Moore’s, Desault’s, Sayre’s, Fox’s, and Levis’s Devices—Recumbent Position— 
Scapula—Body and Angles of Scapula—Acromion—Coracoid—Neck and- Glenoid 
Cavity — Humerus — Upper Extremity — Intra-Capsular Fractures —Anatomical 
Neck—Extra-Capsular Fractures—Great Tuberosity—Superior Epiphysis—Surgi- 
cal Neck—Shaft—Apparatus for—Lower Extremity—Supra-Condyloid Fractures 
—Diagnosis from Luxation at Elbow—Condyloid Fractures—Fracture across the 
Base and between the Condyles—Condyles—Internal Condyle—External Condyle 
—Internal Epicondyle—Treatment of Fractures at the Lower Extremity of the 
Humerus—Apparatus—Compound and Comminuted Fractures of the Elbow- 
Joint—Fractures of the Bones of the Forearm—Radius and Ulna—Radius—Neck 
—Below Tubercle—Middle Third—Lower End—Varieties—Silver-Fork Deform- 
ity—Treatment of Fractures of the Radius—Splints—Fractures of the Ulna— 
Shaft—Processes—Olecranon—Coronoid—Styloid—Fractures of the Hand—Carpal CONTENTS OF VOLUME I. 
13 
PAGE 
Bones—Metacarpal Bones—Phalanges—Compound Fractures of the Hand—Frac- 
tures of the Bones of the Pelvis—Sacrum—Coccyx—Ossa Innominata—Ilium— 
Pubis — Ischium—Acetabulum — Fractures of the Lower Extremity — Femur— 
Upper End of Femur—Intra-Capsular Fracture—Extra-Capsular—Mixed—Tro- 
chanteric— Diagnostic Table between Intra- and Extra-Capsular Fractures and 
Posterior Luxation—Trochanter Major—Epiphysis of the Great Trochanter— 
Shaft of the Femur—Upper Third—Middle Third—Lower Third—Treatment of 
Fractures of the Shaft of the Femur—Fractures near to and at the Condyles of the 
Femur—Fractures through the Base of the Condyles—One Condyle—Both Con- 
dyles—Apparatus—History of the Treatment of Fractures of the Thigh—Frac- 
tures of the Femur in Children—Lower Epiphysis—Compound and Comminuted 
Fractures of the Femur—Fractures of the Patella—Compound Fracture of the 
Patella—Fracture of the Ligamentum Patellae—Bones of the Leg—Tibia and 
Fibula—Tibia—Fibula—Compound Fractures of the Bones of the Leg—Fracture 
of the Bones of the Foot—Astragalus—Os Calcis—Sustentaculum Tali—Meta- 
tarsal Bones—Phalanges of the Toes—Inflammatory Affections of Bones—General 
Anatomical Considerations — Periostitis—Circumscribed — Diffused—Pathology— 
Osteitis and Caries—Changes in Bone—Abscess of Bone—Multiple Abscess—Sup- 
puration—Endosteitis or Osteomyelitis—Sclerosis—Actinomycosis—Rarefaction— 
Necrosis — Multiple Necrosis — Non-Suppurating Necrosis—Humid Necrosis— 
Epiphyseal Necrosis—Necrosis of Flat Bones—Irregular—Sequestra—Cloacae— 
Symptoms of Necrosis—Removal of Sequestrum—Instruments used—Rachitis— 
Osteomalacia—Fragilitas Ossium—Hypertrophy of Bones—Atrophy of Bones . 794 LIST OF ILLUSTRATIONS TO VOLUME I. 
FIG. PAGE 
58. Spiral reversed applied to upper ex- 
tremity 67 
59. Same of four fingers .... 67 
60. Same of the penis .... 67 
61. Spiral of the hand, or demi-gauntlet . 68 
62. Spiral reversed of the lower extremity 68 
63. French spiral reversed ... 69 
64. Heel covered with spiral reversed roller 69 
65. Spiral of the chest .... 69 
66. Spica of the shoulder .... 70 
67. Single spica of the groin ... 70 
68. Double spica of the groin ... 71 
69. Spica of the foot..... 71 
70. Spica of the thumb .... 72 
71. Figure-of-eight of the elbow-joint . 72 
72. Anterior eight of the chest... 73 
73. Posterior eight of the chest . . 73 
74. Figure-of-eight of the neck and axilla 73 
75. Same of one eye 74 
76. Same of jaw and head, or Barton’s 
bandage 74 
77. Gibson’s bandage . . . ' . 75 
78. Occipito-facial roller .... 75 
79. Crossed bandage for the angle of the 
jaw 75 
80. V bandage of the head and jaw . 76 
81. Recurrent bandage of the head . . 76 
82. Same after amputation of the thigh . 77 
83. Single suspensory and compressor 
bandage of the breast ... 77 
84. Bilateral suspensory and compressor of 
the breasts 77 
85. Velpeau’s bandage .... 78 
86. Square handkerchief .... 79 
87. Oblong handkerchief .... 79 
88. Triangle handkerchief ... 79 
89. Cravat ...... 79 
90. The first step in forming the square 
cap of the head .... 79 
91. Square cap of the head complete . 79 
92. Anterior and posterior view of fronto- 
occipital handkerchief ... 80 
93. The auriculo-occipital triangle . . 80 
94. The vertico-mental triangle . . 81 
95. The fronto-occipital labialis cravat . 81 
96. The occipito-sternal handkerchief . 81 
97. The parieto-axillaris cravat . . 82 
98. The simple bis-axillary cravat . . 82 
99. The compound bis-axillary cravat . 83 
100. The simple bis-axillo-scapulary cravat 83 
101. The compound bis-axillo-scapulary 
cravat ...... 83 
102. The dorso-bis-axillary handkerchief . 84 
103. The mammary triangle ... 84 
104. The palmar triangle .... 84 
105. Triangular cap of the shoulder . . 85 
106. The cervico-brachial sling ... 85 
107. Triangular cap for amputation applied 
to the thigh ..... 85 
FIG. PAGE 
1. Clinical thermometer .... 36 
2. Modified clinical thermometer . . 36 
3. ASsthesiometer ..... 38 
4. Dynamometer ..... 40 
5. Micrococci, bacteria, bacilli, and spirilla 45 
6. Irrigating apparatus for bichloride solu- 
tion ....... 47 
7. Steam spray-producer .... 49 
8. Hand spray-apparatus .... 50 
9. Method of scraping lint ... 52 
10. Pellets of charpie ..... 52 
11. Tent 52 
12. Bullets of charpie .... 53 
13. Mesh supported on a probe ... 53 
14. Roll 53 
15. Pledget 53 
16. Oblong compress 54 
17. Perforated compress .... 54 
18. Pyramidal compress .... 54 
19. Prismatic compress .... 54 
20. Semi-cuneiform compress ... 55 
21. Maltese cross 55 
22. Half Maltese cross .... 55 
23. Triangular compress .... 55 
24. Cribriform compress .... 55 
25. Two-tailed retractor .... 56 
26. Three-tailed retractor .... 56 
27. Single T bandage ..... 56 
28. Incomplete double T bandage . . 56 
29. Double T bandage .... 56 
30. T bandage of the ear .... 57 
31. Same applied 57 
32. T bandage of the head .... 57 
33. Double T bandage of the nose . . 58 
34. Single T bandage of the nose . . 58 
35. Double T bandage of the chest . . 58 
36. Double T of the abdomen ... 59 
37. Compound T of the groin ... 59 
38. Perforated T of the hand ... 59 
39. Four-tailed sling 60 
40. Same for the back of the neck . . 60 
41. Sling for the top of the head . . 60 
42. Six-tailed sling of the head ... 61 
43. Four-tailed sling of the chin . . 61 
44. Four-tailed sling or mask of the face . 62 
45. Four-tailed sling of the breast . . 62 
46. Machine for rolling bandages . . 63 
47. Forming a roller bandage by the 
hands ...... 63 
48. Single roller ...... 63 
49. Double roller 63 
50. Corners of roller turned in and pinned 64 
51. Longitudinal pinning of roller . . 64 
52. Transverse pinning of roller . . 64 
53. Securing the roller by a knot . . 64 
54. Circular roller of the neck ... 65 
55. Oblique roller of the arm ... 65 
56. Spiral roller of the arm ... 65 
57. Making the spiral reverse ... 66 16 
LIST OF ILLUSTRATIONS TO VOLUME I. 
FIG. PAGE 
108. The metatarso-malleolar cravat . . 85 
109. The malleolo-phalangeal triangle . 85 
110. The tarso-patellar cravat ... 86 
111. The tibio-cervical handkerchief, or 
sling of the knee .... 86 
112. Cravats of the tibia and the foot . 86 
113. Two views of the Barton handkerchief 87 
114. The abdomino-inguinal cravat, or sin- 
gle spica of the groin ... 87 
115. The coxo-inguinal cravat ... 88 
116. The sub-femoral handkerchief . . 88 
117. Double spica of the groin ... 88 
118. Suspensory, or scroto-lumbar triangle 88 
119. A minute artery, exhibiting several 
points of contraction independent 
of the heart’s action . . . 104 
120. Natural form of the canal of an artery 
when empty ..... 104 
121. Different vascularity in the inflamed 
and non-inflamed ears of a rabbit . 105 
122. Uninflamed wing of the bat . . 106 
123. Inflamed wing of the bat . . . 106 
124. Position of the red and white corpuscles 
in an inflamed vessel . . .107 
125. Non-inflamed mesentery of the frog . 107 
126. Inflamed mesentery of the frog . . 108 
127. Migration or transudation of leuco- 
cytes ...... 109 
128. Section of a blood-clot . . . 110 
129. Inflammatory infiltration . . . Ill 
130. Cornea of a frog three hours after its 
removal 112 
131. Irregular-shaped masses containing 
broods of new cells . . . .113 
132. Cornea of a frog sixteen hours after 
irritation . . . . .113 
133. Protoplasm of the fibre-sheath con- 
nective-tissue corpuscles . . 114 
134. Transverse section of an inflamed 
muscle ...... 114 
135. Section of the croupous layer from the 
fauces 115 
136. Purulent catarrh of the conjunctiva . 115 
137. Varicosities of the capillaries of an in- 
flamed part ..... 120 
138. Leucocytes 121 
139. Vascular epithelia from the urinary 
bladder of a frog . . . .124 
140. Nuclei of epithelial cells from the uri- 
nary bladder of a frog . . . 124 
141. Stomata between epithelial cells of mi- 
nute vein 125 
142. Vascular epithelia with nuclei and 
stomata 125 
143. Tin irrigating vessel .... 129 
144. Irrigation of the leg .... 129 
145. Ice-bag 130 
146. Petitgand irrigating tube . . . 130 
147. Concave hot-water can . . . 131 
148. Gum hot-water bag .... 131 
149. Atomizer 132 
150. Boston steam atomizer . . . 132 
151. Philadelphia steam atomizer . . 132 
152. Scarificator ..... 133 
153. Pump cupping apparatus . . . 133 
154. Gum-ball cupping apparatus . . 133 
155. Mode of ligating a leech-bite . . 134 
156. Artificial leech : . . . .134 
157. Suction-tube of artificial leech . . 134 
158. Hypodermic syringe .... 142 
159. Seton-needle armed with silk . . 147 
160. Porte-moxa 148 
161. Living pus-corpuscles . . . 151 
161. Dead pus-corpuscles .... 151 
161. Dead pus-corpuscles treated with acetic 
acid, showing nuclei . . . 151 
162. Exploring-needle .... 158 
FIG. PAGE 
163. Blunt- and sharp-pointed bistoury . 160 
164. Drainage-tube, with openings . . 160 
165. Conical tent 160 
166. Infiltration in the formation of an ab- 
scess ...... 162 
167. Vessels in the walls of an abscess . 162 
168. Sharp-pointed bistoury . . . 164 
169. Dieulafoy’s aspirator .... 168 
170. Aspirator of Potain .... 168 
171. Hypertrophied papillae at the thick- 
ened edges of an ulcer . . . 172 
172. Loops of blood-vessels in granulation- 
tissue 173 
173. Cell-changes in cicatrization . . 174 
174. Fungous ulcer 178 
175. Sloughing ulcer ..... 178 
176. Indolent ulcer 181 
177. Adhesive-plaster strips applied . . 184 
178. Skin-grafts on a granulating surfaee . 185 
179. Macleod’s forceps for skin-grafting . 186 
180. Method of using Macleod’s forceps . 186 
181. Cicatrization in skin-grafting . . 187 
182. Black skin engrafted upon white man 187 
183. Thrombus of the brachial artery . 191 
184. Mortification of the arm from a tight 
bandage. ..... 193 
185. Line of demarcation .... 195 
186. Deepened line of demarcation and con- 
ical form of stump .... 195 
187. Dry or senile mortification of the toes 198 
188. Dry mortification of the arm . . 199 
189. Relation between the internal and ex- 
ternal clot in a wounded vessel . 215 
190. Longitudinal section of the crural ar- 
tery of a dog after ligature . . 216 
191. Longitudinal section magnified 225 
diameters ..... 216 
192. Transverse section of the crural artery 
of a dog, through a clot . . . 217 
193. Transverse section of the crural artery 
of a dog four days after ligature . 218 
194. Transverse section of the femoral artery 
of a dog eight days after ligature . 219 
195. Injected longitudinal section twenty 
days after ligature .... 219 
196. Manner of pressing the brachial artery 221 
197. Compression of the femoral artery . 222 
198. Door-key prepared for pressing the 
subclavian ..... 222 
199. Pyramidal compress .... 222 
200. Oblong graduated compress . . 222 
201. Application of the Spanish windlass . 223 
202. Tourniquet of Petit .... 223 
203. Tourniquet applied to the thigh . . 223 
204. Lister’s tourniquet .... 224 
205. Gross’s tourniquet .... 224 
206. Signorini tourniquet .... 224 
207. Skey’s abdominal tourniquet . . 224 
208. Abdominal tourniquet . . . 225 
209. Cauterizing-irons .... 225 
210. Paquelin’s thermo-cautery . . . 226 
211. Torsion forceps ..... 226 
212. Torsion of an artery .... 227 
213. Amussat’s plan of applying torsion . 227 
214. Hewson’s torsion forceps . . . 227 
215. Acupressure-pin ..... 228 
216. Wire fastened to the eye of the needle 228 
217. Loop of iron wire .... 229 
218. First acupressure method of Simpson 229 
219. Second acupressure method of Simp- 
son ....... 229 
220. Third acupressure method of Simpson 229 
221. Circumclusion of an artery . . 229 
222. First stage of torsoclusion . . . 230 
223. Second stage of torsoclusion . . 230 
224. First stage of retroclusion . . . 230 
225. Second stage of retroclusion . . 230 LIST OF ILLUSTRATIONS TO VOLUME I. 
17 
no. PAGE 
226. Buck’s method of acupressure . . 231 
227. First stage of Hutchison’s method of 
circumclusion 231 
228. Second stage of Hutchison’s method of 
circumclusion 231 
229. Spier’s artery-compressor . . . 231 
230. Gross’s forceps for deep vessels . . 232 
231. Serres-fines ..... 232 
232. Spring forceps 232 
233. Author’s artery forceps . . . 233 
234. Liston’s forceps 233 
235. Fenestrated forceps, with a slide catch 234 
236. Artery forceps, with spring blades . 234 
237. Fenestrated spring forceps, with liga- 
ture 234 
238. Tenaculum 234 
239. Reef knot and surgeon’s knot . . 235 
240. Position of the fingers in tightening a 
ligature 235 
241. Elastic loop attached to a retained liga- 
ture 236 
242. Aveling’s transfusion apparatus . . 240 
243. Hunter’s apparatus for transfusion . 241 
244. Dressing forceps ..... 242 
245. Rubber drainage-tube . . . 242 
246. Drainage-tube in position . . . 242 
247. Horse-hair or catgut drains applied . 243 
248. The uniting or invaginated bandage . 244 
249. Cutting adhesive strips . . . 244 
250. Removing adhesive strips . . . 245 
251. Surgical needles 246 
252. Interrupted thread suture . . . 247 
253. Shot-suture 247 
254. Shot-compressor ..... 247 
255. Diagonal, continued, or glover’s suture 247 
256. Suture passed from side to side . . 248 
257. The same with loops cut . . . 248 
258. Pin for twisted suture . . . 248 
259. Figure-of-eight suture . . . 248 
260. Cutting pliers 249 
261. Quilled suture 249 
262. Rubber suture ..... 249 
263. Button suture 250 
264. Thumb torn off, with tendon adhering 257 
265. Dissecting-wound ulcer . . . 269 
266. Anatomical tubercle of the fingers . 271 
267. Anthrax bacteria .... 272 
268. Poison-apparatus of the spider . . 284 
269. Scorpion, showing curved hook at the 
caudal extremity .... 285 
270. Enlarged view of the poison-fang of 
the rattlesnake .... 286 
271. Head of the rattlesnake . . . 286 
272. Poison-apparatus of the bee . . 289 
273. Charge of shot united by the heat of 
the exploded powder . . . 291 
274. Old round United States musket-ball . 292 
275. Springfield rifle-ball .... 292 
276. Enfield rifle-ball .... 292 
277. Austrian ball ..... 292 
278. Chassepot ball 292 
279. Needle-gun ball ..... 292 
280. Mitrailleuse ball .... 292 
281. Martini-Henry ball .... 292 
282. Bavarian ball ..... 292 
283. Snider ball ...... 292 
284. Comminuted fracture of femur pro- 
duced by a conical ball . . . 293 
285. Balls altered in form by impact . . 295 
286. Silver probe 300 
287. Nelaton’s bullet probe . . . 300 
288. Thomassin’s bullet forceps . . . 301 
289. Gemrig’s bullet forceps . . . 301 
290. Coxeter’s bullet extractor . . . 301 
291. Lever for dislodging balls . . . 302 
292. Comminution of the humerus by a 
conoidal ball ..... 309 
PIS. page 
293. Comminuted gunshot fracture of the 
femur 311 
294. Gunshot comminution of knee-joint . 313 
295. Knee-joint destroyed by a shell-explo- 
sion 313 
296. Microscopic appearances of a wound 
eight hours after its infliction . 317 
297. Cell infiltration changed into spindle 
forms . . . . . .317 
298. Communication of blood-vessels across 
the wound ..... 318 
299. Connective-tissue net-work in wound . 318 
300. Diagrammatic view of the layers of the 
scalp and skull .... 323 
301. Fracture of the skull by a bludgeon . 332 
302. Fracture of skull by the edge of a brick 333 
303. Fracture by the pole of a hammer . 333 
304. Comminution of the internal table . 334 
305. Radiating fracture of the base of the 
skull 336 
306. Diagram illustrating method of pro- 
duction of fracture .... 341 
307. Diagram illustrating the same . . 341 
308. Young skull with depressions over its 
surface ...... 341 
309. Fracture through the frontal suture . 343 
310. Clot of blood between the dura mater 
and bone 352 
311. Dura mater dissected from the bone by 
a clot 352 
312. Sabre-cut of both parietals . . 358 
313. Fissured fracture of skull . . . 358 
314. Fracture of the internal table without 
injury of the external . . . 359 
315. Denuded surface of the external table 
over the region of fracture of the 
internal 359 
316. Fissure of the external table . . 359 
317. Internal view of the same . . . 359 
318. Gunshot perforation of the external 
table 360 
319. Internal view of the same specimen . 360 
320. Iron arrow-head .... 365 
321. Buffalo rib pierced by an arrow . . 365 
322. Arrow in a soldier’s skull . . . 365 
323. Cogshill wire-twister .... 366 
324. Dr. Bill’s wire loop applied to an 
arrow-head 366 
325. Fungus cerebri in a child . . . 370 
326. Comminuted button of bone from the 
head of an epileptic . . . 373 
327. Cylindrical trephine .... 376 
328. Conical trephine .... 376 
329. Small-sized trephine .... 376 
330. Rouger forceps 376 
331. Ordinary silver probe .... 376 
332. Trephine brush 377 
333. Elevator 377 
334. Lenticular 377 
335. Hey’s saw ...... 377 
336. Modified form of Hey’s saw . . 377 
337. Holsen’s chisel ..... 377 
338. Crucial and horse-shoe incision . . 378 
339. Trap-door flap deflected and the tre- 
phine applied to the skull . . 378 
340. Motor centres of the brain with their 
convolutions exposed . . . 380 
341. Motor points of the cerebral cortex . 382 
342. Lines for cerebral localization . . 383 
343. Salivary fistula 391 
344. Author’s treatment of salivary fistula 391 
345. Seton for parotid fistula . . . 392 
346. Occipito-sternal handkerchief for a 
cut-throat wound .... 398 
347. Sling of the nape of the neck . . 400 
348. Author’s intercostal artery needle . 406 
349. Author’s intercostal artery compressor 406 18 
LIST OF ILLUSTRATIONS TO VOLUME I. 
FIG. PAG* 
350. Emphysema of the entire body . . 409 
351. Author’s canula and trocar with bag 
for thoracentesis .... 420 
352. Tapping the chest .... 420 
353. Trocar for puncturing the chest. . 420 
354. Drainage-tube in the chest . . 421 
355. Rubber drainage-tube prepared . . 421 
356. Attaching the duodenum to the stomach 438 
357. Pylorectomy ..... 438 
358. Duodenum united to the stomach . 439 
359. Tying a small intestinal wound . . 447 
360. Lembert’s intestine suture . . . 447 
361. Continuous Lembert suture . . 447 
362. Gely’s intestine suture . . . 448 
363. Glover’s intestine suture . . . 448 
364. Czerny-Lembert suture . . . 449 
365. Lembert suture 449 
366. Intestinal fistula .... 462 
367. Intestinal fistula with spur loop . . 462 
368. Diagram of strangulated intestine . 463 
369. Dividing the septum in artificial anus 464 
370. Dupuytren’s enterotome . . . 465 
371. Same applied 465 
372. Lotz’s enterotome .... 466 
373. Gross’s forceps for artificial anus . 466 
374. Carroll’s knot-tying instrument . . 474 
375. Bushe’s compressor for hemorrhage 
from the rectum .... 474 
376. Trocar and canula for tapping the ab- 
domen 479 
377. Tapping in abdominal dropsy . . 480 
378. Portion of the ileum invaginated . 481 
379. Intestinal twist ..... 486 
380. Strangulation of the ileum by the ap- 
pendix vermiformis . . . 483 
381. Obstruction by a fibrous band . ’ . 483 
382. Obstruction by a band of inflammatory 
lymph 483 
383. Annular stricture of the colon . . 486 
384. Davidson syringe .... 490 
385. Hydrostatic injection apparatus . . 490 
386. View of left lumbar colotomy . . 500 
387. MacBride yoke ...... 502 
388. Bivalve anal speculum . . . 503 
389. Trivalve anal speculum . . . 503 
390. Anal speculum with side oval opening 503 
391. Anal speculum with an elongated fe- 
nestra and with stylet '. . . 503 
392. Wire anal speculum with stylet . . 503 
393. Sims’ speculum 504 
394. Hard rubber syringe .... 504 
395. Membranous occlusion of the anus . 505 
396. Rectum terminating at the top of the 
sacrum 506 
397. Rectum terminating in the vagina . 506 
398. Partial prolapse of the rectum . . 517 
399. Complete prolapse of the rectum . 517 
400. Concentric folds of a prolapsed rectum 517 
401. Rectal polypi ..... 520 
402. Structure of an adenoma or mucous 
polypus of the rectum . . . 521 
403. Fibrous stricture of the rectum . . 525 
404. Stricture of the rectum . . . 525 
405. Cauliflower epithelial cancer of the 
rectum 527 
406. Hollow gum rectal bougie guided by 
the finger 528 
407. Rectal bougies with rounded or blunt 
extremities ..... 529 
408. Conical-shaped rectal bougies . . 529 
409. Olive-shaped rectal bougies . . 529 
410. Instrument for rupturing or dilating 
a rectal stricture .... 530 
411. Forceps to divulse a rectal stricture . 530 
412. Instrument for dividing rectal stric- 
ture 531 
413. MacBride yoke applied . . . 533 
PIG. PAG* 
414. Division of the structures in a fistula 
in ano ...... 538 
415. Group of prolapsed hemorrhoids . 541 
416. Section of an internal hemorrhoid . 541 
417. Hose for irrigating hemorrhoids . 544 
418. Rectal obturator for retaining piles . 544 
419. Hemorrhoidal truss .... 544 
420. Needle armed with a thread . . 545 
421. Smith’s clamp for piles . . . 546 
422. Cautery ...... 546 
423. Ligature applied to hemorrhoid . . 548 
424. Ecraseur applied .... 548 
425. Author’s rectal chemise . . . 549 
426. Sacculated and pyriform hernial sacs . 551 
427. Gomrig’s modified Hood truss . . 555 
428. Inguinal truss, with pad turned 
down so as to answer for a femoral 
hernia ...... 555 
429. Truss for umbilical hernia . . . 556 
430. Hard rubber truss for inguinal hernia 556 
431. Another form of same truss . . 556 
432. Umbilical truss ..... 556 
433. Ring hard rubber truss . . . 556 
434. Single French truss .... 557 
435. Chase’s truss ..... 557 
436. Wutzer’s hernia instrument . . 558 
437. Author’s instrument for the cure of 
hernia ...... 559 
438. Author’s needle ..... 559 
439. Wire shown in inguinal canal . . 561 
440. Dowell’s needle ..... 561 
441. Sac dissected free from the cord . . 563 
442. Sac drawn into the internal ring . 563 
443. Plicated arrangement of the neck of 
the sac ...... 568 
444. Direct linear incision over the hernial 
tumor ...... 574 
445. First incision, by transfixing a fold of 
integument . . . . .575 
446. Finger seeking for the stricture . .576 
447. Stricture at neck of sac . . . 576 
448. Cooper's hernia bistoury . . . 577 
449. Levis’s notched hernia director . . 577 
450. Allis’s hernia bistoury . . . 578 
451. Spica of the groin, to retain the dress- 
ing after operation for hernia . 579 
452. Anatomy of inguinal hernia . . 585 
453. Direct and oblique inguinal hernias . 585 
454. Inguinal scrotal hernia . . . 586 
455. Inguinal scrotal hernia, congenital . 586 
456. Infantile scrotal hernia . . . 587 
457. Encysted hernia. . . . . 587 
458. Truss adjusted, inguinal hernia . . 590 
459. Truss adjusted, posterior view . . 590 
460. Truss for single inguinal hernia . 590 
461. Rubber truss, without dorsal pad . 590 
462. Rubber truss, double inguinal hernia . 590 
463. Truss applied to inguinal hernia . 591 
464. Truss applied to inguinal hernia from 
the affected side .... 591 
465. Truss applied for double inguinal her- 
nia ....... 591 
466. Poupart’s ligament and the region of 
femoral hernia .... 593 
467. Anatomy of femoral hernia . . 594 
468. Femoral hernia 594 
469. Femoral hernia, truss applied . . 598 
470. Umbilical hernia .... 600 
471. Cork pad bandage for hernia . . 601 
472. Umbilical truss ..... 601 
473. Umbilical truss applied . . .601 
474. Side view of apparatus for umbilical 
hernia 601 
475. Concave pad for irreducible umbilical 
hernia 602 
476. Tenaculum with detachable handle . 610 
477. Palmar fascia 611 LIST OF ILLUSTRATIONS TO VOLUME I. 
19 
MG. PAGE 
478. Superficial palmar arch and its digital 
branches 612 
479. Topography of the hand,—position of 
the palmar arch and its branches . 612 
480. Aneurismal varix, or cirsoid aneurism, 
of the scalp ..... 615 
481. Arterial dilatation of vessels in the 
palm of the hand and fingers . 615 
482. Naevus occupying a cranial bone . 617 
483. Intricate convolution of vessels in 
naevi 618 
484. Submucous venous angeioma of the 
upper lip 619 
485. Submucous venous angeioma of the 
lower lip ..... 619 
486. Venous angeioma of the hand . . 619 
487. Section of a venous angeioma . . 620 
488. Pins passed beneath a naevus . . 621 
489. Tying a naevus with a pin and double 
ligature ...... 621 
490. Double ligature passed under the 
naevus ...... 621 
491. The subcutaneous ligature applied . 622 
492. Erichsen’s double ligature applied to 
an elongated naevus . . . 622 
493. The loops divided and section of 
naevus tied 623 
494. Venous angeioma of the face . . 623 
495. Angeiomatous tumor of the lip . . 623 
496. Varicose disease of the saphena magna 632 
497. Varicose state of superficial veins of 
the abdomen 632 
498. Longitudinal section of a vein, show- 
ing the unequal thickening of its 
walls 634 
499. Varicose condition of the saphena in- 
terna ...... 635 
500. Elastic stocking applied . . . 636 
501. Elastic stocking including the entire 
limb 637 
502. Internal coat divided, external one 
unbroken ..... 639 
503. Forms of incised wounds of arteries . 640 
504. Calcification of arch of the aorta . 643 
505. Calcification of the brachial artery . 644 
506. Microscopic appearance of arterial 
atheroma ..... 644 
507. Fusiform aneurism, with lamellae . 648 
508. Sacculated aneurism of the arch of the 
aorta 648 
509. Aneurismal sac consisting of the three 
tunics of the artery . . . 649 
610. Sac formed of the middle and external 
coats of the vessel .... 649 
511. The internal and middle coats broken 649 
512. Aneurismal sac which has burst . 650 
513. Rupture of the sac of aneurism and 
formation of second . . . 650 
514. Popliteal sacciform aneurism . . 651 
615. Fusiform aneurism of the aorta . . 651 
516. Concentric deposition of the layers of 
fibrin 651 
517. Collateral circulation after ligature of 
the femoral ..... 664 
518. Hunter’s, Brasdor’s, and Wardrop’s 
operations 669 
519. Signorini tourniquet .... 671 
520. Bellingham clamp .... 672 
521. Carte’s compressor .... 672 
522. Carte’s circular compressor . . . 672 
523. Watson’s weight compressor . . 672 
524. Charriere’s compressor as modified by 
Gibbons 673 
525. Briddon compressor .... 673 
526. Dissecting aneurism .... 680 
527. Dissecting aneurism of the aorta . 680 
528. Horner’s awl ..... 682 
FIG. PAGE 
529. Traumatic (circumscribed) aneurism 
in the palm of the hand . . 683 
530. Traumatic (circumscribed) aneurism 
of the radial artery . . . 683 
531. Direct aneurism, oraneurismal varix . 684 
532. Intermediate or varicose aneurism . 684 
533. Aneurism of the arch of the aorta . 687 
534. Diagram of ligation of an aneurism of 
the innominate .... 696 
535. Intraorbital aneurism . . .710 
536. Intraorbital aneurism by anastomosis . 711 
537. Aneurism of aorta near its bifurcation 719 
538. Abdominal aneurism . . . . 719 
539. Scalpel ...... 735 
540. Forceps 735 
541. Tenaculum ...... 735 
542. Grooved director .... 735 
543. Retractor ...... 735 
544. Eyed probe ..... 735 
545. Tourniquet 735 
546. Cooper's aneurismal needle . . 735 
547. Parrish’s aneurismal needle . . 735 
548. Fingers searching for the vascular 
groove 736 
549. Incision for ligation .... 736 
550. Retractors holding aside the sides of 
the incision ..... 737 
551. Division of the sheath . . . 737 
552. The carotid and its branches exposed . 741 
553. Lines of incision for the ligation of the 
arteries of the neck . . . 742 
554. Sides of the wound held asunder by re- 
tractors ...... 743 
555. Collateral circulation after ligature of 
the common carotid . . .743 
556. Anatomical components of the supe- 
rior cervical triangle . . .749 
557. Relations of the lingual artery . . 751 
558. Facial, occipital, and temporal arteries 
exposed ...... 754 
559. Anatomy of subclavian region . .757 
560. Ligation of the subclavian artery . 759 
561. Collateral circulation after ligation of 
the subclavian .... 761 
562. Anatomy of the pectoral region . . 764 
563. Interpectoral fascia .... 765 
564. Deep pectoral or true axillary fascia . 766 
565. Surgical relations of the axillary ar- 
tery 767 
566. Surgical relations of the axillary ar- 
tery 768 
567. Line of the axillary artery . .769 
568. Incision over axillary artery . .769 
569. Ligation of the axillary . . . 770 
570. Brachial artery encircled by the liga- 
ture ...... 771 
571. Ligation of the brachial artery at the 
middle and lower thirds . . . 772 
572. Surgical anatomy of the forearm . 773 
573. Lines of the radial and ulnar arteries 773 
574. Incision for the ligation of the radial 
artery at its upper third . . 773 
575. Ligation of the radial at its lower third 774 
576. Ligation of the radial at its lower third 774 
577. Ligation of the radial and ulnar arte- 
ries 774 
578. Ligation of the radial at the root of 
the thumb 775 
579. Anastomosis between the radial and 
ulnar recurrent arteries . . . 775 
580. Author’s retractor for holding aside 
the peritoneum during the opera- 
tion upon the iliac arteries . . 777 
581. Peritoneum pushed up and the exter- 
nal iliac artery raised on the liga- 
ture ...... 777 
582. Gluteal and ischiatic arteries . . 779 20 
LIST OF ILLUSTRATIONS TO VOLUME I. 
FIG. PAGE 
583. Relation of the common, external, and 
internal iliac arteries to their ac- 
companying veins .... 780 
584. Collateral circulation after ligation of 
the common iliac artery . . . 780 
585. Anatomy of Scarpa’s triangle . . 784 
586. Femoral artery in Hunter’s canal . 785 
587. Ligation of the femoral artery at the 
apex of Scarpa’s triangle . . 786 
588. Ligation of the femoral artery in the 
aponeurotic canal .... 786 
689. Ligation of the popliteal . . .788 
590. Popliteal artery exposed . . . 788 
591. Anatomy of the posterior tibial artery 789 
592. Ligation of the posterior tibial at its 
upper third 790 
593. Ligation of the posterior tibial above 
the ankle ..... 790 
594. Relation of the anterior tibial artery 
to the muscles of the leg . . 791 
595. Line showing the course of the ante- 
rior tibial in the leg . . . 792 
596. Ligation of the anterior tibial at the 
lower third of the limb . . . 793 
597. Incision for ligation of the dorsalis 
pedis 793 
598. Incomplete fracture of the radius . 796 
599. Comminuted fracture .... 797 
600. Compound comminuted fracture of the 
leg 797 
601. Impacted fracture of the neck of the 
femur 797 
602. Oblique fracture 797 
603. Transverse fracture .... 797 
604. Epiphyseal fracture .... 798 
605. Longitudinal fracture . . . 798 
606. Angular displacement . . . 799 
607. Rotatory displacement . . . 799 
608. Disposition of the blood after a frac- 
ture 802 
609. Spindle-shaped appearance of the re- 
parative material .... 803 
610. External and internal callus . . 803 
611. Position of the reparative material in 
a fracture with overlapping . . 803 
612. Establishment of the medullary canal 804 
613. Transportation of a patient upon a 
settee 810 
614. Fracture-bedstead made from an ordi- 
nary bedstead .... 811 
615. Jenks’s fracture-bed .... 811 
616. Binders’-board splint .... 812 
617. Perforated tin and zinc splints . . 812 
618. Wire splints 813 
619. Ahl’s felt splints .... 813 
620. Wooden slats pasted to sheepskin . 813 
621. Apparatus for rolling plaster ban- 
dages 814 
622. Yon Bruns’s cutting pliers . . . 815 
623. Bran-bag ...... 815 
624. Fracture - cradle for supporting the 
bedclothing ..... 817 
625. Ununited fracture, with rounding of 
fragments ..... 824 
626. Ends of an ununited fracture con- 
nected by fibrous tissue . . . 824 
627. Ununited fracture simulating a ball- 
and-socket joint .... 824 
628. Ununited fracture united by callus . 824 
629. Smith’s apparatus for ununited frac- 
ture of the thigh .... 825 
630. Smith’s apparatus for ununited frac- 
ture below the knee . . . 825 
631. Humerus treated by Physick for un- 
united fracture .... 826 
632. Dieffenbach’s drill .... 826 
633. Awl-shaped drill .... 827 
FIG. PAGE 
634. Gimlet for pinning together the frag- 
ments ...... 827 
635. Hamilton’s bone-drill . . . 827 
636. Bone-drill ...... 828 
637. Overlapping of the ends of a broken 
bone ...... 847 
638. Angular union of a fracture of the 
femur ...... 847 
639. Lower fragment of the femur rotated 
outward ...... 847 
640. Deformed union of the radius and 
ulna ...... 848 
641. The same corrected instantaneously . 848 
642. Splint placed on the concave side of a 
curve ...... 848 
643. Splint placed on the convex side of a 
curve 848 
644. Bone-drilling machine . . . 849 
645. Adams saw for subcutaneous division 
of the thigh-bone .... 849 
646. Kadius and ulna blended by callus . 850 
647. Redundant callus .... 851 
648. Exuberant callus following a gunshot 
fracture ...... 851 
649. Foot-drop from pressure by callus on 
the peroneal nerve .... 852 
650. Fracture of the spinous process and 
lamina ...... 864 
651. Comminuted fracture of the vertebrae 865 
652. Fracture of the odontoid process . 869 
653. Fracture of the odontoid process . 869 
654. Mercier catheter .... 871 
655. Double catheter 871 
656. Appearance after recovery from an ex- 
tensive fracture of the bones of the 
face 876 
657. Screw elevator 878 
658. Fracture through the body of the infe- 
rior maxilla ..... 880 
659. Double fracture of the inferior maxilla 880 
660. Splint cut out 882 
661. Cup for the jaw 882 
662. Barton’s bandage for fracture of the 
inferior maxilla .... 883 
663. Gibson’s bandage for fracture of the 
lower jaw ..... 883 
664. Garretson’s bandage for fracture of the 
lower jaw 883 
665. Hamilton’s bandage for fracture of the 
lower jaw ..... 883 
666. French apparatus for fracture of the 
lower jaw 884 
667. Crossed of the angle of the jaw for 
fracture through the neck of the 
condyle 884 
668. Gunning’s interdental splint . . 885 
669. Gunning’s interdental splint . . 885 
670. Gunning’s interdental splint applied . 885 
671. Kingsley’s interdental splint . . 886 
672. Bean’s interdental splint . . . 886 
673. Bean’s splint applied .... 886 
674. Fracture of a rib at its vertebral and 
also at its sternal extremity . . 892 
675. Fracture of ribs, with bridges of bone 893 
676. Adhesive strips applied . . . 894 
677. Double T of the chest . . . 894 
678. Fracture of the sternum . . . 897 
679. Oblique fracture through the middle 
of the clavicle .... 900 
680. Fracture at the acromial end of the 
clavicle 900 
681. Position of fragments in fracture of 
the clavicle 901 
682. Fracture of clavicle internal to the 
coraco-clavicular ligament . . 902 
683. Mayor’s handkerchief dressing for 
fracture of the clavicle . . . 904 LIST OF ILLUSTRATIONS TO VOLUME I. 
21 
FIG. PAGE 
684. Velpeau’s dressing for fracture of the 
clavicle ...... 904 
685. Moore’s figure-of-eight of the elbow 
for fracture of the clavicle . . 905 
686. Moore's figure-of-eight of the elbow, 
anterior view ..... 905 
687. Sayre’s dressing for fractured clavicle, 
posterior view ..... 906 
688. Sayre’s dressing for fractured clavicle, 
anterior view 906 
689. Axillary pad ..... 907 
690. Axillary pad secured by the first roller 
of Desault ..... 907 
691. The second roller of Desault . . 907 
692. The third roller of Desault . . 908 
693. Fox’s ring, sling, and pad . . . 908 
694. Front view of Fox’s apparatus . . 908 
695. Posterior view of Fox’s apparatus . 908 
696. Pad, sling, and strap of Levis’s clav- 
icle apparatus .... 909 
697. Front view of Levis’s apparatus ad- 
justed to a patient .... 909 
698. Posterior view of Levis’s apparatus 
adjusted to a patient . . .910 
699. Posterior eight for fractured clavicle . 910 
700. Fracture of the posterior angle of the 
scapula ...... 912 
701. Transverse fracture through the body 912 
702. Fracture of the acromion process . 914 
703. Fracture of the coracoid process of the 
scapula . . . . . .915 
704. Fracture of the coracoid . . . 916 
705. Fracture of the neck of the scapula . 916 
706. Stellate fracture of the glenoid cavity 
of the scapula . . . .917 
707. Fracture through the anatomical neck 
of the humerus .... 919 
708. Intra-capsular fracture of the neck of 
the humerus . . . . .919 
709. Impacted intra-capsular fracture of 
the humerus ..... 919 
710. Incomplete separation of the epiphysis 
of the humerus .... 921 
711. Fracture through the surgical neck of 
the humerus 922 
712. Fracture through the surgical neck of 
the humerus 923 
713. Author’s internal angular splint . 924 
714. Cap for the shoulder and the arm . 924 
715. Dressing for fracture of the surgical 
neck of the humerus . . . 925 
716. Arm bound to the body, the latter con- 
stituting the inner splint . . 925 
717. Fracture at the lower third of the hu- 
merus, with overlapping . . 926 
718. Paralysis of the extensors of the hand, 
or wrist-drop ..... 927 
719. Angular, concave, and short straight 
splints 927 
720. Dressing for fracture of the shaft of the 
humerus...... 928 
721. Apparatus for wrist-drop applied . 928 
722. Supra-condyloid fracture . . . 929 
723. Author’s anterior angular splint. . 930 
724. Posterior angular trough . . . 930 
725. Transverse and vertical fracture of the 
condyles of the humerus . . 930 
726. Fracture of the internal condyle . 931 
727. Fracture through the external condyle 
of the humerus .... 932 
728. Fracture of the internal epicondyle . 932 
729. Fracture of the external condyle, with 
backward displacement . . . 933 
730. Splint applied ..... 934 
731. Anterior angular splints of different 
angles ...... 934 
732. Articulated anterior angular splint . 934 
fig. PAGE 
733. Anterior angular splint, with a Stro- 
meyer screw ..... 934 
734. Obtuse angular trough-shaped felt 
splint 935 
735. Rectangular trough-shaped felt splint 935 
736. Lower fragments of forearm drawn 
partially between the upper ones . 939 
737. Overlapping of the upper and lower 
fragments of forearm . . . 939 
738. Lateral displacement .... 939 
739. Fracture dressing for both bones of 
the forearm ..... 940 
740. Fracture at the middle of the radius . 942 
741. Transverse fracture of the articulating 
extremity of the radius . . . 945 
742. Transverse fracture of the lower end 
of the radius and of the styloid 
process of the ulna . . . 945 
743. Fracture of the styloid process of the 
radius ...... 945 
744. Comminuted fracture of the carpal ex- 
tremity of the radius . . . 945 
745. Comminuted fracture of the radius . 945 
746. Fracture described by Barton . . 945 
747. Silver-fork deformity of Velpeau . 946 
748. Fracture of the styloid process of the 
radius and of the ulna, with great 
abduction of the hand . . . 947 
749. Deformity after fracture of the styloid 
process of the radius . . . 947 
750. Dressing for fractures at the lower end 
of the radius ..... 948 
751. Nelaton splint applied . . . 949 
752. Board cut to conform to the outline of 
the forearm ..... 950 
753. Bond's splint for fracture at the lower 
end of the radius .... 950 
754. Shape of Hays’s splint . . . 950 
755. A view of Hays’s modification of Bond’s 
splint ...... 951 
756. Coover’s splint for fracture at the lower 
end of the radius .... 951 
757. Levis’s splint for Colies’s fracture . 951 
758. Oblique fracture through the base of 
the olecranon ..... 953 
759. Fracture through the base of the olec- 
ranon process 953 
760. Fracture of the olecranon process, with 
ligamentous union .... 954 
761. Adhesive plaster securing the olec- 
ranon process in position . . 954 
762. Dressing with slight flexion . . 954 
763. Dressing with full extension . . 955 
764. Sir Astley Cooper’s dressing . . 955 
765. Hamilton’s dressing .... 956 
766. Fracture of the coronoid process . 956 
767. Splint for fracture of the carpus and 
metacarpus ..... 960 
768. Splints for fracture of the phalanges . 961 
769. Fracture of the ilium .... 965 
770. Fracture of the rami of the pubis . 966 
771. Fracture of the ramus of the ischium 967 
772. Fracture of the acetabulum and of the 
ramus of the ischium . . . 968 
773. Head of the femur driven into the 
pelvis 972 
774. Femur at middle life .... 972 
775. Femur in old age .... 972 
776. Complete intra-capsular fracture . 973 
777. Oblique intra-capsular fracture . . 973 
778. Impacted fracture, intra-capsular . 974 
779. Neck of femur absorbed after intra- 
capsular fracture .... 974 
780. Displacement following fracture 
through the neck of the femur . 976 
781. Fascia lata in fracture of the neck of 
the femur 976 22 
LIST OF ILLUSTRATIONS TO VOLUME I. 
fig. PAGE 
782. Prof. H. H. Smith’s case of supposed 
bony union after an intra-capsular 
fracture .977 
783. Senile atrophy of the neck of the femur 978 
784. Ligamentous union of intra-capsular 
fracture ...... 979 
785. Limb placed over a double inclined 
plane formed by pillows . . . 980 
786. Fraeture in the course of the inter- 
trochanteric lines .... 980 
787. Transverse fracture .... 980 
788. Comminuted extra-capsular fracture . 981 
789. Impacted fracture of the neck of the 
femur ...... 981 
790. Excessive callus following an ununited 
extra-capsular fracture . . . 985 
791. Redundant callus in an ununited ex- 
tra-capsular fracture . . . 985 
792. Fracture of the epiphysis of the tro- 
chanter major, with a fracture of 
the condyles ..... 986 
793. Displacement of the upper fragment 
of the femur in a fracture at the 
upper third 990 
794. Deformed union of a fracture at the 
upper third of the femur . . 990 
795. Fracture of the femur at the middle 
third ...... 991 
796. Diagram illustrating the supposed dis- 
placement of the lower fragment of 
the femur ..... 991 
797. 798. Uprights for pulley . . . 993 
799. Short strip for fastening the foot-board 
to the long extending band . . 993 
800. Extension apparatus ready to be ap- 
plied 993 
801. Extension apparatus applied to the 
limb ...... 994 
802. Dressing for fracture of the shaft of the 
femur ...... 994 
803. Levis’s extending apparatus . . 995 
804. Fracture at the upper third dressed on 
a double inclined plane . . . 996 
805. McIntyre’s splint .... 996 
806. McIntyre’s splint applied, as modified 
by Liston 997 
807. N. R. Smith's anterior wire splint . 997 
808. Limb suspended by the anterior splint 
of N. R. Smith .... 998 
809. Apparatus applied for fracture at the 
upper third of the thigh . . 998 
810. Upright or stanchion .... 999 
811. Making extension for the plaster 
dressing 999 
812. Oblique fracture immediately above 
the condyles of the femur . 1000 
813. Upper fragment in front of the con- 
dyles of the femur .... 1000 
814. Impacted fracture above the condyles 
of the femur ..... 1000 
815. Fracture of the external condyle . 1001 
816. Double inclined plane of Bell, properly 
James’s ...... 1002 
817. Amesbury’s double inclined plane 
splint 1002 
818. Amesbury’s splint applied . . . 1002 
819. Liston’s splint and junk-bag . . 1003 
820. Liston’s splint applied . . . 1003 
821. Boyer’s splint applied . . . 1004 
822. Application of the Scultetus bandage . 1004 
823. Desault’s apparatus applied . . 1004 
824. Hutchinson’s modification of Physick’s 
splint 1005 
825. Physick’s and Hutchinson’s modifica- 
tion of Desault’s splint applied . 1005 
826. Hodge’s attachment to Physick’s long 
splint 1005 
FIG. PAGE 
827. Hodge’s splint applied . . . 1006 
828. Hartshorne’s splint .... 1006 
829. Hartshorne’s splint applied . . 1006 
830. Horner’s modification of Physick’s and 
Desault’s splint .... 1007 
831. Horner’s dressing applied . . . 1007 
832. Gurdon Buck’s dressing applied . . 1008 
833. Gibson’s single inclined plane . . 1008 
834. Dressing for fracture of the thigh in a 
child 1010 
835. Fracture through the epiphysis of the 
femur, with irregular surface . 1010 
836. Fracture through the epiphysis, sepa- 
ration smooth .... 1010 
837. Packard’s bracketed splint. . . 1012 
838. Bracketed extension splint for com- 
pound fracture of the thigh . . 1012 
839. Comminuted fracture of the patella, 
also transverse fracture of the pa- 
tella united by fibrous tissue . . 1013 
840. Separation of the fragments of the 
patella by the action of the quadri- 
ceps muscle ..... 1013 
841. Depression in front of the knee . . 1014 
842. Author’s splint for fractured patella . 1015 
843. Author’s splint applied . . . 1016 
844. Hamilton’s splint for fractured patella 
applied 1017 
845. Dorsey’s splint for fractured patella . 1020 
846. Burges’s apparatus for fractured pa- 
tella 1020 
847. Lausdale’s apparatus for fracture of 
the patella 1021 
848. 849. Boisnot’s apparatus for fractured 
patella . . . . . . 1021 
850. Hartshorne’s apparatus . . . 1021 
851. Gerdy’s dressing . .... 1021 
852. Sir Astley Cooper’s dressing for frac- 
tured patella 1022 
853. Levis’s apparatus .... 1022 
854. Malgaigne’s hooks .... 1022 
855. Fracture at the upper extremity of the 
tibia and fibula .... 1024 
856. Anterior angular deformity and over- 
lapping following fracture . . 1025 
857. Boyer’s dressing for fracture of the 
bones of the leg .... 1026 
858. Fracture-box with hinged sides . . 1026 
859. Fracture of the leg dressed with the 
fracture-box ..... 1027 
860. Fracture of the leg treated by the box 
and suspension apparatus . . 1028 
861. Salter’s cradle 1028 
862. Fracture of the bones of the leg dressed 
by extension in the fracture-box . 1029 
863. Adhesive plasters applied to the heel 
and instep 1029 
864. Neill’s mode of applying extension and 
counter-extension .... 1029 
865. Neill’s long fracture-box for treatment 
of compound fractures of the leg with 
overlapping 1029 
866. Splint for treating fracture of the bones 
of the leg in the Pott position . . 1030 
867. Bindefs’-board splint for fracture of 
the leg 1030 
868. Liston’s McIntyre splint applied . 1031 
869. Perforated tin splint .... 1031 
870. Malgaigne’s apparatus for oblique frac- 
ture of the leg applied . . . 1031 
871. Fracture of the shaft of the tibia . 1032 
872. Fractured malleoli and lower end of 
the tibia 1032 
873. Bavarian immovable splint . . 1034 
874. Articular surface for the astragalus . 1035 
875. Fracture at the lower fifth of the fibula, 
with the attendant deformity . . 1036 LIST OF ILLUSTRATIONS TO VOLUME I. 
23 
FIG. PAGE 
876. Deformity after a badly-treated Pott’s 
fracture ...... 1037 
877. Dupuytren splint applied . . . 1037 
878. Splint for support of the ankle after 
fracture with deformity . . . 1038 
879. Comminuted fracture of the post-as- 
tragaloid portion of the os calcis . 1042 
880. Double angular or Pott’s splint, 
modified for fracture of calcaneum . 1043 
881. Monro’s modification of Thillaye’s 
apparatus for fracture of calcaneum 1044 
882. Monro’s dressing for fracture of the os 
calcis ...... 1044 
883. Osteophytes, from osteitis . . . 1050 
884. Caries or ulcer of the tibia . . 1051 
885. Silver probe 1053 
886. Author’s spiral wire probe . . . 1053 
887. Gouge for removing carious bone . 1054 
888. Gouge forceps ..... 1054 
889. Bone scraper ..... 1054 
890. Bone scraper ..... 1054 
891. Burr-head drill ..... 1054 
892. Abscess in the head of the tibia . . 1055 
893. Death of the entire humerus from os- 
teomyelitis ..... 1057 
894. Sclerosis of the femur . * . 1059 
895. Sclerosis of the femur, with irregular 
periosteal deposits .... 1059 
896. Cylindrical sequestrum from the femur, 
following amputation . . . 1064 
897. Cylindrical sequestrum from the femur 1064 
898*. Sequestrum formed by the entire di- 
aphysis of the tibia surrounded by 
new bone ..... 1065 
PIG. PAGE 
899*. Extra-granular deposition of bone in 
necrosis of the humerus . . . 1065 
900*. Nodulated deposition of callus in ne- 
crosis of the shaft of the tibia . 1065 
901*. Necrosis of the tibia, with cloacae . 1065 
902*. Necrosis of the tibia, with a seques- 
trum protruding through a cloaca . 1066 
903*. Tubular sequestrum of the femur after 
amputation 1066 
904*, 905*, 906*. Different forms of bone 
chisels 1068 
907*. Hammer 1068 
908*, 909*. Bone pliers .... 1069 
910*, 911*, 912*. Different forms of bone 
forceps ...... 1069 
913*. Lever 1069 
914*. White’s surgical engine . . . 1070 
915*. Drills of different sizes . . . 1070 
916*. Trephine 1070 
917*. Two views of the circular saw . . 1070 
918*. Two views of the circular knife . 1070 
919*. One form of the burr drill . . 1070 
920*. Bonwill’s surgical engine . . . 1071 
921*. Rachitic skeleton in the museum of 
the University of Pennsylvania . 1075 
922*. Curved tibia and fibula from rachi- 
tis ... . . 1076 
923*. Supplemental hypertrophy . . 1083 
924*. Expansive hypertrophy of the occipi- 
tal bone ...... 1083 
925*. Hypertrophy including all the layers 
of the skull bones .... 1083 
926*. Hypertrophy of the tibia with an- 
terior curvature .... 1084 PRINCIPLES AND PRACTICE 
OP 
SUEGEEY. 
CHAPTER I. 
SUBGICAL DIAGNOSIS. 
That is an exceedingly crude and erroneous conception which regards 
surgery as a mere handicraft, or as an art restricted to the treatment of 
external disease. It will never be possible to draw the lines which separate 
this department of seientitic knowledge from that of medicine: the two are 
indissolubly one, and all attempts to divorce them detract from both the 
dignity and the power of the surgeon. 
The successful management of disease presupposes its distinct recognition. 
Without such antecedent knowledge the practitioner is not only incompetent 
to administer to the necessities of his patient, but is also liable to commit ir- 
reparable mischief. To determine with certainty the nature of a malady by 
stripping away all disguises, involves in many instances well-trained habits 
of observation and an enlightened judgment. It is my design, therefore, 
on entering upon this work, to devote a few pages to the subject of surgical 
diagnosis. 
Anatomy, physiology, pathology, organic chemistry, and physics form the 
ground-work of diagnosis. For the proper interpretation of morbid phe- 
nomena the senses must be carefully educated and the mind trained to 
precise logical methods of thought. There is a very great difference in the 
rapidity with which different men, of unquestioned surgical ability, form 
their judgments on the nature of disease or injury. There are some who 
reach their conclusions with a celerity which resembles more an intuition 
than an orderly process of deductive reasoning; while others pass over the 
same ground like the prudent general who fortifies every captured post 
as he advances into the enemy’s country. On the whole, the latter are 
those who meet with the fewest defeats. The nature of many affections 
is so obvious that recognition is possible on the instant; but there are other 
maladies, and perhaps a larger number, which demand for their compre- 
hension the most careful and exhaustive investigation. As the issues of 
life and death are often suspended on the decision arrived at by such in- 
quiries, it becomes every surgeon to feel the solemnity and the responsibility 
of his work. 
A third class of cases will he encountered, so obscure and unpronounced as 
to baffle the keenest analysis. Whenever, therefore, the surgeon is compelled 
to proceed on a basis of probabilities, it is in most instances a good rule to 
wait. Often in my professional life, when in a maze of doubt and uncer- 26 
SURGICAL DIAGNOSIS. 
tainty, have I imitated with the happiest results the storm-beset mariner, 
who, in the darkness of the night, and nearing an unknown coast, casts 
anchor and waits for the day. A few hours even of delay may open a crevice 
in a hitherto hidden case of disease, which will be sufficient to illuminate 
its obscurity and resolve all uncertainties. 
The difficulties which are encountered in the investigation of morbid 
phenomena arise from several causes. First, there is on the part of many 
persons a disinclination to communicate information which would appear in 
any way to reflect on the moral or social character of themselves or their 
families, and hence they will deliberately withhold testimony which is neces- 
sary to the proper understanding of their disease. Secondly, many affections 
diverse in nature present phenomena having common points of resemblance. 
Thirdly, there is an individual peculiarity or idiosyncrasy, that is, some pecu- 
liar stamp of organization which renders its possessor, in his or her suscep- 
tibility to, or behavior under, morbid impressions, unlike the majority of 
other persons under the influence of similar causes. And, fourthly, there 
exists the power of reflex and sympathetic action dependent on physiological 
and anatomical peculiarities of structure, to mask, or to divert attention 
from, the real seat of trouble. 
There are two factors concerned in forming a diagnosis,—the senses and 
the reason, or the physical and the rational. By the first the mind receives 
those impressions which, being compared and classified, are compacted into 
a judgment or an opinion. 
There are two modes of investigating disease, namely, by analysis and 
by synthesis. In the first, our inquiries commence at the beginning of the 
affection, thence following it down to the time of examination; in the second 
method the order is reversed, the disease being traced back to its origin. 
The first or analytical process is generally adopted, though it will often 
he found necessary to use the other, or synthetical, plan. Whichever course 
is pursued, the certitude of a conclusion in many cases can be attained only 
by elimination, that is, by systematically excluding the diseases which most 
closely resemble the one under consideration, thereby proving what it is by 
demonstrating what it is not. Generally speaking, it is preferable, in insti- 
tuting an inquiry with a view to discover the character of a complaint, to 
begin with the general history of the case, and afterwards to take up its 
particular characteristics. This course has the twofold advantage of being 
the most natural method of procedure and of establishing confidential and 
pleasant relations between the practitioner and his patient. To secure the 
last is of the utmost importance to the success of the examination. 
Some men are singularly unfortunate in this respect: they are never able 
to secure the confidence of the sick; while others, by a cheerful manner, by 
a few kind, assuring words, and by an attractive address, obtain in a few 
moments a magnetic mastery over their patients. In pursuing the examina- 
tion the patient may, if intelligent, be allowed to give his or her own history of 
the disease, but should he kept closely to the subject, and all digressions should 
be discountenanced. There is much skill in questioning. The interrogations 
should be put in plain, simple words, free from ambiguity and technicalities, 
and the answers required should be terse. No suggestive or leading ques- 
tions ought to be asked, as these tend to give color to the answers. Every- 
thing like levity of manner or merriment at the language used by patients is 
improper, if not cruel. No interrogation should be made merely from motives 
of curiosity, and such as are of a private nature should be couched in the most 
delicate and least offensive phraseology. Many questions of this nature, when 
the patient is a young woman, are best addressed through a female friend. In 
the examination of females, except when absolutely necessary, no part of the 
body should be uncovered. No needless repetition of instrumental explora- 
tions, or of painful movements, is justifiable. The surgeon must not forget 
t he moral transformations of character wrought by disease, by which the most 
amiable and self-possessed become peevish, morose, and irritable ; and he must SURGICAL DIAGNOSIS. 
27 
make due allowance for deportment which under other circumstances would 
be properly esteemed rude and uncivil. He must also assure, by a concilia- 
tory and encouraging manner, the unlettered, who, from want of training 
in the use of language and in the command of words, are unable fittingly to 
communicate their sensations. Under all circumstances of intercourse with 
the sick and injured, let the surgeon never forget that being himself human, 
and therefore liable to be overtaken by the same diseases, the same accidents, 
and the same misfortunes as the humblest of his fellow-beings, he should be 
ready to compassionate and to sympathize with them in their distresses, in 
their infirmities, and in their mental eccentricities. Especially have the 
poor the strongest claims to our consideration. To be sick is ordinarily 
esteemed a misfortune, but to be both poor and sick is a trial to the spirit 
of no ordinary kind. 
In the investigation of a surgical disease there are two lines of inquiry 
to be pursued,—the general and the special. The first, or general, consists 
in eliciting a historical narrative from the patient or his friends, with 
reference to his past life and the disease under which he labors. Under 
the first inquiry will come the age, sex, occupation, habits, mental and 
moral states, antecedents, social condition, residence, information derived 
from others, and duration. Under the second will be included the testimony 
of the senses. 
Age.—The age of a patient has a most important bearing on the examina- 
tion of a case of disease. In the very young the exalted sensibility of the 
nervous system imparts a peculiar complexion to many of the affections of in- 
fantile life. Thus, the mere irritation of the gum in dentition or of a narrow 
prepuce is sufficient, through reflex irritability, to excite the most violent 
spasmodic agitation of the entire muscular system. It is also during the 
period of infantile and adolescent life that those morbid phenomena which 
are comprised under the generic term struma, or scrofula, make their ap- 
pearance. A tumor in the neck of a child suggests at once an adenoid 
growth or an angeioma. A pain at the knee, accompanied with slight lame- 
ness, arouses a suspicion that the case is one of coxalgia. In adults, or in 
advanced life, the cervical enlargement would probably be either cystic, 
fatty, or sarcomatous, whilst pain and lameness, complained of in the lower 
extremity, would be referred to a rheumatic origin. Abdominal pains in 
a child, a disturbed, grunting respiration, and unusual postures of the body 
for rest after taking exercise, would suggest the probability of spinal disease. 
A spreading ulcer on the oral surface of the cheek of a young person would 
be diagnosed as noma or cancrum oris, while similarly situated in an adult it 
would probably prove to be a malignant affection. 
Again, force applied near to the extremities of a long bone in a youth 
is liable to cause a separation of the epiphysis,—an accident which would 
be impossible in an adult. A blow which in mature life causes a fracture 
through the shaft of the femur would, in an aged person, most likely result 
in an intra-capsular fracture. Irritation of the bladder in a young subject 
would be referred to the presence of calculus or to a tight phimosis; but 
in an adult, or in a person over fifty, the investigation would have to include 
the consideration not only of stone, but also of stricture, cystitis, hypertrophy 
of the prostate body, and hemorrhoids,—diseases which more especially be- 
long to mature and advanced life. 
Sex.—The peculiarities of sex exercise both a determining and a modify- 
ing influence on morbid processes. There exists a radical difference, both 
psychical and physical, between the male and the female, and no amount of 
training, under the modern interpretation of the equality of the sexes, can 
ever remove this distinction without at the same time destroying the true 
grace and dignity of the female character. The sexual system of woman, 
reacting upon a susceptible organization, imparts a shading to most of her 
diseases. The perturbing influence resulting from commencing menstru- 
ation and from its disappearance is exhibited in peculiar derangements of 28 
SURGICAL DIAGNOSIS. 
the nervous and muscular systems. Thus, we have convulsions, hysterical 
joints, hysterical blindness, spurious paralysis, irritable bladder, and, farther 
on towards the climacteric decline, fibroid and carcinomatous growths of the 
uterus and of the mammae. 
Males, on the contrary, enjoy a remarkable immunity from these affec- 
tions. Among them, hysterical disturbances are comparatively unknown. If 
a male suffer from cancer, it is generally of the epithelial form, and on the lip; 
if from articular disease, it will not be a simulation, but a genuine inflam- 
matory attack, rheumatic or otherwise; if attacked by convulsions, they 
will usually be epileptic, and indicative of serious cerebral disease ; if over- 
taken by paralysis, the brain or the spinal marrow will probably be found to 
have suffered some lesion; if vesical trouble is experienced, the symptoms 
will depend as a rule on structural, not on functional, changes. 
Both sexes are liable to hernia; but femoral rupture is most common in 
females, and inguinal in males. Disorders of the heart and blood-vessels are 
common in both men and women. In the former they are often the expres- 
sions of atheroma, aneurism, or valvular disease; in the latter they are 
generally the result of transmitted irritation. 
The predominance of the functional and the emotional in females should, 
however, never be allowed to betray the surgeon into error, by causing him 
to relax the vigilance of his watch for the real disease, or by inducing him to 
form hasty conclusions. Through mistakes of this kind many women have 
suffered long, and at length have fallen victims to maladies which, had they 
been early recognized, might have been cured. 
Occupation exercises no small degree of influence in predisposing persons 
to certain diseases. Examples of this are seen in the enlargement of the 
bursa in front of the patella, commonly called “ housemaid's knee,” and in 
the little bursal tumors which form over the olecranon processes of the ulna 
in the school-boy who rests upon the points of his elbows. 
Persons who are obliged in the prosecution of their business to work in 
damp or wet localities frequently suffer from rheumatic and bone affections. 
Occupations or trades which expose the operators to gaseous emanations 
furnish examples of disease. In this way are produced necrosis of the jaw 
and stomatitis from the vapors of phosphorus and mercury. In callings 
demanding great muscular strain, the predisposition to aneurism and to 
cardiac disorder is marked; and it is to be feared that some of the popular 
amusements of the day, such as boat-racing and gymnastics, contribute to 
the same result. Carters, stevedores, and laborers, who, from the nature of 
their vocations, are often led to consume large quantities of stimulants, are 
prone to attacks of delirium tremens on the reception of any severe injury. 
This is often witnessed in our hospitals among patients who have met with 
fractures. 
Another familiar illustration of the effect of occupation in the production 
of disease is the soot-cancer which attacks the scrotum of chimney-sweeps. 
The employment of individuals should not escape our notice in those in- 
stances of spinal curvature, or of loss in the bilateral symmetry of the limbs, 
which are occasionally encountered, and which, without some explanation of 
this kind, would constitute a source of much anxiety. A man constantly 
working a foot-lathe or a single-handed lever will, by his business, materially 
modify the nutrition, and consequently the size, of the limb used in driving 
such instrument. The shoemaker also who, while at his bench, constantly 
bends over his work, will in time change the curves of his spine and the 
conformation of his chest. 
Habits.—Many of the ailments which overtake individuals are self-inflicted. 
They follow as a consequence of pernicious habits, and a knowledge of these 
at once discloses the true character of many morbid phenomena. Thus, a 
sore on the prepuce or on the glans penis, if known to follow impure con- 
nection, will at once be pronounced a chancre; if a patient presents himself 
with purulent urethritis, the confession of a previous intercourse with a SURGICAL DIAGNOSIS. 
29 
“ woman of the town” will determine its probable character. A virtuous 
and pure-minded young woman, or an innocent nurse, may present symp- 
toms of such a character as would seem to challenge her personal purity; 
hut if it can be ascertained that the lover of the first suffered from a 
syphilitic crack or ulcer of the lip, or that the infant which nursed from 
the breast of the last came into the world with a hereditary taint, we can 
perfectly comprehend how the presence of this loathsome curse may be 
entirely consistent with the innocence of its victim. 
So in regard to sexual weakness, or to impotency, both the diagnosis and 
the prognosis will be materially assisted by ascertaining that the loss of 
power is the effect of venereal excess. 
An ophthalmologist, in certain obscurations of the vision which result 
from the excessive use of tobacco, would give a most unfavorable prognosis 
did he not learn that the patient was an inveterate smoker. 
Mental and moral states.—The power of the mind and of the emotions over 
the organic functions of the body is generally conceded, but that it is a more 
common factor in the production of disease than is generally allowed 1 doubt 
not. Many times have I witnessed instances of irritable bladder accom- 
panied by turbid urine following the simple harass and worry of mercantile 
and other business complications. I have seen almost complete suppression 
of the urinary secretion continue for days in a person who, in a state of 
intense anxiety, watched by the bedside of a sick friend. A heart-murmur 
may be developed in a moment under the urgency of a strong mental shock, 
and as suddenly may the secretion of any of the different glandular organs 
be suspended by fright. The depressing effect of mortification, remorse, fear, 
and frustrated plans upon the vital energies of the body is always inimical to 
the work of repair after surgical injuries. 
On the other hand, there are those who, from possessing an undue exalta- 
tion of the imagination, conjoined with an ardent temperament, are prone 
to give an exaggerated and unreal coloring to their complaints, which might 
lead the practitioner into error were he not apprised of this peculiarity. 
To inspire faith, hope, and courage in the minds of the despondent sick is 
one of the highest duties of the physician, and will in many instances work 
greater marvels than can be obtained from drugs. 
Antecedent history.—This includes a knowledge of both ancestral and per- 
sonal constitutional characteristics. It is not always easy to elicit reliable 
statements on these points. Many persons are peculiarly sensitive about 
what may be called the physical defects of their ancestors, and purposely 
withhold the knowledge which they possess. No fact, however, is better 
established in medicine than the transmissibility of bodily infirmities, and 
in obscure cases of pulmonary disease, or in tumors whose characters are not 
well pronounced, in articular atfections and in manifestations resembling 
syphilis, such knowledge is of the highest moment in forming a correct 
diagnosis, and also in adopting a proper line of treatment. If the case 
under consideration is one in which, without any positive detectable lesion, 
there are indications of a tubercular disease, in consequence of the unpro- 
nounced nature of the symptoms the physician may hesitate about advising 
an immediate removal to a more congenial climate; but if told that a pater- 
nal or maternal progenitor of the patient died from consumption of the lungs, 
his decision is formed without hesitation. In the same way will he decide 
on the nature of a morbid growth, on coxalgia, and on other diseases, by the 
antecedents of the patient. 
In pursuing this inquiry it must he remembered that transmissible diseases 
sometimes pass over one generation, so that the stream will occasionally 
require to be traced to the grandfather or the grandmother before the foun- 
tain which has tainted the blood is reached. 
The individual or ■personal history comprises a knowledge of the constitu- 
tional bent, impress, or temperament. With some persons the vascular system 
is highly developed, as manifested by a strong, vigorous heart, a bounding pulse, 30 
SURGICAL DIAGNOSIS. 
an active capillary circulation, a florid color, and an habitual warmth of the 
surface. These indicate a sanguine temperament, and its possessor is thereby 
predisposed to acute inflammatory disease of different organs. The surgeon, 
aware of such tendencies, must be ever on the alert, during the progress of 
any case of disease or injury under his care, for the earliest evidence of such 
complications. In other instances there will be seen persons in whom the 
circulation is sluggish, the complexion dark, the sensibility obtuse, and in 
whom the mental operations and the movements of the body are conducted 
with slowness and deliberation. These are the leading characteristics of 
the phlegmatic temperament. Individuals having such an organization endure 
without complaint, suffer with a certain stolid indifference, and rarely betray 
by their manner what is going on, either in the mind or in the body. Here the 
practitioner majr be led into a false security, little comprehending the mighty 
currents of mischief which may be flowing beneath a calm, unruffled surface. 
The nervous temperament crops out in irrepressible and restless action, a 
circulation stirred into activity on the presence of the slightest indisposition 
or accident, and whose demonstrations of uneasiness and suffering always 
appear to be extravagant or disproportionate to the extent or degree of tiie 
injury incurred. Here it will be necessary to make a reasonable allowance 
for the excessive exhibition of nervous sensibility. 
It is not always that these temperaments are as distinctly defined in nature 
as the portraits which have been drawn. Sometimes they are blended so that 
the same individual will exhibit the lineaments of two or more. 
Social condition.—It is often desirable to know the social state of a patient, 
whether married or single. Inquiries under this head would include sexual 
indulgences,—lawful and illicit,—number of pregnancies, miscarriages, puer- 
peral complications and accidents, and the existence of any venereal disease. 
Residence.—Surgical diseases are often modified by local influences, a knowl- 
edge of which should always, if possible, be obtained. The constitutional 
changes induced by exposure in miasmatic districts at some recent or remote 
time will often manifest themselves in the form of an intermittent, or in an 
enlarged spleen or liver, in the course of a surgical malady. The anxiety 
following the occurrence of a rigor after some grave operation will be mate- 
rially lessened if it is ascertained that the patient has been exposed to those 
conditions of heat and moisture which are associated with miasmatic emana- 
tions. The character of disease as it appears in that class of a metropolitan 
population which live in damp cellars, scarcely illumined by a single ray of 
sunshine, and who in addition subsist on articles of food defective in quality 
and in preparation, is very unlike that which occurs under opposite hygienic 
conditions. 
Personal knowledge of patient by others.—The diagnosis of a disease is often 
established by a knowledge of the determining cause. This information the 
patient, if disposed, can frequently communicate, or it may be obtained from 
a friend or some eye-witness. If a joint becomes suddenly swollen and pain- 
ful, and we are informed that this condition followed immediately on the 
reception of a sprain, the diagnosis is clear; in the absence of such a history 
it might with equal propriety be referred to a rheumatic cause. If it is 
known that a person suffering from epilepsy had, previous to the appear- 
ance of a convulsion, received a severe blow upon the head, this fact would 
serve not only to fix the traumatic origin of the disease, but also to determine 
under certain circumstances the propriety of an operation. A man picked 
up in a state of profound coma, especially if the smell of liquor can be de- 
tected on his person, might be supposed to suffer only from extreme intoxi- 
cation ; but if a bystander can testify to a fall from a window or from a horse, 
in which t he patient struck upon his head, the diagnosis will be corrected. 
A laborer was carried from the highway into an adjoining house in a state 
of collapse, and died shortly after. There was not a mark of violence upon 
his body. Only a few minutes before, he had left his home in perfect health. 
It is doubtful if even a post-mortem examination, had it been made, would SURGICAL DIAGNOSIS. 
31 
have solved the mystery which enshrouded his death. It was, however, 
afterwards ascei’tained that he had been thrown violently upon his abdomen 
against a projecting mass of stone by a runaway horse. Without this in- 
formation all opinion as to the nature of the injury would have been purely 
hypothetical. Facial paralysis is not unfrequently the effect of a blow be- 
low the ear; the gravity of the case will be lessened by a knowledge of 
such an injury. In hydrophobia, in certain specific ulcers, in phosphorus- 
necrosis, in incipient coxalgia, in some instances of mental aberration, and 
in many other affections which will naturally occur to every practitioner, 
the statements of the patient or of others constitute a valuable auxiliary to 
diagnosis. 
jDuration.—The length of time for wrhich a swelling or tumor has existed is 
usually deemed a matter of considerable moment in determining one of the 
first questions presented to the surgeon for his decision, viz., is the growth 
malignant or not ? Cancer and allied tumors are, for the most part, rapid 
in their increase, while those which pursue a chronic course are generally 
benign. Too much importance, however, must not be attached to the dura- 
tion alone of a disease, as there are many exceptions to the rule that malig- 
nancy and rapidity of growth are unvarying associates, or that chronieity 
and harmlessness are always found together. 
Attitude.—The educated eye will often detect the character of a disease 
in the posture assumed by a patient. A lad in the early stage of hip-joint 
disease advances the limb, flexes the knee, and everts the foot of the affected 
side. In luxation of the femur, the variety of displacement is determined in 
a great degree by the position in which the extremity is found. A luxation 
of the scapulo-humeral articulation will be predicated on the posture of the 
elbow. Tn acute peritonitis, the dorsal decubitus and the drawn-up limbs 
sufficiently declare the internal inflammation. A limb so rotated after an 
accident that the outer side of the foot rests upon the bed, will suggest at 
once the probability of a fracture through the neck of the femur. A child 
who walks with a stiff, studied air, having the shoulders drawn up, and with 
abducted arms, furnishes the signs of spinal caries. In hydrothorax and in 
extreme ascites, where the breathing is difficult, the upright position in bed 
is the one generally observed ; and in order to fix the points for the insertion 
of the pectoral, the great serrati, the sterno-mastoid, and other muscles of 
extraordinary respiration, the hands are planted upon the bed and the head 
is thrown back, so as to acquire additional dilating power over the walls of 
the chest. In cases where the patient constantly slips down towards the 
foot of the bed, we have the evidence of extreme debility. The above are 
only a few examples of a great number which might be adduced under the 
head of position: indeed, there is scarcely a disease or an injury which is 
not in some way accompanied by something peculiar in the disposition of 
the head, trunk, or extremities. 
Surface expression.—The knowledge gained from the expression of the face 
and other parts of the body is highly instructive. Disease, both mental and 
physical, displays its signals upon the countenance in characters so legible 
that they admit of an easy interpretation. The white, puffy, or sallow face 
attending certain degenerations of the kidneys, the clay- or straw-color com- 
plexion in cancer, the waxy hue and extreme pallor of the face and lips after 
excessive loss of blood, the red stripe across the nose and the unilateral flush 
of the cheek in pneumonia and in phthisis, the timid look and downcast eyes 
which so commonly betray the practice of secret vices, the strongly-con- 
tracted corrugated muscles of the eyebrows in acute abdominal inflamma- 
tions, the spasmodic closure of the eyelids against the light in strumous 
ophthalmia, and the strabismus following cerebral trouble or defective accom- 
modation, are examples in point. To these might be added the rapidly ex- 
KNOWLEDGE ACQUIRED BY THE SENSES. 32 
SURGICAL DIAGNOSIS. 
panding and contracting also of the nose in embarrassed respiration, the dila- 
tation or contraction of the pupils in injuries of the brain, the sardonic grin 
of tetanus, the form of the teeth in transmitted syphilis, the drooping eyelid 
in certain intra-cranial accidents, and the sharp, wasted, and contracted feat- 
ures of the Hippocratic face, betokening impending dissolution; with many 
others equally illustrative. 
Turning to other parts of the body, we may mention the flattened shoulder 
and the salient acromial process of the scapula following dislocation of the 
humerus, the prominence of the spinous processes of certain vertebrae and 
the resulting curvatures seen in Pott’s disease, the loss of the sharp defini- 
tion between the buttocks and the thigh in coxalgia, the enlargement of the 
epiphyseal cartilages in rickets, the depressed and adherent cicatrices fol- 
lowing necrosis, the scars in the groin and elsewhere which tell a tale of 
previous syphilitic trouble, and the elongated prepuce often accompanying 
vesical calculus in children. 
Mensuration.—The careful measurement of parts and their comparison 
with corresponding portions of the body constitute another means of diag- 
nostic information. The metallic ribbon or the tape-line, with its graduated 
numbers, is usually employed for this purpose. In fractures and dislocations 
of the thigh this method is often resorted to in order to ascertain the length 
of the injured as compared with the sound limb. When a comparison be- 
tween the lower extremities is to be made in cases of fracture, it is absolutely 
necessary, for the accuracy of the measurement, that the patient be laid upon a 
firm, unyielding surface, that the limbs be placed side by side, and that the 
trunk be in a straight line with the extremities: the least lateral inclination of 
the body or the pelvis will necessarily alter all the details of the mensuration. 
These measurements, when feasible, should always be made between certain 
salient portions of the skeleton which from their fixed and unvarying posi- 
tion can usually be relied on: thus, the anterior superior spinous process of 
the ilium, the tuberosity of the pubic bone, and the internal malleolus of the 
tibia are the landmarks for measurement in fractures of the thigh ; the 
anterior superior spinous process of the ilium, the tuber ischii, and the 
trochanter major, in dislocations of the femur; the internal and external 
condyles of the humerus, with the olecranon process of the ulna, in fractures 
or luxations of the elbow-joint, etc. 
The tape-line is often employed in determining the difference between the 
sides of the thorax in serous effusions info the pleural sac, and also in ascer- 
taining the circumference of an enlarged joint as compared with its fellow, in 
which case the two limbs should be placed as nearly as possible in the same 
position, either of flexion or of extension. 
Deviations of the spine from the perpendicular are sometimes tested by 
the plumb-line, and antero-posterior curvatures are measured by a ribbon of 
malleable metal. One of the most accurate modes of outlining these curva- 
tures is to take a plaster roller a few feet in length, and, wetting it in water, 
run it up and down the vertebral column longitudinally. In a few minutes 
the plaster will set, when the strip may be removed, and will prove to be an 
exact cast of the curves. 
Form.—The form of a swelling may be determined, in many instances, by 
a simple glance of the eye; in other cases it can be learned only by the sense 
of touch. For example, a patient may pi’esent a large tumor in the neck 
or on the back. With the eye it is seen to have a uniformly round, oval, or 
pyriform surface, but when the same swelling is felt with the fingers it is 
found to be lobulated, the presence of which peculiarity may aid materially 
in deciding the diagnosis. Alteration in the figure of parts conveys, in frac- 
tures and dislocations, very important information. An angular projection 
in the continuity of the thigh, of the arm, or of the leg, following an injury, 
is strong presumptive evidence of fracture. 
The shape of a swelling is frequently determined by anatomical peculi- 
arities of structures, and when these are known the practitioner is often SURGICAL DIAGNOSIS. 
33 
enabled to fix both the location and the nature of the enlargement. Thus, a 
swelling sharply bounded by the base of the jaw above, by the horn of the 
hyoid bone below, by the angle of the jaw posteriorly, and by the anterior 
belly of the digastric muscle anteriorly, is known to occupy the chamber 
allotted to the sub-maxillary gland. A swelling which appears upon the 
front of the thigh below Poupart’s ligament and to the outer side of the 
crural vessels, may have followed the sheath of the psoas and iliacus internus 
muscles, and this circumstance would suggest at once a psoas abscess and the 
existence of caries of some of the vertebrae belonging to the lumbar region of 
the spine. A swelling in front of and circumscribed by the borders of the 
patella tells its own tale,—it is dropsy of the bursa. So also is it with those 
enlargements seen in connection with the tendons about the wrist. 
Color.—The knowledge communicated by observing the color of the sur- 
face of the body is very important. There is the bright scarlet red which 
accompanies acute inflammation; there is a dark dusky red, which belongs 
to low forms of erysipelas; and there is a dull red color, blended with purple, 
or mottled, which is characteristic of chronic inflammation and of venous 
obstruction. Park purple, yellow, and green discolorations appear beneath 
the surface, commonly called ecchymoses, which are the result of broken 
vessels, chiefly venous; when such extravasations find their way to the 
surface several days after a severe injury to the limb, they should suggest 
the propriety of instituting the most careful examination, for fear a fracture 
has been overlooked. There is also an azure blue and purple color, which 
precedes the ulceration of malignant growths, and a mottled or black hue, 
which betokens the dissolution of the soft parts. 
Translucency.—The nature of many swellings is determined by the trans- 
parency of their contents. This test can be applied in two ways,—first, by 
taking the patient into a darkened chamber and holding the tumor, pre- 
viously made tense, between a lighted taper or candle and the observer, the 
latter at the same time resting the hand vertically over the upper surface 
of the swelling, in order to intercept the upper rays of light; secondly, 
translucency may be ascertained in a strong sunlight by folding a sheet of 
paper into a hollow cylinder, and, with one extremity resting upon the 
part, viewing the swelling through this tube. By either of these devices 
we are able to diagnose hydrocele, meningocele, spina bifida, and other 
cysts. 
Muscular movements.—Movements may be either less or greater than those 
which are natural, and in each case they supply valuable aid in diagnosis. 
When the ribs are broken or a lung is collapsed, the walls of the chest, on the 
affected side, remain almost entirely quiescent. An injury to the cervical 
vertebra) will render the head stiff and motionless; an inflamed joint is in- 
tolerant of the least disturbance ; and when an arm or a leg is broken, all 
voluntary movements are as a rule at once suspended. 
Exaggerated movements are frequently witnessed as a result of morbid 
conditions : hence the rapid action of the chest-walls in cardiac and pulmo- 
nary disease. There are exaggerated movements which arise from a defect 
in co-ordination; for example, the oscillating eyeball in nystagmus, the tremor 
of paralysis agitans, the muscular disturbance in chorea, etc. There are 
mal-directed movements, such as belong to locomotor ataxia, and others again 
which are automatic and indicative of extreme danger, as picking the bed- 
clothes, or grasping at imaginary objects in the air,—conditions so often seen 
in low forms of fever. 
Movement, again, may be executed of an awkward, eccentric character, as 
where a person, in walking, instead of advancing the limb directly forward, 
swings it around in the segment of a circle. Here the quadriceps extensor 
of the thigh is paralyzed, and the work of the latter has to be substituted 
by tbe action of another group of muscles. 
Sounds.—The sense of hearing, especially in a medfbal point of view, is 
one of the most valuable channels for the reception of diagnostic knowledge. 34 
SURGICAL DIAGNOSIS. 
It is through the ear that the most occult changes which take place in the 
chest are detected. Auscultation, however, is not without its value to the 
surgeon. It is in this way that he is able to recognize those serous and 
purulent accumulations in the pleural sac, or in the pericardium, which 
frequently demand surgical interference for their removal. 
To hear the clink of t he steel sound is much more decisive of the presence of 
a urinary calculus than any knowledge obtained simply by the sense of touch. 
The peculiar bruit which forms one of the most constant signs of aneurism 
can only be recognized through the organs of hearing ; and it is also true of 
that sound which has been compared to the noise made by a fly or bee in 
a paper bag, and which is present in arterio-venous aneurism. 
It may be necessary to resort to the use of this sense in order to detect 
the crepitation of fracture. By the use of the stethoscope the ear is greatly 
assisted in the detection of both normal and abnormal sounds. 
By the sense of touch a knowledge of the consistence, movement, weight, 
exact form, sensibility, and temperature of a part is obtained. The touch 
should be cultivated with the greatest care. Many errors have been com- 
mitted, and some lamentable blunders, from defective tact. 
Consistence.—The more liquid the contents of a swelling the softer will be 
its consistency. Inflammatory transudations into the soft parts, when they 
consist of serum, are usually very compressible, can be displaced, and pit 
on pressure. When they consist of fibrogenous and cell materials, they are 
firm and hard, commonly called indurations, or infiltrates. The dense hard 
wall of lymph at the circumference of an abscess is an example in point. 
When the contents of a growth are liquid and enclosed by a limiting wall, 
or by a sac, the sensation imparted to the fingers on palpation is one of fluc- 
tuation. Highly vascular and fatty growths, like encephaloid and adipose 
tumors, may, on the application of the same test, yield a similar sensation, 
though, when carefully studied, it will be found to be elasticity rather than 
fluctuation. When air is extravasated through connective tissue, it is revealed 
by crackling or crepitation on pressure. 
Movement.—The attachments and the depth of tumors are ascertained by 
the degree of motion which they allow; and their nature is often revealed, 
as in aneurism, by their centrifugal expansion. Undue movement in the 
continuity of a bone, accompanied by crepitation, is indicative of fracture; 
while diminished motion or rigidity is a symptom of luxation, or of anchylosis. 
There is a motion which travels in short waves, and which causes a tremor 
or fremitus. It is one of the tests employed by the practitioner in making 
explorations of the chest for effusions in the pleural sac,—the hand being 
placed upon the thorax while the patient speaks. 
Weight.—Considerable importance is attached to the weight of a tumor in 
forming a differential diagnosis. A growth in the mammary gland or in the 
testis, which, when raised by the fingers, gives the impression of weight out 
of proportion to the size of the body, furnishes reasonable grounds for regard- 
ing the disease as either scirrhous or fibrous in its nature. 
Exact form.—It is only by handling a swelling or tumor that an exact idea 
of its form can be attained. In this way a group of enlarged inguinal glands, 
by the lenticular disposition of its parts, can be distinguished from a hernia; 
a fatty growth can be recognized by its lobulated form. In the same way 
may the surgeon trace the outline of the foetus in cases of extra-uterine preg- 
nancy, recognize the knobbed surface of a uterine fibroid, and detect the 
notched border of an enlarged spleen. 
Temperature.—Though the touch is a rough means of ascertaining temper- 
ature in comparison with instrumental measures, yet to lay the hand upon 
a part is quite sufficient in many instances to guide our therapeutics when 
great delicacy of observation is not required. 
TOUCH. SURGICAL DIAGNOSIS. 
35 
By the sense of smell the surgeon may discover, in the peculiar odor 
from the nasal passages of a patient suffering from catarrhal disease, the 
existence of necrosed bone, before any exploration of the fossae is made; 
pyaemia is sometimes revealed in the sweet or fresh-hay odor which emanates 
from the breath ; a stercoraceous fistula is known by the existence of a faecal 
smell in the discharges which escape; and in a perineal sinus its connection 
with the bladder may be predicated on the urinous odor which accompanies 
the issuing fluids. The peculiar earthy smell of the soft parts in a state of 
mortification is another familiar example in point. 
SMELL. 
EXAMINATION OF THE INTERNAL ORGANS. 
It will often be necessary, in order to render a diagnosis exhaustive, to 
extend the inquiry to the state of the different organs of the body. 
Circulation.—The state of the heart and blood-vessels, as regards both their 
action and their structural alterations, demands a careful consideration. 
Valvular defects are recognized by characteristic sounds, which it is the 
province of the medical rather than of the surgical diagnostician to describe. 
In the administration of anaesthetics and in estimating the capacity of pa- 
tients to undergo prolonged operations, such alterations of structure must 
not be overlooked. The relation between atheroma, aneurism, and senile 
gangrene; the varicose condition of the superficial abdominal and thoracic 
trunks, as indicative of deep-seated obstruction to the venous circulation; 
embolic plugging of the veins in connection with phlebitis; the venous mur- 
murs in the great vessels of the neck in amende conditions of the system, 
and the connection between lividity of the face and pulmonary or cardiac 
disease,—these are a few of the subjects which will require investigation. 
The pulse, as an index to the state of the circulation, requires for its proper 
interpretation considerable experience. Its frequency, force, volume, and 
rhythm, or regularity, are the chief features to be noted. 
The pulse, it must be remembered, varies in all these particulars at different 
times in the same individual, even in a state of health. There is no absolute 
standard for the arterial beat; what in point of frequency may be normal in 
one individual may be abnormal in another: consequently it is a wise precau- 
tion, when estimating the condition of the circulation in a patient, to inquire 
if any peculiarities in this respect are known to exist. In females or in 
children the action of the heart and arteries is generally quicker than in 
males or in adults. 
The presence of the physician, or the exhibition of any display by the 
assumption of a grave or wise air on his part, or even by the formal exposure 
of a watch, will often disturb the circulation so as to vitiate the examination 
and render all inferences drawn from it unreliable. Hence the medical man, 
with the address of one learned in his art, will prepare the way for his 
investigation by some preliminary inquiries of a general character, until the 
perturbation attending his visit has passed over and the patient feels entirely 
at ease in his presence. 
The pulsations are variously affected by different morbid conditions,— 
reflex, functional, and organic. 
In infra-diaphragmatic inflammations the pulse is usually contracted, hard, 
and cord-like; in inflammations above the diaphragm it is full, round, and 
bounding. The effect of compression and of concussion of the brain on the 
circulation is very marked. In the first the beat of the artery is full and 
slow; in the second it is slow and thready. A severe hemorrhage imparts a 
peculiar character to the pulse; the artery is small, and the blood flows 
through it in such a manner as to communicate to the fingers a feeble but 
sharp, tremulous, and jerking sensation. The beat of the vessel is often 
changed in its rhythm; it may be intermittent, irregular, or dicrotic, either 36 
SURGICAL DIAGNOSIS. 
as a result of gastric derangement or from organic disease of the heart. A 
very rapid pulse, or one habitually frequent, betokens danger, and in com- 
pression and concussion, when the pulsation of the heart from having been 
slow becomes rapid, a fatal termination is probably near at hand. 
Thermometry.—An increased evolution of heat is a constant attendant of 
fever, and the degree of caloric will be in correspondence with the extent 
and rapidity of tissue-change. The temperature of persons in health varies 
very little, oscillating between 98.6° and 99.5° Fahr. The first observation 
to determine local temperature in inflammation was made by John Hunter, 
though several thermometric observations in disease were practised as early 
as 1638, by Sanctorius. There are two forms of the clinical thermometer in 
common use. (Figs. 1, 2.) The instrument when used 
should be placed in the axilla or under the tongue. When 
in the former region, the part should be wiped dry and the 
arm closed against the side for a short time, after which the 
thermometer may be introduced. The time usually required 
for the mercury to reach the proper numeral is from three 
to five minutes. Two observations a day are usually suffi- 
cient, and these should be made about eight o’clock in the 
morning and about seven in the evening, the registration 
being kept on forms specially provided for the purpose. 
Generally there is a uniform correspondence between the rise 
of temperature and the frequency of the pulse,—that is, with 
any degree above 98° Fahr. there is an increase of eight or 
ten beats of the heart. All elevations of temperature above 
the normal standard are expressions of tissue-waste, and 
when reaching 105° and upwards the danger to a patient 
is very great. A considerable number of experiments was 
made by Dr. Hare on patients of my own, with a view to 
determine the effect of emotional causes on temperature. It 
was found, in almost every case, that the animal heat rose 
one or two degrees before any important operation. It is 
not uncommon to find the temperature run up a degree or 
two in a surgical patient in consequence of the nervous 
perturbation incident to the renewal of a dressing. The 
same elevation may be due to prolonged constipation. 
jRespiration.—Observations drawn from the state of the 
respiration should include the frequency, the ease, and the 
regularity of the process; whether the inspiration or the 
expiration is most impeded, and the effect of all such dis- 
turbances on the walls of the chest or of the abdomen, and 
on the voice. 
The frequency of the respiration is increased by any cause 
which interferes with the expansion of the lung-tissue or 
which disturbs the pulmonary circulation. Thus, in pneu- 
monia, where the pulmonary tissue is filled by inflammatory 
infiltration, and in hydrothorax or in emphysema, in which 
the fluid crowds the lung back towards the spine, preventing the free en- 
trance of air into the air-cells, nature instinctively attempts to compensate 
for the diminished aeration of the blood by numerous short respiratory acts. 
The breathing is modified by cardiac disease. When the patient is reposing 
quietly in the recumbent position it may be entirely natural; if obliged to 
turn over in bed or to rise it becomes quickened; and on walking or climb- 
ing an ascent it becomes greatly hurried and labored. Emotional causes 
also operate to disturb the regularity of the respiration. Joy, apprehension, 
or highly-wrought anticipation frequently so unsettles the quiet currents of 
feeling that, like a lake stirred by fitful gusts of wind, the breath goes and 
comes, sometimes with regularly-measured intervals, and at other times in 
tumultuous and rapid movements of the chest. 
Fig. 1. 
Fig. 2. 
Clinical thermome- 
ters. SURGICAL DIAGNOSIS. 
37 
In cases where the depurating function of an important eliminating organ 
like the kidneys is from structural disease imperfectly executed, the brain 
and other organs soon begin to feel the toxic effects of the products of re- 
tained tissue-waste. In atheromatous conditions of the vessels of the heart 
the circulation moves tardily, and it is not uncommon under such circum- 
stances to witness a singular irregularity in the breathing,—at one time so 
quiet, while the medulla is dosed with anesthetic blood, as scarcely to be ob- 
served, and at another time, when the necessities of the organs compel them 
to cry out for fresh blood, carried on with the greatest rapidity until the want 
is supplied. 
Inspiration is in some instances more impeded than expiration. The cause 
of this is to be sought for in a mechanical obstruction of the trachea, the 
larynx, or the glottis. Thus, in oedema of the glottis, in croup, or where 
the passage of a bolus of food is arrested at the termination of the pharynx, 
the canal of the vocal respiratory tube may be so encroached upon as to 
resist the entrance of air. In pleurisy or in pleurodynia the inspiratory act 
will be brought to a sudden arrest before its completion, and in fracture of 
the ribs both inspiration and expiration are conducted, so far as the injured 
side is concerned, with the utmost quietude, and may be in rare instances 
entirely suspended. 
One of the marvellous adaptations to extraordinary conditions which exist 
in the human body is the interchangeableness of function between its dif- 
ferent parts. This is beautifully illustrated in the mechanism of the chest 
and of the abdomen. When the ribs are broken, the fractured walls of the 
thorax become almost motionless, the respiration being carried on by the dia- 
phragm and the abdominal muscles; while in a case of peritonitis the reverse 
is true,—the abdominal parietes are rendered quiet, being supplemented by 
the muscles of the chest. In cases of intra-cranial pressure the respiration is 
conducted in a slow, labored, and noisy manner. 
There are frequently unusual sounds accompanying the respiration which 
have their significance. The stridulous crowing and wheezing noise often 
accompanying difficult inspiration is due to the air rushing through a narrow 
aperture in the larynx or in the trachea. There is a grunting expiration 
which is associated with disease of the spine in children: the rales which 
presage approaching dissolution are due to the passage of air through the 
laryngeal and tracheal mucus: the stertor attending the breathing in cer- 
ebral compressions is faucial, from paralysis of the soft palate. 
There are alterations in the voice which are produced by a modification of 
the air passing through the vocal apparatus, and which indicate changes of 
structure in the fauces, pharynx, and larynx, and in the system at large. 
From these causes arise the inarticulate mumbling of words in tonsillitis 
and post-pharyngeal abscess, the whisper in paralysis or in swellings and 
tumors about the vocal cords, the indistinct, guttural, and broken words 
which attend the dyspnoea of aggravated lung and heart disease, and the 
feeble, tremulous voice of extreme weakness from the exhaustion of febrile 
and other diseases. Hiccough and sighing are also phenomena which be- 
come sources of anxiety, from their frequent connection with great debility 
or the sudden invasion of mortification. 
The surgeon sometimes solicits the assistance of the respiratory function 
to aid him in the diagnosis of disease, as coughing in suspected cases of 
hernia. 
Nervous system.—The recent advances made in cerebral physiology and the 
localization of cerebral centres furnish a new and practical field for surgical 
diagnosis, and when properly interpreted enable the operator to push his ex- 
ploration for the relief of intra-cranial trouble into regions which hitherto 
have been regarded as forbidden ground. It is often a very difficult part of 
the surgeon’s duty to determine the exact value of many nervous phenomena 
which crop out in the progress of a case. The inquiry under this head will 
include intelligence, sensation, and motility. 38 
SURGICAL DIAGNOSIS. 
Intelligence.—The whole mental and moral condition of a patient may 
be changed by physical disease or injury. This change may consist, first, 
in an intellectual aberration or delirium, a condition very common in affec- 
tions attended by great arterial excitement. This delirium may be passive, 
muttering, or incoherent, characteristics which belong to asthenic states 
of the system; or it may be wild and uncontrollable, as in some forms of 
cerebritis. Again, the delirium may be intermittent, subsiding with the 
febrile paroxysm, and reappearing with its recurrence, a condition not to 
be regarded as particularly dangerous; or it may be constant, as in menin- 
geal and cerebral inflammations, and suggestive of a much more serious state 
of things. 
Sometimes the intelligence is only dull, heavy, obtuse, not absolutely de- 
ranged ; the patient can be roused, and will respond correctly to questions 
which may be asked, but soon lapses into a lethargic state. Examples of 
this nature are common in oedema of the brain, in slight forms of uraemia, 
and in concussion of the brain. Complete suspension of the intelligence is 
a constant attendant of cerebral compression. Mental dulness, passing into 
stupor, and finally into profound coma, indicates such serious lesion of the 
brain that a fatal termination may be predicted with considerable certainty. 
There is a form of quiet delirium, often delusive in its drift, which follows 
the extraction of cataract in aged persons, appearing to be in some way 
dependent on impressions communicated from the eye to the brain, and 
which often proves very troublesome. The patient is constantly trying to 
remove the dressings, can with difficulty be restrained from getting out of 
bed, and often imagines himself away from home. In all eases of delirium 
the surgeon must carefully push his inquiries in every direction to ascertain 
whether this mental disturbance is the result of reflected irritation or of 
disease in the brain-tissue, the latter of course investing the case with the 
gravest aspect. 
The moral endowments are likewise liable to many and singular perver- 
sions, the result of physical disease. Among these may be mentioned the 
irritability, obscenity, and profanity which characterize some cases of con- 
cussion of the brain, the cerebral disturbance from febrile excitement, and 
the nymphomania which is sometimes developed by both local and central 
irritations. 
Sensation.—Cutaneous, mucous, and muscular sensibility also demand 
consideration. The instruments used for determining the cutaneous sen- 
sibility are the sesthesiometer (Fig. 3), an ordinary pin, the compasses, 
Fig. 3. 
iEstliesiometer. 
and a feather, applied when the eyes of the patient are closed. For testing 
the muscular sensibility and contractility, the electro-galvanic battery is 
used. 
The sensibility of the skin may be greatly diminished under the anaesthetic 
action of certain morbid poisons circulating in the blood, as that of syphilis, surgical Diagnosis. 
39 
or in consequence of nerve-lesions, giving rise to numbness. It may be ex- 
cessively exaggerated, so that the gentlest touch with the finger, or even with 
the plume of a feather, will provoke the most extraordinary manifestations 
of suffering, a condition often witnessed in hysterical joints and in imaginary 
disease of the spine. This perversion of sensibility is exhibited in a diversity 
of ways. It may consist of intense itching, as after poisoned wounds; of a 
horrible feeling of ants crawling over the surface; of a localized burning 
sensation; of a sense of being brushed with nettles, or of a cold stream of 
air passing rapidly along the surface of a part. These states of the periph- 
eral nerves may be caused either by reflex irritants or by disease of the 
ganglionic masses of neurine, or of the nervous cords themselves. 
Parts normally of low sensibility become acutely sensitive when inflamed: 
the violent paroxysms which involve the entire muscular system of a child 
with an inflamed gum, and the exquisite suffering from a similar state of the 
integument of the heel caused by pressure, demonstrate the truthfulness of 
this statement. 
Pain is intensified sensibility, communicated to the consciousness probably 
through special tracts of the medulla spinalis. Much may be learned from the 
character or quality, the location, and the duration of suffering. Shooting 
and darting pains are peculiar to scirrhus; burning pains, to inflammation 
of the skin; lightning-like pains, to locomotor ataxia; throbbing sensations, 
to the presence of inflammatory products under resisting structures, as in 
whitlow; sickening pain, to contusions of the testicles; and gnawing and 
boring feelings, to caries and necrosis. 
When located at the end of the urethra, pain points to vesical calculus; 
shooting down from the loins to the testicle, as in renal colic, it indicates the 
presence of a stone in the ureter; at the point of the I'ight shoulder-blade, 
it is frequently a result of hepatitis; and at the knee it is among the most com- 
mon signs of coxalgia. These are examples of pain remote from the actual 
seat of disease; and the surgeon should always endeavor to learn the true 
source of this symptom. The patient should be invariably asked to locate 
the sensation. Constant suffering arises either from inflammatory pressure or 
from the pressure of morbid growths ; intermittent pain is, for the most part, 
non-inflammatory or neuralgic. Of this nature are the supraorbital and 
facial attacks of suffering and the pain of colic. The deferential diagnosis 
of pain from the two causes is further established by the intolerance of the 
affected part to pressure in the former, and the relief imparted by the same 
pressure in the latter. In inflammatory pain the severity of the suffering is 
generally less than in that of neuralgia. A fixed and persistent pain, in a 
definite locality, is a symptom which should never be lightly passed over 
by a physician. Fugitive pains have commonly, though not always, a 
rheumatic origin. In estimating the value of this symptom in arriving 
at a diagnosis, the temperament of the patient must be considered. All 
persons are not alike affected. Some endure tortures in a stolid, stubborn, 
and uncomplaining manner, while others on the slightest attack will exhibit 
the most extravagant demonstrations of suffering. 
Motility.—Muscular movements possess the highest importance in solving 
some of the morbid problems which come within the domain of surgical 
diagnosis. Eccentric movements of muscles may depend primarily on the 
condition of the central masses of neurine from which they arc energized, 
on the state of the nerves running in their substance, or on alteration of the 
sarcous cells. The phenomena resulting from these sources are loss of power, 
tremor, twitchings, spasms, contraction, choreic movements, atrophy, etc. 
Loss of power may affect a single muscle or a group of muscles, one extrem- 
ity or the entire body. When it includes one side of the body, the cause will 
naturally be referred to the brain; when an arm, or a leg, or both lower 
extremities, are affected, the origin will usually be spinal. The pressure of 
a tumor, the extremity of a displaced bone, or a mass of redundant callus 
may completely paralyze one or several muscles. A sudden and sustained 40 
SURGICAL 'DIAGNOSIS. 
exercise of muscular power, particularly if it is exerted under an unfavora- 
ble disposition of leverage, by drawing on the nerve-force too heavily, occa- 
sionally leads to a temporary paralysis (reflex) of the overtaxed muscles. 
The power of the muscular contraction is measured by an instrument called 
a dynamometer. Fig. 4 
is an illustration of one 
variety. Paralysis of cer- 
tain groups of muscles 
follows fracture of the 
vertebra;, and explains 
many deformities, as 
club-foot, spinal distor- 
tions, etc. Tremors are, 
unfortunately, too often 
the effect of irremediable 
central diseases. Spasms 
and twitchings may arise 
from some local irritant, 
as a spiculum of bone, a 
preternaturally narrow prepuce, dentition, or from causes located in the 
stomach or in the uterus, and therefore amenable to treatment. Permanent 
contractions of the muscles are usually unpromising affections, being fre- 
quently associated with sclerosis of the anterior column of the medulla 
spinalis. Loss of power may again be due to muscular atrophy or to fatty 
degeneration, the sarcous cells being replaced by fat, the energizing factors 
being unimpaired. In all these pathological phases of the motor apparatus 
the use of faradaic and electrical stimuli becomes necessary, not only to 
determine physiological activity, but also to detect in what particular the 
imperfection consists,—that is, whether it is the muscle, the source of its 
power, or the medium through which the power is communicated, that is at 
fault. 
The gait, posture, and various attitudes of the body should also in this 
connection attract particular attention. The walk of a child, or the attitude 
assumed when standing, reveals tubercular disease of the spine or of the hip. 
The habitually flexed state of the thigh gives rise to a suspicion of psoas 
abscess. The advanced lower extremity, with the foot everted or inverted, 
and the forward inclination of the body, following an accident, suggest the 
probability of a femoral luxation. 
Fig. 4. 
Dynamometer to test the muscular power of the muscles of the hand. 
The figures express the number of pounds exerted. 
DIGESTIVE APPARATUS. 
The influence which the digestive organs, from their extensive sympathies, 
exercise in the production of morbid phenomena is almost incalculable. Ex- 
tensive disturbances of the respiratory, circulatory, and nervous systems are 
frequently referable to organic or functional disorder of some portion of the 
digestive apparatus. It should be examined in detail. The tumid, the pale, 
and the scabbed or fissured lip respectively indicate a strumous and anaemic 
state of the system and general disorder of the intestinal and glandular secre- 
tions. Gums spongy, shrunken from the teeth, and bleeding when touched, 
imply faulty or scorbutic conditions of the blood, or the injudicious use of 
mercurials. 
Lead, silver, and pulmonary tuberculosis often register themselves by a 
characteristic line upon the gums, and from the surface of the latter may 
project morbid growths of different kinds. The teeth of the child may, by 
their notched edges, tell a tale of parental vice, to which allusion has already 
been made. 
The state of the tongue is a valuable index to general and local disorder 
of the system. When dry, there is an arrest of secretion,—a common con- 
dition in febrile excitement, and in itself not very important; but if to this SURGICAL DIAGNOSIS. 
41 
there be added a rigid prominent state of the papillae and a dark color oc- 
curring during the progress of traumatic or other fever, the case is beset 
with danger. In faucial and gastro-intestinal inflammation, and in the ex- 
anthemata, the organ is red and occasionally glazed; in anaemia it is pale, 
soft, and flabby. 
The coating upon the tongue may be scanty and white, an indication 
usually for the use of tonics; it may be thick and have a white and yellow 
color intermixed, as in disordered liver-function; and it may be incrusted 
with a dark and pasty substance, consisting of vitiated secretions and dis- 
organized blood-corpuscles; this coating may not only adhere to the tongue, 
but also often gathers about the teeth and gums (sordes), and may be regarded 
as denoting danger. 
A white and yellow coat may accumulate on the tongue from congested 
or inflamed fauces or pharynx. 
The form of the tongue should be noted. In habitual disturbance of the 
digestion, and in feeble states of the general system, it will often be found 
broad, soft, and Assured, and with rounded edges. In inflammatory diseases 
of the respiratory tube it is sometimes depressed in the centre, giving the 
sides an elevated appearance ; and in meningitis and cerebritis, as long as the 
brain is not subjected to too great pressure, it will be long, narrow, and pointed, 
The tongue may be altered in form and present a blue, spongy appearance 
from angeiomatous growths. 
The motions of the organ should not pass unobserved. A tremulous tongue, 
or one which is protruded slowly and with difficulty from the mouth, implies 
great debility and betokens danger. When it is thrust out to one side, there 
is probably unilateral paralysis, or, at least, paresis of its muscles on the 
opposite side. 
An inspection should likewise be made of that region which lies between 
the tongue and the floor of the mouth, into which project the sublingual 
and submaxillary glands, and where ranula and salivary calculi are readily 
detected when present. 
Both the tongue and the inside of the cheeks should be examined for ulcers 
and mucous patches when there is reason to suspect a syphilitic taint. 
Embarrassed deglutition or enunciation, hoarseness, and stiffness of the neck 
will suggest a careful inspection of the fauces and pharynx, noting if there 
be hypertrophy of the tonsils, elongation of the uvula, relaxation of the 
velum palati, enlargement of the pharyngeal glands, or any post-pharyngeal 
prominence which might be invoked to explain the symptoms complained of. 
When signs of obstruction in the oesophagus are present, the examination 
should be made by carrying appropriate bougies or probangs along this part 
of the alimentary tube. 
Vomiting or retching, especially when preceded by a dyspeptic history, 
demands a careful exploration of the abdominal contents and of the hernial 
passages, for tumors, obstructions, and rupture. The appearance and odor of 
the matters ejected from the stomach also require notice. 
The outlines of enlarged organs, like the liver and the spleen, or of a dis- 
placed organ, such as the kidney, may, with care, by percussion and manipu- 
lation, be accurately traced. In distention of the abdominal parietes from 
accumulations of fluid, the diagnosis will be facilitated by palpation, by ob- 
serving the flattened or prominent flanks, and by the use of the exploring 
needle. 
The escape of blood from the rectum after a difficult defecation may be 
traced to its proper cause by ocular, digital, and instrumental exploration, 
and as this symptom may attend hemorrhoids, fissure, stricture, ulcers, cancer, 
and intussusception, it may be necessary to resort to all of the above-men- 
tioned measures. The form of the faeces will often reveal rectal stricture, 
being in small cylinders, like pipe-stems or pencils, sometimes round, and at 
other times flat, angular, or broken into fragments. Putty-colored dejections 
imply the absence of bile in the intestine; and when of the color and con- 42 
SURGICAL DIAGNOSIS. 
sistence of tar they often consist of venous blood. Pain at the anus in some 
instances is itself diagnostic of the disease. When coming on a short time 
after defecation, and increasing in intensity for several hours in succession, 
it belongs to anal fissure. 
Tenesmus is not only a sign of colitis, but may be also excited by a foreign 
body in the rectum, and when accompanied by frequent and slight watery 
passages it is an evidence of faecal impaction. 
The sexual system of both males and females is so conspicuously con- 
cerned as a disturbing factor in many of the derangements of the body 
that it cannot be ignored in the analysis of many cases of disease and injury, 
nor should it, in such inquiries, be dissociated from the urinary organs. The 
loss of the venereal appetite, its inordinate excitement, or its presence with- 
out the ability to execute the act, are conditions which require a careful ex- 
amination of the cerebro-spinal centres, the organs themselves, and the state 
of the urine, as well as an investigation of the habits of the patient. 
The existence of spermatorrhoea, or of secret indulgences,—a vice common 
to both sexes,—must not be overlooked in instances where a patient, in con- 
sequence of the presence of palpitation, nervous restlessness, dyspepsia, and 
loss of strength, applies for relief, without having any detectable organic 
lesion to explain these symptoms. 
Priapism and its connection with spinal, cerebral, and cerebellar injuries; 
the retraction of the testicle in renal colic, with pains along the course of 
the ureter; phimosis; elongation of the prepuce; urethral pain and its loca- 
tion, whether at the extremity of the glans penis, at the neck of the bladder, 
or along the entire length of the canal, and whether experienced at the com- 
mencement or at the termination of micturition, also the size and shape of 
the stream of urine, are all subjects for inquiry in connection with stone, 
prostatic hypertrophy, or stricture. Of like importance is the existence of 
urethral discharges, of stricture, and of an irritable or inflamed bladder. 
In females the menstrual function, as regards its establishment, excess, 
suppression, irregularity, or decline, must he considered as the probable cause 
of constitutional disturbance. 
So also in irritable bladder the surgeon must explore the viscus for stone, 
and the urethra, the vagina, and the rectum for morbid growths. In uri- 
nary incontinence, the vesico-vaginal septtim should be examined for a possi- 
ble fistula ; and in the same defect in children, the rectum should be searched 
for ascarides. Nor would such examination be complete unless the vagina 
and the uterus were included in the exploration, as only by such precautions 
could the existence of polypi, or of fibroid or other growths, be detected. 
The existence of any pale red, watery, or chocolate discharge, with an un- 
pleasant odor, from the vagina should also be noticed. 
The importance of sound kidneys to the success of a surgical operation is 
so commonly recognized that no surgeon, understanding his duty to a patient, 
would undertake any such procedure, save in case of emergency, without 
first ascertaining their condition. The examination of the secretion should 
be physical, chemical, and microscopic, and should include quantity, specific 
gravity, color, reaction, and composition. 
Albumen, pus, muco-pus, blood, urates, phosphates, and oxalates must 
each be carefully noted and traced to their proper source. These subjects 
will be treated of in detail under the head of diseases of the genito-urinary 
organs. 
Except in two or three instances, nothing has been said in regard to the 
instruments commonly used for diagnostic purposes, as these will require to 
be noticed in connection with special subjects. 
GENITO-URINARY APPARATUS. CHAPTER II. 
ANTISEPSIS. 
The seminal thought of antiseptic surgery may perhaps be traced to John 
Colbach, a member of the College of Physicians, England, whose collec- 
tion of tracts, printed in 1704, contained a description of a new and secret 
method of treating wounds, by which healing took place quickly without 
inflammation or suppuration ; but it is to one of Old Scotia’s sons, Sir Joseph 
Lister, that the everlasting gratitude of the world is due for the knowledge 
we possess in regard to the relation existing between micro-organisms and 
inflammation and suppuration, and the power to render wounds aseptic 
through the action of germicidal substances. 
It was long known that parts divided subcutaneously healed without the 
ordinary phenomena of purulent formations, a result attributed to the ex- 
clusion of atmospheric air. On the assumption of this being true arose the 
method of occlusion, as practised by J ules Guerin, an eminent French sur- 
geon, which consisted in sealing up wounds by dressings impermeable to 
atmospheric air. Finding this unsatisfactory, he subsequently followed out 
the same idea by maintaining a vacuum around a wound by means of an 
exhausting apparatus. Both of these experiments proved fruitless. There 
were, however, a number of scientific laborers, as Schwann, Pasteur, Pouchet, 
and others, who were diligently pushing their experimental studies in search 
of the secret of fermentation, and who, by methods of exclusion, finally 
reached some very significant facts. Though following different paths of in- 
vestigation, the lines of discovery all converged on the same truth,—namely, 
that neither atmospheric air nor other gases possessed any power to develop 
fermentation. The investigators were able to prove that air previously 
subjected to a high temperature, or filtered through a mass of cotton-wool, 
could be freely admitted to putrescible material without exciting fermen- 
tation. The necessary inference from these experiments was that it was 
not the air in itself, nor the gases of which it was constituted, but something 
which it contained, that constituted the active agent in fermentation. Take 
as an illustration the urine, which, out of the body, rapidly undergoes de- 
composition. If a flask,—as in the experiment of Sir Joseph Lister,—the 
mouth of which is covered with cotton-wool, be placed in a hot-air chamber 
for several hours exposed to a high heat (300° Fahrenheit) and then allowed 
to cool, all organic matters in the air of the flask will have been thoroughly 
destroyed, and that which subsequently enters is compelled to pass through 
the cotton-wool cover. If now a portion of urine be passed into the flask, 
observing in so doing all antiseptic precautions, as washing the penis with a 
lotion containing carbolic acid, or, as would now be done, with a solution 
of corrosive sublimate, and then pressing the gland into the mouth of the 
vessel, with the cotton-wool accurately packed round the organ, and to be 
replaced when the latter is withdrawn, it will be found that the fluid can be 
preserved for an indefinite period without undergoing any change answer- 
ing to fermentation. This is as true of organized solids as it is of organic 
fluids. If a portion of flesh be removed from the body of an animal and 
be introduced into a vessel the air in which has been perfectly sterilized by 
heat, and the mouth of which is protected by a cotton-wool pad, the flesh will 
undergo no putrescent changes. It is thus that fragments of flesh and of 
bone-dust, torn and rasped away in subcutaneous osteotomies, undergo no 44 
ANTISEPSIS. 
putrefactive decomposition, but are ultimately disposed of by absorption. 
The fact having been established that fermentation depended on the presence 
of particles derived from the external world, the next step was to ascertain 
the nature of these particles. In the arts it was known that the phenom- 
enon of raising bread by introducing a particle of leaven into the flour, or 
of developing alcoholic fermentation, was due to the presence of a vegetable 
organism; the inference was naturally reached that the putrefactive changes 
in the fluids and solids of the body might depend upon the presence of 
organisms of a similar nature, and the aid of the microscope was invoked 
in order to assist in the solution of this part of the problem. It is true that 
the presence of low forms of plant life in all fluids undergoing fermentation 
was not a new discovery; but that putrefactive changes depended on the 
presence of such organisms, and that their existence under these circum- 
stances was not an accident, was not known. At one time their presence 
was accounted for on the theory of spontaneous generation ; but, as this doc- 
trine was no longer tenable, the conclusion became irresistible that they 
reached the fluids and solids from external sources. These, then, were or- 
ganic particles destroyed by heat, the absence of which factor explained 
non-putrefactive phenomena. Such an interdependence, therefore, exists 
between the latter process and the presence of these simple microscopic 
vegetable particles that we are authorized in saying, no micro-organisms, no 
fermentation. 
Another question which arises out of the consideration of this subject is 
the modus operandi of these particles of living matter in producing the 
mysterious movements observed in fermentation. It is not catalysis. The 
very fact that these organisms are living cells presupposes that simple as 
they may be, occupying indeed the lowest plane of vegetable life, yet for 
their growth and multiplication, for the work of secretion and excretion, 
a proper supply of food becomes a necessity,—as much a necessity for this 
simple vegetable cell as for a tree composed of myriads of cells. It is only 
after the yeast-plant, has acquired a certain degree of growth that the alco- 
holic fermentation begins, and therefore it is assumed that fermentation is 
only another name for the chemical changes wrought on the food in the 
laboratory of the parasitic cell. Not only do these new and strange products 
cause local irritation and inflammation in the tissues in which they are 
formed, but they are also susceptible of being introduced into the circula- 
tion of the body, giving rise to septic poisoning and death. 
It is through the microscope in the hands of trained observers that we 
learn of the prodigious opulence of organic forms. These micro-organisms 
float in the dust, cling to every object, are inhaled at almost every inspiration, 
and swarm in all waters. These infinitely small masses of vegetable proto- 
plasm are called sehizomycetes or bacteria. Infinitely small though they be, 
yet through their silent and mysterious agency the most startling results are 
determined. Pasteur has shown that in the processes of fermentation and 
putrefaction they play the leading part, and that some of those fatal epi- 
demics which have at different times threatened with destruction certain in- 
dustries of France, as the silk-worm disease, the chicken cholera, and the 
cattle anthrax, were the work of such minute organisms: so that, small as 
may be these particles of living matter, yet they may become sufficiently 
potent to destroy the herds and stop the looms of a nation. These facts 
applied to the study of surgical pathology have illuminated as with a sun- 
beam those morbid and often fatal processes which are so commonly ob- 
served in the human body, especially in connection with wounds, and it is 
by such application that Lister has established a great general principle, 
which will live while the world remains, which has already revolutionized 
surgical methods, and which makes its discoverer stand to-day the most con- 
spicuous figure of the surgical world. 
Antiseptic surgery has come to stay, and the sooner this fact is recog- 
nized the better for both surgeon and patient. The question may possibly ANTISEPSIS. 
45 
be asked in courts of justice, “Are you a disciple of the gospel of cleanli- 
ness?” and verdicts may depend on its answer. 
It is entirely beyond the pale of this work to attempt anything more than a 
general description of those bacteria which belong strictly to surgical disease. 
Students in this department of natural history are not agreed as to their 
classilieation. Some, as, for example, Billroth, have contended that the differ- 
ent forms described by Cohn and others were only the same organism seen 
at different stages in its life-history,—a statement certainly not correct in 
the light of more recent observations. Some regard these organisms as 
allied to the alg®, and others place them with the fungi. There seems to be 
at present an opinion, notably that of Koch and of Klein, that a harmless 
organism cannot become changed into a disease-producing one. 
The most common forms of these micro-organisms are—1st, Micrococci 
(Fig. 5, A). These are round bodies, and constitute an important group, of 
which systematic writers enumerate five divisions, based on the arrangement 
of their cells, their mode of division, and the diseases in which they are 
found. Those which most concern the surgeon are the pyogenic, diphthe- 
ritic, erysipelatous, gonorrhoeal, and the yellow pyogenic cocci occurring in 
osteomyelitis. Pure cultures of these varieties when introduced into the 
body reproduce with great uniformity morbid conditions corresponding to 
those in which they are found. Probably in the case of the diphtheritic 
variety this statement is scarcely warranted by facts. 
2d. Bacteria.—These are oval or rod-shaped, their length exceeding their 
breadth (Fig 5, B), or they may 
exist as spiral tilaments (Fig. 5, 
D) (spirilla), or in rods more 
or less twisted (Fig. 5, C) (ba- 
cilli). Some of these forms are 
ciliated and possess the power 
of locomotion. Not unfre- 
quently they become aggre- 
gated into masses, joined to- 
gether by a gelatinous or ad- 
hesive material, forming the 
so-called zoogloea. 
One of these organisms (Bac- 
terium ureae) is met with in 
urine, causing the ammoniacal 
fermentation. They are found 
in the inflammatory exudation of pneumonia, in the membranes of diph- 
theria, in splenic fever or anthrax, in cholera, and in tuberculosis. 
The manner of multiplication or growth of micrococci is by division, and 
m certain bacilli by spores. In some members of these organisms the 
division takes place transversely, as in the bacteria; in the micrococci the 
division occurs in both directions, transversely and longitudinally. The spores 
possess a singular tenacity of life, and are not easily destroyed by either heat 
or chemical agents, so that they may remain dormant for years and again 
spring into destructive activity under a favorable environment. The presence 
of oxygen is favorable to the growth of most forms of micrococci. A few 
thrive only in its absence. Water, and organic substances containing nitro- 
gen and carbon and the salts of potash, with phosphates, constitute the true 
pabulum of these organisms. 
These micro-organisms are the active agents in fermentation and decom- 
position. The chemistry of the arts is in many respects dependent on their 
presence. The stability of complex organic substances is broken up through 
their agency, and the resulting products often acquire properties which 
render them poisonous to the system. 
These organisms enter the body through a break in the continuity of the 
soft parts, through the lungs, the stomach, and the urinary passages. There 
Fig. 5. 
A, micrococci; B, bacteria; C, bacilli; D, spirilla. 46 
ANTISEPSIS. 
is reason to believe that inoculation may be effected through the unbroken 
skin by inunction. Garre and Bockhardt have succeeded in producing pus- 
tules by rubbing into the skin of the arm a cultivation in gelatin of the 
staphylococcus pyogenes aureus. It is their presence in the system, or 
rather the chemical changes which they induce, that give rise to inflamma- 
tion, wound-fever, suppuration, and septicemia. 
Bergmann claims to have discovered in the products of decomposed tissues 
a peculiar crystalline substance which he calls sepsin, by others termed 
ptomaines, a material formed through the agency of microbes, and the intro- 
duction of which into the circulation gives rise to systemic infection. The 
micro-organisms which multiply in the tissues about a wound or in its dis- 
charges, causing inflammation and suppuration, are described as micrococci. 
Koch has formulated certain rules designed to establish the relation be- 
tween bacteria and disease: 1st, the micro-organisms must be found in 
the blood, lymph, or diseased tissues of man or animal suffering from or 
dead of the disease; 2d, the micro-organisms must be isolated from the 
blood, lymph, or tissues and cultivated in suitable media,—that is, outside of 
the body; 3d, a pure cultivation when thus obtained must, when introduced 
into the body of a healthy animal, produce the disease in question; 4th, 
in the inoculated animal the same micro-organism must be found. 
If, then, inflammation and suppuration are closely allied to fermentation, 
and if fermentation is dependent on the presence of living organisms derived 
from the external world, it should follow that if these microbes can be pre- 
vented from entering a wound, or are effectually destroyed immediately after 
they have entered it, inflammation with its sequences should fail to appear. 
The clinical evidence on this point is too conclusive to admit of any debate. 
W e are in possession of agents which are fatal to the life of these organisms. 
These agents are called germicides. The most important members of this class 
of remedies are carbolic acid and bichloride of mercury. There are many 
others, less active in germicidal properties, as chloride of zinc, salicylic acid, 
alcohol, sulpho-carbolate of zinc, bromine, chlorine, iodine, iodoform, boracic 
acid, eucalyptus oil, sulphurous acid, naphthalin, formic acid, sulphate of 
copper, turpentine, and permanganate of potash. 
Preparation of Materials generally used in Aseptic Surgery. 
Carbolic acid.—Solutions are employed both as a bath for instruments and 
as a spray,—the former in the proportion of one part of pure crystallized 
carbolic acid to twenty parts of water, the latter in the proportion of one 
part of the acid to forty parts of water. 
Carbolic acid associated with olive oil, glycerin, or, best of all, cosmoline 
(one to twenty), is also employed for oiling catheters or lithotrites before 
using. These instruments should always be placed for a short time in the 
solution of carbolic acid (one to twenty) before being lubricated with the 
above articles. It is convenient to know that six and a half teaspoonfuls 
of pure cax*bolic acid added to one pint of water make the solution one to 
twenty. 
Bichloride of mercury.—This salt has proved to be the most potent of 
all germicidal agents. It is employed as a lotion to the surface of the 
integument, and also to the wound. The lotion ordinarily used in opera- 
tions varies in strength from one part of the salt to one thousand or two 
thousand parts of water, and should be applied to the wound during the 
operation either by irrigation or from sponges. If used in abdominal surgery, 
a much weaker solution will be necessary (one to ten thousand). Seven 
grains and a half of the bicloride of mercury in one pint of warm water 
represent one to a thousand. 
The association of tartaric acid with bichloride of mercury (tartaric mer- 
curic chloride) possesses certain advantages over the bichloride alone which 
render it preferable, inasmuch as it prevents the mercurial salt from uniting PREPARATION OF MATERIALS. 
47 
with the albumen of the tissues and thus losing its character as a germi- 
cidal agent. I am not certain, however, that the general system is as well 
protected against the poisonous effects of the mercury as by the simple 
bichloride. 
The solution is applied to the wound either by douching or by irrigation,— 
in the former method by squeezing the liquid from a sponge at short intervals 
as the operation progresses, and in the latter by allowing the fluid to flow 
over the part by means of a rubber tube tipped with a nozzle and connect- 
ing with a glass reservoir which contains the bichloride solution (Fig. 6), and 
which is suspended some distance above the patient. 
Sterilized water.—If a surgeon should happen to 
be compelled, by force of circumstances, to perform 
an operation without having access to the aforemen- 
tioned agents, he should employ water which has 
been thoroughly boiled and placed in well-stoppered 
vessels. Distilled water would be preferable could it 
be readily obtained. A solution well suited to ab- 
dominal operations is the boro-salicylic of Thiersch, 
the proportions of the constituents being seventeen 
parts of boracic acid, two parts of salicylic acid, and 
one thousand parts of hot water. 
Chloride of zinc constitutes another valuable anti- 
septic agent. A solution consisting of two grains to 
the ounce of water, when applied with a camel’s-hair 
brush to a wound, prevents putrefactive changes. 
Sponges.—The finest quality of sponges should be 
obtained. Before being used they should be deprived 
of all calcareous matter by beating, and placed in 
a very dilute solution of hydrochloric acid for ten or twelve minutes, after 
which they should be well washed in distilled water, and kept in a jar con- 
taining a solution of carbolic acid (one to twenty). After each operation 
the sponges should be thrown into a water-bath, and allowed to remain for 
six or eight days, in order to get rid of the fibrin which becomes entangled 
in their pores, after which they are to be washed in water previously boiled 
or distilled, and then thrown into the carbolic acid solution. There is a very 
good and cheap sponge, not costing over two cents a piece, which might be 
thrown away after a single use, thus avoiding the risk of infection which 
would attend a second employment. 
Basins.—These may be made of tin or of porcelain. If the bichloride of 
mercury is employed for washing the wound, the containing vessel should be 
porcelain. All the instruments employed in the operation must be placed in 
the basin containing the carbolic acid solution (one to twenty). 
Towels.—These are to be wrung out in either the carbolic acid or the 
bichloride solution, preferably in the latter, which should be quite warm, in 
order that the surface of the patient may not be chilled when the wet towels 
are placed around the part to be operated on. 
Carbolized, catgut.—This material is used for ligatures, and not unfrequently 
for stitches or sutures. That made by Marr, High Holborn, U.C., London, 
has been most satisfactory in my hands. In its preparation chromic and sul- 
phurous acids are used, rendering the thread stronger and the knot entirely 
secure. It must be kept in tin boxes, and should be placed in a solution of 
carbolic acid (one to twenty) at least twenty minutes before using. 
Another preparation (“ Kocher”) is made by placing the catgut for twenty- 
four or thirty hours in oil of juniper (that made from the berries), and 
afterwards keeping the threads in alcohol. I have used the catgut thread 
prepared in various ways, and give a very decided preference to that made 
by Marr, of London. 
Silver wire and silkworm-gut.—Either answers admirably for sutures: they 
must be placed in the carbolated solution before using. 
Fig. 6. 
Irrigating apparatus for the bi- 
chloride solution. 48 
ANTISEPSIS. 
Carbolized silk thread, when used for sutures, requires to be subjected to 
some preliminary treatment. Mr. Lister recommends the preparation of a 
mixture by melting together nine parts of beeswax and one part of carbolic 
acid, in which the threads are to be steeped for a few minutes, and then the 
redundant wax removed by drawing them through a piece of cloth. Thus 
prepared, they should be kept rolled up in carbolized gauze. Before being 
used they are to be dropped into the carbolized solution (one to twenty) for 
a few minutes. Silk may be made aseptic by keeping the threads in alcohol, 
after they have been boiled for half an hour in a solution of carbolic acid 
(one to twenty). 
Carbolized gauze.—This material consists of cheese-cloth, or tarlatan, 
charged with a mixture of one part of carbolic acid, four parts of resin, 
and four parts of paraffin; the last two articles being employed to hold the 
carbolic acid and to diminish the consistence of the resin. From this gauze 
are prepared the deep dressing, the superficial dressing, and the roller band- 
ages. The dee]) dressing is made with eight or ten layers of the gauze wet 
with the bichloride of mercury solution (one to two thousand). The super- 
ficial dressing is made of twelve or fifteen layers sufficiently large to extend 
some distance beyond the wound in all directions. 
Corrosive sublimate gauze is prepared by thoroughly cleansing the gauze 
by boiling it for half an hour to an hour in a solution of crude or washing 
soda, then rinsing out the fabric in two or three changes of cold water, 
after which the gauze, being freed from the liquid by wringing, or, if con- 
venient, by passing it through the ordinary clothes-wringer, is immersed in a 
solution of bichloride of mercury for twenty-four hours, when it should be 
removed, pressed out, dried, folded, and placed in tin or glass jars for preser- 
vation and use. When applied to the wound the sublimate gauze should be 
prepared in two different compresses, as in the carbolic dressing, each con- 
sisting of at least ten layers, the one intended for the deep pad being much 
the smaller and fashioned so as to extend about two inches on each side and 
beyond the extremities of the wound, and the larger made to extend at least 
six or eight inches in the same directions. 
Sawdust, moss, and peat dressings.—The sawdust dressing is prepared by 
steeping pine- or hemlock-dust for eighteen or twenty hours in a solution of 
bichloride of mercury (one to one thousand), afterwards drying the dust on 
clean pieces of muslin, and then packing it in bags of carbolized gauze, run- 
ning a number of basting-threads through the pads to keep the contents 
equally distributed. When these pads are used as a dressing, a layer of car- 
bolized or sublimate gauze is interposed between them and the wound. Peat 
and moss dressings are rarely used in American hospitals. 
Protective.—This article consists of oiled silk brushed over with copal var- 
nish. When dry, a mixture of one part of dextrine, two parts of powdered 
starch, and sixteen parts of cold carbolized water (one to twenty) is brushed 
over the surface. This material is intended to defend the approximated 
edges of the wound against the irritating effects of the carbolic acid in the 
gauze, and before being applied should be cut in a strip sufficiently long to 
cover the wound, and be dipped in the bichloride solution. 
Mackintosh cloth.—This consists of cotton cloth having a thin film of india- 
rubber spread on one side. This material is designed to prevent the dis- 
charge from a wound soaking through the gauze dressing. Its place in the 
latter is under the superficial layer of the gauze dressing, with the rubber 
surface towards the wound. It should be dipped in the bichloride solution 
before being used. The mackintosh can be used a second time, provided it 
be thoroughly washed either in the carbolated water or in the bichloride 
solution. In the absence of the protective, waxed paper, oiled silk, or rubber- 
tissue may be substituted. It is very doubtful if the mackintosh contributes 
at all to the value of the dressing: in fact, by retaining the discharges within 
the layers of the subjacent compresses a good soil is prepared for the multi- 
plication of organisms. It would be better, therefore, to omit this part of PREPARATION OF MATERIALS. 
49 
the dressing and to allow the air to filter through the external pad of cotton 
in order to desiccate the discharges. 
Absorbent, salicylized, or sublimated cotton.—This is to be placed around the 
margins and over the surface of the carbolized gauze. It serves, by filtering 
the air, to fortify the weak points or edges of the dressing against the 
intrusion of germs. 
Iodoform, in virtue of its antiseptic properties, is a valuable adjuvant to 
the dressings. It should be sprinkled thickly over the wound and along 
the line of approximation. Its antiseptic properties are developed after it 
becomes mingled with the discharges from wounds. 
Rollers.—These should be made of carbolized or sublimated gauze, and are 
used to secure the dressings in place. Both rollers and gauze should be kept 
in tin boxes, in order to avoid contact with dust. 
Nail-brush.—This is a part of the antiseptic armamentarium which the 
surgeon should be very careful to use, in the way of cleansing the hands 
ami nails of all foreign matter, before beginning his operation. 
Pins to fasten the roller bandages at different points must be at hand. 
Alcohol, turpentine, and ether are useful adjuvants, and should also be at 
hand, as these agents are very effective for removing any fatty matters 
which may adhere to the skin. 
Spray-apparatus.—This steam apparatus is designed to develop a cloud of 
carbolized spray, which is not only to be directed on the wound during the 
operation, but also employed to impregnate the atmosphere over and around 
the seat of operation. 
There are two kind of spray-producers, one a steam (Fig. 7) and the 
other a hand apparatus (Fig. 8). The two instruments are very much alike 
Fig. 7. 
Steam spray-producer. 
in their operation. The conversion of the carbolized water contained in the 
bottles into spray is produced by a forcible current of steam or of air 
passed through a horizontal tube, the point of which is immediately over a 
vertical one, the latter communicating with a reservoir containing the car- 
bolized water. 
The strength of the carbolic acid solution used in the steam spray-appa- 
ratus should be one to twenty, that in the hand spray-apparatus one to forty, 
as in the former the steam reduces materially the strength of the solution. 
Since the introduction of the bichloride of mercury as a germicidal agent 
the carbolic spray has been very generally abandoned. 
Application of Antiseptic Methods to Operation.—The region or part of 
the body which is to be the subject of operation must be thoroughly 
cleansed. If covered with hair it must be shaved, and the skin washed or 
rather scrubbed for several minutes with a lotion of carbolic acid (one to 
forty), with a solution of bichloride of mercury (one to three thousand), 
or with ether, alcohol, or turpentine, in order to remove the fatty matters 
which accumulate in the folds of the skin and around the orifices of the seba- 50 
ANTISEPSIS. 
ceous-gland ducts. In all important operations, especially those involving 
the abdominal cavity, a general bath, containing some boracic acid, will en- 
hance the prospect of success. When the operation is not one of urgency, 
not only is it desirable thus to purify the skin, but a pledget of carbolized 
gauze wet with a solution of carbolic acid (one to twenty) or with a lotion 
of bichloride of mercury (one to one thousand) should be allowed to remain 
over the part for several consecutive hours. 
Fig. 8. 
Hand spray-apparatus. 
Surgeon and assistants.—Next, the surgeon and his assistants must exer- 
cise the greatest care to cleanse their hands from all foreign matters by- 
washing them in water with carbolized soap, scrubbing the skin with the nail- 
brush, and scrupulously removing all accumulation from around and beneath 
the nails, completing the ablution with alcohol, and finally with a solution of 
bichloride of mercury (one to one thousand). Equally important is it that 
both surgeon and assistants should divest themselves of the coat ordinarily 
worn, substituting for the same a white linen apron, with sleeves which button 
closely round the wrists. These aprons ought never to be worn in a subse- 
quent operation without having been previously washed. As dust is liable to 
lodge on these garments, it is well to keep them rolled up in a clean cover 
when not in use, and to take the precaution of sponging the sleeves lightly 
with the bichloride lotion at the time of operation. 
Guarding the person of the patient.—In order to prevent any septic matter 
from coming in contact with the person of the patient, and at the same time 
to furnish an aseptic surface on which an instrument may rest, it will be 
necessary to place under and for some distance around the seat of operation 
rubber cloth which has been washed in bichloride or carbolic acid solution 
(preferably the former), and over this spread towels wrung out in the same 
liquid. If the towels alone are used, the solution should be warm, so that 
the surface of the patient shall not be chilled. Especially is this proper 
when the towels are to be laid over the thorax or the abdomen of the patient. 
Disinfection and arrangement of instruments.—All instruments should have 
metal handles, when possible, smooth, without grooves or ridges. As the bi- 
chloride solution blackens and soils instruments, it is best to employ the car- 
bolic lotion (one to twenty) as their bath. A porcelain or tin basin eighteen ANTISEPSIS. 
51 
inches long, thirteen inches wide, and two and a half or three inches deep 
will be ample to accommodate the instruments necessary for any operation. 
In this basin containing the carbolic acid solution the instruments should 
be placed for at least half an hour before using. 
It is often the case that on a surgeon’s changing the instrument, or laying 
one down momentarily, it comes in contact with a portion of the patient’s 
clothing not protected by an antiseptic covering. The instrument ought not 
to be used until again placed in the carbolized liquid. A basin of bichloride 
solution (one to one thousand) should always be in readiness, into which 
the surgeon may, as the operation proceeds, dip his hands from time to 
time. Hot water will answer the purpose if the mercurial solution is not to 
he had. Instruments should not be used in a second operation without having 
been previously boiled in water for half an hour. In no other way is it 
possible to render them perfectly free from septic matters. CHAPTER III. 
SURGICAL DRESSINGS 
Under the head of surgical dressings are included all those materials, ap- 
pliances, and apparatus employed by the surgeon in the cleansing, uniting, 
protection, and support of wounds and abscesses, in the control of hemor- 
rhage, in the correction, by mechanical measures, of deformities, and in the 
retention of broken bones and of displaced joints. In the present chapter, 
however, I shall speak only of those which are generally in use in the treat- 
ment of wounds and fractures. 
Lint.—There are two kinds of lint, the common or domestic lint and the 
patent lint. Common lint is prepared by stretching a strip of old linen 
and scraping its surface with 
an ordinary table-knife until a 
soft, cottony mass is collected. 
(Fig. 9.) 
Patent lint, so generally used 
in hospitals, is made from new 
linen, the transverse threads 
of which are removed, and the 
surface of the longitudinal 
ones scraped by machinery. 
The absorbent power of lint 
is greatest when prepared from 
new linen. At present it is less 
used than formerly, other ma- 
terials, much less expensive, 
having taken its place. 
Charpie is made by unravel- 
ling or taking apart the t hreads 
of linen. During the late 
American war vast quantities 
of this material were prepared 
by households, from old table-cloths and other pieces of linen. 
The dressings which are constructed from charpie are the following: 
Pellets.—These are little balls, made by rolling a mass of charpie into a 
round form between the palms of the hands. 
(Fig. 10.) They may be used to tampon 
wounds in order to arrest bleeding, or may 
be introduced in suppurating cavities to 
absorb the pus. 
Pellets differ from bullets in having the 
little ball covered with a piece of muslin 
or of linen, the edges of which are tied after the manner of a 
sack. (Fig. 10.) 
They are useful as compresses for the arrest of hemorrhage, and as a tem- 
porary substitute for a truss in cases of hernia, being bound on the part 
with a roller. 
Tents are made by taking a little roll of charpie, doubling it upon itself, and 
then twisting it between the thumb and fingers into a cone. (Fig. 11.) The 
Fig. 9. 
Method of scraping lint. 
Fig. 10. 
Pig. 11. 
Tent. 
Pellet. SURGICAL DRESSINGS. 
53 
tent can also be made of patent or domestic lint. It is used to keep patulous 
the opening of an abscess. After the contents have escaped, the apex is in- 
serted into the incision made by the knife, and the tent is carried in to the 
proper extent by imparting to it a rotary motion. 
Bullets are prepared by rolling pieces of charpie or lint between the fingers 
or the palms of the hands into round balls. (Fig. 12.) They may be used 
to absorb the discharges from a suppurating cavity, or to arrest hemorrhage 
from a wound. 
The mesh.—The mesh is formed by placing a number of threads of charpie 
parallel to one another, and then either twisting the mass at the middle upon 
itself (Fig. 13), or tying a thread tightly around the centre. In the latter 
case it is often termed a roll. (Fig. 14.) The mesh or roll is used to pack 
fistulous openings, to prevent wounds from closing too soon, to absorb dis- 
charges, and to control hemorrhages. In its application a probe or a director 
Fig. 13. 
Fig 14. 
Fig. 15. 
Fig. 12. 
Bullets. 
Mesh supported 
on a probe. 
Roll. 
Pledget. 
is placed against the centre, at the point where it is twisted or tied, and in this 
way, when doubled upon itself, it can be conducted into a wound or sinus. 
The 'pledget is a form of compress made by arranging the threads of charpie 
somewhat parallel with one another, turning their extremities inwards, and 
imparting a fixedness of form by compressing the mass between the palms 
of the hands. (Fig. 15.) In this way it can be fashioned into almost any 
form, square, oblong, or round. 
The pledget is often placed over the ends of stumps after amputation, 
and also over other wounds, to absorb the discharges. Meshes, tents, and 
pledgets are sometimes smeared with cerate or sweet oil and carbolic acid. 
Other materials have been introduced into surgical practice cheaper than 
lint, and equally efficient, the most important being oakum and paper. 
Oakum, introduced by Dr. Sayre, is made from old cast-off ropes, such as 
have formed a portion of the rigging of ships. Picking oakum at one time 
constituted a part of prison labor. When carefully prepared, it makes an 
excellent dressing, being soft, possessing good absorbent properties, and emit- 
ting a pleasant odor from the tar contained in the fibre. It may be used to 
wash wounds and to pad splints, and by shaping it into a cushion-like mass 
or ring it can be employed with great advantage to relieve salient parts of 
the body from pressure, such as those over the tuber ischii, over the sacrum, 
and upon the heel. This material is extensively used in all the Philadelphia 
hospitals. 
Paper lint is made from old rags decolorized by chloride of lime and passed 
between rollers into sheets. It was first used as a surgical dressing by Dr. 
Studdeford, of Lambertville, New Jersey. I was induced to give it a trial 
in the Pennsylvania Hospital, and was led to believe that with certain im- 
provements it could be made both an economical and a valuable dressing. 
These have been successfully carried out by Dr. Huffnagle, of New Hope, 
Pennsylvania. The preparations of this material now in use are the follow- 54 
SURGICAL DRESSINGS. 
ing: a soft, pliable lint, possessing excellent absorbent properties, and ap- 
plicable to every purpose for which patent lint, muslin, and linen are used; 
it is put up in rolls; a piece six and a half yards long and half a yard wide 
weighs one pound. It is sometimes treated with salicylic and boracic acid, 
and also with the corrosive sublimate solution. Water-dressing lint, which 
differs from the other in being thicker and more porous, and is used in cases 
where a water dressing is indicated. Poultice mass, a thick, loose-textured 
lint, one surface of which is covered by a thin film of varnish, and thereby 
rendered impermeable to moisture. It is used as a substitute for the ordinary 
poultice by soaking it in hot water and placing it over the affected part. 
Waxed paper.—This material was introduced into the Pennsylvania Hos- 
pital by Dr. Addinell Ilewson. It is prepared by floating tissue-paper for a 
few seconds on the surface of melted beeswax contained in a broad, shallow 
pan, and then drawing the sheets between the edge of the pan and a roller, 
or between the former and the edge of a pine stick, in order to remove the 
redundant wax. When placed over wet dressings or poultices, it serves to 
retain their moisture. 
Oiled silk, oil-cloth, rubber tissue, and rubber-cloth mackintosh are all employed 
to cover dressings where it is desirable to retain heat and moisture. Under 
other circumstances, unless the dressings are changed as soon as they be- 
come foul, the effect of these water-proof coverings is pernicious. They 
produce too much warmth, favor the decomposition of discharges, and serve 
to keep diseased parts bathed with inflammatory products of an irritating or 
a poisonous nature. 
Compresses are formed from carbolized or sublimated gauze, muslin, linen, 
lint, flannel, paper lint, tow, or oakum. They are designed to afford firm sup- 
port, supply pressure, fill up inequalities, control bleeding, and 
disinfect the discharges. They are square, oblong, perforated, 
or graduated, and vary in thickness. 
The square compress is made by folding upon itself a piece 
of any of the fabrics above named, alternately side- 
wise and lengthwise, until the requisite size is ob- 
tained. 
The oblong compress is made either by folding the 
square once on itself, or by folding the material in 
one direction and then doubling it in its length. 
(Fig. 16.) 
The perforated compress differs from the others 
only in having a hole cut in its centre (Fig. 17), and 
is designed to relieve pressure by allowing a salient 
point of the body to rest in the opening. 
Graduated compresses are pyramidal, prismatic, and semi-cuneiform. 
The pyramidal compress is made by placing a succession of regularly dimin- 
ishing square compresses upon one another until the pyramid is formed; to 
keep them from displacement, a stitch should be passed 
through from the apex to the base. (Fig. 18.) This 
compress is adapted to making concentrated pressure. 
The prismatic compress is made by placing in successive 
layers a number of oblong compresses, each one more 
narrow than the preceding. 
To keep the parts from be- 
coming disarranged, a stitch 
must be passed through the 
different strata in the middle 
and at either end. (Fig. 19.) 
Such compresses are useful in 
making concentrated linear pressure, as, for example, over the radial or the 
ulnar artery. 
The semi-cuneiform compress, sometimes called the graduated compress, is 
Fig. 16. 
Fig. 17. 
Oblong com- 
press. 
Perforated 
compress. 
Fig. 18. 
Fig. 19. 
Pyramidal compress. 
Prismatic compress. SURGICAL DRESSINGS. 
55 
constructed by placing in superimposed layers a number of oblong com- 
presses, each layer shorter than the preceding one. (Fig. 20.) This com- 
press may be quickly extemporized by reversing 
a roller upon itself, the reverses being even at one 
end and successively shorter at the other. Such 
compresses are used when it is necessary to apply 
graduated pressure, as in fractures at the lower 
end of the radius. 
Retaining compresses constitute a class of surgical 
appliances which serve to keep in position other dressings or to shield parts 
against injury. They are the following: 
The Maltese cross, which is formed by taking a square piece of muslin or linen 
and folding it upon itself twice, the first fold making it oblong, and the second 
square. Thus prepared, one angle will be found to 
consist of four layers separable from one another. Let 
this angle be slit down within two or three inches of 
its centre, and then the piece opened out, when it will 
be found to have the form 
shown in Fig. 21. 
The half Maltese cross is pre- 
pared by folding a square 
piece of muslin or linen into 
an oblong figure, and then 
slitting down one of the loose 
angles to within two or three 
inches of the centre. When 
opened out it will have the form of Fig. 22. These crosses are much used in 
amputations, to cover in and keep dressings in contact with the stump. The 
centre should be placed so as to rest against the end of the stump, and the 
angles folded smoothly around the surface of the limb. 
The triangular compress is formed by doubling a large sqiiare of muslin or 
linen diagonally, forming a triangle (Fig. 23); or, if it is desirable to have a 
single thickness or layer, by slitting it diagonally from 
angle to angle. This forms a very good retaining com- 
press for stumps, or to confine poultices upon the hand. 
In applying it as a retaining compress, the base of the 
triangle is placed underneath the limb, the apex hang- 
ing free. The latter is then brought up in front of the 
stump, turned over the upper surface of the limb, and 
there retained by tying or pinning around the parts 
the crossed angles of the base. 
The cribriform compress is made by folding a square piece of linen three or 
four times upon itself, and then cutting out small pieces, or, as it is termed, 
“slashing the sides.” A more uniform and a neater plan is, after folding 
the square a number of times upon itself, to perfo- 
rate it at numerous points with a shoemaker’s punch. 
(Fig. 24.) The openings will permit the escape of dis- 
charges which flow from a wound or from a suppu- 
rating surface. 
Retractors are linen*or muslin strips, designed to hold 
parts out of the way of injury. 
The retractor of two tails is formed by slitting a piece 
of muslin fourteen inches long and three inches wide 
one-half of its length, and cutting out a diamond-shaped 
piece at the termination of the slit, to prevent the ex- 
tension of the latter. (Fig. 25.) 
The retractor of three tails differs from the other in being one inch wider, 
and in having two slits instead of one. (Fig. 26.) 
These retractors are used in amputations to keep the soft parts out of the 
Fig. 20. 
Semi-cuneiform compress. 
Fig. 21. 
Fig. 22. 
Maltese cross. 
Half Maltese cross. 
Fig. 23. 
Triangular compress. 
Fig. 24. 
Cribriform compress. 56 
SURGICAL DRESSINGS. 
way of the saw. The first is suited to the thigh or the arm, where there is 
a single bone, one tail passing on either side, after the division of the muscles, 
after which they are crossed and drawn upwards 
by an assistant. The second retractor is used 
in amputations of the leg or of the forearm: the 
middle tail being carried through the interosse- 
ous space, and the lateral ones around the bones, 
they are collected together and drawn up as in 
the first instance. 
There are a number of retaining dressings, 
which are called T bandages. 
The single T bandage, called also crucial, is 
composed of two parts, a horizontal and a ver- 
tical strip of muslin, each two or three inches 
wide. The vertical is to be sewed to the middle 
of the horizontal strip. (Fig. 27.) The vertical 
strip is generally slit for some distance into two 
tails (Fig. 28), which renders it better suited to 
the purposes for which the bandage is required, 
namely, that of retaining dressings to the peri- 
neum after operations for fistula of the bowel, or 
for the support of the bowel against prolapse, or 
to prevent the protrusion of piles. 
The double T bandage differs from the single 
one in having two vertical strips separate in 
their entire length, and sewed to the horizontal band two inches apart, and 
equidistant from its centre. (Fig. 29.) The bandage is best made from a 
roller two and a half or three inches wide, the horizontal portion being about 
two yards and the vertical bands less than a yard long. It is employed for 
the same purposes as the single T bandage. The different parts of these 
Fig. 25. 
Fig. 26. 
Two-tailed re- 
tractor. 
Three-tailed re- 
tractor. 
Fig. 28. 
Fig. 27. 
Fig. 29. 
Single T bandage. 
The incomplete double T bandage. 
Double T bandage. 
dressings should be rolled into cylinders, and each pinned to its correspond- 
ing strip, when prepared for future use, as it prevents the bandage from 
becoming soiled, and maintains the principle of order and neatness. When re- 
quired for immediate use, it is not necessary to roll the parts up in this manner. 
The T bandage of the ear.—This differs from the single T bandage in having 
an auricular-shaped piece of muslin interposed between the vertical and the 
horizontal band (Fig. 30), the vertical band being fifteen inches in length and 
the horizontal one a yard and a half long. The breadt h of each need not ex- 
ceed one inch. The auricular part is sometimes slit in order to allow the ear 
to pass through. This bandage is an admirable one for keeping a poultice or 
fomentation to the ear or over the mastoid region. T BANDAGES. 
57 
Application.—The horizontal portions, being rolled, are carried around the 
head. After making two turns, the vertical strip with its auricular attach- 
Fig. 31. 
Fig. 30. 
T bandage of the ear. 
T bandage of the ear applied. 
ment is brought down over the ear, or, if slit, on either side, as may be re- 
quired, then behind and under the jaw, and up to the opposite temple, where 
it is to be secured by passing over it the horizontal band (Fig. 31), when 
both are made fast with pins. 
The single T bandage of the head consists of a horizontal strip one yard and 
three-quarters long, and a vertical one fifteen inches in length, each strip being 
one inch wide. The vertical strip may be made with ad- 
vantage much wider where it is necessary to cover in a 
broad surface. This bandage is well adapted to retain 
a dressing upon a portion of the scalp. (Fig. 32.) 
Application.—Place the point of junction between 
the horizontal and the vertical part of the bandage 
over the middle of the forehead, just above the nose; 
carry the ends of the horizontal strip around the 
head, and the vertical strip back to the occiput, where, 
after being crossed by the former, it should be brought 
forward to the forehead, and again crossed by the hori- 
zontal turns, each strip being secured by three pins. 
The double T bandage of the nose may be prepared 
from a narrow roller or a piece of tape. The two 
vertical strips should be one yard long, and the hori- 
zontal one about two yards, each strip not exceeding 
three-quarters of an inch in breadth. 
Application.—Place the middle of the horizontal strip on the middle of the 
upper lip, and carry the vertical ones upwards along the sides of the nose to 
its root, where they are to be crossed and conducted to the back of the neck, 
and there held by an assistant while the horizontal band is carried back over 
the sides of the face below the ear to the back of the neck, and crossed over 
the vertical bands, the ends reversed, and afterwards brought forward above 
the ears, over the temples and forehead, and there pinned or tied, the other 
bands being secured in the same way. (Fig. 33.) 
The single T bandage of the nose.—This T is sometimes described as a sus- 
pensory. Tt consists of a central part or sheath, to which are attached two 
pieces of tape, a horizontal and a vertical strip, the former one yard long, 
and the latter one foot. The centre or sheath is made by folding a piece of 
muslin into an oblong square, two inches and three-quarters long and two 
Fig. 32. 
T bandage of the head. 58 
SURGICAL DRESSINGS. 
inches wide, and then cutting it into a triangle with unequal sides, as indi- 
cated by the dotted lines BC, CD, Fig. 34. 
Application.—Apply the shield over the 
nose, and carry the short tail over the middle 
of the head to the back of the neck, where 
it should be held by an assistant; then carry 
the ends of the horizontal tails across the 
face to the back of the neck, where they 
should be crossed over the vertical tail, 
brought forward, and tied or pinned over 
one of the temples. The vertical strip is 
then to be turned upon itself, and made fast 
with a pin. (Fig. 34.) The sling will an- 
swer very well to retain a water or other 
dressing to the nose. 
The double T of the thorax consists of a 
piece of muslin eight or nine inches wide, 
and sufficiently long to surround the chest 
and overlap a few inches. To the middle of 
the upper border of the horizontal piece is 
to be attached a strip of muslin two and a 
half or three inches wide, and two feet long. 
This strip must be slit up into two tails 
within two inches of its attachment; or two 
distinct pieces may be sewed a short distance apart to the horizontal band, 
thus making a double T of the chest. 
Application.—The broad portion of the bandage is carried around the chest, 
below the axilla?, and the ends overlapped and pinned. To prevent its slipping 
Fig. 33. 
Double T bandage of the nose. 
Fig. 34 
Fig. 35. 
Single T bandage of the nose. 
Double T bandage of the chest. 
down, the two ends of the narrow strip are brought over the shouldei's, one 
on either side of the neck, and pinned to the front of the chest-portion. (Fig. 
35.) This bandage is decidedly superior to all others for retaining dressings 
upon the chest after excision of the mamma, and is occasionally employed as 
a dressing for fractured ribs. 
The double T of the abdomen consists of a horizontal band eight inches wide, 
and sufficiently long to encircle the pelvis and overlap, with two vertical 
bands, twenty inches long and two inches wide, sewed to one of its borders, 
nine inches apart, and equidistant from the centre. 
Application.—The broad or horizontal portion is placed around the pelvis, 
and the ends overlapped and pinned; the vertical strips are next conducted 
over the posterior border of the buttocks and the perineum, across the groins, 
and pinned to the horizontal band in front. (Fig. 36.) 
This bandage is principally used to retain dressings upon the surface of T BANDAGES. 
59 
the abdomen, or to exert compression after paracentesis abdominis or the 
removal of ovarian growths. 
The T of the groin consists of a horizontal and a vertical band, each about 
two yards long and two inches wide, and a triangular piece of muslin eight 
or ten inches long, and five or six inches wide at the base. The base is to be 
sewed to the middle of the horizontal band, and the apex to the vertical band. 
Application.—Place the base of the triangle over the groin, on a line with 
Fig. 36. 
Fig. 37. 
Double T of the abdomen. 
Compound T of the groin. 
Poupart’s ligament, and secure it by carrying the ends of the horizontal 
hand about the pelvis and pinning or tying them together. The triangular 
piece is next brought down in front of the groin, and made fast by carrying 
the strip attached to its apex round the posterior and outer surface of the 
limb, across to the opposite side of the pelvis, and down over the posterior 
face of the latter, terminating by a circular turn around the thigh. (Fig. 37.) 
The T bandage of the buttock does not differ from that of the groin, ex- 
cept in the size of the triangular piece of mus- 
lin, which should be nine inches wide at its 
base, and twelve inches long. 
Application.—The base of the triangle is 
placed above the buttock, and the horizontal 
band fastened around the body; the apex is 
next brought across to the inner side of the 
limb, and retained by the vertical hand being 
carried about the thigh, across the buttock, 
and pinned to the horizontal part on the op- 
posite side of the body. 
This bandage serves to retain dressings to 
the nates. 
The T bandage of the hand is made by taking 
a strip of muslin fourteen inches long and one inch wide, and stitching to 
the middle of one of its borders a piece of muslin five inches wide and ten 
Fig. 38. 
Perforated T of the hand. SURGICAL DRESSINGS. 
inches long, across the middle of which are to be cut four round openings. 
(Fig. 38.) 
Application.—Pass the four fingers through the circular holes in the mus- 
lin, folding one part back over the palm, and the other over the back of the 
hand, and secure these by circular turns of the horizontal band. 
This T of the hand forms a very convenient bandage to retain lotions or 
poultices on the hand. 
Slings. 
Slings constitute another form of bandages, and are designed to retain 
dressings to different parts of the head, the face, the arm, and the scrotum. 
They consist of two parts,—the body and the tails. The body varies both in 
breadth and in length, and the tails number usually two, four, or six pieces. 
The two-tailed sling consists of a single strip of muslin four or five inches 
wide and one yard long. It is familiar to every one as a simple support of 
the hand and arm in fractures of the upper extremity. 
Application.—The forearm being placed at right angles with the arm, the 
middle of the body of the sling is passed underneath the wrist, and its ends are 
carried up in front of the chest and tied or pinned on one side immediately 
below the clavicle. When tied behind the neck the knot is liable to excoriate 
the skin. 
The four-tailed sling is made by slitting down a piece of muslin at each 
end, leaving a portion in the centre undi- 
vided. (Fig. 39.) The length and breadth 
of a sling will be determined by its par- 
ticular application. 
When designed for the head, it should 
be five or six inches wide and thirty-two 
inches long. Such a sling is well suited to 
retain dressings upon the back of the neck 
or on the top of the head. 
Application.— Place the body of the 
sling across the back of the neck, bring the upper tails along the sides of the 
head immediately above the ears, and, after crossing over the forehead, bring 
them back, and fasten with pins behind the ears. (Fig. 40.) 
The four-tailed sling for the top of the head.—Place the body of the sling on 
the top of the head, bring the posterior tails forward, and secure with a pin 
Fig. 39. 
Four-tailed sling. 
Fig. 40 
Fig. 41. 
Four-tailed sling for the back of the neck. 
Sling for the top of the head. 
or knot beneath the chin; carry the anterior tails back, and fix in a similar 
way at the back of the head. (Fig. 41.) 
Galen's bandage, or the six-tailed sling.—This sling is made by slitting into three 
tails, to within three inches of its centre, a piece of muslin one yard long and a SLINGS. 
61 
quarter of a yard wide. The middle strip should be the widest of the 
three. 
In its application the body of the sling is placed on the top of the head, and 
the middle tails are brought down and tied under the chin. The anterior tails 
are next' carried back to the occiput and crossed, after which the posterior 
strips are brought forward and made fast by pins. (Fig. 42.) 
The four-tailed clavicular sling.—This sling, designed for the treatment of a 
broken clavicle, requires a piece of muslin seven inches wide and two yards 
long. The body should be twelve 
inches in length, and a small conical 
cut should be made in its centre. 
Application.—Place the body of the 
sling underneath the elbow, so that 
the olecranon prominence shall settle 
into the small opening in the centre; 
bring the lower tails up, one over 
the front, and the other over the 
back, of the chest, and secure them 
with a knot. The upper tails are 
next to be carried around the body 
and made fast. This sling forms a 
very convenient and efficient mode 
of treating fractures at the acromial 
end of the clavicle, and answers also 
as a good temporary support for a 
fracture near the superior end of 
the humerus. 
The four-tailed sling of the chin.— 
This sling is made by slitting down 
at each end, to within two inches ot 
its middle, a piece of muslin forty 
inches long and three inches wide. 
Application.—Place the body of the sling beneath the chin, carry the upper 
tails across the neck and below the ears, and give them to an assistant. 
Then carry the lower tails up over the face, 
in front of the ears, to the top of the head, 
where they should be crossed, returned to 
the temporal ridges, and pinned. The upper 
tails are next taken from the assistant, 
crossed on the nape of the neck, and brought 
forward round the head, and above the ears, 
and, after crossing them, the lower tails at 
the temples are made to overlap each other 
on the forehead, where the ends are to be 
secured with pins. (Fig. 43.) 
This sling is sometimes made of a centre- 
or chin-piece, slit for two inches at each 
end, and having four stout pieces of tape 
one yard long sewed to these short tails. 
It makes a somewhat neater dressing when 
prepared in this way. It is chiefly used in 
fractures and in dislocations of the jaw, or 
when it is desired to apply a dressing to the 
chin. 
The four-tailed sling or mask of the face.— 
This consists of a central or facial part and 
four tapes, two on each side, to hold it in 
place. To construct the central part or 
mask, fold a piece of muslin nine inches square upon itself, and round off the 
Fig. 42. 
Six-tailed sling of the head. 
Fig. 43. 
Four-tailed sling of the chin. SURGICAL DRESSINGS. 
upper and lower free angles, so as to convert it into an ovoidal form; then, 
opening the muslin, draw across from side to side two lines, dividing it into 
three equal parts. A short distance on each 
side of the upper line cut out an oval open- 
ing for the eyes, make a transverse slit in 
the middle of the lower line for the mouth, 
and a vertical slit, commencing a short dis- 
tance above the last, and extending up to a 
point midway between the eye-holes, for the 
nose. The tapes are to be next attached 
to the upper and lower parts of the sides, 
the first strip being eighteen inches long, 
and the last eight or ten inches. 
Application.—The body or mask is to be 
placed over the face so that the eyes, the 
nose, and the mouth shall correspond to 
its openings, when it is secured in position by the tails being carried to the 
back of the neck and behind the head, the last strip being crossed, brought 
forward, and tied over the forehead. (Fig. 44.) This forms an excellent 
method of retaining dressings to the face, such as are frequently required 
after burns, scalds, etc. I have often used 
this mask with great benefit as a means 
of applying a water dressing to the face 
in bad cases of acne. In order to retain 
the moisture, I have the mask made of 
patent lint, and direct that a piece of oiled 
silk of a similar form shall be basted on 
its outer surface. 
The four-tailed sling of the breast is pre- 
pared by taking a piece of muslin from 
six to eight inches square, cutting out a 
Y-shaped piece from each of the four 
angles, two and a half to three inches in 
depth, and then stitching the sides to- 
gether, thus giving the square a concave 
form. To each corner sew a broad piece 
of tape one foot and a half in length. 
Another method, but a less perfect one, 
is to cut four slits, one or two inches deep, 
in the middle of the four sides, and attach 
the tapes to the angles. 
Application.—Raising the breast, place 
over it the body of the sling, tying the upper tails or tapes behind the neck, 
and the lower ones about the body. (Fig. 45.) This is a valuable support 
to the breast, and will be found quite useful in applying pressure or retaining 
dressings, such as lotions, poultices, etc. 
Fig. 44. 
Four-tailed sliner or mask of the face. 
Fig. 45. 
Four-tailed sling of the breast. 
The Roller Bandage. 
The roller is a bandage made from cheese-cloth, muslin, linen, calico, silk, 
or flannel. The material which answers the best purpose is unbleached 
muslin. When torn into a strip and rolled into a cylinder it is called a 
roller. Although the roller is often made by sewdng strips together, yet for 
general use it should consist of a single piece. These strips vary in length 
and in breadth, ranging from two to ten yards in length, and from three- 
quarters of an inch to three inches in width. The rollers now used to retain 
antiseptic dressings are made from cheese-cloth, and are treated with either 
carbolic acid or corrosive sublimate. (See chapter on Antisepsis.) 
In order to form the cylinder, it may be rolled by the hands, or, more expe- THE ROLLER BANDAGE. 
63 
ditiously, by means of a machine called the roller. This simple contrivance 
is an indispensable appointment for hospitals and for rooms appropriated to 
practical surgery, it can be screwed to the edge or end of a table when 
needed for use. 
In using the machine, one end of the strip of muslin designed for a roller is 
wrapped around the spindle, which is turned with one hand, while with the 
Fig. 46. 
other the piece is guided evenly under a i*od of metal which extends between 
the two sides of the machine. (Fig- 46.) When the piece is wound up, 
the mass must be grasped by the hand, 
when, reversing the spindle, the latter can 
be drawn from the centre of the roller. 
The ravellings which adhere to the ends 
of the latter must now be pulled off. 
When the roller is formed by the hands, 
one end of the strip should be doubled 
upon itself to the extent of three inches, 
and this again repeated two or three 
times, in order to form a little mass or 
nucleus; or the end may be rolled into a 
little cylinder with the lingers, and after- 
wards between the palm of the hand and 
the thigh, until it has attained some little 
bulk, when it should be held by its ends 
between the thumb and index finger, or 
the index and middle fingers, the unwound 
portion of the strip being supported be- 
tween the radial border of the ring-finger 
and the thumb. By imparting simultane- 
ously the movement of pronation and supination to the two hands, the strip 
can be wound up with great facility. Every student should practise this 
manipulation, changing the mass of the roller from one 
hand to the other until either can be 
used indifferently. (Fig. 47.) 
Kinds of rollers.—There are two 
kinds of rollers,—the single (Fig. 48) 
and the double (Fig. 49). 
The parts of the single roller are 
its extremities, body, surfaces, and borders. 
There are two extremities,—the initial, which is the free end, and the 
Machine for rollinsr bandasres. 
Fig. 47. 
Forming a roller bandage by the hands. 
Fig. 48. 
Fig. 49. 
Single roller. 
Double roller. 64 
SURGICAL DRESSINGS. 
terminal, which is the one in the centre of the cylinder. The body is the mass 
between the two extremities. The surfaces are two in number, the external 
and the internal; and the borders are designated upper and lower, according 
as they are towards the proximal or the distal part of the limb. 
The double roller, in consequence of its being rolled from each end of the 
strip, differs from the single roller in having two bodies and no initial end. 
The double roller might, without inconvenience, be expunged from the list 
of surgical dressings. 
Hollers are designated by different names, according to their direction 
or to the particular end had in view in their application. Those varieties 
which take their names from the course or direction of the bandage are 
called circxdar, spiral, oblique, spiral reversed, recurrent, figure-of-eight, and spica. 
Those named from the etfect produced are called uniting, dividing, expelling, 
and compressing rollers. 
Before describing the most useful of these bandages, I may remark that 
the ability to apply a roller, or, indeed, any surgical dressing, properly, is a 
very high qualification, and one which can be attained only by practice. No 
man is competent to give proper attention to a patient who is the subject of 
injuries demanding surgical care, unless he can apply a roller with precision 
and neatness. I am quite sure that on the use of the roller not unffequently 
depends the success or the failure of the young physician just entering upon 
the duties of his profession. People generally are not unobservant spectators 
of the deportment of medical men, and of the skill which they may display 
in the use of technical resources. Too much credit cannot be awarded to 
those gentlemen who have for a number of years been engaged in conducting 
private courses upon practical surgery, the fruit of which labor I see in almost 
every professional excursion which i make through this and the adjoining 
States. 
General directions for applying a, roller.—1. The body of the roller should be 
held in one hand by its ends between the thumb and two or three of the 
Fig. 50. 
Fig. 63. 
Fig. 61. 
Fig. 52. 
The corners turned 
in and pinned. 
Longitudinal and transverse intro- 
duction of the pin, the ends of the 
roller having been previously turned in. 
Securing the roller by a knot. 
fingers, or in the palm of the hand. The external surface of the initial end 
should be laid upon the part to which it is to be applied, and fixed with the 
finger or the thumb of the other hand until the body is conducted round 
the limb, when the hands should exchange offices as the roller is passed from 
one to the other. These movements are repeated two or three times, one 
turn accurately covering the other in order to secure the initial end, after 
which the remaining part of the bandage is applied according to the required 
indications, and made fast either by turning in its angles or by folding the 
terminal end upon itself (Fig. 50), and then inserting one or more pins, 
either longitudinally or transversely, with their points buried out of sight. 
(Figs. 51. 52.) If the pins be used in a longitudinal direction, the heads 
should point towards the proximal end of the limb; if transversely, they 
should look outwards. 
Another plan often employed to secure the terminal end is to slit it up a 
short distance and tie the extremities into a knot. (Fig. 53.) SPECIAL ROLLERS. 
65 
2. The roller, except in a few instances, should always commence at the 
distal extremity of the limb, the first turn being made at the wrist in the 
case of the upper extremity, and at the ankle in the lower extremity, then 
passing to the hand or the foot, and subsequently ascending the limb. 
3. The roller must be applied smoothly, with uniform, equal, or even press- 
ure. A neglect of this precept, making it tight at one place and loose at 
another, will produce cedematous swellings, and may cause gangrene. 
4. A roller should be removed and reapplied whenever it becomes disar- 
ranged or loose, or in case of subsequent swelling making it too tight. The 
sensations of the patient should receive due consideration. When the bandage 
is felt to be too tight, it should be immediately relaxed. 
5. In removing a roller, after the terminal end has been unloosed it should 
be unwound in a direction the reverse of that which was used in its applica- 
tion, and as the unrolled bandage is passed from hand to hand, the loose 
turns should be gathered carefully together into a mass, so that they may 
not become entangled about the part and give rise to. pain or to disarrange- 
ment of the limb. 
Special Rollers. 
The circular roller.—This roller is very simple, and consists in causing one 
turn to overlap accurately the preceding one. 
(Fig. 54.) 
Use.—Its application is limited to retaining a 
dressing to the eyes, the temple, the forehead, or 
the neck. 
The oblique roller.—In this bandage the roller 
is made to ascend the limb in a direction so 
oblique as to leave intervals between the con- 
secutive turns. (Fig. 55.) 
Use.—Its chief value is to retain dressings to 
a part where pressure is a matter of secondary 
importance. 
Fro. 54 
Circular roller of the neck, 
Fig. 55. 
Oblique roller of the arm. 
The spiral roller.—This roller ascends the limb in a spiral manner, each turn 
overlapping the preceding one about one-third. (Fig. 56.) This bandage an- 
swers every purpose when applied 
to parts of uniform dimensions; 
but, as the arm or leg increases in 
circumference, it is impossible for 
a spiral roller to press with equal 
and uniform force upon all parts 
of the surface. (See a, b, c, Fig. 56.) 
To remedy this defect the bandage 
is subjected to a reverse by which 
it can be applied evenly to the in- 
equalities of a part. 
Spiral reversed.— The peculiarity 
of this roller is the reverse given to 
its turns, which makes it the most useful of all roller bandages. Simple as 
this little manoeuvre of making a reverse appears, there are persons who never 
Fig. 56. 
Spiral roller applied to the arm. 66 
SURGICAL DRESSINGS. 
acquire any facility in forming it. Attention to the following details will tend 
very much to simplify its execution. 
After laying down the initial end of the roller, and making it fast by 
two or three circular turns, change the direction of the bandage to that 
of a spiral, and, preparatory to making the reverse, place a finger upon 
the upper edge of the roller so as to keep it in contact with the limb; then, 
unrolling the bandage three or four inches, carry the body of the roller 
towards the limb, so as to allow the strip to remain quite slack, and then, by 
a motion of the wrist, turn the hand from supination to pronation, when the 
reverse will be smoothly formed. (Fig. 57.) These reverses should be made 
Fig. 57. 
Making the spiral reverse. 
in the same line, and never over a salient portion of the skeleton if it can 
possibly be avoided. 
Spiral reversed of the upper extremity.—This roller should be two and a half 
inches wide and seven or eight yards long. The initial end being first fixed 
by a few circular turns around the wrist, the roller is carried obliquely 
across the back of the hand over the palm to the ends of the fingers, and then 
made to ascend by spirals to the junction between the thumb and the index 
finger. A few figure-of-eight turns are next made in order to cover in the 
root of the thumb together with the carpal portion of the hand, after which 
the roller is conducted by spiral reverses to the elbow. The elbow is covered 
in either by reverses, by spirals, or by figure-of-eight turns, always observing 
first to flex the arm moderately, provided that position is afterwards to be 
maintained. From the elbow the roller is continued up to the shoulder, where 
it is fastened with a pin. (Fig. 58.) This bandage is a matter of daily 
application, and should be practised by the student with great care, in order 
that he may be able to apply it with just the proper degree of pressure, 
regularity, and neatness. It is frequently applied in fractures at and above 
the elbow; it is used after operations, and often in cases of oedematous 
swellings of the arm and the leg. 
The spiral reversed of the finger.—This roller should be three-quarters of 
an inch or an inch wide and about a yard long. 
In its application two or three circular turns about the wrist are first 
made to fix the initial end of the roller; it is then carried obliquely across 
the back of the hand and to the front of the finger, after which the spiral 
reverses are made up to the metacarpo-phalangeal joint, when it is com- 
pleted by two circulars of the wrist, and the end slit into two slips and tied 
around the joint. SPECIAL ROLLERS. 
67 
The spiral reversed of the four fingers.—The roller for this purpose should 
be seven yards long, and of the same width as the preceding one. 
To apply it, first make the usual circulars around 
the wrist, cross over the back of the hand to the 
first interdigital cleft, and by oblicpie turns to the 
extremity of the first or index finger; then return 
by spiral reverses to its junction with the meta- 
carpal bone, and pass to the second or middle fin- 
ger, descending to its ex- 
tremity by obliques, and 
back to its root by re- 
versed turns, and so in 
succession until all the 
fingers are covered in; 
then finish by spiral turns 
around the metacarpal, 
carpal, and wrist bones. 
(Fig. 59.) 
The spiral reversed is 
frequently applied to a 
single finger in cases of 
wounds or of fracture, 
but to all the fingers very 
rarely. 
The spiral reversed of 
the penis.—This bandage 
should be three-quarters 
of an inch wide and 
twenty inches long. To 
apply this roller, draw 
the penis forward and 
make two or three circu- 
lars close to the pubes; 
then by an oblique turn 
pass to the glans, and 
return to its root by 
spiral reverses, slitting 
up the terminal end and 
tying the strips around 
the organ. (Fig. 60.) 
This bandage is not se- 
cure, and though occa- 
sionally employed to re- 
tain dressings after oper- 
ations for phimosis, or 
to compress the urethra 
over a bougie in case of 
hemorrhage after operation upon that canal, yet it is unsatisfactory, and 
might well be erased from the list of dressings. 
Spiral of the hand, or derni-gauntlet.—This bandage requires a roller one inch 
wide and seven yards long. After a few circular turns of the wrist are first 
made, the roller is carried obliquely across the back of the hand or across its 
palm, according to the direction in which it runs, passing round the root of 
the little finger, and back to the wi’ist. Around the latter a single circular 
turn is made, and from thence the bandage is carried to the ring-finger, and 
again to the wrist, and so by similar turns until all the fingers and the thumb 
have been included, when the terminal end should be secured at the wrist. 
(Fig. 61.) 
This bandage is used to confine dressings of various kinds to the back 
Fig. 58. 
Fig. 59. 
Spiral reversed of the four fingers. 
Fig. 60. 
Spiral reversed of the penis. 
Spiral reversed of the upper ex- 
tremity applied. 68 
SURGICAL DRESSINGS. 
of the hand or to its palmar surface, but, though very secure, is not generally 
used by dressers. 
The spiral reversed of the lower extremity.—This is an indispensable dressing, 
Fig. 61. 
Fig. 62. 
Spiral of the hand, or demi-gauntlet. 
and should be studied with great care. It 
requires two rollers, each two and a half 
inches wide and seven yards long, as a 
single roller fourteen yards in length is 
too bulky to be properly handled. 
In applying this roller, the patient and 
operator may be seated opposite to each 
other, the heel of the former resting on 
the knee of the latter, or, what is better, 
the limb may be supported by an assistant, 
the patient either sitting or lying. The 
surgeon, taking one of the rollers, makes 
a few circular turns around the ankle, 
above the malleoli, then crosses obliquely 
over the dorsum of the foot to its outer 
or inner side, according to the hand used 
in holding the roller, passing next under 
the sole of the foot to the metatarso-pha- 
langeal joint of the little or great toe; 
the bandage is now made to cover in the 
foot by successive spirals, embrace the 
ankle with a figure-of-eight, and ascend the limb by spiral reverses to the 
knee, where the first roller will terminate. The second roller is next taken, 
and by one or two circular turns fixes the terminal end of the first, after 
which it is conducted up the limb, covering the knee either by spiral re- 
verses or by figure-of-eight tm*ns, the remaining portion of the bandage 
being exhausted upon the thigh. (Fig. 62.) 
The French spiral reversed commences at the metatarso-phalangeal articu- 
lation and covers the foot with reverses to the front of the ankle, then passes 
from the latter to the leg, which is enclosed as in the ordinary spiral pre- 
viously described. (Fig. 63.) It is not so secure a bandage as the first, 
since the turns of the foot are liable to become displaced. 
Spiral reversed of the lower extremity. SPICA BANDAGES. 
69 
In neither of the bandages described are the heel, or the tips of the toes, in- 
cluded ; the dense tissue of the former, and the close adhesion of its skin to the 
subjacent parts, render this unnecessary, and the exposure of a portion of the 
toes enables the surgeon to 
determine by their color 
and temperature the con- 
dition of the circulation. 
Should it be desirable at 
any time to cover the heel, 
it can be done as follows: 
after commencing by the 
usual spiral reversed, and 
having reached the instep, 
conduct the bandage over 
the point of the heel, up in 
front of the ankle, down 
under the heel, and around 
to the opposite side, and 
again in front of the ankle, 
under the heel, and round 
its surface to the front of 
the joint, after which it 
should be continued up the 
limb. (Fig. 64.) The spi- 
ral reversed rollers are con- 
stantly employed in frac- 
tures, ulcers, etc. 
Spiral of the chest.—A 
roller three inches wide and 
ten yards long is required 
for this dressing. Two or 
three circulars around the 
waist are to be first formed, the patient being in the sitting posture, and then 
the roller is made to ascend in spirals, each turn covering one-third of the 
preceding one until the axillae are reached, when the terminal end should be 
brought over the shoulder and pinned in front (Fig. 65) to the turns on 
the front of the chest or round the neck, and then attached to the spirals. 
This bandage is sometimes used in cases of fractured ribs, and also to retain 
dressings after the removal of the female mamma. 
Fig. 63. 
Fig. 64. 
Heel covered with spiral reversed 
roller. 
Fig. 65. 
French spiral reversed. 
Spiral of the chest. 
Spica Bandages. 
These form a useful class of bandages. They take their name from the re- 
semblance which they bear to the leaves of an ear of corn. They are divided 
into single and double and into ascending and descending spicas. 
The spica of the shoulder.—When the successive turns pass from the shoulder 
to the neck, they constitute the ascending spica; when from the neck to the 
shoulder, the descending spica. The roller should be two and a half inches 
wide and eight yards long. In its application, make first two circulars at the 
upper part of the arm; then, if the roller is running from without inward, 
carry it obliquely across the front of the upper part of the chest, through 
the axilla of the opposite side and across the back to the place of commence- 
ment; then, passing under the arm of the same side, form the spica over 
the outer part of the neck or the shoulder, according as the descending or 
ascending bandage is contemplated. These turns are to be repeated—each 
turn overlapping the preceding about one-third—until the roller is nearly 
exhausted, when its terminal end, being carried round the back of the neck 
and down the front of the chest, should be pinned. (Fig. 66.) 
This spica will be found a useful termination of the roller employed in 70 
SURGICAL DRESSINGS. 
securing splints to the arm in fractures at the upper part of the humerus; 
also well suited to coniine dressings to the 
shoulder. Between the borders of the axilla 
and the roller a little cotton should be in- 
terposed to prevent excoriation. 
The spica of the groin.—This dressing re- 
quires a roller two inches and a half to three 
inches wide and ten yards long. The initial 
end of the roller is made fast by two or 
three circulars of the thigh, or the same 
number around the body above the crest of 
the ilia. If the bandage is commenced at 
the upper part of the thigh, it should, after 
these primary circulars, be conducted up 
in front of the groin, obliquely across the 
outer side of the pelvis or lower part of the 
abdomen, according as it is designed to be 
an ascending or a descending spica, then 
round the posterior part of the body and 
the corresponding part of the opposite side 
down in front, underneath, and up over the 
inside of the thigh. These turns are to be 
repeated until the roller is exhausted. In 
this, as in the spica of the shoulder, each 
turn overlaps the preceding one about one- 
third. (Fig. 67.) 
This spica is admirably suited to make compression over the groin, as in 
cases of enlarged glands or after operations for hernia. 
Fig. 66. 
Spica of the shoulder. 
Fig. 67. 
The double spica of the groin.—A roller designed for the double spica should 
be two and a half inches wide and twelve yards long; or two rollers each six 
yards in length may be used. 
Single spica of the groin. SPICA BANDAGES. 
71 
After making two circular turns around the pelvis from right to left, and 
on reaching the left groin, the roller should be carried obliquely downwards 
over the outer side of the same thigh and brought up along its inside in such 
a manner as to cross over the descending turn; next, it should be carried 
l’ound the posterior surface of the pelvis to the right groin, and, passing down 
over the inner surface of this thigh, should be conducted up along its outer 
side, and from thence carried round the front of the pelvis to the left side. 
These turns may be repeated, and the dressing finished by two or three circu- 
lars of the pelvis. (Fig. 68.) This bandage may be used in cases requiring 
pressure over both groins. 
The spica of the foot.—This band- 
age, sometimes called the bandage 
of Ribbail, requires a roller two 
inches wide and seven yards long. 
In its application, the simplest plan 
is to make two circular turns around 
the metatarso-phalangeal articula- 
tion, and two spirals over the meta- 
tarsus to the instep ; then carry the 
roller about the point of-the heel, al- 
lowing its lower edge to project well 
towards the sole of the foot; from 
thence carry it along or parallel with 
the outer or the inner side of the foot 
as the case may be, and cross over the 
tarsal extremity of the metatarsal 
portion of the foot under the sole 
and back to the instep, where the 
spica is to be formed. From this point 
tlie roller passes again round the 
heel a little higher up, overlapping 
a part of the previous turn, and 
again along the side of the foot to 
the instep, beneath the foot and back 
to the instep, making a second spica, 
and again back to the heel, and so 
continues forming one after another 
in the ascending order until the foot and heel are entirely covered, when the 
remaining part of the roller can be finished by spiral reversed turns upon the 
leg. (Fig. 69.) This bandage, while it is very beautiful 
and artistic, really possesses no superiority over the ordi- 
nary spiral revei-sed of the lower extremity. 
The spica of the thumb requires a roller three-fourths of 
an inch wide and three yards long. Fix the initial end of 
the roller by three circular turns around the wrist. On 
completing the third turn, carry the roller between the 
index finger and the thumb, passing round the latter to 
its inner side; from thence across its metatarsal bone to 
the wrist; around the wrist back again to its outer side, 
as in the first instance, repeating in a similar manner these 
turns, forming the spicas over its radial border, each turn 
overlapping two-thirds of the preceding one, and finally 
terminate the roller at the wrist. (Fig. 70.) This roller 
may be used to secure a dressing after excision of the 
metacarpal bone of the thumb, or in cases of luxation to 
give security after a reduction of the metacarpo-phalangeal articulation. 
Figure-of-eight bandages.—These form a useful class of bandages, and take 
their name from the fact that the turns, when complete, resemble the figure 
eight. The bandage is much employed about articulations; and in the ordi- 
Fig. 68. 
Double spica of the groin. 
Fig. 69. 
Spica of the foot. 72 
SURGICAL DRESSINGS. 
nary spiral reversed of either the upper or lower extremity, many prefer it 
as best suited to cover in the joints,—as the ankle, the knee, the wrist, and 
the elbow. 
The figure-of-eight of the elbow requires a roller two or two and a half inches 
wide and two yards long. 
Place the initial end on 
the outer side of the 
forearm a short distance 
below the elbow-joint, 
and, after tixing it in 
position with the finger, 
carry the roller obliquely 
upwards across the front 
of the joint above the 
internal condyle, round 
the inner and posterior 
surfaces of the arm to a 
point above the external 
condyle, then obliquely 
downwards over the 
front of the joint, where 
it should intersect the 
first portion of the band- 
age, finally pass to the inner and posterior surfaces of the forearm and to the 
point of beginning, where it may be secured, or the turns may be repeated 
two or three times, and before making them fast a circular may be made 
around the joint, the arm being at the same time slightly flexed. (Pig. 71.) 
This bandage was quite common at a time when the practice of physicians 
was more sanguinary than it is at present; a strip of ribbon took the place 
of the roller, and the two ends were tied in a knot directly over the bend 
of the arm. 
The figure-of-eight of the chest.—There are two figure-of-eight bandages of 
the chest, viz., the anterior and the posterior. They are sometimes described 
as the anterior and the posterior crossed of the chest. 
Each requires a roller two and a half inches wide and seven yards long; 
and in both the patient should be in the sitting posture when the bandage is 
applied. 
The anterior eight.—The surgeon, standing in front of the patient, first 
makes two or three circular turns at the upper part of the arm, followed by 
the same number of reverses, thus making the initial end of the roller secure. 
Drawing next the shoulders well forward, the roller must be carried over the 
shoulder above the articulation, and obliquely downwards across the front of 
the chest and through the axilla of the opposite side. Prom thence the 
roller is made to ascend upwards, behind and over the shoulder, and for- 
wards and downwards over the chest to the place of commencement. These 
turns are to be repeated, each overlapping the preceding one about two- 
thirds of its breadth, and ascending or descending according to the pleasure 
of the operator, until the bandage is exhausted. The margin of the axilla 
should be protected against undue pressure from the roller by interposing 
some cotton between the latter and the skin. (Fig. 72.) This bandage is 
used to approximate wounds on the front of the chest, attended with loss 
of substance. 
The posterior eight.—This differs from the preceding one by the intersec- 
tions being made on the back instead of on the front of the chest. The 
surgeon, standing behind the patient, makes two or three circular turns and 
as many reversed turns of the roller from within outwards around the upper 
part of the arm, and drawing the shoulders backwards secures them in this 
position by successive turns around the axilla' and shoulders of the two sides. 
(Fig. 73.) The same care should be observed as in the former bandage to 
Fig. 70. 
Fig. 71. 
Spica of the thumb. 
Figure-of-eight of the elbow-joint. SPICA BANDAGES. 
73 
protect the margins of the axilhe from undue pressure by the use of cotton. 
This bandage will serve to approximate wounds which gape on the back of 
the trunk, or may be used in certain fractures of the clavicle. 
The figure-of-eight of the neck and the axilla.—The roller required for this 
Fig. 72 
Fig. 73. 
Anterior eight of the chest. 
Posterior eight of the chest. 
bandage should be two inches wide and four or five yards long. Fix the 
initial end of the roller by making two circular turns of the neck, then carry 
the roller either in front of or be- 
hind the shoulder—according to 
the direction given to the band- 
age—through the axilla, and 
then round the neck, passing 
from one to the other until the 
bandage is exhausted. (Fig. 
74.) 
This bandage will serve to 
secure a dressing to the side of 
the neck above the shoulder. 
Figure-of-eight of the eye.—The 
roller for this bandage should 
be two inches wide and five 
yards long. 
First make two or three cir- 
culars of the forehead and the 
occiput, always in a direction 
from the eye to be covered. 
After reaching the back of the 
head with the third turn, carry 
the roller down under the oc- 
ciput and up over the face, the 
affected eye, the root of the 
nose, and across the opposite 
temporal ridge, repeating these 
turns three or four times, and 
terminating by a circular as at the commencement. This bandage is some- 
Figure-of-eight of the neck and axilla. 74 
SURGICAL DRESSINGS. 
times termed the crossed of the eye. (Pig. 75.) It will answer to retain 
dressings to the eye or eyebrows after operations, especially where com- 
pression is required. 
The double figure-of-eight of both eyes.—The roller for this bandage should 
be two inches wide and eight yards long. 
Make two circular turns of the head, and, 
on completing the second, carry the roller to 
the back of the neck, under the ear, and up 
across the face, over the eye and the root of 
the nose, to the temporal eminences of the 
opposite side, and from thence down to the 
back of the neck. These turns should be re- 
peated two or three times, after which, on 
completing the last one, and reaching the 
parietal eminences, the roller should be carried 
round the forehead, obliquely across the root 
of the nose, the eye, and the cheek of the 
opposite side, repeating these turns three 
times and terminating by circular turns around 
the forehead and the occiput. 
Figure-of-eight of the jaw and the head.—This 
is sometimes called Barton’s bandage. It re- 
quires a roller two inches wide and five or six 
yards long. The initial end is placed below 
and to one side of the occipital protuberance, 
where it is held by a finger, while the roller 
is carried obliquely across the head, a little in advance of the parietal pro- 
tuberance, to the opposite temple; from thence down the side of the face, in 
front of the ear, beneath the jaw, and up over the 
corresponding portions of the face and temple of 
the opposite side. At the junction of the coronal 
and sagittal sutures two turns of the bandage now 
intersect; then it should descend in front of the 
parietal and below the occipital protuberance, on 
one side of which it should cross the initial end of 
the bandage, and be conducted forward beneath 
the ear and around the jaw to the place of begin- 
ning. The subsequent turns are made in the same 
order as the first. (Fig. 76.) A pin should be 
inserted at the different points of intersection. 
For fractures of the jaw and luxations, as well 
as to retain various surgical dressings, this band- 
age is of the greatest value. 
There are certain other bandages applicable 
to the head which do not strictly belong to any 
of the classes named, and which may very properly be introduced in this 
place. 
Gibson's bandage.—This dressing requires a roller two inches wide and six 
yards long. The initial end of the roller is placed over the temple of one 
side and fixed with a finger, while the roller is carried over the junction of 
the coronal and sagittal sutures to the opposite temple, down in front of the 
ear, over the side of the face, under the jaw, and upwards over the opposite 
side of the face to the place of beginning. Repeat these turns three times, 
then reverse the roller and pass round the head above the ears three times. 
In making the third of these turns, instead of bringing the roller above the 
ear at the place of beginning, carry it below, and round the base of the jaw 
and chin to the back of the neck. Three of these turns should be made, 
and the bandage terminated by reversing it behind the occipital protu- 
berance and bringing it forward over the vertex. (Fig. 77.) Pins, as in 
Fig. 75. 
Figure-of-eight of one eye. 
Fig. 76. 
Figure-of-eight of the jaw and head, 
or Barton’s bandage. BANDAGES FOR THE HEAD. 
75 
Barton’s bandage, should be inserted at the different points of intersection. 
The simplest manner of remembering the turns of this roller is to view 
it as consisting of three vertieo-mental, three occipito-frontal, and three 
Fig. 78. 
Fig. 77. 
Gibson’s bandage. 
Occipito-facial roller. 
cervico-mental turns. It is a very solid bandage when properly applied, and 
answers the same object as that of Barton. 
The occipitofacial bandage requires a roller four yards long and two and a 
half inches wide. The initial end of the bandage being placed over the temple 
on one side, the roller should be carried up over the vertex, down over the 
temple and side of the face, under the chin, and up on the opposite side to 
the point of beginning. These turns should be repeated a number of times, 
and the roller terminated by reversing its course and conducting it round 
the back of the head from one temple to the other, over both of which the 
bandage must be pinned. (Fig. 78.) 
This roller can be employed with advantage in dressing wounds over the 
parotid region or on the side of the face. 
The crossed or oblique of the angle of the 
jaw.—This requires a roller two inches wide 
and five yards long. Apply the initial end 
of the roller upon the temple and fix it by 
two or three circular turns around the 
head, from right to left if the left angle is 
to be acted upon, and from left to right if 
the other angle is to be treated. On bring- 
ing the roller to the back of the head, on 
the third turn conduct it over the nape of 
the neck, behind the ear of the sound side, 
beneath the jaw to its angle on the injured 
side, and from thence up over the face, the 
temple, and obliquely across the head, down 
behind the ear of the sound side, repeating 
these obliques, and ending by making a cir- 
cular of the cranium. (Fig. 79.) This 
bandage is used occasionally for fractures of 
the neck and ramus of the jaw, in which case 
a compress should be interposed between the 
angle of the injured side and the roller. 
The V bandage of the head and, jaw.—This 
requires a roller two inches wide and five yards long. Make two or three 
circulars of the vault of the cranium. In forming the last, instead of passing 
round above the ear, bring the roller down below the auricle and around the 
Fig. 79. 
Crossed bandage for the angle of the jaw. 76 
SURGICAL DRESSINGS. 
jaw; after repeating this last turn, alternate the turns of the head and 
jaw. (Fig. 80.) In extensive operations upon the lips, or after the removal 
of tumors of the neck below the ear, this dressing is valuable. This bandage 
was devised by I)r. Hunter. 
The recurrent bandage of the head.—The roller for this bandage should be 
two inches wide and five yards long. Make two or three circular turns 
of the vault of the cranium, and, on reaching the middle of the forehead, 
Fig. 81. 
Fig. 80, 
V bandage of the head and jaw. 
Recurrent bandage of the head. 
at the root of the nose, reverse the roller, fixing the reverse with a finger, and 
carry it back over the head parallel with the sagittal suture to a point below 
the occipital protuberance, where it should be retained by an assistant, while 
the roller is again reversed and brought forward to the forehead, overlapping 
the outer two-thirds of the preceding strip. These recurrents should be 
repeated until one side of the head is covered, when the other must be simi- 
larly treated, observing to make all the recurrents converge near the root 
of the nose and below the tuberosity of the occipital bone, where they can 
he held underneath the thumb of the surgeon and the fingers of an assistant, 
after which one or two circulars of the vault of the cranium will fix them 
securely in place. (Fig- 81.) This bandage is designed to retain a dressing 
to the head. 
The recurrent bandage for amputations.—This requires a roller two and a half 
inches wide and six or seven yards long for the thigh, and for the leg and the 
arm one or two inches wide and five yards long. In its application, a few cir- 
cular turns are made four inches above the end of the stump, after which the 
roller is reversed on the middle of the front of the limb, carried over the centre 
of the stump, and back over the under surface of the limb to a point opposite 
the one where it commenced in front. These recurrents are to be repeated, 
covering first one-half of the stump, and then the other half, and all con- 
verging to a point in front and another behind the limb, where they can be 
commanded by the fingers of the surgeon and an assistant, or, if the size of 
the limb will allow, both may be grasped by the thumb and fingers of the sur- 
geon, after which a few circulars will secure all in position. (Fig. 82.) This 
bandage is constantly in use to retain dressings applied after amputation. 
The unilateral suspensory and, compressor of the breast.—This roller should 
be two or two and a half inches wide and eight yards long. 
In its application, the patient must be in the sitting position in bed or on 
a stool, and the surgeon stands on the side to be dressed. Place the initial 
end of the roller behind and below the posterior border of the axilla of the BANDAGES. 
77 
affected side, carry the roller across the back to the opposite shoulder, over 
the latter, obliquely down over the front of the chest, and underneath the 
breast to the axilla of the 
affected side, from thence 
across the initial end of 
the roller, and repeat these 
turns two or three times, 
after which form a circular 
of the body, and continue 
alternating circulars and 
obliques, each turn as it as- 
cends covering in the pre- 
ceding one about a third. 
(Fig. 83.) Thus applied, 
the bandage serves to sup- 
port, to suspend, and to 
compress the breast. The 
successive turns, both ob- 
lique and circular, should be 
repeated until the gland is 
covered in. This bandage 
may be used to apply press- 
ure to tumors of the mam- 
mary gland, or in cases of mammary abscess to prevent the formation of sinuses. 
The bilateral suspensory and compressor of the breasts.—This bandage can 
be made with a roller ten or twelve yards long and two and a half inches 
Fig. 82. 
Kecurrent dressing after amputation of the thigh. 
Fig. 88. 
Fig. 84. 
Single suspensory and compressor bandage of the breast. 
The circular turns should be made over the one breast and 
under the other. 
Bilateral suspensory and compressor 
of the breasts. 
wide, or with two rollers each six yards in length. If a single one be used, 
the initial end should be placed over the posterior border of the right axilla, 
and the cylinder carried obliquely across the back and over the left shoulder; 
from thence the roller must be continued in front of the chest, under the 
right breast, and back to the point of beginning. After making two or 78 
SURGICAL DRESSINGS. 
three of these cervico-axillary obliques, the roller should be carried across 
the back to the left side, and the same number of turns made as on the 
right. After this the turns should alternate on the two sides, and the dress- 
ing should be completed by making horizontal circulars of the chest until 
both mammary glands are covered in. (big. 84.) This bandage should be 
applied with uniform pressure. It is well adapted to support and to compress 
the breasts, either in cases of mammary abscess or to favor the absorption 
of morbid growth in the glands. 
Velpeau's bandage requires a roller two and a 
half inches wide and eight or nine yards long. 
The patient having placed the hand of the 
affected side on the opposite shoulder, apply 
the initial end of the bandage at the posterior 
part of the axilla of the sound side, carry the 
roller obliquely across the back, over the side 
of the neck and clavicle of the injured side, 
thence down over the front and outside of the 
corresponding arm, under the elbow, and up 
through the axilla of the sound side. Make a 
second turn, following precisely the same course, 
until the point of the elbow is reached, when the 
roller should be carried around the chest, binding 
the arm to the body. After this the turns from 
the shoulder to the front of the elbow, and thence 
through the sound axilla, should alternate with 
the circular ones around the body until the arm 
and chest have been covered in. (Fig. 85.) This 
is one of our most useful bandages, serving frequently as a sufficient dressing 
in fractures of the clavicle, and of the acromial and coracoid processes of the 
scapula, and to give security to the arm after reduction of a scapulo-humeral 
luxation. 
Fig. 85 
Velpeau’s liandage. 
Provisional or Handkerchief Dressings. 
To improvise a surgical dressing from common or ordinary materials is 
often a matter of great importance, and every surgeon doubtless has bad 
frequent occasion to resort to many simple appliances in cases of emergency. 
Out of handkerchiefs and strips of muslin, M. Mayor, a surgeon in Switzer- 
land, has devised a system by which, it is claimed, accidents may be treated 
quite satisfactorily, in the absence of the ordinary means, with materials 
within the reach of every one and to be found in almost every locality. I 
shall select from this system the dressings that, in my judgment, are most 
useful. 
The basis upon which this system of bandages rests is the handkerchief or 
the muslin square; and could we always command the old-fashioned pongee 
silk or even the large cotton handkerchief of former days, there Avould be 
much to commend these dressings to general use. Unfortunately, however, 
it is only in those good old homesteads where the modern linen square of 
eight or ten inches has not yet displaced the ample bandanna, and where 
utility is exalted above display, that it is possible to procure a piece of the 
requisite size. It will be necessary first to describe the forms and names given 
to the different parts of these dressings. 
The square.—The square is made either from a silk or a cotton handker- 
chief, or from a piece of muslin, flannel, or calico. This square may be 
changed into different forms by folding its parts together. (Fig. 86.) Thus, 
if the angles be turned in towards the centre, it will make a smaller square; 
if it be doubled upon itself, it will form an oblong. (Fig. 87.) If the two 
opposite angles of the square be placed together, it will make the triangle 
(Fig. 88), the parts of which are the base, summit, and angles. 
When the triangle is folded from its summit towards the base, it forms the HANDKERCHIEF DRESSINGS. 
79 
cravat (Fig. 89), and if the cravat be twisted, it makes the cord, the parts 
of each being the body and the extremities. Handkerchief dressings are 
Fig. 86. 
Fig. 87. 
Fig. 88. 
Fig. 89. 
Triangle handkerchief: d, base; c, 
summit; a, b, angles. 
Cravat: a, body; 6, c, 
extremities. 
Square handkerchief. 
Oblong hand- 
kerchief. 
secured either by pins or knots. When a knot is adopted, it should be either 
a single bow or a cravat tie. 
Handkerchiefs for the Head and Shoulders.—There are a number of 
handkerchief dressings for the head and shoulders that are named according 
to the form which they take or the parts to which they are applied. 
The square cap of the head.—Fold the handkerchief into an oblong square, 
the edge of one side being three inches in advance of the other. Place the 
long side next to the head, allowing it to hang down some distance in front 
of the face. (Fig. 90.) Seizing the ends of the uppermost or short side, 
draw them down and tie them under the chin; then draw downwards and 
Fig. 90. 
Fig. 91. 
The first step in forming the square cap of the head. 
Square cap of the head complete. 
forwards the ends of the under or long side, and, folding them back, tie them 
behind over the back of the neck. (Fig. 91.) This handkerchief covers 
in the entire head, and may answer the purpose of the recurrent roller; 
though it is too warm a dressing for comfort. 
The fronto-occipital triangle.—In treating of these triangles, it will simplify 
the subject to remember that the base of the triangle is always placed over 
the frontal region and the apex or summit over the occipital. In forming, 
therefore, the one under consideration, the base of the handkerchief, folded in 80 
SURGICAL DRESSINGS. 
a triangle, is placed over the forehead, while the summit is allowed to hang 
down over the occiput. The ends are next carried backwards along the sides 
of the head, above the ears, and either tied behind the occipital protuberance 
or crossed, brought forward, and pinned at each side, after which the apex is 
turned forward and pinned to the body of the handkerchief. (Fig. 92.) 
Fig. 92. 
Two views of the fronto-occipital handkerchief, anterior and posterior. 
The occipito-frontal triangle differs only in reversing the handkerchief, the 
base being placed over the occiput and the apex over the forehead, while the 
ends are brought round, and either tied in front or crossed and pinned. 
These handkerchiefs all fulfil very much the same purpose, viz., that of 
retaining dressings to the head. 
The bi-temporal triangle.—The base is placed over one of the temporal re- 
gions and the apex over the other; the ends are carried round to the opposite 
temple, crossed, brought back, and secured with pins, and the summit or apex 
is turned up and pinned above the temporal ridge. 
This-triangle is designed to retain dressings upon the side of the head. 
The auriculo-occipital triangle.—The base is placed in front of the ear to be 
covered, and the apex directed backwards. The 
lower end is next carried under the jaw and up 
over the face in front of the ear on the sound side, 
where it is made to meet the upper end, the two 
being tied together; or the two ends may pass, 
overlapping each other, and be pinned, the one 
beneath the ear of the affected side, the other in 
front of the ear of the sound side. (Fig. 93.) 
This triangle will answer to keep a dressing 
in contact with the ear, such as a poultice or a 
lotion. 
Vertico-mental triangle.—Place the body of the 
handkerchief over the vertex ; bring the ends 
down over the ears, and cross them under the chin, 
carrying them upwards and pinning them to the 
descending portions of the handkerchief; last, bring the apex round one side 
of the head and secure it with a pin. (Fig. 94.) 
This handkerchief will answer to retain dressings to the head, the ears, the 
parotid region, or the under part of the chin. 
The fronto-occipito-labialis cravat.—Form the handkerchief into a cravat, 
and place the body of the same upon the forehead; carry the ends back, and 
cross them upon the posterior part of the neck, then bring them forward, 
Tig. 93. 
The auriculo-occipital triangle. HANDKERCHIEF DRESSINGS. 
81 
underneath the ears, and cross them over the upper lip, securing the ends in 
the usual manner. (Fig. 95.) 
Fig. 94. 
Fig. 95. 
The vertico-mental triangle. 
The fronto-occipito-labialis cravat. 
This dressing may be used to aid in supporting the approximation of a 
lip wound, in which case a compress should be placed on each side. 
The occipito-sternal triangle.— 
Let one handkerchief be formed 
into a triangle and one into a 
cravat. Tie the latter around 
the chest, forming the sterno- 
dorsal cravat; place the body 
of the former over the occiput 
and its apex over the fore- 
head, bring the ends down on 
each side of the face, and fas- 
ten them to the cravat about 
the chest. (Fig- 96.) The 
apex can be turned back over 
the vertex and pinned. This 
dressing may be used to approx- 
imate wounds on the front of the 
neck. The figure represents a 
night-cap drawn over the head 
and a part of the dressing, in 
order to prevent displacement. 
The parieto-axillaris cravat.— 
Form one handkerchief into a 
cravat, and place its body in the 
axilla, and tie the ends over the 
shoulder, forming the axillo- 
acromial cravat. Make a second 
handkerchief into a triangle, and, placing its body over the side of the head, 
tie its ends into the first, over the shoulder. (Fig. 97.) Care should be 
observed to protect the margins of the axilla against excoriation, by inter- 
posing some cotton between the skin and the axillo-acromial cravat. 
This handkerchief will serve to approximate wounds on the side of the 
neck, or to prevent contraction after burns. 
The cervical cravat is made by forming a handkerchief into a cravat, and 
placing the body on the front, the back, or the sides of the neck, according 
Fig. 96. 
The occipito-sternal handkerchief. 82 
SURGICAL DRESSINGS. 
to the part to be dressed, the ends being carried round, crossed on the oppo- 
site side, and returned, after which they may be fastened with pins. The 
turns are made as one would 
apply the ordinary neck-hand- 
kerchief. 
The axillo-cej-vical cravat.— 
Place the body of the cravat in 
the axilla, cross the ends over 
the shoulder, and tie them on 
the opposite sides of the neck. 
This cravat is well suited to 
retain a dressing in the axilla. 
The simple bis-axillary cravat. 
—Place the body of the cravat in 
the axilla, cross the ends over 
the shoulder, and, after carrying 
one across the back and the 
other across the breast, tie them 
together at the anterior border 
of the axilla of the opposite side. 
(Fig. 98.) 
Its use is similar to that of 
the preceding cravat. 
The compound bis-axillary cra- 
vat requires two handkerchiefs 
in cravat form. One is tied as an 
axillo-acromial cravat through 
one axilla, while the body of 
the other is placed in the opposite axilla, and its ends being brought across 
the chest, one in front and the other behind, are passed through the loop of 
the first and tied in front of the 
breast. (Fig. 99.) 
This handkerchief is designed 
to retain dressings in both ax- 
illa;. 
The simple bis-axillo-scapulary 
cravat.—This is a posterior eight, 
and is best formed with a strip 
of muslin three inches wide and 
two yards long, as the handker- 
chief is ordinarily too short to 
make the necessary turns. Place 
the centre of the strip, or hand- 
kerchief, if sufficiently long, in 
front of the shoulder and the 
axilla; bring one end back over 
the top of the shoulder and the 
other through the axilla, cross 
them between the scapulae, car- 
rying the axillary end over the 
shoulder of the opposite side 
and back through the axilla, 
and the humeral end forward 
through the axilla, the two over- 
lapping each other; then fasten 
their ends front and back. (Fig. 
100.) 
This dressing will answer as 
an extemporaneous one for fracture of the clavicle. 
Fig. 97. 
The parieto-axillaris cravat. 
Fig. 98. 
The simple bis-axillary cravat. HANDKERCHIEF DRESSINGS. 
83 
The compound bis-axillo-scapulary cravat. — Form two handkerchiefs 
into cravats. Tie one as a loose ring, or form the axillo-acromial hand- 
Fro 99. 
Fig. 100. 
The compound bis-axillary cravat. 
The simple bis-axillo-scapulary cravat. 
kerchief of one side, and, placing 
the body of the other handkerchief 
in front of the opposite shoulder, 
bring the ends back, one over the 
shoulder and the other through the 
axilla; then form these into a single 
knot, and complete the dressing by 
passing the ends through the ring or 
loop of the other cravat, and tying 
them into a knot. (Fig. 101.) When- 
ever it becomes necessary to draw 
the shoulders back forcibly, this 
handkerchief may be used with ad- 
vantage. 
The dorso-bis-axillary handkerchief. 
—Tie one handkerchief, formed into 
a cravat, around the body below the 
axillae (bis-axillary cravat). Place the 
body of another, in triangle, upon the 
posterior part of the neck, securing 
the summit to the middle of the first 
on the back, and its ends or angles 
to the same in front. (Fig. 102.) 
This handkerchief is well suited to 
retain a dressing in contact with the 
back, or the back and shoulders, and 
is really one of the most important 
of the entire class. 
The mammary triangle, or the sling of the breast.—Fold a handkerchief into 
a triangle; place its base underneath the breast, and its apex over the cor- 
The compound bis-axillo-scapulary cravat. 84 
SURGICAL DRESSINGS. 
responding shoulder; then carry one end under the axilla, and the other 
over the opposite side of the neck, tying the two behind the scapula of the 
affected side, and pin to these the summit. (Fig. 103.) 
Fig. 103. 
Fig. 102. 
The dorso-bis-axillary handkerchief. 
The mammary triangle. 
This triangle serves to suspend the breast, or to hold in place any dressing 
which may be applied to the gland. 
Handkerchief Dressings of the Extremities.—Some of these are quite 
useful, others of very little practical value. The most important are the 
following: 
The palmar triangle.—Place the base of a handkerchief in triangle across 
the back or the front of the wrist, according as it is designed to dress the 
palm or the dorsum of the hand; fold the summit back upon the wrist, and 
secure it there by carrying the ends around the same. (Fig. 104.) 
Fig. 104. 
The palmar triangle. 
This handkerchief supplies the means of retaining poultices and other 
applications to the hand. 
The triangular cap of the shoulder.—Place the base of a handkerchief in 
triangle over the insertion of the deltoid, and the apex over the top of the HANDKERCHIEF DRESSINGS. 
85 
shoulder, then carry the ends round the arm and tie them. I have found 
this handkerchief to maintain its position better by placing the base over the 
top of the shoulder, then tying the ends round the arm, and turning the apex 
upwards, pinning it to the body of the handkerchief. (Fig. 105.) 
It is designed to secure dressings to the shoulder or the upper part of the 
arm. 
The cervico-brachial sling.—Tie one handkerchief in cravat round the neck, 
so that it shall hang in a loose loop in front of the upper part of the chest. 
Place the base of a second in triangle under the wrist, and the summit behind 
the elbow, then fasten the ends to the cervical cravat, and bring the apex 
Fig. 105. 
Fig. 106. 
Fig. 107. 
The triangular cap o. 
the shoulder. 
The cervi co-brachial sling. 
Triangular cap for amputation, applied 
to the thigh. 
forward around the elbow-joint, and pin to the body of the handkerchief. 
(Fig. 106.) 
This dressing is commonly used to support the forearm, when flexed, after 
fractures, etc. 
If the handkerchief is a large one, the cervical cravat may be dispensed 
with, and the ends of the triangle passed round the neck and tied on one side. 
Triangular cap for amputation.—Fold a handkerchief into a triangle, and, 
placing the base under the stump, turn the summit up in front, and secure it 
by carrying the extremities around the limb and knotting them together. 
(Fig. 107.) 
This cap answers the purpose, to some extent, of the recurrent roller, 
which is generally used to bind a dressing over the stump of an amputation. 
The metatarso-malleolar cravat.—Form a handkerchief into a cravat, and 
place the body obliquely across the dorsum of the foot; carry one end under 
the foot and up in front of the ankle, and the other around the leg above the 
malleoli, attaching them together in front of the joint. (Fig. 108.) 
Its use is to retain a dressing 
upon the foot. 
The malleolo-phalangeal triangle. 
—Form the handkerchief into a 
triangle; place the base under the 
foot opposite to the instep ; fold the 
summit back over the toes and the 
dorsum of the foot, and carry the 
ends round the malleoli, making 
them fast in front. (Fig. 109.) 
This handkerchief may be com- 
pleted by tying the ends in front, 
or by crossing them over the dor- 
sum and making them fast under 
the sole of the foot. It is sometimes 
called the cap of the foot, and answers the same purpose for the foot as the 
carpo-dorsal or palmar triangle does for the hand. 
Fig. 108. 
Fig. 109. 
The metatarso-malleolar cravat. The malleolo-phalan- 
geal triangle. 86 
SURGICAL DRESSINGS. 
The tarso-patellar cravat requires three handkerchiefs, all in cravat form. 
One is to be placed about the knee as a figure-of-eight; a second round the 
foot in front of the ankle; the third is passed through the loop of the latter, 
the ends being carried one on each side through the figure-of-eight of the knee, 
and pinned or tied as they are turned downwards. (Fig. 110.) 
This dressing will serve a temporary purpose in holding the fragments of 
a broken patella approximately in position. 
The tibio-cervical handkerchief, or sling of the knee.—Place the body of one 
handkerchief in cravat upon the shoulder opposite to the leg to be suspended, 
carrying the ends, one in front and one behind the body, across to the oppo- 
site side, and knotting them together. The other handkerchief form into a 
triangle, and, flexing the leg, place the base under the tibia, above the ankle; 
Fig. 112 
Fig. 111. 
Fig. 110. 
The tarso-patellar cravat. 
The tibio-cervical handkerchief, or 
sling of the knee. 
The tibial cravat. The cut also 
shows the cravat of the foot. 
carry the ends up and tie into the cervical cravat; finish by bringing the 
summit round in front of the knee and pinning it to the body of the hand- 
kerchief. (Fig. 111.) 
This sling will support the limb wdien the leg has been the seat of a frac- 
ture, and enable the patient to move about on crutches until it can be placed 
upon the floor. 
The tibial cravat.—Place the body of a handkerchief, folded into a cravat, 
obliquely across the posterior surface of the leg, and carry the extremities HANDKERCHIEF DRESSINGS. 
87 
around the limb, the one below the knee and the other above the malleoli. 
(Fig. 112.) 
This handkerchief is well adapted for the purpose of retaining stimulating 
plasters to the limb. 
Barton's handkerchief.—This device of the ingenious surgeon Dr. John Rhea 
Barton is formed by placing the body of a narrow cravat around the point 
of the heel. One end— 
that corresponding to the 
outer side of the foot— 
should be a third longer 
than the other. The short 
or inner end should be 
held parallel with the 
foot, while the long or 
outer end must be crossed 
over the instep, turned 
round the inner end, car- 
ried back under the sole 
of the foot, and looped 
round its own side. The 
two ends may now be 
knotted together, drawn 
upon, and so adjusted that 
the pressure shall be ex- 
erted upon the instep and 
the heel, parts naturally 
able to endure it. (Fig. 
113.) 
This handkerchief is designed to make extension in fractures of the leg. 
The abdomino-inguinal cravat, or single spica of the groin.—Two handker- 
chiefs, sufficiently long to make the dressing, should be folded into cravats, 
and their ends tied together. Place the body of one underneath the thigh, 
close up to the nates; bring the ends to the front and cross them over the 
groin, and finish by carrying them round the opposite sides of the body, 
and tying them together on one side rather than behind, so that the knot 
shall not press injuriously upon the back. (Fig. 114.) 
This cravat may be employed to retain a dressing, or to make pressure 
over a bubo. 
A second spica of the groin, which might be termed the coxo-inguinal hand- 
kerchief, is formed by spreading the body of a cravat widely, placing it ob- 
liquely across the hip and groin, and then carrying one end round the inner, 
posterior, and outer portions of the thigh, and the other end round the ilium 
and the sacrum, bringing it to the front of the groin, and connecting it with 
the first, or, if too short, pinning each separately to the body of the cravat. 
(Fig. 115.) 
This handkerchief will answer very well to retain dressings which are re- 
quired to be applied over the outer side of the hip, thigh, and groin. 
The sub-femoral, or gluteal handkerchief.—Two handkerchiefs are required. 
One, in cravat, is to be tied around the body just above the crest of the 
ilium ; the other, in triangle, is to be placed with its base obliquely beneath 
the gluteal fold, and the ends tied around the thigh. The summit is then 
passed under the body of the cravat, turned back, and pinned upon itself. 
(Fig. 116.) 
This handkerchief will keep its position with great certainty, and may be 
used to retain poultices or other applications to the buttocks. 
Double spica.—Tie together two handkerchiefs folded each into a cravat; 
place the knot on one side of the lumbar spine, and, after bringing their ends 
forward along the sides of the pelvis, just below the crest of the ilium, carry 
them over the front of the groins, then down between the thighs, bringing 
Fig. 114. 
Fig. 113. 
Two views of the Barton 
handkerchief. 
The abdomino-inguinal cravat, or single 
spica of the groin. 88 
SURGICAL DRESSINGS. 
them up in front, and, after crossing them over each other, fasten the ends 
to the body of the cravat with pins. (Fig. 117.) 
This handkerchief will serve to retain a dressing to both groins. 
The suspensory, or scroto-lumbar triangle.—This dressing requires two hand- 
kerchiefs. One must be folded into a cravat and tied around the loins (dumbo- 
Fig. 116 
The coxo-inguinal cravat. 
The sub-femoral handkerchief. 
abdominal cravat) ; the other is to be formed into a triangle, the base of which 
should be placed under the scrotum, and the extremities brought up, passed 
beneath the circular cravat, and tied in front. The apex of the triangle 
Fig. 117. 
Fig. 118. 
should be next carried up, passed beneath the abdominal cravat, and turned 
down in front, where it may be fastened with a pin. (Fig. 118.) 
This bandage, in the absence of the ordinary suspensory, will fulfil most of 
the requirements of such a dressing. 
Double spica of the groin. 
Suspensory, or scroto-lumbar triangle. CHAPTER IV. 
INFLAMMATION. 
In the study of any science or art there are certain elementary facts which 
it is necessary to master before the inquirer is able to comprehend and use 
the truths of the first, or successfully wield the resources of the last. Sur- 
gery is both a science and an art, and he who aspires to the possession of its 
principles and their successful application will be confronted at once with a 
process so universal in its operation, so constantly recurring, that to ignore 
its diligent study is to enter upon one of the most responsible of the learned 
professions with the certainty of disaster and defeat. This process is inflam- 
mation. The word is a very old one, and its derivatives are found in almost 
every language, invariably expressing the idea of heat. 
If the surface of the body be pricked or scratched with a needle, if a 
tendon be divided, a tumor removed, a bone broken, a limb amputated, an 
artery tied, inflammation will be present : it is a double-edged sword, cutting 
either way, for good or for evil; the friend of the surgeon, or his deadliest 
enemy. 
During the year 1874, in the city of Philadelphia there was a total mor- 
tality, exclusive of still-born children, of fifteen thousand four hundred and 
twenty-four, of which number not less than eleven thousand may be fairly 
attributed directly or indirectly to inflammatory complications. A disease so 
generally present must have a transcendent interest for both physician and 
surgeon. Until the time of John Hunter, comparatively little progress had 
been made in the systematic study of the disease. For thirty years, this 
most remarkable man of his time, pursuing a purely inductive method, de- 
voted himself to its study; and he succeeded in giving to the world the first 
methodical arrangement of the subject, in the form of a treatise which ex- 
hibits a degree of patient industry, research, and logical acumen that has 
secured for his name and memory an enduring immortality. Inflammation 
is a concrete term, designed to express the totality of several distinct processes, 
and therefore incapable of being defined by any single word. It is sufficient 
for our purpose here to say that it is a form of hyper nutrition. 
Varieties of Inflammation.—The well-marked differential characteristics 
of inflammation have given rise to various classifications founded on certain 
dominating features, which may be arranged after the following order: 
1. The tendency of the disease.—When inflammation passes through its stages 
in an orderly manner and then subsides, leaving the tissues unharmed, it is 
termed healthy; when marked by great violence, and accompanied by much 
structural change, it is unhealthy. These terms possess some fitness, and might 
without any great impropriety be accepted as sufficiently generic to com- 
prehend the various forms of inflammation. It may be urged that to speak 
of a morbid action being healthy is a contradiction in terms; but I can dis- 
cover no inaccuracy in the use of the word. It will be conceded that there is 
a force ever present in all pathological mutations of structure, which resists 
destruction and tends to conserve and restore. The old physicians called it 
the vis medicatrix naturae. There can certainly be no impropriety in regard- 
ing this as a healthy influence. It would include all those inflammations in 
which the restorative principle or power is dominant, while the unhealthy 90 
INFLAMMATION. 
class would include all those in which the same force has been overmastered 
and the tissues have been altered or destroyed to an unusual extent. 
2. Constitutional vigor.—When inflammation occurs in a good constitution, 
and advances rapidly to its termination, it has been called sthenic; when in a 
feeble and broken-down constitution, progressing tardily, asthenic. 
3. Peculiarities of the blood.—This feature forms the basis for the so-called 
specific inflammations. Thus, we have the rheumatic, gouty, syphilitic, ery- 
sipelatous, scorbutic, and scrofulous varieties. 
4. Textural peculiarities.—-This was purely an anatomical division. Every 
tissue, when inflamed, was supposed to present phenomena peculiar to itself, 
and unlike those of any other. According to this view, there were as many 
kinds of inflammation as there were tissues in the body. It is quite true that 
inflammation of cellular tissue tends to suppuration, and that of serous mem- 
branes to a transudation of serum or lymph; but none of these characteristics 
can properly be regarded as constituting philosophical grounds for generaliza- 
tion, since they deal with something other than the essence or nature of the 
process involved. 
There is also common inflammation, such as may arise from ordinary causes, 
as blows, irritants, etc.; latent inflammation, in which the symptoms are so 
faintly expressed as to escape observation; diffuse or circumscribed inflamma- 
tion, according to its tendency to spread or remain within definite bounds; 
and many other varieties, which unnecessarily embarrass and encumber the 
subject. 
The division which I prefer to adopt is one that is exceedingly comprehen- 
sive, and has, moreover, a strong hold upon the professional mind,—namely, 
that, into acute and chronic. Acute inflammation embraces all cases or varieties 
which run their course quickly, the symptoms being well marked: it is gener- 
ally met with in good constitutions. Chronic inflammation includes all cases 
in which the process is slow, the usual signs, such as redness, swelling, heat, 
and pain, being present in a moderate degree, and in which there is a ten- 
dency to linger for a long time in a part, manifested by the presence of some 
tenderness, a brownish-red or purple discoloration, a certain amount of thick- 
ening or induration of tissue, and which often disappears and returns on the 
slightest provocation. Such a form of inflammation may exist from the 
beginning, or it may be the result of a gradual degeneration of the acute, 
either from constitutional influences or inefficient treatment. 
Causes of Inflammation.—In general, inflammations arise from causes 
which are either external or internal, and are divided into 'predisposing and 
exciting. 
By a predisposing cause is meant any influence or influences which render 
a part, or an organ, peculiarly prone to inflammation upon the application 
of an excitant which, under other circumstances, would prove altogether 
insufficient. 
By an exciting or determining cause is meant any influence or impression 
which immediately and directly is instrumental in developing the phenomena 
of inflammation. To make entirely clear these definitions, I may adduce as 
an illustration the case of a person seized with paralysis of motion and 
sensation,—a case of paraplegia. A change in the sensibility of the parts 
leaves them less able to endure pressure, and liable to become inflamed, to 
ulcerate, and slough. The paralysis is a predisposing cause ; the weight of 
the body, or pressure, is the exciting cause. 
Predisposing Causes.—Among the predisposing causes which favor the 
development of inflammation may be mentioned,— 
Temperament.—The constitutional peculiarities which form the basis of the 
so-called temperaments play a less conspicuous role now than in ancient 
times; but it is nevertheless true that these states of the body do incline to 
distinct forms of disease. An individual with a blood-vessel system sur- 
charged with red blood, with a bounding heart, and with all the cell-changes CAUSES OF INFLAMMATION. 
91 
of the tissues in a full tide of activity, combines in himself such vital condi- 
tions as predispose, from a very slight excitant, to inflammation of the pleura, 
lungs, stomach, or kidneys. An organization just the reverse—the lym- 
phatic—is liable to disease of the joints or glands ; and persons possessing an 
acutely-organized nervous system are frequently the subjects of intracranial 
and intraspinal inflammation, followed by serious disturbances of the loco- 
motor apparatus of the body. 
Hereditary influences.—Parents not only transmit peculiarities of family 
resemblance and moral dispositions to their children, but also a bias of organi- 
zation, which disposes them to become victims of the most serious and dis- 
tressing diseases, such as consumption, syphilis, cancer, gout, etc. It is just 
here that certain very grave moral questions arise touching one of the 
tenderest relations of life,—that of the marriage of parties with known 
transmissible diseases,—the ignoring of which, under such circumstances, 
involves a personal responsibility little short of actual guilt. One of the 
most difficult tasks is to obtain from patients a confession of any derived 
morbid proclivity; no one cares to acknowledge any defect at the fountain- 
head, as he is well aware that such an admission involves the purity of the 
stream. Some of these hereditary legacies crop out in early life, as scrofula 
and syphilis, and others much later, as gout and cancer. 
Age.—Young children are particularly disposed to inflammations of the 
larynx, trachea, and meninges of the brain. Adolescence is liable to inflam- 
matory affections of the glands, as the parotid in mumps, tonsils in quinsy, 
and the lymphatic in scrofula. Diseases of certain articulations, as the hip 
and the knee, giving rise to coxalgia and white swelling, are quite common 
at the same period of life. 
The middle-aged are prone to pneumonia, rheumatism, bronchitis, and 
phthisis pulmonalis; and old age is subject to affections of the prostate body 
and bladder, and to various inflammatory changes of the heart and arteries. 
Sex.—The sexual system of the female, subjected to the perturbations of 
menstruation and parturition, together with her sphere in social life, predis- 
poses her to particular kinds of inflammation, such as peritonitis, mammitis, 
malignant and other growths. 
Occupation.—All occupations, whatever they may be, incline, in some de- 
gree, to certain affections more than to others. Manufacturers of sand-paper 
suffer much from diseases of the air-passages, in consequence of the angulari- 
ties of the silicious particles with which the air is filled. I have been in- 
formed by the proprietor of one of these establishments that the mortality 
from this cause is very great. Those, also, who attend the modern threshing- 
machine, or who are exposed to irrespirable gases, suffer in like manner. 
The laborer, whose duties call him to wet or damp localities, is exposed to 
rheumatism, bronchitis, and pneumonia ; the painter, to colica pictonum ; and 
the student, or man of business, whose occupation is sedentary, is liable to 
derangement of the digestive apparatus, which of itself is a fruitful source 
of many inflammatory affections. 
Habits.—The laws of health cannot be violated with impunity. Immod- 
erate indulgence in the use of alcoholic drinks will favor disease of the 
stomach, liver, and kidneys; excessive venery, structural changes in central 
portions of the nervous system ; and neglect of cleanliness, multiform cuta- 
neous eruptions. 
Food.—This proves a fruitful predisposing cause of inflammatory disease. 
The gourmand who eats to repletion a rich stimulating fare, lays the foun- 
dation for disease of the stomach or liver. When of an improper kind, 
defective in certain components, as nitrogen, or in certain acids or alkaline 
salts, such as potash, it tends to the production of ulcerations, purpura, scurvy, 
and fevers of an adynamic type. The prolonged use of bread containing 
ergot may, by its effect on the muscular walls of the vessels, starve the 
tissues, which will so modify or disturb nutrition as to induce inflamma- 
tory changes. To food insufficient in quantity and imperfect in quality and 92 
INFLAMMATION. 
preparation may be ascribed much of the disease among the poorer classes, 
especially during the summer season. 
Temperature and locality.—The heat of summer of southern or tropical 
latitudes predisposes to disease of the liver and intestinal canal, while the 
rigor of high northern regions invites inflammatory trouble in the vocal and 
pulmonary organs. A most fruitful source of disease is that which arises 
from a residence in certain localities,—such, for example, as along stagnant 
water-courses or marshes, exposed to those miasmatic exhalations which 
poison the system and give rise to fevers and sequels of a grave character, 
as enlargement of the spleen, orchitis, etc. 
The blood.—There are several ways in which the blood itself may predis- 
pose to inflammation. It may undergo such chemical changes as will favor 
the formation of thrombi and emboli. These obstructive masses arrested in 
the vessels and transported to the capillaries, where they become impacted, 
prove centres of inflammation. Again, when, from imperfect oxidation of 
nitrogenized matter, uric acid accumulates, there is a liability to gouty and 
rheumatic attacks. 
Inflammation.—An attack of inflammation will often leave a part, from 
structural change, with diminished power to resist injurious impressions, and 
therefore prone to secondary attacks. A person who has once suffered from 
tonsillitis will be particularly open to similar invasions. The inflammatory 
changes which take place in important life-organs operate powerfully as 
predisposing causes to disease elsewhere. So we find diseases of the heart 
expose the lungs and kidneys to tissue-changes. In affections of the liver 
the vessels of the rectum become involved, producing hemorrhoids; in acute 
rheumatism, the endocardium; and in certain of the exanthemata, as scar- 
latina, the kidneys. 
Undue functional activity.—There is a reciprocity existing between various 
organs of the body by which they can supplement or substitute one another. 
The skin in this way can do, for a time at least, the work of the kidney, or 
the kidney that of the skin. The extraordinary demands, however, involved 
in such a vicarious work tend to produce inflammation from the hyperremia 
necessarily present. It is in this way, no doubt, that the suppressed secretion 
of the glandular apparatus of the skin disposes to nephritis; or, where the 
kidneys are disqualified to effect the elimination of certain products of textural 
waste, as urea, or uric acid, abscesses, boils, and carbuncles invade the sur- 
face of the body. 
Excessive muscular exertion, exacting as it does heavy contributions from 
the nervous centres, may likewise provoke inflammatory changes in the 
medulla spinalis. 
So also the eye, overtaxed by the long-continued inspection of minute 
objects, is liable to inflammatory disorders. 
Mental and. emotional states.—These form powerful predisposing and also 
exciting causes of inflammatory disease. Intense and protracted application 
to intricate subjects of study, by attracting an undue amount of blood to the 
brain, keeps up a habitual congestion, one of the elements in inflammation. 
Inordinate excitement opens the way for cardiac disease ; sudden fear, over- 
whelming grief, the anxious watchings so often witnessed in the sick-room, 
all exercise a pernicious influence on secretion and structural metamorphosis 
generally, through their depressing action on the nervous system, so that 
inflammatory explosions are favored from imperfect elimination or defective 
oxidation. Our insane institutions furnish many illustrations of the verity 
of these statements. Fear, grief, and joy must act through the eye and 
ear, organs of special sense, thus showing what a marvellous connection and 
interdependence exist between different portions of the nervous system. 
Exciting Causes of Inflammation.—To attempt to enumerate every cause 
of this kind would be an endless task, for they are as varied and numerous 
as the objects of nature herself. Yet the subject may be simplified and order EXCITING CAUSES OF INFLAMMATION. 
93 
evoked out of the multitudinous and diverse causes by placing into groups or 
classes all such as sustain a particular relation to the body, or have a simi- 
larity of action. 
The first division is into external and internal exciting causes. All agents 
which are without and independent of the body, and capable of exciting 
inflammation, belong to the external class; and all such as are directly or in- 
directly connected with the interior of the body or its components, acting 
locally or constitutionally, belong to the internal class. Each of these primary 
divisions admits of two subdivisions. They may be tabulated as follows: 
External Exciting Causes of Inflammation 
Mechanical. 
Chemical. 
Internal Exciting Causes of Inflammation 
Mechanical. 
Chemical. 
External Exciting Causes of Inflammation.—Under this head are classed 
those which operate mechanically and those which operate chemically. 
The mechanical causes are cuts, punctures, scratches, contusions, frac- 
tures, luxations, and parasites, both animal and vegetable. 
The chemical causes are caustics,—either acids*or alkalies,—heat, cold, 
rubefacients, blisters, and other irritants. Heat and cold are sometimes 
regarded as physical rather than chemical causes. 
Internal Exciting Causes of Inflammation.—These are likewise mechan- 
ical and chemical. Among the mechanical may be enumerated vesical, sali- 
vary, and biliary calculi, which, by movement, irregularity of surface, or 
enlargement, provoke structural change, not only in the parts with which they 
are in contact, but also in those quite remote. A stone in the kidney will, 
after long irritation, induce a cystitis, and a concretion in the gall-bladder, or 
in the common bile-duct, will excite peritonitis. Tuberculous deposition in 
the pulmonary tissue will determine localized pneumonia; necrosis of a bone, 
inflammation of the surrounding soft parts ; embolism and thrombosis will pro- 
duce a similar result in the blood-vessels and distant organs by obstruction; 
and large depots of extravasated blood, or even pus, the retained secretion of 
a gland, or pressure from morbid growths, may all provoke inflammation in 
the contiguous tissues. In regard to the last, the local irritation produced by 
growing tumors, nothing is more common than to find the neighboring struc- 
tures blended together by inflammatory adhesions, and often greatly com- 
plicating operations for their removal. 
Internal chemical causes are likewise numerous: 
1. Normal secretions of organs.—The escape of bile through an ulcerated 
opening in the gall-bladder, or of the urine from a lesion in the walls of the 
urinary bladder, will excite a destructive peritonitis; or, if allowed to flow 
over the buttocks, will soon chafe the skin. 
2. Perverted secretions.—The laehrymation from an inflamed eye, which 
runs over the cheek, will soon inflame and excoriate the skin ; the secretion 
from the glands of the Schneiderian membrane of the nose under catarrhal 
irritation will do the same for the upper lip. The chemical changes which 
take place in the urine when the bladder is imperfectly emptied of its con- 
tents are, in time, almost certain to excite cystitis. 
3. Abnormal states of the blood.—The blood determines inflammation after 
different modes. It may abound to such a degree in its normal constitu- 
ents as to produce over-stimulation of the organs to which it is distributed: 
it is often the case that the brain, kidneys, and liver suffer from this cause. 
Or it may be deficient in these components, and unequal to supply the de- 
mands of the system, and so constitute a prolific source of disease. If we 
take a look at the background of metropolitan life, it is not difficult to un- 
derstand the inflamed eyes, enlarged glands, and cutaneous diseases which 
abound on every side. The necessity for a varied and mixed diet in order to 
sustain the proper nutrition of the body is no longer a subject for discussion. 94 
INFLAMMATION. 
The fearful ravages of scurvy, which has so often decimated ships’ crews 
and armies, and the outbreaks of typhus among the starved soldiers of be- 
leaguered garrisons, are sad illustrations of this statement. 
The blood may be surcharged with the products of textural waste and 
become a tissue-poison. If from any cause there is an obstruction to the 
venous circulation through a part, and the blood is too long delayed, it be- 
comes a local irritant. Such is the explanation of those inflammations which 
attack limbs in which the veins are in a varicose condition. Again, the blood 
may contain certain medicinal agents which by their presence excite inflam- 
mation Turpentine and cantharides taken into the stomach or introduced 
through the skin in sufficient quantities will produce strangury, or inflam- 
mation at the neck of the bladder; mercury, inflammation of the salivary 
glands; certain preparations of potash, as the iodide, inflammation of the 
skin or mucous membrane of the nasal passages. 
The entrance of pus or other putrescent septic matters into the blood may 
be the cause of extensive inflammations, both by the arrest of the pus-cor- 
puscle in the capillaries of the lung or liver, and by the change in its com- 
position from the presence of spoiled serum or fibrin, acted on by either 
vegetable or non-organized ferments. 
Again, the blood may be the recipient of certain subtle poisons of animal 
origin,—as in scarlatina, rubeola, smallpox, or syphilis,—introduced through 
the medium of the atmosphere, the point of a lancet, or sexual contact, 
which penetrate it like a leaven, and, after a period of apparent latency, 
cover the entire surface of the body with intense inflammation or disgusting 
crusts. Were it not that repeated observation has rendered it certain, it 
would be absolutely incredible that an emanation from the body of a person 
Buttering from measles, so subtle as to defy careful scrutiny by the most 
powerful glasses and the most delicate chemical reagents, should so affect the 
entire mass of the circulating fluid through the partition-walls of the lungs 
as to involve the whole integument of the body, the conjunctiva, and the 
mucous membrane of the fauces and air-passages in a flame of inflammatory 
disease. There is something analogous to this in the cutaneous inflammation 
which attacks many persons who come within the atmosphere of certain 
members of the vegetable kingdom, as the Elms Toxicodendron. In the 
preference manifested by morbid poisons for definite districts of structure on 
which to expend their force, we see something akin to the elective affinities 
which rule in the domain of chemical action. 
4. Certain seasons of the year determine particular inflammations. Thus, 
during summer, or the flowering period of grasses, many persons suffer from 
what is termed “ hay catarrh.” or a peculiar morbid state of the mucous 
membrane of the nasal passages.—whether from the pollen of plants, odor- 
iferous emanations from vegetable growths, or peculiar electric conditions of 
the atmosphere, it is difficult to determine. 
5. Nervous influence.—The agency of nerves, especially sensitive ones, in 
causing inflammation, is unquestionably very potent. Note the gangrene 
following injury to the spinal cord, or the pneumonia resulting from damage 
to the pneumogastrie nerve. The conjunctivitis and keratitis which follow 
division of the trifacial are examples also in point. I have seen, fol- 
lowing an injury of the median and ulnar nerves, a severe inflamma- 
tion attack the hand, and in one case ulceration and necrosis of the prox- 
imal phalanx of the ring-finger, necessitating its removal. Similar cases 
were frequently witnessed in our military hospitals during the late war. 
There is a discrepancy of opinion as to the manner in which such injuries 
provoke inflammation. Whether, as thought by Snellen, a part deprived of 
its normal sensibility is rendered helpless against mechanical and chemical 
influences of an injurious nature ; whether the loss of control over the vessels 
of a part supplied by the divided nerve allows them to become surcharged 
with blood, which state of congestion determines the inflammation (an expla- 
nation harmonizing with the experiments of Graefe) ; or whether congestion is EXTENSION OF INFLAMMATION. 
95 
favored by the interruption of the ordinary nerve-influence concerned in the 
tissue-changes of nutrition, as held by Samuel, are all questions which admit 
of discussion. Snellen, after dividing the trigeminus in a rabbit, stitched the 
lids together, and also fastened the ears over the eye, yet he asserts that 
no inflammation ensued. Apparently this would prove that the eyelids pro- 
tect the organ against inflammatory disease. Graefe, in order to determine 
their value in this particular, cut them away, together with the tear-glands, 
and yet the resulting inflammation from exposure fell short of that which 
follows division of the nerve. In facial paralysis I have seen the lids re- 
main open for a long time without any result other than a slight redness 
of the conjunctiva. I believe, however, that all of these above-mentioned 
causes operate in developing inflammation; that is, the failure of the organ 
to recognize the presence of foreign matters, local hypersemia, and disturbed 
nutrition. 
Extension of Inflammation.—Inflammation, when once established, may be 
propagated in several ways: 
1. By sympathy.—However obscure or difficult of explanation the fact, it 
cannot be questioned that a peculiar fellow-feeling exists between corre- 
sponding parts or organs of the body, so that when one suffers the other 
becomes likewise affected. The best solution of this problem will be found 
in the nervous distribution. On no other theory can we account for facts 
like the following. Rheumatic inflammation of the knee-, ankle-, or wrist- 
joint is frequently succeeded by the same disorder in the corresponding joint 
of the opposite side. Certain forms of skin disease make their appearance in 
this symmetrical manner. If one eye becomes inflamed, the other is liable 
after a time to suffer in the same way. Ophthalmologists understand this 
well, and, in cases where the eye first attacked is disorganized, or vision is 
hopeless, perform enucleation, with immediate relief to the other when it is 
inflamed. The same influence is exemplified in those cases of orchitis which 
follow inflammation of the parotid gland. 
2. By infection.—Inflammation of the hand or foot is frequently followed 
by inflammation of an axillary or inguinal gland without any evidence of 
intermediate disturbance. It seems highly probable that in such cases some 
of the products of tissue-metamorphosis have been carried, through the me- 
dium of the lymphatics, to the glands in question. This is certainly often 
witnessed in the buboes which follow chancre or gonorrhoea. 
3. By the blood.—The blood may propagate inflammation by carrying pus, 
emboli, or thrombi from a diseased point into vessels too small for their pas- 
sage, and which from mechanical irritation become foci of secondary inflam- 
mation. Or, from a little pimple, the result of inoculation, it may disseminate 
something which will establish inflammation in many of the structures of the 
body. 
According to the doctrine of bacteriology, the presence of micro-organisms 
or of the ptomaines plays the principal role in all inflammations, so that the 
terms infection, blood-poisoning, tissue-metamorphosis, etc., possess a new 
meaning. 
4. Continuity of structure.—When inflammation, beginning at one point, 
continues to extend uninterruptedly over the same plane of tissues, or others 
adjoining, as we see a drop of water or ink spread over a sheet of bibulous 
paper, it is said to increase by continuity of structure. Some use the words 
continuity and contiguity to express two different modes of inflammatory 
extension. I can discover no distinction. The superimposed layers of struc- 
ture are all really united by the small blood-vessels, nerves, and the accom- 
panying threads of connective tissue. After this manner a urethritis becomes 
a cystitis; a pharyngitis becomes a laryngitis; a conjunctivitis, a keratitis; 
or an erysipelas, a cellulitis. It is not improbable that such a propagation 
of inflammation is the result of infection from textural changes induced 
through parasitic agencies. 96 
IN FLA MM A TION. 
ACUTE INFLAMMATION. 
The symptoms of inflammation are divided into the local and constitutional, 
—that is, such as are connected with the part inflamed, and such as belong 
to the system at large. 
Local Symptoms.—These symptoms are change of color, form, temperature, 
sensibility, and function. In the main, this is only another way of express- 
ing the compact formula of Celsus, written over eighteen hundred years 
ago: Notoe vero injlammationis sunt quatuor: rubor, et tumor, cum calore, et 
dolore. 
Change of color.—This consists in increased redness of the inflamed part, 
and is seen of all shades, from the faintest red to a scarlet, purple, or bluish 
hue. The degree to which this sign is present will depend upon several con- 
ditions. The more acute, and, before any marked structural changes have 
occurred, the more pronounced, will be the seai'let color. The vascularity 
of the part inflamed will also have a determining influence on the degree 
of redness. Certain tissues are very rich in blood-vessels,—for example, the 
skin, conjunctiva, and, indeed, all mucous membranes,—and hence the color 
in such, when inflamed, will be very red, while in those which are non-vas- 
cular or less abundantly supplied, as cartilage, the cornea, tendons, ligaments, 
arachnoid membrane of the brain, and other structures, it will be very faint, 
or only seen in the vessels contiguous to the part. The disposition of the 
color varies much in the inflammation of different structures. In that of the 
conjunctiva it is reticulated, corresponding to the network-like distribution of 
its vessels, or in conical eminences, answering to the papillary loops arranged 
over the palpebral part of the membrane. In the sclerotic it is in radiating 
streaks, and when in the iris it will often appear as a red zone at the circum- 
ference of the cornea, as if laid on with a brush. In certain cutaneous inflam- 
mations it will appear in points, spots, circles; or in crescents, as in rubeola. 
Sometimes it is diffused, and at other times abruptly defined. Sometimes it 
extends in long lines, as in inflammation of the superficial lymphatics, and at 
other times sends out blushing promontory-like arms with deep marginal 
indentations. 
Again, the color is modified by the activity of the circulation. In inflam- 
mation of a carbuncular nature, where the tissues are dense and unyielding, 
and in which the inflammatory products are abundant, the vessels are so 
compressed that the blood makes its way through with difficulty, and, being 
long detained in the parts, assumes the character of venous blood. From 
this cause the infiltrated tissues are bluish at the centre, shading off at the 
circumference to a purple, or, if the obstruction is less and the circulation 
more active, a dull red. 
When inflammation exists in a part in which the vitality, from injury or 
other causes, is very low, threatening gangrene, the color becomes dusky or 
reddish-brown. Cutaneous inflammations which arise from certain specific 
causes, as syphilis, possess a copper hue. It is no exaggeration to say that 
every grade and variety of inflammation has a characteristic color, which 
the trained eye of the physician will soon detect. 
Redness, however, is not always a sign of inflammation: there is the blush 
which mantles the cheek from diffidence or shame; and a color that comes 
when the hot blood mounts to the face in anger or indignation. These are 
emotional results. Then there is the redness of the mucous membrane of 
the stomach and small intestine during digestion, or of a muscle in a state of 
contraction. Here it depends upon functional activity. 
There is also redness from the application of rubefacients, as mustard, or 
stimulating liniments ; from standing before an open fire, or exposing the face 
to a keen frosty atmosphere. In such cases it is due to irritation. 
Again, there is a change of color seen in a part abnormally dependent, as 
when the head is allowed to hang down, or when the circulation is embar- SYMPTOMS OF INFLAMMATION. 
97 
rassed, as in croup or carcinomatous growths. In such the color may be red, 
purple, or tawny, and is dependent upon a mechanical impediment to the 
circulation. In these cases, for the most part, the color is temporary, tran- 
sient, goes and conies, while that from inflammation is more permanent. 
When the redness is inflammatory, pressure with a finger will empty the 
vessels and make pale the part, but the moment that pressure is removed 
the color reappears; when non-inflammatory, the vessels fill more slowly. 
It often happens that the vessels of an inflamed part give way under the 
force of the circulation, and extravasation of blood follows. Such stains are 
not affected by pressure. 
Change of form, or swelling.—The swelling of an inflamed part is due to 
several causes: first, to the increased amount of blood in the part; second, 
to the transudation and extravasation; and third, to the multiplication of 
organic forms or cells. The degree of swelling depends much upon the 
anatomical peculiarities of the inflamed part. Where the components are 
firmly bound together by inelastic connective tissue, it is scarcely noticeable. 
Where the connective tissue is abundant and loose, it will be very marked. 
Thus, an inflammation on the posterior part of the body, where the textures 
are dense, will be followed by less swelling than over the eyelid or the cheek, 
where they are very loosely bound together. In inflammation of bone the 
swelling will be altogether inconsiderable, as compared with that of the soft 
parts of the arm. The swelling is usually very great when mucous mem- 
branes are inflamed. In acute conjunctivitis the lining membrane of the 
eyelid will often protrude beyond the lid, as a red turgid mass (chemosis). 
An inflamed pile will acquire a great bulk in a few hours; the loose tissue 
at the top of the larynx or glottis may, from the same cause, swell so as to 
threaten suffocation, as in oedema of the glottis. The stream of urine may 
be much diminished in the same way in acute urethritis. All of these swell- 
ings depend upon the abundance of the submucous connective tissue. Where 
the inflamed part is deep-seated, below the deep fascia, the resistance of the 
latter prevents much external manifestation of swelling. Not always, how- 
ever, is the distention noticeable even when the effusion is great. A synovitis 
may be followed by considerable fluid in the joint, and yet no visible signs 
of enlargement be present; the cavity of the pleura may be filled with serum 
and no bulging of the chest be observed; the Schneiderian membrane of 
the nasal passages may pour out an incredible discharge without materially 
encroaching upon the cavities of the nasal fossse. The resisting walls of a 
joint and of the thorax, and the open surface of the mucous membrane of the 
nose, with its very sparse basis of connective tissue, explain these peculiari- 
ties. The swelling is circumscribed or diffuse, from three conditions: the 
consistence of the effused product, whether abounding in serum or in lymph ; 
the close, compact arrangement of the parts of the tissue; and the manner 
in which the spaces, made by interlacing fibres, are filled by masses of fat. 
Fascial attachments also exercise a limiting influence, as when a fluid is below 
the supra-spinous or the submaxillary fascia). Peculiarities of inflammation 
also determine the form of swelling, being limited in the furuncular and 
diffused in the erysipelatous variety. The form of the swelling often reveals 
its exact situation. The firmness of the tumefaction differs in different cases. 
It is sometimes quite soft, and is easily pressed aside by the finger, which, on 
its removal, leaves an indentation or pit; such a swelling is often called cede- 
matous, the effused fluid being very frequently thin, serous, or watery, and 
the color white and waxy. Or it may be firm and unyielding to pressure, as 
is seen in erysipelas or carbuncle, in which case the transudation contains 
a large amount of fibrin, interpenetrating the components of the inflamed 
tissue. Occasionally there is a true hypertrophy and resistance, not from 
simple transudation, but from the development of connective tissue more or 
less matured. Such, however, is mostly met with where the active stage of 
the inflammation is overpast and the process glides into the chronic form. 
In addition to these the swelling may be due to extravasation of blood or 98 
INFLA MM A TJON. 
formation of pus. An inflammatory swelling may disappear rapidly or tardily. 
A large accumulation of serum in the cavity of the peritoneum, or in the 
cellular tissue of the lower extremities, may vanish in twenty-four hours 
under a hydragogue cathartic or active diuretic. When the removal is rapid, 
the inflammation has passed its active stage, is subsiding, and the transuda- 
tion, consisting so largely of serum, and therefore being of little density, is 
readily absorbed, and its expulsion through the intestines and kidneys effected. 
Not so, however, with transudations of a more consistent nature, in which a 
large amount of organic forms and fibrin prevails. Here there must be retro- 
grade metamorphosis, disintegration, decay, liquefaction, fatty transformation, 
etc., before the swelling can be disposed of; this is a work of time, and there- 
fore more gradual and protracted. 
Alteration in temperature, or heat.—When the hand is laid upon an inflamed 
surface, a sense of warmth is experienced materially greater than that of 
other portions of the body. The patient likewise is conscious of unusual 
local heat, and speaks of the part being hot or burning. The question has 
been warmly discussed, Is the heat of an inflamed part greater than that of 
the blood which circulates in it, say 98° ? 
John Hunter attempted to solve the problem by thermometry at St. George’s 
Hospital. He laid open the tunica vaginalis for the cure of a hydrocele, and 
introduced a thermometer, which registered 92°. Inflammation was excited 
by packing the sack with lint, and again the bulb of the instrument was in- 
serted, revealing a temperature of 98|°. Though there was an increase of 6i°, 
yet still it was less than the heat of the blood itself. This and similar experi- 
ments were frequently repeated, and uniformly with the same result. The 
difficulty in reaching the truth in this matter was due to the fact that, as in a 
room with an open fireplace, or containing a coil of pipe for the circulation 
of steam, there is a tendency to the establishment of an equilibrium of heat 
among the various pieces of furniture, so in the body the circulation of blood 
through a tissue tends to the same end ; apd secondly, to inability to construct 
such instruments as were sufficiently sensitive to appreciate the most minute 
quantities of caloric. That there is a certain measure of heat,due to the 
amount of blood in a part, altogether independent of inflammation, cannot be 
questioned. I have several times repeated the experiment of M. Bernard, 
that of dividing the sympathetic cord in the neck of a rabbit, by which the 
external carotid vessels are paralyzed and rendered unable to regulate the 
amount of blood which fills their branches: the redness and the increase of 
temperature of the integument of the ear were quite apparent when con- 
trasted with the corresponding part of the opposite side. The experiments 
of Mr. Simon with a thermo-electric battery, constructed by Dr. Edward 
Montgomery,* have furnished us with a definite solution of the vexed question. 
It was found that at the centre of inflammatory action the heat was greater 
than that of the arterial blood supplying, or of the venous blood leaving, the 
part,—and, further, that the venous blood possessed a higher temperature 
than the arterial. The conclusion was inevitable that this additional warmth 
must have been derived from the focus of inflammation. There is therefore 
the local evolution of heat in an inflamed part, and the correlative of this 
heat, in all probability, textural change. 
Alteration in sensibility, or pain.—This symptom of inflammation is a sliding 
scale, and is present in all degrees, from mere increase of sensibility, or ten- 
derness, to the most acute suffering. Usually its severity is in proportion to 
the intensity of the inflammation, reaches its height when the process is 
at its zenith, and diminishes or disappears as this process declines. It may 
be measured by the stages of the morbid action,—exquisite at the centre, 
becoming less and less as the circumference is approached. Most extensive 
inflammation may exist without the realization of pain. The pleural sac 
may be filled with serum and yet the patient never have been conscious of 
any pain, or, at least, have had very inconsiderable sensations of it. Not- 
* Holmes’s Surgery, vol. i. pp. 18, 19. SYMPTOMS OF INFLAMMATION. 
99 
withstanding the extensive denudation of the intestinal mucous membrane in 
cholera, the patient may have suffered no abdominal pain; perhaps, as sug- 
gested by a writer, the cramps or spasms are its equivalent. The sensa- 
tion of pain is due to injury sustained by the nerves of an inflamed tissue, 
which injury is not felt in the part, but is referred to it through the agency 
of the brain. This damage may consist in irritation, pressure, stretching, 
laceration, or disorganization of the nerve-substance. Its intensity is often 
conditioned upon the degree of structural resistance,—not upon the extent of 
the inflammation. A felon will produce more acute suffering than an inflam- 
mation covering the entire scalp; a toothache, more than a peritonitis; a cir- 
cumscribed ostitis, more than a colitis. There is something peculiar in the 
insensibility of many internal organs. Most extensive inflammatory changes 
will take place in the liver, kidneys, lungs, brain, and spleen without the 
presence of pain; the soft texture, and, with the exception of the brain and 
kidneys, the elastic nature of their capsules, allowing the swelling to increase 
centrifugally, explain in part this circumstance. The fact that there may be 
serious structural lesions without suffering should keep the practitioner ever 
on the alert. While there are differences in the degree of pain, there are also 
differences in its kind. Every tissue complains in a way peculiar to itself. In 
the pleura it is lancinating; in the peritoneum it is extreme tenderness ; in bone 
it is deep-seated, gnawing, and with frequently an evening exacerbation; in 
the testicle it is sickening; in muscular or fibrous tissue, as in rheumatism, 
it is dull, heavy; in the skin, burning or itching; in cancer, stabbing; and 
in parts firmly bound together, especially if dependent, it is throbbing, as 
in whitlow and hemorrhoids. Pain frequently induces violent reflex move- 
ments : a conjunctivitis will sometimes provoke spasm of the orbicularis 
muscle ; a colitis, spasm of the levator ani and abdominal muscles; a cys- 
titis. contraction of the muscular walls of the bladder; and a painful gum in 
a child will excite convulsive movements of the entire voluntary muscular 
system. In all these cases offensive impressions are made upon the sensitive 
nerves of the part, and these impressions are conducted to the spinal centre, 
from which come the violent movements through the motor branches. 
Pain is not always felt in the inflamed part, but often quite remote from the 
seat of disease.—at the knee in hip-joint disease, at the end of the urethra 
in vesical calculus, and near the inferior angle of the scapula in affections of 
the liver. In inflammations of the organs of special sense there are phe- 
nomena of a peculiar kind, which may be considered as related to inflam- 
mations of these organs in the same way that pain is to other tissues. Such 
are the explosive sounds heard in the ear, the brilliant coruscations of light 
seen in the eye, and perverted olfaction in deep inflammations of the nasal 
cavities. Pain may exist without inflammation, as in neuralgia, and it is often 
a matter of the first importance to establish the diagnosis. When neural- 
gic it will be out of all proportion to any visible signs of textural change; 
shooting, or darting, in its character; in the course of well-recognized nerve- 
trunks; intermittent or periodical; frequently coming on in the fore part of 
the day and declining towards evening; often changing its seat, or going and 
coming at irregular intervals ; and when near the surface frequently accom- 
panied with distention of the contiguous veins. There is an abdominal pain, 
that of colic, which is not the pain of inflammation: it is relieved by press- 
ure, and is intermittent, depending for its existence upon spasm of the muscu- 
lar walls of the intestine, by which the nerves are compressed. The sudden 
cessation of pain often preominates mortification, especially when succeeding 
acute suffering, as in cases of intestinal disease followed by perforation; and 
if in addition there is present a frequent, feeble pulse, cold, clammy perspira- 
tion, hiccough, etc., it is still more diagnostic. 
All persons do not suffer alike from this sensation. Some possess an organ- 
ization so fine and delicately acute that the slightest scratch produces severe 
suffering, while others, cast in a ruder mould, appear never to realize more 
than a little discomfort. Women endure pain with more fortitude than men. 100 
INFLAMMA TION. 
Deprecate pain as we may, it is an evil not without some compensation. It 
is the sentinel of the bod}7 posted at every gate to warn us of danger. A 
cramp in the stomach admonishes the gourmand of some imprudence in diet 
which must be corrected; a pain in the eye or head gives notice to the un- 
tiring student that both must have a season of rest; and the paroxysm of 
agony which announces the passage of a grain of sand along the ureter shows 
the necessity of at once correcting a vice which may lead to vesical calcu- 
lus. On the other hand, when this sentinel is disarmed and unable to give 
the alarm, as in cases of paralysis, how often do we meet with extensive 
ulcerations from pressure, the patient being entirely unconscious of their ex- 
istence! It is quite true that all the detailed phenomena of inflammation 
may be present and yet the condition not be one of inflammation, as in the 
everted eyelid of a crying child, in priapism in prolapse of the anus, or in the 
stomach during digestion. Most of these are examples, however, of great 
functional activity, but may, if too long maintained or overtaxed, lead to 
inflammation. 
Alteration of function.—It is impossible that a part'perturbed by causes 
which so profoundly affect sensibility, circulation, and nutrition should con- 
tinue to execute its work in a normal manner. Alteration of function in 
inflammation may manifest itself in various ways. 
1. In supersensitiveness.—This will often crop out before a single sign of 
inflammation can be detected. In incipient strumous ophthalmia, the eye 
becomes intolerant of light, almost photophobic, before a single line of color 
is discernible. In the developing stage of intracranial inflammation, the 
softest sounds will fall on the ear like the explosions of artillery. The bladder, 
upon the approach of inflammation, no longer remains a passive reservoir for 
the urine, but resists and expels it; and the stomach either refuses to do or 
performs imperfectly the work of chymification. 
2. Disordered secretion.—The glandular secretions are changed in quantity. 
The salivary glands, when inflamed from the injudicious use of mercury, 
have their secretion greatly augmented; so also the glands of the nasal 
cavities, as in coryza. Secretion may likewise be diminished. Inflammation 
of the kidneys is followed by a marked falling off, and frequently complete 
suppression, of urine. This suspension of the secretory function prevents 
the elimination of those materials which, when retained in the blood, exert 
a poisonous influence on the system. The same is true of the bile in hepa- 
titis. Secretions also undergo changes in quality, or chemical changes, from 
inflammation. The lachrymal discharge, which naturally is so bland and 
soothing to the eye, will become irritating; the mucous membrane of the 
bladder will react upon its contents, so as to change entirely the chemical 
constitution of the urine, and form combinations and deposits which greatly 
intensify its irritating properties. 
3. Imperfect or suspended function.—If the eye is inflamed, the vision will 
often be defective, or disturbed by coruscations of light; if the ear, it will 
be rendered unfit to appreciate sounds correctly; in cerebritis, delirium and 
raving take the place of reason; in inflammation of the mucous membrane 
of the nasal passages, the sense of smell is, for a time, entirely suspended; and 
in glossitis the taste is temporarily lost. 
Constitutional Symptoms.—T doubt not that in every case of inflamma- 
tion, however insignificant or slight, the system at large realizes some disturb- 
ance, but like the influence felt from a pebble dropped into a lake, which, 
though affecting every drop of its water, yet is too inconsiderable to be 
detected by any of our present means of observation. When, however, the 
process is excited by some peculiar cause, as a puncture in making an autopsy, 
or when it involves a considerable surface of a particular portion of the body, 
as in erysipelas of the scalp, or when it occurs in peculiarly irritable indi- 
viduals, a train of symptoms will be developed which will affect the entire 
body. Nothing, perhaps, more forcibly illustrates the confederate bond or SYMPTOMS OF INFLAMMATION. 
101 
the organic unity of the human body than the general perturbation which 
spreads from local impressions, either morbid or healthful. 
The constitutional disturbance following an operation or an injury is called 
surgical or traumatic fever, and is inflammatory in its nature,—a condition 
not recognized by the pulse or by the sensations of the patient alone, but 
by the elevation of temperature, which can be measured only by the clinical 
thermometer,—an instrument that should be the constant companion of the 
surgeon. This increase of temperature is always present in fever. Even be- 
fore the patient complains of chilliness or suffers from rigors, the thermometer 
will disclose a degree of heat greater than when his sensations are those of 
warmth.* An elevated temperature—that is, a temperature above 100°—is 
always indicative of mischief, as it is an expression of tissue-destruction, the 
danger increasing with every additional degree, while its steady reduction 
augurs a favorable change in the course of the disease. A patient with a tem- 
perature over 107° seldom recovers. We have, then, in thermometry a means 
of detecting the earliest approach of danger, and are thus prepared to meet it 
long before a single signal could be discerned in any other way accessible to 
the most acute observer. This fever which follows local injury, and which 
we call traumatic, appears, in part at least, to be due to infection; that is, the 
introduction into the blood of the products of textural change, rendering 
that fluid warmer, more irritating, and, in a measure, incompatible with the 
demands of the tissues through which it circulates. The changes wrought in 
the blood will be noticed when the intimate nature of inflammation is con- 
sidered. Surgical fever, like that which is termed idiopathic fever, may assume 
a continued, remittent, or intermittent type, depending on causes which are 
entirely independent of the injury or operation. A patient with a compound 
fracture, if previously exposed to miasmatic influences, may, after the develop- 
ment of the inflammatory disturbance,—which, as a rule, is a continued fever, 
—be afterwards attacked with one of a remittent or intermittent form. If the 
patient is young, and possesses a sound, vigorous constitution, the course of 
the fever will be characterized by active symptoms ; in other words, it will be 
acute or sthenic ; but if he is feeble or has a broken constitution, one shattered 
by previous disease, privation, or abuse, its prevailing tendency will be ady- 
namic or typhoid,—a complication which will add greatly to the gravity of 
the case. In persons with a predominating nervous system, the element of 
irritability may be added to those already existing. When the injury is fol- 
lowed by a profuse and protracted suppuration, hectic fever may follow, by 
which the danger is greatly enhanced. Sometimes, after traumatic fever 
arises, erysipelas will attack the injured part, and the whole drift of the 
disease will be changed from a dynamic to an adynamic form, in conse- 
quence of an additional element in the way of a blood-change; the same is 
true of surgical patients exposed to the vit iated at mosphere of an overcrowded 
hospital ward. Traumatic or inflammatory fever is somewhat irregular in the 
time of its appearance. It may arise within twenty-four hours, or it may 
be delayed for several days. In a case of amputation following a compound 
fracture, which I recently had under my care, it did not make its appearance 
until eight days after the operation. 
There are various causes which operate to produce these differences, among 
which may be mentioned : shock, during which condition the circulation is in 
abeyance; local inertia, by which is meant an indolent, inactive state of the 
diseased or damaged part, such as we see where the arteries are in an ab- 
normal condition ; and structural peculiarities, some resenting violence more 
quickly than others, as, for instance, the peritoneum sooner than the parietes 
of the abdomen, and the scalp sooner than the cranium. 
* In ascertaining the heat of the body the thermometer is usually placed in the axilla, or its 
bulb may be introduced into the mouth under the tongue. In either situation the instrument should 
be allowed to remain from three to four minutes. Thermometers after being used should be carefully 
washed, in order that they may not become the medium of communicating disease. Usually there 
will be, in all cases of inflammatory or sympton/atic fever, a fall in the morning and a rise in the 
evening temperature. 102 
INFLAMMA TION. 
Inflammatory fever is wide-spread in its effects, disturbing the orderly 
operations of the entire body. 
1. The nervous and muscular systems.—Previous to its development there 
arc often yawning and stretching, a period of lassitude and general muscular 
soreness, with pain in the loins, similar to the feelings experienced by one 
who has been engaged in a long and exhausting day’s labor. 
2. The nervous and circulatory systems.—There is next alteration in tempera- 
ture : the patient experiences a sense of unusual warmth pervading the body, 
alternating with sensations of chilliness. If he changes his position in bed, 
or moves a limb, a rigor creeps over the body. The pulse becomes fuller and 
more frequent, rising from seventy-five (approximately its standard in health) 
to eighty-five, ninety, or one hundred or more beats per minute, sometimes 
full and bounding, at other times frequent and hard, or frequent and feeble. 
The pulse, it must be remembered, is modified by age, peculiarities of constitu- 
tion, and the tissue or organ inflamed. These must be all taken into the ac- 
count preliminary to the formation of a judgment. In young children, at least 
under three years of age, it will vary in health from ninety to one hundred and 
ten beats a minute ; and therefore what is normal frequency in a child means 
fever in the adult. There are persons in whom the pulse is naturally veiy 
slow. A young man who was occasionally my companion in fatiguing shoot- 
ing-excursions had a pulse which never exceeded thirty beats per minute, and 
his uncle, who was a physician, informed me that he had known it on one or 
two occasions to fall to sixteen beats. We generally associate a full, hard, 
and frequent pulse with acute inflammation in vigorous constitutions; and 
this is true when the supra-diaphragmatic viscera are involved; but when 
the stomach, peritoneum, or intestines are attacked, the artery will be small, 
tense, or corded, yet none the less indicative of the intensity of the process. 
There are also peculiarities incident to advanced life, such as diminished 
nerve-power with a feeble heart, in which we cannot accurately measure 
fever by the pulse, but only by the thermometer. 
3. The secretory system.—The secretion of the various glands in inflamma- 
tory fever is also disturbed. The mouth, tongue, and lips are dry and parched 
with incessant and insatiate thirst. Thirst, which is so distressing a sensation 
in fever, is only a call for water upon the part of the tissues. Water is an es- 
sential requisite for those chemical changes which are ever in operation in the 
human body. The changes stimulated by the hot blood increase the urgency 
of this demand, so that the tissues become dry, and their capacity to absorb 
moisture is increased. Dr. Parkes, in his Gulstonian lectures on Fever,* 
advances the theory that in the tissue-metamorphoses induced by the dis- 
ease, certain products are formed which may strongly attract water, such, for 
example, as some gelatinous body constructed from the albuminous matters 
of the blood, and this in turn may be converted into urea or uric acid, as 
gelatin always is when taken into the system, and thus eliminated from the 
body through the kidneys. In this connection the presence of sugar, which 
has so strong an attraction for water, and which is the cause of the thirst in 
diabetes, is brought forward to give plausibility to this ingenious explanation. 
Be this as it may, the folly of denying water to a patient consumed by febrile 
excitement must be apparent to every one. 
To continue the detail of symptoms: the skin is hot and dry ; the secretion 
of the kidneys is diminished in quantity and changed in quality, being high- 
colored and scalding. The urine is loaded with uric acid, rising, as found 
by Becquard, to 5.9 per cent, (the natural average being a little over 1 per 
cent.) ; the extractive matters are nearly doubled, while the fixed salts dimin- 
ish about one-half and the chlorides in a still greater degree, that of sodium 
almost entirely disappearing during the acute stage. The biliary secretion is 
diminished, afterwards increased and changed in its constitution, as seen in 
the deep-green or tar-like dejections which prove so acrid and irritating to 
the lower end of the bowel. The bile is sometimes returned to the blood, 
* Medical Times and Gazette, vol. x. page 333. NATURE OF INFLAMMATION. 
103 
imparting a yellow or icterode tinge to the conjunctiva and skin. The tongue 
becomes covered with a white, yellow, or brown coat; the taste is perverted, 
the bowels are torpid, the appetite is lost, with perhaps a loathing for all kinds 
of food. The special senses become in some instances keenly acute, especially 
the eye and the ear, so that all strong lights and sounds disturb and distress 
the patient. The sense of smell may become so extremely acute that odors 
which under other circumstances would not be recognized are decidedly 
offensive. There is fulness and pain in the head, with flushed face, and as 
evening approaches the restlessness increases, the respiration is more hurried, 
perhaps interrupted by sighs, the mind wanders, the sleep is uneasy, dis- 
turbed, broken at short intervals, and so the night is passed until the morn- 
ing dawns, when the patient becomes more quiet and perhaps falls into a 
slumber, which may last for two or three hours. Not every case furnishes 
such a group of phenomena, either chronologically or numerically. The 
inflammatory fever may be so slight as scarcely to be observed, like a mere 
ripple upon the surface of a lake, or it may assume such violence that the 
strongest constitution will go down before the attack. The duration of these 
constitutional symptoms is not uniform; sometimes they pass away in a 
few hours, but again last for five or six days, during which time not only is 
the assimilation of food suspended, but the waste resulting from oxidation 
is increased, in consequence of which the patient emaciates. The subsidence 
is marked by general amelioration of all the symptoms, very much in the 
order of invasion. The restlessness and delirium pass away; the heart’s 
action diminishes in both force and frequency; the skin becomes moist; a 
free perspiration sometimes breaks out over the body; the tongue loses its 
dryness ; the thirst is diminished ; the headache disappears ; the urine becomes 
more abundant and deposits a lateritious sediment; the evacuations from the 
bowels assume a healthy color; the face regains a cheerful expression: in fine, 
so great is the change from the previous condition that the patient may be 
fittingly compared to a ship which has been driven and tossed for many days 
by fierce winds and tempestuous seas, yet has struggled on until the tempest 
is overpast and the anchor dropped in some quiet harbor. 
Nature of Inflammation.—What is inflammation? We define a fracture to 
be a solution in the continuity of the fibres of a bone; a cataract to be an 
opacity of the crystalline lens, or of its capsule, or both. These are concise 
terms. But when we attempt to define inflammation by a few sharp, incisive 
words, we find ourselves surrounded by such limitations that any statement 
beyond a record of its phenomena is little more than conjecture. Indeed, in 
attempting to discover such a definition we are chasing a phantom. Like 
nutrition, the term inflammation is a generic one, and comprehends several 
very distinct series of phenomena. For their intelligent study we may 
arrange these phenomena under the following heads: 1, disturbed nerve- 
action ; 2, disorder of the blood-vessels and their contents; 3, passage of 
the contents of blood-vessels through their walls; and, 4, change in the 
perivascular tissues of the inflamed part. 
1. Disturbed nerve-action.—When an irritant, such as a drop of corrosive 
acid, or a hot iron, is brought in contact with the surface of the body, there 
is a consciousness of pain. This consciousness depends upon the presence of 
sensory nerves which have been damaged by the irritant, and which pass 
from the surface to a centre, the eerebro-spinal. Not only are impressions 
transmitted centripetally, but also, in answer to such, an influence is sent out 
along another line of nerves, which are centrifugal or efferent, and this in- 
fluence produces muscular movement. The experiments of Claude Bernard, 
showing that from the sympathetic cord in the neck are derived nerves 
which control the superficial arteries of the head, constituted the initial step 
to other investigations, which render it quite certain that the vascular system 
is under the regulating influence of a set of nerves, which together are called 
the vaso-motor system. These nerves are found to quicken and slacken the 104 
INFLAMMATION. 
heart’s movements; they regulate the size of the blood-vessels, and are also 
concerned in the process of secretion. While they all pass through the sym- 
pathetic, their origin is really in the cerebro-spinal centre. We have also 
learned that arteries by virtue of such nerve-endowments execute rhythmical 
movements altogether independent of the heart, from which they are derived. 
(Fig. 119.) The receptive and executive centre of this vascular system of 
nerves has not been definitely determined, but there are reasons for be- 
lieving that it is located in the upper extremity of the spinal cord, or perhaps 
Fig. 119. 
A minute artery, exhibiting several points of contraction independent of the heart’s action. 
in the entire cord, a view which receives support from the experiments of 
Dr. Nussbaum.* Excitation of these nerves occurs from either external or 
internal irritants, whether mechanical or chemical, and, I doubt not, forms an 
important antecedent to all the subsequent changes involved in the process 
of inflammation. 
2. Disorder of the blood-vessels and their contents.—A few anatomical and 
physiological remarks in reference to a part of the vascular system will facil- 
itate the study of this division of our subject. The circulation is effected by 
means of three kinds of vessels,—arteries, veins, and an intermediate set, the 
capillaries. The arteries and veins possess three coats. In the present con- 
nection the middle tissue has for us the greatest interest. It is composed of 
elastic tissue and unstriated muscular fibres arranged circularly. The relative 
proportion of these two structures varies at different portions of the vessels. At 
the root of the arterial tree—the aorta—there is little muscular with much 
elastic tissue, but as we approach the capillaries, and the vessels diminish in 
size, the muscular is largely in excess over the elastic element. In the veins 
the former structure largely preponderates at all points, and accordingly we 
find the power of contraction is greater or more noticeable in the smaller 
than in the* larger arteries; indeed, in the smallest of the latter it may be so 
great as entirely to exclude for a time the entrance of blood. Now, it follows 
that the arteries possess a physical property due to the presence of elastic 
tissue, and a vital property, that of contractility, due to their circular mus- 
cular fibres. The same may be affirmed of the veins, though to a different 
degree. From this organization the arteries are constantly acted upon by two 
distinct forces,—a vital one, which tends to lessen or close 
their canals, and a mechanical one, elasticity, which, together 
with blood-pressure, tends to enlarge or keep them open, so 
that during life they are ever oscillating between these an- 
tagonisms. It is this that produces the elliptical form of 
these tubes. (Fig. 120.) 
The nature of the capillaries is still a subject of discussion. 
By Leidesdorf and Strieker they are considered as homoge- 
neous tubes of protoplasm, possessing the property of contraction and dila- 
tation, movements which, according to Strieker, correspond to those wit- 
Fig. 120. 
Natural form of the 
canal of an artery 
when empty. 
* Localization of the Vaso-Motor Centre, by Dr. Moritz Nussbaum, Archiv fiir Gesammte Phy- 
siologic, Med. Times, August 14, 1875, page 723. NATURE OF INFLAMMATION. 
105 
nessed in the cells of certain glands. His and Rouget regard them as formed 
between layers of cells and lined by an endothelium, the first view being the 
more probable one. 
Dr. Woodward, Assistant Surgeon, U.S.A., in some very careful observa- 
tions on the minute arteries, veins, and capillaries, was enabled, as he sup- 
posed, by nitrate of silver stainings, to demonstrate the existence of stomata 
or pores at the junction of the vascular endothelia. (See History of the 
Causes and Nature of Inflammation, p. 115, post.)* 
The behavior of the vessels and their contents under various excitants 
has been carefully studied under the microscope by using the transparent 
tissues of animals, such as the mesentery, tongue, and cornea of the frog, or 
the wing of the bat. The first effect of the application of certain irritants is to 
induce a state of contraction, afterwards followed by dilatation, of the vessels, 
while by the use of others dilatation is immediately produced. From all the 
knowledge which we possess in regard to this alteration of size in the vessels 
of an inflamed part, it is highly probable that it is conditioned on the nature 
of the excitant. We certainly see this in the action of some drugs: ergot, 
for instance, will cause contraction of the arteries, while the nitrite of amyl 
will produce their dilatation. If such effects take place under circumstances 
other than inflammatory, it is not unreasonable to infer similar results from 
the action of those agents which provoke the disorder under consideration. 
Certain it is, however, that, whether the one or the other takes precedence, 
the final effect is dilatation. The diminution in the lumen or canal of a 
vessel is effected by contraction of its circular muscular fibres through the 
motor trunk of a vascular nerve, and is therefore an active condition ; its 
dilatation, on the contrary, cannot be such, as there are no longitudinal 
muscular fibres, and when it exceeds that 
produced by the elastic tissue in its walls, 
it is the result of muscular enfeeblement, 
or paralysis. Coincident with the dilata- 
tion. which includes arteries, veins, and 
capillaries, the circulation becomes quick- 
ened, and the blood-corpuscles crowd into 
the vessels in large numbers, so as to make 
visible many channels which under other 
circumstances could not be seen: hence 
the redness or rubor of the affected part. 
No new vessels are formed, but the old 
ones are dilated, and, admitting files of 
red corpuscles, now become apparent. 
The experiments of Hunter and Paget 
strikingly verify this statement. That 
of Hunter consisted in injecting the two 
ears of a rabbit, in one of which inflam- 
mation had been produced by freezing. 
The contrast between the healthy and 
the unhealthy one is shown in Fig. 121. 
Those in the left appear to be much more 
numerous and tortuous than those in the 
right ear. The experiment of Paget was 
made on the wings of the bat (Figs. 122 
and 123), inflammation being excited in 
one by means of the cautery. The ves- 
sels increase not only in width, but likewise in length, which gives them a 
serpentine, tortuous, and even varicose appearance. 
Fig. 121. 
The different vascularity of the two ears in a 
rabbit in which Hunter’s experiment has been 
performed. 
* These observations had been previously made by Eberth and others. There are few histologists, 
however, at present who believe in the existence of these pores. The interpretation of the lines in- 
dicated by staining, according to Strieker, is as follows,—namely, that they are living matter differing 
only from other parts of the cells by chemical changes, which render them more susceptible to the 
action of the nitrate of silver. 106 
INFLAMMATION. 
The dilatation begins in the arteries, and afterwards extends to the veins. 
The acceleration of the circulation, on the supposition that the action of the 
heart and the resistance of the capillaries remain unchanged, cannot be 
attributed to the alteration in the size of the vessels. On the contrary, we 
should expect the reverse to 
be true,—namely, a diminished 
rapidity in the movement of 
the blood, just as streams 
travel at a slower rate after 
passing from narrow into more 
expanded channels. On every 
side, and for some distance 
around, the blood is seen 
streaming in towards the focus 
of irritation, and crowding the 
vessels with corpuscles. It is 
to this circle of rapid move- 
ment that the term determina- 
tion applies, and it gives a 
plethora to the vessels some 
distance beyond the immediate 
area of inflammatory action. 
After a time another change 
takes place. The movement 
of the blood becomes slower; 
the red corpuscles, closely 
packed together, are disposed 
to cohere, and to occupy the 
central axes of the vessels. This tendency in the red corpuscles to cling to 
one another is not jn any way peculiar to inflammatory blood, for the same 
behavior is observed in healthy blood which has escaped from the vessels. 
This slowing of the circulation 
when observed under the mi- 
croscope is exceedingly inter- 
esting. At one point a group 
of red corpuscles is seen rolling 
along, then stopping, and again 
moving forward with apparent 
difficulty; at another, a few 
adhering corpuscles attempt 
the passage of a capillary 
channel and fail, then retro- 
grade and again charge the 
obstruction, sometimes with, 
at other times without, suc- 
cess. In another part of the 
field a mass of corpuscles ap- 
pears to have become ar 
rested in the vessel when 
others moving rapidly for- 
ward against the barrier set 
them free by the impulse, or, 
failing in this, whirl off into 
other channels where the ob- 
stacles are less formidable. 
This circle of diminished activity in the flow of the blood is what is termed 
congestion. It has been said that the red corpuscles select the centre of the 
vessels, thus leaving a space between them and the vascular walls which is 
occupied by white corpuscles (Fig. 124), the number of which appears to 
Fig. 122 
Uninflamed wing of the bat. After Paget. 
Fig. 123 
Inllanied wing of the hat. NATURE OF INFLAMMATION. 
107 
have greatly multiplied. These corpuscles, or leucocytes, seem to have a 
strong attraction for one another and for the walls of the vessels, to which 
they are disposed to adhere, their move- 
ments being much less rapid than those 
of the red. As the process advances, 
the crowding of the vessels with corpus- 
cular bodies reaches its limit, so that at 
and for a short distance around the 
focus of inflammation the blood-move- 
ment ceases: this state constitutes stag- 
nation or stasis. Nothing can more beau- 
tifully illustrate the difference in num- 
bers of the red and white corpuscles, and 
their relation to one another, and to the 
walls of the vessels, in the uninflamed 
and the inflamed state, than Figures 125 
and 126, which show the circulation in 
the mesentery of the frog under these 
two conditions, and which are faithful 
representations, drawn from nature, 
under the camera of the microscope, by 
I)r. E. O. Shakespeare. 
We have thus advanced three stages 
in the process,—determination, conges- 
tion, and stagnation. The different phe- 
nomena remind one very forcibly of a crowd of living beings in a great city, 
attracted towards some scene of excitement. On every side, along every 
street, lane, and alley, men, women, and children are seen running in hot 
haste, their faces all turned towards a common point: this is determination. 
As this central point is neared, the crowd is so closely collected that move- 
ment becomes slow and difficult, and the pace is slackened; some turn off in 
one direction, others in a different one; some retrace their steps, and others 
Fig. 124 
The position occupied by the red and white 
corpuscles. 
Fig. 125. 
Non-inflamed mesentery of the frog, 400 diameters, reduced a, a, venule with red and white 
corpuscles ; b, b, gelatinous nerve-fibre ; c, capillary; d, d, dark-bordered nerve-fibre; e, e, con- 
nective tissue with connective-tissue corpuscles and leucocytes scattered sparsely through it. 
press their way forward, jostling their neighbors without formality: this is 
congestion. Still farther inward, at the very focus of attraction, the throng 
is so densely packed that movement is impossible : this is stagnation. 
At the seat of stasis, or rest, the capillaries appear to be densely packed 
with red corpuscles alone, altered in form and apparently without any liquor 108 
I NFL A MM A TIO N. 
sanguinis. The cause of this stasis is, according to Ryneck of Gratz, due to a 
change in the vital properties of the capillary walls: the ground for such an 
opinion will presently appear. But perhaps the most astonishing part of this 
Fig. 126. 
Inflamed mesentery of the frog. 400 diameters, reduced % : a, 6, venule filled with red and white 
corpuscles; the red in the centre and the white crowding along the walls; c, c, capillary dis- 
tended with red and white corpuscles ; number of the white much increased; d, d, connective tissue 
between venule and capillary filled with migrated leucocytes; e, e, connective tissue with less 
infiltration; /, dark-bordered nerve-fibre; g, number of nuclei in sheaths increased. 
process is that which takes place with the slowing of the blood,'—namely, 
the passage of the latter from the interior to the exterior of the vessels. 
3. Passage of the contents of the vessels through the watls.—Various terms are 
employed to express this change of place of the vascular contents, such as 
“effusion,” “exudation,” and “migration.” I prefer and shall use the word 
transudation. There is a normal transudation which is constantly in operation 
to supply needful demands of the tissues: it is this which gives to the latter 
their moisture or succulence,—a kind of nutritive bath. The inflammatory 
transudation differs chiefly from the normal in a marked increase of the con- 
stituents of the liquor sanguinis, as well as in a larger number of corpuscular 
forms. It may occur from mechanical causes, altogether independent of in- 
flammation, as when a group of indurated glands press upon the axillary 
vein, or the gravid uterus upon the cava or iliac vessels, obstructing the 
return current of blood, in consequence of which the liquid portion finds its 
way through the porosities which, if it be true that physical particles are 
never in absolute contact, must exist in the walls of the vessels. The ana- 
sarca from hepatic and cardiac diseases is also of this nature. A familiar 
illustration of this can be witnessed in the leather hose of the firemen : under 
the pressure of the column of water the whole extent of surface sweats with 
moisture which has been pressed through its pores. This will not, however, 
account for the escape of the corpuscular part of the blood. The white 
corpuscles, or leucocytes, which linger about the sides of the A'essels, begin 
to penetrate their walls. They are seen to disappear gradually from the 
inside, and to appear on the outside, in the form of button-like prominences, 
or partly in and partly out of the vessel, in dumb-bell forms; these become 
pyriform, then remain attached by a delicate thread, and finall}r are entirely 
disengaged (Fig. 127), to wander off among the perivascular structures, by 
the amoeboid movements with which they are endowed. This passage is called 
a migration. Not only do leucocytes wander out of the vessels, but to some ex- 
tent also the red corpuscles. This is effected, according to one view, through 
minute stomata which are supposed to exist on the minute vessels along the 
lines of junction between the cells of their endothelium. It has been ob- NATURE OF INFLAMMATION. 
109 
jected that these stomata, many of which do not exceed one ten-thousandth 
of an inch in diameter, are entirely too small to admit the passage of a white 
corpuscle, a body averaging about one three-thousandth of an inch in diam- 
eter. Such an objection is without force when we consider the extraordinary 
change of form which the leucocytes undergo, and the not improbable dila- 
tability of the stomata themselves. Others, regarding the capillaries as con- 
sisting of protoplasm, do not deem the presence of stomata at all necessary 
to the migration, but simply contact of 
the protoplasm of the vessels with that 
of the white corpuscles, by which the 
walls open, and again close behind the 
leucocytes as they escape. The experi- 
ments of Byneck, if they do not prove 
conclusively that stomata exist, show at 
least that the act is a chemico-vital one, 
in which the walls of the vessels play a 
prominent part. By displacing the blood 
of curarized frogs and injecting in its 
place milk or defibrinated blood, and 
then irritating the mesentery, he was 
enabled to produce promptly the phe- 
nomena of determination, slowing, and 
transudation. Using a solution of com- 
mon salt to replace the blood, and then 
introducing a solution of chromic acid, 
or the sulphate of copper, so as to dam- 
age the vital properties of the walls of 
the capillaries, he found, upon transfusing with the milk or defibrinated 
blood, that neither stagnation nor transudation followed. There can be little 
doubt that the minute blood-vessels, which constitute a great irrigating net- 
work, sustain a relation to the work of nutrition which gives them an im- 
portance very different from that of the larger arteries and veins. They are 
indeed living tubes, and not simply canals of conduction. 
The blood undergoes not only a change of place, but also a change of con- 
stitution, which will be best understood by a comparison of its physiological 
and pathological characteristics. It is normally a very changeable tissue, 
and if a hundred analyses were made of the blood of the same individual, 
at a hundred different periods, no two would agree in all particulars. Still, 
this does not materially affect the comparison between inflammatory and 
non-infiammatory blood. The red and white corpuscles, when in physio- 
logical harmony with the demands of the tissues, bear a certain numerical 
relation to each other; that is, they are in the proportion of about four hundred 
red corpuscles to one leucocyte. It is true, some modification of this statement 
must be made in the case of the veins of the liver and spleen, in which the 
white corpuscles are much more numerous; and the same is true after a full 
meal. These corpuscles, again, in health are indiscriminately intermingled, 
and glide along without showing any disposition to loiter by the way. Now, 
in inflammatory disturbances of the blood-vessels the normal proportion is 
changed: the white corpuscles are increased in number, and remarkably so 
in inflammations of certain organs, such as the spleen and lymphatic glands, 
so as even to form one-half of the corpuscular part of the blood. As the 
red corpuscle is probably formed from the white, the cause of such increase 
would seem to be an arrest in the development of the latter. Again, in 
inflammatory blood, as has been stated, instead of moving promiscuously 
through the affected vessels, the corpuscles assume somewhat distinct posi- 
tions, the red in the centre, and the white along the sides. 
The transudation, in addition to leucocytes, consists of liquor sanguinis. 
This fluid, however, as found in the inflamed tissue, possesses certain notable 
chemical differences from that of uninflamed blood, which appear to have 
Fig. 127. 
Migration or transudation of leucocytes, or the 
passage of white corpuscles through the walls of 
the vessels. 110 
INFLAMMA TION. 
been acquired during or after its passage through the vessels. The liquor 
sanguinis of normal blood contains a large amount of albumen,—about one- 
tenth. A portion of this, when drawn from the vessels, undergoes quickly 
spontaneous coagulation, forming fibrin. It is the latter which produces the 
coagulation of the blood, forming a porous, gelatinous mass, or clot, in the 
meshes or interstices of which are entangled the corpuscles. If the coagu- 
lation takes place slowly, the corpuscles have time to sink to the bottom of 
the clot before being caught, which leaves its upper portion colorless, and 
forms what is known as the buffy coat. This upper part, wanting the resist- 
ance of the corpuscles, contracts more than the lower, so that the clot finally 
assumes the form of a truncated cone, the edges and upper surface of which, 
continuing to contract, give to the solidifying mass a concave or cupped shape. 
(Fig. 128.) In inflammation the fibrin is greatly increased, even to the extent 
Fig. 128. 
Section of a blood-clot, the corpuscles naving been washed out, leaving a sponge-like 
mass of fibrin ; the upper surface showing the cupped form. 
of three or four times the normal amount, as in cases of inflammation of the 
lungs and serous membranes, and in proportion to the increase is the extent 
of the huffy coat. How fibrin is formed, and what is its relation to nutrition, 
are questions which physiology has not as yet answered. As a concrete sub- 
stance, it does not exist in the blood; it only becomes so after leaving tha 
vessels. We have various theories explanatory of its formation, from the 
action of paraglobulin on certain albuminoid or fibrogenous substances, or 
from a substance called plasmine by Schmidt and Dennis, according to whom 
the variations in the amount of fibrin in coagulated blood are due to a 
decomposition of this plasmine unequally into “concrete” and “dissolved 
fibrin.” When, however, we consider that the fibrin is increased by bleeding, 
and by starvation ; that the blood of the hound or of the horse yields it in 
larger quantities after than before the chase or the race ; and that, as shown 
by the experiments of Brown-Sequard, it is increased by muscular action,—it 
appears most reasonable to regard it as excrementitious, or a product of tissue- 
waste, and therefore more naturally associated with destructive than with 
constructive processes. It seems to me that this substance, which takes 
no part in organization, has. nevertheless, a very important office.—one not 
unlike that of the scaffolding and temporary arch-supports of a building,— 
thus supplying a frame-work for the support of those organic forms which 
are immediately concerned in tissue-construction, and which, when this is 
sufficiently advanced, disintegrates and is removed, just as the scaffolding 
and arch-supports are taken down when the building is completed. 
The serum of the blood, the watery fluid in which the clot floats, contains 
in solution albuminous substances not spontaneously coagulable, and different NATURE OF INFLAMMATION. 
111 
saline ingredients, the latter making as much as ten parts in the hundred. 
N o w, in inflammation there is a change. The albumen, phosphates, carbonates, 
and chlorides, especially the chloride of sodium, are largely increased. Beale 
states that in inflammation of the lung the organ becomes loaded with chlo- 
ride of sodium, while it disappears almost entirely from the urinary secretion. 
Still, there is no constant uniformity in the constitution of inflammatory 
transudations. Sometimes they are quite fluid, possessing little fibrin, and 
exhibiting no tendency to organization, as when a rapid transudation follows 
inflammation of the pleura, forming a hydrothorax in one person, while in 
another a few hours will be sufficient to glue the contiguous layers together 
by a bond of fibrin. Or, we may have in one case a transudation into the 
cavity of a joint, as thin as water, which never assumes the importance of 
an organized tissue, while in another fibrous bands are formed, which pro- 
duce a form of anchylosis. Paget recognized two kinds of transudation : 
one tending to adhesion or organization,—fibrinous lymph,—and the other 
to suppuration,—corpuscular lymph; the first rich in fibrin, the last in cor- 
puscles. In inflammatory irritation of mucous membranes—catarrh, for 
example, of the nose—the transudation may be thin and watery, a mere 
exaltation of gland-function, or hypersecretion, with rapid epithelial detach- 
ment ; or it may be purulent, in which case there will be an active prolifera- 
tion of the protoplasm of the deep layer of the epithelium and transuded or 
migrated leucocytes ; or it may assume the consistence of a false membrane, 
as in croup, spreading over the surface of the trachea, adapting itself to every 
inequality of its surface, and made up of a stratification of solidified fibrin 
with interposed and interpenetrating cells. 
These transudations, again, are often modified by the products of textural 
change, intermixed with particles of disorganized tissue, such as shreds of 
the fasciae, lime-salts, fatty matters, and blood-corpuscles. These masses of 
blood, which are so often seen in transudations, occur from two different 
causes: in one these corpuscles are present by migration, whilst in the other 
they are present from actual rupture of the overstrained vessels, and form, 
therefore, a hemorrhage or apoplectic extravasation. 
The escape of the transudation is followed by infiltration. Both the liquid 
and the corpuscular constituents which have thus escaped from the vessels 
spread through the peri- 
vascular structures (Fig. 
129). finding their way into 
every crevice and space, 
and interpenetrating often 
the finest components of an 
organ, wedging them asun- 
der, crowding and com- 
pressing nerves and blood- 
vessels, and thus giving 
rise to pain or preventing 
access of the blood to or 
escape from a part, in 
many cases inducing a 
wide-spread devastation of structure. This infiltration spreads from the 
operation of several causes, such as the impetus communicated by the intra- 
vascular pressure, gravitation, and the locomotor or amoeboid endowments 
of the corpuscles. It is this infiltration which chiefly gives rise to the swell- 
ing in inflammation, and upon its quality will depend the consistence of the 
intumescence. When very thin and watery it will be soft, as in oedema, but 
when possessing much fibrinous matter it will be firm and resistant. 
4. Change in the nutrition of the perivascular tissues.—Thus far we have been 
occupied with nerves, blood-vessels, and the blood; but we have now to con- 
sider the influence of inflammation upon the tissues external to these. When- 
ever a part is invaded by a transudation of inflammatory liquor sanguinis 
Fig. 129. 
Inflammatory infiltration. 112 
INFLAMMATION. 
it is the signal for an extraordinary degree of cell activity. Whence come 
these cells, and what is their origin, are questions which have received especial 
attention, is their presence due to the germination or proliferation of those 
which normally belong to the inflamed tissue, stimulated into reproductive 
activity by the influence of the transudation upon their quiescent protoplasm, 
or do these cells come from abroad, as emigrants which have wandered out 
of the contiguous vessels, and, vandal-like, have overrun the tissues ? Both 
views have their advocates. The non-vascular tissues, with a view to deter- 
mine this problem, have been selected as peculiarly adapted to such study. 
The most conclusive of these investigations are those made by Professors 
Norris and Strieker,* at the Institute for Experimental Pathology in Vienna, 
on the subject of traumatic keratitis produced in the cornea of the frog. 
That the bearing of these may be properly understood, it may be necessary 
to state that preparations of 
this structure should be made 
after the method of Von Reck- 
linghausen, which consists in 
immersing the cornea, with 
its lining membrane upward, 
in a few drops of the aqueous 
humor drawn from the eye, 
and examining it under cir- 
cumstances which will prevent 
evaporation, — that is, in a 
chamber where the air is sur- 
charged with moisture. Un- 
der such circumstances the 
cornea appears to be entirely 
homogeneous, without the 
least evidence of structure, 
and is therefore admirably 
adapted for the transmission 
of light. As soon as its vitality begins to decline, the structureless character is 
lost, its epithelial cells, leucocytes, and corneal corpuscles become visible, and 
the membrane a little less transparent. In the experiments alluded to, it 
was found that very soon after the application of a point of nitrate of silver 
to the cornea its structural elements became apparent,—namely, the epithe- 
lial layer, together with a number of white corpuscles,—and still later the 
cornea corpuscles with their nuclei and radiating processes were visible. Not 
only so, but the peculiar amoeboid movements were observed. Thus far it was 
quite apparent that the protoplasm of these inert, dormant masses of formed 
material had been penetrated by some new revivifying force. (Pig. 130.) In 
addition to the phenomena just detailed, other round bodies besides the nuclei 
were seen lying in the centre of the corpuscles, foreshadowing the future 
proliferation or multiplication of cell forms. Following the process further, 
a few hours later many of the corpuscles were found to have undergone 
another change,—that is, they became granular, at the same time retracting 
their rays,—and this continued until these processes entirely disappeared, 
and nothing was seen within the field of view but multiform, irregular-shaped 
masses, containing a brood of new cells. (Fig. 131.) Still later the multi- 
plication of these bodies became more and more apparent, and after the 
lapse of twenty-four hours the increase of new forms was so rapid that 
the whole tissue became clouded and inundated with their presence. (Fig. 
132.) At the beginning but few leucocytes were visible, but at the stage 
just described their numbers had become countless, and suppurative kera- 
titis was established. What interpretation shall we place on these phenom- 
ena? Whence came this flood of leucocytes, rendering the structure so 
Fig. 130. 
Cornea of a frog three hours after its removal: showing the cor- 
puscles with their rays and the round masses lying in their bodies 
after irritation with nitrate of silver.—From Norris and Strieker's 
Studies. 
* Versuche iiber Hornhautenziinduug, von W. F. Norris und S. Strieker, Wien, 1869. NATURE OF INFLAMMATION. 
opaque ? Certainly not from the few cells native to the part; not by emi- 
gration, for there were no vessels in the cornea whence they could come; 
we are forced to the conclusion that they originated chiefly from the corneal 
corpuscles by proliferation, and 
from the basis substance being 
converted into cells. 
On the other hand we have 
Cohnheim, whose views do not 
accord with these observations, 
lie maintains that the leuco- 
cytes, or pus-corpuscles, which 
appear in corneal inflammation 
are all emigrants, and that the 
normal corpuscles do not in any 
way participate in or contribute to 
their supply. Burdon Sanderson 
states that Cohnheim’s observa- 
tions on traumatic keratitis began 
at a point of time where those of others ceased. This would disqualify him 
for pronouncing upon the earlier changes in the histological elements of the 
structure. 
In cartilage we have phenomena resulting from irritation which furnish still 
stronger evidence that emigration is not exclusively the source of pus-corpus- 
cles, as the cartilage-cell buried in the intercellular matrix under traumatic 
stimulation enlarges, becomes granular, and, by division of its nuclei, filled 
with crowds of new cells, answering to pus-corpuscles, and which subsist upon 
the intercellular substance, giving it a worm-eaten or porous appearance. 
Cartilage, indeed, formed the sub- 
ject of the first experiments which 
were made to show the division of 
cells as the result of inflammatory 
irritation, by Redfem, of England. 
The vascularity of connective tis- 
sue renders it difficult to deter- 
mine, in consequence of the rapid 
emigration, the exact behavior of 
its stable or fixed components; 
but the patient observations of 
Strieker prove that under irrita- 
tion they swell, become mobile, 
and send out processes; and al- 
though he wTas not able to say 
that he witnessed their actual di- 
vision, yet in the activities noted 
it was difficult not to believe that 
they contributed their part in the 
formation of pus, though perhaps generally at an advanced stage of the 
process. 
The experiment of Prof. Lortet, of Lyons, illustrates in a very simple man- 
ner the conjoined participation of emigrant and connective-tissue corpuscles 
in the production of pus. It consisted in introducing into the cellular tissue 
beneath the skin of a rabbit the swimming-bladder of a fish, containing a 
solution of salt. When removed after several hours, it was found full of emi- 
grant cells, which of course must have come from the vessels, but, in addition, 
the corpuscles of the surrounding connective tissue were in a state of active 
cell proliferation. 
The effect of inflammatory irritation on muscular tissue has been studied 
by Waldeyer, Weber, Strieker, Simon, and Tschainski, the result of whose 
investigations appears to establish the fact of the germination of the con- 
113 
Fig. 131. 
Irregular-shaped masses containing broods of new 
cells. 
Fig. 132. 
Cornea of a frog sixteen hours after irritation : showing the 
numerous groups of new cells. 114 
INFLAMMA TION. 
nective-tissue or stable corpuscles of the finer ramifications of the sheath 
and the intrusion of wandering cells. (Fig. 133.) These cells, in all proba- 
bility from these two sources, finally become so numerous that they take the 
place entirely of the sarcous 
elements; that is, they not 
merely displace, but really 
destroy, the muscular sub- 
stance contained in the fibre- 
sheaths. (Fig. 134.) Exam- 
ples of such changes are 
often seen in the muscles 
in the vicinity of an old 
necrosis, where the long- 
continued inflammation has 
left little else than fibrous 
tissue, oil-drops, and cell 
forms. 
Bone, also, hard and unyielding as it is, when attacked by inflammation 
undergoes nutritive changes very quickly. Its canals enlarge, becoming filled 
with cells: some from the vessels of the Haversian and medullary canals, 
and others from the myeloid cells of the medulla. These exacting organisms 
compel a separation in the animal and earthy constituents of the structure, 
which are in a great measure re- 
moved by mechanical and chem- 
ical transformations, giving to the 
bone a porous, gnawed, and worm- 
eaten appearance, and making it 
so brittle as to break down under 
the slightest pressure. 
Blood-vessels, when falling a 
prey to inflammation, exhibit great 
numbers of cells, which are derived 
from their nutritive branches and 
penetrate the inner tunic, with 
others which have their genesis in 
cells of the coat itself. 
When glandular organs become 
inflamed, the same increase of cor- 
puscular bodies is witnessed. And 
it is to be inferred that these have three origins or sources: viz., from the 
cells of the gland; from migration; and from the stable connective-tissue 
corpuscles of the gland. 
In the inflammation of mucous membranes, the epithelial and mucous cells 
not only increase by multiplication, but wandering cells appear in great force. 
In the fauces, as shown by Bindfleisch, the entire formation consists almost 
wholly of cells which are linked to one another by outgrowths, and which, 
together with a change in their protoplasm, form a closely-set net-work. 
(Fig. 135.) So in the false membranes of the trachea, which prove so mechan- 
ically obstructive to respiration, the same abundance of cell forms is seen 
reposing upon and interpenetrating fibrinous planes of transudation. In 
inflammatory, purulent, or other catarrhs of mucous membranes, we have 
illustrations of multiplied cell forms, whatever may be their origin (Fig. 136), 
though perhaps in the earlier history of such the increase may be referred 
more to proliferation than to emigration. 
Serous membranes, under the influence of inflammation, exhibit great 
activity in the protoplasm of their epithelial cells, and abound in wandering 
leucocytes, which, supported in a scaffolding of fibrin, pass, with the peculiar 
intercellular material present, from the mobile to the fixed or stable condition, 
forming connective tissue, and so become a bond of union between contiguous 
Fig. 133. 
The protoplasm of the fibre-sheath connective-tissue corpuscles 
becoming active, as seen in the multiplication of nuclei.—From 
Norris and Strieker’s Studies. 
Fig. 134. 
Transverse section of an inflamed muscle. The dark, 
irregular masses represent bundles of muscular fibres 
changed; while the other parts show two fibre-sheaths 
completely occupied by cells having displaced sarcous 
matter, and the intermediate connective tissue filled with 
crowds of proliferating cells.—From Weber. HISTORY OF THE CAUSES AND NATURE OF INFLAMMATION. 
115 
surfaces, or, when not in contact, produce a kind of fleecy or frost-work pile 
over the surface. 
Thus we see that inflammation, wherever found, is characterized by extraor- 
dinary cell activity 
both in those elements 
which are native and 
in those which are for- 
eign to the tissue in- 
volved ; that the cause 
of this activity is 
the abundant transu- 
dation ; that the cause 
of the abundant trans- 
udation is an extraor- 
dinary amount of 
blood, and a vital 
change in the walls of 
the capillaries, allow- 
ing the blood to pass 
through ; and that the 
cause of this unusual 
amount of blood and 
its transudation is an irritation, either external or internal, acting upon the 
walls of the vessels through a vascular system of nerves. 
In normal nutrition, the want of the tissues—that is, their demand for 
nutritive material—is communicated to the blood-vessels through the vaso- 
motor nerves. It is a kind of irritation, and it is this gentle, ever-acting 
stimulus which secures the 
due amount of blood-supply; 
transudation both of liquid 
and of formed material is 
ever going on to meet it, aaid 
there is a constant decay and 
renewal of cell life. 
The more carefully we 
analyze and compare the 
phenomena of normal nutri- 
tion and inflammation, the 
more we are disposed to for- 
mulate them into a single 
compact statement, and con- 
clude that inflammation is a 
disordered nutrition carried 
on under such an extrava- 
gant plenum of supply that the germination and mutation of cell life are 
generally too hurried to mature, and are therefore unstable and short-lived. 
Fig. 135. 
Section of the croupous layer from the fauces: a, b, croupous membrane 
made up almost wholly of cells with processes forming a cell net-work; c, 
natural mucous membrane underlying.—From Rindiieisch. 
Fig. 136. 
Purulent catarrh of the conjunctiva: a, a, epithelium; 6, sub- 
mucous connective tissue; the outermost cells lire pus-cells.—Prom 
Rindfleisch. 
History of the Causes and Nature of Inflammation. 
The student of the present day finds himself pressed on every side with 
the facts of the living present, and rarely finds leisure to trace back over the 
centuries the stream of medical literature: therefore it may not be amiss to 
make a rapid review of the theories which have at different periods been 
entertained upon the subject of inflammation. Hippocrates, who lived four 
hundred and sixty years before the Christian era, believed that this, with 
almost all other diseases, was produced by changes in the humors, which he 
styled coction, such as the lateritious deposits in the urine at the termination 
of a paroxysm of fever.* Erasistratus, who flourished one hundred years 
* Works of Hippocrates, Syden. Soc. Ed., vol. i. pp. 176-270. 116 
INFLA MM A TION. 
before the same era, a man of remarkable ability and independence of thought, 
offered a different explanation, originating, no doubt, in the erroneous notions 
entertained in regard to the circulation: “ Should the air coming from the 
heart force the blood back into the extremities of the arteries, it becomes 
impacted there and produces inflammation.” Celsus,* contemporary with 
Christ, confined himself to describing the symptoms of inflammation and its 
treatment, and was the author of the celebrated formula, “ Rubor et tumor, 
cum ealore et dolore.” Galen, the greatest of the Greek physicians after 
Hippocrates, and who died about two hundred years after Christ, used very 
much the same terms in describing the phenomena of inflammation as those 
employed by Celsus, giving as the cause an afflux of the blood. His four 
humors consisted of blood, serum, bile, and black bile. “ The food,” he says, 
“ if badly digested, becomes corrupted, and the blood charged with these 
corrupted matters creates heat and swelling in parts in which itrots.”f The 
Arabian school, with Avicenna as its ablest expounder, was governed alto- 
gether by Greek antecedents, and furnishes nothing new. Coming down 
to 1520, we learn from the writings of a representative man of that period, 
Ambrose Pare, that for thirteen hundred years not one step had been taken 
towards a more rational understanding of the process, and that on this subject 
the discoverer of the ligature knew no more than those who had preceded 
him. Richard Wiseman, who flourished and wrote extensively in the seven- 
teenth century, only reiterated the doctrines of Galen. About 1675. a doc- 
trine of which Yan Helmont was the principal expounder taught that a 
sentient principle, “ archams,” existing in the body, and which was offended 
by acidity, etc., sent the blood to a part to produce inflammation. Thomas 
Willis, an English physician, one of the first members of the Royal Society, 
and who was deemed worthy of burial in Westminster Abbey, attributed 
inflammation to obstruction in the vessels from the blood becoming too ad- 
hesive through an accumulation in it of sulphur.j; Archibald Pitcairn, a 
Scotch physician, distinguished for bis poetical and mathematical abilities, 
the preceptor also of Boerhaave, and whose writings occupy a conspicuous 
place between the years 1660 and 1723, makes all diseases to consist in 
changes in the quality or velocity of the blood. Inflammation he defines 
to be stagnation of the blood in the vessels of the part affected, and due to 
its viscid nature.§ 
The discovery of the circulation could not fail to introduce more enlightened 
views upon a subject so palpably connected with the blood, and hence from 
Pitcairn’s time its influence is seen in shaping the doctrines of medical writers. 
Boerhaave, in writing upon this subject, says, “ the stagnation of the blood is 
caused in the smallest arteries by whatever makes the ends of the vessels, in 
their cones and cylinders, so narrow that the diameter of their orifices is 
made less than the diameter of the blood-globules ; the latter being pushed 
on by the remaining vital strength produce the effects of the present inflam- 
mation.” De Gorter, another of the eminent men who gave reputation to 
the great school at Leyden, attributed the cause of inflammation to a greatly 
increased vital motion in the stimulated part.|| Stahl, the distinguished 
physician and chemist, the author of the doctrine of Phlogiston, made in- 
flammation to consist in stasis of the blood 
Hoffmann’s definition of inflammation was, “ stasis in the capillaries of a 
part into which the blood was driven by spasm of the arteries which pre- 
vented its equal circulation.” This doctrine of spasm was destined afterwards 
to play an important role in the system of Cullen. The period between 1706 
and 1766 was celebrated for the introduction of certain terms and the an- 
nouncement of doctrines which, although improved by physiological experi- 
* Celsus de Medicin!,, lib. iii. chap. x. 
f De Humoribus, ed. Huhn, vol. xvi. p. J31. 
j Works, fob, Lond., 1684, Pharmaceutiae Rationalis, part ii. p. 59. 
g Physico-Mathematical Elements of Medicine. 
|[ De Sorter on Vital Motion, 1737. 
Systematic Medicine, Theoretic Part, sect, ii., Pathol., Halle, 1707, p. 246. HISTORY OF THE CA USES AND NATURE OF INFLAMMATION. 
ment, have ever since formed a part of our medical and surgical language, 
and have only within a comparatively short period received their full inter- 
pretation. When a part is exposed to injury it attracts to itself an unusual 
amount of blood. This power was termed “ irritation,” or “ irritability.” It 
assumed a certain susceptibility or property in a tissue or organ to recog- 
nize impressions, and to respond to such when of a certain kind, as in inflam- 
mation, by determining an afflux of blood to the same; and thus we find 
Boissier de Sauvages demonstrating on a kitten’s ear, in some respects, the 
same phenomena which Hunter exhibited in the rabbit’s ear, Paget in the 
wing of the bat, and still later others in the mesentery of the frog,—namely, 
an increased vascularity upon the application of a stimulus. During this 
same period the influence of the nerves within the walls of the blood-vessels 
upon the circulation was clearly announced by Borden, and still more clearly 
by the Scotch physiologist Whytt, the successor of Sinclair in the University 
of Edinburgh, who affirmed that the action of the small vessels in inflam- 
mation was due to the influence of the nerves.* 
Coming down to the last century, the student will find the subject of in- 
flammation largely discussed in the writings of one of the most remarkable 
men that have ever adorned our profession. Not only was he a great medical 
philosopher, but he was also a marvel of patient industry. His entire life was 
comprised within a period of sixty-five years, in about thirty of which he not 
only built up a great museum and trained many eminent surgeons (among them 
Abernethy, Sir Astley Cooper, Sir Everard Home, and others), but also pro- 
duced works which ruled English medical thought with almost unchallenged 
sway for nearly half a century after he was dead. Hunter did not regard in- 
flammation as a disease, but as a salutary operation consequent upon violence 
or some disease.f Believing in a certain kind of union of divided parts 
without inflammation, that which is now called “ immediate union,” he defined 
inflammation as that “action which is produced for the restoration of the 
most simple injury in sound parts, which goes beyond the power of repair by 
the first intention.” He believed in the existence of a principle dwelling in 
the body,—in every part of the body,—an intelligent, vital power, which pre- 
sided over inflammatory as well as other processes, the results of which were 
based upon their utility. In other words, Hunter believed in a principle, an 
entity, residing in, and united with, every part of the body, yet independent 
of it; an essence possessing intellectual and moral endowments, and which, 
standing like a sentinel on every watch-tower, always on the alert to detect 
every injurious or hurtful intrusion, called into action, for specific definite ends, 
those operations which we call morbid. In this particular his system rested 
upon a foundation not unlike that of Van Helmont, Stahl, and others. In 
reference to the capillaries, their fulness in inflammation was not regarded 
as being caused by relaxation, but by active distention. He was the enemy 
of the doctrine of humors. The blood he believed to be a living fluid, fibrin 
its most important element, and he esteemed its power of coagulation as akin 
to the property of contraction possessed by a muscle. He divorced inflam- 
mation and repair, and taught surgeons that suppuration was not necessary 
to the healing of wounds. He made seven varieties of inflammation,—ad- 
hesive, suppurative, ulcerative, gangrenous, cedematous, erysipelatous, and 
carbuncular. 
We come now to a period when the microscope was introduced into medi- 
cine as a means of investigation, shortly before the year 1768. The tissues 
which, from their transparency, furnished the most satisfactory demonstra- 
tion of the circulation in the minute vessels, were the foot and mesentery 
of the frog; and it was after witnessing the movements of the blood 
through the capillaries of the latter that FabreJ declared that obstruction 
in these could not be a necessary condition of inflammation, for when one 
117 
* Whytt’s Physiological Essays, 1755. 
f Hunter’s Treatise on Blood, Inflammation, etc., 1793. 
j Fabre, Essays on Physiology, Pathology, etc., Paris, 1770. INFLAMMATION. 
118 
vessel became blocked the blood immediately sought other channels; and 
he immediately arrived at the same conclusion with Borden and Whytt, 
that the nerves attract the blood towards the place in which the}* are 
stimulated. Dr. Wilson Phillip, from contemplating the same phenomena, 
concluded that debility of the capillaries was the initial step in inflammation, 
inducing retardation of the blood, which obstruction provoked increased 
action in the contiguous arteries. During the early years of the present 
century, certain terms were introduced, such as the “pouring out,” in inflam- 
mation, of serum, fibrin, etc., by Mr. Dowler; or the “ effusion” of liquor san- 
guinis, by Dr. Babington ;* and we may now say that two things had been 
generally conceded in the study of inflammation : 1, that the capillaries played 
an active part; and, 2, that the process was attended with an exudation. This 
exudation or pouring out, Mayo, in his “ Outlines of Pathology,” believed to be 
due to obstruction of the circulation in the inflamed part. This same author 
asserts with great earnestness that he clearly recognized in his microscopical 
observations the transformation of the blood-globules into pus, and thus antici- 
pated what has been recently accepted as the doctrine of pyogenesis. Macart- 
ney f attributed to the sympathetic nerve, or to what he called the “ organic 
consciousness” derived from that nerve, the first place in the production of in- 
flammation, and concluded that the tonic dilatation of the capillaries was in- 
duced by the organic sense of injury or danger. He added to the local signs of 
inflammation “ an alteration or suspension of the natural secretions of a part,” 
and explained the redness as being caused by the minute capillaries which, 
when dilated, admitted red globules, but which in the normal condition con- 
tained only colorless serum. Macartney was an advocate of the doctrine of 
Hunter, that inflammation was not necessary for the repair of tissue. The dim 
shadowings of the vaso-motor system can be discerned in Macartney’s teach- 
ings. About the year 1838, two German anatomists, Schwann and Schleiden, 
while pursuing their physiological studies, the former in the vegetable and the 
latter in the animal kingdom, discovered that the structures of both were alike 
made up of minute microscopic organisms or cells. These cells were supposed 
to arise from a homogeneous material,—blastema,—and by their various com- 
binations and differentiation the different tissues were formed. It was upon 
this important announcement of the cell doctrine that Dr. Bennett constructed 
his theory of inflammation, regarding the process as one of modified nutrition, 
the contraction and dilatation of the capillaries being due, the first to spasm, 
the last to paralysis. The enlargement of the vessels allowed a larger amount 
of blood than natural to crowd into their channels, while the cell attraction of 
the tissues determined an exudation of the liquor sanguinis, the presence of 
which constituted inflammation. The the*Hy of Bennett excluded both the 
vascular and the nervous system from actively, at least, participating in these 
results. In fact, the cell doctrine filled so largely the vision of physiologists 
and pathologists, that the blood-vessels were degraded to the position of mere 
conduits and carriers, the constructive and destructive builder being the cell, 
while in inflammation the exuded liquor sanguinis of an impure or vitiated 
quality interpenetrating the tissues constituted the pabulum for strange 
cell growths. Between the years 1841 and 1843, two very important dis- 
coveries were made by William Addison and Dr. Williams, both of England. 
Addison,J in speaking of the circulation in the frog’s foot when inflamed, 
clearly recognized the distinction between the red and the white corpuscles,— 
the different positions which they occupied in the vessels,—the red moving 
along the centre and the white sticking to the circumference. He also asserted 
the identity of pus and the white corpuscles. Dr. Williams,§ in 1841, noticed 
the similarity between the corpuscular constituents of inflammatory exuda- 
tions and the white corpuscles, and expressed the opinion that these passed 
*• Medico-Chirurgical Transactions, vol. xvi., 1831. 
f Macartney on Inflammation, 1838. 
j London Medical Gazette, December 18, 1840; January 11, 1841. 
$ Practice of Medicine, 1848, 3d American edition. HISTORY OF THE CA USES AND NATURE OF INFLAMMATION. 
through the walls of the vessels in the form of nuclei, and after their escape 
developed into pus- or lymph-corpuscles. He also observed an increase in 
the number of white corpuscles in the vessels of an inflamed part, and at- 
tributed the phenomena of inflammation to capillary obstruction, produced by 
viscidity of the blood from the presence of an unusual number of white cor- 
puscles, and also to increased action of the capillaries. In 1842, Emmert* 
in speaking of the action of the vessels in inflammation, recognized a pri- 
mary contraction followed by dilatation, and asserted that between the walls 
of the vessels and the corpuscles there existed an attraction, and that this 
attraction was antagonistic to a contracted condition of the vessels. In the 
same year Vogel f taught that in inflammation the irritant, be it what it might, 
acting through the nerves, induced a vital attraction between the blood and 
the tissues. In this way stagnation took place, the vessels dilating simply by 
the accumulation of blood. The exudation following was attributed to this 
same attraction. 
Alison]; believed that inflammation consisted in a local increase of a vital 
property of attraction among the particles of blood, and between them and 
the surrounding textures, and that the proximate cause of this process was 
to be sought as much in the influence of the solids upon the blood while 
passing through the vessels as in the blood itself. The chief reason assigned 
for such a view was the limitation of disease to a definite or circumscribed 
locality. 
The pathological work of Rokitansky appeared between 1842 and 1846. 
This author makes blood crasis the central doctrine, asserting that all local 
diseases are determined by a primary blood constitution, which he terms a 
crasis or dyscrasis. According to this view, inflammation was the result of a 
fibrinous crasis, and exudation rather a mechanical process, due to an at- 
tenuation of the walls of the vessels from distention ; and when transuded 
upon the surface of the membranes, such as the serous or the mucous, it was 
in consequence of the least resistance being in that direction. He does not 
deny, however, that local disease may create a general or blood dyscrasia. 
In 1846, Augustus Waller § witnessed, and was the first to describe, the 
passage of the white corpuscles through the walls of the vessel,—a very 
remarkable phenomenon, which, since 1863, has been still more satisfactorily 
demonstrated by Von Recklinghausen, Max Schultze, and Cohnheim, distin- 
guished names belonging to the German school. 
Wharton Jones, in 1851,|| in a paper on inflammation, after carefully con- 
sidering the phenomena presented by the web of a frog’s foot, arrived at the 
following conclusions: 
1. That the contraction of the vessels and repulsion of the blood-corpuscles 
from one another and from the walls of the vessels, and the consequent accel- 
eration of the circulation, are results due to neiwous influence. 2. That dilata- 
tion of the vessels, and an attraction of the blood-corpuscles for one another 
and for the walls of the vessels, are caused by diminished nerve-influence. 
3. That stasis, or stagnation, is the result of both combined. 4. That the 
exudation of serum which begins with the stasis is due to obstruction in the 
vessels, and that of plasma, from attenuation of the walls of these vessels 
from distention and pressure against their interior. 
Thus far, it will be perceived, there has been a tendency to explain inflam- 
mation by searching for some single cause, or to make it consist in a certain 
condition. In 1853 the Lectures of Mr. Paget on surgical pathology were 
published. In these we find a broader and more philosophical treatment of 
the subject. He first endeavors to establish the conditions of healthy nutri- 
tion,—namely, 1, a regular and not far distant supply of blood; 2, a right 
* Beitrage zur Pathologie und Therapie, Heft i., Berne, 1842. 
t Wagner’s Handworterbuch der Physiologie, art. Entziindung, Gottingen, 1842, p. 317. 
J Outlines of Pathology, etc., 1844. 
$ Philosophical Magazine, vol. xxix., 1846, p. 397. 
|| Guy’s Hospital Reports, vol. vii., 1851. 120 
INFLAMMATION. 
state and constitution of the blood; 3, a certain influence of the nervous 
force; and, 4, a natural or healthy state of the part. In inflammation all 
these conditions are altered. Mr. Paget’s experiments were made upon the 
wings of bats, which removed the objection so often made, that conclusions 
drawn from phenomena witnessed in cold-blooded animals were unsafe data 
upon which to construct a theory for similar processes in man. Various stimuli 
were applied, such as scratching with a needle, acetic acid, capsicum, and the 
pointed cautery, and the phenomena observed were sudden contraction and 
subsequent dilatation of the vessels, with diminished velocity in the blood- 
current during the first, and a rapid flow during the last, of these changes. 
This dilatation, with increased rapidity in circulation in the damaged part, 
constitutes the active congestion or determination of authors. After a short 
period he noticed that the movement of the blood became slower, now ebbing 
and then flowing, until finally in some vessels it ceased entirely, so that at 
the centre or focus of the inflamed part there was stagnation more or less 
complete ; around this, fulness with slowness of movement,—congestion; and 
still more externally, fulness with activity of movement,—determination. In 
addition, Mr. Paget noticed, what had been previously observed by Kolliker, 
a varicose condition of the capillaries (Fig. 137), and a pulsation in the veins, 
first discovered by Wharton Jones. 
As to the causes which induce the blood-changes noticed in inflammation, 
he acknowledges that these have not been removed from the domain of 
theorjq and therefore offers no speculation. The same statement is made in 
regard to the agency of the nerves, 
—that while there is abundant 
evidence, in the modified sensa- 
tions of an inflamed part, that 
they are in some way concerned 
in the process, the exact relation 
which they bear to the disturb- 
ance is not, in the present state 
of our knowledge, demonstrable. 
Lastly, the changes in the part 
itself Mr. Paget makes to consist 
in the natural degeneration of 
structure, which is intensified by 
the altered conditions of nutri- 
tion, and its interpenetration of 
substance by the products of the 
inflammation. It will be seen 
from these remarks that this dis- 
tinguished author regards inflam- 
mation as a destructive process, 
—one of decay; and that when constructive force is manifested the 
resulting tissues are unstable and temporary. 
In 1858 was published the “ Cellular Pathology” of Virchow, in which the 
idea of a living organism like the cell originating from a formless blastema, 
or what is sometimes termed free-cell development, was refuted, and the 
doctrine of every cell depending for its existence upon a pre-existing cell 
was placed upon a solid and rational foundation. With Virchow the active 
agency in inflammation was transferred from the blood-vessel to the cell of 
the connective tissue. It is the cell changed in its nutrition which attracts 
the contents of the vessels ; the vessels are dilated by paralysis, nothing but 
serum can escape from them unless by rupture, and the cell forms are only 
the proliferation of the connective-tissue cells. The initial cause with Vir- 
chow was irritation, thus reviving an old term which has lately figured in the 
explanations given of this process. 
In 1861, Lionel Beale, the distinguished microscopist, made public certain 
views which conflicted with the cell doctrine of Virchow, especially as to form, 
Fig. 137. 
Varicosities of the capillaries of an inflamed part.— 
From Paget. HISTORY OF THE CA USES AND NATURE OF INFLAMMATION. 
121 
not as to function. These views were based upon the theory of protoplasm. 
That which corresponds to the cell is in the system of Beale termed a mass 
of formative or germinal matter, spherical particles extremely minute. This 
microscopic particle is a living substance, possessing the power of amoeboid 
movements, or of sending out shoots or buds and thus multiplying itself to a 
degree beyond computation. These masses of germinal matter are surrounded 
with what he calls formed-material,—really dead material,—formed by the 
germinal masses and elaborated from the blood. To illustrate : anatomists 
describe cartilage as consisting of a hyaline matrix, with cartilage-cells em- 
bedded in its substance. According to Beale, it should be formed-material, 
with embedded masses of germinal matter. Beale’s doctrine would class con- 
nective tissue as formed or dead material, incapable of performing any life- 
actions whatever, and therefore destructive to Virchow’s favorite notion of the 
cell proliferation of this tissue. Inflammation, with Beale, is not the result 
of irritation, nor yet a chemical process, but an excessive supply of pabulum 
or blood, inducing active growth and multiplication of the germinal masses. 
When the capillaries are distended with blood, formative matter passes 
through the walls of the vessels and greatly multiplies in the extravascular 
spaces. The heat of inflammation he thought was the result of the rapid 
formation of germinal matter, and in his scheme the part performed by the 
nerves was secondary. Nucleated fibres are distributed to the capillaries 
and the intermediate tissue,—the first efferent, the last afferent. When a 
large amount of pabulum or blood is attracted to a part in which nerve- 
fibres of the latter class are distributed, the consequent swelling must com- 
press these fibres, the stimulus of which, conducted to the vaso-motor centre, 
will induce, through efferent cords, capillary contraction, and in this way 
diminish the congestion or plethora by lessening the amount of pabulum or 
blood. If, however, the pressure from the attracted pabulum in a part con- 
tinue for some time, the nerves may be paralyzed, and thus allow the vessels 
to dilate and to become surcharged with blood, constituting congestion. This 
was Beale's self-regulating system. 
In 1863, Von Recklinghausen* directed his investigations to a process which 
Lieberkiihn as early as 1854, and afterwards Virchow, had noticed in a gen- 
eral way.—namely, the amoeboid movements of white blood-corpuscles, or 
what are now generally called leucocytes. He found that their movements 
were of the same nature with those of amoebae, and therefore that they wrere 
capable of moving from place to place. This locomotive power was shown by 
putting into the lymph-cavity of a frog the cornea of a rabbit, after injecting 
vermilion into the sac. On the occurrence of inflammation the cornea was 
found filled with leucocytes red with particles of vermilion, and similar in 
every detail to the pus-corpuscles in the lymph-cavity. The manner of 
movement is very curious. The little mass, perhaps at first spherical, 
sends out a filamentous process, sometimes several, one diminishing or re- 
ceding as another elongates; the contents of the cor- 
puscles run into the process, thus moving it,—the ac- 
tion reminding one of an insect using its antennae and 
limbs. (Fig. 138.) The power of receiving into their 
substance foreign matters was also shown by injecting 
milk into the lymph-sac of a frog, and finding the leu- 
cocytes filled with milk-globules. When these bodies 
were observed upon inflamed surfaces, as on a serous 
membrane, Recklinghausen supposed they had origi- 
nated by proliferation and migration of connective-tissue corpuscles. The 
remarkable contributions of this investigator opened up the way for still 
further progress, for in 1867 Cohnheimf announced the migration of the white 
corpuscles in inflammation from the interior to the exterior of the vessels, 
and that pus-corpuscles and white blood-corpuscles or leucocytes are identical. 
Pig. 138. 
Leucocytes. 
* Virchow’s Archives, vol. xviii., 1863. 
+ Ibid., vol. xl. 122 
INFLA MM A TION. 
The phenomena of inflammation witnessed by Cohnheim in the mesentery of 
a frog which had been curarized were as follows: dilatation of the arteries, 
followed by that of the veins; at the commencement, acceleration, soon fol- 
lowed by retardation, of the blood-flow; accumulation of the white corpuscles in 
the peripheral part of the vessels, especially the veins, to which they adhered, 
while the red corpuscles moved through the central axes of the vessels. The 
accumulation of the white corpuscles in the veins kept pace with the slowing 
of the blood-movement; these corpuscles or leucocytes were seen gradually 
to pass, by virtue of their amoeboid movement, through the walls of the 
vessels. Just in proportion as the little body disappeared from the inside, a 
corresponding button-like prominence was seen on the outside of the vessel, 
which gradually became pyriform, and filially maintained its hold only by a 
thread-like filament, which at last gave way, allowing the little sphere of 
protoplasm to launch forth into the perivascular space, and by its locomo- 
tive power to stalk about according to the forces by which it was controlled. 
This act was called the migration of a leucocyte. Passage through the walls 
of the vessels was effected also by the red corpuscles in the capillaries, forced 
through, however, he thought, by the blood-pressure, not by an amoeboid 
action. Cohnheim, therefore, after experiments on the cornea, mesentery, 
and tongue of the frog, concluded that the pus-corpuscle was only a migrated 
leucocyte, and that the corpuscular elements of the perivascular tissues or 
fixed corpuscles formed no part of purulent accumulations. The essence, 
then, of the Cohnheim doctrine of inflammation was, the migration of the 
white blood-corpuscles or leucocytes. 
In 1869, certain experiments were instituted by Prof. William F. Norris,,* 
then at Vienna pursuing his studies, and Prof. Strieker, by which a further 
acquisition was made to our knowledge on this subject. Traumatic keratitis 
was induced in the cornea of a frog by the application of the nitrate of 
silver. The structure at the same time was excised, and examined both in 
the serum of the animal and after being subjected to the action of a solution 
of the chloride of gold. Changes were obvious in the fixed corpuscles of the 
cornea. They became enlarged and granular, their nuclei multiplied, and in 
less than twenty-four hours the characteristic movements of amoebae were 
detected. 
Strieker subsequently produced inflammation in the nictitating or con- 
junctival membrane of a frog’s eye, and then, taking a cornea, cut it in two 
pieces, and transplanted each into this membrane, one piece immediately and 
therefore living, the other dead, its vitality having been destroyed in a bath of 
distilled water. After twenty-four hours both were examined: the first, or 
living piece, was filled with pus-corpuscles; the last, or dead piece, had very 
few. The conclusion drawn from these experiments of Norris and Strieker is 
the active participation of the tissue-corpuscles of an inflamed part in making 
up its cell-constituents, in opposition to the doctrine of Cohnheim that such 
come together from the vessels as wanderers. Strieker, regarding the capil- 
laries as being composed of protoplasm, explained the passage of the cor- 
puscles through their walls in inflammation by supposing these walls to be 
in an active molecular condition, opening for their passage and immediately 
closing on their escape. The same author has shown that in inflammation 
the walls of the capillaries very early undergo fatty change, and that as it 
progresses they become irregular on the surface, prolonged into processes, 
and these uniting with others form a reticulated frame-work not unlike con- 
nective tissue. 
In 1870, observations were made by Ryneck with a view to solve the prob- 
lem of the blood-stasis in inflammation. The thigh of a frog was surrounded 
with a ligature, the web placed within the field of his glass, and an irritant 
applied. The blood flowed with great rapidity to the focus of irritation. 
The ligature was next removed, and the stasis was seen to continue only at 
* Yersucbe iiber Hornhautentziindung, von W. F. Norris und S. Strieker. HISTORY OF THE CAUSES AND NATURE OF INFLAMMATION. 
123 
this point: therefore the circulation is not necessary to stasis. Milk was 
next substituted for the blood, and its globules behaved exactly after the 
manner of the blood-corpuscles under similar circumstances : therefore stasis 
is not due to the presence of the blood-corpuscles. 
Again, certain metallic solutions, such as copper, were passed through the 
capillaries, by which their vitality was changed or destroyed. An irritant 
was then applied, but no stasis took place; from which it would appear that 
there exists some causal relation between the walls of the capillaries and 
the stagnation of the blood in inflammation. That viscidity, or excess of 
fibrin in the blood, is not the cause of stasis has been pretty clearly proved 
by Professor Lister. 
When an irritant is applied to a part it causes (1) acceleration of the blood- 
current, with either dilatation or contraction of the vessels, according to the 
nature of the irritant; and (2) stasis and transudation, occurring simultane- 
ously, and probably produced by changes in the vital properties of the walls 
of the vessels, an opinion set forth by both Eyneck and Strieker. 
Leucocytes appropriate or absorb the tissues with which they are in con- 
tact. Such was the opinion of Aston Key and the Coodsir Brothers. The 
theory of this distinctive power of the leucocytes receives strength from the 
experiment of placing a piece of fresh cellular tissue beneath the skin. In 
a few days it is saturated with a liquid full of white corpuscles having full 
ingestive powers. 
The conclusions of Burdon Sanderson upon the subject of inflammation 
are as follows: 
“I. In every inflammation we have three classes of changes: 1. Effects 
of disorder of the vascular nerves and their centre, as witnessed in accelera- 
tion of the blood-stream with either dilatation or contraction of the vessels. 
2. Effects due to change in the properties of the walls of the capillaries, mani- 
fested by stasis and exudation. 3. Effects of the stimulation of cells by the 
exudation of liquor sanguinis, as seen in the rapid growth and multiplication 
of cells resulting in the production of tissue or pus. 
“ II. Of these three orders of phenomena, the effects due to change in the 
properties of the walls of the capillaries can alone be considered as essen- 
tial to the presence of inflammation, which may therefore be considered as 
having its seat in and about the veins and capillaries, the earliest and most 
uniform effects of irritation or injury being witnessed in these localities. 
“ III. The nervous and vascular effects of local irritation cannot be strictly 
considered as successive stages of one process; for the determination of blood 
to the place of irritation—the result and purpose of the vaso-motor disturb- 
ance—does not bear any relation to the local vascular change, save in deter- 
mining a more abundant exudation, but the vascular and tissue changes are 
to be considered as successive changes of one process. 
“IV. The manner in which the living walls of the vessels are changed by 
injury so as to permit the passage of the blood is not determined ; the same 
is true of the nature of this change; but from certain observations made in 
reference to the structural alteration of the capillaries in disease and in re- 
pair, the inference is that the change consists in the transition of the material 
from the formed to the plastic state. > 
“V. The effect of inflammation is to modify the action and properties of 
cells. Those which are stable, or form a part of permanent structures (as, 
for example, the connective-tissue corpuscles), enlarge and manifest amoeboid 
movements, multiplying either by division or endogenous growth.” 
The manner in which the corpuscles make their way through the walls of 
the vessels, or effect migration, has been and is still a subject of controversy. 
Cohnheim believed in the existence of pores, or stomata; Strieker, in active 
molecular change in the walls of the vessels. In 1870, Colonel J. J. Wood- 
ward, Assistant Surgeon, U.S.A.,* in some very careful observations on the 
* Report to the Surgeon-General on Certain Points connected with the Histology of Minute 
Blood-Vessels. 124 
INF LAMM A TION. 
histology of the minute blood-vessels of the frog, prepared with stainings of 
the nitrate of silver, not only satisfied himself of the existence of pores, or 
stomata, but also by micro-photography secured capital pictures of the same 
Pig. 139. 
From a vein in the urinary bladder of a frog, showing the vascular epithelia, with their nuclei, 
of a minute vein formed by three radicals. The dark zigzag lines are the boundaries of these 
cells stained with nitrate of silver. 
Pig. 140. 
From the urinary bladder of a frog, showing a minute artery, with a few capillaries, and (a, a) the 
nuclei of the epithelial cells. 
(Figs. 139, 140, 141, and 142). These pores, or openings, are situated at the 
junction of the endothelial cells. 
In 1873, Arnold,* of Heidelberg, experimenting on the tongues of frogs, 
* Virchow’s Archives, August, 1873. NERVE-AGENCY IN INFLAMMATION. 
125 
also came to the conclusion that the passage of the corpuscles was effected 
through openings, or pores. On the other hand, Professor Balogh, of Pesth * 
Fig 141. 
Fig. 142. 
c, c, c, Stomata between epithelial 
cells of minute vein. 
Vascular epithelia, with their nuclei, a, a; 
vascular stomata, viz., the clear orifices 
surrounded with dark lines b, b. 
and Dr. Feltz, of Strasbourg,-}- have not been able to discover such openings, 
and therefore do not admit their existence. 
Nerve-Agency in Inflammation.—Enough is known to prove that the vascu- 
lar system is not one of passive conduits or channels for blood-transportation. 
It is necessary to the well-being of the organs that the circulation should be 
equalized; that it should not be flood-tide at one place and ebb at another. 
No system of elastic tubes could execute the office of definite distribution. 
In certain pathological conditions the accumulation of blood in limited dis- 
tricts is another evidence of there being some influence at work by which a 
regulating power over the circulation through the vessels is maintained in 
health. The very arrangement of the structure of the vessels proves this. 
We find in their walls muscular fibres disposed circularly, and yellow elastic 
tissue; but muscular tissue would be useless without nerves; and, while 
much is yet to be learned in this direction, enough is known to render it 
highly probable that portions of the nervous system play an important role 
in the process of inflammation. Between the nerves and the parts to which 
they are distributed there are reciprocal influences or actions. Nothing is 
more familiar than the wide-spread tenderness which sometimes follows the 
local injury of a nerve, such as the prick of the finger with a pin, from which 
the entire hand, and even the arm, may become painful. If the cord of the 
sympathetic in the neck of a rabbit be divided above the inferior ganglion, 
after the method of Claude Bernard, the vessels of that side of the head, both 
within and without the cranium, become filled with blood, giving rise not 
only to increased redness, but also to increased temperature ; dilatation, there- 
fore, has followed the lesion. It is said that in such a case there are other 
influences at work to attract the blood in undue amount to the damaged 
region, such as the increased nutrition and secretion stimulated by the plethora, 
and the active chemical changes which follow the accompanying elevation of 
temperature. Still, it must be evident that the initial cause, whatever be the 
sequelae, was the nerve-injury. 
Magendie, after division of the fifth nerve,| found that inflammation followed 
in the conjunctiva, cornea, iris, and finally the entire eye. The investigations 
of Valentin were followed by similar results. Moritz Schiff § ascertained that 
* Virchow’s Archives, xlv. 19. 
f Journal de l’Anatomie et do la Physiologie, January and February, 1870. 
j Journal de Physiologie experimentelle, 1824. 
| Untersuchungen zur Physiologie des Nervensystems, 1844. 126 
IN FLA MM A TION. 
to produce inflammatory and suppurative changes in the eye it was only neces- 
sary to divide the ophthalmic branch of this nerve; while the experiments 
of Meissner* would seem to indicate that the inflammatory change depends 
upon its inner fibres (perhaps trophic) alone, as no such result followed when 
these were left undivided. The agency of the fifth nerve over the circulation 
in the vessels of the eye has been also further corroborated by the late Yon 
Graefe.f the celebrated German ophthalmologist. 
Again, if the lingual nerve distributed to the submaxillary gland be subjected 
to irritation, as practised by Ludwig, a profuse flow of saliva immediately 
begins. This was produced in the same manner as when tobacco or some 
other irritant is taken into the mouth,—that is, through the glosso-pharyn- 
geal as afferent and some other nerve as efferent: it is a reflex phenomenon. 
What that efferent nerve is will appear by the experiment of Schiff, in which 
the chorda tympani was divided, after which no amount of irritation of the 
mucous membrane of the mouth could excite the secretion. It would seem 
clear from this test that this little filament is a trophic nerve, and determines 
the blood to the gland ; in other words, determines dilatation of the vessels. 
If now the cervical sympathetic be galvanized, as was done by Eckhard, the 
saliva lessens in quantity and is changed in density; the vessels diminish in 
size, the gland becomes pale, and the blood dark and venous in character. 
If the excitation be now applied to the lingual and chorda tympani nerves, 
red blood rushes into the gland, the vessels pulsate and become dilated, and 
secretion increases rapidly. The conclusions from such experiments are, that 
the sympathetic produces contraction, and the chorda tympani dilatation, of 
the vessels supplying the submaxillary glands. 
Again, LovenJ has shown that the vessels can be influenced in their size 
and the circulation in its movement by irritating certain sensory nerves. If 
the auricular nerve be divided and its central end irritated, dilatation of the 
vessels of the ear follows. 
The experiments of Saviotti§ and Riegel,|| which were undertaken with a 
view to determine whether the blood-vessel changes in inflammation were 
referable to direct or to reflex influence through the nerves, would appear to 
show that mixed nerves, like the sciatic, contain filaments from the sympa- 
thetic ; that the latter, or ganglionic nerves, have a central origin,—the 
medulla oblongata; that irritation of certain sensory nerves does produce 
contraction of the vessels after a reflex manner, through the filaments borrowed 
from the ganglionic system. In fine, the existence of a vaso-motor system of- 
nerves, the sympathetic, with a spinal centre, the medulla oblongata, whose 
peculiar office it is to regulate the lumen of the vessels and the force and 
rapidity of the circulation through their channels, may be accepted as a well- 
established fact. There is some diversity of opinion as to the character of 
these changes in the size of the vessels, whether active or passive. There is 
no dispute as to contraction. This is deemed to be an active change, pro- 
duced by a motor force forwarded to the vessels through a certain set of nerves; 
but it is regarding the dilatation that opinions disagree. According to some, 
it is simply paralysis ; with others, it is a passive act, or a return to an original 
condition ; and, with another class, it is neither, but as much an active change 
as that of contraction, and produced by a special set of nerves. Moritz Schiff 
was a strong advocate of the latter view, and supported it by section of 
the vascular nerves of the ear of a rabbit. This was followed by an arrest 
of the regular movements of these vessels, and, after a time, a diminution 
or contraction of their walls. His inference from this was the following: 
“ If the movements were the result of relaxation of the muscles around the 
vessels, division of their nerves should increase their dilatation; while just 
the reverse is the case.” 
Considering the subject from an anatomical stand-point, I cannot suppose 
* Henle und Pfeuffer, Zeitschrift (3), xxix. 96. 
f Archiv fur Ophthalmologie, 1854. 
| Virchow’s Archives, vol. 1. 
£ Ludwig’s Arbeiten, 1867. 
|| Strieker’s Jahrbucher, Heft i. TERMINATIONS OF INFLAMMATION. 
for a moment that dilatation is an active process. There can be no anatomical 
explanation for such a view. The muscles being circular cannot actively 
dilate; the yellow elastic layer tends to keep the vessels open, as does also 
the blood. The muscular fibres antagonize these and strive to close them, 
and it is only when this opposing agency is removed by weakness or paralysis 
that their canals can enlarge. 
In a subject of such importance, and where a large field is yet to be 
explored within the domain of neuro-pathology, hasty generalizations are un- 
safe, and it is the part of wisdom and sound pliilosophy to refrain from enun- 
ciating laws until we are in possession of a larger store of facts. There are 
many earnest, cautious, and well-trained laborers in the physiological labora- 
tories and institutes of research, who, though they may be embarrassed and 
crippled by that morbid sentimentalism which can look with complacency on 
the destructive absurdities of female dress and dissipation and yet grow pale 
and horrified at the death of a frog, yet will, despite all these disadvantages 
and discouragements, eventually find out the secret and clear up all obscurities. 
127 
Terminations of Inflammation.—There can be only two terminations of 
inflammation,—resolution and mortification. 
By resolution we mean the recession or disappearance of the phenomena 
of inflammation, leaving the tissues unharmed, or as they were before the 
attack. It is a triumph of the conservative force over the destructive opera- 
tions of disease. This may take place in a few hours, or it may require days. 
The redness begins to fade, because the obstruction in the blood-channels of 
the inflamed district ceases, and the corpuscles move along without interrup- 
tion ; the vessels also begin to regain their natural size; the swelling dimin- 
ishes, by the absorption of the transudation,—that is, by the serum as well as 
the wandering cells entering the vessels, either the veins or lymphatics or 
both, or by the cells undergoing fatty degeneration, in which state they can 
be readily taken up by the vessels; the pain subsides, the pressure and irri- 
tation being removed from the nerves; and the heat disappears, as all unusual 
textural change ceases. Such is resolution. 
The possibility of inflammation ending in this manner makes it very 
desirable that we should always endeavor, during the inception and early 
stage of the disease, to bring about such a result. To this end we have 
two directly opposite plans of treatment,—cold and heat. The first should 
be used early, to stimulate contraction of the vessels, and thereby prevent 
exudation; the second, later, to impart sufficient warmth, and maintain, to 
some extent, the migrated cells in a mobile state, by which their dispersion 
is favored. 
The second termination is mortification. Here the conservative force 
has been overmastered; the chemico-vital affinities which preserve textural 
form and insure structural function are so radically changed that the con- 
stituents of the part are disjoined and seek new combinations,—in other 
words, the part dies. . 
Metastasis.—This term has been used to express another termination of 
inflammation. It cannot, however, be properly so considered, but only as a 
sudden change of place in the inflammation. The most familiar example in 
illustration is the sudden translation of inflammation from the urethra to the 
epididymis, as sometimes takes place in gonorrhoea. The possibility of such 
a sudden transfer of attack from one organ or part to another is always a 
source of anxiety to the practitioner, particularly in gouty and rheumatic 
diseases, since the inflammation may at any moment be transferred from the 
foot or a joint to the stomach or the heart. 
Treatment of Inflammation.—The treatment of inflammation may be con- 
sidered under two heads, local and constitutional; and the indications are, first, 
to remove all causes which excite or maintain the disease; second, to secure 
resolution, or, if that be not possible, then to facilitate the removal of all in- 128 
flammatory changes or results with the least possible damage to the inflamed 
part. With regard to the first, it is fortunately often within the power of 
the surgeon to put an end to the disease promptly. If a mischievous boy 
forces some body into his ear or nose and brings on an attack of inflamma- 
tion, the cause is patent, and taking it away secures the subsidence of the 
disease; if a stone in the bladder excites a cystitis, its removal will be the 
first step towards the arrest of the inflammation ; if a splinter or ball enters 
the body, its extraction is the surest antiphlogistic. These causes are quite 
various: as, for example, occupation, as in the case of sand-paper manufac- 
turers, in whom the air-passages suffer from exposure to silicious dust; or 
an improper habit, as instanced in the pharyngitis caused by smoking. In 
whatever they may consist, their discovery and removal, if possible, consti- 
tute the first duty of the practitioner. 
Local Treatment.—One of the most important local measures in the 
treatment of inflammation is rest. Motion tends to quicken the circulation in 
a part, and to favor textural change; the opposite—rest—removes a certain 
amount of stimulus from the vascular nerves, and tends to diminish func- 
tional activity. Thus, if a joint is inflamed, it must be placed at ease ; if the 
student carries his studies far into the night until the head aches and the 
eyes become inflamed, he cannot expect to enjoy a clear mind and a strong 
eye until both have obtained respite,—the first by diminishing the hours 
of study, and the last by avoiding the stimulus of artificial light. To obtain 
the most thorough benefit from rest, it may be necessary to insist upon the 
quietude not only of the part inflamed, but also of the entire body. Every 
surgeon must have met with cases of local inflammation which obstinately 
refused to- yield to treatment until general repose was enforced. 
Position.—To derive the full benefit of rest, it will often be necessary to asso- 
ciate with \t position. A part inflamed, where it is possible, should be elevated, 
in order to offer the resistance of gravity to the current of arterial blood, 
and the advantage of the same force to drain away that in the veins. Thus, 
when an extremity is the subject of inflammatory disease, it must be raised 
on an inclined plane. To secure the full advantage of position, muscular 
relaxation must not be overlooked : hence the necessity for moderately flexing 
a leg or an arm in cases of articular disease. It is not, of course, necessary to 
confine a patient to bed in every case of inflammation; a hand or an arm so 
affected may be supported in a sling, and the patient walk about; but when 
the lower extremity is the seat of disease, articular or otherwise, when the 
body has experienced severe concussion, when the brain, lungs, intestines, 
or kidneys are threatened with inflammation, the value of absolute repose 
is incalculable, both as a prophylactic and as a cure. 
Gold.—This is a powerful agent; it lowers all vital activities. Its influence 
is seen alike in the vegetable and in the animal kingdom. In the former, the 
movement of the fluids is arrested and growth suspended. Many animals re- 
main dormant during the winter months; no developmental force is displayed 
in the egg while kept at a low temperature ; and in polar regions the inhab- 
itants never attain the stature or mental vigor of races in the more temperate 
regions of the earth. When a low degree of cold is applied to a part of the 
body, it diminishes sensibility, and finally destroys it: it repels the blood and 
slows the circulation; it diminishes heat and transudation, and arrests the 
chemico-vital activity of the cells of the tissues, thus modifying the nutritive 
changes which are concerned in growth. Its influence, therefore, is realized 
by the nerves, blood-vessels, and protoplasmic masses of the part. It is, con- 
sequently, antagonistic to the conditions which favor inflammation and sup- 
puration, and therefore is peculiarly valuable as a preventive. About the 
commencement of the present century, James Currie employed cold water to 
the surface of the body in typhus fever, and among the older military sur- 
geons the remedy was extensively used. In the Crimean War, and during 
our own late war, its value was well established. At Vienna, the local applica- 
tion of cold has been made to the abdomen in cases of peritonitis, it is alleged, 
INFLAMMATION. TREATMENT OF INFLAMMATION. 
129 
with satisfactory results; and at St. Thomas’s Hospital, London, it is a favorite 
remedy with Mr. Sidney Jones in the treatment of joint-disease, as both a 
preventive and a controlling agent against inflammation. The temperature 
to be employed will vary from 50° to the freezing-point, the sensations of 
the patient having a proper weight in determining this. That which affords 
the greatest relief from suffering should be used, whether it accords with 
our preconceived opinions or not. In its application, the person, clothing, and 
bed of the patient must be kept dry. Ice-water, either alone or medicated 
with various drugs, as laudanum, permanganate of potash, sulphate of zinc, 
acetate of lead, vinegar, carbolic acid, or bichloride of mercury, may be used. 
The simplest mode of using cold is, after adjusting the part, to apply over 
it pieces of old linen which have been saturated with water, renewing them 
as often as they become deprived of their moisture ; or it may be most ad- 
vantageously applied by irrigation, as recommended by McCartney, a method 
for which I have a great partiality. The mechanism by which this is accom- 
plished is very simple. Either of two plans may be adopted, according to 
pleasure. Under the part to which the water is to be applied is placed a piece 
of rubber or oilcloth, fashioned into a gutter, and so inclined as to convey 
the redundant fluid into a vessel at the side of the bed. A basin containing 
the water is next placed on a table or stand higher than the bed; into this 
is dropped one end of an ordinary candle-wick, or a strip of linen, the other 
end being laid upon a piece of linen covering the inflamed surface. Soon 
Fig. 143. 
Fig. 144 
Tin irrigating vessel, with 
stop-cock to regulate the flow. 
Irrigating a part by the suspended tin irrigator. 
the fluid, by capillary attraction, will find its way along the threads of the 
wick and diffuse itself over the linen veil, running off, when this latter is 
surcharged, along the rubber placed below. A small gum tube may also 
be used as a siphon. A second plan is to take a strong bottle capable of 
holding a pint or a quart, knock off the bottom, and insert in the mouth a 
cork, through which a hole has been made to receive loosely a round plug 
of pine wood. Let the bottle be suspended over the bed, a short distance 
above the surface to be treated, the limb having the oilcloth adjusted as in the 
former method; then add the water, and loosen the plug in the cork just 
sufficiently to allow the water to escape in *drops which shall fall upon the 
linen covering the diseased part. A more convenient vessel (Fig. 143) I 
have had constructed by Mr. Gremrig, which requires only regulation by a 
stop-cock. The entire arrangement is exhibited in Fig. 144. 130 
INFLAMMA TION. 
The power of this simple remedy, thus applied, in controlling destructive 
inflammatory action, especially in lacerated wounds of the hand and foot, is 
marvellous. 
When it is desirable to apply ice, it may be broken into small pieces, and 
introduced into a bladder, or into gum ice-bags (Fig. 145), and laid upon or 
placed about the part to be treated; or it may be introduced into tin boxes, 
and these applied to the part,—a method which is in favor with Esmarch. In 
this way the cold is imparted without wetting the 
surface on which it rests. In all cases, whether wet 
or dry cold is used, a piece of flannel or linen should 
be interposed between it and the skin. Where the 
skin is unbroken, or in joint-inflammation, dry cold 
answers every purpose; but in the case of lacerated 
wounds, such as we often meet with in the hand and 
foot, inflicted by fire-arms, machinery, or railroad- 
cars, it is inferior to the moist plan, the latter not only serving as an anti- 
phlogistic, but likewise washing away the products of inflammation and 
decomposition, by which the risk of blood-contamination is greatly lessened. 
Another method of applying cold is that of Petitgand, which consists in 
filling with water a piece 
of rubber tubing several 
feet in length and of very 
thin walls, and, after se- 
curing the extremities so 
as to prevent the escape of 
the water until the adjust- 
ment of the tubing, coiling 
it about the inflamed part 
(Fig. 146) and making it 
fast by the turns of a roller. 
Thus secured, one end, a, is 
introduced into a vessel of 
water placed at a higher 
level than the patient, and 
the other, c, into a bucket 
so situated as to receive 
the waste. 
It is in the commence- 
ment and early stages of 
inflammation that benefit 
is to be derived from cold; 
but there are certain cau- 
tions to be observed in its 
use. If the part to *be treated is damaged to so great a degree as to render 
its recovery somewhat doubtful; if repair has commenced but progresses 
feebly and slowly; if the patient complains of chilliness; or if there exists 
partial or complete paralysis,—then must the utmost caution be exercised in 
its use, or we may so lower nervous and vascular action as to destroy what 
little reactive force still lingers in a part. 
Heat, with or without moisture, will, particularly in the later periods of in- 
flammation, prove a valuable resource. Warmth is a derivative; it attracts 
the blood to the surface, quickens chemical change, is a stimulus to the 
locomotive endowments of the migrated corpuscles. A bag filled with hot 
sand, hot ashes, hot salt, or steamed bran, when placed about the chest in 
pneumonia or pleurisy, is most effective in relieving engorgement or conges- 
tion ; a tin can filled with hot wafer (Fig. 147), or a rubber bag (Fig. 148), fulfils 
the most valuable purpose in alleviating the pain of inflammation or neuralgia. 
When associated with moisture it mollifies the tissues, softening them so that 
they yield before effusions and take off pressure from the curves. When it is 
Fig. 145. 
Ice-bag. 
Fig. 146. 
Petitgand irrigating tube: a, bell-mouth extremity of the tube; b, tube 
coiled around the limb; e, end fitted with regulating screw. TREATMENT OF INFLAMMATION. 
desirable to employ moist heat, it may be done by saturating a piece of patent 
lint or linen with warm water, placing it over the part, and, to prevent evap- 
oration, covering it with oiled silk, rubber cloth, or waxed paper. Spongio- 
piline can be substituted, or, what is much cheaper and equally efficacious, 
the paper poultice mass,—thick, soft, felted paper, having on one surface a 
film of rubber* In cases requiring a local anodyne, such a dressing may 
be made very soothing by the addition of a little laudanum to the water. 
Should the case be one of an open wound, or an ulcer with offensive dis- 
charges, two or three teaspoonfuls of ehloralum, bromo-chloralum, or, better 
131 
Fig. 148. 
Fig. 147, 
Concave hot-water can. 
still, a solution of permanganate of potash, or of salicylic or carbolic acid, 
may be added to the water with the effect of deodorizing all such dis- 
charges. 
Fomentations.—In internal inflammations, either articular or abdominal, 
fomentations will sometimes be found beneficial. Several folds of thick 
woollen flannel wrung out of boiling water, laid over the inflamed region and 
covered with oiled silk, constitute the most eligible mode of using a fomenta- 
tion. Various decoctions may be so applied with great benefit, especially in 
concussions of the abdominal and thoracic viscera,—the most common ones 
being made by pouring boiling water over hops or chamomile,—the latter 
seeming peculiarly comforting to the sensations of the patient. To derive 
the greatest benefit from such dressings, they should be renewed as often as 
they lose their heat. 
Steaming.—The vapor from hot water, when directed upon a part tense 
and swollen, constitutes another agent of value. In cases of earache, stiff 
rheumatic joints, or catarrhal attacks either of the nasal or bronchial mucous 
membranes without exudation, much good will be realized from its use. The 
manner of using steam is very simple. Every housekeeper understands it. 
Pour some boiling water into a tin cup and invert over it a funnel, through 
the neck of which will issue the steam; or one end of a rubber tube may be 
slipped over the spout of a boiling tea-kettle, and the other applied to the 
ear, mouth, nose, or whatever part may demand its use. If we desire to 
apply it to a joint or limb, the part must be surrounded with either a blanket 
or a piece of gum or oiled silk. The fluid thus converted into steam is often 
medicated by the addition of vinegar or hops, useful in tonsillitis and pharyn- 
gitis; or quicklime, in croup; tincture of opium, in irritating coughs; pow- 
dered cubebs, in chronic bronchitis, etc. 
Moisture is occasionally employed in the form of a spray, atomized, either 
cold or warm, and is especially beneficial in inflammatory states of the 
pharynx and larynx. (Fig. 149.) The fluid used in this way is often 
charged with such agents as alum, nitrate of silver, tincture of iodine, 
tannic acid, and various other remedies. To create the spray it is only neces- 
Gum hot-water bag. 
* This paper dressing was first used by Dr. Studdiford, of Lambertville, New Jersey, since which 
time I have suggested several improvements, which make it a cheap and valuable surgical dressing. 132 
INFLAMMATION. 
sary to compress and relax alternately the lower ball attached to the hose 
of the instrument. The atom- 
ization is frequently effected by 
means of steam. There are two 
patterns of the steam atomizer, 
either of which answers an ad- 
mirable purpose, the Boston 
(Fig. 150) and the Philadelphia 
steam atomizer (Fig. 151). 
Each consists of a boiler for 
the water, a, with a spirit-lamp 
beneath to supply the heat, two 
tubes with capillary canals, b,— 
one communicating with the 
boiler, through which issues the 
steam, the other with a cup con- 
taining the liquid to be atom- 
ized, f, and their free extremi- 
ties nearly at right angles with 
each other, while in front is a 
funnel-mouthed glass tube, d, 
secured by a rubber band to the top of an upright to receive the spray and 
conduct it to the mouth of the patient, who receives the other end between 
the lips. 
Heat and moisture are also employed in the form of poultices,—applica- 
tions of great value, especially when the object is to favor suppuration, for 
which purpose nothing else can answer so well. The materials in common 
use for poultices are stale bread crumbled into small pieces and reduced to a 
Fig. 149. 
Atomizer for fluids at ordinary temperature. 
Fig. 150. 
Fig 151. 
Boston steam atomizer. 
Pliiladelphia steam atomizer. 
pulp by stirring it well with boiling water; flaxseed meal—the finer the better 
to retain heat—brought to the consistence of a soft paste by the same means; 
powdered slippery elm introduced into a bag and dipped into hot water before 
applying; corn-meal stirred in water and kept boiling until it assumes the 
consistence of thick mush. When once reduced to a soft homogeneous mass, 
the material should be spread smooth and evenly over a piece of muslin, and 
covered with some fine fabric like tarlatan. Sometimes we shall realize much 
more benefit by not interposing anything between the poultice and the surface. 
These, when applied, should be covered with waxed paper or oiled silk, that 
the heat and moisture may be retained. Such poultices may be medicated 
in various ways. If it is desired to assuage pain, laudanum, opium, or mor- 
phia may be added ; if to constringe the vessels, acetate of lead or Goulard's 
extract; if to deodorize, yeast, porter, charcoal, carbolated oil, or Labar- TREATMENT OF INFLAMMATION. 
133 
raque’s solution. They should be changed once in six hours, and never be 
made too heavy. 
Local Blood-Letting.—In the early stage of inflammation we possess no 
means more influential in arresting the progress of the disease. It operates 
directly by unloading the over-distended vessels. Blood may be drawn in 
different ways: 
1. By scarification,—with the point of a delicate thumb-lancet. The in- 
strument should be carried back and forth over the inflamed surface with a 
rapid and light hand. This method is occasionally used in a turgid state of 
the vessels of the conjunctiva. 
2. By incisions.—These should be made with an ordinary bistoury or scalpel, 
and their depth and length must be determined by the urgency of the case. 
In phlegmonous erysipelas, urinary infiltration of the perineum and scro- 
tum, paronychia, and ischio-rectal abscess, they should be both deep and free, 
extending down to the deep fascia, and below it, if the inflammatory products 
are so situated. When early practised in the above diseases, the beneficial 
effects are both immediate and permanent; not only are the vessels relieved 
from distention, but the nerves also from pressure, by giving exit to the pent- 
up blood, serum, and lymph. To neglect so imperative an indication is to 
trifle with the welfare of structure and the life of the patient. Care must be 
observed that no vessels of any magnitude are damaged. 
3. By scarification and cups.—There are two plans of cupping,—the dry and 
the wet. In the first no incisions are made, only the cup being applied to the 
surface and exhausted, by which both counter-irritation and depletion are 
effected. The discoloration of the parts shows that considerable blood has 
been drawn through the vessels into the cellular tissue. In the second 
method, numerous slight incisions are made at the same moment by a scari- 
ficator (Fig. 152), and the cup, applied directly over these, draws away the 
Fig. 153. 
Fig. 154. 
Fig. 152. 
Scarificator. 
Exhausting by the pump. 
Exhausting by the gum ball. 
blood by suction. Cups should not be applied directly over the inflamed 
surface, in consequence of the pain which would be experienced. The air 
in the cups may be exhausted by taking little slips of paper, either dry or 
moistened with alcohol, and, after igniting them, throwing them into the 
glasses a moment before they are turned down upon the surface; or it 
may be removed by an atmospheric pump after the cup is in position (Fig. 
153); or by the attachment of a gum ball (Fig. 154). In inflammations of the 
thoracic viscera, or of the contents of the cranium and the spinal canal, great 134 
INFLAMMA TION. 
relief may be expected from their use, especially when general bleeding is 
inadmissible. As the scarifications leave cicatrices which are never erased, 
wet cups should not be applied upon exposed parts of the body. 
4. Leeches.—These, when accessible, enable us to take blood from localities 
where cups cannot be applied, as about joints, at the verge of the anus, 
the cervix uteri, etc. They should not be applied directly over the inflamed 
part, but contiguous to it; nor should they be allowed to attach themselves 
to parts which are very loose in their texture from abundance of underlying 
connective tissue, such as the scrotum or eyelids, otherwise extensive ecchy- 
mosis will follow. When they are used for an inflamed eye, or in orchitis, 
they should be placed near the internal canthus, where there is a free in- 
osculation of vessels, or over the spermatic cord. The bleeding may be 
encouraged after the leech drops off, by warm fomentations. Occasionally 
the hemorrhage proves troublesome, and requires attention. The measures 
best suited to such cases are the following: sprinkle a little of the 
salt of the persulphate of iron or alum over a piece of linen, and 
place it upon the bleeding point, retaining it with a compress; or 
saturate a dossil of lint with Monsel’s solution of iron, and with it 
cover the bite; or touch with the fine point of a crayon of nitrate 
of silver. Should these fail, apply the point of a knitting-needle 
heated to redness; and lastly, if it becomes necessary, pass a fine 
pin below the wound and cast about it a thread (Fig. 155), which 
cannot fail to arrest the bleeding. An artificial leech is frequently 
used for the abstraction of blood, particularly in inflammatory affec- 
tions of the eyes. A rod forced down gives a rotary motion to an 
elliptical-shaped knife, which cuts a small valvular flap, like that 
made by the leech, from which the blood is sucked by a long tubular 
cup containing a piston (Fig. 156). In Fig. 157 the lancet is made 
to cut by a rapid revolution with a cord, or by forcing down a stylet. 
Fig. 155. 
Mode of liga- 
ting a leech- 
bite. 
Fig. 156. 
Fig. 157. 
Artificial leech: a, the lancet; b, the suction-tube. 
o, Suction-tube. 
b, Lancet propelled by a cord. 
Diminishing or cutting off the supply of blood.—This is an American plan. 
Dr. Onderdonk, of New York, originated and executed it in a case in 1813. TREATMENT OF INFLAMMATION. 
135 
During the late war, Professor Campbell,* now of Georgia, noticed in cases 
where he was compelled to ligate the principal artery of a limb to arrest 
secondary hemorrhage that the most marked improvement took place in the 
wound. In Professor Campbell’s cases the operation became a necessity in 
consequence of hemorrhage. 
Mr. Maunder, surgeon in the London Hospital, has practised the operation 
in several cases of acute traumatic suppurative inflammation, and from a 
limited experience deduces the following conclusions :f 
“ 1. That ligature of the superficial femoral artery has arrested acute 
inflammation of the knee-joint consequent upon a wound. 
“ 2. That ligature of a main artery will quickly diminish profuse suppu- 
ration and prevent death by exhaustion. 
“3. That, while it arrests profuse suppuration, it will, by allowing the 
patient to gain strength, afford an opportunity for amputation at a future 
time. 
“4. That gangrene and secondary hemorrhage as the result of ligature 
should not be anticipated in a healthy subject. That our dread of these has 
arisen from our knowledge of the consequences of the ligature in instances 
of known diseased vessels,—aneurism, for example. 
“ 5. That symptoms of inflamed bone, ‘ starting pains,’ quickly disappeared 
when the femoral had been tied. 
“6. That arterial tension of the rest of the body will be increased bene- 
ficially by the ligature.” 
I have little apprehension of failure of the circulation after ligature of 
main arteries in healthy subjects; but, with present antiseptic methods, I 
would not recommend this operation in injuries of large joints, such as the 
knee, elbow, and wrist, and when, by the use of the above-mentioned reme- 
dies, suppurative inflammation may be prevented or controlled. 
Digital compression.—Diminishing the supply of blood to an inflamed part 
by digital compression, a suggestion of Professor Vanzetti, of Padua, has 
been tested in Prague, Paris, and, to a limited extent, by Mr. Moore, of the 
Middlesex Hospital, London, with encouraging results. Neudbrfer speaks in 
extravagant terms of its value, after trying the plan in over one hundred 
cases. 
Counter-irritants.—There is no small diversity of opinion as to the value of 
this class of remedies. In many cases of inflammation of internal organs I 
am favorable to their employment as adjuvants to other remedies. They 
should be used so as to produce simply a rubefacient or reddening etfect; 
when carried beyond this they prove prejudicial. 
They act by establishing artificially an attractive point for the blood, and 
thus diminish both the force and the quantity of that fluid in all contiguous 
parts. An inflamed tissue is like a beleaguered garrison: its enemy, the blood- 
current, pours in upon it from all sides; the physician comes to the rescue, 
and, like a sagacious general, attempts to draw oft* the enemy or divide its 
forces by sending a detachment to threaten another post. Counter-irritants 
form these detachments. They should, therefore, be applied not so near as 
to add to the already overcharged vessels of the inflamed part, nor yet so far 
distant that their operation will not be felt by these vessels. Their value is 
greatest when the acute stage is beginning to wane. 
Of this class of remedies we may notice mustard-plasters; they are prepared 
by taking the flour of mustard, or, if that is not at hand, the bruised seed of 
the sinapis nigra, or black mustard, and mixing it with just sufficient wheaten 
meal and water to make a paste, which should be spread smoothly upon 
muslin or brown paper, and covered with a piece of tarlatan or very fine linen, 
so that, the agent shall not come immediately in contact with the skin. In a 
few minutes its rubefacient effect will be produced, and the patient will com- 
* Southern Journal of the Medical Sciences; also Transactions of the International Medical Con- 
gress, September, 1876. 
f London Lancet, July 10, 1875. INF LAMM A TION. 
plain, first, of a sense of warmth, and then of burning, which last, after a little 
time, begins to subside, when the plaster should be removed. Usually from 
ten to fifteen minutes will suffice to procure the requisite action. It should 
never be allowed to vesicate, as the part would then become exceedingly 
painful, and would sometimes be difficult to heal. Such a plaster, worn for 
the proper period over the chest, abdomen, or back, in cases of fugitive pains, 
or congestion of the lungs, of the intestines, or of the spinal marrow or its 
meninges, is often followed by the most striking alleviation of suffering. 
Other articles of this nature, such as the linimentum saponis, turpentine 
and olive oil, and chloroform liniment, may be employed with advantage for 
similar conditions. 
Vesicants.—These are not only counter-irritants, but also depletives; they 
produce a large flow of serum, and so unload the vessels. The articles for 
such purpose in common use are the ceratum eantharidis, cantharidal collodion, 
acetum eantharidis, and cantharidin tissue. They should be removed after 
four or five hours, and the part covered with a warm poultice, which will 
raise the vesicles and save considerable suffering. The absorption of the 
cantharidin sometimes produces a troublesome irritation at the neck of the 
bladder,—strangury. This may be often prevented by incorporating a little 
camphor with the cerate, or by covering the blister with tissue-paper satu- 
rated with dilute acetic acid. Its early removal, however, is the surest 
method of preventing such an effect. The use of a laudanum injection, and 
drinking freely of some diluent, as barley-water or slippery elm or flaxseed 
tea slightly acidulated with lemon-juice, will soon relieve such symptoms 
should they arise. As a rule, blisters should not be applied to the very young, 
to the aged, or to persons debilitated by previous disease. In such they are 
liable to produce great constitutional irritability and occasionally sloughing. 
They come in with the best advantage after the storm of inflammatory 
violence is over, when the disease has been measurably broken, but not de- 
feated. Blisters may be produced in a very short time by placing upon the 
surface a piece of lint saturated with either aqua ammoniae or chloroform, 
and covering it with oiled silk; vesication will speedily follow. The value 
of these substances as vesicants, however, is much inferior to that of can- 
tharides. The after-management of a blister plaster consists in its careful 
removal, so as not to strip off the cuticle, making minute punctures with the 
point of a lancet or needle at the base of each bleb to drain away the serum, 
and afterwards dressing with simple cerate, a light flaxseed-poultice, or, if it 
is desirable to keep the surface discharging, with compound resin or savine 
ointment. Occasionally the blistered surface becomes intensely red and pain- 
ful, with here and there a small suppurating ulcer, producing great nervous 
disturbance of the patient. Emollient poultices will contribute to allay these 
symptoms; also the benzoated oxide of zinc ointment, and best of all, in 
my experience, a linen rag well scorched with a hot smoothing-iron, thinly 
covered with simple cerate, and then well dusted with prepared chalk. This 
dressing laid over blisters will generally give marked relief, and induce rapid 
healing. 
Counter-irritation may be carried to a still greater degree of intensity by 
producing suppuration, for which purpose we have setons, issues, moxas, and 
the hot iron. These old heroic remedies have gone much out of fashion. 
Now and then some one fond of lingering about the mausoleums of ancient 
medicine and bringing to light their rude weapons of torture attempts to re- 
vive and popularize their use; but I do not think I misrepresent professional 
sentiment in America by saying, save in exceptional cases of a chronic nature, 
let them rest in peace. 
Iodine, while it acts as a counter-irritant, produces undoubtedly another 
effect, which we are wont to term alterative; and the same may be said of the 
nitrate of silver, which has been extolled by Higgenbottom, of England, as a 
local application in inflammation, and which, if the solid stick is used, will 
often arrest and resolve it. In solutions of eight or ten grains to the ounce TREATMENT OF INFLAMMATION. 
137 
of distilled water its value in pharyngitis is well known; and so also is that 
of weak solutions in cases of gonorrhoea and conjunctivitis. Iodine is most 
efficacious in chronic inflammations attended with transudations, organized 
and unorganized. If early used it is often capable of aborting inflammation. 
As it is ordinarily applied its efficacy is doubtful. It should be brushed over 
the seat of the diseased part as long as the tissues will receive it, and it is 
astonishing how much can be introduced into the skin. Iodine, when it 
begins to produce irritation and burning, should be discontinued for a time 
until these subside, as the suffering is often intolerable. The peculiar action 
of the drug may be secured without any of its unpleasant effects, by asso- 
ciating it with other substances, as in the following formula: 
R Liquoris Iodinii Compositi, fgvi; 
Pulveris Saccbari Albi, 
Pulveris Acacise, aa gr. xl; 
Aquae Destillatae, fzii. 
M. 
Solutions of cocaine (four per cent.) constitute another powerful antiphlo- 
gistic when applied to inflamed mucous surfaces. It is especially applicable 
to cases of inflamed tonsils, inflamed mucous membrane of the nose, and 
inflamed hemorrhoids. It should be brushed over the alfected surfaces 
freely every fifteen or twenty minutes. 
Compression constitutes a valuable remedial measure in inflammation. It 
can be applied either by the roller, adhesive straps, or elastic bands. If the 
roller is applied with an evenly-distributed pressure, it is of great impor- 
tance ; but if done without reference to this, it is capable of much damage. 
Pressure acts in several ways: it secures muscular quietude; supports the 
vessels and opposes transudation, by resisting over-distention of their walls; 
and quickens the absorption of the serum and lymph, reducing, in this man- 
ner, the thickening of the tissues. In old, indolent ulcers, the conjoined 
pressure of adhesive straps and roller works marvels in removing structural 
alterations and helping forward the work of repair. Though useful in all 
stages of inflammation, it is peculiarly so in the chronic form of the disease. 
When applied in acute cases, some care is necessary that the bandage shall 
not become too tight in consequence of swelling. 
Antiseptics.—Since the publication of Professor Lister’s papers on carbolic 
acid dressings, much interest has been attracted to the subject of antiseptics 
in inflammation ;* but, as these remedies will receive attention in connec- 
tion with the treatment of wounds, I shall not at this place enter upon their 
consideration. 
Constitutional Treatment.— Blood-letting.—This is a potent remedy, and 
must be used with the greatest judgment. Though unquestionably greatly 
abused by practitioners, from Botalli down to 1836, when Maekilwainf and 
Robert raised their warning voices against its indiscriminate use, 
yet there is reason to believe that physicians and surgeons of the present 
day sometimes err in the other extreme, intimidated by popular clamor, 
and so lose vantage-ground in dealing with certain grave inflammatory dis- 
eases. I do not propose to enter upon a defence of the remedy; but when I 
see a headache disappear, as if by magic, after a slight bleeding at the nose; 
a lung, in pneumonia, relieving itself by a bloody expectoration ; an erysip- 
elas affecting a stump after amputation, resisting every remedy, but vanish- 
ing in a night after a slight secondary hemorrhage,—I do not hesitate to say 
that I still find it necessary occasionally to employ the lancet. 
The general abstraction of blood acts in several different ways as an anti- 
phlogistic. It is derivative, as the current tends to the point of escape; it 
removes out of the body a certain amount of infected stimulating fluid; it 
* Their value as a preventive measure against inflammation after wounds is incalculable, especially 
vhen conjoined with proper drainage. 
+ Medicine and Surgery, 1838. 
J Elements of Medicine, by R. Williams. 138 
INFL AM MA TION. 
diminishes the temperature, and lowers the sensibility of those central masses 
of the nervous system which govern the walls of the blood-vessels. This last 
effect is very striking in the anaesthesia which follows large hemorrhages. 
I venture, therefore, to say that in the invasive stage of inflammation of the 
pleura, lungs, peritoneum, brain or its membranes, in a person of a strong, 
vigorous constitution, it is a remedy of incalculable value and stands with- 
out a rival among our therapeutic resources. Thus employed, it either cuts 
short the morbid process at once or renders it an easy conquest by other 
means. It would not be proper to employ general bleeding in strumous 
constitutions, in persons of a feeble organization, or even in strong, vigorous 
individuals when the prevailing type of disease is of an asthenic kind. The 
citizens of a great metropolis, like Philadelphia, are less able to tolerate 
the loss of blood than the sturdy inhabitants of the country. Children and 
aged persons bear its loss badly. The practice of drawing blood by proxy 
is a great error. No medical man, however wise or experienced, can say, 
without personally witnessing the operation, what amount of blood a pa- 
tient shall lose. The pulse must settle that question; effects, not ounces, 
must be considered. The best position for the patient during bleeding is 
the semi-recumbent. If sitting, fainting may be produced before a sufficient 
quantity has been drawn to make any impression upon the disease. The 
diminished force of the pulse, the artery becoming more compressible, and 
the sensations of relief experienced by the patient, are to determine the 
amount to be abstracted. When, from some idiosyncrasy, improper position, 
or excessive loss of blood, a patient becomes pale, sick at the stomach, with 
indistinct vision, and a perspiration breaking out over the face, indicating 
the approach of syncope, the recumbent posture, with the head low, should 
be adopted. If these symptoms do not pass away in a few minutes, certain 
restoratives should be employed as exciters of respiration, such as dashing 
cold water upon the face or applying the vapor of ammonia to the nose. 
Fainting is to be avoided when blood is drawn for the relief of inflammation, 
as the subsequent reaction would be so violent as to render void the benefits 
derived from the operation. 
Depressants.—These are remedies which weaken the power of the heart’s 
action, diminishing both the force and the frequency of its stroke. Aconite 
belongs to this class. Fleming’s tincture of the root is a very active prepa- 
ration, and, when given in doses of three, four, or five drops at intervals of 
two or three hours, will, after the exhibition of a few doses, reduce the num- 
ber of the heart’s pulsations very markedly. Veratrum viride exercises a 
similar power over the circulation. The preparation generally employed is 
Norwood’s tincture, which may be administered in doses of three or four 
drops every hour or two until its constitutional effect is produced. It is 
no unusual occurrence to find the pulse reduced in a few hours from one 
hundred and twenty to sixty or seventy beats in the minute. When these 
agents are administered, the patient should be seen frequently by the med- 
ical attendant, or the nurse should be sufficiently intelligent to recognize 
changes in the pulse. If these precautions are not observed, a dangerous 
depression may be induced, from which the patient may never rally. These 
remedies come in most happily after venesection, holding the circulation in 
abeyance after it has been reduced by the latter, or as a substitute for the 
lancet in cases where the urgency is not great. When the heart has been 
unduly enfeebled by their use, alcoholic stimulants are indicated until the 
danger is past. 
Antimony exercises a power upon the heart and arteries not unlike that 
of aconite and veratrum. When given to the extent of producing nausea, 
the power of the heart is diminished, the pidse becoming feeble and frequent. 
If pressed to emesis, the change in the circulation is quite remarkable: the 
arteries become fuller and the blood-current slower, attended with an active 
state of the glandular apparatus of the skin, and sometimes looseness of the 
bowels. Tartar emetic in substance and antimonial wine are the two forms TREATMENT OE INFLAMMATION. 
139 
of this drug most commonly used. When the former is administered, it 
should be in minute doses, not exceeding one-thirtieth of a grain, in solu- 
tion, and repeated at intervals of one or two hours, suspending its use or pro- 
longing the periods between its exhibition whenever the patient complains 
of nausea. I have frequently given it as in the following formula during 
the traumatic or surgical fever of vigorous patients: 
R Antimonii et Potassae Tartratis, gr. i; 
Liquoris Potassae Citratis, f§vi; 
Liquoris Morphiae Sulphatis, f^vi. 
3f.—Sig. Dessertspoonful every two hours. 
Except as directed above, antimony is no favorite with me, and is seldom 
necessary in surgical practice. In all cases where there is gastro-intestinal 
irritation it is contra-indicated, and in feeble constitutions, in the very young, 
and in the aged, its administration is improper. 
Diaphoretics and diuretics.—The skin may be said to be an enormous gland. 
Through the countless emunctories which open upon its surface there is con- 
stantly eliminated, by sensible and insensible perspiration, an amount of solid 
and liquid materials equal to at least sixteen ounces daily; and its aid should 
be invoked in inflammatory disturbances of the system. Diaphoretics and 
diuretics are depletive in their action, and hence reduce temperature. They 
remove the products of textural change, and thus render the blood less irri- 
tating to the nerve-centres. Of the greatest importance is the action of the 
kidneys; the skin may supplement their function, but can never supersede 
it. Every surgeon knows well their importance to the success of an opera- 
tion. Through these channels are removed urea, chlorides, phosphates, and 
sulphates. 
The articles best suited to depurate through the skin and kidneys are the 
liquor ammonise acetatis,—popularized by Raimond Minderer, physician to 
the Fugger family, at Augsburg,—the liquor potassse citratis, the spiritus 
setheris nitrosi, and the nitrate of potash. The first two may be given in 
dessert- or tablespoonful doses, the sweet spirit of nitre to the amount of one 
dessertspoonful, and the nitrate of potash in quantities of five to ten grains 
at intervals of two or three hours. For the proper action of either diuretics 
or diaphoretics an abundant supply of water, charged with carbonic acid, 
plain or acidulated with lemon-juice, is necessary. By its use the solids of 
the urine are greatly increased, as shown by the experiments of Bocker, 
through the chemical activities which are stimulated by its presence, while 
to the parched mouth, dry skin, and burning thirst of the patient the relief 
is incalculable. 
In this connection may be noticed the use of water for sponging the 
surface of the body, by which its heat from the increased aeration of the 
blood and slowing of the circulation is diminished. Of the use of baths, 
or the various packings employed by those who conduct water-cures, I shall 
say nothing ; for, whatever may be their value in certain forms of rheu- 
matism or cutaneous diseases, they are certainly unsuited to most surgical 
eases. 
Cathartics.—Like the skin and the kidneys, the mucous membrane of the 
intestinal canal forms an extensive emunctory. When brought into activity 
the etfects are derivative, depletive, and refrigerant. There are few cases of 
disease in which it is not deemed necessary to exhibit a cathartic more or less 
active. The object in view will determine the particular member of this class 
to be used. Sometimes it is desirable to remove only the intestinal contents, 
which, by their accumulation, may act as a source of irritation ; and for this 
purpose a Seidlitz powder, castor oil, or a compound rhubarb pill will be 
sufficient. Sometimes it is necessary not only to unload the bowels, thus 
getting rid of various secretions and other effete matter, but also to quicken 
or stimulate the action of the different glandular organs directly or indi- 140 
I NFL AMMA TION. 
rectly connected with the intestine. For this purpose we have the sul- 
phate of magnesia, or, what is better, the sulphate of soda, magnesia, or its 
citrate, bitartrate of potash, calomel, and the compound cathartic pill. The 
more drastic cathartics, such as elaterium, jalap, and croton oil, are much 
less employed than in former years. The salines mentioned produce watery 
discharges, thus unloading the blood-vessels, diminishing vascular fulness, 
reducing the temperature of the body, and inviting the flow of blood towards 
the intestinal mucous membrane. When the pressure is in this way removed 
from the interior of the vessels their capacity for receiving inflammatory 
products, especially of a liquid nature, is greatly increased; and hence their 
value in dropsical accumulations. For this reason cathartics are often asso- 
ciated with diuretics, as calomel, squill, and digitalis, or with the bitartrate 
or sulphate of potash. The diseases in which their exhibition is most clearly 
indicated are inflammation of the brain or its meninges, inflammation of the 
liver and of joints, and catarrhal attacks of the throat or lungs. They are 
contra-indicated in all cases where there is inflammation of the gastrointes- 
tinal mucous membrane or the peritoneum, or where the patient is enfeebled 
by exhausting disease. Cathartics, 1 feel confident, are greatly abused. Ex- 
cept in early dropsical accumulations and active intracranial inflammation,' 
energetic purgatives should be given with great reserve. 
Mercurials demand more than a passing notice, having been greatly abused 
in the past, and being greatly slandered at the present time. As cathartics 
they are among our most certain remedies ; as correctives of vitiated secre- 
tions, especially the intestinal and hepatic, they have no rival; as aplastic or 
defibrinating agents, they are most potent; and as sorbefacients, capable of 
disposing of inflammatory products, they are invaluable notwithstanding all 
the opposition encountered. I should regard their proscription as a public 
calamity. They are adapted to every stage of inflammatory disease : at the 
commencement, to remove all offending matters from the bowels; and after- 
wards to establish the healthy action of the glandular apparatus of the skin 
and mucous membranes, kidneys, and liver ; and also to subdue vascular ex- 
citement. The last effect is probably due to their antiplastic influence upon 
the blood, by which it is made less stimulating to the ganglia which influ- 
ence the action of the heart and arteries. At a still more advanced stage, 
and indeed after the inflammation has declined, their value is conspicuous in 
preventing structural change by resisting the production of fibrin, or by effect- 
ing its removal when once deposited. The diseases over which they exercise 
the greatest control are inflammation of the serous and synovial membranes, 
as the pleura, peritoneum, and the lining membrane of the articulations; in- 
flammation of certain mucous membranes, as those of the larynx and trachea; 
inflammation of the brain and its membranes ; hepatitis, iritis, endocarditis, 
and syphilis in many of its manifestations. The preparations most desirable 
for use are calomel, corrosive sublimate, and blue mass. When a gentle 
cathartic action is desired, three or four grains of calomel, with the same 
amount of pulverized rhubarb, will generally secure this result; or six 
or eight, grains of blue mass, followed in two or three hours by a Seidlitz 
powder, will act in much the same way. Where our object is to control 
inflammatory action, or its results, the dose should not exceed one-fourth 
of a grain of calomel, or one grain of blue mass, to be given according 
to the urgency of the case,—every hour it may be in some cases of croup, 
where minutes count as days. In other affections the value of alkalies as 
antiplastic remedies suggests their use in conjunction with calomel, as prac- 
tised by Dr. Ludlow, of this city ; and I have found great benefit result, espe- 
cially in croup, from administering one-sixth of a grain of the mild chloride 
of mercury and three grains of the bicarbonate of soda every hour until the 
disease begins to yield. The bichloride of mercury, either alone or in com- 
bination with the iodide of potash, has a more restricted application, being 
suited more particularly to the treatment of syphilis ; and the same may be 
said of the protiodide of mercury. The tendency of the mercurial preparations TREATMENT OF INFLAMMATION. 
141 
to act upon the bowels will render it necessary to associate them, wrhere the 
specific effect of the drug is desired, with a small portion of opium. Under 
all circumstances the greatest caution should be observed not to carry the 
mercurial impression too far. Salivation is rarely, if ever, necessary. Should 
the gums become inflamed, or any tenderness be experienced when closing the 
teeth firmly together, or the least odor discovered, the remedy must be sus- 
pended at once, or given at such intervals and in such diminished doses as 
will barely maintain the impression as long as the case may demand. The 
extreme susceptibility of some persons to the constitutional influence of this 
remedy requires that the physician should keep the closest watch over his 
patient. 
Anodynes.—These are among the greatest blessings we possess; for there 
is nothing so much dreaded as pain, and its existence in any great degree 
always operates to the detriment of a patient. They should always be 
administered in full doses after operations of any magnitude, when pain is 
experienced. The relief from suffering and the mental quietude which they 
induce contribute largely, by keeping in abeyance the nervous system, to 
counteract inflammation and favor reparative processes. Unless, however, 
restlessness or pain is present, or is likely to be, I see no indication for their 
use, and do not advise their administration. It is sometimes a very nice 
point to determine when they should be given. During the period of sur- 
gical or traumatic fever, when the pulse is rapid, the skin hot and dry, the 
bowels costive, with headache and thirst, the effect of opiates is unpleasant, 
and they should be withheld until, by the free evacuation of the bowels, and 
the use of diaphoretics or refrigerants, the circulation becomes quiet and the 
temperature falls. If it is considered desirable to use them during this stage, 
by reason of pain or great nervous disturbance, they may be given most 
advantageously in combination with such articles as tend to increase the 
activity of the kidneys and skin. The following formulas embody the best 
combinations of the kind, in my experience: 
U Antimonii et Potassae Tartratis, gr. |; 
Spiritus AStheris Nitrosi, fgiii ; 
Liquoris Morphiae Sulphatis, 
Aquae Aurantii Florum, aa f^ss. 
M.—Sig. Dessertspoonful in half a tumbler of 
water every two hours. 
U Morphise Sulphatis, gr. i; 
Misturae Potassae Citratis, 
Curacoge, fjjss. 
M.—Sig. Dessertspoonful every two hours. 
After the stage of excitement is past, or when suppuration is established, 
anodynes are generally well borne. In intracranial inflammations their use is 
interdicted by some authorities; but I have never seen any effects, when 
they have been employed under such circumstances, calculated to shake my 
confidence in their value: on the contrary, after depletion by bleeding or 
purging, and when associated with diaphoretics and diuretics, they are pro- 
ductive of great good. 
The preparations commonly used are opium, morphia, laudanum, deodor- 
ized tincture of opium, liquor morphias sulphatis, Dover’s powder, and chloral 
hydrate. With some persons opiates do not act pleasantly, giving rise to 
sick stomach or headache. With such we can sometimes secure their toler- 
ance by combining with them a little hyoscyamus. One grain of the latter, 
with one-quarter of a grain of morphia, taken at bedtime, answers a good 
purpose. Chlorodyne can sometimes be used when all others fail; and the 
same is true of camphor and lupulin. The hypodermic use of morphia is 
particularly indicated when the stomach is irritable. One-quarter of a grain 
placed under the skin by the hypodermic syringe (Fig. 158) will usually pro- 142 
I NFL A MM A TION. 
duce a prompt impression in a few minutes. When we have to deal with 
restlessness rather than pain, the bromide of potash or of ammonia, given 
in twenty- or thirty-grain doses every two or three 
hours in some mint-water, will be followed by ex- 
cellent effects; and when associated with five or 
eight grains of chloral the result will be still more 
decided. 
Tonics.—Remedies of this kind are indicated when 
the inflammatory symptoms are rapidly declining 
and the patient’s strength begins to fail, or in cases 
where, the acute stage being past, a chronic condi- 
tion is threatened, as manifested by a passive con- 
gestion of the vessels of the inflamed part, with 
swelling. What is demanded under such circum- 
stances is tonicity of fibre and a more active ex- 
change of blood. Quinia and the various prepara- 
tions of iron serve best. The former, though not 
so agreeable to the taste, should be administered in 
solution rather than in pill form, and in doses of from 
ten to twenty grains during the twenty-four hours. 
Of the iron preparations the tincture of the sesqui- 
chloride is perhaps the most reliable, and should be 
given in small doses frequently repeated, rather than 
in large ones at long intervals. Five drops every 
hour or two is better than twenty drops every three 
or four hours. Various elixirs of iron are much in 
use, but are not so reliable as the form described, 
some ot tne vegetable bitter infusions act well, as those of gentian and 
cinchona. The old Huxham’s tincture (the compound tincture of cinchona) 
is a valuable preparation. 
Stimulants.—These, like tonics, are to be used when the system demands 
support, and should generally be administered with articles of nourishment, 
such as milk, in the form of milk-punch or wine-whey. Brandy, when pure, 
is to be preferred; but, if it cannot be obtained, whiskey is the next best sub- 
stitute. When we have to contend with a sick or irritable stomach, cham- 
pagne will often be found to answer the purpose best. That stimulants are 
greatly abused in the sick-room there can be little doubt. They are fre- 
quently exhibited too early in the attack, or given in too large quantities. 
The necessity for them must be determined by the effect upon the circulation. 
If under their administration the pulse becomes less frequent and more full, 
the skin less dry and the patient more quiet, their use is proper. Whatever 
of prejudice is arising against alcoholic remedies, it is nevertheless true that 
they cannot be discarded entirely from the list of our resources without 
serious injury to the sick. No man can practise his profession long without 
discovering that in many cases his great duty is to sustain life and patiently 
wait and watch for the final triumph of what we are wont to call nature; 
and these are cases demanding stimulants and food. 
Diet.—The modern plan of stuffing patients from the very inception of an 
attack of disease or the reception of an injury is most pernicious, and de- 
serves the strongest condemnation. A sick man with his system aflame with 
fever, with headache, dry skin, torpid bowels, scanty urine, and a disgust 
for food, does not want broths and other articles of nourishment. Nature 
under these circumstances abhors all such things, and the effect of their pres- 
ence in the stomach and intestines can only be that of a foreign substance, 
giving rise to additional irritation. Where the symptoms are as above stated, 
cold water,—with or without lemon-juice,—barley-water, or water containing 
some toasted bread, or milk, supplies all that is needful. When the period 
of febrile disturbance begins to subside, indicated by diminished frequency 
of the pulse, cessation of thirst, moist skin, restoration of the various secre- 
Fig. 158. 
Hypodermic syringe. CHRONIC INFLAMMATION. 
143 
tions, and a more natural taste, then is the time to begin the administration 
of food, such as beef-tea or essence of beef, animal broths, milk, eggs, arrow- 
root, chicken or beef jellies, ice-cream, and still later, if the digestive organs 
are in a condition to receive such, cream toast and broiled meats. Nourish- 
ment should be given at stated intervals, like medicine, and not irregularly. 
Ventilation, etc.—Attention should be paid to the condition of the atmos- 
phere of the sick-room, taking care to see that it is kept pure by the free ad- 
mission of fresh air, the prompt removal of all soiled dressings and of dejec- 
tions, the use of disinfectants, change of under-garments and bed-linen, the 
maintenance of a proper temperature,—not exceeding 68° or 70°,—and the 
allowing of no more persons in the room than are necessary to supply proper 
attention to the patient. Unless there be reasons to the contrary, as when 
there is inflammation of the eyes, or of the brain or its membranes, a free 
admission of light is desirable. 
Nurses should be quiet, self-possessed, orderly, cheerful, and not given to 
whispering or to loud talking; they should possess the very rare tact of 
accommodating themselves to the whims and peculiarities of the sick, con- 
trolling or restraining them with such delicacy and kindness of manner as to 
conquer without opposition and to secure at once their confidence and good 
will. 
Having thus detailed the extent of our resources with which to combat 
inflammation, it is proper to state that in a considerable proportion of cases 
we find no necessity to do more than enjoin rest, together with cool anodyne 
lotions, a refrigerant mixture with a little morphia, and proper attention to 
the bowels and diet. Just so long as the natural resources of the system 
appear equal to the emergency, it is the duty of the surgeon to look on, 
carefully watching the progress of the case, and not presuming to interfere 
until these show signs of failure. He is a rash practitioner who is not con- 
tent to be the servant of nature and quietly wait until her voice is raised for 
help. 
CHRONIC INFLAMMATION. 
Chronic inflammation presents certain phenomena quite unlike, in many 
particulars, those of the acute form of the disease. In some instances the 
latter passes into the former either as a result of timid treatment or from 
favoring conditions of the general system; in others the process is wanting 
in active demonstrative features from the beginning. So subdued and insid- 
ious is its course in some cases that much structural damage may be effected 
before even its existence is recognized. How often do we see extensive 
change in the hip-joint occurring before inflammation has been suspected! 
The same may be said of the liver; cirrhosis may be far advanced and yet 
escape the notice of the physician; and the pleura may also be the seat of 
inflammation, followed or not by effusion, and yet its existence be entirely 
overlooked. It is astonishing how uncomplaining the tissues and organs 
of the body are when quietly invaded. The morbid changes are effected so 
slowly and imperceptibly, without coercion, that the healthy and unhealthy 
consort together with a degree of tolerance which may mislead both the 
patient and the practitioner. 
Symptoms.—The phenomena which declare the existence of acute inflam- 
mation are also present in the chronic variety, but in a greatly modified form, 
as follows: 
Change of color.—Instead of the red crimson blush of the former, the color 
is reddish-brown, purple, livid, or of a blue shade, the blood finding its way 
with difficulty through the part, losing its oxygen and assuming the char- 
acteristics of venous blood. It is quite common to notice in such parts 
stains of different hues, due no doubt to the deposition of pigment by the 
decomposition of blood-corpuscles. Such discolorations may remain long 
after the disease subsides, and are most commonly seen upon the legs, about 
the seat of old ulcers. In the negro it is quite common to see, in the vicinity 144 
I NFL AMMA TION. 
of such ulcers, the pigment completely removed, the parts being unnaturally 
white. 
Heat.—No perceptible rise of temperature, in many cases, will be detected 
by the hand, although it requires hut the test of thermometry to prove that 
in chronic inflammation it is really elevated. 
Pain.—This is dull in its character, the patient often complaining only of 
soreness in the parts involved. 
Sivelling.—This is the result of the effusion of serum or lymph. Generally it 
takes place slowly, and imparts a marked degree of hardness or induration to 
the affected parts. This condensation, unless the disease he controlled, tends 
to spread to the surrounding structures, some distance beyond the original 
seat of the disease, and destroys the pliancy and mobility of the tissues. 
The embarrassment to the venous circulation by this induration produces 
oedema in the parts contiguous. When serous tissues are attacked, such as 
the synovial membranes of a joint, or the peritoneum or pleura, the exuda- 
tion consists largely of epithelial desquamation and serum, constituting 
dropsies; when mucous membranes become the seat of such inflammation, 
the swelling will be determined by the depth to which the disease extends. 
When superficial, there being no obstacle to the escape of the exudation, the 
consistence of the latter will be watery, purulent, or muco-purulent, with 
abundance of epithelium, constituting a catarrhal variety; but when it 
involves chiefly the submucous or connective constituent, then the intu- 
mescence may be great, as is seen in the larynx or trachea, offering serious 
resistance to the entrance of air by diminishing the calibre of the tube. 
Constitutional Symptoms.—In many cases of chronic inflammation there are 
no constitutional signs detectable; but in others, as where a joint is affected, 
or a bone or some internal organ involved, there will be restlessness, fever, 
perspiration, thirst, diarrhoea, and emaciation. The fever may be constant 
or continuous, or remittent in its type, with exacerbations, perhaps most 
frequently in the evening. 
Causes.—These are either local or general. Of the former, it may be said 
that whatever overtasks a part or an organ favors the disease. In this way it 
frequently follows acute inflammation, the part being so enfeebled or crippled 
as not to be able to recover itself; or, to state the matter in a more definite 
form, the vessels which have been overstrained by a superabundance of blood 
in an acute attack have not been able to contract to their normal size, and 
they continue to be overdosed with blood. Thus a joint once inflamed is prone 
to recurring attacks upon slight provocations, and in each succeeding one the 
chronicity is more and more marked. Again, the cause may be due to pro- 
longed functional activity: the stomach, habitually stimulated by food and 
drinks excessive in quantity or unsuited in quality, from the constant pres- 
ence of an undue amount of blood necessary to meet the unreasonable demands, 
becomes chronically inflamed; excessive walking may induce inflammatory 
softening of the spinal cord, the vessels having been unduly dilated by the 
constant demand for blood in order to honor the drafts upon the nerve-centres 
with which the motor nerves of the lower extremities are related; and the 
eye, from constant use, may suffer the most serious structural changes. 
Among the.constitutional causes may be enumerated diathesis, such as the 
strumous or syphilitic, in illustration of which we have glandular enlarge- 
ments, joint and bone disease; peculiar states of the system, such as are present 
in gouty and rheumatic persons, giving rise to inflammation of the kidneys, 
bladder, fibrous and joint structures; disease of special organs, as the heart, 
exciting bronchial catarrh; disease of the liver, inducing hemorrhoids; and, 
finally, any cause which enfeebles the system, such as protracted fevers. 
Pathology.—In chronic inflammation the vessels are found in a state of 
unusual dilatation, with an increased quantity of blood in the affected part. 
The anatomical components of the inflamed district are filled with serum 
and plastic matter, the corpuscular part of which will be found in varying 
stages of organization,—in one place maintaining the usual form of leucocjdes, CHRONIC IN FLA MM A TION. 
145 
at another advanced to connective-tissue corpuscles, and at others, again, 
having reached the stage of true connective tissue. This serves to fuse 
together the different structures, to destroy or greatly diminish the pliancy 
of the parts, none of which are proof against infiltration, and to render 
them thick, resistant, and hard,—a true hypertrophy. The walls of the ves- 
sels which traverse the inflamed district become adherent to the structures 
amidst which they are placed, and are thus rendered unable to contract upon 
their contents, so that the blood moves sluggishly along their channels and 
tends to maintain a constant state of congestion. With these changes the 
normal tissues undergo fatty transformations, completely changing their 
natural characteristics, and giving the whole a homogeneous, whitish appear- 
ance. This is well exhibited when cutting into the soft parts overlying a 
bone which has long been affected by necrosis. 
The phenomena differ much in different tissues, according as the serum or 
the lymph predominates. Thus, in mucous membranes, in addition to infil- 
tration, there may be increased glandular activity, manifested by profuse 
secretion; and there will often be a rapid formation and an equally swift 
desquamation of the epithelial cells, while occasionally, also, an imperfectly 
organized or false membrane is formed. When serous or synovial structures 
are attacked, such as the pleura, or a joint, should the serum be in excess, it 
will form interpleural dropsy (hydrothorax), or hydrops articuli; but should 
the plastic or fibrinous element dominate, there will be thickening from the 
formation of connective tissue, which either adheres to or becomes blended 
with the serous membrane. Under the same condition bands of a similar 
nature may intersect the cavity of a joint, abridging its movements, and 
giving rise to a form of anchylosis. Another condition, often seen in dis- 
eased joints, with sinuses in the soft parts, is the formation of badly-organ- 
ized granulation-tissue or fungosities. Suppuration or the formation of pus 
may take place in a chronically inflamed part, and when enclosed in a proper 
membrane it constitutes a cold abscess. 
Treatment.—The indications are, first, to remove the cause, to ascertain 
which the most searching scrutiny must be instituted ; and, second, to restore 
the parts involved, as much as possible, to their original condition. To effect 
these ends the treatment is divided into constitutional and local. 
Constitutional Treatment.—The surgeon must first make a general esti- 
mate of the case with which he has to deal, just as a civil engineer takes a 
sweeping survey of the topographical features of a locality before he elabor- 
ates the details of his work. Among these preliminary considerations will 
be the age, sex, social condition, habits, antecedents, vigor or feebleness of 
the patient, dui’ation of the disease, etc. The surgeon should never forget 
that chronic inflammation is not, like a mathematical statement, a fixed quan- 
tity, but is a condition of degrees, and therefore demands a treatment more 
or less energetic. 
Rest.— This is often of primary importance; and by rest I do not mean 
freedom from all motion, but from all voluntary motion. A patient with a 
chronically inflamed knee- or ankle-joint should not exercise on the limb, but 
it does not follow that the articulation should not be passively moved; a 
patient may be allowed to ride out in the open air with a fixed joint, when 
it would be obviously improper for him to walk. 
Diet or regimen.—This must be regulated with special reference to the case 
in hand. If the system is exhausted, either by disease, destitution, or bad 
habits, the diet should be generous, such as fresh meats, milk, eggs, sub- 
stantial broths, and occasionally wines, brandy, or malt liquors. If, on the 
other hand, the patient has been a full, free liver, the diet should be more 
restricted and unstimulating, consisting of light broths, farinaceous articles, 
and milk. 
Medicinal agents.—In patients who have previously indulged freely in table 
excesses, the use of cathartics will be found necessary, such as blue mass 
followed by a dose of magnesia, sulphate of soda, citrate of magnesia, or the 146 
INFLAMMATION. 
compound cathartic pill. In asthenic cases, a rhubarb pill, or a Seidlitz 
powder, will fulfil the purpose very well. 
Mercury is among our most valuable resources. We have no remedy 
which so modifies or arrests inflammatory phenomena, or which so certainly 
insures the removal of inflammatory products, as this much-abused agent. 
In strumous, tubercular, or broken-down constitutions its use is improper. 
The preparations best suited for administration are calomel, blue mass, and 
the bichloride. Here, as in acute inflammation, they should be given in 
small doses frequently repeated, as one-fourth of a grain of calomel, or one 
grain of blue mass, or the sixteenth or twentieth of a grain of the bichloride, 
three or four times a day, restraining their cathartic tendencies by the ad- 
dition of a small quantity of opium. They should never be carried to the 
extent of salivation. In cases of irritable stomach, mercury may be often 
advantageously introduced into the system by inunction. Sometimes, asso- 
ciated with iodine, as the protiodide of mercury, it will be found useful, in 
doses of half a grain two or three times a day. 
Iodine, in some of its forms of preparation, as the tincture, or solution 
(Lugol’s), or in combination with potassium (iodide of potash), is another 
valuable alterative. The last has been for years a very popular remedy, and 
deservedly so. It may be given in doses of from five grains to one drachm 
three times daily, and should be largely diluted to prevent irritation of the 
stomach. In exhibiting this, or any other alterative preparation, I much 
prefer small doses frequently repeated : for example, instead of giving three 
ten-grain doses (thirty grains) during the day, I prefer the same amount in 
six doses of five grains each. By such a plan I feel assured that we obtain 
more certainly the constitutional influence of the drug, without offending the 
stomach or disturbing the digestion. 
Cod-liver oil forms another remedy of great value. Its beneficial effects are 
most noticeable in children, although it is not without good results in the 
middle-aged and the old. Whenever there is debility, with loss of flesh, or a 
strumous vice of organization, such as is seen in pale children with swollen 
glands and purulent discharges from the mucous membrane of the nose, it 
will rarely disappoint us, provided the stomach will tolerate its presence. Its 
efficiency will be increased by the simultaneous exhibition of the iodide of 
iron, either in syrup or in pill. The oil should be given one hour after meals, 
and in doses of from one teaspoonsful to a tablespoonful. 
Tonics form an important part of our remedial resources. Where the 
digestion is feeble, or the patient anaemic, or exhausted by the long continuance 
of disease or from the effects of injudicious treatment, they fulfil a valuable 
purpose. Those most worthy of notice are the compound infusion of gentian, 
—with or without the addition of the tincture of mix vomica,—quinine, com- 
pound tincture of cinchona, tincture of the chloride of iron, nitric or nitro- 
muriatic acid. Where the digestion is somewhat impaired, with want of 
appetite, and where mercury is not contra-indicated, the bichloride may be 
given with great advantage with the compound infusion of gentian. The 
following formulas may be used : 
R Tincttme Nucis Vomicae, gtt. lx; 
Infusionis Gentianse Compositi, fjfvi. 
M.—Sig. Dessertspoonful every four hours. 
R Acidi Nitrici, gtt. iv ; 
Infusionis Gentianse Compositi, ffvi. 
M.—Sig. Tablespoonful before each meal. 
R Hydrargyri Chloridi Corrosivi, gr. ss ; 
Infusionis Gentianse Compositi, f^vi. 
M.—Sig. Dessertspoonful four times a day. 
Local Treatment.—In many cases local treatment is all that will be 
required. Among the most important of this class of remedies are the 
following: CHR ONIC I NFL A MM A TION. 
147 
Removal of the cause.—Whenever practicable, this should take precedence 
of all else. If a sequestrum of bone has provoked the inflammation, it should 
be taken away, and the disease will disappear. If the eyelashes are inverted, 
change their direction, and the cure is assured. 
Local bleeding.—To unload the vessels of a part already surcharged, is to 
diminish transudation and modify its nutrition. Blood may be taken by 
scarifications, incisions, cups, and leeches. Incisions not only deplete the 
blood-vessels, but also drain away the interstitial deposits, especially those 
of the more liquid kind, such as serum. 
Blisters, by producing a large flow of serum, and by the new action which 
they excite, are sometimes desirable. They may be large, covering directly 
the diseased part, or they may be small and frequently repeated, either over 
or at a little distance from the affected region. They are used with the 
greatest benefit after the abstraction of blood. 
Counter-irritation, by means of stimulating liniments, such as the linimentum 
saponis, or by mustard-plasters, will occasionally prove serviceable, by divert- 
ing the blood from the deeper parts. 
Alteratives, as the mercurial ointment, iodine ointment, tincture of iodine, 
and nitrate of silver, are often very useful. 
Setons and issues, though far from being popular at the present time, are 
capable of doing great good, and will by and by be better appreciated. I 
believe they are capable of accomplishing all, and more than all, that is 
claimed for the actual cautery. They should be placed at some distance from 
the diseased locality, yet not so far as not to influence its circulation. They 
should not be allowed to extend deeper than the subcutaneous cellular tis- 
sue. The seton may consist of a single thread introduced by a needle, the 
latter withdrawn and the ends of the thread knotted together; or an entire 
skein of silk may be used, the insertion of which can be effected either by a 
seton needle (Fig. 159) or by raising between the thumb and fingers a dupli- 
Tig. 159. 
Seton needle armed with silk. 
cation of integument, pushing a straight, sharp-pointed bistoury through its 
base, and then conducting along its blade a probe, armed with the seton. The 
favorite localities for the introduction of such are the back of the neck, 
the side of the thorax below the axilla, and the inside of the thigh. The 
irritation which follows its introduction is best allayed by means of a warm- 
water dressing or a poultice of flaxseed meal, until suppuration is well es- 
tablished, after which the seton should be gently moved, and cleansed with 
warm water and soap daily, covering it over with a pledget of lint, and 
securing the dressing with a strip of adhesive plaster. 
The issue is established by covering the surface selected with a piece of 
adhesive plaster, having an opening cut out of the centre half an inch in 
diameter, in which is placed a piece of caustic potash the size of a small pea 
and covered in with another piece of plaster. In two or three hours a slough 
will be produced, the separation of which is facilitated by a poultice. This 
ulcer is kept open by inserting into it a pellet of lint smeared with savine 
ointment, or a lentil bean, keeping either in place with a dressing similar to 
that described for the seton. 
Moxa.—The application of the moxa is not much used at present. Moxa 
may be made very readily by wetting some lint or cotton with a saturated 
solution of nitrate of potash, and then rolling it into a conical-shaped mass. 
After drying it is ready for use. It is occasionally pi*epared from the medulla 
of certain plants, which burns slowly after being dried; also from the fungoid 
growths which are attached to decaying trees. In its application, the moxa 148 
I NFL A MM A TION. 
should be supported in an instrument (Fig. 160) called the porte-moxa, the 
apex of the cone to be ignited and its base placed upon the skin. The heat 
Fig. 160. 
Porte-moxa. 
gradually reaches the part, and as the tire approaches the base of the raoxa 
the pain becomes intensely severe. 
Irrigation and pressure.—The constant application of cool water by means 
of an irrigating apparatus,—already described under the head of local reme- 
dies in acute inflammation,—especially when conjoined with pressure by 
means of a firm roller, constitutes a method of removing inflammatory 
products, and thereby the swelling and induration, in chronic inflammation, 
unsurpassed by any other. By this plan, in ten days I have succeeded in 
reducing a limb measuring twenty-three and three-quarter inches in circum- 
ference to nineteen inches. 
Pressure alone, by a roller, elastic bands, or adhesive strips, will likewise 
prove efficacious. By either plan the vessels are compressed, the amount of 
blood diminished, and transudation prevented, while the imperfectly organ- 
ized materials deposited in the midst of the tissues undergo such retrograde 
changes as insure their removal. 
Manipulation—that is, rubbing, kneading, and moving the part with the 
fingers—forms another valuable resource. It is best adapted to cases in 
which the inflammatory action has in a great measure subsided, leaving the 
tissue thickened, matted together, and stiff. 
Electricity and galvanism, possess a certain degree of discussing power over 
the structural changes of chronic inflammation; but I confess that I have 
not seen any uniformity of action in this direction. 
There are also agents which, by virtue of their action upon the living walls 
of the vessels, excite contraction, diminishing thereby the size of their chan- 
nels, and thus preventing undue vascularity. Such are astringents, as the sul- 
phate of zinc, acetate of lead, nitrate of silver, alum, etc. These remedies are 
best adapted to the inflammation of mucous membranes, as the conjunctiva. 
In addition to the two general divisions of inflammation of which we have 
now treated, it is proper to state that other varieties are recognized among 
writers, arising in consequence of peculiar conditions of the general system, 
or from the presence of a dyscrasia. Thus, we have erysipelatous, strumous, 
tubercular, syphilitic, rheumatic, and gouty inflammation. These I regard in 
the light of complications, and believe their recognition to be of importance, 
as it enables us to modify the treatment,—as, for example, in erysipelatous 
inflammation we never lose sight of the tendency to form subcutaneous ab- 
scesses ; in strumous, tubercular, and syphilitic inflammation the necessity 
for tonic and alterative combinations must be kept in mind ; and in the rheu- 
matic and gouty variety we must attend to the depuration of the blood, 
through the kidneys and other secretory organs. This, however, is not the 
place to discuss such complications. 
Effects or Results of Inflammation.—The results of inflammation are sim- 
ply those materials which pass from the blood-vessels into the midst of the 
tissues. They are sometimes spoken of as “ effusions,” as those materials 
which “ infiltrate the tissues,” at other times as “ inflammatory exudations,” 
or “ transudations.” They consist of liquor sanguinis, blood, and pus. 
1. Liquor sanguinis.—This is the liquid part of the blood, consisting of 
fibrin, albumen, water, earthy and alkaline salts, and in which—in circulating 
blood—float the corpuscles. It is coagulable by heat and acids. External to 
the vessels the liquor sanguinis may lose fibrin and a part of its corpuscles, EFFECTS OR RESULTS OF INFLAMMATION. 
149 
and appear as a colorless, watery fluid, called serum, and hence many authors 
speak of the transudation of the latter as a product distinct from the former; 
but, as we never And serum entirely free from the other constituents of the 
liquor sanguinis and responding to the same reactions, the transudation will 
admit of being treated under two varieties, the serous and the fibrinous, the 
chief difference being in the amount of fibrin respectively contained. Mr. 
Paget uses the terms “corpuscular’ and “fibrinousEokitansky, “croupous” 
and “fibrinous;” for the latter, Prof. Gross employs the word “lymphization.” 
Others have designated these two varieties “aplastic" and “plastic” 
a. Serous variety.—This may appear very rapidly and in great abundance, 
a few hours only being sufficient to fill the cavity of the pleura or of a joint, 
or its production may be slow and almost imperceptible. It follows both 
acute and chronic inflammation, but most commonly the latter. Different 
structures, when inflamed, furnish it in widely different degrees. Connective 
tissue yields the largest amount: hence its abundance in facial and serous in- 
flammations. Mucous membranes may pour it out from their free surfaces, 
in which case it contains leucocytes, epithelial cells, and increased glandular 
secretions, as seen in the early stage of inflammatory attacks of the Schnei- 
derian membrane of the nasal cavities, and in cholera; or it may accumu- 
late in the submucous stratum of connective tissue, as in oedema of the glottis. 
Serum is frequently mixed with other materials, which change its color. 
Thus, in ascites, hydrocele, and some cysts, it is of a yellow or straw color; 
in cold abscesses it is sometimes seen as a whey-like fluid, containing cheesy 
particles or masses of depraved fibrin. Occasionally it has a red or reddish- 
brown appearance, due to the presence of blood, in consequence of rupture 
of contiguous vessels. 
The presence of serum is not always an evidence of inflammation. To 
some extent it is always passing through the walls of the vessels and bathing 
the tissues. The normal moisture or succulence of cellular tissue is due to 
its presence; it is needful for pliancy, and fulfils, in some degree, the office 
of a lubricator to the component parts of such structures, as the synovial 
fluid does to joint-surfaces. It may appear also as the result of purely 
mechanical obstruction, as seen in the swollen limbs of the pregnant female 
from the pressure made by the gravid uterus upon the ascending cava, or 
in the arm when a tumor presses against the axillary vein. When diffused 
through the cellular tissue it constitutes anasarca. Pressure made upon such 
a part leaves, when removed, an indentation or depression. When serum 
accumulates in a serous or synovial cavity it forms dropsy, as abdominal 
dropsy or ascites, joint dropsy or hydrops articuli. This variety of transu- 
dation, so deficient in fibrin, possesses little or no power of organization. 
b. Fibrinous variety.—The other form of liquor sanguinis transudation is 
characterized by a large amount of fibrin, and tends to organization. It is 
more especially the product of acute inflammation occurring in sound, vigor- 
ous constitutions. Its production is not alike in all tissues of the body. In 
inflammation of the serous membranes, such as the pleura or peritoneum, 
it appears quickly and in abundance, presenting usually one of three con- 
ditions : 1st, studding the surface of the affected membrane wdth a kind of 
frost-work roughness; 2d, in the form of bands and thread-like reticulations, 
limiting the movements of the contiguous layers of the membrane; and, 3d, 
uniting solidly together these layers by an intermediate tissue, and preventing 
all motion between them. These appearances are quite familiar as a result of 
pleurisy. 
Mucous membranes when inflamed yield a transudation similar, and not 
inferior in quantity, to that of serous membranes. A notable example of this 
exists in croup, in which disease it is not unusual to see the fibrogenous 
material deposited as a membrane of almost leathery consistence, or even 
forming a perfect cast of the tracheal tube. Organs of a very compact con- 
struction, such as bone or tendons, when inflamed, yield a comparatively small 
amount of fibrin. 150 
INFLAMMA TION. 
Between these two varieties of the liquor sanguinis—serous and fibrinous, 
the first containing many organic forms but little fibrin, the second, much 
fibrin—are many intermediate grades of this transudation ; a fact which 
depends upon the intensity of the inflammation, the condition of the blood, 
the constitutional integrity of the patient, and the tissue involved. The 
same conditions determine the fate of the transudation, whether it will end 
in reabsorption, organization, or suppuration. 
Inflammatory transudations differ essentially from those which take place 
as the result of blood-pressure from mechanical causes, such as follow the 
contact of a tumor with a great venous trunk; differ much from the consti- 
tution of the blood in the vessels of an inflamed district. This difference con- 
sists in the amount of both organic and inorganic constituents,—the former 
possessing a vast increase in cell organisms and an increased amount of the 
chloride of sodium and phosphates, the latter closely resembling serum. 
This increase can be accounted for only by the metamorphosis of the tissues 
inflamed. The proof of this statement will appear by an examination of the 
organic forms of an inflamed part, and by the analysis of the fluid which 
streams from a recent wound, such as that which soaks the dressings first 
removed from a stump after amputation. The cell constituents are migrated 
leucocytes and connective-tissue corpuscles, the latter passing from the stable 
to the mobile condition. 
This fibrinous exudation may work either good or evil. Among its friendly 
offices is the repair of parts which have been injured either by the knife of 
the surgeon or by accidental violence; wounds are reunited, broken bones 
solidly joined together, depots of pus encapsulated, and foreign bodies become 
encysted to remain harmless in the midst of the tissues. On the other hand, 
mucous canals, such as the urethra or the lachrymal sac, may be narrowed 
or obliterated, forming strictures or fistules; joint-surfaces may be united, 
producing anchylosis; opacities may result, destroying the transparency of 
tissues, as the cornea, and so damaging the vision ; together with many other 
structural changes with which every surgeon is familiar. 
2. Transudation of blood.—Inflammatory exudations are mingled with blood- 
corpuscles, the coloring-matter of which often gives a peculiar shade to the 
material. Their presence is due both to migration and to rupture of the old 
or new vessels, the walls of which have been over-distended, or softened to 
such a degree as to be unable to withstand the pressure of the blood-currents. 
It may amount to a real hemorrhage, and by its presence disturb the favor- 
able progress of the case. There is no reason to believe that these red cor- 
puscles play any important role in the work of organization or repair. 
3. Suppuration, by which we mean the formation of pus in a part, is one of 
the most common results of inflammation. This material is one with which 
the surgeon has much to do. 
What is pus? As seen when taken from an acute abscess in a healthy 
person, it is a yellowish-white fluid, with often a greenish shade, apparently 
homogeneous, of a creamy consistence, unctuous or viscid to the touch, having 
a sweetish taste, almost free from odor, with a neutral reaction, and a specific 
gravity ranging from 1021 to 1040. 
If this fluid be placed in a test-tube and allowed to stand for a time, it will 
separate into two portions,—an upper, clear, thin layer, which is serum, 
liquor puris, or intercellular ma terial, and a lower portion, having a yellowish 
color and more consistency, which consists of cells, pus-cells. 
The chemical composition of pus, in consequence of the contained protean 
matters, has not been absolutely determined. 
The serum or pus-liquor holds in solution the same materials as the serum 
of the blood, i.e., water, albumen, mucus, extractive matters, fat, and different 
salts,—principally chloride of sodium. Besides the constituents above men- 
tioned, pus is now known to contain several other matters, such as pyin, 
paraglobulin, myosin, tyrosin, fatty acids, and leucin. 
Microscopical appearances.—When a portion of pus is placed within the field SUPPURATION. 
151 
of the microscope, it is seen to consist of cells from to Tshmi °f an inch 
in diameter, having various forms, and tilled with minute granules. These 
cells possess amoeboid movements, and are really living organisms (Fig. 161). 
If a little dilute acetic acid be placed upon the slide, the granular particles 
quickly disappear, and the nuclei—from one to four—come out clearly defined; 
after which, if an alkaline solution be added, the entire cell disappears. 
Fig. 161. 
a. Living pus-corpuscles. 
b, Dead pus-corpuscles. 
c, Dead pus-corpuscles treated with 
acetic acid, showing nuclei. 
Although these bodies are living organisms endowed with the power of 
growth, multiplication, and locomotion, and with a capacity to assume various 
forms, yet, as we see the corpuscles when taken from abscesses, most of them 
have lost these attributes, are dead, and, either within or without the body, 
have become the prey of destructive chemical action. 
Pus having the characteristics described is termed healthy or laudable pus; 
but from modifying circumstances other varieties are recognized, as follows: 
1. Ichorous,—when it possesses but little consistence, being thin, and irri- 
tating or excoriating the parts with which it comes in contact. Open cancers 
and gangrenous tissues supply pus of this nature. 
2. Sanious,—when it is mingled with blood, presenting a mixture of dark 
red and yellowish-white or straw color, and often exceedingly fetid, such as 
flows from old ulcers or sinuses leading to diseased bone, and which frequently 
contain bone salts, especially those of lime. 
3. Curdy or scrofulous,—when thin or whey-like, and containing cheesy 
flakes or little masses of caseous-like matter. Cold abscesses, abscesses of 
lymphatic glands, and joint-disease furnish good examples of this kind. 
4. Muco-pus,—when whitish and slightly ropy, being a mixture of mucus 
and pus. This variety is often seen in chronic inflammations of the bladder, 
or of the nasal mucous membrane. 
5. Gummy or ropy.—This variety is frequently seen in syphilitic constitu- 
tions, especially in the breaking down of gummy tumors; the fluid is straw 
color, and has the consistence of thin syrup or gum mucilage. Abscesses 
which follow the use of hypodermic injections furnish pus of this kind. 
6. Contagious.—Certain kinds of pus, when applied to the body under 
favorable conditions, are capable of producing both local and general infec- 
tion. This is called contagious pus. A familiar example of local infection is 
that from purulent ophthalmia. It is not an unusual circumstance to see large 
numbers of boys and girls in houses of refuge and homes, attacked by this 
disease from using the same towels, and even the same basins. Such was 
the case at the Philadelphia House of Refuge and other public institutions 
a few years since. Gonorrhoea is another example. In other instances the 
constitution becomes invaded, as in smallpox, syphilis, glanders, etc. It is 
not, however, the pus, but certain organic forms or particles of living matter 
(microbes) associated with it which poison the general mass of the blood. 
Burdon Sanderson* and Professor Cohn have shown such forms in vaccine 
virus, consisting of chaplets of minute spheroids, designated by the latter “ mi- 
crosphaera vaccina f which, from their capacity of division and their behavior 
under chemical reactions, are known as micrococci. 
A great number of substances may be accidentally mixed with pus, such 
as the secretions of glands, epithelial cells, shreds of dead tissue, particles of 
* Observations on the Pathology of the Infective Processes, Twelfth Report on Medical Affairs, 
Privy Council, 1870. 152 
IN FLA MM A TION. 
bone or its salts, pigment, and blood. It may contain gases of different kinds, 
as in abscesses near the rectum,—also certain minute organisms, which in 
some instances are said to produce a blue color, like that seen in the blue milk 
described by Liicke, but which would seem rather to be due to a crystalline 
substance residing in the serum, discovered by Fados, and called pyocyanine. 
This blue pus was seen by Dr. Gibb* in the case of a female whose mammary 
glands were affected, and, from the changes produced by certain chemical 
tests, was attributed by him to the presence of cyanuret of iron. His paper 
contains a record often cases collected from various sources. Pus of different 
shades of color is described the same writer, such as olive, orange, slate, 
black, and green. Blood in different amounts, and in different stages of dis- 
integration, will supply many shades of red; and bile will furnish sevei’al 
varieties of a yellow or orange color. 
Diagnosis op Pus.—In most cases a simple inspection by the eye will 
enable us to pronounce with certainty as to the existence of pus in a fluid ; 
yet sometimes it is found mixed with other matters which conceal its pres- 
ence and demand either instrumental or chemical tests for its recognition. 
The resemblance between the pus-corpuscle, the mucus-corpuscle, and the 
white blood-corpuscle is so exact that the microscope has not established any 
distinction, and their identity is no strange doctrine at the present time. 
The addition of liquor potassae to a fluid in which pus is supposed to exist 
will, in the event of its presence, produce a thick, ropy, gelatinous condition. 
No such appearance will follow if mucus alone be present; on the contrary, 
the fluid will become thinner. 
Dr. Day, of Geelong, has introduced a test which deserves notice. It con- 
sists in adding a very little water to a fluid supposed to contain pus, and then 
a few drops of a liquid prepared by exposing to the air an alcoholic solution 
of guaiacum (saturated) until it acquires the property, by the absorption of 
oxygen, of assuming a green color when brought in contact with iodide of 
potash. If pus, however small in quantity, be present, a blue color will be 
produced. Dr. Dayf states that when applied to dried pus of a laudable 
character the test proves inert, but if the same be moistened with water 
the characteristic reaction appears. He found, also, that there was a very 
important difference in the persistence of the susceptibility of different kinds 
of pus to respond to this test, alleging that pus from phlegmonous erysipelas 
or carbuncle, however dry, retained the property of answering to the test for 
months when moistened; and he attempts in this way to explain the preva- 
lence of erysipelas in moist states of the weather. This test-liquid, if kept 
on hand for any length of time, must be placed in the dark, and in a well- 
corked bottle, since the air and light induce such changes as render it entirely 
valueless. 
Origin of pus.—This is probably twofold : first, and principally, from the 
vessels, migrated leucocytes or white blood-corpuscles; and, secondly, from 
the stable connective-tissue corpuscles, rendered again active by the inflam- 
matory transudation. The pus-cell is undistinguishable from the colorless 
blood-corpuscle, whether contrasted in size, form, or behavior. In this view 
of the subject, or in a histological sense, every inflammation results in sup- 
puration or in the formation of pus, but in the technical sense it is the super- 
abounding presence of pus that constitutes suppuration. 
Theories of suppuration.—Simpson taught as early as 1722j; that pus was 
formed in the blood-vessels and was therefore a secretion. This view was 
adopted by Dr. John Morgan, one of the founders of the Medical Department 
of the University of Pennsylvania, and advocated by him in a thesis in 1763, at 
Edinburgh, where he obtained the degree of Doctor of Medicine. This thesis 
was entitled “ Iluonme<rt<;, sive Tentamen Medicum de Puris Confectione.”§ 
* British Medical Journal of Science, vol. vi. page 201, new series, 1850-51. 
f Medical Times, March 11, 1871. 
j Dissertationes de Re Medica, 1722. 
| Professor Carson’s History of the University of Pennsylvania, page 45. SUPPURATION. 
153 
This doctrine of pus being a secretion was embraced by Hunter and accepted 
generally by the profession of Europe. Hunter did not believe that pus, as 
such, existed in the blood, but held that it was formed by certain changes or 
new combinations which it underwent while passing through the vessels. 
For these changes he supposed some alteration in the structure and disposi- 
tion of the old vessels, or an improvised system of new ones,—something, it is 
presumed, like the so-called “pyogenic membrane" of the French. 
Gendrin, in his “ Anatomical History of Inflammation” (1826), speaks of see- 
ing the blood-corpuscles when becoming stagnant in the mesentery of the frog 
gradually change into pus, by losing their coloring envelope and assuming 
a yellowish-gray color. Kaltenbriinner not only saw and described what 
was seen by Gendrin, but attirmed that the solids participated in the purulent 
product, as numerous granular particles were observed to separate from the 
parenchymatous structures of the parts inflamed and become changed into 
pus. Is it not probable that in these very early microscopical studies of 
Gendrin and Kaltenbriinner we have the germs of the modern doctrines of 
Yirchow and Cohnheim, the difference being in the interpretation of phenom- 
ena? In addition to the production of pus in the vessels and from the solids 
of an inflamed part, others, as Carswell,* believed that blood extravasated in 
a tissue underwent purulent transformation. Thus stood the subject of pyo- 
genesis until the inauguration of the cell doctrine by Schwann and Schleiden. 
They assumed the existence of a structureless “blastema” or formative fluid, 
out of which, by the aggregation of particles about a nucleus, arose cells. 
In this way, according to Schwann, pus-cells originated in the serous trans- 
udation consequent upon inflammation. With certain unimportant modifi- 
cations, this was the doctrine of Hughes Bennett. Paget regarded pus as 
a degeneration of lymph or dead exudation corpuscles, and Rokitansky be- 
lieved it to be formed from inflammatory plasma or transudation. With the 
“cellular pathology” of Virchow was introduced a new doctrine as to the 
origin of pus; one which confers on this substance the distinction of a young 
tissue, and makes it the product of the rapid proliferation of connective-tissue 
corpuscles and epithelial cells. Dr. Lionel Beale gives to the cell masses of 
living matter the name “germinal” or “formative matter.” He combats the 
doctrine of Virchow, as well as all others which preceded it, asserting that pus 
consists of germinal masses of matter, which under the stimulus of inflam- 
matory exudation become increasingly active, multiplying and producing, as 
“ formed material,” the cell wall and cell contents, except the nucleus. These 
bodies constitute the pus-corpuscles. 
Still later we have the very remarkable experiments of Cohnheim, who, 
after introducing a coloring substance, such as aniline, into the blood of a 
frog, found it in the pus-corpuscles of the inflamed cornea of the animal. 
This fact, together with the migration of the blood-corpuscles observed to 
take place through the walls of the vessels, constituted plausible ground for 
the doctrine of the identity of pus-cells with the white corpuscles of the blood. 
Thus, in summing up this rapid review of pyogenic literature, we have 
pus-corpuscles viewed as a secretion; as the result of the decomposition or 
destruction of tissue; as a product from a formless blastema; as derived from 
proliferation of connective-tissue corpuscles; as born from germinal matter; 
and as leucocytes or migrated white blood-corpuscles. 
In view of all the facts now in our possession, there can scarcely be a doubt 
that pus is derived from three sources,—namely, the white blood-corpuscles, 
the corpuscles of connective and other tissues, and the basis substance of 
these tissues. Billroth. Von Recklinghausen, Hoffmann, and others, believe 
that the connective tissue plays a very important role in the process. 
Causes of suppuration.—In the light of modern pyogenic literature, the 
presence of puritic organisms may be regarded as the true cause of sup- 
puration. Several varieties of micrococci are met with in abscesses, but 
* Illustrations of the Elementary Forms of Disease. 154 
I NFL A MM A TION. 
those commonly associated with pus are the staphylococcus pyogenes aureus, 
the staphylococcus pyogenes albus, and the streptococcus pyogenes. The 
mould produced by the culture of these organisms on a proper soil is always 
capable, when introduced into the tissues, of forming abscess. 
Two questions will naturally present themselves to the pathological student: 
Does the formation of genuine laudable pus ever occur independently of such 
organisms? and, May these pyogenic organisms exist in the blood, the lymph, 
and the tissues without causing suppuration ? 
With regard to the first inquiry, 1 believe it may be considered as estab- 
lished, from the carefully-conducted experiments of Rosenbach and of Klem- 
perer, that healthy pus and micrococci are always found together; and that 
these organisms may be present in the lymph and the blood without giving 
rise to suppuration is equally true. It has often been observed that these 
micro-organisms are found in both these liquids one day or one hour, and the 
next day or next hour have disappeared,—whether eliminated through the 
excretory organs or consumed by the white corpuscles is not known. From 
the above facts it may be assumed that for the pathogenic phenomena of these 
parasites to be displayed a certain favorable environment is necessary. This 
will explain the ditferent tendencies to the formation of pus in different 
individuals, or in the same individual at different times. 
These micrococci growing and multiplying in the tissues or in the dis- 
charges of a wound, and causing the formation of new and irritating prod- 
ucts, may be accepted as one of the very common causes of inflammation and 
suppuration, though the same result may follow the presence of other irri- 
tants in different individuals. One person may be the subject of an extensive 
inflammation terminating by resolution, while in another a very slight attack 
is followed by suppuration. One man undergoes an amputation, and the wound 
heals almost by the first intention, while a second, whose constitutional organi- 
zation apparently does not differ from that of the other, will, after a similar 
operation, have a suppurating wound for weeks. The cause of such diversity 
can only be referred to peculiarities of tissue, or to the imperfect use of 
germicidal agents. In some instances the cause is apparent from the exist- 
ence of a scrofulous or tuberculous diathesis, or it ma}7 be found in an over- 
whelming inundation of the inflamed tissue with transudation,—conditions 
peculiarly favorable to the growth and multiplication of parasitic organisms, 
for experience has shown that the more abundant the infiltration the more 
probable will be the production of pus. 
When a part is invaded by erysipelas, the tendency to suppuration is very 
marked. 
Mucous membranes, ordinarily, when inflamed, tend to suppuration,—as 
shown in catarrhal attacks of the air-passages. 
Mechanical irritation, such as results from the presence of any foreign 
body in the tissues, gives rise to suppuration. In this way it will be caused 
by a ball, or by portions of clothing, or by dead fragments of bone, carrying 
with them organisms. Thus also may vast numbers of abscesses be formed 
in the internal organs by disintegrated masses of a thrombus plugging up 
the minute vessels into which they are carried by the circulation. Such a 
condition is peculiarly fitted to the formation of abscesses, inasmuch as the 
fixation or rest of the embolic mass is favorable to the multiplication of the 
micrococci. 
Subcutaneous wounds, such as are made in the division of tendons and 
fascia, have little tendency to suppurate: the exclusion of air, with its germs, 
explains this fact. 
Tissues in which suppuration occurs.—Wherever we find cellular tissue there 
may we expect suppuration. The moi*e abundant this tissue the more likely is 
inflammation to result in this manner. Structures in which connective tissue 
is absent, such as cartilage, do not suppurate; a ball lodged below the deep 
fascia, or even in internal organs, is more likely to become encysted than 
when subcutaneous. I can conceive of no reason for this except the com- SUPPURATION. 
155 
paratively small amount of connective tissue existing in and between muscles 
or uniting the components of other organs. Subcutaneous abscesses are far 
more common than deeper collections of pus. 
Inflammation of mucous membranes results in suppuration very quickly. 
Serous membranes when inflamed tend either to adhesion or to serous effu- 
sion. If an inflammation attacks the mucous membrane of the nose or of the 
bronchi, a few hours are all that is necessary to produce suppuration; but if 
the pleura should be the seat of inflammation, in the same length of time the 
two layers, costal and pulmonary, will either be glued together by lymph or 
pressed asunder by serum. 
This fact, then, that the more abundant the connective tissue the more 
common the suppuration, is strongly corroborative of the alleged part which 
connective-tissue corpuscles play in the formation of pus. 
Absorption of pus.—Pus once formed in a part may disappear in three ways: 
1, it is possible for many of the corpuscles to re-enter the vessels; 2, others 
may become stable connective-tissue corpuscles; and, 3, the serum may enter 
the vessels, leaving the corpuscles behind, which, forming a cheesy pulp or 
emulsion consisting of granules, fat, and other debris of both cells and tissue, 
may be entirely removed by the vessels, or, when not in large amount, become 
converted into a cretaceous mass by the deposition of the salts of lime. 
Value of suppuration.—Among the older physicians much importance was 
attached to suppuration, believing, as they did, that such a discharge, whether 
spontaneous or artificially produced, served to eliminate matter prejudicial to 
the well-being of the body, depurating the blood, and attracting disease from 
internal organs; and hence, with this school, setons and issues played an im- 
portant part in the treatment of affections of the lungs, liver, and brain. I 
am convinced, from personal observation, that they often work great good in 
chronic inflammations where the patient’s strength has not been too much 
impaired, not by depurating the blood, but by acting as counter-irritants and 
depletents. 
There is a wide-spread impression also that pus is frequently a vicarious 
discharge, attracting disease from other organs, and that therefore no attempt 
should be made to arrest its flow. Hence the care with which pustular erup- 
tions upon the scalp of children, fistulas, and old leg-ulcers are often cherished 
as safety-valves to the system. I have been unable to discover any such re- 
lation, and have never seen any evil results from their cure. On the contrary, 
long-continued suppuration is liable to induce albuminoid degeneration of 
internal organs, as the liver, kidneys, spleen, and intestine. Pus when pure 
furnishes protection to granulating surfaces, but perhaps its most wonderful 
property is seen in the channelling which it effects between distant points, and 
by which it is conducted harmlessly out of the body. 
Signs of suppuration.—Generally suppuration is preceded, at least in all 
acute forms of the disease, by well-marked inflammatory phenomena, such as 
redness, pain, heat, and swelling. 
Redness.—This symptom is at first quite intense, but changes as the process 
advances, the color becoming darker, and almost purple. The skin assumes a 
smooth, glossy appearance, the parts around when pressed upon are cedema- 
tous, and this is especially true if the pus is situated at a distance from the 
surface or underneath the deep fasciae. A sallow or cream color is also a fre- 
quent characteristic of deep abscess. Suppuration of an internal organ may 
give rise to periodical redness; for example, the evening flush in certain dis- 
eases of the lungs. 
Pain.—This, like the pain of inflammation, differs according to the nature 
of the structure involved. When deep tissues are attacked, it is a dull, heavy 
ache ; in other cases it is acute and lancinating, as in abscess of the mammary 
gland; or throbbing and pulsatile, with a feeling of great tension or fulness 
of the part, as in felon. When the suppuration is mature the pain usually 
ceases. The pain is sometimes periodical, as in disease of the bones or joints, 
coming on in the evening and continuing for several hours. 156 
IN FLA MM A TIO N. 
Several factors are concerned in the causation of pain, as pressure on the 
nerves, disorganization of the nerves, and irritation resulting from the prod- 
ucts of tissue-destruction, probably ptomaines. 
Heat.—The temperature of the part, at first high, diminishes after the sup- 
puration is well established. 
Swelling.—The degree of alteration of form will be determined by the re- 
sistance encountered from depth of structure and the more or less compact 
nature of the tissues involved. When the matter is deeply placed, little or no 
swelling may appear externally, and the only evidence, aside from the previous 
history, will be a brown or leaden color of the skin, with oedema, and at some 
point diminished resistance to pressure. The more abundant and loose the 
connective tissue the greater will be the swelling. The prevailing form, 
however, when not resisted by peculiarities of structure, is a conical one. 
The exact situation of a purulent accumulation is often revealed by its form, 
as in the submaxillary region when outlined by the attachments of the sub- 
maxillary fascia, or by the point at which it seeks to be discharged, as at the 
outer side of the crural arch in psoas abscess. The tendency of pus to seek 
the surface of the body is one of the remarkable facts connected with its 
history. It cannot be explained by the theory of its taking the direction of 
least resistance. If so, why should an abscess of the liver tend to the surface 
of the abdomen rather than into its cavity, or one below the deep fascia of the 
neck to the surface rather than towards the thoracic cavity ? Rindfleisch* 
ascribes it to the diffusion of connective tissue, which is itself capable of being 
resolved into pus; but the explanation is defective: it will not account for 
the external discharge of either a hepatic or a pulmonary abscess. It is 
sometimes called the intelligence of matter. I know of no such material 
endowment aside from the operation of a law of conservation impressed upon 
every part of the body by its Divine Maker. 
The progress, of suppuration towards the surface renders the part acumi- 
nate, or forms what is termed u pointing." It is rare for superticial abscesses 
to have more than one place of pointing: deep ones may have several. At 
the summit of the elevation the skin is very thin, of a purple or yellow color 
from the pus being visible, devoid of sensibility, and ffnally gives way, allow- 
ing the contents to escape. 
Fluctuation.—As suppuration advances there is an alteration not only of 
form but also of consistence. The swelling becomes softer as the tissues be- 
come fluid, and when subjected to certain manipulations yields the sensation 
of fluctuation. There are three methods of ascertaining the existence of fluc- 
tuation, namely, palpation, alternations of pressure, and triple pressure. The 
first is accomplished by placing one or more fingers lightly upon one side of 
the swelling, and tapping or percussing the opposite side with a single finger 
of the other hand. The second is performed by placing one or more fingers 
of the two hands on opposite sides of the swelling, and alternately making 
pressure : as the fluid is displaced by one hand the wave is felt by the other. 
The third, and the one which is best adapted to small accumulations, consists 
in embracing the swelling between the thumb and fingers of one hand while 
the summit is pressed by a single finger of the other. For large collections, 
either purulent or serous, the first method is the most positive, but for small 
ones the second and third are to be preferred. Tact is requisite in the prac- 
tice of all, and is attainable only by practice, the secret consisting chiefly in 
delicacy of touch and contact. 
In chronic or cold abscesses the local phenomena may be entirely wanting, 
the process being slow and insidious, while the constitutional ones after the 
suppuration is established assume the gravest character. 
Constitutional Signs.—Suppuration, when extensive, or in parts endowed 
with peculiar sensibility or possessing much resistance of structure, gives rise 
to well-marked constitutional disturbance. When the transudation assumes 
* Pathological Histology, Translation, Phila., 1872, page 113. SUPPURATION. 
157 
the suppurative transformation, the patient experiences rigors alternating 
with heats, fever, and profuse sweats. These rigors in deep abscesses may 
return at regular periods with the uniformity of an intermittent. The severity 
of both constitutional and local symptoms depends much upon the location of 
the disease. When suppurative inflammation takes place in the ischio-rectal 
fossa, under the temporal fascia, in the tonsil or under the post-auricular 
aponeurosis, we may have a rapid pulse, dry tongue, dry, burning surface, 
incessant thirst, great restlessness, and delirium, with diminished renal and 
other secretions. When suppuration is prolonged, even though not very 
abundant, it makes a profound impression upon the system. The face becomes 
pale, the palms of the hands and soles of the feet burn, the pulse is frequent, 
a steady emaciation goes on, the appetite fails, the cheeks glow with an un- 
natural redness, there are evening or night sweats, perhaps diarrhoea, and, 
indeed, all those symptoms which characterize hectic fever. 
The relation between the constitutional disturbance and the suppurating 
focus is undoubted. The ptomaines formed by bacterial agencies enter the 
lymphatics, and through these the general circulation, causing septic intoxi- 
cation or fever. 
Diagnosis.—The recognition of an abscess is not always an easy task. The 
most egregious and not unfrequently fatal mistakes have been made, and not 
a year passes that I do not witness such errors. The usual characteristics of 
acute abscess, such as change of color, pain, swelling, pointing, and fluctua- 
tion, are not peculiar to this disease alone, but are met with in other affec- 
tions. rfhe conditions most likely to be confounded with abscess are serous 
accumulations either as an infiltration or in the form of cysts, aneurism, 
encephaloid growths, adipose tumors, and hernia. 
There are certain localities very prone to infiltration of serum, as the eye- 
lids, prepuce, back of the hand, and the neighborhood of articulations, and 
such infiltrations will impart a sensation to the finger simulating fluctuation. 
These intumescences are unlike abscess in the following particulars: there is no 
contrast of color, but a uniform redness over the entire surface; there is no point- 
ing. no thinning of the skin ; and the swelling is equally yielding at all points. 
Cysts may be distinguished from abscess by the absence of any inflamma- 
tory history, by their want of color or tenderness, by their slow growth, and 
by the absence of rigors. When so situated as to admit of the “ light” test, 
they are often found translucent. 
Aneurism.—When an abscess forms over some great vessel, as in the axilla, 
groin, or popliteal space, it will resemble somewhat an aneurism. How shall 
we distinguish one from the other ? 
In acute abscess there have been the signs of previous inflammation. Hot 
so in aneurism. This does not apply to cold abscesses; but the patients who 
furnish examples of the two diseases are very unlike. Pale, scrofulous per- 
sons, under twenty years of age, are the subjects of cold abscess, while aneu- 
rism occurs in vigorous adults. Both may pulsate, but the pulsation of an 
aneurism is expansive, or eccentric. I mean by this, if an aneurismal swell- 
ing be grasped by the fingers, it will be felt to expand centrifugally in all 
directions. In abscess, the movement is one of upheaval, produced not by 
any force within the swelling, but by one exterior to it. It is sometimes 
possible, by insinuating the fingers beneath, so to isolate an abscess as to 
remove it beyond the influence of the underlying vessels. Never so with 
aneurism. Generally in the latter the ear will detect a bruit. Not so in 
abscess. Pressure on the cardiac side of either an aneurism or an abscess 
will arrest pulsation, but the former will diminish in size, while the latter 
will remain unchanged. Pressure on the distal side will increase the tension 
of an aneurism; it has no effect on abscess. Both aneurisms and certain cold 
abscesses, as psoas, when pointing in the groin, can be “ reduced,”—that is, 
their contents pressed out of sight; but when that pressure is removed, the 
sac of the former will be refilled rapidly, the latter slowly. There will also 
be a history of bone disease in the latter. 158 
INFLAMMA TION. 
Encephaloid growths, possessing, as they so frequently do, conical projec- 
tions, with local discoloration and deceptive fluctuation, are not unfrequently 
mistaken for abscess and laid open with the bistoury, to the great injury of 
the patient. The chronic and—in the early stage—painless course of en- 
cephaloid disease, its possessing not one but multiple eminences, and fre- 
quently the enlarged veins running over the surface, will indicate its true 
nature. Mistakes, when committed, have been generally due to confounding 
elasticity with fluctuation, but these are very different. 
Adipose tumors.—These may be distinguished from acute abscess by the 
absence of any inflammatory history, by their being without oedema or indu- 
ration, and by their having a doughy consistence and lobular form. 
Hernia.—In differentiating abscess from hernia the following considera- 
tions will conduct us to a just conclusion. Hernias are confined to certain 
definite regions not common to abscesses. They often occur suddenly, after 
some unusual effort; their progress is from above downward; they recede in 
the recumbent, reappear in the erect, position ; usually they are reducible, 
elastic, doughy, resonant when containing intestine, and impart a distinct 
impulse to the hand in coughing. I have frequently known cold abscess 
below Poupart’s ligament confounded with femoral hernia; but the mistake 
is inexcusable. Psoas abscess when it finds its way to the thigh is always 
on the outside of the vessels; hernia is on the inside. 
We have still one resort in cases of doubt, which generally gives a satis- 
factory solution of the problem, and that is the exploring needle (Pig. 162). 
Fig. 162. 
Exploring needle. 
This delicate instrument is simply a fine needle containing a groove. It 
may be thrust with impunity into any growth, and will conduct away a 
portion of the contents, if such exist, whether pus, blood, serum, or air. It 
is one of the most important aids in diagnosis, and resolves many surgical 
difficulties like a charm. 
Divisions of Suppuration.—Suppuration may be divided into superficial, 
diffused, and circumscribed. 
Superficial Suppuration.—In superficial suppuration the pus is poured out 
from a free surface, as the mucous membrane of the nose, urethra, vagina, etc. 
Examples of this are seen in catarrh, gonorrhoea, and leucorrhoea. 
Diffused Suppuration.—In diffused suppuration the pus, having no limiting 
barrier, travels in different directions, infiltrating or separating the parts in 
which it occurs, and often inflicting great structural damage, such as is fre- 
quently seen in erysipelas, after compound fractures, poisoned wounds, and 
severe contusions. The extremities, scalp, and abdominal parietes suffer 
most frequently. When the suppuration occurs beneath the occipito-frontal 
aponeurosis of the scalp, the periosteum is liable to be separated from the 
bone; and the same is true of other parts, in deep suppurations. 
This variety is met with in both good and bad constitutions. It is cer- 
tainly not always due to deficiency of fibrin, by which the interspaces of the 
cellular tissue are sealed up and an obstacle offered to the purulent diffusion, 
but often to a wide-spread inflammation of the connective tissue, or to its 
insufficiency in amount. 
Both of these causes operate in those cases of the disease which follow 
compound fractures, where the suppuration extends between separate, or the 
fasciculi of individual, muscles, and where the connective component is sparse 
as compared with the subcutaneous layer. DI VISIONS OF SUPPURATION. 
159 
Instead of being a disease, as has been alleged by some writers, peculiar to 
scrofulous and broken-down constitutions, it has, in my experience, most fre- 
quently occurred in patients of the very best organization. Erysipelas, which 
so often gives rise to this kind of suppuration, is a disease of the robust as 
well as of the weak. 1 have seen all the cellular tissue of the inferior ex- 
tremity destroyed by diffuse suppuration from exposure, even in a man of 
exceptional vigor and strength of body. 
This extension of suppuration seems to be purely an infective process, the 
surrounding or contiguous parts being invaded by vast crowds of micrococci, 
which find a soil or environment favorable to their multiplication. 
Symptoms.—As seen in erysipelas and after surgical injuries, the local signs 
may attract at first but little notice, the earliest indication of mischief being 
the constitutional disturbance. The patient is suddenly seized with a chill 
or rigors, followed by heats or sudden rise of temperature, and later by a 
copious perspiration; the circulation becomes quickened, the pulse being 
small and frequent; there is thirst, loss of appetite, and restlessness, with 
general derangement of the renal, intestinal, and other secretions. If the 
disease is extensive, and accompanied by much structural injury, the general 
symptoms become more urgent and threatening. The tongue assumes a dry, 
red, shining appearance, sometimes with a streak of dark fur along the 
centre; the strength rapidly fails ; delirium sets in; the face becomes sallow 
and pinched; and the patient dies from constitutional irritation and blood- 
poisoning. 
The local symptoms are somewhat peculiar, as contrasted with other forms 
of suppuration. The color is a dark, dusky red; the swelling not defined, 
nor very prominent, but diffused ; the skin cedematous, from effusion of serum, 
especially when the pus is deeply situated, as under a resisting fascia; the 
pain extends over a considerable surface, instead of being concentrated, and 
sometimes is felt at a point remote from the disease. When the pus is con- 
fined in the profound parts of the neck, from pressure upon the brachial 
plexus of nerves, the pain or numbness may be experienced in the arm or 
hand; when in the buttock, the pain may be in the leg below, along the 
course of the sciatic nerve and its branches ; when the parts are palpated, or 
pressed alternately between the hands, provided there is little resistance of 
tissues, a sound may be elicited similar to that of water in a half-tilled rubber 
bag or bladder; the parts have lost their elasticity and firmness, and are soft 
and unresisting. 
Diffuse suppuration, when not early recognized and promptly treated, is 
attended with the greatest danger to both limb and life. It is not the local 
damage done that renders our prognosis grave,—although that of itself is 
serious,— but it is the transudation and tissue-sewage, which spoil the blood, 
rendering it unfit for the demands of the organs, and developing the typhoid 
symptoms which so rapidly supervene. 
Treatment.—The treatment of diffuse suppuration should be decisive. The 
surgeon, in all eases where the disease is likely to occur, should make frequent 
and critical examinations. In phlegmonous erysipelas, it may be forestalled 
by free incisions into the part, unloading the subcutaneous cellular tissue of 
its transudation and the engorged vessels of their blood. In regions where 
important structures are crowded together, such as the neck, and when the 
pus is below the deep cervical fascia and may open into the oesophagus or 
cavity of the chest, we should not wait for pointing, but, selecting a place 
where there is some feeling of fluctuation, however obscure, should make an 
opening sufliciently free for the escape of the purulent accumulation. 
It is not always safe to open such by a thrust, as in an ordinary abscess, 
yet to be described. A thoughtless or ignorant plunge of the bistoury may 
open large vessels, giving rise to dangerous hemorrhage. A safer method is 
to incise the skin and divide the different strata of tissues upon a director until 
the pus is reached; or to make a puncture sufficiently deep to penetrate the 
deep fascia, and then introduce a director, breaking up the obstructing tissues 160 
I NFL A MM A TION. 
until the matter makes its appearance, when, if necessary, a blunt-pointed bis- 
toury (Fig. 163) may take the place of the director, and the wound be enlarged. 
Fig. 168. 
Blunt- and sharp-pointed bistoury for opening abscesses. 
To prevent the opening from closing prematurely before the disease is 
removed, a drainage-tube (Fig. 164) should be inserted into the opening by a 
rotatory movement effected 
between the thumb and in- 
dex finger. This tube can be 
shortened, from time to time, 
until the granulations fill up 
the abscess cavity or canal, 
When a rubber tube is not 
on hand, a piece of old linen 
can be twisted into a conical 
tent (Fig. 165), and, after 
being soaked in carbolated 
water, pressed into the open- 
ing. As this is liable to be- 
come foul, it should be re- 
moved daily and a fresh one 
substituted. 
When diffuse suppuration takes place in the extremities or other parts of 
the body, the opening or openings must be made at dependent points, in order 
to drain away the pus by gravitation. The 
cavities should then be thoroughly washed by 
either the solution of bichloride of mercury 
(one to forty) or that of carbolic acid (of the 
same strength). Rubber drainage-tubes also 
become necessary to prevent purulent accumu- 
lations. and in addition the usual antiseptic 
dressings of carbolated or sublimated gauze, absorbent cotton, and a firmly- 
applied roller. 
Rubber drainage-tubes were introduced into surgical practice by Chas- 
saignac, and require to have openings either cut or punched in the walls of 
the tube at intervals of at least one inch. There are different ways of intro- 
ducing these tubes. Commonly it is done by the dressing-forceps. When a 
long tract is to be traversed, and the tube is to come out at either end (usually 
the case), a very good plan is to secure the drain by a thread to a long probe 
with an eye. The probe, after being carried along the sinus to its termina- 
tion, can be made to push out the soft parts, which are then laid open, 
enabling the surgeon to seize the instrument and draw it out. thus bringing 
the drainage-tube into position, after which the probe can be detached. 
The pus from this kind of suppuration is not healthy. It has little con- 
sistency, is mixed with blood and shreds of necrosed tissues, and excoriates 
the parts over which it flows. The odor is often offensive, especially when the 
pus comes from the vicinity of the rectum, in which case it is so impregnated 
with gases from the bowel as to be almost intolerable. Hence the impor- 
Fig. 164. 
Drainage-tube, with openings. 
Fig. 165. 
Conical tent. DIFFUSED SUPPURATION. 
161 
tance of disinfecting and deodorizing the sinuous tracks of the disease and 
imparting to them a healthy action by injections. For this purpose we may 
use any of the following, two or three times in the twenty-four hours: per- 
manganate of potash (one grain to the ounce of water); carbolic acid and 
water (one part of the acid to thirty parts of water) ; bromo-chloralum (one 
part to eight or ten parts of water); salicylic acid (one part of the acid, three 
parts of phosphate of sodium, and forty parts of water); phenol sodique (one 
drachm to six ounces of water). 
When the suppuration, though not profuse, continues to linger, and the 
parts fail to unite, much advantage will be derived by injecting daily a weak 
solution of the sulphate of copper, three grains to the ounce of water. This 
will impart a healthy stimulus to the vessels. A solution of permanganate 
of potash or of bichloride of mercury, or dilute alcohol, one part to six or 
eight parts of water, will be found of great value in similar circumstances. 
The great object, be it remembered, is to allow no accumulations in and no 
crevices or spaces between the components of the atfected district. After 
thus disinfecting the tissues involved in the suppuration, the usual antiseptic 
dressings should be applied. The frequency of dressing must be determined 
altogether by the amount of discharge and the temperature. 
The constitutional treatment must not be overlooked. Pain and restless- 
ness must be allayed by opiates, and the strength sustained by tonics, such 
as quinine, tincture of the chloride of iron, and a nutritious diet, consisting 
of milk, animal soups, and stimulants; attention should be given to secure 
thorough ventilation and sunlight, that the air of the apartment may be 
pure and fresh. 
Circumscribed Suppuration.—When pus is surrounded or circumscribed 
by a limiting wall, it constitutes an abscess, a term derived from the Latin 
abs (from) and cedo, cessum (to go). The wall may be a natural one, as the 
pleura or the synovial membrane of a joint, or a preternatural one, the work 
of inflammatory transudation and organization. 
Abscesses may be divided into acute, chronic, and disseminated. Mr. Paget 
has described a form which he terms residual. 
Acute Abscess—Phlegmonous Abscess.—Acute abscess is frequently met 
with in persons of a good constitution, and it passes rapidly through the 
various stages. 
Symptoms.—It is ushered in by the phenomena of inflammation well pro- 
nounced,—namely, pain, heat, redness, and swelling, together with more or 
less fever. The pain is acute, burning, throbbing, and, when the part is pen- 
dent, every contraction of the left ventricle gives a pulsatile throb and tension 
often amounting to agony; the heat can be appreciated by the hand. The 
swelling is at first hard, which corresponds to the stage of vascular engorge- 
ment and exudation, but as the disease advances becomes acuminate and softer 
at the middle. Coincident with softening, which marks the stage of pus-for- 
mation, rigors set in, followed by hot skin and sweating. As the softening 
progresses, the color of the surface changes from red to a purplish, and 
finally, as the pus nears the surface, to a yellow hue, the skin becoming 
glossy and so attenuated that the pus may be seen beneath. The pain and 
constitutional symptoms now subside, and when the part is examined after 
the usual manner fluctuation is discovered. 
Pathology.—In the formation of an abscess, the part is so infiltrated with 
liquor sanguinis and leucocytes as to fill up the meshes of the connective tissue 
and form a hard tumor. After a time many of these leucocytes, in virtue 
of their locomotive power and the intrusion of others streaming in from all 
sides, are pressed towards a central point or focus of the swelling (Fig. 166.) 
The result of such overcrowding is to compress the vessels, lymphatics, and 
connective-tissue fibres to a degree sufficient to arrest their nutrition. The 
consequence is that they become necrosed and melt down. Many of the 
connective-tissue corpuscles, thus liberated, or passing from the stable to the 
mobile state, together with the associated fat and other tissue debris, break INFLAMMATION. 
up, pass into a fluid state, and become mingled with the other cell organisms 
and transudation (Fig. 167), so that softening or fhictuation replaces the indu- 
ration at this central point, and in common language it is said that “ matter 
has formed” or the disease has resulted in an abscess. At the circumference 
Fig. 166. 
Infiltration in the formation of an abscess.—From Billroth. 
of this abscess there is a wall of living tissue which serves to circumscribe or 
partition it from the surrounding parts. It is this wall which distinguishes 
the circumscribed from the diffuse abscess, and which serves to imprison that 
which otherwise would disorganize the adjacent structures by infiltration or 
poison the blood by its absorption. This limiting wall is formed by a fibrinous 
deposit intermingled with cells, projecting into which are loops of blood- 
vessels, so that when the pus is evacuated there is left a central cavity, 
corresponding to the necrosed 
parenchyma, surrounded on 
all sides by the wall just de- 
scribed. 
Now, while it is common to 
speak of this wall as a barrier 
against purulent extension, an 
office which it doubtless does 
perform, we must not lose sight 
of the fact that it is true granu- 
lation-tissue. Billroth has well 
remarked that an abscess is 
only a hollow ulcer. This 
granulation - tissue does not 
differ from that which forms 
in the parenchyma of a part 
contiguous to a separating 
slough, or just within the line 
of an ulceration by which the 
dead is separated from living tissue; or from that which is seen filling up 
the chasm of an open wound or ordinary ulcer. In fine, it is the material 
for repairing the destruction made by the abscess. 
Treatment.—As all abscesses are a sequence of inflammation, it is possible 
to prevent their formation by arresting the progress of the latter, or, in other 
words, by inducing resolution. This is clearly the first indication. The 
second proceeds on failure to effect the first, and consists in favoring the 
maturation of the abscess as rapidly as possible, or, what is its equivalent, 
provoking an abundant transudation. The third consists in evacuating the 
pus accumulations; and the fourth, in securing the restoration of the parts 
to their natural condition. 
To effect the first indication, that of resolution, the case must be taken in 
hand at its incipiency. Whatever tends to lessen vascular tension and con- 
gestion, allowing a free circulation in the inflamed district, tends to disarm 
Fig. 167. 
Injection of the vessels in the walls of an abscess; outgrowths 
from those near its circumference. ABSCESS. 
163 
bacterial products of their power to do harm. Most potent of all resources 
for this purpose is the abstraction of blood. When the disease is in the 
subcutaneous cellular tissue, this may be accomplished by leeches, cups, 
scarifications, or incisions, always remembering the importance of having 
whatever instruments are used rendered perfectly aseptic. How often do 
we see an attack of acute tonsillitis or conjunctivitis aborted by the timely 
use of leeches or free scarifications! If the patient is of a strong, full 
habit of body, general blood-letting will be indicated, provided the organ 
attacked is an important one. By such a measure a pneumonia may be 
arrested short of suppuration, the vessels of the lung being unloaded, and 
the vascular tension diminished. Any advantage thus gained must be fol- 
lowed up and maintained by the sedative influence of cold lotions, such as 
lead-water and laudanum. Cloths saturated with the liquid should be laid 
over and beyond the affected parts, and frequently renewed,—not covered 
with oiled silk, but exposed, so as to intensify their action by evaporation. 
Should the swelling continue to linger, notwithstanding that the active in- 
flammatory symptoms have disappeared, a blister directly over the diseased 
locality will frequently, after the escape of serum, rapidly secure its removal. 
When cold gives rise to increased and continued pain, it should be exchanged 
for warmth, the degree to be determined by the sensations of the patient. 
Even when suppuration has taken place to a limited extent, we should not 
despair of being able to effect its dispersion or absorption. Moderate warmth, 
conjoined with pressure, will facilitate this desirable termination: cloths wet 
with warm water and laudanum, and retained by the turns of a roller firmly 
applied, constitute the best mode of using these measures. 
When the above means fail to secure resolution or absorption of the mat- 
ter, and suppuration goes forward, then we should proceed at once to favor 
the process, or ripen the abscess as rapidly as possible. Hot poultices of 
bread and water, or flaxseed-meal, laid over the part and covered with oiled 
silk, and renewed every six or eight hours, constitute the best applications 
for this purpose. The heat and moisture soften the skin and invite a free 
transudation. The abscess, by disintegrating the connective tissue, advances 
forward or points; the skin desquamates and sloughs, becoming so attenuated 
that at last it is no longer able to withstand the pressure of the pus, and gives 
way, allowing the matter to escape. This is nature’s method of opening an 
abscess. It is not usual, however, to wait for the spontaneous discharge of 
the accumulation: the surgeon interferes and makes an outlet by artificial 
means. The time when such intervention is proper will be determined by 
the locality of the disease. In abscesses of the ischio-rectal fossae, an outlet 
should be made early, before pointing, otherwise the intestine may be per- 
forated and a fistula established. Early interposition is also necessary in 
such as are termed retro-pharyngeal. Abscess of the tonsil should be opened 
early, and never allowed to break spontaneously. I have seen a young man, 
a medical student, lose his life by refusing obedience to this maxim. The 
abscess burst posteriorly, poured a torrent of pus into his trachea, and before 
assistance could be rendered he was dead. 
Without specifying particular cases demanding prompt interference, I will 
say that whenever an abscess is accompanied with great suffering from ten- 
sion, or is likely to produce serious structural damage, early interference is 
proper. Mr. Liston’s case will serve to enforce this doctrine. An abscess in 
the neck had become adherent to the carotid, into which, from delay, it finally 
ulcerated, and when opened the patient lost his life from hemorrhage. When 
no urgency exists for an early evacuation of the matter it is usual and proper 
to wait until the collection is mature, as indicated by distinct fluctuation and 
pointing. The opening should be made with a sharp-pointed straight or 
curved bistoury (Fig. 168), the surface having been previously well cleansed, 
first with alcohol, and afterwards with a solution of bichloride of mercury 
(one to twenty), as also the hands of the operator and his knife. In large 
abscesses, where the carbolic-acid spray is not employed, irrigation with the 164 
1 NFLAMMA TION. 
bichloride of mercury (one to one thousand) should be substituted during 
the process of opening. The finger and thumb of one hand being pressed 
on opposite sides of the swelling, so as to make the parts tense, the surgeon 
with the other, holding the bistoury in the manner of a writing-pen per- 
pendicularly to the abscess, thrusts the point of the blade into the most 
prominent portion, carrying it onward until all resistance ceases, or until the 
pus is seen welling up on the sides of the blade, when the instrument should 
Fig. 168. 
Sharp-pointed bistoury. 
be changed to the oblique position, so as to make the point more superficial 
and the opening enlarged to the required extent from within outwards as 
the knife is withdrawn, the object being to give a free and unembarrassed 
escape to the purulent matter. I prefer a good-sized opening. If the 
patient be timid, or afraid of pain, the part may be first rendered insensible 
by the ether or rhigolene spray, or by ice. 
In opening abscesses deeply situated in regions where there are important 
blood-vessels, there must be no reckless plunges of the knife. The rule laid 
down when treating of diffuse suppuration is equally applicable here,—namely, 
to incise the superficial layers below the skin on the director, opening the deep 
fascia, and breaking up the wall of the abscess with its extremity. 
If the.opening be sufficiently large, the pus will escape, usually mixed with 
some blood, and the flow, after a little Avhile, may be assisted by gentle press- 
ure, never carried, however, to the extent of giving severe pain. If the abscess 
is large, the opening should be prevented from healing by introducing a small 
tent, until tbe cavity is sufficiently contracted. After its evacuation the 
usual antiseptic dressing should be applied until all pus ceases to escape, 
when the surface of the incision may be covered with a strip of carbol- 
ized gauze spread with boracic ointment. Should it be impossible to com- 
mand antiseptic dressing, a warm flaxseed-meal poultice will be the proper 
application for two or three days. In either case the dressing should be 
secured with a firmly-applied roller, in order to bring into close apposition 
the sides of the cavity vacated by the pus, and thus secure its obliteration 
by the union of the granulations which form its periphery. Any induration 
which may linger at the circumference of the abscess is favorably affected 
by such pressure. 
This induration which forms the circumference of the central depot of pus 
disappears in three ways. A part is discharged through the opening, as pus; 
a part undergoes a retrograde metamorphosis, and is disposed of by absorp- 
tion ; wThilst the remaining portion is developed into connective tissue, and 
becomes a stable component of the surrounding structure, the evidence of 
which is seen in the compact nature of the cellular tissue which continues 
for some time about the seat of an abscess. 
Occasionally there are complications following an abscess which require 
notice. It may refuse to heal from several causes. 1. From an imperfect 
apposition of its surfaces: this must be obviated by accurately-adjusted press- CHRONIC OR TUBERCULOUS ABSCESS. 
165 
ure by means of graduated compresses and rollers. 2. From an indolent state 
of the granulation-tissue: this may be corrected by stimulating injections, such 
as the sulphate of copper, three grains to the ounce of water; nitrate of silver, 
two grains to the ounce of distilled water; or dilute carbolic acid, followed by 
compression. 3. From imperfect drainage, in consequence of which a certain 
amount of pus remains: this will require another opening, made at a dependent 
point, and probably the introduction of a drainage-tube. 4. From crevices in 
the limiting wall, allowing the pus to diffuse itself through the contiguous 
parts: here the difficulty should be met by counter-openings, injections, and 
compression applied, not only over the diseased district, but also beyond its 
limits. 5. From hemorrhage, which, if not controlled by pressure, wil l require 
that the abscess be freely laid open and all coagula removed. Should this not 
answer, then the bleeding vessel must be sought for, and secured by ligature. 
6. From a leaf of deep fascia preventing the approximation of the walls of 
the abscess: this will require a free subcutaneous division. 7. From con- 
stitutional weakness: this will be best combated by the use of tonics, such as 
quinine, tincture of the chloride of iron, nourishing diet, and fresh air. 
Fistulous tracts may remain and complicate the healing. These are very 
prone to form when the abscess is in the perineum, axilla, or groin, parts that 
do not allow of entire quiet or rest. These are best treated by laying open, 
on a director, with a probe-pointed bistoury, the entire extent of the fistulous 
canals, and packing them with dry or oiled lint. 
Chronic or Tuberculous Abscess.—Chronic abscess appears in surgical 
writings under various designations, as cold, scrofulous, and tuberculous 
abscess. There are objections to be urged against any of these names, ex- 
cept the latter. A chronic abscess is one which is slow in its progress, and 
in a large proportion of cases owes its existence to a peculiar state of the 
constitution, a diathesis, or dyscrasia. It should not be forgotten, however, 
that between the acute and the chronic abscess there are many degrees, in 
consequence of which we fail, in numerous cases, to discover any sharp lines 
of distinction. In the more typical forms of the disease chronic abscess 
differs from the acute in the age and constitution of its subjects, as well as 
in its origin, progress, symptoms, anatomy, and results. 
It generally occurs in the young and in those who have embedded in their 
organization a tuberculous vice. It is symptomatic of disease of the joints, 
bones, and lymphatic glands. Such are those abscesses which form about the 
hip, knee, elbow, and other articulations, consequent upon strumous arthritis, 
those that make their appearance on the back and groin in disease of the spine, 
those which form in the glands of the neck and axilla in scrofulosis, and occa- 
sionally in the mammary gland and in the subcutaneous connective tissue. 
Abscesses of this kind which change their place, or rather which, in conse- 
quence of gravitation and fascial attachments, dissect their way to points 
remote from their origin, are called congestive. Such abscesses are those which 
originate about the lumbar vertebrae, and, following the psoas fascia, are 
conducted beneath Poupart’s ligament to the thigh. The name should be 
discarded. 
There are acquired conditions of the system, not peculiar to age, which pre- 
dispose to chronic, not tuberculous, abscess, generally confined to the subcu- 
taneous tissue. These are seen after low fevers, or in the course of organic 
disease of the kidneys, in which the blood has been spoiled by the introduc- 
tion, from without, of some pernicious material, or where the kidneys fail to 
eliminate certain compounds, which, by their presence in the circulation, 
work a similar mischief. It is no uncommon experience to see these abscesses 
follow typhoid fever during convalescence, or develop in the course of acute 
Bright’s disease of the kidney. Whatever destroys the plasticity of the 
blood or defibrinates it would appear to favor this kind of suppuration. I 
have seen, in a patient who had at different times taken largely of alkaline 
remedies for disease of the bladder, numerous little painless knots of indu- 
rated tissue form at points where morphia had been inserted hypodermically, 166 
IN FLA MM A TION. 
and which gradually ripened into abscesses, the pus of which was unhealthy 
and intermixed with a gummy or ropy tluid. Such abscesses when absorbed 
leave a depressed and white cicatrix. Professor Stille relates to me the case 
of a man who, to obtain relief from a painful affection, had recourse suc- 
cessfully to the hypodermic use of morphia. Some time afterwards he was 
attacked with rheumatism, and for this he used alkalies freely. In a short 
time the places where the subcutaneous injections had been made, and which 
had hitherto remained entirely quiescent, began to swell, and abscesses formed. 
Old inflammatory indurations, such as are seen about bones or articulations 
which have been the subjects of disease, often take on this form of suppura- 
tion. This corresponds in part to Mr. Paget’s residual abscess, and is one of 
nature’s methods of getting rid of the thickening. 
Tuberculous abscess is slow in its development and progress. It is quite 
common to see such collections after months attain a considerable size, and 
then for a long time remain unchanged. I can recall cases which remained 
without opening for two years. 
The symptoms of chronic abscess are peculiar. They are not at all demon- 
strative. The disease may arise so insidiously, and with so little inconvenience, 
that its presence will not even be suspected. It is no uncommon occurrence 
to meet with cases of lumbar abscess which have been treated for lumbago, 
the patient realizing nothing more than some uneasiness, stiffness, or slight 
pain in the back. When the swelling becomes visible it is not red or inflamed, 
but rather is blanched or pale; the sensibility is trifling; it may be handled 
even rudely without pain; the temperature is not exalted,—whence the term 
“cold abscess” of the Germans. It has little tendency to point: the absence 
of acute inflammation and the great thickness of the sac are conditions which 
are unfavorable to this, and when such a result does occur it is preceded by a 
dark or bi’own rather than a scarlet color. There is little if any oedema, and 
the integument, which before was movable over the sac, becomes adherent to 
its surface. Chronic abscesses are remarkable, again, for the enormous bulk 
which they frequently attain, or, what is equivalent to this, the amount of pus 
which they contain without becoming acuminated. I have removed fifteen 
pints from such an abscess. 
The contents of chronic abscesses are peculiar. The matter may be thin, 
whey-like, but generally is more consistent, of a yellowish color, containing 
many cheesy-looking masses and often shreds of necrosed tissue. These 
cheesy or caseous masses contain the pathogenic essence of the disease, and, 
like similar deposits in lung-tubercle, reveal, on being subjected to proper 
examination, a peculiar bacillus. This caseous material, when exposed to the 
air with its pyogenic organisms, becomes exceedingly dangerous. Unless in 
close proximity to the bowel, or where there is bone disease or considerable 
structural debris, there is not much odor. When the pus is subjected to a 
microscopical examination it will be found much changed, its corpuscles 
blighted and broken up by chemical and other agencies, an abundance of 
granular or molecular particles floating in the liquid, together with numerous 
crystals of cholesterin, the product of fat metamorphosis. 
The encapsulating wall of a cold abscess differs only in thickness, strength, 
and development from that present in the acute form of the disease. Much of 
the inflammatory transudation is organized into connective tissue, so that this 
wall becomes a fibrous sac sometimes of great thickness. It is permeated by 
blood-vessels, and by the older writers was supposed to be endowed with the 
power of secreting pus,—whence the origin of the name “ pyogenic” membrane. 
Its formation is a very slow process, for two reasons, viz., the chronic form of 
inflammation present and the small amount of connective tissue. It often util- 
izes pre-existing structures, fashioning them into a wall or sac, as may be seen 
in the iliac and psoas abscess, in which the strong sheaths of these muscles 
constitute a part of the enclosing membrane. The exterior of this wall or sac 
is irregular, bristling with prolongations which interpenetrate the surrounding 
parts, while the interior has a villous or granular appearance, the eminences CHRONIC OR TUBERCULOUS ABSCESS. 
167 
consisting of loops of blood-vessels buried in transudation corpuscles, and 
frequently covered with cheesy flakes. These vessels are the source of the 
leucocytes which form the pus of the abscess, the connective tissue, at least 
in several localities, playing a very subordinate part in its production. 
A practical point of some importance connected with the sac of a cold 
abscess, is the difficulty in some instances of recognizing fluctuation: this 
is due to its great thickness, and the difficulty is increased if there be only a 
small amount of pus present. 
Occasionally the wall of a chronic abscess is constricted at one or more 
points, giving rise to a variety called multilocular, the constrictions between 
the loculi being determined by unyielding connections of overlying fasciae or 
other structures. 
Constitutional Symptoms.—These, like the local ones, at first attract but 
little notice. The surgeon will, however, detect a steady loss of flesh, increased 
anaemia, a red spot on the cheek, an unnatural bluish-white state of the scle- 
rotic coat of the eye, diminished strength, a frequent pulse, and towards even- 
ing an elevation of temperature, dry condition of the skin, with burning palms 
of the hands and soles of the feet, succeeded by perspiration and sometimes 
diarrhoea, with free deposits of urates in the urine. These symptoms become 
greatly intensified when the abscess is opened, and complete the picture of 
hectic fever, unless the evacuation is conducted under strict antiseptic methods. 
The diagnosis of chi*onic abscess has been treated of under the head of sup- 
puration in general. 
Prognosis.—To forecast the future of a case of chronic abscess is not always 
an easy task. The considerations which are to guide the surgeon in forming 
an opinion as to the probable issue of a given case are the age and constitution 
of the patient, the location and size of the accumulation, and the structure 
involved. The youth possesses a greater capacity of vital resistance than 
either the child or the old man. When of large size, the excessive draft upon 
the blood, and the constitutional disturbance incident to the opening of the 
abscess, are prone to wear out the patient through sheer exhaustion. Should 
the patient have been reduced by disease before the occurrence of the abscess, 
his chances of recovery are diminished ; or should there be a latent predisposi- 
tion to tuberculosis, it may be rendered active by the suppuration and rapidly 
destroy life. The locations in which such abscesses are attended with special 
danger are within the pelvis, mediastinum, front of the cervical vertebrse, and 
neck; they may open into the bladder or trachea, or even form attachments 
to vessels, the opening of which by ulceration may be followed by fatal hemor- 
rhage. The pressure of these abscesses is sometimes sufficient to obliterate 
blood-vessels, or cause a defensive thickening of their external coat. When 
the collection is produced by bone disease, age exercises an all-controlling in- 
fluence in our prognosis. Inflammation of the spine, hip, and knee in children, 
which so generally give rise to abscess, if early taken in hand admits of a 
large percentage of cures, whilst similar affections in the adult and aged tend 
to a fatal termination. 
Abscesses of lymphatic glands, while they are generally very slow in their 
formation, are not usually dangerous, nor are those which form in the subcu- 
taneous cellular tissue, provided they are not the sequence of bone disease. 
Treatment.—Until a comparatively recent period it was the practice, 
in the treatment of tuberculous abscess, to observe a masterly inactivity, 
and it is often said at the present time that the profession has followed too 
blindly the teachings of the older surgeons. In the absence of that knowl- 
edge for which we are indebted to Lister, the old treatment was not un- 
reasonable. Now, however, that we have come to understand the relation 
of suppuration to pyogenic organisms, the management of tuberculous or 
cold abscess does not materially differ from that proper to the acute form of 
the disease. It is true the contents of a cold abscess, when small in amount, 
may be absorbed. Such a disposition of the purulent material often occurs 
in tubercular disease of the spine, and consequently it is proper not to act 168 
INFLAMMATION. 
precipitately, but to allow a short time to elapse before interfering. When, 
however, the swelling steadily goes on increasing, the sooner operation is done 
the better. Supposing that the admission of air was the cause of all the 
hectic symptoms following the discharge of these abscesses, the older sur- 
geons devised different plans to accomplish the evacuation and at the same 
time exclude the atmosphere. The method of Abernethy was to enter the 
abscess by an indirect incision,—that is, by drawing the skin to one side 
and pushing a sharp-pointed bistoury into the sac. After the pus escaped 
the skin was allowed to resume its natural position: the two openings, that 
in the integument and that in the sac, did not correspond, thus preventing 
the access of air. With the same end in view, the aspirator is often employed. 
Several forms of this ingenious instrument are in use. That of Dieulafoy 
(Fig. 169) or some of its modifications are in common use. The instrument 
consists of an exhausting glass syringe, with two 
pieces of gum tubing, one of which fits on the nozzle 
at the lower end of the syringe, and to which a trocar 
is attached, and the other to a side-nozzle designed to 
carry oft' the aspirated fluid. A valve in the first noz- 
zle shuts off or opens communication with the abscess. 
The needle, or trocar, is to be plunged into the swell- 
ing, the valve opened, and the piston drawn up; this 
has the effect of sucking into the syringe the purulent 
fluid; the stopcock is next turned so as to close the 
communication with the trocar, and as the piston is 
forced down the pus passes through the side-nozzle and 
is conveyed through the attached tube into a vessel 
containing water. This instrument is an improvement 
on the American syringe of Bowditch. 
An apparatus in several respects superior to this is 
that of Potain (Fig. 170). It consists of a strong wide-mouthed glass jar 
with a closely-fitting gum stopper perforated by two tubes each having a 
stopcock. To one of these is attached a rubber hose, the free end of which 
is constructed so as to 
articulate with a canula, 
through which runs a tro- 
car ; the other admits the 
nozzle of an air-pump. 
When used, the exhaust- 
ing sjwinge is connected 
with its tube and the air 
removed from the bottle, 
leaving a vacuum, which 
is maintained by closing 
the cock a. The canula 
armed with a trocar is 
plunged into the abscess, 
after which the latter is 
withdrawn until its ex- 
tremity is free from the 
stopcock b, which is im- 
mediately turned to pre- 
vent the ingress of air. 
The stopcock c, next to the bottle, being now opened, the matter rushes into 
the vacuum. One of the great advantages of this instrument is that it 
receives unpleasant odors as well as the pus. 
The proper course to adopt in dealing with cold abscess is to make a direct 
opening into the sac with the ordinary bistoury, observing at the same 
time the most rigid adherence to antisepsis,—having the skin thoroughly 
cleansed by first scrubbing with alcohol and afterwards washing with biehlo- 
Fig. 169. 
Dieulafoy’s aspirator. 
Fig. 170. 
Aspirator of Potain. ULCERATION. 
169 
ride of mercury lotion. The bistoury and all the instruments used in the 
operation must be placed in the bath of carbolic acid, and the hands of the 
surgeon subjected to the usual cleansing process. After the opening is made 
the region of operation should be kept aseptic either by the carbolic acid 
spray or by irrigation with the bichloride solution. At one time it was the 
practice to remove the accumulation by instalments, with several days’ in- 
terval between. This course is entirely unnecessary. The contents having 
been removed, a large-sized rubber drainage-tube is introduced into the sac, 
and the latter thoroughly washed out with the bichloride of mercury lotion 
thrown in through the drain-tube. In some tuberculous abscesses where a 
large exposure of the interior is made, it is a wise precaution to curette the 
inner surface of the sac in order to remove every particle of the caseous ma- 
terial, which, should it happen to enter the system, is liable to produce tuber- 
culosis elsewhere. The external dressing must be the ordinary antiseptic 
one of carbolated or sublimated gauze, salicylized absorbent cotton, and car- 
bolized rollers. At each subsequent dressing, which requires to be repeated 
when soiled with the discharges,—probably once in from two to six days,— 
the same attention to details is to be observed as at the beginning: always 
washing out the abscess-cavity through the drain-tube with either the earbo- 
lized or the bichloride solution. In this way, the interior of the sac being 
kept constantly drained, its walls contract, and, finally, that which at first 
was a large cavity becomes converted into a narrow tubular canal, furnishing 
but a small granulation surface for the production of pus. 
Of course, in all cold abscesses where it is possible to gain access to the 
cause, the removal of the latter takes precedence of every other measure, or 
at least must be effected as soon after the evacuation of the pus as possible. 
The constitutional treatment now becomes of great moment. The strength 
must be sustained by a liberal diet, a reasonable amount of stimulants, and 
the use of tonics, such as quinine, tincture of the chloride of iron, infusion 
of gentian or quassia, with mineral acids, as the nitric, sulphuric, or nitro- 
muriatic. 
Cod-liver oil constitutes a valuable remedy in such cases, especially when 
they are attended with loss of flesh. To relieve pain and procure rest, opium 
in some of its forms is indicated; and exercise in the open air, whenever the 
strength of the patient permits, must not be neglected. 
ULCERATION. 
Ulceration is a result of inflammation, both of the acute and of the chronic 
variety; most frequently of the latter. It is the destruction of a part by 
small instalments; that is, molecular death instead of death in mass. In other 
words, ulceration is mortification on a minute scale. 
Ulceration exists under two forms, the open and the concealed. The first 
or open form presents various degrees as to depth. It may only involve the 
epithelial layer of a tissue, as that of the skin or mucous membrane, when it 
is called an abrasion or excoriation, such as is seen in lachrymal obstruction, 
where the tears run over the eyelid upon the cheek ; or where the skin of the 
thigh and that of the abdomen come in contact at the fold of the groin ; or 
when the vagina is subjected to acrid discharges from the uterus. When 
it involves the entire thickness of the skin, or mucous membrane, with or 
without the subjacent tissues, it is commonly called an ulcer. 
The concealed variety, sometimes called ulcerative absorption, includes that 
inflammatory destruction of tissue which goes on in internal organs; as the 
lungs, liver, and kidneys, or in the bodies of the vertebrae. It does not neces- 
sarily communicate with the surface of the body; though this may occur as a 
secondary result by the formation of an abscess, leaving a sinus, or fistulous 
tract. While no tissue can be said to be entirely exempt from ulceration, 
save the hair and nails, there are certain ones which are much less disposed 
to become affected than others. Among these may be enumerated arteries, 
nerves, muscles, tendons; also the heart, brain, and salivary glands. 170 
ULCERATION. 
Causes.—These are predisposing and exciting. The predisposing causes, in 
general, are all such as impair the nutrition of a part. 1. The quality of the 
blood may give rise to ulceration. Instances of this are seen in those ulcer- 
ations which so often follow typhoid and scarlet fever ; in those which succeed 
the introduction of certain poisonous matters into the circulation, causing, for 
example, smallpox and syphilis; and in those eruptions which so often appear 
upon the body of internes who have been long under the influence of a hos- 
pital atmosphere, or which develop on the persons of students who have been 
much occupied with the duties of the dissecting-room. Under the same head 
may be placed the multitudinous ulcerations found among the poor and indi- 
gent classes of a city population, who, from bad air, insufficient sunlight, and 
scanty or improper food, are under the most unfavorable hygienic conditions. 
In all such subjects the blood is so modified as to be unsuited to the demands 
of the tissues. 2. The amount of blood and the rate of circulation in a part 
are fruitful predisposing causes. Under this head are to be recognized two 
very opposite conditions,—too great, and too small, a supply. When a part 
is inundated with blood and transudation, as in acute inflammation, there is 
always danger of textural necrosis and consequent ulceration from capillary 
compression. Under such circumstances the destruction may be both rapid 
and extensive, as in phagedama. An ordinary soft chancre, rubbed by the 
clothing, may suddenly become red, swollen, and painful, and in a few hours 
a large portion of the glans penis be destroyed. When the other extreme 
exists, namely, too small an amount of blood, the parts die from inanition,— 
are starved to death. Such a condition may result from defective motor power 
in the heart, the blood not being driven to the tissues in sufficient quantity 
to supply their demands. It may also result from organic change in the 
walls of the vessels, as in .atheroma, from embolic plugging of the vascular 
canals, from pressure on their walls by morbid growths, or even from the 
weight of the body, as is often witnessed in cases of bed-sores. The rate or 
activity of the circulation constitutes another important factor. When the 
blood lingers in a part,—either from excessive dilatation of the vessels, from 
venous obstruction, or simply from gravity,—loaded as it must be with the 
products of textural change, it ceases to answer the wants of the tissues, and 
becomes inimical to their life. It is in this way that structures which have 
been the subjects of repeated attacks of acute inflammation, or of chronic 
inflammation, are prone to ulceration. These facts explain the liability of 
varicose and paralyzed limbs to suffer in this manner. 3. Structural pecu- 
liarities predispose to ulceration. Thus, cicatrices, whether in the soft parts 
or in bone,—their vitality being low,—under certain conditions of the blood 
such as exist in scurvy and other diseases, readily take on ulceration. 
Exciting Causes.—These comprise all those which are immediately con- 
cerned in provoking inflammation, among which may be enumerated wounds, 
bruises, and extremes of temperature; irritants of various kinds, as caustics 
and poisons, also those of smallpox, syphilis, and glanders. 
The fact that local ulceration can be produced the application of an 
animal poison to the body, and that such an ulcer, when formed, is capable 
of reproducing itself by inoculation, has furnished the basis for a variety 
of this process, called specific, in contradistinction to what is called common 
ulceration. 
Pathology.—Whether the ulceration consists in a simple abrasion, or in- 
volves the subjacent parts, we have the usual procession of inflammatory 
phenomena, namely, increased vascularity, manifested by unyisual redness; 
infiltration of tissue by the transudation of serum, lymph, and leucocytes, 
giving rise to swelling; together with undue sensibility and warmth. When 
the action involves only the epithelium, the cells are rapidly pushed forward 
and ejected before they become flattened and horny, giving to the surface 
a raw appearance. When a greater depth of tissue is implicated, as in ordi- 
nary ulcers, the papillae of the skin become enlarged by increase of their 
vascular loops, and by the liquid and cell infiltration of their connective PATHOLOGY. 
171 
tissue. The intercellular substance of the latter, as a consequence of the 
inflammation, undergoes softening, by which its corpuscles are liberated, and 
these, together with the migrated leucocytes, give rise to suppuration. 
In this way the involved tissues, whatever they may be,—epithelial, con- 
nective, muscular, bone, or even morbid growths,—become dissolved, sepa- 
rate into particles, or disintegrate by molecules, leaving an open sore or 
ulcer. Just here we reach a point which displays the relation between 
ulceration and gangrene. They are identical in kind, differing only in the 
amount of tissue involved at one time. In both there is a slough: in ulcera- 
tion it is only in particles, while in gangrene it consists of a mass of many 
particles. Mr. Paget, while admitting the general resemblance of the two 
processes, thinks there is a difference, stating in support of such distinction 
that a patient will go about with an ulcer, while a gangrene of the same 
dimensions would confine him to bed. 
Around the margin of such a sore there will be some thickening, produced 
by inflammatory cell infiltration, which infiltration is concerned both in a 
defensive work for the surrounding parts, and in a constructive one, designed 
to repair the breach already made. It is the presence of the first which 
resists the extension of an ulcer. 
When, however, the surrounding parts do give way, and the ulcer enlarges, 
it is not by absorption, or, if so, only in a very limited degree, but by molec- 
ular decay and ejectment. This decay and liquefaction are in part due, as 
has been shown by Mr. Groodsir,* to the new crowds of cells attracting to 
themselves the materials which should go to the nutrition of the affected 
tissues, the want of which hastens their dissolution. 
The discharge which flows from an ulcerated surface is at first a thin, yel- 
lowish fluid, often containing a little blood, sometimes mixed with shreds of 
dead tissue, and called ichor. This is a kind of sewage formed from the blood, 
serum, and part of the debris of the decomposing structures, and exercises 
some solvent power over portions of the dead and dying fragments of tissue 
included within the boundaries of the ulcer. These by being macerated in 
the fluid have their liquefaction thereby favored. This ichor possesses irri- 
tating properties, and, when brought in contact with sound parts, excites 
inflammation. This is well exemplified in the red and excoriated condition 
of the skin surrounding an open cancer. That these discharges are in part 
made up from the structures affected is quite evident from the reactions 
which they display when subjected to appropriate tests. Thus, in the ulcer- 
ation of bone the presence of the lime salts is readily detected by certain 
mineral acids. 
Wrhat becomes of the tissues, the absence of which creates the chasm or 
loss of substance at the seat of ulceration ? The answer to this question 
will, I think, be fairly stated when it is said that they disappear in two ways, 
—partly by absorption and partly by ejectment in the discharges. In the 
concealed variety, unless an opening occurs, it is altogether by absorption. 
Examples of this are constantly seen in those ulcerations which are con- 
nected with disease of the spine, or in those which are excited by the continued 
stroke of an aneurism against the vertebrae: to such the term ulcerative ab- 
sorption is quite appropriate. In these cases the order of removal is, first, 
the liquefaction of the organic part of the bone tissue, and next, such com- 
plete solution of the inorganic salts as to admit of their passage into the 
lymphatic and venous trunks. 
In the open ulceration the removal is not altogether by ejectment, although 
in the main it is so. It is the absorption of certain products of decomposed 
tissue, in this variety, which in some instances poisons the system and in 
other cases provokes inflammatory fever. 
When ulceration is established in order to empty an abscess, the most 
direct course towards the surface is taken, unless opposed by density or 
* Anatomical and Pathological Observations, page 15. 172 
ULCERATION. 
resistance of tissue. The sensibility of a part in a state of ulceration varies 
very much, depending greatly upon the activity of the accompanying in- 
flammation. Common laborers are seen every day attending to their occu- 
pations with extensive ulcerations on the limbs, without complaint or great 
inconvenience, while in others a small sore, one which is red, hot, swollen, and 
painful, with no small constitutional disorder, will confine them to the house. 
In the first the inflammation is chronic, in the second it is acute. When situ- 
ated in localities where much motion exists, there is usually considerable pain 
present, as when over the olecranon process of the ulna or the patella, or 
over muscles like the hamstrings and gastrocnemii. Intestinal ulcerations 
often produce extensive destruction, even perforating the entire thickness of 
the bowel, as occasionally occurs in the glands of Peyer in typhoid fever, 
and yet the patient be entirely unconscious of pain. Not unfrequently the 
pain is paroxysmal, is described as boring or gnawing, and comes on in the 
evening, or when the patient gets warm in bed. These are characteristic of 
the ulceration of bone, either from syphilitic or other causes. Sometimes 
the sensibility takes the form of intense itching, especially where the ulcera- 
tion is situated on the vulva, anus, scrotum, or inside of the thighs, and so 
intense may this be as almost to drive the unfortunate sufferer to the verge 
of insanity. 
Location.—Scarcely any portion of the body can claim exemption from 
ulceration, especially if the cause be of a specific origin; but the lower ex- 
tremity, particularly below the knee, is the part most commonly attacked by 
the disease. In this locality it is generally confined to a limited portion of 
the limb,—namely, above the malleoli or at the lower third of the subcutane- 
ous part of the tibia. The election of this region is due to several causes, 
which will be noticed when treating of ulcers. 
Age and Social Condition.—Common ulceration is a disease of middle and 
advanced life, and is met with most commonly among the poor and indigent, 
simply because in these we have too often a combination of conditions, such as 
exposure, defective diet, and indifference to hygienic measures, which favor 
inflammatory attacks. When the disease is met with in the young, it is due 
to specific causes, such as scrofula or inherited syphilis. 
Tiie Work of Repair.—After the inflammatory new formation in a part, 
and its consequent destruction, we have the molecular separation or detach- 
ment taking place in the form of a slough saturated with ichor. This slough, 
which gives to the ulcerated surface a grayish appearance, is finally dissolved 
or washed out in the discharges. The discharge or ichor, which was of a sani- 
ous character, greatly diminishes in quantity. A new transudation of cells 
and fibrinous lymph takes place into the surrounding living tissues; the ichor 
Fig. 171. 
a to c showing thickened edges of ulcer; b, the hypertrophied papillae beneath the open surface.— 
From Billroth, after Forster. 
is replaced by a more consistent, yellowish discharge, which is pus; the circum- 
ference of the ulcerated part becomes a little tumid from inflammatory infil- 
tration, which diminishes outwardly. (Fig. 171.) Into the midst of the new 
cell formation shoot myriads of vascular loops, projected from the contigu- THE WORK OF REPAIR. 
173 
ous vessels; each convolution of a vessel gathers about itself a colony of 
cells, and gives to the entire surface of the ulcer the appearance of numerous 
red points closely massed together, each of which constitutes a granulation, 
and indicates the vascular districts of the natural tissue. A granulation 
consists, therefore, of a loop of blood-vessels, a crowd of migrated leucocytes, 
and fibrinous lymph. (Fig. 172.) Out of this granulation-tissue the chasm 
is to be filled; without it repair is impossible. 
The edges of the ulcer soon lose their abrupt definition, and become 
rounded, or decline gradually towards the 
centre. The continued proliferation of this 
new formation finally fills the chasm, not 
by rising to the level of the surrounding 
skin, but by the descent of the latter from 
the removal of the infiltration and by con- 
traction to the level of the granulations. 
The ulcer contracts by a shortening of its 
fibrous tissue and by the deep layer of 
cells becoming developed into rudimentary 
connective-tissue filaments united together 
by intermediate fibrinous material, while 
many of the more superficial cells are con- 
verted into pus-corpuscles, and are seen 
adhering to the surface of the ulcer as a 
yellowish fluid. As the ulcerated part be- 
comes filled by this new formation, the 
pointed or granular appearance will be 
less noticeable, in consequence of the union 
of contiguous granulations. 
The importance of these interesting bodies entitles them to a somewhat 
more detailed notice. I have said that granulations consist of convoluted 
loops of capillary blood-vessels, arteries, and veins, embedded in the midst of 
round, nucleated, migrated leucocytes and fibrinous lymph. It is necessary 
for their production that the acute inflammation shall have subsided. They 
vary in size from that of a millet- to that of a mustard-seed. When healthy 
they present a beautiful florid hue, the walls of their vessels being exceed- 
ingly delicate, and often give way, pouring out blood, when rudely touched. 
They are not known to possess either nerves or lymphatics, although en- 
dowed with both sensation and absorption, as proved by the fact that the 
patient feels when they are touched, and that the application of morphia or 
arsenic will be followed by narcosis or poisoning. Their sensibility may be 
due to their relation with the nerves of the contiguous tissue, like that of 
the teeth or of the long, stiff hairs about the mouths of certain animals, and 
their power of absorption may be through the venous part of the capillary 
loop. 
They are not confined to open surfaces, but may be seen in the interior of 
diseased joints or the cavities of inflamed bones. While they grow from any 
structure, yet the subcutaneous connective tissue furnishes the most congenial 
soil for their rapid development. Like any other tissue, they are liable to 
become diseased. Sometimes they grow with a rank exuberance, rising above 
the skin and spreading over its surface like a mushroom, constituting the so- 
called “ proud flesh.” Sometimes they lose their characteristic color, become 
pale, flabby, oedematous, and devoid of sensibility. They may also shrivel 
up, assume a blue color, become exquisitely sensitive, bleed on the slightest 
touch, and in addition are frequently covered with dark crusts consisting of 
blood and serum. To the educated eye of the surgeon they not unfrequently 
convey important information of impending trouble, their shrunken, pale, 
and dry appearance often ushering in an attack of pyaemia or hospital 
gangrene. 
Cicatrization.—When the skin and granulation-tissue attain the same level 
Fig. 172. 
Loops of blood-vessels surrounded with cells 
and intercellular substance, constituting granu- 
lation-tissue. 174 
ULCERATION. 
the surface of the latter becomes smooth, glossy, and less granular by the 
union of contiguous granulations, the chasm contracts, the pus diminishes in 
quantity at the place of juncture between the skin and new formation, and at 
this point a delicate red line is seen, followed by a thin blue film, which grad- 
ually advances towards the centre ; this is the formation of the epidermis, or 
new skin, and consists in the transformation of the round cells into flat ones. 
This constitutes the process of cicatrization. It begins at the circumference, 
and is doubtless determined by contact with the old skin, the influence of 
which is evident from the fact that the farther removed from the latter the 
slower is the process of cicatrization. There is no evidence that cicatrization 
ever takes place in any other way. The supposition that islands or isolated 
patches of epidermis can form at irregular points over a granulating surface, 
independent of the old skin, is not supported by any well-established cases. 
On the truth of this statement is founded the practice of skin-grafting. 
Fig. 173. 
Section through the border of a granulating ulcer, showing the cell-changes on its surface from 
the point of cicatrization inward : a, surface of ulcer covered with pus; b, below the pus-cells, the 
true granulation-tissue, consisting of cells and loops of vessels ; c, deepest cells, assuming spindle 
forms on their way to connective tissue; e, epithelial formation, or cicatrization begun; f, cells 
beginning to take on epithelial forms; and g, cells in a condition preliminary to epithelial trans- 
formation.—From Rindfleisch. 
The surface of an ulcer just commencing to cicatrize will, if examined from 
the centre to the circumference, be found to present well-marked distinctions. 
Farthest from the edges will be seen abundance of pus-cells; within these, 
and nearer the edge, others which are about to assume epithelial or flattened 
forms ; still farther in, cells which are in an advanced stage of transition from 
round to flat or epithelial cells ; and at the borders of the ulcer, epithelial cells 
fully developed. (See Fig. 173.) 
While the cicatrization is going forward, the underlying granulations un- 
dergo important changes. Many of the cells disintegrate and disappear by 
absorption, while others become spindle-shaped. This change, with the simul- 
taneous fibrillation of the intercellular or flbrogenous substance, forms connec- SIMPLE ULCER. 
175 
tive tissue. When the process is complete the result is called a cicatrix. At first 
this is quite red, but as time advances it becomes paler, in consequence of the 
contraction of the adjacent connective tissue obliterating the blood-channels 
or leaving them as solid filaments, and at last, as its vascularity diminishes, 
it becomes white, presenting a striking contrast with the adjoining skin, so 
that the cicatrix or scar remains forever visible. Wonderful as the restora- 
tion is, the new tissue which replaces the lost never attains the perfection of 
the latter. It is dryer and more dense, does not possess hair, has no sudor- 
iferous or sebaceous glands, and seems never to lose the tendency to con- 
traction, so that frequently through this persistent property the most serious 
deformities are produced, such as are seen after burns or scalds, causing 
eversion of the eyelids and lips, or drawing the chin down upon the breast. 
The low vitality of a cicatrix renders it less capable of defending itself against 
either external injury or morbid conditions of the general system: hence a 
little undue pressure, a contusion, or an attack of disease in which the blood 
has been vitiated, will suffice to provoke its ulceration or to engraft upon it 
that singular condition known as keloid. 
ULCERS. 
After the foregoing observations on ulceration the subject of ulcers may- 
be next considered. 
What is an ulcer? It is a granulating surface following ulceration or 
mortification. 
Classification.—Scarcely any two writers agree on this subject; and to at- 
tempt anything like a historical enumeration of the various divisions adopted, 
from the formidable ones of Sir Everard Home, Benjamin Bell, and Sir Astley 
Cooper to the simple one of Mr. Sjnne, would be as unprofitable as it would 
be laborious. The unnecessary multiplication of varieties, together with the 
ridiculous refinements which some authors have adopted, gives such gigantic 
proportions to the subject that students are apt to turn aside from the study 
of the subject in despair of ever being able to master the task. 
I shall divide all ulcers into two classes,—local and constitutional. Under 
the head of local ulcers are included all those which depend for their exist- 
ence on external or local causes, such as contusions, cuts, burns, scalds, 
varicose veins, dead bone, etc. Under the head of constitutional ulcers are 
classed all such as owe their beginning and continuance to a vice of the 
general system, a dyscrasia, such as exists in cancer, scrofula, syphilis, or 
variola, or those that arise from a cause that affects the proper distribution 
of nerve-force, as paralysis. 
Common or Local Ulcers.—There are two varieties of common or local 
ulcers, namely, the simple and the complicated. 
Simple Ulcer.—As it is only by an accurate knowledge of the character- 
istics of the simple sore or ulcer that we are able to appreciate those con- 
ditions which constitute complications or deviations, it will be necessary to 
describe its peculiarities and appearance. 
1. Location.—The simple ulcer may be situated on any part of the body, 
though generally it is seen upon the inferior extremity, and largely confined 
to the lower half of the anterior and outer portion of the leg. The reasons 
for this preference are obvious. This part is much exposed to injury, as well 
as to variations of temperature. Over the subcutaneous surface of the tibia 
there is little cellulo-adipose material, in consequence of which the vitality 
of the parts is endangered by slight contusions. In addition to these causes 
another may be stated as arising from the remote distance of the parts from 
the heart, by which the circulation through the veins of the leg, always much 
under the influence of gravity, is more or less embarrassed. 
2. Form.—These ulcers may assume a variety of forms, depending some- 176 
ULCERS. 
what on the manner in which the determining cause operates,—whether 
concentrated, like a blow, or diffused, like a scald; whether produced by a 
cut or a laceration: yet the prevailing tendency is to assume a round or oval 
form. 
3. The borders are smooth, rounded, free from irregularities or indentations, 
and shelve off with a gentle declivity towards the ulcer. The skin for a 
short distance around is a trifle more consistent or firm, from inflammatory 
infiltration, and with a degree of redness slightly greater than the normal 
condition, but is without marked induration or unusual sensibility. 
4. The depth depends somewhat on the amount of tissue destroyed: it is 
deceptive, being less than it appears to be. 
5. The granulations are florid and acuminated, giving to the surface of the 
sore a granular appearance, possess a considerable degree of elasticity, do not 
bleed when gently touched, and never rise above the level of the surrounding 
skin. 
6. The discharges consist of healthy pus, which is not in excess, and which, 
being neutral in its reaction, is bland and free from all irritating properties 
either to the granulations or to the skin. 
In the development of such an ulcer there may be present acute inflam- 
mation, the parts being intensely injected with blood, hot, swollen, purple, 
oedematous, and exceedingly painful. When the ulcer is situated on the leg 
the entire limb may participate in the suffering. The constitution will sym- 
pathize with the local disturbance, as manifested by high febrile excitement, 
with headache, dry and hot skin, parched mouth, coated tongue, and loss of 
appetite, with disordered secretions. After the destruction has been effected 
and the slough ejected, these symptoms subside, and the ulcer puts on the 
appearances previously detailed. 
Treatment.—When the structural change is simply epithelial, giving rise to 
excoriation, bathing the parts with warm water and applying the benzoated 
oxide of zinc ointment, or dusting with a powder composed of iodoform or of 
equal parts of calomel and prepared chalk, will usually remove the disease. 
During the inflammatory stage—that is, preliminary to the formation of an 
idcer—the treatment should be vigorously antiphlogistic; the object being 
to limit the destruction of tissue. The patient should be kept at rest in the 
recumbent position, and the part, when feasible, elevated, or placed on an 
inclined plane, or in a sling, so as to lessen the force of the circulation. If 
the inflammation and tension are great, blood may be freely drawn by 
leeches or cups. I have never seen irritation from leech-bites when prop- 
erly placed. They should be applied a little distance from the disease, so 
that the incisions may not add to the local irritation. After the abstraction 
of blood, refrigerant lotions of cold or cool water, or of lead-water and laud- 
anum, should be employed, applied by saturating cloths with the liquid and 
renewing as often as they become dry. Irrigation, after the manner de- 
scribed in the treatment of acute inflammation, is a very efficient mode of 
applying cold. After the acute symptoms are past, some caution is requisite 
in the use of this agent. It may be continued too long, and so depress the 
vitality of the structures involved as to favor, rather than prevent, their de- 
struction. Anticipating the possibility of such a result, a moderate degree 
of warmth may be substituted by using lukewarm water, or by covering the 
dressing with a piece of oiled silk to prevent the evaporation which intensifies 
the cold. The bowels should be freely opened with a saline cathartic, pre- 
ceded by three or four grains of calomel, after which the neutral mixture, con- 
joined with small doses of morphia, may be given every two or three hours. 
The diet should be restricted to the lightest articles, such as milk, arrow-root, 
barley-water, and broth. When the definition between the dying and living 
tissues is formed, and the former begins to soften down and liquefy, a warm 
flaxseed-meal, bread-and-water, or yeast poultice renewed every five or six 
hours will hasten the process of separation. Preliminary to the application 
of the poultices the parts should be disinfected by washing with the perman- COMPLICATED ULCERS. 
177 
ganate of potash or chlorinated soda. The diet, at this stage, should be gen- 
erous, such as eggs, beef-essence, or even solid food, if the patient’s stomach 
can properly dispose of such. This treatment is, of course, based on the 
existence of an unimpaired, vigorous constitution, and an active inflamma- 
tory condition. Cases will occur in which, from a feeble, broken-down state 
of health, a nutritious diet, stimulants, and tonics will be demanded from the 
beginning to the termination: it involves no very great amount of judgment 
to determine which will be the proper course to pursue. 
When the preliminary work of destruction and separation has been accom- 
plished, and that of construction or repair has begun, the surgeon has little 
to do. The ulcer must never be rubbed with a sponge or rag; all redundant 
matters must be washed away by allowing a stream of warm water to fall 
upon its surface from the pores of a sponge. A piece of lint saturated with 
tepid water or a solution of boracic acid should be laid over the sore, and 
kept in place by the turns of a roller applied smoothly and with uniform 
pressure. The part must be maintained at perfect rest, for which purpose it 
is often necessary to use a splint in order to secure true immobility. Under 
such a course ulcers of the character described will usually speedily heal. 
Complicated Ulcers.—From the typical ulcer described there are many 
shades of departure, but when carefully studied these deviations can be 
compressed into two divisions, viz., ulcers with an exuberance and ulcers with 
a deficiency of new or reconstructive formation. 
Ulcers with Excess of New Formation.—This complication may exist from 
the beginning of the sore, or may be subsequently engrafted upon it from 
local or constitutional influences. In such an ulcer the sensibility may be 
moderate or may be intensely acute; the surrounding parts, cedematous, 
red, or purple; the edges, swollen and indurated; the sides, perpendicular, 
irregular, or everted; the form, round or oval; and the depth, variable 
and uneven. The granulations ai’e redundant, and the discharges profuse, 
thin, and frequently intermingled with blood. When the surrounding parts 
are red, swollen, and tender, the edges perpendicular, and the granulations 
either shrunken or turgid and of a dark-red color, bleeding when touched, 
or streaked over with little blood-clots and often associated with sanious dis- 
charges, we have what is called by many writers the irritable sore. These 
conditions are generally the result of an inflammatory invasion of the ulcer, 
though, when present in a very mild degree, they may be caused by hyper- 
emia alone. This variety is frequently met with in nervous females, particu- 
larly such as suffer from disturbances of the digestive apparatus, attended 
with flatulent and acid eructations. 
In this complication there is an active cell proliferation both in the walls 
of the ulcer and in its granulations, but notwithstanding this the latter do not 
grow. Their dark-red color indicates obstruction to the veins from the in- 
flammatory infiltration at the edges of the ulcer pressing upon their trunks, 
and hence the blood is too long delayed in the new tissues, which become 
asphyxiated from containing more carbonic acid than is consistent with 
construction or cell life. 
When the granulations, rather than the borders, of the ulcer become sur- 
charged with blood, and the transudation goes on with great activity, the 
new formation increases with marvellous rapidity, overtops the sides of the 
sore, and spreads over the surrounding parts even for inches. This is the so- 
called fungous ulcer. (Fig. 174.) I have seen it most commonly on the calf 
of the leg. In severe cases it is a formidable-looking growth, and I have 
known limbs with such an ulcer condemned to amputation, under the im- 
pression that the disease was malignant. 
When the granulations are not only exuberant but pale and bathed in a 
thin serous discharge, we have the cedematous ulcer. 
If the surrounding parts become suddenly of a dusky red color, hot and 
swollen, with darting or dull pains involving the entire leg, if the discharges 178 
ULCERS. 
change to a blood-stained serum, the ulcer enlarging by inflammatory de- 
struction of its sides, and its granulations becoming necrosed, forming a 
gray, shreddy, ash-colored slough, like wet felt, and if accompanying these 
local conditions there is a quick, irritable pulse, with fever, headache, rest- 
lessness, thirst, and disordered secretions, we have the sloughing ulcer. (Fig. 
175.) The proliferation of new formation in this variety is so active as to 
divert supply from the more stable constituents of the sore and consequently 
cause its death. 
Fig. 175. 
Fig. 174. 
Fungous ulcer. 
Sloughing ulcer. 
While it is possible for such complications as have been enumerated to 
arise in a person of good constitution from local irritation, violence, or im- 
proper applications, among which may be mentioned friction by the clothing, 
—a very peculiar and injurious excitant,—sour poultices, and irritating caus- 
tics, yet these are exceptional examples. As a rule, the local characteristics 
are but expressions of the general state of health. Thus, the irritable ulcer 
is often produced by excesses in eating and drinking; the fungous and ede- 
matous sore is determined by constitutional disturbances which are induced 
by an imperfect supply of good food, advancing years, lymphatic tempera- 
ment, anaemia, and disorders of menstruation; while the sloughing variety 
may be due to contact with foul, irritating dressings, or to dissolute and un- 
cleanly habits. 
Treatment.—Preliminary to all remedies is rest, absolute rest, in the re- 
cumbent position, and with the limb in a fracture-box or suspended by an 
anterior splint, especially if the patient is difficult to control. Next in im- 
portance is a diligent and searching inquiry into the habits and constitutional 
state of the patient. Generally it will be found that the digestive apparatus 
is at fault; and in order to unload the bowels and establish a healthy con- 
dition of the secretions of the intestinal and accessory glands, there is noth- 
ing more efficacious than a purge of calomel and jalap, ten grains each ; or, 
if a less energetic measure is indicated, eight or ten grains of blue mass may 
be substituted, followed, in an hour or two, by half an ounce of sulphate of 
soda or magnesia. 
Should there be pain and restlessness, opiates must be administered in 
combination with the neutral mixture or nitrous ether. One tablespoonful 
of neutral mixture or a teaspoonful of the sweet spirit of nitre with a six- COM FLIC A TED UL CERS. 
179 
teenth to a twelfth of a grain of morphia, every two or three hours, answers 
the best purpose. For four or five days the diet should be light, consisting, 
for the most part, of milk, animal broths, and farinaceous substances, after 
which it may be changed with advantage to one of a more solid kind. All 
highly-seasoned articles of food and stimulants must be interdicted. If the 
patient has been a habitual tippler, it will not be prudent to withdraw all 
stimulants, but the quantity should be limited to two or three glasses of wine 
daily. If whiskey or brandy be preferred, it is best given with milk. 
A person whose health has been seriously shattered by a life of excess, 
exposure, or want will require a sustaining treatment. The food should con- 
sist of beef-essence, milk, milk-punch, eggs, and broiled meats,—five or six 
grains of pepsin being administered with each meal to assist the digestion. 
Tonics will also be demanded. Six or eight grains of quinine should be taken 
in the course of the day, with or without iron, according to the state of the 
blood. Infusions of cinchona or of gentian, conjoined with the tincture of 
mix vomica or nitric acid, may from time to time be alternated with the qui- 
nine ; and if there be emaciation and progressive loss of strength, the phos- 
phorized cod-liver oil will prove very serviceable, provided it is tolerated by 
the stomach. 
Local Treatment.—The limb should be placed in an elevated, easy posi- 
tion. If' the parts are tender, red, and swollen, scarifications, or leeches if 
obtainable, should be applied a short distance from the sore, and the surface 
kept wet with a water-dressing, applied by irrigation, or by lajdng over it a 
piece of old linen or lint well saturated with tepid water and renewed as 
often as it becomes dry; or the method of Chapman may be adopted, which 
consists in taking pieces of lint two inches wide and sufficiently long to more 
than encircle the limb, which are to be wet with hot water and applied like 
adhesive plasters, beginning a short distance below and terminating some dis- 
tance above the ulcer, each strip overlapping somewhat the preceding one. 
These strips are to be next covered with a piece of oiled silk, and a flannel 
roller applied. The roller I regard as an indispensable part of the dressing 
of an ulcer; but the utmost care should be observed in its use. It should 
include the foot, and be laid on smoothly and with uniform pressure. To 
neglect these points is to damage rather than benefit the case. When there 
is much discharge from the ulcer, the lint should be wet with carbolated or 
boracie acid water (one part of carbolic acid to forty parts of water, or five 
grains of boracic acid to one ounce of water). Used in this way it absorbs 
and renders the discharges harmless, and should be renewed every second day, 
or oftener if a sense of discomfort is experienced. Few ulcers of the irritable 
kind will resist the water treatment, with rest and the correction of such 
constitutional disorders as may be present. In a few days the temperature, 
color, sensibility, and consistence of the parts about the ulcer will abate, 
the granulations begin to assume a healthy color, and the work of repair 
commence. 
In cases where the surface of the ulcer is obstinately irritable, not yielding 
to the water treatment, the application of a solution of chloral (twelve grains 
to the ounce of water) or dusting with iodoform often gives decided relief. 
A solution of the nitrate of silver (twenty or thirty grains to the ounce of 
distilled water) brushed not only over its surface but also for some distance 
around will exercise the happiest effect in diminishing the sensibility and 
converting it into a healthy sore. 
Should there be severe pain of a neuralgic kind which can be referred with 
certainty to the proper nerve, the latter should be divided, as advised by Mr. 
Hilton. 
When there is unusual proliferation of the granulation-tissue,—as in the 
fungoid ulcer,—or when it becomes oedematous, a condition ordinarily as- 
sociated with excessive growth, the indication is to cut off the redundant 
blood-supply which determines this excess. To effect this there are two 
methods,—compression and excision. The first is adapted to all cases in 180 
ULCERS. 
which the new formation only slightly overtops the margins of the ulcer; 
and when conjoined with agents possessing slightly astringent and escharotic 
properties, nothing can be more satisfactory. In carrying into effect this 
plan of compression, all adherent matters should be removed with a wash of 
permanganate of potash, a layer of pulverized loaf-sugar or exsiccated alum 
sprinkled over the granulations, and two or three strips of adhesive plaster 
drawn tightly across the ulcer, covering and extending a little beyond its 
surface. A piece of patent lint should next be placed over the plaster, and 
the usual roller applied. This dressing must be removed every two or three 
days and renewed as in the first instance, until the new tissue is reduced 
below the level of the skin. When thus brought within the proper limits, 
this dressing may be laid aside and one of lime-water substituted, the appli- 
cation of which consists in saturating a piece of patent lint with the liquid, 
placing it over and beyond the ulcer, covering it with a patch of oiled silk, 
and making all fast by a roller, firmly applied. 
The second method—that by excision—is proper when the granulations 
are not only above the level of the skin but spread over its surface like a 
mushroom. For such growths, caustic potassa and the hot iron are recom- 
mended by some surgeons; but excision is simple and rapidly effective. The 
operation is the work of a few moments, and consists in paring the mass 
away to the proper level with a keen-edged scalpel. The bleeding, though 
profuse at first, will soon cease, after which the water-dressing should be 
applied. 
When the granulations of an ulcer lose their vascularity and die, forming 
an ash-colored or gray mass, either with or without any marked alteration 
of the edges, it forms the sloughing ulcer already described. This must not 
be confounded with phagedamic destruction, a disease or morbid process 
altogether different, and which, except from causes of a specific nature, such 
as give rise to hospital gangrene or syphilis, is not seen in connection with 
ulcers. 
To correct this complication, our remedies, in many cases, will have to be 
directed to the system at large as well as to the local condition. Any dis- 
order of the digestive organs which can be discovered must be corrected by 
laxatives, the use of tonics, a nutritious diet, and stimulants. 
In order to get rid of the necrosed tissue, and establish a free circulation in 
the ulcer by favoring the removal of the cell infiltration, a bread-and-water 
or flaxseed-meal poultice, moistened with a little lead-water and laudanum, 
should be applied, at each renewal the surface of the sore being cleansed with 
a wash consisting of one part of nitric acid to twenty parts of water. After 
two or three days’ poulticing it may be necessary, in order to secure a further 
removal of the inflammatory infiltration, to paint the surrounding parts with 
Lugol’s solution of iodine, to which may be added a little pulverized white 
sugar and gum acacia to render it less irritating. 
Ulcers with Deficient New Formation.—These form a very large proportion 
of all the ulcers which the surgeon is called upon to treat. They abound 
in our almshouses and at our dispensaries, and are the bane of the laboring 
classes, both male and female. They are often multiple, and of many years’ 
standing. It is no uncommon thing to meet with such sores which have 
been in existence for ten or fifteen, and in some cases twenty or more, years. 
They are sometimes termed chronic or indolent, and sometimes callous ulcers, 
and may have possessed their structural and vital peculiarities from the be- 
ginning, or may have begun as simple sores and been gradually transformed 
into the complicated ones. An ulcer of this kind is variable in form: it may be 
round, oval, irregular, or may change from one shape to the other in the course 
of its eventful career. The same is true of its depth, although generally it is 
deeper than the simple form. The edges are sharply defined, abrupt; they may 
be inverted or everted. The granulations are generally small and pale, often 
absent, but may be redundant, flabby, and so saturated with a watery serum ULCERS WITH DEFICIENT NEW FORMATION. 
181 
as to be translucent. The discharges are thin, occasionally consistent, blood- 
stained, and offensive. The sensibility is very dull. Having been the subject 
of both acute and chronic inflammation, the parts below and around the ulcer 
are thickened and indurated ; the transudation, having gradually ripened into 
connective tissue, has by condensation formed a wall compressing the blood- 
vessels and preventing a free access of blood to, and its return from, the 
chasm to be repaired. (Fig. 176.) 
The venous channels necessarily 
becoming dilated have given to 
the surface of the surrounding 
parts a dark-red, blue, or deep- 
purple color. The skin is often 
covered by eczema, or it is smooth, 
glazed, and shining, and in aged 
persons whose legs are very thin 
it is frequently of a dark-brown or 
drab color. In the negro it assumes 
sometimes a piebald appearance, 
from the absorption, in patches, of 
the pigment-cells. 
These ulcers, when of long stand- 
ing, are thought by some authors 
to perform a vicarious office for 
the system; and it is, perhaps, 
the influence of a popular notion 
of this kind which renders many 
persons thus affected disinclined to 
apply for surgical relief. I think there is no ground for such an opinion in 
the observation of those who have had the largest opportunities for forming a 
correct judgment. 1 am sure that, after a very large experience in the Phil- 
adelphia Hospital,—an institution which, from the character of its inmates, is 
peculiarly rich in this class of disease,—I can recall no instance which would 
give any support to such an opinion. Should, however, any symptoms of 
this kind arise, they are to be counteracted by keeping the bowels loose and 
restricting the diet. 
The vicarious function imputed to ulcers, especially that of menstruation, 
I find has been very rarely met with. Blundell * instances the case of a girl 
in St. Thomas’s Hospital who had a discharge from an ulcer on the hand 
which replaced a uterine discharge for three successive periods; another case 
is mentioned by Ash well f of a nurse in Guy’s Hospital who menstruated 
regularly from a large ulcer on the thigh ; also one by I)ewees,| and one 
each by Whitehead,§ Mason,|| Boring,and Wiseman.** In Mason’s case, 
a girl commenced menstruating at eight and continued until her eleventh 
year, when the discharge ceased for two years, during which time an abscess 
formed on the right cheek, suppurated in the centre, and bled from the edges; 
and blood would occasionally ooze from its surface even after it healed. The 
instance given by Boring was that of a colored woman who ceased menstru- 
ating at thirty-two, when blood flowed from an ulcer for a number of days 
corresponding to her former menstrual period. Sometimes a bleb formed 
monthly alongside of the ulcer, which, on being punctured, yielded blood. 
Finally the ulcer became so large that amputation of the leg was performed, 
after which, at menstrual periods, blood-sacs or blebs would appear on the 
stump. Wiseman’s case was that of a “gross, full-bodied maid, twenty-three 
Fig. 176. 
Indolent ulcer, or one with deficient proliferation or new 
formation. 
* Blundell, Principles and Practice of Obstetrics, by Lee, page 632. 
f Ashwell, Diseases of Women, by Goddard, 1845, page 76. 
i Dewees, Treatment of Diseases of Females, 1828. 
ij> Treatise on Abortion and Sterility. 
|| Mason, Edinburgh Medical Journal, 1866. 
New York Journal of Medicine, 1856, and Ranking’s Abstract, vol. xxiii. page 258. 
** Richard Wiseman, Chirurgeon to Charles II., 3d edition, London, 1719, page 311. 182 
ULCERS. 
years old, wanting her menstrual discharge; an abscess pushed out from the 
inside of the thigh, which resulted in a callous ulcer, discharging blood on 
periodical occasions.” 
1 am not disposed to believe that the peculiarities of this ulcer, because it is 
found among the poor and laboring classes, depend upon constitutional causes, 
as the result of malnutrition, insufficient food, intemperance, etc. Those vari- 
eties which we have already considered as complicated by excessive prolifera- 
tion are much oftener referable to such causes. On the contrary, the agencies 
which operate to prevent healing, and to continue the ulcer indefinitely, are 
local, such as exposure, carelessness, indifference to ordinary acts of cleanli- 
ness, and great muscular exertion in the erect position. 
A common complication of ulcers is that arising from a varicose condition 
of the veins of the leg, or from the presence of dead bone, both of which may 
also form determining causes of ulcers. When the veins of the leg, as the 
radicals of the saphena interna or externa, become dilated, their trunks tor- 
tuous, and their valves disabled and useless, the embarrassment to the venous 
current cannot fail to influence the capillary circulation in a manner favor- 
able to congestion of the tissues, and in this way maintain constantly one 
factor of inflammation, so that, on the slightest provocation by a cut or a 
bruise, the latter process is fully established, passing on to ulceration and 
the formation of a sore, which is termed the varicose ulcer. 
It is unnecessary to discuss the propriety of admitting this ulcer into our 
surgical nosology. The opinion of Mr. Gray, that varicose veins are rather 
a result of than an antecedent to ulceration, meets no confirmation in my 
observation. I do not say that such a condition of a limb is the exciting 
cause of an ulcer, but that it is a very strong predisposing one. An injury 
which from its trifling nature would pass over without damage or evil con- 
sequences to a sound leg will, in one with imperfect veins, be followed by 
ulceration; and, further, unless this imperfection is provided for by suitable 
pressure, the resulting ulcer will prove exceedingly difficult to heal. Inde- 
pendent of direct injury, such an ulcer may form by the extreme tenuity or 
thinning of the wall of a vein in a varicose condition, until at last the in- 
flammation of the overlying skin is established, followed by ulceration; or 
the vein may give way, attended with a profuse bleeding, and leave, after 
the vessel is closed, an ulcer in the contiguous parts. It is in these ulcerated 
varicose limbs that eczema is so often present. 
When inflammation attacks the periosteum of a bone, or the bone itself, 
the disease may extend to the overlying soft parts and terminate in suppu- 
ration and an open sore. Such an ulcer depends for its existence upon the 
diseased bone. 
Treatment.—The treatment of indolent ulcers, so often avoided, is not 
troublesome when their pathology is understood. The difficulty does not 
lie in the ulcer, but in the surrounding walls; it is not in the quality of the 
blood, but in the manner of its supply. The fact that the subjects of these 
ulcers are obliged, from the very nature of their pecuniary circumstances, to 
continue their employment, is a hinderance, but not an insuperable one, to 
the cure. 
Save in exceptional cases, I do not believe in the constitutional origin of 
these ulcers; a glance at the sturdy Irish men and women who are so often 
the victims of this variety of disease will reveal enough to prove a sufficient 
refutation of such a doctrine: nevertheless the prudent surgeon will carefully 
inquire into the state of the general health, and correct any evils which may 
exist. I have lived long enough to learn that it is a waste of time and words, 
so far as ulcers are concerned, to dilate to this class of patients upon the 
importance of a well-regulated diet and abstinence from intoxicating drinks. 
In most instances, in this country, their food, though plain, is as good, if not 
so delicately prepared, as that of the higher classes, and if they do indulge 
in stimulants the evil effects are measurably counteracted by the active and 
laborious nature of their callings; their habits are much less pernicious, in- ULCERS WITH DEFICIENT NEW FORMATION. 
183 
deed, than those of men who, after eating highly-seasoned food and drinking 
wines, spend the day in indolence and ease. 
First, let the parts be thoroughly cleansed. Direct the patient, on his re- 
turn from work in the evening, to place the leg in a bucket of warm bran- 
water—that is, water in which a small bag of wheat bran has been immersed 
for a short time—and allow it to soak for at least one hour; then, wiping it 
clean and dry, to envelop the parts with a towel wet in warm water or in a 
lotion of boraeic acid and covered with oiled silk. This should be renewed 
in the morning before the patient goes to work. The same course should 
be pursued for two or three consecutive evenings. This water-bath and 
dressing will serve to macerate and soften the indurated tissues about the 
ulcer, by which a more perfect circulation is established: indeed, until this 
marginal induration is dispersed or melted away, all stimulating dressings 
to the surface of the sore are powerless for good. The next step involves 
the aid of an experienced hand. A piece of patent lint, doubled on itself 
and large enough to extend three inches beyond the limits of the ulcer, is 
soaked in warm water containing a very little alcohol, placed over the parts, 
and covered with oiled silk. A roller is next applied with the greatest pre- 
cision to the foot and leg. This should be removed and reapplied every 
morning for four or live days, when it will usually be found that the hard- 
ness at the circumference and base of the ulcer has diminished, and that the 
granulations have begun to crop out. Now is the time for a more permanent 
dressing,—that is, one with adhesive strips, preliminary to the roller. This 
is commonly known as the method of Baynton,—a surgeon at Bristol,*— 
and consists in encircling the limb with adhesive strips two inches wide, com- 
mencing one inch below the ulcer, and terminating two or three inches above 
it. The plasters, according to this plan, were to be applied first over the part 
of the limb opposite the sore, and the ends made to cross over the latter two 
or three inches, each overlapping the preceding by one-third of its width, after 
which the foot and leg were to be bandaged with a calico roller. The domi- 
nant idea of Baynton was that of bringing the edges of the ulcer towards 
each other; yet that he had not overlooked the principle of equable pressure, 
as asserted by Mr. Critchett, is evident from the use of the roller firmly cov- 
ering in the foot and leg. This plan of Baynton as improved by Scott,f of 
London, and afterwards by Mr. Critchett,| consists in applying adhesive strips 
first to the foot, leaving out the point of the heel, and thence extending them 
up the leg, over the ulcer, ending at or above the knee, and over all adjusting 
a roller bandage. As a rule, I do not think that American surgeons adhere 
rigidly to either of these plans. The one which I ordinarily employ, when 
the ulcer is near the malleoli, is as follows. Let the patient be seated on a 
chair, with the foot placed upon a stool of equal height; with a razor remove 
the hair from the limb, after which it should be elevated for a few minutes, 
in order to drain away all redundant blood. This done, the surgeon begins 
the application of adhesive strips. These should be from three-quarters of 
an inch to one inch in width, and long enough to extend three-fourths of the 
distance around the limb. The first strip is applied over the instep, termi- 
nating on the sole of the foot; overlapping this about a third of its width is 
placed a second ; and so on successively until the ankle is reached. Placing 
the middle of a second series of strips behind the heel, their ends are brought 
forward and crossed, the first over the instep and ankle; from thence they 
are continued up the leg, ending three inches above the ulcer. Those over 
the sore should have minute perforations, to allow the discharge to pass out. 
In applying these plasters to the ulcer, some place the middle of the strips 
across its surface, and then, drawing on each end, secure them simultaneously 
to the leg. It is much better, in order that the edges may receive firm press- 
ure, to apply one end of the plaster at a point nearly opposite the sore, and 
® Descriptive Account of Treating Old Ulcers of the Leg, by Thomas Baynton, 1792. 
f John Scott, Treatise on Diseases of the Joints, 1828. 
j Critchett on Ulcers. 184 
ULCERS. 
bring the other over, making it fast on the other side. While the limb is 
still in the elevated or horizontal position, a roller bandage must be carefully 
applied from the toes to the knee. (Fig. 177.) 
The roller is absolutely necessary to the completion of the dressing, as it 
not oidy aids ,in equalizing the support, but supplies additional pressure to 
the indurated tissues. Again, even at the risk of repetition, I would insist 
upon its smooth, even, and uniformly distributed support, otherwise it will 
come far short of its design. In two days 
it will be proper to take off the bandage, 
and, removing with a sponge the dis- 
charges which may have come through 
the plasters, again apply it as before. 
The adhesive strips should not be dis- 
turbed. if possible, for a week ; though, 
if the leg becomes painful and the dis- 
charges profuse, they may be loosened 
earlier and renewed from the ankle up- 
wards. Dr. Hunter, who has had much 
experience at our dispensaries in treating 
this class of patients, always applies a 
little oxide of zinc ointment over the 
margins of the ulcer before the strap- 
ping: it tends to prevent eczema by 
defending the skin. 
If the plan above described is care- 
fully followed out in all its details, most 
ulcers of the class under consideration 
will be brought to successful cicatrization. When the ulcer is higher up. say 
five or six inches above the ankle, I have not found it necessary to begin the 
strapping at the foot, but two inches below the sore, terminating at the same 
distance above it. The roller will give the needful support to the other parts. 
The rubber bandage, first recommended by Dr. Martin, of Boston, in the 
treatment of indolent ulcers, will often be found more convenient, and even 
more efficient, than the process by strapping. The gum bandage should be 
two and a half inches wide and four yards long, and should have two pieces 
of tape secured to the terminal end, with which to fasten the roller to the 
limb below the knee. The limb, having been wrell cleansed with soap and 
warm water, is to be elevated in order partially to empty the veins ; then the 
roller, beginning at the metatarso-phalangeal articulation, is made to cover 
in the foot and leg by spiral turns, without reverses, each turn overlapping 
one-third of the preceding one and being drawn with an even degree of firm- 
ness. The bandage should be removed at night after the patient retires, the 
limb being wiped dry, and is to be again applied in the morning before the 
erect posture is resumed. Nothing should be interposed between the skin 
and the roller. An objection is sometimes urged against the dressing that it 
keeps the limb wet with perspiration, the odor from which is not always 
pleasant. To obviate this I direct the bandage to be perforated with numerous 
holes, which, while they do not lessen its value, allow the moisture to escape. 
Occasionally an old ulcer will be met with Avhich will prove invincible under 
ordinary treatment, and it will be necessary to resort to other agencies pre- 
paratory to the strapping or bandaging. The stronghold of its obstinate re- 
sistance will be found in the surrounding induration, the tissues being matted 
together by the products of chronic inflammation; and until this is removed 
it is impossible for the work of new formation to commence. If it is red 
and very sensitive, a few bold incisions, made down to the deep fascia, will 
prepare the way for the water-dressing and pressure. Some advise paring 
the indurated borders away with a bistoury. I once thought well of it, but 
I am now satisfied that the operation in most cases is unnecessary. If un- 
due sensibility does not exist, a fly-blister covering the sore and parts beyond, 
Fig. 177. 
Plaster strips applied, and the roller com- 
mencing to cover them in. SKIN-GRAFTING. 
185 
as employed by Mr. Syme, will not only unload the overstrained vessels, but 
act as a salutary stimulus to the sore ; after which pressure by adhesive strips 
and the roller or by the gum-elastic bandage will complete the work of cure. 
When great sensibility is associated with marginal infiltration and an arrest 
of repair, the application of a little iodoform will not only relieve suffering, 
but often excite a healthy action in the sore. An ulcer will sometimes refuse 
to heal in consequence of being over a tendon, as the tendo Achillis, or a 
muscle, as the sphincter ani, the movements of which disturb and defeat all 
efforts at repair. This can only be corrected either by absolute rest of the 
part, all movements being controlled by a splint, or, when this is not practi- 
cable, by the subcutaneous division of the tendon or muscle. 
Ulcers are sometimes so extensive that cicatrization fails to close them in, 
although the granulations may be healthy. The influence of the marginal 
cells is too feeble to reach across the chasm and keep up the cutification, 
and so the skinning reaches a certain point and then stops. This is often 
seen after extensive burns or destruction of the integuments by machinery. 
Under such circumstances modern surgery resorts to the process of grafting. 
Skin-Grafting.—For the successful execution of this mode of treatment a 
healthy granulating surface is necessary, and if the ulcer be wanting in this 
particular it must, whatever its 
character, be brought into the re- 
quired condition by proper treat- 
ment. The operation consists in 
the removal of small pieces of the 
true skin and their implantation 
upon the granulating surface. 
These grafts should be taken 
from the patient, not from an- 
other person. A neglect of this 
precaution may result in the 
communication of disease. It is 
not necessary that the pieces ex- 
cised should extend deeper than 
the rete mucosum, and they may 
therefore be obtained without 
drawing blood, and with scarcely 
any pain. A portion of one of 
these pieces so obtained should 
be divided, upon a cork or the 
finger-nail, into smaller frag- 
ments, each about the size of a 
mustard-seed, which are to be 
laid on the sore (Fig. 178) about 
equidistant from its margin and 
from one another. It is not 
necessary that any depression 
be made among the granulations 
for their reception; they should 
be simply laid on the surface; 
nor is it a matter of much impor- 
tance which side of the graft is 
uppermost,—just as in planting 
a seed it matters not how it is 
placed in the earth the root will strike down into the soil and the stem rise 
up into the air. To retain these grafts in place, pieces of adhesive plaster 
should be drawn over the ulcer, or, what is still better, the very delicate rub- 
ber tissue much used in the Scotch and English hospitals. A light compress 
of lint and a few turns of a roller complete the dressing. The patient must 
Fig. 178. 
Skin-grafts placed upon a granulating surface. 186 
ULCERS. 
be kept in bed. On the third or fourth day the dressing should be removed, 
with great care and delicacy, in order that the grafts may not be uprooted or 
dragged away. After the surface of the ulcer has been cleansed by allowing 
a gentle stream of warm water to fall upon it from a sponge,—never by 
wiping its surface,—the dressing should be renewed as in the first instance. 
These little islands of skin will often appear dissolved, looking like a mere 
speck of apparently lifeless matter; but after a few days a bluish-white film 
is seen, and, below and around, puncta vasculosa, which are the evidences of 
vitality, and then begins the cell proliferation of the “graft.” Not only does 
it extend, but the margins of the ulcer feel the power of its presence, and 
begin with new energy to stretch across the chasm of granulation-tissue, and 
join hands, as it were, with the little scattered islands of transplanted skin. 
Fig. 179. 
Macleod’s forceps used by Bryant. 
There are several instruments which are in use for lifting the grafts. The 
simplest is a pair of delicate rat-toothed forceps and a pair of line scissors 
curved on the flat. Mr. Bryant, of Guy’s Hospital, London, uses an instru- 
ment, the suggestion of Mr. Macleod, which is a combination of the forceps 
and scissors (Fig. 179), the application of which is seen in Fig. 180. 
Fig. 180. 
As far back as 1847, Professor Frank II. Hamilton, of New York city, 
planned an operation for closing a large ulcer by transferring a portion of 
integument to the centre of its surface, believing that it would form a nu- 
cleus for the production of new skin, and in 1854 he carried it into execu- 
tion* Although the portion so transferred had a pedicle, yet the method 
bore some resemblance to the present one of grafting, the integument being 
taken from a part distant from the ulcer, and not being designed to till it up, 
but only to occupy a portion of the granulating surface. How much the 
operation of this distinguished surgeon may have had to do with attracting 
the attention of the interne of La Charite, M. Reverdin, to the subject, I 
know not, but in 1869 the latter presented to the Surgical Society of Parisf 
the history of a large ulcer which he had cured by excising a minute por- 
Method of using Macleod’s forceps. 
* New York Journal of Medicine, 1854. 
f Gazette des Hopitaux, January, 1870. SKIN-GRAFTING. 
187 
tion of skin and embedding it in the surface of the sore. Shortly after this, 
attention was more generally attracted to the subject by the publication of 
the results of skin-grafting at St. George’s Hospital by Mr. G. D. Pollock,* 
since which the operation has been largely practised on both sides of the 
Atlantic, and with such success as to render it an established mode of treat- 
ing certain kinds of ulcers. 
It would appear that the grafts not only grow by virtue of the multi- 
plication or proliferation of their own cells, but that they also stimulate, 
by some catalytic power, proliferation of the skin-cells which form the 
boundaries of the ulcer, so that the two run out cicatrizing promontories 
or arms towards each other, which finally coalesce and divide the sore into 
separate parts. (Fig. 181.) That these grafts lose none of their structural 
peculiarities by change of place appears from an experiment made by 
Bryant. He grafted into the ulcerated leg of a white man four fragments 
taken from the skin of a negro; they grew rapidly, closing up the gap with 
a black patch. (Fig. 182.) 
Epidermic grafting has been attempted by M. Marc See, of Paris, the late 
Mr. Poland, of Guy’s Hospital, Professor Hodgen, of St. Louis, Guyon, and 
Fig. 181. 
Fig. 182. 
Prolongation and union of cicatricial tissue. 
Black skin in Brvant’s case. 
others who think that the ulcers were improved by the presence of the epi- 
dermic cells. It consists in scraping the cuticle and placing it upon the ulcer. 
There is nothing, however, to show that any cicatrizing influence was ex- 
erted, or that the practice is worthy of imitation. 
We are not yet prepared to determine how nearly the new skin formed by 
grafting approaches the old in the quality of enduring pressure, and in the 
property of contraction which belongs to other cicatrices. It does not 
possess either glands or hair, but it enjoys a sensibility quite as great as that 
of the other parts of the surface, and should be carefully protected for some 
time after the restoration of the ulcer. 
When an ulcer is perpetuated by the presence of varicose veins, the great 
indication is to correct, as far as possible, the embarrassment of the venous cir- 
culation, on the presence of which depends the obstinate, chronic course of such 
sores. When the social condition of the patient admits of rest in the recum- 
bent position it should be enforced, the limb being elevated ; it will certainly 
facilitate the cure. But, as a very large proportion of such ulcers occur upon 
persons who cannot conveniently be laid aside from their accustomed oceu- 
* Transactions of the Clinical Society, London, 1871. 188 
ULCERS. 
nations, it is a great satisfaction to know that rest is not essential to their 
healing. The sore is usually characterized by defective rather than excessive 
proliferation, and should, together with the surrounding parts, be subjected to 
the influence of a warm-water dressing or a flaxseed-meal poultice for a few 
nights, until it becomes cleansed of all tissue-debris. Through the day, also, 
the water-dressing, and a roller bandage applied when the limb is elevated, 
from the toes to the knee, answer every purpose. After this, strapping and 
the roller, renewed every two, four, or six days, according to the amount of 
discharges which soak the dressings, will meet the local indications. Con- 
stitutional treatment will often materially assist healing. Many cases of vari- 
cose enlargements of the leg-veins are due to mechanical causes within the 
abdomen, such as result from constipation or from hepatic enlargements press- 
ing upon the large vessels of the body and of course affecting all their tribu- 
taries. A good purge, and afterwards keeping the bowels soluble with some 
saline administered from time to time, will, by removing these causes, greatly 
assist the surgeon in bringing to a successful issue the work of repair. 
It is often true that relapses follow, but it is because the limb has been 
neglected. A well-adjusted roller bandage, or an elastic stocking, should be 
always worn for the support of the veins. In obstinate cases it is advised to 
destroy the offending veins by caustics, ligatures, or subcutaneous incision,— 
a practice which, so far as I have been able to observe, does not commend 
itself to my favor. 
If, on exploration by means of a probe, dead bone is discovered communi- 
cating, either directly or indirectly, with an ulcer, its removal will be neces- 
sary for a cure. 
Eczema frequently affects the skin in the vicinity of ulcers; it is often 
caused by improper dressings. Nothing has proved so effectual in my ex- 
perience in removing this troublesome condition as bathing the parts well 
with tar-water, and afterwards rubbing into the affected surface a powder 
consisting of equal parts of calomel and subnitrate of bismuth. 
I have said nothing about ointments, astringents, balsams, vapors, and a 
formidable array of other remedies. These are fast disappearing from the 
dressing-case of the surgeon. 
These causes may consist in structural changes affecting the function of 
organs, or from such widely-distributed influences as affect the fluids and 
solids of the body, producing what is termed a dyscrasia. Coming under the 
first head are the following : 
Ulcers from Defective Innervation.—When, from paralysis, division, or the 
pressure of a morbid growth, the nerve-influence of a part is interrupted, 
that part loses a certain amount of self-protecting power: hence the bed-sores 
or ulcers which afflict bedridden paralytics, and which, from the consequent 
irritation and exhaustion, often hasten death. 
To defective innervation, I think, belongs the cold ulcer of Mr. Paget, which 
appears at the ends of the fingers and toes, and occurs generally in females 
with faulty menstruation, defective digestion, and feeble pulse, the parts being 
slightly livid from imperfect circulation. 
Treatment.—To prevent ulceration from defective innervation requires a 
strict attention to the state of the skin over those parts most exposed to 
pressure. For this purpose water- and air-beds, air- and hair-cushions, ring- 
pads, and felt soap-plasters are much employed. The frequent use of friction 
with alcohol or stimulating embrocations, like the camphorated soap liniment, 
by keeping up an active capillary circulation, is the most valuable of all local 
measures. When, in defiance of all precautions, such sores form, they should 
be managed according to the plan detailed for sloughing ulcers. 
In the cold ulcer the remedies should be directed so as to correct the func- 
tional disturbances of the organs prominently involved. Eight or ten grains 
Ulcers from Internal or Constitutional Causes. MORTIFICATION. 
189 
of blue mass should be administered, followed by a saline, after which prepa- 
rations of iron, as the tincture of the chloride, come in with advantage. In 
addition, the patient should be allowed a generous diet, should live much in 
the open air, and should have the parts well rubbed with a weak solution 
of the bichloride of mercury or sulphate of copper. 
Perforating Ulcer.—This ulcer or sinus is met with on the plantar surface 
of one or both feet, and usually opens on that part of the latter which corre- 
sponds to the fleshy anterior abutment overlying the metacarpo-phalangeal 
articulation of the great toe. The sinus leads down to diseased bone, and 
the integument for some distance around the external orifice of the ulcer is 
thickened and callous. Sometimes several of these ulcerating canals exist, 
and are accompanied by caries of the metatarsal and other bones of the 
foot. Another distinguishing characteristic of the disease is anajsthesia, 
more or less complete, not only of the parts immediately around the ulcers, 
but also in the districts of the leg supplied by the skin nerves. The dis- 
charge from the sores is not profuse, and consists of an unhealthy thin pus. 
Walking becomes difficult and painful, and the foot loses its proper shape. 
I do not think the disease is common in this country. I have seen only a 
single case. It is said to have occurred in the hand. The dissections which 
have been made in cases of perforating ulcer tend to confirm the views of 
Duplay, Savory, and others, that the disease has a neurotic origin, the nerve- 
fibres about the sinus or fistulous tracts having in a great measure disap- 
peared, while the anterior tibial and posterior tibial nerves were found in 
a state of sclerosis. The fact, also, that the disease is often accompanied 
by ataxic symptoms, as lightning pains, reflective muscular co-ordination, 
amesthesia, and lessened patellar reflexes, is a further confirmation of this 
view. 
Treatment.—Amputation sufficiently high not to include diseased struc- 
tures offers the only remedy likely to effect any good result. The pallia- 
tive measures consist in keeping up the strength of the general system by 
tonics, cod-liver oil, and nutritious food, at the same time directing the use 
of crutches in order to relieve the foot from pressure. 
Another variety of constitutional ulcers, those resulting from a blood dys- 
crasia, such as the tuberculous, syphilitic, scorbutic, cancerous, and lupoid, 
will be considered under the heads of these various diseases. 
When all the phenomena which convey to the mind the idea of life in a part 
are absent, such as circulation, secretion, sensibility, and heat, we say the part 
is dead or mortified. When treating of this subject the older writers were 
in the habit of using the terms mortification, sphacelus, and gangrene. The 
signification which they attached to the first two was death, and to the last 
dying, or all those changes which are in operation preliminary to death. 
The retention of these terms is calculated to produce confusion and misap- 
prehension in the mind of the student; they should be discarded from surgi- 
cal nomenclature, and I shall retain only the term mortification, a derivative 
from two Latin words,—mors, “ death,” and facio, to “make.” When morti- 
fication takes place in soft parts the dead portion is called a slough; when in 
bone, a sequestrum. Mortification in bone is expressed by the term necrosis. 
No part of the body can claim exemption from this destructive process, except, 
perhaps, the heart, though some tissues are more prone to suffer than others. 
The greater the vascularity of a tissue or organ, the greater is the tendency 
to mortification, especially when they are subject to inflammation. Among 
those in which the disposition is greatest are the dermoid, connective, and 
adipose tissues; also the blood, mucous membranes, and muscles. Those 
which resist mortification longest are cartilage, tendons, bone, blood-vessels, 
large nerve-trunks, and brain-substance. It is not uncommon to see an artery 
still pervious to blood stretching across a chasm which has been formed by 
MORTIFICATION. 190 
MOR T1FICA TION. 
tissue-destruction. The final giving way of such trunks explains the fearful 
hemorrhages which occur in phthisis pulmonalis. Tendons remain long after 
the parts around them have been destroyed, and cartilages will retain their 
integrity when the bones with which they are associated are extensively dis- 
organized. Glandular organs, except the lymphatic, are not often the subjects 
of mortification. 
Causes.—A proper supply and a proper exchange of healthy blood are 
conditions necessary to the nutrition, and, consequently, the life, of any tis- 
sue or organ of the body. Whatever, therefore, prevents these predisposes to 
destruction or death. Many of these causes are in no way connected with 
the body, and are external; others lie within the organism, and are, therefore, 
internal. 
External Causes.—These may be called traumatic, such as contusions, 
lacerations, pressure, caustics, burns, cold,—a class of injuries quite familiar 
to the hospital surgeon. They operate in two ways. When a heavy piece 
of casting or the wheel of a railroad-car crushes a limb, grinding it into a 
pulp, blood-vessels, nerves, and all the components of the part mortify. The 
blood-supply is immediately cut off, the molecular constituents of the tissues 
are so disturbed that the force of cohesion which operates between their 
particles, maintaining form and consistence, is lost, and they become the 
sport of those pure chemical mutations which are so active in decomposition. 
If a potent caustic, such as caustic potash or sulphuric acid, be applied to a 
part, in a few moments the latter is reduced to a blackened mass, blood and 
blood-vessels participating in the destruction. The same result follows the 
application of the actual cautery. In such examples as these the death is 
entirely independent of inflammation. Should, however, the vulnerating 
body operate with less intensity, so that a certain, though much diminished, 
amount of blood still reaches the damaged part, the sensibility of the tissue, 
though impaired, is not entirely lost. Under such a state of crippled cir- 
culation and innervation, inflammation will follow, by which the death of 
the part is insured. Here there are two factors at work to kill.—the injury 
which has impaired the vitality of the part, and the inflammation, which 
gives the finishing blow. In traumatic mortification death may be confined 
to a very circumscribed region, or to the area of contact, or it may extend 
far beyond, rapidly implicating an entire extremity. This is witnessed occa- 
sionally after railroad accidents or severe compound fractures, and is called 
“ spreading gangrene." 
Internal Causes.— Under this head are to be classed all such as act by 
obstruction, both inflammatory and non-inflammatory. 
Inflammatory obstruction.—This proves a fruitful source of mortification. 
When an intense inflammation, like that of erysipelas or carbuncle, befhlls 
the skin or the subcutaneous tissues, the vessels are engorged with blood, the 
latter becomes stationary in the capillaries, and the parts are infiltrated with 
transudation, so that death follows by such a strangulation of the vessels as 
prevents the passage or renewal of the blood-supply. The terminal arteries, 
capillaries, and commencing veins are all implicated in such cases. 
Arterial obstruction.—The obstruction of an artery may be brought about in 
several ways. When a ligature is placed about the principal vessel of a limb, 
like the femoral in cases of popliteal aneurism, the only hope for the parts 
below rests upon the collateral trunks. Should these fail to convey the blood 
through the anastomosing branches, mortification will follow. 
Again, a tumor may so press upon an artery that the parts to which it 
is distributed will be deprived of blood and die. 
Thrombosis.—By this is meant obstruction of a vessel or vessels by a coag- 
ulum of blood. When complete, and in the principal arterial trunk (Fig. 
183), the mortification which follows is of the acute kind, and is apt to prove 
fatal. It is sometimes caused by inflammatory change in the wall of a vessel, 
producing a degree of roughening, or some little irregularity on its inner 
surface, which, like a thread stretched across the lumen of a vessel, serves to INTERNAL CAUSES. 
191 
embarrass the free movement of the blood and finally form a clot. That 
such a coagulum may form altogether independent of 
inflammation is certainly true, even in persons of excel- 
lent health. Two such cases have come under my ob- 
servation ; one in the brachial artery, near the bend 
of the arm, in a shoemaker, in good health, and about 
thirty-five years old. The forearm mortified, and was 
subsequently amputated, the man recovering. The 
second case was that of a young, healthy female, who, 
while bending over the wash-tub, was seized with 
cramps in the leg, which soon became swollen : morti- 
fication of the entire limb followed, from the effects of 
which she rapidly sank and died. Obstruction of the 
femoral artery below the groin was readily diagnosed. 
These two cases would seem to favor the idea that the 
thrombi were detennined by the sharp angle formed in 
the vessels from the peculiar nature of their occupa- 
tions, the first by hammering on his lapstone and drawing the waxed-end, 
the other by bending over the wash-tub. A case of thrombus of the femoral 
artery, with a fatal termination, in a person believed to be free from any 
disease, has been reported by Dr. Walter F. Atlee, of this city. As these 
thrombi have both a parasitic and a vital connection with the vessels, they 
sometimes undergo softening, in consequence of which fragments are detached, 
which are called emboli, and which, when swept along in the blood-current, 
plug up the vessels and induce mortification. These peculiar formations are 
favored by rheumatic and feeble anaemic states of the system. They are 
most common in young females, and tend to a fatal termination. 
Arterial obstruction is favored by a weak heart, a feeble circulation, endo- 
carditis, narrowing of the lumen of the vessels, rigidity of their walls, anaemia, 
and atheroma. 
iVneurismal dilatation is occasionally a cause of arterial obstruction. A 
short time since, a patient with popliteal aneurism, under my care, lost his 
leg by mortification in consequence of a fragment of coagulated blood from 
the sac being carried down into the vessels below. 
Circular gangrene.—There is a form of mortification which I have not 
found mentioned by surgical writers. It occurs usually on some part of 
the lower extremity. A dusky-looking spot makes its appearance, which 
gradually deepens into a charcoal-black color, is often perfectly circular in 
form, and does not exceed in size a silver half-dollar. The gangrene involves 
the skin and subcutaneous tissue. It is accompanied by marked signs of 
exhaustion, and doubtless depends on an embolic plugging of one of those 
very small arterial vessels which supply a definite district of structure: 
hence the accurate circumscriptive and characteristic form of the slough. 
The four cases of the disease which I have seen all occurred, save one, in 
females. One of the patients was a woman of a gross habit of body; a 
second was a lady who had suffered a long time from a suppurating cyst; 
the third was a female of about forty-five years, and was run down in health 
from previous disease. The male patient had been a hard drinker. 
Diseases of an exhausting kind.—Diseases which produce a profound altera- 
tion in the structure of the blood, as and exanthematous fevers, 
Bright’s disease and diphtheria, give rise to conditions favorable to arterial 
obstruction or embolism. I had a young man in the Pennsylvania Hospital 
with mortification of the foot and lower third of the leg, coming on during 
convalescence from typhoid fever. A line of separation formed, and the limb 
was removed with a successful result. A similar case I saw with a brother 
practitioner, in which, however, the patient foolishly declined amputation and 
died. Several cases I can recall of a less serious nature, in which the limb 
was not lost. 
Blood-change, with a feeble heart.—This condition will favor mortification, 
Fig. 183 
Thrombus of the brachial 
artery extending into the 
radial. 192 
MORTIFICA TION. 
entirely independent of either thrombi or emboli. Of this nature probably is 
the disease called noma, cancrum oris, or water-canker, to which the attention 
of the American profession was called long since by Coates and Jackson,* and 
which attacks the cheeks, lips, and gums of pale and weakly children. These 
causes are actively at work in those cases in which the disease appears at the 
outposts of the body, as the point of the nose, tips of the ears, and extreme 
ends of the fingers and toes. To this cause, in part at least, I refer the singu- 
larly symmetrical mortification of the limbs occasionally met with in France, 
which has been described by Haynaud. 
Internal organs may suffer in this way. Numerous examples of mortifica- 
tion of the lung by arterial and venous obstructions are given by Ranctifuso,f 
Simonin,! Dumont Pallier,§ Fritz,|| M. Hayden,** and others. Cases 
of extensive plugging of the pulmonary arteries by emboli and thrombi with- 
out the occurrence of mortification are given by others, among whom may 
be named Pagetff and Kirkes.|J When we consider that the bronchial and 
not the pulmonary arteries nourish the lungs, we can understand why there 
should be some doubt as to the part played by these clots in inducing morti- 
fication, and whether these obstructions may not be consequences rather than 
causes of the disease. 
Diabetes mellitus is frequently found associated with gangrene, and no 
doubt stands in direct causal relation to it. 
Venous obstruction.—This may be, in rare instances, a cause of mortifica- 
tion, by leaving no way of escape for the blood which has been carried into 
a part by the arteries. I can recall no case in which mortification could be 
referred to this condition. The numerous venous channels and their com- 
munications render it almost certain that if one trunk is compressed another 
will supplement the defect and so carry on the circulation. In strangulated 
hernia, where the knuckle of intestine is completely encircled by the con- 
stricting ring, rendering all attempts to restore it unavailing, the bowel 
retains for some time its vitality, though both arteries and veins are ob- 
structed, a condition which makes the danger of mortification much more 
imminent than when the arteries alone are involved. 
Agents introduced into the blood.—The calibre of the vessels may be so 
diminished by contraction of their muscular walls, through the agency of 
materials taken into the system, as to produce the starvation and consequent 
death of a part. Of this nature is the mortification following the use of 
ergot,§§ which produces a persistent contraction of the muscular coat of the 
vessels. Or, again, the blood which moves in the vessels may be killed so 
suddenly by the instillation of a poison, like that of the rattlesnake or the 
cobra, that an entire limb will fall rapidly into mortification. 
Certain kinds of food in which there is no nitrogen, as sugar and gum, 
when fed for some time to dogs, will produce sloughing of the cornea. 
Defective innervation.—Whatever interferes with the transmission of nerve- 
force from the ganglionic masses to different portions of the body becomes 
a cause of mortification. This is due to a tardy circulation from vascular 
weakness in those portions of the body which are imperfectly innervated. 
Under this head come the sloughs about the nates and limbs of persons suf- 
fering from paralysis, or those which follow the division of important nerves, 
like the median, ophthalmic branch of the fifth pair, and peroneal. The 
® Benjamin H. Coates, North American Medical and Surgical Journal; and Prof. S. Jackson, 
Medical Recorder, vol. xii. 
f Virchow’s Archives, vol. xviii. page 557. 
J Gazette M6dicale de Paris, No. xxvii., 1860. 
| Gazette des HSpitaux, No. xxiv., 1859. 
j| Bulletin de la Soci6t6 Anatomique, April, 1860. 
If Gazette Hebdomadaire, 1864, page 611. 
*® Dublin Medical Journal, May, 1875, page 476. 
ff Trans. Med.-Chirurg. Society of London, vol. xxvii. pages 162 and 353. 
Trans. Med.-Chirurg. Society of London, 1852, page 296; see also page 321. 
|| De l’Asphyxie locale, et de la Gangrene sym6trique des Extremit6s, 1862; Billroth, page 302. ACUTE MORTIFICATION. 
193 
simple pressure of a shoe or a bandage on the foot of a child that has 
been the subject of infantile paralysis may in twenty-four hours produce a 
slough. To defective innervation may be referred cases of sloughing of the 
ankle, such as Sir Benjamin Brodie describes as coming on after injury to 
the spine. 
While thus enumerating some of the causes of mortification under dis- 
tinctive heads, it must not be forgotten that this disease is the result not of 
any single cause, but of the combination of many; in other words, that 
destruction is as complex a process as construction. 
Varieties.—There are two varieties of mortification, the acute and the 
chronic. These are sometimes designated as the moist and the dry. Be- 
tween these two, the acute and the chronic, will be found cases in which 
the phenomena of both are present, and which therefore partake of a mixed 
character. 
Acute Mortification. 
When mortification is of inflammatory origin, the symptoms which precede 
it are both local and constitutional. 
Local Symptoms.—These are intense redness, burning pain, swelling, and 
heat, with extreme tension of the tissues. They are followed by a change of 
color, the parts becoming of a dusky-brown or dark-violet color, and afterwards 
yellow, intermixed with a green, livid, or dark-purple hue. Red streaks appear 
along the course of the superficial vessels, and the surface assumes a mottled 
appearance. The temperature falls, the sensibility begins to diminish, the 
swelling becomes softer and cedematous, and vesicles or blebs rise on the sur- 
face, filled with a straw- or dark-colored serum. All these threatening symp- 
toms may be present and yet the life of the part not be extinguished. There 
may be still circulation, sensibility, and a certain degree of heat; and when 
in this state its recovery is not impossible. If, however, the progress of the 
disease is not arrested, a more extensive separation of the cuticle takes place, 
which, on the slightest pressure, becomes detached, leaving a moist, slippery 
surface, with a peculiar, offensive, and sickening odor. The color changes 
to a dark gray, brown, or black. (Fig. 184.) When pressed upon, the parts 
crackle, from the ichor and gases by which they are interpenetrated. The 
Fig. 184. 
Mortification of the arm from a tight bandage.—From Bell. 
bloody serum and gases present are the product of blood- and tissue-decom- 
position, and give to the dead portion a most fetid and disagreeable odor. 
The accumulation of gas, if the integument or deep planes of fascia remain 
unbroken, will produce a swelling yielding a peculiar resonance when per- 
cussed ; but when these tissues give way the parts rapidly shrivel up. 194 
MOR TIFICA TION. 
If a mortified limb be laid open, a marked difference will be observed in 
its different components. The cellular tissue will present a gray, sodden ap- 
pearance, detached in shreds or fibres; the muscles will be dark and pulp- 
like; the tendons but little changed, perhaps beginning to break up into 
filaments; the periosteum gone, and bones dry and brown; the medullary 
membrane alive in some cases weeks after all else is dead. 
The color which belongs to mortification is the result of the decomposition 
of the red corpuscles: their coloring-matter, being mixed with the water and 
serum, stains not only the cellular tissue about the veins, giving rise to the 
dark-red streaks which follow the course of the superficial vessels, but, in 
some degree, all the disorganized components of the affected portion. The 
chemical changes which ensue upon the destruction of the tissues by the 
action of oxygen or by oxidation are both numerous and complex. What- 
ever their intermediate forms, the last result is the formation of carbonic 
acid water and ammonia. The disgusting odors which emanate from the 
putrefying mass are not from any single product, but from several, among 
which are sulphuretted hydrogen, sulphuret of ammonia, and valerianic and 
butyric acids. Several crystalline bodies are also formed, differing according 
to the structure or organ destroyed, such as ammoniaco-magnesian phosphate, 
margarin, stearin, tyrosin, and leucin. 
Notwithstanding that the mass consists of dead material, yet, singularly 
enough, in its midst are to be seen innumerable living organisms, as the 
aspergillus oidium, or mould, vibriones, bacteria, etc. These forms do not 
arise by spontaneous generation, but have gained admittance from without. 
Some writers, such as Pasteur, believe that in the presence of these organisms 
consists the essence of decomposition or putrefaction; in other words, that 
they play the part of ferments. 
Constitutional Symptoms.—During the early part of the inflammatory 
stage the pulse is rapid, and possesses considerable force; the temperature 
is high, reaching four or five degrees above the natural standard; the thirst 
is intense, accompanied with headache, nervous restlessness, a hot, dry skin, 
and sometimes delirium. As the disease advances, a marked change takes 
place; the pulse loses its volume and resistance, becoming feeble and more 
frequent; the tongue is dry, and of a dark-brown color; the skin moist, with 
cold, clammy sweats; the countenance anxious, and pinched; the voice feeble; 
there is great loss of muscular strength, so that the patient is compelled to 
maintain the dorsal decubitus and slides down in the bed; the urine becomes 
turbid; occasionally a diarrhoea sets in; there is a disposition to doze, with 
incoherent muttering; in fine, there are present well-pronounced typhoid 
symptoms. 
The excessive prostration which follows the death of even a very limited 
portion of the body is difficult to understand. Guthrie thought it was caused 
by shock to the nervous system. I am disposed to think, with Brodie and 
others, that it is due to blood-poisoning,—a form of septicaemia induced by 
the introduction of tissue-sewage into the system. 
Separation op the Dead from the Living.—After a variable period, 
depending on both local and constitutional causes, the dead part or slough 
is disconnected from the living. The mechanical connection remains some 
time after the vital one ceases, and this must be severed. While the process 
of mortification is in progress, from whatever cause, internal or external, 
an inflammatory work is being done in the parts some distance beyond its 
limits. This work consists in the infiltration of the structures contiguous to 
the dead parts with both lymph and leucocytes, erecting in this way a barrier 
against the intrusion of injurious matters into the sound tissues. A red line, 
which fades away into the adjoining parts, produced by capillary distention, 
appears beyond the dead skin. This is the line of demarcation. It completely 
encircles the disease, its border being irregular, serpentine, or zigzag. (Fig. 
185.) The effect of this inflammatory infiltration is to produce softening and 
solution of the textures into which it is poured, thus dissolving the connec- TREATMENT. 
195 
tion between the dead and the living parts. Many of the cell components of 
the affected structures, together with migrated corpuscles, appear as pus, and 
form a healthy discharge, in place of the fetid and irritating ichor which pours 
Fig. 185. 
Line of demarcation. 
through every crevice of the foul slough. When once this auspicious line is 
formed, and the process of separation fully commenced, it will be announced 
by the appearance of a groove, showing a loss of substance, which groove 
continues to deepen by the ulceration which dissolves one plane of structure 
after another, viz., skin, fasciae, muscles, tendons, 
periosteum, and bone, leaving an irregular, serrated 
surface. The direction taken by the ulceration 
is never perpendicular, but oblique, the inclination 
being towards, not from, the slough. (Fig. 186.) 
When only one or two planes of tissue are mor- 
tified, the infiltration is not only around but also 
beneath the slough. The rapidity with which the 
ulceration progresses depends upon the nature of 
the structure. Those which resist longest are the 
tendons, cartilages, bones, and arteries. In the 
case of a mortified leg, two or three weeks will 
suffice to reach the bone, but the latter will require 
three or four months for its separation. In such 
cases the bone always protrudes some distance 
beyond the soft parts, the stump having a conical 
form. (Fig. 186.) 
The resistance of the blood-vessels, especially 
the arteries, to the destructive process is a wise 
provision to prevent hemorrhage. It gives time 
not only for their closure by the preliminary clot, 
but also for the secure obliteration of their canals 
by organized lymph. The extent to which they 
are closed is sometimes so great that an amputa- 
tion of the limb, it is stated, has been made four 
inches above the dead part without the loss of blood. I have never seen such 
a case, but I do not deny its possibility. 
Treatment.—The indications in the treatment of acute mortification are, 
to remove the cause when possible, limit the destruction of tissue, favor its 
separation, and support the general system. Depression is the dominating 
tendency of the disease, and this fact must never be left out of sight. Hence 
the general abstraction of blood is not allowable. I do not say that in the 
early period of the precedent inflammation venesection may not, in persons 
of a robust, plethoric habit, exercise a salutary and controlling power over 
the local conditions which threaten mortification; but, when the work of death 
has begun, general bleeding can do no good, but much harm. It may, indeed, 
destroy the inflammation, but from the tendency to prostration it may also 
destroy the patient, or at least weaken repair. In many cases of traumatic 
mortification it is impossible to set bounds to the destruction; but in others, 
Fig. 186. 
Direction taken by the ulceration 
in mortification, and the conical 
form of the stump. 196 
MO It TJFICA TION. 
both traumatic and idiopathic, the disease can be greatly circumscribed. The 
remedies for this purpose are constitutional and local. 
Constitutional Treatment.—This consists in rest; regulating the bowels, 
if necessary, with mild laxatives; alleviating pain and restlessness by ano- 
dynes, which last should be conjoined with refrigerants when the skin is hot 
and dry. The strength must be sustained by tonics, as quinine and iron, stim- 
ulants, and nutritious food. Hygienic measures should be rigidly enforced, 
such as thorough ventilation, frequent change of clothing and bed-linen, and 
the free use of disinfectants and deodorants. 
Local Treatment.—The local treatment must be regulated by the circum- 
stances attending each particular case. In general, it may he affirmed that 
the relief of stricture and tension is of paramount importance. Tension and 
compression of tissue are closely allied. Thus, in a strangulated intestine 
the stricture must be divided or the gut will perish. When a part is much 
swollen by the products of inflammation, and begins to present a dark-red, 
claret, or livid hue, the application of a blister over and beyond the diseased 
portion—a favorite remedy with Physiek—will take off much pressure by 
inducing a free flow of serum; but where the danger is still more imminent, 
as in phlegmonous erysipelas, or after a rupture of the urethra, free, bold 
incisions should be made, sufficiently long, deep, and numerous to unload 
the tissues of their infiltrated blood, serum, and pus, and thus restore a free 
circulation through the invaded district. 
To favor the separation of the slough, poultices, by promoting a free sup- 
puration, are exceedingly useful. They should be mixed with such substances 
as will absorb and destroy all odors emanating from the decomposition of 
structure. A little charcoal, yeast, or porter mixed with flaxseed- or corn- 
meal will answer a good purpose. The poultice should be renewed three or 
four times in the twenty-four hours, according to the amount of liquid prod- 
ucts or sewage flowing from the slough; and at each renewal the parts should 
be thoroughly cleansed with a solution of the permanganate of potash or 
chlorinated soda, earbolated water, one to forty; bichloride of mercury, one to 
one thousand. When the structures are entirely dead and become loose, they 
may be clipped away with the scissors; never, however, cutting into points 
where there is the least evidence of vitality, for fear of provoking a dangerous 
bleeding. Nature can effect the separation much better and with greater 
safety than the surgeon ; and it is a rare occurrence, where there has been no 
meddling, for the separation to occur before the vessels have been sealed. 
When the slough is disengaged and ejected, we have to deal writh a simple 
granulating ulcer. Poultices should then be laid aside and the use of water- 
dressings substituted. 
Hemorrhage.—Should this follow in the course of detachment, a strong solu- 
tion of alum-water should be applied, conjoined with pressure; this failing, we 
may resort to the hot iron; and, as a last recourse, to ligature of the supplying 
artery. 
Amputation.—Cases will be encountered in which the subject of amputa- 
tion comes up for consideration. This will, in many instances, demand the 
most discriminating judgment, and it is one upon which surgeons do not 
altogether agree. In deciding upon so important a question we are to con- 
sider that mortification must be referred to one of the three following classes 
of causes: local, general, and mixed. When the cause is purely local (and 
by local I mean confined to the visibly damaged part), the knife can go above 
the disease; wdien general, it cannot; when mixed, it may or may not. The 
last forms the debatable ground. Let us make a practical application of these 
general statements. 
First. In all cases of traumatic mortification extensively involving the 
components of a limb, where the line of demarcation is established and the 
strength of the patient is not too greatly exhausted, there can be but one 
opinion as to the propriety of amputation : this should be done as near to the 
line of separation as will allow of the formation of a sufficient flap. CHRONIC MORTIFICATION. 
197 
Second. In incipient traumatic mortification,—that which begins within 
what is called the primary period (from thirty-six to forty-eight hours),—the 
surgeon should operate at once, without waiting for any line of separation, 
provided the patient’s general condition will allow. Gangrene from extremes 
of temperature, such as heat or cold, constitutes an exception to this rule: in 
such condition amputation must be preceded by the line of demarcation. 
Third. In cases of traumatic mortification of the upper extremity, where 
the disease is well established and rapidly progressing, as in spreading gan- 
grene,—a variety of the disease in which micro-organisms play an important 
part,—amputation at the shoulder-joint does sometimes save life, and should 
be practised. In similar cases of the lower extremity there is little to recom- 
mend a resort to the knife, since usually there is a general factor present, as 
shock, concussion of the spinal marrow, defective heart-power, or a diseased 
state of the kidneys. Better under such circumstances to wait for nature’s 
sign, the line of demarcation, though rarely does it appear. These cases 
belong to the mixed class ; and while interference may be proper in the upper 
extremity, it is not so in the lower, unless where the disease is confined to the 
leg, when amputation through the knee may possibly succeed. 
Fourth. When mortification is due to embolism in a young subject, and the 
clot can be located, there is no necessity for delay if the general condition 
does not forbid. Amputation above the seat of obstruction is entirely proper. 
Fifth. Mortification following atheroma does not contra-indicate amputa- 
tion, if the operation can be done at a point where the vessels are free from 
obstruction. 
Sixth.—When mortification follows the application of a ligature to an 
artery, as the brachial or femoral, the cause is purely a local one, the col- 
lateral branches being unable to convey blood to the parts below, and there- 
fore there is no necessity to wait for a line of demarcation; the limb should 
be removed above the seat of the ligature. 
Seventh.—When mortification follows an injury to a main artery, either 
from gunshot or other violence, the cause is a local one, and therefore there 
$s no necessity for delay; the limb should be removed above the point of 
injury. The death of a part after such a damage is analogous to that which 
sometimes follows the ligature. 
Chronic Mortification. 
In striking contrast with the disease just described is the one now under 
consideration,—chronic or dry mortification. In the first or acute variety 
the disease is preceded, when it arises from inflammatory causes, by the 
usual symptoms of redness, heat, pain, and swelling; in this form, inflam- 
matory signs are either entirely absent or are very imperfectly expressed: 
in the first, the parts are mottled, swollen, and oedematous; in this, they are 
dark, shrunken, and hard: in the first, the liquid products of decomposition 
are abundant ; in this, the tissues are dry and mummified: in the first, there 
is odor ; in this, none is recognized. Dry mortification, though commonly a 
disease of advanced life, may occur at an earlier period. I have seen it in two 
young men under twenty-five years of age, and cases are recorded in children 
under twelve. Males are more commonly the subjects of the disease than 
females. It does not always assume the characters detailed, but may occa- 
sionally resemble the acute humid form, especially in those cases having an 
inflammatory history. Under the name of “gangrene of the toes and feet,” 
it was first described by Pott, of London; and it is often designated as senile 
gangrene. 
Causes.—There are several causes which are influential in producing the 
disease, among which may be mentioned a feeble, fatty heart, incapable of 
propelling the blood with vigor into the remote vessels of the extremities, in 
consequence of which a capillary stagnation takes place, extending into the 
larger branches of the arteries; also calcification of the arterial tissues, de- 198 
MORTIFICATION. 
stroying their elasticity,—a condition recognized long ago by Cowper,* and 
also by Becketf and This change in the arteries, giving rise to 
irregularities of surface, tends to interfere with the smooth and regular flow of 
the blood, inducing the formation of thrombi and the detachment of fibrinous 
plugs which serve to obstruct either a main trunk or some of the small ter- 
minal branches. The disease is no more common in persons who have been 
addicted to the pleasures of the table, or whose constitutions have been ruined 
by excess, than in those whose lives have been regular in every respect. The 
last four cases that came under my notice were in men who had been remark- 
able for possessing sound and vigorous bodies,—three of them farmers,—and 
who, up to the time of their attack, enjoyed excellent health. 
Symptoms.—The approach of the disease, especially when of the acute 
type, is sometimes indicated by signs of constitutional indisposition, which, 
however, are usually so slight as to attract but little notice. These signs 
consist in diminished appetite, loss of strength, frequent and often irregular 
pulse. 
Local disturbances also foreshadow the disease. There is increased sensi- 
bility, the toes and feet becoming painful, or the latter may feel heavy and 
benumbed. Darting pains sometimes shoot through the toes and up into the 
limbs; the temperature falls; the patient complains of cramps, and finds it 
difficult to maintain a comfortable warmth in the foot. In some instances all 
monitory signs are absent, and the first announcement of the disease is the 
appearance of a brown spot, sometimes not larger than a pin’s head, on one 
or several of the toes. On this a vesicle may or may not arise. This spot 
becomes darker, and finally black; it slowly extends, sometimes with, often 
without, any marginal redness; and the pain is frequently very intense, is 
paroxysmal, and depressing. (Fig. 187.) 
Fig. 187. 
Dry or senile mortification of the toes. 
As the disease advances, the parts desiccate, become shrivelled, contracted, 
hard, and as black as charcoal (Fig. 188); it creeps upwards until most of the 
limb is involved, when, from loss of sleep, irritative fever, and exhaustion, the 
patient dies, in the course of three or four months. There are, however, ex- 
ceptional cases, in which the disease lingers about the toes for a much longer 
period of time, and where undoubtedly the occlusion of the vessels is limited 
or imperfect. Sometimes, though rarely, a line forms, the part drops off by 
ulceration, and the surface cicatrizes, the patient recovering as by a miracle. 
In other cases the disease partakes of the acute form. The toes assume a 
dark-red color, become swollen and exceedingly painful; the parts above pre- 
sent a mottled appearance from embarrassed circulation; blebs or phlyctenulae 
rise over the surface, tilled with bloody serum; the subcutaneous tissue under- 
® Philosophical Transactions, vols. xxiii. and xxiv., pages 1195 and 1970. 
f Becket’s Chirurgical Observations, 
j Thompson on Inflammation, page 537. CHRONIC MORTIFICATION. 
199 
goes a rapid decomposition and becomes filled with liquid matters, from which 
emanate the foulest odors. The patient soon begins to suffer from septicaemia; 
the pulse becomes frequent and feeble, the tongue dark, profuse sweats break 
out over the surface of the body, the mind wanders, the hands become tremu- 
lous, and the sufferer dies in a typhoid condition. Very recently I saw, in 
Fig. 188. 
Dry mortification of the arm.—From Liston. 
the same family, two eases of senile mortification of the feet,—father and son. 
In the father’s case the malady was of the slow, dry, chronic form; in that of 
the son it was of the acute variety. The latter died in six weeks; the former 
lived about three months. 
There is a variety of chronic mortification which is believed to depend upon 
the use of food containing ergot, and which formerly prevailed to a consider- 
able extent in Germany, Switzerland, France, and other parts of the continent 
of Europe. It was first described by Dodard* in 1676. A number of cases 
were brought into the IIotel-Dieu at Orleans, in which, as Saviard, in 1694, 
informs us, the upper as well as the lower extremities were affected. No age 
was exempt from its ravages. Pereiraf supposes that this disease was a very 
ancient one, and that it was this affection which Sigebert and Bayle described 
as prevailing in 1089 in certain parts of Lorraine, in which the hands and feet 
became black and rotted off. The last author makes allusion to the peculiar 
color of the bread consumed by the people. The disease was described by 
Noel, in 1710, in a memoir to the Eoyal Academy of Sciences in Paris. The 
year before (1709) it would appear that one-fourth of all the rye in certain 
provinces of France—as, for example, Sologne—was affected with the ergot, 
and it is not surprising, therefore, that we read of five hundred cases entering 
the hospital at Orleans. Its appearance in Switzerland in 1809, and again 
in 1816, formed the subject of a paper by Langius. In Dauphiny it was de- 
scribed by Gassoud and Bossau in 1709. In consequence of certain inves- 
tigations made by Model.| from which he deduced the conclusion that the 
lower animals were exempt from the disease, the Eoyal Society at Paris en- 
listed the services of Tessier, who made numerous careful experiments with 
a view to determine the truth of this allegation, and while it was found that 
animals resisted for a long time the baneful effects of the grain, yet they 
finally perished from this form of mortification. Similar experiments, in 
1811, were instituted by Block.§ which did not, however, sustain those of 
Tessier, as large quantities of the ergot were fed to animals, such as sheep 
and cows, for periods varying from four weeks to three months, without any 
manifestation of the disease. Notwithstanding these contradictory state- 
ments, our present knowledge of the action of ergotin in producing contrac- 
tion of the muscular coat of the vessels furnishes strong evidence that the 
popular notion that this mortification was due to the diseased rye was cor- 
rect, although it is highly probable that to produce its peculiar effect the con- 
taminated flour must be used for a considerable length of time. I am not 
* Journal des Savans, 1676 ; Cooper’s Surgical Dictionary, 
f Elements of Materia Medica, Part II., 1840. 
j Dictionary of Natural History, Bomare, vol. xix. 
§ Chelius’s Surgery, by South, vol. i. page 75. 200 
MORTIFICA TION. 
aware that the disease is ever seen in this country, although it is alleged that, 
during the years 1819 and 1820, cattle, both in this State and in New York, 
died from this cause, having eaten the diseased grain of meadow-grass. I 
have seen it on this rich and luxuriant grass to a much greater extent than 
on rye. The disappearance of the disease from those regions where it for- 
merly prevailed is doubtless due to two causes, viz., the substitution of wheat 
for rye in the preparation of bread, and the introduction of mechanical appli- 
ances, such as the smut-machine so generally in use, for the removal of all 
matters foreign to the sound grain before it is ground into flour. 
The disease, as described by those familiar with its appearance, begins in 
one or both feet, and is attended with a burning heat, redness, and pain some- 
times excruciating. In the course of four or live days these phenomena dis- 
appear, and the parts become cold, black, and insensible, without odor, and 
thoroughly desiccated. In some instances there is considerable swelling, 
attended with fever and delirium. Occasionally the mortification partakes 
more of the moist kind, with putrid emanations. In exceptional cases a line 
of separation forms and the dead part drops oft'; though generally the disease 
advances up the limb until the patient is destroyed; and in a case narrated 
by Thompson both limbs sloughed off at the hip-joint. 
Prognosis.—The prognosis in chronic mortification is exceedingly unfavor- 
able. In young subjects, or when produced by embolism from blood-change, 
there is a prospect of limitation and of the recovery of the patient after am- 
putation. A line of demarcation occasionally forms, the parts separate, and 
cicatrization follows. Such a termination, however, is so rare that it does not 
affect the general rule,— namely, death, in a period of time varying from eight 
weeks to four months. 
Treatment.—The disease is one which rapidly exhausts the powers of the 
system, and demands unceasing support : consequently, the most nutritious 
articles of food are requisite, which should be assisted by tonics, such as 
quinine and the tincture of the chloride of iron. In the use of stimulants 
the surgeon must be guided by their effects: should they produce restless- 
ness and too much warmth of surface they should not be given. To relieve 
pain and procure sleep, opium in some of its forms should be freely admin- 
istered, either by the mouth or hypodermically. Constipation must be cor- 
rected by gentle aperients, otherwise the opium will produce headache and 
disturb the digestion. 
Local treatment is limited to maintaining the warmth of the limb by envel- 
oping it in some non-conducting substance, like cotton batting. After using a 
great variety of applications, I am disposed to believe that all are alike value- 
less; but when any odor is present the dead part should be surrounded with a 
piece of lint moistened with phenol sodique and covered with oiled silk. The 
position in which to place the part can only be determined by consulting the 
patient’s feelings, some deriving the most comfort in the dependent and others 
in the horizontal posture. 
As to amputation in senile gangrene, the operation so generally prescribed, 
the question is one which the surgeon should not decline to consider without 
a very thorough inquiry into the peculiarities of the case. So important, 
however, is it to ascertain the condition of the vessels above the disease before 
subjecting the patient to the knife, that I would recommend the operator to 
make an exploratory incision with that end in view before he proceeds to 
remove the limb. Little danger would be involved in uncovering the pos- 
terior tibial or anterior tibial artery at the middle third of the leg, or the 
popliteal artery in the ham. It is needless to say that only within the region 
of unobstructed blood-vessels would it be proper to amputate. Thus, Garleke 
and others have operated successfully in senile gangrene of the foot by am- 
putation through the thigh. I have seen similar cases recover where the 
same course had been pursued. The use of antiseptics and of the animal 
ligature has in a great degree rendered operations on calcified vessels free 
from the risk of secondary hemorrhage. HOSPITAL MORTIFICATION. 
201 
HOSPITAL MORTIFICATION. 
This disease has been described under different names by different writers, 
as gangrcena contagiosa, phagedcena gangrcenosa, gangrcena nosocomialis, putrid 
ulcer, pulpy gangrene, pourriture d'hopital, hospital gangrene, diphtheria of 
wounds, etc. 
In this country it is generally known as hospital gangrene. It has been the 
scourge of military hospitals, camps, and naval transports; it has invaded 
prisons, and occasionally has appeared in civil hospitals. The propriety of 
discussing the disease in its present connection may be questioned by some, 
and with a certain degree of force. Being a complication, in most instances, 
of wounds, it would seem most fitting that its consideration should be re- 
served for that division of our subject. Yet, being a species of a generic 
process,—that of mortification,—there can be no inconsistency in treating 
of it in the present place. 
The existence of a wound is a necessary condition to its development. This 
need not be large: any breach in the continuity of tissue—a scratch, the 
prick of a pin, the sting of an insect, or a contusion—will offer a surface for 
its development. Bryant* informs us that when it prevailed in the wards of 
Guy’s Hospital, London, in 1849, contusions were often attacked. I can find 
no evidence which will require any modification of the statement that for the 
development of the disease an open surface is necessary. We know very well 
that contusions which recover without vesication or ulceration in healthy 
wards will not do so in a vitiated hospital atmosphere. This is due, not to 
local impressions, but to a contaminated state of the air entering the system 
through the lungs, which vitiates the blood, and through this medium impairs 
the function of those nervous ganglia whose action is so necessary to repair. 
If under such unfavorable conditions inflammation follows a contusion, and 
a little vesicle or ulcer results, removing thereby the cuticle which usually 
forms, when intact, an impenetrable coat of mail against the admission of 
morbific agents, then the enemy, whatever it may be, will enter, and the morti- 
fication follow. Although I witnessed a large number of cases of this disease 
during the late war, in no instance was there a single idiopathic case. 
It may prevail in two forms,—the endemic and the sporadic. In the first, 
scarcely a single open surface, from whatever cause, within the affected dis- 
trict, will escape. In the second, the disease appears to be confined to isolated 
cases and sores of a specific nature, as chancre and open cancer. These ulcers, 
it is alleged, are more liable to suffer from the latter than from the former 
variety, and I have witnessed in the Philadelphia Almshouse facts corrobo- 
rative of this statement. 
Causes.—It is certainly not due to dirt or to a broken-down constitution, 
or to both together, since we learn from Macleodf that the barrack hospital 
at Scutari, which was very offensive and overcrowded with enfeebled soldiers, 
suffered no more from the disease than did others in a much better situation. 
During our late war it was frequently seen to attack the strong and vigorous 
while the feeble escaped, though, as a rule, patients enfeebled by loss of blood 
or from any other cause are most liable to the disease. Neither is it due to 
overcrowding alone, as this has often happened without the appearance of a 
single case. 
Not one of these conditions existed as I saw the disease at the Chestnut 
Hill Military Hospital, nor in the De Camp and McDougal Hospitals, as 
related by Hamilton yet that these are material factors favoring an out- 
break of the mortification can scarcely be questioned, as they conduce to 
the growth and multiplication of micro-organisms, the presence of which 
constitutes the true origin of the ulceration. The disease will be impossible 
in the future with aseptic surgery. It may prevail at any season of the year. 
* Bryant’s Surgery, page 435. 
f Crimean War, page 166. 
f Hamilton’s Surgery, page 61. 202 
MORTIFICATION. 
A moist or damp atmosphere, however, seems to be peculiarly favorable to 
its development. 
It is both contagious and infectious; that is, it is capable of being propa- 
gated by contact, and also through the medium of the atmosphere. In proof 
of the first, it is stated by Holmes Coote* that during the appearance of the 
disease, in 1846, at St. Bartholomew’s Hospital, its extension in two instances 
was unmistakably traced to the use of an infected sponge. A putrid slough 
taken from a case of hospital mortification and applied to a healthy wound 
will communicate the disease to the latter. The observations of Pouteau 
show that a sponge or lint bearing the discharges from the pulp of an infected 
sore will communicate the disease to a healthy ulcer, though the constitution 
of the patient and the hygienic surroundings are of the best kind. Its in- 
fectious nature is rendered probable by the appearance of cases at the ex- 
treme parts of a ward, the intermediate ones escaping,—and that, too, in 
instances where neither instruments, dressings, nor personal contact could 
explain the fact. In point, also, is the statement of Guthrie in his Commen- 
taries,f that hospital gangrene which was confined to the lower wards, at 
Leyden, in 1798, broke out in the upper wards thirty hours after the surgeon, 
in order to obtain better ventilation, broke an opening through the ceiling, 
thus forming a communication between the two rooms. Those nearest the 
opening were first attacked, the disease extending afterwards throughout the 
apartment, evidently due to the diffusion of germs. 
Yon Pitha and Fock believe that the disease has a miasmatic origin.| The 
tenacity with which this materies morbi clings to substances which have been 
in use as dressings during the disease is well shown in the circumstance nar- 
rated by Guthrie, that lint which had been used to dress the sores of hospital 
mortification in Paris, although it had been washed, dried, and bleached, yet, 
when sent to Holland, poisoned every wound to which it was applied. 
The division of hospital mortification into the ulcerous and the pulpy is one 
without much practical value, the difference being only in the amount of 
tissue involved. In the first the parts die in small instalments, in the second 
in large masses. 
Symptoms.—These are local and constitutional. The first play the most im- 
portant role, and, I doubt not, precede the former. I mean by this that the 
constitutional symptoms are the result of the inoculation. 
Local Symptoms.—These vary much in different cases. When the disease 
attacks a contused part, or a welt,—which, under the old system of flogging, 
was not an uncommon occurrence,—a vesicle first forms, filled with bloody 
serum, partly covered, most likely caused by the violence. This vesicle opens 
and discharges, forming a sore, the pain of which is burning and pungent. 
The parts around become livid, and a gray slough forms. The contact of 
this dead mass with the living gives an increased impetus to the disease, 
and it extends rapidly. When an open surface, like an ulcer or amputation, 
is invaded, the previously healthy or purulent secretions are arrested, the 
surface becomes dry, and the granulations pale. The sore is soon covered 
with a whitish exudation, or with minute blood-clots and gray sloughs. 
Hitherto devoid of any unusual sensibility or odor, it now becomes tender, 
painful, and offensive; the parts on the border of the ulcer are swollen and 
livid, while beyond they are of a dark-red color. The edges are sharply cut, 
with a tendency in the sore to become round in form; afterwards they become 
ragged, everted, or sunken. The minute sloughs scattered over the surface 
become confluent, so that in a period of thirty-six or forty-eight hours the 
whole ulcer is converted into a dead, ash-colored mass, with an exuding 
ichorous discharge. Even far beyond the limits of the sore the skin may be 
undermined by the extension of the disease through the underlying con- 
nective tissue, a condition which is not uncommon when the mortification 
attacks the track of a ball. It is in the connective tissue that the disease 
* Holmes’s Surgery, vol. i. page 164. f Bryant’s Surgery, page 435. 
J Billroth’s Surgical Pathology, American edition, page 322. HOSPITAL MORTIFICATION. 
203 
produces such formidable devastation, so formidable that a large portion of 
the muscles of a limb may be uncovered in a very short time. Muscular 
tissue resists the process much longer than do the fascite. The destruction 
is sometimes so rapid that even the blood-vessels, which usually are slow 
to yield to common forms of mortification, give way, followed by frightful 
hemorrhages; and the bones, denuded of their periosteum, become black and 
necrosed. In such aggravated instances the sewage from the putrid sloughs 
sometimes enters the lymphatics, contaminating the glands with which they 
are connected,—as the axillary or inguinal,—and gives rise to suppuration, 
thus establishing a new focus of death. 
Constitutional Symptoms.—In some cases a certain degree of general 
indisposition is experienced before the local symptoms are recognized. The 
patient may complain of headache, a sense of constriction across the fore- 
head, and loss of appetite, with a loaded tongue and an accelerated pulse; 
but in the cases which have come under my own observation the topical 
preceded the constitutional signs. When, however, the local disease proves 
unusually destructive, the system sympathizes to a marked degree : the pulse 
becomes feeble and frequent; a cold perspiration bedews the surface; the coun- 
tenance assumes an anxious expression; the breathing becomes oppressed; 
the tongue is sometimes dark brown, at other times yellow; the stomach is 
irritable ; spasmodic twitehings attack the limb, greatly aggravating the pain 
experienced about the sore; the mind wanders, and the prostration, which 
rapidly increases, is followed, unless the disease is arrested, by death in a 
period of from nine to fourteen days. 
Prognosis.—When the necessary resources are at hand, and are promptly 
used, the prognosis is highly favorable. Nothing can be more striking than 
the immense superiority of the modern modes of treatment over those in use 
among the older surgeons. This superiority is due to sounder notions of the 
natui’e of the disease, it being now regarded as a local rather than a constitu- 
tional disorder. The mortality during the Peninsular War, in 1813, amounted 
to one-third of the cases attacked. During the Crimean contest, as we learn 
from Macleod, the fatality was very much less. The deaths from this cause 
in our late war were very few indeed, and when an unfortunate termination 
did occur it was from hemorrhage, from suppuration following extensive 
destruction of the soft parts, from exposure of joint-cavities, or from septi- 
caemia wearing the sufferer but through sheer exhaustion, and occasionally 
from the implication of some important organ. 
Treatment.—-First in importance is a change of place,—a removal from the 
infected district,—and, if the weather is not too inclement, the erection of 
hospital-tents in the open air. When the gangrene broke out at the Chestnut 
Hill Hospital situated near Philadephia, it was arrested in twelve hours by 
removing the affected patients into an adjoining grove of chestnut timber. 
Should the latter plan be inadmissible, a separate building, thoroughly 
cleansed and ventilated, must be secured. In this change of place, every 
germ-bearing thing connected with the affected ward must be left behind, 
nurses, beds, bedding, sponges, instruments, and dressings, and a fresh supply 
of each provided; while an abundance of chloride of lime should be distrib- 
uted about the new quarters. 
Local Treatment.—This is next in importance, and consists in disinfect- 
ing and deodorizing the adhei*ent slough, arresting the ulcerative process, 
and exciting a healthy inflammatory action beyond the limits of the sore. 
Germicidal agents are the most potential for these purposes, two of which 
transcend all others in value,—nitric acid and bromine. The mineral acids 
were first used by Mr. Guthrie, at Santander ;* and bromine by Dr. Gold- 
smith,f during our late war. Preliminary to the use of either, if the disease 
is extensive, the patient should be moderately etherized, as their application 
is attended with considerable pain. With a pair of scissors and forceps all 
* Commentaries on Surgery, page 161. 
f American Medical Times, Sept. 12, 1863, page 121. 204 
MOIiTlFICA riON. 
loose and disorganized parts of the slough should be clipped away, and the 
surface cleansed with a wash of permanganate of potash (three grains to one 
ounce). Next, with a mop made by securing a piece of lint or a dossil of 
cotton to the end of a stick, the fuming nitric acid or the undiluted bromine 
should be worked into all the interstices of the slough, or, if this is too com- 
pact, its parts should be broken with a director, so that it may be freely in- 
terpenetrated by the caustic in every direction as deep as the living tissue. 
Near the attached portions of the slough, openings may be made at short 
intervals with the director, and the acids thrown in with a glass syringe. 
Where the parts are rapidly breaking down, as in the ulcerative variety, the 
simple application of these agents to the circumference of the disease will 
arrest the destruction. The surface thus converted into a charred mass 
should be covered with a flaxseed-meal poultice sprinkled over with char- 
coal ; or with a warm-water dressing medicated with a little phenol sodique 
or a very weak solution of bromine (one part to twelve of water). If the 
caustic application has been thoroughly made, its repetition will not be neces- 
sary. The sewage from the dead pulp will be destroyed, and the molecular 
decay arrested. In this way inoculation of the contiguous structures is pre- 
vented, and a healthy inflammation established. The transudation which 
follows such inflammation will not only disjoin the dead from the living, but 
will also furnish the granulations necessary to restore the chasm. As soon as 
the granulations form, a simple ulcer results, and the sore should be managed 
as directed under the head of Ulceration. Other preparations have been used, 
and with highly beneficial effects, as the acid nitrate of mercury, by Professor 
Gross; the permanganate of potash (one drachm to one fluidounce of water), 
by Dr. Hinkle, of Marietta (also a favorite remedy with Dr. Ashhurst) ; lactic 
acid, by Professor Jackson ; spirits of turpentine, by Dr. Hackenberg; tar- 
water, by Dugas, of Georgia ; sugar or syrup, by Dr. Packard ; and butter- 
milk, by Dr. W. F. Atlee. Monsel’s solution, iodine, chlorinated soda, and 
creasote have all had their advocates. Among the French surgeons the actual 
cautery was, at one time, much in use. In cases attended by hemorrhage the 
hot iron or the galvano-cautery would be desirable, as furnishing the most 
certain means of controlling the bleeding, as well as of destroying all the 
specific characters of the slough. Should the hemorrhage continue to recur, 
a ligature must be applied to the bleeding vessel; if practicable, at the seat 
of disease. Dr. Weeks, Surgeon U.S.Y.,* tied the dorsalis pedis in one case, 
the anterior tibial in another, and, in a third, the brachial artery, with suc- 
cess, applying immediately afterwards the bromine. Pressure by means of 
an acupressure-pin will answer a good purpose in cases where the artery is 
accessible. 
Constitutional Treatment.—This should be supporting throughout. 
The bowels must be regulated, if required, by gentle laxatives, such as 
the sulphate of magnesia, a Seidlitz powder, or a rhubarb pill; pain and 
restlessness must be subdued by the free use of opium, and the strength 
maintained by quinine and the tincture of the chloride of iron, together 
with a diet consisting of concentrated animal broths, milk, milk-punch, and 
eggs. 
Throughout the whole treatment there should be the most rigid enforce- 
ment of every hygienic precaution. All instruments used in the wards 
should be cleansed and kept in a carbolic acid bath (one part of acid to twenty 
parts of water). No sponges should be employed : wads of oakum answer 
every purpose for washing, to be thrown away immediately after using. 
The soiled dressings, as they are removed and placed in vessels, should be 
sprinkled with a solution of the permanganate of potash and then destroyed 
by fire. The clothing of the nurses, as well as that of the patient’s bed and 
person, will demand frequent change, and a constant supply of fresh air, 
with thorough ventilation, is of the first importance. 
* Hamilton’s Surgery, page 70. HISTORY OF HOSPITAL MORTIFICATION. 
205 
In consequence of extensive destruction of the soft parts, laying bare the 
bones, or opening joints, amputation sometimes becomes necessary: in this 
event the surgeon should delay not only until the separation is accomplished, 
but also until repair has been well established, when, if the strength of the 
patient allow, he should be isolated and the operation performed. 
History of Hospital Mortification. 
As with the early history of many other diseases, that of hospital mortifi- 
cation is involved in much uncertainty, and while authors discover a knowl- 
edge of this disorder in the allusions made to certain forms of ulcerations by 
Aetius, Avicenna, Rolandus, and others, still, all is mere conjecture. I doubt 
very much whether the disease existed, save perhaps in a sporadic form, an- 
tecedent to the discovery of gunpowder and the construction of fire-arms. It 
was only after the introduction of these into the contests of nations that war 
became very destructive, or that large numbers of wounded men were likely 
to be suddenly massed together. Then, again, the construction of hospitals, 
and especially of military hospitals, was an outgrowth of Christian civiliza- 
tion, and, on anything like a colossal scale, is of very modern date. 
Richard Wiseman, surgeon to Charles II., alludes to the ravages of a dis- 
ease which attacked wounds, and in his quaint language says, “ the lips sink 
and are flaccid, a gleet followeth, and the flesh within withers; also the pulse 
and the sense in the part do both languish.”* 
The first distinct allusion to the disease was made by La Motte, in 1722, 
in his treatise on Surgery. It had appeared at the Hotel-Lieu in Paris, and 
was first named by him pourriture d'hopital. It is only, however, after the 
publication of the works of Pouteau.f sixty-one years later, that we find a 
clear description of this form of mortification. Pouteau’s knowledge was 
drawn from cases in the Hotel-Lieu at Lyons; and when a dresser in this 
hospital he had himself suffered from the disease. 
In 1785, Gillespie,| an assistant surgeon in the English navy, published a 
paper on the same subject, under the title “ Observations on the Putrid 
Ulcer.” He mentions its prevalence among the seamen landed on Pigeon’s 
Island, St. Lucia, in 1781, where a naval hospital was established. At the 
same time the inmates of the naval hospital at New York, at least those from 
the West India squadron, suffered much from the affection, though there was 
in both a scorbutic element. In 1788, Lussassois,§ one of the surgeons of 
the Hotel-Lieu at Lyons, published an article on the same subject. Both 
he and Gillespie regarded the disorder as infectious. In 1796 two pamphlets 
appeared,—one by Moreau and the other by Bourdin, both Frenchmen ;|| 
but according to Thompson “ these papers added nothing new to our knowl- 
edge of the disease.” 
Rollo,in 1797, devotes a chapter in his book on Diabetes to a “ sore acted 
on by a new or overlooked species of matter,” which is supposed to cor- 
respond to hospital mortification. In 1799, Lr. Blane speaks of the disease 
prevailing very much in ships, and in the naval hospital at the Cape of Good 
Hope, in so severe a form that even bones like the scapula and the ilium were 
attacked. The same year Lr. Trotter** described the disease, and among its 
peculiarities he mentioned an irregularity of the sores, which gave to their 
edges a deeply-indented form. John Bell,ft in 1801, treats of hospital gan- 
grene, and, in the course of his remarks, says that “ no dressings ever can cure 
the disease,”—rather a rash assertion in the light of modern therapeutics; 
though he very justly adds that the only safety for the patient is outside of a 
* Chirurgical Treatises, vol. ii. page 213, 5th ed., 1719. 
f Posthumous Works, vol. iii., 1783. 
j Gillespie on Putrid Ulcer, London Medical Journal, vol. vi. page 373. 
$ Dussassois, Gangrene des Hopitaux. 
i| Sur la Gangrene Humide des Hopitaux, 1788. 
Diseases of Seamen, by Rollo. 
** Trotter, Medicina Nautica, vols. ii. and iii. 
ft John Bell, Principles of Surgery. 206 
MORTIFICA TION. 
hospital air. In 1804 and 1805, Dr. Thompson* says, “two theses of high 
merit were written—one by Dr. Leslie, the other by Dr. Johnson, students 
in the University of Edinburgh—on this form of gangrene.” 
In 1804f two papers were published on the subject,—one by Ballard, and 
the other by Harness, both connected with the Royal Navy. 
In 1806, Marshall, in a letter to Ballingall. attributed the occurrence of the 
disease in the Feversham Hospital to the use of infected sponges; and in 1809, 
Mr. Lyttle, also of the English navy, wrote a treatise, in which he declares 
that this gangrene caused the loss of more men to the naval service than all 
other diseases incident to seamen.J 
Sir James McGrigor, Chief Medical Director in the Peninsular War§ of 
1813, also speaks of the disease in a letter to Ballingall, and attributes its 
prevalence to the unhealthy sites of hospitals, conjoined with a pre-existing 
enfeebled state of health in the patients. In the same year Dr. John Thomp- 
son|| devoted to this subject a carefully-prepared chapter, or rather lecture, 
at the end of his book on Inflammation, in which he expresses his preference 
for the term putrid ulcer. Though it is alleged that specific sores are not 
liable to be attacked by this mortification, yet he mentions cases of open 
cancer, and chancre, which he had seen repeatedly become the seat of dis- 
ease. Its contagiousness he admits, and recommends, as the best means of 
managing the disease, separation, cleanliness, and ventilation, followed by the 
use of emetics and purgatives, and, locally, the use of turpentine with resin 
ointment. He opposes the use of opium, wine, and a full diet, especially in 
the commencement of the disease, and recommends the employment of blood- 
letting. He states that the gangrene often attacked wounds made by the 
lancet. 
Baron Larrey, notwithstanding that he must have been quite familiar with 
this mortification, has nowhere given to it more than a very meagre notice. 
In Egypt the disease was peculiarly fatal, the men dying in a few 
and presenting appearances like those of yellow fever. In his “ Chirurgie 
Militaire” it is scarcely alluded to. He recommends quinine, opium, and the 
actual cautery.** In his “ Memoirs of Military Surgery”ff he speaks of the 
epidemic disease of Brunn, in the campaign of Boulogne, as appearing among 
the French and Russian wounded. The wounds in which suppuration was 
first developed were affected with hospital putrefaction, which spread with 
great rapidity. The odor proved infectious, attacking those who were near, 
and also the medical attendants. The disease likewise made its appearance 
in the Ilopital la Charite, distant from the others and perfectly clean. In his 
“ Observations on Wounds and their Complications”j;j; he insists on a differ- 
ence between ordinary gangrene and hospital putrefaction, having witnessed 
both in the campaigns in Germany. His local treatment consisted in the use 
of Labarraque’s solution and the cautery. 
In 1815 there were four valuable contributions on the subject, byllennen, 
Brugmans, Delpech, and Aubry. IIennen§§ had encountered this scourge of 
military camps first in the Cordeleria Hospital at Bilboa, a hospital admi- 
rably located on a gravelly soil, four miles from the city, six miles from the 
sea. and on the bank of a river. When it broke out, the prevailing winds 
were from the sea, the thermometer ranging between 68° and 78°. The 
arteries rapidly sloughed, followed by hemorrhage, and the ligatures, which 
* Thompson, Lectures on Inflammation. 
f Blackadder, Observations on Phagedaena Gangraenosa, Edinburgh, 1818. 
j Malignant and Contagious Ulcer. 
if/ Medico-Chirurgical Transactions, vol. vi. page 455. 
|| Lectures on Inflammation, page 369. 
Larrey, Military Surgery, vol. ii. page 18, Translation by Hall, 1814. 
** Larrey, Clin. Chirurg., i 829, vol. i. page 72. 
ff Memoirs of Military Surgery from 1792 to 1812, vol. i. page 412, and vol. ii. page 1, Translation 
by Hall, Baltimore, 1814. 
ft Op. cit., Translation by Rivinus, Philadelphia, 1832, page 48. 
$$ Observations on Military Surgery, Edinburgh, 1818; also London Medical Repository, March, 
18i5. HISTORY OF HOSPITAL MORTIFICATION. 
207 
were placed on the vessels above, separated in a few days, giving rise to 
exhaustive and fatal bleedings. He never saw the lancet or cupping wounds 
attacked, as stated by Thompson ; and he says that a remarkable feature of 
the disease was its tendency to change all sores into a circular form, whatever 
may have been their previous shape. In the Gensdarmerie Hospital at Brus- 
sels, which was filthy, there were three hundred wounded men, and among 
them one hundred and forty cases of compound fracture, many of whom had 
lain from one to two weeks after the battle of Waterloo without dressings; 
and here the fatality was frightful. In the Elizabeth Hospital at Brussels, 
which was clean, there were only a few cases. At the hospital on the Ant- 
werp Canal, out of the city, and which was crowded, this gangrene attacked 
the stumps three hours after amputation, and so rapid and destructive was 
its progress that in twenty-eight days there was but a single surviving stump. 
A few cases were seen presenting the phenomena of yellow fever, such as were 
described by Larrey. Hennen advocated bleeding, the use of the fermenting 
poultice, and, in aggravated cases, the cautery. 
Brugmans, of Leyden,* analyzed the air of infected wards, and claimed to 
have discovered a peculiar animal matter having a tendency to putrefaction 
and which he supposed played an important part in the production of the 
disease. It is this writer whom Guthrie quotes as saying that “ when the 
disease existed in Leyden in 1798 it was communicated from a lower to an 
upper ward of the hospital by cutting an opening between to improve the 
ventilation:” hence he argued its contagious nature, and claimed also that its 
introduction into Holland was through charpie sent from French hospitals. 
Del pee hf attributed to the depressing influence of defeat much of the 
mortality among the French from this mortification: despondency, however, 
is one of the symptoms of the disease. He treated successfully one hundred 
and fifty cases before Pampeluna with the actual cautery, and concluded, 
after a careful study of the disorder, that it was communicated to wounds 
by poisonous exhalations. 
Aubryj; saw this gangrene in Prague, in 1814; in Rouen, in 1812; and on a 
vessel bound from Spalatro to Zara, in 1807. He believed in its communica- 
bility by contact, and mentions the case of a surgeon at Prague who wounded 
his finger and in four days sutfered from an attack. lie also pointed out the 
distinction between this sore and ulceration, and was an advocate of the use 
of opium internally, with that of vinegar locally. 
In 1818, II. H. Blackadder,§ surgeon to His Majesty’s forces in the Pen- 
insula, published a monograph on this form of mortification, in which the 
subject is treated in a learned and exhaustive manner. He regarded the 
disease as purely local and contagious. While examining the stump of a 
patient who had died of the disease, he became inoculated through a scratch 
in the finger. Pain and inflammation set in sixty hours after the accident, 
and in four days had extended up the arm, followed by rigors and headache. 
It was two months before the sore cicatrized, and six months before the 
natural color of the part returned. Blackadder was a strenuous advocate 
for arsenic, which he applied, in the form of Fowler’s solution, directly to 
the wound. This remedy was used also by Higgins, after the battle of 
Waterloo, at the hospital at Antwerp, and at the same place by 0’Connel.|| 
No instances of poisoning were observed. In order to settle the question of 
its contagious nature, inoculated himself in 1810; a vesicle formed, 
and ran a regular course until the fourth day, when its progress became so 
alarming that he permitted it to be destroyed; but it was a month before he 
recovered. Experiments to determine its contagious nature were also insti- 
tuted by Dupin, Richeraud, Dupuytren, and Willaume, all of whom decided 
s Annales de Litterature Medicale Etrangere et Nationale, vol. xix., Nos. 106 and 107, 1815. 
f Memoire sur la Pourriture d’H&pital, 1815. 
j Dissertation sur la Complication des Plaies et des Uleeres, Paris, 1815. 
$ Observations on Phagedaena Gangrsenosa, Edinburgh, 1818. 
|| Dissert. Med. Inaug. de Phagedaena, page 4. 
4 Traite des Typh. Traumat, Gangr. ou Pourriture d’Hopital, Paris, 1822. 208 
MOR TIFICA TION. 
adversely, while Pointe, Danillo, Clerc, Vautier, and Delpech stoutly main- 
tained the affirmative of the proposition. 
Hutchison, in his ‘ Surgical Observations,”* published in 1826, gives a large 
number of reports from surgeons in the Royal Navy, showing the effect of 
hygienic measures upon the disease, and, in addition, the Report of Portal 
and Deschamps to the Royal Institute of France upon the Memoir of Delpech 
on Pourriture d’Hopital, in which they entirely approve of his conclusions. 
In 1826, and again in 1848, John Boggie,f surgeon to His Majesty’s forces 
in the Peninsular War of 1813, published his “Observations on Hospital 
Mortification made at the Ropewalk Hospital, Bilboa.” The treatment at 
first had been stimulating, and the result was the loss of 83 out of 1294 cases. 
Dissatisfied at such a mortality, he adopted the antiphlogistic treatment, 
bleeding largely, even to the extent of three pounds in some cases, exhibiting 
cathartics and emetics, avoiding opium and wine, and enforcing a diet of tea, 
gruel, and farinaceous food. By this plan he alleges that he reduced the 
mortality to 25 in the next 857 cases, or 1 in 34; and after he had succeeded 
in getting this treatment well established, a further reduction in the death- 
rate was attained,—that is, in 796 cases only 6 died, or 1 in 131. Boggie 
makes two varieties, the “sloughing” and the “ phagedsenic.” He regarded 
the disease as constitutional, communicated both by contact and through the 
air, and he says he never saw wounds made by the lancet or scarificator 
attacked. When the destructive process was rapid, he applied the cautery 
or acids. 
Guthrie! thought the disease contagious and infectious. Out of 1614 cases 
at Santander, Bilboa, Vitoria, and Pasages, 512 died in five months. He gives 
an extensive summary of the subject, and, on the whole, favors the treatment 
of Boggie. 
Wright§ records an outbreak of the disease in the Baltimore Almshouse in 
1830 and 1831. in which 20 died. 
South, in Chelius’s Surgery, states that Arnott saw it in the Middlesex 
Hospital in 1835. and also at the Westminster and York Hospitals, Chelsea. 
Samuel Cooper.|| in speaking of this mortification, refers to the declaration 
of Lisfranc, that hospital gangrene is now a mere trifle, and that by the use 
of the actual cautery it is entirely under the power of the surgeon. 
was an advocate for strong acids as a local measure, and says 
he never saw a death from the disease. 
Coote** records its appearance at St. Bartholomew’s Hospital, and also at 
St. George’s and other institutions, during the autumn and winter of 1846-47. 
The cases all recovered under hygienic changes and the local employment 
of nitric acid. The disorder had never been known in these hospitals be- 
fore, and was thought to be due to atmospheric conditions. In Holmes’s 
Surgery,ff this same author says the disease, in 1846, was in two instances 
traceable to a sponge which, although boiled, had yet retained contagion. 
He also gives the history of a woman residing in an unhealthy part of Lon- 
don, whose breast had been removed, and in whom the wound was afterwards 
attacked by this disease. Two persons sleeping in the room which she had 
occupied were attacked with fever and diarrhoea, and he thinks that, had they 
possessed open wounds, both would have suffered from mortification. 
Fabian,!! in 1848, recommended a French compound, the “ citron comme 
topique,” as being possessed of considerable value. 
* Practical Observations on Surgery, 1826, page 194. 
f Medieo-Chirurgical Transactions, Edinburgh, 1826; also, Observations on Hospital Gangrene, 
London and Edinburgh, 1848. 
J Commentaries on the Surgery of the Peninsular War, 5th edition, 1853, London, page 155; also 
Lancet, 1848, vol. ii. pages 628, 685. 
§ American Journal of the Medical Sciences, vol. x. 
|j Medical Times, August 28, 1847, page 524. 
Medical Gazette, June 11, 1847, pages 1024, 1030. 
Lancet, 1847, vol. i. pages 374, 405, 515. 
ff Holmes’s Surgery, 1869, vol. i. page 163. 
Malgaigne’s Revue Med.-Chirurg., October, 1848, page 207. HISTORY OF HOSPITAL MORTIFICATION. 
209 
Velpeau,* in treating upon the subject, expresses his belief in its con- 
tagiousness and also in its animalcular origin. 
Walker,f surgeon at the Barcena Hospital, Bilboa, from September, 1813, 
to January, 1814. says that the character of the disease changed at the ap- 
proach of winter, becoming more inflammatory, and yielding to the anti- 
phlogistic treatment of Boggie. Under the stimulating plan more than one 
in three died. 
TiceJ saw the disease at Coimbra, where several of his nurses suffered 
from attacks contracted by dressing the sores of those affected. He notices 
particularly the extreme depression or despondency which affected the 
sufferers, and considers it pathognomonic of the approach of the disease. 
He regards it as a constitutional disease. Boutflower entertained the same 
views. 
Professor Restelle,§ surgeon-in-chief of the Sardinian army, saw 400 cases 
at Alessandria in 1848 and 1849, and believed that, if proper precautions are 
observed, stumps may be protected against attacks. Caustic potash was his 
favorite local application. He succeeded in inoculating healthy wounds with 
the virus, and thought that the disease was the result of some local influence 
on sores, assisted, no doubt, by a vitiated atmosphere. 
Parke,|| a surgeon in the Russian military service during the Crimean 
War, gives a description of the lamentable condition of the hospitals at 
Simpheropol. Patients were massed together without classification; those 
with typhus fever and those with surgical injuries were in the same wards, 
which were so defective in ventilation and cleanliness that the surgeons 
would suffer from headache after an hour’s exposure to the vitiated atmos- 
phere. The mortality cannot be accurately ascertained, but it was doubtless 
very great, as at Simpheropol the average number of patients was 15,000 
and the average daily deaths were 133 from typhus and mortification. Parke 
bestows high encomiums on creasote. 
The report of the committee to Parliament on the Medical and Surgical 
History of the British Army in Turkey arid the Crimea in 1858 attributes 
the outbreak to filthy and badly-ventilated hospitals with insufficient accom- 
modations. 
Taylor,surgeon to the 29th Regiment of Her Majesty’s forces, India, ex- 
presses the opinion that the disease as it appeared at Ferozepore was local 
and not constitutional; the wounds which appeared most prone to take on 
the disease were those inflicted by grape and canister-shot; and he says that 
nitric acid gave the most relief from the gnawing and burning pain. 
Some idea of the terrible fatality of the disorder may be obtained from 
the statement of Lallour,** surgeon to the French transport-ship Euphrate, 
that during a single passage of that vessel to the Bosphorus, requiring but 
thirty-eight hours, sixty bodies were thrown overboard. The mortification 
attacked all wounds, and even cicatrices. The actual cautery was attended 
with good effect. 
Macleod,ff in speaking of the cause of the disease, thinks that something 
different from bad accommodations and filthiness is necessary to explain its 
appearance. The wounded men who lay thickly around the foul latrines 
suffered no more than those in other localities. It broke out immediately 
after a sirocco which prevailed at the time, and manifested no preference for 
any particular class of wounds, wounds of entrance and wounds of exit suf- 
fering alike. The men prone to scurvy were the most favorable subjects. 
* Ranking’s Abstract, 1848, vol. viii. page 130. 
t Lancet, 1848, vol. ii. page 688. 
j Ibid., pages 630, 631, 685. 
| British and Foreign Medico-Chirurgical Review, October, 1850, page 545. 
|| American Journal of the Medical Sciences, April, 1860, page 570. 
f Macleod’s Surgery of the Crimean War. 
** Ibid. 
ft Notes on the Surgery of the War in the Crimea, London, 1858 ; also Edinburgh Medical Jour- 
nal, 1855-56. 210 
MORTIFICATION. 
In his experience nitric acid exercised the most decided control in arresting 
the process of destruction. 
Surdun* found iodine, applied externally, to act well, and gives seven cases 
of amputation in soldiers on shipboard, all of whom were attacked, and all 
recovered. 
Grohf gives a record of 59 cases, of whom 7 died. His treatment con- 
sisted in ventilation, fumigation, stimulants, chloride of calcium, and mineral 
acids. 
Dr. Joseph Jones,J who saw much of the disease in Southern hospitals 
among Confederate soldiers, wrote a very exhaustive treatise on hospital 
gangrene. He believed that neither contact nor abrasion is necessary for its 
production. He could never trace any connection between the disease and 
scurvy, but thought the affection was due to some organic poison acting as 
a ferment. Soldiers who were well fed recovered most rapidly, so that the 
Union troops suffered less than the Confederates. Out of 385 cases at Em- 
pire Hospital, Georgia, one-quarter died. In the Army of the Tennessee there 
were, during July and August, 1864, 344 cases, with 26 deaths, or, including 
September and October, nearly 3000 cases, one-half of whom were disabled 
for the war. Fresh air, ventilation, change of locality, and the local use of 
nitric acid constituted the plan of treatment. 
Jiingken,§ who saw the disease in the Charite Hospital and also at Dres- 
den, decided that there is no specific save cleanliness and removal into the 
open air under a tent-roof: without these the cautery is of little use, as the 
gangrene will return after the slough is detached. 
Hutchison|| tried treatment by submersion with alleged good success, the 
cases cleaning off in three days, and in ten days healing rapidly. 
In 1863 a number of papers appeared on this subject, amounting, as far as 
I can learn, to nineteen. 
Norths gives 60 cases at the United States Army Hospital at Frederick, in 
the fall of 1862, with 3 deaths. In only 7 cases were there any constitutional 
symptoms present. Nearly all the nurses who had any wounds suffered. 
Browne,** in speaking of the mortification as it was seen at the Marine 
Hospital at New Orleans, states that no foreign organisms or fungoid growths 
were discovered in the sloughs. 
Brinton,ff in his “ Report to the Surgeon-General on the Condition of the 
Louisville Military Hospital,” says that the disease showed little tendency to 
spread from bed to bed, although isolation was not enforced. Out of 88 cases 
there were only 2 deaths, and these suffered from other complications. Bro- 
mine was his favorite local application, it being injected hypodermically at 
the margins of the disease. Dr. Brinton believes in the local nature of the 
disorder. 
Hinkle,A.A.S., U.S.A., saw the disease at the Campbell and Jervis 
Hospitals, Baltimore, and at the Armory Square Hospital, Washington. The 
permanganate of potash was his favorite remedy, internally and externally. 
Peters reports cases from the same hospitals. Lloyd,§§ Stanford.|||| and 
all bear testimony to the value of bromine, when applied pure. 
* Gazette Hebdomadaire de M6decine et Chirurgie, January 12, 1857. 
f Groh on Hospital Gangrene, Wien. Med. Zeitschr., 1858, pages 35, 38; Schmidt’s Jahrbucher, 
No. v. vol. cvi. page 198. 
J Jones, Investigations on the Nature and Causes and Treatment of Hospital Gangrene, United 
States Sanitary Commission, Surgical Memoirs, vol. ii., 1871; also New Orleans Medical Journal, 
January and April, 1869. 
§ Allgemeine Med. Centralzeit., xxx. 67; Medical Times and Gazette, Nov. 2, 1861. 
|| Hutchison, Medical Times and Gazette, 1862, vol. i. page 8. 
•|[ American Medical Times, 1863, vol. i. page 255. 
** Ibid., May 2, 1863, page 215 ; also Proceedings of the New York State Medical Society, 1863-64. 
ff American Medical Times, May 23, 1863, page 250 ; also American Journal of the Medical 
Sciences, July, 1863, page 279. 
American Medical Times, November 28, 1863, page 254. 
|| Ibid., November 28, 1863. 
||| Ibid., 1863, vol. ii. page 24. 
f*[f Ibid., August 22, 1863, page 84. HISTORY OF HOSPITAL MORTIFICATION. 
211 
To M. Goldsmith,* Surgeon U.S.V., the profession is indebted for the use 
of bromine in hospital mortification. His observations were made at Hew 
Albany, Nashville, Murfreesborough, and Louisville. In drawing the compari- 
son between bromine and nitric acid, he gives 152 cases treated with the first, 
with only 4 deaths, all of which were complicated; and 13 cases with the 
last, with 8 deaths. Of 13 other patients, in whom various remedies were 
used, 5 died. Dr. Goldsmith believes it to be a local disease. 
Detmold,f in his “ Lectures on Military Surgery,” asserts his belief in the 
local nature of hospital mortification. He thinks it may arise from the 
presence of some microscopic fungus; he does not believe it ever attacks 
an unbroken surface; and he says that it may be introduced into the best- 
policed hospital by patients or by infected clothing. 
Weeks| furnishes the record of 115 cases, in Louisville, 104 of which were 
treated with bromine and 11 by other remedies. Of the 104 only 3 died,—2 
by pyaemia and 1 by cellulitis; of the 11, 3 also died. He regards the affec- 
tion as a local one, and believes that the materies morbi enters by the wound 
and not by the lungs, and that the constitutional symptoms are secondary. 
He has frequently seen cases of embolism of the lungs and other parts of the 
body following the disease. Laurence§ is also a localist, esteeming the con- 
stitutional symptoms, when present, as secondary. 
Radcliffe,|| A.A.S., U.S.A., saw the disease among the prisoners who had 
been brought from Richmond to the United States General Hospital at 
Annapolis. He relied on nitric acid and stimulants for its treatment. 
Surgeon U.S.A., and the medical historian of the war, insti- 
tuted observations at all stages of the disease, to determine the question of 
a cryptogamic origin, and, after using the highest powers, failed to discover 
any microscopic organisms except vibriones, which are met with in all de- 
composing animal substances. 
Hamilton,** though he does not advocate the constitutional origin of the 
disease, states that he saw two cases of hospital gangrene without any previous 
wound, in one of which the soft tissues were destroyed over nearly the entire 
length of the tibia. The number of cases which he had under observation 
at the McDougal Hospital was 36. Of this number 18 were treated by nitric 
acid, the average duration of the treatment extending over sixteen days ; 14 
were treated with bromine, their average duration being twelve days; and 1 
with iodine, recovery taking place in seven days. 
Parkerff thinks the causes of hospital gangrene identical with those of 
typhus, with the addition of a suppurating wound. 
Ball];t saw 43 cases, under the care of Weir, at Frederick, and says that 
when the wind blew from the tents towards the hospital in which were 
placed the gangrenous cases, new cases would appear in the latter; but when 
the current of air was in the opposite direction, no new ones arose. He also 
states that when the door was left open into the gangrenous ward, patients 
occupying the beds nearest the door were first attacked. 
Post§§ witnessed the disease at Nashville and Louisville Hospitals. This 
surgeon tied the posterior tibial artery at the bottom of a gangrenous 
wound, the patient making a good recovery. His treatment was by stimulants 
and bromine. Moses|||| also relied on bromine, one application in his hands 
usually proving sufficient. He regarded the disorder as purely a local one. 
* American Medical Times, September 12, 1863, page 121; also Report on Hospital Gangrene, 
Pyaemia, etc., Louisville, 1863. 
-f- American Medical Times, Feb. 21, 1863, page 97. 
J Ibid., 1863, vol. ii. page 46. 
| Laurence’s Lectures on Surgery, page 197. 
ii American Medical Times, April 4, 1863, pages 161, 172. 
f Ibid., April 11, 1863; and Report to the Surgeon-General. 
** Ibid., 1863, vol. ii. pages 181, 205. 
ff Ibid., Sept. 5, 1863, page 109. 
tt Ibid. 
|Ibid., Sept. 12, 1863, page 122. 
1111 American Journal of the Medical Sciences, vol. xlvii. page 331. 212 
MORTIFICATION. 
Alley* was also an advocate for the use of bromine. Pittino’sf article 
on the subject relates to the cases at Annapolis from Libby Prison. CraneJ 
treated three cases with chlorinated washes. 
In 1864, Pick,§ at St. George’s Hospital, London, dissatisfied with nitric 
and carbolic acids, passed a stream of chlorine gas through the affected ward, 
and found the disease completely arrested in four cases. In his opinion 
opium was omnipotent. Under the use of this remedy, in 47 cases the dis- 
ease was subdued in forty-eight hours, and in a smaller number in one day. 
In 1864, also, an article was published by Bartholow|| on this form of mor- 
tification ; one by in which, besides recognizing two forms of the 
disease, he advocates the use of pyroligneous acid as a local remedy; and 
one by Hackenberg,** in which turpentine is highly extolled. 
Mr. Maunderj'j' believes that the disease may arise from a vitiated atmos- 
phere, entirely independent of a specific materies morbi, and also that it may 
be introduced into a hospital from without. lie is an advocate of nitric acid 
and a water-dressing. 
Packard!! recommended the use of a hydro-carbon as a local dressing. He 
sprinkled or poured over the parts white sugar or thick syrup, and covered 
the ulcer with lint. He believes the disease to be a local one. 
Le Conte suggested the free use of powdered charcoal, chiefly to deodorize 
the foul slough. 
Atlee,§§ in a review of Hr. Goldsmith’s book on hospital gangrene, says 
that patients get well in spite of bromine, not by it; he thinks the infection 
is received both by open wounds and through the lungs; and he extols the 
external application of buttermilk, as practised by Pfeiffer at the Satterlee 
Hospital. 
Kempster|||| believed strongly in the constitutional origin of the disease, 
general symptoms being prominent in the cases which he witnessed at the 
Patterson Park Hospital, Baltimore, in 1864. 
saw the disease at Hospital No. 1, Nashville, in 1864, where 14 
deaths occurred in 202 cases. With him bromine ranked first, and chloride 
of zinc next, as local remedies. At the same time 300 were treated at the 
Cumberland Hospital with nitric acid, of whom 50 died. 
Thomson*** made numerous microscopical examinations at the Houglas 
Hospital, but wifhout discovering any organisms which could be charged 
with an infective influence. He cautions against over-stimulation, and gives 
cases in which bromine succeeded in curing the disease after nitric acid had 
failed. 
Lane fff advocates the continuous use of dilute nitric acid. 
Bligh!!! tried both nitric acid and bromine in our late war, and decided 
in favor of the last. 
Smart,§§§ Inspector-General of Hospitals of the Royal Navy, uses carbolic 
acid as a preventive, and permanganate of potash as a curative agent. For 
obstinate or aggravated cases he believes the chloride of zinc and the actual 
* Buffalo Medical Journal, Sept. 1863. 
f American Journal of the Medical Sciences, July, 1863, page 60. 
j Ibid., page 66. 
| British Medical Journal, 1864, vol. i. page 262. 
|j American Journal of the Medical Sciences, March 6, 1864, and Jan. 1865, page 274; also Cin- 
cinnati Lancet and Observer, Oct. 1864. 
f American Medical Times, 1864, vol. i. page 4. 
** Ibid., Nov. 28, 1864, page 264. 
ff Clinical Lectures and Reports, London Hospital, 1864, page 104; also Braithwaite’s Retro- 
spect, vol. 1. page 215. 
tj American Journal of the Medical Sciences, Jan. 1865, page 114. 
|$ Ibid., Jan. 1864; also, July, 1865, page 61. 
|j| Ibid., April, 1866. 
Ibid., Jan. 1867, page 281; also Nashville Medical Journal, Aug. 1866. 
*** American Journal of the Medical Sciences, vol. xlvii. page 393. 
fff Medical Times and Gazette, March 30, 1867. 
Lancet, Aug. 29, 1868, page 278. 
||| Ibid., Oct. 1, 1870. HISTORY OF HOSPITAL MORTIFICATION. 
213 
cautery to be among the most valuable agents. In 1857 and 1859 he wit- 
nessed the disease at Hong-Kong. He considers it a low inflammatory action 
of zymotic origin, the microzymes being in the atmosphere or adherent to 
dressings. Fresh air, he thinks, without remedies, will cure the disease. 
Miller,* at the 17th Corps Hospital, Atlanta, Georgia, could not procure 
bromine, but used, with excellent effect, a saturated solution of iodine. 
Professor Spencef insists in his lectures that the open air is the only 
proper place for this class of cases. If it is attempted to treat them in the 
wards of a hospital the success will depend on the multiplied contrivances 
for ventilation and cleanliness. 
BryantJ saw the disease at Guy’s Hospital, London, in 1849, when con- 
tused as well as open wounds were attacked. He thinks the ulcerative form 
is preceded by constitutional symptoms, the sloughing form always by local 
signs; and he interdicts entirely the use of sponges. 
Treibes§ regards the affection as a diphtherite, in the first instance, purely 
local, and uses electricity. 
Billroth|| ventures the opinion that the epidemic prevalence of this kind 
of mortification may be due to minute organisms of rare occurrence. 
Yon Pitha and regard the disease as an epidemic, and as miasmatic 
in origin. 
Heiberg** had an opportunity of seeing all the cases at Berlin, in the 
Franco-Prussian Wqr. The temperature-curves, being very irregular, re- 
vealed no special type of the disease. Low diet and ice-water formed the 
internal treatment, and chloride of zinc well worked into the incisions, with 
subsequent dressings of oil, the local management of the sores. 
* American Journal of the Medical Sciences, Oct. 1871, page 462. 
■f Lectures on Surgery, Edinburgh, 1871, page 67. 
j Bryant’s Practice of Surgery, London, 1872, page 447. 
£ Lancet, Nov. 2, 1874, page 646. 
|| Billroth’s Surgical Pathology, American ed., 1875, page 322. 
f Ibid. 
m Virchow’s Archives, liii. CHAPTER V. 
WOUNDS. 
General Considerations.—A wound is a solution of continuity in any tissue 
or organ, produced by direct or indirect violence. The infliction of a wound 
is followed by hemorrhage, pain, and retraction of tissue. 
Wounds are most conveniently classified according to the nature of the 
vulnerating body by which they are produced. 
There are six varieties,—incised, lacerated, contused, punctured, poisoned, 
and gunshot wounds. 
The indications in the treatment of wounds are, the arrest of hemorrhage, 
removal of foreign bodies, thorough disinfection, complete drainage, the proper 
apposition of the divided parts, and the use of such measures as will co-operate 
with nature to the fullest extent in the repair of the damage, as proper 
dressings, absolute rest, perfect ventilation, and judicious diet. 
Hemorrhage.—There is no sight so appalling and sickening as a formidable 
hemorrhage. The sight of even a few drops of blood will often, with many 
persons, produce fainting. Scenes of this kind are quite common at the open- 
ing of every session in the operating amphitheatres. Abhorrence of blood is 
most wisely implanted in our humanity, and exhibits the value set by God 
on human life. Except on the battle-field, in street-fights, or assassinations, 
death from hemorrhage is not common; and with the resources at our 
command (the wounded vessel being outside of the trunk) the surgeon who 
allows a patient to perish before his eyes, save in exceptional cases, may well 
question his fitness for the responsible work in which he is engaged. 
When a large artery is opened by disease, accident, or incompetency, the 
blood gushes out with a bound, in a red, angry stream, and if not immediately 
checked the face grows pale, the color leaves the lips, and the patient, in 
consequence of the rapid diversion of blood from the brain, falls into a state 
of syncope. Here we have a beautiful illustration of that provision which 
exists in the organization, by which life, even in the direst extremity, is con- 
served. The rapid depletion of the brain and spinal marrow deprives the 
heart of its motor power, and so weakens its stroke that the blood moves 
slowly and feebly, scarcely reaching the smaller vessels, thus allowing time 
for the formation of a clot at the bleeding orifice. After a time the heart 
begins to recover its strength; the blood is impelled with more vigor; it 
reaches the extremities and surface of the body; the pulse at the wrist can 
be felt, the color returns to the lips, the warmth to the body, and now the 
stream becomes forcible enough to dislodge the protecting clot. The bleed- 
ing is renewed with an impetuosity little less than at first, when again the 
deadly yet friendly syncope intervenes to stay, for a time, the work of 
destruction. At each repetition of such a scene the symptoms prove more 
urgent: the face assumes a deathly pallor, appearing transparent, puffy, and 
wax-like; the lips become bluish; the pulse feeble, less frequent, and, finally, 
imperceptible. The temperature falls first at the extremities, and progres- 
sively over the body, the surface of which is covered with a cold, clammy 
perspiration. If the patient attempts to rise, he is seized with dizziness; 
objects become indistinct and vanish into the darkness; the pupils are widely 
dilated; the mind becomes confused; the stomach sickens; the ears are filled CLOSURE OF VESSELS. 
215 
with strange sounds, and everything seems to whirl; the thirst is insatiate ; 
there is an uncontrollable restlessness, and a sense of suffocation ; the arms are 
thrown over the head, as if to grasp something by which the muscles on the 
exterior of the chest might aid in the work of respiration; the breathing is 
carried on in sighs and gasps; there is an entire absence of pain, and the 
countenance wears a frightened and anxious expression. The patient strug- 
gles to rise, but as often falls back in a faint, no longer able to hold out in the 
unequal conflict; the respiration becomes more feeble, the eyes glazed and 
motionless, with occasional muscular twitchings of the face and extremities, 
until at last the sufferer sinks into a state of unconsciousness, and death quietly 
claims his victim. How forcibly has the sculptor impressed upon his marble, 
in the attitude of the Hying Gladiator, a truthful representation of a man 
whose life is slowly ebbing away from hemorrhage! 
To control hemorrhage permanently, the vessel must be closed by an 
organized structure, the result of inflammatory action. In small vessels, and 
sometimes in those even of the size of the radial, nature may accomplish the 
work without any assistance from the surgeon. I shall first explain her 
method. When a wound is inflicted by a sharp-edged instrument, involving 
vessels of moderate size, there will be a sudden and profuse gush of blood. 
After a short time it diminishes, and finally ceases altogether, or amounts 
only to an oozing. How is this process accomplished ? 
The vessels, the blood, and the perivascular tissues are all concerned in 
the work of haemostasis. When an artery is divided, it contracts within its 
sheath, and the fibres of connective tissue or other contiguous structures 
sink across its extremity, often concealing it from view, and requiring, for 
its exposure, that it shall be drawn out of its hiding-place. Not only does 
the artery retract, but it also contracts to its flattened or ovoidal form, 
thereby diminishing its canal, and thus offering a mechanical resistance to 
the escape of the blood. If a large amount of blood is lost, the heart’s 
action will be weakened, in consequence of which the column of blood is 
propelled with diminished force against the walls of the vessels. We fre- 
quently see, after a sudden and exhausting hemor- 
rhage, the injured vessel lying in the wound col- 
lapsed, and without exhibiting the least sign of 
pulsation. It is because the wave of blood has not 
sufficient momentum imparted to it by the heart 
to reach the divided artery. 
What part does the blood play? This fluid pos- 
sesses the property of coagulation, forming what 
are called clots, or thrombi. The moment it escapes 
from the vessels it usually undergoes this change, 
which is favored by mechanical points of obstruc- 
tion. If a little irregularity forms on the inner side 
of an artery or vein, or if a fine thi’ead is stretched 
across the lumen of a vessel, very soon there will 
bean embolism or thrombus induced. As soon as 
the flow slackens the blood begins to coagulate. 
The straggling fibres of the sheath of the vessel or 
contiguous muscles at its orifice play the part of 
the threads just described,—that is, serve as a net 
to entangle the fibrin,—so that a clot accumulates 
at the end of the artery and around it, extending 
up its canal as high as the first chief collateral 
branch (Fig. 189); and the same occurs in the other, 
or distal, portion of the wounded trunk. We have 
now a plug which, in its relation to the vessel, resembles somewhat the glass 
stopper of an old-fashioned decanter. The portion of the clot or thrombus 
within the artery does not accurately fill its canal. It is conical in form, 
the apex directed upwards, and the base occupying closely the circumference 
Fig. 189. 
The relation between the internal 
and external clot, or nature’s meth- 
od of arresting hemorrhage : a, the 
external clot, continuous with that 
of the sheath at b and c; e, the in- 
terior clot, conical in form, and rising 
to the first collateral trunk. 216 
WOUNDS. 
of the arterial orifice. After a time, however, the clot increases by attract- 
ing to itself a new deposition of fibrin until it more perfectly occupies the 
lumen of the vessel. So far the thrombus is not of a permanent kind, and 
is liable to become displaced by a column of blood impelled by the recovered 
power of the heart, producing a renewal of the hemorrhage. 
To make such closure secure 
against all contingencies there 
must be a vital union between 
the thrombus and the walls by 
which it is surrounded; and 
this brings me to the perma- 
nent closure of vessels. In order 
to study this process satisfacto- 
rily, I had a number of ligations 
made of the arteries of dogs, by 
Dr. William H. Mastin, one of 
the resident physicians of the 
University Hospital. The ani- 
mals were killed at different 
periods, and carefully injected, 
after which I had an opportu- 
nity of studying each specimen 
as it was prepared by one of 
our most eminent mieroscopists, 
Dr. E. O. Shakespeare. These 
experiments, if they were prop- 
erly interpreted, establish the 
fact of the transformation of 
the coagulum, clot, or throm- 
bus into an organized struc- 
ture, and its unification with 
the walls of the vessel. 
When a ligature is placed 
about an artery and firmly tied, the vessel is constricted and puckered up 
at the point of application. The effect of such constriction is to divide the 
middle and internal coats, which be- 
come both incurved and retracted, 
the external or fibrous coat remain- 
ing unsevered. The blood thus ar- 
rested begins to coagulate first at the 
seat of ligation, where it occupies the 
ent ire circumference of the canal of the 
vessel. To this coagulum or thrombus 
are added successive layers or laminae, 
and as the column rises it becomes 
conical in form, reaching up to the 
first collateral branch, and either not 
touching the walls of the vessel or 
resting only against one of its sides. 
(Fig. 190.) The direction of these suc- 
cessive additions or laminae in the 
thrombus is transverse or slightly 
oblique. 
If a portion of this internal throm- 
bus be examined, at any time after its 
coagulation, with a sufficient power, it 
will be seen to consist of a vast crowd 
of red corpuscles, with here and there, indiscriminately scattered, a few white 
ones, and all supported in the fibrinous framework of the clot. (Fig. 191.) 
Fig. 190. 
Longitudinal section of the crural artery of a dog twenty- 
four hours after ligature, magnified 60 diameters : a, constricted 
point, or seat of ligation ; b, b, walls of vessel; c, clot or throm- 
bus, with its transverse or laminated striation and conical form. 
Fig. 191. 
Longitudinal section, showing the clot in the crural 
artery of a dog twenty-four hours after ligature, mag- 
nified 225 diameters. The dark points indicate the 
white corpuscles, all the other points the red corpuscles. CLOSURE OF VESSELS. 
217 
Pressing the investigation further, let a section of the artery and its clot be 
made twenty-four hours after ligature, and a wonderful change will be noticed 
in the numerical relation of the two kinds of corpuscles. Even in this short 
period of time the red, which had predominated so greatly, have begun to 
disappear, and the white corpuscles are now seen thickly scattered over the 
field. If successive sections of this clot be made from the base towards the 
summit, it will be seen that the white corpuscles diminish in numbers from 
below upwards; that is, they are most numerous in the oldest part of the 
clot. The secure manner in which the clot or thrombus is first mechanically 
connected with the enclosing walls of the vessel is here worthy of observation. 
This connection is threefold: first, by being crowded into the corrugations 
made by the puckering of the vessel at the place of ligature; second, by 
moulding its surface into the plications of the tunica intima, or internal coat; 
and last, by the peculiar behavior of this coat, which, after being severed by 
the ligature, splits into filaments or threads, which float into the midst of the 
coagulating blood, and, like guys, serve to moor the clot securely in place. 
(Pig. 192.) The questions which at this stage of the process demand expla- 
nation are very difficult of solution. AVe are not yet in a position to answer 
Fig. 192. 
Tranaverse section of the crural artery of a dog through the base of the clot forty-six hours 
after ligature, magnified 225 diameters : a, adventitious and fibrous tunic ; b, tunica media; c, 
plications of the tunica intima, or internal coat; d, the clot filling up the foldings of the internal 
coat, with the threads of the intima winding like the tendrils of a vine in its midst. The dark 
bodies are the white corpuscles, now very numerous. 
them with any certainty, and any attempt in that direction brings us at once 
into the domain of conjecture. These questions are, Where do these crowds 
of white corpuscles come from? and what is the destiny of the red globules? 
With reference to the first, the origin of the white bodies, several expla- 
nations may be advanced. They may originate by proliferation from the 
few which naturally belong to the thrombus, as no limit can be fixed to the 
rapidity of cell multiplication under certain stimulation; they may be emi- 
grants wandering into the clot from the vasa vasorum, according to the 
views of Recklinghausen and Rubnoff; they may be derived from the stable 
cells of the tunica intima, which accords with the opinions of Romberg and 
Thiersch; and last, and least probable, they may be but a retrograde meta- 
morphosis of the red corpuscles, on the supposition that the red are developed 
from the white corpuscles. I cannot, however, help believing that these cells 
are derived from three sources: first, from the proliferating white corpuscles 
of the clot; second, from the fixed corpuscles of the endothelium; and last, 
from the emigrants from the vasa vasorum. It is quite as probable that the 
endothelial cells should participate in the work of repair, in other words, 
change from a passive to an active state, as that those of connective tissue 
should do so under the disturbing influence of inflammation. Those experi- 218 
WOUNDS. 
merits which show the presence of cells in new formations bearing granules 
of cinnabar previously injected into the blood, would seem to establish a claim 
for emigration. This last view is not in accord with that of Billroth, who 
denies to the stable cells of the intima any participation in the work what- 
ever, attributing the multiplication of white corpuscles to the leucocytes of 
the clot, and to wranderers from the neighboring vessels, coinciding in this 
respect with the statements of Recklinghausen and Bubnoff. As to the red 
corpuscles, they very soon become decolorized by the separation of crystals 
of haematoidin, and, it is supposed by some, form an intercellular substance 
by uniting with the fibrin of the thrombus. 
If the thrombus be examined on the fifth day, another notable change 
will be seen. Many of the cells have become spindle-shaped,—one step in 
the direction of forming con- 
nective tissue; others have 
sent out prolongations, which, 
joining with similar processes 
from contiguous cells, form to- 
gether a net-work with very 
distinct nuclei at the points 
of contact or communication. 
In this system of inosculating 
processes we have the provi- 
sion for the vascularization of 
the thrombus. These processes 
become blood-channels (Fig. 
193), and, although as yet con- 
taining no blood, they are, like 
the irrigating canals which 
are cut in various directions 
through some arid waste, de- 
signed to receive the streams 
which are to give life and fruit- 
age. While these changes are 
in operation within the throm- 
bus, the walls of the vessel are 
by no means passive. An active 
inflammatory transudation is 
going on, infiltrating its tunics, 
and extending even into the 
loose cellular tissue of the ad- 
ventitious coats. It is this 
which rives asunder the fibres, 
lamellae, and fasciculi of the arterial tunics, and admits of their being inter- 
penetrated by cell organisms or leucocytes, which wander out of the nutrient 
vessels, and which, like those of the clot within, assume the spindle forms, 
which are the promise of the future connective tissue. 
In the course of eight days the work foreshadowed in the thrombus of 
five days is well advanced. Many of the blood-channels are completed, and 
others are in process of completion, the processes of the latter connecting 
with the nuclei on the walls of the former; the spindle form of the cells, 
both of the clot and walls, is more pronounced, and near to the intima they 
have reached the stage of immature connective tissue. (Fig. 194.) The clot 
is beginning to shrink, from loss of moisture in the intercellular substance, 
the whole becoming more compact. In all these changes or stages of trans- 
formation it would appear that the constructive force develops out of the 
materials of the original clot an organized tissue,—that is to say, the white 
cells of the thrombus retain their vitality and undergo multiplication, pass- 
ing on to spindle forms; that the fibrin which determines the coagulation is 
not substituted by something else, but transformed into intercellular material, 
Pig. 193. 
Transverse section of the crural artery of a dog four days 
after ligature, magnified 225 diameters: a, thrombus or clot 
bounded by the plication of the tunica intima, its cells spindle- 
shaped, the net-work of branching processes, with the nuclei at 
their intersection, foreshadowing the subsequent vessels in a state 
of formation; b, clot torn away, and showing proliferating en- 
dothelial cells adhering to the intima; c, cell infiltration of the 
tunica media; d, d, and e, similar infiltration of the external 
tunica and perivascular tissue. HEMORRHAGE AND ITS TREATMENT. 
219 
the fibrillation of which, with the spindle-cells, constitutes true connective 
tissue; and, finally, that from other cells a system of inosculating canals is 
constructed, thus forming a vascularized structure. 
Thus far we have traced the leading changes in the clot towai-ds organ- 
ization. We have seen the infiltration of the tunics of the vessel with 
cell forms, similar to those in the coagulum, and their intermingling at 
the tunica intima, obliterating in some degree their distinction from the 
latter. It still remains to establish a very important vital connection 
between the two, and that is the connection or inosculation of blood- 
vessels. The thrombus is in possession of a system of capillaries, but 
they contain no blood; and the next step is to form such a union with 
the vessels of the artery as will establish not only a unity of blood-chan- 
nels, but also a oneness of circulation. To accomplish this it would appear, 
from certain preparations recently 
made by Dr. Shakespeare illustra- 
tive of this point, and which I had 
the opportunity of examining, that 
in this inosculation between the ves- 
sels of the thrombus and those of the 
walls the former take the initiative, 
penetrating the tunica intima, first, 
near to the point where the artery has 
sustained the greatest injury by the 
action of the ligature. (Fig- 195.) 
Fig. 194. 
Pig. 195. 
Transverse section of the femoral artery of a dog 
eight days after ligature, magnified 400 diameters: a, 
tunica media; b, intima; o, capillary channels, with 
branching processes communicating with nuclei in 
the walls of the capillaries; d, spindle-cells; e, simi- 
lar cells developed into connective tissue and form- 
ing communication with those of the intima. 
An injected longitudinal section of the crural artery 
of a dog, twenty days after ligature, magnified 60 diame- 
ters : showing the vessels of the organized clot, the ves- 
sels of the walls, and their inosculation. 
Treatment of Hemorrhage from Wounds.—The means for arresting bleed- 
ing are very numerous, and are called ha3mostatics. They may be divided 
into Vital, Chemico-vital, and Mechanical. 
Vital Haemostatics are such as induce contraction of the muscular fibres 
of the vessels by acting upon their physiological irritability: they may 
operate either locally or through the constitution. 
External or Local Vital Haemostatics.—The most potent agents of this class 
are the following: 
Cold.—The exposure of a wound to the atmospheric air will secure the 
contraction of small vessels, and even those of considerable size are sensibly 
affected by its presence. John Hunter saw the carotid artery of an ass 
markedly diminish when opened to the air. The object of the common 
practice of leaving a wound open for some time is to take advantage of the 220 
WOUNDS. 
haemostatic influence of the atmosphere; and to realize the greatest effect 
from its action a fan may be used to maintain a succession of currents. Cold 
can be applied in the form of water or of ice. If the former, it may be squeezed 
from the pores of a sponge in a shower over the wound, or be thrown in a 
steady, fine stream from the nozzle of a syringe: the latter plan exercises a 
powerful influence in securing the contraction of small vessels. If ice be 
employed, it should either be broken into pieces and laid directly upon the 
bleeding surface, as in operations upon the vagina and the cavity of the 
uterus or the rectum, or be enclosed in rubber bags, bladders, or tin boxes, 
which are to be placed about the bleeding parts. 
Heat.—Another very powerful haemostatic is hot water, acting as it does on 
the physiological contractility of the vessels much more energetically than 
cold. The application is most conveniently made by dipping a napkin or part 
of a towel in boiling water, squeezing out the redundant fluid, and then press- 
ing the cloth for half a minute against the bleeding surface. This method is 
peculiarly well suited to wounds in which there is a general oozing of blood. 
Alcohol possesses considerable power in exciting the contractility of vessels, 
and may be employed by moistening a soft sponge with the liquid and pressing 
it gently upon the bleeding surface. 
Turpentine also acts on the vital contractility of the vessels, and may be 
applied by saturating dossils of lint with the liquid and placing them over 
the bleeding points. 
Internal Vital Haemostatics.—The principal internal vital haemostatics are 
oil of turpentine, oil of erigeron, ergot, acetate of lead, and aromatic sul- 
phuric acid. The first three possess unquestionable power over the vessels, 
and may be used with great benefit, especially in pulmonary, uterine, and 
nasal hemorrhages. Ten to fifteen drops of turpentine may be exhibited in 
a mucilaginous menstruum every two or three hours until relief is obtained, 
not forgetting, however, its tendency to produce vesical irritation. The oil 
of erigeron should be given in the same doses. The best form for administer- 
ing ergot is the fluid extract: forty drops should be given every half-hour in 
a little water. In hemorrhages which come from the portal vessels, the result 
of hepatic pressure, aromatic sulphuric acid often proves of great utility 
when given in doses of fifteen drops every two or three hours, largely diluted. 
The Chemico-vital class includes all agents which favor coagulation of 
the blood and produce contraction of the muscular walls of the vessels. The 
most important are tannic and gallic acids, alum, matico, the iron salts, nitrate 
of silver, cocaine, and chloride of zinc. When carefully examined, it will be 
found that, the effects of some of these agents are also mechanical, as the 
coagulum which they favor serves the part of a plug to the bleeding orifices 
of vessels. Among these, alum is the least objectionable. It should be dis- 
solved in warm water and applied when tepid, as it will then be deposited 
in fine crystals about the vessels. Nitrate of silver sometimes answers a 
good purpose, particularly in cases of leech-bites which continue to bleed: 
a crayon may be rubbed down to a point with a few drops of water, and 
the wounds lightly touched with the solid stick. Of the iron salts, the per- 
ehloride, Monsel’s solution, and the subsulphate are the most popular. The 
first two may be used pure, or diluted with three or four parts of water, and 
applied by saturating a compress with the liquid and placing it upon the 
surface from which the blood issues; the latter, or subsulphate, should be 
sprinkled over the point of hemorrhage. Both the perchloride and the sub- 
sulphate produce a hard, insoluble coagulum, which is very difficult to detach, 
and are much used to arrest the bleeding from leech-bites. Except in such 
cases, I have an abhorrence of the entire class, save perhaps alum and alcohol, 
since they all interfere both with the apposition and the healing of wounds. 
The styptic fluid of Pagliari, consisting of benzoic acid and alum, at one time 
popular on the Continent, and the alcoholic solution of Venetian soap and 
carbonate of potash, a favorite, I believe, with Professor Joseph Pancoast, 
are open to the same objection. HEMORRHAGE AND ITS TREATMENT. 
221 
Mechanical Means.—These are position, pressure, actual cautery, 
cautery, torsion, acupressure, and the ligature. 
Position.—This consists in taking advantage of gravitation so as to diminish 
the force of the circulation through the vessels in the neighborhood of the 
wound. The part should be elevated by being placed upon an inclined plane. 
Any one can test the effect of position on the arterial beat by first elevating 
the arm over the head and then allowing it to hang by the side, examining 
in each instance the radial pulse. It will be found to be much less forcible 
in the first than in the last position. The same is well seen in the distended 
and flaccid state of the veins of the hands according as the extremity lies 
along the side of the body or is elevated. 
The position of extreme flexion, by which a mechanical obstacle is placed 
in the way of the circulation by the acute angle formed in the course of the 
artery, is worthy of notice. This plan was adopted by Mr. Hart in the treat- 
ment of aneurism. It is applicable in wounds near the hand or foot, and is 
efleeted by forcibly flexing the forearm on the arm, or the leg upon the thigh 
and the thigh upon the abdomen, and so retaining them by the turns of a 
roller. The position is a very uncomfortable one, and sometimes becomes 
intolerable to the patient. The web of the spider, so popular as a domestic 
remedy, belongs to the mechanical class, and acts simply by entangling the 
blood and favoring coagulation. 
Pressure may be made by the fingers, by compresses, by rollers, the garrot, 
and the tourniquet. 
Digital compression is admirably suited as a temporary method, and also 
in cases of emergency, for the control of hemorrhage. When the finger can 
command an artery there is no necessity for alarm. It cannot, however, ex- 
cept by relays, be maintained for any considerable period of time : the fingers 
become weary and powerless. To be practicable, the vessel must be contigu- 
ous to a bone, against which it can be pressed ; as, the brachial against the 
humerus, the radial upon the radius, and the femoral upon the pubic bone. 
Even the abdominal artery, from its relation 
to the spinal column, may be placed entirely 
under the control of the hand. A knowledge 
of the relation of arteries to the bones of the 
skeleton will enable an intelligent assistant 
to render material service to the surgeon 
while executing an operation : for example, 
a thumb and finger over the jaw in front of 
the masseter muscles will command most of 
the superficial circulation of the face, and in 
amputation at the shoulder-joint an associate’s 
hands are necessary in the last steps of the 
operation in order to prevent a dangerous es- 
cape of blood, by grasping the axillary vessels. 
The manner of using the fingers for the 
purpose under consideration will depend upon 
the vessel to be compressed. If the circu- 
lation through the brachial artery is to be 
controlled, the fingers should be placed over 
the vessel, along the inner edge of the biceps 
muscle, with the thumb on the opposite side 
of the arm. (Fig. 196.) If the current through 
the femoi-al artery is to be restrained, the 
thumb may be placed upon the vessel as it 
passes over the pubic bone, while the fingers 
grasp the outer part of the thigh, or, if lower down, both hands may be 
used, one thumb being placed upon the other, with the fingers embracing 
opposite sides of the limb. (Fig. 197.) 
If the carotid requires compression, the thumb should be placed at the 
Fig. 196. 
Manner of pressing the brachial artery. 222 
WOUNDS. 
inner edge of the sterno-cleido-mastoid muscle, opposite the lower edge of the 
thyroid cartilage, and thrust downwards 
and inwards, so as to force the vessel 
away from the vein and against the trans- 
verse processes of the cervical vertebrae, 
the fingers passing across the median line 
of the neck to the opposite side, but mak- 
ing no counter-pressure. The temporal 
artery is best obliterated by placing a 
thumb in front of the ear, above the 
zygoma, with the lingers resting against 
the opposite temple. 
To make effectual digital compression 
upon the abdominal aorta, the patient 
must be in the recumbent position on 
the back, with the limbs drawn up and 
the shoulders raised, so as to relax the 
abdominal parietes; three fingers of one 
hand should be planted over the vessel, 
a little to the left of the umbilicus, the 
thumb reaching out to the flank, while 
the fingers of the other hand should be 
placed upon those of the first, in order to 
supply the necessary degree of pressure. 
When a dangerous flow of blood takes 
place from an open wound, a finger should 
be thrust directly into the orifice, down 
to its lowest depth, where it must remain until measures are taken for the 
permanent control of the vessel. 
Some arteries are so deeply situated that the fingers are insufficient to 
Fig. 197. 
Compression of the femoral artery below Pou- 
part's ligament, with both hands. 
Fig. 198. 
Fig. 199. 
Door-key prepared for pressing the subclavian. 
Pyramidal compress. 
maintain the requisite pressure,—for example, the subclavian. The best, sub- 
stitute in this case is the common door-key, the handle of which should be 
wrapped with a narrow roller (Fig. 198) and pressed into the subclavian 
hollow of the neck immediately above the clavicle. 
Compresses are often useful. When the vessel is deep they should be 
graduated or pyramidal in shape (Fig. 199), the apex being placed over the 
vessel above the wound and firmly bound to the part by a roller. They are 
sometimes useful in wounds of the palmar arch; 
they may be square, and placed over the approxi- 
mated wound and secured by a bandage. Where 
the bleeding comes from several points, or where 
it is a general oozing, the compress is one of our 
best dressings. 
An oblong graduated compress (Fig. 200) serves 
a valuable purpose in certain wounds,—for example, those of the palmar 
arch, in which it should be placed over the course of the radial and ulnar 
arteries and bound fast with a roller. The roller alone, applied from the 
Fm. 200. 
Oblong graduated compress. HEMORRHAGE AND ITS TREATMENT. 
223 
distal to the proximal extremity of the limb, answers a good purpose in 
passive hemorrhages. When large vessels—as the femoral, radial, or ulnar 
—are opened, no dependence, except as a temporary measure, should be 
placed on pressure, nor should it be long continued, as it may interrupt 
the circulation to such a degx-ee as to pro- 
duce mortification. In cases where com- 
presses are applied the roller should in- 
variably be used, and should include the 
entire limb, commencing at the distal and 
terminating at the proximal extremity. 
The garrot, or Spanish windlass, is well 
adapted to arrest bleeding in cases of 
emergency and where no tourniquet is at 
hand. A handkerchief folded into a cra- 
vat, and knotted in the middle for a com- 
press, should be tied loosely about the 
limb and twisted with a walking-cane or 
stick (Fig. 201); or, if the knot is insuf- 
ficient to compress the artery, a small 
stone, in the absence of a better compress, 
may be enveloped within it. 
The most effectual device for the tem- 
porary arrest of hemorrhage is the tour- 
niquet. There are several forms of this 
instrument. Leaving out the old contri- 
vance of the plate and screw of Scultetus 
and the more improved one of Morel, we 
are indebted to Petit for the tourniquet 
so generally in use. (Fig. 202.) To apply 
it properly the limb should be surrounded with a few turns of a roller to pro- 
tect the skin from pressure, while the body of the bandage is laid over the 
artery to act the part of a compress. (Fig. 203.) The base of the instru- 
Fig. 201. 
Application of the Spanish windlass. 
Fig. 202. 
Fig. 203. 
Tourniquet of Petit. 
Tourniquet applied to the thigh. 
ment should be placed over the compress, and the strap buckled on the out- 
side of the limb, the opposite to that represented in the cut, after which, by 224 
WOUNDS. 
turning the screw at the top, the pressure can be regulated at pleasure. If 
kept too long upon the limb its presence becomes exceedingly painful, and 
may produce mortification. I have seen a patient almost lose his life by 
loosening the instrument, preferring to die from the loss of blood rather 
than endure the torture. In the selection of a tourniquet, care should be 
taken that the strap is made out of linen webbing and that the buckle is a 
strong one, so that when once applied it can be trusted. 
As it is the constriction of the limb which produces the severe suffering 
attendant on the protracted use of the tourniquet of Petit, others have been 
invented, which, acting only on opposite portions of the limb, do not interfere 
with the venous circulation, and which, though not so safe or secure as the 
one described, yet, where it is necessary to keep an instrument for many 
hours on the limb, may be used with great comfort to the patient. Such is 
the tourniquet of Lister. (Fig. 204.) The horseshoe tourniquet of Professor 
Gross (Fig. 205) and that of Signorini (Fig. 206) act much in the same way. 
Fig. 205 
Fig. 204. 
Professor Gross’s tourniquet. 
Fig. 206. 
Lister’s tourniquet, which, when 
applied, affects only the circulation 
through the main artery. 
Signorini tourniquet. 
Where it is desired to command the circulation of the lower extremities 
by compressing the abdominal aorta, we have a valuable instrument in the 
tourniquet of Mr. Skey. (Fig. 207.) It is constructed so as to encircle the 
body, with a posterior pad resting against the lumbar spine, and an anterior 
one, which can be run down by a screw, forcing the abdominal parietes upon 
the abdominal artery, a little to the left of the umbilicus. A modification of 
this tourniquet is shown in Fig. 208, though it will be found, I think, less 
secure, in consequence of its to slip out of place. 
Cauterization.—The use of the hot iron is one of the most ancient means 
of arresting hemorrhage. Its action is mechanical, by forming out of the 
charred tissues a compress or obstruction at the end of the vessel. It is by 
no means an obsolete resource, and is frequently employed to seal up the flow 
of blood from a deep-seated vessel or vessels out of the reach of the ligature, 
or where there is a free oozing of blood from numerous points, such as occa- 
sionally follows extensive operations on the maxillary bones, in the removal 
of hemorrhoids, and sometimes after excision of the tonsils. There are vari- 
ous forms of cauterizing-irons (Fig. 209), as the olive, the button, the axe, and 
others, modified to suit different localities. We may extemporize a cautery HEMORRHAGE AND ITS TREATMENT. 
225 
by using a piece of iron wire, a knitting-needle, or a stove-poker. That the 
cautery may exercise the proper effect, care must be observed to raise it to 
the proper temperature,—a dull red heat. If carried above this point, to an 
Fig. 208. 
Fig. 207. 
Skey’s abdominal tourniquet. 
Abdominal tourniquet. 
intense red or white heat, it will not only destroy the end of the vessel, but 
will also at the same time remove the charred portion as the cautery is 
withdrawn, leaving the orifice of the artery open. The slough made by 
the actual cautery usually comes away in the course of seven or eight 
days; and the wound should be carefully watched about that time, to 
provide against secondary bleeding, which may follow the separation. 
Fig. 209. 
Several forms of cauterizing-irons. 
G-alvano-cautery.—Another method of applying the cautery is by the elec- 
tro-galvanic battery,—an expensive apparatus, and not likely to be in the 
hands of professional men generally. Its use will be described in another— 
the operative—division of this work. 
Poquelin's thermo-cautery.—This instrument (Fig. 210) can be used with 
great advantage as a cautery. It consists of a hollow button or knife, G, the 
end and edges of which are of platinum, mounted on a handle, F, and con- 
nected with a benzol-reservoir, C, by means of a gum tube. When in use, the 
end of the cautery is heated very hot in the flame of a spirit-lamp, A ; after 
which the vapor of the benzol is driven through the hollow in the knife or 
button by means of an elastic air-bulb, E. 226 
WOUNDS. 
The methods thus far described must be considered, except in cases of 
small vessels, as only temporary, to meet present urgencies. We now pass 
to the consideration of methods which are designed to be permanent. 
These are torsion, acupressure, and the ligature. 
Fig. 210. 
Paquelin’s thermo-cautery. 
Torsion.—To apply torsion to a vessel a pair of stout forceps are required, 
with serrations not sufficiently sharp to lacerate the artery. (Fig. 211.) The 
vessel, being seized, should be drawn well out into view and the forceps 
rotated until all resistance ceases (Fig. 212), but not to the extent of break- 
ing off the end. This is the plan as practised by Thierry, Velpeau, Frieke, 
and Bryant. In small vessels the last precaution need not be observed. 
Should the artery be diseased, the rotations should be fewer in number. 
The effect on the vessel is not unlike that produced by ligature : the internal 
and middle tunics break and become curled in, while the external or con- 
nective-tissue coat is formed into a tight twist below. Another plan—that 
of Amussat—consists in drawing out the vessel with one pair of forceps and 
Fig. 211. 
seizing it at a right angle to its longitudinal axis with another pair, the 
blades of which should be pressed sufficiently firmly to lacerate the internal 
tunics, while the twist is made with the first pair of forceps. (Fig. 213.) 
A very ingenious forceps for the torsion of vessels has been devised by Dr. 
Addinell Hewson (Fig. 214), which combines in one instrument the two used 
by Amussat and others. 
Torsion forceps. HEMORRHAGE AND ITS TREATMENT. 
227 
Torsion, or the twisting of an artery, is by no means a modern plan of 
arresting hemorrhage, as it was referred to by Celsus; but, whether prac- 
tised to any extent or not, it never appeared prominently before the pro- 
Fig. 212. 
Fig. 214. 
Fig. 213. 
Torsion of an artery. 
Amussat’s plan of applying torsion. 
fession until 1829, when Amussat, and, shortly after, 
Velpeau and Thierry, revived its use. The fact, ob- 
served by all surgeons, that an arm or a leg may be torn 
from the body with the loss of only a few drops of blood, 
owing to the twisted and lacerated condition of the ves- 
sels, no doubt suggested this method. Like a prudent 
and conscientious man, unwilling to jeopardize human 
life on a theory or speculation, Amussat commenced his 
experiments on the lower animals, and, having suc- 
ceeded, even in vessels as large as the femoral and the 
carotid, he adopted it in operations on the human sub- 
ject, in one case applying the method to the axillary 
after an amputation at the shoulder-joint. The same 
year, M. Leiber, Rust, and Dieffenbach, of Berlin, 
Fricke, of Hamburg, Schroeder, of Dresden,* and, 
shortly after, Koch, of Munich, practised it, with, as 
they affirm, entire success. The French surgeons ap- 
pear not to have been so successful, Delpech and Louis 
having failed in several instances. The subject, how- 
ever, was deemed of sufficient importance by the Insti- 
tute of France to demand a careful examination, and 
accordingly Baron Dupuytren was appointed to make 
a report on the subject: this report was unfavorable 
to the method except as applied to small vessels.f 
After passing out of use, it was again revived by the late Professor Syme, 
and has been for three years applied by Mr. Bryant, and also by Foster, of 
Guy’s Hospital, London, to all vessels of the extremities and superficial parts 
of the trunk, without accident. In America, torsion has not been received 
with much favor. Dr. Hewson has used it at the Pennsylvania Hospital, 
and speaks favorably of his success. 
The advantages claimed for it are—1. The facility with which it can 
be practised. In answer to this I may say that I have seen as much time 
Hewson’s torsion forceps 
(two views). 
* Cooper’s Surgical Dictionary, vol. i. page 861. 
f Dupuytren’s Clinical Surgery, vol. i. page 410. 228 
WOUNDS. 
consumed in twisting an articular artery of the arm before the bleeding 
could be stayed (and that, too, by one entirely familiar with the work) as 
would have sufficed for an amputation arid all the subsequent dressings by 
the old method; and, further, that I have seen it fail altogether in more than 
one instance, compelling a resort to the ligature before the rebellious trunk 
could be subdued. The use of anaesthetics has in a great degree removed 
the necessity for excessive haste in surgical procedures. 2. Greater safety 
is claimed for torsion. I am not aware that we are in possession of any ex- 
tended comparisons between this and other methods, but my own observa- 
tions furnish instances in which secondary hemorrhage has followed torsion 
even of sound vessels,—a circumstance which I think rarely occurs after 
ligature. 3. It is said that by torsion healing is facilitated, because of the 
wound’s being free from any irritating or foreign body. Yet the end of the 
twisted artery, comminuted and bruised, frequently separates as a slough, 
and becomes as much a foreign body as the ligature. The experience of both 
Yelpeau and Manec goes to show that not only is this so, but also that the 
healing after torsion is as slow as when the ligature is used: according to 
the latter authority, indeed, it is even more tedious. 
That large arteries, such as the femoral or the brachial, have been safely 
treated in this way is no doubt true: both Foster and Lee affirm that it is 
peculiarly suited to such vessels. That secondary hemorrhage has followed 
this method, and life been sacrificed, is, however, equally true; and, not 
being prepared to admit that torsion possesses any superiority over the liga- 
ture, I am unwilling, except in small vessels or in a hospital where patients 
are always under medical surveillance, to sanction its use as suited to general 
practice. 
Arterio-version.—Dr. Weber, of the Medical Department of the University 
of Wooster, Ohio, proposes to turn vessels inside out by means of an in- 
strument which he calls the arterio-verter.* The execution of the task is 
represented as not difficult; but its success is not yet assured. 
Acupressure.—The late Sir James Simpson, of Edinburgh, introduced acu- 
pressure as a new method for arresting hemorrhage, in December, 1859. 
The instruments required to secure vessels by this plan are very few and 
simple,—a long pin or needle with a wax head (Fig. 215), short needles with 
Fig. 215. 
Acupressure-pin. 
a thread of iron wire made fast to the eye (Fig. 216), and, lastly, some soft 
iron wire to be used as loops. (Fig. 217.) The application of these simple 
instruments is made after three methods. 
Fig. 216. 
Wire fastened to the eye of the needle. 
First method.—This consists in passing a long needle, like that represented 
in Fig. 218, through both sides of a wound, so as to press upon the bleeding 
vessel and close its canal, after the manner in which—to use Professor Simp- 
son’s own illustration—one would secure the stem of a rose to the lapel of 
his coat. The point of the finger of one hand being placed against the cut 
* New York Medical Record, No. 234, May 1, 1875. HEMORRHAGE AND ITS TREATMENT. 
229 
end of the vessel, with the other the needle is made to enter the flap on one 
side, and appear within two lines of the surface of the wound a very little 
short of the same side of the artery; the head of the pin being next depressed, 
Fig. 217. 
Loop of iron wire. 
the point is passed over the vessel, after which it should be raised and pushed 
onward until it appears at the other side of the flap or wound. (Fig. 218.) 
Second method.—A needle armed with an iron-wire thread (Fig. 219) is 
entered two or three lines on one side of a vessel, passed beneath instead of 
over its trunk as in the first method, and made to appear at a corresponding 
distance on the opposite side. A loop of wire is next slipped beneath its point, 
Fig. 218. 
Fig. 219. 
First method of Simpson. 
Second method of Simpson. 
carried in front of the vessel, and made fast by twisting the ends about the 
other end of the needle. (Fig. 219.) 
Third method.—The needle, threaded with the iron wire, is passed beneath 
the vessel. The loop of wire thread is placed under the point of the needle 
and in front of the vessel, as in the second method; but in securing this loop 
Fig. 221. 
Fig. 220 
Third method of Simpson. 
Circumclusion of an artery. 
consists the difference. Instead of the ends being passed beneath the eye end 
of the needle and crossed to make them fast, both ends are placed together, 
as a common thread or wire, and wound once around the shaft. (Fig. 220.) 230 
WOUNDS. 
In both methods the wire should be made sufficiently tight to bring together 
the sides of the vessel. 
Very soon after the introduction of Simpson’s method, Knowles, a house- 
surgeon in the Aberdeen Poyal Infirmary, suggested a modification which 
dispensed with the loop. Other improvements were made by Professor 
Pirrie, of the Aberdeen University, and also by Dr. Keith. These gentle- 
Fig. 223. 
Fig. 222. 
First stage of torsodusion. 
Second stage of torsodusion. 
men published an interesting paper on the subject of acupressure, in which 
seven methods are described. 
The whole subject has been greatly simplified by Professor Pirrie, in the 
adoption of a comprehensive classification by which the methods are all 
included under the three following divisions, which clearly indicate the 
manner in which the vessel is treated. These divisions are styled circumclu- 
sion, toi’soclusion, and retroclusion. 
In circumclusion the pin is passed beneath the vessel, the wire loop placed 
over its point, and the ends brought over the artery and made fast, as in the 
second and third methods of Simpson. (Fig. 221.) 
In torsoclusion the point of the needle or pin is pushed through a portion 
of tissue parallel with the course of the vessel to be secured, then carried 
Fig. 224. 
Fro. 225. 
First stage of retroclusion, 
Second stage of retroclusion. 
over its anterior surface, and at the same time swept round until brought to 
a right angle with the artery, when the point is thrust into the soft parts 
beyond. (Figs. 222, 223.) 
In retroclusion the pin is passed in and out of the tissues a short distance 
from the side of and at a right angle with the vessel, then passed in front of 
the artery to the opposite side, after which the pin is reversed, the head being HEMORRHAGE AND ITS TREATMENT. 
231 
carried over, and the point, returning to the side of entrance, is nushed into 
the soft parts beneath the vessel. (Figs. 224, 225.) 
To these methods may be added that of Dr. Buck, 
of New York, which is a combination of torsion 
and transfixion. In applying it the artery is first 
seized with a pair of torsion forceps and twisted two 
or three times on its axis, when the pin is thrust 
through the vessel close to the instrument, and fixed 
in the surrounding tissues. (Fig. 226.) 
Dr. Hutchison, surgeon to the Brooklyn City Hos- 
pital, describes another method applicable to vessels 
in their continuity. This consists in first exposing 
the vessel by a preliminary incision, and placing 
along its side a loop of wire, then entering a pin 
from the cutaneous surface, carrying it through all 
the structures and onward over the wire, beneath the 
vessel, bringing out the point on the opposite side. The loop of wire is then 
carried in front of the artery and over the point of the pin, after which the 
ends are next drawn upon and fastened about the exposed portion of the 
pin. (Figs. 227, 228.) This is a form of circumclusion like the third method 
of Simpson, though less practicable. 
Professor Nathan B,. Smith, of Baltimore, has suggested an instrument 
Fig. 226. 
Dr. Buck’s method, 
Fig. 227. 
Fig. 228. 
First stage of Hutchison’s method of circumclusion. 
Second stage of Hutchison’s method of circumclusion. 
which embodies also the idea of circumclusion. It is a loop of wire passed 
through a double silver canula, by which the end of the divided artery is 
lassoed and the canula brought out of the wound. The disengagement of 
the apparatus is effected by pulling one end of the wire, by which it is made 
to cut through the vessel. It is not probable that such a contrivance will 
meet with very general favor. 
An instrument invented by Dr. Spier,* surgeon to the Brooklyn City Hos- 
Fig. 229. 
Dr. Spier’s artery-compressor. 
pital, has been highly spoken of by Professor Hamilton. It consists of a 
flattened metal tube, through which runs a rod having a hook at the end 
sufficiently blunt not to cut an artery, and which can be protruded or re- 
tracted by means of a screw. (Fig. 229.) In using the instrument the hook 
* Transactions of the International Medical Congress, Philadelphia, 1876, Proceedings of Surgical 
Section. 232 
WOUNDS. 
is pushed out and placed round the artery, the screw at the opposite end is 
then turned, and as the hook recedes within the tube the inner and middle 
coats are crushed and will retract; after which it may be disengaged, when 
it will be found that the bleeding is entirely arrested. It has been used with 
entire success on vessels of the size of the femoral, and acts very much after 
the manner of torsion. 
Different kinds of forceps have been used at various times to control 
bleeding from vessels too deeply placed to be reached by the ligature, such as 
those of Professor Gross (Fig. 230) and Nunneley of Leeds, and still more 
Fig. 230 
Gross’s forceps for deep vessels. 
recently those of Yerneuil, who has coined a word for the plan,—namely, 
forci-pressure. Desault advocated the use of such contrivances as far back 
as 1790. Instruments of this kind are often valuable to the surgeon when 
it is desirable to complete an operation before permanently securing the 
vessels. Such are the serres-fines (Fig. 231) and the small spring forceps 
(Fig. 232, a, b). 
Dr. Pollock, of Pittsburg, adopted a plan of controlling hemorrhage by 
passing a loop of pliable wire about a bleeding vessel after amputation, 
bringing the ends out through the integument, a little distance apart, and 
securing them over a roll of muslin or other material. The same method 
was employed by Dix,* of England, and was, indeed, practised as early as 
1543 by Marianus Sanctus, and in 1553 by Alphonsius Ferrius,f two Nea- 
politan surgeons; also by Ambrose 
Pare and Jacques Guillemeau, in 
1594: all, however, used silk thread 
in place of wire. 
Ligature.—The direct or imme- 
Fig. 232. 
Fia. 231. 
Serres-fines. 
Spring forceps. 
diate application of a thread to a wounded vessel is, on the whole, the most 
satisfactory mode of arresting hemorrhage. There is a feeling of security 
which attaches to no other plan, and which enables the surgeon to leave 
his patient at whatever distance, feeling, if the artery be sound, that he is 
absolutely safe. It is impossible to fix the period when the ligature was first 
used for the arrest of hemorrhage, or the surgeon who was the first to apply 
it. It was well known to Celsus in the first century of the Christian era, 
and still later it was used by Galen, Avicenna, Guy de Chauliac, and others; 
but the glory of introducing it as a haemostatic in amputation is unquestion- 
ably due to Ambrose Pare, who in 1564 published his new discovery, the 
knowledge of which, to use his own language, he was taught by the special 
favor of the sacred Deity. When it is remembered that before this bleeding 
* Edinburgh Medical Journal, Sept. 1864, page 213. 
f Simpson on Acupressure, page 312. HEMORRHAGE AND ITS TREATMENT. 
233 
was generally stanched by hot irons, humanity can never be sufficiently 
grateful that God put it into his head and heart to work such a deliverance. 
On account, however, of the opposition of Gourmelen and the criminal neg- 
lect of surgeons generally, it was two hundred years before this discovery 
of Pare was adopted by the profession, and then it came into favor chiefly 
through the influence of Sharpe, a surgeon of Guy’s Hospital, London, who 
boldly championed the claims of the ligature to popular confidence. 
The materials employed for constructing ligatures are silk, hemp, flax, 
silver, lead, iron, and different animal substances. Uncolored silk is pre- 
ferred by some surgeons. Before adopting the animal thread I had been 
in the habit, for a long time, of using either flax or hemp material, and was 
rarely annoyed by finding it break in the hands of an assistant while tighten- 
ing the knot. For those who are partial to the use of silk as a ligature there 
are two kinds which answer best, viz., the saddlers’ and the dentists’. 
Ligatures, of whatever material, should be round, as their pressure is then 
more uniform and concentrated than when flat or ribbon-shaped. For small 
vessels, like those divided in removing a scirrhous mamma or a fatty tumor, 
the thread need not be larger than ordinary sewing-silk and should be about 
nine inches in length ; and indeed this size is quite large enough for arteries 
such as the radial, ulnar, or tibial. For vessels like the femoral, iliac, or 
axillary, a single strand of saddlers’ silk is sufficiently stout. Two sizes will 
answer all cases. The great cords sometimes employed, resembling fishing- 
lines, are entirely unnecessary. The thread should always be well waxed, 
in order to prevent the loosening of the first knot and to render the ligature 
less irritating from the coating of an animal substance. 
When the silk or hemp cord is used, the vessel should be drawn out, 
either by an artery forceps or by a tenaculum. There are several varieties 
of the artery forceps, some with rat-toothed blades and others serrated. For 
ordinary vessels, such as demand the ligature in common operations, I prefer 
Fig. 233. 
The author’s artery forceps. 
an instrument like that represented in Fig. 233, the blades of which are 
long and slender, armed each with a tooth, and can be made fast by a button 
slide. 
Another forceps, somewhat like this, but with shorter blades and having a 
curved spring catch (Fig. 234), is preferred by some. This spring or fasten- 
ing is liable to get out of order, and consequently detracts from the value of 
the instrument. 
Fig. 234. 
Sometimes called Liston’s forceps. 
Many prefer forceps having fenestrated blades, of which there are several 
patterns. The one delineated in Fig. 235 has a slide catch, which serves to 
fasten the blades together. In Fig. 236 is represented a form of forceps which 234 
WOUNDS. 
open by pressure and close by the spring of the blades. With this instru- 
ment, perhaps the most satisfactory of all, the surgeon can both secure and 
tie a vessel without an assistant, as it will retain its hold and by its weight 
draw the vessel out while the thread is applied. There is another fenes- 
Fig. 235. 
trated instrument (Fig. 237), the blades of which, from their convexity when 
closed, greatly facilitate the passage of a ligature over the vessel. 
Whatever form of artery forceps is used, it is desirable to have such as 
possess a mechanism that will hold the blades together when once closed. 
Fenestrated forceps, with a slide catch. 
Fig. 236. 
Artery forceps which close by the spring of the blades. 
The tenaculum invented by Bromfield, surgeon to Guy’s Hospital (Fig. 238), 
is perhaps more generally used among American surgeons than the forceps. 
The curve should be neither too abrupt nor too straight. 
In applying the ligature the vessel should be seized either by the tenaculum 
Fig. 237. 
Fenestrated spring forceps, with a ligature ready to be slipped down and tied. 
or by the forceps and drawn out from the parts in which it is buried. It 
should, as far as possible, be carefully isolated from every other structure. 
Veins and nerves are generally closely associated with the arteries, and 
neither of these should be included within the compass of a ligature. The 
Fig. 238. 
Tenaculum for taking up vessels. 
ligation of a nerve will produce severe suffering, and often spasm of the limbs. 
From this cause I have known a patient to die of tetanus, and others to suffer 
greatly until the thread was detached. When Lord Nelson’s arm was ampu- 
tated in consequence of a gunshot injury of the elbow-joint, his surgeon in- 
cluded a nerve along with the artery. The ligature did not separate for four 
months, during the whole of which time his sufferings were very great.* 
* Simpson, Acupressure, page 29. HEMORRHAGE AND ITS TREATMENT. 
235 
Some of the older surgeons, as stated by Petit, considered the tying of a nerve 
along with a vessel to be of little consequence, and no less eminent a surgeon 
than John Hunter* entertained the same notion. Even in the securing of 
small vessels it is desirable to embrace nothing but the artery, although this 
is rarely done, as it is hardly feasible not to include some of the surrounding 
tissues : the rule, therefore, should be to embrace just as little as possible. In 
diseased vessels, such as are calcified, and where the coats are very brittle, it 
has been advised to tie a cushion of the soft parts about the artery, so that 
the ligature shall not separate too soon, and thus to give time for the occlu- 
Fig. 239. 
Reef knot. 
Surgeon’s knot. 
sion of the vascular canal. I have often adopted the plan, and with gratifying 
success. With the same object in view, some direct the use of a flat ligature, 
as being less likely to cut rapidly through the vessel than if round. Cline, the 
eider, used this, with an interposed piece of cork. Scarpa substituted for the 
cork a piece of linen ; and Manec advised the introduction of a piece of bougie 
into the canal of the vessel before the application of the thread. The advan- 
tages of all such contrivances are exceedingly doubtful. Indeed, I cannot 
recall a case of secondary hemorrhage in such a condition of the arteries, where 
the usual ligature was employed, and think the danger is overestimated. 
The ligature having been placed about the artery, it should be made fast by 
the ordinary surgeon’s or by the reef knot (Fig. 239), in tightening which either 
the index Angers or the thumbs 
should be run down near to the ves- 
sel (Fig. 240), taking care that the 
thread is above the point of the 
forceps or beneath the point of 
the tenaculum, according as one or 
the other instrument is employed, 
and that no more force is used 
than is necessary to secure it 
firmly upon the vessel. Few per- 
sons apply a ligature quickly and 
at the same time gracefully. It 
requires no great exertion of mus- 
cular power, and, were it not for 
the annoyance arising from delay 
consequent on broken threads, it 
would be amusing to witness the awkward display of physical strength 
which many surgeons exhibit in performing the simple act of bringing 
together the walls of an unresisting artery. 
When the ligature is tied, one end should be clipped off quite close to the 
knot and the other brought out of the wound (Fig. 241), for which improve- 
ment we are indebted to James Veitch, Esq., at one time surgeon to the 
Naval Hospital at Plymouth. Some surgeons have recommended cutting off 
both ends close to the knot and closing the parts. It is difficult to deter- 
mine by whom this plan was first practised. It would appear that as far 
back as 1786 it was in use by Mr. Lancelot liaise, assistant surgeon to the 
Fig. 240. 
Position of the fingers in tightening a ligature. 
* Works of John Hunter, vol. i. page 541. 236 
WOUNDS. 
Haslar Hospital, and in 1798 the method was adopted by Dr. Maxwell, of 
Dumfries.* It was frequently done at St. Bartholomew’s by Mr. Laurence 
as early as 1814. It was suggested to Hennen in 1813 by assistant staff- 
surgeon Hume, who stated that it was the practice of an American naval 
surgeon. Hennen, favorably impressed with the plan, treated a number of 
cases in this way, both at the time and subsequently at Waterloo, and with 
such success as to justify a favorable report to Dr. Charles Forbes, deputy- 
inspector of hospitals. In 1814 it was practised by M. Delpech. A more 
extended experience, however, has shown that, while in some cases these 
little knots become encysted and remain harmless in the tissues, in a large 
number of instances, not being aseptic, they act as irritants, retard healing, 
provoke abscesses, and are subsequently discharged from the wound: so that 
the plan may be regarded as an unsurgical procedure. 
The time required for the disengagement of a silk or hemp ligature from 
a vessel will vary from three days to three weeks, according to the size of 
the vessels. They appear to separate more slowly when applied in the con- 
tinuity of a vessel, and it is not uncommon to find a ligature on an artery 
like the femoral or iliac quite firm after the lapse of twenty or twenty-five 
days. Much also depends on the amount and nature of included structures. 
When dense fibrous or ligamentous tissues are embraced with the vessel, the 
separation will be tardy, from the slowness of ulceration. I have seen a 
ligature adhere to the radial for twelve weeks from this cause. 
Ligatures should be brought out of the angles of a wound, when not too 
distant; or, if too remote, at the nearest point to their attachment. To 
prevent their being prematurely disturbed in the removal of dressings, they 
should be collected together and secured to the skin by strips of adhesive 
plaster. Those commanding large vessels should be distinguished from the 
others by making a knot at the end. The removal of ligatures is effected by 
making gentle traction on the ends projecting from the wound. This, after 
five or six days, will be sufficient for the separation of those attached to the 
ordinary muscular branches, but will be too soon by several days for such 
as secure the principal trunks of a part. At each successive dressing those 
which remain should be subjected to the same manipulation. When a liga- 
ture is retained several days longer than is usual in similar cases, we can 
frequently remove it by simply twisting it several times between the thumb 
and the index finger; and should this fail, a most effectual plan will be found 
in taking a light gum band, such as is often 
used to hold together packages of letters, 
and fastening the ligature to one end of the 
elastic loop, fixing the other, slightly on the 
stretch, to the skin. (Fig. 241.) The con- 
stant and uniform traction of the gum will 
soon accomplish detachment of the thread. 
Animal Ligatures.—The use of animal ligatures was first suggested by Dr. 
Physick in 1814, under the impression that such a material would consort 
kindly with the tissues and undergo softening and absorption. The late 
Dr. Jameson, of Baltimore, used buckskin cut into narrow strips and firmly 
rolled. A short time before his death the doctor informed me that he had 
tied with this material all the accessible arteries of the body. Dr. McSweeny, 
of Cork, recommended the gut of the silk-worm, and Sir Astley Cooper at one 
time used catgut. He tied the femoral artery successfully with this material 
in a case of popliteal aneurism. Catgut, or, more properly, sheep-gut, has 
been popularized by Sir Joseph Lister, and may be said to have justly dis- 
placed the old silk thread almost entirely from ordinary surgical practice. 
The gut is treated with chromic and sulphurous acids, rendering the thread 
strong and at the same time so pliable that there is no tendency in the knot 
to become untied. Before being used it must be placed in a lotion of carbolic 
Fig. 241. 
Elastic loop attached to a retained ligature. 
* Hennen, Military Surgery, page 178. HEMORRHAGE AND ITS TREATMENT. 
237 
acid (one to twenty) for fifteen or twenty minutes. There can be little doubt 
that catgut treated in this way is superior to all other forms of ligature. It 
produces the least possible irritation or suppuration, and closes the vessel 
often without the division of its coats, as appears from a case of Holmes,* in 
which the subclavian and carotid were ligatured. The death of the patient 
two months after from another cause afforded an opportunity to examine these 
vessels, when both were found closed by a thin septum without any separa- 
tion of the external coat. An additional advantage is the facility with which 
the ligature is absorbed, enabling us to secure the quick healing of wounds. 
These conditions, together with an encapsulating ring of lymph, which is not 
disturbed by suppuration, contribute immensely to the safety of the patient, 
especially one with diseased arteries, against the occurrence of secondary 
hemorrhage. The few cases recorded in which the catgut softened and be- 
came partially untied do not in the least affect my confidence in this liga- 
ture: it is the only one which I employ, and after its use I have never seen 
abscess or hemorrhage. 
At one time I used for ligatures the tine plaster made lrom the peritoneum 
of the bullock, cutting it into narrow strips and rolling them into round 
threads. These cords maintained their hold on the vessels satisfactorily, but 
did not possess sufficient strength for large arteries, and, in addition, were 
not aseptic. 
JDr. Paul Eve speaks favorably of threads stripped from the sinews of the 
deer. I have used threads prepared from the sinews of the giraffe, which 
are very strong and pliable, but possess no advantage over catgut. 
Metallic Ligatures.—The growing popularity of silver and lead wire as a 
surgical suture directed the attention of the profession to their use for the 
ligature of arteries. Though we are not in possession of a sufficient number 
of cases to warrant any general deduction, yet on the whole the results are 
not unsatisfactory. Wire provokes very little irritation, and is soon encased 
in a wall of lymph, becoming permanently encysted. The lead ligature, had 
it sufficient strength, would be unquestionably the least irritating of non- 
absorbable threads. In 1859, Dr. Stone, of Hew Orleans, tied the common 
iliac with a silver thread, since which time this wire has been applied by 
Professor Gross to the femoral, by myself to the brachial, and, in 1866, by 
Dr. Claudius H. Mastin, of Mobile, to the external iliac. In the use of the 
metallic as in that of the animal thread, both ends are cut off, but the final 
disposition is quite different in the two cases. In the latter, as already stated, 
the ligature is expected to become soft, disintegrate, and disappear entirely 
by absorption, and in the first, to become encapsulated by the inflammatory 
deposition of lymph. 
Comparison of Haemostatics.—What is the great desideratum in a mechan- 
ical haemostatic? The answer to this question is obvious, viz., that which in 
addition to safely closing the vessels interferes least with intermediate union 
or the so-called union by the first intention. 
The objections to be urged against the thread ligature may all be em- 
braced under the following heads : It is incompatible with the nature of the 
tissues in which it lies ; it is a foreign body, and acts the part of a seton; and 
its separation involves inflammatory consequences, which increase the amount 
of foreign matter in a wound ; that is to say, the formation of pus, and the 
disintegration and mortification of the strangulated ends of the vessels, give 
rise to the production of matters which not only retard healing, but by their 
absorption into the vessels tend to poison the blood and produce pymmia and 
undue surgical fever. 
If the choice lay between acupressure and the silk ligature, the latter, it 
appears to me, should be preferred. It is by no means established that the 
* Holmes’s Principles and Practice of Surgery, page 120, American edition. 238 
WOUNDS. 
subsequent healing differs in any particular or that the wound unites more 
quickly by one than by the other plan. There are, however, certain objections 
which, in my judgment, may be urged against acupressure : 1, there is greater 
liberty taken with the vessel, that is, a larger extent of the vessel is disturbed 
than by the ligature, especially in executing the methods of torsoclusion and 
retroclusion; 2, it includes a much greater amount of the surrounding soft 
tissues; 3, by pushing needles blindly through the flaps of a stump or into 
the tissues, out of sight, in order to maintain the resistance necessary to form 
adequate pressure, one can scarcely avoid wounding contiguous nerves; 4, it 
gives no superior safety against secondary bleeding ; 5, it places too much 
power in the hands of the patient, who may from curiosity or thoughtless- 
ness easily pull the needle or pin from the vessel; 6, there are no accumulated 
observations which establish, as a consequence of the method, a less degree 
of liability to surgical fever, pyaemia, or any other accidents incident to 
wounds. 
The objection charged against the ligature of being a seton I do not accept 
as entirely valid: indeed, if it be true that evil effects arise from the use of 
ligatures by producing sloughs and infective fluids from their decomposition, 
then the presence of a seton may become to some extent a safeguard, by 
conducting such products out of the wound. No one conversant with sur- 
gical dressings can have failed to notice the moist condition of ligatures due 
to this very office which they perform. When, however, we attempt a com- 
parison between the common ligature and the animal ligature, especially the 
antiseptic catgut ligature, the argument is wholly in favor of the latter. 
General Treatment op Hemorrhage.—When a large loss of blood has 
been sustained, followed, as it usually is, by a state of syncope, and the sur- 
geon is not prepared for operative measures, he should not be too forward in 
establishing reaction, although it is his duty to guard against the risks of 
cerebral anaemia by keeping the patient in the recumbent position, with the 
head on a plane with, or even lower than, the rest of the body. Syncope, as 
has been already stated, favors the arrest of bleeding, and therefore offers a 
truce, during which time the surgeon provides against any recurrence. When 
hemorrhage has been so excessive or prolonged as to endanger life, everything 
depends on sustaining the great nerve-centres from which emanates the motor 
power of the heart. The body should be placed on an inclined plane, the head 
being dependent, and the extremities tightly bandaged from the feet and 
hands to the trunk, so as to secure as much blood as possible in the brain. 
Attention has been called to the large amount of blood contained in the 
visceral blood-vessels of the abdomen, and to the fact that this blood can be 
utilized in cases of extreme prostration from hemorrhage by applying suf- 
ficient pressure over the abdominal parietes to force the contents of the venous 
trunks into the vessels of the brain. There should be a free access of cool 
air to the apartment, although the body must be kept warm by the applica- 
tion of dry heat; volatile stimulants, like ammonia, are to be held to the nose, 
in order to excite the respiratory movements, and brandy is to be cautiously 
given in milk, both as a stimulant and to replenish the empty blood-vessels. 
When the bleeding is from small vessels, like those of the nose, lungs, or 
uterus, the surgeon has the choice of several remedies, which may be admin- 
istered internally, and which possess very decided haemostatic properties. 
These are the fluid extract of ergot, twenty drops every half-hour; turpen- 
tine, ten drops in a mucilage every half-hour, watching its effect on the 
bladder; gallic acid, ten grains every twenty-five minutes; acetate of lead, 
three grains every two hours; oil of erigeron Canadensis, five drops every 
ten minutes. Opium is a most valuable remedy, and should be given, in some 
of its forms, in doses sufficient to control all restlesness and mental anxiety. 
To replenish the vessels as rapidly as possible, milk should be given freely, 
and occasionally some strong coffee. To remove the effects of hemorrhage,— 
as anaemia, palpitation, and nervous irritability,—the tincture of chloride of 
iron, a generous diet, and good wine are the best remedies. TRANSFUSION. 
239 
Transfusion.—When a patient is in danger of perishing from hemorrhage, 
resort should be had at once to transfusion,—that is, the introduction of blood 
from a sound person into the vessels of the patient. I have seen individuals 
dying from epistaxis rescued from the very verge of dissolution by the timely 
passage of a few ounces of blood into a vein of the arm. Not only is such a 
course indicated in excessive hemorrhage, but 1 have known several cases of 
obstinate anaemia greatly benefited by the same practice. It is an operation re- 
quiring skill and delicacy of manipulation. There are two methods for effect- 
ing transfusion,—immediate and mediate. By the first, the blood, without being 
subjected to any treatment, is transferred directly from one person to an- 
other; by the second, it is drawn from the vein of one into a vessel, and, 
after having been deprived of its fibrin or not, according to the preference 
of the operator, is thrown, by means of a proper instrument, into the vein 
of another. Hueter, of Greifswald, advises the blood to be thrown into the 
arterial in preference to the venous system, believing that thus it passes to 
the heart in a more even and less rapid manner. 
The points for consideration in transfusion are the following: 1, the cases 
which are suitable subjects for such an operation ; 2, the proper kind of 
blood to be used; and, 3. the best instrumental appliances for executing the 
operation. 
First. Cases demanding transf usion are all such as are in a state of dangerous 
exhaustion from loss of blood, whether from wounds, epistaxis, or post-partum 
hemorrhage : cases of obstinate and progressive anaunia ; in fact, all instances 
of extreme debility, the result of blood deterioration, and where there is no 
organic disease, necessarily incurable, as phthisis pulmonalis and cancer. 
Second. The proper kind of blood to be used.—It should be human blood,— 
arterial or venous,—from a person of known good health and free from any 
constitutional vice. The blood may be used as drawn, or it may be defi- 
brinated: the former I think the preferable plan. One of the difficulties 
anticipated was the coagulation of the blood before its transference from the 
giver to the receiver, and, in order to prevent such a contingency, reservoirs, 
funnels, and glass cylinders have been invented, so as to have a surrounding 
chamber for warm water, in order to maintain the blood at the temperature 
of the body. Purman and Dennis entertained these fears of coagulation 
from cold, and adopted contrivances to prevent it, the former by a tube sur- 
rounded with a linen cover and containing warm water, and the latter by exe- 
cuting the operation in a hot-water chamber. At present, however, it is 
ascertained that danger from this cause is imaginary, and that cold is just 
as likely to prevent or delay coagulation as heat. Dr. Richardson recom- 
mended at one time the addition of a few drops of ammonia to each ounce of 
blood, with a view to maintain its fluidity, and Braxton Hicks, still later, 
used a solution of phosphate of soda for the same purpose. The plan of 
defibrinating the blood arose from this same idea of coagulation. This is 
accomplished by drawing the blood into a vessel and whipping it, until de- 
prived of its fibrin, with a piece of broom-corn taken from a new broom, freed 
of the seed-capsules, and thoroughly cleansed; then passing the residuum 
through a piece of linen or a wire strainer, as in the Hunter apparatus, thus 
leaving only the blood-corpuscles and serum for injection. It is quite certain 
that blood deprived of its fibrin is not in the least deteriorated in value for 
the purpose required ; but, with the proper apparatus on hand for immediate 
or direct transfusion, I can see no necessity for subjecting the fluid to any 
preliminary treatment. 
Third. The proper instruments or apparatus.—A great variety of contrivances 
have been in use at different periods for this purpose. If the immediate plan 
be adopted, which I certainly prefer, we have in the Aveling syringe all that 
can be desired. It is a simple india-rubber tube, with a bulb in the middle, 
without valves. At each end of the rubber tube is a stopcock, into which 
is fitted a silver tube, one round and blunt-pointed, the other sharp and bev- 
elled ; a scalpel, thumb lancet, and pair of forceps make up the complement 240 
WOUNDS. 
of instruments. When the apparatus is to be used, the metallic tubes must 
be detached from the rubber part of the syringe, and the latter dropped into 
a basin of tepid water and filled with the liquid, first squeezing the bulb, to 
expel all air, and then allowing it to draw in the water, after which the 
stopcocks must be closed, in order to prevent its escape. The patient should 
be brought to the side of the bed. and the most prominent vein at the bend 
of the arm laid bare by raising a duplicature of skin, transfixing and dividing 
it with the sharp-pointed bistoury. The vein is next grasped with the for- 
ceps, incised, and the oblique-pointed tube, previously filled with water, in- 
serted, its point being directed upwards or towards the body, and given in 
charge to an assistant (A, Fig. 242), who holds it in place by seizing it be- 
tween the thumb and fingers. The blood-donor should now take his seat at 
the bedside of the patient, with his arm nearly parallel with that of the 
latter, and, an oblique opening having been made into the median cephalic 
Fig. 242. 
Aveliug’s apparatus introduced into the arms of the recipient and donor. 
or basilic vein, as in venesection, the round-pointed tube, likewise filled with 
tepid water, must be introduced into the vessel, with the point directed down- 
wards or towards the hand, and held in situ by another assistant (B). The 
tube should next be connected with the apparatus, the stopcocks opened, 
and the transfusion begun. This should be slow, and is effected by the oper- 
ator pressing together the sides of the tube next to the blood-donor with the 
thumb and ringer of one hand, while with the other he compresses the bulb 
of the syringe (C), by which the blood (about two drachms) is forced into 
the vein of the patient. The hand (D) must be next changed over, grasp- 
ing the india-rubber tube on the side of the patient, releasing the bulb from 
pressure, by the expansion of which the blood is drawn in from the donor, 
when the pressure is again applied to the tube on the side of the latter and 
the bulb a second time compressed. By these alternate manipulations, four 
or five ounces of blood can be transferred from one to the other. Great care 
must be taken throughout the whole procedure that no air is allowed to enter 
the circulation, since otherwise the life of the patient would be jeopardized. 
If the mediate plan be adopted, the apparatus of Dr. Allen, as modified by 
Drs. Morton* and Hunter, will answer the purpose best. This consists of a 
German-silver vessel, the interior of which is hopper-shaped, wide above and 
narrow below, provided with a very fine conical wire strainer, and having a 
surrounding hot-water chamber to maintain the blood at the proper tempera- 
ture, to indicate which a thermometer is secured to the outside of the vessel. 
The syringe used to inject the blood is of glass, having a capacity of four 
* The difference between the Morton and the Hunter apparatus is in the attachment of a wire 
strainer in the latter. REMOVAL OF FOREIGN BODIES FROM WOUNDS. 
241 
ounces. A flexible tube is fitted to the nozzle of the syringe, and to this is 
attached a blunt canula, which can be disconnected at pleasure. For the 
purpose of defibrination, a fine wire brush is employed. (Fig. 243.) 
In transfusion by this instrument, or by the mediate plan, a vein is uncov- 
ered at the bend of the arm or above the inner ankle of the patient, and the 
canula is inserted into its canal and secured by a ligature. The most satis- 
factory way of doing this is to make an oblique incision over the vessel, and, 
carefully isolating it from its surrounding connections, lift it upon a director. 
Fig. 248. 
Hunter’s apparatus for transfusion: a, tbe blood-receiver; 6, wire strainer; c, thermometer; 
d, tube for introducing hot water into the water-chamber; e, syringe, with its scale marked in 
half-ounces ; /, wire brush. 
An assistant should now place a finger over the vessel below, so as to inter- 
rupt the blood-current, while the operator makes a small transverse opening 
in its walls, and immediately introduces the canula. This preliminary measure 
being completed, the next step is to open the vein of the blood-donor and allow 
the stream to flow into the wire strainer, where it is to be whipped with the 
metallic brush, in order to separate the fibrin. The corpuscles and serum pass 
through into the tin cup below, where they are preserved at the proper tem- 
perature by the hot water previously introduced into the water-chamber. The 
strainer is now removed, and the syringe, well warmed, is charged with the 
defibrinated blood. The piston is forced down sufficiently to expel all air and 
fill the tube, after which it is fitted to the pipe in the vein, and the blood 
slowly injected into the system of the patient, the amount necessary varying 
from three to ten ounces. A rigor is often experienced immediately after the 
transfusion, but this in a short time passes over. In some cases syncope is 
threatened, but the tendency to that condition quickly vanishes. If the case 
has been judiciously selected, and the operation dexterously executed, the 
improvement in the patient’s condition will soon become apparent. The 
bloodless lips assume a better color, the pulse becomes fuller, and there is a 
consciousness of returning strength. The success realized by Allen, Morton,* 
and Hunter in transfusion entitles the subject to the serious attention of the 
profession. 
Removal of Foreign Bodies from Wounds.—The removal of anything extra- 
neous to a wound is the second indication. There are exceptional cases in 
which this becomes the first indication, as where a dagger, a pin, or pointed 
pieces of glass are found projecting from the divided tissues upon douching 
the wound or throwing a stream of water upon it from the nozzle of a syringe. 
There are, however, matters of another kind, which, though not usually consid- 
ered in this connection, are the most truly foreign of all, and demand imme- 
diate attention. These are microscopic organisms, which, floating in the 
air and adhering to all surrounding objects, come into contact with the 
* Morton on Transfusion, American Journal of the Medical Sciences, New Series, 1874, p. 111. 242 
WOUNDS. 
wound, and are the chief factors in all the mischief which follows its in- 
fliction. To destroy these bacteria demands the use of germicidal agents, 
which are to be employed from the very commencement to the end of the 
dressing. The best lotion for this purpose is the bichloride of mercury (one 
to one thousand). If this be not obtainable at the time, hot water which 
has been previously well boiled may be substituted. This will answer for 
the removal of fragments of sand, dirt, or clots of blood. Substances wdiich 
are found embedded in the tissues of the wound can best be extracted 
by the fingers of the surgeon or by dressing forceps. (Fig. 244.) That 
Fig. 244. 
neither may convey septic matter into the wound, the hands should be effect- 
ually cleansed by scrubbing them with soap and water, then washing them 
in alcohol and afterwards in the bichloride solution, and the forceps should 
be subjected to a bath of carbolized water (one to twenty). 
Drainage.—Not only is it necessary to render a wound aseptic, it is equally 
important to maintain it in the same condition. It is the accumulation of 
the bloody serum, which occurs in all wounds during the first thirty-six or 
forty-eight hours, that creates mischief, by giving rise to distention, inflam- 
mation, suppuration, and often septic poisoning. The free removal of this 
is a prime necessity, and can be properly effected only by what are termed 
drainage appliances. Two plans are adopted to accomplish the purpose,— 
one by means of tubes, and the other by capillary attraction. The materials 
employed as tubes are rub- 
ber, bone, and glass. The red 
and the dark rubber are to 
be preferred, having different 
diameters,—from one-eighth 
to three-eighths of an inch,— 
and having numerous holes 
cut or punched into them at 
short intervals. (Fig. 245.) 
These tubes should be placed , 
in a bath of carbolic acid solu- 
tion (one to twenty) before 
being used. They must ex- 
tend the entire length of the 
wound, and be cut off nearly 
on a level with the surface of the skin at each end, and, to prevent their 
slipping in, a safety-pin may be passed through each extremity. (Fig. 246.) 
The hone drainage-tube is made by 
decalcifying chicken- or turkey-bones 
in a weak solution of hydrochloric acid, 
and keeping them in turpentine or oil 
of juniper until used. They have never 
proved satisfactory in my hands, in con- 
sequence of their liability to collapse, 
thus obstructing the canal. Bone drain- 
age-tubes are not removed when intro- 
duced into a wound, but are absorbed. 
Glass drainage-tubes are cylinders of 
glass, having a shoulder at one end by 
which they are secured in position. They are much employed in abdomi- 
Dressing forceps. 
Fig. 245. 
llubber drainage-tube. 
Fig. 246. 
Drainage-tube placed in the wound before closing. APPROXIMATION OF WOUNDS. 
243 
nal surgery, and with the greatest advantage. Their efficiency is much in- 
creased by passing down the canal of the tube a piece of absorbent cotton 
twisted into a cord. The latter acts as a capillary drain, and when saturated 
can be removed and its place supplied by another cord. 
Capillary drains are made of horse-hair and catgut. The horse-hair is pre- 
pared by thorough washing, first in soap and water, afterwards in dilute alco- 
hol, and finally by soaking for some time in boiling water. After being thus 
rendered free from all organic matters, it must be kept in a solution of 
carbolic acid (one to twenty). 
Catgut before being used requires, like the horse-hair, to be placed in a 
solution of carbolic acid (one to twenty). In using the horse-hair as drains, a 
bundle of the hairs, eighteen or twenty in number, is secured at the middle 
by means of a thread of catgut. The latter 
is passed through the eye of a needle, which 
serves, by penetrating the upper part of 
one of the flaps, to draw the skein into the 
highest portion of the wound. The threads 
are next separated into two or three fasci- 
culi, and brought out of the middle and the 
extremities of the wound. (Fig. 247.) When 
catgut is used the threads should be small, 
and can be disposed of in the same manner 
as the horse-liair. The catgut threads are 
absorbed, and do not require to be removed. 
The horse-hair can be removed by instalments, a few hairs at a time. 
Wounds which do not extend below the deep fascia are rendered aseptic, 
and require neither tubular nor capillary drains. 
The Approximation of Wounds.—The retraction or gaping of divided parts 
is due to the elasticity of the tissues, contraction of muscles, direction of the 
wound, and position. Parts that are compactly bound together, like those of 
the scalp or face, do not retract much, while in those in which the anatomical 
components are more loosely united, as the skin in front of the chest, arm, or 
thigh, the separation is very marked. A part closely attached to an under- 
lying muscle—particularly when the latter is severed—will, when wounded, 
retract very much, and if the muscle be a cutaneous one. like the platysma 
myoides, the edges of the skin will be inverted. When the direction of the 
wound is transverse to the course of the muscles, the gaping will be much 
greater than when it is parallel. The separation of a wound in front of the 
neck, or on the back of the arm. will be greatly increased by extending the 
head or flexing the arm. The bringing together of the retracted edges, and 
so retaining them, constitutes the third indication, and is accomplished by 
position, rollers, compresses, plasters, and sutures. 
Position.—By position is meant such a disposition of parts as will insure 
their relaxation: thus, in cut-throat wounds bringing the chin towards the 
breast, or in axillary wounds approximating the arm to the side, will alone 
effect their closure. 
Pollers and Compresses.—According to old methods, these are employed 
after either an indirect or a direct manner. In the former they serve to sup- 
port other dressings, in the latter they are the chief means of approximation. 
The preparation of a roller for the latter purpose requires that it shall be long 
enough to pass four or five times round the part, as, for example, the leg or 
arm, and in breadth equal to the length of the wound. Roll the strip into a 
cylinder, leaving a portion of the terminal end unrolled, which last is to be 
torn into two or three tails long enough to encircle three-fourths of the limb. 
At a proper distance, nearer the cylinder, cut a number of slits correspond- 
ing to the tails. To make the application of the so-called invaginated band- 
age, two compresses should be placed parallel with the course of the wound 
and two inches from its sides, and as the roller is brought round from the 
Fig. 247. 
Horse-hair or catgut drains applied. 244 
WOUNDS. 
opposite side of the limb towards the wound the tails are passed through the 
slits (Fig. 248), and as the ends of the roller are drawn in opposite directions 
the edges of the wound are forced 
together, and so maintained by 
successive circular turns of the 
cylindrical part of the bandage. 
If this is used in a wound of an 
extremity, it should be preceded 
by the application of a spiral re- 
versed bandage, carried from the 
fingers or toes to the seat of in- 
jury, to prevent strangulation by 
the invaginated roller. 
Plasters.—Since the introduc- 
tion of antiseptic methods in the 
treatment of wounds, adhesive 
plaster is rarely used. When it 
is to be employed for some time, 
I much prefer the old emplastrum 
adhaesivum. The plaster can be 
rendered aseptic by drawing the 
strip through a warm solution of 
carbolic acid (one to twenty, or one to forty). This plaster is made boiling 
together litharge and olive oil, to which is added some resin, and sometimes 
a little soap, the latter rendering it less liable to crack and scale off in cold 
weather. The mixture is spread upon muslin, is covered with tissue-paper, 
and made into rolls. For use it should be cut, with a pair of scissors, into 
strips from three-eighths of an inch to one inch in width, and from one inch 
to twelve inches in length, according to the extent of the wound to be closed. 
The plaster should be cut lengthwise of the cloth rather than transversely, 
to prevent stretching of the strips, an assistant holding one end, while the 
surgeon or dresser, holding the other, uses the scissors as a knife, by pushing 
forward the separated blades. (Fig. 249.) The part to which the plasters 
Fig. 248. 
The uniting or invaginated bandage applied to a longitudinal 
wound of the arm. 
Fig. 249. 
Cutting adhesive strips. 
are applied must be divested of all hair, and then thoroughly cleansed with 
soap and water, both to save the patient pain in their removal and to insure 
their firm adhesion. In their application, the strips should be well warmed 
by placing the unspread surface over a vessel, such as a bottle or tin coffee- 
pot, containing boiling water; or, when these are not accessible, over a stove- 
pipe or a gas-light, or before an open fire; or, if these are not available, by 
rapidly passing a sponge moistened with chloroform over the plaster. When APPROXIMATION OF WOUNDS. 
245 
sufficiently softened, an end of the plaster should be made fast to one side of 
the wound, the edges of which, being brought closely together by the fingers 
of the surgeon, are thus retained by carrying the strip across and making it 
secure to the opposite side. The first strip should be applied across the 
middle of the wound and an interval of half an inch allowed between each, 
for the purpose of drainage. When applied to a wound of the extremities 
the plasters should not extend more than two-thirds around the part. The 
period for their removal will depend on circumstances. So long as they 
maintain their connection with the part, and the apposition of the wound is 
good, without any evidence of the accumulation of pus or blood, they should 
not be disturbed, but only cleansed by passing lightly over the surface a soft 
sponge moistened with tepid ear- 
bolized water. I am sure there is 
too much meddling with wounds, 
too much anxiety to renew dress- 
ings, by which the quiet and re- 
pose so necessary to the work of 
healing are disturbed. When the 
removal of plasters becomes neces- 
sary, they should be detached with 
great care; not by lifting one end 
and dragging it across the wound 
to the opposite side, by which the 
cut may again be opened, but by 
raising both ends at the same time 
and detaching last that part which 
lies across the approximated edges. 
(Fig. 250.) It is a judicious pre- 
caution, in order to avoid the risk 
of sundering the delicate union, to apply a fresh strip over the place of each 
one removed before another is raised. Great gentleness and care are neces- 
sary in cleansing a wound during the process of dressing. The discharges 
are best got rid of by showering,—that is, by squeezing water medicated with 
the bichloride of one to one thousand solution, carbolic acid, or permanganate 
of potash, from a sponge held a short distance above the parts, and pressing 
out with the fingers or the sponge any accumulations that may be present. 
If this precaution is neglected, the union will be not only retarded but also 
complicated, exposing the patient to abscesses, erysipelas, or sinuses. 
Rubber plaster has one advantage over the ordinary emplastrum adhsesivum, 
as it adheres without being warmed. When continued too long, or when re- 
applied a number of times, it will macerate the skin and cause troublesome 
excoriations. This may be prevented in some degree by perforating the strip 
with numerous pin-holes before applying it to the skin. The plaster should 
be drawn through warm carbolated water before being applied. 
Ichthyocolla plaster.—This plaster is made by applying to silk a solution of 
isinglass in spirits of wine. The addition of a little glycerin makes it more 
pliable and manageable. It is applied by cutting strips and moistening the 
glazed surface with a damp sponge. In every other respect the same details 
are to be observed as in the use of the adhesive plaster. 
Collodion.—This agent, introduced as a surgical dressing by Dr. Maynard, 
of Boston, consists of a solution of gun-cotton in ether and alcohol, and 
should be kept in glass-stoppered bottles. It is best employed after the plan 
of the late Dr. Paul B. Goddard, by cutting strips of soft silk gauze and 
attaching them first to one side of the wound by brushing the collodion over 
each with a camel’s-hair brush. In a short time—which may be shortened 
by blowing upon them—the ether evaporates, leaving a thin film, which 
glues the strips to the surface, after which the wound is drawn together, and 
so held by bringing the other ends of the strips across and uniting them to 
the opposite side. The liquid should not be allowed to touch the raw surface, 
Fig. 250. 
Keinoving adhesive strip. WOUNDS. 
as it acts the part of an irritant. This dressing is not acted on by moisture. 
After the approximation the wound may be sealed up from the air by brush- 
ing the collodion freely over all. Collodion is sometimes mixed with tannin 
(Bichardson’s “ styptic colloid"). Where there is an oozing of blood it favors 
coagulation, and forms a crust or scab, which tends to exclude the air. The 
addition of carbolic acid, salicylic acid, or bichromate of potash, with a view 
to their antiseptic effects, promises very little good indeed. I)r. Hewson has 
been in the habit of using lead ribbon with collodion instead of gauze, par- 
ticularly in wounds of the scalp. Numerous slits are made in the lead to 
serve the purpose of the apertures in the gauze. The collodion dressing 
can be removed by moistening with alcohol. 
Court-plaster.—This plaster is prepared by brushing over silk a solution of 
isinglass and gum benzoin in spirits of wine, and then giving a coating of 
Chian turpentine. A better variety, one less irritating, is that made from 
dissolved caoutchouc applied to silk. This is applied by moistening the sur- 
face with warm water, and is well suited to slight wounds of a superficial 
nature. 
Skin plasters.—These are made from the intestine of the sheep or the peri- 
toneum of the bullock, and have a very limited use. They answer well for 
closing the lids of the eye after the operation for cataract, or for covering 
excoriated surfaces. To render their application practicable, the dry skin 
must be first laid in position and then brushed over with a wet camel’s-hair 
brush. 
Sutures.—The sutures in common use are five in number,—the interrupted 
the continued, the twisted, the quilled, and the button or relaxing suture. The 
depth to which they should be inserted must be determined by the depth of 
the wound. If very superficial, they should be only through the skin; if 
deeper, well into the subcutaneous tissue; the object being in all cases to 
bring into close apposition the entire thickness or depth of the-wound, and 
to prevent gaping. The greatest care should be observed to have the raw 
edges accurately abutted and free from inversion or eversion. All interspaces 
permit oozing and the collection of purulent matters. Their distance of 
entrance and exit from the margins of the wound should be from one-eighth 
to three-eighths of an inch, though sometimes, as in the treatment of lacera- 
tions of the female perineum, it is required to exceed one inch. In their 
insertion they should be carried from without inwards through one side, 
across the wound, and from within outwards through the opposite side. 
The interrupted suture is the one most generally employed, and requires for 
its application a needle, straight 
or curved, and a thread of silk, 
catgut, silk-worm gut, silver, iron, 
lead, or horse-hair. In my experi- 
ence, the most imperfect instru- 
ment made by American surgical 
cutlers is this needle. Whatever 
be its form, except for needles used 
in suturing intestinal wounds, the 
cutting end should be triangular in 
shape, should extend but a short 
distance back from the point, and 
should never exceed in its trans- 
verse diameter that of the shank 
or thread extremity of the instru- 
ment. The eye should be as large 
as possible, well rounded, so as not to cut the thread, and, when wire is used, 
countersunk, so that the thread will not project above the common surface, 
thus removing one great obstacle to its easy passage. (Fig. 251.) There 
are modifications of the needle suited to special operations, which will be 
treated of in their appropriate places. A needle after being used should 
Fig. 251. 
Different forms of surgical needles : a showing the 
oblong eye, and 6 the countersunk eye, by which the 
wire can be placed below the surface of the needle. SUTURES. 
247 
be passed through the flame of a lamp and washed in carbolic acid water, 
a precaution too often overlooked, and the neglect of which may make it the 
bearer of infection. The introduction of the tirst suture is usually across 
the middle of a wound, unless there are projecting points or angles, when 
it will be proper to connect these first, that correspond- 
ence of the margins may be insured, though an equally 
accurate adjustment can be obtained by the surgeon and 
his assistant sewing from the ends towards the middle 
at the same time. After its insertion, each thread is cut 
off at a convenient length, and the process is repeated 
until a sufficient number are in place, leaving, as in the 
application of adhesive plaster, proper intervals between 
for drainage. Ordinarily each suture is secured as it 
is inserted, observing to bring the edges accurately in 
contact, but not so tightly as to pucker and produce 
strangulation. The knot may be either a double reef 
or bow, the latter admitting of being tightened, if 
necessary, and should always be made at the point of 
entrance or of exit,—never over the line of approxima- 
tion. (Fig. 252.) The wire thread is made fast by 
simply twisting the ends about each other, or by passing 
them through a perforated shot (Fig. 253) and com- 
pressing the latter by a pair of strong forceps. (Fig. 254.) This shot-clamp 
is well suited to secure the hair thread. 
The time for the removal of sutures, save in exceptional cases, is usually 
from the third to the fourth day : after this they become sources of irrita- 
Fig 252. 
Interrupted thread suture 
introduced and knotted. 
Fig. 253. 
Fig. 254. 
Shot-compressor. 
Wire thread clamped 
with a pellet of shot 
tion. The metallic thread may, if it is deemed necessary, remain longer, 
as it generally excites less inflammatory disturbance in the tissues, and 
indeed is found so superior to the old silk thread suture as in most in- 
stances to have displaced it. There are, however, localities, as, for ex- 
ample, the eyelids, in which the parts are so delicate and extensible that 
the apposition is made more satisfactorily by silk. 
In removing the metallic thread properly, great 
skill is required. It should be cut on one side and 
the hook-like end straightened, after which, the 
twist being seized by the forceps and the blade 
of the scissors placed against the inside of the un- 
divided end, it is made to revolve about the latter 
as it is withdrawn. 
The continued suture.—This is not often resorted 
to. It is called the glover’s suture. It is applied in two ways,—over and 
over diagonally (Fig. 255), and from side to side without crossing over the 
Fig. 255. 
Diagonal, continued, or glover’s 
suture. 248 
WOUNDS. 
wound (Fig. 256). By the last method, if a loose loop be allowed on each side, 
an interrupted suture may be quickly made by dividing the loops (as in Fig. 
257). The uninterrupted or continuous suture has been used in intestinal 
wounds. 
Fig. 256. 
Fig. 257. 
From side to side. 
Making an interrupted suture out of a continuous one 
by cutting ttie loops in the position of the dotted lines. 
The twisted suture is used in cases where it is desirable to bring divided 
surfaces into firm contact in order to prevent bleeding. It is generally used 
in the treatment of hare-lip. To make this suture, it is necessary to provide 
needles or pins, thread, and a pair of cutting pliers. Some use the ordinary 
sewing-needle, surmounting it with a glass head ; others use the common 
insect-pin ; and others, again, a silver pin with a steel point, which can be 
disengaged after the former is in place. None of these is free from ob- 
jection. 1 have long employed a very slender and finely-pointed steel pin 
of considerable length surmounted with a 
large glass or wax head. (Fig. 258.) Such 
a pin is managed with certainty, and passes 
through the tissues with scarcely any re- 
sistance, enabling us to dispense entirely 
with needle- or pin-holders. Professor Gross is partial to a fine gold pin, 
especially in wounds of the face, where it is desirable to prevent a scar. 
In applying this suture, the pins, after being placed in a lotion of carbolic 
acid (one to twenty), should be passed obliquely through the sides of the 
wound; on one side from without inwards, and on the opposite from within out- 
wards, the entrance and exit being from one-quarter to half an inch distant 
from the edges. The distance between the pins 
must be determined by the necessities of each case, 
and the depth be sufficiently great to pass below 
the vessels of the sides. The pins in place, waxed 
threads are passed several times around each one, 
elliptically, or often in the form of the figure 8, 
and drawn with sufficient firmness to bring in 
contact the surfaces of the wound, after which 
they are secured by a knot. (Fig. 259.) Some- 
times a long thread is used, and passed from pin 
to pin. I am not aware that the method pos- 
sesses any advantages whatever: indeed, I con- 
sider the procedure unsurgical, as it obstructs the 
intermediate spaces and prevents drainage. The 
pliers (Fig. 260) are next brought into requisition, 
the pointed extremities of the pins cut off, and, to 
prevent undue pressure, a strip of adhesive plaster 
may be passed beneath their extremities. 
The time for the removal of the pins varies from 
thirty hours to three days: to effect it, the head 
should be grasped with a pair of ordinary dress- 
ing forceps and gently rotated a few times, after which traction may be 
conjoined to rotation, when the pin readily becomes disengaged, leaving 
the loops of threads in position, glued to the parts by the secretions, and 
Fig. 258. 
Pin for twisted suture. 
Fig. 259. 
A wound traversed with three 
pins : a, the pin in situ ; b, the pin 
with a thread thrown about it; 
c, thread arranged in the form of 
a figure 8. SUTURES. 
where they may be allowed to remain for a day or two longer as a uniting 
medium. 
Fig. 260. 
Cutting pliers. 
The quilled suture is quite limited in its application, being confined for the 
most part to the closure of lacerations of the female perineum; and I think 
that I have proved it to be unnecessary even here* It takes its name from 
the little cylinders of plaster, in size and form resembling the ordinary goose- 
quill, about which the threads were tied. To apply this suture, stout curved 
needles, armed with double silk threads, 
are passed through the sides of a wound, 
from three-quarters of an inch to one inch 
from their edges; the needles are next 
disengaged from the free ends of the 
threads, leaving their loops projecting 
some distance from the points of en- 
trance. Two pieces of rubber bougie, 
or two rolls of adhesive plaster, are 
next placed in a longitudinal direction 
and parallel with the course of the 
wound, one piece being carried through 
the loops, the other laid between the 
free ends of the sutures. (Fig. 261.) As 
the latter are tied firmly around the 
cylinders, the edges are not only drawn together, but also slightly everted. 
There are other sutures, and instruments for their introduction, which will 
be described in their appropriate places. 
The French surgeons were in the habit at one time of approximating wounds 
by means of serres-fines ; but these are productive of more irritation than or- 
dinary sutures, and have little claim to professional notice in this connection. 
The rubber suture.—This suture, the invention of Rigal, 
substitutes for the thread of the twisted suture little 
rings of gum-elastic. (Fig. 262.) The difficulty in its use 
arises from an inability to apply the proper amount of 
pressure, in consequence of which patients complain of a 
sense of constriction in the parts upon which the rings act. 
Relaxation or button suture. — There are operation 
wounds where, in consequence of the amount of tissue 
removed, the edges cannot be brought together without 
great tension, likely to cause the rapid cutting out of the 
interrupted stitches. It is under these circumstances that 
the button suture, or suture of relaxation, becomes prac- 
ticable. To apply this suture, there are required two flat 
pieces of sheet-lead, each having at the middle two small 
holes a short distance apart, and a silver thread with a 
needle at each end. The two needles are passed through 
the two holes of one plate, then through one of the flaps 
of the wound some distance from its margin, next through 
the other flap at an equal distance from its border, and finally through the 
two apertures in the other lead button. (Fig. 263.) If now the needles be 
removed from the wire, and the two ends of the latter be drawn upon and 
Fig. 261. 
Quilled suture. 
Wound closed. 
Fig. 262. 
Rubber suture. 
'* Lacerations of the Female Perineum, by the author. 250 
WOUNDS. 
twisted together, the tension will be taken off the interrupted sutures which 
are subsequently introduced for coaptation. 
External dressings.—After the closure of 
the wound, in order to render the asepsis 
more complete it is well to inject a por- 
tion of the bichloride of mercury solution 
through the drainage-tube, one end of 
which should be closed between the thumb 
and fingers until the cavity is slightly dis- 
tended, when the fluid may be allowed to 
escape, thus securing the penetration of the 
solution into every crevice of the divided 
tissues. 
The parts are now prepared to receive 
the external dressing, consisting of a little 
iodoform sprinkled over the line of approxi- 
mation and a strip of protective to shield 
the edges of the wound from the irritation 
of carbolic acid or corrosive sublimate. 
Next in order come the two compresses of 
either the carbolized or the sublimated gauze, each consisting of eight or ten 
layers, the deep compress to be made wet in the bichloride solution and the 
superficial one to be applied dry. The dressing is to be further fortified by 
covering the surface and borders of the antiseptic pads with a layer of sub- 
limated cotton, the whole to be secured by the turns of a carbolized or 
sublimated roller bandage. The dressing being completed, it only remains 
to maintain the part in a state of perfect rest. 
In wounds of the extremities, the roller bandage must begin at the hand 
or foot and extend some distance above the seat of injmy, go as to insure a 
firm and uniformly-distributed pressure to the muscles and blood-vessels, as 
well as to obliterate all cavities or recesses beneath the united parts, so that 
there shall remain no little pockets for the accumulation of blood or pus. 
This cannot be too strongly insisted upon, controlling as it does muscular 
and inflammatory action. 
Renewal of dressings.—In large wounds, as in excisions of articulations, 
amputations, or removal of the mammary gland, a considerable amount of 
blood-stained serum may be expected to follow, saturating the dressings and 
requiring their renewal after from twenty to thirty-six hours. This discharge 
is usually over during the period mentioned, so that the second dressing 
may be allowed to remain for four, five, or six days without being disturbed. 
Frequently the indication for redressing will be found in an elevation of 
temperature; and on this account the thermometer should be used morning 
and evening. The necessity for removing the drainage-tube, either in part 
or entire, at some time between the fourth and sixth day constitutes another 
reason for repeating the dressing. The stitches can be removed usually about 
the sixth or seventh day, in wounds of the face rarely later than the third 
day. Should the drainage-tube show signs of obstruction, a tine, delicate, 
soft catheter may be passed carefully through its canal. This is better than 
injecting fluid through the tube, as by the latter procedure the flaps may 
be detached and the healing disturbed. The same care is to be observed 
in redressing as at the first. As soon as one edge of the dressing is raised, 
the bichloride solution (one to one thousand) should be allowed to flow 
underneath, thus douching or irrigating the wound and the surrounding 
parts as successive portions of the compresses are removed. The fresh 
dressing should always be in readiness to take the place of the old one before 
the latter is taken off. 
If there has been no error committed in carrying out, with strict details, 
the antiseptic method, the wound may be expected to heal without undue in- 
flammation or suppuration, and with only very slight surgical fever. When 
Fig. 263. 
Button suture. COMPLICATIONS. 
251 
the contrary proves to be the ease, the surgeon on carefully reviewing the 
different stages of the technique will generally be able to recall some sin 
of omission or commission. 
After the union has taken place and the sutures are removed, the line of 
cicatrix requires some protection for a short time, and for this purpose a strip 
of carbolized or sublimated gauze, spread with a thin layer of boraeic oint- 
ment, answers an excellent purpose. Mr. Cheyne’s formula for this ointment 
is the following: 
hi Paraffine, 2 parts ; 
Vaseline, 1 part; 
Mix, and add 
Boraeic Acid, 1 part. 
Open Treatment op Wounds.—This plan of treatment dates back to the 
beginning of the present century, and was brought prominently into notice 
by Von Kern, a German surgeon. With some slight modifications it was em- 
ployed by the late Professor Wood, of New York. The method consists in 
freely exposing the wound to the air, the edges being either allowed to lie in 
contact without restraint, or retained by a few loose stitches (Burrow). As 
the action of the oxygen of the air has been shown by Pasteur to be inimical 
to the growth and multiplication of certain micro-organisms, the open plan is 
by no means an unimportant one, and if compelled to choose between it 
and the old method of treating wounds by occlusion and without drainage, 
I should have no hesitation in electing the former. I do not believe, how- 
ever, that, with our present knowledge of antiseptic dressings, the open mode 
is destined to have any general acceptance. 
Pneumatic Aspiration.—This method, devised and practised by Maison- 
neuve and, with a slight modification, by Guerin, consisted in slipping over 
the part operated on, thigh, arm, or leg, a closely-fitting rubber hood, the free 
end of which projected some distance beyond the stump, and communicating 
by means of a rubber tube with a large jar, the tube forming the connec- 
tion by means of a metal canula which passed through the cork of the jar. 
Through the same cork ran a second vulcanized rubber tube, the other ex- 
tremity being attached to an air-pump. By exhausting the air from the jar 
from time to time the discharges from the wound flowed into the bottle, 
thus excluding the air from the stump, and at the same time keeping the 
wound free from serum or other accumulations. The plan never gained much 
popularity, though it was by no means devoid of a certain degree of merit. 
Constitutional Treatment.—In extensive wounds, whether made by the 
knife of the surgeon or by accident, some degree of constitutional disturbance, 
even when treated antiseptically, will manifest itself, in the form of dry skin, 
increased heat, thirst, and accelerated pulse, frequently accompanied with 
headache and high-colored urine. It may be so slight as to demand but little 
attention, and, even wThen well marked, it disappears in two or three days. 
It is quite sufficient to restrict the diet for that time, allowing only toast- 
water. barley-water, tapioca, milk, chicken-water, or articles of a similar 
nature, until the perturbation is overpast, when the diet must be of a more 
generous kind. Little medicine will be required. A few doses of neutral 
mixture, or of spirit of nitre largely diluted with cold water, a gentle laxa- 
tive of Rochelle salt, and an anodyne as soon as the skin becomes moist and 
the pulse less frequent, will fulfil every indication. 
Complications.—From various causes, both local and constitutional, the 
healing of a wound may be interrupted, or complicated. 
1. Inflammation.—The edges of a wound may become red, swollen, sen- 
sitive, arid discharge a sanious fluid,—conditions altogether incompatible 
with healing. This may occur shortly after the first dressing, or it may 
set in several days later, in which ease the union is dissolved and the parts 
exhibit a tendency to gape. A diligent search should be made to discover 
the cause. If the parts have been irritated by motion, absolute rest must 252 
WOUNDS. 
bo enforced; if some officious intermeddler has suggested an improper 
application, it should be removed; if the condition is the effect of irregular 
habits, a mercurial purge, followed by tonics and carefully-regulated diet, 
should be ordered. As a local application nothing answers so well as irriga- 
tion with warm water. Laudanum and water, applied by moistening cloths 
with the liquid, spreading them over the wound, and renewing as often as 
they become dry, also acts very favorably. The retaining roller in such cases 
should never be made very loose. Should the redness and sensibility not 
yield to such remedies after thirty-six hours, a few leeches may be used 
contiguous to the wound. A little blood taken in this way will often change 
the whole character of the sore in a few hours, as if by magic. 
2. The union of a wound may be delayed by persistent suppuration. In 
such cases the failure is referable either to improper dressings or to a defective 
constitution of the blood and a tardy local circulation. The pus is generally 
unhealthy, and often emits an unpleasant odor. This indisposition to heal 
may also be caused by excessive or redundant flaps, allowing hollow spaces 
beneath. I have seen from this cause amputations of the mammary gland 
refuse to heal for many weeks after the usual period for union. 
The treatment must be directed to the system at large, as well as to the 
rebellious parts. Quinine and iron, wine, and a nutritious diet, with an 
anodyne, especially at bedtime if the patient passes restless nights, com- 
pose the constitutional measures; while as local agents the free use of 
permanganate of potash to deodorize the discharges, stimulating the parts 
with a dressing of dilute alcohol (one part to eight parts of water), and 
injecting any pouches with a solution of sulphate of copper (three grains 
to the ounce of water) or bichloride solution (one to two thousand), answer 
admirably. Excellent effects are also obtained by injecting water in which a 
little carbolic acid has been dissolved (one to forty). All such wounds should 
be dressed twice daily, and be well supported by accurately-adjusted com- 
presses, to bring in close contact all ununited surfaces and prevent any 
purulent accumulation. 
3. Wounds may be complicated by epidemic influences. Thus, at periods 
when erysipelas or diphtheria or hospital mortification prevails, the danger 
is imminent. No wound should be allowed to remain in award where these 
exist. When erysipelas attacks a sore, it is announced by a rigor, t he margins 
are dusky red and very sensitive to the touch, the work of repair is imme- 
diately arrested or retrogrades, and the discharges become thinner, diminished 
in quantity, or ichorous. When the wound is one of some magnitude, the 
general system will participate profoundly in the complication. The pulse is 
frequent and feeble; the tongue is dry and covered with a brown crust, with 
a dry red streak in the middle; the strength rapidly fails; delirium super- 
venes, and the patient either dies in defiance of the best-directed efforts, or is 
the subject of a protracted convalescence. 
In diphtheritic attacks the wound becomes dry and pale, is covered to a 
greater or less degree with the peculiar gray, grayish-white, or buff-colored 
exudation, and there is no attempt at reparation. This is accompanied or 
followed by rapidly-increasing prostration, and the case is converted at once 
into one of the gravest nature. 
When a wound becomes the subject of mortification, there is an end to 
repair. The edges are swollen, bloodless, and painful; the granulations 
shrivel up and disappear; the discharges cease, or are greatly perverted, 
becoming thin, bloody, and of an offensive odor, while the tissues are rapidly 
converted into a grayish slough. The system sinks into a typhoid condition, 
and, unless the malady is speedily arrested, the patient soon succumbs to it. 
For the most part, these evils have a local origin, and are generally pre- 
ventable, unless there has been some gross neglect or oversight in regard 
to the hygienic surroundings of the patient; and the surgeon will do well to 
consider how far he is responsible for such complications. The statements 
of Lister of Edinburgh. Thiersch of Leipsic, Nussbaum of Munich, Volkmann COMPLICATIONS. 
253 
of Halle, and other eminent members of the profession, are of so startling a 
character that they demand the most solemn consideration. In the hospitals 
under the care of these surgeons erysipelas and gangrene had been for years 
adding to the mortality of their wards, defeating the best-planned operations 
and rendering certain others so hopeless as to discourage their performance; 
but since the introduction of the antiseptic plan in its details, these formida- 
ble diseases have been practically banished. 
In the treatment of such a complication, first in importance is isolation. 
These cases, if in a hospital, must at once be removed from the general ward 
into a separate and well-ventilated apartment; if they occur in private prac- 
tice, a searching investigation must be instituted to discover the probable 
sources of infection. This scrutiny must extend to nurses, sponges, dress- 
ings, knives, furniture, and even to the medical attendants. A surgeon who 
is in attendance upon cases of erysipelas, if he is indifferent to change of 
clothing and personal cleanliness, jeopardizes the life of any patient who 
comes under his knife. A short time since I lost a case of lithotomy by 
diphtheritic infection, communicated, I have no doubt, by an assistant who 
was in attendance on cases of diphtheria. 
When a wound is attacked by erysipelas, it will be proper to administer a 
gentle purge of eight or nine grains of blue mass, which is to be followed in 
one hour by two or three drachms of Rochelle salt. This will relieve in- 
testinal irritation and correct faulty secretions. After this the tincture of 
the chloride of iron may be used with great benefit, in conjunction with 
quinine. Six or eight drops of the former and one grain of the latter may 
be given every two hours. Hypodermic injections of pilocarpine, as recom- 
mended by Professor Da Costa, exert a valuable influence as a means of 
eliminating the poison through the skin. The diet should consist of nutri- 
tious broths free from fat, of milk, and, if the case demands more support, of 
milk-punch or wine. As a local remedy, the tincture of iron, or, what is 
better, hot flaxseed-meal poultices, applied freely over the inflamed surface 
and some distance beyond, exercise a most beneficial effect. Dr. Garretson 
is partial to a mixture of the tincture of iron, tincture of cinchona and quinia* 
as a local dressing. 
In cases of diphtheritic infection of wounds the treatment in most respects 
answers to that laid down for erysipelas. Washing the parts with a solution 
of boracic acid, local stimulation by nitrate of silver upon the encrusted sur- 
face, and internally, in addition to iron and quinine, the free use of the chlo- 
rate of potash and tincture of capsicum, are indicated. If the erysipelatous 
disease be checked, the redness and tenderness subside; or, if the complica- 
tion be diphtheritic, the adhering exudation melts away, the granulations 
become more florid, the discharges grow purulent, and the constructive work 
is resumed and carried forward to completion. 
Should the complication be that of phagedsena, it must be arrested by 
potent caustics, such as nitric acid or bromine, applied as directed in the 
treatment of hospital mortification, and the entire mass of disorganized 
tissue converted into a harmless eschar, the separation of which will be 
best effected by emollient poultices and the careful use of the forceps and 
scissors. Tonics, stimulants, and food, with opium to relieve pain, must be 
given; and after the slough is removed, the granulating surface is to be 
treated as an ordinary ulcer. 
4. Hemorrhage.— This may be primary or secondary. If there is a free 
oozing of blood, elevation of the part, the use of cold, and well-directed 
pressure, will control it. The bleeding may be due to some vessel which 
has been overlooked at the first dressing, in which case it will occur a few 
hours after the closure of the wound. Should the dressings become soaked 
and the flaps distended with fluid and clotted blood, a sense of local warmth 
is experienced by the patient. Under such circumstances the wound must 
* Garretson, Oral Surgery, 2d edition, p. 930. 254 
WOUNDS. 
be opened, all clots removed, and a ligature placed on the vessel. When 
hemorrhage occurs after the lapse of several daj’s, it may be caused by an 
unhealthy condition of the wound, in which repair ceases and ulceration 
destroys the tissues, thus opening a vessel. A frightful loss of blood often 
takes place in this way. It is an exceedingly unpromising task to cut into 
the half-decomposed tissues and ligate the offending artery, for in a few days 
the thread conies away, before occlusion is effected, and the bleeding is re- 
peated. It is better to apply well-directed compression, and, that failing, to 
use acupressure, or secure the principal vessel at a proper point above. 
5. Muscular spasms, which sometimes follow wounds, may be due to an irri- 
table condition of the system, or to injury of nerves. This distressing compli- 
cation must be promptly subdued, as nothing proves more inimical to healing. 
The application of a roller alone will often answer every purpose, or, that fail- 
ing, the hypodermic injection of morphia, conjoined with a comfortable position 
of the part, and in some cases the use of a splint to insure perfect rest. 
6. Sinuses and fistulous tracts often delay the healing for a long time. These 
may result from redundant flaps in operations, imperfect drainage, want of 
accurate contact between divided surfaces, or the movements of underlying 
muscles. If from the first cause, the simplest and most expeditious remedy 
is abridgment; if from the second, counter-openings or a drainage-tube; if 
from the third, injections of sulphate of copper or carbolic acid, with uniform 
pressure by compress and roller; and if from the last, subcutaneous or open 
division of the offending muscles, with absolute rest. 
7. Maggots.—These result from the deposition of ova by flies. There are 
numerous articles which serve to destroy these bodies, such as sweet oil, 
spirits of turpentine, etc. Turpentine, however, though very effective, is too 
irritating. Nothing answers better than pouring into the wound melted 
lard, cooled sufficiently to be borne without pain, which the animals 
by entering the respiratory apertures which are near the tail. The anti- 
septic treatment of wounds will effectually prevent their presence, and is 
particularly indicated as a dressing in hot climates, where maggots are so 
prone to infest sores. 
Incised wounds may be open or subcutaneous, and are made by sharp 
instruments,—sometimes by accident, at other times by the knife of the 
operator. In extent they vary from a slight cut with a penknife, not ex- 
tending through the integument, to one several inches in length. The more 
quickly the cut is inflicted the less acute is the pain. A finger is sometimes 
severed accidentally by a chisel with very little suffering. A high state of 
mental excitement will often mask it, as in a fierce street-fight, when many 
extensive wounds are inflicted without the injured party being aware of their 
existence. The skin is the most sensitive of all the tissues, from its rich 
supply of nerves ; as a consequence, more pain is experienced in cutting from 
without inwards than in the opposite direction. 
The infliction of a wound, if an open one, is followed very uniformly by 
the following phenomena : pain, retraction or gaping, and hemorrhage. 
The pain at first is very acute, but gradually subsides, leaving in its place a 
certain degree of tenderness. A very great difference exists as to the quality, 
severity, and duration of pain in different persons,—a difference depending 
on location and peculiarities of organization. Upon receipt of the injury it 
is exquisite suffering, subsiding into smarting or burning, and finally soreness 
or stiffness. A supersensitive condition tends to complicate in some measure 
the kindly healing of a wound. Pain may entirely disappear, and after an 
interval of days return, in which case it is an evidence of undue inflamma- 
tory disturbance. 
The retraction, depending on the elasticity of tissues, direction, and muscular 
relations, must necessarily differ in different localities,—a point which has 
already been considered in the general observations upon wounds. 
Incised Wounds. INCISED WOUNDS. 
255 
The bleeding which follows the division of structures will be much or 
little, according to the size and number of the vessels of the part, the morbid 
changes present, and diathesis. Inflamed tissues pour out much blood, from 
over-distention and loss of contractility in the walls of the vessels. This 
inability to contract is not always due to muscular paralysis of the walls of 
the offending vessel, but to their union with a non-contractile structure. It 
is from this cause that dangerous bleedings are occasionally encountered 
from the tonsils after amputation, their elasticity being destroyed by chalky 
and other rigid inflammatory deposits. Most of the vessels in a wound cease 
to bleed by the operation of natural processes. 
Treatment.—The indications in the treatment of an incised wound are: 
the arrest of hemorrhage; the removal of all foreign matters which may be 
present; the apposition of the gaping edges; the application of external 
dressings; and attention to ail the details included in the term after-treat- 
ment. 
1. The arrest of bleeding is accomplished by various measures already 
described. It is well to wait a short time, in order to ascertain to what 
extent nature will aid in this work. Though the first gush of blood may 
be impetuous and profuse, it often quickly diminishes. Elevation of the 
part, exposure to the cold air, and the local application of cold or pressure, 
will close many, perhaps all, superficial vessels. Should we find, however, 
after a reasonable delay, that there are certain arteries which continue to 
bleed, they must be secured by the ligature, torsion, or acupressure. 
2. The removal of foreign substances.—These must, when possible, be re- 
moved, by the fingers, the douche, streams of bichloride of mercury solution 
(one to one thousand), or of warm carbolized water (one to forty), and by the 
forceps. Among foreign bodies we must not overlook blood-clots. These, 
when present to any great extent, become sources of irritation, and by their 
decomposition induce inflammation and suppuration. 
3. Approximation.—In coaptating the edges of a wound, whether by plas- 
ters or sutures, the hair should be removed from the vicinity of the injury. 
It serves to collect and retain the discharges, and renders the removal of 
adhesive strips, when used, painful. 
4. External dressings.—If the wound is trifling in extent, and is rendered 
aseptic by the usual solution of bichloride of mercury (one to one thou- 
sand), no drainage-appliances will be required. After stitching together the 
edges with the requisite number of fine sutures, it will only be necessary to 
cover the part with a strip of sublimated gauze, which can be made to adhere 
by brushing over its surface a quantity of the collodion solution of iodo- 
form, through which the air cannot penetrate to the wound. If, however, 
the wound is extensive, the antiseptic dressing should be adopted in all its 
details. 
When circumstances are such that antiseptic measures cannot be employed, 
the surgeon must rely on the use of hot water, previously sterilized by boil- 
ing, for washing and cleansing the wound, and, after its closure, must apply 
compresses wet with the same, over which may be laid a piece of oiled silk, 
also wet in the hot water, before applying the roller bandage. Wrhen it is 
necessary to employ drainage and the usual tubes are not attainable, horse- 
hair can generally be secured, which, when well cleansed with soap and boil- 
ing water, constitutes a good substitute. 
5. After-treatment.—The part should now be placed in an easy, elevated 
position, and kept at rest. It will always be proper to examine the condition 
of the wound not later than the third day; and when this is done, the same 
precautions should be observed as in the first dressing. The state of the 
wound at this first renewal of dressings will generally determine the frequency 
of subsequent ones. If union seems to have taken place in a good measure, 
and there is no evidence of accumulation within, no elevation of temperature, 
and no undue redness, swelling, or tenderness about the edges, the dressing 
need not be disturbed for three or four or five succeeding days; but if there 256 
WOUNDS. 
is suppuration, the removal of the purulent matter becomes imperative, and 
the dressings should be renewed daily, pressing out all such accumulations, 
and continuing the antiseptic measures as before. 
Should other than animal ligatures be used, they are to be withdrawn 
as soon as they have become sufficiently disengaged from the vessels. If no 
undue amount of surrounding tissue has been included, those on small ves- 
sels can usually be removed from the fourth to the seventh day; but those 
on vessels like the radial, ulnar, tibial, and femoral may require from ten to 
twenty days before they ulcerate through. So also in regard to sutures: as 
soon as union is assured, or should they cut through one side before adhesion 
takes place, they must be removed. 
Incised wounds are liable to complications of an inflammatory nature, 
induced sometimes by improper dressings or neglect of rest, at other times 
resulting from causes acting through the system at large. Whenever inflam- 
mation of a common nature is developed, there is an arrest in the work of 
repair; the edges redden, swell, and tend to separate; a thin, blood-stained 
fluid is discharged, which soon becomes more purulent. Should the inflam- 
mation prove to be erysipelatous, a blush will appear at the margin of the 
wound, often accompanied by oedema, great tenderness, and a rapid breaking- 
down of whatever union may have taken place. This may be preceded by a 
chill or rigor, with an elevation of temperature, followed by acceleration of 
the circulation, hot, dry skin, headache, parched mouth, and intense thirst. 
In the treatment of these complications, the first indications are to secure, 
if possible, the resolution of the inflammation by removing any source of 
irritation discoverable, to paint the part over with carbolized oil, or cover 
it with pledgets wet with lead-water and laudanum, and to administer a 
mild cathartic, such as a few grains of blue mass, followed by two or three 
drachms of Rochelle salt; after which a refrigerant like the neutral mixture 
may be used. If resolution cannot be effected, recourse must be had to 
warm-water dressings or a light poultice, in order to favor suppuration, on 
the establishment of which the local and constitutional disturbances will dis- 
appear, when the wound may again be brought together by adhesive strips, 
with a view to secure the union of the granulating surfaces, observing to 
cleanse the parts with bichloride of mercury solution (one to two thousand) 
or chlorinated soda, and to remove any shreds of dead cellular tissue which 
may be present. 
The subcutaneous variety of incised wounds embraces all such as are made 
in the division of tendons, fasciae, and muscles by the tenotome for the pur- 
pose of correcting deformities, congenital or otherwise, or of securing quiet to 
some indolent ulcer. There are present, in such cases, the usual phenomena of 
open incised wounds,—namely, pain, retraction, and hemorrhage,—although 
they are considerably modified. The pain is not great, as the opening made in 
the integument is very small, and the hemorrhage is not very profuse, unless 
there has been an unwarrantable or careless use of the knife. The almost 
entire exclusion of the atmosphere, and, of course, of the minute organisms 
which it contains, conduces to rapid healing. Hence, while a certain degree 
of tenderness and swelling may follow, the inflammatory symptoms are for 
the most part slight and the repair rapid. The dressing of such wounds is 
reduced to the utmost simplicity, requiring only a little ethereal solution of 
iodoform or an adhesive strip over the puncture, a roller, and rest. Should 
exceptions occur, in which the bleeding proves excessive, the application 
of cold and pressure will be required; or should the inflammatory symptoms 
prove severe, the treatment will not differ from that proper to the open 
variety. 
Lacerated and Contused Wounds. 
In wounds of this class there is a certain degree of both bruising and 
tearing, and these two characteristics are so generally present that their 
consideration under the same head is not inappropriate. LACERATED AND CONTUSED WOUNDS. 
257 
Such wounds are produced in a great variety of ways: for example, by a 
blow from a bludgeon, from fragments of blasted rocks, by the horn of an en- 
raged animal, a fall against a curbstone, or the passage of a wagon-, carriage-, 
or car-wheel. The increase of manufactories, the introduction of mowers 
and reapers, the multiplication of machine-shops and steam-mills, together 
with the many other labor-saving mechanisms which belong to our modern 
civilization, all are calculated to add to the number of these Wounds. 
There is a form of laceration which is called brush-burn, made by friction, 
as when a part is pressed against the belting of machinery in rapid motion, 
or when a person allows a rope to slip rapidly through the closed hand. I 
have seen it produced by a large mass of ice falling from a height and striking 
the body in such a manner as to glide with great velocity over the surface. 
The heat developed produces an injury not unlike a burn, and the skin in severe 
cases sloughs. 
Contused wounds are seen of all degrees, from a mere bruise of a linger to 
the complete evulsion of a limb from the trunk, or the purification of the 
entire body. An extremity becoming entangled with belting or drawn into 
the cogs of revolving wheels presents a frightful mutilation of structure. The 
skin is torn, retracted, and discolored with 
lubricating oils; the muscles are riven asun- 
der, pulpified, deeply stained with blood- 
clots, and have fragments of clothing and 
bone ground into their substance; while the 
tendons, torn away from their attachments, 
hang in coiled cords or are slit into shreds, 
as seen in the case illustrated by Fig. 264, 
where a thumb has been caught and torn 
away from its metacarpal connections, car- 
rying with it the three tendons from their 
muscular insertions. 
Contused and lacerated wounds possess 
certain chai*acteristics which are very unlike 
those of the incised variety. 
1. The edges of the former are irregular, 
hanging in points or ragged flaps, discolored 
by a purple ecchymosis, cold, and often sep- 
arated to a considerable extent from the subjacent parts. If the injury ex- 
tends into the muscles, they are dark and swollen, reeking with blood-stained 
fluids, and have a bruised and broken appearance. 
2. The pain, instead of being sharp and severe as in incised wounds, is 
slight or is of a dull nature, often accompanied with some degree of numb- 
ness. This is particularly noticeable in cases where the injury has been the 
work of an instant and the force irresistible. The nerves, participating 
in the bruising and crushing in common with other parts, are incapable of 
transmitting impressions, which explains the lack of sensibility. In some of 
the more simple cases of this form of injury, as in the contusion of a finger, 
the pain is often very severe. 
3. These wounds usually bleed very little, even though arteries and veins 
the size of the femoral, brachial, or axillary be torn. I have seen the arm 
wrenched from the body, dangling only by a few strips of integument, and 
yet no bleeding take place. Generally, howmver, when trunks of the magni- 
tude of those above mentioned are divided, there is considerable oozing,— 
sufficient, indeed, to make a serious impression on the strength of the patient ; 
and this fact should never be lost sight of. The absence of active hemor- 
rhage is the result of the manner in which the violence deals with the ves- 
sels. It is usually the conjoined action of crushing or mashing, and torsion 
or twisting, by which the internal and middle coats are broken, and turned 
or curled inwards. The vessel is also drawn into its loose sheath of cellular 
tissue, the fibres of which close over the orifice. The mechanical obstruction 
Fig. 264. 
Thumb torn off, with tendons adhering. 258 
WOUNDS. 
of these fragments of broken tissue is quite sufficient to resist any free escape 
of blood and favor the formation of a thrombus. In injuries of this kind 
sufficiently extensive to produce the constitutional state of “ shock,” the 
consequent lessening of the contractile power of the heart gives a further 
security against hemorrhage, as the blood is not propelled along the vessels 
with sufficient force to dislodge the thrombus. 
While it is true that there is an absence of free bleeding at the time of the 
reception of a lacerated wound, it is equally true that this injury is often 
followed by secondary hemorrhage. This may occur a few hours after the 
accident, when reaction has taken place and the heart has regained sufficient 
vigor to urge forward the blood with power enough to disturb or displace the 
clots at the mouths of the torn arteries; or it may break out later, from the 
fifth to the fourteenth day, in which case it is the result of the separation 
of sloughs. The prudent practitioner will be on the alert for both of these 
contingencies. 
4. Contused and lacerated wounds are prone to slough. The damage done 
to the vessels, nerves, and other structures disqualifies them for carrying 
blood or executing the work of innervation, in consequence of which the 
nutrition is either greatly impaired or destroyed, so that they fall into 
decomposition and perish. 
5. In the healing of contused and lacerated wounds there is a larger sur- 
face of granulation-tissue, and a more abundant and protracted suppuration, 
than in other varieties. This condition follows from the necrosis of the in- 
jured parts, portions of which must be separated and extruded in the form 
of particles, fragments, and shreds, the lifeless components of the wound. 
This separation goes on with varying degrees of rapidity, according to the 
structure involved. Muscle quickly disappears, so also do the skin and fat; 
but dense fasciae and tendons yield very tardily. The more readily a part, 
from the looseness of its texture, can be penetrated by migrated leucocytes, 
the more quickly can it be removed. The final separation, or disjunction of 
the dead from the living, is but a repetition of that process which has been 
already described under the head of mortification, and involves the processes 
of inflammation and suppuration. 
The constitutional symptoms of extensive contused and lacerated wounds are 
often very marked, consisting of a slow, feeble, irregular pulse, a cool, moist 
skin, a pale countenance, with great prostration, and mental alarm. In this 
combination of phenomena we have the equivalent of “ shock.” Even in 
cases unattended by shock it is not uncommon to have some fever present 
after the lapse of two or three days. This is perhaps of an infective nature, 
from the absorption of the sewage resulting from dead and dying particles of 
damaged structure, and may be inaugurated by a rigor or chill, followed by 
increase of temperature. This is traumatic or surgical fever. We may also 
have after its subsidence, and when suppuration becomes established, a repe- 
tition of the febrile disturbance. 
Prognosis.—In wounds of this class, of moderate extent, a favorable ter- 
mination may be confidently anticipated ; but they are by no means exempt 
from danger even when simple. The presence of those matters which result 
from decomposing particles may be followed by fatal consequences. Their 
entrance into the absorbents may induce ichorrhaemia or pyaemia. I have 
seen a hospital patient with a simple contused finger die from this cause. 
The danger from this source is undoubtedly far greater before granulations 
have formed,—that is, during the work of separation,—probably because when 
repair has commenced a line of defence has been established by the surround- 
ing wall of tissue. 
But there is another peril which may follow, even when the whole surface 
is covered with healthy granulations, especially should the pai*t be exposed 
to a current of cold air, or the body to influences liable to provoke a chill; 
and that is tetanus. I view with horror the surgeon who dresses a healing 
wound while a draught of cold air is blowing upon it. LACERATED AND CONTUSED WOUNDS. 
259 
A poor man was in the habit of coming to my office to have a contused 
wound of the hand dressed. All the dead parts had separated, and the part 
was tilling up with granulation-tissue; his general health was excellent, and 
the ulcer presented nothing peculiar. In crossing the river in one of the ferry- 
boats, on a cold, raw day, he unwittingly took refuge in the ladies’ cabin, and 
was rudely compelled to withdraw. Standing upon the deck, he became cold 
and finally chilled. That evening he was attacked by tetanus and died. 
A manufacturer who had suffered from a lacerated wound of the hand 
had recovered sufficiently to leave his house and visit his place of business. 
On returning home in a street-car, his hand, which had still a small open 
granulating surface, was allowed to lie on the ledge of an open window. It 
became cold, and this was followed by a rigor, culminating in an attack of 
tetanus, from which he recovered only after several weeks. 
There is another complication which must not be lost sight of, namely, 
sloughing. This may be very limited and superficial, confined to shreds of 
integument; or, if the injury includes the deep structures, it may prove more 
extensive. Deep suppuration, either before or simultaneous with the slough- 
ing, may occur, dissecting the components of the part and increasing the 
disorganization. The most alarming form of mortification is that termed 
traumatic, in which the entire limb may fall into decomposition, and which 
shows no tendency to establish a line of demarcation. Such cases are often 
seen after railroad accidents, and betoken extensive destruction of blood- 
vessels as well as of the other constituents of the part. The limb not only 
becomes rapidly black, but is also tilled with the liquid products of decom- 
position. Such a condition may follow even when the visible signs of the 
injury appear limited. 
A patient was brought into the University Hospital with a contused and 
lacerated wound of the forearm. The injury appeared to be confined to this 
part of the extremity ; yet in less than twelve hours the entire limb to the 
shoulder passed into a state of mortification, from which he rapidly sank and 
died. It is not an easy task to account for such sudden and wide-spread 
destruction without admitting some constitutional peculiarity, induced by 
“shock,” in addition to the local injury. I am quite certain that in some 
instances the determining cause has been the existence of diseased kidneys. 
Many of the cases of this kind which I have seen have been in persons who 
drank freely, and in whom, if examination had been made, structural altera- 
tions of these organs would have been discovered. 
It is impossible in wounds of this class to know precisely the extent of 
damage to the vessels; and hence the surgeon should be on his guard for 
secondary hemorrhage. 
In lacerated wounds in the neighborhood of tendons, as at the wrist, hand, 
or foot, the prognosis should be reserved. There is a tendency to thecal or 
bursal inflammation and suppuration, which may spread like a conflagration 
and utterly disorganize the part. 
A patient entered the University Hospital during the winter of 1875, who 
had some time previously received a contusion of the thumb. The inflam- 
mation at the time of his admission had traversed all the thecal sacs and 
canals of the hand, terminating in the diffusion of pus beneath the palmar 
aponeurosis in every direction. 
Treatment.—The indications are the same as in the treatment of incised 
wounds. 
1. The arrest of hemorrhage.—Though in the class of wounds under con- 
sideration we do not encounter impetuous bleeding, yet there is a quiet 
leakage going on which will in time tell seriously upon the patient’s 
strength. Should this come from small vessels, a little pressure will con- 
trol it. A careful search should be made wffiere there is reason to believe 
that large trunks have been damaged; and should it prove that such is the 
case, they should be tied with ligatures, whether bleeding or not, to render 
them secure against the effects of reaction. 260 
WOUNDS. 
2. The removal of foreign bodies.—Whatever these may be, they should be 
carefully extracted. Sometimes dirt or gravel is ground into the wound 
by the wheels of a wagon or by falling masses of rocks: this should be 
washed out by a douche of warm carbolized water from a sponge held some 
distance above the part, or by a stream from the nozzle of a syringe. Some- 
times portions of the clothing, blackened with tar or grease, or fragments of 
glass, are forced into the midst of the broken structures : in this case the for- 
ceps or fingers will be found the most convenient and effective instruments 
for their removal. Even the natural components of the part may, after such 
accidents, become foreign, and demand removal with as much urgency as 
those which enter from without: thus, portions of integument hanging by 
a thread, pieces of detached muscles, and comminuted fragments of bone, 
having lost all vital connection with the wound, are to be taken away. Just 
here it is proper to introduce a caution in regard to taking too much liberty 
with ragged portions of structure. It is often very difficult to decide with 
certainty what will be the fate of irregular and partially separated flaps 
of integument. Some very unpromising tags do survive; and therefore the 
knife or scissors should be used sparingly, and when the least uncertainty 
exists it is better to give the patient the benefit of the doubt, and allow such 
shreds to remain: if they survive, well; if not, no harm will come of their 
being left to the process of natural separation. In all wounds about the face 
and scalp this rule applies with tenfold force, in consequence of the great 
vascularity of the tissues. In dealing with fragments of bone, we may hope 
to obtain their reunion so long as their periosteal connection with the shaft 
remains. 
3. The apposition.—Wounds of this kind, being prone to slough, from their 
diminished vitality, will not endure tension or stretching, and when their 
sides can be placed in contact it is better to avoid stitches and simply apply 
adhesive strips, leaving ample intermediate spaces for drainage. If there is 
a tendency to displacement, the angles or processes of the margins should be 
loosely united by inserting a few stitches of silver thread. As preliminary 
to the use of either sutures or plasters, the parts should be cleanly shaven of 
hair. 
4. External dressings.—In applying an external dressing the antiseptic 
method may be adopted, or simply water may be used. In wounds of this 
kind I confess to a great fondness for water, slightly impregnated with car- 
bolic acid or corrosive sublimate (one to five thousand) solution. Some of the 
grandest triumphs of conservative surgery, especially about the hands, have 
been obtained by means of water-dressings. If the wound is small, it will be 
sufficient to apply wet compresses, renewing them from time to time as they 
become warm and dry; but in more extensive injuries of this nature I much 
prefer to employ irrigation (as shown at page 129). The temperature of the 
fluid must be regulated in accordance with the extent of damage sustained 
by the soft parts. If their temperature and color are good, it may be em- 
ployed cold; if not, it must be cool or lukewarm,—otherwise the circulation 
and innervation, already feeble, may be so depressed as to induce sloughing. 
Water used in this manner moderates the local vascular disturbance and 
washes away serous, purulent, and other products from the wound. The 
water may also be advantageously medicated with chlorinated soda, per- 
manganate of potash, or salicylic acid, all of which have the effect of 
deodorizing and rendering innocuous the putrid formations in the wound, 
and of destroying such atmospheric organisms as are believed to promote 
suppuration. During the separation of any dead portions of the wound and 
the establishment of suppuration, the temperature of the water may be raised 
a few degrees, by which an increased amount of blood will be invited to the 
part, and those capillary activities of transudation and suppuration main- 
tained which are necessary for the separation of the dead from the living. 
Should an inflammatory infiltration ensue, stuffing the parts with blood- 
stained serum, and threatening to strangulate by its accumulation the CONTUSED WOUNDS. 
261 
structures in the midst of which it extends, incisions will be demanded, which 
by emptying the surcharged tissues may limit if not arrest mortification. 
When the sloughs begin to loosen, the vigilance of the surgeon should 
be increased in anticipation of secondary hemorrhage, particularly in deep 
wounds and in the vicinity of large vessels. Both patient and nurses must 
be carefully instructed how to act in the event of such an occurrence. Let 
the directions on this important point be clear and well impressed: other- 
wise lives will often be lost during the terror and disorder which an angry 
outbreak of blood produces. The means to be adopted in such cases is 
pressure over the main arterial trunk of the limb, as the femoral in the leg, 
or the brachial in the arm. I often direct, in view of such emergencies, the 
loose adjustment of a tourniquet, which can be screwed down at the first 
signal of danger. A profuse bleeding originating in this way may cease from 
syncope or exhaustion or the formation of a precarious clot before the arrival 
of the surgeon, and he may be betrayed into a dangerous error by supposing 
that the storm is past. The probabilities are that when the heart recovers 
its power the bleeding will be repeated, and with these alternations of cessa- 
tion and renewal the life of the patient will slip away through professional 
timidity and indecision. It is proper, then, in all cases where we have 
reason to believe that a large vessel is opened, to make the ligature of the 
chief artery of the limb at once. To seek for it in the wound, even were 
it found and ligated, would only be to expose the patient to the liability of a 
repetition of the accident, the parts being in an unhealthy and sloughing 
condition. 
After the sloughs are all removed, the work of granulation begins in order 
to repair the breach. These granulations are open to all the accidents of 
ulcers, and should be treated on the same principles. Irrigation may be 
suspended as soon as cicatrization begins, and the healing surface covered 
by a pledget wet with plain water, and, as the cicatrization advances, this 
may be substituted by a dressing of Goulard’s cerate or boracic ointment. 
The discolorations or ecchymoses which frequently exist around a wound 
require time for their removal, though the work may be hastened by stimu- 
lating lotions,—the best, in my judgment, being dilute alcohol in which a 
little muriate of ammonia is dissolved (five grains to the ounce), and applied 
by wetting pledgets of linen with the fluid. Spirit of camphor is a popular 
domestic remedy, and so also is the tincture of arnica, both of which answer 
a very good purpose. 
Constitutional Treatment.—In cases attended with shock, should reac- 
tion not soon occur, external warmth must be applied to the extremities, spine, 
and epigastrium, and warm milk or beef-tea, with a little wine or whiskey, 
given at intervals; though stimulants should be exhibited with caution, and 
not prematurely. After reaction, pain and nervous excitement, when present, 
are most easily relieved by opiates,—the best being the deodorized tincture of 
opium by the mouth, or morphia hypodermically. During the febrile state, 
the administration of cold drinks, with a little sweet spirit of nitre, an oc- 
casional laxative, and an unirritating but nutritious diet, constitutes all the 
necessary treatment. 
Should traumatic mortification set in, all our resources must be brought 
forward to counteract the accompanying exhaustion, such as milk-punch, 
beef-essence, eggs, substantial broths, chicken-jelly, and beefjelly. If the 
stomach becomes irritable, with a tendency to nausea or vomiting, cham- 
pagne or carbonic acid water will be useful. Pain and restlessness are best 
controlled by anodynes, and quinine and iron become valuable as tonics. 
Contused Wounds. 
Contusions are concealed wounds, and possess many features of great in- 
terest. They are produced in a variety of ways,—by blows, falls, or forcible 
pressure, as when a person is crushed under falling timbers or walls or is 262 
caught between the buffers of cars. These injuries are met with in various 
degrees of severity, from a slight bruise or pinch of the skin, followed by a 
little discoloration, to the purification of all the components of a limb or the 
rupture of fasciae and blood-vessels and the laceration of internal organs, such 
as the spinal cord, brain, liver, spleen, intestines, and bladder. It is almost 
incredible what an amount of damage can be done to the deep-seated parts 
without even a lesion of the skin. Many persons, especially aged women, 
who are emaciated, are particularly affected by such injuries,—the slightest 
blow, or pressure with the fingers, giving rise to ecchymosis. In scorbutic 
states of the system the same tendency exists. 
The symptoms of a contusion are pain, swelling, discoloration, and, in severe 
cases, “ shock.” 
The pain experienced after a blow is not intense or acute. It is described 
as a numbness or dead feeling, which may remain for a long time, or end in 
a tingling or pricking sensation, especially if the trunk of a nerve has been 
bruised. When the violence has been inflicted over portions of the skeleton 
having but a thin covering of soft parts, like the tibia, and where the perios- 
teum has been injured, the pain merges into a condition of extreme tender- 
ness, the parts becoming intolerant to the slightest pressure. The same vio- 
lence which originates the pain produces often a loss of power. If a severe 
blow be inflicted over the deltoid, or across the arm, the limb falls powerless 
by the side. The contusion may be produced indirectly, as where a person 
falls upon his feet from a height, and finds himself unable to stand, with 
defective sensibility in the injured parts. The spinal marrow in such a case 
has suffered from the transmitted force. 
The swelling and discoloration are closely connected, and are due to the ex- 
travasation of blood and blood-stained serum. They occur immediately after 
the injury, but may not be visible until some time has elapsed. The vessels 
which furnish the blood are for the most part veins, in consequence of their 
walls being less able to resist injury. The degree of swelling will depend 
upon the number or size of the vessels broken and the anatomical structure 
of the part. Thus, the cellular tissue of the scalp, being compact and in- 
extensible, does not allow of much distention, while the integument of the 
eyelids, the conjunctiva, and the skin of the penis enlarge to a great extent. 
The blood which escapes runs through the interstices of the tissues, and may, 
where no peculiarities of structure exist, spread over an extensive surface, 
influenced much by gravity, and settling to the most dependent situations; 
or it may press the fibres of fasciae aside, compressing them together, and 
forming a cavity or depot for its reception. These blood-accumulations 
remain in a fluid state. Such blood-tumors are frequently seen in the scalp 
of the new-born child, the result of long pressure within the walls of the 
pelvis, and occasionally follow the application of the forceps when the ad- 
justment is not altogether accurate. Sometimes the swelling arises from a 
different cause than blood, illustrations of which are seen in the welts that 
rise in a few seconds upon the body or limbs of an animal which has been 
struck with the whip-lash. These enlargements consist for the most part 
of blood-stained serum which has transuded through the walls of the vessels 
surcharged with blood under the stimulus of violence. 
Discolorations or ecchymoses appearing after the lapse of days are indica- 
tions of deep-seated injury, the blood—especially the more liquid part of it— 
finding its way slowly through the planes of structure to the surface. This 
phenomenon is quite common after fractures. 
These ecchymoses exhibit different shades of color, being sometimes quite 
black, and by an inexperienced eye might readily be mistaken for the begin- 
ning of mortification ; at other times they are blue, or even red. After a few 
days these spots may change to a green, yellow, or brown, or a mingled tint 
in which all are blended. Some of these shades depend upon the relative 
proportion of the corpuscular and fluid constituents of the blood. The more 
of the former, especially if from veins, the darker the stain. Should there be 
WOUNDS. CONTUSED WOUNDS. 
263 
a sufficient lesion of the skin to admit air, the color becomes more red, from 
the action of oxygen. The varied tints or shades in the later stages of 
ecchymosis must be referred to the decoloration or reaction of hsematin on 
the blood-serum present. The ecchymosis present in the profounder parts— 
as among the muscles—consists of unchanged arterial or venous blood. Ec- 
chymoses are sometimes followed by blebs or vesicles, and, that they may 
not be confounded with mortification, the following considerations will serve 
to clear up uncertainty. In mortification, once established, the conditions 
are absence of pain and sensibility, loss of temperature, crackling from the 
elimination of gases, and an offensive odor, none of which are present in a 
case of uncomplicated ecchymosis. If an artery be opened, there is usually 
a rapid escape of blood, giving rise to a diffuse swelling, which yields after a 
time a distinct pulsation, forming a spurious aneurism, in the periphery of 
such a swelling there is coagulated blood, but in the centre it is liquid, and, 
under the influx of fresh fluid, is kept in a state of motion imitating the 
circulation. 
Blood-swellings are frequently found to become circumscribed after inju- 
ries, the circumscription being formed by the condensation of the areolar and 
other tissues, and this after a time may, through nutritive or inflammatory 
deposits, assume the character of a membrane or cyst. These “ depots,” as 
they are called, are very curious things. The contained blood may assume 
three conditions,—solid, semi-solid, and liquid. The explanation for these 
different states I am not prepared to give. I have seen such collections most 
frequently upon the back and over the gluteal region. The thrombi which 
form in the labia of the female after a difficult parturition are of this nature. 
The final disposition of these “depots” is not always the same. Generally 
they are absorbed, particularly when the blood remains fluid. I have often 
seen such a termination, even when their great size—equal to the head of a 
young child—made such an event improbable. They may become sources 
of irritation, provoke inflammation, arid result in suppuration,—a result most 
likely to take place in those which are hard or coagulated,—and finally they 
may undergo organization, and pass into connective tissue, in the same man- 
ner as does a thrombus within a blood-vessel. I am quite certain that many 
cysts begin in this way: after the removal of the blood the wall remains, 
and, being lined by a layer of secreting cells, it furnishes the fluid of the 
cyst; though it is probable that sometimes the contained fluid is simply the 
liquor sanguinis of the original effusion, becoming straw-colored or clear by 
the removal of the formed constituents of the blood. 
Results of Contusions.—For the most part, except in aggravated cases, 
recovery takes place without any unusual drawbacks; yet the effects of con- 
tusions are not unfrequently troublesome, and sometimes fatal. The most 
common sequel is abscess. This may be the result of the succeeding inflam- 
mation, and may prove of a diffuse kind, without any limiting wall, as is 
often seen in the ischio-rectal region, the scrotum, or the palm of the hand, 
after a bruise. 
Erysipelas may follow a contusion,—oftener seen on the scalp, perhaps, than 
elsewhere,—and, what is still more serious, mortification, limited or extended 
according to the degree in which the vessels and nerves have been involved. 
Cicatricial contraction, especially of the palmar aponeurosis, is another con- 
sequence, coming on, it may be, several months after the original injury, and 
producing great deformity of the fingers. 
Hypercesthesia of a part which has been the subject of a contusion is by no 
means uncommon, particularly when the injured tissues lie near the bone,—as 
over the subcutaneous portion of the tibia or the cranial bones. There is 
frequently associated with this tenderness some induration or thickening, 
which has its origin in the periosteum. This sensibility may assume a peri- 
odical form, an evening exacerbation of pain setting in about bedtime, and 
often foreshadows the commencement of bone-disease. Contusion of joints, 
when accompanied by comminution of the bones, is a very dangerous injury, 264 
WOUNDS 
often ending in pyaemia and death ; and the same may be said of contusions 
of the liver, kidneys, and spleen. 
A bruise is often followed by an intractable neuralgia, consequent upon 
direct nerve-injury, or it may induce in the same manner a localized paralysis. 
Fatty tumors I have seen spring up in the seat of an old contusion. Malig- 
nant disease is frequently called into activity in this way. In very many 
instances I have known cancer of the female breast rapidly develop after a 
blow, accidental or otherwise, upon the gland. 
When a diathesis is present,—such as rheumatism, gout, or syphilis,— 
bruised parts are pre-eminently liable to morbid attacks. In the case of 
a young man who was under my care, and who was the subject of heredi- 
tary syphilis, if his shoe pressed moderately hard at any point on the foot, 
or a finger was slightly pinched, ulceration was almost certain to follow. As 
far as my observation extends, such results are more common in transmitted 
than in acquired syphilis. 
Treatment.—The arrest of the extravasation is the first indication, though 
often this has ceased spontaneously before the patient is seen; the second is 
to hasten the removal of the blood already effused, and to limit the conse- 
quent traumatic inflammation. 
The measures for the arrest of bleeding consist in applications of cold, as 
ice in rubber bags or bladders, or ice-water, applied by saturating pledgets of 
linen or muslin, binding them firmly upon the part, and renewing them fre- 
quently, or as often as they become dry. The same caution is proper here 
as in contused and lacerated wounds,—namely, not to carry the cold treat- 
ment too far when the damage has been so extensive as to render sloughing 
probable; otherwise that event, through the depressing effect of a low tem- 
perature, may be brought about unexpectedly. Astringents and stimulating 
lotions conjoined are valuable remedies, not only for controlling or limiting 
extravasation, but also for hastening its removal, which is ordinarily a slow 
process at best. Among this class of remedies I know of nothing so effica- 
cious as a mixture consisting of common table-salt three drachms, muriate of 
ammonia one drachm, and bay-water six ounces. Pieces of linen or lint wet 
with the liquid must be applied frequently over the injured parts. Other 
remedies are in popular use, such as the tincture of arnica pure or diluted, 
acetate of lead, sulphate of zinc, acetic acid, spirit of camphor, and alcohol. 
These all possess a decided value as sorbefacients, particularly the alcohol, 
which I frequently employ. It may occasionally be desirable to remove the 
blood, though such cases are exceptional. It is frequently done among pugi- 
lists in the case of black and swollen eyelids, and the practice is worthy of 
imitation where it is an object to get rid of such an ecchymosis quickly. A 
puncture should be made into the cellular tissue of the lid, just above the 
eyelashes, and the blood pressed out, after which a pledget wet with ice-water 
should be bound on, to prevent a further accumulation. Depots of blood are 
best left to themselves, or at most should be only moderately compressed by 
pad and roller. On no consideration should they be opened, except when 
they have provoked suppuration, as they are prone, when lanced, to behave 
much after the manner of a cold abscess after its evacuation. Should, how- 
ever, a necessity arise for their incision, the cavity should be frequently 
injected with a solution of salicylic or carbolic acid, and compression applied, 
so as to keep the walls in contact and secure their consolidation. In cases 
where the vitality of the damaged structures is seriously impaired, the circu- 
lation being feeble and embarrassed and the skin cool, warm-water dressings 
are demanded. To maintain these at the proper temperature they should 
be covered with oiled silk or rubber-cloth. Should a contusion end in a 
circumscribed slough, its separation will be hastened by a flaxseed poultice, 
observing to deodorize and disinfect the dying tissues at each dressing with 
washes of permanganate of potash, chlorinated soda, or carbolic acid water. 
In instances of diffused aneurism the treatment must be governed by the 
magnitude of the vessel wounded. If the lesion involves an artery like the PUNCTURED WOUNDS. 
265 
radial, or even the brachial, the proper course will be to cut down upon 
the vessel and tie its extremities; if the popliteal or femoral, to amputate 
the limb. 
Amputation will become necessary in those cases in which the components 
of a limb are broken into a pulp, the bones comminuted, and the vessels 
destroyed, as indicated by loss of temperature and the absence of circulation. 
Contusions of the abdominal viscera are frequently met with as the result 
of falls or of the passage of wheels over this part of the body. The injury is 
characterized by a slow, feeble pulse, cool skin, torpid bowels, and sometimes 
retention of urine. In such cases there is nothing comparable to external 
heat and moisture. A piece of flannel, folded two or three double, should be 
soaked in hot water or a hot decoction of hops, laid over the abdomen, and 
carefully covei*ed in with oiled silk or rubber-cloth, in order to prevent evap- 
oration and retain the heat. A light mush or bran poultice answers very 
much the same end. 
Where pain is present in contusions, and is of sufficient importance to de- 
mand an anodyne, opium in any of its forms may be administered until relief 
is obtained. The diet should be regulated according to the necessities of the 
case. WTiere dead parts are to be separated, or where profuse suppuration 
ensues, the system will require support, and therefore the necessity arises 
for nutritious food, tonics, and perhaps stimulants. 
Punctured Wounds. 
Punctured wounds are produced by sharp-pointed instruments, such as 
needles, pins, nails, tacks, glass, thorns, splinters, hooks, dirks, bayonets, 
swords, and the teeth and horns of animals. Wounds inflicted by the fangs 
of reptiles, the stings of certain insects, and the suctorial apparatus of others, 
though punctured, do not properly come under this head, as there is an im- 
portant element in such, viz., the introduction at the same time of some 
poison or irritating secretion, which confers upon them their chief importance. 
The effect on the tissues is different according to the sharpness of the 
point of the vulnerating body. If a needle or pin be driven into the body, 
it enters and acts as a wedge: the break in the continuity of the structures 
is made by the point, whilst that which follows makes room for itself by 
crowding or pressing together the parts in which it is lodged. If the point 
be more blunt, like that of a nail, or of the tooth or horn of an animal, 
a contusion is added to the puncture; indeed, the contusion precedes the 
puncture, as the parts are bruised before an entrance is made. When glass 
or splinters enter the flesh, their irregularities of surface cause some degree 
of laceration; and if a dagger or a sword inflict the wound, the double or 
single edge of the weapon produces such incision with puncture. 
The serious nature of these wounds is perhaps rather exaggerated. The 
surgeon constantly, in his investigations and operations, inflicts such injuries 
without anticipating any evil consequences. The introduction of the ex- 
ploring-needle to ascertain the nature of growths and clear up obscure points 
is a matter of daily practice ; during the reign of acupuncture parts were made 
to bristle with needles ; the trocar is plunged into the walls of the abdomen, or 
into the scrotum, as in ascites or hydrocele ; long aspiration-needles are thrust 
through the walls of the chest and into lung-cavities; the seamstress pricks 
her fingers with needles and pins; and women, under singular psychological 
caprices, make pincushions of themselves to attract a kind of notoriety; yet 
in all these wounds how uncommon is it to see the least inconvenience follow! 
Uncomplicated punctured wounds cannot, in view of such facts, be deemed 
dangerous. The cause which renders them so should be referred,—1, to the 
structures wounded ; as when nerves, tendons, or blood-vessels are pierced. 
When a nerve is wounded, and the foreign body remains in its substance, or 
provokes inflammation and the formation of cicatricial tissue, the injury may 
be followed by excessive neuralgia, or sensibility of the most distressing kind, 266 
WOUNDS. 
or muscular spasms, or even epilepsy and tetanus. Should the offending 
body enter a tendon or an aponeurosis, in time it excites contraction and 
consequent deformity. I once removed a needle from the tendon of the long 
flexor of the thumb, which had been for a long time embedded, and was pro- 
ducing contraction and spasms of pain. When a needle enters a vessel, the 
opening closes on its removal, without bleeding; but if a nail or a dagger 
pierce its walls, aneurism or profuse hemorrhage and death will follow. 2, to 
foreign matter conveyed into the wound, as may happen in cases of post- 
mortem examinations: in such a case inflammation of the lymphatics and 
veins may be set up, and abscess may follow. In this way, too, the surgeon’s 
needle, when not properly cleaned, may become the carrier of a deadly poison. 
3, to the addition of laceration, which gives increased impoi'tance and possible 
danger to punctured wounds, because the fluids which result from the devi- 
talized fragments of such lacerations may find their way into the lymphatics, 
poisoning the blood, and giving rise to a wide-spread constitutional disturb- 
ance, like that of ichorrhsemia or pyaemia. 4, to the imprisonment of the 
inflammatory products, there being no opening for their escape. In the palm 
of the hand and sole of the foot this is eminently true. I have seen hands 
hopelessly lost from this cause, and death follow in a colored lad from a 
splinter wounding the foot. 
Substances like needles or pins show a remarkable tendency to wander 
or change their position in the body, moved, no doubt, by the play of the 
muscles and tendons. I once removed from the knee-joint a needle, the head 
of which 1 discovered in the internal lateral ligament, while the other ex- 
tremity was fairly within the articulation. It had at a previous date entered 
the thigh. In the case of the needle referred to above as being in the tendon 
of the long flexor over the first phalanx of the thumb, it was known to have 
entered the forearm several months previous. 
Bodies less pointed, or irregular on the surface, remain stationary, as the 
irregularities entangle in the tissues and oppose movement: should their 
composition prove of an unirritating nature, they may become encysted and 
remain harmlessly imprisoned in the tissues for an indefinite period of time. 
There is, however, great uncertainty as to the quiet sojourn of such materials. 
They are liable to become disturbed and create inflammation and abscess. 
I have removed portions of glass which for several months had been quiet 
occupants of the body but which at last gave trouble and required excision. 
Treatment.—The indications in the treatment of punctured wounds are, 
the removal of the injuring body; the control of hemorrhage, should any 
follow; the application of proper dressings; and the relief of pain, or of 
muscular or other disturbance. The extraction of the foreign body is often 
a matter of no difficulty, as a portion of it may project from the surface, 
the fingers or a pair of forceps being all the instruments required for that 
purpose. The fish-hook is an exception, its barb rendering its removal by 
force out of the question without laceration; and therefore, instead of pulling 
it out, an incision should be made upon its extremity, and the hook pushed 
forward until disengaged, or it may be driven onward until the point appears, 
when it may be seized with a pair of forceps and extracted after cutting off 
the shank with a pair of pin-forceps. Portions of glass sometimes enter the 
flesh and are buried out of sight, as where a tumbler or bottle is bi’oken in 
the hand, or where the arm is driven through a window. The introduction of 
a probe will enable us to localize the body, and its extraction is effected by a 
pair of long, slender forceps, the ends of the blades being well roughened. 
Needles will often foil the best-directed efforts for their removal. They 
generally break off upon entering the body and quickly pass out of sight. 
The place of entrance is usually indicated by a dark point. By grasping a 
duplicature of the integument between the thumb and finger we are often 
able to feel the body, or to excite some complaint of pricking on the part of 
the patient. I often have located such substances by pressing the skin at 
different points in the vicinity of the place of entrance with the rounded POISONED WO ENDS. 
267 
extremity of a probe, some uneasiness being expressed when the instrument 
touched over the situation of the body. The magnet has been used to 
localize needles and particles of steel, but it is a resource of doubtful utility. 
The best course is to incise the parts obliquely to the supposed direction of 
the needle, introduce a probe, and make a gentle and delicate exploration of 
the wound. Its contact with the body is not difficult of detection, although 
threads of fasciae yield a similar sensation and may deceive one not familiar 
with such operations. Once recognized, it may be easily seized and extracted 
by the long, slender-bladed forceps. 
The hemorrhage in punctured wounds is usually slight, and is readily con- 
trolled by a compress wet with the solution of the bichloride of mercury (one 
to one thousand) and bound over the wound by a roller. If painful, the addi- 
tion of a little laudanum to the solution exercises a soothing effect upon the 
part, and, I doubt not, tends to moderate the succeeding inflammation. When 
a punctured wound is made over a joint, or in the midst of tendons and 
strong aponeuroses, elevation, and rest upon a splint, with the use of external 
cold, in the form of ice, are imperative, and generally give a favorable termina- 
tion to the case. If important vessels be wounded, giving rise to an amount 
of bleeding not controllable by ordinary pressure, the wound must be enlarged, 
and the vessel sought for, and tied at both ends, or, this failing, the principal 
trunk of the limb must be ligated. 
The pain which sometimes follows wounds of this kind should be promptly 
subdued by adequate doses of opium. 
In defiance of the best-directed efforts, inflammation will occasionally follow 
punctures, particularly when the palm of the hand, the sole of the foot, or the 
extremity of a finger has been the subject of injury. The danger in such an 
event is great, and demands both bold and prompt surgery. The disease 
travels rapidly along the numerous synovial and bursal membranes, and the 
products of the inflammation—being imprisoned by unyielding walls of fasciae 
—will occasion not only dreadful suffering from pressure upon the nerves, but 
also great structural disorganization. When, therefore, the disease does not 
yield to elevation of the part and hot fomentations, a free incision must be 
made so as to give exit to all such accumulations, after which an antiseptic 
dressing should be applied. 
The addition of contusion or laceration to a punctured wound increases 
its gravity. It is very common to meet with cases of dog-bite, or scratches 
made by the claws of the cat, which prove very obstinate, and are not unfre- 
quently followed by extensive erysipelas, and even sloughing. These are best 
treated with warm water and laudanum, washing them first with a solution 
of permanganate of potash. 
In cases where inflammatory symptoms follow, attended with marked con- 
stitutional disturbance, it will be proper to direct a gentle cathartic, such as 
Rochelle salt or castor oil, to remove all sources of intestinal irritation, and 
this should be followed by some febrifuge, like the neutral mixture or sweet 
spirit of nitre. The diet at the same time should be restricted; and as the 
inflammation subsides, medicine may be discontinued, and a more liberal 
allowance of food directed. When abscesses form and the suppuration proves 
profuse and prolonged, quinine and iron, together with stimulants and a full 
diet, become necessary. 
Poisoned Wounds. 
Poisoned wounds are those which, in addition to a puncture, abrasion, or 
scratch, have at the time of their infliction some peculiar poisonous or irri- 
tating matters introduced into the body capable of producing both local and 
constitutional disease. In some instances the mere maceration of the skin, 
without any visible break in its continuity, is sufficient for the reception of 
the poison. These poisons differ in their nature and in the sources whence 
they are derived. They may be arranged as follows: 268 
WOUNDS. 
First. Poisons from the bodies of man and beast, both dead and living, the 
product of disease or of decomposition. 
Second. Poisons derived from arachnidans and reptiles, the product of a 
special poison apparatus. 
Third. Poisons derived from insects, formed in the salivary glands. 
I shall consider these in their order. 
1. Poisoned wounds contracted from the bodies of man and brutes. 
Dissection or post-mortem wounds.—These wounds are very much less 
frequent in Philadelphia at present than they were thirty years ago. As 
a student I remember suffering myself, and witnessing others suffer, from 
this class of injuries. Since the introduction of the chloride of zinc as an 
antiseptic agent these accidents have almost entirely disappeared. This sub- 
stance appears to possess the property of rendering innocuous the products 
of morbid cadaveric changes. For several years, while teaching anatomy, 
during winch time my hands were constantly in contact with the fluids of 
the dead body, no inconvenience was experienced ; nor can I recall any case 
of dissection-wound among those engaged in the anatomical rooms where 
the cadavers used had been preserved by the chloride of zinc. Occasionally 
bodies were injected for lecture-room demonstration with what is popularly 
known in Philadelphia as “the red mixture,”—a combination of rock salt, 
nitrate of potash, carbonate of soda, and molasses, introduced by the late 
Professor Iforner, of the University of Pennsylvania, and imparting a beau- 
tiful red color to the muscles. In several instances I have seen the char- 
acteristic poisoning follow a wound inflicted whilst dissecting subjects so 
treated, and I suffered severely in one instance myself. 
The bodies of persons who have died from peritonitis, especially when 
puerperal in its origin, or of those who perish from erysipelas, pyaemia, and 
carbuncle, are particularly dangerous, in consequence of being charged with 
irritating, putrid, and septic matters, the product of micro-organisms. The 
risk of infection diminishes as putrefaction advances. Examinations of the 
body made shortly after death, as in post-mortem cases, are fraught with 
more danger than those made in ordinary dissections. The state of health 
at the time of exposure has much to do with the operation of animal poisons. 
This is corroborated by the fact that when students of medicine receive a 
poisoned dissecting-wound it is generally towards the termination of the 
winter session, when the constitutional vigor is somewhat impaired by the 
combined influences of confinement in lecture-rooms, diminished exercise in 
the open air, and the enervating effects of badly-ventilated and overheated 
lodging-apartments. Individuals suffering from organic disease of the kid- 
neys are dangerous subjects for dissecting-wounds. It is also true, as Sir 
James Paget has observed, that persons long exposed to the atmosphere and 
duties of the dissecting-room enjoy a certain immunity against the action of 
the septic materials of the cadaver, just as those living in miasmatic regions 
after a time become comparatively proof against malarial poisoning. 
There are peculiarities of constitution which render some persons particu- 
larly liable to suffer either from contact with the fluids of the dead body or 
from the presence of its offensive exhalations. A prominent surgeon of my 
acquaintance has on several occasions been as thoroughly poisoned from in- 
haling the foul odor emanating from the cadaver as though the materies morbi 
had been placed beneath the skin. In whatever the poison consists, it certainly 
possesses a power of existence and propagation entmely independent of its 
origin, as it may be communicated by the blade of a knife used months pre- 
viously in dissections. The part which generally suffers in wounds of this 
class is the dorsal surface of the hand, a part where the skin is most delicate. 
There are two forms of dissecting-wounds,—one in which the local, and the 
other in which the constitutional, symptoms predominate. Dissection-wounds 
which have chiefly a local significance consist in a scratch, puncture, or abrasion 
produced by a knife, needle, or spiculum of bone, which, two or three days 
after the accident, is followed by a red, angry point, usually on some part of POISONED WOUNDS. 
269 
the hand, accompanied by intense itching or smarting, which sensation may 
be the tirst symptom to apprise the patient of what has happened. This 
red point is soon surmounted by a minute vesicle, tilled with serum, which 
opens and discharges, forming an ulcer, from which flows a sero-purulent 
matter, often tinged with blood. In many instances the disease is arrested at 
this stage; the minute ulcer becoming surrounded by a wall of lymph, the 
dead particles of tissue separating, granulations springing up, and cicatrization 
gradually taking place, leaving for some time a livid discoloration. 
In other cases the resulting ulcer is surrounded for a short time with an 
erythematous blush ; its boundaries enlarge, the edges become indurated, ele- 
vated, irregular, and everted; the soft parts for some distance around are 
swollen, and assume a brawny appearance; the bottom of the ulcer becomes 
covered with a gray pultaceous layer of necrosed connective tissue; the few 
granulations present are pale and unhealthy, and the pain is very severe, 
having a burning and throbbing character; the patient’s appetite fails, he 
passes sleepless nights, and may have a slight rigor, followed by febrile dis- 
turbance of the circulation. 
The ulcer may remain in this condition, in defiance of all treatment, for 
two or three weeks, before the slough separates and repair commences. The 
sketch below (Fig. 265), taken from the hand of a prominent professional 
friend, furnishes an excellent representation of the dissecting ulcer described. 
Fig. 265. 
Ulcer the result of a dissecting-wound. 
In other cases, from the centre of local mischief one or more red lines 
extend up the arm along the course of the lymphatics. At the same time 
there may be a slight rigor, followed by an elevation of the temperature, a 
frequent pulse, and headache. At this stage the lymph in the absorbent 
vessels, under the influence of the poison, may undergo coagulation, and the 
further progress of the disease be arrested. Should this not occur, and the 
lymphangitis continue to extend, the glands, as the supra-condyloid and 
axillary, into which the lymph-vessels empty, will receive the infectious 
matter and become inflamed, tender, and swollen. Here again the enemy 
may be arrested, and its further passage effectually disputed, by the inflam- 
matory transudation into the gland-structure, which so modities the virus 
as to prevent its passage into the emergent lymphatics, in consequence of 
which the constitutional infection is escaped. Not unfrequently the glan- 
dular inflammation, excited by the presence of the virus, runs on to suppu- 
ration, and this may also disarm the poison of all specific properties and 
abort the disease. It is possible that many of the phenomena described 270 
WO UNDS. 
may be caused by the operation of putrid matters alone, independent of any 
specific poison. 
Dissect ing-wounds with marked constitutional involvement.—Tn this form of the 
disease the constitutional symptoms to be described may arise twenty-four 
hours after inoculation, and before there are any local manifestations of the 
injury. This was so in the case of Professor Dease, of Dublin, who died on the 
eighth day after the attack, it is altogether probable that in such a case the 
poison passes directly into a vein and at once induces changes in the blood. 
Generally, however, in the form of the disease under consideration, a prelimi- 
nary lymphangitis and glandular enlargement are present. In addition to 
these the entire arm becomes swollen, oedematous, and of a dusky-red color. 
The swelling frequently extends to the neck, shoulder, and down the side of 
the trunk. There is evidently present in such cases a diffuse cellulitis similar 
to that seen in erysipelas, which is attended with the same disposition to the 
formation of diffuse abscess. 
The constitutional disturbance which accompanies this grave condition 
reveals more than the local operation of the poison. It indicates that the 
latter has entered the circulation, and, acting as a ferment in the blood, has 
given rise to the phenomena of septicaemia or pyaemia. There are alterna- 
tions of rigors with flushes of heat; a high temperature, and a feeble, frequent 
pulse ; a dry, furred tongue, which soon becomes brown : a sallow or icterode 
condition of the skin, with emaciation, delirium, and extreme weakness, fol- 
lowed by profuse sweats, diarrhoea, pleuritic stitches, and cough. Notwith- 
standing the presence of so formidable an array of symptoms, the patient may 
struggle through and recover, even out of the very jaws of death. As a rule, 
however, such cases prove fatal, only one out of seven, according to Travers, 
recovering. 
The disease, when it exists in this form, is capable of being communicated; 
and the surgeon who has charge of such a case should be exceedingly discreet 
in dressing the wounds of others. If there be present a latent disease of the 
kidney in a person suffering from the constitutional effects of a dissecting- 
wound, it will be developed into fatal activity by the poison. It was in con- 
sequence of such a complication that two very promising young physicians 
died in Philadelphia,—one becoming inoculated whilst making an autopsy in 
the Pennsylvania Hospital, and the other after receiving a slight scratch while 
exploring a foul slough on the leg of an unhealthy child. 
Treatment.—Professional men who are much engaged in making post- 
mortem examinations, students of medicine, demonstrators of anatomy, and 
those pursuing the study of pathology, should thoroughly anoint their hands 
with sweet oil before exposing them to putrid or other matters of the cadaver. 
Should a finger receive a cut, scratch, or puncture, the bleeding should be 
encouraged by squeezing the part above the wound between the thumb and 
finger. The wound should be washed under a stream of water, and, if there 
be no chaps or abrasions on the lips or tongue, be vigorously sucked, after 
which it may be immersed in a solution of the chloride of zinc. I am quite 
confident that this latter agent will, if promptly used, destroy everything of 
a specific nature about the wound and render it entirely harmless. I have 
always opposed the practice, so prevalent at one time, of applying to dissect- 
ing-wounds the nitrate of silver. It has no penetrating power, like that of 
zinc : it only forms a film, and seals up the poison within. When the vesicle 
or pustule has already formed, with the usual itching and surrounding red- 
ness, it should be opened and covered with a hot flaxseed-meal poultice moist- 
ened with laudanum. This proves very soothing and favors suppuration. 
If the ulcer be very painful, the application of a solution of chloral, or pen- 
cilling its surface with iodoform, will give great relief. The hand should he 
placed on a splint, or in a sling, to secure quiet; the bowels opened by a 
mercurial cathartic, such as the compound cathartic pill; the diet—partly 
solid and partly liquid—regulated so that it shall be nutritious and at the 
same time unirritating. If red lines have begun to stretch up the arm, it MALIGNANT PUSTULE. 
271 
should be encircled by a blister above the disease, which, if timely applied, 
will stay the further progress of the inflammation. Professor E. Wallace 
speaks highly of the use of strong mercurial ointment applied over the entire 
arm in such cases. Extreme tension of the member, indicating cellular infil- 
tration, must be met by free incisions, as in phlegmonous erysipelas. If 
abscesses form in the cellular or glandular structures, they must be opened 
early, and the whole arm enveloped in a lotion of hot water containing a 
little laudanum, and covered in with oiled silk, waxed paper, or rubber tissue. 
In the severer form of the disease,—that in which the constitution is invaded, 
—the treatment does not differ from that proper in a case of typhoid fever. 
The great object will be to sustain the powers of life until the poison is elimi- 
nated, which may involve a struggle of many weeks. To this end there 
should be given tonics, as quinine and iron, opium in some form to relieve 
pain and procure sleep, stimulants, such as brandy or whiskey, and a diet in 
which milk and animal broths have a conspicuous 
place. A patient who has gone through such an 
ordeal safely, with perhaps a wasted and deformed 
finger, will be a long time in recovering strength,— 
will require a change of air, and perhaps the use of 
cod-liver oil and other alteratives. Many never re- 
gain altogether their original health, being harassed 
from time to time with boils and carbuncles, or af- 
fected, on slight changes of the weather, with sore- 
ness of the joints. 
Anatomical Tubercle.—Persons who are in the habit 
of making autopsies, or of discharging the duties 
of demonstrators in anatomical-rooms, their hands 
being constantly exposed to the fluids of the cadaver, 
are occasionally affected with a rugose or wart-like 
thickening of the skin over the knuckles, to which 
the name Verruca microgenica has been given (Fig. 
266) by Dr. Wilks. It is not necessary for the pro- 
duction of the disease that there should be any break 
or scratch in the skin, the simple irritation of its 
surface serving to produce the epithelial thickening 
and hypertrophy of the cutaneous papillae beneath. 
The disease is certainly very rarely met with in America, as I can recall but 
a single example of the kind. Its treatment consists in the application of 
dilute nitric acid. 
Fig. 266. 
Anatomical tubercle of the 
fingers.—From Bryant. 
Malignant Pustule. 
This is a disease of a most serious character, derived, it is believed, from 
the bodies of cattle which have been the subjects of a peculiar affection known 
as murrain, or splenic fever, which is of very ancient origin, and was one of 
the plagues sent by God upon the cattle of Pharaoh, as we learn by reference 
to Exodus ix. 3. Among the Greeks and Romans the disease was called an- 
thrax, sacer ignis, and carbunculus. The Arabians knew it as the Persian fire, 
and the French as charbon. when occurring in man. It affects horned cattle, 
sheep, horses, and asses. Though the disease has prevailed chiefly in France, 
Germany, Switzerland, and other countries of the continent of Europe, it is 
not unfamiliar in many parts of the United States, especially the cattle- 
raising districts of the West and Southwest, as Ohio, Illinois, Tennessee, and 
Louisiana. It is infectious, and may prevail either in an epidemic or in a 
sporadic form. When it attacks a herd of cattle the fatality is sometimes 
very great. 
Causes.—The nature of the disease for a long time was very obscure. 
Heusinger* believed it to bo malarial in its origin, operating through certain 
* Die Milzbrandkrankheiten der Thiere und des Menschen, Histor.-geog.-pathol. Untersuchungen, 
Erlangen, 1850. 272 
WOUNDS. 
nervous ganglia upon portions of the blood-vessel system, producing stasis, 
transudation, and extravasation, and forming in these foci of local disturb- 
ance some peculiar septic material, which being taken 
up by the lymph or blood, and acting as a ferment, 
is thus disseminated through the body. Virchow* 
entertains very much the same view. Pollenderf 
discovered in the blood of diseased animals certain 
vegetable organisms or rod-like bodies which in his 
judgment constitute the contagious principle. (Fig. 
267.) These bodies are considered by another writer 
—DavaineJ—as bacteridice, so extremely small that 
he calculated eight or ten millions might exist in a 
single drop of affected blood. Others—among them 
Brauell and Sanson—believe that the disease arises 
from geological conditions of soil. 
Through the labors of Pavaine, Pasteur, Koch, 
Greenfield, and others, there scarcely remains any doubt that the disease is 
due to the presence of a pathogenic organism,—the Bacillus anthracis, a 
minute rod-shaped body or filament varying in size from t° °f an 
inch. The experiments of these investigators show that this organism is 
susceptible of being cultivated in proper fluids, and, when introduced into 
the body of animals, of producing the characteristic symptoms of the disease. 
Not only so, but the celebrated Frenchman Pasteur has succeeded, through 
successive cultures, in so lessening the virulence of the poison by attenuation 
that it may be inoculated into an animal with the effect of causing a very 
mild splenic fever, from which the animal soon recovers, and which renders 
it insusceptible to subsequent infection. 
It is thought by some writers that the carcasses of affected animals buried 
in the earth impart certain materials to the ground which render it highly 
poisonous. Some regions in Switzerland are called anthrax, from the fact 
that the numerous bodies of diseased cattle remaining unburied have rendered 
the air poisonous and capable of infecting those who come within its influence. 
The effect of murrain on the animal is to render every part of the body poison- 
ous,—blood, flesh, hides, hair, hoofs, horns, and excrement. It is alleged that 
dogs, after feeding on such carcasses, die. I have witnessed, however, these 
animals eating freely of the flesh of cattle which have died of murrain, with- 
out any evil effects; and it is known that the buzzard consumes such carrion 
with like impunity. 
Anthrax in man.—The disease never arises in man except as the result of 
a poison derived from infected animals. It enters the system by inoculation 
in different ways. Tanners and butchers become affected through an abra- 
sion of the skin, or perhaps without such lesion, through the hair-follicles. 
Fournier§ speaks of persons engaged in the tapestry-factories of Montpellier 
contracting the disease from the wool (“wool-sorter’s malady”); and Kolb|| 
mentions the fact of persons becoming affected from rags in a paper-factory 
in Styria. Broca asserts that workers in leather are often the subjects of 
the poison and Dr. Stone, of Massachusetts, reported a number of cases 
which were traced to handling and preparing curled hair. 
Though it is true that animals which feed on the bodies of diseased cattle 
escape the disease, yet they become media for communicating it to others. 
Professor Gross mentions the history of three persons who were attacked by 
the disease after picking the feathers and removing the viscera of a buzzard. 
The proboscis of an insect like the fly may become the bearer of the poison. 
Fig. 267. 
Anthrax bacteria. 
* Virchow’s Archiv, 1857, xi. 132. 
f Mikroskop. und mikrochem. Untersuchungen des Milzbrandblutes, etc., Casper’s Vierteljahr- 
schrift f. ger. u. off. Medicin, 1855, viii. 103. 
J Comptes-Rendus de l’AcadOmie des Sciences, 1863, t. lvii. p. 220. 
$ Observations et Experiences sur les Charbons malins, Dijon, 1757 and 1769. 
jj Wiener Med. Presse, Nos. 7 and 8, 1870. 
Bull, de l’Acad. de Med., 1868, xxxiii. 367. MALIGNANT PUSTULE. 
273 
The harness worn by infected animals, the grain growing from a soil in which 
the bodies of diseased cattle have been buried, the soil itself, are all said to 
be capable of communicating the disease, so wonderfully do they retain the 
poison. Even alcohol seems to have no destructive power over the poisonous 
material. In the summer of 1875 I was called to a neighboring town to see 
a case of obscure disease, which proved to be malignant pustule. The patient 
was in a dying condition when i reached him. During his illness a handker- 
chief was frequently moistened from a bottle containing alcohol, and applied 
to the face of the patient. Six months after, the wife of this gentleman, 
having occasion to apply some alcohol to her face, without thinking of its 
former use, took the same bottle from a closet and used it for that purpose. 
In a short time a pimple made its appearance, which rapidly assumed all 
the characteristics of malignant pustule; and her life was sayed only by 
free incisions into the diseased part. 
Symptoms.—In a variable period, from a few hours to twelve or fourteen 
days, a person who may have been engaged in skinning, washing the wool, 
or handling the viscera or even the hides of infected animals, discovers a 
small red point on the hand, the itching or burning sensation of which is 
very similar to that which is experienced in serious dissection-wounds. This 
pimple in a short time is converted into a papule, surmounted by a reddish 
or bluish vesicle. The rupture of this vesicle occurs spontaneously, or by 
violent scratching, and leaves a dry and livid excoriation, around which an 
inflammatory swelling takes place, and at the outer margin of which sec- 
ondary vesicles, like satellites, make their appearance. From this focus of 
local poisoning other changes follow. An inflammatory thickening extends 
far beyond the limits of the inoculated point, with transudation of serum, 
rendering the parts cedematous and painful. This swelling may spread over 
the entire arm, face, or head, according to the position of the pimple. Red 
streaks or lines frequently follow the course of the absorbents, ultimately in- 
volving the glands in direct communication with these vessels. Should the 
infiltration be great, gangrene may invade the cellular tissue. In the course 
of forty-eight hours, or longer, constitutional symptoms set in. The skin 
becomes hot, though previously it may have been cool; the pulse quickens; 
pains like those of rheumatism are experieiiced in the limbs and articula- 
tions ; the strength rapidly fails, the mind wanders, the thirst increases ; the 
tongue becomes dry and covered with a scanty dark coat; the bowels are 
disturbed ; profuse cold sweats follow, with difficulty of respiration, and pros- 
tration. Should not the eschar become detached by suppuration and the 
disease take a favorable turn, death will ensue in five or six days. 
There is another form of the disease, which is supposed by Gluipon to be due 
to poison introduced into the system either through the influence of infected 
air entering by the air-passages or through eating the flesh of diseased ani- 
mals. The late observations of Wagner and others establish this as an intes- 
tinal variety of the affection. In this form the external manifestations are 
secondary: when they appear, there is usually swelling of the eyelids, face, 
or other parts of the body, the intumescence having a yellowish hue. I am 
quite certain that I once witnessed a fatal instance of this disease,—how 
contracted I am unable to say,—which might, but for this color, have been 
mistaken for erysipelas. This case was attended with great difficulty of 
breathing and a feeble action of the heart. 
In cases which are regarded as having an intestinal origin,—that is, from 
diseased flesh taken into the stomach,—the constitutional symptoms will 
often make their appearance in a few hours, or they may be delayed one or 
two days. When the invasion does take place, the patient is usually seized 
with a rigor, nausea, vomiting, abdominal pains, and great debility; but it 
may develop in a more quiet way, like certain febrile diseases, with chilli- 
ness, restlessness, a general sense of indisposition, headache, loss of appetite, 
and increasing prostration. After eight or ten days carbuncles make their 
appearance on the surface, followed by oedema and gangrene of the cellular 274 
WOUNDS. 
tissue, with labored respiration, lividity of the face, collapse, stupor, and 
death. 
Pathology.—In that form of the disease which is the result of inoculation 
through the skin, if incisions be made into the integument the cellular tissue 
will be found loaded with serum and lymph, and in those portions correspond- 
ing to the anthrax it will be in a state of necrosis, tilled with an infiltration 
of serum, lymph, and blood, extending into the surrounding cellulo-adipose 
structure. In the submucous tissue of the mouth, fauces, and larynx spots 
of ecchymosis are seen, due to the dissolved condition of the blood. The 
cervical and intra-thoracic lymphatic glands participate in the disease, being 
infiltrated with serum and blood very similarly to the subcutaneous tissue. 
Underneath the serous membrane of the chest, as well as in the cavity of 
the pleura, there are transudations of serum. The blood in the heart and 
principal trunks is dark red, and remains in a fluid condition, and when mi- 
croscopically examined is seen to contain numerous rod-shaped organisms 
(bacilli). The supposition is that these organisms, by inducing fermentation 
and the formation, through chemical agencies, of irritating materials, give 
rise to wide-spread inflammatory mischief. In the intestinal variety, the 
walls of the stomach and alimentary canal lose their shining or glistening 
appearance, being infiltrated with stained serum. In the cavity of the peri- 
toneum exists a transudation similar to that in the pleural cavity, perhaps 
containing a larger amount of changed blood. The same blood-stained fluid 
is met with in the mesentery, with infiltration of its glands. Hemorrhagic 
infarctions, along with serum, exist in the submucous tissue of the intestines, 
giving rise to a swollen, cedematous condition. Upon the mucous surfaces, 
as on the skin, are found true carbuncles, which, made up of bloody serum 
and necrosed submucous tissue, and having a grayish-yellow color, project 
in a papular form from the mucous surface of the intestine. Underneath 
the capsule of the kidneys and the mucous membrane lining the infundibu- 
lum and pelvis are serous and bloody extravasations. The same is true of 
the liver, and of the brain and its membranes. It will appear from this enu- 
meration that the dominant pathological features consist in the transudation 
of serum and blood, both in the subserous and submucous tissues as well as 
into the cavities of the one and upon the surfaces of the other. 
The microscopical appearances of the carbuncles are very significant. Dis- 
seminated through the diseased tissue, as well as in its cells, are seen crowds 
of bacteria, both round and rod-like. According to Davaine,* by the third 
day these simple organisms form a large constituent of the carbuncular mass, 
from which they penetrate into the blood-vessels and are thus widely dis- 
seminated throughout the system. These bacteria or bacilli are found also 
in all the submucous, subsei'ous, glandular, and other infiltrations belonging 
to the disease. 
Prognosis.—Much depends on an early recognition of, and a prompt atten- 
tion to, the disease. The subcutaneous form is less serious than the intestinal; 
it is more readily diagnosed, and therefore can be attacked immediately on 
its appearance. Lengyel and Koranyi lost only thirteen out of one hundred 
and forty-two cases, and Nicolaif but eleven out of two hundred and nine. 
The two patients who have been under my own care recovered. In intes- 
tinal anthrax a favorable result is very rare. 
Treatment.—The treatment resolves itself into the preventive and the 
curative. To accomplish the first, the strong arm of legislative sanction is 
required, enforced in the most rigorous manner, making imperative the in- 
spection of all animals, and disallowing the use of any part of diseased cattle, 
either for food or mercantile purposes. A further protection would be ex- 
tended by employing in tanneries and wool and hair manufactories such an 
agent as carbolic acid, which it is believed destroys the specific property of 
the poison and renders the materials employed innocuous. The tenacity 
* Ziemssen’s Cyclopaedia of the Practice of Medicine, 1875, vol. iii. p. 425. 
f Ibid., vol. iii. p. 426. FOOT AND MOUTH DISEASE. 
275 
with which the spores of this bacillus retain their virulence is shown by 
Koch, who found that even when embedded in dried putrefied blood for a 
long time their power to infect was not lost. The agents which prove most 
destructive to these organisms are solutions of bichloride of mercury, per- 
manganate of potash, bromine, and chlorine. The curative treatment con- 
sists either in excision of the carbuncle in its entirety, or in free incisions 
into and beyond its limits, followed by thorough cauterization with caustic 
potash, chloride of zinc, nitric acid, bromine, or carbolic acid. In one of 
my own cases the anthrax was isolated from the surrounding parts by two 
elliptical incisions, and then divided in a crucial manner before cauterization ; 
in the other it was excised; in each a favorable result followed. When in- 
cision is practised, the wounds should be afterwards filled with lint soaked 
in carbolic acid, and covered with a light poultice of flaxseed-meal over- 
spread with brewers’ yeast or basilicon ointment, to facilitate the separation 
of the slough. 
When the disease has passed beyond the local infection and involves the 
general system, or when it appears in the intestinal form, our hopes must 
rest on the use of such agents as are supposed to exert a salutary or specific 
influence upon septic matters, and the proper nutrition of the system. For 
the first, carbolic acid should be liberally administered internally, with quinine 
and a generous diet, together with wine or brandy. Anodynes should be 
given to alleviate pain and restlessness when present; and when there is 
much oedema and infiltration, free incisions are allowable, to limit the stran- 
gulation of tissue, enveloping the parts subsequently with lotions of warm 
chamomile-tea or carbolated water. 
Foot and Mouth Disease. 
The foot and mouth disease is met with among cattle, swine, sheep, and 
goats, and is characterized by both local and constitutional symptoms. The 
local manifestations consist of vesicles and ulcers on the mucous membrane of 
the mouth, at the top and in the cleft of the hoof; also, in the form of pustules, 
on the udder and teats of cows. The constitutional disturbance is manifested 
by well-marked febrile excitement. This disease is infectious, and capable of 
being communicated from one animal to another, both by contact and through 
the medium of the atmosphere. The virus, in whatever it may consist, is 
transportable by clothing, harness, and other materials. It is contained not 
only in the vesicles and ulcers, but also in all the secretions and excretions of 
the affected animal. 
This affection may be communicated to man either through the unboiled 
milk or by inoculation,—a discovery made by Hertwig, who, with other 
medical men, induced the disease in his own person by drinking the milk 
taken from cows laboring under the affection. It is from this cause that so 
large a number of the calves of cows affected with the disease die, the milk 
producing inflammation of the stomach and intestines. 
Symptoms op the Disease in Man.—Like many other animal poisons, it 
has a period of latency or incubation, and one of activity; the former lasts 
from three to five days, the latter is initiated by febrile disturbance, often pre- 
ceded by a rigor. There are also headache, a dry mouth, and loss of appetite. 
These symptoms are followed, after a few days, by vesicles on the lips, tongue, 
palate, and pharynx. These contain a faint-yellow and turbid fluid, and after 
rupture leave ulcerations. The inflammatory state of the mucous membrane 
excites a profuse salivation, with difficulty in deglutition. These vesicles are 
not confined to the mouth and pharynx, but ma}r appear upon the hands, 
sometimes on the feet, and with a tendency to attack the matrix of the nails. 
The occurrence of diarrhoea with abdominal pains indicates inflammatory dis- 
turbance of the stomach and intestines. The disease usually runs its course 
in ten days or two weeks, and terminates in recovery. Children suffer most. 
Treatment.—A careful scrutiny of the milk should be made, in order to 276 
WOUNDS. 
secure a pure supply ; the mouth must be frequently cleansed with a wash of 
chlorate of potash sweetened with honey, or one of salicylic acid, or of borax. 
The points of ulceration should be touched with a crayon of nitrate of silver, 
and the diarrhoea and pain corrected, when present, with chalk mixture and 
the camphorated tincture of opium. 
Glanders, or Farcy. 
Glanders and farcy are not two distinct affections, as might be supposed 
from the manner in which they are sometimes treated in surgical works. 
Farcy is a result of glanders, being only the cutaneous manifestation of the 
latter. It is a contagious and infectious disease appearing in the horse, and 
from this animal, under favoring circumstances, communicated to man. The 
disease, it is alleged, can be communicated to all domestic animals except 
horned cattle. It has prevailed extensively in France, Hungary, and other 
countries of Europe: in Hungary twenty thousand horses are said to have 
died of the disease in eight years. There is no evidence that the disease ever 
arises spontaneously among horses. It is certainly not necessary that there 
shall be any abrasion or crack in the continuity of the skin or mucous mem- 
brane for one animal to communicate it to another. The virus is of so subtle 
a nature that it is probably absorbed through the air-passages, or perhaps 
taken into the system with the food. The discharges from an infected ani- 
mal have been placed for some time -in contact with the nasal mucous mem- 
brane of a sound horse without communicating the disease. I have seen a 
glandered horse stabled for a period of weeks with others which were sound 
without any of the animals becoming affected. Lamirault,* as stated by 
Bollinger, placed one hundred and thirty-eight healthy horses among others 
which were glandered; they were fed and worked together, and j7et only 
twenty-nine of the former suffered from the disease. These examples show 
that there must be certain favoring constitutional conditions for its commu- 
nication. The disease, as it appears in animals, has a period of incubation 
which varies in duration from four or five days to several weeks, according 
as it is produced by direct inoculation or by the contiguity of an infected 
horse. As it develops, an inflammatory action localizes itself in the mucous 
membrane of the larynx and air-passages, as well as in the upper part of the 
nasal cavities, sometimes giving rise to cough and fever, with a discharge 
from the nose, consisting of a thin and watery or at other times of a yellow 
or purulent matter. The inflammatory change in the Schneiderian mem- 
brane of the nasal cavities and the resulting ulceration are followed by a 
discharge, which becomes sanious, offensive, and irritating to the parts over 
which it flows, and which accumulates in brown or yellowish crusts about the 
anterior nares. The glands under the jaw become enlarged, and in the sub- 
cutaneous tissue of the legs, head, neck, abdomen, and other portions of the 
body, indurations form, some of which remain as hard knots, while others 
break down into ulcers with ragged edges; these constitute Avhat are commonly 
known as “farcy buds" and “farcy sores.” At the same time, emaciation pro- 
gresses, the coat of the animal becomes rough and staring, the strength wastes, 
and death follows from exhaustion, pyaemia, and sometimes from pneumonia. 
The infecting material of glanders exists in all the nodules, ulcers, and dis- 
charges induced by the disease, and from the investigations and experiments 
of Schultz and Loftier it would appear to consist in the presence of a specific 
variety of bacillus. 
Glanders in man.—The earliest observations on the communicability of 
glanders to man were made by a French military surgeon, Lorin,f since whose 
time valuable papers on the subject have been contributed by numerous Ger- 
man, English, and French writers, among whom may be mentioned Travers, 
* Tiering, Canstatt’s Jahresbericht f. d. J. 1849, p. 35. 
f Observations sur la Communication du Farcin des Chevaux aux Hommes, Jour, de M6d. Chirurg. 
et Pharm., Ftivrier, 1812. GLANDERS, OR FARCY. 
277 
Elliotson, Rayer, Virchow, and Koranyi. Glanders is communicated through 
a crack or abrasion on the hands; by the nasal discharges being blown vio- 
lently from the nostrils of the horse into the eye or a sore upon the face; or 
it may follow the bite of the diseased animal. It is often communicated by the 
filthy and reckless practice of grooms or stable-men wiping their faces with 
the sponge used in washing the mouths and nostrils of horses. It may be 
contracted also by grooming, by post-mortem examinations of diseased horses, 
or even by inhaling the volatile emanations or poison whilst sleeping in a 
stall near a glandered animal. Eating the meat of a diseased horse—which 
under pressing circumstances is sometimes done—may communicate the 
affection. It is in this way, according to Bollinger, that the disease among 
lions in menageries arises. From man it can be communicated back to 
animals, and there are not wanting cases showing that one man may com- 
municate it to another. Of one hundred and six cases collected by Bollinger, 
forty-one occurred in hostlers; eleven in coachmen; fourteen in farmers, 
owners of horses ; ten in veterinary surgeons ; and twelve in horse-butchers 
and flayers; the remaining eighteen being distributed among seven other 
industries ; showing that those occupations which bring persons most in con- 
tact with horses are those which most predispose to the disease. 
Symptoms.—The disease has been divided into the acute and the chronic, 
distinctions founded on the rapidity of its course. The latest writer upon 
the subject, Dr. Bollinger,* makes an intermediate or subacute variety. By 
some it is supposed that the type of the disease is determined by the manner 
of infection; that when it is contracted by inoculation through a crack or 
abrasion in the skin, its course will be acute, and when through the inspira- 
tion of poisoned air, it will be chronic. By whatever mode this virus is 
introduced into the system, there will be a period of incubation lasting from 
three to sixteen days. 
The symptoms which usher in the acute disease are not unlike those which 
foreshadow an attack of typhoid fever or rheumatism, such as muscular 
soreness, indisposition to exertion, headache, loss of appetite, general malaise, 
with articular pains, and decided physical weakness, with or without fever. 
Should there be no external lesion, red spots make their appearance in the 
skin, not unlike the early stage of variola, some of which develop into pus- 
tules, while others remain for some time as circumscribed indurations, varying 
from the size of a buckshot to that of a pea. These may become so numerous 
as to cover the entire body. Some of these indurations open and discharge 
a sero-sanguinolent fluid, leaving deep, unhealthy ulcers, which extend through 
all the subjacent structures. When there has been a scratch or crack, through 
which the poison or virus has entered, the earliest local manifestation will 
be redness, pain, and swelling, commencing at the point of inoculation and 
extending up the arm, if it be this part which has been injured, and, like 
erysipelas, having a dusky-red color. Radiating streaks in the line of the 
lymphatics are also frequently present. The crack or abrasion breaks 
down into an ulcer, with indurated and irregular edges, and discharging 
unhealthy and irritating pus. While these changes are taking place in the 
skin and subcutaneous structures, the mucous membrane of the nose becomes 
involved, although, it is said, less frequently in men than in horses. At first 
the discharge from the cavity is a thin, tenacious mucus, exuding from the 
general surface, as the result of a diffuse inflammation. In a short time the 
secretion becomes more purulent or catarrhal, and finally bloody, with an offen- 
sive odor. As in the skin, so also in the submucous tissue, indurations form, 
which follow a course similar to the first, bursting or ulcerating, and forming 
deep-seated erosions, which may, when situated beneath the Schneiderian 
membrane, finally attack the cartilages of the nose. This nasal condition is 
attended with a diffused or erysipelatous redness and pain of the entire organ. 
These inflammatory changes are not confined to the nasal mucous membrane. 
* Ziemssen’s Cyclopaedia of the Practice of Medicine, vol. iii. 278 
WOUNDS. 
They seem to spread from the nose by structural contiguity to the palate, 
pharynx, larynx, trachea, and bronchia, producing hoarseness, alteration 
of voice, cough, and expectoration of a character corresponding to that 
of the discharge from the nose. This inflammation appears also in the 
fauces and mouth, and travels along the ductus ad nasum to the conjunctiva, 
extending likewise to the intestinal mucous membrane and exciting diarrhoea. 
The tongue is coated with a dark crust, the thirst becomes urgent, and the 
circulation is accelerated, though weak, with a temperature of six or seven 
degrees above the normal standard. The submaxillary and sublingual glands 
also enlarge and suppurate, and as the disease advances the weakness becomes 
greater, emaciation progresses, the mind wanders, and the patient finally 
sinks, in four or five weeks, into a state of insensibility, from which he never 
recovers. It is doubtful if any cases of acute glanders terminate otherwise 
than fatall}^. 
In the chronic variety of glanders the progress of the disease is more tardy, 
though the lesions are essentially the same as in the acute. There is also in 
the former a greater recuperative power displayed, many of the ulcers heal- 
ing and leaving a layer of cicatricial tissue, which, when it is situated in the 
mucous canals, may, from its tendency to contraction, produce such a narrow- 
ing and deformity of the nasal fossae as will interfere very materially with the 
proper execution of their functions. The duration of chronic glanders is about 
four months; and it is this variety which is the least fatal. As many as fifty 
per cent, of the cases, it is said, recover more or less perfectly. 
Pathology.—The chief pathological features are the widely-disseminated 
abscesses through the cellular tissue, also the presence of papules, pustules, 
and nodules in the submucous and subserous structures, together with en- 
largement and suppuration of the salivary glands, doughy thickening about 
and purulent etfusion within the articulations. Few organs escape its ravages. 
In the spleen, liver, lungs, brain, and testes, are found inflammatory infiltra- 
tions and abscesses. The indurations, when examined microscopically, exhibit 
little else than an enormous aggregation of dead leucocytes or pus-cells. 
Treatment.—Unfortunately, there are no remedies which exercise any 
specific influence over the disease when it is once established. The great in- 
dication is to sustain life in the fearful struggle, with the faint hope that the 
morbid products may be ultimately eliminated. To this end may be admin- 
istered quinine, alcohol, milk, and nutritious broths. The internal use of car- 
bolic acid, from its antiseptic properties, is worthy of further trial. When 
a local sore has been poisoned by the virus, the part should be excised, or 
destroyed by powerful caustics, like the caustic potash or bromine, and all 
indurations, whether suppurating or not, should be freely incised and treated 
with carbolic acid and olive oil (one part of the acid to nine parts of oil). 
Equinia mitis.—Persons who handle the feet of horses suffering from what 
is called grease—a viscid, offensive discharge from the fissure between the 
quarters of the heel—have frequently an eruption of superficial pustules 
from the irritating property of the discharge. It is a common affection 
among hostlers and veterinary surgeons, and proves entirely harmless. The 
treatment is very simple, and consists in washing the parts clean and touch- 
ing the diseased points with a weak solution of the sulphate of copper (four 
grains to the fluidounce of water). 
Hydrophobia. 
This dreadful malady, the most terrible disease that can befall a human 
being, was not unknown to the ancient physicians; and there are frequent 
allusions to it in the classical writings of the Greeks and Romans. 
Though it is alleged that the disease may arise spontaneously in animals 
of the canine species, yet the statement rests on a very improbable foundation. 
Among the supposed causes may be enumerated the following: 
1. Extreme heat.—The disease, however, is not peculiar to any climate. It HYDROPHOBIA. 
279 
is met with at the equator and in the frozen regions of the North. In 1863 
it prevailed to such an extent in Northern Greenland* as to destroy all the 
dogs in certain localities. 
2. Certain seasons of the year.—There is no evidence that the disease is in 
any way influenced by particular periods of the year. Of the three hundred 
and two cases given by Bouley, eighty-nine were in the spring, seventy-four 
in the summer, sixty-four in the autumn, and seventy-five during the winter 
months. 
3. Starvation and thirst.—There are no facts to render it probable that 
the want either of food or of water can originate the disease. Dogs have 
frequently died from starvation on shipboard, where supplies were short or 
exhausted, yet without manifesting any signs of hydrophobia. Dupuytren, 
Magendie, Radi, and others have starved dogs to determine this point, but 
in no instance has rabies been induced; and Pillwax noticed that when the 
disease was quite prevalent in Vienna the dogs which suffered most were 
those belonging to the wealthy, and therefore likely to be well supplied with 
food. 
4. Ungratified sexual passion.—The fact that castrated dogs and spayed 
bitches enjoy no immunity from the disease is a sufficient refutation of the 
theory of this being a cause. 
5. Anger or rage.—It has been often asserted that the bite of an irritated 
or enraged dog is sufficient to produce rabies; yet every one has witnessed 
instances of such bites without any evil effects whatever, save an indolent 
wound, the inactivity of which is to be referred more to the contused charac- 
ter of the injury than to any other cause. 
Janewayf alleges that the mephitic virus of the skunk will give rise to 
hydrophobia. I have known many conflicts between the dog and this animal, 
the only effect being to render the former for a time offensive from the pres- 
ence of an unpleasant odor. 
It is the opinion of the very best authorities, such as Youatt, Schraeder, 
Virchow, and others, that the disease can arise, either in the dog or in man, 
only by the introduction of a specific poison or virus through an abrasion of 
structure, and that a poison also which is not communicable, like malignant 
pustule, through intermediate agencies, such as flies or fleas, or through the 
consumption of flesh or milk. The disease in its origin is not peculiar to dogs, 
but is frequently communicated to them from the fox. It is stated by Oertl, 
as recorded by Bollinger, that hydrophobia prevailed as an epizootic among 
the foxes of Carinthia from 1866 to 1872, and that many dogs, as well as 
other animals, were bitten by them. 
The peculiar infecting material or virus is contained in the salivary and 
other secretions of the mouth ; possibly also in the blood. It is necessary 
that there shall be an abrasion for its reception into the system. Upon the 
unbroken surface of either skin or mucous membrane the virus is harmless. 
HertwigJ gave to animals the milk and flesh of others suffering from or dying 
of hydrophobia, without any positive results; the saliva and blood were also 
administered internally, with no injurious effect. The same writer placed 
sound animals in the stalls and kennels of rabid ones, tied them with the 
same halters, allowed them to lie on the same bedding, and in no instance 
with the effect of inducing the disease. Of the number of animals bitten, a 
very small proportion go mad. Of one hundred and thirty-seven bitten from 
1823 to 1827, and kept under observation by the Veterinary School at Berlin, 
only six died from hydrophobia. In Wiirtemberg, from 1864 to 1867, out of 
nine hundred and forty-three animals thus injured, only twenty-eight were 
attacked with rabies.§ Youatt, however, one of the very best authorities, 
believes that two-thirds of bitten animals go mad; and Trousseau places the 
* Leisering, Jahresbericht iiber Thierheilkunde, 1866, p. 448. 
f New York Medical Record, March 13, 1875. 
j Die Krankbeiten der Hunde und deren Heilung, Berlin, 1853. 
£ Ziemssen’s Cyclopaedia of the Practice of Medicine, vol. iii. p. 442. 280 
WOUNDS. 
number at about one-half. This infrequency is perhaps not due to any con- 
stitutional indisposition to or want of susceptibility on the part of the animal 
receiving the poison, but to causes calculated to wipe off or cleanse the virus 
from the teeth before the wound is inflicted. 
Symptoms.—Among animals there is a want of uniformity in the phe- 
nomena of the disease. There is a stage of incubation, which, though subject 
to great variations as to time, is usually from four to six weeks ; and thei’e is 
reason to believe that even during this period the bite of the animal may 
produce the disease. Even after the invasion of hydrophobia, the order and 
manifestation of the symptoms are such as to warrant the division, made by 
Youatt, into the furious or violent and the sullen variety; though others, ami 
among them Yirchow, think that these are only different stages of the dis- 
ease. That the division is just I am convinced, having witnessed typical 
cases of each. 
The furious form.—In this variety there is a premonitory or inaugurating 
stage, which may last from twenty-four hours to three or four days. During 
this time the behavior of the animal is changed. The dog appears unhappy, 
discontented, restless; frequently changes his position or place; avoids ob- 
servation, and does not court caresses; and is easily irritated and provoked 
to snap or bite from causes which ordinarily would not disturb his temper. 
The conjunctiva becomes injected, which, with the corrugated brow, imparts 
a sullen appearance to the animal, lie is given to licking objects or sub- 
stances at hand, such as the carpet, floor, or cold stones; the appetite is 
lost or perverted, so that substances are devoured which usually would be 
avoided, as old rags, straw, or his own faeces. Emaciation takes place rapidly, 
and the animal becomes subject to hallucinations, jumping or snapping at 
imaginary objects. There may be sexual excitement. The gait becomes un- 
steady and staggering, and substances are dropped from the mouth, or are 
swallowed with difficulty. The disease, however, does not always approach 
after the manner described. It often breaks forth, without premonition, into 
the violent state. The dog escapes from his kennel, and roams aimlessly 
over the country, traversing fabulous distances in a short time; he snaps or 
bites at anything in his way, gnaws his own feet or tail, and is equally indif- 
ferent to strangers and to friends. The voice is altered, becoming hoarse and 
husky; the eyes glare with fury. Water, contrary to the popular notion, is 
not avoided, but is drunk with avidity, except in cases where there is mus- 
cular spasm of the pharyngeal muscles. Sometimes the saliva flows from the 
mouth mixed with foam; at other times there is a total absence of the secre- 
tion. This stage is characterized by an intermission, during which the animal 
may return to his home, and his demeanor become so changed as to remove 
all suspicion of disease. In a short time, however, another paroxysm sets in, 
and in three or four days from the attack the final stage—that of paralysis— 
is reached, during which the emaciation greatly increases, the flanks fall in, 
the hair becomes rough and staring, the eyes are sunken and shining, the 
lower jaw falls, and the tongue protrudes, all of which, together with the 
air of extreme dejection, gives a horrid appearance to the animal. The 
paralysis affects most the hinder extremities: he staggers, falls, rises on 
his fore legs when unable to stand on all four, and will snap and bite in this 
position. The breathing, which before was hurried, now becomes labored, 
and he passes into a state of coma, or dies in a violent convulsion after the 
lapse of from five to seven days from the commencement of the attack. 
The sullen variety.—In this form of rabies the animal is quiet, shy, loses 
appetite, is not very irritable, shows no great disposition either to bite or to 
wander away, and loses flesh rapidly. Deglutition becomes difficult; the 
food is dropped from the mouth in the attempt to swallow; the lower jaw 
falls ; there is frothing at the mouth, with dribbling of mucus and saliva; the 
voice is lost, and paralysis, not only of the jaw, but also of the hinder limbs, 
occurs; the body is seized with tremors, and in two or three days the animal 
dies. It is said that in this variety of the disease the dog shows no disposi- HYDROPHOBIA. 
281 
tion to lick ; but in one of my own dogs which died of rabies, and from whose 
case this description has been taken, it was a prominent symptom in the 
early part of the attack. 
Hydrophobia in man.—That the disease shall arise in man it is necessary 
that the virus be introduced through a scratch or wound, usually made by 
the tooth of a rabid animal, such as a dog, fox, cat, or wolf There are no 
facts to warrant the belief that the disease has ever been communicated from 
man to man; though there is no doubt that the saliva is infectious in its 
nature and is capable of producing the disease in animals. 
Period of incubation.—The period which elapses between the reception of 
the virus and the explosion of the disease is subject to great variation. The 
shortest period recorded is three days; and generally it does not extend 
beyond three or four weeks. There are cases in which the poison has re- 
mained latent for over two years ; and in a case which occurred in Lancaster 
County, Pennsylvania, under the care of the late Dr. Wallace, there is every 
reason for believing that the stage of incubation lasted seventeen years. 
This period is shorter in the young than in the old. Whatever may be the 
duration of this stage, there are no sensations which furnish any evidence of 
the presence of so deadly a poison. The scar or cicatrix presents nothing 
peculiar; the sensations of anxiety, trepidation, and restlessness, alleged 
by some to follow when the seat of the injury is touched, are altogether 
mythical; though at the time when the disease is about to develop the scar 
may become inflamed and swollen, accompanied with a burning sensation 
and radiating pains. 
It is a very difficult task to determine what proportion of persons bitten 
suffer from hydrophobia, simply because many dogs that inflict wounds are 
pronounced mad when such is not the case. There are two circumstances 
which diminish the probability of infection after the bite of a rabid animal. 
First, when the wound has been inflicted on the leg or arm, the tooth is 
likely to be despoiled of its deadly virus in passing through the clothing. 
It is estimated than not more than twenty per cent, of those bitten on the arm 
and twenty-eight per cent, of those wounded on the leg die of hydrophobia. 
Second, where the animal has bitten a number of persons in quick succession, 
the teeth having been frequently wiped, the individual last injured is least 
liable to suffer. 
The greater the vascularity of the part, the greater is the risk when in- 
jured ; and this explains why the disease is so much more frequent after bites 
on the face than after wounds on the hand, the proportion being ninety per 
cent, in the first and sixty-three per cent, in the last. 
Bollinger informs us that the mortality of persons injured by dogs sup- 
posed or known to be mad does not exceed eight per cent.; that is, out of 
thirteen hundred and sixty-two individuals bitten, one hundred and five 
die of hydrophobia. The disease would seem to be much more common in 
France than in England, as over three hundred and nineteen persons died 
of hydrophobia, between the years 1850 and 1862, in the former country, 
while in the latter the deaths from this cause during the same period did not 
exceed ten or twelve a year. 
As to its communicability from man to man, I am not aware that there 
is a single well-attested instance: yet there is no reason why such a result 
should not follow the bite of a rabid individual. If the saliva of a person so 
affected can be successfully inoculated into the body of the dog,—as proven 
by Magendie and Breschet,—why not into the system of human beings ? 
Males are more frequently the subjects of the disease than females, and 
children between ten and fifteen years of age suffer oftener than adults or old 
persons, from the fact that they are more exposed. 
Premonitory Symptoms.—The symptoms which usher in the disease are 
very much akin to those which introduce an ordinary catarrhal or febrile 
attack. These are, loss of appetite, chilliness, headache, muscular soreness, 
discomfort about the throat, with great depression of spirits, which finally 282 
WOUNDS. 
culminates in peevishness, irritability, restlessness, and a gloomy apprehen- 
sion of impending evil. The thoughts turn at once to the bite, and to this 
cause does the doomed patient refer all his distress. The sleep is broken with 
frightful starts; there will most likely be difficulty both in deglutition and in 
articulation ; great thirst will be present, yet with an uncontrollable aversion 
to liquids. It is from this last symptom that the disease has taken its name, 
hydrophobia; yet the fear of water is present only when the deglutition is 
paralyzed. The eyes become injected, and there is a sense of pain or oppres- 
sion at the prsecordia, accompanied with sighing or sobbing. The sexual 
organs are frequently in a condition of unusual excitation, the patient being 
annoyed by priapism; and the face, arms, and legs are disturbed by involun- 
tary movements. This stage may last from a few hours to three days. In 
exceptional instances it has been prolonged to two weeks. 
The furious stage.—This stage is characterized by great physical and mental 
excitement. The fear of water becomes a very prominent symptom, and any 
attempts to drink provoke the most terrible convulsions: indeed, so great 
is the exaltation of both the common and the special sensibility of the body 
that a current of air, a sudden movement on the part of an attendant, the 
reflection from some lustrous object, or a loud voice, is quite sufficient to pro- 
duce the most violent spasm of the muscles of the throat, chest, and even of 
the entire body. In the last case which I witnessed of the disease, there was 
an almost constant tendency in the head to be drawn backward. In con- 
sequence of the convulsive contractions of the muscles of the pharynx and 
chest, there is a sense of suffocation, and the breathing is carried on in gasps. 
The distress is intensified by the urgent thirst which is present, any attempts 
to gratify which fill the patient with fear, and even terror at the very sight 
of the vessel containing water. The voice is changed, becoming hoarse and 
husky, from loss of power in the intrinsic muscular apparatus of the larynx; 
pain at the epigastrium is complained of; the eyes are injected, being either 
staring or unsteady, and the pupils are dilated; the mouth is filled with 
froth, which becomes so viscid aud tenacious that it is expelled with great 
difficulty, the patient hawking and forcing it out by short and violent expira- 
tions until it is scattered over his clothing and every article about his person. 
The face has not only an air of deep distress, but also an expression of mingled 
anxiety and horror, which, together with its purple and livid color during a 
paroxysm, presents a spectacle the most dreadful that it is possible to behold. 
During all this time the mind is generally clear, and the unfortunate sufferer, 
in the intervals between the convulsive attacks, talks incessantly, frequently 
cautioning his friends to avoid being injured by him, praying that they will 
not desert him in his distress, or begging that an end be put to his life in 
order that he may escape from the misery which has become intolerable. 
This stage usually continues from one to three days. 
The stage of paralysis.—This stage is not always recognizable. As the 
case advances, the pulse becomes frequent and weak, and the paroxysms occur 
at shorter intervals, until at last, after one of unusual severity, the patient 
dies, apparently in a state of asphyxia or collapse. The end may approach 
in a more gradual and quiet manner; the convulsions grow less violent, and 
finally cease altogether, or are substituted by general muscular twitchings; 
the respiration becomes easy, though frequent; the power to swallow may 
return; the eyes are more fixed, or assume the condition of strabismus; the 
pupils are contracted; the lower jaw drops; the saliva dribbles from the 
mouth, a perspiration breaks out over the body, and the patient passes away 
from sheer exhaustion. 
The disease rarely extends beyond two or three days. J. L. Smith, of New 
York, in an analysis of one hundred and twenty cases, found that sixty-five 
died in from one to two days. Thamhayn, in two hundred and two cases, 
says that fifty-six died in forty-two hours; seventy-three in forty-eight 
hours; thirty-eight from the second to the third day; nineteen between the 
third and fourth days; seven in five days; five in six days; and four in seven HYDROPHOBIA. 
283 
days * Bollinger states that of the whole number dying of hydrophobia, 
nine per cent, die on the first day, thirty-six per cent, on the second day, 
and fourteen per cent, on the third day; that is, one-half within three days. 
Pathology.—Little light has been thrown upon the subject by post-mortem 
examinations. The blood-vessels of the brain and spinal marrow, together 
with their membranes, are found surcharged with blood, with serous effusions 
depending most probably upon mechanical causes. The medulla oblongata 
seems to constitute the focus of vascular disturbance, according to Gowers, 
many of its vessels being found ruptured or filled with coagula, with large 
numbers of white corpuscles in the spaces about the vessels. The same hy- 
persemia exists in certain nerves and ganglia, as those belonging to the cervi- 
cal sympathetic and pneumogastric. The mucous membrane of the fauces and 
pharynx, and their glands, are found deeply injected, and the latter enlarged. 
This vascular injection may extend to the stomach and intestines. The lungs 
are engorged with blood and oedematous, with hemorrhagic infarctions. The 
vesicles described by Marrochetti, of Moscow, and by Xanthos, said to be 
found under the tongue on each side of the framum of animals which have 
been bitten by others, and which are said to contain the poison, have no 
existence. 
Diagnosis.—There are some points of resemblance between hydrophobia, 
tetanus, and hysteria; but it is not probable that either of the last two will 
be confounded with this terrible malady. 
Hydrophobia may be distinguished from tetanus by the following symp- 
toms. In tetanus there is no horror of fluids, nor excessive sensibility to 
currents of air. In tetanus the muscular rigidity is continuous; in hydro- 
phobia, while muscular rigidity is present at times, there are intervals of 
complete relaxation, and finally paralysis comes on, the jaw falling, and the 
saliva dribbling from the mouth: moreover, in connection with these symp- 
toms there will be the history of an antecedent bite. Again, the wild, injected 
eye, the furious excitement, and the horrible expression of the face in hydro- 
phobia, altogether unlike the sardonic grin in tetanus, leave little room for 
doubt as to the true character of the disease. 
From hysteria it is distinguished by the fact that in hydrophobia the con- 
vulsions arise whether the patient is asleep or awake, and affect the muscles 
both of respiration and of deglutition. In hydrophobia, also, the reflex sen- 
sibility is dominant, whereas in hysterical and other convulsive diseases the 
reverse is true. 
Certain cases of acute mania bear a striking resemblance to rabies; but 
in the former there is no difficulty in deglutition. 
Treatment.—The condition of a person bitten by a rabid dog, while it is 
one of great peril, is not absolutely hopeless. There is ground for encourage- 
ment should the bite have been inflicted through the clothing, as we have 
learned that in such cases only from twenty to twenty-eight per cent, go mad; 
and, again, the success which has attended the early treatment by cauterization 
furnishes an encouraging prospect of escape from the terrors of the disease. 
Bouley, as quoted by Bollinger, says that of two hundred human beings 
bitten by rabid animals one hundred and thirty-four were cauterized, of which 
number ninety-two remained well, or sixty-nine per cent.; whereas in sixty- 
six cases not cauterized the death-rate reached eighty-four per cent.f On 
the reception of a bite by a rabid animal, the wound should be immediately 
sucked, provided there is no abrasion of the mucous membrane of the lips; 
or, when feasible, well drawn with a cupping-glass. It should next be washed 
with carbolic acid and water (one part of the acid to nine parts of the water), 
and then thoroughly cauterized with caustic potash. Youatt has unbounded 
confidence in cauterization with nitrate of silver, having tested its efficacy 
'* Bryant’s Surgery, p. 385. 
t Bollinger, however, after estimating the results of cauterization, concludes that only thirty-three 
per cent, of those thus treated fall victims to the disease, whilst eighty-three per cent, of those on 
whom the operation is not practised die. 284 
WOUNDS. 
frequently in his own person ; but certainly the greater potency of caustic 
potash would give additional security. It is also advised, after the slough 
drops out, to keep up suppuration for several weeks by savine or resin oint- 
ment, in order to insure the destruction of the virus. 
Among the prophylactic means are those sanitary measures which can only 
be enforced by legislative authority, such as the taxation of dogs, the destruc- 
tion of all allowed to run at large, and the compulsory use of a muzzle. In 
Berlin, during the nine years in which dogs were required to be muzzled, not 
a case of hydrophobia occurred. When it is considered that there are at 
least twelve millions of dogs in Europe, the only wonder is that the disease 
is so infrequent. 
Where all precautions have proved unavailing, or where none have been 
employed, and the disease is developed, our duty consists in alleviating as 
much as possible the sufferings of the patient; for beyond that we are utterly 
powerless to effect any good. I need not describe the various remedies which 
have from time to time been employed, such as belladonna, atropia, curare, 
mercury, large bleedings, quinine, transfusion, carbolic acid, and many others. 
Nor does opening the trachea, as advised by Physick, promise anything better. 
Our only resort must be to full doses of morphia hypodermically adminis- 
tered, the inhalation of ether or chloroform, and injections into the rectum of 
milk and beef-tea with brandy. A case of rabies in a girl twenty-four years 
of age is said to have been treated successfully by Offenberg, at Berlin,* by 
seven hypodermic injections of woorara, the amount used being three grains 
during a period of five hours and a half. 
It is not improbable that through the labors of Pasteur we shall at no 
very distant day be enabled to prevent this terrible disease, to a great extent, 
by the inoculation of dogs with a virus attenuated by successive cultures 
to a degree sufficient to insure immunity, or possibly, by the introduction 
of the attenuated virus into the systems of persons bitten by rabid animals, 
to modify and render harmless the action of the poison. 
Poisons derived from Arachnidans and Reptiles.—Spiders (Aranece) are said 
to produce poisonous etfects by their bites. On this subject there is a 
difference of opinion. Any one who tries the experiment will 
find that it is difficult to provoke these creatures to assume 
the defensive. Professor Leidy has informed me that their 
bites are quite harmless. Still, it is difficult to conceive that 
where a poison-apparatus exists the use of it shall be free from 
all irritation. The poison-glands of the spider are placed in 
the abdomen, communicating with the mandibles, at the ex- 
tremity of which are sharp hooks (Fig. 268), which serve the 
double purpose of making the puncture and conveying the 
virus into the wound. The effects of the spider-wounds, as 
I have seen them, have never been very marked, consisting 
simply of a red, indurated point, with a moderate degree of 
itching. Dr. G. W. Semplef reports several cases followed 
by the most alarming local and general symptoms. 
Some varieties are more poisonous than others. In several 
of the Southern States there is a small black spider which is very much 
dreaded by the negroes, and I have been informed by a number of physicians 
living in the South that its bite is generally followed by well-marked signs of 
poisoning. In addition to the pungent pain at the seat of injury, there is 
nausea, with severe griping pains in the abdomen, followed by a sense of 
sinking, prsecordial distress, difficult breathing, numbness, and in some cases 
paralysis of the arms. If the disease be not checked, the pulse becomes 
frequent and feeble, the surface is cold, and there is great anxiety and 
extreme prostration. 
Fig. 268. 
Poison-apparatus 
of the spider: a, poi- 
son-gland ; b, man- 
dible ; c, hook. 
* New York Medical Record, October 21, 1876. 
f Virginia Medical Monthly, December, 1875. WOUNDS BY ARACHNIDANS AND REPTILES. 
285 
The scorpion is very common in hot climates. It is found in this country 
chiefly in certain parts of Texas. At the extremity of the prolonged tail is 
a curved hook or sting, connected with which are two poison-glands (Fig. 
269). The poison is destructive to many animals, such as birds and frogs, 
death following the sting in a few seconds, according to Heinzel. In the 
experiments of Guyot,* even animals as large as the dog and the guinea-pig 
perished in fifteen minutes after the introduction of the poison. It is said 
Fig. 269. 
Scorpion, showing curved hook at the caudal extremity. 
that the virus acts directly upon the red blood-corpuscles, rendering them 
coherent, and thus plugging the capillaries. 
In man the wound of the scorpion is followed by redness, swelling, and 
pain, all of which generally after a few hours subside. In hot Eastern 
climates the venom is more active, and its introduction into the body is 
often followed by death. The scriptural allusions to the scorpion correspond 
with the venomous character of the animal as found at the present day in 
Syria. The symptoms which follow its sting are great feebleness of the 
heart, a purple hue of the face and lips, vomiting, priapism, and numbness or 
loss of power in the tongue, with inability to control the faecal contents of 
the bowels on account of paralysis of the sphincter. Violent convulsions 
sometimes precede death. 
The tarantula.—The bite of this arachnide, a native of Italy and Syria, is 
much less dangerous than that of the scorpion. The current notion that it 
is followed by a species of intoxication, resulting in an uncontrollable desire 
for dancing, no doubt grew out of the custom among the laboring classes of 
Italy, of exciting a free sweat by protracted dancing,f to cure intermittents, 
common in the harvest season, when such bites are most frequent. 
Centipedes.—These belong to the order Myriapoda. The centipede is found 
in portions of Southern Europe, and in this country is met with in Texas 
and other Southern localities. The animal is of a cylindrical form, with 
numerous articulations. The anterior feet terminate, each, in a hook or claw, 
which connects with a poison-gland. The animal is capable of inflicting a 
wound and introducing a poison which is followed by considerable irritation 
and may result in death. The symptoms are a severe burning pain, swelling, 
and redness, with a central dark discoloration, in the injured part, followed 
by inflammation of the lymphatics and lymphatic glands in closest relation 
to the damaged tissues, and the appearance of dark purple spots. The con- 
stitutional symptoms are pains through the extremities, nausea, vomiting, 
dizziness, headache, and feeble and irregular pulse, occasionally followed by 
death. 
Treatment.—The treatment of all these wounds—whether the irritant 
be a specific poison or a salivary secretion, or whatever the vulnerating 
* Jour, de Med. vet. de Lyon, 1852, t. viii. p. 191. 
f Holmes’s System of Surgery, vol. i. p. 676. 286 
WOUNDS. 
instrument—is very much the same. No single remedy appears to act more 
efficiently than aqua ammonise. In one of the cases reported by Dr. Semple, 
in which a fatal collapse was threatened, the above remedy was thrown by 
means of a hypodermic syringe into the blood through the walls of a vein, 
with immediate relief. Should there be much general disturbance of the sys- 
tem, brandy and ammonia internally are the best remedies. 
In the case of the scorpion-wound, Dalange, as stated by 
Bollinger,* advises the immediate application of a ligature 
above the point stung, and over it several free incisions, the 
bleeding from which is to be encouraged by suction with the 
mouth. When the bite is that of the scolopendra, or cen- 
tipede, Sebastiany, as quoted the same author, advises 
the internal administration of carbolic acid and chloral, with 
external astringents. 
The centipede is sometimes brought to Eastern cities con- 
cealed in hogsheads of sugar. I have seen a stevedore suffer 
for weeks from violent local and constitutional symptoms in 
consequence of a sting received on the hand while handling 
one of these hogsheads on the wharf. The fingers remained 
purple, and the hand and arm weak, for a long time. His 
general health was seriously impaired by the injury; and 
when I last saw him he looked like a man who had passed 
through a tedious and wasting spell of sickness. 
Wounds by Venomous Snakes.—Another class of dan- 
gerous wounds are those produced by poisonous serpents. 
Snakes belong to the class of reptiles. In the United States, 
while there are many varieties of snakes, the number of 
venomous ones is quite limited, consisting chiefly of the crotalus, or rattle- 
snake, the elaps, and the trigonocephalus, or copperhead. In India the cobra 
is the most poisonous snake, and in England and on the Continent, the viper. 
The poison-apparatus consists of a 
pair of recurved fangs, either tubular 
or grooved on the concave surface 
(Fig. 270) : these, in the passive state 
of the reptile, are folded horizontally 
against the upper jaw and concealed 
in duplicatures of the gum. The 
poison is secreted by two glands situ- 
ated behind the eye, the excretory 
ducts of which lead to the base of 
the fangs and are encompassed with 
a strong compressor muscle, there 
being no intermediate receptacle or 
sac for the poison. When the rattle- 
snake is about to bite, the body is 
thrown into a coil, the head becomes 
erect and is thrown back, and, as the 
jaws open, the fangs are carried forward by appropriate muscles (Fig. 271), 
and, when the reptile strikes, are driven into the flesh, the jaws at the same 
time closing, by which a few drops of the venom are squeezed along the fangs 
into the deadly puncture. In disengaging the poison-fangs from the flesh, the 
wound, first made as a puncture, becomes somewhat ragged or lacerated. 
The poison of the rattlesnake has been very carefully studied by Dr. S. Weir 
Mitchell, of this city, whose elaborate and exhaustive monograph upon the 
subjectf deserves to rank with the great work of Fayrer on the Thanatophidia 
of India. The virus is a thin, albuminous, almost transparent fluid, sometimes 
Fig. 270. 
An enlarged view of 
the poison-fang of the 
rattlesnake ipp, cavity 
of the tooth; w, the 
groove for conducting 
the poison. 
Fig. 271 
Head of the rattlesnake: a, poison-gland and duct; 
e, the muscle compressing the poison-gland. 
* Ziemssen’s Cyclopaedia of the Practice of Medicine, vol. iii. p. 539. 
f Researches on the Venom of the Rattlesnake, Smithsonian Contributions, 1861. WOUNDS BY VENOMOUS SNAKES. 
287 
having a shade of green ; it has neither smell nor taste ; its reaction is acid; it 
has a specific gravity of 1044, coagulates at a temperature of 140°, and becomes 
solid at 160°. The amount of venom usually contained in the gland or ducts 
does not exceed a few drops. Whether the animal is torpid or not, the viru- 
lence of the poison is never lost; though it is most intense during the warm 
season or when the reptile is most active. Its power to retain its deadly prop- 
erty is well shown by the fact that its activity was not in the least impaired 
by acids or alkalies, chlorine, bromine, boiling, freezing, or drying. The 
poison of the cobra, according to Shortt,* is rendered inactive when mixed 
with potash. Under the microscope numerous cells are seen floating in 
a liquid. Its chemical constitution consists of an albuminous body, crotaline, 
not coagulable by heat at 212°; an albuminoid compound, coagulable at the 
above temperature; coloring matter, with an undetermined substance, both 
of which are soluble in alcohol; and a trace of fatty matter, together with 
salts, chlorides, and phosphates. 
Venomous snakes of the same species cannot poison one another, but those 
which are not venomous enjoy no immunity. Warm-blooded animals succumb 
most quickly to the poison. The bite of the copperhead is much less dangerous 
than that of the rattlesnake : indeed, I have never known an instance of the 
former to prove fatal. In India, according to Fayrer, with a population of 
one hundred and twenty millions, eleven thousand four hundred and sixteen 
deaths from snake-bite alone occurred in a single year. The cobra de capello 
and the rock snake are the reptiles which produce this mortality. 
In Africa, snakes of enormous size and of exceedingly venomous character 
are described, which are said to be sufiiciently bold to chase their victims 
with a speed which defies escape. In the little company of Susi and Chuma, 
which was bearing the remains of the lamented Livingstone to Bagamoio, 
was a little girl named Losi. While passing through a rocky place, this 
child, carrying a water-pot on her head, was attacked by a snake called by 
the natives a mampa. The reptile dashed across the path and struck her 
upon the thigh. Though every effort was made in her behalf, in less than 
ten minutes the child expired. A few days after, a similar scene was en- 
acted at the same spot, and most probably by the same snake; the victim 
being in this instance a stout adult male native. 
Symptoms.—The symptoms following snake-bite are both constitutional 
and local. 
The constitutional effects are those of a tremendous shock, faintings, 
terror, nausea, trembling, and extreme depression. These are followed by 
numbness, stupor, and incontinence of urine and fseces, with a clammy per- 
spiration. The action of the heart becomes weak, the respiration slow and 
oppressed, the skin icterode ; and the patient may die within half an hour, 
or, where the fang has penetrated a vein, in a few minutes. In a case which 
occurred in the practice of Ur. Shapleigh, of this city, death followed in three- 
quarters of an hour. 
The local symptoms consist of agonizing pain, a rapid and extensive ecchy- 
mosis or hemorrhage, and swelling of the entire limb, which becomes covered 
with blebs, is mottled, cold, livid, and rapidly passes into a state of gangrene. 
When the case is slow in its progress, the inflammation may assume the con- 
dition of phlegmonous erysipelas, the serous transudation rendering the part 
oedematous, or, when the transudation partakes of a fibrinous character, hard 
and dusky-red in color. The absorbents of the part also become inflamed, 
and the glands in which they terminate are enlarged. 
Post-mortem appearances.—The examination of a case of fatal snake-bite 
reveals extensive engorgement of the right heart, of the brain and its 
membranes, and of the kidneys, lungs, and liver, the blood being dark and 
imperfectly coagulated. There is also present ecchymosis of the thoracic 
and abdominal viscera. The remarkable transudation of the blood witnessed 
* Experiments with the Poison of the Cobra de Capello, Lancet, 1868, pp. 556, 615. 288 
by Mitchell, due doubtless to an altered condition in the physiological char- 
acter of the vascular walls, may throw some light upon a somewhat similar 
process in inflammation. The effect of the venom appears to destroy at once 
the vitality of the blood, rendering it unfit for the supply of the nerve-centres, 
and thus depriving the heart of that force which is necessary for the work 
of the circulation. 
Treatment.—The indications in the treatment of snake-bite are, first, to 
prevent the entrance of the venom into the circulation ; second, to effect its 
extraction; third, when these objects have not been attained, to support the 
system until the elimination of the poison takes place. 
To accomplish the first, that of preventing the poison from entering the 
blood-vessels, a cord should be instantaneously thrown about the part above 
the wound and drawn sufficiently tight to arrest the circulation at once, and 
then the part should be excised, the incision being carried much beyond the 
limits of the wound. After the operation the flow of blood should be en- 
couraged by suction with the mouth, in order to effect the second indication, 
namely, that of extracting the poison. Should there be no crack or ulcer on 
the lips or in the mouth there will be no danger in adopting this plan, as f he 
poison may be swallowed with impunity. If the finger or toe be struck, it 
will be best to resort to immediate amputation. That excision can be suc- 
cessfully practised without previous constriction will appear from the follow- 
ing case narrated to me by a medical friend: 
He had gone into Western Pennsylvania during the summer, in order to 
establish some lines of old surveys. While lunching at noon, he and two 
of the woodsmen went to a spring, close at hand, to slake their thirst. One 
of the men threw himself down upon his hands and knees to drink directly 
out of the pool, wrhen he was struck on the fleshy part of the bare arm, a 
short distance above the wrist, by a rattlesnake, which had been lying con- 
cealed in the leaves and had been touched by bis hand. The doctor was so 
terrified at the sight as to be completely stupefied and rendered incapable 
of making a single effort for the life of the man. Not so, however, with his 
hardy and ready-minded companion. The wounded man instantly shook off 
the reptile (as did Paul the viper which came out of the fire and fastened on 
his hand on the island of Melita), whilst his companion, quick as thought, 
unclasped his knife, and, pinching up the flesh, removed at one sweep a large 
mass from the arm and covered the bleeding surface with a quid of tobacco; 
all this was done before my friend had even recovered from his bewilderment. 
No evil effects were experienced, and the woodsman continued his work as 
though nothing had occurred. 
When the constitutional action of the poison has commenced, the case re- 
solves itself into one of stimulation. The various remedies which have been 
brought forward from time to time and vaunted as specifics, such as olive oil, 
bromine, the Tanjore pill, Bibron’s antidote,* and others, are powerless for 
good. The subcutaneous injection of equal parts of aqua ammoni® and water, 
as near the wound as possible, has been strongly recommended by Halford, 
and practised by Elder, though not regarded with much favor by the physicians 
of India, wdiere it has been much employed. Alcohol is the most reliable 
remedy. In several cases treated by I)rs. Cooper and Getty, both surgeons 
in the United States army, this was the only agent employed. It must be 
given early, and in large doses, in order to induce a condition of intoxication; 
and the amount necessary to effect this is almost fabulous. In one of Surgeon 
Cooper’s cases it required for this purpose one bottle of brandy and one and a 
half bottles of whiskey; and in another, two bottles of proof Bourbon whiskey .f 
Should the patient be unable to swallow, the whiskey or brandy must be given 
by the rectum. Alcohol, however, does not act by neutralizing the poison. 
Mitchell has shown that it simply sustains the action of the heart until the 
poison or its effects have been either exhausted or eliminated from the system. 
WOUNDS. 
* Bibron’s antidote consists of potash, corrosive sublimate, and bromine, 
f Smith’s Surgery, vol. i. p. 445. WOUNDS BY VENOMOUS SNAKES. 
289 
Quite recently the permanganate of potash has been brought forward by 
Dr. Lacerda Filho as an effectual antidote to the poison. 
Poisons derived from Insects.—There are a number of insects which inflict 
upon man wounds of a poisonous nature. These belong to the order Hymen- 
optera, such as the bee, wasp, hornet, and yellow-jacket. The poison is se- 
creted in glands situated in the abdomen of the insect, which empty into a 
sac communicating with the sting. (Fig. 272.) When the insect is irritated, 
the sac is compressed by means of a muscular ap- 
paratus and the sting protruded beyond its covers, 
by which a puncture is made and an exceedingly 
small amount of the poison conducted into the 
wound. In its withdrawal the sting, in conse- 
quence of its serrations, is frequently detached 
from the body of the insect, and remains in the 
wound. 
Symptoms.—When a sting is inflicted, a sharp, 
burning, and itching pain is experienced, followed 
by indurated welts or wheals, the centre of which 
is pale and the circumference red, not unlike the 
eruption of measles. Generally the injury proves 
harmless, the pain, swelling, and redness disappear- 
ing in the course of a few hours. Should, however, 
such wounds be greatly multiplied, as when an in- 
dividual is attacked by a swarm of bees, they may 
prove fatal. Death has followed the sting of even a 
single bee.* Such wounds are not free from danger 
when inflicted about the eyes, lips, tongue, or mouth; 
as the rapid tumefaction which follows in loose ex- 
tensible structures, like the tongue or the parts about 
the top of the larynx, exposes the patient to the risk 
of suffocation. There are recorded instances in which 
death has followed in a few minutes after the injury, 
in consequence, it is supposed, of the sting having 
penetrated a vein and conveyed the poison directly 
into the blood. In persons of a very impressible organization, who have been 
stung, it is not uncommon to witness nausea and vomiting, and sometimes 
symptoms of collapse. 
Treatment.—The part should be examined for the sting, which is often 
left in; and, when this is the case, it should be extracted with a pair of 
delicate flat-bladed forceps. A solution of sugar of lead applied to the wound 
is a very good remedy. Dilute carbolic acid (one part of the acid to nine 
parts of water, or, still better, with eight parts of olive oil) is frequently 
employed with marked relief. The application of salt and water, of harts- 
horn, or of spirit of camphor, will also be found efficacious. These all appear 
to neutralize the poison. A very popular and soothing remedy in domestic 
practice consists in the application of wet clay, which should be employed 
when other means are not at hand, renewing it as often as it becomes dry. 
When there is great swelling of the tongue, or oedema at the top of the 
larynx, threatening suffocation, as may happen when a bee is taken un- 
observed into the mouth with honey and inflicts a sting, free incisions should 
be promptly made to empty the loaded tissues. 
There are other insects—as the bed-bug (Cimex), the flea (Pulex), and the 
mosquito (Culex)—capable by their bite of producing much irritation, not 
from the contents of poison-glands, but from the salivary secretion, which is 
formed from tubular glands floating in the body of the insects. The treat- 
ment of their bites does not differ from that proper to the sting of the bee. 
Fig. 272. 
The poison-apparatus of the bee: 
a, a, tubular glands for secreting 
the poison ; b, receptacle ; c, sting; 
d, d, sting-covers. 
* New York Journal, May, 1857; also Medical Times and Gazette, 1860, p. 389, and British Medical 
Journal, April 24, 1869, p. 374. 290 
WOUNDS. 
Terrible as are the evils of war, medicine and surgery have done much 
to mitigate the distress and suffering incident to its conflicts. The events 
of the last few years have afforded American surgeons opportunities on a 
very extended scale for the study of gunshot injuries. The improvements 
in modern arms and missiles have materially modified the nature of these 
casualties. Among the old military surgeons, these wounds were invested 
with peculiar characteristics, acquii'ed, it was thought, from the explosive 
nature of gunpowder: they were regarded as poisoned wounds, and, it was 
believed, had to be subjected to a long and tedious process of irritation and 
suppuration, by incisions and stimulating compounds. It is only within 
the last seventy-five years that any material advance has been made in the 
management of these injuries. The slow improvement of English military 
surgery, according to Hennen, was to be attributed to the indifference, neg- 
lect, and even contempt, writh which professional men were formerly treated 
by the governments under which they lived. This was in striking con- 
trast with the esteem in which army surgeons were held in ancient times. 
Among the Greeks, the physicians who accompanied armies into the field 
were regarded as worthy of the highest consideration. At the siege of 
Amiens, in 1597, field-hospitals were first established; and, as such an event 
rendered it necessary to provide professional assistance, we may refer to the 
reign of Ilemy IV. of France the commencement of a better day not only 
for military surgery but also for the humane treatment of soldiers. This 
early effort to supply a place for the reception of those who were wounded in 
battle culminated in the construction and support, by France, of the Hotel 
des Invalides,—the glory of Louis XI V.; and in England, about the same 
time, of the Chelsea Hospital. An outgrowth of these provisions for the 
sick and wounded, on the Continent at least, was the establishment of mili- 
tary schools for medical and surgical instructions. There have been times 
in which the presence of a surgeon wTas necessary to secure the success of a 
campaign. The feeling that relief is at hand, in the event of accident or in- 
jury, is a powerful stimulus to the courage of soldiers. The besieged garrison 
of Mentz owed its deliverance more to the personal influence of the surgeon 
of Henry IV., Ambrose Pare, than to French valor. There were critical 
periods during the wars of the first Napoleon when the presence of Baron 
Larrey exercised an influence on the army not inferior to that of the Emperor 
himself. 
The treatise of John Hunter on the “ Blood, Inflammation, and Gunshot 
Wounds,” published in 1794, was one of the eaidiest contributions to military 
surgery in England. The genius of this great man enriched everything that 
it touched; and although a more extended experience has shown that in some 
points his views required material modification, yet in the main the princi- 
ples which he enunciated were correct. What may be considered the errors 
of Hunter were corrected by Guthrie during the Peninsular War. This last- 
named surgeon, from a large experience, was enabled to demonstrate the 
superiority of primary over secondary amputations, and the propriety of am- 
putation at the shoulder- and hip-joints, also to indicate the proper course to 
be adopted in cases of gangrene from injured vessels, and in phlegmonous 
erysipelas. The military campaigns of Napoleon were scarcely more impor- 
tant in a political point of view than were the writings which embody the 
accumulated experience of Larrey in establishing modes of sui*gical treat- 
ment which were advantageous to human life. The Crimean War, whatever 
it may have accomplished for the peace of the world by the success of the 
allied arms, furnished at least the materials for testing satisfactorily vital 
surgical questions; and these materials have been placed in a permanent and 
available form by Macleod and D. Chenu. The same may be said, to a cer- 
tain extent, of the later and more decisive wars which have been waged in 
Europe, as that between Austria and Prussia, and that between France and 
Gunshot Wounds. GUNSHOT WOUNDS. 
291 
Germany. In all these struggles, the medical and surgical history of the 
conflict, under the fostering care of the respective governments,—after the 
example of England,—became an integral part of the service. And, lastly, 
in the war between the North and the South, the government assumed the 
responsibility of preserving to the world the medical and surgical treasures 
of that fratricidal conflict. 
The character of arms and projectiles.—Gunshot wounds may be inflicted by 
a great variety of missiles. The mere explosion of powder from the muzzle 
of a gun, at close range, will produce a serious injury, one which will combine 
the characters of a burn with those of contusion and laceration. Our hos- 
pitals furnish numerous examples of such accidents in consequence of the 
use of fire-arms by reckless boys. I have seen a person instantly killed by a 
heavy discharge of powder when close to a gun. Suicidal attempts are some- 
times made by discharging a pistol, charged with powder alone, into the open 
mouth: the laceration and bruising which follow may eventuate in death, 
from oedema of the larynx, or from blood-poisoning consequent on sloughing. 
When a wad is added to the charge, the danger is increased, and at short range 
the former may enter the body. Life has been lost in several instances in this 
way during sham fights. 
It is by powder and wadding that quarrymen are so often wounded from 
the premature discharge of a blast. 
Shot, when received at close quarters, make a wound not unlike that pro- 
duced by a large musket-ball, inasmuch as the charge moves for a short 
distance almost in a solid mass. I was once called to see a young lad who, 
in the act of dragging a gun muzzle foremost through a fence, disturbed the 
hammer and discharged the contents of the piece into his arm. The charge 
consisted of bird-shot, and entered a short distance above the wrist on the 
anterior part of the arm. There was but a single opening, like that made by 
a ball, with inverted, ragged edges. If a load of shot enter a part just as the 
individual grains begin to separate, the wound will be cribriform. It occa- 
sionally happens that the heat developed in the combustion of the powder 
will partially melt the leaden shot and weld them into a solid mass, forming 
a bullet with an irregular and granular surface. Such a 
condition is seen in Fig. 273, taken from a specimen in my 
possession. Fragments of metal or wood, buttons, pieces of 
coin, portions of clothing, splinters, slugs, nails, and gravel- 
stones are not unfrequently driven into the body, producing 
fearful lacerations. 
The two great modern improvements in the construction 
of arms and projectiles consist in the adoption of rifled 
guns and cylindro-conoidal balls. Such changes have in- 
creased immensely the range of these weapons, rendering 
them capable of inflicting fatal wounds even at the distance of a mile. Dr. 
Brinton informed me that he witnessed, in front of Petersburg, a soldier shot 
through both thighs, by an ordinary Minie ball, at the distance of one mile, 
which broke both femurs and inflicted a fatal wound. 
The arms in common use are the Sharp, Enfield, Chassepot, and needle 
gun. Some of these are breech-loaders. The same principle observed in the 
construction of small arms, namely, that of rifling the bore and changing 
the form of the missile, has been applied to guns of large size; so that an 
Armstrong gun will project a ball with considerable certainty to the distance 
of five miles. 
Balls are of three kinds,—round, cylindro-conoidal, and egg-shaped. The 
old round ball was at one time formed of stone. At the castle of Edinburgh 
may be seen a monster cannon (Mons Meg) with a stone ball attached. 
Some of the balls used three hundred years ago weighed eight hundred, and 
some even eleven hundred, pounds. For the time, such projectiles were quite 
formidable in the work of destruction. In 1453, Mahomet II. battered the 
walls of Constantinople with stone missiles. 
Fig. 273. 
A charge of shot 
united by the heat of 
the exploded powder. 292 
WOUNDS. 
The old round musket-ball (Fig. 274), as used by the English, French, and 
Eussians, weighed from a trifle less than one ounce to one ounce and a half, 
the heaviest being that employed by the Eussians. The musket-ball used by 
the United States government weighs 387 grains; calibre .69. 
Fig. 274. 
Fig. 276 
Fig. 277. 
Old round United States 
musket-ball. 
Cylindro-conoidal balls differ considerably in size and weight. The Spring- 
field rifle ball (Fig. 275), calibre .58, weighs 500 grains; the Enfield rifle ball 
(Fig. 276) for the muzzle-loader was formerly 530 grains, but for the present 
breech-loader is about 450 grains; the Austrian ball (Fig. 277) weighs 400 
grains; the French Minie ball, 680 grains; the French Chassepot ball (Fig. 
278), 380 grains; the needle-gun ball is egg-shaped (Fig. 279), and weighs 
530 grains; the ball of the mitrailleuse is longer than the others, and weighs 
one ounce and three-quarters (Fig. 280); the Martini-Henry ball (Fig. 281), 
recommended for the British infantry, and made of lead hardened with tin, 
Springfield rifle ball. 
Enfield rifle ball 
Austrian ball. 
Fig. 278. 
Fig. 279. 
Fig. 280. 
Fig. 281. 
Fig. 282. 
Fig. 283. 
weighs about 428 grains; the Eussian ball is heavy, and weighs one ounce 
and six drachms. Other conical balls are in use, as the Bavarian (Fig. 282), 
and that of the Snider gun (Fig. 283). 
Pistol-balls are generally conical, and at short range are quite as dangerous 
to life as those of larger arms. 
These missiles are sometimes charged with detonating powder, like that 
contained in percussion-caps, and are then designed to explode after entering 
the body. These have, I believe, by common agreement of nations, been 
withdrawn, as inconsistent with the spirit of modern warfare. 
Cannon-balls.—These, like the projectiles for small arms, are either round 
or cylindro-conoidal. They are made of iron, and weigh from one to one 
hundred pounds. The latter when tired from a rifled cannon, like the Arm- 
strong gun, prove effective at the distance of four or five miles. 
Shells are hollow spheres filled with gunpowder, and sometimes, as in the 
shrapnel shells, with both powder and balls. The explosion of these missiles, 
sending fragments in all directions, sometimes does fearful execution. The 
Duke of Wellington, however, thought shrapnel shells of very little impor- 
tance, rarely disabling any one. GUNSHOT WOUNDS. 
293 
Grape-shot consists of three layers of cast-iron balls contained in canvas, 
disposed about a central pin of wood, and secured together by a cord. The 
resemblance to a bunch of grapes explains the origin of the name. 
Canister-shot is composed of small cast-iron balls mixed with sawdust and 
contained in a tin case, which is closed at each extremity. 
The effect of a change of form and the resulting momentum is to confer 
on the cylindro-conoidal ball a power of penetration far greater than that of 
the old round missile. As compared with the latter it is less likely to lodge 
in the body. Even at the distance of eight hundred or one thousand yards 
it will pass completely through a part, and at a shorter distance through three 
or four persons who may be in range. 
The wounds which it produces are more severe. The destructive effects 
of the conical projectile are best seen in shot wounds of the long bones. If 
the momentum is not materially diminished, it will pass through, making a 
simple perforation; if, on the contrary, its velocity has been in some degree 
spent, it will split and comminute the bone in a 
frightful manner. (Fig. 284.) Not only is this 
the case, but the concussion will extend far be- 
yond the limits of contact or fracture, laying 
the foundation for subsequent inflammatory 
processes, such as osteomyelitis, which may 
involve the life of the entire bone. The case is 
very different with the old round ball, which 
passes through a bone, either making a small 
hole or breaking it into a few irregular masses. 
Oftener it merely penetrates into the cancelli, or 
is flattened against the bone and remains in the 
tissues. In the case of wounds of the soft parts 
the difference is quite marked between the effects 
of the two projectiles. The cylindro-conoidal 
ball, moving at a marvellous velocity, destroys 
thoroughly the vitality of the parts for some dis- 
tance around its track, so that sloughing follows 
to a much greater degree than after wounds by 
the old round missile. 
Again, the cylindro-conoidal ball is much less 
likely to be turned out of its course or deflected. 
This is not to be ascribed to the mere momentum 
alone, but also to its form and axial revolution. 
The eccentric course of a deflected ball is a curi- 
ous fact. A very trifling circumstance may de- 
termine it, such as the angle of contact, a tendon, a muscle in a state of con- 
traction, a piece of coin, a handkerchief, or some other object. A ball so 
changed in its course may follow a very circuitous route. It may enter the 
front surface of the chest, follow the curve of a rib, and pass out opposite, 
at the side of the spine, or remain among the muscles of the back, thus 
making half the circumference of the thorax; or, striking the forehead, it 
may follow the convexity of the cranium and lodge or emerge at the occiput. 
Hennen gives six fatal cases in which balls followed the concave or pleural 
surface of the ribs. In two of these the bullet entered on the right side of 
the sternum, and, passing between the lungs and the pleura costalis, trav- 
ersed the left side, escaping at the spine. In two other cases the ball entered 
the abdomen near the umbilicus, and, running between the parietes and the 
viscera, made its exit at the side of the spine directly opposite* The same 
author relates the case of a friend, in whom the ball entered over the thyroid 
cartilage, made the entire circumference of the neck, and was found lying in 
the wound of entrance. Ballingallf mentions a case which had been related 
Fig. 284. 
Comminuted fracture of femur pro- 
duced by a conical ball. Spec. 5489, U. S. 
Army Medical Museum. 
* Hennen’s Military Surgery, p. 37. 
■(■ Outlines of Military Surgery, p. 209. 294 
to him by Mr. Gulliver, in which a musket-ball entered the posterior part of 
the thorax, followed its concave surface, and was found lodged in the inner 
surface of the sternum. It is this circuitous route of balls which leads often 
to the hasty and erroneous conclusion that a cavity has been directly crossed 
by the projectile. The manner in which balls pass through the body without 
damage to blood-vessels, nerves, or viscera is very remarkable. It was not 
uncommon during our late war to meet with instances in which a bullet went 
through the neck or axilla at the portions most crowded with structures 
essential to life, with impunity; and examples are cited of balls traversing 
the abdomen without damage to its contents. 
When a deflected ball takes a circuitous course under the skin, its track 
will sometimes be revealed by a red wheal or discoloration beneath the skin, 
made by the extravasated blood tinding its way to the surface. 
Openings of entrance and exit.—Whether the projectile be round or cylindro- 
conoidal, the opening made in entering is smaller than that made in leaving or 
passing out of the body. The opening of entrance is usually smaller than the 
ball, owing to the elasticity of the skin. The edges are generally inverted, 
perhaps ecchymosed. If the ball be round, the opening will have very much 
the same form; if conical, it may be irregular, slit-like, or cruciform. The 
opening of exit will be larger, often lacerated, and the edges everted. This 
is just what occurs in firing a ball through a board, or even in driving a nail 
through the same. In the old round ball, as well as in the conical, the degree 
of difference between the relative sizes of the openings of entrance and exit 
will be in a great measure determined by the momentum. Should the pro- 
jectile enter the body with undiminished velocity, and pass through, the differ- 
ence in diameter between the orifice of entrance and that of exit will not 
be great. If, however, the momentum has been diminished by atmospheric 
resistance and the attraction of gravitation, or by the resistance encountered 
in passing through a part, or by all these combined, the openings of entrance 
and exit will both be comparatively large, especially the latter, inasmuch as 
the ball in escaping is not only passing from a denser into a rarer medium, 
but it is the ball, plus a certain quantity of displaced tissue, which must be 
accommodated. It is the operation of these causes which determines the 
eversion of the edges of the opening of exit. There are exceptional circum- 
stances which serve to make the opening of entrance the larger of the two, 
as where the ball carries with it some foreign bod}7" and buries it in the flesh. 
Every author on military surgery gives examples of this nature. Hennen 
mentions an instance in which a projectile carried a piece of the cranium of 
one soldier and produced by it a large lacerated wound in the thigh of a 
second; another in which the wound of entrance, situated in the thigh, was 
magnified by a portion of the ulna with its olecranon process; and a third 
in which a tooth was carried along with the ball and lodged in the temple of 
a soldier. Hamilton relates a case in which a number of teeth with a ball 
were removed from the neck above the sternum. I have seen a similar effect 
produced by a part of an officer’s saddle being broken off and driven before 
the ball into the thigh. A conical ball in the course of its flight may be so 
altered in position as to enter the body with its long axis parallel to the sur- 
face, thus making a large, ragged wound of entrance, and, by encountering a 
certain kind of resistance in its passage, may have its direction so changed 
as to emerge apex foremost, making the wound of exit smaller than that of 
entrance. It is possible for the opening of entrance to be also that of exit. 
Such cases are certainly very rare; but the possibility of their occurrence is 
shown in the case related by Hennen, in which a ball, after passing round the 
neck, lay in the opening of entrance; or it may occur in another way, by the 
projectile striking a bone and rebounding through the opening made in enter- 
ing. A single ball may make two openings of entrance and a like number of 
wounds of exit, as where the forearm is flexed upon the arm or the leg upon 
the thigh at the time of being struck by a ball, in which position the missile 
may pass through the forearm or thigh and afterwards enter and pass through 
WOUNDS. GUNSHOT WOUNDS. 
295 
the arm or leg. There may be a single point of entrance and several of exit. 
This is likely to be the case when a ball on entering strikes some salient object 
and is divided into several fragments, each of which in passing out makes an 
opening for itself. Larrey and Guthrie furnish each an example in which 
there were six openings of exit. Again, there may be two or more openings 
of entrance and one of exit produced by the ball striking some object on 
which it is split into two or more pieces, each entering the body by a separate 
opening, while one only has sufficient momentum to pass out. 
Change which the ball undergoes after leaving the gun.—A ball travelling with 
sufficient momentum to pass through a part, and making only a flesh-wound, 
will be very little changed in figure or appearance. Especially is this true of 
the conical bullet, which is more solid than the round one, being compressed 
into form, and not cast in a mould, as was the old spherical projectile. There 
is usually on one side of the base of a ball which has been fired, an oblique 
or flattened surface, supposed to be due to the manner in which it leaves the 
gun. When a round ball strikes point-blank against a resisting body like 
bone, it will be flattened; if conical, the point will be blunted and the body 
often bent upon itself, contorted, or changed into an irregular, shapeless 
mass. If only a portion of the conical extremity strikes against the metal 
of the soldier’s accoutrements or against bone, it will be planed, leaving a 
smooth facet on one side. The dividing of balls into several pieces is usu- 
ally produced by the encountering of solid objects before entering the body. 
Examples of balls altered in form by impact are shown in Fig. 285, kindly 
furnished by the Surgeon-General U.S.A. 
Fig. 285, 
Balls with little momentum.—The effect of diminished velocity on rifle-balls 
has already been noticed,—that of causing deflection or lodgement in the 
body. Studied in connection with cannon-balls, this effect is very remark- 
able. Such a projectile, moving at great velocity, will produce the most fearful 
destruction of parts, carrying away a limb, leaving the soft parts hanging 
in shreds and the shattered bones protruding below, or, if the contact be less 
direct, sweeping off the flesh to the bone, and yet perhaps not prostrating 
the individual. When the momentum of such a ball is largely expended 
by the conjoined influence of atmospheric resistance and gravitation, or by 
ricochet, it is by no means disarmed of its power to do harm, though rolling 
slowly over the ground ; and when we consider the amount of force that is 
necessary to move so great a mass of metal even at this slow rate, together 
with the weight itself, it is not difficult to understand those cases in which 
a foot has been hopelessly destroyed by thoughtlessly placing it against such 
a body with a view to arrest its progress. The capacity of such a ball to 
produce the most extensive bruising, or even laceration, of internal organs, 
without leaving any external marks of violence, is well known. This at one 
time wras attributed to what was called windage,—that is. the sudden conden- 
sation and expansion of the air as the ball passed close to the body. Such 
was the explanation given by Forbes,* of Edinburgh. Mr. Ellis thought it 
was produced by electrical changes caused by the rapid flight of the ball. 
Guthrie’s explanation is doubtless the correct one. He considered that a 
low instead of a high rate of velocity of the ball, and actual contact instead 
* Edinburgh Journal for 1812-13. 296 
WOUNDS. 
of contiguity, were required. When the momentum is in a great measure 
expended, the ball rolls on its axis over the surface like a wagon-wheel, and 
this determines the internal damage of organs whose texture is not very 
strong, whilst the skin, from its great elasticity, presents little evidence of 
injury. 
Character of gunshot wounds.—Wounds made by balls are both contused and 
lacerated, and they heal by granulation. Even when the vulnerating projec- 
tile is fragmentary, as a split ball or a portion of an exploded shell, the parts 
are scarcely ever divided after the manner of an incised wound. In conse- 
quence of this, such injuries are followed by sloughing, and in most instances 
throughout the entire length of the tract, though not to the same degree 
in all parts of the body. Usually the circumferential extent to which the 
vitality is destroyed will be greatest about the point of entrance, diminishing 
gradually from this to the orifice of escape; that is to say, the death will be 
most extensive where the velocity of the projectile has been greatest. This 
explains the fact that the opening of entrance frequently becomes, in a few 
days, larger than that of exit. If we study closely a gunshot injury, the 
structures in the neighborhood of the wound will be found to differ in their 
appearance. For a short distance around the opening made by the ball the 
parts will be bruised, compacted together, and of a pale-red color. Nearer 
the circumference, in a short time, an inflammatory process will be found 
at work infiltrating the parts with a transudation of fibrinous matter and 
cells; and, still farther out, there will be an increased afflux of blood, with an 
cedematous condition, due to the presence of serum. In this inner circle we 
recognize structures so pulpified that they must be cast off as a slough; in 
the second, a work of separation, suppuration, and the materials of recon- 
struction, or granulation-tissue; and in the outer, or third, an area of blood- 
determination. 
Belative frequency with which different farts of the body are wounded.—Zetzell, 
in speaking of the portions of the body most frequently injured by balls,* has 
given the following estimate: for every two persons shot in the belly, there 
will be three or four wounded in the neck and breast, seven in the head, ten 
in the arms and hands, four in the hips, five in the legs, one in the knee, and 
two in the feet. All such calculations, however, come short of the truth, and 
are subject to great variations from different circumstances, as the nature of 
the ground or of the defence, and the relative position occupied by contend- 
ing bodies of troops. In the late war between the North and the South the 
position of the wounds differed very much in different engagements. 
Symptoms.—These are local and constitutional. 
The local symptoms vary much, according to the position, structure involved, 
extent, and personal peculiarities. Many wounds are received without the 
person being even conscious of the fact. A soldier, in the heat and excite- 
ment of a elosety-contested battle, may forget the injury until the day is lost 
or won. General Hancock, at the critical battle of Gettysburg, though he 
received a dangerous wound of the thigh, was for some time unconscious of 
the injury. Usually, however, there is a feeling of a sharp blow, a sting, a 
warm sensation, or a sense of numbness. An examination reveals the hole 
made by the bullet. If a nerve be touched, the pain may be exquisite, and 
compel the strongest man to cry out. The suffering is sometimes experienced 
in a part remote from the injury, as in the arm after a wound of the neck 
injuring the brachial plexus of nerves. Where a bone is broken, the pain is 
usually severe. When a ball divides an important nerve, like the median or 
the sciatic, there will be loss of power in the parts supplied by these trunks. 
When a bullet passes through the brain, the wounded man will, if making a 
charge at the time, fall forward to the earth. When struck in other parts 
of the body, the soldier may stagger, yet recover himself, or he may reel and 
fall to the ground. On the battle-field of Gettysburg many of the slain lay 
upon the back. 
* Hennen’s Military Surgery, p. 31. GUNSHOT WOUNDS. 
297 
Hemorrhage.—Hemorrhage may be primary or secondary. Most persons 
who die on the held perish from this cause. Where vessels of small size are 
divided by a ball or other missile, or where a limb is torn away by a cannon- 
ball, there will be little bleeding, the coats of the vessels being lacerated and 
twisted, conditions unfavorable to hemorrhage. Where a large trunk is torn, 
like the femoral, carotid, or subclavian, the bleeding will be profuse from both 
the wound of entrance and that of exit. The danger will be less if at the time 
of the injury the vessel be completely severed, as the ends are thereby enabled 
to contract within the sheath, thus favoring the formation of a clot both in 
the surrounding tissue and within the lumen of the artery. A wound may 
not bleed at the time of its reception, yet after reaction may pour out a serious 
and perhaps fatal amount of blood. There is also a concealed hemorrhage 
following penetrating wounds of the chest or abdomen, which is dangerous 
because out of sight. There may be a concealed bleeding even in wounds of 
the extremities, due to the circuitous route of a ball or to a change in the re- 
lation of parts after the reception of the wound. I witnessed such a case in 
a young man who had accidentally shot himself through a portion of the calf 
of the leg in which no vessels of importance could have been injured in the 
ordinary extended position of the member, yet a quiet hemorrhage had been 
going on for some time, forming a large collection in the limb, without a drop 
flowing externally. Internal hemorrhage is indicated by prolonged shock, 
pallor, and nausea. 
Secondary hemorrhage.—This is a common sequence of gunshot wounds. 
Yessels are frequently contused or grazed by the passage of a ball, and 
subsequently the parts die and separate as a slough, giving rise to secondary 
bleeding. It may follow sloughing of the contiguous parts, in which the 
artery becomes involved by extension of the disease, or it may be due to a 
spiculum or sequestrum of bone or a fragment of shell changing place and 
wounding a vessel. Secondary hemorrhage occurs from the sixth to the 
fourteenth day after a wound, though it may be delayed several weeks, and 
in a case given by Chisolm three hundred and twenty-eight days elapsed 
before its appearance. When secondary hemorrhage takes place, it is ordi- 
narily without premonition; there is a sudden outburst of blood, which may 
prove almost instantaneously fatal, but more commonly induces fainting, by 
which it is temporarily arrested. 
Constitutional Symptoms.—The dominant constitutional feature of a gun- 
shot wound is shock. The degree of shock present is subject to great varia- 
tions, from peculiarities of mental and physical organization as well as from 
the nature of the part involved. One man will have a limb carried away or 
suffer extensive laceration of structure, and yet betray little if any perturba- 
tion, while another, with a wound of trifling significance, will grow faint and 
deadly pale, his skin will become wet with a cold perspiration, and vomiting 
and tremors may follow, with such great mental agitation as frequently to 
assume the form of delirium or hysterical raving. This “shock,” however it 
may be modified by physical and mental conditions, is, as a rule, determined, 
both as to continuance and degree, by the severity of the injury. When a 
ball traverses a cavity and wounds an important organ, or crashes through a 
large joint like the knee, breaking the bones in pieces, it will be well pro- 
nounced. Even when wounds appear unimportant, we may measure their 
danger by failure or delay on the part of the patient to react. Many wounded 
men die of shock, either on the battle-field or after their removal. 
Prognosis.—There are so many contingencies which may befall wounded 
men that it is very difficult to forecast the result of any given case. The 
slightest scratch may be attacked by erysipelas and terminate fatally in one 
person, while another may struggle successfully through the most serious 
injuries of the brain or chest. General Mitchell, after encountering the 
dangers of many hotly-contested fields unharmed, finally died from a trifling 
abrasion of the skin over the tibia, received in stepping from a boat at Pitts- 
burg Landing. Hospital gangrene or erysipelas may break out and decimate 298 
WOUNDS. 
a camp; pyaemia, especially where the bones have been extensively damaged 
or much blood lost, destroys many men; secondary hemorrhage adds to the 
mortality; tetanus will claim a certain number of victims. This last disease is 
most common after naval engagements, perhaps from the wounds being made 
so frequently by splinters. Sir Gilbert Blane states that out of eight hundred 
and ten wounded in the West Indies during the battle in April, 1782, twenty 
cases of tetanus occurred, or about one in forty.* Stromeyer informs us that 
one in three hundred and fifty wounded in the Schleswig-Holstein War per- 
ished from tetanus. Larrey, in his “ Memoires,” says that the disease was very 
common among the wounded near the Nile during the campaigns of Bona- 
parte in Egypt. In our late national conflict numerous cases were observed. 
Then there must be taken into the account the hospital accommodations, 
which are often insufficient to receive the wounded, especially after a bloody 
battle. Overcrowding, insufficient hospital supplies, too few surgical assist- 
ants or nurses, unhealthy localities, and epidemic influences, with others which 
might be enumerated, are all subjects to be considered in venturing a prog- 
nosis. Should the patient escape unscathed from such an array of enemies, 
there are still others which claim no small number of victims, among which 
may be mentioned prolonged suppuration from bone disease, which may 
destroy the patient by sheer exhaustion or by developing into activity some 
latent weakness, like tuberculosis, kidney-degeneration, or aneurism. A ball 
may remain long encysted, and yet suddenly become displaced and drop into 
the chest or brain and provoke a fatal inflammation. Old sinuses which re- 
main open are exposed to attacks of erysipelas which may destroy life. Neu- 
ralgia also may be excited, and by its continued severity wear out the sufferer. 
Even if he escapes all these, there remains the possibility of paralysis and 
epilepsy; to which may be added deformities from inflammatory conditions 
of the fasciae, tendons, and articulations. 
Treatment.—The treatment of gunshot wounds is divided into provisional 
and permanent; or that which is proper at the time of the accident and that 
which is demanded after removal to a hospital or home. In military practice 
it is common, both with our own and with other nations, to establish, at con- 
venient and well-sheltered points, different corps of surgical assistants, who 
can render prompt aid in cases of urgency, and afterwards forward the 
patients by ambulances and stretchers to the field- or more distant hospitals. 
The functions of the surgeon in this first work consist in the administration 
of wine, whiskey, aromatic spirits of ammonia, or similar restoratives to 
relieve shock,—directing that the head be kept low. lie is to remove any 
foreign bodies that are exposed to view, and, after having washed the sur- 
rounding parts with the bichloride of mercury solution (one to one thousand), 
apply sublimated gauze compresses, secured by a few turns of a sublimated 
or carbolized roller, and, if necessary, adjust a splint to a broken limb. When 
there is profuse bleeding, the vessels should be tied at once, or, if that be not 
feasible, the hemorrhage should be controlled, for the time, by a tourniquet, 
or the finger of an assistant applied in the wound. Tourniquets for the 
most part are painful instruments if they are long retained on a limb, and are 
not without danger to its life. The instrument known as Lister’s, figured on 
page 224, is the least objectionable, as the pressure operates only on opposite 
surfaces of the limb, leaving the venous circulation without embarrassment. 
In a case of great emergency, and in the absence of proper instruments or 
professional skill, the Spanish windlass (Fig. 201, page 223) could be used as 
a temporary expedient. 
Permanent treatment.—When the regimental hospital is reached, then com- 
mences the permanent treatment. This may be included under the following 
heads: 1, the relief of shock; 2, the arrest of hemorrhage; 3, the removal 
of foreign bodies, which includes the extraction not merely of balls, but 
also of portions of clothing, fragments of comminuted bone, and extraneous 
* Ballingall’s Military Surgery, p. 257. GUNSHOT WOUNDS. 
299 
matter of whatever kind; and, 4, the control of inflammatory action and the 
employment of all means tending to the restoration of the patient. 
1. The relief of shock.—Where the shock is slight, it will pass over in a 
short time, demanding nothing more than the recumbent position, a little 
warm broth, a sinapism over the prsecordial region, and external heat to the 
extremities and spine. Where it is more profound, in addition to these 
measures, the head must be kept low, in order that the brain may receive a 
sufficient supply of blood; and diffusible stimulants, such as brandy and am- 
monia, should be administered by the mouth, or injected into the bowel if 
the patient cannot swallow. If there is reason to believe that internal bleed- 
ing exists, it will be necessary to exercise caution against establishing reaction 
too rapidly: accordingly, when the pulse, and the color and temperature of 
the skin, begin to return to the normal standard, stimulants should be with- 
held, or given very sparingly. 
2. Arrest of hemorrhage.—Where the bleeding is slight, amounting only to 
a free oozing, elevation of the part, cold, and compression will suffice for its 
arrest; when from a vessel of magnitude, the artery should be sought for, 
by enlarging the wound, and both of the divided extremities be tied, at the 
earliest possible moment, as the difficulty of the operation is gi’eatly increased 
after inflammatory infiltration takes place. The operation should be done 
antiseptically when the circumstances of the case will permit. It is far better 
to secure a bleeding vessel in the wound than to tie the chief trunk at a dis- 
tant point. In cases where the damage is of such a nature as to inquire the 
removal of the limb, there will be no necessity for ligating vessels before the 
amputation, except where the condition of the patient will not warrant a 
resort to primary removal. Ligatures for primary hemorrhage in military 
surgery are rare as compared with those for secondary bleeding, as will appear 
from the records of our late war. 
3. Removal of foreign bodies.—This, of course, involves the examination of 
the wound, which should be made at the earliest possible moment after the 
patient reaches the regimental hospital, in order that a correct diagnosis may 
be made. The patient at this time is in the very condition for such an exami- 
nation. The sensibility of the wound is not acute, and there is no swelling 
or inflammatory alteration of the adjoining parts. While it is quite true that 
balls become in many instances encysted, yet even in such cases they are 
liable to become displaced by the movements of muscles and give rise to 
abscesses; or, dropping from the walls of the thorax or abdomen into these 
cavities, to excite fatal inflammation. Nor is there any period at which such 
accidents may not occur. I have removed balls which had remained quietly 
encapsulated for years, yet finally broke away from their beds and provoked 
suppuration. Professor Gross removed a ball, weighing six drachms, from the 
leg of a patient where it had remained for forty-nine years. Of four thousand 
soldiers having balls or other foreign bodies in their persons, examined by 
Ilutin during a period of five years, twelve only had not suffered. 
Since our late war, cases are constantly presenting themselves to surgeons 
in which balls have remained in the body quiescent for years, and then have 
begun to create trouble, requiring removal. 
That the examination may be conducted under the most favorable circum- 
stances, it is essential that the patient be placed, as nearly as can be ascer- 
tained, in a position corresponding to that which he occupied at the time of 
receiving the wound. This often gives the clue to the position of the ball. 
11 is only in this way that it is possible to explain the character of certain 
wounds. A soldier, during our late war, while standing on a height and 
having his arm raised at full length preparatory to ramming home a charge, 
—his rifle being a muzzle-loader,—was shot in the back by a person occupying 
a lower position. The ball lodged under the skin at the back of the wrist, 
from which it was extracted. It had, consequently, passed the whole length 
of the back, over the shoulder, and along the arm to the hand. The behavior 
of the ball was entirely inexplicable until it was discovered that the man was 300 
WOUNDS. 
loading at the moment of receiving the wound. A proper observance of this 
rule will convey much valuable information by enabling the surgeon to com- 
pare the openings of entrance and exit, as related to joints, bones, great vessels, 
and cavities. When there is but a single opening, the inference is that the ball 
is somewhere in the part. The exceptional eases are exceedingly rare. Even 
should there be two openings, the one corresponding to that of entrance, and 
the other to that of exit, it does not follow that no foreign body remains in 
the flesh. The hall may have carried in portions of clothing, buttons, or bone, 
which remain, while the projectile has passed through. The best instrument 
for the exploration of a gunshot wound is the linger, which should be thor- 
oughly cleansed, and washed in a solution of the bichloride of mercury when 
this is practicable, before being introduced into the opening. The information 
which it communicates is accurate and conclusive. The finger-nail should be 
guarded by scraping it over a piece of carbolic soap twenty-five per cent, in 
strength, to fill up the space beneath, that no unnecessary violence may be 
done to the wound. If the finger is too short, we can sometimes, by making 
counter-pressure with the other hand, bring the foreign body sufficiently near 
to be touched. By the direct use of the finger, balls, and soft substances, such 
as wads or portions of clothing, are readily recognized; so also may be ascer- 
tained the degree of comminution in a bone, the injury done to a joint or a 
cavity, and the amount of laceration in the subcutaneous soft parts. The 
wound should be douched with the sublimated solution (one to one thousand) 
during the exploration. The whole question of amputation may be deter- 
mined alone on the mental information acquired by the sensations trans- 
mitted from a very small surface of a finger. When the finger is too short 
to reach to the full extent of the wound, it must be supplemented by instru- 
mental prolongation. For this purpose we have recourse to probes. A probe 
should be of silver, nine inches long, with an enlarged and rounded extremity, 
and sufficiently flexible to admit of its being bent so as to follow other than 
straight passages. (Fig. 286.) It should be used with a gentle and light 
Fig. 28fi. 
Silver probe. 
hand, in order to avoid making false passages by getting out of the track, and 
to commit no injuries to vessels which lie in its course. As other substances— 
such as bone—may communicate impressions similar to those made by contact 
of the probe with a ball, and tbat operations may not be made on a mere pre- 
sumption of the presence of a bullet, a very ingenious instrument was devised 
by Nelaton. which consists of a little ball of china or porcelain on the end of 
a long probe (Fig. 287), which on being brought in contact with lead receives 
Fig. 287. 
Nelatou’s bullet probe. 
a mark, or when striking against a fragment of shell takes an impression 
of rust, which remains on withdrawing the instrument from the wound. All 
probes or other instruments employed, either for the location or extraction of 
shot missiles, should, whenever possible, be subjected to the antiseptic bath of 
carbolized water (one to twenty) before being used. Other ingenious methods 
have been devised for exploring gunshot wounds, such as RuhmkorfFs elec- 
tric apparatus, the electric probe of Favre of Marseilles, De Wilde’s signal- 
bell, and the sounding-board probe of L’Estrange.* Such complicated devices 
are not adapted to general use. The Nelaton probe, with all its advantages, 
* Quite recently Dr. Girdner has produced a modification of Professor Bell’s induction balance with 
telephone attachment which promises to prove of value in locating balls. GUNSHOT WOUNDS. 
301 
may lead the surgeon astray, as when a bullet in passing through or in 
grazing a bone has a portion of its lead planed off, which adhering to the 
surface of its track may communicate the characteristic stain to the ball of 
the probe. The instrument of Dr. Lecompte, by which a fragment of lead 
may be pinched off, was esteemed useful by Longmore and others. The ar- 
ticulated probes, or rubber bougies, have little practical value. When a ball 
is touched, the sensation communicated to the finger is that of a solid, per- 
haps irregular-shaped, body. Short and frequent taps will assure the surgeon 
of its presence. The location of a projectile is sometimes revealed by the 
loss of power or the painful condition of a part, showing the missile to be in 
contact with certain nerves. A dusky-red line and emphysematous crackling 
serve, in certain cases, to disclose its course. 
When the balls or other foreign bodies have been discovered, the next step 
is their removal. For this purpose a great variety of bullet extractors, scoops, 
and gimlets have been invented. Of these there are two which practically 
supersede all others, that of Thomassin (Fig. 288), and those of Gemrig 
and Kolbe, which are essentially alike in their construction. (Fig. 289.) The 
Fig. 288. 
Thomassin’s bullet forceps. 
Fig. 289. 
Genirig’s bullet forceps. 
Grasping a ball. 
Thomassin forceps is eight inches in length, with delicate blades, which are 
each armed at the extremity with a sharp tooth, and which are well designed 
to sink into and command a strong hold on a ball. The forceps of Gemrig and 
Kolbe differ from that of Thomassin in the possession by one blade of two 
branches, arranged in a fenestrated manner and terminating in short teeth. 
The instrument which is some- 
times called Thomassin’s (more 
properly Coxeter’s, Fig. 290) is 
designed to fasten the ball be- 
tween a fixed surface and a mova- 
ble stilet, and is much more in- 
genious than useful. There is another bullet forceps, the blades of which 
can be disjoined, introduced separately, and afterwards locked. It has few 
advocates. 
In using the bullet forceps it should be introduced closed and carefully 
conducted along the tract to the point designated by the finger or the probe 
until the foreign body is reached. The blades should then he expanded and 
made to embrace it, and when firmly infixed should be used both as a lever 
and tractor in the extraction of the ball. It is surprising what an amount of 
force is necessary sometimes to effect the removal of a ball, even when lying 
in the soft parts, in consequence of the fibres of the latter sinking into the 
irregularities of the metal. It will facilitate the removal of foreign substances 
if, while the finger is in the wound, any shreds or fibres of tissue which may 
intersect it be pressed aside, thus clearing a way for the forceps. 
When the ball is found flattened into a distorted mass, or when the foreign 
Flo. 290. 
Coxeter’s bullet extractor. 302 
WOUNDS. 
body, whatever it may be, is irregular in its form, care should be observed 
that it be grasped in sueh a way that its long axis shall correspond to the 
course of the wound. Forcibly tearing a body through the tissues, regard- 
less of incompatible diameters, may inflict serious damage to important struc- 
tures. In the extraction of fragments of shells it may become necessary to 
enlarge the wound. 
When a ball does not pass entirely through a part, but is felt lying either 
under the skin or in the muscles below on the opposite side, or out of reach 
through the opening of entrance, it should be fixed by proper pressure with 
the finger, to prevent a change of place, and then reached by cutting directly 
down upon it. 
Portions of clothing are best detected by the finger, as are also splinters or 
fragments of bone, and are most easily removed by the ordinary dressing for- 
ceps. In dealing with bone-splinters or fragments, we must be guided by 
the extent of periosteal attachment. If a piece is entirely separated from 
its bony and periosteal connections, there can be only one course proper, and 
that is its removal at once. If a splinter is disconnected with the bone, and 
has a very slight periosteal connection, that is, so slight as not to exceed one- 
fourth of its surface, it should be extracted ; when exceeding this, it is better 
to readjust it and leave it undisturbed. The idea that all such splinters, not 
entirely separated from their connections with the bone, should be pressed 
into place, under the impression that they will become incorporated with the 
new bone or callus, and thus, like splints, give solidity to the union, is unsound 
both in theory and in practice; no vital union will ever occur. That they may 
become embedded in the callus—that is, encysted—is not improbable; 1 have 
seen this take place; but they will eventually give trouble, by exciting in- 
flammation, suppuration, and necrosis in the new bone as well as in the soft 
parts, after the manner of a sequestrum, and will require removal. 
Where there is much comminution and the fragments are driven into the 
cancellated structure, either amputation or excision must be resorted to. 
When balls are embedded in bone, their removal is just as important as 
when in the soft parts. If a portion of the missile projects, it may be seized 
with the Thomassin forceps and ex- 
tracted ; or it may be dislodged first 
by a lever (Fig. 291) and then re- 
moved by the forceps or scoop. If 
deeply buried in the bone, the latter 
should be cut away at one point un- 
til the lever can be carried beneath 
it. It may be necessary to enlarge the opening in the soft parts to effect this. 
Lastly, it may be extracted by the instrument which combines the screw and 
forceps. 
There is a limit to the search for balls and other foreign bodies. A great 
deal of unnecessary importance has been attached to the extraction of balls, 
and a great deal of harm done by a prolonged search for these missiles. 
Penetrating shot-wounds are believed to be aseptic, and become septic only 
by the measures used in exploration and extraction. It should not be for- 
gotten, also, that the damage done by balls occurs at the time of their en- 
trance; after this their power for harm is comparatively trifling. Espe- 
cially is the danger of persistent searching great when the missile is lodged 
in the chest, lungs, or brain. 
4. Local and constitutional treatment.—After the removal of all readily 
accessible foreign matters and the shaving of the hair, the wound should be 
thoroughly cleansed by washing it with the bichloride solution, and covered 
with a pledget of the antiseptic gauze and salicylized cotton, the same being 
made fast by repeated turns of the aseptic roller. When the antiseptic 
method cannot be employed, lint soaked in carbolated oil or in eucalyptus 
oil thinned with alcohol may be substituted. If the wound be in the arm, the 
limb should be placed in an easy position upon a splint, in order to maintain 
Fig. 291. 
Lever to dislodge a ball from its position. GUNSHOT WOUNDS. 
303 
entire quiet; if in the leg, the patient must be placed in the horizontal posi- 
tion in bed. The treatment of gunshot wounds by irrigation, where there is 
much laceration of the soft parts, as frequently occurs in the bursting of guns 
or shells, has yielded such splendid results in my hands that I always resort 
to it when feasible, using water containing either carbolic acid or permanga- 
nate of potash. During an active campaign, when there are many wounded, 
where the hospital accommodations are only temporary, and the patients are 
in transition from place to place, it is impossible to carry out the antiseptic 
treatment with sufficient detail, and therefore the most eligible dressing, under 
the circumstances, is plain cold, iced, or carbolated water, with or without the 
addition of a little laudanum, frequently wetting the pledget in order to keep 
it cold. Cold water is not a modern dressing: it was used by Larrey, Guthrie, 
and others. No attempt should be made to close such wounds by strapping, 
or other means; close union is not to be expected. The opening, as a rule, 
must fill up by granulation; and this will be preceded by inflammatory, 
suppurative, and sloughing processes, which demand a free exit for the dis- 
charges. In twenty-four hours after a wound has been received, the parts 
around become a little swollen, less pliable than in health, with a circle of in- 
flammatory redness, and with increased sensibility. A little thin transudation 
may escape from the orifice made by the bullet. The inflammation results in 
suppuration in four or five days, by which dead tissue is detached and escapes 
with the discharge, after which granulations spring up, and the opening closes 
after an uncertain period of delay. While such is the usual behavior of shot- 
wounds, yet if rendered perfectly aseptic no sloughing follows. The evidence 
of this is seen in those cases where a ball enters the body and no attempt at 
extraction is made, the external opening being simply protected from the air. 
The repair follows without suppuration or sloughing. The practice at one 
time popular with French surgeons, of laying open the entrance and some- 
times the whole track of gunshot wounds, with a view to change their char- 
acter or to convert them into incised wounds, has at present no advocates. 
It is useless to close the external orifice by quick union when a process of 
mortification is going on in the deep parts, the products of which must find 
a way of escape. When a wound is extensively lacei*ated and the patient 
enfeebled by imperfect reaction, cold water, if used, must be employed with 
caution, or the vitality of the parts, already impaired by local and general 
violence, may be hopelessly destroyed under the depressing influence of a 
low temperature. The temperature of the water in such cases should be 
very little below that of the body. As soon as suppuration is established, a 
tepid liquid should be substituted for a cold one. At this time the parts are 
to be carefully scrutinized, and if an abscess forms, free incisions should be 
promptly made. It may be necessary also to use drainage-tubes; otherwise 
extensive burrowing of pus may follow. These punctures should be so 
planned that by their dependent openings a good clrainage will be secured. 
There are sufficient reasons in all such cases to apprehend the diffusion of 
pus among the components of a part, as the different planes of tissue which 
serve to limit these products have been opened into one another by the pene- 
tration of the projectile. Should the wound prove indolent or the discharges 
unhealthy, the condition of the sore may be improved by injections of bichlo- 
ride solution, carbolated water, salicylic acid, or very dilute alcohol. When 
attacked by erysipelas, followed by much tension, free incisions become im- 
perative, in order to unload the subcutaneous tissue and prevent suppuration 
and sloughing. After this the best application is lint saturated with carbo- 
lated water and laudanum (carbolic acid, one drachm; water, six ounces; 
laudanum, three drachms). Gunshot wounds usually heal first at the point 
of exit, the granulations gradually advancing to the opening of entrance, 
which closes and cicatrizes last. Xeuddrfer thinks this is due to the changed 
movement of the ball, by losing its rotary motion as it leaves the part, and 
producing in consequence a division of the structures similar to that in an 
incised wound. It is by no means established that such a change of motion 304 
WOUNDS. 
occurs; and I incline to the opinion that the difference is to be ascribed to 
diminished momentum, and a correspondingly less degree of injury to the 
parts. 
The slow progress in healing which so often characterizes this class of 
wounds tends to impair the nutrition and functions of the limbs. The 
muscles waste, the joints become stiff, and the tendons move painfully 
through their sheaths. This should be counteracted by friction with stimm 
lating liniments or alcohol, conjoined with systematic movements. The 
tendency to contraction of muscles, either from the flexed state of the limbs 
or from local irritation transmitted along certain nerves, must be carefully 
watched, and resisted by extension and passive motion, or even by tenotomy 
where these fail. 
After relieving shock and securing reaction, by the means which have 
been already described, as preliminary to all other treatmetit it is the duty 
of the surgeon in severe cases to enforce absolute rest. The bowels should be 
regulated, opiates administered to relieve pain and procure rest, a nutritious 
diet and thorough ventilation enforced, and stimulants and tonics adminis- 
tered in cases where there is prolonged suppuration. As many wounded 
men are brought from miasmatic localities and from overcrowded hospitals, 
there may be an additional complication in the development of malarial fever 
or intestinal troubles, such as diarrhoea and dysenteiy, all of which militate 
against the repair of the wounds. In such instances quinine must be given 
freely, and for the intestinal trouble scruple doses of subnitrate of bismuth, 
with one-eighth of a grain of morphia, three times a day. In cases where there 
is relaxation of the bowels, with anaemia, the liquor ferri pernitratis, in doses 
of eight or ten drops, largely diluted with water, and administered three 
or four times a day, will have a good effect. If the diarrhoea depends upon 
ulceration in the lower part of the colon, injections of nitrate of silver 
will be productive of good. No remedies, however, will avail much with- 
out a properly-regulated diet; and no other article of nutrition is so useful 
as milk. 
I was once consulted by a physician who had suffered continuously with 
chronic diarrhoea ever since the close of the late war. He had been a 
prisoner in the Libby prison, and contracted it at that time. The peculiar 
pain which he experienced induced me to examine the lower end of the 
bowel, where I discovered at the verge of the anus a fissure, for which I 
divided the underlying fibres of the sphincter. The operation cured both 
the fissure and the diarrhoea. 
Secondary hemorrhage.—As secondary hemorrhage is liable to follow gun- 
shot injuries, every precaution should be taken in anticipation of such an 
event: especially should there be unwearied watchfulness when the region 
traversed by the ball is in the neighborhood of important vessels. These 
after-bleedings occur rarely earlier than the seventh or later than the twen- 
tieth day, as it is during this period that sloughs are ordinarily detached. 
Occasionally the hemorrhage may be postponed to a much longer time, so 
that the vigilance should not be relaxed for several weeks. To be entirely 
prepared for such an event, a tourniquet should be placed loosely about the 
part when feasible, and minute instructions given to both nurse and patient 
as to its proper position and the mode of screwing it down. The localities 
of the great blood-vessels should be marked at those points where digital 
pressure can be applied with the best effect, and full directions must be given 
to the patient to command the orifice of the wound with his finger should 
bleeding occur. 
When hemorrhage does arise, the case has assumed the gravest proportions, 
and in this event there are three courses left to the surgeon: first, to enlarge 
the wound, seai’ch for the vessel, and tie both of its extremities; second, to 
tie the main artery in its continuity; and, third, to amputate. If the first 
course be determined upon,—and in my opinion it should always take the 
precedence of the other methods,—it should be executed at once, and the AMPUTATION AND EXCISION IN GUNSHOT WOUNDS. 
ends of the vessel made secure with the animal ligature; after which the 
limb should be elevated, to diminish the force of the blood-stream in the faulty 
vessel. 
The sloughing condition of the soft parts, and an imperfect thrombus, are 
the chief factors immediately concerned in determining the hemorrhage; and 
these depend upon a defective state of the blood and an imperfect nutrition 
of the tissues about the wound. To correct these constitutional and local 
defects it is necessary that the patient should have an ample supply of nu- 
tritious food, with a proper proportion of sound vegetables. Wine, whiskey, 
or brandy, in moderation, will be indicated, together with quinine, iron, and, 
not the least important, plenty of fresh air. 
The wound should be kept free from all the products of decomposed tissue 
by antiseptic measures, or, where this is not possible, by being frequently 
washed with a solution of permanganate of potash and injected with car- 
bolated water, a solution of bichloride of mercury (one to two thousand), 
or dilute alcohol (one part of alcohol and eight parts of water). 
In addition to these measures, the precautions against another bleeding 
must be renewed, and nothing left undone in the way of preparation for 
such an event. Let it be remembered that it is the amount of blood lost on 
such occasions which often decides the battle for life, and which too often 
induces a fatal pyaemia. Should the hemorrhage be renewed, let the vessel be 
tied in its continuity with the animal ligature, and the same after-treatment 
be pursued as in the first instance; should this likewise fail, then let the 
limb be removed within the limits of sound structure. 
305 
Amputation and Excision in Gunshot Wounds. 
The damage inflicted by gunshot projectiles will demand in many cases a 
resort to amputation. It will scarcely be doubted that in the exigencies of 
military practice many limbs are doomed to the knife, and very properly so, 
which in civil practice could be saved. I have on several occasions heard the 
remark made that many limbs had been needlessly sacrificed by surgeons 
during our late war,—a charge entirely unfounded in fact. Indeed, 1 am 
quite satisfied from personal observation that if any error was committed it 
was in efforts to save limbs, and not in their removal. Amputation in prop- 
erly selected cases is a most humane procedure; it is not a humiliation or an 
opprobrium, but a surgical triumph. 
The period for amputation.—The time to remove a limb is a question of great 
moment, and had attracted much discussion from the days of Ambrose Pare 
until about 1760. Old Richard Wiseman’s advice was to amputate quickly. 
When Bilguer was appointed Sui’geon-in-Chief to the Prussian army, an 
order was issued directing that no amputation whatever should be done for 
gunshot injuries,* and of the six thousand wounded Prussians not a limb was 
cut off. “ To cut off a leg,” said Bilguer, “ after a bad wound is but to add 
wound to wound; to heap new pain upon a disordered system.” What was 
the result of this insane order? One-half of the cases of gunshot fractures 
of the extremities died, and of the remaining half, one-third were entirely 
disqualified for any occupation whatever. This fearful mortality was in 
striking contrast with the success of Larrey, who saved three-fourths of his 
cases by primary amputation. There is no necessity at this day to defend 
the propriety of amputation in gunshot injuries. 
There are three periods in which amputation may be done: these are 
called primary, intermediary, and secondary. The first period is that ante- 
cedent to the development of inflammatory fever, and cannot extend over 
more than thirty-six hours, or forty-eight hours at the farthest. The second 
period is that of inflammatory or traumatic fever, and varies much in its 
duration. The third period begins after the subsidence of the second and 
* Ballingall’s Military Surgery, p. 368. 306 
WOUNDS. 
the establishment of suppuration. These subjects will be again referred to 
and discussed under the head of general amputations. 
Duchenne, in 1625, advised early operations, before the constitution was 
disturbed by inflammatory symptoms. Richard Wiseman* recognized the 
importance of immediate or primary amputation after gunshot injuries. 
Le Dran,f in 1737, enforced a similar doctrine, with cogent reasons for his 
choice. Ranby,J surgeon to King George II., entertained similar views upon 
this subject. In 1756 the Royal Academy of Surgery in France made the 
subject one for a prize essay, which was awarded to Faure. This thesis, 
though not altogether adverse to primary operations, circumscribed their 
application to very narrow limits. Boucher, on the other hand, was a strong 
advocate for early amputations. The testimony of Thompson, Guthrie, and 
Ilennen exhibits the superiority of primary over intermediary and secondary 
operations in a still stronger light than that of their predecessors. Among 
English military surgeons, with the exception of Hunter and O’Halloran, 
there was little diversity of opinion on this subject. Guthrie declared that 
the question did not admit of dispute; and to the same effect were the decla- 
rations of Hennen and Ballingall. Dr. Schrive has shown that during the 
Crimean War, among the French troops, the success for the most part in pri- 
mary operations was two-thirds greater than in secondary. The experience 
of the English did not materially differ in this particular from that of the 
French. Among the three thousand Russians wounded at the siege of Sebas- 
topol, one-half of the primary amputations proved successful, while two- 
thirds of the secondary ones were fatal. Still later we have the accumulated 
experience of the Franco-Prussian War and that of our own country, both 
going to show the soundness of the prevailing doctrine. 
In the able analysis given Dr. Otis,§ the surgical historian of the late 
war, we find 5456 cases of amputation in the continuity of the arm for shot 
injuries. The ascertained result in 5273 cases was a mean fatality of 23.6 per 
cent. Of this number there were 3259 primary operations, with 602 deaths, 
a mortality of 18.4 per cent.; 902 intermediary operations, with 302 deaths, 
or 33.4 per cent.; and 411 secondary amputations, followed by 114 deaths, or 
27.7 per cent. 
So decisive are these figures that when a limb is doomed to amputation 
the only condition justifying delay is shock. Should this last over thirty-six 
or forty-eight hours, it will be best to wait until the resulting traumatic or 
inflammatory fever is over and the stage of suppuration established. 
Cases demanding amputation after gunshot injury.—In general, when a limb 
is carried away by a cannon-ball, leaving a tattered, shapeless stump, the 
case is one demanding amputation, and at a point sufficiently far above the 
wound to insure sound tissue to cover the extremity. All cases, however, are 
not so easily solved as this, and I proceed to formulate them as follows: 
1. Wrhen the principal vessels and nerves remain uninjured, the bones not 
badly comminuted, and the soft parts not extensively torn, it would be im- 
proper to amputate. An immovable dressing, with attention to drainage, 
will often reward our efforts to save a limb, with excellent recovery. 
2. When the bones of a limb are comminuted and the fragments thrust 
into the surrounding soft parts, these tissues themselves being greatly lacer- 
ated, and the principal vessels torn, the removal of the member admits of no 
question: it should be amputated. 
3. An arm or a leg may be crushed by the fall of heavy ordnance, pulpi- 
fying the muscles and comminuting the bones, yet the skin exhibit only 
contusion. When grasped with the fingers it will be found soft and without 
resistance. Such an injury will be followed by a rapidly spreading mortifica- 
tion : the limb should be removed. 
* Surgical Treatise, by Richard Wiseman, 1696, 3d London edition, 
f Treatise on Military Surgery, 1737. 
j On Methods of Healing Gunshot Wounds, 1781. 
| Surgical History of the War of the Rebellion, vol. ii. AMPUTATION AND EXCISION IN GUNSHOT WOUNDS. 
307 
4. When the soft parts of a limb are carried away for a considerable extent 
down to the bone, dividing the chief vessel, it should be amputated. 
5. The mere division of the brachial artery, without any serious damage to 
the soft parts or bone, is not a sufficient reason for amputation. It is better 
to secure the vessel at each extremity, and wait to ascertain if the collateral 
vessels will not preserve the vitality of the arm. Should they prove unequal 
to the task and signs of mortification develop, the only resort is the knife, 
which should be applied above the injury. 
6. When the wound involves the elbow-joint, excision should be substituted 
for amputation. 
7. When the shoulder-joint is implicated, the head of the humerus being 
comminuted and the axillary or brachial vessels not divided, excision should 
be adopted. 
In cases where the comminution is not extensive and the bone not splin- 
tered, it may answer to pick away the fragments and treat the injury con- 
servatively. 
Excision of the head of the humerus.—Larrey may be said to have popularized 
excision of the shoulder-joint. The labors of Esmarch, founded on the ex- 
perience of the Schleswig-Holstein War, served to attract further attention 
to the subject. He records 19 cases of excision of the head of the humerus, 
12 of whom recovered with a useful arm, and 7 died. Of the 13 excisions of 
the head of the humerus performed in the English army of the Crimea,— 
8 primary and 5 secondary,—there was only a single death. In a collection 
of 856 cases of the same operation on account of gunshot injuries,* 582 re- 
covered and 267 died, leaving 7 cases in which the result was undetermined. 
Of 951 determined cases of excision of the shoulder-joint, 603 recovered and 
348 died; a mortality of 36.6 per cent. The result of operations done at the 
different periods was ascertained in 831 cases. Of 515 primary excisions, the 
mortality was 31.06 per cent.; of 224 intermediary operations, the death-rate 
was 46.4 per cent.; and of 92 secondary operations, 29.3 per cent. Adding 
together the intermediary and secondary operations, the mortality was 41.4 
per cent.f In addition to the above, Dr. Otis has collected 378 cases of ex- 
cision of the head of the humerus from various sources, with 215 recoveries, 
156 deaths, and 7 cases undetermined; a mortality of 42 per cent. The same 
author records 1086 cases of excision of the head of the humerus performed 
during our late war. Except in 135 cases, in which the result was unknown, 
the mortality for primary was 31 per cent., 46 per cent, for intei’mediary, and 
29.3 per cent, for secondary operations. The difference in favor of primary 
excisions, according to this statement, amounts to about 10 per cent.; and 
the fatality of intermediary excisions appears so great that no consideration, 
save one of extreme necessity, would justify an operation at this period. 
Amputation at the shoulder-joint.—The records of the Surgeon-General’s Office, 
as tabulated and analyzed by Dr. Otis, exhibit 827 cases of amputation at the 
shoulder-joint for shot injuries and diseases consequent upon these. These 
amputations were distributed as follows: 499 primary, with a death-rate for 
known cases of 24.1 percent.; 157 intermediary, with a mortality of 45.8 per 
cent.; 66 secondary, with a mortality of 28.7 per cent.; and 130 in which the 
period could not be determined, the mortality being 23.5 per cent. The mean 
death-rate of the aggregate number of all periods was 28.5 per cent. 
Expectant and conservative plans.—It is understood by these terms, as 
applied to shot injuries of the scapulo-humeral articulation, that the arm 
was placed at rest, inflammatory symptoms combated, abscesses opened, 
and fragments of bones removed as they became loose. There are 505 such 
cases analyzed in the “Surgical History of the War,” exhibiting a mortality 
of 27.5 per cent. 
Comparison of methods.—If a comparison be instituted between the different 
* Prize Essay on Resections, by Dr. H. Culbertson, Trans. Amer. Med. Assoc., 1876. 
f Otis, Surgical History of the War of the Rebellion, vol. ii. p. 600. 308 
WOUNDS. 
methods of treating shot wounds of the shoulder-joint, it will be seen that the 
death-rate by excision is 36.6 per cent.; by amputation, 28.5 per cent.; and by 
expectancy, 27.5 per cent.; a result favorable to the last method. These facts 
teach the importance of discriminating with the utmost care the cases suited 
to each method, and show that the mere implication of the shoulder-joint, 
even though attended with fracture of the head of the humerus, is not suffi- 
cient ground for a resort to the radical measure either of excision or of ablation. 
Excision should be confined to cases attended by comminution of the head and 
upper part of the shaft of the humerus, even though it may be necessary to 
remove five or six inches of the bone. Amputation is proper in cases in which 
the blood-vessels are severed, or where the soft parts of the shoulder are car- 
ried away and the superior extremity of the bone broken into fragments. 
It is more than probable that, were antiseptic measures carefully practised 
in the management of those shot injuries involving the scapular extremity 
of the humerus, the death-rate would be very greatly lessened from the above 
figures, and probably place excision in a more favorable light. 
Excision in the continuity of the humerus.—In gunshot wounds of the arm, 
comminuting or splintering the humerus, there are three courses open to the 
surgeon,—excision, amputation, and conservatism. Aside from experience, 
there are certain reasons for regarding the operation of primary excision in 
an unfavorable light. A bone shattered by a conical ball will in most cases 
undergo, to some extent, necrosis. The tremendous shock transmitted through 
its structure by such a missile affects its nutrition far beyond the limits of 
impact and fracture, giving rise often to osteomyelitis and other diseases. 
These conditions, together with the tedious suppuration which follows, sepa- 
rating extensively the periosteum, tend to defeat bony union. In two in- 
stances of gunshot fracture of the humerus which appeared exceptionally 
favorable for excision, I recently operated without success, both terminating 
in a false joint. 
The experience derived from the Schleswig-Holstein and the Crimean War 
proved unfavorable to excision in the continuity of the humerus; and the 
results of similar operations during the late American War are not calcu- 
lated to commend this procedure, but rather to condemn it. Excision in the 
continuity of the humerus for shot fractures was done in 696 cases* during 
our late civil war, with 477 recoveries, 191 deaths, and 28 undetermined,—a 
mortality-rate of 28.5 per cent. A further examination shows that of the 
number stated to have recovered, 164 cases resulted in non-union, and 37 
subsequently required amputation. Of these 696 operations, there were 487 
primary, with a mortality of 30.7 per cent; 93 intermediary, with a mor- 
tality of 31.1 per cent.; 41 secondary, with a mortality of 12.1 per cent.; 
and 75 in which the period could not be ascertained, with a death-rate of 19 
per cent. These statements exhibit the superiority of secondary operations 
over all others. 
In 3005 cases of shot fractures treated by expectant and conservative plans, 
and recorded in the “Surgical History of the War,” 451 died and 2509 sur- 
vived. Of the last number, 1055 were returned to duty, and 1454 discharged. 
There is, therefore, a mortality-rate of 15.2 per cent, against 28.5 per cent, by 
excision, or nearly one-half greater by the latter than by the former plan. 
Amputation of the arm.—It is difficult to determine in all cases with pre- 
cision what amount of injury will justify amputation of the arm. When the 
limb has been swept away above the elbow by a cannon-ball, leaving the parts 
ragged, a resort to the knife, in order to form a satisfactory stump, admits of 
no discussion. When the soft parts have been extensively torn away, the 
bone splintered and greatly comminuted, implicating perhaps the elbow- or 
shoulder-joint,—and when the brachial artery is divided,—the propriety of 
amputation can scarcely be doubted. There are, however, other cases of 
injury to the arm in which the course of the surgeon is not so clearly marked 
* Otis, Surgical History of the War of the Rebellion, vol. ii. p. 696. AMPUTATION AND EXCISION IN GUNSHOT WOUNDS. 
309 
out, and where he will be reduced almost to inaction before the perplexing 
difficulties which confront him. It may serve to relieve in some degree the 
state of indecision and distrust of judgment to know that men who have 
enjoyed the largest experience as military surgeons become more and more 
conservative in their operations and more disposed to rely on the constitu- 
tional resources of their patients. Comminution or splintering of the hume- 
rus, when near the middle of the bone (Fig. 292), does not justify amputation. 
When there is extensive shattering near the articular ends of the shaft, the 
case becomes more grave; but if the blood-vessels and nerves remain sound, 
and the soft parts be not too extensively torn, excision should be substituted 
Fig. 292. 
Comminution of the humerus by a conoiilal ball.—Army Medical Museum. 
for amputation. Nor does a shot fracture, according to some writers, even 
though attended with a division of the brachial artery, unless accompanied 
with other injuries, such as extensive laceration of the soft parts or great 
comminution of bone, warrant the removal of a limb. In this opinion I do not 
concur. The division of the brachial artery will, in almost every instance, 
cause the death of the limb below. In tine, amputation must be a last resort, 
an extreme measure. It is possible, however, to carry conservatism too far; 
and I believe that this is the tendency of the military surgery of the present 
day. 
In the “Surgical History of the War”* there is an analysis of 5456 am- 
putations of the arm for shot injuries. The result was ascertained in 5273 
cases, showing a mean fatality of 23.6 per cent. Of these operations, 3259 
were primary.—done within forty-eight hours,—with 602 deaths, or 18.4 
per cent.; 902 intermediary, with 302 deaths, or 34.4 per cent.; and 411 sec- 
ondary, with 114 deaths, or 27.7 per cent. The mean fatality of all periods 
was 23.6 per cent. There is also in the same volume an analysis of 2960 
cases of gunshot fractures of the humerus treated by expectancy, with 451 
deaths, or slightly over one-seventh of the whole number. By a comparison 
of the two plans, that of amputation and that of expectant and conserva- 
tive measures, it will be seen that there is the difference between one-fifth 
and one-seventh in favor of the latter. It must not, however, be overlooked, 
as Dr. Otis has observed, that in all probability the simplest and most 
favorable cases were selected for expectant and conservative modes of treat- 
ment, and that a large number of eases were excluded in making up the 
estimate which were, at the commencement, treated conservatively, and 
afterwards by excision or amputation, in which the mortality-rate was very 
great. Many of these fatal cases would doubtless have recovered had the 
latter operations been performed at the outset. I doubt not, from what I 
observed in the large military hospitals during the war, that if a comparison 
could be instituted between the radical and conservative methods of treat- 
ment, free from all vitiating circumstances, it would be found to be adverse 
to the latter. 
Excision of the elbow-joint.—Excisions of this articulation for shot injuries 
have been attended with variable success in the hands of different surgeons. 
In the French armies, according to Chenu, the operation was singularly fatal. 
During the Franco-German War, out of 212 excisions by the French sur- 
geons, 164 died; a death-rate of 77.3 per cent.f When this is compared 
with that of the English surgeons during the Crimean War,—seventeen cases 
recovering in a total of twenty,—and with the results of our own war, it is 
* Surgical History of the War of the Rebellion, vol. ii. p. 805. 
f Ibid., vol. ii. p. 901. 310 
WOUNDS. 
impossible to avoid the conclusion that there must have been something radi- 
cally wrong in the management of these cases. There were, during our late 
war,* 626 excisions of the elbow-joint, partial and complete, of which number 
470 recovered, 146 died, and in 10 the terminations were not known; a mean 
mortality of 23.7 per cent. These operations and their results were distrib- 
uted as follows: 322 were primary, of which 250 recovered, 68 died, and 4 
remained unknown ; 197 were intermediary, of which 127 recovered, 69 died, 
and 1 was undetermined; 54 were secondary, 49 of which recovered, and 5 
died; in 53 cases the period was uncertain, 44 of which recovered, 4 died, and 
5 remained unknown. The superiority of primary operations over those 
practised at a later period is so great that the former are always to be pre- 
ferred when possible. It will appear from the above statement that excisions 
of the elbow-joint and amputation in the continuity of the arm during our 
late war yielded nearly an equal percentage of deaths, the former being 23.7 
per cent, and the latter 23.6 per cent. As compared with excisions of the 
head of the humerus, the mortality being 36.6 per cent., that of the elbow 
furnishes a lower death-rate. In a grand total of 598 excisions, partial and 
complete, of the elbow-joint for shot wounds,f 479 recovered, 113 died, and 6 
remained undetermined. 
The large collection and analysis of cases of excision of the elbow-joint 
(1438) by Gurlt give nearly the same result as stated above,—namely, a mor- 
tality of 24.87 per cent. 
Amputation at the elbow-joint.—This operation becomes necessary when the 
forearm has been extensively lacerated and the vessels torn by shot or shell, 
so that the alternative is offered of disarticulation at the elbow-joint or ampu- 
tation at the lower third of the arm, a point which yields a less favorable result 
than when the operation is done higher up. As practised during the late 
American War, the operation of amputation at the elbow-joint proved, so far 
as the limited number of cases show, more favorable than amputation in the 
continuity of the arm. In 39 cases in which the termination was ascertained, 
there were only 3 deaths, or 7.6 per cent.J 
Amputation in the continuity of the forearm.—The laceration of the soft parts, 
accompanied with comminution of the bones and division of the radial and 
ulnar vessels, constitutes a condition demanding amputation. The superi- 
ority of primary over other periods of such amputation is well illustrated in 
the summary given by I)r. Otis, in which the mortality of primary operations 
is shown to be 9.6 per cent.; that of intermediary, 23.5 per cent.; and that 
of secondary, 15.7 per cent. 
Excision of the bones of the forearm.—Primary excision of these bones is 
an operation rarely demanded. When the radius or the ulna is splintered or 
comminuted, the expectant plan of treatment is to be preferred. 
Excision of the wrist-joint.—So important is the hand that the surgeon may 
venture much in attempting its preservation. The operation of excision of 
the radio-carpal joint was done during the late American War 96 times. Tn 
6 cases the excision was complete, and in the others more or less complete. 
The number of deaths following these operations was 16, a mortality a trifle 
greater than in amputations performed for shot injuries of this joint. Unless 
the disorganization of the articulation produced by a ball is extensive, such 
cases are best left to a course of expectancy and conservatism; and though 
the patient will most probably pass through a long period of suppuration, 
in consequence of caries of some of the components of the articulation, yet 
ultimate recovery with a stiff joint, after the removal of loose sequestra, is 
not improbable. 
Shot wounds of the hand.—The organization of the hand is so perfect, in 
consequence of the rich supply and free communication of blood-vessels and 
nerves, that nothing short of a very complete disorganization will justify its 
■*' Surgical History of the War of the Rebellion, vol. ii. p. 894. 
f Prize Essay on Resections, by Dr. H. Culbertson, Trans. Amer. Med. Assoc., 1876. 
j Surgical History of the War of the Rebellion, vol. ii. p. 909. AMPUTATION AND EXCISION IN GUNSHOT WOUNDS. 
311 
amputation; and when a resort to the knife becomes necessary, it should be 
confined only to hopelessly-damaged parts. 
Gunshot injuries of the thigh.—Shot wounds of the thigh, comminuting and 
splintering the femur and dividing the femoral artery, will generally demand 
amputation. The mortality of all gunshot fractures of the thigh, with or 
without amputation, is very great. According to Macleod, during the Cri- 
mean War, among the rank arid tile only 14 out of 174, and among the officers 
5 out of 20, cases of compound fracture of the thigh recovered without am- 
putation. In 96 of the above 174 soldiers amputation was performed, and of 
the remaining 78, without operation, 64 died. In the cases of the 20 officers, 
10 were made the subjects of amputation, and of the remaining 10, not 
operated on, 5 resulted fatally.* The recoveries of thigh amputation among 
soldiers during the Crimean War were estimated at 34.7 per cent. That 
nearly two-thirds of such operations should prove fatal appears almost in- 
credible; and yet, notwithstanding this high death-rate, the fatality was less 
than that following excision or other conservative plans. As in civil so in 
military practice, the mortality of thigh amputations increases as the trunk is 
approached. In the lower third of the femur the recoveries are estimated at 
43.3 per cent.; in the middle third, at 40 per cent.; and in the upper third, 
at 12.9 per cent. 
In instituting a comparison between amputation and other or conservative 
measures, we have in the surgical history of our own recent war a collection 
of 2003 gunshot fractures of the thigh,f among which are 82 cases impli- 
cating the hip-joint, and 770 in which for the most part the knee-joint was 
involved. Of those implicating the hip, the mortality-rate after amputation 
was 100 per cent. after excision, 83.33 per cent.; and by conservative meas- 
ures, 100 per cent. By extending the comparison of these three plans to the 
different portions of the thigh, the result is as follows. In gunshot wounds 
in the upper third, after amputation, the mortality was 75 per cent.; after 
excision, 72 per cent.; by conservative measures, 71.81 per cent. In the 
middle of the thigh, after amputation, the mortality was 54.83 per cent.; 
after excision, 86.66 per cent.; by conservative means, 55.46 per cent. In the 
lower third, after amputation, the death-rate 
was 46.09 per cent.; after excision, 50 per 
cent.; and by conservative measures, 57.79 
per cent. In those shot injuries of the thigh 
involving the knee-joint, with or without 
fracture, the mortality after amputation was 
72.23 per cent.; after excision, 90 per cent.; 
and by conservative plans, 83.76 per cent. In 
a comparison of 822 cases treated by ampu- 
tation with 1117 cases treated by conserva- 
tive measures, there is 8 per cent, in favor 
of the former, and this holds good in each 
region except the upper third, a fact which 
would suggest the propriety of practising 
conservatism in this particular part. 
Gunshot fractures involving the head and 
neck of the femur.—These fractures are inju- 
ries of the most serious character. (Fig. 293.) 
There were no successful cases of amputation 
at the hip-joint for such wounds in the Eng- 
lish or French army. Langenbeck had one successful case in seven opera- 
tions. All primary operations of this kind during the Italian War died. 
During our own war the result was different. 
How to deal with these fractures involving the superior articulating ex- 
Fro. 293. 
Comminated gunshot fracture of the upper 
extremity of the femur.—Army Medical Mu- 
seum. 
* Holmes’s Surgery, vol. ii. p. 223. 
f Circular No. VI., Surgeon-General’s Office, p. 21. 
j Only two cases were the subjects of amputation. 312 
WOUNDS. 
tremity of the femur can only be determined by a careful analysis of recorded 
cases with their peculiarities. The following tables* exhibit a comparison 
between excision and amputation in shot fracture of the upper extremity of 
the femur: 
Excision. 
No. 
Died. 
Recovered. 
Death-rate. 
Primary 
43 
40 
3 
93.0 
Intermediary 
60 
58 
2 
96.0 
Secondary 
41 
26 
15 
63.4 
Uncertain 
27 
24 
3 
88.8 
Total 
171 
148 
23 
86.5 
Amputation. 
No. 
Died. 
Recovered. 
Doubtful. 
Death-rate. 
Primary 
82 
75 
7 
94.4 
Intermediary 
55 
52 
3 
94.5 
Secondary 
40 
33 
7 
82.5 
Reamputation 
11 
4 
7 
36.2 
Uncertain 
66 
61 
4 
i 
93.8 
Total 
254 
225 
28 
1 
88.9 
In deciding between amputation and excision, the choice must be deter- 
mined by the character of the injury. The conclusions drawn from the 
records of the Surgeon-General’s Office are as follows. Amputation will be 
proper—1, when the thigh is torn off, or the upper part of the femur com- 
minuted, with great laceration of the soft parts; 2, when a fracture of the 
head, neck, and trochanters of the femur is complicated with a wound of the 
femoral vessels; 3, when a gunshot fracture involving the hip-joint is com- 
plicated by a severe compound fracture of the limb lower down, or by a 
wound of the knee-joint. There are two other conditions mentioned by Dr. 
Otis which theoretically demand primary or early intermediary amputation, 
though experience is yet wanting to give them true practical value: 1, where, 
without any fracture, the vessels are cut off close to the pelvis; 2, where a 
fracture in the region of the trochanters is complicated with such a degree 
of longitudinal Assuring as will render excision improper. 
Primary excision of the hip-joint is demanded in all uncomplicated cases of 
gunshot fractures of the head or upper extremity of the femur; intermediary 
excisions when an early diagnosis has not been made, and in cases of gunshot 
fractures of the trochanters followed by inflammation of the joint. 
Secondary excision becomes proper in caries of the head of the femur, 
whether it be the result of direct injury or of extension of disease from frac- 
tures below or about the trochanters, or of damage to the soft parts. The 
expectant treatment is almost always fatal. These views do not correspond 
with those of Lecouest or Larrey, who thought that amputation should be 
confined to cases of fracture associated with wounds of the femoral vessels, 
and even then should always be secondary. 
Dr. Culbertson, in his Prize Essay,f has collected from various sources one 
hundred and twenty-one cases of excisions of the hip-joint for gunshot 
wounds, with a mortality of 89.07 per cent. Gurlt’s collection of similar 
cases amounts to one hundred and thirty-nine, with sixteen recoveries, one 
hundred and twenty-two deaths, and 1 undetermined. 
* Surgical History of the War, vol. iii. 
| Resection of Joints, Tnins. Amer. Med. Assoc., 1876. AMPUTATION IN GUNSHOT WOUNDS. 
313 
Gunshot wounds of the knee-joint.—These are injuries of the gravest import. 
When a ball traverses this articulation, injuring the condyles of the femur 
or the head of the tibia, or both (Big. 294), and lacerating the ligaments 
and other soft parts, or when the joint is completely disorganized by the 
bursting of a shell (Fig. 295), the shock imparted to the system is some- 
times so great as to border on collapse. Just how to deal with gunshot 
wounds of the knee-articulation has been a somewhat unsettled subject. 
There are four plans open to our choice: excision, amputation at the joint, 
amputation at the lower third of the thigh, and immobilization. Excision 
has been most discouraging in its results. There were no successful cases of 
such an operation during the Schleswig-Holstein War, nor during that in 
the Crimea. Of eight cases operated on by Neudorfer in the Austrian army, 
during the Italian War in 1859, three recoveries are reported. Of one hundred 
and ninety cases of knee-joint excision collected by Otis and Huntingdon, 
Big. 295. 
Fig. 294. 
Knee-joint comminuted by a ball which is buried 
in the head of the tibia.—Army Medical Museum. 
Knpe-joint destroyed by a shell explosion.—Army Medi- 
cal Museum. 
fifty-seven of which were done during our late war, one hundred and forty 
died, forty-five recovered, and five were undetermined; a death-rate of seventy- 
five per cent. The lowest mortality occurred in the secondary excisions, being 
62.5 per cent., against 73.1 per cent, in the primary and 87.1 per cent, in the 
intermediate excisions. The cause of death was generally pyaemia, amount- 
ing to eighty-five or ninety per cent. If now we compare the results obtained 
by excision with those obtained by amputation at the lower third of the 
thigh, we find that the different authorities record nearly the same mortality 
for each,—namely, about fifty per cent. Doubtless under antiseptic treat- 
ment this would have been reduced to twenty-five per cent., and until anti- 
septic methods are practised in military surgery it will be impossible to 
ascertain with any degree of certainty the real merits of either plan. Lan- 
genbeck entertains a more favorable view of conservative measures than 
either American or British surgeons. He had seen during the war of 1870 314 
WOUNDS. 
and 1871 one hundred cases of penetrating wounds of the knee-joint recover 
without suppuration. In the Bohemian War of 1866, according to his state- 
ment, eleven cases of gunshot wounds of the knee-joint were saved out of 
eighteen. In the Prize Essay by Dr. Culbertson, already referred to, sixty- 
one cases of excision of this articulation for gunshot injuries are recorded, 
out of which number fifteen recovered, forty-five died, and the result in one 
case was unknown. Gurlt records one hundred and forty-six cases, with 
thirty-three recoveries. Langenbeck resorts to amputation or to excision 
only when the broken fragments at the articular ends of the femur or tibia 
are entirely detached, or where, in addition to comminution, there is exten- 
sive laceration of the soft tissues about the joint. Other cases are treated 
by immobilization and by antiseptics. The experience of Bergmann in the 
Russo-Turkish War is sufficient to show that by the application of antiseptic 
methods to this class of injuries the mortality will be greatly reduced. He 
saved fourteen out of fifteen cases treated early, and thirty-five out of fifty- 
nine relieved late. Reyher in the same service saved fifteen out of eighteen 
cases by antiseptic measures. 
Under the old plan of treatment there can be little doubt that where the 
choice lay between amputation and excision, the former was the preferable 
operation. With, however, the splendid successes achieved by antiseptic sur- 
gery to guide us, the most rational course in the treatment of shot wounds 
of the knee-joint will be to remove all detached fragments of bone from the 
articulation, wash out the cavity thoroughly with the solution of bichloride 
of mercury (one to one thousand), introduce drainage-tubes, dress antisep- 
tically, and secure absolute immobilization of the parts by judicious splints, 
reserving amputation for those cases in which entire disorganization of the 
bones and extensive destruction of the soft parts exist. 
Amputation at the knee-joint.—In cases where the femur remains uninjured 
and the tibia is shattered so near its tuberosity as not to admit of the removal 
of the limb below this point, amputation through the knee-joint is to be adopted 
in preference to that in the lower third of the thigh. It is difficult to under- 
stand why this operation should have been so unsuccessful with the French 
surgeons in the Crimea,—only six being saved out of sixty-nine such ampu- 
tations,—while with American surgeons there were fifty-two recoveries in one 
hundred and thirty-two operations. Those which were done during the pri- 
mary period furnished a death-rate of 36.7 per cent.,—that is, in forty-nine 
operations thirty-one recovered, a mortality much below that following am- 
putation at the lower third of the thigh. 
Excision of the ankle-joint for gunshot wounds.—The excisions practised on 
this joint have been exceedingly discouraging in their results. We are told 
by Holmes that during the Crimean War there were no cases of excision of 
this articulation by either the English or French surgeons. The Otis and 
Huntingdon collection, 183 in number, the result being ascertained in 176 
cases, gives 58 deaths, or a mortality of 32 per cent. Grossheim furnishes 50 
cases from the Franco-Prussian War, with 26 recoveries and 20 deaths, 4 cases 
being undetermined. During the German-Danish War, 1863, Langenbeck 
excised the joint eight times, with one death. There were two elements in 
Langenbeck’s cases which must be taken into the account,—namely, sub- 
periosteal resection and complete immobilization,—neither of which, either in 
the knee or in the ankle, was adopted by our surgeons. Of 45 cases collected 
by Dr. Culbertson in which excision was performed, 32 recovered and 12 died. 
Gurlt’s collection of ankle-joint excisions, 150 in number, gives a death-rate 
of 32.92 per cent. Amputation either through the joint (mortality 12.43 
per cent.), or above in the continuity of the limb (mortality 12 per cent.), is 
a much more successful operation than excision, which fact of itself should 
determine our course where the articulating extremities of the bones are 
comminuted or the tibial arteries torn. Where a conservative course is re- 
solved on in shot-wounds involving the ankle-joint, fragments of bone should 
be removed, the gouge employed if necessary, the articulation well cleansed AMPUTATION IN GUNSHOT WOUNDS. 
315 
antiseptically, drainage-tubes introduced, and the parts immobilized in good 
position. 
Gunshot fractures of the hones.—Balls occasionally pass through a bone with- 
out causing a complete fracture, especially when a missile strikes near its 
expanded articular extremity. Sometimes the external wall is comminuted 
and driven into the cancellated tissue, constituting a comminuted depressed 
fracture; sometimes the bone is fissured, the lines of separation running in 
different directions; and, finally, the bone may be comminuted with the frag- 
ments widely separated and displaced. When a ball perforates a bone the 
wound of entrance and of exit present the same characteristics as in shot- 
wounds of the soft parts, the former being smaller than the latter. There 
is a noticeable difference, however, in the wound of exit, which in bone is 
much larger in proportion to the wound of entrance. 
Contusion of bone is frequently produced by spent balls, and also by de- 
flected balls. 
In simple fracture nothing is required but to wash the external wound 
and surrounding parts with the solution of bichloride of mercury, seal up 
the wound with the collodion solution of iodoform, and apply a properly con- 
structed splint. 
In the more aggravated form of fracture with comminution, the frag- 
ments, unless greatly displaced, should not be disturbed. The wound must 
be treated antiseptically, and the parts immobilized by splints or by plaster 
of Paris, which can be strapped at points corresponding to the wounds in 
the soft parts. 
Primary excision of the ends of bones fractured by shot should not be 
practised, as union is likely not to occur, and in addition the risks of general 
infection are increased. Amputation will be required where, in addition to 
extensive comminution, the chief blood-vessels of the limb are sundered. 
The expectant or conservative treatment should take precedence in all cases 
furnishing a reasonable hope of recovery. Applied to the humerus, this 
course furnishes a mortality of nearly ten per cent, less than when the limb 
is amputated, and in the management of similar injuries of the femur the 
mortality is twenty per cent, less than in amputation. 
Excisions in the continuity of the bones of the leg.—These operations are 
very limited in their application. The following percentages, from the 
“Surgical History of the War,” may be regarded as approximately valuable 
in enabling us to form an opinion upon the subjects which they illustrate: 
For excision of the humerus in continuity, a mortality of 28.5 per cent., 
based on a total of 696 cases. 
For excision of the bones of the forearm, a mortality of 11.2 per cent., 
based on a total of 986 cases. 
For excision of the metacarpal bones, a mortality of 8.8 per cent., based 
on a total of 116 cases. 
For excision of the femur, a mortality of 69.4 per cent., based on a total 
of 175 cases. 
For excision of the bones of the leg, a mortality of 28.2 per cent., based 
on a total of 387 cases. 
For excision of the metatarsal bones, a mortality of 19.3 per cent., based 
on a total of 97 cases. 
These figures exhibit a death-rate for the femur which should exclude it 
from the list of bones warranting excision for shot-wounds. Yery good re- 
sults have been obtained from excision of the radius or the ulna; also from 
partial excision of the metacarpus, the metatarsus, and the fibula. Ex- 
cisions of the humerus leave a useless limb. The statistics drawn from the 
records of military surgery, so far as our late war is concerned, fail in one 
important particular, in not giving the usefulness of the limb after excision. 
Sabre Wounds.—Such wounds are inflicted when combatants are engaged in 
hand-to-hand conflict, and are generally received on the face, on the head, 316 
WOUNDS. 
or over the scapula. The treatment of these injuries does not differ from that 
proper to incised wounds, and consists in arresting hemorrhage, cleansing 
the parts, and uniting the flaps b}r sutures and adhesive plasters. The best 
local application is water or the antiseptic dressing, and, when conjoined 
with rest, this will usually limit inflammation and suppuration. 
Healing. 
In the construction of an imposing edifice or some intricate piece of 
mechanism, it is a delightful and instructive task to observe carefully the 
materials, and the manner in which the artificer fashions and finally combines 
them into a symmetrical structure, full of beauty and design ; and so, after 
the surgeon has properly adjusted a wound, he may sit down and become a 
spectator of one of the most extraordinary works of construction, one which 
is as far above the masterpieces of human art as God is above man. 
Surgeons recognize five methods by which a wound may be repaired : first, 
immediate union; second, adhesive inflammation; third, granulation; fourth, 
union of granulations; fifth, scabbing. The first two are usually included in 
the term “ union by the first intention.” In his union by the first intention, 
John Hunter, as remarked by Mr. Paget, seems to have had in view two 
conditions : one in which no inflammation and no lymph are present, the 
union taking place by blood ; the other in which coagulated lymph is thrown 
out. The union by adhesive inflammation corresponds to Mr. Paget’s “ pri- 
mary adhesion.” Union by granulation answers to the “ second intention” 
of the older authors; union of granulations, to the “ third intentionand 
union by scabbing or scarring is cicatrization under a crust. 
1. Immediate union.—This means the direct coalescence or union of divided 
parts, blood-vessel to blood-vessel, nerve-filament to nerve-filament, connec- 
tive-tissue fibre to fibre, without any intermediate glue, bond, or ligature of 
blood or of lymph; no seam or scar; the whole process the work of five 
or six hours. Mr. McCartney, of Dublin, was the first to describe this 
mode of healing, and thought it quite common in slight cuts; while Mr. 
Paget, who adopts the same term, gives it a much wider significance, even 
extending it in some cases to wounds as large as those resulting from the 
removal of the mammary gland. It requires an imperial faith to believe 
that the gaping mouths of hundreds of capillaries, whose diameters do not 
exceed one three-thousandth of an inch, shall so abut that their canals 
will become continuous, that muscular fibre will meet its fellow, and all the 
other disjointed parts return to their former connection. To my mind it is 
simply impossible. I do not believe that any wound, however slight, and 
however favorable the local and constitutional conditions may be, ever heals 
except through an inflammatory product, called primary cellular tissue by 
Billroth, granulation-tissue by Virchow, and germ-tissue by Rindfleisch. This 
tissue may be exceedingly small in quantity, and the antecedent disturbance 
of the nerves and vessels of the part so inconsiderable as not to attract any 
special notice: still, such disturbance is present, and quietly works out the 
result,—that of uniting divided parts. 
When a part is severed by a sharp instrument, as previously stated, there 
will be pain, retraction of tissues, and hemorrhage. If the vessels are small, 
coagulation takes place, and the flow of blood gradually diminishes, finally 
ceasing altogether. This coagulation forms between the lips of the wound, 
and extends some distance on each side into the severed vessels as far as 
their first collateral bi’anches or inosculations of the capillary net-work. 
(Fig. 296.) The four succeeding cuts, presenting semi-diagrammatic views 
of the process of healing, were drawn from microscopic sections by Dr. 
Shakespeare. 
The obstruction of these vessels by clots is equivalent to the loss of so many 
blood-channels to the circulation, and therefore devolves \ipon those which re- 
main an additional amount of work. From this cause, and the traumatic irrita- HEALING. 
317 
tion, these vessels become distended under the increased blood-pressure, which 
gives rise to some degree of redness about the wound. The same cause which 
crowds these blood-channels with blood-corpuscles determines a transudation 
of the liquid contents of the 
vessels and the migration 
of white corpuscles, so that 
in addition to the redness 
there will be some degree 
of swelling. If we examine 
sections of a wound twenty- 
four hours old, the space be- 
tween its lips and the tissues 
on either side will be seen 
filled with large numbers of 
white corpuscles, which con- 
tinue to multiply for some 
time. While this rapid mi- 
gration of wandering leuco- 
cytes is going on, there is 
a disappearance of the red 
corpuscles, which, together 
with the fibrin, formed the 
clot. A change is also no- 
ticeable in the connective 
tissue of the parts: instead 
of retaining its fibrous form, 
it softens and in a great 
measure disappears. As this 
disappearance bears a cer- 
tain relation to the number of cellular forms present, the idea has been 
advanced that the fibres become the pabulum for these organisms,—a l-esult 
which is not improbable. Be this as it may, it is certain that after the lapse 
of twenty hours the wound appears to contain little else than a large accumu- 
lation of cells, embedded in 
a gelatinous or uniting sub- 
stance consisting most prob- 
ably of fibrin and the residue 
of the former intercellular 
substance. These cells next 
undergo a change of form, 
becoming first oblong and 
then spindle-shaped. Part 
of the blood at least which 
filled up for a certain dis- 
tance the divided vessels and 
surrounding parts during 
this time is gradually being 
removed by absorption, and 
a portion probably becomes 
organized. At this stage, 
then, the union of the sides 
of the wound is effected by a 
bond consisting of cells and a 
solidifying intercellular sub- 
stance. This union possesses 
considerable strength, and is 
quite sufficient to retain the flaps in contact without any artificial support. 
(Fig. 297.) Next follows the vascularization of the uniting medium. This 
is accomplished by outgrowths from the capillary loops on either side of the 
Fig. 296. 
The microscopic appearances of a wound eight hours after its in- 
fliction in the integument of a guinea-pig: a, the wound slightly 
gaping, and filled with blood-corpuscles and fibrin, and on each side 
capillaries similarly filled, the coagula extending also some distance 
into the sides of the wound; b, blood-vessels; c, sweat-gland; d, a 
sebaceous gland. The central part of the cut represents capillaries, 
nerves, and connective tissue. 
Fig. 297. 
The cell-infiltration changed into spindle-forms, and, for the most 
part, the clots from the divided capillaries removed. 318 
WOUNDS. 
chasm, which finally meet and coalesce, thus establishing a vascular bond 
between the two sides, by which time the spindle-shaped cells have, with 
the intercellular substance, reached for the most part the stage of connec- 
tive tissue. These uniting 
cells and intercellular sub- 
stances together with the 
interpenetrating vessels con- 
stitute granulation or re- 
constructing tissue, and, in 
my judgment, form the only 
medium of repair. As there 
is present a large number 
of cells bridging over the 
space between the lips of the 
wound, so we have also an 
exceedingly rich plexus of 
vessels, giving to the young 
cicatrix a color much redder 
than that of the contiguous 
parts. (Fig. 298.) This mul- 
tiplication of blood-channels 
serves to relieve the adjoin- 
ing vessels from over-disten- 
tion, in consequence of which 
all undue redness about the 
margins of the wound disap- 
pears. The consumption and 
reabsorption of the liquid in- 
filtration, and the solidification of the intercellular substance with its 
fibrillation, remove the swelling, while the absence of pressure from the 
nerves relieves whatever of 
tenderness or pain may have 
lingered about the wound, 
and thus all the signs of 
inflammation disappear. 
The union being now se- 
cure, the uniting materials 
themselves become the sub- 
ject of change. The bundles 
of connective tissue, formed 
from the spindle-cells and 
intercellular substance, be- 
come more compact, and the 
rich net-work' of vessels in a 
great measure disappears, or 
remains not as tubes but as 
solid threads, like connective 
tissue, which serve as con- 
necting filaments stretching 
across the former chasm. 
There are three explanations 
for this diminished vascu- 
larity : first, the work of re- 
pair, though an extraordi- 
nary one, demands only for 
a short time an increased 
number of channels for the blood, from which reparative materials are 
derived; second, the formation of vessels to answer a temporary purpose, 
especially in the early economy of the foetus, is well known to every em- 
Fig. 298. 
Thu communication of blood-vessels across the wound by a rich 
plexus and the new connective-tissue bond. 
Fig. 299. 
The position of the wound occupied by connective tissue, its fibres run- 
ning somewhat obliquely; the vascular net-work having disappeared. HEALING. 
319 
bryologist: these, after having met the requirements of the law, gradually 
disappear; third, the compression to which these vessels are subjected by the 
condensation of the connective tissue must favor their obliteration. As a 
consequence of the non-vascularization, the cicatrix is rendered paler than 
the adjoining skin. When the uniting structure is examined, after the loss 
of its blood-vessel plexus, it presents little else than merely a closely inter- 
woven mesh of connective tissue with attached nuclei, the fibres of the 
former being disposed obliquely, somewhat like the plume of a quill, rather 
than directly across the position of the former wound. (Fig. 299.) The effect 
of this close aggregation and condensation of the new formation, pressing 
out the serous moisture which visually bathes connective tissue, is to pro- 
duce contraction and loss of elasticity or suppleness in the bond of union, 
by which the distance between the sides of a wound is greatly diminished. 
This tendency to contraction of cicatricial tissue appears to be inherent and 
continuous, often giving rise to serious evils and deformities, so that it be- 
comes a prime necessity so to condition wounds that there shall be the least 
possible amount of uniting tissue present. 
Healing by granulation is that mode which authors describe as taking place 
in an open or gaping wound. The granulations rise from the bottom and 
sides of the chasm, reach the level of the surrounding parts, and then cicatrize 
or skin over. This mode of repair is like that of an ulcer. If under such 
circumstances the sides be drawn towards each other, and so maintained, the 
granulations will unite with each other, diminishing the extent of the gap. 
What is a granulation ? The answer is very simple. A granulation is a 
mass of cells, intercellular substance, and blood-vessels. In the union which 
I have just described in detail—that is to say, intermediate, or union by the so- 
called process of adhesive inflammation—the reparative material consists of 
cells, intercellular substance, and blood-vessels, which cells pass through oblong 
and spindle forms into connective-tissue corpuscles. This is neither more nor 
less than granulation-tissue : so that really there is no difference in the uniting 
material, but only in the amount present and in its disposition. In the first 
case, in consequence of the close approximation of the sides of the wound, 
nothing but a strip or line appears on the surface; whereas in the latter, or 
union “ by granulation,” a wide interval exists between the sides of the wound. 
Let the union advance a few days, and it will be very easy to convert the 
first into the second by drawing asunder its sides. 
Union under a scab is said to take place without granulation. The blood, 
mixed with dust, dirt, hair, or other foreign materials, hardens into a crust, 
impervious to air, under which cicatrization goes on without inflammation 
or the production of granulation-tissue. This is said to be the ruling mode 
of union in lower animals. If any one will take the trouble to detach the 
scab before repair is complete, he will see a ruddy surface, sometimes gran- 
ular in appearance, and although the elevations may be very few in number 
yet they are nevertheless granulation-tissue. 
After examining this subject with no small degree of care, I reiterate the 
doctrine which I have taught for several years, that nature follows but one 
method in the repair of wounds, and that is through cells, intercellular substance, 
and blood-vessels; in other words, through granulation-tissue, alike present whether 
the wound be small or great, open or subcutaneous. 
To secure a quick and healthy restoration or union of wounds it is a prime 
necessity to diminish as much as possible the need for a large amount of 
granulation-tissue. This is best accomplished by the removal of all blood- 
clots and other foreign matters, the close and accurate approximation of 
divided surfaces, absolute rest, and the prevention of excessive vascular dis- 
turbance, thus reducing the cicatrix to the smallest possible dimensions. 
There is reason to believe that if a wound be made thoroughly aseptic the 
blood which flows into it will undergo organization. 
Ulceration of cicatrices.—Cicatrices often break down from undue pressure, 
or tension, and occasionally from constitutional causes, as scurvy or alcoholism. 320 
WOUNDS. 
These are difficult to heal, often remaining open for years. The management 
of such ulcers consists in immobilizing the parts ; applying stimulants, such 
as sulphate of copper or nitrate of silver; strapping with adhesive plaster; 
grafting; and, should these fail, excision, replacing the diseased with sound 
tissue when possible. When the ulceration has a constitutional origin it will 
be necessary to address our remedies to the particular vice in operation, by 
administering tonics, alteratives, good food, and wholesome air. 
Hypertrophy of a cicatrix, or keloid.—This singular change in a cicatrix 
is occasionally witnessed after operations or in the scars from burns. The 
change is introduced by the cicatrix becoming ridged up, thickened, rounded, 
while its vascularity is increased, causing it to assume a bluish, purple, or 
pinkish color. It frequently becomes very sensitive. A young girl pre- 
sented herself at the clinic of the University with a keloid growth developed 
on the site of a former burn. She complained of a burning sensation in the 
part, and the mere contact of the clothing occasioned great suffering. At her 
earnest solicitation for temporary relief, it was removed ; but it returned, as 
was expected, in the cicatrix of the wound, though with a diminution of sen- 
sibility. Such growths consist of connective tissue and corpuscles in various 
stages of development. When these hypertrophied cicatrices are free from 
sensibility they should not be meddled with, as their growth is always lim- 
ited and they frequently disappear spontaneously. If*, on the other hand, 
they become irritable and painful, a repetition of blisters, followed, on heal- 
ing, by frictions with iodine or mercurial ointment with which a little ex- 
tract of belladonna is incorporated, will often prove successful in effecting 
a cure. 
Nodular cicatrices.—These are sometimes called warty, and consist in the 
elevation of the cicatrix and the subsequent development of irregular knotty 
masses over its surface. These prominences may break down into ulcers. 
Though sometimes seen in the cicatrices following the excision of cancerous 
growths, as in the female mamma, or after the removal of a sarcoma, yet 
they may be benign and appear in entirely harmless scars. Epithelial cancer 
is frequently developed from such surfaces. 
Painful cicatrices.—Cicatrices may become painful in different ways. A nerve- 
filament may become compressed by the contraction of its fibres, or a true 
neuroma may be developed. Such are not uncommon occurrences in stumps 
following amputations. When the extreme sensibility is the effect of the 
first condition, a delicate tenotome should be passed beneath the cicatricial 
tissue and the whole shaved away from its connection with the bone. If it 
results from the inclusion of a bidbous enlargement of a nerve, nothing will 
answer but the excision of the cicatrix with the diseased nerve. There are 
other kinds of cicatricial diseases, independent altogether of wounds, purely 
subcutaneous, which will be discussed under the head of deformities. 
Diseases of cicatricial or scar tissue.—The cicatricial tissue which results from 
healing is in most respects a delicate structure, much less capable of resisting 
injurious impressions, either from within or from without, than the surround- 
ing parts, and often the subject of disease. 
Spurious cicatrization.—Examples of this defect are often seen in strumous 
ulcers, or in fistulous openings from either osseous or rectal disease. The sur- 
face is of a pale-blue or gray color, concealing the granulating tissue below, 
and giving a deceptive appearance of healing. A probe readily breaks 
through, and reveals the true condition as one in which a film of cuticle has 
formed without the conversion of the granulation-material beneath into 
fibrous tissue. To correct such a defect it is necessary, if it be a strumous 
ulcer, to cauterize well with the nitrate of silver and administer constitutional 
remedies adapted to such a diathesis, as cod-liver oil and the different prepa- 
rations of the iodide of iron ; if it arise from bone disease, the removal of the 
affected portion will alone effect a solid cicatrization ; and if from fistulas in 
the perineum, communicating with or lying near to the rectum, the remedy 
lies in these being freely laid open. HEALING. 
321 
Immovable cicatrices.—A cicatrix sometimes adheres to the parts beneath in 
such a way as to prevent sliding or movement. This is frequently noticed 
after the healing is completed in bone disease, after amputations, and indeed 
to some extent after all wounds, whether accidental or made by the knife 
of the surgeon. It gives to the cicatrix a depressed appearance. It is most 
likely to occur when the wound extends through two or more planes of 
tissue. The loosening of such can take place only by the formation of a 
soft and open net-work of connective tissue, moist and pliable, in the deep 
portion of the cicatrix. Time works a great improvement in such cases: 
indeed, it is the chief element in whatever improvement may follow, though 
external agents are not without their value,—such as soaking the part in 
warm water or steaming it, followed by rubbing and kneading. This acts 
as does pressure on plastic deposits, by securing the removal of a certain 
amount of intercellular material, and giving a more open or loose texture 
to the remaining part of the cicatrix. When scars remain intractable to all 
such measures, and the inconvenience experienced is very great, they may 
be divided subcutaneously, pressure being used to prevent bleeding: in the 
course of three or four days motion should be established to prevent the old 
attachments. 
Contraction of cicatrices.—The singular property of contraction possessed 
by a cicatrix is often productive of the most serious evils. This is seen 
most frequently after burns, scalds, or the ulceration following excessive 
mercurialization. The eyelids and lips may be everted, the mouth drawn 
awry, the chin bound to the breast, the articulations forced out of position. 
The possibility of such distortions, even in ordinary scars, demands great 
forethought on the part of the surgeon when planning and executing opera- 
tions, especially about the face. Unfortunately, we are too often powerless 
to accomplish much in cases of an extensive nature. Two plans of treatment 
present themselves,—one that of resisting the contraction by counter-force, 
as in the case of an extremity, by angular splints moved by a screw, or by 
attaching weights to the limb, which shall act gently yet continuously, and 
which will so affect the nutrition of the new formation that the shortening 
is prevented until the tissue assimilates the characteristics of healthy con- 
nective tissue. The second plan consists in removing the cicatrix and sup- 
plying its place with healthy integument, either by transplantation or by 
sliding. When feasible, this proves the more satisfactory method. CHAPTER YI. 
INJURIES OF THE HEAD. 
GENERAL CONSIDERATIONS. 
The important office of protecting an enormous nerve-centre, subservient 
to intellection, sensation, and motion, devolves upon the head; and while 
each component is admirably adapted to answer a special purpose, there is a 
remarkable conspiration in all towards a general object, viz., the defence of the 
brain. The mechanism of the head is admirably designed to neutralize the 
effect of external violence. The hair which covers the scalp, the adipose 
cells which lie closely compacted together in the connective tissue, and the 
stratification and mobility of its components, all tend to break or diminish 
the intensity of blows. The form, also, of the skull is that best suited to de- 
compose force. It is not a plain hollow sphere, fashioned out of a single 
piece, but consists of numerous separate pieces, and these are united, not by 
tongue and groove, nor by overlapping, except in a very limited degree, but 
by serrations. Nor are the different pieces of uniform density in their entire 
thickness, each of the three tables possessing a peculiar arrangement of its 
particles most favorable to the neutralization of force. Lastly, as an addi- 
tional means of protection, the skull has an articulation with the spine which 
admits of great freedom of movement in different directions, thus allowing it 
to recede from blows and elude serious damage. 
Injuries of the Scalp. 
Wounds of the cranial coverings may consist in contusions, incisions, lacera- 
tions, and punctures. 
Surgical anatomy of the scalp.—A brief description of the components of the 
scalp and their arrangement will aid materially in the study of its injuries. 
The order of tissue-planes is—skin, superficial fascia, oecipito-frontal mus- 
cles with their aponeuroses, and sub-aponeurotic connective tissue. 
The skin is secured very closely to the occipito-frontal aponeurosis by an 
intermediate cellulo-adipose structure, consisting of perpendicular and oblique 
connective-tissue fibres, possessing but little elasticity and containing small, 
shot-like masses of fat. In this tissue or fascia are situated many sebaceous 
glands, and in it run numerous blood-vessels and nerves. The arteries are de- 
rived from the temporal, occipital, auricular, supra-orbital, and frontal. The 
nerves are from the fifth and seventh pairs, the small occipital from the 
superficial cervical plexus, and the great occipital from the second and third 
cervical nerves. The occipito-frontal muscles underlying the superficial 
fascia are digastric in form, having fleshy portions in front and behind, with 
an intermediate tendon, which is usually called the aponeurosis. This struct- 
ure is penetrated by vessels, branches of those already described, which in 
this wTay reach the pericranium. Between the aponeurosis and the peri- 
cranium is another fascia, consisting of delicate, elastic connective-tissue 
fibres, entirely free from all fat, and usually containing much serous moisture. 
The different strata of the tissues of the scalp are shown in Fig. 300. 
Contusions.—Contusions of the scalp are quite common both in children INJURIES OF THE SCALP. 
323 
and in adults. A child falls against the corner of a table or stool or upon 
the floor, an adult receives a blow with a bludgeon or is thrown from a 
vehicle against a curbstone, and in a few seconds a swelling or bump makes 
its appearance. This swelling 
is due to the extravasation of 
blood and serum, and possesses 
certain peculiarities of form 
which serve to distinguish it 
from all other swellings in the 
region. It is sharply defined, 
terminating abruptly within 
moderate limits, and not insen- 
sibly blending with, or fading 
into, the surrounding parts. It 
is also depressed in the centre, 
and conveys, to one not familiar 
with such appearances, the idea 
of a depression in the skull. If, 
moreover, a finger be forced 
firmly against the bottom of this 
sunken spot, an increased indentation will be made, which would not be con- 
sistent with the supposition of a depressed fracture. The explanation of such 
appearances will be found in the anatomy of the superficial fascia. The force 
concentrated on a point of the scalp depresses the skin and displaces the fat, 
forcing it into the meshes of the surrounding connective tissue so as to form 
a compact wall on all sides, the skin remaining depressed, from the absence 
of elasticity in the subcutaneous fascia. A swelling, technically termed caput 
succedaneum, is frequently seen in the scalp of new-born children, in cases 
where the labor has been tedious and the head long delayed in the pelvis. 
These are sometimes described as being underneath the aponeurosis; and 
though such is sometimes the case, they are oftener in the superficial fascia. 
The blood which they contain does not coagulate, but remains liquid. These 
blood-swellings sometimes provoke suppuration, and are converted into ab- 
scesses. When diffuse accumulations, either of blood or of pus, follow injuries 
to the scalp, they are below the aponeurosis, and therefore can readily extend 
through the loose sub-aponeurotic fascia. 
Treatment.—The treatment of such contusions consists in the applica- 
tion of cold-water compresses; or, if the swelling is disposed to linger, of 
pledgets wet with a solution of muriate of ammonia, alcohol, or tincture 
of arnica. These failing, the swelling should be brushed over with tincture 
of iodine, and a moderate amount of compression applied. No operative in- 
terference is allowable, save when the tissues degenerate into an abscess, in 
which event, whether in the superficial fascia or beneath the aponeurosis, it 
is proper to lay it open by a free incision and afterwards treat it antiseptically. 
In every case which I have seen where the tumor had been thoughtlessly 
opened, there followed a tedious suppurating sore. Tn one instance, a blood- 
swelling was opened by the medical attendant, and in defiance of all treat- 
ment, refused to heal. On opening it freely, a small tent, which had been 
used to keep the puncture from closing, was found inside, the removal of 
which was followed by a cure. 
Wounds.—Open wounds of the scalp may partake of the character of in- 
cised, lacerated, or punctured wounds, though generally they are lacerated ; 
when not extending below the aponeurosis, there is little separation of the 
flaps, but when below this the detachment may be great. In transverse 
wounds over the forehead the retraction is greatest, particularly if deep 
enough to divide the underlying muscle. A brick falls from a scaffold or 
building upon the head, the edge of which makes a lacerated wound; a 
carter is thrown from his wagon, his head striking against the curbing of the 
street, or the wheel of a wagon grazes the scalp: if in any of these cases 
Fig. 300. 
Diagrammatic view of the layers of the scalp and skull: a, the 
skin; b, the occipito-frontal muscle and aponeurosis; c, the su- 
perficial fascia; d, the pericranium; e, the sub-aponeurotic con- 
nective tissue ; /, the cranial bone, consisting of an internal and an 
external table, with an intermediate porous or diploic structure. 324 
INJURIES OF THE HEAD. 
the wound extends deeper than the aponeui'osis, a large flap may be torn 
away from the pericranium, as the connection between the two is very slight. 
Some years ago, I was called to see, with Dr. Jones, of this city, the case of a 
woman who, while engaged in the manufacture of macaroni, had her hair 
caught in a revolving shaft, by which the entire seal]) was torn away from 
the cranium. Though accurately replaced and sutured, it failed to unite, and 
was followed by general exfoliation of the cranial bones, after which the head 
was covered by an extensive cicatrix. During my last service in the Penn- 
sylvania Hospital, a young girl was brought into the surgical ward who had 
met with a similar, though more extensive, injury, and in a similar way. Not 
only was the entire scalp torn from the head, but along with it one of the 
ears and a portion of the integument on one side of the face. After a linger- 
ing illness of three weeks, the poor sufferer died, worn out by pain and sup- 
puration. 
A curious case of extensive separation of the scalp is related by Dr. Paul 
Eve.* An ignorant midwife, mistaking the protruding scalp of a foetus for 
the bag of waters, made a deep gash in it with a pair of scissors. The 
wound extended below the aponeurosis, and when the labor-pains increased, 
the head was extruded through the rent in the scalp, the latter being everted 
and turned down over the face and neck very much as one would peel the 
skin from an orange. 
Treatment.—In all large wounds of the scalp the hair should be cleanly 
shaved for a short distance around the seat of injury. All foreign matter, 
such as dirt, or particles of sand or glass, should be carefully washed away 
with the usual bichloride solution or with carbolized water, or extracted, and 
the hemorrhage arrested. In wounds of this region the bleeding is usually 
quite profuse for a short time, but rarely so persistent as to require the liga- 
ture, being generally controlled by a wet compress and roller. When over 
the temple or occiput or behind the ear, the ligature will sometimes be neces- 
sary, as the temporal, occipital, and posterior auricular arteries are quite large 
in these localities. In sloughing of the scalp, troublesome hemorrhage may 
follow, and in such cases the plan of Ilewett should be adopted, that of press- 
ing over each main trunk until the one at fault is found, and then controlling 
its circulation, either by a compress and roller, or by tying. It is more dif- 
ficult to secure vessels in the scalp than elsewhere, as they retract within 
the dense unyielding structure. It is always proper, however extensive the 
detachment of the flap may be, to replace it in situ. Irregularities or ragged 
points should not be cut away, unless hanging by a slender thread of tissue. 
The vascularity of the scalp is so great that the vitality will be retained in 
fragments which have but a very limited connection with the flap. Foreign 
matters being removed, the bleeding arrested, and the parts well cleansed, 
the closure of the wound becomes the next duty. This may be accomplished 
by adhesive strips, by separating two or three hairs on each side of the wound 
and passing them through a perforated shot, or by the metallic suture. There 
is a popular notion that sutures should not be introduced into the scalp, under 
the supposition that they tend to excite erysipelas. I believe that this fear 
is without foundation, and have, therefore, no hesitation in advising their use 
when deemed necessary. Where there is any loss of substance it will be im- 
proper to attempt apposition by making tension. The structures, being with- 
out elasticity, will not tolerate such traction ; the suture will quickly cut out, 
and the tension may provoke an inflammatory attack. The usual antiseptic 
dressings should be placed over the wound and kept in place by recurrent 
turns of the carbolized gauze roller. 
Suppuration may follow contusions and wounds, if not properly dressed. 
If in the superficial fascia, abscesses are circumscribed, and heal kindly after 
being opened. When an abscess is formed in the sub-aponeurotic tissue, it 
will be diffused, and should be opened freely at a dependent point and drain- 
* Remarkable Cases, by Paul Eve. INJURIES OF THE SCALP. 
325 
age established. Unless early recognized and evacuated, sloughing of the 
scalp is likely to follow; the pericranium will become detached, and not only 
so, but the dura mater may be similarly loosened from the inner surface of the 
cranium, and the bone, thus deprived of its vascular supply, die. In all cases 
where the scalp is extensively separated from the pericranium, the latter is 
prone to become detached. Persons who have been scalped by the Indians 
often sutfer from exfoliation of bone from this cause. It does not follow that 
in every case of pericranial separation the bone will die. On the contrary, 
1 have seen full two square inches of the frontal bone denuded from the 
effects of a burn, and frequently a less surface from other causes, and yet 
granulation-tissue cover it over, form a new periosteum, and cicatrize soundly. 
A surgeon in the early frontier wars with the Indians recommended, in cases 
where the bone becomes uncovered after scalping, to drill a few openings 
through the external table into the diploe, in order to invite granulation 
from the latter. 1 had occasion once to practise this suggestion on a lad who 
had a portion of one of the parietal bones exposed from a severe injury of 
the head. Little red points made their appearance through the openings, 
but the ultimate destiny of these granulations, and their influence on the 
exposed table, were rendered negative by the sudden death of the patient 
from convulsions. 
Gunshot wounds of the scalp.—These are made by spent balls or by balls and 
fragments of shells in which the impact is at an angle more or less obtuse. 
The missile may cut a groove through the scalp, or may travel between it 
and the bones. It is rare in such cases for the bones to escape being bruised. 
Such wounds are lacerated, and when produced by pieces of shell are attended 
frequently with loss of substance. 
Treatment.—As the wound is probably aseptic, the hair should be removed 
from around it, the parts well washed with the ordinary bichloride solution 
and dressed antiseptically, and the ball allowed to remain until its track is 
healed, after which it can be easily cut down upon and removed; whereas, 
if the wound were probed and incisions made for extracting the missile, the 
track would be liable to become septic, followed by suppuration. 
The general treatment will consist in rest, attention to the bowels, and a 
non-stimulating diet. 
Complications.—The complications which follow wounds of the scalp, from 
wThatever cause, are more important than the simple injury done to the soft 
parts. Erysipelas, neuralgia, headache, convulsions, and intracranial suppu- 
ration constitute the most common of these sequels. In our late war, wounds 
of the scalp were very common. Including incised, punctured, and lacer- 
ated, we have recorded 669 cases, with 9 deaths and 11 disabled. Of gunshot 
wounds, there were 7739, with 162 deaths, or a mortality of two per cent., 
mostly from encephalitis. In the Crimean War, Macleod records 630 cases, 
with 8 deaths,—a mortality of one per cent. 
Erysipelas may attack the scalp either from atmospheric conditions or con- 
stitutional impairment. Though frequently encountering the disease in the 
head and face in the idiopathic form, I rarely meet it as a result of trauma- 
tism. It may be confined to the skin, or it may involve the connective tissue 
under the aponeurosis. This last variety is attended with great danger. The 
disease begins with a slight swelling and redness at the border of the wound, 
spreads over the head, and may extend to the face. If the sub-aponeurotic 
cellular tissue participates in the disease, the scalp becomes puffy and oede- 
matous, assumes a dusky-red color, and is attended with great swelling. The 
head appears almost double its size, and, should the disease extend to the face, 
the eyelids become swollen, and also the nose and lips, producing such a com- 
plete change in the expression and appearance of the face that it is often 
impossible to recognize the features, however familiar they may have been 
before. The disease is attended with well-marked constitutional disturbance, 
often inaugurated with a chill, headache, loss of appetite, coated tongue, fre- 
quent pulse, and delirium. 326 
INJURIES OF THE HEAD. 
The treatment must be regulated by the form of the disease, and the habits 
and constitution of the patient. If confined to the skin, in which case there 
will be redness and puffiness but not much swelling, the hair should be re- 
moved and the parts covered with lead-water and laudanum, or iodine may be 
painted on the skin thickly, just beyond the limits of the disease, in hopes of 
arresting its extension. The use of a mixture of tincture of chloride of iron 
and quinine, applied with a brush over the affected surface, has been strongly 
recommended by Garretson. I am still undecided as to the value of local 
applications, and, while it is quite proper to resort to such in order to pre- 
serve the morale of the patient, I doubt very much if they exercise an}’ 
curative influence over the inflammatory action. Should the deep structures 
be invaded, and the patient suffer from severe headache, it will be proper, in 
an individual possessed of a strong, vigorous constitution, with a full and re- 
sisting pulse, to resort to general blood-letting, carefully watching the effect. 
As soon as the pain in the head is relieved and the pulse reduced in force and 
frequency, the flow should be stopped. If, on the other hand, the patient is 
weak, of a feeble constitution, or of intemperate habits, the lancet will do harm, 
and should never be used. In such cases our attention must be given, mainly, 
to the support of the body, administering freely beef essence, plain milk, and 
milk-punch, with tincture of chloride of iron and quinia : if the patient be- 
comes very restless, opium may be given with advantage. The tendency to 
abscess must be kept prominently in view. To avoid purulent collections, 
the wound should be laid open; and if the tension becomes great, a few free 
incisions from one to two inches in length must be made, so planned as to 
avoid any of the large vessels of the scalp. After these precautions have 
been observed, a tepid laudanum and lead-water dressing should he applied 
over the parts. Not every case demands incisions, nor should they be made 
unless we have good reason to believe that suppuration is imminent. 
Neuralgia and epilepsy are not uncommon sequences of scalp-wounds. The 
cicatrix in such diseases will be found to be supersensitive, and the proper 
treatment is the excision of the scar. Hodge met with a case of epilepsy 
from this cause, which was permanently cured by cutting out the sensitive 
cicatrix. Hr. Mears, of this city, cured a case by a similar operation. 
Injuries of the Bones of the Cranium. 
The bones may be contused or broken. 
Contusions are produced in a variety of ways, as by balls which have not 
sufficient momentum to penetrate the substance of the bone, or by brickbats, 
stones, or bludgeons. Cases of severe contusion are frequently associated 
with an open wound of the scalp, and sometimes with fracture of the skull, 
as well as damage to the cranial contents. If the pericranium is bruised, it 
may result in its separation and in a slight exfoliation of bone from the external 
plate. If the violence reaches to the diploe, disturbing the blood-vessel sys- 
tem of that structure, which I regard as the source of nutrition to the entire 
bone, it is liable to be followed by inflammation of one or both tables. When 
inflammation, either acute or chronic, commences in the diploe, it should be 
regarded as a dangerous occurrence, as the disease tends to transcend the 
limits of the bone and to separate the pericranium from the external and 
the dura mater from the inner table. The separation of the bone from its 
outer and inner periosteal membranes, as well as its final death, is due to 
the inflammatory transudation so compressing the vessels as to cut off or 
embarrass the necessary supply of blood. Nor does the danger end here: 
an abscess under the dura mater will often provoke inflammation and suppu- 
ration in the other membranes of the brain, and in the brain itself. There is 
also here, as in disease of the cancellated tissue of other bones, a liability to 
blood-infection or pyaemia, from the introduction of purulent matter into the 
large veins which exist in the diploic structure. Other changes than those 
enumerated may follow cranial contusion. INJURIES OF THE BONES. 
327 
1. Exostosis.—An inflammatory deposit from the vessels of the pericranium 
is sometimes, through the deposition of lime salts, converted into an exostosis 
or bony tumor. 
2. Hypertrophy.—Shortly after a contusion, thickening may commence and 
extend over much of the superior part of the skull. I had in my possession, 
until within a short period, the skull of an individual who had been struck 
on the back of the head by a slung-shot. A year or more after the receipt 
of the injury, though a married man, he became addicted to masturbation. 
The irritation of the sexual organs became so great that he had to be placed 
under restraint, having lost every instinct of decency. He finally died 
in the Philadelphia Almshouse, but from what cause I could not ascertain. 
On examining the skull, the traces of the old contusion were quite visible 
below and to the right of the protuberance of the occipital bone, with marked 
increase in the thickness of its internal table. The cause of his perverted 
and uncontrollable habits was doubtless cerebellar irritation from this hy- 
pertrophy. 
3. Atrophy.—Sometimes, after a severe blow upon the skull, a change takes 
place in the nutrition of the damaged part, by which it is much diminished 
in thickness. This change is effected by interstitial absorption, similar to 
that which occasionally affects the neck of the femur after falls upon the 
trochanter. 
Both hypertrophy and atrophy of the cranial bones have their counterparts 
in those changes following contusions of the soft tissues. A bruise about 
a joint is often succeeded by a permanent thickening of its structure, and 
a blow over the shoulder results in wasting of the deltoid muscle. 
4. Caries and necrosis.—Contusions may end in caries or necrosis, affect- 
ing one or both tables of a single bone, or extending over the entire vault. 
The case of Saviard, related in the “ Records of Obstetrical Surgery” for 
1762, is the most remarkable instance of cranial necrosis, the entire calvaria 
having been lost after a contusion of the head. It has been thought that 
such extensive destruction of the bones of the cranium must be due to some 
predisposing constitutional state, such as syphilis. This may in some in- 
stances be true ; but I have seen a number of very extensive exfoliations of 
the external table, and in one instance of the outer table of the entire cal- 
varia, where no such pre-existing condition could be reasonably inferred. 
Symptoms of inflammation in the cranial bones.—It is not probable that any 
symptoms indicative of the disease will be recognized until some time after 
the injury has been received. Indeed, a patient may, after an accident to 
the head, be able to follow his occupation, with perhaps no other discomfort 
than a dull though constant headache. After two or more weeks this pain 
will increase in severity, the circulation become accelerated, and the patient 
complain of slight vertigo, some muscular feebleness, or perhaps rigidity of 
the muscles in the back of the neck. These symptoms will be followed by 
wakefulness, or by a troubled, broken sleep, twitchings of the muscles, convul- 
sions (sometimes of an epileptiform character), paralysis, stupor, and death. 
A lad, twelve years old, under my care in the Pennsylvania Hospital, was 
admitted for a severe contusion of the head. A portion of the external table 
of the frontal bone became necrosed. He suffered no pain nor any constitu- 
tional disturbance whatever. At the end of six weeks, without any premon- 
itory symptoms, he fell down in a convulsion and expired. In this case the 
disease of the bone had excited inflammation of the arachnoid, which was 
followed by a collection of pus over the tentorium. When suppuration takes 
place in the diploe, or pyaemia follows the disease, it is announced by rigors, 
elevation of temperature, and sweatings. When suppuration exists between 
the inner table of the skull and the dura mater, its presence is said to be 
indicated by the existence of what Percival Pott called a upuffy tumor1' in 
the scalp, over the seat of abscess. This sign is not always met with in intra- 
cranial suppuration, and may exist when the latter is not present, as, for 
example, just before the separation of the pericranium which follows a bruise, 328 
INJURIES OF THE HEAD. 
or where a serous effusion or pus exists beneath its structure, and in inflam- 
mation of the diploe or in osteomyelitis. Indeed, little value is attached to 
this swelling as pathognomonic of internal abscess. The most characteristic 
signs of such suppuration are headache, rigors, fever, coma, and hemiplegia. 
Treatment.—Inflammation once established in the walls of the cranium is 
a very unmanageable disease. If limited to the external table, exfoliation will 
follow in due time. The dead bone should be removed as soon as it is discov- 
ered to be movable, and not before; and, until this takes place, the case may 
be left with great propriety to natural processes. When the diploic structure 
is inflamed, though we cannot arrest its progress or secure resolution, we 
may limit or prevent intracranial disease, and for this purpose the head should 
be cleanly shaved, the patient moderately purged, blood locally abstracted, 
cold applied, small doses of a mercurial administered, and absolute rest in 
the recumbent position enforced. 
The sequels of bone contusion should command the greatest attention. If 
the bruise is superficial, producing a plastic subpericranial transudation, an 
exostosis may follow. It is only when this outgrowth steadily increases in 
size that any operative interference is admissible. I have frequently seen 
such tumors after a short time cease to grow, and remain entirely quiescent. 
If this result should not be realized after three or four months, the mass 
should be removed by bone-forceps, chisel, or saw. 
For hypertrophy or atrophy we have no remedies, except when they are due 
to a constitutional taint, which will be considered elsewhere. 
Intracranial abscess may follow various injuries of the skull, as contusions, 
fractures, or wounds, or may result from meningitis or cerebritis. The pus 
may form between the dura mater and the internal table of the cranium, in 
the membranes, or in the substance of the brain. 
Abscess following acute inflanvmatory conditions of the meninges or 
traumatic violence to the skull rarely appear earlier than the second week, 
usually after the third or fourth week. The accumulation is generally cir- 
cumscribed, but occasionally is diffused, and may dissect its way to the sur- 
face when cerebral or open into a ventricle. The sides of the abscess-cavity, 
when circumscribed, are somewhat irregular, lined with thickened neuroglia, 
and surrounded by a ring of inflammatory softening. There are no symp- 
toms which enable the surgeon to diagnose intracranial abscess with cer- 
tainty. The most common phenomena are pain, local at first, afterwards 
more diffused, rigors, slow pulse, wakefulness, nausea, possibly with vomiting, 
and mental hebetude, culminating in profound stupor; occasionally there are 
convulsions, muscular twitching, and monoplegia or hemiplegia. Barker 
and Nancrede call attention to subnormal temperature in these cases. 
Treatment.—As intracranial abscess, if allowed to progress without inter- 
ference, invariably terminates fatally, a question of no small interest arises 
in this connection as to the use of the trephine. Shall a way be opened for 
the escape of pus? Pott performed the operation in eight cases, with five 
successes. Dupuytren, in one instance, opened an abscess successfully 
which was beneath the membranes, one inch deep, in the substance of the 
brain; Guthrie, one in the arachnoid, which was circumscribed; and Roux, 
as recorded by Hewett, one probably in the brain. Noyes,* of New York, 
emptied a collection of pus beneath the dura mater, under circumstances 
not unlike those of Roux’s case, the suppuration having followed a dis- 
eased bone in which a sinus existed. The closure of this sinus, in Noyes's 
case, was followed by epileptic convulsions, which were due to brain- 
pressure from the accumulation of pus, and for which the trephine was 
used. The epilepsy was not cured, though relieved. This patient died, 
three years after, from cerebritis. Jones and Chinault,f of Richmond, Ken- 
tucky, trephined the skull and evacuated an abscess, with blood, under the 
dura mater, forty-two days after a fracture. The patient made a good re- 
* Hamilton’s Surgery, page 533. 
f Ibid., page 533. INJURIES OF THE BONES. 
329 
covery. Of eleven cases of trephining for cerebral abscess, collected by 
Prof. S. W. Gross from military records, five recovered. Detmold* even 
carried his puncture into the lateral ventricle, to reach a collection of pus. 
The patient did not survive the operation. Nancrede trephined a patient 
who at the time of the operation was apparently moribund, but who, after 
incision into the brain and the discharge of one or two fluidounces of 
pus, revived and lived until the sixth day. Dr. O. W. Maher trephined a 
female child, four and a half years old, for abscess of the brain following 
compound fracture of the skull, and situated in the right frontal lobe. The 
child made a good recovery. Weir performed a similar operation, and evac- 
uated two drachms of pus. The abscess followed an injury to the head re- 
ceived six years previously. Yon Bergmann gives an interesting ease of shot 
injury of the skull, followed several months afterwards by suppuration. The 
existence of paresis of the muscles on the left side of the face led to the 
diagnosis of an abscess situated in the lower part of the fissure of Rolando. 
Although the pus was not discovered at the time of the operation, yet shortly 
afterwards it found its way to the surface and was discharged. The case 
proved fatal, other abscesses having formed. 
Wilson reports a case of abscess of the brain in a boy eleven years of 
age, the result of injury. The trephine was applied to the skull at a point 
indicated by the symptoms, and three ounces of pus were discharged: the 
patient recovered. Schlede and Tuckenbrod furnish a case of cerebral ab- 
scess following suppurative disease of the middle ear which was operated 
on successfully. Macewen, of Glasgow, operated on a similar ease of cere- 
bral abscess the result of disease of the middle ear: the patient, I believe, 
recovered. Gowers and Barker also report a case of abscess of the brain 
from a similar cause, cured by trephining. The case of the distinguished 
ex-Senator Conkling, if reports are correct, was one of cerebral abscess due 
to disease of the middle ear: the abscess was located and emptied by Dr. 
Sands. The case terminated fatally. 
There are several difficulties which environ this subject. First. Even 
where the symptoms following a contusion of the head, such as rigors, de- 
lirium, stupor, and hemiplegia, indicate the existence of suppuration, its 
exact locality is a matter of great uncertainty. It may, as previously stated, 
be below the dura mater, below all the membranes of the brain, in the brain 
itself, or remote from the seat of cranial injury. Holmes and Bell each 
opened the cranium in a case where the symptoms of cerebral pressure were 
well marked, but no pus was found. In the case which I have given of the 
boy dying of abscess, in the Pennsylvania Hospital, following injury of the 
frontal bone, the pus was situated on the tentorium. Second. The suppura- 
tion is often diffused, the result of an equally wide-spread meningitis. Third. 
The symptoms on which the operation is based are often due to pyannia, in 
which the general system is hopelessly involved, abscesses existing in the 
lungs, liver, sinuses of the brain, and other parts of the body. Hewett 
gives eight cases of trephining for abscess at St. George’s Hospital, all of 
which proved fatal from pysemic and structural changes of different kinds 
in and below the arachnoid. In one case, in which I punctured the protruding 
dura mater and gave exit to the accumulation, the patient subsequently died 
from pvsemia. 
It will be found that the successful eases of trephining for abscess have 
been, for the most part, those where the pus was beneath the bone and ex- 
ternal to the dura mater, or where either a fracture or a sinus led to the exact 
locality, or where the pus was circumscribed. Of the seventeen cases men- 
tioned by Holmes which were left without operation at St. George’s Hospital, 
all died. With such an alternative, therefore, I shall always feel it my duty, 
where there are good grounds for believing in the existence of suppuration 
and with a reasonable conviction as to its locality, to open the skull and 
* American Journal of the Medical Sciences. 330 
INJURIES OF THE HEAD. 
give to my patient the only chance, desperate as it may be, which remains 
for his rescue. The most favorable cases for operation are those in which 
paralysis of a single muscle or group of muscles exists, as it indicates a 
circumscribed collection; though in a case recorded by Guthrie in which 
paralysis was present, no collection was found on opening the skull. The 
existence of pyaemia is decidedly unfavorable to an operation, as, even 
should we be fortunate enough to reach the collection of pus, its evacuation 
would not correct the constitutional infection. Of fourteen cases of formal 
operations for cerebral abscess, ten recovered and four died. 
As to the proper place in which to apply the trephine, the judgment of the 
surgeon must determine the position, after a careful and comprehensive con- 
sideration of the case based on the symptoms present and on the cerebral to- 
pography. Should the “ puffy tumor” of Pott be present, it must not be under- 
estimated, and the incision, if the cerebral symptoms do not contra-indicate, 
should be made directly through this swelling, to the bone. Where the scalp 
is detached and can be raised up from the outer table, the trephine should be 
applied at that point, and if, underneath, the bone is of a dull-gray color, the 
indications are still more definite. When the diploe is reached, should pus 
make its appearance, it is deemed an unfavorable sign, as the case is proba- 
bly one of pyaemia, whatever else may exist. After the ring of bone is ex- 
cised, should no pus be found external to the dura mater, the latter should 
be carefully examined, in order to ascertain whether a purulent collection 
exists beneath. This will be indicated by a tendency in the dura mater to 
rise up or protrude into the opening made in the bone; and if such be the 
case, the membranes should be punctured with a sharp-pointed bistoury. 
If no pus is encountered in this position, and yet there is reason to believe 
that it is in the brain-substance, what course is next indicated? Shall an 
opening he made into the brain at a venture, or shall the surgeon be content 
to wait for instructions by the future progress of the case? There are 
reasons for both courses. Roux* once trephined for abscess, and, not finding 
any collection after opening the membranes, proceeded no further. The 
patient died, after which an abscess was found almost at the surface of the 
brain. Petit trephined a child, after a compound fracture, without obtaining 
any pus and without any alteration of the urgent symptoms, though some 
bloody serum escaped. Two days after, an abscess found its way spontane- 
ously to the opening and discharged, after which the boy recovered. In 
a very remarkable case,* in which a knife-blade was driven through and 
broken off in the skull, and had remained several years without causing any 
unusual symptoms, but finally gave trouble, Dupuytren trephined the head, 
removing the foreign body, and afterwards cut into the brain, emptying a 
large collection of matter, and thereby saving the life of his patient. We 
need not err in either direction in cases of such obscurity. The exploring- 
or the aspirating-needle should be introduced into any suspicious locality, 
and if the instrument discloses a purulent collection, the bistoury must open 
the way for its escape; if not, all incisions are rash and unsurgical. When a 
cerebral abscess is opened, the cavity should be washed out with a solution 
of the bichloride of mercury (one to two thousand), a drainage-tube intro- 
duced, and the antiseptic dressing applied. The scalp flap, under the cir- 
cumstances, should not be stitched, but should simply be allowed to rest 
without restraint in position, or an oval piece may be removed from the most 
dependent part of its border for accommodating the drain. 
If the operator, with all the precautions that have been enumerated, fails 
to find the abscess, wThat next? Unless some new development shall have 
occurred, rendering a second perforation more promising than the first, there 
is no indication for its repetition. There can be no justification for boring 
holes around the entire head or at several different points (as one would 
prospect for oil), after the recommendation of Ileister and Benjamin Bell. 
* Archives Generates, vol. xxiv. page 81. FRACTURES OF THE SKULL. 
331 
Fractures of the Skull. Anatomical Considerations.—The mechanism 
of the head, when properly understood, will explain very satisfactorily the 
effects of external violence. Its spherical form serves not only to decompose 
forces when applied to its surface, their vibrations radiating in all directions 
from the point of contact, but also, by conducting these vibrations to the 
base, often determines fractures in this locality. The structure of the bones, 
consisting of two tables of different degrees of density, with an intermediate 
spongy or diploic tissue, explains such facts as the following: the external 
plate may be broken without injury to the internal; the internal may be 
fissured without fracture of the external; there may be fracture of the ex- 
ternal table, with depression, without encroaching upon the brain, the bone 
being driven into the diploic structure. 
When the calvaria is removed, three distinct fossae are seen occupying the 
inner surface of the base, the posterior one called the cerebellar fossa, and 
the anterior two the cerebral fossae. These rise, as we advance from behind 
forwards, in planes or terraces, one above the level of the other. Notwith- 
standing the great expanse of bone forming the superior portion or vault of 
the cranium, it is contracted at its base into three comparatively very narrow 
cavities. The orbital plates of the frontal bone form the floor of the anterior 
fossa, the petrous parts of the temporal bones separate the middle from the 
posterior, and the basilar process of the occipital bone forms not only a 
portion of the posterior but rests against both the body of the sphenoid 
and the margins of the petrous portions of the temporal bones. It also consti- 
tutes the bony roof of the pharynx : hence the hemorrhage into the throat 
when it is broken. The petrous parts of the temporal bones lodge the organs 
of hearing, which explains the bleeding from the ears and the oozing of the 
cerebro-spinal fluid when these bones are fractured. It follows from these 
anatomical peculiarities that there are three basal foci, towards which all 
violent forces concentrate. It is also true that such forces take the shortest 
or most direct route to the base. 
In applying physical laws to the mechanism of the skull, we have the 
explanation of the fact that a blow over the frontal region, should it be 
ft>rcible enough to reach the base, will fracture the orbital plate, or plates, of 
the frontal bone which form the floor of the anterior cerebral fossa. By the 
same law, a force applied upon the vertex will reach the middle fossa, and as 
the petrous parts of the temporal bone are the foci of this region, one or the 
other of these will probably be broken. When the violence is received over 
the occipital or posterior portion of the head, the force will be accumulated 
at the basilar process of the occipital bone, reaching in this way the posterior 
or cerebellar fossa ; but, as the basilar process rests against the apices of the 
petrous bones, the fracture may involve the middle fossa also. 
The thickness of the cranial bones and morbid alterations of their structure 
constitute predisposing causes of fracture. The walls of the skull are fre- 
quently quite thin and will yield to a very moderate force, while in other in- 
stances they are very thick and are capable of resisting an almost incredible 
amount of violence. In the advanced state of syphilis we not unfrequently 
meet with such changes in these bones as render them quite brittle, and 
incapable of withstanding a very ordinary stroke. 
Classification of Cranial Fractures.—Fractures of the cranium may be 
divided, according to position, into fractures of the vault and fractures of the 
base. They admit of another general division, based upon the degree of pene- 
tration,—namely, into complete and incomplete,—complete when the fracture 
extends through both tables, and incomplete when onty one table is broken. 
Wherever situated, or whatever the degree, however, they are best arranged 
under two heads, simple and complicated. A simple fracture consists in a 
mere solution in the continuity of the fibres of the bone, without any ex- 
ternal wound or implication of the cranial contents. A complicated fracture 
is one in which there is something superadded to the break in the bone, and 332 
INJURIES OF THE HEAD. 
which adds danger or importance to the injury. The complications are the 
following : 1, an external wound, constituting what is called a compound 
fracture; 2, location, when the fracture is situated at the base of the skull; 
3, depression, in which the fragments of the broken bone are driven in, so as 
to encroach upon the cavity of the skull or upon the brain, with or without 
an external wound; 4, gunshot fractures, produced by fire-arms; 5, puncture, 
in which a sharp-pointed weapon, like an arrow-head, sabre, nail, bayonet, or 
walking-stick, penetrates the soft parts and bone. 
Fracture by contre-coup is used in such a vague sense that it should be dis- 
carded from the nomenclature of cranial injuries. Strictly interpreted, it 
applies only to a fracture which takes place directly opposite to the point 
where a blow is applied to the head, an occurrence. I apprehend, which very 
rarely happens, unless the opposite point is a fixed or resistant one, in which 
case it would not be properly a fracture by contre-coup. That fractures do 
occur at points opposite to the contact of violence is a matter of common 
observation ; but these are examples of direct fractures. If a man falls head- 
long from a height upon the vertex, he is liable to have a fracture at the base 
of the skull, but in such a case there are two antagonizing forces,—the 
resistance of the ground, and the weight of the body, plus its momentum, 
communicated to the base through the articulation of the spinal column with 
the occipital bone. Mr. Bryant reports the case of a man brought into Guy’s 
Hospital* in a dying condition, who had fallen upon his head from a scaffold 
with such force that the summit of the spinal column was driven into the skull. 
Causes of Cranial Fractures.—Fracture of the skull may be caused in 
various ways, as by falls upon the head, by blows, by punctures with sharp- 
pointed missiles, and by fire-arms. 
The location and form of cranial fractures are often determined by the 
manner in which the injury is inflicted, and the form of the vulnerating body. 
When the head is caught between two opposite forces, the fracture is likely 
Fig. 301. 
Practure of the skull produced by a bludgeon.—From a specimen in the University Museum. 
to be a double one, corresponding to the points where the pressure is applied. 
Where fractures take place in the vault of the cranium, they are usually the 
result of direct force. Fractures at the base of the skull follow diffused force, 
as where a person falls from a height and strikes upon the head, or is buried 
under falling timbers or walls. These injuries involving the base often com- 
* Guy’s Hospital Reports, vol. v., 3d series. FRACTURES OF THE SKULL. 
333 
mence in the vault and extend into the former, radiating in various directions, 
sometimes completely encircling the skull, and occasionally forcing asunder 
the sutures. In the case of a restaurant-proprietor to whom I was called, 
who had fallen from the third-story window of his house upon the brick pave- 
ment of the yard, a post-mortem showed a fracture passing round the cranium 
from vertex to base, separating the head into two parts, with also an antero- 
Fig. 302 
Fracture produced by the edge of a brick.—From a specimen in the University Museum. 
posterior division of its base. Diffused force applied to the skull will some- 
times open sutures which have been long closed. 
When the head is struck with a bludgeon or other blunt body, the fracture 
will generally be simple and without depression, but comminuted, and confined 
to the locality of the force. (Fig. 301.) When a blow is inflicted with an 
implement having a dull edge, as the side of a shovel, the back of a butcher’s 
Fig. 303. 
Fracture produced by the pole of a hammer. 
meat-cleaver, or the edge of a brick, the fracture will probably be an oblong 
one, complicated with an external wound, and depressed. (Fig. 302.) When 
the vulnerating body is circumscribed and flat, like the pole of a hammer or 
hatchet, in which case the force is very concentrated, there will probably 
follow a starred, comminuted, and depressed fracture. (Fig. 303.) In all 334 
INJURIES OF THE HEAD. 
cases the internal table exhibits greater comminution than the external. 
(Fig. 304.) A piece may be completely excised from the cranium, down to 
the membranes of the brain, by a 
sabre blow; in which case the in- 
jury is called an incised fracture. 
Repair op Fractures op tiie 
Skull.—When the separation be- 
tween the fragments is not too 
great, union is effected by an inter- 
mediate fibrous tissue, in which are 
frequently deposited bone salts. 
This callus, so far as I have ob- 
served, is always intermediate. 
Were it otherwise, and should the 
callus occupy the cerebral surface 
of the fragments, it would be fol- 
lowed by irritation of the brain and 
its membranes similar to that pro- 
duced by an exostosis growing from 
the inner table of the skull. Where 
fragments of considerable size have 
been removed after comminuted 
fractures, the void is occupied by 
a fibrous membrane, which in time 
may become partially ossified. 
Prognosis.—Fracture of the skull in itself is not a serious injury. The 
danger to be apprehended arises from the damage sustained by the contents 
of the cranium, and, however simple an injury of the head may be, a surgeon 
should be cautious in venturing an opinion as to its final termination. Very 
simple accidents prove fatal, while others which appear almost hopeless re- 
cover. I have seen a blow upon the temple with the closed fist produce death 
in a few hours, and I have known the skull to be broken in by an axe, lacerating 
the membranes of the brain and the brain-substance, and yet recovery follow 
without an alarming symptom. When the fracture is a simple one, situated 
in the vault, and without any decided concussion or any signs of compression 
of the brain, a favorable result may be anticipated. The addition of marked 
concussion to a case of simple fracture gives it a graver aspect. A depressed 
fracture is a serious complication, and when accompanied by compression of 
the brain it is a very dangerous one indeed. Fractures which involve the 
base of the skull are in most instances fatal; and here, as elsewhere, it is 
not the bone lesion which makes the case so serious, but the meningeal and 
cerebral sequences. A moment’s inspection of the base of the skull, through 
which pass the upper part of the spinal marrow, numerous pairs of nerves, 
and important vessels, is quite sufficient to explain the fatality of such 
accidents. 
The mortality of skull-fractures is very great. In 128 of such injuries 
brought into the Hew York Hospital, according to Lente, 106 died, a mor- 
tality of 82.8 per cent. Of 305 cases treated in the Pennsylvania Hospital 
during a period of forty-four years, 146, or 48 per cent., proved fatal. 
Fig. 304. 
Comminution of the internal table in fracture of the skull. 
Simple Fracture of the Skull.—The existence of a simple fracture of the 
skull must be a matter of inference. There are no signs which indicate 
its existence. If an individual receives a severe concentrated blow upon 
the head, and there follow symptoms of concussion or compression, we very 
naturally suspect the presence of a fracture, though it is quite true that 
such cerebral injuries often follow without any break whatever in the bones. 
Comminuted and even depressed fractures may exist without being detected. 
The extravasated blood which collects beneath the scalp serves to conceal FRACTURES OF THE SKULL. 
335 
them from the touch, or the break may be under the temporal aponeurosis 
and muscle and cannot be reached by pressure with the lingers. The swell- 
ing which follows the local violence will often mask the damage. If after a 
blow upon the forehead, or behind the ears, the overlying cellular tissue be- 
comes infiltrated with air, crackling when pressed upon, we may very prop- 
erly assume the existence of a fracture of the external table of the frontal 
sinus or mastoid cells, even if no other visible or tangible signs are present. 
There are certain topographical features of the skull which may lead the 
surgeon astray: such are the inequalities upon the surface, the depressions 
which result from the angular conjunction of bones, the results of syphilitic 
ulcerations, the lines of the sutures, and the presence of the Wormian pieces. 
All such sources of possible error must be kept in mind. There are, however, 
cases in which a simple or a comminuted fracture can be determined with 
certainty. When, for example, a bone is broken in the line of the old suture, 
the mobility of the fragments can be recognized by pressure. Sometimes, 
when there is comminution, the linger can discover the movement of the 
pieces. 
Treatment.—The indications in the treatment of a simple fracture of the 
skull are to secure reaction when there is severe concussion, and prevent the 
occurrence of inflammation. If the patient is cold and pale, with a small, 
feeble, and frequent pulse, and is in a state of semi-unconsciousness, he should 
he placed in bed, and heat applied to the epigastrium, along the spine, and 
to the lower extremities, by means of hot bricks, or bottles filled with hot 
water and wrapped in pieces of flannel. If the state of collapse continues 
over a few hours, it will be proper to administer a small amount of stimulus 
by the mouth, or, should the patient be unable to swallow, it may be thrown 
into the bowel. When given by the mouth, a single teaspoonful of good 
whiskey or brandy in a little milk every hour will be sufficient, unless the 
collapse increases, when a dessertspoonful may be given every half-hour. If 
used in an enema, two tablespoonfuls, with the same amount of milk or beef 
essence, once in three or four hours, will be sufficient. The greatest caution 
is necessary in giving stimulants in such cases. The state of depression or 
collapse is one unfavorable to the ready absorption of the stimulants intro- 
duced into the stomach, so that there is danger of their accumulation, and 
of the reaction, when it does take place, becoming excessive. On the earliest 
signs, therefore, of recovery, such as vomiting, returning warmth and color, 
a fuller pulse, and improved consciousness, stimulants should be withdrawn 
and our remedies directed towards moderating arterial excitement and the 
cerebral congestion. The head should be elevated, and ice applied, either in 
a rubber bag or in bladders. In severe cases the head should be closely 
shaven preliminary to the application of cold, by which means its effect will 
be greatly intensified. Should the pulse become full and frequent, the tem- 
perature rise above the normal standard, the skin become hot, with headache 
and flushed face, general blood-letting will be required; or if the symptoms 
are not urgent, the local abstraction of blood by cups to the back of the neck 
will answer. When the vascular pressure upon the vessels of the brain has 
been controlled, the vantage-ground should be maintained by the use of tinc- 
ture of veratrutn viride, two to four drops every hour, until the diminished 
force and frequency of the pulse indicate its constitutional operation, when 
the dose must be either lessened or the intervals of administration lengthened, 
in order to avoid serious depression of the heart. The bowels should be kept 
freely open, as another means of attracting blood from the head, and care 
taken that the bladder is emptied. The patient once extricated from the 
immediate dangers of the injury, the next step is to prevent inflammatory 
sequences. For this purpose I know of no single remedy comparable to 
calomel in preventing meningitis and encephalitis. One-fourth of a grain 
every three or four hours may be given, and, if the bowels are moved more 
than twice in the twenty-four hours, a quarter of a grain of opium, or five 
drops of laudanum, should be administered sufficiently often to keep the 336 
INJURIES OF THE HEAD 
evacuations within the proper limitations. The earliest evidences of the con- 
stitutional action of the drug must be the sign for either its withdrawal or its 
less frequent administration. Should the patient complain of headache and 
sleeplessness, bromide of potash, in doses of twenty grains once in two or 
three hours, will, after a few doses, usually give relief. During the first few 
days, when all our professional resources are directed against inflammatory 
complications, the diet must be of the simplest kind,—such as milk, toast- 
water, and chicken-water,—but when six or eight days have elapsed, a more 
liberal allowance of food may be permitted. Entire quietude of body and 
of mind is an important consideration in the management of such a case. 
Complicated Fractures and their Signs.—When an external wound accom- 
panies a fracture of the skull it is called a compound fracture. The wound in 
the soft parts is generally both contused and lacerated, and is rarely followed 
by the loss of much blood. The exposure of the cranium enables the surgeon 
to ascertain with certainty the presence of a fissure. The introduction of 
the finger (rendered aseptic) into the wound, and a careful examination of the 
surface of the bone, will usually reveal even a slight irregularity; or if the 
bone is wiped clean with a soft piece of aseptic sponge, the eye will detect a 
red line corresponding to the breakage. The practice of scraping away the 
periosteum and staining the surface with a colored fluid like ink, which will 
sink into the narrowest crevice and form a persistent dark line, should never 
be resorted to, unless there is an urgent necessity for so doing. 
When an external or scalp wound exists, as in compound fracture of the 
skull, the treatment will be the same as in ordinary wounds of the scalp, or 
that which would be proper in a compound fracture in any other portion of 
the skeleton,—namely, thorough cleansing with the bichloride of mercury 
solution (one to one thousand), removal of the hair, arrest of bleeding, 
closure of the wound, so as to convert it, if possible, into a simple fracture, 
and the application of antiseptic dressings. 
Fractures of the base of the skull.—These may or may not be attended with 
an external wound, and when such is pres- 
ent it can have no direct communication 
with the bone lesion, save occasionally 
when the roof of the orbit is involved. 
They are rarely attended with much dis- 
placement, though sometimes after very 
great violence, and when the sutures are 
broken asunder, there may be marked de- 
pression or elevation of one or other of the 
fragments. They may be very limited and 
simple in character, confined to a small 
portion of a bone, or they may encircle 
the skull, or may radiate in various direc- 
tions across its base. (Fig. 305.) When 
they involve more than a single fossa the 
determining force is usually a diffused one. 
Causes.—It is no ordinary force which 
produces a fracture at the base of the skull. 
In most cases this force is communicated 
from the vault and is diffuse in its charac- 
ter ; as when a person is thrown with great 
violence from a carriage, or falls from a 
considerable height, the head striking the 
curbing or pavement of the street. The 
accident is not uncommon to sailors who 
tumble from a mast headlong upon the ship’s deck. It may result from 
force directly applied, as in the two cases recorded by Mr. llewett in his 
very valuable treatise upon fractures of the cranium, in which the condyles 
Fig. 305. 
Extensive radiating fracture of the base of the 
skull. FRACTURES OF THE SKULL. 
337 
of the inferior maxillary were driven into the skull by a blow upon the chin. 
I have seen the accident follow direct force by a child falling upon a cane 
and driving its extremity through the orbit and the orbital plates of the 
frontal bone. A sailor was brought into the University Hospital who had 
fallen one hundred feet from the mainmast of a vessel. There was a wound 
over the right malar bone, and the man was unconscious, with heavy breathing 
and rapid pulse. In a few hours he died. An examination showed a separa- 
tion of the articulation of the angular process of the malar with the external 
angular process of the frontal, a fracture of the orbital process of the former, 
and also one extending across the orbital plate of the frontal bone into the 
frontal sinus. In this case the fracture was the effect of direct force. A blow 
upon the nose may break the cribriform plate of the ethmoid, the force being 
communicated through the bony septum of the nasal fossa. In exceptional 
cases a fracture of the base may result from a fall upon the buttocks, or 
even upon the feet, the force reaching the skull indirectly through the spinal 
Column. In speaking of the mechanism of fractures at the base of the skull, 
it was stated that they were found in three distinct localities corresponding 
to the three fossm on the inside of the base of the skull, and that these 
maintained such a relation to the vault of the cranium that the locality of 
the impinging force, when acting from above, determined the particular fossa 
which the fracture would implicate. 
Symptoms.—The signs of fracture of the base of the skull will differ accord- 
ing to the region involved. 
Fractures of the anterior cerebral fossa.—When occurring in this region, the 
most common symptoms are hemorrhage from the nose, loss of smell, due to 
disturbance of the olfactory bulbs which rest upon the cribriform plate of the 
ethmoid bone, and hemorrhage into the orbit, giving rise to sub-conjunctival 
ecchymosis. This blood may come from four sources,—the vessels of the 
dura mater over the orbital plates, the ophthalmic artery, the ophthalmic vein, 
and the cavernous sinus. The blood sometimes fills the orbit, protruding the 
eye, and forming a pulsatory swelling or false aneurism. When the body 
of the sphenoid is fractured, blood may flow either through the nose into the 
frontal sinuses or into the pharynx through the sphenoidal sinuses, and 
in this last way reach the stomach, and, when thrown up, may mislead the 
medical attendant, leading him to think that the case is complicated with 
haunatemesis. These signs of hemorrhage and suspended olfaction are not 
decisive of fracture at the anterior part of the base of the skull. A blow 
upon the nose will produce not only an epistaxis, but also the loss of smell; 
and a similar injury over the eye may be followed by orbital hemorrhage. 
In the last, however, the eyelid will participate in the violence, and become 
blue or black from the effused blood, a condition which is not commonly 
present in the sub-conjunctival ecchymosis from fracture, though it may follow 
it should the bleeding continue long. 
Fractures of the middle cerebral fossa.—In this fossa the petrous portion of 
the temporal is the part usually broken, though the fracture may implicate 
the adjoining bones. The symptoms which indicate the accident are hemor- 
rhage, and the escape of the cerebro-spinal fluid from the ear, with paralysis 
of the face, and loss of hearing on the injured side. These phenomena are 
readily understood when the offices of the temporal bone are considered,—i.e., 
as furnishing a chamber for the organ of hearing, a canal for the passage 
of the portio dura, and another tube—the external auditory—for conduct- 
ing the vibrations of air to the membrana tympani. The paralysis some- 
times extends to the muscles of the uvula and the soft palate, indicating a 
lesion of the sphenoid, the spheno-palatine nerves being closely l’elated to 
that bone. 
Hemorrhage from the ears itself is an unimportant, or at least a negative, 
sign of fracture, unless profuse and continuing for several days. I frequently 
witness bleeding from the ear after injuries of the head and face, where 
there is no reason to suspect the existence of a fracture. Bryant relates a 338 
INJURIES OF THE HEAD. 
case of fracture of the petrous part of the temporal bone, in which the lateral 
sinus of the brain was laid open and the tympanum filled with blood; and 
a second, in which the internal carotid was torn where it passes through the 
bone, the hemorrhage finding its way into the pharynx and from thence 
filling the lungs. Neither case survived the accident over two hours.* The 
escape of a reddish or clear fluid from the ear is a sign of much greater im- 
portance than the flow of blood. Various surmises have been offered to ex- 
plain the origin of this limpid or blood-stained fluid. Langier and Chassaignac 
supposed that it came from the serous part of the extravasated blood ; other 
writers claim that its origin is from the venous channels or sinuses of the 
brain ; and others, again, believe that it is a leakage from the labyrinth, the 
liquor Cotunnii. There can be no doubt, however, that the fluid in question 
is the same as the cerebro-spinal, and that it is derived from the sub-arachnoid 
space or ventricles. The observations of Robert, Hilton, and Hewett, and 
its analysis by Chaton, all go to prove the identity of the two liquids. Hil- 
ton, in a case of a boy with fracture at the base of the skull, attended with 
a discharge of this fluid, performed the following experiment. Believing 
that if the material was cerebro-spinal in its origin it should be increased 
by cerebral congestion, he produced this condition artificially by compressing 
both internal jugular veins. In a short time the discharge was greatly in- 
creased in quantity, diminishing again after the removal of the pressure: 
the result proved the correctness of his theory. 
This cerebro-spinal fluid is limpid in color, abounds in chloride of sodium, 
and contains traces of albumen and sugar. To permit its escape from the 
ear, it is necessary that the petrous portion of the temporal bone shall be 
broken, the dura mater and arachnoid membranes lacerated, and the membrane 
of the tympanum ruptured, when the fluid will trickle through the crevice 
into the auditory canal and be discharged externally. Should the membrana 
tympani not be ruptured, the fluid will take the opposite direction, and run 
into the throat through the Eustachian tube. The time at which this dis- 
charge appears after fracture varies. It may commence immediately after 
the accident, or it may follow a free hemorrhage. In some instances it does 
not appear for several days after the injury, and usually after eight or ten 
days it ceases to be discharged, the fissure being closed by inflammatory 
lymph. Errors are doubtless often made in regard to the true nature of 
watery discharges following injuries at the base of the skull. The blood- 
stained serum which commonly flows from a wound after the active hemor- 
rhage is over may be mistaken for this cerebro-spinal fluid. A simple con- 
gestion of the Schneiderian membrane of the nasal and frontal air-passages 
will induce a free flow of a colorless fluid, the origin of which, if associated 
with local violence, might be misinterpreted. When, however, the discharge 
is limpid in its appearance, and immediately follows the accident, or when it 
occurs some time after the cessation of all bleeding and possesses the chemical 
constitution of the sub-arachnoid fluid, there can be little doubt as to its true 
source. The escape of the cerebro-spinal fluid is not confined to fractures of 
the temporal bone; it may flow into the nose or pharynx when the injury 
involves other portions of the base. It may also be discharged in both sim- 
ple and compound fractures of the vault of the skull. It is difficult to esti- 
mate the quantity of this fluid which is lost, unless it is carefully collected 
in some vessel. It will saturate the pillows of the patient in a short time, 
and the flow has been known to reach from fifteen to eighteen ounces in a 
few days. 
In simple fractures accompanied with rupture of the cerebral meninges 
this fluid may become diffused beneath the occipito-frontal aponeuroses, 
forming a tumor or swelling, to which the term cephalhydrocele has been ap- 
plied. Professor Conner, of Cincinnati, in a valuable paper on this subject, 
which will be found in the Proceedings of the American Surgical Society 
* Bryant’s Surgery, page 50. FRACTURES OF THE SKULL. 
339 
for the year 1884, has collected nineteen cases of this affection, occurring 
very uniformly in young children under three years of age, a fact which 
is properly attributed by Dr. Conner to the mobility of the cranial bones, 
which allows of the latter being broken and depressed without the vulner- 
ating force causing an external wound of the overlying soft parts. Cephal- 
hydrocele may occur in a compound fracture after closure of the scalp- 
wound. The swellings with which such an affection might be confounded 
are abscess and a collection of blood, but by the use of the grooved needle a 
correct diagnosis can be readily established. The result of Professor Con- 
ner’s analysis of the collected cases of this affection is a mortality of fifty 
per cent, in all cases following simple fracture, and thirty-three per cent, in 
those following compound fracture,—the cause of death in the two classes 
being, in the first, meningitis, and, in the second, suppuration or abscess. In 
either case the treatment consists in aspirating the fluid whenever pressure- 
symptoms begin to appear. 
Fractures of the 'posterior or cerebellar fossa.—These fractures extend through 
the anterior inferior part of the occipital bone in different directions, running 
into the occipital foramen or through the basilar process, or involving both. 
Frequently cases are met with in which both the posterior and the middle 
fossa are broken at the same time,—an accident which, so far as my observa- 
tion extends, follows falls or blows upon the posterior part of the head. 
The hemorrhage which follows a fracture through the posterior fossa may 
flow into the pharynx, in this way reaching the stomach, and be subsequently 
vomited, or it may extravasate into the soft parts about the neck and over 
the mastoid portion of the temporal bone, gradually finding its way to the 
surface and giving rise to a subcutaneous eechymosis. Surgeons very justly 
attach much importance to this discoloration, as indicative of fracture, in 
cases where there has been no external contusion and yet where the vio- 
lence has been of a nature sufficiently severe to render such an injury 
probable. 
The signs, therefore, which most clearly indicate fracture of the base of the 
skull are free and persistent hemorrhage from the ears, nose, and pharynx, 
and into the orbits, and the escape of cerebro-spinal fluid. The constitutional 
signs which follow fractures of the cranial base are those of concussion or 
compression. 
Prognosis.—Fractures at the base of the skull are among the most dan- 
gerous accidents which can befall the human body, though not necessarily 
fatal. According to Robert, recovery never takes place where there is a loss 
of the cerebro-spinal fluid; yet I have seen two cases certainly, and I think 
three, in which the patients got well notwithstanding the presence of this 
discharge. In the first of the two patients, where the nature of the fluid 
was limpid, it was quite profuse from the right ear. and continued for about 
two weeks, having been preceded by a very free bleeding. The second case 
was one in which the frontal sinuses were crushed, and the orbital plate of 
the frontal bone comminuted, by the kick of a horse; the membranes of the 
brain were lacerated, and a considerable amount of brain-substance was dis- 
charged. The serous-looking fluid which saturated the dressings was too 
abundant to have been the product of inflammatory irritation of the lining 
membrane of the frontal sinuses. It had all the appearances of the fluid 
derived from the sub-arachnoid space. The man recovered, and in four 
weeks from the time of the accident he was again in the hospital, with a 
broken thigh. Notwithstanding occasional cases of recovery, the prognosis 
of fracture of the base of the skull is very unfavorable. It is not the frac- 
ture which makes the accident so grave: that may heal by fibrous tissue, or 
by an intermediate or an overlying deposition of soft bone. The danger con- 
sists in the consequences of the injury, such as inflammation of the membranes 
of the brain, inflammation, suppuration, contusion, or laceration of its sub- 
stance, and compression from extravasation of blood. 
Fractures with depression.—By a depressed fracture is meant a fracture in 340 
INJURIES OF THE HEAD. 
which the fragments are forced helow the level of the surrounding bone. 
The danger of such an injury is apparent when it is considered that, inasmuch 
as the brain tills the cranium, any depression of the walls of the latter, save 
in exceptional cases, must encroach upon the encephalon and give rise to con- 
sequences, immediate and remote, of a very dangerous nature. In the diag- 
nosis of such injuries the following considerations must not be overlooked. 
First, the peculiar concave form assumed by extravasations of blood in the 
scalp after contusions. There are many instances where incisions have been 
made into such swellings under the impression that the depression existed in 
the bone. Second, there are localities in which, from structural peculiarities, 
depression may exist without encroaching upon the brain, particularly in the 
adult skull, as, for example, over the frontal and mastoid sinuses. 
Varieties of depression.—Depression of the skull may exist with or without 
an external wound; the depression may be confined to either the external 
or the internal table alone; and, lastly, it may involve both tables or the entire 
thickness of the bone. 
Fractures of the external table.—Occasionally in civil, and often in military, 
practice, indentations or fractures of the external table are seen. I saw some 
years ago a very well marked case of the kind. A spent pistol-ball had struck 
the forehead of a man and rebounded into his hat. A considerable depression 
existed, without any signs of the internal table having been involved in the 
injury. In such cases the depressed portion of bone is accommodated in the 
spongy cancelli of the diploe without encroaching upon the brain. While this 
is possible at any portion of the cranial vault, yet those portions of the frontal 
and temporal bones which correspond to the frontal and mastoid sinuses, by 
reason of the wide separation of their walls, admit of the greatest inward 
displacement without compressing the brain. When the external table of 
the frontal or mastoid cells is broken, the nature of the accident is revealed 
by the escape of air into the overlying soft parts from either the nasal or 
the pharyngeal cavities, producing emphysema of corresponding portions of 
the scalp. 
Fractures of the internal table.—The internal table may be broken and the 
external remain intact. Examples of this kind are given by Sir Astley 
Cooper, Velpeau, Adams, Hennen, Brodie, and others. I once trephined a 
patient for epilepsy, the internal table of whose skull presented a stellated 
fracture without any break in the outer wall of the bone. There is a form of 
fracture produced by blunt-pointed bodies, such as nails or picks, in which 
the external table is traversed without much displacement, while the internal 
one is comminuted and extensively displaced. In all fractures of the skull 
which involve both tables the internal table suffers more than the external. 
For the explanation of this fact there are three factors: first, its physical 
structure being the more brittle of the two; second, the operation of a law 
which determines a fracture first on the side of greatest extension, or. as iron- 
masters express it, on the “ side of pulland, third, the mass of material 
carried before the fracturing force. 
The law which determines a fracture of the skull is the same by whatever 
kind of force it is produced. The fibres of the bone yield first, as has been 
stated, on the side of extension, just as when a stick is bent over the knee 
the surface opposite to the point where the pressure is applied first gives way. 
The application of the law has been well illustrated by Tevan. A reference 
to the diagrams on the opposite page (Figs. 306, 307) will serve to make the 
explanation clear. 
Let A B (Fig. 306) represent a portion of the vault of the skull, and C D 
and E F two vertical lines parallel with each other. If a force be applied to 
the convex surface of the section at G, the extremities of the arch, A B, will 
be separated from each other, and the section will assume the appearance of 
HI in Fig. 307. The effect of this separation will be to destroy the parallelism 
of the lines C D and E F and make the lines J K and L M converge at the 
upper and diverge at the lower surfaces of the bone. The effect of such a change FRACTURES OF THE SKULL. 
is to force together the particles of the bone above at if, and to draw them 
asunder below at O, the point where the fracture, if present, will first take 
place. 
341 
Fig. 306. 
Fig. 307. 
Fractures of both tables with depression.—Fractures of this nature may exist 
with or without an external wound. They are very often comminuted, and 
in some instances are broken in the form of pointed spieulse, which puncture 
the membranes and wound the brain. These fractures may exist without 
symptoms of compression being present, but they are always fraught with 
danger from prospective consequences, such as hemorrhage, abscess, and, 
still more remotely, muscular weakness, defective articulation, epilepsy, and 
various mental imperfections. 
Depression without fracture of the skull.—This cannot happen in an adult, 
but is occasionally seen in young subjects, and when present is usually of 
considerable extent, involving an entire bone. The explanation of this form 
of depression must be sought for in the mobility of the different pieces of the 
young skull, the sutures not being solidly closed. In a case of this accident 
which I saw with Dr. William Brinton, of West Chester, Pennsylvania, the 
depression was fully one inch and a half in diameter. It finally disappeared, 
the child making a good recovery. Extensive depressions are sometimes 
made by the forceps of the accoucheur, some of which are never effaced. 
There are indentations which occur from pressure of various kinds, affect- 
ing portions of one or more pieces of the young skull (Fig. 308), and de- 
pending upon structural peculiarities 
in the bones, such as a deficiency in 
their earthy constituents, by which 
they are rendered flexible and supple 
like parchment. 
Intra-uterine fractures of the skull 
are occasionally met with, and may 
be produced by blows inflicted upon 
the abdomen of the mother, by press- 
ure against the pelvic bones in pro- 
tracted labors or in cases of deformity, 
and by the forceps when improperly 
placed upon the foetal head. 
Diagnosis of depressed fracture.—It 
is not always an easy task, in the 
absence of an external wound, to as- 
certain the existence of a depressed 
fracture. The blood effused beneath 
the scalp conceals the indentation. 
The symptoms of compression—if 
present—may be due to a clot of blood, and not to depressed bone. When 
the signs are urgent, the scalp should be incised at the seat of contusion 
down to the periosteum, so that the surgeon may determine the true nature 
of the injury by the finger and the eye. Where an external wound is 
present, communicating with the bone, there is no difficulty in determining 
the condition of the latter and in reaching a correct diagnosis. 
In regard to certain simple and complicated fractures of the skull, the fol- 
Pig. 308. 
A young skull with a number of depressions over its 
surface.—From a specimen in the Museum of the College 
of Physicians. 342 
INJURIES OF THE HEAD. 
lowing observations may aid in determining the particular line of practice 
to be adopted. 
1. Fracture without depression.—In a fracture of this kind, and in the ab- 
sence of symptoms of compression, the treatment should consist of rest in 
the recumbent position, the application of cold to the head, gentle purgation, 
and a restricted diet. Should any cerebral disturbance appear, indicative of 
irritation or inflammation, such as headache, restlessness, intolerance of light 
or sound, and a frequent pulse, a more active antiphlogistic course will be 
demanded. Blood should be taken locally from the hack of the neck and 
behind the ears, small doses (one-eighth of a grain) of calomel given every two 
hours, full doses of bromide of potash administered, and all causes of 
and mental excitement carefully excluded. 
2. Fracture with depression.—When, in addition to fracture, the detached 
portion is driven down below the level of the surrounding parts, it constitutes 
the condition known as depression. This depression may exist in a very 
marked degree and yet not seriously encroach upon the brain; and in the 
absence of all symptoms of compression, and the depression being slight, the 
treatment will not differ from that appropriate in a case of simple fracture 
of the skull. 
3. Fracture with marked depression, or comminution without symptoms of com- 
pression.—The additional element of comminution has furnished ground for 
a diversity of opinion among surgeons with reference to the best mode of 
treatment. This difference grows out of the fact that at some remote period 
there may be developed, in consequence of the irregularities of the fragments 
irritating the meninges of the brain, a degree of cerebral excitement which 
may culminate in epilepsy, or in that still more deplorable calamity, insanity. 
To guard against such evils, some surgeons advise laying open the scalp, ap- 
plying the trephine, and elevating the fragments. In favor of such a practice 
we have the very high authority of Professor Gross. Though I was formerly 
of the opinion that unless brain-symptoms were present no operative measures 
were proper, yet having in the last few years witnessed a large number of 
cases of epilepsy due to old depressions from fracture, and in view of the fact 
that antiseptics have largely removed the risks of operations on the skull, 
I believe it is the duty of the surgeon to elevate the depressed bone, whether 
comminuted or not, provided the depression is great and the force deter- 
mining the fracture has been a concentrated one, in which case the internal 
table of the skull will suffer more than the external table. 
4. Fracture with depression and signs of compression.—In a fracture of this 
kind the displaced bone encroaches so much upon the brain as to give rise to 
unconsciousness, paralysis, noisy breathing, dilated pupils, and a slow pulse, 
—a group of symptoms which constitutes “ compression.” In the treatment 
of such a case some authorities advise an immediate resort to the trephine, 
while others inculcate delay, hoping that with blood-letting, cold, and time, 
the brain will become tolerant of the pressure and the compression pass away, 
—resorting to operative measures only when the symptoms persist. In the 
case of children it is best not to proceed too precipitately in the use of the 
trephine, as I have seen in such subjects very urgent symptoms disappear, in 
consequence, I think, of the movable cranial bones being thrust up by the 
pulsation of the brain. In adults such a result is not to be looked for; and 
hence the sooner the depressed bone is elevated by mechanical means the 
better. 
5. Compound fracture with or without symptoms of compression.—A compound 
fracture of the skull is one in which, in addition to the lesion of the bone, there 
is a communicating wound of the scalp. Such fractures are very dangerous 
injuries, and have various complications. The bone may be comminuted and 
depressed, the membranes torn, and the brain compressed and lacerated. 
They are usually attended with severe shock and considerable hemorrhage. 
The later dangers are from inflammation of the contents of the cranium, 
abscess, and fungous protrusions. Compound fractures with depression, CONCUSSION OF THE BRAIN. 
343 
whether accompanied by symptoms of compression or not, are proper cases 
for the use of the trephine or elevator. The existence of the external wound 
removes one objection to the use of the instrument. In cases of comminution 
the loose pieces of bone should be taken away. By so doing, one cause of irri- 
tation is removed and a free way of escape for the discharges is provided. In 
a number of cases I have seen a large quantity of the cerebral substance 
hanging from the wound, with extensive comminution of the cranial bones, 
and, after extracting the pieces and dressing the parts, recovery has followed 
with singular rapidity. Indeed, the greatest success I have had in the use 
of the trephine has been in cases which, from the extent of the damage done 
to the skull, seemed to be almost hopeless. The wound should be well washed 
with a solution of corrosive subli- 
mate (one to one thousand), the 
surrounding hair closely shaven, 
the depressed fragment or frag- 
ments raised, drainage provided 
for, and antiseptic dressings ap- 
plied, secured by a recurrent asep- 
tic roller. The constitutional treat- 
ment wTill consist in absolute rest, 
exclusion of strong light, regula- 
ting the bowels, and a diet of milk. 
Restlessness must be controlled 
by bromide of potash and neutx-al 
mixture. 
Separation of the sutures.—The 
skull may be broken through in 
the line of a suture. Such an in- 
jury is the result of no ordinary 
force: hence in those cases where 
the base of the cranium is broken it is not an uncommon event to find some 
of the sutures disjoined. In the vault of the cranium, the sagittal and the 
coronal are those that generally suffer. Even when a suture is obliterated 
by ossification, as is often seen in the frontal part of the sagittal, a fracture 
may follow its course with the greatest accuracy. Such a case is shown in 
Fig. 309, the separation being the result of a stroke with a flat piece of iron. 
Fig. 309. 
Fracture through the frontal suture.—From a specimen in 
the University Museum. 
Punctured Fractures.—Such fractures often occur in the neighborhood of 
the orbits, and are produced by walking-canes, nails, umbrella-handles, or 
picks. I have seen cases where children while playing with “ grace-hoops” 
fell upon the rod used in this amusement, driving its extremity through the 
upper eyelid and the orbital plate of the frontal bone into the brain, and in 
two instances have removed portions of the latter which protruded from 
the wound, recovery following in both without any unusual symptoms. 
Treatment.—In the treatment of this variety of fractures the course of 
the surgeon must be determined, not by the symptoms present at the time of 
the injury, but in view of those which are likely to follow as a consequence 
of inflammation of the brain and its membranes, the internal table being 
usually comminuted and driven into the brain. Whenever, therefore, the 
puncture is situated in the vault of the cranium, the trephine should be em- 
ployed, by which fragments of bone can be removed and a way opened for 
the escape of all inflammatory products. The dressings should be the usual 
aseptic ones, with drains of horse-hair or catgut. 
Concussion of the Brain. 
Many writers take exception to the term “ concussion” when applied to in- 
juries of the brain, on the ground that the word is vague and indefinite. The 
same objection, however, would apply with equal force to compression and 344 
INJURIES OF THE HEAD. 
many other terms which are employed to express disease or injuries. In the 
sense in which I use the word—that of a determining cause of certain phe- 
nomena, and not the phenomena themselves—I can conceive of no better 
term than concussion. The force may be either direct or indirect; that is, 
either applied directly to the head or transmitted along the spine. 
There are four varieties of concussion : 1, cerebral vibration without visible 
lesion ; 2, vibration followed by sero-sanguinolent transudation ; 3, vibration 
attended with extravasation of blood ; and, 4, vibration accompanied with 
laceration of the brain-substance. 
1. Cerebral vibration without visible lesion.—In this variety the force, whether 
applied directly upon the skull and conducted through its bony walls to the 
brain within, or indirectly by being transmitted through the spinal column, 
produces a simple molecular disturbance of the cells composing the neurine. 
Symptoms.—A man receives a blow of moderate force upon the head, or 
falls from a considerable height, alighting upon his feet, lie staggers, per- 
haps falls upon his knees, but instantly rises, and then quietly sits down. For 
a few moments he is bewildered and confused ; he cannot collect his thoughts; 
there is some pallor of the countenance; a perspiration breaks out upon the 
surface of his face, followed by yawning, nausea, and perhaps vomiting. In 
a short time, however, he regains his intelligence, is able to rise and walk, 
possibly with a slight tremulousness of the limbs, and in a few hours has 
entirely recovered from the injury. This is a case of simple cerebral vibra- 
tion. if it were possible to open the cranium and examine the brain under 
such circumstances, the presumption is that the keenest eye, armed with the 
best instrumental aid, would fail to detect any appreciable alteration of struc- 
ture ; yet, were it feasible to carry the search into those delicate relations 
which subsist between the cells composing the brain-substance, we should 
doubtless discover a sufficient explanation of the phenomena. I am unwill- 
ing to admit that in these mild cases of concussion any cerebral lesion what- 
ever exists, and must say to those writers who maintain the contrary opinion, 
with all due deference, that the cases which they cite will not stand a rigid 
criticism. 
Conditions analogous to this are seen in other parts of the body, and indeed 
sometimes in matter subject only to physical laws. For example, a person 
may take hold of some object and apply for a long time a great amount of 
muscular force, but at length the hand suddenly relaxes its grasp and drops 
powerless by the side. In this condition it may remain for a few hours and 
then recover its strength. If the arm could be dissected immediately after 
the occurrence, no pathological change would be revealed. 
Passing to grosser matter, or such as is governed only by physical laws, 
we see a temporary alteration or suspension of these pi’operties. A watch 
falls upon the floor and immediately ceases to record the time. It is taken to 
a watchmaker, and after the closest scrutiny he fails to discover what has 
happened, but explains the condition as one of “jar” or “strain.” A sudden 
shake will sometimes put the mechanism again in motion. If a magnetic 
bar of iron receives a violent blow, its power as a magnet is greatly weak- 
ened. These are examples of the suspension of function and property by 
molecular vibration. 
When the violence has been more intense, the symptoms will be more 
marked and urgent. Insensible, pulseless, and with flaccid limbs, the patient 
resembles a dead, rather than a living, man. The countenance is pale, the 
features are shrunken, the surface is cold, the pupils are sometimes dilated 
and at other times contracted, or, as is not unfrequently seen, one is dilated 
and the other contracted. The breathing, when once established, is feeble, 
quiet, and occasionally interrupted by a long-drawn sigh. The circulation is 
feeble and intermittent; the fteces and urine are sometimes passed involun- 
tarily. More commonly the urine is retained, the bladder becoming greatly 
distended. Deglutition is either difficult or impossible, the surface is covered 
with perspiration, and the temperature often falls two or more degrees below CONCUSSION OF THE BRAIN. 
345 
normal. The special senses, though not destroyed, are obtuse and greatly 
enfeebled. The eyelids remain closed, or, if opened for a moment, no notice 
is taken by the individual of surrounding objects. Ordinary sounds are not 
recognized by the patient, but when spoken to in a loud and commanding tone 
of voice and roughly shaken, a single word in response may be obtained, and 
that delivered in a short and petulant manner. The group of symptoms thus 
detailed belong to what is commonly called the stage of collapse or shock, and 
may continue for a single hour or for many days. As the vital powers begin 
to assert themselves, the second stage, or that of reaction, sets in. Vomiting 
occurs, which is an evidence of returning sensibility in the stomach, the pulse 
becomes fuller, less frequent, and stronger, the perspiration dries up, the 
warmth of the body returns, the color appears in the face, and the mental 
hebetude gradually passes away, followed perhaps by headache, a flushed 
face, and vertigo. 
2. Vibration followed by the transudation of a sero-sanguinolent fluid —In addi- 
tion to the symptoms already detailed as accompanying simple vibration, there 
are certain peculiarities present Avhich, I think, are indicative of brain-press- 
ure. The stage of collapse is more pronounced and prolonged than in simple 
vibration, there is much greater difficulty in rousing the patient from the 
state of stupor, and the breathing is often noisy, though not stertorous. The 
patient frequently assumes a peculiar position in bed,—that is, curled up on 
the side, or in a state of general flexion, the legs being bent upon the thighs, 
the thighs flexed upon the pelvis, the head upon the chest, and the chest bent 
forward upon the abdomen. When forcibly turned over or compelled to 
change his position, the patient quickly resumes the original posture, mani- 
festing no small degree of temper, and sometimes profanity, at the disturb- 
ance, and then relapses into a sullen or semi-unconscious state. The urine is 
frequently passed in the bed, as are also, though less commonly, the fames. 
There are other symptoms which, though not peculiar to this variety of 
concussion, are not unfrequently present; for example, a well-marked con- 
vulsion. This may occur in both adults and children, and usually takes place 
when they begin to recover from the flrst effects of the injury. A sudden 
accession of violent muscular tremors is sometimes present. The tremor may 
be contined to one side, or to one limb, or may affect the entire body, and, 
like the convulsions, manifests itself when the collapse begins to pass over. 
In some instances the patient will recover his senses for a short time and again 
relapse into a state of stupor, with labored respiration, and in fatal cases 
will gradually sink into a state of complete coma, with stertorous breathing, 
dilated pupils, and a rapid, feeble pulse. This state is one in which the border- 
line between concussion and compression has been passed, and the patient 
dies much in the same way as one who has a depressed bone, a clot of blood, 
or a collection of pus pressing upon the brain. 
Morbid Changes.—The essence of this variety of concussion consists in 
the transudation of a bloody serum through the walls of the cerebral blood- 
vessels, which I presume is due to paralysis of their vaso-motor nerves, 
by wdiich they are rendered incapable of regulating the amount of blood 
within their canals, and thus become over-distended. This change is analo- 
gous to that which we constantly observe in the stage of inflammatory con- 
gestion in other parts of the body. I have witnessed numerous cases of this 
condition. It may exist to a great degree and be overlooked, as the serum 
gravitates to the dependent parts of the skull or sinks through the occipital 
foramen into the spinal canal. 
Hewett mentions a case* in which a patient was admitted into the Ilopital 
St.-Antoine who had fallen some distance upon the pavement. lie was col- 
lapsed, and after a fewT hours died. The head was examined, and no evidence 
of any intracranial damage was discovered. The fact was incidentally com- 
municated to Dr. Deville, at the time making the round of his wards, who, 
* TheSses de Paris, 1834, No. CXIX. p. 19. 346 
INJURIES OF THE HEAD. 
going to the dead-house, had the spinal canal examined, in which was found 
a great quantity of extravasated blood, extending up to the cavity of the 
cranium. 
It must not be overlooked that death may be caused by lesions of other 
organs produced at the time of the concussion, and thus be wrongly attributed 
to the latter. Hewett mentions the case of a boy who fell from a considerable 
height. When brought into St. George’s Hospital, he presented well-marked 
symptoms of compression, and shortly after died. The examination of the 
head disclosed a little extravasated blood, but not sufficient to account for 
the sudden death. When, however, the chest was opened, a rupture of the 
heart was found to exist, which at once solved the mystery. Mr. Hewett 
further declares that in all cases of death from head-injuries which he has 
witnessed, the intracranial damage was sufficient to account for the result. 
The same in effect has been stated by Mr. Le Gros Clark ; and in further sup- 
port of the truth of these assertions it may be stated that in none of the cases 
which have been recorded by authors as cases of death without lesion was 
any examination made of the spinal canal. 
A sailor was brought into the University Hospital suffering from concus- 
sion, the result of a fall from the rigging of a ship. Thirty-six hours after 
his admission he died. On making the autopsy there were no indications 
whatever of any structural change in the brain sufficient to explain the cause 
of death; but on removing it from the skull a large amount of bloody serum 
was found in the spinal canal. 
3. Vibration followed by extravasation of blood.—In this form of concussion 
we have a condition which has been termed contusion of the brain. 
Symptoms.—There are, so far as we know, no symptoms which unerringly 
indicate either circumscribed or disseminated blood-extravasation of the brain; 
yet the presence of muscular spasms of the limbs, with great restlessness, fur- 
nishes a reasonable ground for suspecting the existence of such a condition. 
Dupuytren believed that about the fourth or fifth day the disease might be 
recognized by the appearance of those symptoms which ordinarily indicate 
encephalitis. Sanson, on the contrary, believed that there were certain signs, 
such as great restlessness, unconsciousness, with spasms of the extremities, 
etc., which revealed at once the nature of the lesion. Such phenomena are 
witnessed frequently, though they are far from being invariably present. 
A man was brought into the University Hospital with a fracture extending 
into the base of the skull, accompanied with great loss of the eerebro-spinal 
fluid through the ear. lie died after the lapse of five days. The autopsy 
showed a diffused extravasation at the base of both the middle and anterior 
lobes of the cerebrum, and also within their substance. In this case the 
rolling from side to side was confined to the head, the restlessness was ex- 
cessive, the breathing, though heavy, did not amount to stertor, the spasms 
or tetanic contractions of the limbs were violent and at first intermittent, 
and, although the patient would forcibly resist any change made by the nurse 
in the position of his limbs, he could not be roused to consciousness. 
In a fatal case of concussion wThich I had under care the prominent symp- 
tom during life was an irregular, labored, and noisy respiration, with great 
dulness over the posterior part of the chest. An examination after death 
showed a blood-extravasation in the medulla oblongata and intense engorge- 
ment of both lungs. The urgent symptoms did not appear until twenty-four 
hours after the injury. 
In a third case which was brought into my ward, and which proved to be 
one of disseminated cerebral extravasation, the patient remained unconscious, 
with a loud, almost snoring, respiration, having a tetanic rigidity of the 
muscles of the limbs, a very high temperature, and twitching of the muscles 
of one side of the face. There was also a remarkable reflex irritability of 
the orbicularis palpebarum muscle on one side, which when touched with 
the finger would contract with great vigor. 
Morbid Appearances.—These consist of extravasations of blood, either CONCUSSION OF THE BRAIN. 
347 
central or peripheral. When central, or in the substance of the brain, the 
blood may be confined to a small space, corresponding to what is termed 
circumscribed extravasation. When disseminated extensively through the 
brain, appearing as little red points, it constitutes diffused extravasation. 
These extravasations or minute blood-clots may be confined to the vesic- 
ular or gray matter of the brain, or they may exist deep in the substance 
of the white or tubular portion. The little clots form small cavities at 
the expense of the brain-substance, as we find that, when they are displaced 
or turned out, excavations remain, with irregular margins and a surround- 
ing discoloration. These extravasations present the appearance of apoplec- 
tic clots. Similar extravasations occur in the meshes of the pia mater. Duret 
has attempted to account for the presence of these latter disseminated ex- 
travasations by the pressure exerted upon the minute arterioles from a 
supposed central determination of the cerebro-spinal fluid distending the 
perivascular lymph-sheaths. A more rational explanation, in my judgment, 
is the rupture of the minute vessels in consequence of the sudden inrush 
of blood following the anaemia which occurs immediately on the application 
of violence to the head. All these extravasations are associated with con- 
tusion of cerebral tissues. All divisions of the brain and all parts of these 
divisions are not equally affected by such lesions. It has been definitively 
settled by Hewett and others that, although these ecchymoses are possible 
in any part of the encephalon, yet the anterior and middle lobes of the cere- 
brum suffer most, and not only so, but that they are chiefly confined to the 
under surface of these lobes. In thirty-seven cases of this injury, according 
to Hewett, the posterior lobes were contused in four instances, the anterior 
in eight, and the middle in twenty-five. There are several reasons given to 
account for the greater liability of the middle and anterior lobes of the cere- 
brum to suffer from these clots. These parts of the brain rest upon the bony 
floor of the middle and anterior cerebral fossae, in contact with the irregu- 
larities of these cavities, whilst the posterior lobes are supported upon a 
membranous base, the tentorium. These facts, though thought by Fano to 
have been altogether overlooked, were long since, as mentioned by Hewett, 
recognized, by Sir Benjamin Brodie. There are regions also in which frac- 
tures at the base of the skull most frequently occur, because they fall within 
the compass of those converging lines of force which in passing from the 
vault to the base follow the shortest routes, and must necessarily affect 
severely the contents of this part of the base as well as the skull itself. 
When the extravasation takes place in the cerebellum, the collection, like 
that in the cerebrum, is generally found on the under surface. The pons 
Yarolii and medulla oblongata are least liable to suffer. In a fatal case of 
concussion which I had under care, the prominent symptom was an irregular 
and difficult respiration. On an examination after death, the extravasation 
was found in the medulla oblongata. It has been observed that lesion of the 
latter is frequently followed by a persistent slow pulse. 
The appearances presented where the patient has survived some time after 
the injury indicate that the work of absorption has been in progress, as the 
clots have been absorbed and in their place are seen well-defined cicatrices. 
When the blood-extravasation comes from the vessels of the pia mater, it 
will spread over the brain, giving its surface an intensely red color and forming 
what is termed peripheral extravasation. When the ecchymosis occupies this 
position, there has usually been noticed entire unconsciousness, with other signs 
which resemble those of compression rather than those of concussion. When 
the vessels of the pia mater are ruptured, the injury is usually accompanied by 
laceration of the arachnoid and extravasation of blood into its cavity. 
4. Vibration followed by laceration.—In this variety of concussion the brain- 
substance is torn, and the lesion is frequently found associated with fractures 
of the bones of the skull and injury to the meninges. 
Symptoms.—Where there is iaceration of the brain in addition to those 
symptoms which have been detailed as belonging to concussion in general, 348 
INJURIES OF THE HEAD. 
there is usually great restlessness; the patient tosses from side to side, 
endeavors to remove his clothes, the limbs are kept in constant motion, the 
bed-clothing becomes twisted into ropes, and not unfrequently moans and 
sometimes frightful screams are uttered. The respiration in such cases may 
be quiet, the pulse slow, the pupils somewhat dilated, and the temperature 
little changed from the normal standard. The patient will often answer 
questions when asked. Though the urine is usually passed in the bed, this is 
not wholly due to incontinence, as there is no dribbling, and the bladder 
will retain its contents for two or three hours. 
Prognosis in Concussion.—A degree of uncertainty hangs over every case 
of severe concussion, and this suggests the propriety of giving a very guarded 
prognosis. When the patient reacts in a short time, with restored intelligence, 
senses unimpaired, and without a severe and persistent headache, recovery 
may be anticipated with a reasonable degree of certainty. If, however, the 
surface continues cold and the sphincters relaxed, and the heart remains feeble 
and irregular, the pulse becoming increasingly frequent in its action, with pro- 
gressive stupor and a heavy, labored respiration, a fatal termination is fore- 
shadowed. When a patient, after concussion, recovers his consciousness and 
again relapses into a state of stupor, or when there is a repetition of con- 
vulsions, with a snoring respiration and a marked fall in the temperature, 
the case is exceedingly unfavorable. Great restlessness, screaming, and a 
rapid pulse are infallible evidences of approaching death. When the reaction 
is excessive, accompanied by a full, bounding pulse, intense headache, delirium, 
and intolerance of light and sound, there is imminent danger of inflammation 
of the brain and its membranes, which will seriously complicate the case. 
As intracranial inflammation from traumatic violence begins usually about 
the fifth or sixth day, it is a favorable sign when this period is passed without 
any unusual symptoms. The occurrence of vomiting after concussion should 
be regarded as a favorable sign, indicating as it does a return of the suspended 
nerve-action. 
Treatment.—The indications in the treatment of a case of concussion are, 
first, to establish reaction, and, second, to counteract intracranial inflammation. 
In very mild cases, in which the patient is merely stunned but recovers in a 
few minutes, nothing is necessary save to enforce a few hours of quiet for 
both mind and body. The brain is capable of regaining its orderly operations 
without any officious interference, and may be safely let alone. Where the 
shock is more severe and the concussion well pronounced, the surgeon must 
still be careful how he meddles, and should be content, for a time at least, to 
place the patient in the recumbent position, with the head low, removing all 
constriction from the neck, admitting a free access of air to the patient, and 
applying external heat to the spine, to the lower extremities, and to the epi- 
gastrium. If deglutition is unimpaired, a little water or warm tea may be 
administered from time to time. The common practice—prompted by the 
anxiety of friends—of at once administering. brandy or whiskey cannot be 
too strongly reprobated ; nor would any sane physician for a single moment 
entertain a thought of abstracting blood. The first error leads to a dan- 
gerous reaction, the last to fatal collapse. If, however, the body continues 
for hours cold and bathed in perspiration, the heart feeble, and the con- 
sciousness increasingly difficult to rouse, stimulants become necessary, and 
should be administered by the mouth if the patient can swallow, or, if not, 
they can be introduced into the rectum. They should be given in small quan- 
tities and at considerable intervals of time. The reason for such a course 
will be obvious when it is remembered that in the state of collapse absorption 
is in a great degree suspended, and if given too frequently the stimulants may 
accumulate, and when the mucous membrane of the stomach begins to resume 
its function they will enter the blood in such quantities as to lash the heart 
into excessive action, carrying the reaction far beyond the point of safety 
and increasing the risks of encephalitis. A single teaspoonful of brandy or COMPRESSION OF THE BRAIN. 
349 
whiskey or one ounce of wine-whey every three-quarters of an hour, until the 
signs of restoration begin to appear, will be quite sufficient, after which these 
agents should be withheld. The disappearance of collapse and the com- 
mencement of reaction are the signals for marshalling our resources to mod- 
erate and control the action of the heart and arteries and to save the brain 
from undue blood-determination, especially at a time when the feeble condition 
of the walls of its blood-vessels renders them powerless to regulate their con- 
tents. To this end the head must be raised, and covered with an ice-bag or 
with cloths wrung out of cold water ; the bowels should be thoroughly purged 
with an active cathartic ; all strong lights and sounds should be excluded, and 
the diet ordered to consist of toast-water and milk. Should these means not 
prove sufficient, and should the fever increase, with elevation of temperature, 
a flushed face, injected conjunctiva, delirium, and muscular weakness, blood 
should be drawn from the arm, or be taken locally by cups from the temples, 
from behind the ears, and from the back of the neck. The head should be 
shaven, in order that the effect of the cold may be more decided, and mercury 
should be given in small and frequent doses. Sleeplessness and restlessness 
are best relieved by full doses of bromide of potash, half a di’achm every 
three hours. Opium, when the bromide fails, will often produce the happiest 
effect in calming excitement and disposing to quiet sleep. The deodorized 
tincture appears to me to be the best form for its administration, and this may 
be given in doses of from five to eight drops every two or three hours, until the 
desired effect is obtained. When the acute symptoms are subdued, or should 
the patient exhibit signs of prostration, more nourishment can be allowed and 
a moderate amount of stimulants exhibited. Tonics appear to do well only 
after convalescence is established, and it is at this period that the surgeon 
must rigidly enforce the recumbent position. It is not safe to allow a patient 
to sit up, either in or out of bed, for at least ten days or two weeks after his 
attack is overpassed; and, as preparatory to this change of position, the head 
and shoulders, and finally the body, should be gradually raised by additional 
pillows, that there may be no sudden change in the cerebral circulation. I 
have seen a patient, after passing through all the dangers of concussion, sud- 
denly perish from being allowed to get out of bed at once, without any of 
these preliminary precautions. Patients, after recovery from severe concus- 
sion, often remain pale and suffer from vertigo and feebleness of the limbs. 
In such cases, iron, rest, and a good diet constitute the best treatment. 
Compression of the Brain. 
Can the brain be compressed ?—that is, can its components, by external or 
internal force, be more closely compacted together than when in their nor- 
mal condition ? This question has been often asked. I can see no reason 
to doubt that such compression is possible, though the discussion of the sub- 
ject would have very little practical importance. The term compression is 
open to many objections when abstractly considered, as the brain may be 
subjected to pressure without any of the signs usually attached to the term; 
yet where the word is used as a conventional phrase there can be no con- 
fusion or misunderstanding resulting from its retention in the surgical nomen- 
clature of cranial injuries. 
The experiments of Duret tend to show that the symptoms indicating 
compression of the brain are the results of extreme intravascular tension 
produced by irritation of the sensory nerves within the cranium, the me- 
chanical cause being merely an exciting one. 
Compression of the brain may result from five different causes,—depressed 
bone, extravasation of blood, inflammatory products, foreign bodies intro- 
duced from without, and tumors. 
Symptoms.—The symptoms which characterize a typical case of com- 
pression may be arranged as follows: alteration of sensibility and motion, 
of respiration, and of circulation. 350 
INJURIES OF THE HEAD. 
1. Alteration of sensibility and motion.—The patient is dead as to the external 
world,—is entirely insensible and unconscious. No impression can be made 
on the special senses which will be recognized, nor does any articulate word 
or sound escape the lips. There is paralysis, general or partial, according as 
the compressing cause affects both hemispheres of the brain or one; where 
partial, the paralysis will be on the side opposite to the injury. There is 
inability to swallow, with retention, followed by dribbling, of urine ; the pupils 
of the eye are fixed in a state either of dilatation or of contraction, or one 
pupil may be dilated and the other contracted. 
2. Alteration of respiration.—The breathing is noisy, snoring, or, as it is 
termed, stertorous, and puffing; the first due to the paralysis of the muscles 
forming the soft palate, and the last to a similar condition of the buccinator 
and other muscles about the mouth. 
3. Alteration of circulation.—The pulse is full, slow, and labored, and some- 
times irregular, beating from forty to sixty strokes in the minute. The tem- 
perature, in consequence of the diminished frequency of the pulse, is a little 
below the natural standard. 
Diagnosis.—Typical cases of concussion and compression possess well- 
marked and characteristic distinctions, which may be contrasted with ad- 
vantage in the following manner: 
CONCUSSION. 
COMPRESSION. 
Unconsciousness incomplete; patient can be 
made to answer, though it may be briefly and in 
single words. 
Special senses, though greatly blunted, are not 
abolished. 
Power of movement not destroyed; if the posi- 
tion of a limb be changed, the patient will resist or 
bring it immediately into the original position. 
Respiration is quiet and feeble. 
Pulse feeble, frequent, and intermittent. 
The stomach sickens and rejects its contents. 
The faeces may be discharged incontinently, 
as may also the urine. 
Deglutition not destroyed. 
Pupils variable, though generally contracted; 
the eyelids somewhat open. 
Temperature of the body less than natural. 
Complete unconsciousness; may scream into 
patient’s ear at the top of the voice, but will re- 
ceive no answer. 
Special senses entirely suspended. 
Complete or partial paralysis; in most cases 
hemiplegia. 
Respiration full and noisy. 
Pulse full and slow. 
The stomach is insensible to any impression; 
no nausea or vomiting. 
Bowels are torpid, and the bladder incapable 
of emptying itself, though the urine may escape 
by overflow. 
Deglutition impossible. 
Pupils variable, though generally much dilated 
and the eyelids closed. 
Temperature almost natural; a little below the 
natural standard. 
No surgeon, however, will have been long engaged in hospital practice 
before he discovers that these sharp differential distinctions are subject to 
great variations and modifications. I have frequently seen cases of head- 
injury presenting at first the signs of concussion, which after the lapse of a few 
hours became those of compression; others, again, in which the phenomena 
of compression, at first present, gradually glided into those of concussion ; and 
still a third or mixed class of cases, in which it was difficult, if not impossible, 
to refer them to either one or the other division. In all cases of compression 
the condition which produces what is commonly known as concussion is in 
some degree present, but is masked by the predominance of the former. Not- 
withstanding these irregularities, however, there remain a large number of 
cases in which the time-honored distinctions hold good, and possess, there- 
fore, a practical value. These distinctions and their causes may be formu- 
lated as follows: 
1. When a person receives a violent blow upon the head by a stone, brick, 
or bludgeon, or is precipitated upon the pavement from a height, fracturing 
the skull and driving the fragments in upon the brain, which injury is followed 
immediately by insensibility, paralysis, a slow pulse, and stertorous respira- 
tion, with perhaps a widely-dilated pupil, the case is doubtless one of com- 
pression from depressed bone. INTRACRANIAL EXTRAVASATION OF BLOOD. 
351 
2. When after a similar injury, with or without fracture, there follow only 
the ordinary symptoms of concussion, more or less complete, but after the 
lapse of a few hours, or perhaps a day or two, symptoms of compression set 
in, the cause in all probability is the extravasation of blood, which, leaking 
from the broken vessels, has only after some time accumulated in a quantity 
sufficient to compress the brain seriously. The different sources from which 
the blood may be derived are discussed under the head of intracranial extra- 
vasation. 
3. When a missile, such as a ball, or other foreign body, is driven through 
the skull into the brain and the wound is followed by symptoms of compres- 
sion, the cause is multiple, consisting of fragments of bone, the vulnerating 
body, and an extravasation of blood. 
4. When, after an injury of the skull, with or without fracture, symptoms 
of compression set in, at some period between the sixth and the thirtieth day, 
the cause is generally the presence of a purulent extravasation or of an 
abscess. 
5. When, in consequence of a fracture of the skull, with depression, symp- 
toms of compression immediately follow, and after a time pass away, the 
inference is that the depressed portion of bone has been detached and thereby 
rendered movable, so that the elevation of the brain which takes place during 
the ventricular contraction of the heart and the act of expiration has been 
sufficient to raise the fragment into place. Such cases, however, are exceed- 
ingly rare. When the depressed portion of bone is in the temporal region 
and it rises without artificial aid, the act must be due to the temporal muscle 
pulling the piece to the proper level, after the paralysis consequent on contu- 
sion of its fasciculi has disappeared. 
6. When, after a severe head-injury, with or without a fracture, the patient 
lies insensible, with general paralysis and with a quiet respiration, scarcely 
discernible, no sagacity can do more than surmise what intracranial lesion 
has occurred. 
There are also cases of compression caused by morbid growths in the brain, 
and by constitutional syphilis, which fall within the province of operative 
surgery. 
Intracranial Extravasation of Blood. 
Intracranial extravasations of blood occur in five localities,—between the 
bones of the skull and the dura mater, in the cavity of the arachnoid, in the 
pia mater, in the ventricles, and in the substance of the brain. They may 
take place quickly, in a few minutes, or may form in a more gradual manner 
after the lapse of several days. In some instances the extravasation is con- 
fined to a limited area, in others it extends over a large surface. 
The collections in the last two positions have been considered under the 
heads of concussion and compression. 
Extravasations between the bone and the dura mater.—When a blow or a fall 
is received upon the head, the force is transmitted through the skull, and, 
if sufficiently intense, it will detach the dura mater from the bone. As the 
connection between the two consists in part of blood-vessels,.some of the latter 
are necessarily broken, and an escape of blood follows, forming a clot (Fig. 
310), which will be temporarily limited by the extent to which the separation 
takes place at the time of injury. If the large branches of the middle menin- 
geal artery are torn, or the main trunk from which they arise, the hemorrhage 
will be profuse, quickly forming a clot, dissecting away the dura mater from 
the bone for a considerable extent (Fig. 311), and producing in a very short 
time well-marked symptoms of compression. In most cases of intracranial 
clots following violence, the blood comes from the meningeal arteries or their 
branches. When the bleeding is very slow, it may be many days before com- 
pression comes on, as the brain becomes somewhat adjusted to the gradual 
accumulation. 
In extensive hemorrhages from rupture of the meningeal artery, the blood, 352 
INJURIES OF THE HEAD. 
naturally gravitating downward, may ultimately, as shown by Hutchinson, 
compress the cavernous sinus, causing venous distention with dilatation of 
the pupil from pressure on the third nerve, and also paralysis on the oppo- 
site side. 
When a sinus is ruptured, the blood-extravasation takes place into the cavity 
of the arachnoid, though it may also find its way between the dura mater and 
the bone. It is said that the lateral sinus is oftener the subject of rupture 
Fig. 310. 
Fig. 311. 
Clot of blood between the dura mater and bone. 
Dura mater dissected from the bone at 
a, by a clot. 
than either the longitudinal or the cavernous. The reverse has been true in my 
experience. A number of cases have been collected by writers in which the 
middle meningeal artery has been wounded. I)r. S. W. Gross has examined 
eight cases of gunshot injuries of the head in which this vessel was torn. A 
sailor was brought into the University Hospital with an extensive fracture 
of the side and base of the skull, from the effects of which he died. A very 
large clot of blood was found between the bones and the dura mater, derived 
chiefly from a wound of the middle meningeal artery a short distance above 
its entrance into the skull. Whether the hemorrhage comes from the rup- 
ture of a sinus or of the meningeal artery, the smaller vessels in either case 
contribute to furnish a certain amount of blood, as it is impossible to detach 
any portion of the dura mater from the bone without opening numerous 
blood-channels. 
Symptoms.—The signs of extravasation of blood between the cranial bones 
and the dura mater are not always uniform. Where the bleeding is slow, 
in consequence of either collapse or a very circumscribed detachment of 
the membrane, the ordinary phenomena may not appear for several hours, 
perhaps days. The signs in well-marked cases are those of compression. 
The patient, after a blow or fall upon the head, passes in a short time into 
a condition of unconsciousness; the breathing, at first labored, becomes ster- 
torous and puffing; the cheeks rise at each expiration, and the pulse is full 
and slow ; the pupils are dilated, and there is paralysis and elevation of tem- 
perature on one side of the body. To these symptoms may be added reten- 
tion of urine, and frequently loss of control over the boAvels. Irregularities 
are occasionally seen in which none of these symptoms are present. In the 
case of a sailor brought into the University Hospital, who fell into the hold 
of a vessel, striking the head immediately above the external angular process 
of the frontal bone, and who died three days after the injury, there was no 
unconsciousness, even until a few minutes before his death, but only a slight 
degree of dulness. He was able to swallow without difficulty, and there was 
an entire absence of paralysis: indeed, the limbs were rigid and stiff, rather INTRACRANIAL EXTRAVASATION OF BLOOD. 
353 
than powerless. The post-mortem revealed both a blood-clot beneath the 
dura mater and a fissure of the frontal bone. Irregularities are frequently 
seen in regard to the condition of the pupils after traumatic extravasation 
of blood. Instead of being dilated, they may be contracted, or one may be 
large and the other small. The cause of the dilated pupil in compression is 
due to pressure upon the third cranial nerve. The pulse may also differ from 
the typical condition, and, instead of being full and slow, may be small, fre- 
quent, and irregular. There are conditions in which the traumatic origin of 
a clot and its location may be readily mistaken. A man may be seized with 
apoplexy and fall upon his head, inflicting a wound of the scalp or a frac- 
ture of the skull. If at the time of the attack no witness was present who 
could communicate the attending circumstances to the surgeon, the latter 
may be led into a great error by mistaking the cause for the effect. A 
person may be so profoundly intoxicated or narcotized as to exhibit symp- 
toms closely resembling those of compression from blood, and aside from 
the odor of the liquor, or some evidence of opium-poisoning, it would be 
very difficult to ascertain, at least for some time, the true cause of the con- 
dition. Kichardson, of London, has indicated a very simple method of dis- 
tinguishing between the stupor arising from apoplexy or compression, and 
that from profound intoxication. In the first, the temperature differs little 
from the healthy standard; in the last, it is always considerably below. In 
some of the police stations of London thermometers are kept for the purpose. 
In most instances, however, a just conclusion can be reached from the history 
of the case. An individual receives a blow, or falls upon the head, or he is 
knocked insensible, or perhaps is only momentarily stunned. In a few min- 
utes or an hour he is able to rise, and perhaps walks to his home, or is carried 
to a hospital. In a short time afterwards he becomes dull and drowsy, the 
pulse beats slow and full, he is roused with difficulty, and finally falls into 
a heavy sleep, with stertorous respiration, and paralysis of one-half of the 
body. Such a case is most probably one of compression from extravasated 
blood beneath the dura mater, and due to rupture of some of its vessels. 
Should the symptoms come on in a few minutes, and without fracture, either 
an extensive detachment of the dura mater has occurred or the blood issues 
from the large branches of the meningeal: if from the last cause, the clot 
will be located at the side and base of the brain. If the symptoms ai’ise 
only after several hours, or it may be days, there is reasonable ground to 
infer that the detachment of the dura mater is at a point where the vessels 
are small and the flow very slow. In cases of depressed fracture, should 
compression follow the injury immediately, it will be due to the displaced 
bone; if after the lapse of some time, it will more likely arise from a clot 
of blood. The symptoms of compression from a blood-clot may be delayed 
even after a considerable separation of the dura mater, in consequence of the 
collapse succeeding a severe injury, by which the heart is so enfeebled that 
the circulation does not reach the torn vessels with sufficient force to over- 
come the combined resistance of their clots and that arising from the retrac- 
tion and inversion of their tunics. As soon, however, as reaction sets in, 
these coagula are displaced, the bleeding begins, and the characteristic signs 
of compression appear. When in addition to the signs of compression there 
is present great restlessness, with disturbance of the muscular system and 
convulsions, the case is probably one of laceration of the brain-substance, 
and constitutes a most unfavorable complication, one which is by no means 
uncommon. Mr. Hewett* states that “the post-mortem records of St. 
George’s Hospital show that within the last few years there have been 
twenty-five cases of large extravasations of blood between the bone and 
dura mater, in all of which the brain was more or less extensively lacerated.” 
Mere muscular twitchings, tremors, and contractures, without paralysis, 
may be caused by injury to those branches of the fifth pair of nerves which 
* Holmes’s Surgery, American edition, vol. ii. p. 258. 354 
INJURIES OF THE HEAD. 
supply the dura mater, and do not necessarily indicate brain lesion, only cor- 
tical irritation. Paralysis generally means lesion. 
Treatment.—Compression from extravasated blood beneath the dura 
mater can be relieved only by the removal of the cause, as the absorption 
of a clot in this locality, I presume, rarely occurs. To do this it is necessary 
not only to make an opening in the skull, but also to know where it should 
be made. When a ball is lodged in the arm or leg, and is followed by con- 
stant pain or disordered sensibility within certain limits, even though remote 
from the seat of injury, its position may be inferred with considerable cer- 
tainty from an acquaintance with the distribution of the nerves. When, 
however, we attempt to apply such a test to injuries of the brain, the analogy 
fails, not because a connection between special regions of the encephalon and 
definite functions does not exist, but because there is such a mutual depend- 
ence between the different portions of the brain that disturbance of function 
from traumatic causes does not always give the clue to the seat of lesion. 
The similarity of phenomena from morbid influences acting upon the brain 
widely different in position has been ably brought out in the recent papers 
of Brown-Sequard. If, however, a depressed fracture exists, we have then 
a tolerably certain guide. If a severe contusion has left its traces on the 
scalp, though less reliable than the former, yet it is not without diagnostic 
value. But when neither depression nor contusion is present, how shall we 
interfere for the relief of the patient? In the absence of either of these 
signs, and if there is no paralysis, it is our duty to decline any operation, 
and to be content with keeping the head elevated, making applications of 
cold, and administering the fluid extract of ergot to excite contraction in the 
muscular walls of the injured vessels. If, however, paralysis is present, one 
point is gained : the extravasated blood is, as a rule, on the opposite side; but 
in what part? If the compression followed the injury very quickly, the 
inference is that the source of the blood is near the point where the middle 
meningeal enters the skull, or where its first branches are given off,—that is, 
near the anterior inferior angle of the parietal bone ; and half an inch above 
this point the skull should be bored. The approach to this point must be 
effected through the temporal region. An incision should be made parallel 
with the course of the zygoma, and one inch and a half above it, commencing 
about half an inch outside of the external angular process of the frontal 
bone. The skin, and the superficial and deep temporal fasciae, should be di- 
vided in succession, securing any branches of the superficial temporal artery 
which may spring. The temporal aponeurosis should be opened by a crucial 
incision, by which a more ready access can be obtained to the deeper parts. 
The temporal muscle, thus exposed, requires to be divided vertically, and its 
fasciculi pressed aside in order to expose the bone, and any branches of the 
deep temporal which bleed should be secured by the ligature. Upon the 
portion of bone now uncovered the trephine can be applied, and after the 
excision of the piece, and the removal of any clots discovered, the meningeal 
artery, should the bleeding come from this point, may be tied, or the canal 
in which it lies plugged writh soft wood or wax, or the mouth of the vessel 
sealed with the point of a heated knitting-needle. If by this operation we 
fail to discover the clot, we are to remember that the posterior branch of the 
middle meningeal is quite large, and, if torn, would pour out considerable, 
blood in a very short time, and we may next proceed to trephine the skull 
over the inferior posterior angle of the parietal bone with a view to reach 
the vessel. Even in cases where the paralysis is on the side of the injury, 
indicating an extravasation of blood on the opposite side of the brain, I can 
conceive of no substantial reasons why the trephine may not be applied over 
that part of the skull answering to the seat of pressure. The results of cases 
which, in view of the uncertainty of reaching the offending cause by the tre- 
phine, have been managed expectantly justify a much bolder surgery than 
that usually inculcated. Of one hundred and forty-seven cases treated ex- 
pectantly, according to the analysis of Wiesman, one hundred and thirty- INTRACRANIAL EXTRAVASATION OF BLOOD. 
355 
one died, while of one hundred and ten treated by operative measures the 
mortality was only thirty-six. 
Extravasations into the cavity of the arachnoid.—As there is nothing to limit 
the extension of the blood in this position, it diffuses itself through the sac 
of the arachnoid, and may spread over the entire surface of one or both hemi- 
spheres. This blood appears susceptible of organization. In no other way 
can we explain the anatomical appearances of these extravasations. The 
blood, after undergoing coagulation, becomes enclosed in a membrane, which 
is often adherent to the reflected layer of the arachnoid, so that there are 
really two sacs, one within the other. At other times the blood-sac remains 
in a great measure disconnected from that of the arachnoid, lying loosely in 
its cavity. The vascularity of such blood-cysts would seem to depend on 
their connection with the reflected layer of the arachnoid, as vessels in con- 
siderable numbers, when such connection exists, pass from one to the other. 
The contents of these cysts are not always alike. In some a part of the 
original clot may be present, presenting various degrees of discoloration, and 
leaving a yellowish-green residue; in others the contents remain liquid, 
possessing the properties of blood-serum; in others again are found clots, 
some of which bear the marks of having been recently formed from the 
giving way of the vessels of the sac, and still others, doubtless, contain broken 
remains of the original coagulum. 
These cysts are not peculiar to any age, and when the accumulation is 
great their pressure will atfect both the brain and the cranial bones, flatten- 
ing the former, and inducing absorption and thinning of the latter. If the 
collection is circumscribed, it will form for itself a cup-shaped depression in 
the sui’face of the brain, but if the extravasation is diffused, forming a cap 
for the hemisphere, there will be a general depression of the convolutions. 
Treatment.—There are no signs distinctive of intra-arachnoid extravasa- 
tion ; therefore our treatment must be in a great measure empirical, and 
should be directed to the relief of symptoms which are due to brain-pressure. 
As this extravasation occurs in the sac of the arachnoid, the blood, meeting 
with no obstacle, will spread over an extended surface of the brain, on which 
account symptoms of compression will develop slowly or may be absent alto- 
gether. Diffused pressure is generally attended with headache, restlessness, 
loss of control over the temper, constipated bowels, and involuntary move- 
ments of the muscles. These symptoms may culminate in epilepsy or in- 
sanity. Whatever uncertainty of diagnosis there may be, there are certain 
remedies most clearly indicated,—namely, the general or local abstraction of 
blood, the application of cold to the head, a brisk saline cathartic, and the 
bromide of potash in doses of twenty grains every three hours. Should 
there be much headache, the administration of small doses of a mercurial, 
both for its absorbent and its anti-inflammatory properties, will be produc- 
tive of benefit. If the mercurial affects the mouth, it should be omitted, and 
the iodide of potash substituted, in doses of ten or twelve grains three times 
a day. The diet at first should be restricted, but should be made more liberal 
as the case advances. 
Are there any circumstances which would justify the use of the trephine 
in cases of supposed intra-arachnoid hemorrhage ? If a man receives a blow 
upon the head, and there follows, after several hours, compression of the 
brain, it would not be amiss to open the skull, guided by the contused soft 
parts, and apply the trephine. If blood is present in the cavity of the arach- 
noid, it will be discovered by the deep-blue color showing through the dura 
mater, and can be removed by incising the latter membrane. 
Extravasation of blood from the vessels of the pia mater.—An injury which 
produces rupture of the vessels of this membrane gives rise to a copious 
hemorrhage. The blood is not limited by peculiarities of structure, but be- 
comes diffused, and may spread over the cerebrum, gravitating to the cere- 
bellum, the medulla, and the spinal cord. The freedom of movement allowed 
the extravasated blood from the distribution of the pia mater explains the 356 
INJURIES OF THE HEAD. 
absence of blood-cysts in this membrane. It might be expected that where 
the blood is permitted to settle down to the base of the skull and into the 
spinal canal there woiild be less tendency to compression; but I have reason 
to believe that such is not the case. 
This form of blood-extravasation is often produced by diffused force and 
affects both hemispheres. In two cases of railroad injury recently under my 
care, the symptoms of compression were well marked, and the diffused char- 
acter of the effusion was predicated on the existence of general paralysis. 
The post-mortem showed the entire brain to be covered with a thin layer of 
extravasated blood, derived from the vessels of the pia mater. 
There is a peculiar extravasation of bloody serum, which I have seen in 
fatal cases of severe head injury, derived from the vessels of the pia mater, 
and unaccompanied by any evidence of brain-laceration or blood-clots. The 
only explanation for such a large accumulation of fluid without visible lesion, 
which occurs to me, is that of a vascular paralysis so modifying the vital 
properties of the walls of the blood-vessels of the brain as to favor a free 
escape of their liquid contents. 
Treatment.—We have not the means of ascertaining with any certainty 
the presence of such extravasations. The same general and local measures 
are to be employed as in apoplectic attacks. The use of the trephine is, 
however, admissible when there are focal symptoms. 
Wounds of the sinuses.—Injuries of this nature are produced by a fragment 
of depressed bone, or by a shot-missile, rarely by violence applied to the skull 
independent of bone lesion. Occasionally the accident has followed the use 
of the trephine. The bleeding where the opening is at all extensive is very 
profuse, and may rapidly prove fatal. 
The treatment in such injuries is the prompt removal of fragments of 
bone, applying, if necessary for the purpose, the trephine, and freely ex- 
posing the injured sinus. When the aperture is small, pressure with a dossil 
of lint may be sufficient to arrest the hemorrhage; when large, the sides of 
the rent should be stitched together by a fine catgut thread applied as the 
glover’s suture. 
This class of injuries is exceedingly fatal,—especially so since the introduc- 
tion of the conical projectile. The old round ball was frequently deflected 
after penetrating the integument, passing between the bone and the scalp, 
and either escaping at a distant point or lodging in the soft parts of the scalp; 
but the momentum of the modern missile generally carries it crashing directly 
through the skull and brain and driving fragments of the bone into the cere- 
bral tissue. Some of the most terrible wounds of the skull are produced by 
fragments of shells. In whatever way caused, whether by balls or by por- 
tions of exploded shells, the prognosis will be unfavorable. Concentration 
and intensity of force confer upon all such injuries the gravest importance. 
The chief distinguishing feature between these wounds and those usually 
encountered in civil practice or from ordinary traumatic causes is that in 
the former the external or visible injury appears unimportant and conveys 
no idea of the extent of the internal or invisible damage. There may be 
an opening in the integument or in the external table so small as almost to 
escape observation, and yet the skull may be extensively fissured, the internal 
table comminuted, the membranes and sinuses torn, and the brain-substance 
contused or lacerated. In the ordinary cases of head wounds which come 
into our hospitals, caused by the wheels of wagons, or by missiles like stones 
and bricks, giving rise to black-and-blue discolorations of the integument, 
swollen eyelids, free hemorrhage, and the detachment of large and ii*regular 
portions of the scalp, the external injury is no index to the internal, which 
may indeed be quite insignificant. 
The evil consequences of gunshot wounds of the head are immediate and 
remote. Under the former or immediate consequences may be mentioned 
Gunshot Wounds of the Head. GUNSHOT WOUNDS OF THE HEAD. 
357 
concussion, compression, and hemorrhage, and under the latter compression, 
inflammation of the brain, of its membranes, or of both, the formation of 
thrombi in the sinuses, abscess, pyaemia, necrosis of bone, muscular weakness, 
vertigo, headache, loss of memory, epilepsy, and paralysis. 
Mortality of gunshot wounds of the head.—According to Macleod, during the 
Crimean War there were 630 cases of scalp wounds, of which 8, or 1.1 per 
cent., died; 61 cases of fracture of the cranial walls without known depres- 
sion, 23, or 37.7per cent., proving fatal; 74 cases of fracture with depression, 
with a mortality of 53, or 71.6 per cent.; 67 in which the skull was pene- 
trated, 67, or 100 per cent., dying; and 19 in which the skull was perforated, 
85.7 per cent, proving fatal. Alcock gives 28 cases of fracture, and 22, or 
78.5 per cent., of deaths. Meniere, during the war in India, records 9 cases 
of wounds penetrating the skull, 88.9 per cent, resulting in death. The 
same author collects from other sources 10 additional cases of penetrating 
wounds, all of which were mortal. 
The Surgical History of our own late civil war, though exhibiting a heavy 
mortality, yields a more favorable result than that indicated by the figures 
already recorded. 
Taking wounds of the scalp, incised, punctured, and lacerated, there were 
669, with a mortality of only 2 per cent.; of gunshot wounds of the scalp 
there were 7739, with a mortality of 162, and most of these from inflamma- 
tion of the encephalon. 
The results of a summary of 4350 gunshot injuries of the cranium are 
exhibited in the following table: 
No. of Cases. 
Recovered. 
Died. 
Undeter- 
mined. 
Ratio of 
Mortality. 
328 
273 
55 
16.8 
138 
128 
10 
8.7 
95 
20 
1 
19 
19 
12 
7 
36.8 
64.6 
Fracture of both tables without known 
2911 
1001 
1826 
84 
364 
231 
129 
4 
35.8 
85.5 
486 
68 
402 
16 
73 
14 
56 
3 
80 
9 
9 
100 
2 
1 
1 
50 
4350 
1729 
2514 
107 
Excluding the 107 undetermined cases in the above collection, the general 
mortality from the different forms of shot injuries above specified is 59.2 per 
cent. The mortality following shot wounds of the cranium in the Confed- 
erate armies, according to McGuire, was 60 per cent. 
Gunshot injuries of the scalp.—Wounds of the scalp may be caused by frag- 
ments of shells, sabres, bayonets, or balls, and they may partake of the char- 
acter of incised, lacerated, or punctured wounds. A missile, even though it 
strikes the head obliquely or at a very acute angle, merely grazing the bone, 
is likely to communicate a serious shock or disturbance to the encephalon. 
Should, however, the injury be confined to the soft parts, and be produced by 
a piece of shell or a conoidal ball moving with great velocity, the tissues will be 
damaged in such a manner as to produce some degree of sloughing, and, "when 
the vessels of the pericranium are injured, cause exfoliation of the external 
table of the underlying bone. When the momentum of a ball is in a large 
measure expended, it may simply contuse the scalp without penetrating, or, 
if it effects an entrance, merely lodge between the soft parts and the bone. 
Treatment.—The treatment of uncomplicated scalp wounds from the cas- 358 
INJURIES OF THE HEAD. 
ualties of war does not differ from that proper to injuries of the same region 
met with in civil practice. Bleeding should be arrested, foreign bodies re- 
moved, the parts cleanly shaven, the wound disinfected and dressed antisep- 
tically, and absolute quiet enforced. Care must be taken, should an abscess 
follow, to have it opened early and at a dependent point, to insure drain- 
age ; and, as an additional precaution against the diffusion of inflammatory 
products through the sub-aponeurotic connective tissue, a recurrent bandage 
should be applied accurately to the head. When suppuration occurs beneath 
the aponeurosis, drainage must be provided. 
Gunshot wounds of the cranial hones.—These may be divided as follows: first, 
contusions of the bones without fracture; second\ incised wounds and frac- 
tures of the external or internal table, or of both tables, of the bones, without 
impinging upon the brain ; third, fractures with depression; fourth, fractures 
with penetration and perforation; fifth, crushing fractures. 
1. Contusions of the cranial bones.—A ball or other missile may strike the 
skull without sufficient momentum to effect either a lodgment or entrance, 
and only produce at the time a slight degree of concussion, from wffiich the 
patient after a brief period recovers, and yet the after-effects may prove very 
serious. I have seen men permanently invalided in this wray from the dis- 
turbance to which the brain has been subjected, giving rise to severe head- 
ache, confusion of ideas, loss of memory, feebleness of the limbs, irregularities 
of muscular action, or defects in co-ordination, moral eccentricities, violent 
outbreaks of temper, epilepsy, etc. As these diseases may exist without any 
serious impairment of the general health, the unfortunate victims are some- 
times unjustly charged with malingering. These contusions are often fol- 
lowed by detachment of the dura mater, or by rupture of a sinus or of the 
vessels of the pia mater, giving rise to fatal compression of the brain from 
hemorrhage, also by laceration of the brain-substance and the foi’mation of 
intracranial suppuration. In those cases in which death is represented to 
have followed contusions of the skull, without any detectable sign of injury 
to its contents, it is probable that the investigation has not been sufficiently 
thorough. 
2. Fracture without depression.—These wounds differ, according to the nature 
of the vulnerating body and the angle of contact. When inflicted by the 
sabre, a part of the skull or its entire thickness down to the dura mater 
Fig. 312. 
Fig. 313. 
A sabre-cut of both parietals.—Spec. 1672, 
Army Medical Museum. 
Fissured fracture.—Army Medical 
Museum. 
may be cut out (Fig. 312), so that it shall hang by the pericranium and scalp. 
The bones may be grooved to a considerable depth by the flight of a ball 
striking at an acute angle, or they may be fissured, the lines of fracture running 
in various directions. (Fig. 313.) Whenever the bone is furrowed, the danger GUNSHOT WOUNDS OF THE HEAD. 
359 
of necrosis, pymmia, and intracranial abscess is imminent. The internal table 
alone may be broken and the external table escape, the lines of fracture run- 
ning in different directions. (Fig. 314.) The external table in such cases 
frequently becomes denuded at the place where the force is applied. (Fig. 315.) 
Fig. 314. 
Fig. 315. 
Fracture of the internal table without 
injury of the external.—Spec. 23115, Army 
Medical Museum. 
Denuded surface of the external table over 
the region of fracture of the internal.—Army 
Medical Museum. 
The mortality following fractures of the internal table, it will be seen by refer- 
ence to the table on a preceding page, is very great, amounting to 95 per cent. 
The external table may be fissured without displacement, and the internal 
table broken and extensively splintered. (Figs. 316, 317.) When the outer 
table alone is broken, it is an evidence of diminished velocity in the body 
producing the fracture, and hence the low mortality following such injuries, 
as will appear from the table, being only 8.7 per cent. In other instances the 
missile may comminute both tables, so that the fragments can be felt moving 
freely under the fingers, and this may occur both with and without compression 
of the brain. Terrible as these accidents appear, they are really less dangerous 
than those in which the tables are fissured. There are obvious reasons for 
Fig. 317 
Fig. 316. 
Fissure of the external table of the skull.— 
Spec. 24, Army Medical Museum. 
Internal view of the same, showing the 
splintering of the internal table.—Spec. 24, 
Army Medical Museum. 
this difference. Fissures are an evidence of intense and diffused force, or, in 
other words, are the result of a high degree of velocity in the projectile 
which produces them. The intracranial inflammatory products consequent 
upon such violence, being sealed up, constitute an additional element of 
danger. 
In comminuted fractures the fragments are often so movable as to yield to 
the motions of the brain and permit the escape externally of blood and other 
fluids. The termination of such cases, in both civil and military practice, is 
more favorable than when the bone is less extensively injured. 1 have had 
ample confirmation of this fact in my hospital practice. 360 
INJURIES OF THE HEAD. 
3. Fractures with depression.—A ball or other missile may strike the skull, 
and produce a fracture with depression, without either lodging iti the walls 
of the cranium or entering the cavity. This result will follow whether the 
vulnerating projectile be moving at a low or at a high rate of velocity. When 
the first is the case, it is necessary that the impact with the skull be in a 
great measure direct; and when the injury occurs under the second condi- 
tion, the ball must strike at an angle more or less acute with the surface of 
the bone, otherwise it would either penetrate or perforate. A reference to 
the table on page 357 will show that the mortality-rate of such fractures is 
very low as compared with that of fractures without depression, being only 
35.8 per cent.,—a disparity which seems altogether too great. If all the cir- 
cumstances attending the 2911 cases on which the analysis was based had 
been ascertained, they would in all probability have explained the increased 
death-rate. In the Crimean War, out of 76 cases of fracture with depression 
and without penetration, 55 died. 
4. Penetrating and perforating fractures.—When a ball enters the cranium 
it makes an opening of entrance smaller than that of exit. The former may 
be a round puncture without any Assuring of the external table, and yet the 
internal will be extensively broken by the passage of the ball plus the portion 
of the external table carried before it. (Figs. 318, 319.) Fragments of the 
internal table are often in this manner driven into the brain, tearing the mem- 
branes and lacerating its substance. Such fractures are in a vast majority of 
cases fatal. If death follows in twenty-four or thirty-six hours, it will be 
Fig. 318. 
Fig. 319. 
Gunshot perforation of the external table, 
showing opening of entrance, without As- 
suring.—Spec. 1473, Army Medical Museum. 
Internal view of the same specimen, show- 
ing extensive splintering of the internal 
table. 
from shock and the extravasation of blood and serum; when the fatal result 
is longer delayed, encephalitis or abscess will ultimately destroy life. When 
the projectile remains within the cranium, the danger is greater than when 
it passes through or perforates, as in the former case there is one foreign body 
more in the cranium. The statistics of our late war show a difference of 5 per 
cent, in favor of perforating over penetrating fractures, the mortality in the 
former being 80 per cent., and in the latter 85.5 per cent. 
Penetration of the skull is sometimes effected by sharp-pointed missiles, as 
bayonets, daggers, nails, ramrods, arrow-heads, and other similarly-formed 
bodies. Of six recorded cases of such wounds, five being inflicted by the 
bayonet and one by the sword, all died save one,* and he was rendered unfit 
for duty by an imperfection of speech, with pain in the cicatrix and head 
coming on after any excitement, mental or physical, and accompanied with 
defective sensation in the right arm. The puncture in this case was over the 
left parietal bone. The causes of death in the five fatal cases were—in one, 
extravasation of blood; in a second, hernia cerebri; in a third, encephalitis; 
and in the remaining two, abscess of the brain. 
A remarkable case of penetrating wound of the skull is recorded by Dr. 
Harlow, of Vermont, produced by a tamping-iron over three feet in length 
and one inch in diameter, which was driven entirely through the head, 
* Surgical History of the Late American War, vol. i. p. 33. GUNSHOT WOUNDS OF THE HEAD. 
361 
entering at the angle of the lower jaw and emerging near the centre of 
the coronal suture. The direction taken by the iron was such as to render 
it probable that, in addition to fracturing the temporal, the sphenoid, and 
the parietal bones, and traversing the anterior lobe of the cerebrum, it 
wounded the superior longitudinal sinus. This patient recovered, and lived 
twelve years after the injury, though he suffered most of the time from 
mental peculiarities which rendered him unlike his former self, and he finally 
died in an epileptic convulsion. 
5. Crushing fractures are those in which there is not only extensive com- 
minution of the bones of the skull, but also divulsion of the sutures and 
laceration of the brain and its membranes. These terrible injuries are pro- 
duced by solid shot, by fragments of shells, and even by rifle-balls when tired 
at close range. Though a crash of the skull is generally instantaneously 
fatal, yet soldiers have sometimes survived two weeks after such an injury. 
A private in the Eleventh Pennsylvania Reserves was wounded at the battle 
of Fredericksburg, Virginia. December 13, 1862, by a shell which detached 
almost the entire parietal bone. He was sent to the Lincoln Hospital, at 
Washington, where he died on the 26th of December. He was able for some 
time to swallow food and drink, though in a condition of stupor. On his 
admission into the hospital, one-third of the left hemisphere had sloughed 
away, and at the time of his death almost the entire cerebrum had undergone 
a similar change.* Crash of the skull, however, possesses little interest for 
the surgeon, as it is uniformly fatal. 
Treatment.—When the skull is broken, but not depressed, and there are 
no symptoms of compression present, the treatment will consist in establish- 
ing reaction (should the symptoms of shock be present), by placing the patient 
in the recumbent position, with the head slightly elevated, and applying ex- 
ternal warmth along the spine and to the lower extremities. Where the 
reaction is slow, the patient being pallid and feeble, with a cold perspiration 
upon the surface of his body, a little brandy or whiskey and milk may be cau- 
tiously administered, with a view to assist the recuperative powers of the sys- 
tem ; but as soon as the evidences of reaction appear, such as warmth of the 
skin, a fuller pulse, a return of color to the face, a dryer skin, and perhaps 
vomiting, all stimulants must be withdrawn, and the head raised by an ad- 
ditional pillow. The danger of hopeless collapse being past, the next anxiety 
of the surgeon will be to prevent intracranial inflammation and its effects. In 
anticipation of this, bladders or rubber bags filled with broken ice should be 
kept to the head, and the bowels freely opened. If the circulation become too 
active and forcible, attended with headache, it should be controlled by tinc- 
ture of veratrum viride, or by the general or local abstraction of blood. The 
importance of the use of mercury as an antiphlogistic cannot be overrated, 
and it should be given in all cases where, from the severity of the injury, 
there is reason to fear inflammatory sequences. The diet at first should be 
restricted, consisting of toast-water, light gruels, or a little milk, but after 
a few days it may be increased in quantity and quality. The condition of 
the bladder must be carefully inquired into, and the urine drawn when the 
patient is unable to relieve himself of the distention. Should symptoms of 
cerebral compression develop in the progress of the case, the question of 
instrumental perforation of the skull will arise. 
When in addition to the fracture there is depression of bone, with the symp- 
tom of brain compression, we have a complication which involves the exer- 
cise of much surgical judgment. The great question to be determined is this : 
When should the trephine be used to elevate the depressed bone ? Upon 
this point there is some discrepancy of opinion. There are conditions in 
which the indications for operative interference are plain and admit of no 
discussion ; as where there is an external wound, with comminution of the 
* Surgical History of the Late American War, vol. i. p. 212. 362 
INJURIES OF THE HEAD. 
bone, its fragments being driven in upon the brain, with or without symptoms 
of compression being present, or where there is depression, with the signs 
of compression steadily increasing, even though there is no external wound. 
In punctured wounds also there can be little doubt about the propriety of 
using the trephine, in order to allow of a free escape of blood and inflamma- 
tory products. A diversity of opinion might occur in those cases in which, 
with marked depression, the signs of compression are not urgent. The fright- 
ful fatality which has followed the employment of the instrument in such 
cases has greatly restricted its use with military surgeons. Stromeyer states 
that in one of the battles during the Schleswig-Holstein War there were eight 
depressed fractures of the skull, with moderate symptoms of compression, 
which were left to nature, and all of which, with one exception, recovered. 
In the case which proved fatal there had been some meddling, as a number 
of pieces were extracted several days after the injury. During the entire war 
only a single instance of recovery followed the use of the trephine. The ex- 
perience of English surgeons during the Crimean War harmonizes with that 
of Stromeyer, only four cases of trephining having recovered. With the 
French, as stated by Dr. Schrive, the operation was generally unsuccessful. 
We learn, on the authority of Dr. Williamson, as quoted by Hewett, that 
after the Sepoy mutiny in India no soldier who had been trephined reached 
Chatham,* although there were among the number eight cases of fracture of 
both tables of the skull with depression. In the later Franco-German War 
the operation was rarely performed. In our own late war the results of 
the operation, as they are recorded in the “ Surgical History of the War,” 
are quite favorable to the use of the trephine, and in striking contrast with 
the general experience of military surgeons abroad. The operation was per- 
formed in 220 cases, 95 recovering, 124 dying, and one result being unknown, 
giving a death-rate of 56.6 per cent. In 454 cases the broken or depressed 
fragments were either removed or elevated by other means than the trephine, 
275 of which number recovered, 176 died, and 3 remained uncertain,—a 
death-rate of only 39 per cent. Flattering as these results appear, until, 
however, we have ascertained, approximately at least, the exact nature of 
the injuries for which the operations were done, both as to structural damage 
and the cerebral symptoms present,—considerations which the distinguished 
author of the work himself fully recognizes,—it would be unsafe to speak 
with confidence on the subject, and especially where the weight of English, 
French, and German military surgical authority is directly antagonistic. I 
am inclined to believe that the truth lies somewhere between these two 
extremes, and that, while the European practice has been too restricted, the 
American may have been too meddlesome. I cannot believe that the opera- 
tion of cutting out a circular piece of bone from the skull is in itself very 
serious, so long as the dura mater is not torn, scarcely more so, indeed, than 
that of excising a portion of a rib and exposing the pleura costalis. The 
success following the use of the trephine when employed by the older sur- 
geons for injuries of the skull, as compared with that realized by those of 
the present day, argues no superiority of judgment or skill on the part of 
the former, but simply proves that the old round ball was a harmless missile 
as compared with the modern conical one. The dangers arise from the 
original injury, and consist in the damage sustained by the brain and its 
membranes. In a paper published by Dr. S. W. Grossf there is a compari- 
son instituted between the treatment of gunshot wounds of the skull by 
trephining and that by expectancy, with the following result. In 160 cases 
of such injuries in which the trephine was employed the death-rate was 60.62 
per cent., and in 573 cases in which the expectant plan was adopted the 
mortality was 74.34 per cent. In 126 cases in which fragments were ex- 
tracted or elevated by instrumental means without boring the skull, the 
* Holmes’s Surgery, vol. ii. p. 178. 
f On Trephining after Gunshot Injuries of the Head, American Journal of the Medical Sciences, 
April, 1867. GUNSHOT WOUNDS OF THE HEAD. 
363 
mortality was 55.55 per cent. Comparing the results of trephining with 
the other modes of lifting or removing portions of bone, such as the elevator, 
forceps, or saw, the difference in favor of the latter is 5.07 per cent, of re- 
coveries. The rate of recovery after all operative means was 41.61 per cent. 
By expectant or conservative methods the ratio of success was only 25.26 
per cent., thus showing a result of 16.35 per cent, of recoveries in favor of 
the operative plans. 
In cases of penetration, any exploration in search of the missile should be 
conducted with the utmost caution. It is impossible, after a probe has passed 
out of sight, to know whether it is following the track made by the ball or 
whether it is penetrating the brain-substance, and therefore, where the opening 
in the skull is sufficient to admit the finger, the latter should be used in prefer- 
ence to any other means of exploration. As there are likely to be fragments 
of bone belonging to the internal table driven into the brain, the trephine 
should be employed and their removal effected. These are cases for drainage 
and strict antiseptic treatment. The fatality following foreign bodies allowed 
to remain in the brain suggests that no reasonable efforts should be spared to 
effect their extraction. The quiet manner in which the brain tolerates the 
presence of foreign bodies is in some instances very remarkable. A case is 
reported by I. Palmer, Esq.,* of a soldier who, on account of drunkenness, 
was put into the guard-house, and on the following morning was sent to the 
hospital with some slight complaint. He remained in the ward two days, 
when he was suddenly seized with symptoms resembling those of apoplexy, 
and died in a few moments. On examination, a small wound was found in 
the left upper eyelid, which had been made by the stem of his pipe, part of 
which was discovered, surrounded by a collection of purulent matter, in the 
left anterior lobe of the brain. lie had fallen on his pipe while drunk, and the 
stem had penetrated the cranium without his being conscious of the injury. 
M. Huppertf mentions the case of a man, aged forty-two years, who for more 
than forty years had enjoyed good health, but who for a year before his death 
had some mental disturbance consequent on an injury of the head. On exam- 
ination, there was found in the brain a piece of slate-pencil three inches long 
lying in the white substance close under the right superior and lower cornua. 
The scalp and membranes were intact, but from the appearance of the occip- 
ital bone it was probable that the pencil made its entrance in early youth. 
It had caused no severe symptoms, but, as the writer suggests, it predisposed 
the man to suffer quickly and severely after the reception of what was a slight 
injury to the head. Sir Philip CramptonJ reports the case of a gentleman 
who, in the winter of 1814, while an officer in a Highland regiment, received 
a thrust from an umbrella, the point of which struck him below the left eye- 
brow. He went home and had the wound examined, as it bled slightly. In 
the upper eyelid the wound was three-fourths of an inch in length. On the 
second morning after the accident a physician was summoned, who found him 
in strong convulsions, which lasted until nine o’clock in the evening, when he 
died. On examination, the brass ferrule of the umbrella was found in the left 
hemisphere of the brain, it having penetrated the orbital plate of the frontal 
bone. Hr. V. Biart§ narrates the case of a man confined in the Kansas State 
Penitentiary, who attracted much attention among his fellow-convicts by 
boring a hole in his skull with an awl and introducing pieces of wire. The 
physician in charge removed several pieces which had pierced both cerebral 
hemispheres. The wound of entrance was situated in the right parietal bone, 
near its posterior inferior angle. He stated at the time that he had passed 
other substances into his brain. He was sent to the State Insane Asylum, 
and was perfectly well, with the exception of his mental condition. About 
a month after his admission he committed suicide by taking a large dose of 
* Dublin Journal of the Medical Sciences, vol. xi. p. 353. 
f Archiv der Heilkunde, 1875, pp. 97, 104. 
j Dublin Journal of the Medical Sciences, vol. xi. p. 352. 
| St. Louis Clinical Record, October 1875, p. 150. 364 
INJURIES OF THE HEAD. 
morphia. At the autopsy the brain was found congested, and a wire three 
inches long and three-sixteenths of an inch thick was found running from the 
wound of entrance to the fissure of Sylvius; a flat nail, one and three-fifths 
inches long, was also found lying near the wire. 
In the cavity of the arachnoid membrane, and glued to its surface by 
lymph, I once saw lying a needle, one inch and a quarter in length, the sur- 
face of which was considerably corroded. The subject was a young man 
about twenty-two or twenty-three years old, and had evidently died from 
some other cause than disease of the brain. The only theory I could suggest 
for the presence of the needle in such a locality was the probability of its 
having entered between the sutures of the cranial bones during his childhood, 
and before their close approximation. 
In two or three instances a ball has been traced through the brain, local- 
ized on the opposite side, and removed by the trephine. Electricity has 
been employed for the purpose of locating balls in the brain. The induc- 
tion balance, however, thus far has not proved of much service. McGuire, 
of Eichmond, has collected a number of cases* of unusual wounds of the 
brain followed by recovery. The importance of removing a foreign body 
from the brain, when it can be done without too much injury to the organ, 
has been well showm by Dr. Wharton.f In an analysis of 308 cases of foreign 
bodies of various kinds lodged in the brain, 167 cases were found to have 
terminated fatally, and 141 ended in recovery. In 104 cases the body was 
removed, recovery following in 68 cases and death in 36. In 204 instances 
in which the foreign body was not extracted, 73 cases recovered and 131 
died. Of the whole number (308), 272 were the result of gunshot injury, 
of which number 124 survived and 148 proved fatal. In 86 cases the body 
was extracted, with 54 recoveries and 32 deaths. In 36 cases of penetrating 
wounds other than gunshot, the foreign body was removed in 18. Of these 
36 cases, 17 recovered and 19 died. The term recovery, however, must be 
understood in a limited sense, for many represented as “getting well” suffered 
afterwards with vertigo, mental disturbance, and epilepsy. 
In the cases classified under the head of gunshot injuries, the missiles were 
musket- and pistol-balls, buckshot, and the breech-pins of guns. In the other 
cases the mutilating bodies were knife-blades, splinters of wood, ferrules of 
canes, stems of tobaco-pipes, wire, nails, and slate-pencils. The following 
table will place the subject in a perfectly intelligible form : 
TABLE OF 308 CASES OF FOREIGN BODIES IN THE BRAIN, 
Description. 
No. of Cases. 
Body 
removed. 
Body not 
removed. 
Recovered. 
Died. 
r 
86 
54 
32 
Result of gunshot injury 
272 j 
186 
70 
116 
Result of injuries other than gunshot 
36 | 
18 
18 
13 
4 
5 
14 
Arrow Wounds 
Arrow wounds belong to the punctured class. During the early frontier 
wars with hostile Indian tribes, arrow wounds were quite common, but at 
present they are comparatively rare. Eighty-three cases of such injuries are 
reported in Circular No. 3J as having been inflicted upon different parts 
of the body. Twenty-six of these were fatal, and they were invariably so 
when the cavity of the cranium, chest, or abdomen was penetrated, and 
* Annual of the Universal Sciences, vol. ii. p. 299. 
f Thesis, by Dr. H. R. Wharton, University of Pennsylvania, 1876. 
j Surgeon-General’s Office, Washington, D.C. ARROW WOUNDS. 
365 
also when the larger bones and joints were implicated. The arrow-head 
is spear-shaped (Fig. 320), made of hornstone, quartz, or iron, having either 
smooth or serrated margins. When sped from a strong bow it moves with 
a velocity little inferior to that of a rifle-ball, and if within proper range will 
penetrate or transfix a bone as well as the soft parts. Fig. 321 is a good 
illustration of this fact. Punctured wounds of the skull are sometimes made 
by arrows, as in Fig. 322. It is said by Dr. Otis* that these wounds resemble 
incised ones, the arrow passing through both tables without Assuring or 
splintering the walls of the skull. This does not accord with the statement 
of Dr. Bill, who is the author of a very valuable paper upon arrow wounds,f 
and who found after such injuries not only fissures of the external table, but 
also splintering and depression of the internal. The wound made by the 
Fig. 320. 
Fig. 322. 
Iron arrow-head.—Army Medical Museum. 
Fig. 321. 
Arrow in the head of a soldier killed by a Comanche 
Indian, with no fissure beyond the point of penetration. 
—Army Medical Museum. 
Buffalo rib pierced by an arrow.—Army Medical 
Museum. 
arrow-head partakes of the properties of both a punctured and a lacerated 
one, and is followed by considerable suppuration. There is a popular notion 
that these wounds are also poisoned, in consequence of the treatment of the 
arrow-heads by which they are inflicted with certain animal poisons before 
being used. The practice is certainly not general, but in a great measure, 
according to army surgeons, is confined to a single tribe, the Pi-Utes. Of 
seventy-six cases of arrow wounds inflicted by Navajo, Apache, and Utah 
Indians, Dr. Bill saw no wounds which were poisoned ones. The poison used, 
as stated by the same author, is that of the rattlesnake, and it is prepared by 
first exposing the liver of some animal and provoking the reptile to strike it. 
thus emptying into its substance the contents of the poison-gland. The liver 
is next removed, wrapped up in the skin of the animal, and buried: after a 
few days, when decomposition has taken place, it is dug up, and the tips of 
the arrows are dipped in the decayed material. A few days later, when the 
adherent matter has become dry, the points receive an additional coating of 
blood, after which they are considered fit for use. 
Treatment.—When an arrow has penetrated the skull, or other bones, the 
first step is to prepare an unobstructed way for its extraction. Mere traction 
will prove inadequate for the purpose, and should never be made through the 
shaft, as it will separate from the arrow-head and complicate the case. When 
it is deeply buried, the soft parts contract around its neck, or that part of 
the shaft where the point is connected wdth the neck, so that the expanded 
base and the serrations of its sides act like the barbs of a fish-hook, and resist 
* Circular No. 3, Surgeon-General’s Office, p. 150. 
f American Journal of the Medical Sciences, vol. xliv. p. 365. 366 
INJURIES OF THE HEAD. 
withdrawal. The preliminary measure, therefore, is to ascertain, if possible, 
the direction of its surfaces, incise the track freely on either side of the shaft 
down to the margins of the dart, and then, grasping it with a pair of strong 
forceps, rock it from edge to edge until the impaction gives way, when a 
little traction will effect its removal. Should the missile be of stone, care must 
be observed not to exercise force in an improper direction, or it may be broken 
in two pieces. Additional difficulty will sometimes be encountered in the 
extraction of an arrow should its head be of iron, as it is liable to become 
bent in making its way between a bone and the overlying structures. Under 
such circumstances a great degree of force will be required to accomplish its 
removal. 
When an arrow-head enters the cavity of the thorax or of the abdomen, the 
difficulties of extraction are greatly enhanced. It is in these cases that the 
attachment of the shaft is so important, since it serves as a guide to conduct 
a wire noose over the arrow-head, by which the latter can be drawn out. To 
apply this snare the soft parts must be laid open along the track to the end 
of the wound. A piece of soft iron wire should next be passed through either 
a double canula or a Cogshill wire-twister. (Fig. 323.) The loop projecting 
Fig. 323. 
Wire passed through the Cogshill wire-twister. 
beyond the end of the instrument should receive a single twist, and then be 
bent off at an angle, after which it is to be slipped over the pi’ojecting end of 
the shaft and thus slid down to the arrow-head. By drawing upon one end 
of the wire the noose will be made to encircle the dart (Fig. 324), and its 
extraction is effected by pulling both wire and arrow-shaft at the same time. 
Whatever may be the difficulties encountered, the extraction of the missile 
is a paramount matter, and no device offering a reasonable probability of 
success should be left untried. When there is reason to believe that the 
Fig. 324. 
Dr. Bill’s wire loop applied to the arrow-head. 
internal table of the skull is splintered and depressed by an arrow-head, the 
use of the trephine will be as clearly indicated as in punctured wounds from 
other causes. 
Injury of the Cranial Nerves. 
Injury of one or more of the cerebral nerves is by no means an uncommon 
occurrence in cranial fractures, whether produced by gunshot or other kinds 
of violence. When the base of the skull is examined, and the number of 
foramina for the transmission of the cranial nerves considered, it is a matter 
of surprise that the injury is not more common. The evidence indicating 
such an injury is the loss of function belonging to the particular nerve in- 
volved. All are not alike liable to injury: the seventh, second, first, third, 
and fifth are those most commonly damaged. The causes which produce 
either the destruction, diminution, or suspension of function of the nerves 
differ in different cases. A ball may pass through the brain and completely 
sever a nerve. In such a case the loss of function is immediate, absolute, SEQUELS OF HEAD-INJURIES. 
367 
and hopeless. A violent or diffused force may fracture the base of the skull, 
lacerating or bruising to a greater or less extent the portio dura and the 
portio mollis nerves. The facial paralysis and the defect or loss of hearing 
sufficiently attest what has happened, and give additional strength to the 
probability of a fracture through the petrous portion of the temporal bone. 
A blow upon the nose may be followed by loss of smell, an evidence of injury 
to the olfactory bulbs, and perhaps fracture of the cribriform plate of the 
ethmoid. After an injury of the head the upper eyelid may drop, indicating 
a lesion of a branch of the third pair. 
Paralysis may not appear for several days after an injury. Such cases are 
more favorable in their issue than when it comes on instantaneously, as in 
the first instance the cause is probably pressure either from blood or from 
inflammatory infiltration, and is therefore susceptible of improvement through 
the agency of the absorbents. It is possible to have a paralysis from con- 
cussion alone. I have seen instances of the loss of smell, and also of hearing, 
after a blow upon the head, in which there was no reason to believe that any 
fracture existed. In most cases the function is only suspended, and is in a 
few days recovered. 
Treatment.—The surgeon in such cases can only address his remedies 
to the inflammation which must unavoidably follow; to control which the 
head should be elevated, local cold applied, and blood abstracted when indi- 
cated by severe and continuous headache. The derivative and depletive 
effects of purgatives, especially of the saline class, render their use very 
desirable in the commencement of the inflammatory symptoms, and, after 
their action, alterative doses of mercury should be given, either in the form 
of calomel or in combination with iodine. 
Inflammation of the brain or of its enveloping membranes from traumatic in- 
juries of the head is exceedingly common. It is not necessary for such a result 
that extraordinary violence shall have been inflicted. It may follow wounds 
of the scalp, contusions of the bones, concussion, and fracture. The last, espe- 
cially if there be splinters or fragments wounding the meninges or the brain, 
is peculiarly prone to excite such action. There are two ways in which extra- 
cranial inflammatory diseases reach the interior of the skull, namely, by 
translation and by extension ; most commonly by the latter. The vascular 
communication between the scalp, the bony walls of the cranium, and the dura 
mater and arachnoid, is quite free and direct. The temporal, occipital, frontal, 
and the meningeal branches of the internal maxillary arteries have a free 
inosculation in the diploic structure of the cranial bones, so that inflammation 
may extend readily from the exterior to the interior of the skull by continuity 
of structure. The pia mater and brain, on the contrary, receive their chief 
blood-supply from the internal carotid and vertebral arteries. These anatom- 
ical facts indicate what my experience confirms, that, except after concussion, 
inflammation of the brain, as a result of extracranial injury, independent of 
inflammation of the dura mater and arachnoid, is rarely seen, and that the 
former, when it does take place, is consecutive to the latter. In cases of 
depressed fracture, particularly spiculse penetrate the membranes and 
wound the brain, the inflammation of the latter will often take precedence of 
that of the membranes. As has already been hinted, in severe concussion 
also, whether from direct or indirect causes (especially the latter), encephalitis 
is first developed, and whatever of meningitis is found present follows as a 
secondary result, or by an extension of disease from within outwards, inas- 
much as the vessels of the encephalon and those of the dura mater suffer 
most, in consequence of the disturbance or vibration communicated to the 
neurine which underlies and surrounds them. 
Symptoms.—There are certain symptoms which indicate the existence of 
intracranial inflammation, but I know of none which are sufficiently uniform 
Sequels of Head-Injuries. 368 
INJURIES OF THE HEAD. 
to enable us to differentiate between that which is meningeal and that which 
is encephalic. Among the earliest symptoms will be headache, and I think 
that local pain is most characteristic of commencing meningitis, whereas 
general or diffused pain points to encephalitis. This local suffering will, 
however, apply only to the initial stage of inflammation of the dura mater 
and arachnoid; the extension of the disease, a little later, will give a more 
general character to the pain. Restlessness, sleeplessness, and nausea con- 
stitute early signs of inflammation of the contents of the cranium, especially 
of the meninges. A supersensitive state of the organs of special sense indi- 
cates the existence of the same condition. Under such circumstances the 
pupils of the eyes become strongly contracted, and the light proves intoler- 
able ; loud sounds cannot be endured, and even the taste and smell become 
painfully acute. The pulse will be accelerated, the artery at first being small 
and hard, and having a quick beat, which as the disease advances will become 
fuller and less resistant; the eyes also will be injected and the face flushed; 
the temperature running up to 104° or even higher. When the difficulty is 
meningeal, the temporals throb violently; when encephalic, the carotids. I 
mention this last sign with some qualification, as 1 have not observed it in a 
sufficient number of cases to warrant a confident statement as to its uniform- 
ity. The mind becomes unsettled, the delirium sometimes being of a quiet 
nature, at other times furious or maniacal, particularly when the gray sub- 
stance of the encephalon is attacked. The secretion of urine is diminished, 
the bowels are constipated, and in cases where suppuration takes place there 
will be frequent rigors. As the disease advances, irregular twitchings of the 
muscles, tremors, spasms, and paralysis, followed by incontinence of urine, 
will occur,—a group of symptoms which some authors consider as indicating 
the implication of the white substance of the brain,—and finally death closes 
the scene, either by a convulsion or profound coma. In all advanced cases 
of brain-injury, a very frequent and feeble pulse, indicating a failure of the 
inhibitive power over the organ, may be regarded as a precursor of death. 
Intracranial inflammation may commence in twenty-four hours after an 
accident, especially when the reaction following collapse is violent, over- 
loading the vessels of the brain and membranes with blood; but, generally 
speaking, it does not arise earlier than the fourth or fifth day. When the 
disease is developed through continuity of structure, passing from without 
inwards,—that is, from the scalp or contused bone to the interior of the 
cranium,—it may not set in for four or five weeks. 
Morbid Appearances.—In fatal cases of traumatic intracranial inflamma- 
tion, there will be seen on examination undue vascularity of the membranes, 
with opacity and thickening. If confined to the dura mater, as it may be in 
chronic inflammation, in addition to discoloration and thickening, pus may be 
found between the membrane and bone. When the arachnoid has suffered, 
its surface will be found covered with a thin film of lymph, its cavity often 
containing serum or a sero-purulent fluid, and the serum will sometimes fill 
the ventricles. When all the membranes have been involved, they are not 
unfrequently found firmly united, by organized transudation, to one another 
and to the brain. The morbid alterations noticed in encephalitis consist in a 
multitude of red points, which must not be confounded with the blood-specks 
of contusion; there are also present softening of the brain-substance, discolora- 
tions of various hues, and occasionally abscess. 
Treatment.—It has been said that in the present state of our knowledge 
we are not yet in position to distinguish encephalitis from meningitis; but, 
fortunately, our ignorance on this point does not in the least embarrass the 
treatment. If the surgeon expects to rescue his patient, his course must be 
prompt and decided: there must be no compromise with the modern follies 
of expectancy, the result of which is well exhibited by the mortality of intra- 
cranial injuries during our late war, which, as stated by Dr. Otis, amounted 
to four-fifths of the cases treated, whereas under the antiphlogistic system 
practised in similar cases by both English and German surgeons during their SEQUELS OF HEAD-INJURIES. 
369 
late wars, one-half recovered. It is a hand-to-hand conflict, and the value of 
minutes cannot be overestimated. If there is reason to believe that a spicu- 
lum of bone has penetrated the brain, the trephine should be used at once 
for its extraction. The moment that pain, restlessness, nausea, and an ac- 
celerated pulse appear, let the struggle begin. The head should be elevated, 
shaven, and covered with an ice-bag; blood should be drawn from the arm, 
and locally from the back of the neck. General bleeding should not be 
practised recklessly: its etfect on the pulse should be watched with great 
care, stopping the flow as soon as the artery begins to lose its force or re- 
sistance, but repeating the operation, if necessary. A brisk cathartic must 
be next administered, followed by tincture of veratrum viride to control the 
action of the heart. The effect of a purgative will be found valuable at 
intervals during the entire progress of the case. The value of calomel in 
alterative doses, with inunctions of mercurial ointment, so as to secure the 
constitutional action of the remedies quickly, cannot be overestimated; 
while to relieve thirst, cold acidulated drinks should be given freely. To 
sustain the system for the first few days, barley-water, toast-water, and milk 
are quite sufficient. The violence of the inflammation being checked, the scalp 
should be covered with a blister, and restlessness, if present, relieved by the 
bromide of potash, or, that failing, by the use of opium in combination with 
the mercurial. It is important also that all strong light and loud sounds 
should be excluded. The convalescence is usually slow, and a relapse easily 
induced by any indiscretion on the part of the patient. He should not be 
allowed to sit up for two weeks after the subsidence of the disease, and then 
the change from the horizontal to the perpendicular position should be made 
in the most gradual manner. The bowels are to be kept open, and the food 
should be unirritating, being largely farinaceous. Stimulants must be avoided, 
and indeed an entire freedom from all excitement, mental or physical, is a very 
necessary precaution. Should abscess form, the surgeon must be governed 
by considerations already laid down. 
Fungus Cerebri.—As a consequence of the loss of a portion of the cranial 
walls from a comminuted fracture, from necrosis, or from the use of the tre- 
phine, the protrusion of an intracranial growth frequently takes place, which 
is designated fungus cerebri, encephalocele, or hernia cerebri. The last two 
terms have no appropriate significance when applied to this disease, and I shall 
use only the first, or fungus cerebri, as the most appropriate. The presence 
of this growth is supposed by some to be due to the absence of the necessary 
brain-pressure, as when the dura mater is torn in addition to the fracture. 
Velpeau thought that the disease was due to the expansibility of the brain 
under excitement, and that it was less likely to follow a large than a small 
opening in the skull. Flourens’s views accord with those of Velpeau, the ex- 
pansibility of the brain being considered to be produced by the distention of 
the blood-vessels at its base, consequent upon the absence of the usual resist- 
ance of a part of the cranial walls or of the dura mater. I doubt not that 
there is some truth in these statements, as it is certainly less frequently met 
with where the dura mater remains intact. Still, it is quite true that it 
sometimes arises even when the membrane remains unbroken, pushing it 
outward, until, in consequence of pressure, it inflames, ulcerates, or sloughs. 
Indeed, it is impossible to appreciate the conditions which determine such a 
production. I have seen cases in wThich there was not only extensive loss of 
bone, but also laceration of the membranes, with escape of considerable brain- 
tissue, and yet the patients made rapid recoveries without any tendency what- 
ever to the formation of a fungus, while in other instances of a similar kind 
the disease sprang up in a few days and proved fatal. In other cases that 
I have observed in which the opening in the skull was quite small, the 
growths were often absent, but were sometimes present, and irrepressible. 
Fungus cerebri may appear in a few days after the injury to the head, or not 
for three or four weeks. 370 
INJURIES OF THE HEAD. 
Morbid Anatomy.—The mass as it presses its way externally, rising above 
the level of the opening in the cranial walls and spreading mushroom-like 
over the surface of the scalp, presents a white irregularly-indented mass 
similar to the convolutions of the brain. (Fig. 325.) Sometimes it is quite 
soft and discolored with blood, at other times it is of a gray color and firm, 
consisting of softened brain-substance, nerve-fibres, white and red blood-cor- 
puscles, fibrin, and serum. The vascularity of the growth varies, it being 
sometimes abundantly supplied with 
blood, at other times only moderately 
rich in vessels, and its sensibility, if 
any, exceedingly low. In other cases 
the brain-substance constitutes a very 
small portion of these growths, indeed, 
appears accidental to them, and with- 
out any vital connection, consisting of 
exuberant granulations, the result of 
inflammation induced either by con- 
tusion of the brain-substance or by the 
presence of blood. The collections of 
pus frequently seen at the base of the 
growth are results of this inflamma- 
tion, and to the same cause are due the 
serous infiltration and softening of the 
brain-substance for some distance be- 
neath and around the fungus, also the 
presence of blood-clots and the con- 
tiguous yellow or red discolorations. 
These alterations of structure may extend quite deeply, even into the ven- 
tricles, in consequence of the very scanty supply of connective tissue in the 
brain, by the presence of which inflammatory products in other localities 
are ordinarily circumscribed. 
Fungus cerebri may affect any part of the brain, but is most commonly 
seen at some portion of the vault of the cranium,—the part most exposed 
to open fractures and to lacerations of the membranes. The base would 
perhaps be equally liable to such protrusions were there any considerable 
separation of the fragments after fracture in this region. 
When after removal of bone and destruction of the dura mater a fungus 
makes its way through the opening in the skull, and also through the wound 
in the scalp, it spreads circumferentially, overlapping for some distance the 
soft parts, and having a mushroom shape. Portions of the surface farthest 
removed from its origin, having a lower vitality, become dark, soften, and 
separate from the main mass. The pedicle of the growth in some instances 
becomes strangulated by the margins of the opening through which it passes, 
and the entire fungus drops off* as a slough, either to appear again or to be 
followed by cicatrization and recovery,—the latter a termination, unfortu- 
nately, very rare. During all this time the mental condition of the patient 
may lie unimpaired. The usual progress of the disease, however, is from bad 
to worse: an irritating and offensive discharge flows from the surface of the 
growth; when it is rudely touched, quite a copious flow of blood may follow; 
the mind wanders; there are irregular muscular movements, especially of the 
face, broken sleep, startings up with a frightened air, emaciation, rigors, and 
a feeble pulse, which is at first slow, but becomes frequent and feeble as the 
case advances. The patient gradually wears out from exhaustion, or dies in 
a state of coma or convulsion due to inflammatory changes within the cranium 
affecting the brain and its membranes: not unfrequently he dies from pysemia. 
Extensive softening and loss of brain-substance is often seen. I once examined 
the case of a young girl, in which almost one-half of the right hemisphere of 
the brain had entirely disappeared. 
Though recovery occasionally occurs, a very large proportion of the cases 
Fig. 325. 
Fungus cerebri from a child whose skull had been 
broken by the kick of a horse. SEQUELS OF HEAD-INJURIES. 
371 
die. Of fourteen eases recorded by a surgeon of Glasgow, twelve died; of 
three cases given by Mr. Stanley, two died; Mr. Hill reports three cases, all 
of which recovered.* During our late war, fifty-one cases of fungus cerebri, 
following gunshot wounds of the cranium, were reported, forty-four of which 
number terminated fatally. Of the seven who survived, four appear to have 
recovered perfectly without any mental or physical infirmity; the remaining 
three suffered so much from vertigo and headache as to be incapacitated for 
any continuous mental effort. It is proper to state that of the forty-four 
fatal cases eight were examples of brain-protrusion rather than genuine cases 
of fungus cerebri. 
Diagnosis.—There are other growths which on a superficial inspection 
might be mistaken for fungus cerebri. 1. A blood-tumor may protrude, de- 
rived from the vessels of the dura mater, or, when the latter is torn, from 
those of the pia mater, and will occasionally contain some brain-substance. 
The early appearance of such a tumor,—that is, a few hours after the acci- 
dent, or at most three or four days,—together with the homogeneous nature 
of the swelling, it being for the most part blood throughout, will be sufficient 
to distinguish it from fungus cerebri. 
2. Malignant disease occasionally originates in the dura mater, and as it 
increases the overlying bone is rapidly absorbed, or is finally destroyed by 
caries, after which the growth protrudes as a fungoid mass. Between this 
and fungus cerebri there are certain notable differences. First, in fungus 
cerebri there is a previous history of injury, as of fracture with or without 
laceration of the membranes of the brain. Ho such previous violence is 
necessary to the existence of a malignant growth. In the latter disease the 
bone will become so thin, its salts disappearing at the same time, that it will 
crepitate, when pressed upon, like parchment; fungus cerebri never produces 
such an osseous change. In fungus cerebri, when its structure is opened, 
disorganized brain-tissue is seen mingled with its other components, which 
is not true of malignant fungus. Fungus cerebri is soft, friable, with little 
power of cohesion, and when its vessels are broken the blood adheres as 
dark clots or crusts over different parts of its surface; malignant fungus is 
much firmer, and bleeds from distinct points, the fluid being red, like arterial 
blood. Fungus cerebri frequently detaches portions of its substance as a 
slough ; malignant fungus rarely does so. 
Treatment.—There are two very opposite plans of treatment, the one 
aggressive, the other conservative. 
In order to remove every cause which can possibly tend to develop the 
disease, the surgeon should be very careful to examine all compound fractures 
of the skull for depressed splinters. These are vastly more dangerous than 
scales or flat fragments of bone. They penetrate the membranes and wound 
the brain, or, even should they not do so, they produce irritation of the dura 
mater, which is almost certain to develop intracranial inflammation, ulcera- 
tion of the membranes with protrusions, and often epilepsy and abscess. 
Hence in the use of the trephine the utmost care should be observed not to 
harm the dura mater. 
When the fungus is once established, the practice with some surgeons is to 
repress the growth, either by compression with pledgets of lint or a sponge, 
or by excision, slicing the mass off on a level with the bone and then apply- 
ing compression over the pedicle. The conservative plan, which has its ad- 
vocates, is to meddle as little as possible, simply keeping the part clean by a 
gentle stream of water, and attending to the inflammation within, which is 
the cause of the protrusion. 
In the application of pressure the chief danger is to the brain. When too 
great, it is often followed by stupor or much uneasiness, and should be im- 
mediately removed or lessened. Ho harm can come from making pressure 
upon that portion of the growth which spreads over the scalp beyond the 
limits of the opening of the bone: indeed, it is highly proper that this should 
* Cooper’s Surgical Dictionary, vol. i. p. 935. 372 
INJURIES OF THE HEAD. 
be done. The plan which fulfils most satisfactorily the objeot is to take a 
piece of aseptic lint cut into a circle large enough to extend a little beyond 
the limits of the fungus ; out of its centre remove a portion somewhat larger 
in circumference than the opening through which the protrusion takes place, 
wet the lint with a solution of corrosive sublimate, place it over the mass, 
and cover the fungus with sublimate gauze. By this plan the growth is 
protected against atmospheric organisms, and as cicatrization advances, en- 
croaching little by little upon the pedicle, the fungus is finally cut off and 
the opening in the skull covered over by healthy granulations. 
As fungus cerebri is an inflammatory production, whatever is influential in 
preventing this morbid process will necessarily lessen the tendency to the 
disease: in this respect a rigid attention to antiseptic measures in the 
management of the wound is of the utmost moment, and will usually prevent 
the occurrence of this serious complication. 
Epilepsy.—Considering the vast number of cranial injuries from all causes, 
epilepsy, as a consequence of such, is rather uncommon. 
While depression is not a necessary antecedent for the production of epi- 
lepsy, in a large majority of cases under this head such a state of the bone 
is seen to exist. This affection is often preceded by defective memory and 
articulation, and by inability to sustain any connected train of thought or to 
transact ordinary business. After some time there may follow a momentary 
loss of consciousness, or a peculiar, indescribable sensation in the head, and 
finally the development of true epileptic convulsions. 
Should the trephine be applied to excise old depressed portions of bone 
which, by irritating the membranes of the brain and the brain itself, provoke 
this distressing disease ? La Motte, seventy-five years ago, was the first to 
use the instrument for this purpose, and there can be no doubt that under 
certain conditions the operation is not only proper, but even urgently de- 
manded. It is the apprehension of this disease that induces some surgeons 
to apply the trephine in cases of depressed fractures, even when no urgent 
symptoms are present,—and properly so, as I believe. 
In a paper by Dr. Billings on the subject of trephining for epilepsy, sixty- 
two cases are collected, of which number forty-two were cured, sixteen died, 
and four remained without improvement. Professor Gross* has operated 
four times, with one cure. 
The following five cases are from my own practice: 
The first was that of a young man whose left parietal bone had been 
fractured by the point of a mattock, close to the sagittal suture, eleven 
years previously, and who remained almost insensible for twenty-four hours 
after the receipt of the injury. Six years later he was attacked with epilepsy, 
the convulsions occurring almost daily, at times numbering as many as eleven 
in the twenty-four houi’s. The memory was impaired, though not to the 
degree which I have often seen. The depressed portion of bone was cut 
out with the trephine, revealing a depressed comminuted fracture of the 
internal table, Avith marked thickening of the dura mater beneath. The 
patient recovered, and when I last heard from him, after the lapse of a 
considerable period of time, he remained entirely well. 
The second case was that of a man about twenty-seven years old, a foreigner 
by birth, who, seventeen years before coming to America, had had his skull 
fractured by a beam of timber falling upon liis head, and who, after recover- 
ing from the immediate effects of the injury, became an epileptic. The fre- 
quency and severity of the convulsions produced such an uncontrollable iras- 
cibility of temper that his parents, unable to exercise over him the needful 
restraint, were compelled to send him to the Philadelphia Almshouse Hos- 
pital for the Insane, in which place I found him while making the round 
of its wards. There was a linear depression of the external table, about 
three-quarters of an inch in length, a little to the left of the sagittal suture. 
Believing the case to be a proper one for trephining, I made the operation 
* Surgery, vol. ii. p. 177. SEQUELS OF HEAD-INJURIES. 
373 
before the medical class attending the clinical instruction of the hospital. 
The patient had a convulsion on the table during the administration of the 
anaesthetic. After removing the bone there was found a stellated fracture 
(Fig. 326) of the internal table, with a rough, discolored 
thickening of the dura mater, but without evidence of 
depression. For four weeks he had no attacks, and was 
discharged from the house. Afterwards I learned that 
the convulsions returned, though greatly diminished in 
frequency, intensity, and duration, so that he became 
quite docile and lived happily at home. 
The third case was that of a young man about twenty, 
greatly enfeebled mentally and physically, with an exten- 
sive depression in the left temporal region, the result of 
a fracture received ten years previously. The dura mater 
had been wounded by the splintering of the internal table. 
This patient died from encephalitis. 
The fourth case was that of a man who had sustained a shell-injury of the 
left parietal bone, leaving an extensive depression. The epileptic attacks had 
become so frequent and severe that he was compelled to abandon his busi- 
ness, that of a merchant. The trephine was applied at two points and the 
intermedial bridge of bone cut away. The operation was followed by a 
marked improvement, though I have learned, indirectly, that after his return 
home the paroxysms became again quite frequent. 
In the fifth case the disease was attributed to an injury of the skull re- 
ceived some years previous to the patient’s application for relief. A small 
depression indicated the point where the violence had been applied. On re- 
moving this part of the skull an extensive exostosis was seen to be pressing 
on the brain beneath, the apex of which had caused the absorption of the 
dura mater. The man died a few days after the operation, from the pro- 
trusion of a fungous growth. 
Since these five cases I have trephined for traumatic epilepsy fifteen times, 
making the entire number twenty. Of these, three were cured; four were 
greatly relieved,—that is, the frequency of the seizures was reduced,—in 
one case from twelve or fourteen a day to one in three or four weeks, in the 
other to a less degree; in four the relief was trifling; in seven no benefit 
was experienced ; and two died. In all the cases in which the operation was 
done antiseptically (nine or ten) no deaths occurred. My results, it will be 
seen, have been singularly unsuccessful as compared with those collected by 
Dr. Billings, and also with those reported by Mr. Walsham, eighty-two in num- 
ber, forty-eight of which are claimed as cured, and thirteen as improved, four 
receiving no benefit, and seventeen proving fatal. Professor Briggs, in thirty 
cases of trephining for epilepsy, claims twenty-five cures, with only one death. 
Notwithstanding my ill success, I feel sure there is a good future for the 
operation. Many of the operations for the cure of traumatic epilepsy fail 
in consequence of the long time intervening between the development of 
premonitory symptoms and the application for surgical aid, during which 
time what was at first only a reflex effect from dural irritation becomes 
central and organic: therefore, to derive permanent benefit from operative 
procedures, the surgeon should act early, even before the disease culminates 
in convulsions. A second cause of failure, I think, is a too limited use of the 
trephine, thereby not removing fully the source of cerebral irritation in the 
form of depressed bone, cicati’ices involving the membranes of the brain, 
and, if necessary, the cerebral cortex corresponding to the motor area in- 
volved. In true cases of Jacksonian epilepsy this last becomes imperative, 
as it is from this portion of the brain that the attacks emanate. Dr. Deaver, 
Demonstrator of Anatomy in the University of Pennsylvania, recently suc- 
ceeded in curing a case of Jacksonian epilepsy by excising the motor centre 
of the left arm; and a similar operation has just been done by Dr. Hearn, of 
this city. Because immediate disappearance of convulsions does not in all 
Fig. 326. 
A button or bone taken 
from the head of an epi- 
leptic, showing comminu- 
tion of the internal table; 
followed by cure. 374 
INJURIES OF THE HEAD. 
cases follow operation, the surgeon should not be discouraged, since in cases 
where the disease has been due to reflected irritation some time may be 
required for secondary changes to subside: hence the propriety of an after- 
treatment calculated to restore the nervous equilibrium, as freedom from all 
mental and physical excitement, a carefully-prepared diet, and the use of 
bromides. Within a very short time the operation of trephining has been 
extended to cases of insanity depending on traumatism. Horsley, McDonald, 
and Price report successful cases. Dr. Fletcher, Superintendent of the In- 
diana Insane Hospital, has reported eight cases of trephining for traumatic 
insanity, and in all, save one, the patients who had been violent, profane, 
melancholic, or suicidal were rendered docile and safe. 
The conditions which, in my judgment, justify a resort to the trephine in 
epilepsy are, first, where the disease is the result of trauma; second,where 
the disease originates within the limits of the motor centres of a deflnite 
group of muscles, as the face, arm, or leg; and, third, cases where cicatrices 
exist, either in the scalp or in the cerebral meninges. 
The most unfavorable cases, the ones unsuited for operation, are those in 
which the seizures give no warning, but explode instantaneously, and in 
which no special group of muscles seem to take precedence in the attack, 
those of the extremities and those of the face being simultaneously affected. 
Pain in the head.—This is often a troublesome sequel of head-injury. Some- 
times it is localized or confined to a small spot, when it should always be re- 
garded with anxiety, indicating as it does that some brain-mischief is going 
on, such as softening or abscess. Diffused pain, particularly under mental 
excitement or when exposed to solar heat, is a less serious condition, though 
not altogether without danger. These pains are often aggravated by ex- 
posure to inclement weather. 
Vertigo is a very common sequel, a fact well illustrated in the Surgical 
History of the late war, where it is stated to have been very common after 
contusions of the cranium, rendering the patients, in many cases, incapable 
of subsequent service. 
Mental defects.—Under this head may be mentioned loss or impairment of 
the memory, inability to express ideas or to pursue processes of reasoning, a 
capricious temper, aphasia, or loss of language, imbecility, and insanity. 
Involvements of the muscular system.—These conditions, dependent upon intra- 
cranial irritation or abscess, consist in feebleness of the limbs, spasmodic con- 
traction of the flexors, tremors, twitchings, or paralysis affecting one side of the 
body. The genito-urinary apparatus often suffers, the patient losing power 
over the bladder or being subjected to the annoyance of great vesical irrita- 
bility, the urine being often loaded with phosphates and mucus. Occasionally 
the urine is albuminous, or it may be greatly increased in quantity and become 
saccharine, constituting what is termed traumatic diabetes, the pathology of 
which, though supposed by some authors to consist in structural alterations 
of the floor of the fourth ventricle and by others ascribed to imperfect 
oxygenization, has really never been determined with any degree of cer- 
tainty. Sometimes there is complete impoteney, while in other cases there 
is inordinate sexual excitement, accompanied by painful erections. 
Derangements of the organs of special sense.—These derangements may in- 
volve the eye and its appendages, and consist in the loss of the power of ac- 
commodation, the presence of double vision, glaucoma, conjunctivitis, ptosis, 
etc. The sense of olfaction is sometimes lost, or it maj’ be perverted, the 
patient complaining of the presence of strange odors. The hearing may be 
rendered obtuse or utterly destroyed. In some instances there are unusual 
sounds experienced, like the hissing of steam, the ringing of bells, or the roar 
of the sea. These cause great distress. Scarcely any organ of the body can 
claim exemption from the far-reaching effects of head-injury. The function 
of the liver may be disturbed, producing traumatic jaundice, and the heart 
may become preternaturally excitable or depressed. 
Pycemia.—Pyaemia is by no means so common as abscess, though the TREPHINING. 
375 
peculiar arrangement of the venous system of the diploe would indicate the 
contrary. Dr. Otis states that the returns of the army show but a single 
case in which the disease was referred to this cause. 
Tetanus is quite rare as a sequence of head-injuries. 
Treatment.—The exact nature of the meningeal or brain condition on 
which depend the sequels that have been enumerated is so obscure that 
our treatment must be largely empirical and directed against the symptoms 
as they arise. Entire freedom from mental and physical excitement is of 
the first importance. Solar heat must be avoided. The readiness with which 
reflex impressions reach the brain from disordered states of the gastrointes- 
tinal mucous membrane will suggest the necessity for keeping the bowels 
regular and avoiding the use of all articles of food calculated to disturb the 
digestion. The state of the kidneys should be ascertained, as not unfre- 
quently serious cerebral disturbance depends upon inflammatory conditions 
of these organs; and when such is the case, the use of alkaline diuretics, as 
the acetate or the bicarbonate of potash, will be indicated. To relieve pain, 
dizziness, and restlessness, the bromide and the iodide of potash, with the 
fluid extract of ergot, may be exhibited with advantage. Cupping over the 
nape of the neck, followed by a blister, when the attack is more than usually 
severe, will confer great relief; and the same may be said of an active mer- 
curial purge. A seton inserted into the back of the neck, where the disease 
proves tedious, in some instances exercises a salutary effect by inviting the 
blood from the brain and preventing cerebral irritation. Time, after all, 
appears to be the great remedy, and, where there is no serious structural 
alteration of the intracranial contents, it will often work the cure. 
Trephining. 
Before describing the operation of trephining it will be proper to formu- 
late the various conditions which demand a resort to instrumental measures. 
In general, it may be stated that it is only in cases where the brain-injury 
is local that trephining can promise any benefit. The conditions which pro- 
duce symptoms requiring instrumental perforation of the cranium are the 
following: 
1. Simple fracture followed by symptoms of compression. 
2. Fractures (in the adult) with very marked depression, without symp- 
toms of compression. 
3. Compound and compound comminuted fractures with depression, with 
or without symptoms of compression. 
4. Punctured fractures, with or without symptoms of compression. 
5. Cases of traumatic epilepsy where the traces of injury can be recog- 
nized upon the cranium, and where the origin of the initial symptoms points 
to a limited area of the cortex being affected, and to Jacksonian epilepsy. 
6. When from three to five days after a compound fracture symptoms of 
meningitis or encephalitis develop, and there is reason to believe that these 
have been produced by a scale or spicule of bone from the inner table press- 
ing against the brain, the use of the trephine will be indicated with a view 
to remove the osseous splinter, or, in case such spicule should not be present, 
to give exit to the inflammatory products which sooner or later must destroy 
life unless removed. 
7. In cases of brain-compression, whether from traumatic or other causes, 
in which there are strong reasons for believing that the symptoms are the 
result of blood or pus, or of a neoplasm, and where the surgeon is able to 
locate the cause with a reasonable degree of certainty, the trephine should 
be used. Thus, when an injury over the temporo-parietal region is followed 
by paralysis of a single limb, by aphasia, or by hemiplegia with or without 
hemispasm, trephining is indicated; so also in cases of head-injury without 
external wound in which the paralysis is believed to be due to hemorrhage. 
The contra-indications to trephining, based on neurological studies, are 376 
INJURIES OF THE HEAD. 
as follows: 1. When hemiplegia coexists along with paralysis of sensation, 
showing that the lesion is wide-spread. 2. When the injury involves the base 
of the cranium, causing paralysis of the parts supplied by the cranial nerves, 
when Cheyne-Stokes respiration is present, or when neuro-retinitis exists. 
Operation.—Having summarized the conditions which require a resort to 
the trephine, I shall proceed to describe the instruments necessary for its 
proper execution, and their use. 
These instruments consist of an ordinary scalpel to incise the scalp and 
Fig. 327. 
Fig. 328. 
Fig. 329. 
Cylindrical trephine. 
Conical trephine 
Small-sized trephine. 
expose the bone, a trephine, a probe with a flat end, a brush for the teeth of 
the trephine, an elevator, a lenticular, a Hey’s or Scultetus saw, a Holsen’s 
chisel, a pair of forceps, a tenaculum, and some ligatures. 
There are two trephines in use, the cylindrical and the conical. (Figs 
327, 328.) The instrument is generally made too large. For opening the 
skull in cases of depressed bone, there is no necessity for having 
the trephine more than half an inch in diameter (Fig. 329), a* 
the object is merely to cut a hole for the introduction of the 
elevator. The necessity for two trephines of different diameter, 
exists when operating over the frontal sinuses. The two tablet 
of the skull at this place not being parallel with each other, i 
becomes necessary that the outer table be cut with the large 
instrument, and the inner table with the small one. It is not 
a matter of much importance, especially with a careful surgeon 
which form of the trephine—the cylindrical or the conical—is 
used. The former is perhaps the better instrument of the two 
as the button of bone removed by it fits best when replaced. The 
trephine is armed with a sharp-pointed centre-pin, which can be 
slid up and down at the will of the operator and can be fixed b) 
a sliding button on the stem of the instrument. The object of 
this pin is, by penetrating a short distance into the bone, to act 
the part of a pivot or axis, around which the saw can move 
until a groove is cut sufficiently deep to prevent the instrument 
from slipping, after which it must be drawn within the crown 
The Eouger (Fig. 330) is a powerful cutting forceps, of great 
value in enlarging the opening 
in the cranial bones. 
The probe (Fig. 331) is de- 
signed to clean out the debris 
from the track of the trephine. 
and does not differ from the ordinary silver probe of the pocket-case. A 
quill tooth-pick will answer very well as a substitute. The brush (Fig. 332) 
is used to clean the bone-dust from the teeth of the trephine in order that 
Fig. 330. 
Fig. 331. 
Rouger forceps. 
Ordinary silver probe. TREPHINING. 
377 
the instrument may cut without obstruction. The elevator (Fig. 333) and 
the lenticular (Fig. 334) are employed, the first as a lever and the second as 
a tractor, in raising depressed portions of bone to the proper level. The 
Fig. 335. 
Fig. 334. 
Fig. 336. 
Fig. 333. 
Fig. 332. 
Trephine brush. 
Elevator. 
Lenticular. 
Key’s saw. 
Modified form of Hey’s saw. 
saws (Figs. 335, 336) are designed to cut, in either a straight or a curved 
course, portions of bones which have become wedged, and to open a way 
for the elevator. These saws have a very limited application to injuries of 
the head. 
In operating for the cure of epilepsy, for the removal of intracranial 
growths, or on account of hemorrhage or abscess, a large trephine in the 
crown, one inch and a half in diameter, is to be preferred. 
The chisel of Holsen (Fig. 337) is useful in detaching pieces of commi- 
nuted bone, and by means of its lateral prolongation is capable of being 
used as an elevator. The scalpel is employed to raise the scalp and expose 
the bone, the tenaculum to lift any vessel which may require the ligature, 
and the forceps—an ordinary pair—to remove the circular piece cut by the 
trephine. 
A trephine may be applied at any portion of the skull; but when the case 
is one admitting of a choice, there are certain portions which should be 
avoided. These localities are the following: in the course of the superior 
longitudinal sinus which lies under the antero-posterior median line of the 
Fig. 337. 
Holsen’s chisel. 
skull; over the frontal and sagittal sutures; over the occipital protuberance, 
beneath which rests the torcular Iierophili, the point of confluence of several 
sinuses; over the frontal air-cells, which would expose the patient to the risk 
of a fistula from the escape of air; and, lastly, over the anterior inferior angle 
of the parietal bone, at the point of entrance into the skull of the middle 
meningeal artery. When the location of the injury compels the surgeon to 
disregard these suggestions, he should exercise the greatest care to avoid 
inflicting damage upon the exposed blood-channels. 378 
INJURIES OF THE HEAD. 
Operation.—Previous to operating, the head of the patient should be 
cleanly shaved and thoroughly washed, first with soap and water, and 
afterwards with alcohol or ether, in order to get rid of any greasy matters 
which may have accumulated about the orifices of the gland-ducts. After 
this a final ablution with the corrosive sublimate solution (one to one thou- 
sand) will complete the preparation of the scalp. When the case is not 
an urgent one, a compress wet with the last-named solution should be worn 
over the scalp for twenty-four hours before the operation. The best position 
for the patient about to undergo trephining is on a table, with the head 
resting on a firm pillow, covered with oil-cloth, the entire field around the 
seat of operation being protected by towels wet in the bichloride solution. 
If the case is one of complete compression, there will be no necessity for 
administering an anaesthetic, as the patient will be entirely insensible to the 
operation. In cases of epilepsy or punctured wounds, demanding the use of 
the instrument, anaesthetics are not contra-indicated. The next step consists 
in exposing the bone to be bored and elevated. Should there be an external 
wound, it maybe enlarged in the proper directions; if not, there are two in- 
cisions which accomplish this object, the crucial and the horseshoe. (Fig. 
338.) The latter I greatly prefer, as by lifting a semicircular 
flap like the lid of a box, it can be held out of the way by the 
operator himself. In raising this trap-door the knife should go 
down at once to the bone, and the incision be so planned that 
in the recumbent position there shall be no obstruction to free 
drainage. If any considerable vessels are divided, ligatures 
should be applied. The surgeon at this stage is able to examine 
the true nature of the injury. Should the fracture be a commi- 
nuted one, he may be able 
to slip the blade of a pair 
of forceps beneath the edge 
of a fragment, and gently 
pull it away; or he may find 
the depressed piece kept 
down by the jutting over 
of a point of the contiguous bone, which 
will require, for the admission of the 
elevator, the removal of this angle, to 
effect which will demand the use of the 
Hey’s saw or the Iiolsen chisel. If, how- 
ever, the depression be in the form of a 
groove or gutter, the skull must be 
bored. The periosteum being divided in 
a circular form to prevent its laceration 
by the teeth of the saw, the centre-pin 
should be pushed down, and the instru- 
ment planted, not upon the depressed 
bone, but chiefly upon the undepressed 
(Fig. 339), allowing it to project a short 
distance over upon the former. After a 
few movements communicated to the 
trephine by the hand of the operator carried from pronation to supination, a 
groove sufficiently deep will be cut to steady the instrument, when the centre- 
pin must be withdrawn; otherwise, being in advance of the saw, it would 
plunge into the brain before the bone was cut through. The rotary motion 
being resumed should be frequently interrupted, the teeth of the trephine 
cleansed from the bone-dust and blood with the brush, and the progress deter- 
mined by a most careful exploration of the groove with the flat end of the 
probe, cleaning out the dust, and noticing particularly any inequalities in the 
division of the bone. By grasping the circular disk of bone frequently with 
a pair of forceps, its mobility is easily ascertained. A valuable sign of the 
Fig. 338. 
Fig. 339. 
The crucial 
and the horse- 
shoe incision. 
Trap-door flap deflected, and the trephine applied 
to the skull. CEREBRAL TOPOGRAPHY. 
379 
progress of the instrument will be seen as soon as the external table is 
divided and the trephine enters the vascular diploe,—namely, a free flow of 
blood welling up through the groove. As the cutting advances, the utmost 
care should be observed : some portions will divide less rapidly than others, 
and the trephine must be inclined so as to press most upon these points, 
allowing it to advance chiefly by its own weight, and remembering that the 
issues of life and death hang upon a few movements of the hand. There is 
no urgency. The fate of the patient does not depend upon a few minutes 
of time, and consequently this stage of the operation should be executed with 
gentleness, deliberation, and patience, by which the surgeon will generally 
succeed in dividing the last fibres of bone and removing the little circular 
piece without the trace of a scratch upon the dura mater, a desideratum of 
no small importance to the success of the operation. As soon as the disk 
of bone is removed, the point of the elevator should be slid beneath the 
depressed fragment, using the sound bone as a fulcrum, and thus raising the 
former to the proper level. 
This operation will answer not only for the elevation of depressed bone, 
but also for the evacuation of blood or pus lying beneath the bone and the 
dura mater. On no conditions should the latter be wounded or opened, 
except when there are unmistakable signs of the presence of blood or pus 
underneath the membrane, as such an opening adds to the complication of 
the case. 
Should there be bleeding from a sinus or from one of the meningeal arteries, 
a little compress with a dossil of lint, retained for a few hours, will usually 
arrest the flow; or if this prove insufficient, the walls of the sinus can be 
brought together by a catgut thread. The subsequent treatment consists in 
introducing a few horse-hairs, catgut threads, or a small rubber tube into the 
wound, replacing the flap with sutures, and applying the usual antiseptic 
dressing in detail,—viz., iodoform, protective, carbolized or sublimated gauze 
compresses, and borated or salicylized absorbent cotton,—the whole being 
kept in place by recurrent and circular turns of an aseptic roller. It re- 
quires no argument to prove, at this day, that the operation of trephining 
has been rendered a comparatively safe one when antiseptic precautions are 
faithfully observed. The opening made in the skull is rarely closed by bony 
matter, but generally by a fibrous membrane, through which the movements 
of the brain can be readily felt, and for the protection of which it may be 
advisable to wear over the scalp a little shield of leather or metal. By 
keeping the button of bone removed by the trephine between warm car- 
bolized or sublimated cloths or sponges, it can be replaced in the opening of 
the skull with a reasonable probability of forming a vital union with the 
surrounding bone. 
Cerebral Topography. 
Through the labors of Broca, Hitzig, and Ferrier, the cortex of the cere- 
brum is now known to consist of an assemblage of organs, each concerned 
in the production of definite physiological and psychical phenomena. On 
this fact of the localization of cerebral functions is based as a corollary tbe 
doctrine of the localization of cortical lesions, which has led to the exten- 
sion of operative surgery into a domain hitherto little explored. The light 
which has illuminated this department of surgery comes from laboratories 
devoted to experimentation on lower animals, as dogs and monkeys, and 
from clinical and pathological observation. 
In presenting a brief summary of the divisions of the brain, the functions 
of its convolutions, and the relations of the latter to the cranial walls, for sur- 
gical purposes, the old nomenclature will be found of little importance. The 
anterior lobes of the hemispheres comprise the frontal convolutions, desig- 
nated respectively the upper, middle, and inferior frontal convolutions, to- 
gether with the ascending frontal, prsecentral, and orbital convolutions. All 
of this part of the cerebrum anterior to the coronal suture is called the prce- 380 
INJURIES OF THE HEAD. 
frontal lobe. There is abundant evidence to show that this part of the brain 
has nothing to do with either motility or sensation. In illustration of this, 
in addition to the numerous cases of injury involving this portion given by 
different authors, I may mention two or three out of many cases which have 
come under my own observation. 
A man working in a rolling-mill was struck on the forehead by a segment 
of metal from a bursting fly-wheel. A large part of the frontal hone was 
carried away, the membranes torn, and a considerable amount of brain-sub- 
stance from the prefrontal lobes lost. There was no loss of sensation or of 
motion, and the man made a good recovery. 
A prominent physician of Philadelphia sustained a dreadful fracture with 
comminution and depression of the left frontal bone. The trephine was 
twice applied, and as many as twenty-seven pieces of bone were removed. 
No paralysis existed at any time, and the patient entirely recovered. 
A child at play fell upon a pointed stick, which entered the orbit, pene- 
trated the orbital plate of the frontal bone, and passed into the brain, a por- 
tion of which came through the opening externally. No loss of sensation 
or motion resulted, and the child soon got well. 
Perhaps the most conclusive case bearing on the point under consideration 
is the famous one of Phineas Gage, reported by Dr. Harlow. This man, in 
consequence of the premature explosion of a blasting charge, had a bar of 
iron one inch and a quarter in diameter, and over three and a half feet long, 
driven obliquely through the praefron tal lobes. The metal entered imme- 
diately behind the junction of the malar and upper maxillary bones, passed 
into the brain immediately behind the orbit, and escaped at the top of the 
skull anterior to the coronal suture. No loss either of motility or of sensi- 
bility followed, and the man recovered. 
Injuries of this part of the brain, even of the most formidable nature, are 
to be regarded as hopeful, not only' on account of its comparatively less im- 
portance physiologically, 
but also because of the 
favorable position of the 
wound for drainage. 
Motor region.—This re- 
gion lies posterior to the 
prsefrontal lobes, and bears 
a very important relation 
to the fissure of Rolando, 
a sulcus bounded by the 
ascending frontal, ascend- 
ing parietal, and poste- 
rior parietal convolutions. 
This region includes also 
the bases of the three 
frontal convolutions, and 
is supplied by the middle 
cerebral artery. 
Within this region are 
grouped the following mo- 
tor areas or centres : first, 
of the opposite lower limb, 
at the upper extremity 
of the ascending parietal 
convolution, both behind 
and in front of the fissure 
of Rolando (R, Fig. 340); second, of the upper extremities, at the middle 
part of the ascending frontal convolution and the adjacent portion of the as- 
cending parietal convolution anterior to the fissure of Rolando (A) ; and of the 
face, at-the lower third of the ascending frontal convolution, extending down 
Fig. 340. 
Exhibiting motor centres, with their convolutions exposed (ascending 
parietal convolution): L, leg; A, arm; F, face; S, speech. CEREBRAL TOPOGRAPHY. 
381 
on its posterior aspect to the lower third of the ascending parietal convolu- 
tion; the upper and anterior part of this area is more peculiarly the motor 
centre for the upper part of the face (F), while its posterior and lower aspect 
influences the movements of the parts about the mouth ; third, of articulate 
speech, the centre being the posterior extremity of the inferior frontal con- 
volution (S). 
Sensory region.—It is generally conceded at present that the frontal and 
parietal regions of the cerebral hemispheres are not centres of sensation, in- 
asmuch as there is abundant evidence, both clinical and experimental, to 
show that the most extensive injuries may occur in these regions without 
implicating sensation. We must, therefore, look for the sensory areas in 
the occipital or the parieto-temporal lobes. That they are not located in the 
occipital lobes is evident both from pathological observations and from phys- 
iological experimentation: indeed, the function of these lobes still remains ob- 
scure. By some physiologists they are regarded as trophic centres, by others 
as connected in some way with the organic sense of the abdominal viscera, 
and by still others as being more directly psychical, or connected with the 
operation of the mind, both ideal and emotional. In corroboration of this 
last view it is asserted that mental aberration or insanity is most commonly 
connected with disease of this part of the brain. Intermediate, however, 
to this region (occipital) and the motor one already described, there exist a 
number of convolutions, which together constitute the inferior parietal and 
temporo-sphenoidal lobes, and these, with the hippocampus major from the 
parieto-temporal region, corresponding in general to the middle cerebral fossa, 
embrace most probably the areas of sensory perception, both special and 
general. Thus, Ferrier has shown that bilateral destruction of the angular 
gyrus, a part of the inferior parietal lobe, is followed by blindness, that a like 
damage to the superior temporal convolution results in utter loss of hearing, 
and that destruction of the lower part of the inferior temporal convolution is 
followed by complete abolition of taste. By parity of reasoning it is be- 
lieved that a destructive lesion of the region about the hippocampus major 
will cause loss of common sensibility, unilateral or bilateral according as 
one or both sides are damaged. That any doubt should be expressed as to 
this result is due to the fact that the region about the hippocampus, or un- 
ciate convolutions, is so inaccessible that, before it can be reached, so much 
damage will have been done to the brain-tissue as materially to vitiate con- 
clusions drawn from physiological experiment. It is proper also to say that 
experiments by different physiologists on the temporo-parietal region have 
been somewhat conflicting in their results. 
A diagram (Fig. 341) from Ferrier’s works, exhibiting the brain removed 
from the cranium, and representing the cerebral convolutions and their con- 
nection with the muscular movements of different parts of the body as deter- 
mined by experiments on lower animals, will prove interesting in connection 
with our subject. 
1. Superior or posterior parietal lobule. The application of an electrode 
to this part is followed by a forward movement of the opposite hind limb, 
as in walking. 
2. Upper extremity of the ascending parietal and adjoining portion of the 
ascending frontal. Electrical stimulation of these causes flexion, with out- 
ward rotation of the opposite thigh, retraction inward of the leg, and flexion 
of the toes. 
3. Upper extremity of the ascending frontal convolution close to the semi- 
lunar sulcus. Electrical stimulation causes movements very much the same 
as those designated in 1 and 2. 
4. Behind 3 and below 2. Adjacent margins of the ascending frontal and 
ascending parietal convolutions at their upper portions. Electrical stimula- 
tion causes the opposite arm to be adducted, extended, and retracted, and 
the hand to be pronated. 
5. The ascending convolution at the base of the superior frontal. Elec- 382 
INJURIES OF 
THE HEAD. 
trical stimulation causes extension forward of the opposite arm. Areas a, b, 
c, d, different points on the ascending parietal. When subjected to electrical 
stimulation, the action begins in the thumb and forefinger, followed by 
clinching the fist and energizing the extensors of the arm. 
Fig. 341. 
General view of the motor portions of the cerebral cortex. 
6. Ascending frontal convolution at the knee of the pr®central sulcus under 
stimulation produces flexion and supination of the arm and brings the hand 
to the mouth. 
7. Ascending frontal convolution below 6. Stimulation causes retraction 
and elevation of the corner of the mouth. 
8. Ascending frontal convolution below 7. Stimulation causes elevation 
of the upper lip and of the al® of the nose. 
9 and 10. Lower extremity of the ascending frontal convolution. Stimu- 
lation of this part causes the tongue to be protruded from the mouth and 
then retracted. 
11. Lower extremity of the ascending parietal convolution. Stimulation 
is followed by l’etraction of the angle of the mouth through the platysma 
myoides muscle. 
12. Including the posterior half or third of the superior and middle frontal 
convolutions. Stimulation causes the eye to open widely, the pupils to dilate, 
and the head and eyes to turn to the opposite side. 
Prcefrontal region.—As a rule, no effect is produced by stimulation of the 
frontal lobes in advance of No. 12. 
13-13. Posterior limb and anterior limb of the angular gyrus. Stimula- 
tion causes the eyes to turn to the opposite side, the pupils contract, and 
the eyelids partially close. 
14. Superior temporo-sphenoidal convolution. Stimulation is followed by 
puckering of the opposite ear, the head and eyes turn to the opposite side, 
and the pupils dilate. 
A careful study of these regions will be of great practical importance CEREBRAL TOPOGRAPHY. 
383 
when the trephine is to be applied over motor areas of the cerebrum. For 
example, the motor area of the lower extremities extends some distance on 
each side of the fissure of Eolando. Again, a considerable portion above and 
below the middle of the sulcus of Eolando and posterior to it is concerned 
in the different movements of the arm. It will also be noted that the por- 
tions of the cortex which originate movements of the face and tongue are 
situated on both sides of the sulcus of Eolando, and that the speech centre 
occupies a position in front of the sulcus. 
It will be seen from the foregoing description of the cerebral centres that 
a large number of the palsies which follow lesions, traumatic or pathological, 
affect a comparatively limited portion of the cerebrum. The most interesting 
forms of these to the surgeon, in view of probable operative measures, are 
paralysis of the face, of the speech (aphasia), and of the upper or lower ex- 
tremity. As the centres of these parts lie grouped about the fissure of 
Eolando and are entirely accessible, the practical question consists in deter- 
mining the relation of these motor areas of the cerebral cortex to the walls 
of the skull with sufficient accuracy to enable the surgeon to operate with 
precision in any case demanding their exposure. 
Lucas-Championniere, Turner, Thane, Eeid, and others have given lines 
for this purpose. Those represented in Fig. 342, the result of careful obser- 
vations made by measurements and sections of the skull covered by the scalp, 
I think may be regarded as accurate. Draw a line, CG, from the lower border 
of the orbit, through 
the external auditory 
meatus, to the base of 
the mastoid process of 
the temporal bone. 
Upon this base erect 
two perpendicular par- 
allel lines, EF, GH, 
the anterior line com- 
mencing in the sulcus 
in front of the ear, the 
posterior line from the 
posterior border of the 
mastoid process, and 
both prolonged to the 
top of the head. From 
the external angular 
process of the frontal 
bone extend a line to a 
point one inch and a 
quarter below the pa- 
rietal eminence, X- 
This marks the course 
of the fissure of Syl- 
vius. If now, begin- 
ning at H, a line be 
carried to the inter- 
section of the line EF 
with that of the fis- 
sure of Sylvius, the course of the fissure of Rolando will be defined, along 
which lie the leg, arm, face, and speech centres. (See Fig. 340.) Around 
the point where the fissure of Sylvius touches the line GH lies the angular 
gyrus, L. Posterior to the latter is situated the parieto-occipital lobe, M, and 
immediately below this the cuneus, N. One inch and three-quarters below 
the parietal protuberance, and two inches and one-quarter from the surface, 
directly inward, will be found the posterior horn of the lateral ventricle, O. 
A line drawn from the upper part of the occipital protuberance to the ex- 
Fig. 342. 
Topographical lines for cerebral localization. 384 
INJURIES OF THE HEAD. 
ternal angular process of the frontal bones gives the position of the trans- 
verse fissure, IK, and another line extended from the same protuberance, to 
the notch between the ear and the side of the head, indicates the position 
of the longitudinal sinus, P. 
Intracranial suppuration following disease of the middle ear may require 
exposure of the temporo-sphenoidal lobe. The trephine in such a case 
would be applied above the line IK, transverse fissure, and half an inch 
in front of the line GH. 
It will be seen that the motor areas which range along the fissure of Ro- 
lando are all covered in by the parietal bone. The convolutions concerned 
in furnishing motor phenomena are, probably, for the lower extremity, the 
upper part of the ascending parietal and ascending frontal; for the upper ex- 
tremity, the middle third of the ascending frontal; for the lace, the lower third 
and the foot of the ascending frontal; for speech, the foot of the third frontal. 
Rules to be observed in operating on the Brain. 
1. The entire head must be closely shaved of all hair, and the scalp 
effectually cleansed by scrubbing first with soap and water and afterwards 
with a mixture of carbolic acid (one to twenty) with a solution of corrosive 
sublimate (one to two thousand). Alcohol or ether is frequently used for 
the same purpose, the object being to get rid of all loose epithelial and fatty 
matters. If time allows, a compress of carbolated gauze, wet with a solution 
of the bichloride of mercury (one to one thousand), should be worn over the 
field of operation for some hours before the use of the trephine. 
2. Immediately before beginning the operation a quarter of a grain of 
morphia should be exhibited, if the patient be an adult. The action of this 
drug, as shown by Mr. Horsley’s observations, not only serves to contract 
the arterioles of the brain and thereby diminish the hemorrhage, but also 
lessens the necessity for giving a large amount of the anaesthetic, chloroform 
being preferred for these operations. 
3. The patient must be in the recumbent position, with the head slightly 
raised on a firm pillow and turned on the side opposite the seat of operation. 
The flap raised for exposing the skull should be ample, and so planned that 
the great vessels which supply it shall not be cut, and that when restored 
to its position it shall be one favorable to free drainage. The incision of the 
scalp should go down at once to the bone, so that the periosteum shall be 
raised with the flap. 
4. The trephine should be a large one, an inch and a half in diameter, 
and, to facilitate the rapid exposure of the brain, may be applied at two or 
more points some distance apart, the intermediate portion or bridge of bone 
being quickly removed by cutting forceps. 
The excised bone, after being divided into pieces, should be placed be- 
tween warm carbolized sponges, to be utilized in filling up the space between 
the dura mater and the scalp. Having sufficiently exposed the dura mater, 
the next step is its division, before doing which the vessels of the mem- 
brane should be secured by passing round them a curved needle bearing a 
fine catgut thread. In incising the dura mater, which can be done either 
with a knife or a pair of scissors, one blade of the latter being blunt-pointed, 
a sufficient border should be left at the circumference of the wound for 
suturing it to the main or reflected portion of the membrane. At this stage 
of the operation an inspection of the brain should be made, to discover any 
prominence indicating the presence of abscess or tumor, or any change from 
the normal color, after which the pia mater should be displaced, if possible, 
from the depressions between the convolutions and pressed aside out of the 
way of the knife. 
6. The brain-substance or cortex being uncovered, it may be necessary 
to adopt some plan in order exactly to localize the desired area, and for this 
purpose electrical stimulation can be called to our aid. In cutting out the CEREBRAL TOPOGRAPHY. 
385 
diseased portion of the brain it has been advised, with great propriety, not 
to hold the knife obliquely, but as nearly vertically as possible, since by so 
doing the smallest number of vessels will be wounded. 
7. When the operation of trephining is done in search of an abscess, and 
the surface-indications fail to reveal the exact position of the pus, the ex- 
ploring-needle should be passed in different directions into the substance of 
the brain, substituting the bistoury for the needle when the suppurating focus 
is located, in order to give exit to the accumulation. 
Dressing.—Bleeding having entirely ceased, and the part having been well 
washed with the bichloride solution (one to two thousand), the dura mater 
is next laid down and stitched, leaving a little space for a few drain-threads 
of catgut. If the pieces of excised bone are to be utilized, they are now to 
be laid in between the dura mater and the tegumentary flap. In my own 
expei’ience, the introduction of the excised portion of bone has not always 
proved satisfactory. In replacing the flap the part most dependent in the 
recumbent position should not be stitched, but should be left free for the 
exit of the drain-threads and the escape of the serous discharges. The 
entire procedure, from first to last, when the dressings are applied, must be 
conducted with a rigid observance of all antiseptic measures. It is well to 
examine the wound on the second or third day, to see that there is no ob- 
struction to the discharge, or, if it is obstructed, to open a way for its escape by 
pushing a probe or a director between the flap and the border of the wound. 
If the drain-threads have not been absorbed, they may be removed at the 
expiration of the third or fourth day, by which time the serous discharge 
will have ceased. The stitches in the flap of integument can be removed in 
five or six days. 
The general treatment of the patient will consist in keeping him or her 
perfectly quiet, allowing milk only as a diet for the first seven or eight days, 
after which other nourishment of an unirritating character can be allowed. 
The bowels should be kept open at least once every second or third day; and 
if the patient should be unable to rest at night, bromide of potash may be 
administered. 
That this department of surgery is not devoid of practical results will ap- 
pear from a review of what has been achieved by a number of operators. 
Guided by anatomical and physiological laws, Broca, in 1871, evacuated a 
cerebral abscess by trephining, and thus relieved a paralyzed, aphasic patient. 
Stimulated by his success, other opei’ators have followed his example, with 
good results. Dr. Amidon* has collected 115 unselected cases of such opera- 
tions, of which number 29 died; he remarks, however, that at the time of 
operation 25 of the fatal cases showed symptoms endangering life, leaving 
only 4 cases, or 3.2 per cent., in which the fatal issue could be even remotely 
traced to the operation. Of 21 cerebral cases, excluding fractures of the skull 
or other immediate effect of injury, operated upon by Dr. Maeewen,f 18 
recovered, with good results, and 3 died, each of the three having been in 
extremis at the time of operation. Of 84 cases of trephining in traumatic epi- 
lepsy cited by Dr. Walsham,j; 48 were completely cured, 13 were relieved, and 
17 died, or 20.2 per cent.; he adds, if deaths following too long after the tre- 
phining to be attributed to the operation were excluded, the mortality would 
be reduced to about 10.6 per cent. In a recent case of tumor operated on 
by Heath, the epilepsy recurred with greater frequency. Of 35 unselected 
operative cases, collected by Dr. Baum from very recent literature, 7 suc- 
cessful cases were for abscess resulting from otitis media ;§ 5 cases, with 1 
death, for abscess || from other causes; 9 cases, with 5 deaths, for tumors ;^[ 
* Annals of Surgery, 1885, vol. i. p. 206. 
f Medical News, Philadelphia, 1888, vol. liii. p. 173. ‘ 
X St. Bartholomew’s Hospital Reports, 1883, vol. xix. pp. 137, 142. 
|| Barker, Ferrier, Greenfield, Maeewen, Sehondorff, Tuckenbrod, and Gowers and Barker. 
I Harrison, Horsley, Thomas, and Wilson (recovery), and St. George (death). 
f Keen (2 cases), Baracz, and Markoe (recovery); May, Hammond, Suckling, Weir, and Weir and 
Birdsall (death). 386 
INJURIES OF THE FACE. 
8 cases, with 1 death, for hemorrhage* and blood-clot; 2 successful cases for 
traumatic epilepsy, 1 each by Dr. Deaver and Dr. Oliver; 2 cases, reported 
as recovered, by Dr. J. W. Bryant, one for inflamed diploe, the other for 
pressure-symptoms; and 2 cases, probably of syphilitic origin, stated as 
recovered, 1 each by Drs. Earmie and Williams and Drs. Rannie and Grieve. 
Injuries of the Face. 
Anatomical Peculiarities.—The facial region, though greatly exposed, 
possesses, in the articulation of the head with the summit of the verte- 
bral column and in the ready assistance of the arms under the quick direc- 
tion of the intelligence, a very etfective combination for its defence against 
all injurious external influences, save such as are unexpectedly swift and 
irresistible. This region has certain anatomical peculiarities, which should 
always be considered in dealing with the accidents to which it is exposed. 
Its skeleton consists of thirteen pieces of irregularly-shaped bones, for the 
most part thin and fragile in their texture and richly supplied with blood- 
vessels. Some of these bones possess canals for the passage of important 
arteries and veins, as the inferior dental and infra-orbital; also for the safe 
passage of nerves, as those belonging to the fifth pair. The integument is 
not movable over the underlying fascia, but adheres closely to the muscles 
beneath, by which those lines and depressions are accurately maintained 
which confer on the face what is called expression. Some of these lines 
are passive, and belong to the state of repose; others are brought out only 
under the influence of the different emotions. The muscles are embedded 
in soft cushions of fat, the absorption of which, in cases of exhausting dis- 
ease, communicates the ghastly look to the countenance. The integument 
is richly supplied with blood-vessels and nerves. The arteries are derived 
from the external and internal carotids. The external carotid supplies 
the facial, parotidean, transverse facial, temporal, and internal maxillary; 
the internal carotid furnishes the frontal and supra-orbital. Most of the 
arteries are very tortuous or serpentine in their course. The veins empty 
into the jugular. 
The nerves are derived from the fifth and seventh pairs, the former con- 
ferring sensation upon the face, and motion to the muscles of mastication 
through its motor trunk, and the latter imparting motion to the muscles of 
expression. 
In front of the ear, and extending from the zygomatic arch to the neck, 
lies the parotid gland, its excretory duct, or the duct of Steno, crossing the 
face to the anterior border of the masseter muscle in the direction of a line 
drawn from the lobe of the ear to the ala of the nose. The skin is abundantly 
supplied with sudoriferous and sebaceous glands. The bones which consti- 
tute the skeleton of the face are so disposed as to provide chambers for the 
accommodation of three important organs of special sense, viz., vision, olfac- 
tion, and gustation. The region is consequently one very highly organized, 
and on this account its wounds heal with great rapidity. 
Contusions or Unopened Wounds of the Face.—These injuries are often 
inflicted in pugilistic encounters, though they may result from other causes, 
and are followed by a dark discoloration and by swelling, in consequence of 
the extravasated blood. The parts which suffer most from this cause are the 
eyelids,—hence the common expression of a “ black eye,”—which depends 
upon the delicacy of the skin and its loose connections with the orbicularis 
palpebrarum muscle permitting the blood to find its way through the parts 
without difficulty. 
Treatment.—In the exercise of what is sometimes called the “ manly art,” 
and when the extravasated blood and serum are so profuse as to close the eye- 
* Armstrong, Ball, Deaver, Macewen, Powers, Stoker, and Williams (recovery), and Symonds 
(death). WOUNDS OF THE FACE. 
387 
lids and interfere with the progress of the “ mill,” it is a common practice, 
and a very good one, for the seconds of the ring to make punctures with the 
point of a lancet, press out the blood, and apply cold water to the parts. In 
ordinary cases of facial contusions, however, the proper treatment for the 
first six or eight hours is to apply compresses wet with cold water and bind 
them to the parts by a roller, the effect of which is to constringe the vessels 
and stop all leakage, after which the case may be left to natural processes, or 
to the use of slightly stimulating applications, such as water mixed with a 
little alcohol (alcohol, one part; water, ten parts). As the continued use of 
cold prevents that vascular activity which is necessary to remove the blood, 
its value is limited to the first few days, after which it should be discontinued. 
Some remedies are vaunted as possessing a specific influence over these ecchy- 
moses, such as tincture of arnica, linimentum saponis, tincture of hamamelis 
Virginica, etc., but there is no evidence whatever that they exercise any such 
power. The rich supply of vessels and lymphatics generally insures a rapid 
absorption of the foreign matter; and where the individual possesses a good, 
sound constitution, I believe all local applications are less influential in the 
removal of extravasation than is generally supposed. To conceal the dis- 
coloration, when quite small, a piece of ordinary adhesive or court plaster is 
the best application, or it may be touched with a flesh-colored paint. 
Constitutional shock, I have noticed, greatly delays the removal of ex- 
travasations of blood, whether in the eyelids or in other portions of the face. 
Patients, for example, who are brought into our hospitals with numerous 
contusions from railroad collisions, retain the discolorations very much- longer 
than those whose bruises are only local; and if any applications are made in 
such cases, they should be warm, as well as slightly stimulating. The use 
of tonics like quinine, with an ample diet, will materially assist in securing 
the removal of the blood in cases where the general system has been severely 
shocked. 
Open Wounds of the face are produced by sabres, knives, etc., in which 
case they belong to the incised class; or they may be contused and lacer- 
ated, as when inflicted by the conjoined action of a blow upon the mouth 
and the resistance of teeth behind- the lips. Of the same nature are those 
injuries which are called scratches, such as are made by the nails of man 
and other animals, or when the face is dragged over gravel or small pebbles. 
Punctured wounds of the facial region are not unfrequently produced by 
hooks and by bayonets, and gunshot wounds by balls and other missiles 
used in warfare. 
Treatment.—As in wounds elsewhere, the first indication is to arrest 
hemorrhage. In consequence of the rich vascular supply, the bleeding in 
incised wounds of the face is usually for a time quite profuse; but, except 
when the facial, angular, labial, or lateral nasal arteries are involved, it soon 
subsides spontaneously. Should the bleeding not cease after exposure to the 
air or the application of cold water, the vessel or vessels must be searched 
for and tied with the animal ligature, both ends of the latter being cut off. 
Second, all foreign matters should be removed from the wound, either by 
picking them away with the fingers or forceps or by douching or by a small 
stream of sublimated water (one to one thousand) from the nozzle of a 
syringe. When the usual antiseptic is not at hand, use hot water. 
The third indication is the closure of the wound; and this demands more 
than a passing notice. The utmost care should be observed to place the dis- 
joined parts as nearly as possible in the position which they had before the 
accident: especially is this imperative when the wound is situated near the 
angle of the mouth or nose, or when it is near the eyelids or over the eye- 
brow. A little carelessness on this point may change the whole expression 
of the face. It is astonishing what an alteration in the facial individuality of 
a person will follow the mal-adjustment of a wound at the angle of the mouth, 
below the orbit, or over the eyebrow. A cheerful face may be transformed 388 
INJURIES OF THE FACE. 
into one of melancholy, a soft eye into a repulsive stare, and the open and 
assuring brow into a malign frown, making a face 
“fit for treason, stratagem, and spoils.” 
In several instances I have had occasion to perform operations in order 
to remedy such defects produced by badly-adjusted wounds. The approxi- 
mation is best effected by the interrupted suture, using a very fine aseptic 
silk thread, which I prefer to silver wire, the latter not being sufficiently 
flexible to prevent the tissues from twisting with the wire. When the 
cartilage of the eyelid is divided, it is not necessary to insert the stitches 
deeper than the muscular layer; the addition of a compress and roller will 
retain the parts more securely. In very slight transverse wounds of the 
eyelids the approximation may be maintained with adhesive or skin plaster. 
Wounds involving only the integument of the nose do not require sutures, as 
the skin is inextensible, and the exercise of tension will result in ulceration, 
by which the threads cut quickly out; or it may provoke a diffuse inflamma- 
tion. When the cartilage is divided, sutures should be employed; but they 
must not be inserted deeper than the integument. Large wounds of the 
face should be dressed with the usual antiseptic pads, but small ones are 
sufficiently protected by applying to their surfaces with a camel’s-hair brush 
the iodoform and collodion mixture. 
Wounds of the lips are readily closed by the interrupted suture. When 
the entire thickness of the lip is divided, pins should be inserted as deep 
as the mucous membrane, to control the coronary vessels, and the parts be 
brought together by the twisted suture. Except in the lips, it is very seldom, 
however, that I find it necessary to use pins in closing wounds of the face, 
and when they are employed they should be very slender and delicate. The 
integument on the posterior surface of the auricle of the ear, when divided, 
should be closed with the interrupted suture, but such stitches should not 
include more than the integument, even when the cartilage is involved, 
though, if the division is extensive, they should be introduced on both sur- 
faces. After the insertion of sutures, the wound may be sealed by brushing 
it over with the mixture of collodion and iodoform. The vascularity of the 
parts is such that union takes place very quickly, and it is rarely neces- 
sary to allow a suture to remain longer than forty-eight hours. In lacerated 
wounds, however, it will require a longer period ; and the only circumstance 
which should govern the removal of stitches is ulceration. When the threads 
begin to cut through, they should be removed, and the necessary support 
given by adhesive or other plasters. 
In scratches, the little crusts of blood which form upon the surface con- 
stitute the best dressing, and should not be disturbed : by the time these drop 
off, the reparation beneath will have been completed. The numb, stiff feeling 
which so generally follows these injuries is best relieved by covering the 
parts with a little boracic ointment to which some morphia has been added 
in the proportion of one grain of the latter to one drachm of the former. 
Gunshot Wounds of the Face.—These wounds are by no means uncommon, 
and may involve either the soft parts or the hones. The mutilation which 
sometimes follows these injuries is horrible in the extreme, but the wonderful 
power and capacity of repair possessed by the parts render these lesions less 
serious than their appearance would at first indicate. 
There is a case related by Guthrie which I never recall but with mingled 
feelings of pity and admiration. An officer at Badajos had his entire face 
carried away by a cannon-shot. One eye, though displaced, still remained, 
by means of which, forgetful of himself, he was enabled to write the thanks 
which he could not speak for the kindness rendered to him by the attendants. 
In the Crimean War, according to Macleod, there were 382 flesh wounds 
of the face, with only a single death, and 155 penetrating and perforating 
shot wounds of the bones, with 13 deaths, or a mortality of 8.3 per cent. GUNSHOT WOUNDS OF THE FACE. 
389 
The death-rate in our late war, as shown by Dr. Otis, is greater than is 
usually supposed to attach to such injuries when attended with fracture. 
In his analysis, wounds of the orbital region are included. The following 
table* will serve to show the varieties and results of 9815 such wounds: 
Cases. 
Duty. 
Discharged. 
Died. 
Unknown. 
Sabre and bayonet wounds 
64 
40 
15 
2 
7 
Fractures of bones from various causes.. 
64 
37 
17 
3 
7 
Injuries of the soft parts 
271 
167 
83 
3 
18 
Gunshot flesh wounds 
4914 
2396 
1310 
58 
1150 
Gunshot, orbital region 
Gunshot fractures of the bones of the 
1190 
379 
679 
64 
68 
face 
3312 
1154 
1488 
340 
330 
Total 
9815 
4173 
3592 
470 
1580 
As there are 1580 cases in which the termination was not known, it is 
only fair to estimate the mortality from the remaining 8235, which yields a 
death-rate of 5.7 for all degrees of injury. Of the 2982 known terminations 
of facial fractures the death-rate was 11.4 per cent. 
The report of M. Chenu on the “Medical Service of the Crimean War” 
supplies the records of 1414 wounds of the face from various causes, with 
184 deaths, or a mortality of 13 per cent.f In the Italian War of 1859 there 
were recorded 955 cases of injuries of the face, by the same author, with 114 
deaths, or a mortality of 11.9 per cent.j; 
When considered in their entirety, the mortality of face-injuries is very 
small,—a result which might be expected when it is remembered that there 
are no great vessels exposed, that the bones are for the most part small, 
thin, and porous, and consequently, when perforated, do not furnish extensive 
splinters, that there are numerous outlets for the products of inflammation, 
as the mouth, nose, and orbits, and, last and not least, that, by reason of 
the rich supply of vessels furnished by the facial and internal maxillary 
arteries, it is only with great difficulty that the vitality of the bones can be 
destroyed. 
Treatment.—Wounds involving only the soft parts, whether incised, punc- 
tured, contused, or lacerated, demand no treatment different from that appro- 
priate to similar wounds from other causes, but when they are made by the 
passage of a ball the suture is generally dispensed with. Sloughing to some 
extent, urdess antisepsis be observed, will follow in the track of the missile, 
and hence all attempts at quick closure will prove futile. The practice of 
paring away the contused edges of such wounds, thus converting them into 
incised ones, and then uniting by stitches, at one time advocated by Larrey, 
and also tested during our late war by medical officers in.the Confederate 
army, is of very doubtful propriety. After arresting hemorrhage by the liga- 
ture should any vessels require a thread, and removing any foreign matter, 
it will be proper to inject the track of the missile with sublimate solution 
and apply pledgets of carbolated or sublimated gauze, secured by an aseptic 
roller, renewing the dressing as often as may be necessary. Partially de- 
tached, distorted, or torn tissues should be pressed into position, and never 
cut away unless suspended by a very slender bond. When the soft parts 
are severed in such a way as to form ragged and displaced flaps, the intro- 
duction of metallic or other sutures will be necessary as a means of retaining 
the parts in position until the detachment of the sloughs, or until the ten- 
dency to displacement is passed. When antiseptic measures are impractica- 
ble, water dressings (hot, if possible) may be substituted. Adhesive plasters 
can sometimes be used with the same object. 
* Surgical History of the War, Part I. vol. ii. p. 382. 
f Ibid., p. 383. 
t Ibid., p. 383. 390 
INJURIES OF THE FACE. 
When balls penetrate the bones of the face, they may be wedged in be- 
tween broken fragments, either in the frontal, maxillary, or ethmoid sinuses, 
or they may pass into the mouth, nose, or orbit. A careful exploration with 
the probe should be made in order to localize the missile, which should be 
extracted if possible. The same care is to be observed in reference to the 
management of fragments of bone as in the adjustment of the soft tissues: 
they should be pressed into position, and only removed when their connec- 
tion with the surrounding parts is so slight as to leave no hope of their 
vitality being maintained. 
The constitutional treatment consists in restricting the diet for two or 
three days, keeping the bowels in a soluble condition by a saline cathartic, 
and when pain is experienced administering opiates in doses sufficient to 
furnish relief. 
Secondary effects.—Hemorrhage is often not only a troublesome but also a 
very serious complication of gunshot injuries of the face. It is not usually 
difficult to control when primary or at the time of the accident. The use of 
cold and the ligature, or the application of a carbolized gauze tampon, with 
compression, is generally quite sufficient for this purpose. It is the secondary 
hemorrhages that prove so annoying and add such gravity to these cases: 
this bleeding may occur at any period from the fifth to the twenty-fifth day. 
If not controlled by the tampon and pressure, and if the vessel from which 
the blood escapes cannot be discovered and tied, there remains but one al- 
ternative, namely, ligature of the carotid. Styptics are useless, and some 
of them, such as Monsel’s preparation of iron, are filthy as well as inefficient. 
The reports furnished from the office of the Surgeon-General, and analyzed by 
Dr. Otis, show fifty-two cases of ligature of the primitive carotid, and two of 
the external carotid, for hemorrhage consequent upon gunshot wounds of 
the face. The result was ascertained in all but a single instance, recov- 
ery following in fifteen cases, and death in thirty-eight, or 71.7 per cent. 
With the exception of two cases, which were wounds of the soft parts, 
all the rest requiring the ligature were connected with fractures located 
most frequently in the lower jaw (twenty-three cases), next in the upper 
jaw (twenty-two cases), and lastly in the malar and mastoid regions (nine 
cases). In four cases the artery was ligated a second time : of these one re- 
covered. The success of ligature is not very flattering; but fifteen successes 
out of fifty-two cases will compare favorably with the results in amputation 
of the thigh at the upper third. The obstinacy with which some of these 
deep-seated vessels bleed is to be referred not only to the inflammatory 
changes which follow facial injuries, but also to the fact that on account of 
lying wholly or in part in bony canals they are prevented from contracting. 
A very remarkable case of obstinate hemorrhage occurred in the Pennsyl- 
vania Hospital under the care of Dr. Morton, in which the spheno-palatine 
vessel was wounded by a piece of glass penetrating the parts between the lip 
and the anterior nai’es. So intractable did the bleeding prove that the carotid 
was tied ; but, while this proved effectual for the time, the patient subse- 
quently died from hemorrhage the result of ulceration of the internal jugular. 
Salivary Fistula.—Salivary fistula, as a result of face-injuries, is frequently 
encountered, both in civil and in military practice. It may involve either the 
salivary glands or their ducts. The duct of Steno is most commonly impli- 
cated, though that of the submaxillary and those of the sublingual do not 
escape. Salivary fistula is caused by wounds of the cheek, by ulceration fol- 
lowing salivation, and by the extraction of teeth, the alveolus being broken 
and the accident being followed by inflammatory closure of the excretory 
canal, and abscess which opens upon the external surface of the cheek. The 
abscesses which follow low fevers may open a few lobules of a salivary 
gland and give rise to a fistula. Bryant speaks of such* I once saw a case 
of congenital salivary fistula in which the opening was on the anterior part 
* Surgery, p. 243. SALIVARY FISTULA. 
391 
of the helix of the auricular cartilage. The obstruction of the Stenonian 
duct by the presence of a salivary calculus sometimes causes a tistula. When 
it arises from this cause it will be preceded by a soft, fluctuating swelling in 
the line of the duct. The opening, when the duct of Steno remains free, is 
usually just below the malar bone (Fig. 343), and is surrounded with a red 
or purple color, with depression of the soft parts. 
I have known the disease to be confounded with 
necrosis of the upper jaw, which is occasionally 
associated with the affection, and indeed myself 
committed this blunder on one occasion. The 
discharge which flows from the fistulous orifice will 
indicate the true nature of the affection. It is 
thin and watery; whereas in caries or necrosis it 
is purulent. Dr. Garretson* mentions a variety 
of salivary fistula in which, by the subcuta- 
neous ulceration of a few lobules, the secretion 
escapes, and by burrowing in the tissues of the 
face forms a cyst, the opening of which may be 
remote from the duct. In a case of sublingual 
fistula which came under his observation, the 
cyst formed in front of the hyoid bone. 
Treatment.—The treatment of salivary fistula 
is often attended with indifferent success. When 
the fistula is situated upon the cheek, the internal opening of the duct 
of Steno should be carefully sought for, and graduated probes inserted, 
dilating its orifice until no obstacle is offered to the escape of the secre- 
tion into the mouth. At the same time the external opening on the face 
should be cauterized with nitrate of silver, or the galvano-cautery when 
convenient, and immediately covered with 
gauze and collodion, or the rubber plaster. 
The dilatation should be repeated every 
day or two. Cases are occasionally cured 
after this manner. It was the plan pursued 
with success in the few instances of salivary 
fistula which occurred during our late war. 
The same treatment will succeed in small 
fistula} communicating directly with a few 
lobules of the gland. Many cases, however, 
will be encountered in which we are obliged 
to resort to other methods. That which in 
my judgment will be found to yield the 
most satisfactory result, is first to find the 
opening at the end of the Stenonian or 
parotid duct, on the inside of the cheek, 
and, if possible, insert a fine silver probe 
(though this is not absolutely necessary), 
then, taking a stout silk thread, pass the 
same by means of a needle between the ex- 
ternal surface of the cheek and the duct, 
some distance above the opening of the lat- 
ter. The ends of the thread, being brought 
out at the corner of the mouth, should be 
secured with a piece of adhesive plaster to 
the cheek. In making the internal punctures the operator should be careful 
not to transfix the duct, but to pass beneath it so as to isolate it as much as 
possible from the cheek. (Fig. 344.) The probe, if lodged in the excretory 
canal, will materially assist in effecting this important feature of the opera- 
tion. The external opening, or that on the cheek, should, after three or four 
Fig. 343 
Salivary fistula.—Garretson. 
Fig. 344. 
Author’s method of treating salivary fistula. 
The cheek is represented as everted, showing 
the orifice of the duct of Steno, and the seton 
deposited between the duct and the outside of 
the cheek, with its two ends brought out at 
the corner of the mouth. As the threads cut 
their way out by ulceration, the duct is de- 
tached from the external opening in the cheek. 
* System of Oral Surgery, p. 509, 2d edit. 392 
INJURIES OF THE FACE. 
days, be touched with nitrate of silver, and covered with a piece of adhesive 
plaster or gauze and collodion. The threads serve to convey the salivary 
secretion into the mouth, and at the same time to detach the duct from the 
fistula, thus allowing the external opening to heal. As soon as the saliva shows 
no tendency to discharge externally, the seton may be removed, should it not 
have already ulcerated through. The seton has been employed after another 
fashion, by passing a few threads of silk through the eye of a fine probe 
and conducting them through the fistula and the duct into the mouth, then 
securing together the ends of the threads which lie respectively on the cheek 
and within the mouth. (Fig. 345.) In about 
two weeks, should this plan prove successful, 
the saliva will drain into the mouth, after 
which the threads should be taken out, when 
the opening on the cheek will close up spon- 
taneously, or may be treated by the cau- 
tery, in order to excite healthy granulation 
and cicatrization. Neither operation, in my 
judgment, possesses any value. The oper- 
ation of Professor W. Horner consisted in 
excising a round portion of the cheek, in- 
cluding the fistulous track, with a shoe- 
maker’s punch, counter-pressure being made 
by a wooden spatula placed inside of the 
mouth. The external wound was closed by 
sutures. 
Dr. Garretson has met with encouraging success in the treatment of sali- 
vary fistula of the parotid duct by first making an incision through the fistu- 
lous track in the cheek, and then introducing a pyramidal cotton tent, the 
base presenting to the mouth and the apex to the outside of the cheek: this 
is retained in position by a slender thread fastened to its summit, and is 
secured to the skin with adhesive plaster. This tent is subsequently replaced 
with a wire seton, made by doubling fine silver wire on itself several times, 
so as to occupy one-half the thickness of the bheek, a single thread of the 
same wire being continued through the outer half to the surface of the face. 
This wire seton is kept in position by clamping a grain of shot on each ex- 
tremity. The surgeon who has much to do with these fistulse will be com- 
pelled to vary his plans to meet particular cases, and need feel no disappoint- 
ment if he is obliged to repeat the operation perhaps several times before he 
is successful. 
In cases where there is much loss of substance it will often be necessary to 
resort to plastic processes to close such openings. 
The loss of the lower lip, or the destruction of submental portions of the 
face, will give rise to a dribbling of saliva, which is vastly more detrimental 
to health than a salivary fistula, as it tends not only to impair the digestion; 
but also, by the drain, to enfeeble the general strength. 
An interesting case, of a colored boy, was treated by Dr. Hunter at the 
University Hospital, in which the entire chin, including the middle of the 
lower jaw, and all the soft parts down to the hyoid bone, had been carried 
away by a gunshot accident, leaving the tongue protruding into the chasm. 
After the parts had cicatrized, a plastic operation was executed, which suc- 
ceeded in restoring the lip, with the mental and submental regions, so per- 
fectly that the saliva, which before had kept the patient’s clothing drenched, 
could be perfectly retained. 
Fro. 345. 
Seton for salivary fistula of the parotid duct. 
Necrosis constitutes another of the after-effects of face-injuries, though the 
bones, in consequence of their high vitality, are not particularly prone to this 
disease as a result of traumatism, unless some constitutional vice is called 
into activity. If a ball is lodged in the nasal or maxillary cavities, it will 
after a time excite inflammatory disease of the bone; and in all cases where NEURALGIA. 
393 
a shot-injury has been received in the face, an exploration should be insti- 
tuted with a view to determine the presence of the missile, and, if found, its 
removal, if practicable, should be promptly effected. Whenever any diseased 
portions of the bones of the face become loose, they should be pulled away 
with as little division of the soft parts as possible. 
Neuralgia.—In consequence of inflammatory thickening of one of the 
trunks of the fifth nerve, or of its sheath, or in consequence of an injury to 
the bony canal in which it is placed, subjecting it to pressure, very distress- 
ing attacks of neuralgia are developed. Unlike those forms which arise from 
cold and miasmatic excitants, or from reflex influences, such as a decayed 
tooth, internal treatment avails little; but it should never be omitted before 
advising an operation. I can recall instances of a very unpromising kind, 
in which an operation had been urged upon the patient, which neverthe- 
less recovered under the use of iodide of potash, arsenic, and quinine. When 
constitutional remedies fail, then a resort to resection of the nerve at fault 
becomes proper. The three branches of the fifth or trifacial nerve which have 
been the subject of such operations are the ophthalmic, superior maxillary, 
and inferior maxillary. (Treat credit is due to Carnochan, of New York, who 
may be said to have been the first to demonstrate the feasibility and value of 
such sections, and whose results have been verified by numerous operators 
since. 
WThen the supra-orbital branches of the ophthalmic nerve have been in- 
jured, giving rise to neuralgia of the brow and certain parts of the scalp, the 
accompanying artery becomes distended and pulsates strongly, and the parts 
in the course of the nerve-distribution are excessively tender. This tender- 
ness is greatest when the pressure with the finger is light; firm pressure 
over the nerve where it issues from the supra-orbital foramen will afford 
relief. The attacks of pain will frequently be alleviated or cured temporarily 
by rubbing over the parts an ointment consisting of five grains of veratria 
and one drachm of simple cerate, or a hypodermic injection in the course of 
the nerve of one-quarter of a grain of morphia. After the attack the patient 
should be placed upon a course of quinine, arsenic, and iron. This plan of 
treatment failing, the trunk of the nerve where it emerges from the supra- 
orbital foramen should be exposed, and a portion excised. It is proper to 
state, however, that this operation, while it almost certainly gives temporary 
relief, does not always effect a radical cure, the disease often returning with 
the original intensity. 
Where the disease involves the superior maxillary nerve, the pain is ex- 
perienced in the soft parts of the cheek, and should it prove rebellious to the 
usual therapeutic measures appropriate to neuralgia, the only alternative is 
excision of the nerve. The same procedure will be applicable to the inferior 
maxillary nerve under similar conditions. 
Facial Paralysis may follow a gunshot wound of the face, the trunk of 
the facial nerve being involved either directly by the missile or indirectly 
by inflammatory deposit. I have seen it follow a blow delivered at the root 
of the ear, and in two instances the paralysis occurred from the introduction 
of aqua ammonise into the ear in mistake for a solution of morphia, in each 
case causing inflammatory infiltration of the parts behind the parotid gland. 
Should the nerve be divided, restoration of function is scarcely probable. 
When it is merely compressed by plastic exudation, a favorable prognosis 
may be given, muscular power returning with the absorption of the lymph. 
The appropriate remedies in such cases will be the internal use of iodide of 
potash and bichloride of mercury, and the occasional application of a blister 
over the mastoid portion of the temporal bone. 
Lachrymal Fistula, a not unfrequent sequel of face-injuries, will be treated 
of under the head of diseases of the eye. 394 
INJURIES OF THE NECK. 
Deformities consequent on loss of substance, vicious cicatrices, and slough- 
ing are subjects upon which no special rules can be laid down, and must 
be managed under the general principles given under the head of plastic 
surgery. 
WOUNDS OF THE NECK. 
Wounds of the neck may be incised, contused, lacerated, punctured, and 
gunshot. They may be self-inflicted, suicidal; they may be made with 
murderous intent, homicidal; or they may be accidental. 
Wounds of the neck admit of being classified according to the surgical 
divisions of this region,—that is, into wounds of the middle, lateral, and 
posterior cervical regions. 
Wounds of the Middle Cervical Region.—This region is occupied chiefly 
by the larynx and trachea, behind which are situated the pharynx and the 
oesophagus. The thyroid gland rests on either side and in front of the upper 
part of the trachea, immediately below the cricoid cartilage. On each side 
are situated the carotid arteries and the internal jugular veins. The anterior 
jugular veins lie along the inner borders of the sterno-cleido-mastoid muscles. 
At the point where the trachea passes beneath the sternum it is touched at 
the right anterior and outer side by the innominate artery, and has in front 
the innominate vein of the left side. The crico-thyroid arteries run across 
the membranous space between the cricoid and thyroid cartilages; the supe- 
rior thyroids descend by the sides of the thyroid cartilage to the thyroid 
body ; and the inferior thyroids, and occasionally the middle thyroid, are in 
close relation with the trachea, as they are distributed by their branches to 
the lower portion of the thyroid gland. 
Wounds of this region are termed superficial or deep according as they 
are above or below the deep fascia of the neck. When suicidal, the knife, in- 
asmuch as most persons are right-handed, is drawn from left to right, and for 
the same reason the wound is often higher on the left than on the right side. 
Such injuries are not necessarily confined to the front of the neck, but often 
extend into the lateral regions. According to Durham, during a period 
of four years there were 6696 cases of suicide in England, of which number 
1235 were cut throats. When inflicted with a view to self-destruction, the 
act is generally committed under great mental depression, maniacal excite- 
ment, or delirium, and the implement employed is usually a razor or knife; 
even penknives are sometimes used for this purpose. The wound may be 
situated at any point from the chin to the sternum. These injuries become 
serious when the}7' penetrate the air- or food-passages, or when they implicate 
large vessels. If the incision is made above the hyoid bone sufficiently deep, 
it will enter the mouth, and may divide the muscular connections of the 
tongue, or even the tongue itself, allowing it to be drawn back over the 
larynx and produce suffocation. When below the hyoid bone, between the 
latter and the thyroid cartilage, the epiglottis cartilage may be cut and 
topple over into the larynx. Should the crico-thyroid membrane be incised, 
the cavity of the larynx will be opened; if the wound is below the cricoid 
cartilage, the trachea is liable to be penetrated. Sometimes the injury is in- 
flicted with a desperation which carries the vulnerating body entirely through 
the larynx or trachea, and may even sever the pharynx or the oesophagus. 
Mr. Durham, in one hundred and fifty-eight cases of cut-throat wounds, 
found the location to be as follows: 
Cases. 
Above the hyoid bone 
11 
Through the thyro-hyoid membrane 
45 
Tlirough the thyroid cartilage 
35 
Through the crico-thyroid membrane or cricoid cartilage 
26 
Into the trachea 
41 
Homicidal wounds on the front of the neck are occasionally made with a 
view to turn popular suspicion from the perpetrator and give the murder the WOUNDS OF THE MIDDLE CERVICAL REGION. 
395 
semblance of having been self-inflicted. I know of no means of establishing 
a distinction drawn from external appearances. It is said that when suicidal 
the wound is likely to be oblique, and more extensive on the left than on the 
right side, because usually the knife is held in the right hand; but my expe- 
rience does not sustain this observation. Importance is also attached to the 
depth of the wound, suicides not generally cutting, it is alleged, as deep as 
homicides : yet I have seen the former entirely sever both trachea and oesoph- 
agus. The incisions made by suicides are said to be irregular, and often mul- 
tiple ; but those made by homicides, especially if there has been a struggle, 
often partake of this character. 
Prognosis.—Wounds which do not penetrate the mouth, larynx, or oesoph- 
agus, or which do not involve vessels below the deep fascia, though not en- 
tirely free from danger, usually do well; but when deep, and implicating the 
above structures, the complications are so numerous that all such injuries 
should be regarded as very serious in their nature. These complications are 
the following: 
1. Hemorrhage.—When a large vessel is divided, as the carotid artery or 
the internal jugular vein, death follows in a few minutes. In the case of a 
man who divided his carotid while in a state of mania a potu, death did not 
follow for several hours after the infliction of the wound. The act was com- 
mitted with a dull knife, which no doubt lacerated the artery and may have 
prevented the fatal gush of blood usual after such wounds. It is rather un- 
common for the great vessels to be reached in these attempts at self-destruc- 
tion, the prominence of the laryngeal apparatus no doubt constituting their 
protection. An ingenious explanation is given by Mr. Ililton, who thinks 
that when the air-tube is opened below the glottis, the sudden rush of air 
from the lungs, and the consequent contraction of the walls of the chest, 
deprive the thoracico-humeral muscles of their fixed support, and the arm 
drops. If this be true, it is a beautiful illustration of that marvellous con- 
servatism which is found existing in every part of the body, and which, like a 
sleepless sentinel, is not inoperative even when a man raises his hand against 
his own life. I doubt very much, however, if this be the true explanation of 
the immunity enjoyed by these large vessels. The acute pain produced by 
the edge of the knife makes the would-be suicide shrink from his purpose, 
and awakens him to a consciousness of the fearful nature of the act which 
he is about to perpetrate. Man dreads nothing so much as pain, and I am 
convinced, from what I have been able to elicit from those who have made 
ineffectual attempts to destroy their lives, that this explains the depth of 
cut-throat wounds. Such persons rarely make a second attempt. Heath 
may ensue from wounds of the thyroid, the lingual, or even the crico-thyroid 
arteries, should the blood pass into the air-passages, producing asphyxia. 
The latter may be produced by the falling into the larynx of a partially- 
divided cartilage, as the epiglottis or the arytenoid. 
2. Emphysema.—When the wound penetrates the larynx or trachea ob- 
liquely, so that the opening through the integument does not correspond with 
that through the air-tube, the air may extend either subcutaneously or be- 
neath the mucous membrane, in the first position permeating the soft parts 
of the neck and the thorax, and, should it enter the loose tracheal fascia, 
reaching to the mediastinum; and in the last encroaching so much upon the 
cavity of the larynx as to produce asphyxia. I once saw a patient die from 
embarrassed respiration caused by pressure upon the phrenic nerves by an 
emphysema of the neck and chest. This is the explanation given by Ililton 
for death under similar conditions. 
3. Entrance of air into veins.—The admission of air into a vein has, in rare 
instances, proved a cause of death. Partial division of a vein exposes a 
person to such an accident more than does a complete section. 
4. Dysphagia.—Inability to swallow may result from two conditions,—from 
a wound of the oesophagus, by which solids and fluids can escape into the neck, 
or from some injury to the spinal accessory or glosso-pharyngeal nerves, by 396 
INJURIES OF THE NECK. 
which the complex co-operation of the faucial and constrictor muscles con- 
cerned in deglutition is destroyed or rendered imperfect, and which may allow 
the substances taken into the mouth to pass into the larynx or to be rejected. 
Nor are the dangers of such wounds confined to the time of the accident. 
They may be postponed to a later period, and manifest themselves by in- 
flammatory conditions, such as purulent infiltration of the loose tissues about 
the larynx and trachea, oedema of the glottis, and broncho-pneumonia. The 
latter has been the cause of death in most of the fatal cases which have come 
under my care, where the patient did not immediately perish ; and it is just 
as likely to follow when the injury is above the hyoid bone as when it in- 
volves the vocal and respiratory tubes. I lost a case from this cause which 
was under my care in the surgical ward of the Pennsylvania Hospital. A 
horrible gash had been made between the jaw and the hyoid bone which 
extended nearly from one angle to the other of the lower jaw, opening the 
mouth, and dividing the genio-hyoid, genio-hyoglossi, and portions of the 
hyoglossi muscles. Even after an escape from the dangers just enumerated, 
there are complications which may retard recovery, such as exuberant gran- 
ulations from the surface of the wound encroaching upon the calibre of the 
air-tube and obstructing the respiration, or fistulous openings affecting or 
destroying the voice. 
Wounds of the Lateral Region of the Neck are generally either accidental or 
homicidal, and are for the most part inflicted by knives or balls. The vessels 
which are exposed to danger are the carotid, superior thyroid, lingual, oc- 
cipital, facial, internal and external subclavian, vertebral, transversalis colli, 
and inferior thyroid arteries; and the external and internal jugular, subcla- 
vian, and innominate veins. I remember a distressing case, in which a little 
girl, the niece of a prominent physician of this city, perished in a few mo- 
ments, by falling upon a pitcher, in which she was carrying some water to 
her uncle. A fragment of the vessel was driven into the neck above the 
clavicle, penetrating the subclavian artery. Bryant relates a case of Mr. 
Berkett’s,* in which death was produced very much in the same way, by a 
fragment of a broken chamber-vessel wounding the internal jugular of a 
child. Wounds of this region, when inflicted near the root of the neck, may 
open the chest by penetrating the pleural sac. The brachial plexus, phrenic, 
and pneumogastric nerves are likewise exposed to injury. Professor Gross 
mentions a case in which the brachial plexus, or one of its branches, was 
injured. The man lost the power of the right upper extremity, which was 
followed by great wasting of the part, and by severe pain, which involved 
the arm to the ends of the fingers. On one occasion, I was consulted by a 
gentleman from the Southwest, who had been assaulted in the street of his 
native town. Both the brachial nerves and the subclavian artery had 
been damaged, and there was not only partial paralysis of the arm, but also 
an aneurismal swelling above the clavicle. As the respiratory movements 
of the diaphragm depend upon the phrenic nerves, any wound of these must 
prove mortal. The brachial plexus occasionally contributes a filament to the 
phrenic nerve which passes into the thorax over the third part of the sub- 
clavian artery. I have in my possession a preparation in which the entire 
phrenic follows this course, so that the nerve might be damaged at a point 
where it would scarcely be suspected. Bransby Cooper lost a patient from 
spasms of the diaphragm by just such an anomaly, in a case where the sub- 
clavian was ligated. Wounds of the pneumogastric nerves are fatal from 
the interruption of those centripetal influences which excite respiration. 
Where the nerve on one side only is involved, recovery is not impossible: at 
least the cases related by the late Dr. John H. B. McClellan and by Billroth 
favor such a conclusion. 
Wounds of the Posterior Region of the Neck, when confined to the soft 
* Transactions of London Pathological Society, 1857. WOUNDS OF THE POSTERIOR REGION OF THE NECK. 
397 
parts, are much less important than those in front and on the side. As there 
are no great vessels or nerves, the danger from hemorrhage and paralysis is 
avoided. Shoidd the injury penetrate very deep, especially at the base of the 
skull, it may prove rapidly fatal, or produce paralysis by wounding the spinal 
cord. The exposed condition of the contents of the spinal canal in this region 
is due to the horizontal direction of the spinous processes, by which vulnerable 
spaces are left between. The popular notion that posterior cervical wounds 
are followed by sexual impotence must be founded on cases of injury to the 
cord or its membranes. The testimony of Lecouest, who had abundant op- 
portunities for observation on this point during the conflicts of the French 
with the Turks, gives no countenance to this opinion. Should the spinal 
canal be penetrated and the membranes of the cord wounded, the escape of 
the eerebro-spinal fluid would indicate the nature of the accident. 
Treatment.—The first duty of the surgeon is to arrest hemorrhage, in 
whatever region the wound may be situated. Until provided with the neces- 
sary means for ligation, a finger or lingers should be thrust into the wound 
to stay the flow of blood, or, if the bleeding is arterial and from the .upper 
part of the neck, the primitive carotid may be temporarily compressed against 
the transverse processes of the cervical vertebrae. To attain free access to 
the wounded trunk, it will sometimes be necessary to clear away the ex- 
travasated blood-clots and enlarge the wound in the direction of the vessel. 
When the internal or external carotid is involved, it is better to tie the primi- 
tive trunk ; and the same course should be adopted in cases where the bleeding 
comes from even smaller branches, provided it is persistent and the vessel 
cannot be located or can be reached only by a tedious division of structure. 
Should the hemorrhage come from the external jugular, the vein may be 
compressed or ligated ; if from the internal, the vessel should be encircled 
with a ligature. In cases where the jugular or other large venous trunks are 
punctured or slit, the safest plan is to tie both above and below the wound, 
instead of closing the orifice as one would secure an opening in a bag, namely, 
by raising the edges with a pair of forceps or tenaculum and tying a thread 
about the fold. The risk of ligating large veins has been overestimated. A 
very interesting and exhaustive paper has been written by the younger 
Gross* on wounds of the internal jugular, which ably illustrates this state- 
ment. I once tied successfully the internal jugular of a child not quite a 
year old, three-quarters of an hour after it had been divided by its mother, 
who, under a temporary aberration of mind arising from extreme want, 
cut the throats of her two children and of herself. Her own wound and 
that of one child proved suddenly fatal. The other child, which I pulled out 
from beneath the bedclothing, and which I had supposed dead, until I 
noticed some blood begin to flow from the wound, was rescued by securing 
the internal jugular vein, which had been slit. The syncope following the 
first gush of blood, and the imperfect expansion of the chest, no doubt had 
arrested the hemorrhage. In punctured wounds of the internal jugular, or 
where the source of the bleeding cannot be definitely determined, compres- 
sion, by pellets of carbolized gauze or of patent lint forced into the opening 
and made secure by a compress, roller, or adhesive strips, should be first em- 
ployed. In cut-throat wounds, another matter of great importance is to 
ascertain if there be any clots of blood in the air-passages, and, if so, to effect 
their removal with the greatest despatch. Patients have perished from suffo- 
cation by a neglect of this precaution. The fingers should explore the pharynx 
and upper part of the larynx, dislodging any such clots ; and if lower down in 
the larynx or trachea, they must be removed by forcibly compressing the chest 
while the head is allowed to hang over the edge of a bed or table. With the 
same object in view, the air-passage may be assisted with the common injec- 
tion syringe, when nothing better is at hand; and if the case is urgent, and no 
instrumental means are accessible, by sucking out the blood with the mouth 
applied to the opening. When the wound is situated above the hyoid bone, 
* American Journal of the Medical Soiences for January, 1867. 398 
INJURIES OF THE NECK. 
and the anterior attachments of the tongue are divided, allowing extreme 
retraction of the organ, another danger to respiration arises from the resulting 
obstruction at the entrance to the larynx. In such a case the organ musl 
be drawn forward, and, if necessary, so maintained by a silver suture passing 
between its under surface and the hyoid bone. If the epiglottis is partially 
divided and falls over the glottis, it is best to remove it entirely out of the 
way. 
Hemorrhage being arrested, the next duty is the approximation of the 
wound. When superficial and in the middle or anterior region of the neck, 
it may be closed by the interrupted suture; but when deep, and penetrating 
the air-tube, all such sutures are useless, and sometimes dangerous. Quick 
union is not to be expected. The escape of air and mucus, the movements of the 
air-tube in respiration, and, when the wound is high up and opening into the 
mouth, the escape of saliva, combine to prevent the rapid healing of the parts 
Should there be much oozing of blood, stitches will prevent its escape ex- 
ternally, compelling it to flow into the trachea ; and if there is inflammatory 
or other swelling about the glottis, the opening below becomes necessary for 
the purpose of respiration. It is only in cases where the trachea or larynx 
is entirely divided, or where, in consequence of several cuts in different direc 
tions, portions of cartilage be 
come displaced, that sutures 
should be introduced ; and when 
inserted, they should never touch 
the mucous membrane, as their 
presence would provoke a spas 
modic cough calculated to pre 
vent healing. The best adjust 
ment, save in these exceptiona 
instances, is that by position 
Two or three pillows being placec 
under the shoulders, the heac 
should be depressed towards the 
chest just sufficiently to bring the 
sides of the wound in contact 
If it be depressed too much, the 
edges will overlap ; if not enough 
they will gape. To maintain the 
head in the proper place, it may 
be covered with a night-cap to 
each side of which is sewed 
strip of muslin long enough to 
be fastened to a band of the 
same material passing rounc 
the chest; or the occipito-sterna 
handkerchief of Mayor (Fig 
346) may be used, and made 
secure by placing a night-cap upon the head. 
When the pharynx or oesophagus is wounded to any extent, the food wil 
escape during deglutition into the neck, or may find its way into the pos 
terior mediastinum. If the oesophagus be severed, the ends should be unitec 
with sutures, and also when only partially divided this will be required 
In all cases of wounds of the pharynx or oesophagus, the patient must be 
nourished by concentrated broths, milk, and brandy conveyed to the stom 
ach, morning and evening, through a gum tube passed through the mouth 
or the nose to a point beyond the wound. On no account should the patien 
be allowed to swallow except by this method. This treatment will be equally 
proper in cases where the pharynx or oesophagus is wounded from within 
outwards, as I have known to occur during attempts to pass an instru 
ment through a stricture of the tube. Cases will occasionally be encoun 
Fig. 346. 
Occipito-sternal handkerchief for approximating a cut-throat 
wound. TREATMENT. 
399 
tered in which the mental condition is such that it is impossible to secure the 
co-operation of the patient in the introduction of aliment into the stomach 
by instrumental measures. The person may be maniacal or sullenly resistant. 
Under these circumstances a resort to ether or chloroform will be proper, 
or the patient may be sustained for a few days by nutritious enemata until 
intelligence is restored. When, from delirium, attempts are made to tear 
off the dressings, it will be necessary to resort to the strait-jacket. Cut- 
throat cases demand the utmost amount of care for some time. To prevent 
inflammatory attacks of the air-passages or lungs, the air of the apartment 
should be kept at a uniform temperature,—about 70°,—and to prevent the 
inspiration of dust the wound must be covered with a square of linen moist- 
ened with carbolic acid and water (one part of the acid to forty parts of 
water). All accumulations of mucus or blood in the wound are to be care- 
fully wiped away, and cough and restlessness allayed by suppositories of 
opium or the use of morphia hypodermically. 
Cases may occur in which, from inflammatory swelling or internal granu- 
lations, suffocation will be threatened. When not relieved by opening the 
wound, it will be necessary to perform tracheotomy and insert a tube below 
the point of obstruction. 
Should the granulations become exuberant,—a condition which, in con- 
sequence of the disturbance of the parts, is not unfrequently met with,— 
they must be repressed by the use of nitrate of silver. The cicatrization 
which follows extensive wounds of the larynx or trachea sometimes pro- 
duces such contraction or narrowing of the tube as seriously to impede the 
entrance of air; and if the case becomes urgent, the only alternative is to 
open the trachea, if possible, below, and introduce a tube. Through such 
an opening dilatation of the stricture has been accomplished by means of 
rubber bougies. Liston, Cohen, and others have reported cases of cure by 
this plan. 
It may happen that the wound does not entirely close up, but terminates 
in a small aerial fistula, in consequence of which the voice is left incomplete. 
The operation for closure is often unsuccessful. If there be no cause, such 
as stricture or other obstruction, contra-indicating its cure, the circumference 
of the opening may be freshened, and if the edges do not readily come 
together the integument should be loosened from the parts beneath and 
united by several interrupted sutures across the opening, after which a com- 
press placed over the parts and firmly retained by adhesive 'strips passing 
to the.back of the neck will complete the dressing and prevent emphysema 
from the air getting between the skin and cartilage. If sufficient integument 
cannot be obtained in this way to close the opening without tension, it is 
better to adopt an antiplastic method and slide or turn in a flap from the 
neighboring parts. I successfully treated a laryngeal fistula some time since 
by this plan. The operation consists in first freshening well the circumfer- 
ence of the fistula and then lifting a tongue of integument in front of the 
larynx and trachea below, its base corresponding to the inferior semi-circum- 
ference of the fistula; this tongue is rolled upon itself, forming a cylindrical 
plug, pressed into the opening, and united to its border by the twisted 
suture. In this operation there is certainly less danger of the air getting 
between the skeleton of the larynx and the soft parts. 
The larynx may be severely contused by a blow, by the grasp of the 
hands in a street-fight, or by the garrote of the highwayman. After 
such injuries there will be soreness and swelling of the neck, pain on swal- 
lowing, and partial or complete loss of voice from injury to the laryngeal 
nerves; and, when the violence has been severe, loss of consciousness, and 
even death. 
The treatment consists in surrounding the neck with hot fomentations of 
chamomile-tea, the warmth and moisture being retained by covering with 
oiled silk. Should much swelling follow the injury, with increasing diffi- 
culty of breathing, laryngotomy or tracheotomy will be demanded. 400 
INJURIES OF THE NECK. 
In the treatment of wounds of the back of the neck, the head must be 
kept somewhat extended, the wound washed with a solution of bichloride 
of mercury (one to one thousand), the edges 
brought together with deeply-inserted inter- 
rupted sutures, and the usual carbolized or sub- 
limated gauze compresses laid over the parts, 
the compresses to be retained by a roller or by 
a sling for the nape of the neck. (Fig. 347.) 
Gunshot Wounds of the Neck.—Four thou- 
sand eight hundred and ninety-five cases of 
gunshot wounds of the neck without injury to 
the cervical vertebrae have been tabulated from 
the reports of the Surgeon-General at Washing- 
ton,* showing a mortality of fifteen per cent. 
This heavy mortality is explained by the fact 
that the cases were taken not only from the 
field and general hospitals, but also from regi- 
mental and casualty reports. These wounds 
were distributed as follows: 
Fig. 347. 
Dressing of a wound in the posterior 
cervical region by the sling of the nape 
of the neck. 
Character of Wound. 
Cases. 
Died. 
Dis- 
charged. 
Duty. 
Unknown. 
Gunshot wounds of the neek 
4789 
570 
1056 
2394 
769 
Gunshot wounds injuring trachea 
41 
21 
11 
8 
1 
“ “ “ larynx 
30 
10 
8 
2 
10 
“ “ “ pharynx 
13 
7 
2 
3 
1 
“ “ “ oesophagus 
10 
6 
2 
2 
“ “ “ trachea and larynx 
4 
1 
3 
“ “ “ trachea and pharynx.... 
2 
2 
“ “ “ trachea and oesophagus.. 
2 
2 
“ “ “ larynx and oesophagus.. 
1 
1 
“ “ “ pharynx and oesophagus 
1 
1 
“ “ “ pharynx and larynx 
2 
2 
Summary 
4895 
618 
1083 
2413 
781 
The frequency with which balls traverse the neck, threading their way 
harmlessly through a region where so many life-structures are grouped into 
a space so small that one may almost span it with a single hand, is a matter 
of common observation with military surgeons. The only explanation which 
seems plausible is to be found in the form, elasticity, and mobility which 
belong to the cervical components. The larynx and trachea, being cylin- 
drical, elastic, and loosely connected with surrounding parts, favor the deflec- 
tion of missiles, and the movable nature of the other structures admits of 
their slipping out of the wTay of danger. On no other supposition can we 
explain the very striking fact that during our late war the larynx and 
trachea were injured only 82 times in 4789 neck wounds. The prominence 
of the larynx accounts for its being injured oftener than the trachea. 
Treatment.—As in other wTounds. the indications are: first, to arrest 
hemorrhage; second, to remove the foreign body when accessible; third, to 
dress the wound antiseptically; and, fourth, to prevent, as far as possible, all 
complications. 
Should the blood flow freely, it can be controlled temporarily by a finger 
thrust into the opening or by plugging with a roll of carbolized lint until the 
surgeon is prepared to adopt more radical measures. Should the blood come 
from one of the branches of the great vessels of the neck, the wound should 
be enlarged and each end of the divided artery ligated. Only will it be proper 
* Surgical History of the War, Part I. vol. ii. p. 414. GUNSHOT WOUNDS OF THE NECK. 
401 
to tie the main trunk when the source of the bleeding cannot be ascertained. 
This course will be equally proper whether the hemorrhage is primary or 
secondary. 
Secondary bleeding is of frequent occurrence, and when the surgeon is 
compelled to resort to ligature of the carotid for its control, the termination 
of the case becomes one of great uncertainty. This will appear in a clearer 
light when I state that during the late American war the carotid was tied 
29 times for injuries of the neck alone, with 22 deaths; and when we add 82 
other instances in which the same vessel was ligated for various injuries of 
both face and neck, making a total of 131 cases, with a mortality of 97 
deaths, the operation is placed in a still more unfavorable aspect. The 
greatest success was always obtained when the surgeon was successful in 
finding the branch involved and secured both of the divided extremities. 
Modern methods of dressing wounds would doubtless give a different result. 
In the extraction of balls, portions of clothing, or other bodies, the same 
rules are to be observed as in gunshot wounds elsewhere. It is even more 
important to extract a missile from this region, when feasible, than in many 
other portions of the body. 
Sublimated or hot-water dressings form the best local application to such 
injuries. 
Secondary Complications.—Aside from hemorrhage, which has been 
treated of, the following may be noticed. 
Injury to the nerves of the neck, paralyzing the arm, tongue, glottis, and 
other parts, from the passage of balls, is quite common. A nerve-cord may 
be cut at the time of the injury, causing paralysis; or inflammatory thick- 
ening, taking place some time after, may compress a nerve-trunk so as to 
induce loss of motion and severe pain. The compression of a nerve may 
also be due to contact with a lodged ball. 
During our late war a ward in one of the military hospitals in the city 
of Philadelphia was set apart for the reception of such injuries, which fur- 
nished the material for the valuable work published by Drs. Mitchell, More- 
house, and Keen. 
Paralysis due to inflammatory thickening is not utterly hopeless. The 
absorption of the lymph may relieve the nerves from pressure, and they may 
again become suitable conductors of nerve-force, by which the muscular 
power of the part to which they are distributed will be more or less com- 
pletely regained. While time has much to do with the removal of these 
plastic deposits, the work will be hastened by manipulation, by inunction with 
the ointment of the iodide of mercury, and by the internal use of iodide of 
potash. After there is reason to believe that the compressing cause has been 
removed, electro-galvanic stimulation in the course of the nerves will be pro- 
ductive of much good. 
The fact that the mere contact of a ball with a nerve is sufficient to suspend 
or destroy its function has suggested the necessity of making diligent search 
for such missiles when lodged in the neck, as their removal would open the 
best prospect for recovery. Two very interesting cases, one occurring in 
the Confederate and the other in the United States service, illustrate this 
point. 
A sergeant belonging to the Sixtieth Alabama regiment wTas wounded on 
the 13th of March, at Petersburg, by a conoidal ball, which entered the face 
above the left angle of the mouth, knocking out three teeth, passing through 
the tongue, and lodging in the space above the hyoid bone. The bleed- 
ing, which was profuse at first, continued for several days before the vessels 
were secured. A careful exploration failed to discover the ball. The wound 
finally healed, but in the middle of the following July, after great interference 
in his deglutition, his tongue became paralyzed, doubtless from the ball get- 
ting into contact with the hypoglossal nerve. By the 15th of August the 
paralysis had disappeared. On the 20th of September severe pain set in, and 
an abscess formed to the right of the hyoid bone. After its evacuation he was 402 
INJURIES OF THE NECK. 
relieved until the middle of December, when the neck became again painful, 
and the depressor muscles of the larynx were found to be paralyzed, indi- 
cating pressure upon the descendens noni branch of the hypoglossal nerve. 
An examination at this time by Dr. Michel, of Montgomery,* led to the dis- 
covery of the ball at the lower part of the neck, close to the trachea; and 
its extraction was followed by a complete recovery. The ball had gradually 
travelled the entire length of the neck, revealing its progress by the unusual 
nerve-symptoms which were present. 
The second case was that of a private in the United States Sharpshooters, 
who was wounded at Chancellorsville, May 2, 1863. While in the act of firing 
his piece, a conoidal ball entered the left side of the neck, half an inch above 
and one inch from the sternal end of the clavicle, and, passing behind the 
trachea, lodged under the right clavicle, near where the subclavian rises out 
of the chest. There was very little bleeding, but a numb sensation was ex- 
perienced at the elbow and in the fingers, the latter becoming flexed. From 
carrying the limb in the flexed position, the elbow-joint finally became per- 
manently fixed, hut this false anchylosis was broken up under chloroform and 
the function of the articulation restored. On the 31st of October following 
the injury he was returned to duty, and on September 14,1864, was discharged 
from service, the limb still continuing painful and very sensitive to cold and 
heat. In the fall of 1865 he suddenly lost the power of supporting the head, 
and could not rise from bed, the head being drawn to one side by muscular 
spasm, which lasted only for four days. At the end of December the pain at 
the point of lodgement began to increase, and on the 31st of January, 1876, 
Professor N. S. Lincoln cut down upon and removed the ball, which was 
found resting against the subclavian artery, with a cord of the brachial 
plexus stretched over its surface. The patient recovered entirely, the limb 
becoming as large and as strong as the other. 
If the missile, however, is a ball alone, the assumption is that the wound 
is aseptic, and that the vulnerating body, unless in contact with some part 
which is quite movable, will remain harmlessly in the spot where it lodges, 
so that unless the ball can be readily reached I do not believe that prolonged 
efforts at extraction should be made. Unless such are conducted under the 
strictest plans of cleanliness, the wound, which if let alone would probably 
have healed kindly, is converted into a suppurating sore. 
Aphonia.—Partial or complete loss of voice following gunshot wounds of 
the neck is due to damage sustained by the larynx or trachea, to inflamma- 
tory or cicatricial changes about the vocal cords, and finally to injury of the 
laryngeal nerves. Many cases from these causes were reported both by 
United States and by Confederate surgeons. In some the disability was 
permanent, in others temporary. The treatment consisted in combating 
the inflammation, and where the life of the patient was endangered by the 
occurrence of apnoea, a tracheal tube was inserted. 
Spasmodic cough which follows injuries of the vocal and respiratory tube 
may be caused by nerve-pressure. Of this nature was the case of a colonel 
in the Second Mew York Cavalry, who was wounded in Alabama on the 28th 
of August, 1864, by a conoidal hall, which entered the neck just above the 
right sterno-clavicular articulation, injured the sternal origin of the sterno- 
mastoid muscle and the trachea, and passed out at the upper point of the 
right shoulder. He was mustered out of service November 8, 1865. The 
muscular power of the arm was greatly enfeebled, and when a finger was 
pressed over the cicatrix, which corresponded to the clavicular origin of the 
sterno-cleido-mastoid muscles, cough and a spasmodic contraction of the 
laryngeal and pharyngeal muscles were excited. Loud speaking, or the 
pressure of a bolus of food passing through the oesophagus, would provoke 
similar spasms. At night he frequently experienced attacks of severe dysp- 
noea and constriction of the trachea. Mo amelioration of his symptoms had 
taken place after the lapse of eight years, and the inference was in favor of 
* Surgical History of the War, Part I. vol. ii. p. 424. GUNSHOT WOUNDS OF THE NECK. 
403 
cicatricial pressure of the recurrent laryngeal, rather than of inflammation 
of its structure.* 
Necrosis of the cartilages of the larynx is not an unfrequent sequel of gun- 
shot wounds of this organ; and the hyoid bone may share a similar fate. 
The existence of sinuses and the use of the probe will reveal such a condition. 
The surgeon must wait until the work of separation has been well effected 
by natural processes, when the fragments may be pulled away by the 
forceps. 
Torticollis may follow gunshot wounds of the neck from cicatricial con- 
traction, from inflammatory adhesion of muscles, and from injury to the 
nerves. Sevei’al instances are given in the “Surgical History of the War,” 
where there was no reason to suppose that any nerve was damaged. This 
does not agree with the statement of Stromeyer, who believes that perma- 
nent wry-neck does not follow gunshot wounds of the neck implicating the 
muscles alone. 
Pycemia, according to our army reports, was not a common sequence of 
neck-injuries. 
Erysipelas frequently occurred after such injuries, but, independent of other 
complications, was rarely fatal. 
* Surgical History of the War, Part I. vol ii. p. 407. CHAPTER VII. 
INJURIES OF THE CHEST. 
Chest wounds are divided into the non-penetrating and the penetrating, and 
may be incised, punctured, lacerated, contused, or gunshot. 
Wounds of the Chest. 
Non-penetrating Wounds.—There are two varieties of the non-penetrating 
class, viz., the tegumentary and the musculo-tegumentary. 
Tegumentary wounds possess no special peculiarities. They do not extend 
deeper than the fascia which covers the muscles of the thorax, and no ves- 
sels of magnitude are exposed to injury. The integument, except in front of 
the sternum, in consequence of the abundant cellulo-adipose tissue, is quite 
extensible, and therefore its wounds admit of an easy approximation, either 
by adhesive strips or by sutures; the latter are to be preferred, as the former 
are liable to become displaced by the movements of the muscles which pass 
from the chest to the arm. The disturbing influence arising from the great 
mobility of the shoulder renders it almost imperative for rapid repair that 
the arm should be secured to the side after the dressing of even superficial 
wounds in this region. 
Musculo-tegumentary wounds.—The chief muscles which overlie the chest 
are of two kinds,—the extrinsic and the intrinsic. The former consist of the 
pectorals in front, the latissimus dorsi, trapezii, and rhomboidei posteriorly, 
and laterally the serrati and external oblique. These are broad muscles, and, 
with the exception of those last named, are influenced much by the move- 
ments of the arm. When a wound extends through the integument and 
divides a portion of one of these muscles transversely, there will be a marked 
retraction of its sides, save in the case of the external oblique, which, from 
the extended surface of its costal origin, admits of a very slight separation. 
To meet these peculiarities, it will be necessary, in addition to closing the 
tegumentary wound with interrupted sutures, to carry the arm in such a 
direction as will relax and approximate the divided edges of the muscles, 
and to so maintain the member by a proper bandage. I have not found it 
necessary to adopt the practice of carrying the sutures through the divided 
muscles except when the wound includes the tendinous part of their struc- 
ture, when it will be proper to do so, as the threads will retain their hold 
for some time before cutting out. If, however, a different course is de- 
termined upon, there can be no objection. The dressing should be made 
antiseptically. 
The reports from the Surgeon-General’s Office at Washington furnish 11,549 
cases of flesh wounds of the chest during our late war. The result was 
ascertained in all save 658. Of the remaining number, 10,891, only 113 died, 
or about 1 per cent. Macleod records 255 similar wounds during the Crimean 
War, with but 3 deaths. 
The intrinsic muscles overlying the chest are the intercostals, placed be- 
tween the ribs, and consisting of two planes running in opposite directions. 
Three planes of fasciae also exist,—one over the external intercostals, one 
between the internal intercostal and the pleura costalis, and one, quite thin, 
between the two intercostal muscles. Wounds which extend into the inter- 
costals, so long as they do not penetrate the innermost layer of fasciae, are TREATMENT OF HEMORRHAGE. 
405 
not serious, though the movements of the ribs in respiration will interfere 
with their rapid reparation, and the loss of intercostal resistance may pos- 
sibly admit of a hernia of a portion of the lung. 
The treatment does not differ from that proper to tegumentary wounds. 
No stitches should be inserted into the intercostals, and the chest move- 
ments on the affected side should be limited, either by encircling the thorax 
with a bandage or by broad adhesive strips carried from the spine to the 
sternum. If the patient suffers from cough, opiates will be demanded. 
Hemorrhage in non-penetrating wounds of the chest is usually slight. 
Along the posterior border of the scapula, and below the axilla, it will some- 
times be necessaiy to ligate a vessel. A dangerous hemorrhage is possible 
from either the supra-scapular, posterior scapular, or long thoracic arteries. 
A fatal case is given by Dr. Dean, of the army, from a wound of the former 
of these vessels, the bleeding occurring on the tenth day after the injury, and 
another is given by Dr. Crosby, U.S.V., in which the life of the patient was 
in serious jeopardy from a wound of the latter trunk.* The blood, when 
there is not a direct opening, may collect between the muscles and form an 
extensive extravasation over the side of the chest. There are, however, two 
vulnerable points upon the chest where important vessels are greatly ex- 
posed. One is immediately below the clavicle, in a small triangular space 
between the deltoid and pectoral muscle, in which lie the cephalic vein and 
the acromial thoracic artery. The other is situated between the clavicular 
and sternal portions of the great pectoral muscles, at the bottom of which 
are situated the axillary artery, vein, and plexus of nerves. When the 
axillary vessels are divided in this situation, one of two results is inevitable, 
—sudden death or aneurism. In the event of such an accident, should there 
be time for surgical interference, the subclavian should be compressed upon 
the first rib, in the supra-clavicular space, until the wounded vessel can be 
exposed below the clavicle and its divided extremities tied. 
Between the two planes of intercostal muscles, near the lower border of the 
ribs, rest the intercostal vessels and nerve. The position of the artery is not 
an exposed one, and it is rarely torn, except in wounds accompanied by a 
comminuted fracture of the rib, in which event it is liable to be opened by a 
spicule of the bone. Hence wounds of the intercostal vessels are most com- 
monly the result of shot-injuries, and are generally of a very serious import. 
The intercostals are quite large vessels posteriorly, and, coming directly from 
so large a trunk as the thoracic aorta, will, if wounded, give rise to an ob- 
stinate and profuse hemorrhage. In a case reported in the “ Surgical History 
of the War,” two quarts of blood were found in the cavity of the thorax; and 
of the fifteen cases recorded in the same volume, eleven proved fatal, or 73.3 
per cent. Seven of. these cases were treated b}7 compression, two of which 
number recovered; and eight by ligature, with two recoveries. Of these eight 
operations, one was for primary bleeding, three for secondary, and four for 
intermediary hemorrhage. 
When there is a comminution of the rib, the wound should be enlarged, 
the loose fragments of bone removed, and the vessel, if possible, exposed and 
tied. If this be not deemed advisable, a piece of carbolized gauze should be 
inserted into the opening, and be well packed by dossils or pellets of the same 
material. This proving inadequate, the rib maybe encircled with a ligature, 
by taking a strong, sharply-curved needle, with a blunt point (Fig. 348) having 
in it an eye for the thread. Introducing a strong silk thread, catgut ligature, 
or silver wire, through this eye, prolong the wound a little posteriorly, and, 
dipping the point of the needle under the lower edge of the rib, follow closely 
its inner sm’face, and, by depressing the handle of the instrument, make the 
point present, covered by the integuments, at the upper margin of the rib. 
An incision should now be made so as to uncover the point of the instrument 
and enable the operator to remove the thread from its eye, after which the 
instrument should be withdrawn. The ends may be disposed of by tying 
* Surgical History of the War, Part I. vol. ii. p. 519. 406 
INJURIES OF THE CHEST. 
them together over a roll of lint, or by passing them through the openings 
in a bone button and then securing the knot. Another plan of dealing with 
the ligature after thus encircling the rib is to pass the end which was removed 
Fig. 348. 
Author’s needle for securing the intercostal artery. 
from the eye of the instrument through an ordinary good-sized needle, slightly 
curved at its extremity, and, re-inserting it at the puncture made at the upper 
part of the rib, carry it between the integuments and the external surface of 
the rib, bringing it out at the original wound. This, which is quite easily ac- 
complished, constitutes a subcutaneous ligation, without the inclusion of soft 
parts. The upper puncture should then be closed with an adhesive strip. 
Ligatures applied in this way unavoidably compress artery, vein, and nerve. 
The vessel may be compressed in another way by an instrument which I have 
had constructed for this purpose. (Fig. 349.) This instrument consists of two 
branches, the permanent one (a) having a little mortice on its concave surface, 
into the middle of which is fitted a short piece of sea-tangle. The other branch 
of the instrument (b) is movable, and can be run down or up on the shank 
(c) by turning the handle (d). In applying this compressor, the fixed branch 
is passed into the wound and over the inner surface of the rib, after which 
the outer branch is to be screwed down upon the outside of the rib, a thin com- 
press being interposed to prevent excoriation of the skin. The object of the 
Fig. 349. 
Author’s intercostal artery compressor. 
little piece of sea-tangle set into the groove on the inner branch of the instru- 
ment is that by its swelling it may compress the vessel which lies below the 
common level of the rib in the costal groove. Professor Gross has suggested 
drilling a hole through the rib, and passing, in this way, a silver wire around 
the vessel. Whatever plan is adopted, care must be taken not to wound 
the pleura unnecessai’ily, which can only be avoided by keeping close to the 
inner surface of the rib. 
Another source of hemorrhage is from a wound of the internal mam- 
mary artery. This vessel—a branch of the subclavian—passes through 
the chest between the pleura and internal intercostal muscles, resting upon 
the cartilages of the ribs parallel with the sternum and about half an inch 
from its margin. At the space between the sixth and seventh ribs its 
division reduces the size of the vessel so much that it becomes much less 
important than at a higher point. The vessel is exposed to injury from shot 
and other wounds which take effect near the borders of the sternum. The 
accident, though quite rare, was recognized five or six times during our late 
war,* five of the cases proving fatal. The operation adapted for tying the 
vessel is that of Goyrand. The first three or four intercostal spaces offer the 
most convenient points of access to the vessel. An incision is made two or 
* Surgical History of the War, Part I. vol. ii. p. 523. PENETRATING WOUNDS OF THE CHEST. 
407 
three inches in length along the margin of the sternum, and the skin, subcu- 
taneous tissue, and great pectoral muscle are divided, exposing the aponeu- 
rosis of the external intercostal. This last muscle is next incised from one 
rib to the other; then, the internal intercostal being exposed, it is also divided, 
underneath which, unless disturbed or displaced by the injury, will be found 
the artery with its accompanying veins, which can now be encircled with a 
ligature, conducted, by means of an eyed probe, along the groove of a director 
passed underneath the vessel. 
Penetrating Wounds of the Chest.—There are two divisions of penetrating 
wounds,—those simply opening the cavity of the thorax, and those impli- 
cating some portion of its contents. 
The cavity of the thorax is entered whenever a vulnerating body penetrates 
the pleura costalis. Such wounds are made by dirks, knives, sabres, needles, 
bayonets, forks, balls, and other bodies. 
Symptoms.—When it is considered that the lungs most accurately fill up 
the pleural sacs, pressing against the costal arches at all points, and follow- 
ing the movements of the thoracic walls, it seems difficult to believe that 
the costal pleura can be penetrated without injury to the lungs. Of the pos- 
sibility of such an occurrence, however, there can be no doubt. I have seen 
a number of such cases, and the experience of almost any surgeon will furnish 
similar examples. The entrance of air and a traumatic pleurisy are the con- 
sequences of such an accident. The first may be fraught with evil. The 
second does not often become more than a local inflammation, and usually 
proves quite manageable. 
In penetrating wounds of the chest, how are we to determine with absolute 
certainty that the pleural cavity is opened without damage to its contents ? 
Except, perhaps, in a very extensive wound of the intercostal structures, by 
which the cavity of the chest is exposed to the eye, all surgeons agree that 
such a diagnosis is one of great difficulty, simply because it is well known 
that those signs which ordinarily indicate a wound of the lung may be present 
without the existence of such injury. 
Treatment.—The wound should be examined by the fingers or the probe, 
and the surface of the chest critically inspected, with a view to ascertain the 
direction and location of the ball, if the missile be of that nature, always re- 
membering the tendency of a bullet to be deflected. Sometimes the ball will 
be found under the skin, at other times impacted between the ribs, surrounded 
with a portion of the clothing of the patient, or often lodged under the scapula. 
Wherever found to be accessible, it must be extracted, and the opening covered 
with a carbolized or sublimated compress. When the wound is an incised 
one, it should be closed by sutures and a compress, with a broad bandage 
carried around the chest and secured sufficiently tight to control its move- 
ments. The quiet of the chest-walls is a very important element in the 
treatment, in view of the tendency to the formation of sinuses after such 
wounds. The diet should be restricted for ten or twelve days, and opium 
administered to allay any cough which may be present. The existence of 
pain in the location of the wound, aggravated on taking a deep inspiration, 
and accompanied by an increase in the temperature of the body and by 
accelerated pulse, denotes the development of pleuritis, which may extend 
to the lungs, giving rise to a pleuro-pneumonia. If the symptoms are urgent, 
it will be proper to abstract blood; if not, wet cups over the side of the chest 
will answer. These shoidd be followed by a large warm flaxseed-meal or 
mush poultice, covered in with oiled silk or rubber cloth, and renewed every 
six or eight hours. To allay irritation, relieve pain, and maintain an active 
condition of the glands of the skin, four or five grains of Dover’s powder, 
given once every four or five hours, will act beneficially. 
Wounds of the Diaphragm.—It is somewhat difficult to determine the exact 
import of wounds of the diaphragm, as they are rarely uncomplicated, the 408 
INJURIES OF THE CHEST. 
attendant injury sustained by the thoracic and abdominal viscera being quite 
sufficient, independent of any diaphragmatic lesion, to cause death. They are, 
however, not invariably fatal. The constant movement to which this muscle 
is subjected in carrying on the work of respiration prevents, generally, the 
restoration or healing of perforations or incisions made through its structure. 
This fact, first stated by Guthrie, was amply confirmed by the observations 
made during our late war, in which one hundred and twenty-six cases occurred. 
On this account it is quite common for portions of the abdominal viscera, 
which from their connections admit of much movement, to pass through 
these abnormal openings into the chest, constituting diaphragmatic hernia. 
In a case recorded by Dr. Sargeant, a portion of the colon was attached to 
the second rib. Death has followed from strangulation of the intestine in 
the opening. Strangulation of such hernia would justify a laparotomy. 
The diaphragm is sometimes torn or ruptured by violence applied to the 
external walls of the thorax, such as forcible compression, or falls,—an effect 
which is no doubt due to the extraordinary effort made by the muscle to 
resist the squeezing of the border of the chest. In this view, the rupture is 
more the result of muscular power than of the outward injury. The left 
side of the muscle is much more frequently ruptured than the right, a fact 
which is explained by the preponderance of the muscular over the tendinous 
structure on that side. 
There are no symptoms characteristic of wound or rupture of the dia- 
phragm. If after an injury, shot or otherwise, involving the region of this 
muscle, there should be abdominal respiration with severe pain beneath the 
cartilaginous border of the chest, a lesion of the diaphragm may be inferred ; 
and if after a wound similarly located gurgling sounds and a tympanic reso- 
nance are discovered in the chest, indicating the presence of some portion of 
the abdominal viscera in the thorax, such an accident will be rendered still 
more probable. 
No treatment other than rest, local and general, with anodynes to relieve 
pain when present, will be required. 
Wounds of the Contents of the Chest include those which affect the organs 
in the pulmonary chambers, namely, the lungs, and those in the mediastinum, 
the pericardium, heart, and great blood-vessels. 
Symptoms of a wound of the lungs.—The lungs may sustain extensive damage 
by a contusion or concussion of the thoracic walls, producing laceration of 
the pulmonary tissue, without the presence of an external wound. The same 
result may follow a broken and displaced rib. In the “ Surgical History of 
the War” will be found twenty-five cases of visceral rupture, including the 
heart or its great vessels and the lungs, without wounds of the thoracic walls. 
When these injuries occur in civil practice the subjects are generally quite 
young, the great elasticity of the chest-walls in this class of patients being 
favorable to such accidents. Dr. Bennet, Professor of Surgery in Trinity 
College. Dublin, has tabulated thirty eases of these injuries in adults, with 
nineteen deaths and eleven recoveries. More commonly, lung wounds origi- 
nate from knives, sabres, bayonets, and balls. By whatever cause a wound 
of the lung is produced, there is an immediate consciousness on the part of 
the patient of having received a ver}7 serious injury. It is followed by alarm, 
trembling, pallor, and sometimes collapse. Among the immediate effects will 
be the escape of blood and air* This blood may enter the air-passages and 
be spit up by the mouth (haemoptysis), or it may flow into the cavity of the 
chest (hsemothorax), and also into the lung-tissue by infiltration. The nearer 
the wound is to the root of the lung, where the vessels are large, the more 
profuse will be the hemorrhage and the greater the danger. Should the 
opening in the wall of the chest be direct and sufficiently patulous, blood 
* The air in the air-cells contains no organisms, being free from dust, and consequently the evils 
resulting from its presence in the pleural sac are much less dangerous than those which follow when 
air enters the sac through an external wound. PENETRATING WOUNDS OF THE CHEST. 
409 
may flow externally; and from the same condition of the wall, a collapse of 
the lung will be probable, produced by the air from without and that from 
the damaged organ rushing into the pulmonary chamber during inspiration. 
A patient thus suddenly deprived of one-half of the surface of aeration will 
be in imminent danger of death. 
The signs denotive of the accident are a struggle for breath, grasping 
anxiously at any object within reach, and wildly tossing from one position 
to another. The power of the heart is diminished, the pulse becoming very 
feeble; the surface is cold, clammy, and bloodless: and there is inability to 
lie for any time on the sound side. The physical signs are, the absence of 
the usual respiratory sounds, preternatural resonance, and immobility of 
the walls of the chest, on the atfected side, while on the sound side both the 
movements and the pulmonary sounds are greatly exaggerated, in consequence 
of the extraordinary demands made upon the uninjured lung. 
Escape of air.—This is another evidence of perforation of the lung. When 
the air escapes into the cavity of the pleural sac, it constitutes pneumothorax. 
A stratum of the atmosphere surrounding the lung, while it increases the 
difficulty of respiration from the resistance which it offers to the inspiratory 
expansion, does not necessarily involve collapse: indeed, both sides of the 
chest may be opened without collapse of the lungs, though the occurrence of 
such a condition must be exceedingly rare. 
Should the opening be sufficiently large, the 
air may be heard passing in and out of the 
chest during expiration and inspiration. 
Fromotopncea.—Air expelled from the wound 
and intermixed with blood and mucus, pre- 
senting a frothy or foam-like appearance, is a 
very significant sign of a wounded lung; and 
the same is true if a bloody and frothy mucus 
is expectorated. The air may escape into 
the interlobular tissue or beneath the pleura 
pulmonalis, constituting pulmonary emphy- 
sema ; or, instead of passing out of the wound, 
it may be disseminated through the cellular 
tissue of the side, giving rise to external tho- 
racic emphysema, indicated by the crackling 
sound experienced when pressure with the 
fingers is made upon the integument. This 
emphysema may extend over the entire side, 
or even over the whole body. (Fig. 350.) 
The facility with which air may be diffused 
through the open spaces in the subcutaneous 
connective tissue is sometimes taken advan- 
tage of by professional beggars, who, in order 
to excite popular commiseration, make a punc- 
ture through the skin of a child, and, inserting the fine nozzle of a syringe, 
inflate the integument. 
It must be observed, however, that all of the enumerated signs may be 
present without a wound of the lung,—a fact which renders the diagnosis 
one of considerable uncertainty. 
Hemoptysis may follow a concussion of the chest and also a non-pene- 
trating wound of the same; and it is possible to mistake the source of such 
hemorrhage. I recall a case in which it was supposed to have come from a 
lesion of the lungs, when on a closer scrutiny it was found to proceed from a 
large syphilitic ulcer in the fauces. If, however, the blood be intermingled 
with a frothy mucus, the evidence is in favor of a lung-penetration. 
Emphysema and pneumothorax are also possible without any implication 
of the lung. The air may be drawn into the chest through the external 
opening during inspiration, and, in consequence of the non-correspondence of 
Fig. 350. 
Emphysema of the entire surface of the body. 410 
INJURIES OF THE CHEST. 
the opening in the integument with that through the intercostal space, it 
is not expelled in the act of expiration, but becomes ditfused through the 
cellular tissue exterior to the walls of the thorax, giving rise to emphysema. 
That this is not a common sequence of penetrating wounds will appear from 
the statement made in the Surgical History of our late war,* that in 8715 
cases it was observed only thirty-eight times. Air may also collect in the 
pleural cavity, forming pneumothorax. The final disposal of the air in em- 
physema or pneumothorax has been the subject of much conjecture. There 
can be little doubt that, mixed with the fluids with which it is surrounded, 
it becomes absorbed. It is difficult to imagine any other solution of the 
problem, when we see an enormous tympany of the intestines disappear in a 
few hours without expulsion through either outlet of the alimentary canal. 
Pain and cough.—The pain is usually burning in character, and the cough 
a suppressed and worrying one. 
There are other diagnostic signs, which are equally equivocal with those 
ah’eady named, such as the size of the wound and its comparison with the 
dimensions of the vulnerating blade, and the relative position and posture 
of the assaulter and assaulted. While it is quite proper to take these into 
the consideration of obscure cases, they must not be invested with too much 
importance. A wound equal to or much greater than the widest part of a 
knife-blade is often inflicted with a trifling depth of penetration. A sabre 
or sword wound may pass several inches between the soft parts and the ribs 
without opening the cavity of the chest; and balls often follow a circuitous 
route, both without and within the chest, without implicating the lungs. 
The surgeon may be induced to try certain tests, which I mention only to 
condemn, as being not only hazardous, but also unreliable. The first is to 
instruct the patient to endeavor to force air through the external wound by 
taking in a full inspiration, and then, holding the breath in order to close the 
rima glottidis, to make an attempt at expiration, while a taper is held at the 
orifice of the wound (the sides of which are separated), under the supposition 
that if the lung be wounded the air will be driven out and disturb the 
flame. The possibility that the expelled air has entered through the wound, 
or that a clot or a transudation of lymph with inflammatory swelling may 
prevent the escape of air, even when a lung is wounded, is a sufficiently 
cogent reason for objection ; but there is another of much more weight,—i.e., 
that the experiment is not unattended with danger, as it may dislodge a clot, 
break up adhesions of the lungs, and otherwise disturb the work of repair, 
upon which the life of the patient may be suspended. 
The same objections apply with equal if not greater force to that meddle- 
some surgery which dares to introduce a probe or a finger through the open- 
ing in the walls of the chest. The following case will serve as an instance of 
the evil effects of such interference. A private, belonging to the 111th New 
York Yolunteers, was wounded, April 2, 1865, at Petersburg, by a conoidal 
ball, which entered the left side, near the spine, between the eighth and ninth 
ribs, and lodged in the thorax. He was sent to a field-hospital at City Point. 
He had hemorrhage and haemoptysis, and was greatly depressed. He rallied, 
however, from the shock, and was sent to the Armory Hospital, Washington, 
on April 5, where he died April 6, from the displacement of a clot during an 
examination of the wound.f 
Lumbar ecchymosis has been noticed in chest wounds, but is so rare that its 
value as a diagnostic sign will be seldom appreciated. 
Seeing, then, that there are no signs which declare with absolute certainty 
the existence of a lung wound, and, moreover, since it is not essential to the 
management of a case that such knowledge should be attained, the surgeon 
will wisely refrain from pressing his inquiries into the region of danger. 
Complications.—These are immediate and remote, or primary and sec- 
ondary. 
The immediate or primary complications result from the presence of a for- 
* Surgical History of the War, Part I. vol. ii. p. 613. 
f Ibid., p. 482. COMPLICATIONS. 
411 
eign body in the cavity of the chest or in the lung, such as a ball, shot, wadding, 
or jiortions of the clothing; air in the pleural sac,—pneumothorax; air in the 
cellular tissue on the outside of the chest and in the interlobular tissue of the 
lung,—emphysema; blood in the pleural sac,—hemothorax; blood in the tissue 
of the lung,—traumatic pulmonary apoplexy; and, lastly, hernia of the lung. 
The. remote or secondary complications are the result of inflammatory 
changes, and are—an accumulation of serum or pus in the cavity of the pleura, 
constituting hydrothorax and pyothorax; pleuritis. gluing the pulmonary, 
costal, and (liaphx-agmatic pleurae together; pneumonia, fistula, and hernia of 
the lung, or pneumocele. The last is occasionally a primary complication, as 
has already been stated. 
Prognosis.—The gravity of wounds involving those portions of the chest 
which accommodate the organs of respiration must be determined by their 
depth. When the wound does not penetrate the thoracic parietes, a favorable 
termination may be expected. Even in gunshot flesh wounds, where there is 
often the additional element of visceral concussion, the mortality is very low. 
When the chest has been subjected to severe contusion or concussion, such as 
is caused by railroad accidents, by the falling of walls or the timbers of houses, 
by spent cannon-balls, or by fragments of shells, the prognosis should be given 
with great reserve, as extensive damage is frequently inflicted upon the in- 
ternal organs without any very marked injury being visible upon the surface. 
In penetrating and perforating wounds the danger to life is very great. 
The testimony of all military surgeons concurs on this point. Balls, pieces 
of clothing, and other materials, may remain quiescent for some time in the 
cavity of the chest; or they may find their way by ulceration into a bronchial 
tube and be coughed up, or into the oesophagus or even the intestine, and 
find their way safely out of the body, the patient making a good recovery; 
but these are the exceptional cases. Oftener the patient is worn out by 
protracted suppuration and the consequent irritative fever. By some, these 
injuries of the contents of the chest are supposed to develop phthisis pul- 
monalis. Hennen* mentions one case of this kind. Other writersf have 
furnished instances in which it is asserted that tuberculosis of the lungs was 
cured by wounds of the pulmonary organs. The evidence offered in either 
case, however, will not bear even a lenient criticism. 
In the late American war the result was ascertained in 8404 cases of this 
class of chest wounds, furnishing a death-rate of 62.5 ; and when this is 
placed in comparison with the reports of others, the result is found to vary 
but little. This is well exhibited in the folloiving table of chest wounds, 
collated by Dr. Otis| from different writers. 
Action. 
Wounds. 
Died. 
Mortality- 
rate. 
New Zealand (Mouat) 
23 
15 
60.8 
French in the Crimea (Chenu) 
491 
450 
91.6 
British in the Crimea (Matthew) 
164 
130 
79.2 
French in Italy (Chenu) 
256 
119 
46.48 
Austrians and Italians (Demme) 
159 
97 
61 
Hanoverians in Schleswig-Holstein (Stromeyer) 
97 
17 
17.6 
Prussians in Danish War, 1864 (Loeffler) 
137 
57 
41.6 
Danes in Danish War, 1864 (Loeffler) 
.113 
76 
67.2 
Prussians in Six Weeks’ War (Maas) 
12 
4 
33.3 
Prussians at Langensalza (Stromeyer) 
47 
31 
65.9 
Prussians at Landeshut (Brefel) 
15 
8 
53.3 
Germans in Franco-Prussian War (Billroth) 
30 
9 
30 
Germans near Metz (Fischer) 
34 
19 
55.8 
French at Sedan (MacCormac) 
31 
17 
54.8 
Total 
1609 
1049 
65.2 
* Hennen’s Principles of Military Surgery, p. 391. 
f Larrey’s Memoires, tom. iii. p. 376. 
J Op. cit., p. 608. 412 
INJURIES OF THE CHEST. 
When the ribs are broken by the penetrating missile, extensive laceration 
of the lungs may follow. It has been observed by Dr. Brinton that fractures 
at the point of entrance are much more serious than those at the point 
of exit,—that is, when a ball on entering the chest strikes a rib, carrying 
before it fragments and spiculae of the broken bone, the injury is usually 
fatal, whereas when it enters through an intercostal space and breaks 
the rib in passing out, the danger is materially lessened. This may be 
asserted of all penetrating wounds of the chest. The danger is enhanced 
by the addition of a fracture of the clavicle and of the scapula. The 
laceration produced by balls, fragments of shells, and portions of clothing 
renders such wounds more fatal than those made by incision or puncture, 
on account of the sloughing and suppuration which follow the former. The 
less the penetration and the more remote from the root of the lungs, the 
greater is the prospect of recovery, in consequence of the diminished risk of 
profuse hemorrhage. 
When the foreign body remains in the chest, the prognosis becomes less 
favorable, though should it become encysted the danger may be delayed 
to a distant day. Judging from my own observation, and from cases of 
reported recoveries in which the certainty of the lesion was often obscure, 
I cannot resist the conclusion that the mortality is much greater in wounds 
of the lungs than writers generally represent. The chances of recovery are 
greatly enhanced if the patient survives five or six days without sloughing 
symptoms. 
I am not aware that there are any cases of permanent recovery after a 
gunshot wound of both lungs. 
Treatment.—The treatment in penetrating wounds of the chest is local 
and constitutional. 
The local treatment includes a careful inspection of the wound and the 
removal of any foreign body which can be discovered. IIow far such exam- 
ination is to be carried must be determined by the judgment of the surgeon. 
If there has been much hemorrhage before the patient is seen, and clots are 
discovered in the opening, it will be wdse not to disturb them for the present, 
as their displacement will probably provoke a renewal of the bleeding; but 
where such a condition does not exist, it is allowable to use both the finger 
and the probe to determine if any foreign matters are accessible. Beyond estab- 
lishing this point, further explorations are pernicious. When the opening is 
made by a ball, a carbolized or sublimated gauze dressing should be applied, 
and confined by a carbolized roller, a T-bandage of the chest, or broad ad- 
hesive strips; if the opening is a punctured or an incised one, it should be 
closed with sutures. 
When blood and air escape very freely, the question arises, Is it proper to 
seal up the wound, or not ? This is best determined by the circumstances of 
the case. I have had occasion to adopt both plans with success. To attempt 
what is called “ hermetically sealing” every case of penetrating and per- 
forating wounds is simply unphilosophical. The absurdity of such a practice 
has been very thoroughly shown by the masterly analysis of Dr. Otis, of the 
United States Army. 
When a moderate amount of blood and air escapes through a chest wound, 
the opening should be drawn together by sutures and adhesive plasters. If 
the flow is profuse, the wound should be allowed to remain open, as otherwise 
there will follow hsemothorax and pneumothorax, with attendant distress in 
the breathing. If under any circumstance severe dyspnoea should follow the 
closure of the wound, it should be opened. In order to favor the evacuation 
of the blood, the patient should be laid on the affected side, so as to make the 
wound dependent. Much comfort will be realized by giving to the chest a 
proper support, leaving the opening unclosed, but covered with sublimated 
or carbolated gauze and absorbent cotton. The support can be made either 
by the many-tailed bandage or by adhesive plasters passing from the spine 
to the sternum, as is done in the dressing of a broken rib. The latter mode COMPLICATIONS. 
413 
is to be preferred, as the plasters, being confined to the affected side, leave 
the other unembarrassed for the work of respiration. When the ribs are 
comminuted, loose fragments are to be cautiously picked away, in order that 
no additional injury may be done to the pleura or the lung. 
The constitutional treatment consists in confining the patient rigidly to the 
recumbent position. He should not be allowed to rise either to urinate or to 
defecate. Cough will be best relieved by Dover’s powder. The bowels must 
be regulated with laxatives, when necessary; and the diet must consist of 
nutritious but unstimulating food, such as iced milk, and chicken or beef 
broth. The depressed or collapsed state which so frequently attends wounds 
of the lung, unless extreme, is of vastly more importance to the patient than 
all the remedial resources of the surgeon, as it conduces to a natural haemo- 
stasis. When reaction sets in. it must be watched with the utmost vigilance. 
The small clots which have obstructed the divided vessels must, if possible, 
not be dislodged; and whenever the heart begins to beat with a force which 
impels the blood too forcibly against these little blockades, it must be weak- 
ened by a depressant, the best being either veratria or aconite. 
Immediate Complications. Hemorrhage.—This is among the most common 
as Well as the gravest of the complications of penetrating chest wounds. It 
occurred in 346 out of 8715 cases during the late American war, 137 proving 
fatal.* When the hemorrhage is profuse, and comes from the wound or the 
mouth, or from both, the chest should be surrounded with ice-bags, and full 
doses of fluid extract of ergot administered every half-hour. The wound 
must be allowed to remain open, and the patient be placed in a position 
to admit of the free escape of the blood,—that is, on the wounded side. 
If the Incmoptysis does not diminish, and the strength of the patient begins 
to fail, the wound must be closed, the external refrigerant applications con- 
tinued, and heat applied to the extremities. Should the pulse, color, and 
temperature improve, there is encouragement to persevere in this course; but 
if the pallor and dyspnoea increase, and the pulse becomes more feeble, it is 
apparent that the blood is flowing into the chest and compressing the lung, 
consequently the wound should be immediately opened, and the patient 
turned on the injured side, to favor the escape of the blood. But suppose, 
notwithstanding this be done, that the hemorrhage continues with unabated 
violence: shall the wound be again closed, in the hope of stopping the flow 
by imparting pressure to the bleeding lung and thereby favoring coagulation, 
even at the risk of being compelled to open it again ? Such undoubtedly 
would be the proper course to adopt. In addition to this measure, the 
surgeon should, besides keeping the external application of cold to the chest, 
administer one-drachm doses of the wine of ergot, with a few drops of laud- 
anum, every twenty-five minutes, until eight or ten doses have been taken, 
when the remedy should be discontinued, or exhibited at longer intervals. 
In emergencies like the above, it was the practice among military surgeons, 
even as late as the Crimean War, to open a vein in the arm, and by free 
venesection induce, as rapidly as possible, a state approaching to syncope, 
in order to control the bleeding. This practice, employed without discrim- 
ination, doubtless has destroyed many lives, and that it is both unnecessary 
and dangerous has been well shown by the experience of Dr. Frazer,—the 
first to expose this error,—as well as by that of our own surgeons during the 
late war. In a case, however, where the haemoptysis is so profuse as to 
threaten to destroy the life of the patient in a very short time, or where 
there is reason to believe that blood is infiltrating the lung-tissue, I concur 
in the propriety of venesection, as I have seen the most convincing proofs 
of its efficacy; but, except in such a desperate strait, where the object is to 
gain a little time for the action of remedies, bleeding from the arm should be 
discouraged. Antimony has been recommended, in virtue of its depressing 
influence upon the heart; but the prostration which sometimes follows its 
use renders it a dangerous agent and one entirely unsuited to such cases. 
* Surgical History of the War, Part I. vol. ii. p. 612. 414 
INJURIES OF THE CHEST. 
The fact that we have in veratrum viride and ergot remedies capable of 
lessening the power of the heart and of contracting the calibre of vessels 
without producing sickness, and that these remedies can be managed with so 
much certainty, renders both the lancet and antimony unnecessary, except 
in the extreme cases mentioned. If, by the means already enumerated, the 
hemorrhage is brought under control, and the patient survives live or six 
days, there is ground to hope that recovery will follow, though the bleeding 
be renewed, as it sometimes is, even after the lapse of three or four weeks. 
The word recovery should be used in a guarded sense. It may be complete 
and permanent as applied to the immediate symptoms, though often the 
injury lays the foundation for subsequent disease, which will terminate 
fatally. 
Hcemotliorax.—When the blood, instead of escaping, accumulates in the 
cavity of the thorax, it constitutes what is called hamothorax. If the quan- 
tity of the fluid is great, the lung will be compressed, preventing its ex- 
pansion, and giving rise to dyspnoea. This condition may be suspected when 
the pulse becomes feeble, the skin cool and moist, and the countenance pale, 
and when nausea, restlessness, and diminished respiratory chest movement are 
present. The physical are more decisive than the rational signs. There will 
be dulness on percussion, most marked at the dependent portion of the chest, 
with a corresponding absence of the respiratory murmur. Should the pleural 
sac become filled with blood, the percussions will be dull or flat over the 
entire side, the intercostal spaces will be bulged out, and all sounds, whether 
respiratory or vocal, will be entirely destroyed. Lumbar ecchymosis will 
sometimes exist, though there is such a want of uniformity in this particular 
sign that its absence will have little weight in our diagnosis. The lumbar 
discoloration is produced by a slow leakage of blood between the muscular 
fasciculi of the diaphragm and those of the quadratus lumborum, the liquid ex- 
tending around to the inner margin of the erector spin® muscles and diffusing 
itself through the cellular tissue over the loins. For the existence of such 
an extravasation it is necessary that the blood should find its way beneath 
the reflected pleura, and this can take place only through the opening made 
by the vulnerating body; whence its infrequency. 
The prognosis must be formed by the extent and persistence of the bleed- 
ing. When the quantity of blood is not great, as indicated by the percussion 
and auscultatory sounds; when the pulse increases in force and diminishes 
in frequency, the color returning to the face and lips ; when the patient be- 
comes composed, and the breathing less embarrassed, a reasonable hope of 
recovery may be entertained. 
Treatment.—The treatment consists in closing the wound, as already 
described, in the hope that the flow may be arrested by the pressure of a 
eoagulum. Should the difficulty of breathing, and the other signs of hemor- 
rhage, increase, the wound must be opened, and the patient be placed, as far 
as possible, in such a position as will make the opening dependent, in order to 
favor the escape of the blood. Should the fluid have become clotted, it may 
be found impossible to dislodge it through the original opening, and other 
measures should be adopted to accomplish the desired object. In some in- 
stances the opening has been enlarged. If there is sufficient reason to be- 
lieve that by increasing this outlet the blood will escape, then let it be done; 
and this conclusion may be reached if the clots are found pressing into the 
wound and there becoming fastened. When such an operation is not deemed 
proper, it will be better to close up the wound, and to aspirate the chest 
through a lower intercostal space with a large-sized trocar, so that the 
coagula may pass through. In any case where there is a considerable accu- 
mulation of blood in the pleural sac, aspiration should be resorted to as soon 
as practicable,—that is, in five or six days, when it is reasonable to infer 
that the wounded vessels have been securely occluded. If this be neglected, 
the patient will be subjected to the additional risks of suppuration and 
septic poisoning. HERNIA OF THE LUNG, OR PNEUMOCELE. 
415 
Emphysema.—The extravasation of air through the cellular tissue exte- 
rior to the cavity of the chest, which may be known by the crackling sound 
elicited upon pressure by the fingers, is not a serious complication. It is a 
very common sequence of a broken rib, where the lung has been scratched; 
and I have never found that it seriously complicated the favorable progress 
of the case, though Mr. Erichsen states that in a case of this kind he has seen 
suppuration follow, bathing the broken ribs in pus. When there exists an 
external wound, and the air reaches the subcutaneous tissue, during either 
inspiration or expiration, so long as it remains within reasonable bounds it 
may very properly be left to nature, the closure of the wound and a proper 
degree of compression generally effecting its removal. If it becomes of suf- 
ficient importance to demand interference, the surgeon should examine the 
direction of the wound. If the external and internal openings do not corre- 
spond,—that is, if the communication between the two is indirect or cir- 
cuitous (a peculiarity often causing the emphysema),—let the communica- 
tion be made direct by an incision ; or if the difficulty is not explainable in 
this way, a few punctures may be made, followed by compression with a 
bandage to an extent consistent with the comfort of the patient. Pul- 
monary emphysema is an occasional result of a lung wound, the air passing 
between the lobules or beneath the pleura of the lungs. It will be noticed 
under the next head. 
Pneumothorax.—Like emphysema, with which it is generally associated, 
pneumothorax may arise from the air entering the chest through an external 
opening, or from the air-cells of the injured lung. When it accumulates to a 
degree sufficient to compress seriously the lung towards its root, it will give 
rise to much distress, offering the same resistance to the entrance of air into 
the lung as is presented when the latter is compressed by blood. 
The symptoms which indicate pneumothorax are, dyspnoea, pain, extraor- 
dinary resonance of the chest, the absence of the usual respiratory and vocal 
sounds upon the affected side, and an exaggeration of these sounds on the 
uninjured side, in consequence of the increased labor devolving upon the 
normal lung. When the injured side is only partially filled with air, the 
obstruction to the function of the lung being less, both the rational and 
the physical signs will be modified. The percussion-sound will be less tym- 
panitic, and the vocal and respiratory murmurs possess a pitch which is 
expressed by the term “ metallic tinkling.” The difficulty of breathing will 
also be less urgent. The chief distinguishing characteristics between lung- 
pressure from blood and that from air are, that in the latter there is reso- 
nance of the chest-walls and the ordinary signs of internal hemorrhage are 
absent. 
When the air-cells become dilated, or when the air infiltrates the interlobular 
tissue of the lungs or the space beneath the pulmonary pleura, it will give 
rise to symptoms analogous to those of pneumothorax, but susceptible of 
being distinguished from them. In these forms of emphysema the percus- 
sion-sounds are somewhat less resonant than in pneumothorax, the expira- 
tion more prolonged and difficult, and the respiration more feeble and asth- 
matic, with absence of metallic tinkling. 
Treatment.—So long as the air in the pleural sac does not seriously 
impede the breathing, interference is unnecessary, as this air will event- 
ually be absorbed. When, however, the respiration becomes labored and 
the patient is threatened with suffocation, an attempt must be made to 
effect its escape. Here, as in hemorrhage, the wound should be opened, 
and, if not sufficient, may be enlarged. If the opening has healed, or does 
not afford vent for the air, the chest should be tapped with the aspirating 
apparatus. 
Hernia of the lung, or pneumocele.—A portion of the lung may insinuate 
itself between the lips of a chest wound and protrude externally, consti- 
tuting what is called a hernia of the lung. This may follow immediately 
after the accident, or it may take place weeks later, in which last case it 416 
INJURIES OF THE CHEST. 
overcomes the resistance of an insufficient cicatrix. This complication was 
noticed seven times in twenty thousand cases of chest wounds reported during 
our late war, five of which seven were primary. Though it is said that these 
protrusions occur most frequently at the anterior part of the chest and on 
a line with the nipple, yet in the cases noticed above, five were as low 
as the ninth rib. All were the result of gunshot wounds, and varied in 
size from one to five inches in diameter. Several reasons have been offered 
in explanation of these protrusions of the lung. I am disposed to believe 
that the cause is to be referred to peculiarities of structure. Every anatomist 
will have observed among a large number of cases certain ones in which the 
fissures separating the lobes of the lungs are very deep, by which great free- 
dom of movement is allowed, thus favoring a protrusion when the resistance 
of a portion of the walls is removed. 
Diagnosis.—In primary pneumocele the diagnosis is not difficult. The 
extended mass is of a deep chocolate color and crepitates under pressure. 
When it is secondary it will be covered by the integuments and some con- 
nective or cicatricial tissue. It will exhibit a noticeable change of form, 
swelling during inspiration and subsiding on expiration. When pressed under 
the fingers, crepitation will be felt. Percussion will elicit a clear sound, and 
auscultation will detect the soft vesicular murmur. 
Prognosis.—Of the cases reported to the Surgeon-General of the United 
States Army, three, it is believed, proved fatal; but, as there were additional 
complications involving the abdominal viscera, death cannot be fairly attrib- 
uted to the pneumocele. There is reason to believe that, aside from other 
injury, the accident is one from which recovery may be looked for. 
Treatment.—As there is but a single case on record where a successful 
reduction of a pneumocele has been effected,* all efforts with that end in view 
will most likely prove fruitless, and for this reason persistent attempts to 
restore the lung should not be made. When projecting through a wound 
it is likely to become strangulated by the entrance of blood and air, in which 
case it becomes dark-colored and sloughs off. Two plans are open to the 
surgeon: either to leave the mass alone, only protecting it by a piece of lint 
wet with carbolic acid and oil until nature casts off the slough, or to encircle 
the neck of the tumor with a ligature on a level with the surface of the 
chest, and strangulate it at once. When the mass is dead, it should be sliced 
off externally to the cord with a scalpel, and the stump treated with carbolic 
acid and oil. In secondary cases of pneumocele—generally the most common 
—the only thing to be done is to protect the swelling against injury by wear- 
ing a shield, which can be attached to a T-bandage surrounding the chest or 
to a spring similar to that used in the ordinary truss. 
The primary or immediate complications of chest wounds, such as the 
presence of missiles, blood, or air, together with the traumatic violence, tend 
to excite secondary complications of an inflammatory nature. These are as 
follows : 
Pleurisy and pneumonia.—It has not been my privilege to examine many 
fatal penetrating and perforating wounds of the chest; but, so far as my 
experience extends, in cases where the patient has lived sufficiently long, 
inflammation either of the pleura or of the lungs, or of both, has been in- 
variably present, though, as a rule, quite circumscribed in extent. It is 
doubtless true that this form of pleurisy and pneumonia is, save in excep- 
tional cases, generally limited to the neighborhood of the wound, and does 
not greatly exceed the extent which is necessary for the repair of the injury. 
If this be so, neither pleurisy nor pneumonia can be justly regarded as a 
complication. 
Symptoms of traumatic pleurisy do not differ materially from those of the 
idiopathic disease. There is pain on inspiration, though not, as a rule, so 
acute as in the latter, and this pain may exist in so slight a degree as to 
* Gazzetta Mediea di Milano, Feb. 1844; Surgical History of the War, Part I. vol. ii. p. 568. HYDROTHORAX. 
417 
excite no complaint. The friction-sound in traumatic pleurisy is generally 
circumscribed. 
The signs which are said to indicate traumatic inflammation of the lung 
are of doubtful value. The escape of air into the chest, the imperfect dilata- 
tion of the pulmonary organ, and sometimes its complete collapse, render the 
percussion and auscultatory sounds exceedingly unreliable. In a case which 
I saw with a physician in the southern part of this city, in which a man in a 
fit of jealousy plunged a knife into the side of a young woman, and where 
there could scarcely be a doubt that the lung was wounded, which injury 
I have reason to believe was followed by a limited pneumonia, the physical 
signs were valueless. Instead of flatness on percussion in these cases we 
may expect resonance from the pneumothorax present, while the non-expan- 
sion of the lung will prevent our recognizing either crepitant, subcrepitant, 
or bronchial sounds. The same uncertainty will attach to all inferences 
drawn from the rational signs. The difficulty of respiration, cough, pain, 
discolored sputum, and accelerated circulation may exist entirely indepen- 
dent of pneumonia. An intermixture of blood with purulent matter in the 
expectoration, coming on from three to four days after the accident, will 
furnish a reasonable ground for supposing the presence of the disease. 
Treatment.—The treatment in cases of traumatic pleurisy and pneumonia 
should be chiefly expectant. Too much importance cannot be attached to 
the matter of rest. The chest should receive a support of broad adhesive 
strips, carried from the spine to the sternum. Opium, in the form of 
Dover’s powder, to allay cough, pain, or nervous restlessness, and to secure 
more perfectly the enjoined quiet or rest, will prove invaluable ; and should 
the pulse become too frequent and full, veratria will be the best remedy 
to secure its reduction. The diet most desirable for the first four or five 
days will be milk and light broths, after which solid food may be allowed. 
Neither bleeding, calomel, nor antimony is indicated, for if the inflammatory 
disease is local in its character it is probably not greater than the necessities 
of the case demand. A transudation of lymph and leucocytes is required 
to unite the damaged parts, and whatever tends to interfere with such a 
work must cause evil instead of good. Of all the inflammatory affections 
following wounds of the chest, which I have treated in civil and military 
hospitals and in private practice, in none have I taken blood from the arm; 
and when I had reason to believe that the disease was transcending the 
limits of safety, dry cupping, followed by a blister, was found to answer 
every purpose. And I may say that so uniform have been the recoveries 
that there remains but one of two conclusions: either there was an error in 
diagnosis or the treatment was peculiarly suited to the injury. 
Hydrothorax and empyema—the first an accumulation of serum and the 
second of pus in the pleural sac—are frequently met with as secondary com- 
plications of chest wounds, and also as primary and secondary results of 
inflammation of the pleurae. From whatever cause, we are not to expect to 
find these fluids typical examples of serum and pus. The former is often 
stained with blood, especially when of traumatic origin. When hydrothorax 
follows acute pleurisy, the fluid may be almost colorless or of a straw color, 
its consistence thin and watery, or thick like syrup, and containing flakes 
of lymph. The pus in empyema does not answer to what we ordinarily 
see discharged from an abscess in a healthy person. It is puriform rather 
than purulent, thin rather than consistent, contains curd-like masses of un- 
healthy lymph, is often discolored with blood, and may be charged with foul 
gases, emitting, when drawn, an offensive odor. It is astonishing with what 
rapidity such accumulations will form. I once saw a young man who, imme- 
diately on being attacked with a severe pain in the side, left Princeton and 
came direct to Philadelphia,—a two hours’ ride. On the evening of the same 
day, when I visited him, the right chest was filled with fluid. 
Accumulations of this nature may occur so quietly and gradually, and cause 
so little uneasiness, as scarcely to be suspected. In chronic inflammations of 418 
INJURIES OF THE CHEST. 
the pleurae we have examples of this kind, and especially where they have a 
tubercular origin. These are the cases which furnish illustrations of enor- 
mous thickening of the pleura, with its surface encrusted with a thick depo- 
sition of sedimentary matter, or of transformations here and there into a dense 
fibro-cartilaginous or bone-like substance. Pus may accumulate in the cavity 
of the chest by the rupture of a vomica, the opening of a pulmonary abscess, 
and, in rare cases, of an hepatic abscess. The purulent matter is occasionally 
found encysted by a circumscribed adhesion of the costal and pulmonary 
pleurae, and I)r. Townsend records the case of a patient who died in the Whit- 
worth Hospital, in whom the pleural sac was divided into three chambers, 
each containing pus.* Several years ago I tapped a child four months old, 
in whom a post-mortem revealed this separation of the pleura into distinct 
compartments. This is a matter of much practical importance in the oper- 
ation of paracentesis thoracis, as each sac will probably require a distinct 
puncture of the trocar. 
Symptoms.—The rational signs of hydrothorax or of empyema are short 
and difficult breathing, often performed with a peculiar grunting sound, a 
constant sense of oppression, and, when the accumulation is great, a general 
enlargement of the side, with bulging of the intercostal spaces and sometimes 
oedema of the overlying integument. The patient, in most cases, will find 
the easiest position to be that on the affected side. The history of the patient 
must be taken into account, such as the existence of a previous injury, pain 
in the side, rigors, frequent pulse, flashes of heat, etc. 
The physical signs are the following: a dull or fiat sound on percussion, 
corresponding to the height of the accumulation, and therefore most marked 
at the base of the chest when the patient is placed in the sitting posture. 
If the thorax be shaken, a splash may be heard and felt, provided the fluid 
be sufficiently liquid, similar to that which one hears when a partially- 
filled vessel is agitated. The vocal resonance will be diminished, and, if 
the collection is of sufficient magnitude and on the left side, there may 
follow displacement of the heart, or the lung may be compressed against 
the posterior part of the chest so as to force out its air. Such a condition 
will prevent pulmonary expansion, and will obliterate all voice or breathing 
sounds. 
In order to make the diagnosis perfect it is always safer to use the ex- 
ploring-needle, the introduction of which will communicate the desired 
information. It is possible to confound an abscess in the parietes of the 
thorax with a deposit of pus in the pleural cavity pressing its way through 
an intercostal space. The differential diagnosis may be established by re- 
membering that, if the external swelling communicates with the cavity 
of the chest, its size or prominence will be influenced by full inspirations and 
expirations, being diminished in the former and increased in the latter; if 
in the parietes, the swelling will not be affected by these movements. 
Treatment.—When the accumulation of serum or pus is small, the health 
of the patient not too much broken down, and the disease not due to tuber- 
culous disease or to the presence of foreign bodies in the lung, much may 
be done by proper local and constitutional remedies in effecting the removal 
of the fluid. Where there is reason to believe, in consequence of local pain 
and an elevated temperature, that a chronic inflammatory condition of the 
pleurae still exists, a huge blister over the chest will be indicated; or, where 
such condition does not exist, the thorough application of the compound solu- 
tion of iodine will prove of value. Should the accumulation have an acute 
origin, we may administer active cathartics, such as bitartrate of potash, or 
diuretics, the best of this class being the infusion of digitalis. 
In the majority of the cases under consideration we have to deal with a 
low grade of inflammation, and in constitutions much enfeebled by previous 
disease or injury we are compelled to rely upon tonics and alteratives, with 
nourishing food and fresh air. The syrup of the iodide of iron and cod-liver 
* Cooper’s Surgical Dictionary, vol. i. p. 622. THE OPERATION OF THORACENTESIS. 
419 
oil, and rhe iodide of potash with the tincture of cinchona, are remedies 
which will also be found to prove exceedingly useful. Jaborandi possesses 
active diuretic properties, and has been used with success in thoracic accumu- 
lations of a sero-purulent nature. When, however, the collection is large, so 
much so as to embarrass the respiration and injuriously compress the lungs, 
the only alternative is the evacuation of the fluid through an artificial open- 
ing in the walls of the chest, and the introduction of a rubber drainage-tube 
with antiseptic dressings. 
During our late war paracentesis thoracis was performed 28 times, with 9 
recoveries; in all of these cases, save 8, the necessity for the operation arose 
from traumatic injury. Of the 25 cases reported by Dr. Hughes,* in which 
this operation was done in Guy’s Hospital, London, 13 recovered. Of 10 
cases of empyema treated by operation under the care of Dr. Peter, at La 
Pitie,f 7 were entirely successful. The French—and among them Trousseau 
especially, who was one of the first to perform this operation—are more 
given to tapping the chest than either the English or the American sur- 
geons. Among Americans, Drs. Wyman and Bowditch have done much to 
popularize the practice. Of 79 cases tapped by the latter gentleman, 29 
recovered. More recently I learn that Dr. Bowditch has operated 200 times 
upon 154 patients; but the results I have not been able to ascertain. 
There is reason to believe that we are generally too backward in punc- 
turing the chest for the relief of these collections. A large accumulation of 
pus cannot lie harmlessly in the pleural cavity for any length of time. It is 
damaging to the lung, and must in some degree vitiate the blood and induce 
septic symptoms. 
The operation of thoracentesis.—In the performance of this operation the 
indications are to open the chest at the lowest point consistent with safety, 
and to avoid wounding either the lung, the diaphragm, or the intercostal 
vessels. On the right side the sixth, and on the left the seventh, intercostal 
space will be the proper one to puncture. The presence of the liver makes 
it safer to select a higher point on the right than on the left side. In per- 
sons who are very fat, rendering it difficult to distinguish the ribs, the proper 
intercostal space on the right may be ascertained by remembering that the 
seventh rib—the lower boundary of that space—is the last one attached di- 
rectly to the sternum; by placing the finger upon this point, and tracing the 
rib towards the spine, we are enabled to recognize the place for operation. 
For the left side a similar procedure will answer equally well, as the lower 
border of the seventh rib forms the upper boundary of the proper or seventh 
intercostal space. In these directions it must be understood that the inter- 
costal spaces are enumerated from above downwards. Having ascertained 
the proper space, the next important step is to determine the point for punc- 
ture, which should be about midway between the spine and the sternum and 
immediately above the upper margin of the rib, that the vessels which lie 
within the lower border shall not be endangered. 
There are four instruments in use for the operation of thoracentesis,—the 
Bowditch syringe, the aspirator, the trocar and canula, and the bistoury. 
The second and the last are best adapted for the purpose. The aspirator of 
Dieulafoy, or its modification by Potain (see Fig. 170), is decidedly the best 
instrument; and in cases of hydrothorax following acute pleurisy, or where 
there is reason to believe that the inflammation has subsided, it should have 
the preference. The instrument is used in the same manner as directed in 
tapping a cold abscess. 
Should the operator not be provided with this ingenious instrument, he 
may use one which I devised for this purpose, consisting of a canula and 
trocar with a stopcock, and a gum bag or bottle having a nozzle at one 
extremity fitted to the end of the canula, and at the other a stopcock, by 
which it can be emptied when filled. 
* Guy’s Hospital Reports, vol. ii. p. 366. 
f British Medical Journal, October 30, 1869, p. 475. 420 
INJURIES OF THE CHEST. 
In the operation the instrument should be thrust through the parietes into 
the chest, a small incision through the integument having been first made 
Fig. 351 
Canula and trocar with gum bag, attached at one end to the stopcock of the canula, and 
having at the other extremity a stopcock also. 
to facilitate its passage. (Fig. 351.) The entrance into the cavity of the 
pleural sac having been effected, the nozzle of the gum bag must be 
immediately fitted into the canula. Should the fluid not flow freely into 
the rubber receptacle, the instru- 
ment may be converted into an as- 
pirator by first closing the stopcock 
between the canula and gum bag 
and opening the one at the other 
extremity of the latter. If the bag 
be now compressed with the band, 
so as to expel all its air, and the 
stopcock then closed, a vacuum is 
produced, which, the moment the 
cock connecting with the canula is 
opened, causes the thoracic accumu- 
lation to rush in and fill the bag. By 
the repetition of this process the 
fluid may be drawn out by suction. 
In the absence of the rubber bag a 
bullock’s or hog’s bladder may be em- 
ployed as a substitute. (Fig. 352.) 
There is a modification of the trocar and canula which is more convenient 
for tapping the chest than the one just described. The canula is furnished 
with a branch (a), and a stopcock (b) between the latter and its outer ex- 
tremity. (Fig. 353.) 
In using this instrument, slip over the branch a piece of gum tubing, allow- 
ing the free end to rest in a basin or other vessel containing water. After 
making the puncture in the usual manner, withdraw the trocar, and imme- 
diately turn the stopcock, shutting off all communication with the external 
opening of the canula, when the fluid will pass through the tube into the 
Fig. 352. 
Tapping the chest with the trocar, canula, and bul- 
lock’s bladder. 
Fig. 353. 
Trocar for puncturing the chest. 
water, thus preventing the entrance of air. When the fluid begins to flow 
less freely than at first, pressing the sides of the lower part of the thorax 
together will serve to force it out; a voluntary cough on the part of the 
patient will etfect the same object, or a change of posture from the sitting to 
a semi-recumbent or recumbent position, or turning upon the affected side. 
Immediately on withdrawing the canula the opening should be closed with THE OPERATION OF THORACENTESIS. 
421 
an adhesive strip, over which should be applied a compress, secured with an 
additional plaster. 
I am convinced that too much importance cannot be attached to the ex- 
clusion of air from the chest in these operations. In cases of chronic sero- 
purulent accumulations it will be proper, 
after tapping, to introduce a drainage- 
tube, in order that the pleural sac may be 
kept drained until a cure is effected : this 
obviates the necessity of repeating the 
tapping. The best drainage-tube is made 
of rubber, and is perforated with holes. 
In performing the operation, make an 
incision close to and parallel with the 
upper border of the proper rib, dividing 
the different layers of tissue until the 
cavity of the pleura is opened ; then, pass- 
ing one end of a stout thread through the 
eye of a needle similar to that used for 
ligating the intercostal artery (see Fig. 
348), fasten to the other end of the cord 
a gum-elastic drainage-tube. Introducing 
the needle into the incision, carry it up- 
wards around the rib, or ribs, making the 
point project beneath the integuments at 
the upper border of the rib above; then 
cut down upon its extremity, disengage 
the thread from its eye, remove the needle, 
and pull the drainage-tube into position, 
when, to keep it from becoming dis- 
placed, the ends may be tied together. 
(Fig. 354.) The fluid will be drained 
away as it accumulates. The same result 
will be obtained by simply inserting the drainage-tube through the wound a 
short distance into the chest and properly securing it in place. An excellent 
way to do this is the mode suggested by Erichsen, which consists in passing 
a piece of rubber tubing through a square piece of gum-cloth, splitting it in 
four parts, and attaching each to a corner of the 
shield. (Fig. 355.) A silver tube with a shoulder 
is frequently used for the same purpose. I have 
seen a number of accidents occur from drainage- 
tubes slipping into the chest. Quite recently I 
had occasion to remove a catheter nine inches 
in length from the pleural cavity of a physician, 
where it had been for many months. Two ribs 
were resected, for the double purpose of reach- 
ing the tube and of effecting the cure of the sup- 
purating cavity. In old cases of empyema in 
which the suppuration refuses to subside, the 
excision of a portion of two or three ribs, so as 
to allow the walls of the chest to collapse, offers 
the only prospect for accomplishing a cure. 
Antiseptic precautions should be observed when 
performing this operation, by placing the instruments in carbolated water, 
making the puncture under the antiseptic spray, and dressing with carbolated 
gauze and salicylized cotton, oakum, mackintosh, etc. When the dressings 
are renewed, which for the first few days should be twice and afterwards 
once a day, the spray and other details belonging to the antiseptic method 
must be faithfully carried out. 
If the case does well, the drainage-tube may be removed at a period varying 
Fig. 354. 
Drainage-tube introduced into the chest. 
Fig. 355. 
Kubber drainage-tube ready to be in- 
troduced into the chest. 422 
INJURIES OF THE CHEST. 
from two to four months. Occasionally, after puncturing the chest, a quan- 
tity of blood discharges with the purulent matter. This sometimes continues, 
so as to create uneasiness on the part of the patient’s friends. I have never 
seen it prove serious, and believe that it is due to the rupture of the delicate 
vessels wdiich exist in the granulations of the thickened pleurae, just as they 
are found in the walls of an abscess, and which give way in consequence of 
the removal of pressure. The use of injections into the cavity of the pleura, 
after tapping, has been advocated by some practitioners. The tincture of 
iodine, and solutions of carbolic acid and of permanganate of potash, are 
the articles recommended. In chronic cases their use is of exceedingly 
doubtful propriety. A number of deaths have taken place at the time of 
the injection. 
Fistulce of the thorax.—Openings made into the cavity of the chest, either 
from gunshot or by operation, may refuse to heal and remain as fistulse. It 
will be found, in such cases, that a sac exists some distance below the ex- 
ternal opening, in consequence of failure in the pleurae to unite. A fistula 
may be due to necrosis of a rib. Injections for the relief of such conditions 
are useless. The proper course is to establish another opening at the bottom 
of the sac and introduce a drainage-tube, after the manner described in treat- 
ing empyema. If the fistula depends upon a diseased rib, the latter should be 
excised. 
Mediastinal Wounds.—It is possible for the mediastinum to be penetrated 
and yet its contents escape injury. Even a body so large as the shaft of a 
carriage has passed through the anterior mediastinum without injury to any 
organ within the chest; and numerous examples of balls and sabres traversing 
this space have been furnished by authors, in which no damage was sustained 
by the contained organs. There is, however, danger of pericarditis, pleuritis, 
and abscess succeeding such injuries. The most important constituents of 
the mediastinal space are the heart, surrounded with its pericardium, the 
great vessels which proceed from its base, the descending aorta, and the 
oesophagus, with the pneumogastric nerves. 
The pericardium, the heart, and its vessels.—These parts are frequently dam- 
aged by concussions, by punctured, incised, lacerated, and gunshot wounds. 
Symptoms.—A severe concussion of the chest will often produce a feeble, 
irregular action of the heart, accompanied by dyspnoea, pallor, and extreme 
weakness, and has been known to cause rupture of the pericardium. 
The pericardium may occasionally be wounded without the heart partici- 
pating in the injury. When the vulnerating body, like a needle, remains in 
the membrane of the pericardium, or lies loose in its cavity, as sometimes 
happens with balls, the danger is necessarily enhanced, not only from the 
pericarditis and consequent effusion, but also from injury to the heart. The 
signs of a wounded pericardium are very ambiguous. The pericarditis which 
ensues may be expected to furnish the peculiarly localized friction-sound, and 
after effusion an extended area of dull percussion, with perturbation of the 
heart’s action ; but to affirm with certainty the existence of an uncomplicated 
wound of this membrane, after an injury of the chest, is scarcely possible. 
During the late American war a number of such cases were recorded. The 
symptoms were pain, dyspnoea, and delirium, but in some of the cases the 
lung participated in the injury, and may have been as influential in producing 
these phenomena as the pericardial injury. 
Wounds of the heart, though among the most dangerous of all injuries, are 
not in all cases necessarily fatal. 
Symptoms.—The signs which indicate a wound of the heart are not uniform. 
Syncope, deadly pallor, and a scarcely perceptible pulse, with a cold perspira- 
tion, are among the most common, and follow as a result of the escape of 
blood into the pericardium, compressing the heart. Should the wound be 
small, or in a direction in which the muscular fibres of the heart are not cut 
transversely, thus avoiding retraction or gaping, or where a clot closes the MEDIASTINAL WOUNDS. 
423 
orifice, these signs may not appear immediately, but gradually. In addition 
to these there may be thirst, dyspnoea, anxiety, fear, and pain, though this 
last symptom is said to be more common in wounds of the pericardium than 
in those of the heart. A singular convulsive moment of the muscles of 
one foot was noticed by Dr. Keen,* an hour and a half after death, in a case 
of laceration of the heart. These sometimes involved the entire foot, at 
other times the great toe, and occasionally all the toes. 
In the 452 cases collected by Dr. Fisher,f death was immediate in 104 
instances, and in 276 took place at periods varying from one hour to nine 
months. Of the 452 cases there were 72 recoveries. In 36 of these the 
fact of a previous wound of the organ was verified by an examination held 
long after the injury, and this is fair ground for supposing that the remaining 
36 had been properly diagnosed. Of these 72 cases, 10 were punctured, 43 
incised, 12 gunshot, and 7 lacerated wounds. They were distributed as fol- 
lows : 50 were wounds of the heart, and 22 were wounds of the pericardium. 
The vulnerating bodies inflicting the injury to the heart, and producing 
punctured wounds, were needles in 8 cases, and a style and a thorn, each, in 1 
case. Those producing incised wounds were knives in 10 cases, daggers in 
7, poniards in 2, a bayonet in 1, and in 10 the implements were uncertain; 
7 were caused by gunshot, in 4 of which the balls remained; and 3 were 
lacerated and ruptured. Of the 22 wounds implicating the pericardium, 13 
were incised, 5 gunshot,—in 1 case the ball remaining in,—and 4 lacerated 
and ruptured. The same author notices the relative frequency with which the 
different portions of the organ were wounded. In 123 instances it was the 
right ventricle, in 101 it was the left ventricle; the right auricle was injured 
in 28 instances, the left in 13, and the apex of the heart in 17. In all wounds 
inflicted in front, the right ventricle is most exposed, forming as it does so 
large a portion of the heart presenting anteriorly. This greater frequency 
with which the right ventricle suffers has been still further corroborated by 
the statistics of 011ivier,| who, in an article upon the heart, and in a collec- 
tion of 61 cases of wounds of that organ, found that the right ventricle was 
implicated in 29, the left ventricle in 12, and both ventricles in 9 instances. 
In the same collection the right auricle suffered in 3 cases, the left auricle 
in 1 case, and in the remaining 7 the wounds were divided between the base 
and the apex of the organ. Very much to the same purport is the analysis of 
M. Jamain.§ Of 121 cases collected by this author, 43 were wounds of the 
right ventricle and 28 of the left ventricle. The duration of life after the 
infliction of fatal heart wounds differs very much in different cases. 
Rupture of the heart may occur, with or without laceration of the peri- 
cardium, in consequence of force applied directly or indirectly to the ex- 
ternal walls of the chest. It may also take place spontaneously. Gamgee 
has reported 28 cases of rupture of the heart by external force. The lesion 
took place with almost equal frequency on the right and on the left side of 
the organ. The right ventricle suffered nearly three times as often as the 
left, while in the case of the auricles the left was ruptured seven times and 
the right four times. In a patient of Dr. Packard’s, who was struck by a 
locomotive, both the auricles and the intermediate septum wTere ruptured. 
Of spontaneous rupture of the heart Barth gives 24 cases, in all of which 
the rupture w7as located in the left ventricle. There are instances of a similar 
lesion recorded by different waiters in which the right ventricle and also the 
right auricle have given way. In traumatic rupture death may be instanta- 
neous, or that event may be delayed for ten or fourteen days. In spontaneous 
rupture, death, though usually sudden, may not occur for several days. 
Prognosis.—In most cases of wound or rupture of the heart, death is 
* Transactions of the Pathological Society of Philadelphia, vol. v. p. 94. 
t Ueber die Wunden des Herzens und des Herzbeutels, Archiv f. Klin. Chir. von Langenbeck, 
1868, B. ix. p. 571. 
f Dictionnaire de M6decine, 1834. 
§ These de Concours, etc., vol. viii., 1857. 424 
INJURIES OF THE CHEST. 
instantaneous, or at least takes place in a few moments, the patient only 
uttering an exclamation or giving a few convulsive gasps. In some instances, 
however, life has been prolonged for several weeks, and in a few, despite the 
fearful nature of the accident, recovery has taken place. 
Dr. Purple* records 42 wounds of the heart which did not prove imme- 
diately fatal. In the case of Pool, reported by Carnochan, of New York, the 
patient survived eleven days with a bullet embedded in the apex of the heart. 
Dr. Kandalls has narrated the case of a negro boy who lived sixty-seven days 
with a number of shot in the substance of the heart, and a still more remark- 
able instance is furnished by Ferrus, in which a patient lived twenty-one 
days with the heart transfixed by a skewer. A curious case is relatedf of a 
patient who survived three weeks with a watchmaker’s file in his heart, the 
tool having passed through the left ventricle and the right auricle. Ilen- 
nenj gives the history of a patient from the Koyal Hospital at Ilaslar, who 
received a bayonet wound through the colon, stomach, diaphragm, lung, 
and right ventricle, and yet survived the accident nine hours. Chastenet.§ 
a military surgeon at Lisle, mentions a case of bayonet wound of the right 
ventricle in the person of a soldier who lived ten days after the injury, and 
died, as he believed, from mortification of the extremities, the wound in the 
pericardium and heart having cicatrized, as was shown at the post-mortem 
examination of the body. Fournier || gives an instance of a soldier who was 
shot through the breast; a great flow of blood immediately followed, and the 
man was thought to be dead. He, however, gradually rallied, and in three 
months recovered, but suffered for a long time from palpitation. Three 
years afterwards he died from another cause, when the ball was found buried 
in the apex of the heart. 
Four cases of gunshot wounds of the heart not proving immediately fatal 
are recorded in the Surgical History of the American one of which 
lived fourteen days after a shot-injury of the right auricle. In the same 
work is recorded the case of Private John Keynolds, a Michigan sharp- 
shooter, who was shot in the left breast at Spottsylvania, Virginia. At the 
necropsy, held two years after, the evidence of a previous wound of the 
right auricle was discovered. A distinct cicatrix was seen, from the effect 
of which a rupture of the cavity took place, which was followed by instan- 
taneous death. 
Mr. Poland** alludes to the case of a lad, reported by David and Stewart, 
who lived five weeks with a piece of wood in the right ventricle of the heart. 
Velpeauff mentions the history of a person who received a stab in the left 
side. The symptoms which followed were of such a nature that at the time 
the heart was supposed to have been pierced. Nine years after, the man died 
from causes altogether independent of the previous injury. The autopsy 
established the truth of the former diagnosis, as the cicatrix of the wound 
was found in both the pericardium and the right auricle. 
Mr. Durham had a case of bayonet wound of the heart implicating both 
ventricles, the septum, and the auricle. The patient lived forty-six hours 
and walked some yards after receiving the injury. Dr. Andrews reports a 
case of heart wound which was under the care of Professor von Bergmann, 
of Dorpat, in which the injured man walked fifteen miles after receiving the 
wound, and finally recovered. 
In the London “Lancet” for January, 1879, is recorded the case of a man 
who received a perforating shot wound of the left ventricle, which did not 
prove fatal for fifty-four days. 
* New York Journal of Medicine, May, 1855. 
f Repertoire d’Anatomie et de Clinique Chirurgicale. 
j Hennen, Military Surgery, p. 404. 
$ Journal de Medecine Militaire, vol. ii. 
|| Dictionnaire de Medecine, 1834. 
Surg. vol., p. 528. 
** System of Surgery, vol. ii. p. 606. 
ft Traite d’Anatomie Chirurgicale, tom. i. p. 604, 2e 6d. WOUNDS OF THE HEART. 
425 
Mr. Jackson* reports the case of a man who received two shot wounds of 
the chest, one of the balls passing through the right ventricle, and who lived 
for three hours and a half, being able in the mean time to make a deposition 
and to name his assassin. 
Surgeon G. F. Nicholson, of Peshawer, India,f records a case of shot wound 
of the heart in which the ball passed through both auricles and also through 
both lungs, the patient living forty-two hours after the injury. 
That bodies of different kinds may find their way into the heart and peri- 
cardium of man and other animals, and remain for a long period without 
creating any trouble, has been frequently exampled by different authors. 
HallerJ gives an instance of a needle, and Hennen of a pin, found in the 
heart of a bullock. I once saw a nail embedded in the heart of a bullock, 
which doubtless had remained for a considerable time in the organ, as the 
metal was quite corroded by oxidation. Professor Gross had in his pos- 
session a pericardium taken from a man twenty-two years of age, which 
contains an encysted needle that is two inches in length, and that gives evi- 
dence of having been long a harmless intruder in its present locality. Dr. 
Iver Hardt reports twenty-two cases of needle in the heart. Most of these, 
nineteen in number, were discovered after death in making autopsies, their 
presence not having been suspected before the post-mortem. 
Treatment.—The patient must be kept in the recumbent position, with 
the head low, in order to prevent fatal syncope from brain ansemia. External 
warmth should be applied to the extremities and along the spine, and opium 
administered to allay pain and quiet fear and nervous restlessness. The hope 
of the surgeon must rest upon the continuance for some time of a condition 
approaching collapse, by which the power of the heart will be greatly weak- 
ened and the stability of a clot more assured. If signs of dangerous reaction 
set in, the tincture of veratrum viride should be employed to restrain the 
action of the organ. Should life be prolonged, and subsequent inflammatory 
phenomena arise, reliance must be placed upon blisters, opium, and heart 
sedatives. 
The removal of foreign bodies from the heart is quite within the pale of 
operative surgery. Yon Bergmann extracted from the heart of a young girl 
a knitting-needle which had been driven in by a blow from a slipper. The 
needle passed through the walls of the chest below the third rib of the left 
side. The injury was followed immediately by asphyxia, and the needle 
was detected by a dark discoloration between the sternum and the mamma. 
There could be no doubt of the needle’s having entered the heart. A blowing 
systolic murmur was heard at the apex, and the pendulum-like movement 
of the vulnerating body and the rapid pulse, both of which ceased on the 
extraction of the foreign body, sufficiently attested the nature of the injury. 
An interesting case is reported in the “ Centralblatt fur Chirurgie” of a 
heart wound under the care of Stetzner. A student who had been drinking 
heavily forced a sewing-needle into his heart. Thirty-six hours after the 
injury the symptoms became so urgent that a portion of the fifth rib was 
resected, exposing the left pleural cavity. The pericardium was next opened 
and the needle discovered lying diagonally in the left ventricle. In attempt- 
ing to remove it, the violent action of the heart changed its position, so that 
it was lost, which, together with another accident, that of an iodoform tam- 
pon slipping into the pleural cavity, where it remained, induced the operator 
to abandon further attempts at extraction. The patient, however, recovered. 
Hydrops pericardii.—I believe that dropsy of the pericardium rarely follows 
wounds either of this sac or of the heart. IIennen§ mentions a single case, 
in which eight ounces of serum were found in the pericardial sac. Peri- 
carditis, attended with transudation of serum, however, will frequently follow 
* Ranking’s Abstract of the Medical Sciences, vol. xxxi. p. 165. 
f Medical News, July 31, 1886, p. 123. 
j Bibliotheca Chirurgica, vol. ii. p. 378. 
§ Military Surgery, p. 413. 426 
INJURIES OF THE CHEST. 
other wounds and contusions of the chest, and may also arise from rheumatic 
and other inflammations, as well as from organic disease of the heart. 
The symptoms of effusion are pyramidal dulness, and feeble cardiac sounds, 
most distinct towards the upper part of the sternum. In the early stage of 
such accumulations, and when they are the result of chronic inflammation, 
friction-sounds may be recognized. When the collection becomes large, there 
will be irregularity of the heart’s action, a feeble, irregular pulse, and great 
anxiety and distress in breathing, accompanied with a certain degree of ful- 
ness of the parietes of the chest over the region of the heart. The diagnosis 
should, where the case becomes one of extreme urgency and involves the 
question of operation, be verified by the use of the exploring-needle. 
Tapping the pericardium was first performed in America by Dr. John C. 
Warren in 1852. This was a successful case. The proposal to open the sac 
dates back to the seventeenth century, though its execution, so far as is 
known, was not accomplished until 1819, by Romero, of Barcelona. 
There is a difference of opinion as to the proper place for making the 
puncture, some advising the space between the fourth and fifth ribs, some 
the one between the fifth and sixth, and others—among them Larrey—the one 
between the seventh rib and the ensiform cartilage. Looking at the subject 
simply from an anatomical point of view, the space between the sixth and 
seventh ribs, one inch to the left of the margin of the sternum, would appear 
to be the most accessible route to the cavity of the pericardium, remem- 
bering that the internal mammary artery lies a little external to the side 
of the sternum and the intercostal at the lower margin of the rib. As in 
abscesses, the prominence of the swelling should have due weight in deter- 
mining the place of puncture, as the presumption is that the cavity can be 
reached most safely where the bulging is most marked. The resistance 
which the skin offers to puncture should be removed by a preliminary 
incision with a bistoury, through which the trocar should be passed and 
pressed cautiously onward until there is reason to believe that the peri- 
cardium has been perforated, when the stylet should be withdrawn. If no 
fluid escapes, the trocar must be inserted and carried farther inwards until 
the collection is reached. To prevent air from entering, a piece of gum 
tubing can be slipped over the canula and its end dropped into a basin of 
water. The aspirator may be more advantageously employed for the purpose 
of tapping. 
The results of the operation will be determined in a great measure by the 
cause of the dropsy. If it arise from organic disease of the heart, the relief, 
of course, can only be of a temporary nature. Of the 22 cases collected by 
Gunther, 7 proved successful, 4 died, and in the remainder the result was 
not obtained. 
Dr. John B. Roberts, of Philadelphia, has published an analysis of 41 cases 
of paracentesis pericardii. Of this number “ 27 were males, 8 females, and in 
6 the sex was not known. The age of the patients was as follows: 11 cases 
were under 21 years, 15 were over 21, and in 15 the age could not be de- 
termined. The oldest person operated on was sixty-eight years of age, and 
was tapped twice, once on the right side of the sternum; the youngest 
was six years old, and was also tapped twice. The result of these opera- 
tions is extremely encouraging: 19 of the patients recovered, 21 died, and 
1 case remained uncertain as to its termination, yielding 46.34 per cent, of 
recoveries.”* 
The operation has, I believe, been performed only once in this city, and 
that by Dr. Herbert Norris. The patient did not recover. A noticeable 
feature in this case, I am told by the doctor, was the existence of violent 
movements imparted to the canula by the heart. 
Wounds of the vessels of the thorax.—Wounds of the internal mammary and 
intercostal arteries have already been considered. Wounds implicating the 
great vascular trunks contained in the chest are generally quickly fatal, and 
* New York Medical Journal, December, 1876. WOUNDS OF THE SUBCLAVIAN VESSELS. 
427 
yet in some rare cases the prolongation of life for a short period of time, in 
consequence of pressure upon the injured vessel by fragments of bone, balls, 
clothing, etc., should be incitement enough for the surgeon to make an effort, 
hopeless though it may seem, for the rescue of a dying man. Even a wound 
of the aorta may not prove immediately fatal; and one case is recorded in 
which recovery followed this accident. This is the case of Heil,* in which 
the patient lived a year after a wound of the ascending aorta, and died from 
another disease. Pelletan records the case of a man who lived two months 
after a puncture of the aorta near its origin,f and Saviard that of another, 
who survived the wound eleven days. Acting Assistant Surgeon Piper! 
furnishes the notes of the case of a private, accidentally shot by a pistol-ball 
through the arch of the aorta, who lived long enough to be carried from the 
place where the wound was inflicted to the post-hospital, a short distance off. 
Acting Assistant Surgeon White§ also met with an instance of a punctured 
wound of the aorta, near its root, in which the patient died on the day of its 
reception. 
Wounds of the cavce terminate fatally, though death is not in all instances 
instantaneous. Acting Assistant Surgeons White and Horton|| each report 
a case of a wound of the descending cava, the first caused by a pistol-ball, 
the patient living long enough to be carried to a convenient post-hospital; 
the second produced by an arrow, and which did not prove fatal for forty 
hours. 
Wounds of the innominate vessels.—In two instances where the innominate 
artery was wounded, one lived twenty-four hours and a second six days. 
How much longer this last case might have survived it is impossible to say, 
inasmuch as death was brought about by an attempt to extract the ball, in 
doing which a furious hemorrhage was provoked, destroying the patient.^f 
Wounds of the subclavian vessels.—A wound of these vessels, though in all 
probability fatal, is not utterly hopeless. Five cases are reported during the 
late American war,** which demanded surgical interference, the patients 
living from two to sixteen days, and in one of which a Confederate surgeon 
successfully tied the left subclavian. 
One of these cases illustrates very forcibly how a ball may not only wound 
a large vessel, but may also at the same time obstruct its canal in such a 
manner as to prevent a fatal bleeding. It was the case of a private belonging 
to the Sixteenth Pennsylvania Cavalry, who was admitted into the Satterlee 
Hospital, August 26, 1864, with a gunshot fracture of the clavicle, first rib, 
and scapula. There was no pulse at the wrist, and both sensation and motion 
were wanting in the arm. on the injured side. On September 1, several spiculse 
of bone were removed from the wound. Six days after, hemorrhage occurred, 
when an unsuccessful attempt was made to ligate the subclavian. The patient 
shortly after died, and on making the autopsy the subclavian was found both 
pinned and plugged with spiculse of broken bone for two inches of its course. 
Treatment.—In wounds of the large blood-vessels of the chest, when life 
is not immediately extinguished by hemorrhage, the duty of the surgeon is 
to disturb the patient as little as possible. If moved into a hospital or other 
place of shelter, it should be done on a stretcher, in the gentlest manner pos- 
sible, keeping the head and shoulders low, applying external warmth, and 
giving little heed to collapse. All attempts to explore the wound or to search 
for the foreign body are of secondary importance, especially if there is reason 
to believe that the missile is acting the part of a tampon. Assistants should 
be instructed what course to adopt in case of renewed bleeding, and if the 
vessel is accessible, as the subclavian or the innominate, a cool, decided, and 
persistent attempt should be made at ligation. No patient should be allowed 
* Henke, Zeitschrift, 1837. 
f Clinique Chirurgicale, 1810, t. iii. p. 241. 
f Circular No. 3, Surg. Genl. Office U. S. A., p. 35. 
# Ibid., p. 99. 
|| Surgical History of the War, Part I. vol. ii. p. 520. 
f Ibid., p. 521. ** Ibid., p. 521. 428 
INJURIES OF THE CHEST. 
to perish unhelped. If there be but a single ray of hope coming from out 
the light of past centuries of surgical history, let the sufferer have the benefit 
of it, and the surgeon’s efforts cease only when death has decided the conflict. 
Wounds of the (Esophagus in its thoracic portion are very rare. During 
our late war no cases of such injuries, so far as I can ascertain, were observed, 
save one bj7- Assistant Surgeon J. C. McKee, that of a private belonging to 
the Fifteenth New Jersey Volunteers, who was shot in the chest by a conoidal 
ball at Spottsylvania. After death the oesophagus was found lacerated by the 
missile, which remained in contact with the tube. There were no symptoms 
to indicate the nature of the injury. The only sign which would indicate the 
existence of such a wound would be the escape through the external open- 
ing of fluids taken by the mouth. Holmes notices a case, taken from Boyer’s 
“ Treatise on Surgical Maladies,” produced by a bayonet-stab in the chest, 
through which were discharged different materials swallowed. This patient 
ultimately recovered. The treatment of a case of this nature will con- 
sist in sustaining the patient by nutritious injections of milk and beef-essence 
thrown into the bowel for several days, until there has been time for union 
to take place. 
Wounds of the Thoracic Duct must be not only fatal, but also among the 
rarest of surgical injuries; and it is difficult to conceive of such an accident’s 
occurring without the contiguous parts participating in the damage. (See 
Injuries of the Lymphatics, vol. iii.) CHAPTER VIII. 
WOUNDS AND DISEASES OF THE ABDOMINO-PELYIC 
CAVITIES AND THEIR CONTENTS. 
General Directions in Laparotomy.—In order to avoid needless repetition 
in cases requiring the operation of laparotomy, I shall, before taking up the 
consideration of special eases, lay down the rules to be observed in perform- 
ing the operation. 
The patient should be placed on a table, in the recumbent position, and 
exposed to a good light. The lower limbs are to be placed together and se- 
curely wrapped in a blanket, over which a few turns of a roller are made. The 
surface of the abdomen must be thoroughly cleansed with soap and water, 
afterwards with alcohol or ether, and finally with a lotion of corrosive sub- 
limate (one to one thousand). A compress of carbolized gauze wet in the 
latter solution and allowed to remain over the surface of the abdomen for 
several hours before the operation is a useful precaution. Towels wet in a 
warm solution of the bichloride of mercury are to be spread over the parts 
around the field of operation. The urine should be drawn before the opera- 
tion begins. Two forms of sponges must be on hand, one round and the 
other broad and flat, and should be absolutely clean. The first are intended 
to be used to soak up the blood from divided vessels; the second, or the thin, 
broad ones, are designed to be introduced into the abdomen in order to pre- 
vent the intestines from protruding through the wound and to catch any 
blood or other matters which might otherwise come in contact with the 
peritoneum. Every sponge should be counted before and after the operation, 
to see that none have been allowed to remain in the abdomen. The same 
sponge should not be used too often during the operation, and never a second 
time without being washed out in hot water. While the parietes are being 
divided, the vessels are to be seized with the small Imemostatic forceps, as 
time is usually too important for formal ligation by ligatures. Once com- 
pressed by these forceps, the vessels seldom require tying. 
The instruments must be kept in a bath of carbolic acid (one to twenty), 
and their number should be counted before and after the operation. The 
parietal peritoneum is best divided by being first raised with the forceps in 
the hands of the operator and an assistant, the opening being made between 
the two instruments, and not until all bleeding has been stopped. 
Assistants.—The operator will generally require four assistants,—one to 
take charge of the anaesthetic, one to work with himself, and two, who may 
be nurses, to take, wash, and return sponges, and to replace soiled water with 
a clean fresh supply. Operator and assistants must have observed the usual 
preliminary ablutions both as to person and as to clothing. Any one who 
a short time previous to the operation has been engaged in making a post- 
mortem, or who has been treating cases of erysipelas or other contagious or 
infectious disease, is disqualified to act as an assistant: indeed, it is not well 
to have many spectators present in abdominal operations. 
If during the progress of the operation, which in difficult cases may be 
prolonged, the patient is threatened with collapse, the use of hot water over 
the intestines will tend to energize the heart. When it becomes necessary to 
have the intestines out of the wound, they should be carefully covered with 
wet aseptic towels, and should be handled as little as possible. 430 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
The abdominal cavity should be flushed with warm water and all fluid 
carefully mopped out before closing the wound, and in doing this the pelvic 
cul-de-sac, being the most dependent, should receive special attention. 
During the closing of the wound in the abdominal walls a flat sponge 
should be allowed to remain between the intestines and the parietes until all 
the sutures are introduced and ready to be secured, after which it can be 
withdrawn through an interval between the threads. The sutures must in- 
clude the peritoneum. To prevent confusion in separating the sutures, the 
ends of each may be clasped between the jaws of a ha3mostatic forceps as 
they are successively introduced. 
After closure a little iodoform may he sprinkled over the line of approxi- 
mation and the usual antiseptic compresses and cotton applied, the whole 
being supported by a many-tailed flannel bandage firmly applied around the 
abdomen. 
Wounds of the Abdomen are divided into non-penetrating, penetrating, and 
visceral. 
Non-penetrating Wounds are subdivided into tegumentary and musculo-tegu- 
mentary, and may, in their origin, be contused, incised, punctured, lacerated, 
or gunshot. The frequency of abdominal as compared with other gunshot 
wounds, Otis found to be in the ratio of 3 to 8; and he adds that about one- 
tenth of all who perish in battle die from injuries of the abdomen. 
Contusions of the abdominal walls are quite common, and are the result of 
blows, falls, the passage of wheels, and pressure between opposing forces. 
They are characterized by discoloration or ecchymosis, presenting all shades 
of color,—blue, purple, yellow, and green. These marks are due to the rup- 
ture of vessels, chiefly veins; yet the branches are small, and, being situated 
in the subcutaneous cellular tissue, their rupture produces little inconve- 
nience. Occasionally, especially in the lumbar region, blood-swellings form 
of considerable magnitude. There is another ecchymosis of much greater 
importance. It is preceded by a diffused swelling, the discoloration not 
reaching the surface until after three or four days, and, when present, fol- 
lows injuries at the lower and outer portions of the abdominal parietes. This 
condition implies a lesion of deeper and more important vessels, such as the 
deep circumflex iliac. If neglected, sad structural havoc will be committed 
by the extensive separation of the planes of muscular tissue in which the 
blood is situated. In the case of a young boy who was under my care in the 
Pennsylvania Hospital, who had received an injury on the left side of the ab- 
domen, I found this condition to exist to a very unusual degree. These ex- 
travasations may result in abscess, which, if deep, will be of a diffused or non- 
circumscribed nature. Peritonitis may likewise follow even slight contusions. 
The prognosis in contusions of the abdominal parietes is not unfavorable, 
unless there is reason to suspect deep hemorrhage, the formation of abscess, 
or peritonitis, any one of which adds greatly to the danger of the case. 
Treatment.—When the contusion consists of a slight ecchymosis, nothing 
more than a stimulating application, such as soap liniment, will be required, 
in order to quicken the absorption of the changed blood. Should a blood- 
tumor result, it must not be opened, unless it provokes an abscess: pressure 
alone, by adhesive strips or by a bandage, will contribute to its removal by 
absorption, though the process may be slow. After a blow above the crest of 
the ilium, should there be a diffused swelling, the case must be watched with 
the most scrupulous care. The introduction of a grooved needle will deter- 
mine its nature, and if it proves to be blood and continues to increase, a free 
incision should be promptly made, for the double purpose of evacuating the 
accumulation and securing the wounded vessel. When suppuration follows 
contusions or blood-clots, a free incision will be equally imperative. 
Incised and Punctured Wounds.—There are several degrees of these wounds, 
founded upon their depth. They may extend through the integument and INCISED AND PUNCTURED WOUNDS. 
431 
superficial fascia, thi*ough the muscles and aponeuroses to the peritoneum, or 
through all the laminae into the cavity of the abdomen. Transverse wounds 
will gape more than vertical ones. They are produced by knives, razors, 
daggers, sabres, bayonets, horns of animals, etc. When not deeper than the 
subcutaneous tissue, the bleeding is usually insignificant, as the pudics, super- 
ficial epigastric, and superficial circumflex iliac vessels are small. An exception 
to this statement must be made in case the spermatic cord be injured. I have 
seen a troublesome bleeding follow a wound of the spermatic artery. When 
the muscles or aponeuroses are divided, the wound assumes greater impor- 
tance. The deep epigastric, circumflex iliac, and mammary are liable to be 
severed or torn, and are capable, under such circumstances, of giving rise to 
a dangerous hemorrhage. When these wounds are extensive, and situated 
in the median line (linea alba), or above the crest of the ilium, in front of the 
erector spin* muscles, they are likely to be followed by such weakness in 
the walls of the abdomen as strongly to predispose the patient to hernial 
protrusions. Their proximity to the peritoneum increases likewise the risk 
of inflammation of that membrane. 
Treatment.—The arrest of hemorrhage will demand the first attention of 
the surgeon. If the wound is not deeper than the superficial fascia, little 
blood will be lost, and perhaps no vessels will require the ligature ; though no 
branch which shows a disposition to bleed should be allowed to remain un- 
tied. When the muscles are involved, the greatest care must be observed to 
discover and secure any artery which has been injured; and on this ac- 
count there should be no haste in closing the wound, especially when it is 
in a locality where a principal trunk of the parietal vessels is situated. If, 
regardless of this maxim, the parts be sewed together, we may have the 
mortification to find the muscles separated from one another by blood, 
with all the concomitant evils. I have seen a patient almost moribund 
from an oversight of this kind. When compelled to reopen such a wound, 
there will be difficulty in finding the vessel and a strong probability of subse- 
quent abscesses and even sloughing. Six cases of fatal hemorrhage from 
wounds of this kind are noticed in the “ Surgical History of the War,” in one 
of which a final resort was had to ligation of the external iliac, without success. 
It will be best to tie both ends of vessels which are found bleeding, enlarging, 
if necessary, the wound for that purpose. It is possible, where the wound 
extends into the muscles, to have interstitial bleeding without any blood 
flowing externally, a fact which should place the surgeon upon his guard 
against such a contingency. When the hemorrhage has been arrested and 
all matters foreign to the parts have been removed, the wound should be 
thoroughly cleansed with carbolic acid and water or the corrosive sublimate 
solution, and its edges brought together by interrupted sutures, inserted 
sufficiently deep to include all the divided structures. This direction must 
be faithfully observed, otherwise the retraction of the muscular fibres will 
greatly weaken the parietes. This deep stitching has been thought by some 
to be unnecessary, because, they say, the threads soon cut through the in- 
cluded muscles. If, however, a sufficient hold is taken, this will not follow 
until a bond of connecting material has been provided. The most difficult 
region in which to secure union is the epigastric. The sparse amount of 
connective tissue renders the skin less extensible and more prone to gape. 
After the closure of the wound and its protection by earbolated or subli- 
mated gauze and salicylized cotton, the dressings and the abdomen should 
be surrounded by a broad bandage, its walls being relaxed by raising the 
shoulders of the patient. Rest in the recumbent position, a restricted diet, 
and opium if pain is present, constitute the remaining treatment. If the 
wound is quite small, and not deeper than the integument, after its closure we 
may be content with a compress kept in place by one or two adhesive strips. 
Penetrating Wounds.—Two varieties of penetrating wounds of the abdomen 
are recognized: one without and one with the escape of a portion of the 432 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
viscera. The peculiar structural arrangement of the abdominal walls—that 
is, the planes of muscular tissue running in different directions, downwards, 
upwards, and transversely—admits of the abdominal parietes being incised 
to a considerable extent and yet no visceral protrusion following, as some of 
the muscular fibres will always remain undivided and will immediately close 
over the opening on the withdrawal of the vulnerating instrument. In other 
instances, even when the opening is quite small, a portion of intestine or 
omentum will press its way through. In such cases the wound will gener- 
ally be located in the linea alba or near to the linea semilunaris, where the 
tendinous or aponeuorotic structure prevails. 
Whether with or without protrusion, penetrating wounds are fraught with 
danger, from the consequent risk of peritonitis. It is true that traumatic 
peritonitis, like traumatic pleuritis, has no great tendency to become general, 
but is usually circumscribed or limited to the vicinity of the wound, and is 
not likely to exceed the legitimate demands of repair. When it transcends 
this it is probably due to an accumulation of blood or pus acting the part of 
an irritant. These two elements of evil cause much of the surgeon’s anxiety. 
Though it is exceedingly rare for the viscera to escape injury in penetrating 
wounds, yet there are some very remarkable cases in which it is believed 
that not only balls but even sabres have passed through the abdomen with- 
out damaging any portion of its contents. While the possibility of such an 
occurrence is not to be denied, there can be little doubt that many so recorded 
are without sufficient evidence to justify their being accepted as trustworthy. 
Dr. Hare,* of Hew Hampshire, relates the case of a boy, fifteen years of 
age, who, in sliding from a hay-mow, came in contact with a barbed hay- 
hook, which entered the perineum, passed obliquely beneath the pubis, and 
emerged at a point two inches below the umbilicus and one inch from the 
right side of the linea alba. The hook being separated from the handle, the 
two parts were removed. In three weeks the patient was well. A still more 
remarkable example of a penetrating wound is given by Dr. Houston,j- the 
nature of which was clearly established by an autopsy sixteen years after the 
injury. The case was that of a woman, who, in slipping down from a hay-mow, 
struck upon the handle of a pitchfork, which, entering the vagina, passed 
through the pelvis and abdomen in the midst of the viscera, perforated the 
diaphragm, and, after traversing the chest, struck against the second rib. 
The handle was removed and the patient recovered. The opening in the 
diaphragm did not heal; and when the examination of the body was made, 
a portion of the abdominal viscera was found in the chest, a fact which ex- 
plained the peculiar gurgling sounds that were often heard in the thorax 
during the life of the woman. 
Penetrating wounds with protrusion.—The degree of protrusion will be de- 
termined by the extent of the parietal wound. The omentum, from its 
extent, and the small intestines, from their mesenteric attachment, having 
the greatest latitude of movement, are peculiarly prone to escape. I have 
seen large portions of the bowels force themselves through a very small 
aperture in the abdominal walls. These accidents not unfrequently follow 
fights in which one or other of the parties is cut with a knife. 
Treatment.—When the case is one of simple protrusion, without intes- 
tinal or omental injury, the parts should be returned into the abdomen with 
the least possible delay. It should not be forgotten that every moment the 
viscera remain outside of their normal cavity exposed to the air, the danger 
of inflammation is increased. It is not uncommon in wounds received in 
street encounters to find the parts soiled with dirt and particles of gravel. 
All such matter must be carefully removed by the douche. The water should 
be warm and carbolized (one to forty), and may be applied by being squeezed 
from a sponge or thrown from the nozzle of a syringe, the displaced viscera 
at the same time resting on soft carbolized towels or flat carbolized sponges. 
It is not always an easy task to restore the protruded structures. They may 
* Boston Medical and Surgical Journal, vol. xxii. p. 71. 
t Ibid. PENETRATING WOUNDS WITH PROTRUSION. 
433 
be constricted by the edges of the wound and refuse to recede. Under such 
circumstances the body should be bent or flexed so as to relax the parietes 
and admit of the widest separation of the opening. To secure the full value 
of this position, either the fingers or retractors should be inserted on each 
side of the wound and the walls of the body be well drawn forward. Should 
the difficulty consist in the intestines being distended with gas, the gut must 
be gently compressed between the thumb and finger, in order to force the 
air into that part of the bowel which is within the abdomen; if successful, 
the collapsed tube can be readily replaced. The gas may be removed also 
by making minute punctures in the intestine with a needle, though the 
practice is not to be commended. If these different plans fail, the wound 
should be enlarged with a probe-pointed bistoury, the intestine at the same 
time being guarded by the fingers against injury. 
Where the wound is large, and when several coils of intestine have escaped 
and become filled with air, much difficulty is often experienced in consequence 
of the involuntary efforts of the patient extruding them as often as they are 
returned. The remedy in such cases is the use of an anaesthetic preliminary 
to efforts at reduction. On retuiming the prolapsed viscera, the omentum 
should have precedence of the intestine, when both are present. If reduced 
together or in mass, there is danger of the bowel becoming so entangled in 
the folds of the omentum as to create obstruction or strangulation. This 
was the case in two instances which I can recall. 
It is worthy of notice that the intestines in being restored are sometimes 
forced between the parietes and the reflected peritoneum, an error which may 
be readily committed, and which is best avoided by following the receding 
mass with the fingers and ascertaining in this way that the wound is entirely 
clear of obstruction. Should a portion of the omentum be strangulated in 
the wound for some time before application is made for relief, it will in all 
probability be found adherent to the circumference of the opening, and per- 
haps its vitality destroyed. Whether this last be the case or not, it will be 
obviously improper to attempt its reduction. Such adhesions cannot be 
broken up with impunity, and if this were done, to restore a mass of de- 
teriorated structure after so long a sojourn outside of its normal cavity 
would be only to cast a firebrand into the abdomen. The protruded portion 
should be surrounded with a ligature on a level with the parietes, and the 
mass cut away, allowing the stump to cicatrize in the wound in case the 
use of antiseptics has been omitted, otherwise the stump may be turned into 
the abdomen. I have removed large portions of the omentum in this way 
with entire success. After the reduction of the intestines the wound must 
be carefully examined, and any vessels requiring ligature are to be secured. 
Next in order is the closure of the divided parts ; and here the rule to include 
all the structures which have been severed applies with increased force. It 
was some time before I could accept this method, believing that the perito- 
neum was so resentful of irritation that the prick of a needle must tend to 
kindle inflammation; but I have long since learned better, and now know 
that to neglect its inclusion with the other components of the abdominal 
walls is to leave the patient exposed to the very evil which it is vital to avoid. 
The sutures—which should be silver, silk, carbolized catgut, or silk-worm-gut, 
must accordingly be carried through all the layers, including the peritoneum, 
and in sufficient numbers to bring them together, thus obviating 
any vacuities that might otherwise remain in the cellular tissue which con- 
nects the peritoneum to the parietes, and thereby preventing interstitial ex- 
travasation. The additional treatment, including dressings, position, and 
constitutional management, does not differ from that described under non- 
penetrating wounds. 
Rupture of the abdominal walls without the integument being broken.—This 
injury is not common, but may exist without lesion of the abdominal con- 
tents. The causes which produce such a rupture are falls, the passage of 
wheels, tetanus, etc. Professor Da Costa witnessed the case of a cavalryman 434 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
who, in consequence of a fall from his horse, had the left rectus muscle torn. 
The umbilicus protruded very much as the effect of the injury. A painter 
was brought into my hospital ward having fallen from a second-story window 
upon the pavement. lie was restless, pale, cold, and almost pulseless. There 
was no wound of the integument, but on the left side of the abdomen, a 
little above Poupart’s ligament, there was a marked bulging, very resonant 
on percussion, yielding a gurgling sound, and which I regarded as a portion 
of the intestine that had passed through a rent in the broad muscles. A 
post-mortem shortly after his admission verified the existence of this lesion. 
Pollard* gives a case of rupture of the rectus muscle in a hospital patient 
who fell against a bed-post; and the same author thinks that in such in- 
stances there may have existed a previous muscular degeneration predis- 
posing to a lesion of this nature. The symptoms of rupture are very much 
the same as those of internal hemorrhage, though it does not necessarily 
follow that much blood is lost. The face is pale, the pulse small and feeble, 
the skin cold and clammy; there is a sense of extreme prostration, accom- 
panied with anxiety, restlessness, and tossing about of the patient. 
Treatment.—In order to bring about reaction, external warmth should be 
applied, and wine or brandy administered internally. I do not attach any 
importance to the use of milk, beef-tea, or other articles of liquid nourish- 
ment. In the condition of shock they are not appropriated, and, lying in the 
stomach, do more harm than good. Stimulants also remain without being 
absorbed, and for this reason should be exhibited in small amount and at 
considerable intervals. Should the patient survive for any length of time, 
it may be necessary to cut down and restore the intestine. Such an oper- 
ation would have been demanded in the above-mentioned case which came 
under my care, had death not taken place early, as the rent had produced 
strangulation of the bowel. If by position and taxis the intestine can be 
restored, and retained by a compress and bandage, such a plan should be 
adopted in preference to an operation ; but if not, there is no reason why the 
skin should not be divided, the constriction relieved, the bowel reduced, and 
the parts united by deep sutures, which will conduce to establish a stronger 
bond of union than that which results from cicatrization without sewing. 
Foreign Bodies in the Stomach.—Foreign bodies frequently enter the 
stomach, either by accident or design. Writers have divided these bodies 
into round, flat, pointed, and irregular. The division is one of practical im- 
portance. Eound bodies, as bullets, marbles, or pebbles, are often swallowed 
by boys for amusement. Coins also not unfrequently are swallowed in the 
same way, or by accident. I have known a person to swallow seven or eight 
bullets as a piece of entertainment for some companions. Knives, forks, pins, 
and hair have also slipped into the stomach, both with and without the con- 
sent of the patient. The insane are much given to the habit of bolting bodies 
of an unusual character. A case is reportedf in which a soldier was shot 
in the abdomen, the ball entering the stomach, in the cavity of which it was 
found. Bodies like pins or needles, if they succeed in reaching the stomach, 
may make their way through its walls and travel to distant points, much in 
the same manner as when broken in external parts of the body. In this 
way may be explained the presence of certain foreign substances in unusual 
situations. 
Eound bodies make their way out of the stomach and through the in- 
testinal canal more easily than those having an angular, elongated, or irregu- 
lar shape. Articles of unusual size and form will succeed in passing the 
pylorus. In one or two instances the foreign body has perforated the stomach, 
as in Eddy’s case, and been extracted through the abdominal parietes. Bodies 
pass the pyloric orifice of the stomach which, independent of observation, 
we could scarcely credit. I published, some years ago, a very remarkable 
* Holmes’s System of Surgery, vol. ii. p. 629. 
f Surgical History of the War, Part II. vol. ii. FOREIGN BODIES IN THE STOMACH. 
435 
ease of presence of foreign bodies in the intestines. It occurred in a female 
subject which I was examining in the dissecting-room of the Philadelphia 
School of Anatomy. Scattered along the intestinal canal from the jejunum 
to the rectum were found the following articles: three spools of cotton, the 
thread partially unwound; two roller bandages, one two inches and a half 
wide and about one inch thick, while the other had become partially unrolled, 
one end being in the ileum and the other in the rectum; a number of skeins 
of thread, a quantity being packed tightly in the caecum ; and, finally, a pair 
of suspenders. I afterwards learned that this woman had been insane. 
Mr. Bryant speaks of a stomach, very much thickened, in Guy’s Hospital 
Museum. It was that of a sailor who had been in the habit of swallow- 
ing clasp-knives. This man had at different times disposed in this manner 
of no less than twenty knives. Finally the blade of one perforated the colon 
and destroyed his life. Several blades were found, partially eroded, in the 
stomach. 
Doran mentions an instance of a woman in whose stomach nine ounces 
of pins were found, and Hager* reports a case of a Polish woman who 
carried for five months in her stomach twenty iron nails, seven iron sash- 
bolts, one hundred and one pins, two paternoster beads, and various other 
things. 
Mr. Taylor, of Edinburgh, narrates the case of a patient who swallowed 
an artificial plate with six teeth, which was passed by the anus three days 
afterwards. 
Treatment.—The physician is often applied to by parents in great alarm 
in consequence of a child having swallowed a piece of coin or a marble. 
Though I have known a number of such cases, in no instance can I recall 
any evil consequences resulting from the accident. 
The practice of exhibiting a cathartic immediately after the foreign sub- 
stance has been swallowed is to be deprecated. A body hurried along the 
intestinal tube in the current of glandular secretions, and under the energetic 
peristalsis excited by the purge, may, especially if it be rough, seriously 
damage the mucous and other tunics of the bowel. It should be left for two 
or three days to the physiological processes of the stomach and intestine, 
which generally serve to carry it forward, and at the same time to encase 
it in feculent matter, rendering its surfaces harmless to the bowel, after 
which, if it is not passed spontaneously, a cathartic may be administered 
of such nature as will produce a consistent evacuation, the best being a mix- 
ture of sulphur, senna, and the bitartrate of potash,—half a drachm of each 
being taken in a little syrup, or the compound liquorice powder may be 
substituted. 
When the body is one the passage of which is very improbable, such 
as a knife or fork, and which is liable to produce inflammation, ulcer- 
ation, and perforation of the organ, or to excite a destructive peritonitis, 
the question of opening the stomach and extracting the body will arise. 
When performed for this purpose, the operation is called gastrotomy, from the 
Greek words ya<TTrjp, the stomach, and rifivcu, to cut. 
Operation of Gastrotomy.—This operation was first performed by Florian 
Mathis, a surgeon of Brandenburg, in 1602. When it is contemplated to open 
the stomach, no solid food should be taken by the patient for thirty-six hours 
before the operation, and for six or eight hours not even liquids, in order that 
the viscus may be empty and the risk of extravasation be thereby diminished. 
Even with the possibility of vomiting, it is better to administer ether or 
chloroform, to insure entire quietude. The patient being placed upon the 
back, an incision should be made two or three inches in length, commencing 
at the linea semilunaris, and extending obliquely downwards and outwards 
half an inch below and parallel with the cartilaginous border of the chest. 
After the incision through the integument, the remaining layers, fascial, 
tendinous, muscular, and peritoneal, should be lifted in succession, and divided 
* St. Bartholomew’s Hospital Reports, vol. ii. p. 118. 436 
WOUNDS AND DISEASES OF ARDOMINO-PELVIC CAVITIES. 
upon a grooved director. This done, the right, or pjdoric, extremity of the 
stomach will he brought into view, which should be fixed and retained at the 
wound, either by pinching up a fold with the fingers or by passing a thread 
through its coats. The surgeon then divides the anterior wall of the organ 
in the direction of the external wound to an extent nearly sufficient for the 
extraction of the foreign body, which is best accomplished by a pair of poly- 
pus or gullet forceps. The wound in the viscus should now be closed by 
Lembert sutures, and the opening in the parietes, including the peritoneum, 
united by deep interrupted stitches of silver wire. During the operation 
the utmost care should be observed to prevent either blood or the contents 
of the stomach from entering the sac of the peritoneum. All vessels, there- 
fore, must be tied and the bleeding be allowed to cease before the parietal 
layer of the serous membrane is divided, and an assistant must be ready 
with a soft, warm, carbolated, moist sponge to receive any matters which 
may escape from the organ. The entire procedure should be done antisep- 
tically. 
During the after-treatment the shoulders of the patient should be kept 
somewhat elevated, and the lower extremities flexed over a pillow. No food, 
liquid or solid, must be allowed to enter the stomach for eight or ten days 
after the operation. All nourishment should be administered by the rectum 
during this time. After the lapse of ten days, milk and beef-essence may be 
taken, in small quantities at a time, by the mouth. 
When the object is to establish an artificial opening or gastric fistula, the 
incision through the walls of the stomach will require to be made even 
smaller than in the operation of gastrotomy, and the edges of the opening 
must be stitched to the margins of the parietal wound. (See Gastrostomy.) 
The operation of gastrotomy for the removal of foreign bodies, if we ex- 
clude the cases referred to by Frissac, Bouisson, Garcia, New, and Ewing, 
which have been regarded with suspicion by Otis, has been done twenty 
times, the operators being Mathis, Ilubner, Schwabe, Cayroche, L. Bell, 
Gluck, Labbe, Henry, Bille, Felizet, Schonborn, Thornton, Kocher, Billroth, 
Gussenbauer, Bernays, of St. Louis, Loreta, Polaillon, and Berg. These 
operations resulted in seventeen recoveries and three deaths. In Berg’s 
case, a female, twenty-six years of age, a quantity of hair was removed from 
the stomach. In another case which was reported, two pounds of hair were 
extracted. 
In the case operated on by Polaillon and reported to the French Academy, 
the body, which was a steel fork, was diagnosed by suspending from a thread 
a magnetic needle, which on being brought near to the abdominal walls 
over the epigastric region was distinctly deflected. 
Koch, who has reviewed the literature of gastrotomy, it is proper to say, 
accepts only twelve cases as being unimpeachable,—viz., those of Schwabe, 
Filanus, Bell, Labbe, Kocher, Gussenbauer, Schonborn, Thornton, Billroth, 
Crede, Polaillon, and Richardson. If to Koch’s twelve cases recognized as 
genuine, we add those of Bernays, Loreta, and Berg, of the correctness of 
which there is no doubt, we shall have fifteen cases, with fourteen recoveries 
and one death. 
Pyloric Stenosis.—Coarctation of the pylorus or of the cardiac orifice of 
the stomach as the result of the cicatrization of a gastric ulcer is occasionally 
met with. 
The signs of this condition are great dilatation of the stomach, recurring 
attacks of severe burning pains in the epigastrium, obstinate vomiting of 
food and other matters, and constant thirst. In some instances, if the vis- 
cus lias been thoroughly emptied by the stomach-tube a localized hardness 
may be detected in the region of the pylorus on deep pressure being made. 
Diagnosis.—The disease may readily be mistaken for carcinoma, but the 
chronic course of the induration, the absence of cachexia, and the enor- 
mous dilatation of the stomach should serve to establish the distinction. PARTIAL GASTRECTOMY OR PYLORECTOMY. 
437 
Treatment.—This consists in washing out the stomach daily with a solu- 
tion of borax (grs. xv-xx; water, Oi), repeating the same until the water 
returns clear, and exhibiting peptonized milk and peptonized beef. 
Digital dilatation.—For the cure of pyloric stenosis Professor Loreta, of 
Bologna, has devised the operation of digital dilatation. It is performed 
as follows. On the day of operation the stomach should be washed out, 
at least twice, with the borax solution at an interval of two or three hours. 
After the last lavage, the surface of the abdomen having been thoroughly 
cleansed with a wash of bichloride of mercury (one to one thousand), an 
incision is to be made four and a half or five inches in length, beginning 
at a point about one inch and a half to the left, and one inch below the ensi- 
form cartilage downward and outward, and parallel with the border of the 
ribs on the right side. After dividing the skin, fascia, and muscles, the peri- 
toneum is next opened to an extent equal to that of the first incision, taking 
care first to secure all bleeding vessels. The pyloric end of the stomach being 
now recognized, it is to be drawn through the external wound. Grasping 
the organ near its lesser curvature and just to the left of the pylorus, by 
means of two flat-bladed forceps, the blades of which are covered by some 
soft material in order to prevent injury being done to the organ, the latter is 
next opened between the instruments, and the index or little finger introduced 
and by gradual pressure made to pass through the pyloric opening, dilating 
the same by the introduction of a second finger until the capacity of the 
opening is sufficiently enlarged. The wound in the stomach is to be closed 
by ten or twelve fine catgut Lembert sutures, not including the mucous 
membrane. It is sometimes advised to unite the latter membrane indepen- 
dently by a fine suture. After bringing the edges of the peritoneum together 
by the animal thread, the muscles and the integument are to be brought 
together by deep and superficial sutures, and the dressing completed by 
placing a pledget of carbolized gauze, reinforced by a layer of salicylized 
cotton, over the wound, and encircling the abdomen with a broad bandage. 
Professor Loreta’s first case of pyloric dilatation (a successful one) was 
performed September 14, 1882.* Since that date it has been repeated a 
number of times by its author and by other Italian surgeons, the death-rate 
being, as far as can be ascertained, about thirty-five per cent. The operation 
has been done twice by Dr. Charles MacBurney of New York, in both in- 
stances with a fatal result. Loreta has applied the dilatation to both the 
pyloric and the cardiac opening. The circumstances justifying a resort to 
an operation confessedly attended with great danger would be those in 
which, after washing out the stomach as directed by Dr. Russell, the sup- 
port of the patient by lavements and the introduction of peptonized food 
into the stomach had failed to furnish the necessary nutrition. 
Partial Gastrectomy or Pylorectomy.—This operation, suggested by Merrein 
and subsequently advocated by Gussenbauer and by Winiwarter, was first 
carried into effect by Pean in 1879, by Rydygier in 1880, in both cases unsuc- 
cessfully, and by Billroth successfully in 1881. Excision of the cardiac end 
of the stomach has been done once by Dr. Lane, of California, but unsuccess- 
fully. The operation has been done chiefly for the removal of carcinoma 
of the pylorus. 
Operation.—The preliminary steps of the operation are the same as in 
that for the relief of pyloric stenosis, differing only in a single particular, the 
incision commencing below instead of one inch to the left of the ensiform 
cartilage. The right extremity of the stomach, after exposure, is to be drawn 
through the abdominal wound and held by a soft towel wet in warm carbo- 
lized water. The surgeon now proceeds to separate the pylorus and growth 
from its omental attachments, lesser and greater, every vessel being tied in 
two places by passing round each a curved needle armed with an aseptic 
silk thread, and cutting between the ligatures. This done, a flat sponge 
* The first operation has been claimed for Schede, in 1877, and Richter, of Berlin, is credited with 
having first suggested the procedure. 438 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
wrung out of carbolized hot water is to be placed underneath the pylorus 
and duodenum. In removing the diseased portion of the organ the scissors 
will be found to be the best 
instrument for the purpose. 
The incision should be made 
a short distance beyond the 
limits of the disease, and by 
cutting from above down- 
wards, and from left to right, 
leaving the lower third of the 
organ undivided. The result- 
ing wound is then closed by 
the Woelfer modification of 
Czerny’s sutures. By this 
method two rows of stitches 
are introduced, thus giving 
great security to the sew- 
ing. The first or innermost 
series include only the muscular and peritoneal coats, and are introduced 
from within outward, and when tied bring together the cut edges of the 
wound ; the second series are passed from without inward, also including the 
two external tunics, constituting the ordinary Lembert suture, and when tied 
invert the parts, bringing the serous surface in contact. The sutures should 
be inserted less than one-eighth of an inch apart. The divided portion of 
the pylorus being closed (Fig. 356), the remaining third may now be severed, 
and likewise the duodenum 
on the opposite side of the 
growth. The operation is 
completed by bringing the 
two portions of the canal to- 
gether and joining them by 
sutures similar to those de- 
scribed above. (Fig. 357.) 
The parts being returned into 
the abdomen, the external 
wound is closed by inter- 
rupted sutures, and the re- 
maining part of the technique 
carried out by means of the 
ordinary antiseptic dressings. 
Mikuliez has collected 32 
cases of pylorectomy, with 
only 8 recoveries from the 
operation. Winslow has analyzed 61 cases of the operation, of which num- 
ber 44 died and 16 recovered. 
Considering the fearful mortality following pylorectomy, and the nature 
of the disease for which it is usually done, I doubt very much if the oper- 
ation comes within the sphere of legitimate surgery. 
Gastro-enterostomy.—This operation consists in establishing a communica- 
tion between the stomach and some portion of the small intestine, usually 
the duodenum or the jejunum,—the object being to support life in carcinoma- 
tous disease of the pylorus of an aggravated character. The first operative 
steps for gastro-enterostomy are the same as for pylorectomy, except that, the 
preliminary division of the parietes should be made about one inch farther 
to the right. After the stomach has been exposed it should be seized and 
drawn out of the external wound. Displacing the omentum, the nearest 
loop of intestine, preferably the duodenum or the jejunum, is next caught 
and drawn out in like manner, and its contents carefully displaced by ma- 
nipulation, its empty condition being then maintained by two india-rubber 
Fig. 356. 
Attaching the duodenum to the stomach. 
Fig. 357. 
Pylorectomy with sutures introduced through the divided portion 
of the pylorus. GASTROSTOMY. 
439 
bands, half an inch in breadth, passed through the mesentery and round the 
bowel, and tied with moderate firmness. An incision one inch in length 
is now made longitudinally on the anterior surface of the stomach about 
two inches from its greater curvature, and a similar one on the free border 
of the intestine. The connection between the two is next made by two 
rows of the modified Czerny’s suture as done in pylorectomy. The first 
row of stitches is introduced through the lower edge of the opening in the 
stomach and the corresponding part of the intestinal incision, and of course 
on the side of the cut surfaces. After thus completing the semi-circum- 
ference of the wound, the intestine is turned over and the second row of 
sutures (Lembert’s) introduced. (Fig- 358.) Before restoring the parts to the 
abdomen, the loop of in- 
testine should be stitched 
to the stomach for a short 
distance on each side of 
the communication. This 
is done to prevent any 
sharp angulation be- 
tween the stomach and 
the intestine by dragging 
of the latter, a condition 
calculated to produce ob- 
struction. This opera- 
tion of gastro-enteros- 
tomy was introduced by 
Surmay, and has been 
practised by Langen- 
buch, Robertson, South- 
am, Wolffer (the first to 
operate, in September, 
1881), Bydygier, Monas- 
tyrski, Billroth, Pearce, Ogston, Gould, and others. Winslow and Ashhurst 
have collected 22 cases of gastro-enterostomy, showing 7 successes, 1 partial 
success, and 14 deaths. Though in many respects a more justifiable operation 
than pylorectomy, yet if the mortality cannot be reduced it will probably, 
especially when done for malignant disease of the pylorus, receive but little 
favor among conscientious surgeons. 
Gastrorrhaphy is an operation designed to close any opening through the 
walls of the stomach. It has been practised in cases of wounds, fistula, and 
perforating ulcers of the organ, and in cases belonging to the first and the 
last category offers the patient the only chance of life. 
The operation does not differ from that of gastrotomy, which has been 
already described, and for which it is only another name. 
Gastrostomy.—This operation, devised by Egebert, a Norwegian military 
surgeon, in 1837, and first performed by Hedillot in 1846, is intended to es- 
tablish a fistulous opening between the stomach and the abdominal walls for 
the introduction of nourishment when the oesophagus has become perma- 
nently obstructed by stricture or morbid growths. 
Operation.—An incision is made on the left side four inches in length and 
one inch below and parallel with the costal border of the thorax, dividing 
the different strata of tissues in order until the peritoneum is reached. After 
all bleeding has been arrested, this membrane is divided and its edges stitched 
to the integument on the entire circumference of the wound. The stomach 
is next seized and drawn into the opening, and a series of stitches, arranged 
circularly, so as to enclose a space the size of a quarter of a dollar, is intro- 
duced through the peritoneal and muscular coats, then through the integu- 
ment, and firmly tied. These sutures bring the two peritoneal surfaces, 
that of the stomach and that of the abdominal parietes, into close contact. 
Next, in order to effect a similar apposition of the serous surface of the 
Fig. 358. 
Duodenum united to the stomach. 440 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
stomach with that portion of the peritoneum which lines the surface of the 
wound, a second row of sutures is inserted within and opposite to the in- 
tervals of the first and externally through the skin. The external wound is 
now closed up to the space occupied by the circular rows of stitches and 
dressed antiseptically. 
Where the necessity for food is urgent, the exposed surface may be punc- 
tured with an aspirating needle and nourishment introduced through the 
canal of the instrument. In the course of three or four days the adhesion 
between the organ and the abdominal walls will be complete, thus sealing 
off the peritoneal cavity from the exterior, when it will be proper to open 
the stomach with a sharp-pointed bistoury sufficiently to admit of the intro- 
duction of a rubber tube about one-quarter of an inch in diameter and having 
a broad shoulder to prevent its slipping into the organ. 
The early operations of gastrostomy were exceedingly fatal. According 
to Lesas, 1 out of 31 cases recovered. After the introduction of anti- 
sepsis, according to the same author, there were 28 recoveries in 132 cases. 
The mortality, as might naturally be anticipated, depended on the character 
of the disease for which the operation was done: thus, in 28 cases subjected 
to this procedure for stricture of the oesophagus, inflammatory and syphilitic, 
12 recovered. Professors Gross and Ashhurst have tabulated 250 cases of 
gastrostomy, giving 158 deaths, or a mortality of 74 per cent. Dr. Porter, 
of Wayne, Indiana, has recently performed the operation successfully. Ex- 
cept in cases of impermeable stricture of the oesophagus of a non-malignant 
character, gastrostomy should not be advised. 
Penetrating Wounds implicating the Viscera.—Wounds of the Stomach.— 
The epigastric region is a dangerous locality in which to receive injuries. A 
blow applied here with much force has frequently been followed by death 
without, it is said, any appreciable lesion. This is possible, owing to the 
proximity of the great solar plexus; though I doubt not that, if a careful 
examination had been made in such fatal cases, in most of them, at least, 
sufficient visible explanation would have been found for the unfortunate 
result. I was once called to see a miller who had been thrown violently 
from a horse, striking the abdomen just below the sternum against the 
corner of a wall. Though greatly shocked, he was able to rise and walk 
three-fourths of a mile to his home, where he died in a few hours in an agony 
of pain such as I have never witnessed in any other case during all my pro- 
fessional life. There was no abdominal distention or tenderness, no marked 
pallor or moist cold skin, no vomiting or hiccough, nothing indeed to indicate 
extravasation, hemorrhage, or peritonitis; and yet 1 cannot doubt that the 
man had a rupture of the stomach. So dangerous are injuries of this region 
that even in the pugilistic ring it is considered foul” to plant a blow below 
the belt. 
The danger is enhanced if at the time of receiving an injury the stomach 
is distended with food or gas. Dr. Collins* narrates the case of a boy who 
fell twelve feet shortly after eating a hearty meal, producing a rent two 
inches long on the anterior surface of the stomach near the pyloric extremity, 
which proved fatal in nine hours. Mr. Bryant records an instance of rupture 
of the mucous membrane of the stomach of a child seven years old, produced 
by a blow when the organ was distended with food. 
Rupture sometimes follows the distention of the organ after eating a liberal 
meal, in consequence of the coats having been eroded from a carcinomatous 
ulcer. A paper-hanger who had for several years suffered from dyspeptic 
symptoms, after taking breakfast left his house in his usual health, to enter 
upon the duties of the day. lie had scarcely passed the yard gate when he 
fell to the ground as though shot by a pistol-ball. On my visit a few hours 
after the accident, in consultation with his physician, we found him pale, 
cold, vomiting, and almost pulseless, with distended abdomen, and suffering 
* Boston Medical and Surgical Journal, vol. lxxiii. p. 202. WOUNDS OF THE STOMACH. 
441 
intense pain. The opinion entertained at the time was that the stomach had 
been ruptured from cancerous ulceration. The autopsy established the cor- 
rectness of the opinion. A contusion of the stomach may be followed by a 
circumscribed slough, the separation of which, several days after the injury, 
will probably be followed by a sudden and unexpected death. 
Symptoms of rupture of the stomach.—The signs which indicate such an acci- 
dent are extreme prostration, intense pain, and vomiting of blood together 
with other matters. In the course of a few hours the features shrink, the 
face assumes a Hippocratic expression, the abdomen becomes tender, the 
patient lies upon the back, with the thighs drawn up, indisposed to make 
the slightest movement; the pulse is feeble and frequent, the skin cold and 
clammy ; in fine, all the symptoms of intense peritonitis are present, the scene 
closing with retching, hiccough, and death. 
Incised, punctured, and gunshot wounds of the stomach are generally 
fatal, though there have been a few instances of recovery, so that we need 
not utterly despair in such cases. Every one is familiar with the case of 
Alexis St. Martin, whose stomach, by means of a gastric fistula, has en- 
lightened physiologists so much on the subject of digestion. This man 
still lives, and enjoys good health at the age of about eighty }rears. Physick* 
relates the case of a man who was under the care of Dr. Archer, of Mary- 
land, who, shortly after a hearty meal, received a wound of the stomach two 
inches long, through which passed meat and cabbage. In the absence of 
medical assistance at the time, a shoemaker sewed up the opening in the 
parietes. This was subsequently opened, and the patient made a good re- 
covery. Dr. Peters,f of the United States Army, reports the case of Private 
Bowers,J who received a shot wound of the stomach at South Mountain, 
which wound discharged for two months through a fistulous opening in the 
abdominal walls, but afterwards healed. In an aggregate of one thousand 
and seventy-two shot wounds of the abdomen, the stomach was implicated 
seventy-two times during our recent war. Guthrie records several cases of 
cure of wounds of the stomach. The cause of death after such injuries is 
extravasation into the peritoneum, followed by shock and exhaustion. It is 
a curious fact that, in exceptional cases, the contents of the stomach do not 
escape, although the viscus may be filled with food. Dr. R. K. Smith § saw 
a wound one inch in length at the cardiac end of the stomach, and, though 
the organ was full at the time, there was no extravasation or vomiting, though 
the patient lived twenty-six hours. An occurrence of this kind is probably 
due to paralysis of the muscular coat, which often follows wounds of the 
hollow viscera and arrests their movements. 
Symptoms.—The signs of a wound of the stomach are shock, pain, abdom- 
inal distention, vomiting of blood and other matters, prsecordial distress, and 
hiccough. The least equivocal of these are vomiting of blood, pain, and col- 
lapse ; and when these are associated with the escape of the contents of the 
stomach through the external opening, the nature of the accident admits of 
scarcely a doubt. 
Tbe establishment of a fistulous opening very commonly follows, should 
the patient survive the injury sufficiently long. 
Treatment. — If the stomach protrudes, the wound should be sutured 
and the organ restored to the abdominal cavity after the manner described 
in detailing the treatment of intestinal protrusion. The external opening 
being closed, as in parietal wounds, the patient is to be kept upon the 
back, with the shoulders and limbs elevated, and both the general system 
and the peristalsis of the organ kept quiet by the subcutaneous use of 
morphia or by suppositories of opium. The patient may be allowed broken 
pieces of ice, but no nourishment should be administered by the mouth 
for at least eight or ten days, the strength in the mean time being sustained 
by enemata of milk, beef-essence, and brandy. The urine should be drawn 
* Gibson’s Surgery. 
J Ibid., vol. ii. p. 46. 
f Surgery of the War, Part II. vol. ii. p. 42. 
§ Medical Examiner. 442 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
with the catheter, and no efforts at defecation should be allowed for ten 
or twelve days. 
Where no protrusion of the organ exists, and yet the evidences of a wound 
are present, shall the seat of injury be sought after and the stomach be drawn 
out and sutured and the cavity washed out ? This of course will be the proper 
practice: even a careful search, made with due gentleness, will be allowable. 
Should the wound of the organ be found lying against the external opening 
and the contents passing through, it has been debated whether to leave it 
undisturbed, to stitch it to the margins of the abdominal opening, to enlarge 
the external wound, or to draw it forward, sew, and return. When the 
wound does not exceed one inch in length, and has been seen within twenty- 
four hours, the viscus should be drawn out, stitched, and restored to its 
cavity, provided no adhesion has taken place between the peritoneal surface 
and that of the parietes. When much larger, it will be wiser to stitch it to 
the external opening; and if thirty-six hours have elapsed without symp- 
toms, it is better to leave it to natural processes, as by that time adhesion 
between the margins of the wound and the parietes will have commenced. 
Whenever there has been escape of the contents of the stomach into the 
peritoneal cavity, the latter should be sufficiently exposed to admit of all 
such extravasated matters being removed by enlarging the wound in the 
parietes, if that be necessary for the purpose. The fluid to be employed for 
cleansing the cavity in such cases is either hot water or water medicated 
with boracic acid (grs. v. to water gi) or with corrosive sublimate (one to 
ten thousand), and should be thi’own in with a Davidson syringe, at the same 
time allowing it to flow out without obstruction. This is often best favored 
by turning the patient on the side. In removing the last portions of the 
fluid, aseptic sponges held in the grasp of long forceps will be necessary in 
order to reach the pelvic basin. 
The Surgical Records of the late American War furnish 11 cases of punc- 
tured and incised wounds of the stomach treated by suture, some without 
and others with enlargement of the external wound, 10 of which recovered 
and 1 died. 
These injuries are prone to terminate, should the patient live sufficiently 
long, in gastric fistula. A number of such cases were noticed during our late 
war. These openings may reinain permanent, as in the case of Alexis St. 
Martin, or gradually close, as in the one recorded by Dr. Peters. When 
there is a natural tendency to cicatrize, it may be facilitated by occasionally 
pencilling the orifice with a crayon of nitrate of silver. 
Rupture of the Omentum and Mesentery is a very unusual accident. It 
may occur without any external lesion other than contusion of the abdom- 
inal walls from violence. Through a rent in either of these structures a por- 
tion of intestine may slip and cause strangulation at some future time by 
contraction of the sides of the opening. Though hemorrhage must neces- 
sarily follow a lesion of the above nature, whether in the mesentery or in 
the omentum, yet the bleeding will be more profuse in rupture of the former 
membrane, in consequence of the great size of its vessels. 
The signs of the injury will be such as characterize internal hemorrhage, 
though diagnostic certainty is not possible. If death does not follow the 
lesion in a few hours from hemorrhage, it will be likely to take place after a 
time from peritonitis or from suppuration. 
Treatment.—Laparotomy should be performed when the signs of internal 
hemorrhage continue, and the damaged vessel or vessels sought for and tied. 
Rupture of the Intestine.—A blow or fall upon the surface of the abdomen 
will sometimes produce a rupture of the intestine without any external lesion. 
The probability of such an accident is increased if at the time of receiving 
the injury the bowel is distended with flatus. Dr. E. K. Sanborne, of Lowell, 
Massachusetts, records a case of rupture occurring in an adult, who was RUPTURE OF THE INTESTINE. 
443 
struck on the abdomen by the handle of a hand-cart and at the same time 
pressed against a wall. The man was able to wheel his cart across the yard, 
but was immediately afterwards seized with intense pain, and died in forty- 
six hours. The autopsy revealed a rupture extending not only through the 
entire gut, but also one inch into its mesenteric attachment. 
I)r. (I. W. Otis witnessed an instance of rupture of the ileum, produced by 
a blow over the right iliac region from the fist of a fellowT-workman, from 
which the patient died in twenty-four hours ;* and another case has been re- 
ported by I)r. Cabot,f in which a young man, aged nineteen, was kicked in 
the abdomen by a horse and died in twenty-eight hours, the jejunum having 
in it a rupture one inch in length. The portions of the small intestine usually 
ruptured are the jejunum and the ileum, rarely the duodenum. The caecum is 
most liable when the injury is located in the large bowel. In a collection of 
sixty-three cases of rupture of the intestine, by Poland, the large intestine 
suffered only five times. Instances are recorded in which the peritoneal coat 
of the intestine has been alone ruptured, either from external violence or 
from extreme flatulent distention. 
When rupture of an intestine takes place, it is followed by extravasation 
of its contents and by hemorrhage into the peritoneal sac. 
Chavasse, a surgeon in the French Army, has collected one hundred and 
forty-nine cases of contusion and rupture of the intestines without wound 
of the abdominal walls, produced, as far as ascertained, thirty-six times, by 
kicks from horses, twenty-three times by the passage of wagon-wheels over 
the body, and thirteen times by kicks from men. Fourteen of these rup- 
tures were complete; but in no instance was such a laceration found in the 
large bowel. In order of frequency the sigmoid flexure of the colon suf- 
fered most frequently, the caecum next, and then the ileum and jejunum. 
The mortality from these injuries was 96 per cent. 
Symptoms.—The symptoms which follow rupture of the intestine are not 
unlike those which indicate a similar injury of the stomach. These are in- 
tense local burning pain, a slow and feeble pulse, pallor, and vomiting. The 
abdomen, though not swollen, soon becomes tender, and towards the last is 
distended; the features shrink, the face assuming a Hippocratic appearance ; 
the strength rapidly fails, and death usually follows in from twenty-four to 
thirty hours. 
The post-mortem appearances are those of a rapidly-developed peritonitis. 
The intestines are deeply injected, covered with patches of lymph, their con- 
volutions glued together at different points with plastic matter, and the peri- 
toneal sac containing frocal matter, and a blood-stained, dirty, or greenish 
fluid, in which float particles of exudation. Upon opening the abdomen an 
exceedingly fetid gas sometimes is discharged, a single inhalation of which I 
have known to induce a degree of poisoning from which the person did not 
recover for several weeks. 
Rupture of the peritoneal coat alone, it is thought, can be diagnosed from 
that which involves the entire thickness of the intestinal tube. In the former, 
vomiting is absent; in the latter, it is present: in the former, the patient is 
exceedingly restless and constantly changing place in the bed; in the latter, 
the position is a fixed one. The pain is also less severe in the incomplete 
than in the complete rupture. 
Treatment.—When the intestine is torn, little can be done by the usual 
practice, except to mitigate suffering by the use of opium in some of its 
forms, given by the mouth, by the rectum, or hypodermically. Hot fomen- 
tations will aid in alleviating the distress, and a little brandy-and-milk may 
be given from time to time. 
So hopeless, however, are these cases under this method of treatment, that 
when a reasonable degree of certainty exists as to the nature of the injury, 
the surgeon should feel it to be his duty, at least in the early stage of the 
injury, to open the abdomen and wash out, by a continuous stream of water, 
* Boston Medical and Surgical Journal, vol. ii. p. 7. 
f Ibid., vol. Ivi. p. 498. 444 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
all extravasated matters and dress the wounded bowel in the usual manner, 
observing, of course, every antiseptic precaution. 
Perforation of the intestine, such as occasionally takes place in enteric 
fever, may occur and yet possibly the patient survive. This was believed 
to be true in the case of a prominent surgeon of Philadelphia; but such re- 
coveries are so phenomenal that they should have no influence in preventing 
a resort to operation. 
Penetrating Wounds of the Intestines without Protrusion.—These wounds 
may be incised, lacerated, punctured, and gunshot. In looking into the ab- 
domen when its anterior wall is opened, and observing how closely the con- 
tents are packed together, it would seem impossible that any body should 
enter or pass through the cavity without inflicting a fatal injury; and yet 
there are not wanting instances in which it has been traversed without any 
harm to the viscera resulting. This I can understand when the vulnerating 
body is blunt; but when it is sharp-pointed, like a bayonet or a sword, or 
when the missile is a ball, such harmless passage is to me so incomprehen- 
sible that I cannot assent to those marvellous cases which are recorded, 
believing that some error must have existed. 
The manner in which the intestines are convoluted or coiled renders them 
exposed to multiple wounds. 
The jejunum and ileum suffer most, in consequence of the large space which 
they occupy in the abdomen. 
Whilst all intestinal wounds are very fatal, those of the large intestine are 
less dangerous than those of the small. This is due to three causes : first, to 
the absence in the former, at certain portions, of a peritoneal covering, as in 
the posterior surface of the ascending and descending colon ; second, to fixed- 
ness of position ; third, to the comparatively solid nature of its contents. The 
effect of mobility and extensive peritoneal investment is well illustrated by 
the fact that wounds of the transverse are more fatal than those involving 
either the right or the left colon. Forty-one cases of wounds of the colon 
during our late war are known to have recovered. Injuries implicating 
the caput coli and the descending colon furnished the largest number of 
recoveries. 
Balls and other bodies sometimes enter the intestine and are voided by 
stool. In most cases it is doubtless the colon into which the missile passes. 
Dr. Forbes* reported two very interesting cases of this kind. In one a ball 
entered the chest just above the right nipple, and, from the direction in which 
it was fired, most probably wounded both the lung and the liver. The patient 
expectorated a bloody sputum. Eighteen days after, the ball, weighing fifty 
grains, was passed at stool. The second case was that of a lad who was shot 
by his companion in the abdomen, the pistol being charged with gravel-stones. 
Ten days subsequent to the injury, the boy passed four of these stones by 
stool. Both patients recovered. 
Small wounds of the bowel are not necessarily followed an escape of its 
contents. Three conditions follow, which offer an obstacle to such a result, 
viz., a temporary paralysis of the muscular coat; a contraction in the sides 
of the wound, reducing materially its size, as shown by the experiments 
of Professor Gross; and a protrusion of the mucous membrane acting as an 
obturator. In the case of a Ute Indian who died in my hospital ward from 
chronic diarrhoea the result of extensive ulceration of the colon, a perfora- 
tion in the duodenum the size of a quarter-dollar existed, which was so com- 
pletely closed by the prolapsed mucous membrane that nothing had escaped 
from the bowel. 
The fatality of penetrating wounds of the abdomen is very great. The 
records of our late war exhibit a mortality of 87.2 per cent., 3031 having 
died out of 3717 cases, the undetermined cases being rejected. Taking into 
account all wounds of the belly where the result was ascertained, 3227 died, 
* Transactions of the Philadelphia College of Physicians, 3d Series, vol. ii. p. 183. PENETRATING WOUNDS OF THE INTESTINES. 
445 
or 48.2 per cent.; and of those positively known to be intestinal wounds, 9 
in every 10 were fatal. The analysis of 3134 flesh wounds yielded a mor- 
tality of 25.3 per cent. This is certainly too high a death-rate, and is so 
regarded by Dr. Otis, who explains it as being due to the inclusion in the 
estimate of 1000 cases the result of which was not known.* 
Symptoms.—Among the most constant signs of a wounded intestine with 
extravasation are meteorism and the passage of blood, followed by pain, peri- 
tonitis, a quick and feeble pulse, coldness of the surface, a dorsal decubitus, 
rapidly failing strength, and hiccough. The escape of fajcal matter externally, 
which sometimes follows incised wounds, is a still more significant sign; in 
this case the damaged portion of the intestine generally lies at the opening 
in the parietes. 
Resonance after abdominal injui’ies must not be regarded as decisive of an 
intestinal wound. Spinal shock is followed by the same phenomenon, from 
enfeeblement of the muscular walls of the bowel. After wounds of the ab- 
domen, air may be discovered in the walls as well as in its cavity. There 
are two ways in which this can occur: first, the air may escape from a 
wounded bowel, and, in addition to entering the cavity of the peritoneum, 
may find its way between the parietal peritoneum and the transversalis mus- 
cles, spreading through the subperitoneal connective tissue and gradually 
reaching the subcutaneous tissue; second, the air may enter from without 
through the external wound, and be disseminated between the laminae of the 
parietes. It will be recognized, when so situated, by the crackling or crepi- 
tating sensation communicated to the fingers on pressure. Erichsenf mentions 
a case of emphysema following a puncture of the bladder through the rectum. 
The air entered the subperitoneal connective tissue, and passed through the 
isehiatic openings, and down upon the back of the thigh. 
Professor Senn, by a very ingenious device, has enabled us to determine 
with almost absolute certainty the existence of an intestinal wound by in- 
sufflating the bowels with hydrogen gas, introduced through the rectum. The 
gas is forced into the intestines from a rubber bag under a pressui*e of two 
pounds, and in case of perforation escapes through the opening into the 
bowel and through the external wound, whei-e it may be l'ecognized by the 
odor and ignited into a flame by the application of a taper or a match. 
Treatment.—The propriety of enlarging the parietal wound and seeking 
for the damaged intestine, in order to unite its edges by suture, and at the 
same time to remove all extravasations, was sti’ongly urged by Professor 
Dugas, of Georgia, in a paper read before the International Congress at 
Philadelphia in 1876.| He thinks that death in such wounds is oftener the 
result of septicaemia than of peritonitis,—a conclusion in which I do not 
concur. 
The reasons which have been urged for non-interference in such eases are, 
first, the uncertainty as to the injury sustained by the abdominal contents 
until the development of those inflammatoiy changes which no opei'ation 
could improve; second, the danger of distux-bing adhesions which constitute 
the safety of the patient (the death of Fisk, who was shot by Stokes, in New 
York, it is alleged was due to meddlesome explorations); and, third, the in- 
ci’eased l’isks of peritonitis by further incision of the peritoneum and by 
handling the intestines in search of the supposed wounds. 
Of the propriety of performing laparotomy in these cases, however, there 
can be no doubt. It is only remarkable that we should have been so long 
content to stand by and, under the influence of unquestioned precedent, see 
patients perish without an effort to remove the cause of death. Yet there is 
a wonderful fitness of things in this world. Inventions and discoveries are 
the offspring of the wants of social and economic life. Until the latter be- 
come a necessity, the former make no sign. Laparotomy was the logical 
sequence of antisepsis. In all cases, therefore, of penetrating wounds of the 
* Surgical History of the War, Part II. vol. ii. p. 202. 
f Erichsen’s Surgery, vol. i. p. 560. 
J Transactions. 446 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
abdomen, where from the nature of the vulnerating body there is reason to 
believe that the intestine has been wounded, it is unquestionably the duty 
of the surgeon to open the abdomen and search for the lesion; and the same 
course may be said to be proper in cases where the signs point to the exist- 
ence of internal hemorrhage. 
The median incision is to be preferred in all cases of shot wounds, as it 
gives the most perfect access to the different parts of the abdomen. 
Where the surgeon does not see the case until eight or ten hours after the 
occurrence of the accident, and finds the contents of the bowel discharging 
through the parietes with no symptoms of peritonitis, any attempt to draw 
it out, either with or without enlarging the wound, in order to apply sutures, 
will be improper. It must be left alone, as also the opening in the walls of 
the abdomen. Even in the short space of a few hours the intestines and 
parietes will begin to adhere, constituting the chief hope of safety for the 
patient. 
Wounds of the intestines and omentum with protrusion.—These injuries are 
more favorable than those in which the wounded bowel does not protrude, 
as faecal extravasation into the peritoneum is not so liable to follow, pro- 
vided the protrusion occurs immediately on the reception of the wound in 
the parietes, as is the case in most instances. When the resistance of the 
abdominal walls is removed by an incised wound, the escape is usually with 
considerable force, not inappropriately termed “gushing out;” and this 
movement is an important element in determining the intestinal injury, 
as by it the bowel is pressed against the vulnerating body. Dr. A. R. Kil- 
patrick, of Woodville, Mississippi, relates the case of an abdomino-intestinal 
wound in a colored man aged forty-seven years, caused by an axe flying 
from its helve while in the hands of a fellow-workman, which, striking the 
abdomen and dividing the recti muscles transversely, inflicted a wound six 
inches in length. Closely following the falling axe was a hat-crown-full of 
intestines, consisting of colon, ileum, and jejunum. They remained in this 
situation for one hour and a half before being seen by the doctor, at which 
time stereoraceous matter and some melon-seeds were seen passing from the 
injured bowel. The sound viscera being returned into the abdomen, the 
wound of the intestine was closed by sutures, both ends of which were 
brought out of the external opening, and the abdominal wound closed by 
interrupted sutures. In three days the intestinal sutures came away, and 
on the eighth day a large quantity of bloody serum and faeces was dis- 
charged through the parietes of the abdomen. In twenty hours the wound 
had closed. The patient recovered.* This case serves to illustrate the 
rapidity with which adhesion of the bowel to the walls of the abdomen takes 
place, thus forming a barrier to surrounding extravasation. 
Treatment.—If the omentum is injured, the torn vessels must be' care- 
fully searched for, each one ligated with the animal ligature, both ends being 
cut off, and the mass returned. When it is much lacerated, with the certain 
prospect of sloughing, the mass should be surrounded with a carbolized silk liga- 
ture, the damaged part cut away, and the sound portion restored to its proper 
cavity, the stump, if the case is not managed antiseptically, being secured 
in the external wound, through which the ends of the ligature are allowed to 
hang. If the method of true cleanliness is observed, it can be dropped back 
into the abdomen. The extent to which the omentum may be removed is 
well illustrated in a case related by Dr. J. B. Stanton, of Ellicottville, New 
York.f A woman aged thirty, seven months advanced in pregnancy, had 
the abdomen ripped open by the horn of a cow. The intestines protruded 
in mass, the liver and stomach were exposed to view, and the omentum was 
so torn that it was removed entire, weighing, it is said, about seven pounds. 
On the fourth day the woman aborted, the child living only three hours, 
the patient, however, making a rapid recovery in twenty days. 
If the displaced omentum has been allowed to remain in the wound until 
* Boston Medical and Surgical Journal, vol. xxxi. p. 76. 
f Ibid., vol. lix. p. 249. PENETRATING WOUNDS OF THE INTESTINES. 
447 
adhesion has taken place, no attempt should be made to restore it: it must 
be permitted to slough off, or it may be surrounded by a ligature on a level 
with the skin and the protruding part cut away. 
The management of a wounded intestine must be regulated by the extent 
of the injury. When it is a small puncture, not exceeding one-eighth of an 
inch, the sides of the opening are to be picked up with a pair of forceps and 
surrounded by a ligature, as one would tie the mouth of a sack: both ends 
of the thread are to be cut off. (Fig. 359.) When the wound to be closed 
Fig. 359. 
Fig. 360. 
Manner of tying a small punctured wound. 
Lembert’s suture for intestinal wound. 
is an incised one, a number of variously-formed sutures have been sug- 
gested for the purpose, as the glover’s, the interrupted, Gely’s, and Lem- 
bert’s. The Lembert suture is to be preferred. It is an interrupted one, and 
consists in introducing and bringing out a carbolized silk or catgut thread 
after the manner shown in Fig. 360. The entrance and exit of the needle 
on one side and its entrance and exit on the other should be three-sixteenths 
of an inch from the margins of the wound, and should include the muscular 
and serous coats only, the middle suture being first inserted. The distance 
between the stitches ought not to exceed one-tenth of an inch, and when the 
requisite number are deposited the ends are to be tied together and cut off 
close to the knot. The bowel, being sutured, is next restored to the abdominal 
cavity. 
The advantage very justly claimed for this suture is the influence which 
it exerts in inverting the external coat of the intestine, by which its serous 
surfaces are brought in contact, thus securing quick union and counteracting 
the tendency to eversion and the protrusion of the mucous membrane of the 
intestinal wound, an accident which would greatly delay, if not defeat, the 
adhesion. 
A rapid way of making the Lembert suture is to introduce it continuously 
(Fig. 361), and afterwards cut the loops, con- 
verting the continuous into separate threads. 
What is the fate of the sutures ? Their first 
effect is to excite a local peritonitis, during 
which they are covered with an inflammatory 
transudation, or are temporarily encysted. 
After this the threads begin to advance to- 
wards the interior of the bowel by ulceration, 
the external wall of lymph preventing the 
products of the ulceration from coming in contact with the peritoneum. The 
sutures finally reach the cavity of the intestine, and are passed with the 
faeces. The animal suture may be absorbed before reaching the interior of 
the gut. In the process of healing, the intestine at and around the wound 
becomes adherent to the surrounding parts, that is, to adjoining loops of the 
bowel, to the omentum, or to the parietes of the abdomen. After the sides 
of the wound unite, the redundant lymph is absorbed. The mucous mem- 
brane heals slowly, chiefly on two accounts, viz., from contact with the in- 
testinal contents and secretions, and from the disturbing influence of the 
peristalsis. In cases where the wound in the intestine is a lacerated one 
and its edges very ragged, and where in all probability sloughing will follow, 
Fig. 361. 
Continuous Lembert suture. 448 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
it is better to trim the irregularities away before closing. After the sutured 
bowel has been restored to the abdomen, the external wound must be closed 
by deep interrupted sutures, including the parietal peritoneum, and the parts 
dressed antiseptically. 
When the intestine is divided across, attempts to unite the two parts by 
the usual plan of inversion and abutment of the serous surfaces, the adjust- 
ment being maintained by sutures, are attended with great risk. Under such 
circumstances the ends of the intestine must be brought into the external 
wound and made fast to its circumference by passing sutures at several 
points between the two, as well as between the edges of the adjoining gut. 
An artificial anus is to be expected, which, though a disgusting and dis- 
tressing condition, is not irremediable. 
The suture of Gely (Fig. 362), though capable of closing an intestinal 
wound and at the same time of producing inversion of the serous coat, is 
inferior to and more difficult of application than that of Lembert. The 
glover’s suture (Fig. 363) has been employed for stitching incised wounds 
Fig. 363. 
Gely’s suture for wounded intestine. 
Glover’s suture for closing intestinal wound. 
of the bowel; but the objection to its use is the difficulty with which the 
serous surfaces are brought together. 
The after-treatment of intestinal wounds consists in enforcing absolute 
rest, the use of opiates in quantities sufficient to control the peristalsis of the 
bowels, and the administration of a little milk at intervals of three or four 
hours for the first four or five days, after which the quantity may be some- 
what increased, and in two or three da}Ts more may be supplemented with a 
little beef-essence. The bowels should not be disturbed earlier than the 
eighth or tenth day, unless symptoms of peritonitis arise, when saline aperi- 
ents must be used, Rochelle salt being the best of this class of remedies. If 
the wound is not in the large intestine, an enema will often answer in place 
of ordinary laxatives. 
A very interesting article on Laparotomy for Intraparietal Abdominal 
Wounds has been published by Sir William MacCormac, the following being 
a resume of the cases: 
Of 18 cases of stab wounds penetrating the abdominal cavity and on ac- 
count of which laparotomy was performed, 10 recovered and 8 died. 
Of 30 cases of gunshot wounds penetrating the abdominal cavity, 7 re- 
covered, 22 proved fatal, and 1 was doubtful. 
Of 10 cases of rupture of the urinary bladder, 6 recovered and 10 ended 
fatally. 
Of 12 cases of rupture and contusions of the intestines, or other abdominal 
injury, all died. 
Mr. Barker, Surgeon to University Hospital, London, records 26 cases of 
laparotomy for gunshot wounds, with 16 recoveries and 10 deaths. 
Combining the laparotomies done for shot wounds alone as recorded in the 
tables of Sir William MacCormac and those of Mr. Barker, there will be found 
58 cases, with 23 recoveries and 35 deaths. During our own late war there 
were 56 cases in which the small intestine, on account of punctured or incised 
wounds, was sutured, 42 of which ended successfully and 14 fatally. In some 
of these cases the external wound was enlarged, and in others it was not. ENTERECTOMY AND ENTERRORIIAPHY. 
449 
In shot or other wounds of the intestine, when multiple perforations are 
made in close proximity to one another, it will be advisable to resect the 
damaged portion of the bowel and either to secure its extremities in the 
external wound or to unite them together by sutures. 
Enterectomy and Enterorrhaphy.—When it becomes necessary to resect a 
portion of the intestine on account of gangrene, morbid growths, faecal fis- 
tula, or extensive damage by shot wounds, the bowel must be brought out 
of the external wound and placed on a soft towel or a flat sponge which has 
been wet in a warm carbolized or sublimated lotion (one to live thousand). 
Its contents are to be pressed out and a rubber cord passed through the 
mesentery and around the intestine at either end a little beyond where the 
excision is to be made. In cutting out a few inches of the intestine it will be 
readily understood that when its ends are brought together there will be a 
puckering of the now redundant mesentery, which will cause a kink in the 
bowel and probably be obstructive. To avoid such a contingency, one of two 
plans must be adopted,—either excise a Y-shaped portion of the mesentery 
answering to the resected part of the intestine, or double the membrane 
upon itself and tack the two layers together by a number of interrupted 
sutures, the latter certainly being the quickest way to dispose of this part 
of the operation. If the plan by excision be adopted, the divided edges 
must be sewed together by a glover’s suture, the vessels being tied separately 
in order to control the bleeding. After the mesentery has been secured 
up to the points where the bowel is to be severed, the excision of the dis- 
eased loop will be made by the scissors, in such a manner that its mesen- 
teric border at each extremity shall be shorter than its free border. As the 
last portion of the bowel is divided, and with it the attached mesentery, 
it is well to grasp the ends of the diseased portions with compression for- 
ceps, so that no foul matter from within the loop may fall on the field of 
operation. The approximation of the two ends of the intestine is com- 
menced on the mesenteric border and continued round the cylinder. The 
modified Czerny-Lembert suture (Fig. 364), consisting of two rows, affords 
the greatest security to the part. If the ordinary Lembert suture be 
used (Fig. 365), the stitches should be introduced close together and great 
care taken to bring the serous surfaces into 
accurate contact. The parts, being then well 
douched with an antiseptic solution, are re- 
turned into the abdomen, and the external 
wound is closed and dressed antiseptically. 
Enterectomy cannot be regarded as a mod- 
ern operation. Randohr is said by Dr. Ill* 
Fig. 364. 
Fig. 365. 
Czerny-Lembert suture. 
Lembert suture. 
to have removed two feet of gangrenous intestine as early as 1827. The 
operation appears to have been done a number of times before 1836, both 
by English and by Continental surgeons. In 1838 I excised successfully nine 
inches of gangrenous intestine from a hernia. The colon has in most in- 
stances been the subject of this operation. Reichel’s statistics of 121 cases 
give 58 recoveries, 58 deaths, and 5 ending in faecal fistula. Ashhurst has 
* New York Medical Record, September 22. 1883. 450 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
collected 186 cases, 93 of which are alleged to have recovered and 86 to 
have died, the fate of the remaining 7 being undetermined. Weir has ana- 
lyzed 36 resections for carcinoma of the intestine, with a mortality of 51.5 
per cent. 
Dr. Charles Penrose, of this city, recently resected twelve inches of the 
transverse colon in a female for carcinoma, the patient making a good 
recovery. 
Dr. Sutton, of Pittsburg, has twice resected considerable portions of the 
intestine, one patient recovering in whom ten inches of the gut wTere excised, 
the other dying. In a case of strangulated umbilical hernia in which the 
intestine was in a state of gangrene, I resected fourteen inches of the jeju- 
num with the necessary amount of mesentery and sutured together the ends 
of the intestine. The patient on the second day following had a profuse 
hffimatemesis, and died in collapse. 
Wounds of the Liver and Gall-Bladder.—The liver may be ruptured without 
an external wound, in like manner as are the stomach and intestines. The 
passage of a wagon-wheel, a grazed shot, a blow, or a fall upon the side 
are some of the causes which produce this injury. Rupture may affect 
either surface of the liver: Mr. Bryant thinks the upper is oftener ruptured 
than the lower. The injury may exist without laceration of its peritoneal 
coat. 
The liver is sometimes wounded by fragments of broken ribs, with or 
without an external opening. It is also the subject of incised, punctured, 
and gunshot wounds. The gall-bladder may be wounded in common with 
the liver, or independent of the latter. It is sometimes opened by ulceration 
excited by the presence of gall-stones. 
Symptoms.—The signs of a wound of the liver are extreme prostration, 
from hemorrhage (the organ being exceedingly vascular), vomiting, the 
discharge of bile through the external opening,—when such is present,— 
jaundice, thirst, and often itching of the skin. The contact of the biliary 
secretion—whether from the liver or from the gall-bladder—with the peri- 
toneum will excite inflammation of that membrane. 
Prognosis.—The prognosis is exceedingly unfavorable. Should the patient 
survive the loss of blood, there remains the risk of peritonitis, and still later 
that of abscess. Should the serous covering of the organ remain intact, the 
prospect of recovery is enhanced, as the bleeding will be limited in amount, 
and the peritoneal sac will be saved from contact with either blood or bile. 
Iiennen gives two and Guthrie five cases of recovery after wounds of the 
liver. Dr. Andrews, of this city, also saw a case in which an extensive wound 
of this organ was followed by restoration to health. 
Dr. Otis, with his usual care, admits thirty-two indubitable recoveries after 
shot wounds of the liver, twenty-three of which were complicated by injury 
of the other viscera of the abdomen. A very interesting example of lesion 
of the liver was under the care of Dr. Morton at the Pennsylvania Hos- 
pital. The rupture was nearly five inches in extent, and at the time of the 
patient’s death had almost entirely cicatrized. Few recoveries follow a wound 
of the gall-bladder. Two such are among the cases of liver wounds reported 
by Dr. Otis* Stromeyer records only a single instance in which a patient 
got well after such a wound. 
Treatment.—The treatment consists in giving opium to relieve pain and 
secure rest. Inflammatory symptoms must be met with the usual anti- 
phlogistic remedies. If the signs of internal hemorrhage are present, wine 
of ergot with gallic acid may be administered, and ice-bags applied over the 
hypochondriac region; if the symptoms continue, laparotomy offers the only 
chance of relief. If an external wound is present, and it is possible, by 
digital or other modes of examination, to ascertain the existence of a lesion 
of the organ, and if the signs of progressive hemorrhage exist, the operation 
* Surgical History of the Late American War, Part II. vol. ii. p. 148. HYDATIDS OF THE LIVER. 
451 
of laparotomy should be promptly performed, and the bleeding be arrested 
by the cautery or by suturing the parts with a catgut thread. This opera- 
tion has been done quite recently (April 18, 1888) by Professor Postempski 
in the Ospedale della Consolazione, at Rome. The patient was doing well 
several days after. 
Abscess of the Liver.—This may be the result of a wound or contusion of 
the organ, or it may arise from dysenteric, miasmatic, or malignant causes. 
These abscesses open in various directions,—sometimes into the duodenum, 
sometimes into the bronchial air-passages, in rare instances into the oesopha- 
gus, but most frequently externally, through the walls of the abdomen. In 
a case which I once had under my care, the abscess was discharged through 
a small opening into the oesophagus immediately above the diaphragm. 
Whatever direction the purulent matter takes, it is generally preceded by 
inflammatory adhesion of the adjacent parts, so that a dangerous extravasa- 
tion is avoided. These abscesses are frequently very obscure in their origin, 
and in their early history are difficult to diagnose. 
Symptoms.—The signs of hepatic abscess are, pain in the region of the 
liver, sometimes dull, at other times lancinating, tenderness over the right 
hypochondrium, jaundice, emaciation, rigors, febrile disturbance, and perspi- 
ration. Cough is not an uncommon attendant, especially if the abscess tends 
towards the lungs. The external manifestation of the disease is seen in a 
bulging or prominence of some part of the abdominal walls, when the pus 
approaches the surface in this direction, generally at the epigastrium or near 
the cartilaginous extremity of the eighth or ninth rib. 
Prognosis.—The prognosis in hepatic abscess is unfavorable. A very large 
proportion of patients perish from exhaustion consequent upon the constitu- 
tional irritation which follows the liberation of the pus. 
Treatment.—Hepatic abscess should not be prematurely opened. It is 
important that the work of inflammatory consolidation between the gland 
and the walls of the abdomen be thoroughly accomplished, and until this 
has been effected there is little to be done, except to sustain the patient’s 
strength by proper nourishment and the administration of tonics, such as 
quinine and aromatic sulphuric acid. This consolidation of the liver and 
parietes, when very tardy, may be hastened by introducing at several points 
over the seat of greater prominence an acupuncture needle. When pointing 
takes place, which usually occurs near the epigastrium or below the cartila- 
ginous border of the ribs on the right side, accompanied by fluctuation, and 
the skin over the swelling assumes a purple discoloration, the abscess should 
be opened by making an incision with the ordinary sharp-pointed bistoury, 
and after the evacuation of the collection of pus a rubber drainage-tube 
should be introduced into the cavity of the abscess, which is afterwards 
washed out with a solution of horacic acid. If this course is not deemed 
proper, aspiration may be practised. The pus which comes away is usually 
mingled with the biliary secretion. Many patients, after the opening is made, 
rapidly lose strength, and die in two or three weeks. 
Hydatids of the Liver.—Tumors of this nature occupied by echinococci 
have frequently been met with in the liver. Their recognition can be made 
out only by tapping with a fine aspirating needle and examining the fluid 
removed. Should this be devoid of color, alkaline, non-coagulable, and of a 
low specific gravity, it is more than probable that the swelling is of the 
nature of an hydatid, though in advanced stages of the disease the fluid may 
be muddy or yellow. The characteristic phenomenon of fremitus, which 
belongs to hydatid tumors, cannot always be recognized. 
Treatment.—When the swelling steadily increases in volume, demanding 
interference, an attempt should be made first to destroy the tumor by elec- 
trolysis, introducing for this purpose one or more needles into the sac and 
connecting them through the negative pole with an electro-galvanic battery 452 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
of eight or twelve cells, the positive pole being applied to the abdominal 
surface near to or over the swelling. The treatment should be continued 
from eight to fifteen minutes at each sitting, and may be persevered in, pro- 
vided the tumor decreases, for several weeks. If this fails, then the sur- 
geon must direct his efforts to effect adhesion between the hydatid sac and 
the walls of the abdomen by acupuncture or by passing a caustic issue over 
the most prominent portion of the enlargement. When the tumor and walls 
of the abdomen are united, the contents may be removed, either by incision 
or by aspiration. When the former is employed, it may be advisable 
to imitate the operation of Tait, by making the opening a free one and 
uniting the edges of the sac to the sides of the external wound and intro- 
ducing a drainage-tube. In an hydatid cyst situated on the upper surface 
of the liver Mr. Owen has opened and drained across the pleural sac. 
Gall-Bladder.—The gall-bladder is liable to suffer from rupture, wounds, 
fistula, accumulations of bile, mucus, pus, calculi, and hydatids. Sometimes 
it becomes involved in carcinoma, the disease being either primary or ex- 
tending to the organ secondarily. 
Rupture may follow any forcible violence applied to the external surface 
of the abdomen over the region of the gall-bladder, when the latter is some- 
what distended. 
Wounds are usually the result of stabs inflicted during fights or from shot 
missiles. 
Unless in cases where there is an external escape of bile following injuries 
known to involve the region of the gall-bladder, it is impossible to arrive at 
any correct diagnosis of the above accidents. Whether the damage sus- 
tained be rupture or an incised or shot wound, the result almost uniformly 
is a fatal one, the patient perishing from peritonitis, and consequently little 
can be done beyond palliating symptoms as they arise. The same fatality 
attends injuries of a similar character inflicted on the cystic, hepatic, and 
common bile-ducts. 
Distention of the gall-bladder to an extreme degree is often met with from 
the accumulation of bile, calculi, mucus, and pus. 
Distention from bile is for the most part obstructive in its nature, the ob- 
struction being located in the common duct, and consisting of inspissated 
mucus, inflammatory swelling, or calculi, and occasionally resulting from the 
pressure of a malignant growth or from the cicatrix of a duodenal ulcer. 
Distention of the gall-bladder is indicated by the presence of a pyriform 
or oblong tumor below the cartilaginous border of the ninth and tenth ribs, 
projecting downwards and forward in the direction of the umbilicus, elastic 
to pressure, and accompanied by a moderate sense of fulness and some ten- 
derness to the touch. When the obstruction is seated below the junction 
of the hepatic and cystic ducts, thus allowing of biliary regurgitation, there 
will also be present the usual phenomena of jaundice, as putty-colored fseces 
and saffron-colored urine. These distentions may acquire enormous dimen- 
sions. Bright mentions a case, and Kline another, where the gall-bladder 
reached to the pelvis. In a patient of my own it extended below the crest 
of the ilium. In one instance, that of a patient of Todd, of Dublin, the 
gall-bladder and its duct contained two quarts of vitiated biliary fluid ; in 
another, reported by Gibson, there were eight pounds; and in one operated 
on by myself twenty-four ounces were removed. 
Treatment.—The surgeon should be in no hurry to resort to operative 
measures in cases of distention of the gall-bladder. The swelling may subside 
spontaneously. This has often happened when the cause was the impaction 
of a duct by a calculus, the latter after a time making its way out. The 
same result may follow where the distention has been due to a catarrhal 
state of the ducts. Let the treatment, therefore, at first be medicinal, using 
such means as are calculated to liquefy the secretion and subdue inflamma- 
tory swelling. The remedies best suited to effect these ends are chloro- CHOLECYSTO TOMY. 
453 
form, phosphate of soda, and nitrate of silver. When the distention exhibits 
no tendency to lessen, but rather progressively increases, becoming at length 
of a threatening size, an aspirating needle should be introduced and the 
contents of the swelling drawn off'. 
Gall-Stones.—Distention from calculi is no uncommon condition. These 
concretions are sometimes formed in a manner analogous to that which 
determines the formation of urinary calculus,—namely, the deposition of 
cholesterine or coloring-matter around a nucleus of inspissated mucus or 
casts from the small ducts. The chemical constitution of these stones is 
not uniform. They may consist of pure crystalline cholesterine, though 
more commonly they are made up of the other elements of bile. Sometimes 
they exhibit a regular stratified appearance, cholesterine predominating in 
one layer, pigment and bile sodium in another. Oftener there is an entire 
absence of any orderly arrangement of structure, the concretion being a 
simple aggregation of biliary matters. These calculi vary greatly in number, 
size, and external configuration. There may be a single stone filling up the 
entire gall-bladder, or there may be several hundred of small size, ranging 
from that of a mustard-seed to that of a cherry-stone, having a dark brown 
color, and often marked with facets, produced by contact with one another. 
Symptoms.—There is a tumor, when the accumulation is large, projecting 
from beneath the costal border of the chest on the right side, irregular in 
outline, and directed across the abdomen towards the umbilicus. There has 
been usually a precedent history of biliary colic, with jaundice and vomiting, 
though both may be absent. The distention may ultimately give rise to 
inflammation and peritonitis. Ulceration of the walls of the gall-bladder 
sometimes happens, allowing its contents to escape. 
In the case of the wife of a medical friend, rupture occurred, followed by 
fatal peritonitis. In several instances the gall-bladder has become adherent 
to the walls of the abdomen, followed by the formation of a fistula open- 
ing upon the surface. I once removed from the iliac fossa a large number 
of biliary calculi, an opening having formed between that region and the 
gall-bladder, the latter having extended into the pelvis by distention of its 
walls. 
Treatment.—When the symptoms belonging to an impaction of the gall- 
bladder become urgent, an operation will be necessary. Should a fistulous 
opening have formed, the tract should be fully dilated and the concretions 
removed through the enlarged channel; but where no fistula exists, a formal 
operation may be made. 
Cholecystotomy.—The operation of cutting through the abdominal walls 
and into the gall-bladder for the extraction of biliary calculi dates back to 
the early part of the last century, and seems to have been advocated by 
Sharpe, a surgeon in old Guy’s Hospital, London. At different periods the 
operation has been alternately advocated and condemned. In 1878 Dr. 
Marion Sims formulated and executed the operation, removing a large num- 
ber of calculi and also much fluid matter. The case proved fatal. Since 
this operation cholecystotomy has been done a number of times. Among 
those whose names are found associated with this operation may be men- 
tioned Kocher, Keen, Tait, Ransohoff, Bryant, Gardner, Bddowes, Wanne- 
brouco, and Langenbuch. The last-named surgeon, in one instance, removed 
the very large number of one hundred and twenty-five calculi from the gall- 
bladder. In Lawson Tait’s hands the operation has been very successful: 
out of 16 operations all recovered. Keen and Musser tabulate 35 cases, with 
9 deaths. 
In performing cholecystotomy an incision should be made over the tumor, 
parallel either with its long axis or with the outer border of the rectus 
muscle. After dividing the abdominal parietes and exposing the gall-bladder, 
the surgeon can choose between two plans for conducting the operation. 
The first consists in stitching the walls of the viscus to the edges of the 454 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
external wound, and allowing an interval of a few days to elapse, in order to 
secure union between the peritoneal surface of the abdominal walls and that 
of the gall-bladder before opening the latter, thus preventing the escape 
of bile into the abdomen ; the other method allows of no delay, the gall- 
bladder being opened immediately upon the exposure of the viscus, and its 
edges stitched by either the continuous or by numerous interrupted sutures 
to those of the wound in the parietes, including the peritoneum, the latter 
being first well drawn up into the wound, and the contents removed. The 
weight of authority is rather in favor of the last-named method, and the 
good success which has attended its execution in the hands of Mr. Tait 
would seem to commend its general adoption. In all cases before opening 
the gall-bladder the viscus should be aspirated, in order to get rid of its 
fluid contents and thus lessen the risk of the bile entering the peritoneal 
cavity. The utmost care should be observed also to keep the incised walls 
of the gall-bladder well up into the external wound, with the same object 
in view. The employment of long flat pieces of sponge, properly adjusted 
on each side of the viscus, will conduce to the same end. The advisability 
of closing the external wound after the operation has been challenged,—in 
my judgment, very properly. It would be better to close the wound only 
partially, allowing the remainder to heal by granulation, even though the 
operation should be followed by a fistula, thus preserving a way for the 
escape or removal of stones which may subsequently form. A drainage-tube 
should always be introduced into the gall-bladder. The entire procedure, 
including the dressing of the wound, should be conducted under strict anti- 
septic methods. 
Cholecystectomy, or excision of the gall-bladder, has been performed by 
Langenbeck five times, with four recoveries; by Thirar three times, with 
three recoveries; and by the younger Gross and by Courvoisier each once, 
both cases proving fatal. The operation may become necessary when there 
exist such lesions in the walls of the organ as threaten its integrity, or pos- 
sibly on account of a neoplasm. To effect the removal of the viscus it will 
be necessary to raise the liver forward, at the same time pressing aside any 
portion of the intestinal tube which may be in the way, after which the 
organ can be dissected away from the groove in which it lies, tying the cystic 
duct at two points with carbolized silk threads and dividing it between. 
Entero-Cholecystotomy or Cholecystenterostomy.—This operation is designed 
to establish a communication between the gall-bladder and some portion of 
the intestinal canal. It was suggested by Nussbaum in 1880. Winiwarter 
in one instance succeeded in securing a connection between the gall-bladder 
and tbe colon, and Kappeler one between the gall-bladder and the duodenum. 
The proper part of the intestinal canal to connect with the gall-bladder, 
when such a fistula is deemed necessary, will be either the duodenum or the 
jejunum. The connection with the latter will be the easiest of accomplish- 
ment. Dr. Gaston, of Georgia, by his experiments on dogs has thrown much 
light on this subject, and a very valuable paper upon it has been contributed 
by a surgeon of Florence, Francesco Colzi. 
The operation is intended to relieve the inconvenience resulting from biliary 
fistula or from some insurmountable obstruction of the common bile-duct. 
Operation.—The operation is divided into four stages. The first stage 
consists in dividing the abdominal parietes and exposing the gall-bladder and 
intestine,—preferably the jejunum, on account of its mobility. The second 
stage consists in uniting the inferior fundus of the gall-bladder and intes- 
tine together by Lembert sutures, including only the serous and muscular 
coats; the third, in stitching both to the abdominal wound ; and the fourth, 
in establishing a communication between the intestine and the gall-bladder by 
perforating the intervening septum through the fistulous opening, when such 
exists, and maintaining the opening in a patulous state for some time by WOUNDS OF THE SPLEEN. 
455 
introducing a rubber tube. This last stage must be postponed for six or 
seven days, or until adhesion between the contiguous peritoneal surfaces 
has taken place, thus sealing the field of operation from the general serous 
cavity. 
Wounds of the Spleen are less common than wounds of the liver. They 
are usually punctured, incised, or gunshot injuries, and are generally accom- 
panied by serious damage to other organs in the abdomen. In some instances, 
where a portion of the abdominal parietes has been carried away by a missile or 
has been extensively divided by a sabre or a knife, the viscus has protruded 
through the opening. 
The organ is occasionally ruptured, in consequence of falls, blows, and even 
by muscular exertion. 
Symptoms.—Aside from the presence of an external opening sufficiently 
large to admit of the organ being seen, there are no synrptoms which indicate 
with certainty the existence of such an injury. When, however, the position 
of a wound is in the splenic region, and after its reception there is increasing 
pallor of the countenance, indicating the existence of internal bleeding, there 
is ground for supposing that the organ has been wounded. 
Prognosis.—At one time these injuries were considered to be invariably 
fatal; but, although in a majority of instances death is an inevitable con- 
sequence, there are numerous examples of recovery. Larrey and Guthrie 
have witnessed instances of this, and Ilennerfs testimony is to the same 
effect. The accuracy of diagnosis in some of these cases was verified by 
post-mortem examinations made long after the accidents, in which the cica- 
trices answering to such lesions were distinctly recognized. Two examples 
of recovery after gunshot wounds of the spleen, and one after a bayonet 
wound, are recorded in the “Surgical History of the War.”* 
Rupture of the organ in consequence of external violence, so far as I am 
aware, has been invariably fatal. It has been observed that the accident is 
less likely to provoke peritonitis than when the intestine is wounded, blood 
being less irritating than faeces. 
The fatality following injuries of the spleen is due to hemorrhage, and, 
notwithstanding its great vascularity, these cases are not so quickly fatal as 
are those of the liver. The elastic nature of its capsule and of its trabeculae 
serves to compress the organ and in this way prevent a very rapid escape of 
blood. 
Exceptional cases occur, in which the patient survives the danger of hemor- 
rhage and afterwards perishes from abscess. Two instances of this kind were 
observed during our late war.f The inflammation which follows wounds of 
the spleen, like that following wounds of the liver and lung, is generally local 
in its character, showing little tendency to become diffused. Hypertrophy 
of the spleen is often associated with leucocythsemia. 
Treatment.—The patient must be placed on the injured side and kept 
perfectly quiet. Cold should be applied over the left hypochondriac region, 
and gallic acid freely administered, together with the wine of ergot, until 
surgical assistance can be obtained to give the patient the benefit of a lapa- 
rotomy. 
The most favorable cases are those in which the organ lies in the external 
wound or is prolapsed. When so situated, and there is no evidence of its 
structure being injured, it should be carefully replaced. When, however, 
there exists a wound or a laceration, such a course would be improper. In 
the latter event, the vessels must be secured, and if the part involved be very 
limited in extent it should be allowed to remain in the opening. In extensive 
wounds without prolapse and not manageable by the cautery or by deep cat- 
gut sutuTes the organ should be removed. When extensively damaged, the 
proper course will be to encircle the mass with a stout ligature and either 
cut it away or permit it to slough away. This operation has been success- 
* Part II. vol. ii. p. 150. 
f Ibid., p. 19. 456 
WOUNDS AND DISEASES OF ABDOMINO-PELV1C CAVITIES. 
fully performed in a number of instances. Dr. Hatchett,* after a gunshot 
wound of the abdomen in a soldier at Perryville, Kentucky, causing a dis- 
location of the spleen, surrounded the viscus with a ligature. The mass 
sloughed off, and the patient recovered. 
Abscess of the Spleen, though very rare, does occasionally occur. The 
diagnosis of such a case is attended with much uncertainty. A fluctuating 
swelling in the splenic region accompanied by rigors would give reasonable 
grounds for suspecting the existence of such a condition. The aspirating 
needle would aid in removing uncertainty on the subject, and at the same 
time serve to empty the pus. Should the organ be adherent to the abdominal 
walls, incision and drainage, as in hepatic abscess, might become necessary. 
Splenectomy.—The operation of removing the spleen may become necessary 
for other than traumatic injury. The organ is subject to displacement (floating 
spleen), and to hypertrophic, cystic, and other changes, and when these can- 
not be controlled by the usual remedies and the disease is progressive, sple- 
nectomy may be presented to the patient in proper eases as a legitimate 
resort. 
The operation, it is believed, was first performed by a Neapolitan surgeon, 
named Zacarelli, in 1540 or 1549. It was undertaken in consequence of a 
miasmatic enlargement of the organ, and proved, it is believed, entirely suc- 
cessful. 
The conditions for which splenectomy has been performed are simple 
hypertrophy, leucocytha3mic hypertrophy, floating spleen, hydatid disease, 
cysts, and traumatism. The results of the operation vary very much ac- 
cording to the conditions for which they were done. A large number of 
splenectomies have been collected by Otis. Collier, S. W. Gross, and Ash- 
hurst, the aggregate, including six collected by myself, the operators in which 
were Dr. W. H. Myers, I)r. McCann, Dr. Montgomery. Professor Casini, Pro- 
fessor Liebmann, of Triest, and Professor Goodell, being seventy-six cases.f 
All the operations performed for simple hypertrophy, malarial hyper- 
trophy, and leucocythaemia, thirty-two in number, resulted in death, with 
the exception of two, those of Liebmann and Myers. This, of course, would 
exclude cases belonging to the above classes from the realm of operative sur- 
gery. Cases in which the organ was removed for displacement of floating 
spleen, fifteen in number, all recovered except three; and of twenty-four 
operations done for traumatic injuries all save one were followed by recovery. 
No case of enlarged spleen should be subjected to operation until a careful 
microscopic examination of the blood has been made. If after such exami- 
nation an increase in the white corpuscles is discovered, splenectomy will 
only precipitate the fatal result. 
In performing the operation, an incision should be made, beginning at 
the cartilaginous border of the thorax on the left side, and extending down 
from four to seven inches in length, external to and parallel with the linea 
semilunaris. The different layers of the abdominal walls are to be divided 
upon a director, and all vessels secured which show a disposition to bleed, 
before opening the peritoneum. The sides of the wound being separated, 
and all adhesions with the abdominal parietes being broken up, the diseased 
organ should be drawn out of the body and its vessels tied a short distance 
from the hilus with strong carbolized silk threads. 
The greatest care must be taken in handling the organ to avoid rupturing 
the vessels connected with its hilus, and also to secure all arteries or veins 
found in adhesions before dividing the same. 
Wounds of the Pancreas.—Wounds of the pancreas are rare, as might he 
expected from its deep and sheltered position. During the late American 
* Surgical History of the War, Part II. vol. ii. p. 19. 
f In Dr. Goodell’s case the operation was undertaken for an ovarian tumor. WOUNDS OF THE PANCREAS. 
457 
War two cases were reported in which there was protrusion of the organ,— 
a rather remarkable occurrence when we consider how firmly it is bound in 
position. In one of these cases the gland slipped through the external wound 
while the patient was in the act of straining at stool. It was removed with 
the wire ligature by Surgeon J. G. Thompson, death being caused, it was 
believed, by the implication of other organs. The second case died from 
hemorrhage,—a result to be expected when we consider the intimate relation 
of the great blood-vessels of the spleen to the gland. The existence of such 
wounds, aside from ocular inspection, must be purely a matter of conjecture. 
In none of the tive cases of wounds of the pancreas reported to the Surgeon- 
General, three of which were under treatment for twelve days, was the true 
nature of the injury recognized before death. Rupture of the pancreas is a 
very rare accident, and when it does happen it is accompanied by damage 
to other parts. The treatment should be conducted on the same principle as 
that employed for injuries of the spleen. 
An exhaustive paper on the affections of the pancreas has been published 
by Dr. Senn, and is well worthy of a careful study. Extirpation of the 
organ does not fall within the pale of surgery. Partial removal is possible. 
Cysts of the pancreas are not uncommon. They first appear between the 
umbilicus and the epigastrium, gradually extending downwards until they 
may reach the pelvis. Among the early symptoms attending these cysts is 
deep-seated neuralgia, from pressure of the tumor on the solar ganglia. The 
examination of the fluid in the cyst will also assist in establishing its char- 
acter. Diabetes has been observed in connection with pancreatic cysts. The 
contents of the latter consist either of a brownish fluid or of blood. Rup- 
ture of the pancreatic artery due to calcification occurred in the case of one 
of my personal friends, causing rapid peritonitis and death. Abscess of the 
pancreas, simulating in some respects cyst, has been observed. Aneurism of 
the aorta, hydatid cysts, cysts of the gall-bladder, and morbid growths con- 
nected with the spleen and the liver, are the affections which may be con- 
founded with cysts of the pancreas. The bruit belonging to the first, the 
hooklets of the fluid of the second, and the regional limitations of the latter 
in their incipiency, constitute important considerations to be taken into ac- 
count in forming a differential diagnosis. The power of cystic fluid when 
pancreatic to emulsify fat is another differential sign. 
Treatment.—Wounds of the pancreas, could they be recognized, would 
justify laparotomy, though an attempt to control hemorrhage by ligation or 
pressure would probably be followed by very indifferent success. 
Cysts are most satisfactorily treated by opening the abdomen, puncturing 
the cyst-wall with the ordinary ovariotomy trocar, and after washing out 
with a solution of corrosive sublimate (one to ten thousand), or with a solu- 
tion of boracic acid, introducing a drainage-tube and stitching the sides of 
the opening in the sac to the external wound. In opening the abdomen to 
expose the cyst the stomach will be seen to cover its anterior surface, re- 
quiring an opening to be made through the omentum in order to remove the 
fluid. By this plan I treated successfully a very large pancreatic cyst in a 
female; a similar case was treated with like success by Dr. Bull, of New York. 
Results of operation.—Pancreatectomy complete has been done five times, 
with four deaths and one recovery, as follows : once by Bozemani, twice by 
Rokitansky, twice by Billroth, and once by Reidel. Bozemani’s and Roki- 
tansky’s operations were undertaken for ovarian tumors. 
Incomplete removals.—Ashhurst records six cases, those of Caldwell, Labor- 
derie, Kleberg, Thompson, Justin, and Allen, but does not give the results. 
The case attributed to Laborderie has been challenged. 
Excision and drainage.—Nine cases have been treated by this method, and 
all successfully. The operators were Senn, Sabbotick, Ogston, Kulenkampft, 
Gussenbauer, Hahn, Kuester, Bull, and Agnew. 
A comparison of methods will show that incision and drainage constitutes 
the proper plan for the treatment of cysts. 458 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
Wounds of the Kidney and Supra-renal Capsules.—These may be incised, 
contused, lacerated, or gunshot. They are frequently associated with injury 
to the spleen, liver, intestines, or vertebrae. The fatality of wounds of the 
kidney depends upon the position of the injury and the portion of the organ 
involved. When the anterior surface is implicated, the danger is extreme, as 
the peritoneal sac will be exposed to urinary extravasation, which will rapidly 
excite a fatal inflammation. When the posterior surface of the organ alone is 
injured, the risk to life is lessened, that part being remote from the peritoneum 
and lying in a bed of loose cellulo-adipose tissue. An escape of urine into this 
structure may result in an abscess which will open externally. 
Bruises, lacerations, ruptures, and displacement of the kidney may follow 
a severe blow or a fall upon the back. The rupture, in such cases, may be 
confined to the surface of the organ, it may involve the pelvis, or it may 
penetrate deeply into and even through the entire substance of the viscus, 
and is often accompanied by external ecchymosis over the lumbar region. 
The accident is usually attended with injury to other organs within the ab- 
domen. A young man, under the care of Dr. Hinekle. of this city, was 
thrown from his bicycle, his loin striking against the edge of a marble horse- 
block. He lapsed in a short time into a state of profound collapse and died. 
The right kidney, at the autopsy, was found to have been riven into three 
distinct and separate masses, and a large accumulation of blood was present 
in the upper pelvis. 
Wounds of the cortical or secretory portion of the kidney are represented 
as being less dangerous than those of the tubular or conducting portion. 
Urinary extravasation does not always follow gunshot wounds of the kidneys, 
the swelling and plastic transudation which follow the injury of the ball acting 
as a barrier to its escape. Incised and punctured wounds are more favorable 
to such escape. 
The supra-renal capsules are rarely wounded. A single case is recorded 
during the late American War, in which the ball lodged in the body and 
became encysted. The patient lived almost one month, and died of pytemia, 
produced most probably by an extensive injury of the lung, which had been 
inflicted by the ball and the splinters from a rib. No peculiar symptoms 
were revealed. 
Symptoms.—The signs of a wounded kidney are not always clear. The 
most significant one is hsematuria, though this is not invariably present. 
There is usually much uneasiness or pain in the back, and sometimes lumbar 
fulness, with a frequent desire to urinate, the water at first being slightly 
stained and afterwards more deeply colored wfith blood. The hemorrhage 
into the bladder may be so great as to distend the organ with clots. There 
is also pain along the course of the spermatic cords, attended with retraction 
of the testicle, nausea, and vomiting. Casts and pus appear in the urine 
shortly after the injury, and a fever of irritation is generally present at some 
period in the progress of the case. When the wound is inflicted through the 
lumbar region, urine and blood may escape through the external opening. 
The prognosis in wounds of the kidney is exceedingly unfavorable. Though 
twenty-six cases of alleged recoveries were recorded by the surgeons of the 
United States Army during the late war, yet Dr. Otis declines to accept 
many of these without expressing some doubt as to their genuineness. In 
these twenty-six cases the right and the left kidney suffered with almost 
equal frequency, the former thirteen and the latter twelve times. In one 
case it was not stated which organ was injured. 
Assistant Surgeon It. I. Perry* reports one case of recovery after a wound 
of the kidney in which there could be no reasonable doubt as to the verity of 
the diagnosis. Numerous cases of recovery after shot wounds of the kidney 
are recorded by various surgical writers, both military and civil,—among them 
being Legouest, Baudens, Guthrie, Hennen, Dupuytren, Billroth, Stromeyer, 
Pendleton, and Richardson. 
* Confederate States Med. and Surg. Jour.; Surgical History of the War, Part II. vol. ii. p. 144. WOUNDS OF THE URETER. 
459 
Hennen* gives the history of an officer who was shot, the ball being after- 
wards extracted at the side of the twelfth dorsal vertebra. The wounded 
man suffered intense agony in the back, and passed bloody urine. Seven 
weeks after, an abscess formed in the lumbar region, which, on being opened, 
discharged offensive matter and a fluid having a urinous odor. A second 
abscess formed lower down, from which a similar discharge took place. After 
this the passage of the urine became more difficult, and finally it could only 
be discharged in drops. While making an agonizing effort to empty the 
bladder, a burst of urine, accompanied with the discharge of a piece of cloth, 
took place, after which the patient’s recovery was rapid. This foreign sub- 
stance had been carried by the ball into either the substance or the pelvis of 
the kidney, and from thence had passed along the ureter to the bladder, from 
which it was discharged through the urethra. Stromeyer furnishes the case 
of an officer who, two months after a shot wound of the kidney, passed a con- 
cretion from the bladder. The inference was that this had formed in the 
pelvis of the kidney and passed into the bladder through the ureter. 
The immediate causes of death after a wound of the kidney are hemorrhage, 
shock, and urinary infiltration giving rise to peritonitis. The causes which 
operate at a later period to destroy life are pyaemia, abscess, cystitis, and 
hectic fever. As wounds of the kidney are so generally complicated with 
those of other portions of the abdominal contents, it is difficult to determine 
what part of the mortality should be credited to the former. 
Treatment.—As in other wounds, any foreign body which can be discovered, 
without a too officious exploration, must be removed. If urine flow from the 
opening, no obstacle should be offered to its escape. The patient should be 
placed in such position as will favor a free drainage from the wound, not only 
of the urine, but also of other discharges. If the signs of internal hemorrhage 
are present, the surgeon must insist upon entire quietude of the body; he 
should administer gallic acid and ergot, and, if pain is experienced, should 
direct a sufficient amount of opium to allay all suffering. If there is shock, 
it is better to allow the patient to rally by the recuperative forces of his 
own body, without any active interference on the part of the surgeon, as the 
danger of hemorrhage is thereby much lessened. If, however, the shock 
amounts to collapse, external warmth and stimulation will become impera- 
tive. As all undue activity of the kidney is to be deprecated, no fluids should 
be allowed further than may be necessary to relieve urgent thirst. When 
reaction sets in, it must be controlled by the use of refrigerants and seda- 
tives. In the event of coagula forming in the bladder, they should be broken 
up and removed by the use of a large-sized catheter, through which should 
be injected a weak alkaline solution, with a view to dislodge the clots and 
prevent the further coagulation of blood. To obviate the difficulty arising 
from the eyes of the catheter becoming obstructed with coagula of blood, 
the instrument of Willard or an aspirating bottle may be connected with 
the catheter, by which it can be kept clear. If these resources fail, a cys- 
totomy will be required. In cases of shot or other wounds of the kidney 
in which the life of the patient is threatened from hemorrhage or abscess, it 
may be necessary to perform a nephrectomy. 
Wounds of the Ureter.—Injury of the ureter is quite rare. Ilennen men- 
tions the ease of a French dragoon who received a musket-ball under the 
twelfth rib on the left side, the missile passing out to the left of the second 
lumbar vertebra of the opposite side. Air, which was supposed to have 
entered the ureter through the wound in the flank, was passed from the 
urethra. The case as recorded is open to criticism, and, as the patient re- 
covered, the accuracy of the diagnosis could not be verified. Mr. Stanley 
has recorded two cases and Mr. Poland one. In those of Mr. Stanley large 
urinous cysts formed in the lumbar region, which were tapped several times: 
one of the patients at length recovered. 
* Military Surgery, p. 422. 460 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
The ureter has been wounded in the removal of abdominal tumors. A 
case of this kind, in which the duct was accidentally divided in extirpa- 
ting an ovarian cyst, was related to me by a medical friend. The renal ex- 
tremity was secured in the external wound, and a urinary fistula followed. 
The patient lived several months, dying finally from some obstruction in the 
course of the duct. 
Symptoms.—Unless in cases of ovarian operations, where the parts are 
exposed to view, the existence of a wound of the ureter must be largely a 
matter of inference. Placed as the ducts are behind the peritoneum, the 
urinary extravasation which follows the accident may take place into the 
loose connective tissue below the kidney without exciting peritonitis, as in 
wounds which affect the posterior portion of that organ without involving 
the membrane in front. An abscess or a cyst may follow, which will be likely 
to point in the lumbar region, and the tapping of which would reveal the 
true nature, if not the source, of the secretion. 
Treatment.—If after an injury, shot or otherwise, in the region of the 
ureter a lumbar swelling appears, an aspirating needle should be introduced 
in order to determine the nature of the extravasation. If it proves to be 
urine, a free opening must be made through the loin for its escape. This is 
necessarily followed by a fistula. The dangers of peritonitis, of abscess, and of 
severe constitutional irritation constitute cogent reasons for the extirpation 
of the kidney, as only by such a procedure can the fistula be cured. When 
the ureter is accidentally torn in the removal of abdominal tumors or of the 
uterus, the renal end should be temporarily tied until the operation is com- 
pleted, when the duct may be turned into the vagina, as was done by 
Mr. Morris, of London. Simon, of Heidelberg, in a case of rupture of the 
urethra occurring during an operation, successfully removed the kidney. 
Sequels of Abdominal Wounds. 
Inflammation of the Kidney.—Should inflammatory symptoms of the kidney 
arise, they must be controlled by saline cathartics, by cupping over the loins, 
by the use of the hip-bath, or by warm poultices applied to the lumbar regions. 
Opium will be required, given to the extent necessary to relieve pain. 
Perinephritic abscess.—Whenever abscesses form, they should be early evac- 
uated by free incisions, followed by the use of large-sized drainage-tubes. 
Nourishment by the mouth had better be withheld for the tirst two or three 
days, or until there is reason to believe that the intestines have escaped 
injury, after which milk and animal broths may be allowed. 
Fistula?.—These may succeed abscesses. The discharge of urine and puru- 
lent matter will oppose the healing either of an abscess or of a wound ; the 
opening will contract and granulate up to a certain point, leaving a narrow 
canal, which may obstinately refuse to close. 
The treatment of such cases consists in cleansing the parts and waiting 
patiently to see if the opening does not gradually become obliterated. There 
are a number of instances recorded in which obliteration was eventually 
consummated. If, however, after a reasonable delay, the case continues 
unchanged, it will be proper to examine the sinus with a view to discover 
if there is any cause for a continuance of the fistula, which it is possible 
for the surgeon to remove. If the fistulous track is sinuous or circuitous, 
it should be incised so as to make the opening between the kidney and the 
surface of the body as direct as possible ; if a urinary salt has incrusted 
the walls of the fistula, this should be removed by injections of dilute nitro- 
muriatic acid; and if a calculus has formed in the course of the sinus, its 
extraction should be immediately effected. As a last resort, the kidney should 
be extirpated. 
In addition to fistulae of the kidneys and ureter, already described, there 
may be similar openings communicating with the stomach, liver, gall-bladder, 
and intestines. FISTULA OF THE GALL-BLADDER. 
461 
Fistula of the Stomach.—This may arise from wounds, cancer, and ab- 
scesses, and, from whatever cause, usually proves fatal. The well-known 
case of Alexis St. Martin is an example of gastric fistula following a wound. 
I)r. Middeldorpf* and Dr. Murchison have collected forty-six cases of such 
fistuke, twenty-one in men and twenty-three in women, with two in which 
the sex was not ascertained. Those having a traumatic origin were most 
commonly met with in men, the non-traumatic in women. Three cases of 
traumatic gastric fistula were recorded during our late war.f These were not 
immediately established, but followed the wound at periods varying from 
two to seven weeks. All proved fatal,—one living one week, another four 
weeks, and the third almost twelve weeks. But two recoveries from gastric 
fistula after gunshot wounds have been recorded,—one being St. Martin, 
who lived with a permanent fistula; the other a French soldier, recorded 
by Baron Percy, who was wounded in 1794, and in whom the fistula healed 
spontaneously. 
Treatment.—No attempt in the way of an operation should be made to 
close up a gastric fistula until nature has done all in her power towards that 
end. Should the patient survive any length of time, the wound will contract 
very much by cicatrization, leaving a fistulous track quite small as compared 
with the original opening. This may be reduced still further in size by cau- 
terization with nitrate of silver. When closed to its smallest dimensions, the 
alternatives will remain, either to employ some mechanical appliance, as an 
obturator, or to turn into the fistula (its edges having been previously fresh- 
ened) a flap of integument taken from the neighborhood of the opening, the 
cutaneous surface of which should be placed inwards, and retained by a few 
silver sutures. I am not aware that this operation has been performed; but, 
as it succeeds in exstrophy of the bladder and in fistulous openings of the 
larynx, there is no reason why it should not be attempted in gastric fistula. 
Middeldorpf almost succeeded in curing a case by attaching a flap of skin to 
the edges of the opening-! In this case, I believe, the raw surface was placed 
inwards. When there are fistulous tracks, other than the one connecting 
with the stomach,—tracks which burrow in the subcutaneous tissues,—they 
should be laid open and thus obliterated, preliminary to any operative 
measure for closing the abnormal opening. As the fluids which flow from 
gastric fistuke are profuse in amount, the greatest attention must be observed 
to keep the parts clean. Oakum placed over the opening will form the best 
external application for this purpose, and should be renewed as often as it 
becomes soaked with the discharges. 
If the inconveniences resulting from gastric fistula become unendurable, 
the operation of gastrorrhaphy otters a reasonable hope of deliverance to the 
patient. 
Fistula of the Gall-Bladder.—Biliary fistulse are not common. They occur 
as a result of distention of the gall-bladder by an accumulation of calculi, 
from obstruction of the common bile-duct caused by inspissated mucus, or 
from the pressure of a malignant growth. Abscess of the liver, blows over 
the right hypochondrium, gunshot and other wounds, are also causes of the 
disease. Antecedent to such fistulse, the gall-bladder becomes adherent 
—through inflammation—to the abdominal walls. In this way the biliary 
secretion is prevented from coming in contact with the peritoneum. The 
discharges which flow from the fistula consist of bile, muco-pus, and some- 
times blood. I once removed a number of gall-stones from the iliac fossa 
of a lady. They had reached this locality in all probability by adhesion of 
the gall-bladder to the iliac fascia, and by subsequent ulceration. These 
fistulse rarely ever close, but wear the patient out by prolonged irritation. 
Treatment.—The parts around the fistulous orifice are to be kept clean, 
* Brit, and For. Med.-Chir. Review, Oct. 1860, p. 645. 
f Surgery of the War, Part II. vol. ii. p. 52. 
j Holmes’s System of Surgery, Part II. vol. ii. p. 683. 462 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
and defended against the irritating discharges. If biliary calculi engage in 
the opening they must be extracted. Little success has attended attempts to 
close these fistulse, and if the main duct is hopelessly obstructed all attempts 
of this kind would be obviously improper. 
Faecal Fistula.—Faecal fistula is the result both of accident and of disease. 
Under the first head may be enumerated contusions, blows, gunshot and 
other wounds of the abdomen; under the last, intestinal obstruction from 
various causes, such as accumulations within the bowel, stricture, cancer, 
etc. There is an intestinal fistula which sometimes follows strangulated 
hernia, commonly called artificial anus, but which possesses certain peculiari- 
ties, to be noticed farther on. In the first, or ordinary faecal fistula, only a 
portion of the intestinal tube is destroyed, the surrounding parts becoming 
adherent to the abdominal walls, thus cutting oft4 all communication with 
the cavity of the peritoneum (Fig. 366) and preventing a fatal extravasa- 
tion of the contents of the bowel. This work of the inflammatory adhesion 
of two serous surfaces—that of the intestine and that lining the abdominal 
parietes—precedes the formation of the external opening, while in cases 
resulting from wounds it follows the lesion in the abdominal walls. If there 
Fig. 366. 
Fig. 367. 
Intestinal fistula. A loop of intestine is 
adherent to the abdominal parietes at an 
obtuse angle, the fistulous opening involving 
only a small extent of the tube. 
Intestinal fistula. The loop of intestine is 
adherent to the abdominal walls at an acute 
angle, thereby forming a spur or ridge. 
is a large part of the intestinal wall lost, the entire contents of the bowels 
may he discharged through the opening. Especially will this be the case if 
the angle formed by the two sides of the adherent loop of intestine is acute, 
as such a position favors the formation of an internal ridge or septum which 
is projected from the mesenteric portion of the bowel (Fig. 367), as well as a 
prolapse of the mucous membrane into or through the external opening in 
the abdominal walls. When, on the other hand, this angle is obtuse, this 
mechanical obstruction does not exist, and consequently only a portion of 
ftecal matter escapes through the fistula, the remainder passing down along 
the natural channel. Sometimes this slight angular disposition of the ad- 
herent gut is such that no stercoraceous matter is discharged externally, 
except when the contents of the bowels are very thin, as in diarrhoea. 
In the artificial anus following strangulated hernia a different condition 
exists from that described above. In hernia, a loop or knuckle of the intes- 
tine is protruded through the hernial passages, so that when its vitality is 
destroyed by the stricture and all below sloughs off, there remain two intes- 
tinal tubes lying alongside of each other, like the two barrels, of a double- 
barrelled gun, the canals of which are discontinuous, and their two orifices 
look outward towards the external opening. (Fig. 368.) It is possible, FAECAL FISTULA. 
463 
however, after hernia to have a stercoraceous fistula similar to that first 
described, as when an intestine, after division of the stricture, is returned 
into the abdomen under the impression that its structure has not been seri- 
ously injured, and yet afterwards a portion of the tube sloughs, and the 
opening left becomes attached to the upper part of the canal. This attach- 
ment may occur without an internal extravasation of fteces, most probably 
because the incarceration destroys the peristalsis, and while in this quiescent 
state the tube becomes glued fast to the walls 
against which it lies, by inflammatory action. 
In the two varieties described, namely, faecal 
fistula and artificial anus, the openings into 
the intestines are immediately in contact with 
the walls of the abdomen. Holmes speaks of 
two other varieties, one in which the orifice 
into the gut is attached to the upper part of 
the hernial sac which had been previously 
restored into the body, and which necessa- 
rily removes this opening some distance from 
the parietes; and another in which the open- 
ing of the gut discharges into a canal formed 
in the plastic deposit which agglutinates the 
contiguous coils of intestine, and through 
which the fseces flow to the external orifice in 
the abdominal walls. This last I have never 
seen, and think it must be a rare form of the 
disease, for, so far as my observation extends, 
it is not common to find other loops than the 
affected one glued together by inflammatory 
transudation. It is not uncommon to have 
several external openings in faecal fistulae, 
the result of dissecting abscesses in the parietes, a condition which materially 
complicates the cure. 
Prognosis.—Faecal fistulae involving the small intestines are unfavorable 
in their termination. This part of the alimentary tube being chiefly con- 
cerned in the work of nutrition, its contents are in a liquid state, and their 
escape is followed by emaciation and loss of strength, the patient finally 
dying from inanition. When the angle of this bowel is very acute at the 
point of union with the parietes, and as a consequence the spur or septum 
much prolonged from the mesenteric border of the intestine, so as to prevent 
the contents passing down into the bowel below, the prospects of a favorable 
issue are materially lessened. In faecal fistulae of the large intestine the 
prognosis is much more favorable. The solid state of the contents of the 
colon, and their effete nature, are conditions which conduce to recovery; and 
when the more fixed portions of this intestine are implicated, as the caecum, 
the ascending or the descending portion, the probabilities of a cure are greatly 
enhanced. Of fifty-nine cases of such fistulae in the Eeports to the Surgeon- 
General of the United States Army,* fifty closed, nine remaining open. The 
time required for the healing in the successful cases was, in seventeen cases, 
one month; in twenty-eight, one year; and in five, periods varying from one 
to four years. 
Treatment.—In ordinary stercoraceous fistula, the wisest course is to leave 
the case to purely natural processes. Should there, however, be a number 
of sinuses or fistulous tracks in the walls of the abdomen, it will be necessary 
to lay them all freely open upon a director, except the one most directly 
connected with the opening in the intestine. The pai’ts must be kept clean, 
and the person of the patient rendered free from odor by frequently renewing 
the dressings. The best compress in such cases is a pledget of oakum 
(previously treated with a solution of the sulphate of iron), which should be 
Fig. 368. 
A diagrammatic view of a loop of intestine 
which has been strangulated. The dotted 
lines represent the knuckle which has 
sloughed off at the seat of constriction, 
above which are seen the two orifices of the 
bowel, and the relation which the tubes 
hold to each other. 
* Surgical History of the War, Part II. vol. ii. page 98. 464 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
laid over the fistula and kept in place by a broad binder, or by adhesive 
plasters. After cicatrization has materially diminished the opening, a firm 
compress of oiled linen, containing a piece of heavy sheet-lead, should be 
placed upon the aperture, and over this the oakum, the whole dressing being 
secured by a bandage. This plan of pressure, which is that of Desault, will 
often effect a cure, and should be thoroughly tried before having resort to 
an operation. It fulfils very much the same indication as the recumbent 
position recommended by Brodie,—both tending to direct the intestinal con- 
tents towards the posterior surface of the bowel. Often the slightest external 
opposition to the escape of the feculent matter will suffice to turn its course 
into the bowel below. The plan has in several instances proved successful 
in faecal fistulas which have come under my care. Many curious devices 
intended as obturators have been invented with a view to plug up the outer 
orifice; but these appliances, tending as they do to prevent contraction of 
the fistula, exercise a pernicious influence, and should be rejected. The 
best mechanical contrivance I believe to be a hard rubber truss, which 
should possess a large pad, and be placed over the fistulous opening, with 
a pledget of soft oakum interposed between the surface and the pad. The 
pressure from this instrument affects only the surface, and, while it pre- 
vents prolapse of the mucous membrane of the bowel, it also restrains, to a 
considerable degree, the escape of faecal matter. Should the above meas- 
ures fail, the use of the actual cautery, applied to the edges of the fistula, 
from time to time, will in some instances effect a closure of the opening by 
cicatricial contraction. 
In some of these cases, when the loss of flesh and the physical and mental 
discomfort are great, resection of the gut and suturing the ends together 
would be entirely justifiable. 
Artificial Anus.—In faecal fistula, known as artificial anus,—usually a con- 
sequence of strangulated hernia,—the condition of the person is most pitiable, 
being so offensive to himself and his friends that it is entirely proper to resort 
to operative measures, even though at con- 
siderable risk to life, in the hope of being able 
to rescue the patient from a most deplorable 
infirmity. 
The obstacle to be overcome in this form 
of artificial anus is the septum formed by 
the walls of the two intestinal tubes, which 
lie in contact with each other, and which, 
like the spur or ridge resulting from the an- 
gularity of the bowel in other forms of faecal 
fistulse, constitutes the chief difficulty in the 
way of a cure. 
All of the operations devised for this ob- 
ject have been inspired by the suggestion, in 
1798, of Schmalkalden, a German surgeon, 
and consist in dividing this septum or parti- 
tion by a thread introduced through its sub- 
stance by means of a curved needle, bringing 
the ends out of the external opening, and 
gradually tightening them, in order to estab- 
lish by idceration a permanent opening through the obstruction. The first 
surgeon to carry this suggestion into effect was Dr. Physick, who, in 1809, 
operated with success upon a patient in the Pennsylvania Hospital. His 
method differed somewhat from that advised by Schmalkalden, in that the 
ligature was used for seven days, only with a view to insure consolidation 
or union between the contiguous walls of the intestine (Fig. 369), the open- 
ing being afterwards made by a curved bistoury, after the removal of the 
thread. 
Fig. 369. 
Thread introduced through the intestinal 
septum, and the ends hanging out of the 
wound. ARTIFICIAL ANUS. 
465 
Dupuytren employed an enterotome (Fig. 370), a form of forceps with 
serrated blades and having a screw in the handles by which the instrument 
can be tightly closed. In using this instrument, the blades are conducted 
one into each intestinal orifice, guided by the previous introduction of a cath- 
eter, and, after the position of the partition has been ascertained, the handles 
are screwed together (Fig. 371) with sufficient force to induce colicky pain. 
After the lapse of seven or eight days the instrument becomes loose and may 
be removed. The part compressed is destroyed, and will soon separate as a 
slough, establishing the desired opening between the two contiguous tubes. 
Fig. 370. 
Dupuytren’s enterotome. 
The value of this operation may be judged from the fact that it has been 
successful in closing more than forty cases of artificial anus. 
To correct a defect in the enterotome of Dupuytren, that of making un- 
equal pressure, in consequence of which the septum is divided first nearest 
to the articulation of the blades, Blasius 
introduced an instrument the blades of 
which are parallel and are moved by a 
screw. Dr. Lotz, of Pennsylvania, in- 
vented an instrument in which this par- 
allelism of the blades is conjoined with 
fenestrse. (Fig. 372.) These fenestrre 
are about one-quarter of an inch wide 
and one inch long. 
The instrument of Professor Gross, de- 
signed for the same purpose (Fig. 373), 
is a forceps with fenestrse like those of 
Lotz’s. In the use of these fenestrated 
appliances the blades are introduced, one 
into each orifice of the bowel, and then 
brought together and secured either by 
screws, as in Lotz’s, or by a button catch, 
as in Professor Gross’s instrument. As 
soon as adhesion has taken place between 
the walls of the intestine, a result usually 
requiring three or four days, the septum 
should be divided by a curved bistoury 
passed through the fenestra;, after which 
the instrument is to be gradually relaxed, 
and in two or three days more entirely 
removed. During the time the enter- 
otome remains in the bowel it will be 
necessary to alleviate the suffering of the 
patient with opium or morphia. If suc- 
cessful in opening the normal route for the fteces, it will be essential next to 
address remedies to the external opening, with a view to insure its cicatriza- 
tion. For this object we may employ nitrate of silver or sulphate of copper, 
conjoined with external compression. 
The operation as performed by Dupuytren, if reliance is to be placed on 
statistics, seems to have been followed by considerable success. He gives the 
result of forty-one operations, in which twenty-nine proved to be perfect 
cures, and three died. Thirteen of the operations were made on account of 
Fig. 371. 
Application of Dupuytren’s enterotome. 466 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
sloughing of the bowel from strangulated hernia. The statistics of Ileimann, 
in which are recorded eighty-four cases of operation for faecal fistula after 
Dupuytren’s method, show a still higher ratio of success, fifty of the number 
recovering perfectly, and but seven dying. Even in those instances where 
the operation was not entirely successful, the external opening into the bowel 
was reduced to a small fistula,—a matter of considerable importance, as it 
brought this dreadful infirmity, to a great extent, under the control of me- 
chanical measures. 
Resection.—With the advance of abdominal surgery another method has 
been practised,—viz., opening the abdomen, resecting the affected portion of 
intestine, and uniting the ends by suture. The merits of this bold procedure 
Fig. 372. 
The instrument of Dr. Lotz. 
Fig. 373. 
Professor Gross’s forceps for the cure of artificial anus. 
have been investigated by Bouilly and Assaky. Of thirty-six cases of resec- 
tion for the relief of artificial anus, sixteen recovered and eighteen died: the 
remaining two terminated in fistula. The mortality is very much greater 
than that following the Dupuytren operation This may possibly be reduced 
by antiseptic surgery, but under present circumstances resection should be a 
last resort. 
Should other measures fail, and if there is no anatomical objection, the 
surgeon may call to his aid the resources of anaplasty; though the success 
which has heretofore followed these attempts has been by no means en- 
couraging. 
Wounds of the Pelvis. 
Wounds of the pelvis may be classified according as they involve the ex- 
ternal soft parts, the bones, the contents, or all three together. 
These wounds may be contused, incised, lacerated, punctured, and gunshot, 
and often prove to be very serious accidents. 
Wounds of the Soft Parts.—Contusions, the result generally of forcible 
pressure, as when a person is caught between the buffers of cars, are followed 
often by large blood-swellings, especially when the violence has been received 
upon the nates. This collection of blood may be subcutaneous or in the midst 
of the gluteal muscles, and usually does not descend lower than the gluteo- 
femoral groove, in consequence of the anatomical arrangements of the fascial 
and muscular structures isolating in a good degree the nates from the thigh. 
When the contusion is less severe, such as follows a kick, there is a liability 
to the formation of abscess, greater, I think, than when similar violence is 
applied to other regions of the body. As the gluteal muscles are actively 
concerned in walking, standing, and indeed in almost all the movements 
of the pelvis upon the thighs, these contusions produce no small degree of 
disability or lameness. 
Treatment.—Rest and anodyne lotions, such as lead-water and laudanum, 
constitute the chief remedies. The blood-swellings commonly disappear in WOUNDS OF THE PELVIC BONES. 
467 
time, and on no account should these be opened, except when they provoke 
suppuration. Should an abscess form, whether from the irritation of blood 
or from an inflammatory disturbance, the matter must be evacuated early, as 
it tends in this region to become disseminated and to cause much damage to 
the parts. Incised and lacerated wounds should be dressed antiseptically, 
being closed by the interrupted silver suture and supported with a well- 
fitting compress of carbolized gauze, secured by spica rollers of the same 
material. Gunshot wounds of the soft parts are often very slow in healing, 
—whether the missile remains in or passes out,—particularly when the track 
of the ball is extensive and sinuous. 
Fistulous openings frequently remain, in consequence of the movements of 
the muscles, and give rise to the suspicion of bone-disease when nothing of 
the kind is present. If a ball lodges in the soft parts, a proper search for its 
location must be made, and, when found, it should be promptly extracted. 
Rest and pressure are nowhere so important as in these wounds, and, 
should abscesses form in the buttocks from tortuous ball-tracks, our chief re- 
liance will consist in laying them open, or in dilating them and introducing 
a drainage-tube, in order to avoid the formation of pockets for the accumu- 
lation of pus. 
Wounds of the Pelvic Bones.—In shot wounds or fractures of the pelvic 
bones, the ball may make a clean perforation, may graze their surfaces with- 
out penetration, or may produce extensive comminution. The ilium, from 
its extent and position, is more exposed, and consequently suffers oftener, than 
the other pieces of the pelvis. This will appear with greater force when we 
learn that out of 1494 cases of gunshot fractures of the pelvic bone, during 
the late war, the ilium suffered in 829 instances, and in 799 of these it was 
the only bone involved.* The left ilium, it was also noted, suffered oftener 
than the right. 
The prognosis after gunshot fractures of the ilium is favorable when the 
injury is confined to the bone and does not involve the contents of the pelvis. 
In the 799 shot injuries just referred to, the result was ascertained in all but 
13 cases, giving a mortality of 192. 
Gunshot fractures of the pubic bones are more serious than those of the 
ilium. The relation of the bladder and the close proximity of the femoral, 
obturator, and spermatic vessels will explain this fact. The records of the 
late American war supply 86 cases of such injury, with 43 deaths. The 
largest number of the fatal cases—one-third—died from complications of the 
bladder. Dr. Otis observes that this bone, owing to its toughness and its 
fibrous and tendinous attachments, is rarely comminuted. 
Shot fractures of the ischium, from the dependent position of the bones, 
are less dangerous than those of the ilium. We learn from the “ Surgical His- 
tory of the War” that there were 73 such injuries returned, with a mortality 
of 35. 
The sacrum supports the rectum and the large plexus of nerves which 
endows the extremities and the pelvic viscera with motion and sensation. 
From this fact it would be supposed that, when the sacrum is shattered by 
gunshot missiles, the injury must be attended with the most serious conse- 
quences ; but the statistics do not sustain this conclusion. Of 142 such frac- 
tures, 62 died. In an aggregate of 1545 pelvic fractures, there were 570 
deaths. This cannot be regarded as a heavy mortality, when it is considered 
that in most cases some portion of the contents participated in the injury, 
though occasionally a ball was known to have traversed the pelvis without 
doing any damage to its viscera. 
In many instances of shot wounds of this part, the resulting evil is due to 
splinters being detached from the bones and driven into the bladder, rectum, 
and other parts within the cavity of the pelvis, so that while it is necessary 
in a systematic treatment of gunshot wounds of the pelvis to make the dis- 
* Surgical History of the War, Part II. vol. ii. p. 213. 468 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES 
tinction between those affecting its bony walls and those implicating its con- 
tents, it is nevertheless true that the two are not often dissociated. 
Treatment.—In shot fractures of the pelvic bones it is important to as- 
certain if any osseous fragments or splinters, portions of clothing, or other 
foreign matters have been driven into the interior. The finger should dili- 
gently explore the track made by the missile, and, if necessary, the external 
wound may be enlarged for that purpose. A finger in the rectum may aid 
in discovering displaced fragments of bone. Should any such be detected, 
their removal will conduce immensely to the patient’s recovery. 
A second indication is to maintain a free escape externally of all inflam, 
matory products, which is best effected by conducting to the bottom of the 
wound a good-sized drainage-tube. The probability of the bladder being 
injured requires that a soft catheter be immediately introduced into the organ 
and retained for three or four days, to guard against urinary extravasation. 
The position of the patient also demands some attention, with a view to 
prevent displacement of fractures by muscular action. If the crest of the 
ilium has been broken, the body should be inclined towards the affected side, 
so as to relax the broad muscles of the abdomen which are attached to its 
surface. If the anterior superior spinous process has been detached, the thigh 
will require to be flexed, in order to relax the sartorius and the tensor 
vagime femoris. Great comfort is derived from surrounding the pelvis with 
a broad bandage, so as to remove the distressing feeling so commonly com- 
plained of, i.e., that of “ falling apart.” Should abscesses form in the soft 
parts overlying the pelvic bones, they must be opened as soon as recognized, 
in order to prevent burrowing between the planes of the gluteal and other 
muscles. If the general constitution becomes disturbed, either from the local 
irritation or from profuse and continued suppuration, anodynes will be re- 
quired to secure relief from pain, and tonics, together with a liberal diet, to 
maintain the strength. 
Wounds of the Bladder.—The urine being an exceedingly irritating secre- 
tion, any injury which destroys the continuity of the coats of the bladder, 
permitting an escape of its contents, usually proves quickly fatal. 
Rupture of the bladder.—This accident has occurred many times, and may 
be produced by the wheel of a loaded wagon passing over the lower part of 
the abdomen, by a kick given in a drunken brawl, or by a fall against some 
projecting object. The accident cannot readily occur except when the viscus 
is considerably distended by urine. In the collapsed or empty state, it is 
sheltered by the pubic bones, and, remaining within the pelvis, is out of the 
of violence applied over the hypogastric region. The accident occurs 
most commonly in persons who are under the influence of liquor. It is well 
known that individuals in this state, having their sensations blunted by the 
stupefying influence of alcohol, neglect to empty the organ, except when it is 
much distended. In addition, the muscular system of a drunken man is in a 
relaxed, helpless condition, and in a great measure powerless to resist force, 
so that when a blow is applied over the lower part of the abdomen it reaches 
the bladder without opposition, and determines the rupture. Besides the 
causes already enumerated, the organ may be ruptured from over-distention, 
caused by some mechanical obstruction to the passage of the urine, as in 
stricture of the urethra. Notwithstanding the power of the bladder to with- 
stand great distention without accident, as shown by the experiments of U1- 
mann and Dittel, yet the first-named surgeon has collected nine cases of rup- 
ture of the bladder produced by distending the viscus with fluid preparatory 
to performing suprapubic lithotomy. In most of these cases the rupture 
was intra-peritoneal. 
The bladder has been ruptured by the gravid uterus pressing against its 
walls during the throes of parturition, where the physician has neglected to 
use the catheter. It would appear that when a rupture takes place, the pos- 
terior wall of the bladder suffers most. In 78 cases collected by Dr. Stephen WOUNDS OF THE BLADDER. 
469 
Smith, the lesion occurred 50 times in the posterior wall, 9 times in the ante- 
rior wall, and 6 times at the neck of the organ. In the 37 cases collected by 
Houel,* this unequal distribution of the lesion is not so marked, 15 being in 
the posterior wall, 12 in the anterior wall, and the rest, with two exceptions 
in which the locality was not noted, on the sides and near the urachus. Males 
suffered much oftener than females, due, no doubt, to differences in occu- 
pation. 
The relation of the bladder to the peritoneum influences somewhat the 
result of these ruptures. The posterior and lateral surfaces are covered 
by this serous membrane, but the anterior and the ubas-fo7id" are not. When, 
therefore, the rent involves the posterior part, the peritoneal layer is like- 
wise torn, and the urine reaches the peritoneal sac, kindling at once a fatal 
inflammation. When the rent takes place within the peritoneal part of the 
viscus, this membrane suffers most as to the extent of the tear. When the 
anterior surface and that behind the prostate body is ruptured, the extrava- 
sation is into the cellular tissue of the pelvis, developing pelvic cellulitis and 
sloughing, as fatal, but not so rapid, as peritonitis. Of the 78 cases collected 
by Dr. Stephen Smith, only 5 recovered, the majority dying within five or 
six days ; and of the 37 cases recorded by Houel, all but 2 proved fatal. 
Rivington has collected 129 cases of intra-peritoneal rupture of the blad- 
der, with 8 recoveries, some of which, however, will not stand criticism. In 
Walters’s case a laparotomy was done, which excludes the case from the 
above class. Morris reports a rupture of the bladder from which the patient 
recovered without operation, the character of the accident having been veri- 
fied one year later in consequence of the cicatrix breaking open. 
The bladder is not unfrequently wounded by spicuhe detached from the 
bones of the pelvis in fractures and by balls. Pieces of clothing, balls, hair, 
and other foi'eign bodies may pass immediately into the cavity of the bladder, 
or they may reach the interior of the viscus by ulceration at various periods 
of time after the reception of the injury. 
Gunshot wounds of the bladder are less mortal than other injuries of this 
viscus. This fact, which was pointed out by Larrey, has been verified by 
the experience of our late war. In 183 cases of this nature,f 87 survived 
the immediate effects of their wound, though the larger number suffered 
from urinary, stercoraceous, and recto-vesical fistulas, with other sequels, 
which wore the patients out, in some instances after months and years of 
irritation. That extravasation of urine does not in all cases follow shot 
wounds of the bladder may possibly be due to the circumstance, as is popu- 
larly believed, that soldiers go into action with empty bladders, but more 
probably is to be accounted for by the reason given by Larrey, that the pas- 
sage of the ball leaves an eschar which closes the opening. Be this as it may, 
there can be little doubt that the prospects of recovery after a shot wound of 
the bladder will be enhanced when the wound is far removed from its base 
and the organ undistended with urine at the time of the injury. 
Balls and other substances, after entering the bladder, form nuclei for uri- 
nary concretions. One case of this kind came under my observation several 
years ago. This patient was relieved of his calculus by Dr. Forwood, of 
Chester, who operated with equal success on a second case of a similar nature. 
The records of Otis and those of Dixon J exhibit 32 operations for the removal 
of calculi formed about projectiles which had entered the bladder, 13 of which 
number were done by American surgeons. Foreign matters, such as cloth 
or bone, which had entered the bladder, have been passed through the urethra. 
Several instances of this kind occurred during our late war. 
Incised and lacerated wounds of the bladder are not common accidents. 
Punctured wounds are more frequently encountered, being produced by 
splinters broken off from the pelvic bones, and sometimes by the point of a 
* Des Plaies et des Ruptures de la Vessie. 
f Surgical History of the War of the Rebellion, Part II. vol. ii. p. 264. 
j Dixon, Medico-Chirurg. Trans., 1850, vol. xxxiii. p. 19. 470 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
bougie in cases of difficult catheterization, the anterior wall near the neck 
usually being the seat of the wound. 
Symptoms.—When the lesion is rupture of the bladder, there follow dif- 
fused pelvic pain, great anxiety of countenance, collapse, vesical tenesmus. 
ha3maturia, and, unless the rupture be extra-peritoneal, inability generally 
to pass water voluntarily. If, in addition to these symptoms, a catheter 
introduced into the bladder draws nothing but a little blood, and if the 
statements of the patient furnish reasonable evidence that no urine had 
been passed for some hours before the injury, the existence of rupture may 
be regarded as almost certain. 
In estimating the value of catheterism as a means of diagnosis, it must not 
be overlooked that it is possible to draw a large quantity of urine even after 
a rupture of the bladder; but in such cases the instrument passes through 
the rent and enters the peritoneal sac, into which the extravasated fluid has 
escaped. Another point of importance connected with the use of the catheter 
as a means of diagnosis is the difficulty of rotating the instrument within 
the bladder when its walls are collapsed, and the tardy manner in which the 
urine, when present, flows, due to the failure of the muscular walls of the 
viscus to contract. If the rupture is intra-peritoneal, the symptoms of peri- 
tonitis soon develop. The patient will be found with a rapid, feeble pulse, 
pinched countenance, tympanitic belly, thirst, and vomiting, maintaining a 
dorsal decubitus and with the knees drawn up. 
The surgeon may call to his aid in a doubtful case the use of vesical in- 
jections of a harmless fluid, like that of Thiersch, which consists of boracie 
acid seventeen parts, salicylic acid two parts, and water one thousand parts: 
this should be thrown into the bladder through a catheter, and if no dis- 
tention of the viscus follows, the evidence of a rent in its walls is clear. 
When there is an external wound, or when there is the additional compli- 
cation of a wound of the rectum, and the urine escapes through one or both 
of these channels, the symptom of bladder-lesion is conclusive. The duration 
of life after rupture of the bladder rarely extends beyond four or live days, 
and when thus prolonged it is an evidence that the rent is through the 
non-peritoneal portion of the viscus. When the injury involves the parts 
covered by the serous membrane, the intense peritonitis which quickly 
follows will destroy life in from twenty-four to forty-eight hours. In some 
instances of this injury the patient has died in a fewT hours, never coming 
out of the state of collapse. 
The pathological appearances which are found after wounds of the bladder 
differ according as the extravasation is fascial or peritoneal. When the 
former, the pelvic connective tissue is found necrosed and interpenetrated 
by urine, serum, blood, and pus. When the extravasation is peritoneal, the 
cavity of the abdomen contains a large amount of dirty serum, in which 
are suspended numberless flakes of lymph, the latter also adhering, like an 
incrustation, both to the reflected and to the visceral layers of the serous 
membrane. Though in some cases there will be found a feeble agglutination 
of the intestinal loops, yet generally only a few adhesions exist, the inflam- 
matory transudation not being capable of organization. 
Treatment.—The indications in the treatment of wounds of the bladder 
are to remove the extra vasated urine, disinfect the parts which have been 
exposed to contact with the contents of the bladder, close the rent in the 
latter, and provide for the constant removal of the urine. To effect the first 
indication, that of getting rid of the extravasated urine, it has been suggested 
to pass, when feasible, a long catheter through the lesion in the walls of the 
bladder, and remove the urine through the natural passages. It has also 
been proposed to introduce a long aspirating needle through the abdominal 
parietes into the pelvis,—or, in the case of a female, through the utero- 
vaginal interspace into Douglas’s cul-de-sac,—and draw out the urine. If the 
wound were situated in the pre-vesical space, the aspirating-needle would only 
be required to pass behind the pubes. Lastly, the operation of laparotomy WOUNDS OF THE PROSTATE BODY. 
471 
is recommended, and it is the only one that is entitled to confidence, the only 
one that enables the surgeon to fulfil satisfactorily all the indications. 
Operation.—The pre-vesical space, as in the suprapubic operation for stone, 
must first be opened, and if the rent is found to be above or within the peri- 
toneum, the wound will require to be enlarged upwards. The opening having 
been discovered, its sides should be held together, temporarily, by means of 
pressure-forceps, the blades being well protected by rubber shields. The 
surgeon next proceeds to disinfect the peritoneal cavity by washing out the 
abdomen and pelvis with Thiersch’s mixture. The rent is then to be sutured. 
Three methods of applying the suture have been practised,—by an ordinary 
running, or over-and-over, stitch (glover’s); by an interrupted one of either 
aseptic silk or catgut, including the muscular and submucous layers; and 
by a Lembert when the rent is intra-peritoneal. The single sero-serous or 
Lembert suture will be sufficient, and should include all the tunics of the 
bladder, except the mucous. If the wound is in the pre-vesical part, the 
glover’s suture will answer the purpose well. The introduction of the 
sutures will be facilitated by first passing a couple of long threads through 
the coats of the organ, by which to hold it in the proper position. The 
accuracy of the closure should next be tested, by injecting into the bladder 
a few ounces of a solution of boracic acid: if it be found water-tight, the 
cavity of the abdomen, if opened, should be again flushed with the anti- 
septic solution, and the external wound closed and dressed with the usual 
antiseptic dressings. A soft catheter should now be tied in the bladder, 
and the latter drained for four or five days, the instrument being changed 
once every twenty-four hours. If peritonitis should have developed, a glass 
drainage-tube bad better be placed in the abdominal cavity. 
We are greatly indebted to Sir William MacCormac for the forcible manner 
in which he has presented to the profession the subject of laparotomy and 
vesical suture in rupture of the bladder. The tables of this distinguished 
surgeon comprise sixteen cases in which rupture of the bladder has been 
treated by laparotomy and suture. Adding to these five cases collected 
by Grant,—one by Holmes, one by Grant, one by Keyes, one by Hitch- 
cock, and one by Fox,—we have twenty-one cases. In two of the cases the 
lesion was not intra-peritoneal, and one was doubtful. Excluding the doubt- 
ful one, we have twenty cases, with seven recoveries and thirteen deaths. It 
is proper to state that in Walters’s case the suture was omitted. Should rup- 
ture occur through that portion of the bladder corresponding to the vesical 
triangle,—that is, behind the prostate and between the vesicuiae seminales,— 
a non-peritoneal portion of the organ, the urine will escape into the cellular 
tissue of the pelvis. In such a case the perineum should be laid open as in 
the lateral operation for stone, the urine and inflammatory products evacu- 
ated, the cavity injected with a solution of the bichloride of mercury (one 
to two thousand), and a drainage-tube carried to the bottom of the wound. 
There will be little need for using the catheter in a case of this kind. 
Should peritonitis arise, leeches over the abdomen and saline cathartics 
administered so as to keep up a moderate action of the bowels ai’e the 
remedies to be first employed. Hot flaxseed poultices placed over the abdo- 
men will tend to alleviate suffering. Opium may be given when the pain is 
severe. Thirst should be allayed by small bits of ice; and for nourishment 
milk will be sufficient. 
Wounds of the Prostate Body.—Wounds of the prostate, other than those 
produced by the maladroit use of the catheter or the bougie and those de- 
signedly made in the operation for stone or in perineal section, are exceed- 
ingly rare. Not more than seven cases of shot wounds of the gland were 
observed during our late war, all of which, with a single exception, proved 
fatal, not from the lesion in the prostate body, but from concomitant damage 
to the organs or to the vessels within the pelvic cavity. 
Symptoms.—In one of the cases of shot injury, priapism was mentioned as 472 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
a prominent symptom. The discharge of blood through the urethra and of 
urine by the wound, and the existence of pain in micturition and defecation, 
possess little diagnostic value, as these symptoms may be present in other 
pelvic injuries, as, for example, in wounds of the bladder and the rectum. A 
digital exploration through the rectum, a catheter being at the same time 
placed in the bladder, will enable the surgeon to determine the presence of a 
foreign body, if such has lodged in the gland, and also to detect lacerations 
or loss of its substance. 
In view of the attendant complications, no specific instructions can be given 
as to treatment. Should there be retention of the urine, the catheter will be 
required to empty the bladder. If abscesses form in the loose connective 
tissue of the perineum, the latter must be laid open and the pus evacuated. 
Should urinary infiltration follow, a statf must be introduced into the bladder 
and the viscus laid open by a free incision through the prostate, as in the 
lateral operation for stone, the wound being allowed to close by granulation. 
Wounds of the Anus and Rectum. 
Wounds of the anus and rectum may be incised, punctured, lacerated, and 
gunshot. 
Incised wounds are not common, and when met with they are generally 
either accidental, as when produced by the knife in dividing the neck of the 
bladder in lithotomy, or designed, as in the operation for fistula in ano. 
In one instance, that of a Catholic clergyman. I witnessed a rupture of the 
sphincter ani caused by violent muscular efforts made in the act of defecation. 
Punctured wounds result from falls upon the handles of hay-forks or upon 
the rounded or pointed posts of chairs and iron rods, and from the too forcible 
use of the rectal bougie in cases of stricture. 
Hall* records a singular case of punctured wound of the rectum in a man 
who fell some distance upon the stem of a tree the size of a walking-stick. 
It entered the anus, passing up the bowel a distance of ten inches, or until 
arrested by his feet striking the ground. Not only was the rectum torn, 
but the bladder also was opened, the urine escaping for days from the anus. 
The patient, notwithstanding the formidable nature of the wound, entirely 
recovered. A similar accident is recorded in the “ London Medical Gazette,”f 
in which a chair-leg entered the anus, penetrated the anterior wall of the 
rectum, passed into the bladder as high as its apex, and wounded the peri- 
toneum. The injury proved fatal in twenty-four hours. 
Dr. Forwood.J of Maryland, met with a case of rectal injury produced by 
the sharpened foot of a chair entering the ischio-rectal fossa and penetrating 
the bowel above the upper sphincter; and Dr. Compton,§ of Indiana, reports 
a wound of this nature made by a man sitting down upon the sharp extrem- 
ity of a corn-stalk. The careless use of the clyster-pipe has been known to 
produce a wound of the rectum. Mayo relates such a case, in which, after 
the perforation, the injection was thrown into the abdomen, destroying the 
patient by peritonitis. Professor Pope gives the history of a child who 
was fatally injured in this way ; and a professional friend some years ago 
communicated to me the details of a serious pelvic cellulitis induced by the 
bungling use of the injection-pipe. 
The rectum may also be detached from its surrounding connections without 
its walls being opened. A young woman was brought into the University 
Hospital with such an injury, the bowel having been torn from the sacrum 
by a car-bolt in a railroad accident, from the effects of which she died. 
Lacerations of the anus and rectum are sometimes caused by the horns of 
enraged animals, and quite frequently by the foetal head when too long in 
contact with an over-distended perineum. In such instances the perineum 
is first torn, the rent afterwards extending into the bowel. 
* American Journal of the Medical Sciences. 
I Medical and Surgical Reporter, September, 1876. 
f February, 1847. 
g Ibid., Nov. 18, 1876. GUNSHOT WOUNDS OF THE RECTUM. 
473 
Symptoms.—These wounds are followed by profuse bleeding, from the injury 
sustained by the hemorrhoidal vessels. The hemorrhage from the veins is 
often more profuse than that from the arteries. A simple inspection of the 
parts with the eye, especially when the anus is involved, will be sufficient to 
detect the injury. When higher up in the bowel, a linger introduced into 
its cavity will serve to discover any opening which may exist, and if an ex- 
ternal wound is present, a probe passed through it may be made to touch the 
linger in the bowel, should there be a communication between the two. The 
escape of air or of faeces through the wound in the contiguous parts will serve 
to reveal its true nature. When there is no external opening, the use of the 
anal speculum will afford valuable assistance in determining the presence of 
an internal one. It is in cases where an internal opening alone is present that 
the escape of the contents of the rectum into the surrounding parts produces 
inflammation and suppuration in the connective tissue of the perineum. 
Prognosis.— When the wound is a lacerated one, and there is much dis- 
turbance of the surrounding connections of the rectum, there is always ground 
for anxiety. Hemorrhage, diffuse cellulitis, abscesses, sloughing, pya3mia, and 
peritonitis are the probable consequences of such an injury. 
Treatment.—Wounds of the anus demand little attention; they heal up 
kindly in a short time, requiring only cleanliness and the use of water- 
dressings. When the rectum is involved, the great object is to prevent fiecal 
and gaseous extravasation, and to insure the absolute quietude of the parts 
for a few days. To accomplish these indications, the rectum should be cleared 
of all faecal matter by repeated injections of solution of boracic acid, of the 
strength of from one to two drachms to the pint of water, after which opium 
must be given in doses sufficient to guard against the descent of the con- 
tents of the intestine into the rectum, for a period of eight or ten days, by 
which time we may hope that the wound in the bowel will be closed. To 
prevent faecal or gaseous extravasation, if the rectum cannot be kept empty, 
the sphincters should be divided, so as to allow a free escape from the gut. 
The diet should consist chiefly of cold scalded milk, so as to have as little 
effete matter as possible remaining in the bowels. After the lapse of twelve 
days a very gentle laxative may be administered, such as a compound rhu- 
barb pill, or the compound liquorice powder, either of which will give a solid 
stool. 
Should the wound fail to heal by this plan of treatment, there remains but 
one course, namely, that of laying the parts open from the perforation to the 
surface, as in anal fistula, and then allowing the chasm to fill up by granula- 
tion ; or, if the wound is too deep for the safe use of the knife, by introducing 
the elastic ligature and dividing the parts by the slower process of ulceration. 
Gunshot Wounds of the Rectum.—Such wounds were by no means uncom- 
mon during our late war, and frequently proved fatal from hemorrhage, 
pelvic extravasation of faeces, and exhausting suppuration. The hemorrhage 
may come from the hemorrhoidal, gluteal, or iliac vessels. Shot wounds of 
the rectum are frequently complicated with similar injuries of the bladder, 
also with faecal or anal fistulae, with paralysis of one or both of the lower ex- 
tremities, with injury to the sacral nerves, and with fracture of the bones 
of the pelvis. 
During our late war there were 103 cases of shot wounds of the rectum 
collected by Otis, with a mortality of 42.7 per cent. The bladder was im- 
plicated in 34 of these wounds, with a mortality of 41.17 per cent. 
Treatment.—The great indications in gunshot wounds of the rectum are 
to arrest hemorrhage and to prevent faecal extravasation. The control of 
bleeding—when from the bowel—is best effected by dilating the gut with a 
speculum and searching for the point whence the blood issues. When found, 
the vessel, with some of the surrounding tissue, should be lifted by a tenacu- 
lum, and a thread passed over the instrument with a pair of forceps. To tie 
the ligature—with the finger—in such a location is no easy task. It may be 474 
WOUNDS AND DISEASES OF ABDOMINO-PELVIC CAVITIES. 
accomplished with Carroll’s instrument (Fig. 374), or, what is more practi- 
cable, the vessel may be seized with a haemostatic forceps, the blades locked, 
and the instrument allowed to re- 
main. When the hemorrhage comes 
from several points, or from an ex- 
tensive surface of the intestine, a 
fenestrated wire speculum should 
be introduced, by which the bowel 
can be well dilated. The free ad- 
mission of air, and the stretching 
to which the parts are subjected, 
will produce a haemostatic effect, 
or, if this is not sufficient to arrest 
the flow, a stream of ice-water, 
alum-water, or dilute Monsel’s so- 
lution of iron may be thrown con- 
tinuously from a syringe into the 
cavity of the gut: should this fail, 
the surgeon may resort to packing 
with iodoform gauze. The instru- 
ment of Dr. Bushe (Fig. 375), con- 
sisting of a bladder fitted to a nozzle 
with a stopcock, is used for the 
same purpose. The bladder is 
passed into the rectum, and after- 
wards filled with ice-water. Thus 
distended, it not only communicates 
cold to the parts, but also acts as a 
compress. At the same time the 
hips of the patient should be ele- 
vated, in order to relieve the hem- 
orrhoidal vessels from the blood- 
pressure. 
To prevent faecal extravasation, 
Fig. 374. 
Fig. 375. 
Carroll’s knot-tying instrument. 
Bushe’s compressor for hemorrhage 
from the rectum. 
the sphincters may be divided, as practised by Dupuytren, Simon, and several 
American army surgeons. Though not always successful in obviating such 
extravasation, the operation undoubtedly promises better results than can be 
obtained from any other measure at our command. CHAPTER IX. 
DISEASES OF THE ABDOMEN. 
Diseases of the Umbilicus. 
Hemorrhage.—Bleeding from the umbilicus of new-born children, after the 
separation of the ligature from the cord, occasionally occurs, and in some 
instances becomes very serious in its consequences. When the hemorrhage 
is obstinate, it is ordinarily associated with some vice of the general system, 
and in a majority of cases will prove fatal. The treatment consists in first 
attempting to arrest the flow by astringents, such as alum, the subsulphate 
of iron, or styptic cotton. Should these not succeed very soon, it will be 
necessary to resort to some more decided measures, as infants bear the loss 
of blood badly. The actual cautery or the solid nitrate of silver may be 
applied to the bleeding surface, or a pin may be pushed through the base of 
the navel and surrounded by a ligature. 
Ulceration.—This is met with both in infants and in adults. In the 
former after the separation of the ligature from the cord there is left a 
raw stump which refuses to heal, from which purulent matter is discharged, 
and which also, when rudely touched, bleeds quite freely. In adults ex- 
coriation and ulceration arise, either from negligence in keeping the parts 
clean, or, in very obese persons, from the contact of adjoining surfaces, by 
which the cuticle becomes macerated and detached in the retained per- 
spiration. The best remedies in all these cases are frequent ablutions, and 
dusting the parts with calomel and prepared chalk (equal parts). If this 
fail, the surface of the ulcer should be lightly touched every three or four 
days with the nitrate of silver or with iodoform. 
Morbid growths.—Fibrous growths, though quite uncommon, are occasion- 
ally seen to spring from the bottom of the umbilical depression. Their at- 
tachment is either pedunculated or sessile, and sometimes extends beyond 
the circumference of the navel. They are smooth upon the surface, firm 
and inelastic to the touch. A more common growth is one consisting of 
hypertrophied cutaneous papilla?,—a variety of papilloma,—the surface of 
which is irregular, consisting of rod-like eminences, and often becoming foul 
with offensive discharges. As long as these tumors remain quiet they should 
be left alone, or at most be carefully cleansed. When they continue to grow, 
their removal may be accomplished by the scissors or knife, or by strangu- 
lation with a ligature. When their attachment is pedunculated, the latter 
answers every purpose. By whatever method they are taken away, the 
surface left should be treated with nitric acid, or caustic potash, to prevent a 
return. 
Cysts.—A collection of fluid sometimes takes place between the peritoneum 
and the abdominal parietes,—a form of encysted dropsy,—which, should it 
happen to be beneath the umbilicus, may protrude that structure and form 
an external swelling. This cannot, however, be properly considered an 
umbilical cyst. Such enlargements may be confounded with hernia. A case 
was related to me in which an attempt was made to remove what was supposed 
to be such a cyst but which proved to be an umbilical hernia. The reduci- 
bility of hernia, at least in its early history, and, in most instances, its reso- 
nance, neither of which belongs to cysts, will assist in establishing a distinction 476 
DISEASES OF THE ABDOMEN. 
between the two diseases. A resort to the aspirating-needle will also serve, 
in some degree, to clear up doubts. Tapping and the injection of iodine will 
be the proper treatment when the disease is progressive. 
Carcinoma.—The most common form of malignant umbilical disease is 
epithelioma; but some years ago I saw what I believe to have been a true 
scirrhus of this part. The growth of malignant disease is characterized by 
induration, pain, and a pimply, black discoloration of the skin. It may de- 
velop both internally and externally. The skin sometimes becomes inflamed, 
and ulceration follows, constituting a very offensive and spreading sore. Un- 
fortunately, the surgeon’s duty is limited to directing such agents as will 
promote cleanliness, relieve pain, and sustain the system, though when early 
detected excision should be practised. 
A variety of fistula) occur at the umbilicus, some of wThieh are congenital, 
and others inflammatory, in their origin. They are as follows: 
Urinary fistula.—The urachus may remain open at birth, and the urine 
escape at the umbilicus, forming a fistula. An early effort should be made 
to secure its closure by applying to its orifice nitric acid on a silver probe. 
A child was once brought to my clinic in which the urachus had not closed. 
There was no fistulous opening in the umbilicus, but the latter became dis- 
tended when the urine was allowed to accumulate in the bladder. I am 
unable to say whether the defect proved permanent. 
Stercoraceous fistula.—In consequence of a blow over the umbilical region, 
a limited peritonitis may be developed, and a portion of intestine become 
glued to the parietes posterior to the navel. This may ulcerate and open 
through the latter. The opening requires to be kept free from obstruction, 
and after a few weeks, should the fistula show no tendency to close, an 
attempt may be made to close it by freshening the edges and uniting them 
with the twisted suture. 
Ovarian fistula.—I saw in a distant part of Pennsylvania, in the person of 
a lady, an umbilical fistula which communicated with the right ovary. At 
the time of my visit it was obstructed with rolls of hair; fragments of bones 
were also occasionally discharged. The cause leading to this fistula was a 
very tedious and difficult labor, followed by pelvic cellulitis, after which the 
swelling and ulceration at the umbilicus took place. This lady made a per- 
fect recovery. Such cases are best left for a time to nature, only observing 
to keep the channel clear when signs of obstruction exist. When no amend- 
ment takes place, ovarectomy may be performed. 
Ascites. 
Ascites is a collection of fluid in the peritoneal sac. It may be obstructive 
or inflammatory. 
Under the head of obstructive causes may be enumerated disease of the 
liver, spleen, kidneys, and heart, and also the presence of ovarian and 
uterine tumors. Whatever tends to retard the flow of blood through the 
vena cava ascendens favors abdominal dropsy. The inflammatory origin 
of ascites is peritonitis, generally the chronic form of the disease, which 
may be induced by mechanical pressure. Thus we see large accumulations 
of abdominal fluid following the presence of an ovarian cyst, uterine growths, 
and malignant disease of the omentum. As these roll about in the abdomen, 
rudely rubbing against the surface of the peritoneum, they provoke inflam- 
mation, followed by the transudation of serum. The serous membrane in 
cases of this nature is often much thickened by plastic deposit and likely to 
be adherent to the growth which causes the inflammation. Acute perito- 
nitis, should the patient not die from shock during the developmental stage, 
is attended with more or less serous effusion. 
The fluid in ascites is usually of a straw color, not unlike that present in 
hydrocele. It coagulates by heat, is somewhat unctuous to the feel, and con- 
tains various saline materials. When it is the result of acute peritonitis, the ASCITES. 
477 
fluid differs in several particulars from that having an obstructive origin or 
that which is caused by chronic inflammation. In the first or acute form, it 
is of a reddish tinge or presents a dii’ty-brown appearance, has a sickly 
odor, and contains numerous flakes of lymph, and also purulent matter. It 
is a dangerous fluid, and seems charged with a highly active poison, often 
producing, when applied to a scratch or a puncture, severe local and general 
septic poisoning. 
Symptoms.—Abdominal dropsy usually appears in a gradual manner. It 
is preceded by oedema about the ankles and feet, which slowly extends up 
the leg and thigh and sometimes to the integument of the penis and scrotum. 
In Bright’s disease of the kidneys, it is not uncommon to see the connective 
tissue of the entire surface, from the roots of the hair to the soles of the feet, 
filled with serum, as also the serous-lined cavities of the body. If pressure 
be made for a few moments with the finger upon the oedematous parts, the 
fluid will be displaced, and a depression will remain for some time after. This 
is called ££ pitting.” Those portions of the body on which rests its weight in 
sitting or in lying will often, for the same reason, present large indentations. 
As the fluid accumulates in the abdomen, its anterior and lateral walls be- 
come distended. This distention is first seen at the lower part of the body, 
towards which the fluid naturally gravitates. The height of the collection 
can be very clearly ascertained by placing the patient in the upright position 
and percussing the abdomen from above downwards. The line at which the 
resonance ceases and the sounds become flat will indicate the position of the 
effusion. The fluid does not float the intestines forward, but occupies the 
space between the bowels and the parietes. If the fingers be placed on one 
side of the abdomen and the opposite wall be lightly tapped with the other 
hand, fluctuation may be recognized, becoming more and more distinct as 
the distention increases. As the disease advances, the fluid at length presses 
against the diaphragm, thus resisting the descent of this muscle in respira- 
tion, causing great difficulty of breathing, and compelling the patient to 
maintain the sitting posture in bed; the urine diminishes in quantity, the 
appetite fails, the pulse becomes frequent and feeble, emaciation progresses, 
and the sufferer finally dies from exhaustion. 
Diagnosis.—Ascites may be confounded with ovarian disease, with preg- 
nancy, with distended bladder, and with abscess. From ovarian dropsy 
ascites may be distinguished by the previous history of the patient, the former 
disease being generally very slow in its progress and not seriously involving 
the general health for a long time after its appearance, while in the latter, im- 
paired health often precedes, and always accompanies, the abdominal swelling. 
.Not only so, but a careful interrogation of the internal organs will generally 
reveal some structural change as the cause of the dropsy, such as valvular 
disease of the heart, cirrhosis of the liver, or disease of the kidneys, as mani- 
fested by the presence of albuminous urine and casts from the uriniferous 
tubes. The position of the swelling in its incipiency will also throw light 
upon the subject, being median in ascites and unilateral in ovarian dropsy. 
In the latter the sac is frequently multilocular, the constrictions correspond- 
ing to the partition-walls of the cyst, and the irregularities of its surface 
may be distinctly felt through the parietes of the abdomen. In ascites the 
fluid, when in large quantity, presses out the flanks, while in ovarian disease 
there is an absence of this bulging, the projection being for the most part 
directly forward. When the practitioner remains uncertain in his diagnosis, 
an exploring-needle or trocar may be introduced with a view to examine the 
appearance of the fluid, which in ascites is ordinarily thin and of a straw or 
amber color, whereas that from ovarian cysts, with now and then an excep- 
tion, is ropy, viscid, thick, even gelatinous in consistence, and has a dark- 
yellow or brown color. 
From pregnancy, ascites may be distinguished by the following considera- 
tions : in the former there are nausea, vomiting, capricious appetite, enlarged 
mammary glands, brown discoloration around the nipple, a firm, inelastic, 478 
DISEASES OF THE ABDOMEN. 
uniform swelling in the median line, a flat percussion without fluctuation, 
absence of the menstrual discharge, and finally the sound of the foetal heart, 
together with the test of “ ballottement.” The general health in pregnancy 
is not much disturbed; in ovarian dropsy there is usually loss of flesh and 
strength. 
To confound ascites with a distended bladder is a mistake not likely to 
occur; yet the error has been committed, as I have reason to know. In 
distended bladder there is more or less desire to pass urine, the patient fre- 
quently making ineffectual efforts to micturate, attended with much distress 
about the penis and bladder; the swelling is median, smooth, without fluc- 
tuation, and may be felt through the walls of the rectum. It also attains a 
considerable size in from twenty-four to thirty-six hours. Should any doubt 
remain, the introduction of a catheter will solve it by simultaneously re- 
moving the contents of the bladder and those of the tumor. 
Abscess in the walls of the abdomen may simulate ascites, chiefly from the 
presence of fluctuation. The unilateral position, and the occurrence of chills, 
with perspiration and other hectic symptoms which belong to the former, 
will serve to establish the distinction. The exploring-needle here, as in many 
other swellings, will render the diagnosis clear. 
Ovarian dropsy and even the gravid uterus have been mistaken for abdom- 
inal dropsy, or ascites. To confound the latter with a unilocular ovarian cyst 
preparatory to puncturing the abdomen would not be a serious error, but to 
thrust a trocar into the gravid womb would be a dangerous and an unpar- 
donable mistake. Ascites differs from ovarian dropsy both in the form of 
the swelling and in the character of the fluid. In the former the distention 
of the walls of the abdomen is quite uniform, with more or less protrusion 
of the flanks, the flatness and fluctuation being recognized over all parts of 
the surface. In ovarian dropsy the flatness on percussion and the fluctuation 
on palpation are confined to the central region of the abdomen, the sides or 
flanks being quite resonant. Should the operator still remain in doubt, resort 
may be had to the grooved needle, the fluid of ascites being oi’dinarily of a 
straw color, while that of an ovarian cyst is generally dark, resembling soft 
soap. The existence of pregnancy may be determined by the cessation of the 
menstrual flow and the absence of fluctuation. On making a vaginal ex- 
amination, the uterus will be found to have risen out of the pelvis, its neck 
being absorbed in the general enlargement of the organ and the os soft and 
compressible. 
Prognosis.—The prognosis is exceedingly unfavorable, as the disease gen- 
erally depends upon structural change in organs, such as the heart, kidneys, 
and liver, over which our remedies have little control. 
Treatment.—The indications in the treatment of ascites are to remove 
the fluid and to correct, as far as possible, the causes which give rise to its 
production. There are two methods of accomplishing the first,—that is, the 
evacuation of the fluid,—namely, the therapeutic and the operative. In 
employing the first of them we aim to act chiefly upon the skin, the kidneys, 
and the intestinal canal, or upon all. In order to stimulate the kidneys, in 
my experience there is no better diuretic than the infusion of digitalis. A 
dessertspoonful should be given every four or five hours until the secretion of 
urine is largely increased. Or it may be necessary to combine a cathartic 
and diuretic. A very popular combination is bitartrate of potash and juniper- 
berries. Where the patient is not too much exhausted, the old formula of 
Eberle I have found to answer an admirable purpose: 
R Potassii Bitartratis, 
Potassii Sulphatis, gss; 
Pulveris Scillse, gii ; 
Antimonii et Potassii Tartratis, gr. i. 
M.—8. One teaspoonful every four hours until 
active purgation and diuresis follow. PARACENTESIS ABDOMINIS. 
479 
When the abdominal dropsy and oedema are due to cardiac disease, the use 
of small doses of calomel, with squill and digitalis, often does much good: 
R Hydrargyri Chloridi Mitis, gr. v ; 
Pulv. Scillse, 
Pulv. Digitalis, aa gr. xx. 
M.—Ft. chartulae no. xx. 
Sig.—One powder four times a day. 
In many cases, however, neither diuretics nor hydragogue cathartics will 
make any impression upon the disease, the pressure exerted upon the kid- 
neys and other organs within the abdomen by the fluid defeating their action. 
In such an event it becomes necessary to resort to operative measures. 
Paracentesis Abdominis.—This operation, though a very simple one, should 
not be undertaken until the distention becomes a source of marked distress, 
or is accompanied with obstinate vomiting, a condition more common in 
ovarian than in abdominal dropsy. The proper point at which to puncture 
the abdominal wall is in the median line, about two inches below the um- 
bilicus. A trocar and canula (Fig. 376), a thumb-lancet, a basin, and a strip 
of adhesive plaster, with a four-tailed bandage sufficiently long to go twice 
round the body and broad enough to include the entire surface of the abdomen, 
are all that is required for the operation. 
The only caution which need be given in the use of the trocar, is to be sure 
that the intestine does not lie in contact with the abdominal wall at the 
Fig. 376. 
place where the instrument is made to enter. Carelessness on this point 
has resulted in a wound of the bowel. 
The patient, having emptied the bladder, may sit upon the edge of a bed, 
with the feet resting upon a stool and the back supported either by pillows 
or by a friend, or, if too weak to maintain the upright position, may lie on 
the side, close to the edge of the bed. The body of the bandage being now 
placed over the front of' the abdomen, the tails are to be crossed behind the 
back, those on the right passing over to the left and those on the left passing 
over to the right, and are given to an assistant on each side. The surgeon 
then makes an opening in the body of the bandage over the median line, two 
inches below the umbilicus; through this he punctures simply the skin with 
the thumb-lancet, and immediately thrusts in the trocar, guarded by the index 
finger fixed one inch and a half from the extremity of the instrument (Fig. 
377), pushing it onwards until all resistance is overcome, when it should be 
withdrawn, leaving the canula in place. The fluid should be received into 
a basin, and when the latter is full the operator can place a thumb or finger 
against the extremity of the tube, temporarily arresting the flow until the 
vessel is emptied into some receptacle and returned, when the fluid may be 
again allowed to discharge. As the accumulation is withdrawn, the bandage 
should be tightened up by drawing upon its tails, thus supplying to the vis- 
cera and blood-vessels the pressure which they have lost from the abstraction 
of the fluid, and in this way preventing that sense of sinking or fainting which 
occasionally follows tapping. Should the patient grow pale, sick, and weak 
during the operation, a little brandy-and-water may be given, and, if in the 
sitting posture, the position may be changed to one on the side. The canula 
may become obstructed from a loop of intestine, or from masses of lymph 
or from blood-clots causing an impediment to the flow: in such an event a 
Trocar and canula for tapping the abdomen. 480 
DISEASES OF THE ABDOMEN. 
change in the position of the instrument, or a knitting-needle or probe passed 
through its canal, will serve to clear away the obstruction. As soon as the 
fluid has been discharged, the canula should be removed, the opening covered 
with a strip of adhesive plaster, and the tails pinned either to one another or 
to the body of the bandage. 
Fig. 877. 
Tapping in abdominal dropsy. 
There are trocars in use which differ from the one described by having a 
branch-pipe, to which a piece of rubber hose can be attached, for conducting 
the water into a vessel under the bed or out of the way. (See Fig. 353.) 
An aspirator also answers the purpose admirably. 
Encysted dropsy of the abdomen is occasionally met with,—that is, an 
accumulation of serum cut off from the general peritoneal sac. The circum- 
scribing walls of these cysts are the result of a chronic peritonitis. In three 
cases recorded by Dr. William Pepper,* the cause was doubtless traumatic, 
and was most probably due to the stimulus of coagulated blood within the 
peritoneum. The walls of these cysts may be constituted in various ways: 
sometimes they are formed by the peritoneum in front and the omentum 
behind; sometimes by the omentum in front and a portion of the intestines 
posteriorly, a number of coils having been glued together by inflammatory 
lymph ; and in other instances by the folds of the omentum alone. The 
fluid which they contain is clear serum. These cysts may be converted into 
purulent sacs, as in the interesting case reported by Dr. Mears,f in which two 
gallons of a purulent fluid were drawn from a cyst between the omentum 
and intestines. In a similar case I drew over three gallons from a cyst on 
the right side of a female patient. 
The existence of such cysts will be indicated by the circumscribed character 
of the swelling, by their yielding a flat percussion-sound, and by the surround- 
ing portions of the abdomen being resonant; also by the fixed position and 
unchanging character of the enlargement, in whatever position the patient 
may be placed. When transformed into a pus-cavity, there will be a liistory 
of previous chills and possibly hectic symptoms. 
The treatment of encysted dropsy consists in evacuating the fluid by the 
trocar or aspirator, as in abdominal dropsy. The tapping may require to 
be repeated, and, if there follows a steady diminution in the size of the swell- 
ing, nothing else may be required. When cysts suppurate, it will be best to 
open them, evacuate the contents, and treat by drainage-tubes and antiseptic 
fluids. 
In cases which require frequent tapping I have, after drawing off the fluid, 
introduced a drainage-tube into the abdomen, and in this manner obviated 
the necessity for using subsequently the trocar. 
* Transactions of the College of Physicians, vol. i., 3d ser., 1875, p. 181. 
f Ibid., p. 171. I NTES TINA L OBSTR UCTION. 
481 
There is a variety of peritonitis designated as tubercular, which is charac- 
terized by the effusion of serum into the abdominal cavity, accompanied by 
plastic deposits over the peritoneum and the presence of tubercle-bacilli. 
The disease is to be suspected when the signs of peritonitis are present 
without any of the ordinary organic causes being detectable. Febrile phe- 
nomena may or may not exist. Opening the abdomen and washing out 
the cavity with antiseptic fluids, as Thiersch’s solution, or, better, boracic 
acid solution, followed by drainage with a glass tube, has effected a perfect 
cure. 
A preliminary tapping may be adopted in these cases, with a view to a 
diagnostic purpose, the liquid having been found to contain the germs. 
Intestinal Obstruction. 
By intestinal obstruction is meant the existence of any obstacle to the 
passage of the fecal contents of the bowel. The causes which produce this 
condition are numerous, the most common ones being bands, invagination, 
twists, diverticula, enteritis, impaction by biliary calculi, enteroliths, stric- 
tures, hardened feces, and tumors. Dr. Wilks* describes a rare form of 
congenital obstruction which affects the duodenum of infants and is attended 
with constant vomiting. 
From whatever cause the obstruction arises, when the onset is sudden and 
the symptoms urgent the disease is said to be acute. When, on the contrary, 
the attendant phenomena come on and progress slowly, the pain, tympanitis, 
abdominal tenderness, and gastric irritation being only moderately severe, 
the case is one of chronic obstruction. 
Deaths from intestinal obstruction are so numerous that the subject is one 
invested with more than ordinary importance. In Germany, on the author- 
ity of Professor Poser, of Marburg, 4000 deaths occur annually from this 
cause, and in England, with a population of 26,000,000, there were during a 
single year (1882) 1820 deaths from the same cause. 
Intussusception or invagination.—In this form of obstruction the upper part 
of a portion of the intestine slips into a segment of the gut below, very much 
as the finger of a glove is turned back upon itself. (Fig. 378.) It may 
take place at any portion of the small or large intestine, and is sometimes 
multiple, existing at two or more points in the course of the 
bowel. Some writers have denied that intussusception ever 
occurs in the small intestine. I have myself seen it involving 
this part of the bowel in several places, and in Mr. Gay’s 
collection of casesf it was found thirty-three times in this 
part of the tube, though it is situated usually at the ileo- 
csecal union. Treves estimates the relative frequency of in- 
tussusception in different portions of the intestine as follows: 
61 per cent, in the ileo-crecal, 52 per cent, in the colon, 24 
per cent, in the enteric and 23 per cent, in the ileo-colic por- 
tion of the intestine. Leichtenstern’s statistics vary some- 
what from the above, and are based on an analysis of 100 
cases, 44 per cent, of which were ileo-caecal, 30 per cent, 
enteric, 18 per cent, colic and rectal, and 8 per cent, ileo-colic. 
Bulteau’s collection of 763 cases of obstruction gives 51.4 
per cent, for the ileo-csecal, 28.8 per cent, for the small in- 
testine, and 19.8 per cent, for the large intestine. It may 
involve only three or four inches, or it may include a large 
amount of the bowel. The invaginated portion is constricted 
at some point by the circular muscular fibres of the intestine, 
giving to the affected part an hour-glass appearance. The cause of intussus- 
ception is obscure, probably from some irregularity in the distribution of 
nerve-force and the result of reflex irritation. The not very uncommon as- 
Fig. 378. 
A portion of the 
ileum invaginated. 
* London Pathological Transactions, vol. xii. pp. 101, 121. 
f Trans. Med. Soc. London, 1861-62. 482 
DISEASES OF THE ABDOMEN. 
Bociation of epithelial careinoma and polypoid growths with intussusception 
may serve to explain a certain number of cases of invagination. Though not 
confined to any period of life, or to either sex, yet it is most commonly met 
with in children, and in a very large percentage of this class (about fifty per 
cent.) in children under eleven years of age, a period of life in which intes- 
tinal irritation is common. According to Treves, in chronic intussusception 
fifty per cent, of the cases occur between the ages of twenty-one and forty 
years. In regard to sex, intussusception is somewhat more common in males 
than in females. Thus, in 1289 cases analyzed by Leichtenstern 678 occurred 
in males and 611 in females. 
It is estimated that intussusception constitutes about one-third of all cases 
of intestinal obstruction; but this estimate, in my judgment, is too high. 
Symptoms.—The occurrence of intussusception, particularly in the ileo-colic 
form, is usually sudden, and is characterized by abdominal distress or pain, 
almost invariably of paroxysmal or intermittent character, usually confined 
to a limited space, though it may be diffused over the entire abdomen at first. 
There is a constant desire to evacuate the bowels, but all efforts for this pur- 
pose result only in the passage of some tenacious or ropy mucus frequently 
mingled with blood, or of blood by itself. Though diarrhoea is often pres- 
ent in the early stage of the attack, straining or tenesmus may or may 
not be present. Frequently a hard, circumscribed swelling can be detected 
through the walls of the abdomen, or a mass of invaginated mucous mem- 
brane may be felt in the rectum. The value of a distinct tumor as a diag- 
nostic sign will be appreciated, when it is stated that it is found to be present 
in nearly one-half of the cases. Should the case linger or tend to pursue a 
chronic course, the abdomen becomes tender, which often announces the 
commencement of peritonitis. Abnormal distention or meteorism is not gen 
erally present at the beginning of an attack. Vomiting is not a constant 
accompaniment of invagination, and has little diagnostic value as a sign 
of the disease. The duration of invagination varies from one day to two or 
three months. 
Prognosis.—The prognosis is unfavorable, though numerous instances of 
recovery are on record, even under the most discouraging conditions. Should 
the patient survive the first severe shock attending the onset of the disease, 
he may afterwards die of peritonitis or exhaustion. 
Should this danger be successfully passed, the patient 
may recover,—a result which can take place by spon- 
taneous reduction of the invagination, by the forma- 
tion of a fistula, or by the sloughing of the strangu- 
lated part of the intestine and its discharge through 
the bowel below, a termination which takes place, 
according to Leichtenstern, in forty-two per cent, of 
the cases. The older the patient, the greater the 
probability of such a result. 
Even when the bowel is discharged in this way the 
recovery is not assured, as many patients ultimately 
perish from intestinal lesions incident to the process 
of elimination, the mortality from this cause amount- 
ing to about forty per cent. 
Intestinal twist, or volvulus.—A loop of intestine 
is sometimes twisted upon itself, the mesentery or mesocolon forming its 
axis, until the canal of the bowel is completely obstructed (Fig. 379), a 
condition which is supposed to be due to a redundancy of the mesentery or 
mesocolon, or two contiguous coils of intestine may become so tangled as 
to cause obstruction. Even knotting of the bowel has been observed. The 
sigmoid flexure of the colon most frequently suffers from volvulus. It is 
estimated that volvulus forms about one-fortieth of all cases of intestinal 
obstruction. It is more common in men than in women, and in subjects 
beyond rather than under the middle period of life. 
Fig. 379. 
Intestinal twist. INTESTINA L OBSTR UCTION. 
483 
Constipation and colic have in numerous instances preceded for a long 
time the development of the twist. The symptoms are in many respects 
like those of intussusception. There is pain, severe but not unendurable, 
sometimes paroxysmal, at other times continuous, often localized over the 
seat of the volvulus. Tenderness on pressure is early complained of, gase- 
ous eructations are common, and vomiting may or may not exist, and when 
present is rarely stercoraceous. The tympanitic distention, occupying at 
first the left iliac region, soon becomes general and extreme. Important 
information may be gained by injections of fluid into the rectum, which will 
be found by percussion and by the amount retained not to pass beyond the 
sigmoid flexure. Manual exploration through the rectum would be allowable 
in a case of such gravity as volvulus. The temperature in cases of twist is 
rather below than above normal. If unrelieved, the patients usually die in 
from five to eight days. 
Strangulation by circumferential constriction, as by bands and through slits.— 
This may follow from a loop of intestine slipping through an opening or a 
slit in the omentum through bands left by an old peritonitis, or it may result 
from the bowel becoming encircled by a process of omentum. In one case 
which I examined, the ileum was strangulated by the appendix vermiformis, 
the free extremity of which had become adherent to the caecum. (Fig. 380.) 
The diverticula or worm-like processes which are occasionally seen project- 
ing from the intestine sometimes occasion a fatal strangulation by the free 
end of the tube becoming attached to the mesentery, or to some part of the 
intestinal tract or to the parietes, thus forming a ring or loop through wThich 
a coil or loop of the bowel slips. Obstruction is also often caused by bands 
Fig. 381. 
Fig. 382. 
Fig. 380. 
Obstruction from a fibrous band. 
Strangulation of the ileum by the appendix vermiformis. 
Obstruction by a band of inflammatory lymph. 
of organized lymph constricting the intestine so as to prevent the passage 
of its contents. (Pigs. 381, 382.) 
Obstruction resulting from bands forms not less than one-fourth of all 
cases of intestinal obstruction. Males suffer oftener than females. In all 
cases of circumferential constriction the attack is sudden; pain is an early 
and prominent symptom, and, when the attack has been sudden and acute, 
almost unendurable, though it may become subsequently less severe. Little 484 
DISEASES OF THE ABDOMEN. 
importance can be attached to the locality of the pain as indicating the seat 
of obstruction : it is more commonly at some point more or less distant from, 
rather than at, the portion of intestine involved. If any preference as to place 
exists, it will most probably be at or near the umbilicus. Abdominal ten- 
derness to pressure occurs a short time after the onset of the obstruction. 
At first local, it eventually becomes general. The original spot of tenderness 
should be carefully noted, as it usually marks the locality of the lesion. 
Vomiting is rarely absent. It comes on early in the attack and soon becomes 
stercoraceous. Abdominal distention is not a conspicuous feature. The tem- 
perature is often below normal. The thirst is urgent, the urine is diminished 
in quantity, the pulse becomes frequent and feeble, the skin grows moist 
and clammy, the respiration is frequent and shallow, the eyes are sunken 
and surrounded by dark rings, and the prostration becomes more and more 
pronounced, until the scene closes, either from collapse or from peritonitis. 
Many cases commence with diarrhoea and vomiting after some indiscretion 
in diet, these symptoms soon being followed by obstruction from congestive 
swelling. With a single exception (volvulus), acute obstruction is most fre- 
quently located in the upper or small intestine, while chronic obstruction 
generally involves the lower or large intestine. 
Acute peritonitis.—An acute attack of peritonitis may so completely paralyze 
the muscular walls of the intestines as to destroy all peristalsis and produce 
obstruction. In such cases the difficulty arises from the loss of function, not 
from any mechanical impediment. When death follows an attack of this 
kind, it is due to the serous inflammation, and not to the retention of faecal 
matter. Inertia of the bowel from this cause is characterized by great 
tenderness and tympanitic distention of the abdomen, a dorsal decubitus, 
with flexion of the limbs, and a hard, contracted, and frequent pulse. 
Chronic or Slow Obstruction,—In this form of the disease the causes, 
whatever they may be, operate slowly. Among these the following may 
be mentioned: 
1. Accumulations of fceces or of foreign matters.—Obstruction from feculent 
accumulations is not uncommon. When present, it is due to carelessness in 
securing regular alvine evacuations. It is more often seen in women than in 
men, and more especially in those who are advanced in years and lead a 
sedentary life. 
Obstruction occasionally arises from foreign bodies, such as hay, straw, 
rags, and other materials which have been swallowed. I have seen an im- 
movable impaction produced in this way. Such cases are almost invariably 
met with in insane persons. In making an examination of the body of a 
lunatic, I once found the caecum packed with hay and straw. 
In cases of obstruction from faecal impaction, there is usually an antecedent 
history of habitual constipation, which has extended perhaps over months, 
and has been gradually becoming more obstinate. The patient has suffered 
occasionally from flatulence and colicky pains, but without any material 
change in the health. 
When the accumulation finally culminates in obstruction, the abdominal 
pain, distention, and tenderness are not extreme, there is little shock, and 
often no vomiting. An examination of the abdomen will frequently detect 
through the parietes a hardened mass, with an irregular surface, which when 
strongly pressed xipon becomes altered in form, and which yields when per- 
cussed a dull, flat sound. In a lady who suffered from constipation, I dis- 
covered a hard mass in the right lumbar region apparently the size of a 
large orange. Some months afterwards she discharged masses of intertwined 
worms, with the effect of relieving the bowels and removing the supposed 
tumor. Enormous quantities of scybala which had gradually accumulated 
in the bowel I have seen discharged after the obstruction had given way. 
2. Obstruction from organic change in the walls of the intestine. — These 
changes may be either malignant or benign. The malignant or cancerous CHRONIC OR SLOW OBSTRUCTION. 
485 
degeneration, generally cylindrical epithelioma, is in most cases, originally at 
least, confined to the large intestine, though other portions of the bowel are 
liable to be attacked. In ninety-eight cases of intestinal cancer located in 
the large bowel, tabulated by Treves, the disease occurred fifty-eight times 
in the sigmoid flexure and eleven times in the descending colon, in the re- 
maining twenty-nine cases being found at other parts of the tube. The 
rectum is often the seat of carcinoma, though the disease rarely causes com- 
plete obstruction. A certain portion of the rectum appears to be peculiarly 
liable to the disease,—viz., about two and a half inches above the sphincter. 
Secondary deposits or metastases are not very common in rectal carcinoma. 
When not in the large intestine, the pylorus is, especially in the aged, a favor- 
ite locality for the disease. Though the deposit may be irregularly disposed 
in the walls of the intestine, yet it is very often found assuming a singularly 
definite or ring-like form around the circumference of the tube. Sometimes 
it sends out profuse granulations, forming a fungus wThich fills up the cavity 
of the bowel and which bleeds freely when rudely handled. Fragments of 
this cauliflower mass frequently slough, and are discharged with the evacua- 
tions. The progress of this variety of intestinal cancer towards a fatal ter- 
mination is usually rapid. In other instances the deposit takes place in the 
submucous connective tissue, raising the mucous membrane into irregular 
hard nodules, which gradually encroach upon the canal of the bowel and 
finally result in more complete obstruction. This answers to schirrus or hard 
cancer. When the disease takes this form its progress is more chronic. In 
some few cases I have found the feature of irregularity or nodulation en- 
tirely absent, and the mucous membrane smooth, having lost its natural du- 
plications or folds. If a finger be passed into the bowel, the induration will 
be found to be uniformly distributed about its circumference. These are the 
cases in which the patient possesses little power to expel the faeces, even 
long before the calibre of the tube is much narrowed, requiring injections to 
wash out the accumulations. This disability results from the cancerous in- 
filtration of the muscular as well as the cellular coats of the bowel, whereby 
its contractility is destroyed. The malignant changes begin in the epithe- 
lium of the glands of Lieberkiihn, etc. 
No age is exempt from intestinal cancer, though it is more peculiarly a 
disease of mature life. Obstruction from malignant disease is usually the 
work of many months, in some rare cases of years. A careful inquiry into 
the antecedent history of the patient will usually disclose the previous ex- 
istence, for a long time, of dyspeptic symptoms, such as flatulence, sour eruc- 
tations, oppression after eating, and colicky pains. There has also been a 
steady though not rapid loss of flesh and strength. If the deposit is in the 
neighborhood of the pylorus, or in some part of the small intestine, there 
will be vomiting of the food. When the disease is located in the large in- 
testine, there will be pain and constipation, with alteration in the size and 
form of the faeces, the stools being sometimes small and round, and at other 
times angular or flat, according to the shape of the stricture; or the passages 
may be frequent and small, consisting of broken fragments of feculent mat- 
ter, which are dislodged with difficulty and often only after several ineffect- 
ual attempts. In some instances blood, mingled with mucus and pus, or a 
watery, blood-stained fluid, having a highly offensive odor, is discharged from 
the rectum. The pain is severe, and often of a lancinating character. When 
the cancerous deposition is large, it may be discovered through the abdominal 
parietes, and when in the rectum, by an exploration with the finger. 
There is also a structural alteration of the intestine producing obstruction 
which has an inflammatory origin entirely free from malignancy, and which 
assumes very much the appearance of an annular valve similar to that at the 
pyloric orifice of the stomach, and gradually contracts until only a small 
orifice is left between the upper and the lower portion of the bowel. As 
far as my own observation extends, it is most common in the large intes- 
tine ; and in one case which was under my care it followed a blow over the 486 
DISEASES OF THE ABDOMEN. 
left side of the abdomen. The ring seemed to have been formed from the 
normal crescentic folds on the interior of the gut: it is represented in Fig. 383. 
Gastro-enteritis constitutes a not infrequent cause 
of intestinal obstruction, the swollen state of the 
mucous membrane forming the obstacle to the faecal 
movements. This condition is usually brought on 
by flagrant errors in diet or by violent purgation. 
Many cases of obstruction from mechanical causes 
are complicated by gastro-enteritis arising from the 
injudicious use of purgatives. A subacute peritonitis 
is frequently associated with the gastro-enteritis. 
Cicatrices, which result from the healing of intes- 
tinal ulcers caused by chronic dysentery, intestinal 
catarrh, tuberculosis, or syphilis, will also produce 
obstructions of a serious nature, from the inherent 
tendency of the new material to contract. 
A very curious instance of obstruction having an inflammatory origin I 
saw with Dr. Francis Haynes, of this city. The patient had for many months 
been harassed with a chronic diarrhoea, which was finally succeeded by ob- 
stinate constipation and stercoraceous vomiting. There was no tympany; 
the abdomen remained flat and without any marked tenderness. At no time 
was there much disturbance of the circulation nor were any active symp- 
toms present. The man steadily emaciated, and after three weeks from 
the commencement of the attack died. The last week of his life some 
liquid discharges from the bowels took place, having a faint odor of feculent 
matter. 
On examining the body, coils of intestines were found adherent to one 
another and the entire canal converted into a rigid, inflexible tube. The in- 
flammatory infiltration involved all the coats of the bowel, and had become 
organized to a degree which entirely destroyed the function of peristalsis. 
3. Obstruction from gall-stones.—Obstruction from biliary calculi occasion- 
ally takes place in the small intestine, most frequently in the lower part of 
the ileum. The occlusion is most common in females and in subjects beyond 
mature life. In these cases, the calculus, being of considerable magnitude, 
finds its way from the gall-bladder into the duodenum by ulceration, and. after 
having passed to some point in the small intestine, becomes arrested, and in 
turn prevents the passage of other and smaller concretions, until the blockade 
becomes permanent and the symptoms of obstruction are developed. I saw, 
in consultation with Dr. Hickman, of this city, a case of intestinal obstruc- 
tion in an elderly lady, which terminated fatally. At the autopsy there 
was discovered impacted in the jejunum a large biliary calculus, which had 
found its way from the gall-bladder into the intestine by ulceration. There 
are no distinctive signs which reveal occlusion from the impaction of gall- 
stones. Sometimes, but with no regularity, there has been a history of 
jaundice, constipation, biliary colic, and local peritonitis. The pain is less 
severe than that accompanying obstruction from bands: the vomiting is 
profuse, especially when the stones are lodged high in the intestine, though 
not attended with much distention of the belly. Should a circumscribed 
hardness or tumor be detected through the abdominal parietes, a diagnosis 
might bo reached by the introduction of a delicate needle into the swelling. 
That occlusion from biliary calculi is not common will appear from the sta- 
tistics of Leichtenstern, who in an analysis of eleven hundred and fifty-two 
cases of intestinal obstruction found only forty-one from this cause. 
Obstruction may be caused by concretions of different forms of lime or 
of magnesia, termed enteroliths. These accumulations are found associated 
with various foreign materials of a vegetable nature. The masses which are 
occasionally met with in the intestines of those living largely on coarse oat- 
meal are somewhat of the same nature, being composed of the husks of the 
grain mingled with chalky materials. 
Fig. 383. 
Annular stricture of the colon 
From a young man who died from 
obstruction. CHRONIC OR SLOW OBSTRUCTION. 
487 
4. Obstruction from morbid changes in contiguous organs.—A fibroid tumor 
developed from the posterior wall of the uterus may compress the rectum so 
as to prevent the passage of the faeces, or the weight of such a growth may, 
by retroverting the uterus, produce a like effect. Ovarian cysts have in some 
instances caused an obstinate obstruction from pressure. 
The most common causes of intestinal obstruction are, first, peritoneal 
bands and diverticula; and, second, intussusception. In 135 cases collected 
by Mr. Hinton,* 36 were from the first-named and 24 from the last-named 
cause. Of I)r. Brinton’s 600 cases,'f 31 per cent, were produced by bands, 
43 per cent, by intussusception, 17 by stricture, and 8 by twists. Of 75 
cases terminating fatally at Guy’s Hospital, Dr. FaggeJ says that 17 were 
from incarceration by adventitious bands. That intestinal obstruction forms 
a considerable proportion of the general mortality of a community is shown 
by the 12,000 autopsies analyzed by Dr. Brinton, in which one death in 280 
cases was from this cause. In this estimate death from strangulated hernia 
wTas not excluded. 
Differential Diagnosis.—While the signs of intestinal obstruction from 
the various causes have been enumerated, it is nevertheless true that they 
are so alike in all as to render a diagnosis one of great uncertainty. In 
attempting to reach the true origin of a given case, the first inquiry should 
be in regard to the invasion of the disease. Has it been sudden or slow in 
its development? If sudden, three causes will naturally present themselves, 
—strangulation, intussusception, and peritonitis. If the onset be sudden, 
the pain intense and localized about the umbilicus; if no hernial tumor cun 
be discovered, or if a hernia have shortly before been reduced ; if there be 
persistent stercoraceous vomiting and moderate abdominal distention, with 
marked prostration, the patient being over twenty years of age, there is 
good reason to conclude that the obstruction is due to strangulation from a 
band, a loop, adhesions, or a diverticulum. The restriction of the pain to 
the left iliac region, in a male patient, accompanied with great meteorism, 
together with the presence of the symptoms which have just been detailed, 
indicates a volvulus or twist in the sigmoid flexure of the colon. Loss of 
symmetry in the two sides of the abdomen, if present, one side being flat 
and the other distended, as alleged by Mr. Erichsen, will also denote this 
condition of the intestine. In three instances I have seen obstruction follow 
the sudden restoration of an old hernia. 
If the patient be a child, the attack sudden, the pain severe and intermit- 
tent ; if there be a frequent desire to stool, with tenesmus and vomiting, 
followed by a dischai’ge of blood and mucus, such as occurs in dysenteric 
attacks; and if, in addition, the abdomen do not become increasingly tym- 
panitic, with subsidence rather than increase of pain, and with perhaps the 
presence of an elongated tumor in the abdomen and possibly another in the 
rectum, the inference is that the case is one of invagination. 
If a patient, previously en joying good health, after a full meal of indigest- 
ible food, be seized with flatulence, and pain in the abdomen, with great ten- 
derness and distention of its walls; if the bowels be obstinately constipated, 
without vomiting, and the pulse frequent, hard, and contracted ; if the limbs 
be drawn up towards the body, the patient remaining rigidly upon the back, 
with a haggard and pinched countenance, the obstruction is in all probability 
due to peritonitis or catarrhal enteritis. 
In slow or chronic obstruction, the disease is commonly located in the large 
intestine. The lower its seat in the bowel, the less will be the tendency to 
vomiting. The higher its location, according to some writers, the more will 
the urine be diminished in quantity. This, however, does not coincide with 
my own observations. A portion of the large intestine can be examined by 
the eye or explored by the fingers, enabling the surgeon to detect any morbid 
growths which may exist within certain limits. This exploration has been 
* Assoc. Med. Jour., 1853. f Brit. Med. Jour., Jan. 1876, p. 431. 
j Guy’s Hospital Reports, 1868. 488 
DISEASES OF THE ABDOMEN. 
extended even up to the middle colon by carrying the hand and arm up 
into the bowel, as practised by Simon. A surgeon should have very cogent 
reasons for resorting to such a procedure. It is perhaps feasible, with a 
little patience, to pass the rectal tube as high as the transverse colon, pro- 
vided no obstruction exists below that portion of the bowel; but to accom- 
plish this it is necessary that there be no redundance of the sigmoid flexure, 
and that the tube be quite flexible. I believe that in a majority of in- 
stances in which it is thought that the transverse colon is reached, the 
physician is deceived by the tube’s doubling on itself. It is proper to 
state that there may be serious obstruction without a complete block of 
the bowel. 
If in such a case the patient be a nervous woman, an aged man, or a 
young child, and there be a history of constipation, a constant desire to re- 
lieve the bowels without being able to pass anything more than a little fluid 
discolored by particles of feculent matter even though a cathartic has been 
administered, and if there be a sense of fulness and local distress in the 
rectum, the general health not being impaired, the case is probably one of 
faecal impaction, and the use of the finger will verify or disprove this conclu- 
sion. It is not uncommon to meet with such rectal collections after typhoid 
fever and other exhausting diseases, where, from a feeble peristalsis and from 
debility of the muscular apparatus at the lower end of the bowel, there is not 
sufficient power to dislodge the accumulations. I have seen much suffering 
result from the practitioner’s failure to appreciate the true condition of a 
patient with these symptoms. 
When the impaction is higher up, that is, above the rectum, the hardened 
mass of faeces may be discovered by the fingers through the abdominal walls, 
provided the person be not too obese. 
When a person seized with obstruction has for a long time suffered from 
dyspeptic symptoms, with torpid bowels; when there have been alternations 
of constipation and diarrhoea, with an occasional discharge of blood; when 
there has been a steady loss of flesh and strength, with a cachectic impress 
upon the face ; and when, as not unfrequently occurs, a stercoraceous abscess 
opens into the bladder or the vagina, or upon the surface of the abdomen, 
the existence of cancer may be affirmed with great certainty. Often in 
these malignant depositions the tumor or induration can be felt through 
the parietes of the body. 
Stricture of the bowel, when beyond the reach of the finger, may be con- 
jectured from the resistance offered to injections, or when the latter are 
immediately and forcibly rejected from the bowel. 
When the obstruction arises from tumors, the existence of the latter can 
generally be discovered by an examination through the abdominal walls or 
through those of the vagina or rectum. 
Much may be learned as to the locality of the obstructing cause, whether 
located in the small or in the large intestine, by considering the structural 
and the functional differences of the two. The small intestine is the more 
highly organized. Its blood-supply is greater, the relations of its nerves to 
the ganglia are more numerous and intimate, its function is more active, 
and its serous surface is more extensive, than those of the large intestine. 
It is reasonable, therefore, to expect that when the obstruction involves this 
portion of the alimentary tube the symptoms will be more acute, the vomit- 
ing more constant, and the shock incident to the attack more pronounced. 
It is thought that the higher the obstruction is seated in the small intestine, 
the earlier and the more persistent will be the vomiting. As to the element 
of acuteness of symptoms, an exception must be made in regard to volvulus. 
An important fact connected with duodenal and jejunal occlusion is the 
absence of feculent matter in the vomited materials. 
Treatment.—The treatment of intestinal obstruction will be considered 
under two heads,—first, the therapeutic, and, second, the operative. 
Therapeutic Treatment.—The most rigid analysis should be instituted in TREATMENT OF INTESTINAL OBSTRUCTION. 
489 
order to ascertain as nearly as possible the cause of the obstruction. All the 
hernial regions should be carefully examined, in search of a rupture. I have 
seen a number of fatal cases of obstruction in which this cause had, unfortu- 
nately, been overlooked. Much evil is often done by the irrational practice 
of indiscriminately administering active cathartics. It is in this way that 
a fatal peritonitis is often engrafted upon the intestinal block. Eemedies 
of this class have no application in intestinal obstruction except when it 
depends upon faecal accumulations. 
When there is reason to believe that the case is one of impaction of the 
great cul-de-sac of the rectum, the finger should be well oiled, introduced into 
the bowel, and the principal feculent masses broken up and removed. This 
method is to be preferred before any of the instruments recommended for this 
purpose. After the collection is in a good measure dislodged, the remainder 
can be washed out by large enemata of sweet oil and flaxseed mucilage, or 
by soap-and-water. I have never derived much benefit from the solvent 
power of ox-gall, so often recommended as an injection in these cases of im- 
paction. When the accumulation is at the upper part of the colon, and the 
mass can be felt through the walls of the abdomen, it may be first broken 
down by pressure before exciting the peristalsis of the bowel for its removal. 
I succeeded in this way in starting an obstinate fsecal obstruction which had 
resisted the ordinary measures employed for its dislodgement. After break- 
ing the faecal mass, the action of the intestine should be solicited by large 
injections of flaxseed-tea, turpentine, and oil. To obtain the full benefit of an 
enema, it should be thrown into the bowel very slowly with a Davidson 
syringe (Fig. 384), so as not to provoke a premature expulsion. The bowel 
must be coaxed. 
The most potent of all remedial agents in the treatment of obstruction 
caused by bands or intussusception, and at all amenable to drugs, are opium 
and belladonna. The combination of these two drugs, when judiciously ad- 
ministered, secures both relief from pain and relaxation of spasm. The dose 
must be graduated according to tbe severity of the suffering, and need not 
be given beyond what is necessary to relieve pain. When the latter is in- 
tense, one or two grains of opium or the equivalent of morphine should be 
administered to an adult at once, repeating the same, if required, in an hour, 
after which a quarter or, at most, half a grain combined with one-tenth of 
a grain of belladonna, and given once every two or three hours, will be suffi- 
cient to maintain whatever advantage has been gained. Not only is the 
deranged peristalsis corrected by this treatment, but vomiting, if present, 
is moderated and often arrested. It prepares the way also for the use of 
enemata; for injections are of little value until the disordered peristaltic 
movements of the bowel have been overcome. In chronic cases of occlu- 
sion, or in acute cases when the urgent symptoms have disappeared for some 
time, it may become necessary, in order to move the contents of the bowel, to 
resort to some ver}r gentle aperient, which, however, should never be given 
alone, but always associated with opium or belladonna, or with both. The 
two members of this class which prove most efficacious and cause the least 
irritation are calomel and rhubarb. The combination which has been most 
successful in my own hands is the following: 
R Hydrargyri Chloridi Mitis, gr. vi; 
Ext. Belladonna, gr. iii; 
Pulv. Rhei, gr. iii ; 
Pulv. Opii, gr. ii. 
M.—Ft. pil. no. xxiv. 
One pill may be given every two or three hours, and, if much intestinal 
distention exists, one-eighth to one-quarter of a grain of nux vomica may be 
added to the pill. 
Enemata should be administered once in six or eight hours. Many cases 490 
DISEASES OF THE ABDOMEN. 
of obstruction from enteritis and even bands will, under this plan of treat- 
ment, be brought to a successful termination. 
The hydrostatic plan of administering injections is to be preferred in these 
cases. It consists in pouring the fluid to be introduced into the bowel into a 
rubber bag having a long, flexible tube with a nozzle at its end (Fig. 385). 
The pressure can be regulated with great gentleness and uniformity by raising 
the bag to any required height. By injecting a large quantity of warm water 
Fig. 385. 
Fra. 384. 
Davidson syringe. 
Hydrostatic injection apparatus. 
containing a little salt, flaxseed-tea, or olive oil, we may hope to overcome and 
successfully relieve faecal obstructions, whether depending upon inertia of 
the bowel or upon an incomplete stricture. As a medium for conveying an 
injection into the bowel, a long gum rectal tube may be introduced, carrying 
it as high up as possible, and throwing the fluid through its cavity. When a 
stricture exists within reach of the finger, the latter should be used to pilot 
the tube through, taking care not to perforate the bowel, the structure of 
which is often rendered weak by disease. 
Whatever the injection may be, it is important that as large a quantity 
should be employed as the intestine will tolerate without creating too great 
distress. I believe injury is often done by too large injections. The value 
of large enemata consists in the expansion which they cause of the walls of 
the gut, and the possible consequent unwinding of a twist or the reduction 
of an invagination. 
Injections of air have also been recommended. Mr. Erichsen believed that 
he succeeded in curing two cases of intussusception by this plan. I doubt 
very much its usefulness, and believe it to be inferior to the plan of liquid 
enemata. The insufflation can be accomplished by passing a rectal tube 
through a gum ball and inserting into the end of the tube the nozzle of a 
Davidson’s syringe. The gum ball, when pressed firmly against the anus, 
will prevent the escape of the air during the time it is being forced in by 
the syringe. An apparatus especially designed for the purpose has been 
devised by Mr. Lund, of Manchester. Ziemssen attaches much importance 
to injections of carbonic acid gas as a means of distending the colon. The 
manner of generating the gas consists in introducing, separately, solutions 
of bicarbonate of soda and of tartaric acid into the bowel through a long 
rectal tube, following these in a few minutes with a quantity of water, and 
preventing the escape of gas by pressing the nates close together. 
Kneading, or massage, somewhat popular with French physicians as a means 
of overcoming obstruction, is another remedy. Except in cases of occlusion TREATMENT OF INTESTINAL OBSTRUCTION. 
491 
from faecal accumulations, I would not recommend its use, believing that 
force of this kind is calculated to increase rather than to lessen the local 
trouble. 
Metallic mercury is an old remedy, and may be given with advantage in 
cases where it is believed that a faecal mass requires only to be started in 
order that it shall pass the seat of obstruction. Its action is mechanical. 
The metal when taken divides into a multitude of small pellets, which work 
their way through the different parts of the block, and especially between 
the latter and the wall of the intestine. It may be given, in divided doses, 
to the extent of a pound. 
Electricity (faradic current).—This agent, applicable to so many disorders 
of the human body, has its advocates as a therapeutic measure in intes- 
tinal obstruction, and by exciting peristalsis may be productive of benefit 
when the obstruction is faecal. The electrodes should be applied at different 
places,—namely, the negative one on the abdomen, the other in the anus ; and, 
again, one pole (negative) on the spine, the other over the abdomen. Truch- 
lenberg and Obelensky advocate washing out the stomach with water as a 
valuable procedure in cases of obstruction. 
When the tympany is very great, relief will be experienced by tapping the 
intestine with a fine bistoury needle. In instances in which I have had oc- 
casion to resort to puncture, the comfort, though not of long duration, was 
very marked for a time. The instrument which I employed for the purpose 
was the ordinary hypodermic needle, wThich should be made aseptic before 
using. Farmers often practise this operation on their cattle when the in- 
testines become inordinately distended with gas from eating too freely of 
green clover. 
However obstinate a case may be, the surgeon should not relax his efforts 
to obtain relief. In a case of intestinal obstruction from inflammatory stric- 
ture, which I attended with I)r. Moffat, of this city, the difficulty was not 
overcome until after the lapse of forty-eight days. The patient died some 
time afterwards from wrhat seemed to be marasmus. The large intestine was 
found sufficiently dilated to hold three gallons of water, the stricture being 
at the sigmoid flexure of the colon. In a second case, the patient was per- 
manently relieved after a period of thirty-five days from the commencement 
of her attack. 
As already stated, a spontaneous cure of intussusception has frequently 
occurred the invaginated portion sloughing away and being discharged 
from the rectum. In one case, eighteen inches of intestine were discharged 
through the anus ;* in another case, recorded by Bushe,'}'fifteen inches of the 
ileum were passed. Van Buren reports one case in which five feet of the 
bowel were discharged, followed by recovery ; and a similar instance is given 
by Peaslee. Professor Gross! also speaks of having had presented to him, 
by the late Professor Dawson, a portion of the colon twenty-nine inches in 
length which had been passed by a child six years old. Dr. Milner, of Chester, 
Pennsylvania, gave me the particulars of a case in his own practice in which 
several inches of the intestine sloughed and were discharged, the patient, a 
child, recovering perfectly. 
In 20 cases recorded by Mr. Hinton, 11 terminated in sloughing, with 9 
recoveries; in 59 cases collected by Haven, mortification occurred 12 times, 
with 10 recoveries ; in 50 cases collected by Dr. J. L. Smith, of New York, 
7 recovered; Duchaussoy has gathered from various sources 135 cases, with 
29 recoveries : making an aggregate of 264 cases, with 55 recoveries. Leich- 
tenstern has greatly augmented this number, having collected and analyzed 
557 cases, of which number 149 terminated in sloughing, 88 of which recov- 
ered and 61 died. Of the remaining 408, in which sloughing did not follow, 
345 died and 63 recovered. 
Food.—Not the least important matter connected with obstruction is the 
* Duncan’s Commentaries, vol. ix. p. 278. f Medical and Physical Journal, 1823. 
t Gross, Surgery, vol. ii. p. 675. 492 
DISEASES OF THE ABDOMEN. 
best plan for supporting the patient’s strength. When vomiting is present, 
it is not only useless to administer nourishment by the mouth, but positively 
injurious. Peptonized milk should be thrown into the rectum at intervals of 
from four to six hours, uidess it creates pain, in which case it must be aban- 
doned. The thirst, which is often urgent, can be appeased by allowing the 
patient small pieces of ice in the mouth. 
Operative Treatment.—The dangers attending the exposure of the abdom- 
inal contents have been so greatly diminished by antiseptic plans of procedure 
that the surgery for intestinal obstruction has undergone, very properly, a 
radical change. Formerly laparotomy in these cases was the last resort, and, 
consequently, a forlorn hope. Now it is the duty of the surgeon to pursue a 
more aggressive course, and, after having allowed a reasonable time for the 
employment of the ordinary therapeutical measures, to proceed without fur- 
ther delay to open the abdomen and to remove the cause of obstruction by 
operative means when feasible. 
When the case is one of intussusception, there is a difference of opinion 
among surgeons as to the propriety of operation, especially of early operation. 
Those who advocate delay justify their course on the ground that in a con- 
siderable percentage of cases (forty-one or forty-two per cent.) sloughing 
occurs and the patient recovers; but it must be borne in mind that statistics 
show that about forty per cent, of the patients in whom this termination 
occurs perish subsequently, sooner or later, from the structural alterations 
left in the bowel as a result of this manner of elimination, and this mortality 
increases with age. Again, over one-half of all cases of intussusception are 
met with in children under eight or ten years of age, during which period 
the percentage of termination by sloughing is exceedingly low, averaging not 
more than four per cent. The general mortality in intussusception ranges 
somewhere between sixty and seventy per cent., while that following opera- 
tion does not exceed fifty-eight per cent. Many of these laparotomies done 
for intussusception were performed late, and necessarily under circumstances 
very unfavorable for recovery. I am strongly, therefore, in favor of lapa- 
rotomy in cases of intussusception after the usual measures have failed to 
obtain relief; but, in view of the fact that eighty per cent, die within seven 
or eight days, the operation should be made early. If so done and conducted 
under the modern methods of abdominal surgery, I shall be greatly disap- 
pointed if the mortality in this disease be not greatly reduced. 
When the invaginated portion of the bowel has been reached, it will be 
necessary to draw upon both the upper and lower portions of the incarcer- 
ated mass. Some advise drawing the sheath of the invagination downwards. 
If the upper part alone be pulled upon, the bowel will become narrowed by 
elongation, so as to constrict more tightly the included portion. Indeed, it is 
often found impossible to disengage the parts, and their resection, with an 
artificial anus, will become necessary. Professor Barker, surgeon to the 
University College Hospital, London, has analyzed 73 cases of intussusception 
of the caecum, ascending colon and transverse colon. Laparotomy was done 
in 34 cases, 23 being children, with 5 recoveries and 18 deaths, and 11 being 
adults, with 7 recoveries and 4 deaths; in 5 cases irreducible after lapa- 
rotomy, 4 being children and 1 adult, all died ; in 14 cases, 7 being children 
and 7 adults, the intussusception was resected, with 1 recovery, an adult ; in. 
10 cases in which an artificial anus was attempted,—4 children and 6 adults, 
—all died ; and in 10 cases of artificial anus without laparotomy,—3 children 
and 7 adults,—all died. 
Eockwell, in his table of laparotomy for acute intestinal obstruction, gives 
11 cases of intussusception, with 6 recoveries and 5 deaths. 
If the obstruction depend upon narrowing of the intestinal tube from car- 
cinoma, and the growth occupies the rectum or the descending or transverse 
colon, a resort to operative measures may be required, with a view to estab- 
lishing an artificial anus; and when there is a complete blockade from malig- 
nant disease favorably situated and continuing for days, with tympany, pain, TREATMENT OF INTESTINAL OBSTRUCTION. 
493 
and inability to retain food, colotomy or enterectomy, preferably the former, 
should be done without delay. The relief from horrid suffering, even if 
life is only prolonged for a few months by the operation, will amply com- 
pensate the patient for submitting to the inconvenience of an artificial anus. 
Weir has collected 40 cases of enterectomy performed for carcinoma, and in 
all, with the exception of one case, the disease was located in the larger intes- 
tine. In 5 of these cases the operation was done when the patients were 
greatly exhausted, the obstruction being acute, and all died ; in 1 the oper- 
ation was abandoned, and in 1 the result is not given. Of the remaining 33, 
17 died, or 51.5 per cent. When it is ascertained that fifty per cent, die of the 
operation, and that recurrence of the disease takes place in at least ninety- 
five per cent, of those who survive, it is not difficult to pronounce as to the 
value of enterectomy for cancer. When it is deemed proper to practise 
enterectomy, it will be better to establish an artificial anus than to suture 
and return the intestine into the abdomen. 
Mr. Maunder, in a case (not carcinoma) where the cause of the difficulty 
was higher than the colon, cut directly down upon a distended coil of intes- 
tine, puncturing the tube in order to allow the imprisoned air to escape, and 
then drew the intestine through the incision in the parietes, and, after en- 
larging the opening in its walls, stitched it to the external wound, thus form- 
ing successfully an artificial anus.* Mr. McCarthy! by the same method 
succeeded in saving the life of a patient suffering from obstruction located in 
the small intestine. In neither of these cases was the nutrition of the in- 
dividual seriously impaired by the artificial anus, although it was situated so 
high in the alimentary canal. 
Professor Ashhurst has tabulated and analyzed from his own collection of 
cases and those of Schramm 346 cases of laparotomy performed for all vari- 
eties of intestinal obstruction, with a mortality of 69.3 per cent. Sixty-five 
of these operations were done for intussusception, with 16 recoveries and 49 
deaths, or a mortality of 75.4 per cent.; 29 for volvulus, with 8 cures, 20 
deaths, and 1 undetermined, a mortality of 71.4 per cent.; 21 for internal 
strangulation after reduction of hernia, with 6 recoveries and 15 deaths, a 
death-rate of 71.4 per cent.; 23 for impacted foreign matters and faeces, with 
9 recoveries, 13 deaths, and 1 undetermined, a mortality of 59.1 per cent.; 
37 for tumors, stricture, and ulcers, with 10 recoveries, 25 deaths, and 2 un- 
determined, a mortality of 71.4 per cent.; 119 for bands, adhesions, diver- 
ticula, etc., with 38 cures, 80 deaths, and 1 undetermined, a death-rate of 
67.8 per cent.; 26 for different forms of hernia and ileus, with 8 cures, 17 
deaths, and 1 undetermined, a death-rate of 68.0 per cent.; 7 for other forms 
of obstruction, with 3 cures and 4 deaths, a death-rate of 57.1 per cent.; 19 
for causes not ascertained, with 6 cures, 12 deaths, and 1 undetermined, a 
mortality of 66.7 per cent. 
I am of opinion, however, that deductions based on data collected previous 
to the antiseptic period are of no value at present in operative surgery, and 
that to arrive at just conclusions on the value of operations in any disease 
the work of the surgical statistician must begin anew. An examination of 
tables on the subject of laparotomy for intestinal obstruction, constructed 
from cases occurring within the last decade, in many of which the operation 
has been done under antiseptic precautions, will render evident the justice 
of the above statement. 
Eockwell’s collection, embracing cases of laparotomy done for intestinal 
obstruction between the years 1877 and 1888, records 69 cases, of which 37 
recovered and 32 died,—a gain over the older operations. 
In 100 cases of laparotomy published, with a single exception, within the 
last decade, and collected for me by Mr. Mitchell, a student of the University 
of Pennsylvania, the result was as shown in the following table. The 
growing success of the operation is undoubtedly due to antiseptic methods 
of treatment. 
* British Medical Journal, April 1, 1876. 
f Ibid. 494 
DISEASES OE THE ABDOMEN. 
Analysis of 100 Cases of Laparotomy for Intestinal Obstruction. 
Disease. 
Cases. 
Recoveries. 
Deaths. 
Bands 
34 
15 
19 
Intussusception 
13 
6 
7 
Twists 
9 
4 
5 
Tumors 
6 
3 
3 
Adhesions 
5 
2 
3 
Intestinal concretions 
4 
1 
3 
Incarceration by loops or rents 
6 
2 
4 
Stricture 
5 
2 
3 
Appendix vermiformis strangulation 
3 
1 
2 
Diverticula 
6 
3 
3 
Impacted gall-stone 
6 
2 
4 
Abscess 
1 
1 
Undetermined 
2 
1 
i 
100 
43 
57 
General principles to be observed in performing laparotomy for intestinal obstruc- 
tion.—The median incision is to be preferred, admitting as it does of a general 
exploration of all parts of the abdominal cavity, both with the eye and with 
the hand. The cavity being exposed, the surgeon must proceed in a system- 
atic manner to ascertain the locality and nature of the obstruction, with as 
little handling of the abdominal contents as possible. Unless the nature of the 
obstruction requires otherwise, the intestines should not be allowed to escape 
through the wound. This can be prevented by an assistant drawing forward 
the sides of the incision and by the pressure of soft, flat, warm carbolized 
sponges. If the intestinal coils are much distended, they may be punctured 
by a tine aspirating-needle previously disinfected, and the gas allowed to 
escape, provided the progress of the examination is much obstructed. In 
commencing the search, let the surgeon examine, as far as possible with the 
eye, the interior of the abdomen. If nothing is learned by the vision, the 
hand may next be carried into the cavity, with a view to ascertain by the 
touch the location of the obstructive cause, whether in the large or in the 
small intestine. To gain this information, the fingers should be passed into 
the right iliac fossa and placed against the caecum. If this be found dis- 
tended, the difficulty may reasonably be referred to the colon; if distention 
does not so extend, to the small intestine. If the sign points to the colon, let 
the fingers follow the ascending, transverse, and descending portions of the 
bowel in search of the obstruction. As intussusception frequently involves 
the ilio-caecal part of the intestine, the operator should bear this in mind 
while his fingers are in the right iliac region, especially if the existence of a 
firm irregular body be discovered. When the signs, on the other hand, point 
to the small intestine, the collapsed coil must be sought for. The difficulty 
now consists in following the proper direction. This may be settled by com- 
mencing with the ileum where it enters the caput coli and conducting the 
investigation from right to left until the end of the collapsed gut is reached. 
In a case of laparotomy for intestinal obstruction at which I was present 
while penning this article, the seat of constriction was readily discovered by 
finding the collapsed coil lying in the cavity of the pelvis, a symptom of great 
diagnostic value. The inner surface of the hernial passages should also be 
examined during the search. As soon as the cause of the obstruction is re- 
lieved, whatever it may be, the cavity of the abdomen should be washed out 
by a stream of warm water which has been previously well boiled and fil- 
tered, and a glass drainage-tube introduced extending downwards to the floor 
of the pelvis, after which the closure of the wound is to be made in the usual 
manner by a sufficient number of deep silver sutures, including the perito- 
neum. The remaining part of the toilet will consist in covering the wound TYPHLITIS AND APPENDICITIS. 
495 
with a strip of protective, over which is placed a compress of carbolized 
gauze and a roll of salicylized absorbent cotton, the whole to be retained in 
place by a broad binder about the abdomen. 
Typhlitis and Appendicitis.—One of the most interesting surgical regions 
within the abdomen is located in the right iliac fossa, and contains the 
caecum, or head of the colon, and the appendix vermiformis. The great fre- 
quency of inflammatory disease in this region has recently caused this part 
of the body to be made the subject of very careful study, physiologically and 
pathologically, and valuable contributions to iliac surgery have been made 
by Morton, of Philadelphia, Sands, of New York, and others. Though the 
appendix vermiformis has been regarded as a mere rudimental appendage to 
the caput coli and altogether functionless, yet, analogically considered, this 
view is not tenable, for we tind that these undeveloped representatives of 
parts which in other animals and in a different sex are perfect organs do 
play some part, though a subordinate one, in the economy. The clitoris of 
the female and the utriculus of the male, for example, are not simply append- 
ages or expi’essions of a general plan of organization, contributing as they 
do, the former to erotic sensations and the latter to urethral secretions. 
The practical question, however, to the surgeon is the pathological one, and 
its relation to surgical interference. Why should these rather than other 
parts of the intestinal tube be so frequently the subjects of inflamma- 
tory accidents? Several reasons may be assigned in explanation. First, 
the material received by the caecum from the small intestine is largely ex- 
crementitious, and when formed from improper or crude indigestible ingesta, 
modified by the processes of fermentation, it becomes positively irritating. 
Secondly, the ileum enters the caecum at nearly a right angle, and at a point 
some distance above its floor, leaving a dependent pouch well suited for re- 
taining a residuum of faeces. The sedimentary matter tends to form hard 
concretions, just as granules of phosphates form in urine from obstructive 
and other causes. Every anatomist must have bad his attention frequently 
called to the presence of hard, round, or irregular gritty masses of desic- 
cated faeces lying in the cells or pouches of the caecum, which, from appear- 
ance, had been there for a considerable time. These fragments when rolled 
about by the intestinal peristalsis would be calculated to create irritation and 
inflammation, or to be forced into the canal of the appendix. Inflammation 
of the caecum, through continuity of the mucous membrane, would readily 
extend into the appendix. Aside from traumatism and independently of 
the presence of foreign masses, I do not believe that appendicitis is often 
a primary affection. 
The inflammation which attacks the caput coli or the appendix vermi- 
formis is generally catarrhal in its incipiency. and is induced by a variety of 
causes. Among these may be mentioned crude, indigestible food and con- 
cretions of different kinds. These concretions are usually made up of dry 
faeces mingled with inspissated mucus, and frequently contain phosphate 
of lime. They are very often mistaken for cherry-stones or the seeds of 
other fruits. Occasionally sharp-pointed bodies, fragments of bone, and 
worms have been found in the appendix. Besides these local causes there 
are others of a general character which are influential in exciting destruc- 
tive inflammation of the appendix and ca>cum, as tuberculosis and typhoid 
ulceration of the tubular and agminated glands which abound in the appen- 
dix and at the ileo-caecal opening. Fenwick found in a collection of 129 
cases of perforation, in which the cause was mentioned, 28 due to concre- 
tions, 14 to hardened fteces, and 5 to foreign bodies. Tn my own experience 
hard masses of faeces, either alone or partly calcified, have been the cause 
of these perforations. Typhlitis or appendicitis, once established, follows 
different courses. Sometimes the inflammatory products are formed between 
the caecum and the iliac fossa, occupying the loose cellular tissue which con- 
nects the two, and consequently are retroperitoneal. And this holds good 496 
DISEASES OF THE ABDOMEN. 
both as regards inflammatory tissue and suppuration when the latter occurs, 
so that two varieties of the disease must be recognized, the non suppurative 
and the suppurative. In other instances the inflammatory products, lymph 
or pus as the case may be. are intraperitoneal, though in the event of an 
abscess forming it does not necessarily follow that the purulent matter shall 
enter the general serous cavity, as the latter is in many if not in most cases 
sealed off by adhesions from the diseased area, the pus being contained in 
loculi or pockets between the coils of intestine. Finally, the typhlitis, or 
appendicitis, may terminate in ulcerative perforation, causing acute septic 
peritonitis from the escape of faecal matter. 
Symptoms op Non-Suppurative Typhlitis.—The disease commences with 
pain and uneasiness in the right iliac region, with tenderness on deep pressure. 
The attack may be preceded by either constipation or diarrhoea, followed by 
nausea and vomiting, the temperature rising to 102° or 103°, and the pulse 
beating over a hundred. Not infrequently the approach of the disease is 
quite protracted, there having been a history of slight griping pains at first 
of momentary duration and at considerable intervals, usually referred to the 
csocal region, though with many exceptions. A swelling soon makes its ap- 
pearance in the ctecal region, above and in a line with Poupart’s ligament, 
and can readily be outlined, with the fingers, through the abdominal walls. 
Percussion over the tumor yields sometimes a resonant, at other times 
a dull or flat sound, a difference not without some diagnostic significance, 
as it may be construed to mean, in the first instance, that the inflammatory 
tissue is behind the csecum or retroperitoneal, and in the other case that it 
is in front of this part of the bowel. Another feature connected with the 
resonance of the tumor is a disposition on the part of the patient to keep 
the limb of the diseased side somewhat flexed. 
Course or Progress.—At this stage of the disease one of two terminations 
may follow,—namely, resolution or suppuration. If 1’esolution, the inflam- 
matory phenomena will, in the course of five or six days, culminate, and the 
swelling and other symptoms gradually subside, the inflammatory tissue 
being removed by natural processes. Often there will remain for a long 
time a certain amount of induration in the iliac fossa, which can be detected 
by making deep pressure over the region : this I assume to be the remains 
of organized lymph, the result of a localized peritonitis, which may interfere 
with the function of the ileo-csecal section of the bowel, causing some pain 
as the contents of the intestine pass the valve. It is this inflammatory re- 
siduum which, in many cases, gives rise to recurrent attacks of inflammation 
when the patient exposes himself prematurely to causes of a predisposing 
nature. A prominent physician of Philadelphia after an attack of typhlitis 
suffered a number of relapses from this cause by driving over the roughly- 
paved streets of the city. 
Treatment.—A patient attacked with typhlitis, or appendicitis, should be 
kept in bed, and an ice-bag placed over the iliac region. If the pain is severe, 
a sufficient amount of opium, in some form, should be exhibited from time 
to time, and, if the tenderness is very marked, benefit will be derived from 
the application of leeches. The practice of administering cathartics in the 
early stage of the disease is to be deprecated. No solid food must be al- 
lowed : milk, with a little lime-water, in moderate quantities constitutes the 
proper nourishment. After the pain has disappeared, small doses of calomel 
(the tenth or twelfth of a grain, with two or three grains of bicarbonate of 
soda) may be given every two hours, which will generally secure a passage 
in the course of twenty-four hours. 
Suppurative Typhlitis or Appendicitis.—It is impossible to determine at 
the beginning of an attack what course the inflammation may take, and 
therefore the diagnosis is for a time always surrounded with doubt. When, 
however, the inflammatory swelling persists without material change for 
seven or eight days, or fluctuates, some days showing symptoms of increase, SUPPURATIVE TYPHLITIS. 
497 
and other days of diminution, at the same time losing its resistance, and if 
the skin is of a sallow or dirty hue, or if slight rigors followed by perspira- 
tion occur, the existence of pus is more than probable. It must at the same 
time be remembered that these abscesses often form without the usual septic 
phenomena of suppuration being present. With this uncertainty as to the 
condition, the use of the exploring-needle would naturally suggest itself to 
the surgeon as the most certain measure for resolving the difficulty. I have 
used it a number of times with entire satisfaction after exhausting other 
means of diagnosis. Some surgeons, however, object to its employment, 
fearing that some septic element may be introduced, either by the instru- 
ment, or the escape of irritating fluids from the intestine should the 
latter be punctured, and thus kindle a destructive peritonitis. Though I 
have seen no such evil consequences follow these explorations, I do not 
doubt the possibility of their occurrence. 
It has been asserted that these abscesses are always intraperitoneal. That 
such is not the case I know very well. I have seen these collections of pus 
pass beneath Poupart’s ligament into the muscles of the thigh, having de- 
stroyed the iliac fascia. In a case which I visited in consultation with Dr. 
Styles, the pus found its way up underneath the arcuated ligaments of 
the diaphragm and emptied into a bronchial air-passage. Occasionally the 
tumor can be felt, through the rectum or the vagina, projecting into the 
pelvis. More rarely it opens into the cfecum. In all these cases the peri- 
toneum forms the upper and lateral walls of the abscess, the pus extending 
through the subperitoneal connective tissue. 
Intraparietal abscess following typhlitis or appendicitis cannot be certainly 
diagnosed from the retroperitoneal variety of the disease. In what 1 have 
supposed to be cases of the former kind, the local peritonitis has been unusu- 
ally acute, the tumor more diffused and devoid of resonance. 
Treatment.—Two courses of action are promulgated by surgeons for the 
management of suppurative typhlitis and appendicitis. On the one hand, 
early operations are advised, while, on the other, a certain delay is recom- 
mended. My own plan of procedure—and I have had to deal with a goodly 
number—is not to act hastily. While it is true that the sooner the pus is re- 
moved the better, yet the risk to the patient in waiting for a reasonable time 
for a possible resolution of the tumor is quite inconsiderable. If after waiting 
seven or eight days no amelioration occurs, or if after such a lapse of time 
the local symptoms continue to increase, the time has arrived for operative 
interference. I do not say that there are not cases in which, from their acute 
course, operations should not be undertaken much earlier, but these are the 
exceptions. 
Operation.—The external parts should be rendered thoroughly aseptic by 
removing the hair and cleansing the skin with alcohol and the usual bichlo- 
ride of mercury solution. The incision should be lateral, and made a short 
distance above and somewhat parallel to Poupart’s ligament. The different 
layers constituting the abdominal parietes are to be divided consecutively 
until the peritoneum is reached. At this stage of the operation a careful ex- 
amination should be made. If the abscess is retroperitoneal and mature, its 
wall will be found projecting underneath the serous membrane, or, if not, the 
latter may, with great care, if not too adherent to the wall of the abscess, be 
pushed up, as in ligation of the external iliac artery, in order to admit of a 
deeper view. When properly exposed, a free incision through the subperito- 
neal cellular tissue will give exit to the contents of the abscess. After dis- 
charging the pus, the cavity is to be washed out with either a hot solution of 
boracic acid or a weak solution of bichloride of mercury (one to three thou- 
sand). A large glass drainage-tube may now be carried to the bottom of the 
abscess-cavity and the usual antiseptic dressing applied. Professor Sands, 
who has written a very sensible article on the treatment of perityphlitis, 
advises, in case the peritoneum is found not to be adherent to the abscess- 
wall, but moves freely over its surface, not to incise, but to pack the wround 498 
DISEASES OF THE ABDOMEN. 
with iodoform gauze, and either wait for a spontaneous opening to form, or 
open at a later period, thus avoiding the dangers of a septic peritonitis. 
In cases of local intraperitoneal abscess, after opening the peritoneum, 
discharging the contents of the abscess, separating intestinal adhesions, and 
washing out with a hot antiseptic solution,—preferably either Thiersch’s or 
one of boracic acid alone,—a glass drainage-tube should be introduced, the 
abdominal wall closed with sutures, and the usual antiseptic dressings applied, 
leaving an opening for the drain-tube. 
Perforation of the Appendix or Caecum.—It is possible that perforation of 
the appendix, with escape of its contents, may occur and yet the patient not 
suffer from general peritonitis. The appendix is sometimes seen to be curled 
up under the caecum ; and if in such a position an appendicitis should develop, 
the region might be sealed off from the general serous cavity by plastic 
deposit before the perforation occurred. It may be that some intraperitoneal 
abscesses have such a history. The rule, however, in cases of ulcerative per- 
foration, tubercular or typhoidal, from which the appendix suffers most fre- 
quently, is a rapid development of general septic peritonitis. The attack 
is sudden: an intensely acute pain, great abdominal tenderness, tympany, 
vomiting, a feeble, frequent pulse, and rapid collapse mark the event. 
Treatment.—In cases of the above character there is no time for delay. 
Operations, to be of any service, must be done at once. An oblique or 
vertical lateral incision should be made directly over the caecum, which will 
be found usually between one and two inches above the outer third of Pou- 
part’s ligament. By this incision the region will be fairly exposed to the 
eyes and the nature of the lesion at once detected. The cavity should now 
be flushed thoroughly with hot water, boraeic solution, or Thiei’sch’s solution, 
thus washing out whatever matters may have escaped from the intestine and 
at the same time disinfecting the peritoneum. Should the perforation be found 
in the appendix, the tube should be ligated with an aseptic thread near the 
caecum and then amputated. If the perforation is located in the caecum, the 
edges ought to be turned and the opening closed with Lembert sutures. A 
second flushing of the abdominal cavity may next be made, and, after careful 
sponging out of all liquid, a glass drainage-tube, as in other cases, must be 
introduced to the bottom of the cavity, and the wound in the parietes closed 
by sutures. The external dressing, being the usual antiseptic one, will not 
differ from that proper to other cases of abdominal wounds. In perforation of 
the appendix the result of glandular ulceration in typhoid fever, little benefit 
is likely to follow operations where the accident occurs before convalescence. 
After-Treatment.—As the cavity closes up by granulation and by contrac- 
tion of its walls, the drainage-tube may be allowed to remain as long as any 
discharge continues. The surrounding packing will require to be changed as 
often as it becomes soiled. The drainage will be facilitated by introducing 
into the glass tube a rope of twisted absorbent cotton, which should be 
changed every hour or two for some time. 
In the further conduct of the different forms of typhlitis and appendicitis 
little is to be done, other than to keep the patient quiet in the recumbent 
position, allow a milk diet, administer anodynes only when required by pain, 
and see that the bowels are properly regulated. 
Colotomy.—This operation, in cases of carcinomatous occlusion of the rec- 
tum, constitutes an important palliative measure, and may be executed in dif- 
ferent ways. Littre, who was the first to suggest the operation, as early as 
1710, recommended reaching the sigmoid flexure through the left iliac region, 
but it was not until sixty-six years afterwards that the suggestion was put 
into execution, on the right side, by Pillore, who cut into the c{ecum through 
the right iliac region and stitched the bowel to the wound in the parietes. 
The operation was undertaken in consequence of the presence of a malig- 
nant mass in the rectum. Twenty-one years later,—1797,—Fine opened suc- COLOTOMY. 
499 
cessfully the transverse colon, through the umbilical region, for cancer of 
the rectum. The previous year, Callisen advocated the left lumbar region 
as the best route to the intestine, and the sigmoid flexure as the proper 
portion to be opened. 
Colotomy is most successful when the obstruction is situated in the rectum 
or in the sigmoid flexure, as it enables the surgeon to select for his operation 
the descending portion of the intestine, which is the most fixed, and which 
offers the largest non-peritoneal surface. The method usually pursued is a 
modification of Callisen’s, and is known as that of Amussat, a French surgeon 
who applied it to the ascending colon. In its performance the left lumbar 
region is selected. Three incisions have been recommended,—a vertical one 
by Callisen, a transverse one by Amussat, and, more recently, an oblique one 
by Bryant. That of Amussat or of Bryant is to be preferred, and is equally 
well adapted for left or right lumbar colotomy. The chief advantages of 
the transverse or oblique incision over the vertical are a more capacious and 
gaping wound, the division of fewer lumbar arteries, and an easier recogni- 
tion of the structures to be divided. 
Left lumbar colotomy.—In order that the loin be made as prominent as 
possible, the patient should be laid on the right side, over a pillow rolled into 
a cylinder, the body being turned somewhat upon the face and breast. A 
point one inch posterior to the middle of the crest of the ilium being ascer- 
tained, it should be marked with tincture of iodine or with ink, in order that 
it may be clearly distinguished by the surgeon during the different stages of 
the operation. The colon will be found exactly in a line with this mark. 
An oblique incision is next made through the integuments, five inches long, 
midway between the crest of the ilium and the last rib, commencing over 
the erector spin® muscles, about one inch and three-quarters external to the 
spine, and terminating one inch above and posterior to the anterior superior 
spinous process of the ilium. The different strata of muscles and the lumbar 
aponeurosis are to be consecutively divided on the director, all vessels being 
secured as the operation proceeds. 
The fascial origin of the transversalis muscle, being reached, must be 
opened, when the external margin of the quadratus lumborum will be seen, 
and will perhaps rise up into the wound. Search should now be made for 
the colon. In some cases the kidney is so low as to require being pushed 
aside that the intestine may be found. In a patient operated on by Dr. 
Morton, in the Pennsylvania Hospital, a large renal cyst so concealed the 
colon as to require tapping before the bowel could be reached. If the loose 
fatty tissue in the lumbar region be displaced or broken up, the intestine 
will be found one inch posterior to the middle of the crest of the ilium. 
Should the operator fail by this guide to find the bowel, let him next touch 
the kidney, in front of which the intestine is placed. / 
In making this search, the surgeon must be careful to work backwards, 
towards the quadratus lumborum muscle. If the exploration be carried for- 
ward, there will be great danger of opening the peritoneum. To identify 
the intestine, the operator should examine for the circular constrictions or 
the longitudinal bands which distinguish this part of the tube. Frequently 
the faeces can be felt through its walls. It has been suggested by certain 
writers to distend the bowel by injecting a fluid into the rectum, so that its 
position may be more readily recognized. The objection to this procedure 
is the probability that a part of the liquid will escape into the cellular 
tissue of the lumbar region when the gut is opened. Sometimes the in- 
testine presents at the wound the moment that the transversalis origin 
of the lumbar aponeurosis is divided. Should this not follow, I find that 
a strong pressure of the hand against the outside of the lumbar region will 
serve to produce the required protrusion. 
When the bowel is found, it should be drawn forward by the fingers, so as 
to expose its posterior surface, and two ligatures passed through its walls, 
three-quarters of an inch from each other, in a direction corresponding to 500 
DISEASES OF THE ABDOMEN 
the longitudinal axis of the tube. These threads must next be committed to 
an assistant, who is to retain the intestine forward in the external wound 
while the surgeon makes an opening into the gut, three-quarters of an inch in 
length, from above downwards, and between the sutures. Through this in- 
cision the ligatures are to be drawn out, and divided in the centre, making 
four sutures out of the two, by which sutures the intestine is to be stitched 
to the sides of the external wound, including only its integument. (Fig. 386.) 
I find it necessary to introduce two additional sutures, so as to command the 
entire circumference of the intestinal opening. The wound in the abdominal 
wall should next be united by silver wire close up to the bowel. In the course 
of three or four days, union between the parts will have been measurably 
Fig. 386. 
Showing the extent and direction of the incision in left lumbar colotomy, and the intestine 
opened and attached to the integument. 
effected, and in fotir or five more the stitches can be removed. Should there 
be no discharge of fteces at the time of operation, it is well: a little delay in 
this particular will give time for the adhesion of the parts and render the 
escape of the intestinal contents into the cellular tissue of the loin less probable. 
The wound should be dressed antiseptically, and, when cicatrization has been 
completed, a compress or a rubber truss with a pad should be adjusted to 
command the opening and prevent the escape of the fasces. 
The operation on the right side does not differ from that on the left, except 
in the caecum being opened instead of the descending colon. The fact that 
by this operation the large intestine can be reached without opening the 
abdominal cavity or disturbing the peritoneum makes it a much more 
desirable method than that of Littre, in which the sigmoid flexure of the 
caecum was approached in front, and by which both the parietal and the vis- 
ceral layer of the peritoneum were wounded. The result in a large number 
of cases exhibits the superiority of Amussat’s method over all others. Of 17 
patients in whom Littre’s operation was performed. 10 died; while in 31 in 
whom the bowel was opened after Amussat’s plan, there were but 14 deaths.* 
As early as March. 1838, Dr. William Ashmead, of this city, opened the 
left colon by a vertical incision in the triangular space between the latissimus 
dorsi and external oblique muscles. In 1847, Professor J. M.Bushe performed 
colotomy for a cancerous stricture of the sigmoid flexure of the colon, the 
patient living fourteen days after the operation. This, sometimes stated to 
be the first colotomy in this country, was nine years after that of Dr. Ash- 
mead. Dr. Packard, in 1875, opened the left, colon in consequence of an 
obstruction of the rectum from cancer of the uterus. The patient lived 
* Crips, of St. Bartholomew’s Hospital, London, strongly advocates the anterior or inguinal colotomy. 
In twenty-two operations only one died. An incision two and a half inches in length is made one 
inch and a half above the anterior superior spinous process of the ilium, the outer extremity inclining 
upwards. After opening the abdomen, the parietal peritoneum is stitched to the skin on both the 
upper and the lower border of the wound, and the loop of the colon stitched to both; and when 
the case is not urgent the bowel is not opened until the fifth or sixth day later, or until adhesion 
has taken place between the intestinal and the parietal peritoneum, the wound being dressed in the 
interval antiseptically. COLOTOMY 
501 
eight and a half months. In 1880 I performed colotomy on a patient of 
Dr. Harris’s for the relief of carcinomatous obstruction of the rectum. The 
operation was followed by great comfort, and prolonged the life of the 
young woman several months. In a second case in which I operated, a 
patient of Dr. II. Yarrow’s. Surgeon U.S.A., life was prolonged for many 
months. After the artificial anus was established, the faecal discharges were 
passed through the opening with singular regularity every twenty-four or 
forty-eight hours, and no unpleasant odor was noticed about the patient. 
This accords with the experience of other operators. 
The general result of colotomy operations may be gathered from the tables 
of those who have given the subject a very careful and patient examination. 
Caesar Hawkins* collected and analyzed 44 cases of colotomy; being a 
record of all cases which he could find up to the year 1853. Of this number 
23 recovered and 21 died. The operation was done 15 times for stricture of 
the rectum and of the sigmoid flexure of the colon, thought to be of a non- 
malignant nature ; 3 times for non-malignant stricture of the ascending and 
transverse colon ; in 1 case for a twist in the ascending colon; in 1 case for 
adhesion of the rectum to the uterus; in 1 case for a strangulation of the 
ileum by a band; in 1 case for fistula in ano; in 1 case for agglutination of 
the rectum to the uterus from cancer; 15 times for malignant disease of the 
rectum and of the sigmoid flexure of the colon; in 1 case for cancer of the 
colon and omentum ; in 1 case for cancerous stricture of the caecum; and in 
4 cases for causes unknown. This collection included persons of all ages, 
from twenty-one to seventy years: 22 of the number were females and 21 
males ; sex of one not ascertained. Taking up the subject at the period where 
Mr. Hawkins stopped in 1853, Dr. Erskine Masonf has collected 80 cases of 
colotomy down to 1873. In 74 of these the descending and in 2 the ascending 
colon was opened by Amussat’s method. In 1 case the bowel was opened 
after Callisen’s plan. Three of the cases were operations on the small intes- 
tines. The result, as far as could be ascertained, was 54 recoveries and 23 
deaths. The shortest period of survival after the operation was sixteen 
hours, the longest six years. It was ascertained that the peritoneum was 
wounded 7 times, in consequence of which 4 died. If we add together the cases 
of Hawkins and Mason, with 1 by Dr. Ross, of Montreal,| 1 by Thomas,§ 1 by 
Packard, 1 by Morton, and 1 by myself, we have a total of 129 cases, with 
81 recoveries and 48 deaths,—a highly favorable result indeed. 
The most extensive statistics on colotomy are those of Dr. Balt, amounting 
to 351 cases. The operations as condensed by Professor Ashhurst were 
done— 
154 times for carcinoma of the bowel, with a death-rate of 32.0 per cent. 
20 “ “ intestinal fistula, “ “ 10.0 “ 
52 “ “ imperforate rectum, “ “ 52.9 “ 
40 “ “ obstruction of the bowel, “ “ 50.0 “ 
4 “ “ ulceration of the bowel, “ “ 25.0 “ 
72 “ “ stricture of the bowel, “ “ 43.1 “ 
9 “ “ different affections, “ “ 44.4 “ 
Of the 351 cases, 133 terminated fatally, making the death-rate 37 per 
cent., the same as given in the collection made by Brkelen. 
Erkelen’s statistics, comprising 262 eases of colotomy for all causes, give a 
mortality of 58.4 per cent., and for 110 cases in which the operation was per- 
formed for carcinoma, a mortality Of 37.1 per cent. 
Colectomy.—Cases will be encountered in which it becomes necessary to 
excise or resect a portion of the colon. The most common conditions re- 
quiring such an operation are carcinoma, gangrene following strangulated 
hernia, intussusception, when after exposing the bowel it is found impossible 
* Transactions Royal Med. and Chirurg. Society, London, vol. xxxv. 
f American Journal of the Medical Sciences, Oct. 1873. 
J Canada Med. and Surg. Journal. 
£ Thomas, Edinburgh Med. Journ., Sept. 1869, p. 262. 502 
DISEASES OF THE ABDOMEN. 
to reduce the invagination, and extensive shot wounds of the intestine. Two 
plans are adopted in dealing with the bowel after excision. 
The operation of excision is executed in two ways. According to one 
method, the ends of the intestine after resection are brought into and 
stitched to the edges of the external wound ; by the other plan, after excision 
the ends of the bowel are approximated, stitched together by sutures, and re- 
turned free into the cavity of the abdomen. The former method, involving, 
as it does, less risk to the life of the patient, should be adopted. Several 
years ago I resected successfully eight inches of the small intestine for gan- 
grene following hernia, leaving the extremities in the abdominal opening. 
I n a second case, in which I removed twelve inches of the gut in a state of 
gangrene from strangulated umbilical hernia, stitched the ends together, and 
returned the loop into the abdomen, the result was not so fortunate, the 
patient dying on the second day. Dr. Charles Penrose resected successfully 
twelve inches of the transverse colon for carcinoma, bringing the ends of 
the gut into the abdominal wound. While the danger is less when this plan 
is adopted, it does not necessarily leave the patient with an artificial anus 
or stercoraceous fistula, as both can be cured by subsequent operation. 
The details of colectomy do not differ from those of entereetomy. The 
mortality of the operation, based on one hundred and fifty cases, amounts to 
fifty per cent. 
Treatment after Laparotomy and Colotomy.—After closing the wound 
the patient must be kept quiet on the back, with the shoulders raised some- 
what, to relax the parietes. Opium should be given only to relieve pain and 
secure peristaltic rest. The use of the catheter will be required, and the 
bowels may be allowed to remain quiet for eight or ten days, after which 
an action should be solicited either by enemata or by some gentle aperient 
given in small doses and repeated at intervals of two hours. For the first 
twTenty-four or thirty-six hours the patient should abstain from all nourish- 
ment by the mouth, using only small pieces of ice. Should the exhaustion 
following the operation be very great, small quantities of milk with a little 
brandy may be given from time to time. Vomiting, which sometimes per- 
sists after laparotomy, is best controlled by minute doses of calomel (one- 
twelfth of a grain) with one-thirtieth of a grain of morphia administered 
every hour until the stomach becomes quiet. External heat to the body 
by hot-water bags must not be overlooked. In the event of peritonitis 
setting in, the bowels should be acted upon by saline cathartics. 
Diseases of the Anus and Rectum. 
General Observations.—In the investigation of diseases of the anus and 
the rectum, there are several points connected with the examination of patients 
which demand consideration. 
First. Position for examination.—In females, the position which I prefer is 
that on the side or partly 
on the breast, with the 
limbs well drawn up to- 
wards the abdomen and 
the hips near to the edge 
of the bed. When the pa- 
tient is a male, the best 
posture is that upon the 
elbows and the knees, the head and shoulders being low, and the hips well 
elevated and placed opposite a good light. In this position the viscera gravi- 
tate towards the chest, and when the proper speculum is introduced, the air 
expands the bowel to a degree which admits of the most satisfactory exami- 
nation. Many of the operations on the rectum can be properly done only 
with the patient on the back and in the lithotomy position. With the 
use of the MacBride yoke (Fig. 387), this posture can be maintained and the 
Fig. 387. 
MacBride yoke. DISEASES OF THE ANUS AND RECTUM. 
503 
usual assistants for supporting the limbs dispensed with. Clover’s crutch will 
answer the same purpose. If the object is to examine the interior of the 
anus, a towel or a napkin interposed between the lingers and the integument 
will enable the surgeon to unroll or evert the mucous surface, if at the same 
time the other buttock be drawn in the opposite direction by one hand of 
the patient or by that of an assistant. If it is desirable to enter the bowel 
with the linger, the nail should be well shielded by scraping it a few times 
over a piece of moist soap, which will fill up the space underneath. By a 
digital examination we may ascertain the existence of hemorrhoids, stric- 
ture, the presence of morbid growths, foreign bodies, and faecal accumula- 
tions. 
In the female we can evert the lower end of the rectum very satisfactorily 
by inserting a finger into the vagina and pressing upon the recto-vaginal 
septum. The introduction of the hand and arm into the bowel has recently 
been practised by Simon and others, with a view to explore the colon and 
other parts within the abdomen. The benefits resulting from such violence 
are of so doubtful a character, and the evils which have resulted are so 
serious, that I feel compelled to condemn the practice, save in exceptional 
cases. 
Forcible dilatation of the external sphincter, as practised in the treatment 
of fissure, will oft'en prove of great value in enabling the surgeon to examine 
the condition of the bowel. 
The instrumental exploration of the rectum is accomplished by different 
Fig 388. 
Fig. 389. 
Trivalve anal speculum. 
Bivalve anal speculum. 
Fig. 891. 
Fig. 390. 
Anal speculum with an oval opening on the side. 
Fig. 392. 
Wire anal speculum with stylet. 
Anal speculum with an elongated 
fenestra and with stylet. 
kinds of specula. The ordinary forms of anal specula are the bivalve (Fig. 
388), the trivalve (Fig. 389), the cylindrical, of which there are two kinds, 
one having an oval opening on its side (Fig. 390) and the other an elongated 504 
DISEASES OF THE ABDOMEN. 
fenestra and stylet (Fig. 391) ; also the fenestrated wire speculum with stylet 
(Fig. 392). 
The bivalve, trivalve, and wire specula are constructed of metal, and the 
cylindrical ones are made of glass or of hard rubber, the inner surface of the 
tube being highly polished, so as to prove a good reflector of light. The in- 
strument which in a large majority of cases I prefer—indeed, the only one 
which 1 consider of much value—is the ordinary Sims’ speculum (Fig. 393). 
To cleanse the mucous membrane 
of the bowel, a piece of soft sponge 
or a pledget of lint and a pair of 
dressing-forceps will be required. 
A very thorough exposure of the 
rectum, to the extent of three inches, 
may be obtained by etherizing the 
patient and using the two index fin- 
gers as one would employ a bivalve 
speculum, thus forcibly dilating the 
sphincters. Preliminary to an exami- 
nation of the rectum, it is often neces- 
sary to clear the bowel of all f»cal 
accumulations by means of an injection: indeed, in obscure cases of rectal 
disease, no examination is complete without this preparatory measure. Ene- 
mata may be prepared from different materials. Those in common use are 
plain water, cold or warm; water, with the addition of a tablespoonful of 
salt or of some Castile soap; flaxseed-tea, sometimes with the addition of 
the spirits of turpentine ; castor or sweet oil, with molasses and lard; starch 
suspended in water; with many others of less value. Where any lesion or 
tumor exists, or where an operation is contemplated, the injection should 
consist of a solution of boracic acid (5iv to water Oi). 
When clysters are administered, the patient should be placed on the side 
near to the edge of the bed, with the knees drawn up. WThen a small 
enema is required, one, for example, not exceeding two or 
three ounces, the best instrument for the purpose is a hard- 
rubber syringe holding about four ounces (Fig. 394); and if 
the nozzle be curved, the patient will be able to use it without 
assistance, especially when in the standing position. When 
larger injections are required, the best instrument for the pur- 
pose is the Davidson syringe. (Fig. 384.) 
The metal or hard-rubber nozzle in all clyster syringes 
should be discarded and bone used instead, the extremity 
being blunt and smoothly rounded. Whether bone or metal 
be employed, great comfort and safety will be realized by 
slipping over the nozzle a rubber shield. The softness and 
flexibility of the gum admit of its being introduced into the 
bowel without the least inconvenience or pain. The point of 
the nozzle, after being smeared with lard, cold cream, or zinc 
ointment, and all air expelled from the syringe, should be 
inserted into the anus and directed upwards and backwards 
towards the sacrum, so as to keep the instrument in the axis 
of the bowel until both sphincters are passed, when the con- 
tents of the instrument should be slowly discharged into the rectum. When 
it is desirable to retain an injection permanently, the quantity must be small, 
and the patient should maintain the recumbent position for fifteen or twenty 
minutes after its reception. 
Fig. 393. 
Sims’ speculum. 
Fio. 394 
Hard-rubber syr- 
inge. 
Congenital Malformation of the Anus and Rectum.—Such anomalies in 
development are of rather rare occurrence: unfortunately, in most cases 
they are not entirely correctible by surgical operations. 
Malformations of the anus are of three kinds: first, preternatural narrowing MALFORMATIONS OF THE RECTUM. 
505 
of the anal aperture, sometimes opening in abnormal positions on the peri- 
neum ; second, cutaneous or membranous occlusion (Fig. 395); and, third, 
entire absence. An additional complication may exist in conjunction with 
any of these varieties,—namely, that of a 
fgecal fistula,—which may communicate with 
the vagina, the bladder, the urethra, or may 
open upon the surface of the body, near to or 
remote from the perineum. The statistics of 
Zohrer and of Collins comprise 66,654 new- 
born children, only 3 of whom suffered from im- 
perforate anus. These defective conformations 
of the anus and of the rectum, according to 
Curling, are more common to males than to 
females. In 90 cases, 68 were males and 22 
females. This difference in favor of male 
children is not sustained by the tables of M. 
Bouisson. Of the 100 cases tabulated by this 
author, 53 were females and 47 males. Leich- 
tenstern’s statistics on the subject give 241 
males to 184 females. In my own experience, 
the male sex has been much oftener the sub- 
ject of this vice of development than the female. 
In the first variety, or that where the anal orifice is preternaturally small, 
the opening is not always in the normal position. In a case which I saw with 
Dr. Henry S. Gross, of this city, it was situated at the anterior extremity of 
the raphe of the scrotum, or where the latter joins the penis, and it received 
with difficulty the point of a small silver probe. In these cases of simple 
anal malformation there will be more or less bulging of the parts by the 
descent of the meconium when the child cries or strains. If the anus is 
absent, this protrusion or conical extension of the perineum will not be 
present, but the finger pressed against the anal region may detect an impulse 
from the pressure of the intestinal contents which the eye cannot discern. 
These are the forms of anal malformation which admit of treatment. 
When the orifice in the gut is contracted, or when the occlusion consists 
of a thin membrane, the proper plan is to make a crucial incision, and to 
instruct the nurse or the mother to introduce, daily, a bougie, made by 
melting or shaving a tallow candle down to the proper size. When the anal 
orifice opens some distance from the proper place, it should be slit up to the 
bowel upon a director, after the manner of dividing a fistula. 
In cases of entire absence of the anus, a careful dissection will be required 
in the direction of the raphe, through the skin, muscular and cellulo-adipose 
structures, taking care to follow the slight curve of the coccyx and sacrum, 
and using from time to time an exploring-needle, in order to detect the pres- 
ence of the meconium and thus have a guide for the safe progress of the 
incision. If the rectum is successfully reached and opened, it is necessary 
to bring it down and to attach it, by means of interrupted sutures, to the 
margin of the external wound, after the . manner of Amussat, in order to 
prevent the cicatricial contraction of the newly-formed anus. In these cases 
of imperfection and of absence of the anus, the external sphincter is gener- 
ally present, though it may not be complete in all respects. Its entire absence, 
however, would not entail faecal incontinence, as the office of guarding the 
lower end of the gut against involuntary discharges belongs to the internal 
sphincter. A very unfavorable complication of imperforate anus is that of 
faecal fistula. 
The most common malformations of the rectum are the following : first, 
partial absence,—that is, the bowel ending at various distances from the 
anus (Fig. 396); second, entire absence, and, in rare instances, the colon also 
wanting; and, third, abnormal termination in the vagina (Fig. 397), bladder, 
urethra, or in other unusual position. These vicious conformations of the 
Fig. 395. 
Membranous occlusion of the anus. 506 
DISEASES OF THE ABDOMEN. 
rectum may be associated with a perfect anus, or with any of its imperfo- 
rate forms. 
It is only when the rectum terminates a short distance from the surface 
that the meconial tumor can be felt. It may protrude into the anus, when 
the latter is present, or it may be detected by inserting a finger into the anal 
orifice. Unless the surgeon is able to see or to feel this distention pro- 
Fig. 396. 
Pig. 397. 
Rectum terminating at the top of the sacrum. 
Rectum terminating in the vagina. 
duced by the imprisoned contents of the intestine, any opinion as to the 
termination of the rectum can only be mere conjecture. 
When there is associated with an imperfection of the bowel an imperfectly- 
developed pelvis, the lower diameters being much contracted, the entire ab- 
sence of the rectum, on the authority of Rokitansky and Curling, may be 
assumed. It is alleged that if a catheter or sound introduced into the 
bladder or vagina is found to strike directly in contact with the sacrum, it 
indicates the absence of the rectum. The sensations imparted by this test 
are not, however, by any means decisive on this point. 
When the abnormal condition of either anus or rectum is such that no 
escape of the intestinal contents can take place, the child soon loses its appe- 
tite, cries, and refuses its nourishment; the abdomen becomes distended, vomit- 
ing follows, and the little sufferer sinks and dies, as in ordinary obstruction 
of the bowels. That a child may survive for a long time with such a mal- 
formation is attested by the case related by Bodenheimer, in which a child 
with absence of the rectum was not operated upon for three months after 
birth, and yet enjoyed perfect health. The intestine was found three inches 
from the surface, and the child was known to be alive two years after the 
operation, quite well, and with perfect control over the bowel. 
Treatment.—In cases where the anus exists, and the rectum terminates 
low down in a membranous cul-de-sac which is likely to be distended by the 
straining efforts of the child, a grooved needle should be first introduced into 
the swelling, in order to ascertain its contents, and, if they are found to consist 
of meconium, a puncture should be made with the point of a knife sufficiently 
large to admit the blade of a blunt-pointed bistoury, with which the wound 
may be freely enlarged. When the rectum ends higher up, and is associ- 
ated with absence or imperforation of the anus, exploratory punctures are 
hazardous, especially when made with an instrument the size of the ordinary 
trocar. It is impossible to determine how low the peritoneum descends, and 
these stabs in the dark may do great harm by wounding this membrane. 
The best plan to pursue is that of making a careful dissection, the child being 
etherized and held in the position of a patient about to be cut for stone. The 
incision should be made in the direction of the perineal raphe, over the place 
where the anus is normally situated, and be continued cautiously up, close to CONGENITAL MALFORMATION OF THE ANUS AND RECTUM. 
507 
the coccyx and to the sacrum, guided by a finger in the anterior part of the 
wound. If the surgeon be fortunate enough to reach the gut and to make 
an opening into its cavity, he should endeavor to draw it down by the forceps 
and connect it by sutures as near the surface of the external wound as pos- 
sible. The depth to which it is proper to go in search of the bowel has not 
been determined. Mr. Erichsen reached the rectum, in one case, at the dis- 
tance of three inches from the surface, but the child subsequently died from 
pelvic cellulitis. 
Curling places the limit of incisions at one inch and a half, and any one 
who carefully dissects the perineum of an infant will, I think, entirely agree 
with this writer. Beyond this depth, the cul-de-sac of the peritoneum will 
probably be laid open. Whenever, therefore, the search for the rectum at 
this distance proves fruitless, the operation of colotomy should be made, rather 
than to pursue farther a blind search in a dangerous region. In connection 
with this object two questions arise: first, is the attempt to save the life of 
a child by the resort to an artificial anus advisable ? and, second, if so, which 
is to be preferred, the lumbar or the inguinal operation ? 
To determine the first is a very simple matter: it is always the duty of 
the surgeon to save life, and if he neglects to employ all the resources of his 
art to that end, he fails to meet the moral requirements of his position. 
In regard to the best method of reaching the colon in infants there is a 
difference of opinion. The objections urged against lumbar colotomy are the 
great depth of the descending colon ; its mobility in consequence of the length 
of the mesocolon, rendering it difficult to find, or, when reached, exposing the 
peritoneum to injury in the act of opening the bowel; and, finally, the pos- 
sible displacement of the colon, the gut being frequently situated on the right 
of the median line. A distended and resonant condition of the right iliac 
region, with a flat state of the left, will indicate to some extent this displaced 
position of the bowel. It is certainly much easier to reach the intestine by 
Littre’s operation—that is, in the inguinal region—than by Amussat’s plan, 
through the loin; but the former involves, of necessity, the opening of the 
peritoneum, which exposes the patient to the risk of peritonitis. The cases 
collected by Mr. Curling are not sufficiently numerous to justify any decided 
conclusions from a comparison of the two plans, though most favorable, as 
far as they go, to the operation in the groin. 
In fourteen cases in which Littre’s operation was performed, nine recov- 
ered, while in seven instances in which lumbar colotomy was done, only two 
proved successful. After examining the bodies of infants with reference to 
this point, the objections urged against the Amussat method of reaching the 
colon appear to me to be well made. 
The great extent of the sigmoid flexure in new-born children, in conse- 
quence of which it is sometimes seen lying in the right iliac fossa, induced 
Huguier to insist that the operation should be done on that side; but this 
disposition of the bowel is by no means sufficiently common to warrant any 
such procedure. Mr. Erichsen, recognizing the difficulties which attend the 
opening through the loin, advises that the operation be done in the right 
lumbar region, thereby reaching the Cfecum or the head of the colon, a 
measure of doubtful propriety. 
The success which has followed colotomy in children for imperforation of 
the anus and the rectum cannot well be determined. M. Guersant* operated 
eleven times without a single success. A few cases of recovery are recorded 
by Yidal de Cassis, Pochard, Maisonneuve, and Amussat. 
The operation of lumbar colotomy for imperforate anus or rectum in the 
infant does not materially differ from the same operation in the adult. If 
inguinal colotomy be preferred, the steps of the operation do not differ much 
from those for tying the iliac artery. An incision should be made over the 
left iliac region, parallel to and half an inch above Poupart’s ligament, and 
extending from one inch external to the anterior superior spinous process 
* Bull, de Th6r., tom. xlix. 508 
DISEASES OF THE ABDOMEN. 
of the ilium to a point opposite the middle of the groin. The skin being 
divided, the subcutaneous cellular tissue and the different tendinous and mus- 
cular layers should be raised and incised upon a director. When the perito- 
neum is reached and opened, the sigmoid flexure of the colon will probably 
present at the wound. Two needles, each armed with a silk thread, should 
be passed through the walls of the intestine in a longitudinal direction. By 
these threads the bowel is to be drawn through the wound: it is then to be 
opened in its long axis, each margin being securely attached to the cutaneous 
edge of the parietal wound by a number of interrupted stitches. 
Even in those cases where an opening is established in the groin, it is not 
impossible, later on, to coax the bowel down into the pelvis until it approxi- 
mates the perineal surface. This was successfully accomplished by Dr. Byrd, 
of Illinois, his method being similar in principle to that of Demarquas (only 
substituting rubber for lead). An elastic string, with a long, delicate needle 
attached at one end and a small rubber bulb at the other, was passed from 
the intestine through the perineum. The cord by its elasticity gradually 
drew the yielding intestine down towards the floor of the perineum, where 
an opening in the natural location was made and the continuity of the two 
established. 
Abnormal communications of the anus or rectum with adjoining organs 
constitute a serious complication : 
First. The opening may exist between the anus and vagina, the rectum 
terminating some distance above. In such a case the anus should be divided 
posteriorly, and an incision cautiously carried upwards, following the sacrum. 
If the bowel be discovered, it must be opened, drawn down, and connected 
to the anus by sutures. In a case of this kind related by Amussat, the anus 
was entirely ignored, an opening being made between the latter and the 
coccyx, through which the rectum was reached and opened. This patient 
survived, grew up to womanhood, and was married. 
Second. The rectum may terminate in the vagina, either with or without 
an anus. In either case the proper treatment consists in carrying a curved 
director into the vagina, and through the fistulous communication into the 
gut. The director should next be turned in such a manner as to press into 
the anus, or, in the absence of the latter, against the perineum, when a free 
incision should be made down upon its point, and be sufficiently enlarged to 
make a direct and ample way of escape for the meconium. 
In two cases of this kind which I have operated on, one at the Pennsyl- 
vania Hospital and the other at the University Hospital, the result was 
entirely successful. The fteces were gradually diverted from the vagina and 
the fistula closed up. There are a number of recorded cases of this imper- 
fection, in which no effort was made to correct the infirmity, the presence of 
which does not appear to have shortened life or to have prevented preg- 
nancy. When the opening between the bowel and the vagina is large, this 
operation may fail, in which case there remain two resorts: one of closing 
the recto-vaginal opening, by paring its edges and uniting them by sutures 
after the anal orifice is well established; and the other, by incising the peri- 
neum antero-posteriorly,—in the absence of the anus,—dissecting the rectum 
from the vagina, pulling it down, and securing it by sutures to the external 
opening. This is the operation of Bizzoli, and resembles in many points that 
of Dieffenbach. 
Third. The rectum may terminate in the bladder or in the urethra, and, as 
in those cases where the communication exists with the vagina, the condition 
does not involve any immediate risk to life, since the contents of the bowels 
can be discharged through these unnatural routes. Very commonly, however, 
sooner or later, the fistulous orifice becomes obstructed by the fteces, as they 
begin to assume the solid form, or by foreign bodies, such as the seeds of fruit 
taken into the stomach. The certainty of such an obstruction is ample justi- 
fication for making an attempt to reach the rectum by a cautious dissection 
through the perineum, detaching it from its connection with the bladder or CONDYLOMATA. 
509 
the urethra, drawing it to the position of the new anus, and there connecting 
it by means of a number of interrupted stitches. Should the surgeon fail to 
discover the bowel, the operation of colotomy may be performed. 
Fourth. The anus or rectum may open upon the surface at unusual locali- 
ties; for example, on the raphe close to the scrotum, at the posterior commis- 
sure of the labia, and at other parts of the perineum. The treatment in such 
cases is to slit up the abnormal fistulous track, when near to the usual position 
of the bowel, and establish a free opening at the proper place for the normal 
anus. Larrey saw an infant seven months and a half old in whom the anus 
opened in the loin, three inches external to the spine. 
All operations to correct these abnormal conditions of the intestine must 
be done antiseptically. 
Condylomata.—These formations are frequently seen scattered about the 
verge of the anus. They are sometimes called papillomata, at other times 
vegetations or warts. They appear as flat sessile elevations having a granu- 
lar, moist surface. These growths may be either distinct, or in patches closely 
grouped together, and often emit a very unpleasant odor. They are composed 
of hypertrophied papilla?, or, what is the equivalent of these, of loops of blood- 
vessels, supported by connective tissue and covered with layers of epithelial 
cells. They grow exuberantly in a moist locality, a condition which generally 
exists about the anus, produced by the contact of the nates. They are sup- 
posed to arise frequently from carelessness in matters of personal cleanli- 
ness ; but in most instances their presence can be traced to a syphilitic or 
gonorrhoeal origin. They differ so widely in appearance from external hem- 
orrhoids that, did 1 not know to the contrary, I should scarcely conceive it 
possible that the two diseases could be confounded with each other. External 
piles are either round, pendent tumors, or loose folds of the integument, having 
a smooth surface, whereas condylomata are flat, and possess an irregular, warty 
appearance. 
Treatment.—The treatment consists in enforcing careful and frequent 
ablutions with carbolic acid soap and water, drying the parts thoroughly, 
and afterwards dusting with a powder consisting of equal parts of calomel 
and gallic acid, interposing beween the folds of the buttocks a piece of 
old linen. The great object is to prevent the vegetations coming in contact, 
and to avoid the presence of moisture. Should this not answer, the growths 
should be clipped off on a level with the skin with a pair of scissors, and the 
bleeding surfaces touched with nitric or chromic acid. The hemorrhage 
which follows their removal is sometimes very profuse, and, should it not 
subside spontaneously, can be controlled by applying the powdered subsul- 
phate of iron. When these warts return, the patient should be placed on a 
gentle mercurial course of treatment, never, however, carried to salivation. 
For this object the corrosive sublimate, in doses of one-thirtieth of a grain, 
will answer the purpose best. 
Pruritus Ani.—Itching of the parts about the anus is most frequently the 
consequence of some disease or irritation within the bowel, such as piles, 
ulcers, worms, or other parasites. In certain persons it is due to constipation, 
and in others appears to be connected with some peculiar state of the nerves 
of this region. A medical officer in the United States army, whom I treated 
for a distressing pruritus, informed me that the disease was very common 
in Mexico, and was produced by the same cause that had led to the affection 
from which he himself suffered, namely, the habitual use of a hot aromatic 
species of pepper. The leucorrhceal discharges of women often excite the 
disease by remaining in contact with the skin of the perineum and developing 
an eczema. The itching frequently occurs at night, after the patient retires 
to bed, and occasionally prevents sleep for hours. The sensations some- 
times experienced are those of something crawling in the lower end of the 
bowel. When the irritation is severe, the disposition to scratch becomes 510 
DISEASES OF THE ABDOMEN. 
irresistible, and the nails are often applied so vigorously as to cause excoria- 
tion and inflammation. The repetition of the scratching, and the prolonged 
irritation, so alter the skin that it loses its pliability, and becomes red, dry, 
and rough, or preternaturally white and scaly. A sea-captain who was a 
subject of pruritus ani told me once that when the itching came on. so 
intolerable was the distress, and so utterly was he at the mercy of his 
sensation, that all self-control was lost, and, though doing the honors of the 
table of his ship at the moment, and in the presence of ladies, he has invol- 
untarily dropped the carving-knife and commenced vigorously to scratch his 
anus. 
Treatment.—If there is reason to believe that the pruritus depends upon 
the presence of hemorrhoids, an operation for their removal will usually 
effect a cure. If it is caused by asearides, they must be expelled by injec- 
tions of carbolic acid and sweet oil (one part of the acid to six parts of oil). 
Enemata of turpentine and flaxseed-tea also answer a good purpose as a local 
anthelmintic, and the same is true of the dilute tincture of the sesquichloride 
of iron. If an idcer exists in the bowel and causes the pruritus, little relief 
can be expected until it is healed by the application of caustics. Parasitic 
irritation is best relieved by injections of dilute sulphurous acid, or by sup- 
positories of lac sulphuris. In some instances the disease is caused by consti- 
pation, or arises from causes connected with imperfect digestion: derange- 
ments of this kind must be corrected by a pill consisting of rhubarb, extract 
of belladonna, extract of nux vomica, and the bichloride of mercury. All 
stimulants and highly-seasoned food should be discarded. When the pruritus 
depends upon a disordered state of the nerves of the anus, independent of 
any local excitant,—a condition occasionally seen in delicate females,—the 
proper course will be to improve the general health by administering iron, 
quinine, and arsenic combined, directing local and general bathing and living 
as much as possible an out-door life. To relieve the itching, there are a 
number of local remedies which may be applied with advantage. Among 
these may be mentioned frequent ablutions with cold water, and the use of 
palm soap, from which a thick lather should be made and pressed into the 
anus with the finger. Mercurial and citrine ointments will often prove useful, 
and their efficacy will be enhanced by the addition of a little carbolic acid 
and morphine. Among the lotions which give relief are lead-water, camphor- 
water, tar-water, thymol, and a solution of borax. The oxide of zinc oint- 
ment is best adapted to heal the excoriated surfaces. The nitrate of silver, 
of the strength of ten grains to one ounce of distilled water, is used for a 
similar purpose* When all other remedies have failed, I have used the follow- 
ing with the most gratifying result: sulphate of zinc and alum, equal parts, 
are to be placed in an earthen vessel and heated sufficiently to drive off their 
water of crystallization, or until they become a confluent, hard mass. From 
half a drachm to one drachm of this substance, powdered and dissolved in a 
little water, should be thrown into the rectum. In a few minutes it will de- 
stroy the itching. I have succeeded thus in curing cases of the disease which 
had for years defied all other remedies. The prescription, I believe, is an old 
English remedy. An injection which I have used with success when other 
remedies have failed is one consisting of thirty grains of the bromide of 
potash dissolved in half an ounce of slippery-elm tea. A suppository contain- 
ing three or four grains of iodoform, introduced into the rectum on retiring 
to bed, will be found to have an excellent effect in nocturnal pruritus. Many 
persons derive great comfort from wearing a pad of oakum made to fit up 
against the anus,—a suggestion of Van Buren’s. I have found that washing 
out the lower bowel with an enema of water immediately before retiring 
to bed will often insure a complete exemption from this local irritation 
during the night. Allingham directs, for the same purpose, a metal or bone 
rectal plug, with two shoulders, to prevent its slipping into the intestine. This 
is to be introduced into the bowel at bedtime. The pressure which it exerts 
on the nerves and vessels of the parts effectually prevents the itching. SPHINCTERISMUS. 
511 
Sphincterismus.—This is a spasmodic contraction of the sphincter muscle 
of the anus. After it exists for some time the muscle becomes hypertrophied, 
and feels like a ring of iron. It is generally associated with spasm of the 
levator ani muscles, in consequence of which the orifice of the anus is so 
drawn up as to be scarcely visible. The patient in such cases often finds 
it difficult to expel the faeces, on account of the resistance offered by the 
strongly contracted muscle, and suffers considerable pain. I at one time 
believed that this state of the sphincter was always caused by the presence 
of a fissure or ulcer of the rectum, but I am now convinced that it may exist 
entirely independent of any such disease. It is not unfrequently the cause 
of faecal accumulations in the rectum, which cannot be extruded without 
digital aid. 
Treatment.—A careful examination of the anus and the rectum should 
precede all treatment, with a view to ascertain if there is any local disease 
which will explain the muscular spasm. If an ulcer is discovered, its treat- 
ment is of primary importance. When no structural alteration can be de- 
tected, and if the affection is associated with constipation, the bowels should 
be moved by gentle laxatives, like magnesia or rhubarb, and the diet regu- 
lated in such a manner as to exclude all highly-seasoned articles of food. 
Before retiring to bed, the patient will do well to take a hot hip-bath for 
twenty minutes, after which a suppository containing half a grain of the 
extract of belladonna may be introduced into the bowel. Should these means 
not prove successful, a bougie smeared with belladonna ointment may be 
passed through the anus daily, with a view to reduce the irritability of the 
muscle. In obstinate cases, or such as do not yield to the gentle measures 
just described, it will be necessary to apply forcible dilatation. This is 
best done by etherizing the patient, introducing the index fingers into the 
bowel, and stretching the rebellious muscle until all resistance is overcome. 
If this proves unsuccessful, there remains, as a last resort, the division of 
the sphincter by the knife, as in cases of fissure. When the patient is pale 
and anaemic, and suffers from palpitation, flatulence, and sleeplessness, a course 
of iron, sea-bathing, and exercise in the open air, with a plain, nutritious, and 
unirritating diet, will form the best plan of treatment. Stimulants must be 
positively forbidden. 
Loss of Co-ordination in the Muscles of Defecation.—The act of defecation 
is accomplished by the co-operation of the abdominal muscles and the dia- 
phragm with the muscular walls of the rectum, the levatores ani, and the 
internal sphincter. In expelling the faecal mass through the outlet of the 
gut, there are two very essential acts, namely, the consentaneous contraction 
of the walls of the rectum and the levatores ani, and the simultaneous dila- 
tation of the sphincter. The effect of the first of these acts is to diminish 
the intestine both in its calibre and in its length, and to force the contents 
towards the anus. The effect of the second act is the opening of the lower 
orifice of the bowel, for the escape of the evacuation. 
In a few instances I have met with cases in which the muscular co-ordina- 
tion just alluded to, and which is necessary for the extrusion of the faecal 
mass, was lost. The contents of the bowel would come down to the sphincter, 
and the latter would partially dilate, but that movement by which the lower 
extremity of the bowel is to some degree everted and elevated, and which is 
necessary to complete the final act, did not take place, rendering it necessary 
for the patient to dig the evacuation out of the intestine with the fingers. 
The defect appears to reside in the imperfect action of the longitudinal 
muscles of the rectum and of the levatores ani. This incapacity, though it 
may be caused by an injury to the lower end of the spinal cord, in which 
resides the centre directing the reflex movements concerned in defecation, is 
often connected with an impressible or a supersensitive state of the nervous 
system, closely allied to hysteria, and is consequently more frequently met 
with in females than in males. In the case of a lady, who came to Phila- 512 
DISEASES -OF THE ABDOMEN. 
delphia to consult on account of this ineompetency, I discovered a small 
erectile growth in the rectum, the extirpation of which very promptly 
removed the disability of the bowel. 
Treatment.—A careful examination of the anus and the rectum should be 
made in search of polypi, ulceration, or any other disease possible to the 
locality; nor should the uterine or vesical organs be overlooked. If any 
structural alteration is discovered which would tend to cause this singular 
defect, it should be removed as far as practicable. If nothing of the kind 
can be found, the treatment must be directed to the improvement of the 
general system, comprising cold hip-baths, electro-galvanism, iron, and asa- 
fetida, with constant out-door exercise. 
Fissure of the Anus.—Few affections of the bowel entail more suffering 
than anal fissure, sometimes called painful ulcer of the rectum. The posi- 
tion of a fissure is usually just within the verge of the anus, beginning at 
the cutaneo-mucous line and extending upwards towards the rectum for a 
distance rarely exceeding half an inch. It is a mere linear ulcer or crack in 
the mucous membrane of the anus, often so narrow that, unless the corruga- 
tion of the latter be unfolded, it will escape observation. Fissures may occupy 
any portion of the circumference of the anus, but in a majority of instances 
they will be found at its posterior or coccygeal side. They are occasionally 
multiple. Fissure is a disease of adult life, and is more common to women 
than to men. Nevertheless, very young children are not exempt from the 
affection. I have seen it in infants not over two months old. 
Causes.—Fissure arises from a variety of causes, such as atony of the 
rectum, allowing the bowel to become impacted with hardened faeces, which, 
when discharged, overstretch the mucous membrane, thus either producing 
a direct lesion or provoking inflammation which results in the narrow ulcer. 
Chronic diarrhoea will induce the disease; also hemorrhoids and polypi. 
Sometimes it has a syphilitic origin, and at other times the cause will be found 
in a general derangement of the health. 
Symptoms.—The most significant symptom of fissure is pain. This pain is 
of no ordinary kind. It is not generally experienced at the time of defeca- 
tion, but sets in twenty minutes or half an hour after. At first a hot, throb- 
bing sensation is experienced, which soon merges into a severe pain, and 
this continues to increase in severity until the suffering of the patient be- 
comes agonizing. The behavior of persons during the paroxysm differs 
much in different cases. One will walk the floor like a madman; another 
will gradually settle into some position which to a spectator would appear 
very uncomfortable, but from which no entreaty could induce the sufferer to 
change. The sphincter ani will be found in a state of spasm, feeling to the 
finger like a ring of iron. After six or seven houi’s the suffering begins to 
abate, and gradually disappears, only to reappear, however, after the next 
evacuation from the bowels. In consequence of this, many dread the re- 
currence of the daily stool, and put it off or take some remedy to produce 
constipation. 
To resolve all doubts, the anus should be examined. Let the patient be 
placed upon the side, with the limbs drawn up; raise the buttock, and with 
the fingers open the anus. If the mucous surface is not sufficiently exposed, 
an effort on the part of the patient like that put forth in defecation will 
accomplish this object, and if the disease is present a red linear ulcer will 
appear. When this is of long standing, the surface may be ash-colored 
and the margins indurated. Sometimes, instead of the ulcer being linear 
or elongated, it will be round or oval, in which case its situation will be 
somewhat higher in the bowel. 
The effect of the prolonged repetition of such suffering as characterizes 
anal fissure is disastrous to the health of the patient. A female was brought 
to this city, believed to be a suitable subject for an insane asylum. She had 
become a profound melancholic. An examination revealed the existence of FISSURE OF THE ANUS. 
513 
an anal fissure, the cure of which restored her to health both of body and 
of mind. 
I once visited a young lady who had retired from society under the deepest 
mental despondency, and who had kept her room, a voluntary prisoner, for 
almost three years. It was with difficulty that she was persuaded to allow 
me an interview. After securing in some degree her confidence, and artfully 
drawing out some confessions, I suspected the existence of fissure, and verified 
it by an examination. When I told her that in a few minutes I could restore 
her to health and happiness, she believed that I was wantonly trifling with 
her sad condition. The operation was made, and a few weeks after a letter 
was received, replete with the most extravagant expressions of gratitude and 
joy- 
A very curious instance of the reflex influence of anal fissure came under 
my notice some years ago. A medical friend had suffered for a year with a 
severe paroxysmal cough. He had lost flesh, and was regarded by his friends 
as rapidly passing into a decline. He informed me that he experienced a 
severe burning pain in the rectum, which lasted some hours, after stool. 
On examination I discovered a fissure, for which I divided the sphincter. 
The cough disappeared with the ulcer, and has never returned. 
The extreme sensibility of this form of ulceration is due to the exposure of 
a nerve-filament. The anus is abundantly supplied with nerve-filaments, 
from both the sacral plexus and the pudic, and hence these fissures some- 
times induce irritability of the bladder, perineal and lumbar pains, disordered 
digestion, and, in females, occasionally paroxysms of hysteria. 
Diagnosis.—Fissure is often confounded with hemorrhoids, but the mistake 
is inexcusable. The pain, heat, and discomfort arising from piles are felt at 
the time of the evacuation, afterwards subsiding, and are rarely acute; the 
suffering from fissure sets in some time after the bowels are moved, and 
continues to increase in intensity for several hours. 
Treatment.—The methods of treating fissure are by cauterization, by dila- 
tation, and by incision. The caustics best adapted for this purpose are either 
the fuming nitric acid or the acid nitrate of mercury, one application of which 
will sometimes destroy the pain and excite healthy granulation and cicatri- 
zation. After the use of such caustics, an ointment may be applied, consisting 
of calomel and morphine, half a drachm of the former and three grains of the 
latter to an ounce of lard. If there is much rigidity of the sphincters, a little 
extract of belladonna may be added. Should it produce a dry mouth and 
throat, with dilatation of the pupils, the latter must be omitted. The bowels, 
while under this treatment, must be kept soluble with a confection of senna 
and washed sulphur. 
Dilatation, the operation of Kecamier, Van Buren, and others, consists in 
introducing the two thumbs into the bowel back to back, and then forcibly 
separating them from each other until the sides of the bowel can be stretched 
as far out as the tubers of the ischia. If the operation has been done prop- 
erly, a noise may be heard of something giving way, which is due to the 
rupture of the mucous membrane. Both cauterization and dilatation will fail, 
or at least are often succeeded by relapses: consequently for years I have re- 
sorted to incision combined with dilatation, and 1 believe it to be an unfail- 
ing cure for the disease. The patient should have the bowels cleared out the 
day before the operation, by a gentle cathartic; and, as the treatment is 
painful, an anaesthetic should be administered, after which, the person being 
placed upon the side and the ulcer exposed, the surgeon draws his knife 
through its base, dividing a few of the underlying fibres of the sphincter. 
He next introduces the index finger of one hand, previously well oiled, into 
the anus, and entering a sharp-pointed curved bistoury three-quarters of an 
inch from the side of the anus, to the depth of three-eighths of an inch, pushes 
it onwards towards the bowel until the point is felt by the finger within, 
when it is made to puncture the mucous membrane and then to cut out to 
the surface. The knife is now laid aside, and the anus well dilated with the 514 
DISEASES OF THE ABDOMEN. 
fingers, in order to paralyze any fibres of the lower sphincter which may 
have escaped division. If no vessel springs large enough to require a liga- 
ture, a piece of oiled lint or linen should be immediately placed in the wound. 
The subsequent treatment consists in keeping the patient in the recumbent 
position, and in the use of a little opium to confine the bowels. After three or 
four days a laxative may be given, from which time daily alvine passages 
should be encouraged. In seven or eight days the patient can begin to move 
about; but for at least two weeks he should avoid standing too long on the 
feet. No dressing is necessary, save that of bathing the parts with a little 
warm water and carbolic acid soap to remove any offensive discharges. The 
object of this operation is to secure rest to the ulcer by destroying the con- 
tinuity of the fibres of the underlying muscle, the contraction and relaxa- 
tion of which defeat all attempts at healing. There is a difference of opinion 
among surgeons as to the position and the depth of the incision. Some are 
content to divide a few muscular fibres immediately under the ulcer. I 
prefer to incise the entire external sphincter on one side, without reference 
to the ulcer, merely drawing the knife through the latter to freshen its sides. 
It has been proposed to divide the sphincter subcutaneously; but the ex- 
travasation of blood is liable to produce abscess in the loose tissue about 
the bowel. Search should always be made for polypi, and, if found, they 
must be removed by the ligature or by the knife; otherwise the operation 
for the fissure will prove unavailing. 
Foreign Bodies in the Rectum.—Foreign substances may enter the rectum 
in two ways,—by descending from the intestine above, or by being forced in 
through the anus. By whichever route the entrance is effected, the presence 
of such substances will often give rise to pain, tenesmus, ulceration, and 
abscess. Bodies which enter the rectum from above vary greatly in their 
character. In Ireland, in 1846, or after the blight affected the potato, there 
occurred man}'- instances of large rectal accumulations consisting of the 
skins and diseased parts of this staple vegetable.* The stones of fruit are 
sometimes swallowed and finally lodge in this part of the intestinal canal. 
In one instance, reported by Hazelhurst,f two hundred and eighty plum- 
stones—almost half a peck—were removed from the rectum of a negro, where 
they had remained for a week. Pins or pieces of coin which are accidentally 
swallowed will sometimes be arrested in the rectum. The thin, flat scale 
from the oyster-shell, often swallowed with oysters, I have known to become 
fastened in the mucous membrane of this part of the bowel and produce 
intense distress and pain. Worms curiously intertwined with one another, 
forming a ball coated with mucus, occasionally collect in the rectum. Faecal 
masses not unfrequently accumulate in the cul-de-sac of the gut. This is 
quite common in persons convalescing from typhoid fever, in whom there 
is often a lack of muscular power to expel the contents of the bowel. Old 
men, enfeebled by age or disease, frequently suffer in the same way from 
atony of the lower intestine. Women, after protracted labors, are frequently 
temporarily incapacitated for expelling the rectal accumulations, in conse- 
quence of the loss of contractility in the muscular apparatus either from 
pressure or from over-distention of the perineum by the foetal head; hys- 
terical females likewise furnish examples of impaction of the lower bowel. A 
singular case of fiecal accumulation is recorded! where the hardened mass, 
which when dislodged weighed four pounds, had remained in the rectum for 
six years. 
When foreign substances enter the rectum through the anus, the occur- 
rence is usually the result of mischief or malice, or is instigated by a hys- 
terical condition of the body. A beggar,§ on a wager, succeeded in intro- 
* Lancet, January, 1849, and January 19, 1850. 
f Hazelhurst, American Journal of the Medical Sciences, Oct. 1852, p. 569. 
J Gazette Medicale de Paris, July 20, 1849. 
£ Pollock, Wien. Med. Presse, 1869, No. 8. FOREIGN BODIES IN THE RECTUM. 
515 
ducing a cliampagne-flask, twelve and a half inches in length and two and 
three-quarter inches in diameter, into his rectum, where it remained, causing 
great suffering, for twenty-six days before its removal. A Hindoo,* while in 
a drunken frolic, had a glass goblet, three and a half inches long and two 
and five-eighth inches in diameter, pushed into his rectum by a lewd woman. 
It was subsequently broken, and extracted piecemeal. Marchetti records a 
singular case, in which some mischievous students introduced a pig’s tail, 
with the bristles cut short, into the rectum of a “ woman of the town.” 
Symptoms.—The symptoms which indicate the presence of foreign sub- 
stances in the rectum differ according to the nature of the offending material. 
When these consist of bones, scales of oyster-shell, or other pointed or 
sharp bodies, they cause pain and inflammation of the mucous membrane 
of the bowel, accompanied by tenesmus and sometimes bloody discharges. 
When there is an accumulation of hardened faeces, it is indicated by a sense 
of fulness and weight in the bowel, a constant desire to go to stool, spasm 
of the sphincter ani, pains in the lumbar region, and frequently the pas- 
sage of small liquid discharges. It is this last sign which so often misleads 
both the friends and the physician, who suppose that these frequent thin pas- 
sages are evidence of an unobstructed intestine and are to be regarded as a 
diarrhoea, to relieve which I have known opium to be administered for some 
time. When large bodies, such as tumblers, billets of wood, pointed sticks, 
and other similar articles, are thrust into the gut, they give rise to great 
distress and pain, and occasionally to peritonitis and collapse. 
Treatment.—The ingenuity of the surgeon will often be taxed to dislodge 
these substances. If a bone be fixed across the rectum, a finger inserted into 
its cavity will be sufficient to disengage one end and render extraction easy. 
Often, however, foreign bodies become buried in the folds of the mucous 
membrane from inflammatory swelling, and cannot be displaced in this way. 
When this is the case, the offending substance should be divided, and the 
pieces removed separately. This is readily done by conducting a pair of 
blunt-pointed bone-forceps to the body, along the finger inserted into the 
bowel, and cutting it in two parts, or by dilating the sphincter with a tri- 
valve or a sinus speculum and cutting it under the eye. Small bones can be 
severed with a pair of blunt-pointed scissors. Rings can be hooked out with 
the finger. When the body is large, and of a shape badly adapted for manipu- 
lation, the patient should be placed under an anaesthetic, and, a quantity of 
sweet oil having been thrown into the bowel, the sphincter should be well 
dilated with the fingers, after which the removal may be effected by blunt 
hooks or strong forceps, similar to those used for the extraction of stone 
from the bladder. It may be necessary to break the body and remove it 
piecemeal; or. if it is very rough, and likely to wound the bowel in the 
removal, it should be secured by long forceps, and a cylindrical speculum 
run down over its surface before extraction, the plan practised in Mai’chetti’s 
case already mentioned. Hardened fseces require to be broken up and hooked 
out with the finger. If a portion of the mass is too high up for the finger, 
a metal scoop may be emplojmd. Generally after a portion is removed the 
remainder can be got rid of by the use of injections of flaxseed-tea or soap- 
and-water. Ox-gall has been recommended as an enema in such cases, from 
its solvent action upon feculent matter ; but it is of little importance. Anaes- 
thetics should not be given, as a rule, in cases of faecal impaction, since, after 
breaking down the mass and using enemata, we require the expulsive efforts 
of the patient, which he is usually able to make as soon as the bulk of the 
accumulation is diminished and the distention of the bowel lessened. When 
the rectum is infested with worms, their expulsion may be effected by injec- 
tions of turpentine, creasote, or carbolic acid, with some mucilaginous fluid, 
like slippery-elm or flaxseed tea. The tender and swollen condition of the 
bowel which follows operations for the removal of foreign bodies is best 
allayed by a small injection of starch-water with a few drops of laudanum. 
* Parker, American Journal of the Medical Sciences, April, 1840, p. 409. 516 
DISEASES OF THE ABDOMEN. 
Irritable Rectum.—When the rectum becomes intolerant of the presence of 
faecal matter or of flatus, and manifests a disposition to expel such contents 
oftener than is natural, it is termed an irritable rectum. In addition to the 
frequent desire to defecate, there is generally some soreness at the verge of 
the anus and an uncomfortable sense of fulness and heat in the rectum. The 
irritability may be constant or only occasional. Females appear to be the 
subjects of the disorder oftener than males. It is rarely found except in 
persons of a nervous and excitable temperament. A careful examination of 
the anus and rectum will often fail to discover any structural change which 
can explain this condition, and we are compelled to regard it as one of re- 
flected irritation. 
The most probable sources of such irritation are enlarged prostate, urethral 
stricture, constipation, and disorders of the digestive organs. I have seen 
cases which arose from emotional causes, in which a person on the eve of 
making an address would be seized with an irrepressible desire to evacuate 
the bowels. The irritability of the rectum in such instances is due to the 
increased peristaltic activity, which hurries the faeces into the lower bowel 
other than in the normal quiet manner. 
Treatment.—In cases of this nature, a patient and searching examination 
of the rectum should be made, in order to ascertain if there is any local cause 
for the irritation, and, if so, to remove it, after which the disease will most 
probably disappear. To relieve the local irritability for the time-being, 
nothing answers so well as a small enema of starch suspended in lukewarm 
water, thrown into the bowel, and to be permanently retained. Should this 
be rejected, it will be proper to add fifteen or twenty drops of laudanum to 
the injection, which usually secures its retention. In one case of a very 
troublesome nature, where every possible soui’ce of reflected irritation had 
been searched for and removed, nitric acid was applied with success to a very 
circumscribed portion of the mucous coat of the rectum, which differed from 
the other parts of the membrane only in being slightly increased in redness. 
Dilatation of the Rectal Pouches.—At the lower part of the bowel, a short 
distance above the anus, the mucous membrane is thrown into a number of per- 
pendicular ridges or folds, which, joining below, form a series of small pouches, 
wThich are in a great measure etfaeed by distention. The anatomy of this 
part of the intestine was long since carefully examined and described by Pro- 
fessor Horner. The surgical importance of these sacs was first noticed by Pro- 
fessor Physick, under the term “ encysted rectum.” He found that to their 
dilatation and inflammation were to be ascribed several unpleasant sensations 
complained of by patients, such as pruritus, vermicular movements within the 
anus, and pain after stool, extending from the bowel to the nates and thighs. 
The disease is most commonly found in persons advanced in life and of a 
costive habit, or in whom the faecal accumulations have been too long retained 
in the rectum from inertia of the muscular apparatus of the bowel. These 
pouches once dilated admit, it is said, of the entrance of small seeds, inspissated 
mucus, and other foreign matters, thus giving rise to the symptoms above 
noticed. The disease is certainly very rare. In cases, however, of an obscure 
and ill-defined trouble at the lower end of the intestine, it will be proper to 
examine these pouches, in order to ascertain if any foreign substances have 
become arrested. This is accomplished best by the method of Physick, wThich 
consists in bending the end of a pocket probe into a hook, passing it up the 
bowel, and then withdrawing it, with the point against the mucous surface. 
If the sacs are enlarged, they can be drawn down, and if at the same time 
the patient strains, they can be brought outside of the anus, when, if neces- 
sary, they may be clipped off with a pair of scissors. I have very frequently 
examined the rectum with a view to discover this state of its pouches, but 
have never been successful, either in the dead or in the living. 
Prolapsus Ani et Recti.—There are two varieties of prolapsus recti, the one PROLAPSUS ANI ET RECTI. 
517 
partial and the other complete. In the first there is merely a more or less 
complete circular protrusion of the mucous membrane through the anus. 
(Fig. 398.) In the second the rectum in its entirety—that is, including all 
its tunics—is protruded through the anus. (Fig. 399.) In either condition, 
when the prolapse is well pronounced, the circular and the concentric dupli- 
Fig. 399. 
Partial prolapse of the rectum. 
Complete prolapse of the rectum. 
catures of the raucous membrane of the intestine will be quite marked. (Fig. 
400.) 
The disease is much more common among children than among adults, 
and is caused by diarrhoea, constipation, ascaridal irritation, polypi, dys- 
entery, crying, coughing, and very often by the presence of urinary calculus. 
Fig. 400. 
Concentric folds of a prolapsed rectum. 
The habit among nurses or mothers of allowing children to sit at pleasure upon 
the commode or the chamber conduces to the production of the disease. In 
addition to these causes, the anatomical conformation of the sacrum and the 
rectum in children predisposes to such displacements. Both the bowel and 
the bone are much straighter than those of the adult, and in consequence 
the muscular force exerted in the act of defecation acts more directly upon 
the outlet of the bowel. In the simple or incomplete variety, the protrusion 
is produced by the elongation of the submucous connective tissue, which 
frequently contains a considerable amount of serum, constituting an oedema- 
tous state of the parts. When the protrusion remains out for any great 
length of time, the gut undergoes considerable structural alterations. The 
mucous membrane, at first red, soft, and moist, becomes paler, hard, and 518 
DISEASES OF THE ABDOMEN. 
dry; its folds are in a measure effaced, and lose their pliability by inflam- 
matory deposition in the submucous tissue, producing much thickening; while 
the surface becomes dark and rough, with here and there an adherent crust 
or scab. 
Complete prolapse of the rectum may carry with it a portion of perito- 
neum, into the pouch of which one or more loops of the small intestine will 
fall, constituting a form of hernia. In rare instances the bladder and the 
ovaries have descended into the serous pocket. The presence of intestine in 
connection with prolapsus recti can be recognized by the altered position of 
the rectum, the opening of the gut being directed back or towards the coccyx, 
by the resonance of the swelling, and by its reducibility on pressure. 
The causes which produce prolapsus recti in adults and in aged persons 
are of a different nature from those operating in childhood. Any obstacle to 
the passage of the urine, such as stricture or an enlargement of the prostate 
bodjr, predisposes to the disease. Chronic coughs have a similar tendency, 
and so also has the habitual use of injections. There is a weakness of the 
sphincter, and indeed of the entire muscular apparatus of the perineum, 
especially in persons far advanced in life, which also gives rise to prolapse of 
the rectum. I attended a lady, ninety-seven years of age, for fracture of the 
thigh at the lower third of the bone. The shock attending the injury pro- 
duced great muscular debility, and especially of the sphincters of the anus 
and the rectum. A prolapse of the bowel followed, to a degree which I 
had never before witnessed. It increased from day to day until it extended 
through the opening in the fracture-mattress, and was received in a wooden 
bowl which I had placed beneath the bed, supported upon a stool. It was a 
complete invagination of the entire rectum and a portion of the sigmoid 
flexure of the colon, and measured at least twelve inches in length. Under 
the use, twice a day, of a decoction of oak-bark, applied by means of a syringe, 
and afterwards brushing over its corrugated surface some olive oil, it began 
gradually to retract, and in six weeks was entirely reduced. Hemorrhoids 
are frequently associated with procidentia of the rectum. There are persons 
who possess the power of extruding and retracting the rectum at pleasure. 
I once had under care a soldier who was in the habit of amusing his comrades 
by bending forward, protruding the bowel to the extent of six or seven 
inches, and then with equal facility restoring it to its proper position. In 
recent cases of procidentia, the displaced bowel may become strangulated by 
the grasp of the sphincters. 
Treatment.—In the treatment of procidentia recti, it is of primary impor- 
tance to ascertain the cause of the disease, the removal of which is often alone 
sufficient to effect a cure. If there is evidence of the existence of worms 
infesting the rectum, they should be removed by anthelmintics. An injection 
into the bowel of turpentine or of carbolic acid, suspended in some flaxseed- 
tea, will prove efficacious in expelling these parasites. Should there be found 
a vesical calculus or a rectal polypus, its removal will effect a cure. If diar- 
rhoea is present, it must be treated by the use of the hydrargyrum cum ereta, 
followed by Dover’s powder, in order to restore the healthy intestinal secre- 
tions and quiet the peristaltic action of the bowels; if there is constipation, 
it is to be treated by the confection of senna and sulphur. When none of 
these causes exist, and the disease is the result of feeble health, our remedies 
must be directed to the improvement of the constitutional vigor of the patient. 
The diet must be nutritious and the patient be kept much in the open air. 
The remedies best suited for internal administration are iron, cod-liver oil, 
pepsin, and strychnine, or some of the bitter infusions with dilute phosphoric 
acid. 
Local treatment will often become necessary, both as a temporary and as a 
permanent measure. As the cases which we are now considering are for the 
most part met with in young subjects, our instructions must be carried out 
through a nurse or mother. Care must be taken that the child evacuate 
the bowels in the recumbent position, and on the side in preference to the PROLAPSUS ANI ET RECTI. 
519 
back, in order to diminish the pressure exerted by the diaphragm, abdominal 
muscles, and the intestines against the perineum and upon the lower end of 
the bowel. If the protrusion follows, and does not recede spontaneously, a 
stream of cold water or of a decoction of oak-bark should be thrown upon the 
mucous membrane by a syringe, and the part carefully returned by oiling two 
of the fingers and with their palmar surfaces pressing it within the sphincter, 
afterwards applying a pad and T bandage. These measures, if persevered in 
for a few weeks, will generally effect a cure. If, notwithstanding this treat- 
ment, the disease persists, the bowel coming down on any trifling exertion, 
or remaining out in spite of all efforts to the contrary, a more active pro- 
cedure will be necessary. We have the choice of three remedies: submucous 
injections of ergot, cauterization, and the knife. The use of ergot may be 
tried by introducing into the submucous tissue of the rectum six or eight 
drops of a concentrated fluid extract, each drop of which will represent one 
grain of the ergot. These injections are to be repeated every second day for 
two weeks. Should this fail, cauterization must be tried. There are three 
articles belonging to this class of remedies which are used for this purpose,— 
nitric acid, acid nitrate of mercury, and nitrate of silver. I much prefer the 
first mentioned. The pain following its application is not very severe, nor 
is its duration long; and the remedy appears to be peculiarly adapted to the 
mucous surfaces of the rectum in children. In applying it, an anaesthetic 
should be administered to the child, the part thoroughly cleansed, and the 
fuming acid freely applied with a little mop vertically, or in the long axis of 
the extruded gut, leaving intervals between untouched, taking care to avoid 
the skin. The cauterization should be immediately followed by the free use 
of sweet oil, and the bowel restored. To prevent its descent when the effects 
of the anaesthetic are over, a quantity of soft cotton-wool should be intro- 
duced into the rectum, a compress laid over the anus, and the buttocks drawn 
tightly together by means of adhesive plasters passed from one to the other. 
This is the method of Allingham, and will be found in most cases to prove 
successful. To prevent straining, allay irritation, and keep the bowels quiet, 
paregoric should be given in doses sufficient to have the desired effect. After 
the fourth day the external dressings are to be removed, and a dose of oil 
administered, the action of which will bring away the cotton-wool. 
In the case of adults, the disease is often very obstinate and much less 
manageable than in children. The rectum should be carefully examined, to 
see if any growths, such as polypi or hemorrhoids, are present, causing the 
prolapse; and if such are discovered, they should be removed, as preliminary 
to other treatment, the operation probably effecting a cure. If a urethral 
stricture exists, it will be necessary to dilate the canal; if the prostate offers 
an obstacle to the flow of urine, it will be better to avoid the straining, 
when great, by the occasional use of the catheter. In cases where none of 
the above causes operate to produce the disease, the alternative is a resort 
to cauterization or to the removal of some of the redundant portions of the 
mucous membrane. Cauterization with nitric acid, in my hands, has proved 
very successful. In one instance in Avhich the nitrate of silver was used, the 
suffering which followed was exceedingly severe and prolonged, occasion- 
ing sloughing, severe chills, fever, delirium, and extreme prostration, from 
which the patient did not recover for many weeks. Though the prolapse 
wras cured in this case, it well-nigh cost the patient his life. In two other 
instances in which this salt was applied to the bowel, the distress was 
agonizing and without benefit. Dr. Van Buren recommends linear cauter- 
ization with the hot iron, the resulting cicatrices serving to contract the 
bowel. In adults, and particularly in aged persons, when an operation is 
deemed advisable, it is best to adopt some one of the various modifications of 
Copland’s plan, which consisted in removing by ligature elliptical portions 
of the mucous and submucous structures of the prolapsed bowel. The most 
satisfactory of these is either to excise two or three ovoidal portions of the 
mucous folds with a pair of scissors curved on the flat, and unite the divided 520 
DISEASES OF THE ABDOMEN. 
parts by the interrupted suture; or, what is preferable, to pinch up in two 
or three places the excess of tissue with a Smith’s clamp,—as is shown under 
the head of piles,—and cut off the folds a short distance in front of the 
instrument, applying to the stump the actual cautery. 
In bad cases, where remedies have proved unavailing, or where patients 
have declined an operation, much good may be done by douching the parts 
with cold water and applying an oiled compress supported with a T bandage, 
which will not only prevent further protrusion, but will also protect the 
patient’s clothing from being soiled by the discharge of the intestinal mucus. 
In some cases of prolapse the insufficiency of the sphincters is such as to 
allow a degree of faecal incontinence, for which it may be necessary to ad- 
minister astringents conjoined with small doses of an opiate. 
In otherwise hopeless cases of prolapsus recti (complete), excision of the 
protruded gut, if done with due antiseptic precautions, will offer a fair chance 
of cure. The excision should be made below the fibres of the sphincter, 
and may be an almost bloodless operation if the gut, after having been first 
surrounded with a gum cord, be divided longitudinally, in order to make sure 
that no intestinal complication exists. The rectum is next pierced trans- 
versely and two rubber tubes passed, and, after tying firmly each half, the 
mass is to be cut away below. The circular elastic cord first applied is then 
to be removed and the parts to be dressed antiseptically. 
Polypus of the Rectum.—Two varieties of polypi are found in the rectum,— 
the soft or gelatinoid, and the firm or fibroid. The former, doubtless, is much 
more common than the latter: it is the only variety met with in children. 
These gelatinoid polypoid growths are quite as frequently seen in adults as 
in children. The appearance of the first variety differs from that of those 
which infest the nasal cavities in being more firm and having a red color. 
They are made up of fine connective tissue and of hypertrophied follicles, 
with numerous vessels, and are clothed with a round epithelium. They are 
only exaggerated outgrowths of the normal anatomical elements of the mu- 
cous and submucous structures of the intestine. The fibroid variety consists 
chiefly of dense, compact, interlacing fibres of connective tissue and of blood- 
vessels. These growths are generally pedunculated, rarely sessile. The ped- 
icle is sometimes one inch or more in length, and may be so slender as to 
break away in the act of straining at stool. They will occasionally protrude 
from the rectum, and require to be replaced like a pile. They are both 
single and multiple, and vary in size 
from that of a pea to that of a hickory- 
nut. 
Rectal polypi differ both in form and 
in external appearance. They may be 
either round or fusiform in shape. 
(Fig. 401, a and b.) They are some- 
times red, and at other times have a 
dark-blue color. In some instances 
they are covered with numerous little 
eminences, resembling the surface of a 
raspberry or a mulberry; in other cases 
they are perfectly smooth, and in others 
again are beset with numerous little 
villous processes, similar to those be- 
longing to the mucous membrane of 
the small intestine. The villous struc- 
ture is occasionally so pronounced that it might with propriety be designated 
as the villous polypus. I once removed from a merchant, living in an adjoin- 
ing State, a growth of this kind (Fig. 401, c), which had, in consequence of 
severe pain and frequently-recurring hemorrhages, entirely disqualified him 
for business. He recovered his health and strength rapidly after the opera- 
Fig. 401. 
a, fusiform polypus; b, round polypus; c, villous 
polypus. POLYPUS OF THE RECTUM. 
521 
tion. It is not uncommon to find a polypus in the midst of a cluster of 
piles, and in cases of fissure they are frequently present. 
Structure of Rectal Polypi.—These growths are true adenomata, and 
consist of dilated Lieberkuhn glands of the mucous membrane of the rectum, 
embedded in connective tissue, with numerous blood-vessels, and covered 
with the ordinary epithelium of the bowel. (Fig- 402.) The glands which 
constitute so large a portion of these bodies are frequently dilated into sacs. 
Rectal polypi and the nasal mucous polypi are almost identical in structure. 
Symptoms.—A polypus may exist in the rectum without its presence being 
suspected, so little inconvenience does the patient experience. This is likely 
to be the case when the pedicle is short, and its movements, in conse- 
quence, restricted. When the foot-stalk becomes sufficiently long to admit of 
the descent of the growth into the anus, it gives rise to much uneasiness, 
which may finally amount to tenesmus. There will in such cases be a fre- 
Fig. 402. 
Structure of an adenoma or mucous polypus of the rectum.—From Billroth. 
quent desire to go to stool, and during the attempt at defecation a body 
comes down arid protrudes externally, which is often mistaken for hemorrhoids 
or for a prolapse of the bowel. When these polypi become abraded or in- 
flamed, they will bleed very freely, and furnish an ill-formed and offensive 
muco-purulent discharge, which excoriates the parts about the verge of the 
anus. In cases where there is tenesmus and the feeling of a movable body 
in the rectum, with the discharge of blood and mucus, and without any 
protrusion, a careful examination of the bowel should be made to determine 
the cause. The insertion of a finger into the rectum will frequently enable 
the surgeon to detect one of these growths or its pedicle; or if a full injec- 
tion of tepid water be thrown up the bowel, all obscurity as to the nature 
of the disease will generally be removed by the descent of the polypus with 
the expulsion of the enema. In cases where an operation has been unsuc- 
cessfully performed for the cure of anal fissure, the existence of a polypus 
may be suspected, the removal of which will be necessary to effect a cure 
of the ulcer. Children who lose blood at stool, although no growth is 
visible, may be suspected to labor under polypus, and should be carefully 
examined at the time of stool or by using the water injection. 522 
DISEASES OF THE ABDOMEN. 
Treatment.—Polypi may be removed either by the ligature or by the 
clamp and cautery. In the first method, the bowel being emptied by an 
enema, the growth must be secured as it appears, and, being drawn down 
with the fingers or by a pair of forceps, should be strangulated by a liga- 
ture tightly tied around its pedicle. Thus secured, the body may be cut off. 
After the operation the patient should remain in bed and the bowels be kept 
quiet for five or six days, after which a laxative may be administered, the 
action of which will bring away the ligature. If the clamp be employed, the 
blades of the instrument must embrace the pedicle of the growth and be 
screwed down tightly. The polypus is next cut away three-eighths of an 
inch in front of the instrument, and the stump thoroughly cauterized with 
the hot iron to prevent bleeding, after which the clamp may be removed. 
The patient had better remain in bed for thirty-six hours subsequent to the 
operation. Removal of polypi by the knife or by the scissors, without the 
ligature or the cautery, should not be countenanced in general practice, as a 
very troublesome bleeding may follow. 
Inflammation of the Anus and of the Rectum may be traumatic, catarrhal, 
or specific. 
Traumatic inflammation is caused by rough or sharp bodies in the faeces 
becoming entangled in the folds of the bowel, or the latter may be injured by 
the introduction of hard substances from below. 
Catarrhal inflammation of the rectum may arise from indiscretion in diet, 
from the effects of cold locally applied, or from parasitic irritation, and is ac- 
companied by pain, tenesmus, and mucous, or mucous and bloody, passages. 
The constant straining is apt to be followed by more or less oedema of the 
mucous membrane, the projection of which beyond the verge of the anus re- 
sembles prolapse of the bowel. The inflammation sometimes extends to the 
cellular tissue outside of the bowel and results in abscess and fistula. 
Specific inflammation of the rectum may be contracted either through 
unnatural connection or in consequence of the vaginal discharges in cases of 
gonorrhoeal disease running down and collecting about the anus. 
Treatment.—If there is reason to believe that a foreign body has entered 
the rectum, a search should be made, and if detected the offending cause 
must be removed, after which injections of starch-water with a few drops of 
laudanum will be all the treatment required. 
In catarrhal cases, the use of a milk diet, absolute rest on the back, and a 
saline cathartic will generally be followed by the subsidence of the disorder. 
In cases where this treatment fails to effect a cure, the bowel should be 
washed out with a solution of boracic acid in water (5i to Oi), followed by a 
suppository of iodoform containing four grains of iodoform and half a gi’ain 
of opium, and repeated once every four or five hours. 
Gonorrhoeal inflammation of the rectum should be treated by injections of 
nitrate of silver, in the proportion of ten grains of the salt to half a pint of 
distilled water; or sulphate of zinc may be used in the same way, half a 
drachm to a pint of water being the proper strength, to be repeated daily 
for three or four successive days. 
Ulceration of the Anus and of the Rectum.—There are ulcerations of the 
anus which are quite different from fissure in appearance, causes, and effects. 
The entire verge of the bowel will in some instances present a ragged, chapped 
appearance; or just within the cutaneo-mucous junction will be seen an ulcer 
of an oval and sometimes irregular form, having thickened borders, and its 
bottom presenting a grayish color. The integument immediately around the 
anus is often red and moist. In consequence of excoriation or the presence 
of eczema, the heat, smarting, and itching experienced are sometimes very 
annoying. Though the sensibility is much exalted, it is not common for 
patients to suffer to the same degree as in fissure. There are many causes 
which operate to produce anal ulceration, among which may be named con- ULCERATION OF THE ANUS AND OF THE RECTUM. 
523 
stipation, chronic diarrhoea, and vaginal discharges, especially from gonor- 
rhoea or from constitutional syphilis. 
When ulceration is situated higher up, either just below the internal 
sphincter or above that muscle in the rectum, we have a much more formi- 
dable disease. Such ulcers may be single or multiple. They are caused by 
tuberculous and syphilitic conditions of the general system, by traumatic 
injuries, and occasionally by chronic dysentery. 
Symptoms.—Ulceration of the rectum is a very insidious disease. It is 
developed slowly and with so little suffering that it may make much progress 
before it is detected. Among the earliest signs of its existence is a tendency 
to morning diarrhoea, the patient being obliged to visit the water-closet im- 
mediately on rising from the bed. At first the passages are free and semi- 
consistent, but after a time become scanty and watery and are accompanied 
with much flatulence. As the disease advances, a tenacious white gelatinous 
material is discharged, sometimes mixed with a purulent or muco-purulent 
matter. Until this is gotten rid of, the patient will suffer pain and tenes- 
mus, after which he may enjoy comparative comfort for many hours, or until 
another accumulation like the last takes place. 
The progress of the ulceration will in time increase the tendency to 
diarrhoea and aggravate the local distress. The patient is harassed with 
flatulence and griping pains, the strength begins to fail, pains radiate along 
the thighs and perineum, and the body loses flesh. These ulcers may be 
detected by the insertion of the finger into the bowel, but much more 
satisfactorily by introducing a speculum and exposing in a good light the 
interior of the intestine, when they will be seen varying in size, having 
elevated and thickened edges, their surfaces presenting a dark-red color, 
and occupied by indolent granulations or covered with a gray substance 
consisting of the debris resulting from the death of the reparative material. 
These ulcers are prone to extend upwards in the rectum and downwards 
towards the anus, the latter being vastly more painful than the former. 
At the same time the surrounding induration increases, the discharges 
become bloody and purulent, and knots of inflammatory thickening will 
be seen scattered over the mucous membrane at different points contiguous 
to the ulceration. 
The disease is by no means limited to the mucous membrane; it extends 
to the follicular glands and to the submucous tissue, and in aggravated cases 
attacks and destroys the muscular structure of the bowel, causing inconti- 
nence of both the flatus and the faeces, and subsequently producing coarcta- 
tion or stricture of the bowel. In numerous instances the ulceration has 
opened into the vagina and into the bladder. Patients may continue for 
years with this disease, dragging out a miserable existence, and finally die, 
either from a diffuse pelvic cellulitis or from peritonitis. 
Treatment.—In the treatment of anal or rectal ulceration, the cause of 
the disease must first be ascertained. If it has a syphilitic origin, it will be 
necessary to administer alterative remedies, such as the iodide of potash or 
one of the preparations of mercury, or both combined. Under the use of 
these remedies alone I have succeeded in curing some very aggravated cases 
of this disease. If there is reason to believe the case to be of a tuberculous 
origin, the use of cod-liver oil and the iodide of iron will be indicated. 
Kolischer succeeded, in tuberculous ulceration, in effecting a cure by injecting 
into the centre of the granulating mass a solution of biphosphate of lime, con- 
tinuing the injection for a number of weeks until calcification and cicatriza- 
tion took place. Many cases occur which it is impossible to trace to either of 
the above causes, and in which we must be governed in our treatment by a 
comprehensive view of all the possible sources of irritation. If the case is 
a recent one, it may be brought to a successful termination by attention to 
the digestive organs, with very little local treatment. Imperfectly-digested 
food, vitiated intestinal secretions, and stimulants, all exert a damaging in- 
fluence upon these ulcerations. The bowels should be acted upon by a few 524 
DISEASES OF THE ABDOMEN. 
grains of blue mass, followed by some castor oil. The rectum must be washed 
out with an enema of boracic water or of flaxseed-tea, and afterwards one 
or two ounces of starch-water, containing fifteen to thirty drops of lauda- 
num, may be thrown up, which will produce a very soothing effect on the 
bowel. This injection may be used daily, should the diarrhoea demand it. 
When the evacuations are not too frequent, the starch-water, without the 
anodyne, will prove very comforting to the sensations of the patient, as it 
serves to shield the mucous surface from irritating secretions. The diet 
should be highly nutritious, and of such a nature as to supply but little effete 
matter. Nothing so perfectly meets these requirements as unskimmed milk, 
taken at pleasure, either plain or scalded, and to this the patient should 
be rigidly confined. Flatulence, which is so common in rectal disease, is 
best relieved by compound tincture of cardamom and the fluid extract of 
chamomile, or by the time-honored remedy of carbonate of magnesia and pow- 
dered charcoal. A hot hip-bath for twenty minutes, twice or thrice a week, 
will prove useful, and absolute rest in the recumbent position must be rigidly 
enforced. In more advanced cases of the disease, it will be necessary to 
make a direct application of remedies to the ulcer. For this purpose I am 
partial to the acid nitrate of mercury, and, next to this article, to pure nitric 
acid. The use of nitrate of silver has never proved entirely satisfactory in 
my hands. The ulcer must be exposed by the speculum and the acid freely 
applied with a mop of cotton, after which the starch and laudanum should 
be immediately injected into the bowel, or a suppository introduced con- 
taining four or five grains of iodoform and one grain of opium. Once or 
twice a week is often enough to use the acid, and as soon as there is evidence 
of an improvement in the disease it should be discontinued, or should be ap- 
plied only at long intervals. When the ulceration extends into the deeper 
structures of the bowel, and is followed by contraction or by stricture, dila- 
tation by graduated rectal bougies will become necessary. 
Stricture of the Rectum.—Strictures of the rectum are of two kinds, the 
non-malignant and the malignant. 
Non-Malignant Stricture.—This division includes all contractions or nar- 
rowings of the bowel having a traumatic origin. First. Many cases are caused 
by abrasions and lacerations of the mucous membrane by the improper use 
of clyster-pipes, by a too extensive removal of tissue in the operation for piles, 
by forcing foreign bodies into tbe rectum, and also by sharp-edged or sharp- 
pointed substances, such as scales from oyster-shell or a fragment of bone, 
becoming entangled in the folds of the lining membrane of the intestine. 
Hardened faeces are said to cause stricture very much in the same way; but 
I have never seen a case which could be properly referred to such an origin. 
Second. The disease may result from the cicatrization of extensive ulcers of 
the rectum, or of those which follow the cauterization of the mucous coat in 
prolapsus ani. Third. Stricture may be secondary, b}" an extension of inflam- 
mation from the surrounding cellular tissue to the coats of the bowel. I have 
seen two cases of stricture of the rectum succeeding a very bad tistula in ano, 
in which the perineal structures were traversed in different directions by 
sinuses. Fourth. Stricture not unfrequently follows both primary and sec- 
ondary syphilis: in the first by unnatural intercourse, and in the second by 
inflammatory deposition, ulceration, and cicatrization. Accidents common 
to mucous and submucous tissue form constitutional infection. Under this 
head comes the horseshoe ulcer of Sir James Paget. Uterine displacement, 
as retroversion, pelvic tumors, and enlargements of the prostate body, have 
been improperly described as causes of stricture. They often do encroach 
upon the rectum, pressing its walls together and interfering with the passage 
of faeces; but this is obstruction, not stricture; it is mechanical, not organic, 
in its nature. There is also a spasmodic stricture described which is purely 
reflex, caused by the irritation of an ulcer, and is temporary in its duration. NON-MALIGNANT STRICTURE. 
525 
I have seen stricture of the rectum follow contusion of the bowel in conse- 
quence of the delay of the foetal head in the pelvic cavity. 
Except from syphilitic causes, non-malignant stricture of the rectum is not 
a common disease; and it is for the most part confined to middle life. Females 
are more frequently affected than males. The structural changes in the coats 
of the intestine differ in different cases. Sometimes the disease appears to 
involve only the mucous and submucous tissues, giving rise to an annular 
elevation or valve-like projection. Under the head of intestinal obstruction 
will be seen a cut (Fig. 383) illustrative of such a variety. Sometimes the 
inflammatory infiltration is chiefly in the muscular walls of the rectum, and 
becomes gradually transformed into a dense fibrous tissue, extending some 
distance up and down the bowel. (Fig. 403.) In two cases formerly under 
my care, the thickening was confined wholly to the submucous and mus- 
cular tunics, the mucous membrane remaining perfectly smooth. (Fig. 404.) 
Fig. 403. 
Fig. 404. 
Fibrous stricture of the rectum, 
Stricture of the rectum. 
The disease, as it encroaches upon the cavity of the intestine, may be very 
circumscribed, constricting it like a cord, or it may extend up and down the 
bowel for some distance. The resistance offered by the obstruction provokes 
strong expulsive efforts on the part of the patient, which produce not only 
hypertrophy of the muscular walls not implicated in the disease, but also 
often a marked dilatation of the intestine above the seat of disease. 
Symptoms.—Stricture doubtless may be present in some cases a long time 
before being suspected, so little inconvenience is experienced. Usually, how- 
ever, the patient is conscious of some uneasiness in the rectum. There is 
constipation, with more than ordinary difficulty in passing the stool,—a feel- 
ing as though the act had not been completed. Sometimes there is diarrhoea 526 
DISEASES OF THE ABDOMEN. 
alternating with constipation. The faeces are often discharged in broken 
fragments, or they may be wire-drawn, coming out in pencil- or pipe-like 
form, and sometimes they are flattened or triangular. The last two forms 
are by no means indicative of stricture, as I have often seen the evacuations 
assume these shapes from the mechanical pressure of an enlarged prostate 
or from a uterine fibroid. As the disease advances, ulceration takes place, 
followed by a discharge of blood and of a gelatinous or muco-purulent fluid. 
This discharge stains the clothing, and irritates and excoriates the parts 
about the anus. The pain becomes more severe, shooting along the penis, 
thighs, and upward to the small of the back. Patients often complain, after 
defecation, of exhaustion and a peculiar sense of “goneness” about the epi- 
gastrium. The digestive organs become deranged, as is manifested by slight 
nausea, loss of appetite, flatulent distention of the bowels, and a gradual loss of 
flesh. The inflammation may extend beyond the limits of the gut, and result in 
peri-rectal abscesses opening into the cavity of the intestine above the stricture, 
or below upon the surface of the perineum, and even into the bladder or into 
the urethra, and in the female into the vagina, proving finally fatal by wearing 
the patient out from irritation and suppuration or by exciting a destructive 
peritonitis. The local exploration of the parts furnishes, however, the only 
decisive evidence of stricture. Mr. Colles, as a sign of rectal stricture, attaches 
some importance to a peculiar prominence which joins posteriorly and sepa- 
rates anteriorly on each side of the anus, giving to the outlet of the bowel an 
appearance not unlike that of the mouth of a ewer. When the finger is in- 
troduced into the intestine, should a stricture be present, the obstruction will 
in most cases be encountered within the first two or two and a half inches. It 
cannot well be mistaken. The finger readily recognizes the encroachment 
upon the canal, and may, by a little pressure, be carried through and beyond 
the diseased portion. 
In cases where the disease is situated slightly beyond the reach of the 
finger, the patient should be urged to bear down forcibly while in the stand- 
ing position, slightly bent forward, when the stricture may be brought suffi' 
ciently low down to be within command of the touch. Where the disease is 
still farther up, a long speculum will sometimes disclose its existence. The 
use of bougies as a means of detecting rectal stricture is of doubtful value. 
The information they impart is very indefinite. Their liability to become 
entangled in the folds of the bowel, or to strike against the promontory of 
the sacrum, may be urged against their employment. 1 have known several 
instances in which strictures have been predicated from the resistance offered 
to the passage of a bougie, where nevertheless the bowel was afterwards found 
to be free. 
Malignant Stricture, or Cancer.—This, in my experience, constitutes a very 
large proportion of all cases of stricture of the rectum, and it is among the 
most terrible afflictions to which the human body is subject. The disease is 
met with chiefly in middle and advanced life. Whether males or females 
suffer most is a question upon which authors differ. Ten cases out of eleven 
admitted to the Hotel-Dieu, Paris, Desault tells us, were in females. Curling 
records sixty-seven cases of rectal cancer, forty-four of which were in males. 
Mr. Copland believed that women were most frequently the subjects of the 
disease. Allingham has seen the disease oftener in men than in women; 
Professor Gross’s testimony is to the same effect; and in my own experience 
a very large proportion of cases has been in males. 
The seat of cancer of the large intestine is generally within reach of the 
finger. Most commonly it is found about one inch and half above the anus; 
next in order of frequency, about two and a half or three inches from the out- 
let of the bowel; and, last, in the sigmoid flexure. In its progress the disease 
does not appear to be influenced by gravity, as the tendency is to extend up- 
wards rather than downwards. The forms under which it appears are the 
epithelial, the medullary, the melanotic, and the colloid. MALIGNANT STRICTURE, OR CANCER. 
527 
The epithelial or columnar-celled form is by far the most common. It 
may commence at the anus and extend upwards to the intestine, or it may 
be primarily seated in the rectum. When situated at the anus, this affection 
may linger for many months at the junction of the skin and mucous mem- 
brane before assuming an aggressive form. The disease, like that on the lip, 
in its commencement presents different appearances. There is sometimes a 
circumscribed, hard, flat mass seen at the cutaneo-mucous junction, with a 
gradually-extending induration. Sometimes there will be found a crack or 
a small ulcer with ragged borders, attended with little pain, and which, were 
it not for the surrounding infiltration, might be confounded with a fissure ; 
in other cases it appears as a warty growth. Whatever may be its early 
appearance, as it advances irregular tuberous masses form, ulcerate, and split 
like warts into numerous papillary or cauliflower eminences, wThile from the 
raw surface and the intermediate clefts a muco-purulent fluid is discharged, 
and not unfrequently a profuse hemorrhage takes place from the surface of the 
rapidly-growing mass. In its progress the anus and the lower part of the rec- 
tum may become filled with a luxuriant fungoid 
growth, so as seriously to obstruct the escape of 
the faeces. (Fig. 405.) Epithelial cancer of the 
rectum cannot be deemed a rare disease. Every 
year I witness several examples, and generally 
in persons between thirty-five and sixty years 
of age. 
Scirrhus.—The so-called scirrhus of the rec- 
tum is really epithelioma, and commences, like 
the latter, in the epithelial cells of the Lieber- 
kuhnian glands (adeno-carcinoma of writers). 
The progress of the growth, in many respects, 
is somewhat different from that usually pur- 
sued by rectal carcinoma. The disease begins 
two or three inches above the internal sphincter, 
most probably in the submucous connective 
tissue, and infiltrates all the tunics of the bowel, 
encroaching upon its cavity and pushing out 
the mucous surface into irregular hard nodules. 
These nodules not unfrequently ulcerate and 
form raw, bleeding surfaces or ulcers with in- 
durated and ragged edges, and the infiltration 
and contraction which follow serve to produce 
stenosis of the canal of the bowel. The disease 
tends to extend peripherally, so that it is not uncommon to find the contigu- 
ous organs, as the bladder in the male and the vagina in the female, implicated 
in the disease, and all bound and matted together in one mass of inflammatory 
and carcinomatous material. It is from this tendency that we so frequently 
witness communications taking place between the rectum and the surround- 
ing organs, by which the contents of the bowels pass into the urinary bladder 
or into the vagina, adding greatly to the distress of the unfortunate patient. 
The same cause occasionally produces abscesses and fistulous openings through 
the perineum. In some cases the rectum becomes secondarily involved, the 
disease beginning in the vagina or uterus and extending to the bowel. 
Sarcoma of the rectum is occasionally met with, and when present tends 
to infiltrate all the tunics of the gut. The spindle-celled variety occurs most 
frequently. 
Melanotic carcinoma is quite rare, and I believe has not been met with in 
any other part of the intestinal tube than the rectum. Mot more than 
thirteen cases have been recorded,* and most of these by Molliere and 
Kelsey. Lange and Ball each report one case. The disease, according to Vir- 
chow, is common in the horse. Colloid carcinoma is also exceedingly rare. 
Fig. 405. 
Epithelial cancer of the rectum forming 
cauliflower outgrowths. 
* Manual of Universal Medical Sciences, vol. ii. p. 169, Sajous. 528 
DISEASES OF THE ABDOMEN. 
Encephaloid cancer of the rectum, though not common, is occasionally seen. 
A well-marked case of this nature was some years ago under my care, in the 
person of a female about sixty years old. The rapidly-growing mass showed 
little tendency to infiltrate the coats of the intestine. It tilled the rectum, 
and destroyed the patient in four months, from hemorrhage and from blood- 
poisoning. 
Symptoms.—Ano-rectal cancer may exist some time before the disease is 
suspected. The first discomforts caused by the disease are generally referred 
to hemorrhoidal irritation, but the induration, ragged protuberances, and in- 
disposition to yield to ordinary applications will reveal its true character. 
When the rectal portion of the tube is the seat of the disease, there will be 
some uneasiness experienced in the part, and some difficulty in passing the 
evacuations, accompanied with straining and an irritable state of the urinary 
bladder. The faeces will be altered in form, becoming unnaturally small, and 
will be forced out in broken pieces. Small liquid discharges, intermixed with 
particles of faecal matter, are frequently passed, conveying the impression of 
the existence of a troublesome diarrhoea. The pain becomes more severe, is 
burning and lancinating, and extends to the back, perineum, bladder, penis, 
thighs, and buttocks. Mucus or muco-pus streaked with blood is passed from 
the bowel, and, when the fungous granulations are present, a watery discharge, 
having an offensive, sickening odor, escapes involuntarily from the anus. As 
the obstruction increases, the patient suffers from a sense of fulness at the 
lower part of the abdomen, with flatulent distention. The further progress 
of the disease is marked by loss of appetite, of strength, and of flesh; the 
complexion assumes that straw color or that sallow hue which reveals so un- 
mistakably the malignant nature of the affection. 
The local signs of the disease cannot be well mistaken. When the finger 
is carried into the bowel a short distance, it encounters an abnormal growth, 
which may be confined to a portion of the intestine or involve its entire cir- 
cumference. the surface of which may be smooth and moderately uniform, or 
irregular and rough, and which in either case is indurated. When ulceration 
has taken place and fungoid outgrowths are studded over the intestinal sur- 
face, the sensation imparted is very peculiar. It is that of a finger breaking 
through a moist, friable, nodular, spongy mass, and unlike that experienced 
from contact with any other morbid product. Once felt, it will never be 
forgotten. When the growth is of the fungoid or cauliflower form, the 
bowel is often changed in its direction, and the opening through the midst 
of the diseased mass can be discovered only after a search in various direc- 
tions : in such examinations the finger will, when withdrawn, be found cov- 
ered with blood mingled with an unhealthy, offensive, muco-purulent material. 
Cancer of the ano-rectal region has only one termination, and that a fatal 
one. It may run its course in five or six months, or death may not occur 
until the lapse of two or even three years. The patient dies, worn out by 
pain and irritation, blood-poisoning, and 
secondary deposits in the liver, lungs, and 
other organs, sometimes by peritonitis, 
and in exceptional cases by hemorrhage. 
Treatment.—The treatment of non- 
malignant stricture is accomplished by 
dilatation and by incision. 
Dilatation.—This may be effected by 
the finger alone, or by the finger armed 
with hollow rubber cylinders of differ- 
ent sizes, each having a little opening 
in its extremity for the tip of the digit, 
in order that the instrument may be intelligently directed by the sensations 
of the operator. (Fig. 406.) When the stricture is situated at an incon- 
venient distance from the anus for the use of the finger, graduated metallic 
or gum bougies should be employed. The latter are to be preferred on 
Fig. 406. 
Hollow gum rectal bougie guided by the finger. MALIGNANT STRICTURE, OR CANCER. 
529 
account of their smoothness and flexibility, qualities which conduce to the 
safety of the intestine. With stiff, inflexible instruments there is danger of 
perforating the walls of the bowel. These gum bougies should be rounded 
(Fig. 407), conical (Fig. 408), or olive-shaped (Fig. 409) at one extremity, 
Fig. 407. 
Fig. 409. 
Rectal bougies with rounded or blunt extremities. 
Fig. 408. 
Olive-shaped bougies. 
Conical-shaped rectal bougies, 
and about ten or eleven inches in length, their diameters ranging by regular 
gradation from one-fourth of an inch to one inch. 
YVffien the stricture is sufficiently low in the rectum, the index finger, well 
oiled and the edges of the nail protected by a layer of soap, should be in- 
serted and carried upwards to the seat of obstruction. After a little gentle 
manipulation, its extremity may enter the constriction and be gradually 530 
DISEASES OF THE ABDOMEN. 
carried through. At the next attempt the dilatation may be increased by 
slipping over the finger one of the hollow cylinders of gum, and at each suc- 
cessive attempt a larger one, until the obstruction is removed. When the 
disease is higher up, and cannot be treated by the digital plan, resort must 
be had to the graduated gum bougies, beginning with the smaller numbers 
and rising by easy gradations to the larger ones. There should be no at- 
tempt to accomplish too much in a short time. The work should be done 
gently and slowly. Nothing is gained by employing much force. The bowel, 
often weakened by the structural changes, may readily be perforated. If the 
dilatation be forced too rapidly, an inflammation is likely to be excited, which 
will not only render the bowel so irritable as to necessitate the suspension of 
all operative measures, but will also increase the strength of the stricture by 
causing a new deposition of plastic material. In cases where the approach 
to the stricture is not direct or is somewhat devious, the surgeon will succeed 
in finding and passing the obstruction better with the olive-shaped instrument 
than with any other, especially when it surmounts a flexible handle. The finger 
should in all instances accompany bougies as far as possible. Some prefer, after 
passing the bougie, to have it remain for several hours in the stricture,—a prac- 
tice which I do not deem necessary. The frequency with which strictures are 
to be dilated must be regulated by the sensations of the patient. If no undue 
irritation is developed, every second or third day will not be too often. In 
constrictions not attended with much sensibility, and where a considerable 
amount of force is requisite to effect dilatation, a very efficient plan is to 
introduce a Molesworth elastic tube and gradually distend it by hydrostatic 
pressure. Allingham employs Barnes’s india-rubber bags for a similar object. 
Strictures which are membranous or band-like, and which possess an elastic 
Fig. 410. 
Instrument for rupturing or dilating a rectal stricture. 
property, causing them to contract rapidly after dilatation, are best managed 
by division. 
Division.—There are three methods of dividing non-malignant stricture,— 
namely, by divulsion, by internal division, and by external division. 
Several instruments have been devised for divulsion. The one represented 
in Fig. 410 is frequently employed for this purpose, and also for dilatation. The 
Fig. 411. 
Forceps used to divulse rectal stricture. 
arms of the instrument, being closed, are conducted through the constriction, 
after which they are screwed asunder until the parts give way. I find it 
more convenient, and equally effective, to use for the above purpose a pair of 
long forceps, such as are employed for removing uterine polypi. (Fig. 411.) 
The finger being introduced into the bowel, the blades of the forceps should 
be guided through the stricture, and then separated as widely as necessary. MALIGNANT STRICTURE, OR CANCER. 
531 
Internal division may be performed, where the stricture is low, with a probe- 
pointed hernia bistoury, conducted flatwise along the finger through the con- 
striction, and then, by turning its edge against the resisting membrane, nick- 
ing the same at two or three points, after which the finger or bougie, or the 
forceps used in divulsion, may be employed to enlarge the opening to the 
requisite extent. When the constriction is some distance up the bowel, the 
division can be more satisfactorily executed by a long, double-bladed knife. 
(Fig. 412.) The cutting part of the blades is limited to about three-quarters 
Fig. 412. 
Instrument for dividing rectal stricture. 
of an inch at their free extremities, the point of each being blunt. In using 
the instrument, it is passed through the stricture, closed, and afterwards the 
blades are forced apart by pressing the lever with the thumb. In all cases 
where there is much sensitiveness of the bowel it is best to administer an 
anaesthetic before any operation is practised. 
The use of the knife for the internal division of rectal stricture is not with- 
out danger, and should be discouraged. 
External division, or the method of Verneuil, is effected in different ways,—by 
the eeraseur, by the electro-galvanic cautery, and by the knife. The operation 
is very much superior to that by internal division. 
If the eeraseur be selected for dividing the parts, the patient should be 
etherized and placed in the lithotomy position, with the hips well elevated, 
the rectum having been previously well washed out with a solution of boracic 
acid. The surgeon introduces a finger into the bowel and presses it through 
and beyond the stricture, after which a trocar and canula are introduced be- 
tween the anus and the coccyx and pushed steadily upwards until the instru- 
ment can be felt through the walls of the bowel by the finger in the rectum, 
when by turning its point against the latter a communication is at once estab- 
lished between the outside and the inside of the intestine. The trocar must 
now be withdrawn, leaving the canula in position, through the canal of which 
the chain of the eeraseur or the galvano-cautery loop can be passed and the 
intermediate tissue severed. The same result can be obtained in a more expe- 
ditious way by using a long probe-pointed bistoury and laying open the 
parts at a single cut. Little bleeding will follow if the surgeon is careful to 
make the incision along the middle of the posterior wall of the rectum and 
anus. After washing the parts out with a solution of bichloride of mercury, 
and controlling the bleeding, the wound should be stopped with iodoform 
gauze and dressed antiseptically. I have had no experience in this operation. 
If the stricture is located low down in the bowel, say within two or two 
and a half inches of the anus, the procedure might be worthy of a trial. 
In strictures of syphilitic origin, sometimes congenital, in addition to 
the local treatment by dilatation, the use of mercury, with or without the 
iodide of potash, is indispensable. A certain number of fistulse are no doubt 
the result of congenital stricture. As strictures, even when well dilated, 
have a strong tendency to recur, I make it a rule, as soon as the calibre of 
the bowel is sufficiently enlai’ged, to intrust the work of dilatation to the 
patient, with directions that a large-sized bougie be passed once every week. 
In order to avoid all possibility of injury to the bowel, I direct, as the sim- 
plest and safest instrument for this purpose, a tallow candle, dipped to the 
proper size and rounded at one extremity. During the period of dilatation 
the bowels should be kept regular from the very beginning of the treatment, 
which is best accomplished by the use of a pill, two or three times a day, 
consisting of one-twelfth of a grain of extract of belladonna, half a grain of 532 
DISEASES OF THE ABDOMEN. 
extract of nux vomica, and half a grain each of rhubarb and aloes. Should 
this not prove sufficient, and should the fteces accumulate above the stricture, 
injections of warm water will be required to clear the bowel. 
Electricity is strongly recommended by Whitmore and others as a remedy 
in non-malignant stricture. The rectal cathode must be fairly engaged in 
the stricture during the treatment, which should last from five to fifteen 
minutes at a sitting, the number of elements being increased as the case pro- 
gresses. Short of a cauterizing strength I doubt if much impression will 
be made on the dense tissue of a stricture by electrolysis, though it is 
claimed that it acts by inducing a retrograde metamorphosis of the inflam- 
matory material. 
In the treatment of carcinomatous or malignant stricture our efforts too 
often, in consequence of delay, are restricted to the alleviation of the patient’s 
sufferings. Dilatation can be of no service so long as the faeces pass; and 
there are objections to the use of bougies,—the chief being the danger of 
perforation of the bowel and of hemorrhage. The' bowels are to be kept 
soluble by the use of gentle laxatives, such as compound liquorice-powder 
or the bitartrate of potash and washed sulphur. When accumulations form 
above the mass occupying the rectum, a tube should be cai'efully carried up 
and injections of boracic acid solution or flaxseed-tea be thrown into the 
bowel. Pain, when severe, must be relieved by opiates, administered either 
by the mouth or hypodermically. When the bowel becomes seriously blocked 
up or communications form between the rectum and the bladder, or when the 
evacuations are attended with intense distress, the surgeon may resort to 
lumbar colotomy or to excision,—the first for the purpose of securing to the 
patient an uncertain period of relief from acute suffering, and thus rendering 
the remainder of life endurable, and the second with some hope of effecting 
a cure. 
In epithelial cancer of the anus the operation of excision is quite as prom- 
ising as that which follows excision of the lip for a similar disease. When 
there is severe spasm of the sphincter, in consequence of an extension of 
rectal cancer downwards to the anus, the muscle should be divided by the 
knife. When the rectum becomes obstructed with fungoid granulations 
which bleed profusely, and when it is not deemed proper to excise the dis- 
eased part, much relief may be obtained by scraping the granulations away 
with a scoop, as is often practised in cancer of the womb. If cleanly done, 
it not only opens the cavity of the bowel, but also arrests the hemorrhage. 
Excision of the Rectum.—This is a formidable but not a very difficult oper- 
ation. The first operation for the removal of the rectum is usually credited 
to Faget, a French surgeon, one hundred and fifty years ago. This, however, 
was probably an excision of the anus rather than of the rectum. It was not 
until about the year 1826, when Lisfranc published a number of cases, and 
later on, when these were followed by the cases of Dieffenbach and Billroth, 
that excision of the rectum began to attract particular attention. Dieffen- 
bach performed the operation thirty times, and Billroth sixteen times. Dr. 
John B. Roberts, of Philadelphia, has contributed a valuable paper on this 
subject.* Of 33 cases collected by Schmidt, of Leipsie,f 20 were reported 
cured, 2 improved, 8 died, the disease returned in 1, and 2 were doubtful. In 
this country thirteen cases have been operated upon,—2 by Bushe, 1 by 
Mott, 1 by Marsh, 1 by Bridden, 3 by Levis, 1 by Dr. Joseph R. Wood, and 
4 by myself. Of this number 5 are known to have died, 1 died seven months 
after the operation with what was said to be consumption, 2 were living 
sixteen months after the excision, in 2 the termination is not known, and 3 
were cured. 
It is impossible to determine the period of immunity from the disease 
enjoyed by those who have submitted to the operation. Dieffenbach says 
* “Excision of the Rectum,” Medical and Surgical Reporter, June 9, 1877, p. 501. 
f Gunther’s “ Blutigen Operationen,” iv. i. p. 65. EXCISION OF THE RECTUM. 
533 
that of the thirty cases of excision of the rectum done by himself a large 
proportion continued well for many years. I am sure no other surgeon can 
report such a success. JSTussbaum, in one case, removed four inches of the 
rectum, the prostate gland, the corresponding portion of the urethra, and a 
part of the neck of the bladder,—the patient recovering and living for three 
years after the operation* Notwithstanding these and other favorable re- 
ports, the return of the disease is the rule ; and when excision is proposed to a 
patient it should be on the ground of palliation and not of cure. Allingham 
says that in 26 cases, the history of which he was able to follow. 5 perished 
from the operation, and 16 died at periods varying from one year to four 
years after the excision, as follows: 7 in one year, 5 in eighteen months, 2 
in two years, 1 in three years, and 1 in four years. The remaining 5 of the 
26 were living at the time of the report. The death-rate from the operation 
alofte, based on the statistics of Piechaud (149 cases) and those of Andrews 
(608 cases), may be set down at about 24 per cent. Ball estimates the mor- 
tality, based on an analysis of 175 cases, at 16.5 per cent. 
The conditions which, in my judgment, justify the operation are the follow- 
ing : 1, when the disease is limited to the walls of the intestine; 2, when there 
is room to remove the bowel without implicating the peritoneum; and, 3, when 
the health of the patient is not seriously impaired by the disease. If the 
cancerous infiltration extends into the isehio-reetal fossa, if the bladder or 
the uterus is involved, and if the patient is anaemic and very feeble, the 
operation should not be proposed. The causes of death after excision of the 
rectum are pyaemia, pelvic cellulitis, and peritonitis. 
Operation.—The bladder having been previously emptied, the patient is 
to be etherized and to be placed on the back, in the lithotomy position, upon 
a firm table, each limb being sup- 
ported by an assistant, or the 
MacBride yoke (Fig. 413) being 
used to support both. If a male, 
a sound should be introduced 
into the bladder and given to 
one of the persons having the 
limbs in charge. The surgeon 
then carries an incision from the 
perineal centre along the raphe 
to the anterior margin of the 
anus, encircling the latter by 
two semilunar cuts, and contin- 
uing the division directly back 
to the coccyx. In the female 
the incision should begin at the 
vagina. If the anus is not in- 
volved in the disease, the exter- 
nal sphincter may be preserved by raising the integument and muscle to- 
gether and turning them on each side. As soon as the lower extremity of 
the rectum is reached, the dissection should be chiefly done by the fingers 
of the surgeon, by the director, or by the handle of the scalpel, keeping close 
to the bowel, and tying each vessel as it springs. When the intestine has 
been thoroughly isolated from all its surrounding connections, to a point 
above the cancerous infiltration, it should be drawn out through the external 
wound, and the diseased portion severed from the sound. In doing this, only 
a small part must be divided at one time, and every bleeding artery tied or 
clamped with haemostatic forceps as the surgeon proceeds, or the bowel may 
be ligated in sections before division. This accomplished, double ligatures 
should be introduced through the bowel from its mucous surface outwards, 
and afterwards stitched to the integument at the margins of the wound. If 
the recto-vaginal septum is included in the disease, as was the case in one of 
Fig. 413. 
MacBride yoke applied. 
* Medical and Surgical Reporter, June 9, 1877, p. 501. 534 
DISEASES OF THE ABDOMEN. 
the patients from whom I removed about three inches of the rectum, it will re- 
quire to be excised, and its sides subsequently united by interrupted sutures. 
If the operation is conducted after the manner described, very little blood 
will be lost. The subsequent treatment consists in controlling the bowrels by 
opium for eight or nine days, sustaining the system with milk, milk-punch, 
and beef-tea, and removing the ligatures as they become loose. To counter- 
act the contraction which follows excision of the rectum, the patient should 
wear a hard-rubber tube three or four inches long, having projecting flanges 
at one extremity by which it can be secured in place. This must be removed 
during defecation. 
When the disease is situated high up in the bowel its removal will be facili- 
tated by adopting the plan of Kraiske, or, better, that of Alexander, with 
certain modifications. The bowel, after being thoroughly washed out with 
an antiseptic solution, should be plugged with cotton-wool, in order to prevent 
as much as possible the entrance or escape of faeces within the limits of the 
contemplated operation. The patient being then placed in the lithotomy posi- 
tion, an incision is made from the end of the coccyx forward to within a short 
distance of the anus, when the knife is carried round the latter until it joins 
the median wound. If the anus is involved in the disease, it should, with the 
superficial sphincter, be raised and turned to one side for future utilization. 
From the commencement of the first incision, at the extremity of the coccyx, 
a second one is carried upward over the median line of the sacrum down to 
that bone, and high enough to bring it on a level with the rectal disease. The 
sacrum and the coccyx being next cleared of the soft parts, a finger is in- 
sinuated between these bones and the rectum, and the latter detached from 
its posterior and lateral connections. The sacrum and coccyx are next to 
be cut away with the saw of the surgical engine, the chain-saw, or strong 
bone-forceps: in doing this, great care must be taken not to injure the sacral 
nerves beneath the bowel. Before proceeding further, in case the entire 
circumference of the bowel is involved, the bladder should be moderately 
distended with water, and a sound or catheter left in the viscus in order to 
raise the recto-vesical fold of the peritoneum and render less difficult the 
separation of the bowel from the bladder, the prostate, and the membranous 
portion of the urethra. The diseased intestine being now fairly exposed, 
the surgeon proceeds to remove it. Much of the dissection can be done with 
the finger and by blunt-pointed scissors. The attachments of the levator 
ani muscles to the rectum should be raised on a blunt hook and divided. 
Bleeding vessels had best be secured as they are divided. After the bowel is 
completely isolated from all surrounding attachments, it remains to cut it 
away from the tube above the disease. This is best done either by including 
the circumference of the gut by sections in ligatures and severing each as 
it is tied, or by placing a rubber hand around the intestine above, and cut- 
ting it off at a single stroke of the knife, securing the individual vessels 
before removing the band. The sound portion of the rectum should then 
be drawn down and attached to the soft parts below by numerous stitches. 
Two or three large drainage-tubes being now introduced and the parts well 
dusted with iodoform, the perineal depression should be well packed round 
the drain-tubes with iodoform gauze, over which must be placed a good-sized 
pad of cotton-wool, which will require to be changed at least twice a day. 
That the faeces may be diverted from the rectum while the healing is in 
progress, Durante advises that colotomy precede rectotomy. Mr. Adams, 
of London, also advocates lumbar colotomy as an operation precedent to 
that of rectotomy. His reason for this is plausible, different from that of 
Durante,—namely, that on a recurrence of the disease or in cicatricial con- 
traction there would be still an open and painless route for the evacuation. 
It would, in my judgment, be better to wait until such necessity ai’ose before 
subjecting the patient to such an operation. In a number of cases where the 
disease has been situated high up in the rectum the peritoneum has been 
wounded in the removal of the bowel without any serious after-effects. PERI-ANAL AND PERI-RECTAL ABSCESS. 
535 
As to the intrinsic value of these extensive operations, I do not think we 
are yet in a position to commit the profession either for or against their 
performance, but, until better evidence is furnished than that which we are 
at present possessed of, I am disposed to adhere to my former position,— 
namely, that when carcinoma has passed beyond the walls of the rectum, or 
is so high up in the bowel that the finger (the patient being under ether) 
cannot reach the limits of the disease, the case is not one for the knife. 
Under such circumstances, when the obstruction becomes serious, the best 
operation is colotomy. 
Peri-Anal and Peri-Rectal Abscess.—The peculiar character of the tissues 
about the anus and rectum—that is, in the ischio-rectal fossa—renders this 
region liable to attacks of inflammation and of abscess. The connective 
tissue is loose, supports a large amount of fat, and has ramifying through it 
numerous branches of the inferior hemorrhoidal arteries and veins, and the in- 
ferior hemorrhoidal, the pudic, and the perineal nerves. These veins are with- 
out valves, and empty into the portal system. The abscesses of this region are 
of two kinds, acute and chronic, and may be subcutaneous, or between the 
skin and the superficial sphincter muscle, and submuscular, or in the ischio- 
rectal fossa. The acute abscess arises from constipation, from disorders of 
the liver which obstruct the venous circulation and favor congestion of the 
hemorrhoidal veins, and occasionally from local injury. These abscesses run 
their course with rapidity. They appear as a red, tender, painful, indurated 
swelling at the side of the anus, with a sense of fulness and throbbing in 
the bowel, accompanied by rigors, fever, an elevated temperature, restless- 
ness, and great suffering both in defecation and in urination. They do not 
become very prominent externally, but extend deeply into the ischio-rectal 
space,—a fact which should never be forgotten, and which determines the 
course of treatment to be pursued. 
Treatment.—In the very incipiency of the inflammation, leeches, followed 
by cold anodyne lotions, may avert the disease; but in most instances the 
practitioner is consulted too late to hope for this result, and it is better to 
apply hot poultices in order to favor the formation of pus as soon as pos- 
sible. The pain is best relieved by some preparation of opium. The surgeon 
should not wait until fluctuation becomes distinct. A large quantity of pus, 
as has been stated, may exist without the presence of this sign, and if not 
early liberated it will produce sad havoc in the structure of the ischio-rectal 
fossa about the bowel, and even form a fistulous opening into the intestine. 
As soon as the smallest point of softening can be discovered on the surface, 
the abscess should be laid open, with a corresponding portion of the bowel. 
If only punctured, a fistula will be likely to follow. If the patient is super- 
sensitive or timid, the parts may be sprayed with ether or rhigolene or may 
be benumbed with ice before the opening is made. If the abscess is not opened 
early, the contents will become exceedingly offensive, being loaded with sul- 
phuretted hydrogen, broken-down blood, and dead connective tissue. After 
the matter has been discharged, the poultices should be continued for two or 
three days, and, if the fetor continues, the cavity of the abscess may be washed 
out with a solution of permanganate of potash or of chlorinated soda. When 
the poultices are laid aside, a piece of lint moistened with carbolated oil (one 
part carbolic acid, twelve parts olive oil) will form the best application. 
Chronic abscess.—This abscess may readily escape recognition. It does 
not commence on the surface. It may originate in the cellular tissue of 
the ischio-rectal fossa, or it may begin by ulceration of the rectum. In both 
instances a cellulitis of the peri-rectal or peri-anal regions will be induced,— 
in the first form by derangement of the venous circulation of the parts, and 
in the second by air, faeces, and intestinal secretions passing through the 
ulcer in the walls of the bowel into the surrounding tissues, and causing, 
like other foreign matters, inflammation. Should the intestinal opening 
admit only a little air, it may be a long time before an abscess will form. 536 
DISEASES- OF THE ABDOMEE. 
The patient will be annoyed occasionally by a tender and indurated swelling 
in the vicinity of the anus, which, after a few days, gradually subsides, only 
to have the experience repeated at no distant day. After this fashion the 
inflammation extends quietly in different directions through the perineum, 
and often through the buttock, until a number of concealed sinuses are 
formed, the pus finding its way into the bowel through the opening in its 
walls, or, as sometimes occurs, escaping externally by one or more points of 
ulceration. Should feculent matter extravasate the surrounding cellular tis- 
sue, this abscess will assume more the behavior of the acute form, and this 
is true to some extent when it follows traumatic causes, as blows, kicks, etc. 
Occurring, as the disease so often does, in persons of a strumous or tubercular 
constitution, it has been called the strumous abscess, and when its origin is 
of this nature the pus betokens the constitutional vice by being thin, curdy, 
and often offensive. These cases generally end in a fistula of the bowel. 
Treatment.—When the chronic abscess extends to the surface of the peri- 
neum it should be treated by incision, including the wall of the bowel, as in 
acute abscess, and its branches, whether one or many, must be carefully fol- 
lowed by a director and freely laid open, after which they may be packed 
with lint or iodoform gauze. If a communication with the bowel exists, the 
treatment will be that appropriate to anal or rectal fistula. In these cases 
it will often be necessary to direct our remedies to the improvement of the 
general health, by the use of the iodide of iron, cod-liver oil, and a good diet. 
Perineo-Anal and Perineo-Rectal Fistulae.—These fistuhe are very common. 
Though generally an affection of middle life, they are met with, to a limited 
extent, at all ages. I have seen the disease in a babe six weeks old, and 
have every reason to believe that it was congenital. It is more common to 
men than to women, and is generally the result of an abscess, though it may 
follow a wound. The disease is seen in all classes, conditions, and professions. 
These fistula) are divided into complete and incomplete. A complete perineo- 
anal or perineo-rectal fistula is one in which there are at least two openings, 
—one in the anus or rectum and the other upon the surface of the perineum 
or the buttock. The incomplete form has two varieties,—one, in which there 
is an opening in the anus or in the rectum but none externally on the sur- 
face ; the other, in which there is an opening on the surface but none in the 
anus or in the rectum. These forms are sometimes called “ blind fistuhe.” 
Complete fistula.—In complete fistula the external opening may be single 
or multiple. Its location varies. Usually it is near to the margin of the 
anus; but it may be over the coccyx, at the anterior part of the perineum, and 
even upon the buttock. When there are more external openings than one, 
they will generally be found to lead to a common canal or sinus. The open- 
ing upon the surface appears as a little point of granulation-tissue, or it may 
be covered with a thin him or cuticle. It is sometimes so small, and differs 
so little from the surrounding skin, as to be easily overlooked. The internal 
opening in perineo-anal fistula is at some point between the two sphincters, 
—sometimes just above the cutaneo-mucous line, but more commonly about 
half an inch above the orifice of the anus. In the perineo-rectal form the 
internal opening is above the internal sphincter. In rare instances more 
than one opening will be found within the bowel. The sinus, or the fistulous 
canal which unites the external and the internal opening, may consist of a 
single track, or it may have several branches, all tending to converge to a 
main road. The fistula may lead directly to the internal opening, or it may 
follow an angular, tortuous, or circuitous route. It sometimes begins on one 
side of the anus and passes across the perineum anteriorly to the other before 
opening into the bowel. This is called the “ horseshoe fistula.” 
Incomplete fistula.—Of the two varieties, the one in which an external 
opening alone exists is the least common. Many lead down to the side of 
the rectum or the anus; or they may extend away from the intestine. It is 
probable that many which are pronounced incomplete would, on a more PERINEO-ANAL AND PERINEO-RECTAL FISTULAE. 
537 
patient and delicate exploration, be found to be complete. The other variety, 
that having only an internal opening, is by no means rare, and often exists 
for months without being suspected. The patient has frequent discharges 
of a muco-purulent fluid from the bowel; a portion of the contents of the 
intestine getting into the surrounding cellular tissue provokes inflammatory 
deposits and abscess in the contiguous structures, which can be detected by 
the presence of an indurated or hardened point in some part of the perineum. 
If a speculum be introduced and pressure be made over the indurated part, 
the pus can be seen flowing into the bowel. 
Causes.—It is not always easy to determine the causes of a fistula. Com- 
mencing, as it does, in the formation of an abscess, the question arises, What 
influences are in operation to excite the inflammation which determines the 
abscess ? In some cases the cause is apparent, as when an injury has been 
received upon the perineum, or when the bowel has been wounded by a fish- 
bone, a pin, or the scale from an oyster-shell, which has been swallowed and 
become arrested in the rectum. Dr. Eeed has communicated to me the par- 
ticulars of a case of fistula in a female. The opening was situated on the 
border of the labium. On laying it open, two grains of corn were found near 
the rectum. These must have ulcerated through the walls of the bowel. 
Hardened fteces may damage the mucous membrane and induce an ulcera- 
tion which will terminate in fistula. Hemorrhoids may produce a similar 
result, the inflammation extending into the connective tissue exterior to the 
intestine, and the mucous membrane becoming perforated, as stated by Syme. 
The connection of fistula with tubercular disease of the lungs has been very 
generally noticed, and is regarded by many as a salutary effort on the part 
of nature to divert disease from the pulmonary organs. I do not believe 
that any relation, other than an accidental one, exists between the two affec- 
tions, or that a fistula performs any office of this nature. The explanation 
of the presence of fistula in pulmonary disease, in my judgment, will be found 
in the structure of the hemorrhoidal veins and that of the perineum. The 
former are without valves, and the latter, or the muscular apparatus of which 
it consists, acts in consonance with the movements of the diaphragm. In 
coughing, the venous current is forced back upon these defenceless vessels, 
they become dilated, and the circulation through their channels suffers em- 
barrassment, which eventually excites inflammation, followed by abscess and 
perforation of the bowel. 
Diagnosis.—The diagnosis of fistula may be approximately established by 
the presence of ulcerated openings or by abscesses in the perineum, which 
refuse to heal, or, healing for a short time, reopen; by the existence of a 
hard point without any external orifice, which varies in size at different 
times and is tender to pressure. The positive existence, however, of fistula 
can be established by recognizing the escape of flatus or of faeces through the 
external opening, when such exists, and by making an exploration with the 
probe. In using this instrument, the patient should be placed upon the side, 
as directed under the head of preliminary observations. The index finger of 
the surgeon being introduced into the bowel, the probe should be inserted 
into the fistulous opening, and by gentle pressure made to follow the abnor- 
mal track. ISIo force should be used; otherwise false passages may be made. 
If the instrument fails to go in one direction, it must be tried in another; 
it may be used straight or curved, and with a little patience the proper route 
to the bowel will be found. When the end of the probe is recognized through 
the walls of the intestine, the finger in the rectum will serve to conduct it 
through an internal orifice, should such be present in the bowel. When no 
external opening exists, the necessary information may be gained by intro- 
ducing a rectal speculum, when, by pressing at different points over the sur- 
face of the perineum, the pus may be discovered flowing into the bowel. 
Treatment.—The treatment of fistula in ano is palliative and radical. The 
palliative treatment will be required in cases where there is an indisposition 
to submit to an operation, or in persons so greatly enfeebled and broken down 538 
DISEASES OF THE ABDOMEN. 
by other disease that the reparative power of the body is inadequate to the 
restoration of the parts. Under such circumstances, the bowels are to be 
regulated, the parts frequently bathed with hot water, and the sinuses in- 
jected with a weak solution of the sulphate of zinc or copper (two grains 
of the salt to the ounce of water), and the friction of the buttocks relieved 
by smearing over the parts a little oxide of zinc ointment. A solution of 
bichloride of mercury (one to one thousand) constitutes an excellent injection 
for the sinuses. 
The radical treatment consists in dividing all the structures between the 
extremities of the sinuses and the surface of the perineum, for which purpose 
the knife and the seton are employed. I will not deny that a fistula may 
close through the use of stimulating injections and cauterization; but such a 
result is exceedingly improbable. Syme narrates the case of Louis XIY., 
treated by Dionis for fistula in ano. So reluctant was his majesty to submit 
to the knife, that he resorted to every possible expedient to discover some 
other mode of cure. He sent a number of persons afflicted with the disease 
to the waters of Bareges, and others to those of Bourbonne, and some he placed 
in rooms, where they were subjected to various remedies. After a year’s 
fruitless experiment, without a single cure, he at last consented to allow M. 
Felix, his surgeon, to make the cutting operation, the cost of which, when the 
fees were distributed among the different parties, amounted to the very rea- 
sonable sum of fourteen thousand seven hundred pounds sterling. 
To effect a cure, it is necessary to place at rest the muscles about the anus 
and rectum, whose motions would serve, in part, to prevent healing; and 
also to establish a direct instead of a circuitous communication between the 
bottom of the fistula and the surface, so that the air, faeces, and muco-puru- 
lent discharges shall not be imprisoned, but shall find a ready exit from the 
tissues. For this purpose the knife is to be preferred, unless the fistula is too 
high up in the bowel to be safely divided. 
Twelve hours before cutting a fistula in ano, the bowels should be cleared 
out by a gentle cathartic, and immediately before the operation the rectum 
should be washed out with a solution of boracic acid. The patient having 
been etherized and placed upon the side, with the limbs well drawn up, the 
surgeon introduces into the fistula a flexible grooved director, which he re- 
ceives on the extremity of the 
index finger previously intro- 
duced into the intestine, and 
hooks it forward, bringing it 
out of the anus. A curved, 
sharp-pointed bistoury is next 
introduced into the groove of 
the director, and all the overly- 
ing structures are divided. (Fig. 
414.) Should no opening into 
the bowel exist, it is necessary 
to make one, which is best done 
by giving to the director a ro- 
tary motion while counter-press- 
ure is made by the finger within, 
at the point where the two are 
separated by the thinnest layer 
of tissue. A careful search must 
now be made for any other fis- 
tulous tracks which may be 
present, and, if such be discovered, each must be laid open upon the director, 
from end to end. In case the sides of such sinuses close over the wound, 
and their edges be thick and purple, it is better to cut them away with a pair 
of scissors or a knife. It was formerly taught that when the fistulous canal 
extended above the point where the internal opening was situated, it must 
Fig. 414. 
Division of the structures in a fistula in ano. PERINEO-ANAL AND PERINEO-RECTAL FISTULA. 
539 
be followed to its termination and the incision in the bowel be made at that 
place, and for some time I was of this opinion, but I have learned to think 
differently. If the parts be divided as deep as the point of communication 
with the cavity of the bowel, that is all that will be required. The old opinion 
is erroneous, or, at least, has not been verified in my later experience. 
When no external opening exists, the surgeon must feel for an indurated 
point, w7hich usually can be discovered upon making firm pressure over the 
perineum, and upon this he should cut, after which, if the director be inserted 
in the wound, it will enter the fistula and pass into the intestine. The end 
of the instrument being drawn through the anus with the finger, the incision 
of the raised parts should be made as in the complete variety. 
The parts being properly laid open, the pyogenic lining of the fistulous 
tracks should either be well curetted, or be dissected out with the scalpel, and 
the wound packed with carbolized lint or iodoform gauze, in order to prevent 
the sides from falling together and to encourage the growth of granulation- 
tissue from the bottom of the cut. To prevent the displacement, a compress 
of carbolized gauze covered with a pad of absorbent cotton-wool should be 
laid over the perineum and made secure by a T bandage. If the wound is 
not deep, I am in the habit, after the first free bleeding is over, of drawing 
through it a stick of caustic potassa and afterwards applying the oiled lint. 
This will produce a superficial slough, and it matters not if the packing works 
out, as the chasm must fill up by granulation-tissue. The bowels should not 
be moved for three or four days after the operation : to effect this, half a 
grain of opium morning and evening will usually suffice. After the lapse of 
this number of days, a gentle laxative will be required, from which time 
forward regular alvine evacuations are desirable. The parts must be cleansed 
with sublimated water, and the lint renewed daily until the wound becomes 
so shallow that a dressing is no longer required. 
It is not often that a serious hemorrhage follows the operation for fistula 
in ano. A free bleeding takes place at the moment of incision, but in a 
short time subsides by exposure to the air. If a vessel continues to bleed, 
it must be secured by the ligature, or be twisted. If the flow of blood is from 
the general surface rather than from a particular point, as happens occasion- 
ally when tissues are hard from inflammatory infiltration, the wound must be 
packed with lint, and a compress and a T bandage applied. The possibility of 
internal bleeding must not be overlooked ; and should the patient experience a 
sense of fulness in the bowel, become sick at the stomach, and grow pale, with 
a failing pulse, such hemorrhage may be suspected, whereupon the dressing 
should be removed and the rectum dilated with a fenestrated speculum, in 
order to admit the air or pieces of ice, and also to compress the parts. 
It sometimes happens that the external opening of the fistula is on the 
buttock, or some part of the perineum distant from the bowel. In such 
cases I have practised with entire success the plan of introducing deep, or 
deep and superficial, sutures into all that part of the wound beyond the verge 
of the anus, thus securing quick union, and packing only that portion which 
includes the bowel and the soft parts a short distance beyond. 
Excision of fistulso and suturing their edges together is strongly recom- 
mended by some surgeons. I do not believe that the practice is likely to be 
generally adopted, as it is almost impossible to keep a wound of this kind 
aseptic and thus secure rapid union. 
In operating on horseshoe fistula;, while it is necessary to lay open all the 
fistulous tracks around the bowel, yet it is not required to divide the walls 
of the rectum or the anus on both sides, but only on that side through which 
the fistula passes. 
When the fistula extends so far up the bowel as to render a cutting opera- 
tion hazardous, the seton may be substituted for the knife, by which means 
the work of division will be done slowly, but not less surely than by the bis- 
toury. To introduce a seton, an eyed probe should be armed with two or 
three threads of silk, or, what is better, with a piece of gum cord. Intro- 540 
DISEASES OF THE ABDOMEN. 
ducing the point of the probe into the fistula and carrying it forward into the 
bowel, it is to be received by the finger in the intestine and drawn out through 
the anus, where it must be disengaged from the cord, leaving the latter in the 
abnormal track with one end hanging from the external opening of the fistula 
and the other from the anus. If silk thread is used, the ends are best secured 
by being passed through the holes in an ordinary bone button and tied, 
gently tightening them every three or four days until the included structures 
are divided. When the elastic cord is employed, the ends can be tied directly 
together. The latter is in many respects preferable to silk, as a seton, in this 
locality. When the cords have ulcerated their way through, the resulting 
track should be kept packed with oiled lint. 
The question will often arise as to the propriety of operating upon fistulse 
in persons suffering from tubercular disease of the lungs. Believing, as I do, 
that such sores have no safety-valve or derivative office by which disease is 
attracted from the pulmonary organs, I have no hesitation in recommending 
that they be cured as quickly as possible. They do harm by the drain which 
they effect from the system, and they annoy and distress the patient from a 
sense of personal uncleanliness. Before, however, undertaking such an oper- 
ation in a tubercular subject, the surgeon must have reasonable ground for 
believing that the health of his patient is sufficient to insure the reparation 
of the wound. If there is ground for grave doubts on the subject, it is better 
to abstain from using the knife, as the wound will remain an open one, or 
perhaps assume a sloughing condition. 
Hemorrhoids. 
Hemorrhoids, commonly termed piles, are fibrous or vascular growths, situ- 
ated, the first below, and the second above, the sphincter ani muscle. They 
are divided into external and internal hemorrhoids. In either variety of the 
disease the initial step in their formation is a disorder of the blood-vessels, 
especially of the hemorrhoidal veins. Immediately above the internal sphinc- 
ter is an intricate plexus, formed by the radicles of the hemorrhoidal and 
pudic veins. Those on the sides of the anus terminate in the plexus. Some 
of the trunks emanating from the latter empty into the mesenteric and some 
into the internal iliac veins, so that around the lower end of the rectum the 
general venous and portal systems commingle. 
External Hemorrhoids.—These are situated at the verge of the anus, and 
appear as pendulous folds of hypertrophied skin. They frequently become 
inflamed, swollen, and excessively tender, and are generally associated with 
internal piles. They may be single or multiple, and vary in size from that of a 
buckshot to that of a walnut. As these tumors have two surfaces,—a cuta- 
neous and a mucous,—their color will not be uniform. Over the part covered 
by the skin it will be much like that of the surrounding integuments; and 
over that covered by the mucous membrane it will be purple, in consequence 
of the veins being visible through the surface of the latter. 
The vascularity of external piles diminishes in proportion to the length 
of time for which they have existed. They become gradually transformed 
into fibrous masses by hypertrophy of the submucous and subcutaneous con- 
nective tissue. In the formation of external piles, the hemorrhoidal veins 
become dilated and tortuous; being destitute of valves, they are prone to this 
change, and, as they lie beneath the sphincter, the varicose condition must 
manifest itself either above or below this muscle. When an external pile is 
examined in the commencement of its growth, it is quite soft in consistence, 
and has a deep purple color. If cut into at this stage, there will follow a pro- 
fuse flow of blood, chiefly venous. Exposed as it is to influences which tend 
to excite inflammation, the convolutions of the veins become matted together 
by plastic deposits, either obliterating their canals or distending their walls 
to the point of rupture, in either case producing coagulation of the contained HEMORRHOIDS. 
541 
blood. WThile these changes are in progress, the connective tissue increases 
and the vascular channels diminish. If a section be now made of the tumor, 
there will probably be found a clot of blood surrounded by a dilated vein or 
lying in the midst of dense connective tissue. Finally, if a still later period 
be selected for dissecting the tumor, it will be found to consist wholly of 
connective tissue. 
Internal Hemorrhoids.—Internal piles are situated from half an inch to two 
and a half inches above the internal sphincter muscle. They are round, oval, 
and cylindrical in form. They are sometimes scattered at irregular distances 
over the surface of the bowel, and at other times are clustered together in 
groups (Fig. 415); their attachment may be broad or narrow, and occasion- 
ally is double, forming a considerable intermediate loop. They are invested 
entirely by mucous membrane, the surface of which may be villous, granular, 
or smooth, and the color is commonly dark red, becoming purple when pro- 
lapsed and constricted by the sphincter. In consistence, internal piles are 
soft and spongy, much resembling an erectile growth. They are sometimes 
spoken of as open and blind, according as they do or do not bleed. These 
terms express no distinctive characteristics in the tumors, and might without 
disadvantage be abandoned. 
The structure of internal hemorrhoids may be very well studied by insert- 
ing pipes into the inferior mesenteric vessels and distending them wTell with 
a tallow injection, the latter being afterwards dissolved out. After making 
sections of the tumors, the interior presents a cavernous appearance (Fig. 
Fig. 415. 
Fig. 416. 
A group of prolapsed hemorrhoids. 
Section of an internal hemorrhoid. 
416), and consists of tortuous and dilated veins and arteries, the former 
predominating. The vessels are connected by straggling threads of fibrous 
tissue, and the whole growth is covered with mucous membrane. There is 
another variety of piles which consists of cylindrical elongations of limited 
portions of the normal columns of the rectum. They are very vascular, 
abounding in small arterial branches, and are of a bright scarlet color. The 
anatomical difference between this and the former variety of hemorrhoids is 
the absence of any great dilatation of the vessels in the latter. 
Causes.—The hemorrhoidal veins, as has been stated, form a very intricate 
plexus beneath the internal sphincter muscle. These vessels are destitute of 
valves, and the blood which circulates through their channels is carried back 
to the heart chiefly through the mesenteric veins, which terminate in the 
vena porta. Whatever tends to favor an undue accumulation of blood in the 
hemorrhoidal plexus predisposes to piles. For this reason they frequently 
follow diseases of the liver, which cause obstruction to the portal circula- 
tion. The mechanical pressure of abdominal tumors, and that from the 
gravid uterus, are frequent causes of the disease, by keeping the rectal veins 542 
DISEASES OF THE ABDOMEN. 
over-distended. Diseases which provoke much straining, as stricture of the 
urethra, enlargement of the prostate, and stone in the bladder, are also 
actively concerned in the production of piles. The most common cause, 
however, is constipation. 
They are met with in all classes, though oftener occurring in persons of 
indolent, sedentary, and luxurious habits of life. No age is exempt from the 
disease. They are seen at all periods of life, from early infancy to extreme 
old age. Nor are piles peculiar to either sex, males and females suffering 
with equal frequency. They are often associated with fissure, fistula, and 
cancer of the ano-rectal region. 
Symptoms.—When the disease is slight, or when the tumors are just begin- 
ning to form, only a slight uneasiness may be experienced, such as a little 
soreness, heat, or itching at the verge of the anus. These sensations are 
aggravated if the bowels remain costive. If there are external piles, they 
frequently become inflamed, swollen, and painful, and in some instances sup- 
purate, which usually results in their cure. When internal piles have in- 
creased to any considerable extent, or have become inflamed, they produce 
not only the symptoms of heat and itching at the extremity of the bowel, but 
also a sense of fulness in the rectum, as though some foreign body were pres- 
ent ; there is a feeling also, after defecation, as though a portion of the faeces 
still remained. When the hemorrhoids become large, they frequently descend 
along with the evacuation and protrude externally, being covered with a pro- 
fuse mucous secretion, and if the sphincter is firm their color becomes deep 
purple in consequence of the muscular constriction to which they are sub- 
jected. Sometimes, after prolapsus, they recede spontaneously within the 
bowel; at other times it is necessary for the patient to press them back with 
the hand. In some instances the protrusion is constant, and may consist of 
one or more piles lying in the centre of the anal orifice, or they may project 
around its entire circumference. The last condition is frequently confounded 
with cedema of the mucous membrane, which forms a thick and swollen ring 
about the anus, but which, unlike hemorrhoids, is smooth and uniform in- 
stead of being indented and lobular. Frequently, during hemorrhoidal pro- 
trusion, some vessels give way, followed by a free escape of arterial blood, in 
consequence of the constriction of the sphincter muscle. Or the flow may 
be caused by excoriation or by ulceration. The quantity of blood lost varies 
in different cases: it may be only a teaspoonful, or it may amount to several 
ounces. This discharge, repeated at each succeeding passage from the bowels, 
soon begins to make a very decided impression upon the system. The patient 
loses flesh and strength, the face becomes pale, anaemic, and puffy, and finally 
assumes a waxy color, and vertigo and nausea are often present. In some 
cases, in consequence of relaxation of the sphincter, the piles remain per- 
manently prolapsed, or they may descend when the patient is long on his 
feet, or when he makes some considerable muscular effort, especially in the 
stooping posture. 
The diagnosis of hemorrhoids is not difficult, and is most satisfactorily de- 
termined by requiring the patient to sit over a vessel containing hot water 
and strain the tumors down outside of the anus. Their irregular ovoidal 
form, broad attachment to the intestine, red or purple color, and the absence 
of any very acute suffering sufficiently declare their natui’e. 
The symptoms of hemorrhoids should never be confounded with those of 
fissure of the anus; although the mistake is frequently made. 
Treatment.—When external piles become inflamed, they often cause severe 
suffering. Under such circumstances it is best for the patient for a few days 
to remain in the recumbent position, in order to take off the blood-pressure 
from the anus, and at the same time to cover the parts with a cold lotion of 
lead-water and laudanum. If the pain is very severe, a few punctures should 
be made into the swollen pile with a needle; or, what is still more effective, 
a free incision should be made into its substance, unloading the distended 
veins, or perhaps turning out a central clot of blood. Though it is generally INTERNAL HEMORRHOIDS. 
543 
advised to apply remedies cold to these tumors, I have often found that hot 
applications afforded relief when the others did not. In this particular the 
sensations of the patient should be consulted, and the temperature regulated 
accordingly. When external piles become the subjects of frequent inflam- 
matory attacks, they should be clipped off; but never during the inflamed 
condition. The operation is very simple, and consists in raising the tumors 
by a tenaculum or forceps and cutting them off at the base with a pair of 
scissors. If a vessel springs, it should be embraced by a ligature. 
The treatment of internal piles is palliative and radical. 
Palliative Treatment.—Very much may be done in this way to render 
the patient comfortable. The diet must be carefully regulated, all highly- 
seasoned or over-stimulating food being avoided, and stimulants of every 
kind forbidden. If the bowels are constipated, it is of the first importance 
to correct this condition, either by the use of stewed fruits, oatmeal porridge, 
or cornmeal mush with molasses, or, if these articles prove insufficient for 
this object, by taking at bedtime a teaspoonful of a powder consisting of 
equal parts of sulphur and cream of tartar mixed with a little syrup. The 
addition of a portion of the confection of senna to this powder will make it 
somewhat more active as a laxative, and may be employed with advantage 
when the bowels are very sluggish. A single teaspoonful of the sulphate 
of soda, taken in a tumbler of water three-quarters of an hour before break- 
fast, will procure a satisfactory movement, and appears to act specifically 
upon the portal vessels. The use of cold-water injections, so much ex- 
tolled by most writers, certainly exercises a salutary influence, by unloading 
the rectum and allaying local irritation; but their habitual use I am con- 
fident does harm, by creating a torpor or inertia of the lower bowel, so that 
their repetition becomes more and more necessary. For this reason I have 
for some time discouraged the use of enemata. When much internal sore- 
ness and irritation are experienced in the hemorrhoids, a small enema, con- 
sisting of one ounce of lime-water with a teaspoonful of linseed oil, will give 
great comfort. This should be administered after the bowels are opened, 
and to retain it permanently the patient should lie down for fifteen or 
twenty minutes, until the disposition to expel it has passed over. A satu- 
rated solution of the chlorate of potash, used as an enema, in the same quan- 
tity as the lime-water, will also prove a valuable remedy. These local applica- 
tions, when they do not effect the desired end, may be materially assisted by 
the use of copaiba. A capsule containing twenty drops may be taken four or 
five times a day. Sir Benjamin Brodie employed this remedy in conjunction 
with the liquor potassse. Fifteen drops of the latter, with half a drachm of 
the former, rubbed up with mucilage and cinnamon-water, were given three 
times a day. The combination, when the stomach will receive it kindly, is 
among the best of internal remedies. A confection of pepper, known as 
Ward’s paste, was at one time quite popular with British surgeons. Sir 
Everard Home was in the habit of applying it locally, having been led to this 
practice by a patient who, instead of taking the paste by the mouth, pushed 
a quantity up the rectum, with the effect of curing his hemorrhoids. When 
the piles protrude during defecation, they should be immediately pressed 
within the sphincter: otherwise the constriction of the sphincter, acting like 
a cord and preventing the return of the blood, will cause the tumors to become 
so swollen as to render their replacement a task of much difficulty. To re- 
store incarcerated piles, the patient, if a male, should be placed upon the 
elbows or knees, the pelvis being well elevated; if a female, upon the side, 
with a pillow slipped under the hips. The fingers of the surgeon, being well 
oiled, should grasp the piles, and, by gradually squeezing them, press out the 
blood, when they will readily recede. Should this manipulation not succeed, 
it is best to etherize the patient, and, by dilating the sphincter, to remove at 
once all obstacle to their reduction. When the hemorrhoids have a tendency 
to prolapse during the act of standing or of walking, or from weakness of the 
sphincter muscle, cold water applied to the anus and perineum, in the form of 544 
D IS EASES OF THE ABDOMEN. 
a fine stream, immediately after defecation, will act as a powerful tonic to 
the muscular structures of the ano-rectal region, and, as I have frequently 
seen, will render them sufficiently vigorous to prevent protrusion. The in- 
strument which I direct for applying the cold 
water is a gum hose, five or six feet long, at 
one end of which is a bell-shaped expansion of 
metal, and at the other a bone nozzle. (Tig. 417.) 
After filling the hose, the bell-mouth is dropped 
into a basin of water elevated some distance 
above the head of the patient, and the stream 
permitted to flow from the nozzle against the 
perineum and anus with con- 
siderable force, using for each 
lavement at least one gallon of 
cold water. This should always 
be used immediately after a 
stool. There is something pe- 
culiar in the action of a fine 
stream of water: it produces a 
much more energetic contrac- 
tion of muscular fibre than that 
caused by bathing or sponging. 
A bidet is also convenient. In 
obstinate cases of prolapse, relief 
may often be obtained by introducing, after the replacement of the piles, a 
rectal obturator. (Fig. 418.) If the obturator cannot be worn, relief may be 
secured by using a hemorrhoidal truss. This apparatus consists of a 
horizontal band supporting a steel 
spring, at the free extremity of 
which is an oval ivory pad with 
two perineal straps. (Fig. 419.) 
In applying the instrument, the 
band is buckled round the pelvis, 
the steel rod passed between the 
nates, with the ivory pad resting 
against the verge of the anus, and 
the perineal straps made fast to 
the front of the horizontal band. 
Persons who suffer from prolapse 
of hemorrhoids should avoid cush- 
ioned chairs, using rather those with 
cane seats. They should not sit down during defecation, as in this position 
the parts about the perineum are spread open so as to favor the displacement 
of the tumors. The evacuation is best accomplished when semi-erect, and by 
voluntarily contracting the sphincter the passage should be “wire-drawn,”— 
that is, strained through the anal aperture with the least possible dilatation 
of the sphincter ani muscle. Immediately after stool the patient ought to lie 
down for fifteen or twenty minutes, until the engorged veins of the rectum are 
emptied and the parts are contracted down to their former condition. It is 
always desirable for those suffering from hemorrhoids to establish the habit of 
going to stool before retiring to bed, as they will obtain the fullest benefit from 
recumbency. A little attention to the above directions, carried out system- 
atically and persistently, will contribute immensely to the comfort of those 
who are affected with hemorrhoids, and in many instances will effect a cure. 
Radical Treatment.—The radical cure of piles consists in their removal. 
There are seven methods of accomplishing this,—viz., by strangulation, by 
the cautery, by the ecraseur. by caustics, by injections, by crushing, and by 
excision. Strangulation and the cautery are the plans to be preferred. The 
operation by the ecraseur is not unattended with danger from hemorrhage, 
Fig. 417. 
Fig. 418. 
Hose for irrigating hemorrhoids. 
Kectal obturator for 
retaining piles. 
Fig. 419. 
Hemorrhoids truss. INTERNAL HEMORRHOIDS. 
545 
and. in consequence of including a large amount of mucous membrane, some- 
times produces cicatricial contraction of the rectum. Caustics are slow and 
often painful. Excision by the knife is the operation of Whitehead. 
Operation by Ligature.—This plan is almost entirely devoid of danger, 
and is executed either by ligature or by the canula and wire. The ligature 
is to be preferred. The patient’s bowels should be well opened the day pre- 
vious to the operation, after which an opiate should be administered consist- 
ing of one grain of opium. In order to protrude the tumors, the patient 
should be directed to sit over a vessel containing hot water, the vapor of 
which serves to attract an increased amount of blood to the hemorrhoidal 
veins, thereby enlarging the tumors and at the same time removing the re- 
sistance of the sphincter. A little straining while in this position will cause 
the piles to descend. A large injection of warm water thrown into the rec- 
tum will, when expelled, effect the same end ; or they may be hooked down 
by the finger, the sphincter having been well dilated with the thumbs intro- 
duced into the bowel and forcibly separated. In the female, this may be 
done by acting through the vagina. The next step is the etherization of the 
patient, as the operation is one attended with severe pain. This done, each 
pile, or, if not too large, a group of two or three piles, should be transfixed 
with either a single or a double tenaculum, drawn wTell out, and a long liga- 
ture of strong hempen thread passed through their base by means of a needle 
supported on a handle. (Fig. 420.) The thread being cut, and disengaged 
Fig. 420. 
Needle armed with a thread previously to passing it through the base of a pile. 
from the eye of the needle, the latter is withdrawn, by which a double liga- 
ture is formed. A slight incision through the skin, a little beyond its junction 
with the mucous membrane, should now be made, as suggested by Horner, 
after which, the pile being wrell drawn down, the thread should be tied firmly 
in a single knot, the outer one occupying the groove cut in the integument. 
The tenaculum should now be removed, and each ligature drawn upon with 
additional force before making the second knot. The object of incising the 
skin for the external ligature is to save pain, to hasten the separation of the 
included mass, and to render the cure more certain by the consequent cica- 
tricial contraction ; the design in not making the second knot until after the 
tenaculum is removed, is to provide for the shrinkage which follows the es- 
cape of blood, and to enable the operator to make the strangulation complete. 
The value of having each ligature long will be appreciated wThen they are 
being drawn upon previously to making the second knot, as the ends can be 
wrapped round the hand and much force exerted in making them tight. If 
the tumors have been properly secured, in a little time they will become blue, 
showing that their circulation has been completely arrested. The ligatures 
may now be cut off near to the knots, and the strangulated masses returned 
into the bowel, after which a small enema, consisting of two tablespoonfuls of 
starch-water with forty-five drops of laudanum, should be thrown into the 
rectum. The after-treatment consists in confining the patient to bed, keep- 
ing the bowels quiet by the use of a grain of opium daily, and directing 
for the first four or five days a liquid diet, after which solid food may be 
allowed. If the pain following the operation proves severe, anodynes must 
be given to the extent of securing relief. In most cases the patient will be 
unable—at least for a few days—to pass the urine, and will require the use 
of the catheter twice or three times in the twenty-four hours. In the course 
of seven or eight days a gentle laxative should be given, when the loops of 
the ligatures will generally be passed in the stool, and two days following 546 
DISEASES OF THE ABDOMEN. 
this event the patient may be allowed to rise and go about. Frequently 
during the treatment patients suffer from spasmodic contraction of the 
levator ani muscles and flatulent distention of the abdomen. Opium is the 
best remedy for both of these conditions. The odor which emanates from the 
discharges about the anus, caused by the decomposing piles, is best corrected 
by frequent ablutions with carbolic acid soap and water, or by bathing with 
dilute bromo-chloralum. To allay the extreme external tenderness of which 
some patients complain, nothing proves more soothing than a free application 
to the parts of cacao-butter melted with the benzoated oxide of zinc ointment. 
This operation is simple, safe, and efficient; indeed, it may be said to be 
almost free from danger. I have never witnessed in a single instance any 
alarming symptoms follow the use of the ligature. Cases are recorded in 
which patients have perished after the ligation of hemorrhoids, from ery- 
sipelas, from pyaemia, and from tetanus; but such terminations are very un- 
common. Allingham states that of three thousand two hundred and thirteen 
operations for piles at St. Mark’s Hospital there have been only five cases 
of tetanus, and not one of pyaemia. 
Next to the ligature, strangulation and removal by the clamp and cautery, 
or by crushing, are to be preferred, provided the piles are small. This opera- 
tion was introduced by 
Mr. Cusack, of Dublin, 
Ireland. The instru- 
ment best adapted for 
the purpose is the 
clamp of Mr. H. Smith, 
of London. It consists 
of two blades, one of 
which is grooved, the 
other serrated. To 
the back of each blade 
is screwed a piece of 
ivory, designed to protect the skin from the heat of the cautery. The blades 
have a screw by which they can be firmly 
brought together. (Fig. 421.) A knife, a pair 
of forceps, and a cauterizing-iron (Fig. 422) 
complete the apparatus. 
Operation by the Clamp.—The patient 
being etherized, the pile is drawn down and 
embraced by the clamp close to its attach- 
ment with the bowel. The screw is next 
run down so as to strangulate effectually the 
pedicle, when the mass in front of the instrument is cut off, either with 
the knife or scissors, leaving a stump about three-eighths of an inch long. 
This is next thoroughly seared or cauterized with the hot iron, after which 
the blades are unscrewed and the clamp is removed. The patient should be 
confined to bed after this operation for five or six days, and the bowels kept 
quiet with an opiate; after this a laxative should be given, when the case 
may be considered cured. 
Injections offer another mode for removing hemorrhoids. The material 
employed is carbolic acid in with an equal quantity of glycerin. 
The liquid is to be introduced into the centre of the hemorrhoid by means 
of the ordinary hypodermic syringe. When carelessly done, the operation 
is not unattended with danger: it has given rise to pelvic cellulitis and to 
fatal embolism. The cases which I deem best adapted for injection are those 
in which the tumors are not accompanied with oedema of the mucous mem- 
brane, are not too large, and are moderately distinct. The following 
precautions should be observed in the use of this remedy: 
1st. Never use more than four drops of the mixture to a tumor: more 
than this is likely to cause sloughing. 
Fig. 421. 
Smith’s clamp for piles. 
Fig. 422. 
Cautery. INTERNAL HEMORRHOIDS. 
547 
2d. See that the needle goes to the centre of the hemorrhoid, which should 
be firmly grasped at its base between the thumb and a finger, and not released 
for twenty or thirty seconds after the deposit of the carbolic acid. 
3d. Do not treat more than two or three tumors at one sitting. 
Generally a hot or smarting sensation is experienced on the introduc- 
tion of the liquid, but this soon passes away. The effect of the acid is to 
mummify or shrivel up the hemorrhoid. The patient should remain quiet 
for twelve hours after a treatment. If the injection is not sufficient for the 
removal of the tumor, it can be repeated at intervals of three or four days. 
Crushing, or the method of Mr. George Pollock, is adapted to a case in 
which the tumors are distinct from one another, and consists in dragging 
down the hemorrhoid with a volsella or tenaculum and grasping it be- 
tween the blades of a powerful forceps, which are forced together with 
sufficient strength to destroy and disorganize the mass. Mr. Aliingham has 
devised a special instrument for the purpose. 
Treatment by Caustics.—There are persons who, from timidity, are un- 
willing to submit to either the ligature or the clamp, yet for whose relief 
something must be done, especially when the tumors bleed freely. In such 
cases the surgeon may resort to caustics. Nitric acid has been extolled by 
Mr. Houston, of Dublin, and others. As a means of arresting the capillary 
oozing of blood in soft vascular piles it will sometimes be found a valu- 
able remedy. The acid is best applied through a fenestrated speculum 
with a piece of pine wood, taking care that the redundant liquid is removed 
by means of a dossil of cotton or lint and that the surrounding parts are 
well protected, and afterwards smeared with olive oil. The effect of the acid 
is to produce a granulating surface, the contraction of which after cicatri- 
zation may temporarily arrest the growth of the pile, and may sometimes 
effect a cure. Chloride of zinc has been used as an application to hemor- 
rhoids. It produces a deep slough, which results in the cure of the piles, 
but it requires too much care in its application to warrant its general use. 
Removal by the Ecraseur.—Chassaignae employed the ecraseur for the 
removal of hemorrhoidal tumors, and there are a few American surgeons who 
still prefer this instrument I have known instances in which patients came 
near losing their lives from hemorrhage after its employment, and in con- 
sequence I have long ceased to use it. The method of Chassaignae was 
first to pedunculate the tumors, by carrying over them a loop of strong 
thread, introduced into the rectum around the finger, and, after hooking 
down the piles with the latter, getting an assistant to tighten the ligature 
firmly about the base of the tumor. (Fig. 423.) The chain of the ecraseur 
was next passed over the hemorrhoids close up to the cord, and, while the 
mass was held by a tenaculum (Fig. 424), it was slowly crushed off by the 
movements of the lever of the instrument. When the ecraseur is used, a 
much simpler method is to drag down the tumors and pass a long needle or 
pin across their base, then to slip the chain over the hemorrhoids down to the 
pin, and, by slowly turning the handle of the instrument, cut them off, taking 
twenty or twenty-five minutes for accomplishing the work. 
Excision is accomplished as follows. The bowel is to be well cleansed by 
injections previous to operation. After etherization the patient is to be placed 
in the lithotomy position. An incision is then made around the anus close to 
the cutaneo-mucous line, and the mucous membrane dissected free from the 
superficial sphincter. The finger or the handle of the scalpel will now serve to 
detach the hemorrhoids and mucous membrane from the muscular walls of the 
bowels until a point is reached above the tumors, when by making traction 
on the raised parts the piles can be brought down outside of the anus, when 
the mucous membrane can be divided above the tumors and attached by nu- 
merous carbolized silk sutures to the edge of the integument below. As the 
vessels lie immediately beneath the mucous membrane, there is but little 
hemorrhage, and those vessels which bleed when the division of the lining 
membrane is made above the piles can be controlled by torsion or by the 548 
DISEASES OF THE ABDOMEN. 
pressure which follows the stitching together of the skin and the mucous 
membrane below. Whitehead claims for this operation the greatest success, 
Fig. 423. 
Ligature applied in order to narrow the base of the hemorrhoidal mass previous to applying the 
ecraseur.—After Chassaignac. 
and his favorable opinion as to its value is based upon an experience gained 
from three hundred cases without any accident whatever. 
Fig. 424. 
The ecraseur applied.—After Chassaigtiac. 
Dilatation.—Forcible dilatation of the external and internal sphincters 
has been recommended by Verneuil as a valuable procedure for the cure of 
hemorrhoids. The vessels being relieved from constriction, the tumors dis- INTERNAL HEMORRHOIDS. 
549 
appear before the sphincters recover their power. Yerneuil claims for the 
plan that it has resulted in cure in ninety-eight per cent, of the cases in 
which it has been employed. I have had no experience in this operation, 
and can only say that the success claimed for the method is to me a surprise. 
Complications.—Though a very uncommon occurrence, yet bleeding may 
follow the separation of the ligatures, especially in cases where the hemor- 
rhoids have been partially disorganized. The resistance ottered by the sphinc- 
ter will prevent the blood from escaping externally, and a dangerous concealed 
hemorrhage may take place without being suspected. Patients generally, 
in this kind of internal bleeding, are conscious of something trickling away, 
and will so express themselves. When a large amount of blood is lost, they 
become pale, sick at the stomach, and cold, while the pulse is feeble and fre- 
quent, and the surface is covered by a clammy sweat. Whenever hemorrhage 
exists, a careful examination of the bowel should be immediately instituted. 
It may proceed from a single vessel, or from a very limited surface of the 
mucous membrane, and be controllable at once by a ligature. If the part from 
which the blood issues be too extensive for inclusion by the ordinary liga- 
ture, an acupressure-pin should be pushed beneath the bleeding surface and 
a wire or silk thread thrown about it. If these measures prove insufficient, 
it is advisable to proceed at once to tampon the rectum. A number of in- 
genious suggestions and contrivances have been made for this purpose, but 
none are more reliable than the sponge of Allingham, or the rectal chemise 
which I have had made. The first consists of a soft conical or bell-shaped 
sponge, with a loop of strong silk or hempen thread passed through its 
summit, the two ends of the thread hanging below. The sponge, having 
been soaked in water and afterwards squeezed dry, is to have its pores well 
powdered with persulphate of iron or with alum, and then to be pushed on 
the end of the finger or by a bougie through the anus and four inches or 
more up the bowel. This accomplished, the rectum is next to be stuffed 
with charpie or cotton wool well dusted with persulphate of iron or with 
alum, after which, by pulling upon the thread with one hand and at the same 
time pushing up the cotton wool or charpie with the other, the sponge is 
both drawn down and spread out, so as to press accurately on all sides against 
the inner surface of the rectum. To allow 
the passage of flatus, which is frequently a 
troublesome and painful attendant of opera- 
tions upon the rectum, a flexible catheter 
may be passed through the summit of the 
sponge before packing the bowel, or it may 
be introduced between the latter and the 
tampon. This tampon should be allowed to 
remain for eight or ten days before it is re- 
moved, preliminary to which the packing 
must be picked out from the cavity of the 
sponge. 
The rectal chemise, which fulfils the same 
end as the sponge of Allingham, is prepared 
as follows. Through the openings at the 
end of the largest-sized gum catheter pass a 
strong silk thread ; take three square pieces 
of the material usually known as mosquito- 
netting, place them one on top of the other; 
at the centre of these squares or pieces make an opening, and pass the 
catheter through it, securing the two together by the threads. (Fig. 425.) 
In applying the instrument, the different layers of the chemise must be 
moistened with water, and afterwards well filled with the persulphate of 
iron. It is then conducted some distance into the rectum on a finger pre- 
viously inserted; after which it is expanded like a parachute by packing be- 
tween the catheter and its hood with long strips of lint thrust up on the end 
Fig. 425. 
Author’s rectal chemise, 550 
DISEASES OF THE ABDOMEN. 
of a bougie, until the bowel is distended on every side. The catheter will 
serve to conduct away the flatus; and when, after eight or ten days, its 
removal becomes necessary, this is very easily effected by drawing out the 
ribbon-like pieces of lint which were used as packing. 
In cases where hemorrhoids are complicated with polypus, fistula in ano, 
stricture, or uterine displacements, the cure of the latter is necessary to the 
success of any operation upon the former. 
When hemorrhoids are the result of organic disease of the liver, perma- 
nently obstructing the circulation through the portal veins, or when they 
arise from the pressure of abdominal tumors or of the gravid uterus, no 
operation is proper, for unless the cause be removed the disease will certainly 
return. 
HERNIA. 
Hernia, in the widest acceptation of the term, is the protrusion of any 
organ or structure through a natural or preternatural opening. Thus, we 
speak of hernia of the brain, of the iris, of the bladder, etc. In the 
more restricted and proper sense, it is the protrusion of an intestine, of 
omentum, or of both, from the interior to the exterior of the abdominal 
cavity, in the course of certain blood-vessels. The abdominal walls, for the 
most part, are admirably constructed to prevent visceral protrusions. They 
consist of stratifications of muscular and aponeurotic tissues, the fibres of 
which are disposed in different directions. The external oblique muscles 
run from above downwards ; the internal oblique, from below upwards; the 
transversalis, transversely; and the recti, with their tendinous intersections 
and sheaths of strong fibrous tissue, extend perpendicularly between the 
pelvis and thorax. There are, however, certain points in the parietes which 
are necessarily less capable of resisting pressure from within than others ; 
and these points correspond to where the blood-vessels designed to supply 
the outstanding oi’gans leave the body. A knowledge of these vessels is the 
key to a proper understanding of hernia. 
General Division of Hernia.—There are two grand divisions of hernia, con- 
genital and acquired. Under the first division are included all herniae that 
occur before birth; under the second, all that result from weakness of the 
abdominal parietes or from accident after birth. 
Varieties of Hernia.—When a hernia follows the course of the spermatic 
cord or blood-vessels, it is called a spermatic or an inguinal hernia; when it 
takes the direction of the femoral or crural vessels, it constitutes a femoral or 
a crural hernia ; when its direction is in the course of the umbilical vessels, it 
is termed an umbilical hernia ; if in the course of the obturator arteries, it is an 
obturator hernia; if it follows the gluteal or ischiatic vessels, it constitutes a 
gluteal or ischiatic hernia. The last three forms are very rare. In addi- 
tion to these varieties, there are a number of hernise which do not follow, in 
all cases, the course of the blood-vessels. They are the diaphragmatic, the 
pudendal, the perineal, the properitoneal, and the sacro-rectal hernias, and hernia 
of the foetal cord. 
Anatomical Components.—The components of a hernia are its sac, its contents, 
and its coverings. 
The sac is a serous membrane, and is derived from the parietal layer of the 
peritoneum. It is pushed before the hernia, gradually forming an elongated 
pouch. In congenital hernia the sac exists before birth, being formed not 
by the rupture, but by the descent of the testicle. The failure to close this 
tubular prolongation by a natural process of contraction, and thus to shut off 
communication with the common j>eritoneal cavity, explains the occurrence 
of a congenital hernia. 
Csecal hernia, when it occurs, is without a complete sac. This is due to HERNIA. 
551 
the fact that the iliac surface of the bowel is non-peritoneal, and when it 
passes out of the abdomen to form a hernia the serous layer is detached 
from its free surface. 
Hernial sacs differ greatly in size, form, and appearance. In size, they vary 
from that of a marble to that of a cocoanut; in form, they may be tubular, 
pyriform, sacculated (Fig. 426), or spherical; and in appearance, smooth, thin, 
and translucent, or rough, thick, and opaque from inflammatory changes. The 
larger and the older the sac, the more does its character differ from that of the 
serous membrane from which it is derived. 
Whatever the form of the sac, it is divided 
into the neck, fundus, body, and mouth. (Fig. 
426.) The neck is the narrow, constricted 
part produced by the ring through which it 
passes. The effect of the constriction is to 
corrugate or plicate this part of the sac. 
These plications may disappear when the 
membrane is returned back into the cavity 
of the abdomen, or they may be glued to- 
gether by inflammatory lymph and rendered 
permanent. The fundus is the most depend- 
ent portion of the sac; the body is that part 
between the fundus and the neck; and the 
mouth is the expanded opening which looks towards the abdominal cavity. 
Contents, of the sac.—The contents of the sac have formed the basis for cer- 
tain names which have been given to hernial tumors. Thus, when the sac 
contains a portion of intestine, it is called an enterocele; when it contains 
omentum, an epiplocele; and when both intestine and omentum are present, 
an entero-epiplocele. The terms cystocele and gastrocele are used to express 
protrusions of the bladder and of the stomach. In a few instances the ap- 
pendix vermiformis has found its way into the inguinal canal. Besides the 
above-named constituents, the sac usually contains a serous fluid, which some- 
times accumulates in large quantities, especially when associated with abdom- 
inal dropsy. In rare cases, when a hernia has been cured, the sac may 
remain open and become filled with a fluid, giving rise to what has been 
called a hydrocele of the sac. Even an epiploic appendix has been known to 
become detached and find its way into the serous pouch. In enterocele, the 
ileum is that part of the intestine generally found in the sac, which fact is 
due to the loose nature of its mesenteric attachments. The amount of intes- 
tine which enters the sac varies greatly in different cases. It may not be 
larger than the end of the finger, or it may consist of several coils. In rare 
instances the entire small intestine has been seen in the sac. The large 
intestine is rarely found to form a part of a hernia. When a large portion 
of the bowel enters the hernial sac and is allowed to remain, it is prone to 
undergo structural changes, affecting its color, consistence, and functions. 
Its normal translueence is lost; its structure becomes less polished and less 
elastic ; bands of lymph connect the intestinal loops ; and the peristalsis is 
imperfectly executed. The patient is frequently harassed with flatulence 
and with colicky pains. In epiplocele, the effect of a long residence in the 
sac is to produce great thickening of the omentum. In entero-epiplocele, tbe 
intestine is sometimes found pushed before the omentum, sometimes entirely 
surrounded by it, and at other times the two are curiously intertwined. The 
bowel has in some instances become strangulated, in consequence of being 
constricted by the omentum. In old cases of entero-epiplocele it is not un- 
common to find bands of lymph uniting together portions of the omentum 
and the intestine, and occasionally both are bound to the interior of the sac. 
The coverings of a hernia are the different strata of tissues—cutaneous, 
fascial, aponeurotic, muscular, and serous—which overlie the contents. They 
are not the same in all forms of hernia. 
When a hernia returns spontaneously, or can be restored by manipulation 
Fig. 426. 
Sacculated sac. 
Pyriform hernial sac. 
a, neck ; b, mouth; c, body ; 
d, fundus. 552 
I) IS EASES OF THE ABDOMEN. 
into the cavity of the abdomen, it is called a reducible hernia; when the con- 
tents of a hernia cannot be thus returned, it is said to be irreducible; and 
when the contents become constricted, so as not only to resist reduction but 
also to give rise to pain and to vomiting, it is designated a strangulated hernia. 
Causes.—The causes of hernia are predisposing and exciting. 
Predisposing.—Among the predisposing causes may be enumerated the 
following: 
Muscular weakness of the abdominal parietes.—This is often associated with 
a large accumulation of fat. This weakness may be produced by wounds; 
by the atrophy which follows protracted illness ; by distention from large 
accumulations of ascitic fluid, and from pregnancy ; and by a variety of other 
causes, such as coughing, straining, jumping, vomiting, and lifting heavy 
weights. 
Occupation.—The laboring classes, being the most numerous, furnish the 
largest number of hernise. Occupations which require much physical effort 
when the body is in the stooping posture expose most to the disease, as the 
walls of the abdomen being thus relaxed are less able to resist the pressure 
of the viscera. The common habit among laborers of girding the loins tends 
to produce the disease. It has been said that musicians who use wind-instru- 
ments are much exposed to rupture. This does not correspond with my 
observation. Persons following this calling execute their music in the erect 
position, and during the act of blowing the diaphragm is gradually ascend- 
ing, allowing the viscera of the abdomen to rise. Gymnasts and contortionists 
might be supposed to be particularly liable to hernia, yet this class of per- 
sons are remarkably free from the disease. Indeed, the more I observe of 
hernia the less importance do I attach to occupation in the production of the 
malady.* 
Sex.—Males suffer more than females,—the proportion, it is said, being four 
of the former to one of the latter. This statement is based upon a report of the 
London Truss Society, in which it appears that out of 96,886 persons apply- 
ing for trusses only 18,492 were females. I find, on inquiry at the different 
truss- and instrument-makers’ establishments in Philadelphia, that those who 
purchase trusses are for the most part males. That this sex should be more 
liable to hernia than the feminine, might be anticipated from the different 
character of their employments: yet I think the difference is overestimated. 
Females are less disposed than males to seek relief for such affections, and I 
am quite certain that if the comparison is made in private practice the dispro- 
portion will not be so great as it is usually represented. Males are said to be 
most liable to inguinal, females to femoral and umbilical hernise. With refer- 
ence to females, age exercises a modifying influence in this respect. Under 
twenty years, they are more liable to inguinal than to femoral hernia; but 
during the middle period of life—i.e., between twenty-five and forty-five years 
—femoral is much the more common form. The explanation of the above facts 
must be sought for in certain anatomical peculiarities. In young females the 
canal of Nuck formed by the round ligament with its processus vaginalis, 
not being easily closed, invites an inguinal protrusion, whereas the superior 
development of the pelvis, in obedience to the function of child-bearing, in 
maturer years renders the crural arch less able to resist visceral pressure 
than before, and hence the frequency of the femoral variety. The proportion 
of cases of hernia to the entire population of a country is materially influenced 
by climate and the prevailing industries. Ileat and toil are important fac- 
tors in determining the ratio. In France, according to Malgaigne, one man 
in every thirteen, and one woman in every fifty-two, suffer from hernia. In 
the United States, one out of fifteen would not be too high an estimate. I 
have ascertained from Dr. Abel, one of the resident physicians of the Phila- 
delphia Almshouse, who, at my request, collected some materials relating to 
the subject of hernia, that there are annually in the male and female out- 
* For statistics, see Medical Statistics of the Provost-Marshal-General’s Bureau, War of the Rebel- 
lion, pp. 471, 476, et seq. HERNIA. 
553 
wards of the above institution twelve hundred people, and that of this 
number about ten per cent, suffer from different forms of this defect. 
Age.—In infants, congenital and acquired hernia) are very common during 
the first year of life,—estimated by Malgaigne at one case in every twenty-one 
children. It is during this period that children are harassed with intestinal 
irritations, causing fretting, crying, and straining,—all of which favor the 
production of the disease. If, however, we take into consideration the large 
number of children as compared with adolescent and adult individuals, the 
frequency of the disease in the former may not be greater than in the latter. 
From the first to the thirteenth year the disease steadily diminishes in fre- 
quency, after which it again increases to old age. In an analysis of 77,997 
cases of hernia by the London Truss Society, the largest number of cases 
(15,627) occurred between forty and fifty. In the 334,321 recruits who formed 
the subjects of the Reports of the Provost-Marshal-General,* the largest num- 
ber of cases was found in men over forty years of age, amounting to a ratio 
of ninety-one per thousand. 
Congenital defects of development.—Under this head may be enumerated 
muscular or tendinous deficiency at the lower part of the abdomen. It is 
from this cause that in exstrophy of the bladder it is common to have double 
hernia. There is also, in some instances, a transmitted weakness of the 
muscular and the aponeurotic structures in the neighborhood of the groin, 
in consequence of which several members of a family may suffer from 
intestinal protrusions. Again, the funicular process of the peritoneum may 
not close at the internal ring, thereby leaving the inguinal canal open, and 
inviting the descent of a hernia. 
An elongated state of the mesentery is alleged by Mr. Birkett to be another 
predisposing cause. This elongation, I am disposed to believe, is not ante- 
cedent to the hernial protrusion, but subsequent to it. 
Nativity.—In scrutinizing the nativity of 501,068 persons examined during 
the War of the Rebellion,f the ratio per one thousand among foreigners 
rejected for hernia is found to differ very greatly, while in those from the 
different parts of the United States the difference is very slight indeed. By 
glancing at the subjoined tablej these facts will be readily observed: 
Hernia. 
Number Ratio 
Nativity. examined re->ected 
examined. per 1000 
All nativities 501,068 44 
Portugal 81 123 
Spain 148 114 
Locality. ex“ r“d 
examined. per 1(J00_ 
All States 501,002 31 
Minnesota 6,489 54 
Vermont 7,224 43 
Hungary 89 89 
Iowa 6,846 41 
Germany 54,944 82 
Italy 339 76 
Illinois 18'l26 38 
Missouri 8,576 36 
Maryland 16,920 34 
Holland 989 65 
France 3,243 65 
Poland 171 64 
Denmark 333 62 
Sweden 1,190 55 
Wales 1,104 52 
Russia 122 49 
Norway 2,290 48 
United States (white) 315,620 39 
Michigan 12,179 33 
New York 95,576 32 
Maine 20,479 31 
Indiana 29,279 31 
District of Columbia 6,954 30 
Kentucky 16,028 29 
Pennsylvania 12,686 29 
New Hampshire 10,013 27 
Ohio 37,700 27 
England 16,196 39 
United States (colored) 25,828 38 
Ireland 50,537 36 
Scotland 3,476 34 
British America 21,645 31 
South America 79 25 
United States (Indians) 121 0 
Massachusetts 36,380 26 
Connecticut 11,017 26 
Delaware 6,361 26 
Rhode Island 4,072 24 
West Virginia 764 20 
* Medical Statistics of the Provost-Marshal-General’s Bureau, War of the Rebellion, 
f Ibid., Chart XIV. 
J Ibid., Chart XL. 554 
DISEASES OF THE ABDOMEN. 
In the above list of nativities the most remarkable feature is the frequency 
of hernia among the German recruits. Comparing the number of this 
people examined (54,944) with the Irish (50,537), the difference will be seen 
to be 46, the ratio being 82 for the former and 36 for the latter. The 
number of the two nationalities being so nearly equal, the comparison may 
be regarded as just. I can conceive of no explanation for the disparity, 
unless it be that the extensive use of beer among the German population 
causes fatty degeneration in the muscular walls of the abdomen, and thus 
predisposes them to hernial protrusions. 
Exciting Cause.—The exciting cause of hernia is muscular action, by 
which, in certain postures of the body, the viscera are forcibly thrust against 
the lower portion of the abdomen, which yields at those points naturally 
weakened by the passage of blood-vessels. 
Manner of Occurrence.—Sometimes when a person is making an extraor- 
dinary muscular effort, or when an accident occurs in which an individual 
is thrown forcibly from a vehicle, the protrusion may be the work of an in- 
stant ; but these are exceptional cases, the usual process being a gradual and 
slow one, requiring several months before the swelling has attained sufficient 
bulk or importance to attract attention particularly. 
Relative Frequency of the Different Forms of Hernia.—Inguinal her- 
nia is much the most common form of the disease. Of 411 cases of hernia 
collected by Dr. Abel from the records of the Philadelphia Hospital, 377 
were inguinal, seven of the number being double, or on each side. Next in 
order of frequency is femoral hernia; and last, umbilical. Taking a large 
number of cases of hernia as a basis for estimating the relative ratio of the 
different kinds, 75 per cent, will be found to be inguinal, 10 per cent, femoral, 
and 5 per cent, umbilical. Inguinal hernia is most common on the right side. 
The reason for this, I believe, is the greater liberty given to the intestines in 
that direction by the mesentery. This can be verified by observing on the 
cadaver the extent to which the intestines can be turned to the right. 
Of 334,321 recruits, substitutes, drafted and enrolled men of various 
nativities examined during the late American war, there were 17,296 rejected 
on account of hernia, a ratio of fifty per thousand.* The relative frequency 
of the different forms of hernia in those rejected was as follows: 
Hernia, not specified 
“ umbilical 
328 
(t 
8,598 
(( 
left “ “ 
5*420 
U 
1*166 
u 
right femoral 
(( 
left “ 
110 
(( 
34 
Total 
Symptoms.—There are certain signs common to all varieties of hernia, 
which may be enumerated as follows. 1. The presence of a swelling in cer- 
tain defined localities, known as hernial regions ; as in the region of the cord, 
the scrotum, the groin, or the umbilicus. 2. The swelling is usually painless, 
without unusual heat, and presents no discoloration. 3. The swelling is 
not fixed or permanent, but recedes and disappears entirely in the recumbent 
position,—or, at least, can be readily pressed back into the abdomen,—and re- 
appears when the erect position is assumed. 4. In the act of coughing, a dis- 
tinct impulse can be felt by the hand when placed over the tumor, and in 
the effort of straining or crying, a sudden enlargement will be observed in 
its size. 5. When the contents of the sac are entirely intestinal, the tumor 
will be elastic to the feel, resonant on percussion, and when returned will re- 
cede quickly in its entirety, and with a distinct gurgling sound or “flop.” 
When the contents of the sac are exclusively omental, there will be an absence 
* Medical Statistics of the Provost-Marshal-Geueral’s Bureau, War of the Rebellion, p. 80. HERNIA. 
555 
of resonance and of elasticity; there will be no sensible impulse communicated 
to the swelling either on straining or coughing; the tumor will have a doughy 
feel, and can only be restored, a small portion at a time, by taxis. When the 
intestines are distended by gaseous accumulations, no alteration of form occurs 
in the tumor. Omental hernia is most common on the left side. 6. When 
both intestine and omentum occupy the sac, the characteristic signs of each 
will be present, but so blended and modified that it will be difficult to determine 
with certainty by the touch the existence of both. 
It is remarkable how little even large and unreduced hernise interfere with 
the general health; and with many persons the only inducement to wear an 
instrument to retain the bowel in position is to get rid of the inconvenience 
of the bulky swelling. 
Treatment.—The treatment of hernia is divided into the palliative and the 
radical. The palliative method consists in restoring the hernial contents to 
the cavity of the abdomen, and retaining them there by a properly-fitting 
truss. This should be done at the earliest possible moment. No patient is 
safe so long as the rupture remains outside of the body. Children form no 
exception to this rule, though some think it is better to delay the application 
of an instrument to such subjects until they are several months old, when 
the skin will be better able to endure pressure. If the precautions hereafter 
mentioned be used, there is no necessity for such delay. 
Many varieties of trusses are in use, some of which are very badly adapted 
to fulfil the end in view. The parts of a truss are a steel band to surround 
about two-thirds of the pelvis, a pad to command the hernial rings, a strap 
containing numerous holes in order to secure the apparatus in place, and 
sometimes an additional strap, used as a perineal band, to prevent the truss 
from slipping up over the hips. 
The steel spring should be light and flexible, and covered either with leather 
or with hard rubber. The pad is formed of various substances, such as 
iron, wood, hard rubber, and sometimes stuffed leather. It should be plano- 
convex in form. It is connected with the spring by a flexible stem, or by 
screws passing through a slot in a piece of brass, by which its position can 
be changed according to the requirements of the case. Generally speaking, 
the hard pads are to be preferred both in point of comfort and efficiency. 
The Hood truss, as modified by Mr. Gemrig, of this city, and the hard rubber 
truss of Mr. Seeley, are among the most valuable forms of this instrument. 
The first, that of Mr. Gemrig’s pattern (Figs. 427 and 428), is suited to either 
Fig. 427. 
Fig. 428. 
Gemrig’s modification of the Hood truss, suited to 
both single and double inguinal hernia. 
The pad turned down so as to answer for a femoral 
hernia. 
a single or double inguinal or to a femoral hernia. If properly fitted, it main- 
tains its position with much certainty, and can be worn with great comfort 
by the patient. The same surgical cutler makes a very excellent truss for 
umbilical hernia, elastic bands being used instead of steel springs to keep the 
instrument in place. (Fig. 429.) 
The hard rubber truss (Fig 430) possesses in an eminent degree the prop- 
erties of durability, lightness, and cleanliness. It does not absorb the per- 
spiration from the body, and is not injured by moisture. Persons wearing 
this instrument can bathe without removing it from the body. Different 
forms of this truss are shown in Figs. 430, 431, and 432. 
There are certain hernise which require for their retention not only the 
compression of the entire canal, but, in addition, pressure concentrated at 556 
DISEASES OF THE ABDOMEN. 
the external ring. These two indications can be very satisfactorily fulfilled 
by the truss represented in Fig. 433, in which the pad consists of two parts, 
an exterior or larger one, fashioned like a ring, and an interior or smaller 
Fig. 430. 
Fig. 429. 
Truss for umbilical hernia. 
Hard rubber truss for inguinal hernia. 
one, which occupies the opening in the former. A spring, acting upon the 
central pad, graduates the degree of pressure required. Other forms of 
trusses are in use (Figs. 434 and 435), and in many cases supply the 
necessary protection. 
Fig. 432. 
Fig. 431. 
Hard rubber truss for inguinal hernia. 
Hard rubber truss for both reducible and irreducible 
umbilical hernia. 
The Application op a Truss.—The presence of either a physician or a 
surgical cutler is usually necessary for the proper adjustment of a truss. Even 
with a large number of instruments at 
hand, it is seldom that one can be ap- 
plied satisfactorily without some altera- 
tion being made. It should be adapted to 
the person of the patient so as to fit like 
a well-made garment. The strength of 
the truss should be sufficient to pre- 
vent a protrusion of the rupture, but 
not greater than will effect this end. I 
have seen the walls of the abdomen 
over the inguinal region seriously atro- 
phied and deep indentations made by the 
wearing of a very strong spring. Be- 
fore applying the instrument, the per- 
son should assume the supine posture, 
with the shoulders elevated and the 
limbs drawn up, so as to relax the parts 
and to allow the contents of the sac 
to be pressed back into the abdomen. The hips should then be raised and 
the truss carried around the pelvis in the position Avhich will be shown 
under the special forms of hernia. The strap being made fast, the patient 
Fig. 433. 
Hard rubber truss designed to make both general 
and concentrated pressure. A, ring with centre 
pad; B, centre pad projected from ring; C, ring 
alone. HERNIA. 
557 
may rise from the bed and assume the standing position. To be certain 
that the hernial passages are thoroughly secured, the patient may cough, 
bend forwards and backwards, stoop down with the limbs widely separated, 
and finally sit down with the limbs crossed. If these different tests be 
applied without the hernia escaping beneath the truss, the instrument may 
be accepted as a proper one. It is better not to wear a truss too long after 
its first application, as the skin is liable to excoriate, especially during warm 
weather; the instrument should be taken off in the course of five or six 
hours, and the removal must always be done in the supine position, never 
while on the feet. In order to harden the skin and render it tolerant of the 
Fig. 434. 
Fig. 435. 
Single French truss. 
Chase’s truss. 
pressure, the parts upon which the pads rest should be well bathed with 
alcohol containing a quantity of powdered alum, and then rubbed with the 
hand until they become red. Before rising, the truss must be again replaced. 
A little attention of this kind will, in the course of a few days, enable the 
person to wear the instrument without the least inconvenience: indeed, so 
callous does the integument become that many, after a short time, rarely 
remove the instrument night or day. If the hernia at any time slips out 
beneath the truss, the latter should be removed without a moment’s delay. 
The person ought to lie down at once, and, by gentle pressure in the proper 
direction, restore the protrusion to its normal cavity, and, after being assured 
of its complete reduction, again apply the truss. 
Kadical Cure or Hernia.—Many operations have been devised by sur- 
geons at various times for the radical cure of hernia. Some of these have en- 
joyed a greater popularity than others, but not one can be said to command 
any large share of professional confidence. All of the plans which have been 
advocated have one object in view, that of obliterating the hernial passages 
by inflammatory adhesion in the walls of the sac. The most important will 
be presented, as follows : 
The truss.—In infants, and in subjects under ten years of age, there can 
be little doubt that if a truss with a hard pad of wood, of ivory, or of rubber 
be worn continuously, day and night, the patient will be radically cured. In 
this class of persons the processes of development are in active operation, 
and if the sides of the sac be maintained in close apposition their consolida- 
tion will follow and the hernial passages be closed. Indeed, the tendency to 
recovery is so strong in children that the hernia sometimes undergoes a 
spontaneous cure. For this reason it is of the utmost importance that the 
truss be applied early, and be worn for two or three years continuously. 
After ten years of age, cures are much less likely to take place; and after 
adolescence they are not to be expected at all, under ordinary circumstances. 
I shall say nothing of the barbarous and repulsive methods of castration, 
the actual cautery, and excision of the hernial sac, which at one time, 
during the dark ages of the surgical art, were extensively practised, but shall 
present some of the more important operations which have from time to time 
been devised for the radical cure of the disease. These may be considered 
under three divisions: 1, invagination and circumclusion; 2, transplantation; 
3, local irritants conjoined with compression. 558 
D IS EASES OF THE ABDOMEN. 
Invagination.—The principle of invagination has been put into operation in 
various ways, and is, in common with the other methods, for the most part 
applicable only to cases of femoral hernia. 
Gerdy's method.—This surgeon, on the tip of his finger, thrust the integu- 
ment through the external abdominal ring into the canal, and up to the neck 
of the sac. Two double silk threads, half an inch apart, were next carried 
across the canal, from side to side, by means of a stout curved needle, the 
finger serving to protect the cord and the abdominal cavity behind, and by 
these threads the invaginated structures were brought into contact by tying 
their ends together over two cylinders of wood or a bougie, placed parallel 
with the canal, so as to form the quilled suture. After the removal of the 
finger, a camel’s-hair brush, loaded with spirit of ammonia, was carried up 
into the invaginated pouch of skin, and applied freely to its surface, the 
object being to remove the cuticle and to secure adhesion of the contiguous 
parts. The threads were usually removed about the eighth day. 
Signorini's method.—This plan differs from the preceding one in the follow- 
ing particulars: after invaginating the skin into the sac, a female catheter 
takes the place of the finger, and while the plug of tissue is in this way re- 
tained securely well up towards the internal ring, three long pins, a few lines 
apart, are passed across the canal, and the parts drawn tightly together by 
figure of-eight turns with an equal number of threads. 
Wutzer's method.—In 1838, Wutzer, of Bonn, planned a new method of 
occluding the inguinal canal by invagination. An instrument consisting of 
three parts, viz., a cylinder, a concave cover, and a long, curved, flexible needle, 
was employed for this purpose. Cylinders of different sizes, adapted to differ- 
ent ages, accompany the apparatus. The cylinder is from three-eighths to half 
an inch in diameter, about three inches long, smooth, and slightly flattened 
on one surface. It is rounded at one extremity, and at the other has two 
upright pieces of metal, one in the form of a round rod, and the other flat, 
with a slot. A canal runs through the centre of the cylinder, and opens 
upon its upper surface a short distance from the free or rounded end. This 
canal is designed for the passage of the curved needle. The cover is concave, 
and at one extremity is prolonged into a handle or process, having a hole for 
the passage of the rod connected with the cylinder, and shaped so as to fit the 
slot of the latter; near its other end is an opening for the passage of the needle. 
A small screw upon the rod serves to approximate the cover and the cylinder. 
The cut below (Fig. 436) will make this description of the instrument intel- 
Fig. 436. 
Wutzer’s instrument for the cure of hernia. 
ligible. In performing the operation, the patient should be placed in the 
recumbent position, and the hernia, if out, returned into the abdomen. The 
surgeon now, on the end of the index finger, pushes up a portion of the 
scrotal integument through the lower ring into the canal. After this, the HERNIA. 
559 
cylinder, without the cover, and with the needle withdrawn so that the point 
shall not appear, is conducted into the inguinal canal along the finger, and 
the latter withdrawn, after which, being assured, by the fixedness of the in- 
strument, that it is properly placed, the operator pushes forward the needle, 
causing it to emerge through the anterior parietes of the canal and appear 
upon the surface of the skin. The concave piece is now fitted to the rod and 
slot of the cylinder, the needle is conducted through the opening near its 
end, and, by means of the screw, the cover is run down, compressing with 
a moderate degree of firmness the structures interposed between the two 
parts of the instrument. The handle is now disengaged from the needle, 
and the point of the latter guarded with a small cork. The apparatus is al- 
lowed to remain seven or eight days, after which it must be removed ; though 
the patient should not be allowed to rise from his bed for twelve or fourteen 
days later, and even then will require a truss for some months, to protect the 
parts until the consolidation of the cicatricial tissue is complete. 
The author's operation.—This operation requires, first, an instrument in its 
appearance resembling a bivalve speculum, having two blades three inches 
in length, rounded at their extremities, and in one of which there are two 
longitudinal grooves. The handles are four inches long, are connected at 
an obtuse angle with the blades, and are controlled by a screw (Fig. 437). 
Fra. 437. 
Author’s instrument for the cure of hernia. 
Second, two needles, one long and slender (Fig. 438), the other short and 
strong, each curved at the extremity, at which there is an eye, and both 
mounted on wooden handles. The long needle should have a slight enlarge- 
ment upon the metal three inches from its extremity, in order to determine 
when its point has reached the end of the longitudinal groove in the blades 
of the speculum. 
The patient’s bowels should be thoroughly opened on the day previous to 
the operation, after which he should be confined to the horizontal position. 
The hair being shaved from the pubis and the patient etherized, an incision 
is made over the scrotum through the skin, commencing at the external 
Fig. 438. 
Author’s needle. 
abdominal ring and terminating two inches below that point. The delicate 
integument is next carefully dissected away from the subjacent parts for 
some distance on either side. This accomplished, the exposed fascial and 
dartos structures are next lifted on the index finger and pushed through 
the external ring up to the summit of the canal. The speculum, closed, is 
now introduced along the finger, and when the operator is certain that it 
is properly placed, a fact which is determined by its immobility, the finger 
must be withdrawn. The blades of the instrument being next separated by 
running down the screw connected with the handles, the long needle, bearing 
a silver thread, is introduced into one of the longitudinal grooves and carried 
up to the end of the blade, when, its handle being depressed, the point is 
made to appear upon the surface of the body over the summit of the inguinal 560 
DISEASES OF THE ABDOMEN. 
canal. The thread is now disengaged from the eye of the needle, when the 
latter is withdrawn, and, receiving the other end of the wire, is inserted into 
the other groove and carried, as in the first instance, to its extremity and 
forward through the superincumbent tissues, emerging upon the surface 
three-eighths of an inch from the first. The needle being removed and the 
two ends of the metallic thread drawn up, the invaginated structures will 
be securely maiqtained at the internal ring. In order to bring together the 
sides of the inguinal passage, to crowd together the parts which it contains, 
and to excite sufficient inflammation to glue them together, three transverse 
silk or wire sutures are next pushed across the canal between the separated 
blades of the speculum, by means of the shorter needle, and their ends tied 
together over a cylinder of lint placed upon the abdomen. The speculum 
being now removed and the wound in the integument of the scrotum closed, 
a compress of lint should be laid over the parts and the dressing retained in 
place by a spica bandage. To avoid all efforts at straining, the bowels should 
be kept closed for seven or eight days by opium, and the urine, if not easily 
passed on the side, must be removed by the catheter. The stitches should 
be taken away on the eighth day; but the patient must not be allowed to 
resume the erect position for ten days longer. 
Wood's operation.—There are two operations known by this name. One 
is by an American surgeon, Dr. T. Wood, of Cincinnati, and the other by 
an English surgeon, Prof. John Wood, of London. Both combine the prin- 
ciple of invagination with the approximation and union of the tendinous 
structures about the hernial passages. As the last has attracted considerable 
attention in England, it will be proper to describe it in this connection. The 
operation is a complex one, and somewhat difficult to understand. 
The parts being shaved and the hernia reduced, an assistant makes press- 
ure over the internal ring, to prevent any protrusion during the operation. 
The surgeon, beginning about two inches below the external ring, with a 
tenotome opens the skin of the scrotum for nearly an inch, and, insinuating 
the knife flatwise between the scrotal fascia and skin, separates the two for 
some distance on every side. The finger now lifts the raw surface which 
has been exposed and carries it into the inguinal canal, the parts being 
thoroughly relaxed by flexing the limbs, thus favoring this step of the 
operation. With the point of the finger the margin of the conjoined tendon 
must be next recognized, when a strong, curved, blunt-pointed needle, 
mounted on a wooden handle, is guided along the invaginating finger beneath 
this aponeurosis and made to penetrate it from behind forwards. The skin 
is next drawn strongly upwards and inwards, and the needle pushed through 
sufficiently far to expose its eye, into which a silvered copper wire is hooked 
and brought out of the external wound as the needle is withdrawn. The 
wire is next disengaged from the needle and the latter conducted along 
the border of the finger and pushed through the aponeurosis of the external 
oblique muscle, close to its connection with Poupart’s ligament, and opposite 
to the internal abdominal ring. The skin is now pressed inwards until the 
point of the needle is made to appear at the first puncture, when the upper 
extremity of the wire is hooked to the needle and conducted by the latter 
into the scrotal wound. The next stage of the operation consists in sepa- 
rating the cord from the hernial sac, which is accomplished by raising a 
fold of the latter at the upper angle of the scrotal opening and sliding the 
former back, very much after the manner of separating the vas deferens 
from the other constituents of the cord in the operation for varicocele. This 
effected, the needle is entered at the external wound, carried up along one 
side of the canal, passed across between the cord and the sac to the oppo- 
site side, and then brought out near the point where it entered, where it 
is again connected with one end of the wire, and, being withdrawn, con- 
ducts the copper thread along the same circuitous route and out of the open- 
ing in the scrotum. The two ends of the wire are now carefully straightened 
and drawn up until the loops appear at the skin, when they should be twisted HERNIA. 
561 
together and secured over a cylinder of boxwood, a process which draws into 
apposition, in a spiral manner, the structures at the external abdominal ring. 
The whole operation is to be done antiseptically. This ingenious subcutane- 
ous loop not only secures the invagination of the scrotal tissues, but also 
approximates the boundaries of the inguinal canal, both transversely and 
antero-posteriorly. (Fig. 439.) The patient is confined rigidly to bed, and 
Fig. 439. 
Inguinal canal exposed in order to show the course of the wire. 
on the eighth or ninth day the wire is untwisted, though it is not removed 
until about the fourteenth day. 
Mr. Wood has been able to follow ninety-six cases out of three hundred 
and thirty-nine operated on by his method for a period beyond two years,— 
one of these was seen twenty-five years and one ten years after,—and all 
without any return of the hernia. In one hundred and fifty-two other cases, 
examined at different periods between the operation and two years after- 
wards, there had been no recurrence of the rupture. The operator makes 
the successful cases of the three hundred and thirty-nine patients amount 
to over seventy-three per cent. 
Dowell's method.—Dr. Dowell, of Texas, has devised a plan which con- 
sists in circumclusion of the boundaries of the inguinal canal. The prelim- 
inary measures of shaving the pubes and scrotum and opening the bowels, 
as in the operations already de- 
tailed, having been observed, the 
patient is placed in the recumbent 
position, with the shoulders ele- 
vated and the limbs flexed. The 
surgeon, after satisfying himself 
that the hernia has been entirely 
reduced, carries the index finger 
through the external ring and up 
into the inguinal canal, pushing 
before it the superimposed struc- 
tures. He next takes a semi- 
circular needle, sharp at either 
extremity, three inches long, with an eye near each point (Fig. 440), and 
armed with a strong silken thread. This needle is entered one inch and a half' 
above the external ring, is carrried across the inguinal canal, following the 
Fig. 440. 
Dowell’s needle for the cure of hernia. 562 
DISEASES OF THE ABDOMEN. 
posterior edge of the tip of the finger, and is brought out through the skin on 
the opposite side, near to Poupart’s ligament. This stitch passes through 
the integument, the aponeurosis of the external oblique, and the hernial 
sac near the posterior wall of the canal. Without entirely withdrawing the 
needle, as soon as the point becomes disengaged from the tendon it should 
be pushed back over the front of the finger, and made to emerge through the 
first puncture, or opening of entrance, near to Poupart’s ligament. Both ends 
of the thread now lie together in the primary puncture, and the loop com- 
pletely encircles the inguinal canal. The next step is to remove the silk thread 
and replace it with a silver one. To effect this, it is only necessary to double 
the wire upon itself, and tie one end of the silk cord to the centre of the loop, 
when, by pulling-upon the other extremity, the metallic thread is drawn in 
as the other is drawn out. This process is repeated two or three times, and 
each wire firmly drawn and twisted over a cylinder of lint placed upon the 
surface of the abdomen. Over these sutures is applied a little strip of gauze 
and collodion. The patient is to be rigidly confined to bed, the bowels kept 
quiet, and the diet restricted. After eight days the stitches are to be taken 
out, and in ten or twelve days more the patient may be allowed to rise and 
walk about.* 
The operations just enumerated constitute the most important of those 
which have been planned on the principle of circumclusion. The practical 
question which arises from the consideration of the various plans for the 
radical cure of hernia is that of their true merit or claim to professional con- 
fidence. It is very difficult to determine the relative value of the different 
methods, as only in a few of the so-called successful cases have the patients 
been kept sufficiently long under observation to ascertain the permanence of 
the cure. 
Of the sixty-two cases treated by Gerdv, four are known to have died, and 
as we have no means of discovering how many, if any, were radically cured, 
the fatality following the method is a sufficient reason for its condemnation. 
In regard to the operation of Wutzer, a countryman of this distinguished 
surgeon, Dr. Weber, who appears to have been cognizant of the result in 
fourteen persons operated on by Professor Wutzer, says that not a single 
case was cured; and such was my own experience in the few cases in which 
I employed this method. With reference to my own operation, the success 
obtained has not been sufficiently uniform to justify me in speaking of it in 
any other way than with distrust. Nor does the complex and ingenious 
method of Professor Wood, of London, command professional confidence; 
for, although the first reports of this surgeon’s operations were most flatter- 
ing, as will be seen by reference to the preceding page, yet a later report 
furnishes only 119 cures in 310 operations. The results of the same opera- 
tion in the hands of American surgeons have been most disappointing. 
Dr. Dowell, up to September 12, 1876, reports 96 operations for the cure of 
hernia by his method, with 80 cures and 16 failures. 
This latter operation has been practised on several patients in the Uni- 
versity Hospital, by Dr. Hunter, apparently with success at the time, but 
finally terminating in failure. 
The latest methods are those of retroclusion, or the operations of Barker 
and Macewen. 
Barker's method consists in laying open the canal, dividing the sac, and, after 
reducing its contents, separating with care the sac from the spermatic cord. 
When this has been accomplished, a double carbolized thread is passed, by 
means of an aneurismal needle, beneath the sac. One thread being pulled 
upwards is now tied tightly around the neck of the sac near to the internal 
ring, and the other thread being drawn downwards is tied with equal firm- 
ness near to the external ring, and the intermediate portion of the sac may 
or may not be cut away. The long ends of the upper thread are next carried 
up the canal and passed, means of needles having long handles, inside of 
* Dowell on Hernia, Philadelphia, 1876, p. 67. HERNIA. 
563 
the internal ring and through the abdominal wall, separated from each other 
about half an inch. The ends are then drawn up and tied, thus dragging the 
upper portion of the sac into the abdomen and blockading the internal ring. 
Sutures are now passed across the canal at different points in front of the 
cord. These, in addition to the conjoined tendon, should include the upper 
part of the two pillars of the external abdominal ring. After all the sutures 
are in position, they should be knotted, beginning above and going down to- 
wards the pubes. It only remains to introduce a drainage-tube in the lower 
angle of the wound and to suture the integument, after which the usual anti- 
septic dressing should be applied. A light-pressing truss or a spica bandage of 
the groin should be worn for a few weeks after the patient gets out of bed. 
Maceweri’s method.—An incision is made over the external ring three inches 
in length, and the dissection continued until the sac is exposed and detached 
in its entirety from the surrounding parts. The sac must now be drawn well 
down and its neck separated from the spermatic cord by the finger passed 
up the inguinal canal to the internal ring. After being thus detached from 
all its connections, a catgut thread is fastened to the lower end of the sac, 
and then passed backward and forward, at short distances apart, until the 
external ring is reached, when the end of the thread, after being introduced 
through the eye of a long curved needle, is passed up the canal and out 
through the abdominal wall some distance above the internal ring. By draw- 
ing strongly on the thread the sac is pulled up in a series of short loops (Fig. 
441) into the internal ring, where it is made secure by knotting the thread. 
Fig. 441. 
Fro. 442. 
Sac dissected free from the cord, 1; 
threads passed through the sac, 3, 2. 3, 
and out through the aponeurosis at 3. 
Sac drawn into the internal ring 1, and 
fixed by cross-sutures 2, 2; 3, middle su- 
tures including the conjoined tendon; 
lower suture 2, 2, through the pillars of 
the external ring. 
A series of sutures are now passed across the canal in front of the spermatic 
cord, beginning below and passing upwards, the first one or two lying in front 
of the conjoined tendon and uniting together the pillars of the external ring, 
the succeeding two including the conjoined tendon, and the last one passing 
through the sac at the internal ring. (Fig. 442.) The sutures are not to be 
tied until they are in place, after which they may be knotted. By these 
stitches the conjoined tendon is drawn across the floor of the canal towards 
Poupart’s ligament, thus fortifying the parts against a hernial protrusion. 
The wound in the soft parts is then closed and dressed antiseptically. This 564 
DISEASES OF THE ABDOMEN. 
operation has been done a number of times in our Philadelphia hospitals, and 
with promising success. 
Radical cure of femoral hernia.—An incision is made over the saphenous 
opening and the sac exposed. After replacing its contents the sac is to be 
detached from the surrounding parts and divided, after being surrounded 
and tied with a strong carbolized thread. The stump is next pushed up into 
the internal crural ring, and the posterior part of the femoral sheath sutured 
to the pectineal portion of the fascia lata a short distance below Poupart’s 
ligament. Without removing the thread from the needle, the latter is turned 
upwards under the crural arch, and made to cross the arch and to pierce the 
inferior border of Poupart’s ligament. Two or three additional sutures taking 
the same route, and placed a short distance apart, are to succeed the first, 
after which the threads are to be tightened and secured, thus closing the 
crural ring. Care must be taken not to injure the femoral vein during the 
passage of the sutures. A few threads of catgut should now be placed in 
the lower angle of the wound, and the latter closed and dressed antisepti- 
cally. 
Radical cure of umbilical hernia.—Two incisions are made, one on each 
side of the hernial tumor, commencing a short distance above, and termi- 
nating below, thus enclosing the hernia within an ellipse. These incisions 
at first should scarcely penetrate the skin, but afterwards are to be deepened 
by a careful dissection until the neck of the sac is reached and opened. The 
hernial contents should then be returned into the abdomen, if reducible; if 
not, the adhesions must be broken up and reduction effected. A flat sponge 
secured by a cord is now pressed through the opening into the abdomen, and 
kept in contact with the inner surface of the parietes, while the surgeon 
passes the requisite number of sutures through the edges of the ring and 
the neck of the sac. Before knotting the last two threads the sponge must 
be drawn out. It may happen that, where the contents of the sac cannot be 
released and returned without breaking down adhesions, the omentum will be 
found so changed in structure as to render it unsafe to replace it. In such 
an event the mass should be transfixed on a level with the abdominal wall, 
with a double ligature, and. after each half is securely tied, cut away, and 
the stump dropped into the abdomen. The sutures are now to be introduced 
as in the first instance. The next step is to separate, by dissection, the sac 
from the skin for three-quarters of an inch above the row of sutures which 
have been tied, and then to cut away the sac with its contents. It only 
remains to unite the sides of the sac projecting above the first series of 
sutures by a second row, including the sheaths of the recti muscles. In 
closing the wound of the skin it is well to provide for drainage by a rubber 
tube. The external dressing should be the usual antiseptic one. 
Transplantation.—The plan of blockading the hernial passages by the 
transplantation of tissue was first proposed by Dzondi. Dr. Jamieson, a 
surgeon of Baltimore, Maryland, treated successfully in this way a case 
of crural hernia. The patient was a female on whom the doctor had 
previously operated for strangulation. The bowel subsequently descend- 
ing, at the request of the lady he undertook the radical cure, which con- 
sisted in laying open the parts, dissecting up a flap from the adjoining 
integument, turning the flap into the crural ring, and closing the soft 
parts over the fleshy mass by a number of interrupted sutures. This case 
I believe to be a solitary illustration, in this country, of the plan by trans- 
plantation. 
Local irritation conjoined with compression.—The attempt to obstruct the 
inguinal canal by inflammatory adhesion of its contents to the surrounding 
walls has been made in different ways by exciting the necessary irritation in 
the sac. Belmas introduced pieces of goldbeater’s skin and bits of gelatin; 
Professor Joseph Pancoast injected, by means of a fine trocar and canula, the 
tincture of iodine ; Velpeau, with the same object in view, used scarification; 
and still more recently Professor Armsby and Dr. Eiggs have employed the IRREDUCIBLE HERNIA. 
565 
seton. By all these surgeons the application of a truss was made a necessary 
part of the after-treatment. 
Other plans for the radical cure of hernia have been devised, at various 
times, both in this country and abroad, but for the most part have long since 
passed into disuse. 
Professor Gross advocates laying open the parts, and, after freshening the 
edges of the inguinal canal, uniting its sides by silver sutures. 
After a careful review of the various operations proposed and practised 
for the radical cure of hernia, not one can be said to be altogether satisfactory: 
that of Macewen, in my judgment, promises to be the most successful, and, 
when executed under antiseptic methods, is attended with little danger to life. 
In all cases where herniotomy is done for the relief of strangulation, the radical 
cure should be attempted ; but I doubt very much the propriety of such oper- 
ations being made in hernise that give the individuals no inconvenience and 
are easily retained by a properly-fitting truss, and especially so in cases of 
umbilical hernia. 
Irreducible Hernia. 
A hernia may be either temporarily or permanently irreducible. The first 
form is frequently designated as incarcerated hernia. 
Causes.—Among the causes which render a hernia for a limited time irre- 
ducible are the following: an accumulation of gas, a collection of fsecal or 
other matter in the iniestines, and an increase in the volume of the tumor 
by an unusual extent of protruded intestine or omentum. 
Symptoms.—A person who is in the habit of wearing a truss neglects, in a 
moment of thoughtlessness, to put it on, or it may be that in consequence of 
some unusual effort the hernia slips out beneath the pad and is unduly com- 
pressed. In a short time, especially if the person has previously indulged in 
flatulent articles of food, he is seized with colicky pains, begins to eructate 
air, and suffers from nausea, which may end in vomiting. The hernial tumor 
becomes distended and often painful, and when percussed it may be found 
unusually resonant or flat, according as its contents are gaseous or solid. 
Treatment.—Cases of this kind are frequently very injudiciously managed. 
Such a tumor is often attacked by a rude and protracted taxis, and is con- 
verted into one of acute strangulation by the induced congestion and even 
inflammation of the sac and its contents. The patient should be placed in 
bed, with the shoulders raised and the limbs drawn up, in order to relax the 
abdominal walls, and the scrotum should be elevated, with a view to relieve 
the dragging sensation so often felt. As the patient is often greatly alarmed 
in these cases of obstruction, the surgeon should quiet his fears and remove 
all unnecessary anxiety by the assurance that relief will be speedily ob- 
tained. When convenient, the patient may be placed in a hot bath, and a 
large enema of flaxseed-tea and turpentine or of salt water thrown into the 
bowel immediately after he comes out of the water. The warm bath tends 
to relax the parts about the region of the hernia, and the stimulating enema 
favors intestinal peristalsis, by which the obstruction causing the stricture 
may be moved from the protruded bowel. After the action of the injection, 
a very gentle use of taxis should be made, in the manner to be presently 
described, preliminary to which it is best to administer an anaesthetic, in 
order to insure complete muscular relaxation. Should these measures fail 
and the tenderness of the parts increase, ice may be applied to the tumor, 
and a cathartic administered. The sulphate of magnesia, given in drachm 
doses every hour, or a wineglassful of the citrate of magnesia, given every 
half-hour, is most likely to be retained by the stomach, and will in the course 
of six or eight hours produce, in some instances, free alvine discharges and 
the spontaneous recession of the hernia. In cases of this form of irreducible 
hernia unattended by a sick stomach, I much prefer castor oil to all other 
cathartics. It appears to excite a more energetic peristalsis than other mem- 
bers of its class, and in several instances of obstructed hernia I have by this 566 
DISEASES OF THE ABDOMEN. 
article succeeded in effecting relief when other measures had failed. When 
the hernial protrusion is very sensitive and painful, and resists the usual meas- 
ures for reduction, blood should be taken by leeches applied over the course 
of the cord, followed by the application of an ice-bag and the internal exhi- 
bition of opium with the extract of belladonna. One-third of a grain of the 
former with one-eighth of a grain of the latter may be given every two 
hours, lengthening the intervals of administration as soon as the narcotic 
effect of the prescription is produced. During this treatment the occasional 
use of enematawill prove serviceable. If under these agencies the sensibility, 
pain, and tension of the hernia abate, the taxis should be again cautiously 
attempted, or, what answers equally well, an elastic purse may be slipped 
over the tumor, the gentle but steady compression of which tends to dislodge 
the obstructing cause. When the obstacle to reduction appears to be a large 
accumulation of gas, a fine aspirating or hypodermic needle may be thrust 
into the tumor and the air drawn away. After exhausting the resources 
already detailed, and when the case culminates in strangulation, the knife 
becomes the last and only measure for relief. 
Permanently irreducible hernia.—By such a hernia is meant one which can- 
not be restored into the cavity of the abdomen. The causes which produce 
such a result are numerous. Some of these affect the sac. others its contents, 
and others again the openings through which the hernia passes. 
The changes which take place in the sac and render a hernia irreducible 
are the following. 1. The neck of the sac, when it is surrounded by the in- 
ternal ring, has a plicated or puckered appearance. As long as these plaits 
do not adhere to one another, the neck is susceptible of expansion by 
the unfolding of these duplicatures. If, however, they become united by 
inflammatory changes, the orifice remains rigidly contracted and unyielding, 
and offers a permanent resistance to restoration. 2. The sac sometimes un- 
dergoes material alterations in form. It may become constricted at certain 
portions of its body, forming compartments with very narrow communi- 
cations, in which its contents are permanently detained. The protruded 
structure in such cases is generally omentum. 3. The sac may become so 
enormously enlarged,' and accommodate so considerable a portion of the 
intestine and omentum, that the consequent elongation of the mesentery and 
the contraction of the abdominal cavity will serve to defeat all attempts to 
restore the displaced viscera. 4. The contents of the sac may become ad- 
herent to each other or to the sac itself, in consequence of intercurrent 
inflammation attended with the transudation of plastic lymph, rendering 
their return into the abdomen impossible. 5. The transversalis fascia or its 
infundibuliform process may become extensively thickened by inflammatory 
deposits, and so adherent to the surrounding parts as to form an insuperable 
obstacle to the return of the hernia. 
Irreducible ruptures, when neglected, are prone to increase in size, and when 
they become very voluminous the contents undergo material changes. In 
some instances these changes so completely obliterate the thin, supple, smooth, 
and moist condition of the omentum, converting it by interstitial deposits 
into a thick, stiff, irregular, and dry mass, that reduction is not only prevented 
but the membrane is even rendered unfit for a residence either in the scrotum 
or in the abdomen, and it has been known to cause an inflammation of the sac 
which has stealthily crept upwards and finally caused a general peritonitis. 
Irreducible hernise, especially when large, tend to develop symptoms of 
indigestion, in consequence of the hinderance offered to the circulation, to the 
peristalsis, and to the intestinal secretions. The consequence is, that patients 
suffering from such ruptures are often harassed by flatulent pains, eructa- 
tions, and constipation. Many complain of a constant dragging sensation 
along the course of the cord, attended with uneasiness and weakness in the 
lumbar region. These symptoms arise from the stretching of the cord and 
from the irritation reflected along the ilio-lumbar nerve. 
Treatment.—The chief indications in the management of an irreducible STRANGULATED HERNIA. 
567 
hernia are to prevent strangulation, to protect the parts against injury, and to 
prevent a further increase in the size of the tumor. The patient should be 
exceedingly careful in regard to diet, avoiding especially all flatulent articles 
of food, such as onions, beans, boiled cabbage, sweet potatoes, or any article 
which is likely to cause an accumulation of wind in the intestines. The bowels 
must also be regulated by the use of oatmeal porridge, corn-meal, wheaten 
grits, stewed fruit, etc.; and should these not prove sufficient to secure a 
daily evacuation, a little rhubarb-root or a few senna-leaves taken at bedtime 
will have the desired effect. To prevent the increase of the rupture, and to 
shield it from injury, the use of a truss or a suspensory bag is all-important. 
When the hernia has not passed out of the inguinal canal, or when it belongs 
to the femoral or umbilical varieties, the pad of the truss should be made 
concave, so as accurately to receive into its depression the rupture and at 
the same time to make a slight degree of pressure upon its surface, in order 
to prevent a further protrusion. Should this cavity in the pad prove too 
large, it can be filled up somewhat with a layer of cotton. When the hernia 
has reached the scrotum, the proper apparatus will be a suspensory bandage, 
which should be drawn up firmly to impart the proper degree of support. 
Attempts are sometimes made to convert an irreducible into a reducible 
hernia. Where there is reason to believe that the obstacle to reduction is of 
recent origin, as the formation of an inflammatory adhesion, either from vio- 
lence or from neglect to wear a truss, it will be proper to make an effort at 
restoration. With this end in view, the patient must be confined to bed, 
with the shoulders elevated and the limbs drawn up. Pressure over the 
tumor, to an extent not incompatible with the comfort of the person, should 
be made by a bag containing shot,—a kind of compress which adjusts itself 
neatly to the form of the surface upon which it is placed. The diet should 
be restricted, absorbents, like the iodide of potash and the bichloride of mer- 
cury, administered, and once in six or eight days an active purge given, 
both with a view to aid in the absorption of the incarcerating bands of lymph 
which detain the contents of the sac in their unnatural location and to detach 
and separate the same by exciting active peristaltic movements in the pro- 
truded bowel. If such a course be maintained for three or four weeks, the 
surgeon will occasionally have the satisfaction of finding the hernia restored 
to the abdomen. Except, however, where the irreducibility depends upon a 
cause like the one above mentioned, the probabilities of restoration, in the 
form of hernia under consideration, are so slight that it will be useless to 
subject the patient to any such course of treatment. 
Strangulated Hernia. 
Strangulated hernia is that condition in which the contents of the sac are 
so constricted or girt about that there follow pain, obstruction, vomiting, 
irreducibility, and absence of expansive impulse. Some idea of the relative 
frequency of strangulation in the different varieties of hernia may be formed 
from a collection made by Hancock* of 529 cases, of which number 250 were 
femoral, 250 inguinal, 16 umbilical, 8 congenital, and 5 ventral. 
Strangulation is in most instances a sudden event. A person in a moment 
of forgetfulness, or it may be of carelessness, leaves off his or her truss. An 
attack of coughing, straining at stool, or a long walk forces an additional coil 
of intestine or fold of omentum into the sac and causes at once the character- 
istic symptoms of serious constriction. The same result may arise from a 
disturbed peristalsis, from distention of the intestine by gas, or from its im- 
paction by faecal and other accumulations. In a case of strangulated hernia 
in the person of a negro operated on by Dr. Mastin, of Mobile, the intestine 
was filled with a large number of the small bones of a pig’s feet which had 
been swallowed along with the flesh. There may be also such an entangle- 
ment of, or inflammatory change in, the contents of the sac as to cause stran- 
* Hancock on Strangulated Hernia. 568 
DISEASES OF THE ABDOMEN. 
gulation. From whatever cause the latter may arise, the danger is momenta- 
rily increased by the impediment offered to the circulation in the walls of the 
intestine or in the omentum, in consequence of which they become swollen, 
congested, and of a dark or purple hue. 
In this state, the contents of the sac are exposed to death in one of two 
ways,—either from being entirely deprived of blood or from an inflamma- 
tion which will terminate in mortification. In the first condition the loss 
of vitality may follow in a few hours, and answers to what is termed acute 
strangulation; in the second the progress of the disease is slower, and may 
extend over many days, constituting chronic strangulation. A recent hernia 
is less liable to this accident than an old rupture. In the former, however, 
when stricture does take place, the danger to the intestine is very great. 
Large hernias are less liable to become strangulated than small ones, and 
when this condition does occur the symptoms are not so urgent as in the 
latter. The effect of a stricture upon two or three loops of intestine is less 
obstructive to the circulation than when it includes only a single coil of the 
bowel. In the first case the surface embraced is irregular, allowing some 
channels to remain open for the passage of blood, whereas the reverse is true 
in the second. The addition of the omentum to the contents of the sac will, 
for the same reason, diminish the risk of rapid mortification. Mr. Bryant 
has shown, in a paper based on the statistics of Guy’s Hospital, that the 
average duration of inguinal hernia before becoming strangulated is twenty 
years, and that when a recent rupture of this variety becomes strictured it is 
usually of the congenital kind. The same paper makes the average duration 
before strangulation, in femoral hernia, eleven years, and in umbilical rupture 
constriction is much less frequent than in either of the other forms. 
Seat of stricture.—The seat of stricture may exist at the rings, and at the 
neck of the sac, or the constriction may be caused by adhesions or entangle- 
ments between the contents of the latter. When situated at one of the rings, 
the strangulation is not caused by the contraction of the ring upon the neck 
of the sac,—since, consisting of fascial or tendinous material, it does not 
possess the property of contractility,—but by the great 
disproportion between the bulk of the rupture and the 
opening through which it passes; in other words, this 
ring does not contract upon the hernia, but the hernia 
presses against the ring. In the inguinal variety the in- 
ternal ring and the neck of the sac usually form together 
the seat of constriction. The neck of the sac, being pli- 
cated or thrown into duplicatures by passing through 
the ring (Fig. 443), cannot become unfolded unless the 
latter will yield; or it may happen that the contiguous 
surfaces of the plications of the sac have become adherent through inflam- 
matory lymph, and, in this way being rendered incapable of expansion, cause 
stricture of the hernial contents. 
In femoral hernia, the rupture is subjected to the resistance of the strong 
membranous aponeuroses, Hey’s and Gimbernat’s ligaments, in addition to 
that of the neck of the sac. 
Effects of strangulation on the contents of the sac.—These effects differ accord- 
ing to the tightness of the stricture. A few hours, in some instances, may 
suffice to destroy the vitality of the extruded parts, while in others the 
strangulation may continue for five or six days without hopelessly impairing 
the integrity of the imprisoned structures. Whether the case be acute or 
chronic in its nature, the first effect is to obstruct the circulation, causing 
congestion in the contents of the sac, in consequence of which the intestine 
becomes of a claret color, gradually deepening into a livid or a purple hue. 
The effect of this congestion is to produce points of ecchymosis and also 
serous transudation into the structure of the bowel. The omentum, when 
it forms a constituent of the strictured hernia, will exhibit the same condi- 
tion of engorgement, though not to the same degree. Its veins will be dis- 
Fig 443. 
Plicated arrangement of 
the neck of the sac. STRANGULATED HERNIA. 
569 
tended, but its color will not be so dark as that of the intestine under similar 
circumstances. 
Not only does the transudation of serum interpenetrate the coats of the 
intestine, but a considerable amount is poured out into the sac. Should the 
strangulation not be relieved, the parts pass into a state of intense inflam- 
mation, lymph is effused into the structure of the bowel, destroying its plia- 
bility and softness, and in some degree also its smooth, moist, and glistening 
appearance, and rendering its surface rough. Sometimes the hernial con- 
tents will be found adherent to one another, and to the inside of the sac. 
If the progress of the inflammation continue unchecked, mortification sets 
in, sometimes including the entire loop of intestine, at other times affect- 
ing only spots at different parts of its surface. This change is indicated by 
the appearance of ash-colored and also black sloughs which give way readily 
under moderate pressure, by the presence of bloody serum in the sac, and 
often by an offensive odor, the result of commencing decomposition. The 
omentum, when it participates in the constriction, may perish in part or in 
mass, preliminary to which it often changes from a red to a green hue, and 
finally to a deep-black color. The surgeon should not too hastily conclude 
that an intestine is hopelessly disorganized because its surface is ecchymosed, 
its color very dark, and the sac filled with a blood-stained serum. All these 
changes may take place and still the bowel may recover if relieved of the con- 
striction. During the process of inflammation and mortification the parts of 
the neck of the sac become closely adherent to the surrounding tissues, thus 
forming a barrier against faecal and other extravasation into the peritoneal 
cavity during the separation of the extruded parts. It is remarkable how 
long the process of destruction may continue without the inflammation ex- 
tending to the serous lining of the abdomen. Many persons perish without 
any peritonitis whatever, though generally a low form of the disease is de- 
veloped, which, like that from ordinary causes, is followed by the agglutina- 
tion of the coils of intestine to one another, and the presence of a dirty serum 
and masses of unhealthy lymph within the cavity of the abdomen. The 
mortification of the contents of the sac, and of the sac itself, is the signal for 
inflammatory changes in the superincumbent structures; the skin becomes 
red, tender, and swollen, and at last assumes a green color; the parts crackle 
beneath the fingers from the elimination of gases, become infiltrated with a 
bloody, fetid pus, and rapidly pass into ulceration, in consequence of which 
an artificial anus is established. 
Symptoms.—The signs of strangulation may come on gradually, or they 
may appear suddenly in a few minutes. The tumor becomes distended, reso- 
nant, tense, tender, and painful to the touch ; the hernia, if reducible before, 
cannot now be returned; pain is experienced in the abdomen, generally re- 
ferred to the region of the umbilicus; a sense of constriction around the body 
is often complained of; the characteristic impulse in the rupture is lost, and 
the patient frequently lies with the limbs drawn up, in order to relax the 
muscular parietes of the belly. When the tumor consists chiefly or exclu- 
sively of omentum, the bulk of the swelling is not materially changed by 
the strangulation, and instead of the enlargement being tense, elastic, and 
resonant it is soft and yielding, and gives a flat sound on percussion. 
In a short time symptoms of a more general nature arise. A conscious- 
ness on the part of the patient of what has occurred is followed by mental 
agitation, alarm, and great restlessness. Evacuations may be secured by 
enemata, but they come from that part of the intestine below the strict- 
ure, the latter forming an impassable barrier to the contents of the bowel 
above and causing constipation. The obstruction is soon followed by nausea 
and vomiting. The matters first thrown up are the articles of food which 
have been recently taken into the stomach, followed by ropy mucus and 
bile, and finally by the feculent contents of the intestine,—the so-called 
stercoraceous vomiting. If the case be allowed to advance without inter- 
ference, the changes consequent on inflammation of the protruded structures 570 
DISEASES OF THE ABDOMEN. 
give rise to symptoms of a still more alarming condition. The abdomen be- 
comes tympanitic and tender; the patient lies with the shoulders elevated 
and the limbs drawn up ; the circulation is quickened, the pulse being feeble 
and frequent; the tongue becomes dry and brown, the countenance pinched 
and anxious ; the eyes lose their lustre ; and when, at last, mortification begins, 
the pain suddenly leaves the tumor, a cold sweat breaks out over the sur- 
face of the body, followed by hiccough, an intermittent pulse, quiet, mut- 
tering delirium, and extreme prostration, the scene being soon closed by 
death. The event usually takes place, unless prevented by the formation 
of an artificial anus, in five or six days. Death, however, is not always the 
result of mortification. Many persons die from shock, and many from peri- 
tonitis, without the vitality of the imprisoned contents of the sac being 
seriously impaired. 
Diagnosis.—Generally there is little difficulty in recognizing the existence 
of a strangulated hernia. The presence of a tumor in one of the usual her- 
nial regions, possessing a certain amount of tenderness, without impulse, and 
the obstinate retching, vomiting, and constipation which usually accompany 
it, form a collection of symptoms which rarely lead the practitioner astray. 
Yet cases will occur in which the diagnosis cannot be established without the 
most critical investigation. Thus, in concealed inguinal hernia a portion of 
the intestine may be strangulated at the internal ring, so small as to render 
it impossible for the surgeon to discover its existence, either by sight or by 
touch. I have witnessed a number of deaths from this form of hernia, which 
had been treated as cases of colic. In all instances of abdominal pain, the 
practitioner should examine the rings in view of a probable strangulation. 
In most cases of concealed strangulation there has been a pre-existing bistory 
of hernia, for which the patient has worn a truss. If with such a history 
there exist the constitutional signs of a strictured rupture, even though no 
tumor can be discovered, this fact should lead the surgeon to expect its ex- 
istence, and will warrant an exploratory operation to verify or disprove the 
conclusion. 
A hernia may become either permanently or temporarily irreducible, and 
give rise to symptoms simulating strangulation. Thus, an old rupture some- 
times becomes swollen from an accumulation of gas, and in this state is 
followed by constipation and vomiting. In such a case, however, the char- 
acteristic impulse is present, there is no pain in the swelling or in the region 
of the umbilicus, the vomiting is not stercoraceous, and the strength of 
the patient is little affected,-—symptoms which do not, as a rule, answer 
to strangulation. A hernia which is irreducible is exposed to attacks of in- 
flammation, in which condition the resemblance to strangulation is very close, 
in consequence of the extremely sensitive state of the tumor, and its feeble 
impulse, together with the existence of constipation, flatulence, and vomiting. 
I have been frequently called to operate in such cases under the supposition 
that the bowel was strictured. There are, however, several notable differences 
between this condition and that of strangulation. The sensibility and pain 
of the swelling in the inflamed hernia are, as a rule, much greater than in the 
other, though the abdominal tenderness is less; the impulse, though dimin- 
ished in force, is not entirely obliterated ; the constipation, though obstinate, 
is not complete ; the vomiting is neither persistent nor of the ftecal character; 
nor is there the same degree of prostration, restlessness, and anxiety as in 
strangulated hernia. 
When a person having a double hernia is attacked with symptoms of stran- 
gulation, the surgeon may be greatly perplexed to determine which is the 
subject of constriction. A case was related to me by a medical friend in which 
three hernise existed in the same person, two being inguinal and one femoral, 
all irreducible. The woman was attacked with the usual signs of strangula- 
tion. It was impossible, by any external examination of the tumors, to iden- 
tify the one involved. Herniotomy was performed on one without success, 
and on the second with a similar result, the third proving to be the one STRANGULATED HERNIA. 
571 
affected. No other resort is left to the surgeon under such circumstances 
than to operate, selecting the hernia which furnishes, on a careful examina- 
tion, the strongest evidence of being the subject of stricture. If the patient 
be a female, and there be present an inguinal and a femoral rupture offering 
alike negative signs of strangulation, the femoral should be selected for oper- 
ation, as being the one most likely to cause the trouble. 
Treatment.—How to manage a strangulated hernia is a subject of the 
deepest interest to both patient and practitioner. It is not exceeding the 
truth to say that many lives are sacrificed annually by improper treatment. 
The great indication is to overcome the stricture, and, when the procedure is 
not contra-indicated by structural change, to restore the hernial contents into 
the abdominal cavity. The two means for accomplishing this end are taxis 
and herniotomy. The longer a rupture remains strangled, the greater will be 
the danger and the greater the difficulty in reduction. These are cogent 
reasons for an immediate resort to such measures as promise relief. The 
risk of mortification or of inflammation and its consequences is greater when 
the tumor is small than when it is large, for reasons already stated. 
When called to a case of strangulated hernia, it is the duty of the physician 
to proceed directly to its reduction. The patient should be placed in a hori- 
zontal position, and ether or chloroform administered, so as to secure the most 
thorough muscular relaxation ; before which it should be understood by the 
individual that, in the event of a failure to return the rupture, the operation 
shall pi’oceed at once, while he is still under the influence of the anaesthetic. 
The use of ether or chloroform takes the place of the formidable prelim- 
inaries to which persons were subjected under the old system of reduction, 
namely, venesection, tobacco clysters, hot baths, etc. The next step is such 
a disposition of the body and of the limbs as will secure the most thorough 
relaxation of all the tendinous, muscular, and other structures concerned. 
This position is very much the same for all varieties of hernia, namely, the 
head and shoulders elevated, with the lower extremities flexed and drawn 
up towards the abdomen. If the hernia be femoral, in addition to flexion, 
the knee of the affected side should be turned inwards towards its fellow- 
member. 
Taxis.—This term is derived from the Greek word signifying to put 
in order. In the hands of unskilful men the taxis serves to put things very 
much out of order, and it should be undertaken only under a clear apprehen- 
sion of the regional anatomy of the hernia and the rationale of the force to be 
employed. Some proceed, it would seem, under the impression that the work 
is to be done by force ; others act as though the whole manipulation consisted 
in pushing. Now, it should be clearly understood that neither the one nor the 
other is proper; that the parts must be handled with great gentleness, and 
not rudely, otherwise inflammation may be provoked, or even rupture of the 
sac or of the intestine may follow. When the force is applied by pushing the 
mass upwards, it will merely crowd the contents of the sac against and 
around the seat of stricture, or force them into some side-pouch. The two 
dominant thoughts in the use of the taxis are to steady the neck of the sac 
and to empty the intestine of its contents, for by so doing the disproportion in 
size between the bowel and the rings is lessened. As soon, therefore, as the 
patient is rendered insensible and the parts are properly relaxed, the surgeon, 
if the hernia be an inguinal one, places the thumb on one side and the fingers 
on the opposite side of the external ring, so as to prevent the sac from bulging 
over the pillars of the latter; with the other hand he grasps the body of the 
tumor, and, first drawing it downwards and outwards, in the line of the canal, 
so as to straighten the cavity of the bowel, he begins to compress the hernia 
with a moderate degree of firmness, graduating the force in such manner 
that, with the exception of the fundus, where it should be greatest, the press- 
ure shall be evenly distributed over the tumor. This compression must be 
maintained continuously for eight or ten minutes, when perhaps a peculiar 572 
DISEASES OF THE ABDOMEN. 
sensation will be felt and heard (gurgling), caused by the air passing out of 
the rupture. This is the sure precursor of reduction, and in a few moments 
more the sudden slip of the entire contents back into the abdomen will be 
noticed. When the omentum alone is the occupant of the sac, the restoration 
is effected slowly, one fold after another of the membrane receding until all 
is replaced. 
In applying taxis to femoral hernia, should the tumor have turned upwards 
over Poupart’s ligament, it must first be dragged down into the groin, after 
which the thumb and fingers of one hand should be placed on opposite sides 
of the saphenous opening, while with the other the rupture is compressed 
and simultaneously pushed backwards and slightly upwards, in order to 
direct it into the saphenous opening and through the femoral ring into the 
body. There is a limit to the use of the taxis. If the reduction is not 
accomplished in ten minutes, our efforts should cease, and resort should be 
had at once to the knife. A large or an old hernia will tolerate a longer 
manipulation than a small or a recent one. In any event, taxis should not 
be persisted in for more than ten minutes. Not unfrequently the hernia has 
been subjected to prolonged manipulation before the surgeon is called, and, 
if there is reason to believe that the taxis has been used properly, it will be 
better to confine further efforts at replacement within the limits of five or six 
minutes. When, from handling, the hernia has become exceedingly sensitive 
or painful, and when there is reason to believe that mortification has begun in 
the contents of the sac, taxis is not allowable. Mr. Birkett thinks that the 
presence of hiccough contra-indicates the employment of taxis. This is the 
case when, associated with the sudden subsidence of pain, there are present 
a feeble, frequent pulse, and cold sweats, with extreme prostration, as these 
are the signals of commencing mortification; but hiccough is sometimes 
present when there is no evidence whatever that the vitality of the hernial 
contents is destroyed, and under such circumstances manual attempts at 
reduction should not be withheld. 
Surgeons sometimes place the patient in unusual postures as adjuvants to 
the taxis; such, for example, as laying the person on an inclined plane, with 
the head and the shoulders low, and the limbs bent over on the abdomen; 
or suspending the individual by the heels; or simply raising the pelvis 
upon a pillow, the thorax and lower limbs being at the same time flexed 
upon the body. Another device consists in grasping the relaxed parietes of 
the abdomen and pulling them as far forward as possible. A folded sheet 
has been passed around the lower part of the body and the viscera forcibly 
drawn upwards. A sudden douche of cold water upon the epigastrium, when 
the walls of the abdomen were relaxed, causing a forcible inspiration, has 
succeeded in replacing a hernia when other methods had failed. In one in- 
stance I knew a rupture to be restored by the patient’s horse taking fright and 
upsetting his wagon, after prolonged taxis had been unsuccessfully applied. 
Persons from long practice often acquire a remarkable tact in reducing 
their own hernise ; and in such cases the surgeon should never discourage 
them from making the attempt. I recall an instance of a large rupture, 
in which the patient, after a fruitless manipulation, replaced the bowel by 
pressing the tumor between his thighs. Spontaneous recession of a protru- 
sion, after repeated taxis, has often occurred. In two cases within my own 
knowledge in which the patients were given over to the knife, the usual 
means of reduction having been exhausted, the hernia disappeared while the 
surgeons were preparing for the operation. In ruptures where the bowel 
has been greatly distended with gas, restoration has been accomplished by 
puncturing the intestine with a very fine trocar and canula or wifh an aspi- 
rator, thus liberating the imprisoned air. I have used for a similar object 
the needle of the hypodermic syringe. 
Inguinal hernia is much more frequently restored by taxis than is femoral; 
and it should not be forgotten that, as a rule, the last form of hernia is much 
less tolerant of manipulation than the first. STRANGULATED HERNIA. 
The reduction of a hernia does not always remove the strangulation; and 
when this is the case there is ground for the gravest apprehension. The 
circumstances w hich may continue the symptoms are the following: the 
hernial contents instead of receding singly and independently of the sac may 
be returned along wdth the latter; this is termed reduction en masse or en bloc ; 
or the strangulation may be due to bands, or to entanglement existing be- 
tween the omentum and the bowrel, in any of which cases the restoration 
does not remove the cause of stricture. Again, the constriction to which 
the bowels have been subjected by the stricture may be so great that the 
peristalsis of the tube remains paralyzed ; and, lastly, the rupture may, in con- 
sequence of the sac giving way, be thrust into some side-pocket, or between 
the peritoneum and its underlying connective tissue, as shown by Mr. Birkett, 
so as to be out of sight and leave the impression that it has been properly 
reduced. 
Other cases are met with, generally in connection with congenital hernia, 
in wffiich diverticula are formed from the inguinal sac, extending dowmwards 
and backwards beneath the iliac fascia into the iliac fossa, or inwards into the 
loose tissue in front of the bladder, between the pubes and the peritoneum, or 
upwards between the integuments and the external oblique muscle. These are 
examples of what are termed interstitial, intraparietal, or properitoneal hernise. 
The recognition of any of the above conditions which serve to continue 
the symptoms of strangulation must necessarily be a difficult task; indeed, 
their existence will, in most instances, be purely a matter of conjecture. 
When a hernia is reduced without sensible sound or gurgling, and the canal 
appears to be unusually collapsed, or wThen the rings are very free and open 
and no membranous structure answering to the sac can be felt in the hernial 
track, a reduction in mass may be suspected. It has been said that this acci- 
dent occurs only in inguinal hernia; yet I twice saw it take place in cases 
of femoral hernia. When reduction is noiselessly effected and the sac not- 
withstanding remains in the inguinal passage, the signs of constriction still 
continuing, the case is possibly one of entero-epiplocele, in which either an 
adherent band exists or some entanglement remains between the bowel and 
the omentum. 
The condition which has been named peristaltic paralysis of the intestine 
furnishes no characteristic signs. If in restoring a hernia the usual gui’gling 
sound has been present, and the sac can be detected lying in the canal, 
and yet symptoms of strangulation persist, the existence of such a state is 
not improbable. 
When the hernia has been forced into some recess between the layers of 
the abdominal parietes, its existence will be a matter of speculation; though 
if the tumor has lessened gradually under pressure, and tinally disappeared 
without gurgling or jerk, and the vomiting and distress still continue, such 
a state may be suspected. 
The proper course to be pursued in the complications described is, at 
first, one of expectancy. Stercoraceous vomiting, pain, and tympany may 
continue for a short time after the reduction of a hernia, and yet after- 
wards gradually subside and the patient recover. This perpetuation of the 
symptoms of stricture may be due to local peritonitis or to the muscular 
paralysis of the bowrel, which, after the disappearance of the serous inflam- 
mation or the gradual recovery of the suspended function of peristalsis 
in the bowel, will pass away. When, however, the strangulation persists 
over eight or ten hours, an exploratory operation will be proper. The 
canal should be laid open, and if it is found vacated by the sac the evidence 
of a reduction in mass is complete. The sac may have receded from the in- 
guinal canal and yet still be engaged in the internal ring. In either event, 
the reappearance of the hernia should be solicited by causing the patient to 
cough, and at the same time drawing down the sac, if it is found at the upper 
ring. If the surgeon, by these measures, is successful in effecting the re- 
descent of the rupture, the sac should be- opened and its contents liberated, 
573 574 
DISEASES OF THE ABDOMEN. 
as in ordinary cases of strangulation. If after this the symptoms continue, 
there is reason to suspect the existence of bands or entanglement; but the 
duty of the practitioner, so far as operation is concerned, ceases when the 
interior of the sac is explored. If the explanation is not found there, further 
search, by opening the cavity of the abdomen, is a justifiable procedure. 
If the sac is found ruptured, an accident which renders probable the ex- 
istence of an intra-parietal displacement of the hernia, forcible coughing 
should be enjoined, in the hope that by such effort the patient may succeed 
in dislodging the viscus from its unnatural position and enable the surgeon 
to relieve the constriction and restore the rupture. 
Rupture of the intestine is an accident which may follow the too forcible 
manipulation of a hernia, especially when the coats of the bowel have be- 
come softened through inflammatory or other changes. The occurrence 
would be indicated by the sudden collapse of the distended tumor and the 
rapid development of pain and of tympany, phenomena which follow faecal 
extravasation into the peritoneum. Such cases demand prompt laparotomy. 
After reduction has been successfully effected in cases of strangulated 
hernia, the vomiting, pain, abdominal distention, anxiety, and exhaustion 
soon disappear, provided the contents, when replaced, are not hopelessly 
damaged or peritonitis does not supervene. The patient, however, should be 
confined to bed for three or four days, the diet being restricted, and on the 
second day the bowels may be opened either by an enema or by a gentle 
aperient. Before he leaves the recumbent position, a truss should be adjusted 
to prevent a recurrence of the protrusion. 
Herniotomy.—The operation of herniotomy consists in dividing the super- 
incumbent coverings of the rupture, relieving the stricture, and restoring the 
contents of the sac into the abdomen, unless the latter proceeding is contra- 
indicated by conditions hereafter to be described. 
The time to operate is immediately after the taxis has failed and before the 
patient comes from under the influence of the anaesthetic. The most con- 
venient position for the surgeon is to place the patient either across the bed, 
the hips resting upon its edge, and the feet supported upon a low stool, 
or, what answers equally well, to bring the patient to the side of the bed. 
The hair over the pubes 
and scrotum on the side of 
the hernia should be cleanly 
shaven, and if there is rea- 
son to believe that any con- 
siderable accumulation of 
urine exists in the bladder, it 
must be drawn off with the 
catheter. The parts must be 
thoroughly scrubbed with al- 
cohol or ether, and then 
washed with the bichloride 
of mercury solution, and the 
field of operation well pro- 
tected by towels wet in the 
same. A single assistant, in 
charge of the anaesthetic, is 
all the aid required; though a second one, who shall attend to the sponging 
and, if necessary, to the ligatures, will facilitate somewhat the rapidity of 
the operation. These preliminaries having been arranged, a linear incision 
should be made over the tumor, extending from its upper to almost its lower 
extremity. This incision may be linear and direct, which I prefer (Fig. 444), 
or it may be made by raising a fold of the integument, transfixing the 
same with a sharp-pointed bistoury, and cutting from within outwards 
(Fig. 445). The layers are to be lifted on a grooved director and divided until 
Fig. 444. 
Direct linear incision over the hernial tumor. STRANG ULA TED HERNIA. 
the sac is reached. It should not be forgotten that the coverings of the 
hernia are sometimes extremely thin, and should the first incision be made 
with a heavy hand the knife may pass through into the bowel. I once saw 
this accident occur in the hands of a surgeon; and the impression which was 
made upon my mind has never passed away. It is proper to observe here 
that it is not necessary to separate layer after layer, in the order pursued by 
the anatomist in a class-room demonstration, but simply to divide cautiously 
all the structures overlying the sac. Any vessels which bleed freely should 
be tied, in order that nothing may interfere with the succeeding steps of the 
operation. Considerable em- 
barrassment is often experi- 
enced in recognizing the sac. 
It usually appears as a round 
or an oblong tense bag, hav- 
ing a bluish color, and with 
some fine, straggling vessels 
scattered over its surface. 
Though generally a thin mem- 
brane, it is occasionally thick 
and almost of a leathery con- 
sistence and feel. To remove 
all doubts, it may be grasped 
between the thumb and fin- 
gers, and if its opposite sur- 
faces can be rubbed or slid 
upon each other its identity 
will be established; or if there 
remain still some obscurity or 
uncertainty, let a puncture with a fine needle be made into the part, when, if 
it be the sac, the escape of a few drops of serum will declare its true nature. 
Opening the sac.—The sac having been exposed, the most important ques- 
tion in connection with the entire subject of hernia arises,—Shall it be opened 
or not? If the reduction can be effected without opening the sac, a great 
work has been achieved ; indeed, the operation, in that event, is very simple 
and almost entirely free from danger. By this method the peritoneum is not 
wounded, the intestine and omentum escape being handled, and there is no 
risk of blood entering the cavity of the abdomen. Petit, in 1718, over one 
hundred and fifty years ago, earnestly inculcated this plan of performing 
herniotomy. More than thirty years before, Eavaton had introduced it to 
the notice of English surgeons. There is reason to believe, however, that 
Franco, who first operated for strangulated hernia as early as the sixteenth 
century, was in the habit, when possible, of not laying open the sac, and 
the same practice was inculcated by Ambrose Pare and Ledran, and in 
more recent times by Bonnet, Eoser, Bransby Cooper, Diday, Dunzel, and 
others. Mr. Ashton Key, in 1833, published an able paper upon the sub- 
ject, which had the effect of popularizing the operation of reduction without 
division of the sac, not only in Great Britain but also in other countries. Of 
125 cases of herniotomy furnished by Mr. Gay* in which the old plan was 
adhered to, 52 died, whilst in 73 cases in which the sac was not opened the 
mortality was 13. Mr. Luke operated on 82 cases. In 57 the hernia was 
reduced without opening the sac, and of this number 7 died. Of the 25 in 
which the sac was divided 8 died.f In a summary of 59 cases of femoral 
hernia operated on in Guy’s Hospital during a period of eight years, in 
which the sac was divided, the mortality was 50 per cent., whereas in 45 
cases in which it was not disturbed the death-rate was 30 per cent. Of 35 
inguinal hernia}, in the same institution, requiring operation, and where the 
sac was opened, 60 per cent, died; and in 9 instances in which it was not so 
575 
Fig. 445. 
First incision, by transfixing a fold of integument over the 
hernial tumor. 
* Gay on Femoral Hernia, 1849. 
f Medieo-Chirurgical Transactions, vol. xxxi., 1848. 576 
treated, 2, or 22 per cent., died,—a difference of 40 per cent, in favor of Petit’s 
method.* In a collection by Hancockf of 548 cases of hernia requiring 
operation, the sac was opened in 474. Of this number 307 recovered and 
167 died; and of the 74 in wThich it was not opened 52 proved successful. 
The fatality following the ordinary operation is also well shown in the 545 
cases collected from various sources by Turner, in which the sac was divided, 
260 of whom died. There is reason to believe that in femoral hernia the 
necessity for observing the Petit method is less urgent than in the inguinal 
varieties. Dr. DutrelepontJ reports 12 cases of strangulated hernia operated 
on without opening the sac, with a single death. In my own experience, the 
Petit method has been so successful that I never think of dividing the sac 
except in cases where its contents cannot be restored, or where, in conse- 
quence of the long time that the hernia has been strangulated, there are 
strong reasons for believing that the parts are not in a condition to be returned 
into the abdomen. Those who oppose the practice do so on the ground that 
there must always be some uncertainty in the mind of the surgeon as to the 
state of the contents when the sac remains unopened. It is possible that an 
error may be committed on this point; but I apprehend that for every life lost 
from this cause fifty are sacrificed by unnecessarily dividing the sac to inspect 
the intestine and omentum. Ko surgeon is deterred from attempting the re- 
duction of a strangulated hernia by taxis at any time short of the appearance 
of mortification, and yet there must be a like ignorance in regard to the state 
of the parts which he returns into the abdomen. 
As soon as the sac is exposed, it should be carefully divested of all bands 
of connective tissue about its neck, and the index finger carried up in order 
to discover the seat of constriction. (Fig. 446.) In femoral hernia this is 
DISEASES OF THE ABDOMEN. 
Fig. 446. 
Fig. 447. 
Finger seeking for the stricture. 
Stricture at neck of sac. 
found at Key’s ligament, the sharp edge of which stretches across the sac, or 
it may be at the neck of the latter. In inguinal hernia the stricture is gen- 
erally at the neck of the sac (Fig. 447), and next in frequency at the internal 
ring, where there will be found bands of dense connective tissue, which 
resist the reduction by preventing the dilatation of this portion of the sac. and 
which should be carefully cleared away. The next step consists in dividing 
the stricture, wherever found. This is a work often of great delicacy. There 
* Bryant’s Surgery, p. 318. 
f Hancock on the Operation for Strangulated Hernia, 1850, p. 53. 
j Langenbeck, Archiv fiir Klinische Chirurgie, Berlin, 1868, Bd. ix. p. 471. are three objects to be kept in view in executing this part of the operation: 
first, to make no further division than is just necessary to relieve the hernia 
STRANGULATED HERNIA. 
577 
Fig. 448. 
Cooper’s hernia bistoury. 
from constriction and admit of the easy reduction of its contents; second, 
not to injure the intestine or omentum; and, third, to avoid 
wounding important blood-vessels. The simplest plan is to 
carry the index linger to the seat of stricture, with its palmar 
surface looking upwards, its dorsal surface at the same time 
serving to keep the sac out of the way. By a little patience and 
address, the nail may be insinuated beneath the edge of the con- 
stricting band, when the hernia bistoury of Cooper (Fig- 448) can 
be conducted flatwise along the finger to the point of resistance, 
beneath which the blunt point of the instrument should be pressed, 
and then, being turned with its edge against the strictui’e, a little 
pressure by the finger beneath will answer to nick the part, after 
which, the knife being withdrawn, the finger can usually effect a 
sufficient dilatation to allow of the reduction. If the division is 
not sufficient, the operation can be repeated until the object is at- 
tained. A too free use of the knife is to be deprecated, as it tends 
to weaken the parts and increase the tendency to future hernial 
protrusions. A number of ingenious contrivances have been de- 
vised in order to divide the stricture without exposing the intes- 
tine to injury, For this purpose the notched director of Dr. 
Levis (Fig. 449) answers a very good end when Iley’s ligament 
is the seat of strangulation. 
When it is found that, after thinning the neck of the sac and 
removing all sources of exterior constriction, it is impossible to 
return the hernia, the sac must be opened. This is best done by 
pinching up, with a pair of forceps, a little duplicature on its an- 
terior surface and nicking it with the knife, the edge being placed 
horizontally, after which a director should be introduced, and by 
means of a pair of scissors the opening can be enlarged upwards 
towards its neck. Some caution is necessary in doing this, that 
the intestine be not wounded. The fluid contained in the sac de- 
fends its contents from injury by occupying the space between the 
two, just as in ascites the serum interposed between the intestines 
and the abdominal parietes allows the cavity to be tapped without 
damage to the viscera. In some instances there may be little 
if any fluid in the sac, and then increased care must be observed. 
It is not necessary to lay open the sac in its whole extent; only 
the upper half will require division, as the less extensive the wound 
in this structure the better, for it is this damage which inaugurates' 
the peritonitis likely to follow. The index finger should next be 
carried up along the inner surface of the sac until the seat of con- 
striction is reached at its neck, when the hernia bistoury is slid 
flatwise along the palmar aspect of the digit to the same point. 
Guided by the nail, it must be pushed up between the contents 
of the sac and its tightly-girdling neck, and then, with the short 
cutting edge turned upwards, it should be pressed against the 
stricture by the tip of the underlying finger until the resistance 
is felt to give way, when it should be withdrawn and the part dilated. In 
incising a stricture situated at Iley’s ligament, the sac or its contents, when 
opened, can be kept out of the way of injury by the fingers of one hand, 
Fig. 449. 
Levis’s notched 
director, on 
which to di- 
vide the stric- 
ture in hernia. 578 
DISEASES OF THE ABDOMEN. 
while the probe-point of the knife is insinuated beneath the edge of the 
constricting fascia with the other. A very ingenious hernia bistoury has 
been devised by Dr. Allis, of this city, which renders the operation for re- 
lieving the stricture one of entire safety. It is a probe-pointed knife, having 
a movable sheath which can be slid up and down by means of a nut, con- 
cealing or exposing a cutting edge at pleasure. (Fig. 450.) It is introduced 
beneath the constriction as a flat probe, no part of the edge being visible, 
and after it is properly placed the operator retracts the sheath by turning 
Fig. 450 
Allis’s hernia bistoury. Fig. 1, the bistoury complete; Fig. 2, a, the blade detached from 
its cover, c; b, the nut which moves over the thread at the end of the cover, e. 
the screw which is placed at the junction of the blade and the handle, cuts 
the stricture, and again restores the cover to its original position, when the 
knife can bo safely withdrawn. Whatever instrument is employed to release 
the strangulation, the incision must be executed so as to avoid important 
blood-vessels, directions for which will be given under the special forms of 
hernia. 
After relieving the constriction and finding the parts in a proper condition, 
the surgeon proceeds to restore them to the cavity of the abdomen. If the 
sac has not been opened, this is effected by simply compressing its walls 
between the thumb and fingers. When the sac is opened, and both intestine 
and omentum are present, one should be returned before the other, the 
intestine having precedence. This is best done by first drawing down and 
straightening the bowel, compressing its sides together to displace any air 
which may be present, and then pushing it by instalments through the 
mouth of the sac with the finger of one hand, while with the other hand 
another portion is made to approach the canal. In the same manner one 
fold after another of the omentum is restored, and as the last piece dis- 
appears from the sac the finger should follow it the entire length of the her- 
nial passage in order to ascertain if the canal is free. In all these manipu- 
lations the greatest gentleness should be practised and every movement 
made with a distinct object in view. The fingers should be well cleansed in 
hot water or in a solution of bichloride of mercury, that their contact with 
the bowel may be rendered as harmless as possible. The operator should 
also be careful, in his efforts at reduction, that the sac and its contents are 
not pushed up together, constituting restoration “in mass.” Holding the 
sac down Avhile its contents are pressed upon often facilitates the passage of 
the rupture into the body. 
Keduction having been effected, the parts should be brought together by a 
few stitches of silver wire or catgut, a drainage-tube placed in the lower 
angle of the wound for a few days, and the antiseptic dressing applied, 
the whole being made secure by a spica bandage of the groin. (Fig. 451.) 
The limb of the affected side is most conveniently placed by being slightly 
raised on a pillow laid under the knee. An anodyne may be next admin- 
istered, and the bowels kept quiet for six or eight days, after which a move- 
ment may be solicited by a dose of castor oil. The diet for the first five or 
six days should be entirely liquid, such as milk and chicken-tea or beef- 
essence : if the hernial contents have been severely congested, it will be 
better to sustain the patient for the first few days by rectal alimentation, so 
that the damaged bowel, having perfect quiet, may have time to recover STRANGULATED HERNIA. 
579 
from the effects of the injury. As soon as the wound is sufficiently healed, 
the patient may rise from bed, the parts being supported by the application 
of a truss. 
Difficulty in reduction will occasionally be encountered from a variety of 
conditions. 
1. Adhesions.—These are always the result of recent or of old attacks 
of inflammation. These adhesions may exist between the individual loops 
of intestine, between the latter and the omentum when present, or between 
Fig. 451. 
either and the inside of the sac. The uniting lymph, when of very recent 
origin, is soft, and is readily broken up, but when of long standing will have 
the strength and consistence of well-formed bands of connective tissue. 
When the adhesions are found chiefly at the mouth of the sac, it is usually in 
cases where the vitality of the parts below has been destroyed. Such ad- 
hesions constitute a defensive work on the part of nature to prevent faecal 
extravasation when the sloughs separate. When the adhesions are soft and 
easily overcome, they should be broken up and the parts returned ; but when 
they are old, firm, and extensive, any attempt at detachment will be danger- 
ous, and the surgeon must be satisfied with relieving the strangulation and 
allowing the hernia to remain in the sac. The same course must be adopted 
when the adhesions preliminary to mortification exist. 
2. Volume of the contents.—I have seen, after division of the stricture, what 
seemed to be the entire small intestine, together with a large amount of omen- 
tum, enter the sac, and the bowel become so distended with air as to defy 
reduction. In such a case the tube should be punctured with a hypodermic 
needle, when after the collapse of its walls it can be returned into the abdomen. 
3. Fcecal accumulation.—Accumulations of hardened faecal masses may offer 
a serious obstacle to reduction. The difficulty may be overcome by careful 
manipulation, the obstruction being pressed back into the bowel above. 
Should this fail, the stricture should be divided and stretched to an extent 
which will admit of the bowel with its contents—which may be pressed 
into a favorable form—being passed into the body. 
Spica of the groin, to retain dressing after operation for hernia. 580 
DISEASES OF THE ABDOMEN. 
4. Volvulus.—Efforts at reduction are sometimes defeated by a loop of the 
intestine being twisted a number of times upon itself. Simply reversing the 
turns and detaching any soft adhesions which may be present will overcome 
this difficulty. 
Complications affecting the Vitality of the Intestine.—The inter- 
ference with the circulation of the intestine from a tight stricture will induce 
structural changes of a very serious nature. 
Congestion.—The bowel, when exposed, is frequently seen in a state of 
extreme congestion, roughened with lymph, and presenting a red, purple, or 
even chocolate hue, and the fluid of the sac straw-colored or blood-stained; 
all of which may be consistent with its vitality. When the stricture has 
been divided and the pressure taken from the blood-vessel, the deep shades 
of color will generally lighten. Should this not be the case, the parts may be 
covered for a few minutes with a soft piece of linen saturated with hot 
water, with a view to establish the circulation. If doubt still remains, the 
surgeon may prick the intestine with a fine needle, and if blood flows, the 
tube retaining its cylindrical form and its tense, elastic, and slippery feel, 
he has the evidence of remaining life. In all such conditions, the best 
place for the bowel is within the abdomen, and to this cavity, after washing 
its surface with a solution of bichloride of mercury, it should be restored at 
the earliest possible moment. 
Mortification—Should the fluid of the sac have a dark, muddy appearance, 
the intestine remain greenish-black or black in color and without its char- 
acteristic lustre, or if its coats have become rough* ecchymosed, and softened, 
and emit a putrescent odor, the part is hopelessly dead and entirely unfitted 
for reduction. The stricture should be divided in the usual manner and the 
intestine freely laid open, allowing a free escape of its contents, after which 
the parts should be resected and stitched, the outer half of each cylinder to 
the surrounding parts. Subsequently an operation to establish the conti- 
nuity of the canal can be made. 
In some instances it will be very difficult to decide the question of vitality. 
For example, when the bowel is of a deep congested chocolate color, which 
persists after division of the stricture, when it does not recover its normal 
size at the point of constriction, but retains the groove or indentation made 
by the engirdling force, and when it creaks under pressure, it is better, the 
stricture having been well divided, to allow the intestine to remain outside 
of the abdomen, simply covering the parts with a light piece of old linen 
kept constantly moist with warm water for four or five hours, when the 
bowel should be again examined, and if the color has improved and its 
cylindrical form begun to return, it may be replaced just within the mouth 
of the sac, so that, in the event of mortification setting in, a chance may be 
afforded for such adhesions as shall serve to protect the cavity of the peri- 
toneum from fecal extravasation. 
Partial mortification.—If only a very circumscribed portion of the bowel 
has undergone death, and presents a dark spot either open or ready to drop 
out, the part should be gathered up with a pair of forceps and surrounded 
with a fine thread, both ends of which must be cut off close to the knot, and 
the intestine reduced. The surgeon must decide by the security with which 
the encircling ligature retains its hold upon the puckered coats of the bowel, 
as to the extent of mortification which will admit of this treatment. When 
the diameter of the piece exceeds three-sixteenths of an inch, the ligature is 
scarcely admissible. When a portion of the bowel too large to be treated 
by the ligature has undergone mortification, the question naturally arises, Is 
it proper to return the intestine in such a state into the body ? Some very 
excellent authorities direct in the affirmative, enforcing the propriety of not 
pushing the damaged gut farther than just within the mouth of the sac, so 
that it may become attached to the parietes of the abdomen before the 
slough separates. I cannot coincide with such a view: the practice is a 
dangerous one, and will be likely to result in the loss of the patient’s life. STRANGULATED HERNIA. 
581 
There can be no certainty that the bowel will remain at the opening of the 
hernial sac; consequently there will be great risk of faecal extravasation. 
A better course is to pass a silk thread through the walls of the intestine 
slightly beyond the line of demarcation, after which the knuckle should be 
restored to the abdomen, with the exception of the diseased portion, which 
must be retained by the ligature at the neck of the sac. When the dead 
part becomes detached and the sides of the resulting opening contract ad- 
hesion to the surrounding tissues, the thread can l3e removed. Another 
mode of procedure is to excise the dead portion and close the opening with 
the usual Lembert sutures. The former plan, however, is attended with 
least risk to life. 
A strangulated hernia may be neglected, or efforts at reduction continued 
from time to time, in the vain hope of avoiding the knife, until a slough forms 
in the walls of the intestine, in consequence of which the overlying soft parts 
become inflamed and ulcerate, forming a stercoraceous abscess. Should the 
contents of the bowel escape into the tissues exterior to the sac, the sub- 
cutaneous cellular tissue is rapidly necrosed, the skin becomes green and yel- 
low, and the parts crepitate under pressure, from the gases which are liberated 
in the process of decomposition. In such conditions a free incision must be 
made through all the superincumbent layers of tissue into the bowel. An 
artificial anus is likely to follow. In a case of femoral hernia in which the 
strangulation had continued unrelieved for seven days, I found, from the 
appearance just described, that the bowel had given way. An opening was 
made, and. as the faeces were flowing freely, the stricture was not divided. 
The wound gi'adually granulated, and finally closed, the evacuations resuming 
their natural route through the rectum. This could have occurred only 
by the agglutination of the contiguous walls of the intestinal loop, their 
subsequent ulceration establishing a direct communication between the two. 
This case is by no means unique: a sufficient number have come under the 
observation of surgeons to render a similar termination quite possible under 
like circumstances. 
Complications affecting the Omentum.—The omentum is subject to 
the same accidents as the intestine. It may be congested, in which case 
the linear arrangement of its vessels and its distended veins will be apparent, 
but their color is never as purple as that presented by a strangulated in- 
testine. Such a condition, however, does not preclude its reduction. As 
the intestine may be enwrapped in the omentum, or even pass through an 
opening in its substance, a careful unravelling of the two should always be 
accomplished before returning either. In old hernise the omentum is prone 
to become, from inflammatory and nutritive changes, greatly hypertrophied. 
In such a state, surgeons are very generally agreed that its reposition into 
the abdomen would expose the patient to the risk of peritonitis, and there- 
fore the alternatives are presented of either allowing it to remain in the sac 
or of cutting it away. VVlien the hypertrophy is slight and free from inflam- 
mation, it may be left in the sac; but when excessive, it is best to remove 
the diseased structure by surrounding the mass with a strong ligature close 
to its neck, or, if too bulky for a single cord, to draw it a little distance out 
so as to expose the part near to the upper ring, and transfix it with a needle 
bearing a double ligature, which should be tied firmly upon each half, and 
the mass cut off below. The ends of the ligature are to be brought out of 
the external wound, and retained sufficiently tight to hold the stump at the 
neck of the sac until the portion below the threads sloughs off, when they 
will come away with the latter. The stopper thus formed becomes useful in 
fortifying the canal against subsequent protrusions. 
Mr. Holmes says that of twenty cases of hernia at St. George’s Hospital 
in which the omentum was removed, a few died, but the examination after 
death showed that the fatal result was not attributable to the ligature of the 
omentum. Of eleven cases in which the omentum was alkrwed to remain in the 
sac, the majority recovered, notwithstanding abscess and sloughing occurred 582 
DISEASES OF THE ABDOMEN. 
in some of them. It would seem, therefore, that though the omentum, when 
exposed to irritation, is, like all fatty tissues, prone to inflammation and sup- 
puration, these processes have little tendency to extend by continuity of struc- 
ture after traumatic injuries such as the ligature or retrenchment by the 
knife, and especially when antiseptic measures are observed. 
The omentum does not possess by any means the same capacity to resist 
congestive and inflammatory attacks that the intestine possesses. For this 
reason it is not unfrequently found unfit to reduce when the intestine is 
uninjured. 
The omentum may be the seat of serous or sero-sanguinolent cysts, formed 
in its connective tissue, and also around the walls of one of its veins. When 
the cysts are quite small, and when the omentum in which they are developed 
is in a condition to be returned, they should not be meddled with; but when 
large, they may be punctured and the fluid discharged. 
In all cases where the intestine or the omentum is not returned into the 
abdomen, or is retained at the mouth of the sac, the external wound must 
not be closed, since it is important to have a free, dependent drainage-tract 
and thereby divert all inflammatory products from the cavity of the peri- 
toneum. The parts should be covered with a carbolated water-dressing, or 
with a fermenting poultice. 
Hemorrhage.—The vessels which are particularly likely to be cut in the 
operation for strangulated hernia are the epigastric and the obturator. A 
number of such accidents have been recorded by Lawrence, but they could 
have occurred only as the result either of anatomical ignorance or of reckless- 
ness. In the event of such a blunder being committed, it would be necessary 
to expose the vessel and secure it by a ligature. 
Prognosis.—The prognosis in cases of strangulated hernia subjected to 
herniotomy must be based upon a variety of considerations. Among these 
the most important are, the duration of the strangulation, the extent to 
which taxis has been practised, the treatment of the sac, and the condition 
of the hernial contents. The age of the patient, the duration of the rupture, 
the integrity of life-organs like the kidneys and lungs, and the form of the 
rupture, must also be taken into account in conjecturing the probable issue 
after such an operation. 
Time is a matter of great moment to a person suffering from strangulated 
hernia. The chances of recovery after seventy-four hours rapidly diminish. 
The bulk of the rupture and its contents will serve to lessen somewhat the 
evil effects of time, as large hernias, and those in which both intestine and 
omentum are present in the sac, suffer less from strangulation than those in 
which the rupture is small and the contents consist of either the bowel or 
the omentum alone. This is due to the fact that the extensive dilatation of 
the hernial passage renders the circulation less precarious. Mr. Gay* has 
tabulated one hundred and eighteen cases which show the effect of time on 
the mortality of strangulation : 
Cases. 
Recoveries. 
Deaths. 
First day 
43 
6 
Second day 
41 
30 
11 
Third day 
3 
6 
Fourth day 
2 
3 
Fifth day 
0 
4 
Sixth day 
3 
4 
Tenth day 
0 
3 
Total 
81 
37 
Rude and prolonged efforts at reduction greatly diminish the prospects of 
a patient’s recovery after herniotomy. I have constant occasion to deplore 
the well-meant mistakes which are thus committed by practitioners. It 
would be well if every professional man could be made to feel that every 
* Gay on Hernia. STRANGULATED HERNIA. 
583 
minute over ten which he consumes in vain or badly-applied attempts to 
return a strangulated bowel involves danger to the life of his patient. 
As an evidence of the injurious etfects of prolonged taxis, M. Boyer* states 
that for five years, when his practice was to make long-continued efforts at 
reduction, eight cases out of nine operated on proved fatal. During the next 
five years, when he employed taxis to a more limited degree, four out of seven 
died; and in the course of the succeeding five years, after almost entirely 
abandoning the use of this manipulation, he saved ten out of fourteen cases. 
M. Manec,f who usually proceeded to the operation without resorting to taxis, 
saved twenty-six out of twenty-eight patients. Herniotomy performed 
within twelve or fourteen hours after strangulation and done antiseptically 
will be very uniformly successful. 
When the surgeon is forced to open the sac, another factor is introduced, 
which seriously complicates the cure and increases the fatality of herniotomy, 
as already shown, though the use of antiseptic agents promises to lessen the 
mortality from this cause. 
When either the intestine or the omentum has been damaged in its 
vitality to such a degree as to render it unfit to be returned into the body, 
the danger to life is very great, either from peritonitis, or more remotely, 
should the patient survive, from the effects of an artificial anus. 
The young are more likely to recover after herniotomy than the aged. 
The influence of age upon the result of operations for strangulated hernia is 
shown in the following analysis of a collection of three hundred and fifty- 
seven cases:t 
Age. 
Total 
operated on. 
Recovered. 
Died. 
2 
2 
3 
3 
“ 10 and 20 ' “ 
7 
6 
1 
“ 20 and 30 “ 
55 
36 
19 
51 
32 
19 
63 
40 
23 
73 
52 
21 
“ 60 and 70 “ 
60 
32 
28 
“ 70 and 80 “ 
30 
17 
13 
“ 80 and 90 “ 
“ 90 and 100 “ 
11 
6 
5 
2 
2 
Total 
357 
228 
129 
The earliest age at which the operation for strangulated hernia has been 
done, so far as I can learn, is that of the case by Dr. Thomas H. Andrews, 
of this city. The patient was forty-five hours old, and made a rapid re- 
Dr. Coleman, of Trenton, New Jersey, operated successfully on a 
child one year old. 
A hernia of recent origin, should it demand an operation, is more likely to 
terminate fatally than one of long standing. This is easily explained, since 
the orifices through which the rupture suddenly descends have not been 
subjected to much dilatation, and therefore exercise a dangerous degree of 
constriction upon the contents of the sac. 
Certain hernise, the femoral and the umbilical, are less tolerant of operation 
than others, and consequently more prone to a fatal end. 
The value of sound kidneys and other life-organs, both in the abdomen and 
in the thorax, to a successful herniotomy, as well as to other capital opera- 
* Revue Med.-Chirurg., 1847. 
J Hancock on Strangulated Hernia, p. 90. 
f Ibid., 1847. 
£ Philadelphia Medical Times, vol. vi. 151. 584 
DISEASES OF THE ABDOMEN. 
tions, cannot be overestimated. A defect in these may turn the scales ad- 
versely to the patient when all other circumstances tend to recovery. 
In the eighteen years from 1860 to 1878, 324 persons are reported to have 
died in the city of Philadelphia* from strangulated hernia. If we compare 
with this mortality that from all causes for the same period, about 352,000, 
we shall find that there was a fraction less than one death from strangu- 
lated hernia to every thousand from all other diseases combined. 
In most instances death is caused by general peritonitis, excited by the 
local irritation of the stricture, by unskilful manipulation, and by fsecal ex- 
travasation. In some cases, especially when the subject is advanced in life or 
broken in health, death ensues from shock; and in a few instances, as when 
an artificial anus is established, it may be the result of exhaustion from 
defective nutrition. 
Special Hernise. 
The most common varieties of hernia are inguinal, femoral, and umbilical; 
in addition to which may be mentioned the rarer forms of the disease, namely, 
the obturator, sciatic, perineal, vaginal, pudendal, ventral, and diaphragmatic. 
Inguinal hernia constitutes a large proportion of the different varieties of 
the disease, at least sixty-six per cent. It is more common in males than in 
females, is oftener found on the right than on the left side, and constitutes 
more than one-half of all the cases of strangulation. 
There are two forms of inguinal hernia: the indirect or oblique, and the 
direct or ventro-inguinal. 
Surgical anatomy.—A brief enumeration of the anatomical components of 
the inguinal region will materially assist the reader in practically under- 
standing the subject. Let it be remembered that a hernia in passing from 
the interior to the exterior of the body follows the course of certain blood- 
vessels, carrying before it a layer of all the intermediate structures, and that 
these structures constitute its “ coverings.” Inguinal hernia follows the sper- 
matic vessels or the spermatic cord. 
The leading anatomical points to be considered are as follows : 
The external abdominal ring is a triangular space situated in the tendon 
of the external oblique muscle, one branch of which is implanted upon 
the tuberosity and the other upon the crest of the pubic bone, constituting 
what are termed by anatomists the “pillars” or “columns” of the ring. 
From the edges of these pillars is prolonged a membranous structure,—the 
intercolumnar fascia,—which closely invests the cord as it passes into the 
scrotum. The different strata of tissues composing the abdominal parietes 
above Poupart’s ligament are arranged in the following order: skin, super- 
ficial fascia, tendon of the external oblique, of the internal oblique, and 
of the transversalis muscles. Underneath the last-named muscle lies the 
cord, resting upon the transversalis fascia, which separates it from the peri- 
toneum. Two inches above the external ring, and one inch above the middle 
of Poupart’s ligament, the cord makes its appearance, coming apparently 
through an opening in the fascia transversalis. This apparent opening 
is the “internal ring.” If the cord be drawn outwards and downwards 
it will be seen that the transversalis fascia, like the intercolumnar fascia 
at the external ring, is continued downwards over the spermatic cord as 
a funnel-shaped prolongation, the “ infundibuliform fascia.” The space be- 
tween the internal and external rings is the “ inguinal canal.” At the pos- 
terior wall of the internal ring, behind the cord and running upwards and 
inwards, are situated the deep epigastric blood-vessels. The internal ring 
being situated at a greater distance above Poupart’s ligament than the 
Inguinal Hernia. 
* From a manuscript report of cases of death from strangulated hernia, furnished to me by Dr. 
Wm. H. Ford, Secretary of the Board of Health, Philadelphia. INGUINAL HERNIA. 
585 
external, the space between the two is necessarily oblique in its direction. 
(Fig. 452.) A hernia which enters the internal ring, passes along the canal, 
and presses its way through the external ring, descending into the scrotum 
or into the labium, is called a complete oblique inguinal hernia. The cover- 
ings of such a hernia consist of the different layers forming the abdominal 
walls; that is, considered from without inwards, they are skin, superficial 
fascia, intercolumnar fascia or the tendon of the external oblique, the internal 
oblique, and the transversalis muscle, or “ cremaster,”—the latter consisting 
of fibres derived from the other two,—the transversalis or infundibuliform 
fascia, and, finally, the peritoneum or sac. In many cases of inguinal her- 
nia the transversalis or infundibuliform fascia does not form a covering, as 
it gives way before the descent of the bowel. When a hernia enters the 
Fig. 452. 
Fig. 453. 
a, tendon of the external oblique muscle with the ex- 
ternal abdominal ring and cord; 6, c, skin and superficial 
fascia; d, tendon of the external oblique; e, f, internal 
oblique and transversalis or cremaster muscle ; g, trans- 
versalis or infundibuliform fascia with the cord passing 
through the internal ring, h, behind which lies the epi- 
gastric artery, i. 
a, oblique inguinal hernia; b, direct or ventro- 
inguinal hernia; both having descended into the 
scrotum. 
inguinal canal through the internal ring, but does not pass out through the 
external ring, it is called an incomplete inguinal or concealed hernia. The 
coverings of this form of rupture are the same as those which belong to the 
complete variety. Tt often happens that the intestine or omentum, instead 
of following the indirect course of the canal, presses directly out through the 
external abdominal ring into the scrotum, forming another variety of rup- 
ture,—the direct or ventro-inguinal. (Fig. 453.) 
It is not always easy to determine whether an inguinal hernia is oblique 
or direct. If the tumor is large, the internal ring is dragged down to the 
external one, so that when the hernia is reduced and followed by the finger 
the latter seems to go directly into the abdomen. Females are said to suffer 
rarely from the direct form of the disease. There is a difference of opinion 
in regard to the coverings of the last-named hernia. Into the front of the 
linea ilio-pectinea of the pubis, directly behind the external ring, is inserted 
the conjoined tendon of the internal oblique and transversalis muscles. Some 
writers accordingly regard this tendon as constituting one of the investments 
of the rupture in question. This, however, is not the case, as the protrusion 
passes round the outer edge of the conjoined tendon. The coverings differ from 
those of the other forms of inguinal hernia only in the absence, in a great meas- 586 
DISEASES OF THE ABDOMEN. 
ure, of the fibres of the cremaster muscle, the latter being, with the cord, pushed 
to the outer side of the ring as the hernia passes through into the scrotum. 
Many persons suffer from inguinal hernia on both sides. The size of the 
swelling varies much in different cases. It may be so small as scarcely 
to be recognized, and it may be so voluminous as to extend almost to the 
knees. There are not wanting instances in which both indirect and direct 
hernia existed in the same person on the same side. In cases of oblique 
inguinal hernia accompanied with an undescended testicle, that is, where the 
gland lies in the inguinal canal, the former will sometimes lie in a position 
very different from that occupied where no such complication is present; the 
obstruction presented by the testis in front forces the rupture, in order to 
obtain room, out towards the spinous process of the ilium, and, when the pro- 
trusion is large, even down over Poupart’s ligament upon the thigh. This 
forms one variety of intraparietal hernia. 
In a young man on whom 1 operated for a strangulated hernia, the tes- 
ticle was first encountered occupying the principal part of the canal, above 
which was found the bowel turned 
directly back, the sharp flexion of 
which appeared to constitute the 
cause of the constriction. 
Scrotal Hernia.—When either a 
direct or an indirect inguinal hernia 
passes through the external abdom- 
inal ring and enters the scrotum, it 
is called a scrotal hernia. In such 
a rupture the sac—formed from the 
parietal peritoneum—and its con- 
tents are placed anterior to the 
tunica vaginalis, with the testicle 
near the bottom of the scrotum. 
(Fig. 454.) 
Three other forms of scrotal her- 
nia are met with, which owe their existence to peculiarities in the vaginal 
process of the peritoneum accompanying the testicle in its descent from the 
loins into the scrotum, form- 
ing the tunica vaginalis testis. 
The first is commonly known 
as congenital hernia, and is due 
to the fact that the vaginal 
process does not contract 
around the cord and thus cut 
off communication between 
the cavity of the abdomen 
and that of the tunica vagi- 
nalis. Accordingly, the two 
cavities being continuous, the 
intestine passes down and 
lies in contact with the 
testicle (Fig. 455), or may 
descend, leaving the latter 
within the canal, or even in 
the abdomen. The second 
form, called infantile hernia 
(though it is also seen in per- 
sons of mature age), is caused 
by the upper or abdominal portion of the vaginal process, sometimes called the 
funicular process, remaining open, while the lower part, or that near the exter- 
nal ring, is closed. The hernia enters the funnel-like process thus formed, and, 
Fig. 454. 
Inguinal scrotal hernia; its relation to the tunica 
vaginalis and testicle. 
Fig. 455. 
Congenital hernia, showing testicle and hernia in the same sac. INGUINAL HERNIA. 
587 
pushing it gradually downwards until it is protruded into the scrotum, fash- 
ions for itself a sac distinct from the tunica vaginalis, the testicle being below 
with an independent covering. (Fig. 456.) The third variety is the encysted 
hernia of Cooper. This rupture is produced by the vaginal process closing at 
the internal but remaining open at the external ring. The hernia pushes be- 
fore it the parietal peritoneum as in the formation of an ordinary rupture, and 
carries it gradually downwards until it is protruded into the unclosed tunica 
vaginalis below, forming in this way two sacs. (Fig. 457.) This variety of 
the disease was termed by Ifey, infantile hernia. 
Fig. 457. 
Fig. 456. 
Infantile hernia, having the funicular process as its sac. 
Encysted hernia. 
Hernia in females.—The forms of inguinal hernia which occur in females, 
and the coverings, are the same as those in males. The round ligament occu- 
pies, in the canal, the place of the spermatic cord in the male, and the labium 
the place of the scrotum. 
Diagnosis.—There are a number of tumors which occur in the regions 
occupied by inguinal hernia and which serve in many instances to embarrass 
the practitioner. Some of these can be made to appear and disappear by 
position or by pressure, which circumstance enhances the difficulty of diag- 
nosis. There are three kinds of swellings which resemble inguinal hernia. 
These may be generalized as the reducible, the irreducible, and the mixed. The 
reducible swellings are varicocele, congenital hydrocele, and hydrocele of the 
funicular sheath of the cord. 
The irreducible swellings are hydrocele and hfematocele of the vaginal 
tunic, sarcocele, undescended testicle, enlarged glands, and abscess. 
The reducible swellings which simulate inguinal hernia.—The first to be noticed 
is varicocele, and the points of likeness and dissimilarity may be contrasted as 
follows: 
In inguinal hernia the swelling occupies the 
scrotum. 
The swelling appears in the erect, disappears 
in the recumbent position. 
Distinct impulse on coughing or in straining. 
Round or oval in form, having a smooth, uni- 
form surface and an elastic feel. 
The skin unaltered in color. 
When reduced in the recumbent position, and 
the patient rises to the erect position, the swelling 
reappears first at the upper part of the scrotum, 
gradually descending to its bottom. 
When reduced and a finger is placed over the 
external ring, neither coughing, straining, nor 
standing will cause the tumor to appear in the 
scrotum. 
INGUINAL HERNIA. 
In varicocele the swelling occupies the scro- 
tum. 
The swelling appears in the erect, disappears 
in the recumbent position. 
Faint impulse on coughing or in straining. 
Elongated in form; irregular in surface; a 
soft, doughy feel, with the sensation like that of 
interlacing or contorted cords. 
The skin often having a blue color, in conse- 
quence of the proximity of the dilated veins to 
the surface. 
On rising to the erect position after recum- 
bency, the swelling reappears first at the bottom 
of the scrotum, gradually rising towards the 
abdomen. 
When reduced and a finger is applied with mod- 
erate pressure over the external ring, the swelling 
will quickly reappear. 
VARICOCELE. 588 
DISEASES OF THE ABDOMEN. 
The presence of omentum as a constituent of the hernial sac may cause it 
slightly to resemble varicocele, but the feel of the soft fatty tissue of the former 
is very different from that of the latter, and the impulse which hernia com- 
municates on coughing is quite unlike that received from a bundle of veins 
and the slight distention produced by any force transmitted through the 
abdominal contents. 
Congenital hydrocele may occupy either the tunica vaginalis testis or the 
funicular sheath of the cord; and in distinguishing hernia from either of 
these conditions the following considerations will aid in establishing the 
proper diagnosis: 
INGUINAL HERNIA. 
Reducible by taxis or the horizontal posi- 
tion, disappears suddenly, and generally with a 
gurgling sound. 
Is not translucent by the light test. 
Recedes slowly and silently. 
Is translucent by the light test. 
CONGENITAL HYDROCELE. 
More difficulty may be experienced in distinguishing the hernia from en- 
cysted hydrocele. The fluid in the latter may be pressed into the inguinal 
canal, or, if confined to the canal, can be pressed up to its summit and out of 
sight, just as a hernia may be; but hydrocele, on the removal of this press- 
ure, or upon the cord being grasped below the external ring, and without 
straining or coughing on the part of the patient, will quickly reappear. Such 
will not be the case with a hernia. 
The irreducible swellings which resemble inguinal hernia.—The first swelling 
to be noticed is hydrocele. This is a very common disease, but can be readily 
distinguished from hernia by the following peculiarities : 
HERNIA. 
HYDROCELE. 
Commences above and descends into the scro- 
tum. 
The cord cannot be felt when the hernia is in 
the scrotum. 
Impulse communicated in coughing or strain- 
ing. 
Reducible. 
Opaque by light test. 
Hangs to the body. 
No fluctuation. 
Commences below and rises upwards. 
Between the external ring and the top of the 
hydrocele the cord can be felt. 
No impulse experienced. 
Non-reducible. 
Translucent by light test. 
Stands off from the body. 
Fluctuation. 
In consequence, generally, of an injury, a collection of blood may form in 
the cavity of the tunica vaginalis, constituting a hcematocele. How shall we 
avoid confounding it with hernia ? 
HERNIA. 
HEMATOCELE. 
History of an injury not usually present. 
The tumor is soft, offering little resistance to 
pressure. 
Tumor moderately heavy. 
Admits of impulse. 
Skin natural. 
Cord concealed by the tumor 
Exploration by the grooved needle reveals no 
blood. 
Generally the history of an injury. 
Firm and resistant. 
Markedly heavy. 
No impulse. 
Skin often discolored. 
Cord free and easily grasped. 
Grooved needle reveals blood. 
Sarcocele, or enlargement of the testicle, has really, except in position, few 
points of resemblance to scrotal hernia. Yet the diseases are often confounded 
with each other. The following considerations will serve to establish the lines 
of difference: INGUINAL HERNIA. 
589 
INGUINAL HERNIA. 
SARCOCELE. 
Always a reducible tumor at some stage of its 
history. 
The inguinal canal occupied, and the cord con- 
cealed. 
Impulse on coughing. 
Tumor light. 
Tumor soft. 
Tumor has a uniform surface. 
Always irreducible. 
The canal unoccupied, and the cord free. 
No impulse on coughing. 
Tumor heavy. 
Tumor hard. 
Tumor has an uneven surface. 
An undescended testicle may be mistaken for hernia. The resemblance 
between the two is increased in those instances where the gland is unstable 
in its position, becoming the sport of the cremaster muscle and of the guber- 
naculum, and where sometimes it is found in the upper part of the scrotum 
and at other times in the inguinal canal. Two or three differential points 
will remove all obscurity in such a case: 
INGUINAL HERNIA. 
UNDESCENDED TESTICLE. 
Testicle in the scrotum. 
Soft in consistence. 
Firm pressure causing no peculiar pain. 
Absence of the gland from the scrotum. 
Hard in consistence. 
Firm pressure giving rise to a sickening pain. 
There are cases in wrhich the canal contains both a hernia and a testis. The 
latter is in advance of the former; and pressure will determine which is the 
gland. 
Situated above Poupart’s ligament, a little below the internal abdominal 
ring, are one or two lymphatic glands, w7hich, by one not altogether familar 
with tumors in this region, might be regarded as an incomplete hernia. The 
differential features of the two are as follows: 
No history of a previous disease, such as 
gonorrhoea or syphilis, or of a local irritation in 
any part of the lower extremity. 
Direction of the tumor in the long axis of the 
inguinal canal. 
Admits of little movement at any time, and 
lies deep. 
Devoid of any great sensibility. 
Generally reducible. 
Uniformly soft in consistence, and the super- 
incumbent skin of a natural color. 
INGUINAL HERNIA. 
Usually traceable to a local irritation, or to a 
constitutional state. 
Direction of the tumor oblique to the long 
axis of the canal. 
In its commencement quite movable, and is 
superficial in position. 
During the acute stage of the enlargement is 
very sensitive and painful. 
Not reducible. 
At first hard, afterwards becoming soft; the 
skin in the early stage often of a red color and 
oedematous. 
ENLARGED INGUINAL GLANDS. 
In a number of instances I have seen an abscess, having its origin in the lum- 
bar vertebrae, find its way between the muscular planes of the abdomen and 
form a prominent swelling in the course of the inguinal canal. This swelling 
is diminished by the recumbent position or is susceptible of being reduced in 
size by pressure, and, when manipulated, may yield a peculiar sound. These 
facts give to such an abscess some of the signs of incomplete hernia. The 
distinction may be determined by attention to the following points: 
INGUINAL HERNIA. 
ABSCESS. 
Occurs in persons of unimpaired health, and 
without previous or premonitory symptoms. 
Without fluctuation. 
Occurs in persons usually having a constitu- 
tional vice, and who have long suffered from sore- 
ness, pain in the loins, accompanied with loss of 
flesh, and with hectic symptoms. 
With fluctuation. 
In addition to the affections now enumerated, fatty tumors are occasion- 
ally encountered in the canal, more or less connected with the cord; and 
also dropsy of the sac. The cord itself may become inflamed and thickened, 
in either case forming a swelling which occupies exactly the position of an in- 
complete hernia. The irreducibility of such tumors, the absence of a distinct 
impulse, and the difference in consistence,—being doughy in fatty growths 590 
DISEASES OF THE ABDOMEN. 
and very hard in inflammatory disease of the cord,—will serve to distinguish 
such from rupture. 
Treatment.—Inguinal hernia, whether incomplete or complete,—that is, 
whether in the inguinal canal, in the scrotum, or in the labium,—if reducible, 
should be restored to the abdominal cavity, and there retained by a carefully- 
adjusted truss, the pad of which should be so placed as to compress the entire 
Canal. A very common error committed in the application of a truss is that 
Fig. 458. 
Fig. 459. 
Truss adjusted to a case of inguinal hernia. 
Posterior view of the truss. 
of bringing the pad so low as to rest on the pubic bone, and consequently, in 
bending, the surface of the abdomen corresponding to the inguinal passage 
recedes from the pad and allows the hernia to escape. The instrument as 
modified by Mr. Gemrig (Fig. 458), having a bearing on both inguinal re- 
gions (though lightly on the sound side), is not liable to change its position, 
Fig. 461. 
Fig. 460. 
Rubber truss, without the dorsal pad. 
Fig. 4r»y. 
Hard-rubber truss for single inguinal hernia. 
Rubber truss for double inguinal hernia. 
and the posterior pads resting on the fleshy portions of the pelvis on either 
side of the sacrum are connected by a strap having a number of holes, by 
which the truss can be tightened or relaxed. (Fig. 459.) INGUINAL HERNIA. 
591 
The hard-rubber truss is likewise well suited for the treatment of inguinal 
hernia. The best patterns are those represented in Figs. 460, 461, and 462. 
In the application of the rubber truss to an inguinal hernia of one side, 
two patterns are employed,—one in which the spring and the pad cross over 
from the sound to the affected side (Fig. 463), and the other in which the 
spring and the pad come round the side on which the rupture is situated. 
(Fig. 464.) When the hernia is double, a pad is attached to each extremity of 
the spring, and when the truss is applied, a strap extends from one pad to the 
other, in order that the instrument may keep its place securely. (Fig. 465.) 
Irreducible inguinal hernia, when in the scrotum, requires the use of a 
suspensory bandage,—a dressing which greatly relieves the weight and 
Fig. 463. 
Fig. 464 
Truss applied to an inguinal hernia from the 
affected side. 
Truss applied to an inguinal hernia and crossing 
over from the sound to the affected side. Below, 
same truss, detached. 
dragging sensations so often complained of by patients suffering from large 
hernise, and also resists, in some degree, an increase in the protrusion. "When 
the hernia remains in the canal and is irreducible, a truss with a concave 
pad (Fig. 460, a) may be worn with advantage, in the use of which the surgeon 
should see that the concavity is ample enough not to press injuriously upon 
the tumor. Infants having hernia form no 
exception to the rule requiring an early ap- 
plication of a truss. If the instrument is 
properly fitted, and if the surface of the skin 
upon which the pad rests is well rubbed with 
alcohol and afterwards dusted with prepared 
chalk or with lycopodium, no apprehension 
of excoriation or of ulceration need be felt. 
It is in this class of patients that a cure may 
be confidently expected, and hence the neces- 
sity for an early resort to the instrument. 
Strangulated inguinal hernia.—When the 
hernia becomes strangulated and cannot be 
restored by taxis, an operation wfill at once 
become necessary. The hair should be 
shaved from the pubes on the affected side, 
the urine removed from the bladder, and an incision made, extending from 
the external ring almost to the lower extremity of the tumor. The different 
layers of tissue constituting the coverings of the hernia should be raised upon 
Fig. 465. 
Truss applied for double inguinal hernia. 592 
DISEASES OF THE ABDOMEN. 
the director and divided to the full extent of the external or tegumentary 
wound, securing at the same time any vessels which may spring. Tt is very 
improbable that the operator will be able to lift the stratifications of tissue 
in the order usually described, and if he could do so it would prove of little 
value. He will, however, be always able to recognize one of these coverings,— 
the cremaster muscle, which is separated from the sac only by some connective 
tissue, so that when this muscle is reached he should proceed with increased 
caution. When the hernial sac has been laid bare, the next step consists in 
ascertaining the situation of the stricture and dividing it sufficiently to admit 
of the reduction. In oblique inguinal hernia the stricture will be found in 
the cellular tissue external to the neck of the sac, commonly described as 
the internal ring, at the inner surface of the neck of the sac ; and it is said 
that it may be at the external ring, or under the edge of the internal oblique 
and transversalis muscles. According to my own observation, it is generally 
situated either at the internal ring or at the neck of the sac. Where it is 
possible, the surgeon should effect reduction without opening the latter. In 
dividing the stricture, the knife must be guided flatwise upon the finger, and 
when it is fairly underneath the resisting band it should be turned so that it 
will lie exactly parallel with the course of Poupart's ligament, after which its 
edge should be directed against the constriction and pressed by the underly- 
ing digit directly upwards, in order to avoid wounding the epigastric artery, 
which lies behind and to the inner side of the hernia. 
Should symptoms of strangulation be present without any visible tumor, 
and there be grounds to suspect the existence of a concealed or an incom- 
plete inguinal hernia, the surgeon should have no hesitation in laying open 
the canal in order to verify or to disprove its existence. In such a case 
the incision should be made over and in the course of the inguinal canal, 
beginning one inch above the middle of Poupart’s ligament, and extending 
into the external ring. The skin, superficial fascia, tendon of the external 
oblique, and some of the fibres of the internal oblique and transversalis mus- 
cles, will require to be divided, when the internal ring will be exposed, and 
the rupture, if present, detected. 
Should the case be one of direct or ventro-inguinal hernia, the stricture 
must be sought for at the external abdominal ring, or at the edge of the 
“conjoined tendon;” and in dividing it, the edge of the bistoury should be 
directed upwards and slightly inwards, to avoid the epigastric artery, which 
lies external to the rupture. 
Dropsy of the hernial sac is an inflammatory disease, usually induced by trau- 
matism, operating at the time the hernia occurs or at any period after, though 
sometimes due to irritations wholly arising within the sac. When the disease 
arises from active violence, as contusions, the dropsy takes on an acute form, 
accompanied by the usual signs of inflammation, heat, swelling, and pain. 
When existing in the chronic form the signs are swelling and fluctuation, un- 
accompanied by pain or undue sensibility. Males suffer oftener than females, 
and the accumulation is usually met with in inguinal (congenital or acquired), 
and occasionally in femoral, hernia. 
-Diagnosis.—Hernial dropsy may be confounded with ordinary hydrocele, 
either of the cord or of the vaginal tunic. The light test will generally enable 
the surgeon to establish the distinction, and that chiefly through the relation 
of the fluid to the intestinal or omental contents of the sac, being in hernial 
dropsy either above or external to the latter, not at the bottom of the scrotum. 
In some rare instances the dropsical accumulation may occupy the sac of an 
old hernia, its contents having been retained within the abdomen. 
Treatment.—In the acute variety the application of leeches, followed by 
lotions of lead-water and laudanum, the parts being well supported, will con- 
stitute the proper plan of treatment. In the chronic form such means are 
valueless. The sac should be laid open, and, if occupied by a mass of omen- 
tum thickened by interstitial deposits, it should be excised. If there is an 
enterocele, reduce, if possible, paint the inner surface of the sac with tine- FEMORAL HERNIA. 
ture of iodine, and close with a few sutures, leaving a drainage-tube in for 
a few days. 
Professor McArdle and Dr. Kolipinski have collected twenty-nine cases of 
hydrocele of the hernial sac. 
593 
Femoral Hernia. 
In femoral hernia, the intestine, omentum, or both, pass from the abdomen 
beneath Poupart’s ligament, and appear at the inner and anterior portion of 
the thigh. When the tumor is large, it will frequently be found to lie parallel 
with Poupart’s ligament, and sometimes to turn over that structure and rest 
upon the lower part of the abdomen. 
Anatomy.—When the skin and superficial fascia are removed from the front 
of the thigh, below Poupart’s ligament, the fascia lata will be exposed. Rest- 
ing upon this strong muscular envelope is the internal saphenous vein, which, 
a short distance below Poupart’s ligament, disappears from viewT in the midst 
of a loose mass consisting of inguinal lymphatic glands, fat, and connective 
tissue. Through this tissue also pass the superficial epigastric, the superficial 
circumflex iliac, and the superficial pudic arteries and veins; also numerous 
lymphatic vessels from the subcutaneous portions of the thigh, abdomen, and 
generative organs. The etfect of so many structures entering and passing out 
at this point is to cause numerous perforations in the fascia, and hence this 
mass of glandular and connective tissue is termed the cribriform fascia. When 
the fascia is carefully cleared away, a peculiar opening—saphenous, or like the 
figure 6—is exposed in the fascia lata, at the bottom of which opening lie the 
femoral vessels enclosed in their sheath, and through wThich passes the saphe- 
nous vein in order to empty into the femoral. That portion of the fascia lata 
is external to the saphenous opening is the sartorial, and that part 
which is internal to this orifice is the pectineal fascia. The inner border of 
the outer or sartorial portion is crescentic or sickle-shaped, and is called the 
falciform process, the upper extremity of which, connected to and folded 
beneath Poupart’s ligament, constitutes Hey's ligament. (Pig. 466.) The 
space between Poupart’s ligament and 
the innominate bone is the crural arch. 
At the inner or pubic extremity of this 
arch the ligament is attached some dis- 
tance back along the linea ilio-pectinea, 
forming a strong crescent-shaped mem- 
brane. Gimbernat’s ligament, its concavity 
looking outwards. 
Passing through this crural arch, and 
enumerated from without inwards, are 
the iliacus internus and psoas magnus 
muscles, between them the anterior cru- 
ral nerve, and inside the femoral artery 
and the femoral vein. It so happens that 
the femoral vein does not quite reach 
to the inner boundary of the crural 
arch, or, what is equivalent, to Gim- 
bernat’s ligament, in consequence of 
which a weak point exists at this place, 
to which the name femoral ring is ap- 
plied. This ring is therefore situated 
between the femoral vein and Gimber- 
nat’s ligament, and it is through this 
space that a femoral hernia descends from the abdomen to the thigh. It is 
not possible for the protrusion to occur at any other part of the crural arch. 
One not familiar with the anatomical provisions of this part of the pelvis 
might ask, Why cannot a hernia pass out at any point between Poupart’s 
Fig. 466. 
a, Poupart’s ligament; b, saphenous opening, 
beneath the external abdominal ring; c, sartorial 
fascia; d, pectineal fascia; e, Hey’s ligament;/, falci- 
form process; g, saphenous vein, entering the fem- 
oral vein. 594 
DISEASES OF THE ABDOMEN. 
ligament and the structures which fill the crural arch, or behind these and 
the innominate bone ? The answer to this question is as follows : 
Between the peritoneal sac which contains the intestines and the muscles 
which lie in front and behind, viz., the abdominal and the iliacus internus 
and psoas magnus, is interposed a fascia, which anteriorly is called the trans- 
versalis, and posteriorly the iliac. These two unite along the inner surface 
of Poupart’s ligament, and thus render it impossible for any of the abdom- 
inal viscera to slip through beneath the ligament and that part of the crural 
arch which is occupied by the psoas and iliacus internus muscles. The space 
internal to these muscles is that portion appropriated to the passage of the 
blood-vessels, and may be called the vascular part of the crural arch, in con- 
tradistinction to the other, the muscular part. The transversalis and iliac 
fasciae, which along the muscular portion of the arch are attached to Pou- 
part’s ligament, divide when they reach the vascular part, the iliac passing 
out upon the thigh behind and the transversalis in front of the blood-vessels, 
thus forming a sheath for the femoral artery and vein as they lie in the 
saphenous opening. To prevent any of the abdominal contents from reaching 
the thigh, either in front of or behind the vessels, two strong membranes pass 
from Poupart’s ligament and the vascular sheath in front to the iliac fascia or 
the sheath behind,—one between the artery and the vein, and the other on the 
pubic or inner side of the vein. We are thus brought to the little space be- 
tween the femoral vein and Gimbernat’s ligament,—the femoral ring,—which 
alone remains unfortified, and where alone visceral escape, except in very rare 
instances, is possible. Fig. 467 will furnish an explanation of the anatomical 
Fig. 467. 
Fig. 468 
a, muscular portion of the crural arch occupied by the 
iliacus intertills; b, psoas magnus; c, crural nerve, with 
iliac fascia in front; d, Poupart’s ligament; e, femoral ar- 
tery ; /, femoral vein, with the iliac and transversalis fascia 
separating at the inner edge of the muscles, g, and passing 
in front and behind the vessels to form their sheath, with 
its vertical membranous partition, h; i, Gimbernat’s liga- 
ment ; j, femoral ring. 
Femoral hernia. 
structures described in the text. Above the femoral ring an important artery 
—the obturator—is frequently met with. Though such is an anomalous posi- 
tion for this vessel, it is a very common distribution, occurring in about one 
out of every three cases, and should be remembered in all operations for stran- 
gulated femoral hernia, as in the course of the vessel from the epigastric 
to the obturator foramen, through which it passes to the thigh, it is exposed to 
injury in the act of dividing the stricture. The neck of the sac of a female 
hernia is also related to the epigastric artery and to the spermatic cord, the 
first being on its outer side, and the last above and to the inner side. 
The process by which a femoral hernia is formed is as follows. The intes- 
tine, or omentum, or both, enclosed in the peritoneum or sac, are impelled 
against the inner part of the crural arch, and, meeting with little resist- FEMORAL HERNIA. 
595 
ance at the internal ring, that is, between the femoral vein and Gimbernat’s 
ligament, gradually press through, glide underneath Poupart’s ligament, fol- 
lowing the vessels, and then, having entered the saphenous opening, come 
forward upon the thigh, forming a tumor or a swelling, more or less distinct, in 
the groin. (Fig. 468.) The coverings of such a hernia are the skin, the super- 
ficial fascia, the cribriform fascia, the subperitoneal cellulo-fatty tissue, some- 
times called the septum crurale, and the sac. Some enumerate the sheath of 
the vessels, called by Cooper the fascia propria, as one of the investments of 
femoral hernia. That it ever forms one of the coverings is exceedingly doubt- 
ful. I have never witnessed in my operations for strangulated femoral rup- 
ture anything which resembled this structure ; and when it is considered how 
very frail is the connection of the vascular sheath with Gimbernat’s ligament, 
it is easy to understand how it must give way and allow the hernia to pass 
down. 
Femoral hernia occasionally deviates from the course which has been de- 
scribed. The tumor may remain in the saphenous opening without entirely 
displacing the cribriform fascia or coming forward upon the thigh; in 
which case it is called incomplete femoral hernia,—analogous somewhat to 
the inguinal form of the disease which remains in the inguinal canal and is 
called incomplete inguinal hernia. Cloquet has described a rare variety of 
this rupture, in which the intestine passes behind the sheath of the vessels, 
or between the latter and the pectineus muscle ; and Partridge, one where 
the protrusion takes place on the outside of the vessels. Hesselbach also 
speaks of a multilobular form, caused by portions of the sac passing through 
different openings in the cribriform fascia. So rare, however, are these 
varieties of femoral rupture that they are to be regarded rather as surgical 
curiosities than as subjects of practical interest. 
The contents of the sac of a femoral hernia differ very little from those 
of an inguinal hernia. They consist of both intestine and omentum, 
but in most cases not to the same extent as in the latter rupture; nor 
does the omentum so frequently constitute a part of the sac as in inguinal 
hernia. 
Symptoms.—The existence of a femoral hernia is usually recognized by the 
presence of a firm oval swelling below Poupart’s ligament, at the inner side 
of the thigh, and between the spine of the pubic bone and the femoral vessels. 
The exact position of the protrusion is determined by the size of the hernia. 
When large, in consequence of the resistance encountered by the attachment 
of the cribriform fascia at. the lower margin of the saphenous opening, the 
swelling will either lie transversely along the lower border of Poupart’s liga- 
ment or will turn over the latter upon the abdomen. In the last position 
it has often been mistaken for an incomplete inguinal hernia. Even small 
hernise manifest a disposition to turn upwards over Poupart’s ligament. In 
the act of coughing, an impulse is communicated to the tumor, and on per- 
cussion a distinct resonance can often be elicited. In some cases the protru- 
sion does not pass through the saphenous opening, but remains in the femoral 
ring, and consequently makes scarcely any external appearance. When such 
a condition is suspected, the investigation must be made when the parts are 
thoroughly relaxed. This can be best effected by elevating the shoulders, 
flexing the leg upon the thigh, and the thigh upon the abdomen, the knee 
being at the same time turned towards the opposite side. If a finger be now 
pressed into the saphenous opening and upwards under Poupart’s ligament, 
the hernia, if present, may be recognized by the characteristic impulse on 
coughing. 
Diagnosis.—Femoral hernia may be confounded with other affections 
which have their location in the groin, the most common of which are 
incomplete inguinal hernia, enlargement of the inguinal lymphatic glands, 
psoas abscess, varicose dilatation of the saphenous vein, and fatty and sar- 
comatous growths. 
Incomplete inguinal hernia is distinguished by the following characteristics: 596 
DISEASES OF THE ABDOMEN. 
When in the usual position, Poupart’s ligament 
can be recognized above the tumor. 
The form is oval or spherical, and the tumor 
lies transversely to the long axis of the thigh or 
parallel with Poupart’s ligament. 
When turned over Poupart’s ligament, if the 
tumor be drawn down towards the thigh, the 
former can be distinctly felt by the finger in its 
entire course. 
Femoral artery can be felt pulsating on the 
outer side. 
The spine of the pubis is on the inner side. 
The neck of the tumor can be traced deep into 
the thigh, below Poupart’s ligament. 
Quite movable. 
In the recumbent position, when the thigh is 
flexed on the abdomen, the mobility of the tumor 
is materially increased. 
Most common in the female. 
Most common in mature life. 
FEMORAL HERNIA. 
Poupart’s ligament is recognized below the 
tumor. 
The form is oblong, and the tumor lies oblique 
both to the longitudinal axis of the thigh and to 
Poupart’s ligament. 
Should the tumor cover Poupart’s ligament, it 
must be raised up in order that the latter shall 
be felt. 
Femoral artery is some distance below. 
The spine of the pubis is on the outer side when 
the hernia is in the ring. 
The neck of the tumor is more superficial, and 
above Poupart’s ligament. 
Not much mobility. 
Under a similar position the mobility of the 
tumor is not materially increased. 
Most common in the male. 
Common at all periods of life. 
INCOMPLETE INGUINAL HERNIA. 
Much information may also be gained by examining the respective rings, 
in order to ascertain if they are unoccupied, by drawing upon the protru- 
sion and at the same time watching the effect upon the contiguous parts, 
whether the tension of the soft parts is in the direction of the thigh or in 
that of the abdomen, and by carefully noticing the direction of the impulse, 
whether downwards or forwards in the course of the thigh, or downwards 
and inwards towards the external abdominal ring. When the hernise which 
have been described are reducible, little difficulty can arise in forming the 
proper diagnosis, as the finger will determine the unoccupied ring, and, by 
commanding it, prevent the return of the tumor, either in standing or in 
coughing. 
Enlargement of the inguinal glands has, in my experience, been more fre- 
quently confounded with femoral hernia than any other swelling in this 
region. The signs of the two may be contrasted as follows : 
FEMORAL HERNIA. 
ENLARGED INGUINAL GLANDS. 
Unless strangulated, a painless tumor, without 
discoloration of the skin or undue sensibility to 
the touch. 
A smooth, regular, and somewhat elastic swell- 
ing. 
Pulsation of the femoral artery external to the 
tumor. 
Impulse communicated on coughing; tumor 
deeply situated. 
If reducible, the disappearance of the swelling 
effected by posture or taxis. 
Tumor rendered more fixed by extension of the 
limb. 
Acute adenitis is painful, and the superim- 
posed skin is red and sensitive to the touch. 
An irregular swelling, the individual glands of 
the group often being recognized by the fingers, 
and having a hard feel. 
Pulsation of the femoral artery beneath and to 
the inner side of the tumor. 
No impulse communicated on coughing; tumor 
superficial. 
Not affected by position or by taxis. 
Tumor not affected by straightening the limb. 
Hernia and enlarged glands may coexist, in which case the diagnosis would 
he rendered more perplexing. If symptoms of strangulation be present in a 
case of enlarged glands, an exploratory incision should be made, in order to 
remove all uncertainty. 
Psoas abscess is frequently mistaken for femoral hernia. Such an error 
betrays considerable anatomical ignorance, notwithstanding that there are 
several points of resemblance between the two diseases. For example, both 
tumors are below Poupart’s ligament; both are without discoloration of the 
skin, and without undue sensibility; both are, at some stage, diminished by 
recumbency and pressure; and both receive an impulse on forced expiration. 
Here, however, the resemblances cease. The broad distinctions are as follows: FEMORAL HERNIA. 
597 
FEMORAL HERNIA. 
PSOAS ABSCESS. 
No previous history of lumbar pains or im- 
paired health. 
When reduced, the swelling recedes with a sud- 
den slip, and often with a gurgling noise. 
Without fluctuation. 
Internal to the femoral vessels. 
Obscure pain in the back and the loins, and a 
gradual failing of the strength and vigor of the 
body. 
Disappears slowly and noiselessly. 
AVith fluctuation. 
External to the femoral vessels. 
The last distinction is the most important, as a psoas abscess following the 
sheath of the psoas muscle will be conducted beneath the outer part of the 
crural arch,—that part occupied by the psoas and iliacus internus,—and of 
course external to the femoral artery and vein, whilst a femoral hernia, fol- 
lowing the course Of the vessels, will pass through the inner part of the arch 
to the thigh internal to the femoral vein and artery. Should a pelvic abscess 
pass through the obturator foramen, or through the femoral canal, the task 
of distinguishing the disease from hernia would be more difficult; but a care- 
ful inquiry into the previous history of the patient, and the use of the exploring 
needle, will satisfactorily declai*e the nature of the tumor. 
From varix of the saphena magna, femoral hernia may be distinguished by 
attention to a few contrasted points: 
Marked impulse on forced expiration. 
Not removed by pressing the tumor down- 
wards. 
Not affected by pressing on the saphenous vein 
below. 
No varicose condition of the vein below the 
tumor. 
When restored by the recumbent position, will 
not reappear when the patient rises to his feet if 
the saphenous opening be blocked by the finger. 
FEMORAL HERNIA. 
Slight impulse on forced expiration. 
Temporarily disappears by pressing the swell- 
ing downwards. 
Temporarily diminished by pressing on the 
vein below. 
Varicose state of the vein below the tumor. 
After subsiding under similar circumstances, 
cannot be prevented from returning by pressure 
over the saphenous opening. 
VARIX OF THE SAPHENA MAGNA. 
Fatty growths are frequently seen in the femoral region of the thigh, and 
occasionally occupy the saphenous opening. The differential peculiarities 
may be arranged as follows: 
FEMORAL HERNIA. 
ADIPOSE TUMOR. 
Elastic in its consistence. 
Having a regular or uniform surface. 
Impulse on coughing or straining. 
Always reducible at some period of its history, 
and when restored to the abdomen does not re- 
turn except in the standing position, or upon some 
forcible effort at straining or coughing. 
Doughy in its consistence. 
Often made up of lobules. 
No impulse on coughing or straining. 
Never reducible, or, if so, admits only of being 
pushed into the saphenous opening, reappearing 
immediately after the removal of pressure, with- 
out reference to position, etc. 
Sarcomatous and other malignant tumors occupying, as they frequently do, 
the front of the groin, have been sometimes mistaken for hernial tumors. 
Their rapid growth, irregular surface, peculiar configuration of the surface- 
veins, and, after a time, the purple discoloration of the overlying skin, together 
with their irreducibility and their distance from the saphenous opening, are 
sufficient to establish a just distinction between such morbid growths and 
femoral rupture. 
Treatment.—The treatment of reducible femoral hernia consists in the 
application of a proper truss. The pad should be smaller than that used for 
inguinal hernia, and decidedly more convex, in order that it may command 
the saphenous opening. It should be placed at nearly a right angle with 
the spring, so that the pressure may be exerted in the long axis of the fem- 
oral passage, just at the inner edge of the vessel and immediately below Pou- 
part’s ligament. As in inguinal hernia, the truss should encircle the pelvis, 
resting in the concavity which exists below the crest of the ilium. (Fig. 469.) 598 
DISEASES OF THE ABDOMEN. 
Nothing beyond the retention of the hernia can be expected from any appara- 
tus whatever, as the femoral ring, lying as it does beneath Poupart’s ligament, 
cannot be subjected to a compression sufficient to effect its occlusion. 
In irreducible femoral hernia the concave 
pad should be worn, in order to prevent an 
increased protrusion. In the event of an ac- 
cident happening to a truss, rendering it in- 
adequate to retain the rupture, a conical 
compress, placed over the saphenous open- 
ing and secured by a spica of the groin, can 
be extemporized with advantage. 
Strangulated femoral hernia.—In no form of 
strangulated hernia is time so important as 
in the one under consideration. The constric- 
tion to which the intestine is subjected by the 
dense aponeurotic membranes which bound 
the femoral rings and canal, increased by the 
sharp angle which the sac is compelled to 
make as it emerges through the saphenous 
opening, is sufficient, in many instances, to destroy the life of the hernial con- 
tents in a few hours. I always approach a case of femoral hernia, which has 
been strangled for more than thirty hours, with great distrust as to the result, 
and especially so when the tumor is of recent origin. 
In attempting reduction, the patient should be placed under an anaesthetic, 
the head and shoulders well raised, the leg on the affected side flexed upon 
the thigh, and the latter bent upon the pelvis, with the knee turned inwai'ds 
towards the opposite side. This position insures the most complete relaxa- 
tion of the structures about the saphenous opening. The surgeon now draws 
the tumor down upon the thigh,—should it have turned up over Poupai’t’s 
ligament,—and then, after using steady, gentle compression to its sides for 
one or two minutes, pushes it backwards into the external femoral opening, 
and at the same time upwards in the direction of the internal femoral ring. 
The reduction will be favored by placing the thumb and fingers of the other 
hand on the margin of the saphenous opening, in order to prevent the contents 
of the hernia from overlapping its sides. To secure the full benefit of taxis, it 
is absolutely necessary that the practitioner should understand the anatomical 
peculiarities of the femoral region. The three movements demanded for re- 
duction, by the relation of the hernia to the region through which it descends, 
are the following,—downwards, backwards, and upwards. If these have been 
properly tested for six or eight minutes without success, an immediate resort 
to the knife will be necessary. 
Operation.—After the skin has been well cleansed with alcohol or ether, 
and subsequently washed with corrosive sublimate lotion (one to one thousand), 
the surrounding parts being covered with towels wet in the same, the patient 
should be brought close to the edge of the bed, or he may be laid across the 
bed, with the limbs resting on a chair or a stool placed at its side. A vertical 
incision is next made over the entire length of the tumor, beginning a little 
above Poupart’s ligament. The layers requiring dissection are the skin, super- 
ficial fascia, and cribriform fascia. These should be raised and incised with 
great care upon a grooved director, displacing with the point of the instru- 
ment any glands or masses of fat which may be in the way of the dissection. 
Occasionally the superficial pubic vessels will require a ligature, though the 
bleeding is usually very slight in this operation. After exposing the sac, the 
surgeon must seek for the stricture, which is generally found to consist of the 
upper horn of the falciform process of the sartorial part of the fascia lata, 
commonly called Iley’s ligament, or at Poupart’s ligament. I have never met 
with a case in which the constriction was at Grimbernat’s ligament. The sac 
should now be pressed down with the fingers of one hand, while the probe- 
point of the hernia bistoury is slid flatwise under the overarching fascia above, 
Fig. 469. 
Truss for femoral hernia applied. UMBILICAL HERNIA. 
599 
and its edge turned against the tense membrane with sufficient firmness to 
produce a slight division of its structure, after which the parts can be stretched 
to the required extent if the first nick is not sufficient. An attempt should 
now be made to effect reduction without opening the sac; failing in this, the 
sac must be divided and its contents exposed. This accomplished, the surgeon 
will introduce the index finger into the neck of the sac, and, finding the stric- 
ture to be there, proceed to relieve it in the same cautious way as when at 
Iley’s or Poupart’s ligament. In using the knife for the purpose, the position 
of the blood-vessels must be kept in mind. The position of the femoral vein, 
to the outside of the hernia, renders an incision in that direction dangerous. 
The division should always be made directly upwards. The artery most ex- 
posed to injury is the obturator, which is derived from the epigastric and 
passes over the neck of the sac to the thyroid foramen. As this anomaly is 
a very common one, the operator should always act as though it were pres- 
ent, and, to avoid wounding the vessels, should blunt the edge of the knife 
by drawing it over his forceps. The instrument will thus be rendered too 
dull to harm the artery, and yet will be sufficiently sharp to divide a tense 
membrane like the stricture. The hernia having been returned into the 
body, a drainage-tube should be placed in the lower angle of the wound, the 
parts tacked together with a few stitches of the interrupted suture, and 
the ordinary antiseptic dressing applied. 
Umbilical Hernia. 
Two varieties of hernia appear in the median line of the body,—the um- 
bilical and the median ventral. Umbilical hernia may be either congenital or 
acquired. 
The congenital form of hernia is often associated with other defects in de- 
velopment, and is caused by an imperfection in the umbilical cicatrix and in the 
recti muscles allowing a portion of the abdominal contents to pass through 
the oritice, and by separating the umbilical artery and veins to form for itself 
a cavity in the connecting cellular and gelatinous tissue of the cord. The 
absence of the skin, and the translucent nature of the uniting substance of 
the umbilical cord, will admit of the hernial contents being seen within its 
substance. So delicate is this covering which encloses the intestine that it 
has been known to give way and leave the bowel uncovered. 
Acquired umbilical hernia is met with both in infants and in adults. 
The infantile form of the disease may immediately follow birth, even be- 
fore the foetus is separated from its placental connection,—a fact which sug- 
gests the propriety, on the part of the accoucheur, of always examining the 
umbilical end of the cord, in order to ascertain if such a hernia exists, since 
otherwise the intestine might be included in the ligature which surrounds 
the funis. Usually, however, infantile umbilical rupture appears in four or 
five months after birth, or before the constituents of the umbilicus have 
become firmly cicatrized to the surrounding structures. 
The disease is usually caused by crying or by straining, and hence its 
frequency in children who suffer from colic or intestinal tenesmus. 
Umbilical hernia of adults.—Women are very much oftener the subjects 
of the disease than men; and the obese suffer oftener than the spare. 
Females who have borne children are most disposed to this rupture. In every 
hundred cases of hernia, five or six will prove to be of the variety under con- 
sideration. The size to which umbilical hernise grow, especially on very fat 
persons, is remarkable. The sac contains omentum, a portion of the large 
and small intestine, and occasionally the stomach, spleen, and liver. Gay 
and Nourse each found the latter in an umbilical hernia, and Professor Gross 
records a case in which the sac contained the gravid uterus at nearly full term. 
The weight of the tumor when large drags the umbilicus down very much 
below its usual situation. (Fig. 470.) Considerable discrepancy of opinion 
has existed in reference to the coverings of an umbilical hernia. JDe la Faye, 600 
DISEASES OF TEE ABDOMEN. 
and, later, Petit, denied the existence of a hernial sac, alleging that the peri- 
toneum was always torn. This accident, 
no doubt, does sometimes occur, but it is 
by no means common. On the contrary, 
the presence of a peritoneal covering has 
not only been demonstrated by Cooper and 
by Scarpa, but has also been amply con- 
firmed by many later writers. In addition 
to a sac, the hernia is covered by cellular 
tissue and the skin. In large herniie the 
superincumbent parts sometimes become 
greatly attenuated, the peritoneum and 
fascia disappearing by absorption, in which 
case the contents of the tumor are almost 
directly in contact with the skin ; a fact 
of some importance, and inculcating cau- 
tion when it becomes necessary to operate 
in cases of strangulation. This thinning 
of the tissues may eventuate in ulceration 
and sloughing. Such was the result in an 
Irishwoman who was at one time under my care. When the slough dropped 
off, a portion of omentum slipped through the opening, and, becoming con- 
stricted, caused symptoms of strangulation, for which I was obliged to 
operate. 
Symptoms.—The signs of an umbilical hernia are generally very distinct, 
and consist of a convex, irregular, or pyriform swelling, protruding at the 
navel, varying in size from that of a marble to that of the adult head, in- 
creased on coughing or by an energetic expiration, yielding both a resonant 
and a flat sound on percussion, and in its early stage receding during recum- 
bency, or susceptible of being reduced by pressure. It is frequently accom- 
panied with colicky pains, flatulency, and nausea. 
Diagnosis.—Umbilical hernia is not likely to be confounded with any other 
affection, though the presence of a fatty or a malignant tumor, when situated 
in this region, might embarrass one not conversant with such diseases. The 
fatty tumor is generally lobular; yields a uniformly flat percussion ; commu- 
nicates no impulse; is not affected in size by coughing or straining; nor is it 
reducible. In malignant disease the induration is unlike the mixed elastic 
and doughy feel of a hernia. In addition, the immobility and irreducibility 
of such a tumor, and the absence of any increased protrusion during acts of 
forcible expiration, are quite sufficient to distinguish it from rupture. 
Treatment.—For cases of congenital umbilical hernia there are two plans 
of treatment,—by compression and by ligature. The first is to be preferred, 
being less likely to induce peritonitis. The hernia must be pressed from 
the cord into the abdomen, and while an assistant retains the sides of the 
aperture in close contact a conical compress is laid over the navel and re- 
tained in place by a broad strip of adhesive plaster extending around the 
body of the child. When the ligature is used, two or more pins are passed 
through the sides of the abdominal opening,—care being taken not to wound 
the peritoneum,—and the parts are drawn together by threads, after the 
manner of the figure-of-eight suture. 
In infantile hernia, a truss should be applied immediately on the appear- 
ance of the disease, with the almost certain prospect of effecting a cure. I 
have long been in the habit of using a very simple contrivance, and one 
which demands scarcely any skill to construct. A cork about one inch in 
diameter is cut into a plano-convex form, three-quarters of an inch thick 
from the base to the summit; its flat surface is then placed upon the centre 
of a strip of porous plaster three inches wide and sufficiently long to en- 
compass the body of the patient. I prefer this plaster to the ordinary adhe- 
sive material. The exposed part of the cork should next be covered by a 
Fig. 470. 
Umbilical hernia. UMBILICAL HERNIA. 
601 
piece of soft chamois leather, which can be stitched in a circular manner 
to the plaster. (Fig. 471.) In the application of this dressing the pad or 
cork should be placed directly over 
the navel, and the two ends of the 
plaster carried round the body during 
the act of expiration, by which it will 
be fixed with sufficient tightness to 
insure the necessary pressure. Such 
a dressing will maintain its place se- 
curely for four or five months, when 
it can be renewed. This simple con- 
trivance I have found to prove more satisfactory than the umbilical truss so 
commonly applied in cases of infantile rupture. A very common defect in 
the pad of the ordinary instrument is its long nipple-shaped process, which 
by acting as a wedge is calculated to prevent closure of the umbilical aper- 
ture ; and when this truss is used, care should be taken that a convex block 
be substituted for the conical one. 
In the management of umbilical hernia in the adult, a truss should be 
early applied, as there is always a strong tendency in the rupture to increase 
in size and to become irreducible from adhesion of its contents either to the 
sac or to each other. There are two trusses 
which answer well as means of retention in 
ordinary cases. One consists of a convex pad 
two inches or two inches and a half square, 
having elastic bands attached to surround the 
body; the other is a large concave pad, with a 
convex prominence in its centre (Fig. 472), 
which is placed over the umbilicus and retained 
in place by two steel springs surrounding the 
body. (Fig. 473.) 
It is, however, the umbilical hernise of very obese women, with pendulous 
abdomen, which so often perplex the surgeon. In such something more than a 
mechanism to control the hernial aperture is needed. There is required a 
general support for the entire abdomen. A few years ago I had Mr. Seeley, 
of this city, prepare an apparatus which has given me great satisfaction in 
cases of both reducible and irreducible umbilical rupture. For the first, or 
Fig. 471. 
Form of the cork-pad bandage for infantile umbilical 
hernia. 
Fig. 472. 
Umbilical truss. 
Fig. 473. 
Fig. 474. 
Umbilical truss applied to the body. 
Side-view of the apparatus applied for reducible 
umbilical hernia. 
reducible form, an oblong hard-rubber convex pad, three inches long by two 
and a half inches wide, and having two studs, one at each end, is fastened 
to an elastic bandage shaped so as to be adapted to the form of the abdomen 
and capable of being tightened by straps and by buckles placed at each side, 
designed to unite the front with the back part of the bandage. Two steel 602 
DISEASES OF THE ABDOMEN. 
springs covered with hard rubber, having a slot at one end and a pad at the 
other, with a connecting strip of leather, complete the apparatus. To apply 
this truss, the hernia should be pushed back and the pad be laid over the seat 
of the protrusion ; next the elastic bandage must be drawn up, by means of 
the side-straps and buckles, sufficiently far 
to give the requisite support, after which the 
steel springs are placed around the body, the 
pads resting on each side of the spine poste- 
riorly, and the slots slipped over the two 
studs on the anterior convex block. (Fig. 
474.) In cases of irreducible hernia, where 
the object is to prevent the increase of the 
tumor, it is only necessary to substitute a 
hollow pad for the convex one. (Fig. 475.) 
In all other respects the apparatus is the 
same as that described for reducible forms 
of the disease. In place of the hard-ruhber 
concave pad, I direct one to be formed out 
of gum-wood, which can be readily prepared 
of any size by a turner. 
Persons suffering from large irreducible 
umbilical hernia are frequently harassed with 
symptoms which simulate those of strangu- 
lation, such as abdominal pains, flatulency, 
tenderness over the rupture, constipation, 
and frequently vomiting. These phenomena 
are generally the consequence of some im- 
prudence in diet, the intestine becoming dis- 
tended with gas, or perhaps from its coils 
becoming entangled with the omentum. In such cases evacuations from the 
bowels should be solicited by large injections of warm water containing salt, 
or of flaxseed-tea and turpentine. The abdomen should be covered with hot 
fomentations, and small doses of calomel and opium (one-sixth grain of cal- 
omel and one-fourth grain of opium) administered every hour until relief is 
obtained. Persons having such hernias should be counselled to exercise the 
greatest care in regard to articles of food. Everything calculated to produce 
flatulency must be discarded, and daily alvine evacuations secured. 
Strangulated Umbilical Hernia.—Of one hundred cases of strangulated 
hernia, about six or seven will be of the umbilical variety. The symptoms 
of strangulation are often of a slow or chronic character, rather, indeed, 
those of obstruction than of strangulation. These are nausea, vomiting, 
and severe colicky pains in the rupture, the latter becoming very intense, 
either generally or at some particular part, together with constipation. 
These symptoms may continue for two or three days, and yet the patient 
be conducted safely through the attack without a resort to the knife. Iij 
most cases of umbilical hernia a considerable amount of omentum is present 
in the sac with the bowel. The former, lying as it does as a broad membrane 
immediately between the intestines and the umbilicus, is liable to be protruded 
through the orifice of the navel, or through an opening in the linea alba, in 
such a manner as to invest the peripheral surface of the intestine like one 
of the coverings, rather than to be projected as a fold, the form in which it 
generally appears in other varieties of hernia. The pseudo-strangulation 
may be produced by an ei*ror of diet, the bowels becoming filled with gas, 
or, if the rupture be an irreducible one, by an additional coil of intestine 
entering the sac, or by some entanglement of the contents. Whatever the 
cause, not a moment is to be lost in overcoming the difficulty. The patient 
should be placed under the influence of an anaesthetic, the head and the 
shoulders raised, and the limbs drawn up so as to relax the abdominal parietes. 
The surgeon next grasps the tumor with one or both hands, according to its 
Fig. 475. 
Below, concave pad for irreducible umbili- 
cal hernia, with belt and with spring de- 
tached, and above, the same applied to the 
body. STRANGULATED UMBILICAL HERNIA 
603 
bulk, and, after drawing it forward in order to elongate and consequently 
narrow its contents, he compresses it with a view to displace the flatus, and, 
lastly, pushes the contents of the rupture upwards and backwards. If a 
certain portion of the hernia be more tense and resistant than the rest, the 
taxis should be addressed to that part, as it is highly probable that the obstruc- 
tion is dependent upon the presence of a loop of intestine in addition to that 
ordinarily within the sac. Should the taxis fail, calomel and opium offer a good 
prospect of success. One-fourth of a grain of each, given every hour until 
twelve or fourteen consecutive doses have been taken, accompanied by the 
application of ice in a rubber bag or in a bullock’s bladder to the tumor, will 
frequently result in the subsidence of all the symptoms, or will enable the 
sui’geon, when, after twelve hours, he renews the taxis, to accomplish with 
ease the reduction of a part or the whole of the hernia. In two instances, 
in the case of a lady whose umbilical hernia had become strangulated and 
where taxis had failed, I was able to restore the rupture by renewing 
the manipulation fourteen hours later, calomel and opium having been ad- 
ministered and cold applied locally during the interval. Great benefit is 
occasionally derived in these cases from administering, after the first five or 
six hours of the above treatment, a large enema of flaxseed-tea and turpen- 
tine. The stimulus of the injection appears to excite a peristalsis, which is 
imparted to the implicated intestine, if the latter be not too tightly con- 
stricted, and favors the expulsion of the contained gas. When the symptoms 
become more acute, as will be manifested by obstinate vomiting, often ster- 
coraceous, by increase of pain, and by febrile disturbance, the only hope for 
the patient is in an operation. 
Operation.—After the established antiseptic preliminaries have been 
arranged, an incision should be made exactly in the mesial line, commencing 
two inches above the upper part of the tumor and terminating some two or 
three inches below, upon the surface. As the coverings are often greatly 
attenuated, the knife must be used with caution. The different layers, con- 
sisting of the integument and the subcutaneous adipose tissue, being raised 
and divided on the director, the linea alba and then the sac will be exposed. 
Clearing away with the director any bands of connective tissue which may 
still remain adherent, the finger should search for the tendinous margin of 
the umbilical opening, where perhaps the constriction will be found, and, if 
so, it may be relieved by passing between the tendon and the sac the usual 
herniotomy bistoury and cutting in a direction away from the hernia. It 
will be fortunate if the reduction can be effected without dividing the sac, 
for when the latter becomes necessary the doom of the patient is probably 
sealed, death following in almost all such cases. If, however, the strangula- 
tion cannot be overcome without such a resort, there is no alternative but 
to lay it open and divide the stricture within. If the contents are found 
extensively adherent, no further attempts at reposition should be made; the 
constriction being relieved, the intestine or omentum may be allowed to 
remain in the unreduced state. Before deciding upon this course, however, 
the surgeon should carefully, unravel the one from the other, to determine 
their irreducibility. If the intestine has become gangrenous, it is to be 
treated in the same manner as in other forms of rupture under similar condi- 
tions. Holmes* records a case of strangulation which was referred to an 
umbilical hernia, but which afterwards was found to be within the abdomen, 
and suggests that where, under a like misapprehension, the umbilical sac is 
opened and no explanation for the strangulation is found, the finger should be 
carried into the abdomen in search of the constriction, as was once done suc- 
cessfully by Mr. Bryant. Anomalous cases are occasionally met with in which 
the hernia is bilobed and the constriction is caused by the separating band ; 
and in still rarer instances the rupture, though forming a single swelling, has 
passed through two distinct openings in the median line contiguous to each 
other. In old cases of irreducible strangulated umbilical hernia the omentum 
* Surgery, p. 650. 604 
DISEASES OF THE ABDOMEN. 
is often found so thickened, rough, and altered in character, from its long 
residence outside of the body, that even when reduction is possible it would 
be improper to restore it. After the operation is completed, and if the con- 
tents are in a sound condition, the parts should be brought together by the 
interrupted suture, and supported by compresses of carbolized or sublimated 
gauze covered by absorbent cotton and secured by antiseptic rollers. 
Ventral Hernia. 
Ventral hernia may appear at any part of the abdominal walls. The 
usual situation of such, however, is in the course of the linea alba, and, for 
anatomical reasons, oftener above than below the umbilicus, the recti muscles 
diverging from each other as they ascend to their thoracic attachment, and 
leaving the “white line" less protected in this region. In the lumbar region 
there is a small space posterior to the angle formed by the intersection of 
the external and internal oblique muscles, which occasionally admits of a 
protrusion, forming a lumbar hernia. 
The Germans describe a form of ventral hernia not entitled to that dis- 
tinction, as it consists of an extreme extension or stretching of the entire 
anterior abdominal walls. 
Causes.—Generally this form of rupture is the result of wounds weaken- 
ing the parietes, or of the stretching of the tissues incident to the partu- 
rient state. I have seen such herniae form after Caesarean section, and in 
one ease of the kind was obliged to operate for a strangulation of the mass. 
A lady was recently under my care in whom, judging from the size of the 
swelling, all the intestines were external to the abdomen, having passed 
through the linea alba, forming a pendulous tumor, which lay between the 
thighs. The contents of this protrusion could be returned, and the edges 
of the recti muscles distinctly felt by the fingers. 
Contents.—The contents of a ventral hernia do not differ in any particular 
from those of other varieties of the disease, except when small, when it is 
said that the omentum alone is the usual occupant of the sac. Iloin and 
Garengeot speak of one form of the affection in which the stomach alone 
constitutes the tumor, an inference drawn from the gastric irritability which 
is present. Scarpa, however, could discover no reason why, in such a case, 
other portions of the intestinal tube may not be included, and states that no 
dissection has ever been made to prove the contrary. The irritability of the 
stomach he considers to be merely sympathetic. The locality of the protru- 
sion, on the left side of the ensiform cartilage, constitutes the only difference 
from hernia in the median line. 
The coverings of a ventral hernia are the skin, the subcutaneous cellulo- 
adipose tissue, and the peritoneum; when the rupture occurs in the lumbar 
region, some of the fibres of the tranversalis muscle may be added. 
Ventral hernia, when in the linea alba, can be distinguished from the umbil- 
ical form of the disease by the following peculiarities. Ventral hernia becomes 
a pedunculated swelling when it attains to any.great size; umbilical hernia 
retains its spherical or round figure without regard to bulk. Ventral hernia, 
passing through a slit-like opening in the linea alba, possesses a neck which 
is somewhat oblong or flattened, whereas umbilical rupture, passing through 
the umbilical ring, is round in shape, and the edge of the circular aperture 
can be distinctly felt by the finger. Umbilical hernise increase in volume 
much more rapidly than do the ventral, and cause a marked change in the 
appearance of the navel. As in umbilical rupture, so in ventral, the patient 
is often annoyed by gastric and intestinal irritation, giving rise to flatulent 
colic, constipation, and sometimes nausea. 
Treatment.—Reduction is best accomplished by placing the person in the 
recumbent posture, relaxing the parts by position, and applying pressure or 
taxis to the swelling. Should it not recede spontaneously when restored to 
the abdomen, a truss similar to that used for umbilical rupture will be neces- OBTURATOR HERNIA. 
605 
sary to the patient’s safety. If the protrusion be situated at some other point 
than the median line, the instrument will have to be modified to answer the 
peculiarities of the case. 
Obturator Hernia.—Obturator or thyroid hernia passes from the interior 
to the exterior of the pelvis through an opening in the upper part of the 
thyroid membrane, occupied by the obturator artery, vein, and nerve. The 
position of the hernia is such that it is clearly recognizable only when the 
tumor is of considerable size. The sac is formed by the peritoneum, and 
its contents may be either intestine or omentum. The coverings consist of 
the skin, subcutaneous cellular tissue, fascia lata, peetineus, and adductor 
longus muscles. The relation of the obturator vessels and nerves to the 
neck of the sac is not always uniform. In the fifteen cases collected by 
M. Yinson, the vessels were situated in six cases on the inside, in six on the 
outside, and in the remaining three behind the sac.* 
Symptoms.—Obturator hernia would scarcely be suspected unless the atten- 
tion of the surgeon were called to its possible existence by the symptoms 
of intestinal or omental strangulation being present, without there being 
any rupture in the ordinary hernial localities. When such signs exist, and 
are found associated with an appreciable fulness and hardness in Scarpa’s 
triangle, with the femoral artery pulsating in front, the femoral and inguinal 
rings being free, and perhaps some pain experienced along the inside of the 
thigh, answering to the distribution of the obturator nerve, the existence of 
an obturator hernia may be inferred. As other forms of hernia may coexist 
with the thyroid, a careful diagnosis in a case of strangulation of the latter 
could be reached only by finding the former reducible. This form of rupture 
rarely occurs in persons under forty-five or fifty years of age. It is sup- 
posed that the wasting of the muscles about this time of life has something 
to do in its production. Operations have been frequently performed to re- 
lieve the strangulation of obturator hernia. M. Obre'f was able to diagnose 
a case of this kind in consequence of discovering, on a comparison of the two 
thighs of a patient suffering from signs of intestinal strangulation, a little 
more fulness of the Scarpa space on one side than on the other. Guided 
by these appearances, he operated with success. Mr. Bransby Cooper| also 
operated successfully on a case of obturator hernia at Guy’s Hospital. In 
this instance the fibres of the peetineus muscle appeared to have caused the 
stricture, as after their division the hernia underwent spontaneous reduction. 
Mr. Birkett has collected twenty-five cases of strangulated thyroid hernia, 
and others are occasionally noticed in medical journals: so that the disease 
cannot be regarded as extremely infrequent. 
Treatment.—When reducible, the rupture should be returned by elevating 
the pelvis, flexing the limb upon the abdomen, and making firm pressure 
downwards and upwards. To prevent a recimrence of the protrusion, a 
truss must be worn with a conical pad so adjusted as to press backwards 
and upwards. Holmes states that Mr. Kingdon has in five instances reduced 
thyroid hernia. 
When there is reason to infer the existence of a strangulated obturator her- 
nia, an incision three inches in length should be made in front of the thigh, 
over the saphenous opening, extending from Poupart’s ligament downwards, 
dividing in succession the skin, the superficial fascia, and the fascia lata 
femoris. The peetineus and the adductor muscles, being now exposed, should 
be raised and severed sufficiently to expose the sac, when the reduction may 
be effected by nicking the seat of stricture, which, as nearly as can be ascer- 
tained from the cases collected, and from the anatomical peculiarities of the 
region, will be found in the edge of the thyroid membrane, at the neck of 
the sac, or in the fibres of the peetineus muscles. 
* NMaton’s “E16mens de Pathologie Chirurgicale,” vol. iv. p. 403. 
•)■ Medico-Chirurgical Transactions, vol. xxxiv. p. 232. 
J Medical Times, vol. i. p. 113, 1853. 606 
DISEASES OF THE ABDOMEN. 
Hernia of the Foetal Cord.—This variety of hernia is quite rare. I saw a 
case of the kind in a new-born child, the patient of Dr. Stewart, of this city. 
The intestines passed through the umbilicus, following the vessels of the cord, 
and covered by the investment of the latter. 
Treatment.—The hernial contents are to be pressed back into the abdo- 
men, the cord ligated on a level with the parietes, and a compress secured 
by a flannel binder or an adhesive plaster worn over the navel. 
When strangulation takes place, it will be necessary to uncover the hernial 
contents and nick the stricture, which will be found at some point in the 
circumference of the umbilical ring. 
Ischiatic Hernia.—In this form of rupture the hernia passes through the 
great sacro-ischiatic foramen in the course of the sciatic blood-vessels, below 
the pyriformis muscle, and is concealed by the gluteus maximus. Such cases 
are exceedingly rare, and perhaps would never be recognized. Sir Astley 
Cooper records a fatal case of strangulated ischiatic hernia which was dis- 
covered only after death. The dissection in this instance showed the existence 
of a sac, the mouth of which lay in front of the internal iliac artery and be- 
tween the obturator artery and veins,—the former being above and the latter 
below. The application of a truss in the event of such a rupture being diag- 
nosed would be of doubtful utility, as the pressure of a pad could not be 
made so as to command the outlet with any degree of certainty. Should a 
gluteal hernia occur, it would differ from the ischiatic variety only in escaping 
from the pelvis above the pyriformis muscle. 
Diaphragmatic Hernia.—There are three ways in which the abdominal 
viscera may enter the chest, constituting this form of hernia: first, from a 
congenital imperfection in a portion of the diaphragm, usually on the left 
side; second, by a dilatation of some one of the natural apertures thi’ough 
which pass the oesophagus, aorta, and ascending cava; and, third, by a wound 
of the muscle. When from the last-named cause, such hernise are usually 
fatal; though I have given a case, under the head of abdominal wounds, in 
which a person lived many years after an accident of this kind. There are 
no means of determining with certainty this form of hernia; though the 
intestinal disturbance, and the existence of tympanitic and gurgling sounds 
within the thoracic walls, together with the presence of great thirst, would 
serve to render pi’obable the existence of this affection. Even if it were 
recognized, the surgeon would be powerless to relieve his patient without an 
operation, which would, in all probability, prove as fatal as the disease itself. 
Pudendal Hernia is occasionally seen forming a tumor in the labium, which 
it reaches by passing down between the vagina and the ramus of the ischium. 
It can be recognized by the impulse communicated on coughing, by its soft, 
elastic feel, and by its reducibility on pressure applied close to the inner 
edge of the ramus of the ischium. I have never been able by any contri- 
vance to prevent the return of the hernia after reduction. An oblong com- 
press applied over the labium and retained by a T bandage, or an ivory pad 
attached to the truss sometimes worn for prolapsus ani or for hemorrhoids, 
may be employed; but either will be found unsatisfactory, and will soon be 
laid aside. I have never seen any disability arise from the presence of such 
a rupture; but my experience in this variety of hernia is quite limited. 
Vaginal Hernia.—In this rupture the tumor does not descend so low as in 
the pudendal variety. It is situated within the orifice of the vagina, en- 
croaching upon this canal, and is a soft, compressible tumor, having an im- 
pulse on coughing, and easy of reduction, though quickly reappearing on the 
removal of pressure. The course of this hernia corresponds to the space be- 
tween the rectum and the uterus, and, when it does not arise from a congenital 
imperfection of the parts, it is doubtless most commonly caused by the over- PROPERITONEAL HERNIA. 
607 
stretching of the vaginal walls and the underlying connective tissue, in par- 
turition. A protrusion of the bladder frequently occurs in the female, which 
must not be confounded with vaginal hernia. The distention of the former 
by the accumulation of urine, and its collapse after the passage of that secre- 
tion, together with the fact that the catheter can be carried into the swelling 
through the urethra, will serve to establish the distinction. 
Perineal Hernia appears in the perineum, a little to one side of the raphe, 
forming a noticeable swelling, of a round shape, between the bladder and the 
rectum in the male, and between the rectum and the vagina in the female. 
The route followed by this form of rupture before reaching the perineum is 
along the inner surface of the levator ani muscle. It is this muscle which 
prevents the protrusion from passing into the ischio-rectal space and appearing 
at the side instead of in front of the bowel. How the rupture is related to 
the pelvic fascia has not been determined. If the latter were torn, the hernia 
would lie between the recto-vesical and the levator ani layers of the fascia ; 
and if not broken, it would seem necessary that both the lamina of this mem- 
brane which is reflected on the side of the bladder, and that between the 
bladder and rectum, should form coverings. The swelling does not always 
appear in the perineum, but can be discovered by an examination through 
the rectum. The disease has followed the operation of lithotomy, in conse- 
quence of a careless division of the peritoneum wfith the gorget* In the 
parturient female, the danger from pressure by the child’s head would prove 
very serious in the event of such a hernia being present. The same would 
be true of the vaginal form of the disease. The existence of this hernia can 
be inferred from the presence of intestinal disturbance, from the sound emitted 
when it is pushed back, and from its impulse. 
Treatment.—The use of a large pessary has been recommended as a 
means of preventing a descent of the rupture, as has also the application 
of a hemorrhoidal truss the pad of which shall be so formed as to rest firmly 
against the perineum. The first appliance fulfils the indication very imper- 
fectly, and the second cannot do more than prevent a further increase in 
the protrusion. 
Sacro-Rectal Hernia.—It has happened that in a case where the pieces 
composing the sacrum have failed to join by ossification, a portion of the 
intestine has passed through the defective part and formed a tumor over the 
lower part of the spine, to which the above name has been given. Such a 
swelling would bear some resemblance to spina bifida, but could be distin- 
guished from the latter by its reducibility, by the gurgling sound heard on its 
restoration into the pelvis, and by its expansive impulse. The treatment of 
such a hernia would consist in securing a pad over the seat of the protrusion 
by either a porous or an adhesive plaster, or by a spring truss, until the 
opening became closed by progressive ossification. 
Properitoneal Hernia is a form of rupture so designated by Kronlein, and 
answers to what is termed interstitial or intraparietal hernia. The leading 
characteristic of this form of rupture is its relation to the peritoneum, its 
sac being a diverticulum, situated in front of or between the peritoneum 
and the transversalis fascia, often forming an oblong tumor above and nearly 
parallel with Poupart’s ligament. Dr. Dulles, in an interesting article on 
inguino-properitoneal hernia, has brought together the eases of Kronlein, 
in number twenty-four, and one operated on by himself, making twenty-five 
cases of this variety of hernia. Since the publication of Dr. Dulles’s paper, 
Dr. Torrey, of Brooklyn, New York, reports a similar case, and to this I may 
add two others of my own, both occurring in young men with an unde- 
scended testicle, making in all twenty-eight cases. The analysis made by 
Dr. Dulles shows that the great majority of the patients (twenty-four in 
* Cooper’s Surgical Dictionary, vol. i. p. 998. 608 
DISEASES OF THE ABDOMEN. 
number) were males, and only four females. In nearly all the hernia was 
congenital, and in many it was associated with an undescended testicle. 
The chief practical point to the surgeon connected with properitoneal hernia 
is his liability, in cases of strangulation, to fail to appreciate the exact rela- 
tions of its anatomical parts, and consequently, after having divided what is 
believed to be the stricture, he may suppose he has reduced the rupture into 
the abdominal cavity, when it has only been pushed into an adventitious 
pouch or diverticulum; and the same error may be committed when taxis 
alone is employed. In either case the symptoms of strangulation will con- 
tinue though the tumor may disappear. 
Should this form of hernia occur in connection with femoral rupture, it 
would be called cruro-properitoneal. 
Cystocele.—In addition to the forms of rupture already described, the blad- 
der has been known to protrude through the external abdominal ring, and 
also through the femoral opening; and in one case of inguinal cystocele given 
by Ruysch, the sac contained a portion of intestine in addition to the blad- 
der. Yerdier, Petit, and Pott have each given an instance of cystocele 
in which the bladder contained calculi. These formations no doubt were 
caused by the obstruction offered to the escape of the urine in the unnatural 
positions of the viscus. A curious ease is related by Yerdier, in which the 
stone in a cystocele was mistaken for a bubo, and caustic applied for its de- 
struction, by which a urinary fistula was formed.* 
The cause of vesical hernia is probably habitual neglect in passing the 
urine, in consequence of which the walls of the organ become overdistended 
and the ligaments unduly stretched, thus allowing the organ to be pressed 
into unusual channels by the superincumbent viscera. 
Symptoms.—The presence of fluctuation, the desire to urinate on compress- 
ing the tumor, and the diminution of the latter during micturition, will enable 
the practitioner to recognize the nature of the affection. 
Treatment.—After reducing the cystocele, a truss should be applied to 
prevent its return. 
The diverticular hernia of Littre consists of either a congenital offshoot or 
a prolongation from some portion of the intestinal canal, generally the ileum. 
Or it may be formed by a protrusion of the serous and mucous coats of the 
bowel, in consequence of the muscular tunic giving way. In either con- 
dition the affected portion of the tube may enter the inguinal or the femoral 
canal and constitute the contents of the sac. 
* Cooper’s Surgical Dictionary, vol. i. p. 100. CHAPTER X. 
WOUNDS OF THE EXTREMITIES. 
The danger of wounds of the extremities consists in the injury done to the 
blood-vessels, nerves, articulations, and bones. 
The principal blood-vessels, whether the limb be in a state of repose or of 
defence, are so situated as to be least exposed to harm. When the arm hangs 
quietly by the side of the body, the brachial, radial, and ulnar arteries are 
directed inwards, and the palm of the hand, in which lie the palmar arches, 
is turned backwards. When the arm is raised in an attitude of offence or of 
self-defence, the same vessels remain in the least exposed position. In the 
lower extremity, the femoral artery passes to the inner and posterior part of 
the thigh, the posterior tibial is placed between two planes of muscles, and 
the anterior tibial is likewise deeply situated, besides receiving an additional 
protection from the salient spine of the tibia. At the inner ankle, where the 
posterior tibial passes into the foot, a deep recess exists, formed by the con- 
cavity of the os calcis and the projection of the internal malleolus, which 
conduces greatly to the safety of the vessel. 
When a wound involves the integument, or both the integument and the 
muscles, the treatment does not differ from that proper to similar injuries in 
other parts of the body. The hemorrhage must be controlled, all foreign 
substances removed, the parts united by the interrupted silver suture, 
antiseptic dressings applied over the wound, and the dressings confined in 
position by a roller bandage. When a muscle is divided, the stitches should 
include its extremities, and the arm be placed in that position which will 
insure the most perfect relaxation of the parts. Tendons, when severed, 
should be united by the animal suture. 
The most vital portions of the upper extremity are the following: First. 
The axilla, especially that part below the middle of the clavicle, in which lie, 
not far from the surface, the axillary artery and vein, the cephalic vein, and 
the axillary plexus of nerves: below this point the great folds of the armpit, 
and the relation of the latter to the side of the chest, serve to shelter the ax- 
illary vessels and nerves from injury. Second. The inner edge of the biceps, 
along which lie the brachial artery and median nerve, is another vulnerable 
region. Third. The antibrachial fossa, or that part in front of the elbow, is 
an important space. In this are situated the median basilic and median 
cephalic veins, together with numerous filaments of the internal cutaneous 
nerve, and deeper, under the bicipital aponeurosis, the brachial, radial, ulnar, 
and interosseous arteries, with the median nerve. Fourth. In the forearm 
over the course of the radial and ulnar arteries, the former of which is 
superficial in its entire extent, the latter also at its lower fourth, in which 
situations these vessels are particularly exposed to injury. Fifth. At the root 
of the thumb, where the radial artery passes to the back of the hand, and in 
the palm of the hand, in which are lodged the two palmar arches with their 
numerous large, inosculating branches. In this last portion of the upper 
extremity we have a region which, when wounded, demands for its treatment 
the highest surgical skill. 
Wounds of the Upper Extremity. 610 
WOUNDS OF THE EXTREMITIES. 
Wounds of the Arm.—The arteries of the arm are frequently divided by 
stabs or cuts; they are sometimes torn in fractures, or, in the case of the 
axillary, by forcible attempts to reduce old luxations. Not unfrequently the 
vessels at the wrist or in the hand are wounded by chisels or by broken pieces 
of glass. When the axillary or the brachial artery has been severed, there 
will be no pulse felt at the wrist. If the damage to one of the large vessels 
of the arm is caused by a bullet or by a puncture, there follows a swelling 
more or less diffused, in which pulsation is generally detected. 
Treatment.—In all injuries of the blood-vessels of the arm and the forearm, 
the proper course is to seek for the artery in the opening made by the vulner- 
ating body, enlarging the wound, if necessary, for the purpose, and tying both 
ends of the divided trunk. When a ligature is placed on the proximal end of 
a wounded vessel, above a collateral branch, the latter should likewise be tied : 
otherwise the blood may tind its way back through the anastomosing branches. 
There are circumstances which may require a departure from this rule. 
For example, an injury involving the axillary high up, accompanied by much 
swelling from blood and inflammatory products, will be best treated by open- 
ing the neck and securing the subclavian external to the scalenus muscle, 
as such a course will necessitate a less extensive division of tissues, and 
will include a part of the vessel which is some distance from any branches. 
Again, in a wound at the upper part of the forearm, near the elbow-joint, in 
which the vessels have been previously tied at the seat of injury, but, in con- 
sequence of a soft, oedematous, and sloughing state of the soft parts, secondary 
hemorrhage has taken place, it is better to tie the brachial above the articu- 
lation. 
Wounds of the Hand.—Wounds of the palmar arch or of its branches form 
no exception to the general law above mentioned. It has been recommended 
in these injuries to tie that vessel in the forearm the compression of which 
arrests the bleeding; but when it is considered that between the palmar 
arches and the radial, ulnar, and interosseous arteries a free intercommu- 
nication of branches exists, which branches are singularly uniform in their 
size, the unsoundness of such a practice becomes obvious. When the wound 
is small, difficulty is sometimes experienced in placing the ligature securely 
on the bleeding vessel, the thread slipping off when the tenaculum is with- 
drawn. In such cases an instrument in which the handle and a part of the 
shank can be detached from the curved extremity (Fig. 476) will be found 
Fig. 476. 
Tenaculum.—Handle capable of being detached at a, from the point. 
very useful, as the latter may he allowed to remain in the opening until the 
ligature becomes separated by ulceration, when both will come away together. 
When the opening is not sufficiently large to allow free access to the bleeding 
trunk, it should be enlarged to the required extent. In making incisions for 
this object, no thrusts are permissible. The surgeon must understand the 
distribution of the vessels, and with such knowledge he may proceed with 
entire confidence to expose the deep part of the hand. The skin must first 
be divided, and next the superficial fascia, when the palmar aponeurosis will 
be brought into view, which can be readily recognized by its white, tendinous 
appearance. The important vessels are all beneath this structure. To open 
this membrane safely, a slight puncture should be made through its sub- 
stance, and a grooved director introduced, by means of which the fascia can 
be raised from the vessels and nerves beneath, and its successful division 
accomplished, giving an exposure of the parts sufficiently ample for securing 
both ends of the wounded vessel. WOUNDS OF THE HAND. 
611 
After tying vessels belonging to the palmar arch, or the arch itself, and 
particularly where the tissues are somewhat unsound, the force of the blood- 
stream in the hand should be diminished by placing oblong compresses over 
the radial and ulnar arteries and securing the same in position by a roller, 
beginning at the hand and extending up to the elbow; or, if the pressure of 
a bandage be painful, the object may be attained by elevating the arm and 
flexing it to an acute angle. 
In the treatment of Jacerated wounds of the hand, whether caused by 
machinery or by the bursting of fowling-pieces, the surgeon must consider 
well his case before having recourse to amputation. The vitality of the 
upper extremity attains its maximum in the hand. Here are concentrated 
the branches of three considerable arterial trunks, having an intimate inos- 
culation with one another ; here also is a rich supply of nerves ; and here are 
the insertions of thirty-six muscles. All these components are supported 
by a skeleton consisting of some twenty-seven small bones, with curiously- 
contrived articulations, well calculated to combine solidity with mobility, 
and having a large continuous surface of synovial membrane. It is the 
vital energy necessary to move harmoniously such a combination of parts 
which confers on the human band its singular power to resist injuries and 
repair the most extensive mutilations. Indeed, unless in cases of utter dis- 
organization of all the components of this part of the limb, I never despair 
of its recovery. 
In the treatment of lacerated wounds, no remedy compares in value to 
irrigation with water containing corrosive sublimate (one to two thousand). 
At first the water should not be applied too cool, for fear of lowering the cir- 
culation below the degree necessary for the work of separating the damaged 
fragment of tissue and of reconstructing the injured parts; but as these 
processes advance, less attention is necessary on this point. Bleeding from 
the digital arteries which lie along the borders of the finger is easily con- 
trolled by pressure made with a compress and a narrow roller. 
Punctured, poisoned, and contused wounds of the hand are frequently fol- 
lowed by deep-seated abscesses, which prove excessively painful, are accom- 
panied by severe constitutional disturbance, such as rigors, fever, headache, 
sleeplessness, and entire loss of appetite, and, unless promptly treated, pro- 
duce the most extensive disorganization of structure, leaving the member stiff, 
distorted, and withered. These palmar abscesses may be situated in four 
localities: first, in the subcutaneous tissue, in which locality they are least 
harmful, as they readily come to the surface; second, beneath the middle 
chamber of the palmar fascia, which corresponds to the hollow of the hand; 
third, under the thin expansion of this fascia which covers the muscles that 
form the ball of the little finger; and, fourth, under a similar extension of 
Fig. 477. 
Palmar fascia, strong in the middle and less so at its margins. 
the palmar fascia which spreads over the muscles constituting the ball of the 
thumb. (Fig. 477.) The great strength of the central portion of the palmar 
aponeurosis and its membranous connections with the two middle metacarpal 
bones renders purulent collections in the second position exceedingly danger- 
ous to the welfare of the hand. The medical attendant is often misled in 
such cases, as the resistance encountered by the inflammatory products on 612 
WOUNDS OF THE EXTREMITIES. 
the palmar surface serves to force them upwards beneath the annular ligament 
of the wrist into the arm, or directly backwards between the interosseous 
spaces to the back of the hand. Hence, in these abscesses, though the disease 
begins in front, the swelling is greatest over the posterior surface of the 
metacarpus. Even when the case is clearly appreciated, the physician will 
often have some timidity in adopting the proper line of practice (which con- 
sists in laying open the palm of the hand), for fear of wounding the superficial 
palmar arch or its branches. 
The lowest point reached by the curve of the arch corresponds to a line 
starting at the junction of the thumb and index finger and drawTn directly 
across the palm of the hand to its ulnar border. An incision may be carried 
up to this line with safety. The digital arteries given off by the arch, and 
Fig. 478. 
Superficial palmar arch and its digital branches. 
destined to supply the fingers, pass down opposite to the interosseous spaces 
and divide at the interdigital clefts, sending branches along the sides of the 
fingers. (Fig- 478.) Incisions, therefore, which are made over the middle 
of the palmar surface of the fingers, and over the course of the metacarpal 
bones, may be continued upwards safely to the transverse line. . (Fig. 479.) 
The recognition of these facts, and 
the exercise of care in incising 
the integument and in raising the 
palmar fascia upon the director 
before its division, will enable the 
operator to execute his task with- 
out danger. The parts, having 
been freely laid open and curetted, 
should be washed out with a so- 
lution of bichloride of mercury, 
dusted with iodoform, and dressed 
antiseptically. Where there has 
been burrowing of pus, the drain- 
age-tube must not be omitted. 
Punctured wounds of the hand 
are not unfrequently followed by 
a slow contraction of the tendons 
or of the palmar aponeurosis, 
causing deformity of one or more of the fingers. 
In all cases of'injury of the hand in which a palmar splint is employed, 
the padding should be formed so as to allow the fingers to be slightly flexed. 
Wounds of the Nerves will be indicated by loss of motion and sensation 
in the parts to which they are distributed, thus enabling the surgeon to 
designate the particular trunk involved. Such injuries are not altogether 
hopeless, as the divided ends occasionally unite and the nerve resumes its 
function, the paralysis disappearing. We are not yet sufficiently informed 
on the subject of the regeneration of neurine to determine how wide a chasm 
between the retracted "ends of a nerve-trunk can be bridged with material 
Fig. 479. 
The transverse line indicates the lowest point of the palmar 
arch, and the vertical lines the positions free from vessels. WOUNDS OF THE LOWER EXTREMITY. 
613 
capable of conducting motor and sensory impressions. In one instance I 
resected over an inch of the ulnar nerve above the elbow for a violent neu- 
ralgia of that part of the arm supplied by its branches, and with complete 
relief to the patient. Seven years after, partial power was regained in the 
muscles paralyzed, and with this restoration of function the pain returned 
again with great severity. We do know, however, that the nearer the ex- 
tremities are brought in contact the greater will be the probability of obtain- 
ing a useful union. With this view it has been very properly suggested to 
suture the ends of divided nerves. The idea that these cords would resent 
such liberties—an opinion based on the evil effects of including a nerve in a 
ligature, or of transfixing it with a pin—proves to be incorrect. Sewing 
together its divided ends materially differs from constricting the nerve-trunk. 
In cases, therefore, where a nervous cord of importance has been cut, it will 
be best to endeavor, by stitches including its sheath, and by position, to effect 
the nearest possible approximation. 
Contusion of the ulnar nerve in the groove between the internal condyle 
and the olecranon process of the ulna is a common occurrence. The sensa- 
tions of numbness and tingling experienced in the little finger and the ring 
finger, with the unpleasant glow of heat which succeeds the injury, are well 
known. The effect of such contusions is generally transient, passing over 
in a few moments ; though when the violence has been severe the inside 
of the elbow and arm may become swollen and painful, and the function of 
the fingers supplied remain suspended for some time. In such cases cold 
anodyne lotions may be applied at the seat of injury; if the symptoms 
do not yield in two or three days, a blister should be laid over the contused 
nerve, with a view to remove the inflammatory thickening of its sheath. 
Punctures of a branch of the internal cutaneous nerve where it is distrib- 
uted over the median basilic vein—an injury which was not uncommon 
when venesection was more generally practised than at present—may be 
followed by a red and painful condition of the arm. Anodyne lotions and a 
blister constitute the proper remedies. 
Punctures of the digital nerves will sometimes cause exquisite tenderness, 
pain, and disability in one or more of the fingers. These symptoms may 
not set in until months or even years after the accident. After a time 
the skin becomes glossy, having a dull-red or purple color, and the affected 
member stands off from the other fingers in an awkward, helpless manner. 
Where only a single digit is involved, excision of the digital nerves will be 
indicated ; but when most of the hand suffers, the median or the ulnar above 
the wrist-joint will require excision. 
There is a pseudo-neuralgia of the fingers occasionally met with in females. 
I have never witnessed a case in which more than a single digit was affected. 
This “ mimicry,” as it has been termed by Mr. Paget, when located in joints, 
can be distinguished from true nerve-trouble by the absence of the glossy and 
dull-red skin whicli characterizes the latter, and also by the fact that, when 
the patient’s mind is attracted from the hand, no difference can be detected in 
the position or in the movements of the affected from the other fingers. 
Wounds of the Lower Extremity. 
The same general principles which are applicable to the treatment of 
injuries of the upper extremities are to be observed in those which involve 
the lower. The great blood-vessels of the thigh being situated at the ante- 
rior and inner portions of the limb, wounds taking effect in these regions 
are attended with the greatest danger. In the ham the popliteal vessels lie 
deep, and are protected by being on the posterior aspect of the thigh : con- 
sequently they are rarely the subject of traumatic violence. 
In the leg the anterior and posterior tibials, except in front and behind 
the inner ankle, are very slightly exposed to external injury, except from 
gunshot missiles. It occasionally happens that in compound fractures of 614 
WOUNDS OF THE EXTREMITIES. 
the leg these vessels are torn. Punctured and other wounds of the foot are 
frequently followed by tetanus, and the same may be affirmed of similar 
injuries of the hand. 
Wounds of the foot should be treated in the same manner as wounds of 
the hand. 
Wounds of the articulations will be considered under the head of Diseases 
and Injuries of the Joints. CHAPTER XI. 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
Angeiomata. 
The term angeiomata is applied to a class of tumors which consist for the 
most part of blood-vessels. They include in their anatomy arteries, capil- 
laries, veins, and connective tissue. These growths are often congenital, 
though occasionally they arise from external violence. There are three va- 
rieties of angeiomata,—the arterial, the capillary, and the venous. The arterial 
varix is sometimes called cirsoid aneurism; the capillary varix is frequently 
described as aneurism by anastomosis. 
Arterial Varix.—This is a dilatation of one or more arterial branches. As 
the vessels dilate they become lengthened and tortuous and con- 
voluted in their course. Sometimes they turn completely upon themselves, 
forming a spiral cord. This condition of the arteries is the counterpart of 
venous varix. The convolutions are united together by means of a small 
amount of connective tissue. The arteries chiefly affected are those of the 
scalp. In Fig. 480 there is a very good illustration of extensive cirsoid disease 
of the temporal and occipital arteries on one side of the head, taken from a 
young woman who applied at my clinic for relief. Occasionally the vessels 
Fig. 480. 
Fig. 481. 
Arterial dilatation of the vessels in the palm of the 
hand and three fingers. 
Arterial varix, or cirsoid aneurism, on one side of 
the scalp. 
of the hand become dilated in a similar manner, in which ease the disease 
may be limited to the palm of the hand, including one or two fingers, while 
the others remain entirely free. In rare instances three or more of the fingers 
may participate in this vascular enlargement. (Fig. 481.) Why the arteries 
of the scalp and of the hand should take precedence of other vessels belong- 
ing to the arterial system it is difficult to understand. These trunks have 616 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
naturally a serpentine form, but this circumstance, while it may favor the 
contorted disposition of the vascular elements of the tumor, could have no 
influence in determining the dilatation of its blood-vessels. As the disease 
frequently appears after an injury to the vessels, it is highly probable that 
there is an inflammatory cause in operation to produce the remarkable 
changes which follow. There are no reasons for supposing that these can 
be the result of those structural alterations which often give rise to true 
aneurism, such as atheroma. This form of arterial dilatation differs from 
that of aneurism in the expansion of the vessel being more general and uni- 
form, though in some instances distinct circumscribed pouches or sacs are 
pushed out from the sides of the vessel. The walls of the arteries, as 
the disease advances, become more and more attenuated, chiefly at the ex- 
pense of the muscular and elastic coat, until the surface of the tumor presents 
a blue color, from the blood being seen through the integument, the latter 
having been thinned out by the pressure from within. When the head is 
allowed to hang down, causing the dilated trunks to distend, this color is very 
noticeable. So thin do the walls of the affected vessels become, that when 
divided they collapse in the same manner as does a cut vein. Though the 
swelling is composed chiefly of arteries, yet, in consequence of the sluggish 
movement in the inordinately capacious channels, the blood is more venous 
than arterial in its character. Some years ago I witnessed two cases of 
cirsoid disease of the scalp—one in a man and the other in a woman—in 
which there was a very marked absorption of the cranial bones beneath the 
varix. 
Symptoms.—The signs of arterial varix are quite characteristic. Such a 
tumor consists of a bundle of soft, compressible, tortuous, and pulsating swell- 
ings in the course of the principal vessels of the scalp, over which the skin 
presents usually a bluish color. 
Treatment.—Except in cases where the disease shows a tendency to ex- 
tend rapidly and the vessels to open, no operative measures should be at- 
tempted. I have witnessed this form of varix in persons over sixty years 
of age, in whom it had existed from birth, and who suffered very little incon- 
venience from its presence. But there may be exceptional cases—for example, 
when repeated hemorrhages threaten to destroy the patient’s life—in which 
the surgeon is compelled to resort to some measure for the cure of the disease. 
Under such circumstances there are several plans from which he can select. 
Professor Bruns* has advocated the ligature of the two external carotids, 
the vessels which most directly, through their branches, supply the scalp 
with blood. Ligature of the primitive carotid on the affected side has been 
performed by Mussey,f Warren,J Bushe,§ Wood,]| and Mott in this country, 
and by several surgeons in Great Britain and on the Continent; but out 
of eighteen cases it does not appear that the operation, except in two in- 
stances, was followed by permanent benefit, and on three occasions the 
patient perished under the knife.It has been proposed by Von Grafe, who 
has performed the operation in this way, to divide the mass of dilated vessels 
crosswise, afterwards stuffing the wound with agaric and sponge, with the 
double object of arresting the hemorrhage and of inducing a destructive sup- 
puration in the parts. Wyeth has tabulated 72 cases of erectile tumors, 
cirsoid and fungous growths, situated about the head and face, which were 
treated by ligature of the primitive carotid. In none of the patients were 
both common carotids tied. The result of this procedure was as follows: 
21 died; and of the 51 who survived, 27 were cured, 10 improved, and the 
remaining 14 not improved. These results argue very little for the liga- 
ture. Brodie attempted the removal of an arterial varix by passing a pin 
beneath the growth and strangulating the mass by means of a strong liga- 
ture; ultimately, however, the disease returned. Resort has been had to 
* Handbuch d. Pract. Chirurg., i. 161, 1854. 
J Warren, Practical Remarks on Tumors. 
|| New York Journal of Medicine, 1857. 
f American Journal Med. Sciences, 1830. 
§ New York Medical Journal, vol. i., 1819. 
Holmes’s System of Surgery, vol. iii. p. 538. ANGEIOMATA. 
617 
galvano-puncture,—introducing needles into the tumor and connecting them 
with the poles of a powerful battery,—the object being to induce the forma- 
tion of a solid coagulum in the growth. This practice has been accompanied 
with some degree of success. With the same object in view, injections of 
perchloride of iron and nitrate of silver have been used, a plan not unattended 
with danger, unless care be taken to arrest the circulation temporarily in the 
part for a few minutes after the injection. The only operation which seems 
to offer a fair prospect of success is that by excision, and this should be 
adopted in preference to any other method when the necessity arises for its 
performance. The plan consists in commanding the blood-supply of the 
growth by cutting down at its circumference and beyond the limits of the 
disease and securing the vessels in detail. The operation demands great care 
and patience, short incisions being first made through the skin and a stout 
thread immediately passed, by means of a curved needle, beneath the ex- 
posed vessels. This procedure is repeated until the entire varix has been 
invested, when the diseased mass may be removed, after which the wound 
should be covered with an ordinary water-dressing. Professor Gibson* 
adopted this plan with success as early as 1823. I have followed it fre- 
quently and with success. 
Capillary Varix.—This is an erectile growth, sometimes designated by the 
term telangiectasis, and not unfrequently by that of ncevus maternus, or mother's 
mark. There is no part of the body exempt from this affection, except such 
tissues as are non-vascular. There are two varieties of capillary varix,—the 
superficial and the deep. In the first the disease is limited to the superficial 
part of the skin, appearing as a red or claret-colored spot or stain, and varying 
from the size of a millet-seed to several inches in extent. The surface of 
small naevi is often surmounted by small, granular elevations, resembling 
a strawberry or a raspberry. The disease is generally congenital, but may 
arise after birth, not unfrequently in consequence of some local injury. 
Mothers often refer these marks to some mental impression received during 
pregnancy. In answer to the question 
which I once addressed to a lady whose 
infant had a round red nsevus over the 
eyebrow, “To what circumstance do you 
attribute this mark on your child?” she 
replied, “ While riding on horseback, the 
animal carried me under a cherry-tree, and 
a ripe cherry struck me on the forehead.” 
Another mother, whose child bore on his 
shoulder the mark of a horseshoe, ascribed 
the disease to her horse falling and striking 
her on the back with his foot. 
The deep variety occupies the lower 
layers of the skin, presents a blue color, 
can be emptied of its blood by pressure, and 
when large possesses a pulsation synchro- 
nous with that of the heart. Under ex- 
citement the growth deepens in color and 
becomes turgid with blood. The most 
common localities for the development of 
naevus are the scalp, face, ear, breast, back, 
genitalia in the female, and bones. (Fig. 
482.) In some instances they are found 
scattered over almost the entire surface 
of the body. On the scalp they frequently 
elect the integument over the anterior fontanel as a point for development. 
Their progress varies greatly in different persons. Frequently they remain 
Fig. 482. 
A nsevus occupying a cranial bone. 
* Gibson’s Surgery, vol. ii. p. 340. 618 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
stationary to the latest period of life. Sometimes they grow rapidly for a 
short time and then cease, and in a few instances they disappear sponta- 
neously, or, receiving an injury, are destroyed by inflammatory changes which 
follow. Though a source of great anxiety to parents, and not unfrequently 
of mortification to children, yet, even in the most aggravated examples of the 
disease, and when left without any surgical interference whatever, they rarely 
if ever endanger life. 
Anatomy.—Naevus consists not onty of intricate and anastomotic convolu- 
tions of dilated capillaries, but also of a new formation of minute vessels, 
supported in a frame-work of connective tissue. These vessels, though, on 
a casual inspection, appearing to be intertwined in an indiscriminate and 
Fig. 483. 
Intricate convolution of vessels in nsevi: a, net-work of newly-formed vessels around 
the site of a sweat-gland ; b, a similar net-work in the papilla; of the mucous mem- 
brane of the mouth.—From Billroth, magnified 60 diameters. 
disorderly manner, on a closer scrutiny will be seen, when injected, to be 
arranged into small, distinct masses, the vessels of which form a net-work 
that resembles in its outline the figure of the sudoriferous and sebaceous 
glands, to which in part they belong. (Fig. 483.) 
Venous Angeiomata.—These growths, almost uniformly congenital, are 
developed in the subcutaneous and submucous connective tissue. They are 
also found in some of the internal glandular organs, as the liver and the 
kidneys. They are rarely seen in muscles or in bone. Occasionally they 
are encountered in the midst of fatty and other morbid growths. The favorite 
localities for these venous angeiomata are beneath the mucous membrane, on 
the inside of the cheek, on the inside of the upper (Fig. 484) and the lower 
lip (Fig. 485), over the alveolar processes of the jaws, on the tongue, and 
on the palatine arches. Occasionally the disease is met with on the hand, 
extending over its dorsal surface and to the tips of the fingers, forming a soft, 
blue, spongy, and sacculated swelling. (Fig. 486.) Very recently I have seen 
three instances of these growths situated beneath the scalp, all congenital. 
Diagnosis.—Venous angeiomata possess the following peculiarities: they 
have a soft, doughy, or spongy feel; they enlarge in the act of coughing or 
crying, or during muscular struggles; they are without pulsation. When 
squeezed between the thumb and the fingers they can be emptied of blood, ANGEIOMA TA. 
619 
but on removing the pressure the tumor immediately refills. Their color is 
leaden or blue, and it is only in exceptional cases that the tumor is congenital. 
The diseases with which venous angeiomata may be confounded are lipoma- 
tous tumors, cysts, and encephalocele. Fatty growths differ from the disease 
under consideration in not being susceptible of changes of form or of color, 
Fig. 484. 
Pig. 485. 
Submucous venous angeioma of the upper lip. 
Submucous venous angeioma of the lower lip, 
and in not being diminished by pressure, unless, as is possible, a venous 
tumor be developed in their structure. Cystic growths cannot be emptied 
by compression, are smooth and regular on the surface, and are elastic in- 
stead of being soft and compres- 
sible, characteristics which serve 
to distinguish them from the 
venous tumor. In obscure cases, 
the grooved needle should be 
employed to clear up any doubt 
which may exist in the mind of 
the surgeon. The diagnosis be- 
tween venous angeioma and en- 
cephalocele is in some instances 
peculiarly difficult, as the two 
diseases occasionally coexist, the 
skin over the latter being sur- 
mounted with an erectile growth. 
In attempting to establish the 
distinction the surgeon will be 
assisted by bearing in mind that 
encephalocele appears at some 
point in the line of a cranial suture, is never entirely reducible, and is always 
congenital. 
Anatomy.—Though we are not in a position to speak with certainty in 
reference to the initial stage in the development of venous angeiomata, yet it 
seems probable that the growth consists originally of veins, which, in conse- 
quence of chronic inflammation, induced by external injury, by alterations 
in the constitution of the blood, or by hereditary influences, finally become 
transformed into a cavernous structure. The best example of this structure 
is the corpus spongiosum or the corpora cavernosa of the penis. When 
a venous growth has been extirpated, it will be seen to consist of a reticu- 
lated frame-work of elastic connective tissue, so arranged as to present numer- 
ous compartments of various sizes and forms, which are lined with a delicate, 
smooth membrane, covered with the ordinary spindle-shaped cells which line 
the blood-vessels. (Fig. 487.) It is through these compartments or cham- 
Pig. 486. 
Venous angeioma of the hand. 620 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
bers that the blood circulates. At the circumference of this cavernous mass 
these chambers communicate with the contiguous veins. Around these 
growths will be found a condensation of the adjacent connective tissue, which 
forms for them a capsule more or less complete. If the inflammatory origin 
of venous angeioma be conceded, it is not difficult to sketch the manner in 
which its sponge-like structure is formed. If we start with a number of 
small veins lying in the midst of the ordinary binding tissue, the first effect 
of an inflammatory hypersemia would be to crowd emigrant leucocytes 
into the part, and to excite an active cell proliferation, thereby increasing the 
amount of young connective tissue, and 
tying together, with its threads, the net- 
work of small veins. The subsequent 
cicatricial contraction of the new forma- 
tion would produce not only sectional 
constriction, but also a more forcible 
contact of adjoining veins than pre- 
viously existed. The effect of such con- 
striction would be to offer an obstruction 
to the circulation of the blood, and to 
cause dilatation, and finally complete 
disjunction, of the vessels at numerous 
points in their winding course; and the 
effect of the intensified pressure at the 
points where the veins lie in contact 
with one another would be to cause in such situations the absorption of their 
walls and the communication of their channels, finally establishing a number 
of open spaces lined by the remains of the previously existing veins, and 
surrounded externally by a wall of connective tissue. 
Treatment.—The great object to be attained in the treatment of either 
capillary or venous erectile growths is to cut off their supply of blood. 
This is accomplished in various ways. It may be effected by causing the 
coagulation of the blood in the growth, and thus offering a mechanical ob- 
stacle to its nutrition. For this purpose these tumors have been injected 
with the perchloride of iron, and have been treated by the galvano-cautery. 
The first method is not unattended with danger, death having followed the 
use of the injection, which is a sufficient reason for its condemnation. The 
second is often impracticable, from the expensive character of the apparatus 
necessary for its execution. Another mode of cure is by inducing a destruc- 
tive inflammation in the narvus, and in this way substituting for its vas- 
cular element one of connective or cicatricial tissue. With this object in 
view, needles may be heated to a white heat in the flame of a blow-pipe, 
and passed into the substance of the tumor, or a minute particle of vaccine 
virus can be introduced into the nsevus. Arsenious acid has been employed 
in the same manner. Painting the surface of the diseased spot with a strong 
solution of corrosive sublimate in collodion (foi’ty grains of the first to one 
drachm of the last) will sometimes eradicate small patches of the disease 
when not deeply situated. The application of a thin layer of paste, made 
by mixing the crystals of chloride of zinc with a little wheat flour, will 
produce the same result, and with more certainty than the use of the bi- 
chloride of mercury. Solar cauterization has been effectually used for the 
cure of small nsevi, by concentrating upon their surface, with an ordinary 
lens, the rays of the sun. 
In cases of venous angeioma too large for excision or for strangulation, 
we may use, with every prospect of success, setons, consisting of silk threads, 
in number varying from three to six, and passed with a fine needle through 
the base of the tumor. They should be allowed to remain until a free sup- 
puration is established in the growth, when they may be removed, first one, 
and after a few days a second, and so on until all are taken awuiy. When 
a mevus is situated on the scalp over a fontanel, and where, in consequence 
Fig. 487. 
Section of a venous angeioma. ANGEIOMATA. 
621 
of its proximity to the membrane of the brain, it would be improper to ligate 
or to excise, two or three applications of fuming nitric acid, by means of a 
rod of glass, will be the proper remedy. With this exception, I prefer, in 
all cases of erectile growths, capillary or venous, to operate either by stran- 
gulation or by excision. 
Strangulation.—When the nsevus is small, two pins may be passed beneath 
the growth at right angles with each other, observing that they enter and 
pass out through sound skin. A strong silk or hemp thread should next be 
passed beneath, and drawn sufficiently tight to insure thorough strangulation. 
(Fig. 488.) The pins should have their points nipped off with the cutting- 
pliers, and then covered with two strips of adhesive plaster. In eight or ten 
days the whole will drop off, leaving a new surface, which 
will quickly cicatrize under a simple cerate dressing. 
Some surgeons advise the removal of the ligature five 
or six hours after its application, under the impression 
that less sloughing, and consequently less deformity, 
will follow the constriction. I think the advantages 
derived from this practice are over-estimated. 
If the nsevus is too large for strangulation by the 
two needles and a single thread, it must be treated by 
first pushing a pin beneath the growth in the course 
of its long diameter, then passing a needle bearing a 
strong double ligature at right angles with the pin, 
and, after separating the threads, tying each half sep- 
arately. (Fig. 489.) If in tightening these cords they 
show a tendency to slip off the sound upon the diseased 
skin, it may be prevented by lifting the mass upwards through the pin, 
while the threads are drawn upon, or, if this plan fails, by directing an 
assistant to introduce a pin only into the 
skin, between the ligature and the dis- 
eased surface, retaining it in position un- 
til the threads, being tightened, form for 
themselves a deep groove in the sound 
tissues, when the pin may be withdrawn. 
Care should always be observed Avhen per- 
forming the operation by strangulation to 
select strong hemp thread, which will ad- 
mit of being drawn upon with great force. 
I sometimes use, with great effectiveness, 
a modification of the very ingenious ligature employed by the late Sir Wil- 
liam Fergusson. A needle is armed with a long double ligature, which is 
passed underneath the base of the tumor in one direction and then again at 
right angles with the first, 
leaving a long, loose loop 
on one side and four free 
ends on the other side of 
the nsevus. (Fig. 490.) 
Let the loop be next cut, 
and there will be eight dis- 
tinct threads, dividing the 
tumor into four equal parts. 
The opposite threads of 
each quarter should now 
be tied together with the 
utmost force, the effect 
of which will be to cut 
off completely the circulation of the diseased part. To make the ligature a 
subcutaneous one, as was done by Fergusson, a groove must be cut in the 
skin over each quarter for the reception of the thread. 
Fig. 488. 
Pins passed beneath a 
naevus, and ligature thrown, 
ready to be tightened and 
knotted. 
Fig. 489. 
Tying a nsevus with a pin and double ligature. 
Fig. 490. 
Double ligature passed under the nsevus, showing the loop and four 
free ends. 622 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
When the growth is not large, its subcutaneous strangulation may be ac- 
complished by inserting a needle, bearing a thread, into the sound skin on 
one side of the diseased part and bringing it out on the same side, a short 
distance from the point of entrance. Inserting it again at the point of 
emei’gence, it is pushed along under the skin and again brought out through 
its surface. This process of bringing the needle out and again introducing it 
through the same puncture is repeated until the entire growth is surrounded, 
when, the two ends of the ligature being forcibly drawn upon, the thread will 
disappear beneath the skin and effect the necessary constriction. (Fig. 491.) 
When the integument is not included in the ligature, the pain consequent 
upon the strangulation is very greatly diminished. 
When angeiomata of extraordinary size are en- 
countered, it will be necessary, in using the ligature, 
to include the diseased mass in a number of threads, 
after the manner practised by Mr. Erichsen. A 
long double ligature, one-half being colored black, 
is passed beneath the tumor back and forth in such 
a way as to leave loose loops on both sides. (Fig. 
492.) These being divided and the black and white 
ones on each side tied together (Fig. 493), the 
growth will be strangulated in small sections. When 
using this ligature, the ends on one side should not be tied in a hard knot, 
as it may become necessary to tighten the cords a second time in order to 
effect a thorough strangula- 
tion. The odor which is emit- 
ted in the destruction of very 
large nsevi by the process of 
strangulation requires to be 
corrected by disinfectants. As 
soon as the sloughing is well 
established, the parts should 
be covered with a solution of 
permanganate of potash, chlo- 
rinated soda, bromo-chloralum, 
or, what is superior to all 
others, either a solution of the 
sulphate of iron or a ferment- 
ing poultice. In young chil- 
dren, the removal of a large 
tumor of the erectile kind by 
the above method will be fol- 
lowed by considerable exhaustion, necessitating not only an ample supply of 
food, but also the use of tonics and stimulants. 
It will frequently happen that the ulcer left after the detachment of a 
large slough will be tardy in healing, in 
which event the sides of the raw surface 
must be drawn well towards each other 
by adhesive strips, so that by the union 
of the granulations the extent of exposed 
surface may be diminished. 
Excision.—There are several ways of 
practising this plan. First, the diseased 
part may be included between two elllip- 
tical incisions and removed, the vessels 
tied, and the edges of the wound after- 
wards united by sutures or by adhesive strips. Second, the skin may be 
dissected in flaps from the growth,and the latter be strangulated bypassing 
underneath its base a double ligature. (Fig. 494.) After its separation the 
flaps may be laid down over the chasm, and kept in position by sutures 
Fig. 491 
The subcutaneous ligature applied. 
Fig. 492. 
Erichseu’s double ligature applied to an elongated nsevus. 
Fig. 493. 
The loops divided and the section of nsevus tied. ANGEIOMATA. 
623 
or by adhesive plasters. Third, and best, after uncovering the tumor it 
may be cleanly dissected away from all 
its attachments and at once removed, 
securing any vessels which show a dis- 
position to continue bleeding, and closing 
the wound in the same manner as after 
other operations. I have in this way 
very satisfactorily removed large venous 
or cavernous angeiomata, in one case 
occupying the entire side of the face, 
and in another covering nearly the 
whole forehead. In excising the vascular 
growths I have employed with great sat- 
isfaction the Pean forceps, the bleeding 
portion being compressed between the 
blades of the instrument as the dissection 
progressed. According to Mr. Teale, the 
skin can be advantageously preserved 
even when discolored, as it subsequently 
assumes a natural hue. In two in- 
stances I have preserved nasvoid skin 
when removing the disease by excision, 
and in both, after a time, there could be 
seen scarcely any difference or contrast in color between the previously dis- 
colored and the sound integument. Often the bleeding which follows the 
excision of a telangiectasis will be found to proceed from a single arterial 
trunk, which appears to 
be the only source of 
blood-supply. When ex- 
cision, in any of its modi- 
fications, is adopted, the 
surgeon must not trench 
on the diseased part. All 
the incisions should be 
made in sound tissue, be- 
yond the limits of the 
tumor, or at least exte- 
rior to its capsule ; and if 
this caution be properly 
observed, these growths 
can be removed without 
any unusual hemorrhage, 
and with entire safety. 
In some cases it is practi- 
cable, after dissecting off 
the integument, to enu- 
cleate the diseased mass 
by the use of the fingers, 
the handle of the scalpel, 
and the forceps. When 
the angeioma occupies a 
limited part of the lip, 
and involves most of its 
structures between the skin and the mucous membrane, it is most satisfac- 
torily treated by including the diseased part in a Y-shaped incision, as in 
harelip, and uniting the margins of the wound with the figure-of-eight or 
twisted suture. When the tumor is too extensive for this operation, it should 
be subjected to strangulation by a number of double ligatures. In a case of 
angeioma of the upper lip, Professor Joseph Pancoast applied acupressure 
Fig. 494. 
A venous angeioma of the face which I treated 
by turning off the skin and strangulating the 
spongy mass beneath with a double ligature 
passed beneath its base with a needle. 
Fig. 495. 
Angeiomatous tumor of the lip treated by acupressure. 624 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
with success. (Tig. 495.) When situated in the parotid region, the tumor 
should be removed by excision ; but when it is of unusual size, it will be 
safer to adopt the use of the actual cautery, introducing white-hot needles 
into the tumor, and repeating their application, at intervals of eight or ten 
days, until the growth becomes well atrophied. The thermo-cautery is an 
excellent instrument for applying intense heat, but is too expensive for gen- 
eral use. By some surgeons the seton is regarded as preferable to the actual 
cautery for the management of extensive angeioma of the parotid region, 
and its adoption will sometimes be necessitated by the strong prejudice which 
many entertain against the fire treatment. The manner of using it has been 
previously described. 
Moles are closely allied in structure to angeiomatous growths. They are 
met with on the face, and over other portions of the body. They appear 
sometimes as deep-red spots, in which may be seen a number of very tor- 
tuous vessels. They remain permanent, showing no tendency to increase, are 
entirely harmless, and demand no treatment whatever. Sometimes they 
appear as flat elevations, having a brown or a chocolate color, caused by 
the pigment which they contain. These moles are frequently surmounted 
with hair, and in some instances are associated with great thickening of the 
skin. In the case of a young lady who consulted me for a deformity of 
this nature, the mole extended over almost one side of the face, and was 
covered with a strong growth of hair. 
When these growths become a source of dissatisfaction, they may be excised, 
observing, as in the ordinary naevus, to keep beyond the limits of the diseased 
tissue. If the surface exposed be too large for approximation and suture, the 
surgeon must resort to a plastic operation to close the gap. 
Angeioma of the Tongue.—The disease may be unilateral or bilateral; it may 
be confined to the anterior extremity of the organ, or may extend far back 
towards its root. It is easily recognized by the blue color, which can be dis- 
tinctly seen through the mucous membrane, and by the soft, spongy character 
of the swelling, which can in a great measure be emptied of its blood by 
compression, but quickly refills on the removal of the pressure. In a case 
of angeioma of the tongue, under my care, the disease disappeared under the 
use of hypodermic injections of ergot: eight or ten minims of the fluid ex- 
tract, each minim representing one grain of the ergot, were introduced into 
the growth once every six or eight days. In a case of this kind, should such 
injections fail, and the disease increase, it must be removed by the scissors, 
or by the ecraseur, and if any bleeding follows, the vessels should be secured 
by ligature. The operation of strangulation by the ligature is attended with 
so much swelling of the tongue and with such an offensive discharge that it 
should be abandoned, endangering as it does the life of the patient from laryn- 
geal oedema, from hemorrhage, or from blood-poisoning. 
Angeioma of the Labium usually appears on the inside of the greater labium 
of young children, and may extend outwards to the thigh, or downwards to 
the perineum. Other portions of the vulva are not exempt from the disease. 
When situated in this locality, the affection is generally of the venous variety, 
and exhibits the same characteristics as when on other parts of the body. 
When the tumor continues to grow, its removal will be best accomplished by 
one of the several forms of ligature described, or, still better, by the knife. 
Injuries and Diseases of the Veins. 
Wounds.—Wounds of small veins are less serious than similar injuries of 
the arteries, chiefly because they are not so much under the influence of 
the heart’s action, and consequently there is less danger from hemorrhage. INJURIES AND DISEASES OF THE VEINS. 
625 
When large venous trunks, like the subclavian, innominate, internal jugular, 
or axillary, are divided, death will follow in a few minutes from the loss of 
blood. The bleeding which proceeds from wounded veins in the neck is influ- 
enced very much by the respiration. During inspiration, when the walls of 
the thorax are dilated and no obstacle is offered to the passage of blood to- 
wards the right side of the heart, the wounded vein will remain partially col- 
lapsed, without shedding a drop of blood; but in expiration, when the great 
venous channels are compressed at the root of the neck by the diminished 
diameters of the chest, and there is a momentary arrest in the downward flow 
of the current, the blood will well up as from a fountain. In ligating a 
large vein, like the internal jugular, a certain degree of cerebral congestion 
must ensue from suddenly depriving the return circulation of so large a 
channel. 
When a vein is severed, neither the retraction of the divided ends nor the 
diminution in its lumen is so great as when an arterial trunk is divided 
across. 
Incised wounds are the least harmful: they generally heal quickly, as is 
well exemplified in the rapid repair which follows venesection. Large veins 
only, when woiinded, require the ligature; others are satisfactorily managed 
by pressure. Deep veins tolerate ligation better than superficial ones. I have 
frequently had occasion to tie the posterior tibial and popliteal veins after 
amputation at the knee-joint, and have never witnessed any unusual symp- 
toms. Dr. S. W. Gross* has shown, in a paper on the ligature of veins, that 
the dangers after such operations have been perhaps unduly exaggerated. 
In wounds involving the chief vein of an extremity (for example, the femoral), 
and when the bleeding cannot be controlled by pressure, it has been advised 
by Langenbeck to tie the main artery rather than to ligate the wounded 
vessel. In a case of popliteal aneurism which had extended into the femoral 
region, and where, in consequence of an inflammatory adhesion of the parts, 
I wounded the femoral vein in passing the thread around the artery, the 
venous hemorrhage, which for a time was profuse, immediately ceased on 
tightening the ligature, and did not afterwards return. Under the circum- 
stances this, I believe, was the proper treatment; but in ordinary wounds of the 
femoral, or of any other large vein, this practice should not be imitated: the 
damaged trunk should be exposed and tied above and below the seat of lesion. 
Some writers advise, in case the opening into a large vein is small, to stitch 
the orifice with a fine silk thread rather than to encircle the entire trunk of 
the vessel; Travers’s plan was to grasp the edges of the wound with for- 
ceps and encircle them with a fine thread.—the object in each case being the 
same, namely, to avoid the closure or obliteration of the lumen of the vessel. 
The plan is a very dangerous one, and altogether unreliable. The glover’s 
suture with a very fine thread, if antiseptically done, is a much better way 
of closing such wounds. 
Veins not larger than those of the subcutaneous tissue will sometimes bleed 
persistently. In such cases the cause is usually some impediment in the flow 
of the blood towards the heart, and in their treatment the obstruction must 
be sought out, and, if possible, removed. In prolapsed hemorrhoids the 
grip of the sphincter will often cause a large loss of blood in a few minutes, 
which can be promptly controlled by dilating the muscle and returning the 
piles into the rectum. An enlarged liver may cause a free bleeding from 
the portal veins. Our remedies under such circumstances must be directed 
to reducing the size of the offending organ. Uncomplicated venous oozing 
is best corrected by the elevation of the part, and the application of cold, in 
order to diminish the force and activity of the circulation. A wounded vein, 
when surrounded with purulent fluid, may open an avenue for the introduc- 
tion of septic matters into the system, which will seriously poison the blood. 
I have seen a trifling wound of the cephalic, below the line of the deltoid, 
prove fatal from this cause. Contusions of the soft parts are often followed 
* American Journal of the Medical Sciences, January and April, 1867. 626 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
by the laceration of veins, giving rise to dark discolorations or to ecehymoses, 
and sometimes to large collections of blood, which will remain in a liquid 
state for a long time. These accumulations should never be opened unless 
they terminate in abscess. Time and the use of stimulating applications, in 
order to quicken the absorbents, constitute the proper therapeutic measures. 
Healing in veins.—The repair of wounds made in veins in no respect differs 
from the same process in arteries, a subject which has been treated of in the 
earlier chapters of this work. 
Air in Veins.—The entrance of air into a vein is a most dangerous occur- 
rence. Where the accident has taken place, it has been during operations 
upon the neck and in the axilla. Dr. Cordwent* reports a case in which he 
thinks death was caused by air entering the veins of the uterus after labor. 
That the veins of the neck should furnish most of the instances of this acci- 
dent is doubtless to be ascribed to the fact that the venous trunks in this 
region are in many places attached to portions of the deep fascia, which pre- 
vents a collapse of their walls when wounded. The danger attending surgical 
operations from the entrance of air into the veins was first prominently 
noticed by Beauchesne, in 1818. In several instances persons have perished 
from this cause while under the knife of the surgeon. Dupuytren lost a patient 
in this way while dissecting a tumor from the neck.f A similar accident 
befell Mr. Barlow while operating in the same region. Mott and Stevens each 
came near losing a patient from what was believed to be the admission of 
air into the circulation : in Mott’s case, the vein opened was the facial. 
Death from this cause is said to have followed an amputation of the leg.| 
Professor Gibson, while extirpating a growth from the neck of a man before 
the medical class of the University, was startled by a gurgling sound and 
the sudden syncope of his patient. Though the case did not terminate fatally, 
the syncope was referred to the entrance of air into one of the veins. 
Symptoms.—When air enters a vein, a whistling, hissing, lapping, or gur- 
gling sound is heard ; a deathly pallor spreads over the face; the pulse becomes 
small and feeble ; the pupils are fixed and widely dilated ; the respiration is 
short and hurried, and entire unconsciousness, convulsions, and fatal collapse 
follow. 
Cause of death.—Several explanations have been offered for the cause of 
death in cases of the above accident, but none of them are altogether satisfac- 
tory. Examinations after death show air in the right side of the heart, an 
unusually bloodless appearance of the lungs, and in the left auricle and ven- 
tricle a small amount of blood intermixed with air, giving it a frothy appear- 
ance. The same fume or frothy admixture of blood and air is seen in the 
arteries and veins of both the pulmonary and the systemic vessels. Among 
the most plausible explanations is that which supposes that the air, after en- 
tering the right auricle, is carried to the right ventricle, and that during the 
contraction of the right ventricle the presence of the air prevents the closure 
of the tricuspid and semilunar valves, in consequence of which the two 
openings which they guard remain pervious in both the systole and the 
diastole of the heart, allowing the air to reach the pulmonary arteries, and 
in this way preventing the entrance of blood. 
Treatment.—In view of the possibility of so fatal an accident, the surgeon 
should be exceedingly careful in all opei’ations involving the deep portions of 
the neck or of the axilla, and, especially when prying out adherent growths 
from these regions, should have firm pressure made by assistants upon the 
contiguous veins, both above and below. In the event of air gaining access 
to the circulation, the head should be immediately lowered, the divided vein 
should be tied or compressed, and the respiration should be maintained by 
artificial means, using for this purpose either a tracheal canula, the “ ready 
* St. George’s Hospital Reports, vol. vi. 
f Medico-Chirurgical Transactions, vol. xvi. 
J Medical and Surgical History of the British Army in Turkey and the Crimea, vol. ii. p. 277. PHLEBITIS. 
627 
method,” or electro-galvanism. Brandy should be administered by the rectum 
or subcutaneously. The compression of the abdominal vessels, as advised by 
Mercier, is worthy of consideration, the object being to force the blood towards 
the brain and heart and great cerebral nerve-centres. A similar result would 
be favored by elevating the body and extremities. As a last resort, if time 
permit, a few ounces of blood may be transfused. Many of the suggestions 
made by writers to meet emergencies of this kind, such as aspirating the 
jugular vein, or the heart, arteriotomy, tracheotomy, etc., are mere specula- 
tions, having no practical value. 
Phlebitis.—There are two kinds of inflammation of the veins, the idiopathic 
and the traumatic. Either is more common than arteritis. The veins most 
commonly involved are the saphena magna, the femoral, and the pelvic trunks. 
The disease may appear in both the acute and the chronic form. 
Causes.—The causes of phlebitis may be arranged under the following heads: 
1. Ectasis; that is, from the extension or overstretching of the walls of the 
vessel, in consequence of which, the movement of the blood being retarded 
and the mechanism of the valves impaired, a eoagulum or thrombus is formed, 
the presence of which is prone to excite inflammation in the walls of the dis- 
ordered vessel. This condition may occur in persons enjoying good health, 
and the inflammatory changes may be entirely local. Persons whose employ- 
ments require the standing position are liable to such thrombi, particularly if 
at the same time they are exposed to cold. Pressure from abdominal tumors 
will give rise to the same coagula. 
2. Traumatism.—Under this head are included cuts, lacerations, bruises, and 
punctures. The frequency of such injuries without the occurrence of phlebitis 
shows that there is in the healthy condition of the blood and of the solids a 
strong indisposition in the veins to take on inflammation. The.rapidity with 
which a vein heals after venesection, or after the ligature of a hemorrhoidal 
tumor, is additional proof of this fact. It is in these traumatic cases that 
the surgeon occasionally witnesses the extension of the disease in a direc- 
tion opposite to that of the circulation. This fact, first noticed by Hunter, 
is doubtless due to a mechanical cause,—to coagula formed in the tributaries 
of the injured vein. 
3. Constitution of the blood.—After typhoid fever, typhoid pneumonia, scarla- 
tina, and other affections attended with alterations in the constitution of the 
blood, it is not uncommon to meet with phlebitis from obstruction of the 
saphena and other veins by the formation of thrombi, the coagulation being 
due, according to Schmidt, to the mutual reactions of the fibrinogen and 
the fibrinoplastin of the blood. It is often after the violence of the disease 
has expended itself and convalescence commenced that these thrombi form. 
To the same category of blood-change are to be referred those cases of in- 
flamed veins which occur in gouty and rheumatic states of the system, also 
in milk-leg, or phlegmasia dolens. 
4. Introduction of septic matters.—The effect produced on the blood by the 
introduction into the veins of certain products connected with textural 
change is of such a nature as to cause coagulation, or to excite those inflam- 
matory changes in the walls of the vessels which induce the fonuation of 
a clot. This condition is closely related to pyaemia or septicaemia. Such 
materials effect an entrance into the vessels not by being absorbed, but by 
passing directly into the current of the circulation through an opening in 
the injured veins. Thus, we find that when surgical operations are done in 
structures where the walls of the veins, being adherent to the surrounding 
parts, do not collapse, as, for example, in the cancellated tissue of bones, 
symptoms of septicaemia are frequently developed. Pyaemic conditions fol- 
lowing the puerperal state are caused in the same way, as the large patulous 
uterine sinuses invite the entrance of vitiated matters. 
5. Continuity of tissue.—The continuity of the connective tissues renders it 
easy for inflammation to extend from one point to another, and hence when 628 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
phlegmonous erysipelas attacks a part, or when the loose connective tissue 
contiguous to a vein becomes inflamed, the disease may very readily be con- 
ducted to the coats of the vessel and cause the deposition of a solid plug in 
their canals. 
It will be seen from the above remarks that the existence of a thrombus 
plays a very important part in the production of phlebitis. Sometimes it 
antedates the inflammation and becomes an exciting cause of the latter. 
At other times it succeeds it, and is an effect of those changes which occur in 
the walls of the vein, especially in the tunica intima, which I am led to 
believe has most to do with thrombosis. 
The late Professor Charles D. Meigs attributed to the internal coat of 
the blood-vessel system, or to the endangium, as he termed it, a para- 
mount influence over the blood. The changes which the clot or thrombus 
undergoes vary greatly in different cases. When the clot follows some 
injury, or when, as from the application of a ligature to a venous trunk, its 
object is a salutary one, designed to establish a barrier against the intru- 
sion of harmful materials into the circulation, the coagulum will extend in 
both directions to a collateral or tributary branch, into which it will pass. 
Sometimes it is not limited by such side-channels, but is continued upwards 
and downwards, blockading an entire vein and its branches. The obstruc- 
tion is not always complete. The thrombus may contract, maintaining its 
connection only to one portion of the vessel, and allowing a side-passage, 
which will admit the onward flow of the blood. Or the clot may, by the 
agitation to which it is subjected from the blood-stream, become decolorized, 
forming a plug of fibrin, through the centre of which are often tunnelled one 
or several openings for the current of the circulating fluid. The final dispo- 
sition of the thrombus is not always the same. It may undergo organiza- 
tion, as does the clot which forms in an artery after its ligature (see page 218), 
and become blended with the walls which enclose it, the whole finally being 
converted into a fibrous cord ; or it may soften down, and become changed 
into a bland, impalpable fluid, which will consort harmlessly with the blood 
and be removed out of the body. Unfortunately, these disintegrations of a 
clot do not always vanish in so innocent a manner. Fragments may sepa- 
rate from the common mass and be swept along in the circulation to the right 
side of the heart, and, after passing into the pulmonary artery, become im- 
pacted in the capillary vessels of the lungs, giving rise to metastatic inflamma- 
tion and abscess; or the thrombus may degenerate into a puriform-looking 
fluid, consisting of altered red and white corpuscles and of granular matter, 
which, mingling with the blood, acts as a ferment, and not only perpetuates 
and extends the phlebitis, but also induces a fatal septicaemia. In all these 
changes the influence of microbes must not be overlooked. 
Symptoms op Acute Phlebitis.—Acute phlebitis is characterized by tender- 
ness along the course of the affected veins, by the existence of peri-venous 
thickening, so that they have a cord-like feel under the finger, and by oedema 
and venous congestion, the result of an impeded or obstructed circulation. 
When the affected vessels are superficial, lines of a dusky-red color may be 
seen in the course of the inflamed trunks. The entire limb becomes stiff and 
supersensitive, and the temperature falls below the natural standard. More 
or less constitutional disturbance is always present; indeed, it often begins 
coincident with the local affection, manifesting itself by rigors, fever, a fre- 
quent pulse, headache, thirst, nausea, dry tongue, and sometimes by the 
presence of delirium. 
Diagnosis.—Phlebitis may be confounded with angeioleucitis. In the latter, 
however, there is no oedema, and the lines of color are both narrower and 
redder than those present in inflammation of the veins. In angeioleucitis the 
lymphatic glands, in direct communication with the affected absorbents, are 
usually tender, and more or less swollen. 
Pathology.—In phlebitis, the earliest inflammatory changes commence in 
the connective or adventitious coat of the vein, and consist of congestion in PHLEBITIS. 
629 
the vasa vasorum, and of transudation, producing redness and swelling in the 
course of the vessels. This transudation may be largely serous, or it be 
fibrogenous and contain a large number of young cell-forms; it interpene- 
trates the middle and inner coats of the vein, separating their layers, and, by 
the new formation of connective tissue, induces such a degree of thickening as 
entirely to destroy the normal elasticity of the vessel and convert it into a 
rigid sclerosed tube. Should the inflammation prove less intense, the infiltra- 
tion may be gradually absorbed, and the natural pliability of the walls of 
the vessel be restored. When the disease advances to suppuration, there is 
induced a serious alteration in the histological elements of the vein-tissues, a 
change not peculiar to these vessels, but common to all tissues when under 
inflammatory influences,—that is, molecular disintegration and a fatty meta- 
morphosis,—changes which prove destructive to the internal in common with 
the other coats of the vein. The production of a clot, as one of the effects 
of inflammation in a venous trunk, has been already noticed. 
Acute phlebitis, arising in bad constitutions or in persons who have been 
greatly enfeebled by exhausting disease, may assume a course which has 
been called diffuse phlebitis; or it may originate in an attack of phlegmonous 
erysipelas, the inflammation extending from the subcutaneous connective 
tissue to that in which lie the embedded veins, and thence to their walls 
proper, terminating in a diffused suppuration, which extends between the 
coats and travels along the sheaths of the vessels, causing their softening and 
disorganization, together with the formation of thrombi. These softened 
clots, intermingled with the vitiated products of inflammatory changes, enter 
the circulation and destroy the patient from pyaemia. 
The symptoms accompanying this form of the disease are local tenderness 
and redness in the course of the hard, thickened vein. When the vessels in- 
volved are deep-seated, these signs are not present; but when tenderness is 
experienced on firm pressure being made over the position of the profound 
veins, when the limb is enlarged and dense, but does not pit under the finger, 
and when there are present rigors, a feeble, frequent pulse, sweatings, a 
brown, dry tongue, a sallow countenance, with accumulation of sordes about 
the gums, and diarrhoea and delirium, the diagnosis may be established with 
considerable certainty. 
Treatment.—The treatment of phlebitis differs according as the superficial 
or the deep veins are affected. In that variety which is often seen succeed- 
ing an attack of typhoid pneumonia, typhoid fever, or gout, and involving 
the subcutaneous veins, no remedy in my experience is equal to the local 
abstraction of blood. A few American leeches placed along the course of 
the inflamed vein will quickly diminish the pain and extreme tenderness of 
the parts, after which the limb should be wrapped in a lotion of lead-water 
and laudanum and covered with oiled silk. As soon as the redness and undue 
sensibility subside, the compound solution of iodine with laudanum, brushed 
daily over the entire length of the diseased vessel, will form the most effective 
application. In traumatic injuries, especially wThen followed by pronounced 
shock or when the person is broken in health, much may be done in the 
way of preventing phlebitis. As the disease sometimes originates in an ex- 
tension of inflammation from the surrounding connective tissue, the utmost 
care should be observed to evacuate any abscesses which may arise, to secure 
thorough drainage, and to see that no foreign matter in the wound is over- 
looked. The whole procedure is to be conducted antiseptically. When in- 
flammation attacks the deep veins, even though early discovered, the local 
abstraction of blood does not appear to exercise any beneficial effect in con- 
trolling or ameliorating the disease. The constitutional treatment consists 
in removing by a gentle cathartic all sources of intestinal irritation, reliev- 
ing pain by anodynes, and supporting the patient’s strength by the use of 
tonics and stimulants, such as iron, quinine, brandy, whiskey, or wine, and 
by the most nutritious preparations of food. If in the course of the disease 
a vein becomes opened by idceration, causing hemorrhage, the flow of blood 630 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
can be controlled by a well-adjusted compress and roller over the seat of 
lesion. 
Chronic Phlebitis.—The subjective nature of the symptoms in chronic phle- 
bitis often allows the disease to exist for some time without being recog- 
nized and until considerable structural change has taken place. Veins whose 
circulation is much under the influence of gravity, as those of the inferior 
extremity and of the rectum, are most commonly the subjects of the disease. 
This is explained by the resulting dilatation causing congestion in the venous 
trunks. In those of the rectum, the absence of valves forms an additional 
incitement to congestion. Such inflammation is not necessarily connected 
with thrombosis, as we constantly witness the disease in the varicose veins 
of the leg without the production of clots. Chronic inflammation of veins 
may succeed the acute form of the disease. The morbid alterations of struc- 
ture in chronic phlebitis are not unlike those observed in other tissues under 
a similar process. There is increased thickening of the external and middle 
coats, partly by migrated forms and partly by the proliferation of the con- 
nective elements of the parts. In these changes the tunica intima appears 
to escape. Cornil* locates the chief thickening between the internal and 
middle coats. As in chronic inflammation elsewhere, so here, the obstruction 
to the circulation from surrounding induration causes dilatation of the in- 
trinsic veins of the walls until they become enlarged into sinuses. As chronic 
phlebitis occasionally follows the acute, the converse is likewise true, in which 
event coagula will form, and the,patient will be exposed to the risk of their 
future metamorphosis. 
Treatment.—The chief indications are to overcome the obstruction to the 
circulation, control the inflammation, and etfect the removal of the plastic 
deposits in the tunics of the vessels. To favor the passage of the blood, the 
limb should be elevated; to subdue the inflammatory action, leeches and 
blisters, followed by the application of Lugol’s solution of iodine, are the 
most potent agents ; and for the removal of the thickening, warm-water irriga- 
tion, associated with compression by a roller bandage, promises the best results. 
Hypertrophy.—This change in the walls of a vein may originate in a chronic 
inflammation such as has been described, or it may be purely a physiologi- 
cal necessity, resulting from a plenum of blood. In the first instance there 
is an organization of the transudation into connective tissue ; in the other 
there is an increase of growth in the elements of the different coats, particu- 
larly the external and the middle, in consequence of which there follows a 
uniform or symmetrical enlargement in the walls and in the canal of the 
vein, the latter becoming lengthened and tortuous. The capacity of the 
veins for physiological hypertrophy is one of those wise provisions for ex- 
traordinary occasions which are so often witnessed in the human body. If 
a tumor or a clot obstruct the iliac vein, the superficial branches of the 
femoral are very soon seen over the abdominal walls, enlarged and tor- 
tuous, in order to supplement the office of the disabled channel. A growth 
in the axillary region compressing the axillary vein is quickly followed by 
an unusual prominence of the subcutaneous vessels over the thorax. The 
most notable example, however, of an amplification of the venous channels 
to meet a temporary emergency is that seen in the gravid uterus, in which 
the veins almost completely enclose the organ in an intricate net-work of 
enormous blood-clmnnels. With hypertrophy of the veins there is generally 
associated an enlargement of the companion arteries, a singular illustration 
of the effort made by nature to maintain a just balance between the two 
systems of vessels. 
The treatment of cases of venous hypertrophy consists in removing the 
causes of obstruction wherever possible. Thus, if a tumor compresses a large 
vein, it should be removed, provided the growth is one adapted to an opera- 
tion ; and when the pressure is due to inflammatory infiltration, the latter 
* Archives de Physiologie, 1872, p. 602. VARIX. 
631 
must be got rid of by blistering, massage, compression, and alteratives, among 
which latter mercury and the iodide of potash rank highest. 
Atrophy.—Veins may become atrophied in consequence of the sclerosis 
which sometimes follows inflammation, and also from diminished functional 
activity. Atrophy is exceedingly common in advanced life : hence the discolor- 
ations or bruises so easily produced by a trifling pinch of the skin in old per- 
sons, the walls of the veins being so greatly attenuated. If a limb be kept in a 
state of rest for several weeks, as in a case of fracture of the leg, the tissue- 
demand for blood is greatly lessened, and there will follow an appreciable 
wasting in all the vessels of the extremity, but chiefly in the veins. It is 
this diminished capacity in the venous system of the limb which causes the 
distressing sense of stuffing experienced by the patient when he first re- 
assumes the erect position, the veins being temporarily disqualified to return 
with due celerity the suddenly-increased volume of the circulating fluid in- 
troduced by the arteries. Atrophy of any organ is attended by a corre- 
sponding change in the veins which supply it. The atrophy of many tissues 
is accompanied with fatty degeneration of their normal components, a meta- 
morphosis from which the veins are markedly exempt, calcareous transfor- 
mations being much more common. 
Fhleboliths.—Small, round, or oblong bodies are met with in veins, either 
lying loose in their canals or attached by a delicate thread of fibrous tissue 
to their walls. These bodies are probably formed by the calcification of a 
blood-clot, and are chemically composed, as has been ascertained by Dr. 
Frankland,* of albuminous and fibrinous matters, conjoined with phosphate 
of lime, having also a trace of sxdphate of potash and sulphate of lime, all 
of which materials are furnished by the blood. These bodies manifest a 
preference for particular veins, such as the prostatic and the vesical. They 
are occasionally found in old varicose vessels. 
The veins are rarely the subject of carcinoma. Virehowf describes a giant- 
cell myosarcoma which originated in the inferior vena cava. The case is, 
perhaps, unique. A carcinomatous tumor originating in the vicinity of a 
vein may finally include the vessel, destroy its walls, and send portions of 
the rapidly-proliferating outgrowths into its cavity, giving it the semblance 
of a venous cancer. 
Varix.—The terms varix, varicose veins, and phlebectasis are used to 
express a condition of certain parts of the venous system in which the vessels 
are dilated, elongated, tortuous, and knotty. Though most of the veins are 
susceptible of such alterations in structure and form, the disease for the 
most part is limited to the spermatic, pudendal, and hemorrhoidal veins, and 
to the saphena veins of the lower extremities. (Pig. 496.) Varix of the 
veins of the upper eyelid is occasionally seen. Rokitansky describes a vari- 
cose condition of the veins of the pia mater met with in persons of intem- 
perate habits. The same writer speaks of a similar condition of the veins 
of the choroid plexus. A peculiar configui’ation of the vessels around the 
umbilicus has been noticed, due to the existence of a communication between 
the superficial veins of this region and an enclosed umbilical vein, consti- 
tuting the caput Medusae of Severinus. The superficial pudic and mammary 
veins occasionally become dilated. (Fig. 497.) Varices of the veins of the 
neck have been described by Morand, Cline, and Roux. In the thorax the 
intercostals have, in rare instances, been seen dilated and tortuous; and 
Portal records examples of a similar condition of the vena azygos. Even 
the superior vena cava, according to Morgagni, may become the subject of 
the disease. Cases are on record of enlarged and convoluted veins in the 
abdomen. In the pelvis, the veins at the neck of the bladder (prostatic) and 
those of the rectum are frequently found varicose; the first often giving rise 
Holmes’s System of Surgery, vol. iii. p. 373. 
| Virchow’s Archives, Bd. Iii., 1871. 632 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
to vesical hemorrhage, and the last constituting piles. Only once have I seen 
true varices on the upper limb ; but Boux, Cartier, and others describe 
cases of this kind. Though the disease was familiar to the ancient medical 
writers, yet none, it appears, were ever apprised that any other than the 
superficial veins were 
affected. That these 
should suffer and the 
deep trunks escape was 
referred' by Boyer, Sir 
Everard Home, and 
others to the slight sup- 
port rendered by the 
skin and subcutaneous 
fascia to the former, 
while the latter received 
a strong support by mus- 
cles and the prolonga- 
tions of the deep fascia. 
That this view is incor- 
rect has been satisfac- 
torily shown by Yer- 
neuil, who found that 
the dilatation often be- 
gins in the deep veins, 
the subcutaneous trunks 
becoming secondarily af- 
fected ; a fact which I 
had ample opportunities 
to verify some years ago, 
when engaged in teaching anatomy. Mr. Gay thinks 
that the arterial trunks are implicated in varices; 
an opinion in which, I believe, few writers 
concur. Except where there is some me- 
chanical pressure near the entrance of a 
subcutaneous vein into a larger trunk,— 
as that of the saphenous into the femoral, 
—I believe it will be found that in all 
cases of varices of the leg the deep veins, 
as well as those whi ch establi sh a connection between the two sets, are af- 
fected similarly to the subcutaneous ones, and in all probability take prece- 
dence in the dilatation. 
Causes.—In general, whatever obstructs the flow of blood towards the 
right side of the heart, causing over-distention of the walls of the great 
veins, favors the formation of varices. Among these causes may be enu- 
merated the following: 
1. Organic affections of the heart, such as disease of the semilunar valves of 
the pulmonary artery or of the aorta, and imperfection of the mitral valves; 
conditions which favor pulmonary congestion by interrupting the free transit 
of the blood through the lesser circulation, and thereby causing engorgement 
of the cavse and smaller vessels. 
2. Obstruction in the 'portal system.—The deleterious effect of an impeded 
blood-flow through this part of the venous system is more concentrated 
than when a like cause operates on the other system of veins. In the former 
the hemorrhoid veins suffer most. Thus, in sclerosed conditions of the liver 
(cirrhotic liver) piles are very commonly present. 
3. Pressure upon the great veins within and without the body constitutes another 
very common cause of varix. This pressure may be made by the gravid uterus 
resting upon the cava or on the iliac veins ; by an ovarian or a uterine tumor ; 
by aneurism of the abdominal aorta ; or by faecal accumulations in the colon. 
Fig. 496. 
Fig. 497. 
Varicose state of superficial veins of the 
abdomen.—From Bryant. 
Varicose disease of the saphena magna. VARIX. 
633 
The pressure which operates externally in retarding or obstructing the venous 
circulation is often due to the existence of a tumor in the groin resting over 
the femoral vein, or to a constriction of the limb by a tight garter. Again, 
a long continuance in the upright position may lead to dilatation of the veins 
from the action of pressure; hence we often meet with varices in persons 
whose occupations require them to be on their feet for most of the day. In 
this position, the pressure of a long column of blood like that in the saphena 
vein of the leg is very great. 
4. Diminished accommodation for the venous circulation is another factor in 
the production of this disease; that is, when one or more veins have been 
rendered useless by their channels becoming blocked up with coagula from 
inflammatory or other causes, thereby making an increased demand on 
the remaining vessels to supplement the deficiency. The force resulting 
from this addition to the volume of their usual contents is exerted upon the 
sides of the overtaxed veins, in consequence of which they become varicose. 
It is in this way, most probably, that deep-seated contusions of the lower 
extremities act in developing varices, as many of the veins are, subsequent 
to such injuries, lost to the circulation by inflammatory changes or by 
sloughing. 
5. Trades and occupations, regarded by some as causes of varix, except, 
perhaps, such as demand for their prosecution the standing position, exercise 
little influence in causing the disease; and the same may be affirmed of con- 
stitutional temperaments. 
6. Hereditary predisposition to phlebectasis is said by Hasse* to exist; and 
I think his views on this subject are borne out by clinical observation. 
7. Sex and age.—Some writers believe that males, and others that females, 
are most liable to the disease. There may be something connected with 
the social and industrial life of the sexes in the different nations which will 
explain the diversity of opinion on this subject among British and French 
authors; but I am disposed to believe that in this country the two sexes are 
equally the subjects of this disease. The influence of age in determining 
the formation of varices cannot be questioned; for, while the affection may 
occasionally be witnessed in children and in aged persons, the middle period 
of life is that in which varicose veins are most commonly contracted. 
The principal reason for varix being generally confined to the lower ex- 
tremity is that the contents of the veins tributary to the inferior vena cava 
are very much under the influence of gravity, being far removed from the 
centre of the circulation. 
Pathology.—The changes which occur in a varicose vein are such as 
affect its form, the structure of its wall and of its valves, and the peri-venous 
connective tissue. 
Form.—I need not speak of those varicosities of the minute skin-veins, 
which are often seen scattered over the leg in straggling lines of a light-blue 
or a purple color. These varices are quite harmless, rarely give any incon- 
venience, and, indeed, seldom develop into the more aggravated form of the 
disease. When the superficial veins of the leg have to sustain an unusual 
degree of blood-pressure, either from obstruction in the course of their main 
trunks or from the blocking up of a neighboring channel, requiring them to 
supplement the deficiency, their walls become stretched, and their canals cor- 
respondingly dilated. The effect of these changes is to thin the coats of the 
vein and to diminish its power to resist the internal pressure. At this stage 
of the disease (taking the internal saphena as the subject of our description), 
a number of soft, compressible, blue swellings, very noticeable when the 
patient is standing, appear over the inner part of the leg and the foot. The 
effect of this distention of the veins is to produce a plenum of blood in the 
capillaries with which they are connected, and thus cause a transudation of 
serum and of white corpuscles, not only into the fibrous material which en- 
compasses the veins, but also into their tunics. The dilatation up to a certain 
* Cooper’s Surgical Dictionary, article “ Varix.” 634 
DISEASES AND INJURIES OF TIIE BLOOD- VESSELS. 
point is usually quite uniform, the vessels being straight and cylindrical, 
but as the disease advances they become elongated, are thrown into serpen- 
tine flexures, and develop sacculated projections, giving them a tortuous and 
knotty appearance. This convoluted and elongated con- 
dition of varicose veins is usually regarded as the result 
of interstitial growth ; but more than this is necessary 
for its explanation. The effect of dilating an elastic tube 
of dead matter will he to shorten, not to lengthen, its 
canal. A living tube like a vein is subject both to vital 
and to physical laws, and therefore the analogy fails in 
this particular; but the operation of the former does not 
exclude, it only modifies, the action of the latter. Indeed, 
in many respects the physical forces dominate the vital, 
both in normal and in abnormal growth. In explaining, 
therefore, the convoluted form of the veins, it is necessary 
to remember that the infiltration in their walls and in 
the surrounding connective tissue forms hyperaemia, the 
effect of over-distention, that it is not equally dissemi- 
nated, but exists at some points to a greater degree than 
at others, and that the new cell-elements of the transuda- 
tion becoming transformed into connective tissue give rise 
to a like inequality in the thickening of the coats of the 
veins. (Fig. 498.) This thickening in the walls of the 
vessel is chiefly confined to the middle or muscular coat, 
and is produced not by an increase in the number of mus- 
cle-cells, but by the addition of white corpuscles, which 
ripen into connective tissue. This unequal distribution 
of the nutrient elements renders the vein weaker at 
some portions than at others; and it is at these weak 
or thin parts that the walls first yield, causing a slight 
lateral deviation in the course of the vessel, which, in consequence of a 
similar change in the direction and force of the blood, is increased more 
and more, until a marked curve or convolution is formed in the vein. The 
effect of one curve is to reflect the circulating current forcibly against an 
opposite and higher point of the vein, and to cause another curve in that 
direction. A bed may be cut for a stream of water whose sides shall be 
geometrically parallel with each other, and yet, if left unrestrained by arti- 
ficial barriers, it will soon groove out for itself a channel like the trail of a 
serpent, simply because a slight indentation was formed on the side of one 
of its banks. The same law is in operation to produce the curves in a vari- 
cose vein. 
Another structural change is one affecting the valves of the enlarged veins. 
Mr. Gay says that veins which become varicose are generally without valves, 
a statement in which I do not concur. The effect of dilating the venous 
canals is to separate the cusps so widely that they are no longer capable of 
commanding the channel which they are designed to guard, and are pressed 
forcibly on both surfaces,—on the upper side by the weight of a column of 
blood which presses backwards, and on the distal side by the stream of blood 
moving towards the heart. The conjoined influence of distention and press- 
ure either causes their atrophj” and final disappearance, or, from their ex- 
treme tenuity, produces laceration, converting them into a number of floating 
threads. In some instances wdiere dilatation of the diseased vein advances 
very gradually, the valves inci’ease pari passu in strength, becoming markedly 
hypertrophied, and executing their functions unimpaired. From the very 
commencement of the disease the peri-venous connective tissue participates 
in the morbid changes. It is at first infiltrated with serum, giving rise to a 
slight oedema in the course of the dilated vein, and later is crowded with 
migrated leucocytes, which become developed into connective-tissue corpus- 
cles, and finally into true fibrous tissue, the condensation of which increases 
Fig. 498. 
Longitudinal section of 
a vein, showing the un- 
equal thickening of its 
walls. VARIX. 
635 
the thickening about the veins, glues firmly together their convolutions, and 
fills their cavities with coagula. This infiltration of the connective tissue, 
inflammatory in its nature, sometimes extends far beyond the limits of the 
affected vessels, involving the lymphatics and the subcutaneous fascia of the 
limb, producing a general hypertrophy of the connective tissue, and forming 
a pseudo-elephantiasis. Instead of the walls of varicose veins and the sur- 
rounding connective tissue becoming hypertrophied, a change of an opposite 
nature is frequently induced; the veins become attenuated, and the con- 
nective tissue for the most part disappears, the vessels contracting an at- 
tachment to the skin. Under such circumstances pouch-like protrusions 
appear over the limb, which, when the person is standing, present a blue 
appearance. 
Symptoms.—Yarix may arise so gradually that the patient is unable to fix 
the period of its commencement; but generally there are some precursory 
signs which foreshadow the disease. The most common are an unwonted 
fatigue and fulness of the affected limb or limbs, experienced after walking 
or after long standing. These sensations are often associated with a slight 
swelling or oedema about the ankles, and with numbness of the leg. After a 
time a slight blue protrusion appears in the course of the internal or the ex- 
ternal saphenous vein at a point where a tributary branch enters a main 
trunk. Obstruction to the current here is immediately realized in the con- 
tiguous veins, which in turn become dilated, and in this way the circle of 
embarrassed circulation and dilatation ex- 
tends, causing a tortuous and knotty condi- 
tion of the veins, involving more and more 
of these trunks of the leg (Fig. 499), until 
the entire venous system of the limb may 
participate in the disease. In the recumbent 
position, or when the leg is elevated, the 
swollen vessels disappear, or become much 
diminished, but they quickly reappear when 
the patient stands upon the fe.et. 
Effects.—A very common sequence of the 
embarrassed circulation in a limb affected 
with varix is eczema., The surface becomes 
inflamed, and minute vesicles are formed, 
which open and pour out a thin serum, 
which keeps the parts moist, or, mingling 
with the detached cuticle, desiccates into 
scales. 
Varicose ulcer.—A similar state of the cir- 
culation frequently develops an i nflammation, 
which results in ulceration and the formation 
of the varicose ulcer. 
Hemorrhage.—The venous distention may 
thin out both the walls of the vein and the 
tissues immediately around, until the parts 
become so weak that a slight bruise, or a little 
additional pressure, consequent on standing, will cause a rupture of the varix 
and the effusion of a large amount of blood. In addition to the above, stiff- 
ness of limbs, burning in the feet, and cramps of the legs are frequent at- 
tendants of the disease. 
Fig. 499. 
Varicose condition of the saphena interna. 
Treatment.—Where the cause producing varix is of temporary duration, 
such as pressure from the gravid uterus, or from a removable tumor, abdom- 
inal or otherwise, great relief will he experienced when the cause ceases to 
exist. Much may be done to relieve obstruction in the dilated vessels by 
avoiding the use of garters, by regulating the bowels, when costive, with 
saline aperients, thus preventing an over-fulness of the portal system, and by 636 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
administering ferruginous tonics, with cold bathing, when the patient is weak 
and his muscular fibre relaxed. When varix of the leg is thoroughly"devel- 
oped, surgery, though it possesses no means of cure, is capable of affording a 
degree of palliation which will render the patient entirely 
comfortable. With this object in view, local compression 
should be applied. This remedy, though commonly recog- 
nized as that of Delpech and Sanson, is really as old as 
Avicenna. It may be made by adhesive strips, by the 
roller alone, or by the elastic stocking. The latter will 
furnish the most expeditious means of imparting a uniform 
support, and will be found the most convenient dressing to 
wear. It should never, as is too commonly the case, be 
applied next to the skin, as the perspiration will quickly 
impair its value by rendering the fibre of the stocking 
rotten and by destroying its elasticity; neither should it 
be worn without including a considerable portion of the 
foot. The limb should be elevated so as to drain the blood 
out of the distended varices, after which a very thin cot- 
ton, linen, or silk stocking, long enough to reach to the 
knee, must be slipped on the leg, and over this is to 
be drawn the elastic stocking. (Fig. 500.) When the pa- 
tient retires at night, this dressing must be removed, and 
the limb bathed in cold water and afterwards subjected to 
brisk friction with a woollen cloth. In the morning, the 
stocking should be replaced before the patient rises to his feet. In the ab- 
sence of the elastic hose, the ordinary laced stocking, shown under the head 
of surgical dressings, may be substituted with advantage. When the veins 
of the thigh participate in the disease, the elastic stocking should be con- 
tinued up to the groin (Fig. 501), a piece of thin muslin being interposed 
between the skin and the dressing. The roller may be used in different 
ways, as an ordinary spiral reversed of the lower extremity,—always re- 
membering to raise the limb before its application, and to make the turns 
with the utmost uniformity of pressure,—or as an immovable dressing. In 
the latter form it is necessary, after emptying the vessels by position, first 
to make the spiral reversed of the limb, and then over this to place a second 
roller, which should have brushed into its pores boiled starch or liquid glass 
(silicate of soda); or the second may be a plaster roller, which will require 
to be dropped into a basin of water for a few minutes previous to its appli- 
cation. The immovable dressing will in a short time become firm and hard, 
and may be worn continuously for several weeks. Adhesive straps, recom- 
mended by Travers, are well suited to varices located about the ankle, and 
should be used in the same manner as when employed for the cure of leg- 
ulcers. (See page 183.) The gum elastic roller answers an excellent purpose 
in bad cases of varicose veins. It requires to be removed and cleansed daily. 
Various operations have been vaunted from time to time for the cure of 
varices. Among these may be mentioned laceration, cauterization, excision, 
incision, seton, ligature, caustics, electro-galvanism, and injection. Laceration 
is an old Roman operation, and consisted in exposing the vein and tearing it 
across by traction. Cauterization was practised by Celsus ; the diseased vein 
was laid bare by dividing the skin, and the hot iron applied directly to its 
walls. Excision is likewise an ancient measure. It was practised by Celsus, 
though confined to the treatment of veins which were only slightly tortuous. 
It was revived by Boyer and Richerand, but fell into discredit and disuse. 
Lisfranc at a later period attempted the operation in a modified form. Very 
recently, it is said, this operation has been l’epeated on the saphena magna* 
Incision was tried by Pare and Petit. The seton, recommended by Fricke, 
consisted in passing a thread a number of times through the vein and allow- 
ing it to reqiain for several days. Da vat had attempted to obliterate veins 
Tig. 500. 
Elastic stocking applied. 
* Ziemssen’s Cyclopaedia of Practical Medicine, vol. vi. p. 501. VARIX. 
637 
on the same principle, by inserting two pins at right angles across the vessel 
and binding them together with a thread. The ligature of varicose veins 
has at different times attracted considerable attention. This method was 
employed by Paulus iEgineta, Ambrose Pare, Boyer, 
Beclard, and Sir Everard Home. Boyer combined in- 
cision with the ligature, first tying the vein in two places 
and laying it open between the threads. Dupuytren tied 
the vessel with a single thread and cut the vein across 
above the ligature. Sir Everard Home exposed the vein 
and placed a thread about it, hoping for the obliteration 
of its canal without division by the knife. Brodie, in- 
stead of ligating the main trunk of the affected vein, 
placed his ligatures upon its principal tributaries. Sub- 
cutaneous section of varices was first introduced by this 
surgeon. Ligation was effected in a different way by 
Yelpeau. A pin was first passed beneath a single vein, 
or beneath a group of convolutions, and a figure-of-eight 
turn made by carrying a ligature about its extremities. 
The surface of the skin was protected against ulceration 
by interposing a section of a bougie between the threads 
and the skin. Professor Hamilton selects one of the 
largest veins at the inside of the knee, passes beneath it 
a needle armed with a thread, and then, placing over the 
skin a little pledget of lint to defend the integument from 
pressure, ties the two ends of the ligature firmly together. 
A second inclusion of the vein is made in a similar man- 
ner, one or two inches above the first. These ligatures 
are repeated eight or ten times, until all the principal 
trunks have been secured. In seven or eight days the 
threads will have cut their way to the surface by ulceration, and may be re- 
moved. Poultices of flaxseed-meal are applied over the parts, and a recum- 
bent position is maintained during the treatment. Mr. Lee, like Yelpeau, 
used the pin and the figure-of-eight suture, but with this difference, that he 
introduced two such sutures, and subsequently made a subcutaneous division 
of the veins included between the needles. Hr. Levis, of this city, has in a 
number of instances ligated varicose veins by a subcutaneous loop of silver 
wire. Sanson and Startin endeavored to substitute the ligature by applying 
destructive compression in another way,—the first by grasping the vein to- 
gether with the integument by spring forceps, and the latter by a bar-needle 
and clasp. 
Caustics have enjoyed considerable popularity, and are still regarded with 
favor by some surgeons. They act by inducing coagulation of the blood in 
the vein over which they are placed. The particular agents of this class 
which have been recommended and used are the Vienna paste, caustic potash, 
and nitric acid. The Vienna paste was a favorite caustic with Berard, Skey, 
and Mayo, and in this country with Professors Pancoast and Gross; it is the 
only remedy of the kind which I have ever used for the purpose under consid- 
eration. It is prepared by mixing five parts of quicklime with four parts of 
caustic potash, arid converting the mixture into a paste with spirits of wine 
immediately before using. The method of applying the agent is to take 
several small patches of adhesive plaster and cut in each a little perforation. 
These are to be applied, at short distances apart, over the course of the prin- 
cipal vein or veins, and the little openings filled with the paste, each being 
afterwards covered with a second patch of plaster. The caustic causes 
sloughing of the skin over the vein, filling the latter with inflammatory clots. 
In France, the paste of Canquoin, which consists of equal parts of chloride of 
zinc and farina, moistened with water, has been very largely employed in 
varices. Verneuil states that it has been used in over two thousand cases 
without a single accident. 
Fig. 501. 
Elastic stocking including 
the entire limb. 638 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
Electro-galvanism has been employed by Capaletti,* and in this city by 
Dr. Grier, with a view to obliterate the vein-canals by inducing thrombosis. 
Injection of the veins with perchloride of iron has been practised in France 
to a considerable extent, and, it is alleged, with very satisfactory result. 
The injection is accomplished by means of a small glass syringe and a very 
delicate trocar and canula.f The contact of this salt of iron with the blood 
causes the formation of a solid clot in the cavity of the vein; and before the 
injection is made, a firm bandage must be placed on the limb above, and 
retained there for some time, with the double object of making the vessel promi- 
nent, and of preventing the stream of blood from detaching and carrying a 
fragment of the clot to the heart and the lungs. 
It will be perceived that the object in all these multiplied operations is one 
and the same, namely, the obliteration of the diseased veins. The objection 
which has been urged against most of them is the risk of a diffused phlebitis, 
erysipelas, etc. While it is true that in a number of instances death has 
followed from these causes, yet the danger arising from tying and otherwise 
meddling with veins has been doubtless very much exaggerated; indeed, there 
is very little danger in any of the operations mentioned if asepsis be enforced. 
In my opinion, however, all these procedures, when applied to the veins of 
the leg, are not only unphilosophical but also injurious. To deprive the 
venous system of an important trunk like the saphena is to turn an undue 
amount of blood into neighboring veins and produce in them an increased 
dilatation. According to my own observations, in case of varix operated on 
by myself with caustic, and in others which I know had been treated with 
the ligature, the disease has invai’iably returned. I do not, therefore, believe 
that any operation which has yet been devised for the radical cui’e of varices 
is entitled to professional confidence. 
Diseases and Injuries of the Arteries. 
The arteries possess a wonderful facility for eluding injury. This is to be 
referred to several causes : 1, to position, the vessels being generally deeply 
situated, and occupying the least exposed localities of the body; 2, to the 
elasticity of their walls; 3, to mobility in their sheaths, and in the loose cel- 
lular tissue with which they are surrounded; and, last, to the protection 
of contiguous muscles, which serve to deflect vulnerating bodies. Wounds of 
the large vessels are not very common in civil practice. 
Contusions, though most common in gunshot wounds, may occur from other 
kinds of violence. The resulting inflammation may terminate in one of 
three ways: first, in the narrowing and even the obliteration of the lumen 
of the vessel from the contraction of its tunics, or, secondly, in the forma- 
tion of a coagulum obstructing its channel,—in either case causing mortifica- 
tion of the parts below unless the collateral trunks are equal to the task of 
transmitting the blood; thirdly, in ulceration, thus establishing an opening 
in the artery and giving rise to dangerous hemorrhage. 
Treatment.—Should mortification follow a contusion of the artery, it will 
not be necessary to wait for the line of demarcation, but the limb should be 
immediately removed above the seat of lesion. When ulceration takes place, 
followed by hemorrhage, a ligature should be applied above and below the 
opening in the vessel. 
Lacerations may be complete or incomplete, and may occur with or with- 
out an external wound. In complete laceration—an accident of frequent 
occurrence in manufactories — the artery is torn entirely across; and the 
injury is usually accompanied by extensive contusion and laceration of the 
soft parts. 
* Archives Generates, 1848. 
f Memoires de la Socicte de Chirurgie de Paris, vol. iv.: paper by M. Desgranges. DISEASES AND INJURIES OF THE ARTERIES. 
639 
Incomplete lacerations are those in which the internal and middle coats 
are torn, and the external tunic remains intact. ('Fig:. 502.) The lacerated 
layers curl inwards upon themselves, 
and may block up the lumen of the 
vessel. The current of blood after such 
an injury is liable to stretch the exter- 
nal coat of the artery into an aneu- 
rismal sac, or, by getting in bet ween the 
coats, to detach them from one another 
for a considerable distance, constituting 
the interparietal or dissecting aneurism. Another form of laceration, but a 
rare one, is where the external and, it is said, even the middle coat is severed, 
the internal one alone remaining sound. It is highly probable that in this 
very uncommon injury some of the muscular and elastic fibres remain, since 
otherwise the delicate and brittle lining of the vessel would give way under 
the pressure of the blood. 
Treatment.—In general it may be observed that in all wounds attended 
with much hemorrhage, the first duty of the surgeon is to arrest the loss of 
blood by applying, when feasible, a tourniquet to the limb, or by introducing 
a finger or a compress into the opening; the second is to determine its source, 
whether arterial or venous, and whether from a principal trunk or from one 
of its branches; the third, to apply a ligature to the vessel at the seat of 
injury. The blood from an artery issues in jets, is of a scarlet color, and 
is controlled by pressure on the cardiac side; while that from a vein wells 
up, has a blue or a purple color, and is arrested by pressure on the distal side. 
The following considerations will aid the surgeon in ascertaining the identity 
of the bleeding vessel. When the hemorrhage is from a main trunk it will 
be more persistent than when from a branch; pressure made at different 
situations will reveal the true vessel by controlling the bleeding at one point 
rather than at another; and if a vessel like the axillary, the brachial, or 
the femoral be torn, the pulse will cease at the wrist or at the ankle. An 
artery should not be tied near an important branch without including the 
latter in a ligature. To neglect this precaution is to expose the patient 
to the risk of secondary hemorrhage, in consequence of the uncertainty 
attending the formation of a permanent clot. 
In complete lacerations there will be little bleeding, in consequence of the 
paralysis of the torn vessel and the manner in which its tattered tunics are 
turned in so as to blockade the orifice of the artery and give support to the 
internal clot. Vessels of the size of the axillaiy, and even of the carotid, 
may be entirely severed and yet only a few’ drops of blood escape. While 
this is true, it would be a fatal neglect to trust in such a case to the oper- 
ation of natural processes alone. If left to itself, in a short time, when the 
paralysis begins to disappear or the shock which the patient has sustained has 
passed off, the force of the blood-stream will dislodge the coagulum, and hem- 
orrhage wdll follow’; or, should this not take place, the subsequent sloughing 
of the shattered coats will most probably open the vessel. In all cases, then, 
of complete laceration of an artery, both ends of the trunk should be tied, 
observing to place the ligature sufficiently distant from the seat of the injury 
to include a sound portion of the vessel. 
Hor is this rule less imperative in the two forms of incomplete lacera- 
tion, in both of which the artery must be tied above and below the point of 
damage, whenever that can be ascertained, thereby preventing the forma- 
tion of aneurism or a destructive hemorrhage. 
Fig. 502. 
Internal coat divided, external one unbroken. 
Incised Wounds.—These may be complete or incomplete. In the first the 
vessel is cut entirely across, and the injury is followed by retraction and con- 
traction of the divided ends, by a gush of blood, and by the formation of a 
coagulum as described under the head of hemorrhage. The second or incom- 
plete division may take place in various ways. It may be a mere nick, not 640 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
extending through all the tunics of the vessel, or it may be longitudinal, 
oblique, transverse, and sometimes horizontal, cutting out an ovoidal portion 
of the tube entire. Whatever the direction or the size of these wounds, 
there will be more or less retraction or gaping, this, however, always being 
greatest in such of the tubes as are transverse, in consequence of the direction 
of the elastic component. This is well illustrated in Fig. 503. The subsequent 
phenomenon of coagulation of the blood 
without and between the walls of the 
wounded trunk does not materially dif- 
fer from that which follows its complete 
division. These wounds are not only 
more troublesome than those extending 
through the entire circumference of the 
artery, but they are also more certain to 
be succeeded by secondary hemorrhage, 
as the retraction and contraction affect 
only a limited portion of the vascular 
tube, and that imperfectly, so that the 
resulting clot, being on the side of the 
artery, is constantly disturbed by the 
passing stream of blood. 
Treatment.—As in lacerated wounds, 
so in those which are incised, both ex- 
tremities of the divided artery will require ligation. The distal extremity, 
owing to the collateral circulation, is as likely to bleed as the proximal. The 
blood when coming from the former wells up, instead of issuing in jets as it 
does from the latter. The same practice must be extended to incomplete 
or partial wounds, however slight, even when they do not penetrate the 
cavity of the vessel. The old practice of cutting the artery between the 
ligatures, as performed by Abernethy, has been long since abandoned as 
useless, if not dangerous, by predisposing to secondary bleeding. In wounds 
of a superficial vessel, an acupressure-pin above and below the lesion may be 
employed in an emergency. All ligatures should be made with the catgut 
thread and with antiseptic precautions. 
Punctured wounds demand the same treatment as those belonging to the 
other classes. Shot injuries of the vessels have been treated of under the 
head of gunshot 'wounds. 
Fig. 503. 
1, longitudinal slit below, the consequent gaping 
seen above; 2, oblique slit, and in consequence a 
more extensive retraction of the wound; 3, transverse 
slit, exhibiting the greatest degree of gaping; 4, 
the effect of cutting out longitudinally a portion of 
the cylinder. 
Arteritis.—The arteries possess a wonderful power to resist disease, and 
hence they are found surrounded by purulent accumulations and by malig- 
nant growths, or lying in the midst of sloughing tissues, or even stretching 
across chasms formed destructive ulceration, and yet still capable of carry- 
ing blood to the parts to which they are distributed. Idiopathic inflamma- 
tion of these vessels is, therefore, an unusual occurrence, and, when it does arise, 
is traceable to some constitutional vice in the blood, such as exists in syph- 
ilis, gout, and rheumatism. As a traumatic result arteritis is very common, 
being present in every case of ligature or wound. The order of frequency 
in which the tunics of the vessel are involved by inflammatory changes is 
determined by the exciting cause. When arising from internal or idiopathic 
conditions, the tunica intima is first affected, and from this the disease 
travels outwards, extending to the middle and the external coat, and even 
to the loose cellular tissue about the vessel. If the arteritis has a traumatic 
origin, the inflammation will advance in the opposite direction, that is, from 
the outer to the inner coat. The earliest evidence of the external form of 
the disease, that most commonly encountered by the surgeon, is hyperaemia 
of the nutrient vessels of the cellular tunic of the artery and its sheath, fol- 
lowed by a fibrinous and cell transudation. Should the inflammatory dis- 
tention of the capillaries continue, a similar infiltration will extend to the 
middle coat, the effect of which will be to involve the tunica intima, pro- ARTERITIS. 
641 
ducing endo-arteritis. Partty from the swelling and partly from the spasm 
of the muscular walls of the vessel excited under irritation of the vascular 
nerves and thereby diminishing the canal of the artery, the inner coat is 
thrown into plications, and its nutrition seriously disturbed. The walls of 
the vessel thus filled with the products of the inflammation may undergo 
several important structural alterations. 
Results of arteritis.—The most common results are a new formation of con- 
nective tissue, suppuration, atheroma, calcification, thrombosis, and aneu- 
rism. These transformations may be considered to be the result of a chronic 
inflammation. The organization of the cell transudation, and the prolifera- 
tion of the staple elements of the parts into connective tissue, may take 
place in the sheath or in the fibrous or muscular layers of the vessel. When 
in the sheath, it may produce a sclerosis or thickening around the artery, and 
its adhesion to the surrounding parts. When hyperplasia of the connective 
tissue occurs in the external and middle tunics, it causes a corresponding 
wasting of the muscular and elastic components of the last-named coat, in 
consequence of which the vessel is rendered less able to resist the pressure 
of the blood ; dilatation follows, frequently terminating in aneurism. 
Another effect of arteritis is the formation of clots within the canal of the af- 
fected vessel, probably due to some subtle change in the vital characteristics 
of the intima. These clots are sometimes regarded as standing to the inflam- 
matory phenomena in the relation of cause and not of effect. The obstruc- 
tions which such coagula form may be partial or complete. The clots are 
frequently conical, resembling the thrombi which form after the ligation of an 
artery. The final disposition of these clots is not always the same : they 
may become organized and incorporated with the walls of the vessels, com- 
pletely obliterating its lumen; or they may soften down and mingle with 
the circulating fluid, again rendering the canal pervious; or portions may 
become detached and block the artery at another point, in which case, should 
the collateral branches prove unable to transmit the blood to the parts below, 
mortification will follow ; or if the fragments of the thrombus are sufficiently 
minute, they will pass into the capillary vessels and cause numerous points 
of obstruction. 
When the disease advances to suppuration, the pus, if in the adventitious 
coat, is rarely circumscribed by a limiting wall, but becomes diffused along 
the course of the artery. When the suppuration is in the middle coat, it may 
exist in the form of distinct abscesses, liable to open into the vessel and 
mingle their contents with the blood, causing a fatal pyaemia. 
Symptoms.—There are no symptoms which are so specifically characteristic 
of deep-seated arteritis as to enable the practitioner to detect with certainty 
its existence. The tension of the vessel, arising from a diminution of its 
canal, the empty state of its branches, the diminished temperature of the 
parts to which it is distributed, and the impaired movements of the limb on 
the affected side, are all grounds for suspecting the presence of the disease. 
When the inflammation is seated in arteries which are accessible to the 
touch, there will be less obscurity. The affected vessel will have a hard, 
cord-like feel, and be tender on pressure; there will be deep lancinating and 
radiating pains, and the entire limb will be stiff and helpless. In the com- 
mencement the disease may be mistaken for rheumatism. When obstruction 
is present, the pulsation of the vessel below will be diminished in force, or 
may be entirely suspended; and when the vitality of the parts supplied by 
the crippled artery is threatened, their temperature will fall, and their color 
become dark and mottled. 
Treatment.—When arteritis arises from idiopathic causes, as rheumatism 
or gout, the best remedies will be the iodide of potash with colchicum and 
belladonna. If the patient is strong and vigorous, or if the attack has been 
provoked by a too free indulgence in eating and drinking, these remedies 
must be preceded by an active purge, consisting of calomel followed by a 
saline cathartic. To relieve pain and to procure rest, Dover’s powder will 642 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
prove most serviceable. As a local application, the use of laudanum-and- 
water will often prove very comforting to the feelings of the patient. 
Atheroma.—The term atheroma is used to express a peculiar degeneration 
of the arteries. Though no vessel can be said to be exempt from the disease, 
yet it is most commonly seen in the arch of the aorta, and in the iliac, tibial, 
cerebral, coronary, brachial, radial, and ulnar arteries. Males appear to be 
oftener affected with this degeneration than are females. The natives of the 
United States are singularly exempt from this affection, as compared with our 
foreign population. The disease is said to be very common in Great Britain, 
and also in Paris. 
There are two varieties of atheroma, the senile and the 'premature. The 
first is rarely seen in the young, but is most commonly observed after fifty 
years of age. The second begins as early as thirty, is generally the result 
of alcoholism, and is much more common than is generally supposed. In 
cases of extensive atheroma it is not unusual to find the corresponding 
vessels of the two sides suffering alike. Veins are seldom affected with 
atheroma. There are three stages, — infiltration, fatty degeneration, and 
calcification. 
Anatomical characteristics.—The disease generally commences in the internal 
coat of the artery, and in the deepest or the most external lamelke of this 
coat. These layers become thickened, to accommodate which change the 
innermost part of the intima is pressed in the direction of least resistance, 
that is, inwards towards the canal of the vessel, causing numerous flat pro- 
jections of various sizes and of irregular outlines. These thickenings are 
caused by the multiplication of cell-elements in the lamella, some of which 
originate in an active proliferation of the connective-tissue corpuscles of the 
part, and others, probably, are emigrants from the vasa vasorum. The effect 
of this infiltration is twofold: first, to sclerose or harden the tunica intima; 
and, second, to interfere with its nutrition, by offering a mechanical ob- 
stacle to the access of blood. The effect, therefore, of a diminished blood- 
supply is to inaugurate a retrograde metamorphosis of both the new and the 
old elements. Their cell contents become changed into fatty materials, and 
this constitutes the commencement of the second stage. To the eye the ves- 
sel now presents numerous spots or streaks of a yellow or light-gray color, 
which in time become confluent, forming patches of considerable size, and 
which have a greasy feel. While this degeneration is in progress in the 
external layers of the intima, cell infiltration goes on in the more internal 
ones. Not only does this fatty transformation invade the cells, but it also 
induces changes in the intercellular substance of the connective tissue, the 
softening down or the liquefaction of which—intermingled with fat-globules, 
granules, and fragmentary particles of disorganized lamellse—constitutes a 
soft, pulpy mixture, which has been called the atheromatous abscess. As 
the disease advances, one lamina after another of the internal coat yields 
to the transudation, the fatty transformation at the same time following 
closely on the infiltration, until there may remain only the most delicately 
attenuated film of the intima between the blood and the soft atheromatous 
substance beneath. This film frequently becomes fissured, and allows the 
purulent-looking accumulation to escape into the vessel and to become in- 
termixed with the blood. The opening which remains, and which extends 
between the intima and the middle coat of the artery, often in a very irreg- 
ular, sinuous manner, forms the so-called atheromatous ulcer. The effect of 
the swelling of the tunica intima, from the presence of plastic matter and 
of cell-forms, is to encroach upon and diminish the lumen of the vessel. 
This swelling has been improperly interpreted by certain writers, who have 
supposed that this diminution in the canal was caused not by transudation 
in and beneath the layers of the internal coat, but by a deposition upon its 
inner surface. 
The effect of the above changes is to modify seriously the physical prop- ATHEROMA. 
643 
erties of the arterial tube. Tt loses much of its elasticity, is deficient in 
firmness of texture, becomes soft, dilating unequally, and is easily lacer- 
able. Though it is true that the internal coat usually takes precedence in 
atheromatous change, yet the disease is by no means limited to this part 
of the vessel. The middle or muscular layer participates in a similar meta- 
morphosis. The order of the phenomena in such an event corresponds to 
that described as occurring in the intima. Cell-forms appear between the 
inner and the middle coat, and interpenetrate the fibres of the muscular 
layer; the sarcous contents of the muscle-cells are replaced by fat, form- 
ing greasy, yellowish, circular streaks about the vessel, which eventually 
constitute the same kind of creamy pulp as that in the atheromatous ab- 
scess already described. With such alterations in the nutritive processes of 
an artery, it would be singular if its external or fibrous coat should escape 
being involved in the disease. Accordingly, we find that a period is reached 
when the tunic becomes red and swollen with transudation, and its fibres 
swarm with migrated leucocytes and with other cells which arise by an 
active proliferation of its stable connective-tissue corpuscles. Many of these 
forms are developed into connective or cicatricial tissue, white in color, hard 
and inelastic in its constitution, and 
which, with the wasted elements of the 
middle coat, may become blended with 
the remains of the intima. 
Calcification.—The degenerative stage 
which next appears is that of calcifica- 
tion ; that is, the deposit of lime salts in 
the fibrous and other remaining compo- 
nents of the vessel. This deposition is 
by no means uniform. It may occur in 
irregularly-disseminated grains, giving 
a rough, granular appearance to the 
vessel; it may form in scales, rendering 
the artery rigid and inelastic,—a con- 
dition common to the aorta and other 
large trunks; it may appear as thin, 
elongated plates, with irregular borders, 
and separated from adjoining ones by 
fat-globules, so as to give a pavement-like appearance to the sui’face of the 
artery (Fig. 504) ; or these plates may increase in thickness and in extent 
until the tube becomes converted into a hard cylinder. Another singular dis- 
position of these salts is an annular aggregation of grains, which follow the 
circular disposition of the muscular fibres of the media, giving an appearance 
to the artery not unlike that of the trachea. These calcified rings may become 
united by intermediate deposits until the tube is transformed into a canal 
of almost stony hardness. The femoral, popliteal, tibial, radial, and ulnar 
arteries furnish the most common examples of this condition. (Fig. 505.) 
Microscopic appearances.—A microscopic examination of an atheromatous 
artery reveals the existence of oil-globules, small scales having a white, shining 
appearance, fragments of earthy matter, numerous minute particles, crystals 
of cholesterin, and leucocytes, together with the proximate constituents of 
fat,—oleine, margarine, and stearine. These components are found mixed 
with other tissue-debris of the affected artery. (Fig. 506.) The earthy 
deposition, when carefully examined, exhibits neither bone-cells nor that 
orderly arrangement of parts which forms the Haversian system found in 
true osseous substance, and therefore cannot properly be termed a process 
of ossification. 
Causes.—We have seen that atheroma is essentially a fatty and a calca- 
reous degeneration of the walls of a vessel. There are two views entertained 
by writers on the nature of this arterial degeneration. Moxon* believes that 
Fig. 504. 
Arch of the aorta laid open, exhibiting an aggrega- 
tion of calcified plates. 
* Guy’s Hospital Reports, vol. xvi., third series, p. 431, 1871. 644 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
it originates in inflammation, and that the inflammation is induced by vas- 
cular tension. In support of his opinion this writer states that those diseases 
which tend to diminish such tension, as phthisis and mitral insufficiency, are 
rarely attended by atheroma. 
Niemeyer* and Virchowf 
both believe in the inflamma- 
tory doctrine. Holmest re- 
gards strain or overstretching 
of the arterial walls as prin- 
cipally concerned in produ- 
cing the disease. Gulliver§ 
adopts the non-inflammatory 
view, holding that the inner 
coat is primarily affected, and 
that the stenosis of the arte- 
rial canal is to be attributed 
to a deposit from the blood upon the intima, without any 
previous infiltration of the other coats. This view would 
transfer the essence of the disease from the tunics of the 
vessel to the blood. The fact that atheromatous change is 
in almost all instances met with in the arterial system of 
vessels would seem to connect it in some Avay with artei'ial 
blood, and therefore to favor the idea of a primary deposition 
from that fluid; but, on the other hand, the alteration being 
frequently seen to occur in patches, and not generally affect- 
ing extensive portions of a vessel, would militate against this 
doctrine. It has been stated by some writers, who are ad- 
verse to this opinion, that the disease is not confined to the 
arteries alone, but occasionally invades vessels carrying ve- 
nous blood, and one—the pulmonary artery—in which the 
blood is intensely venous. I am unable, however, to find 
more than a single recorded case of this kind,—one reported 
by Dr. Gerald Yeo :|| in this the pulmonary artery and all 
its branches were atheromatous, caused, it was supposed, by 
a constriction which existed at the mitral opening, and by 
hypertrophy of the right ventricle. If such were the proper 
explanation, it would tend to confirm the doctrine of Holmes, 
namely, arterial tension. Too much weight, however, must 
not be attached to exceptional cases in the investigation of pathological ques- 
tions. The most probable view, in my judgment, is that the disease is in all 
cases inflammatory in its origin, that the predisposing causes may be either 
alterations in the constitution of the blood or arterial strain, and that the 
deposit which takes place in the layers of the tunica intima is due to the 
altered nutrition of that, membrane from the interpenetration of its laminae 
by migrated leucocytes and from the proliferation of its normal cell-elements. 
The effect of chronic inflammation in determining fatty degeneration of 
tissues in other parts of the body, even in non-vascular structures like the 
cornea and cartilage, is well known ; and I can discover no reason why 
similar degenerations occurring in the arteries should require a different 
explanation. Gout and rheumatism are regarded as being active in the pro- 
duction of atheroma. Syphilis is also deemed a fruitful source of the disease. 
With reference to the last-named affection, Moxon asserts that it exercises no 
influence whatever in causing these changes, though I think there can be no 
doubt that syphilitic blood, remotely at least, has much to do with arterial 
degeneration. 
Alcohol, in my judgment, is more actively concerned than all other causes 
Fig. 505. 
Fig. 506. 
Microscopic appearance of arterial athe- 
roma. 
The brachial artery, 
and part of the radial 
and ulnar arteries, 
converted into rigid, 
calcified tubes. The 
annular arrangement 
of the grains of lime 
salts is seen where the 
interior of the vessel 
is exposed. 
*• Text-Book of Practical Medicine, vol. i. p. 345. f Cellular Pathology. 
f System of Surgery, vol. iii. p. 396. $ Medico-Chirurgical Trans., vol. xxvi. p. 86. 
|| Transactions of the Pathological Society of Dublin, vol. v. part ii. p. 123. ATHEROMA. 
645 
combined in bringing about atheroma, especially of the variety which I have 
termed premature.” 
Nor must we overlook the effect of those changes which are incident to 
advanced life, changes which notably lower the life-forces of the body, and, 
of course, the functional activity of the different organs. The muscles grow 
less supple, the ligaments stiff and inelastic, the cartilages of the ribs and the 
larynx ossify, and the heart-muscles become enfeebled by fatty transforma- 
tion. All these phenomena, which belong to the decline of life, would appear 
to invest the changes attending senility with paramount importance as a 
favoring cause of arterial atheroma. 
Symptoms.—There are no symptoms which enable the practitioner with 
any certainty to detect atheromatous transformation in vessels, unless the 
change has advanced to calcification and the artery is accessible to the touch, 
when the rigid, irregular, and granular surface of its walls will sufficiently 
declare the existence of such a change. If, however, a man has passed his 
fiftieth year, or has been the subject of gout, of rheumatism, or of syphilis; 
if the pulse becomes a little irregular in its action and the respiration is quick- 
ened on his taking the usual exercise, without any abnormal sounds of the 
heart being present other than, perhaps, a slight murmur, and without there 
being any physical alteration in the pulmonary organs to explain the defect 
in breathing; and if, in addition to these symptoms, the fatty ring (arcus 
senilis) is seen at the circumference of the cornea, the existence of atheroma- 
tous change in the aorta and other vessels near the heart may be deemed 
highly probable. 
Treatment.—There are no remedies with which we are acquainted that 
are capable of removing the transformation under consideration. The solvent 
action of lactic acid upon the lime salts would suggest the free use of milk 
as an article of diet, not with the hope of removing calcification when once 
established, but to favor a constitution of the blood which should be, in some 
degree at least, incompatible with its existence. Much may be done, how- 
ever, in this way of palliation by attending to the condition of the kidneys 
and digestive organs, at the same time directing the patient to lead a quiet 
life and avoid every cause calculated to quicken the action of the heart and 
to increase arterial tension. 
Consequences of Atheroma.— Thrombosis, or obstruction of an atheromatous 
artery by the formation of a clot, is frequently induced by the grains, scales, 
or plates of calcified matter projecting into the lumen of the vessel, and 
offering those irregularities which, by contact with the blood-stream, favor 
coagulation. This is a common cause of cerebral embolism. 
When the arteries of an extremity become obstructed, the condition is an- 
nounced by pain, loss of heat, numbness, and stiffness of the limb. The skin 
becomes mottled, and finally dark and gangrenous. When the obstruction 
grows slowly, the collateral vessels may be able to supply the parts below 
with blood; but when the thrombus is quickly formed, the danger of morti- 
fication is imminent. 
Ulceration.—The rupture of the intima and the escape of a portion of 
softened atheroma into the vessel, leaving an irregular excavation in its walls, 
the circumference of which becomes thickened by a formation of organized 
transudation, constitute what has been termed an ulcer; but there is a form 
of ulceration which destroys all the coats of the artery, opens externally, and 
is followed by hemorrhage. I lost a patient from this cause by an ulcer per- 
forating the common iliac a short distance above where a ligature had been 
applied on account of secondary hemorrhage after ligature of the external 
iliac for aneurism. I am not prepared to say in which part of the vessel, in 
this case, the ulceration began, whether the external or the internal, though 
it is believed that in true ulceration of arteries the external tunic is first 
attacked by the inflammation. 
Dilatation.—When a portion of the internal coat of an artery is destroyed 646 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
by atheromatous degeneration, the blood finds its way through the opening, 
and, by pushing off the fibrous from the muscular tunic, forms the dissecting 
aneurism; or, instead of separating the tunics in this manner, the middle 
and exteimal coats may yield over a limited part of the vessel, giving rise to 
a diverticulum, or pouch-like protrusion of its walls, presenting the ordinary 
appearance of a true aneurism. The pouch may become so thinned by the 
pressure of the blood as finally to give way and destroy the patient by 
hemorrhage. 
Hypertrophy of the left ventricle, and arterial dilatation.—The change which 
takes place in the physical and vital properties of a calcified artery is such 
as to act both upon the centre of the circulation and upon its peripheral ex- 
tensions. When an artery is sound, and the blood is driven into its canal by 
the contraction of the left ventricle, it first expands by virtue of the elasticity 
of its middle coat, and then contracts upon its contents by the reaction of 
the muscular and elastic layers. The propulsive power of the heart is thus 
supplemented, and the stream rapidly hurried forward. When, however, 
these vessels are changed into rigid, unyielding tubes, their walls offer a 
direct resistance to the force of the heart, and thereby slow the blood-cur- 
rent. Such an obstacle compels the heart to exert a more vigorous stroke, 
and diverts a larger amount of blood into those vascular trunks which remain 
sound. The effect is to induce hypertrophy of the left ventricle, and dilata- 
tion of the vessels unaffected by the disease. 
Loss of temperature.—When the smaller ramifications of the greater circu- 
lation are calcified, for example, those of the lower extremity, the retarded 
flow of the blood and its defective distribution diminish the activity of tissue- 
change, and as a consequence lessen the evolution of heat. From this cause 
persons who are the subjects of this degeneration will frequently complain 
of cold feet. 
Cramps.—The spasmodic contractions of the muscles of the legs, so com- 
monly complained of by aged persons, are to be attributed to the altered 
condition of the blood from its tardy circulation, rendering it unfit for the 
demands of the nerve-centres, and thus causing these displays of irregular 
nerve-action. 
Mortification.—The obstruction offered to the circulation by coagula, 
which form so readily in calcified vessels, or the sluggish movement of the 
blood through its rigid channels, may so starve the districts to which the 
diseased vessels are distributed as to induce their mortification. Senile and 
other forms of gangrene are illustrations of this condition. 
Treatment.—Little can be done in the way of treatment for the relief 
of the complications arising from atheromatous degenerations. Everything 
calculated to stimulate the heart should be avoided, the patient leading a 
quiet life, free from all excitement. When the temperature becomes lowered 
and the extremities suffer from cold, often the precursors of mortification, 
external warmth and stimulating frictions must be applied, in order to favor 
the circulation of the blood. Opiates should not be withheld when pain and 
restlessness are present. For the cramps in the legs which so often harass 
aged persons suffering from calcified arteries, nothing affords more prompt 
relief than dry heat applied to the parts. 
When mortification follows, the fetor must be corrected by deodorizing 
agents, such as charcoal and fermenting poultices, or by solutions of per- 
manganate of potash, bromine, or carbolic acid. The general strength will 
require to be supported by nutritious food, tonics, and stimulants, and all 
pain must be relieved by anodynes. Few persons survive the disease, death 
taking place during the progress of the mortification. In rare instances, whei*e 
the arterial obstruction has been quickly formed, and the death of the part 
rapid, a line of demarcation has been established, and the limb successfully 
removed. 
Amyloid Degeneration.—This obscure affection is most commonly observed ANEURISM. 
in the smallest arteries, especially in those distributed to the elementary parts 
of large secreting organs like the kidney and the liver. When found in large 
vessels, it is in those very closely related to the heart, as the aorta, carotid, 
and innominate pulmonary arteries. It is regarded as an infiltration, entering 
both the cells and the non-cellular components of a structure, and imparting 
to these a swollen, distorted, shining, and vitreous appearance. In chem- 
ical constitution the amyloid formation is an albuminate, but it behaves under 
certain reagents in a manner different from ordinary albumen. The addition 
of iodine produces with this peculiar substance a brownish-red color. Like 
fibrin, the material does not normally exist in the blood, but is the product of 
certain subtle changes which take place during transudation, as has been 
stated by Friedreich, between the albuminous matters of the blood and the 
tissues through which these matters pass. The deposit affects both the inner 
and the middle coat of an artery, and has been seen in the fibrous tunic, ex- 
tending even to the connective tissue beyond the vessel, transforming these 
tunics into white, glassy-looking particles. The swelling resulting from the 
infiltrate encroaches on the canal of the vessel, much as in atheroma, and in 
small arterioles may ultimately occlude their channels. The amyloid degen- 
eration is induced by protracted suppuration, and by syphilitic and other 
causes, which slowly induce those alterations of the blood and tissues which 
establish what we are wont to term a diathesis or a dyscrasia. When at- 
tacking internal organs, it constitutes a serious bar to operations on the body. 
An aneurism is a tumor which contains blood, and which communicates 
directly with an artery. Fernelius* was the first to ascertain the proper 
relation of aneurismal tumors to the arteries. 
Division.—Aneurisms are divided, first, into internal and external:—internal, 
when situated within the great cavities of the body; external, when located 
upon the vessels of the head, neck, and extremities. To the former division 
belong aneurism of the cerebral arteries, aneurism of the aorta, of the iliacs, 
and of the mesenteric arteries. 
A second division is into spontaneous and traumatic, according as they arise 
without or with a visible injury. 
A third division is into true and false aneurism: true, when the blood is 
contained in a sac formed by one or more of the coats of the affected vessel, 
and false, when it escapes from the artery into the surrounding tissues, either 
in consequence of a wound in the vessel or from rupture of an aneurismal 
sac. In the last instance we have an explanation of the manner in which a 
true may be converted into a false aneurism. Another variety under the false 
division, so placed by Broca and others, is dissecting aneurism. 
A fourth division is that of arterio-venous aneurism, under which are two 
varieties, the direct or aneurismal varix, and the intermediate or varicose aneu- 
rism. 
Breschet,f in addition to the varieties named, makes two others, namely, 
aneurism by anastomosis, so called by John Bell, and cirsoid aneurism. These 
two, so entirely different in their anatomy from aneurism, I have treated 
under the head of angeiomatous growths. Hunter believed in a hernial aneu- 
rism,—that is, one in which, the external and middle coats of a vessel being 
torn or divided, the internal one, or the intima, pressed through the opening 
thus made and formed a tumor. Dr. Crisp refers to such a specimen in the 
Museum of the London College of Physicians. Mr. Eriehsen, however, after 
having examined this specimen, came to the conclusion that the external coat 
of the aneurism had been dissected off. I am not aware that a single ex- 
ample of this form of the disease, verified by dissection, exists in any patho- 
logical cabinet. 
ANEURISM. 
* Universa Medicina de Ext. Corp. Affect., lib. vii. cap. 3, Venet., 1564. 
f Sur differentes Especes d’Anevrismes. 648 
D IS EASES AND INJURIES OF THE BLOOD-VESSELS 
True aneurism may arise spontaneously or from traumatic causes. It con- 
sists in a dilatation or a stretching of one or more of the coats of an artery. 
When this stretching is uniform in all directions, that is, in the entire cir- 
cumference of the vessel, it is called a fusi- 
form or spindle-formed aneurism. (Fig. 507.) 
When the dilatation takes place from a small 
portion of the artery and projects from its 
surface like a bud, it constitutes the sacciform 
or sacculated aneurism. 
The fusiform aneurism is not a common va- 
riety of the disease, and is generally restricted 
to a few vessels, like the aorta, carotid, and 
iliac. In the commencement of the aneurism 
the sac probably possesses all the tunics of 
the artery, a circumstance which in a meas- 
ure explains the peculiar shape of the swell- 
ing. In addition, the walls are greatly thick- 
ened either by an unusual nutrition or by 
inflammatory formations of connective tissue, 
imparting such a degree of strength to the 
sac that it rarely becomes ruptured. The 
rapidity with which the blood passes through 
a channel so direct as that of a fusiform aneu- 
rism proves unfavorable to the formation of 
stratified fibrin or of blood-clots, and hence 
these deposits are usually absent in this form 
of the disease. When the inner surface of 
the sac becomes rough and convoluted,—a not 
uncommon condition,—both coagula and fibri- 
nous laminae may form. Figure 507 is an 
illustration of the presence of such formations. 
As a fusiform aneurism may form independent 
of any atheromatous change, it is highly 
probable that it is a product of arteritis. At 
all events, it is certain that inflammation plays 
a conspicuous part in the progress of this 
. variety. 
Sacculated aneurism is much the most common form of the disease. It be- 
gins by a projection from the side of the affected artery, which gradually 
enlarges, until a tumor of great magnitude may be formed. (Fig. 508.) 
The aneurismal sac.—The formation of the sac is generally a gradual 
process. First, at some point where the artery, in consequence of structural 
change, is unable to resist the pressure of the blood, the coats begin to yield, 
forming on the side of the vessel a little 
prominence or bud-like dilatation. This 
will continue to enlarge, the resistance of 
the arterial tissues diminishing as the 
tumor increases in size. During the period 
of enlargement the coats of the vessel 
which form the walls of the aneurism un- 
dergo important changes. They may con- 
tinue for some time to retain their con- 
tinuity and, in a measure, their distinctive 
characteristics, all three forming a con 
stituent of the sac. When this is the case 
the intima will generally be found thick- 
ened by chronic inflammation, and maintaining an unbroken structure, even 
when the sac is of considerable size. At the same time that this inflamma- 
tory hyperplasia is going forward, a retrograde process is also in operation, 
Fig. 507. 
Fusiform aneurism, with layers of fibrin 
and canal for the blood in the centre.—After 
Hodgson. 
Fig. 508 
Sacculated aneurism of the arch of the aorta. ANEURISM. 
649 
converting this coat into plates of lime, the projection of which on the inner 
surface of the sac may have considerable influence in causing the formation 
of thrombi. The middle coat appears to be the most powerless to withstand 
the dilatation. Its muscular constituents separate into small circular sections, 
and as these become stretched and attenuated they rapidly undergo fatty 
metamorphosis and, in a great measure, disappear (Fig. 509) ; or the internal 
coat may give way, the middle and external ones remaining (Fig. 510) ; 
and, last, the internal and middle tunics may yield, the external or fibrous 
coat alone preserving its integrity. (Fig. 511.) Even when all the coats 
remain intact it is not always possible to recognize them. They are often 
much changed by inflammatory infiltration, in a great measure obliterating 
their normal appearances; sometimes they are thickened, and at other times 
Fig. 509. 
Fig. 510. 
Fig. 511. 
Aneurismal sac consisting of the 
three tunics of the artery. 
Sac formed of the middle and ex 
ternal coats of the vessel. 
The internal and middle coats 
broken, and the external coat of 
the artery remaining. 
wasted ; sometimes they are hypertrophied at one point and atrophied at an- 
other ; and not unfrequently all three of the tunics are agglutinated together 
into one layer, in which the characteristics of the separate coats become 
indistinguishable. In most cases of sacculated aneurism which have attained 
any considerable size, the external or fibrous layer of the artery alone forms 
the wall of the sac. This coat, however, is generally altered from its normal 
state by the inflammatory changes to which it has been subjected during 
the progress of the disease. It may acquire great thickness and density, or 
it may be thinned out until it is no longer able to resist the force of the 
circulation, when it gives way (Fig- 512), destroying the patient in a few 
moments from hemorrhage. The sac may reinforce itself by becoming united 
to contiguous parts, and remain in this way unchanged for a long time. In 
some instances the sac has ruptured and its contents have been discharged 
into the surrounding tissues, out of which a second sac is sometimes con- 
structed. (Fig. 513.) This occurrence is a wonderful illustration of the 
amazing resources possessed by the body to provide for extraordinary 
emergencies. 
The size of an aneurismal sac will vary. It may not be larger than a pea, 
and it may attain the size of the foetal head. I have seen an aneurism of the 
abdominal artery equal in volume to the uterus at full period. A few years 
ago there was a man, well known to the profession of Philadelphia on account 
of the frequent assessments which he made on their benevolence, who, in 
consequence of an aneurism of the abdominal aorta, was obliged to incline his 
body very much to one side in order to counteract the weight and protrusion 
of the other from the unusual size of the tumor. 
Form of the sac.—In the variety of aneurism under consideration the sac 650 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
may be spherical, oblong, or pyriform. Its walls, not being of equal thick- 
ness or strength, may yield more at one point than at another, giving to its 
surface a multilocular appearance. The expansion of the sac from the point 
where it is immediately connected with 
the artery often renders the aneurism 
pedunculated, whatever may be the form 
of its body. (Fig. 514.) When the aneu- 
rism springs from the arch of the aorta 
it is frequently fusiform in shape, and 
Fig. 513. 
Fig. 512. 
Aneurismal sac which has 
burst. 
Rupture of the sac of aneurism, and the forma- 
tion of a second out of the condensed tissues 
around the extravasated blood. 
may develop downwards (Fig. 515), or in a direction opposite to that in 
which the vessel sustains the greatest strain from the force of the blood. 
Occasionally the aorta rises into a pyramidal sac, its branches participating 
in the dilatation. 
Opening into the sac.—The communication between the artery and the sac is 
sometimes small, and at other times large; it may he round or oval, and gen- 
erally the boundaries of the opening are smooth. The internal and middle 
coats may terminate abruptly at the orifice, or they may be continued a little 
way into the sac. 
Contents of sac.—When the sac is spindle-shaped or fusiform, appearing 
as a cylindroid dilatation of the vessel, the blood generally rushes through 
in a direct current unchanged; but in the sacciform aneurism the circulation 
is impeded, the blood moves with diminished rapidity, and as indentations in 
the banks of a stream cause eddies or reflux currents, so a diverticulum or 
an expansion from the side of an arterial trunk causes very much the same 
disturbed movements in the circulatory blood. The effect of such obstruc- 
tion is to induce a laminated deposition of fibrin, the first layer being placed 
against the inner surface of the sac, and other layers successively inwards 
(Fig. 516), until, in favorable cases, the sac may become filled with concen- 
tric stratifications of this substance and the aneurism undergo a spontaneous 
cure. These layers of fibrin are pale, or have a light buff color, are very 
elastic, and are almost leathery in their consistence. Those laminse which ANEURISM. 
651 
lie nearest to the inner surface of the sac are thoroughly decolorized, whilst 
those more internal, and of course of more recent formation, are blood-stained 
and comparatively soft. In addition to the decolorized clots, others having 
a red, soft look lie within the last, and have been not inaptly compared in 
appearance to currant jelly. Broca imputed to this fibrinous concretion im- 
Fig. 515. 
Fig. 514. 
Popliteal sacciform aneurism, 
having a pedunculated attach- 
ment to the vessel. 
Fusiform aneurism of the aorta. 
portant vital properties. By this author it was called “ active clot.” Some 
of the older writers believed that the layers of the fibrinous clot were 
derived from the blood-vessels of the inner surface of the sac, and not from 
the blood moving through its interior. That such coagula are susceptible 
of organization I entertain no doubt. There are strong reasons for be- 
lieving that the cure of an aneurism and the obliteration of its sac are effected 
very much in the same manner as a vessel is closed after ligature,—that is, 
by thrombosis, the development of the white corpuscles of the clot into con- 
nective tissue, the construction of blood-channels, and, after this, a free inter- 
communication of these channels with the vessels in the walls of the sac, the 
whole being eventually converted into a dense cord of connective tissue. As 
the process of fibrinous deposition commences early in an 
aneurism, it is doubtless designed to strengthen the sac, 
and to indicate the plan pursued by nature to effect a 
spontaneous cure. It is easy to understand how much the 
force of the heart-stroke, exerted against the inner sur- 
face of the sac, will be neutralized by the interposition of 
an elastic substance like these stratifications of fibrin. The 
effect may be compared to that of buffers placed between 
the bumpers of cars. Aneurisms which are deficient in 
such laminae, either in consequence of their unusual form 
or from some peculiar constitution of the blood unfavor- 
able to coagulation, increase rapidly in size. A fragment 
of blood or fibrinous clot is liable to become detached and 
to be washed from the sac into the vessel below, where 
it may cause an obstruction to the circulation so com- 
plete as to result in mortification. I treated a patient 
during the winter of 1875 for popliteal aneurism. After pressure of the fem- 
oral had been maintained for twenty-four hours, all pulsation ceased in the 
tumor, and the man was regarded as cured. On the following day a person 
Fm. 516. 
Concentric deposition of 
the layers of fibrin in an 
aneurism which has been 
laid open. 652 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
who had received a severe railroad injury was brought into the ward and 
placed in an adjoining bed to that occupied by the individual with aneurism. 
The sight of the mutilated limb had such an effect on the mind of the latter 
that he commenced vomiting and tossing about on his bed. A few hours 
later, pulsation was again observed in the tumor, the temperature of the foot 
began to fall, and in a short time mortification commenced. This ease was 
an illustration of a detachment of some portion of the clot which had formed 
during compression, and its subsequent blocking up of one or both tibial 
arteries. 
Effect on adjoining structures.—As an aneurismal sac enlarges it becomes 
united by inflammatory transudations to the soft parts with which it may 
come in contact. Such adhesions render a timely service to the aneurism, by 
retarding the enlargement of the sac, and rendering its rupture less probable. 
In all other respects, however, the pressure caused by a growing aneurism is 
followed by serious consequences. When the tumor encroaches upon large 
veins it will give rise to congestion and to oedema in the part drained by their 
trunks. Thus, an aneurism of the carotid may cause dangerous cerebral symp- 
toms, from over-distention of the intracranial veins and sinuses; and in the 
same manner does the cellular tissue of the arm or of the leg become cedematous 
when an aneurism of the subclavian or of the femoral obstructs the flow of 
blood through the axillary or the crural veins. If the pressure is continued 
for any length of time, the cavity of the vein becomes closed by inflammatory 
adhesion of its walls. When the pressure is exerted against a nerve it will 
cause severe neuralgic suffering, and in some instances produce loss of power 
in, or spasmodic disturbance of, the parts supplied by its branches. In aneu- 
rism affecting the arteries at the root of the neck, we frequently have hic- 
cough and irregularities in the movements of the diaphragm, from pressure 
on the phrenic nerve, and also a sense of suffocation from spasm of the glottis, 
due to like compression of the recurrent laryngeal. Dyspnoea may result in 
another and still more distressing way, by the tumor encroaching upon the 
trachea and obstructing the passage of air into the lungs. The thoracic duct 
is sometimes implicated in the enlargement of the tumor, by which the lymph- 
stream is interrupted, followed by rapid emaciation. The sac may contract 
adhesions to important organs, and by ulceration open into their cavities, 
causing instant death. Thus, an aneurism may open into the trachea, the 
oesophagus, or the pericardium, or occasionally into the heart or into a large 
vein. It. A. Jamieson* records a case of popliteal aneurism which opened 
into the knee-joint. Amputation of the thigh was performed, but the patient 
died the following day. I once examined the body of a man who died from 
a long-continued, but not a severe, hemorrhage, as was thought, from the 
lungs, though the most careful examination revealed no lesion in these or 
in any other organs. After a very diligent search through all the cavities 
of the body for an explanation of his death, it was finally discovered in 
the existence of a small aneurism of the thoracic aorta, not larger than a 
hickory-nut, which had become united to the oesophagus and through an ex- 
tremely small ulcerated opening poured its blood into that tube. Even the 
bones are powerless to resist the incessant hammering to which they are sub- 
jected by contact with an aneurismal sac. Portions of the vertebra; gradually 
disappear by absorption, leaving irregular gnawed excavations in the spinal 
column; the sternum and the ribs undergo similar changes. Twice have I 
seen patients suffering from aneurism of the aorta, in whom a portion of 
these bones had disappeared, and the tumors had passed t hrough the openings 
and lay directly under the integument over the front of the chest. It is rare 
to find any purulent matter at these points of ulcerative absorption, a fact 
long since observed by William Hunter.f The structures which longest defy 
the encroachments of an aneurism are the cartilages, and it is not uncommon 
to see the bodies of the vertebrae extensively destroyed while the interverte- 
bral disks still stand amid the surrounding ruin. In addition to the above 
* Lancet, 1871, vol. i. p. 851. 
f Medical Observations and Inquiries, vol. i. p. 384. ANEURISM. 
653 
changes, remarkable displacements of surrounding parts are frequently found 
associated with enlargement of the sac. Thus, in aneurism of the subclavian 
and of the axillary, the shoulder may be thrown upwards, or the scapula 
project very much from the body ; and in post-orbital aneurism, the eye will 
become preternaturally prominent. 
Aneurism is more common on the right side than on the left. In the tables 
of Norris on the “Ligation of Arteries for Aneurism and for Hemorrhage,”* 
there are tabulated 260 cases of true aneurism, 143 of which were on the 
right side and 117 on the left. The greatest disparity was found in aneu- 
risms of the carotid artery, 33 in number, of which 21 were on the right side, 
8 on the left side, and in 4 the side is not stated. The nearest approach to 
an equal number on the two sides was found in 126 popliteal aneurisms, 62 
being on the right, 60 on the left, and 4 not stated. In examining the list of 
aneurisms collected by Hunter I found the same result. In 16 cases of carotid 
aneurism, 7 were on the right and 1 on the left side, and in 8 the side was 
not mentioned; and of 143 popliteal aneurisms, 41 were on the right side, 43 
on the left, and 59 not stated. 
Number and duration.—It is not common to meet with more than a single 
aneurism in the same person. Occasionally the disease is seen affecting 
both popliteal arteries. Sir Astley Cooper found seven aneurisms in the 
body of a man; Tyrrel saw eight in the same person; and Pelletan counted 
sixty-three.f 
The duration of aneurism varies in different persons. In the young, who 
possess an energetic circulation, its course is usually rapid; but in persons 
somewhat advanced in years, and who lead a quiet life, the disease may not 
terminate for three or four years. 
Causes op Aneurism.—The causes of aneurism are predisposing and ex- 
citing. 
Predisposing causes.—Considering the beautiful combination of muscular, 
elastic, and fibrous materials constituting the walls of the arterial system, it 
is extremely improbable that, without some important antecedent structural 
change, they should ever become the subjects of aneurismal dilatation. 
Atheroma.—To atheromatous degeneration is credited the large proportion 
of spontaneous aneurisms; and it is true that we find the latter electing 
those vessels which are most commonly the seat of this transformation. It 
must not, however, be overlooked that atheroma is a change which attacks 
the vessels at a period of life generally beyond fifty, while aneurism prevails 
most frequently between thirty and forty. The particular form of atheroma 
which is most concerned in the production of aneurism is what I have de- 
scribed as the premature, and is generally caused by the excessive use of 
alcohol. Intemperance I believe to be the most prolific of all causes in the 
development of arterial degeneration. 
Syphilis.—The doctrine that constitutional syphilis is a fruitful source of 
aneurism, and especially of the intra-thoracic form of the disease, has for some 
time been gaining strength, and may be said, at present, to be deeply rooted 
in the medical mind. Our knowledge of the relation between syphilitic poison 
and arterial degeneration is entirely too meagre to warrant any hasty gener- 
alizations on this point. The multitudinous manifestations of syphilis, when 
it is once intrenched within the body, are so far-reaching that many medical 
men are swept from the solid ground of induction into a maze of conjecture, 
attributing every accident and every illness to this constitutional vice. If 
aneurism is so commonly the sequence of a syphilitic diathesis, how shall we 
explain the infrequency of the former disease in females, who furnish so many 
examples of the latter affection ? During an experience of twelve years in the 
Philadelphia Hospital, an institution which is exceptionally rich in syphilitic 
disease, I never witnessed a single case of aneurism among the inmates of the 
venereal department. 
Age.—Aneurism is largely a disease of middle life, the greatest number of 
* Norris, Contributions to Surgery, p. 220. 
I Lancet, 1864, vol. i. p. 245. 654 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
cases occurring in the decade between thirty and forty. Under twenty years 
of age the affection is very unusual; and the same may be said of cases ap- 
pearing after sixty. The annals of surgery furnish a few examples of aneu- 
rism in the young. Syme* operated in one case of popliteal aneurism in a 
boy seven years of age. T. Smithf tied the external iliac in a femoral aneu- 
rism, the patient being twelve years old. The same surgeon says, “ No case 
so young has been recorded at the Hospital for Sick Children out of 12,000 
inmates for fourteen years.” Sir Astley Cooperj; mentions a case of aneurism 
of the anterior tibial artery in a lad eleven years of age. Instances are 
also recorded by Ogle, Hutchinson, Armitage, and others, in which the ages 
of the patients affected with aneurism varied from four to seventeen years. 
These, however, do not affect the general rule, viz., that the disease is one 
belonging peculiarly to middle life. 
Lisfranc reports 120 cases, 59 of which occurred in persons between thirty 
and forty-five. In this list, one case of a boy thirteen years old, and 3 cases 
between fifteen and twenty years of age, are mentioned. After fifty the 
number diminished rapidly, as follows: between fifty-five and sixty, 3 cases; 
between sixty and seventy, 3 cases; and between seventy and eighty, 3 cases. 
Of 551 cases of internal aneurism collected by Crisp,§ 398 were met wTith 
in persons between thirty-five and forty years of age. Hayden || states that 
of 15 cases of aneurism of the aorta under his care, 11 were in persons be- 
tween thirty and fifty. The same author furnishes a table of 84 cases of 
aneurism of the aorta, 56 of which were between thirty and thirty-five. 
Of 246 aneurisms—not including any of the aorta—which I have analyzed, 
125 appeared between thirty and forty. Only 4 of the entire number occurred 
under twenty years, and 19 over fifty years of age. Lebert’s collection of in- 
ternal aneurisms amounts to 342, the largest number of which in any one 
decade (80) occurred between the ages of thirty and forty; and the same is 
true of the 243 cases collected by Liddell, of New York. 
Sex.—The influence of sex as a predisposing cause of aneurism is very re- 
markable. Crisp, out of 551 cases, found that less than one-eighth occurred 
in females. An analysis of 320 cases, made by myself, showed 269 males and 
26 females; in 25 the sex was not ascertained. Lisfranc reports 154 cases 
of aneurism, 141 being in males and 13 in females. Hodgson, in 63 cases of 
aneurism of all kinds, found 56 in males and 7 in females. In a collection 
of 143 cases of aneurism (not including aneurism of the aorta) made by 
Hunter, 123 were in males, 8 in females, and in 12 the sex wTas not named. 
In Norris’s tables on the “Ligation of Arteries for Aneurism and Hemor- 
rhage,” I find 361 cases of aneurism of the subclavian, iliac, carotid, and 
femoral arteries, 337 of which were in males and 24 in females. 
Sir Astley Cooper, in an experience of forty years, saw only eight cases of 
popliteal aneurism in females, and an immense number in males. John 
Hunter is represented as having said that he had seen only a single case 
of spontaneous aneurism in a woman. The explanation of this remarkable 
disproportion is thought by many to be due to a difference in occupations, men 
being engaged in those pursuits which demand great muscular efforts, while 
women are most concerned with employments of a lighter and less active 
nature. In certain sections of this country females labor in the fields, and 
are as much accustomed to the strain of out-door toil as are males. On the 
continent of Europe this farm-work of females is more commonly witnessed 
than in America. In neither country, however, is there any evidence that 
women who lead such a life are more subject to aneurism than their sisters 
whose industrial sphere is restricted to the duties of the house and family. I 
have long observed the freedom of females from atheromatous degeneration 
of the vessels, and to this constitutional peculiarity, perhaps more than to 
any other cause, are we to ascribe their exemption from aneurism. 
* Edinburgh Monthly Journal, 1844. f British Medical Journal, March, 1867, p. 280. 
J Cooper’s Lectures, vol. ii. p. 40. $ Diseases of Blood-Vessels, p. 118. 
|| Hayden, Diseases of the Heart and the Aorta, vol. ii. p. 1077. ANEURISM. 
655 
Occupation.—As the laboring population furnishes the greatest number of 
aneurisms, we are very naturally led to infer that such employments as demand 
much muscular exertion predispose to the disease. Hayden, in his excellent 
work on the Heart and the Aorta, gives the analysis of 57 cases of aortic 
aneurism, with the following result as to occupation : 12 were mechanics, 10 
soldiers or pensioners, 8 laborers, 5 porters, 4 cabmen, 4 gentlemen, 4 house- 
keepers (females), 2 grooms, 1 policeman, 1 butler, 1 tailor, 1 dairyman, 1 cattle- 
driver, 1 coal-heaver, 1 strolling player on wind instruments. Lawson* states 
that the deaths from aortic aneurism during 1866, in the English army, were 
eleven times more frequent than among the civil population. I do not believe 
that occupation, that is, the ordinary employments performed by the working 
population, can be placed among the predisposing causes of aneurism. There 
is nothing in honest labor to produce arterial degeneration. The fact of the 
disease being most commonly encountered in this class of our population 
should be ascribed to their greater numbers as compared with other classes, 
and to the combined influences of intemperance, exposure, and defective 
hygienic surroundings. 
Nativity.—National peculiarities of constitution exercise considerable in- 
fluence in favoring the development of aneurism. Billrothf states that, in 
Germany, aneurism of the extremities is rare. The disease is equally un- 
common in Italy.| In France it is more frequent; and in England it prevails 
to a greater extent than in any other country. The number of deaths from 
aneurism alone in England and Wales, during five years,—from 1865 to 
1870,—was 593.§ Among the native inhabitants of the United States the 
disease is not very common. Professor Gross || states that during a practice 
of twenty-three years in Ohio and in Kentucky he rarely met with a case 
of spontaneous aneurism. In Philadelphia the disease is less frequently seen 
than in New York,—the population of the latter city being less homogeneous 
than that of the former. From 1865 to 1870, a period of five years, there 
were treated in the New York Hospital 11,344 cases of disease and injury, 
of which number 33 were aneurism. 
Exciting causes.—Whatever causes undue stretching of a previously diseased 
artery, or produces a curve or an angle in its direction, becomes an exciting 
cause of aneurism. Under the first head come unusual muscular efforts, by 
which the vessel is overstrained; under the second head, any posture of the 
limb which creates an abrupt bend in the artery and thus exposes it to in- 
creased blood-pressure. 
Emotional states, which quicken the force of the heart’s action and increase 
the tension of the vessels, may excite aneurismal dilatation. It is the aorta 
which, from its nearness to the heart and the existence of an arch or curve, 
more particularly suffers from such influences. 
Embolism is said occasionally to cause aneurism. A fragment of a blood- 
clot or of a fibrinous clot may (dock up an artery and produce a dilatation of 
the vessel above the seat of obstruction. records a case of tempo- 
rary dilatation of an artery from embolism, which subsided as soon as the 
collateral vessels were able to accommodate the circulation. The embolism 
was verified by dissection after the death of the patient. 
Vessels affected.—All vessels are not equally prone to aneurism. The 
arch of the aorta, in point of frequency, stands first,—a fact which is probably 
due to the combined influence of structure, form, and blood-impact. This 
part of the vessel contains a large amount of elastic and comparatively little 
muscular tissue; its curve is sharply defined, and consequently the force 
which it is compelled to sustain at each contraction of the heart is very great. 
Lisfranc, in instituting a comparison between the different vessels, excluded 
the aorta, and found that, in 179 cases of aneurism, the popliteal was affected 
59 times; the femoral in the groin 26, and at other points 16 times; the 
* English Army Medical Reports, 1866. 
f Crisp, p. 129. 
|| Gross’s Surgery, vol. i. p. 706. 
f Billroth’s Surgical Pathology, p. 536. 
| Reports of the Registrar-General, 
f Dublin Quarterly Journal, May, 1853, p. 371. 656 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
carotid 17 times; the subclavian 16 times; the axillary 14 times ; external 
iliac 5 times; brachio-cephalic 4 times; brachial 3 times; common iliac 3 
times; anterior tibial 3 times ; gluteal twice; and the palmar arch once. 
In 322 cases which I analyzed from a collection furnished me by Dr. 
Hunter, 145 were popliteal; 88 femoral, distributed as follows,—55 in the 
upper third of the vessel. 9 in the middle third, and 24 in the lower third; 
21 carotid; 15 axillary; 13 innominate; 12 brachial; 12 subclavian ; 9 intra- 
orbital ; 3 temporal; 3 gluteal; and 1 subscapular. 
Symptoms.—The existence of external spontaneous aneurism may be de- 
duced from the form and position of the swelling, from the manipulation and 
the auscultation of the tumor, and from the pressure-effects of the latter on 
surrounding parts. 
Form.—Though aneurisms frequently differ in their outline, yet the pre- 
vailing form is either round or oval. The tumor may be when first discov- 
ered not larger than a marble. 
Position.—Aneurism must occupy certain well-defined localities,—that is, 
it must appear in the course of a principal arterial vessel. 
Manipulation.—1. The hand placed over an aneurismal tumor receives two 
distinct impulses, one of which is synchronous with the contraction of the 
left ventricle of the heart, and is generally very distinct, and the other 
answers to the dilatation of the left ventricle, and is a kind of tremor, pro- 
duced by the rebound of the blood-column. The peculiarity of the first move- 
ment is its centrifugal character, expanding the tumor in all directions, and 
is very noticeable when the swelling is grasped on all sides with one hand, or 
when it is embraced between the two hands. 2. When the surgeon, or an 
assistant, applies a finger over the artery on the cardiac side of the tumor 
firmly enough to occlude the vessels temporarily, all movement or pulsation 
will be suspended in the swelling; and if the circulation continues to be con- 
trolled by the finger for some time, the tumor, being deprived of its supply 
of blood, will gradually diminish in size, and become soft and compressible. 
When the artery is again released from the pressure the swelling and pulsa- 
tion will rapidly return. 3. If pressure be applied on the distal side of the 
tumor, interrupting the free escape of its blood, the impulse communicated to 
the hand will be sharp and abrupt, from the sudden arrest of the current, 
and will increase the distention of the sac. 4. The pulsation in the vessels 
below the aneurism is generally more feeble on the affected than on the sound 
side. 
Auscultation.—When the ear is placed over an aneurism, a peculiar inter- 
mittent sound or bruit will be heard. This bruit was first observed by Am- 
brose Pare. This sound is sometimes blowing, sometimes purring, and at 
other times harsh and rasping. 
Phenomena arising from the Pressure of the Tumor.—(Edematous 
swelling and distention of the subcutaneous veins in the parts below the 
tumor are not unfrequent accompaniments of aneurism, and are the effect of 
pressure upon a principal vein obstructing the return of blood towards the 
heart. Pain, often of an acute, darting character, is also frequently experi- 
enced, in consequence of a nerve being pressed upon, or expanded over the 
surface of an enlarging sac. Numbness, coldness, and a tired feeling in the 
limbs are also symptoms caused by pressure. 
Patients who suffer from aneurism are sometimes able to designate a time 
when, on making some unusual effort, they have experienced the feeling of 
something having given way, and, perhaps, a momentarily acute pain has 
been felt, as though a sharp blow had been delivered by some invisible hand. 
Circumstances which modify Pulsation and Auscultation-Sounds.— 
When the opening between the sac and the artery is very small, or when 
the former is in a great measure filled with fibrin or with blood-clots, pulsa- 
tion may be entirely wanting in an aneurism. In such cases pressure should 
be made on the proximal side of the tumor to empty it of its blood, when, 
the ear being placed over its surface, and the pressure being suddenly re- ANEURISM. 
657 
moved, the peculiar sound, faint though it may be, can sometimes be recog- 
nized as the current rushes into the sac. 
Rupture of the aneurismal sac will generally be followed by the cessation 
of pulsation. Inflammatory infiltration between the integuments and the sac 
is also capable of masking pulsation. 
The same causes which affect the pulsation in an aneurismal tumor may 
destroy or modify the auscultation-sounds,—for example, a small aperture 
between the vessel and its sac, or an obstruction of the opening by means of 
broken fragments of coagula. The bruit is generally most distinct when the 
sac does not contain much fibrinous deposit, and when its orifice is ample and 
irregular. Not only does the solidification of the contents of an aneurism 
diminish both its pulsation and its bruit, but it also renders it less soft and 
compressible than when the contents are fluid. 
Diagnosis.—In a well-marked case of aneurism, the throbbing under the 
eye and the touch, the communication to the ear of strong blowing or high- 
pitched rasping sounds, the subsidence and the enlargement according as the 
artery with which the swelling is connected is compressed on the cardiac side 
or released from pressure, constitute such a group of significant phenomena 
that it would seem almost impossible that any error should be committed as 
to the nature of the disease. All cases, however, do not present sucb a col- 
lection of unmistakable symptoms, and, accordingly, we find the records of 
surgery contain a number of sad errors in diagnosis, committed, too, by men 
most eminent in the profession. Ferrand, Desault, and Dupuytren each 
opened an aneurism supposing it to be an abscess. The same mistake was 
made by Pirogoff. Three instances of a similar mistake have come under my 
own observation. In all the error proved fatal. In other cases operations 
have been undertaken for the cure of aneurism and the tumor has proved 
to be of an entirely different nature. Earle* ligated the subclavian artery 
for what was supposed to be an axillary aneurism but which was found to 
be a neuroma. It cannot be doubted that cases of great obscurity do occa- 
sionally arise in which the surgeon finds himself reduced to a state of in- 
decision, incapable of advancing and yet unwilling to 2’etreat without an 
immediate solution of the difficulty. These must, however, be exceedingly 
rare occurrences. As a general, after an unfortunate engagement in which 
he has sustained defeat and when the smoke and the tumult of' the strife are 
past, can often, after a careful survey of the field, discover in some slight 
omission or trifling oversight the whole explanation of the disaster, so the 
surgeon who has been so unfortunate as to commit the blunder of thrusting 
a bistoury into an aneurismal sac will, generally, when he comes calmly to 
review all the circumstances attending the case, discover that but for some 
small neglect on his part all the evil might have been averted and the disease 
brought to a happy termination. Professional men of iarge and ripe ex- 
perience attain, by constant contact with disease, a habit of forming their 
judgments by a kind of intuition. They are not conscious of any process of 
ratiocination or of analysis, such as they toiled through in the earlier years 
of professional life. This is an acquisition which can never be imparted to 
others ; it dies with the man. Such knowledge begets a degree of self-confi- 
dence which may sometimes betray its possessor into error. It is this feeling 
of personal infallibility which explains many surgical calamities,—it is the 
cause of that “ holden vision” of which Pirogoff speaks. 
The swellings with which aneurism may be confounded are abscess and 
encephaloid disease, solid tumors, erectile growths, and cysts. 
Abscess.—An abscess may possess characteristics which render it not un- 
like an aneurism. The points in which the two diseases bear a fictitious re- 
semblance are the folloAving: both are round or oval in form; both present 
to the touch a degree of hardness and of softness ; both may pulsate, and both 
may communicate a sound to the ear. 
* Medico-Chirurgical Transactions, vol. xxviii. p. 314. 658 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
On a closer examination of the two swellings, however, it will not be diffi- 
cult to distinguish the one from the other, as will appear by placing the two 
in contrast, as follows : 
ANEURISM. 
ABSCESS. 
In aneurism the pain may be acute and parox- 
ysmal, or dull and aching, not throbbing. The 
surface of the tumor is not tender, and there is 
absence of redness. 
In aneurism the tumor retains its usual round 
or oval figure, without becoming acuminate or 
changing color, except in rare cases, in which 
the sac becomes inflamed and suppurates. 
In aneurism the induration begins by the depo- 
sition of fibrin at the circumference of the tumor, 
and advances inwards towards its centre. 
In aneurism there will be no fluctuation, except 
in the few instances in which suppuration of the 
tumor takes place. 
In aneurism the pulsation will be expansile or 
centrifugal, acting in all directions. 
In aneurism the pulsation is general, strong, 
and feels near to the hand when placed upon the 
surface of the swelling. 
In aneurism the tumor cannot by manipulation 
be dislodged from its position, so as to arrest its 
pulsation. 
In aneurism the bruit in the tumor is loud, 
blowing, rasping, and whirring. 
In aneurism pressure on the proximal side 
will cause the swelling to subside and the thrill 
to disappear, both quickly reappearing on the 
removal of the pressure, while pressure on the 
distal side will increase the distention and size 
of the tumor. 
An aneurism when small may, by compressing 
its sides, be emptied of its liquid contents, but 
the tumor quickly refills on releasing it from 
compression. 
Aneurism is not attended with rigors, chills, 
and sweatings. 
In abscess there is a previous history of in- 
flammation, manifested by throbbing pain, heat, 
redness, and swelling. 
In abscess the swelling, as it increases, tends to 
become pointed, and at the summit has a purple 
color. 
In abscess the induration softens in the centre 
and extends towards the circumference. 
In abscess there will be, after a short time, 
fluctuation. 
In abscess pulsation, when present, being due 
to an underlying vessel, will consist in a simple 
upheaval or rising and falling of the entire 
swelling. 
In abscess the pulsation is feeble, local, weak, 
and remote. 
An abscess can often be raised up or slid away 
from the vessel on which it rests, and the pulsa- 
tion be stopped. 
In abscess the sound communicated from the 
artery to the swelling in consequence of the 
pressure may have a blowing character, but never 
the thrill or purr of aneurism; generally the 
sound transmitted through an abscess to the ear 
is that of a dull, concentrated stroke. 
In abscess the size of the swelling is in no way 
influenced by pressure either on its proximal or 
its distal side. 
An abscess, especially a cold lumbar abscess, 
when appearing in the groin below Poupart’s 
ligament, may, by compression, have the pus 
pressed back into the pelvis, but when the press- 
ure is removed it refills very slowly. In cold ab- 
scess there is also a long history of previous bone 
disease. 
In abscess the formation of pus is usually an- 
nounced by a rigor, and when the suppuration is 
large, by debilitating perspiration. 
In some cases, as pointed out by Delpech, aneurism and abscess may co- 
exist, the latter being formed in the tissues external to the former. Such was 
the condition in the unfortunate case in which Pirogoff laid open the sac of 
an aneurism supposing it to be a phlegmonous abscess. The well-known case 
of Mr. Liston is sometimes mentioned as another example in point. The ob- 
scurity in such a combination is rendered still more perplexing, as the tension 
occasioned by the inflammatory infiltration of the parts between the sac and 
the skin will mask the pulsation of the tumor. In such a case a strict inquiry 
should be instituted to ascertain whether, previous to the condition which be- 
tokens the presence of suppuration, there existed a tumor; and, if so, whether 
it was a pulsating one. The ear and the stethoscope should also be employed 
to learn if any aneurismal sounds are present. 
It has happened that an aneurism has opened into an abscess, in which 
case the ordinary characteristics of the former, such as pulsation and thrill, 
would be added to the latter. This occurrence is most likely to be realized 
in the axilla, in the neck, or in the popliteal regions, localities in which the 
loose textures around admit of an easy change in the position of growing ANEURISM. 
659 
tumors. The accident would have to be predicated on the pre-existence of 
a swelling which had suddenly become a pulsating tumor and yielded on 
auscultation the characteristic aneurismal thrill. 
Solid tumors, scirrhous, fibrinous, or glandular, may be distinguished from 
aneurism by their dense structure, by the absence of pulsation and of thrill, 
and by their unchanging size, whether pressure be made on either their 
proximal or their distal side; all of which characters are unlike those of 
aneurism. Should such a tumor borrow pulsation from a vessel over which 
it is situated, the fact may be detected by shifting the position of the growth, 
or by insinuating the fingers beneath its base and separating it from the 
artery, when the pulsation will disappear. 
Encephaloid growths, possessing, as they often do, a distinctive pulsation in 
consequence of their rich supply of vessels, are liable to be mistaken for aneu- 
risms. No less distinguished surgeons than Mr. Guthrie, Mr. Moore,* and 
Mr. Stanley have tied the primitive iliac artery for tumors which were sup- 
posed to be aneurisms, but which on examination proved to be encephaloid. 
I was once called to ligate the carotid artery for a pulsating tumor in the 
neck, believed to be an aneurism. In this case the signs of the latter disease 
were so pronounced that not until a post-mortem examination was made, 
some months after, did one of the medical attendants believe that I was 
right in declining to tie the artery. 
A careful consideration of the following particulars will generally conduct 
the surgeon to a proper diagnosis: 
Aneurism is found generally in relation with a 
principal artery. 
The aneurismal tumor usually regular and 
smooth in its outline. 
Aneurism quite distinctly circumscribed. 
Aneurism generally grows slowly, and is pain- 
less unless a nerve be encroached upon. 
Aneurism at first is a soft, elastic swelling, be- 
coming firmer and harder as it increases in age. 
Aneurism is a pulsating tumor from its com- 
mencement. 
The sounds in aneurism are strong, blowing, 
rasping, and abruptly terminated. 
Aneurisms diminish in size and sounds by 
pressure of the main artery on the cardiac side 
of the sac. 
Aneurism diminishes the force of the arterial 
pulse below the tumor. 
The color of the skin natural over an aneu- 
rism. 
Glands in the vicinity of an aneurism remain 
unaffected. 
No cachexia or emaciation in anerurism. 
The pulsation and bruit generally increase in 
intensity in proportion to the growth of the an- 
eurism. 
Pulsation and bruit felt and heard at all points 
over an aneurism. 
ANEURISM. 
Encephaloid growths not necessarily near an 
important arterial trunk. 
Encephaloid tumor often irregular, having a 
number of prominences upon its surface. 
Encephaloid disease usually without any 
sharply-defined limitations. 
Encephaloid disease grows rapidly, and is 
often very painful. 
Encephaloid growths are hard at first, becom- 
ing spongy and soft as they progress. 
Pulsation is acquired after the disease has at- 
tained considerable bulk, and is never very dis- 
tinct. 
The sounds in encephaloid disease are soft, 
subdued murmurs, and not sharply terminated. 
Encephaloid growths are little alfected in their 
dimensions or in their sounds by pressure on the 
proximal side of the tumor. 
Pulsation of the artery below encephaloid 
growths little if any affected. 
As the disease advances, the skin over an en- 
eephaloid tumor becomes purple or lilac in color. 
Glands ultimately become enlarged in the 
neighborhood of encephaloid disease. 
Both cachexia and emaciation in encephaloid 
disease. 
Pulsation and bruit not affected by the magni- 
tude of the tumor. 
Pulsation and bruit often felt and heUrd over 
only portions of encephaloid growths. 
ENCEPHALOID GROWTH. 
Erectile growths bear a strong resemblance, in some instances, to aneurism. 
In the former, however, the swelling, when pressed between the fingers, has 
a spongy feel, unlike the sensation imparted by the elasticity of the latter, 
and the blood, when forced out of the cells of the growth, returns in an irreg- 
ular manner, dilating the mass unequally,—very different from the regular 
distention of an aneurismal pouch. Nor are the pulsation or the sounds in 
erectile tumors counterparts of those in aneurism. In the first, the pulsation 
is quite feeble, and seems to consist of a number of disjoined throbs, instead 
* Lancet, 1852, vol. i. p. 194. 660 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
of a uniform eccentric force reaching equally all parts of the sac. The bruit 
also of an erectile growth, being a soft, muffled sound, is in striking contrast 
with the whirr or the thrill of an aneurism. To these differential signs may 
be added the blue or red color of the skin, often present in erectile growths, 
and the absence of any enlargement of the tumor when pressure is applied 
on its distal side. 
Cysts have been mistaken for aneurisms, and aneurisms for cysts. A case of 
each error has been recorded by Stephen Smith,* in a valuable paper entitled 
“ Difficulties attending the Diagnosis of Aneurism.” The absence of expan- 
sive pulsation and of a true bruit, together with only an unimportant subsi- 
dence of the tumor when the artery is compressed on its cardiac side, pecu- 
liarities which belong to pulsating cystic growths, would serve in most cases 
to establish their distinction from aneurism. 
Aneurism has in a few instances been confounded with rheumatism. Such 
an error is probable in cases of aneurism of the abdominal or the thoracic 
aorta. In their early history, the dull, heavy ache in the loins or between 
the shoulders, which results from the contact of the tumor with the spinal 
column, simulates that of rheumatism. Careful auscultation, however, would 
undeceive the practitioner and enable him to refer the suffering to its proper 
source. 
Holmes has spoken of the difficulty which attends the diagnosis of aneu- 
rism in which the usual signs of pulsation and bruit are absent,f and men- 
tions a case involving the abdominal aorta. The same author makes a very 
important suggestion, viz., that the administration of an anaesthetic might, by 
taking off the tension of the abdominal walls, reveal the signs of an aneu- 
rism which under other circumstances could not be detected. Failure to 
ascertain the existence of such an aneurism, however, is practically of little 
moment, as no operation could be contemplated for its cure, even if properly 
recognized. A much more serious error would be to confound an aneurism 
which had undergone a spontaneous cure with a morbid growth, and remove 
(as was done in one case mentioned by Mr. Erichsen) a thigh for its cure. 
Termination.—When an aneurism is allowed to progress without any sur- 
gical interference, it will terminate either in a spontaneous cure or in death. 
Spontaneous cure.—This result is quite uncommon, though it is possible, even 
in the largest vessels. In one case of aneurism of the abdominal aorta which 
was under my care, the sac became solid, and was gradually disappearing at 
the time the patient left the city. Professor Gross | mentions a case of spon- 
taneous cure in an aneurism of the subclavian artery, and Mr. Erichsen one 
in which the popliteal had undergone a similar change. 
This mode of cure may be brought about in various ways: 1. By the depo- 
sition of fibrinous stratifications until the cavity of the sac is occluded, and 
the blood, no longer able to enter, is compelled to seek other channels. 2. In- 
flammation may attack the structures overlying the aneurism, and, extending 
to the sac, cause a thrombosis, similar to that in an inflamed artery, which 
may effectually close its cavity. 3. The aneurism may grow in a direction 
which will subject the artery upon which it is placed to a change in its course, 
or to such compression of its walls as will interrupt the force of the blood- 
current in the sac, and induce the formation of coagula within its walls. 
4. A fragment of fibrin, or of blood-clot, becoming detached, may be swept 
into the vessel below, and by preventing the escape of blood from the sac 
produce a blood-stasis in its cavity favorable to coagulation. 5. Inflammation, 
followed by mortification, may attack the sac, in which case a coagulum forms 
not only in the aneurism, but also in the vessel which supplies it with blood. 
After the parts around become matted together by inflammatory adhesion, the 
slough, along with the grumous contents of the sac, becomes detached, and 
the chasm is repaired by granulation-tissue, if the constitutional resources of 
* American Journal of the Medical Sciences, Oct. 1873, p. 403. 
f St. George’s Hospital Reports, 1872-74, vol. yii. p. 192. 
J Surgery, vol. i. p. 719. ANEURISM. 
661 
the patient are sufficient to endure the irritation. 6. Rupture of the sac fol- 
lowed by the escape of blood into the adjoining tissue, compressing the artery 
so as to cause its obliteration, is another rare mode of spontaneous cure. Such 
a case is mentioned by Sir Astley Cooper as having occurred in Guy’s Hospital.* 
7. Any constitutional cause which will diminish the power of the heart’s ac- 
tion, and thereby weaken the force and the rapidity of the circulation, will 
tend to induce coagulation and the obliteration of an aneurismal tumor. The 
other termination is death, and may be caused either by sloughing or by rup- 
ture of the sac, followed by hemorrhage; or by the effects of pressure upon 
surrounding parts. The symptoms which indicate sloughing are, a circum- 
scidbed redness of the skin, tenderness to the touch, and finally the formation 
of a dark spot, which gradually extends and deepens, until the penetration 
of the sac is accomplished. 
When the aneurism opens internally, without any break in the continuity 
of the skin, death may follow immediately; or, if the orifice be small and the 
resistance of the tissues around considerable, a clot may block up the vent 
and the flow of blood be stayed for some time, the patient ultimately, how- 
ever, dying by a displacement of the coagulum and a renewal of the bleeding. 
Treatment.—The treatment of aneurism is embraced under two heads, 
constitutional and local. 
Constitutional.—Too much importance cannot be attached to the constitu- 
tional management of aneurism, even in cases where operative measures are 
contemplated. The great indication in the treatment of the disease is to se- 
cure the obliteration of the sac. In all sacculated aneurisms the deposition 
of fibrin begins almost simultaneously with the pouch-like protrusion of the 
arterial tunics, and along with this deposition occurs the formation of soft, 
red blood-clots. These processes are attempts at a spontaneous cure, and 
the surgeon, following the leadings of nature, endeavors to produce a similar 
result. The object being to favor the formation of fibrinous clots, what- 
ever contributes to that end should be paramount. First, it is important 
to slow the circulation and to lessen its force. The method adopted by Val- 
salva for this purpose consisted in absolute rest, frequent venesections, purga- 
tions, and gradual starvation, until the patient was reduced to a condition 
of extreme debility, after which a nutritious diet was allowed, with a view to 
increase the plasticity of the blood. The plan is entirely too heroic for our 
modern notions of treatment, and indeed has been very wisely abandoned. 
A more rational procedure is that of Tufnell as employed in internal aneu- 
rism. The patient is confined to the recumbent position, not being allowed 
even to change his position in bed oftener than is necessary for personal 
comfort. A very spare though nutritious diet, chiefly of meat, and not exceed- 
ing eight ounces a day, is directed, and with no more water than is absolutely 
necessary. To prevent restlessness and procure sleep at night, chloral or 
morphia is given at bedtime. In Valsalva’s plan the object was to lessen the 
quantity of blood and to weaken the strength of the patient, and consequently 
diminish the power of the heart’s action, thus favoring the formation of a clot 
in the aneurism. But while it is true that the force of the heart was by these 
measures lessened, its frequency of action must undoubtedly have been in- 
creased. In Tufnell’s plan, however, the object is not so much to lessen the 
power of the heart as it is to reduce its frequency of action, by the enforced 
rest and by the absence of stimulating food. The benefit to be derived from 
absolute rest of body and mind is of immense importance. The pain subsides, 
the aneurism beats less forcibly, it diminishes in size, and becomes more solid, 
circumstances which conduce to the comfort of the patient and to the pro- 
longation of life. In conjunction with the treatment by rest, the iodide of 
potash, a remedy in great favor with Balfour, is sometimes administered, 
and with apparent benefit. The application of ice, first recommended by 
Guerin, of Bordeaux, has been extolled by some. I have no experience 
* Cooper’s Surgical Dictionary, vol. i. p. 160. 662 
in its use. Hodgson, however, declares that it causes intolerable pain when 
applied to the tumor, and Broca charges the remedy with having produced 
mortification of the superincumbent skin, a result which I should apprehend 
as probable, from the low vitality of tissues stretched as these are over a 
large aneurism. Though internal aneurism may be considered an incurable 
disease, in some rare instances recovery has taken place.* 
For several years I have been in the habit, before applying severe com- 
pression for the cure of external aneurism, of subjecting my patient, for 
four or five days, to a preparatory course of treatment. This preliminary 
measure consists in confinement in the recumbent position, elevation and 
flexion of the limb when the aneurism is in the lower extremity, a restricted 
though nutritious diet, and the internal exhibition of tincture of aconite or 
of veratrum viride, in order to reduce the force and frequency of the heart’s 
action. It is to this preparatory measure that I attribute, in some degree at 
least, the satisfactory results which I have realized from compression. 
Local Measures.—Incision and Ligation.—This operation, among the 
earliest procedures for the cure of aneurism, and known generally as the 
plan of Antyllus, consisted, when possible, in first controlling the circulation 
through the tumor by compressing the vessel above, after which an incision 
was made directly into the aneurism over its entire length. The coagula 
being next turned out, the orifice of the artery leading into the sac was 
searched for by the finger or by a catheter, and, when discovered, the vessel 
was tied both above and below the tumor. The cavity of the sac was now 
packed lightly with lint, with a view to establish suppuration and granula- 
tion, by which the disease was expected to be obliterated. Keyslere, a 
surgeon in Italy, we are informed by Pelletan,f practised this operation 
successfully, using only a single ligature on the cardiac side of the sac. The 
operation, in consequence of its fatality, has been very property abandoned. 
Patients frequently died before leaving the table, from hemorrhage, or after- 
wards were worn out by hectic, in consequence of the profuse and prolonged 
suppuration which followed the operation. The late Mr. Syme, by adopting 
this method in the treatment of aneurism of the carotid, external iliac, and 
axillary arteries, has again given to the subject considerable surgical im- 
portance. Gay has also applied this plan to the femoral, and Ilenry Smith 
to the popliteal. In cases of spontaneous aneurism, arising from a diseased 
state of the vessels, the folly of placing a ligature on the artery contiguous 
to the sac has been well demonstrated. When the blunder is committed of 
cutting into an aneurism supposing it to be an abscess, this operation then 
assumes a truly practical importance, as, in my judgment, it is the proper 
one to be adopted in such event. 
Ligation.—Until the time that the proper use of the ligature was recog- 
nized for the cure of aneurism, surgeons seem to have possessed no intelligent 
comprehension of nature’s method of cure. It was deemed necessary, what- 
ever plan was adopted, that the tumor should be removed in its totality; and 
hence arose the practice of opening the sac, turning out its contents, and 
stanching the hemorrhage by the cautery, by the ligature above and below 
the disease, or by the still more radical measure of amputating the limb. To 
British surgery is the world indebted for rescuing this subject from the domain 
of conjecture and placing it on a philosophical basis. Until the proposition 
made by John Hunter, in 1785, of tying the vessel on the cardiac side at a 
point remote from the disease, the mortality from aneurism was very great. 
The French, as is well known to medical readers, claim for one of their 
countrymen, Anel, the honor of having made the first practical application 
of this principle ; but there is very little resemblance between the two opera- 
tions, except in the fact of their being both on the proximal side of the sac. 
That of Anel was done seventy years before that of Hunter,—in 1710. The 
subject of the operation was an Italian priest, who, in consequence of a wound 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
* See Tufnell, Transactions of the International Congress at Philadelphia, 1876. 
f Pelletan, Clinical Surgery. ANEURISM, 
663 
of the brachial artery made during venesection, suffered from an aneurism 
at the bend of the arm, which, two weeks after the injury, commenced to 
bleed from the original wound. Anel exposed the artery close to the sac and 
surrounded it with a ligatui-e. All pulsation immediately ceased in the swell- 
ing, and the patient quickly recovered. The operation performed by Hunter 
was for popliteal aneurism in a coachman admitted into St. George’s Hos- 
pital. The femoral artery was exposed and gently compressed by four liga- 
tures,—the object of this multiplication of threads being to affect a consider- 
able extent of the vessel by moderate pressure, rather than to concentrate 
the force of a single ligature on a small portion of its walls. Pulsation dis- 
appeared in the aneurism, and it gradually disappeared by absolution, the 
patient perfectly recovering. If we now contrast the two operations it will 
be seen how widely they differ. In the case of Anel the aneurism was trau- 
matic in its character, and the presumption is that he bad to deal with a sound 
vessel. In the case of Hunter the aneurism was spontaneous, and was doubt- 
less dependent upon a diseased state of the arterial tunics. Again, in the 
case of Anel the ligature was applied close to the sac on its cardiac side; in 
the case of Hunter the artery was tied also on the cardiac side, but distant 
from the aneurism,—namely, at the femoral, where it was supposed the 
vessel would be found sound. The operation of Desault (also claimed as 
taking precedence of that of Hunter), except in the fact of its being done on 
a different vessel,—the popliteal,—and for spontaneous instead of traumatic 
aneurism, is in all respects like that of Anel. There are other points con- 
nected with these two historic operations of Hunter and Anel which tend 
to show that with the former the operation was predetermined by a course 
of reasoning, while that of Anel was the result of an emergency and under- 
taken without any fixed convictions of what was to follow. In Hunter’s 
procedure are implied the probability of finding a healthy condition of the 
arterial walls; the possibility of curing an aneurism without entirely de- 
priving it of blood ; the utilization of the coagula as a means of occluding 
the sac; and the sufficiency of the collateral vessels to maintain the circula- 
tion and the vitality of the parts below. There is no evidence that the mind 
of Anel had grasped any one of these important principles. 
The Hunterian opei’ation, whenever the ligature is employed for the cure 
of spontaneous aneurism, should be adopted; that is, in an aneurism of the 
popliteal the ligature should be applied to the femoral artery, and in an aneu- 
rism of the femoral the external iliac should be tied. Various kinds of thread 
are in use among surgeons. Silk, hemp, silver wire, lead wii’e, and catgut 
have each their advocates. I prefer in all cases to employ the animal thread, 
cutting off both ends and closing up the wound. This ligature has never yet 
failed in my hands, even when applied to vessels the size of the external iliac. 
Acting upon a suggestion received from Mr. Lister, I requested Dr. Wharton, 
one of the resident physicians in the University Hospital, to treat a number 
of specimens of catgut which had been subjected for some time to the action 
of carbolic acid and sweet oil, with chromic acid and glycerin. After several 
experiments, Dr. Wharton found that three grains of the acid to the ounce 
of glycerin produced a soft, supple state of the thread, depriving it of all 
tendency to the spontaneous untying of the knots which were placed upon it. 
Catgut prepared in this way does not require to be subjected, as a preliminary 
measure, for more than two weeks to the antiseptic mixture of carbolic acid 
and olive oil. At present the ehromicized catgut thread of Lister answers 
every purpose after having been previously soaked in carbolated water (1 to 
20) for twenty-five minutes. 
When the ligature is applied, after the Hunterian plan, at a point distant 
from the disease, the pulsation and the bruit immediately cease in the aneu- 
rism, as all direct communication between the blood in the vessel and that in 
the tumor is intercepted. There is likewise a sensible diminution in the size 
of the swelling. Not only does the ligature interrupt the circulation through 
the vessel which it surrounds, but it also arrests at the same point the force 664 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
transmitted from the heart, in consequence of which there follows congestion 
of the capillaries and venous trunks below. This condition is succeeded by a 
sensible rise in the temperature of the limb. In several instances, immedi- 
ately after ligating the femoral or the iliac for aneurism, I found this eleva- 
tion of temperature of the limb on the affected side to be greater than on 
the sound side. The blood arrested in its course through the main channel 
immediately seeks the collateral branches, which undergo 
rapid dilatation, and in a short time become sufficiently 
capacious to answer all the demands of the parts below. 
(Fig. 517.) With the diminished supply of blood there is 
also a noticeable loss both of nerve-power and of sensibility 
in the limb. The patient is unable to move the part as 
before, and it may be a long time after recovery before this 
muscular disability passes away. The same care as in pa- 
ralysis is necessary to prevent the heel and other parts of 
the extremity from becoming sore. In addition to the im- 
pairment of its nervous functions, the limb becomes some- 
what wasted. All of these phenomena are defects of nu- 
trition, and proceed from one and the same cause, viz., a 
defective supply and an unequal distribution of blood. 
Though the main channel to the aneurism is interrupted 
by the ligature, the circulation in the tumor is not entirely 
arrested. The blood reaches it through the collateral 
vessels, and sometimes in sufficient quantities to be recog- 
nized by the presence of a feeble pulsation. This is espe- 
cially true if the treatment by pressure has preceded that 
by ligature, in which case the anastomosing vessels have 
alread}7 been considerably dilated. This circulation, how- 
ever, in the tumor in no way interferes with the progress 
of the cure : on the contrary, it renders it more certain and 
safe, by favoring the deposition of fibrinous lamella?. Were 
an absolute stasis of the blood in the aneurism to follow 
ligation, the sudden formation of a large mass of eoagulum 
might become an irritant, and cause inflammation, suppu- 
ration, and sloughing of the sac. 
Causes which render the Ligature ineffectual.— 
The causes which defeat the cure of an aneurism after liga- 
tion by the method of Hunter are the following: 
1. Secondary hemorrhage.—This may result either from a 
diseased state of the vessel, rendering the detachment of 
the ligature premature and the process of healing defec- 
tive ; from the opening of the sac; or in consequence of 
a peculiar state of the blood inimical to coagulation. 
2. Too free a supply of blood by anastomosis.—When the 
collateral vessels are large and the circulation in the tumor is not sufficiently 
diminished to allow of the rapid deposit of fibrin, the consolidation of the 
aneurism may be prevented. It is probable that in some cases, in which the 
pulsation has returned strongly in an aneurism after ligature, there is an 
unusual arrangement of the vessels, or the clot within the sac is displaced, 
rendering its cavity again pervious to the passage of blood. The latter oc- 
curred in a case of popliteal aneurism which I once had under care. In evi- 
dence of this, the foot became gangrenous from the plugging of its vessels 
by the detached thrombi. The case mentioned by Erichsen, of two femoral 
arteries supplying a popliteal aneurism, which was operated on by Sir Charles 
Bell, one vessel only having been tied, will serve to show, though the tumor 
was cured, that such an anomalous distribution may have been present in some 
instances of returning pulsation which have been recorded by writers. There 
are, however, examples in which pulsation and bruit in aneurism cured by 
the ligature have returned and disappeared several times, or have reappeared 
Fig. 517. 
Collateral circulation 
after ligature of the 
femoral. ANEURISM. 
665 
after the disease had been cured several years, and which evidently depended 
on the strength of the circulation in the anastomosing vessels supplying the 
sac. In the case of femoral aneurism operated on by Sir Benjamin Brodie 
and recorded by Mr. Prescott Hewett,* pulsation and thrill returned five and 
a half months after ligation of the iliac. Under rest and pressure these 
symptoms disappeared. Two years later there was a recurrence of the pul- 
sation, but no increase in size. Two months after this the tumor began to 
increase in size, but without either pulsation or bruit, and finally, after at- 
taining the bulk of an ostrich-egg, began to diminish, and underwent a 
spontaneous cure, as was satisfactorily ascertained by an examination after 
death, the patient having died of phthisis. An aneurism may, in conse- 
quence of the rich supply of anastomosing vessels, become active, though 
that activity may manifest itself only in the growth of the tumor, all sounds 
and movement being absent. Sir Astley Cooper mentions a case of popliteal 
aneurism in which he tied the femoral, and, as he supposed, with a successful 
result. Some time after, the swelling, without pulsation, began to increase 
in size, attended with such suffering as induced him to amputate the limb. 
H. L. Brown, of West Bromwich, England,! tied the primitive carotid for 
an aneurism of the external carotid. Five years after, the tumor again com- 
menced growing, but without pulsation. Oliver Pemberton, Surgeon to the 
General Hospital, Birmingham,! tied the external iliac for femoral aneurism. 
Two years and a half afterwards, the old tumor began to enlarge, though 
without pulsation or sound. In such cases as these the increase in size is due 
to additional depositions of fibrin in the course of the newly-formed channels 
through the old stratifications of clot. When the aneurismal sac is peduncu- 
lated, or stands off from the artery, the circulation through the latter may 
be entirely restored by means of the collateral vessels, without in any way 
reproducing the aneurism. 
The treatment required for cases in which the aneurism has again become 
active, with or without pulsation, is rest in the recumbent position, with the 
application of firm pressure to the entire limb, including the tumor, by means 
of a roller bandage. This failing, the pressure may be conjoined with flexion 
of the leg upon the thigh, and of the thigh upon the abdomen ; and, finally, 
should all fail, an Esmarch elastic bandage may be adjusted to the limb with 
a moderate degree of firmness and kept in place for half an hour daily for 
several days, observing to remove it each time gradually, and afterwards to 
keep the part elevated. 
Opening of the Sac.—Opening of the sac after ligation may take place in 
three ways,—by suppuration, by mortification, or by rupture. 
Suppuration.—Should suppuration follow the ligation of the artery it will 
be announced by the usual signs of inflammation, namely, increased swelling, 
heat, redness, and pain, attended by the constitutional disturbances ordinarily 
accompanying abscess, such as rigor, an accelerated circulation, and occa- 
sionally perspiration. The tumor, though it may have diminished in size for 
a short time after the operation, now enlarges, throbs, becomes acuminate, 
and finally opens, exposing the interior of the sac, the contents of which 
have become softened and converted into a dark-colored paste or fluid by 
the disintegration and admixture of the fibrin and other blood-clots of the 
aneurism. After this accident, should the communications not be closed be- 
tween the artery and the sac above and below, a sudden gush of blood may 
instantly destroys the patient, or, if this does not follow, life will be jeopardized 
by repeated attacks of bleeding. The danger from suppuration of the sac is 
lessened the longer the process is delayed, as time is allowed for permanently 
interrupting the continuity between the vessel and the aneurism. Large 
aneurisms are more prone to suppurate than small ones, and there is no 
period, from three or four days up to as many months, in w7hich a patient 
can be said to be exempt from such a risk. A broken state of the general 
* Medico-Chirurgical Transactions, yol. ix.; Lancet, July, 1877. 
f Lancet, July 28, 1877, p. 121. J Ibid. 666 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
health, or the sudden transformation of the contents of the sac into a blood- 
clot instead of the orderly fibrinous deposition, may be placed among the 
exciting causes of this accident. 
Sloughing may, like suppuration, be preceded by inflammatory symptoms, 
or the first indication of the change may be a small black speck on the sur- 
face of the tumor, which gradually enlarges and deepens until the attenuated 
tissues are penetrated, when results similar to those which follow suppuration 
ensue. Frequently before the mortification sets in, the contents of the aneu- 
rism, which may have been quite firm, begin to soften. Hemorrhage does not 
necessarily immediately follow the detachment of the slough ; several days 
may elapse, in which broken-down grumous blood is discharged before bleed- 
ing sets in. In one case under my care it was six days between the opening 
of the sac and the occurrence of hemorrhage. The bleeding generally is 
from the distal side of the aneurism. 
Rupture, except from suppuration and from mortification, is an exceedingly 
rare result. 
Treatment.—Suppuration once established, there is no longer any neces- 
sity for delay ; the surgeon should proceed at once to lay open the sac, as the 
longer the softened contents of the aneurism are retained the greater will be 
the probability of the destruction of any reparative work which may have 
been done in the vessel, and of the parts becoming flooded with blood. Pre- 
viously, however, to opening the sac, every precaution should be taken to pro- 
vide against hemorrhage. A tourniquet must be placed over the artery above, 
or, when this is not feasible, other resources should be at hand, as the fingers 
of an assistant, the padded door-key, or possibly graduated compresses. If 
the suppuration has taken place some weeks after ligation, the sac may have 
no direct vascular connection with the artery, in which case nothing more 
will be required than to dress the abscess with a carbolated water-dressing 
until the disorganized blood and fibrin have been discharged, when the 
cavity may be lightly packed with iodoform gauze or lint steeped in carbolic 
acid and olive oil, and dressed antiseptically. In a short time granulations 
will spring up, and the chasm be gradually repaired. The surgeon, however, 
must never relax his vigilance, even in cases where no hemorrhage immedi- 
ately follows the opening of the sac; it may break out at any moment, and 
therefore the tourniquet should be kept in position, ready to be screwed 
down at a moment’s notice, and the most minute instructions communicated 
to the nurse, or to other attendants, to thrust the fingers or properly-con- 
structed compresses into the sac when the tourniquet is not practicable. 
Hemorrhage, whether from separation of the ligature or from opening of 
the sac, is not a very frequent occurrence, but generally is most unpromising 
to the life of the patient when it does take place. In 180 cases collected by 
Lisfranc, it followed in 32. In the 530 cases examined by Porta, it occurred 
73 times. The tables of Norris contain 300 cases of ligature for aneurism, 
in 49 of which secondary hemorrhage took place. In 314 cases of aneurism 
collected for me by Hunter and Griffith, 37, so far as could be ascertained, 
suffered from secondary hemorrhage after ligature. Aseptic dressings will 
doubtless lessen the risks from bleeding. 
When the bleeding comes from the seat of ligature, either out of the 
proximal or the distal end of the vessel, the hemorrhage must be controlled 
by direct pressure with the fingers, aided, if necessary, by a graduated com- 
press ; or a tourniquet, when feasible, may be placed over the vessel. The 
wound should be next opened, and, after being enlarged upwards and down- 
wards, a ligature must be placed on both the proximal and the distal por- 
tion of the artery. If the hemorrhage is again repeated, and from the distal 
end of the vessel, there is no alternative but to amputate. 
When the bleeding comes from the sac, the surgeon has five courses open 
to his election : first, to lay open the sac and tie the artery above and below; 
second, to tie the artery above the seat of the first ligature; third, to apply 
compression above and below the tumor, or to stuff it with lint; fourth, to ANEURISM. 
667 
use the actual cautery; and, fifth, to amputate. To tie the vessel close to 
the sac is to include portions of the artery most certainly diseased, with 
the prospect of an early recurrence of the hemorrhage when the ligatures 
become detached ; and hence the operation has uniformly failed. To tie the 
artery above the seat of the previous ligature, while it may reach a sound 
part of the vessel, cannot materially affect the circulation through the col- 
lateral vessels, the connection of which branches with the sac constitutes 
the source of the bleeding. Compression, within or without the sac, is at- 
tended with equal uncertainty. When externally applied, it can be endured 
for but a short time, and when used internally, it can act only as a stopper, 
which, when detached, again allows the blood-flow. A possible result of in- 
ternal pressure by stuffing the sac is the closure of the bleeding vessel or 
vessels by an extension of the inflammation and the suppuration beyond the 
limits of the sac, from the irritation caused by the presence of the foreign 
body used in packing its cavity. Sealing up the vessel by the hot iron has 
proved successful in one case, that of Morrison ;* and when there is reason to 
believe the bleeding comes from a small branch, the cautery should be tried. 
To remove the limb may not always be feasible, but when this is possible it 
offers the patient, in my judgment, the best prospect of life. 
Mortification.—Mortification of the parts below the ligature is confined 
chiefly to the lower extremity, and arises from an inadequate supply of blood 
through the collateral vessels. This defect is not attributable to the want of 
a sufficient number of anastomosing arteries. In this respect all persons are 
nearly equally supplied, though the capacity of these branches may differ. 
Mr. Syme believed that mortification was always the result of injury to the 
vein. Twice have I seen this accident occur without any evil effects what- 
ever, and a number of cases are recorded in which the femoral vein has been 
tied, either by accident or by design, with impunity. It is more reasonable to 
refer the death of the limb to obstruction of the profunda femoris artery by 
coagula, and to a feeble heart, unable to drive the blood onwards with suffi- 
cient power to dilate properly the branches of the compensating system of 
vessels. An additional impediment to the collateral circulation may be an 
aneurismal sac of unusual size. 
Statistics show that mollification is not an uncommon result after the lig- 
ature of vessels for aneurism. In 300 cases tabulated by Norris, it followed 
40 times, 28 of this number taking place after ligature of the femoral. In 
a collection of 222 cases furnished me by Drs. Hunter and Griffith, mortifi- 
cation was observed to occur 29 times. According to Porta, 71 per cent, 
of patients attacked by gangrene after ligature die. The disease may prove 
to be very limited, affecting only two or three of the toes, when the collateral 
circulation has been imperfectly established, though generally it extends 
rapidly up the limb, and is of the acute, moist form. The period at which 
mortification commences is usually within two days after the application of 
the ligature. 
The fatality, from all causes, attending the ligature of vessels for the cure 
of aneurism is greater, perhaps, than is generally supposed. The tables of 
the late Di\ George Norris contain 379 cases, of which number 127 died. Of 
169 cases of ligature for aneurism,f 49 proved fatal, or 29 per cent. ; and 
of 50 cases collected by Dr. Griffith,J 7 were followed by death, or 14 per 
cent. These results do not materially differ from those of Porta and Lisfranc, 
the former giving a mortality of 117 out of 418 cases, and the latter a mor- 
tality of 38 out of 125 cases. Between 1868 and 1876 there were 28 cases 
of aneurism treated by the ligature in the Pennsylvania Hospital :§ 20 of 
these recovered, and 8 died. The arteries ligated for the cure of these aneu- 
risms were as follows: common carotid 6 times, with 2 cures and 4 deaths; 
* Norris’s Contributions to Practical Surgery, p. 245. 
f Hunter,—manuscript collection. f Griffith, — manuscript collection. 
§ Morton’s Table of Ligature of Large Arteries at the Pennsylvania Hospital, American Journal 
of the Medical Sciences, April, 1876. 668 
D IS EASES AND INJURIES OF THE BLOOD-VESSELS. 
subclavian, once, with 1 cure; common iliac, once, 1 cure ; external iliac, 4 
times, with 3 cures and 1 death ; femoral, 13 times, with 10 cures and 3 deaths; 
anterior tibial, once, with 1 cure ; and the brachial, once, with 2 cures. 
Treatment op Mortification.—In order to favor the restoration of the 
circulation, the limb should not be surrounded by a roller, as is sometimes 
done after ligature of the main vessel. Nor should it be elevated above the 
plane of the body. With a view to maintain the temperature of the part, 
the extremity must be enveloped in a thick wrap of cotton, and a bottle of 
hot water, rolled in a piece of flannel, applied to the sole of the foot. The 
fact that the limb is preternaturally warm after ligature, as has been pre- 
viously stated, in no way contra-indicates the use of external or artificial heat. 
The warmth following the operation is due to stasis, not to an acceleration of 
the blood-current, and is no expression of an increased vitality; rather, indeed, 
is it allied to the caloric which inaugurates tissue-decomposition. The diet 
must be regulated in accordance with the condition of the patient. When 
the constitution is broken by long suffering or by previous bad habits, the 
food should be nutritious and easily digested, assisted by tonics and stimu- 
lants. If the person is vigorous, the diet should be free from all stimulating 
qualities, and for the first three days moderate in quantity. 
When mortification commences, the surgeon must be guided in his treat- 
ment by the peculiarities of the case. If the disease lingers about the toes, 
or creeps up the foot very slowly, it is better to, delay the use of the knife. 
In such cases there is a reasonable hope that the death may be confined to 
a very limited portion of the limb, and it is wise to wait until the process 
defines its own boundaries, after which the part may be removed. Of 49 
cases of mortification following ligation, according to Porta, 14 recovered, 10 
without and 4 with amputation. .During the period of uncertainty the sys- 
tem should receive every possible assistance in the work of establishing the 
circulation. External beat must be kept up; the diet must be liberal, with 
quinine and alcoholic stimulants; and opium must be administered when 
necessary to relieve pain or procure rest. When, however, the disease is well 
pronounced, and extends rapidly over the foot and ankle to the leg, all tem- 
porizing should be abandoned, and amputation immediately performed. The 
limb should be removed a short distance below the place where the ligature 
was applied. The presumption is that the collateral circulation has been 
sufficiently formed in a part of the extremity, and hence it is not necessary 
to apply the knife close up to the point where the artery is tied. 
There is a state of incipient gangrene indicated by oedema and by discolor- 
ation of the foot, produced by the pressure of a large sac, which, although 
not sufficient to arrest the circulation before the application of the ligature, 
yet afterwards, when the force of the blood is diminished, begins to produce 
threatening effects. In such cases it will be proper to lay open the sac and 
remove the pressure by turning out its contents. 
Tetanus, though an unusual sequence of ligature for aneurism, does occa- 
sionally follow. Three cases of this kind, after ligature of the femoral, are 
tabulated by Norris. May it not be possible that a branch of the anterior 
crural nerve, which lies close by the side of the artery, was tied with the 
vessel in these cases? 
Erysipelas and phlebitis have also followed this operation; though their 
occurrence is exceedingly rare. 
Apoplexy and paralysis have in several instances occurred after ligature 
of the carotid. 
Ulceration of the artery above the seat of ligation may open the vessel and 
give rise to fatal hemorrhage. Twice have I seen this occur. 
Statistics sufficiently extensive are as yet wanting to enable us to make a 
comparison between the silk or the hemp ligature and the catgut thread ; but 
I am encouraged to believe that when a sufficient number of cases can be col- 
lected to warrant a deduction, it will be found that the animal thread has 
lessened the mortality following the ligature of arteries for aneurism. In the ANEURISM. 
669 
168 cases of ligature for aneurisms which I have spoken of, there were 12 
arteries tied with catgut thread, as follows: 6 popliteal,'3 femoral, 2 external 
iliac, and 1 brachial, with 11 recoveries and 1 death. 
Ligature of the Artery on the Distal Side.—In consequence of the in- 
accessible position of certain aneurisms rendering it impossible to place a liga- 
ture between the tumor and the heart, the idea was conceived of interrupting 
with the ligature the circulation on the distal side of the swelling. This opera- 
tion bears the name of Brasdor, a French surgeon of Paris, and was advocated 
about the same time by Desault. It was put in execution by Deschamps, who 
tied the femoral artery below an aneurism of this vessel situated in the groin. 
The operation, however, was not successful. The principle involved in the 
mode of treatment will be better understood when the effects of such a dis- 
position of the ligature are understood. The interruption of the blood-current 
from the sac when the artery is tied on its distal side is followed by the same 
demand on the collateral branches to provide for the circulation below, as when 
the vessel is tied above the aneurism. The enlargement of these circuitous 
channels meets this emergency, and tends to divert the blood in some measure 
from the sac, while the abrupt closure of the outlet from the latter has the 
effect of both slowing the blood-flow and producing counter-currents in the 
aneurism, two conditions which conspire to determine a fibrinous deposition, 
the usual method of cure. Sir Astley Cooper, after Deschamps, tied the 
femoral for a case of external iliac aneurism on this principle, but with only 
temporary success, as the patient, some time after the detachment of the 
ligature, died, probably from a rupture of the sac. In 1825, in a case of 
aneurism of the carotid at the root of the neck, in an aged female, Wardrop, 
of London, made the first successful operation, after the Brasdor plan, by 
tying the vessel above the tumor, the patient making a complete recovery. 
The operation has been repeated 
a number of times, but with very 
indifferent success. Of 38 cases 
collected by Erichsen, 25 proved 
fatal, and in the remaining 13 the 
disease was not arrested. Two 
years after his first operation, 
Wardrop tied successfully the 
subclavian for an aneurism of 
the innominate artery, applying 
the principle of Brasdor, by in- 
cluding a branch of the diseased 
artery instead of the vessel itself. 
This is known as the Wardrop 
method. There are, therefore, 
four modes of ligating arteries 
for aneurism, twro on the cardiac 
and two on the distal side of the 
tumor. The first two are those 
of Anel and Hunter, the last two 
those of Brasdor and Wardrop. 
The accompanying cuts (Eig. 518) 
will exhibit the distinction be- 
tween these plans. 
Compression.—This method dates back to a very early period, having beer 
employed about the end of the seventeenth century for the cure of aneurisn 
by Bardelot. It was afterwards practised by Ileister, Guattani, Ciniselli 
Flajani, and others. Based, however, as this old plan of compression was 
on a misconception of natural processes of cure, it met with little success 
Its advocates, entertaining views like those inculcated by Scarpa, viz., tha1 
the cavity of the vessel was to be obliterated by the adhesion of its sides 
applied their compression directly over the aneurism, by pads of various 
Fig. 518. 
Hunter. 
Brasdor. 
Wardrop. 670 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
materials and by roller bandages, in order to force the blood out of the tumor 
and bring its surfaces in contact with each other. The principle of the cure 
of the disease by the deposition of fibrinous eoagula was evidently not un- 
derstood. The earliest mode of applying pressure was, first, directly upon 
the sac, as stated above; secondly, immediately upon the artery above the 
sac; and, thirdly, intermediately upon the vessel above the sac. 
By the first plan the surgeon attempted an impossibility, the emptying of 
the contents of the aneurism. The strata of fibrin, being solid, and closely 
applied to the inner surface of the tumor, could not be forced out of its cavity, 
while by displacing the fluid part of the blood he excluded the very material 
which was required to cure the disease, preventing the further deposition 
of fibrin. Aside from these objections, the danger of causing mortification, 
by blocking up the vessels leading from the aneurism by thrombi or by emboli, 
must have been very great. 
Immediate pressure applied to the artery was introduced about the close 
of the eighteenth century, by Cline, Deschamps, Percy, Assalini. and others. 
By this method the artery was exposed above the sac, and embraced tem- 
porarily, that is, for twenty-four or thirty-six hours, by some constricting 
medium. The earlier innovators used an ordinary broad ligature, interposing 
between it and the vessel a little roll of linen or a piece of soft wood like 
cork. Cline employed tapes, which he tied over a cylinder of cork; while 
Deschamps, Percy, Dubois, and Assalini used artery-compressors, similar 
in appearance to canulas, and the forceps. Cures were occasionally effected 
in this way, not, as was supposed, by adhesion of the sides of the compressed 
vessel interrupting all communication between it and the sac, but by the 
rapid coagulation of the blood within the latter, just as occurs after one mode 
of using complete pressure at the present time. The dangers of this plan 
are quite sufficient for its condemnation. An artery cannot be temporarily 
compressed with impunity, even though the force be merely sufficient to 
arrest the passage of the blood through its canal. Ulceration of its coats is 
liable to follow; and, even should this not occur, it is difficult to understand 
what advantage this form of pressure could have over the old ligature. On 
the contrary, the result of later experiments establishes the superiority of 
the latter in point both of efficacy and of safety. 
In 1810, intermediate pressure, made over the course of the artery above 
the aneurism, was introduced by Pelletan and Dubois; yet these surgeons, 
as well as those who immediately followed them, seem to have been possessed 
with the old notion that there must be a complete obliteration of the canal 
of the artery. To give effectiveness to this idea necessitated the application 
of such a degree of force that few persons could tolerate the treatment, and 
consequently this plan fell into discredit, except as a measure preliminary 
to ligation, for which purpose it was regarded with favor by Todd, the 
object being to prepare the collateral vessels for the work of carrying on 
the circulation when the blood should be arrested in the main channel. It 
remained, however, for the surgeons of Dublin to solve this vexed question, to 
which the t hought of the profession had clung with a singular tenacity. To 
Bellingham, Tufnell, Hutton, and Carte are we indebted for the principle, as 
well as for the most thorough practical demonstration of its application in the 
cure of aneurism by compression. Properly speaking, this principle was not 
a new announcement, but only another application of that established by Hun- 
ter in the use of the ligature. This pressure may be complete or incomplete ; 
that is, the current through the artery may be entirely arrested, or only 
partially so. Murray, of Xewcas11 e-on-Tyne, who adopts the former plan, 
which, it will be perceived, is a revival of the method of Pelletan, has shown 
that an absolute stasis of the blood of the sac is entirely compatible with 
a safe and rapid consolidation of its contents. O’Ferrall, of Dublin, has some- 
what extended the principle of inducing complete stagnation of the cir- 
culation in the aneurism, by applying compression simultaneously on both 
sides of the sac. The majority of the Dublin surgeons, on the contrary, ANEURISM. 
671 
prefer the partial interruption of the blood-current, as calculated to produce 
both a safer and a more certain cure, by closing the sac with orderly, solid 
stratifications of fibrin, rather than by causing the sudden formation of a soft 
blood-clot. That excellent cures are effected by both procedures cannot be 
doubted. I cannot conceive why there should be any more risk in completely 
arresting the current of blood in the sac by pressure than by the ligature. 
In practice I always adopt the rule of complete pressure, and I have seen 
nothing as yet to induce me to abandon this plan. On the whole, it would be 
wisest not to pronounce dogmatically on the relative merits of the two theories 
until we are in possession of larger data from which to draw a deduction. 
Preparation for compression.—A patient suffering from aneurism, who is 
to be subjected to this mode of treatment, requires some preliminary treat- 
ment. To this I attach much importance. The entire process, in all its de- 
tails, should be explained to the patient, that we may enlist his interest and 
his intelligent co-operation in the treatment. He should be placed upon a 
well-stuffed mattress. Nothing can be more unsatisfactory than a soft bed, 
into which the hips of the person sink. A few pillows must be provided, with 
which to raise the head and shoulders of the patient, and on which the outer 
side of his semi-flexed limb may rest. For three to five days previous to 
beginning pressure, absolute rest in the recumbent position should be enforced. 
The person should not rise either to pass urine or to defecate ; the diet must 
be restricted in quantity, though not materially altered in quality, and the 
action of the heart diminished in force and in frequency by repeated doses 
of veratrum viride. If the patient is aged and feeble, such a course would 
be obviously improper, and we may be content to exact only the pi’eseribed 
quietude in bed. When the active part of the treatment begins, the diet 
should be both liberal and nutritious, such as milk, animal broths, and eggs. 
It will be necessary, also, to detail at least four assistants to attend the case, 
persons reasonably well instructed in medicine, two of whom shall be on duty 
at the same time, and who shall alternate every six hours. 
Means for applying compression.—These are instrumental and digital. A 
great number of contrivances have been devised for instrumental compression. 
The great indication in the construction of an apparatus for this purpose is 
that the extremity shall not be constricted so as 
to interrupt the venous circulation,—that is, that 
pressure shall be exerted only upon two portions 
of the limb, over the vessel and over the surface 
directly opposite. Sometimes this is accomplished 
by means of the Signorini tourniquet (Fig. 519) 
or some one of its various modifications, such as 
the Bellingham clamp (Fig. 520), or one of the 
Carte compressors (Figs. 521 and 522), which 
have the merit of being more fixed when placed 
in position. The instrument of Dr. P. II. Watson 
(Fig. 523) is preferred by some, as the peculiar form of its weight enables the 
surgeon to concentrate the pressure more effectively than by the ordinary 
pad. In order to distribute the compression, or to alternate it at different 
points over the course of the artery, compressors have been constructed with 
two or more pads. (Figs. 524 and 525.) By such a modification one pad, 
after being run down over the vessel and kept in place for a time, can be 
elevated, while the circulation is still controlled by a second being screwed 
down before the other is raised. The objection to the use of the Charriere, 
the Briddon, or any other form of compressor which has a linear arrange- 
ment of pads, is that the pressure cannot be conducted on the one artery 
system, which Mr. Walker, of Liverpool, deems so important, as the pads 
atfect different portions of the vessel, and are necessarily constantly changing 
the collateral circulation from one series of vessels to another. For example, 
when the pressure is applied to the superficial femoral the blood will be 
turned into the profunda and its branches, and when it is changed to the 
Fig. 519. 
Signorini tourniquet. 672 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
common femoral the circulation will have to seek a passage through the 
circumflex, obturator, and other branches of the internal iliac. The impor- 
tance of this theory I believe to be greatly over-estimated, and, as far as my 
Fig. 521. 
Fig. 520. 
Bellingham clamp. 
Carte’s compressor. 
own observation extends, it is not sustained by facts. Whatever form of 
apparatus is adopted, soft compresses must be placed between the body of 
the instrument, the pads, and the parts against which these rest. If it is 
proposed to arrest entirely the circulation through the artery, the force re- 
quired to effect this will be greater than can long be endured by the patient, 
Fig. 523. 
Fig. 522. 
Carte’s circular compressor. 
Watson’s weight compressor. 
in which case it will be necessary to administer an anaesthetic. The use of 
this agent as an adjuvant in the treatment of aneurism was, I believe, intro- 
duced by Dr. Murray contemporaneously with his method of complete pressure. ANEURISM. 
673 
I have kept a patient during the pressure under the influence of ether continu- 
ously for seven or eight hours, without the least inconvenience. When the 
plan of only slowing, not of entirety interrupting, the circulation in the sac is 
adopted, the instrument, after being adjusted to the limb, must be gradually 
tightened, just to the point—not beyond it—of inability to recognize pulsa- 
tion in the aneurism when the hand is laid over its surface; and to insure 
this degree of pressure it will be necessary to apply this test from time to time. 
Fig. 525. 
Fig. 524. 
Charriere’s compressor as modified by 
Gibbons. 
Briddon compressor. The pads can be separated or approximated by 
the thigh-pieces slipping past each other, and the screws running through 
squares connected with elastic bands render the pressure more tolerable. 
I have seen an intelligent patient, guided by his own sensations, tighten the 
instrument when necessary. Tolerance to this pressure can usually be ob- 
tained by the hypodermic use of morphine. To secure the most satisfactory 
action of the drug, it should be administered to the patient on the earliest 
evidence of distress, before he becomes restless and agitated, and must be 
repeated at such intervals as may be necessary to maintain the required ex- 
emption from suffering. No specific time or fixed dose can be prescribed. 
The sensibility to pain and the power of personal control differ so much in 
different persons that the surgeon must be guided by the peculiarities of each 
case. Generally, I have found that a quarter of a grain of morphine placed 
under the skin, at first every two or three hours, and, as the case progresses, 
at longer intervals, will secure the necessary quiet and relief from pain. 
Acupressure.—Another form of instrumental compression is that by means 
of acupressure pins. These are to be used according to one of the methods 
laid down under the head of acupressure, and are designed to be temporary in 
their application. In this respect acupressure is closely allied to the different 
forms of temporary ligation by tapes, wire, and other materials. The reports 
of cases treated by this plan are too few to warrant any expression of opinion 
in its favor. 
Digital compression.—In 1846, Vanzetti, of Padua, suggested digital com- 
pression as a substitute for instrumental pressure, since which time it has 
gradually grown in popularity, until at present it may be considered an 
established surgical procedure. The first case treated successfully by this 
plan alone was one of popliteal aneurism, under the care of Professor Knight, 
of New Haven. 
For several years I have relied almost exclusively on digital compression 
in the treatment of this disease. By this measure I have succeeded in curing 
a large number of popliteal aneurisms in succession. In one case the result 
was obtained in eight hours. Vanzetti permanently arrested all pulsation in 
a popliteal aneurism in four hours, and in Guy’s Hospital Reports for 1869 
Bryant records a case in which a patient cured himself in four and a half hours 674 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
by this plan. Boughter* reports an instance of double aneurism of the femoral 
artery in which he effected a cure of the lower tumor by digital pressure in 
five hours and a half. Fischer,f in a collection of 188 cases of aneurism of 
various arteries, found that of 121 cures 104 were accomplished by digital 
compression alone. The author, by a more rigid analysis excluding a certain 
number of failures which he thinks ought not to have been treated by instru- 
mental means, believes that the 104 cures should be subtracted from 138 instead 
of 188 cases. In 90 instances the popliteal was the vessel affected: of these 55 
were cured by digital pressure,—in 20 of them after other modes of treatment 
had failed. In only one case, and that in an aged man, could death be at- 
tributed to digital compression, mortification setting in after the cure of the 
tumor, probably from extensive disease of the vessels of the extremity. This 
mode of making pressure may be alternated with instrumental means. 
Digital compression possesses certain advantages over other plans, from its 
being less painful, and more under the intelligence of the operator, and from 
its applicability to cases of aneurism in localities where instruments cannot 
conveniently be applied. To carry out this very simple method, it is neces- 
sary to have at least six or eight properly-instructed assistants, who can 
relieve one another every ten or fifteen minutes. It is no ordinary person 
who can exert the proper degree of pressure for a longer period than fifteen 
minutes. The force can be applied with the greatest certainty either by 
placing two fingers of one hand over the vessel and planting upon them the 
flexed index finger resting against the thumb of the other hand, or by using 
the two thumbs, one on top of the other. Some recommend placing a bag 
of shot on top of the fingers, in order to make pressure with the least ex- 
penditure of force. The pressure must be made until an assistant, with his 
hand placed over the aneurism, announces the cessation of pulsation, a test 
which should be constantly repeated. When the time comes for one assistant 
to be relieved, his companion must command the artery in like manner before 
the first removes his fingers. To prevent the surface of the skin from be- 
coming sore, I find nothing answers so good a purpose as dusting it freely with 
either powdered starch or prepared chalk ; and to enable the patient to endure 
the treatment, it will be requisite in most cases to use hypodermic injections 
of morphine, as in instrumental compression, though not to the same extent. 
The period during which it will be necessary to maintain pressure will depend 
partly on the ability of the patient to bear the treatment, and partly on the 
effects produced upon the contents of the sac. The cure, as has been stated, 
may be perfected in five or six hours, or it may require several days. I 
generally keep up the compression continuously for thirty-six hours, when, if 
the desired end is not attained, it is omitted for eight or ten hours, that the 
patient may have some unbroken rest, after which it is again renewed and 
persisted in as in the first instance, again stopping for the necessary repose, 
and resuming treatment after it has been obtained. When the tumor is found 
to become more solid and the pulsation to diminish sensibly, the surgeon 
has encouragement to persevere ; but if, after the lapse of four or five days, 
no such signs can be detected, this plan may be abandoned, and, after a suffi- 
cient interval of rest for the patient to recover fully from the exhaustion 
consequent on the pressure, some other method must be adopted. 
General compression.—Since the introduction of Esmarch’s elastic bandage 
as a means of effecting bloodless operations, the application of the gum roller 
has been extended to the treatment of aneurism, and a number of successful 
cases have been recorded in the different medical periodicals. In two in- 
stances of aneurism in which I employed this method, no favorable result 
was obtained ; but, as the event proved, neither was a favorable case for any 
kind of treatment. The first application of the Esmarch bandage for the 
cure of aneurism was, I believe, by Dr. Walter Reid. The patient—a male, 
aged thirty-seven years—was cured in fifty minutes. The tumor was situated 
on the left popliteal artery. 
* Philadelphia Medical Times, October, 1871. 
f Prager Vierteljahresschrift, 1369. ANEURISM. 
675 
In applying the bandage, the elastic roller is commenced at the foot and 
wound firmly up the limb to the aneurism; it is then passed lightly over the 
tumor until its upper boundary is reached, when it is applied with the same 
degree of firmness as below. The tubing is next tightly wound about the 
thigh above the last turns of the bandage, and made fast, after which the 
latter is removed from the limb. The mode of action combines the Murray 
and O’Ferrall plans, in which the pressure is complete, is made on both sides 
of the swelling, and causes stagnation in the contents of the sac. The length 
of time for which it would be safe to preserve the extremity in this bloodless 
state has not yet been determined: in one of my cases the blood was not 
let into the part for one hour and a half. While it would be unjust to speak 
disparagingly of this measure in view of the limited number of cases treated, 
it is reasonable to presume that the force with which the blood rushes into 
the vessels when the cord is removed would seriously disturb the perma- 
nency of a recent clot formed in the sac. Another objection which strikes 
me as an important one is, that in the event of the ligature becoming neces- 
sary there has been no previous dilatation of the collateral vessels, a condi- 
tion so necessary to the life of the limb. Repeated trials, however, can alone 
establish the claims of the elastic bandage to professional confidence. 
Flexion.—The treatment by flexion is only a very simple device acting 
in the same manner as the method by compression. This plan of treating 
aneurism was introduced to the notice of the profession by Dr. Maunoir, of 
Geneva, Switzerland, in 1857, though it had been previously emploj’ed by an 
Italian surgeon. At a later date—1859—the successful application of flexion 
was made by Mr. Ernest Hart, of London. Mr. Spence, of Edinburgh,* after 
the failure of the ligature in a case of popliteal aneurism, succeeded in curing 
the disease by forced flexion. This was shortly after the method had been 
proposed. Mr. Leith Adamsf was equally successful in effecting the cure of 
a popliteal aneurism by flexion in sixty-eight hours, after instrumental press- 
ure had failed. Mr. T. HolmesJ also cured an aneurism of the popliteal by 
this plan in three days. These were among the earlier cases treated by forced 
flexion. Later, Fischer collected 57 cases of aneurism treated by flexion, the 
successes and failures being about equal. This method has been largely 
practised both abroad and in this country. 
Any one may test for himself the effect of flexion on the circulation by 
forcibly bending the forearm on the arm, or the leg on the thigh. The acute 
angle made in the brachial and popliteal arteries will so completely break the 
force of the blood that the pulsation in the vessels at the wrist and at the ankle 
will scarcely be perceptible. Herein consists the modus operandi of flexion : 
the abrupt bend in the artery diminishes the activity of the circulation in the 
aneurismal sac, and thus favors the formation of fibrinous clots. The applica- 
tion of this method is, from anatomical considerations, necessarily limited, 
and can be employed to advantage only in cases where the disease is situated 
at the bend of the arm, at the groin, or in the popliteal space. In treat- 
ing a case of aneurism by flexion—for example, an aneurism affecting the 
popliteal vessel—the limb should be bandaged firmly from the foot to the 
knee, lightly over the knee, and firmly again around the thigh to the groin. 
The patient being then placed in the recumbent position, on his back in bed, 
the leg should be flexed upon the thigh, and the thigh upon the abdomen. It 
wfill be seen that in this position the pressure is made on both sides of the sac,— 
below, by the bend at the knee, and above, by the bend at the groin. In order 
to retain the limb in this position, a roller should be passed round the leg and 
the pelvis, and a second round the leg, thigh, and pelvis. At the commence- 
ment of the treatment the flexion should not be too much forced ; but it may be 
increased as the case advances. Though it is said that the patient while under 
this treatment may be allowed to sit up, or even to move about upon crutches, 
* Edinburgh Medical Journal, November, 1859, p. 434. 
f Medical Times and Gazette, June 26, 1861, p. 82. 
f British Medical Journal, vol. i., 1868. 676 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
it is only when at rest and in bed that the full benefit of a quiet circulation is 
experienced. The time required to effect a cure, in favorable cases, varies from 
a few hours to two weeks. Some discrimination is necessary in selecting 
cases of aneurism adapted to this plan of treatment. Indifference to this 
matter has resulted in serious consequences. In one case the artery appears 
to have been torn across ;* and in a collection of forty-nine cases given by M. 
Liegois,f treated by this method, seven are said to have perished from rupture 
of the sac. In aneurisms where the tumor is large or growing rapid!}", or 
where there is evidence of an extensively diseased state of the arterial sys- 
tem, some other method than flexion should be adopted. In many cases of 
aneurism, especially in very sensitive or irritable constitutions, flexion and 
compression may be advantageously combined, enabling the patient to endure 
the treatment with little inconvenience, as the use of the two plans conjointly 
requires that neither shall be pushed beyond a moderate degree. 
The united summary of Fischer’s and Liegois’s cases of aneurism treated 
by flexion furnishes the following results: Of 106 cases of popliteal aneurism, 
45 were cured, 54 failed, and 7 undetermined. In 29 of the successful ones 
other methods were used in combination with flexion. 
Manipulation.—This process, proposed by the late Sir William Fergusson, 
consists in compressing or squeezing together the sides of the tumor in such a 
manner as to break up and dislodge fragments of its solid contents and allow 
them to be swept into the orifice of the vessel leading from the distal side of 
the sac. By blocking up the vessel in this way, and arresting the current 
through the aneurism, it was believed by its distinguished originator that the 
cure would be perfected by the formation of the necessary amount of clot. 
This plan has not met with much favor, but, on the contrary, has been re- 
garded among surgeons with distrust. When the danger of rupture or of 
inflammation of the sac is considered, or the probability of mortification and 
paralysis arising from embolic plugging of the distal vessels, the practice is 
one which merits unqualified condemnation. That these accidents are not 
imaginary the cases reported by Tillaux and Esmarch prove. 
Galvano-Puncture.—It is not surprising that in the extended application 
of electro-therapeutics to the treatment of surgical disease so powerful an 
agent should be tested as a curative means in aneurism. The permanent 
sealing up of vessels by a powerful current of electricity was suggested in 
1831 by Petrequin, and practised as early as 1832 by Mr. B. Phillips. About 
the same time this subject attracted the attention of a number of other medi- 
cal men, among them Mr. Keate. The matter, however, only came promi- 
nently before the profession about the year 1845, and then mainly through 
the results obtained by M. Petrequin and Dr. Burci, two surgeons, the former 
a native of France and the latter an Italian. In 1847 the subject was again 
introduced to professional notice by Gmeiraneau, of Poitiers.| who, by two 
applications of galvanism, cured an aneurism of the palmar arch. The 
method consists in decomposing the blood in an aneurism and thereby caus- 
ing coagulation, by introducing two or three electro-puncture needles into 
the sac, and connecting the positive pole of an electro-galvanic battery con- 
sisting of twenty or thirty cells for eight or ten minutes in succession with 
each needle, at the same time keeping the negative pole on the surface of the 
tumor with a piece of moist rag or sponge interposed. There are those who 
insist that the positive pole should rest on the skin and the negative be 
applied to the needles, on the ground, I suppose, that the disengagement of 
the hydrogen and the oxygen of the blood would take place with less disturb- 
ance. The formation of a clot by electro-galvanic decomposition of the blood 
is an uncertain result, and, when it does follow, the coagulum is so soft and 
possesses so little cohesiveness that it is prone to break down and open again 
the cavity of the sac to the entrance of blood. In some instances inflamma- 
* Holmes’s System of Surgery, vol. iii. p. 501. 
f L’Union Medicale, August 14, 1869. 
j Archives G6n6rales de M6decine, November, 1847. ANEURISM. 
677 
tion and sloughing have followed the operation, and the patient has been de- 
stroyed by hemorrhage. Whether this condition of the sac was induced 
by the heat of the needles or by rapid coagulation of the blood, is a question 
which has not been determined. 
Of 23 cases of aneurism treated by electro-galvanism, and collected by 
Bonnet,* only 2 cures can be legitimately claimed for this method, as in 7 of 
the 9 reported successes other measures had been simultaneously used. Of 
the 50 cases of aneurism analyzed by Ciniselli.f 23 are recorded as cured, 
with 7 deaths. This result is in such striking contrast with that given by 
Bonnet that it would be wise not to pronounce too hastily on the merits of 
this plan. The threatening complications which occurred both in the suc- 
cessful and in the unsuccessful cases of Ciniselli’s collection may possibly 
have been due to causes which, on a larger and more careful study of the 
subject, will prove to be remediable; and this view is strengthened by the 
observation of later experiments. 
Dr. John Duncan has given the result of this plan of treatment in a col- 
lection of 89 cases, 31 of which number are stated to have recovered. The 
largest number of cases of electro-puncture for the cure of aneurism brought 
together for analysis is that of Petit, comprising 114, with 69 recoveries. 
The results of the last two writers do not materially differ. 
Introduction op Substances into the Sac, and also Subcutaneously.— 
Efforts have been made at various times to induce coagulation of the blood by 
introducing into the sac certain liquid and solid materials. Monteggia, of Italy, 
suggested for this purpose the use of solutions of tannic acid and of acetate 
of lead, substances which possess a solidifying power over the blood. The per- 
ch loride of iron, from its property of quickly causing coagulation, is the agent 
at present almost exclusively used for this purpose. The manner of employing 
the fluid is that practised by Pravaz, whose experiments on the effects of this 
preparation of iron have been chiefly instrumental in introducing it into the 
list of remedies for the treatment of vascular and other tumors. Twenty 
drops of a solution of the perchloride of iron should be slowly deposited, ac- 
cording to Dieulafoy, in an aneurism containing three or four ounces of blood, 
by means of an ordinary hypodermic syringe. While the coagulation is taking 
place (the work, usually, of eight or ten minutes), and for at least one hour 
after, the circulation through the sac must be arrested, by pressure, both 
above and below the tumor, with a twofold object, that of favoring the solidi- 
fication of the blood, and of preventing any fragments of the concretion from 
entering the efferent part of the vessel. The operation, if not contra-indicated 
by the formation of the desired clot, or by the development of inflammatory 
phenomena in the sac, may be repeated in four or five days, observing the 
same details as in the first instance. Twice only have I directed the use of this 
agent, and then in a case of true femoral aneurism, which had proved rebel- 
lious to other forms of treatment. Eight drops of the liquid on the first occa- 
sion, and twelve on the second application, were introduced, without causing 
any pain or other inconvenience; but no positive result was noticed from 
its use. Malgaigne informs us that of eleven cases treated by this method, 
four died, two recovered, and none who survived escaped without having 
suffered from some serious complication. Holmes states that of eighteen 
cases of aneurism in which the injection was used, four proved fatal, the 
causes of death being gangrene of the sac, and phlebitis. Such a death-rate, 
and the hazards attending the operation even should the patient escape with 
his life, justify us in rejecting the method of injecting true aneurism with 
any of our present known coagulating agents, as one which should be ban- 
ished from surgical practice. 
Ergotin.—Langenbeck conceived the idea of injecting into the subcutane- 
ous tissue, external to the sac, a concentrated preparation of ergotin. It was 
thought that the property possessed by this drug, of exciting contraction in 
* Cooper’s Surgical Dictionary, vol. i, p. 166. 
| Sulla Electropunctura nella Cura degli Aneurismi, 1856.—Holmes. 678 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
the muscular walls of the uterus and of the blood-vessels, might in like man- 
ner favorably affect the sac of an aneurism. A case of subclavian aneurism 
is reported, in which sixteen injections of ergotin wTere made in the course 
of six weeks, with marked diminution of the swelling, and which was subse- 
quently cured by digital compression, kept up six hours a day for six days.* 
Professor Langenbeck gives a case of aneurism of the radial artery, of old 
standing, cured in eight days by the subcutaneous injection of ergot. If the 
sac is destitute of muscular fibres, the ergot can exert no contracting influ- 
ence over the tumor, though it might diminish the flow of blood into the 
latter, a condition favorable to coagulation, by diminishing the calibre of the 
afferent and efferent portions of the artery. May not the slight success 
which has followed the use of this agent have resuited more from inflamma- 
tory effects around the sac, caused by the irritation of the liquid in the cellu- 
lar tissue, than from its physiological action on the organic muscular fibres 
of the parts ? 
When ergotin is employed in the treatment of aneurism, the best form of 
the article is, perhaps, Squibb’s fluid extract, each minim of which represents 
one grain of the ergot. Ten drops of this preparation may be introduced be- 
tween the skin and the sac, by means of the ordinary h}Tpodermic syringe. 
The repetition of the injection must be determined by the degree of irritation 
produced, and by the progress of solidification in the tumor. Oftener than 
once in two or three days would be improper under the most favorable cir- 
cumstances. 
Introduction of Solid Substances into the Sac.—Attempts have been 
made, by introducing solid materials into the sac of an aneurism, to secure 
coagulation of its blood, a practice drawn from the well-known effects of 
stretching a thread across a vessel, or of the presence of any irregularity 
encroaching upon its lumen, the foreign body soon becoming covered with a 
layer of fibrin. The earliest attempt of this kind was made by Moore,f who, 
in a case of aneurism of the aorta, introduced into the sac, through a delicate 
canula, twenty-six yards of iron wire. Though the tumor became more solid 
and the pulsation ceased, the amelioration of the symptoms was only tem- 
porary ; violent inflammation of the sac was produced, which extended to 
the pericardium, and the patient died five days after the operation. 
Bacelli, of Rome, introduced into an aneurism, through a hollow trocar one- 
seventeenth of an inch in diameter, a watch-spring fourteen inches long by 
one-twenty-fifth of an inch broad. Inflammation and gangrene of the sac 
followed, and the patient died on the thirtieth day following the operation. 
Dr. Richard J. Levis, of this city, in 1876, in a case of aneurism of the sub- 
clavian and innominate arteries, which had extended into the thorax, intro- 
duced several yards of horse-hair into the sac. A second case of aneurism 
of the external iliac was treated in a similar manner by the same surgeon. 
Both cases terminated fatally, the last by inflammation and suppuration of 
the sac, the patient dying from hemorrhage. 
Dr. Maury used the horse-hair in a similar manner, in aneurism of the sub- 
clavian artery, in a patient admitted into the Philadelphia Hospital, but with 
an unsuccessful result. And Dr. Bryant, of London, employed the same 
material in a case of popliteal aneurism, wThich was also followed by the 
death of the patient. The last-named surgeon has used catgut. 
These experiments, to be sure, have been made on the most hopeless forms 
of aneurism; but it is doubtful if their repetition will yield any more satis- 
factory results. 
Acupuncture Needles.—Attempts have been made to cure aneurism by in- 
troducing into the sac in different directions very delicate and highty-polished 
acupuncture needles. This plan, the suggestion of Velpeau, has rarely been 
practised. Dunville relates a case of aneurism of the arch of the aorta, in 
which nine fine needles, two and a half inches long, wTere introduced. The 
* Lancet, 1873, vol. ii. p. 750. 
t Medieo-Chirurgical Transactions, vol. xlvii. p. 129. ANEURISM. 
679 
patient died in two weeks from hemorrhage. As fourteen inches of fine wire 
had been previously deposited in the sac, it is difficult to determine to which 
were to be credited the subsequent inflammation, sloughing, bleeding, and 
death. In a case of femoral aneurism seated in the groin, after the failure 
of pressure, and the patient being unwilling to allow the application of a 
ligature to the external iliac artery, I introduced seven acupuncture needles 
into the tumor, and retained them for twelve hours, but without either evil 
or good results. Macewen cured a popliteal aneurism by conjoining acupunc- 
ture with pressure: the latter, no doubt, was most influential in bringing 
about the result. 
Comparison of Methods.—I do not think it is possible, at present, to es- 
tablish any fair comparison between the different methods employed for the 
treatment of aneurism. Many cases which are recorded as cures have been 
managed by a combination of measures, so that it is impossible to determine 
which exercised the controlling power. In many others, subjected to press- 
ure, instrumental and otherwise, the appliances have been badly selected, or 
the assistants unskilled, or insufficient in number; in not a few, the treat- 
ment may have been prematurely abandoned, when a little more patience 
and perseverance would have crowned the work with success.—an objection 
which cannot be urged against the ligature ; and in some instances, doubtless, 
the plan selected was not well adapted to the cases treated. Enough, how- 
ever, I think, is known to narrow down the treatment to three plans,—rest, 
the ligature, and compression. The exceptional cases, such as may be prop- 
erly regarded as surgical in their character, may become subjects of some of 
the other forms of treatment already described. 
Holmes* has instituted a comparison between the methods by ligature 
and by compression, as applied to aneurism of the popliteal in the various 
hospitals of Great Britain, with the following result. Of 44 cases in which 
the femoral was ligated after compression had failed, 36 recovered and 8 died. 
Among the recoveries, 4 took place after amputation, and in 1 the aneurism 
returned. Of 77 cases treated by the ligature at once, 11 died, and the entire 
number of failures was 15, showing a percentage of 14.3 deaths and 19.48 
failures. Of the 124 cases treated by compression, 66 were cured at once; 
in 44 of the others the ligature was applied with success in 31, making the 
entire number of successful cases 97, and of unsuccessful 27. Of these last 
only 13 died, 5 after amputation without previous ligature, and 8 after liga- 
ture, the death-rate being 10.5, and the rate of failure 21.8. This exhibits a 
slight percentage of deaths in favor of compression. The statistics of Holmes 
bring out another fact, namely, that ligature after compression is more fatal 
than when done at once, the rate of mortality wThen the ligature was applied 
after pressure had failed having been 29.54 per cent., while it wTas only 19.48 
per cent, when the ligature was applied without any previous treatment. 
Under any circumstances, the treatment of spontaneous aneurism is at- 
tended with much uncertainty as to the final issue. The same considerations 
which govern the surgeon in undertaking any grave operation should have 
equal weight when applied to cases of aneurism. Where the kidneys are dis- 
eased, or the patient is much exhausted by prolonged suffering, and where 
there is extensive disease of the heart, or a second aneurism is present, affect- 
ing the abdominal or the thoracic aorta, any operation is of doubtful pro- 
priety, and most of all the ligature. One thing, I think, will be apparent on 
a careful examination of this subject, that an aneurismal sac is very sensitive 
to irritants of any kind, and that therefore all methods which consist in sub- 
jecting an aneurism to the presence of foreign bodies, in order to secure co- 
agulation of its contents, are dangerous procedures. In all aneurisms which 
come properly within the scope of surgical treatment, pressure, in some one 
or in several of its forms,—including flexion as one of these,—should be first 
and fairly tested, always preceded by preparatory measures, such as entire 
quiet in the recumbent position, a properly-regulated diet, and the exhibition 
* Lancet, May 1, 1875, p. 598. 680 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
of heart-sedatives, subjects which have been already noticed. If, after a patient 
trial, these measures fail, and if there be no contra-indicating circumstances 
of a constitutional or local character, resort be had to the ligature, 
allowing, however, before making the operation, ample time, when the case 
is not urgent, for the soft parts to recover from the effects of the pressure, 
and for the general system to overcome the exhaustion consequent on the 
previous treatment. 
False Aneurism.—Under false aneurism I include all collections of blood 
which communicate with the cavity of an artery, but which are not circum- 
scribed by a sac derived from the walls of the vessel. Under this head come 
dissecting aneurism, traumatic aneurism, and true aneurism in wdiich the sac 
has ruptured and its blood escaped into the surrounding parts. 
Dissecting Aneurism.—The term was first used by Laennec, though the 
disease had been previously described by Morgagni and others. In this form 
of aneurism the tunica intima yields, and the blood finds its way into the 
tunica media,—as shown, first, by Dr. Pennock,—and may become diffused for 
a considerable distance up and down the vessel, separating the layers of the 
middle coat from each 
other; or, if the blood 
passes beyond the lim- 
its of this coat, it may 
spread itself through 
the connective tissue of 
the adventitious tunic. 
Mr. Erichsen describes 
a variety of dissecting 
aneurism in which the 
blood, after breaking 
through the intima and 
rending asunder the 
layer of the middle 
coat, again enters the 
cavity of the vessel at 
a point some distance 
from the first opening. 
(Fig. 526.) Mr. Shek- 
elton,* as early as 1822, 
described a similar form 
of the disease. In one 
case, recorded by Dr. 
Henderson,f the upper 
opening into the coats of the aorta took place near to 
the left subclavian and the lower opening into the left 
common iliac artery. Dissecting aneurism (Fig. 527) is 
limited for the most part to the aorta, and most frequently 
to its arch, particularly the ascending portion of the latter, 
in 10 out of 19 cases analyzed by Dr. Peacock,| it involved 
the first part of the vessel. The innominate artery may 
participate in the aneurism by continuity of structure. The disease affects 
both males and females, though the latter suffer most frequently. Of 15 
cases collected by Dr. Peacock, and 21 by Dr. Crisp, making together 36 
cases in which the sex was given, 17 were males and 19 females. The ages 
of the patients varied from twenty-four to eighty-four years. There are no 
symptoms which reveal the existence of this form of aneurism, and its ter- 
Fig. 526. 
Fig. 527. 
Dissecting aneurism of the aorta extending 
the entire length of the vessel.—From a speci- 
men in the University of Pennsylvania, pre- 
sented by Dr. Pennock. 
Dissecting aneurism, in 
which the blood, after 
leaving the vessel, passes 
some distance between its 
walls and again enters its 
canal.—Holmes. 
* Dublin Hospital Reports, vol. iii. 
f London and Edinburgh Medical Journal, July, 1843. 
j Edinburgh Medical and Surgical Journal, vol. ix., 1843. ANEURISM. 
681 
mination is usually by rupture, in which the blood, when the ascending part 
of the aorta is involved, escapes into the pericardium. 
Shekelton* alludes to two cases found in bodies used for dissection, in 
which a partially spontaneous cure had occurred. In one, the anterior part 
of the abdominal aorta was tunnelled, and the canal, which was lined with a 
deposition of fibrin, opened by two orifices, one into each of the common iliacs. 
In the second, the walls of the left primitive iliac were separated, and 
through this the blood passed to the limbs, while the circulation in the pelvis 
was carried on through the usual channel of the internal iliac. 
Traumatic Aneurism.—This is another form of false aneurism, and maybe 
produced in various ways : 1, by punctured wounds ; 2, by gunshot wounds, in 
which the vessel may be immediately opened, or, if the artery be only grazed, 
this may not take place for several days, or until the detachment of a slough; 
3, by the sharp fragment of a bone, as sometimes occurs in fractures; 4, by 
forcible attempts to reduce old luxations; 5, by overstrain in which an artery 
gives way; and, 6, by the ulceration or the sloughing of a true aneurismal 
sac. There are two forms of traumatic aneurism, the diffused and the cir- 
cumscribed. Both may exist with or without an external wound. Between 
traumatic and spontaneous aneurisms there is this important distinction, 
that in the first there is usually before the accident a sound condition of 
the injured vessel, whereas in the last the artery is diseased. 
Diffused traumatic aneurism.—When an artery is wounded by a stab, the 
blood escapes through the external wound, but may cease to flow, either in 
consequence of the resistance offered by the tissues, or, more generally, from 
the pressure which is immediately applied. The wound, being closed and 
bandaged, unites, and to a careless spectator all may appear well. The blood, 
however, continues to escape from the opening in the artery, diffusing itself 
through the surrounding parts, slowly if the lesion in the vessel is small and 
the contiguous structures are compactly bound together by dense connective 
tissues or strong aponeuroses, or rapidly when the opening is large or the 
vessel lies in regions like the axilla, the popliteal, or the gluteal, where the 
anatomical components are loose and extensible. The progress of such an 
extravasation is retarded by the condensation and the inflammatory adhe- 
sion of the surrounding structures, and also by coagula of blood and masses 
of fibrin. 
Symptoms.—The signs of this accident are the presence of a soft swell- 
ing, wThich may have been preceded by a copious external hemorrhage 
which ceased on the application of a firm compress; or, where there is no 
obstacle to the escape of blood externally, as in a direct wound, there may be 
no swelling discoverable until after the wound has united and the compresses 
used in dressing have been removed. As the tumor enlarges, its arterial 
origin will be disclosed by the presence of pulsation, attended by a blowing 
or a purring sound, and the absence of the pulse in the vessel below. The 
size of the aneurism will be determined by its locality. In the axilla, where 
the tissues are loose and its boundaries very movable, in the thigh or at the 
root of the neck, it may attain a very great bulk, whereas in the palm of the 
hand or at the bend of the arm it may, in consequence of the strength and 
resistance of the fascia, grow very slowly. The tendency of diff use aneurism 
is to extend, stretching and separating the anatomical components of the 
parts in which it is situated, and filling the space with soft clots, until inflam- 
mation, abscess, or sloughing takes place, when, an external opening being 
formed, the patient is liable to perish from hemorrhage. 
Treatment.—All temporizing expedients in cases of a growing, diffuse 
aneurism are hazardous. Occasionally a case is cured by compression or by 
flexion; but the success of such measures is too uncertain to justify delay 
in adopting a more radical course. The safety of the patient depends upon 
exposing the divided extremities of the injured vessel and securing them 
* Hayden, Diseases of the Heart and Aorta, Part II. p. 1219. 682 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
with ligatures. In deeply-situated arteries, such as the posterior tibial in 
the calf of the leg, or the gluteal in the buttock, this is not always an easy 
task. It is always desirable to tie the vessel as near the seat of the original 
injury as possible, rather than to ligate the trunk at a distant point. When 
the latter is practised, the surgeon has no security against a renewal of the 
bleeding from the distal side of the aneurism. 
In performing the operation, the circulation must be controlled by first ap- 
plying a tourniquet to the artery above the tumor. An incision should next 
be made into the swelling its entire length, and all the coagula, liquid blood, 
and necrosed tissue belonging to the extravasation turned out. A careful 
search must now be made for the wound in the artery. Should it have been 
cut entirely across, greater difficulty, in consequence of its retraction, will 
be experienced in finding the vessel than would have been the case if its 
continuity had not been entirely severed. 
After getting rid of all foreign accumulations, and washing out the wound 
well with injections of a solution of bichloride of mercury, in order to re- 
move everything which tends to obscure the examination, the surgeon, if he 
fails to identify the artery, may have the tourniquet or other pressure slowly 
relaxed, at the same time keeping his eye intently directed to the wound, 
that he may detect the point where the blood begins to make its appearance. 
Should the hemorrhage commence, he may in this way identify the locality 
of the vessel. Sometimes the same end can be accomplished by carefully 
exploring with the point of a probe the region in which the artery should 
be found, the presence of which may be disclosed by the instrument entering 
its orifice. It may be that a false aneurism occupies a position not admitting 
of the use of the tourniquet. In such a case the operator must proceed with 
great caution. He should first make an opening into the swelling just suffi- 
cient to admit the finger (aseptic) of one of the hands, so as to prevent the 
external escape of blood, while he conducts the digit to a point which he 
believes to be the orifice of the artery; the external wound should be slowly 
enlarged, frequently stopping to ascertain if the finger is rightly placed, a 
fact which will be known by the absence of bleeding, and changing it from 
point to point, should the hemorrhage occur, until the right one has been 
reached, after which he may boldly extend the incisions to the utmost bounds 
of the tumor, scrape away the clots, and cautiously dissect down upon the 
vessel above the finger, and surround it with a ligature above and below the 
seat of injury. I have found the awl described by Professor Horner (Fig. 
528) admirably suited for applying the thread to the artery under such cir- 
Fig. 528. 
Horner’s awl, with the ligature looped over its extremity. 
eumstanees. The instrument has a short curve, and has a shoulder, instead 
of an eye, a short distance from its extremity, the latter being awl-shaped. 
The needle is made very strong, and is mounted on a stout handle. In using 
it, a thread is looped, passed over the point, and tightened above the shoulder. 
It is then dipped into the tissues on one side of the artery to which the liga- 
ture is to be applied, and brought out on the other side; the thread is then 
hooked over the point with a tenaculum, after which the instrument can be 
withdrawn and the cord tied. After the cardiac end of the vessel has been 
secured, and the bleeding thus stopped, the distal end must be searched for 
and subjected to a similar treatment. If the surgeon, notwithstanding the 
best-directed efforts, fails to ligate the artery,—an exceptional occurrence, 
however,—he must rely upon properly-constructed compresses rendered anti- 
septic by a solution of carbolic acid, or on the actual cautery. ANEURISM. 
683 
The wound after the operation for diffused aneurism does not unite quickly, 
like an ordinary incised one, but granulates, as in wounds of the open class. 
The greatest attention must be given to the dressing. The parts having 
been first washed out with a solution of bichloride of mercury (one to one 
thousand), a drainage-tube should be introduced, the edges of the wound 
brought together by sutures, and the usual antiseptic dressing applied. When 
the suppuration is free, the dressing, in all its details, must be repeated once 
in two days. The diet, and the administration of tonics and stimulants, must 
be determined by the constitutional state of the patient. 
False circumscribed aneurism is one in which the escape of the blood from 
the wounded artery is followed by inflammatory infiltration of the surround- 
ing parts and the conver- 
sion of this transudation 
into a circumscribing wall 
of connective tissue. In 
the commencement of 
false aneurism there is 
usually no difference be- 
tween the diffuse and the 
circumscribed variety, the 
point of distinction con- 
sisting in the investing 
wall of lymph. The tumor 
is frequently seen at the 
bend of the arm, in the 
palm of the hand (Fig. 
529), and near the wrist 
(Fig. 530) where the radial 
artery is superficial and 
exposed to injury. Vene- 
section, a fragment of a percussion-cap, the point of a knife, or a particle of 
glass, most commonly cause the accident. 
When the aneurism is the result of a small puncture, the circumscribing 
sac is often formed in part by the dense connective tissue constituting the 
sheath of the artery. This is more especially the case where the aneurismal 
swelling, in consequence 
of pressure being imme- 
diately applied to the 
bleeding orifice, does not 
appear until several days 
after the accident. Under 
such circumstances the 
opening in the vessel has 
been partially repaired, 
but the union does not 
possess sufficient strength 
to withstand the blood- 
pressure, and either gives 
or becomes stretched and 
thickened. The forma- 
tion of a sac transforms the condition of the tumor very much into that of 
a true aneurism, and the same concentric deposition of fibrin takes place as 
in the latter. 
Symptoms.—The swelling is of less magnitude than in the diffuse form of 
the disease, is somewhat sharply defined, possesses considerable resistance, 
pulsates synchronously with the contraction of the left ventricle of the heart, 
and yields a distinct bruit to the ear. Pressure upon the artery above arrests 
pulsation in the tumor and causes it to diminish sensibly in size. 
Treatment.—As circumscribed aneurism is, anatomically, closely allied 
Fig. 529. 
Traumatic (circumscribed) aneurism in the palm of the hand, caused 
by a fragment of percussion-cap. The skin has been turned off, and a 
double ligature passed beneath, preparatory to its strangulation. 
Fig. 530. 
Traumatic (circumscribed) aneurism of the radial artery, produced 
by the point of a penknife. 684 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
to true aneurism, it should be treated first by compression. As the tumor 
is generally found in a superficial situation, the artery can be very easily 
controlled, and the pressure should be applied a short distance above the sac. 
Flexion can often be advantageously used in conjunction with pressure, either 
digital or instrumental. When compression fails, resort must be had to the 
ligature. After providing for the possible occurrence of hemorrhage by 
placing a tourniquet loosely upon the arm, or detailing an assistant to make 
digital compression if necessary over the artery leading to the aneurism, an 
incision should be made over the tumor, commencing a short distance above 
and terminating a like distance below. The skin should be carefully dissected 
off on each side, and the vessel exposed and tied, both on the cardiac and on 
the distal side of the swelling, with the animal thread, after which the skin 
can be replaced and the flaps stitched together with a few points of the in- 
terrupted suture. Some writers direct the laying open of the sac and the 
removal of its contents when the vessel is tied. This procedure I never adopt 
in practice unless the swelling is very large. After the artery is ligated, the 
coagulum in the aneurism is gradually absorbed, and the wound in the soft 
parts unites by quick union, whereas if the sac is laid open the cavity must 
suppurate and the chasm be repaired by a slower process of granulation. 
When the aneurism is connected with the radial artery near the wrist, it 
will be necessaiy to tie both the superficial volar and the radial vessels on 
the distal side, to interrupt completely the circulation in the sac. 
When the tumor is seated in the hand and is connected with the superficial 
palmar arch, I am in the habit, after dissecting the skin from the swelling, of 
passing a needle, armed with a strong double ligature, beneath its base and 
strangulating each half separately. After the mass sloughs otf, the skin can 
be still used to cover up the part. 
Arterio-venous Aneurism.—Another form of false aneurism is that which 
is commonly known as the arterio-venous. Of this there are two varieties,— 
Fig. 531. 
Direct aneurism, or aneurismal varix, exposed by a vertical section. 
one in which the walls of an artery and of a vein are closely united by 
inflammatory adhesion and a direct communication exists between the two, 
—direct aneurism,—generally called 
aneurismal varix (Fig. 531); and 
one in which a sac is formed out 
of the connective tissue between 
an artery and a contiguous vein, 
separating the two some distance 
apart, and through which the blood 
passes from the artery before enter- 
ing the vein : this is an intermediate 
or varicose aneurism. (Fig. 532.) 
These aneurisms are generally situ- 
ated at the bend of the arm, and, 
with few exceptions, are of trau- 
matic origin; though they may 
also arise spontaneously. When traumatic, they are usually caused in the 
operation of venesection by the blade of the lancet passing through the 
Fig. 532. 
Intermediate or varicose aneurism; the sac lying between 
the median basilic vein and the brachial artery.—After Sir 
Charles Bell. ANEURISM. 
685 
median basilic vein and the bicipital aponeurosis and puncturing the bra- 
chial artery beneath. Goupil—a French surgeon—states that in fifty-seven 
cases the accident occurred thirty-one times from venesection. The infre- 
quency of this aneurism at present is largely due to the disuse of bleeding 
as a remedy in disease. The affection, however, is not confined to the artery 
and the veins of the arm. It has been met with between the aorta and the 
ascending vena cava, between the femoral artery and its accompanying vein, 
and between the carotid artery and the internal jugular vein. In one case 
an arterio-venous aneurism was seen in the vessels of the popliteal nerve.* 
I have seen the direct variety follow an amputation of the thigh, in which 
the bruised artery and vein had been included in the same ligature, the chan- 
nels of the two vessels becoming continuous during the separation of the liga- 
ture. The effect of this interchange of blood upon the vessels is quite marked. 
The artery, under such circumstances, gives more blood to, than it i*eceives 
from, the vein. The latter, as well as its branches, becomes dilated, tortuous, 
and thickened for a considerable distance above and below the swelling, and, 
receiving with the arterial blood the direct force of the heart’s action, beats 
synchronously with the contraction of the left ventricle. The artery, having 
much of its blood turned into the new channel, becomes contracted below, so 
that its pulsation is much diminished in strength, and is often quite indistinct 
on the distal side of the tumor. Above the point of communication its walls 
are sometimes dilated and thinned. In a case of arterio-venous aneurism 
which was brought into the University Hospital, and which subsequently 
died from gangrene, the deep-seated veins participated more in the dilatation 
than did the subcutaneous ones. 
Bardelebenf tabulates 91 cases of arterio-venous aneurisms: the largest 
number, 49, were caused by venesection; next in order of frequency came 
3 resulting from shot wounds. 
Symptoms.—There are symptoms common to both varieties of arterio- 
venous aneurism. In each there is generally the history of a previous wound; 
in each there is a distinct blue, pulsating, compressible tumor, which can be 
emptied by pressure on the artery above, and to a great extent by pressure 
upon the swelling alone; in each, also, there are sounds recognizable by the 
ear, which are blowing or hissing in their character, or are like the sound 
caused by a fly on a pane of glass, or—as Porter designates it—by a fly in a 
paper bag; a most excellent simile. On a closer examination of the two 
forms of the disease, however, certain differences can be detected; for example, 
in the direct variety there is a more decided tremor or fremitus propagated 
over the tumor, and the sounds are more continuous than in the intermediate 
form. In the latter, the tumor, which at first was soft and compressible, be- 
comes more firm in consequence of the fibrinous concretion which forms in 
the sac, and the blowing sound is more pronounced than in the direct form. 
The intermediate variety can be often recognized by compressing the venous 
SAvelling until it is emptied, when a second tumor—the interposed sac—can 
be felt beneath, which in turn can also be diminished by pressure. 
The progress of arterio-venous aneurism is usually very slow. Cases are 
recorded in which no perceptible increase has been noted for eighteen, 
twenty, and even thirty years. When the tumor does enlarge, much evil 
may result from the pressure. The obstruction to the circulation will 
cause oedema of the limb, loss of power in the arm by encroaching upon the 
median nerve, loss of temperature, ulceration or sloughing of the sac or 
the vein, followed by hemorrhage and, in some instances, by mortification of 
the limb. 
Treatment.—If the injury can be recognized at the time of its reception, 
there is little doubt that by applying a firm compress over the vessels at the 
bend of the arm—when the wound has been inflicted in this location—and 
then arresting the circulation through the main artery by means of com- 
* Medico-Chirurgical Transactions, vol. xx. 
f International Surg. Encyclopaedia, vol. iii. p. 535. DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
686 
pression and flexion, the occurrence of arterio-venous aneurism might be 
almost prevented. This treatment, however, will be the proper one at any 
stage of the disease. Should it fail, and the aneurism cause no particular 
inconvenience or disability and show no tendency to material increase, it 
will be best to avoid any interference, as operations for the cure of this affec- 
tion have often proved fatal. When the disease, by its growth, demands 
that some radical measure shall be undertaken for its cure, that which prom- 
ises the best result is to dissect the skin carefully from the tumor, and, ex- 
posing the brachial artery, to tie it above and below, close to the aneurism, with 
the catgut thread. When feasible, a third ligature should be carried round 
the communication between the artery and the vein, so that in the event of an 
anastomosing branch communicating with the artery intermediate to the two 
ligatures, the blood shall be prevented from entering the vein. The difficulties 
of'the operation should not be under-estimated, as the inflammatory changes in 
the parts will often render it difficult to discover the communication between 
the artery and the vein, or readily to distinguish—in consequence of the pul- 
sation—the two sets of vessels from each other. There need be no opening 
of either the dilated vein or the sac beneath, when such exists. The integu- 
ment should be replaced and the wound treated as after ordinary operations, 
by bringing its edges together with stitches and afterwards applying anti- 
septic dressings. 
ANEURISM OF SPECIAL VESSELS. 
Thoracic and Cervical Aneurism. 
Aneurism of the Thoracic Aorta.—The thoracic aorta, intrenched within 
the walls of the thorax, is too often beyond the reach of surgical treatment: 
still, much may be done to retard the progress of an aneurism of this vessel 
and contribute to the comfort of the patient. Men are more subject to aortic 
aneurism than women. 
The thoracic aorta exceeds all other vessels in the frequency with which 
it is attacked with aneurism. Of 915 cases of the disease embraced in the 
tables of Mr. Crisp, 382 involved the thoracic aorta. Myers found that this 
part of the aorta suffered from aneurism 94 times in 109 cases. The ascend- 
ing and transverse portions of the vessel are most frequently affected. Of the 
109 instances of aneurism analyzed by the last-named author, 37 were in the 
ascending, 38 in the transverse, and 19 in the descending part of the arch. 
This is in all probability due to the fact that the ascending and transverse 
portions of the vessel sustain the severest strain of the heart’s stroke. 
Aneurism of the arch of the aorta is not inconsistent with the existence 
of a perfectly sound heart; though Mr. Walshe thinks the disease tends to 
produce hypertrophy of this organ. 
Symptoms.—These may be arranged under two heads,—the rational and 
the physical. 
The rational signs are numerous and varied, and are due to the effects 
of pressure upon the contiguous parts. Hence the prominence of these 
signs will depend on the magnitude and form of the tumor, and upon the 
direction in which it grows. 
Large and sacculated aneurisms give rise to greater functional disturbances 
than small and fusiform ones; and those which develop in the direction of 
the neck cause moi’e urgent and threatening symptoms than those which 
enlarge in the direction of the chest. 
Pain is both an early and a late symptom of intra-thoracic aneurism : it is 
localized, is usually of a dull, deep-seated nature, and is experienced behind 
the sternum or between the shoulders. The severity of the pain is increased 
on taking any active exercise, or by any cause which accelerates the circu- 
lation. Besides this fixed pain, the patient is attacked, after a time, with 
another and more acute kind of suffering, pains which are darting, inter- 
mittent, or neuralgic in their character. These extend into the neck and ANEURISM OF THE THORACIC AORTA. 
687 
head, generally on the left side, corresponding to the branches of the cer- 
vical nerves; sometimes the pain encircles the upper part of the chest, in 
the direction of the intercostal nerves ; and often it shoots down the side of the 
thorax, and along the inner surface of the arm, following the distribution of 
the intereosto-humeral nerve. When the aneurism encroaches upon the ver- 
tebrae, sternum, ribs, or other portions of the bony walls of the chest, the 
pain experienced is of a hot, boring, and gnawing character. 
Dyspnoea.—This is a very common and a very distressing symptom, and is 
caused by the aneurismal tumor pressing on the bronchial or the tracheal tube, 
or even upon the lung itself. Often it is a reflex result from pressure upon 
the recurrent laryngeal or the pneumogastric nerve, and is attended with a 
croupy or stridulous respiration, feeble voice, cough, and mucous expectora- 
tion. The aphonia which so often accompanies aggravated forms of the aneu- 
rism may be caused either by laryngeal congestion from venous obstruction, 
or by paralysis of the vocal cords on one side from pressure on the recurrent 
laryngeal nerve. The same cause which interferes with the function of the 
recurrent laryngeal nerve may affect the sympathetic when it passes into 
the thorax, and produce the symptom first noticed by Dr. Hare in 1838,* 
namely, contraction of the pupil of the eye. 
Difficult deglutition is another effect of pressure, and results from compres- 
sion of the oesophagus. The latter tube, being behind the bronchi, is so deeply 
placed that the tumor will have acquired consider- 
able bulk before this symptom is experienced, except 
in cases in which the sac is formed on the descending 
part of the aorta, where the artery is closely related 
to the oesophagus. Under such circumstances, dys- 
phagia may appear before the aneurism is large, and 
in the early stage of the disease. Localized sweating 
has also been observed. 
Dolbe speaks of the peculiarity of the pulse-tracings 
in aortic or thoracic aneurism, these being remarkable 
for low amplitude, with sharp hooklets in the lines, as 
occurs in aortic insufficiency. 
Venous congestion.—Aneurism of the arch of the 
aorta extending up into the neck may materially in- 
terfere with the venous circulation. (Fig. 533.) The 
transverse innominate, internal jugular, subclavian, 
and descending cava veins are all liable to pressure 
from this cause; and when the obstruction is very 
marked, it will be followed by turgescence of the 
veins of the neck, with lividity of the face, a sense 
of fulness in the head, and oedema of the arm. When 
the pressure extends to the azygos or the hemiazygos 
vein, a dilated condition of the venous trunks on the 
front of the chest is likely to follow. In addition to 
these signs, we may have the aneurism exceeding the 
limits of the thorax, appearing in the neck and tilling up the supra-sternal 
fossa. When the tumor takes this direction, the branches of the aorta may 
be so pressed or distorted as materially to weaken their pulsation. 
Drummond, of England, has mentioned a procedure for determining the 
existence of intra-thoracic aneurism, which should be tested. It is based 
upon the sudden systolic expansion of the sac forcing the air out of the 
lungs, and consists in taking a deep inspiration, then closing the mouth and 
expiring slowly through the nose, during which, if the ear or the stetho- 
scope be applied to the trachea, short putting or blowing sounds, correspond- 
ing to the cardiac systole, will be heard. 
Physical Signs.—When the aneurism is in contact with the anterior walls 
of the thorax, there will be a corresponding area in which the percussion- 
Fig. 533. 
Aneurism of the arch of the 
aorta rising into the neck,— 
posterior view. 
* Medical Gazette, 1838. 688 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
sounds are dull, though, if the tumor subsequently change the direction of 
its growth and recede from the surface, the dull sound may be replaced by a 
resonant one. When the hand is laid upon that portion of the surface of the 
chest which corresponds to the position of the arch of the aorta, a vibratory 
sound, tremor, or fremitus will often be experienced. The thrill and pulsa- 
tion which characterize aneurism elsewhere are rarely heard and felt when 
the disease is intra-thoracic; though when the tumor rises into the neck or 
presses against the walls of the chest, these signs are readily detectable. 
There is a singular absence of uniformity in the auscultation-sounds. A 
double impulse and double sound may exist with or without a systolic mur- 
mur ; a double murmur may be present without either impulse or sound ; 
and it is possible not to be able to recognize impulse, sound, or murmur. 
Occasionally a case will be met with in which the systolic murmur is loud 
and blowing. 
Diagnosis.—The absence of any distinctive physical signs, and the fact 
that the pressure-effects which have been described may attend growing 
tumors situated in the upper part of the thorax, render the diagnosis of 
intra-thoracic aneurism one of considerable uncertainty. I have seen cases 
of malignant disease springing from the bronchial glands in which every 
symptom belonging to aneurism of the arch of the aorta was present. Ab- 
scess, especially when in the posterior mediastinum, will also give rise to 
symptoms which simulate strongly those of aneurism within the chest; and 
the same may be said, to a certain extent, of cardiac hypertrophy and of 
pulsating empyema. 
Writers have attempted to differentiate these diseases; but the lines of dis- 
tinction, except in typical or pronounced examples, are too faint to command 
an assuring confidence. The surgeon must rest his diagnosis on a comprehen- 
sive consideration of all the symptoms which are developed in the progress 
of a case. 
Duration and Termination.—The duration of intra-thoracic aneurism 
rarely exceeds one year, but is determined, of course, by the rapidity of growth 
and the parts subjected to pressure. Walshe never witnessed a case in which 
the patient lived over thirty-eight months. Dr. Williams mentions* one in- 
stance of a person who had been suffering for thirty years with an aneurism 
of the arch of the aorta. Intra-thoracic aneurism may terminate in different 
ways. The sac may become adherent to the trachea, to the bronchi, or to the 
oesophagus, and, by ulceration, open into these tubes, destroying the patient 
by hemorrhage. It may also open into the pulmonary artery or into the cava. 
When the ascending portion of the aorta is involved, the tumor frequently 
bursts into the pericardium. Instances are not rare in which the walls of the 
thorax disappear by absorption, the tumor passing through the opening thus 
made, and being covered only by the soft parts. Such was the case in an 
aneurism of the arch of the aorta of a patient in the wards of the Univer- 
sity Hospital. In some cases life is destroyed by asphyxia, or the individual 
may die, worn out by prolonged functional disturbance. 
Treatment.—The treatment best adapted to thoracic aneurism is one 
which will lessen the action of the heart; and this end is most satisfactorily 
attained by rest, a carefully-regulated diet, and, where there is severe dyspnoea, 
by the abstraction of blood and the exhibition of anodynes. Mr. Tufnell, 
by enforcing complete rest and a systematic diet, has succeeded in curing 
eight cases, six of these being aneurism of the abdominal aorta and two of the 
arch of the aorta.f He confines the patient to the horizontal posture from 
eight to thirteen weeks, allowing a change of position only to the side or 
upon the face, and that change to be made very slowly. The bowels and 
the bladder are emptied without rising, the mattress having the conve- 
niences of a fracture-bed. The diet is arranged as follows: for breakfast, 
* British Medical Journal, May 12, 1876 : quoted from Hayden. 
f Tufnell, Treatment of Internal Aneurism, 1864; also Medico-Chirurgical Transactions, vol. xxxix., 
Second Series, 1874; also Transactions of the International Medical Congress, Phila., 1876, p. 571. ANEURISM OF THE THORACIC AORTA. 
689 
two ounces of white bread and butter, with two ounces of cocoa or milk; 
for dinner, three ounces of meat, with three ounces of potatoes or bread, 
and four ounces of water or light claret; for supper, two ounces of bread 
with butter, and two ounces of milk and tea. This diet is modified some- 
what when required by the failing strength of the patient. Opium is 
administered in sufficient quantity to relieve pain. 
The iodide of potash has enjoyed considerable reputation in the treatment 
of aneurism. The remedy, according to Walshe, was first recommended in 
1859, by Bouillaud, and in 1869 was prominently brought before the profession 
by Dr. George W. Balfour* This physician reported a number of cases of 
aneurism successfully treated with this agent, one of which was intra-thoracic. 
Duckworthf has also succeeded in curing an aneurism of the arch of the 
aorta with this remedy. The dose of the iodide of potash administered 
ranged from thirty to ninety grains daily for months. There can be little 
doubt that this salt exercises some sedative influence over the action of the 
heart; but whether this property or the prolonged rest was the curative 
factor in the cases which have been recorded is still an unanswered question. 
That such aneurisms occasionally undergo spontaneous cure is also note- 
worthy. A case of this kind is recorded in the “ Lancet,in which an 
aortic sac solidified while at the same time the left subclavian and left com- 
mon carotid arteries were obliterated. Where medical means have failed to 
arrest thoracic aneurism, there have not been wanting those who, like 
Petrequin, Ciniselii, and others, were bold enough to attack the disease by 
surgical measures. Ciniselii applied electro-puncture in 23 cases of intra- 
thoracic aneurism, 5 of which were reported as cures, and only 1 of the 
number died from the effects of the operation, in consequence of gangrene 
attacking the place of puncture. The cases most favorable for this treat- 
ment are said to be those in which the Hansverse portion of the arch of the 
aorta is involved, where the opening between the vessel and the sac is small, 
and when the disease is extending along the vessel to the neck. The practice 
of Ciniselii has been imitated by Anderson, Cbarlton-Bastian, and others. 
In well-selected cases, the possibility of curing aortic aneurism by distal 
ligature of the left carotid, or of the right carotid and the subclavian arteries, 
receives apparently some support, not only from the cases of Tillanus and 
Rigen, but also from those of Wright of Montreal,§ Greenhow,|| and Heath. 
In Heath’s case, an aneurismal sac of the arch of the aorta had undergone 
almost a cure by the spontaneous obliteration of the left carotid and left 
subclavian arteries. In 1869, Cockle discussed with much ability the pro- 
priety of extending distal ligation to cases of aortic Heath has 
in two instances ligated the left carotid artery for aneurism of the ascending 
and transverse portions of the arch of the aorta. His first case was relieved 
for a period of four years, when the swelling again made its appearance. 
On the 10th of March, 1876, Holmes** applied a ligature to the left carotid 
artery in a case of aneurism affecting the arch of the aorta, in a young 
woman twenty-one years of age. This patient, though not cured, was much 
improved, both as regarded the growth of the tumor and her general symp- 
toms. It is worthy of notice that in this case the woman had been six 
months under the “ rest” treatment, and had also received hypodermic injec- 
tions of ergotin previous to the operation. 
Duncan has collected 27 cases of aneurism of the aorta treated by galvano- 
puncture, in which 5 were cured, 10 relieved, 9 received no benefit, and 3 
died. Favorable reference is also made to this mode of treatment by 
Bowditch, of Boston. When the aneurism is growing, slowly, but continu- 
ously, and the diagnosis is reasonably well established,—rest and other 
* Edinburgh Medical Journal, 1869. j British Medical Journal, August 23, 1873. 
J Lancet, 1876, vol. i. p. 426. \ Ibid., 1872, vol. ii. p. 70. 
|| Clinical Society’s Transactions, London, 1876, vol. ix. 
j Lancet, March 27 and April 10, 1869. 
** Clinical Society’s Transactions, London, 1876, vol. ix. p. 114. 690 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
medical measures having failed to ameliorate,—electrolysis offers some pros- 
pect of relief, probably of cure. 
Ligature of the left primitive carotid for aneurism of the aorta.—In most 
instances this is the proper vessel to tie in cases of the disease. It has been 
ligated 19 times, with the following result: 1 case was doing well seven years 
after (Holmes), 1 four years and a half, 2 two years, 1 five months, 2 four 
months, 1 three months, and 1 twelve months after: of the remaining 10, 
Prof. Ashhurst’s patient lived longest after the operation,—viz., seven weeks. 
In none of the 19 cases was a cure accomplished, and in at least 4 cases it 
is fair to infer that life was shortened* 
IAgature of the right primitive carotid has been done 5 times, all the cases 
dying but 1 (Annandale’s patient), who was not benefited by the operation. 
Ligature of the carotid and the subclavian artery for aneurism of the aorta has 
been performed 17 times, with 7 deaths, 9 relieved, and 1 undetermined. Of 
those relieved, 1 lived four years after the operation, 1 twenty months, 1 
seven months, 1 six months, 1 thirteen months, 1 fifteen months, 1 ten days, 
1 ten weeks, and 1 thirty-four days. In one of the cases (Hobart’s) the sub- 
clavian was tied inside of the scalenus anticus, or in the first part of the 
vessel; the remaining ligations were made at the third portion of the sub- 
clavian artery. In Spears’s case the subclavian was treated by his artery- 
compressor two days previous to its ligation; and in Wells’s cases the 
carotid and the subclavian were tied simultaneously. The same principle 
of distal ligation of the carotid alone and of the carotid and subclavian 
has been applied to aneurism involving both the aorta and the innominate 
arteries. 
Moore and Murchison introduced a quantity of iron wire into the sac of an 
intra-thoracic aneurism: the patient died five days after the operation I 
am not disposed to fix the bounds of surgical venture in a work so noble and 
eminently humane as that of saving or prolonging the life of a fellow-being; 
but, with a full knowledge of all that has been achieved in this direction for 
the cure of aneurism of the arch of the aorta, I may assume to say that the 
cases which justify a resort to electro-puncture or to the ligature are very 
limited in number, while the desperate attempt at solidification by the intro- 
duction of any foreign substance yet known into the sac of such an aneu- 
rism is a rash, if not a criminal, trifling with human life. The operation of 
opening the larynx or the trachea, in order to relieve the distressing symp- 
toms of spasm of the glottis and the sense of suffocation which so often attend 
intra-thoracic aneurism, is of doubtful propriety, as it is impossible, in most 
instances, to refer the dyspnoea to its proper source. The laryngoscope might 
furnish valuable assistance in discovering the part played by the recurrent 
laryngeal nerve in producing the obstruction to the admission of air. Except 
when the impeded respiration arises from a cause of this kind, an opening 
into the air-passage could be productive of no benefit. 
Aneurism of the Innominate Artery. 
The anatomical relations of the innominate and the arch of the aorta are 
such that it is often difficult, and sometimes impossible, to distinguish aneu- 
rism of the former from that of the latter vessel. Not unfrequently both 
are simultaneously affected, or the dilatation may extend from the aorta to 
the innominate, until the two arteries form a common pouch. The subclavian 
and the primitive carotid vessels may likewise participate in aneurism of 
the innominate trunk. It occurs, according to the tables of Crisp and of 
* In addition to those tabulated by Ashhurst, there are two cases of aortic aneurism treated by 
Fergusson by ligature of the right carotid. In one the pulsation ceased for one year; the patient 
died two years later. In the second case—complicated by aneurism of the innominate artery—the 
aortic disease was cured, while the disease of the innominate was only delayed. (St. Bartholomew’s 
Hospital Reports, 1886, xxii. 285.) A case of aneurism of the aorta and the primitive carotid is 
reported by Deleno, in which the left carotid was tied. The patient died two years after, the tumor 
having returned. (Progres Medical, Paris, 1882, x. 366.) Lisfranc, somewhat less than five times in every hundred cases of the 
disease. 
Symptoms.—Placed as the vessel is, behind the left sterno-clavicular junc- 
tion, aneurism of the innominate artery often begins as a small, round or 
oval, pulsating tumor, which may be seen and felt in this region, or a little to 
the inner side in the supra-sternal fossa. If the sac continues to grow in this 
direction, the sterno-hyoid, sterno-thyroid, and sterno-cleido-mastoid muscles 
will be pushed forward, forming a considerable swelling at the root of the 
neck. Should the sac be developed from the thoracic surface of the vessel, no 
tumor whatever may be detectable in the neck. The percussion-sounds over 
the region of the tumor will be dull, and the auscultation-sounds may be in all 
respects similar to those of the heart. The impulse communicated through 
the overlying parts will usually be strong, and the aneurismal bruit may or 
may not be present. 
Effects of Pressure.—These may be divided into those which affect the 
circulation, arterial and venous; those which affect the nerves; those which 
affect deglutition and respiration ; and those which affect the osseous and car- 
tilaginous structures of the thorax. In consequence of the impediment to the 
flow of the blood through the subclavian artery, the right radial pulse is gen- 
erally weak, sometimes beating discordantly with the action of the heart, and 
occasionally hardly distinguishable at the wrist. From the same cause the 
circulation in the carotid branch of the innominate may be much lessened in 
force. When the tumor grows into the chest, both the aorta and the heart 
may be subjected to displacement, which may account for some of the eccen- 
tric phenomena witnessed in the irregular action of the heart. 
The relation of the descending cava and of the transverse, subclavian, and 
internal jugular veins to the innominate artery is such that these vessels 
cannot long escape the effects of pressure. When the blood-current becomes 
interrupted through the deep jugular and transverse veins, both of which lie 
in front of the artery, between it and the walls of the chest, the obstruction 
will be announced by enlargement of the superficial veins of the neck, by 
lividity of the lips, by a puffy condition of the eyelids, and, in extreme cases, 
by oedema of the face, and by projection of the eyeballs in consequence of the 
intraorbital effusion. In like manner the left arm may become oedematous, 
from embarrassment of the circulation through the subclavian. Eying within 
the pressure-sphere of an enlarging innominate aneurism are a number of 
nerves of great functional importance. In front of the artery are the pneu- 
mogastric and cardiac branches of the sympathetic ; behind, the recurrent 
laryngeal and the sympathetic ; to the outer side, the phrenic ; and still more 
externally, the brachial cords and branches of the cervical plexus. 
Among the rarer structural changes induced by aneurism of the innominate 
is a protrusion of the bony walls at the summit of the thorax. The sternum, 
clavicle, and upper two ribs, with their cartilages, may be carried forward, 
and in some instances may undergo a partial absorption. 
Symptoms.—Pain is an early symptom of innominate aneurism. It may 
arise from irritation of the branches of the cervical or brachial nerves, and is 
generally constant and dull in the region of the tumor, but frequently parox- 
ysmal, extending up the side of the neck and face, over the front and side 
of the chest, over the scapula, and down the right arm. Cough is rarely a 
prominent symptom in innominate aneurism : when present, it is due to irri- 
tation of the recurrent laryngeal nerve. Contraction of the pupil, a symptom 
of very frequent occurrence, must arise from pressure of the sac upon the 
sympathetic. 
Difficult breathing is another symptom. It may result from direct pressure 
—generally lateral—against the trachea, or it may be a reflex effect from the 
encroachment of the tumor upon the recurrent laryngeal nerve. In such an 
event there will be paresis of the vocal membrane; the voice may be deep 
and hoarse, or it may be high-pitched; at other times the patient may not 
be able to speak above a whisper ; a brassy, stridulous cough, either dry or 
ANEURISM OF THE INNOMINATE ARTERY. 
691 692 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
attended by the secretion of a frothy, laryngeal mucus, is also sometimes 
present. In aggravated cases of dyspnoea, the wild, frightened stare, and 
the extreme agitation produced by the struggle for breath, are extremely 
distressing to witness. 
When the dyspnoea is marked, there will be more or less difficulty in deglu- 
tition, the oesophagus participating in the compression. 
Diagnosis.—Aneurisms of the innominate and of the arch of the aorta are 
frequently confounded, especially when examined at an advanced period in 
their history. Considered from an anatomical stand-point, there should be 
well-defined phenomenal differences. These have been well brought out in 
exhaustive detail by Holland* in a careful analysis of forty-five cases of 
innominate aneurism, which is well worthy of a patient perusal. Let it 
be remembered that the position of the arch of the aorta is wholly thoracic, 
median, and to the left of the spine, while that of the innominate is both 
thoracic and cervical, above and to the right of the aorta. One familiar with 
the other relations of the vessels will anticipate the differential distinctions 
which are subjoined. 
INNOMINATE. 
ARCH OF THE AORTA. 
The presence of a tumor which can generally 
be felt and seen at the right sterno-clavicular 
articulation. 
The presence of an external tumor excep- 
tional. 
The reason for this, distinction is found in the greater depth of the aorta, 
and in the fact that the least resistance to the growth of the aneurismal sac 
is in the direction of the chest and not in that of the neck. 
Pain over the anterior part of the chest, on 
the right side of the neck, head, and face, and 
down the arm and chest of the right side. 
Pain deeply situated; often between the 
shoulders or under the sternum, and frequently 
encircling the upper part of the chest. 
The differential peculiarities of the pain above noticed result from the fact 
that the cervical nerves are more within the reach of pressure from an innom- 
inate than from an aortic aneurism, and that many of these nerves supply the 
superficial portion of the front and side of the chest, of the neck, face, and 
head, and also the shoulder and inner side of the arm. That the pain should 
be on the right side, and not on the left, follows from the situation of the 
innominate artery on the right of the median line. The chest-encircling pain 
of aortic aneurism is due to the pressure of the tumor upon the superior 
intercostal nerves. 
Pain generally acute and neuralgic, rarely 
dull, gnawing, and boring in its character. 
Pain frequently gnawing and boring. 
The significance of these qualities in the pain of the two affections is im- 
portant. Pain of an intermittent and acute character generally originates 
from pressure or irritation of contiguous nerves, while the deep, dull, gnawing 
kind arises from the erosion of bone, and is common in aortic aneurism, in 
consequence of the relation of the tumor to the spine. It is doubtful if 
any tumor except an aneurism produces absorption of bone by external con- 
tact. M. Cayolf alleges that he has known a cancerous mass to destroy por- 
tions of the dorsal vertebrae. Such cases, however, must be extremely rare; 
and hence the character of the pain would be a valuable sign in determining 
obscure cases of supposed aortic aneurism. 
Venous congestion and oedema common over 
the right side of the neck and arm. 
Venous congestion and oedema more common 
over the chest. 
This follows, inasmuch as the obstruction to the venous current will be 
* Dublin Journal of the Medical Sciences, vol. xiii., February-May, 1852. 
f Dictionnaire de Medecine, art. Estomac, p. 365; quoted by Holland. ANEURISM OF THE INNOMINATE ARTERY. 
greater from a right than from a median tumor, while pressure upon the 
azygos veins, which are nearest to the aorta, will explain the dilatation of 
their anterior thoracic branches in aneurism of the arch. 
693 
Dyspnoea and cough common, but not usually 
intense. 
Dyspnoea and cough, as the disease advances, 
often very severe and persistent. 
This difference in the respiratory embarrassment is explained by the fact 
that the trachea, and the recurrent laryngeal of the left side, are peculiarly 
exposed to pressure from aortic aneurism by the resistance of the sternum 
to the forward growth of the tumor. The same facts will explain the more 
common existence of cough in this form of the disease. 
Left lateral deflection of the trachea and of the 
oesophagus. 
No lateral deflection. 
This displacement follows from the relative position of the two vessels to 
the trachea and the oesophagus: the innominate aneurism, being on the right 
side, pushes them to the left, while an aortic growth, being in front, presses 
them directly backward. 
Numbness and loss of power in the right arm. 
These symptoms uncommon. 
This arises from the brachial plexus of nerves being nearer to the in- 
nominate than to the aorta. 
Pulsation in the right radial weak. 
Pulsation in both radials weak, though weaker 
on the left than on the right side. 
The feebleness of the pulse in the radials may be affirmed of all the vessels 
of the two sides, the difference on the two sides being due to the greater 
tendency of the sac in aortic aneurism to extend towards the left. 
Stridor occasional. 
Stridor common. 
This might be anticipated from the pressure-effects of an aortic tumor upon 
the pneumogastrie and its recurrent laryngeal branch. 
Murmurs propagated from the sac in the direc- 
tion of the subclavian and carotid arteries. 
Double heart-sounds very common. 
When present, confined to the region of the sac, 
and may be on the left side and downwards. 
Double heart-sounds not common. 
These aneurisms will naturally occur in the direction of least obstruction 
to the onward flow of the blood. It is difficult to explain the double sounds 
so commonly heard in innominate aneurism: some believe that they are 
formed in the tumor, and others that they are transmitted from the heart. 
Prognosis.—Aneurism of this artery never undergoes a spontaneous cure. 
The disease proves fatal from hemorrhage, exhaustion, or asphyxia. 
Treatment.—Two plans are open to the choice of the surgeon,—the med- 
ical and the surgical. The former holds out the best prospect for prolonging 
the life of the patient, and should, in my judgment, be generally adopted. 
The medical treatment is that which has been practised with encouraging 
success by Mr. J. Tufnell in aneurism of other vessels, and has been described 
under the head of aneurism of the arch of the aorta. It consists in confining 
the patient in the recumbent position in bed, regulating the diet, and miti- 
gating pain by anodynes, to which may be added the use of iodide of potash, 
in fifteen-grain doses, administered three times a day. 
In considering the subject from a surgical stand-point, the question will nat- 
urally arise, What can be done for the cure of an aneurism of the innominate 
artery? In consequence of the shortness of the trunk, two operations are at 
once excluded from the methods of deligation, namely, the Hunterian and the 694 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
Brasdor. The only ligature possible under the circumstances, therefore, would 
be one applied to one or both of the branches of the innominate,—that is, to the 
common carotid or to the subclavian, or simultaneously to both. This form of 
ligation is often described as that of Wardrop, and, though distal, differs from 
Brasdor’s in this particular, that in the former, when applied to carotid aneu- 
rism, the only one possible where the conditions can be realized, no branch 
is given off between the ligature and the sac. Is it probable, then, that by 
tying one or both of the branches of the innominate the current in an aneu- 
rismal sac of that vessel would be arrested in a manner which would insure the 
deposit of stratified fibrin or induce a rapid embolic consolidation of the tumor? 
Theoretically, the ligation of the right primitive carotid would, as some have 
supposed, by lessening, not entirely arresting, the circulation through the 
sac, conduce most to the first mode of consolidation, while the second, or 
embolic occlusion, would be more likely to follow simultaneous ligation of 
both the subclavian and the carotid artery. Both of these operations have 
been performed, and the results will appear from the subjoined list of cases 
collected by Mr. Heath,* with a few additions: 
Cases of Distal Ligature for Aneurism at the Root of the Neck. 
I. Aneurism of the Innominate treated by Ligature of the Third Part of the 
Subclavian. 
1. Dupuytren. Died on the ninth day. 
2. Wardrop, 1827. Died two years afterwards. Wardrop on Aneurism. 
3. Broca, 1862. Died six months afterwards. 
4. Blackman. Died on the eighth day, from hemorrhage. 
5. Bryant, August, 1871. Ligation of the third part of the subclavian. Patient alive in 1873. 
Bryant’s Surgery, p. 294. 
II. Aneurism of the Innominate treated by Ligature of the First Part of the 
Axillary. 
1. Laugier, 1834. Died one month afterwards. Lancet, 1834, vol. i. p. 889. 
III. Aneurism of the Innominate treated by Ligature of the Right Common 
Carotid. 
1. Evans, 1828. Recovered. Wardrop on Aneurism. 
2. Mott, 1829. Died seven months afterwards. Mott’s Velpeau. 
3. Ashton Key, 1830. Died in a few hours. Medical Gazette, vol. vi.; Guthrie on Arteries. 
4. Case reported by Neumeister, 1830. Died five days afterwards. Holland, Dublin Quarterly 
Journal, February, 1852. 
5. Morrison, 1832. Died one year and eight months afterwards. American Journal of the Medical 
Sciences, vol. xix. p. 329. 
6. John Scott. Died. Lancet, 1834-35, vol. i. p. 893. 
7. Dohlhoff, 1837. Died on the sixth day. Broca on Aneurism, p. 632; Rust. Magazine, 1838, 
vol. li. p. 529. 
8. Fergusson, 1841. Died seven days afterwards. London and Edinburgh Journal, 1841, vol. i. 
p. 786. 
9. Porta, 1842. Died forty hours afterwards. Porta, Alt. patol. delle Art., p. 35. 
10. Hutton, 1842. Died sixty-six days afterwards. Dublin Journal, vol. xxv. p. 499. 
11. Vilardebo, 1843. Died twenty-one days afterwards. Archives G6n5rales de M6decine, 1847, 
p. 547. 
12. Campbell, 1844. Died on the nineteenth day. London and Edinburgh Journal, 1845. 
13. Rompani, 1844. Died on the twenty-first day. 
14. Wright, 1855. Died sixty days afterwards. Montreal Medical Chronicle, April, 1856. 
15. Ordile, of Naples, 1850. Died. Verbally communicated to Holmes by operator. 
16. Lane, 1852. Died in two months. 
17. Addinell Hewson, 1867. Died twelve days afterwards. Pennsylvania Hospital Reports, 1868, 
vol. i. 
18. Broadbent, 1860. Died on the hundred-and-fifteenth day. 
19. A. Newton. Died on the tenth day. 
20. PirogofF. Recovered from the operation, but not cured. 
21. PirogofF. Died three weeks afterwards. 
22. Heath. Died very soon. 
23. Desgranges. Died in twelve months. 
* Since this table was made, 10 additional cases of ligature of the right carotid artery for innomi- 
nate aneurism have been recorded, making in all 33 cases, with 20 deaths. In some of these the 
aorta was involved in the disease. Internat. Surg. Encyc., vol. iii. ANEURISM OF THE INNOMINATE ARTERY. 
695 
IV. Aneurism of the Innominate treated by Consecutive Ligature of the Carotid 
and Subclavian Arteries. 
1. Fearn. Carotid, August 30, 1836; subclavian, third part, August 2, 1838. Died four months 
afterwards. 
2. Wickham. Carotid, September 25, 1839; subclavian, third part, December 3, 1839. Died. 
Medico-Legal Transactions, 1840. 
3. Malgaigne. Carotid, March, 1845; axillary, first part, October 17, 1845. Died. Bulletin de 
la SociStfi Anatomique, 1848, vol. xxiii. p. 291. 
4. Bickersteth, 1864. Subclavian, May 16, third part; carotid, seven weeks later. Died in three 
months and ten days. 
5. Admani and Spears. Died in three months. 
6. Beanly. Recovered. 
7. Gay. Recovered, and died one year afterwards. 
8. Kuster. Undetermined.* 
V. Aneurism (supposed to be) of the Innominate Artery treated by Simultaneous 
Ligature of Carotid and Subclavian Arteries. 
1. Rossi, 1843. Died. Gazette M6dicale, 1884, p. 58. 
2. McCarthy. Died on the fifteenth day, from hemorrhage. 
3. Durham. Died in six days. 
4. Lane. Died, from rupture of sac, in three months. 
5. Holmes. Died on the fifty-fifth day, from rupture of sac. 
6. Weir. Died in fifteen days. 
7. Green. Died in three months. 
8. Pollock. Died in ten days, from dyspnoea. 
9. Enson. Died on the sixty-fifth day, from hemorrhage. 
10. Barwell. 1 
11. Barwell. Four cases recovered, and one died from the anaesthetic. Of the four successful 
12. Barwell. |- cases, two died from bronchitis, one three months and the other two years after 
13. Barwell. | the operation; of the remaining two, one is still living. 
14. Barwell. J 
15. Stimpson. Patient lived twenty-one months. 
16. King. Died in one hundred and eleven days, from rupture of sac. 
17. Hutchison, of Brooklyn. Died on the forty-first day. 
18. Little. Patient lived three and a half years, and diod of another disease. 
19. King, of Hull. Was well two months after the operation. 
20. Palmer. Died in four months. 
21. Denucti. Recovered without benefit. 
22. Eliot. Died inside of a month, from hemorrhage. 
23. Ransohoff. Died on the seventh day. 
24. Marsh. 
25. Browne. Case living at last report, three and a half months after the operation. 
26. Bergmann. Case living at last report. 
27. Banks. Died. 
28. Rosenstern. Died. 
29. Ashhurst. Recovered. 
30. Packard. Died. 
31. Percival. Relieved. Northampton General Infirmary. 
32. Heath. Relieved. Doing well six months later. 
33. Morton. Relieved. 
34. McBurney. Relieved. Doing well six months later. 
35. Prueger. Relieved. Died one year afterwards, from exhaustion. 
36. Mynter. Recovered. Doing well six months later. 
37. Barwell. Sixth case. Recovered. 
38. Jessops. Died in forty-nine days. 
39. Jessops. Improved. 
40. Jessops. Improved. 
41. Dunlop. Recovered. British Medical Journal. 
42. Dunlop. Recovered. British Medical Journal. 
Examining the different operations in detail, and their terminations, we have 
the following results. In 5 cases the subclavian artery alone was tied; and 
of this number 3 died and none were cured, though 1 lived two years, due, 
it is supposed, to a circumstance which probably would rarely occur again, 
namely, the return of circulation in the right carotid artery, in which it had 
been absent before the operation. 
Of those in which the right carotid alone was tied (32 cases), 5 recovered, 
2 were improved, 5 were unimproved, and 20 died,—a very unpromising oper- 
• Doughty and Mott tied the carotid and the subclavian for supposed aneurism of the innominate. 
The patient died four years after, and at the autopsy no aneurism was found. 696 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
ation. Of those in which the left carotid was tied (10 cases), 2 recovered, 
4 were improved, 1 was unimproved, and 3 died. 
Of the 8 cases in which consecutive distal ligation of the carotid and sub- 
clavian was performed, 3 died inside of three months, 2 died from causes not 
attributable to the operation, 1 recovered, and in 2 instances the result is not 
known. 
Of the 42 cases of simultaneous ligation of the carotid and subclavian arte- 
ries, 17 died, 17 recovered, 5 were relieved, 1 was not benefited, and in 2 the 
result was undetermined. Of the fatal cases, 6 died within eight days, and 
9 at periods varying from fifteen days to three months. Of those reported 
recovered and relieved, 20 in number, 1 lived three and a half years, 2 one 
year, 1 twenty-one months, 2 four months, 3 were doing well two months 
after the ligation, 1 three months and a half, and 2 six months, leaving 8 
uncertain. 
The causes of death following the various operations were secondary 
hemorrhage, asphyxia, bronchitis, pneumonia, erysipelas, inflammation and 
suppuration of the sac, exhaustion, and cerebral disturbance. 
In studying the results of the forementioned operations a distinction must 
be drawn between cases reported as recoveries and those set down as cures. 
If cures have been rarely effected, one thing has been determined, namely, 
that the collateral vessels are able to re-establish the circulation after simulta- 
neous deligation of the subclavian and carotid. In the forty-two cases in which 
this practice was adopted there was no failure from incompetency of the 
thyroid axis and internal mammary vessels, by their anastomoses, to supply 
the blood in sufficient quantity for the 
demands of the neck, head, and upper 
extremities. 
If an operation is undertaken, reasoning 
from anatomical premises, as well as from 
the knowledge derived from actual opera- 
tions, the simultaneous deligation of the 
subclavian and carotid arteries offers very 
much the best prospect for success in in- 
nominate aneurism, as by this measure the 
greatest degree of quiet is secured to the 
contents of the sac, a result which is hot 
attainable by the ligature of either the 
carotid or the subclavian alone, or of both 
consecutively, for in the first case a large 
arterial channel is open for the sweep of 
the blood-current, and in the second the 
time which has usually intervened be- 
tween the two ligations has been sufficient 
for the enlargement of the collateral ves- 
sels to a size the aggregate of which will 
be almost equal to that of the trunk they 
substitute. The annexed cut (Fig. 534) will serve to show the position of 
the ligatures employed in aneurisms of the innominate, and also the vessels 
chiefly concerned in establishing the collateral circulation. 
Fig. 534. 
Diagram of an aneurism of the innominate: a, 
ligature of the carotid; b, ligature of the sub- 
clavian ; c, the vertebral artery ; d, thyroid axis; 
e, internal mammary; /, superior intercostal. 
Aneurism of the Carotid Artery. 
Aneurism of the carotid, in consequence of the less liability of this vessel 
to atheromatous degeneration, is not of very common occurrence. It is 
placed, in frequency, between aneurism of the abdominal aorta and that of 
the subclavian artery. In 551 cases of aneurism tabulated by Mr. Crisp, 25 
were of the carotid. The collection of Holmes (337 cases) gives very nearly 
the same proportion (11 in number). In Lisfranc’s collection, numbering 
179, there are 17 carotid aneurisms. In the manuscript collection of Hunter ANEURISM OF THE CAROTID ARTERY. 
697 
and Griffith before mentioned, there are 162 cases of spontaneous aneurism, 
20 of which were carotid. As in other aneurisms, the affection is more com- 
mon in males than in females, though the disparity in sex in this respect 
between the disease in the carotid and in other vessels is much less marked. 
Of the 25 cases of the disease in Crisp’s collection, 12 were in women ; of 
the 34 cases in the tables of Norris, 7 were females; in the 20 cases (manu- 
script) referred to above, 4 were women. When the disease is situated at 
the bifurcation of the vessel, females suffer as frequently as males. Carotid 
aneurism is not unfrequently met with in young persons. In 16 cases ana- 
lyzed by Hunter, 1 was under ten years, 1 between twenty and thirty, 8 
were between thirty and forty, and 2 between sixty and seventy. The 
situation of carotid aneurism is generally near the middle of the vessel, 
sometimes higher up, occasionally at its bifurcation, and rarely near its 
origin. The right carotid is oftener the seat of the disease than the left. 
The growth of aneurisms affecting this vessel is usually slow, and the 
pressure-effects are less distressing than in cases of the disease involving the 
other vessels at the root of the neck. 
Symptoms.—The disease appears at first as a small, pulsating swelling, 
round or oval in shape, and soft and compressible under the fingers. When 
the ear is placed over the tumor, a distinct thrill and bruit de soufflet will be 
heard, sounds which, together with pulsation, are arrested and the size of the 
tumor diminished by firm pressure on the carotid between the aneurism and 
the heart. As the disease progresses and the swelling becomes large, the 
patient begins to suffer from the effects of pressure. The larynx, trachea, 
and oesophagus are pushed to one side, and the pneumogastric nerve is com- 
pressed, giving rise to impaired respiration, difficult deglutition, and frequently 
to cough. Pains are experienced in the side of the neck, head, and face, from 
irritation of the branches of the superficial cervical plexus of nerves; not 
unfrequently an unusual capillary congestion is present, from pressure upon 
the sympathetic. When the sac attains sufficient size to obstruct the pas- 
sage of the blood through the internal jugular, or to interfere with the circu- 
lation through the internal carotid, a train of threatening cerebral symptoms 
is introduced, such as defective vision, vei’tigo, and stupor. 
Diagnosis.—There are a number of enlargements which appear in the 
neck and which are liable to be confounded with carotid aneurism, among 
which may be mentioned enlargement of the cervical lymphatic glands, abscess, 
tumors, varix of the internal jugular, cysts, enlargement of the thyroid gland, and 
aneurism of other vessels at the root of the neck. The tables of Norris* on 
the ligature of the carotid furnish no less than seven errors of diagnosis in 
thirty-eight operations. 
Enlargement of the lymphatic glands.—The relation which these bodies hold 
to the carotid (being placed along the sheath of the vessel) is such that when 
they become enlarged it is not always easy to distinguish the swelling which 
is formed from that of aneurism. Attention, however, to the following points 
will generally conduct the surgeon to a correct conclusion. Glandular 
enlargements are rarely accompanied with either bruit or thrill, and the im- 
pulse communicated to these bodies from the artery against which they rest is 
a heaving one, not an expansive one, as in aneurism. The tumor, when glan- 
dular, is irregular, the separate glands composing the enlarged group being 
generally recognizable by the touch ; whereas in aneurism the swelling is 
smooth. Pressure on the carotid affects the size of adenoid growths slightly, 
if at all, but sensibly diminishes an aneurism. In addition to these char- 
acteristic distinctions may be mentioned the fact that glandular enlargements 
are in a great degree confined to young persons possessing other marks of a 
strumous diathesis, and are frequently multiple,—that is, exist in other re- 
gions of the neck,—while aneurism appears, as a rule, at a more advanced 
age, and in all constitutional conditions. 
Abscess.—Scarpa relates a case in which an aneurism of the carotid was 
* Norris’s Contributions to Practical Surgery, p. 267. 698 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
opened under the impression that it was an abscess; and the case of Liston,* 
to which allusion has been made, furnishes another instance of the difficulty 
which may be encountered in determining the true nature of deep cervical 
swellings. The formation of a deep abscess is almost always preceded by a 
diffused induration, tender to pressure, with redness, heat, and oedema of the 
superincumbent parts, the swelling, after a time, beginning to soften from its 
centre towards its circumference. In contrast with these characters, aneu- 
rism is a circumscribed soft swelling, without undue sensibility, redness, or 
heat, and, except when of considerable magnitude and obstructing the venous 
circulation, is unattended by oedema. In deep abscess of the cervical region 
there is pain, stiffness, and a fixed position of the head and neck, without 
centrifugal expansion, not affected in size by compression of the carotid 
artery, and generally associated with constitutional disturbance, as rigors, 
fever, and sweats. Aneurism is at first without pain, stiffness, or helpless- 
ness of the neck, has a radiating expansion, is lessened by proximal pressui'e, 
and is not necessarily accompanied by constitutional symptoms. Abscess, at 
first hard, gradually softens into fluctuation ; aneurism, at first soft, continues 
so, or if hard it is from the formation of fibrinous concretions, and becomes 
so at an advanced stage of the disease. Lastly, if a doubt still remains it 
can be settled by the use of a fine exploring-needle. 
Tumors.—Encephaloid and sarcomatous diseases frequently appear in the 
neck. These growths are hard, somewhat irregular in outline, immovable, 
rapid in their progress, and have, as they advance, a lilac discoloration of 
the skin, without the tenderness which accompanies the redness of abscess, 
and are without thrill or bruit; none of which characteristics distinguish 
aneurism. 
Adipose tumors are generally quite movable, lobulated, doughy, without 
pulsation or sounds, and are not affected by arterial pressure. Aneurism 
is more fixed, possesses a smooth surface, is soft, with pulsation and sounds, 
both of which are modified or suspended by compression of the vessel with 
which the tumor is connected on the cardiac side. 
Varix of the internal jugular.—The internal jugular, or one of its tributaries, 
may fonn a considerable pouch-like dilatation, which might readily be mis- 
taken for aneurism. I once removed such a tumor from a young woman, which 
was situated below the angle of the jaw. It wTas pedunculated and growing 
rapidly. On carefully uncovering the swelling 1 was able to trace it to its 
source, viz., one of the large roots of the deep jugular. A ligature was placed 
around the narrow part of its connection to the vein before its detachment, 
and the operation was followed by a rapid recovery. Venous dilatations are 
much softer than aneurisms; they disappear under very gentle compression, 
and become distended during expiration, as also by pressure on the proximal 
side from the interruption offered to the flow of venous blood towards the 
heart, none of which influences affect an aneurismal tumor. 
Cysts are not affected by pressure, yield no pulsation or sounds, and by 
palpation communicate a sense of fluctuation. 
Thyroid enlargements.—It is only when one of the lateral lobes of this 
body is affected either by hypertrophy or by cystic disease that any difficulty 
can possibly exist in distinguishing the swelling from aneurism. Goitre gen- 
erally appears at an early age, and in females; aneurism is most common in 
more mature life, and is usually in males. In goitre the swelling obeys the 
movements of the trachea, rising and sinking in the act of deglutition, and 
can generally be drawn over towards the median line sufficiently far to show 
its independence of the carotid artery. In aneurism the tumor is not affected 
by swallowing, and cannot be disengaged from the vessel with which it is 
connected. Goitre is usually slower in its growth than aneurism. The 
pressure-effects of bronchocele are much less serious than those of aneurism. 
The difficulty of diagnosis is somewhat increased in those cases of thyroid 
enlargement in which, in consequence of the great dilatation of the blood- 
* Cooper’s Surgical Dictionary, vol. i. p. 210. ANEURISM OF THE CAROTID ARTERY. 
699 
vessels of the gland, there are added to hypertrophy two other elements,— 
pulsation and bruit. A tumor of this kind, receiving its blood-supply from 
the carotid, will, like aneurism, be diminished in size and will have its sounds 
suspended by proximal compression. There are, however, certain noticeable 
distinctions between the two diseases which will serve to conduct the practi- 
tioner to a proper judgment. In the thyroid swelling the tumor continues to 
follow the movements of the trachea, and the enlargement is rarely confined 
to one lobe, but extends to the median line of the neck and across to the 
opposite side, affecting both the isthmus and the opposite lobe of the gland. 
This cannot be said of aneurism. Another very important distinction be- 
tween the two diseases is the following, viz., that while pressure on the 
affected carotid will completely arrest pulsation and thrill in aneurism, it 
does so only partially in the thyroid body. To suspend all movement and 
sound in the latter it is necessary that the circulation be stopped through 
both carotids, inasmuch as the thyroid tumor receives its blood from both 
of these vessels. 
Brachio-cephalic and aortic aneurisms.—A carotid aneurism may extend 
so low down in the neck, or an aortic, innominate, or subclavian aneurism 
may extend so far up into the same region, that no amount of skill will be 
sufficient to distinguish the latter from the former. Mr. Cockle* relates four 
or five cases of supposed aneurism of the carotid and of the innominate in 
which ligation was performed, which, on post-mortem examination, proved 
to be aneurism of the arch of the aorta. The surgeon must be guided by 
such information as can be gained from a searching inquiry into the early 
history of the case, discovering, if possible, the exact locality of the swelling, 
whether commencing below and extending up, as would be the course of an 
innominate or a carotid aneurism, or beginning above and growing down- 
ward, as would be probable in a carotid tumor. Lateral deflection of the 
trachea and the oesophagus, should it exist, would exclude aneurism of the 
arch of the aorta. 
Termination.—Carotid aneurism, when allowed to advance without inter- 
ference, usually runs its course in from twelve to eighteen months, the patient 
dying from the effects of pressure, from gangrene of the sac, or from ulcera- 
tion and hemorrhage, the blood often being poured into the trachea or bronchia, 
or into the chest. In some instances embolism of the cerebral blood-vessels 
has carried off the patient. 
Treatment.—Three methods are employed for the treatment of carotid 
aneurism, namely, rest, compression, and ligation. 
Rest.—This plan has been described in connection with aneurism of other 
arteries, and does not differ in detail from that enforced for aneurism of the 
aorta. It should always be first adopted, as in case of failure the prospect 
of success by other methods will be materially enhanced. Of eleven cases 
treated by rest, regimen, etc., three were represented as cured. 
Digital compression.—When the aneurism is situated sufficiently high to 
admit of the fingers being placed between the tumor and the origin of the 
carotid, there will be a strong probability of effecting a cure. M. Rouge, of 
Lausanne,f succeeded in consolidating an aneurism of the carotid by digital 
compression in seventeen days, the pressure being maintained on an average 
about seven hours each day. More recently five other cases successfully 
treated by this plan have been recorded : one by Mr. Sheppard, of Worcester 
one by Dr. J. G. Kerr, of Canton, China,§ one by Mr. Holmes,|| 
one by Mr. Gay, and one by Sir R. Dagin, mentioned by The 
pressure must be made by relays of assistants, and should be applied at the 
root of the neck, under the anterior edge of the sterno-cleido-mastoid muscle, 
with sufficient force to thrust the vessel back against the transverse process 
* Lancet, 1869, vol. i. p. 489. 
f Boston Medical and Surgical Journal, vol. iv., N. S., p. 179 ; quoted from British Medical Journal, 
j Medical Times and Gazette, 1863, vol. ii. p. 643. 
# American Journal of the Medical Sciences, vol. liii., April, 1867. 
|| Lancet, June 21, 1873, p. 868. f Lancet, 1872, vol. i. p. 470. 700 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
of the seventh cervical vertebra. To render the pressure most effective, 
the head should be flexed, in order to relax the sterno-mastoid muscle and 
thus allow the finger or the thumb to sink easily down upon the artery. 
The internal jugular at this position in the neck is sufficiently distant from 
the carotid to be out of reach of the pressure. The plan pursued by M. 
Rouge is well worthy of imitation. The artery was grasped between the 
thumb and three fingers, the former being placed along the front, and the 
latter along the posterior, edge of the sterno-eleido-mastoid. In this way 
the vessel was subjected to bilateral pressure, by which any inconvenience 
resulting from irritation of the pneumogastric or sympathetic nerves was 
avoided. Should the patient experience much pain during the treatment, 
the compression may be rendered endurable by the hypodermic use of mor- 
phine. When neither proximal pressure nor ligation is possible, digital com- 
pression might be advantageously made on the distal side of the swelling. 
Manipulation, or kneading, though practised a number of times, has proved 
fruitless. It is not to be recommended. 
Injection of ergot into the connective tissue around the aneurism has been 
practised, but with so little success as to be entitled to no confidence. 
Ligature.—Deligation may be performed both on the proximal and on the 
distal side of the tumor. 
Proximal ligature.—This is the preferable mode of tying the vessel, and 
should always be practised when the aneurism occupies the middle or the 
upper part of the artery, admitting of deligation between the innominate 
and the tumor, or, when on the left side, between the disease and the arch of 
the aorta, in the cervical portion of the carotid. 
jDistal ligature.—When, in consequence of the bulk or the position of the 
aneurism, it is impossible to ligate on the cardiac side, the operation of Brasdor 
may be done. Should the case be one for surgical treatment, the common 
carotid may be tied above the sac, or, if the latter be too near the division 
of the vessel, simultaneous deligation of the external and internal carotids 
may be performed. The ligature of the innominate holds out no encourage- 
ment whatever, and may be justly excluded from consideration. Should the 
disease be of so aggravated a nature as to preclude anjr operative procedure, 
there is still left one hope, though a forlorn one, viz., the plan of Valsalva. 
There is recorded at least one cure of a carotid aneurism by this method ;* 
and what has occurred once may occur again. 
Results of ligation.—Of 25 cases of carotid aneurism recorded by Mr. Crisp,f 
21 were treated by ligature. Of these operations 10 were successful, and 
11 proved fatal. In 5 of the patients the ligation was done on the distal 
side, of which number 3 recovered, and the lives of the remaining 2 are 
represented to have been prolonged. The causes of death in the fatal cases 
were, in 5 hemorrhage, in 2 inflammation of the sac and artery, in 1 spasm 
of the glottis, and in 3 doubtful. Dr. Norris| has tabulated 38 cases, with 
16 deaths and 22 recoveries. The collection of Hunter and Griffith § con- 
tains 24 cases, with 11 deaths and 13 recoveries. The statistics of Dr. 
Pilz,|| of Breslau, comprise 87 cases of ligature for carotid aneurism, 31 of 
which number died. Thus we have an aggregate of 170 deligations for this 
disease, with 69 deaths, or 40.6 per cent. Wyeth’s collection of deligations 
for carotid aneurism amount to 106, with 77 recoveries and 29 deaths. Three 
of the latter were due to causes not referable to the operation. The distal 
ligature of the carotid for aneurism has been applied eight times, as follows: 
1. In 1826, by Wardrop. Patient recovered. 
2. In 1826, by Wardrop. Patient not improved. 
3. In 1827, by Lambert. Patient died from a hemorrhage, which came 
from the vessel above the ligature, though the aneurism was cured, being 
filled with fibrin and blood-clots. 
* Boston Medical and Surgical Journal, 1829, vol. ii. p. 339. 
J Contributions to Practical Surgery, p. 263. 
|| Langenbeck’s Archives, 1868, vol. ix. 
f Crisp on Aneurism, p. 218. 
§ Manuscript collection. ANEURISM OF THE EXTERNAL CAROTID. 
701 
4. In 1827, by Bustle. Patient recovered. 
5. In 1829, by Montgomery. Patient died. 
6. In 1840. by Colson. Patient recovered. 
7. In 1840, by Demme. Patient died. 
8. In 1852, by Lane. Patient died. 
Of the above 8 cases 3 recovered and 5 died. This is a heavy mortality; 
but no authoritative conclusion can be drawn from data so limited, and, in 
view of the hopeless future which is before a patient so situated, I should 
consider myself amply vindicated from the charge of rashness if I performed 
distal deligation on the strength of such precedents. 
The period at which the ligature separates varies in different eases. In 
those collected by Norris, 21 in number, the thread came away in 13 before 
the twentieth day, in 7 between the twentieth and the thirtieth day, and in 
1 on the thirty-third day. In Dr. Hunter’s collection of 16 deligations for 
carotid aneurism, the time at which the ligature became detached was as- 
certained in 10 instances, as follows: 3 between the tenth and the fifteenth 
day ; 2 between the fifteenth and the twentieth day ; 4 between the twentieth 
and the thirtieth day; and 1 between the thirtieth and the fortieth day. 
The method formerly in practice, of opening the sac and tying the vessel 
above and below the aneurism, has been performed a number of times in 
cases of traumatic aneurism, the operators being Frothingham in this country, 
and Hey and Syme in Scotland. 
The chief cause of death, after ligation, is hemorrhage, either from suppu- 
ration of the sac or from the artery after separation of the ligature. In one 
instance noticed by Norris the bleeding did not occur until seventy days after 
the operation. Death may also follow from cerebral disturbance, and from 
bronchitis, or from an insidious inflammation of the lung. The connection 
between this last-named sequel and carotid ligature is very imperfectly un- 
derstood. Mr. Erichsen is disposed to attribute the pulmonary disease to 
“ derangement in the functions of the brain and medulla oblongata,” produced 
by a disturbed intracranial circulation, and disposing, secondarily, through 
these centres to a condition of pulmonary congestion favorable to the develop- 
ment of pneumonia. I believe that had a careful examination been instituted 
in cases fatal from this cause, it would have been found that the pneumogastric 
nerve had sustained some damage during the operation. I have known death 
from inflammation of the lungs to occur twice from this cause. Death from 
bronchitis is a very common result after cut-throat wounds, and I have reason 
to believe it arises from damage sustained by the superior laryngeal branch 
of the pneumogastric nerve, causing congestion and inflammation of the 
laryngeal mucous membrane, which is propagated by tissue-continuity to 
the respiratory passages below. To the nerve-injury also may be attributed 
the spasmodic cough which occasionally follows the ligature of the carotid. 
Cerebral or pulmonary disorders should be treated as are similar affections 
arising from other causes, namety, by local or general bleeding, counter- 
irritation, cathartics, and a regulated diet. 
Aneurism of the External Carotid. 
Aneurism of the external carotid, except from traumatic causes, is exceed- 
ingly rare, so much so that many surgical authors make no allusion whatever 
to the subject. Dr. S. W. Gross has reported the case of a negro woman 
in whom, six months after she had been wounded in the neck with a pistol, a 
pulsating tumor appeared below the angle of the jaw, which increased in size 
until it measured eight inches in one direction and five inches in the other. 
In a case of Mr. Heath’s, the aneurism of the external carotid was attended 
writh unilateral atrophy of the tongue. 
Treatment.—In the event of an aneurism of the external carotid, digital 
compression should be first tested, and, that failing, deligation of the common 
carotid should be performed. In Dr. Gross’s case, to which allusion has been 702 
made, this course was adopted, with the effect of making a perfect cure, the 
tumor having entirely disappeared in the course of a twelvemonth. 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
Aneurism of the Branches of the External Carotid. 
The temporal, facial, posterior occipital, and the branches of the internal 
maxillary have all been the subjects of aneurismal enlargement, and, as in 
dilatation of the parent trunk, the disease has followed some kind of injury. 
In 1870 a male patient, forty years of age, presented himself at my office with 
a spontaneous aneurism of the occipital. The tumor was the size of a hickory- 
nut, and projected between the trapezius and complexus muscles. As the 
disease had existed for over a year, and appeared to be stationary, it was 
allowed to remain without interference. I have also seen one example of an 
aneurism of the middle meningeal artery in a dissecting-room subject. The 
tumor had made for itself a considerable concavity by the absorption of 
that portion of the parietal bone against which it lay, and, judging from the 
extremely thin layer of the external table remaining, would certainly, had 
the patient survived, have appeared in a short time on the external surface 
of the skull. Such an event has occurred, and the unfortunate patient lost 
his life through the surgeon’s laying open the swelling with a bistoury 
under the impression that he had to deal with an ordinary abscess. Pro- 
fessor Gross saw a case of aneurism on the anterior branch of the temporal 
artery, which had been induced by an injury sustained by the vessel in 
cupping. 
Treatment.—If the vessel is accessible to the touch, an effort should 
be made to secure consolidation in the contents of the sac by digital com- 
pression. In the event of this failing, the artery and the sac should be ex- 
posed by turning aside, by a careful dissection, the superincumbent tissues, 
and the vessel ligated above and below the tumor, with the animal thread; 
after which the reflected flaps are to be restored to their original position, 
and maintained in place by the interrupted suture or by adhesive strips. 
The sac should not be opened. 
Aneurism of the Internal Carotid. 
The internal carotid may be the subject of aneurism in its cervical, petrous, 
and intracranial portions. Aneurism of the intracranial portion may be fur- 
ther divided into aneurism of the trunk and of its branches. 
When the cervical portion of the vessel becomes the seat of aneurism, 
the case assumes the deepest interest, from the obscurity which environs 
the swelling. The deep situation of the artery, covered as it is externally 
by the stylo-hyoid, stylo-pharyngeus, and stylo-glossus muscles, and by dense 
aponeurotic structures which extend down to the styloid process, prevents 
any very marked prominence of such a tumor on the surface of the neck, and, 
as the artery is separated from the pharynx only by the mucous membrane 
and the constrictor muscle, its extension inward becomes an anatomical 
necessity. Indeed, in this peculiarity lies the chief difference between aneu- 
rism of the internal carotid and aneurism situated at the division of the 
common trunk. Such a pharyngeal protrusion might be mistaken for an 
enlarged suppurating tonsil, and be punctured with a bistoury; though the 
symptoms of pulsation, which can be both felt and seen in aneurism, would 
render an error of this kind as inexcusable as it would be disastrous. 
Aneurism of the petrous and intracranial portions will be considered in a 
subsequent section. 
Treatment.—Digital compression of the common carotid merits a trial 
before a more radical measure is decided upon, and should this not succeed, 
the only course will be the ligature of the primitive carotid, an operation 
'which has, so far as I can determine, been done but twice,—by Mr. Syme and 
by myself,—and in both cases with a fatal result. ANEURISM OF THE SUBCLAVIAN ARTERY. 
703 
An exceedingly interesting,case of aneurism of the left internal carotid in 
a female was under my care, as a private patient, in the University Hospital. 
The tumor had acquired a great size, not only encroaching on the fauces, but 
projecting between the ramus of the inferior maxillary bone and the mastoid 
part of the temporal bone, forming a swelling larger than a goose-egg, with 
a distinct pulsation and bruit. Ligation of the left primitive carotid vessel 
failed to arrest the movement in the tumor. This appeared to be due to the 
blood-supply derived through the branches of the external carotid. The in- 
cision was accordingly prolonged upward, and the superior thyroid and the 
lingual and occipital were next tied, when neither motion nor sound could 
be discovered in the aneurism. A notable diminution in the swelling followed 
the ligation: after ten days, however, pulsation again appeared, but could 
be arrested by interrupting the current of blood through the right primitive 
carotid artery. A ligature was now placed on this vessel. No cerebral symp- 
toms were observed after either the first or the second ligation. Although 
no further pulsation or bruit appeared in the aneurism, yet, seven days after, 
during my absence from the city, ulceration occurred, and the tumor 
opened into the mouth, followed by a profuse hemorrhage, which the resi- 
dent physician arrested by stuffing the sac with lint. On my return I found 
the patient suffering from septic fever, from which she ultimately died. The 
course I should have adopted, had I been present at the time of the rup- 
ture of the aneurism, would have been to resect the ramus of the jaw, lay 
open the swelling, and tie, if possible, the internal carotid below, and also 
above, the aneurism. Dr. Deaver ligated quite recently the primitive carotid 
for aneurism of the internal carotid. The result is as yet not known. 
The subclavian artery is the subject of aneurism almost as frequently as 
the carotid. In the tables of Mr. Crisp it occurred twenty-three times in 
295 cases. It is most common in men. In the late Mr. Poland’s collection 
of subclavian aneurisms,* numbering 120, there are 100 males and 11 females; 
in 9 eases the sex was not ascertained. In 85 the disease was on the right 
side, and in 28 on the left; 72 were idiopathic, and 13 traumatic. In 57, cases 
collected by Dr. Norris, 50 were males and 7 females. As far as could be as- 
certained, 31 were on the right side and 23 on the left. The greater tendency 
in the right vessel to become diseased is perhaps due to the muscular and 
vascular strain to which the right arm, from its general use, is subjected. The 
largest number of cases occur between the fortieth and fiftieth years of life. 
The disease is rarely, if ever, seen under thirty. In a few instances both 
arteries have been simultaneously affected. Although every part of the 
vessel may be the seat of the disease, yet the third part of the subclavian, 
that portion which lies external to the scaleni muscles, suffers most. When 
the left subclavian is the seat of an aneurism, it is always in its cervical por- 
tion. Of 25 cases of subclavian and subelavio-axillary aneurisms reported 
by Koeh,f 17 were spontaneous, 4 were caused by sprains and contusions, 
and 4 by fracture. 
Symptoms.—The subclavian artery, being deeply placed and sheltered by 
the clavicle, may be considerably dilated before the disease is discovered. 
Usually, however, the tumor will be recognized as a small ovoid swelling, its 
long diameter lying parallel with the course of the clavicle. When the 
shoulder is drawn downward the swelling will become noticeable. When 
the fingers are placed in contact with the tumor, that peculiar, expansile, 
life-like pulsation which belongs to aneurismal disease will be felt; and if the 
ear be placed over the subclavian region there will be heard the character- 
istic bruit and thrill. As the tumor increases it tends to extend upward and 
outward, never inward, and occupies the posterior inferior cervical triangle. 
The resistance which the sac encounters between the clavicle and the first 
Aneurism of the Subclavian Artery. 
* Guy’s Hospital Reports, 1870. 
f Langenbeck’s Archives, vol. x. 704 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
rib prevents the aneurism from enlarging in the direction of the chest, except 
in rare cases. In one instance I knew the tumor to develop downward: the 
first two ribs became absorbed, and the sac entered the chest and contracted 
adhesions to the lung, into which it finally opened, destroying the patient by 
hemorrhage. As the disease progresses and fills up the subclavian space, 
severe pressure-effects are experienced. These are such as result from en- 
croachment on the contiguous nerves and veins. As the artery is crossed 
by the phrenic nerve, there may be irregular muscular action of the dia- 
phragm ; and if the brachial plexus is pressed upon, loss of power will follow, 
and a sense of numbness will be experienced in the arm and hand, often at- 
tended with oedema from the obstruction offered by the tumor to the free 
passage of the blood through the subclavian vein. The internal jugular also 
may experience pressure from the growth of the sac, which will account for 
the dilated condition of the external and anterior jugulars, as well as of their 
branches, frequently witnessed in the advanced stage of subclavian aneurism. 
Should the sac become greatly misshapen, or be occupied by coagula of blood 
or of fibrin to any great extent, the channel through the aneurism may be so 
changed that the strength of the arterial pulse will be diminished both at 
the wrist and in the carotid. 
Diagnosis.—Although the surgeon is generally able to recognize the 
true nature and position of this disease, in some instances the diagnosis 
is one of great difficulty. A number of times the subclavian artery has 
been ligated, under the supposition that an aneurism existed, when really 
no such affection was present; and in some cases the aneurism has been 
supposed to be subclavian, when it was afterwards proved to be carotid, 
innominate, or aortic. Tumors, enlarged glands, and exostoses springing 
from an adjacent rib are all liable to be confounded with the aneurism 
under consideration. When the examination is made early in the his- 
tory of the case, subclavian aneurism will be found to be situated more 
externally, towards the outer edge of the clavicular portion of the sterno- 
cleido-mastoid muscle, and higher in the neck, than a similar tumor of the 
innominate or of the arch of the aorta. The thrill in the first will gen- 
erally be propagated in the direction of the arm, while in aneurism of the 
last two vessels the sounds are either median or in the course of the carotid. 
Long before an aneurism of the arch of the aorta, or of the innominate, 
could reach the normal position of the subclavian artery, the characteristic 
pressure-effects, so unlike those which arise from enlargement of the last- 
named vessel, would be present to a distressing degree. Aneurism of the 
subclavian artery does not usually attain anything approaching in size that 
of aneurism of the vessels with which wre are contrasting the disease. Be- 
tween glandular tumors and subclavian aneurism there are two notable dis- 
tinctions. In the first the swelling is hard and irregular, and the disease is 
generally met with in young persons ; in aneurism the enlargement is regular, 
soft, or at least not indurated, and the disease is seldom seen at an earlier 
period than the thirtieth year. Glandular enlargements are as common on 
one side of the neck as on the other; subclavian aneurism is most frequently 
seen on the right side. In other tumors, such as cysts, adipose growths, 
and malignant disease, the active expansive or centrifugal pulsation, and the 
distinct thrill, which belong to aneurism, will be absent. Besides, excluding 
malignant disease, the pressure-effects of other tumors are comparatively 
unimportant. In abscess there is a previous history of local tenderness, 
swelling, induration, and central softening, symptoms which do not belong 
to the early history of aneurism. 
The Prognosis in subclavian aneurism is very unfavorable. The sac may 
open internally, causing a diffused extravasation of blood through the neck, 
or it may burst into the cavity of the chest, or into the lungs, or into some 
other portion of the air-passages, and destroy the patient. Sometimes the 
sac opens externally, from ulceration or from gangrene, and proves fatal by 
hemorrhage. In a few instances the disease undergoes a spontaneous cure. ANEURISM OF THE SUBCLAVIAN ARTERY. 
This result followed in 4 out of 22 cases of the disease reported by the late 
Mr. Poland.* 
Treatment.—The means employed for the treatment of subclavian aneu- 
rism are the following: 
1. The expectant and the medical.—This plan has not been tested on as large 
a scale as it merits. Among the cases tabulated by Mr. Poland, to which 
reference has been made, 35 were managed by this mode of treatment; 11 
recovered, 23 died, and 1 was relieved. Such a result is sufficiently en- 
couraging to entitle to favorable consideration the treatment by rest and diet 
and the other details of Mr. Tufnell’s method, to which should be added the 
administration of the tincture of veratrum viride and the iodide of potash. 
2. Compression.—In consequence of the anatomical relations of the artery 
it is necessary that the pressure, in most cases, should be made dii*ectly upon 
the sac. Four cases treated in this manner—two by Warren, of Boston, 
one by Carner, and one by Holmes—proved successful. The pressure was 
made in the first two instances by a weight. To execute this method 
properly, a piece of rubber or felt should be first moulded to the surface of 
the tumor, and its concavity partially filled with a compress of soft lint. 
After applying the cup over the aneurism, it can be bound on as firmly as 
may be necessary by the spica bandage of the shoulder. I have used a bag 
of shot for the same purpose. When the aneurism occupies the first portion 
of the vessel, distal compression of the artery can be made against the first 
rib, as it passes from the neck into the axilla. In a case in which it was tried 
at the Philadelphia Hospital, no benefit was realized. A conical graduated 
compress, and the fingers of assistants, constitute the best means of applying 
such pressure. If the aneurism is small, and confined to the third part of 
the artery, digital pressure might be practised over the tracheal third. Mr. 
Poland succeeded in effecting a cure of one case in this way. 
3. Ligature.—The ligature has been applied both on the cardiac and on the 
distal side of the disease. There are three operations which have been prac- 
tised on the cardiac side, namely, ligature of the innominate, ligature of the 
first part of the subclavian, or that portion on the tracheal side of the 
scaleni muscles, and ligature of the innominate and the primitive carotid, in 
one case—that of Smyth—including the vertebral artery. 
Ligature of the innominate has been performed thirteen times for subclavian 
and subclavio-carotid aneurism, and in every case but one, that of Smyth of 
New Orleans, with a fatal result. When it is considered that death has, with 
the one exception above noted, been greatly hastened by the operation, it may 
be regarded, when practised for aneurism, as an unjustifiable procedure. 
Ligature of the subclavian within the scaleni muscles.—This operation is feasible 
on the right side, when the dilatation affects the second and third portions 
of the artery; but its results have been as unsatisfactory as those of deliga- 
tion of the innominate. In 1846 this operation was done on the left side by 
Hr. J. Kearney Eodgers, of New York.f An interesting case of subclavian 
aneurism has been reported by Dr. Willard Parker,| in which that surgeon 
tied the carotid half an inch above its origin, the subclavian near to the in- 
nominate, and the vertebral one-quarter of an inch above its root. On the 
twelfth day the ligature came away from the vertebral ; on the fifteenth, 
from the carotid; and on the twenty-fourth day, from the subclavian. The 
patient died on the forty-second day, from secondary hemorrhage. Of twenty- 
seven cases in which this vessel has been tied, all save two terminated fatally 
from hemorrhage. When we consider the position in which a ligature on 
this part of the vessel must be applied, such a result is not surprising. Close 
on the inner side are the innominate and the carotid, and on the outer side 
the vertebral, internal mammary, and superior intercostal arteries, and the 
thyroid axis, a proximity of blood-vessels which must render the formation 
705 
* Guy’s Hospital Reports, 1870. f New York Journal of Medicine, 1846. 
J New York Medical Record for 1867, vol. ii. p. 97; American Journal of the Medical Sciences, 
1864, p. 562. 706 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
of a permanent clot extremely improbable. Should such an operation ever 
be contemplated, the probability of success would be slightly enhanced by 
tying at the same time the thyroid axis and the carotid artery. Under no 
circumstances is the operation worthy of repetition. 
Ligature external to the scalenus anticus.—When the aneurism is situated 
near the termination of the subclavian artery, or at the outer portion of its 
third part, in which case the axillary vessel is usually implicated, a ligature 
can be applied to the artery at the external border of the scalenus anticus 
muscle, or even under the latter by dividing some of its fibres. Poland* 
records 21 instances of this operation, 9 of which recovered and 12 died ; 
3 of the 9 recoveries were in cases of subclavian aneurism proper. In the 
remaining cases the axillary and subclavian had both been involved. Kochf 
reports 65 cases, with 36 recoveries. In most instances the deaths were 
caused by hemorrhage. Wyeth’s collection, 38 in number, gives 18 recoveries 
and 20 deaths. 
Distal ligature.—Theoretically, it would be supposed that distal ligature, in 
cases where the aneurismal tumor occupies the inner and middle portions of 
the vessels, rendering it impossible to place a ligature on its cardiac side, would 
promise a reasonable hope of success by lessening the rapidity of the flow of 
blood through the sac to the upper extremity and thus favoring its coagulation 
within the aneurism. Experience, however, has not confirmed such a hope. 
The operation has been done by Dupuytren, Schuh, Canton, and Petrequin. 
The ligature was applied by these surgeons to the first part of the axillary, 
and in all cases with a fatal result. On the same principle Butcher tied the 
carotid in one case, which ended fatally a few days after the operation. 
4. Galvano-puncture.—In one case, that of Abeille, the patient was cured 
by this agent, but in six others a fatal result followed. The danger attend- 
ing this method does not commend it to professional confidence. 
5. Manipulation, recommended by Sir William Fergusson, has been em- 
ployed 6 times, with 3 recoveries, 2 deaths, and 1 unsuccessful case, by 
Liddell. The objections to this method of treating aneurism have been 
already stated; and, as the tables of Poland and Koch contain in some in- 
stances the same cases, I have taken the collection.of the latter, as giving 
the largest number. They are just as forcible when the plan is applied to 
subclavian aneurism as when it is applied to the disease located elsewhere. 
6. Amputation.—Sir William Fergusson proposed amputation at the shoul- 
der-joint, and the suggestion was carried into effect by Spence, of Edinburgh, 
Holden, H. Smith, Heath, and Rose,—in the cases of Spence and Rose with 
success. Holden’s and Heath’s cases were traumatic in their origin, and in 
Rose’s case the carotid was also tied. Except in the solicitation of the blood 
by the presence of the upper extremity, I cannot see wherein consists the dif- 
ference between this plan and that of tying the axillaxy immediately below 
the clavicle. 
7. Acupressure.—In a case of subclavian aneurism, Mr. Porter, of Dublin, 
tried the effect of acupressure applied to the axillary artery. The patient 
died from hemorrhage six weeks after the operation. 
8. Injections.—These are used in two ways,—by being thrown into the sac, 
and into the cellular tissue exterior to the latter. Petrequin, after failing by 
the ligature to cure a case of subclavian aneurism, injected into the sac a 
solution of perchloride of iron. The fluid secured the coagulation of the 
contents of the aneurism and arrested all pulsation in the tumor, but the 
patient perished subsequently by hemorrhage from the place where the 
artery had been ligated. In two other cases the remedy was followed by a 
fatal result. Langenbeck has employed successfully in three cases hypo- 
dermic injections of ergotin thrown into the cellular tissue between the skin 
and the sac. Dutoit gives also a case treated in the same manner. 
In order that some safe conclusion may be reached in regard to the treat- 
* Guy’s Hospital Reports, 1870. 
f Archives Generates de Medecine, A out, 1869; also Langenbeck’s Archives, vol. x. ANEURISM OF THE VERTEBRAL ARTERY. 
707 
ment of subclavian aneurism, I compare first the different modes of ligation. 
They are as follows : 
1. Ligature of the innominate, 13 times, with 1 recovery; the latter died 
twelve years afterwards with aneurism. 
2. Ligature within the scaleni muscles, 20 times; all fatal. 
3. Ligature of the second and third parts of the subclavian, 65 times, with 
36 recoveries. 
4. Distal ligature, 5 cases; all fatal. 
The subject of ligation for subclavian aneurism is, therefore, narrowed 
down in proper cases to the operation on the third part of the artery. 
If now we review the remaining methods, it will be seen that by expectant 
and medical measures there were treated 35 cases, with 11 recoveries, 23 
deaths, and 1 much relieved; by compression, 4 cases, with 4 cures; by gal- 
vano-puncture, 6 cases, with 1 cure; by manipulation, 6 cases, with 2 re- 
coveries. 2 deaths, 1 unsuccessful, and 1 undetermined; by amputation, 5 
eases, with 2 recoveries; by acupressure, 1 case, with 1 death; by injection 
into the sac, 3 cases, with 2 deaths and 1 failure; by injections around the 
sac, 4 cases, with 4 cures. If these have been accurately reported, it is sin- 
gular that the method has not attracted greater attention. 
Contrasting the various plans at our command for the treatment of sub- 
clavian aneurism, it will, I think, be conceded that the expectant and medi- 
cal treatment should be first tried, with or without compression, according 
to the position of the tumor. These failing, possibly next in order would 
come pressure; and in the event of these proving useless, then the ligature 
of the subclavian artery external to the anterior scalenus muscle, when the 
situation of the aneurism will permit; or, if this be unfavorable, then ampu- 
tation of the arm at the shoulder-joint. 
Traumatic aneurism of the cervical portion of the vertebral artery has been 
noticed by three or four writers. The disease, however, is exceedingly rare, 
not more than twenty-five cases being recorded, and a number of these having 
been wounds rather than aneurisms. The diagnosis of such an aneurism 
would be a matter of great difficulty, in consequence of the deep situation 
of the artery, and hence we find that the common carotid was tied in two 
instances under the impression that the tumor was connected with this vessel 
or with one of its branches ; both cases proved fatal. The existence of a firm 
pulsating tumor on the side of the neck or below the mastoid portion of the 
temporal bone, having an aneurismal thrill, its pulsation and sound not 
affected by compression of the primitive carotid, but diminished by strong 
pressure made directly backwards behind the sternal extremity of the clavi- 
cle when the head is flexed, would furnish strong evidence of the disease 
being connected with the vertebral artery. In a spontaneous aneurism of 
this vessel digital compression could be of no value, as the great depth of 
the artery places it beyond the exercise of any effective force of this kind. 
Should the tumor be sufficiently high in the neck, the deligation of the ver- 
tebral artery would be indicated. Ligation above and below, though a dif- 
ficult operation, would offer the best prospect of effecting a cure. 
Aneurism of the Vertebral Artery. 
Aneurism of the Transverse Cervical Artery. 
A single case of aneurism of the transverse cervical artery is given by Mr. 
Pick in the “Transactions of the Pathological Society of London” for 1869. 
No operation was performed, as the patient, a soldier, was dying from con- 
sumption. 
Intracranial Aneurism of the Carotid, the Vertebral, and their Branches.— 
The internal carotid may become aneurismal at any point in its course from 708 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
the cerebral extremity of the carotid canal in the petrous portion of the 
temporal bone, to the optic foramen. That part which lies in the sella Tur- 
cica of the sphenoid bone, and where it gives off the anterior cerebral, is 
most frequently affected, and may give rise to intraorbital disease. As com- 
pared with other intracranial aneurisms, those of this portion of the vessel 
occur about once in every eight cases. In the collection of Sir William 
Gull,* embracing 62 cases, the carotid on the side of the cavernous sinus was 
affected eight times; and in an interesting paper on the subject of intracranial 
aneurism, by Dr. James II. Hutchinson,f of Philadelphia, the same portion 
of the artery was found to be involved ten times in 85 cases. Aneurism 
within the skull, whether affecting the carotid or its branches, like the dis- 
ease elsewhere, is more common in males than in females, and increases in 
frequency up to the sixtieth year of life. In the analysis of Dr. Hutchinson, 
to which reference has just been made, 48 of the patients were males and 
32 females, and in 5 the sex is not given; 9 were under twenty years of age, 
12 between twenty and thirty, 13 between thirty and forty, 14 between forty 
and fifty, 19 between fifty and sixty, 8 between sixty and seventy, 9 between 
seventy and eighty, and 1 between eighty and ninety. 
The intracranial vessels most commonly affected are the internal carotid, 
the middle and anterior cerebrals, and the vertebral. Of 27 cases of intra- 
cranial aneurism, 10 were found connected with the basilar and 5 with the 
carotid artery.| 
The relative frequency with which the different arteries of the brain are 
the subjects of aneurism will appear from the subjoined tables of Sir William 
Gull and Dr. Hutchinson: 
Sir William Gull. 
Dr. James H. Hutchinson. 
Vertebral artery 
and 
its branches. 
62 Cases of Intracranial Aneurism. 
Vertebral, 4 times. 
Basilar, 20 “ 
Posterior cerebral, 3 “ 
Capillary vessel, 1 *'f 
Vertebral artery 
and 
its branches. 
85 Cases of Intracranial Aneurism. 
Vertebral, 4 times. 
Basilar, 25. “ 
Posterior cerebral, 2 “ 
Internal carotid, 10 “ 
Middle cerebral, 26 “ 
Anterior cerebral, 9 “ 
Anterior communi- 
cating, 6 “ 
Posterior communi- 
cating, 2 “ 
Middle meningeal, 1 “ 
Superior cerebral, 1 “ 
Internal carotid, at 
the sella Turcica, 8 “ 
Middle cerebral, 15 “ 
Anterior cerebral, 6 “ 
Anterior communi- 
cating, 1 “ 
Posterior communi- 
cating, 4 “ 
Internal carotid 
and 
its branches. 
Carotid artery 
and 
its branches. 
The sacs of these tumors are generally cylindrical, and consist of all the 
coats of the vessel. These dilatations vary greatly in size, ranging from the 
dimensions of a grain of shot to those of a walnut. Bouchard and Charcot 
have drawn attention to what are termed miliary aneurisms, most common 
in advanced life, and which consist of minute saccular dilatations of the small 
cerebral vessels, the result, as these writers believe, of periarteritis. When I 
consider the thinness of the walls of the intracranial arteries, vessels so much 
under the influence of the heart’s action and receiving so little support from 
the substance of the brain, it is to me a matter of surprise that aneurismal 
dilatation of the arteries within the cranium is not more common than ob- 
servation would seem to indicate. As compared in frequency with other 
aneurisms, Mr. Crisp found, in 551 cases of the disease, that 7 were intra- 
cranial. 
Effects.—The presence of an aneurismal tumor within the cranium may 
induce inflammatory softening of the brain-substance, with all its attendant 
phenomena, or the tumor may burst and form an extravasation or clot, wThieh 
will occasion paralysis or complete apoplexy. When the tumor lies near one 
of the bones of the cranium, the latter may become absorbed to a consider- 
able extent. 
* Guy’s Hospital Reports, vol. i., 1859. 
f Cooper’s Surgical Dictionary, vol. i. p. 226. 
f Pennsylvania Hospital Reports, vol. ii., 1869. INTRAORBITAL ANEURISM. 
709 
Symptoms.—There are no signs indicative of intracranial aneurism which 
are not common to other and diverse diseases of the brain. There may be 
pain, hemiplegia, more or less complete loss of articulation, difficult degluti- 
tion, defects of vision, facial paralysis, obtuseness of hearing, and mental 
imbecility. Considering the subject from a physiological point of view, and 
bearing in mind the fact that most of the cases of intracranial aneurism are 
found in those vessels which are situated on the pons Varolii, the presence 
of difficulty in deglutition, in hearing, and in articulation, together with 
defects in the motor-sensory apparatus, though not decisive of intracranial 
aneurism, furnishes a sort of presumptive evidence of the existence of such 
a disease, especially if, associated with these symptoms, a thrill is detectable 
through the walls of the cranium by stethoscopic examination. 
Treatment.—It would be proper to contemplate surgical interference 
only in a case of suspected intracranial aneurism. When the peculiar whirr 
belonging to this character of disease is distinctly marked, and when the 
cephalic symptoms are steadily progressing, the ligation of the common 
carotid on the affected side would be entirely proper. This was done in one 
case with entire success by Mr. Coe, of Bristol. 
Intraorbital Aneurism. 
The subject of intraorbital aneurism is one which has caused no small 
amount of discussion. The disease is not a common one, and its true nature 
may be said to be still enveloped in much obscurity. The attention of the 
profession was first drawn to the subject by Travers, and for some time 
these pulsating tumors within the orbit were regarded as aneurisms by 
anastomosis, or, as they are at present more properly termed, angeiomatous 
growths. The investigations of Busk* and of Nunneley, however, would 
seem to render it probable that in most of the cases which have been ob- 
served the disease was truly aneurismal, either spontaneous or traumatic, 
and that the vessel involved was in some instances the ophthalmic, and 
in others the cavernous portion of the intracranial carotid. It is further 
believed that in all cases of a nsevoid or angeiomatous character the disease 
appears before or shortly after birth, and is frequently associated with a 
similar condition of some portion of the tutamina oculi; indeed, that it in- 
volves all the arteries and veins in and around the orbital region. One 
of the strongest arguments against the nsevoid character of the tumor, as 
it generally appears, is that used by Nunneley, which the experience of 
those who have had opportunities of treating the disease will corroborate,— 
namely, that intraorbital aneurism is usually curable by the ligation of the 
common carotid, whereas in ordinary erectile growths ligation of the chief 
vessel leading to such tumors is often unsuccessful. The tables of Norris 
contain 42 ligations of the carotid done for erectile growths about the face 
and head: of this number, 20 were cured, 13 died, and 9 recovered from the 
operation, though not cured. Among these 42 cases, 11 were operations 
for what is termed erectile tumors within the orbit,—doubtless intraorbital 
aneurism,—10 of which were cured and 1 died. This result is strikingly con- 
firmatory of the statement made by Nunneley. A few opportunities have 
been offered for the examination of this form of intraorbital disease by dis- 
section. In those in which such examinations have been made, the morbid 
conditions have not always been uniform. In Nunneley’s case the autopsy 
was made four years after the carotid had been tied, and established the 
aneurismal nature of the tumor, as an obliterated sac of the ophthalmic 
artery was found at the sella Turcica: the vessel also contained patches of 
atheroma. In Delen’s casesf the disease seems to have been either arterio- 
venous, a communication having existed between the internal carotid and 
* Medico-Chirurgical Transactions, vol. xxii. p. 133. 
f De la Communication de la Carotide interne et du Sinus caverneux, 1870; American Journal 
of the Medical Sciences, July, 1864. 710 
DISEASES AND INJURIES OF THE BLOOD- VESSELS. 
the cavernous sinus, or to have been caused by a coagulum in the last-named 
venous canal. This was very much the condition in a case of Bowman’s, 
in which the carotid was tied for what was believed to be an intraorbital 
aneurism. The patient died, and on an examination of the parts a coagulum 
was found blocking up the ophthalmic vein at the point where it enters the 
cavernous sinus. No disease whatever existed in the arteries, either in or 
posterior to the orbit. In a fatal case of large pulsating tumor of the orbit, 
in which the carotid was ligated by Dr. Thomas (4. Morton, a net-work of 
anastomosing vessels was found at the autopsy occupying the inner and 
front portion of the orbit. No other evidence of arterial or venous disease 
existed. In a second case operated on by the same surgeon, which proved 
fatal twenty-four hours after the carotid was tied, all the nerves and blood- 
vessels which entered the sphenoidal fissure were matted together by in- 
flammatory lymph, and the ophthalmic vein and the cavernous and circular 
sinuses were found filled with coagulated blood. The carotid artery was 
sound. Taking the cases of pulsating intraorbital tumors of Nunneley,* 
Morton,f and Kivington,| in which the pathological conditions have been 
verified by post-mortem examination, making in all fourteen, eight of the 
number were found to have been produced by varicose enlargement of the 
ophthalmic vein, from causes 
which were post-orbital and 
chiefly in the cavernous sinus. 
The presumption, therefore, 
is that there are four forms of 
pulsating intraorbital tumors: 
1, aneurism, spontaneous and 
traumatic, of the ophthalmic 
and of the carotid, beginning 
either in the orbit or in the sella 
Turcica; 2, arterio-venous aneu- 
rism, in which an opening ex- 
ists between the internal carotid 
and the cavernous sinus; 3, 
angeiomatous or erectile forma- 
tions, in which all the arteries 
and veins within the orbit, and 
occasionally in the soft parts 
about the orbit, participate; and, 
4, obstructive tumors, which are 
produced by embolism or by 
pressure at the cavernous sinus 
arresting the flow of blood 
through the intraorbital veins. 
Another cause of intraorbital 
pulsating tumors has been sug- 
gested by Collard, viz., paralysis of the vaso-motor nerves of the ophthal- 
mic artery, allowing this vessel and its branches to become inordinately 
dilated. 
Symptoms.—When the disease is aneurismal its appearance is generally 
sudden, the patient being conscious at the time of a sharp crack, as if some- 
thing had given way behind the orbit, accompanied sometimes by an acute 
pain in the same region. The vessels of the palpebral conjunctiva soon 
become involved, sometimes to a degree amounting to chemosis; loud sounds, 
tumultuous and other harassing sensations, are experienced in the head, 
described by the patient as roaring, whizzing, blowing, or forging; the eye- 
ball becomes prominent (Figs. 535 and 536), a distinct pulsation can be felt in 
Fig. 535. 
Intraorbital aneurism—the prominence of the eyeball quite 
marked.—Morton. 
* Medico-Chirurgical Transactions, vol. xlii. 
t American Journal of the Medical Sciences, April, 1865. 
J British Medical Journal, 1875, vol. i. INTRAORBITAL ANEURISM. 
711 
the orbit, and on auscultation an aneurismal bruit can be heard over the side 
of the head and over the orbit. When the circulation through the common 
carotid is arrested by pressure, all 
pulsation and sounds disappear. 
Frequently there is a convergent 
strabismus, or there may be pa- 
ralysis of the third, fourth, and 
sixth pairs of nerves, with de- 
fective vision, and finally entire 
loss of sight, in consequence of 
extensive structural changes, the 
result of inflammatory conges- 
tion affecting the humors and 
tunics of the organ. 
Causes. — The causes which 
are concerned in producing dis- 
ease of the blood-vessels of the 
orbit sometimes have a congen- 
ital origin; frequently they are 
traumatic. In the cases collated 
by Dr. Morton several were traced 
to a severe injury which had 
been received upon the head. In 
Dr. Harlan’s case* the man had 
been struck insensible by a pass- 
ing car, and remained in a par- 
tially unconscious state for al- 
most three weeks. Of 62 cases 
of intraorbital aneurism collected 
by Walter Rivington,f 33 were traumatic and 29 idiopathic. The disease, 
when arising from other than traumatic causes, appears to manifest a prefer- 
ence for the left side, and is more common in females than in males. 
Diagnosis.—The signs chiefly distinctive of aneurism and of aneurism by 
anastomosis, on which some stress has been placed by Dr. Morton, are the 
following. In aneurism, especially of the diffused kind,—that is, an aneu- 
rism in which the sac has given way and allowed the blood to escape into 
the surrounding tissues, or where a dilated vessel has been suddenly rup- 
tured,—the invasion of the disease is instantaneous. The patient is conscious 
of some unusual sound, like the sharp crack of a pistol, which is soon fol- 
lowed by aneurismal sounds in the head, the whirr being synchronous with 
the diastole of the heart, and accompanied with protrusion and pulsation 
of the eyeball. In aneurism by anastomosis the disease is more gradual in 
development, is generally congenital, and although there may be protrusion 
of the eyeball with pulsation and bruit, the latter is continuous,—that is, 
coincident with both the systole and the diastole of the heart. There is also 
less pain and noise experienced in the head. 
The result of post-mortem examinations clearly shows, however, that we 
are not yet in a position to diagnose with certainty these pulsating growths. 
Pulsation, bruit, thrill, either intermittent or continuous, and the arrest of 
these at pleasure by controlling the circulation through the vessel of blood- 
supply, signs which characterize aneurism in other localities, have been 
shown not to be inconsistent with the existence of aneurism by anastomosis, 
and indeed may be present without aneurism at all. Nor are the symptoms 
of exophthalmos less equivocal, whether of sudden or of slow appearance. 
In some of the cases which were subjected to examination after death, in 
which there had been a sudden appearance of pulsation and thrill and exoph- 
thalmos quickly succeeding an injury received upon the head, and where 
Fig. 536. 
Intraorbital aneurism by anastomosis, involving the side of 
the head and face, in a man twenty-five years of age. Appeared 
soon after birth.—Morton. 
* American Journal of the Medical Sciences, July, 1870. 
f British Medical Journal, 1875, vol. i. 712 
DISEASES AND INJURIES OF TIIE BLOOD-VESSELS. 
traumatic aneurism would a priori seem most probable, the morbid condition 
was found to be quite different. All these symptoms may arise from venous 
or from arterial obstruction, such as embolism of the cavernous sinus, or 
from pressure on the ophthalmic artery or on the sphenoidal portion of the 
internal carotid. The influence of inflammation in determining the coagula- 
tion of the blood within the vessels should never be lost sight of in cases of 
intraorbital enlargements following traumatic injuries. The sinuses in the 
sella Turcica of the sphenoid bone are most favorably situated to feel the 
effects of concentrated force applied to the temple or the orbit, and a phle- 
bitis of these channels would be as likely to cause an obstruction and coag- 
ulum as one in the canals of other veins. This certainly took place in one 
of Dr. Morton’s cases. 
Treatment.—As long as the disease exhibits no tendency to increase, it 
is wise to maintain a masterly inactivity, especially as some obscurity must 
generally attend our diagnosis. The disease may remain for a long time 
stationary, or may even undergo a spontaneous cure. Our remedies should 
therefore at first be confined to rest and to digital compression of the primi- 
tive carotid. The latter, first employed by Professor Gioppi, may be kept up 
for two or three hours a day for three or four weeks. In Dr. Harlan’s case it 
was faithfully though unsuccessfully continued from four to six hours a day 
for a period of five weeks. This method has been used in 16 cases. Three 
cures have been reported,—one by Professor Gioppi, of Padua, in 1856; 
one by Scaramuzza,* of Verona, in 1858; and one by Dr. Clarkson Free- 
man, of Canada. The compression was less successful in traumatic than in 
idiopathic cases. Should compression fail and the progress of the disease be 
such as to demand operative interference, resort may be had either to in- 
jection or to the ligature of the common carotid. Dr. Noyes, of New York, 
has reported six cases of cure by the first method.f The agents used were 
in two cases tannin, in one the lactate of iron, and in three the perchloride 
of iron. The case treated by the lactate of iron was under the care of Dr. 
Brainard, of Chicago, and is the more remarkable from the fact that the 
carotid had been previously ligated without success. In instances of erectile 
tumors, if the diagnosis could be certainly established, the use of Monsel’s 
solution of iron would promise a successful result; but if the growth should 
prove to be aneurismal, the same evil might result from the introduction of 
a coagulating fluid as sometimes follows the sudden formation of clots in 
aneurisms elsewhere. The subcutaneous injection of ergot in one case by 
Socin was believed to have aggravated the disease. 
Ligation.—Intraorbital vascular growths may be attacked by the ligature 
in two ways: first, by tying the common carotid; secondly, by strangula- 
tion within the orbit. 
IAgation of the common carotid.—The results of this operation have been 
remarkably successful. PTp to 1861, 20 cases of intraorbital aneurism were 
by Mr. Ernest Hart, 14 of which were cured by ligation of the 
primitive carotid, 2 were partially cured, 1 was unsuccessful, and 3 died. 
Dr. Morton,§ in 1865, collated 34 cases of the disease. In 30 the carotid was 
tied, with the following result: 22 of the patients were cured, 3 were relieved, 
in 2 the operation proved unsuccessful, and 3 died. In 1875, Rivington gave 
a resume of 62 cases of intraorbital aneurism. In 46 of these the primitive 
carotid was ligated, the right vessel twenty times and the left twenty-six 
times; 18 of 44 cases were idiopathic, and 26 were traumatic. Of the idio- 
pathic cases 12 were affected on the right side and 6 on the left, and of this 
number 15 recovered and 3 died; of the 26 traumatic cases, 23 recovered and 
3 died; making a total of 44 cases, with only 6 deaths. Among the 38 re- 
turned as recoveries, 26 were perfect cures, 7 were partial cures, and 5 were 
failures. In a number of the successful cases the vision of the patient was 
recovered. 
* Lancet, 1862, vol. i. p. 274. 
J Lancet, 1862, vol. i. p. 273. 
f New York Medical Journal, March, 1869. 
g American Journal of the Medical Sciences, April, 1865. ANEURISM OF THE AXILLARY ARTERY. 
713 
Strangulation .—In order to produce the strangulation of a mass of diseased 
vessels within the orbit, it will be necessary to divide the external commissure 
of the palpebral muscle along with the reflexion of the conjunctiva from the 
globe of the eye to the lids, and, after retracting the parts widely, to slip a noose 
of strong hemp cord over the ball, and, pushing it down between the walls of 
the orbit and its contents by means of the fingers or by forked probes, to draw 
the ligature sufficiently tight to strangulate effectually the included struc- 
tures. This plan would be proper only in cases where the eye was hopelessly 
disorganized. Strangulation might be performed for a circumscribed erectile 
or other growth within the orbit by exposing the latter cavity, temporarily 
displacing the eyeball, and encircling with a ligatui’e. Mr. Lansdowne,* on 
the 18th of February, 1874, opened the orbit in a case of varicose aneurism 
of that cavity, and successfully applied a catgut carbolized ligature on both 
sides of the tumor. The patient was perfectly cured. In one of Dr. Morton’s 
cases the orbit was boldly opened, the erectile growth enucleated, and the 
hemorrhage arrested by the actual cautery and by pressure. 
Galvano-puncture has been applied in two instances without success ; in one 
treated by Petrequin the patient died. The result was thought by Holmes to 
be due to this treatment. 
Medical treatment.—Dr. Holmes, of Chicago,f in a case of intraorbital tumor 
following an injury, secured success by the use of veratrum viride and 
Squibb’s fluid extract of ergot four times a day for nine weeks. GalezowskiJ 
succeeded, by the internal use of the iodide of potash and intermittent press- 
ure, in so far removing the protrusion of the eye and the abnormal sounds 
that at the time of his report little doubt remained that the cure would be 
made complete. 
Arterio-Venous Aneurism of the Carotid Artery and the Internal Jugular Vein. 
An inflammatory adhesion of the walls of the carotid artery and the jugu- 
lar vein, and the subsequent communication of their channels by ulceration, 
have, in some instances, followed gunshot and punctured wounds of the neck. 
A soft, bluish, compressible swelling, with a strong, blowing, continuous sound 
and purring tremor, the sound strongest during the cardiac systole, indicates 
the nature of the disease. 
A peculiar ectasis of the external jugular vein is occasionally seen, which is 
always the result of injury. It commences in the vessel just before or after 
it has crossed the sterno-cleido-mastoid muscle, forming a circumscribed sac- 
cular dilatation of the vein, attaining the size of a hickory-nut or a walnut, 
without pulsation or thrill. I saw a well-marked example of the affection 
in a patient who once came to my clinic at the University of Pennsylvania; 
and my friend Dr. Mastin, of Mobile, was kind enough to send me the photo- 
graph of a similar case which occurred in his practice, the disease coming on 
several months after a gunshot wound of the neck. 
Treatment.—Arterio-venous varix of the neck requires no operation. It 
demands little attention other than the application of pressure by a com- 
press and adhesive straps. The disease manifests little disposition to increase, 
and may undergo a spontaneous cure. In the venous ectasis, or varix, the 
swelling gradually disappears under pressure. 
The position of the axillary artery is one which, independent of observa- 
tion to the contrary, would appear to be most favorable to the formation of 
aneurism. In its course through the axillary space it is loosely embedded in 
glandular and cellulo-adipose tissues, and is subjected by the varied and forci- 
ble movements of the upper extremity to all conceivable flexures, and conse- 
quently to great strain. Indeed, its location and the various disturbances to 
Aneurism of the Axillary Artery. 
* British Medical Journal, June 5 and 26, 1875. 
f American Journal of the Medical Sciences, p. 44, July, 1864. 
J Gazette des Hopitaux, 1871. 714 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
which it is exposed, notwithstanding the great mobility of the shoulder, ren- 
der this vessel weaker in its defences against injury than the popliteal. Yet, 
on comparing aneurism of the axillary with the same disease in other vessels, 
it is found to occur only about once in every thirty-one cases. For example, 
in Crisp’s collection of 551 aneurisms of various vessels, 18 were axillary. 
The disease is most common on the right side, arising doubtless from the 
more general use of the right arm. and occurs in males oftener than in 
females. The disparity in this respect between the sexes appears to be 
more marked in the disease under consideration than in other external 
aneurisms. In 18 cases of aneurism of this vessel recorded by Mr. Crisp,* 
there were 17 males and 1 female; in 37 cases noticed by Mr. Erichsen,f 
only 3 were females. Both axillary arteries are sometimes simultaneously 
affected. 
Symptoms.—In spontaneous aneurism the symptoms are gradually devel- 
oped. There is first a small tumor, which may not exceed a marble in size, 
and which as it enlarges may be discovered, according to the portion of the 
vessel involved, immediately below the clavicle, in a little space formed by 
the divergence of the deltoid and the clavicular portion of the pectoralis 
major muscles and occupied by cellular tissue and the thoracic acromial 
blood-vessels; or the tumor may project lower down, raising the pectoral 
muscles into a prominence; or, if lower than where the artery is crossed by 
the pectoralis minor muscle, it may develop towards tbe cutaneous surface 
of the axilla. The pulsations and thrill increase in intensity as the growth 
enlarges. In consequence of the relation of the artery to the axillary plexus 
of nerves and to the veins of this region, pressure-effects soon become manifest. 
The limb and shoulder are rendered stiff, and their movements restrained ; the 
muscles become greatly enfeebled ; severe pain is experienced down the arm, 
along the side of the chest, and upward and outward on the shoulder and 
in the neck ; the arm becomes swollen from pressure on the axillary vein and 
its branches, and the pulse fails at the wrist. As the tumor acquires bulk it 
displace the clavicle, pushing it upward and forward, or, by coming in 
contact with the side of the thorax, it may cause the destruction of a portion 
of the upper ribs, and, in rare instances, may enter even the cavity of the 
chest. 
Diagnosis.—The diseases which resemble in some degree axillary aneurism 
are encephaloid cancer, glandular enlargement, abscess, and cysts. In none of 
these is there pulsation or thrill; in none is the size of the tumor influ- 
enced by pressure upon the subclavian artery; and in none is the pain or 
the disability of the arm comparable to that experienced in aneurism of the 
axillary artery. In malignant growths commencing in the upper extremity 
of the humerus, the resemblance to aneurism is often very striking. In a 
patient who applied for admission to the University Hospital, the tumor was 
soft, and the pulsation and bruit were very distinct, disappearing wTien the 
subclavian artery was firmly pressed upon, and promptly returning when the 
pressure was removed. The following peculiarities, however, served to make 
the diagnosis clear: the tumor, though soft, was elastic; it had received its 
form from the deltoid, projecting both in front of and behind that muscle, 
in which situations it wras observed at the commencement. An axillary 
aneurism could not occupy such a locality. In addition to this, the amount 
of pain and disability in the arm was much less than is usual in aneurism. 
Progress.—Axillary aneurism, when allowed to take its course without 
interference, usually terminates, after great suffering, in death from hemor- 
rhage by rupture of the sac, from gangrene of the limb, or from constitu- 
tional irritation. In a very few cases the disease has undergone spontaneous 
cure. 
Treatment.—In the treatment of axillary aneurism, rest, diet, flexion, and 
pressure, when the latter can be applied, should take precedence of all other 
measures. A conical compress placed in the subclavian fossa, and kept in 
* Diseases of the Blood-Vessels, p. 213. 
f Surgery, vol. ii. p. 122. ANEURISM OF THE AXILLARY ARTERY. 
715 
position by the fingers of a corps of assistants for two or three hours each 
day, should be tried for some time, assisted by flexion of the arm, the latter 
being raised and carried across the back of the neck to the opposite side. 
By the hypodermic use of morphine, or by an anaesthetic, the pressure and 
the constrained position can be made endurable. Dr. Middleton Goldsmith 
succeeded in effecting the cure of an axillary aneurism* by distal pressure 
kept up for seven weeks, during the last four weeks of the treatment anti- 
mony and digitalis being given; but I believe this to be the only case of 
aneurism cured by hygienic, medical, or compressory measures. A combi- 
nation of these with flexion would be well worthy of a trial. 
Ligature.—The usual method of attacking axillary aneurism is by deliga- 
tion between the sac and the heart, after both the Hunterian and the Ancl 
method. By the first plan the ligature is placed around the third part of 
the subclavian. By the second plan the artery is tied immediately below the 
clavicle, above the pectoralis minor muscle. The first is to be preferred, for 
several reasons: by its adoption the surgeon will be more likely to expose 
a sound portion of the vessel, will interfere less with the collateral circula- 
tion, and will encounter less difficulty in effecting his object. The mortality 
following the ligation of the subclavian will appear from the following record 
of cases made by different writers. Of 27 cases of axillary aneurism analyzed 
by Professor Grossf in which the subclavian artery was tied, 17 recovered 
and 10 died. Mr. Erichsen,J in 48 cases of spontaneous aneurism of the 
axillary for which the subclavian was tied, found 23 recoveries and 25 deaths. 
Professor Parker furnishes 57 ligations of the subclavian for idiopathic aneu- 
rism of the axillary, and 24 for traumatic. Of the former, 21 died and 36 
recovered; of the latter, 8 died and 16 recovered. In Koch’s § collection of 
axillary aneurisms, embracing 94 cases, in which the third part of the sub- 
clavian was ligated, 51 recovered and 43 died. I find in a collection of 148 
cases of aneurism|| that 21 were axillary. In 16 of the 21 the subclavian was 
tied in its third part, with 11 cures and 5 deaths. We have here recorded 
a total of 271 ligations, with 112 deaths and 154 recoveries. The tables 
of Dr. Norris contain 58 cases of ligation of the subclavian for aneurism, 
probably not all axillary. Of these 32 recovered and 26 died. Dr. Willard 
reports 4 unpublished cases of ligature of the subclavian artery for 
axillary aneurism, 1 of which was traumatic; 3 recovered and 1 died. Mr. 
Hanks treated successfully a case of axillary aneurism by ligation of the 
subclavian.** Dr. Wyeth’s collection contains 75 cases of axillary aneurism 
treated by ligation of the subclavian artery external to the scaleni muscles, 
with 28 deaths. This mortality accords with the results obtained by Bar- 
well after analyzing the statistics of other writers. These statistics are ample 
enough to show that the operation is one attended with a very high death- 
rate ; but when it is considered that the termination of the disease without 
interference is uniformly fatal, the duty of the patient is to elect the opera- 
tion, and that of the surgeon is to execute it with as little delay as possible, 
after having tried unsuccessfully the medical and mechanical plan already 
described. 
Causes of death after ligation are generally intra-thoracic inflammation, 
suppuration of the sac, hemorrhage, and mortification. 
Intra-thoracic inflammation.—Eriehsen found this to occur ten times in 25 
ligations. This is in remarkable contrast with the result given by Norris in 
his table on ligations of the subclavian, from which it appears that only 
five times in 69 operations did this prove to be the cause of death. How 
many of these ligations were done for axillary aneurism I am not able to 
determine. The inflammation may attack the lungs, the pleura, and the 
pericardium. There are several explanations for such sequels. It is highly 
* Boston Medical and Surgical Journal, 1845, vol. xxxiii. p. 537. 
t Surgery, vol. i. p. 776. J Surgery, vol. ii. p. 125. 
\ Lancet, 1873, vol. ii. p. 443. || Hunter and Griffith’s manuscript collection. 
New York Medical Record, 1867-68, vol. ii. p. 97. 
** British Medical Journal, 1888, vol. i. p. 1222. 716 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
probable that in passing the needle around the artery the pleura may be 
wounded and the dome of the chest opened. The close relation of the sub- 
clavian to the serous membrane of the pulmonary cavity, and the structural 
alterations which are so often met with in cases of aneurism, make such an 
accident probable even in the hands of the most dexterous surgeon. Exten- 
sive disturbance of the structures at the root of the neck, incident to the 
operation, may cause inflammation and diffuse suppuration, which are liable, 
by continuity of tissue, to extend into the pleural or the mediastinal spaces; 
and the same effects may follow as the result of an inflamed and suppurating 
sac; or a pleuro-pneumonia may be induced by adhesion of the sac to the 
walls of the chest, and its subsequent ulceration, emptying the contents of 
the aneurism into the pleural cavity, as occurred in an interesting case re- 
corded by Professor Gross ;* or a communication may take place between a 
suppurating sac and the lung through an intercostal space, and the pus find 
its way into the bronchial air-passages and be expectorated by coughing. 
The case of Bullen,f of England, is one in point, and, notwithstanding the 
occurrence, the patient made a complete recovery. Similar connections be- 
tween subclavian aneurisms and the lung have been noticed by NeretJ and 
by Guthrie. 
Suppuration of the sac is of frequent occurrence, sometimes following the 
operation after the lapse of five or six days, and at other times being delayed 
for a much longer period. In Morton’s case it took place on the thirteenth 
day ;§ and as an example of the latest occurrence of the accident may be cited 
the patient of B. Cooper,|| in whom the suppuration followed two months after 
the ligation. Inflammation and suppuration of the sac, though an exceed- 
ingly dangerous event, is frequently succeeded by recovery. Even when fol- 
lowed by hemorrhage, a very uncommon result, the case is not utterly hope- 
less. In a case of axillary aneurism in the Pennsylvania Hospital, in which 
the subclavian was tied by Dr. Morton, suppuration of the sac set in, fol- 
lowed by hemorrhage, twenty-four days after the detachment of the ligature. 
During the thirteen days succeeding the first bleeding the patient had ten 
hemorrhages. These were controlled by pressure, by Monsel’s solution of 
iron, and, last, by ligation of the subscapular artery. The limb finally became 
gangrenous, and was removed at the shoulder-joint. The man made a slow 
but complete recovery. 
Hemorrhage, whether from the seat of ligation or from the sac—most fre- 
quently from the latter—constitutes the most common cause of death. In 
Erichsen’s list it makes about one-eighth, 3 dying out of 25. In Norris’s col- 
lection 8 out of the 26 deaths are due to hemorrhage; and in 12 cases which 
I have recently examined, 4 died from this cause. The accident may take 
place at any time between the fourth and the thirtieth day. 
Mortification of the limb and of the sac.—This may be due to the obliteration, 
from pressure or from embolism, of one of the chief branches of the axil- 
lary concerned in establishing the anastomotic chain, for example, the sub- 
scapular, which communicates freely by its dorsal and posterior scapular 
branches with the supra-scapular and transversalis colli arteries. Or it may 
arise from the exhaustion consequent upon repeated hemorrhages, as was 
the case in Morton’s patient. The mortification may be partial or extensive, 
and is not a common sequence of the ligation. It is as likely to follow liga- 
tion for traumatic injuries of the axillary as it is to result from the same 
operation for spontaneous aneurism. In Professor Gibson’s of mor- 
tification of the hand and forearm, the subclavian was tied for a rupture 
of the axillary artery occasioned by forcible attempts to redxice an old luxa- 
tion. In Hospel’s case,** the death of the arm succeeded the ligation of the 
subclavian, in consequence of a wounded axillary artery. The only four cases 
* Surgery, vol. i. p. 776. f London Medical Repository. 
J Norris’s Contributions to Practical Surgery, p. 230. 
$ American Journal of the Medical Sciences, July, 1867, p. 70. 
|j Ibid., vol. ii., 1828. 
Gibson’s Surgery. ** Gazette des Hopitaux, 1839. ANEURISM OF THE BRACHIAL ARTERY. 
717 
where mortification followed deligation for true axillary aneurism are those 
of Colies,* Blizard,f Brodie,| and Morton. Mortification of the sac is quite 
uncommon; in only two of the 56 eases recorded by Norris did this take 
place. 
Treatment.—There are, perhaps, no complications which cause so much 
anxiety to the surgeon as the various accidents to which an aneurismal sac 
is exposed. Should suppuration ensue, it is best, as soon as fluctuation and 
pointing are well established, to open the abscess and discharge its contents. 
If this should be followed by moderate hemorrhage, a careful examination 
must be made to detect the particular branch from which the bleeding pro- 
ceeds, and, if successful, secure it at once by a thread. If the hemorrhage 
comes in a gush, the first thought must be to prevent the patient from being 
immediately destroyed by the flow. The sac should be at once plugged by 
strips of sublimated gauze, of lint, or whatever may be at hand: as long as 
this measure is sufficient to arrest the bleeding the surgeon may be content. 
The next critical period will attend the removal of the tampon, which, as it 
becomes foul with the discharges, must be gently dislodged in the course of 
five or six days. If at this time the hemorrhage is renewed, the limb should 
be promptly removed at the shoulder-joint. 
The sac is sometimes the subject of suppurative inflammation antecedent 
to any surgical treatment having been adopted for the cure of the aneurism. 
Under such circumstances the tumor becomes swollen, tense, tender, and in- 
flamed, with swelling and severe pain in the arm. The case admits of no 
delay. The subclavian should be exposed and tied in the third part of its 
course. 
Syme on one occasion slit open an axillary aneurism while the subclavian 
was compressed against the first rib, turned out its contents, and tied the 
vessel on the proximal and distal sides of the sac. To execute such a task 
demands a degree of cool deliberation and surgical address which is not pos- 
sessed by every operator. 
Rupture of the sac.—When the walls of the sac become much attenuated 
they are liable to give way and to allow the contents to escape into the adja- 
cent parts, forming a diffused aneurism. Ligature of the subclavian in such 
an event should be performed at once. 
Aneurism of the Brachial Artery and of its Branches. 
In only a single instance have I witnessed a spontaneous aneurism of the 
brachial artery. The patient, an inmate of the Philadelphia Hospital (Block- 
ley), was about sixty years of age : the tumor was situated two inches above 
the bend of the arm, and had attained the size of a pullet’s egg. No cause 
could be assigned for its existence, and the inference that it was an example 
of true or spontaneous aneurism seemed to be legitimate. The artery was 
tied two inches above the tumor, with entire success. The tables of Crisp 
contain no case of such an aneurism. In Liston’s case, mentioned by Crisp, 
in which a pulsating swelling appeared at the bend of the arm after a severe 
muscular effort, the cause was most probably traumatic. A few scattered 
cases may be found in the writings of Pelletan, Scarpa, Flajani, Pilcher, and 
Desault. In the forearm, aneurisms of the radial and ulnar arteries have 
been observed by Sir Astley Cooper, De Morgan, Todd, and Eriehsen. Crisp 
mentions one connected with the inferior part of the radial artery among 
the collection of Langstaff, in the College Museum ; and I have met with one 
situated at the lower portion of the ulnar in a young woman, and with a 
second in the lower extremity of the radial. Holt’s collection amounts to 17. 
Traumatic aneurisms are quite common, especially in the arteries of the 
forearm : they have, in connection with arterio-venous aneurism, been already 
considered. 
* Edinburgh Medical and Surgical Journal, vol. xi. 
J London Medical and Physical Journal, vol. ii., New Series, 1827. 
■(■ Hodgson on the Arteries. 718 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
Treatment.—The treatment of a case of spontaneous aneurism affecting 
the brachial, radial, or ulnar artery differs in no respect from that proper to 
the disease in other vessels. Pressure, supplemented by flexion, should be 
first tried, when the disease exists in the forearm, and if these means fail a 
ligature must be applied: in the case of brachial aneurism, the thread must 
be placed on the artery above the tumor, and in aneurism of the radial or the 
ulnar, on both the proximal and distal sides of the sac, without disturbing its 
contents. Langenbeek cured a case of aneurism of the radial artery in twenty- 
four hours by an injection of ergotin. When the tumor is situated on the 
brachial, near the bend of the arm, it is not advisable to adopt the Hunterian 
plan, by making the ligation a considerable distance from the disease, but 
rather to choose that of Anel, by tying nearer to the sac, in order that the 
thread may include that portion of the vessel which is below the anasto- 
motica magna, and thereby render the restoration of the blood through the 
collateral vessels to the forearm more certain. Should mortification follow 
the ligature of the brachial, amputation will become necessary. 
Aneurism of the Superficial Palmar Arch. 
Aneurism of the superficial palmar arch is an exceedingly rare event. A 
case of this kind (traumatic) came under my care in a lad about ten years of 
age. A pulsating tumor occupied the palm of the hand and had grown to 
about the size of an apricot. The treatment which I adopted in this case, 
and which I. believe to be the only sound one, consisted in carefully dissecting 
off the integument from the aneurism, passing underneath the latter a stout 
double ligature, and strangulating each half separately. After the separation 
of the sac the flaps of integument were replaced. 
Aneurism of the Superficial Volar Artery. 
Aneurism of the superficial volar artery must be of very rare occurrence. 
Pilcher gives a single case. A druggist living in New Jersey consulted me 
in regard to a gradually increasing swelling of several months’ standing situ- 
ated in the midst of or under the muscles of the ball of the right thumb. 
The aneurismal nature of the tumor admitted of no doubt. Pulsation and 
bruit were both present, and both were arrested by firm pressure over the 
radial artery. The patient was in the habit of forcibly pressing corks into 
bottles with this part of his hand, and to this cause I attributed the produc- 
tion of the aneurism. Finding that pressure over the radial above the origin 
of the volar artery entirely controlled the movements of the tumor, I placed 
a ligature about the former vessel. In a few days, however, pulsation in the 
aneurism returned. Several weeks after, I dissected the integument off in 
the form of two flaps, raised the superficial layer of muscles, and tied around 
the base of the swelling, in sections, what appeared to be an anastomosis of 
vessels. The recovery, though slow, was followed by no return of the disease. 
The abdominal aorta is not so commonly the subject of aneurism as the 
thoracic part of the vessel. Males are more frequently affected than females. 
Of 59 cases of the disease, 51 were males and 8 females.* The largest number 
of cases occur between the thirtieth and the fortieth year of life. These 
tumors generally appear at that portion of the artery where the cceliac axis 
is given off, and often acquire an enormous bulk. It has been thought that 
the vessel is weaker at the place where the first abdominal branch arises ; but 
I have never been able to discover that the arterial walls at this point are 
thinner than elsewhere. There are, however, two points worthy of notice 
in connection with this portion of the vessel, which, I doubt not, exercise 
Aneurism of the Abdominal Aorta. 
* Crisp on Diseases of the Blood-Vessels, p. 161. ANEURISM OF THE ABDOMINAL AORTA. 
719 
a determining influence in thus localizing abdominal aneurism. Where the 
aorta enters the ventral cavity, between the pillars of the diaphragm, it 
is arched over by a tendinous band, which prevents, by its inelasticity, the 
dilatation of so much of the vessel as is covered by its fibres, and produces a 
constriction in its walls at each ventricular systole. About one inch and a 
half below, the artery becomes suddenly contracted, giving to this part of the 
vessel a pouch-like form. The mechanical effect of this peculiarity is to 
enlarge by blood-pressure this portion of the aorta to a greater degree than 
elsewhere. Occasionally the disease is seen lower down in the vessel (Fig. 
537), a position well adapted to the treatment by compression. 
Symptoms.—Aneurism of the abdominal aorta usually begins with a dull, 
localized pain, which, as the disease advances, becomes darting, gnawing, 
or tearing. If the parietes of the abdomen are thin, or if they are thor- 
oughly relaxed by drawing up the lower extremities and elevating the 
shoulders, a tumor may be discovered by a digital examination made over 
the epigastric region. Generally, however, the hand recognizes a distinct 
pulsation, and the ear, when applied either over this part of the abdomen or 
Fig. 537. 
Fig. 538. 
Aneurism of the aorta near its bifur- 
cation. — From a preparation in the 
Museum of the University of Pennsyl- 
vania. « 
Abdominal aneurism in which the bodies and articular processes of 
three dorsal and one lumbar vertebrae were destroyed, and the sheath 
of the spinal cord exposed and thickened. 
on the opposite side of the trunk, over the spine, will discover a loud bruit de 
soufflet, or bellows sound, but never a diastolic murmur. The aneurism rarely 
enlarges in a median direction at first, but inclines to the left side, the one in 
which there is the least resistance from surrounding organs, and which an- 
swers to the general relation of the artery with the spinal column. When 
the sac becomes very large there is not an organ within the abdominal cavity 
which may not be disturbed by the pressure of the growth. The functions 
of the stomach often become deranged, giving rise to vomiting; the urinary 
secretion, at first increased, may finally be suppressed ; the bile may be pre- 
vented from passing along the excretory ducts of the liver, and the patient 
is rendered icterode ; the intestines sometimes become distended with gaseous 
or faecal accumulations, causing severe flatulent colic or obstinate constipation. 
The constant pounding of the tumor against the spinal column and the ribs 
is frequently followed by erosion of the vertebrae and weakness of the lower 
extremities from pressure upon the spinal cord. (Fig. 538.) This change is 
usually going on when the patient complains of severe gnawing or boring 
pains in the back. Altogether, the suffering and disability are much less in 720 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
abdominal than in thoracic aneurism, as the tumor in the former has ample 
room for enlarging, and the contents of the abdomen are neither so fixed in 
position nor so immediately essential to life as are those in the middle and 
posterior mediastinal regions. Hence it is not unusual to find persons suffer- 
ing from abdominal aneurism pursuing their occupations until the disease is 
far advanced in its course. A boatman, who was at one time under my care, 
suffering from a large ventral tumor of this kind, insisted upon following 
the duties of his position almost throughout the entire course of the disease; 
and I have already alluded to another case, that of an itinerant peddler, 
who, notwithstanding the fact that his aneurism was so large as to compel 
him to throw his body considerably to the right side in order to preserve 
an equilibrium, continued to ply his vocation with a diligence which was 
truly marvellous in one between whom and instant death there seemed but 
a step. 
Diagnosis.—The morbid conditions liable to be confounded with abdominal 
aneurism are tumors and enlargements of the different organs within the ven- 
tral cavity, and abnormal pulsation of the aorta. With reference to enlarge- 
ment of the glandular organs, carcinomatous or otherwise, within the 
splanchnic cavity, much may be learned from the regional position occupied 
by the swelling, especially at the commencement of the trouble. The fact 
that aneurism is generally median, and in the epigastric space, would serve 
to distinguish it from hepatic, splenic, and renal enlargement, which would 
first appear respectively in the right hypochondriac, left hypochondriac, and 
lumbar regions. The left lobe of the liver does extend somewhat across the 
median line to the left side; but the superficial character of the swelling 
when this part of the organ is implicated, and the continuation of the line 
of dull percussion across from the right lobe, aside from other signs, are 
features which do not belong to aneurism. In malignant diseases of the 
stomach, pancreas, omentum, or other parts within the abdomen there is 
generally a previous history of disturbed digestion and of gradual loss of 
flesh and strength, and frequently a pronounced cachexia is written on the 
face. The tearing or boring pain of aneurism does not belong to other ab- 
dominal growths. Pulsation, one of the common attendants of aneurism, 
may accompany ventral disease, sometimes being transmitted through the 
tumor by its contact with the aorta, and at other times being due to an in- 
herent vascularity of the growth. In the tumor the movement is one of up- 
heaval, in which the mass itself is passive, while in aneurism the force is 
recognized as internal to the swelling, and expansive. In encephaloid dis- 
ease, owing to the rich supply of blood-vessels, and to softness of texture, 
not only does the pulsation very closely resemble aneurism, but often also a 
distinct murmur is present, which will render the diagnosis more difficult. 
When malignant disease begins in the lumbar glands, the destruction of the 
vertebrae may follow, as in aneurism, and the same gnawing, deep-seated pains 
may be experienced as when the bones are attacked in the latter affection. 
In cancer, however, the pulsation is never so strong as in aneurism, and the 
murmur is more soft and continuous. 
The condition most frequently mistaken for aneurismal dilatation is that 
abnormal pulsation of the abdominal aorta which is peculiar to nervous and 
aneemic females and sometimes to males. In this singular affection of the 
artery there is rarely any pain, there is no single rough sound as in aneurism, 
and the age and constitutional peculiarities of the patient are different from 
those which characterize subjects of the latter disease. 
Termination.—Aneurism of the abdominal aorta in most instances ter- 
minates by opening into the peritoneal or retro-peritoneal space, this being 
followed by extensive extravasation of blood and the signs of internal hem- 
orrhage. Occasionally the patient dies from a failure of the functions of 
nutrition, most probably caused by pressure on the thoracic duct or the 
mesenteric glands. The sac may also open into the intestinal canal, into the 
thorax, into the mediastinum, or into the ascending vena cava. Of 59 cases ANEURISM OF THE ABDOMINAL AORTA. 
721 
of aneurism of the ventral aorta,* 11 opened into the retro-peritoneal space, 10 
into the cavity of the peritoneal sac, 5 into the left pleura, 3 into the vena 
cava inferior, 1 into the lung, 1 into the colon, 1 into the pelvis of the kid- 
ney, 1 into the posterior mediastinum, 1 into the chest, 2 died suddenly 
without rupture of the sac, and 2 perished from jaundice. Of the remaining 
21, 9 died from disease of the lungs, the liver, or the heart, or from other 
atfections more or less directly connected with the aneurism, and in 12 the 
terminations were not stated. 
Treatment.—The medical treatment of aneurism of the abdominal aorta 
consists for the most part in rest, a restricted diet, and the internal use of the 
iodide of potash and the tincture of veratrum viride. The latter should be 
administered in doses sufficient to lessen the force and frequency of the heart’s 
action. If the pain is severe, opium in some of its forms may be freely used ; 
and to remove colicky or flatulent distention of the intestines, carminatives, 
such as the compound tincture of cardamom, or turpentine, should be admin- 
istered. The latter is best given in the form of an injection. Sometimes the 
disease is situated sufficiently low in the aorta to admit of surgical treatment. 
In 1864, Murray, of Newcastle-on-Tyne, tried for the first time instrumental 
compression, and with entire success. The pressure was made by a tourni- 
quet applied over the abdominal walls on the cardiac side of the tumor, and 
after a second application, the patient being under chloroform, the cure was 
effected in five hours.f A very interesting feature connected with this case, 
one which may embolden over-sanguine surgeons to renew their attempts at 
ligating the abdominal aorta, is the completeness with which the collateral 
circulation was established after the consolidation of the aneurism. The 
death of the patient several years after, from another aneurism of the aorta, 
near to the foramen aorticum in the diaphragm, and too high up to admit of 
pressure, enabled the surgeon not only to verify, by an examination of the 
body, the correctness of the diagnosis and the cure of the original disease, 
but also to exhibit the vessels which had substituted the obliterated trunk of 
a portion of the aorta in the work of transmitting the blood to the intestines 
and the lower parts of the body. These were the colica media of the supe- 
rior mesenteric, with the colica sinistra of the inferior mesenteric and with 
the colica sigmoidea and hemorrhoidal arteries; the ilio-lumbar by its as- 
cending branches with the superior lumbar, and by its descending branches 
with the circumflex ilii from the external iliac artery. The parietal arteries 
which participated in this work were the internal mammary, the intercostals, 
and the lumbar, with the superficial and deep epigastric and the circumflex 
iliac vessels. 
Since the introduction of this method as an established surgical pro- 
cedure in the treatment of aneurism of the abdominal aorta, a number of 
supposed cases of the disease have been from time to time represented as 
cured. Among these is the one of Heath, of Sunderland,| in which the 
tumor is said to have been consolidated in twenty minutes after the second 
application of the pressure. Such precedents are quite sufficient to warrant 
the application of compression whenever the situation of the tumor will 
allow it. The instrument best adapted to effect the pressure is the tourni- 
quet of Lister, already figured under “ Hemorrhage” (p. 224). This instru- 
ment surrounds the body, the pad being accurately adjusted to the artery 
above the tumor and allowed to compress no more of the abdomen than is 
absolutely necessary for the purpose in view. Particular attention should 
be given to these points, as much damage has been done to the different 
viscera and to the solar plexus of nerves, sufficient in a number of cases to 
cause the death of the patient, as will be seen by reference to the table on 
the following page. The pressure should be carried to the extent of arrest- 
ing the current of blood through the vessel as completely as possible, and 
may be continued, if the pulse remains good, for four or five hours, the 
* Crisp on Diseases of the Blood-Vessels, p. 163. 
J British Medical Journal, October 5, 1867. 
f Lancet, February 8, 1873. 722 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
patient being kept during this time under the influence of an anaesthetic or 
of morphia hypodermically administered. If the treatment is not well borne, 
it will be better to apply the compression for half an hour or an hour daily, 
keeping the patient perfectly quiet on his back in the intervals, until the 
success or failure of the method shall have been determined. Before making 
the pressure the bowels should be cleared out, either by an aperient or by a 
hvrge injection, and nothing but liquid nourishment allowed for eight or ten 
hours before commencing the treatment. 
Cases of Aneurism of the Abdominal Aorta treated by Compression. 
No. 
Surgeon. 
Side 
of 
Pressure. 
Duration 
of 
Pressure. 
Kesult. 
Bemarks. 
1 
Murray. 
Proximal. 
5 hours. 
Cured. 
2 
Moxon. 
« 
10* “ 
(( 
3 
Durham. 
(( 
10* “ 
U 
4 
U 
(( 
Fatal. 
From damage to viscera, 
due to pressure. 
5 
Hulke. 
a 
55 min.; 4 hours; 
3 hours :—3 sit- 
tings. 
Cured. 
6 
Pollock. 
u 
Unsuccessful. 
7 
Grreenhow. 
« 
3 min.; 3 hours; 
4 hours :—3 sit- 
tings. 
Cured. 
8 
Paget. 
a 
Fatal. 
From peritonitis, due to 
bruising. 
9 
Bryant. 
Distal. 
From peritonitis, the press- 
ure having damaged the 
intestines and mesentery. 
10 
Marshal. 
(( 
18 hours; 19 hours: 
—2 sittings. 
Unsuccessful. 
11 
Barwell. 
U 
Unsuccessful. 
12 
Phillipson. 
U 
Successful. 
13 
Skerritt. 
a 
Fatal. 
Kupture of the sac. 
It will be seen from the above table that aneurism of the abdominal aorta 
has been treated 13 times by pressure, 6 of the cases proving successful, 3 
unsuccessful, and 4 terminating fatally,—showing a proportion of success 
which is exceedingly encouraging. 
Spontaneous cures of aneurism of the abdominal aorta have been noticed by 
writers. In one case which I had under observation for some time, and in 
which I am very confident the diagnosis was correct, this event took place. 
Aneurism of Certain Branches of the Abdominal Aorta. 
The arteries within the abdomen, besides the aorta, which have furnished 
examples of aneurism, are the superior and inferior mesenteries, the splenic, 
the hepatic, and the renal. An aneurism of the right ovarian artery has been 
recorded by Whitemarsh.* 
In 39 cases collected by Lebert, the superior mesenteric and the splenic 
were each affected 10 times; the hepatic and its branches 8 times; the coeliac 
and the inferior mesenteric each 3 times; the renal twice ;f and in 3 cases 
the aneurisms were multiple. These aneurisms do not attain any great bulk, 
seldom exceeding the size of a hen’s egg, and are usually round or oval in 
shape. Except when connected with the hepatic, the renal, or the coeliac 
axis, they are movable, changing their position in the various actions of the 
body. They possess, also, the characteristics of pulsation and bruit. When 
the coeliac artery is affected, the disease cannot be distinguished from aneu- 
rism of the parent trunk. 
* British Medical Journal, October 5, 1867, vol. ii. p. 177. 
| Ziemssen’s Cyclopaedia of the Practice of Medicine, vol. vi. p. 439. ANEURISM OF THE INTERNAL ILIAC AND ITS BRANCHES. 
723 
In cases of implication of the hepatic artery, the pressure-effects of the 
tumor give rise to pain in the right side, and to jaundice from obstruction of 
the hepatic, cystic, and common bile ducts. The disease may exist without 
ever being suspected, so trifling is the inconvenience sometimes experienced; 
though in a number of instances severe pain has been felt in the back. These 
tumors, like aneurisms elsewhere, terminate by rupture of the sac, causing 
death from hemorrhage. 
The diagnosis of such an aneurism must necessarily be attended with much 
uncertainty; but if a floating tumor can be detected through the parietes of 
the abdomen, having the characteristic pulsation and sounds of aneurism, the 
operation of opening the ventral cavity, and, in case the diagnosis of aneurism 
is verified, of ligating the artery on the cardiac and distal sides of the sac, will 
be entirely justifiable. 
Aneurism of the Primitive Iliac Artery. 
Aneurism of the primitive iliac alone is exceedingly rare. The tables of 
Crisp make mention of only two examples of aneurism of this artery out of 
551 cases of the disease. Both of these were in males, the one occurring 
under the care of Adams, and the other in the practice of Murray, of the 
Cape of Good Hope. In each case the aneurism was on the right side. 
The one under Adams proved to be a varicose aneurism, as it communi- 
cated with the accompanying veins. Both proved fatal,—the first without 
any surgical interference, and the second after deligation of the abdominal 
aorta by Murray. A number of cases (five or six) have been reported within 
the past few years. 
Treatment.—The only treatment in cases of aneurism of the pi'imitive 
iliac is pressure of the abdominal aorta. Mapother, Heath, and others have 
reported cures obtained in this way. In very thin or emaciated subjects, 
with flaccid abdominal walls, digital pressure is possible. Under other cir- 
cumstances the tourniquet of Lister will be necessary. A case has been 
reported by Varick which ended successfully under distal compression. 
No case of aneurism invading the internal iliac is mentioned by Crisp. 
Sandifort has recorded one. The branches of the internal iliac most com- 
monly affected are the gluteal and the ischiatic. Mr. George Fischer* has 
collected 35 cases of such lesions. Of 25 of these, which were gluteal aneu- 
risms, 11 were traumatic and 14 spontaneous; and of the 6 which were 
known to be ischiatic, 2 were traumatic and 2 spontaneous; while of 2 
which were doubtful,—that is, in which it was uncertain whether they were 
gluteal or ischiatic,—1 was traumatic and 1 was spontaneous. The remain- 
ing 2 were anastomosing aneurisms. Of the 14 traumatic, 5 were diffused, 
7 circumscribed, and 2 varicose; 12 of them were caused by punctures, 1 by 
a shot wound, and 1 by getting into a saddle. Of the 21 spontaneous, the 
cause was uncertain in 11; in 9 it was believed to be from previous contusion, 
and in 1 it was associated with a fracture of the pelvis. As regards sex, 28 
were males and 7 females. All the traumatic cases were in males. Those 
which had a traumatic origin occurred between fourteen and fifty years of 
age, and of those which were spontaneous, 10 out of the 21 were between 
twTent,y-one and fifty. 
To distinguish between a gluteal and an ischiatic aneurism is not always 
possible. The gluteal, from the anatomical position of the artery, is usually 
farther back in the buttock, while the ischiatic appears downwards and for- 
wards towards the gluteo-femoral crease. 
Symptoms.—The presence of a pulsating compressible tumor in the gluteal 
region, having a distinct bruit, with pain extending over the nates and down 
the thigh, and accompanied with lameness in the corresponding limb, is an 
Aneurism of the Internal Iliac and its Branches. 
* British and Foreign Medico-Chirurgical Review, vol. xlvii., 1871. 724 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
indication of either gluteal or ischiatic enlargement, especially if there is an 
antecedent history of a wound or of some pelvic injury. 
Diagnosis.—The diseases which most resemble gluteal or ischiatic aneu- 
rism are abscess, cancer, and ischiatic hernia. The exploring-needle would 
determine the existence of a purulent accumulation. To ditferentiate the 
disease from cancer is a more difficult task, sometimes an impossibility. The 
internal iliac artery has been twice tied, once by Guthrie and once by Morton, 
for supposed gluteal aneurism which afterwards proved to be encephaloid 
disease. In carcinoma the increase of the tumor is more rapid than in aneu- 
rism, especially when the disease is spontaneous, the only form, indeed, in 
which any mistake is likely to occur. The antecedents of the patient, and 
the general state of his nutrition, may also furnish some light which will 
serve to assist the surgeon in establishing the true character of the disease. 
In ischiatic hernia the absence of pulsation and of sound, with the resonance 
of the tumor, ought to be sufficient to prevent such a swelling from being 
confounded with aneurism. 
Treatment.—In the traumatic form of these aneurisms the swelling should 
be freely laid open, and both extremities of the wounded vessel secured by 
ligatures. In 6 of Dr. Fischer’s* cases of traumatic gluteal aneurism treated 
in this way, 4 recovered, 1 died from hemorrhage, and 1 failed. Davidge, of 
Maryland, and Dr. George McClellan, of Philadelphia, each tied, with success, 
the gluteal artery for aneurism, Dr. L. A. Dugas, of Georgia,f on March 16, 
1857, tied the ischiatic artery for aneurism of that vessel. In consequence 
of secondary hemorrhage, Dr. Wm. J. Holt, on the 26th of the same month, 
ligated the common iliac artery. The patient died from exhaustion three 
days after the operation. M. C. Sappey, Agrege of the Faculty of Medicine 
of Paris,| previous to the operation of Dugas, tied the ischiatic artery for 
aneurism. Though the patient recovered from the operation, the disease was 
not cured. Morton tied the internal iliac in a case of malignant disease mis- 
taken for aneurism. Professor George W. Campbell, of McGill University, 
Montreal, in a case of traumatic aneurism of the buttock, caused by a sharp- 
pointed piece of iron heated to a white heat, tied successfully the gluteal 
artery without opening the sac.§ In order to control the bleeding during 
such an operation, the abdominal artery should be compressed by the Lister 
tourniquet. 
In spontaneous aneurism of these vessels, pressure of the ventral aorta 
should be first tried, and if this fail, the ligation of the internal iliac will be 
required. This vessel has been tied for aneurism of the gluteal and the 
ischiatic arteries, spontaneous and traumatic, 30 times, with 20 recoveries, 
9 deaths, and 1 undetermined. 
Of 3 cases in which the common iliac was ligated for the same disease, all 
died. 
Galvano-puncture has been used for the cure of gluteal aneurism by Blasius,|| 
but without any beneficial effect. 
The use of injections, such as the perchloride of iron, is advocated by Dr. 
Fischer, based on an analysis of 35 cases, 21 of which were spontaneous 
aneurisms. 
Guided by all the light which can be gathered from different sources, the 
treatment of aneurism of the internal iliac and its branches resolves itself 
into the following. In all cases of true aneurism, employ first pressure over 
the primitive iliac artery or the aorta; failing in this, ligate the internal 
iliac; and as a last resort use injections of perchloride of iron. When the 
aneurism is traumatic, ligation offers the best prospect of a cure. If the 
aneurismal vessel can be reached external to the pelvis, as has been done a 
number of times, proximal ligation should be adopted. 
* British and Foreign Medico-Chirurgical Review, vol. xlvii., 1871. 
f Southern Medical and Surgical Journal, New Series, 1859, p. 651. x 
j Revue Clinique, Paris, 1850; from the Southern Medical and Surgical Journal. 
2 Published in pamphlet form. 
|] Deutsche Klinik, 1859, p. 165. ANEURISM OF THE EXTERNAL ILIAC ARTERY. 
725 
Aneurism of the External Iliac Artery. 
Of 551 cases of aneurism contained in the tables of Crisp, 9 only were 
connected with the external iliac artery, all of which were in the persons 
of males. As in aneurism of other vessels, the disease is most common be- 
tween the ages of forty and fifty. The situation of the external iliac artery 
is such that it is not readily reached through the abdominal parietes by 
manual examination, and from this circumstance the diagnosis of tumors 
in the course of this vessel is often a matter of difficulty. Guthrie tied the 
common iliac for what he supposed to be an aneurism of that artery. The 
death of the patient eight months afterwards disclosed the fact that no disease 
whatever of the vessel existed, and that the tumor was an encephaloid. In a 
case under the care of Post, of New York, the fluctuation was so distinct that 
an incision was made into the swelling, under the impression that pus was 
present. A subsequent hemorrhage established its aneurismal character. 
Stanley tied the common iliac for a supposed aneurism of the external iliac: 
the patient died three days afterwards, and upon an examination of his body 
the tumor wTas found to be encephaloid. 
Symptoms.—In aneurism of the external iliac, a tumor can be recognized 
through the abdominal walls in the course of the vessel as it passes along the 
brim of the lesser pelvic basin. That the examination may be made satisfac- 
torily, the ventral walls should be relaxed as much as possible by placing the 
patient in the recumbent position, with the shoulders elevated and the lower 
limbs drawn up towards the body. In this posture the outlines of the swell- 
ing may be made out. and if it is aneurismal its expansive pulsation may be 
felt, and the bellows murmur and the thrill recognized by the ear. When the 
aorta or the common iliac is compressed, both pulsation and thrill in the 
tumor cease, but are promptly renewed on withdrawal of the pressure from 
the artery above. As the aneurism enlarges it occasions considerable pain 
in the groin, along the crest of the ilium, and in the front of the thigh. The 
patient becomes unable to straighten the limb, and in walking leans forward 
in order to relieve the psoas magnus and the iliacus interims muscles from 
pressure. 
Diagnosis.—The difficulties which the surgeon sometimes encounters in 
distinguishing aneurism within the pelvis from other morbid growths in this 
region are due to the faithfulness with which all the signs of the former 
affection can be simulated by medullary cancer. When the latter disease origi- 
nates in the lymphatic glands which lie along the course of the iliac artery, 
it may completely surround the vessel, which relation, in connection with 
the soft nature and the great vascularity of its substance, will cause both pul- 
sation and aneurismal murmurs. Even in the absence of pulsation and thrill, 
the existence of aneurism is not excluded, for the solid contents of such a 
tumor may accumulate to such a degree as to render the throb and bruit 
inappreciable by the touch or to the ear. It is only by a careful investi- 
gation of all the circumstances attending the origin and the progress of the 
case that a safe conclusion can be reached. In pursuing such an inquiry, 
the questions most pertinent to the occasion would be the following: Did 
the local pain or inconvenience experienced appear suddenly, and during some 
unusual muscular strain? were the phenomena of pulsation and of bruit 
present in the incipiency of the disease? have the pain and helplessness of 
the limb been steadily increasing? has the patient retained his flesh? is he 
free from any expressed cachexia ? does the tumor materially lessen in size 
when the circulation is arrested in the iliac or in the aorta ? has the person 
affected passed his fortieth year of life ? If these interrogatories are an- 
swered in the affirmative, there will be a strong presumption that the disease 
is aneurismal. 
Iliac aneurism, when left without interference, though it may undergo a 
spontaneous cure, will in most instances terminate fatally in eight or twelve 726 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
months, the rupture of its sac and hemorrhage; or in consequence of the 
pressure of the tumor upon the companion vein, and the obstruction to the 
passage of the blood through the aneurism to the parts below, destroying the 
vitality of the limb and causing it to mortify. 
Treatment.—Aneurism of the external iliac should be first treated by in- 
strumental compression, applied to the abdominal artery by means of the 
Lister tourniquet, the patient being kept under the influence of an anaesthetic 
or under that of morphine hypodermically given, during the progress of the 
treatment. In an aneurism of the external iliac as large as a child’s head, I 
succeeded in effecting a perfect cure by this plan, by two treatments. The 
first continued for two hours under ether one day, and the second for half 
an hour, without the anaesthetic, on the day following. The circulation can 
be controlled much more perfectly by compressing the abdominal aorta 
opposite the umbilicus, than by acting upon the common iliac. Dr. R. J. 
Levis was equally successful, by instrumental compression of the external 
iliac, in curing in six hours a case of ilio-femoral aneurism; and a like re- 
sult was obtained by Dr. Nichols, of New Orleans, by means of digital 
compression. Some of these cases of aneurism of the external iliac and in- 
ternal iliac vessels might be treated successfully with the rectal lever. 
Ligature.—Should compression fail, it will be necessary to resort to the 
ligature, applied to the external iliac above the sac, or to the common iliac 
when the disease is near to the latter artery. If from any cause the above 
operation is not feasible, the external iliac may be tied on the distal side of 
the sac ; and in such an event the thread should be placed on the vessel above 
the origin of the deep epigastric and circumflex iliac branches. Deliga- 
tion of the external iliac for aneurism of this vessel may be considered a 
promising operation. Of the 9 cases of external iliac aneurism which are 
recorded by Crisp, 4 were treated by this plan, and all recovered. The 
tables of Dr. George Norris* contain 97 cases of ligature of the external iliac 
artery for aneurism, 71 of which were cured and 26 died. Cutterf has 
collected 30 cases of ligation of this vessel for aneurism, with 19 cures and 
11 deaths. The general mortality of ligature of the external iliac artery for 
aneurism is about twenty per cent. 
The primitive iliac has been ligated for the cure of aneurism, chiefly of 
the external iliac, and for other causes, 81 times, with 58 deaths and 23 re- 
coveries. The abdominal aorta has been tied 10 times for aneurism of the 
common and external iliac arteries, and each time with a fatal result. The 
following table contains a brief summary of these remarkable operations. 
Operation. 
Sex. 
Age. 
Result. 
Aneurism and Operation. 
1. Sir Astley Cooper, 
1817. 
Male. 
38. 
Death in 
40 hours. 
The aneurism was connected with the iliac 
(left), but had become diffused in conse- 
quence of a rupture of the sac. The liga- 
ture was applied three-quarters of an inch 
above the point where the vessel divides 
into the primitive iliacs. The aorta was 
reached by an incision to the left of the 
umbilicus, opening the parietal perito- 
neum, pushing aside the coils of intestine, 
and reaching the artery by scratching an 
opening through the visceral layer of the 
peritoneum: a distal ligature had been 
previously applied to the external iliac in 
this case. 
2. James, 1829. 
Male. 
44. 
Death in 
3 hours. 
External iliac aneurism. The vessel had been 
tied on the distal side of the sac. The aorta 
was tied five lines below the inferior mesen- 
teric artery, by opening the peritoneum in 
front. 
* Norris’s Contributions to Surgery, Philadelphia, 1874. 
f American Journal of the Medical Sciences, New Series, July, 1864. ANEURISM OF THE FEMORAL ARTERY. 
727 
Operation. 
Sex. 
Age. 
Result. 
Aneurism and Operation. 
3. Murray, 1834. 
Male. 
33. 
Death in 
23 hours. 
External iliac aneurism of the right side; the 
limb was threatened with mortification in 
consequence of pressure on the pelvic blood- 
vessels by the great size of the sac. The 
aorta was approached from the left side, 
the incision being made from the anterior 
extremity of the tenth rib to the anterior 
superior spinous process of the ilium, the 
vessel being exposed behind the perito- 
neum; tied three lines above its bifurca- 
tion. 
4. Monteiro, 1842. 
Male. 
31. 
Death in 
10 days. 
False aneurism, caused by rupture of the up- 
per part of the femoral, the blood diffusing 
itself through the pelvis and the thigh. 
Incision similar to that of Murray, and the 
aorta secured behind the peritoneum, four 
or five lines above its bifurcation. 
5. South, 1856. 
Male. 
28. 
Death in 
43 hours. 
Aneurism very large, involving both the ex- 
ternal and the common iliac arteries. The 
vessel was tied above the peritoneum. 
6. McGuire, 1868. 
Male. 
30. 
Death in 
11 hours. 
Aneurism involved the left external iliac, and 
both primitive iliacs. The sac gave way 
during the operation. The ligature was 
applied to the aorta near to the inferior 
mesenteric. 
7. Watson, 1869. 
Male. 
50. 
Death in 
12 hours. 
8. W. Stokes, 1869. 
9. Czerny, Vienna. 
10. Czerny, Heidel- 
berg. 
Male. 
50. 
Death in 
13 hours. 
Death in 
26 hours. 
Died. 
Iliac aneurism. The vessel was tied behind 
the peritoneum, though the latter was 
slightly wounded in the operation. 
Femoral and external iliac had been previ- 
ously tied. 
There are no difficulties which the hand of the surgeon will not brave when 
there is the faintest prospect of saving human life ; but there is a point where 
the unalterable laws of structure are superior to the art of the operator, and 
where his hand must be stayed. This point, it is thought by some, has been 
reached in reference to ligation of the abdominal aorta for the cure of an- 
eurisms ; and yet I am unwilling to believe that ten failures constitute a suf- 
ficient argument for a dogmatic condemnation of this operation. Had such 
precedents been allowed to go unchallenged when applied to the surgical 
diseases which fall within the domain of gynaecology, a vast army of noble 
mothers would have been consigned, some to death, others to a seclusion 
even worse than death. No argument, in my judgment, short of the utter 
insufficiency of the collateral vessels to maintain the life of the inferior ex- 
tremities, can be cogent to exclude the ligation of the ventral 
aorta from the pale of operative surgery. 1 should, therefore, in the event 
of undertaking the ligature of the common iliac for aneurism and finding 
on exposure of the parts that the extent of the disease necessitated either 
tying the aorta or abandoning my patient to certain death, have no hesita- 
tion in accepting the former alternative. 
Among aneurisms which are external in position, dilatation of the femoral 
artery comes next in frequency to that of the popliteal. Of the 551 cases 
of aneurism recorded in the tables of Crisp, 66 were of the femoral artery: 
of these 61 were males and 5 females. The disease is equally common on 
either side. Considered in connection with aneurism, there are only two 
surgical divisions of the femoral artery, namely, that portion of the vessel 
which corresponds to Scarpa’s triangle, or from Poupart’s ligament to the 
point where the adductor longus is crossed by the sartorius muscle, and that 
Aneurism of the Femoral Artery. 728 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
portion from the last-named muscle to the aponeurotic canal of the adductor 
magnus. Of 88 aneurisms of the femoral,* 55 occupied the hrst of the sur- 
gical divisions above named, and 33 the second. In 50 cases in which the 
limb is mentioned, 24 were on the right side and 26 on the left. The largest 
number of cases occurred in the decade between thirty and forty, and among 
the laboring population. Malgaigne’s statistics include 68 cases of inguinal 
aneurism, and in 48 of these the disease was 25 times on the right side, 21 
times on the left, and twice on both sides. 
The term “ femoro-popliteal aneurism” is in most instances a misnomer, 
if by it is meant that the disease begins in the femoral and extends to the 
popliteal artery. In my experience the reverse is the case, the aneurism 
commencing in the popliteal and gradually involving the femoral. 
Symptoms.—The signs which indicate aneurism of the femoral artery do 
not materially differ from those which are present when the disease is situ- 
ated in other vessels. There is a gradually-enlarging tumor imparting the 
characteristic pulsation to the hand, the movement being often visible to the 
eye, together with a distinct thrill and blowing sound heard on applying the 
ear over the surface of the swelling. 
Diagnosis.—Most of the cases of aneurism in which errors of diagnosis 
have been committed have been connected with the femoral artery, and in 
every instance the aneurismal swelling was supposed to be an abscess. It is 
impossible that such a mistake can occur if a careful examination of the 
tumor be made. In all cases of aneurism, though the pulsation may some- 
times be masked, the existence of a bellows murmur and a thrill can always 
be detected by the ear, either with or without the aid of the stethoscope. 
Further, it may be observed that pressure on the femoral or on the external 
iliac artery will not only arrest the pulsation and the sound, but will also 
sensibly diminish the size of an aneurismal swelling, whereas in abscess the 
size of the purulent collection will not be affected by interrupting the circu- 
lation. There is also in abscess, usually, a history of tenderness, redness, and 
induration, succeeded by central pointing and softening, symptoms which do 
not, as a rule, belong" to aneurism. In a psoas abscess which finds its way to 
the thigh there is an absence of visible inflammatory phenomena, in which 
respect some resemblance may be said to exist between this disease and fem- 
oral aneurism; but the position of the former, being external to the blood- 
vessels, renders the distinction quite apparent. 
Extension of the Disease.—When the aneurism is situated in the upper 
part of Scarpa’s triangle it may gradually involve the external iliac artery 
by passing beneath Poupart’s ligament into the pelvis, the resistance of the 
ligament causing a constriction of the sac and giving to the latter an hour- 
glass shape. Such was the condition in a case in which I ligated the external 
iliac artery. 
Treatment.—Femoral aneurism is treated by compression, by flexion, and 
by ligature. 
Compression, in a large proportion of cases, if judiciously employed, will 
effect a cure. In seven instances in succession I was able to bring to a favor- 
able termination aneurism of the femoral at periods varying from twenty-four 
to forty-eight hours. Flexion by bending the thigh upon the abdomen has 
also succeeded in curing the disease. 
Ligation.—In 88 cases of femoral aneurismf the external iliac was tied 39 
times, with 31 successes. In 4 of these successes the cure was completed only 
after amputation in 2 cases in consequence of gangrene, and in 2 others 
after distal ligature and distal pressure in order to control hemorrhage. Of 
the 8 fatal cases, 1 died from secondary hemorrhage and 3 from gangrene ; 
in 4 no cause was assigned. In the 66 cases of femoral aneurism tabulated 
by Crisp, and to which reference has been previously made, the external iliac 
was tied 43 times, and the latter vessel together with the femoral twice ; 35 of 
these operations were successful and 10 unsuccessful. Of the latter, 3 died 
* Hunter’s manuscript collection. 
t Ibid. ANEURISM OF THE PROFUNDA FEMORIS ARTERY. 
729 
from hemorrhage, 2 from sloughing of the sac, 2 from gangrene, 1 from ex- 
haustion, 1 from tetanus, and 1 without any known cause. In 33 cases the 
femoral was ligated 19 times, with the following result: 7 recovered, 9 died, 
in 2 the termination was not recorded, and in 1, though the patient re- 
covered from the ligature, the pulsation returned in the sac. In the fatal 
cases the principal cause of death was secondary hemorrhage. With the 
surgeons of Dublin the results after ligating the femoral artery for femoral 
aneurism and for wounds have been singularly favorable, 11 recoveries and 2 
deaths having followed 13 operations* The same may be said of the 12 
cases recorded by Crisp in which the femoral artery was tied, all of which, 
with three exceptions, recovered. It must be observed, however, that in 
the record of these ligations the portion of the vessel secured is not always 
stated. The experience of Mott was also highly favorable to this operation. 
Erichsen states that of 12 cases of ligature of the common femoral for aneu- 
rism but 3 were successful; secondary hemorrhage followed in 9, proving 
fatal in 3 instances, and in 6 being controlled only by ligature of the external 
iliac. Eabe and Barwell’s statistics, taken together, amount to 141 cases of 
ligation of the external iliac for femoral aneurism, with 31 deaths, or a mor- 
tality of 22 per cent. The difference in point of fatality between the ligature 
of the external iliac and that of the femoral in this aneurism is very striking, 
and is to be referred to the uncertainty attending the safe detachment of a 
thread from the femoral when applied so near the origin of a large trunk 
like the profunda femoris. 
When the aneurism is situated in the thigh, not higher than the apex of 
Scarpa’s triangle, unless the vessel proves to be unsound the ligature should 
be applied between the sac and the profunda femoris; but when higher than 
this,—that is, nearer to Poupart’s ligament,—or when the walls of the artery 
are in an atheromatous condition above the aneurism, the alternatives are 
left of tying the vessel above the profunda femoris, or of securing the ex- 
ternal iliac; and since to decide this important question will require a more 
extended experience in these two operations than is at present possessed, 
while I give the preference to the latter operation, I am not prepared to 
condemn a further trial of the former. 
Aneurism of the profunda femoris is exceedingly rare. In one case I have 
seen this vessel participate in the dilatation of the femoral. Erichsen men- 
tions five cases, and Bryant one. 
The symptom attending such an aneurism is the existence of a deeply- 
situated tumor, commencing about two inches below Poupart’s ligament, or 
at the origin of the deep femoral, and extending down towards the middle of 
the thigh, having a strong pulsation, accompanied with a thrill and blowing 
sound. The beat of the superficial femoral can be discovered in front of 
the tumor, and its independence of the latter may be ascertained by raising 
the vessel between the thumb and fingers from the aneurism. In two 
instances I have seen large malignant growths develop in this region of 
the thigh which might from their great vascularity and their relation to the 
femoral artery have been readily mistaken for aneurism, in consequence of 
the pulsation which permeated their structure; but in neither was there 
either thrill or bruit. 
Treatment.—Aneurism of the profunda femoris is favorably situated for 
the treatment by compression, either digital or instrumental. The former 
is to be preferred, and should be applied to the common femoral immediately 
below Poupart’s ligament, or to the external iliac above. In this way Erichsen 
succeeded in curing in twenty-four hours a case which came under his care 
at the University College Hospital. If pressure fails, a ligature should be 
applied to the femoral artery between the origin of the profunda and Pou- 
Aneurism of the Profunda Femoris Artery. 
* Dublin Quarterly Journal, 1869; also British Medical Journal, October, 1867. 730 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
part’s ligament. If statistics are to be unchallenged, this operation is very 
much more serious than is ligature of the external iliac artery, as regards 
either gangrene or hemorrhage. 
Aneurism of the Popliteal Artery. 
Aneurisms of the popliteal constitute a very large proportion of all encoun- 
tered by the surgeon, that artery being more frequently attacked by the 
disease than any other vessel of the body except the thoracic aorta. Of 84 
cases of popliteal aneurism,* 41 were on the right side and 43 on the left 
side; and of 143 examples of the same disease, 123 were in males, 8 in females, 
and in 12 the sex was not stated. The largest number of cases (70) occurred 
between the ages of thirty and forty; though instances of the disease have 
been observed as early as the twentieth year of life, and in one case, men- 
tioned by Syme, it occurred at seven years. Not unfrequently popliteal 
aneurism affects both vessels simultaneously. This was the case 11 times in 
137 cases of the disease recorded by Crisp. 
There are a number of circumstances which render this artery peculiarly 
liable to aneurismal dilatation. These are the slight degree of support 
which the vessel receives from the loose tissue that occupies the ham, the 
abrupt bends and severe stretching to which it is subjected in the movements 
of flexion and extension, and its alleged unusual liability to atheromatous 
degeneration. 
Occupation is thought to exercise a determining influence in the production 
of this aneurism. According to Crisp, sailors and soldiers are most exposed 
to the disease. I do not think, however, that the records of Philadelphia 
hospitals will sustain this statement. The cases of popliteal aneurism which 
I have seen have been distributed about equally among tailors, miners, watch- 
men, and common laborers. 
Diagnosis.—Little difficulty is usually experienced in establishing the ex- 
istence of popliteal aneurism. It is quite common for patients suffering from 
this affection to be able to specify the very moment at which the accident 
occurred. A sharp pain in the ham, or a feeling as if a severe blow had been 
received from an unseen missile, is the recognized manifestation which has 
often been mentioned when persons laboring under the disease have detailed 
to me the history of their cases. Abscess, enlargement of the popliteal glands, 
and enlargement of the bursce which lie under the heads of the gastrocnemius 
muscle, are the diseases with which aneurism of this region has been con- 
founded. In none of these, however, does either thrill or murmur exist; in 
none is the bulk of the swelling affected by pressure upon the femoral artery; 
and in none is the pulsation expansive, phenomena almost always associated 
with aneurism. The existence of inflammatory signs which belong to ab- 
scess, and which are exceptional in aneurism, will likewise aid in establishing 
the diagnosis between these two affections ; and should any doubt, after such 
considerations, still linger in the mind of the surgeon, it may be resolved by 
the use of a very delicate exploring-needle, which will reveal, in case of ab- 
scess, some drops of pus ; in the case of a bursa, a honey-like fluid ; but which, 
if the tumor is aneurismal, will draw off a certain amount of blood. 
Termination.—Popliteal aneuidsm, when allowed to progress without in- 
terference, will cause marked weakness and pain in the leg, from pressure 
against the popliteal nerve, erosion of the femur, oedema from obstruction to 
the flow of blood through the companion vein, mortification of the parts 
below the tumor, and not unfrequently to rupture, the sac discharging its 
contents into the cellular tissue of the ham, or even into the tibio-femoral 
articulation. In a few instances the disease has undergone a spontaneous 
cure. 
Treatment.—Compression.—The success which has attended pressure in 
the treatment of popliteal aneurism renders it always desirable to give this 
* Hunter’s manuscript collection. ANEURISM OF THE POPLITEAL ARTERY. 
731 
method precedence over all others. In seven successive cases I have suc- 
ceeded in effecting perfect cures by digital compression. The pressure should 
be made, in the manner already detailed in my general remarks upon the 
treatment of aneurism, over the femoral immediately below Poupart’s liga- 
ment, where, from its superficial situation, the circulation through the vessel 
can be most easily arrested. Should the surface of the skin become tender, 
the pressure may be shifted to another point lower down, always observing 
to dust the surface compressed with finely prepared chalk. A sufficient num- 
ber of assistants must be on hand to relieve one another, and, in order that 
the patient may be able to endure the treatment, morphine should be injected 
under the skin in such quantities and at such intervals as to prevent any 
severe pain or marked restlessness. Pressure may be advantageously assisted 
by flexion, and is often applied by instrumental means. The “ Stangen- 
druck” of Esmarch is an instrument for this purpose, and consists of three 
pieces of wood, one with a mass of lead at its lower extremity and suspended 
by a second or upright piece, to which a third or horizontal lever is attached, 
enabling the patient to graduate the pressure at pleasure. The degree of 
success attending the method by digital compression may be approximately 
determined, when I state that out of 403 cases of popliteal aneurism treated 
by compression, which I have collected from various sources noticed below, 
250 were cured.* The longest time required for the cure of any one of these 
aneurisms was forty-one and a half days, and the shortest period seventy-six 
minutes. Barwell. in 1883, tabulated 148 cases of popliteal aneurism treated 
by compression, 68 being cured and 80 being failures. 
Ligation.—Until the time that the Hunterian operation was introduced for 
the cure of popliteal aneurism, ligation had proved so unsuccessful that am- 
putation was regarded by some surgeons as offering the best prospect of a 
cure. When, however, the superiority of the proximal ligature was estab- 
lished, the plan of Hunter supplanted, until the introduction of compression, 
all other modes of treatment. 
The femoral should be exposed at the apex of Scarpa’s triangle, and tied 
with the animal thread, both ends of which must be cut off and the wound 
immediately closed. In 110 cases in which the Hunterian operation was 
performed for the cure of popliteal aneurism, 91 proved successful, and 7 
others recovered after amputation of the limb, the ligature having been first 
used.f In 278 cases of ligation for the same disease, which I have gathered 
together from various sources, chiefly from the same collections as have been 
named under the head of compression, 173 were perfectly cured. The tables 
of Norris contain 153 cases of true popliteal aneurism for which the femoral 
artery was tied, 112 of which were cured. Four of the successful cases re- 
quired amputation, in consequence of mortification following the use of the 
ligature. Of the 41 fatal terminations, 20, or one-half, were caused by 
gangrene. Morton, in recording the ligations done in the Pennsylvania 
Hospital for popliteal aneurism from 1835 to 1868, mentions 5 cases, all of 
which recovered.| It will be perceived that the tables of Norris, when 
studied with reference to the fatality attending ligation of the femoral for 
popliteal aneurism alone, yield a much more favorable percentage of cures 
than do statistics based upon ligation of the same vessel for aneurism other 
than popliteal and for hemorrhage from different causes. 
The causes of failure after ligation, in many instances, being pysomia, ery- 
sipelas, hemorrhage, thrombosis, pleurisy, and rupture of the sac, there is 
every reason to believe that the use of antiseptics will greatly lessen the 
mortality following the ligation. 
Acupressure has been used in a few cases of the disease with success by 
Dr. Cheever, of Boston, Mr. Henry Lee, and others. 
* Prager Vierteljahresschrift, 1869; also Lancet, 1855, vol. i. p. 210; 1858, vol. i. p. 192; 1875, 
vol. i. p. 589; also Hunter’s manuscript collection, 1877. 
f Crisp’s Diseases of the Blood-Vessels, p. 226. 
j American Journal of the Medical Sciences, April, 1876. 732 
DISEASES AND INJURIES OF THE BLOOD-VESSELS. 
Occasionally it may be found necessary in popliteal aneurism, where the 
femoral artery is diseased, or because of hemorrhage following the separation 
of the ligature from this vessel, to tie the external iliac. A very remark- 
able case of this kind was some years ago under my care. The patient was 
a stout farmer, thirty-four years of age, apparently healthy, but had led a 
somewhat dissipated life. Four years previous he had, after lifting a heavy 
weight, felt something give way, shortly after which a tumor appeared in the 
ham. The pain and large size of the swelling induced him to seek surgical 
relief. Pressure, after some days of preliminary treatment, was tried, with- 
out success, and following this the Esmarch bandage was applied for one 
hour, with no better result. After allowing the patient a few days’ repose, I 
ligated the femoral artery, with the catgut thread, at the point where the 
vessel is crossed by the sartorius muscle. All pulsation immediately ceased in 
the tumor. Nine days after, secondary hemorrhage occurred. The wound 
was opened, and the bleeding found to proceed from a perforating ulcer in 
the femoral above the ligature. No coagulum whatever existed in the vessel. 
The artery was tied above and below the opening, and the wound again 
closed. Eight days after the second ligation another hemorrhage took place, 
when the wound was again opened, and an ulceration discovered in the pro- 
funda femoris. The vessel was tied above and below the lesion, and the 
wound closed a second time. Everything progressed favorably for eleven 
days, when the bleeding was renewed, at which time the common femoral, 
in my absence, was tied by Dr. Hunter. For fourteen days following this 
operation the patient did well. On the evening of the fourteenth day the 
hemorrhage was renewed, but was promptly controlled by pressure. Indeed, 
at no time was any large amount of blood lost, as the man was carefully 
watched by the nurse and assistants day and night. I now proceeded to 
ligate the external iliac artery, and during the operation noticed that the 
blood remained fluid in the vessel down to the point of the last ligature on 
the femoral. The day following the deligation of the external iliac, a pro- 
fuse flow of blood took place from the wound on the thigh, which I found 
proceeded from the obturator artery. This bleeding vessel was secured, and 
nothing of importance occurred for five days, when an unusually violent 
hemorrhage ensued, in the night, from the thigh, and, as it was found im- 
possible to arrest it, the common iliac was tied by Dr. Hunter. Though the 
patient in this last attack lost a considerable amount of blood, he promptly 
rallied, and had no return of the bleeding until the lapse of seven days, when 
a sudden flow was seen issuing from the opening in the abdominal walls. An 
abdominal tourniquet, which had been previously provided, was quickly 
screwed down ; but too late. The patient expired in a few minutes after the 
hemorrhage was discovered. The post-mortem revealed the existence of an 
ulcer, which had opened the common iliac above the ligature, and through 
which the blood had escaped. 
Cases of double popliteal aneurism should be first treated singly by com- 
pression ; but if this plan fails, and it becomes necessary to resort to the liga- 
ture, the two femorals should not be tied simultaneously, but consecutively. 
In a case of double popliteal aneurism which was under my care in 1867, I 
effected an entire cure by digital compression: 
Mortification of the limb.—When, after the ligation of the femoral, morti- 
fication ensues, and shows an unmistakable tendency to extend, amputation 
is the only resource, and one which offers the patient a very fair chance of 
recovery. 
Aneurism of the Tibial Arteries. 
Aneurism of the tibial arteries is exceedingly rare. Two examples of the 
disease, affecting the posterior tibial, are contained in the tables of Crisp, 
and one of the same artery is in the collection of Norris. In 1875 I saw a 
case of spontaneous aneurism of the anterior and posterior tibial arteries, 
in consultation with Dr. De F. Willard, of this city. The patient was a ANEURISM OF THE PLANTAR ARTERY. 
733 
man sixty-five years of age, and attributed the presence of the tumor to 
a long walk. At each cardiac systole the head of the fibula was driven 
violently outward, and the whole calf pulsated visibly. The aneurism was 
cured in thirty-two hours, by digital compression* Traumatic aneurism is 
more common than the spontaneous, and may be produced by gunshot or 
punctured wounds of the leg. 
Professor Kinloch, of Charleston, has collected 22 cases of spontaneous 
aneurism of the posterior tibial: 8 were cured, 6 died, and of the remaining 
8 a portion remained with some improvement and others derived no benefit 
whatever. 
Treatment.—In the spontaneous form of the disease, pressure of the 
femoral, as in popliteal aneurism, should be first tested, and, if unsuccessful, 
it will be proper to expose the vessel and apply a ligature on both the proxi- 
mal and the distal side of the sac. In the traumatic variety, after the failure 
of compression, the femoral artery must be compressed by a tourniquet, after 
which the swelling should be thoroughly exposed, the extravasated blood 
removed, and the torn vessel tied above and below the lesion. 
Aneurism of the Dorsalis Pedis Artery. 
Aneurism of the dorsalis pedis artery is occasionally encountered, and is 
easily recognized by its position and pulsation and by the facility with which 
its circulation is controlled on making pressure over the anterior tibial artery 
in front of the ankle. The swelling varies in size from that of a cherry to 
that of a walnut. The communication of this vessel with the plantar arteries 
of the foot constitutes a sensible difficulty in attempting a cure. Barwell 
analyzes 18 cases of this aneurism: 4 of these were traumatic, 3 were be- 
lieved to be occasioned by sprains, 4 were spontaneous, and in 7 no circum- 
stances attending the origin of the disease were noticed. The result of treat- 
ment was ascertained in 14 cases. In 9 treated by pressure 2 were cured 
and 7 failed, and of the latter 2 died. The ligature was applied in 7 cases, 
in some above, and in others both above and below, the aneurism, 3 times 
with success and 4 times without success: one of the latter cases afterwards 
required amputation on account of gangrene, and a second died. 
Treatment.—Pressure over the anterior and posterior tibial arteries 
should first be employed, and, that failing, the dorsalis pedis should be tied 
both above and below the sac. 
Aneurism of the Plantar Artery. 
Aneurism of the plantar artery is exceedingly rare, and, on account of the 
numerous arterial communications, is not easily cured. 
Treatment.—Pressure should first be made over the anterior and pos- 
terior tibial arteries, and, that failing, ligation of the plantar vessel above 
and below the aneurism will be the proper procedure. 
* Philadelphia Medical Times, September 25, 1875. CHAPTER XII. 
LIGATION OF ARTERIES. 
General Observations.—No operation upon the human body demands greater 
skill or more exact anatomical knowledge than does the ligation of the great 
arterial blood-vessels. The most elaborate diagrammatic illustrations, together 
with the minutest detail of every step necessary for the execution of such a 
work, can never take the place of the dissecting- and the operating-room. 
These constitute the gymnasium where the student must train before he pre- 
sumes to attempt operations of so delicate a nature as those which constitute 
the subject of the present chapter. The surgeon, before undertaking to expose 
and ligate one of the principal arteries of the body, should possess an accu- 
rate knowledge of the surface or artistic anatomy of the region to be trav- 
ersed, which includes all the depressions, elevations, lines, and prominences 
that belong to its external configuration. He should be acquainted not only 
with all the anatomical components of the surgical regions, but also with their 
exact order and the relations which they sustain to one another. All abnormal 
distribution of vessels should also be understood. In fine, his knowledge of 
special and topographical anatomy should be so thorough that at any moment 
he can reproduce a mental picture of each particular region before a single 
incision has been made. 
Instruments.—The instruments required for the ligation of arteries are one 
or two scalpels, two forceps, one grooved director, an eyed probe, retractors, 
a tenaculum, three or four forms of the aneurismal needle, catgut or silk liga- 
tures, and a tourniquet. These instruments are represented in the cuts on 
the opposite page (Figs. 539 to 547). For dressing the wound after the 
operation, there will be required a needle, silver wire, adhesive plaster, com- 
presses, and rollers. 
As the mariner drives his ship towards some desired haven, and nears the 
point of his destination, every indentation and salient point of the coast- 
line is scanned with interest; but it is only the signals which stream from 
the towering light-house or the floating buoys which command his explicit 
faith. So it is with the surgeon who carries his operation into regions of the 
body surrounded on every side with important life-organs: every structure 
has to him a significance, but there are one or two points distinguished from 
all others, towards which he invariably and instinctively turns for light in 
every moment of perplexity or of doubt. These referential points are gener- 
ally some prominence of the skeleton, or the border of some tendon or muscle, 
selected, above all others, in consequence of invariability and fixedness of 
position. 
Prerequisites for the ligation of arteries.—The following rules may be pre- 
sented for the guidance of the operator in the ligation of vessels: 
1. There must be a distinct recognition of the position and course of the artery 
to be tied. 
To one very familiar with his art this knowledge becqmes an intuition. The 
eye glances over the surface, and a line is drawn mentally in the direction of 
the vessel. To those, however, who are. less familiar with the subject, it may 
be necessary to draw real lines between well-known points which, from ex- 
perience, have been found to indicate the course of the artery. The muscular 
swells and the intermediate depressions also convey important information, 
as the arteries occupy the intermuscular spaces, or follow a direction corre- LIGATION OF ARTERIES. 
735 
sponding to the borders of certain muscles. In order to render the latter 
prominent, it will sometimes be necessary to vary the position of a part. To 
make either the border of a muscle or the extension of lines truly valuable, 
Fig. 539. 
Fig. 540. 
Fig. 541. 
Fig. 542. 
Fig. 543. 
Fig. 544. 
Scalpel. 
Forceps. 
Grooved director. 
Eyed probe. 
Tenaculum. 
Retractor. 
the part observed or measured must be placed in the proper position, and not 
afterwards changed during the operation. Neglect of these points may lead 
the operator wide of his mark. 
Another valuable means by which to localize an artery is the use of press- 
ure, with a view to detect its pulsation. This pressure should be as direct as 
Fro. 545. 
Fig. 546. 
Cooper’s aueurisuial needle. 
Fig. 547. 
Tourniquet. 
Parrish’s aneurismal needle, consisting of a handle and a stem, 
with a number of needles of different curves. These have an eye 
near each extremity, and can he screwed to or detached from the 
stem of the instrument at pleasure. 
possible, should be made with the fingers of one or both hands (Fig. 548), and 
with no more force than is absolutely necessary to acquire the information, 
as when pressure is made obliquely to the surface or with undue power the 736 
LIGATION OF ARTERIES. 
vessel may be so far thrust out of its normal situation that, when the fingers 
are removed, the correspondence between the surface of the skin pressed and 
the artery is materially 
changed from that which 
existed where the pulsa- 
tion was felt. 
2. The exposure of the 
artery.—The order of the 
superposition of tissues in 
the body is as follows; 
first, the skin or integu- 
ment ; second, the super- 
ficial fascia, which con- 
sists of connective and 
adipose tissue; third, the 
deep fascia; and, fourth, 
the muscular structures 
and the intermuscular con- 
nective tissue. The first 
three strata should be divided separately, the second and third layers always 
being raised upon the director before being incised. A difference of opinion 
exists in regard to the direction in which the incision of the tegumentary and 
other planes of tissues should be made ; some advocating their division parallel 
with, and others obliquely to, the course of the vessel to be exposed, the 
middle of the wound answering to the part of the artery to be ligated. As 
a rule, I much prefer an incision parallel with the direction of the vessel, as 
the subsequent apposition of the sides of the wound is more easily effected 
than when it is made oblique. When, however, the operator has some dis- 
trust as to the accuracy of his anatomical knowledge, it is better to adopt 
the latter plan in regard to the skin and superficial fascia, as by so doing he 
will be more likely 
to reach the vessel. 
To prevent the skin 
from sliding when 
being divided by the 
knife, it should be 
fixed by the thumb 
and finger of the 
other hand. (Fig- 
549.) The skin, and 
the superficial and 
deep fasciae, should 
be incised to an equal 
extent. Any vessel which may bleed persistently during the preliminary 
incisions must be tied, so that there shall be no blood to embarrass the future 
steps of the operation. 
Another very important point is to ascertain the intermuscular fissure which 
leads down to the artery. This can generally be recognized before opening 
the deep fascia, if the latter be properly cleaned. The fissure will appear as 
a slightly yellow or fatty line. Another guide, which I have found of great 
value, is the presence of small vessels which, coming up from the artery in 
question, perforate the deep fascia immediately over the intermuscular fissure 
to be opened. , 
The line being determined, the deep fascia should be raised on the director 
and divided. This accomplished, the cutting edge of the knife is no longer 
to be used. The intermuscular space must be opened by running the director, 
the handle of the scalpel, or the finger upwards and downwards, and break- 
ing up the loose cellular tissue until the sheath of the vessels is reached. 
In order to identify the latter, the pulsation of the artery can generally be 
Fig. 548. 
The fingers searching for the vascular groove, and feeling for the pulsation 
of the artery ; the thigh used as an illustration. 
Fig. 549. 
The skin fixed by the fingers of the left ham! while the first incision is being made. LIGATION OF ARTERIES. 
737 
felt; if not, it will become necessary to refer to other anatomical parts, as 
nerves, veins, or prominences belonging to tbe skeleton, which are known to 
have a definite relation to the vessels. 
3. Opening the sheath.—That this may be done with entire safety, the inter- 
muscular space should be widened, by in- 
troducing on each side a retractor and 
drawing its sides apart. (Fig. 550.) If 
the wound is deep, it may be necessary 
to notch the fascia on each side, in order 
to admit of its free retraction. The 
sheath being exposed, a little fold of the 
membrane should be picked up with the 
forceps and divided, with the knife held 
in such a manner that the cutting edge 
will be directed away from the vessel. 
(Figs. 550 and 551.) The little opening 
made by the bistoury should be next en- 
larged, by introducing the point of the 
director and moving it upwards and 
downwards on both sides of the artery 
until the latter is completely isolated 
from its companion vein or veins. In 
accomplishing this part of the operation, 
no more disturbance of the sheath is al- 
lowable than will answer for the passage 
of the ligature. This is not an unimpor- 
tant requirement. If it is disregarded, 
and the membrane extensively lacerated, the nutrition of the vessel will be 
disturbed, which may interfere with the safe detachment of the ligature 
from its walls or cause a diffused perivascular abscess. 
4. The recognition and deligation of the artery.—Though the artery can 
generally be recognized by its 
pulsation, yet sometimes this 
may not be present, or may be 
so faint as to create a doubt 
in regard to the identity of 
the vessel, and then the sur- 
geon must satisfy his mind by 
other tests. Arteries have fre- 
quently been confounded with 
tendons, veins, and nerves. 
Tendons, from being almost 
pearly white and of a dense 
consistence, are in striking 
contrast with arteries, which 
have a buff color and are com- 
pressible. The thin walls of 
veins and the deep blue color of the blood, visible through their coats, are 
sufficient to distinguish them from arteries, the walls of which are thick and 
opaque. The closest resemblance exists between an artery and a nerve. The 
latter, however, rolled between the thumb and finger, imparts only the sensa- 
tion of a solid cord, while the former, treated in the same manner, is flattened, 
and conveys the feeling of two surfaces sliding on each other. In a patient 
not under the effect of an anaesthetic it would, of course, be easy to discrimi- 
nate between the two, from the painful sensations awakened by pinching the 
nerve. The recognition and isolation of the artery being completed, it should 
be raised on the director, along the groove of which may be next passed a 
probe bearing a ligature. The thread being disengaged, both director and 
probe should be withdrawn, and the trunk raised and compressed between 
Fig. 550. 
Retractors holding the sides of the incision 
widely apart, while the sheath of the vessel is 
being opened. 
Fig. 551. 
Raising a fold of the sheath and dividing it with a knife. 738 
LIGATION OF ARTERIES. 
the thumb and fingers before tying the thread, in order to ascertain that the 
pulsation is arrested below, and that no other structure is included with the 
vessel in the ligature. In some instances it will be found more convenient 
to pass the ligature by means of some one of the different needles already 
described, at the same time favoring the passage by making counter-pressure 
with the finger against the point of the instrument. Whatever instrument 
is used for this purpose, the point should be blunt, and it should always be 
introduced between the artery and the vein, so that the latter shall not be 
wounded. 
Ligation of the Innominate Artery. 
Surgical anatomy.—The innominate artery is the largest branch given off 
from the arch of the aorta. In length it varies from an inch and a half to 
an inch and five-eighths. Rising from the commencement of the transverse 
portion of the arch of the aorta, it inclines gently to the right side, and at 
the sterno-clavicular articulation divides into the right carotid and subcla- 
vian arteries. By extending the neck, the innominate can be drawn up and 
rendered more superficial. 
Enumerating the parts from the surface inwards, in front of the vessel lie 
the skin, superficial fascia, deep fascia, sternum, the great transverse and 
inferior thyroid veins, the remains of the thymus gland, the sterno-hyoid 
and sterno-thyroid muscles; behind, the artery rests upon the trachea; on 
its left side are the left carotid and a remnant of the thymus gland; and on 
the right side are the right innominate vein, the right pneumogastric nerve, 
and the inner surface of the summit of the pleura. The artery is occasion- 
ally the subject of an irregularity, both in its division and in its course. The 
bifurcation may take place above or below the sterno-clavicular articulation ; 
the first is most common: either of these departures from the normal point 
will necessarily affect its length, it being longer in the first and shorter in 
the second case. In one instance, in a subject whose neck I was dissecting, I 
observed the innominate to ascend perpendicularly out of the chest and pass 
up directly in front of the trachea, almost to the cricoid cartilage, before 
turning to the right side. The brachio-cephalic branches in this case were 
given off just as the vessel left the trachea. There are eases in which the 
innominate gives off both the right and the left carotid and the right subcla- 
vian arteries, and in rare instances the vessel has been absent. 
Ligation.—There are two incisions for the ligation of the innominate,—the 
L-shaped and the linear. The first was the one employed by Dr. Mott, and 
the second has been recommended by King and by Manec, neither of whom, 
however, ever tied the vessel. By the last method the parts are divided 
along the anterior edge of the sterno-clcido-mastoid muscle. It is simply an 
impracticable procedure, and need not be described. 
Method of Mott.—The patient is placed on his back, with the head well 
thrown back and a little inclined to the left side. The surgeon, stationed 
on the right side, makes a horizontal incision two inches and a half long 
through the skin, superficial fascia, and platysma myoides muscle, com- 
mencing at the median line of the neck, half an inch above and parallel with 
the top of the sternum and the clavicle. A second incision of the same 
length is carried down along the anterior margin of the sterno-mastoid mus- 
cle until it joins the first at the top of the sternum. The sternal and most 
of the clavicular origin of the sterno-cleido-mastoid muscle is next separated 
by a director from the underlying fascia, is divided by an incision in the direc- 
tion of the one first made, using the finger passed beneath the muscle as a guide, 
and is turned out of the way. Pressing aside the thyroid veins, the sterno- 
hyoid and thyroid muscles are now to be carefully raised on the director and 
cut across. A little scratching with the director will reveal the sheath of the 
right carotid, which should be opened and the artery traced down until the 
innominate is reached. At this stage commences the most difficult and dan- 
gerous part of the task, namely, the safe isolation of the artery and its deli- LIGATION OF THE INNOMINATE ARTERY. 
739 
gation. In using the director for the purpose of denuding the vessel, the 
utmost care must be observed to avoid the right and left innominate veins, 
and, in passing the ligature, not to injure the pleura. 
History of ligation of the innominate.—The idea of ligating the innominate 
artery was first conceived by Allan Burns. This anatomist was satisfied 
that the collateral vessels, even in the absence of so large and important a 
channel as the brachio-cephalic, would be sufficient to supply the head, neck, 
and upper extremities with blood. 
The innominate artery was first tied by Dr. Valentine Mott, of New 
York, in 1818, for subclavian aneurism, in a male patient fifty-seven years 
old. The ligature separated on the fourteenth day. Two attacks of sec- 
ondary hemorrhage followed, the one on the ninth and the other on the 
twenty-third day, from the effects of which the patient died on the twenty- 
sixth day. The ligature was found to have cut its way through the vessel 
by ulceration, but no clot had formed to close up its canal. 
The second operation was performed by Graefe, in 1822, on a man like- 
wise suffering from subclavian aneurism. The ligature separated on the 
fourteenth day, and the patient survived sixty-seven days, perishing finally 
from hemorrhage. 
The third ligation was made by Norman, in 1824, for subclavian aneu- 
rism : he lost his patient in sixty hours, from acute pericarditis. 
The fourth operation was done by Arendt, also in 1824, and proved fatal 
on the eighth day, from a rapid inflammation of the sac and pleuro-pneumonia. 
The fifth operation was performed by Hall, in 1830. It was attended 
with great difficulty, in consequence of the diseased condition of the vessel, 
which was wounded during the act of denudation, and for which the wound 
had to be tamponed. The patient died on the fifth day. 
The sixth operation was done by Bland, in a man thirty-one years of 
age. The patient died on the eighteenth day, from the effects of a hemor- 
rhage occurring the day previous. In this case the carotid and the innomi- 
nate were closed by coagula, but the subclavian remained pervious. 
The seventh operation was executed in 1837, by Lizars. The ligature 
separated on the seventeenth day, and on the twenty-first day death occurred 
from hemorrhage. 
The eighth operation was done by Hutin, in 1842. There had been a pre- 
vious wound of the axillary artery, for which the subclavian artery had been 
tied ; this had been followed by severe bleeding, to arrest which the innomi- 
nate was ligated. The patient died in twelve hours after the deligation. 
The ninth operation was performed by Cooper, of San Francisco, in 1859, 
for aneurism of the subclavian and carotid arteries. The patient died on 
the ninth day, in consequence of blood-poisoning from disease of one of the 
kidneys. 
The tenth operation was also done by Cooper, in 1860, for subclavian 
aneurism. The ligature separated on the eighteenth day. Twenty-one days 
following, hemorrhage occurred, and on the forty-first day the patient died. 
In both the operations of Cooper a portion of the sternum and clavicle, an- 
swering to the sterno-clavicular articulation, was removed to admit of an 
easy access to the vessel. 
The eleventh operation, by Gore, was performed for axillary and sub- 
clavian aneurism. Death occurred on the seventeenth day, from hemorrhage. 
The twelfth operation, the most remarkable on record, was done by 
Smyth, of New Orleans. This surgeon, in consequence of a subclavian 
aneurism having a traumatic origin, tied simultaneously the innominate 
and carotid arteries, the former a quarter of an inch below its division, the 
latter one inch above its origin. On the fourteenth dajr secondary hemor- 
rhage took place, which was arrested by filling the wound with shot. Two 
other attacks of bleeding occurred on the thirty-third and fifty-first days, 
which were controlled in the same way as in the first instance. On the 
fifty-fourth day the hemorrhage was renewed, and at this time the vertebral 740 
LIGATION OF ARTERIES. 
artery was tied. After this the brachial artery became closed. In a few 
days, however, the circulation was restored in the arm, and the patient re- 
covered. 
The cases of ligation of the innominate artery attributed to Dupuytren, 
Lynch, Pirogoff, and Peixotto cannot be said to rest on evidence sufficient 
to entitle them to unqualified acceptance. If the operations were really per- 
formed, they all, according to the testimony of those who refer to them, 
proved fatal. Admitting their genuineness, and adding the operations of 
more recent date,—viz., those of Bickersteth (1), Porter (1), Thompson (1), 
Buchanan (1), O’Grady (1), Banks (1), Pirogoff (1), and Bujalski (2),—we 
have thirteen cases besides those given in detail on the preceding page. 
Four times the operation has been abandoned after the exposure of the 
vessel, in consequence of extensive disease in the coats of the artery and 
from other structural alterations, which rendered the ligation impracticable. 
These were the cases of Porter, Post, Hoffman, and Ashton Key. 
There are, therefore, twenty-five cases of deligation of the innominate 
artery, all, with two exceptions, performed for aneurism, and all, save one, 
followed by a fatal result. The cause of death in every instance, with 
the exception of three, those of Norman and Arendt and one of Cooper’s, 
was hemorrhage; and it is more than probable that had these patients 
escaped the accidents from which they died, they would eventually have 
perished in the same manner as the others. In none of the cases, save that 
of Gore, was there even an approximation to a cure of the aneurism, and in 
this, though the sac was filled with coagulum, the tendency to hemorrhage 
was not lessened. Taking into account the close proximity of the innomi- 
nate artery to the heart, the shortness of its trunk, the force of the circula- 
tion to which it is subjected, the evil effects of disturbing the cellular con- 
nections which link together so many important structures at the cervico- 
thoracic line, and the uniform fatality attending this ligation, I have no 
hesitation in saying that, unless the animal thread alters the result, its claim 
to be accepted as a surgical procedure falls far short of that for the ligation 
of the abdominal aorta, and that it should meet with the unqualified condem- 
nation of the profession. 
Surgical anatomy.—In consequence of the right primitive carotid artery 
having its origin from the innominate, and the left from the arch of the aorta, 
it follows that in their thoracic portions the surgical relations of the two 
vessels are not identical. The artery on the right side is shorter than the 
one on the left. The left vessel passes obliquely from its origin, into the 
neck, in front of the trachea, oesophagus, and the thoracic duct, with the 
remains of the thymus body, the left innominate vein, sterno-thyroid and 
sterno-hyoid muscles in front; on the right of the vessel lies the brachio- 
cephalic artery, and on the left are the left subclavian artery and pneumo- 
gastric nerve. After the carotid arteries enter the neck their relations on 
the two sides are identical: the description of one will therefore answer for 
both. Commencing at the sterno-clavicular articulation, the carotid passes 
upwards and backwards, resting on the transverse processes of the cervical 
vertebrae, and in the direction of a line drawn from this point to the space 
midway between the angle of the jaw and the mastoid process of the tem- 
poral bone. The vessel becomes more superficial as it ascends the neck. 
The artery divides into its two branches, the external and internal carotids, 
usually opposite the hyoid bone. This division may take place a little above 
or below this point. In rare instances the vessel has been known to divide 
shortly after its origin, and occasionally the vessels have been seen to arise 
from a common trunk. In front are the skin, superficial fascia, platysma 
myoides, deep fascia, sterno-cleido-mastoid, sterno-hyoid, sterno-thyroid, and 
omo-hyoid muscles, descendens noni nerve, and anterior jugular, lingual, 
Ligation of the Common Carotid Artery. LIGATION OF THE PRIMITIVE CAROTID. 
741 
facial, and thyroid veins. Behind are placed the longus colli and rectus 
anticus major muscles, the sympathetic and recurrent laryngeal nerves, and 
the inferior thyroid artery. Internally are situated the trachea, oesophagus, 
larynx, pharynx, recurrent laryngeal nerve, and some branches of the infe- 
rior thyroid artery; and externally lie the internal jugular vein and the 
pneumogastric nerve, in the sheath with the artery. 
The vessel is crossed by the omo-hyoid muscle, and thereby divided into 
two surgical regions. The lower one, bounded by the sterno-eleido-mastoid, 
sterno-hyoid, and omo-hyoid muscles, is the anterior inferior cervical triangle 
of the topographical anatomist; and the upper one, bounded by the sterno- 
cleido, the omo-hyoid, and the base of the jaw, constitutes the anterior supe- 
rior cervical triangle. 
As the omo-hyoid muscle crosses the sheath of the vessels about its middle, 
this part becomes important in a surgical point of view, and will be found to 
correspond accurately to a line drawn directly across the neck from the cri- 
Fig. 552. 
The carotid and its branches exposed. The sterno-eleido-mastoid muscle and the external 
jugular are drawn outwards by retractors, v, the internal jugular and its tributaries ; c, the 
primitive carotid ; h, the hyoid bone. The descendens noni rests in front of the vessels, 
though external to their sheath. Between the artery and the vein runs the pneumogastric 
nerve. The omo-hyoid is seen passing beneath the sterno-mastoid. 
coicl cartilage outwards. (Fig. 552.) When the surgeon is at liberty to elect 
his operation, the vessel should be tied at the upper border of the omo-hyoid 
muscle. 
Operation below the omo-hyoid muscle.—The patient should be placed in the 
recumbent position, the shoulder raised and thrown back, the head supported 
on a pillow and turned somewThat to the opposite side. An incision should 
now be made two and a half or three inches in length along the inner border 
of the sterno-eleido-mastoid muscle, terminating at the top of the sternum. 
(Fig. 553.) The skin, superficial fascia, and platysma being divided, the deep 
fascia comes into view. Making a small opening into this membrane for the 
entrance of a director, it should be slit up to the full extent of the external 
incision, at the same time taking care that the anterior jugular, if present, 
be not injured. At this stage of the operation a retractor should be inserted 
on each side of the wound and the parts drawn asunder. This done, another 742 
LIGATION OF ARTERIES. 
layer of the deep cervical fascia will be exposed, passing between the sterno- 
hyoid and sterno-thyroid muscles posteriorly and the sterno-mastoid ante- 
riorly. This will require to be 
raised and opened, that the di- 
rector may be introduced, after 
which it should be carefully di- 
vided,—not torn, as is sometimes 
done, an injury well calculated 
to favor a deep, ditfused suppu- 
ration which may travel into the 
mediastinum or into other parts 
of the chest. If now the sterno- 
hyoid and sterno-thyroid muscles 
be drawn inward towards the 
trachea, and the sterno-mastoid 
outward,—which can be accom- 
plished most easily by bringing 
the head a little forward,— the 
sheath of the carotid will be 
brought into view, lying in front 
of which will probably be seen 
the deseendens noni nerve. A 
little fold of the sheath should 
now be picked up with the for- 
ceps and divided, in doing which 
the edge of the knife should be 
directed forward. With the 
point of the director introduced 
through this opening the isola- 
tion of the artery is commenced, 
during which the internal jugular 
vein, occupying the outer side of 
the sheath, will be seen alternately swelling and subsiding as the chest is con- 
tracted and dilated during the acts of expiration and inspiration. Cautiously 
separating the artery, on the inside from the pneumogastric nerve, and on the 
outside from the vein, the thread is next conducted around the vessel from 
without inward, so as to avoid injury to either nerve or vein. In passing the 
needle beneath the artery, it must not be forgotten that the sympathetic nerve 
is situated posteriorly, and, though external to the sheath, might be injured 
if this part of the operation were done in a careless manner. 
In cases where from any cause difficulty is experienced in exposing the 
artery in this region, the sternal part of the sterno-mastoid muscle may be 
cut across, and, if necessary, the sterno-hyoid and sterno-thyroid muscles 
may be treated in a similar manner. In one instance Mr. Key was obliged 
to divide the first-named muscle before he could secure the artery; and Mr. 
Porter, of Dublin, in another case, was able to tie the vessel close to its origin 
by dividing all of these muscles. 
Ligation of the common carotid above the omo-liyoid muscle.—This operation is 
not only much easier of execution from the superficial position of the vessel, 
but is always to be preferred for the application of a ligature, unless some 
peculiarity in the case prevent. 
Operation.—The patient should be placed in the same position as when the 
vessel is tied below. An incision commencing one inch below the angle of 
the jaw should be carried down along the anterior border of the sterno- 
mastoid muscle, terminating half an inch below the cricoid cartilage. The 
superficial fascia, the platysma myoides, and the deep fascia are next to be 
divided consecutively on the director and to the extent of the cutaneous 
incision. Turning the edge of the sterno-mastoid muscle outward and 
bringing the head slightly forward, the intermuscular layer of the deep fascia 
Tig. 553. 
Lines of incision for the ligation of the different arteries 
of the neck, face, and first part of the axillary. LIGATION OF THE PRIMITIVE CAROTID. 
743 
can be next raised and divided, when the sheath of the vessels will be exposed, 
with perhaps the descendens noni nerve, and probably the communicans noni 
likewise. A small duplicature of 
the sheath being now raised with 
the forceps and cautiously opened, 
the director is to be inserted and 
the artery carefully separated 
from the companion nerve and 
vein, after which the needle, in- 
troduced between the artery and 
the pneumogastric nerve and the 
internal jugular, should be passed 
from without inward, carrying 
with it the ligature with which 
the vessel is to be tied. (Fig. 554.) 
The ligation of the primitive ca- 
rotid may be required for the 
cure of aneurism and of erectile 
growths, and also in consequence 
of lesions of the vessel itself, 
caused either accidentally or in 
the removal of tumors, in which 
case the thread should be ap- 
plied on both sides of the wound. 
Tying the carotid on account of 
wounds of its branches cannot be 
regarded as a wise surgical pro- 
cedure. Eecurrent hemorrhage 
will be likely to follow. It may 
be laid down as a rule that in 
wounds of the arteries of the neck the only safe practice is to tie the injured 
vessel, not the trunk from which it arises, and always with a double ligature, 
one on each side of the lesion. 
Collateral circulation.—When the blood-flow through the primitive carotid 
is interrupted by a ligature, the 
circulation is restored to the upper 
part of the neck and to the head by 
inosculation between the inferior 
thyroid arteries from the thyroid 
axis and the superior thyroid ar- 
teries of the external carotids, 
and also between the ascending 
branches of the tranversalis colli 
from the thyroid axis and the 
princeps cervicis from the occipital. 
(Fig. 555.) There is also a free 
communication between the inter- 
nal and the external carotid both 
on the outside of and within the 
skull. It is these numerous inoscu- 
lations which explain the recur- 
rence of hemorrhage even after the 
ligature of the common carotid; 
and to meet this difficulty, at least 
so far as the communication be- 
tween the two carotids is con- 
cerned, it has been suggested, and 
in one case successfully executed, by Dr. Clurdon Buck, of New York, to tie 
at the same time the common and the internal carotid vessels. 
Fig. 554. 
The sides of the wound held asunder by retractors, and the 
common carotid raised on the needle passed from without 
inward, in order to avoid the pneumogastric nerve and the 
internal jugular vein. 
Fig. 555. 
Collateral circulation after ligature of the common carotid: 
a, ligature placed upon the carotid; 6, thyroid axis giving 
off a branch which runs inward, the inferior thyroid, and 
one which passes outward, the transversalis colli,—the first 
inosculating with the superior thyroid at d, from the external 
carotid of the same side, and the second communicating by 
its ascending branch with the princeps cervicis or descend- 
ing branch of the occipital at e, also from the external carotid. 744 
LIGATION OF ARTERIES. 
The mortality following the ligation of the carotid has been very great, 
both in civil and in military surgery. Dr. Norris has tabulated 149 cases of 
ligation of the primitive carotid.* Of this number, 94 recovered, 54 died, 
and in 1 the result was not determined. These ligations were classified, and 
I arrange them in a tabular form, as follows: 
Disease. 
Cured. 
Recovered. 
Died. 
Unknown. 
Aneurism 
38 
22 
16 
Wounds 
30 
15 
15 
Extirpation of tumors before and at the time of 
operation 
18 
12 
6 
Cerebral affections 
6 
6 
0 
Erectile tumors or arterial varices of the head or 
face 
31 
23 
8 
Cure or arrest of growth of other tumors 
11 
6 
5 
Brasdor’s operation for aneurism 
15 
10 
4 
1 
Total 
149 
94 
54 
1 
Dr. Pilz, of Breslau,f has collected 586 well-authenticated and 14 partially- 
corroborated ligations of the common carotid, in all making 600, of which 
number 319 recovered, 259 died, and 22 were without known result. This 
would show 43 deaths in every 100 cases of ligation. Dr. Pilz has followed 
the classification of Norris in arranging the affections for which the vessel 
was tied, as follows ■ 
Disease. 
Cases. 
Cured. 
Died. 
Unknown. 
228 
94 
128 
6 
87 
55 
31 
] 
142 
87 
49 
6 
71 
38 
8 
34 
33 
1 
38 
12 
25 
1 
600 
319 
259 
22 
An analysis of both Norris’s and Pilz’s tables shows that the danger of 
carotid ligations does not depend so much on the size or location of the 
vessel as on the character of the disease for which the operation is done. Thus, 
out of 40 ligations for the cure of cerebral disease (such as epilepsy, etc.), 
included in the two tables, all recovered from the operation save 1, while of 
125 in which the artery was tied for aneurism, 47 died. In a list of 30 cases, 
tabulated by Dr. Morton, in which the common carotid was ligated for the 
cure of intraorbital aneurism, 27 recovered and 3 died.J—another illustra- 
tion of the comparative harmlessness of the operation in instances where the 
disease does not affect the soundness of the vessel. 
Between the years 1836 and 1876 the primitive carotid was ligated in the 
Pennsylvania Hospital nine times, with 6 deaths and 3 recoveries.§ 
In military practice the mortality attending this operation reaches its max- 
imum. During our late war there were 116 ligations of the common carotid 
for wounds of the face and the neck, 81 of which died.|| In every instance in 
which the vessel was tied for a shot- or sabre-wound 'of the neck the patient 
perished. The great fatality attending deligation after such injuries, how- 
ever, must be referred to causes which in themselves are necessarily fatal 
independent of the operation. 
* Contributions to Practical Surgery. f Langenbeck’s Archives, 1868, vol. ix. pp. 257-455. 
J American Journal of the Medical Sciences, April, 1865. 
| Ibid., April, 1876. || Surgical History of the War, Part I., surg. vol. LIGATION OF THE PRIMITIVE CAROTID. 
745 
Maunder has analyzed 106 cases of ligature of the carotid, of which num- 
ber 72 died and 34 recovered. 
The organ which seems to suffer most after ligature of the common carotid 
is the brain, and accordingly we find that cerebral affections stand first 
among the causes of the mortality following this operation. 
In the cases analyzed by Norris, 31 patients perished from brain-disease, 
and in those of Piiz the mortality from this cause was in about the same 
proportion. The relative frequency with which cerebral symptoms arise 
after deligation of the primitive carotid for the cure of the various diseases 
enumerated is approximately as follows: after aneurism, once in every three 
cases; after wounds, once in every four cases; before and during the extir- 
pation of tumors, once in every nine cases; for cerebral disease, once in every 
thirty-four cases ; after Brasdor’s method, once in every seven cases; and for 
erectile tumors, once in every five cases. The greatest immunity—almost 
complete, indeed—appears to have been where the ligation was done for the 
cure or relief of certain nervous affections, such as epilepsy, neuralgia, etc. 
Hemorrhage comes next in order to cerebral disease as a cause of death 
after the ligation of this artery. 
The following cases, collected from various medical journals by Dr. Hunter, 
and tabulated by me, embrace most of the ligations of the common carotid 
on record between 1867 and 1877 : although many ligations of this vessel 
have been made since, yet their collection and analysis would not materially 
alter the deductions drawn from the present table: 
No. 
Operator and Date. 
Side. 
Sex. 
Age. 
Disease. 
> 
"cl 
References and Remarks. 
6 
© 
Ph 
o 
1 
A. Hew son, 1867. 
Right 
Male. 
51 
Innominate aneurism. 
l 
Pennsylvania Hospital Re- 
ports, vol. ii. 
2 
W. Hunt, 1868. 
Female. 
28 
Hemorrhage. 
i 
Am. Jour. Med. Sci., April, 
1876. 
3 
T. Morton, 1869. 
Left. 
Male. 
27 
Hemorrhage. 
i 
Am. Jour. Med. Sci., April, 
1876. 
4 
Mr. Jas. Lane, June 28, 
Right. 
“ 
39 
Aneurism. 
i 
Lancet, October 14, 1871. 
1871. 
5 
Mr. Gambee, April 15, 
Left. 
“ 
Aneurism. 
i 
Lancet, June 3, 1871. 
1871. 
6 
Mr. Jas. Lane. 
Right. 
Female. 
40 
Aneurism at the root 
i 
Lancet, Jan. 13, 1872. Sub- 
of the neck. 
clavian and carotid both 
tied. 
7 
Mr. Heath, for Dr. 
Left. 
Male. 
48 
Aneurism of aorta. 
i 
Lancet, April 20, 1872. 
Cockle, Feb. 26, 1872. 
8 
Mr. Z. Lawrence, Feb. 
“ 
“ 
41 
Aneurism, intraorbital. 
i 
British Medical Journal, Oc- 
19, 1867. 
tober 5, 1867. 
9 
Dr. Christ. Fleming. 
“ 
40 
Aneurism. 
i 
Dublin Jour. Med. Sci., Au- 
gust, 1873. 
10 
Mr. Bowker. 
y’th 
i 
Lancet, October 11,1873. 
the internal maxil- 
lary artery. 
Secondary hemorrhage 
after removal of in- 
11 
Dr. H. B. Sands. 
i 
New York Medical Journal, 
Jan. 1874. 
ferior maxillary. 
12 
Mr. Ilulke. 
Left. 
Male. 
31 
Secondary hemorrhage 
i 
Medical Times and Gazette, 
after removal of cer- 
vical tumor. 
November 29, 1873. 
13 
Dr. R. W. Gebber. 
“ 
40 
Traumatic aneurism. 
i 
Charleston Medical Journal 
and Review, January, 1874. 
Wire ligature used. 
14 
Dr. Robt. Reyburn. 
Right. 
25 
Aneurism. 
i 
Am. Jour. Med. Sci., 1868, 
15 
i 
lvi. 112. 
Medical Record, 1869, vol. iii. 
p. 531. Carotid and sub- 
Dr. H. B. Sands. 
nate. 
clavian tied. 
16 
Dr. H. E. Foote. 
“ 
Male. 
20 
Orbital aneurism. 
i 
New York Medical Record, 
1868, vol. iii. p. 75. Both 
carotids tied. Interval 
one year. 
17 
Joseph Bell. 
Left. 
“ 
42 
Orbital aneurism. 
i 
Edinburgh Medical Journal, 
1867. p. 36. 
18 
Dr. Stephen Smith. 
i 
Right. 
44 
illary. 
Aneurism. 
i 
1876, p. 608. 
Pacific Med. and Surg. Jour., 
August, 1872. 
19 
Dr. P. Dupuytren. 
20 
Dr. G. E. Frothingham. 
Orbital aneurism. 
i 
Michigan University Med. 
Jour., August, 1872. LIGATION OF ARTERIES. 
No. 
Operator and Date. 
Side. 
Sex. 
Age. 
Disease. 
| Recoveries. 
| Deaths. 
References and Remarks. 
21 
Dr. W. H. Bramlette. 
Left. 
Shot wound of the face. 
1 
New York Medical Record, 
1869, ’70, iv. 194. 
St. George’s Hospital Re- 
22 
H. Lee. 
Right. 
Male. 
40 
Aneurism. 
1 
ports, 1870, v. 277. 
23 
H. Lee. 
Left. 
31 
Tumor of the neck. 
1 
St. George’s Hospital Re- 
ports, 1871, ’72, vi. 384. 
24 
T. Holmes. 
Right. 
** 
50 
Thoracic aneurism. 
1 
St. George’s Hospital Re- 
ports, 1871, ’72, vi. 387. 
25 
Pick (3). 
<< 
19 
Ulceration of lingual 
artery. 
1 
St. George’s Hospital Re- 
ports, 1872, ’74, viii. 309. 
26 
T. Holmes. 
Left. 
Female. 
21 
Aneurism of the arch 
1 
Clinical Society’s Transac- 
of the aorta. 
tions, 1876, ix. 114. 
New York Medical Record, 
27 
Dr. J. 0. Hutchison. 
Right. 
Male. 
48 
Aneurism of the arch 
1 
of the aorta. 
1867, ’68, ii. 265. Carotid 
and subclavian tied. 
28 
E. Colsen, Bombay 
Left. 
“ 
48 
Aneurism of the exter- 
1 
Lancet, February 24, 1877. 
Army. 
nal carotid. 
29 
Fred. Ensar, Surgeon 
Right. 
“ 
50 
Aneurism of innomi- 
1 
Lancet, February 6 and July 
Port Elizabeth Ilos- 
nate. 
31, 1875. Carotid and sub- 
pital, South Africa. 
clavian tied. 
30 
0. F. Maunder, Sep- 
Left. 
“ 
37 
Aneurism of innomi- 
1 
Lancet, January 9,1875. 
tember 18, 1867. 
nate. 
31 
C. F. Maunder, Sep- 
“ 
26 
Aneurism. 
1 
Lancet, January 9, 1875. 
tember 22, 1868. 
Lancet, March 16, 1872, p. 
. 357. 
32 
Mr. G. E. Legge Pearce. 
Right. 
55 
Cancer of tongue. 
1 
33 
Dr. Marquardt, of 
“ 
“ 
Stab in the neck. 
1 
Allg. Med. Central Zeit., De- 
Thorn. 
ceniber 1, 1869. 
34 
Mr. J. Wright Baker. 
Left. 
Female. 
32 
Hemorrhage following 
1 
Lancet, June 11, 1870. 
removal of a tumor 
of the neck. 
35 
Mr. H. Knowles. 
Right. 
Male. 
42 
Innominate aneurism. 
1 
Lancet, June 13,1868, p. 750. 
36 
Prof. Ricliet. 
Left. 
Female. 
63 
Orbital aneurism. 
1 
Annales d’Oculistique, 1869, 
t. 61, p. 186. 
Odessa Klin. Monatsschr., 
37 
Dr. Schmidt. 
Right. 
Male. 
23 
Orbital aneurism. 
1 
1871, ix. 219. 
38 
Dr. Gurdon Buck, 1857, 
R.&L. 
“ 
22 
Orbital aneurism, trau- 
1 
New York Medical Journal, 
1859. 
matic. 
1869, p. 664. 
39 
Dr. Halstead. 
Left. 
37 
Orbital aneurism, trau- 
1 
New York Medical Journal, 
matic. 
1869, p. 665. 
40 
F. M. Garner. 
Right. 
“ 
33 
Orbital aneurism. 
1 
Trans. Hunterian Soc., 1874. 
41 
Nelaton. 
Left. 
Female. 
17 
Orbital aneurism, trau- 
1 
Lancet, 1873. 
matic. 
42 
Schiess, Gemuseus, and 
“ 
40 
Orbital aneurism, trau- 
1 
Klin Monat. fur Augen- 
Socin. 
matic. 
heilk., vol. viii. p. 57,1870. 
43 
Drs. A. V. Hippel and 
Right. 
Male. 
21 
Orbital aneurism, trau- 
1 
Graefe’s Arch, fur Ophth., 
Schonborn. 
matic. 
Bd. xx., Abth. 1. 1874. 
44 
Dr. Rivington. 
Left. 
“ 
24 
Orbital aneurism, trau- 
1 
Medico-Chirurgical Transac- 
matic. 
tions, 1875. 
45 
Dr. Niedeu. 
19 
Orbital aneurism, trau- 
1 
Klin. Monat. fiir Augen- 
matic. 
heilk., Jan. Heft, 1875. 
Della Chirurgia in Italia, 
46 
Dr. Gervase. 
Right. 
“ 
34 
Orbital aneurism by 
1 
anastomosis. 
etc., di Alfonso Carrudi, 
Bologna, 1871, p. 131. 
British Medical Journal, Oc- 
47 
Mr. Thos. Annandale, 
“ 
62 
Orbital aneurism. 
1 
March 2, 1875. 
tober 30, 1875. 
48 
Dr. Eugene Peugnet. 
R.&L. 
« 
New York Medical Record, 
ferior maxilla. 
February 5. 1876. 
49 
Dr. G. E. Frothingham. 
Right. 
“ 
23 
Traumatic aneurism. 
1 
Am. Jour. Med. Sci., Oct. 
1876, p. 433. 
50 
D. J. Elliot. 
“ 
41 
Innominate aneurism. 
1 
Am. Jour. Med. Sci., April, 
1877. Subclavian artery 
also tied. 
51 
Mr. Le Gros Clark, 
Left. 
“ 
57 
Hemorrhage after re- 
1 
Medical Times and Gazette, 
June 17, 1872. 
moval of a cancer 
of antrum. 
February 1, 1873, p. 113. 
52 
G. Annesloy, Dr. Ma- 
hon. 
Right. 
Wound of superior 
laryngeal artery. 
1 
British Medical Journal, 
April 10, 1869, p. 329. 
British Medical Journal, 
53 
Mr. James Lane, No- 
Left. 
Male. 
37 
Occipital aneurism, 
1 
vernber 12, 1873. 
traumatic. 
May 15. 1875. 
54 
Mr. Savory, July 17, 
Right. 
“ 
48 
Secondary hemorrhage 
1 
British Medical Journal, 
1872. 
from external carotid 
February 22, 1873. 
55 
Mr. E. S. O’Grady. 
<< 
Subclavian aneurism. 
1 
Brit. Med. .lour., May 10, 
1873, p. 543. Innominate 
and right carotid tied. 
56 
Mr. S. Gambee. 
Left. 
Aneurism, innominate. 
1 
British Medical Journal, 
May 27, 1871, p. 566. 
57 
T. Morton, 1874. 
« 
Female. 
23 
Supposed intraorbital 
1 
Am. Jour. Med. Sci., April, 
aneurism. 
1876. 
58 
T. Morton, 1876. 
Male. 
43 
Pulsating orbital tu- 
1 
Am. Jour. Med. Sci., April, 
mor. 
1876. 
59 
Dr. B. M. Smith, 1877. 
<• 
1 
Virginia Medical Monthly, 
October, 1877. 
rotid. 
60 
Agnew. 
“ 
Female. 
Aneurism of internal 
1 
carotid. 
61 
Agnew. 
Right. 
39 
20 LIGATION OF THE PRIMITIVE CAROTID. 
747 
Of the above 61 ligations, 26 were on the right side, 29 on the left, 2 on both 
sides, and in 4 the side is not stated; 41 were males, 8 females, and in the 
remaining number the sex is not stated; 39 recovered, 20 died, and in 2 no 
result is given. The causes rendering the ligation necessary were aneurism, 
spontaneous and traumatic,—15 being intraorbital,—cancer of the maxillae 
and of the tongue, hemorrhage attending the removal of tumors from the 
neck, shot wounds of the face, and wounds of the lingual and laryngeal 
arteries. 
The period of separation of the ligature from the vessel varies from the ninth 
to the twentieth day. 
Ligation of both primitive carotids.—This operation has been done twenty- 
nine times, with 20 recoveries and 9 deaths. In one case, Dr. Mott, for dis- 
ease of the parotid gland, tied both common carotids at an interval of fifteen 
minutes. The patient died in forty-eight hours, in a state of coma. 
The diseases for which double consecutive ligation has been performed are 
erectile growths of the head and face, vascular tumors of the orbits, epilepsy, 
hemorrhage, and elephantiasis of the neck and face. It does not appear that 
in these eases of double ligation cerebral symptoms occurred more frequently 
than when only the vessel on one side was tied. The circumstances which 
justify its performance will seldom arise. As a means of curing angeiomatous 
growths about the head and face, or of combating epilepsy, it possesses little 
value. Seldom will the surgeon encounter a case of bilateral orbital aneu- 
rism ; so that its utility is narrowed down to cases of hemorrhage, in which, 
being the only resource of the surgeon, it is entirely justifiable. 
The subjoined table contains most of the recorded cases of the ligation of 
both common carotid arteries: 
Table of Consecutive Ligations of both Primitive Carotid Arteries. 
Name of Operator. 
Age. 
Disease. 
Date and Interval of ligations. 
Result. 
1. Dupuytren and 
Robert. 
Aneurism by anas- 
tomosis of the 
Dupuytren tied the right carotid in 
1819. In 1857 Robert tied the left 
symptoms; pa- 
scalp. 
carotid, in consequence of an in- 
ralysis on one 
crease in the disease. Interval, 
thirty-eight years. 
side. 
2. Magill.* 
1823. One month between the liga- 
tions. 
Recovered. 
both orbits. 
3. Oilman. 
20 
Erectile tumor of 
Left ligated in 1823; right, the fol- 
Death from hemor- 
the orbit. 
lowing year. 
rhage on the third 
day. 
4. Mussey.f 
20 
Aneurism by anas- 
Left tied Sept. 20; right tied Oct. 2, 
Recovered. 
tomosis of the 
scalp. 
1827 ; twelve days between. 
5. Mussey. 
19 
Aneurism by anas- 
Twenty-eight days between ligations. 
Recovered. 
tomosis of the 
scalp. 
6. Mdller. 
7. Langenbeck. 
4i 
Erectile tumor. 
Hemorrhage follow- 
One carotid tied Sept. 13, and the 
other Sept. 28, 1831. 
Recovered. 
Died the following 
ing ligation of the 
superior thyroid. 
day. 
8. Preston. 
50 
Epilepsy. 
Right tied Aug. 23, 1831 ; left tied 
Recovered. 
Nov. 14 of the same year. 
9. Kuhl. 
53 
Anastomotic aneu- 
Left tied May 24, 1834; right tied 
seventy-two days afterwards. 
Recovered. Opera- 
rism of the scalp. 
tion was followed 
by cerebral symp- 
toms and hemor- 
hages. 
10. Hamilton. 
18 
Epilepsv. 
Right tied Aug. 1838; left tied March, 
Recovered, though 
1839. 
the last operation 
was followed by 
paralysis of the 
tongue and by 
disorganization of 
the left eye. 
11. Velpeau. 
29 
Anastomotic aneu- 
Right tied Aug. 1839; left tied three 
Recovered. 
rism of both orbits. 
months afterwards. 
12. Pirogoff. 
20 
Hemorrhage from 
Left tied May 16, 1843; right tied 
Recovered; cerebral 
symptoms follow- 
an anastomotic 
June 9, 1844. 
aneurism of the 
ing each opera- 
scalp. 
tion. 
* New York Medical and Physical Journal, vol. : 
j- American Journal of the Medical Sciences, vol. 
iv. p. 576. 
U v. p. 316. 748 
LIGATION OF ARTERIES. 
Table of Consecutive Ligations of both Primitive Carotid Arteries.—( Continued.) 
Name of Operator. 
Age. 
Disease. 
Date and Interval of Ligations. 
Besult. 
13. Mott. 
Malignant disease 
of the parotid 
glands. 
Fifteen minutes between the opera- 
tions. 
Died in forty-eight 
hours, from coma. 
14. Mott. 
Epilepsy. 
Six months between the operations. 
Becovered. 
15. Ellis. 
Secondary hemor- 
rhage following 
gunshot wound. 
Interval of four and a half days. 
Recovered. 
16. J. M. Warren. 
23 
Erectile tumor 
affecting face, 
mouth, and neck. 
Oct. 5, 1845, tied the left; Nov. 7 of 
the same year, tied the right. 
Becovered. 
17. Robert. 
Aneurism by anas- 
tomosis of the 
scalp. 
Tied the left June 5, 1846; the right 
Feb. 22, 1847. 
Becovered. Opera- 
tion was followed 
by cerebral symp- 
toms and tempo- 
rary loss of vision. 
18. Blackman. 
15 
Vascular growth of 
the antrum and 
the nose. 
Twenty-one days between the liga- 
tions. 
Recovered. Tem- 
porary loss of vis- 
ion in the left eye. 
19. Reynolds and 
Van Buren. 
45 
Aneurism by anas- 
tomosis. 
Bight tied in 1844; left tied in 1850. 
Becovered. 
20. W. Parker. 
42 ’ 
Malignant disease 
of the antrum. 
Thirty-two days between the opera- 
tions. 
Death. 
21. J. K. Wood. 
53 
Malignant disease 
of the antrum. 
Bight tied July 18, 1856; left tied 
Dec. 26 following. 
Death on the six- 
tieth day. There 
was delirium, with 
other signs of con- 
stitutional dis- 
turbance. 
22. Weber. 
20 
Epilepsy. 
Left tied July 18, 1856; right tied 
Dec. 2 following. 
Becovered, though 
the disease was 
not cured. 
23. Dr. Gurdon 
Buck.* 
22 
Intraorbital an- 
eurism. 
Bight carotid tied in 1857; left carotid 
tied in 1859; two years between the 
operations. 
Becovered. 
24. Carnochan. 
44 
Elephantiasis of 
the lace and 
neck. 
Bight tied Nov. 1858; left tied June, 
1859. 
Recovered. Disease 
not cured, though 
improved. 
25. Murdock, P. A., 
C.S.f 
Hemorrhage after 
shot wound of the 
neck. 
Left tied May 12, 1863; right tied 
May 15, 1863. 
Died. 
26. Billroth. 
27 
Hemorrhage from 
syphilitic ulcera- 
tion of the carotid, 
consequent on 
caries of the tem- 
poral bone. 
Bight tied Dec. 13, 1864; left tied 
Dec. 26 following. 
Died from second- 
ary hemorrhage. 
27. Buenger. 
34 
Aneurism by anas- 
tomosis ; suicidal 
wound. 
Left first tied, and for the aneurism; 
five years after, the right, for 
wound. 
Recovered, with the 
loss of the right 
eye. 
28. Foot.t 
20 
Orbital aneurism. 
Thirty days between the operations. 
Becovered. Disease 
cured. 
29. Agnew. 
40 
Aneurism of inter- 
nal carotid. 
Left first tied; ten days after, the 
right. 
Died subsequently 
from rupture of 
sac. 
* New York Medical Journal, 1869, p. 664, 
t Surgical History of the War of the Rebellion, Part I., p. 421. 
| New York Medical Record, 1868, vol. iii. p. 75. 
History of the ligation of the 'primitive carotid artery.—Mr. Abernethy has 
generally been credited with having first performed this operation, in 1798. 
Hebenstreit, however, refers to an earlier operation, a case in which a sur- 
geon, in removing a malignant growth from the neck, wounded the common 
carotid, on account of which he tied the artery. lie does not mention the 
name of the operator, nor does he state that he witnessed the accident which 
gave rise to the ligation, or that any record of the fact had been made. 
The necessity for the operation in Abernethy’s case arose from a wound of 
the neck, inflicted by the horn of an infuriated cow. Mr. Fleming,* in 1803, 
made the first successful ligation of the common carotid, for a self-inflicted 
wound of the neck. In 1805 this vessel was first tied by Sir Astley Cooper 
for aneurism, and in 1808 it was again tied by the same surgeon. The first 
operation was unsuccessful, the patient djdng on the thirteenth day. The 
second was followed by recovery. The following year, 1809, the vessel was 
ligated by Travers for orbital aneurism, with entire success. 
* Medico-Chirurgical Journal, vol. iii. p. 50. LIGATION OF THE EXTERNAL CAROTID. 
749 
Ligation of the External Carotid and its Branches. 
Surgical anatomy.—The external carotid artery and its branches, together 
with the internal carotid, all lie in the anterior superior cervical triangle,— 
that is, in the space which is bounded externally by the anterior border of 
the sterno-cleido-mastoid muscle, internally by the median line of the neck, 
above by a line extending from the mastoid process of the temporal bone 
along the base of the jaw to the chin, and below by the intersection of the 
omo-hyoid muscle with the sterno-mastoid, the latter point being the apex 
of the triangle. (Fig. 556.) The course of the external carotid is from the 
Fig. 556. 
The anatomical components of the anterior superior cervical triangle. The retractors 
draw aside the sterno-mastoid muscle and expose the primitive and the external carotid 
and its branches; also the internal jugular, v, with its tributaries, the facial, lingual, and 
pharyngeal; p, parotid gland ; h, os hyoides, to which is attached the stylo-hyoid 
muscle, through which is seen running the tendon of the digastric, under which passes 
the hypoglossal nerve, after crossing the external carotid ; a, hook raising the submaxillary 
gland in order to expose the contiguous parts. 
superior border of the thyroid cartilage, upwards and backwards, to the deep 
sulcus behind the angle of the jaw, occupied by the parotid gland, underneath 
which it passes, ascending to the neck of the condyle of the lower maxillary 
bone, where it divides into its internal maxillary and temporal branches. 
Except it be the first part of the subclavian artery, no other vessel is sur- 
rounded with such a throng of closely-packed structures. In front will be 
found the skin, superficial fascia, platysma myoid, deep fascia, lymphatic 
glands, lingual and facial veins, hypoglossal nerve, and digastric and stylo- 
hyoid muscles ; behind are placed the superior laryngeal and stylo-pbaryngeus 
muscles; and internally are the hyoid bone and the pharynx. (Fig. 556.) I 
do not speak of the anatomical relations of the artery within the limits of the 
parotid regions, where, except in case of wounds or in removing the parotid 
gland, the vessel is not the subject of ligation. 
It may become necessary to ligate the external carotid in consequence 
of a wound of the vessel, or for the cure of an aneurism affecting one of its 
branches. When done for the arrest of hemorrhage, the thread should be 750 
LIGATION OF ARTERIES. 
placed on both sides of the lesion. Mott tied this artery while removing 
the inferior maxillary bone, and Lizars also, in an operation for the excision 
of the superior maxillary. In cut-throat cases, where one of the branches of 
the external carotid is wounded, and where, in consequence of the extrava- 
sated blood in the tissues of the neck, it may be found difficult to discover 
the bleeding vessel, the surgeon may be tempted, as the easiest task, to tie 
the parent trunk. The operation, however, is by no means reliable. The 
free anastomosis which exists between the branches of the two sides would 
most probably be followed by a recurrence of the hemorrhage. On this ac- 
count the double ligation of the wounded vessel should be deemed the only 
safe practice, and this, with a little patience, can generally be accomplished. 
If, however, a different course should be adopted, namely, that of tying the 
external carotid on one side, in consequence of a wound, for example, of the 
superior thyroid, and secondary hemorrhage should follow, in the event of 
not being able to find the bleeding branch it would be proper to tie the ex- 
ternal carotid of the opposite' side. 
Operation.—The patient should be placed in the same position as that 
directed for the ligation of the common carotid. An incision should be made, 
commencing midway between the angle of the jaw and the anterior border 
of the sterno-mastoid muscle, and carried down three-eighths of an inch in 
front of the latter to a point half an inch below the upper border of the thy- 
roid cartilage. (See line of incision, Fig. 553.) The skin, superficial fascia, 
platysma, and deep fascia being carefully laid open,—the last three layers 
upon the director,—the operator will encounter the facial and lingual veins, 
and frequently one or two glands. If these cannot be readily pressed 
aside, it will be best to pass a needle, armed with a thread, at two points 
underneath these trunks, and divide them between the threads. At this 
stage the vessel may be discovered crossed by the hypoglossal nerve and 
the stylo-hyoid and digastric muscles. Tt should now be carefully isolated 
by the director from the internal carotid and the internal jugular, both of 
which lie close along its outer side. The contracted space in which the sur- 
geon is obliged to work renders this part of the operation one of great deli- 
cacy to avoid inflicting some injury on the vein. After being satisfactorily 
separated from the surrounding parts, the vessel should be raised by passing 
the needle between the two carotids, and from without inward, when the 
ligature can be detached and tied. 
Ligation of the external carotid, when considered in the light of M. Guyon’s 
statistics,* has proved a much more successful operation than could possibly 
have been expected from the anatomical peculiarities of the vessel. Of 19 
cases collected by the writer in which this artery was tied, only one proved 
fatal from hemorrhage, and none from causes which could properly be attrib- 
uted to the operation. 
Ligation of the Superior Thyroid.—The superior thyroid is the first branch 
given off by the external carotid, and leaves the vessel about one-quarter of 
an inch below the great horn of the hyoid bone. Its course is upwards, in- 
wards, and downwards, describing a curve before reaching its destination in 
the thyroid body. The vessel is covered in front by the skin, superficial fas- 
cia, platysma myoid. deep cervical fascia, and a few small veins. Before enter- 
ing the thyroid body it divides into several branches, which pass beneath the 
omo-hyoid, sterno-hyoid, and sterno-thyroid muscles. 
The vessel may require to be ligated in case of suicidal or other wounds, 
and it has been tied with a view to diminish a hypertrophied thyroid gland. 
Only a single case is noted during the late American war in which this 
artery was tied.f 
Operation.—An incision along the anterior edge of the sterno-mastoid 
muscle should be made, similar to that for exposing the external carotid, 
# Mtimoires de la Soci6t6 de Chirurgie, 1863, t. vi. p. 197. 
f Surgical History of the War of the Rebellion, Part I., surg. vol., p. 397. LIGATION OF THE LINGUAL ARTERY. 
751 
though it need not commence quite so high in the neck. The skin, super- 
ficial fascia, platysma myoid, and deep fascia being divided, search should 
be made by the director in the deep sulcus between the upper extremity of 
the larynx and the great vessels of the neck. When discovered and de- 
nuded, the needle should be passed round the vessel from above downwards, 
and with the point somewhat directed towards the thyroid body, in order to 
avoid any injury to the carotid. 
Ligation of the Lingual Artery.—This operation is one of the most difficult 
of all ligations. 
Surgical anatomy.—The artery is the second branch furnished from the 
anterior aspect of the external carotid. It leaves the parent vessel about a 
quarter of an inch above the superior thyroid, nearly opposite the great horn 
of the hyoid bone. It first ascends above the level of the latter, and then 
curves abruptly downwards and inwards, and, passing underneath the outer 
margin of the hyoglossus muscle, runs 
parallel with and close to the superior 
cornu of the hyoid bone, finally ascend- 
ing to the tongue, along the under sur- 
face of which it extends from the base 
to the tip of the organ. 
The artery may be divided into three 
regions: the first, external to the hyo- 
glossus muscle, the second, beneath the 
muscle, and the third, from the inner 
margin of the latter to the tip of the 
tongue. The vessel is deeply situated 
in its entire course. Were it not that 
the hyoid, dorsalis linguae, and the sub- 
lingual branches are given off in the 
second part of its course, the third por- 
tion of the vessel, where it is placed 
between the hyoglossus and genio-hyo- 
glossus muscles, would be the most con- 
venient situation for its ligation, as it 
could be reached by an incision in the 
median line of the neck below the chin : 
by this route fewer important structures 
would be encountered. The second part 
of the artery, or that under the hyo- 
glossus muscle, is the portion which has 
been uniformly selected for ligation. 
In front of the vessel are the skin, 
superficial fascia, platysma myoid, deep 
fascia, the inferior border of the sub- 
maxillary gland, a second leaf of the 
deep fascia which passes beneath the 
gland and completes its capsule, the 
facial, superficial lingual, and pharyn- 
geal veins, the stylo-hyoid and digastric 
muscles, the hypoglossal nerve, and the 
hyoglossus muscle. The artery rests 
upon the middle constrictor of the 
pharynx, and lies immediately (about 
one line) above and parallel with the great horn of the hyoid bone. (Fig. 
557.) Difficult as is the approach to the vessel, no artery in the body possesses 
so many landmarks to guide the operator. 
The operation of tying the lingual artery has been performed for wounds 
of the tongue, for suicidal wounds, and for the arrest of malignant growths. 
Fig. 557. 
Relations of the lingual artery : H, hyoid 
bone; h, its great horn; Jif, the body of the 
lower jaw; M', its angle; sh, oh, Ik, insertions, 
into the body and horn of the hyoid bone, of the 
sterno-hyoid, omo-hyoid. and thyro-hyoid mus- 
cles ; ph, the inferior constrictor muscle of the 
pharynx ; sm, the submaxillary gland drawn 
over the jaw, with (/) the facial artery and vein; 
je, the external jugular drawn aside, along with 
the sterno-cleido muscle; d, the digastric mus- 
cle perforating the stylo-hyoid muscle, and 
looped down to the great horn of the hyoid bone 
by its fibrous pulley, d!; hyp, hypoglossal nerve 
running forward alongside of the lingual vein, 
and disappearing under (mh) the mylo-hyoid 
muscle; l, the lingual artery passing beneath 
(hif) the h.voglossus muscle; 1, the superior 
thyroid artery; /, the facial artery, behind 
which lies (ce)' the external carotid; ci, the in- 
ternal carotid artery; ji, the internal jugular 
vein, into which are seen emptying the facial, 
the lingual, and the superior thyroid tributa- 
ries. The white stars mark the point where 
the lingual artery should be tied. 752 
LIGATION OF ARTERIES. 
Mr. Moore, Surgeon to the Middlesex Hospital,* in one case of cancer of the 
tongue, ligated this artery, with a view to reduce the amount of blood carried 
to the ulcer, supposing that it might be an important palliative auxiliary to 
the division of the gustatory nerve, as practised by Mr. Hilton in a number 
of cases of malignant disease of the tongue. 
M. Demarquayf has written a very interesting article on the ligation of 
this artery. Both lingual arteries were simultaneously tied during our late 
war for a shot wound of the tongue accompanied with a fracture of the jaw.J 
The patient survived, but was totally disabled by ill health. 
Operation.—The patient should be placed on the back, with the head 
turned a little to the opposite side and well extended, so as to amplify the 
space between the hyoid bone and the base of the jaw. The surgeon now 
feels for the great horn of the hyoid bone, and, having ascertained its posi- 
tion, begins his incision at the anterior border of the sterno-cleido-mastoid 
muscle, half an inch above a point opposite to the extremity of the great 
horn of the bone, and, carrying it forward and a little downwards so as to 
give it a slight curve with the convexity below, terminates the cut three- 
quarters of an inch short of the median line of the neck, and half an inch 
below the base of the jaw. (Fig. 553.) This incision, I am convinced from 
having very many times practised it upon the cadavei’, admits of the most 
satisfactory exposure of the parts associated with the artery. The head must 
be maintained rigidly in the same position from the beginning to the end of 
the operation. Any material change in this respect, especially in the direc- 
tion of flexion, will alter all the details of the procedure. All incisions should 
be made in a forward direction, or away from the great blood-vessels of the 
neck, which lie close to the posterior extremity of the wound. The skin, 
and the connective and adipose tissues, being divided, the first layers of the 
deep fascia, or the anterior part of the capsule of the submaxillary gland, 
will appear. This must be raised upon the director and laid open, when the 
gland will be exposed. With the finger, or the handle of the scalpel, this 
body should be detached from its deep connections and drawn forward over 
the jaw, great care being taken in doing so that the facial artery and vein, 
which pass through its substance, are not injured. These being pressed out 
of the way, the thin posterior leaf of the capsule of the submaxillary gland 
must be divided, when there will be exposed the white, shining aponeu- 
rosis which loops the digastric tendon to the great horn of the hyoid bone, 
and also the insertion of the stylo-hyoid muscle, after a little more clearing 
away of loose connective and adipose tissue. Immediately behind these will, 
most probably, be seen the hypoglossal nerve, three lines above the cornu 
of the bone, and running across the hyoglossus muscle, forward and up- 
wards, towards the middle of the jaw. The cellular tissue, which holds the 
nerve in contact with the sheath of the hyoglossus muscle, should now be 
scratched through with the edge of the knife, and the former pushed up out 
of the way, as below this nerve runs the artery. All that is now neces- 
sary for the denudation of the artery is to fix the hyoid bone by inserting a 
tenaculum into the digastric aponeurosis, and by carefully insinuating the 
point of the director underneath the posterior margin of the hyoglossus 
muscle and pushing it forward close along the upper border of the great 
horn of the hyoid bone, to separate this muscle from the middle constrictor 
of the pharynx behind. If now the fibres of the hyoglossus be divided, 
the artery will be exposed, when it can be raised by passing the needle from 
above downwards, in order to avoid injury to the hypoglossal nerve. Occa- 
sionally it may be necessary to divide a few fibres of the stylo-hyoid muscle, 
when its insertion extends far back. It is sometimes advised to raise the 
fibres of the hyoglossus muscle with the forceps, and by light touches with 
the edge of the knife, from before backwards, gradually uncover the artery. 
* Medico-Chirurgieal Transactions, vol. xlv. p. 56. 
j" Gazette Medical e de Paris, 1867, p. 634. 
j Surgical History of the War of the Rebellion, Part I., surg. vol., p. 397. LIGATION OF THE FACIAL ARTERY. 
753 
At every step of the operation, after passing the superficial fascia, the oper- 
ator should shape his course by thrusting a finger into the wound and feeling 
for the great horn of the hyoid bone. There are, therefore, three important 
guides to reveal the situation of the lingual artery, namely, the pulley of the 
digastric tendon, and the great horn of the hyoid bone, both of which lie 
immediately below the vessel, and the hypoglossal nerve, which is placed imme- 
diately above the lingual artery and separated from it by the hyoglossus muscle. 
Ligation of the Facial Artery.—The facial artery is frequently the subject of 
ligation, in consequence of operations upon the face, the jaws, and the neck. 
Its superficial position where it emerges from the neck and passes over the 
jaw in front of the masseter muscle renders it quite easy, by making press- 
ure at this point, to control hemorrhage during operations upon different 
parts of the face. The facial artery is remarkable for its tortuous form, both 
in the neck and on the face, a peculiarity well adapted to the ever-varying 
movements of these regions. The vessel after reaching the face passes to 
the angle of the mouth, and from thence up along the side of the nose to the 
internal canthus of the eye, where it communicates, as the angular artery, 
with the supraorbital branch from the ophthalmic. 
Surgical anatomy.—The facial artery is divided into a cervical and a facial 
region. 
In the cervical region, the vessel, after leaving the external carotid a short 
distance above the lingual, runs obliquely forward and upwards, under the 
shelter of the inferior maxillary bone, passes beneath the stylo-hyoid and 
digastric muscles and the submaxillary gland, and bends abruptly towards 
the surface, in order to reach the face. 
It is consequently covered in front, while occupying the supra-digastric or 
submaxillary space, by the skin, the subcutaneous, connective, and adipose 
tissues, the platysma myoid, the deep fascia, and the submaxillary gland; 
it is accompanied by the facial vein. 
The facial portion of the vessel reaches the face by passing from the neck 
over the base of the inferior maxillary bone, which possesses, immediately in 
front of the masseter muscle, a slight groove for the accommodation of the 
artery. Between the latter and the artery is placed the facial vein, which, 
after passing farther up on the face, becomes considerably separated from 
the artery. 
Over the jaw the vessel is very superficial, being covered only by the skin, 
the superficial fascia, the platysma myoid, and a thin layer of the deep cer- 
vical fascia. 
The vessel may demand ligation in consequence of wounds of the neck, 
accidental or designed, and also during the removal of tumors from the 
submaxillary region. 
During the late American war the facial artery was tied five times for 
hemorrhage following shot fractures of the lower jaw. 
The vessel may be ligated either in its cervical or in its facial portion. 
Operation.—The ligation in the first-named region, though condemned by 
Manec on account of its depth, is not a difficult task after the artery has 
entered the submaxillary space. An incision similar to that for exposing the 
lingual vessel should be made, only differing in the following particulars: it 
should be made a little higher or nearer to the base of the jaw, and it need 
not be carried so far anteriorly. Upon dividing the layers overlying the 
submaxillary gland, and hooking up the latter with the finger, the artery 
will be drawn out, in consequence of its fibrous tissue connection with the 
gland, when it can be easily separated from the vein and surrounded by a 
thread. 
The ligation of the facial portion of the artery is a very simple procedure. 
An incision is made one inch in length over the inferior maxillary bone in 
front of the masseter muscle. (See Fig. 553.) The pulsation of the vessel 
can be readily discovered by inserting a finger into the wound, the jaws being 754 
LIGATION OF ARTERIES. 
at the same time closed. By dividing the subcutaneous, connective, and adi- 
pose tissues, the platysma myoid muscle, and the deep fascia, the vessel will 
be uncovered (Fig. 558), and, after being separated from the vein on its outer 
side, should be raised on the needle, which is to be passed between the vein 
and the artery and carried from without inwards. 
Ligation of the Occipital Artery.—The occipital artery arises from the ex- 
ternal carotid, opposite the facial, and passes backwards and upwards, dip- 
ping under the posterior belly of the digastric and stylo-hyoid muscles, and 
under the lower part of the parotid gland, at which place it is crossed by 
the hypoglossal nerve. A little above this point the vessel runs over the in- 
ternal carotid artery, the internal jugular vein, and the pneumogastric and 
spinal accessory nerves. Changing its direction, the artery ascends the neck 
to the level of the transverse process of the atlas, where it again takes a hori- 
zontal course, passing through a groove on the mastoid portion of the tem- 
poral bone, and, after passing under the sterno-mastoid, splenius, digastric, 
and trachelo-mastoid muscles, pierces the insertion of the splenius capitis, 
and is distributed to the posterior part of the scalp. 
The occipital artery may require ligation either on account of wounds or 
for the cure of aneurism. 
Operation.—The ligation of the cervical •portion of the occipital is an 
operation which demands both anatomical knowledge and surgical skill. 
The incision should be made along the anterior border of the sterno-cleido- 
mastoid muscle, beginning between the lobe of the ear and the ramus of the 
jaw, and prolonged downwards two inches and a half. (See Fig. 553.) At the 
upper angle of the wound the integument, and the subcutaneous, connective, 
and adipose tissues, alone should be incised. The deep or parotid fascia in 
this situation must not be opened, otherwise a salivary fistula will be likely 
to follow. At the lower part of the parotid gland the deep fascia may be in- 
cised, after which the finger can be carried beneath the gland and the latter 
be drawn outwards and upwards. A retractor being now placed beneath 
the anterior edge of the sterno-mastoid muscle, the latter should be pulled 
outwards, thus exposing a deep fossa, at the bottom of which will be seen 
the digastric and stylo-hyoid 
muscles. These being pushed 
upwards, the occipital artery 
may be seen crossing the inter- 
nal carotid vessel and the inter- 
nal jugular vein, and resting in 
the curve formed by the cord 
of the hypoglossal nerve as it 
abruptly turns across the neck; 
immediately behind which will 
be the most convenient point to 
incise the artery and to encircle 
it with a ligature. In doing this 
the needle should be passed from 
without inwards, so as not to 
damage the jugular vein. 
The ligation of the occipital 
portion of the artery is a much 
less difficult operation than that 
just described. 
An incision, nearly horizontal, 
should be made, two inches in 
length, commencing at the apex 
of the mastoid process of the 
temporal bone, and extending backwards and very slightly upwards. (See 
Fig. 553.) The operator divides consecutively the skin and subcutaneous 
Fig. 558. 
The facial, occipital, and temporal arteries exposed, and the 
threads passed beneath these vessels. LIGATION OF THE INTERNAL CAROTID ARTERY. 
755 
tissue, the outer border of the sterno-mastoid muscle and its aponeurotic ex- 
pansion, the splenius, and finally the complexus. Search must now be made 
for the artery, by introducing a finger into the inner angle of the wound, 
when it may by the pulsation be detected between the mastoid process of 
the temporal bone and the transverse process of the atlas, from which point 
it can be traced externally to a more superficial position, in the direction of 
the splenius muscle, where it may be isolated from the occipital vein and 
tied. (Fig. 558.) If the vessel be denuded near to the mastoid process, 
unusual care will be demanded not to damage the large mastoid tributaries 
which join the occipital vein in this locality and establish a communication 
between the latter and the lateral sinus of the brain. 
Ligation of the Temporal Artery.—The temporal artery is the continuation 
of the external carotid. The vessel after emerging from beneath the upper 
part of the parotid gland crosses the zygoma immediately posterior to the 
condyle of the inferior maxillary bone, and one-fourth of an inch in front of 
the cartilage of the ear. About one inch and a half above the zygoma the 
artery divides into the anterior and posterior temporal branches. 
The surgical relations of the vessel are quite simple. It is covered by the 
skin, superficial fascia, attrahens auris muscle, a loose connective tissue formed 
from the parotid and temporal regions, and a lymphatic gland. The temporal 
vein lies on the auricular side of the artery, and on both its anterior and 
posterior aspects run nerves, viz., the temporal branches of the facial, and 
the auriculo-temporal from the inferior maxillary. 
In former times the operation of arteriotomy was frequently practised on 
the temporal artery, or on one of its branches. The ligation of the vessel 
may be rendered necessary on account of wounds, or in cases of aneurism. 
Operation.—Between the cartilage of the ear and the condyle of the jaw 
make a vertical incision one inch in length (see line on Fig. 553, showing the 
line for the operation). After dividing the skin, the superficial fascia, and 
some fibres of the attrahens auris muscle, the operator will come upon the 
loose connective tissue which envelops the artery, veins, and nerves, and 
probably a small lymphatic gland. It is generally thought best to ligate the 
vessel a short distance above this, as, in the event of suppuration following 
the operation, there would be less probability of the pus burrowing in the 
contiguous parts, a result certainly to be anticipated if this fibrous capsule 
were opened. The strength of the fibrous bands which surround the artery 
necessitates the exercise of considerable force to effect its complete isola- 
tion. After accomplishing this, the needle, or any other instrument used for 
introducing the thread, should be passed from the ear towards the orbit, 
counterpressure being made with the finger, and a close scrutiny instituted 
to see that no nerve-filament has been included in the loop of the thread. 
(Fig. 558.) 
Ligation of the internal carotid, except in cases of a wound of that vessel, 
is an operation which has been abandoned ; and even when contemplated for 
hemorrhage occurring in the region of this artery, it will be better, in view 
of the great uncertainty attending the true source of such bleeding, to tie 
the primitive carotid. In a shot wound of the face, Dr. W. H. Bramlette, of 
Virginia, tied the external, internal, and common carotid arteries.* In an 
open wound of the neck, and when the injury to the internal carotid is un- 
mistakable, the ligature should, of preference, be applied to the damaged 
vessel, and on both sides of the lesion. The rapidity, however, with which 
death follows such accidents renders it very improbable that the services of 
the surgeon can be sufficiently prompt to avail for the rescue of his patient. 
If such an operation were deemed advisable, the same incision as that required 
for the ligature of the external carotid would be demanded ; remembering, at 
Ligation of the Internal Carotid Artery. 
* New York Medical Record, 1869-70, vol. iv. p. 294. 756 
LIGATION OF ARTERIES. 
the same time, on reaching the cellular envelope of the blood-vessels, that the 
internal carotid is the external of the two arteries, and that on passing the 
needle the point of the instrument should be directed from the internal 
jugular, that is, from without inwards, and that it be so guided by the finger 
as not to injure the external carotid, which lies to the inner side. 
Tho ligation of the subclavian artery was first attempted by Sir Astley 
Cooper, in 1809.* The case was one of aneurism, and was attended with 
such displacement of the clavicle and adjoining parts that the operation was 
found impracticable and had to be abandoned. The same year, however, 
it was accomplished by Ramsden tor aneurism of the axillary artery. The 
patient survived five days. In 1811, Sir William Blizard, and in 1815, Thomas 
Blizard,f each tied the subclavian. Both patients died. Dr. Colies,J in 1815, 
performed the operation, but without success. On the 8th of September, 
1817, Dr. Post, of New York, made the first successful ligation of this vessel, 
and in 1820 Mr. Liston was equally fortunate in a case of subclavian deliga- 
tion. Since that time the artery has been many times tied, with results 
which will be hereafter stated. 
Surgical anatomy.—The subclavian arterjq in its course from the source 
of its origin to the first rib, is crossed by the scalenus anticus muscle, and 
thereby divided into three surgical regions: the first, from its origin to the 
inner border of the scalenus anticus muscle; the second, that part beneath 
or covered by this muscle ; and the third, the remaining portion of the vessel 
from the external margin of the scalenus muscle to the first rib. It is rare 
for either the first or the second part of the vessel to become the subject of 
operation. 
In consequence of the difference in origin of the arteries on the two sides, 
the surgical relations of the first portions of the vessels are not identical. 
First region.—On the right side, the subclavian artery, coming from 
the innominate, begins under the sterno-clavicular articulation, and runs 
upwards and outwards to the inner edge of the scalenus anticus. In 
front lie the skin, the superficial fascia, the platysma, the deep fascia, the 
clavicular origin of the sterno-cleido-mastoid, sterno-hyoid, and sterno- 
thyroid muscles, and a second leaf of the deep cervical fascia. It is also 
crossed by the internal jugular and vertebral veins, and by the pneumo- 
gastric, cardiac filaments of the sympathetic, and phrenic nerves. Behind 
the artery lie the longus colli, the transverse process of the seventh cervical 
vertebra, the sympathetic nerve, and, to some extent, the recurrent laryngeal 
nerve. The thoracic surface of the vessel is in contact with the pleura, and 
below is situated the subclavian vein. 
The first portion of the left subclavian artery, coming from the arch of the 
aorta, is a longer and deeper vessel than the right; it rises almost vertically 
into the neck, instead of forming a gradual curve like the vessel on the oppo- 
site side. It is covered in front by the skin, the subcutaneous connective 
tissue, the platysma myoid, the deep cervical fascia, the sterno-cleido-mastoid, 
sterno-hyoid, and sterno-thyroid muscles, the pneumogastric, the phrenic and 
cardiac branches of the sympathetic nerve, the internal jugular and innomi- 
nate veins, the pleura, the lung, and the left carotid artery. Posteriorly 
are placed the oesophagus, the thoracic duct, the sympathetic nerve, and the 
vertebral column, with the longus colli interposed. On the inside are the 
oesophagus, the trachea, and the thoracic duct; and on the outside is the 
summit of the pleura. 
The relations of the second and third portions of the two subclavian arteries 
are alike. 
Second region.—The second portion of the artery has in front the skin, the 
Ligation of the Subclavian Artery. 
* London Medical Keview, vol. ii. p. 300. 
J Edinburgh Medical and Surgical Journal, vol. xvi. p. 348. 
f Hodgson on the Arteries. LIGATION OF THE SUBCLAVIAN ARTERY. 
757 
superficial fascia, the platysma, the deep fascia, the clavicular head of the 
sterno-cleido-mastoid, a second layer of the cervical fascia, the scalenus 
anticus with its dense sheath, the phrenic nerve, and the subclavian vein. 
Posteriorly, the artery rests upon the scalenus medius; above are the cords 
of the brachial plexus of nerves, and below is the pleura. 
Third region.—This region is the most important from a surgical point of 
view; it is the region of election, and embraces both the greatest extent of 
the artery and its most accessible position. It corresponds to the posterior 
inferior cervical triangle, a space which is bounded anteriorly by the posterior 
border of the sterno-cleido-mastoid muscle, superiorly by the omo-hvoid mus- 
cle, externally by the inner edge of the trapezius muscle, and inferiorly by 
the clavicle and the first rib. In the undissected neck there is a marked de- 
pression above the clavicle, over the region, which is sometimes termed the 
supra-clavicular fossa, and at other times the subclavian fossa. 
In front of the subclavian artery, in the third region, lie the skin, the 
superficial fascia, the platysma, the deep fascia, two or three lymphatic 
glands, the external jugular, supra-scapular, and transverse cervical veins 
and arteries, the descending filaments of the cervical plexus of nerves, the 
subclavian muscle, and the clavicle. Behind, the artery rests on the scalenus 
medius muscle ; above and to its outer side are the omo-hyoid muscle and the 
brachial plexus of nerves. The subclavian vein is immediately behind the 
clavicle and below 
the artery. 
Immediately ex- 
ternal to the inser- 
tion of the scalenus 
anticus muscle, upon 
a prominent eleva- 
tion of the first rib, 
known as its tuber- 
cle, the subclavian 
artery passes into 
the axilla. From 
this fact arise two 
practical hints: first, 
in searching for the 
vessel, the recogni- 
tion of this bony 
prominence by the 
finger will reveal its 
position; and, sec- 
ond, from the base 
of support otfered by 
the rib it is not dif- 
ficult to control the 
circulation through 
the vessels of the 
upper extremity by 
pressing with the 
fingers, or, what is 
better, with a prop- 
erly-protected ring 
of a door-key, thrust 
down beneath the clavicle. Fig. 559 furnishes an exposure of the principal 
anatomical components of the subclavian region. 
Operation.— The point of election, or external to the scalenus anticus muscle.— 
The proper position in which to place the patient is the recumbent one, with 
the shoulders moderately elevated, the head extended, and the face turned 
somewhat to the sound side. Various incisions have been recommended by 
FtO. Ft59 
Subclavian region exposed, m, sterno-cleido-mastoid; t, the trapezius muscle; 
n, the omo-hyoid muscle ]j, hook drawing aside the external jugular vein, which 
is seen receiving the supra-scapular and transverse cervical veins and emptying 
into (v) the internal jugular vein. By pulling this vein aside, the subclavian 
artery is exposed as it emerges from beneath the scalenus anticns muscle. Above 
and to the outer side are the cords of the brachial plexus of nerves. LIGATION OF ARTERIES. 
758 
different surgeons for the exposure of the artery. Boux recommended a 
vertical incision, the lower extremity of which should rest on the clavicle; 
Marjolin directed one like an inverted j_, the base towards the clavicle; Lis- 
franc adopted a single incision, parallel with the upper border of the clavicle, 
and Physick preferred one fashioned like the letter V. A slightly curvilinear 
incision, somewhat straighter than the letter S, meets every requirement of 
the operation. (See line on Fig. 553.) This incision should commence over 
the external half of the clavicular head of the sterno-cleido-mastoid, half an 
inch above the clavicle, and be carried parallel with that bone, and conform- 
ably to its curves, terminating at the inner edge of the trapezius muscle. 
Some prefer drawing the skin down over the clavicle and dividing it directly 
over the bone. It is a convenient way of avoiding the external jugular vein. 
When the integument is relaxed after this mode of incision, its elasticity will 
carry the wound to the proper distance above the clavicle. After dividing 
the skin, the fascia, the platysma, and sometimes a portion of the clavicular 
origin of the sterno-cleido-mastoid muscle, the external jugular vein, if it be 
exposed, should be detached by dividing the surrounding threads of connec- 
tive tissue, and drawing it, with its tributaries, by means of a retractor, in 
the direction which will remove it farthest out of the way of the operation; 
this usually is towards the trapezius muscle. If the vein is large, and cannot 
be disposed of in this manner, and is likely to embarrass the progress of the 
operation, it should be tied with two ligatures and divided between them. 
With the director the surgeon now breaks up the loose cellular tissue and 
the omo-hyoid aponeurosis, tying, if necessary, the transversalis colli artery, 
which will probably be brought into view. He should now make a careful 
examination of the wound, in order to locate the vessel. If the scalenus 
muscle is recognized, the search must be made upon its outer side; if the 
cords of the brachial plexus or the omo-hyoid muscle are seen, the explora- 
tion must be carried farther downwards in the direction of the chest, and 
more inwards, as the artery lies between the scalenus anticus muscle on the 
inside and the brachial plexus on the outside. If these landmarks do not 
serve to convey the required information, let the finger be carried down along 
the outer side of the wound, under the clavicle, until the first rib is touched, 
and then, following the latter inwards until the tubercle is reached, feel for 
the pulsation of the vessel immediately on its outer side. This tubei’de, to 
which so much importance has been attached, is, in my experience, not a very 
reliable guide, in consequence of its development being often very imperfect. 
I attach more importance to the tense edge of the scalenus muscle, which 
can always be distinctly felt down to the first rib, on which it is inserted. 
The examination at this stage may be considerably simplified by drawing the 
shoulder downwards, by which the structures at the bottom of the wound 
will be made much more superficial. The artery having been identified, the 
next step, and a very delicate one, is to effect its denudation without injury to 
the pleura or to the subclavian vein. Hr. Warren, while isolating this vessel, 
in a case of unusual perplexity, opened the chest, which was announced by a 
distinct whistling sound. The accident in this case, however, did not interfere 
with the patient’s recovery. To avoid such complications, the operator should 
place a finger between the tendon of the anterior scalenus muscle and the 
vessel, and with the point of the director cautiously tear away the investing 
cellular tissue from the artery, always keeping the instrument directed to- 
wards the rib, so that it may not go beyond the pi’oper limitation. By the 
sensation imparted to the tip of the finger he will be able to determine when 
a way has been opened for the thread. The needle bearing the ligature should 
now be conducted round the vessel from without inwards, directed by the 
finger stationed at the tubercle, after which, on the removal of the instru- 
ment, and its being certain that the thread is properly placed, the vessel 
may be tied. (Fig. 560.) In my possession is a specimen in which the 
phrenic nerve, instead of occupying the usual position in front of the scalenus 
muscle, passes into the chest over the third part of the subclavian artery. LIGATION OF THE SUBCLAVIAN ARTERY. 
759 
The possibility of such an anomaly will suggest to the surgeon, when tying 
the vessel at the seat of election, the propriety of examining for this irregu- 
larity before securing the thread. Doubtless it was this abnormity which 
produced the diaphragmatic paralysis that once followed this operation. 
Fig. 560. 
The subclavian artery exposed and the ligature passed. 
Operation in the second part, or beneath the scalenus anticus muscle.—Should 
it be found imperative to tie the subclavian in this situation, it will be neces- 
sary to modify the opei’ation described for the ligation of the vessel external 
to the scalenus, by making a more extensive division of the clavicular origin 
of the sterno-cleido-mastoid muscle, and cutting the scalenus anticus par- 
tially across. Before dividing the last-named muscle, it should be raised on 
a director, and only a few fibres should be cut at a time. It will be advisable 
to leave the inner portion of the muscle undisturbed, as the phrenic nerve is 
placed in front, and finally to the inner edge, of its fasciculi. The artery 
having been uncovered, the needle should be passed from above downwards. 
Operation within the scalenus anticus.—The successful execution of a ligation 
of the subclavian in this region, on the right side, involves a degree of bold 
surgical exactitude which is not possessed by all operators, and on the left 
side is beset with so difficulties that nothing short of the direst neces- 
sity can justify its attempt. The subclavian artery has been tied within the 
scalenus anticus, or, as it is sometimes termed, “on the tracheal side of the 
scaleni muscles,” eighteen times, in every case with a fatal result. I have 
arranged these cases in a tabular form: 
No. 
Surgeon. 
Date. 
Sex. 
© 
he 
< 
Disease. 
Result. 
Reference. 
1 
Colies, left side. 
1818. 
Male. 
33 
Aneurism. 
Died 9th day, hemor- 
rhage ; pleura was 
wounded in the op- 
eration. 
Edinburgh Med. and 
Surg. Journal, vol. 
xlv. p. 48. 
2 
Arendt. 
1826. 
Aneurism. 
Died 5th day, exhaus- 
tion. 
Dietrich, p. 184. Term. 
Abli. von prakt. Aerzte 
zu St. Peterburg. 
3 
Boyer. 
1829. 
24 
Aneurism. 
Died in 24 hours, 
hemorrhage. 
Dietrich, p. 31. 
4 
O’Reilly. 
1835. 
39 
Aneurism. 
Died 23d day, hemor- 
rhage. 
Flood on the Arteries. 
Powers, p. 69. 
5 
Hayden. 
1835. 
Female. 
57 
Aneurism. 
Died 12th day, hem- 
orrhage. 
Lancet, vol.i. p. 47, 1837 
-38. 
6 
Liston, carotid 
also tied. 
1839. 
Male. 
32 
Aneurism. 
Died 36th day, hem- 
orrhage. 
Lancet, vol. i. p. 37, 1837 
-40. 760 
LIGATION OF ARTERIES. 
No. 
Surgeon. 
Date. 
Sex. 
8) 
Disease. 
Result. 
Reference. 
7 
Liston, carotid 
also tied. 
Male. 
Aneurism. 
Died 13th day. 
8 
Partridge. 
1841. 
38 
Aneurism. 
Died 4th day, pyse- 
mia. Had pericar- 
ditis and pleuritis. 
Lancet, vol. ii. p. 603, 
1840-41. 
9 
10 
J. K. Rodgers, left 
side. 
Cuviliier, carotid 
also tied. 
1845. 
“ 
42 
Aneurism. 
Aneurism. 
Died 15th day, hem- 
orrhage. 
Died 10th day, hem- 
orrhage. 
New York Med. Journal, 
1846. 
11 
Mott. 
1851. 
Female. 
21 
Aneurism. 
Died 19tli day, hem- 
orrhage. 
American Journal Med. 
Sci., vol. xii. p. 354, 
1833. 
12 
Auvert. 
Male. 
50 
Aneurism. 
Died 11th day, hem- 
orrhage. 
Selecta Praxis Med.-Chi- 
rnrg., Tab. lv, lvi., 
1848, Paris. 
13 
Auvert 
36 
Aneurism. 
Died 22d day, hem- 
orrhage and pneu- 
monia. 
Auvert, op. cit., Tab. 
lvii and lviii. 
14 
Ayres, U.S.V. 
1864. 
* 
Shot wounds 
Died in hour, hem- 
orrhage. 
Med Surg. History War 
of Rebellion, p. 547. 
15 
Bullen 
1864. 
21 
Shot wounds. 
Died in 8 days, hem- 
orrhage. 
Med. Surg. History War 
of Rebellion, p. 547. 
Med. Surg. History War 
of Rebellion, p. 547. 
16 
Parker. 
1863. 
* 
Shot wounds. 
Died. 
17 
Ayres. 
1864. 
Shot wounds. 
Died. 
Med. Surg. History War 
of Rebellion, p. 547 
18 
Bullen. 
1864. 
Shot wounds. 
Died. 
Med. Surg. History War 
of Rebellion, p. 547. 
In order to expose the vessel within the scalenus on the right side, an in- 
cision three inches in length should he carried parallel with the upper border 
of the clavicle, beginning at the top of the sternum. A second, about the 
same length, must be made at the inner border of the sterno-mastoid muscle, 
joining the first at an angle somewhat acute. After dividing the skin, the 
superficial fascia, and platysma, the surgeon should examine for the anterior 
jugular, which is often a large vein and is situated at the anterior edge of 
the sterno-mastoid muscle. If the vessel is present it must be drawn aside, 
and the deep fascia opened, both in front of the muscle and along the course 
of the clavicle to the extent of the first incision. Flexing the patient’s head, 
so as to relax the sterno-cleido-mastoid, the surgeon next separates the 
origins of this muscle by a director and by the finger from the subjacent 
parts, and then, dividing them across, turns their extremities out of the way. 
In the cellular tissue underneath will, perhaps, be found the trunk of the an- 
terior jugular vein and one or two muscular branches of the thyroid arteries. 
Pressing these aside, and dividing the sterno-hyoid and sterno-thyroid mus- 
cles, the operator reaches the sheath of the carotid artery and the internal 
jugular vein, the latter lying in front of the first part of the subclavian. 
Carefully disengaging the vein from some loose cellular connections, it should 
be drawn inward, when the subclavian will be exposed, crossed in front by 
the pneumogastric, cardiac branches of the sympathetic, and phrenic nerves. 
Displacing these, so as to open a way for the needle, the latter must be carried 
round the artery from below upwards, so as not to injure the pleura. In 
bringing the instrument round the posterior surface of the vessel it must be 
made to follow closely its wall, so that the recurrent laryngeal and sympa- 
thetic nerves be not damaged. The thread may be placed between the sca- 
lenus muscle and the thyroid axis, or between the vertebral and innominate 
arteries. 
Collateral circulation.—The subclavian inside of the scalenus gives otf the 
vertebral, the internal mammary, and the thyroid axis. When the vessel 
is ligated in its second or third portion, thus cutting the main channel 
by which the blood reaches the upper extremity, the vitality of the parts 
below can be maintained only in the following manner. Two branches are 
given oft’ by the thyroid axis, which run across the neck in the direction of 
the shoulder. These are the supra-scapular and transversalis colli arteries. 
The first reaches the dorsum of the scapula at the coracoid notch, and the 
second descends along the posterior border of the bone. Coming in the op- LIGATION OF THE SUBCLAVIAN ARTERY. 
761 
Eosite direction, and derived from the axillary, is the subscapular artery, a 
ranch of which—the dorsalis scapulae—meets and inosculates with the supra- 
scapular branch from the thyroid axis, in the muscles upon the scapula, while 
the main trunk of the subscapular 
joins the descending branches of the 
posterior scapular, which is also de- 
rived from the thyroid axis (Fig. 
561): thus the loss of the direct 
channel is supplied. 
The separation of the ligature from 
the subclavian artery after deligation 
takes place in most instances between 
the eleventh and the fifteenth day. 
Ligation in the third part of the 
subclavian has been followed by a 
very heavy mortality. Of 21 cases* 
collected by Mr. Poland, in which 
this part of the vessel was ligated for 
aneurism, 9 recovered and 12 ended 
fatally. 
Dr. Norris’s tablesf contain 69 
cases of deligation of the subclavian, 
with 36 recoveries and 33 deaths, a mortality of 47.8 per cent. The opera- 
tion was done 56 times for aneurism and 9 times for wounds. 
Dr. Willard Parker, of New York.| has tabulated 196 cases of ligature of 
the subclavian artery. This collection embraces those contained in Circular 
No. 5, Surgeon-General’s Office, U.S.A., 35 in number, and those reported by 
Professor Pirogoflf in his “Outlines of Military Surgery,” 9 in number. Of 
these ligations, 107 died and 88 recovered, a mortality of 54.5 per cent. In 
70 of the cases the vessel was ligated for causes other than aneurism: 48 of 
these terminated fatally, a mortality of 68.5 per cent. In 9 instances the 
second part of the vessel was tied, with 4 deaths, and in 174 cases the third 
part was ligated, with 89 deaths. Of the persons operated on, so far as 
noticed, 138 were males and 14 females. The youngest patient was eigh- 
teen years old, and the eldest seventy-three years. In 134 instances the 
side of the body was noticed. Of these, 82 were on the right side and 52 
on the left. 
Dr. Koch’s collection§ embraces 212 cases of subclavian ligation. Of these, 
70 were performed for causes other than aneurism, 48 of which died. 
Dr. Otis records 52 ligations of the subclavian, with 41 deaths, a mortality 
of 78.8 per cent.|| These operations were done for shot injuries. 
Dr. Morton’s table of “ Ligations of Large Arteries, performed at the Penn- 
sylvania contains 2 cases of ligature of the subclavian artery for 
aneurism, with 1 death and 1 recovery. 
Though the fatality attending this operation is very great,, yet it must 
not be forgotten that the conditions which require its performance are in 
themselves often necessarily fatal, and that in traumatic cases death is 
generally the result of the injury, and not of any cause connected with the 
deligation. 
The cause of death in a large majority of instances after ligation of the 
subclavian artery is hemorrhage. 
Complications.—The surgeon may encounter a number of very embarrassing 
difficulties in his attempts to ligate the subclavian artery. Some of these can 
be recognized before the operation is begun. Others are discovered only after 
the parts are exposed. 
Fig. 561. 
The lines beneath the artery mark the division be- 
tween the subclavian and the axillary : a, ligature on 
the subclavian at its third part; 6, thyroid axis; d, 
transversalis colli; c, suprascapular branches; e, the 
subscapular of the axilla; g, its dorsalis scapulas branch, 
the two inosculating with those of the thyroid axis 
behind and at the dorsum of the scapula. 
* Guy’s Hospital Reports, vol. xv., 1870. f Norris’s Contributions to Practical Surgery. 
J Transactions of the American Medical Association, vol. xviii., 1867. 
2 Arch. f. d. Klin. Chirurg., B. x. pp. 195, 280, Berlin, 1869. 
(i Medical and Surgical History of the War of the Rebellion, Part I., surg. vol., p. 547. 
f American Journal of the Medical Sciences, April, 1876. 762 
LIGATION OF ARTERIES. 
In large aneurisms there may be such a displacement of the clavicle and 
the contiguous parts that the vessel is rendered inapproachable. 
The tissues around the sac may be so infiltrated and matted together by 
inflammatory lymph that the safe approach to, and denudation of, the artery 
become matters of the greatest difficulty. 
The sac of an aneurism may involve so much of the artery that no suitable 
place will be left for the application of a ligature. 
The vessel, even when safely reached, may be found so diseased as to forbid 
the deligation. 
The artery may be eccentric in its course, and from this circumstance not 
easily reached. 
In addition to the above may be mentioned the dilatation of veins, enlarged 
glands, and peculiarities of organization, all of which will prove sources of 
difficulty to the surgeon in accomplishing his contemplated object. 
The vertebral artery, arising from the subclavian, runs directly upwards, 
enters the vertebral foramen of the sixth cervical vertebra, passes through 
similar openings in the vertebrae above, and after reaching the upper surface 
of the atlas turns backwards around its articular process and enters the 
cranium through the occipital foramen. This vessel is associated with the 
internal carotid in supplying the brain with blood. 
Surgical anatomy.—The vertebral artery is covered in front by the skin, 
the superficial fascia, the platysma, the deep fascia, the clavicular origin of 
the sterno-cleido mastoid muscle, a second layer of the deep fascia (omo- 
hyoid), the internal jugular vein, the inferior thyroid artery, and, on the left 
side, the thoracic duct. Behind it is in relation with cellular tissue and the 
summit of the pleural sac, having on its outside the thyroid axis, and on 
its inside the internal jugular vein and the carotid artery, together with the 
pneumogastric and sympathetic nerves. 
On account of wounds, or in consequence of subclavian aneurism, it may 
become necessary to ligate this vessel. In the only case of successful ligature 
of the innominate artery, the one reported by Dr. Smyth, the vertebral and 
the common carotid were both tied. Professor Willard Parker has tied the 
vertebral, and at the same time the carotid and the subclavian arteries, for 
the cure of an aneurism of the latter vessel. The vertebral has also been 
ligated by Maisonneuve, in order to arrest a hemorrhage following a shot 
wound of the neck. Two other cases of ligation of this artery have been 
reported by an Italian surgeon. 
Alexander has tied the vertebral arteries for the cure of epilepsy 36 times. 
In some instances a marked improvement followed the operation, in others 
no change for the better was observed. Except in one case, both vessels were 
tied. The same surgeon tied these vessels twice for infantile paralysis, twice 
for locomotor ataxia, and once for chorea. 
Operation.—In case an external wound existed, situated near to the loca- 
tion of the vessel, the latter might be reached by carefully enlarging the 
opening; but when such is not the case, the surgeon must make his way to 
the artery by systematic approaches, either in front of or behind the sterno- 
cleido-mastoid muscle. 
By the.first method the incisions will bo similar to those employed for tying 
the innominate artery,—that is, carrying one cut down along the anterior 
border of the sterno-mastoid to the top of the sternum, and joining it with 
a second running parallel with the course of the clavicle. After dividing the 
cutaneous, the muscular, and the fascial layers, the sternal and a portion of 
the clavicular region of the sterno-mastoid muscle must be severed. Under- 
neath these will be seen the sterno-hyoid and thyroid muscles. These need 
not be divided further than to raise their outer edges, and to expose the 
sheath of the carotid artery and the internal jugular vein. As the latter con- 
ligation of the Vertebral Artery. LIGATION OF THE INTERNAL MAMMARY ARTERY. 
763 
ceals the vertebral artery, it will only be necessary to draw the sheath with 
its contents well inwards towards the trachea, when the vessel will be ex- 
posed. If any difficulty is experienced in determining its position, a finger 
should be introduced into the bottom of the wound, and search made for the 
tubercle at the extremity of the transverse process of the sixth cervical ver- 
tebra. At the root of this process the artery enters its first foramen, and 
immediately below this its pulsation should be discovered. After its careful 
isolation, the thread must be passed from within outwards, in order that the 
internal jugular vein be not harmed. 
By the second method the vertebral is reached by the same incisions as are 
used to expose the subclavian on the tracheal side of the scaleni muscles. 
If this plan be adopted it will not be necessary to divide more than the cla- 
vicular head of the sterno-cleido-mastoid muscle. Due care must also be 
practised not to injure the phrenic nerve while approaching the artery in 
question. 
Ligation of the Inferior Thyroid Artery. 
Except in case of hemorrhage, the result of a wound of the neck, the 
surgeon will rarely feel it his duty to ligate the inferior thyroid artery. Both 
vessels have been tied in hypertrophic conditions of the thyroid glands, but 
with such indifferent success that the practice is not worthy of repetition. 
The vessel is a branch of the thyroid axis, and reaches the thyroid body by 
passing beneath the sheath of the carotid and internal jugular. If from any 
circumstance it is deemed necessary to resort to ligation of the inferior thy- 
roid, the simplest manner of reaching the artery will be to proceed as for the 
ligation of the primitive carotid, namely, by making an incision along the 
inner edge of the sterno-cleido-mastoid muscle, commencing opposite the thy- 
roid cartilage, and prolonging the incision downwards towards the sternum 
to the extent of two and a half inches. On reaching the sheath of the 
common carotid, the operator next looks for a branch of the inferior thyroid 
passing to the thyroid body from beneath the sheath, and if one is discovered, 
it will only be necessary to trace it back until the trunk of the artery is 
reached in the fissure between the great vessels and the oesophagus, where 
it should be tied. 
Ligation of the Internal Mammary Artery. 
The internal mammary artery is a branch from the first part of the sub- 
clavian, which, after its origin, passes downwards beneath the clavicle, and 
descends along the inner surface of the anterior walls of the chest external to 
the pleura, accompanied with its satellite veins, and resting upon the costal 
cartilages a little external to the margin of the sternum. At the sixth inter- 
costal space the vessel divides into the musculo-phrenic and superior epi- 
gastric branches. 
Wounds of the internal mammary are not uncommon on the battle-field. 
It is probable that many perish in this way without the lesion being detected. 
When after a shot or other injury along the margin of the sternum the signs 
of internal hemorrhage appear, without any evidence of the lung being im- 
plicated, a wound of the internal mammary may be reasonably inferred. 
Five cases were reported during the late American war. In two the 
artery was tied, and in the other three an attempt was made (I suppose, 
after the manner of Larrey) to control the bleeding by plugging the wound. 
None of the patients survived the injury. 
Notwithstanding the fact that the internal mammary lies within the bony 
and cartilaginous walls of the anterior parietes of the chest for the first three 
intercostal spaces, its ligation is not a task of great difficulty, unless, in con- 
sequence of comminution of the cartilages of the ribs or of the sternum, and 
the resulting extravasation of blood or of inflammatory products, the parts 
have become changed in their normal relations. 764 
LIGATION OF ARTERIES. 
Operation.—Make a vertical incision, commencing at the lower border 
of the clavicle, two inches and a half in length, parallel with and three lines 
external to the margin of the sternum. Divide consecutively the skin, the 
superficial fascia, the fibres of the pectoral muscle, the external intercostal 
aponeurosis, and the muscular fibres of the internal intercostal. The last 
structure can be best opened by raising and dividing the fasciculi on the 
bent extremity of a director. The last shreds of tissue should be scratched 
through with the instrument, when the artery, with its accompanying veins, 
will be exposed. The last step of the operation consists in isolating the 
vessel and encircling it with a ligature. 
Deligation of the internal mammary below the third or at most the fourth 
intercostal space is scarcely feasible, on account of the close proximity of the 
cartilages ; and if under any emergency the surgeon is compelled to tie the 
vessel at a point so low down, it will be best to cut out one of the costal car- 
tilages with a pair of bone forceps, thus throwing two intercostal spaces into 
one, by which procedure ample room will be obtained for the object in view. 
Surgical anatomy.—The axilla is a conical space situated between the upper 
part of the chest and the arm. The apex of the cone answers to a point be- 
tween the upper border of 
the scapula, the clavicle, 
and the first rib. When 
the arm is brought close 
to the side, the axilla be- 
comes a mere fissure; but 
it presents an extensive 
concavity when the arm is 
drawn off from the body, 
bounded in front and be- 
hind by muscular folds, the 
first formed by the pec- 
toral is major muscle, and 
the last by the latissimus 
dorsi and the teres major. 
When the arm is car- 
ried off from the side, two 
fissures can, in most in- 
stances, be discovered on 
the surface of the chest. 
One, commencing at the 
sterno-clavicular articula- 
tion, can be traced to the 
arm, ending half an inch 
above the anterior margin 
of the axilla. This fis- 
sure marks the division 
between the clavicular and 
the sternal portion of the 
pectoralis major muscle, 
the chief significance of 
which is that when opened 
it leads down to the first portion of the axillary artery. The second fissure 
begins at a triangular depression below the middle of the clavicle, and ex- 
tends downwards and outwards. This fissure is the cellular interspace which 
exists between the clavicular fibres of the pectoralis major muscle on the 
inside and the deltoid muscle on the outside. In this narrow depression lie 
the cephalic vein, and a small branch from the thoracic acromial artery. 
Ligation of the Axillary Artery. 
Fig. 562. 
The great pectoral and deltoid muscles exposed, exhibiting the Assures 
between the clavicular and the sternal portion of the Arst; also the de- 
pression between the pectoral and the deltoid, in which lie the cephalic 
vein and a branch of the thoracica acromialis. The fascia turned down. LIGATION OF THE AXILLARY ARTERY. 
765 
(Fig. 562.) When the skin and the superficial fascia are turned aside from 
the pectoralis major muscle, and the sheath of the latter is raised from the 
clavicle downwards to the fold of the axilla, or to the lower border of the 
muscle, the membrane will be found to divide into two lamellse, one passing 
up between the pectoralis major and pectoralis minor muscles (interpectoral 
fascia), and becoming attached to the costo-coracoid aponeurosis which lies 
in front of the subclavian muscle. (Fig. 563.) The other and deepest layer, 
Fig. 563. 
Pectoralis major turned aside, showing the interpectoral fascia passing over 
and beneath the pectoralis minor muscle. 
passing beneath the pectoralis minor muscle, is the true axillary fascia, and 
is continuous with the sheath of the axillary blood-vessels and nerves up 
into the neck. (Fig. 564.) When this deep leaf of the fascia is opened, a 
number of lymphatic glands, fat, connective tissue, arteries, veins, and nerves 
will be exposed. 
When the pectoralis major muscle is detached from its clavicular origin 
and reflected inwards and downwards, the pectoralis minor will be seen in- 
serted by its tendon upon the coracoid process of the scapula. In front of 
the pectoralis minor runs the cephalic vein, which empties into the axillary 
vein immediately below the clavicle (Fig. 564), and beneath the muscle pass 
the axillary artery, the axillary vein, and the brachial plexus of nerves. The 
pectoralis minor muscle divides the axillary vessels into three surgical re- 
gions,—the first above the upper border of the muscle, the second beneath 
the muscle, and the third from its lower margin to the insertion of the latis- 
simus dorsi and teres major muscles. The first and third regions only are 
those of surgical importance. 
In the first region, that part between the subclavian muscle and the 
pectoralis minor, the axillary artery is covered by the skin, the superficial 
fascia, the pectoralis major muscle, and the two layers of the pectoral fascia, 
having the axillary vein on the inside and the axillary plexus of nerves on 
the outside. It is in this region that the cephalic enters the axillary vein. 
(Fig. 565.) 
Operation.—The patient should be placed upon the back, having the 
shoulders somewhat raised, and the flexed arm carried a little off from the 766 
LIGATION OF ARTERIES. 
body. There are two modes of uncovering the vessel, one by a linear in- 
cision, opening the fissure between the clavicular and sternal portions of the 
pectoralis major muscle, and the other by a rectangular incision, one limb 
of the cut corresponding to the fissure between the deltoid and clavicular 
Fig. 564. 
Pectoralis divided and turned aside, showing the deep pectoral or true axillary fascia. 
The cephalic vein is seen passing through the fascia to enter the axillary vein. 
Numerous nerve-twigs are also represented perforating the fascia. 
portions of the pectoralis major muscle, and the other corresponding to the 
course of the clavicle, but a little below it. (See Fig. 553.) By either route 
the vessel can be reached without much difficulty. For one who is not entirely 
familiar with anatomical details the last method will be the preferable one. 
The first plan has the advantage of not cutting any muscular fibres, but also 
the disadvantage of hampering somewhat the manipulation requisite to the 
isolation of the artery. I shall describe both approaches to the vessel. 
First. Make a vertical incision three inches long, commencing at the 
clavicle, in the middle of the triangular space between the deltoid and 
pectoralis major muscles. A second cut is next made, commencing at the 
first, one inch below the clavicle, and prolonged inwards three inches, run- 
ning parallel with the clavicle. These preliminary incisions should not 
extend deeper than the skin. The necessity for executing the last one an 
inch below the collar-bone arises from the tendency of the platysma to draw 
up the integument when the latter is divided. The superficial fascia should 
next be raised on the director and incised, it being borne in mind in doing 
this that the cephalic vein and the descending branch of the thoracic acromial 
artery lie immediately underneath, in the fissure between the deltoid and 
pectoral muscles. The cephalic vein being exposed, and the thin layer of 
fascia which covers it being divided close along the edge of the clavicular 
part of the pectoral muscle, the finger or a director will suffice to separate the 
latter from both the vein and the deltoid. After dividing the platysma, the LIGATION OF THE AXILLARY ARTERY. 
767 
operator next commences the detachment of the fibres of the pectoral muscle 
from the clavicle, cutting close to the bone by short, light, and repeated 
strokes, completing the division of the deepest fibres upon the director; after 
which the muscle may be turned downwards and inwards. In doing this the 
Pm. 565. 
Surgical relations of the axillary artery above the pectoralis minor muscle : a, 
clavicular part of the pectoralis major detached and turned down; 6, the cephalic 
vein drawn aside by a hook, above which it enters the axillary vein, and beneath 
which are seen the axillary artery and, farther out, the axillary plexus of nerves; 
c, the coracoid process, to which is attached the pectoralis minor; d, the deltoid 
muscle; e, the coraco-clavicular aponeurosis. 
thoraciea acromialis and superior thoracic arteries will be exposed, and very 
probably will demand ligation. The interpectoral and the axillary fascia, 
together with some loose cellular tissue, being now broken up, the next step 
is to identify the axillary artery. In doing this the finger should be intro- 
duced into the wound, and made to touch the upper border of the pectoralis 
minor muscle below and the clavicle above. These points being ascertained, 
the upper and lower limits- of the vessel have been determined, and between 
them the search is to be conducted. If now a careful inspection of the bot- 
tom of the wound is made, the axillary vein will be seen, corresponding to 
the middle of the clavicle. If any doubt remains, the vessel may be pressed 
with the finger close to the subclavian muscle, beneath which it appears, 
when, if it is the vein, its thin walls will become distended by the impediment 
offered to the passage of the blood. The vein having been discovered, the 
surgeon has gained his second landmark. lie knows that the axillary artery 
is on its outer or humeral side, and the search is next made in that direction. 
Perhaps he passes unnecessarily far out and encounters the cords of the axil- 
lary plexus of nerves; in these he has a third landmark, the artery being on 
their inner side: so that the vessel must be found between the vein and the 
nerves. In addition to these referential points, the pulsation of the artery 
may be felt, which will serve still further to dispel any doubt that may 768 
LIGATION OF ARTERIES. 
remain as to its position. In effecting the ligation of the artery, the work of 
denudation should begin on the side next to the vein, and when the two have 
been separated the point of a finger should be interposed while the posterior 
and outer surfaces of the vessel are being isolated. An assistant should also 
draw the cephalic vein outwards and upwards, and if the external jugular 
communicates with the former over the clavicle, it may be necessary, in 
order to pull the cephalic sufficiently far out of the way of danger, to tie 
the communicating branch with two threads and sever the vein between 
them. The artery having been detached from all its surrounding connections, 
the needle bearing the thread must be passed from within outwards above the 
thoracica acromialis and superior thoracic branches, its point being received 
on the end of the finger as it appears between the vessel and the axillai*y 
plexus of nerves. 
Second. The arm being drawn off from the side in order to render apparent 
the fissure between the two portions of the pectoralis major muscle, an oblique 
Fig. 566. 
Axillary artery, vein, and nerves exposed ; also the first portion of the brachial artery. High origin of the 
radial artery also seen. 
incision is made over this depression, three inches in length, commencing 
half an inch from the sterno-clavicular articulation. The skin and fascia 
being divided, the muscular interspace must be opened, and its sides sepa- 
rated with the director and t he fingers. In doing this it must be remembered 
that the course of this fissure is upwards towards the clavicle. If the 
attempt is made to enlarge the opening directly backwards, the artery will 
never be found. As the separation of the two portions of the pectoral pro- 
gresses, the arm should be brought towards the side of the body, in order to 
relax the muscle and to allow of a free exposure of the deeper parts. The 
space between the clavicle and the pectoralis minor being reached, the sub- 
sequent steps of the deligation are the same as in the first method already 
described. 
Surgical anatomy of the third region of the axillary artery.—This includes a 
description of that portion of the axillary between the lower border of the LIGATION OF THE AXILLARY ARTERY. 
769 
pectoralis minor muscle and the insertion of the latissimus dorsi and teres 
major muscles. The vessel is covered in front by the skin, the superficial 
fascia, the pectoralis major muscle, and the axillary fascia. Behind are 
situated the subscapularis, the tendons of the latissimus dorsi and teres 
major muscles, and the musculo-spiral and circumflex nerves. On the outer 
side lie the coraco- 
brachialis muscle, 
and the median 
and musculo-cuta- 
neous nerves; on 
the inner side are 
the ulnar and in- 
ternal cutaneous 
nerves, and the 
axillary vein. The 
branches given off 
by the axillary ar- 
tery are the tho- 
racica acromialis, 
the thoracica su- 
perioris, the tho- 
racica longa, the 
thoracica alaris, the subscapularis, and the anterior and the posterior cir- 
cumflex. (Big. 566.) 
Once in about thirty-five times the radial artery, and much less frequently 
the ulnar, is given off from the axillary,—an irregulai’ity which should not 
be lost sight of in cases of ligation in this part of the vessel, as the one trunk 
might readily be mistaken for the other. 
Operation.—The patient being placed in the recumbent position and the 
arm drawn off from the side, a line may be extended, if desired, from the 
junction of the anterior and the middle third of the axilla to the middle of 
the bend of the arm. (See Fiff. 567.) The upper extremity of this line will 
be found to indicate the posi- 
tion and course of the axillary 
vessels. When the arm is car- 
ried off at right angles with 
the body, the anterior and pos- 
terior muscular folds of the ax- 
illa become strongly prominent. 
Emerging from beneath the an- 
terior folds will be seen the bi- 
ceps flexor cubiti muscle, and 
immediately within this a sec- 
ond ridge or swell, which is the 
coraco-brachialis. (Big. 568.) 
The axillary artery lies along 
the inner edge of the latter. 
Placing a finger in the summit 
of the axilla, at the upper ex- 
tremity of this line, while the 
arm is still abducted, commence 
at this point an incision (Big. 568), which should be prolonged downwards 
along the inner edge of the coraco-brachial ridge for two inches. After 
dividing in succession the skin, the superficial fascia, and the deep fascia 
(the latter upon the director), muscular fibres of the coraco-brachial will be 
exposed, and search must now be made for the vessel, the parts being held 
asunder by a retractor and the finger. (Big. 569.) The arm being brought 
a little nearer to the side, the director alone should be used to lacerate 
any shreds of connective tissue which may obscure the parts. To discover 
Fig. 567. 
The anterior and posterior folds of the axilla, and the biceps muscle: immediately 
under the anterior fold and the bicipital swell is a white line giving the course of the 
axillary artery. 
Fig. 568. 
Limb drawn away from the body, and the index finger of one 
hand of the surgeon fixing the integument at the summit of the 
axilla, while with the other hand he is about to commence the 
incision for the ligation of the third part of the axillary artery. 770 
LIGATION OF ARTERIES. 
the artery, should it not be readily recognized by its pulsation, the operator 
must commence at the coraco-braehialis muscle and work his way inwards. 
First will be seen the me- 
dian nerve, next the mus- 
culo-cutaneous nerve perfo- 
rating the muscle, and then 
the axillary artery, on the 
inner side of which lies the 
axillary vein. After the 
vessel has been isolated, the 
needle should be passed be- 
tween the artery and the 
vein, and its point conducted 
safely round by making 
counter-pressure with the 
finger on the outer side, at 
the same time crowding the 
median and museulo-cuta- 
neous nerves towards the 
coraco-brachialis muscle. 
The ligation of the axil- 
lary artery dates back only 
to the year 1815, when it 
was first tied by Chamber- 
laine, of Jamaica. 
In all cases of ligation where the choice lies between the first part of the 
axillary and the third part of the subclavian artery, the latter should be 
unhesitatingly adopted, as both the easier and the safer operation. 
Fig. 569. 
Ligation of the axillary. The sides of the wound held apart by a 
retractor and the thumb. 
Surgical anatomy.—The brachial artery extends from the tendon of the 
teres major muscle, along the inner and anterior portions of the arm, to about 
three-quarters of an inch below the bend of the elbow-joint, at which point 
it divides into the radial and ulnar arteries. The vessel is quite superficial 
in its entire course. It is placed along the inner edge of the coraco-braehialis 
and biceps flexor cubiti muscles, and in a groove between these and the 
triceps extensor cubiti posteriorly. The exact relations of the vessel may 
be considered in three different positions: 
1. Upper third.—This includes a portion of the vessel equal in extent to 
the humeral portion of the coraco-brachialis muscle, and therefore partly in 
the axillary space. In this division the brachial artery is covered by the 
skin, the superficial fascia, and the bicipital fascia. Behind lie the triceps, 
and the musculo-spiral nerve. On the outer side are the coraco-brachialis 
muscle and the median nerve, and on the inner side are the basilic vein, and 
the internal cutaneous and ulnar nerves. (See Fig. 566.) 
2. Middle third.—This part of the artery lies along the inner border of the 
biceps muscle, and is crossed by the median nerve. 
3. Lower third.—The vessel is situated on the inner margin of the biceps 
muscle and its tendon, and is covered, in addition to the skin and fascia, by 
the bicipital aponeurosis. The median nerve lies a short distance to its 
inner side, and both nerve and artery rest upon the brachialis anticus 
muscle. (See Fig. 572.) The brachial artery in front of the bend of the 
arm is invested with additional interest on account of its relation to the 
cutaneous veins, especially the median basilic, which lies directly over the 
vessel and is separated from it only by the bicipital aponeurosis. This vein 
is generally more prominent than any other at this part of the arm, and 
on this account has always offered an attractive mark for the lancet of the 
Ligation of the Brachial Artery. LIGATION OF THE BRACHIAL ARTERY. 
771 
phlebotomist, by which means the artery has often been wounded, giving rise 
to arterio-venous aneurism. 
There is also in front of the articulation at the bend of the arm a deep 
fossa,—the anticubital,—the sides of which are formed by the pronator radii 
teres and supinator muscles, and the floor by the brachialis anticus muscle. 
In this fossa are the brachial, radial, and ulnar arteries, together with the 
median nerve and a large communicating vein. Hence the danger attending 
penetrating wounds within the limits of this region. 
The branches distributed by the brachial artery are the superior profunda, 
the inferior profunda, the anastomotic, and the muscular. 
Operation.—A line extended from the summit of the axilla to the middle 
of the antibrachial fossa indicates the entire course of the brachial artery. 
(See Fig. 567.) 
Ligation at the upper third.—Place the patient in the recumbent position, 
and draw the arm off from the trunk. Feel for the muscular ridge of the 
coraco-brachialis just within that of the biceps muscle, and along its inner 
border make an incision two inches in length, holding the knife at right 
angles to the surface of the arm. After dividing the skin, the remaining 
layers of fascia should be raised upon the director and incised, when, after 
lacerating its sheath, the artery will be exposed, or can readily be detected 
by its pulsation. If from any cause the latter is not distinguishable, the 
artery may be identified by recalling the fact that there is nothing interposed 
between it and the coraco-brachialis muscle except the median nerve, and 
that the basilic vein lies close along the inner side. After the denudation of 
the artery the needle must be passed from within outwards, so as to inflict 
no injury on the vein, at the same time all necessary precautions being used 
not to include the median nerve in the ligature. (Fig. 570.) 
Fig. 570. 
Brachial artery encircled by the ligature. 
Ligation at the middle third.—Divide the skin for two inches along the 
inner border of the middle of the biceps muscle. Raise and incise the super- 
ficial fascia with its fat on the director, and then open the fibrous mem- 
brane which covers the biceps muscle, taking care not to wound the median 
nerve which crosses over the artery to the inner side of the arm. By lacer- 
ating the cellular tissue along the edge of the muscle the artery will be 
exposed, accompanied by its vense comites. The ligature may be passed in 
either direction. (Fig- 571.) 
Ligation at the lower third.—The surgeon should alternately flex and extend LIGATION OF ARTERIES. 
772 
the arm until the tendon of the biceps muscle is distinctly recognized, along 
the inner edge of which an incision two inches long should be made, dividing 
successively the skin, the superficial fascia, and the bicipital aponeurosis, 
Fig. 571. 
Ligation of the brachial artery at the middle and lower thirds. 
immediately under which will be found the artery, the median nerve being 
some distance to its inner side. (Fig. 571.) 
Ligation of the brachial artery may be required on account of hemorrhage 
or aneurism, and at no point is the operation a difficult one. 
The occasional irregularities in the origin of the radial, and in some in- 
stances of the ulnar artery, should not be forgotten in ligations of the bra- 
chial, as when such abnormities exist the vessels generally lie side by side, 
in which case the proper one for the ligation could only be selected by alter- 
nately making compression on both, and thus learning which commands the 
circulation in an aneurism or the hemorrhage in case of a wound. 
Collateral circulation.—The vessels which maintain the circulation of the 
arm after ligation of the first part of the brachial artery are the circumflex 
and subscapular arteries from the axillary, with the ascending branches of 
the superior profunda artery. Where the ligature is applied at the middle 
or lower third of the brachial artery, the superior and the inferior profunda 
(and if near the elbow the anastomotica magna) communicate with the re- 
current branches of the radial, the ulnar, and the interosseous. (See Fig. 
579.) These compensating vessels of the arm are neither large nor numerous, 
nor are the communications between those of the arm and those of the fore- 
arm very free: so that the risk of gangrene after ligation of the artery is 
very great. 
Ligation of the Radial Artery. 
Surgical anatomy.—The radial is the more superficial artery of the two 
given off by the brachial. It leaves the latter vessel at the middle of the 
bend of the arm, and passes obliquely downwards and outwards to the wrist, 
where it runs beneath the inner extensor tendons of the thumb to the lower 
end of the radius, and enters the hollow at the root of the thumb by passing 
beneath the two inner extensor pollicis tendons, finally reaching the palm of 
the hand between the two heads of the first interosseous muscle. 
In the arm the radial artery, at its upper third, lies between the pronator 
radii teres muscle on the inside and the supinator radii longus on the outside. 
The remaining portion of the artery is placed between the flexor carpi radi- 
alis on the inside and the supinator radii longus on the outside. The radial 
nerve, which at the upper third of the arm lies some distance to the outside 
of the vessel, at the middle third approaches it very closely, though still 
occupying the radial side of the artery, while at the last third it becomes 
again far removed from the vessel, by passing underneath the tendon of the 
supinator longus muscle to the back of the hand. (See Fig. 572.) The 
vessel lies immediately under the skin, the superficial fascia, and the deep 
fascia. 
Operation.—A line extended from the middle of the bend of the arm to 
a point midway between the styloid process of the radius and the tendon 
of the flexor carpi radialis marks the course of the vessel. (Fig. 573.) The LIGATION OF THE RADIAL ARTERY. 
773 
artery may be tied at any part of the arm. I shall describe its ligation at 
the upper and at the lower third. 
Ligation in the upper third.—In the direction of the line already described 
make an incision two inches in length, commencing 
one inch below the bend of the elbow. (Fig. 574.) 
After dividing the skin and exposing the cellulo-adi- 
pose tissue, look for the median vein, and incise the 
fascia in such a manner as to avoid the vessel. The 
deep fascia having been exposed, look for the yellow 
line which separates the supinator muscle on the out- 
side from the pronator radii teres on the inside. If 
this cannot be recognized, the interspace may be dis- 
Fig. 572. 
Fig. 573. 
Arter ies of the lower part of the 
arm and of the forearm and their 
relations. 1, median nerve, ex- 
ternal to which, close along the 
edge of the biceps, 14, lies the 
brachial artery; 2, ulnar nerve, 
passing from tire arm to the fore- 
arm, between the internal condyle 
of the humerus and the olecr anon 
process of the ulna; 4, ulnar ar- 
tery, approaching the ulnar nerve; 
5, median nerve, exposed by cut- 
ting away a portion of the flexor 
sublimis digitorum and the flexor 
carpi ulrraris muscle ; 6, deep fas- 
cia; 7, deep fascia covering the 
radial artery; 8, tendon of the 
flexor carpi ulnaris; 9, palmaris 
longus; 10, radial artery, passing 
over the tendon of the pronator 
radii teres, and resting lower 
down on the flexor longus polli- 
cis, with the radial nerve, 11, on 
its outer side; 12, supinator longus 
drawn aside by hook. 
Lines showing the course of the radial 
and ulnar arteries. 
Fig. 574. 
Making the incision for the ligation of the radial artery at its upper third. 
covered by the finger, after which, the fascia being opened, the artery will be 
found surrounded by adipose tissue, and upon being separated from its ac- 
companying veins may be raised on the needle. (See Fig. 576.) The nerve 
lies so far external to the artery, beneath the supinator radii longus muscle, 
that it should not be seen in the operation, unless the surgeon cuts very wide 774 
LIGATION OF ARTERIES. 
of the mark. In the event of its being exposed, it would serve as a landmark, 
instructing the operator to carry his search more towards the ulnar side of 
the arm. 
Ligation in the lower third.—By strongly extending the hand, the tendon of 
the flexor carpi radialis, which is the first tendon on the inside of the radius, 
may be seen or felt. On the radial side of the tendon make an incision one 
inch and a half long, beginning one inch above the wrist-joint. (See Fig. 
575.) The artery is very superficial, and the incision should be made with a 
Fig. 575. 
Ligation of the radial at its lower third. Opening the deep fascia. 
light hand. After dividing the skin, and the superficial and deep fascise (Figs. 
575 and 576), the last two being previously raised on the director, the artery, 
with its satellite veins, will be discovered between the flexor carpi radialis and 
supinator radii longus muscles. The needle may be passed in either direc- 
tion, as the radial nerve 
leaves the vessel about the 
middle of the forearm. 
(Fig. 577.) 
Ligation of the radial ar- 
tery at the root of the thumb. 
—Between the lower end 
of the radius and the root 
of the thumb is a deep 
fossa, which is bounded on 
the inside by the tendons 
of the extensor ossis meta- 
carpi pollicis and the ex- 
tensor primi internodii 
pollicis, and on the outside 
by the tendon of the extensor secundi internodii pollicis. If the skin, the 
superficial fascia, and a thin membranous layer be turned aside, the artery 
Fig. 576. 
Ligation of the radial at its lower third. Isolating the artery. 
Fig. 577. 
Ligation of the radial and ulnar arteries. Ligature passed at the upper and the 
lower third of the radial, and at the lower third of the ulnar. 
will be found lying in the midst of some fatty tissue and resting upon the 
lateral radio-carpal ligament. LIGATION OF THE ULNAR ARTERY. 
775 
Operation.—An incision one incli and a half long should be made obliquely 
across the fossa, observing to avoid one 
of the chief radicles of the radial vein, 
which lies immediately in the course of 
the wound, and in the superficial fascia. 
After opening the latter and the deep 
fascia, and displacing some loose adipose 
tissue, the artery will be reached at the 
bottom of the depression between the 
tendons of the thumb. The operator 
must not injure the sheath which en- 
velops these tendons, as such an accident 
might be followed by a troublesome and diffuse inflammation. (Fig. 578.) 
Fig. 578. 
Ligation of the radial at the root of the thumb. 
Ligation of the Ulnar Artery. 
Surgical anatomy.—The ulnar leaves the brachial artery in the fossa at 
the bend of the arm, and, passing underneath the superficial flexor muscles 
which arise from the internal condyle, descends along the inner side of the 
arm, between the flexor carpi ulnaris muscle on the inside 
and the flexor sublimis digitorum muscle on the outside. 
The vessel rests upon the flexor profundus digitorum 
muscle, has the ulnar nerve to its inner side, and is 
crossed at the lower third of the arm by the skin, the 
superficial fascia, and the deep fascia. (See Fig. 572.) 
The deligation of the ulnar artery is limited to the lower 
third of the arm, in consequence of the great mass of mus- 
cular tissue which overlies the vessel above this part. 
Operation.—The course of the ulnar artery is indicated 
by a line extended between the radial border of the pisi- 
form bone and a point at the junction of the upper and 
the middle third of the forearm, and three-quarters of an 
inch external to its ulnar border. (See Fig. 573.) 
If the hand be forcibly extended, there will be seen 
above the wrist a prominent fleshy swell, to the inner 
side of the tendon of the palmaris longus. This is the 
flexor sublimis digitorum muscle. Along the inner or 
ulnar side of this swell is a depression, and it is in this 
groove that the ulnar artery lies. 
Make an incision one inch and a half long above the 
wrist, in the depression between the flexor carpi ulnaris 
and the flexor sublimis digitorum, which depression is immediately in line 
with the pisiform bone. Let the superficial fascia be incised, and then, 
flexing the hand so as to relax the deep fascia, raise the latter with the for- 
ceps, and, after cautiously nicking it, introduce the director and slit it up 
freely. 
If now the tendon of the flexor carpi ulnaris be turned a little inwards, the 
artery will be found with the ulnar nerve close along its inner side. From 
the nerve and its accompanying veins the vessel must be separated, and the 
needle passed from within outwards. (See Fig. 577.) 
The radial and ulnar arteries may demand ligation on account of trau- 
matic aneurism, or for wounds, such as are frequently inflicted by glass, 
chisels, and knives. Wounds of the palmar arch demand ligation at the 
seat of injury, and have been considered under the head of injuries of the 
upper extremity. 
Collateral circulation.—The radial artery shortly after its origin gives off a 
branch,—the radial recurrent,—which turns upwards along the outer side of 
the joint. The ulnar artery, in like manner, furnishes the ulnar recurrent, 
and in addition the interosseous trunk. Both recurrent vessels give off de- 
Fio. 579. 
Anastomosis between 
the radial ami ulnar re- 
current arteries, d and e, 
and the superior and in- 
ferior profunda arteries 
from the brachial, b and c. 776 
LIGATION OF ARTERIES. 
scending branches, which communicate with muscular branches given off by 
both of the main ai’teries lower down. It is these inosculations, together with 
the interosseous, which maintain the circulation below, when the radial or the 
ulnar is tied. 
Ligation of the External Iliac Artery. 
Surgical anatomy.—The external iliac artery, the most superficial of the two 
branches of the common iliac, extends from the sacro-iliac juncture along the 
inner margin of the psoas magnus muscle to the middle of the crural arch, 
where it becomes the femoral artery. 
In front are situated the peritoneal sac containing the intestines, the sper- 
matic vessels, and the genito-crural nerve. On the outside lies the psoas 
magnus, to which the artery is attached by a fold of the iliac fascia; above, 
the external iliac vein is situated behind, and below it is to the inner side of 
the vessel. (See Fig. 581.) 
Operation.—The lower bowel having been previously emptied by an 
enema, and the patient placed upon the back, an incision should be made 
parallel with Poupart’s ligament, commencing one inch above the anterior 
superior spinous process of the ilium, and terminating a little external to the 
external abdominal ring. (See Fig. 581.) The incision should be slightly 
curvilinear, having the convexity downwards. The skin and superficial fascia 
being divided by successive touches of the knife, and one or two branches 
belonging to the superficial epigastric and circumflex ilii arteries having 
been tied, the tendon of the external oblique muscle should be raised upon 
the director and incised to the full extent of the external wound. Succeed- 
ing these layers come the internal oblique and transversalis muscles, which 
in turn must be divided in a similar manner, but with increasing caution as 
the fibres of the last are severed. At this stage of the operation it will be 
necessary to tie some branches of the circumflex ilii artery. Beneath the trans- 
versalis muscle lies the transversalis fascia, which serves to connect the latter 
with the peritoneum. And now begins the most delicate part of the task, 
namely, the breaking up of this fascia and the detachment of the sac of the 
peritoneum from Poupart’s ligament and the iliac fossa. This is best effected 
by a pair of forceps and the fingers, and should commence nearer to the exter- 
nal than to the internal extremity of the wound, as there the serous membrane 
is most loosely connected to the subjacent parts. Let the operator commence 
by picking up some of the fleecy fibres of the transversalis fascia with the 
forceps, and with a finger of the opposite hand make counter-pressure on 
the peritoneum. A portion will be found to yield, when the process may be 
repeated, until an opening has been made sufficiently large for the intro- 
duction of the fingers, by which the remaining separation, necessary for the 
exposure of the artery, can most conveniently be accomplished. Too much 
delicacy cannot be observed in detaching the peritoneum from the iliac 
fossa. It is very unfortunate when, either in consequence of strong inflam- 
matory adhesions or from maladroit manipulation, this membrane is torn. 
The intestines are liable to escape through the opening, and the danger of 
a fatal peritonitis becomes imminent. After pushing up the serous sac and 
passing a finger into the opening, the external iliac artery will be detected 
by its pulsation, having the anterior crural nerve a short distance to its 
outer side and the external iliac vein on its inner side as the artery ap- 
proaches the crural arch, but behind at the upper half of the vessel. A broad 
retractor (Fig. 580) may now be slipped along the upper wall of the wound, 
and the parts held out of the way by an assistant, while the surgeon carefully 
isolates the vessel from its surrounding connections, and, passing the needle 
from within outwards between the vein and the artery, brings it round to 
the outer side of the latter, where it should be received on the extremity of 
the finger and conducted safely through. After the completion of the oper- 
ation the margins of the wound should be drawn together by a number of LIGATION OF THE EXTERNAL ILIAC ARTERY. 
777 
interrupted sutures, extending through all the strata of tissues down to the 
peritoneum; and, in order to relieve the stitches from tension, the patient 
should be placed in bed, with the thigh flexed and the shoulders elevated. 
Fig. 580. 
Author’s retractor for holding aside the sac of the peritoneum during operation upon the iliac arteries. 
The ligation of the external iliac artery was first performed in 1796, by Mr. 
Abernethy. The incision which this surgeon adopted was in the direction of 
the course of the artery. He commenced 
above Poupart’s ligament, half an inch 
outside of the external ring, and termi- 
nated his cut three inches above and in 
the direction of the median line. The 
incision recommended by Sir Charles 
Bell for opening the walls of the ab- 
domen in order to ligate the external 
iliac artery corresponds in all particu- 
lars to the one which 1 have detailed. 
Scarpa’s method differs from others in 
that the division of the parietes begins 
below and in front of the anterior su- 
perior spinous process of the ilium. Sir 
Astley Cooper made a semi-elliptical cut, 
convex downwards, of which one of the 
extremities rested a short distance above 
the iliac spinous process, and the other at 
the inner side of the external ring. Many 
others have been described, for example, 
those of Bogros, Lisfranc, Rust, Langen- 
beck, and Delpech ; but they all, except 
in some very unimportant particulars, 
closely resemble one another. The operation of tying the extexmal iliac 
artery was first executed in this country by Dr. Dorsey. 
The ligation of this vessel is commonly required on account of aneurism 
of the common femoral and the lower part of the external iliac. 
The results of the operation may be learned from the tables of INorris,* 
Cutter,f and Morton,| which embrace 157 cases of deligation of the external 
iliac for various causes, of which number 48 died and 109 recovered. The 
fatality attending the operation, when done for shot wounds, is well illus- 
trated in the surgery of our late war, in which the external iliac was ligated 
16 times, with only 2 successes. Gangrene and hemorrhage were the chief 
causes of death in the fatal cases, though a few perished from peritonitis, 
tetanus, and protracted constitutional irritation. When the operation is done 
for aneurism alone, the mortality, based on an analysis of 130 cases, does not 
exceed 30 per cent. 
Fig. 581. 
The sac of the peritoneum pushed up and the 
external iliac artery raised on the ligature. Also 
ligature of the femoral at the point of election. 
* Norris’s Contributions to Practical Surgery, Philadelphia, 
f American Journal of the Medical Sciences, New Series, 48, July, 1864, 
J American Journal of the Medical Sciences, April, 1876. 778 
LIGATION OF ARTERIES. 
Ligation of the Epigastric Artery. 
The epigastric arises from the external iliac artery three or four lines above 
Poupart’s ligament. It lies between the peritoneum and the transversalis 
fascia, and behind the spermatic cord, at the internal abdominal ring. The 
artery, accompanied by its two veins, runs upwards and inwards to the rectus 
abdominis muscle, and is covered anteriorly by the integument, the aponeu- 
rosis of the external oblique, and by the internal oblique and transversalis 
muscles. 
The course of the vessel is indicated by a line extending from the middle 
of Poupart’s ligament to the umbilicus. 
Operation.—Make an incision two and a half to three inches long half an 
inch above and parallel with the course of Poupart’s ligament, the middle of 
which shall be directly opposite the middle of the ligament; one or two ves- 
sels in the superficial fascia will probably require ligation. Next the tendon 
of the external oblique should be raised and divided on the director; then 
turn up the lower border of the fibres of the internal oblique and transver- 
salis muscles, and, after tearing through the fascia transversalis, the artery 
will be exposed near to its origin, where, after being separated from its veins, 
it can be tied. 
The same incisions will answer for the ligation of the circumflex ilii artery. 
After tearing through the transversalis fascia, this vessel will be found running 
parallel with, and close to, Poupart’s ligament. 
Both the epigastric and circumflex ilii arteries are exposed to injury from 
wounds of the abdominal parietes, and under such circumstances demand the 
application of a ligature. The readiness with which the blood from these 
vessels, when they are wounded, presses its way between the broad muscles 
of the belly, should always teach the surgeon the folly of relying on pressure 
for its control. 
Ligation of the Internal Iliac Artery and its Branches. 
Surgical anatomy.—The internal iliac artery leaves the common iliac at 
the sacro-iliac junction. The peritoneum and the ureter are in front of the 
vessel; the internal iliac vein and the lumbo-sacral nerve lie behind; and on 
its outer side is the psoas magnus muscle. 
Operation.—The vessel is reached by the same incisions as have been 
described for the ligation of the external iliac artery, and the detachment of 
the peritoneum is to be conducted in precisely the same manner, differing 
from the other only in the necessity of a more extensive and higher separation 
of this membi’ane in order to reach the vessel, in doing which the operator 
should follow the external iliac artery until the internal trunk has been 
reached. It may be necessary to enlarge the wound in the parietes, upwards 
and outwards, in order to allow of free access to the vessel. In placing the 
ligature, the needle, after the denudation of the vessel, should be carried 
from within outwards, keeping close to the artery, so that the vein, which 
is behind and to the inner side, may not be damaged. The trunk of the in- 
ternal iliac artery varies in length in different individuals. It rarely ex- 
ceeds one and a half inches, but is sometimes found not to exceed one inch. 
It has been observed very truly by anatomists that the lengths of the ex- 
ternal iliac and common iliac arteries bear a certain compensatory relation 
to each other,—that when one is shorter than normal the other is longer 
than usual. 
Ligation of the internal iliac has been done for aneurism of its branches, 
and on account of hemorrhage. 
The artery was first tied in 1812, by Stevens, of Vera Cruz, since which 
time it has been ligated twenty-seven or twenty eight times. (See Gluteal 
Aneurism.) LIGATION OF THE GLUTEAL AND ISCHIATIC ARTERIES. 
779 
Ligation of the Gluteal and Ischiatic Arteries.—These vessels emerge from 
the pelvis through the great saero-ischiatie foramen, and are separated from 
each other by the pyramidalis muscle, the gluteal being above and the ischi- 
atic below. Both vessels are accompanied by a large nerve and by companion 
veins. (Fig. 582.) 
Operation.— When the ligation of either 
of these vessels becomes necessary in con- 
sequence of a wound, it will be proper to 
follow and enlarge the external opening; 
but when undertaken for aneurism, it will 
be very important first to ascertain the 
position of the vessels by projecting a line 
or by touching certain prominences of the 
skeleton. 
Let the surgeon place the patient upon 
his face, with the pelvis somewhat raised 
over a folded pillow. Next let him. feel 
for the following parts : 1, the posterior in- 
ferior spinous process of the ilium; 2, the 
tuberosity of the ischium; and, 3, the tro- 
chanter major of the femur. These being 
ascertained, let a line be drawn from the 
first of these prominences to a point mid- 
way between the last two. An incision 
should now be made in the course of this 
line, and to its whole extent, dividing suc- 
cessively the skin, the superficial fascia, and 
the sheath of the gluteus maximus muscle. 
This done, the surgeon next opens one of 
the fissures between the coarse fasciculi of 
the muscle, and, separating its sides, at once introduces a finger and feels 
for the sacro-sciatic foramen, and, carrying the digit upwards in order to 
discover its bony margin, detects the artery as it turns over this lip of the 
depression towards the dorsum of the ilium. It only remains to have the 
sides of the deep wound held asunder by retractors while the vessel is being 
isolated and tied. 
If it be the ischiatic which requires the ligature, the incisions will be pre- 
cisely the same as those for the deligation of the gluteal artery. In making 
the search for the vessel, however, the finger must be carried below the pyri- 
form muscle, and swept round the muscle and the sharp edge of the sacro- 
ischiatic ligament until the ischiatic artery is felt. 
Fig. 582. 
Posterior view of the pelvis. Gluteal artery 
seen coming out of the sacro-ischiatic foramen 
above the pyriform muscle, and the ischiatic 
below, each accompanied by a nerve. 
Ligation of the Primitive Iliac Artery. 
Surgical anatomy.—The abdominal aorta divides into the two common iliac 
arteries on the left side of the body of the fourth lumbar vertebra, a point 
directly posterior to the corresponding side of the umbilicus. The iliac 
arteries, after their origin, diverge right and left, and at the sides of the 
sacro iliac articulation they divide into two trunks, the internal and the 
external iliac. 
The common iliac arteries are about two inches in length. The right 
vessel, in consequence of having to pass across the body of the fifth lumbar 
vertebra, is longer than the left. The surgical relations of the two vessels 
are not identical. 
The right iliac artery is covered in front by the peritoneum and the ileum, 
and at its termination by the ureter. Behind are placed the two primitive 
iliac veins, and on its outside lie the inferior vena cava and the right iliac 
vein. 
The left iliac artery is covered anteriorly by the peritoneum, the rectum, 780 
LIGATION OF ARTERIES. 
and the superior hemorrhoidal artery, and at its termination by the ureter. 
The left primitive iliac vein is on the inner 
side and also behind the artery. (Fig. 583.) 
Operation.—The incision required for 
the ligation of the common iliac artery 
does not differ from that employed in ex- 
posing the external and internal iliacs. 
except in the single particular of prolong- 
ing the cut to a higher point (two inches) 
above the anterior spinous process of the 
ilium, which gives to the wound a curvi- 
linear form. 
The course of the vessel can be ascer- 
tained by drawing a line from the umbili- 
cus to the middle of Poupart’s ligament. 
Fig. 584. 
Fig. 583. 
Relation of the common, external, and internal 
iliac arteries to their accompanying veins. 
Enlargement of the collateral vessels after liga- 
tion of the common iliac artery.—From a prepa- 
ration of Dr. Peace’s. 
In order to expose the vessel, it is necessary to detach the sac of the peri- 
toneum beyond the limits of the iliac fossa, following closely the external 
iliac artery to the internal iliac, and from thence to the common trunk, at 
the same time pushing the ureter outwards. The peritoneum must be held 
out of the way by an assistant, in order that the vessel may be separated 
from its surrounding connections and the ligature passed round its trunk. 
The greatest gentleness and care must be observed not to injure the veins, 
an accident which will be best avoided by passing the deligating instrument 
from within outwards. 
The operation of tying the common iliac is most commonly done for aneu- 
rism, but may become necessary on account of wounds. When, in conse- 
quence of the former disease, there has been an inflammatory adhesion of 
the peritoneum to the sac, or to the iliac fascia, the ligation may be one of 
great embarrassment, from the difficulty which will be experienced in sepa- 
rating without perforation the serous sac from its attachments. 
The subsequent treatment is the same as has been described after ligation 
of the external iliac artery. 
Collateral Circulation.—The vessels chiefly concerned in establishing 
the circulation of the inferior extremity after the ligation of the common 
iliac are the ilio-lumbar and the obturator from the internal iliac, with the 
lumbar arteries from the aorta and the internal circumflex from the profunda 
femoris. The circumflex ilii from the external iliac vessel also communicates 
with the lumbars. In addition to these, the hemorrhoidal branches of the 
internal iliac anastomose with the hemorrhoidal branches of the inferior 
mesenteric, and the lateral with the middle sacral. (Fig. 584.) The primitive iliac artery was first ligated by Professor William Gibson, 
in the year 1812. The operation was done in consequence of hemorrhage 
from a gunshot wound. Thirteen days after the vessel was tied the patient 
died from a renewal of the bleeding. Dr. Valentine Mott, in 1827, for the 
first time ligated the common iliac artery for aneurism. The vessel has 
been tied sixty-three times, with fifty deaths, twelve recoveries, and one 
without known result. The following table includes a statement of these 
operations: 
TABLE OF LIGATIONS OF THE PRIMITIVE ILIAC ARTERY. 
781 
Result. 
No. 
Side 
X 
02 
6 
b£> 
< 
Disease. 
Operation 
and Date. 
Cure. 
Death. 
Remarks. 
Reference. 
1 
M. 
38 
Hemorrhage from 
W. Gibson, 
1 
Death occurred on 
American Med. Re- 
shot wound. 
Philadel- 
phia, 1812. 
the 13th day. 
corder, vol. iii. 
2 
R. 
M. 
33 
Mott, 1827. 
1 
Amer. Jour. Med. Sci., 
vol. i. p. 156. 
iliac. 
3 
R. 
M. 
30 
Aneurism external 
Crampton, 
1 
Death on the 4th day. 
Medico-Chir. Trans., 
iliac. 
1828. 
vol. xvi. 
4 
M. 
8 
Secondary hemor- 
Liston, 1829. 
1 
Death in 24 hours. 
London Med. Gaz., 
rhage. 
April 24, 1830. 
5 
F. 
Supposed aneurism. 
Guthrie, 1833. 
1 
Death 8 months after. 
London Med. Gaz., 
Not from ligation. 
vol. ii., 1834. 
6 
R. 
M. 
Aneurism external 
Stevens, 1836. 
1 
Death on the 2d day. 
Amer. Jour. Med. 
iliac. 
Sci., July, 1860. 
7 
M. 
38 
1 
Zeitschr. fur d. Ge- 
sammte Wissen- 
iliac. 
1837. 
schaft, Bd. vii., 
Heft iii., 1839. 
8 
Garviso, 1837. 
1 
Death in 4 hours. 
iliac. 
Nov. 1844. 
9 
Hemorrhage from 
external iliac. 
Pirogoff, 
1838. 
1 
Death in 14 days, 
from hemorrhage. 
Annalen d. Chirurg. 
Abtheil. d. Clini- 
cum der Kaiserl. 
Universitat, Dor- 
pat, 1839. 
10 
F. 
2 m. 
Anastomosing an- 
Bushe, 1839. 
1 
Death in 5 weeks. 
N. Y. Med.-Chir. Bui- 
eurism of the la- 
bium. 
letin, vol. i. 
11 
M. 
42 
Aneurism external 
Deguise, 
1 
The aneurismal sac 
Gazette M6dicale, 
iliac. 
1840. 
and the iliac vein 
were wounded in 
May, 1840. 
this case in tying 
the artery. 
12 
M. 
20 
Hemorrhage from 
Post, 1840. 
1 
Died 1st day, from 
N. Y. Jour. Med. and 
wound of the an- 
eurismal sac. 
hemorrhage. 
Surgery, vol. iii. 
13 
R. 
M. 
36 
Aneurism external 
Peace, 1842. 
1 
Died 15 months after, 
American Journal of 
iliac. 
from a return of 
the aneurism and 
subsequent hemor- 
rhage. 
the Medical Sci- 
ences, April, 1843. 
14 
L. 
M. 
41 
Hey, 1843. 
1 
iliac. 
Aneurism. 
1 
vol. xxvii. 
An. de la Chir., Nov. 
1844, and Jour, de 
15 
Garviso, 1843. 
Chirurgie, 1846. 
16 
M. 
42 
Malignant tumor. 
Stanley, 
1 
Death on the 3d day, 
Medico-Chir. Trans., 
1845. 
from peritonitis. 
The ligation was 
done under the 
supposition that 
the disease was 
aneurism. 
vol. xxviii. 
17 
L. 
M. 
53 
Aneurism external 
Lyon, 1847. 
1 
Died from exhaustion 
Monthly Jour. Med. 
iliac. 
in 50 hours. 
Sciences, vol. viii. 
18 
M. 
49 
To prevent hemor- 
Chassaignac, 
1 
Died in 11 hours. 
Bulletin de la So- 
rhage. 
1850. 
ciet6 de Chir. de 
Paris, Paris, 1851. 
19 
R. 
M. 
34 
Aneurism external 
Jones, 1851. 
1 
Died from erysipelas, 
London Jour. Medi- 
iliac and femoral. 
15th day. 
cine, vol. iv. 
20 
L. 
M. 
25 
Aneurism external 
Wedderburn, 
1 
Died from gangrene, 
New Orleans Medical 
iliac and femoral. 
1852. 
4th day. 
and Surgical Jour., 
May, 1852. 
21 
M. 
52 
Malignant tumor. 
Moore, 1852. 
1 
Died in 14 days. The 
Lancet, February 21, 
case was mistaken 
for aneurism. 
1852. 
Table of Ligations of the Primitive Iliac Artery. LIGATION OF ARTERIES. 
782 
Table of Ligations of the Primitive Iliac Artery.— (Continued.) 
Result. 
No. 
3 
* 
GQ 
8) 
Disease. 
Operation 
and Date. 
© 
C 
P 
g 
ts 
Remarks. 
Reference. 
o 
P 
22 
M. 
26 
Aneurism. 
Uhde, 1852. 
i 
Died on the 4th day, 
Deutsche Klinik, No. 
from peritonitis. 
Internal iliac rup- 
tured in tying the 
xvi., April, 1853. 
artery. 
New York Journ. of 
23 
M. 
46 
Aneurism external 
Van Buren, 
i 
Died on 4th day, sup- 
iliac. 
1853. 
puration of the sac. 
Med., Jan. 1857. 
24 
M. 
27 
Rupture of internal 
Edwards, 
i 
Died on the 25th day, 
Monthly Jour. Med. 
iliac aneurism. 
1857. 
from hemorrhage. 
Sciences, Jan. 1858. 
25 
M. 
24 
Ischiatic aneurism. 
Holt, 1857. 
i 
Died on the 3d day, 
Southern Medical and 
from exhaustion. 
Surgical Journal, 
This is the case of 
October, 1859. 
ligation generally 
attributed to Du- 
gas. The ischiatic 
of the same patient 
had been previ- 
ously tied by Du- 
26 
M. 
59 
Supposed aneurism. 
Meier, 1857. 
i 
Died from gangrene 
Amer. Med. Gazette, 
on the 12tli day. 
May, 1859. 
27 
M. 
20 
Hemorrhage from a 
Parker, 1858. 
i 
Died in 10 hours, 
Am. Jour. Med. Sci., 
stab in the groin. 
from exhaustion. 
July, 1860, New 
Series. 
28 
M. 
40 
Hemorrhage. 
Buck, 1858. 
i 
Died from hemor- 
New York Journal of 
rhage in 17 days. 
Med., Nov. 1858. 
29 
R. 
F. 
33 
Aneurism external 
S. Smith, 
i 
Died from hemor- 
New York Journal of 
iliac. 
1858. 
rhage on 48th day. 
Med., March, 1860. 
30 
L. 
M. 
36 
Aneurism external 
Stone, 1859. 
i 
Died from dysentery 
New Orleans Medical 
iliac. 
in 26 days. 
and Surgical Jour- 
nal, Sept. 1859. 
31 
i 
Died in 13 weeks. 
Statistical Sanit. and 
1859. 
Med. Reports, Lon- 
don, 1862, p. 453. 
32 
L. 
M. 
40 
Aneurism external 
Goldsmith. 
i 
Died from exhaustion 
Louisville Med. Jour- 
iliac. 
on 5th day. 
nal, Feb. 1860. 
33 
R. 
M. 
31 
Aneurism external 
Syme, 1838. 
i 
Died from gangrene 
34 
iliac. 
Gurlt. 
i 
on 4th day. 
* Langenbeck’s Ar- 
chives, 1862, B. iii. 
S. 96. 
35 
36 
Biinger. 
Bickersteth. 
i 
* Fick, Cassel, 1836. 
Edinburgh Medical 
r. 
M. 
39 
Aneurism iliac ar- 
1 
Ligature separated 
tery. 
from the artery in 
33 days. 
Journal, July, 1862. 
37 
R. 
M. 
Iliac aneurism. 
Cock, 1864. 
1 
* Guy’s Hospital Re- 
ports, 1864, 3d Se- 
ries, vol. x. 
* Edin. Med. Jour., 
38 
Secondary hemor- 
rhage. 
McKinley. 
1 
1864, vol. ix. P. II. 
p. 808. 
39 
Hargrave. 
i 
* Dublin Med. Press, 
eurism of ex- 
ternal iliac arteyy 
and vein. 
1865, vol. ii. p. 169. 
40 
R. 
Aneurism of aorta. 
Baxter. 
i 
* Chicago Med. Jour., 
1866, vol. xxiii. p. 
460. 
41 
R. 
Inguinal aneurism. 
Maunder. 
i 
Died in 7 days. 
Med. Times and Gaz., 
October 26, 1867. 
42 
Shot wound in up- 
per part of femur. 
Czerny. 
i 
Died in 4 hours. The 
* Billroth, Chirurg. 
external iliac was 
Briefe, u. s. w., Ber- 
first tied. 
lin, 1872, S. 131. 
43 
Spontaneous aneu- 
rism. 
Ladureau. 
i 
Died in 30 days. 
* Rec. de Mem. de 
Milit., Oct. 1871. 
44 
Baker. 
i 
Died in 40 hours. 
* St. Bartholomew’s 
iliac disease. 
Hosp. Rep., 1872, 
vol. viii. p. 120. 
45 
R. 
Busch. 
i 
Died in 40 days. 
* Langenbeck, Arch. 
f. Klin. Chir., 1873, 
B. xv. S. 481. 
46 
L. 
M. 
Shot wound of pel- 
Prof. Brai- 
i 
Died in 3 months. 
* Chicago Med. Jour., 
vis. 
nard. 
March, 1864, vol. 
xxi. p. 97. 
47 
L. 
M. 
Shot wound. 
McKee. 
i 
Died in 2 days. 
* Med. and Surg. Hist. 
Rebellion, Part II., 
surg. vol., p. 334. 
48 
R. 
Traumatic aneu- 
rism. 
Isham. 
i 
Died 4th day. 
* Chicago Med. Jour., 
1860, vol. xxiii. p. 
222. LIGATION OF THE ABDOMINAL AORTA. 
783 
Table of Ligations of the Primitive Iliac Artery.—( Continued.) 
No. 
©* 
X 
© 
© 
bO 
< 
Disease. 
Operation 
and Date. 
Result. 
r 
© 
h ss 
p | a> 
Q 
Remarks. 
Reference. 
49 
1 
eurism of exter- 
Sci., 1864, vol. 
nal iliac artery 
xlviii. p. 36. 
and vein. 
50 
M. 
Shot wound of the 
Hamilton, 
1 
Died. 
Hamilton’s Surgery, 
pelvis. 
1864. 
p. 232. 
51 
1 
52 
1 
1861. 
i. p. 810. 
53 
Luzenburg, 
1 
Gross’s Surgery, vol. 
1846. 
i. p. 810. 
54 
1 
was afterwards tied 
in this case. 
55 
1 
56 
1 
tober 3, 1874. 
57 
1 
July 1, 1876. 
58 
1 
iliac. 
1872.’ 
from exhaustion. 
Jour., July 1, 1876. 
59 
L. 
M. 
Iliac aneurism. 
Barral. 
1 
Died. 
f Gaz. Medicale, Oc- 
tober 3, 1874. 
60 
L. 
M. 
62 
Iliac aneurism. 
Barbarossa, 
1 
Died on the 26th day. 
Gaz. Medicale, Oc- 
1874. 
tober 3, 1874. 
61 
L. 
M. 
40 
Femoral aneurism. 
Hunter, 1877. 
1 
Died 3 days after. In 
Done in the Univer- 
this case the fern- 
sity Hospital, Phil- 
oral had been three 
adelphia. 
times tied, the ob- 
turator once, and 
the external iliac 
once. 
62 
1877. 
tained. 
Oct. 13, 1877, p. 17.' 
63 
1 
ligation of the 
from gangrene and 
Sept. 29, 1877, p. 
femoral (popliteal 
hemorrhage. 
613. 
aneurism). 
12 
50 
All those marked with * have been taken from Dr. Otis’s Medical and Surgical History of the Rebellion. 
Those marked with f have been taken from Dr. Ashhurst’s memoranda. 
Since the above table was 
made there have been 19 ligations of the primi- 
tive iliac, 
wringing the aggregate up to 82, with a mortality of 70 per cent. 
In order to expose and to tie the abdominal aorta, an elliptical incision 
from five to six inches in length should be made, with its concavity towards 
the median line, beginning at the cartilage of the tenth rib and terminating 
one inch below the anterior superior spinous process of the ilium. The 
cutaneous, fascial, and muscular layers being divided, the peritoneum is to be 
separated, in the direction of the spine, from the fascia transversalis and the 
subjacent parts, as in the operation on the iliac artery. When the aorta has 
been reached, the next step consists in isolating it from the branches of the 
sympathetic, which overlie its walls, and also from the ascending cava, which 
lies along its outer side. When this has been effected, the ligature should be 
passed from right to left, so as to elude the vein. 
Sir Astley Cooper was the first to tie the abdominal aorta, in 1817. He 
approached' the vessel by opening both the parietal and the visceral layer of 
the peritoneum. The patient survived forty hours. The operation has since 
been repeated nine times, always on account of aneurism, and in each case 
with a fatal result. The operators were .James, Murray, Monteiro, South, 
McGuire, Stokes, Czerny of Vienna, Czerny of Heidelberg, and Watson. In 
James’s case the artery was exposed after the manner of Cooper. The man 
Ligation of the Abdominal Aorta. 784 
lived only a few hours. In Monteiro’s case the patient lived for neai’ly ten 
days after the ligation. In Stokes’s case the aorta was compressed by 
means of a silver wire ;• death followed in twelve hours. 
LIGATION OF ARTERIES. 
Ligation of the Femoral Artery. 
Surgical anatomy.—The femoral artery occupies the anterior and inner por- 
tions of the thigh. It is crossed by the sartorius muscle, and is thus divided 
into two unequal portions. The first, or that portion above the sartorius, 
occupies Scai-pa’s triangle,—that is, a space which is bounded on the outside 
by the sartorius muscle, on the inside by the adductor longus muscle, above 
by Poupart’s ligament (the base), and below (the apex) by the intersection 
of the sartorius and adductor longus. This tri- 
angle answers to what is called the hollow of 
the thigh. The femoral artery in Scarpa’s tri- 
angle is covered in front by the skin, the super- 
ficial fascia, the deep fascia, and the crural branch 
of the genito-crural nerve. On the inside it is in 
relation with the femoral vein for the first two 
inches of its course, after which the vein passes 
behind the artery, and near the apex of the tri- 
angle gets to its outer side. The anterior crural 
nerve is situated some distance to the outer side; 
though one of its branches, the internal saphe- 
nous, runs down the thigh close to the outer side 
of the artery. (Fig. 585.) After the femoral ar- 
tery passes beneath the sartorius muscle it enters 
an aponeurotic canal, formed between the ad- 
ductor magnus and the vastus interims muscles 
(canal of Hunter), after which it perforates the 
adductor and enters the ham. While in the 
aponeurotic canal the artery is covered by the 
skin, the superficial fascia, the saphena magna 
vein, the sartorius, the aponeurosis, and the in- 
ternal saphenous nerve, which, though in the 
canal, is not in the sheath of the vessels. (Fig. 
586.) The vein is external to the artery. The 
course of the femoral artery will be indicated 
by a line drawn from a point midway between 
the anterior superior spinous process of the ilium 
and the symphysis pubis to the tuberosity of the 
internal condyle of the femur. The arteries given 
off by the femoral are the superficial epigastric, 
superficial circumflex iliac, and superficial pudic, 
the profunda femoris, the muscular, and the 
anastomotica magna. The branches of the pro- 
funda femoris are the two circumflex and the 
three perforating arteries. 
The femoral artery may require ligation on 
account of aneurism and for wounds. The suc- 
cess which has within the last few years attended 
the use of pressure for the cure of aneurism has 
in a great measure done away with the necessity for tying this vessel. The 
most favorable position in which to apply a ligature is at the apex of Scarpa’s 
triangle, a point farthest removed from the profunda femoris artery, and 
consequently the one at which ligation is least likely to be followed by 
secondary hemorrhage. This is the operation of Hodgson, and is in itself 
attended with little danger. Scarpa tied the vessel in the middle of the 
triangle, and Hunter in the aponeurotic canal. 
Fig. 585. 
A view of the contents of Scarpa’s 
triangle. Femoral artery passing from 
the base to the apex of the triangle; 
femoral vein inside, behind, and on the 
outside of the artery; anterior crural 
nerve external. LIGATION OF THE FEMORAL ARTERY. 
785 
Ligation above the profunda femoris, which at one time was deemed a 
very dangerous and unsurgical procedure, has within the last few years 
been regarded with more favor, in consequence of the success which has 
attended the operation in the hands of the Dublin surgeons. Five successful 
ligations of the common femoral have been reported by Dr. G. H. Porter,* 
Fig. 586. 
Femoral artery in Hunter’s canal: flap turned down, consisting of skin, fascia, 
saphenous vein, s, and sartorius muscle, c; a, vastus internus; 5, tendon of the ad- 
ductor magnus; 2, adductor longus; near c" the aponeurotic canal is opened for a 
short distance, exposing the femoral vessels. 
and Dr. Macnamaraf alludes to eight cases of a similar ligation (strictly 
speaking, seven, as in one of the cases the ligature was applied below the 
profunda), of which number one died. Professor Gross tied the common 
femoral in two instances, with one recovery and one death. In the fatal 
case the artery was extensively diseased. 
Dr. Mott has spoken favorably of this operation as one which he had fre- 
quently done with satisfactory results. Though the question may be consid- 
ered as still sub judice, yet if the coats of the artery when exposed were found 
to be sound, I should have no hesitation in making the deligation in this por- 
tion of the vessel; if the coats were found to be diseased, however, I should 
feel it my duty to abandon the common femoral and select the external iliac 
as the safer operation. Considered in the aggregate, ligation of the common 
femoral has been attended with great success. Of the 204 instances con- 
tained in the tables of Dr. Norris, only 50 proved fatal. Crisp’s tables, con- 
sisting of 122 cases, give 107 recoveries, a death-rate of 12 per cent. At 
Guy’s Hospital, during the fourteen years between 1862 and 1876 the femoral 
artery was tied for aneurism 24 times, with 1 death, and at St. Bartholomew’s 
15 times, with 3 Syme tied this vessel 23 consecutive times, without 
a single death. Between the years 1868 and 1876 the femoral artery was 
ligated at the Pennsylvania Hospital 11 times, with 2 deaths.§ 
Operation on the Common Femoral.—A vertical incision two and a half 
inches in length should be made, beginning at the middle of the lower border 
of Poupart’s ligament. After raising and dividing the superficial fascia, one 
or two inguinal lymphatic glands will probably be exposed, which can be 
pressed out of the way by breaking up the surrounding connective tissue 
with the director. Should one or two cutaneous vessels spring at this stage 
of the operation, they must be secured. After a little clearing away of loose 
fat and connective tissue, the sheath of the artery will be exposed, and should 
be opened. The vessel being now separated from the sheath of the vein on 
the inside, and from a branch of the genito-erural nerve which lies on its ante- 
rior surface, the needle should be passed from within outwards, and the thread 
applied within half an inch of Poupart’s ligament. 
Operation at the Point of Election.—To tie the femoral at the apex 
* Dublin Quarterly Journal, Nov. 1860. f British Medical Journal, October 5, 1867. 
J Bryant’s Surgery, p. 217. 
| Morton, Statistics of Ligation of Arteries in the Pennsylvania Hospital, American Journal of the 
Medical Sciences, 1876. 786 
LIGATION OF ARTERIES. 
of Scarpa’s triangle, the limb should be flexed, abducted, and laid on its 
outer surface. An incision three inches long should now be made, beginning 
three finger-breadths below the middle of Poupart’s ligament, and carried 
obliquely to the longitudinal axis of the limb, that is, in the course of the 
femoral artery, or in the direction of a line extended from the middle of Pou- 
part’s ligament to the most prominent portion of the internal condyle of the 
femur. After dividing the skin and the superficial fascia, the deep fascia 
should be opened, exposing the inner edge of the sartorius, which may be 
recognized by the oblique course of its fibres. Turning slightly back the 
border of this muscle, the sheath of the femoral vessels will be seen, and the 
pulsation of the artery may be felt. Much care is required after opening 
the sheath to denude the vessel, so as to 
pass the thread without damage to the 
accompanying vein, which lies behind 
and to the outer side of the artery. To 
avoid this accident in passing the liga- 
ture, the needle, or other instrument 
used for the purpose, should be carried 
from without inwards. (Fig. 587.) A 
small vessel is often divided in this op- 
eration close to the sheath, and should 
always be tied. I have witnessed a 
troublesome bleeding from a neglect on 
this point. 
Operation in the Aponeurotic Canal. 
—The femoral artery may be tied below 
the sartorius, as was done by Hunter, 
though, except under circumstances rendering the operation in Scarpa’s tri- 
angle impracticable, or when a wound involves the vessel at the middle of 
the thigh, this operation is not a desirable one. When undertaken, an in- 
cision should be made, beginning at the apex of Scarpa’s triangle, continued 
downwards and inwards in the line already given, and terminating three 
and a half inches above the internal condyle of the femur. In dividing 
the skin and the cellulo-adipose tissue, avoid any branches of the internal 
saphenous vein or the long saphenous nerve which may lie in the way of the 
incisions. Next open the deep fascia which encases the sartorius muscle, 
Fig. 587. 
Ligation of the femoral artery at the apex of 
Scarpa’s triangle. 
Fig. 588. 
Ligation of the femoral artery in the aponeurotic canal. Retractor holding the wound 
open, and the director passed underneath the fibrous wall of the canal preparatory to its 
division. 
and. drawing the latter downwards, expose the aponeurosis which forms the 
anterior wall of the vascular canal. The parts being now held asunder, the 
surgeon makes a small opening in the aponeurosis, into which he passes the 
director and slits it up, in order to uncover the artery. (Fig. 588.) After LIGATION OF THE POPLITEAL ARTERY. 
787 
separating the artery from the vein which lies to its outer side, the needle 
should be passed from without inwards. 
Peculiarities of distribution.—The femoral artery in a few instances has 
been known to divide below the profunda into two branches, which passed 
down the thigh side by side and at the aponeurotic canal became united into 
one branch to form the popliteal. Sometimes the artery divides into two 
trunks high up on the thigh, one of which splits, forming the posterior tibial 
and the peroneal. Such an irregularity would possess great importance in 
aneurism of the femoral or of the popliteal, as the wrong vessel might be 
tied, and the tumor be in no way affected by the ligature. Cases of popliteal 
aneurism have been recorded in which this abnormal arrangement existed, 
and where it became necessary to ligate both branches. In rare instances 
the femoral artery has been found absent from the front of the thigh, having 
passed through the sacro-seiatic foramen and descended along the posterior 
aspect of the limb. 
The origin of the profunda has also a surgical interest. While it usually 
arises from the femoral two inches below Poupart’s ligament, yet its com- 
mencement is frequently within one inch of the latter, and in one or two 
cases it has arisen from the external iliac artery. 
Collateral circulation.—When the femoral artery is tied below the profunda 
femoris the blood finds its way to the inferior part of the limb principally 
through the communication which exists between the perforating branches 
of the profunda and the anastomotica magna of the femoral, with the articu- 
lar arteries of the popliteal and the recurrent branch from the anterior tibial 
artery. 
When a ligature is applied to the femoral artery above the profunda, the 
blood is conveyed to the femoral below, mainly by the ischiatic, gluteal, 
and obturator arteries from the internal iliac, with the internal and external 
circumflex arteries from the profunda femoris. 
Surgical anatomy.—The popliteal region, or ham, is a lozenge-shaped space, 
the sides of which are formed by the inner and outer hamstring tendons 
above, and the heads of the gastrocnemius muscle below. The region is 
formed at the expense of the lower third of the thigh and something less 
than the upper fourth of the leg. The femoral artery enters the ham after 
perforating the adductor magnus muscle, passing directly through its mid- 
dle, and terminates, after running through the tendinous arch of the soleus 
muscle, at the lower border of the popliteus muscle. It is accompanied by 
the popliteal vein and nerve. The vessel gives off the several arteries to the 
gastrocnemius muscle, the four articulars—twTo external and two internal— 
and the azygos branch to the ligaments and the inside of the knee-joint. In 
the middle of the ham the vessel is covered by the skin, the superficial fascia, 
the deep fascia, and a quantity of adipose tissue. In the superficial fascia 
runs the external saphenous vein. At the upper part of the popliteal region, 
in addition to the above-named structures, there is the semi-membranosus 
muscle, and at the lower part the gastrocnemius, the plantaris, and a small 
part of the soleus in front of the artery. Behind, the vessel, after passing the 
adductor magnus, rests first upon the inner and posterior surface of the 
femur, then upon the posterior ligament of the knee-joint, and last, upon the 
popliteal fascia. On a plane more superficial and external to the artery lies 
the popliteal vein, and still more externally and superficially is situated the 
popliteal nerve. 
The popliteal artery occasionally separates into its terminal branches— 
anterior and posterior tibial arteries—in the middle of the ham, and in rare 
instances it divides like an axis into three trunks, namely, into the two tibial 
arteries and the peroneal artery. 
Operation at the upper third.—Place the patient on the breast, with the limb 
Ligation of the Popliteal Artery. 788 
LIGATION OF ARTERIES. 
extended, then make an incision three and a half inches in length along the 
external border of the semi-membranosus muscle, commencing at the inferior 
third of the thigh. The skin and the fascia) having been divided, the under- 
lying fatty tissue should be broken up with the director or a finger, after 
which the nerve will be exposed, superficial and external to the artery. A 
little deeper will be found the vein, also external to the vessel. After its 
denudation, the artery can be encircled by the ligature carried from without 
inwards, in order that neither the vein nor the nerve shall be included. 
At the lower third.—The patient occupying the same position as in the 
preceding operation, make an incision three inches in length, beginning 
directly opposite the knee-joint, a little external to the median line,—the 
internal head of the gastrocnemius being somewhat larger than its fellow on 
the opposite side. After laying open the 
skin, examine in the superficial fascia for 
the external saphenous vein, which must be 
thrust aside; next divide the fascia, when 
the interval between the two heads of the 
gastrocnemius will be exposed. The limb 
must now be slightly flexed, in order to 
relax the two portions of the muscle, which 
should be separated 
by running the finger 
up and down the cel- 
lular interval between 
them. At the bottom 
of this space will be 
found first the nerve, 
next to the inside the 
vein, and still deeper 
and externally the 
artery. The operator 
should now draw the 
nerve and the vein to- 
wards the inner side 
of the limb (Fig. 589), 
while the needle bear- 
ing the ligature is 
passed around the ar- 
tery from within out- 
wards. (Fig. 590.) 
The middle portion 
of the popliteal artery, in consequence of its great depth, is unfavorably placed 
for ligation, and is, accordingly, not the subject of operation. 
Except for traumatic aneurism, or in the event of a wound, the circum- 
stances which will require the application of a ligature to any portion of the 
vessel will he rarelv encountered. 
Fig. 589. 
Fig. 590. 
Popliteal artery exposed, 
and the ligature passed at 
the upper and the lower 
third. 
Ligation of the popliteal. Two fingers are 
in the wound, one holding aside the nerves 
and the other searching for the vessels. 
Surgical anatomy.—The posterior tibial, the larger of the two branehes of 
the popliteal artery, begins at the lower border of the popliteus muscle, and 
runs down the back part of the leg, crossing, as it descends, to the tibial side. 
In the deep concavity between the inner ankle and the os calcis and under- 
neath the arch formed by the two origins of the abductor muscle of the 
great toe, the vessel divides into two branches,—the external and internal 
plantar arteries, which are destined to supply the sole of the foot. In its 
descent, the posterior tibial artery rests upon the tibialis posticus and flexor 
longus digitorum muscles; and at the lower part of the leg it lies on the pos- 
terior surface of the tibia and the internal lateral ligament of the ankle-joint. 
Ligation of the Posterior Tibial Artery. LIGATION OF THE POSTERIOR TIBIAL ARTERY. 
789 
At the ankle the artery is situated between the tendons of the tibialis pos- 
ticus and the flexor longus digitorum on the inside, and the flexor longus 
pollicis on the outside,—a vein being placed on each side and the nerves 
external to the vessel. The artery is covered by the skin, the superficial and 
deep fasciro, and the gastrocnemius and soleus muscles. The posterior tibial 
nerve, at first to the inner side of the artery, crosses over the latter, and at 
the middle and the lower third of the limb is found 
on its outside. (Fig. 591.) 
The branches of the posterior tibial artery are the 
peroneal, the muscular, the communicating, the nu- 
tritious, and the calcanean. 
Operation.—The posterior tibial can be tied at its 
upper, middle, and posterior thirds. The course of 
the vessel is in the direction of a line extended from 
the middle of the popliteal space to a point midway 
between the internal malleolus of the tibia and the 
tendo Achillis. 
At the upper third.—The operation of tying the pos- 
terior tibial in its first part is one of considerable 
difficulty, and demands for its accomplishment an 
accurate knowledge of the appearances of the struc- 
tures concerned. The artery is best approached from 
the inner side of the leg. 
The leg being flexed, the limb is laid on its outer 
side, when, feeling for the inner angle of the tibia, 
the surgeon makes an incision three and a half or four 
inches in length along its edge, beginning two and a 
half inches from the upper end of the tibia. (See Fig. 
593.) The skin being divided, care must be exercised, 
in opening the superficial fascia, not to injure the 
internal saphenous vein or nerve, both of which lie 
directly in the track of the wound. These struc- 
tures being displaced, the deep fascia must be divided 
to the full extent of the integumental incision. It 
should also be cut transversely, so as to allow a freer 
access to the intermuscular parts. The next step 
consists in detaching the origin of the soleus muscle 
from the tibia. (Fig. 592.) It is at this stage of the 
operation that one of two errors is often committed, 
either of which will lead the operator astray. The 
first consists in opening the intermuscular space be- 
tween the inner head of the gastrocnemius and the 
soleus muscle, and the second, in shaving off all the 
muscular tissue from the bone, by which the tibialis 
posticus muscle is raised along with the soleus. 
The first mistake leads the surgeon above the vessel, 
and the second leads him underneath. There is, 
however, a guide which will point in the right direc- 
tion. If the soleus has been properly detached and 
raised, its under surface will present a white, shining sheet of tendinous 
material, beneath which will be seen a layer of fascia (intermuscular) cover- 
ing the tibialis posticus muscle. If search be now made externally and 
towards the middle of the leg, the artery will be found covered by the inter- 
muscular fascia, the nerve lying to its outer side. After the vessel has been 
separated from the investing connective tissue and the accompanying veins, 
the needle must be passed from without inwards. 
At the middle third.—Make an incision two and a half inches long parallel 
with the inner edge of the tibia, and about half an inch from its border, 
After dividing the skin, the same precautions with regard to the saphenous 
Fig. 591. 
Course of the posterior tibial 
artery : 3, the head of the gas- 
trocnemius cut across; 4, poste- 
rior tibial nerve and popliteal 
artery passing under the tendi- 
nous arch of the soleus, 5, which 
is also cut across; 7, peroneai ar- 
tery ; 11, tendon flexor communis 
digitorum; 12, tendon tibialis 
posticus; 13, posterior tibial ar- 
tery ; 14, posterior tibial nerve. 790 
LIGATION OF ARTERIES. 
vein and nerve will be required in cutting the superficial fascia as in the pre- 
vious operation. It now remains to incise on the director the deep fascia, 
and press outwards the inner margin of the soleus muscle, when the artery 
with its accompanying veins will be exposed, as also the nerve running along 
the outer side of the vessels. After isolating the artery from its satellite 
veins, the thread must be passed from without inwards. 
At the inside of the ankle.—A semilunar incision one inch and a half in 
length should be made, midway between the internal malleolus and the tendo 
Fig. 592. 
Ligation of the posterior tibial at its upper third; wound held open by retractors 
while the surgeon detaches the origin of the soleus. 
Achillis, the knife being held at right angles with the surface of the part. 
After dividing the skin and the superficial fascia, the deep fascia must be 
lifted upon a director and freely opened. (Fig. 593.) Immediately under- 
neath should be found the vessel, with the tendons of the tibialis posticus 
and the flexor longus digitorum muscle on the inside, and the posterior tibial 
nerve and the tendon of the flexor longus pollicis muscle on the outside. 
After isolating the artery from its accompanying veins, the needle should be 
passed from without inwards. 
The necessity for tying the posterior tibial may arise in consequence of 
Fig. 593. 
Ligation of tile posterior tibial above the aukle. Lifting the deep aponeurosis 
previous to isolating the artery. 
traumatic aneurism, or of wounds inflicted by the fragments of a broken 
bone. In spontaneous aneurism of the upper part of the vessel, it will be 
best to tie the femoral artery on the Hunterian plan. 
Ligation of the Peroneal Artery. 
Surgical anatomy.—The peroneal artery arises from the posterior tibial, 
about one inch below the lower border of the popliteus muscle, and, after 
passing across to the outer side of the leg, runs down the posterior and inner LIGATION OF THE ANTERIOR TIBIAL ARTERY. 
surface of the fibula to the lower third of the limb, where it supplies the 
anterior peroneal artery. The vessel diminishes so rapidly in size as it de- 
scends, that below the middle of the leg it has become too small to require a 
formal ligation. The artery for the most of its course lies in the midst of the 
muscular fibres of the flexor longus pollicis pedis, in the angle formed by the 
inner surface of the bone and the interosseous ligament, and is also covered 
by the fibular origin of the soleus. 
Operation.—Make an incision two and a half inches long over the external 
edge or angle of the middle of the fibula. Divide consecutively the skin, the 
superficial fascia, and the deep fascia. The origin of the soleus muscle will 
now come into view. This must be detached for a short distance from the 
fibula and pushed inwards, on doing which the edge of the bone will be dis- 
tinctly exposed. The operator now divides the fibres of the flexor longus 
pollicis, and separates them from the posterior surface of the fibula, at the 
inner surface of which will be found the artery, at the point where the 
interosseous membrane joins the bone. 
791 
Ligation of the Anterior Tibial Artery. 
Surgical anatomy.—At the lower border of the popliteus muscle the ante- 
rior tibial pasSes through an opening in the interosseous membrane and reaches 
the anterior portion of the leg, when it passes down the 
limb, becoming more superficial as it descends, and 
finally, after passing in front of the ankle, reaches the 
dorsum of the foot and becomes the dorsalis pedis artery. 
At the upper third of the leg the anterior tibial is 
deeply situated, resting on the interosseous membrane. 
It is placed between the tibialis anticus and extensor 
longus digitorum muscles, having the anterior tibial 
nerve on its outer side. At the middle third it is lodged 
between the tibialis anticus muscle on the inside and 
the extensor proprius pollicis on the outside, with the 
nerve in front, and also on the outside. 
At the lower third, immediately above the front of the 
ankle, the artery lies between the tendons of the exten- 
sor proprius pollicis on the inside and the extensor longus 
digitorum on the outside, with the nerve also external 
in position. (Fig. 594.) The branches of the anterior 
tibial are the recurrent tibial, the muscular, and the ex- 
ternal and internal malleolar. 
Operation.—The anterior tibial artery may be tied in 
its upper, middle, and lower thirds. The general course 
of the vessel corresponds to a line drawn from a point 
midway between the tubercle of the tibia and the head of 
the fibula to the centre of the intermalleolar space. (See 
Fig. 595.) 
At the upper third.—The limb being somewhat flexed, 
and supported on a pillow placed beneath the ham, an 
incision three inches long should be made equidistant 
from the tubercle of the tibia and the head of the fibula, 
and commencing on a level with the former. After cut- 
ting through the skin and the superficial fascia, the sur- 
geon should endeavor to recognize the intermuscular 
space between the tibialis anticus and extensor longus 
digitorum muscles before opening the deep fascia. This 
may be done by noticing the presence of a yellow or 
fatty line beneath the aponeurosis; or one of the small 
arteries designed for the supply of the integument may be discovered per- 
forating the fascia. In either case the proper route is indicated. The deep 
Fig. 594. 
Relation of the anterior 
tibial artery to the muscles 
of the leg. 792 
LIGATION OF ARTERIES. 
fascia must now be raised upon the director and freely laid open. As both 
muscles have an origin from a prolongation of the deep fascia, their separation 
should be commenced at the lower angle of the wound, where the adhesion 
is less close. After opening the intermuscular space by the finger, the artery 
will be found at its bottom, resting on the interosseous membrane, with a vein 
on either side, and the nerve externally. After the denudation of the vessel 
the thread should be passed from without inwards. When difficulty is expe- 
Fig. 595. 
rienced in recognizing the different tendons in front of the ankle, they may 
be readily identified by moving the great toe, by flexing and extending the 
foot, and by similar movements of the other toes. 
At the middle third.—The artery in this region is more superficial than in 
the upper third of its course. An incision three inches in length should be 
made in the direction of the line already described. After dividing the skin 
and the superficial and deep fasciae, the fissure between the tibialis anticus 
and extensor longus digitorum muscles must be opened, when a third mus- 
cle, the extensor proprius pollicis, will be seen between the other two. The 
surgeon will now open and enlarge the fissure between the extensor proprius 
pollicis and the tibialis anticus, at the bottom of which lies the anterior tibial 
artery with its accompanying veins, and in front or close along its outer side 
is the anterior tibial nerve. After isolating the vessel, care must be taken to 
press the nerve towards the fibular side of the limb while the needle is being 
passed from without inwards. 
At the lower third.—The artery is to be exposed one inch and a half above 
the ankle-joint. In consequence of the superficial position of the vessel, the 
incision need not exceed two inches in length, and should be made in the 
course of the indicated line, beginning three inches above the front of the 
articulation. After cutting thi'ough the skin and the superficial fascia, the 
deep fasci’a should be opened external to the outer border of the tendon of 
the extensor proprius pollicis, which is the second tendon from the tibia. By 
enlarging the intermuscular space between this tendon and the extensor 
longus digitorum the artery will be reached, having the nerve on its outer 
side. After the denudation, and while the ligature is being carried round the 
vessel from without inwards, the nerve must be pressed aside in the direction 
of the fibula. 
The anterior tibial artery may require ligation on account of traumatic 
aneurism, or in consequence of wounds. The artery is occasionally torn in 
compound fractures of the leg, and requires, in such an event, the application 
of a ligature. 
Line showing the course of the anterior tibial in the leg. Ligation at the upper third. 
Ligation of the Dorsalis Pedis Artery. 
Surgical anatomy.—The dorsal artery of the foot, which is but an extension 
of the anterior tibial, lies over the first interosseous space, and between the LIGATION OF THE DORSALIS PEDIS ARTERY. 
tendon of the extensor proprius pollicis on the inside and the innermost 
tendon of the extensor brevis digitorum on the outside, with the accompany- 
ing nerve externally. It is covered by the skin, the superficial fascia, and 
the deep fascia. 
Operation.—The vessel may be found in a line drawn from the middle 
of the anterior malleolar space to a point midway between the anterior ex- 
tremity of the first two metatarsal bones. (Fig. 596.) An incision one inch 
793 
Fig. 596. 
Ligation of the anterior tibial at the lower third of the limb or above the ankle. 
long in the course of the line, or along the outer border of the tendon of 
the extensor proprius pollicis, should be made (Fig. 597), and after cutting 
through the skin, the superficial fascia, and the deep fascia, the artery will 
be found lying immediately internal to the inner tendon of the short ex- 
Fig. 597. 
Incision for ligation of the dorsalis pedis. 
tensor muscle of the toes. After isolating the vessel from its venae comites, 
and pressing externally the nerve, the ligature may be passed from without 
inwards. 
The dorsal artery of the foot will sometimes require to be tied, in conse- 
quence of wounds inflicted by chisels or other vulnerating bodies. CHAPTER XIII. 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
FRACTURES. 
What is a fracture? It is defined to be a solution of continuity in the 
fibres of a bone. It is an accident of great frequency, and more than any 
other has been a fruitful source of litigation between patient and medical 
attendant. In the management of such an injury the surgeon has much to 
contend with,—much that is calculated to create anxiety throughout the 
progress of the case. The frequency with which instances of deformity after 
fracture come under my observation would seem to indicate either incom- 
petency or negligence on the part of those having the care of such cases, or 
insubordination of the patient while under treatment. If the former be 
the case, there can be no impropriety or injustice in holding the practitioner 
to a strict accountability. So many complications attend or follow these in- 
juries, such as inflammation, abscesses, ulcers, hemorrhage, tetanus, delirium 
tremens, necrosis, gangrene, etc., that it is folly to regard this part of profes- 
sional work as a mere mechanical one; on the contrary, it demands on the 
part of the surgeon not only the highest degree of anatomical skill and tact, 
but also a thorough knowledge of the principles of general medicine. From 
the patient there should be exacted the most implicit submission and docility. 
Whenever these cannot be secured, it will be altogether proper for the sur- 
geon to relinquish the case, and to wash his hands of all responsibility. Pro- 
fessional bone-setters, as they are termed, have no claim to public confidence. 
They are generally both ignorant and rash. It should be remembered that 
a bone once broken, however simple the fracture, can rarely be repaired, even 
under the most skilful treatment, without some appreciable deformity or 
disability. There will be some inequality of the surface, or some shortening 
of the limb, or perhaps an abridgment of movement in a contiguous joint. 
There may be comminution of the bones, extensive damage to the soft parts, 
or many other complications, in consequence of which considerable deform- 
ity necessarily ensues, and for which no practitioner is to be blamed. In all 
cases, therefore, where the result of treatment is involved in doubt, it is the 
duty of the surgeon to state frankly to both the patient and the friends his 
apprehension, and thus prepare their minds for any unfavorable result. 
Causes op Fracture.—These are twofold,—predisposing, and exciting or 
determining. 
Predisposing Causes.—1st. Function.—Those bones which are concerned 
in prehensile and locomotive acts are, in consequence of their length, the 
powerful muscles by which they are controlled, and their exposed situation, 
very liable to fracture. 
2d. Form.—The long bones, placed as they are in exposed situations, and 
influenced by the action of muscles, are oftener broken than the short or 
irregular ones: hence the infrequency of the accident in the vertebrae, as 
compared with the humerus or the ribs. 
3d. Mobility.—Such portions of the skeleton as are not fixed by their 
articulations are less frequently broken than are others whose connections 
make them more stable: thus, the scapula and the patella commonly escape, 
while the nasal bones, the tibia, and the clavicle frequently suffer. FRACTURES. 
4th. Age.—No period of life, from the intra-uterine to extreme old age, is 
exempt from the accident of fracture. I have seen two cases of fracture of 
both bones of the leg in new-born children, which doubtless occurred before 
birth, and some years ago I attended a case of fracture of the thigh in a 
lady ninety-two years old. Intra-uterine fractures—sometimes multiple— 
have frequently been observed. A singular anterior curvature of the bones 
of the leg, particularly of the tibia, resembling very strongly a fracture, 1 
have met with in two cases of new-born children. Brown has noticed this 
same peculiarity, with the skin over the surface of the angular prominence 
resembling a cicatrix, and sixteen times in twenty-seven instances of the 
deformity he found the libula to be either entirely or partially absent. In 
childhood, fractures are not common, for several reasons. The bones are 
more elastic; the epiphyses have not become solidly united to the di- 
aphyses, and therefore the bones are more mobile; the ligaments are more 
pliable and supple; the muscles are incapable of exercising great power; 
and during the early years of life, children are usually protected from acci- 
dent by those interested in their welfare. In mature life, fractures are 
among the most common occurrences, because it is the period when men are 
most engaged in active duties, and in the prosecution of those employments 
and occupations in which the body is most exposed to injury. In old age, 
though fractures are not so common as in ripe manhood, the predisposition 
to such injuries is greater from fragility or brittleness of the bones, conse- 
quent on their rarefied structure. There is also, in advanced life, a loss of 
balance between the animal and the earthy parts of the skeleton, which, 
with the diminished pliancy of the ligaments and the loss of muscular activ- 
ity, strongly favors the occurrence of fracture. 
Diatheses constitute predisposing causes of fracture, such as syphilis, cancer, 
rachitis, gout, osteomalacia, scrofula, caries, necrosis, and cysts. 
A remarkable instance of senile fragility came under my notice in the case 
of an aged woman brought into the Pennsylvania Hospital during one of 
my periods of service, who had twenty-four fractures of the ribs, produced 
by a fall down a flight of stairs ten feet high. The patient died shortly after 
her admission. Esquirol describes a woman’s skeleton in his possession in 
which there were over two hundred fractures, and Malgaigne, on the au- 
thority of Saviart, a still more remarkable case of a woman, thirty years of 
age, who was believed to have had a fracture of every bone of the body. 
Nothing but a post-mortem, of course, could establish such a statement. 
Cases of multiple fracture are given by Gibson, Arnott, Lonsdale, and others. 
In 1870 I treated a case of fracture of the thigh in a child aged three years, 
the same bone having been broken the year previous. This child belonged 
to a family of six children, every one of whom had suffered from a fracture 
of some part of the skeleton. Two of their number had sustained each 
three injuries of this nature, and an infant at the mother’s breast, only three 
weeks old, had a broken rib, produced by being turned in its nurse’s arms. 
The explanation of this I found was due to the presence of a syphilitic taint 
derived from the male parent. I)r. Bennet* presented to the Pathological 
Society of Dublin a number of fractures taken from a man who had been 
crushed by a falling roof. The femur, the tibia, and the fibula of the right 
leg were broken, the humerus and all the ribs of the right side, the first 
three ribs of the left side, and the sternum. 
I can recall cases in which simply turning in bed was sufficient to cause a 
fracture of the thigh-bone. Most of these patients were women, some of whom 
suffered from cancer in the mammary gland, or from encephaloid disease of the 
omentum, and also of the femur at the seat of fracture. I have seen a case 
of fracture of the femur produced in the act of drawing on a boot, and of so 
serious a character as to be followed by death. There was reason to believe 
that a syphilitic vice was present and had affected the bones of this patient. 
Gouty and rheumatic states of the system also predispose the bones to 
795 
* Dublin Journal of the Medical Sciences, September, 1874. INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
fracture, not only in consequence of structural alteration in the osseous tissue 
of persons so affected, but also from the muscular disability and the articular 
rigidity which so commonly attend these diseases, and which render the in- 
dividual stiff and defenceless in his movements. 
Exciting Causes.—These are violence and muscular action. 
The violence may be applied to the bone either directly, as when a piece 
of timber or metal falls upon the leg, or when the latter is run over by the 
wheel of a loaded wagon, or indirectly, as when the force is applied remotely 
and is transmitted along the limb, expending itself destructively upon a dis- 
tant bone. In this way an individual who falls upon his band may break 
the clavicle, or a blow upon the top of the head may produce a fracture at the 
base of the skull. There are those who think muscular action does not often 
break a bone. I have frequently seen the patella broken by the powerful 
action of the quadriceps extensor femoris muscle, and in two cases have wit- 
nessed a similar injury to the thigh, where there was no ground for supposing 
that any diseased state of the bones had previously existed. I doubt not that 
the frequency with which drunken persons fall and escape fractures, where 
individuals in the full possession of their consciousness would probably not 
escape, is due in a great measure to the absence of muscular effort. 
Division of fractures.—All fractures 
may be divided into complete and in- 
complete. Complete fractures are those 
in which the bone is broken entirely 
through. Incomplete fractures are 
those in which all the fibres of the 
bone are not severed. Under the last 
division come what are called “ bent” 
or “green-stick” fractures. (Eig. 598.) 
The latter occur most commonly in 
the clavicles of children, and are occasionally met with in the bones of the 
forearm. A second division is into simple and complicated fractures. 
Fig. 598. 
Incomplete fracture of the radius.—Fergusson. 
Simple Fracture.—Writers differ somewhat in their definitions of a simple 
fracture, but, without discussing this subject, I shall define such a fracture 
to be the separation of a bone into two parts. There is always more or less 
injury done to the soft parts, sometimes by the vulnerating body, and in 
every case to the parts immediately in contact with or contiguous to the seat 
of the fracture, by the ends of the broken bones. In several dissections which 
I have made in man, and in the lower animals, the periosteum was found 
broken, sometimes almost flush with the severed fibres of the bone, and at 
other times it was torn into shreds and separated from the osseous fragments 
for some distance from their extremities. The fibres of the muscles lying on 
the periosteum were also torn, and blood had extravasated through the in- 
terstices of the adjoining muscles as well as between their fasciculi. 
Complicated Fractures are those in which there is added something more 
than the mere division of the bone into two fragments. These complications 
are the following: 
Compound Fracture.—This is one in which there is a wound forming a 
communication between the surface and the broken ends of the bone. This 
opening may be quite small, or it may be of considerable magnitude. The 
extremities of the bone may even protrude through the opening. A com- 
pound fracture maybe either primary or consecutive,—that is, it may be com- 
pound at the time of the accident, or it may become so afterwards, from 
various causes. For instance, the fragments may be so near the surface that 
the attenuated skin will inflame, ulcerate, and open, or from the damage in- 
flicted upon the soft parts an abscess may form which subsequently opens 
spontaneously or by the necessary interference of the surgeon. FRACTURES. 
797 
Comminuted Fracture.—In this complication the bone is broken into three 
or more pieces. This definition requires some limitation. A bone may be 
Fig. 599. 
Fig. 600. 
Comminuted fracture. 
Fig. 601. 
Impacted fracture of the neck of 
the femur.—After Miller. 
broken at its upper and lower extremities,—a 
multiple fracture,—and, although there would be 
in such a case four fragments, yet it would not 
be, in the technical sense, a comminuted frac- 
ture. It is only such when the lines of fracture 
communicate with one another. (Fig- 599.) 
Under this head may also be placed the stellated 
fracture. Should such a fracture be associated with an external wound, it is 
then a compound comminuted fracture. (Fig. 600.) 
Laceration of a principal artery or nerve.—This accident is sometimes pro- 
duced by a displacement of one of the fragments of 
a broken bone, or by the missile which determines 
the fracture, and is always a serious complication. 
Dislocation.—The force which causes a fracture 
may at the same time produce the luxation of a con- 
tiguous joint, and thus convert a very simple acci- 
dent into a very embarrassing one. 
Impaction consists in the end of one fragment of a 
broken bone being driven into the cancellated tissue 
of the other, so that the two become locked together. 
(Fig. 601.) 
Delirium tremens and low forms of fever.—The 
favorable progress of a case of fracture may be 
seriously interrupted by the occurrence of an attack 
of mania a potu, or by the invasion of typhoid or 
some other form of fever. 
Direction of fracture.—The direction in which 
the bony fibres yield may be oblique, longitudinal, or 
Compound comminuted fracture of the 
leg.—After Miller. 
Fig. 602. 
Fig. 603. 
Oblique frac- 
ture. 
The Oblique Fracture is the prevailing form. Such 
a direction becomes almost a necessity when we con- 
sider the structure and arrangement of the fibres of a bone. Some fibres are 
Transverse frac- 
ture. 798 
INJURIES AND DISEASES OF TIIE OSSEOUS SYSTEM. 
more elastic than others and will bend, while their neighbors will break. 
The same fibre is not equalty strong at all points. These fibres again con- 
stitute a system of intersecting arches, some of which will be more affected 
by force than others, so that the momentum attending a blow will not travel 
in a direct line, but in one more or less irregular. (Fig. 602.) 
Transverse Fracture is one in which the separation is in a direction at right 
angles with the long axis of the bone. (Fig. 603.) In the short bones, such 
as those of the carpus or the tarsus, or in flat bones, like the scapula or the 
ilium, such fractures frequently take place, but in the long bones their occur- 
rence must be exceedingly rare. I have seldom seen one in the adult which 
could be strictly so regarded. 
What are called epiphyseal fractures are transverse of necessity. (Fig. 604.) 
These may occur at any period before that in which the epiphysis and the 
diaphysis are solidly united by bony matter; though they are not common, 
as the elastic character of the intermediate uniting cartilage tends to prevent 
rather than to favor such an accident. 
Longitudinal Fractures are those in which the fracture runs in a direction 
parallel with the long axis of the bone. 
(Fig. 605.) This fracture is comparatively 
rare in civil surgery, though in military sur- 
gery it is frequently seen, and is the result 
of the formidable cylindro-conoidal ball. 
Fig. 605. 
Fig. 604. 
Signs of Fracture.—The signs of fracture 
should be carefully considered. Taken in 
their clinical order, that in which they 
generally present themselves to the sur- 
geon, they are as follows: 
Deformity.—The part injured has lost its 
usual appearance; it does not answer to 
the corresponding part of the sound side. 
Such comparisons should be made by oc- 
ular inspection, the limbs being placed 
side by side. It is in such injuries that sur- 
face anatomy becomes so valuable,—that 
is, a perfect familiarity with the normal 
contour of the parts. The deformity pres- 
ent will depend on the degree of displace- 
ment and the consequent swelling. There 
are various causes for this displacement, 
among which may be enumerated, 1st, 
the force which produces the fracture, driving the fragments into unnatural 
positions; and, 2d, muscular action, which is perhaps the most influential of 
all. Whenever the resistance which keeps the origin and insertion of a 
muscle at a given distance from each other is removed, the tendency of the 
muscle is to shorten. Allow a limb to remain any considerable time flexed, 
and the flexor muscles will become so shortened that it can with difficulty 
be straightened. In a broken limb, the bony resistance being lost, the same 
contraction takes place; and this action is often intensified by the irritation 
to which the contiguous muscles are subjected from contact with the angu- 
larities and the asperities of the fragments. 
The weight of the limb constitutes another factor in the displacement, and 
especially when the part has been imperfectly supported. One of the best 
illustrations of this statement is seen in fracture of the clavicle, in which 
case the weight of the entire shoulder acts on the outer fragment, carrying 
it out of its proper position. 
The displacement may be either longitudinal, angular, transverse, or rotatory. 
Epiphyseal fracture. 
Longitudinal 
fracture. FRACTURES. 
799 
Longitudinal displacement is that which takes place in the direction of the 
length or long axis of the bone. The oblique line of the fracture favors, by 
its mechanical form, this displacement, one fragment sliding past or over the 
other, producing what is termed overlapping or shortening, and occasioning 
that deformity which is the most constant source of anxiety to the medical 
attendant. As this is due to muscular action, it may, instead of making the 
fragments overlap, exercise an opposite effect, and draw them apart, as in 
fractures of the patella or of the olecranon process of the ulna, and those 
through the neck of the condyle of the inferior maxillary bone. 
This shortening of a limb after fracture may be much greater several hours 
after the injury than at the time of its infliction, particularly when the vio- 
lence has been directly applied, in which case the muscles are so paralyzed 
that they are incapable of drawing the fragments, to any extent, past each 
other. After a time, howrever, when they have recovered their power, the 
shortening will become very evident: hence the necessity of taking advantage 
of this period of enfeebled muscular action to adjust and confine the fracture 
accurately. 
An examination of the various collections of fracture specimens will con- 
vince any one that under the most skilful management some degree of 
shortening will generally take place, nay, may be expected. 
Angular displacement.—In this displacement the fractured ends are at an 
angle, more or less obtuse, with each other. (Fig. 606.) This forms a very 
serious deformity, and in most respects is 
more to be deprecated than the longitu- 
dinal displacement, as it is often increased, 
when in the lower extremity, by the weight 
of the body, even after the union has be- 
come consolidated, and by changing the 
line of muscular action greatly disables the 
patient in his movements. The chief ele- 
ment in its production is muscular action. 
There are cases in which it cannot be 
avoided, as in certain comminuted frac- 
tures, or wThere one fragment impales the 
other. 
Transverse displacement.—Such a displace- 
ment consists in the end of one fragment 
resting in part against the end of the other. 
Its occurrence is certainly not common. 
Rotatory displacement. — This displace- 
ment consists in one of the fragments being 
turned upon its axis. (Fig. 607.) The 
weight of the limb and the action of the 
muscles are the coefficients which deter- 
mine it. Either fragment may undergo this rotation, although it is generally 
the lower one. In fracture of the femur it may occur from allowing the foot 
to turn too far outwards, and in fractures of the bones of the leg below the 
knee it is produced by the same cause. 
Preternatural mobility.—This forms another important evidence of frac- 
ture. The existence of mobility in the shaft of a bone cannot occur without 
a break in the continuity of its structure. When the injury is very near to 
a joint, it will be more difficult to distinguish between the motion due to 
fracture and that due to the movements of the articulation, and wTe may 
have to rely on other symptoms for the resolution of our doubts. There 
are other conditions, however, in which the sign of mobility loses its value, 
as in a fracture at the surgical neck of the humerus, attended with inflam- 
matory stuffing of the surrounding parts; or when the lesion is in the neck 
of the femur and accompanied by impaction ; or in the leg or the forearm, 
when only one bone is broken and the fragments are not displaced. 
Fig. 606. 
Fig. 607. 
Angular displace- 
ment. 
Rotatory displace- 
ment. 800 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Crepitation.—Of all the signs of fracture this is the most conclusive. It is 
that sound or sensation which is produced by rubbing together the ends of 
the broken bone. It has been well said to resemble the sensation which is 
elicited by rubbing together two pieces of loaf-sugar,—it can be both heard 
and felt. There are conditions in which it may not be present, as in impaction, 
or in cases of incomplete separation of the fragments, or where there is 
great overlapping of the ends of the broken bone. There is a sound some- 
times recognized which may be confounded with that of fracture crepitus. 
It is the result of diseased cartilages, of preternatural mobility in a joint, or 
of a fibrinous exudation into the sheaths of tendons, or it may arise from 
an inflamed bursa. .An experienced hand and ear will not likely be misled. 
This imitation is properly a moist friction-sound, much softer and less 
grating than that of true bone crepitus. There is, however, a condition in 
which the two sounds are almost identical, as where the examination has 
not been made for several days after the accident, in which case the inflam- 
matory softening at the ends of the bone, together with the plastic products 
around, furnishes a soft, dull crepitus to the hands of the surgeon when the 
fragments are pressed against each other. In handling a part with a view 
to ascertain the existence of crepitation, the medical attendant should pro- 
ceed Avith clear and definite ideas. There should be no unnecessary or aim- 
less mo\7ements made, inflicting thereby uncalled-for pain. At the same time, 
he must not, from timidity or misplaced sympathy, stop short of a thorough 
examination. If the damaged part be an arm or a leg, the limb should be 
firmly grasped by the hands, one abo\7e and the other beloAv the supposed 
seat of fracture, and moA'ement made in opposite directions; or one hand 
may remain fixed and the other be mo\Ted; or it may be necessary for the 
physician to grasp the limb at the seat of injury wTith the hands,—as in the 
case of a broken thigh,—Avhile an assistant extends the leg by drawing on 
the foot, and afterwards rotates the limb. By these manipulations the ends 
of the fragments can often be brought into such a relation with each other 
as to produce the characteristic sound. In obscure or doiibtful cases the use 
of the stethoscope has been suggested by Lisfranc and others; but where 
such refinements are called for, great caution should be exercised, as sounds 
wThich can be recognized only by this instrument might readily be con- 
founded with those which follow the movements of a tendon or the friction 
OATer a bursa. 
Loss of function.—Generally speaking, there is inability to execute the 
ordinary movements of the part. A man cannot walk on a broken leg, 
raise weights with a broken arm, or breathe fully with a fractured rib. This 
is due to two causes,—the pain which results from such attempts, and the 
uncertainty with wThich the muscles act on a broken lever. Exceptions to 
this general statement, however, frequently occur. The murderer of Presi- 
dent Lincoln was able both to walk and to run on a broken fibula. I ha\Te 
frequently seen the arm moved with great freedom in fractures of the claAdcle, 
particularly in children, and I have known a sailor walk two squares, and 
to the third story of the Pennsylvania Hospital, with a broken thigh. In 
the same institution I have seen a patient walking with a broken patella. 
Where impaction or an incomplete fracture exists, such ability is easily 
accounted for, as the continuity of the lever is not lost. 
Pain.—It has been very properly observed that many diseases can be 
recognized by the character of their pain, just as we can distinguish persons 
by the tone of their voices. In fractures the pain is unlike that resulting 
from other injuries. It is of so acute and intense a character that the move- 
ment of the fragments will elicit a sudden, sharp, involuntary cry from the 
most stolid. The late Hr. Barton noticed this fact long ago, and attached to 
it much importance. The pain, it may be stated, is. as a rule, dependent on 
the movement of the parts. Tenderness or increased sensibility will be pres- 
ent for some time after a fracture, and, indeed, may be persistent throughout 
the entire course of treatment. REPAIR OF FRACTURED BONES. 
801 
Discoloration.—There are two sources of discoloration. First, it may arise 
from the blood-vessels of the subcutaneous connective tissue being ruptured 
by the direct application of force, in which event it will be apparent almost 
immediately after the accident, or in a very fewT hours following. The in- 
flammatory exudation which succeeds such an injury will sometimes result 
in large blebs or vesications, giving a dark or mottled appearance to the 
part. The second source of discoloration is from the vessels of the bone and 
the contiguous parts. This makes its appearance after the lapse of two or 
three days, or later, simply because the blood finds its way with difficulty 
towards the surface through the little apertures in the deep fascia traversed 
by the vessels and nerves. In cases of intracapsular fracture at the hip I 
have known eight days to pass before discoloration or ecchymosis became 
visible. In one instance so great was the discoloration that I wms called by 
the medical attendant to amputate the limb, under the impression that the 
leg was in a state of mortification. 
Disordered sensibility.—This may manifest itself by a burning, tingling state 
of the parts below the injury, by paroxysmal attacks of pain, or by numb- 
ness, and must be referred to injury of the adjacent nerve-trunks by the 
fragments of bone. It frequently provokes muscular spasm, which not only 
involves acute suffering, but also proves instrumental in disarranging the 
adjustment of the fracture. 
In persons of a highly-organized nervous system, after recovering from 
the shock of a fracture, intermittent muscular spasms occasionally occur, even 
when there is no evidence of nerve-pressure. In a patient whom I once at- 
tended lor a broken thigh, so highly was the reflex sensibility of the muscles 
developed that simply touching any one belonging to the injured limb would 
cause it to start out in a strong, cord-like swell. 
Time to examine.—For several reasons, the sooner after the injury the ex- 
amination of a fracture is made, the better. The sensibility of the parts from 
the local shock is less acute at this time. Nor is there any great swelling to 
mask the true natui’e of the injury. At this time the salient points of the 
skeleton, the relations of which are so important to a successful examination, 
are easily touched. To defer an immediate examination is to intensify the 
subsequent inflammation. In fact, every important sign of fracture is ren- 
dered less pronounced by delay. The fact that the work of repair in a frac- 
ture does not begin until some days after the reception of the injury is no 
argument whatever for procrastination. 
Repair of Fractured Bones. 
In the whole range of surgical pathology there is no process so interesting, 
and none which so challenges our admiration, as the process hy which nature 
repairs a fractured bone. Mr. Stanley remarks, very properly, that “hone 
holds a high place among the animal structures.” The notable distinction 
consists in its possessing a developmental force equal to a complete repro- 
duction in all the details of formal perfection, even when the osseous tissue 
is mutilated by force or destroyed in its entirety by disease. 
What is the condition attending or immediately following a simple frac- 
ture in a bone ? There is the severance of its continuity or rupture of its bony 
fibres; the laceration of the medullary and other vessels of the structure ; the 
rupture of the periosteum, and. generally, injury to a greater or less degree 
of the parts immediately contiguous to the hone. According to my obser- 
vation, in experiments on the lower animals, it is rare for a fracture to occur 
without the periosteum being broken or divided in the entire circumference 
of the bone. It may be severed on a line with the fracture, provided the 
direction is not too oblique, or it may occasionally yield at several points, 
leaving others wThich, though stripped off some distance from the surface of 
the bone, still serve to hold the ends of the fragments loosely together. The 
muscular fibres which lie in contact with the periosteum are often broken, 802 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
torn perhaps by the irregularities of the fractured ends. Blood is poured 
out, and that blood, both arterial and venous, comes from the medullary ves- 
sels, the vessels of the Haversian canals, the pei*iosteum, and the parts in 
close proximity to the injury. This blood finds its way into the medullary 
canal between and around the fragments, and into the intermuscular spaces 
around the seat of fracture. (Fig. 608.) After the lapse of time it forces its 
way through the deep fascia by the apertures for the passage of the small 
vessels, and then spreads through the subcutaneous cellular tissue, producing 
the ecchymosis seen beneath the skin. The firmness of the coagulum is 
most marked at the seat of fracture. That which reaches the surface is 
usually a blood-stained serum, and less coagulable than 
that which lies deep. Mr. Paget, speaking of the blood in 
fractures, says, The abundant extravasations that com- 
monly exist in the subcutaneous tissue are generally con- 
fined to it, and are not continued down to the periosteum 
or to the bone.” This is true as regards the blood de- 
rived from the subcutaneous vessels, but it is not to be 
inferred from this statement that there is no blood below 
the deep fascia. On the contrary, it will be found extend- 
ing from the fracture to the surface, and in not a few 
instances, particularly where the bone has been broken 
by indirect force, all the hemorrhage, whether superficial 
or deep, has been derived from the seat of fracture. 
What becomes of this blood? 
This question is a difficult one to answer. A certain 
portion is doubtless removed by absorption,—that is, it is 
taken up by the veins and the lymphatics, and is elimi- 
nated with other effete products of structural change. 
Still, I am convinced that there is another disposition of 
it. When once out of the vessels, the force which bound 
together its various components is no longer operative, 
its unity is lost, and it reverts into its separate chemical 
units, some of which, being of a kind similar to the struc- 
tures with which they are in contact, become incorporated 
with them through cell agency. The hemorrhage which 
follows the laceration or rupture of the blood-vessels of the 
bone gradually subsides, and in the same way as after a 
wound in the soft parts, namely, by the blood coagulating 
within their canals up to a collateral branch. The effect of depriving the 
bone of the blood that previously supplied these non-obstructed arteries is 
to induce a limited necrosis, in which the inorganic and the organic por- 
tions of the structure fall asunder and are removed by absorption, just as 
diseased parts of a vertebra are disposed of without any external opening. 
But we advance a step further. As a consequence of the damage sustained 
by the broken bone and the surrounding pai*ts, inflammation is induced, giving 
rise to a copious transudation of a fibrogenous material, and to the presence 
of vast numbers of corpuscular bodies or leucocytes, which have passed 
through the walls of the contiguous vessels. This transudation becomes 
intermixed with portions of the extravasated blood both surrounding and 
interpenetrating it, so that it becomes in a measure less firm in its consist- 
ence, and acquires a reddish stain, the whole mass forming a gelatinous sub- 
stance often of a pinkish color. The vessels w7hich participate in this work 
are all the vessels belonging to the bone, the periosteum, and in some degree 
those of the soft parts immediately adjacent, though it would appear that 
those of the inner layer (osteogenetic, as it is called) of the periosteum are 
most actively engaged in furnishing reparative material. In support of this 
view we find this membrane apparently separated a considerable distance 
from the bone above and below the line of fracture, though really incorpo- 
rated with the new deposition, which is most abundant opposite to the frac- 
Fig. 608 
Disposition of the blood 
after a fracture.—Miller. REPAIR OF FRACTURED BONES. 
803 
ture, so as to give this part of the bone a fusiform or spindle-like appearance 
(Fig. 609), and forming what was formerly called the “ring,” while that 
which occupies the medullary canal, in case there is no displacement, plays 
the part of a pin (Fig. 610), thus giving to the bone a considerable degree of 
support and firmness, which tends to prevent its displacement. Where over- 
lapping exists, the new material is placed between the contiguous surfaces of 
the bone as well as around them, as seen in Fig. 611, taken from a fracture 
thirteen days after it was made. 
In a short time this material, consisting of cartilage-cells and an intercel- 
lular substance, granular and striated, becomes of a much firmer consistence 
Fig. 610. 
Fig. 611. 
Fig. 609. 
Spindle-shaped appearance of 
the reparative material after 
fracture of the humerus. 
Showing the external and internal 
callus, or the ring and the pin.— 
Paget. 
The position of the reparative ma- 
terial in a fracture with overlap- 
ping. 
by the deposition of saline constituents, constituting what is termed callus, 
or elementary bone, and, coincident with this, the bond of union between and 
around the broken fragments becomes more firm. The amount of callus will 
be determined very much by the degree of motion to which the bone is sub- 
jected, and also by the accuracy of the adjustment. The more the ends of 
the bone are disturbed, and the greater the overlapping, the greater will 
be its quantity. As much of this reparative or reconstructive material 
disappears after the solidification of the fracture, it has been called provi- 
sional callus, while that which is more particularly concerned in cementing 
together or restoring the continuity of the bone-tissue is styled definitive 
callus. These terms, introduced by Dupuytren, are perhaps calculated to 
beget erroneous ideas as to this remarkable process. They would seem to 
imply that the first (provisional or ensheathing callus) is merely an impro- 804 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
vised material, which, like the scatfolding of a building, is wholly taken 
away when the building is finished, or as soon as the definitive callus— 
an after-production—is laid down and inwrought with the texture of the 
broken ends. This is true of that within the medullary canal, but not 
entirely so of that surrounding the fracture. Mr. Paget denies the existence 
of the ensheathing callus, except in the case of the ribs, and perhaps the 
clavicle. I can discover no ground for such a distinction. The ensheathing 
callus is always present to some extent; it becomes definitive callus; they 
are only stages of the same process. The former exists in all fractures of 
the long bones, and only that which is in excess of the necessities of the 
case is subsequently removed, just as the redundant lymph which may be 
about a wound in the soft parts is removed. But the work is not done. 
The union between the opposing ends of the fracture, when accurately ad- 
justed, does not take place until much of the callus without and within the 
bone has been formed. This is probably explained 
by the fact that the compact tissue is less vascular, 
and consequently furnishes a less abundant supply 
of granulation material. The first urgency being 
met, that of bridging over the chasm and giving a 
degree of fixation to the fragments by establishing 
their firm continuity, the work of modelling, or the 
perfecting of the process, is commenced, just as the 
sculptor, after cutting out the outlines of his figure, 
applies himself to the finer details of his work. All 
excess of callus is removed by a retrograde meta- 
morphosis; to this extent it is provisional. The 
very intimate union between the animal and earthy 
constituents of the callus begins to dissolve, the co- 
hesive power of the twain is lost; the salts are first 
removed, and then follow the animal or organic mat- 
ters ; all irregularities or angularities are rounded 
away; the structure of the callus, at first all com- 
pact, and filling the medullary canal and the spongy 
tissue around, becomes more open and porous by 
its partition-walls disappearing, and by the conse- 
quent enlargement of the cancelli, until at last the 
medullaiy canal is restored, as well as the cancel- 
lated tissue of the bone. Not only does this occur 
when the apposition has been accurate, but also 
when the overlapping has been considerable and 
with no small amount of interposed callus. This 
re-absorption of the compact w'alls of the bone, 
opening the medullary canal of one fragment into 
that of the other, as seen in Fig. 612, may require 
years for its completion, long before which the ele- 
mentary callus has become perfect bone, possessing, 
even at an early period, Haversian systems, lacu- 
na), and canaliculi. The particular in which callus 
differs from mature bone is in the proportion of its 
animal and earthy components, callus having over 
twenty per cent, more of the salts of lime than or- 
dinary bone, thus acquiring the increased hardness 
so necessary to the office which it fulfils. 
The development of the organizable material of 
the callus into true bone will be best illustrated by introducing at this point 
the results of a number of experiments which I made upon the bones of 
chickens, dogs, and guinea-pigs. For this purpose, numerous fractures were 
produced, and dissections, followed by microscopic examinations, made at 
various periods from one hour and a half after the injury until the twenty- 
Fig. 612. 
The cancellated tissue being 
gradually re-formed, and the com- 
pact walls of the overlapping frag- 
ments being gradually removed, in 
order to establish the continuity 
of the medullary canal.—Paget. REPAIR OF FRACTURED BONES. 
805 
fifth day. These fractures were all simple. It has been stated that after 
such an injury the blood finds its way into the medullary canal between the 
fragments, adheres to the edges of the periosteum when torn, and permeates 
the muscular and the connective tissue next to the bone. This describes 
most accurately the appearance presented in the first dissection I made one 
hour and three-quarters after the injury. A second dissection was made 
three days later. After removing the skin and fascia, the seat of damage 
was recognized by a swelling over the break, of a peculiar spindle-shaped 
form. Even the tendons were curiously spread out into a ribbon-like ex- 
pansion, and quite adherent to the parts underneath. On the fifth day this 
enlargement is probably at its height, and at this time a specimen was 
divided longitudinally, for the purpose of study. The periosteum was sepa- 
rated for over half an inch above and below the seat of fracture. At the 
latter point the separation was greatest, becoming less above and below: 
hence the spindle form of the enlargement. To the unaided vision, the 
same material which lay beneath the membrane was also external to it, so 
that the periosteum was in reality embedded in or incorporated with it. It 
was also seen between the ends of the bone when not displaced, or between 
the contiguous surfaces when overlapping, and finally for some distance up 
and down the medullary canal. This preliminary formation was a light- 
colored, consistent substance, interspersed with dark-red spots, and gave to 
the fracture a considerable degree of fixation. 
This specimen was placed for microscopic examination in charge of Dr. 
Rhoads, who furnished me with an opportunity to study each section, in 
order that the appearances might be more vividly impressed upon my mind. 
The material in contact with the fracture was found to consist of blood- 
corpuscles in various stages of disintegration, some adhering in rolls and 
preserving in some degree their form, some isolated, others collapsed, with 
irregular or stellated margins; homogeneous lymph ; and great numbers of 
the so-called germinal corpuscles, or, in the light of more recent discovery, 
leucocytes. These components were irregularly intermixed, and here and 
there stained with what seemed to be tbe coloring-matter of broken-down 
blood-corpuscles. The leucocytes varied much in form; some were round, 
others oval. They varied also in size, as though under the active process of 
change. 
In the compact portion of bone, a noticeable contrast existed between the 
Haversian canals near the fractured ends and those more remote. The size 
of the former was much greater, and they presented at numerous points little 
recesses or loculi, leading off from their sides. The blood-vessels could be 
distinctly seen, but they were pushed off from the sides of their bony canals, 
the intermediate space being occupied by crowds of cells in all respects like 
those exterior to the bone, and which came, no doubt, from the Haversian 
vessels. Now, as the Haversian canals open into the medullary space, and 
also upon the broken surfaces of the bone, the conclusion was inevitable that 
many of the cell-bodies seen in the medullary canal came from these sources, 
as well as from the vessels of the medullary membrane. In this rapid en- 
largement of the hard bony canals traversed by the blood-vessels, we have 
an example of one of those singular changes which attend inflammation, 
and which it is difficult to explain. That it is due to absorption from the 
pressure exerted by the exudation is exceedingly improbable, as such press- 
ure would destroy the contained vessels rather than affect the bony walls 
with which they are surrounded. In studying the inflammatory process in 
other tissues, a somewhat analogous phenomenon may be witnessed. In car- 
tilage, for example, the normal corpuscles which lie embedded in the inter- 
mediate substance have their places occupied by a multitude of leucocytes, 
more changeable and active than those which they have replaced, and whose 
insatiate demand for pabulum compels them to prey upon the matrix, the 
consumption of which gives the structure an open, reticulated, or honey- 
combed appearance. It is quite probable, therefore, that the organic constit- 806 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
uents of bone may be attacked by the migrated cells of its vessels, and, thus 
separated from the bone-salts, give rise to the enlarged canals and their irreg- 
ularities. The phenomena presented in this first specimen appear, then, to 
have been those of an inflammatory character, in which all parts of the bone 
at and contiguous to the fracture were engaged. The periosteum incorporated 
with the reconstructive material in seven or eight days entirely disappeared 
as such, undergoing those changes which inflammation produces in ordinary 
connective tissue, while a new membrane was produced external to the spindle- 
shaped mass of new matter, and continuous with the old periosteum at the 
limits of the separation. 
A second specimen, nine days old, was subjected to a similar examination. 
In this fracture the periosteum had not been entirely broken, and conse- 
quently there was no displacement of the fragments. It was divided longi- 
tudinally. The periosteum was not torn from the bone, but was separated 
by the exudation for about one inch above and below, in the same fusiform 
or spindle-like manner as in the specimen first studied, only to a greater 
degree. The reconstructive material lay between the bone and the perios- 
teum, external to the latter, between the ends of the fracture in small 
amount, and within the medullary canal. This does not accord with Mr. 
Stanley’s statement, who alleges that when thus apposed, and without dis- 
turbance, no provisional callus is supplied by nature, but that immediate 
union takes place, an opinion in which, I believe, Mr. Paget concurs. The 
stage of organization was not alike in all portions of the new material. 
The development was evidently advancing from without inwards. The 
greater part of this new formation consisted of round, oval, and elongated 
masses of germinal matter, surrounded by a faintly granular and fibrillated 
intercellular or formed material. These cells were in some situations grouped 
irregularly, at others arranged in an orderly manner in concentric ranks, 
corresponding to the canals seen a little later, and foreshadowing the lam- 
inae of the Haversian systems. The cells which lay between the ends of the 
bone and in the medullary canal were more numerous and less distinctly 
altered from the globular form, and were greatly in excess of the intercellular 
or formed material; this latter was still mingled with a little broken-down 
blood. In the angles between the periosteum and the bone, and in an oval 
space near the centre of the external or ensheathing matter, the transforma- 
tion into soft bone had taken place by the deposit of bone-salts. In these 
situations the Haversian canals were large and numerous, running, some 
diagonally, others perpendicularly, between the periosteum and the old bone. 
Simultaneous with the calcareous conversion of t he intercellular material were 
the formation of the canaliculi and the shaping of the previously-arranged 
cells into distinct lacunae. 
In the spindle-shaped envelope or ferrule we have the ensheathing callus 
of Dupuytren, or what he termed provisional callus, while the portion occu- 
pying the canal answers to the pin. These, according to this distinguished 
surgeon, were only temporary in their duration,—splints, in other words, 
to maintain a degree of connection until a secondary deposit took place 
between the ends of the bone, after which the former were removed, being 
no longer of use. 
Other specimens were examined on the thirteenth and seventeenth days. 
These exhibited a more advanced stage of ossification, though in some places 
many cells were seen which were not cartilage-cells. Between the broken 
ends the intercellular substance had increased, and some progress had been 
made in its conversion into bone, permitting much less movement at the 
break. At other portions of the callus, canaliculi were forming in the inter- 
cellular material, and which evidently commenced on that part of the callus 
most remote from the lacunae. The entire mass of new bone was a trifle 
more open and spongy in its texture, and of a slight rosy tint. Anxious to 
determine the vascularity of the reconstructing substance, on the fifth day 
after making a fracture of the wing of a chicken a delicate pipe was inserted REPAIR OF FRACTURED BONES. 
807 
into the brachial artery, through which 1 injected some ultramarine sus- 
pended in glycerin. A section was made of the bone and submitted to Dr. 
Ehoads for examination. Although the injection was not so satisfactorily 
done as I could have wished, yet the coloring-matter had tilled numerous 
vessels throughout the callus. These vessels in the external callus ran for 
the most part perpendicularly down, the callus ossifying around them. 
Two additional specimens, one twenty-one and the other twenty-three 
days old, were carefully studied. The appearances presented were entirely 
in harmony with the previous specimens. The entire reconstructing mate- 
rial had been converted into bone, so that scarcely a trace of cartilage could 
be seen. The amount of exterior callus had diminished and become more 
compact, and that between the ends of the bone, though much less perfectly 
transformed into osseous tissue by the deposit of the bone-salts in the intercel- 
lular substance than other portions, had nevertheless made material progress. 
Meescher and Votsch state that ossification in birds is always in cartilage ; 
Wagner states virtually the same in the case of rabbits, and in all the cases 
which furnished the subjects of the present experiments the same fact was 
observed. It is asserted that in man the repair or ossification may take place 
either in cartilage, or in fibrous or fibro-eartilaginous tissue. This statement 
needs confirmation. At the time I was engaged in these experiments a patient 
was admitted into the Pennsylvania Hospital who had broken his femur in 
the lower third in the act of pulling off his boot. Six weeks after, the man 
died, and I had the opportunity of examining the bone. Though the frac- 
tured limb had been kept perfectly quiet, the appearance presented was 
identical with that of the bones which I had under experiment. There was 
the same spindle-shaped swelling on the exterior of the bone, extending for 
two inches above and below the fracture, and most of which had been con- 
verted into bone, while in that portion between the ends, and where the 
process was less advanced, lay cartilage-cells embedded in a vitreous-like 
matrix, but not a trace of connective or fibrous tissue. Of course it would 
be unsafe to speak dogmatically from a single example, but it is sufficient to 
excite a doubt as to union, save through cartilage tissue. It is certainly true 
that the amount of peripheral callus is greatly influenced both by the rela- 
tion of the fragments to each other and by the degree of disturbance to which 
they are subjected, becoming exuberant when there is overlapping, and espe- 
cially so when the ends are not sufficiently immobilized; but 1 think that 
any one who will study the fracture specimens in our museums will be con- 
vinced that in all long bones, whatever may be the age of the specimen, there 
is manifest evidence of an ensheathing callus, increasing somewhat the volume 
of the bone at the seat of injury. The conclusions which 1 think are ren- 
dered probable by these and other observations are the following: 
First. That there is no evidence founded on structure, that the process of 
healing in the fractures of man may not be studied by experiments on the 
lower animals, or that the repair in the latter materially differs from that in 
the former. 
Second. That the reparative act is the result of an inflammatory process. 
Third. That the reparative material is furnished by the vessels of the peri- 
osteum. endosteum, and bone, and to some extent by those of the adjacent 
soft parts. 
Fourth. That the uniting material is deposited external to the bone, con- 
stituting an ensheathing callus; also in the medullary canal when there is no 
displacement, and between the ends of the bones; that the conversion of this 
preliminary substance into bone proceeds from the surface towards the centre, 
so that the exterior is hard long before the interior, which will account for 
the movement discoverable in specimens apparently solidly united together. 
Fifth. That the union of bone is through cartilage, and even through cells 
which have not reached the typical form of cartilage, and in this respect does 
not materially differ from the process observed in the primary development 
of bone. 808 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Sixth. That the presence of the ensheathing and medullary callus, thought 
to be exceptional in man, should he considered the rule. 
Seventh. That the terms temporary and provisional callus, as used by Dupuy- 
tren in contradistinction to the definitive, must be accepted with considerable 
limitation, the one not ditfering in any particular of composition from the 
other; that the delay in the production and bony transformation of the in- 
termediate or definitive callus, as compared with the exterior and interior 
portions, is due only to the comparatively small vascularity of the compact 
part of the bone. 
Eighth. That the complete absorption of the ensheathing callus never 
occurs, and that the re-absorption of the medullary callus is not a work of 
nature set in operation because the union at the ends of the bone has become 
complete, but is simply a repetition of the order followed in the development 
of the long bones, entirely independent of the fracture, a work which con- 
tributes both to their lightness and to their mechanical strength. 
The time involved in the whole work of restoration varies no doubt in 
different persons, and is affected by various circumstances, such as the health 
of the patient, the quiet of the parts, and the accuracy of the adjustment. 
The process in its entirety may be described as follows: 
First there is a period of rest,—one in which there is no visible attempt 
made to repair the damage. All seems quiet. Everything within the area of 
injury remains in chaotic confusion ; and as an architect, before he begins the 
work of reconstruction, quietly surveys the mass of ruins of some noble build- 
ing which has gone down under a sudden catastrophe, so the genetic forces 
of the parts seem to brood silently for a time over the scene of disorder before 
any note of preparation is sounded. This is of short duration, not generally 
extending beyond thirty-six hours. Following this comes a reactionary period, 
in which the ordinary phenomena of inflammation are present. There is an 
increased determination of blood to the part, accompanied by a transudation. 
This is sometimes very considerable, giving rise to much swelling and an ex- 
alted sensibility of the parts, and may continue for three or four days ; so that 
the first five or six days are consumed in passing over the stages of local shock 
and inflammatory disturbance. It cannot be said that during this time any 
true reconstructive work has been inaugurated. In this respect the repair of 
fractures in lower animals, as chickens, rabbits, etc., differs from that in man. 
In the former the process of union is well established in seven or eight days. 
The acute symptoms having subsided, another period of three or four days 
elapses, during which a part of the inflammatory products, and a portion of 
the extravasated blood and other debris consequent upon the injury, are 
removed, and the tenderness and swelling, as well as the irritability of the 
surrounding muscles, become diminished. The vascularity, however, of the 
bone, periosteum, and endosteum does not diminish, but rather increases. 
From the eighth to the tenth day the real work of repair begins, that in 
which the true fibrogenous matter, swarming with cellular elements, assumes 
the appearance of order. 
The differentiation of this constructive material into cartilage, or fibro-car- 
tilage and intercellular substance, and the subsequent deposition of the bone- 
salts, ultimately permeating the mass and imparting solidity to the bone, are 
the work of four or five weeks. 
Now, while we have divided this process into stages, allotting to each an 
approximate number of days or of weeks, it must not be supposed that these 
gradations are sharply defined, and that one cannot begin until the other is 
ended : on the contrary, they may blend or coexist, and can only be re- 
garded as approximately true; but they are nevertheless convenient for pur- 
poses of description. 
In children union will often occur with great rapidity; and I have even 
known an adult with a fracture of the femur to rise from his bed and walk 
at the expiration of four weeks; indeed, I am convinced that the healing 
of fractures takes place at an earlier period than is generally believed. REPAIR OF FRACTURED BONES. 
809 
Such is the ordinary mode of repair. It is alleged by some that where the 
apposition is very perfect, as where the fragments rest end to end or edge to 
edge, or where there is an incomplete separation of the fibres of the bone, 
immediate union may take place, just as it is alleged to occur under favorable 
circumstances in the soft parts. I have never seen any specimen which 
would induce me to adopt such a conclusion. 
In compound fractures the existence of an external wound and the sup- 
puration which ensues modify the plan of restoration. The work is greatly 
delayed, and the union is effected through a larger amount of granulation 
than in simple fractures, which, after its transformation into fibro-cartila- 
ginous tissue, becomes incorporated with the lime deposits. In other words, 
the difference between the healing of simple and that of compound fractures is 
much like that between the healing of subcutaneous and that of open wounds. 
In compound comminuted fractures the healing is still longer delayed. 
Detached portions of the bone die from losing their connection with the peri- 
osteum and the medullary tissue, and from the influence of the inflammatory 
products. The work of reparation is delayed until the sequestra are got 
rid of, after which granulations spring up abundantly from the medullary 
and periosteal tissues and undergo ossification. The time required for the 
separation of such necrosed portions may be so great that the restorative 
powers entirely fail, and no union will take place ; or, if united, the connection 
is established in a large sheath of irregular callus, without any cohesion of 
the ends of the fragments to each other. It is in such fractures that we often 
find the hard and the soft parts extensively glued together by inflammatory 
lymph. Where there is loss of bone, in most cases there will be shortening, 
particularly in the adult, although, as shown by M. Ollier, the preservation 
of the periosteum will often provide to some extent against this, by supplying 
the material for partially bridging the gap. 
When a cartilage is broken, the perichondrium behaves like the periosteum, 
furnishing the material for a bond of union, which consists not of cartilage, 
but of bone, and which envelops the parts like a firm ring, but often not rill- 
ing the intermediate space, or that between the ends of the fragments. An 
epiphysis, when detached from its diaphysis, although the original conjunc- 
tion was one of cartilage, will afterwards unite by bone; and as the bones 
grow in length by a deposit in the cartilage which exists between the ends 
of the shaft and the epiphyses, it has been stated that in such fractures the 
bone ceases to grow in the longitudinal direction. I have reason to doubt 
the correctness of this statement, believing that, although no increase in 
length may take place at the injured part, the failure is compensated for by 
increased activity in the nutrition of the intermediate cartilage at the other 
extremity. Fractures which extend through the articular incrusting carti- 
lage seem to have no power to unite. There are other fractures which do 
not unite by callus. They are such as are subjected to the influence of the 
synovial fluid, or whose vascular supply is insufficient. Among these are 
fractures of the neck of the femur within the capsular ligament, of the head 
of the humerus, of the olecranon process of the ulna, and of the acromion 
process of the scapula. Fractures of the patella generally come under the 
same category. 
Treatment of Fractures.—There is but one indication in the treatment 
of fractures, and that is to secure the union of the broken bone with the least 
possible deformity; and this single thought is to animate the surgeon during 
the entire management of the case. 
There is, however, involved in this, first, all that pertains to the transpor- 
tation of the patient from the scene of accident to a hospital or a home; 
second, the preparation of the bed upon which he is to be placed ; third, the 
adjustment of the parts,—that is, restoring them to their proper position, 
commonly termed setting the bone ; fourth, the means for maintaining the parts 
permanently in place when adjusted ; and, fifth, such local and general treat- 
ment as will remove or prevent all morbid processes inimical to the cure. 810 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
The transportation of the patient.—Injuries of this kind are very liable 
to occur when the patient is at a distance from home, in localities where 
buildings are in process of erection, or in manufactories or mines, and it be- 
comes necessary to have the injured person conveyed either to his own resi- 
dence or to a hospital. When it is an inferior extremity, the pelvis, or the 
spine, which has been broken, walking is, of course, out of the question. 
Under such circumstances we may improvise a litter by taking a window- 
shutter, or a broad board, or a settee, which last is preferable to all others. 
Whatever is used, it should be covered with a folded comfortable, and the 
patient laid upon it and borne to his destination by four or more persons, who 
are to break step with one an- 
other, in order to avoid any 
irregular movements. (Fig. 
613.) If the leg is broken, it 
should be placed on a pillowq 
which may be secured about 
the part with handkerchiefs or 
tapes. Where the distance is 
considerable, the patient may 
be transported on a bed or a 
mattress placed in a furniture- 
car, and in lifting him on or 
from the litter or the car, four 
persons will be required, two 
of whom should support the 
body by locking their hands 
underneath the thorax and 
the pelvis, a third should sup- 
port the sound limb, while the 
surgeon or some intelligent 
person should always take 
charge of the damaged part, 
grasping it in such a manner as to insure an equable support, the seat of 
fracture resting on one hand. Where patients have to be sent long dis- 
tances to a hospital, the limb should be surrounded not only with a pillow, 
but also with strips of light board, and these secured firmly about the part 
by handkerchiefs or cords. Where the upper extremity, the ribs, or the jaw 
are broken, a permanent dressing may at once be applied, if the means to do 
so are at hand. If not, then position and fixation are the chief indications. 
In the case of the maxillary bones, the jaws should be tied together with a 
handkerchief in cravat-form, the centre being placed under the chin, and 
the ends secured over the vertex; if it is the ribs that are fractured, the 
vest can be firmly drawn about the thorax; and if the arm, it can be sus- 
pended in a sling and fastened to the body. 
The preparation of a bed for all fractures of the lower extremities and of 
the spine is of the first importance. A firm mattress, tightly stuffed, which 
will not sink under the weight of the hips, is to be chosen, and a round hole 
cut out of the middle and lined with oil-cloth. The piece removed should be 
covered and hemmed or bound, in order to fill the opening in the mattress. 
The sheets require to have a hole corresponding to the opening in the mat- 
tress. The bedstead should be a narrow or a single one, making it con- 
venient for the surgeon to approach his patient from either side. It should 
have a slat or a board bottom, the middle board being broad and having in 
it an opening corresponding to the one in the mattress. On each side of the 
wide board should be nailed a cleat or ledge, on which can be slid a tin or 
earthen vessel designed to receive the evacuations. (Fig. 614.) Most houses 
contain a single bedstead, which, with the aid of a carpenter, or by the handi- 
craft of a surgeon, can very soon be modified so as to serve perfectly the pur- 
pose of a fracture-bed. In many localities the country practitioner is called 
Fig. 613. 
Bearing a patient upon a settee. FRA CTURE-BEDS. 
811 
to treat cases of fracture where the family is not able to purchase either a 
mattress or a bedstead, and he must utilize to the best advantage the resources 
at hand: it is a satisfaction to know that excellent results can be obtained in 
fractures of the thigh and the leg without either a mattress or a single bed. 
Under such circumstances, comfortables may be folded and placed together 
Fig. 614. 
Fracture-bedstead made by altering the ordinary single bedstead. 
upon any bedstead until the requisite support is secured; or, if the patient 
is old and the surface of the body tender, the ordinary feather bed, being 
first beaten out and flattened down, may be covered with the comfortables. 
For receiving the dejections a bed-pan can be slipped under the nates from 
the sound side without materially disturbing the fracture. 
Many ingenious fracture-beds have been devised, most of which are costly, 
and therefore limited in their use, such as the Jenks fracture-bed (Fig. 615), a 
kind of surgical derrick, rendered formidable by the amount of rigging needful 
Fig. 615. 
Jenks’s fracture-bed. 
for its effective operation. Beds have also been devised by Crosby, Hewson, 
Daniel, and others, but figure more in books than in practical use. Indeed, 
so far as my observation extends, both at home and abroad, very little im- 
portance is attached to the use of these contrivances. In injuries of the 
spine, or in cases of paralysis which are likely to prove tedious, in order to 812 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
avoid bed-sores the air- or the water-bed is invaluable, especially the latter. 
Except, however, for those in good circumstances, this bed is too expensive. 
Whatever bed is used, it must be covered with a sheet having an aperture 
corresponding to the one in the mattress. The removal of the soiled sheets 
and the substitution of clean ones require some notice at this point. This 
may be accomplished with the least disturbance to the fractured part by 
removing the pillow, pushing down the dirty sheet beneath the shoulders of 
the patient, then placing over the uncovered part of the mattress the clean 
sheet, previously gathered into reversed folds. The upper part of this sheet 
is next to be smoothed down, tucked under the head of the mattress, and 
made additionally secure by placing upon it the pillow, while the lower part 
is to be fastened to the upper end of the soiled sheet with pins, the points of 
which should be directed upwards and buried out of sight. An assistant now 
raises the pelvis, while the patient, by making the back of the head a point 
of resistance, so elevates the body that the soiled sheet can be drawn down, 
bringing after it the one which is to take its place. 
Removal of the clothing.—The bed being prepared, the next duty is the re- 
moval of the patient’s clothing. A great deal of wastefulness and unneces- 
sary destruction is often witnessed in etfecting this. The coat, pantaloons, 
or boots are cut and slashed in every direction, rendering them for ever after 
useless. A coat may be removed, by a little gentleness and tact, without 
materially disturbing a broken bone; and so also may the pantaloons. Or, 
if difficulty is experienced, let them be opened along a seam. Even the boot, 
which is, perhaps, the most difficult to remove, can be taken from the foot of 
a broken leg by using it after the manner of a lever and coaxing it off, while 
counter-force to the leg is made by the hands of the surgeon. 
Retentive dressings.—The preparation of splints for maintaining the frac- 
ture in position when adjusted becomes the next duty. While I do not 
undervalue the ingenuity and zeal of those who are devising neat and ele- 
gant appliances for the treatment of fractures, it is nevertheless desirable 
that whatever dressings are employed should be simple and always acces- 
Fig. 616. 
Fig. 617. 
Splint formed out of binders’ board. 
Splints prepared from perforated tin and zinc. 
sible. The more complicated and elaborate the splint, as a rule, the more 
limited is the experience of its inventor in dealing with the class of injuries 
under consideration. With a view to furnish the needful lateral or antero- 
posterior pressure, various materials may be used, such as light poplar or FRACTURE DRESSINGS. 
813 
pine boards, binders’ board, gutta-percha, sole-leather, tin, zinc, felt, wire, and 
plaster. When light strips of wood are used, they must be padded with 
cotton, oakum, or old pieces of blanket, which, after being laid upon the sur- 
face of the splint, can be made fast by the turns of a roller. 
Binders' board answers in many cases an excellent purpose. A pattern 
of the part to be supported should first be cut out of paper, and after this 
model the form of the binders’ board can be fashioned. Before its applica- 
tion, the material must be dipped in hot water until it is thoroughly softened, 
when it can be moulded to the part with great accuracy (Fig. 616), the limb 
being previously protected by a thin sheet of cotton wadding. 
Tin and zinc splints (Fig. 617) were used during our late war, having been 
introduced into the army chiefly through the influence of Dr. Harris, of New 
York. 
Fig. 619. 
Fig. 618. 
Splints prepared from wire. 
Dr. Ahl’s felt splints. 
Wire splints (Fig. 618) have been recommended by Dr. Nott, of Mobile, 
and also by Dr. Louis Bauer. 
A felt splint has been prepared by Dr. Ahl, of Pennsyl- 
vania, which is admirably adapted to the treatment of frac- 
tures. (Fig. 619.) This material is porous in its texture, and 
requires to be dipped into hot water or to be held before an 
open fire in order to render it soft and pliable, after which it 
can be moulded to any surface or at any angle. Its form and 
firmness are not affected in the least by cold water. Its value, 
moreover, is not impaired by previous use. It can be again 
rendered flexible by a second immersion in hot water, and 
adapted to another part. This material is also porous, so 
that the part, if it were desired, could be kept wet with cold 
water without affecting the fixed form of the splint. 
Thin slats of light wood, pasted or glued to sheepskin 
leather (Fig. 620), are sometimes used when it is desired to 
distribute the support equally about the limb. Openings 
can be cut in the splint so as to admit salient points of the 
skeleton. 
Immovable dressings are such as are designed to be perma- 
nent, or to be removed only at considerable intervals of time. 
The materials employed for this purpose are quite numerous. 
Seutin, in 1834, used clear-starch for the purpose of rendering 
the dressing hard. Ilis plan of applying the bandage was, 
after protecting the bony prominences of the limb with cotton, 
to encircle it with a number of rollers, each brushed over with the starch. 
Fig. 620. 
Wooden slats past- 
ed to sheepskin; 
opening made for 
the malleolus. 814 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Between the bandages strips of pasteboard were interposed in order to in- 
crease the strength of the dressing at particular points. After the “ appareil” 
became hard, it was slit up along the front, so that the condition of the 
limb could be ascertained at pleasure, and the dressing was afterwards bound 
together with a roller. The “apparatus immobile” is really much older than 
Seutin, having been used at a very early date by Albugene, an Arabian sur- 
geon. Other materials are in common use as substitutes for starch, such, 
for example, as dextrin, the silicate of soda or liquid glass, a mixture of 
pounded chalk and gum arabic reduced to the proper consistence by boiling 
water, also gum-shellac. Flour formed into a paste with water or the white 
of eggs constitutes another useful mixture to stiffen the materials with which 
a fracture is surrounded. It is not necessary, in order to apply the immovable 
dressing, that rollers should be exclusively used. The part may be enveloped 
in a piece of cloth or bed-ticking, or a blanket, or the leg of an old pair of 
pantaloons, or a soft felt hat, any one of which can be rendered sufficiently 
firm by soaking it with one of the mixtures mentioned above. 
Plaster of Paris is very justly esteemed as among the most valuable and 
easily managed forms of an immovable fracture dressing. This material is 
most conveniently employed in the form of rollers,—first brought to the 
notice of the profession, in 1852, by Mathiessen, of Holland. It was not, 
however, until some ten years afterwards that this dressing received in 
this country the attention to which it is entitled. During the late Ameri- 
can war it constituted usually a part of the ambulance supplies. It has been 
extensively employed in the treatment of fracture 
in Bellevue Hospital, Hew York, receiving the 
high commendation of Professor Hamilton, and 
in the University Hospital of this city it forms 
one of my established dressings for the same class 
of injuries. The plaster roller is formed by taking 
strips of crinoline of the proper length and breadth 
and filling the interstices of the fabric by drawing 
the bandage through the plaster, and at the same 
time rubbing it in with the hand and rolling the 
strip as it is filled into a loosely-formed cylinder. 
A very convenient apparatus is in use for the 
formation of plaster rollers, which consists of a 
base with two upright pieces. Between the latter 
is a box or hopper, which is filled with the plaster, 
and through which runs the strip of crinoline, 
previously wound on an iron rod above, and 
which is rolled upon an axle having a handle 
below. (Fig- 621.) These rollers, when once 
formed, should be packed in tin boxes, or, if 
placed in an ordinary box, should be surrounded 
with waxed paper or with oiled silk, in order to 
exclude the moisture of air, the presence of which 
tends to destroy the hardening quality of the 
plaster. 
In applying this or any other form of the im- 
movable dressing, the limb should be first sur- 
rounded with a dry bandage. The plaster roller, 
when used, having been previously dropped for 
two or three minutes into a basin of water, should 
be gently squeezed, and then applied in circular 
and spiral turns, ascending and descending the 
limb until the requisite number of rollers, usually 
three or four, has been employed. During their application, the hand of the 
dresser should be occasionally dipped into water and passed over the bandage, 
in order to smooth down the plaster which accumulates on the surface. In 
Fig. 621. 
Apparatus for rolling plaster band- 
ages. FRACTURE DRESSINGS. 
815 
a few minutes the roller begins to harden, and at the expiration of half an 
hour it is quite solid. During the process of solidification no contraction 
takes place in the dressing, and consequently no allowance need be made for 
shrinkage. 
The period which I regard as the only proper one for the use of the plaster 
roller in the treatment of fractures is after the inflammatory swelling has 
subsided, and when the surgeon can calculate on the fixed dimensions of the 
part. If used earlier than 
this, the limb will most 
probably in a few days 
lie loose in its case, the 
patient being thus ex- 
posed to the risk of an 
ununited fracture, or if 
the swelling is on the in- 
crease the dressing may, 
in consequence of its un- 
yielding nature, jeopardize the vitality of the extremity by interfering with 
its circulation. 
In order to open any form of the appareil immobile, it will be necessary to 
use a pair of strong cutting pliers. (Fig. 622.) 
Bags and pads.—In fractures, especially of the lower extremity, strong 
muslin bags filled with bran, or with sand, are frequently used, designed 
either to protect the limb against the pressure of the splints, 
or to supply lateral support to the broken bone. (Fig. 623.) 
A feather pillow is well suited to give the requisite poste- 
rior and lateral support in fractures of the leg when the 
fracture-box is employed as a dressing. 
Muslin rollers constitute another indispensable dressing, 
and when applied with proper judgment are invaluable. 
They should pass from the distal towards the proximal ex- 
tremity of the limb with an even and uniform pressure. If 
these directions are neglected, the roller becomes one of the 
most dangerous appliances of our art. 
Adhesive plaster forms a valuable addition to our mechan- 
ical resources. To Dr. John K. Swift, of Easton, Pennsyl- 
vania, we are indebted for its introduction as a fracture 
dressing as early as the year 1830; and still later, to Pro- 
fessors Samuel I). Gross, Gilbert, Wallace, and Neill. As a 
means of extension in fractures of the long bones of the 
lower extremity, it was first used by Dr. John Swinburne, 
of Albany. 
Other materials have been employed at different times as 
fracture splints, among which may be mentioned Manila 
paper, recommended by Dr. Cowling, of Louisville, Ken- 
tucky. In its application, the paper should be cut into 
strips, and, after being soaked with starch, should be laid 
upon or made to surround the limb. 
Even the bark of a tree, if removed during the flow of the 
sap, may be used as a fracture dressing, as suggested by Dr. 
Jacobs, of Dublin, Ireland. 
Setting the fracture.—The mechanical appliances being at 
hand, the next duty is the proper adjustment of the bone, 
commonly called setting the fracture. In many cases this 
can be readily done by the surgeon alone, as in fractures of 
the bones of the forearm, or in those of the leg, the ribs, and the jaw. In 
other fractures, as those of the thigh, an assistant may be required. 
The application of force necessary to effect this object is threefold, viz., by 
extension, by counter-extension, and by coaptation. 
Fig. 622. 
Yon Bruns’s cutting pliers. 
Fig. 623. 
15ran-bag. 816 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Extension is applied to the distal extremity of the limb, and consists in 
pulling the lower fragment into its proper relation with the upper one, and 
is necessitated by the existence of overlapping in the broken ends of the 
bone. As a rule, the farther removed the extending power is from the 
broken bone, the better: for example, drawing upon the hand or upon the 
foot, in a fracture of the arm or of the thigh, is better than making traction 
near the injured part, as the muscles are thereby measurably relieved from 
the stimulus of pressure, which serves to provoke resistance-. A displaced 
tendon, or the locking or impaction of the fragments, may obstinately 
oppose the restoration, though this is generally resisted by muscles, which 
are often goaded into a state of great irritability or spasm by the sharp ends 
of the fracture, or by painful pressure upon a nerve. Hence it becomes 
necessary to disarm the muscles of their opposition as much as possible, by 
placing the part in such a position as will secure their relaxation, after which, 
by making the extension gradually and continuously, they may be wearied 
or coaxed into submission. Should these measures fail, the exhibition of an 
anaesthetic will readily overcome the difficulty. 
Counter-extension is to be applied so as to fix the proximal fragment, and 
must counterbalance the extending power, the two forces pulling the frag- 
ments from each other. Counter-extension should also be made in such a 
manner as not to irritate the muscles of the injured limb; that is, it should 
be applied as remotely from the seat of fracture as may be consistent with 
efficiency. In many cases there is no displacement, and therefore these ma- 
nipulations are unnecessary. 
Coaptation consists in making such pressure, counter-pressure, and manip- 
ulation as will press the fragments into their proper relations with each 
other, and must be done by the fingers of the surgeon. In these different 
acts the greatest gentleness, delicacy, and precision should be observed, so 
as to inflict as little pain as may be compatible with the adjustment. This 
being satisfactorily accomplished, the dressings necessary to maintain the 
advantage gained should be next applied. 
The time to set a fracture.—There ought to be no difference of opinion on 
this point. No advantage can result from delay, and therefore the sooner 
the work is done the better. Delay enhances the difficulties, and involves 
increased pain and suffering. The parts become swollen and sensitive,— 
conditions which complicate the examination ; the muscles offer greater re- 
sistance, and the inflammation is intensified by the force required for the 
reduction. 
After-Treatment.—After a fracture is dressed, it may be necessary, if 
the patient complains of pain, becomes nervous, or is disturbed by muscular 
spasms, to administer an anodyne, either by the mouth or hypodermically. 
One-fourth of a grain of morphine injected beneath the skin, if the patient be 
an adult, will generally secure, in a few minutes, relief from suffering. 
After the lapse of twenty-four hours the dressing should be renewed, at least in 
all fractures of the upper extremity. The necessity for such a course arises 
from the swelling which follows the injury, and which may become both 
painful and dangerous, from the resistance of the bandage. The removal 
of the dressing also enables the surgeon to see if any displacement remains 
or has occurred since it was first applied. He should visit his patient again 
on the second day, and, if the bandage is found uncomfortably tight, renew it 
as on the former visit, but if not, it is better that it should remain undisturbed. 
Indeed, from this forward the less meddling the better, and he should inter- 
fere only when the dressings become loose or in any way disarranged, or when 
it is necessary to make passive motion of a joint. Anything more than this 
is pernicious. If the system at large becomes perturbed, and traumatic irri- 
tation or fever ensue, the diet should be restricted for two or three days, and 
the bowels regulated with a mild saline, as a Seidlitz powder, followed by the 
neutral mixture, each dose of the febrifuge containing about one-twentieth 
of a grain of morphine. The state of the bladder must not be overlooked, TREATMENT OF FRACTURES. 
817 
and if the patient is unable to expel the contents of this viscus they should 
be removed by the use of the catheter. In six or eight days, ordinarily, all 
disturbance has passed over, and the visits of the medical attendant may 
be made at longer intervals, namely, on every second day, and finally every 
third day. In fractures of the upper extremity, of the ribs, and of the jaws, 
the patient is in most cases, after a few days, able to walk about, and need 
not, therefore, be confined to the house. If the lower extremity is broken, 
it will be necessary to support the weight of the 
superincumbent bedclothes by the “cradle” (Fig. 
624), or by a substitute, which can be quickly con- 
structed by tying the segments of two hoops to- 
gether. 
The disuse of a joint is soon followed by rigidity 
or stiffness; and as it is necessary in the manage- 
ment of a broken bone to maintain for a time the 
absolute rest of the part, such a condition may 
naturally be anticipated, should the fracture be one 
of an extremity. On this account, after a period of from eight to twelve 
days, gentle movements of the contiguous articulations must be made, which 
are to be repeated at each renewal of the dressings. The nutrition of the 
parts involved in a fracture is also modified, and hence the dry condition of 
the skin, with the accumulation of epithelial debris. Nothing gives more 
comfort or produces a better capillary circulation under such circumstances 
than brisk friction with alcohol, applied with a sponge. Where the patient 
is obliged to remain on his back, as in fractures of the lower extremity, cai’e 
must be observed to prevent the occurrence of bed-sores, by frequently in- 
specting those portions of the body which sustain the greatest degree of 
pressure, and rubbing them with alcohol. Should the skin become inflamed, 
it may be covered with adhesive or with soap plaster, and in addition may 
be further relieved by the use of properly-prepared cushions or fenestrated 
pads. 
Time to lay aside the dressings.—In fractures of the upper extremity, the 
splints may be permanently removed in from four to six weeks. The arm, 
however, should be carried in a sling for two or three weeks longer, in order 
to remind the patient that it is not yet sufficiently strong to endure any great 
amount of muscular force. He should himself practise the various movements 
of the joints of the limb, in order to restore their proper suppleness. Where 
the injury has been in the course of the lower extremity, a longer time must 
be allowed before the splint or splints are laid aside, say from five to eight 
weeks, and when the original dressings are removed it is prudent to sub- 
stitute, particularly in the case of the thigh, or of both bones of the leg, 
a plaster bandage, or, if this be not at hand, light binders’ boards can be 
moulded to the parts and fastened by a roller. These directions apply to the 
ordinary progress of fractures. There are others, fortunately exceptional, in 
which no time can be specifically laid down for the removal of the splints, as 
where the union is tardy or delayed, or where the callus itself is defective. 
Restoration of function.—Generally after the dressings are laid aside the 
surgeon has to contend with rigidity of joints, pain when the latter are 
moved, and swelling of the limbs when placed in a dependent position. These 
conditions, for the most part resulting from disease, demand systematic mas- 
sage conjoined with movements. The latter should never be with excessive 
force, as nothing is gained by attempting too much. The operator should 
be content if a very little is gained each day. The massage will soon so 
modify the nutrition of the muscles, as well as of the other elements of the 
limb, that the vessels will be able to regulate their contents so as to prevent 
undue fulness and transudation. When the fracture has been in the bones 
of the leg, the patient should at first allow the limb to remain down only a 
few minutes, repeating this position at shorter intervals and for a longer 
time from day to day. The same management of the upper extremity will 
Fig. 624. 
Fracture-cradle for supporting 
the bedclothing. 818 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
be necessary when the bones of the upper or lower arm have been broken. 
The sling must not be abandoned suddenly, but gradually. Often the inex- 
perienced physician may be induced to suspend these methods of restoring 
the member to usefulness by the urgency of the patient, who not unfre- 
quently will complain of the great discomfort caused by the treatment; but 
let it be remembered that the extreme sensibility can be lessened and re- 
moved in no other way than by persevering in these methods. 
In many instances it is not necessary to wait until the dressings are aban- 
doned before beginning massage and movement. Much time will be saved 
the patient by practising both as soon as the fracture is well united, or at a 
time when the fragments are sufficiently ossified not to be moved by gentle 
motion and rubbing. 
Throughout the whole treatment of fractures the condition of the skin 
will be much benefited by sponging the surface of the broken member with 
alcohol. Such a practice will materially lessen the epithelial desquamation, 
and will add much to the comfort of the patient. 
Lucas-Championniere has recommended massage in recent fractures, kept 
up for over half an hour,—a practice not likely to be generally adopted. 
There is no doubt that in fractures near the articulations massage can be 
employed with advantage at a very early period after the injuries occur. 
Thus far we have been dealing with sinqfie fractures. Let us next con- 
sider those which present certain complications. 
Compound fractures.—In such, a communicating wound is present, which 
makes the point of departure, and which, insignificant though it may seem, 
gives a serious character to the injury, and often necessitates the loss of the 
limb. This complication is often followed by suppuration, which extends 
through the components of the limb, disorganizing the soft parts, destroying 
the vessels of the bone, and inducing necrosis. Or, by its long continuance 
and profuseness, it may wear out the patient, or may kindle into fatal activ- 
ity some latent predisposition to disease which had quietly lurked in the 
body. Pysemia, erysipelas, and fat-embolism are also among the evils which 
frequently follow in the train of an open fracture. The frequency of com- 
pound fractures as compared with that of simple fractures is about fourteen 
of the former to one hundred of the latter. 
In undertaking the management of a case of compound fracture, the first 
question to be settled is that of amputation. If the great vessels are safe, 
this will seldom be necessary. 
As the evil consequences of this injury seem to depend on the presence of 
a communicating wound, our efforts should be directed to its closure, if pos- 
sible, thus changing the conditions to those of a simple fracture. 
In all cases of fracture with external wound, a rigid antisepsis should be 
observed by thoroughly cleansing the part either with the bichloride of mer- 
cury (one to one thousand) or with carbolic acid (one to twenty), and, after 
closing the wound, applying the carbolated or sublimated gauze dressing. 
Most cases of compound fracture will by these precautions be converted 
into simple ones, which, otherwise, would have ended in suppuration. Even 
when the wound is large and attended with loss of tissue rendering it impos- 
sible to bring the soft parts together, yet if the antiseptic measures are car- 
ried out with thoroughness, the healing will progress with little, if any, 
complication. Small external wounds can be closed or sealed up by a piece 
of sublimated gauze coated with collodion and iodoform or the compound 
tincture of benzoin. If a clot of blood has filled up the aperture it should 
not be detached, but covered with one of the articles named above. Larger 
wounds will require the animal or silver suture. 
In cases where one or both broken fragments protrude, they must be re- 
stored to their proper position by extension and counter-extension, placing 
the limb at the same time in such a position as will relax its muscles and 
thereby favor this result. If the edges of the wound resist the reduction, 
they should be drawn asunder with aseptic retractors, or, if this is not suffi- COMPOUND FRACTURES. 
819 
cient, the opening may be enlarged; and finally, if these means prove unsuc- 
cessful, as a last resort—but only as a last resort—the ends of the bone may 
be removed with a saw, observing to cut away no more than is absolutely 
necessary to etfect the reduction. In doing this, the soft parts should be 
protected by interposing between them and the bone a piece of leather or a 
thin piece of light wood which has been previously soaked in the bichloride 
solution (one to one thousand). 
A compound fracture may be further complicated by comminution, in which 
case there will be three or more fragments, or the bone may be splintered. 
These splinters sometimes are completely detached, or shelled out of the 
periosteum, and when separated from their vascular connections are likely 
to die; on which account they should always be removed. Sometimes their 
attachments are not entirely severed, though if old methods of treatment 
are followed it will be best to extract them, in which case the piece had 
better be pressed into place; for, if this is not done, its presence will delay 
the union.—may even defeat it,—or, if not, the future suppuration will in 
all probability insure its death and render its subsequent extraction neces- 
sary. Especially is it proper to remove such splinters when contiguous to a 
joint or to a cavity of the body. In comminuted fractures, where the osse- 
ous fragments maintain their vital connections and are not very loose, they 
had better be adjusted and allowed to remain, as nature will often unite 
them solidly with the other parts of the fracture. In fractures of the bones 
of the face, even very loose portions should be preserved, as the great vascu- 
larity of this part of the skeleton justifies a more conservative course than 
elsewhere. 
There is, particularly in simple fractures, almost always some ecchymosis. 
In compound fractures it is not so common, because the blood escapes from 
the external wound. It may spread over the greater part of a limb, so as to 
resemble gangrene. Vesication may occur also. As to ecchymosis, time will 
etfect its removal, though this may be hastened by applying some dilute 
alcohol to the surface and thereby stimulating the vessels to increased activ- 
ity. The blisters, when present, should be punctured at two or three points 
with a fine needle, so as to allow the escape of the serum without removing 
the cuticle, and then over all may be applied a light dressing of zinc ointment. 
Hemorrhage after simple fractures.—It is possible in a simple fracture, 
attended with much displacement, for the main artery of a limb to be torn 
by the sharp extremity of one of the fragments. This accident must be 
regarded as a serious occurrence, and will be indicated by the rapid swelling 
of the limb, the presence of pulsation in the tumor, and the cessation of the 
pulse in the arterial branches below the seat of injury, thus forming a diffuse 
or false aneurism. The course to be adopted in such an event is to command 
at once the circulation of the limb by applying a tourniquet, and then proceed 
to ligate the main artery of the limb at the point of election. Should the col- 
lateral vessels be equal to the task of re-establishing the circulation, the arte- 
ries below wfill resume their pulsation, and the heat and sensibility of the limb 
will return, when a favorable termination of the case may be anticipated. If 
gangrene sets in, the sooner amputation is done the better. 
Hemorrhage after compound fractures may be either primary or secondary. 
When primary, it may come from the vessels of the bone, and will generally 
cease after the reposition of the fragments and the application of pressure; 
or it may have its origin in a torn vein or artery external to the bone. If 
from a vein, the bleeding will be checked by pressure over the wound: even 
with veins the size of the femoral or the brachial, when so injured, this course 
will be proper. When the hemorrhage comes from a wounded artery and 
proves persistent notwithstanding position and pressure, the external wound 
should be enlarged, and the vessel searched for and tied above and below. 
If this cannot be effected, and the symptoms become urgent, the artery of 
the limb must be exposed and tied above, at the point of election. The ex- 
ceptions to this course will be in compound fractures of the thigh compli- 820 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
cated by laceration of the femoral artery, and in similar injuries of the leg 
in which both the anterior and posterior tibials are torn. Under such cir- 
cumstances amputation is imperative. A lesion of both the radial and ulnar 
arteries in a compound fracture of the arm, unattended with any extensive 
damage to the soft parts or comminution of the bones, would not justify the 
removal of the limb, as the numerous vascular communications of this part 
are capable of maintaining its life even under very serious mutilations. 
Should an artery like the tibial, radial, ulnar, or even femoral, be wounded 
by the fragments of a simple fracture, and the flow of blood be continued, the 
wounded vessel should not be cut down upon at the seat of lesion, thereby 
adding the complication of a compound fracture, but should be ligated at the 
most favorable point above. In all cases of arterial hemorrhage, whether in 
compound or simple fractures, the surgeon should not resort to the knife 
until all other measures have proved useless. He may even wait in some 
instances, as where the extravasation of blood becomes circumscribed, until 
the fracture is healed, before interfering by operative measures. 
When the bleeding is secondary,—generally the result of sloughing,—the 
offending vessel should be sought for and tied in the wound, if not control- 
lable by pressure ; and if the hemorrhage is repeated with sufficient severity 
to endanger the life of the patient, the limb should be promptly removed. 
The dressing for compound fractures will be described with that of other 
fractures. 
Injury of large nerves may produce great feebleness of the limb, and even 
complete paralysis, but will not necessarily defeat the union of the bone. 
This fact has been well established, both by experiments on the lower 
animals and by observations on the human subject. 
Compound fractures of joints.—When the joint implicated is one of magni- 
tude, as the knee, the hip, the shoulder, the elbow, or the ankle, the case is 
always a grave one. The knee-joint, being extensive and complex, is, of all, 
the most intolerant of injury; involvement of the wrist or of the ankle is 
also serious, though in a less degree: so that compound fractures of these 
articulations will in many instances demand amputation or excision, while 
such as involve the ball-and-socket articulations, and perhaps the elbow- 
joints, if the surrounding soft parts be not too extensively mutilated, will be 
best treated by excision. Now, however, that we begin to understand the 
immense value of antiseptics and drainage in surgery, such radical plans 
of treatment, in properly-selected cases of the character under consideration, 
will be unnecessary. Should the main artery be torn, in addition to the joint- 
injury, amputation must be done at once. 
Fractures not compound extending into a joint.—These may be properly con- 
sidered as complicated. Such a joint is spoiled in some degree. Abridgment 
of movement must be expected, but to what extent it is impossible to foresee. 
It may result in permanent anchylosis. I have seen it end in the loss of the 
limb. The accident must be treated as an ordinary fracture. Should inflam- 
mation of the articulation arise, it must be promptly met by local antiphlo- 
gistics, and as soon as possible passive movement must be cautiously prac- 
tised, in order to preserve, if possible, the function of the joint. 
Fracture with dislocation.—In such a complication, the fracture is to be 
properly supported with splints, and afterwards an attempt made to restore 
the luxation. Should the fracture be near to the displaced articulation, par- 
ticularly if a ball-and-socket joint, it is not probable that the dislocation will 
be reduced. Nor have the attempts made to restore the luxation after the 
consolidation of the fracture been followed by any encouraging degree of suc- 
cess. In such cases it only remains, after the union of the bone, to establish 
as much movement as may be possible with the malposition of the parts. 
In fractures accompanied with the luxation of a ginglymoid joint, reduction 
of the articulation may be effected. 
A compound fracture associated with luxation sometimes occurs, accom- 
panied with such extensive damage to the soft parts as will require the am- COMPOUND FRACTURES. 
821 
putation of the limb. In such a case the dislocation should be first restored, 
if possible, and subsequently the operation be performed. 
Fractures are frequently met with in limbs which have been contracted 
by the cicatrices of burns or which are permanently flexed by anchylosis. 
Such conditions do not materially influence the result, as the splints can be 
adjusted to the angularities of the part. 
In a case of fracture affecting the femur, where a bent anchylosed knee- 
joint exists, we have it in our power to correct the disability by securing 
union of the fragments at a proper angle. I have in three cases availed 
myself of this coincidence, and given the patients useful limbs. 
Necrosis frequently follows compound fractures, especially if there exists 
the additional element of comminution. The detachment of the periosteum 
at the time of the accident, or subsequently, by the suppuration, and the 
disturbance to the medullary tissue, are quite sufficient to account for this. 
The treatment does not differ from that appropriate to necrosis from other 
causes. The surgeon must wait until the sequestrum is well separated,—a 
fact which he ascertains by testing its mobility with a stout probe. When 
the dead portion is loose, it must be removed by enlarging the wound or 
the sinus and cutting away with a chisel such callus, or other bone, as may 
oppose its extraction. 
Mania a potu.—In persons much addicted to the use of alcoholic drinks, 
the existence of a fracture will often induce an attack of delirium tremens. 
Under such circumstances the greatest care must be observed to prevent the 
ends of a simple fracture from being driven through the skin, or of a com- 
pound one from passing out of the wound. It will be necessary to place a 
strait-jacket on the patient, or to secure the arms and body to the bed. A 
pillow may be secured firmly around the seat of fracture ; or what answers 
better than any other plan, is to mould to the limb two pieces of binders’ 
board, interposing plenty of cotton, and making them secure with a roller 
bandage. This will prevent any serious damage to the parts until, by ap- 
propriate treatment, the delirium is cured, when the fracture can be dressed 
permanently. 
Epilepsy.—In aggravated cases of this disease, much difficulty may be en- 
countered from the muscular spasms disturbing the needful quiet of the frac- 
ture. A protective dressing like that for delirium tremens, and full doses 
of bromide of potassium, constitute the best remedial measures. In con- 
nection with these irregularities of muscular action, an interesting case is 
related by Dr. William Hunt, of the Pennsylvania Hospital, of fracture of 
the humerus, in a patient suffering from chorea, in whom it was impossible 
to keep the fragments fixed. The unfortunate man died, being finally worn 
out from sheer exhaustion. 
Anchylosis.—This depends upon a variety of conditions. When the frac- 
ture is near to a joint, doubtless the stiffening is due -to inflammatory de- 
posits within the articulation ; but generally the rigidity is simply the result 
of immobility, in which state the muscles and ligaments become shortened 
and inelastic from the absence of that moisture which is normally present 
among their fibres. The synovial secretion is also less abundant. When 
the stiffness is not very great, frequent movements by the physician, or by 
the patient himself, accompanied with douches of water, kneading, and fric- 
tion, will commonly restore the usual flexibility; but when the pain of such 
manipulation cannot be endured, and when it is requisite to employ consider- 
able force in order to overcome the resistance, which must be rarely the case, 
such movements should be made only after exhibiting an anaesthetic. 
Atrophy.—Another effect of fracture is wasting or atrophy of the soft parts, 
chiefly confined to the muscles and adipose tissue. Malgaigne and Gosselin 
have each spoken at some length on this subject. To me there seems noth- 
ing unusual in this result, nothing difficult to understand. Both the accident 
and the treatment conspire to affect unfavorably the nutrition of the damaged 822 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
member. If a limb be maintained for a protracted period in a state of entire 
rest, even though it may have sustained no injury whatever, a certain amount 
of atrophy follows, the supply of blood being determined by activity of func- 
tion. If in addition the part be encased in splints and compressed by rollers, 
entirely suspending muscular movement, the wasting will be still more notice- 
able. Another factor may also be important to the explanation, namely, the 
activity of reparative work at the seat of fracture attracting necessarily a 
large amount of blood at the expense of the muscular supply. 
Embolism.—This is of two kinds,—venous and fat. The former may be 
caused either by mechanical pressure from imperfect coaptation of the osseous 
fragments, or by traumatic phlebitis. Fragments detached from such a clot 
may lodge in the pulmonary vessels and cause death. Accidents of this kind 
are disclosed by cough, difficult or oppressed breathing, and bloody sputa. 
The physical evidences are those belonging to pneumonia. 
Fat-embolism.—Yon Recklinghausen and Busch have called the attention 
of the profession to the dissemination of medullary fat derived from the 
seat of fracture and lodged in the capillaries of the lungs and in those of the 
brain, kidneys, and other parts of the body. The symptoms which are sup- 
posed to follow the presence of these emboli are stupor, coma, and labored 
respiration. It is, however, by no means established that these fat-cells ai‘e 
responsible for the mischief with which they are credited. 
Pyaemia.—The system is liable to become poisoned by septic matters which 
are generated about the seat of fracture, or which gain an entrance through 
the wound of a compound fracture, especially when the hygienic surround- 
ings of the patient are bad. 
Ununited Fracture, or Pseudarthrosis. 
A fractured bone may not unite, to which condition we apply the term 
ununited fracture, non-union, or pseudarthrosis. 
It is necessary, however, to draw a distinction between a temporary and a 
permanent failure to unite. Delayed or tardy union is no uncommon occur- 
rence. The fact that on examining a fracture after the usual period of treat- 
ment has elapsed, the consolidation is found to be imperfect, is no evidence 
that union will not follow at a later date. If, however, the ends of a broken 
bone remain movable five or six weeks after the time commonly consumed 
in the repair of such injuries, it is fair to infer that the case has become one 
of non-union. 
Causes.—The causes which conspire to produce this condition are both 
constitutional and local. 
The constitutional causes are, in general, all such as tend to depreciate or 
diminish the vital powers of the system, as hemorrhage, an attack of fever, 
exhausting diarrhoea, or defective nutrition. Shock, in a number of instances, 
I have found to retard the consolidation of fractured bones. 
Gestation and lactation are said to exercise a retarding influence upon the 
work of osseous repair. The enormous amount of blood attracted to the 
uterus during pregnancy might be expected to lessen in some measure the 
active process of osteogenesis. 
Scorbutic disease has not only retarded the formation of callus, but has been 
known also to produce its absorption after the bone had become united. I 
have seen a fracture of the thigh which had become well consolidated open 
again in consequence of an attack of delirium tremens inducing the resorp- 
tion of the reparative material. 
Advanced, age has been reckoned among the causes retarding bone repair, 
but it probably exerts little if any influence of this kind. In a lady ninety- 
five years of age, whom I attended for a fracture of the thigh, the union took 
place at the usual period. All the cases of ununited fracture which have 
come under my own observation have been under forty years of age, and 
Amesbury, who had seen about ninety cases, states that none of the patients UNUNITED FRACTURE, OR PSEUDARTHROSIS. 
823 
were past middle life. Twice have I witnessed congenital pseudarthrosis in 
the bones of the leg. 
Syphilis, cancer, and rheumatism have each been charged with being inimical 
to the development of callus, but without any sufficient facts to establish the 
statement. 
Paralysis, affecting as it does both the vascular and the nervous endow- 
ments of a part, may possibly interrupt the process, though the cases in 
which this occurs are exceptional. 
Local causes.—Under this head comes everything which disturbs the 
quietude of the fracture, or provokes undue inflammation at the extremities 
of the fragments. 
It has been supposed that the destruction of the nutritious artery has a 
tendency to retard and not unfrequently to defeat the repair. The cases 
collected and analyzed by Gueretin would appear to favor this opinion, 
though the tables of Norris are adverse to such a view. In most instances 
of delayed union, and especially those of non-union, which have come under 
my own observation, the cause could be traced to certain influences, among 
which may be mentioned the presence of a foreign body, as a fragment of 
necrosed bone, or a ball. Not unfrequently the failure to unite arose either 
from a defect in the apparatus employed as a dressing, which failed to secure 
the perfect immobility of the fragments, or in consequence of the restless 
and refractory disposition of the patient, who would clandestinely take un- 
warrantable liberties with the limb and the splints in the absence of the 
medical attendant, 
On the other hand, cases will occur in which a fracture refuses to unite 
notwithstanding the most faultless management, and even when the consti- 
tutional vigor of the patient appears to be unimpaired. 
While movement in the ends of a broken bone is to be deprecated, it 
should not be forgotten that too great a constriction of the limb by tight 
bandages may embarrass the circulation to such a degree as to arrest the 
process of repair. 
It is said that in hospitals where the immovable dressings are emplojmd 
from the beginning in the treatment of fractures, cases of tardy union and 
of non-union are most common. If such is the case, I am disposed to at- 
tribute the result not to the immobilization of the limb, but to the very 
reverse condition, namely, the imperfect manner in which the part fills the 
dressing after the subsidence of the inflammatory swelling, thus allowing 
too much mobility. 
The bones in which non-union is most frequently met with are the hu- 
merus, femur, tibia, idna, inferior maxillary, and clavicle. The interesting 
tables of I)r. George Norris furnish 150 cases occurring in the femur, 48 in 
the humerus, 19 in the forearm, 33 in the leg, and 2 in the lower jaw. Ac- 
cording to my own experience, this condition is most common in the femur, 
next in the humerus, and next in the tibia. A very strong argument in favor 
of the local origin of non-union is to be found in the rarity of such a condition 
in hospitals where the patients are under strict supervision and skilful man- 
agement. In 946 cases of fracture treated in the Pennsylvania Hospital 
during twenty years—from 1830 to 1850—not a single case of non-union 
occurred; and from 1850 until 1874, during which period 6480 fractures 
were treated in that institution, no false joint, so far as I can learn, took 
place. In the Massachusetts General Hospital, Boston, according to Dr. 
Moreland, only 1 case in 367 fractures was seen. Lonsdale states that in 
4000 cases treated in the Middlesex Hospital, London, only 6 instances of 
non-union were recorded. Hamilton estimates 1 case in 500 fractures. 
When a fracture fails to unite by true callus, the ends of the bone undergo 
various changes. 
First. They become, under the action of the vessels, rounded or conical, 
and incrusted with a fibrous or fibro-cartilaginous structure, without any 
intermediate connection. (Fig. 625.) 824 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Second. The ends may become united to each other by one or several 
bands of fibrous tissue more or less elastic, which union limits, in some 
degree, the mobility of the parts. (Fig. 626.) 
Third. The ends may be rounded and eburnated, or they may be incrusted 
with dense fibrous tissue, or even cartilage, and enclosed in a firm capsule of 
fibrous tissue, the interior of which has a smooth and glistening appearance 
and furnishes a lubricating fluid somewhat analogous to the synovial. This 
sac is doubtless formed as are the bursal cushions in club-foot. This form 
of non-union answers to the true pseudarthrosis. 
Fourth. The end of one fragment may be rounded, and that of the other 
excavated, both being enclosed in a capsular ligament or sac, the interior of 
which is lined by a bursal membrane, the whole closely resembling a ball- 
and-socket joint. (Fig. 627.) A very perfect example of this variety I once 
witnessed in the humerus of a patient who died at the Philadelphia Alms- 
house. 
Fifth. The extremities of the fracture may expand, and afterwards become 
surrounded with a considerable amount of granular callus, while the ends 
remain separate and movable. (Fig. 628.) 
Fig. 625. 
Fig. 626. 
Fig. 627. 
Fig. 628. 
Ununited fracture in 
which the ends of the 
fragments have been 
rounded. 
Ends of an ununited frac- 
ture connected by fibrous 
tissue. 
Ununited fracture sim- 
ulating a ball-and-socket 
joint. 
Ununited fracture of 
the tibia, the ends of 
the fragments being 
surrounded with callus. 
In some very rare instances the bone, instead of assuming any of the above 
conditions, undergoes absorption. A case of this nature is recorded in the 
“Boston Medical Journal,” in which a boy eighteen years old had the hu- 
merus broken. The bone, after the accident, was entirely absorbed, the 
remaining components of the arm continuing unchanged except in form. 
Professor Gross relates a similar instance in a man fifty-three years of age, 
where, with the exception of its head and condyles, the humerus wholly 
disappeared. During the winter of 1875 my attention was called to a case 
of ununited fracture of the humerus of eight years’ standing, in which one- 
half of the humerus had disappeared. 
Treatment.—In many cases of tardy union, all that will be required is to 
immobilize the fragments thoroughly by the plaster or the silicate of soda 
dressing. This will enable the patient to walk about in the open air with or UNUNITED FRACTURE, OR PSEUDARTHROSIS. 
825 
without crutches, according to the bone affected, or, if this is not feasible, at 
least will admit of out-door exercise in a wheeled chair, and thus avoid the 
tedious and depressing influence of long confinement. Three or four weeks’ 
perseverance in such a treatment will generally secure the cure. 
In the management of these cases of delayed union, the general condition 
of the patient must not be overlooked. If the system is enfeebled, the diet 
should be improved and varied, and tonics should at the same time be admin- 
istered, as the tincture of sesquichloride of iron, the compound tincture of 
cinchona with dilute phosphoric acid, or a combination of the phosphates 
when the case is one of true ununited fracture. 
Various measures have been suggested and practised for the cure of false 
joint. They are all designed to produce such an amount of irritation as will 
invite an increased afflux of blood to the part, and thereby favor the produc- 
tion of callus. They may be arranged under the following heads: 
Friction.—This is perhaps the oldest method, and was practised by Celsus. 
If the ends of the bone have not been materially changed, it will often suc- 
ceed, particularly if the case is only one of delayed union. The operation 
consists in removing the dressing, seizing the limb above and below the seat 
of fracture, and rubbing the fragments forcibly against each other. The 
limb is then to be put up with the greatest care in an immovable dressing, so 
as to secure the most complete quietude. The dressing may afterwards be 
slit up and sprung open, so as to admit of its being disengaged from the 
limb, if it is deemed necessary to repeat the friction a second time. 
A second method of applying friction is one which subjects the ends of the 
bone to a continuous, not a temporary, rubbing, and at the same time secures 
them against displacement. For this pm-pose, White, of Manchester, con- 
structed an accurately-fitting leather case for the thigh, which furnished such 
a support to the parts that the patient could move about and receive the 
benefit of fresh air. Professor H. 
H. Smith employs an apparatus 
(Fig. 629) which more perfectly 
than any other fulfils these ends, 
and has been successful in several 
cases in effecting perfect cures. 
The same principle can be carried 
out by mechanical appliances in 
the treatment of ununited fracture 
of the bones of the upper extrem- 
ity. The apparatus of Hudson, 
manufacturer of artificial limbs. 
Hew York, acts somewdiat in the 
same manner. It is a hollow cone 
composed of willow, secured to the 
limb by straps and buckles, and 
furnishes a very equally distrib- 
uted pressure. If, however, any 
walking apparatus is employed, 
that of Professor Smith, as modi- 
fied by Kolbe, fulfils most perfectly 
the end in view. 
External irritation.—Walker and 
Brodie recommended for this pur- 
pose the use of blisters. Stimulat- 
ing friction with various liniments 
has been employed for the same 
purpose. Cline the younger was 
in the habit, at St. Thomas’s Hospital, of establishing an issue over the seat 
of fracture with caustic potash,—a practice which was imitated by Drs. 
Hew'son and Hartshorne. These applications have passed out of use. Little 
Fig. 629. 
Fig. 630. 
Smith’s apparatus for uu- 
united fracture of the thigh. 
Smith’s apparatus for un- 
united fracture below the 
knee. 826 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
good could be expected from such agents, as the point of irritation designed 
to attract the blood was too remote from the seat of fracture. 
Subcutaneous irritation.—This was accomplished in various ways. Irri- 
tating substances, such as nitric acid, caustic potash, nitrate of silver, or 
tincture of iodine, were introduced through a canula, so as to act directly 
on the ends of the fragments. These materials were designed to destroy 
the dense incrustation on the ends of the bone, and to cause such a degree 
of inflammation as would secure the deposition of callus. Another method 
of effecting the same result was by acupuncture, or the insertion of long, deli- 
cate needles through the soft parts and between the fragments, as practised 
by Birch, of London, and also by Malgaigne and Wiesel. Lente, of New 
York, has conjoined electricity with acupuncture. He inserts needles, one 
upon the end of each fragment, and then attaches to these the poles of a 
battery. Successful cures have been effected by this plan. Subcutaneous 
scarifications have been made by introducing a tenotome and cutting in 
various directions through the adventitious formation attached to the bone. 
Miller, of Edinburgh, succeeded in curing five cases by this method; and 
Sanford, of Iowa, reports two cures by a similar procedure. 
The seton.—In 1802, Dr. Physick successfully employed the seton in a case 
of ununited fracture at the lower end of the humerus. This specimen is at 
present in the Museum of the Medical Department of the University of 
Pennsylvania. (See Fig. 631.) The material used was 
silk ribbon, which was passed between the ends of the 
bone by means of a long seton-needle. J. Oppenheim, 
Gulliver, and others simply passed it near to the fracture. 
Great care must be exercised that no important blood-ves- 
sel or nerve is transfixed or wounded in the passage of the 
needle. The seton, according to Dr. Physick, should re- 
main from four to six months ; but there is reason to believe 
that from seven to fourteen days is quite enough for the 
thread to accomplish its work. When retained for a greater 
period, there is danger of the consolidation being defeated 
in consequence of the profuse suppuration which ensues. 
The fatalitv following the use of the seton in pseudar- 
throsis of the thigh has been so 
great that the measure should re- 
ceive unqualified condemnation. 
In ununited fracture of the hu- 
merus it may be adopted with a 
good prospect of success. 
Somme, of Antwerp, has substi- 
tuted wire for thread with a satis- 
factory result. 
The drill.—Dieffenbach bored a 
number of holes with a drill (Fig. 
632) into the bone, near to the frac- 
ture, and then drove into the frag- 
ments pegs of ivory. Cases are 
reported which have been success- 
fully treated by this method, though 
the operation is not free from dan- 
ger, death having followed from 
purulent infection. It is also al- 
leged that the presence of these 
pegs sometimes produces absorption of the surrounding bone, and even 
necrosis. 
The late Dr. Brainard, of Chicago, employed an awl-shaped drill, well tem- 
pered (Fig. 633), and, after introducing it through the soft parts, bored through 
the fragments in different directions, and also through the intermediate struc- 
Fig. 631. 
Fig. 632. 
Humerus treated by Phys- 
ick for ununited fracture. 
Dieffenbach’s drill. UNUNITED FRACTURE, OR PSEUD ARTHROSIS. 
827 
tures. His experience led him to believe that three perforations were suffi- 
cient. A number of cures have been effected by this method. 
Letmold, of New York, passes a drill, or, more properly, a gimlet (Fig. 
Fig. 633. 
Awl-shaped drill. 
634), between the fragments, and then turning the instrument to an oblique 
position makes it pass through one fragment, across the intermediate sub- 
stance, and buries it well into the other fragment, thus pinning the two 
together, the gimlet being allowed to remain until the union becomes well 
advanced. I believe this plan of pinning together the fragments by a sub- 
Fig. 634. 
Gimlet for pinning together the ends of an ununited fracture. 
cutaneous operation was first introduced by Professor Pancoast as early as 
1857. 
Somewhat analogous to this is the operation of Gaillard, of Louisville, 
Kentucky. A canula is first conducted down to the bone through an in- 
cision made over the fracture. A steel rod, having a gimlet-point at one ex- 
tremity and a screw thread at the other, is next passed through the canula 
and bored through the two fragments, thus connecting them together, after 
which, in order to maintain the instrument in place, a nut is run down over 
the thread of the rod. This apparatus is allowed to remain until the union 
is established by callus. 
Fig. 635. 
Hamilton’s bone-drill. 
Other drills are in use for making the perforations in the bone, some of 
which, it is thought, in consequence of the peculiar form of the bit, cut with 
greater ease to the operator than others. Such are represented in Figs. 
635, 636. 
Irritation, with open wound.—Such operations are of very ancient origin. 
The Arabian physicians knew well the importance of getting rid of the fibrous 
tissue on the adjacent surfaces of the bone. Avicenna cut down boldly upon 828 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the fracture and rasped off the incrustation. The operation, according to his 
own account, was often fatal. A similar operation was performed, with slight 
modifications, by Brodie and by Hunter. 
In 1760, White, of Manchester, England, introduced the operation of cut- 
ting down upon the bone, turning out the ends of the fracture, and sawing 
off a portion from each, thus 
getting rid entirely and quickly 
of the fibrous coverings. This 
is probably a very old operation. 
Such resections have been very 
frequently practised both in this 
country and abroad, and with 
varying results. There are few, 
however, at the present time 
who do not regard such a pro- 
cedure, when applied to large 
bones like the femur or the 
tibia, as one of danger to the 
life of the patient. As an aid to the method by ablation, and in order to 
maintain accurate contact, wire thread has been introduced through the frag- 
ments. This suggestion was made by Horeau as early as 1805. The ends 
are first removed by the saw, and a hole drilled through each fragment for 
the passage of the silver wire, by tightening which the parts are firmly se- 
cured together. These were the steps of the operation as executed first in 
this country by Dr. J. Kearney Rodgers. 
Professor Bigelow, of Boston, furnishes a list of ten cases successfully 
treated on the above plan, but with the important addition of preserving the 
periosteum. 
Jordan advises, before resecting the ends of the bone, to detach the peri- 
osteum, assuming that when this is omitted and union does not follow, the 
failure is due to the absence of this membrane over the seat of coaptation. 
He effects the separation by means of a blunt instrument, and, after excising 
the callous extremities of the bone, slips one cylinder of the periosteum 
within the other. 
Fig. 636. 
Bone-drill. 
Caustics.—Caustic potash, nitric acid, and even the actual cautery have 
been applied to the ends of the fragments after their exposure, by Cline, 
Barton, Hewson, Norris, and others. 
Dr. Norris speaks very favorably of this plan of treatment, regarding it in 
obstinate cases, or in such as have long resisted the ordinary measures resorted 
to in the management of false joint, as the most powerful means of exciting 
the requisite irritation for the production of callus in both the bone and its 
periosteum, and at the same time not causing any very prolonged suppuration, 
which would tend to defeat rather than to further the osseous consolidation. 
In order to apply the caustic properly, the seat of the fracture must be 
exposed, the dense fibrous incrustation on the ends of the bone thoroughly 
divided, and the parts dried. The caustic is now applied to the denuded ex- 
tremities of the fragments, the surrounding parts being at the same time 
protected from contact with the alkali or the acid employed. The wound 
should be packed with lint, and the parts placed in a state of entire repose. 
The caustic potash is considered by Norris to be the best agent for the cau- 
terization. -Recently the introduction of pieces of fresh bone below the 
fragments has been practised, with negative results. 
After all these operations, it is necessary that the limb be put up in an 
apparatus which will maintain the fragments in a state of perfect rest. 
With such an array of operations, the reader may be embarrassed to know 
where to fix his faith. We very naturally refer to statistics to settle what is 
certainly, at this date, a very unsettled subject. I am satisfied that the mor- UNUNITED FRACTURE, OR PSEUDARTHROSIS. 
829 
tality from operations of this nature antecedent to the antiseptic era was far 
greater than was generally supposed by the profession. I can recall quite a 
number of cases which I know to have terminated fatally, and which have 
never been placed on record. 
The most valuable paper ever written upon this subject is from the pen 
of Dr. George Norris, of Philadelphia, and has been referred to by sur- 
geons of almost every nationality: I compile from his recent work, en- 
titled “ Contributions to Practical Surgery,” the following table of the 150 
cases: 
No. 
Bone. 
Cured. 
Died. 
Not 
benefited. 
Result 
unknown. 
48 
Femur 
31 
6 
9 
2 
33 
Leg! 
32 
1 
48 
Humerus 
31 
14 
3 
19 
Forearm 
17 
1 
1 
2 
Jaw 
2 
150 
113 
6 
25 
6 
Of 46 cases in which the seton was employed, 36 were cured, 3 were par- 
tial cures, in 5 no benefit was experienced, and 2 died. Of these 46 cases, 13 
were in the femur, 9 of which were cured; 10 were in the bones of the leg, 
10 of which were cured; 16 were in the humerus, with 10 cures ; 6 were in 
the forearm, with 6 cures; and 1 was in the jaw, with 1 cure. The average 
duration of the false joint in these cases was twelve months and twelve 
days. 
in 38 cases resection was practised, 24 of which were cured, 1 partially 
cured. 7 derived no improvement, and 6 died. Of this number, 12 were in 
the femur, of which 7 were cured ; 6 were in the hones of the leg, 5 of which 
were cured; 12 were in the humerus, with 6 cures; 7 were in the bones of 
the forearm, with 5 cures and 1 improved; and 1 was in the jaw, with 1 cure. 
The longest duration of the fracture in the above cases was five years (the 
femur), and the shortest period ten weeks (the humerus). 
Of the 36 patients treated by pressure and rest, 29 were cured, 1 was par- 
tially relieved, and 6 received no benefit. Of this group, 13 were in the 
femur, with 9 cures; 7 in the leg, with 7 cures; 12 in the humerus, with 9 
cures; and 4 in the forearm, with 4 cures. The average duration of the 
fracture in these cases was five months. 
In 11 cases the patients were subjected to the treatment by friction, all of 
whom were cured. 
In 8 cases treated by caustic, 6 were successes and 2 were failures. 
In 11 cases in which other methods were employed, such as iodine injec- 
tions and the hot iron, 7 were cured, 1 remained unimproved, 2 died, and in 
1 no result was given. 
The age was ascertained in 112 cases, and was as follows : 14 were between 
ten and twenty years, 53 between twenty and thirty, 21 between thirty and 
forty, and 24 over forty. 
In examining the cases tabulated by Dr. Norris, I find 25 in which the 
duration of the fracture varied from four to fourteen weeks, and which can 
scarcely be accepted as true cases of non-union, as it is highly probable that 
a large proportion of these were only instances of delayed union and would 
eventually have consolidated. 
The remarkable success of friction as compared with the other plans of 
treatment, namely, 11 cases and 11 cures, as the author remarks, is more 
apparent than real, as in 13 of the cases treated successfully by the seton 
and by resection, friction had been previously tried and had failed. 
The conclusions deduced by Dr. Norris from the analysis of the 150 cases 830 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
collected as a basis of comparison between the relative merits of the seton 
and of resection are, that the seton is “ safer, speedier, and more successful 
than resection or caustic; that it is least successful in the femur and the 
humerusand that the danger from either plan increases with the size of 
the limb. 
In view of the modern method of treating wounds antiseptically, how- 
ever, all deductions drawn from the statistics of Dr. Norris, or of others 
who have followed a similar line of investigation, will be found misleading. 
Cutting operations have in a great measure been disarmed of the dangers 
formerly attending them, and it will now be the duty of surgical statisticians 
to review the whole ground, not only of the subject of ununited fracture, 
but also of all operative procedures, in order to determine the relative merits 
of the different methods of treatment in special cases of injury. 
A few years will have to elapse before a sufficient number of cases can be 
collected for the purposes of generalization and deduction. Whe*n this task 
has been accomplished, I doubt not we shall find that excision will not only 
Results of Different Methods of 
Inferior Maxillary. 
Number. 
Mode of Treatment employed. 
j No. treated. 
Cured. 
j Believed. 
j Failed. 
13 
.2 
A 
a 
© 
£ 
‘5b 
o 
1 
1 
1 
i 
1 
1 
2 
2 
3 
2 
i 
1 
i 
2 
2 
1 
1 
3 
3 
10 
11 
1 
1 
12 
13 
16 
13 
1 
2 
— 
In making our deductions from the table of the Results of the different methods of treatment of pseudar- 
all of the 7 cases in which drilling, together with its modifications, was performed; this also was the case when 
reported. Friction, by scraping the ends through an external opening, was successful in the 1 case recorded, UNUNITED FRACTURE, OR PSEUDARTHROSIS. 
831 
be considered a safe measure, but will also largely supplant other plans of 
treatment, in cases of pseudarthrosis, in the hands of those who religiously 
believe in and practise antiseptic surgery. 
It may not be amiss to say, in this connection, that a certain number 
of cases of pseudarthrosis follow compound fractures in consequence of the 
prolonged suppuration and the disturbed nutrition of the parts incident 
thereto. As these are cases usually dressed under ancient plans, the sur- 
geon of the present day, if not so fondly wedded to old methods that he is 
unwilling to accept the new, may greatly lessen the probability of such ter- 
minations by giving to each case of compound fracture the same diligent 
care as in other wounds to render the injured parts aseptic, and thus prevent 
the occurrence of those inflammatory complications which defeat the proper 
osteogenetic processes of the damaged fragments of bone. 
The results of the various plans of treatment employed for the cure of 
ununited fracture, given in the following pages, are deductions drawn from 
tables comprising 685 cases, and published at length in the first edition of this 
work. 
Treatment of Pseudarthrosis. 
l-i M M H* 
WtCMOCOO^OJCn^WtOl-* 
Number. 
- 
: : m: : : 
No. treated. 
i i : : 
Cured. 
: | ::::::::::::: | Believed. 
o 
p* 
o 
i | i :::::::: i i i i 
Died. 
Not given. 
- 
: m: i : i 
No. treated. 
: | : : 1 : : : : : i i : : : j Cured. 
M 
: m: i i : 
Relieved. 
XMl 
o 
: | | Failed. 
£ 
? 
i | : : : : : i : : : i i : : 
Died. 
: Not given. 
M 
: h-4 • • • • 
No. treated. 
M 
: Mi : i : 
Cured. 
$ 
p 
1 
C 
- 
No. treated. 
M 
Cured. 
: J Relieved. 
w 
: | ::::::::::::: Failed. 
sr 
■ 
Died. 
Not given. 
throsis of the Inferior Maxillary, we find that of the whole number of eases treated, success was attained in 
the teeth were wired together and the external splint, or apparatus, was applied, as noted in the three cases 
while, strange to say, when attempted subcutaneously, the patient died. 832 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Results of Different Methods of Treat- 
Location not 
given. 
Surgical Neck. 
, Number. 
Mode of Treatment employed. 
| No. treated. 
| Cured. 
Relieved. 
| Failed. 
| Lied. 
| Not given. 
| No. treated. 
! Cured. 
| Relieved. 
| Failed. 
| Died. 
Not given. 
1 
2 
2 
2 
3 
2 
1 
3 
1 
1 
4 
1 
1 
1 
1 
5 
i 
1 
6 
1 
1 
7 
1 
1 
8 
2 
2 
9 
1 
1 
10 
i 
i 
11 
11 
4 
4 
3 
12 
15 
7 
8 
13 
14 
1 
1 
1 
i 
15 
5 
9 
2 
1 
16 
“ after reflecting the periosteum, and uniting the ends by wire or thread. 
1 
1 
17 
1 
1 
1 
l 
18 
19 
“ “ and ivory pegs, or steel screws, put in; subcutaneously 
3 
2 
1 
20 
1 
1 
21 
1 
1 
22 
Total 
52 
25 
10 
16 
1 
4 
1 
1 
2 
in number 10 of the table, containing Results of the treatment of non-union of the Humerus by different kinds 
apparatus for fractured clavicle, and was cured; 1 was cured by the swinging angular splint; and 1 was cured 
By drilling, after first performing resection, and uniting the ends of the bone by wire, etc., 32 cases were 
35 cases were treated, of which 21 were cured, 2 were relieved, 11 failed, and in 1 the result was not stated. In 
result was not stated. 
JResults of Different Methods of Treatment 
Location not 
given. 
Junction of 
Upper and 
Middle Thirds. 
Middle Third. 
Number. 
Mode of Treatment employed. 
[ No. treated. 
| Cured. 
| Believed. 
| Failed. 
| Died. 
| Not given. 
| No. treated. 
| Cured. 
| Believed. 
| Failed. 
| Died. 
| Not given. 
No. treated. 
| Cured. 
| Believed. 
[ Failed. 
Died. 
| Not given. 
1 
2 
2 
1 
1 
2 
1 
1 
1 
1 
1 
1 
5 
1 
1 
7 
2 
2 
8 
9 
2 
1 
1 
2 
1 
1 
1 
1 
10 
11 
12 
13 
2 
1 
i 
2 
2 
“ drilling fragments, and ends of bone united by wire ligature. 
2 
2 
1 
1 
14 
i 
1 
15 
8 
3 
4 
4 
3 
1 
4 
1 
3 
In the table of treatment of the Radius and Ulna, 1 case was treated by Boyer’s apparatus, and was cured; 
uniting bones by wire, 3 cases were treated, of which 2 were cured and 1 failed; but when drilling and its modi- 
drilling was 7 treated, of which number 2 were cured, 1 was relieved, and 4 failed. UNUNITED FRACTURE, OR PSEUDARTHROSIS. 
merit of Pseudarthrosis of the Humerus. 
Upper Third. 
Junction of 
Upper and 
Middle Thirds. 
Middle. 
Middle Third. 
Junction of 
Middle and 
Lower Thirds. 
Lower Third. 
Whole Number 
treated. 
| No. treated. 
| Cured. 
| Relieved. 
| Failed. 
ri 
5 
| Not given. 
| No. treated. 
| Cured. 
| Relieved. 
| Failed. 
| Died. 
| Not given. 
. 
rs 
o 
te 
o> 
u 
6 
£ 
i 
i 
7 
u 
J 
1 
2 
: • • | Relieved. 
| •rH 
i = | Died. 
: • | Not given. 
H3 
CD 
"eg 
- 
- 
6 
£ 
i 
'C 
$ 
u 
S3 
© 
i 
| Relieved. 
| Failed. 
© 
S 
| Not given. 
; | No. treated. 
| Cured. 
| Relieved. 
; | Failed. 
j Died. 
| Not given. 
: | No. treated. 
| Cured. 
| Relieved. 
| Failed. 
| Died. 
| Not given. 
| No. treated. 
O CO 05 1 
rd 
© 
h 
S3 
o 
4 
2 
4 
'O 
> 
.2 
i 
fd 
© 
eg 
& 
3 
9 
• • ■ | Died. 
• • : | Not given. 
1 
1 
... 
... 
1 
1 
... 
1 
3 
i 
1 
2 
1 
1 
... 
• 
... 
... 
1 
1 
1 
1 
2 
1 
1 
2 
9 
G 
1 
4 
1 
3 
2 
1 
13 
3 
1 
2 
i 
1 
1 
1 
1 
5 
3 
2 
1 
2 
1 
1 
2 
2 
8 
G 
i 
1 
i 
i 
3 
3 
... 
14 
4 
9 
i 
i 
i 
4 
3 
i 
8 
8 
42 
12 
4 
24 
1 
i 
2 
2 
15 
8 
6 
1 
i 
i 
3 
i 
1 
1 
6 
4 
1 
1 
42 
22 
1 
17 
1 
1 
4 
3 
1 
4 
3 
1 
2 
1 
1 
1 
1 
5 
1 
4 
... 
4 
4 
2 
2 
5 
2 
1 
2 
5 
1 
1 
3 
21 
9 
4 
7 
1 
1 
1 
3 
3 
4 
3 
1 
2 
1 
1 
n 
q 
1 
1 
2 
1 
4 
1 
3 
1 
1 
1 
i 
1 
1 
i 
1 
4 
3 
5 
3 
2 
1 
1 
i 
1 
10 
7 
1 
1 
1 
1 
i 
1 
4 
/1 
1 
l 
i 
1 
3 
1 
1 
1 
1 
1 
1 
1 
9 
1 
1 
12 
_ 
5 
- 
7 
- 
- 
7 
4 
— 
— 
— 
- 
71 
34 
3 
31 
3 
— 
14 
9 
— 
5 
— 
— 
21 
7 
2 
10 
— 
2 
41 
17 
2 
21 
— 
i 
219 
102 
18 
92 
4 
3 
of apparatus, 4 were treated by splints, with a result of 3 cured and 1 failed. One was treated by Crawford’s 
by first extracting a loose external condyle, and then applying an apparatus. 
treated, of which 18 were cured, 4 were relieved, 9 failed, and 1 died. By drilling, together with its modifications, 
all, by drilling, 67 cases were treated: of these, 39 were cured, 6 were relieved, 20 failed, 1 died, and in 1 the 
of Pseudarthrosis of the Radius and TJlna. 
: mm.: : to m: : : : mm! 
No. treated. 
i i i : : mm: : : : mm: 
| Cured. 
g 
CO 
Failed. 
gj 
ctT 
1 i i | Died. 
: j j Not given. 
Ot 
i i i : ton: m: m: : i i 
No. treated. 
&H 
CO 
• ! : : ton: ::::::: 
Cured. 
a 
a 
f*sr. 
2 ° 
*1 Mj 
to 
m: m: :: : 
Failed. 
n p* 
Died. 
® cT 
80 
: j | Not given. 
0- 
to 
m: ::::::::::: m 
No. treated. 
• | Cured. 
e 
: j :::::::::::::: | Relieved. 
O 
3 
CD 
to 
m: : : : : : i : : : : : m 
Failed. 
H 
D* 
Died. 
CO 
tOtOWtMOCOMMMMM^^ri 
No. treated. 
CO 
•' : to co to m to m : : com: 
Cured. 
3 
(r 
o 
CO 
m . : : : m : : : : : m : : 
Relieved. 
a 
§ 
s 
m to m m : co : m: mm: com 
Failed. 
O' 
CD 
-t 
Died. 
CD 
P 
CD 
O. 
Not given. 
2 cases were treated by the ordinary splints, 1 of which was cured and 1 failed. By drilling, after resection, and 
fications were used alone, of the 4 cases treated, none were cured, 1 only was relieved, and 3 failed. The total by INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Results of Different Methods of Treat- 
Location not stated. 
Upper Third. 
| Number. 
Mode of Treatment employed. 
No. treated. 
Cured. 
Relieved. 
Failed. 
T3 
a> 
5 
Not given. 
No. treated. 
Cured. 
Relieved. 
Failed. 
rT3 
© 
5 
Not given. 
1 
Scraping, lacerating, or scratching the ends 
2 
Friction, by forcibly rubbing the ends together 
3 
Acupuncture 
2 
2 
4 
5 
6 
Local counter-irritation, etc., by tincture of iodine 
Firm pressure 
7 
Seton of wire, or silk 
1 
1 
8 
Resection 
3 
3 
1 
i 
9 
10 
“ drilling, and wiring the ends of the bone together... 
“ after reflecting the periosteum, and wiring 
2 
1 
i 
11 
12 
the ends together 
Drilling the ends; subcutaneously 
“ “ “ after a diagonal resection of 
1 
1 
1 
1 
13 
Drilling, and wiring the fragments together 
1 
1 
1 
1 
14 
Actual cautery 
1 
i 
Total 
10 
8 
2 
4 
3 
1 
From the table containing the Results of treatment of non-union of fractures in the Radius only, we find that, 
cured, and 1 failed; and that, by drilling, with its modifications, 3 cases were treated, of which 2 were cured, and 
Location not 
stated. 
Upper Third. 
Middle Third. 
Number. 
Mode of Treatment employed. 
| No. treated. 
Cured. 
| Believed. 
Failed. 
| Died. 
Not given. 
| No. treated. 
Cured. 
| Believed. 
| Failed. 
Died. 
| Not given. 
| No. treated. 
•perno 
| Relieved. 
Failed. 
Died. 
Not given. 
1 
1 
1 
2 
2 
1 
3 
i 
1 
41 
i 
1 
5 
1 
1 
6 
7 
8 
2 
1 
1 
1 
1 
9 
... 
... 
10 
“ “ after reflecting the periosteum, and wiring the 
11 
1 
1 
1 
1 
12 
“ “ “ after a diagonal resection of them; 
13 
14 
8 
5 
2 
1 
2 
1 
1 
1 
1 
Results of Different Methods of Treat- 
From the same table we find that, where the Ulna only was ununited, and drilling was the method used, after 
cases were treated, of which 4 were cured and 1 failed : giving a total, by drilling, of 6 cases treated, with a result UNUNITED FRACTURE, OR PSEUD ARTHROSIS. 
merit of Pseudarthrosis of the Radius. 
to 
: : : 
: • 
j No. treated. 
to 
| i S i l : 
= i m: : 
j Cured. 
: | : : : : : : : : i : 1 : i : | Relieved. 
Failed. 
& 
Died. 
to 
: : : m: 
: : : m i 
No. treated. 
M 
: 1 : m: ! i i i 1 i : : : 
Cured. 
0 
O 
t-iET. 
*° 
® o 
■-» *-*» 
M 
Failed. 
Hg 
D*S 
O' 
Died. 
& 
CL 
Or 
: to m m : 
: : : m 
No. treated. 
09 
: Mi m: 
: : : M 
Cured. 
fcH 
Relieved. 
O 
3 
CD 
to 
: : : : : : hm: : : : : : 
Failed. 
H 
er 
Died. 
EL 
Not given. 
to 
w 
H tO H MM 
to os co to: 
05 : M 
No. treated. 
M M M MM 
M cr» M M : 
05 : M 
Cured. 
3 
cr 
o 
Relieved. 
« 
s 
B 
Ob 
: m : : : 
M M tO M • 
Failed. 
cr 
CD 
Died. 
s 
S' 
pi 
Not given. 
by drilling, after resecting the ends of the bone and uniting them by wire, 4 cases were treated, of which 3 were 
1 failed; giving a total, by drilling, of 7 cases treated, with a result of 5 cures and 2 failures. 
merit of Pseudarthrosis of the Ulna. 
to 
m: 
i i 1 m: 
No. treated. 
» 
m: 
M : : m: 
Cured. 
Relieved. 
g 
CL 
Nailed. 
CL 
Died. 
Not given. 
to 
• m: 
m: 
No. treated. 
Ch 
M 
: m: : i ::::::::: 
Cured. 
P 
o 
p g: 
Relieved. 
1 o 
M 
: : : m: :::::::: i 
Failed. 
S'o- 
CL CL 
® 5T 
P 
Not given. 
CL 
M 
i : m : : ::::::::: 
No. treated. 
M 
: : m 
Cured. 
1 | i M » : ! ! ! M ! U t 
Relieved. 
i 
CD 
•-* 
i | : : i i i 
Failed. 
H 
g 
si 
Died. 
Not given. 
05 
: »-i m 
: to: 
i MHHtOH 
No. treated. 
M 
: -m 
to i 
MMMtOH 
Cured. 
o. 
Relieved. 
S 
d 
B 
cr 
CD 
►f* 
m: 
: to: 
: ! : 1 
Failed. 
Died. 
P 
CL 
- 
: m : 
Not given. 
resecting the ends of the bone, the only case treated was cured; and that, by drilling, with its modifications, 5 
of 5 cures, and 1 failure. 836 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Results of Different Methods of Treat- 
Location not 
given. 
Neck. 
Number. 
Mode of Treatment employed. 
No. treated. 
'd 
<v 
d 
O 
Relieved. 
rr 
‘3 • 
L 
d 
> 
• So 
d 77 
2 o 
3 fc 
i No. treated. 
'd 
d 
o 
Believed. 
rd 
*3 
'd* 
s 
Not given. 
1 
2 
i 
1 
2 
2 
2 
2 
i 
i 
3 
3 
i 
1 
i 
4 
1 
i 
1 
1 
5 
1 
1 
6 
7 
6 
i 
1 
i 
7 
4 
3 
i 
2 
i 
i 
8 
1 
i 
9 
6 
4 
2 
10 
11 
6 
6 
2 
1 
1 
12 
13 
4 
1 
2 
14 
10 
8 
... 
2 ... 
15 
9 
16 
17 
18 
19 
3 
2 
1 . 
20 
9 
1 
1 . 
21 
1 
1 
22 
55 
39 
1 
11 
1 
8 
5 
2 
1 
It will appear from the above table that of the 17 cases treated by forcible friction, 7 were cured and 10 failed; 
By Lilley’s apparatus, invented in 1854, 1 case was cured. By H. H. Smith’s splint, 6 cases were treated, with 
on crutches, having the limb firmly bandaged, and both were cured, while of 4 cases which were allowed to 
and of Dzonde, together with rest, 3 were cured. By Middeldorpf’s swinging mechanism, 4 were treated, with 4 
alone, 5 were cured, 4 failed, and 2 died; by drilling, with its modifications, 18 cases were treated, with 9 cures, 8 
Results of Different Methods of Treatment of 
Number. 
Mode of Treatment employed. 
j Treated. 
Loca 
9 
f~ 
P 
O 
tion 
rd 
V 
> 
P3 
not g 
‘3 
iven. 
'd 
5 
Not given. 
1 
Scraping, scratching, or lacerating ends; subcutaneously 
3 
3 
... 
2 
Forcible friction of the ends together 
3 
3 
3 
Friction of the ends, by walking on crutches or in an apparatus ,... 
3 
3 
4 
5 
6 
Galvanism, externally, in length of limb, or locally 
2 
2 
7 
Local counter-irritation by tincture of iodine and blisters 
3 
3 
8 
Immovable dressing of starch, leather, etc 
1 
1 
9 
1 
1 
10 
Different apparatus; splints, and tonic treatment 
1 
i 
11 
Phosphate of lime, internally 
12 
i 
1 
13 
Seton of silk, thread, or wire 
l 
1 
14 
Tenotomy of tendons of contracted muscles 
l 
1 
15 
4 
3 
i 
16 
“ and fragments wired together 
1 
i 
17 
“ drilling, after reflecting periosteum, and ends wired 
1 
i 
18 
“ and actual cautery to ends 
1 
l 
19 
Drilling, or perforating ends; subcutaneously 
1 
i 
20 
“ “ “ and ivory pegs driven in; subcutaneously 
1 
i 
21 
Ivory pegs driven into ends; not subcutaneously 
22 
Ptyalism and starch bandage 
i 
i 
30 
26 
2 
i 
i 
In the treatment of non-union of the Tibia and Fibula, H. H. Smith’s apparatus was used twice, with 2 cures, 
and of 10 cases managed by splints of different kinds, 7 were cured, and 3 failed. Drilling, with its modifications, UNUNITED FRACTURE, OR PSEUDARTHROSIS. 
837 
ment of Pseudarthrosis of the Femur. 
Upper Third. 
Junction of 
Upper and 
Middle. 
Middle Third. 
Junction of 
Middle and 
Lower Third. 
Whole Number 
Middle Thirds. 
Lower Thirds. 
*6 
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12 
of the 14 treated by a walking apparatus, which is modified friction, 10 were cured, 2 were relieved, and 2 failed. 
4 cures. To R. Moyle’s appliance, by which 1 case was cured, no name is given. 2 patients were allowed to walk 
walk with the leg in an immovable dressing, 2 were cured and 2 failed. By the apparatus of Boyer, of Desault, 
cures. Of 6 cases treated by splints and rests, 4 were cured, 1 failed, 1 died. Of 11 cases subjected to drilling 
failures, and 1 death; giving a total by drilling of 29 cases, with 14 cures, 12 failures, and 3 deaths. 
Pseudarthrosis of the Tibia, Fibula, and Patella. 
Tibia and Fibula. 
Patella. 
Junction of 
Upper and 
Middle Thirds. 
Middle. 
Middle Third. 
Junction of 
Middle and 
Lower Thirds. 
Lower Third. 
Whole Number 
treated. 
Whole Number 
treated. 
73’ 
® 
a 
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3 
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5 
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1 
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6 
3 
3 
... 
— 
— 
Of 6 cases treated by firm bandaging, the patients being allowed to walk on crutches, 5 were cured, and 1 failed; 
was employed in 11 cases, with 9 cures and 2 failures. 838 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Results of Different Methods of Treatment of 
j Number. 
Mode of Treatment employed. 
Location not given. 
Treated. 
Cured. 
Relieved. 
Failed. 
o> 
P 
Not given. 
X 
Scraping, scratching, or lacerating ends; subcutaneously 
1 
1 
2 
Forcible friction of ends together 
1 
i 
3 
Friction of ends, by walking in apparatus 
1 
i 
4 
2 
l 
1 
6 
Electro-puncture, and immovable apparatus 
6 
Galvanism in length of limb, or over fracture 
2 
2 
7 
8 
9 
Different apparatus; splints; tonic treatment 
2 
1 
1 
10 
Injection ot argenti nitras into false joint 
XI 
2 
2 
12 
Seton of silk, wire, or thread 
6 
i 
4 
1 
13 
Tenotomy of the contracted muscles, and forcible extension 
14 
6 
5 
1 
15 
“ drilling the ends, and wiring the ends together 
2 
2 
16 
“ of tibia, and intentional fracture of fibula 
17 
Intentional fracture of fibula, and forcible friction of tibia 
i 
i 
18 
Drilling, or perforating the ends; subcutaneously 
7 
4 
3 
19 
“ “ “ “ and Malgaigne’s spikes 
20 
“ “ “ “ and drill left in 
i 
i 
21 
“ “ “ “ and ivory pegs driven in 
2 
i 
l 
22 
36 
20 
8 
8 
From the table containing the Results of the treatment of ununited fracture of the Tibia, we find that where 
treated and cured, as was also 1 treated and cured by encasing the leg in a starch bandage and allowing locomo- 
were treated by H. H. Smith’s appliance and were cured; making a total of 5 eases, treated by friction of the 
cured. When the patient was kept at rest, and splints were used, 4 cases were treated, of which 2 were cured, and 
used in 1 case, and failed ; so that we get a total of 6 cases treated by splints, or apparatus, and of this number 
Where the method of drilling the ends of the bone, after resecting, was used, 4 cases were treated, and all 4 
cured, 3 were relieved, and 7 failed; giving a total number of 29 cases treated by drilling, of which number 19 
Where the Fibula only was ununited, forcible friction of the ends cured 1 case, and drilling the ends, with the 
not so, were all that are recorded as such in 685 cases of pseudarthrosis. 
Results of Treatment of Pseudar- 
Time the Seton remained. 
Clavicle. 
Humerus. 
Bad. and 
Ulna. 
Badius. 
j Treated. 
TS 
U 
5 
| Treated. 
! Cured. 
Believed. 
| Failed. 
T3 
s 
fl 
® 
> 
‘Sc 
o 
*4 
| Treated. 
Cured. 
| Treated. 
| Cured. 
! Believed. 
| Failed. 
rd 
5 
From one to six days 
2 
1 
1 
1 
1 
10 
4 
1 
4 
i 
4 
2 
1 
1 
“ twenty-one to twenty-three days 
1 
1 
3 
1 
2 
1 
1 
“ twenty-eight to thirty days 
3 
2 
1 
2 
2 
1 
1 
1 
1 
For thirteen weeks, or three months 
1 
1 
From seventeen to nineteen weeks 
2 
2 
1 
1 
1 
1 
1 
1 
Time not stated 
10 
1 
2 
7 
1 
1 
1 
1 
Total 
1 
1 
42 
12 
4 
24 
1 
i 
1 
1 
3 
1 
2 
... UNUNITED FRACTURE, OR PSEUDARTHROSIS. 
839 
Pseudarthrosis of the Tibia and Fibula. 
ci 
1 
: : : : M: M: : i : 
• 
mm: : 
| Treated. 
to 
1 
::::::::::: 
i 
i m: : 
| Cured. 
d 
: I : 1 Believed. 
CD 
>-t 
CO 
1 
: i : : m| M: : : : 
i 
m; • • 
| Failed. 
H 
: | :::::::::::::::::::::: | Died. 
2- 
: I 1 Not given. 
K 
1 
: mm! m : 
! 
: com: 
| Treated. 
5 
1 
i ; m= 
i m: : Mi : m: : ! 
: 
i com: 
| Cured. 
g 
m 
1 
I:::!:::::: 
; 
: ! : i 
| Believed. 
M 
1 
I::::! 
• 
: : : : 
| Failed. 
a. 
i | ::::::: I i s 1 Died. 
: 
1 
: i i : : i 
i : 
: 
• : : : 
| Not given. 
1 
: : : : m; 
M 
: i : m 
| Treated. 
CO 
1 
i i 1 : m| : ! 1 -1 
: 
• : : : 
| Cured. 
H 
M 
1 
:::::: 
i i : 
• 
: i : : 
| Believed. 
CL 
w 
CO 
I 
M 
: : ; m 
| Failed. 
H 
: | i 1 i • : I Died. 
: 
1 
:!•!:: 
■ : : i i : i : : : i 
: 
: • : : 
| Not given. 
• 
05 
1 
mm; : : : 
• m| i : : : : mm; 
M 
: : I : 
| Treated. 
Cl 
1 
m; • i • • 
1 m: : : : : : mm| 
M 
: : : : 
| Cured. 
: | i i : I Believed. 
Cl % 
M 
1 
i 1 : 
::::::::::: 
i 
: : : : 
| Failed. 
a® p 
1 | :::::::: i :::::::::::: : | Died. 
5 3 o 
6 CLf+> 
: | :::::::::::::::::::::: | Not given. 
05 
1 
• : 
►-* : h-* m m : : to .* : : 
M 
: : m to 
| Treated. 
S 
1 
: i 1 mco: 
m: mm! : ! i : i 
M 
i : mm 
| Cured. 
d 
o 
CD 
M 
1 
: i m| : : 
i i i : i 
i 
i : : : 
| Believed. 
C1 
1 
: i : : 1-1: 
• : i : m; : to; j : 
i 
: : : m 
| Failed. 
H 
1 | :::::::::::::::::::::: I Died. 
1 | | Not given. 
s 
| 
-i^CDMOtOMOiMbOlOCOCOCiCO^ 
| Treated. 
s 
1 
m: *mS: 
M 05 »-» co to : to H* to to to 
H-* Cl to to 
| Cured. 
Mf- O. 
B 
1 
i t0M: : M 
: : m: I : : ! I i 
: 
m : m: 
| Believed. 
CD ® 
12 
! 
: toM= 
: : tc: os: m*: i 1 
M 
M- : to 
| Failed. 
• B 
1 | | Died. 
cr 
: 1 :::::: i ::::::::: i i :: i : I Not given. 
" i 
to 
1 
: ! Mi • • 
• 
: 1 M| 
| Treated. 
to 
1 
: : M: i • 
= : = = : i : 
i 
i M; 
| Cured. 
P* 
: | I Believed. 
CD 
: 1 I:::::.:::::::::::::::: I Failed. 
g,c 
: 1 :: i ::::::: i :::::::::: : | Died. 
• s 
o' 
• | | Not given. 
CD 
1 
friction was produced, by allowing patient to walk about on crutches, with the leg firmly bandaged, 1 case was 
tion on crutches; walking about, with the leg firmly fixed in a leathern apparatus, cured 1 case; and 2 cases 
ends of the bone, produced by walking about in splints, or in an apparatus, firmly fitting the leg, and all were 
2 failed; and 1 case failed in which splints and forcible extension were used. Amesbury’s apparatus was also 
only 2 were cured, while 4 failed. 
were cured; where drilling and its modifications were used, 25 cases were treated, of which number 15 were 
were cured, 3 were relieved, and 7 failed. 
drill allowed to remain, cured the other; these 2 cases of the fibula being found ununited when the tibia was 
throsis by the use of the Set on. 
£ 
to : : : to m m m : 
: : toM- m 
Treated. 
05 
m: : : m! 
5 5 m: m 
Cured. 
Femur. 
rt* 
m: : : m-: : : 
: i -i ! i 
Failed. 
M 
i m: s 1 
Died. 
- 
i i i i h: i 
Treated. 
u 
8c 
M 
::::::::: 
! 5 ms : 
Cured. 
CD 
? 
Treated. 
CO 
Cured. 
H 
§ 
Relieved. 
P 
0 
& 
- 
i i i i i 
Failed. 
g 
o' 
Died. 
o 
: : .* : mh: : 
mh^m: 
Treated. 
CO 
Mi MJ 
Cured. 
co ::::::: : 
Relieved. 
Tibif 
CO 
Failed. 
Died. 
-I 
Smmm^cowmm 
to 05 00 CO rf*. 
Treated. 
tO 
00 
•' • • •' comm 
: co co 
Cured. 
cr 
CO 
:::::: : 
Relieved. 
S2j 
c 
B 
o' 
£ 
co h-> m h-» co co: : : 
tO CO h-* to 
Failed. 
to 
■: m: : m 
Died. 
E 
M 
::::::::: 
*::m: 
Not given. 
O' INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Results of Different Methods of Treatment of Pseudar- 
*4 
JS 
a 
3 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
Mode of Treatment employed. 
Inferior 
Maxillary. 
Clavicle. 
Scapula. 
Bibs. 
• M M | Treated. 
• • | Cured. 
| Believed. 
I | Failed. 
Id 
S 
| Not given. 
| Treated. 
| Cured. 
I | Believed. 
| Failed. 
| Died. 
| Not given. 
| Treated. 
| Cured. 
| Believed. 
| Failed. 
| Died. 
| Not given. 
| Treated. 
| Cured. 
| Believed. 
“ ~ u “ “ “ subcu- 
i 
Friction of the ends of hone by moving, or walking about, 
1 
1 
3 
1 
2 
2 
2 
1 
i 
... 
Different kinds of apparatus; splints; rest; tonic treatment 
1 
1 
1 
1 
1 
! 
1 
1 
“ drilling, and the ends of the bone wired together 
“ “ after reflecting periosteum, and the ends 
Intentional fracture of fibula, and forcible friction of tibia. 
Drilling, or perforating, the ends of bone; subcutaneously.. 
“ and ivory pegs or steel screws driven in; subcu- 
2 
2 
1 
1 
::: 
1 
3 
1 
3 
16 
13 
1 
2 
1 
1 
1 
1 
1 
1 
Amputation was performed for the relief of Pseudarthrosis 29 times. The bones operated on UNUNITED FRACTURE, OR PSEUDARTHR0S1S. 
throsis; not including Amputations. Grand Total. 
M 
•is:::: 
: : : 
: 
• : i i 
: : 
: 
| Treated. 
M 
: : : : i i : 
i : : : : : i 
i : : 
i i i ! i ! 
; 
::::::::: 
i i ! ! 
: i 
: 
| Cured. 
: 
::::::: 
::::::: 
: i : 
: 
; ; 
: 
| Relieved. 
g ? 
g 
to : 4- co : o 
11 
l'4 
Si o-mSo! i fei 
: 
8 
9 
81 
Z 
: : : m to to 
w® 
4k 
| Treated. 
I 
m : co — 
o> : : : i : co 
to: : 
Mgi i Ki 
: 
: : o»: m : o»h: 
: i i mm! 
4k to 
4k 
| Cured. 
a 
s 
! i i m! : i 
m= : : : : : 
Mi M 
i m; ; m: 
: 
i i i i m to 
i M 
i 
j Relieved. 
1 
ES 
m! : : : mcc 
•a: : : : : to 
“4: 4k 
mS; ; 
i 
: : m : ox: 03 *-*: 
CO co 
; 
| Failed. 
3 
4k 
::::::: 
: 
: : m; 
i 
:::::: k>: • 
: : 
: 
| Died. 
’ 
CO 
: i : 1-1: i : 
i : : 
M; 
i 
::::::::! 
:::::: 
i ; 
: 
| Not given. 
03 
i : cocoi : : 
-4: : : to: m 
oi 4**: 
to “4 H-*: 4k: 
• 
: : ox: to: ntoi 
i i : i ooi 
-4 M 
to 
| Treated. 
4k 
~4 
i : to: : : : 
4k: i i to: m 
co co: 
to co m : to : 
: 
: i coi toi : Mi 
5 i : i -»i 
coi 
to 
| Cured. 
s? 
CO 
i i : m = • • 
: : : 
: 
:::::::: i 
i : 
: 
| Relieved. 
s| 
8 
: i mm! : : 
coi : : i : : 
to m : 
i a: : to! 
i 
i ! toi : : mm i 
: : : i : : 
4k M 
: 
| Failed. 
PS 
: | ::::::: :::::•: ::::::::::::::::::::::::: : : : 1 Died. 
g. 
M 
::::::: 
::::::: 
: i : 
; 
: • 
: 
| Not given. 
S 
: : m: : cm 
oo: : • • oiH 
c* co: 
81 
11 
i 
8 
13 
2 
11 
2 
15 
2 
14 
4 
3 
-4 CO 
: 
| Treated. 
E§ 
iii::mm 
Ot • • • • • M 
4k co: 
i Si ! oi 
: 
i to 5 M -J to -4 M : 
: : : to m 0 
-4: 
: 
| Cured. 
CO 
::::::: 
: : : : : i i 
i i : 
!-:::: 
i 
:::•;; i i : 
• : : i : « 
i i 
: 
| Relieved. 
1 
$ 
: i m! : mw 
co: : i i m! 
: ! i 
: i : ! m! 
: 
: i to M rfk.: oh! 
i : : m co to 
Sm 
: 
| Failed. 
g 
S 
: : : : : m: 
Mi : 
: o>; : m; 
: 
i ! m! : : ! i : 
i M 
i 
| Died. 
M 
: i i : : i i 
i i : 
:::::: 
: 
:::::: 
• M 
: 
| Not given. 
S 
61 
l 
l 
I 
l 
4k to i 
2 
3 
14 
2 
24 
13 
7 
1 
3 
16 
i 
10 
4 
5 
5 
4k 00 
: 
| Treated. 
g 
g 
H-» M : HHOICO 
: m h-* : : h-» 
4*m: 
2 
3 
6 
2 
15 
: : co : to m ox to : 
: : O’ 4k i—4 co 
H-4 
0 ox 
; 
| Cured. 
i1 
£ 
i : : : : mm 
mm! : : : : 
i ; ; 
i toi i Mi 
: 
i : : i Mi 
toi 
: 
| Relieved. 
E 
S 
: i : : i mw 
m: : : : : : 
: i i 
i -vi i Mi 
i 
t-4: -4 : m : ton: 
: : : nton 
to CO 
i 
| Failed. 
3 
::::::: 
::::::: 
5 
;!!!!: 
i 
: ; 
i 
| Died. 
z 
| : : : i : : : ::::::::::::::::::::::::: i : i 1 Not given. 
? 
03 
: • • 
i i : 
: 
i i «so; ; ; ; H-*: 
: i 
: 
| Treated. 
CO 
: i : • i 
! : : 
: 
: : : : i i : Mi 
:::::: 
: : 
: 
| Cured. 
CO 
i i i i : : i 
::::::: 
i i : 
:i:*-i: 
: 
■ : ■ : : : ■ 
i i 
: 
| Relieved. 
1 
: | ::::::: : : : 1 Failed. 
- 
: | ::::::: i s : 1 : : : i :::::::: : : : : 1 Died. 
i | : : i 1 Not given. 
1 
22 
17 
1 
7 
11 
1 
3 
2 M M M CO ® M 
»(OOl»§MMMMtC 
2 
26 
34 
3 
22 
2 
47 
2 
1 
CO Ox CO O 05 
19 
51 
j Treated. 
1 
to M to CO M to M 
g: K 
8-»; 
Cn §5 M to 00 CO to 
i tOMMtOCO—4tOtC 
19 
11 
7 
5 
2 
Em 
M 
| Cured. 
s 
: : i to: m to 
to m i : : : : 
Mi M 
: ox: m oo : 
: 
• : coi i : m! : 
i Mi i MM 
to M 
; 
| Relieved. 
1 
m : to m i co to 
2 
4 
17 
0-4 1^ 
Mg; i ssi 
: 
m : 5hS: 5 : 
i i i to o. co 
g® 
: 
I Failed. 
H 
s 
: : : : : m : 
i : : : : m! 
to i-*: 
i m! i toi 
i 
i i Mi ; • m; ; 
m i i i i i 
: co 
i 
J Died. 
I 
Ox 
I : : m: i i 
: : : 
i toi i Mi 
i 
: i i ! • : : ! ! 
i i : i i i 
: m 
i 
| Not given. 
were the humerus, 7 times; the femur, 11 times; and the tibia and fibula, 11 times. 842 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Of the 656 cases contained in the tables, 565 were males and 91 females. 
The youngest patient was thirteen and the oldest seventy years of age : the 
largest number was met with between twenty-eight and forty. In 61 of 
the cases the duration of the fractures was less than three months. The 
shortest period (a single case) reported was three weeks, the longest period 
ten years. The whole number cured by the various plans of treatment was 
385. Of the remaining 271, 43 were relieved,—that is, the amount of motion 
in the ends of the bone was lessened,—in 204 no benefit was derived from 
the operations performed, 19 proved fatal, and in 5 the result was not ascer- 
tained. 
In order to present in as compact and concise a manner as possible the 
practical deductions which may be drawn from so large an amount of detail, 
I shall place in tabular form a comparison of only those methods by which 
the largest number of cases of non-union of the most important bones were 
treated. The figures indicating these groups will be found to differ in some 
degree from those which appear in the general tables, but the discrepancy 
is only apparent, inasmuch as after omitting certain obsolete plans I have 
generalized those methods the action of which on the ununited bones is 
quite similar. 
Non-Union of the Inferior Maxillary Bone. 
No fracture is more difficult to keep at rest than that of the lower jaw, 
and it is a matter of surprise that non-union should not occur oftener than 
it does. 
The whole number treated by all plans was 16. 13 were cured, 1 was 
relieved, and 2 died. 
Methods. 
No. 
Cured. 
Relieved. 
Failed. 
Died. 
Unknown. 
Manual friction 
Mechanical appliances 
7 
5 
i 
i 
Seton 
Immobilization 
Resection, with its modifications 
Drilling, with its modifications 
7 
7 
Total 
14 
12 
l 
l 
The mechanical appliances used consisted of external and interdental 
splints, and also of wiring together the teeth. This method, designed to 
secure the rest of the fragments, is practically immobilization. In drilling, 
the ends of the bone were in some instances only perforated, in other cases 
the drill was allowed to remain for some time in the fragments, and in other 
instances the pieces were wired together. After all these operations, it was 
necessary to apply a supporting dressing, like the Barton or the Gibson 
bandage. 
The result of the two plans of treatment adopted in non-union of the in- 
ferior maxillary is in favor of drilling, and by reference to the general table 
it will be seen that the preferable operation is that modification in which, 
after perforating the bone, the two ends are drawn together by wire. 
Non-Union of the Humerus. 
Two hundred and nineteen cases of ununited fracture of the humerus were 
treated by twenty-two different plans, with 102 cures, 18 relieved, 92 failures, 
4 deaths, and 3 unknown. NON-UNION OF THE RADIUS. 
Methods. 
No. 
Cured. 
Relieved. 
Failed. 
Died. 
Unknown. 
Manual friction 
13 
4 
9 
Mechanical appliances 
10 
6 
3 
1 
Seton 
42 
12 
4 
24 
f 
i 
Immobilization 
13 
5 
1 
6 
1 
Resection, with its modifications 
83 
43 
6 
31 
2 
i 
Drilling, with its modifications 
35 
21 
2 
11 
1 
Total 
196 
91 
16 
82 
4 
3 
The mechanical appliances employed were designed not to immobilize the 
fragments entirely, but to admit of slight friction. The modifications of 
resection consisted in boring into the bone a steel screw or gimlet, and in 
drilling and wiring together the ends of the bone, with or without a previous 
reflection of the periosteum. Forty-two of the 83 cases were treated by re- 
section alone, with 22 recoveries, 1 relief, 17 failures, 1 death, and 1 without 
known result. The table above exhibits a success most favorable to resec- 
tion with its modifications, and to drilling. 
Non-Union of the Radius and Ulna. 
The general table contains 37 cases of non-union of the radius and ulna, 
treated by fourteen different methods and their modifications. The result 
was 18 cures, 3 relieved, 15 failures, and 1 undetermined. 
Methods. 
No. 
Cured. 
Relieved. 
Failed. 
Died. 
Unknown. 
Manual friction 
4 
1 
3 
Mechanical appliances 
3 
2 
1 
Seton 
1 
1 
Immobilization 
1 
i 
Resection, with its modifications 
17 
ii 
i 
5 
Drilling, with its modifications 
4 
l 
3 
Total 
30 
15 
2 
13 
It will appear from the above table that the largest success in the treat- 
ment of ununited fracture of both bones of the forearm was obtained by 
resecting and wiring the fragments together. 
Non-Union of the Radius. 
Twenty-three cases of ununited fracture of the radius are comprised in 
the general table, 17 of. which are recorded as cures and 6 as failures. 
Methods. 
No. 
Cured. 
Believed 
Failed. 
Died. 
Unknown. 
Manual friction 
Mechanical appliances 
2 
i 
i 
Seton 
3 
l 
2 
Immobilization 
Resection, with its modifications 
9 
7 
2 
Drilling, with its modifications 
4 
3 
1 
Total 
18 
12 
6 844 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
In the above group of 18 cases, resection and drilling, with their modifica- 
tions, furnish the largest percentage of cures. 
Sixteen instances of non-union of the ulna have been tabulated, with 11 
cures, 4 failures, and 1 in which the termination was not given. 
Non-Union of the Ulna. 
Methods. 
No. 
Cured. 
Relieved. 
Failed. 
Died. 
Unknown. 
Manual friction 
3 
2 
1 
Mechanical appliances 
1 
1 
Seton 
Immobilization 
Resection, with its modifications 
3 
2 
1 
Drilling, with its modifications 
6 
5 
1 
Total 
13 
8 
4 
1 
The superiority of drilling over resection appears in the above comparison. 
Non-Union of the Femur. 
One hundred and fifty-five cases of ununited fracture of the femur appear 
in the general table, with 92 cures, 3 partial cures, 47 failures, 12 deaths, and 
1 unknown. 
Methods. 
No. 
Cured. 
Relieved. 
Failed. 
Died. 
Unknown. 
Manual friction 
17 
7 
10 
Mechanical appliances 
29 
22 
2 
4 
i 
Seton 
11 
6 
4 
1 
Immobilization 
24 
14 
10 
Resection, with its modifications 
32 
19 
i 
4 
8 
Drilling, with its modifications 
18 
9 
8 
1 
Total 
131 
77 
3 
40 
11 
Of the 29 cases treated by mechanical appliances, 14 used instruments 
which enabled them to walk about, 10 of whom were cured. The fatality 
which appears to have followed resection is sufficient to condemn this opera- 
tion, and although the table exhibits only one death after the use of the 
seton, I am cognizant of others which have never been placed on record, 
and which are quite sufficient to subject this method also to condemnation. 
The success which has followed the use of a walking-apparatus, such as that 
of Professor Smith, the employment of which involves no risk whatever to 
the life of the patient, is a sufficient reason why this mechanism should take 
precedence of all other plans of treatment; and in the event of its failure 
to induce consolidation of the bone, the subcutaneous drill or gimlet should 
be next employed. 
Non-Union of the Tibia and Fibula. 
The whole number of cases of non-union of the tibia and fibula comprised 
in the general table is 94, 71 of which were cured, 3 were relieved, 19 failed, 
and 1 died. NON-UNION OF THE PATELLA 
845 
Methods. 
No. 
Cured. 
Relieved. 
Failed. 
Died. 
Unknown 
Manual friction 
10 
7 
1 
2 
Mechanical appliances 
15 
11 
4 
Seton 
4 
3 
1 
Immobilization 
11 
8 
3 
Resection, with its modifications 
20 
13 
i 
5 
1 
Drilling, with its modifications 
10 
8 
l 
1 
Total 
70 
50 
3 
16 
1 
The entire safety of mechanical appliances and of immobility, and the 
success which has attended their use, are reasons sufficiently cogent for their 
adoption in preference to other measures in the treatment of ununited frac- 
tures of the bones of the leg; and in the event of these failing to insure union, 
subcutaneous drilling should be next selected. 
Non-Union of the Tibia. 
The whole number treated was 84, with the following result: 52 were 
cured, 11 were relieved, and 21 died. 
Methods. 
No. 
Cured. 
Relieved. 
Failed. 
Died. 
Unknown 
Manual friction 
4 
2 
2 
Mechanical appliances 
11 
7 
4 
Seton 
10 
3 
4 
3 
Immobilization 
Resection, with its modifications 
14 
ii 
i 
2 
Drilling, with its modifications 
25 
15 
3 
7 
Total 
64 
38 
10 
16 
Of the 11 cases treated by mechanical appliances, 5 wore walking-splints, 
all of whom were cured. When resection is deemed proper, it will enhance 
the prospects of success, in ease any considerable portion of the ends of the 
tibia is removed, either to fracture or to excise a part of the fibula, in order 
to admit of the contact of the ends of the former bone. 
Non-Union of the Fibula. 
Two cases were treated.—one by friction, and the other by subcutaneous 
drilling ; both with a successful result. 
Non-Union of the Patella. 
Six cases were treated,—1 by counter-irritation, 2 by retentive apparatus, 
1 by seton (the thread being placed not between, but alongside of the bone), 
1 by a subcutaneous section of a part of the quadriceps, with a view to 
bring the upper piece down, and 1 by dialling and wiring together the two 
fragments. The result of these different plans of treatment was 3 cures 
and 3 improved. The object aimed at in the treatment of these instances 
of non-union was doubtless to obtain a close ligamentous connection of the 
fragments. 846 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Summary. 
In summing up the whole number treated by the six methods which I 
have placed in comparison, we have 544 cases of non-union, with 300 cures 
and 17 deaths, distributed as follows: 
Methods. 
No. 
Cures. 
Deaths. 
53 
25 
80 
57 
2 
73 
27 
2 
49 
27 
1 
178 
104 
11 
111 
60 
1 
Total 
544 
300 
17 
Eight of the 17 fatal cases occurred after resection and drilling of the ends 
of the bone in ununited fractures of the femur. 
After a careful analysis of the material at hand, and from the results of 
my own observation and experience, I think the following rules embody the 
best guides for dealing practically with this subject: 
1. In the treatment of an ununited fracture of any bone, always begin 
with the simplest and the least dangerous of those measui'es which have 
ordinarily proved most successful, and advance, if necessary, to those the 
employment of which involves greater danger. In conformity with this 
rule, forcible manual friction, conjoined with immobilization, should precede 
all other plans, especially in recent forms of non-union. Next in order 
would come the use of mechanical appliances or apparatus, by which passive 
friction at the ends of the bone can be maintained. Following manual and 
instrumental friction, the use of the subcutaneous drill and its modifications 
will be next indicated; and last, resection, with its various modifications. 
2. In ununited fracture of the femur, the dangers attending either the 
employment of the seton or a resort to resection are so great that these 
methods should be entirely discarded from the surgical resources applicable 
to the condition under consideration, unless performed antiseptically. 
3. In instances of ununited fracture where it is deemed proper to employ 
the seton, the latter should not be allowed to remain longer than from seven 
to ten days, and always with antiseptic precautions. 
Union of a fracture may take place in such a manner as to impair the use- 
fulness of the limb, and sometimes to occasion marked deformity. The causes 
which conduce to these results are insubordination on the part of the patient, 
refusal to submit implicitly to the instructions of his professional attendant, 
carelessness or want of skill in adjusting and dressing the fracture, and a 
choreic state of the muscles of the limb. Deformity may also unavoidably 
follow compound fractures accompanied with severe and extensive contusion 
of the soft parts, in consequence of wdiich it had been impossible to make 
the necessary extension or compression; and, finally, a vicious union may 
result from a patient’s being unable to secure the necessary surgical at- 
tendance. 
The deformity may consist in overlapping of the fragments, producing 
shortening of the limb (Fig. 637); in angular union of the bone (Fig. 638); 
and in rotation of the distal end of the fracture upon its axis (Fig. 639). 
Deformed or Vicious Union. DEFORMED OR VICIOUS UNION. 
847 
Shortening and Rotatory Displacement.—In case of overlapping, the course 
of the surgeon must be determined by the amount of shortening present, 
the time which has elapsed since the injury to the bone affected, and the 
degree of disability imposed by the deformity. Some shortening may be 
Fig. 637. 
Fig. 638. 
Fig. 639. 
Overlapping of the ends of a 
broken bone, causing marked 
shortening. 
Angular union of a fracture at 
the upper part of the femur. 
Lower fragment of the 
femur rotated outwards. 
expected to follow most fractures, and is in no way inconsistent with a good 
cure. In the case of the femur, when the overlapping does not exceed two 
inches, and wffien the union is solid, an operation for its correction is not 
necessary. When, however, the callus is soft, and the fragments are found 
to be movable, the bone should be refractured, and the necessary extension 
applied to restore the limb to its proper length. In consequence of the 
varying progress of ossification in different persons, such a course in one 
person may not be feasible at the end of five weeks, and in another may be 
practicable after a much longer time. When the overlapping follows a frac- 
ture of the humerus, unless, in some way, the usefulness of the arm is 
seriously impaired, it had better be left without interference, however much 
shortening is present, as the advantage resulting from its recalcification will 
scarcely compensate for the inconveniences attending the refracture. 
Angular Union.—Where the displacement is angular, even though the con- 
solidation has become complete, it is of the utmost importance that the de- 
formity should be corrected. In some situations the evils of such a union 
increase with the lapse of time. Thus, in badly-treated fractures of the lower 
end of one or both bones of the leg, followed by eversion of the foot, the 
deformity will become greater and the disability increase daily under the 
superincumbent weight of the body. 
In case of fractures viciously united, and not older than three or four 
weeks, it is possible to correct the deviation from the proper line at once 
by exhibiting an anaesthetic and then straightening the part over the knee 
placed against the summit of the curve. This may be done in some instances 
without disconnecting the fragments, the callus being sufficiently soft to 
admit of the correction without an actual rupture. Fig. 640 gives an illus- 
tration of a deformity following a fracture of the bones of the forearm, which 
I was able to remedy in this manner after the lapse of five weeks (Fig. 641). 848 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
In older cases, where the consolidation is too firm to admit of being treated 
in the above manner, resort may be had to mechanical contrivances in 
order to apply continuous pressure. The construction of some of these 
mechanisms demands considerable skill, but for the most part the appliances 
Fig. 640. 
Deformed union of the radius and ulna. 
Fig. 641. 
The same corrected instantaneously, without refracture, by bending the part over the knee. 
are so simple that the surgeon who possesses any handicraft whatever can 
prepare them for himself. In many of those cases of vicious union which 
are met with in the arm and the leg, nothing is required save a straight, well- 
padded splint, compresses, and two or three roller bandages. The dressing 
can be placed on either aspect of the curve, or may be changed from one to 
the other. Figs. 642 and 643 will serve to illustrate the plans of employing 
pressure for the purpose of correcting curved or angular deformity. 
Fig. 642. 
Fig. 643. 
Splint placed on the concave side of a curve, and 
bound to the part by the turns of a roller. 
Splint placed on the convex side of a curve, and 
bound to the extremities of the part. 
The result of steady persistence in such a method will soon be apparent 
in the gradual improvement of the deviation, even where it has existed for 
two or three months. 
Where the union is so firm that neither extension nor compression nor both 
combined make any impression, something more decided must be done, 
either by acting on the callus in such a manner as to induce softening, or by 
refracturing the bone by the application of a sufficient force. 
To accomplish the first, a small puncture may be made in the soft part 
with a sharp-pointed bistoury, through which a drill can be carried down DEFORMED OR VICIOUS UNION. 
849 
upon the seat of fracture and made to penetrate the callus by a rotatory 
movement in different directions. 
By means of the drill represented in Fig. 644 the perforation of the callus 
can be effected in a few moments. 
In old cases of angular deformity a subcutaneous section of the bone can be 
Fig. 644. 
Bone-drill geared so as to revolve with great rapidity. 
effected without difficulty by means of the Adams saw (Fig. 645), an opening 
being made for the instrument by a long, narrow, sharp-pointed bistoury. 
On the removal of the instrument, the minute wound in the soft parts 
should be closed with a strap of adhesive plaster, and the limb placed at rest. 
After the lapse of seven or eight days the inflammatory action excited in 
Fig. 645. 
Adams saw for subcutaneous division of the thigh-bone. 
the callus will have produced such a degree of softening as to render feasible 
the correction of the deformity by graduated pressure applied on the principle 
already described, and at this time the dressing for that purpose may he 
adjusted. 
If refracture be determined upon, it may be done by placing the knee, as 
a point for counter-pressure, against the seat of deformity, and, after grasp- 
ing the limb above and below, applying the necessary force; or it may be 
accomplished by bending the part over the edge of a table. When the callus 
is so firm as to offer great resistance, it may be first weakened by the drill, 
and then broken at once, after which it should be placed in the proper posi- 
tion, and so retained by appropriate dressings. A difficulty is sometimes 
encountered in the shortening of the muscles, so that, even after the refrac- 
ture, the limb cannot be brought into a straight position without great over- 
lapping: such a complication is most likely tp be met with in the thigh or in 
the leg. A steady, constant extension, by a sufficient weight attached to the 
limb, will elongate the muscles to a moderate degree, and this, together with 
the division of such tendons as oppose the adjustment, will generally render 
the correction feasible. If the various means described prove inadequate or 
inappropriate, there is nothing left but to excise the ends of the bone or the 
projecting angle by a Y-shaped cut. This, of course, involves a compound 
fracture, and is environed with so many dangers that it is only to be under- 850 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
taken when no other course is practicable. The deformity resulting from 
rotatory displacement is to be corrected, where extreme, by the same pro- 
cedure as that adopted for angular union. 
The union of adjacent bones by a bridge of callus is productive of very little 
inconvenience when it takes place between adjoining ribs, or 
between the tibia and the fibula, but when it involves the radius 
and the ulna, as in Fig. 646, it destroys two very important 
movements of the hand, those of pronation and supination, and 
an effort should be made to break the bond by forcibly pronating 
and supinating the hand. Malgaigne records a single case, that 
of Gardiel, in which the separation was effected by cutting down 
upon the callus and rupturing it, an operation which, in so im- 
portant a member as the arm, I would not recommend: when 
an operation is necessary, the callus should be drilled from the 
back of the arm and afterwards ruptured. 
The questions which naturally arise in connection with this 
subject are the following: 
1. Does not refracture expose the patient to the risk of in- 
flammation and abscess? If produced by force alone, they are 
not more likely to follow than after the first accident; if the 
drill is employed, the dangers of inflammation are increased. 
2. Is there not danger that by interrupting the process of 
consolidation, or by making a different disposition of the frag- 
ments, reunion may be prevented? The answer is, that in 
many cases of accidental and intentional refracture the repara- 
tion has gone on with even more rapid progress than after the 
first injury. I am sure this has been my hospital experience. 
3. Is there not danger of breaking the bone at some other 
point than through the original fracture ? This is exceedingly 
improbable. There is a popular notion that the strongest part 
of the bone is at the seat of union. This is not supported by observation. 
I have seen cases in which the same bone has been broken twice at the same 
point, the accidents occurring over one year apart. 
4. In resection may not the gap be too great to be bridged by bone ? This 
is possible. Such cases have occurred, though they are exceedingly rare. 
The interval which is made by excision is generally diminished by the sub- 
sequent shortening of the muscles. 
With this enumeration of the various resources which we have at command 
to correct deformed union, the surgeon may still be at a loss to know what 
course to adopt or which should receive the preference. Let me, then, lay 
down a few rules for his conduct: 
1. Where the deformity is out of sight, and does not materially interfere 
with the use of the limb, let it alone. If the deformity consists in mere irreg- 
ularities or salient points, nothing need be done. The vessels of the part will 
round these away. 
2. If seen at a time when the callus is not compact, but pliable, and if 
pressure is practicable, an effort should be made to diminish or remove the 
deformity by gradual pressure. 
3. If the case has passed beyond this period, refracture by force judiciously 
applied over the knee or a table. 
4. If foiled in this, resort to subcutaneous drilling in order to weaken the 
callus, so that it can be broken ; or, if the case is one of long standing, and 
in a single bone, like the humerus or the femur, a subcutaneous section by 
the saw will be the simplest plan of correcting the evil. 
5. As a last resort, excision may be employed ; but it should be undertaken 
3nly in cases where the deformity involves great disability, and when other 
methods are impracticable. 
Fig. 646. 
Radius and 
ulna blended by 
callus after a 
fracture of both 
bones. MORBID CHANGES OF CALLUS. 
851 
Morbid Changes of Callus. 
Callus undergoes various changes, depending sometimes upon local and at 
other times upon constitutional causes. Among these may be enumerated its 
appearance on portions of the bone some distance from a fracture. It would 
appear from this that the nutrition of a broken bone may he so modified that 
an unusual activity of the periosteum may be excited at points distant from 
the injury, producing spines or stalactitic formations. 
Great redundancy of callus (Fig. 647) is frequently met with. Such will 
generally be the case where the fragments have been subjected to much dis- 
turbance, or where there is great overlapping. In the first the excess is the 
result of irritation ; in the second, of an extraordinary ne- 
cessity. In cases where necrosis takes place after a frac- 
ture, a great excess of new bone will be formed, sometimes 
traversed by numerous openings, and often incarcerating 
the dead portions. This condition will be met with in 
compound and in comminuted fractures. 
The same excessive formation of callus is frequently wit- 
nessed after gunshot fractures. This is especially noticeable 
when the bone is both broken and fissured. In such cases 
nature makes unusual attempts to bind together the severed 
pieces; the periosteum is stimulated to great activity, even 
at points quite remote from the injury, and, in consequence 
of this, shapeless masses of disorderly-arranged ossific mat- 
ter rise from the bone, often sending long spines into the 
midst of the overlying soft parts. (Fig. 648.) 
Callus may undergo absorption. This constitutes one of 
the causes of false joint. This may result from premature 
movement, long-continued anodyne lotions, or such an 
amount of compression by bandages as interferes with 
the easy transit of blood through the venous and arterial 
trunks of the part. Generally there is a constitutional 
cause at work to effect its removal. Yery recently I saw 
a case in which a fracture of the thigh of six weeks’ stand- 
ing, and which had become quite solid, lost its callus and 
again became movable. The cause was doubtless due to 
a low febrile condition, with mental aberration, referable 
to chronic alcoholism. As the patient improved, reunion 
again took place. Mercurial ptyalism occurring in the 
course of repair, there is reason to believe, may not only arrest the growth 
of the callus, but also cause the absorption of what has been already formed. 
Fig. 647. 
Redundant callus about 
a united fracture of the 
femur with overlapping. 
Fig. 648. 
Exuberant callus following a gunshot wound of the upper third of the femur.—Army Medical Museum. 
So also any cause, either therapeutic or dietetic, which destroys the proper 
constitution of the blood and renders it unfit for the food of the tissues, may 852 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
favor the same result. One of the most remarkable of the various effects of 
scurvy on the crew accompanying Lord Anson was the dissolution of the 
union of old fractures. 
In order to treat such cases a careful inquiry must be instituted to deter- 
mine the cause. If the patient is deficient in vigor, mineral tonics should 
be administered, with improved diet, including a free use of vegetables; if a 
scorbutic condition is suspected, all bandages or splints which unduly con- 
strict or press the limb should be removed, and brisk friction with stimu- 
lating liniments be employed. 
Brittleness forms another disease of callus, in wThich there is a defect in the 
proper relation between the animal and the saline constituents of the bone, the 
latter being in excess. For its explanation we must invoke a constitutional 
state,—a cachexia, induced by cancer, syphilis, etc. In those persons who 
suffer from fragility of the skeleton, exposing them to fractures on the recep- 
tion of the most trivial injury, the callus following will partake of the same 
vice. I know of no remedy for such a condition but good diet, fresh air, and 
extraordinary care. 
Sensitive callus.—As we frequently have painful cicatrices in the soft parts, 
so callus, which is the cicatrix of bone, may be the seat of great suffering, in 
consequence of undue pressure upon an adjacent nerve-trunk. 
Paralysis.—When the pressure upon a nerve is great, there may follow not 
only weakness, but even complete paralysis, in the group of muscles supplied 
by its branches. Such effects are witnessed in the 
wrist-drop which occasionally follows fracture of the 
humerus near the point where the musculo-spiral 
nerve winds round the bone; also in the loss of the 
power of flexing and abducting the foot sometimes 
witnessed after fracture of the upper part of the 
fibula. (Fig. 649.) 
We should distinguish between that painful condi- 
tion of a limb which follows a restored fracture, and 
which is so often modified by changes in the weather, 
and that pain which is localized in the callus itself. 
The first seems to be of a rheumatic nature, and will 
often yield to anti-rheumatic remedies, such as the 
iodide of potash, colchicum, or electro-galvanism. I 
have seen a painful state of the limb so severe as to 
lay the patients aside for months follow fractures of 
the fibula after the fragments were consolidated. 
The suffering which is sometimes experienced when 
the callus is exuberant is due in part to the congestion 
of the surrounding soft parts, and is often accom- 
panied with a change in their color and temperatui’e. 
The ancients recognized such conditions, and devoted 
much time to their treatment. The tendency, of 
course, when the union is firm, is to absorption of 
the redundant mass, and we may therefore be content 
with stimulating and anodyne lotions. If the distress 
continues persistent, successive blisters will often be 
found to have the happiest effect. Should these fail, 
and the callus remain undiminished, the mass may be 
drilled, in order to favor its absorption, or be removed by the knife and 
chisel. 
Sometimes when the callus is very voluminous there will be found in it a 
central cavity, perhaps associated with a fracture imperfectly united. Such 
cases are furnished by Guyot.* These, if the suffering is gi'eat, should be 
treated by transfixion with the gimlet, and by rest, as described under the 
head of ununited fractures 
Fig. 649. 
Foot-drop from pressure by 
callus on the peroneal nerve 
after fracture of the upper part 
of the fibula. 
* Archives de M6decine, February, 1836. FRACTURES TREATED AT THE PENNSYLVANIA HOSPITAL. 
853 
Table of Fractures treated at the Pennsylvania Hospital. 
The late Dr. Norris tabulated the fractures treated in the Pennsylvania 
Hospital during twenty years,—from 1830 to 1850,—making an aggregate of 
2182. Of this number, 1726 were cured, 179 were relieved or were removed 
by friends, and 303 died. The relative frequency of these injuries will be seen 
in the table containing the general summary. Taking up the subject where 
Dr. Norris left it, Dr. De Forrest Willard, with the assistance of Dr. R. H. 
Alison, has collected and arranged, as exhaustively as the records allowed, 
all fractures received and treated in that institution down to 1874. 
The following table contains an aggregate of 6485 fractures, not including 
those of Norris. Of this number, 4950 were cured, 393 relieved, 249 un- 
known, and 893 died. So far as noted, 5128 were males and 1043 females; 
2122 were recorded as occurring on the right side, and 2231 on the left. The 
nature of the fractures was as follows: 4932 were simple, 213 were simple 
comminuted, 792 were compound, 532 were compound comminuted, and 16 
were undetermined. The largest number of fractures—1464—occurred 
between the ages of twenty and thirty; the next largest number—1300— 
between thirty and forty. The most material deviation from these ages 
existed in reference to fracture of the ribs,—57 out of the 221 injuries of 
this kind having taken place between forty and fifty. This exception to 
the general rule will be readily explained by the ossification in the car- 
tilaginous connection of the costal arches with the sternum, which exists at 
this time of life, and which, from the loss of elasticity, necessarily renders 
them less able to resist injury. 
The fatality following fractures of the skull is very noticeable among the 
figures in the table. Of 195 instances of this injury, 79 died, or 40 per cent. 
In 16 cases the trephine was used, of which number 8 died. Dr. Norris’s 
collection embraced 110 cases of skull fractures, with 67 deaths, a mortality 
of 41 per cent. 
If to the 6485 cases of Willard there be added the 2182 of Norris, we have 
an aggregate of 8667 fractures, with 6676 cures, 1196 deaths, and 815 cases 
in which the result was undetermined.* 
The relative frequency of these fractures in different portions of the 
skeleton is as follows : 
Willard. 
Norris. 
Total. 
Willard. 
Norris. 
Total. 
Tibia and fibula 
1074 
367 
1441 
Hand 
69 
212 
Femur 
885 
296 
1181 
Foot 
120 
52 
172 
Radius 
777 
208 
985 
Patella 
106 
42 
148 
Humerus 
765 
203 
968 
Pelvis 
80 
14 
94 
Clavicle 
508 
188 
696 
Scapula 
54 
28 
82 
Radius and ulna 
477 
122 
599 
Vertebrae 
48 
25 
73 
Tibia 
315 
122 
437 
Nose 
30 
23 
53 
Fibula 
315 
122 
437 
Superior maxilla. 
24 
24 
Ribs 
221 
88 
309 
Face 
10 
10 
195 
110 
305 
Sternum 
7 
6 
13 
Ulna 
172 
46 
218 
Hyoid 
l 
Inferior maxilla 
158 
51 
209 
Taking the bones of different regions collectively, the relative proportion 
of fractures is as follows: lower extremity, 45 per cent.; upper extremity, 
44 per cent.; head, 6 per cent.; trunk, 5 per cent. 
* The total number of cases of fracture received into the Pennsylvania Hospital amounts at 
present (1889) to 17,561. 854 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Table of Fractures treated at the Pennsylvania 
(Abbreviations.—S., simple. S.C., simple comminuted. 
Bone. 
Form. 
Position. 
Age. 
Sex. 
Side. 
Result. 
195 
s 
39 
59 
23 
M.. 178 
R 
49 
79 
s.c.. 
10 
5 
33 
F... 17 
L 
56 
c 
89 
Front., ethmoid, and sphenoid 1 
“ 20 “ 30.. 
59 
U 
90 
C.C.. 
57 
Parietal 
37 
“ 30 “ 40.. 
35 
195 
— 
— 
Parietal and temporal 
2 
“ 40 “ 50.. 
21 
195 
195 
Temporal 
18 
“ 50 “ 60.. 
13 
Temporal and frontal 
2 
“ 60“ 70.. 
9 
Occipital 
4 
“ 70 “ 80.. 
2 
Occipital and parietal 
3 
— 
Occipital, parietal, and temp. 
l 
195 
“ Base” 
13 
“ Skull” 
50 
195 
Nasal 
30 
s 
. 10 
Under 10 yrs... 
M.. 27 
R 
3 
Cured 
27 
S.C.. 
. 4 
From 10 to 20.. 
. 5 
F... 3 
1, 
7 
Relieved 
3 
c 
. 12 
“ 20“ 30.. 
. 13 
— 
U 
9 
— 
C.C.. 
. 4 
“ 30 “ 40.. 
.. 7 
30 
Both. 
11 
30 
30 
30 
30 
Bone not given. 
R 
3 
Cured 
3 
L 
2 
Unknown 
2 
5 
5 
Zygoma 
1 
s 
. 1 
Parietal also fractured. 
From 20 to 30.. 
.. 1 
M.. 5 
Both. 
1 
Died 
l 
Malar 
4 
c 
. 2 
“ 30 “ 40.. 
. 3 
U 
4 
Cured 
4 
C.C.. 
. 2 
“ 70 “ 80.. 
. 1 
— 
— 
5 
— 
5 
5 
5 
5 
Sup. maxilla. 
. 24 
s 
. 5 
Alveolar process 
6 
Under 10 yrs... 
.. 5 
M.. 21 
R 
5 
Cured 
19 
c 
. 9 
Unrecorded 
18 
From 10 to 20.. 
.. 1 
F... 3 
L 
5 
Died 
5 
C.C.. 
. 10 
— 
“ 20 “ 30.. 
. 6 
— 
U 
14 
— 
24 
“ 30 “ 40.. 
.. 8 
24 
— 
24 
24 
“ 40 “ 50.. 
.. 4 
24 
24 
Inf. maxilla.. 
158 
s 
. 74 
Symphysis 
44 
Under 10 yrs... 
.. 5 
M.. 147 
R 
50 
Relieved and 
S.C.. 
. 7 
Body 
25 
From 10 to 20.. 
.. 27 
F... 11 
L 
34 
cured 
150 
c 
. 58 
Angle 
24 
“ 20 “ 30.. 
. 66 
— 
Centre 44 
Deaths 
8 
C.C.. 
19 
Alveolus 
2 
“ 30 “ 40.. 
. 36 
158 
U 
30 
— 
Ramus 
7 
“ 40 “ 50.. 
. 17 
— 
158 
158 
Condyles 
2 
“ 50 “ 60.. 
. 6 
158 
Unrecorded 
54 
“ 60 “ 70.. 
. 1 
158 
158 
Vertebrae 
48 
. 5 
M.. 46 
C.C.. 
1 
“ 20 “ 30.. 
. 17 
F... 2 
2d cerv. and 1st dorsal... 
1 
“ 30 “ 40.. 
. 13 
48 
4th 
3 
“ 40 “ 50.. 
. 9 
48 
6th 
2 
“ 50 “ 60.. 
. 3 
1st, 5th, and 6th 
1 
“ 60 “ 70.. 
. 1 
4th, 5th, and 6th 
1 
— 
5th and 6th 
1 
10 
48 
Dorsal: 
2d, 4tl), 5th, and 12th... 
1 
5th 
1 
5th and 6th 
1 
7th 
1 
9th, 10th, and 11th 
1 
10th 
1 
11th and 12th 
1 
12 th 
5 
Unrecorded 
4 
16 
Lumbar: 
ISt 
1 
2d 
1 
1st and 2d 
1 
Unrecorded 
3 
6 
Sacrum 
2 
Unrecorded 
14 
48 
Manubrium 
1 
. 3 
M.. 7 
Deaths 
2 
Manubrium and gladiolus 
4 
“ 30 “ 40.. 
. 2 
Body 
2 
“ 60 “ 70.. 
. 2 
7 
7 FRACTURES TREATED AT THE PENNSYLVANIA HOSPITAL. 
855 
Hospital from January 1, 1850, to January 1, 1874. 
C., compound. C.C., compound comminuted. U., unrecorded.) 
Trephining. 
Deaths after trephining. 
Other deaths, causes of. 
Principal occupations. 
C.C 
. 11 
C.C 8 
Compression (C.C., 7; C., 10; S.C, 3 
S., 7) 27 
Laborers 
C 
. 4 
Cause: 
“Injuries” (C.C., 6; C.,3; S.C., 1; 
S., 4).. 14 
Seamen 
.... 10 
s 
. 1 
Cerebritis 2 
Meningitis (C.C., 7; C., 2) 
9 
School-children 
.... 10 
6 
..... 9 
Unrecorded 5 
Shock (C., 2; S.C., 1; S.,2)... 
5 
Drivers 
.... 7 
4 
.... 5 
Hernia cerebri (C.C., 3) 
3 
Railroad-men 
.... 5 
2 
.... 4 
Erysipelas (C.. 1) 
1 
Factory-hands 
.... 6 
— 
Errand-boys 
.... 4 
(C.C., 28; C., 23; S.C., 5; S., 15)... 
71 
None 
Laborers 
11 
Drivers 
.... 4 
Hostlers 
.... 2 
.... 5 
Mania a potu (C.C., 1 ; C., 1) 
2 
Laborers 
4 
Exhaustion 
3 
Drivers 
.... 2 
— 
Railroad-men 
.... 2 
5 
Mania a potu 
2 
Laborers 
.... 45 
Tetanus 
1 
Drivers 
.... 8 
Shock 
Seamen 
.... 7 
Pyaemia 
1 
Servants 
. ... 7 
(Edema of glottis 
1 
Railroad-men 
.... 5 
Pneumonia 
1 
Hostlers 
.... 5 
— 
Boatmen 
.... 4 
8 
Miners 
4 
“Injuries” 
3 
Laborers 
.... 17 
Shock 
3 
Drivers 
.... 3 
4 
.... 2 
2 
2 
2 
2 
Unrecorded 
13 
Carpenters 
2 
27 
* 
1 
.... 4 
1 
.... 1 
Plumber 
.... 1 
2 INJURIES AND DISEASES OF THE 
OSSEOUS SYSTEM. 
Table of Fractures treated at the Pennsylvania 
Bone. 
Form. 
Position. 
Age. 
Sex. 
Side. 
Besult. 
Bibs 
221 
S 212 
1st to 12th 
.... 1 
Under 10 yrs.... 
3 
M.. 196 
B 
.... 71 
Deaths 
.. 24 
S.C... 8 
1st and 3d 
.... 1 
From 10 to 20... 
11 
F... 25 
L. 
... 66 
C 1 
1st and 4tli 
.... 1 
“ 20 “ 30... 
36 
— 
U. 
... 84 
— 
2d and 3d 
.... 1 
“ 30 “40... 
50 
221 
— 
221 
2d, 3d, 4th, 5th, 6th, 7th 
.... 1 
“ 40 “ 50... 
57 
221 
2d 
.... 1 
“ 50 “60... 
36 
2d, 3d, 4th 
.... 2 
“ 60 “ 70... 
21 
3d 
.... 3 
“ 70 “ 80... 
6 
3d, 4th, 5th 
.... 3 
“ 80 “90... 
91 
3d, 4th, 5th, 6th 
.... 1 
— 
3d and 4th 
... 1 
221 
4th 
.... 5 
4th and 5th 
.... 2 
4th, 5th, 6th 
... 1 
4th, 5th, 6th, 7th, 8th ... 
.... 2 
5th 
.... 2 
5th and 6th 
.... 6 
5th, 6th, 7th, 8th 
.... 2 
5th, 6t,h, 7 th 
.... 3 
5th, 6th, 7th, 8th, 9th, 10th. 1 
6th 
.... 3 
6tli and 7th 
.... 4 
6th, 7 th, 8th 
.... 6 
6th. 7th, 8th, 9th 
.... 4 
7th 
.... 4 
7th and 8th 
.... 4 
7th, 8th, 9th 
.... 7 
7th. 8th, 9th, 10th 
.... 2 
8th 
.... 5 
8th and 9th 
.... 4 
8th and 11th 
.... 1 
8th, 9th, 10th 
.... 5 
9th 
.... 7 
9th and 10th 
.... 3 
9tli, 10th, lltli 
.... 1 
10th 
.... 3 
10th and 11th 
.... 3 
10th, 11th,12th 
.... 1 
11th 
.... 4 
12th 
.... 4 
Costal cartilage 
... 1 
Unrecorded 
.... 105 
221 
Clavicle 
508 
S 470 
Outer third 
.... 178 
Under 10 vrs.... 
45 
M.. 422 
B. 
.... 163 
Cured 
447 
S.C... 28 
.... 179 
84 
F... 86 
1.. 
... 203 
. 52 
C 8 
Inner third 
.... 16 
“ 20 “30... 
146 
U 
.... 142 
Died 
. 9 
C.C.. 2 
Unrecorded 
.... 135 
“ 30 “40... 
94 
508 
— 
— 
— 
— 
“ 40 “ 50... 
72 
508 
508 
508 
508 
“ 50 “ 60... 
43 
“ 60 “70... 
10 
“ 70 “ 80... 
12 
“ 80 “90... 
1 
“ 90 “ 100. 
1 
508 
Scapula 
54 
S 49 
Body 
.... 9 
Under 10 yrs.... 
2 
M.. 48 
B 
.... 19 
Cured 
45 
SC... 2 
Acromion 
.... 12 
From 10 to 20... 
4 
F... 6 
L 
.... 20 
Believed 
. 6 
C 2 
Spine 
.... 10 
“ 20 “ 30... 
14 
— 
U 
.... 15 
Died 
3 
C.C.. 1 
Inferior angle 
.... 4 
“ 30 “40... 
10 
54 
— 
— 
— 
Superior angle 
.... 1 
“ 40 “50.. 
15 
54 
54 
54 
Neck 
.... 5 
“ 50 “ 60... 
5 
Glenoid 
.... 1 
“ 60 “ 70... 
3 
Coracoid 
.... 1 
“ 70 “80... 
1 
Unrecorded 
.... 11 
— 
— 
54 
54 
Humerus 
765 
S 620 
Anatomical neck 
22 
Under 10 yrs.... 
118 
M.. 657 
B 
.... 255 
Cured 
647 
S.C... 36 
Surgical neck 
42 
From 10 to 20... 
219 
F... 108 
L 
... 286 
Believed 
. 83 
C 61 
“Neck” 
49 
“ 20 “ 30... 
136 
— 
U 
.... 224 
Died 
. 35 
C.C.. 48 
“ Head” 
14 
“ 30 “ 40... 
98 
765 
— 
— 
Upper epiphysis 
1 
“ 40 “50... 
63 
765 
765 
765 
“ Upper portiou” 
80 208 
“ 50 “ 60 .. 
73 
% 
Middle third 
“ 60 “ 70... 
35 
Condyle 
81 
“ 70 “ 80... 
18 
Inner condyle 
76 
“ 80 “90... 
5 
Outer condyle 
40 
— 
Epiphysis 
6 
765 
“Lower third” 
97 300 
Unrecorded 
.... 124 
765 FRACTURES TREATED AT THE PENNSYLVANIA HOSPITAL. 
857 
Hospital from January 1. 1850, to January 1, 1874. 
Amputations. 
Deaths after amputation. 
Other deaths, causes of. 
Principal occupations. 
Shock 
Laborers 
.... 69 
Mania a potu 
Housewives 
... 17 
Pyaemia 
Drivers 
.... 9 
Peritonitis 
Carpenters 
... 7 
Hemorrhage 
6 
Injury to lung 
Peddlers 
... 5 
Pneumothorax 
Masons 
... 4 
Empyema 
Miners 
.... 4 
Unrecorded 
Boatmen 
.... 3 
24 
Exsection for gun- 
Injuries (S.O., 1; S., 2) 
3 
Laborers 
.... 152 
shot injury, com- 
Mania a potu (S.C., 1) 
1 
School-children 
.... 49 
pound 1 
Pleuro-pneumonia (0.0., 1) 
1 
Young children 
... 15 
1 
3 
Pyaemia (C., 1) 
Housewives 
... 43 
Old age (C., 1) 
Drivers 
... 16 
Unrecorded (S., 1) 
1 
Factory-hands 
... 14 
— 
Seamen 
.... 14 
(C.C., 1; C., 2; S.C., 2; S., 4) 
9 
Shoemakers 
... 7 
Machinists 
... 5 
1 
.... 20 
Shock (S., 1).. . ..' !...'. 
1 
Factorv-hands 
... 2 
Unrecorded (S., 1) 
1 
Drivers 
.... 2 
— 
Sewing-women 
... 2 
* 
(C.C., 1; S., 2) 
3 
C.C 25 
Shock (C.O., 3; C., 1) 4 
Shock (C.O., 4; 0., 2) 
6 
Laborers 
... 125 
C 12 
Pyaemia (C.C., 3) 3 
Injuries (C.C., 1 ; C., 2; S., 1) 
4 
School-children 
... 126 
S.0 1 38 
Exhaustion (O.C., 3) 3 
Exhaustion (0.0., 2; S., 2) 
4 
Small children 
... 27 
Resection 4 
Secondary hemorrhage 
Pyaemia (C., 1; S.C., 1) 
2 
Housewives 
... 45 
Died 1 
(0., 1) 1 
Gangrene (C.C., 1; S., 1) 
2 
Factory-hands 
... 27 
Secondary hemorrhage (C., 1) 
1 
Drivers 
... 23 
(C.C.,9; C.,2) 11 
Concussion (S., 1) 
1 
Carpenters 
... 23 
... 13 
Old age (S., 1) 
1 
Errand-boys 
... 13 
Unrecorded (C.C., 1; S., 1) 
2 
(C.C., 9; C., 6; S.C., 1; S., 8) 
.... 24 858 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Table of Fractures treated at the Pennsylvania 
Bone. 
Form. 
Position. 
Age. 
Sex. 
Side. 
Result. 
777 
S 733 
Upper third 
24 
Under 10 yrs.... 
33 
M.. 477 
R. 
.... 278 
Cured 
703 
S.C.. 6 
Middle third 
53 
From 10 to 20.. 
153 
F... 300 
L. 
... 264 
Relieved 
66 
C 21 
Lower third, including 
“ 20 “ 30.. 
143 
— 
U. 
.... 235 
Died 
8 
C.C.. 10 
“ Barton’s” 
230 
“ 30 “ 40.. 
150 
777 
— 
— 
U.... 7 
“ Colles’ ” 
141 
“ 40 “ 50.. 
125 
777 
777 
“Smith’s” 
14 
“ 50 “ 60.. 
106 
777 
“ Lower portion” 
186 
571 
“ 60 “ 70.. 
40 
Unrecorded 
129 
“ 70 “ 80.. 
16 
— 
“ 80 “ 90.. 
2 
777 
Unrecorded 
9 
777 
Ulna 
172 
S 124 
Upper third, including 
Under 10 yrs.. 
18 
M.. 148 
R 
.... 74 
Cured 
. 153 
S.O... 4 
.. 52 
From 10 to 20.. 
34 
F... 24 
L. 
... 59 
. 16 
C 34 
Coronoid 
.. 3 
“ 20 “ 30.. 
43 
U. 
... 39 
Died 
. 3 
O.C.. 10 
“Upper” 
.. 27 
82 
“ 30 “ 40.. 
27 
172 
— 
— 
— 
Middle third 
32 
“ 40 “ 50.. 
24 
172 
172 
172 
Lower third 
29 
“ 50 “ 60.. 
14 
Unrecorded 
29 
“ 60 “ 70.. 
7 
“ 70 “ 80.. 
2 
172 
Unrecorded 
3 
172 
Radius and 
S 357 
Upper third 
39 
Under 10 yrs... 
53 
M.. 395 
R. 
... 176 
Cured 
. 408 
ulna 
477 
S.C... 5 
Middle third 
147 
From 10 to 20.. 
180 
F... 82 
L. 
... 154 
Relieved 
. 44 
0 57 
125 
“ 20 “ 30.. 
99 
IT 
... 147 
. 25 
C.C.. 54 
Unrecorded 
166 
“ 30 “ 40.. 
58 
477 
U.... 4 
— 
“ 40 “ 50.. 
33 
477 
477 
— 
477 
“ 50 “ 60.. 
31 
477 
“ 60 “ 70.. 
7 
“ 70 “ 80.. 
7 
“ 80 “ 90.. 
3 
Unrecorded 
6 
477 
Hand 
143 
S 37 
Carpus 
9 
Under 10 yrs .. 
2 
M.. 137 
R. 
... 22 
Cured 
. 99 
S.C.. 2 
Metacarpus 
53 
From 10 to 20. 
43 
F... 6 
L. 
.... 31 
Relieved 
. 17 
C... . 75 
Phalanges 
44 
“ 20 “ 30.. 
50 
— 
U 
.... 90 
Died 
. 8 
C.C.. 29 
Thumb 
17 
“ 30 “ 40.. 
25 
143 
— 
Unrecorded.... 
. 19 
— 
Unrecorded 
20 
“ 40 “ 50.. 
14 
143 
— 
143 
— 
“ 50 “ 60.. 
7 
143 
143 
“ 60 “ 70.. 
2 
143 
80 
S 58 
33 
3 
M.. 76 
T? 
.... 24 
. 49 
S.C.. 5 
Acetabulum 
10 
From 10 to 20.. 
9 
F... 4 
L. 
... 17 
Died 
31 
C 4 
Pubis 
5 
“ 20 “ 30.. 
24 
— 
U. 
... 39 
— 
C.C.. 8 
Ischium 
2 
“ 30 “ 40.. 
11 
80 
80 
U 5 
Unrecorded 
30 
“ 40 “ 50.. 
15 
80 
— 
— 
“ 50 “ 60.. 
10 
80 
80 
“ 60 “ 70.. 
4 
“ 70 “ 80.. 
1 
Unrecorded 
3 
80 
Femur 
885 
S 752 
Neck 98 
Under 10 yrs .. 
152 
M.. 745 
R 
.... 349 
Cured 
601 
S.O... 20 
Anatomical neck.. 2 
From 10 to 20.. 
164 
F... 140 
L. 
... 391 
Relieved 
. 44 
C 64 
Surgical neck 2 
“ 20 “ 30. 
149 
— 
D. 
... 145 
Died 
111 
C.C.. 49 
“Extra-capsular”. 16 
“ 30 “ 40.. 
125 
885 
— 
Unrecorded 
129 
— 
“ Intra-capsular”.. 49 
167 
“ 40 “ 50.. 
89 
885 
— 
885 
Trochanter 
4 
“ 50 “ 60.. 
76 
885 
Upper third 
119 
290 
“ 60 “ 70.. 
62 
• 
Middle third 
269 
“ 70 “ 80.. 
34 
• 
Condyles 
15 
“ 80 “ 90.. 
17 
External condyle 
2 
Unrecorded 
17 
Internal condyle 
1 
— 
Epiphysis 
4 
885 
“Lower third” 
129 
151 
Unrecorded 
175 
885 
106 
S 86 
From 10 to 20.. 
1 
M.. 96 
R. 
.... 38 
96 
S.C.. 8 
“ 20 “ 30... 
36 
F... 10 
L. 
... 45 
Relieved 
2 
C 7 
“ 30 “ 40.. 
24 
— 
U. 
... 23 
Died 
8 
C.C.. 5 
“ 40 “ 50... 
25 
106 
— 
“ 50 “ 60 .. 
16 
106 
106 
106 
“ 60 “ 70... 
1 
“ 70 “ 80... 
2 
“ 80 “ 90... 
1 
106 FRACTURES TREATED AT THE PENNSYL VANIA HOSPITAL. 
859 
Hospital from January 1, 1850, to January 1, 1874. 
Amputations. 
Deaths after amputation. 
Other deaths, causes of. 
Principal occupations. 
C.O 
1 
.... 1 
C 
1 
Mania a potu (S., 2).....’ 2 
Laborers 
117 
S 
1 
Gangrene (C., 1) 1 
School-children.. 
78 
— 
Hemorrhage (C., 1) 1 
Sewing-women.. 
27 
3 
— 
Factory-hands.... 
20 
Exsection 
(C.C., 1; C., 3; S., 2; S.C., 1) 7 
Seamen 
18 
Washerwomen... 
15 
Drivers 
15 
Carpenters 
15 
Children 
15 
C.C 
3 
Other injuries (C., 2) 2 
Laborers 
38 
c 
3 
Pyaemia (0., 1) l 
School-children.. 
26 
— 
— 
Housewives 
11 
6 
(C, 3) 3 
Factory-hands.... 
8 
Resection 
1 
Washerwomen... 
6 
Miners 
4 
C.C 
29 
Pyaemia (C.C., 2) 
.... 2 
Pyaemia (C.C., 3; S., 1) 4 
School-children.. 
94 
c 
9 
Exhaustion (C.C., 3).. 
.... 3 
Mania a potu (S., 2) 2 
Laborers 
71 
s 
3 
Other injuries (C.C., 1)... 1 
Tetanus (C.C., 1; C., 2) 3 
Housewives 
49 
— 
Erysipelas (C., 1) 
1 
Gangrene (C., 1) 1 
Factory-hands... 
36 
41 
— 
Exhaustion (C.C., 1; C., 3; S., 1) 5 
Carpenters 
9 
(C.C., 6; C,l) 
.... 7 
Apoplexy (S., 1) 1 
Errand-boys 
9 
Bright’s disease (S., 1) 1 
Mechanics 
8 
Injuries (C., 1) 1 
(C.C., 5; C., 7; S , 6) 18 
38 
.... 1 
Pyaemia 1 
Factory-hands.... 
10 
Exhaustion 1 
Carpenters 
6 
Phlebitis 1 
Mechanics 
5 
Injuries 2 
7 
Shock 9 
Laborers 
26 
Injuries 3 
Carpenters 
4 
4 
Gangrene 1 
Housewives 
3 
Mania a potu 1 
Seamen 
3 
2 
Pyaemia 1 
Peritonitis 1 
Unrecorded 12 
31 
C.C 
10 
Pyaemia (C.C, 4) 
4 
Shock (0 C., 21; C., 7; S., 3) 31 
School-children.. 
115 
c 
6 
Exhaustion (C.C., 1; 
a, 
Exhaustion (C.C., 1; 0., 5; S., 6; S.C., 1) 13 
Young children.. 
74 189 
s 
3 
1) 
.... 2 
Other injuries (C.C., 2; C., 4; S , 6) 12 
Laborers 
169 
— 
Shock (C., 1) 
.... i 
Mania a potu (C C., 1; S., 11) 12 
Housewives 
74 
19 
Other injuries (0., 1) 
i 
Pyaemia (C.C., 2; C., 5; S., 2) 9 
Seamen 
37 
Unrecorded (C., 1; S., 
1). 2 
Compression of brain (C.C., 1; C.,1; S., 1). 3 
Miners 
23 
21 
(C.C., 6; C., 2; S., 2) 
10 
Tetanus (S., 2) 2 
Drivers 
21 
Chronic meningitis (S.C., 1) 1 
Factory-hands.... 
21 
Erysipelas (S., 1) 1 
Shoemakers 
13 
Peritonitis (S., 1) 1 
Railroad-men 
13 
Debility (S.C., 1) 1 
Painters 
12 
Old age (S., 1) 1 
Machinists 
9 
9 
Osteosarcoma (S., 1) 1 
Seamstresses 
8 
Unrecorded (C., 4; S., 5; S.C., 1) 10 
(C.C., 28; C., 27; S., 41; S.C., 5) 101 
Resection of knee. 
1 
Gangrene following 
re- 
Mania a potu (O.C., 1; S.O., 1; S., 3) 5 
Laborers 
30 
section (C.C., 1) 
i 
Pyaemia (C.C., 1) 1 
Housewives 
7 
Exhaustion (C.C., 1) 1 
Factory-hands.... 
4 
— 
Shoemakers 
4 
(C.C., 3; S., 3; S.O., 1) 7 INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Bone. 
Form. 
Position. 
Age. 
Sex. 
Side. 
Result. 
Tibia 
315 
S 255 
Upper third 
45 
Under 10 vrs... 
31 
M. 278 
R 
.... 123 
Cured 
.. 97 
S.C... 11 
81 
. 61 
F.. 37 
1.. 
... 123 
C 35 
Lower third 
120 
“ 20 “ 
30. 
. 63 
U 
.... 69 
Died 
. 28 
C.C.. 14 
Unrecorded 
69 
“ 30 “ 
40. 
. 77 
315 
— 
Unrecorded.... 
.. 186 
— 
— 
“ 40 “ 
50. 
. 41 
315 
315 
315 
“ 50 “ 
60. 
. 24 
315 
“ 60 “ 
70. 
. 7 
“ 70 “ 
80. 
. 5 
“ 80 “ 
90. 
. 1 
Unrecorded 
5 
315 
Fibula 
315 
S 293 
Upper third 
16 
Under 10 yrs . 
. 9 
M. 273 
R 
.... 113 
Cured 
. 289 
S.C... 8 
Middle third 
26 
From 10 to 20. 
. 32 
F.. 42 
L. 
... 105 
Relieved 
. 15 
C 9 
210 
“ 20 “ 
30. 
. 58 
U 
.. 97 
11 
C.C.. 5 
Unrecorded 
63 
“ 30 “ 
40. 
. 107 
315 
— 
— 
“ 40 “ 
50. 
. 60 
315 
315 
315 
315 
“ 50 “ 
60. 
. 37 
“ 60 “ 
70. 
. 10 
“ 70 “ 
80. 
. 2 
315 
S 654 
Upper third 
70 
Under 10 yrs... 
44 
M. 936 
R, 
.... 366 
. 765 
fibula, 
1074 
S.C... 54 
Middle third 
282 
From 10 to 20. 
. 122 
F.. 138 
L. 
... 381 
Relieved 
. 35 
C 213 
399 
“ 20 “ 
30. 
. 250 
U 
.... 327 
160 
C.C.. 153 
Unrecorded 
323 
“ 30 “ 
40. 
. 277 
1074 
Unrecorded.... 
.. 114 
— 
“ 40 “ 
50. 
. 199 
1074 
1074 
1074 
“ 50 “ 
60. 
. 107 
1074 
“ 60 “ 
70. 
. 55 
“ 70 “ 
80. 
. 14 
“ 80 “ 
90. 
. 6 
1074 
120 
S 38 
7 
8 
M. 118 
R 
.... 40 
. 89 
S.C... 6 
Calcaneum 
14 
From 10 to 20. 
. 23 
F.. 2 
L. 
... 43 
Relieved 
. 8 
C 29 
Tarsus 
25 
“ 20 “ 
30. 
43 
— 
U 
.... 37 
Died 
. 23 
C.C.. 48 
First metatarsal 
.. 7 
“ 30 “ 
40. 
. 28 
120 
— 
Third metatarsal 
... i 
“ 40 “ 
50. 
. 11 
120 
120 
120 
Fourth metatarsal 
.. i 
“ 50 “ 
60. 
4 
Fifth metatarsal 
.. 4 
“ 60 “ 
70. 
2 
“ Metatarsal” 
.. 13 
26 
“ 80 “ 
90. 
1 
Phalanges 
9 
— 
Unrecorded 
39 
120 
120 
Table of Fractures treated at the Pennsylvania FRACTURES TREATED AT THE PENNSYLVANIA HOSPITAL. 
861 
Hospital from January 1, 1850, to January 1, 1874. 
Amputations. 
Deaths after amputation. 
Deaths, other causes of. 
Principal occupations. 
C.C 
3 
Exhaustion (C.C., 1; C., 1) 
2 
Pyaemia (C.C., 1; C., 7; S„ 1) 
9 
Laborers 
.... 72 
C 
6 
Gangrene (C.,1) 
1 
Injuries (C.C., 1; S., 3) 
4 
Children 
... 37 
— 
Pyaemia (C., 1) 
1 
Mania a potu (C., 2; S., 2) 
4 
Drivers 
.... 19 
9 
Anaesthesia (C.C., 1) 
1 
Shock (C., 2) 
2 
Housewives 
... 18 
— 
Exhaustion (C.C., 1; C., 1) 
2 
Sailors 
.... 12 
(C.C., 2; C., 3) 
5 
Erysipelas (C.C., 1) 
1 
Factory-hands 
... 12 
Old age (S., 1) 
1 
(C.C.,4; C„ 12; S., 7) 
23 
C.C 
1 
1 
3 
... 102 
Exhaustion (C., 3) 
3 
Housewives 
... 25 
Shock (C.C.,1; C., 1) 
2 
Drivers 
.... 18 
Tetanus (S., 1) 
1 
School-children 
... 15 
Peritonitis (C., 11 
1 
Factory-hands 
.... 11 
(C.C., 1; C., 5; S., 3 ; S.C., 1) 
10 
C.C 
50 
6 
Shock (C.C., 22; C., 8) 
30 
.... 352 
c 
22 
Pyaemia (C.C., 5; S., 1)... 
6 
Injuries (C.C., 4; C., 6; S., 1; S.C., 1).... 
12 
Housewives 
... 109 
s 
1 
Shock (C.C., 2; C., 2) 
4 
Maniaa potu (C.C., 2 ; C., 2; S., 11; S.C., 4) 
19 
Children 
.... 68 
— 
Injuries (C.C., 2) 
2 
Exhaustion (C.C., 7; C., 8 ; S., 2) 
17 
Seamen 
.... 28 
73 
Secondary hemorrhage 
Pyaemia (C.C., 7 ; C., 7) 
14 
Carpenters 
.... 26 
(C.C., 1) 
1 
Gangrene (C.C., 4; C., 1; S., 1) 
6 
Miners 
.... 23 
Tetanus (C., 1) 
1 
Erysipelas (C.C., 1; C.. 1) 
2 
Drivers 
.... 22 
Gangrene (C., 1) 
1 
Tetanus (C.C.,1; C., l) 
2 
Mania a potu (C.C., 1) 
1 
Debility (C., 1; S., 1) 
2 
Convulsions (C.C., 1) 
1 
Heart disease (S., 2) 
2 
Unrecorded (C.C., 4) 
4 
Cardiac embolism (C., 1) 
1 
— 
Hemorrhage (C.C., 1; C., 1) 
2 
(C.C., 21; C., 5; S., 1) 
27 
Variola (C., 1) 
1 
Unrecorded (C.C., 6; C., 15; S„ 2) 
23 
(C.C., 55; C., 53; S., 20; S.C., 5) 
133 
C.C 
32 
4 
Shock (C C , 1) 
1 
.... 33 
c 
9 
Exhaustion (C.C!, 2 ; C., 1) 
3 
Injuries (S.C!., 1) 
1 
Children 
.... 13 
s.c 
1 
3 
1 
.... 7 
s 
2 
Shock (C.C., !...' 
2 
1 
6 
Erysipelas (C.C., 1) 
i 
Debility (C.C., 1) 
1 
Shoemakers 
.... 5 
Total, 
44 
Injuries (C., 1) 
i 
Mania a potu (C.C., 1) 
1 
Mechanics 
.... 3 
— 
Unrecorded (C.C., 1; C., 2) 
3 
Factory-hands 
.... 3 
5 
(C.C., 11; C., 3) 
14 
.... 3 
Lisfranc 
2 
(C.C.,5; C.,3; S.C.,1) 
9 
Chopart 
1 862 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
General Summary of the Fractures treated in the Pennsylvania Hospital from 
January 1, 1830, to January 1, 1874,—Forty-four Years. 
Bone. 
1830 to 1850. 
Dr. Norris. 
1850 to 1874. 
Dr. Willard. 
Total, Forty- 
four Years. 
Per Cent. 
Cranium 
110 
195 
305 
3.5 
Nose 
23* 
30 
53 
.6 
10 
10 
.011 
Superior maxilla 
24 
24 
.3 
Inferior maxilla 
51f 
158 
209 
2.4 
Hyoid 
1 
It 
.001 
Y ertebrse 
25 
48 
73 
.8 
Ribs 
88 
221 
309 
3.6 
Sternum 
6 
7 
13? 
.1 
Clavicle 
188 
508 
696 
8.1 
Scapula 
28 
54 
82 
.9 
Humerus 
203 
765 
968 
11.2 
Radius 
208 
777 
985 
11.4 
Ulna 
46 
172 
218 
2.5 
Radius and ulna 
122 
477 
5991| 
6.9 
Hand 
69 
143 
212f 
2.5 
Pelvis 
14 
80 
94 
1.1 
Femur 
296 
885 
1181 
13.7 
Patella 
42 
106 
148 
1.7 
Tibia 
122 
315 
437 
5 
Fibula 
122 
315 
437 
5 
Tibia and fibula 
367 
1074 
1441** 
16.7 
Foot 
52 
120 
172ft 
2 
Total 
2182 
6485 
8667 
The number of fractures admitted to the Pennsylvania Hospital up to 
May, 1888, amounted to 17,561. Up to the same date 135 cases of ununited 
fractures had been admitted for treatment. 
SPECIAL FRACTURES. 
Fractures of the Vertebrae. 
When we consider that one of the important offices of the spinal column 
is to furnish a canal for the spinal marrow and foramina for the safe conduct 
of the inoto-sensory nerves to the outstanding organs, it can be no matter 
for surprise that its injuries should prove so grave. Buried deeply though 
the column is, in the midst of very numerous and massive muscles, its com- 
ponents bound together by several articulations and by powerful ligaments, 
yet it is frequently the subject of fracture. 
This injury is produced in three different ways: first, by force directly 
applied to the spine, as when a loaded wagon passes over the prostrate body, 
or when it is crushed beneath a heavy piece of timber; second, by indirect 
force, as where a person falls from a considerable height, alighting upon the 
head, the buttocks, or even the feet; and, third, by extreme flexion of the 
column, as often occurs to quarrymen, upon whom heavy masses of earth 
cave in, bearing the body down under the superincumbent weight. 
Women suffer less frequently from this lesion than men, a fact due to the 
difference in the occupations of the two sexes. Children are rarely the sub- 
jects of fracture of the spine, a fact doubtless to be attributed to the great 
flexibility and elasticity of the column. Gunshot fractures of the spine are 
not uncommon accidents, and are often comminuted in their character. 
Fractures of the vertebrae, according to some authorities, occur with about 
* Face included. 
§ Total trunk, 395. 
** Total leg, 2315. 
f Upper jaw included. 
|| Forearm, 1802. 
fj Total lower extremity, 3910. 
J Total head, 597. 
Total upper extremity, 3760. SPECIAL FRACTURES. 
863 
equal frequency in the cervical and dorsal regions. This does not accord 
with my experience, which would place these injuries, as to frequency, first 
in the dorsal region, second in the lumbar, and last in the cervical. 
The seat of the fracture varies in different cases. It may be in the body, 
in the intervertebral cartilages, in the arches, or in the spinous, transverse, 
or articular processes. 
Diagnosis.—Except in fractures of the spinous processes, where the damaged 
part is entirely accessible to the touch, we cannot affirm the existence of such 
an injury with any degree of The presence of certain symptoms, 
following a sufficient cause, furnishes ground for supposing the existence of a 
fracture, and yet these may all be present without any injury of the kind. The 
prominent symptom is paralysis ; this is due to pressure upon the spinal cord or 
its nerves, and may follow any violence which is sufficiently powerful to rup- 
ture a blood-vessel or to produce inflammatory transudations. If, however, 
the paralysis follows on the instant of injury, is persistent, and especially if 
deformity is the presumption is that a fracture exists, and that the 
cord is or has been subjected to pressure from a displaced portion of bone. 
I say has been, inasmuch as in very many cases there is no permanent 
pressure on the cord, the fragment which inflicted the lesion having been 
only momentarily in contact with it, and rebounding as soon as the force of 
the blow was expended. 
If the paralysis is developed only after sevei’al hours, and no deformity or 
preternatural mobility is discoverable, it may be that the concussion has pro- 
duced a lesion of some of the vessels within the canal, and the gradual leakage 
of blood at last makes sufficient compression on the cord to suspend its func- 
tions. There is reason, however, to believe that such effusions of blood are 
not common. When the paralysis is delayed for days, it will probably be due 
to an inflammatory effusion of serum or of lymph, or to inflammatory soft- 
ening of the cord. 
The medulla spinalis, being attached at either extremity of the canal, may 
suffer a lesion of its substance by being overstretched in extreme flexion of 
the spinal column, without the latter being broken, and paralysis may follow 
from this cause. 
Fractures of the Spinous Process.—Fractures of the spinous processes are 
the least dangerous of these injuries, and can be diagnosed without difficulty, 
in consequence of their superficial situation. Those over the lower half of 
the dorsal part of the column, being imbricated, are less likely to yield than 
those in the cervical, upper dorsal, or lumbar regions, which stand more hori- 
zontally. The force which strikes these processes in a downward or in a lateral 
direction will be most favorable for the production of a fracture. Bound as 
they are to each other by supra- and interspinous ligaments, and with muscles 
placed along either side, not much displacement need be expected, unless the 
force has been of a crushing nature. The direction of the fracture is usually 
transverse. (Fig. 650.) 
Symptoms.—Pain is experienced in the part, the detached apophysis can be 
taken between the thumb and the finger and moved, and the crepitus may be 
felt during such manipulations. When the body is bent forward, the tendency 
to separate the processes from each other, together with the tension of the 
integuments, increases the deformity and aggravates the suffering. When 
the trunk is extended and pressure is applied over the seat of injury, there 
will appear a hollow space, or deficiency, in the line of the spine. In addition 
to the foregoing symptoms there will often be discoloration of the superin- 
cumbent soft parts. 
Prognosis.—Should the case progress a few days without any symptom 
of injury to the cord, such as paralysis, a favorable termination may be ex- 
pected. If the reduction is accurate, union will take place; although cases 
are recorded where a false joint was formed. In a case which I had under 
care, occurring in a young man, the detached portion remained for several 864 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
months movable, finally became ’necrosed, and was discharged through a 
sinus. 
Treatment.—If the process is displaced, it should be adjusted, provided it 
does not assume a proper position when the body is in position. The muscles 
are competent in some cases to effect a spontaneous reduction after recovering 
from their temporary paralysis, the consequence of the injury. The patient 
should be placed in the recumbent position, on the back, upon a firm mattress, 
and with a low pillow under the head. A lotion of lead-water and laudanum 
should be applied over the seat of injury. If the pain is persistent, a few 
leeches may be applied with advantage over the seat of fracture. 
Fracture of the Transverse Processes.—Fracture of the transverse processes 
alone is a rare accident, though occasionally met with. The accident is most 
likely to occur at those portions of the spine in which these processes ap- 
proach a right angle with the bodies of the vertebrae. Gunshot fracture of 
these processes has frequently happened. The complications which may fol- 
low the injury are possibly a conjoined fracture of the vertebral extremity 
of the rib in case the accident takes place in 
the dorsal region, or if in the cervical, the 
vertebral artery may be wounded. The frac- 
ture in case of shot wounds will likely prove 
to be comminuted. The treatment in these 
cases will be the removal of the fragments, 
and in case of wound of the vertebral artery, 
ligation of the same at the root of the neck, 
if not accessible at the seat of lesion. 
Fractures of the Vertebral Arches.—The 
arches consist of the pedicles and laminae. 
When we consider the relation of the spinous 
process to the laminae, it is not difficult to 
understand how a force received at the 
summit of the former can be transmitted 
to the latter, so as to sever this part of the arch on either side. The danger 
to the cord in such a fracture is imminent. (Fig. 650.) Even should there 
be no displacement, there will remain the risk of subsequent inflammation. 
Unless, as in the case recorded by Ollivier, the lamina can be felt to move 
by acting on the spinous process, it will be impossible to distinguish such an 
accident from one involving the bodies of the vertebrae, and therefore we may 
consider these injuries with those of the latter. 
Fig. 650 
Fracture of the spinous process, and a 
double fracture of the lamina on one side. 
Fractures of the Bodies of the Vertebrae.—Fractures of the bodies of the 
vertebrae may be produced by falls upon the head, sacrum, or feet; by forced 
flexion of the body under crushing weights, as the falling in of sand-banks; 
or by being caught under scaffoldings. 
I once examined the spine of a patient who jumped from a third-story 
window, alighting directly upon the feet. The os calcis was ground to pieces, 
the tibia extensively broken, and a fracture of the eleventh dorsal and third 
and fourth lumbar produced. 
That violent flexion of the spine enters largely into the modus of such 
injuries there can be little doubt. Malgaigne remarks that there are three 
marked flexible points in the spinal column: 'the first, between the third 
and seventh cervical vertebrae ; the second, between the dorsal and 
the second lumbar ; and the third, between the fourth lumbar and the sacrum. 
These are points where flexibility and inflexibility meet, and near these posi- 
tions fractures most frequently occur. The cases recorded by Ollivier (twelve 
in number), and those of Dupuytren (thirteen in number), with those men- 
tioned by Packard and others, seem to corroborate this author's statement; 
but an analysis of the forty-eight cases contained in the general table of FRACTURES OF THE VERTEBRAE. 
865 
fractures fails to sustain this statement, and, except in the cervical region, 
the same is true in the collection of cases tabulated by Dr. Ashhurst.* The 
direction of these fractures may be transverse, oblique, or vertical, and some- 
times the lines run in different directions, as when the bone is comminuted 
or crushed. There may also be an associated fracture of the arches. When 
the direction is oblique, Malgaigne states (and his word is borne out by the 
observation of others) that the direction is always from above downward, 
and from behind forward, allowing overlapping by the upper fragment 
sliding down, as on an inclined plane, unless checked by the ligaments. 
The cord may be contused and pressed upon, or it may be entirely severed. 
(Fig. 651.) 
Symptoms.—These will he determined by the displacement and by the par- 
ticular section of the column involved. Pain, aggravated on movement, 
and also by pressure ; discoloration and tenderness ; want of correspondence 
in the line of the spinous processes; occasionally deformity of the spine; 
paralysis; disorder of the sexual organs, as manifested by priapism ; an in- 
creased temperature, together wTith 
phosphatic urine, are among the 
symptoms commonly belonging to 
this accident. 
Prognosis.—In all cases of frac- 
ture of the spine the prognosis is 
unfavorable. The circumstances 
to be considered in forming an 
opinion are the region involved, 
the dangers increasing as we as- 
cend the column, in consequence of 
the important organs implicated; 
the amount of injury sustained by 
the cord from contusion or sub- 
sequent inflammation, and from 
sloughing of the soft parts. 
Fig. 651. 
Fractures of the Dorso-Lumbar 
and Lumbar Region.—Fractures 
occurring within the limits of this 
region,—that is, between the tenth 
dorsal vertebra and the sacrum,— 
if attended with displacement, will 
be followed by paralysis of those 
parts which receive their endow- 
ments from the lumbar and sacral 
plexus. The lower extremities 
will become powerless and devoid of sensibility, as. will also the muscles of 
the rectum and the anus, giving rise to incontinence of the faeces. The 
urine, at first retained, soon begins to dribble. There will be also a change 
of temperature; the lower extremities, though quite pale, may exceed 100°. 
One limb may be of a different temperature from the other, and the same 
limb will vary in its heat at different times. The main arterial trunks may 
be full, although the capillaries are comparatively empty. This is due to the 
paralysis of the vaso-motor nerves of the vessels. Yet it is within the limits 
of this region that we have ground to hope for recovery. 
The spinal marrow in the lower part of the dorsal and through the lumbar 
and sacral vertebrae becomes a leash of nerves, the cords of which are sur- 
rounded by a firm fibrous investment, and, sliding freely on one another, they 
glide out of the way of displaced fragments of broken bone, and thus escape 
serious damage. This fact was long since noticed by Dr. Shaw. 
Cooper states that fractures in the lumbar region, with displacement, prove 
Comminuted fracture of the vertebra, in which the spinal 
cord was completely severed. 
* Injuries of the Spine, Ashhurst. 866 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
fatal in from four to six weeks; in the dorsal region, in two or three weeks ; 
in the three lower cervical vertebrae, from the third to the seventh day; and 
above the third vertebra, almost immediately. 
Dupuytren* gives two cases at the Hotel-Dieu,—one a fracture of the tenth 
vertebra in a male, and the other at the lower part of the dorsal region in a 
female,—in which the patients, after some months’ confinement, both recov- 
ered, although partial paralysis was present. 
In the London Hospital Reports,f five cases of fracture in the lower dorsal 
and lumbar regions, with paralysis, are reported, all the patients recovering 
in from four to six months. 
Lente and each give an instance of recovery after fracture of 
the lower dorsal vertebrae, with paraplegia, after six months’ convalescence. 
Malgaigne§ treated a case at the Hopital des Cliniques, in 1843, in which a 
lumbar vertebra was broken, accompanied with paraplegia; the patient re- 
covered, and the paralysis passed gradually away. 
Dr. Shaw|| furnishes four cases of fracture in the mid-lumbar region, with- 
out paralysis, all of whom recovered. 
Quite a number of cases of prolonged life after very severe fractures, at- 
tended with displacements in this region, might be collected. 
Mr. Key records the of a boy with a fracture of the first lumbar 
vertebra, who survived an entire year, notwithstanding the fact that the 
cord was divided across. 
Mr. Birch** had a case which lived over two years, and finally died from 
gangrene of the nates. 
The same authorff relates the case of Mr. Harrold, in which the patient, a 
man twenty-eight years of age, fractured his first and second lumbar vertebrae. 
A fragment had transfixed the theca vertebralis, followed by paralysis of the 
bowels and bladder. The patient survived the injury nearly one year, and 
finally died of a slough over the nates. 
Mr. Hutchinson reports a case|j; of a fractured lumbar vertebra in which 
the cauda equina was raised one-third of an inch by a displaced fragment, 
without other injury. 
Mr. Le Gros Clark gives a very remarkable case§§ of a fracture of the 
fourth lumbar vertebra at its pedicles on each side, with comminution of all 
its processes, so that its body assumed a position in front of the fifth ver- 
tebra, the upper and lower surfaces of these vertebrse being on the same 
plane; and although there was complete paraplegia succeeding the accident, 
in five weeks sensation was restored completely, and motion to some extent. 
Death occurred in the seventh week. 
In a case of fracture of the last dorsal vertebra, which I saw several years 
ago, and in which the paralysis of the lower extremities was complete, the pa 
tient recovered sufficiently to make a sea-voyage, and I believe is still living. 
A young man was caught at the Kensington Depot, Philadelphia, between 
the platform and a car, and notwithstanding the spinal cord was completely 
severed in the mid-dorsal region by a permanently displaced vertebra, yet 
he survived the accident six months, perishing at last from sloughing of the 
nates. (Fig. 651.) 
Fractures of the Dorsal Vertebrae.—As we ascend the vertebral column, the 
spinal canal becomes smaller, particularly in the middle third of the dorsal 
region. In the ordinary movements of the body this division of the column 
* Dupuytren, pp. 356, 357, translation by F. Le Gros Clark. 
I London Hospital Reports, 1840, p. 326. 
American Journal of the Medical Sciences, October, 1857, p. 361. 
$ Malgaigne’s Treatise on Fractures, p. 342, by Packard. || London Medical Gazette, vol. xvii. 
<|[ Cooper on Dislocations and Fractures, p. 467, American edition. 
** Ibid., p. 388. ft Ibid-, p- 390. 
London Hospital Reports, vol. iii. p. 360. 
Lecture on the Principles of Surgical Diagnosis, by Mr. F. Le Gros Clark, British Medical 
Journal, Oct. 3, 1863. FRACTURES OF THE VERTEBRAE. 
867 
is least disturbed, and hence no necessity exists for a canal more capacious 
than is necessary for the lodgement of the cord, but when this part of the 
spine becomes the subject of fracture, for the same reason.—that is. the 
smallness of the canal,—the danger to the medulla spinalis is imminent. 
Viewing the subject from both an anatomical and a physiological stand- 
point, we shall confine ourselves to those fractures which occur between the 
eleventh and the second dorsal vertebra. Every step that we ascend in this 
region an additional section of the body is involved. We not only have 
paraplegia,—loss of power in the rectum and bladder,—but paralysis of the 
abdominal muscles, as well as of the muscular coat of the intestines. This 
state of the walls of the abdomen renders it needful to enforce a caution 
against turning the patient on the breast for examination, as, through the 
want of resistance on the part of the abdominal muscles, the viscera may be 
thrust up against the diaphragm, and by preventing its descent arrest the 
respiration. 
When this portion of the column is the seat of fracture and the cord is 
compressed, there is generally a difficulty of breathing or a sense of suffoca- 
tion. This is due to the imperfect manner in which the act of expiration is 
accomplished. It is common to hear it stated that expiration is a passive 
act, depending on the elasticity of the thoracic walls; but, if so, why should 
this difficulty in breathing be experienced, after these fractures ? Expiration 
is both passive and active, and the difficulty witnessed in these cases must 
be referred to the loss of power, by paralysis, of the abdominal muscles,—the 
serratus posticus inferior, quadratus lumborum, sacro-lumbalis, and longis- 
simus dorsi muscles, which are concerned in the expiratory act; the distention 
of the intestines with gas, giving rise to tympany, tends also to increase the 
difficulty of breathing, by causing pressure against the diaphragm. Another 
distressing attendant of these cases is the tendency to form sloughs over 
those portions which sustain the pressure of the body, as the nates, the parts 
over the sacrum, and even the hard tissues of the heel. 
The nearer the fracture approaches the upper limits of this region, namely, 
to the second dorsal vertebra, the greater will be the embarrassment to respi- 
ration, as a larger number of the intercostal muscles are involved in the 
paralysis. As the respiratory process is thus implicated, the lungs become 
congested, a sense of suffocation ensues, the air-passages fill with mucus 
which the sufferer is unable to dislodge or expectorate, and he may die in a 
state of progressive asphyxia. 
Fractures in the Cervico-Dorsal and Cervical Regions.—The brachial plexus 
of nerves is formed from the three or four lower cervical and the first dorsal 
nerves; the long thoracic, or external respiratory, from the fifth and sixth; 
and the phrenic, from the third and fourth cervical nerves. This region ex- 
tends from the second dorsal to the fourth cervical vertebra. There will be, 
in addition to the paralysis present in the fractures of the previous regions, 
moto-sensory paralysis of the upper extremities, to a greater or less degree, 
according to the particular vertebra involved. If it be the first or the second 
dorsal, it involves but one cord of the brachial plexus, and therefore does not 
entail entire loss of power; but if through the pieces of the lower cervical, the 
other cords of this plexus will suffer, and then the paralysis becomes com- 
plete. The difficulty of respiration is much increased when the great serratus 
muscle is rendered helpless, as its nerve-endowments are derived from the 
fifth and sixth cervical nerves, which form the long thoracic or external 
respiratory. The same increase of temperature, and the same round and full 
state of the radials and other large arteries of the parts, will be present as 
in paralysis of the lower extremities. The surface of the skin will exhibit 
a blanched and dry appearance. The pupils refuse to dilate, a symptom 
which Mr. Hutchinson claims is present only when the injury is in the cer- 
vical or upper dorsal vertebrae. The same author states that priapism is 
only seen when the damage is in the upper or middle dorsal region, and that 868 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
he has never witnessed it after injuries affecting other parts of the cord, or 
the head. I have, however, seen it present in injuries of the latter. These 
erections of the penis are not due to action of the muscles, as the latter par- 
take of the general paresis, but are the result of inefficiency of the vaso- 
motor nerves allowing the blood to flow into the spongy structure of the cor- 
pora cavernosa and corpus spongiosum, through the want of resistance in the 
muscular walls of the vessels. The heart is not free from disturbance in these 
cervical injuries. Its action is slow and full, though free from intermission. 
It is difficult to conceive of a more pitiable condition than that of a fellow- 
being without the power of motion or sensation, practically dead to the 
neck, and suffocating from imperfect aeration. Yet, even under such cir- 
cumstances, patients sometimes live four or live days, breathing only by the 
diaphragm; and some have even recovered. Mr. Hutchinson furnishes two 
instances,* the one a female and the other a male, of fracture in the lower 
cervical region, accompanied by partial paralysis, in both of which the patient 
recovered. Mr. Hilton has placed on record a remarkable casef of a boy in 
whom there was fracture of a cervical vertebra, followed by paralysis of the 
upper and lower extremities and paralysis of the bladder and rectum, yet 
who lived fourteen years, coming to his death at last by an accident. The 
case of Mr. Page, recorded by Mr. Shaw,!—in which a Scotch gentleman 
fractured the fourth cervical vertebra, every part being paralyzed except his 
head, and yet lived for nearly fifteen months,—is still more wonderful. 
A lad, in diving, struck his head violently upon the bottom of a shallow 
stream, and produced a fracture about the third cervical vertebra. Though 
paralyzed from the neck down, he was living five months after the accident. 
Gurlt has seen two cases of fracture of the fifth and sixth cervical vertebrae 
accompanied by laceration of the vertebral artery. 
Should the fracture occur above the fourth cervical vertebra and the cord 
sustain damage, the case will prove fatal in a brief period of time. The 
phrenic nerve, which is the motor nerve of the diaphragm, has its origin 
below this point, and suspension in the action of so important a muscle as 
this must be quickly followed by death. There are, however, a few excep- 
tions to this sudden result. Mr. Curling furnishes an example of a fracture 
of the three upper cervical vertebras, in which the patient survived twenty- 
eight hours. The explanation given was doubtless correct, namely, that only 
a partial injury was inflicted on the cord, and that the change discovered in 
the medulla spinalis on dissection took place subsequent to the injury. 
Hamilton states§ that of 10 fractures of the five lower cervical vertebrae 
which he has collected, 1 died within twenty-four hours, 1 in eleven days, 1 
in fifteen weeks and six days. 1 in four months, and 1—which I have recorded 
as the case of Mr. Hilton—lived fourteen years. 
The two upper cervical vertebrae, being placed at a point where force and 
counterforce meet, frequently give way, especially when the momentum is 
transmitted through the cranium. The fracture may extend through either 
the anterior or the posterior arch of the atlas, or it may detach the odontoid 
process of the axis from its attachment to the body. (Fig. 652.) The axis 
suffers much more frequently than the atlas. The spinal canal of these pieces 
is quite large, and, should no displacement occur, the cord may escape injury. 
The odontoid process when broken tends to escape from the transverse liga- 
ment, or the ligament itself may be torn, completely liberating the pi'ocess, 
which may be forced into the cord. Fig. 653 is an illustration of a case, seen 
in consultation with Dr. Willard, of a comminuted fracture of the odontoid 
process without rupture of the transverse ligament, and accompanied by a 
unilateral luxation. 
In instances of fracture of the odontoid process with displacement, the 
head is rigidly maintained in a fixed position, in cases of unilateral displace- 
* London Hospital Reports, 1866, vol. iii. pp. 347, 348. 
f London Lancet, October 27, 1860. J Holmes’s System of Surgery, vol. ii. p. 393. 
g Fractures and Dislocations, p. 155. FRACTURES OF THE VERTEBRAE. 
869 
ment it is turned to the opposite side, and in both conditions there is an 
unusual prominence of the larynx. Motion and sensation may at first be 
unimpaired, but in the course of a few hours paralysis sets in, which maj' 
affect one side alone. In addition to these symptoms, the diagnosis of the 
injury may be established by the presence of an undue prominence of the 
posterior wall of the pharynx, formed by the body of the displaced vertebra. 
Fig. 652. 
Fig. 653. 
Fracture of the odontoid process.— 
Hamilton. 
Fracture of the odontoid process. The patient lived 
ninety-eight hours. 
It is extraordinary what extensive damage may be inflicted and the cord 
escape serious lesion. Dr. Stephen Smith, in a paper on “ Fractures of the 
Odontoid Process,”* has collected 22 cases. Six of these were spontaneous 
fractures, with 1 recovery; the one recovering discharged a portion of the 
bone through the throat; 4 were produced by gunshot injuries, all of whom 
died; 7 by external violence, all fatal; of 5 cases (two obtained from dead 
subjects) in which a portion of the bone had been discharged, 4 recovered 
and 1 died: making a total of 17 deaths and 5 recoveries. Robert Debenham, 
Esq.,f gives the case of a shoemaker who had a fracture of the odontoid 
process and recovered, the fracture having been verified by dissection two 
years after the injury. Dr. Sinkler has furnished me the notes of a case 
of what was considered a fracture of the odontoid. There was paralysis of 
both arms and of one leg, deformity below the occiput, and the chin was de- 
pressed on the sternum. This patient gradually recovered. Coopert mentions 
a case, afterwards verified by dissection, of a boy who, by a fall, broke the 
atlas across, so as to remove the support of the tooth-like process of the 
axis. The lad was obliged to walk with the utmost circumspection ; if de- 
sirious of examining any object below himself, he would place his hand under 
the chin and lower his head so that he could direct his eyes towards the 
object; if he wished to look upwards, one hand wTas placed behind the occiput 
and the other under the chin, and the head gradually raised. These precau- 
tions were instinctive, and were adopted in order to prevent the dentiform 
process from damaging the cord. He was able to go about and play with 
other children, and lived for a year after the accident. These symptoms are 
present in most cases of fracture of the odontoid process. Dr. Willard Parker, 
of New York, met with a case of fracture of the odontoid process, in which 
the patient lived five months, his death being caused by the process becoming 
displaced to such a degree as to injure the cord. A still more remarkable case 
is mentioned by Mr. Shaw, from a description by Mr. B. Phillips,§ under 
whose care the patient was at the time of the accident. The man fell from a 
hay-rick, striking on his head, but was in a little time able to rise and to visit 
* American Journal of the Medical Sciences, Oct. 1871, p. 388. 
f London Hospital Reports, 1867, vol. iv. p. 210. 
j Fractures and Dislocations, p. 385. 
| Medico-Chirurgical Transactions, vol. xx. p. 78. 870 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
his physician. In two days he was about, but had an enlargement at the 
back of the pharynx, with some difficulty in deglutition. One year after, he 
died from dropsy, and on examination not only was the atlas found broken, 
along with the odontoid process of the axis, but its anterior portion had 
been carried forward and placed in front of the axis, and the occipital bone 
had settled down and rested on the posterior ring of the atlas, which last 
had become united to the body of the axis. 
Cases of spontaneous fracture of the odontoid process from disease have 
been reported by Hyrtl, Else, and Flint, death in each instance taking place 
instantaneously. 
Treatment.—The moment a patient is extricated from a caved-in sand- 
bank, or from the midst of the rubbish of fallen timbers, or when lifted 
from the street or ground, and there is evidence of a broken spine, he should 
be straightened out and laid on his back, and so transported on a board, 
or on a settee, to his home, or to a hospital. This position is most favor- 
able to the reposition of the bones, and best adapted to remove pressure 
from the cord or from the spinal nerves. If the fracture is in the cervical 
region, the head should be maintained in a fixed state by applying pillows 
or a portion of the clothing to each side. Next in importance is the bed 
upon which the patient is to be placed. The water-bed is superior to all 
others when the case is likely to be protracted. It must be borne in mind 
that one of the consequences of this class of injuries is bed-sores, and many 
die of these alone. They result from the continuous pressure upon the 
salient points of the body, which possess but a very feeble capillary circula- 
tion, and are therefore disposed to slough. A man with a fracture, say of 
the dorsal vertebrae, without the power of motion in the parts below, is abso- 
lutely fixed to the spot on which he is laid, and, being without sensation, never 
feels the weariness or unrest of immobility, so that this pressure knows no 
abatement. Water-beds can be obtained at any large establishment for the 
sale of rubber goods, and cost about twenty dollars. A small size is made, 
or a section, which is sufficiently large to extend from the shoulders to a 
little below the hips, and answers very well. Many persons of course cannot 
afford this expense, and in some localities there would be difficulty in ob- 
taining such a convenience. In this event, an ordinary mattress, protected 
with oil- or gum-cloth, can be substituted, and, with the addition of stuffed 
or air cushions, having openings to receive the tender points of the body, 
may obviate the evils resulting from pressure. The patient, once placed 
on his bed, should have a pillow slipped beneath the loins, in order to keep 
the spine from sinking down. It has been advised to employ extension and 
counter-extension, with a view to coi*rect any displacements which may exist; 
and there are cases attended with deformity in which these forces should be 
applied. The benefits claimed for such a process in the few cases in which it 
has been used are encouraging. It must, however, be remembered that of 
twenty autopsies made by Hutchinson* in cases of broken spine, in none was 
there any evidence of permanent compression of the cord. The injury to 
the medulla spinalis is in most instances, as I have previously observed, a 
momentary work, and done at the instant of the accident. The state of the 
skin, moreover, is such that no extension would be tolerated long without 
producing sores. 
The most effective way of extending the spine is to apply to the head the 
apparatus used for stretching the body in cases of antero-posterior curva- 
ture of the vertebral column (see Spinal Disease),—not, however, raising the 
patient beyond the sitting posture,—and then to encase the body in a plaster 
jacket. When the fracture is as high as the mid-dorsal region, it would 
hai’dly be proper to employ the plaster jacket, in consequence of its inter- 
ference with the respiratory movements, which are more or less embarrassed 
by the injury. The jacket having been adjusted, the patient may again be 
placed in the recumbent position. 
* London Hospital Reports, 1866, vol. iii. p. 359. FRACTURES OF THE VERTEBRAE. 
871 
Attention should next be directed to the condition of the hollow viscera. 
The bladder is at first unable to expel its contents, and the catheter must be 
used to remove the urine. In executing this task the utmost care should be 
exercised. The urethra being without sensibility, there is no monitor to 
communicate any injury which it may sustain. The only instrument which 
should be generally used in these cases is the gum catheter of Mercier (Fig. 
654). It will produce the least possible irritation. The urine should be 
Fig. 654. 
Mercier catheter. 
drawn three or four times in the twenty-four hours. After a time, in- 
continence sets in, and then the patient must be furnished with a urinal 
to receive the secretion as it flows away. Even after this incontinence 
begins, the catheter should be used once every twenty-four or forty-eight 
hours, in order to remove any water which may lie below the level of the 
urethra, which by its decomposition would aid in producing vesical inflam- 
mation. This practice is contrary to some very good authorities, but I am 
convinced of its necessity. The bladder in these cases is prone to become 
inflamed, and the urine cloudy and ropy, with a strong ammoniacal odor 
and an alkaline reaction. The phosphates, particularly of lime, are present 
in great abundance, the result of a faulty action of the kidneys, from the 
interruption of the proper nerve-influence, as well as of reactions which 
take place in the bladder. These chemical alterations in the composition of 
the urine result in sedimentary deposits, which are exceedingly prejudicial, 
and should therefore not be allowed to remain in the bas-fond of the bladder. 
It will sometimes prove beneficial to wash out the organ once a week with 
lukewarm water containing three or four drops of nitric acid to the pint of 
fluid. For this purpose the double catheter may be used (Fig. 655), the 
nozzle of a syringe or a gum bag being fitted to one of its orifices. 
Fig. 655. 
Double catheter. 
The bowels, like the bladder, at first allow their contents to accumulate, 
but very soon the evacuations pass without the patient being conscious of 
the act. When they do not act, it is proper to administer a cathartic, the 
reflex sensibility being sufficient to secure its operation. As the patient is 
entirely unable to discover either the dribbling of urine, the escape of faces, 
or any injury of the soft parts, the utmost care should be exercised by 
nurses or other attendants to see that the person is kept perfectly dry and 
clean. While it is desirable to keep the patient entirely quiet on the back, 
to prevent the broken fragments of the vertebra from moving on each other, 
yet the great danger of bed-sores renders an inspection of the parts over 
the sacrum and nates absolutely necessary, and therefore the body should be 
daily turned over on the side, avoiding any twist by carefully moving the 
shoulders and the hips at the same time (if the fracture is in the lumbar 
or the dorsal region), when the exposed parts must be well washed with 
alcohol or soap liniment, rubbed briskly, and afterwards smeared over with 872 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
a little zinc ointment. The draw-sheet should be kept smooth and dry, 
and, to receive the discharges from the bowels, a pad of oakum containing 
some earbolated plaster of Paris may be pushed a little behind the anus. 
Should bed-sores form, in defiance of all precautions, the indications will be to 
favor the separation of the sloughs and to stimulate healthy granulations. To 
effect the first object there is nothing better than large, warm flaxseed-meal 
poultices over which compound resin ointment has been spread; these are 
to be renewed morning and evening, cutting away any dead shreds of cel- 
lular tissue that may loosen, and after the parts are entirely freed from the 
sloughs a dressing of the compound resin ointment alone may be applied. 
If any offensive odor is present, the carbolic acid lotion, or the permanganate 
of potash, or a solution of the nitrate of lead, will answer every purpose for 
its removal. I have succeeded in healing up such sores, when obstinate, by 
covering them in with strips of adhesive plaster. During all this time we 
must never forget the necessity for taking off the weight of the body from 
the diseased parts by interposing ring cushions. Nor must the extremities 
be overlooked. The calf of the leg and the heel are also liable to become 
sore. Happily, in these situations, the pressure can be distributed by cotton 
or soft compresses. Should the patient be fortunate enough to escape the 
usual dangers and begin to recover his lost power, electro-galvanism may be 
employed with advantage. Throughout the entire progress of the case a 
nutritious but unirritating diet should be allowed. 
The use of the trephine to raise depressed portions of fractured vertebrae 
would very naturally occur to a thoughtful surgeon. The suggestion was 
made as far back as Paulus iEgineta. It was first practised by Sir Henry 
Cline, in 1814, on a patient who had a fracture of the eleventh and twelfth 
dorsal vertebrae. The spinous processes of both vertebrae and the arch of 
the eleventh were removed. No benefit resulted, and the patient died on 
the third day after. The operation has been repeated many times, without 
success. Dr. Ashhurst* has analyzed 38 cases, in which operations were 
performed, with the following result: 29 died, 3 were relieved, 2 were not 
relieved, and in the remaining 4 the result was unknown. 
In view of our present knowledge of germicidal agents, in consequence of 
which we are able to render wounds aseptic, I believe there is a promising 
future for spinal surgery, and that in many cases of fractures of the vertebrae 
the exposure of the cord might be made with a reasonable prospect of 
removing pressure and restoring muscular power. 
The operation is by no means a difficult one. The patient being placed on 
his side, inclining a little over on the abdomen, a longitudinal incision is made 
over the spinous processes. The integuments and the muscular and tendinous 
attachments are next detached from the vertebrae and pushed aside, after 
which the spinous processes can be nipped off with the bone-forceps. The 
arches now come fairly into view, and, after being notched with a Hey’s saw, 
may be severed in like manner with the spines, thus exposing the cord and 
allowing an exploration of the damaged region. 
In reference to the mortality following fractures of the spine, as they 
have occurred in the Pennsylvania Hospital, and which I suppose does not 
materially differ from that of other similar institutions, some idea may be 
obtained by consulting the tables on fractures, from which it will be found 
that of the 73 cases treated in that institution, 47 died in the hospital, 17 
were removed by friends, and most of these in all probability subsequently 
died, 1 was reported cured, and 8 remain unrecorded. 
Fractures of the Bones of the Face. 
The bones of the faee, from their exposed position, are very liable to frac- 
ture. The relation which they sustain to the cranium, and of course to the 
brain, makes these injuries sometimes of very serious import. 
* Injuries of the Spine, Ashhurst. FRACTURES OF THE BONES OF THE FACE. 
873 
Fractures of the Ossa Nasi.—The force producing such fractures is usu- 
ally direct, and may be delivered either immediately in front or on one 
side. The direction of the fracture may be transverse, oblique, or longitu- 
dinal. Transverse fractures are most common. In most of the cases which 
have come under my observation, the line of fracture was about half an 
inch above the lower margin of the bone. The upper or frontal portions 
of these bones are very thick and strong, and will resist a great degree 
of force without fracture. If the violence is great, a comminuted fracture 
may be produced. As the parts swell very quickly, these injuries are often 
overlooked, and hence, in a majority of the specimens which are seen in 
cabinets, more or less deformity exists: in my own collection that deformity 
is generally a lateral one, the nose being turned to one side. Commonly, 
but one bone is broken. When the lesion is longitudinal, the nose will be 
depressed. 
Symptoms.—The symptoms of this fracture are epistaxis, swelling, deform- 
ity, mobility, and crepitus. The strictest examination should be insisted upon 
where there is reason to suspect a lesion of these bones. If there is flatten- 
ing or a lateral deviation of the nose, even though crepitus is not discovered, 
the existence of a fracture may be assumed, and, if the displacement is not 
corrected, the surgeon will incur great blame, especially if the patient is a 
female. 
Treatment.—The reposition of the fracture is most conveniently effected 
by introducing an ordinary steel director through the anterior nares and con- 
ducting it along the side of the septum to the roof of the nasal fossa, when 
it can be used as a lever to raise the depressed fragments into place. The 
fingers on the outside, by making counter-pressure, will also aid in modelling 
the parts into form. Sometimes it will require a considerable amount of force 
to correct the displacement, in which case the surgeon must have no hesita- 
tion as to employing it. Once in place, unless the fracture is a comminuted 
one, there will be little tendency in the fragments to resume their unnatural 
position. If there is reason to believe that the reduction has not been com- 
plete, in consequence of the inflammatory swelling masking the parts, a few 
leeches, if they can be obtained, may be applied, and, after a sufficient amount 
of blood has been taken, the nose should be covered with a lotion of lead- 
water and laudanum. In twenty-four hours the swelling will have materially 
abated, and the medical attendant may then ascertain with more certainty 
the condition of the bones, and, if necessary, renew his efforts at adjustment. 
These early attempts at reduction are all-important, as the process of repair 
goes on with great rapidity in these bones, the pieces often becoming united in 
ten or twelve days. Should the patient be young or restless, ether may be 
administered before attempting the coaptation, always remembering to keep 
the throat cleared of blood. The fragments being restored to their place, 
little is to be done but to direct quietness on the part of the patient. 1 have 
no objection to the adhesive strips which are generally directed to be placed 
across the nose: they serve to remind spectators of the accident, and to 
prevent unwarrantable liberties being taken with the organ; though their 
influence in keeping the bone from sinking amounts to nothing. If the 
integuments or the muscles were closely adherent to the bone, such supports 
would be desirable; but no such adhesions exist,—the muscles slide freely 
over the bones, and we can exercise through them no lifting power upon the 
latter. 
Complications.—The nasal bones rest on the perpendicular plate of the 
ethmoid, which forms a portion of the nasal septum. This plate may be 
broken and deflected from its median position. This will tend to obstruct the 
nasal fossa? and will allow the nose to sink and become flattened. The septum 
is not unfrequently found curved to one side as a natural condition, a fact 
which should be remembered when making examinations of the injuries of 
this organ. When broken, the nasal bones should be first elevated, and then 
the perpendicular plate should be pressed into proper line. If the distortion 874 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
is great, it may carry with it the cartilaginous septum to such a degree as 
to turn the end of the nose to one side. 
The perpendicular plate of the ethmoid is continued up into the cranium 
as the crista galli, on the sides of which are attached the cribriform plates of 
the bone, which support the olfactory bulbs. These plates may participate 
in the injury, or the olfactory lobes may suffer concussion, causing a suspen- 
sion or even destruction of the sense of smell. In some instances the damage 
done to the base of the brain results in death. 
The contiguity of the nasal bones to the lachrymal duct explains the dis- 
orders of the tear-sac, such as abscess, fistula, etc., which sometimes follow 
extensive fracture of this part of the face, and may demand operations for 
their relief. 
Hemorrhage.—This, though at first profuse, is seldom a troublesome com- 
plication. It generally ceases after the broken pieces are adjusted. When it 
is persistent, the head and shoulders should be elevated, and cold applications 
placed over the nose ; alum-water may also be injected into the nasal cavities. 
If the bleeding, in spite of these precautions, continues uncontrolled, it will 
be necessary to employ the tampon. 
Emphysema of the eyelids and face constitutes another complication, not, 
however, of a very serious nature. Its presence indicates a rupture of the 
mucous membrane of the nose and of the periosteum, allowing the air to pass 
through the aperture in the bone into the cellular tissue of the face. This 
air will gradually disappear as the healing of the fracture advances, but its 
removal may be facilitated by applying a compress over the closed eyelids 
and upper part of the face, taking care not to place it over the fracture, for 
fear of disarranging the fragments. 
Comminution.—When the bones have been broken into several pieces, the 
greatest difficulty will be experienced in preserving a proper adjustment. It 
is in such cases that it may become necessary to attempt support from within. 
For this purpose various contrivances have been in use, dating back to a 
period as early as Hippocrates, such as plugging the nostrils with charpie, 
the use of tubes of various kinds made of quills, lead, silver, wax, and 
even gold, as recommended by A. Pare, or rubber, by Boyer. The incon- 
venience and distress which follow the introduction of solid plugs into the 
nares, compelling the patient to breathe through the mouth, a sorry sub- 
stitute for the nasal passages, render it necessary that these internal sup- 
ports, when used, should, if possible, be hollow. Where there is difficulty 
experienced in keeping the fragments in position, the plan of Dr. Mason can 
be adopted with advantage, that of passing a strong needle through the nose, 
below the fragments, after their reduction. The needle is kept from be- 
coming displaced by strips of adhesive plaster passing from its ends across the 
nose. Another plan is to cut a gum catheter the proper length, and, insert- 
ing it into the nose, pad around it with a strip of old linen well greased and 
pressed into position with a director. Should the reduction be unsatisfactory, 
apiece of compressed sponge, shaped to conform to the nasal fossa, and coated 
with a thin layer of melted wax, may be inserted. The moisture of the parts 
penetrating the tent will cause the latter to swell and to find its way into the 
irregularities of the cavity, thus carrying the fragments into position. If 
this be retained for twenty-four hours before being withdrawn, the tendency 
to displacement will have materially diminished, and if needful a second tent 
can be inserted. Hippocrates, Avicenna, Albucasis, and others, after reduc- 
tion moulded to the external surface of the organ shields made of flour and 
white of eggs, and sometimes of glue. All such devices are of doubtful 
value, and only when a tendency to external displacement exists are outside 
compresses advisable. 
In compound fractures it is proper to insert one or more points of the silver 
suture, and if comminution is added to the external wound, the pieces, unless 
they are entirely detached from the surrounding parts, should not be removed. 
Necrosis may follow especially compound comminuted fracture of the nasal FRACTURES OF THE BONES OF THE FACE. 
875 
bones, and when a fragment is well separated and loose it should be carefully 
picked away. Displacements of the cartilaginous septum, which are some- 
times conjoined with fracture, are generally followed by unavoidable deformity, 
such as sinking of the nose at the point of junction between the cartilaginous 
and the bony portions or lateral inclination of its extremity. Padding the 
nostrils after the manner already described will measurably prevent this, or, 
if this is inadequate and the depression is marked, it may even be proper, 
after the manner of Hamilton, in order to release the cartilage from its un- 
natural position, to make incisions with a tenotome through its substance, 
and then, inserting a thread deeply into its structure, to lift into place the 
sunken portion, and there retain it by tying the ligature over a rubber arch 
previously thrown over the nose, with its extremities resting on the sides 
of the face. 
Polypi and catarrhal disease of the Schneiderian membrane are said to 
follow fractures of the nose. The latter I have seen, but never the former. 
Amaurosis has been known to succeed this injury. Dr. John W. Martin* 
reports such a case. The sight was after some time restored. 
Fractures of the Superior Maxilla.—The force which produces a fracture 
of the upper jaw must, as a rule, be direct, and also of great violence. A 
kick from a horse, a blow from a lever suddenly released from restraint, 
the impact of a pistol-ball, are among the most common causes of this 
injury. The fracture is often comminuted, and is sometimes attended with 
concussion of the brain, or with fracture of other bones of the face or at 
the base of the skull. Associated as the upper jaw is with no fewer than 
nineteen bones, such results create no surprise, as the blows which it may 
receive are transmitted by these conducting lines of articulations far beyond 
its own limits. This extensive connection of the upper maxilla will explain 
the modus of the singular accident narrated by Packard,f where a man’s 
head was caught between a hoisting-machine and the floor, causing the entire 
separation of the face from the cranium; also the case of a boy, recorded 
by Wiseman! and referred to by Hamilton, in whom the entire face was 
driven in, so that the finger could not be passed behind the palate. In this 
case the restoration could be effected only by introducing a blunt hook be- 
tween the posterior wall of the pharynx and the palate bones, drawing the 
parts forward and holding them in position until the disposition to recede 
was overcome. Dr. Fyffe§ published the case of a man brought into the 
Westminster Hospital who had been thrown from a cab, the vehicle turning 
over upon him, which, in addition to producing a fracture of the lower and 
upper jaws, so detached the bones of the face that the latter moved up and 
down in the act of swallowing, as though nothing held them to the head but 
the skin. In this case not a tooth was broken or displaced. Both this patient 
and the preceding one recovered. 
Fractures of the upper jaw are often produced by force transmitted from 
the malar bone, the latter remaining sound. This portion of the face, being 
prominent, is likely to receive the vulnerating body first. The lines of 
fracture may run in various directions, into the antrum, through the nasal 
process, through the alveolar process, or into the orbital and palatine plates. 
Being concerned in the construction of the gustatory, olfactory, lachrymal, 
orbital, and dental chambers, and containing numerous channels for the lodge- 
ment of blood-vessels and nerves, the superior maxillae possess extraordinary 
reparative power. Mr. Hutchinson had a case in the London Hospital,|| in 
which the entire alveolus with its teeth was completely detached, but after- 
wards united to the body of the bone, without subsequent necrosis. A still 
more remarkable instance of fracture of the upper jaw was treated in the 
*• Medical Press and Circular, September 23, 1874, Hamilton, 
f Malgaigne on Fractures, Packard’s translation, p. 303. 
J Treatise on Surgery, 1734. 
| Lancet, July 18, 1860. 
|| Medical Circular, February, 1867. 876 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
University Hospital, London,* where the whole dental arch was separated 
from the bones and lay upon the inferior maxilla?: this patient recovered 
likewise with good union. 
A lad was brought into the University Hospital, Philadelphia, who had 
been caught between the bumpers of two railroad-cars. The whole face was 
disjoined from the head. The 
upper jaws were greatly commi- 
nuted, the inferior maxilla was 
broken into four pieces, and a 
number of ragged wounds in- 
volved the soft parts of the face. 
Notwithstanding this extensive 
mutilation, all the fragments of 
the upper jaw united; a portion 
of the lower maxilla, being in a 
great measure detached from the 
bone, became necrosed and was 
removed. The deformity remain- 
ing after recovery is well repre- 
sented in Fig. 656. 
The two upper maxillse are occa- 
sionally separated from each other 
in the line of the intermaxillary 
suture. It is often impossible to 
readjust such a fracture, and the 
violence producing the disjunction 
may even prove fatal; though 
a case of this kind which came 
under my observation, in a child 
two years old, recovered without 
any very evident deformity. 
The bones most likely to partici- 
pate in fracture of the superior 
maxilla are the malar, the nasal, 
the palatine, and the pterygoid 
process of the sphenoid. 
Treatment.—A cardinal principle to be observed in the treatment of all 
fractures of the upper maxilla, one which has received the sanction of the 
most eminent names both in this country and abroad, is to preserve and 
replace all fragments and splinters, the tendency to heal in this bone being 
stronger than in the other bones of the skeleton. When a portion of the 
alveolus is broken away, either from its inner or its outer wall,—an accident 
quite common under the old system of extracting teeth by the key,—no 
dressing is demanded. The patient is to avoid chewing any hard substance 
until the detached fragment has contracted an attachment to the bone. It 
may happen that the separated piece will die: if so, as soon as it is suffi- 
ciently loose it should be removed with a pair of bone-forceps. 
When the alveolar process is broken into two or more fragments, the pieces 
must be pressed into place and the jaws closed, so that the lower dental arch 
may serve as a support for the fracture. To maintain the apposition, a Barton 
or a Gibson bandage should be applied. (See Figs. 662 and 663.) If the ten- 
dency to displacement persists, we may apply fine wire to the teeth ; and, if 
this fails, resort should be had to an interdental splint. This may be con- 
structed of gutta-percha. I have used for this purpose, with great advan- 
tage, a piece of cork with a groove cut in its upper and lower surfaces, the 
one to receive the teeth of the lower jaw on the side of the fracture, thus pre- 
venting its displacement, and the other to receive the teeth of the upper jaw; 
I have then bound both together with a roller, as in fractures of the inferior 
Fig. 656. 
Appearance after recovery from an extensive fracture of 
the bones of the face accompanied by several wounds of the 
soft parts. 
* British and Foreign Quarterly Review, October, 1860. FRACTURES OF THE BONES OF THE FACE. 
877 
maxilla. Should the teeth be loosened and partially dislocated, they must 
be pressed back into the alveoli, in the hope that they may be preserved. 
When the nasal process is broken, a director applied through the nose will 
serve to elevate any depression which may exist. 
When the wall of the antrum, which supports the malar bone, is broken 
in, efforts should be made to correct the displacement, as the deformity due 
to the depression of the malar bone, if not remedied, will greatly change the 
appearance of the face. To effect this, the finger may be carried into the 
mouth, as directed by Hamilton,* and made to act on the zygomatic process 
of the malar bone; or the elevation may be accomplished by introducing a 
strong hook under the same process through an incision made at the ante- 
rior edge of the masseter muscle, with antiseptic precautions. 
The same author speaks in commendatory terms of a screw elevator, which 
is applied by making an incision over the malar bone, then screwing the in- 
strument into its structure, and using it as a means of raising the depression. 
Complications.—When the fracture is through the nasal process or involves 
in addition the nasal bones, there may be such a laceration of the soft parts 
as to be followed by emphysema of the face. This will either subside sponta- 
neously, or may require for its removal some gentle pressure by a compress 
and bandage, or the free use of collodion, as recommended by Heath.f 
As the nasal process contributes a part in the formation of the lachrymal 
canal, its fracture may entail inflammatory disease of the sac, and subsequent 
obstruction to the passage of the tears. Under such circumstances the 
treatment applicable to stricture and fistula of the lachrymal passages will 
be demanded. 
As the infra-orbital nerve traverses a canal in this bone, it is liable to be 
injured, especially in fractures near the orbital plate, and this injury will 
give rise to neuralgic attacks or to sensory paralysis. When the painful 
condition can be traced to a mechanical cause, such as pressure, nothing will 
avail but the excision of the offending portion of the bone or of the nerve 
beyond the limits of its injury. 
Hemorrhage.—This may come from the vessels of the soft parts, as the facial 
artery, or from those of the bone, principally from branches of the internal 
maxillary. Secondary hemorrhage in injuries to the bones of the face was 
of frequent occurrence during our late war, and in many instances proved 
fatal. To control this complication, the primitive carotid was ligated in thir- 
teen cases,J ®ve which proved successful. When the bleeding comes from 
the facial artery, or from one of its branches, the vessel should be sought for 
and secured. When the hemorrhage comes from the bone, and does not cease 
after a reasonable time, we have but two resorts,—either the ligation of the 
carotid or the use of the actual cautery. It is by no means conclusive to 
my mind that the first is the better method. The collateral routes will very 
soon conduct the blood into the channels above the ligature, when the hemor- 
rhage will be renewed. At all events, I do not believe it should be our first 
resort. It would be better to excise a portion of bone along the side of the 
fracture, and in this manner seek for the bleeding point or points and apply 
the actual cautery. 
Necrosis.—When the comminution is extensive, some of the splinters may 
die ; and as soon as their separation is ascertained they should be picked away 
with the forceps. 
Fractures of the Malar Bone and Zygomatic Arch.—The malar bone, though 
much exposed, possesses great power of resistance, and will, as we have 
learned, sometimes transmit a force which may be applied to its body with 
sufficient intensity to break the upper maxilla, while sustaining no damage 
itself. The soft parts over the bone are likely to be contused, or they may 
* Fractures and Luxations, p. 104. 
f Injuries and Diseases of the Jaws, p. 57. 
% Medical and Surgical History of the War of the Rebellion, Part I., surg. vol., p. 367. 878 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
be divided like an incised wound, and soon become much swollen. Unless the 
antrum is broken into, there will not be much displacement. Severe pain 
may follow injury to this bone, in consequence of the damage inflicted upon 
the temporo-malar nerve-filaments which traverse its structure. The fracture 
may involve its body or processes, and the force producing it may be propa- 
gated with such violence to the brain as to be followed by serious central 
concussion. 
From experiments which I have made on the cadaver, there is reason to 
believe that the zygomatic process is the part of the bone which is commonly 
broken. In four successive fractures which I produced by the application of 
force to the prominent part of the cheek, it was not only this process which 
gave way, but in each instance the fracture passed into the orbit, terminating 
in the sphenoidal fissure. Very recently I witnessed a fracture of the zygo- 
matic process, produced by a cricket-ball, which extended back along the 
floor of the orbit. 
Symptoms.—The signs of this accident are pain, discoloration, possibly 
mobility and crepitation, and some degree of deformity. Extravasation of 
blood at the outer canthus of the eye is frequently present, and if the 
fracture runs into the orbit, implicating the infra-orbital branch of the fifth 
pair of nerves, there may be a loss of sensation in some of the anterior teeth, 
in the gums, and also in the alse of the nose, together with a portion of the 
face adjoining. 
Treatment.—If there is displacement, it must be corrected by pressure 
applied inside of the mouth or outside of the cheek; this will most likely 
prove effective if the zygomatic process has been broken. If the body of the 
bone is depressed, which implies also a broken antrum, the screw elevator 
(aseptic) (Fig. 657), bored into its substance, will be the most convenient 
Fig. 657. 
method of restoring it to the proper position. Should an external wound 
exist, we may be able to reach the depressed bone through the antrum with 
an elevator and raise it to the proper level. When no displacement exists, 
nothing is required but to keep the parts covered with a lotion of lead-water 
and laudanum. 
The zygomatic arch is sometimes broken; but the accident is rare. Mal- 
gaigne* states that he never had seen an instance of the injury, and had 
been able to collect only five cases. Two examples of this accident I witnessed 
on the same day. 
The force which determines a fracture of this arch will generally be a 
direct one, and the part which yields is usually that on the temporal side of 
the suture. This part of the arch belongs to the temporal bone, and is much 
weaker than that part derived from the malar. Hamilton found the tem- 
poral portion to give way in those fractures of the zygoma which he produced 
on the cadaver ;f and my own experiments have yielded a similar result. 
These accidents have been followed by death, in consequence of injury com- 
municated to the brain. 
Symptoms.—Unless there is deformity or irregularity, it is difficult to affirm 
the existence of such a fracture. The swelling and contusion of the soft 
parts conspire to mask the condition beneath. Unusual movement and 
crepitus may be detected when the zygomatic arch is firmly pressed by op- 
posite forces, yet the margins of the fracture, which runs usually in a trans- 
Screw elevator. 
* Treatise on Fractures, Packard’s trans., p. 289. 
f Fractures and Luxations, p. 106. FRACTURES OF THE BONES OF THE FACE. 
879 
verse direction, may so interlock by their irregularities as to render the bone 
immovable. When we consider the anatomical connections of the zygoma, 
it will be apparent that it can rarely be displaced, except in two directions, 
viz., inwards and outwards. To its upper edge is attached the strong tem- 
poral aponeurosis, and to its low’er border the masseter muscle, structures 
which prevent either upward or dowmward displacement. In most cases, 
therefore, the force, operating from without, will drive the arch inwards, thus 
giving rise to some depression. Duverney* relates an instance in which the 
violence was applied from within, thus forcing the arch outwards. Packard 
records the case of a sailor admitted to the Pennsylvania Hospital,f whose 
zygomatic arch had been broken some time before, by a chain falling on his 
head and shoulders, and which had united with a convex deformity. 
Should the fracture be much depressed, a fragment may penetrate the 
tendon of the temporal muscle and disable the movements of the lower jaw, 
causing at the same time much irritation and pain. 
Treatment.—Should the arch be broken without displacement, it will only 
he necessary to apply an anodyne lotion over the part, and to secure quiet to 
the masseter muscle: the jaws should be bound together with a Barton or a 
Gibson roller. When there is depression, the question of interference will 
depend upon the urgency of the symptoms. If the temporal muscle is not 
injured, the case may safely be left alone, as when the fracture is near the 
middle we have no means of elevating the arch without an external wound. 
Should, however, this muscle be penetrated or compressed,—a circumstance 
certainly of extreme rarity,—it would be proper to introduce an elevator 
through the external wound, if one exists, and, conducting it beneath the 
bone, raise the latter into place. When no wound is present, an incision 
must be made for the lever. When such an incision becomes necessary, it 
should be carried along the lower rather than along the upper margin of the 
zygomatic, as was done by Ferrier and although a few muscular fibres 
belonging to the masseter must be cut, yet we shall have a dependent wound 
for the escape of any collections of blood or of pus which may follow the 
operation. If done antiseptically, no inflammatory effects may be anticipated. 
If the displacement is outwards, external pressure will correct the devia- 
tion. The necessity of confining the jaws together after such fractures is as 
imperative as in similar injuries of the other bones of the face. 
Fractures of the Inferior Maxillary Bone,—These fractures occur about as 
often as fractures of the ulna,—that is, as compared with fractures in other 
bones, in the ratio of 2.4 per cent. In the Pennsylvania Hospital 209 cases 
were treated during a period of forty-four years. 
These fractures are produced by direct force, applied either to the side of 
the bone or upon the chin. A blow from the fist, falls upon the face, a kick 
from a horse, are among the most common causes of the injury. 
They are divided into fractures of the body, ramus, and processes. 
When involving the body, they may be situated at any point from the angle 
to the symphysis of the bone. They may extend through the entire thickness 
of the bone (Fig. 658), or may be confined to the alveolar process. Though 
the presence of an opening or wound communicating with the mouth renders 
these fractures compound, yet this does not necessarily prolong the treat- 
ment or induce a tedious suppuration, as in compound fractures of other bones. 
Double (Fig. 659) and triple fractures are quite common. Hamilton,! in a 
collection of 33 cases, found 13 broken at two or more points; 19 of the 33 
were comminuted. Mr. Poland had a case,|| at Guy’s Hospital, in which the 
jaw was broken into five pieces by the kick of a horse. 
Portions of the alveolus are not unf'requently broken off in the extraction 
* Bulletin de la Society Anatomique, 1810, p. 138. 
f Malgaigne on Fractures and Luxations, Packard’s trans., p. 289. 
j Bulletin des Sciences Medicales, tome x. p. 160. 
| Fractures and Luxations, p. 109. || Bryant’s Surgery, p. 269. 880 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
of teeth: I have frequently had occasion to remove fragments of necrosed 
bone after such operations. There is a difference of opinion among sur- 
geons as to the most common situation of fractures of the lower jaw. Mr. 
Erichsen* thinks that they occur generally in the body of the bone, near to the 
Fig. 658. 
Fig. 659. 
Fracture through the body of the inferior maxil- 
lary bone, near the anterior dental foramen.—Mal- 
gaigne. 
Double fracture of the inferior maxillary bone.— 
Malgaigne. 
symphysis, extending between the lateral incisor and the canine tooth. The 
symphysis is not so commonly fractured. Mr. Southf says that between the 
middle of the bone and the insertion of the masseter muscle, or between the 
insertion of the masseter and the coronoid process, are the usual places of 
this fracture,—a statement which is certainly comprehensive enough, as it in- 
cludes the entire half of the bone. Holmes Coote| says that the usual seat 
of fracture is between the symphysis and the insertion of the masseter mus- 
cle, and rarely at the symphysis. Gross§ states that the most common point 
is towards the anterior extremity of the bone, beginning between the first 
and second incisors, and next in frequency is the ascending ramus; that 
fracture at the symphysis is unusual, and when it does happen it is chiefly 
in young subjects, before the union of the two halves has taken place. 
Bryant11 fixes the position near to the canine tooth, the weakest part of the 
bone. in 22 cases of fracture through the body of the bone, 
found 15 at or near the mental foramen. Syme** says that the fracture is 
usually seated opposite to the bicuspid tooth,—that is, near to the anterior 
mental foramen,—and is rarely met with either at the ramus or at the sym- 
physis. Most of the cases which have come under my own observation were 
situated close to the inner side of the anterior dental foramen. I have seen 
a single case of fracture at the symphysis, in a patient nearly sixty years of 
age. Hamilton has collected eight of this fracture, only one of which 
was under ten years of age. Of 158 cases of fracture of the lower jaw 
admitted into the Pennsylvania Hospital, 5 were under ten years of age. As 
in other fractures, the largest number occur between twenty and thirty. 
The direction of the fracture is generally oblique; occasionally it is vertical, 
or it may be longitudinal in cases which involve only the alveolar process. 
In passing through the thickness of the bone, Malgaigne thinks the course 
of the fracture is oblique from without inwards, and towards the ramus. 
Such is very frequently the case, though the reverse is equally true,—a fact 
which may be corroborated by examining the specimens of the injury in any 
pathological cabinet. When the ramus is the seat of fracture, the course or 
direction of the latter may be through the angle or at a point above, and is 
generally more or less oblique. When the condyloid process is involved, the 
separation occurs through the constricted part called its neck. Fracture of 
the coronoid process is exceedingly rare. I have never seen a case of the 
kind. The great depth and sheltered situation of these processes, which are 
situated behind the zygomatic arches in the temporal fossa, place them far 
* Surgery, vol. i. p. 341. 
| Holmes’s System of Surgery, vol. ii. p. 428. 
Ij Surgery, p. 268. 
** Principles of Surgery, p. 178. 
f Surgery, vol. i. p. 579. 
£ Surgery, vol. i. p. 948. 
Fractures and Luxations, p. 111. 
ft Fractures and Luxations, p. 112. FRACTURES OF THE RONES OF THE FACE. 
881 
out of danger. An extraordinary case of Ilouzelot’s is mentioned by 
Malgaigne,* in which both coronoid and condyloid processes were broken, 
together with the symphysis of the bone. 
Symptoms.—Generally there is not much difficulty in determining the 
existence of this fracture, although when the separation is incomplete it 
may not be detected. There is a fixed and deep pain, which is greatly in- 
creased by any movements which disturb the quietude of the jaw, as opening 
and closing the mouth, swallowing, or even taking a full inspiration. In 
addit ion to pain, preternatural mobility, crepitus, and deformity are present. 
The mobility and crepitus are best determined by grasping the body of the 
jaw between the thumb and finger of one hand and the angle or ramus with 
those of the other hand, and applying force in opposite directions. The 
deformity is twofold. The fragments not only overlap, but one rises above 
the other, thus destroying the continuity in the line of the dental arch. It 
is proper to remark here that there are natural irregularities in the line of 
the teeth altogether consistent with a sound state of the jaw. The direction 
of the fracture is rarely transverse ; generally it is oblique, the obliquity being 
from before backwards, and from without inwards. 
When the break is at the symphysis, one fragment will be a trifle higher 
than the other, the lower being the side on which the fracturing force was 
applied. This, I think, is dependent on weakness of the muscles of this side, 
produced by the injury. 
In fractures which take place in front of the masseter muscle, the pos- 
terior fragment will generally be found exterior to the anterior fragment, 
especially when the line of separation runs obliquely from without inwards 
and upwards and backwards. Should the line of fracture run in the opposite 
direction, the displacement will be the reverse,—that is, the anterior fragment 
will assume a position external to the other. 
In explanation of the overlapping, we must recognize two factors, viz., the 
action of the digastric muscle on the injured side, and the influence of the 
internal pterygoid and the external portion of the masseter muscle of the 
sound side, these two forces acting on the anterior fragment, whilst the 
internal pterygoid and the deep masseter muscles of the injured side affect 
the posterior fragment. 
For the second change—that which results in an inequality in the hori- 
zontal planes of the two fragments—two causes are to be assigned: first, 
the weight of the anterior fragment, and the conjoined action of the digastric, 
genio-hyoid, and genio-hyo-glossus muscles on the same ; secondly, the power 
of the posterior fibres of the temporal muscles, together with the superficial 
part of the masseter and internal pterygoid muscles, acting on the posterior 
fragment. When the body of the bone is broken on both sides, the central 
portion descends and recedes by its own weight and the action of the mus- 
cles attached on either side of the symphysis; When the head is depressed 
towards the chest, this central segment will rise a little, but not to the level 
of the other portions of the jaw. 
When the ramus of the lower maxilla is the part implicated, there is gen- 
erally not much disarrangement of the fragments, in consequence of the two 
planes of muscles, the masseter and the pterygoid, covering this part of the 
bone, and acting as splints. 
When the break occurs in the neck of the condyloid process, there is a 
deep-seated pain experienced in front of the ear, aggravated by opening the 
mouth and by pressure. The upper fragment is drawn forwards and up- 
wards by the external pterygoid muscle, and by grasping the bone at the 
angle and moving it forwards and backwards, crepitus may be distinctly felt; 
if a finger be placed on the condyle of the jaw whilst this movement of the 
angle is made, it will be found to remain motionless. The lower fragment 
will be drawn up by the masseter and internal pterygoid muscles, changing 
the expression of the face on the affected side. 
* Fractures, p. 400. 882 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Fracture of the coronoid process is an accident of great rarity, and is diffi- 
cult to diagnose. Gurlt gives two cases. It may be conjectured when a 
finger placed over the temporal region fails to detect any movement of the 
temporal muscle when the mouth is opened and closed. Sanson states that 
this process, when broken, does not unite. 
In many of the fractures of the jaw there is a considerable flow of saliva 
possessing a very offensive odor. 
Complications.—We might suppose that the inferior dental nerve, from its 
position, would frequently suffer damage in fractures of this bone, and thus 
give rise to troublesome symptoms; and yet, on the testimony of Hamilton 
and others, such injury is almost unknown. Deafness, accompanied with un- 
usual sounds in the head, has been known to follow fractures of the inferior 
maxilla. Rossi has observed local spasms, and Flajani general convulsions 
of the body, after this injury; but all such sequences are probably—as be- 
lieved by Petit and others—the result of intracranial damage, rather than 
of accident to the jaw. 
Bleeding from the ears sometimes follows this fracture, induced by the force 
being transmitted to the external auditory canal through the condyles of the 
jaw. Mr. Holmes, in 1860, spoke of a specimen in which a part of the neck 
of the lower jaw was driven into the external auditory canal. 
Paralysis of one or more of the muscles of the face is also among the 
after-effects of this injury,—the result of contusion. 
Swelling of one or more of the salivary glands is occasionally met with, 
and may end in an abscess opening into the mouth or upon the neck. 
Necrosis will sometimes follow the fracture and retard the cure. 
Prognosis.—Fractures of the inferior maxilla usually do well. We may 
not be able in all cases to prevent a certain amount of deformity, such as an 
irregularity of the dental arch ; but, even when this exists, no material in- 
convenience will be experienced by the patient. 
Tardy union is not uncommon, but non-union is rare. I believe the saliva 
has some influence in producing delay in the consolidation; and the presence 
of the smallest necrosed fragment will defeat the healing. I have seen sev- 
eral cases in which from this cause the union was prevented for over four 
months. The greatest difficulty will be encountered in double and in com- 
minuted fractures; and under the most skilful and ingenious management 
cases will sometimes occur in which a perfect cure is impossible. 
Treatment.—In simple fractures of the body or of the ramus of the lower 
jaw, the parts, if disarranged, should be adjusted by manipulation, and the 
bone evenly supported, and afterwards bound securely to the upper maxilla. 
The fingers of the surgeon will accomplish the first indication. The second 
will be fulfilled by forming out of gutta-percha, or light binders’ board, a cup- 
shaped splint. For this purpose take a piece of either of the above materials 
four inches long and two and a half inches wide, slit it up one-third of its length 
from each end (Fig. 660), and cut out a concave portion from one side; fold 
the ends of one side within those 
of the other side, after it has been 
immersed for a short time in hot 
water. When dry, it will have 
the form of a cup (Fig. 661) for 
the reception of the chin, the 
concave side adapting itself to 
the convex surface of the neck. 
This splint is to be padded with 
cotton and applied beneath the chin and jaw. The third indication—that of 
securing the jaws together—is accomplished by the bandage of Barton. (Fig. 
662.) Professor Gibson employed a bandage very well adapted to effect the 
same ends as that of Barton. (Fig. 663.) Dr. Garretson uses a modification 
of the Barton dressing (Fig. 664), which can be loosened or tightened at 
pleasure without removing the entire bandage. Professor Hamilton, in the 
Fig. 660. 
Pig. 661. 
Splint cut out. 
Cup for the jaw. FRACTURES OF THE INFERIOR MAXILLA. 
883 
management of fractures of the inferior maxilla, employs a dressing com- 
posed of a firm strap, which passes from beneath the chin to the top of the 
head, where it buckles near to the anterior fontanel; a second strap, made 
of strong linen webbing, is looped over the vertical one of leather a short 
Fig. 662. 
Fig. 663. 
Barton’s bandage for fracture of the inferior maxilla. 
Gibson's bandage for fracture of the lower jaw. 
distance above the ears, and is buckled behind the occiput and over the fore- 
head. A third strip passing over the top of the head antero-posteriorly 
secures the vertical and horizontal bands together. (Fig. 665.) The ordinary 
four-tailed sling is sometimes used in dressing fractures of this bone ; but its 
insecurity renders it objectionable. 
In Philadelphia, the bandage of Barton is the one generally adopted, and 
certainly it accomplishes as well as any other in use the twofold purpose of 
Fig. 665. 
Fig. 664. 
Garretson’s bandage for fracture of the lower jaw. 
Hamilton’s bandage for fracture of the lower jaw. 
securing together the jaws and retracting the chin. This dressing is some- 
what like that formerly used by the French surgeons. (Fig. 666.) 
When the fracture is through the neck of the condyloid process, it may 
be necessary to modify the dressing. The upper fragment is liable to be 
drawn forward, upward, and inward by the external pterygoid muscles, and, 
as we have no very certain means, when such is the case, of restoring it 
to its proper functional position, the only alternative is to carry the lower 
fragment in the same direction, in order to effect a juxtaposition. Mal- 884 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
gaigne was able in a case of this fracture to push the condyle back into 
position by means of his finger carried along the upper and lateral wall of 
the pharynx. 
To secure the parts in place, it will be necessary to place a compress of 
muslin in the recess between the neck and the angle of the jaw, and apply 
the bandage designated the “ crossed of the angle of the jaw.” (Fig. 667.) 
Fig. 607. 
Fig. 666. 
French apparatus for fracture of the lower jaw. 
The crossed of the angle of the jaw for frac- 
ture th rough the neck of the condyle. The turns 
should exactly overlap one another. 
The dressings should be renewed whenever they become loose. The 
patient should not attempt to speak or to open the jaws. 
In the course of five or six weeks the bandages may be laid aside ; but the 
patient must be careful not to masticate any very hard substances, for fear 
of refracturing the bone. 
We may now consider the management of cases of a more complicated and 
troublesome nature. 
In addition to the fracture, some of the teeth may be loosened, or even 
entirely detached from the alveoli, and remain suspended by a shred of the 
gum. These should be immediately replaced, unless they happen to be in 
the line of the fracture, for, even if they do not regain their attachment, no 
harm can come of the attempt. Dr. Watson, of this city, had a case in 
which two of the incisors were driven through the bottom of the alveolus 
deeply into the cancellated tissue of the jaw, where they remained without 
giving rise to any inconvenience whatever. 
In cases of either single or multiple, compound or comminuted fractures, 
where the displacement obstinately persists in spite of the ordinary dressing, 
there are several devices in use to overcome the difficulty. Before resorting 
to such, the patient should be placed in bed on his back, with the head 
neither to the one side nor to the other, but sufficiently elevated to bring the 
chin well towards the sternum. Such a position will sometimes remove imme- 
diately all disarrangement of the fragments, and it should be maintained for 
five or six days, when the patient may again be allowed to rise, without any 
tendency to a return of the displacement. If, however, we are not success- 
ful by this plan in correcting the vicious tendencies of the fragments, a forced 
coaptation may be attempted by fastening together the teeth on opposite 
sides of the break. This device is as old as Hippocrates. For this pur- 
pose iron or silver wire is better than silk or hempen thread. The prac- 
tice in my hands, however, has not been satisfactory. The ligatures are FRACTURES OF THE INFERIOR MAXILLA. 
885 
prone to become disarranged, to make the gums sore, and even to loosen the 
teeth. 
A second mode of maintaining the apposition of the fragments is by a cap 
of metal constructed of silver, or of some composition of sufficient resistance 
to be fashioned into a cap, which is made to bridge over the fracture and 
rest upon the teeth on either side. 
A third device is the use of what are called interdental splints. These are 
made of vulcanized rubber or of metal. The most elaborate are those of 
Gunning and of Kingsley, of New York, and that of Dr. Bean,* of Atlanta, 
Georgia. In the preparation of these splints an impression is first taken of 
the teeth, both of the upper and of the lower jaw. The fragments of the 
broken bone are to be taken separately. The impression is made in wax, 
which serves as a pattern for a plaster cast, from which the vulcanite is sub- 
sequently fashioned. 
Among the simplest of Gunning’s splints are the forms shown in Figs. 668 
Fig 668. 
Fig. 669. 
Gunning's interdental splint: A points to the 
perforations for injecting water. 
Gunning’s interdental splint. 
and 669, which receive all the teeth of the lower jaw, extend a short dis- 
tance over the gum, and have perforations through which to throw a stream 
of liquid for the purpose of cleanliness. This splint, when placed in position, 
forms a cap, and is kept in place by securing the jaws together with a 
bandage, or by means of screws passed between the teeth. 
A third splint of Dr. Gunning’s, one which he uses in cases where the 
teeth have been lost, is formed by connecting steel branches with the inter- 
dental part of the apparatus, of which the up- 
per branch passes along the superior part of 
the face, and the lower one along the outside 
of the lower jaw ; these are kept in place by 
three bands, one being placed at the chin in 
order to hold the jaw up in the splint, one run- 
ning from the metal band to the back of the 
neck, and one passing to a cap which is worn 
over the head, and with wThich the splint is 
connected. (Fig. 670.) 
Kingsley, of New York, a very ingenious 
dentist, forms a simple splint from vulcanized 
rubber. In its preparation an impression of 
both jaws is taken in plaster,—the lower jaw 
with its deformity or displacement. The im- 
pression of the latter is divided at the place of 
fracture, and then united so as to conform to 
that of the upper jaw. From this mould of 
the lower jaw the rubber is fashioned into the 
proper form: from it pass steel rods of light 
wire one-sixteenth of an inch thick, which, when the splint is introduced 
into the mouth and adjusted, run from the corner of the mouth along the 
Fig. 670. 
Gunning’s interdental splint applied. 
* Richmond Medical Journal, February, 1866. 886 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
side of the cheek, terminating in front of the ear. (Fig. 671.) When ap- 
plied, the teeth occupy the cavities in the splint, the latter being kept in 
position by a strip of roller passed beneath the chin from one arm of the 
apparatus to the other. 
The splint of Dr. Bean resembles closely that of Dr. Gunning, and is well 
Fig. 671. 
suited for the treatment of comminuted fractures of either jaw. It is con- 
structed of vulcanized rubber, and is fitted to the teeth of both the upper 
and the lower maxilla, by an impression previously taken in wax. (Fig. 672.) 
The splint, when applied, is kept in position by straps which pass over and 
around the head, and also behind the neck. (Fig. 673.) During our late 
war Dr. Bean had charge of a hospital at Macon, Georgia, especially set 
apart for injuries of the jaws, in which over forty cases, attended with pecu- 
liar complications, were treated with the most satisfactory results. 
It will be perceived that all these splints must have a limited value, as 
their construction requires a degree of manual skill not generally possessed. 
Kingsley’s interdental splint. 
Fig. 673 
Fig. 672. 
Bean’s interdental splint. 
In cities or towns where the services of an intelligent dentist can be com- 
manded, their value in many instances cannot be overestimated. 
Professor Hamilton, in 1849, introduced to the notice of the profession* a 
method of preparing gutta-percha for interdental appliances which places 
them within the reach of every one. 
He directs that pieces of the gum be immersed in hot water, and. when 
well softened, moulded into wedge-shaped blocks. These are carried be- 
tween the back teeth on each side of the jaw, observing to bring the pieces 
Bean’s splint applied. 
* Buffalo Medical and Surgical Journal, vol. vi. p. 144, August, 1849. FRACTURES OF THE INFERIOR MAXILLA. 
887 
on the side of fracture sufficiently far forward to include the line of frac- 
ture. After these pieces have been adjusted, the fingers are placed under 
the body of the jaw, pressing it firmly up, closing the mouth, and embedding 
the teeth in the plastic gum. The fingers passed along the base of the jaw 
will ascertain if the line is uniform or if the fragments are on a level. A 
few minutes will suffice to harden the gum, when the mouth may be opened, 
and the splints removed and turned into shape, after which they can be 
re-inserted and the jaws bound together with one of the dressings already 
described. 
In certain cases of unmanageable displacement, the fragments have been 
drilled and secured together by silver wire. A case of this kind is reported 
by Kinloch, of Charleston,* and another by In the last the 
bone was broken during the operation of trephining: the wire was intro- 
duced at once. 
By means of a delicate drill and silver or iron wire, the coaptation may 
be quickly effected, and when the usual resources at the command of the 
surgeon have been exhausted, this plan may be adopted without hesita- 
tion. In applying this suture, a deep hold should be taken in the bone, as 
I have seen the wire cut out in a few days when this precaution had been 
neglected. 
►Should there bo much contusion of the soft parts, a water-dressing will 
answer the best purpose, to which may be added laudanum in case the 
patient experiences severe pain. If an external wound exists, it should be 
closed with the silver suture. 
When the secretions which empty into the mouth become offensive, the 
patient may use, with great advantage, some deodorizing fluid, two or three 
times a day. The permanganate of potash, carbolic acid, and the chlorinated 
washes are too repugnant to the taste. The wash which I prefer is a decoc- 
tion made from the berries of the Bhus glabrum, to which may be added 
chlorate of potash, with a little tincture of myrrh. 
The food of the patient should consist of liquids, such as milk and nutri- 
tious broths, which can in almost all cases be readily drawn into the mouth 
through the apertures between the teeth. Cases have occurred in which this 
could not be done: under such circumstances it would be proper to resort to 
an interdental splint, the simplest being the rubber wedges of Hamilton, 
already described. 
Delayed Union.—Should the bone fail to unite, we must endeavor to excite 
the parts by a local stimulus. The ends of the fracture may be violently 
rubbed against each other. In two cases I succeeded in securing union by 
boring into the ends of the fracture with an awl-shaped drill and afterwards 
putting the jaw up in a Barton bandage. Physick introduced a seton between 
the fragments. In a case reported,| the seton was allowed to remain three 
months, and the cure was complete. A third method consists in drilling and 
wiring the fragments together,—a plan both simple and efficacious. If the 
case is one of long standing,—ten or twelve months,—a thin-bladed knife 
should be passed between the contiguous surfaces of the fracture, to divide 
any cartilaginous incrustation, before using the drill. Premature operations, 
however, are to be deprecated, as fractures of the inferior maxilla may, like 
fractures in other bones of the skeleton, in some instances be very slow in 
uniting, and yet may ultimately consolidate under the ordinary dressings. In 
this wajH have succeeded in establishing firm union of the lower jaw where 
the fragments have remained movable for a period of four months. 
The state of the general health must not be overlooked in these cases of 
delayed union, and where any retarding cause of a constitutional nature can 
be ascertained, it should, as far as possible, be removed. 
* American Journal of the Medical Sciences, July, 1859. 
t Fractures and Luxations, p. 120. 
j Philadelphia Journal of the Medical and Physical Sciences, vol. v. p. 116. 888 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Gunshot Wounds of the bones of the face produce the greatest comminu- 
tion and subsequent deformity. The general rules to be observed in their 
management are the following: 
First. Control of hemorrhage, if any be present. 
Second. The removal, as far as possible, of the vulnerating body, either 
through the mouth or through the face, as i£ most convenient. 
Third. The dressing of the wound. 
Any fragments of bone which are not entirely detached should be pre- 
served. This injunction is less important in fractures of the lower jaw than 
in those of the upper. 
Fractures of the Hyoid Bone. 
Sheltered as the hyoid bone is by the lower jaw, it is seldom the subject 
of fracture ; yet we have quite a number of such accidents recorded. A single 
author* has collected the histories of thirteen cases. 
The cause of this fracture is generally constriction of the neck by a cord, 
as in hanging, or by the grasp of the hand, as when a person in a quarrel 
seizes an antagonist by the throat. A blow or a fall upon the front of the 
neck may produce a similar effect. 
Hamilton, in an analysis of ten cases,f found that three were produced by 
hanging, three by grasping the throat between the thumb and fingers, three 
by blows or falls upon the front of the neck, and one by muscular action. 
Malgaigne gives an instance of a fracture of this bone by the last-named 
cause ; at least it was so believed by Ollivier of Angers, from whom he quotes. 
When produced by hanging, the fracture appears to take place in the body 
of the bone, but when caused by the grasp of the hand, the cornua generally 
suffer. The latter is easily understood, as the force presses the horns of the 
bone towards each other; but why the body should yield first in persons who 
are executed by hanging is not so readily explained. 
Symptoms.—There is pain in the submental region, aggravated by move- 
ment of the neck or of the tongue. Thus, in swallowing, speaking, or even 
opening the mouth, the suffering is so acute that the patient avoids every 
motion of the kind. The relation and the anatomical connections which 
exist between the pharynx and the larynx are such that the former cannot 
move without affecting the latter: so that the patient may be entirely unable 
to swallow. Again, the contiguity of the cornua and the body of the hyoid 
bone to the opening of the larynx is such that the inflammatory swelling 
following such an accident may embarrass the respiration and threaten 
suffocation. Preternatural mobility and crepitus in some cases will be recog- 
nized, though in others these signs may be absent or may escape detection. 
Sometimes the patient, in an attempt to swallow, will feel crepitus when it 
cannot be heard. Displacement can be best detected by introducing a finger 
into the pharynx. The injury may be attended with a discharge of blood 
from the fauces, and after a time eechymosis will appear in the subcutaneous 
tissue of the neck. 
Prognosis.—Although the fixation of the fracture must be, in a great 
measure, impracticable, yet, unless there is some complication in the shape of 
damage to the larynx or in the formation of an abscess, a favorable result may 
be expected. Should a portion of the bone impinge upon the entrance of the 
larynx, the patient’s life might be jeopardized. A case has been recorded in 
which death followed a fracture of the hyoid bone, through one of its great 
horns being thrust between the epiglottis and the rima glottidis.J The 
displaced horn produced a harassing cough and hectic fever, which finally 
wore out the patient. Malgaigne mentions a ease related by M. Ollivier,§ in 
* G. D. Gibb, M.D., Diseases and Injuries of the Hyoid Bone, London, 1862. 
f Fractures and Luxations, p. 136. 
j British and Foreign Medical Review, 1851, vol. viii. 
| Malgaigne on Fractures and Luxations, Packard’s trans., p. 328. FRACTURES OF THE LARYNX AND TRACHEA. 
889 
which the great horn, after its fracture, became necrosed, and was finally 
discharged through a sinus in the neck, the patient recovering with a sub- 
sequent difficulty in deglutition. 
Treatment.—If there is displacement, an attempt should be made to cor- 
rect it, and this can only be done by operating with one finger in the pharynx 
and the other on the outside of the neck, in this manner pushing the detached 
fragment outward and forward, and afterwards endeavoring to maintain the 
adjustment by position and absolute quiet. The patient must abstain from 
opening the mouth, from speaking, and from swallowing. If we consider the 
anatomical relations of the great horn of the hyoid bone, we shall see that, 
aside from the fracturing force, there is only one muscle favorably situated 
to produce displacement, and that is the middle constrictor of the pharynx. 
The great horn is suspended between the thyro-hyoid muscle and ligament 
below and the hyo-glossus muscle and digastric aponeurosis above ; and these 
constitute mutual checks to either upward or downward displacement. The 
middle constrictor, however, passing forward, downward, and a little out- 
ward, will, when the separation of the horn from the body takes place, draw 
the former upward, backward, and inward. In view of these facts, what 
position secures the best adjustment ? On this subject there is some differ- 
ence of opinion among writers. The one which I regard as best calculated to 
approximate the fragments is that in which the head occupies its natural 
position in relation to the neck,—that is, neither extended nor flexed. 
As articulation and deglutition are both acts which favor displacement, 
the patient must not speak, and for the first three or four days should be 
nourished by nutritious enemata. After this, liquids may be taken by the 
mouth, and if the suffering in swallowing is great, resort may be had to the 
oesophageal tube to convey food into the stomach. 
Inflammatory symptoms must be combated by leeches and anodyne 
lotions, and if any mechanical obstruction to the entrance of air into the 
larjnx should threaten suffocation, tracheotomy or laryngotomy will be de- 
manded. 
Fractures of the Cartilages of the Larynx and Trachea. 
The cartilages of the larynx are not often broken, but, when the accident 
occurs, the danger to the life of the patient is most imminent. As these car- 
tilages undergo ossification in advanced life, the presumption would be that 
such injuries occur only in aged pei’sons ; but the cases recorded lead to a dif- 
ferent conclusion. Dr. William Hunt, in his valuable paper on this subject,* 
gives five cases occurring in childhood; and of the twenty-nine reported, 
as far as could be learned, fifteen of the patients were not over fifty-five 
years of age. 
Although all the cartilages, and sometimes the trachea in addition, are 
sometimes broken, yet the thyroid, from its prominence, is most frequently 
damaged ; next in order is the cricoid. The table of IIenoque,f with the ten 
cases of Durham, exhibits, in the sixty-two examples of laryngeal fractures, 
twenty-four of the thyroid and eleven of the cricoid cartilage. 
Causes.—The same causes that produce fracture of the hyoid bone will 
break these cartilages, such as blows on the front of the neck, violent com- 
pression of the neck by the grasp of the hand, or by a cord, in suicidal at- 
tempts. If the parts become displaced, the most urgent symptoms arise. 
Symptoms.—There is pain, followed by rapid swelling and deformity of the 
neck. Sometimes there is an unusual prominence, at other times a flattening, 
of the larynx,—the difference being determined by the manner in which the 
fracture is produced. When caused by a grasp, thus pressing the alee of the 
thyroid cartilage towards each other, there will be a prominence; if, on the 
other hand, the injury is inflicted by a blow applied in front, the deformity 
* American Journal of the Medical Sciences, April, 1866. 
f Holmes’s System of Surgery, vol. ii. p. 462. 890 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
will consist in flattening. Bloody expectoration, emphysema of the neck, 
and alteration or entire loss of the voice, are present. The respiration and 
deglutition become difficult. Dyspnoea is among the most common phe- 
nomena of the injury. In seven out of the nine cases recorded by M. Cavasse 
it existed. In a case which I saw with Dr. Hunt it was urgent, and it was 
also present in the instance narrated by Stokes, of Dublin* In some cases 
the tongue becomes swollen and protrudes from the mouth. Ecchymosis, 
mobility, and crepitation are also among the signs of the accident. Often 
the swelling is so great that the last two symptoms cannot be detected. 
The obstruction to the respiration is accompanied by lividity of the face, a 
feeble and frequent pulse, and a cold perspiration. 
The extravasated blood which follows the injury may be subcutaneous, 
or beneath the deep cervical fascia, or submucous; or it may be in all these 
situations at the same time. 
When the dyspnoea comes on immediately after the accident, it is due either 
to extravasated blood or to displacement of the fragments of the cartilage; 
and when it appears later, it can only be referred to serous effusion or to 
inflammatory swelling. 
Prognosis.—The surgeon should regard every case of fracture of the larynx 
as an injury of the most serious nature, and should be exceedingly cautious 
and reserved in venturing an opinion as to the final result. Even though 
none of the urgent symptoms detailed may be present, the results of the 
subsequent inflammation may quickly change the entire aspect of the case. 
Of the sixty-two cases collected by M. Henoque, fifty proved fatal and twelve 
recovered; of the twenty-seven cases analyzed by Dr. Hunt, ten recovered 
and seventeen died. 
Treatment.—Where the case is one of simple fracture, without bloody ex- 
pectoration, dyspnoea, or other urgent symptoms, the treatment will consist 
in enforcing absolute silence, as all movements of the tongue tend to displace 
the fracture. The patient is to abstain from swallowing; but pieces of ice 
may be allowed to melt in the mouth. He should be nourished for the first 
few days by the rectum, using milk and beef essence as enemata. If inflam- 
matory symptoms arise, leeches must be freely applied to the neck ; and to 
relieve pain and nervous excitement either hypodermic injections of morphia 
or suppositories of opium can be exhibited. Our great resource, however, is 
tracheotomy; and whenever emphysema and bloody expectoration appear, 
the operation should be done without delay. Dr. Hunt states that there is 
no instance of recovery on record, without opening the windpipe, when these 
symptoms existed. Of the eight operated on, six recovered and two died ; 
four got well by antiphlogistic treatment; these, however, were separations 
in the median line, and had neither bloody expectoration nor emphysema. 
After the introduction of the tracheal tube, the surgeon should, as far as 
possible, correct any displacement which may exist, by carrying a director 
through the trachea, when inflammation is not present; should this fail, 
he is justifiable in separating, by incision, the alae of the thyroid cartilage 
for that purpose, if there is ground for believing that the cavity of the larynx 
is seriously encroached upon. The patient may, after tracheotomy, be allowed 
to swallow nutritious liquids by the mouth. 
Unpromising as a rupture of the trachea may be, yet such an accident is 
not altogether hopeless. Mr. Long, of Liverpool,f relates the case of a laborer 
who had his trachea divided by the coupling-irons of two railroad-carriages, 
inflicting at the same time an external wound. By frequently sucking the 
blood out of the trachea by means of a long canula, the man recovered, the 
gap, it was believed, being filled with connective tissue, arranged so as to form 
a tubular communication between the ends of the trachea for the passage 
of air. 
* Dublin Quarterly Journal of the Medical Sciences, May, 1869, p. 307. 
f Medical Times and Gazette, July and October, 1856. FRACTURES OF THE RIBS. 
891 
FRACTURES OF THE BONES OF THE CHEST. 
Malgaigne alleges that solutions in the continuity of the ribs are the most 
common of all fractures.* At the Hotel-Dieu they amount to one-ninth of 
the whole number treated. claims about the same proportion for 
those received into Guy’s Hospital. Of 2275 fractures treated in that insti- 
tution during a certain period. 222 were fractures of the ribs. I doubt very 
much if so large a proportion is met with in American hospitals. Among 
the 2208 fractures treated in the Pennsylvania Hospital during twenty years, 
and tabulated by Norris,| there were 88 fractures of the ribs; and of the 
6480 comprised in the collection of Willard, from the same institution, 221 
were fractures of these bones. 
No age can be said to be exempt from this accident, although it is most 
common to persons in middle and in advanced life. In the young, the great 
mobility and elasticity of the thoracic walls constitute an important protec- 
tion against fracture. The ossification of the cartilages, and the fatty de- 
generation which the costal pieces undergo in the aged, render them less 
able to resist injury. The majority of cases which have come under my own 
observation have been in persons of mature life. Males suffer oftener than 
females. 
These fractures are either complete or incomplete. The former are some- 
times called fissures. Even in a complete fracture the periosteum may not be 
severed. 
Causes.—The causes which produce fracture of the ribs are numerous: 
among the factors may be mentioned falls, blows, kicks from horses, the pas- 
sage of wagon-wheels over the body, the falling of earth-banks, and extreme 
pressure and counter-pressure. Cases are recorded in which muscular action, 
as in the act of coughing, was sufficient to produce this injury. Malgaigne 
has collected seven instances of this kind.§ Nancrede metwitb a case of frac- 
ture of the second rib, in a gardener, brought to the Episcopal Hospital, in this 
city, which was produced by muscular effort in straightening a scythe-blade. || 
There was probably some defect in the bones of these patients, rendering 
them preternaturally brittle. The causes which operate to produce a fracture 
of the ribs act either laterally or antero-posteriorly. If in the first direction, 
as when the wheel of a loaded wagon passes over the side of the chest, or 
the body falls violently sidewise against some projecting object, the fracture 
will take place near the point where the force is applied. If the violence 
is applied after the second manner, that is, antero-posteriorly, thus forcing 
the sternal and vertebral ends of the rib towards each other, thereby in- 
creasing the convexity, the fracture will take place near the summit of the 
arch, or remote from the place where the force is applied, constituting an 
“ indirect fracture.” In fractures caused by direct force, the internal surface 
of the bone first gives wTay, while in those produced by indirect force, the 
external fibres of the rib yield first. There is a difference of opinion as to 
the most common seat of costal fractures. Malgaigne states that the anterior 
third is the part most commonly broken. This does not accord with my ob- 
servation, in regard either to cases treated or to cabinet specimens which 
I have examined, the great majority of which have been on the vertebral 
side of the middle (Eig. 674), or somewhat anterior to the angle of the bone. 
Second in order of frequency come fractures at the anterior third. 
Fractures may occur simultaneously on both sides. Certain ribs, by reason 
of their situation, as the first and the second, being protected by the clavicle, 
Fractures of the Ribs. 
* Treatise on Fractures, Packard’s trans., p. 346. 
f Holmes’s System of Surgery, vol. ii. p. 554. 
j Contributions to Practical Surgery, p. 143. 
$ Treatise on Fractures, Packard’s trans., p. 348. 
|j Philadelphia Medical Times, May 23, 1874, p. 535. 892 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
are rarely broken ; others, like the eleventh and the twelfth, escape injury 
in consequence of their mobility. A case of fracture of the first rib was 
recently reported in the London “ Lancet and two similar fractures have 
been received into the Pennsylvania Hospital. W. Arbuthnot Lanef esti- 
mates the frequency of fractures of the first rib, as compared with that of 
Fig. 674. 
Fracture of a rib at its vertebral and also at its sternal extremity. 
other fractures, at three per cent. His observations were made on dissecting- 
room subjects, numbering somewhat less than two hundred. My own ob- 
servations on a similar class, however, do not furnish so large a percentage. 
The occurrence of the fracture is believed to be due to force transmitted 
through the clavicle. The ribs between the third and the eighth are those 
most exposed to fracture. Sometimes two or more breaks are met with 
in the same rib. The direction of the fracture may be transverse or oblique, 
although in gunshot injuries it is sometimes longitudinal. 
The displacement may be inward or outward,—inward when the frac- 
turing cause has been direct, outward when indirect; though, as a general 
rule, there is not much disarrangement of the fragments. This fact is attested 
by most of the museum specimens of this injury. Vertical displacement of 
broken ribs is counteracted by the intercostal muscles and aponeuroses; 
overlapping, by the decussation of the fibres of the same muscles, and by the 
fixed condition of the vertebral and sternal attachments of the bone. Dis- 
placement in the axis of the rib is prevented by diminished activity in the 
respiratory movements of the thorax after this injury. 
Complications.—These fractures may be complicated by rupture of some 
of the fibres of the great pectoral or of the external oblique muscles ; by the 
presence of an external wound, constituting a compound fracture; by lesion 
of the pleura, exciting pleuritis ; by injury to the lung, producing hemorrhage, 
pneumonia, or emphysema ; by laceration of the intercostal vessels, followed 
by hemorrhage ; by damage to the intercostal nerve, exciting neuralgia; by 
injury to the pericardium and the heart or its blood-vessels; by asthma or any 
chronic cough ; and, lastly, by injury to the diaphragm or to the contiguous 
abdominal viscera. The proportion of complicated fractures is well shown 
in Guy’s Hospital Reports for 1860, vol. vi., where 136 cases are recorded, 
of which only 28 were complicated, and 16 of these were rendered so by the 
occurrence of emphysema, Of 221 cases of this fracture brought into the 
Pennsylvania Hospital, only 8 were complicated. 
Symptoms.—A patient with fractured ribs complains of pain at the seat 
of injury, which is greatly intensified by any attempt at full breathing. On 
this account, he avoids, as much as possible, using the thoracic muscles of 
respiration, accomplishing the work by means of the diaphragm and the ab- 
dominal muscles. If asked to make a full inspiration or to cough, these acts 
are abruptly stopped by a severe stitch, and in making the attempt the patient 
will perhaps feel the grating of the broken ends of the bone. Crepitation, 
which is the most reliable sign, may be ascertained either by placing the hand 
over the seat of injury and then directing the patient to attempt a full in- 
spiration or a prolonged expiration, or by the ear being placed over the part 
* London Lancet, 1888, i. 1291. 
f Boston Medical and Surgical Journal. FRACTURES OF THE RIBS. 
893 
during similar movements. Unusual movement and crepitus may occasionally 
be recognized by placing the fingers on the sternal and vertebral sides of the 
suspected point of injury, and alternating the pressure. When the lung is 
wounded, the injury will be indicated by an emphysematous state of the 
cellular tissue over the exterior of the chest, which may be known by the 
peculiar crackling or crepitation felt and heard when the skin over the thorax 
is pressed upon. When the lesion of the lung is deep, haemoptysis will be 
present. 
Prognosis.—In uncomplicated cases the prognosis is always favorable. 
The union of the fragments is accomplished in about one month. A few 
examples of ununited fractures are recorded. Malgaigne furnishes one in 
which there existed a capsular ligament lined with a synovial membrane.* 
A singular specimen is in the museum of the College of Surgeons, England, 
in which a mass of callus envelops the broken ends, holding them together, 
although no union has taken place at the extremities of the bone.j" Bridges 
of bone sometimes extend from one rib to another. (Fig. 675.) There is 
always present an ensheathing callus, which will be found to be very smooth 
and small in quantity on the inner side of the fracture. 
In complicated cases the prognosis 
will depend on the organ involved and 
the extent of injury sustained. If the 
pericardium or heart is wounded, death 
will quickly follow. A slight injury to 
the pleura, producing traumatic pleu- 
risy, is not often serious, as the inflam- 
mation is usually quite circumscribed, 
and ceases on the removal of the cause. 
Should we be unable to correct the dis- 
placement which produces it, the result 
may prove unfavorable. If the lung 
is wounded, there is always cause for 
anxiety. When the lesion consists only 
of a scratch, it does not seriously com- 
plicate the case ; but when the organ 
is penetrated by one of the fragments, 
the worst consequences may be appre- 
hended. Should the patient not perish 
from hemorrhage, the risks of pneumo- 
nia or of abscess remain to be encoun- 
tered. 
When the chest has been subjected 
to great violence or to concussion, the 
patient may die in a state of profound 
collapse. 
Of 28 cases of fractured ribs treated 
in Guy’s Hospital and complicated by 
lung-injuries, Mr. Bryant informs us 
that 8 died. The mortality attending 
all fractures of these bones, as derived 
from the statistics furnished by the Pennsylvania Hospital, will be seen by 
a reference to the table, namely, 32 deaths in 309 fractures. 
A wound of the intercostal vessels may be considered a grave complica- 
tion, especially when produced by a gunshot. Of 15 cases of this injury 
reported during the late American war, 11 died. As much as four pounds 
of blood was found in the chest in one instance following an injury of these 
vessels. Should the diaphragm be impaled by the broken bone and an 
abdominal viscus be injured, a fatal result may be looked for. 
Fig. 675. 
Fracture of ribs, with ensheathing callus, and 
with bridges of bone uniting adjoining ribs.—Mal- 
gaigne. 
* Treatise on Fractures, Packard’s trans., p. 353. 
•j- Holmes’s System of Surgery, vol. ii. p. 559. 894 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
A traumatic pleuritis, or a pneumonia, which may follow a fracture of the 
ribs is generally local, and by no means so grave, in my experience, as the 
same affection when arising from idiopathic influences. If the patient is 
aged and the subject of any pulmonary disease, such as chronic bronchitis, 
or asthma, and if, in addition, there is any costal displacement in the direc- 
tion of the pleura, or of the lung, an unfavorable termination is probable, 
unless the attending cough can be controlled by the usual remedies. 
Treatment.—The local treatment consists in securing quiet to the frac- 
tured rib. There are several ways of effecting this end. If called to a 
patient after such an injury, and before he has been removed from the place 
of the accident, a temporary dressing should be applied. A handkerchief 
for this purpose may be pinned about the chest, or the vest may be taken 
up with pins in such a way as to give an excellent support to the ribs. The 
permanent dressing may consist of adhesive strips, the plaster splint, a broad 
encircling bandage, or a wide roller. The adhesive plaster may be applied in 
one broad sheet, or, what is better, in several strips. These strips should be 
from two to two and a half inches wide, and long enough to extend over the 
affected side from the spine to the middle of the sternum. They should not 
only support the fracture, but should also cover two or three ribs above and 
the same number below the injured bones, and be applied parallel with the 
course of the ribs. (Fig. 676.) This method of treating fractured ribs was 
introduced into practice by Ilannay, of England, and should take precedence 
of all others. 
A very secure and comfortable dressing can be made in cases where a bi- 
lateral fracture of some of the ribs occurs, by first enveloping the thorax 
with a thin gauze flannel shirt, and 
afterwards surrounding it with the 
plaster roller. 
A third method consists in surround- 
ing the chest with a broad piece of stout 
muslin or cotton flannel, making it se- 
cure with pins, and preventing it from 
slipping down by two strips passing 
over the shoulders and fastened to the 
front and back of the bandage. (Fig. 
677.) 
Fig. 676. 
Fig. 677. 
Adhesive strips applied. 
Double T of the chest applied for fracture of the ribs. 
Sometimes the chest is covered in by circular and spiral turns of a roller 
three inches wide. 
There are valid objections against all plans of dressing which entirely sur- 
round the thorax. They restrain to a very uncomfortable degree the muscles 
of respiration, when it is desirable that they should be left free on the un- 
injured side. In patients suffering from asthma, or from any disease of the 
lungs, the distress is peculiarly severe. Except, therefore, in cases where the 
ribs are broken on both sides, this mode of treatment should be abolished. FRACTURES OF THE COSTAL CARTILAGES. 
895 
It is not necessary that the patient should remain in bed, unless the injury 
has been more than ordinarily severe; and when this is the case the semi- 
recumbent position, generally speaking, is the one which affords the most 
comfort. A patient will intuitively take the posture which gives the most 
relief. 
When external displacement exists, the fragments should be pressed into 
place before applying the dressing. When the displacement is inward, 
the fragments may be sprung into position by pressing the sternum back 
towards the spine. The adjustment can sometimes be effected by the motion 
communicated to the fragments in breathing; but, as all voluntary efforts 
of this kind are very painful, ether may be administered. The long, full 
inspirations which attend complete anaesthesia constitute a powerful means 
of reduction. Where one fragment is depressed. Malgaigne speaks favorably 
of pressing the other down until it touches its fellow. Should their serra- 
tions become locked, the elasticity of the fragment pressed down, when it is 
released, will raise the other into position. Cases may occur, though they 
are certainly very rare, in which the displacement of the rib inward may 
create such urgent symptoms as to render interference imperative: when so, 
the most practical method of restoring the parts to the proper position would 
be to use a strong hook with a moderate curve and sufficiently sharp to 
penetrate the soft parts. This could be entered along the upper border of 
the depressed rib, in order to avoid the vessels, and then passed to its inner 
surface, when the fragments could be drawn out. The manoeuvre is not a 
difficult one on the cadaver. 
The existence of emphysema, which can be recognized by the crepitation 
or crackling on pressure, does not, in most instances, seriously complicate 
the case. It may be safely let alone, as the air will be gradually absorbed. 
If an exceptional case should occur, where its accumulation becomes so great 
as to produce serious embarrassment to the function of respiration, punctures 
might be made in the soft parts for its liberation. 
Hemorrhage, when present, will result either from a wound of an inter- 
costal vessel or from injury to the lung. 
If there is an external wound, with comminution of a rib, and attended by 
hemorrhage, as frequently occurs in gunshot injuries, the fragments should 
be removed. If the fracture is a compound one, without comminution, and 
there is reason to believe that an intercostal artery has been torn, the vessel 
may be tied according to the plan directed under the head of gunshot wounds 
of the chest, provided the bleeding is profuse. If no external wound exists, 
the assumption that the hemorrhage comes from an intercostal, in any case, 
would be a matter of so much uncertainty as to render any operative inter- 
ference improper. 
Pneumonia and pleuritis are generally quite circumscribed, and yield to 
rest, counter-irritation, and opiates. Should they prove to be severe, local 
blood-letting, vesication, and external warmth will be demanded. In cases 
of cough, anodynes become indispensable. 
Fractures of the Costal Cartilages. 
Zwinger, in 1698, noticed such a fracture while making a post-mortem, and 
so also did Lobstein, in 1805. Magendie appears to have seen as many as five 
cases in two years. Gurlt and Paulet together have collected forty cases. 
These fractures are by no means common. The great elasticity of the carti- 
lages doubtless explains their immunity, and while we would naturally expect 
the accident to take place in persons advanced in life, and in whom these 
structures were ossified, yet such is not always the case. Of the three cases 
seen by Malgaigne, one was a boy of seventeen. The case given by Pyper,* 
of a man twenty-five years old, who had a fracture of the cartilages of the 
sixth, seventh, and eighth ribs, was one in which there was no ossification. 
* Lancet, October, 1844. 896 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
The cartilages of the seventh and eighth ribs appear to be the ones most 
commonly broken. The line of separation is always transverse, and the 
fragments are without serrations. The displacement varies in different 
cases. When the cartilage is broken near to the sternum, the sternal will 
generally be in front of the costal fragment; and when the fracture occurs 
near to the rib, the reverse will be true. In some instances there is no dis- 
placement whatever. 
The repair of such fractures is usually by a ferule of bone, which not only 
surrounds the fragments, but extends between their ends. Sometimes union 
does not take place, and a false joint results. In St. Bartholomew’s Hospital 
there are two specimens in which the union appears to have been effected by 
cartilage. Fibrous tissue may also unite the ends together. 
Causes.—These are of the same nature as those which produce fracture 
of the ribs, only intensified in violence, and hence we find, in several of the 
recorded cases, that severe internal injuries accompanied the accident. 
Symptoms.—The signs of the accident are pain, deformity, undue mobility, 
and crepitation. The pain is aggravated both by inspiration and by expiration, 
especially when these movements of the chest are carried beyond a certain 
point. The deformity appears as an undue prominence, due in a measure to 
the elasticity of the cartilage. Both unusual mobility and crepitus can be 
detected by applying pressure over the seat of fracture, but the crepitus is 
neither so rough nor so distinct as that which results from rubbing together 
the ends of a broken bone. 
Treatment.—The treatment does not differ from that proper in cases of 
broken ribs. Adhesive strips, or a compress, placed over the seat of frac- 
ture and secured by enveloping the chest with a broad bandage, answer 
every purpose. Malgaigne has employed a truss in cases of displacement, 
the pad resting over the broken cartilage and the spring passing half-way 
round the chest. When such fractures are kept in position, they heal in 
four or five weeks. 
The sternum, supported as it is on the ends of elastic levers, and therefore 
being very movable, is rarely the subject of fracture. Some idea may be 
formed of the infrequency of the accident, when it is stated that only one 
case was admitted into the Hotel-Dieu in eleven years. Lonsdale saw but 
two cases out of 1901 fractures which were admitted into the Middlesex Hos- 
pital. During five years only two cases were met with at Guy’s Hospital, and 
but one of these was recognized during life. It is quite possible that the 
injury is often overlooked, a supposition which is strengthened by the state- 
ment that during four years—from 1857 to 1860—only nine cases were 
admitted into the wards of St. George’s Hospital * It occurred 13 times at 
the Pennsylvania Hospital in 8662 cases of fracture. 
Causes.—This fracture may be produced by direct violence, as when the 
body is run over by the wheels of a loaded wagon, by the kick of a horse, 
by the stroke of a carriage-pole, or by the caving-in of an embankment. 
Indirect force may also produce this fracture. Numerous cases of this 
kind are recorded. Cruveilhier met with one in which the patient fell 
from a height and alighted upon his buttocks.f A patient was received 
into St. George’s Hospital]; with a fracture of the sternum produced by 
falling headforemost from a hay-wagon and striking the ground with the 
head bent forward. Gross§ and others record cases of such fractures fol- 
lowing falls, where the persons have alighted upon the feet. The injury 
may also be caused by falls on the back, as were those related by David 
in his “Memoir on Counterstroke,” by Sabatier,|| and by 1 can- 
Fractures of the Sternum. 
* Holmes’s System of Surgery, vol. ii. p. 563. 
f Cruveilhier, Bulletin de la Soci6t6 Anatomique, June, 1826. 
J Medico-Chirurgical Review, 1832, vol. xx. p. 536. 
|| Memoire sur la Fracture du Sternum. 
$ Surgery, vol. i. p. 964. 
Bulletin de Therapie, t. vi. FRACTURES OF THE STERNUM. 
897 
not avoid the conclusion that in these cases there was a muscular element 
at work in determining the fracture, rather than the factor of indirect 
force. It is very difficult to ascertain with any certainty the exact position 
of the body of a falling man in the brief but different stages of his descent, 
or to estimate the almost superhuman muscular efforts made by a person 
under such circumstances. In all cases in which the body is greatly ex- 
tended, the sternum is acted upon by forces operating at each extremity 
of the bone, through the sterno-cleido-mastoid, sterno-hyoid, and sterno- 
thyroid muscles above, and the abdominal muscles belowq which are quite 
sufficient to cause a fracture of a spongy bone like the sternum. It is in 
this way that this bone has been broken in parturition, as in the two cases 
related by Chaussier,* to which may be added those of Malgaigne and Pack- 
ard, and one by Borland.f Faget, of Mexico,J mentions an instance of this 
accident, caused by muscular action, in the person of a “ showman,” who, 
while attempting to lift some heavy weights in his teeth while his body was 
forcibly bent backwards, broke the sternum. Gurlt also supplies a case of a 
similar kind. Even a forcible contraction of the diaphragm has been known to 
produce a fracture of the sternum.§ The patient was the victim of scirrhus 
of the stomach, which provoked frequent and violent vomiting: the fracture 
was at the upper third of the sternum, where the bone was said to be sound in 
structure. YVhen the fracture takes place in forcible flexion of the body, it 
seems probable that the lower end of the sternum is fixed by the diaphragm, 
while the upper extremity is driven downward and forward by the force. 
The seat of fracture may be in the manubrium, at the junction of the latter 
with the body of the bone (Fig. 678), in the body, or at the point of union 
between the xiphoid appendix and the body. When 
in the first situation, it has been regarded as merely 
an example of diastasis; but if the ossific union had 
been established before the fracture occurred, it would 
be obviously improper to regard the case as one of 
diastasis. When the body of the sternum is broken, 
the lesion occupies generally one of the lines which 
indicate the former separation of the bone into dis- 
tinct pieces. 
Professor Hamilton records the case of a man, 
twenty-eight years old, who fell upon a candlestick, 
breaking the xiphoid appendix from the body and 
driving it directly backward towards the spine. The 
patient suffered from frequent attacks of vomiting, 
but recovered with the fracture unreduced. 
The manubrium is rarely broken. Of 7 cases of 
fracture of the sternum admitted into the Pennsyl- 
vania Hospital, 1 was in the manubrium, 2 were in the 
body, and 4 in the gladiolus. Fractures of the sternum 
are sometimes comminuted, but rarely compound. 
The direction of the fracture is approximately trans- 
verse ; in a few instances it is longitudinal. 
The displacement is determined by the direction in 
which the fracturing force acts. When the injury is produced by extreme 
extension of the body, the lower fragment is displaced forward, and may 
overlap the upper one slightly, whilst in those produced by flexion the upper 
fragment takes a position in front of the lower one. being driven in the 
direction of the incline, the lower part of the bone being fixed by the bent 
position. Unless some unusual influences such as the above are operating, 
there may be no displacement whatever, the parts being held together by 
Fig. 678. 
Fracture at the junction of 
the manubrium with the body 
of the bone.—Malgaigne. 
* Revue Medicale, 1827, t. iv. p. 260. 
•f Boston Medical and Surgical Journal, April 20, 1875, Hamilton, 
j Roger Dulos, Maladies du Sternum, These Inaugurale, Paris, 1835, Malgaigne. 
$ Gazette des HOpitaux, March 20, 1830. 898 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the aponeurotic expansion of the pectoral muscles in front and the strong- 
membranous expansion behind the bone. 
Symptoms.—The patient is often able to recognize the cracking of the bone 
at the time of the injury. Severe pain is experienced in the parts, which is 
aggravated by any cause producing disturbance of the fragments, such as 
full breathing, pressure, or coughing. Crepitus may be heard or felt by 
placing the ear or the hand over the seat of fracture and urging the patient 
to breathe as strongly as possible. Discoloration and swelling soon follow 
the accident. The sternum is one of the bones of the skeleton which ex- 
hibit a singular variety of form. Some of these malformations are congen- 
ital, others are induced by mechanical causes, and are often so peculiar that 
they might readily be mistaken for the deformity attending a fracture. 
Complications.—These are such as grow out of the relation which exists 
between the sternum and the organs of the chest. A fragment may be 
driven inward and wound the lung, producing emphysema, bloody expec- 
toration, and embarrassed breathing. Dupuytren* and record such 
cases. Even the heart may be wounded. A specimen illustrative of this 
accident is in the museum of University College, London,J the right ven- 
tricle having been torn by a fragment of the fractured sternum. Dupuytren 
witnessed a similar case. Duverney, as quoted by Malgaigne, records two 
cases of the same kind, and Sanson§ mentions one. Blood may accumulate 
in the anterior mediastinum ; an abscess may form in the same region and 
find its way to the lower end of the sternum, pointing in the epigastrium ; 
necrosis of the bone may follow ; and lastly, there may be a fracture of the 
spine associated with that of the sternum. In the report from the Surgeon- 
General’s Office, Washington, six cases of gunshot fracture of the sternum 
are recorded.|| Two of these died, and four survived, but three of the 
four became pensioners in consequence of disability from dyspnoea, cough, 
etc. In the case of entire recovery, the destruction of the bone was so great 
that the arch of the aorta was exposed and its pulsations were seen through 
the external wound. A somewhat similar case was that of the French gen- 
eral Champeux, who received a gunshot wound of the sternum at the battle 
of Marengo^]- which exposed the pulsations of the heart after the removal of 
the fragments. 
Prognosis.—If a simple fracture exists without any of the complications 
noticed, a good recovery may be expected; but where there is evidence of 
intra-thoracic damage, the prognosis should be cautious and reserved. 
Treatment.—If there is evidence of overlapping, or other displacement, 
an effort must be made to correct it, and with this view the patient should 
be made to take a full inspiration, or, failing in this, the body may be ex- 
tended over a firm pillow or cushion, the arms at the same time being drawn 
well up, and the thorax below pressed strongly down. If these efforts are 
not sufficient to correct the displacement, it is better to allow it to remain 
undisturbed. Over the sternum a compress may be placed, and the entire 
thorax surrounded by a broad piece of canton flannel, firmly and neatly 
pinned, and kept from slipping down by two strips passing over the shoulders 
and made fast, front and back, after the manner of the double T bandage. 
(Fig. 677.) An excellent dressing may be made by adhesive strips applied 
across the sternum, extending on each side almost to the angles of the ribs, 
and covering in the bone nearly its entire length. Whatever position is 
most comfortable to the patient should be allowed, whether lying, sitting, 
or semi-recumbent; and in case there is much difficulty of breathing, ac- 
companied with oppression, it may be necessary to avoid all dressing to the 
chest. Operations for the elevation of depressed fractures of the sternum 
* Dupuytren, Legons Orales, vol. ii. p. 215. 
f Flajani, Collezione d’Osservaz., t. ii. p. 214. 
j Cooper’s Surgical Dictionary, vol. i. p. 711. 
| French Medical and Surgical Dictionary, article on Fractures. 
| Surgical History of the War of the Rebellion, Part I., surg. vol., p. 486. 
LeveillS, p. 214. FRACTURES OF THE CLAVICLE. 
899 
may be regarded as of doubtful propriety, though such have been proposed 
by Verduc, Petit, Delpecb, and Nelaton. No cases, however, are given by 
these authorities in which, by incisions, trephine and elevator, or hook, they 
have corrected such depressions. The case given by La Martiniere, in which 
the elevator was used, proved unsuccessful. The difficulty of correcting the 
displacement is not gi’eater than that of preventing its recurrence. 
The internal complications must be met as they arise. Should the pleura 
or the lung be injured or become inflamed, accompanied by dyspnoea and 
cough, the abstraction of blood and the administration of opiates will be 
demanded. The escape of blood into the mediastinum must be left to the 
action of the absorbents. 
The presence of an abscess in the same locality is difficult to diagnose, and, 
although I opened the sternum in one instance in search of a purulent col- 
lection, and with a satisfactory result, the weight of professional authority 
is decidedly adverse to such a procedure. It is better, no doubt, in most 
cases of this nature, to wait until the abscess points, which pointing, for 
anatomical reasons, will probably be at the margin of the sternum, or 
through an intercostal space. When this occurs, it may be opened without 
any injury to the pleura. 
When necrosis follows, we must be content with picking away the dead 
fragments as they separate. Unfortunately, the tendency is to caries rather 
than to necrosis, and without any disposition to limitation. The operation 
practised by Gibson* on the sternum, with a view to arrest the progress 
of the osteitis, namely, excision of the diseased parts, did not accomplish 
any good : the progress of the inflammatory condition was not materially 
arrested. 
FRACTURE OF THE BONES OF THE UPPER EXTREMITY. 
Fractures of the Clavicle. 
The position of the clavicle in the mechanism of the shoulder is one which 
peculiarly exposes this bone to fracture. Its situation is very superficial, 
and its connections to the sternum and the acromion process of the scapula 
are such that it necessarily receives a part of all forces which are transmitted 
through the arm or the shoulder. 
The S-shaped form of the bone is that best adapted to resist the violence 
to which it is so constantly exposed. Malgaigne, in a collection of 2358 
fractures, found the clavicle broken 228 times. Of the 2705 fractures of the 
upper extremity treated in the Middlesex Hospital during a period of sixteen 
years, 772 involved this bone.f In the Pennsylvania Hospital, of the 8662 
fractures treated between the years 1830 and 1874, 696 belonged to the 
clavicle. As compared with the other bones of the skeleton, its fractures 
stand fifth in order of frequency. 
The accident is met with at all periods of life. I have seen it in children 
at the breast. Quite a number of intra-uterine fractures of this bone have 
been recorded: one by Dr. Atkinson, of Philadelphia,J seven by Gurlt,§ and 
one by Professor Gross.|| From twenty to thirty seems to be the period 
in which this injury most frequently occurs. Males suffer oftener than 
females; although Malgaigne asserts that after sixty-five years the prepon- 
derance is in favor of females. 
In 366 cases at the Pennsylvania Hospital in which the side was recorded, 
the fracture occurred 203 times on the left side and 163 times on the right. 
Fractures of the clavicle are produced both by direct and by indirect 
* Surgery, vol. i. p. 269. 
f Holmes’s System of Surgery, vol. ii. p. 764. 
J Boston Medical and Surgical Journal, July 26, 1860. 
§ Handbuch d. Lehre von d. Knockenbriichen, Th. 2, L. 2, p. 695. 
|[ Surgery, vol. i. p. 952. 900 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
forces. Among forces acting directly may be enumerated blows from blud- 
geons, spanners, the wheels of wagons, and falling pieces of timber which 
strike the upper part of the chest. When broken by direct force, the bone 
generally yields near its outer third, a part where it is most slender and 
least able to encounter resistance. The direction of the separation in such 
cases will be more or less transverse. It is in this way that compound and 
comminuted fractures of this bone are produced. The indirect causes are 
all those forms of violence which are received by the hand, the elbow, or 
the shoulder and are transmitted to the clavicle through the arm. In these 
cases the bone may give way at any point between its sternal and acromial 
ends. 
Sometimes these fractures are the result of muscular action. Instances 
of this kind are mentioned by Malgaigne,* Hamilton,t and Gurlt, the latter 
having collected no less than twenty examples of the accident. All of these 
fractures appear to have taken place near the middle of the bone, and, as 
might be expected, on the right side, most persons being right-handed.J 
Fractures produced by indirect force are generally more oblique than those 
caused by direct violence, and run commonly from before backward, involving 
in frequency, first, the middle of the bone (Fig. 679) ; second, the acromial end 
(Fig. 680) external to the trapezoid portion of the coraco-clavicular ligament; 
and last, though very infrequently indeed, the sternal end. 
Fig. 679. 
Fig. 680. 
Oblique fracture through the middle of the clavicle.— 
Malgaigne. 
Fracture at the acromial end of the clavicle.— 
Malgaigne. 
The relative frequency given by Hamilton in 105 fractures was 88 through 
the middle third,—and nearly always in the outer part of this portion,—13 
through the acromial third, and 4 through the sternal third. Of these last, 
two were said to be situated within one inch of the sternal end. E. W. Smith 
asserts that there are no dissections verifying such a fracture,—that is, one 
inside the rhomboid ligament. Malgaigne, however, refers to two specimens 
in the Dupuytren Museum. Lonsdale§ mentions the case of a child in which 
the break was within these limits, or half an inch from the sternum, but 
believes it to be a separation of the epiphysis. Flower very properly thinks 
this could not be, as the epiphysis at the sternal end is a mere disk, hardly 
exceeding one-eighth of an inch in thickness. Blandin|| and Malgaigne 
each describe a case which came under their care in which there is reason 
to believe that the fracture was in this region. 
Fractures of the clavicle are sometimes bilateral. That the accident is 
quite uncommon will appear from the fact that in 2358 cases at the Hotel- 
Dieu only 1 case of this kind Hamilton records two such cases,** 
and states that the Hew York Hospital reported 4 fractures of both clavicles 
in 158 cases received into the institution. Mr. Erichsen met with one case in 
the University Hospital, and Bryan tff has seen such cases more than once. 
Ho instance of the kind is recorded among the 696 fractures of this bone 
treated in the Pennsylvania Hospital. 
Incomplete separation of the bone is by no means uncommon. Especially 
is this true in children and in young persons, both of whom furnish many 
cases of broken clavicle. 
* Treatise on Fractures, Packard’s trans., p. 376. 
f Fractures and Luxations, p. 179. 
J See Table of Fractures. $ Practical Treatise on Fractures, 1838, p. 208. 
|| Gazette des H6pitaux, April 22, 1845. 5T Malgaigne on Fractures, Packard’s trans., p. 398. 
** Fractures and Luxations, p. 184. ff Surgery, p. 842. FRACTURES OF THE CLAVICLE. 
901 
Symptoms.—These are loss of power, pain on pressure, and deformity in 
the line of the bone, which may be easily discovered by running the fingers 
along its surface. The patient is not able, save in exceptional cases, to carry 
the hand to the head or to the opposite shoulder. Instinctively the hand 
of the sound arm is placed under the elbow of the injured one, and, while 
the body is slightly bent forward, the head is inclined towards the damaged 
side. The affected shoulder is lower than its fellow. Crepitus may gener- 
ally be felt by grasping the injured arm and carrying it upward, outward, 
and backward, while the fingers are placed over the seat of the suspected 
fracture. 
Displacement.—When the fracture is complete and passes through the 
body of the bone, or near to the outer third, the displacement will be greatest, 
and is very uniform in its character. As this displacement is largely due to 
the movements of the shoulder, the acromial fragment will be most affected. 
The sternal fragment will be drawn somewhat up by the clavicular fibres of 
the sterno-cleido-mastoid muscle. This, however, will in most cases be in- 
considerable, as both the costo-clavicular or rhomboid ligament and the sub- 
clavian muscle and aponeurosis oppose such a movement. The acromial 
fragment is, first, carried down by the conjoined action of the weight of the 
shoulder, the serratus magnus, the latissimus dorsi. and thepectoralis major and 
minor muscles, thus falling below the level of the sternal fragment; secondly, 
it is drawn inward and forward by the sternal portion of the pectoralis major, 
plus the weight of the shoulder; thus it overlaps the sternal fragment; and, 
thirdly, it is carried under and even behind the sternal fragment, by the same 
agencies, with the assistance of the rhomboideus major and minor muscles. 
These last muscles, acting on the vertebral border of the scapula, serve to 
impress on this bone a movement of rotation, 
which changes the acromial fragment from an 
anterior to an under or posterior position in re- 
lation with the sternal fragment (Fig. 681): so 
that the order of changes to which the acromial 
end of the clavicle is subjected is downward, 
forward, inward, and finally backward. The 
overlapping may amount to one inch. In my 
possession are two broken clavicles in which it 
is one inch and a half. In children the overlap- 
ping is rarely ever, even relatively, as great as 
in adults, and indeed this is true of the entire 
series of displacements. In a few instances the 
acromial has been known to override the sternal 
fragment, the latter being depressed. Desault, 
Malgaigne, Stephen Smith, and others have ob- 
served such cases. When a relation of this kind 
exists between the two ends of the bone, it is 
probably due to force directly applied, impelling 
the sternal fragment down, and thus allowing 
the acromial fragment to slip over it as the shoulder falls inward. 
When the acromial end of the bone is broken, the displacement is not 
great; though even in this position the degree of disarrangement is influ- 
enced by the position of the fracture. If it takes place between the two 
portions of the eoraeo-clavicular ligament, it will be very trifling, as the 
fasciculi of the latter, with the periosteum, serve to resist a separation of the 
fragments; but if the bone is broken internal to this ligament, the displace- 
ment will be quite marked. The inner extremity of the acromial piece will 
be pulled upward by the trapezius muscle, while the weight of the shoulder 
and the influence exerted by the muscles of the chest will carry the acromial 
end downward and inward, placing the entire fragment at a considerable 
angle with its fellow. (Fig. 682.) 
When the fracture is within the limits of the coraco-clavicular ligament, 
Fig. 681. 
Position of fragments in oblique frac- 
ture at the middle of the clavicle. 902 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
its existence must be determined by the pain experienced on pressure, and 
by the movement and, perhaps, the crepitus produced by grasping the frag- 
ments with the fingers and forcing them in 
opposite directions. When external to the 
ligament, there will be less obscurity, and by 
fixing the sternal fragment with the fingers 
and moving the shoulder backward and for- 
ward we can secure the decisive sensation 
of crepitation. 
When the fracture is situated at the ster- 
nal end of the bone and within the limits of 
the costo-clavicular ligament,—an 'exceedingly rare accident,—there will be 
little displacement, unless the fracturing force is applied to the outer side of 
the shoulder, driving the acromial fragment forward and downward; but 
when external to the ligament, the acromial fragment will be driven down- 
ward by the action of the clavicular portion of the pectoralis major, and 
carried forward by the weight of the shoulder and by the pectoralis major 
and minor muscles. 
To detect this form of fracture, the fingers must act directly on the broken 
ends, with a view to discover movement and crepitus. When displacement 
is present, of course the diagnosis is comparatively easy. 
In transverse fractures of the clavicle (certainly not very common), 
wherever situated, there is frequently little or no displacement. Some 
writers have practically denied the existence of such fractures; but there 
can be no doubt of their occurrence. Hamilton* has seen four such cases, 
Stephen Smith two, Desaultf several, and I have seen one, in the person 
of a child three years old. In the “Surgical History of the War of the 
Rebellion”! there is an excellent example of a transverse fracture. The 
entanglement of the serrations doubtless prevents the displacement. 
Compound Fractures of the clavicle, except as a result of gunshot wounds, 
are uncommon, and when they do occur from this cause are often attended with 
serious injury to the organs of the chest. A simple fracture, if very oblique 
and much displaced, may produce ulceration of the integuments and become 
a compound one. The union under such circumstances is delayed. 
Comminuted Fractures, when not from gunshot injury, are the result 
usually of direct force, and are followed by considerable deformity. The 
fragments may be variously disposed. Malgaigne§ had a case in which the 
middle fragment assumed a vertical position between the other two, and 
Hamilton]| met with a similar one. In case of comminution, associated 
with an external wound and followed by necrosis of a fragment, the dead 
bone must be discharged before consolidation of the fracture takes place. 
The case treated by Rente and related by is an example of this 
statement. 
Complications.—The position of the brachial plexus of nerves and of the 
subclavian vessels is such that these structures are exposed to injury by 
depressed portions of the clavicle. If the nerves are compressed, partial or 
complete paralysis of the arm may follow. The death of Sir Robert Peel 
was in part attributed to the existence of a large pulsating tumor under a 
comminuted fracture of the clavicle, supposed to have been due to a wound 
of the subclavian vein.** In Holmes’s Surgery a specimen is described which 
is at present in the museum of St. George’s Hospital, and in which a fragment 
of the clavicle has passed through the internal jugular vein. Erichsenff had 
a case which he supposed to be one of injury to the subclavian vein from the 
same cause, in consequence of the extensive extravasation of blood which 
was present; and subsequently the same surgeon met with another in- 
Fig. 682. 
Fracture of clavicle internal to the coraco- 
clavicular ligament.—Malgaigue. 
* Fractures and Luxations, p. 181. 
t Part First, p. 482. 
|| Fractures and Luxations, p. 183. 
London Lancet, July 6, 1850. 
f Fractures, p. 15. 
$ Fractures, p. 377. 
f Ibid., p. 184. 
ff Surgery, vol. i. p. 348. FRACTURES OF THE CLAVICLE. 
903 
stance of damage to the subclavian vessels, which was followed by gangrene 
of the arm.* 
A patient applied to Professor Gibson to be relieved of paralysis and 
atrophy of the arm following a comminuted fracture of the clavicle. The 
bone wTas much depressed below the level of the neck. 
Dr. H. W. Boone,f Assistant Surgeon U.S.A., published the history of a 
patient who received a comminuted fracture of the clavicle. A fragment of 
the bone compressed the subclavian vein and the brachial plexus of nerves. 
The arm was cold, the veins were much swollen below, and the parts quite 
numb. These symptoms gradually disappeared, and the individual recovered. 
Prognosis.—Fractures of the clavicle unite much more rapidly than do 
those of most other bones of the skeleton. I am confident that I have seen a 
good degree of union take place in from twelve to fourteen days. Union, 
however, without deformity is a rare occurrence,—so rare, indeed, that when 
the fracture is complete and involves the body of the bone with the line of 
separation running obliquely, I can recall no instance of a perfect cure. There 
is almost always some overlapping or some upward angular projection which 
can be seen or felt. Hamilton.J in seventy-two complete fractures, found 
shortening in all except sixteen, and of twenty-seven complete oblique frac- 
tures at the acromial end of the middle third, all had shortening save one. 
The collection of clavicles in the museum of the University of Pennsylvania, 
and that in the College of Physicians of Philadelphia, furnish many examples 
of fracture, but, vThen the injury is located near the middle, or internal to the 
coraco-clavicular ligament, none in wdiich some deformity does not exist. 
Fortunately, neither shortening nor angular deviation materially affects the 
strength or the usefulness of the limb. 
Examples of non-union of the fragments of this bone are by no means 
common. This condition is most likely to follow cases in wThich both clavi- 
cles are simultaneously broken. Malgaigne, in six cases of this accident, had 
three ununited fractures. Even when osseous union does not occur, the ends 
of the bone being united only by dense fibrous tissue, the patient will be able 
to execute the ordinary movements of the arm with a good degree of pre- 
cision and powrer. Hamilton! relates the case of a workman who, with a 
limb defective from this cause, was yet able to raise, within a few ounces, as 
great weights as with the sound arm. Malgaigne gives, among others, the 
case recorded by Gerdy, of an aged cuirassier who, wdth a broken clavicle 
united by a ligamentous cord, could execute his duties without any incon- 
venience. Even where both clavicles have been broken and have remained 
ununited, the disability is not very great. 
Treatment.—If any doubt existed as to the difficulty encountered in the 
management of fractures of the clavicle, it would be quickly dissipated by an 
inspection of the formidable array of contrivances which have been devised 
from time to time to meet the indications required. The anatomist will see at 
a glance that the source of all trouble and perplexity in the treatment of this 
accident is the mobility of the scapula, and until we can give a complete 
fixation to this bone vTe shall never be able to effect wThat are called perfect 
cures. 
What is the problem to be solved ? It is to carry the shoulder upward, 
outward, and backward, and to keep it there, thus restoring the acromial 
fragment—the one principally displaced—to its proper position. Ho one 
has as yet satisfactorily accomplished these ends. There is a movement 
of the scapula by which it describes a considerable arc of a circle upon 
the side of the thorax. When the arm of a person is carried strongly for- 
ward and backward, the inferior angle of this bone can be seen advancing 
and receding beneath the integument. Herein lies the whole difficulty; and 
not until this movement can be controlled shall we be able to command the 
best results. Ho dressing which does not keep the inferior angle of the 
* British Medical Journal, June 7, 1873. 
J Fractures and Luxations, p. 185. 
■f Medical Record, November 15, 1873. 
| Ibid., p. 187. 904 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
scapula forward can fulfil the desired object, however well other indications 
may be met. 
An historical review of the various methods advocated by different surgeons 
for the reduction and retention of this fracture would only present us with a 
vast array of conflicting and contradictory procedures, which would scarcely 
repay for the time expended in their narration. 
All forms of treatment may be arranged under two general heads,—one 
proposing to treat the patient in the erect and the other in the recumbent 
posture ; and they may be described in this order. 
Erect Position.—The three indications to be fulfilled in the reduction of a 
broken clavicle are to carry the shoulder upward, outward, and backward. 
All these movements are designed to affect the acromial fragment. The 
first brings it to the level of the sternal piece; the second removes the over- 
lapping ; and the third restores the line of the bone. To effect these im- 
portant purposes permanently, the surgeon will be compelled to vary his 
appliances. No single dressing will answer for every case. There are three 
plans which I find, in a majority of instances, give me the most satisfac- 
tory results, namely, the dressing of Velpeau, that of Fox, and that by ad- 
hesive plaster. 
As a temporary or provisional dressing,—one which will serve to fix the arm 
while a patient is being removed from the place of accident to his home or 
to a hospital,—the handkerchiefs of Mayor answer an excellent purpose. Fold 
one handkerchief into a triangular form, place the body under the forearm, 
and carry one of the ends over the back and the other over the front of the 
chest to the sound shoulder, over which they should be tied. Fold a second 
handkerchief into a cravat, and tie the arm to the body. (Fig. 683.) 
Fig. 683. 
Fig. 684 
Mayor’s handkerchief dressing for fracture 
of the clavicle. 
Velpeau’s dressing for fracture 
of the clavicle. 
Dressing by a Velpeau roller.—By this method the arm of the injured side 
must be flexed and brought across the front of the chest, so that the hand 
will rest on the shoulder of the sound side and the elbow point in the same 
direction, after which the roller should be applied according to the manner 
of Velpeau. (Fig. 684.) 
This dressing will be found, in a large number of cases, to answer a most 
admirable purpose. The flexed arm, being carried across the chest, draws 
the lower angle of the scapula forward, by making tense the teres major 
muscle, and necessarily causes the acromial fragment of the clavicle to rise 
upward and backward; secondly, the arm, reposing on the most prominent 
convexity of the chest, possesses in the latter a fulcrum which serves to keep FRACTURES OF THE CLAVICLE. 
905 
the scapula out; and lastly, when in this position the elbow is forced upward 
and outward, by the diagonal turns of the roller these last movements are 
increased, and the axillary pad is rendered unnecessary, while the circular 
turns of the bandage make secure all the advantages gained by the position 
of the limb. 
The records of surgery exhibit a singular diversity of opinion on the 
subject of the best position of the upper extremity in fractures of the 
clavicle. Pare had the arm carried back, with the hand resting on the 
hip. Grout brought the fixed arm still farther back, so as to bring it in 
contact with the loin. Guillou placed both the arm and the forearm across 
the back before raising the elbow. Chelius moved the elbow backward on 
the body. 
Moore's.—Professor E. M. Moore, of Rochester, advocates carrying the. elbow 
back, in order to make tense the clavicular fibres of the great pectoral muscle, 
thus neutralizing the action of the sterno-cleido-mastoid muscle on the sternal 
fragment, and, by drawing the scapula towards the spine, raising the acromial 
fragment outward and upward. The mode of apptying the dressing which 
is to accomplish these ends is as follows. Flex the arm across the chest, the 
elbow being brought well to the side of the body; take a strip of strong 
muslin seven or eight inches wide and two and a half yards long, place the 
centre of the strip on the point of the elbow, and conduct the ends upward 
to the axilla, where they are to be crossed, the anterior strip being brought 
behind and the posterior one in front of the shoulder. The bandage is com- 
pleted by bringing the anterior piece down over the back of the shoulder of 
Fig. 685. 
Fig. 686. 
Moore’s figure-of-eight of the elbow for fracture of 
the clavicle, posterior view. 
Moore’s figure-of-eight of the elbow, 
anterior view. 
the injured side and the posterior piece up over the sound shoulder, and, 
after crossing the two in the axilla of the uninjured side, fastening them 
together. The forearm is next flexed and suspended in a sling. This dress- 
ing is designated by its author the figure-of-eight of the elbow, and is repre- 
sented in Figs. 685 and 686. 
Sayre's.—Dr. Sayre, of New York, proposes to accomplish a similar result 
by maintaining the arm in very much the same position by two strips of ad- 
hesive plaster, the first three and a half inches wide, and sufficiently long to 906 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
surround the arm and afterwards the body; this strip is made to encircle the 
arm over the insertion of the deltoid muscle, in the form of a loop, larger 
than the arm, and must be stitched to make it secure. The arm. being 
carried strongly backward and downward, so as to make tense the clavic- 
ular portion of the pectoralis major, is next secured by carrying the strip 
entirely about the body and fastening it on the back to itself. The other 
strip is placed over the sound shoulder, carried obliquely across the back, 
and brought beneath the elbow of the damaged side, a slit being made in 
the plaster to receive the olecranon projection. It is then conducted upward 
in front of the chest to the place of beginning. (Figs. 687 and 688.) 
Fig. 687. 
Fig. 688. 
Sayre’s dressing for fractured clavicle, 
posterior view. 
Sayre’s dressing for fractured clavicle, 
anterior view. 
Professor Gross for many years used adhesive plaster in the treatment 
of this fracture, but, in applying it, very properly kept the arm in a line 
with the body. Professor Hamilton believes that, like other plans, it does 
not prevent, at least in many cases, the overlapping of the fragments. In 
children, I have found that the adhesive plaster sometimes irritates the skin 
to a degree which makes it very uncomfortable. When it does so, it should 
be placed over a roller previously applied. 
We have, then, three positions of the arm, advocated by different writers, 
viz., forward, backward, and vertical, all represented as accomplishing the 
same end. and excellent results claimed for each. I can understand how 
three roads may converge to the same town, but I cannot conceive how 
three travellers who move in different directions can reach the same desti- 
nation. 
The introduction of a w’edge-shaped axillary pad into the dressing for 
fractured clavicle is deemed essential by many very excellent surgeons, 
among them Fergusson, Syme, Liston, and Erichsen, and, in this country, 
Dorsey, Gibson, Horris, Peace, Fox, Hamilton, Smith, Levis, and others. 
The object of this pad is to serve as a fulcrum, by which the shoulder can 
be carried upward and outward, and the overlapping prevented or overcome. 
This is not a modern appliance, but dates back to the time of Galen. It has, 
however, undergone material changes in form and size. It was at first a 
mere cushion, or thick compress, and did not assume the cuneiform shape 
until the time of Desault. It was as long as the humerus, five inches wide, FRACTURES OF THE CLAVICLE. 
907 
and three inches thick at the base. The length of this pad was reduced 
almost one-half by Flamant; and those who at the present time favor its 
use have diminished its size still more, until it 
may be stated to be six inches long, one inch and 
a half thick at the base, and three and a half or 
four inches wide, so as nearly to fill up the axil- 
lary space. (Fig. 689.) 
Desault's.—This pad, and three rollers, each 
two and a half inches wide and eight or nine 
yards long, constitute Desault’s apparatus, which 
is applied as follows. The patient being seated 
on a stool, the arm of the injured side is raised 
to a right angle with the body, and the pad, with 
its base upward, is placed in the axilla. The 
initial end of one of the rollers is laid upon the 
pad, and a few circular turns are made about the chest to fix it, after which 
the roller is carried obliquely across the front of the chest, over the sound 
shoulder, through the corresponding axilla, across the chest, over the pad, 
and along the back over the sound shoulder, returning to the back through 
the axilla, and terminating the bandage by spiral turns about the thorax. 
The pad is thus made secure. (See Fig. 690.) 
The arm, flexed to a right angle, is next brought to the side, by which, 
through the resistance of the fulcrum, or pad, the acromial fragment is carried 
outward. The arm should next be pushed upward and backward, with a 
view to bringing the two fragments to the same level and on a line with each 
other. To maintain this position is the object of the second roller, the initial 
end of which is to be placed in the axilla of the sound side and carried over 
the front of the chest, over the upper part of the arm of the fractured side, 
and round the posterior part of the body to the point of starting, repeating 
Fig. 689. 
Axillary pad. 
Fig. 690. 
Fig. 691. 
The axillary pad secured by the first roller of Desault. 
The second roller of Desault 
these turns until the elbow is reached. As the elbow must be drawn to the 
side by the roller, it is necessary that the first turns be loose, each successive 
one being drawn tighter as they descend. (See Fig. 691.) 
To assist in keeping the arm upward and backward, and to fulfil the two 
indications already named, viz., keeping the acromial fragment on the same 
plane and in the same line with the sternal fragment, a third roller is com- 
menced in the sound axilla, carried obliquely across the front of the chest, 
over the seat of fracture (a compress being interposed), down the back of the 
arm, beneath the elbow, and over the front of the chest to the place of begin- 
ning. From this point the roller is continued through the axilla of the sound 
side, across the back to the seat of fracture, down in front of the arm to the 
elbow, and then across the back to the sound axilla; from which it starts 
anew over the fracture, repeating the turns first made, and in the same order, 
thus forming two triangles,—one in front and one behind the body. The INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
roller is terminated by making a few spirals of the arm and the chest. (See 
Fig. 692.) 
This dressing, when accurately applied, is capable of effecting very satis- 
factory cures; but, in consequence of its complexity, and its liability to become 
Fig. 692 
Fig. 693. 
deranged, it is fast falling into disuse. Professor Gibson, in order to prevent its 
displacement, was in the habit of brushing over the rollers a coating of starch. 
Fox's.—In 1828, Dr. George Pox introduced into the Pennsylvania Hospital 
a very simple apparatus, which has had a wide-spread popularity among 
American surgeons. It consists of a ring, a sling, and a pad. (Fig. 693.) 
The ring is made of muslin or chamois, well stuffed with cotton or hair, and 
large enough to encircle the arm at the shoulder. The sling is made of stout 
muslin, and should receive the elbow, extending up the arm four inches, with 
two broad tapes of linen webbing, one of which is attached'to the upper and 
the other to the lower part of the elbow piece. The wedge-shaped pad must 
be large enough to fill up the axillary space, and may be prepared of twilled 
muslin, wTell stuffed with hair, and with wide tapes connected to the angles 
of its thick end. 
The third roller of Desault. 
Fox’s ring, sling, and pad. 
Fig. 694. 
Fig. 695. 
Front view of Fox’s apparatus for fractured clavicle. 
In the application of this dressing the ring is to be slipped over the arm of 
the uninjured side, and the pad placed in the axilla of the fractured side and 
Posterior view of Fox’s apparatus. FRACTURES OF THE CLAVICLE. 
909 
there maintained by tying the tapes into the ring. The arm is next placed in 
the sling, and the wrist suspended to the ring by the front tapes, after which 
the elbow, being carried upward and backward, must be also secured to the 
ring by the tapes attached to the upper and lower parts of the posterior 
portion of the sling. (Figs. 694, 695.) Cotton should be placed between the 
skin and the tapes, in order to prevent excoriation. The simplicity of this 
apparatus of Dr. Fox’s is calculated to give it great acceptance with the 
profession. It has the sanction of many eminent names, has been in constant 
use in the Pennsylvania Hospital for over fifty years, and still retains its 
popularity there. In the treatment of fractures located at the acromial or 
the sternal end of the clavicle, I know of no apparatus which yields more 
satisfactory results. In those involving the body of the bone, it is incapable, 
in common with all others, of effecting a perfect cure. 
Professor Hamilton employs a dressing which operates very much as does 
that of Dr. Fox. It consists of an axillary pad, a sling, and a roller. The 
pad is placed in the axilla, the sling passed under the arm and the elbow of 
the affected side, and its ends tied over the shoulder of the opposite side, the 
arm being afterwards bound to the body by circular turns of the roller. 
Levis's.—Dr. Levis, in 1856, devised a modification of the Fox apparatus, 
by which the ring is omitted, and a strap substituted for it, which passes 
across the upper part of the back and shoulders. It is very quickly applied. 
Figs. 696, 697, and 698 will sufficiently explain the application of the dressing. 
Fig. 697. 
Fig. 696. 
Pad, sling, and strap of Levis’s clavicle apparatus. 
Front view of Levis’s apparatus adjusted to a patient. 
In the use of any appliance in which the axillary pad is employed, it 
should not be forgotten that undue pressure may be made upon the axillary 
nerves and blood-vessels. Paralysis has followed its use. Hamilton has cited 
a case of this kind, and also Parker of Hew York. When the arm is on a 
line with the side of the body, the nerves are least exposed to pressure. 
When the fracture is near the acromial end of the bone, the case may be 
satisfactorily treated by the four-tailed sling, which can be quickly pre- 
pared by taking a piece of muslin, seven inches wide and two yards long, 
and slitting it down from each end, leaving the centre intact for twelve 
to fourteen inches, in which a small opening should be cut. In its applica- 
tion the arm must be flexed and the hand laid upon the opposite clavicle. 
The opening in the centre of the sling receives the point of the elbow ; the 
arm is next to be pushed well upward and backward, and the lower tails of 
the sling brought up, the anterior one beneath the arm, over the breast and 910 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the opposite shoulder, the posterior one across the back, and the two secured 
together. The upper tails are next carried round the arm and body, and tied 
together on the opposite side of the trunk. Dugas employs a triangular 
sling of muslin, having a strip of roller, three yards in length, sewed to each 
Fig. 698. 
Fig. 699. 
Posterior view of Levis’s apparatus adjusted to a patient. 
angle. The sling is placed under the arm, extending from the elbow to the 
wrist, and the strips are fastened over the shoulder of the sound side and 
around the body. The apparatus forms a secure dressing. 
Figure-of-eight.—Thus far we have been speaking of such appliances as act 
chiefly upon the elbow; but there are others which are intended to operate 
on both the elbow and the shoulder, in order to carry out the indication of 
moving the latter backward. The figure-of-eight bandage is so designed. (See 
Fig. 699.) In its application a pad is placed in the axilla of the injured side, 
and a roller is passed alternately about the shoulders so as to draw the 
scapula} towards each other, after which the flexed arms are pinioned, by 
a second roller, to the front and sides of the chest. This dressing had at 
one time a number of advocates, among both the French and the English. 
Another of t he same class is the apparatus of Brasdor, consisting of shoulder- 
straps of stuffed chamois-skin, fastened to back-pieces of cloth or leather, 
which could be drawn together either by lacing or by buckles. After the 
application of the apparatus, the arm was to be placed in a sling. 
Posterior eight for fractured clavicle. 
Treatment in the Recumbent Position.—This method was sanctioned by 
Hippocrates, Celsus, La Notte, Flajani, Dupuytren, Lizars, Dorsey, Post, 
and others, and came into use in consequence of the unsatisfactory results 
obtained by the plans which were commonly employed. Dr. Edward Harts- 
horne* published an exhaustive paper on the advantages of this position in 
the treatment of fractured clavicle. The patient is to be placed upon a hard, 
unyielding mattress, with the arm and forearm of the injured side flexed and 
placed across the chest, the hand touching the opposite shoulder. In this 
position the inferior angles of the scapula move forward, and the superior 
or glenoid angles backward, the weight of the body upon the lower angles 
keeping them permanently in this position. The head must be placed on a 
low pillow, with the chin slightly depressed, so as to flex the sterno-cleido- 
mastoid muscles and thus allow the sternal fragment to descend. We have 
* Pennsylvania Hospital Reports, 1869. FRACTURES OF THE SCAPULA. 
911 
in the supine position all the conditions necessary for a proper reduction of 
the fracture; and it is interesting to see how instantaneously all deformity 
disappears when such a position is assumed. When the patient is docile 
and obedient, willing to co-operate with the surgeon to the fullest extent, and 
in hospitals, where a careful and constant surveillance can be exercised over 
the inmates, this plan may be adopted for a short time, or until a certain 
amount of reparative material has formed about the fracture and the ten- 
dency to displacement has in some measure diminished, when some form of 
walking apparatus may be substituted. Beyond this the recumbent position 
is scarcely practicable. It is impossible, as a rule, in a fracture like that of 
the clavicle, and involving so little disability, to compel a patient to remain 
fixedly in one position; and even where there is a willingness to do so, there 
are unconscious movements made in sleep which cannot well be controlled. 
With these difficulties to be overcome, together with the fact that the de- 
formity attending other methods of treatment, in which a larger liberty is 
allowed, detracts very little from either the strength or the usefulness of the 
limb, it is not probable that the recumbent position will ever become very 
popular or general. 
In summing up this whole subject, it may be said that we have, at best, 
the choice of imperfect appliances for the treatment of fractured clavicle, and 
that no single apparatus can be used in every case to the exclusion of all 
others. There ai*e three appliances, however, which, with few exceptions, 
will enable the surgeon to accomplish the most satisfactory results, namely, 
the Yelpeau bandage, the Fox apparatus, and adhesive plaster. In fracture 
of both clavicles, the posterior eight bandage or the Brasdor apparatus will 
form the best dressing. 
Fractures of the scapula are not by any means common : the richest cabi- 
nets furnish only a few specimens. Malgaigne states that of the 2358 fractures 
admitted into the Hotel-Dieu, only 4 were in this bone. Lonsdale, according 
to the same author, found 18 among the 1901 fractures treated at the Mid- 
dlesex Hospital. Hamilton has seen 8 cases, and I have met with the injury 
four times. The facts that the scapula is covered with large muscular masses 
of flesh, and that it moves freely over the surface of the chest, sufficiently 
explain the infrequency of the fracture. Of the 8667 fractures treated in the 
Pennsylvania Hospital during a period of forty-four years, 82, or less than 1 
per cent., were fractures of the scapula. The following table, comprising 54 
of these cases, exhibits some interesting points in connection with this injury: 
Fractures of the Scapula. 
Under 10 
10 to 20 
20 “ 30 
30 “ 40 
40 “50 
50 “ 60 
60 “ 70 
70 “ 80 
Age. 
MWdOtC 
4“ to 
co 
Body. 
to 
Acromion. 
© 
o 
Spine. 
o 
0 
o 
* 
Inferior angle. 
s* 
Oi 
Neck. 
3 
>-• 
Glenoid cavity. 
S' 
3 
CO 
Not recorded. 
CO 
Simple. 
to 
Compound. 
w 
- 
Compound 
comminuted. 
o 
to 
Simple commi- 
nuted. 
s 
CD 
Unrecorded. 
CO 
Right. 
to 
o 
Left. 
Side. 
Oi 
Unrecorded. 
oo 
Male. 
GO 
05 
Female. 
Any portion of the bone may be fractured, as the body, the angles, the 
processes, the neck, or the spine. The injury is usually the result of violence 
directly applied; but I have seen the accident follow a fall upon the arm, 
the force being transmitted to the scapula. South thinks that these fractures 912 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
are usually produced in this way. This, however, does not accord with the 
opinions of other surgeons. A case is reported by Dr. Heylen of a fracture 
of the scapula from muscular action alone. Malgaigne, however, doubts the 
verity of the diagnosis. 
Fractures of the scapula are either complete or incomplete. They may be 
simple, compound, comminuted, or stellated. Notwithstanding the muscu- 
lar case in which the bone lies, the displacement in most instances of the 
injury is well marked. 
Fractures of the Body and the Angles of the Scapula.—A specimen of frac- 
ture involving the posterior angle of the scapula is in the Mutter collection 
of the College of Physicians of Philadelphia. The line of fracture begins on 
the upper border of the scapula and passes through the spine, terminating 
some distance below in the fossa infra-spinata. (Fig. 700.) The existence 
of the fracture has been dis- 
credited by some surgeons. 
This specimen, however, is 
quite familiar to Philadelphia 
surgeons. In the Middlesex 
Hospital museum there is a 
specimen, figured in Holmes’s 
Surgery, in which the frac- 
Fig. 700. 
Fig. 701. 
Fracture of the posterior angle of the scapula. Miitter 
collection.—Hamilton. 
Transverse fracture through the body, 
or fossa infra-spinata. 
ture passes through the upper part of the glenoid cavity, and, running in 
a zigzag direction across the fossa supra-spinata for a short distance, divides 
into several radiating fissures. 
Malgaigne alleges that fractures of the body of the bone are most com- 
monly situated above the spine. Hamilton, on the contrary, places them 
below the spine (Fig. 701) ; and this accords with my own observation. In 
three specimens of this injury belonging to the museum of the University 
of Pennsylvania, such is the situation of the fractures. 
Symptoms.—When the spine is involved, on account of its superficial posi- 
tion, any break in its continuity may be determined by passing the fingers 
over the surface of the bone, or by seizing it between the thumb and finger 
of each hand and pressing in opposite directions. If the body below the 
spine is broken, mobility and crepitation may be ascertained by grasping 
the inferior angle with one hand and moving it back and forth, while with 
the other the shoulder is fixed. Some deformity may be expected where 
the separation is complete, and also pain, especially when the arm is carried FRACTURES OF THE SCAPULA. 
913 
forward, as the teres major muscle, by such a movement, tends to drag the 
broken fragments in the same direction. The shoulder is always more or less 
disabled. Malgaigne directs carrying the forearm behind the back, and raising 
the hand as much as possible, a position which makes the posterior border 
of the scapula very prominent and reveals any defect in its edge. When 
the fracture is above the spine of the scapula, the posterior angle will be the 
most accessible point to seize in order to determine the existence of crepitus 
and undue motion. When the lower angle is broken, there can be no diffi- 
culty in forming a diagnosis, as we have this portion of the bone so entirely 
under our observation. 
Prognosis.—The gravity of this fracture depends upon the amount of 
damage done to the soft parts, the degree of comminution, and the shock 
which may have been communicated to the organs of the chest. When the 
injury is a gunshot one, there may follow abscesses, necrosis, and stiffness of 
the arm. It is under such conditions that resection of portions of the bone 
become necessary; and the operation was frequently performed during the 
late American war. When, however, it is a simple fracture, union takes 
place generally with some overlapping. As to this overlapping, there is 
nothing uniform ; sometimes the lower and sometimes the upper fragment is 
in front. The displacement is probably due to the direct influence of the 
force, rather than to muscular action. 
Treatment.—While great differences of opinion prevail among surgeons 
as to the proper dressing, there is one point upon which all agree, namely, 
that of giving fixation to the scapula ; and this involves the entire quietude 
of the arm. After making a proper adjustment of the fracture, a broad strip 
of adhesive plaster should be applied across the scapula, extending from the 
spine to within four inches of the sternum, taking care to press it well down 
along the anterior and posterior border of the bone before the portions in front 
of and behind the chest have been attached. Then place the arm in a Fox 
apparatus, and allow it to hang vertically along the side of the body, at the 
same time lifting the elbow by securing the straps to the ring on the opposite 
shoulder. To prevent the arm from being carried away from the side, a few 
turns of a roller around the arm and body should be applied, or the same 
end may be secured by surrounding the arm and chest with a broad strip of 
muslin, which can be fastened with pins. The vertical position of the arm 
is the one which gives relaxation to both the teres major and rhomboideus 
muscles, and conduces most to the quietude of the fragments. I am aware 
that sometimes we will be foiled in effecting a satisfactory adjustment by 
strictly conforming to anatomical indications: wffiere this is the case, the arm 
should be placed in any position which will best conduce to the apposition 
of the fragments, whether it conflict with anatomical teaching or not. 
Fractures of the Acromion.—It will be seen by reference to the table on a 
previous page that fractures of the acromion process are more common than 
those of the body of the scapula. In Lonsdale’s cases they were equal. The 
exposed situation of this portion of the bone would seem to render it pecu- 
liarly vulnerable. That its fracture does not occur oftener is doubtless due 
to the mobility of the shoulder. The causes producing the fracture are such 
as act either from above, as when some heavy object falls upon the shoulder, 
or from below, as when the head of the humerus is forcibly driven upward. 
The tardy consolidation of the epiphyseal extremity of the acromion process 
wTith the other portion of the bone has doubtless led to many errors in diag- 
nosis, by a separation of the diaphysis being mistaken for fracture. I have 
frequently noticed in the process of boiling bones for the preparation of skele- 
tons that the cartilaginous bond was present, and the tip of the process often 
detached, even in bones which appeared to be those of persons well advanced 
in life ; and I think, after a careful examination of cabinet and other specimens 
of supposed acromial fractures, that the statement of Fergusson, that “ such 
accidents are rare,” will be found to be correct. 914 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
The position of the fracture varies. It may be in front of or behind the 
acromio-clavicular junction, or (Fig. 702) it may extend into the articulation. 
Sir Astley Cooper describes an instance of the latter 
condition attended with a luxation of the clavicle; 
and a similar case came under my own notice. 
Symptoms.—The symptoms which indicate this 
fracture are pain, flattening of the shoulder, deform- 
ity, great disability of the arm, unusual mobility, and 
crepitus. The pain is intensified by moving the arm. 
The rotundity of the shoulder is diminished by the 
weight of the upper extremity dragging the acromion 
fragment downward through the attachment of the 
deltoid muscle. A finger passed over the seat of in- 
jury will detect the irregularity, and may be pressed 
between the fragments, and if the break is posterior 
to the acromio-clavicular articulation there will fol- 
low a deformity resembling that resulting from frac- 
ture of the humeral end of the clavicle, the shoulder 
dropping downward, inward, and forward. 
When the break extends into the acromio-clavicular joint, the end of the 
clavicle will rise up and form a prominence over this part of the shoulder. 
The head will be inclined to the injured side, and the patient will support 
the arm with the opposite hand. Crepitus may be felt by placing one hand 
over the summit of the shoulder, and with the other forcing the arm up- 
ward and rotating it quickly. Discoloration will usually be present, though, 
as in other fractures, it may not appear until some time after the accident. 
This injury has been mistaken for luxation of the humerus. An error of 
this kind is inexcusable. In luxation the acromion process is salient and 
sharply defined; in fracture it is flattened. In luxation the elbow stands off 
from the body; in fracture it lies close to the side. In luxation the bone once 
reduced so remains; in fracture, though the deformity disappears when the 
head of the humerus is pushed upward, it immediately reappears when the 
support is withdrawn. 
Prognosis.—In most cases the union will be ligamentous, forming a false 
joint. Bichat and Arrard had each a case, in which the union was osseous, 
as stated by Malgaigne. In these it is probable that the fragments were not 
entirely detached. Although the extremity of the acromion receives some 
blood-vessels from the acromial branch of the thoraco-acromial artery, its 
nutrition, when broken, must be very defective. Malgaigne says that, with 
a single exception,—one in the Dupuytren Museum,—the little nodules of 
bony matter which form about these fractures are always confined to the 
upper fragment. The movements of the arm, after repair has taken place, 
are not materially impaired, although the power to elevate the limb is very 
slowly regained. 
Treatment.—There are two methods of treatment, one by position, and 
the other by retentive dressings. The first, known as that of Delpech, con- 
sists in placing the patient on his back, carrying the arm directly away from 
the body, and supporting it in this position upon a pillow. This posture 
relaxes the deltoid muscle, which otherwise tends to pull the de- 
tached fragment from the spine, and favors a very accurate adjustment. The 
only objection to this plan is that which is urged against the treatment of 
fractured clavicle by position, namely, inability to enforce the requisite quiet 
for a period sufficiently long to secure union. If the patient is not willing 
to endure this kind of confinement, then the Yelpeau bandage, with the arm 
placed vertically along the side of the body, will be found best suited to the 
case. By this plan the head of the humerus being pushed up becomes a 
splint for the support of the acromion process. When the fracture passes 
through the acromio-clavicular articulation, or behind it, we have a condition 
of things not unlike that which follows a broken clavicle, and we may resort 
Fig. 702. 
Fracture of the acromion 
process.—Malgaigne. FRACTURES OF THE SCAPULA. 
915 
either to this last bandage or to the Fox apparatus, consisting of the ring 
and the sling, either with or without the axillary pad. After a period of 
five weeks the dressing may be laid aside and the arm carried in a sling for 
two weeks longer. 
Fracture of the Coracoid.—This fracture is exceedingly rare, but a suffi- 
cient number of examples are recorded to place its existence beyond a doubt. 
A very well marked specimen is in the possession of Prof. John Neill, of this 
city. (Fig. 703.) In the collection formerly belonging to Prof. Charles Bell 
Gibson there was a similar specimen. 
Hamilton records one in the possession of 
Dr. Mussey, and another«in the museum 
of the Massachusetts Medical College. I 
attended a patient in the winter of 1876 
who, after a severe injury to the shoulder, 
presented the signs of this fracture. One 
year after, I had the opportunity of verify- 
ing my diagnosis, by finding the process 
quite prominent, from the length of the 
connecting bond. As the humerus had 
been dislocated in this instance, I have no 
doubt the fracture was caused by the head 
of the bone. Produced as the fracture 
usually is by severe and direct violence, it 
is frequently associated with other injuries, 
both to the bone and to the soft parts, which 
render the accident one of the most serious character. Of this nature was 
the case related by Duverney,* in which the neck of the scapula and several 
ribs were found broken in a man who died after a fall, apparently in con- 
sequence of the formation of a large axillary abscess. Southf mentions a 
coracoid fracture accompanied by an incomplete luxation of the humerus 
and a fracture of the olecranon process of the ulna. Another of a similar 
kind is given by Holmes.| Boyer also speaks of a fatal case, which was 
caused by the damage done to the soft parts.§ Erichsen|| mentions a speci- 
men in the University College museum, in which, in addition to a fracture of 
the coracoid, there is a fracture extending through the glenoid cavity, with a 
third through the base of the acromion process of the scapula. Hamilton 
thinks he has met with two cases of coracoid fracture, and likewise 
with two. Bryant** has seen one case, in a girl fifteen years of age. 
Symptoms.—The signs of this injury are pain, preternatural mobility, and 
crepitus. If the examination is made early,—before much swelling exists, 
—the coracoid process can be readily touched with the finger, and if, while 
the digit is in contact with the bone, the humerus be moved upward and 
downward, the process, if detached, will be found to follow the movements 
of the arm, and not those of the scapula, in consequence of its connection 
with the coraco-brachialis and biceps muscles. The crepitus may also be 
felt during these manipulations. 
The displacement will depend on the seat of fracture. If it is in front of the 
attachment of the coraco-acromial and coraeo-clavicular ligaments, the tip of 
the process may be drawn somewhat downward by the conjoined action of 
the pectoralis minor, coraco-brachialis, and the short head of the biceps mus- 
cles. (Fig. 704.) If the fracture is within the limits of these ligaments, the 
process will either remain suspended between the ligamentous and muscular 
attachments, or be carried forward, leaving a considerable gap to be filled up 
by fibrous material, as in the Neill specimen. 
Fig. 703. 
Fracture of the coracoid process of the scap- 
ula, with ligamentous union. From a specimen 
belonging to Prof. Neill. 
* Malgaigne’s Treatise on Fractures and Luxations, Packard’s trans., p. 412. 
f Chelius’s Surgery, vol. i. p. 601. J System of Surgery, vol. ii. p. 775. 
§ General Archives of Medicine, 1840, vol. vii. p. 364. || Surgery, vol. i. p. 350. 
If Holmes’s System of Surgery, vol. ii. p. 775. ** Surgery, p. 843. 916 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Prognosis.—This will depend upon the amount of damage sustained by 
other parts. When the organs of the chest have been severely concussed, 
or the contents of the axillary space much 
injured, or the soft parts extensively 
contused, a fatal termination will not be 
improbable. If, however, it is simply a 
fracture of the process, without other com- 
plications, recovery may be confidently 
expected, and with a useful arm. The 
union will be fibrous, not osseous. The 
dissection of Bransby Cooper’s case,* the 
specimens in the Dupuytren Museum, and 
the scapula in the possession of Dr. Neill, 
all establish this condition ; most prob- 
ably the same kind of union existed in 
the case recorded by Hamilton,f in which 
the process was seen to follow freely the 
motions of the arm. 
Treatment.—If the elbow is carried 
backward, and then lifted, with a view 
to gain for the process the direct support 
of the head of the humerus, the tension 
of the coraco-brachialis and biceps muscles will tend to displace the de- 
tached fragment. If the arm is carried across the chest, and so maintained, 
these muscles become relaxed, but the support of the head of the bone is 
lost; and hence the position which meets the demands of such a case is 
the vertical one, with the arm flexed, and either placed in the Fox apparatus 
or secured by a Yelpeau bandage. 
Fig. 704. 
Fracture of the coracoid ; the process drawn 
down by the pectoralis minor, coraco-brachialis, 
and the short head of the biceps muscles. 
Fractures of the Neck and of the Glenoid Cavity of the Scapula.—The term 
neck of the scapula has two significations, according as it is viewed ana- 
tomically or surgically. The anatomical neck is the constricted part which 
supports the glenoid cavity. I know of no 
fracture of this portion of the bone, except 
the case referred to by Professor Spence,| of 
Edinburgh, which, however, was only partial, 
the whole of the glenoid cavity not being 
detached. The surgical neck includes the 
coracoid notch, and the existence of a frac- 
ture through this part of the bone, detaching 
the coracoid process with the articulating 
cavity, is established beyond all doubt. (Fig. 
705.) Sir Astley Cooper claims to have had 
three cases. Duverney saw one, which was 
verified by dissection. Packard met with 
one case, in a little girl two and a half years 
old. Among 6485 cases of fracture treated 
in the Pennsylvania Hospital, one is recorded 
as a fracture of the neck of the scapula, 
though not verified by dissection. Dugas, 
of Georgia,§ reports two cases. When such 
a fracture exists, it is generally found asso- 
ciated with a like injury to the body of the 
scapula. Flower|| mentions one case in the museum of Guy’s Hospital, and 
a second in the museum of the Royal College of Surgeons, and 
supplies a third. 
Fig. 705. 
Position of a fracture of the neck of the 
scapula.—After Fergusson. 
* Sir Astley Cooper on Fractures and Luxations, p. 380, American edition, 
f Fractures and Luxations, p. 212. 
f Edinburgh Medical Journal, 1863. $ Southern Medical and Surgical Journal, vol. xv. p. 1859. 
|| Holmes’s Surgery, vol. ii. p. 776. f Treatise on the Maladies of Bones, 1751, vol. i. p. 227. FRACTURES OF THE SCAPULA. 
917 
Fractures may extend through the glenoid cavity, either riving it into 
pieces (Fig. 706) or chipping off a portion of its margin. Malgaigne has 
shown that this injury to the articulating cavity, when accompanied by luxa- 
tion of the humerus, presents the same phenomena as 
fracture of the neck of the scapula ; and it is highly 
probable that the former injury has sometimes been mis- 
taken for the latter. Fracture of the neck must be the 
result of direct and concentrated violence. Mr. May, 
of England, gives one case—that of a lady—in which 
it was produced by muscular action alone, in the effort 
of placing a necklace over the shoulder. If such was 
really the case, it could only be explained by a diseased 
condition of the bone. Fracture of the glenoid cavity 
may be produced by the head of the humerus being 
forcibly driven against its surface. 
Symptoms.—There will be a loss in the rotundity of 
the shoulder, with unusual prominence of the acromion, 
caused by the sinking of the humerus and by the con- 
traction of the coraco-brachialis and the short head of 
the biceps muscle. The arm will be correspondingly 
increased in length. The degree of flattening and the 
elongation of the limb will be influenced by the extent 
to which the coraco-acromial and clavicular ligaments 
participate in the injury. If not torn, they will be 
competent to suspend the neck and resist the falling of 
the arm ; but if torn, the elongation will be increased. If the hand is placed 
upon the acromion, and the limb raised up and rotated, crepitus will be felt, 
the coracoid process will be found to follow the movements of the arm and 
not those of the scapula, and the head of the humerus may be discovered in 
the axilla. The close relation of the axillary nerves and blood-vessels to the 
neck of the scapula exposes them to injury: in the three cases reported by 
Dugas the fracture was followed by complete paralysis of the limb, and by 
interruption to the circulation through its arterial trunks. Looking at the 
injury from a purely anatomical point of view, these last symptoms would 
seem to be almost a necessary sequence. 
There are some symptoms which are common to this fracture and to 
luxation of the humerus, such as undue prominence of the acromion and 
flattening of the deltoid. The distinction may be established by pushing the 
arm upward, when the deformity will readily disappear, but will reappear as 
quickly, if the case is one of fracture, whenever the support is withdrawn. 
There is, however, a condition in which both fracture and luxation are 
present,—as when a portion of the l'im of the glenoid cavity is split off and 
the head of the humerus glides into the axilla. Under such circumstances, 
if the bone is restored, it will immediately slip back into its unnatural posi- 
tion upon withdrawing the support of the hand. In this respect the frac- 
ture resembles a fracture of the neck of the scapula ; but if it is remembered 
that in the latter injury the coracoid process moves with the arm, while in 
the former it remains fixed, the distinction will be apparent. 
Fracture of the neck of the humerus is not likely to be confounded with 
fracture of the neck of the scapula, as in the former the rotundity of the 
shoulder is not lost, while in the latter it is very markedly flattened. 
Treatment.—The humerus must be made to act as a splint. By pushing 
it upward and outward the neck of the scapula will be carried to the body 
of the bone, and, in order to maintain the parts in position, a thick, wedge- 
shaped pad, five inches long and three inches wide, must be placed in the 
axilla, and the arm suspended in a sling and made fast to the body by a roller 
or a broad bandage : should the sling and bandage prove uncomfortable, 
they may be substituted by a Yelpeau dressing. At the end of four weeks, 
passive movement must be made, in order to establish the functions of the joint. 
Fig. 706. 
Stellate fracture of the 
glenoid cavity of the scap- 
ula. 918 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Fractui’es of the humerus may be divided into three general varieties, 
namely, fractures of the upper extremity, fractures of the shaft, and frac- 
tures of the lower extremity. 
Fractures of this bone are among the most common surgical injuries. 
Malgaigne* says that out of a total of 2358 fractures, 317 were of the humerus. 
Of 8667 fractures received into the Pennsylvania Hospital, 968 belonged to 
this bone. In 663 of these cases, 576 occurred in males and 87 in females ; 
and in 529 instances in which the side was noted, 248 were on the right and 
281 on the left side. 
The largest number of cases of this fracture occur between the ages of ten 
and twenty, and the next largest, between twenty and thirty years of age: 
in the 663 eases above noted, 180 were met with in the first and 119 in the 
second decade. After the fortieth year, the number diminishes rapidly. 
This does not correspond with the statement of Malgaigne, who alleges 
that their increases up to sixty years of age, the largest number 
being between the ages of forty and sixty. Between sixty and eighty, as 
stated by the last-named author, the injury occurs with almost equal fre- 
quency in each sex. 
The largest number occur during the winter months, a fact to be explained 
by the presence of ice and the frozen condition of the ground rendering the 
footing less secure. 
We shall consider these injuries according to the divisions already named. 
Fractures of the Humerus. 
By fractures of the upper extremity we mean all those which occur above 
the insertion of the latissimus dorsi and teres major muscles. These may 
be subdivided into those within the capsular ligament,—intra-capsular,—and 
those without,—extra-capsular. 
Fractures of the Upper Extremity of the Humerus. 
First. Intra-capsular Fractures.—These may traverse either the head or 
the anatomical neck of the bone. When the head is broken, it is generally 
due to a gunshot injury,—a ball, shot, fragment of shell, or some other missile, 
penetrating the joint and not only producing a compound fracture by the 
presence of an external wound, but also often comminuting the bone. Such 
a fracture may occur, however, from the direct application of force to the 
shoulder, or even from force applied at the elbow or the hand, driving the 
head of the humerus violently against the glenoid cavity. 
Diagnosis.—If there is an external wound, the nature of the injury may 
be determined by exploration with the finger or the probe. If no such wound 
exists, our diagnosis is a matter of inference rather than of certainty. 
Prognosis.—When such a fracture takes place, the fragments, if commi- 
nuted, become necrosed, and may be discharged—after a long time—through 
the external wound, if one exists. 
Fractures of the Anatomical Neck.—Although fracture of the anatomical 
neck is by no means a common accident, yet a sufficient number of cases are 
recorded to establish the reality of the injury. The line of separation is 
usually through the slight constriction or groove which separates the head 
from the tubercles, and falls, therefore, within the boundary of the insertion 
of the capsular ligament. (Figs. 707, 708.) 
When the fracture is thus situated, the fragments never become united. 
The head of the bone lying loose in the joint and cut off from its blood- 
supply, we might expect that it would inevitably die. and, by causing inflam- 
mation and suppuration, be ultimately discharged. Yet, as stated by Gurlt,f 
there are no well-attested cases in which the head became a sequestrum and 
* Treatise on Fractures, Packard’s trans., p. 414. 
■(• Gurlt on Fractures, vol. i. p. 745 (c). FRACTURES OF THE HUMERUS. 
919 
was expelled from the articulation. The probability is that when thus sepa- 
rated it will become atrophied through the combined influences of attrition 
with the other frag- 
ment and of contact 
with the synovial fluid 
of the joint. 
As in intra-capsular 
fractures of the hip- 
joint, so in similar ones 
of the shoulder there 
maybe impaction; that 
is, the upper fragment, 
or the head, may be 
impelled into the can- 
cellated tissue of the 
lower fragment and 
be inseparably inter- 
calated, as shown by 
Eobert William Smith, 
of Dublin, in his valu- 
able work on Fractures 
in the Vicinity of 
Joints. So deep may 
it be driven into the 
lower fragment as to split off one or both of the tuberosities. Fig. 709 
represents an impacted fracture within the capsular ligament. 
Symptoms.—The existence of an intra-capsular fracture must, in the very 
nature of things, be very difficult to diagnose. The presence of pain in the 
joint after a direct injury, loss of motion, indistinct crepitus, and the undis- 
turbed relation of the different bony prominences about the articulation, with- 
out the evidence of any other fracture or displacement, constitute sufficient 
grounds for surmising the existence of the injury. In this enumeration of 
symptoms it is assumed that there has been no displacement of the fragments. 
If, however, the shaft of the bone should be drawn somewhat inward, as 
would most likely be the case, by the action of the pectoralis major, latissi- 
mus dorsi, and teres major muscles, or still more likely by the force which 
produced the fracture, then the end of the lower fragment might be felt, 
provided the swelling was not too great. A prudent surgeon, however, would 
not pronounce with too much certainty on the existence of this fracture. 
When impaction exists, the nature of the accident is less obscure. The 
partial disappearance of the head, through its being buried in the upper part 
of the shaft, must leave a vacancy in the joint, and hence the shoulder be- 
comes somewhat flattened, the acromion slightly less prominent, and beneath 
it there will be an appreciable hollow. For the same reason the arm will be 
shortened, and if the fingers be pressed from the axilla against the head of 
the bone while the arm is raised, the change in the size of the head of the 
humerus may be detected. Should the impaction break off a tuberosity, 
crepitus will be present, and may be recognized by placing one hand over 
the joint and with the other rotating the arm. Eobert Smith* records a 
case of intra-capsular fracture in which the head of the bone was re- 
versed, the cartilaginous surface being turned down and driven deeply 
into the cancellated structure of the lower fragment, and the broken 
surface directed upward towards the glenoid cavity. The broken sur- 
face of the upper fragment had become rounded so as to simulate the 
spheroidal form of the cartilaginous surface. In this case both tuberosities 
were broken. Helatonf furnishes two such cases ; and a similar one was 
in possession of Dr. Pope, of St. Louis. Hamilton;}; is disposed to regard 
Fig. 707. 
Fig. 709. 
Fig. 708. 
Fracture through the 
anatomical neck of the 
humerus. 
Intra-capsular fracture 
of the neck of the hu- 
merus.—Malgaigne. 
Impacted intra- 
capsular fracture 
of tli e humerus. 
* On Fractures in the Vicinity of Joints, p. 199. f Elements of Surgical Pathology, vol. i. p. 307' 
X Fractures and Luxations, p. 218. 920 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
these cases as the result, not of fracture, but of inflammatory softening and 
ulceration, in which view Prof. John Neill coincides. Certainly no such 
explanation will account for the case furnished by Robert Smith, in which 
fracture of the tuberosities existed. When inflammatoiy disease attacks the 
bone within the capsule of the joint, the head and not the neck generally 
suffers. As to the revolution of the head, either violence or muscular action 
would be quite sufficient to produce the change. 
I have in my possession a fracture of the anatomical neck of the humerus 
in which the head has made a partial revolution, the cartilaginous surface 
looking inward, and I am quite confident that the displacement was produced 
by the long tendon of the biceps forcing the head in that direction as the 
shaft of the bone was drawn upward and outward. 
Prognosis.—If the fracture passes entirely through the anatomical neck of 
the bone, severing the head from all connection with the lower fragment, union 
will not take place ; the upper fragment will lie loose in the joint and become 
wasted, since it is deprived of all blood-supply. If, however, sepai’ation is 
not complete, or if some fibres of the capsular ligament still serve as a 
bond, consolidation is possible. Sometimes the fracture extends beyond the 
limits of the capsular ligament,—partly within and partly without: in such 
cases we may expect bony union to follow. A like favorable result will occur 
when the head is impacted in the spongy tissue of the lower fragment. In 
these cases it is the lower fragment which furnishes the reparative material. 
Treatment of Intra-capsular Fractures.—In compound comminuted 
fractures of the head of the humerus, such as are pi’oduced by shot wounds, 
two courses of treatment are open to the surgeon, namely, excision and ex- 
pectancy. In exceptional cases the latter may be adopted with propriety, 
—that is, when the comminution is confined strictly to the head of the bone, 
not extending beyond the limits of the anatomical neck. After suppuration 
is once established, the necrosed fragments may be picked away and the 
case do well. When, however, the lesion extends into the tuberosities and 
the upper end of the shaft, excision will be the proper course: the dangers 
which attend a prolonged suppuration under the expectant plan of manage- 
ment are too great to warrant its adoption. Whatever plan of treatment is 
pursued, the arm should be brought to the side, the forearm flexed across the 
chest, and an external concave splint applied, capping the shoulder and ex- 
tending to a point three inches above the elbow, both splint and arm being 
fixed in position by a broad bandage or a roller passed round the body, and 
the hand supported in a sling. When the fracture extends through the 
anatomical neck of the bone, the shaft must be carried up to the head of the 
bone and there retained. This is best accomplished by placing a small 
wedge-shaped pad in the axilla, with the base above, applying the external 
concave splint in the summit of the shoulder and outer part of the arm, and 
securing all by a Yelpeau bandage. 
Second. Extra-capsular Fractures.—These may be either impacted or non- 
impacted. The varieties to be considered are the following: 1st, fractures 
of the great tuberosity; 2d, separation of the epiphysis,—the epiphysis con- 
sisting of the head and tuberosities; 3d, fracture of the surgical neck. 
Fractures of the Great Tuberosity.—Such fractures are the result, usually, 
of direct force, or of force applied when the arm is along the side of the body. 
A portion of the head may be detached with the tuberosity. Robert Smith, 
Bransby Cooper, and Hamilton furnish examples of these fractures. 
Symptoms.—If the tuberosity is entirely detached, it will be drawn back- 
ward by the conjoined influence of the supra-spinatus, infra-spinatus, and 
teres major muscles, and the lower fragment or the shaft of the bone will 
be carried inward by the subscapularis and forward by the pectoralis major 
muscle, producing what is regarded by Malgaigne as a form of luxation. 
As the tuberosity contributes in some degree to the rotundity of the joint, FRACTURES OF THE HUMERUS. 
921 
this feature of the shoulder will be measurably lost, and the acromion will 
become correspondingly prominent. The shaft and the tuberosity being 
drawn in opposite directions, the articulation will be increased in breadth, 
and, if the swelling is not too great, both the head of the bone and the tu- 
berosity may be felt,—the first near the coracoid process, and moving when 
the arm is rotated, the second some distance back, and not responding to 
such movements,—while between them a depression may be discovered. The 
patient will be unable to raise the arm to considerable extent, or to 
rotate it outward, and severe pain will be experienced when it is moved. 
Should the line of fracture traverse the insertion of the muscles on the 
dorsum of the scapula, the tuberosity may not become entirely detached 
from the bone, in which event the symptoms detailed may not be present. 
Under such circumstances the diagnosis would be necessarily rendered less 
certain. 
Prognosis.—The difficulty in securing the accui'ate coaptation of the frag- 
ments will render bony union improbable. Robert Smith believes that the 
parts, when much separated, are always connected by ligamentous tissue. 
Treatment.—The shoulder must be carried back by a posterior figure-of- 
eight roller, in order to bring the shaft to the tubercle, and the arm suspended 
in a sling, and made fast to the body by circular turns of a bandage. 
Fracture through the Superior Epiphysis.—This fracture is confined to 
an early period of life, being seldom met with after the eighteenth year. 
It is usually produced by falls upon the shoulder, and is not unfrequently 
mistaken for a luxation of the scapulo-humeral joint. The head of the 
bone may become completely disengaged from the shaft, or the latter, by 
its rounded extremity, may cling to the concavity of the former after the 
manner described by Professor Moore. fFitr. 710.^ 
Symptoms.—The signs which 
indicate the existence of this 
fracture are loss of power in the 
limb (the arm hanging help- 
less by the side), and the pres- 
ence of a prominence imme- 
diately above the coracoid 
process of the scapula. This 
prominence, which is the upper 
end of the lower fragment, is 
not sharp and irregular as in 
fracture through the surgical 
neck of the bone, but is smooth, 
and moves with every motion 
imparted to the arm. In order 
to obtain crepitus, it is neces- 
sary first to push the shaft of 
the humerus back, and after- 
wards to communicate to it a 
rotatory movement. The sound 
will be much softer and less dis- 
tinct than that which is expe- 
rienced in ordinary fractures. This accident may be distinguished from a 
dislocation by the shoulder still retaining its rotundity, and by the elbow 
not projecting to any marked degree from the side of the body. 
The treatment does not differ from that proper to fracture of the surgical 
neck of the bone. 
Fig. 710. 
Incomplete separation of the epiphysis of the humerus.— 
Moore. 
Fracture through the Surgical Neck of the Humerus.—This fracture may 
be located at any part of the bone, from the tuberosities to the insertion of 
the latissimus dorsi and teres major muscles. Sir Astley Cooper extended the 922 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
limits of this injury as far as to the attachment of the deltoid muscle. 
Under this head are sometimes included fractures through the epiphysis. 
Fractures of the surgical neck are very common accidents, 
especially in persons somewhat advanced in life, or between 
forty-five and fifty-five years of age. They are produced by 
direct violence received when the arm is near to the chest. 
Their direction is transverse rather than oblique (Fig. 711), 
resulting, no doubt, from the diminished length of the osseous 
arches which exist near the extremity of the bone. 
Symptoms.—The arm, after such an injury, is powerless. 
Any movement of the bone causes pain, sometimes of a very 
severe shooting character, and extending to the fingers, in 
consequence of the axillary plexus of nerves being injured by 
the displaced bone. The limb will usually be found shorter 
than its fellow, the degree of shortening being greatest when 
the fracture is very oblique. In comparing the length of the 
two limbs, the measurement should be made from the acromion 
process to the external condyle of the humerus. 
In addition to the above-named symptoms, there will be 
crepitus, which may be discovered by making traction upon 
the arm and then rotating it, while the shoulder is embraced 
between the thumb in the axilla and the fingers on its external 
surface. It sometimes happens that the lower is impelled into 
the cancellated tissue of the upper fragment, especially when 
the fracture is near the connection between the epiphysis and diaphysis, 
thus making an impacted fracture, the recognition of which may be a very 
difficult matter. If after an adequate injury the arm is found disabled, 
somewhat shortened, and painful, and if, in addition, a slight crepitus can 
be discovered by fixing the head of the bone while the limb is forcibly 
rotated, there will be just ground for suspecting the existence of an impacted 
fracture. 
Displacement.—The displacement which follows a fracture through the 
surgical neck of the humerus is confined, when it does occur, principally to 
the lower fragment, which will be drawn inward and upward. The agents 
concerned in these two displacements are the sternal portion of the pectoralis 
major, the latissimus dorsi, and the teres major muscles. These draw the 
arm to the side or inward, while it is pulled upward by the deltoid, the cla- 
vicular part of the pectoralis major, and the coraco-brachialis. together with 
the biceps and triceps muscles. The upper fragment undergoes little change, 
but may be drawn inward by the action of the subscapularis, infra-spinatus, 
and teres minor muscles. (Fig. 712.) The end of the lower fragment may 
sometimes be felt through the skin, near the coracoid process. There is a 
specimen in the museum of the University of Pennsylvania in which the end 
of the bone is united to the coracoid. Sometimes the lower fragment is forced 
outward, penetrating the deltoid muscle, an occurrence which I witnessed some 
years back. Lastly, the inferior fragment may be carried directly backward, as 
was seen in a case of Dupuytren’s. When the displacement is purely the result 
of muscular action and the fragments have slid past each other, we may ex- 
pect the lower one to assume the upward and inward position ; any other must 
be due to the impetus given by the fracturing force. In the majority of 
these fractures there is very little displacement, because the direction of the 
separation is, approximately at least, transverse, and the long tendon of the 
biceps, unless thrown from its groove, will resist the disarrangement of the 
broken pieces. 
Diagnosis.—Fractures of the surgical neck of the humerus have been 
confounded with dislocation, and when the swelling is great such an error 
is not unlikely. Some light may be thrown on the case by ascertaining the 
position of the arm at the time of the accident. If it was abducted and with 
the elbow directed away from the body, a luxation is probable ; if it was close 
Fig. 711. 
Fracture through 
the surgical neck 
of the humerus. FRACTURES OF THE HUMERUS. 
923 
to the side, a fracture. In luxation the acromion process is more prominent 
than in fracture. In fracture the ecchymosis is chiefly seen over the deltoid 
prominence, being confined to this region by the attachment of the deltoid 
fascia; in luxation it is usually found on the inner part of the arm, having 
Fig. 712. 
Fracture through the surgical neck of the humerus : 1, deltoid muscle; 
2, pectoralis major, turned down from its origin; 3, latissimus dorsi, attached 
to the humerus; 4, subscapularis muscle; 5, supra-spinatus muscle. 
been conducted in this direction by the pectoral and axillary fasciae. In frac- 
ture the reduction is easily etfected ; in dislocation it is more difficult. In the 
former there is a strong tendency to displacement after adjustment has been 
accomplished; in the latter no such disposition exists. In fracture, again, we 
can elicit crepitus ; not so in luxation. There is a sound sometimes heard after 
severe contusions about the shoulder, when the arm is moved, which resem- 
bles crepitus. This has a synovial, thecal, or bursal origin, but it is neither 
so dry nor so rough as that from bony crepitus, and when once learned the 
distinction is not very difficult to recognize. Lastly, in fracture, when the 
head of the bone is touched and the arm at the same time rotated, no 
movement will be imparted to the upper fragment, while in luxation the 
reverse will be true. In case of impaction, of course this test will fail. In 
all these fractures the use of ether will assist us greatly in resolving any 
doubts which may exist. 
In young subjects, before the osseous union of the epiphysis and diaphysis, 
a fracture may pass through the connecting cartilage. In such a case the 
crepitus is less harsh, from the nature of the broken surfaces, and is in its 
character more like the impression received from the inflamed sheaths of 
tendons or the interior of a bursa. The other symptoms will not differ from 
those already described as belonging to fractures of the surgical neck. 
Prognosis.—A favorable result may be confidently expected in all cases 
of simple fracture of the surgical neck, both as to the union and the useful- 
ness of the limb. Hamilton* records eleven cases of such fractures which 
he had under observation. In eight the limbs were perfect; in three there 
was deformity, but with a useful arm ; and in one no union took place. 
My own experience does not furnish a single example of failure in the con- 
* Fractures and Luxations, p. 227. 924 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
solidation, although I have occasionally seen considerable rigidity about the 
joint where severe contusion of the soft parts had been experienced at the 
time of the fracture, rendering the patient unable for several months to 
carry the arm to the head. 
Treatment of Extra-capsular Fractures.—The dressing which is 
usually employed consists of two splints,—one an internal angular (Fig. 713), 
Fig. 713. 
Author’s internal angular splint 
and the other a piece of binders’ board, long enough to extend two inches 
above the acromion, down almost to the external condyle, and wide enough 
to include, when moulded into shape, the outer, posterior, and anterior sur- 
faces of the arm. (Fig- 714.) The fracture being reduced, 
a roller is carried from the fingers up to the shoulder. The 
internal angular splint, well padded, is next placed along 
the inner side of the flexed arm, extending well up into the 
axilla, the skin of which should be protected by a pledget of 
soft, clean cotton. The binders’ board should now be well 
soaked in hot water until perfectly pliable, when, a few short 
vertical slits being made in its upper extremity, it can be 
neatly moulded to the shoulder and arm. Some cotton must 
be next placed beneath its upper and lower extremities, after 
which, with a second roller beginning at the hand, these 
splints are to be firmly bound to the arm, finishing with a 
few turns of the spica of the shoulder. The arm is now 
placed along the side of the body and lightly secured to the 
same by a strip of muslin, and finally the hand and wrist 
are to be supported in a sling. The sling should not include 
more than the hand and the wrist, as the weight of the arm 
contributes to the extension. (Fig. 715.) 
By this method the axillary wedge-shaped pad of Sir Astley Cooper is dis- 
carded. This pad wras designed to act upon the lower fragment and keep it 
out, the base of the pad being placed upward. I have never seen the neces- 
sity for its use. When the arm is brought to the side, the pectoralis major, 
latissimus dorsi, coraco-brachialis, and the short portion of the biceps mus- 
cles are relaxed, and can have little if any influence in drawing the lower 
fragment inward. Again, it will be seen that I have directed the arm to be 
bound to the body by a single strip, instead of by the usual roller, which is 
frequently a source of uncomfortable restraint to the patient. 
Another plan of treating these fractures, and one which has given me very 
satisfactory results, is the following: first cover in the entire arm with a 
spiral reversed roller, and then mould to its anterior, outer, and posterior 
surfaces a splint of binders’ board, with a cap for the shoulder, after which 
the arm is flexed and placed against the side, with the forearm across the 
chest. It only remains to bind it to the body by spiral turns of a bandage— 
the turns of the roller being tacked together with a number of stitches—and 
to support the hand in a sling. (Fig. 716.) By this method the internal 
angular splint is dispensed with, the body of the patient taking its place. 
Mr. Tyrrel. in a case of fracture through the surgical neck of the humerus, 
was obliged to carry the arm away from the body, and to maintain it so on 
Fig. 714 
Cap for the shoulder 
and the arm. FRACTURES OF THE SHAFT OF THE HUMERUS. 
925 
a rectangular splint, in order to overcome the outward displacement of the 
upper end of the lower fragment. 
I was obliged, under like circumstances, to resort to a similar position in 
the case of a woman whom I attended with Dr. Watson, of this city. The 
upper end of the lower fragment was persistently drawn out by the deltoid 
Fig. 715. 
Fig. 716. 
Dressing for fracture of the surgical neck of the 
humerus. 
Arm bound to the body, the latter constituting the 
innereplint. 
muscle, and the deformity was only overcome by bringing the arm at a 
right angle with the body, and, after applying the dressing, keeping it in 
this position by a proper support until the tendency to displacement passed 
away. I have seen the same deformity overcome by first abducting the arm, 
while in this position, and bandaging it firmly to the internal splint, and after- 
wards making fast the external splint, wdien the limb was brought again to 
the side. 
The union requires from four to eight weeks, and it is necessary about 
the fourth week to begin passive motion. 
Compound fractures of the surgical neck are to be treated like similar 
injuries elsewhere, namely, by adjusting the fragments, closing the external 
wound, and placing the arm on the splints already described. If the wound 
is large, some caution is necessary in regard to its closure. It must be care- 
fully watched, and on the earliest evidence of the presence of inflammatory 
accumulations a free vent for their escape should be provided. If there is a 
sharp point belonging to the lower fragment, with a tendency to displace- 
ment, and provoking much irritation, it should be turned out of the wound 
and the offending portion removed. 
Fractures of the Shaft of the Humerus. 
These fractures may take place at any point between the surgical neck 
and the condyles of the bone. There is some discrepancy among authors as 
to the most common location. The lower third, in my own experience, has 
generally been the seat of fracture. 
The direction of the fracture is generally oblique, sometimes transverse. 
The separation may be either complete or incomplete. The latter condition 
is met with occasionally in young subjects. 
Causes.—Generally the causes are direct violence. Many eases of frac- 
ture by muscular action alone are recorded; indeed, this bone seems to be 
particularly distinguished for such injuries. Gross* saw a case where the 
humerus was broken by simply throwing a chip. Listonf records one where 
* Surgery, vol. i. p. 981. 
I American Journal, November, 1836, p. 249. 926 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
it was broken by merely stretching out the arm quickly. Bryant* furnishes 
a case in which the fracture was produced in a marital embrace. I have 
seen the accident once occur from the trifling effort of getting into bed. 
Persons sometimes make a trial of strength by sitting on opposite sides of 
a table, placing their elbows on it, and, grasping each other’s hands, each 
struggling to turn outward the arm and wrist of his competitor. In such 
contests the humerus has been snapped asunder, instances being furnished 
by Malgaigne, Lonsdale, Hamilton, and others. Fractures of the humerus 
have been known to occur to the child during parturition.j 
Symptoms.—There will be deformity, unusual mobility, and crepitus. The 
deformity will differ according to the seat of fracture. When broken from 
muscular action, the fragments do not separate, save in exceptional cases, 
the periosteum and the serrations keeping them in contact. Should the break 
occur above the insertion of the deltoid muscle, the lower fragment will be 
tilted outward and drawn up by this muscle, while the upper fragment will 
be drawn inward by the pectoralis major, latissimus dorsi, and teres major 
muscles. 
If the fracture takes place below the insertion of the deltoid, the upper 
fragment may be little changed, as the deltoid on the one side, and the pec- 
toralis major, the latissimus dorsi, and the teres major on the other side, an- 
tagonize one another. The lower fragment may be drawn somewhat up- 
ward and inward by the biceps and triceps muscles. It will, however, be 
found in practice that the direction of these 
fractures and the influence of the fracturing 
force will often neutralize muscular action, 
and present us with a different relation of 
the fragments from that just stated. When 
the fracture occurs through the lower third 
of the bone, the lower fragment is prone to 
slip behind the upper one, in which case the 
shortening, through the contraction of the 
biceps and triceps muscles, becomes very 
marked. (Fig. 717.) The tendency, so far 
as muscular action is concerned, will always 
be to produce shortening. In a specimen in 
my possession, the overlapping amounts to 
almost two inches. 
Prognosis.—In simple fractures, a rapid 
cure may be confidently anticipated in from 
four to five weeks ; yet it must never be 
forgotten that a very large number of the 
cases of ununited fracture occur in this part 
of the bone. There is no explanation for 
this to be found in any peculiarities con- 
nected with the bone, so that there is reason 
to believe that in some instances non-union 
is due to an imperfect immobilization of the 
fragments. Of course these remarks are not 
designed to apply to cases of compound or 
comminuted fractures of the bone, as under such circumstances we have a 
sufficient cause for any failure to consolidate which may follow. 
If the fractured ends are entirely displaced from each other, the soft parts 
participate in the injury, and we may expect considerable inflammatory 
swelling : even abscesses have followed these accidents. The rigidity of the 
shoulder-joint and elbow-joint,—especially of the latter,—the result of a fixed 
flexed position, is certainly greater than that of the knee and the hip in 
fractures of the thigh. An examination of a large number of fractured 
humeri convinces me that, when the separation is oblique, there is almost 
Fig. 717. 
Fracture at the lower third of the humerus, 
with overlapping. 
* Surgery. 
j" Hamilton on Fractures, etc., p. 234. FRACTURES OF THE SHAFT OF THE HUMERUS. 
927 
always some degree of deformity by overlapping, which, however, does not 
impair the usefulness of the limb to any appreciable degree. 
Another danger to which the arm is exposed in these fractures is a paral- 
ysis of certain groups of muscles. Should the musculo-spiral be damaged 
where it passes round the humerus, or lower down, where its posterior inter- 
osseous branch is given off, the extensor muscles will become powerless, as 
also will the supinators : the hand will drop and become pronated. (Fig. 
718.) This condition may remain permanent. A lad ten years of age was 
brought to the clinic of the University with this condition following a frac- 
ture of the humerus. As the absorption of the redundant callus took place, 
and under the stimulus of an electro-galvanic current, his improvement was 
quite noticeable. 
There is reason to believe that even the brachial artery may be compressed 
by one of the fragments, and give rise to sloughing. Hamilton relates the case 
of a physician who was prosecuted for malpractice, before a court in Tioga 
County, Hew York, in consequence of a result of this kind, which had been 
improperly attributed to the maladroit 
use of splints. 
Treatment.—The indications are, 
first, to control muscular action; second, 
to secure muscular relaxation; third, 
to immobilize the fragments; and last, 
to prevent articular stiffening. The 
first is effected by applying a spiral re- 
versed roller as far as the elbow: if 
there is overlapping, an assistant should 
make extension by seizing the arm just 
above the elbow-joint, the forearm 
being flexed at a right angle, while a 
second makes counter-extension by 
grasping the shoulder, the surgeon at 
the same time eoaptating the parts. If any difficulty is experienced in re- 
storing the limb to its proper length, an anaesthetic should be employed, so 
as to remove all muscular resistance. As soon as the adjustment has been 
made, the roller should be continued up to the shoulder. This bandage is 
exceedingly important. It secures quietude to the muscles, is a capital sup- 
port to the fracture, and removes as well as prevents swelling. 
Fig. 718. 
Paralysis of the extensors of the hand, or wrist- 
drop, after fracture. 
Fig. 719. 
Angular, concave, and short straight splints for treating a fracture of the shaft of the humerus. 
The second indication, that of effecting muscular relaxation, can be carried 
out only very imperfectly. With this object, the forearm is flexed to some- 
what less than a right angle. This position relaxes both the biceps and the 
brachialis anticus muscle, and only to a moderate degree extends the triceps. 928 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
It is also necessary to control the movements of the forearm, upon which 
these muscles are inserted. To maintain the arm in the proper position, 
and at the same time to immobilize the fracture, there will be required an 
internal obtuse angular splint, long enough to extend from the axilla to 
the ends of the fingers, with an opening cut at the angle, in order to relieve 
the internal condyle of the humerus from pressure; and a concave splint of 
binders’ board, reaching from the summit of the shoulder to the external 
condyle of the humerus, and moulded into form by being softened in hot 
water. If the binders’ board cannot be obtained with which to make the 
concave splint, the latter may be substituted by three short pieces of light 
wood. (Fig. 719.) These splints, being well padded, are applied as follows : 
the angular splint is laid along: the inner side of the arm and the forearm, 
and the concave one is placed 
over the outer, posterior, and an- 
terior surfaces, after which a rol- 
ler is carried from the hand to 
the shoulder, binding the splints 
firmly to the limb, and terminating 
by a few turns of the spica of 
the shoulder. The dressing is 
completed by suspending the hand 
in a sling. (Fig. 720.) 
When the short splints are used, 
the largest is to be laid upon the 
outer surface, the shortest upon 
the anterior surface, and the one 
intermediate in length along the 
posterior aspect of the arm, all 
being fastened, as in the first in- 
stance, by the ascending turns of 
the roller. 
In order to overcome shorten- 
ing, several devices have been re- 
sorted to, such as the crutch of 
Lonsdale, the ratchet-splint,' the 
adhesive plasters of Martin, of Boston, and the elbow-weight of I)r. Clark; 
but all such appliances, however ingenious, will prove unsatisfactory, in con- 
sequence of the mobile nature of the shoulder. 
Fig. 720 
Dressing for fracture of the shaft of the humerus. 
Fig. 721. 
Apparatus for wrist-drop applied. 
The paralysis incident to nerve-pressure may disappear as the redundant 
callus is absorbed ; but when this is not the case, an apparatus for the sup- 
port of the hand may be applied with advantage. (Fig. 721.) 
The diagnosis of injuries occurring at the lower end of the humerus de- 
mands the most accurate knowledge of the anatomy of the elbow-joint. I 
never approach cases of this nature without a certain degree of anxiety. 
Such fractures are often compound, sometimes comminuted, and attended 
Fractures of the Lower Extremity of the Humerus. FRACTURES OF LOWER EXTREMITY OF THE HUMERUS. 
929 
with much swelling and inflammation of the joint, as well as injury to the 
soft parts. The varieties of fracture met with here are the supra-condyloid 
and the condyloid fractures. 
Supra-condyloid Fractures.—These include two varieties,—one just above 
the limits of the expanded condyles, and the other through the lower epi- 
physis, the latter being very rare. (Fig. 722.) Their symptoms are so 
similar that it is a very difficult task to distin- 
guish the one from the other. The first, or that 
through the lower part of the bone, may be 
transverse or oblique. Sir Astley Cooper thought 
that it was generally oblique and ran in a direc- 
tion downward and forward. This accords with 
my own observation ; though there are not want- 
ing examples in which the reverse is true, namely, 
the fracture running downward and backward. 
The subjects of this injury are usually young. 
Of sixteen cases noticed by Hamilton, ten were 
in children under ten years of age. 
Causes.—A fracture either above the con- 
dyles or through the epiphysis is generally the 
result of force applied directly to the elbow, and 
occasionally of force transmitted through the 
bones of the forearm. 
Symptoms.—There will be preternatural mo- 
bility, shortening of the arm, crepitus, and de- 
formity. Two projections may be discovered, the one in front formed by the 
lower end of the upper fragment, and the other posteriorly, often the larger 
of the two, formed by the upper end of the lower fragment, together with 
the radius and ulna, as these are usually carried backward by the action of the 
triceps muscle. The fracture occurring so near to the articulation is liable to 
be mistaken for a luxation of the elbow-joint. A consideration of the follow- 
ing points will enable the practitioner to establish the distinction: 
Fig. 722. 
Supra-condyloid fracture. 
In fracture, there is shortening of the arm. 
The condyles of the humerus and the olecranon 
process are in the same line. 
There will be crepitus. 
The end of the upper fragment is above the 
bend of the elbow. 
The end of the upper fragment is moderately 
broad, and, if the fracture is not epiphyseal, 
irregular in its outline. 
Reduction is easily effected by extension and 
counter-extension; but the deformity reappears 
on the withdrawal of those forces. 
Forearm is very movable. 
FRACTURE. 
In dislocation, there is no shortening of the 
arm. 
The olecranon is above the line of the con- 
dyles. 
There is no crepitus. 
The end of the humerus is below the bend of 
the elbow. 
The end of the upper piece is broad and com- 
paratively smooth. 
Reduction requires the exercise of consider- 
able force, and when once accomplished there is 
no tendency to a return of the deformity. 
Forearm is fixed, or admits of little movement. 
DISLOCATION. 
Treatment.—Extension and counter-extension being made, in order to 
bring the lower end of the bone into position, the forearm is placed at a 
right angle with the arm, and firmly covered from the fingers to the axilla 
with a roller bandage. Two well-padded rectangular splints are next placed as 
follows : one (Fig. 723) is laid along the anterior aspect of the arm, extending 
from the shoulder to the ends of the fingers, and the other, in the form of a 
trough,—moulded from binders’ board, leather, or gutta-percha,—is placed on 
the posterior aspect of the arm, extending from the middle of the arm to 
the middle of the forearm, and deep enough to receive half the circum- 
ference of the arm. (Fig. 724.) These splints are to be secured by a second 
roller and the arm placed in a sling. I am confident that we have a much 930 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
greater security against displacement in the use of two splints so disposed, 
than by any other method. 
At the beginning of the third week, passive motion should be carefully 
Fig. 723. 
Fig. 724 
Author’s anterior angular splint. 
Posterior angular trough. 
commenced, the arm being firmly grasped at the seat of fracture with one 
hand, while the forearm is gently flexed and extended with the other. 
Condyloid Fractures.—These fractures are variously situated. 1, They may 
run transversely across the base of the condyles ; 2, they may pass vertically 
between the condyles,—intercondyloid ; 3, their direction may be both trans- 
verse and vertical, separating the condyles from the shaft of the bone and 
from each other; 4, the internal or the external condyle may be broken ; 
and, 5, the epicondyle may be detached from the internal condyle. There 
are no fractures through the external epicondyle as yet satisfactorily estab- 
lished. 
Fractures about the elbow-joint are not unfrequently followed by impaired 
motion and by deformity, notwithstanding the most judicious management; 
and the patient should always be informed of the probability of such a result. 
The inflammation and swelling which rapidly follow these injuries often 
mask the accident. 
Fracture across the Base and between the Condyles.—In this variety of frac- 
ture (Fig. 725), first noticed by Desault, there is a separation both between 
and through the base of the condyles, making three 
fragments,—properly a comminuted fracture, and one 
of rare occurrence. Malgaigne was able to collect 
eight cases, and Hamilton has met with the acci- 
dent only six times. 
Symptoms.—The symptoms are an increased breadth 
of the elbow in consequence of the separation of the 
condyles, with mobility of the latter when pressed in 
opposite directions. There is also a free antero-pos- 
terior mobility of the condyles, which does not affect 
the shaft of the humerus. Crepitus may be recog- 
nized when the condyles are moved either back and 
forth or when they are forced together. The radius 
and ulna, losing their support, are displaced back- 
ward, and form an unnatural prominence on the 
back of the arm. 
The cause of this fracture, as far as can be gathered from the description 
given by patients, is violence applied to the posterior part of the elbow when 
the arm is flexed, thus driving the olecranon forward against the condyles. 
Prognosis.—Stiffening and even firm anchylosis of the joint may be an- 
ticipated, although the surgeon should not despair of securing an opposite 
Fig. 725. 
Transverse and vertical frac- 
ture of the condyles of the 
humerus.—Malgaigne. 
Fractures of the Condyles.—Each condyle is surmounted by a bony pro- 
jection, which by American surgeons is termed the epicondyle. A frac- FRACTURES OF LOWER EXTREMITY OF THE HUMERUS. 
931 
ture, therefore, at this portion of the bone may be articular or non-articular, 
according as it involves the condyle proper or its epicondyloid prominence. 
These accidents are always grave, but not to the same degree as the inter- 
condyloid fracture just described. A large proportion of these fractures 
occurs in childhood or during early adolescence. 
Causes.—These are generally falls or blows, in which the force is ap- 
plied either on the side or on the point of the elbow, and in some cases 
is transmitted to the humerus from the hand, through the bones of the 
forearm. 
Prognosis.—In all fractures affecting the condyles or the epicondyles we 
may expect more or less stiffening, as a result of inflammatory deposition 
both within and without the articulation. This, however, constitutes only a 
temporary disability, as the rigidity is usually amenable to treatment. In 
the management of all these fractures, the extended position of the arm is 
the one which must be maintained. 
Fractures of the Internal Condyle.—The external condyle is more frequently 
broken than the internal. This is also asserted both by Malgaigne and by 
Hamilton; though Desault, who was the first to describe the injury, enter- 
tained, in common with Sir Charles Bell and Sir Astley Cooper, the opposite 
opinion, which I believe to be the correct one. 
The direction of the fracture is oblique to the longitudinal axis of the limb, 
and will involve the joint to a 
greater or less extent, accord- 
ing to this obliquity. In most 
cases it reaches the middle of 
the olecranon surface. (Fig- 
726, A and B.) 
Symptoms.—There will be 
pain and rapid swelling,—the 
latter sometimes so great as to 
obliterate all the characteristic 
features of the articulation. If 
the arm is extended, it will in- 
cline inward. The breadth of 
the elbow may be increased. 
This depends, however, upon 
the amount of displacement, as 
in some instances the ligaments 
still hold the condyle in nearly 
its normal situation. By grasp- 
ing the epicondyle between the thumb and fingers, the condyle, if detached, 
will be felt to move independently of the humerus, and crepitus may at the 
same time be felt. The olecranon will be drawn upward and backward, and 
with it the condyle, forming a very marked prominence on the back of the 
arm, especially when the forearm is extended. If a line is extended from 
the acromion process to the internal epicondyle, it will exhibit a certain 
amount of shortening as compared with the external condyle. 
Fig. 726. 
Fractures of the internal condyle. 
Fractures of the External Condyle—These, like those of the internal con- 
dyle, are, save in exceptional cases, injuries peculiar to the young,—not often 
occurring after twelve or fifteen years' of age. They are oblique in their direc- 
tion, and include the articulating surface for the head of the radius (Fig. 727), 
or, passing still more to the inner side, may involve the articulating surface 
appropriated to the ulna. 
Symptoms.—Pain, swelling, deformity, crepitus, and mobility of the de- 
tached part are the signs of this accident. The pain is very acute when the 
joint is moved. There is increased breadth of the joint, the broken condyle 
being drawn either outward or forward, or upward and backward, in spite of 932 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the supinator and extensor muscles. If the latter displacement follows, the 
arm will be slightly flexed and an unusual prominence felt posteriorly. When 
the arm is extended, it will incline to the radial side, and the 
degree of this inclination will be increased in proportion as 
the line of fracture encroaches upon the articulating surface 
of the ulna. If the radius is not entirely detached from the 
condyle, which sometimes occurs, it will follow the latter in 
its displacement; and the same is true of the ulna. 
Diagnosis.—The only injury with which fractures of the 
condyles are likely to be confounded is dislocation. A con- 
sideration of the following points will serve to establish the 
distinction: 
In fracture, extension of the arm will remove the deformity, 
but it will immediately reappear on taking away the traction- 
force. In luxation, a greater amount of force is requisite to 
effect the reduction, and when the bones are once restored 
they so remain. In fracture there is crepitus; in luxation 
there is none. In fracture there may or may not be flexion 
of the arm; in posterior luxation, flexion is always present. 
In luxation the epicondyloid eminences are always in a line; 
in fracture -they do not correspond,—one being higher or 
lower than the other. 
Prognosis.—This fracture may be expected to unite firmly 
in a period of four weeks, though there are numerous in- 
stances of ligamentous or fibrous union. Some stiffness of the 
articulation may be anticipated, the degree of which cannot 
be predetermined ; yet by judicious movements much of this 
will wear away, and a good arm may be confidently expected. 
Fig. 727. 
Fracture through 
the external con- 
dyle of the hu- 
merus.—Smith. 
Fractures of the Internal Epicondyle.—Although there are two epicondyles, 
there are no well-authenticated cases of fracture of the one surmounting 
the external condyle, and therefore I treat only of fracture of the one belong- 
ing to the internal. Granger* first described this injury, in the year 1818. 
Causes.—The epicondyle is an epiphysis, and the fracture, in most cases, 
occurs in childhood, before its bony consolidation with the condyle has taken 
place. It is occasionally produced by muscular action alone. This is not 
surprising, when we consider that the origins of the flexor muscles of the 
forearm concentrate upon this point, and that they are capable of exerting 
great power when the arm is put out to defend the 
body against a fall. Direct blows frequently occasion 
fracture of this process. (Fig. 728.) 
Symptoms.—There will be pain, swelling, discolora- 
tion, mobility, and crepitus. The last can be ascertained 
by seizing the process between the thumb and fingers 
and pressing it in opposite directions. The fracture 
may not disable the patient from performing to some ex- 
tent the different movements of the arm. The deform- 
ity or displacement is, in most cases, downward and a 
little forward, and is due to the action of the pronator 
and flexor muscles. 
Granger states that in this fracture the ulnar nerve 
may be damaged, giving rise to disordered sensibility 
and to loss of power in the parts supplied by its branches, 
as shown by the altered sensibility on the inner side of 
the hand and along the ring and little fingers, and by 
the loss of power in the abductor and the flexor brevis 
minimi digiti muscle, which occurred in some of his 
cases. This condition was sometimes attended with an eruption of vesicles 
Fig. 728. 
Fracture of the internal 
epicondyle. 
* Edinburgh Medical and Surgical Journal, 1818, vol. xiv. p. 196. FRACTURES OF LOWER EXTREMITY OF THE HUMERUS. 
933 
over the affected parts, somewhat akin to the herpes zoster which is occasion- 
ally seen accompanying an attack of neuralgia. It is not probable that these 
effects can result from a displaced epicondyloid fragment, as the nerve lies 
in a groove deep between the internal condyle and the olecranon process of 
the ulna, and quite secure from injury by such a displacement. I cannot 
help thinking that they must have been due to contusion of the nerves by 
the force producing the fracture, or from the line of separation involving the 
condyle itself. Certainly I have never witnessed such a condition, nor am I 
acquainted with any similar cases narrated by other observers. 
Prognosis.—Complete reduction is rarely effected, and stiffness of the 
articulation may be looked for, not necessarily from involvement of the joint, 
but from the inflammatory deposit about the origin of the pronator and flexor 
muscles of the forearm. The abridged movement will not be permanent, 
but will wear away under appropriate treatment, a process, however, some- 
times requiring years for its accomplishment. 
Treatment of Fractures at the Lower Extremity of the Humerus.—In all 
condyloid and epicondyloid fractures the three great indications are to con- 
trol inflammation, to secure a proper adjustment of the fragments, and to 
prevent, as far as possible, anchylosis of the elbow-joint. When there is 
much pain and inflammatory swelling, the application of leeches about the 
articulation will produce the happiest effects; and when these cannot be 
obtained, lead-water and laudanum should be freely applied to the parts. 
During the urgency of the inflammatory symptoms, and while lotions are 
being used, it has been recommended not to encumber the arm with any 
apparatus, but simply to support the limb upon a pillow. If the surgeon 
could always have the patient under strict surveillance, there would be no 
objection whatever to this practice. Except, however, in hospitals, this is not 
possible ; and consequently I prefer placing the arm immediately in a perma- 
nent dressing. With few exceptions, the extended position is the one adopted 
by surgeons as best adapted to the treatment of these fractures; otherwise 
there will be an upward 
and backward displace- 
ment of the broken con- 
dyle (Fig. 729, A and B), 
which will be found to 
leave an unnatural prom- 
inence or a deformity on 
the outer or the inner as- 
pect of the joint, as has 
been well shown by Dr. 
Allis, of this city* This 
is always increased by 
the right-angled position 
of the arm. After union 
has been well established, 
the position of the fore- 
arm may be changed to 
the flexed one. 
In order to maintain 
the arm in the extended 
state, it is necessary to 
employ an anterior splint, 
well padded, and extend- 
ing along the anterior as- 
pect of the arm and forearm, with a felt or leather trough adjusted to the back 
of the joint, and the two secured by turns of a roller beginning at the hand 
and terminating at the shoulder (Fig. 730). When a fair degree of union 
Fig. 729. 
Fracture of the external condyle, with displace- 
ment upward and backward.—Malgaigne. 
Fracture of the internal 
condyle, with upward dis- 
placement. 
* Dr. Allis has written an exhaustive article on this subject. 934 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
has taken place,—that is, in about two and a half or three weeks,—angular- 
splints can be substituted. There are three varieties of this splint,—the 
Fig 730. 
Splint applied. 
fixed, the movable, and the trough-shaped. The first two are constructed so 
that one form can be worn on the inside of the arm and the other on its an- 
terior surface. My preference 
is very decidedly in favor of 
the anterior angular splint, as 
it is better suited to prevent 
posterior displacement of the 
fragments than is the internal 
angular one. When this form 
of the splint is used, it is best 
to have several of different 
angles (Fig. 731), so that the 
position of the joint may be 
changed from time to time after 
the consolidation of the bone is 
sufficiently advanced to prevent displacement. If the two parts of this splint 
are joined by an articulation, the angle can be changed at pleasure, and one 
can be made to accomplish the office of a number. The alteration of the angle 
is sometimes regulated by a rod having a hook at its free end, which fastens 
into the holes of a cleat. (Fig. 732.) This rod is sometimes substituted by 
a Stromeyer screw. (Fig. 733.) The presence, however, of either the rod 
or the screw rendering the application of a roller somewhat inconvenient, I 
Fig. 731. 
Anterior angular splints of different angles. 
Fig. 732. 
Fig. 733. 
Articulated anterior angular splint. 
Anterior angular splint with a 
Stromeyer screw. 
employ a ratchet-hinge. (See Fig. 723.) Professor Gross used a long tin 
case, well padded, and extending from the axilla to the carpus. 
To apply the dressing after the old plan, the arm should be flexed to a 
right angle and covered with a spiral reversed roller from the fingers to 
the axilla. This by some surgeons is deemed unnecessary, but with them I 
cannot agree. In no other way can involuntary muscular action be so con- 
veniently controlled, and, as the irritation from this cause is frequently very 
distressing, the bandage becomes a source of great comfort to the patient. 
Again, when judiciously applied, the roller serves to limit the swelling, and 
in cases where the condyles separate from each other it assists in binding FRACTURES OF LOWER EXTREMITY OF THE HUMERUS. 
935 
them together. After the acute symptoms are past the primary roller is 
not required. 
After this preliminary bandage, the anterior splint should be placed on the 
front of the arm and of the forearm, the latter being previously well supi- 
nated, so that the upper and the lower portion of the limb may be in the 
same plane. A little cotton being now interposed between the front of the 
elbow and the angle of the splint, a second roller should be carried from the 
hand to the axilla, securing the apparatus to the member. For the first 
three days the dressing should be renewed daily, unless it is found to be 
comfortable, neither too tight nor too loose, in which case it may be allowed 
to remain undisturbed for two or three days. The anodyne lotions in the 
mean time can be poured over the bandage at the joint, in the event of there 
being much inflammation present. 
In cases where the tendency to posterior displacement of the condyles and 
bones of the forearm cannot be satisfactorily prevented, a trough-shaped 
posterior angular splint (Figs. 734, 735) may be added to the dressing with 
an excellent result. 
As soon as the inflammation and swell- 
ing subside, the surgeon should begin to 
make passive motion of the joint. This 
at first can be effected by daily altering 
the angle of the anterior splint, which 
can be done without altogether removing 
the dressing. After the lapse of twelve or 
fourteen days this motion is best made 
by removing the apparatus, and, while 
the posterior part of the elbow rests in 
the hollow of one hand with the thumb 
and fingers supporting or pressing to- 
gether the condyles, the surgeon with 
the other hand cautiously flexes and ex- 
tends the forearm. This must be repeated 
every second or third day, and at the end 
of the fourth week all dressings should be 
removed and the limb carried in a sling, 
the patient practising daily the lessons 
which have been witnessed, by executing 
the various movements of flexion, exten- 
sion, pronation, and supination, and these 
should be persevered in, if necessary, for six or seven months. When there 
is any induration about the extra-articular tissues, systematic rubbing and 
kneading will materially aid in restoring the normal suppleness of the 
parts. 
It is common to meet with cases in which the inflammation from constitu- 
tional or local causes has proved uncontrollable and the plastic depositions 
have become so firm and unyielding as to destroy almost all motion. Of course 
such a result is not the work of two or three weeks, but of as many months. 
Under such circumstances a careful examination of the joint must be made 
in order to ascertain if the rigidity is due simply to fibrinous bands in and 
about the articulation, or to a more formidable condition, the vicious union 
of a displaced fragment. If the first, it will be proper to etherize the patient 
and forcibly disrupt the adhesions, following this at stated intervals with 
forced motion. If the latter, the course of the surgeon must lie between re- 
fracture of the bone and not meddling at all. If the case is a recent one, 
namely, of eight or ten weeks’ standing, and the disability great, let the bone 
be again broken ; if beyond this period, it is better to decline interference. 
There are cases, again, where the damage is so great that anchylosis can- 
not be prevented; and then it is the duty of the surgeon to place the arm 
in such a position as will render it most useful under the circumstances, 
Fig. 734. 
Pig. 735. 
Rectangular trough- 
shaped splint. 
Obtuse angular trough- 
shaped felt splint.—Ahl. 936 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
—namely, at such an angle as will admit of the hand being carried to the 
mouth. 
Cases will occur in which several fractures in different parts of the arm 
are present,—for example, fracture of the humerus and fracture of the 
radius and the ulna. An injury of this kind is best treated by a long internal 
angular splint extending from the axilla to the tips of the fingers, another 
splint reaching from the elbow a like distance down along the posterior 
surface of the forearm, and a third, consisting of a concave piece of felt or 
binders’ board, which shall reach from the shoulder to the elbow and include 
the anterior outer and posterior surfaces of the upper arm. These splints, 
if well padded and secured to the limb with roller bandages, will enable the 
surgeon to manage such a complication as the one in question without ma- 
terial difficulty. 
In a complex joint like that of the elbow, a compound or a comminuted 
fracture must be regarded as a very grave injury. 
Causes.—These fractures are ordinarily caused by the arm being caught 
in the machinery of manufacturing establishments, or by its being crushed 
under the walls or timbers of falling buildings. Hot unfrequently the injury 
is the result of a shot wound. The injury may be confined to one bone of 
the articulation, or it may extend to all of them. The swelling is usually 
great, and the succeeding inflammation rapid and very severe. 
Prognosis.—After an injury of this kind, even when limited in degree, 
the prognosis is unfavorable as respects the functional restoration of the 
joint; and in the more aggravated forms of the accident excision or amputa- 
tion is the alternative. 
Treatment.—If there is fracture either of the olecranon or of the con- 
dyles of the humerus, with an external wound, the wound should be well 
irrigated with a corrosive sublimate lotion (one to one thousand), closed with 
sutures, and sealed over with collodion iodoform, after which a pad of car- 
bolized or sublimate gauze should be placed over its site, and reinforced with 
antiseptic absorbent cotton. The arm should then be placed in a rectangular 
position and laid upon an internal angular splint, to which it is to be loosely 
secured by a roller. Pain must be subdued, if severe, by opiates; and as 
soon as the acute symptoms are entirely mastered, motion must be estab- 
lished, with a view to the future usefulness of the joint. The antiseptic 
applications are to be made for a period of ten or twelve days: after that 
period they accomplish little if any good. Should it be found that the joint 
continues to grow more and more rigid, in spite of the movements which 
have been made, it must be placed at a right angle, the position in which, 
as an anchylosed articulation, it will be most useful. 
In other instances the bones may be extensively comminuted and yet the 
vessels remain uninjured and the superincumbent tissues little damaged. 
The course to be adopted under such circumstances will be the excision of 
the damaged bone or bones, the subsequent treatment being conducted in 
the rectangular position, with the antiseptic dressings. After eighteen or 
twenty days, motion may be commenced, in order to prevent anchylosis. If, 
however, in addition to the comminution of the bones, the soft parts are 
much mutilated or bruised, and the brachial artery torn, amputation will be 
indicated, and should be promptly executed. 
Cases will be met with in which the favorable and unfavorable conditions 
are so blended that the surgeon may be undecided what course to adopt. In 
such an event we are to lean to the side of conservatism, as this does not 
prevent a resort to an operation should it be demanded at a future day,— 
that is, after suppuration has been established and the system has recovered 
from the perturbing effects of traumatic fever. 
Compound and Comminuted Fractures of the Elbow-Joint. FRACTURES OF THE BONES OF THE FOREARM. 
937 
The bones of the forearm are very often the seat of fracture. The exposed 
position of this part of the upper extremity in the innumerable acts of prehen- 
sion—olfensive and defensive—in which these bones are concerned, explains 
the frequency of the accident. Both may be broken simultaneously, though 
the radius is most frequently affected, a result which might be anticipated 
from its direct articulation with the hand. The great frequency of fractures 
of the bones of the forearm will appear from a review of the records of any 
general hospital. The tables of Flower and of Hulke of the Middlesex Hos- 
pital, covering a period of sixteen years, furnish 107 cases of fracture of the 
ulna, excluding the olecranon (or 183, including such), 768 fractures of the 
radius, and 191 of both radius and ulna.* 
The frequency of these fractures and their relative proportion may be 
learned from the statement of Malgaigne,f that they constitute one-eighth 
of the entire number treated at the Hotel-Dieu. 
Lonsdale says that of the 1901 fractures treated in the Middlesex Hospital, J 
covering a period of six years, 386 were of the forearm ; and of these, 197 
were of the radius alone. From the same tables it is ascertained that frac- 
tures of the radius are very much the most common ; next, fractures of both 
bones ; and last, of the ulna. 
Of the 1802 fractures of the forearm recorded in the Pennsylvania Hos- 
pital, 985 were in the radius, 218 in the ulna, and 599 in both radius and 
ulna. Those of the radius formed 11.4 per cent, of all fractures admitted 
into the institution. (See Table.) 
These fractures are not peculiar to any period of life. We meet with them 
in young children; but their frequency increases as life advances. This 
remark applies more particularly to the radius, as the ulna alone is not often 
broken before mature age. 
As to the influence of sex, there is a contrariety of opinion. Malgaigne 
asserts that of fractures of the ulna four-fifths occur in males, while in the 
tables of Flower and Hulke, to which reference has been made, the females 
exceed the males one-half. Again, the first author gives, in fractures of the 
forearm and radius, the proportions respectively of 67 to 40 and 95 to 65, or 
three-fifths in favor of males, whilst the same tables record for the same 
bones 373 males against 395 females, and, where both bones have been 
broken, 127 males against 64 females. This discrepancy can, I think, be 
explained on social grounds. 
Fractures of the ulna occur with equal frequency in summer and winter, 
but the radius is much oftener broken during the latter months, especially 
near the lower extremity, the majority of the patients being women beyond 
mature life. 
Of 648 cases of fracture of the radius gleaned from the records of the 
Pennsylvania Hospital, 24 were situated in the upper third, 53 in the middle 
third, and 571 in the lower third, 186 of the latter being at the lower end of 
the bone. In 542 instances the side was mentioned, 278 being on the right 
and 264 on the left side; and in 777 recorded cases of the same injury, 477 
occurred in males and 300 in females. Of this same number of fractures, 733 
were simple, 21 compound, 10 compound comminuted, 6 simple comminuted, 
and 7 not determined. The largest number for any decade—153—occurred 
between the ages of ten and twenty, and the next largest—150—between 
thirty and forty years of age. 
Cause.—This is usually from force applied either directly or indirectly,— 
the former, when a blow or violence of any kind is applied across the forearm ; 
and the latter, when the patient falls upon the hand and the force is trans- 
mitted through the wrist. Malgaigne reports a case of fracture of both bones 
from muscular effort alone.§ 
Fractures of the Bones of the Forearm. 
f Fractures, etc., Packard’s trans., p. 470. 
f Op. cit., p. 471. 
* Holmes’s System of Surgery, vol. ii. p. 764. 
J Cooper’s Surgical Dictionary, p. 724. 938 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Fracture of both Kadius and Ulna, or Fracture of the Forearm. 
Fracture of both bones of the arm may take place at any point between 
their extremities, but it is met with most frequently below the middle of the 
arm, or where the muscles terminate in the tendons, and where the protection 
of the fleshy masses which cover the upper portion of the arm is lacking. 
The bones at the lower half, especially the ulna, are least able to resist violence. 
Fractures at the lower extremities, or near the radio-carpal joint, are not 
at all common. In young subjects they may pass through the epiphysis. 
Causes.—These fractures are occasioned by force, either direct or indirect. 
A blow across the arm, the passage of a wagon-wheel, and falls upon the 
hand, are among the most common causes. The manner in which the force 
is applied determines the location of the fracture. For example, if it is re- 
ceived directly, the bones will be broken at or near the same level; but if 
indirectly, as where the hand is put out and the weight of the body received 
upon it, the fracture will be at different heights, each bone yielding at its 
weakest point, that of the radius being higher than that of the ulna. Mus- 
cular action alone is capable, as in Malgaigne’s case, of producing a fracture 
of the bones of the forearm; but such instances must be exceedingly rare, 
and due to a diseased state of the osseous tissue. 
Symptoms.—Unusual mobility at some point intermediate to the articu- 
lating extremities of the bones, pain on motion, crepitus, and perhaps de- 
formity, are the signs of this fracture. Swelling and discoloration may not 
appear until some time after the accident. Deformity is very often absent, 
or at least it is so slight as not to be detected through the fleshy parts on a 
simple inspection of the arm. The limb is entirely disabled, and if it is 
moved the patient is conscious of both crepitus and pain. 
Sometimes we meet with a very marked and persistent deformity in the 
case of young persons. The arm is curved or bent, no crepitus can be dis- 
covered, and the bones will, in spite of the strongest pressure, sometimes 
remain in this deformed position. This is what is commonly called the 
“ green-stick” fracture, the separation in the fibres of the bones, under such 
circumstances, being incomplete or confined to those on the convex surface 
of the curve. 
The direction of these fractures of the forearm is always more or less 
oblique, and the displacement may be such as to produce shortening, or an- 
gular deformity, anteriorly, posteriorly, or laterally. If the fracture runs 
upward and towards the interosseous space, the lower fragment or fragments 
may be drawn partially between the upper pieces and wedge them apart 
(Fig. 736); or, if the direction of the fracture is dissimilar in the two bones, 
the upper fragment of one bone may pass in front of the lower fragment, 
while the reverse may be true of the other bone. (Fig. 737.) When a lateral 
curve or angularity exists, I have generally seen the concavity of the curve 
on the ulnar side. (Fig. 738.) Should the fracturing force be applied when 
the hand is in a state of pronation, the bones may be displaced in opposite 
directions, the radius backward and the ulna forward. In most cases, how- 
ever, there is very little overlapping, because the fragments do not entirely 
become detached from one another, or in consequence of the line of fracture 
in one bone being so disposed as to resist the displacement of the other; fur- 
thermore, the interosseous ligament serves to act as a check to such displace- 
ment. Another disarrangement which may occur is the approximation of the 
two bones, either of the upper or the lower fragments, followed, of course, by 
a diminution of the interosseous space. This will be produced either by the 
manner in which the fracturing cause operates—as when the arm is di’awn 
into some machinery edgewise—or by the violent action of the pronator 
muscles. 
In the occasional cases of fracture near to the wrist-joint, the lower frag- 
ments are drawn upward and backward, and the injury might be mistaken 
for a luxation of the carpus. The readiness with which reduction is effected, FRACTURES OF THE BONES OF THE FOREARM. 
939 
the reappearance of the deformity when the extending and counter-extending 
forces are withdrawn, the existence of crepitus, and the fact that both styloid 
processes move with the lower fragments, are sufficient to distinguish this 
fracture from a luxation. 
Fig. 736. 
Fig. 738. 
Fig. 737. 
Lower fragments drawn partially between 
the upper ones. 
Overlapping of the upper 
and lower fragments of the 
two bones of the forearm. 
Lateral displacement. 
Prognosis.—A good cure—that is, freedom from deformity and the restora- 
tion of the various movements of the arm—may be anticipated where ordi- 
nary attention is bestowed on the dressings. Where the fractures are on 
the same level, there may be redundant callus deposited, which may impair 
both pronation and supination: indeed, in many cases of fracture of both 
bones there appears to remain some defect in full supination. Occasionally 
non-union is met with in fractures of the bones of the forearm. 
Treatment.—The surgeon reduces the fracture by flexing the forearm, in 
order to relax the muscles which arise from the humerus and are inserted 
at different portions of the lower arm, and, making extension from the hand 
while counter-extension is made by an assistant grasping the arm above the 
elbow, he moulds the parts by pressure into proper position. In many cases 
there is no displacement, and it is useless to subject the patient to the pain 
of unnecessary manipulation. The adjustment being perfected, the hand is 
placed between pronation and supination, the thumb pointing directly up- 
ward, and two light splints of poplar or pine wood, well padded, are placed 
along the anterior and posterior aspects of the limb, extending from the 
elbow to the tips of the fingers, and one inch wider than the arm. After 
the extremities of these splints are well guarded, by placing under each 
some cotton, they are to be bound to the arm by a roller, beginning at the 
hand and extending up to the elbow, where the bandage may terminate by 
a few turns about the joint. The arm now, being placed across the breast, 
is to be supported in a sling extending from the elbow to the fingers. (Fig. 
739.) 
I see this sling in many instances very carelessly applied, supporting only 
a portion of the arm : in such cases deformity is liable to follow, particularly 
if the splints become loose and slip towards the radial side of the arm. This 
dressing should be removed and reapplied after the lapse of twenty-four 
hours, as it may become very tight from the swelling: indeed, it should be 
carefully examined every day for six or seven consecutive days, until the 
surgeon is quite sure that there is no longer any risk to the circulation. 
It is very remarkable that the forearm has most frequently been the sub- 
ject of gangrene caused by improper fracture-dressing; a fact the first notice 940 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
of which, I believe, has been properly credited to Roux. Hamilton* records 
several instances of this kind. 
I once saw a case in the country, in which the arm became gangrenous 
from the injudicious use of a bandage applied for fracture by an intemperate 
physician, and which required an amputation above the elbow-joint. The 
liability to mortification, under such circumstances, has been attributed to 
the superficial position of the radial 
and ulnar arteries, in consequence 
of which they are easily compressed 
by the splints. This is certainly not 
true of the latter vessel, except near 
the wrist, and the radial is not more 
superficial than the brachial. I am 
disposed to believe that, while press- 
ure on these vessels in the forearm 
may in part account for so unfor- 
tunate a result, the pressure of the 
upper end of the anterior splint 
against the brachial artery at the 
bend of the elbow has often much 
to do with arresting the circulation. 
If the foi’earm is dressed in the ex- 
tended position, it will be found that 
when flexed across the breast the 
end of the anterior splint will press 
very forcibly against the brachial 
vessel; and I therefore lay stress 
on the necessity of applying the 
splints when the forearm is bent at 
a right angle with the arm, so that 
this pressure may be avoided. 
The dressing of fractures of the 
forearm cannot be passed over without taking some notice of the opinion 
of surgeons in regard to matters connected with position, interosseous press- 
ure, etc. 
Ambrose Pare and Lonsdale long since expressed their preference for the 
supine position in all fractures of the bones of the forearm. Nelaton also, 
with certain limitations, as when the fracture is in the upper third, inculcated 
the same doctrine; and Chelius may likewise be said to favor this position. 
Occasionally we meet with cases in which, in order to insure a proper re- 
duction, this position is demanded; but they are exceptional, and I agree 
altogether with the great body of American surgeons, in adopting the posi- 
tion of semi-pronation. It is the only one in which the bones are parallel 
with each other, and which secures the most complete interosseous space. 
Not only does this position yield the most satisfactory results, but it is also 
infinitely the most comfortable to the patient. 
To amplify the interosseous space, many contrivances have been devised. 
Of this nature are the convex splints of Amesbury, the concave splints of 
South, and the graduated compresses of Boyer, all of which are without value. 
This space is certainly very important to the proper motions of the hand, 
but it can be secured in another way. A glance at the anterior part of the 
forearm will show us that the muscular masses which occupy it are convex, 
so that when the plane surface of a splint is made to press upon them with 
sufficient power, they are quite sufficient to play the part of a wedge and to 
thrust the bones apart. Should, however, one of the bones, as the radius, 
be broken into three pieces, a pad may be applied to prevent the intermediate 
fragment from striking inward. The enveloping of the forearm with a roller 
before the application of the splints, when properly done, is not objectionable, 
Fig. 739 
Fracture-dressing for both bones of the forearm. 
* Fractures, etc., p. 320. FRACTURES OF THE RADIUS. 
941 
but, being liable to great abuse in unskilful hands, it should be discarded 
from practice. To be of any value in controlling muscular action, the turns 
of the roller would have to be drawn with a degree of firmness which would 
endanger the interosseous space. 
Fractures of the Radius. 
Of fractures of the bones of the forearm, those of the radius are most 
common. The direct articulation of this bone with the hand exposes it to 
shocks in various ways, which is a sufficient explanation of the frequency 
of this accident. 
It may be broken at any point, but most commonly at the lower extremity. 
Hamilton* gives the proportion as to situation in 101 fractures which he had 
collected to be as follows : in the upper third, 3 ; in the middle third, 6 ; and 
in the lower third, 92. Out of 648 fully recorded cases of fracture of the 
radius admitted into the Pennsylvania Hospital, 24 were in the upper third, 
53 in the middle third, and 571 in the lower third (see table on page 858). 
While it is true that fractures of the radius are produced commonly by in- 
direct force, as by falls upon the hand, especially those at the lower third of 
the bone, yet it is often broken by direct force. Packard met with an in- 
stance of this injury produced by muscular action alone. 
Fracture of the Neck.—There are perhaps not more than one or two 
cases of such a fracture (verified by post-mortem examination) in existence. 
One of these is in the Mutter collection, belonging to the College of Physi- 
cians of Philadelphia. Many surgeons therefore very properly believe the 
occurrence of this injury to be of great rarity. Mr. South speaks of it as 
being common ; but Hamilton, with his usual candor, in relating three cases 
which came under his own observation and which presented all the signs of 
such a fracture, says that he was not entirely convinced of the truth of the 
diagnosis. Sir Astley Cooper denied the existence of the fracture, and Mal- 
gaigne regards the lesion as exceedingly uncommon. The difficulty which 
encompasses the siibject is the depth of the neck of the radius from the sur- 
face, it being buried beneath the fleshy portions of the supinator longus and 
brevis and the extensor carpi radialis longior and brevior muscles. Many 
cases which have been accepted as fractures of the neck have, as in Dr. 
Markoe’s case, been most likely forward luxations of the head of the bone. 
Symptoms.—The principal sign of this fracture, theoretically at least, 
wrould be failure in the head of the bone to follow the rotatory movements 
of its shaft. To determine this, the thumb should be pressed firmly down 
upon the head of the bone, just below the external condyle of the humerus, 
and the hand pronated and supinated. In these motions, if a fracture existed, 
crepitus would be apt to be detected, as well as acute pain experienced. 
Treatment.—When a case of this nature is met with, the arm should be 
placed in a flexed position, with a view to relax the biceps muscle, which 
in the extended state would tend both to supinate and to draw the lower 
fragment forward and upward, by virtue of its attachment near to the tu- 
bercle of the bone. The upper short fragment, under the influence of the 
supinator brevis muscle, would be rotated outward. The hand should be 
placed in a state of supination, in order that the fragments, in the event of 
their being separated, may assume their proper relation to each other, and 
either an anterior or a posterior concave angular splint, well padded, should 
be applied to the arm and maintained in situ by a roller. In most of the cases 
treated, and where there were good reasons for believing that the fracture 
had been properly diagnosed, anchylosis followed, with loss of pronation and 
supination,—the hand being generally pronated,—showing that the radio- 
humeral articulation had been invaded by inflammation. This anchylosis is 
to be overcome by force; but the attempt to do so is not to be made earlier 
than the fifth or sixth week; otherwise, the line of union being yielding, 
* Fractures, etc., p. 267. 942 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the bone may be made to form an angular prominence anteriorly by the 
resistance of the tendon of the biceps muscle. 
Fracture below the Tubercle.—A fracture in this part of the bone, if above 
the insertion of the pronator radii teres, removes the upper fragment entirely 
from the influence of the pronator muscles, and the lower fragment from the 
influence of the two supinators, viz., the supinator brevis and the biceps 
flexor cubiti, the latter being a supinator before it acts as a flexor, especially 
in the prone state of the hand. The consequence is, the upper fragment is 
rotated outward and the lower one inward, according to Lonsdale, so that 
if union should occur under such circumstances the movement of supination 
would be lost. There can be little doubt that these statements are true 
within certain limits, and that they should have their weight in the treat- 
ment of this fracture. There are specimens in the Mutter collection of the 
College of Physicians which verify Lonsdale’s views, also in the museum of 
the University of Pennsylvania; and similar specimens exist in the museum 
of the Royal College of Surgeons, London, as stated by Flower.* 
Treatment.—The forearm being flexed to a right angle, the hand should 
be placed in a state of moderate supination, and so retained, either by the 
anterior or the posterior angular splint, the latter to be preferred, as by it 
the supination can be more certainly preserved. This will secure to the arm 
when cured the tw7o important movements of supination and pronation. The 
usual position of semi-pronation does not fulfil the indications in the treat- 
ment of this fracture, and should therefore be abandoned. 
Fractures of the Middle Third.—A fracture in this part of the bone is 
usually the result of violence directly applied, though it may follow a fall 
upon the hand. 
Symptoms.—A fracture in this part of the radius is not difficult of recog- 
nition. There will be a loss both of pronation and of supination ; the upper 
end of the radius, when the hand is rotated, will remain fixed; pain, crepi- 
tus, and preternatural mobility, with, usually, considerable swelling, will also 
he present. 
The displacement which the fragments may undergo, independent of that 
resulting from the force, will be, if the fracture is below the insertion of the 
pronator teres muscle, the tilting forward of the upper fragment by the 
action of the biceps muscle, and its internal rotation by the pronator teres. 
The lower fragment will be drawn towards the ulna by the conjoined action 
of the pronator quadratus and the supinator radii longus. (Fig. 740.) 
It is possible for the upper so 
to entangle the lower fragment 
as to carry the latter from the 
ulna. Overlapping of the frag- 
ments cannot occur unless there 
is a luxation of the ulna, the 
latter performing the office of a 
splint for the radius. 
Prognosis.—Though this is 
generally favorable, yet we often 
encounter among collections of 
fractures specimens where there 
is not only deformity, but also 
such an obliteration of the in- 
terosseous space by the irregu- 
larities of the callus as must 
have destroyed pronation and supination of the hand. 
Treatment.—The arm must be flexed, which at once neutralizes the dis- 
placing power of the biceps, and in a less degree that of the pronator radii 
Fig. 740. 
Fracture at the middle of the radius, with the displacement 
caused by—1, biceps flexor cubiti; 2, supinator radii longus; 
3, pronator radii teres; 4, pronator quadratus.—Hind. 
* Holmes’s System of Surgery, vol. ii. p. 793. FRACTURES OF THE RADIUS. 
teres muscle. This, with pressure on the lowrer end of the upper fragment, 
will serve to reduce it to the proper position. By insinuating the fingers 
into the interosseous space, and by strongly abducting the hand, so as to 
make tense the external radio-carpal ligament, the upper end of the lower 
fragment can be pressed out. The hand should be placed at semi-pronation, 
and a narrow compress three inches in length fixed over both the anterior and 
the posterior aspect of the arm, the upper ends of which should stop a little 
short of the fracture, so as not to affect the upper fragment, the tendency of 
which is to separate from, not to approach, the ulna. Two splints wider than 
the arm, wTell padded, and long enough to extend from the bend of the arm 
to the tips of the fingers, are to be applied along its anterior and posterior 
surfaces, leaving out the thumb, and secured in place by a roller, after which 
the arm should be supported in a sling, across the breast. This dressing, 
excluding the compresses, is the same as that described for fractures of both 
bones of the forearm. If the patient prove restless, disobeying the instruc- 
tions to keep the arm flexed, and the fragments become disarranged, it will 
be necessary to place an anterior rectangular splint upon the anterior part of 
the arm and forearm, and a straight posterior splint upon its back extending 
from the elbow to the ends of the fingers, binding them fast with a roller. 
Or it may be found that unless the hand is kept adducted—that is, 
strongly carried towards the ulnar side—the upper end of the lower fragment 
sinks in and leaves a depression, or encroaches upon the interosseous space. 
In such a case we should substitute the two straight splints by two pistol- 
shaped or Nelaton splints. (See Fig. 751.) These will serve to supply the 
anterior and posterior pressure, and also to maintain the hand in the ab- 
ducted state. Five weeks will generally prove sufficient to effect a cure, 
after the lapse of which time the splints may be thrown aside and the arm 
carried for two weeks longer in a sling. 
943 
Fractures at the Lower End.—These injuries, but little understood by the 
ancients, have been very carefully studied by modern surgeons, among whom 
may be named Pouteau,* Sir Astley Cooper, Desault,f Dupuytren,J Diday,§ 
Malgaigne,|| Voil lender, and especially Dr. John Rhea Barton,** Colles,ff 
and Robert Smith,|| of Dublin. 
These fractures are exceedingly common, and are met with at all seasons, 
though most frequently during the winter months. Although not impossible 
at any period of life, they belong more especially to mature and advanced 
age. After the age of thirty, women furnish the largest number of cases. 
Causes.—While fractures of this nature may follow direct force, yet in 
the vast proportion of cases the violence which breaks the bone is indirect, 
and is transmitted through the carpus by falls upon the palm of the hand. 
That the bone should yield at its most voluminous point is probably due to 
the great preponderance at this part of cancellated tissue, which is enclosed 
by the thinnest possible film of compact matter, and also in consequence of 
the presence of fatty degeneration,—a condition very common in women after 
the middle period of life. The lower epiphysis of the bone does not unite 
with the shaft until the twentieth year, and when the line of fracture is 
transverse and near the articulating extremity it may follow this conjunction. 
I have for some time taught that the mechanism of these fractures consists 
in the manner in which the force is communicated to the bone ;—that if the 
weight of the body is received on the metacarpo-phalangeal portion of the 
hand, the fracture will be a transverse one, in consequence of the resistance 
* (Euvres posthumes, 1783, book ii. p. 251. 
f (Euvres chirurgicales, 1813, t. ii. p. 251. 
j Legons orales, 1834, book iv. p. 161. 
$ Archives GlnSrales de Medecine, 1837, book iii. p. 141. 
|| Medical Gazette, 1832, p. 730. 
*[ Archives Generates de Medecine, 1842, book xiii. p. 261. 
** Medical Examiner, 1838, vol. i. 
ft Edinburgh Medical .and Surgical Journal, April, 1814. 
Fractures in the Vicinity of Joints. 944 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
offered by the anterior radio-carpal ligament to extreme extension. To verify 
the accuracy of this statement, it is only necessary to make the experiment 
on the cadaver. If the entire hand is violently forced back upon the arm, 
the radius will give way above its lower articulating extremity; and if the sub- 
ject is an old one, it requires no very unusual force to produce the fracture. 
The carpus, under such circumstances, acts as a fulcrum in the mechanism 
of the lesion. If, however, the weight of the body is received on the heel 
of the hand, the forcible propulsion of the carpus against the articulating 
surface of the radius will tend to rive the latter into two or more fragments, 
causing a comminuted fracture. 
Another element in these fractures is stated by M. Bouchet* to be extreme 
flexion of the hand. This was suggested by his attempts on the cadaver to 
produce luxation of the wrist-joint In all his experiments the radius gave 
way at its lower extremity. Malgaigne records a case examined by Voille- 
mier, which gives additional force to this statement,—where, in a struggle, 
a man had forced his antagonist’s hand into a state of undue extension, and 
thereby produced a fracture of the end of the bone. 
It occasionally happens that, in addition to the fracture of the radius, 
the styloid process of the ulna is broken. The triangular interarticular 
cartilage may likewise be disarranged, and the external lateral ligaments be 
torn. Voillemierf claims that these fractures are in most cases impacted, 
the upper fragment being propelled into the lower. Mr. Callender! enter- 
tains a similar opinion ; and to these names might be added those of iNelaton, 
Malgaigne, and Erichsen. R. W. Smith denies that they are impacted, except 
perhaps where the ulna and the radio-carpal ligaments are broken. I have 
seen a number of specimens in which impaction existed, but I do not believe 
this condition is a common one. Where the deformity is persistent, and in 
the absence of crepitus, impaction no doubt will be found to exist. 
According as the theory of impaction obtains will there be less prominence 
attributed to the muscles as the cause of deformity. Bryant§ sa}Ts that the 
thirty-six specimens of fracture of the lower end of the radius in the museums 
of the London schools prove that the deformity in each case was due to im- 
paction. 
The location of these fractures is often imperfectly understood. There is 
certainly much discrepancy among authors as to their seat. Dupuytren 
placed the fracture from three lines to one inch from the articulating surface; 
Sir Astley Cooper fixed it, in most cases, about one inch above the styloid 
process ; Nelaton locates it half an inch above the anterior edge of the articu- 
lating snrface of the bone; Colles places it one inch and a half above the 
carpal surface of the bone; and Robert Smith has never seen it higher than 
one inch, and often within one-quarter of an inch, of the articulating surface. 
There are several different fractures at the carpal extremity of the radius 
which will explain the diversity of opinion about the seat of these injuries. 
The first and by far the most common one is a transverse fracture, which 
may cross the bone at any point from the insertion of the radio-carpal liga- 
ments to one inch and a quarter above this line. (Fig. 741.) This injury 
is sometimes accompanied by a fracture of the styloid process of the ulna. 
(Fig. 742.) The second form is one in which the fracture passes obliquely 
through the styloid process of the radius, consequently traversing the outer 
part of its articulating surface. (Fig. 743.) A third form is one in which the 
bone is comminuted, the lines of separation running both transversely and 
vertically (Figs. 744, 745), and the vertical one commencing generally at the 
linear eminence seen on the articulating surface of the bone which separates 
the scaphoid from the semilunar part of the joint. A fourth variety consists 
of a transverse fracture, with a detachment of the posterior lip of the carpal 
* These sur les Luxations du Poignet, Paris, July, 1834. 
f Archives G6nerales de Medecine, 1842, vol. xiii. p. 261. 
j St. Bartholomew’s Hospital Reports, 1865. 
£ Surgery, p. 850. FRACTURES OF THE RADIUS. 
945 
articulating surface of the bone. In the collection of Professor John Neill 
there is a very characteristic specimen of this injury. Last, and perhaps 
rarest of all, is the fracture which breaks off the posterior lip of the artic- 
ulating surface of the radius (Fig. 746), commonly known as Barton’s* frac- 
ture. This lesion is exceedingly rare. It is 
not probable that Dr. Barton himself ever saw 
a dissection of the injury which he described. 
Only two or three specimens of the fracture 
can be found in the different collections of bones 
in Philadelphia. 
Dr. R. W. Smith describes a fracture of the 
radius in which the carpal fragment is driven 
Fig. 741. 
Fig. 742. 
Fig. 743. 
Transverse fracture of the articulating 
extremity of the radius. 
Transverse fracture of the 
lower end of the radius and of 
the styloid process of the ulna. 
Fracture of the styloid 
process of the radius. 
forward, and which is produced by a fall on the dorsal surface of the hand. 
No such injury has, I believe, ever been verified by dissection, and if it does 
Fig. 744. 
Fig. 745. 
Comminuted fracture of the carpal ex- 
tremity of the radius.—H. H. Smith. 
Comminuted fracture of the radius. 
Fig. 746. 
Fracture described by Barton.—From a specimen in Dr. Neill’s collection. 
really exist it would probably be found to consist in a breaking away of the 
anterior lip of the carpal surface of the bone. 
-*• Medical Examiner, November 7, 1838. 946 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Symptoms.—All these varieties of fracture have a general resemblance,— 
in the existence of pain, disability, loss of function, rapid swelling, and a pecu- 
liar distortion of the wrist. A prominence is seen on the back of the arm, 
due to the lower fragment being carried upward and backward, chiefly by 
the momentum of the fall, but partly by the extensor muscles of the carpus 
and of the fingers. A prominence also exists on the front of the arm, though 
not so well marked as the one situated posteriorly. This projection is formed 
by the lower end of the upper fragment. There is also a peculiar inclination 
of the hand to the radial side of the arm, accompanied by a corresponding 
prominence of the styloid process of the ulna, induced by the conjoined action 
of the extensor muscles of the thumb and of the carpus. 
If the thumb of one hand be placed firmly upon the head of the radius, 
and the injured hand at the same time be pronated and supinated, the 
break in the continuity of the bone may be recognized by the sensation of 
crepitus and by the immobility of the upper fragment. The exception to 
this would be in cases of impaction. The swelling, although around the 
entire articulation, is found chiefly on its anterior aspect, and is due to in- 
flammatory effusion into the great carpal bursa. On the back of the wrist 
this swelling depends on a similar condition of the sheaths of the six ex- 
tensor tendons, which occupy the grooves on the posterior surface of the 
radius. The radio-carpal joint, as well as the surrounding connective tissue, 
participates in the inflammatory swelling. 
There is, however, an appreciable difference in the deformity resulting from 
these various fractures. When the articulating end of the radius is broken 
transversely, the posterior prominence formed by the lower fragment is quite 
large, and the abduction of the hand moderate. (Fig. 747.) I f the internal 
lateral ligament is torn, 
or the styloid process of 
the ulna broken, in ad- 
dition to the fracture of 
the radius, the abduction 
of the hand will be much 
increased. 
When the separation 
occurs obliquely through 
the styloid process of the 
radius, the lateral dis- 
placement of the hand 
becomes very marked, the prominence made by the lower fragment is seen 
to be more external than posterior, and the projection of the lower end of 
the ulna is very noticeable. (Figs. 748, 749.) The deformity resulting from 
chipping off the posterior lip of the carpal articulating surface of the radius 
is not very great: neither the anterior nor the posterior prominence is as 
well pronounced as in transverse fractures of the bone, nor is the lower frag- 
ment displaced to the same extent upward as in the last-named fractures. 
The hand likewise may deviate but little from the proper line. 
These fractures resemble, in several particulars, dislocation of the carpus. 
The following considerations will serve to render the diagnosis clear : 
First, luxation is a very rare accident, fracture is a common one; second, 
in luxations which resemble these fractures—viz., those which are anterior or 
posterior—the hand is either flexed or extended, in fracture its inclination is 
generally lateral and to the radial side ; third, in luxation there is no crepi- 
tus, in fracture it can be usually recognized ; and, fourth, the deformity which 
disappears by extension, counter-extension, and pressure will not reappear 
when this force is removed, if the case is one of luxation, but will imme- 
diately return if it is a case of fracture. 
Prognosis.—The prognosis after a fracture at the lower end of the radius 
should be given with considerable reserve, and the surgeon should never 
neglect to prepare the mind of his patient for some degree of disability, such 
Fig. 747. 
Deformity in an extra-articular transverse fracture of the lower end 
of the radius,—silver-fork deformity of Velpeau. FRACTURES OF THE RADIUS. 
947 
as stiffness of the wrist-joint, rigidity of the fingers, and some irregularity 
in the contour of the parts. Hamilton* says, in speaking on this subject, 
that of 92 cases of fracture of this part of the radius, only 26 were known 
to have left no stiffness 
or deformity about the 
joint. Indeed, there are 
many cases where, in con- 
sequence of comminution 
or impaction, rigidity and 
deformity are unavoid- 
able, and no amount of 
surgical skill can prevent 
their occurrence. 
Treatment.—However 
fractures at the lower end 
of the radius may differ 
in their position, they can 
all be treated very much 
after the same manner. 
The dressings consist of 
two light well-padded 
splints, a little wider than 
the arm, and long enough 
to reach from the elbow 
to the tips of the fingers; 
two graduated or wedge- 
shaped compresses, three 
inches long and two inches 
wide; and two rollers, each two and a half inches wide and five yards long. 
Reduction.—Flexing the arm, and taking the hand of the injured member 
of the patient in his own, the surgeon makes extension, while at the same 
time, with the thumb of the other hand planted behind the prominence on 
the back of the wrist, and the fingers placed in front of the arm, he presses 
the lower fragment into place. Generally by this procedure the deformity 
disappears. In cases of comminution with impaction, these measures may 
not succeed in effecting the reduction, in which event others must be 
adopted; among the most successful of which is the forcible flexion of the 
carpus while counter-pressure is made in front of the arm, the patient being 
previously anaesthetized. Indeed, I believe that were every patient placed 
under an anaesthetic as a preliminary step to reduction and dressing, we 
should see fewer deformities about the wrist than are witnessed at present 
after the cure of these fractures. 
Professor Moore, of Rochester, New York, describes as one of the obstacles 
to reduction, in one variety of these fractures, the laceration of the internal 
lateral ligament and the detachment of the triangular interarticular carti- 
lage, in consequence of which the head of the ulna becomes dislocated and 
the styloid process imprisoned beneath the annular ligament. This being 
the case, no reduction of the radius can take place until the ulna is released. 
To accomplish this he directs that the hand be extended and carried at the 
same time to the radial side, then to the ulnar side, still in the state of 
extension, and lastly forward, or to the position of flexion. During these 
procedures, which in their entirety may be called circumduction, the wrist is 
to be maintained in a firm fixed position by the surgeon. If the effort proves 
successful, the head of the ulna takes its place on the radial side of the tendon 
of the extensor carpi ulnaris. Cases will occur in which the impaction cannot 
be overcome, and which, after exhausting the resources at our command for 
disengaging the fragments, will have to be treated in the best manner con- 
sistent with the complication. 
Fig. 748. 
Fracture of the styloid process of the radius and of the ulna, with 
great abduction of the hand. 
Fig. 749. 
Deformity after fracture of the styloid process of the radius. 
* Fractures, etc., p. 281. 948 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
After having adjusted the fragments, and while extension and counter-ex- 
tension are kept up, one of the two wedge-shaped pads is placed on the back 
of the wrist, with its base above resting upon the lower fragment and its 
apex directed downward, and the other reversed in front of the arm, its base 
lying under the lower end of the upper fragment and its apex directed up- 
ward. One of the splints is next placed along the anterior part of the arm 
and secured in position by the remaining part of the roller. This secures 
the advantage which has already been obtained by the extension. The pos- 
terior splint is now laid upon the 
back of the arm, and fastened by 
the second roller, observing to 
leave the thumb free. (Fig. 750.) 
This is the dressing of Barton, 
and very satisfactorily fulfils the 
object in view. The only caution 
necessary to be exercised in apply- 
ing this apparatus is not to bind 
the arm too firmly; indeed, every 
part of the first dressing should 
be made a little loose, in anticipa- 
tion of the swelling which will 
follow, and when practicable the 
surgeon should make a second 
visit to his patient on the day of 
the accident, to slacken the band- 
ages should they have become too 
tight. Under no circumstances 
will it be proper to allow more 
than twenty-four hours to elapse 
before the dressing has been sub- 
jected to a careful inspection; and for five or six days after the injury the 
patient should be seen daily. These are not needless precautions. Dupuy- 
tren, Hamilton, Norris, and others record cases of mortification and subse- 
quent amputation from a neglect of these precepts. If there is no inter- 
ruption to the circulation, and the arm remains comfortable, there will be 
no necessity to disturb the apparatus for the first three days, after which it 
should be removed and reapplied, extension and counter-extension being 
steadily maintained while this is being done. From this time forward, or 
until the fracture is firmly united, requiring usually about five weeks, the 
dressing should be renewed every third day. 
After the lapse of eight or ten days the attention of the surgeon must be 
directed to the work of restoring the various movements of the hand and 
wrist. 
The stiffness which follows this fracture is due to inflammatory deposits 
into and between the sheaths of the tendons, as well as within the radio- 
carpal joint. Gentle movements of the wrist should therefore be commenced 
as early as the seventh day, at the same time supporting the fracture between 
the thumb and fingers in order to give security to the union, and increasing 
these movements from time to time, say every three days, as the consolida- 
tion becomes stronger. It is a curious fact that in these fractures at the 
lower end of the radius the entire limb sympathizes more or less with the 
injury, the elbow and shoulder participating in the stiffness and rendering it 
necessary that the function of these joints be restored by frequent move- 
ments. There need be no apprehension of producing a false joint by this 
early motion. I am not aware of the existence of any case of non-union 
of this fracture. The fingers should likewise be manipulated, and, although 
the patient will experience no small amount of pain, the treatment must be 
insisted upon, as being necessary to the usefulness of the hand. As there is 
always more or less thickening about the articulation, from the deposition 
Fig. 750. 
Dressing for fractures at the lower end of the radius, with 
the wedge-shaped pads.—Smith. FRACTURES OF THE RADIUS. 
949 
of lymph, it will be proper, after the second or third week, to bathe the 
parts at each dressing with a stimulating liniment, such as the linimentum 
saponis. At the expiration of four and a half or five weeks the dressing 
may be removed, when the forearm covered with a roller can be carried in a 
sling. At this time the arm will tolerate more active interference. It may 
be soaked in hot soap-and-water, the indurated parts well kneaded and rubbed, 
and the motions made more energetically. The patient must be instructed 
and urged to use the fingers and hand by grasping objects, and training the 
various articulations in their natural actions, until, approximately at least, 
the original suppleness has been regained. Now, while I believe the plan of 
treatment just described to be the very best, yet it is proper to say that there 
are other appliances which have received the sanction of many eminent 
names. Colies preferred a dressing like that of Barton. Kline, Bransby 
Cooper, and South employed two splints which extended only to the hand. 
Nelaton and other Continental surgeons, as well as many in Great Britain 
and in this country, prefer the pistol-shaped splint. This splint should extend 
from one inch below the elbow to the metacarpo-phalangeal articulations, 
and may be applied to either the anterior or the posterior surface of the arm. 
Nelaton adopted the latter. A short splint must be used in conjunction with 
this pistol-shaped one, extending from the elbow to the wrist. Both are to 
be well and smoothly padded, the long one having the padding so distributed 
as to fill all the inequalities of the arm. After adjusting the fracture, the 
arm must be flexed with the hand at semi-pronation, and the pistol-shaped 
or long splint placed along the posterior surface of the arm, with a thin com- 
press interposed over the seat of fracture ; next the short splint is laid upon 
the anterior surface of the arm, and then both are secured by a roller, leaving 
the thumb free. The arm is now to be placed across the breast and sup- 
ported in the usual sling. (Big. 751.) 
Hamilton is partial to a dressing somewhat like that of Nelaton, consisting 
of one long and one short splint, the former reaching along the anterior sur- 
Fig. 751. 
Nelaton splint applied. 
face of the arm from the elbow to the metacarpo-phalangeal articulations, the 
part designed for the support of the hand being placed at a considerable 
angle with the rest of the splint. The short splint extends only to the wrist. 
Both are to be carefully padded, the padding of the long splint being thickest 
a little above where the lower end of the upper fragment of the fracture 
is to rest. 
In Philadelphia, the most popular splint for the treatment of fractures at 
the lower end of the radius is that of Bond. The originator of this splint 
was evidently guided in its construction by sound anatomical considerations. 
There are certain postures of the hand which are natural and which are 
always assumed when the parts are left unrestrained. These positions are 
moderate flexion of the fingers, and extension of the carpus upon the arm. 950 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
The first is due to the preponderance of the flexors over the extensors of the 
fingers; the second, to an excess in power of the extensors over the flexors 
of the carpus. The abnormal position assumed by the hand, especially after 
fracture of the styloid process of the radius, is, as has been stated, one of 
abduction. To preserve, therefore, the normal position of the hand and of 
the carpus, and to correct the displacements, as well as to allow motion of 
the fingers, Bond had his splint prepared in the following manner. A piece 
of light pine or poplar board, extending from one inch below the elbow to 
the metacarpo-phalangeal articulations, was out so as to conform to the shape 
of the forearm ('Fiar. 752h the lower two inches being at a slight angle with 
the rest of the board, 
and had a convex block 
secured to its upper sur- 
face, with a slight con- 
cavity at its inner end 
for the reception of the 
ball of the thumb. (Fig. 
753.) Such a splint, care- 
fully padded, is placed 
along the anterior sur- 
face of the forearm, the 
palm of the hand resting 
upon the block, which, in 
consequence of the latter 
being placed on the an- 
gular part of the splint, 
is carried from the radial 
to the ulnar side of the 
arm, or in a direction op- 
posite to the deformity. 
Two wedge-shaped compresses, half an inch thick and three inches long, 
which can be readily made by recurrent turns of the roller, are next placed 
on the forearm, the one upon the back and the other upon the front, and 
so arranged that the apex of the first shall be directed downward, its base 
resting directly over the seat of the dorsal prominence, and that of the 
second upward, its base being opposite the lower end of the upper frag- 
ment. These compresses, together with the splint, are next secured to the 
metacarpal part of the hand and to the forearm with a roller, leaving the 
fingers free. 
This splint will often answer an admirable purpose where the fracture 
is not too near the end of the articulating surface of the radius, and where 
there is little tendency to displacement of the lower fragment; but where it 
becomes necessary to make extension, it fails to meet the requirements of the 
case, and is instrumental in producing the very deformity which it is designed 
to correct. 
The splint of Dr. Hays may be considered as an extemporized Bond’s, 
and consists of light 
wood, such as a piece 
of cigar-box, cut to the 
shape of the forearm 
and metacarpal part of 
the hand (Fig. 754), and 
having a roller secured 
transversely at its lower 
extremity. (Fig. 755.) 
This splint, after being 
padded, is applied in the same manner as that of Bond. 
Dr. Coover, of Harrisburg, has designed a splint which consists of a single 
piece, shaped at the lower end in such a manner as to fulfil the indications 
Fig. 752. 
Board cut to conform to the outline of the forearm. 
Fig. 753. 
Bond’s splint for fracture at the lower end of the radius. 
Fig. 754. 
Shape of Hays’s splint. FRACTURES OF THE ULNA. 
951 
contemplated both by the block of Bond and by the anterior graduated 
compress of Barton. (Fig. 756.) 
Dr. E. P. Smith employs a trough-shaped splint, with a block which can be 
moved at pleasure by 
means of two circular 
brass plates, and thus 
the angle of the band 
changed at pleasure. 
This apparatus has the 
disadvantage of being 
too complex to be easily 
constructed. 
Dr. John Swinburne 
treats these fractures by 
placing along the poste- 
rior aspect of the arm a straight splint the breadth of the arm, and extend- 
ing from the elbow to the metacarpo-phalangeal articulations, with two com- 
presses, one at each extremity, 
the lower one covering the wrist 
and carpus, and the upper one 
resting on the space between the 
splint and the forearm. This ap- 
paratus is made fast to the arm 
by adhesive strips applied at short 
intervals. 
Dr. Gordon, of Belfast, employs 
two splints, extending to the carpus,—an anterior one, hollowed out, into 
which the arm is placed in a state of pronation, and a posterior one, broadest 
at its carpal end, rounded, and placed over the radial surface of the forearm, 
both being secured by adhesive straps. 
Dr. Levis employs a metal (zinc) splint (Fig. 757), so fashioned as to main- 
Fig. 755. 
A view of the modified form of Bond’s splint as suggested by Hays. 
Fig. 756. 
Cooyer’s splint for fracture at the lower end of the radius. 
Fig. 757. 
Levis’s splint for Colies s fracture 
tain the hand in a state of flexion, this position being supposed to conduce to 
the accurate reposition of the broken fragments. 
Fractures of the Ulna. 
Fractures of the ulna are divided into those of the shaft and those of the 
processes of the bone. Of 172 fractures of this bone admitted into the wards 
of the Pennsylvania Hospital, 52 were through the olecranon process and 952 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the upper third of the bone, 3 supposed to be through the eoronoid process, 
27 in the upper third, 32 in the middle third, 29 in the lower third, and 29 
unrecorded; 124 were simple, 34 compound, 10 compound comminuted, and 
4 simple comminuted ; 148 were males and 24 were females. Where the side 
was noticed, 74 were on the right side, and 59 on the left side. 
Causes.—These are, in most instances, violence, directly applied, rarely in- 
directly, as, this bone not being immediately connected with the hand, forces 
reaching the arm through the latter are realized in a much less degree by the 
ulna than by the radius. 
Fractures of the Shaft of the Ulna.—The inferior portion of the ulna being 
the smallest, it might be supposed that this would be the part most com- 
monly broken; yet I find that of 88 cases in the table framed from the 
records of the Pennsylvania Hospital 27 were fractures of the upper third, 
32 of the middle third, and 29 of the lower third. It is worthy of notice 
that these fractures are very frequently complicated. Of 172 cases in the 
table, 48 were of this nature, a very remarkable contrast when compared 
with similar injuries of the radius, in which 771 cases furnished but 37 ex- 
amples of complications. The complications alluded to are compound com- 
minution and simple comminution. 
Causes.—When the fracture is confined to the ulna alone, it is generally 
the result of direct force received upon the arm when raised in the attitude 
of defence, or from falls upon its ulnar side. 
Displacement.—Theoretically we might expect that the fragments would 
be drawn towards the radius, thus diminishing the interosseous space, by the 
action of the pronator teres and pronator quadratus muscles. This is true in 
many cases, but it is also true that the displacement may be in any direction, 
being determined by the vulnerating force, independent of muscular action. 
These fractures are generally oblique, and if the radius remains unbroken 
there will be little if any overlapping of the fragments. 
Symptoms.—Some care is requisite to discover the existence of a fracture 
of the ulna when, as often happens, there is no displacement. The inner 
edge of the bone is easily felt, and the fingers should be carried along its 
surface to ascertain if there are any irregularities, or any interruption in its 
continuity. By grasping the ulna above and below the seat of injury and 
exerting force in opposite directions, mobility and crepitus, when the bone 
is broken, will be recognized. When, however, displacement is present, the 
deformity will declare the nature of the injury at once. 
Prognosis.—Union usually takes place without much visible deformity. I 
have seen it, however, fail where there was every reason to believe that the 
case had been properly treated. Non-union is more common in this bone 
than in the radius. 
Treatment.—The displacement must be corrected by the exercise of such 
manipulation as will restore the fragments to their proper position. Thus, 
if they project inward, forward, or backward, pressure should be made di- 
rectly upon the prominent part, while extension is kept up from the hand. 
If the fragments fall outward or towards the radius, no effort should be 
spared to return them to their natural place, as there is great danger, should 
this not be accomplished, of the loss of pronation and supination. To effect 
reduction under such circumstances, the hand must be strongly drawn to the 
radial side, and the soft parts forcibly pressed into the interosseous space. 
The fracture being adjusted and the hand placed in a state of semi-prona- 
tion, two well-padded splints, in all respects like those for fracture of both ulna 
and radius, extending from the elbow to the tips of the fingers, with compresses 
interposed over any salient point which may be present, should be placed 
along the anterior and posterior surfaces of the forearm, and made fast by a 
roller extending from the hand to the elbow. The limb should be placed 
across the chest and suspended in a sling. The change of dressings and other 
details must be conducted as in other fractures of the bones of the forearm. FRACTURES OF THE ULNA. 
953 
Fractures of the Processes of the Ulna.—These fractures embrace those of 
the olecranon, and of the coronoid and styloid processes. 
Fractures of the Olecranon.—This injury, although occurring, according 
to Malgaigne, only nine times in eleven years at the Hotel-Dieu, is certainly 
more frequently met with in American hospitals. In the Pennsylvania Hos- 
pital there have been fifty-two cases in thirty-three years. This accident is 
scarcely ever seen in persons under fifteen or sixteen years of age. The 
direction of the fracture is generally somewhat oblique (Fig. 758), and may 
traverse the bone at three points, 
viz., at the summit, where it joins 
the shaft, through the base of the 
process, and through its middle. 
Causes.—In almost every ease 
it is the result of direct violence, 
either from blows across the back 
of the arm or falls upon the point 
of the elbow. Well-attested cases 
of fracture from muscular action alone are scarcely to be met with; although 
I do not deny the possibility of its occurrence. 
Symptoms.—These are, usually, well pronounced. After a fall or a blow, 
there is severe pain experienced at the elbow, followed by swelling and dis- 
coloration. The function of the joint is materially impaired; the arm can 
be only partially extended, or not at all; the prominence of the olecranon 
changes its normal position, being drawn up by the action of the triceps ex- 
tensor cubiti, and is no longer in line with the condyles of the humerus. 
When the arm is flexed, a marked sulcus will be seen behind the joint, into 
which the fingers can be pressed, which hollow is increased in breadth by 
flexion of the arm, the process and the shaft being separated from each 
other by this position of the arm. The extent to which the detached process 
will be drawn up varies greatly in different cases. The retraction of the 
triceps muscle is restricted by the connection of its tendon with the apo- 
neurosis which covers the muscles on the back of the forearm, and hence, 
when the dense fibrous covering of the olecranon remains unbroken, there 
will be comparatively little displacement of the bone, although the process 
may be moved freely laterally when it is grasped between the thumb and 
fingers. If this fibrous connection, however, be torn, the process will be 
drawn up to the extent of from half an inch to even two and a half inches. 
(Fig. 759.) When the fracture involves the summit of the process, there 
Fig. 758. 
Oblique fracture through the base of the olecranon process 
of the ulna. 
Fig. 759. 
Fracture through the base of the olecranon process, and the detached portion drawn 
up by the triceps muscle. 
should be scarcely any noticeable deformity, as the tendon of the triceps is 
inserted below the line of separation. 
Prognosis.—Fractures of the olecranon are not repaired by the deposition 
of true callus. Those specimens which are regarded as examples of bony 
union, were they subjected to the test of maceration for some time, would 
most probably show that this form of consolidation was only apparent, not 
real. The two principal causes which operate to defeat bony union are an 
imperfect apposition of the fragments, and an increase of synovial fluid fol- 954 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
lowing the accident, which, by diluting or washing away the reparative 
material, prevents its organization. An alleged defect in the supply of blood, 
which has also been enumerated among these causes, does not, in my judg- 
ment, explain the result. A fine injection, on the contrary, proves the ex- 
istence of a very rich supply of blood-vessels over this part of the elbow. 
The union being ligamentous, it is important that the 
fibrous bond should be as short as possible, in order not to 
detract from the movements of the forearm, especially that 
of extension. When it is too long, the usefulness of the 
limb will be somewhat impaired (Fig. 760), though there 
is a singular difference in different persons in reference 
to this matter. In the case of a patient who was brought 
to my clinic with an ununited fracture of the olecranon 
of four months’ standing, the power of extension was in 
a great measure lost. A few months after, though no 
union had taken place, the motions of the arm were 
almost entirely regained. The inflammation which some- 
times follows this fracture has resulted in complete an- 
chylosis. Generally the union is sufficiently complete 
in four or five weeks to admit of a moderate use of the 
limb. 
Treatment.—The arm being extended and the dis- 
placed process drawn down so as to be in contact with the 
shaft of the bone, the middle of a strip of adhesive plas- 
ter, one inch and a half broad and eighteen inches long, 
should be placed immediately above the detached frag- 
ment, and the two ends, after being strongly drawn 
downward and forward, crossed in front of the forearm 
and finally secured to its posterior surface. (Fig. 761.) 
This plaster will hold the olecranon in very good position. A roller two and 
a half inches wide and six or seven yards in length should next be applied 
from the hand up to the elbow, en- 
circling the latter by figure-of-eight 
turns, in such a manner as to give 
additional security to the apposi- 
tion, after which it is to be carried 
up to the shoulder and there ter- 
minated, thus controlling the action 
of the triceps muscle. To maintain 
the arm in the extended position, a 
splint, well padded, and having a 
slight angle, should be placed along 
the anterior face of the arm, extending from the upper third of the limb to 
the wrist, and fastened in position by a second roller. (Fig. 762.) This 
completes the dressing, and commands all the advantages of any other 
apparatus. 
Fig. 760. 
Fracture of the olecranon 
process, with a ligamen- 
tous bond of union which 
would impair the useful- 
ness of the arm in exten- 
sion.—Fergusson. 
Fig. 761. 
Adhesive plaster securing the olecranon process in position. 
Fig. 762. 
Dressing with slight flexion. 
With regard to the position of the limb, there are three views. There 
is, first, the ancient one of semi-flexion, advocated by Hippocrates, Celsus, 
and others; second, that of extreme extension, which is more especially the 
practice of English surgeons, and to some extent that, of American surgeons, 
though by neither is it universally insisted upon ; lastly, the position of slight FRACTURES OF THE ULNA. 
955 
flexion. The first, that of semi-flexion, is obviously at variance with all ana- 
tomical ideas of adjustment. The second, that of extreme extension (Fig. 763), 
involves a position exceedingly uncomfortable to the patient, with the ad- 
ditional disadvantage that if the fracture of the olecranon is near to its base 
Fig. 763. 
Dressing applied for fracture of the olecranon, the arm being in a state of full extension. 
there will be a tendency to an anterior displacement of the ulna. The third 
position, or that of slight flexion, harmonizes'with the normal posture of the 
arm when left unrestrained by muscular contraction, and conduces best to 
the comfort of the patient and to the proper adjustment of the fragments. 
This position is preferred by Continental surgeons, and is the one which I 
have invariably adopted. 
Should there be much contusion of the soft parts, with severe inflamma- 
tion and extensive swelling, no dressing of a permanent nature is admissible 
until the acute symptoms are past. The arm should be extended upon a 
pillow, leeches applied about the articulation, and the parts covered with a 
lotion of lead-water and laudanum until the inflammation is controlled. In 
the course of five or six days an attempt may be made to apply the fracture 
apparatus, first using only the adhesive strip, and after a day or two more 
the roller, then finally the anterior splint. Should the joint, in consequence 
of a compound fracture of the olecranon, or from constitu- 
tional influences, or from any local violence whatever, be 
threatened with anchylosis, the extended position must be 
abandoned and the flexed one adopted, so that, in case the 
articulation becomes hopelessly stiff, the arm may still be 
useful. 
To prevent the usual rigidity of the joint, passive move- 
ment may be commenced about the fourteenth day, the 
movements being very slight at first, and the surgeon sup- 
porting the fracture with the thumb and fingers when they 
are made. This period for motion is earlier than that which 
is generally thought prudent, but I have seen no accident 
happen to the cure from its adoption, and feel confident that 
the practice secures a more useful arm than results when 
the manipulation is postponed to a later day. I am satisfied 
that, so for as stiffness of the elbow-joint is concerned, it is 
as liable to occur in one position as in the other, and there- 
fore in this respect the semi-flexed one has no advantage, 
with the great disadvantage of offering an insuperable objec- 
tion to close union of the fragments. 
Other plans have been and are at present employed by 
surgeons for the treatment of this fracture. The method 
adopted by Sir Astley Cooper (Fig. 764) consisted in ex- 
tending the arm, placing two strips of tape parallel with 
the olecranon, and securing these to the arm by circular turns of a wet 
roller above and below the joint. The ends of the tape being drawn together 
Fig. 764. 
Sir Astley Cooper’s 
dressing. 956 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
and tied served to draw the olecranon towards the shaft of the bone. An 
anterior splint completed the dressing. There are two objections to this plan, 
namely, the interference to the circulation from the circular rollers (which, 
to do any good, must be tight), and the extreme extension of the arm, an 
uncomfortable position under any circumstances. 
Duverney carried a figure-of-eight roller about the elbow, and simply 
placed the arm, somewhat flexed, on a pillow. The objections to this plan 
are its insecurity in the case of many patients, and the necessity for confine- 
ment during the treatment. Boyer’s method consisted in surrounding the 
arm with a roller, from the hand up to the elbow, but before covering in the 
latter he folded a long narrow compress, the middle of which was placed 
above the olecranon, and the two ends drawn down and crossed in front of 
the arm, after which the roller was passed over this compress and continued 
up the arm. No splint was placed in front of the elbow. This method is 
not secure, neither does it maintain the fragments in position. Alcock sub- 
stituted for the compress of Boyer a long strip of adhesive plaster, which 
was similarly applied. The method of Hamilton (Fig. 765) consists in pre- 
Fig. 765. 
Hamilton’s dressing. 
pairing a splint long enough to extend from near the shoulder to the wrist, 
of a width equal to that of the widest part of the arm, and having a notch 
cut on each side, three inches below the olecranon. This splint is to be well 
padded, then placed along the anterior part of the arm, and retained in posi- 
tion by a bandage commencing at the hand and extending up to the elbow. 
When the notches in the splint are reached, the olecranon must be drawn 
down and the roller conducted upward above the process, and down again 
to the notch on the opposite side, repeating these turns, each successive one 
becoming less oblique, and always passing through the notches, until the 
back of the elbow is covered in, after which the bandage is to be continued 
up the limb to the shoulder. 
In compound fractures of the olecranon process of the ulna, the detached 
portion should be placed in its functional position and secured by a silver 
wire suture. The dressing should be made antiseptically, and the anterior 
splint worn, as in simple fracture. 
Fractures of the Coronoid Process of the Ulna.—Of one hundred and thirty- 
three fractures of the ulna admitted into the Pennsylvania Hospital, three 
are noted as fractures of the coronoid process. (Fig- 766.) When it is con- 
sidered that there are prob- 
ably not more than four or 
five cases in existence where 
the accident has been verified 
by dissection, the presumption 
is that not one of these so re- 
corded was really a fracture 
of this process. I have never witnessed an instance of the injury. The cases 
which have been established by autopsy, as stated by Hamilton,* are the 
Fig. 766. 
Fracture of the coronoid process. 
* Fractures, p. 306. FRACTURES OF THE ULNA. 
957 
following: one by Sir Astley Cooper, found in the dissecting-room of St. 
Thomas’s Hospital; one in University College museum, described by Samuel 
Cooper; one by Velpeau ; and one by the late Charles Bell Gibson. Bryant* 
describes a specimen of this fracture in Guy’s Hospital museum, marked 
111925. The cases reported as fractures and collected by Hamilton are twelve 
in number, to which are to be added five cases reported by Lotzbeck, of 
Munich, and three by Leis,f making in all twenty cases. A case reported 
by Hr. Huer, of this city, bears the evidence of being really an injury of this 
kind. There can scarcely be a doubt, therefore, that this fracture does exist, 
although it is one of extreme rarity. 
Causes.—Any force, such as a fall upon the hand, driving the process vio- 
lently against the articulating surface of the humerus, may determine this 
fracture, and in many of the cases reported the accident is described as having 
occurred in this manner; but as the radius, in these cases, participated in 
the injury, its head being displaced anteriorly, it is not improbable that it 
was mistaken for the coronoid process. In the case cited by Bryant, the head 
of the radius was also broken. A consideration of the anatomical relations 
of the coronoid process renders it exceedingly unlikely that this fracture is 
ever produced by muscular action alone. The brachialis anticus has its in- 
sertion on that part of the process where it blends with the shaft of the bone, 
and therefore cannot exercise any great traction-force upon the process itself. 
The injury is not peculiar to any age, as the cases in which it is said to have 
occurred varied in age from six years to sixty. 
Symptoms.—The recorded symptoms of this fracture are luxation of the 
bones of the forearm backward, a preternatural prominence of the olecra- 
non, a hard body (the detached process) felt in the front of the arm, and 
a tendency to luxation whenever the forces employed in reduction are sus- 
pended. 
Prognosis.—Deprived as the process must be of any considerable number 
of blood-vessels, it is probable that the union would be fibrous. This was the 
case in the specimen examined by Sir Astley Cooper. 
Treatment.—The forearm should be flexed to a right angle, covered by a 
roller, and a well-padded right-angled splint secured to its anterior surface. 
At the expiration of twelve or fourteen days the joint should be carefully 
moved, and after four or five days more the dressings may be laid aside and 
the arm carried in a sling. Such a course would seem to be proper in view 
of the possibility of anchylosis. 
Fracture of the Styloid Process of the Ulna.—Fracture of this process may 
be produced by direct force, as when a blow is inflicted or the patient falls 
upon this part of the arm. It is sometimes broken at the same time with 
the lower end of the radius, most probably in consequence of an extreme 
tension of the internal lateral ligament. 
Symptoms.—The signs of the fracture are pain, swelling, and some degree 
of deformity at the inner part of the wrist. When the hand is carried well 
to the radial side of the arm, the process may be seen and felt to leave the 
lower end of the bone. 
Prognosis.—These cases are liable to be followed by some deformity; and 
I think that this is due to the slipping forward of the tendon of the extensor 
carpi ulnaris, thus preventing an accurate apposition of the broken surfaces. 
The union in the only case which I have had the opportunity to examine 
proved to be ligamentous. 
Treatment.—The hand and forearm should be placed upon the Bond 
splint. The splint admits of the hand being carried well to the ulnar side of 
the arm, which position relaxes the internal lateral ligament and favors the 
restoration of the process to its proper place. The extension of the carpus 
will also relax the tendon of the extensor carpi ulnaris. When, by position 
and by manipulation, the parts are properly adjusted, a compress should be 
* Surgery, p. 852. 
f Schmidt’s Jahrbiicher, 1866, vol. cxxxix. p. 134, Hamilton. 958 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
applied over the process, and the splint bound to the arm by a roller carried 
from the hand up to the elbow, after which the limb may be suspended in 
the ordinary sling. If satisfied of the correct position of the process, it will 
not be necessary to disturb the dressing oftener than once in three or four 
days, unless the wrist-joint or the arm has sustained other injury, when the 
same precautions against swelling and anchylosis must be obseiwed as are 
proper in other fractures about the wrist-joint. 
Every fracture of the upper extremity, with the exception of fracture of 
the olecranon process of the ulna and fractures of the bones of the hand, 
may be successfully treated by dispensing with splints, and, after placing the 
arm to the side and the forearm across the body, securing them in place by 
properly-applied roller bandages, the turns of which should be tacked together 
with a needle and thread to prevent slipping. As every practitioner, how- 
ever, is not perfectly adroit in the use of the roller, it would not be wise to 
recommend the plan as one to be indiscriminately or generally employed. 
Fractures of the Hand. 
Fractures of the hand may be divided into those of the carpus, of the 
metacarpus, and of the phalanges. Simple or uncomplicated fractures of the 
hand are not common injuries, but they are often associated with such a de- 
struction of the soft parts as to involve the question of amputation. Firearms 
and machinery constitute the two most fruitful sources of these accidents. 
The records of the Pennsylvania Hospital from 1850 to 1874 furnish 143 
cases of these injuries, distributed as follows : 9 were fractures of the carpus, 
53 of the metacarpus, 44 of the phalanges, 17 of the thumb, and 20 not 
specified. Of these, 37 were simple fractures, 75 compound, 29 compound 
comminuted, and 2 simple comminuted. For reasons of a social nature, 
these fractures are not often met with in females; of the 143 cases to which 
reference has been made, 137 were in the persons of males, and only 6 in 
females. The largest number, 50, occurred between the ages of twenty and 
thirty. Of these 143 cases, 38 demanded amputation, of which number one 
case died. The causes of death in the cases not operated on were as fol- 
lows: 2 from tetanus, 1 from pyaemia, 1 from exhaustion, 1 from phlebitis, 
and 2 from associated injuries. 
Fracture of the Carpal Bones.—The carpal bones, being short, irregular, 
and compactly bound together by powerful ligaments, are rarely the sub- 
jects of simple fracture, and when it does occur it may be readily overlooked. 
Cloquet, in his paper on “ The Hand,” in the “ Dictionary of Medicine,” gives 
two cases in which the fractures were only recognized by dissection after 
death. In the case of a man admitted into the Middlesex Hospital, and 
who died from his injuries, a fracture was found passing through the sca- 
phoid bone.* When the injury does occur independent of any serious damage 
to the soft parts, it is generally produced by falls upon the hand, in which 
the parts are subjected to severe tension, which, as has been shown by 
Bouchet in his experiments on the dead body, is capable of breaking these 
bones. 
Symptoms.—In consequence of the swelling and the absence of much dis- 
placement, there will be difficulty in detecting the injury, though the exist- 
ence of pain on pressure, discoloration, and perhaps crepitus when the hand 
is alternately flexed and extended, may reveal the existence of the fracture. 
Fracture of the Metacarpal Bones.—The metacarpal bones are occasionally 
broken. Of the whole number of fractures admitted into the Pennsylvania 
Hospital from 1850 to 1874, there were fifty-three fractures of the metacarpus. 
Malgaigne records only sixteen cases out of the whole number treated in the 
Hotel-Dieu. 
* Holmes’s System of Surgery, vol. ii. p. 801. FRACTURES OF THE HAND. 
959 
It is very unusual for more than one bone to be broken at the same time. 
Of seventy-one metacarpal fractures recorded in the Middlesex Hospital, 
there were three instances in which two or more bones were broken. There 
is a discrepancy among authors as to the particular bone most frequently 
broken. Some, among whom are Chelius and Boyer, think that the fifth is 
the one most generally involved. Hamilton in his analysis of fourteen cases 
found the metacarpus of the index finger broken six times, and next in fre- 
quency were the fourth and fifth. Berard’s observation coincides with this, 
so far as fracture of the index finger is concerned. In the seventy-eight cases 
noted in Holmes’s Surgery, twenty-seven involved the first metacarpal. I 
have seen this fracture in all the metacarpal bones except that of the index 
finger, but most frequently in the fourth. There would seem to be an ana- 
tomical reason for a fracture of the third and fifth pieces in preference to 
the others, in consequence of the prominence of the first and the weakness 
of the last, in the series of these bones. The situation of the fracture may 
be in any part of the bone, but the middle and the lower third are the por- 
tions oftenest implicated. 
Causes.—Except in cases complicated by extensive damage to the soft 
tissues, these fractures are generally produced by force indirectly applied, 
as where a blow has been dealt with the clinched fist, in which act the force 
is received on the phalangeal extremities of the bones. In this way it often 
occurs with pugilists. Of the fourteen cases collected by Hamilton, eight 
were produced by violence applied to the knuckles. In three cases of my 
own it was done in the same way. In isolated cases, a blow may be so con- 
centrated directly on a single metacarpal bone as to cause a fracture. In 
two instances I have seen this occur. This accident is not peculiar to any 
age, though uncommon in the young. I have seen a fracture of the meta- 
carpus in a child three years of age, and a similar injury in an old man of 
eighty-five. It is said that when met with in the young it is probably merely 
a separation of the epiphysis; but in the instance which I have mentioned 
this could not have been the case, since the fracture was at the distal end of 
the metacarpal bone of the thumb. 
Displacement and Symptoms.—When the fracture is produced by force 
applied to the phalangeal extremity of the bones, the displacement is largely 
due to a change in the position of the anterior fragment, the distal end of 
which is turned towards the palm, the proximal end forming a projection 
upon the dorsum of the hand. The carpal fragment, being firmly bound 
by ligaments, is very much less movable than the other or phalangeal piece, 
The deformity described follows from the shape of the bones, which are con- 
cave anteriorly; and, secondly, from the influence of the lumbricales and 
interosseous muscles, the first favoring the sinking inward of the anterior end 
of the distal piece, and the last producing some shortening or overlapping of 
the fragments. 
Symptoms.—The symptoms of this fracture are pain, preternatural mobil- 
ity, crepitus, sinking or partial disappearance of the corresponding knuckle, 
and a prominence on the back of the hand. Both the mobility and crepitus 
are best demonstrated by grasping the proximal phalanx of the injured bone 
and carrying it forward and backward, while the thumb of the other hand is 
applied over the supposed seat of fracture. 
Prognosis.—When the fracture is uncomplicated, union takes place in 
three or four weeks : it is not uncommon to have some little prominence on 
the back of the hand, not, however, impairing its usefulness to any great ex- 
tent. Occasionally inflammation extends to the surrounding parts, followed 
by abscess and even anchylosis of the metacarpo-phalangeal and also of the 
wrist joints. 
Treatment.—Except in the case of the metacarpal bone of the thumb, 
fractures of the carpus and metacarpus are treated on the same general plan. 
We must observe the concave form of the palm of the hand, and make the 
splint to conform to its shape. For this purpose a light piece of poplar or 960 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
pine board, such as that from a cigar-box or a shingle, should be cut corre- 
sponding to the outline of the arm and the hand. (Fig. 767.) The palmar 
portion must be a little wider 
than the hand, and the splint 
made long enough to extend 
from the middle of the forearm 
to the tips of the lingers. Upon 
it should be placed some padding, 
observing to build up a convex 
elevation with oakum or cotton 
for the support of the hand. If 
there is displacement of the broken metacarpal bone, extension should be 
made from the corresponding finger, and pressure applied directly over the 
fragments so as to force them into position. The hand and arm are then 
laid upon the splint, the form of which admits of the fingers being well flexed. 
If the ends of the bone incline to become unduly prominent, place upon them 
a compress, and secure the hand and arm to the splint by the turns of a roller. 
The forearm should be placed across the chest and suspended in the ordinary 
sling. The dressing requires to be renewed as often as the state of the parts 
demands, following very much the same rules in this respect as in fractures 
of the bones of the arm. 
Sir Astley Cooper describes a fracture through the head (more properly 
the neck) of a metacarpal bone, which may readily be mistaken for a dis- 
location. A specimen of this fracture is in my possession. The existence 
of crepitus and the sinking of both the phalanx and the anterior fragment 
will serve to distinguish it from luxation. In this injury the dorsal projection 
is due to the anterior end of the posterior or carpal fragment. In its treat- 
ment the hand and arm should be placed upon a splint similar to that for 
other fractures of the metacarpus, observing to adjust a compress in the 
palm of the hand, so as to press up the depressed anterior fragment. 
When the metacarpal bone of the thumb is broken, it should be treated 
after the manner of a fractured phalanx, or by having a piece of felt or stout 
pasteboard wet and neatly moulded to its palmar surface, including also its 
phalangeal portion. 
Fig. 767. 
Splint for fracture of the carpus and metacarpus. 
Fractures of the Phalanges.—The multiform acts of the fingers, their ex- 
posure, and their scanty covering of soft parts, render them liable to severe 
injuries; and hence we often find them not only broken but extensively 
comminuted. In one hundred and forty-three cases of fracture of the hand 
admitted into the Pennsylvania Hospital, forty-four were fractures of the 
phalanges. Commonly one bone is broken, and generally by direct violence, 
as when the hand is caught under heavy castings or blocks of stone, or in 
machinery. A case is recorded in which a phalanx was broken by muscular 
action while the patient was making a back-handed stroke at another person.* 
Rarely do we meet with a case of this fracture among females or in very 
young persons. The serious nature of these injuries is well shown by the 
statement of Hamilton, “ that in a record of thirty such fractures twelve 
required amputation.” We have not a sufficient number of statistics to de- 
termine the relative frequency of phalangeal fractures, but, so far as the very 
limited number recorded enables us to draw any conclusion, it appears that 
the thumb and the middle and ring fingers are most frequently broken, and 
that, according to Lonsdale, the first row suffers most from simple fractures. 
Symptoms.—Preternatural mobility and crepitus sufficiently indicate the 
nature of the injury. 
Displacement.—In most cases of simple fracture the fragments are but 
slightly if at all displaced ; but in exceptional ones thei’e may be a lateral 
deviation, ox*, as in a very instructive case related by Hamilton,f a rotation 
* British Medical Journal, March 28, 1874, p. 204. 
f Fractures, p. 332. FRACTURES OF THE HAND. 
961 
of the phalanx on its axis. If the fracture be very oblique, there may be 
considerable overlapping. 
Results.—In simple fractures good union without noticeable deformity 
may be confidently anticipated in four weeks. 
Treatment.—Two methods have been employed in the treatment of these 
fractures, the semi-flexed and the extended position. The first or French 
plan, that which was practised by Ambrose Pare, cannot be regarded as a 
proper one, though it might in many cases be adopted with great advantage, 
as when the fracture extends into one of the phalangeal joints and anchylosis 
is likely to follow, this semi-flexed position being the most useful one for a 
stiff finger. The second plan is the one most popular with American and 
with English surgeons. The fragments being adjusted, a piece of pasteboard 
or felt may be soaked in hot water and moulded to the under and lateral 
surfaces of the finger, extending a little beyond its extremity. A second 
splint is required, consisting of a light piece of wood, one inch wide, and 
sufficiently long to reach from the wrist to one-quarter of an inch in advance 
of the injured digit. (Fig. 768.) This splint, being well padded, should be 
placed along the dorsal aspect 
of the metacarpus and the 
injured finger, and secured in 
position either by the turns of 
a roller three-quarters of an 
inch wide, beginning at the 
extremity of the finger and fin- 
ishing on the metacarpal part 
of the hand and the wrist, or 
by spiral turns of adhesive 
plaster in a similar manner. 
When two or more phalanges are broken, the entire hand should be placed 
upon a well-padded palmar splint, as in fractures of the carpus and meta- 
carpus. Thus placed, one finger becomes a support for another, and pre- 
vents lateral displacement. It will be necessary to examine the dressing 
daily for three or four days, modifying the padding and the compression 
if required by the increase or the subsidence of the swelling. 
After five or six days a plaster dressing may be substituted for the splints. 
For this purpose the roller should not exceed three-quarters of an inch in 
width, and should have secured between its turns a strip of muslin one inch 
wide, and long enough to extend from the end of the injured finger, over the 
back of the hand, to the arm, to which it must be fastened either by a roller 
or by tearing the upper end into two strips for a short distance, and tying 
them around the wrist. 
Some surgeons, among them Boyer, have advocated amputation for frac- 
tures of the last or ungual phalanx, alleging that the recovery of this deli- 
cate piece is very uncertain. I do not concur in this opinion. Two cases of 
this kind which were under the care of Dr. Koerper, of this city, and one 
which came under my own observation, recovered perfectly. Other surgeons 
have had a like success. 
Fig. 768. 
Splints for fracture of the phalanges. 
Compound Fractures of the Hand.—I cannot dismiss this subject without a 
word about compound fractures of the hand. When the external wound is 
limited it does not materially complicate the case, but where there is laceration 
of the soft parts and comminution of the bones we have to deal with a more 
serious state of things, often requiring considerable discrimination and judg- 
ment in order to determine what course of treatment is best to adopt. Should 
a phalanx be broken into several pieces and the soft tissues be bruised and 
torn, in most instances the removal of the finger becomes a necessity. If the 
metacarpus or the carpus is broken, or even comminuted, with extensive 
laceration of the soft parts, it is best to pursue a conservative plan, as the 
hand, being so richly supplied with blood-vessels, possesses a wonderful re- 962 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
cuperative power. Under such circumstances any small detached fragments 
of bone which are present should be removed, and the hand and forearm 
placed on an anterior splint and either dressed with the usual antiseptic 
appliances or kept under the influence of antiseptic irrigation. (See Wounds 
of the Hand.) By the adoption of this plan many very unpromising cases 
recover. 
Fractures of the pelvis are not very common accidents. Malgaigne states 
that only ten cases were admitted into the Hotel-Dieu during eleven years. 
Ninety-four cases were received into the Pennsylvania Hospital during a 
period of fifty-four years. In 50 of these cases the fractures were distributed 
as follows: of the ilium, 33; of the acetabulum, 10 ; of the pubes, 5 ; and of 
the ischium, 2. The largest number, 24, occurred between the ages of twenty 
and thirty years; 76 were in males, 4 in females, and in 14 the sex was not 
stated. The number of deaths was 36. Of 65 cases of pelvic fractures col- 
lected by Dr. Ljmn, 41 recovered and 24 proved fatal. The great strength 
of the pelvic bones and the resistive power of the ligaments which bind 
them together necessitate the application of a tremendous force for the pro- 
duction of fracture. 
Lodging as the pelvis does a portion of the genito-urinary and digestive 
organs, and also great blood-vessels and nerves, the violence which fractures 
one or more of its pieces is liable also to implicate seriously its contents: 
hence the fatality of these injuries. 
Fractures of the pelvis may be single or multiple, and are often conjoined 
with a dislocation of its bones. When the articular surfaces are thus torn 
asunder, a layer of bone is usually detached along with the interartieular 
cartilage. When deeply situated and the fragments are not materially dis- 
placed, fracture of the pelvic bones may easily escape detection. 
Prognosis.—In all fractures of this part of the skeleton our prognosis 
should be very guarded. The risks to which the patient is exposed are 
numerous. He may die from shock; the urethra may be lacerated, or the 
bladder may be torn, giving rise to urinary infiltration of the perineum or 
the pelvis, and followed by suppuration and gangrene. The rectum may be 
wounded, and peritonitis may follow; gangrene of the intestines is not im- 
probable, and sometimes the patient perishes from hemorrhage. Occasionally 
individuals recover under the most unpromising conditions. In the museum 
of the Royal College of Surgeons there is a specimen in which the entire 
pubes has been lost by necrosis as the result of a fracture. The patient was 
a little girl, who entirely recovered from the injury. In the same museum 
is another pelvis, one side of which was broken in several pieces, and yet all 
had reunited, the man dying afterwards from fever. Mr. Moore* narrates a 
case in which repair had taken place where the head of the femur had been 
driven entirely through the floor of the acetabulum and lodged in the pelvis. 
Bryantf gives the case of a female child, where the damage to the pelvic 
bones, accompanied with laceration of the perineum, was so great that all 
the pelvic organs were forced through the lower outlet, and yet recovery 
took place. 
Causes.—Fractures of the pelvic bones are produced by force, both direct 
and indirect,—most commonly by the wheels of a heavily-loaded wagon 
passing across the hips, or by the hips being caught between the buffers of 
cars, or between a wall and the body of a wagon. Falls or kicks upon the 
trochanter, upon the nates, or on the crest of the ilium, are also methods by 
which the injury may be produced. Gunshot fractures of these bones are 
quite common. 
Fractures of the Bones of the Pelvis. 
Fractures of the Sacrum.—The sacrum, of all the bones of the pelvis, is 
least exposed to fracture. Its spongy tissue and its curves, its association 
* Medico-Chirurgical Transactions, vol. xxxiv. p. 107. 
f Surgery, p. 856. FRACTURES OF THE SACRUM. 
963 
and ligamentous connection with the innominate bones, all conduce to its 
protection. It may be broken alone, or its fracture may be conjoined with 
fracture of the other bones. The lowTer half is the portion most liable to 
yield, inasmuch as it is not only the weakest but also the most exposed part, 
the upper portion being protected by the posterior projection of the innomi- 
nate bones. 
Causes.—The causes are in most instances concentrated and intense force 
directly applied to the part, as when a person falls from a considerable 
height, striking upon the lower end of the bone, or upon its dorsum; or 
when the wheel of a wTagon passes across the back of the pelvis. Indirect 
violence may also induce such a fracture, but it is then associated with simi- 
lar injury to the other bones. 
The direction of these fractures may be transverse, oblique, or vertical. 
Most commonly they are transverse. 
Displacement.—The displacement, when present, consists in an anterior 
projection of the lower fragment, due to two causes,—first, the blow, and, 
secondly, the contraction of the gluteus maximus, coccygeus, and sphincter 
ani muscles. Lateral distortion is not likely to occur, as the lesser and 
greater sacro-sciatic ligaments counteract such a change in the position of 
the fragments. 
Symptoms.—There will be pain of a very acute character, which will be 
intensified by any movements calculated to disturb the fragments, such as 
flexion or extension of the body, thereby pinching some of the sacral nerves. 
All straining efforts, as defecation, urination, coughing, or sneezing, produce 
severe suffering. Posterior angular deformity may be visible, and by intro- 
ducing a finger into the rectum and pressing upon the coccyx, both crepitus 
and mobility may be detected. In addition to these symptoms there will 
probably be present paralysis of the bladder and of the rectum, both of 
these organs receiving nerves from the sacral plexus. 
Prognosis.—A force which is sufficient to fracture the sacrum will gener- 
ally inflict so much damage upon the pelvic organs that a fatal result may 
be anticipated. Should the case be one of modified diastasis, as when a 
layer of the bone underlying the cartilage which connects the sacrum with 
the ilium is detached, the prognosis is more favorable. Dr. Banks* reports 
a case of such an injury, the displacement being upward to the extent of 
one inch, notwithstanding which the patient recovered. Dr. Burlingham, of 
Illinois, records a very remarkable case in the April number of the American 
Journal of the Medical Sciences for 1868, of a compound fracture of the 
sacrum, in which the urine flowed for some time through the wound, yet 
the patient entirely recovered. 
Treatment.—If there is only a slight disarrangement of the fracture, 
there will be no necessity for any officious attempts to effect a nice appo- 
sition. The patient should be placed upon the back, the thighs being flexed 
and supported over pillows. In order to take off all pressure from the 
sacrum, an ovoidal air-cushion may be placed under the hips, oiq when an 
appliance of this kind is not at hand, a cushion can be made to slip under 
the pelvis, with an opening cut out corresponding to the sacrum. When 
the bowels require to be opened, this cushion should be removed, and a 
rubber bed-pan placed under the nates. The urine must be drawn at inter- 
vals of six or eight hours, and if there is any evidence of the bladder being 
wounded, a gum catheter should be introduced and allowed to remain, so 
as to keep the organ drained until the damage is repaired. Pain must be 
alleviated by anodynes, and if inflammation of any portion of the contents 
of the pelvis arise, it should be counteracted by leeches to the perineum, 
and by flaxseed or corn-meal poultices laid over the hypogastrium and kept 
warm and moist by being covered in wdth oiled silk. If the patient is unable 
to expel the contents of the bowels, injections of warm water will be required 
to remove any accumulation ; and if, in consequence of paralysis, all retentive 
* Atlanta Medical and Surgical Journal, May, 1866 964 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
power in the bowels is lost, the discharges from the rectum may be received 
upon a pledget of oakum kept under the nates, while the stillieidium of the 
urine can be passed into a urinal placed between the thighs. That the 
fragments may be disturbed as little as possible, it is proper for the first 
three weeks to keep the bowels closed by opium for five or six days at a 
time. Should the displacement be very marked, so as to encroach upon the 
cavity of the pelvis, reduction may be effected by inserting a finger into 
the rectum and pressing the parts backward into their proper place. The 
difficulty, however, will be to maintain the reduction after the finger is 
removed. Both M. Indes and M. Bermond employed permanent mechanisms 
as substitutes for the digit. The first used simply a piece of wood, cylin- 
drical in form, five inches long, and three inches in circumference, which was 
inserted into the rectum and retained by graduated compresses supported 
with a T-bandage. He removed this plug or splint every third day, using 
an injection before its reposition. Bermond, instead of the wooden cylinder, 
used a silver canula, with a bag attached, which when stuffed formed an 
inner and an outer tampon, with a cork in the end of the tube to prevent 
the constant flow of faeces. It was removed only twice during the treat- 
ment, once on the seventh day and again twelve days later. Both of these 
cases recovered. The gum colpeurynter might be used with advantage in 
a case of this kind, by introducing it into the bowel and then distending it 
with water or air. 
Fractures of the Coccyx.—Until the age when the different pieces of the 
coccyx are united by bone, an uncomplicated fracture would be one of the 
most improbable of occurrences. Fractures of this bone are said sometimes 
to occur during parturition, by the pressure of the foetal head while engaged 
at the inferior strait of the pelvis ; but such cases are probably often luxa- 
tion or rupture of the ligaments which unite the articulations. The accident 
may occur not only from the cause just named, but also from kicks, blows, 
and, as I have known, from a rider’s coming down upon the back of the 
saddle in an attempt to mount a restive horse. 
The displacement in fracture of the coccyx is forward, and is produced by 
the same agencies as those which cause the deformity in fracture of the 
sacrum. The damage done to the last spinal nerves in injuries of the coccyx 
often gives rise to an exceedingly painful state of the soft parts overlying 
the bone, to which the name of coccydynia has been given. Necrosis may 
follow this injury, either resulting in spontaneous expulsion of the fragment 
by piecemeal, as in a case mentioned by Cloquet, or necessitating its excision. 
Treatment.—Little more is to be done than to enjoin quiet in the recumbent 
position, placing beneath the nates the oval cushion which I have directed 
in fractures of the sacrum, in order to relieve the coccyx of all pressure. 
The position on the side can be occasionally assumed with comfort to the 
patient. Should the bone project forward, so as to encroach materially upon 
the anus or upon the pelvic outlet, the linger, well oiled, may be introduced 
into the bowel, and the bone pressed back into place. If the deformity re- 
turns, it may be proper to resort to such tampons as have been described for 
fractures of the sacrum. Should there be much inflammation present, leeches, 
followed by a lotion of lead-water and laudanum, will prove of service in 
diminishing the liability to neuralgia, abscess, fistula, and necrosis. South 
was able to cure two tedious cases of extreme sensitiveness of the parts fol- 
lowing fracture of the coccyx by adjusting to the tuberosities of the ischii 
two oblong cushions, which removed all pressure from the lower end of the 
spine when in the sitting position. 
When the patient suffers from coccydynia, it has been advised by Simpson 
to introduce a narrow bistoury between the soft parts and the bone and com- 
pletely sever all connection between the two. This does not always cure the 
patient, as I very well know ; but the harmlessness of the procedure and the 
occasional success of the operation are sufficient reasons for trying this plan FRACTURES OF THE OSSA INNOMINATA. 
965 
before adopting a more radical one. Should it fail and the symptoms continue 
severe and persistent, the excision of the bone may become necessary. 
Fractures of the Ossa Innominata. 
These bones being composed of three portions, the ilium, ischium, and 
pubes, we may have fracture of either piece singly, or of all three at the 
same time. Malgaigne describes what he calls “ double vertical fractures” of 
the pelvis, as when both branches of the pubic bone are broken and a second 
line of fracture is situated behind the acetabulum, in the ilium or sacrum, 
running vertically. The middle fragment will contain the hip-joint, and may 
be displaced upward or downward, or it may be turned by either its upper or 
its lower extremity towards the pelvic cavity. He narrates a very interest- 
ing case of this injury in a woman, reported by Papavoine in the Journal des 
Progres, tome x. p. 234. Both innominate bones may be simultaneously broken. 
These fractures are produced generally b}T direct force, such as falls upon 
the pelvis, intense pressure by wagon-wheels or between cars, or by falling 
timbers, gunshot injuries, kicks from horses, etc. Drs. Joy and McWhinne, 
two Canadian physicians, have recorded a fracture of the anterior superior 
spinous process of the ilium which they allege was caused by muscular con- 
traction alone. 
Fractures of the Ilium.—A large portion of the ilium, namely, the upper 
expanded part, being at some distance from the pelvic organs, forming a por- 
tion of the abdominal wall, and being lined 
within by the iliacus internus muscle, its 
fractures are not so dangerous to life as are 
those of the other bones. 
The bone may be severed through the 
iliac fossa, either transversely or vertically, 
tearing the iliacus internus muscle (Fig. 
769), or it may be broken in a line near to 
and parallel with the crest, through the 
anterior superior spinous process, and even 
through the base of the posterior superior 
spinous process, as in a case narrated by 
Hamilton, but which, I believe, stands 
alone. Malgaigne speaks of these frac- 
tures near the crest as taking their start 
either in front of or behind that remark- 
able projection situated at the junction of the anterior and middle thirds of 
the crest, and running thence either forward or backward, or, in some in- 
stances, in both dii’ections, constituting a double fracture. In many cases this 
observation will be found to be quite correct. 
Symptoms.—There is acute pain experienced on motion. The patient is 
unable to stand or to walk. If, while the limb is flexed and the body inclined 
forward, thus relaxing the muscles and the strong fasciae attached to the 
upper border of the bone both within and without the pelvis, the crest of 
the ilium is grasped and pressed back and forth, mobility and crepitus may 
be detected. The displacement, in some instances, is so slight that no crepi- 
tus whatever can be discovered. In other cases, as when the crest is broken, 
the detached fragment may be found drawn considerably away from the 
other part of the bone by the action of the abdominal muscles. When the 
anterior superior spinous process is broken, it may be displaced downward 
by the sartorius muscle ; and if the line of separation extends some distance 
back into the crest, the tensor vaginae femoris will assist in causing the same 
deformity. Any attempt to turn in bed almost invariably causes pain in 
pelvic fractures. The contusions incident to these injuries are soon followed 
by extensive discoloration. 
Accompanying these fractures will sometimes be found a rupture of some 
Fig. 769. 
Fracture of the ilium, traversing its dorsum 
transversely and vertically. 966 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
portion of the abdominal or pelvic viscera. In a case admitted to the Uni- 
versity Hospital, the pelvic cavity was partially filled with blood, in conse- 
quence of the damage sustained by the iliac veins. Hamilton* records a 
similar injury. 
Treatment.—The patient must be placed upon his back, and the body and 
lower extremities so disposed as to insure the relaxation of those muscles 
which tend to produce displacement. To this end the limb should be drawn 
up, and the body somewhat flexed by raising the head and chest with pil- 
lows. When the crest is separated from the body of the bone and drawn up 
by the broad muscles of the abdomen, the most complete adjustment and 
relief will be secured by simply inclining the body towards the affected side. 
Sometimes, however, it will be found that the patient instinctively assumes 
a position which, although it may be contrary to our anatomical notions of 
what is the true one, gives complete relief from suffering, in which case it is 
well not to insist upon enforcing a compliance with any theoretical ideas 
which may be entertained upon the subject. The position once secured, the 
pelvis should be surrounded with a strong, broad bandage of drilling, made 
fast with pins. 
If the anterior superior spinous process is detached and displaced, the leg 
should be flexed on the thigh and the thigh upon the abdomen, in order to 
admit of the bone being readily reduced, after which an opening should be 
cut in the bandage to receive and to retain in place the broken fragment. 
Adhesive strips can be substituted for the broad encircling bandage. After 
adjusting the fracture, these strips, which should be two inches wide and six- 
teen inches long, may be carried from the tuber of the ischium, diagonally, 
upward and forward across the side of the pelvis upon the abdomen, until 
the bone is entirely covered in. When the anterior process is the seat of the 
fracture, the first strip must cross immediately in front of this part of the 
ilium. When the fracture is a compound comminuted one, any loose pieces 
of bone should be removed, as they are liable to perish, and, acting as foreign 
bodies, cause troublesome fistulous openings. The condition of the bladder 
must be attended to, the catheter being used when the patient experiences 
any difficulty in passing the urine. A bed-pan will be required, in which to 
receive the alvine evacuations, and when there is much abdominal soreness 
relief will be obtained from hot fomentations. The callus which unites 
these fractures, as has been observed by Prof. John Neill, is formed on the 
outer surface of the bone alone. 
Fractures of the Pubis.—The causes of fracture of the pubis are similar to 
those producing like injury of the other pelvic bones, and may affect the 
horizontal ramus, the descending ramus, or the body, and in some instances 
all three simultaneously. It may also be 
detached from its fellow bone at the sym- 
physis, severing the connecting cartilage 
and ligaments. (Fig. 770.) The exam- 
ples of this separation are quite numerous. 
Lentef has described one caused by severe 
pressure of the pelvis between two cars; 
there was also in this instance a wound 
of the bladder. Malgaigne furnishes four 
cases produced by forcible abduction of 
the thighs. He has also collected seven- 
teen cases of disjunction of the bodies of 
the pelvic bones, from causes connected 
with parturition. The case of Cappelleti,J 
recorded as one of fracture from muscular action alone, is vitiated by the 
fact that the weight of the body falling upon the ground is not considered, 
Fig. 770. 
Fracture of the rami of the pubis. 
* Fractures, p. 342. 
f New York Journal of Medicine, Second Series, vol. iv. p. 286. 
j Ranking’s Abstract, No. viii. p. 83. FRACTURES OF THE PUBIS. 
967 
and this may have been an important factor in determining the lesion. The 
rami of the bone are the portions most commonly broken, and the great 
danger attending the accident is from the liability of the bladder to be 
wounded by the displaced spicules or splinters of bone. In one-half of the 
fatal cases analyzed by Lyon, urinary infiltration was the cause of death. 
Helaton relates a case at the Hopital Saint-Louis of a woman who had a 
fractured pubis, a splinter from which had penetrated both the bladder and 
the vagina, and which he removed through the latter canal, yet who recov- 
ered, notwithstanding both urinary infiltration and abscess followed. This 
patient was probably the same, says Malgaigne, that in after-years had a cal- 
culus removed from her bladder by Lenoir, at La Pitie, the nucleus of which 
was a fragment of bone. In a case of fracture of the body of the pubis in 
a female, under the care of Maret, an obstruction was encountered while 
attempting to introduce a catheter. On making an incision into the labium, 
this obstruction was found to be the principal part of the body of the pubis: 
the fragment was removed without difficulty. This patient recovered, and 
afterwards became the mother of two children. Kuptures of the bladder 
are not always produced by a fragment of bone: if the organ happens to be 
distended at the time of the accident, it may be torn by the concussion alone. 
Whenever the opening, as shown by Sir Astley Cooper, is above the perito- 
neum, a fatal termination follows from peritonitis, but when it is below this 
membrane, in the cellular tissue of the pelvis, recovery is possible, though 
abscesses and sloughing may be anticipated. 
Symptoms.—Severe pain, aggravated by pressure on the body of the bone, 
inability to stand or to walk, and a feeling of falling apart, with ecchymosis, 
constitute the principal phenomena attending this fracture. Sometimes by 
grasping the tuber of the ischium with one hand and the body of the pubis 
with the other, and pressing in opposite directions, both crepitus and motion 
may be felt. 
Treatment.—Little is usually to be done in the way of reduction, as it is 
improbable that much displacement will be discovered, save perhaps in cases 
where the bones are separated at the symphysis. The pelvis may be sur- 
rounded with a strong muslin bandage, or writh a broad piece of leather 
having buckles and straps attached by which it can be drawn as tightly as 
may be desired and thus press together the disjoined bones. The dressing 
which I prefer, and which is much more simple and efficient, is a strip of 
adhesive plaster four inches wide and sufficiently long to extend two-thirds 
around the pelvis. Over the hypogastrium a piece of muslin must be laid 
so that the hair covering this region shall not become adherent to the plas- 
ter. In the application of the latter, the thighs must be flexed and kept close 
to each other, so as to relax the adductors, the pectineus, the psoas, and the 
iliac muscles; the innominate bones must next be pressed strongly together, 
and the adhesive strip laid on so as to cross anteriorly from one side of the 
pelvis to the other, its upper margin being a little above the anterior superior 
spinous processes of the iliac bones. Should the rami of the pubic bone be 
displaced, pressure should be made upon the salient points, and, if the patient 
is a female, a finger may be passed into the vagina and thus act very effect- 
ually in pressing a fragment into place. 
The condition of the bladder must be carefully inquired into, as from 
this quarter comes the greatest danger. A gum catheter should therefore be 
immediately passed into the organ and allowed to remain until it has been 
ascertained that this viscus is uninjured. This should take precedence of 
everything else. We must not wait until the extravasation takes place 
before employing the instrument: this is the very mischief which we desire 
to prevent. Should a rupture in the organ exist, if the urine be kept en- 
tirely drained away for seven or eight days we may hope that the rent 
by this time will be sufficiently repaired to prevent leakage. In the event 
of subperitoneal or pelvic urinary infiltration being present, the signs of 
which are pain, swelling, and discoloration (the last two advancing forward 968 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
and spreading over the perineum and the scrotum, and sometimes accom- 
panied by bloody micturition), free incisions must be made without delay into 
the scrotum or the perineum. In some instances the urethra has been torn 
entirely or partially across, near the neck of the bladder, as in the cases of 
M. Nivet and M. Boudet,* also in one reported by I)r. Clark in the Massa- 
chusetts General Hospital.f In such a complication the perineum should be 
opened and the incisions carried into the bladder, as in the operation for 
stone, in order that the urine may have an unobstructed escape. Inflamma- 
tion must be combated by leeches and external warmth, and pain controlled 
by opiates. 
Fractures of the Ischium. 
Fractures of the ischium, though often conjoined with similar injuries of 
the pubis, are not so common as those of the other bones of the pelvis. 
Only twice in fifty recorded cases of pelvic fracture was it met with in the 
Pennsylvania Hospital. The ischium may be broken in the course of its 
ascending ramus, or where the latter joins the descending branch of the 
pubis ; also through the tuberosity ; and last, near to the acetabulum. 
Causes.—In addition to those already de- 
scribed as being productive of pelvic fractures, 
falls upon the buttocks are to be mentioned. 
In one case, pressure made during the instru- 
mental delivery of the foetal head caused the 
accident. The risk to the urethra and bladder 
is quite as great in fractures of the ischium as 
in those of the pubis. In several recorded 
cases of the injury there existed both an ex- 
ternal wound and comminution of the bone. 
Symptoms.—After an accident producing 
fracture of the ischium, there will be inability 
to stand or to walk, or, at least, great difficulty 
in attempting either without support. By 
placing the patient on the breast and grasp- 
ing the tuberosity of the bone, mobility and 
crepitus may be recognized. The fracture can sometimes be discovered by 
a digital examination made through the rectum or through the vagina, even 
when nothing abnormal can be detected by an external inspection of the 
parts. 
When the fracture is a compound one, a careful exploration should be 
made by a finger introduced into the wound. The displacement following 
a detachment of the tuber ischii will be in a downward direction, in conse- 
quence of the attachment of the hamstring muscles. 
Treatment.—The patient may be placed upon either the back or the side. 
If the former position is adopted, the limbs should be moderately flexed over 
pillows, and, to prevent the tuberosities from pressing against the mattress, 
an ovoidal air-bag or a ring cushion, one inch thick, should be placed beneath 
the pelvis, the limbs being then secured together. The catheter must be 
passed in order to ascertain the condition of the urethra and the bladder, 
and to remove the urine if there is the slightest ground for supposing that 
either has sustained injury. 
Fig. 771. 
Fracture of the ramus of the ischium. 
Fractures of the Acetabulum. 
Of fifty cases of fractures of the pelvis placed on the records of the Penn- 
sylvania Hospital, ten extended into the acetabulum. 
The floor of the cavity may be traversed by a single fissure or by a number 
* Malgaigne, Fractures and Dislocations, Packard’s trans., p. 520. 
f Boston Medical and Surgical Journal, vol. iii. p. 646. FRACTURES OF THE ACETABULUM. 
969 
of radiating lines of fracture, without displacement; or it may be driven before 
the head of the femur into the pelvic cavity ; or the margin of the cavity may 
be chipped off; or, lastly, the three pieces which conjoin to form the cotyloid 
cavity may be separated from one another, an accident most likely to occur 
in young subjects. The cabinet of Professor Neill contains a specimen of 
this kind (Fig. 772) in which the union is complete and with very little 
callus on the articular surface. Moore* 
has recorded a case in which the head of 
the femur was driven through the ace- 
tabulum into the pelvis. (Fig. 773.) A 
very remarkable case of this kind was the 
“ Old Piper,” known on both sides of the 
Atlantic,! who died in February, 1839, 
in the Mercer Hospital, from tubercular 
Fig. 772. 
Fig. 773. 
Fracture of the acetabulum and of the ramus of the 
ischium.—From a specimen of Professor Neill’s. 
Travers’s case : head of the femur driven into 
the pelvis.—Bryant. 
disease. Several years before, he had met with a severe injury of the hip, 
which at the time was regarded as a fracture of the neck of the thigh- 
bone. This man, after being treated for some time, was able to walk long 
distances, although somewhat lame. After his death it was found that the 
old injury consisted in a fracture of the pubis and also of the acetabulum, 
allowing the head of the femur to pass into the pelvis, whei’e it had remained, 
covered by a shell of bone. 
When the margin of the acetabulum is broken, it permits the head of the 
femur to slip when the thigh is rotated, producing as a secondary result a 
luxation, in which case the ligamentum teres may be torn. 
Causes.—Fractures of the acetabulum are produced by violence applied 
upon the side of the pelvis, or, more commonly perhaps, by falls or blows 
received upon the trochanter or the knees. 
Symptoms.—These fractures are very obscure, and are liable to be con- 
founded with fractures of the neck of the femur, or with dislocation of 
its head. There are no signs clearly distinctive of this injury. When we 
carefully analyze the symptoms presented in the cases on record, we find a 
singular want of uniformity in their phenomena. 
In a case of this injury under my care some years ago, in a very prominent- 
citizen of Philadelphia, there was no shortening, although the most careful 
measurements were made. Pressure over the body of the pubis caused no pain, 
and the patient was able to sit up and ride a distance of nearly two miles to 
his home after the accident. He was able to raise the limb, and to flex the leg 
upon the thigh, and the thigh upon the abdomen; he could invert and evert 
the toes ; there was no crepitus like that of fracture, and he had entire com- 
* American Journal of the Medical Sciences, August, 1839. 
f Bryant, Medico-Chirurgical Transactions, vol. xxxiv. INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
970 
mand over the bladder. The only movement which caused severe pain was 
the attempt to turn upon the side, and this occasioned violent muscular 
spasms. When the thigh was flexed upon the pelvis and then rotated, the 
arc of the circle described was uniform up to a certain point, but beyond 
that the head of the bone appeared to slip. On the strength of this peculiar 
symptom a fracture of the lip of the cotyloid cavity was suspected, and the 
treatment adopted accordingly. A subsequent autopsy not only proved that 
this was the case, but also revealed a fracture of the floor of the acetabulum, 
through which the finger could be thrust from the pelvic side. 
In distinguishing between fractures of the rim of the acetabulum and 
those of the cervix of the femur, attention should be given to the following 
particulars: 
First, in fractures of the neck of the thigh-bone (unless impacted) the 
foot is everted, often lying on its outer side. In the cases of fracture of the 
rim of the acetabulum the verity of which has been determined by post- 
mortem examinations, the toes were turned inward, in one case very slightly 
outward at first, though afterwards changing to the other direction. 
Second, in fractures of the neck of the femur the trochanter major should 
be found appreciably nearer to the crest or to the anterior spinous process of 
the ilium than in a fracture of the lip of the acetabulum attended with dis- 
placement of the thigh-bone, inasmuch as the head of the latter is much more 
voluminous than its neck, and therefore keeps the trochanter out. 
Third, in fractures of the neck of the femur, if the shortening is overcome 
by extension it will immediately reappear on the removal of the force, in 
whatever direction the axis of the limb is placed. In fractures of the rim 
of the acetabulum, if the thigh is drawn to its proper length, and at the same 
time the head of the bone directed towards the broken side of the cavity, the 
shortening will occur while the limb is so placed. 
Fourth, the crepitus in fractures of the neck should be more rude, rough, or 
grating than in those of the rim of the acetabulum, since in the first there are 
two irregular surfaces of bone rubbing together, whereas in the latter the 
cartilaginous surface of the head of the femur forms a modifying element in 
the sound elicited by contact with the broken surface. This was very notice- 
able in a case which I once examined, the sound being exactly like that which 
is experienced when the surfaces of a relaxed joint are made to play upon 
each other. 
The signs which should distinguish this fracture from a simple dislocation 
are mainly two. First, in simple luxation there is a definite, generally un- 
varying, direction of the foot: it is either inverted or everted. Not so in this 
fracture: the toes may point in any direction. Secondly, in simple luxation 
the head of the bone once restored so remains, while in fracture it slips again 
into its abnormal position as soon as the reducing force is withdrawn. 
The same uncertainty attends fractures of the floor of the acetabulum. 
The shortening varies from half an inch to two inches; the foot may be 
inverted or everted. If, however, the surgeon encounters a case in which, 
after unusual violence has been applied to the pelvis,—as, for example, over 
the trochanter,—there follow shortening, acute pain when the joint is moved, 
crepitus produced by extension and relaxation of the limb rather than by 
rotation and flexion, and if in addition the great trochanter is found nearer 
to the anterior inferior spinous process than that of the sound side, with the 
foot showing no special tendency to eversion, the presumption is that the case 
is one of fracture of the floor of the acetabulum. If the patient should be a 
female, much light might be thrown upon the case by an exploration through 
the vagina, by which any undue prominence within the pelvis could be de- 
tected ; and to those practitioners who advocate the introducing of the hand 
into the rectum for purposes of exploration, a new field for diagnosis is 
opened, though it might be difficult to say which of the twain, the hand or 
the head of the bone, would be capable of doing the most damage within 
the pelvis. In these cases the obturator nerve is liable to injury, and a FRACTURES OF THE FEMUR. 
painful condition of the muscles to which it is distributed would follow. In 
the case of the “ Piper” referred to, considerable pain was experienced; and 
in Morel Lavellee’s patient, recorded by Malgaigne, the severe pain present 
was supposed to be due to coxalgia. 
Treatment.—This should be very much the same as that for fracture of 
the thigh, namely, a fracture-bed, prepared as for the latter, and extension 
by means of a weight attached to the limb by adhesive strips. A broad 
adhesive band drawn across the front of the pelvis, or around it, if the lip of 
the acetabulum is supposed to be broken, will aid in keeping the head of the 
bone in position, by making pressure over the trochanter. The bladder, of 
course, must receive early attention, and the urine be drawn if necessaiy. 
Pain and muscular spasms should be controlled by hypodermic injections of 
morphia, and antiphlogistic remedies employed to meet such inflammatory 
complications as may arise. 
971 
Fractures of the Lower Extremity, 
There is some difference of opinion among writers as to the relative fre- 
quency of fractures in the upper and the lower extremity. Of 1572 fractures 
registered at the Calcutta Native Hospital during a period of twenty-one 
years, 681 were of the lower and 665 of the upper extremity.* Malgaigne 
analyzed 2328 fractures from the records of the IIotel-Dieu, and found 1006 
belonging to the lower and 850 to the upper extremity. Lonsdale examined 
the fractures at the Middlesex Hospital for six years. There were treated 
1901, of which 516 were of the lower and 764 of the upper extremity.! In 
Lonsdale’s collection an account was kept of the walking cases, such as were 
dressed at the hospital but did not enter its wards, and consequently it forms 
the basis for a reliable estimate. Of 8667 fractures recorded on the books 
of the Pennsylvania Hospital, 3910 occurred in the lower extremity and 
3760 in the upper; but these were all in-patients.J 
For the satisfactory treatment of fractures of the lower extremities, espe- 
cially of the thigh, a fracture-bed and mattress are necessary. These have 
been particularly described on page 810, and need not again be referred to. 
These fractures may be divided into those of the thigh, the leg, and the foot. 
The femur is the largest bone in the skeleton, its construction rendering 
it capable of resisting a great amount of force. Before those important 
changes which are incident to advanced life take place in its texture, very- 
great violence is required to sever its fibres. 
The most convenient classification of fractures of the femur is into those 
of the upper extremity, those of the shaft, and those of the lower extremity. 
In forty-four years—from 1830 to 1874—there were treated in the Penn- 
sylvania Hospital 1181 fractures of the thigh, 143 of which were compound. 
In 885 of these, in which the sex was named, 745 were males and 140 females, 
152 occurred in boys under ten years of age, and the largest number (164) 
between the ages of ten and twenty. The mortality in the whole number 
of 1181—which was 164—may appear somewhat heavy; but, when we con- 
sider the severe injuries which in very many of these fractures conrplicated 
the cases, it will not create surprise. 
In frequency, fractures of the femur are ranked by Malgaigne first, by 
others about fifth in order, as compared with like injuries of the other bones 
of the skeleton, except in the case of children, in whom, according to M. 
Colon,§ they stand second in order. They constitute about thirteen per 
cent, of the whole number of this class of accidents registered on the books 
of the Pennsylvania Hospital; that is, they occurred 1181 times in 8667 
cases. 
Fractures of the Femur. 
* Holmes's System of Surgery, vol. ii. p. 842. f Lonsdale on Fractures. 
X The aggregate number of fractures up to the present date exceeds 17,000. 
| Holmes’s System of Surgery, vol. ii. p. 843. 972 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Fractures of the Upper Extremity of the Femur. 
The proportion which fractures of the upper extremity of the femur bear 
to those affecting other parts of the bone was found by Bryant, at Guy’s 
Hospital, to be about one-fifth, or 44 times in 207 cases. In the Pennsylva- 
nia Hospital it is about one-seventh, having occurred 171 times in 1181 cases. 
The divisions under which it is proposed to treat these injuries are intra- 
capsular, extra-capsular, mixed, and trochanteric fractures. 
Intra-capsular Fractures of the Femur.—Fractures which involve the neck 
of the femur, and which fall entirely within the insertion of the capsule of 
the joint, are called intra-capsular. They are peculiar to advanced life, and 
occur most frequently in females. These fractures are remarkable in two 
respects: first, on account of the trifling amount of force necessary for their 
production; and, secondly, for their failure to unite by bony matter. 
The causes of all cervical fractures are predisposing and exciting. If we 
compare the femur of middle life with one from a person of advanced life, 
a notable difference in the form of their upper extremities will be observed. 
In the bone of a person at middle life the neck is long, and joins the shaft 
at an obtuse angle, whilst in the bone of an old person the neck is smaller, 
and is placed more nearly at a right angle with the shaft. (Compare Figs. 
774, 775.) This distinction is 
denied by Mr. Canton,* but I 
have had abundant evidence to 
satisfy me of its correctness. 
Not only is there this change 
in the form of the bone, but 
a very remarkable one takes 
place in its structure. As age 
advances, the nutrition of this 
part of the femur is greatly 
disturbed. The cells of the 
spongy tissue become rarefied 
and filled with fat, the com- 
pact tissue extremely thin, and 
the entire neck diminishes in 
size. Mr. Bransby Cooperf has 
shown that, whatever chem- 
ical alterations take place, the 
fragility of the neck cannot be 
attributed, as has been sup- 
posed, to an increase in the earthy or inorganic salts; on the contrary, these 
salts are very much diminished, and, what is singular, this diminution is con- 
fined to the neck alone, and does not involve the shaft of the bone. As the 
changes just noticed appear to affect females more than males,—a fact en- 
tirely in accordance with their greater tendency to fatty degeneration in all 
the tissues of the body,—we find accordingly the former most frequently the 
subject of these fractures. This changed direction of the neck of the bones 
in the aged, especially in reference to the broad female pelvis, favors the acci- 
dent, from the manner in which the weight of the body is transmitted to the 
femora. There is another change of the neck of the femur, the result of 
rheumatic arthritis, which, by the atrophy it induces, enfeebles the bone and 
renders it liable to be broken. Every year over fifty increases the proba- 
bilities of a fracture of the thigh-bone being intra-capsular. Sir Astley 
Cooper, in 251 cases, met with only two in which the patients were under 
fifty years of age. I have seen one case of the injury, proved by an autopsy, 
in which the patient, a sailor, was under forty years of age. As to the rela- 
Fig. 774. 
Fig. 775. 
Femur at middle life. 
Femur in old age. 
* Holmes’s System of Surgery, vol. ii. p. 847. 
t Guy’s Hospital Reports, 1845, 2d Series, vol. iii. INTRA-CAPSULAR FRACTURES OF THE FEMUR. 
973 
tive frequency of intra- and extra-capsular fractures, it must still be con- 
sidered an open question. Malgaigne examined all the fractures of the 
cervix in the Dupuytren, St. Bartholomew. Dublin, and Richmond museums, 
making in the aggregate 103, and of these 61 were intra-capsular. Nelaton 
and Bonnet believed that extra-capsular fractures were very much the most 
numerous. In the museums of the College of Physicians of Philadelphia 
and the University of Pennsylvania there are 23 fractures of the neck of 
this bone, 10 of which are intra-capsular. Of 171 fractures of the upper 
extremity of this bone admitted into the Pennsylvania Hospital, 49 were 
intra-capsular. 
Causes.—The exciting or determining causes are usually of a very trivial 
nature, such as falls upon the pavement, striking upon the knee or trochanter 
major, turning in bed while the foot is entangled in the clothing, or tripping 
upon the carpet while walking across the room. I have seen the femur 
broken by the muscular effort of pulling on a boot. Some importance is to 
be attached to the direction in which the force is communicated to the bone. 
M. Rodet,* by a series of experiments, came to the following conclusions: 
first, that force acting vertically—as when a person falls upon the feet or the 
knees—will produce an oblique intra-capsular fracture; second, that when 
acting from before backward it will produce a transverse intra-capsular frac- 
ture ; and, third, that when acting from behind forward a mixed fracture, or 
one both within and without the capsule, will result. While these conclu- 
sions in many cases are correct, there are certainly numerous exceptions to 
this rule. 
Pathology.—The fracture may traverse the neck at any point between the 
head and the attachment of the capsular ligament (Fig. 776), sometimes en- 
croaching upon the head itself. The line of separation may be oblique (Fig. 777) 
or transverse, complete or incomplete. The periosteum often remains untorn, 
Fig. 776, 
Fig. 777. 
a Complete intra-capsular fracture, of nine months’ standing, b Same specimen, 
sawed.—Malgaigne. 
Oblique intra-capsular 
fracture. 
and serves to prevent displacement. An incomplete intra-capsular fracture 
has been doubted; but its possibility seems to have been established by Dr. 
Jackson’s case.j Another condition is that of impaction, one fragment—the 
lower—being forced into the spongy substance of the head (Fig. 778), or 
there may be a kind of dovetailing or mutual interpenetration of the pieces. 
Epiphyseal detachments from the head of the femur, in young subjects, 
have been asserted by Liston, and by several others since his day. Until 
this, however, has been verified by an autopsy, this accident cannot be re- 
garded as established. 
* L’Experience, 14 Mars, 1844. 
f Boston Medical and Surgical Journal, vol. iv. p. 351. 974 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
The soft parts also participate in the injury. The reflected portion of the 
capsule is generally more or less torn ; blood flows from the ruptured ves- 
sels ; and, under the stimulus of the injurjq the joint will be filled with 
synovia and serum, mingled with the effused blood. After several days, part 
of the blood will find its wav towards the surface of the hip, and a subcu- 
taneous discoloration appear. If there 
is much displacement or movement be- 
tween the fragments, an inflammatory 
thickening of the capsular ligament will 
result, and in old cases nodules of bone 
may be seen incorporated with its sub- 
stance. The broken ends may be loosely 
connected by fibrous tissue, or they may 
be bound together with considerable firm- 
ness. The head of the bone may be hol- 
lowed out by attrition with the lower 
fragment, and the latter be so rounded as 
to resemble slightly a ball-and-socket joint, 
or both ends may be entirely free and dis- 
connected. In almost all cases where the 
fracture has existed for any considerable 
length of time, the neck of the bone, in a 
great measure, disappears. (Fig. 779.) 
Symptoms.—The signs of intra-capsular 
fracture are the occurrence, after a slight 
accident in a person over fifty years of 
age, of pain, loss of power (or at least di- 
minished power) of the limb, unusual mo- 
bility, deformity, crepitus, and swelling. 
Pain.—This is usually acute, though not 
so severe as in fractures external to the joint, or in the shaft of the bone. 
It is felt extending from the groin a short distance down the thigh, and is 
due to injury of the articular branch of the obturator nerve. The move- 
ments which produce the most severe suffering are those 
of rotation. Patients frequently complain of pain on 
the posterior aspect of the hip near to the great tro- 
chanter, and also at the knee. When situated at the 
latter and persistent, it has been supposed to depend 
upon inflammation of the hip-joint, somewhat resem- 
bling coxalgia. While this, in exceptional cases, may 
be true, it is certainly far from being common. The 
connection which exists between the obturator and 
the saphenous nerves will explain the pain which is 
felt at the inner side of the knee after this accident. 
Loss of function.—In regard to this particular symp- 
tom we meet with remarkable differences in different 
persons. Sometimes the patient is utterly powerless 
to flex or rotate the limb, or to move it in any position 
whatever; and if placed in the erect posture he is 
unable to bear the least weight upon the foot. In other instances, the leg 
can be raised from the bed ; and frequently the patient can flex the entire 
limb by the action of the hamstring muscles, which, as the heel is drawn up, 
also raise the thigh. The muscles which flex the thigh upon the abdomen 
are usually more disabled than those which flex the leg upon the thigh, 
simply because in the latter both the muscles and the nerves which endow 
them are more remote from the seat of injury. There are, however, 
some very remarkable exceptions to this symptom of disability. A case 
of intra-capsular fracture was admitted into the Pennsylvania Hospital in a 
patient under forty years of age, who, after the accident, not only walked 
Fig. 778. 
Impacted fracture, intra-capsular.—Bigelow. 
Fig. 779. 
Neck of femur absorbed after 
intra-capsular fracture. INTRA-CAPSULAR FRACTURES OF THE FEMUR. 
975 
to the institution from a distance of two squares, but also made his way to 
the third story of the building. A second patient, who was under my care, 
and who had a fracture within , the joint, was for years always able to walk 
with a cane, and frequently without one. The verity of the injury was in 
both cases established by a post-mortem examination. These cases have 
been explained in various ways,—by impaction, by intercalation, and by an 
unbroken periosteum preventing a separation of the fragments. While 
these conditions no doubt occasionally do exist and confer the singular power 
which is possessed over the damaged limb, such is not invariably the case. 
In one of the patients just referred to, the head of the bone had become 
deeply excavated by the action of the neck upon its surface, which served 
to prevent displacement of the fragments. 
Preternatural mobility.—The ordinary methods of movement furnish but 
little information, as it must necessarily be a very difficult task, even with 
the keenest tact, to distinguish the movements of the fracture from those 
natural to the joint. When the limb is rotated, the trochanter will be found 
to describe the arc of a smaller circle than does the corresponding process of 
the sound side, inasmuch as the centre of motion is brought nearer to this 
prominence. M. Maisonneuve adopts a plan which gives a practical value 
to the symptom of mobility. He places the patient on the abdomen, and 
carries the injured thigh directly backward, in which direction, if it is broken, 
it will go much farther than when sound, as in the latter case this move- 
ment will be arrested by the neck of the bone striking against the margin 
of the cotyloid cavity. 
Deformity.—H the fragments are driven past each other, there will be 
shortening varying from half an inch to one inch, which may be increased 
to one inch and a half after the lapse of some time. This is due to the 
gluteal muscles recovering the power which had been temporarily abolished 
by the violence producing the fracture. It happens sometimes that there 
is no shortening whatever at the time of the injury, nor for some time after, 
when it appears suddenly and to a considerable degree. When this is 
the case, the fragments are not displaced at the time of the break, but by 
some motion on the part of the patient, some manipulation by the surgeon, 
or possibly some violent spasm of the muscles, the ends of the bone are 
suddenly disarranged, when the limb is drawn upward by the action of the 
glutei muscles, and inward towards the ilium by the pectineus, the ad- 
ductors, and the conjoined action of the psoas and iliacus interims with the 
obturator externus muscles. (Fig- 780.) 
Again, a shortening which is very gradual, and which may extend over a 
period of months, may occur without displacement, in consequence of a slow 
absorption of the cervix, induced under the stimulus of the lesion and the 
attrition of the contiguous surfaces. The cases of extreme shortening—two 
inches or more—which have been noticed by Sir Astley Cooper and others 
can only take place at the expense of the capsular ligament,—that is, by its 
extension or by its rupture. Cases of this nature, however, are exceedingly 
rare. With shortening of the limb there is also a change in the position 
of the trochanter major. It is brought nearer to the crest of the ilium and 
becomes less prominent. A moderate degree of extension, provided there 
is no impaction, overcomes the shortening, which returns, howTever, as soon 
as the force is withdrawn. If the fragments are displaced, some undue ful- 
ness of the groin may be detected in consequence of the upper fragment 
pressing forward. 
Dr. Allis, of this city, has called attention to another diagnostic sign of 
this fracture, or, indeed, of any fracture through the neck of the femur,— 
namely, the existence of a relaxed condition of the fascia lata between the 
crest of the ilium and the trochanter major on the injured side, consequent 
on the loss of the resistance which is furnished by the unbroken cervix. 
Fig. 781 will illustrate the difference in the tension of this fascia in the 
two sides. 976 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Eversion of the foot or external rotation of the limb constitutes another part 
of the deformity. This must be distinguished from the slight outward direc- 
tion of the toes which is the natural position of the limb when left unre- 
strained. The rotation alluded to is complete, the foot lying on its outer 
border, which deformity may be exaggerated by the hand, as pointed out by 
Gerdy, until the toes look backward,— 
a position impossible to the sound limb 
if the pelvis remains fixed. The ever- 
sion of the foot or the external rotation 
of the limb is due to three causes: first, 
Fig. 781. 
Fig. 780 
Displacement following fracture through the neck of 
the femur.—Hines. 
The dotted line represents the fascia lata, its inser- 
tion, and manner of passing over the great trochanter. 
In the right limb the fingers indicate the points 
where it is most lax in case of fracture. 
to the action of the external rotator muscles, the tendons of which are in- 
serted into the trochanteric fossa; secondly, to the absence of that resistance 
which is furnished by the ligamentum teres ; and, thirdly, to the weight of 
the limb. 
There are occasional exceptions to this external rotation after fracture of 
the neck of the thigh-bone, cases in which the foot may turn only slightly 
outward, or may stand vertically, and in a few instances may be even in- 
verted. With regard to the first two positions, the explanation must be 
sought for in one of three conditions, viz., an unbroken periosteum, inter- 
calation of the spicula, or an impaction of the fragments. 
As to inversion of the foot, although I have never seen a case of the kind, 
the fact of its existence cannot be doubted, as we have the testimony of 
Pare, Petit, Stanley, Guthrie, Dupuytren, Malgaigne, Robert Smith, Hamilton, 
Bigelow, and others, to establish the verity of this deformity. In Stanley’s 
case an autopsy proved that the fracture was intra-capsular, as was the case 
also in those of Bigelow and Robert Smith. 
Erichsen ascribes the non-eversion of the foot in these cases to paralysis 
of the external rotator muscles. Such a relation of the fragments as resists INTRA-CAPSULAR FRACTURES OF THE FEMUR. 
977 
external rotation, apparently, can only be determined by the vulnerating 
force being applied in a particular direction, namely, on the posterior aspect 
of the great trochanter, by which the limb will be turned inward at the 
time that the fracture takes place. 
Robert Smith states that when such anomalous positions of the foot exist, 
if extension is made sufficiently energetic to restore the limb to the proper 
length, external rotation will immediately follow as soon as the extending 
force ceases to act. This is confirmatory of the opinion that this inversion 
of the foot is due to a certain interlocking of the fragments. 
Crepitation.—This important symptom is often recognized with difficulty. 
Various directions have been given as to the best method of making it sen- 
sible. That of Sir Astley Cooper consisted in extending the limb to its proper 
length, so that the broken surfaces may be brought opposite to each other, 
and then rotating the leg inward and outward. I have always met with 
the best success by flexing the thigh to almost a right angle with the pelvis, 
and then rotating it while traction is being made, the finger and thumb of 
fhe other hand at the same time embracing the articulation. Persistent 
efforts to establish crepitus may be productive of evil, by rending any peri- 
osteal bands which serve to keep the broken ends together, or by disen- 
gaging an impaction, which, had it been allowed to remain, might have 
been followed by bony consolidation. Hence prolonged manipulation is to 
be deprecated. 
Prognosis.—Intra-capsular fractures, being peculiar to aged persons, and 
remaining ununited, as first shown by Sir Astley Cooper, must be regarded 
as. very serious accidents. The dangers which threaten life arise from a 
kind of hectic fever, from bed-sores, inflammation, and abscess of the joint, 
wearing the patient out in a few weeks or months. The possibility of bony 
union in these fractures has been discussed 
with no little warmth at various times. The 
careful investigations of Sir Astley Cooper and 
the searching analyses of Hamilton are quite 
sufficient to show that, while bony union is 
possible under certain favorable conditions,— 
such as an unbroken periosteum, or, according 
to Bigelow, an impaction,—its occurrence is 
so exceedingly rare as in no way to invalidate 
the truth of the general law of non-union. 
We learn from Hamilton* that the whole num- 
ber claimed by European surgeons is nineteen, 
and about the same number are in this coun- 
try. Two of the latter belong to Philadel- 
phia. Fig. 782 is a representation of one of 
these. This specimen, however, has been 
sawed in half, and found not to be a case of 
bony union. 
To determine with certainty the true rela- 
tion of a fracture to the capsular ligament by 
dissections made months or years after the 
accident is no easy task. A portion of a frac- 
ture may be partly external to the capsule and 
escape detection. Dr. George K. Smithf has 
shown that the attachment of the capsular ligament is not uniform in dif- 
ferent persons: therefore, to arrive at certainty as to these intra-capsular 
fractures, it has been very properly advised that the particular specimen in 
question should be compared with its fellow femur, and not with that of 
another individual. When these facts are considered, with others which 
might be mentioned, such as senile atrophy (Fig. 783) and arthritic disease 
Fig. 782. 
Prof. H. H. Smith’s case of supposed bony 
union after an intra-capsular fracture. 
* Fractures, etc., p. 364, 1871. 
f Insertion of the Capsular Ligament, etc., Philadelphia Medical and Surgical Reporter, 1862. 978 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
of the cervix, there is a very strong probability that the number of alleged 
specimens of bony union might be still further reduced. 
The question naturally arises, Why does union not take place ? Several 
reasons exist for this, among which may be mentioned the following : 
1. Deficient vascularity. The vessels which supply the head of the bone 
enter its substance by the ligamentum teres and the reflected portion of the 
capsule, and when the fracture takes place it must depend entirely for its 
vitality upon the arterial branch which ascends 
the round ligament,—a supply barely sufficient 
for its own existence, and sometimes not equal to 
that. 
2. Whatever reparative material may be depos- 
ited has no local permanence; that is, there are 
no interlacing threads of connective tissue about 
the fracture which can serve as a nidus for its re- 
ception and support while passing through the 
stages of development. 
3. Any reparative material furnished by the 
vessels becomes so diluted by intermixture with 
the increased synovial fluid as to be incapable of 
progressive organization. 
4. Maladjustment of the fragments, or imper- 
fect coaptation, and an inability to maintain that 
perfect quietude so necessary to the repair of 
these injuries, also militate against union. These 
causes, together with the action of the numerous 
powerful muscles which have their attachment near to the fracture, and 
which are disposed about the joint in the most favorable directions for dis- 
turbing the lower fragment, constitute the chief reasons for non-union. 
Age, except in so far as old and infirm persons bear fixed confinement 
badly, can scarcely be regarded as inimical to the repair of bones, inasmuch 
as we constantly see fractures in other parts of the osseous system get well 
as quickly in the old as in the young. In some cases the principal obstacle 
to union consists in the fact that no provisional callus is thrown out by the 
periosteal vessels. 
When patients recover sufficiently to get about, the disability will be 
found to vary greatly. Some are unable to allow any weight upon the 
limb, and it hangs uselessly by the other, being a little flexed; others, with 
the assistance of crutches, can move about with comparative ease; others 
can do the same thing with only the aid of a cane, although they are con- 
scious of the limb yielding whenever the weight of the body rests upon 
the foot. 
Pathology.—The changes which take place in intra-eapsular fractures 
vary much in different cases. The immediate effects of the injury are hem- 
orrhage into the joint, though not profuse, as the vessels are neither numer- 
ous nor large; shortly after, inflammatory phenomena set in, which, as in 
inflammation of joints from other causes, is followed by an increased amount 
of synovial fluid, mixed with serum, and, still later, with flakes of lymph. 
The ecehymosis which occasionally is seen diffused through the superficial 
cellular tissue conies from the vessels of this structure, and is the result of 
direct injury. When the fracture is effected by a twist of the limb, or by 
indirect force, it is not common to meet with discoloration, as there is not 
sufficient blood to find its way to the surface, in addition to which, there is 
the mechanical obstacle of the capsule to its escape. It is not often that 
this capsular ligament is torn. After a time, the redundant exudations and 
extravasations are absorbed, and then the work both of repair and of destruc- 
tion begins. If the apposition is favorable, the fragments may be connected 
by fibrous bands, which will allow of much play between their extremities; 
or there may be a bond, similar in nature, interposed between their broken 
Fig. 783. 
Senile atrophy of the neck of the 
femur, resembling intra-capsular 
fracture. INTRA-CAPSULAR FRACTURES OF THE FEMUR. 
979 
surfaces, so firm and compact as to allow of but little movement (Fig. 784); 
or the fragments may remain entirely disconnected, and undergo different 
changes. Those which are more especially the result of vital activity take 
place in the lower fragment ; that is, its broken surface may become in- 
crusted with cartilage, or ruddy with a layer of granulation tissue, or its 
cervix materially thickened by external or periosteal deposit, or it may 
become concave or concavo-convex, thus conforming to the surface of the 
other fragment. The upper or acetabular fragment, from deficient blood- 
supply, becomes wasted, and even, it is said, 
sometimes entirely disappears, as in the 
two cases reported by Brunninghausen and 
Banco.* 
The capsular ligament, teased and stretched 
by the mobility of the fragments, may become 
thickened, and even ossified, so as to offer 
great resistance to pressure, while at other 
points it may become thinned, or possibly 
absorbed, by contact with a spiculum or with 
some salient point of one of the fragments. 
Treatment.—The treatment of intra-cap- 
sular fracture has formed the subject of con- 
siderable difference of opinion. With Sir 
Astley Cooper it consisted in simply support- 
ing the limb, moderately flexed, on a kind of 
double inclined plane, made of pillows, and 
after the immediate effects of the accident 
were past, say from twelve to fifteen days, 
directing the patient to sit up, and as soon as 
possible to begin to move about on crutches. 
Mr. Erichsen advises a similar plan of treatment, and some American surgeons 
recommend the same course. I do not, however, think that this practice is 
very largely adopted by the profession on this side of the Atlantic; and 
there are strong reasons, in my judgment, why it should not be. There 
have been recorded a sufficient number of cases of bony union after what 
was believed to be intra-capsular fracture, to justify a hope that some of the 
cases encountered by the surgeon may have a similar termination. 
There is cause to assume that in these favorable cases the lesion was partly 
external to the joint, and hence the osseous consolidation wrhich followed. Yet 
the very uncertainty on this point, in any given instance of articular fracture, 
is a sufficient reason for the plan of treatment advised. 
I adopt the rule of treating every case of fracture of the femur, except 
that at the upper third, as though it were situated in the shaft of the bone, 
namely, by placing the patient on the back and applying extension with the 
limb in the straight position, after the manner to be presently described. 
I know of no position more comfortable than the one just named; and so 
long as it is endured without the patient being threatened with bed-sores, or 
without other evidences of constitutional feebleness, it should be maintained 
until the question of union is determined. If, however, the health shows a 
tendency to give way, the horizontal position on the back must be aban- 
doned and the patient be laid upon the sound side, with the limbs flexed, or 
be placed in a high reclining chair and wheeled into the open air; or, if 
physically able, he may walk about on crutches. Nutritious food, tonics, and 
stimulants will be required to sustain the patient’s strength. If there is 
reason to believe that the fracture is an impacted one, care must be taken 
not to disengage the fragments, either by officious manipulation or by the 
addition of too much weight to the extension apparatus. Five pounds will 
be sufficient in most cases to keep the limb in position. 
If the treatment is well borne, and there is evidence of the bone be- 
Fig. 784. 
Ligamentous union of intra-capsular frac- 
ture.—Mayo. From Sir Astley Cooper. 
* Malgaigne, Fractures and Dislocations, Packard’s trans., p. 547. 980 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
coming firmer, it will be necessary to keep it up for a longer period than is 
commonly employed in other fractures of the thigh. If the patient is far 
advanced in life, and at the same time feeble and broken down in health, it 
would be obviously improper to attempt any plan of treatment which in- 
volved much restraint. Under these circumstances, it is better to consult 
the patient’s comfort by resorting only to those expedients which will best 
subserve this end. For this purpose the limb should be placed over, and 
secured to, a double inclined plane, formed either by the splint of that name 
or by pillows, as in Fig. 785. 
Fig. 785. 
Limb placed over a double inclined plane formed by pillows.—Smith. 
Extra-capsular Fractures of the Neck of the Femur.—Fractures of the neck 
of the femur external to the capsular ligament have many points, symp- 
tomatically considered, in common with those within that ligament. 
The causes which produce this lesion are generally such as act directly 
upon the great trochanter, as falls upon this part of the hip, although some- 
times the violence may be dual, being transmitted from a more distant part 
of the limb, as the knee or the foot. 
The laws which govern fractures, while they always operate in entire con- 
sistence with established mechanical principles, can never be formulated with 
absolute accuracy, because, while intensity and direction of force may be 
measured, no two persons ever present exactly the same condition of osseous 
tissue; and yet in these extra- 
capsular fractures there is a re- 
markable uniformity. 
The line of separation usually 
runs in one of three directions. 
First, oblique, — that is, parallel 
with the direction of the anterior 
and the posterior intertrochanteric 
lines (Fig. 786), in which case the 
head and neck make the upper, 
and the trochanters and shaft the 
lower fragment. This variety of 
fracture, I think, usually results 
from indirect force, as where it is 
applied to the knee or to the foot. 
Second, the line of separation may be transverse, and lower down at its 
outer than at its inner extremity (Fig. 787), making two fragments, the upper 
one consisting of the head, neck, and a portion of the trochanter major, and 
the lower one formed by the shaft of the bone. 
Fig. 786. 
Fig. 787. 
Fracture in the course of the 
intertrochanteric lines. 
Transverse fracture. EXTRA-CAPSULAR FRACTURES OF THE FEMUR. 
981 
Third, the fracture may be comminuted, in which case there are three or 
more fragments, the head and neck forming the upper piece, the great tro- 
chanter making the second, and the shaft a third. (Fig. 788.) This injury is 
often the result of force applied to the trochanter major, the resistance being 
at the acetabulum, the comminution resulting from the neck being driven into 
the spongy tissue of the trochanter major, splitting it off from the shaft of the 
femur. 
When the neck is buried in the cancellated tissue of the trochanter and 
the shaft of the femur, it forms an impacted fracture. (Fig. 789.) 
Both Malgaigne and Robert Smith believe that all extra-capsular fractures, 
with detachment of the trochanter major, are impacted. Bryant concurs 
Fig. 788. 
Fig. 789. 
Comminuted extra-capsular fracture.—Malgaigne. Impacted fracture of the neck of the femur.—Miller. 
in this opinion; but Hamilton does not accept this statement unreservedly. 
There are three specimens in Philadelphia—one in the Mutter collection of 
the College of Physicians, one in the possession of Professor John Neill, and 
one in the museum of the University—which certainly prove the contrary. 
Instances have been recorded in which the lower fragment is said to have 
been driven into the upper one; but such must be exceedingly rare. The 
depth of penetration will depend upon the intensity of the fracturing force 
and the brittleness of the cancellated structure into which the neck is driven. 
It rarely exceeds three-quarters of an inch. The firmness with which the 
neck is held, when once forced into the intertrochanteric tissue, will depend 
in some degree upon the integrity of the strong interlacing bands of fibrous 
tissue which are connected with this part of the bone, and which are derived 
from the tendons and fascia about the trochanteric lines and fossa. If this 
fibrous tissue be torn, the trochanters fall apart, and the neck, instead of re- 
maining imprisoned, will escape from the interspace, either by the fracturing 
force, by the movements of the limb, or by the manipulation which may be 
practised. If, on the contrary, these ligating fibres remain intact, the pene- 
tration will likely remain. 
Symptoms.—The resemblance between the phenomena of these fractures 
and of those within the capsular ligament is such as to demand the greatest 
circumspection in the diagnosis. We have pain, swelling, discoloration, 
disability, crepitus, and deformity. 
Pain.—This is more severe than when the fracture is within the joint; 
the tenderness is also more diffused about the peripheral portions of the 
articulation. 
Swelling and discoloration are also more uniformly present. The ecchy- 
mosis is, in most cases, particularly marked, and comes, when the violence is 
direct, from two sources,—one subcutaneous, and the other from vessels about 982 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the bone,—the latter finding its way to the surface after a few days, not being 
restrained by the limitations of the capsular ligament, as in intra-capsular 
fracture. 
Disability.—On this point writers are at variance, and not without reason, 
for the degree of disability differs very much in different persons. 1 have 
seen a case in which the person could not only stand, but could even bear his 
weight upon the foot; and I have also seen a patient with such a fracture 
utterly incapable of making any voluntary movement of the limb whatever. 
The loss of power generally, however, is greater than in the intra-capsular 
variety. 
Crepitus.—This is a sign of uncertain value when considered in connection 
with such an injury. When the impaction is firm it cannot be detected. When 
the fragments are loosely connected, or when they are entirely detached from 
each other, it is easily elicited by rotatory movements of the limb. It is 
proper here to enjoin caution as to persistent efforts being made to discover 
this symptom, as an impaction may be unlocked and marked displacement 
follow. 
Defoi'mity.—This symptom manifests itself in various ways. There is short- 
ening, varying from one-quarter of an inch to one inch ; but when the impac- 
tion is not maintained, the neck may slip down the shaft, and the shortening 
be increased to even two inches. If there is no impaction, and the great 
trochanter is not detached, the latter process will be drawn up towards the 
crest of the ilium by the gluteus medius and minimus, together with the psoas 
and iliacus interims muscles, increasing the shortening and raising the neck 
until it is placed at a right angle with the shaft. If the great trochanter is 
split off, and so liberated from the other fragment or fragments as to be 
movable, it may undergo various changes of position,—that is to say, it may 
be drawn inward by the gluteus medius, or upward by the gluteus medius 
and minimus and by the pyriformis, or rotated outward by the obturator 
interims, quadratus femoris, and the two gemelli muscles, so that this part 
of the bone will appear to have an unusual breadth. Malgaigne once found 
it displaced towards the sciatic notch, and but for crepitus would have diag- 
nosed a luxation. It may be stated in general that the more pieces and less 
impaction, the greater will be the shortening, and that this shortening is little, 
if at all, increased by the lapse of time. Eversion is a second element in the 
deformity. It is met with in all degrees, from the slightest turning out of 
the toes, to the position upon the outer side of the foot, depending upon the 
mobility at the seat of fracture. The opposite position of internal rotation 
of the limb, or inversion of the foot, is sometimes present, and there are 
reasons for believing that it is more frequently seen in this fracture than in 
fractures within the capsule. Robert Smith found that of seven cases of frac- 
ture of the cervix in which there was inversion of the foot, five were extra- 
capsular, while it was present only three times in fifteen cases of the intra- 
capsular variety. There can be little doubt that the force which produces 
the fracture, and the relation of the pieces, have more to do with this than 
muscular action. 
Diagnosis.—To recognize clearly a fracture through the neck of the 
femur, or to assert with positiveness that such a fracture is present, is fre- 
quently a matter of no small difficulty, and occasionally, indeed, of impossi- 
bility ; nevertheless a very careful consideration of all the phenomena of 
such an accident will, I believe, in most cases enable us to arrive at a just 
conclusion. The injuries which may embarrass the diagnosis are fractures 
of the acetabulum, absorption of the neck of the femur the result of arthritic or 
other changes in the nutrition of the bone, described by Mr. Adams,* and 
luxation. 
In fractures of the acetabulum sufficiently free to allow the head of the 
bone to sink in towards the pelvic cavity, crepitus and some degree of short- 
ening may be recognized. The arc described by the trochanter will indicate 
* Cyclopaedia of Anatomy and Physiology, vol. ii. p. 789. EXTRA-CAPSULAR FRACTURES OF THE FEMUR. 
983 
a shorter radius than that of the sound side; and while extension will restore 
the limb to its proper length, yet on the withdrawal of the force the short- 
ening will reappear. In fractures of the acetabulum, shortening and crepitus 
may not be detectable, but the same is occasionally true of fractures of the 
cervix. In fractures of the acetabulum the foot may be inverted or everted. 
The same is true of those involving the neck. When all these facts are 
considered, I am quite willing to confess that an error of diagnosis, even 
on the part of a skilled surgeon, is not only possible, but also altogether 
excusable. 
Again, in those interstitial changes which are met with in the neck of the 
femur as the result of arthritic or traumatic inflammations, by which the 
neck and sometimes the head are partly absorbed, how similar are the symp- 
toms to those of cervical fracture! After a severe contusion of the hip, 
the neck of the bone may undergo a slow absorption, which will be fol- 
lowed by shortening; and if in consequence of rheumatic or other changes 
the articulating surfaces become eburnated, even crepitus may be elicited 
and pain experienced when the head of the femur is moved in the cotyloid 
cavity. 
In the case of Hare against Professor John J. Reese for malpractice, 
before Judge Thayer, of Philadelphia, there were strong reasons for be- 
lieving that the neck of the femur had undergone such interstitial short- 
ening. 
In a case of this nature a differential diagnosis may be established with 
some certainty. Thus, it will be found, on a close examination, that the 
shortening has been pi*ogressive, and did not exist at the time of the in- 
jury. This may be true also of a fracture of the neck ; but the shortening 
is much slower in the first, and extends over a much longer period of time. 
Crepitus, when it is discovered in interstitial change, is only revealed after 
many weeks succeeding the injury, as time is demanded for that surface- 
change (eburnation) which is requisite for its development. In cervical 
fracture, after a few weeks, it is not probable that crepitation can be made 
apparent, although I was able in one case both to feel and to hear it after 
two months. A still more important distinction is to be found in our ability 
to remove the shortening of the limb by extension in fractures of the neck, 
while we are unable to remove the shortening which accompanies interstitial 
disease. Discoloration of the soft parts may attend both. In the first, it is 
from the vessels of the subcutaneous tissue, and appears in a few hours after 
the accident; while in fractures, especially extra-capsular, an increased or 
secondary ecc-hymosis will show itself several days after the injury, coming 
from the vessels about the bone, being thus delayed by the superincumbent 
strata of tissue through which the blood is compelled to pass. 
Again, there may be a fracture of the lip of the acetabulum which will 
allow the head of the femur to become luxated. Here we may have short- 
ening, correctable by extension, but returning on its withdrawal, as in frac- 
ture. Crepitus may also exist. In attempting to establish a distinction, 
due weight should be given to the fact that fractures of the lip of the ace- 
tabulum are very rare at such an age as predisposes to fractures of the 
neck, that the limb possesses less mobility than when broken, and that once 
reduced the shortening can be prevented without extension by turning the 
head of the bone towards the side of the acetabulum opposite to the sup- 
posed fracture. 
While there is often, therefore, some uncertainty in coming to a full un- 
derstanding of the exact character of injuries about the hip-joint, yet we 
can pronounce with considerable certainty upon intra-capsular and extra- 
capsular fractures. By contrasting the peculiarities of each when placed 
in juxtaposition, as is done in the table on the following page, and also by 
comparing these with posterior luxations, clearer ideas may be gained of 
their distinctive peculiarities. 984 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Intra-capsular Fracture. 
Extra-capsular Fracture. 
Posterior Luxation. 
1. Produced by trifling vio- 
lence at any point of the 
limb. 
Considerable violence, most 
frequently upon the great 
trochanter. 
Great violence applied to the 
knee, the thigh being in a 
state of adduction. 
2. Sex.—Most common in fe- 
males. 
Sexes about alike as to fre- 
quency. 
Most frequent in males. 
3. Age.—Fifty and upward. 
Under or over fifty. 
From fifteen to forty-five years 
of age. 
4. Position.—Foot rests on its 
outer side. 
Rests on its outer side; if im- 
pacted, may be at any de- 
gree of eversion. 
Limb inverted and adducted. 
5. Shortening. — Very varia- 
able; may be none; gen- 
erally not over one inch. 
May occur suddenly or 
gradually; readily re- 
moved by extension, and 
returning when force is 
removed. 
From a quarter of an inch to 
one inch; may increase, 
but, if impacted, remains 
the same. Moderate ex- 
tension will restore the limb 
to its proper length; if im- 
pacted, much force is re- 
quired to do so. 
From one and one-half to two 
inches. When restored to 
its proper length by exten- 
sion, the shortening does 
not reappear. 
6. Mobility.—Very great. 
Mobility great, unless the 
fracture be impacted. 
Limb more fixed and rigid. 
7. Crepitation.—Not very dis- 
tinct. 
Distinct, unless impacted. 
No crepitation. 
8. From summit of great tro- 
chanter to the tuberosity 
of the femoral condyles 
no shortening. 
Shortening usually between 
these points. 
No shortening. 
9. Pain. — Not severe; felt 
most near to the tro- 
chanter minor. 
Generally severe, and felt over 
the trochanter major. 
Not severe, but extending 
down the back of the thigh. 
10. Disability.—Great. 
Disability greater, but may 
bear, if impacted, some 
weight on the foot. 
Helpless; cannot endure the 
least weight on the foot. 
11. Contusion and discolora- 
tion.—Little. 
12. Wasting of the limb and 
continued weakness. 
Often much. 
Little, if any, wasting; re- 
garding its strength, weak- 
ness temporary. 
Rarely any. 
Prognosis.—When the patient has sustained slight injury beyond the frac- 
ture, very little apprehension need be entertained as to recovery. The mor- 
tality at the Hotel-Dieu,* namely, one in every three cases, is extraordinary. 
No such mortality exists in any American hospital; and possibly it may be 
due, as Malgaigne asserts, to the plan of treatment pursued in this institu- 
tion. The period at which death takes place in fatal cases varies from two 
weeks to two months. 
Of the 176 fractures of the neck of the femur recorded in the Pennsyl- 
vania Hospital (exclusive of the crushes of the pelvis), only 9 died, and of 
this number 49‘are recorded as intra-capsular, only 2 of which died: in pri- 
vate practice, where the ordinary comforts of life and judicious professional 
attention can be secured, death is rather uncommon. Consolidation of the 
fragments will take place in about the same period as in ordinary fractures of 
the shaft, though some lameness may be expected. The amount of spongy 
and irregular callus which, in many instances, is thrown out, is truly won- 
derful, and particularly if union does not take place. It sometimes conceals 
much of the upper fragment, forming a deep recess, into which the neck of 
the bone is lodged as in a socket. (Figs. 790, 791.) This callus is derived 
from the vessels of the lower fragment, where there is, of course, a large 
amount of cancellated tissue for its supply. 
Treatment.—The same rule is to be adopted in the treatment of extra- 
capsular fractures as in that of those within the joint, namely, extension by 
means of adhesive plasters with a weight attached, and by lateral support 
with sand-bags, as will be described under the head of fractures of the shaft 
of the femur. 
* Malgaigne, Fractures and Dislocations, Packard’s trans., p. 561. FRACTURES OF THE TROCHANTER. 
985 
Care must be taken not to attach too much weight to the limb when im- 
paction is suspected, since otherwise the fragments may be disengaged and a 
great advantage be lost, Whenever the shortening does not exceed one-half 
or three-quarters of an inch, and is not overcome by a reasonable degree of 
Fig. 791. 
Fig. 790 
Excessive callus following an ununited 
extra-capsular fracture.—From a specimen 
in the University Museum. 
Redundant callus in an ununited extra- 
capsular fracture.—Hamilton. 
force, the inference is that such impaction exists. We should therefore be 
content with a weight of five or six pounds, merely to keep the limb securely 
extended. The position of the foot must be changed from that of eversion 
to the perpendicular, or to one in which the toes are directed upward. This 
is sometimes done by passing a strip of muslin about the toes and making it 
fast to some permanent object, such as the mattress or one of the sand-hags. 
A much better plan, in fractures of the neck, is to slip behind and beneath 
the great trochanter a small sand-bag ten or twelve inches long and four 
inches thick. 
Should adhesive plasters not be immediately available wherewith to apply 
the above-mentioned dressing, resort may be had to the double inclined plane, 
or to Desault’s apparatus as modified by Physick or Hodge. 
Should the person be aged and infirm, and begin to fail under the restraint, 
all forms of surgical appliances must be abandoned, and that position assumed 
which will conduce most to the comfort of the patient. 
Fractures of the Trochanter Major.—The trochanter major may be broken 
off from the shaft independently of any other injury to the bone. The acci- 
dent is a very uncommon one. In 1181 fractures of the thigh treated in 
the Pennsylvania Hospital, this injury was recognized only four times. 
Some confusion exists as to the exact nature of this fracture. That de- 
scribed by Sir Astley Cooper as “a fracture through the trochanter major” 
is more properly a fracture of the upper extremity of the shaft, passing 
through the great trochanter, its course being downward and inward 
and not in any way implicating the neck of the bone. It would be quite 
as proper to designate fractures of the neck, with splitting off of the tro- 
chanter, as “fractures of the trochanter major.” Nor is the confusion re- 
lieved by reading his description of the case seen with Mr. Harris, and also with 
Mr. Brodie.* It would appear that in this patient there was neither ci’epitus 
nor shortening, and that after one month he found the trochanter had fallen 
* Cooper on Luxations and Fractures, Godman’s edition, p. 129. 986 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
some distance behind its natural position, but was easily lifted into place by 
the hand. How could such be the case and yet no shortening follow, if it is 
meant to convey to the reader the idea that this fracture extended through 
both shaft and trochanter ? The inference would rather be that this was a 
fracture simply detaching the latter process from the shaft. If, however, the 
fracture passes across the shaft and the great process, the extent of surface 
exposed and the fibrous expansion derived from the contiguous tendons would 
tend to prevent displacement, in which case there would be no shortening, 
and it might be also impossible to elicit crepitus, so that the accident might 
escape detection. In Cooper’s case it was only revealed by dissection.* If 
displacement of the fragments should be present, the summit of the great 
trochantel would remain fixed or he but little affected upon rotation of the 
limb ; the leg would be shortened by the contraction of the gluteus maximus; 
the foot would be everted by the weight of the limb, and when the latter 
was drawn down and rotated, crepitus would be discovered. Strictly speak- 
ing, fractures of the trochanter should be confined to a separation of the 
epiphysis, or to its detachment from the shaft. 
Fracture of the Epiphysis of the Great Trochanter.—Fracture of the epiph- 
ysis is an exceedingly rare occurrence. In my own collection is a well-marked 
example of the injury, accompanied by a fracture of the condyles (Fig. 
792): this, and one reported by Mr. Ashton Key, ap- 
pear to be the only instances of the kind which have been 
verified by an autopsy. The cases narrated by Clarkf 
and by Bransby Cooper,J although the first was ex- 
amined after death, Hamilton thinks were impacted frac- 
tures of the neck. I can scarcely believe that Clark’s 
case can in any way he construed into one of fracture 
of the neck, with impaction. It was certainly a commi- 
nuted fracture of the great trochanter. 
Cause.—The cause of this fracture is force applied 
over the process, as when a person falls violently upon 
the hip. It is by no means peculiar to the aged, having 
occurred in Key’s case at the age of eighteen,—before 
which age the epiphysis had become solidly united to 
the shaft,—since this consolidation occurs shortly after 
puberty. In Clark’s case the patient was thirty-two. 
In my own there was no history, the bone having been 
taken from a subject in the dissecting-room. 
The symptoms of such an injury are, pain experienced 
on movement of the limb, diminished prominence of the 
great trochanter, and its fixed condition uninfluenced 
by the movements of the shaft. When grasped by the 
fingers, the process will be found movable, and if released 
from the tendinous expansion of the vastus externus, its 
displacement upward and backward by the gluteus medius and minimus 
will follow. Lastly, crepitus will be felt when the limb is strongly drawn 
away from its fellow and the trochanter fixed by pressure so as to bring the 
surfaces of the shaft and process into contact. As the continuity of the shaft 
and neck is not destroyed, there can be no shortening or external rotation 
of the limb. 
Prognosis.—When the trochanter is entirely detached and much displaced, 
its union with the femur cannot be expected. This, however, could not per- 
manently affect the usefulness of the limb, as the insertion of other muscles 
capable of producing nearly all the movements of the thigh would remain 
undisturbed. In the specimen which I have figured, there was present a con- 
Fig. 792. 
Fracture of the epiph 
ysis of the trochanter ma- 
jor, with a fracture of the 
condyles. 
* Luxations and Fractures, p. 138, American edition, by Godman. 
f American Journal of the Medical Sciences, Nov. 1836, vol. i. p. 181. 
j Dislocations, p. 192. FRACTURES OF THE SHAFT OF THE FEMUR. 
987 
siderable amount of granular callus ai*ound the circumfei'ence of the fractui’e, 
though there was none between the fragments. 
Treatment.—So little is known in to these fractures of the tro- 
chanter that I confess my inability, with all the light that can be obtained 
upon the subject, to designate any method of treatment established by ex- 
pei’ience; but, looking at the subject from a purely anatomical point of view, 
I can see no l-eason to depart from the extended position of the limb, as 
recommended for fractures of the neck of the bone. The leather bandage 
of Cooper, buckled about the pelvis, is certainly not likely to give any 
advantage in retaining the trochanter in place which might not be as well 
obtained by the use of a broad strip of adhesive plaster. The abducted 
position of the limb, i*ecommended by Branshy Cooper, will scarcely suffice 
to bring the two pieces sufficiently near together for any practical purpose, 
though no possible objection can be urged against any attempt to effect this 
object in that way. 
Fractures of the Shaft of the Femur.—Fractures of the shaft of the femur 
may occur at any point, but it is customary to speak of the bone as being 
divided into thirds : thus, we have its fractures referred to the middle, 
upper, and lower thirds. The middle third of the bone is most frequently 
the region of fracture. Ilolthouse states* that of 70 cases which he ob- 
served, 46 were in the middle, 16 in the lower, and 8 in the upper third. 
Hamilton makes a similar statement,f founded on the specimens in the Mut- 
ter Collection of the College of Physicians of Philadelphia. Of the 24 frac- 
tures of the shaft, 19 are in the middle, 3 in the upper, and 2 in the lower 
third. Of 539 fractures of the thigh received into the wards of the Penn- 
sylvania Hospital, 269 were in the middle, 151 in the lower, and 119 in the 
upper thii'd. The middle third of the bone is the smallest and weakest part; 
it is the summit of the arch, and whether the force be communicated dii’ectly 
or indirectly, it is within this region that it is most intensified. Its fractures 
are frequently compound, and sometimes comminuted. Of 1181 cases taken 
from the i*ecoi’ds of the Pennsylvania Hospital, 143 were compound, and of 
885 classified and reported, 20 were comminuted. (See table.) 
The direction of these fractures is generally oblique, and the obliquity is of 
considerable extent. In childi’en it is generally moi’e transvei’se, as stated 
by Ei’ichsen, than in adxdts; and even in the latter, when near tlie middle, 
where the compact tissue is gi'eatest, we occasionally meet with a transvex-se 
fracture. The line of break vai'ies also as to position. In the upper third 
of the bone there is no uniformity; in the middle third it is downwai*d and 
inward, and in the lower third downward and forward, the upper fragment 
being generally in front of the lower. In children, fractures of the thigh 
are more common than those of the leg. 
Causes.—These are either direct or indirect. The direct are the most 
common, as when the thigh is struck by heavy pieces of timbei’, or by cast- 
ings, or is run over by a loaded wagon, or when, as I have seen occur, a 
hoi’se falls upon his rider. Indirect violence tends to produce fractures of 
the lower or the upper third, the force being transmitted thx-ough the leg, as 
when a person falls from a considerable height upon the feet; the same result 
may follow a fall upon the knee. Muscular action alone has been known to 
produce a fracture of the bone, as in Beauchere’s case,;}; noticed by Holthouse, 
of a man who, to prevent himself from falling backwai’d, made a violent mus- 
cular effort, breaking the bone just below the trochanter. The same cause, I 
have no doubt, produced a fracture immediately below the trochanter in a 
patient of my own, who, having tripped over a croquet-mallet, made a very 
enei’getic attempt to i*ecover himself, when he heal’d the bone give way. I 
might also record a second instance of a fracture of this bone, occuiring in the 
upper third of the femur, produced by turning in bed, the foot being entirely 
* Holmes’s System of Surgery, vol. ii. p. 860. 
J Beauchere, Jour, de Med. de Leroux, t. xxx. p. 336. 
f Fractures, etc., p. 386. 988 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
free. In all these cases, however, there is reasonable ground for believing 
that the bones were unsound, and this is rendered still more probable by 
the fact that these fractures, brought about by such slight causes, have 
been near to the upper extremity, where we know the bone is especially 
prone to degeneration. 
Symptoms.—The following symptoms are common to all fractures of the 
shaft of the bone : 
Pain, which is excessively acute, particularly on movement, and sufficiently 
severe to extort a sharp cry from the most resolute. 
Preternatural mobility, which is easily discovered by raising the leg or the 
thigh, or by adducting or abducting the limb. 
Deformity.—This may appear in the form of an unusual prominence, with 
shortening of the limb; it may consist in angular displacement of the frag- 
ments, in eversion—rarely inversion—of the foot, and in swelling, produced 
both by muscular contraction and by effusion. 
Crepitus.—This is readily elicited by rotating the limb. An assistant 
should be instructed to make traction from the foot until the limb is brought 
to its proper length, and then to rotate the parts while the hand of the sur- 
geon embraces the seat of injury and his ear is brought near to the same. 
This manipulation is particularly necessary when the fracture is somewhat 
transverse in its course. It is proper to say that when the other signs are 
sufficiently marked there can be little necessity for inflicting further pain 
simply to produce crepitation. 
Disability.—The limb is usually helpless, the patient having little, if any, 
voluntary power to change its position. A part of the deformity, especially 
that of angularity, is due to the combined operation of muscular action, the 
violence determining the fracture, and the awkwardness or ignorance of 
those who may attempt to move the patient. 
That which we speak of as shortening, or overlapping of the pieces of 
the bone, is the result, largely, of muscular contraction alone. This is well 
seen in those cases in which the accident follows direct violence, temporarily 
paralyzing the muscles. At first, very little shortening exists, but in a 
few hours, when they recover their power, it becomes quite marked. The 
obliquity of the fracture, also favors the shortening. Instances of trifling 
shortening are occasionally met with, in which there is no subsequent ten- 
dency to increase,—a condition which is explained by the interlocking of 
certain prominent serrations of the fragments. 
Prognosis.—When there is a simple fracture of the shaft of the bone, with- 
out other injury, a favorable result may be expected. When the injury is a 
compound one, and the patient old or broken down by irregular habits of life, 
the case assumes a serious aspect; and if, in addition, the knee-joint should 
be opened, the danger is greatly enhanced, and the prognosis becomes still 
more unfavorable. 
In all cases of fracture of the femur, except in children, an appreciable 
degree of shortening may be expected. There has been much difference of 
opinion among surgeons on this subject, and some years ago the question 
assumed considerable importance from the prominence given to it at a meet- 
ing of the American Medical Association, held at Detroit, where it was de- 
clared, by a prominent surgeon, that under proper dressing there should be 
no difference in the length of the limbs. I think there are few surgeons who 
are prepared to accept this statement. Desault, Amesbury, South, Dorsey, 
and some others claim to have accomplished cures without deformity of any 
kind, but when we interrogate the long line of distinguished men who have 
spoken on this subject, with few exceptions, from Hippocrates down, they 
utter but one voice,—viz., that shortening is the rule. 
Velpeau was quite satisfied with half an inch shortening. Chelius says, 
“ Even in the most satisfactory cases there remains a little shortening.” 
Nelaton admits its uniform presence. Malgaigne writes as follows: “I 
must state positively that I have never obtained anything of the kind,” al- FRACTURES OF THE SHAFT OF THE FEMUR. 
989 
hiding to the assertions of those who claim to cure fractures of the femur 
without shortening. Dr. Warren, of Boston, in a letter to Professor Hamil- 
ton, says, “ I have never yet seen, either in Boston or elsewhere, an oblique 
fracture of the thigh in a patient over seventeen years of age in which there 
was not some shortening.” Gibson writes, “ In oblique fractures of the thigh, 
it is hardly possible, in any case, to calculate on union without more or less 
shortening.” Hamilton, whose surgical skill is exceeded only by his candor, 
after a most careful examination of all the testimony at his command, con- 
cludes “ that in an oblique fracture of the shaft of the femur in an adult, 
where the muscles are not paralyzed, and where the ends have been displaced, 
no means have yet been devised by which an overlapping and consequent 
shortening of the bone can generally be prevented.” Professor Gross says, 
“ the opinion of many respectable practitioners, that it is impossible to effect 
a cure of fractures of the shaft of the thigh-bone without shortening, is only 
too well founded.” 
Mr. Holthouse, in the summer of 1857, examined all the fractured thighs 
under treatment in the different hospitals of London, making an aggregate 
of fifty,—thirty adults and twenty children. This examination was con- 
ducted with the greatest care ; arid the result reached was as follows. Only 
fifteen escaped deformity, and of these, twelve were children, but three adults 
of the thirty being without deformity, making ninety per cent, of adults and 
forty per cent, of children in whom shortening was present. 
The same author further confesses that, with all his efforts to obtain a 
perfect cure at the Westminster Hospital, he never succeeded in a single 
case where the patient was an adult; and in one hundred specimens which 
he examined of this fracture, distributed among the museums of London, 
only one was found free from deformity.* My own experience accords 
entirely with these statements. I have not met with a single case, among 
all the specimens in Philadelphia of fracture of the shaft of the femur, which 
was entirely free from deformity; and I am equally certain that neither in 
hospital nor in private practice, save in the case of children, have I ever 
succeeded in curing a case without an appreciable shortening. 
The discrepancy which exists on this subject may be accounted for, in a 
measure at least, by the want of accuracy in measurement, as well as by the 
time when the mensuration is made. To be accurate, the crests of the ilia 
must be absolutely on the same level, and the measuring-line must be void 
of elasticity. The patient must be likewise entirely honest, as he has it in 
his power to practise a deception by inducing different degrees of tension in 
the extensor muscles of the two limbs, which is not detectable by the keenest 
.observer. Lastly, the surgeon must himself be free from all bias,—a simple 
seeker after truth,—a state of mind which is not always easily reached. 
Again, it is not improbable that a bone will shorten somewhat for some time 
after a patient is discharged as cured, from the influence of the weight of the 
body upon the imperfectly-constructed callus. 
With respect to the amount of shortening, in Holthouse’s thirty-five cases 
it ranged from half an inch to three and one-third inches. In twenty-one 
specimens examined by myself, the average shortening did not exceed three- 
quarters of an inch. Hamilton’s measurements yielded an average shortening 
of three-quarters and one-forty-seventh of an inch. 
In reference to the subject of shortening, Dr. Cox, who made a large num- 
ber of measurements—sixty—among the patients without fractures at the 
Pennsylvania Hospital, states that ho found a marked disparity in the length 
of the two limbs of the same person. 
It is to be understood that this disparity in the length of the two limbs 
is not real, but only follows in consequence of the difficulty in touching 
exactly corresponding portions of the skeleton on the two sides, from the 
varying position of the pelvic factor, and from unconscious muscular action 
on the part of the patient. Any one who will take the trouble to measure 
* Holmes’s System of Surgery, vol. ii. p. 865. 990 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
corresponding femora deprived of the soft parts will find them to be of equal 
length. 
I do not hesitate to say that a fracture in the shaft of the thigh-bone 
which is cured with one-half or three-quarters of an inch shortening is a 
good cure, and gives no room for complaint on the part of the patient; and 
that the surgeon who obtains this result may walk among his professional 
brethren without being conscious of the least inferiority or want of skill in 
the management of this class of surgical injury. 
Fractures in the Upper Third of the Femur.—These fractures are proverbi- 
ally difficult of management, and are particularly prone to be followed by de- 
formity. When close to the trochanters, they are frequently associated with 
fracture of the neck exterior to the capsular ligament. The chief difficulty 
is with the upper fragment, which undergoes different changes in different 
cases,-—the most common being a displacement forward and upward by the 
action of the psoas and iliacus internus muscles and outward by the action 
of the same muscles, together with the gluteus minimus, pyriformis, obtu- 
rator internus, gemelli, and quadratus femoris muscles. (Fig. 793.) When 
the upper fragment is tilted inward in- 
stead of outward, it is probably due to 
the direction of the fracturing force, the 
pectineus and adductor brevis muscles 
maintaining the bone in its abnormal 
position. Mr. Erichsen had three op- 
portunities of verifying the truth of this 
explanation by dissections.* Should the 
fragments be so held together by w edg- 
Fig. 793. 
Fig. 794. 
Displacement of the upper fragment 
of the femur in a fracture at the upper 
third of the hone. 
Deformed union of a fracture at the 
upper third of the femur.—Malgaigne. 
ing of the spiculse, they are liable to be drawn outward so as to form an angle 
salient externally. The muscles which combine to effect such a displacement 
are the gluteus medius and minimus externally, and the adductor internally. 
The great difficulty in controlling the upper fragment is such that, al- 
though there may be no failure in the union, some degree of shortening of 
the limb, and consequent lameness, may be expected. In badly-treated frac- 
tures at the upper third of the bone, the anterior angular deformity may be 
very marked. (Fig. 794.) 
* Surgery, vol. i. p. 374. FRACTURES OF THE SHAFT OF THE FEMUR. 
991 
Fractures in the Middle Third of the Femur.—These fractures are much 
the most frequent of those occurring in this bone, but are not so oblique as 
are those in other portions, because here 
the compact tissue is greatest, and the 
size of the bone least. The line of frac- 
ture is very uniform, being downward 
and from behind forward; the upper 
fragment, in almost all cases, being in 
front of the lower one. Within this 
region also we occasionally encounter 
multiple as wmll as compound fractures. 
The shortening or overlapping is like- 
wise very great, varying from two to 
three inches, and sometimes even more, 
writh marked deformity, swelling, and 
eversion of the foot. The uniformity 
with which the upper is in front of the 
lower fragment is very noteworthy, 
and is the effect chiefly of muscular 
action; the psoas and iliacus internus 
advancing, in some small degree, the 
upper piece of the bone, and the 
adductor magnus and gastrocnemius 
drawing back the lower piece, while 
the overlapping is caused by the rec- 
tus, the hamstring, and the adductor 
muscles. The fracturing force and the 
weight of the limb should not be entirely 
excluded in the enumeration of these 
causes, though their influence must be 
of a very secondary kind. (Fig. 795.) Most of the cases of ununited frac- 
ture of the femur are seated in the middle third, though union, with some 
shortening, may confidently be expected in five or six weeks. 
Fig. 795. 
Fracture of the femur at the middle third, with 
overlapping, the lower fragment being behind the 
upper. 
Fractures in the Lower Third of the Femur.—These follow either direct or 
indirect violence. The direction of the fracture is determined, in some meas- 
ure, by the manner in which the producing cause operates. When from indi- 
rect force, as from falling on the knee or the foot, it will probably be oblique, 
running from above downward and from behind forward. When from direct 
force, as when a piece of timber falls across this part of the thigh, the line 
of separation will be more transverse. When the frac- 
ture occurs near to the knee-joint, the usefulness of 
the articulation may be seriously impaired. The dis- 
placement consists in the upper fragment being tilted 
forward and sliding down towards the joint in front 
of the lower piece. It may be seen or felt as a promi- 
nence on the front of the thigh, pushing forward the 
quadriceps muscle: should the end be pointed or 
sharp, it may penetrate or even pass through all the 
superincumbent tissues, and form a compound frac- 
ture. The lower fracture is generally represented as 
being drawn backward by the gastrocnemius muscle 
so as to be felt in the ham. (Fig. 796.) Malgaigne 
denies this altogether, and says there is not a specimen 
of such a displacement in any museum in Paris. If he 
is to be understood as meaning that the lower frag- 
ment does not fall somewhat back towards the ham, 
he is in error. I have never been able to discover any great encroachment 
upon the popliteal space, although the gastrocnemii muscles do tend to 
Fig. 796. 
Diagram illustrating the 
supposed displacement of the 
lower fragment of the femur. INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
992 
draw this inferior fragment backward, but the action is limited in its opera- 
tion. 
The two vasti muscles, having their origin along the two branches of the 
entire linea aspera, and being inserted into the edges of the tendon of the 
rectus femoris, serve the part of a sling, which, with the expanded insertion 
of the adductor magnus, prevents the bone from falling or being drawn back 
to any great extent. No specimen in this city furnishes an example of any 
very marked posterior displacement of the inferior fragment; and, for the 
anatomical reasons already given, the deformity must be very rare. The 
overlapping of the broken parts, which produces the shortening, is caused 
by those muscles which have their attachments on the pelvis and the leg, 
—as the rectus in front, and the hamstring muscles posteriorly. Eversion 
of the foot—common to all fractures of the thigh—will be present to some 
degree in the one under consideration. In the reduction of this fracture, 
some address is requisite when the rectus is impaled, in order to disengage 
the upper fragment from the substance of the muscle. The method of Boyer, 
by extension and counter-extension in the extended position, will not always 
answer. The best plan is to follow somewhat that recommended by Mal- 
gaigne for the reduction of a fracture above the condyles : “ Flex the thigh 
to nearly a right angle with the pelvis, and then, flexing the leg, with the 
forearm in the ham, make extension, gradually restoring the limb to the 
straight position.” 
Treatment of Fractures of the Shaft of the Femur.—Preparation of 
bed.—To secure a properly-constructed bed, where this is possible, is of the first 
importance. There are several expensive and very ingenious beds, which have 
been already noticed in an early chapter of this book, but which, from the fact 
that they are beyond the means of most persons, must be of very limited use. 
The iron fracture-bedstead, in common use in our hospitals, with an opening 
in the centre guarded by a trap, answers every purpose for our public institu- 
tions and in private houses. With the assistance of a carpenter a single-bed- 
stead may be very soon converted into a fracture one, by substituting for the 
middle slats a broad board with a hole cut through its centre, or two boards 
with a semicircular portion taken from each. On the under side nail two 
cleats, each with a shoulder, along which may be slid a tin bed-pan to receive 
the dejections. Upon this bed place a very firm mattress, from the centre of 
which has been cut out a circular piece six inches in diameter. This must be 
lined with oil-cloth, which shall cover likewise the upper and lower surfaces 
of the mattress for six or eight inches around the hole. In country districts 
the physician has frequently, as I know well from personal -experience, to get 
along as best he may with very crude and imperfect appliances. Men whose 
lives have been spent in a city or in a hospital know little of the extreme 
simplicity of country practice or of the limited range of resources often at the 
command of the country practitioner, and it is to me a source of astonish- 
ment that his results are generally so good. It is quite possible to treat a 
fracture of the thigh on a soft bed which has been beaten down and covered 
with folded comfortables, and to dispense entirely with the usual arrange- 
ments for defecation by placing against the lower end of the bowel a firm 
wad of oakum or of tow on which to receive the evacuations, the act being 
effected in this manner without leaving a soiled spot on the bed. 
The bed being arranged and covered with a sheet having a hole in the 
centre corresponding to that in the mattress, an upright containing a fe- 
nestra with a pulley (Figs. 797, 798) can be placed at the foot of the bed, or 
may be screwed fast to it, a little to one side of its middle. This upright 
must have several holes for the axle, so that the latter can be raised or 
lowered as may be found necessary. In the absence of a roller, a cotton- 
spool, with a strong piece of wire for an axle, will make a very good substi- 
tute. The patient being on the bed, and the fracture adjusted by the usual 
manipulations, the surgeon proceeds to prepare and apply his apparatus 
for extension. For this purpose a strip of adhesive plaster is cut, two and FRACTURES OF THE SHAFT OF THE FEMUR. 
993 
a half inches wide, and long enough to extend from the upper end of the 
lower fragment on both sides of the limb and leave a loon some distance 
below the sole of the foot. When 
the roll of plaster is not sufficiently 
long, this extending band may be 
formed from two strips, which 
must be sewed tirmly together 
where they overlap below the foot. 
On the middle of the spread sur- 
face is to be laid a piece of board 
two and a half inches wide, and 
sufficiently long to prevent the 
plaster from touching the- malleoli. 
A second piece of plaster, eight or 
ten inches long, five inches wide 
in the centre, and two inches and 
a half on each side (Fig. 799), is 
next prepared. The wide central 
part of this strip is placed upon 
the inside of the foot-board, over 
the edges of which it is turned 
down, and the lateral portions are 
brought along the surface of the 
extending band as high as the 
malleolus on either side. The ob- 
ject of this piece is to fasten the 
foot-board securely to the extend- 
ing band, and, by lining the inner 
surface of the latter for some distance on either side, to prevent the plaster 
from pressing upon and adhering to the malleoli. Thus prepared, the appa- 
ratus presents a stirrup-like appearance. (Fig. 800.) Three additional strips 
of plaster are next required, two inches wide, and sufficiently long to encircle 
the limb,—one above the ankle, one immediately above the calf of the leg, and 
the third a short distance above the knee. A cord should be then attached 
Fig. 797. 
Fig. 798. 
Uprights for pulley. 
Fig. 800. 
Fig. 799. 
Form of the short strip for fastening the foot-board 
to the long extending band. 
Extension apparatus ready to be applied. 
to the foot-board, through a hole in its centre, or a piece of a roller may be 
tied around the stirrup, to either of which the extending weight can be tied. 
Bags for lateral support are also to be provided. Two of these are required, 
—one to extend from the foot to the perineum, the other from the foot to the 
axilla. These may be quickly prepared by taking strong twilled muslin, about 
fourteen inches wide, sewing it upon the sides and at one end, so as to make a 
long narrow bag, then turning it so as to have the seams inside, and, after 
filling it with dry sand, either to sew or tie the unclosed extremity. These 
bags must not be filled too tightly, otherwise it will be impossible to shift 
their contents so as to make them conform to the outline of the limb. One 
or two rollers, two and a half inches wide and eight yards long, with two or 
three bricks, being provided, the appareil may be considered complete. 994 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Application of the dressing.—The patient being placed upon the bed, the hair 
should be removed from the limb, and the skin thoroughly cleansed with soap 
and water, and well dried, so as to secure the adhesion of the plasters. The 
extension-bands are next warmed by passing the back of the strips over a 
tin vessel containing hot water, or over a flat-iron or a stove-pipe, or by 
holding them before an open fire, and are then immediately placed along the 
outer and inner surfaces of the leg and thigh, taking care that they cover 
exactly corresponding portions of the limb, so that the stirrup will draw 
equally on the two sides. Next take the circular strips and pass them about 
the leg and thigh, as shown in Fig. 801. The surgeon has now reached a 
stage in the dressing when the 
fracture is to be carefully ad- 
justed by extension, counter- 
extension, and manipulation. 
If the patient complains of se- 
vere pain, or if much muscu- 
lar resistance is encountered, 
it will be best to administer 
an anesthetic, after which an 
assistant, grasping the ankle, 
should bring the limb down 
to its proper length. The extension being now kept up, the surgeon pro- 
ceeds to apply a roller, with firmness, from the ankle to the groin. This 
should never be neglected. If done properly, the muscles remain quiet 
under its pressure, and spasms, with displacement, seldom occur. The cord 
from the stirrup is next to be tied about the upright post, the lower end of 
the bed being raised four or five inches by placing blocks beneath its feet, and 
the sand-bags laid along the inner and outer sides of the limb. After the 
lapse of six or eight hours, the extending weight may be attached; if done 
sooner than this, the plasters will certainly slip. To make this attachment, 
bring the ends of the muslin strip or the cord which is fastened to the stir- 
rup over the pulley, and to its end attach the requisite weight. (Fig. 802.) 
This may consist of a bag of shot, a smoothing-iron, scale-weights supported 
in an iron frame, or a bag containing stones or bricks; it is immaterial what. 
Fig. 801. 
Extension apparatus applied to the limb. 
Fig. 802. 
a, Dressing for fracture of the shaft of the femur, complete. 6, Sand-bags applied. 
I usually find the bricks most accessible: they can be wrapped in paper and 
tied together with a strip of muslin. The amount of weight which will be 
necessary in an adult will be two or three bricks, or about ten or fifteen 
pounds. It has been my practice to begin with two bricks, or ten pounds, 
and after two or three days to add a third, or even more, until the measure- 
ments of the two limbs correspond. This comparison should be made daily FRACTURES OF THE SHAFT OF THE FEMUR. 
995 
until the proper length is obtained. To make our mensuration trustworthy, 
the patient must be on the back, with the body inclined neither to the right 
nor to the left, with the crests of the ilia on the same level, and with the 
muscles of the limb entirely quiescent. The tape used should be the metallic 
one, and the points between which these measurements should be made are 
the anterior superior spinous processes of the ilia, the tuberosities of the 
pubic bones, and the umbilicus above, and the lower extremities of the inner 
malleoli below. By measuring consecutively from these three stand-points, 
a very accurate result may be obtained. 
The weight which to-day fails to bring the limb to its proper length may 
have the desired effect to-morrow. The muscles may for a time resolutely 
hold out, but the steady, uninterrupted pull, night and day, will finally gain 
the victory, not by violence, but rather by gentle constraint. The angle at 
which the extending cord runs from the stirrup to the pulley should be 
graduated so as to allow the heel barely to touch the bed, or even so as to 
clear it entirety. It is seldom necessary to renew the adhesive plasters more 
than once ; and very frequently I have found the first application answer for 
the entire period of treatment. The roller is liable to become displaced after 
eight or ten days, and should be replaced or tightened, at which time the 
extension must be kept up by the hands of an assistant, who at the same 
time will raise the leg sufficiently high to allow the roller to pass readily. 
During the time of treatment, which usually occupies from seven to eight 
weeks, the patient must not be allowed to raise his body up in bed. nor 
should more than a single pillow be placed under his head. After the lapse 
of four or five weeks, if the union progresses favorably, the weight attached 
to the foot may be lessened. At the expiration of seven or eight weeks, the 
patient may be allowed to rise from his bed and move about with crutches, 
but he must not rest the weight of the body upon the limb to any extent for 
at least three or four weeks longer. The urine must be passed in a urinal, 
bottle, or cup, and the diet, except perhaps during the first two or three days, 
need not be different from that used in health. The mode of changing the 
sheets and linen has been described on page 812, and need not be detailed in 
this place. 
Dr. Levis has devised, as a substitute for adhesive plasters whereby to 
Fig. 803. 
Levis’s extending apparatus, both applied to and detached from the limb. 
attach the extending weight, an apparatus consisting of leather cut to fit 
the lower part of the thigh and the leg, and fastened to the limb by buckles. 
(Fig. 803.) Though very ingenious, it fulfils only imperfectly the work of 
an extending appliance. 
The dressing by adhesive plaster, sand-bags, and an extending weight 996 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
reduces the treatment of most fractures of the thigh to the simplest form, 
—indeed, so nearly approaches perfeofion that little else can be desired,— 
and is equally well adapted to cases in which both thighs are broken. 
When the fracture is a short distance below the trochanters, or in some 
part of the upper third of the bone, a difficulty may be experienced in con- 
sequence of the anterior projection of the short upper fragment. In such a 
case the thigh must be first Hexed on the pelvis, and then extension applied, 
during which a concave anterior splint is to be placed upon the front of the 
thigh and bound firmly with a roller. The limb should now be brought 
quietly into the straight position, and, if the deformity is corrected, the usual 
dressing for fractures of the shaft may be prepared and applied. If the dis- 
placement cannot be thus corrected, there remain but two methods for our 
adoption,—either the double inclined plane or the wire anterior splint of 
Nathan R. Smith. Very little extension can be made by either mechanism, 
and considerable shortening must be expected. If the double inclined plane 
be selected, a soft cushion or pillow must be interposed between the limb and 
the splint, and a piece of binders’ board moulded to the front of the thigh. 
Fig. 804. 
A fracture at the upper third of the femur dressed on a double inclined plane.—Smith. 
A few turns of a roller applied some distance above the knee, and also above 
the ankle, will serve to secure the limb to the splint. (Fig. 804.) Another 
apparatus used for the same purpose is that of McIntyre (Fig. 805), which 
can be adjusted to any angle by means of a posterior screw. In applying this 
apparatus, the thigh and leg 
piece must be well padded 
or covered with a cushion, 
and set at an angle of about 
thirty-five degrees. The 
limb being now placed upon 
the splint and the foot made 
fast to the foot-board by 
means of a bandage, the 
screw should be turned until 
the inclination at the knee 
is considerably increased, by 
which the extension is augmented : the weight of the body acts as the counter- 
extending force. (Fig. 806.) 
The anterior splint of Professor N. R. Smith consists of two parallel rods 
of wire about the thickness of an ordinary quill, turned up at each end, so 
as to correspond to the direction of the foot and to the surface of the abdo- 
men. At the middle, the splint is bent at a slight angle, and its sides are 
kept from separating by two or three cross-strips. (Fig. 807.) In the applica- 
tion of this splint, a double inclined plane of pillows must be first constructed 
Fig. 805. 
McIntyre’s splint. FRACTURES OF THE SHAFT OF THE FEMUR. 
997 
on the bed, and across it are to be laid strips of muslin, two and a half or three 
inches wide and twelve or fourteen inches long. These strips require to be 
three inches apart, and to increase in length as they ascend the limb. Upon 
those strips which correspond to the thigh should be laid a light board splint, 
Fig. 806. 
The McIntyre splint applied, as modified by Liston. 
three inches wide and about nine inches long, well padded. Let the limb 
of the patient be now placed on this part of the dressing and the wire splint 
be bent so as to conform to such an angle of the limb as will be required 
to effect the adjustment of the fragments; for in the case presumed to be 
now under treatment the lower fragment must be brought forward to the 
displaced upper one. The next stage of the dressing is to bring the muslin 
Fig. 807. 
Professor N. B. Smith’s anterior wire splint. 
strips up along the sides of the limb, and, turning their ends around the 
wire, pin each end to its own side. They should be secured sufficiently 
loose to allow the splint to be raised a very little from the surface of the 
limb. The apparatus being now suspended by the cord running obliquely for- 
ward, and the limb being raised clear of the bed, additional security should 
be given to the dressing by a roller carried around the splint and limb, 
from the foot to the pelvis, and terminating by making a spica of the groin. 
(Fig. 808.) Dr. Hodgden, of St. Louis, uses occasionally a similar splint 
having a cotton sacking loosely extended between the bars, upon which the 
limb is supported. The suspension can be effected from a hook and pulley 
fixed in the ceiling of the room, or from a cross-bar over the bed, with a 
pulley attached. The apparatus is not to be recommended, however. 
An arrangement for this purpose, very familiar to Philadelphia surgeons, 
is a gallows which rests upon the sides of the bed, and admirably answers 
the end in view. This arrangement is figured under the head of “ Fractures 
of the Leg.” 
In the fall of 1870 I treated a very perplexing case of fracture at the 
upper third of the femur, in a gentleman of this city, by a combination of 
the inclined plane and extension by adhesive straps, which resulted so favor- 
ably that I regard the plan as preferable to all others. In several points it INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
is not unlike that of Dr. Palmer, of the United States Navy. The apparatus 
which I employ consists of a double inclined plane, with hinged sides at- 
tached to the thigh-piece. Upon this the limb is deposited, a pillow being in- 
terposed between the thigh and the splint, and a soft pad placed beneath the 
Fig. 808. 
Limb suspended by the anterior splint of N. R. Smith for fracture at the upper third of the thigh. The 
suspending cord should be fixed to a point some distance above the foot. 
leg. An adhesive strip is next attached to the sides of the thigh, extending up 
as far as the upper end of the lower fragment, and with a loop below, into 
which is to be fastened a piece of light wood, as in the ordinary fracture 
dressing already described. To this piece of wood a cord is attached, which 
is to be carried over a pulley set in an upright that is screwed to the foot of 
the bed. To this cord the extending weights are to be attached. Lateral 
pressure is applied to the thigh by bringing up the sides of the femoral part 
of the plane and securing them by strips of muslin while the leg is retained 
in position by the turns of a roller. (Fig. 809.) 
Fig. 809. 
Apparatus applied for fracture at the upper third of the thigh; the sides of the splint being down in 
order to show the attachment of the adhesive plaster. 
Treatment of fractures of the thigh by the immovable dressing.—This old 
method was first introduced for the treatment of fractures by Abugerig, an 
Arabian physician, and has been advocated at different periods down to the 
present time. It received the sanction of Seutin, Velpeau, Larrey, and others. 
It has been a favorite dressing for fractures of the thigh at the Bellevue Hos- 
pital, Hew York, plaster of Paris being the material used to give immobility 
to the enveloping bands. It is ajjplied as follows: FRACTURES OF THE CONDYLES OF THE FEMUR. 
999 
On a mattress, raised one foot from a table, and reaching within two feet 
of its lower end, the patient is placed. An upright (Fig. 810) is screwed 
against the lower corner of the table, and surrounded with 
a soft wrapping to protect the perineum from pressure. 
The patient is brought down, with one limb on either side 
of the stanchion, so that the nates project beyond the mat- 
tress, where they are supported by a sling, which is made 
fast to a piece of timber running back horizontally from the 
upright. (Fig. 811.) The patient being now etherized, a 
pulley is attached to the foot and ankle and the leg drawn 
to its proper length. The extension must be in a line with 
the axis of the body. The rollers, filled with plaster in the 
Fig. 810 
Fig. 811. 
Upright or stanchion. 
Making extension for the plaster dressing.—After Hamilton. 
manner described under the head of fracture dressings, are next applied to the 
limb and the pelvis, both previously covered with a thin woollen cloth. Four 
or five of these in succession, with pieces of flannel filled with plaster inter- 
posed here and there, serve to supply the necessary resistance. The exten- 
sion is maintained for fifteen or twenty minutes after the dressing is applied, 
or, in other words, until the plaster is firmly set, when the patient is placed in 
bed. On the second or third day he is permitted to move about on crutches. 
Generally the dressing is applied to the foot and leg one or two hours before 
the etherization and reduction, so that the extension may be applied over the 
bandage after it has fully hardened. It is claimed for this mode of treatment 
that a cure is accomplished with little if any shortening, and that the patient 
is not confined to his bed after the first two or three Where patients 
can be kept under constant supervision, I have no doubt very satisfactory 
results may be obtained. It cannot be denied, however, that there are cer- 
tain objections against the plan which are entitled to serious considei-ation. 
First, the limb is entirely concealed from inspection, and the surgeon con- 
sequently is unable to determine the state of the parts; secondly, the dress- 
ing may become so tight from subsequent swelling as to produce gangrene ; 
thirdly, the limb may, after the subsidence of the swelling, lie so loose in its 
shell that, from the want of proper support, the bone may fail to unite. If 
such accidents occur, as they have occurred even in the hands of those 
familiar with the application of the plaster appareil, it would be obviously 
improper to inculcate the general application of this dressing. 
Fractures near to and at the Condyles of the Femur. 
The grave character of these injuries is due to their proximity to a large 
joint. These fractures may run across the base of the condyles, separating 
them from the shaft; they may pass through one condyle, separating it from 1000 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
its fellow, or only detaching a portion of its mass ; they may run between 
the condyles, either vertically or obliquely, and be conjoined with a fracture 
through the lower third of the shaft; or there may be a separation of the 
epiphysis of the condyles. 
Fractures through the Base of the Condyles.—These may follow force ap- 
plied either directly or indirectly. The line of fracture is commonly oblique, 
running downward and forward. (Fig. 812.) With few exceptions, the 
upper fragment will be found in front of the lower; sometimes it is lodged 
between the condyles and the patella. (Fig. 813.) It has been known to 
Fig. 812. 
Fig. 813. 
Fig. 814. 
Oblique fracture immediately above the 
condyles of the femur.—Malgaigne. 
Upper fragment in front of 
the condyles of the femur. 
Impacted fracture above the 
condyles of the femur. 
pierce the quadriceps muscle, and even to tear the capsule of the joint. In 
some instances it has been driven into the cancellated tissue of the condyles, 
constituting an impacted fracture. (Fig. 814.) 
Again, the upper fragment may pass behind the lower one ; though this 
is a very rare occurrence. Hamilton has seen two cases, and in the Marsh 
collection of pathological bones at Albany is a specimen illustrating a similar 
disposition of the broken ends. The blood-vessels of the popliteal region are, 
under such circumstances, exposed to damage from pressure. This has been 
noted by Amesbury, Lonsdale, and others ; and it is quite probable that the 
sloughing of the foot which followed a case of fracture at the lower end of 
the femur, under the care of a surgeon at Lockport, New York,* and which 
resulted in a suit for damages, was due to such pressure. 
The swelling which rapidly supervenes after an injury of this kind may 
mask the true nature of the case for a time, but by making firm and con- 
tinuous lateral pressure for several minutes the extravasation may be dis- 
placed, and the condyles at last reached, when their mobility on pressure, 
without affecting the shaft of the bone above, will sufficiently declare the 
nature of the case. Should the joint be involved, the injury is liable to be 
followed by an acute synovitis, terminating in anchylosis, or in a destructive 
suppuration, from which the patient may at last die. Even when the articu- 
lation has received no damage, the inflammation around may gradually creep 
into the joint, leaving it chronically enlarged and with more or less stiffness. 
The reduction is best effected by flexing the leg upon the thigh, at the 
same time making extension with the forearm in the popliteal space, as in 
certain fractures of the lower third of the femur, to which allusion has 
* Hamilton on Fractures, p. 388. FRACTURES OF THE CONDYLES OF THE FEMUR. 
1001 
already been made. It is important in all attempts to effect reposition of 
the fragments that no careless or aimless movements be practised, lest the 
joint receive injury at the hands of the surgeon. When the adjustment has 
been accomplished, should the direction of the fracture be not too oblique, 
there will be little tendency to a renewal of the displacement, as the volu- 
minous dimensions of the bone at this point offer broad surfaces for the 
support of the fragments. 
Treatment.—After adjustment, the limb should be placed in the extended 
position and the same dressing applied as for fractures in the middle third 
of the shaft,—namely, adhesive strips, weights, and sand-bags. The strips 
must not extend above the knee. The ham should be supported by intro- 
ducing between the knee and the bed a compress of soft flannel. Special 
care must be observed to keep the sand-bags in close contact with the limb, 
in order to prevent lateral movement. 
Fractures of one Condyle.—Fracture of one condyle (Fig. 815) is much 
more rare than that of both, although neither can be considered common. 
Malgaigne has seen but three cases. Packard has collected 
seven additional ones.* These, with one seen by Sir Astley 
Cooper, one recorded by M. P. Boyer, one in the Dupuy- 
tren Museum, one by Dr. Lewis Riggs, reported to Ham- 
ilton,! and one in my own cabinet, making in all fifteen 
cases, constitute all the fractures of this kind known to 
me. A curious feature connected with one of these cases, 
that of Dr. Crosby,J was the failure of the fragment to 
unite, and its removal six months afterwards, through an 
incision made lor that purpose. The operation was followed 
by a complete recovery. 
Fig. 815. 
Fractures of both Condyles.—In this injury the lines of 
fracture run both vertically and transversely,—the former 
between the condyles, and the latter separating them from 
the shaft of the bone. Professor Gross had in his cabinet a 
unique specimen, in which both condyles were broken off, 
leaving the trochlear surface connected with the shaft. Several specimens 
of fracture of both condyles are in the Gibson collection, now in possession 
of the United States Government. There is a specimen of this injury in the 
museum of the University of Pennsylvania, and one in my own collection. 
Causes.—These fractures are produced most commonly by direct force, as 
by a fall upon the knee, or by the articulation being caught between the 
buffers of cars. 
Professor Yolkmann, of Halle, describes another injury sustained by the 
condyles of the femur,—that of having a portion of the articular cartilage 
with a scale of the subjacent bone torn off. The accident is said to occur 
from a fall on the knee during flexion of the limb. In the case of Professor 
Yolkmann,§ the detached piece was extracted from the joint after the manner 
of removing false cartilages, the limb was placed in a plaster dressing, and 
the recovery was complete. 
Mr. Teale, surgeon to the Leeds General Infirmary, describes a similar 
case, produced by a cask slipping against the knee of a laborer. The removal 
of the piece was followed by phlegmonous erysipelas and death.|| 
Brodhurst has met with several cases.1f It is very probable that the de- 
tachment does not always occur immediately on the reception of the injury, 
but subsequently, by exfoliation. 
When diastasis of the epiphysis takes place, the separation is not always 
Fracture of the external 
condyle. 
* Malgaigne on Fractures, Packard’s trans., p. 593. 
J New Hampshire Journal of Medicine, 1857. 
|| Medico-Chirurgical Transactions, vol. xxxix. p. 31. 
St. George’s Hospital Reports, vol. xi. p. 141. 
f Hamilton on Fractures, etc., p. 429. 
§ Deutsche Klinik, 1867, p. 448. 1002 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
confined to the underlying cartilage, but may extend into the diaphysis, as 
was shown in Dr. Little’s case. 
Treatment.—The patient being etherized, the limb should be flexed and 
the displaced bone forced by pressure and counter-pressure into position, 
after which the limb may be placed either over a double inclined plane or in 
a long, straight fracture-box. 
History of the Treatment of Fractures of the Thigh.—The simplicity of 
our present methods for the treatment of fractures of the thigh conveys 
a very imperfect idea of the time and ingenuity expended and the multi- 
form mechanisms which have been invented and modified in reaching our 
present state of knowledge. A rapid review of the subject, in a general 
way, will not be without interest to the student who desires to follow the 
progress of medical thought. Two positions—the extended and the semi- 
flexed—have each had their advocates at different periods. The first, or 
extended one, is the most ancient, dating back to Hippocrates, and the one 
at present adopted by the great majority of surgeons in America and Great 
Britain, and on the Continent. The semi-flexed or physiological position 
was introduced by Pott, the patient being at the same time placed on the 
side. With certain modifications, the plan of this distinguished surgeon was 
Fig. 816. 
Double inclined plane of Bell, properly James's. 
adopted in Great Britain by Sir Astley Cooper, the two Bells, Earle, Ames- 
bury, and others. The j>osition was changed to the back instead of the 
side, and the semi-flexion 
maintained by a double in- 
clined plane, first used by 
White, of Manchester, and 
afterwards modified by 
James, Bell, Amesbury, and 
McIntyre, such as are seen 
in Figs. 816, 817, 818. On 
the Continent, Dupuytren 
became its champion, and 
the influence of his great name secured for it the favorable opinion of many 
of his professional countrymen. Desault and Boyer, however, resolutely 
Fig. 817. 
Amesbury’s double inclined plane splint. 
Fig. 818. 
Amesbury’s splint applied. 
planted themselves against this formidable array of professional power, and 
eventually brought about a careful reconsideration of the subject, and, as a FRACTURES OF THE FEMUR. 
consequence, such a reaction that at present few surgeons of any prominence 
can be found, either in America or abroad, who advocate the semi-flexed 
position, except in certain fractures in the upper third of the shaft, where 
it often becomes imperative. 
The objections to the semi-flexed position are the following. 1. It only 
removes muscular resistance on one aspect of the limb: for example, when 
applied to the thigh, the hamstring muscles alone are relaxed, whilst the 
individual muscles forming the quadriceps are made tense, and these, from 
their great power, are the chief displacing agents. 2. The inherent tendency 
in a muscle to shorten when relaxed, only shows that after a time this state 
of relaxation is changed to one of tension, which will then contribute to the 
overlapping. How quickly the biceps flexor cubiti becomes shortened when 
the forearm is flexed for a short time at a right angle with the arm! 
By the plan of extension, however, not only are the resistance and spasm 
of the muscles overcome by the action of a constant force, but the muscles 
themselves are lengthened by a modified nutrition, so that both longitudinal 
and angular deformity are reduced to their least possible quantities. To make 
effective the principles of extension and its equivalent counter-extension, 
numerous plans have been attempted. As far back as Avicenna, and in later 
times by Petit and Heister, these indications were carried out by bands ex- 
tending from the upper part of the thigh to the head of the bed, and from 
the ankle to the foot of the bed. To avoid the inconveniences of pressure, 
Petit fastened one of his extending bands above the knee and the other to the 
ankle, thus alternating the traction. Others employed the cord and weight 
running over a pulley at the foot of the bed; but this was abandoned 
because the body was drawn down by the extending force. The methods 
of Desault, of Boyer, and of Liston were next introduced. In each of these, 
extension and counter-extension were made by a long external splint ex- 
tending from the crest of the ilium to a point four inches below the 
foot. A soft leather band, well stuffed, was passed about the perineum and 
made fast to the upper end of the splint, by which counter-extension was 
made. An extending band was placed about the ankle and foot, and secured 
to the lower part of the splint, whereby extension was effected, and by 
means of cushions or junk-bags interposed between the limb and the splint 
the parts were protected from undue pressure. The points of difference 
1003 
Fig. 819. 
Liston’s splint and junk-bag. 
between these three mechanisms were as follows. In Liston’s, the foot 
was secured to the processes (Fig. 819) at the lower end of the splint by 
Fig. 820. 
Liston’s splint for fracture of the thigh applied. 
a roller passing from one to the other, and then junk-bag, splint, and thigh 
were all bound together by continuing the roller up the limb. (Fig. 820.) 1004 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
In Boyer’s apparatus, the long splint had a foot-board, which was moved up 
and down by means of a screw, for the purpose of making extension, an 
inside splint extending from the perineum to the foot, and an anterior one 
reaching from the groin to the ankle: the inner and outer splints were en- 
veloped in a splint-cloth. Counter-extension was made by a padded leather 
band passing through the perineum and buckled into the upper end of the 
outer splint, while extension was accomplished by a gaiter attached to the 
ankle and instep. Cushions were placed between the splints and the limb, 
and both were secured together by tapes passing round the extremity. (Fig. 
821.) Desault’s apparatus differed from both: from Liston’s, in having an 
Fig. 821 
Boyer’s splint for fracture of the thigh applied. 
inside splint and in using tapes instead of a roller to secure the dressing; and 
from Boyer’s, in having no movable foot-board. It consisted of an outside 
splint, long enough to extend from the crest of the ilium to a point four inches 
below the foot; and of a second, reaching from the perineum to the sole- of 
the foot. A hole was made in the upper and one in the lower end of the long 
splint, the first for the counter-extending and the second for the extending 
band. A third splint was placed over the anterior surface of the thigh, which, 
together with junk-bags and the Scultetus bandage, completed the apparatus. 
Fig. 822. 
Application of the Scultetus bandage previous to applying the splints after the Desault method. 
The defect of this appliance (Figs. 822, 823) consists in the direction in which 
both the counter-extending and extending forces operate, which favors a lat- 
eral displacement of the fracture. The excoriation and ulceration which were 
Fig. 828 
Desault's apparatus for fracture of the thigh applied. Counter-extending band not shown. 
often produced by the extending and counter-extending bands constituted 
another serious objection. Commanding as this apparatus did for so long a FRACTURES OF THE FEMUR. 
1005 
time the confidence of the profession, and being still used in many localities 
through the country, it will not be amiss to give a brief notice of the changes 
which it has undergone. As it came from the hand of its author, it was an 
imperfect apparatus. Physick, in order to secure counter-extension more in 
the line of the body, and to prevent lateral inclination of the pelvis, neither 
of which was secured by the Boyer dressing, had the outer splint carried up 
to the axilla; while Hutchinson, that the extension might be made in the long 
axis of the limb, devised the block which is now nailed a short distance above 
the lower end of the long splint. (Fig. 824.) As thus modified, the dressing 
Fig. 824. 
Hutchinson’s modification of Physick’s splint. 
is applied in the following manner. The bed being prepared, several pieces 
of bandage or strong tapes are laid down ; over these is to be spread the 
splint-cloth,—namely, a piece of unbleached muslin one yard wide, and long- 
enough to extend from the perineum to the foot. To the foot and ankle is 
next attached the gaiter for the extending bands, and through the perineum 
is passed a well-stuffed counter-extending band. The splints are now rolled 
in the splint-cloth almost to the outer and inner surfaces of the limb, leaving 
barely sufficient room for the interposition of the junk-bags ; after which the 
perineal band must be fastened into the hole at the upper end of the long 
splint, and the extending bands carried round the block below. The limb 
being then extended to the proper length, the lower band is carried through 
the opening at the lower end of the splint and secured by a knot. Finally, 
the strips of bandage are to be tied securely around the splints and the limb, 
holding both firmly together, and to sustain the weight of the bedclothes a 
cradle or hoop should be placed across the leg and foot. (Fig. 825.) 
Fig. 825. 
Physick’s and Hutchinson’s modification of Desault’s splint applied. 
Dr. H. Lenox Hodge, in order to dispense altogether with the perineal 
counter-extending band, and to prevent the patient from rising or sitting 
up during the treatment, at- 
tached to the long splint a piece 
of iron which extends over the 
front of the patient’s shoulder and 
terminates in a blunt hook. (Fig. 
826.) The counter-extension is 
made by a broad piece of adhesive 
plaster placed on the front and 
back of the chest, and secured by 
strips carried around the body, the loop of the longitudinal strip being at- 
tached to the hook at the end of the metal bar. (Fig. 827.) 
Yarious other methods have been devised to effect counter-extension. Thus, 
Fig. 826. 
Hodge’s attachment to the long splint. 1006 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
we have Dr. Joseph’s Hartshorne’s splint (Figs. 828, 829), in which counter-ex- 
tension is made against the perineum at the upper end of the inside splint, and 
extension by a movable foot- 
board worked by a screw. By 
this arrangement the outer 
splint can be detached from 
the inner one without dis- 
turbing either the extend- 
ing or the counter-extending 
force. 
Brunninghausen made the 
broken thigh fast to the sound 
one, forgetting that the con- 
trol of the lateral movements 
of the pelvis was as neces- 
sary as to fix the thigh. 
Ilagedorn’s apparatus— 
which consisted of two splints 
adjusted to the outside of the 
thighs, with a movable foot-board to which both feet were secured—was open 
to the same objection as was the arrangement of Brunninghausen. This defect 
Fig. 827. 
Hodge’s splint applied. 
Fig. 828. 
Hartshorne’s splint. 
was measurably obviated by Gibson’s modification, by which the splints were 
carried up to the axilke. 
Fig. 829. 
Hartshorne’s splint applied. 
Professor William E. Ilorner used a modification of Desault’s splint. The 
long and short splints were padded, in order to dispense with the junk- 
bags ; a strip of leather was stretched across the upper end of the inside 
splint, and on the outer surface, near its upper extremity, two strong 
leather loops were nailed for the passage of the counter-extending band 
(Fig. 830), the ends of the latter being tied to the upper extremity of the 
long splint. Both splints, by this arrangement, were employed in making 
counter-extension. (Fig. 831.) Extension was accomplished by adhesive 
strips. 
Professor John Neill, by attaching a double cord to the extending and 
counter-extending bands, and bringing the ends over the upper and lower 
extremities of the outside splint, made extension and counter-extension at 
the same moment by twisting the rope after the manner of the Spanish 
windlass. FRACTURES OF THE FEMUR. 
1007 
The late Professor Gross used for many years a long fracture-box, with a 
fenestrated foot-piece and two crutches, one for the axilla and one for the 
Fig. 830. 
Horner’s modification of Physick’s and Desault’s splint. 
perineum. Many others might be enumerated, such as Gilbert’s, San- 
born’s, Hodgden’s, Flagg’s, Lente’s, Burge’s, Dugas’s, etc.; but it would be an 
Fig. 831. 
Horner's dressing for fracture of the thigh applied. 
unprofitable task to disentomb these surgical relies of a past period. They 
have all done good service in their time ; they furnish indisputable evidence 
of unwearied labor and thought, wrought out for the benefit of humanity. 
It will be apparent to even a superficial observer that all the methods which 
have been described for the treatment of a fractured femur in the extended 
position are open to the very grave objection either of failing to correct over- 
lapping of the fragments or of having a strong tendency to produce excoria- 
tions, ulcerations, and even sloughing of the soft tissues over the perineum 
and about the ankle, the parts where the counter-extending and extending 
bands must act. 
To obviate these serious inconveniences was unquestionably the great 
desideratum in the treatment of fractures of the thigh ; and this has been 
satisfactorily accomplished through the ingenuity of American surgeons. 
The first of these improvements consists in connecting to the limb the 
extending weight or power by means of adhesive plaster. 
Adhesive plaster was probably first used as a means of making extension 
in the treatment of fractures by Dr. Joseph Swift, of Easton, Pennsylvania, 
and the attention of the profession was invited to it by Professor Gross as 
early as 1830. 
In 1843, I)r. E. Wallace, then a resident physician in the Pennsylvania 
Hospital, at the suggestion of Dr. Ennis, of Easton, employed this dressing, 1008 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
with entire success, in a very troublesome case of fracture of the femur.* 
Dr. Ennis stated that his knowledge of this plan of applying extension was 
derived from a fellow-townsman,—Dr. Swift. 
Dr. David Gilbert was also at a very early period in the habit of using 
this material for the same purpose. The credit of originating this method 
of extension has likewise been ascribed to Dr. Crosby, of Manchester, Ver- 
mont. About the year 1852, Dr. Buck, of Hew York, introduced this plan of 
treating fractures of the thigh into the Hew York Hospital (Fig. 832), and 
Fig. 832. 
Dr. Gurdon Buck’s dressing applied. 
through the influence of this distinguished gentleman the adhesive plaster 
dressing soon acquired a very general popularity with the profession. 
The pulley and weight by which the extension is applied to a broken limb 
cannot, however, be considered as a modern discovery. Hamilton says that 
Howe, of Boston, as early as 1824 recommended the use of such appliances; 
and this, if correct, would antedate the claim for priority in this matter 
made for Mr. Janney, of Exeter, England. Similar mechanical measures 
were employed by Daniel,f and by Dugas, of Boyer speaks of the 
weight and pulley being a very ancient contrivance, and a similar statement 
is made by Malgaigne,§ who says that both were known ro Guy de Chauliac 
and to Seutin. 
The addition of an elastic substance, like india-rubber, for the purpose of 
extension and as an accumulator of power, is also an American improvement, 
having originated in 1856 with Dr. Davis, from whom Dr. Buck states that he 
The second great im- 
provement consisted in 
dispensing with the coun- 
ter-extending bands. Pro- 
fessor Gibson introduced 
a plan of treating frac- 
tures of the thigh upon a 
single inclined plane, by 
which the perineal bands 
were rendered unneces- 
sary (Fig. 833); but a 
more simple method is 
that now generally prac- 
tised, of raising the foot 
of the bed, by which the 
weight of the patient’s body becomes the opposing force to the extension. 
This device was first suggested by Dr. Van Ingen, of Schenectady.|| 
Pig. 833. 
Gibson’s single inclined plane for fractured thigh. 
* Pennsylvania Hospital Reports, Dr. Hunt’s paper, 1869. 
f American Journal of the Medical Sciences, 1829, vol.iv. p. 330. 
j Southern Medical and Surgical Journal, February, 1854. 
| Treatise on Fractures, Packard’s trans., p. 197. 
jj Transactions of the American Medical Association, vol. x. p. 436, New York, 1857 ; Van Buren, 
New York Medical Record, March 30, 1878. FRACTURES OF THE FEMUR IN CHILDREN. 
1009 
The last improvement consisted in abandoning the old plan of supplying 
lateral pressure by the long and short splints, and substituting for this 
purpose bags filled with sand. The practice originated with an American 
army surgeon, and wTas introduced into the Pennsylvania Hospital by Dr. 
Hunt in 1863, and about the same time was commenced in the JYew York 
Hospital. 
Fractures of the Femur in Children. 
It is proper that some distinct notice should be given to the treatment of 
fractures which occur in the femora of children under ten years of age. In 
children over that age I have usually employed the same apparatus as that 
used for similar accidents in the adult, namely, the adhesive strips, the pulley, 
the weight, and the sand-bags. I have met with this fracture in an infant 
of four weeks, in whom it was produced by a nurse falling from the step of a 
carriage and at the same time pressing the child closely to her breast in 
order to defend it from injury. 
The frequency of these fractures is quite remarkable. Of 885 fractures 
of the thigh treated in the Pennsylvania Hospital, 152 were in children under 
ten years of age. Of 140 recorded at the Hopital Sainte-Eugenie in a single 
year, 26 occurred in the femora of children.* 
The injury is limited to the shaft or to the epiphysis. These fractures, 
when properly treated, are rarely followed by any appreciable shortening, 
and heal in nearly one-half the time required for the cure of a like lesion 
in an adult. There are several reasons for the absence of deformity. First, 
these fractures are often incomplete, many of the fibres of the bone main- 
taining their continuity in consequence of the elastic nature of their struc- 
ture ; secondly, the line of fracture is generally more transverse than in 
adults, so that when once the fragments are adjusted there is little tendency 
to displacement; thirdly, the muscles at this age are not capable of exercising 
much power, and hence the employment <5f any great amount of extending 
and counter-extending forces becomes unnecessary. 
Treatment.—The materials requisite for the dressing are a straight splint, 
well padded and sufficiently long to extend from near the axilla to two inches 
below the foot, two plaster rollers, two plain rollers, and a little cotton. 
In order to avoid all struggling, muscular resistance, and pain, an an- 
aesthetic should be first administered to the child. The limb is then to be 
drawn down to its proper length, the fragments adjusted, and the extremity 
covered in with one of the plain rollers, terminating with a spica of the 
groin. Placing a little cotton at the external surface of the ankle, the knee, 
and the crest of the ilium, the long splint is next to be laid along the outer 
side of the body and the limb, and bound in position by the plaster rollers, 
commencing at the foot and ending with a spica of the groin. During the 
application of the rollers, and until they become set, extension must be kept 
up. The dressing is completed by securing the upper part of the splint to 
the trunk with the remaining plain roller,—a very important feature of the 
apparatus, as by so doing the little patient is rendered incapable of sitting 
up. (Fig. 834.) If plaster cannot be obtained, the silicate of soda, or even 
starch, may be used to give resistance to the rollers. 
When the silicate of soda is used, three or four strips of pasteboard covered 
with the liquid should be laid about the seat of fracture, and a third roller 
applied to the entire limb, receiving in turn its due portion of the liquid 
glass. The lower end of the bed should now be raised, and the foot made 
fast to the foot-board below until the dressing becomes firm, which will 
require usually from twelve to fourteen hours. The impenetrable nature 
of the silicate will render the rollers impervious to the discharges of the 
patient, and when soiled they can be washed without affecting the per- 
manency of the dressing. I have never known this dressing to become too 
® Holmes’s System of Surgery,—Surgical Treatment of Children’s Diseases, p. 254. 1010 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
tight in consequence of the swelling; but the possibility of such an occurrence 
should never be overlooked. 
In the event of the bandages becoming too loose, they should be removed 
Fig. 834 
Dressing for fracture of the thigh in a child applied. 
and replaced by others. A folded sheet or a soft towel must be placed under 
the nates, to receive the passages from the bowels, and the child, if old enough 
to comprehend the instructions of the nurse, should be taught to pass the 
urine into a cup or a bottle. A patient and watchful nurse can, with a little 
care, soon teach even a very young child to communicate its desires on these 
points, and thus to co-operate with the attendant in preserving a clean and 
orderly bed. 
Fracture through the Lower Epiphysis of the Femur.—This fracture (Figs. 
835, 836) is rarely met with. Hamilton has collected five cases, the oldest 
patient being fourteen, and the youngest—that men- 
tioned by Madame Lachapelle—being a new-born child, 
the fracture having been caused by the foot being for- 
cibly pulled upon at the time of delivery. The line of 
fracture usually leaves the cartilaginous conjunction and 
passes through a part of the bone. Such was the case 
in Dr. Little’s specimen,* and also 
in the four specimens of this in- 
jury in the museum of St. George’s 
Hospital .f 
The symptoms of this accident 
are the same as those which follow 
a fracture at the base of the con- 
dyles. 
Treatment.—The limb should 
be placed in the extended position, 
and the ham well supported by a 
compress of oakum, and covered 
with an immovable dressing of 
either the silicate of soda or the 
plaster roller. Should the position prove incompatible with a proper adjust- 
ment of the fragments, it may be changed to a semi-flexed one. The latter 
posture of the limb is that recommended by Holmes. 
Fig. 835. 
Fig. 836. 
Fracture of the epiphysis, 
with irregular surface.— 
Hamilton. 
Fracture through the epi- 
physis, separation smooth. 
—Bryant. 
Compound and Compound Comminuted Fractures of the Thigh 
These injuries are of the most serious import. By reference to the table 
on fractures, it will be seen that in the Pennsylvania Hospital, from 1830 to 
* Hamilton on Fractures, etc., p. 460, fifth edition, 
f Holmes’s System of Surgery, vol. ii. FRACTURES OF THE FEMUR IN CHILDREN. 
1011 
1850, seventy per cent, of these fractures died, and from 1850 to 1874, 
fifty-six per cent. The course of treatment will be determined in some 
measure by the nature of the cause producing the injury. Eailroad and 
gunshot injuries are those which most frequently demand a resort to the 
knife. 
In deciding on the question of amputation, there are four things to be 
taken into consideration: first, the condition of the bone; second, the con- 
dition of the soft parts; thii'd, the state of the vessels and of the nerves; and, 
fourth, the age and habits of the patient. 
With regard to the first, it may be said that it is rarely necessary to re- 
move the limb when the injury is confined to the bone, unless it should be in 
a case where the comminution is very extensive. Captain Riddle, of Erie, 
Pennsylvania, was shot in the thigh by a deflected ball from a Creedmoor 
rifle. The femur was broken into forty pieces. Amputation, under the cir- 
cumstances, was very properly performed. Instances of such extensive devas- 
tation are, however, of rare occurrence. The extension of the fracture into 
the knee or into the hip-joint would not be a sufficient reason for the use of 
the knife. 
With regard to the injury of the soft parts, the course to be pursued will 
depend to a great degree on both the nature and the extent of the damage. 
When the muscles are divided by the ends of the broken bone, or by some 
sharp body, the case is very much less dangerous than when they are torn, 
bruised, and pulpified by the external violence, in which case, if the injury 
is extensive and deep, there will be little prospect of saving the limb. 
The strictest inquiry should be made into the state of the vessels and of 
the nerves. If the femoral artery is torn, the extremity will certainly perish, 
and hence amputation will be demanded at once. The fall of temperature 
and the absence of the arterial pulse below indicate this lesion. The lacera- 
tion of the principal nerve will be followed by loss of sensibility and of power 
in the parts to which it is distributed, but of itself is not a sufficient reason 
for amputation. 
The younger the person, the greater will be the likelihood of recovery; and 
in doubtful cases it is always wise, when the patient has youth on his side, 
to abstain from an operation ; but if the individual is advanced in life, or one 
whose system has been deteriorated by bad habits, it will be better to sacrifice 
the limb at once. 
Treatment.—Under the head of remarks on fractures in general, specific 
directions are given about the management of the external wound, the arrest 
of hemorrhage, etc., in compound fractures. We need only observe on these 
subjects that after the control of the latter the wound should be rendered 
aseptic, its edges drawn together, and an effort made to convert the injury 
into a simple fracture by excluding the air with an impermeable dressing, 
never forgetting the possibility—nay, the probability—that we will often fail, 
and therefore that we should watch for the earliest evidences of purulent 
formations and at once give them free vent. 
Here, as in simple fractures, the extended position is to be preferred, and 
the extension made in the same manner, though it is probable that the patient 
will not be able to bear the same degree of traction as in an ordinary frac- 
ture. In this particular his feelings must be consulted, so that the wmight 
attached shall not exceed that which is consistent with his comfort. The 
best disposition of the limb, in the event of antiseptic measures failing to 
prevent suppuration, and the pus becoming diffused through the soft parts, is 
in a long fracture-box embedded in bran, than which, under the circumstances, 
as a rule, no more appropriate dressing can be devised. The bran supplies, 
when packed in between the sides of the box and the limb, an evenly-dis- 
tributed pressure, absorbs the discharges which flow from the wound, and, 
wRen soaked with these discharges, can be removed and its place supplied 
with a fresh quantity without subjecting the limb to any disturbance what- 
ever. If the surgeon succeeds in securing the closure of the external wound, 1012 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
of course there is no necessity for the box or the bran, or for deviating from 
the plan laid down elsewhere for the treatment of an ordinary fracture of 
the bone. The bracketed splint, in some cases of non-closure of the wound, 
may be used with advantage. The splint should be constructed so as to per- 
mit of the wound being dressed without disturbing the limb. A very good 
form of this kind of splint, particularly when the injury is about the knee, 
is that of Dr. Packard (Fig. 837), or the one represented in Fig. 838. Where 
Fig. 837. 
comminution exists, any loose detached portion of bone should be removed 
before closing the wound. 
Packard’s bracketed splint. 
Fig. 838. 
Bracketed extension splint for compound fracture of the thigh. 
Gunshot fractures of the thigh, attended by great comminution of the 
bone, demand in most cases amputation, especially when the injury is within 
the limits of the lower two-thirds of the bone. 
Another complication is fracture of the thigh associated with a crush of 
the leg, requiring amputation of the latter at the knee-joint; still another is 
a fracture of the thigh at the upper third, requiring an amputation immedi- 
ately above the knee. In either event the proper course to be adopted is to 
remove the limb and set the fracture, maintaining it in position by two 
concave splints which embrace the circumference of the thigh. 
Fractures of the Patella. 
Fractures of the patella may be simple, compound, or comminuted. Occa- 
sional instances occur of fissure without entire separation of the bone. The 
direction of these fractures may be transverse, vertical, or oblique ; and from 
the relation of this bone to the knee-joint, these injuries assume great impor- 
tance. Of 2328 fractures at the Hotel-Dieu, 45 were cases of broken patella.* 
Of the 8667 fractures received into the Pennsylvania Hospital from 1830 to 
1874, a period of forty-four years, 148 were fractures of the patella. In 106 
of this number, 86 were simple, 8 comminuted, 7 compound, and 5 compound 
comminuted. 
* Malgaigne on Fractures, Packard’s trans., p. 599. FRACTURES OF THE PATELLA. 
1013 
The relative frequency of the fracture in the sexes is quite remarkable. 
The records of the last-named hospital show that 96 were in males, and only 
10 in females. Only one case was seen under twenty years of age, the largest 
number, 36, occurring between twenty and thirty. After fifty, the compara- 
tive infrequency of the injury is very marked. Occasionally both bones are 
broken simultaneously, and sometimes the same bone several times. Of the 
former, Dr. Kirkbride gives a case which occurred in the Pennsylvania Hos- 
pital ;* Hamilton another ;f Bichat and Sir Astley Cooper each report one ;J 
and one came under my own care in the Pennsylvania Hospital. 
Causes.—These are direct violence and muscular action. In the cases 
which have come under my own observation, they have been produced most 
frequently by muscular action, and when the limb was in a state of greater 
or less flexion, in which position the bone, by its tendinous connection to the 
tubercle of the tibia below and to the tendon of the quadriceps muscle above, 
is bent over the trochlear surface of the femur. Of 29 fractures of the patella 
recorded by Hamilton,§ 27 were produced by direct force, such as falls upon 
the knees, and 2 by muscular force. The most common instances of the action 
of muscular force in producing the fracture are those in which it has resulted 
from mounting a horse, the bone giving way when the rider is raising himself 
from the ground on the stirrup, from sudden efforts to escape a threatened 
fall in which the body is thrown violently backward, from the act of giving 
a kick, as in Bichat’s and Malgaigne’s cases,|| and from the balancing efforts 
of rope-dancers, circus-riders, etc. The opinion of Malgaigne, that the acci- 
dent, wThen from the causes just enumerated, is sometimes due to a diseased 
condition of the bone, is to be accepted only in a very restricted sense. I 
have seen many cases of fracture from extreme brittleness of the bones, but 
only once have I witnessed the patella broken in a person who labored under 
a fragility of the osseous system. Again, in individuals who suffer from such 
diseases as syphilis, cancer, and rheumatism, affections which so commonly 
deteriorate the osseous system, how rare is it to meet with this fracture! 
Lastly, in the aged, where we naturally look for the existence of a fatty 
change in the bones, a broken patella is quite uncommon, its frequency being 
inversely in proportion as we advance in life. From whatever cause, direct 
or muscular, the line of separation is generally transverse: occasionally it is 
oblique, and in a few instances vertical. (Fig. 839.) Only once in 106 cases 
Fig. 840. 
Fig. 839. 
Comminuted fracture of 
the patella, the lines of 
separation being oblique. 
Transverse fracture of 
the patella united by 
fibrous tissue. 
Separation of the fragments of the 
patella by the action of the quad- 
riceps muscle. 
was a vertical separation A remarkable specimen is given by 
Bryant, taken from his father’s museum, consisting of four transverse frac- 
tures. 
Symptoms.—When the patella is broken, severe pain will generally be 
experienced, with loss of power to extend the leg, and considerable swell- 
ing about the knee-joint. The upper fragment will be drawn up by the con- 
traction of the quadriceps muscle (Fig. 840), the lower fragment remaining 
stationary, or only descending a little by its own weight. The contraction 
' * American Journal of the Medical Sciences, August, 1835. 
f Fractures and Dislocations, p. 435. J Malgaigne on Fractures, Packard’s trans., p. 602. 
§ Fractures, etc., p. 434. || Malgaigne on Fractures, Packard’s trans., p. 601. 
Willard’s Tables of Fractures. 1014 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
of the tendon which connects it with the tubercle of the tibia, alleged by 
Malgaigne to take place, is altogether insignificant. A depression will be 
seen between the fragments, into which the finger can be pressed. (Fig. 
841.) This chasm, or sunken interspace, will be increased by flexing the 
leg, the lower fragment following the move- 
ments of the tibia. The degree of separation 
will depend on the amount of laceration sus- 
tained by the fibrous expansion of the quad- 
riceps muscle in which the patella is lodged. 
In a very aged and distinguished artist of 
Philadelphia whom I attended for this in- 
jury, the fragments were quite four inches 
apart, and Sir Astley Cooper mentions a case 
in which the fragments were five inches 
asunder; but usually the interspace is from 
one-half to one inch. The power of extending the leg, though generally, is 
not always, lost. I have seen a case of this fracture in which a patient ad- 
mitted to the hospital for a severe injury of the head was able to walk to his 
bed, the lesion of the patella not being discovered until several days after 
his admission. There was considerable separation of the pieces in this case. 
The limb is commonly found somewhat flexed. Crepitus is not easily pro- 
duced, except in the comminuted or vertical variety, when the pieces are 
more easily brought into contact; the knee rapidly swells, and the joint 
becomes distended with fluid, which is sometimes intermixed with blood. 
This often masks the true nature of the injury, although the effect of this 
swelling is to widen the interval between the fragments. When the fracture 
is the result of direct violence, discoloration from extravasated blood will be 
diffused through the subcutaneous cellular tissue around the knee. The joint 
does not escape inflammation, and on the degree of this will depend its future 
usefulness. 
Injuries to the bursa over the patella, when its sac is ruptured, somewhat 
simulate fracture; but the absence of the other signs which have been de- 
tailed ought to be sufficient to prevent any mistake being made. 
Prognosis.—The union which follows a fracture of the patella is usually 
ligamentous. Bony consolidation of the fragments is certainly of very rare 
occurrence. The late Professor Gross possessed a specimen in which the pieces 
appeared to be conjoined by callus. Cooper mentions several cases of the same 
kind. Bryant figures another, taken from Guy’s Museum, in which a section 
has been made ; and Hamilton thinks he has seen it in two cases. I have 
never seen a specimen which entirely satisfied my mind of the verity of 
this union. Non-union is by no means uncommon. In 31 specimens which 
Mr. Adams examined, 15 were ununited,* 12 were united by fibrous tissue, 
and 4, from their dried condition, remained undetermined. The disability 
varies greatly in different cases, there being a singular want of uniformity 
in this particular even in cases apparently alike. In Kirkbride’s casef the 
bond of union was two and a half inches in length, yet the patient experi- 
enced no inconvenience in the use of the limb. Others, again, with a much 
shorter union, find the limb weak and helpless: a certain degree of anchy- 
losis often remains, the effect of inflammation of the joint tissue. Atrophy, 
with fatty degeneration of the quadriceps muscle, rendering the latter more 
feeble, may also follow this injury, and in some cases is permanent. It may 
be fairly stated that the limb in all cases, however close the intermediate 
union may be, is somewhat weakened and less able to endure fatigue than 
the sound one. 
The character of the connecting bond has been shown by Mr. AdamsJ to 
consist, when the gap does not exceed one inch and a half, of organized 
Fig. 841. 
Depression in front of the knee. 
* Cooper’s Surgical Dictionary, vol. i. p. 753. 
t American Journal of the Medical Sciences, vol. xvi. p. 32. 
t London Pathological Society’s Transactions, vol. xiii. p. 139. FRACTURES OF THE PATELLA. 
1015 
fibrous tissue developed from the reparative lymph deposited between the 
fragments. When the separation is greater, the connecting bond consists 
of the fascia which lies over the bone, and which is somewhat thickened by 
plastic deposits. The arrangement of the uniting material has also been 
described by the same writer as passing between the anterior periosteal 
surfaces of the two pieces, reflected over, and adherent to both fractured 
surfaces, and finally, and most commonly, extending from the anterior peri- 
osteal surface of the upper to the broken surface of the lower fragment. 
The bursa over the patella is incorporated with the uniting structure, and 
no callus ever appears on the articular surface of the bone, the presence 
of which, as has been very properly remarked by Dr. Hunt, would be 
dangerous to the joint. Union may be expected to take place in from four 
to seven weeks. 
Treatment.—The indications are, first, to remove the intra-articular fluid 
by aspiration should the joint be much distended, and to place the limb in 
that position which will secure the most complete relaxation of the quadri- 
ceps muscle ; secondly, to bring together, and so retain, the parts of the 
fractured bone ; and, thirdly, to prevent anchylosis. 
Many of the older surgeons were content simply to place the limb in the 
extended position, with a view to fulfil the first indication ; and this position 
is still advocated by some surgeons, among whom is Mr. Hutchinson,* who 
thinks that the quadriceps muscle has nothing to do with the displacement, 
but that the deformity occurs in consequence of the effusion into the joint. 
This view, however, is not tenable. By raising the leg somewhat, the origin 
and insertion of the rectus muscle are brought nearer together, favoring the 
apposition The apparatus which I employ is very simple, and one which 
any person with the slightest handicraft can quickly construct. It consists 
of a piece of pine board, somewhat convex longitudinally on the upper sur- 
face, thirty inches long, and five inches wide at one end, tapering to four 
inches at the other. On each side, a short distance above and below the 
middle of the board, are to be bored two holes, into which are fitted four 
pegs with square heads. (Big. 842.) This splint must be well padded, and 
Fig. 842. 
Author’s splint for fractured patella. 
placed under the thigh and the leg, the limb being at the same time moderately 
elevated. Below the knee and the lower fragment are next to be applied, 
partially overlapping each other, two or three strips of adhesive plaster, 
each three-quarters of an inch wide and thirteen inches long. These strips 
are brought together at their extremities and wrapped round the upper 
pegs. This secures in position the lower fragment. Five strips of plaster, 
of like length and width, are next applied three or four inches above the 
knee, descending towards the joint, each strip overlapping one-third of the 
preceding one. Bringing the ends of the plaster together, they are to be 
wound around the lower pin. when, by screwing or twisting the pegs of 
the two sides, the lower fragment will be brought into near apposition with 
the upper. To prevent the broken surfaces from tilting forward, a broad 
strip of plaster may be drawn over the line of approximation and fastened 
* Medico-Chirurgical Society’s Transactions, vol. iii. p. 327. 1016 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
to the splint below. A roller is now applied above and below, which secures 
the thigh and leg to the splint. (Fig. 843.) As the swelling subsides, all that 
Fig. 843. 
Author’s splint applied. 
is necessary to maintain the adjustment is to tighten the strips by screw- 
ing up the pegs to which they are fastened. By this plan the removal of 
the dressing is rendered unnecessary until the cure is complete. Between 
the third and fourth weeks the strips may be separated from the pins, the 
knee gently moved so as to overcome stiffening, and the dressing again re- 
adjusted. This process should be repeated every five or six days, or until 
the fifth week, when the splint may be laid aside and the patient be placed 
on crutches. 
By the addition of a metal ratchet to this splint the pegs can be turned 
without the necessity of drawing them out. and without the risk of their 
slipping back. 
Professor Hamilton’s apparatus for fractured patella may be used with great 
satisfaction. It consists of two boards wider than the limb and long enough 
to reach from the tuberosity of the ischium to the sole of the foot. These 
are hinged together at their upper ends. Below, a foot-piece, having two 
fenestrse, is hinged to the lower board, or base; the upper board has two 
long tenons or tongues to pass through these fenestras, so that the angle 
can be adjusted as required. A few gimlet-holes bored through one edge of 
the foot-board will serve for the insertion of a peg which shall keep the plane 
secure at its due elevation. I have had a movable convex block, two inches 
high, screwed to the upper board of this splint, so as to admit of its being 
placed exactly behind the knee-joint, by which means a slight degree of 
flexion at the knee can be preserved, the straight position of the leg being 
as uncomfortable as an extended condition of the elbow. 
Application.—The plane for the limb being well padded, the injured ex- 
tremity is placed upon it as soon as possible, and the board raised to an 
angle of thirty degrees, at which point it is fixed by the peg in the side. 
The foot must be placed at a right angle with the leg, and made fast to the 
foot-board, having a thin pad interposed. The body of the patient may be 
next raised to a semi-recumbent position, which gives the greatest relaxation 
to the rectus femoris muscle, and enables the surgeon to bring the superior 
fragment well dowTn and retain it in place by a roller. This bandage is first 
carried above the upper fragment, then below the lower fragment, and lastly, 
by successive oblique and circular turns, each turn passing through the notch 
in the plane, the whole knee is covered in. With a second roller, beginning 
at the ankle, the entire limb is next bound to the splint. The patient should 
be visited daily, and the dressing carefully inspected to ascertain the condi- 
tion of the limb. If there is no complaint, it need not be disturbed for two 
at which time the second roller may be removed,, and if the uniting one 
about the knee is quite firm, the former may be again applied. Usually on 
the fourth or fifth day the swelling in the articulation begins to subside, when 
the uniting roller should be reapplied with increased firmness. About the 
tenth day the swelling has so much abated that a more permanent dressing 
can be used, and for this purpose, removing the rollers, adhesive strips are FRACTURES OF THE PATELLA. 
1017 
applied in the same directions and order as were observed in the use of the 
uniting bandage, after which the limb is bound to the splint (Fig. 844) with 
Fig. 844. 
Hamilton’s splint for fractured patella applied. 
a roller, which, beginning at the ankle, ascends the leg to the knee, and is 
made to surround the latter by oblique and circular turns, passing through 
the notch in the splint, with a view to give additional fixation to the frac- 
ture, and finally terminating by ascending the thigh to the groin. 
This dressing may be allowed to remain five or six days, when the roller 
should be removed and reapplied, the adhesive plaster remaining undis- 
turbed. These strips may not require renewal during the progress of the 
treatment. 
The first effect of almost any dressing is to evert the fractured surfaces, 
approximating their posterior edges at the expense of the anterior ones; 
but by the present method, in which the entire knee is covered in, this ever- 
sion is corrected. In the absence of this splint, a single board, wider than the 
limb and notched opposite the knee, can be used, raising the lower extremity 
to the proper height and supporting it on some firm base. At the end of 
the fourth or fifth week it will be proper to attend to re-establishing the 
functions of the articulation. The dressings must be removed and gentle 
flexion and extension of the joint made every two days, taking care not to 
presume too much on the strength of the union. At this stage of the treat- 
ment the adhesive plaster is dispensed wdth and the roller only used to fasten 
the limb to the splint. About the fifth or sixth week the patient may be 
allowed to move about on crutches; but no attempt at walking unassisted 
should be made sooner than from the ninth to the tenth week. 
It is proper also to wear for several months a laced knee-cap, with an 
opening in front corresponding to the patella, so as to take off as much as 
possible all tension from the uniting tissue, wdiich is prone to become elon- 
gated and thus allow the fragments to separate. This precaution acquires 
additional force when it is remembered that a slip or a stumble may snap 
asunder the fibrous union. The function of the quadriceps muscle will be 
most quickly restored by daily massage for half an hour. 
When a fragment is broken off from the patella, or in a simple commi- 
nuted fracture of the bone, or when the latter is severed vertically, a com- 
press should be placed on each side of the bone previous to the application 
of the adhesive strips or the roller. It may happen that the joint will have 
received severe injury, and that the inflammatory symptoms which ensue are 
of the greatest severity,—such as to create anxiety for its safety. Under 
these circumstances, the limb must be extended and elevated upon a pillow, 
blood drawn by leeches, and the articulation surrounded with bags of ice, or 1018 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
kept under water irrigation, until the danger is over, when the apparatus 
may be applied. 
It is not uncommon to meet with cases of refracture of the patella where 
the fragments remain a considerable distance apart, the usefulness of the limb 
being, in consequence, materially lessened. There are cases which, if the dis- 
ability is great, seem to justify opening the joint, freshening the edges of the 
disjoined fragments, and wiring them together. Cameron, of Glasgow, ac- 
cording to Mr. Lister, was the first to do this operation. I am not, how- 
ever, prepared to recommend the procedure, unless perhaps in extreme cases 
of disability. Yalaguier, in the Archives de Medecine,* has published the 
results in forty-five operations for old cases of fracture of the patella, of 
which twenty-two were successful, nine were followed by partial anchylosis, 
eleven by complete anchylosis,—all of these, save one, after suppuration of 
the joint,—and three resulted fatally. Surely, with such a record, and in view 
of the fact that many of the operations were done by the most skilful surgeons, 
one may well hesitate to recommend unreservedly this plan of treatment. 
Compound Fractures of the Patella.—These are injuries of the greatest 
severity, usually opening the joint, and resulting in erysipelas, pyaemia, ex- 
haustive suppuration, and death. I have seen a patient die in a few days 
from the ravages of erysipelas after such an accident produced by the kick 
of a horse. Mr. Poland, in a very valuable paper on this subject, has shown 
that in compound fractures of the patella, where the question of amputation 
arises, statistics are, as a rule, against the operation. For instance, of 68 
cases treated without amputation, 56 recovered,—82.35 per cent.,—while of 
7 in which the operation was performed, 5 recovered,—71.42 per cent. Of 
10 cases in which excision was performed, 6 died,—60 per cent. In all the 
fatal cases, suppuration of the articulation was present, and it also existed in 
43 out of the 65 cases which recovered ; 31 of the recoveries suffered more or 
less from anchylosis of the knee-joint. 
Treatment.—If the fracture is compound, an attempt should be made to 
convert it into a simple one, by immediately washing out or flushing the 
joint with a lotion of corrosive sublimate (one to one thousand), suturing the 
fragments together with strong catgut, or with one or two silver threads, 
and, after neatly closing the wound with the requisite number of stitches, 
over which some collodion iodoform should be brushed, applying the usual anti- 
septic external dressings. To secure rest and fixation of the joint, a posterior 
trough-shaped felt splint should be adjusted, and made fast by the turns 
of a roller. The limb may be elevated and laid on a pillow. If the injury 
is a comminuted one, any loose fragments of bone, if entirely detached from 
the soft parts, must be removed. If still having vital attachments, they may 
be tacked together by catgut threads, and, after dressing antiseptically, the 
limb either suspended by the anterior splint of Nathan R. Smith or placed 
upon a single slightly-inclined plane. If not dressed antiseptically, energetic 
measures will be demanded in order to prevent a destructive arthritis. Per- 
sistent irrigation with cold water containing laudanum should be employed, 
or the articulation may be surrounded with bladders filled with broken ice. 
If the swelling, heat, and pain prove to be great, leeches should be applied, 
and, in order to drain away the redundant transudation from the joint, horse- 
hair or catgut threads may be introduced through the wound. Pain is to be 
alleviated or controlled by the free use of opiates, and, as there will generally 
be considerable constitutional disturbance present, these anodynes are best 
exhibited in some febrifuge like the neutral mixture. 
Should the inflammation result in suppuration, the cold applications must 
be discontinued, and the strength be sustained by the use of quinine, iron, 
stimulants, and a generous diet. To supply a ready exit for the pus, a free 
incision into the joint will be required, after which the knee may be enveloped 
either in a flaxseed-meal poultice or in a warm-water dressing. 
* Annals of Universal Medical Sciences, vol. ii. p. 265. FRACTURES OF THE PATELLA. 
1019 
When the injury is followed by a profuse discharge of purulent matter, 
by free lateral movement of the articulating bones, by crepitus the result of 
eroded cartilages, and without any tendency to anchylosis, the indications 
are that the joint has been ruined, and the only hope for the patient lies either 
in amputation or in excision. In an adult, the former operation would offer 
the best chance for recovery, while the latter should have the preference if 
the subject be young. 
The Ugamentum patellae may be ruptured. This is a very rare occurrence 
as compared with fracture of the patella, but it has been noticed twice at 
the Pennsylvania Hospital. Maydl has collected 65 cases of this injury, and 
to these Professor Sands has added 13 cases, making a total of 78. I think 
it probable that the tip of the patella was detached in some of these cases, 
rather than that the ligament was lacerated. 
I once witnessed an instance of rupture of the quadriceps muscle imme- 
diately above the patella, in the person of a Catholic priest who slipped and 
fell upon an icy pavement. 
The treatment appropriate to these injuries when recent does not differ 
from that proper to a case of fracture of the patella. If the dressing is not 
accurately applied there is some risk that the ends of the ligament may not 
unite, or may unite imperfectly, in either event extension of the leg being 
lost or much impaired. In a case of this kind Professor Sands freely exposed 
the tendon, with antiseptic precautions, by a vertical incision in front of the 
joint, and after freshening the ends united them by two silver sutures. The 
atrophy of the tendo patella? in this case was so great, from the long time 
which had elapsed since the accident, that the operator was compelled to 
make oblique and transverse incisions into the quadriceps muscle in order to 
secure apposition. The knee-joint was freely exposed during the operation. 
The patient made a rapid recovery and acquired excellent use of the limb. 
Other methods.—Many other methods have been and are still in use in the 
treatment of fracture of the patella. Paulus iEgineta, and other ancient sur- 
geons, trusted largely to extension alone by means of splints. 
Flajani applied no dressing whatever, relying on rest and fomentations 
for a number of days, and then practising frequent movements of the joint. 
This method, slightly modified, was a popular practice over a century ago 
in London. 
Others relied on rings made of different materials, such as wood, cork, 
wire, etc. These were covered or padded before their application, so as to 
protect the soft parts from undue pressure. Albucasis, we learn from Mal- 
gaigne,* was the first surgeon to suggest this mode of dressing. The frag- 
ments were drawn together and brought within the compass of the ring, 
which was bound to the knee with a roller, the limb at the same time being 
kept in the extended position. 
Another principle introduced into the treatment of this fracture was the 
application of forces acting obliquely and in opposite directions. The origi- 
nator of this plan, we are informed by Malgaigne, was a non-professional 
man,—a mechanic in Leyden. In some form or other it embraces almost all 
the mechanical appliances which have been in successful use in the manage- 
ment of this fracture for over a century. Thus, we have the figure-of-eight 
bandages of Petit, Velpeau, and others, as below enumerated. 
Boyer's apparatus consisted of a concave splint, well padded, extending 
along the posterior part of the limb, with nail-heads on each side opposite 
to the knee-joint, and two straps covered with soft chamois leather. One 
of these straps passed above and the other below the patella ; the upper 
one, running obliquely downward, was buttoned on the nail-heads below, 
while the lower one was carried obliquely upward and attached to the 
nails above. 
* Malgaigne on Fractures, Packard’s trans., p. 614. 1020 
INJURIES AND DISEASES OE THE OSSEOUS SYSTEM. 
Desault's method.—After the same principle was the dressing of Desault, 
in which the limb was extended and elevated, and along its anterior surface, 
running from the groin to the ankle, was laid a strip of bandage, which was 
bound to the leg by a spiral reversed roller, beginning at the foot. Upon 
reaching the knee, two longitudinal slits, one on each side of the patella, 
were made in the muslin strip, through which the fingers of the surgeon 
were passed, in order to draw the upper fragment down into place, after 
which the roller was resumed, forming figure-of-eight turns about the 
knee, so as to hold the broken pieces together, the bandage then being ex- 
hausted by ascending the thigh to the groin. This completed, a straight, 
cushioned posterior splint was bound to the back of the limb, from the nates 
to the heel, and its lower end elevated at a considerable 
angle with the bed. 
Dorsey s splint forms another illustration of a fracture 
device. It was a wooden splint long enough to extend 
from the tuber ischii to the heel, with two strips of muslin 
nailed crosswise, four inches apart and equidistant from 
the centre. (Fig. 845.) The foot and limb were covered 
in with a roller, and the splint, well padded, was placed in 
position. The upper strip was tied over a compress placed 
below the lower fragment, and the lower one over a pad 
fastened above the replaced upper fragment. 
Lonsdale's apparatus acts in the same manner. It is a 
posterior splint with a movable foot-board, and two verti- 
cal iron bars rising on either side of the knee, each having 
a horizontal bar to which is attached a semilunar piece of 
metal, which, by a screw movement, can be made to press 
together the fragments. The complicated nature of the 
mechanism, even if it had no other defects, would con- 
stitute a valid objection to its use. 
Burges's apparatus (Fig. 846), though very beautiful and neat, is alto- 
Fig. 845. 
Dorsey’s splint for frac- 
tured patella. 
Fig. 846. 
Burges’s apparatus for fractured patella. 
gether too complicated for general use. Two concave sole-leather splints, 
one long and the other short, are used : the long splint is placed upon the 
thigh above the patella, and the other on the leg below the lower frag- 
ment, after which they are drawn towards each other by cords, pulleys, 
and weights. 
The apparatus of Lausdale (Fig. 847) and that of Boisnot (Figs. 848,849) 
are much more simple, and are the best forms of these splints. 
By the first, the fragments are forced towards each other by means of FRACTURES OF THE PATELLA. 
1021 
Fig. 847. 
Lausdale’s apparatus for fracture of the patella. 
thumb-screws acting in front of the limb ; by the last, the approximation 
is effected by the action of 
screws and ratchets beneath 
the posterior splint. 
Hartshorne's apparatus 
consists of a slightly angu- 
lar tin splint fashioned to 
the form of the posterior 
part of the limb, and hav- 
ing in it an oval opening 
corresponding to the ham, 
with straps and buckles 
above and below to secure 
it to the thigh. It has two 
straps designed to pass ob- 
liquely above and below the 
fracture, to be fastened to 
hooks on the sides of the 
splint. (Fig. 850.) 
Gerdy's dressing is one which can be readily prepared, but has no special 
advantages over other forms of 
apparatus. Two strips of mus- 
lin are provided, one with three 
slits and the other with three 
tails. The first strip is placed so 
that the slits will answer to the 
edge of the lower fragment; the 
second strip is laid upon the front 
of the thigh, and each is bound in 
position by separate rollers, one 
below and the other above the 
knee. The approximation of the 
fragments is next effected by pass- 
ing the tails of one strip through 
the slits of the other, and securing 
all together by a spiral reversed 
bandage extending from the foot 
to the groin. (Fig. 851.) 
The apparatus used by Wood, 
of King’s College Hospital, Lon- 
don, and that of Dunnage, operate 
on the same general principle. 
The approximation has been at- 
tempted also by means of forces 
acting longitudinally. 
Sir Astley Cooper's dressing was 
of this kind,—one in which the 
Fig. 848 
Fig. 849. 
Boisnot’s apparatus for fracture of the patella. 
Fig. 850. 
Fig. 851. 
Hartshorne’s apparatus. 
Gerdy’s dressing. 1022 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
limb was encircled by two strips of roller, one above and one below the 
patella, and then the fragments were approximated by passing two tapes, 
one on each side of the knee, from one circular band to the other, drawing 
these together, and afterwards covering the limb—in the extended position 
—with a roller. This plan is attended with much local uneasiness, from the 
constriction to which the limb is subjected, and, although it is termed the 
dressing of Sir Astley Cooper, it is one which that surgeon abandoned, be- 
lieving that he had found a better method. This consisted in waiting for 
a few days until the painful tumefaction was over, and then encircling the 
thigh above the patella with a soft leather strip. A second strip was placed 
under the foot, and its two ends were carried up on either side of the leg 
and buckled into the first. (Fig- 852.) 
Levis's mechanism.—The contrivance of Dr. Levis acts much in the same 
way. (Fig. 853.) 
Fig. 852. 
Sir Astley Cooper’s dressing for fractured patella. 
Many others, such as the dextrin dressing of Velpeau, the uniting band- 
age of Petit, etc., might be described, but I shall speak of but a single one 
more,—that of Malgaigne,—by which 
the fragments are brought together 
by means of hooks. (Fig. 854.) These 
curved hooks are separated and ap- 
plied singly, the one being pressed 
down upon the apex of the lower 
fragment, and the other upon the 
superior border of the upper fragment, 
the skin being previously drawn for- 
ward from between the fragments, 
and then the hooks are approximated 
by a screw. Once have I seen death 
follow the use of this infernal machine, 
from an erysipelatous inflammation ex- 
tending into the joint and giving rise 
to abscesses, both within and without 
the articulation. No advantage what- 
ever results from the close contact 
of the fragments accomplished by the 
instrument: it is rather a disadvan- 
tage, as the tendency to refracture is 
increased by the very closeness of the 
union, the intermediate bond not being 
as strong as the ordinary fibrous tissue 
which fills the gap when the pieces of 
the bone are a short distance apart. 
Three times have I seen the union broken a few weeks after the patients 
treated by this method had been discharged from the hospital. 
Since the introduction of antiseptic plans of treatment, the danger attend- 
ing the use of these hooks has been lessened; but I have seen no reason to 
modify the above opinion expressed in the former edition of this work in 
regard to their employment. 
Dr. Thomas G. Morton has devised a form of drill with which he brings 
Fig. 853. 
Fig. 854. 
Levis's apparatus. 
Malgaigne’s hooks. FRACTURES OF THE BONES OF THE LEG. 
together the fragments of the patella. The instrument by means of rota- 
tory movements is passed through the broken pieces, and then close apposition 
is maintained by a nut, which is run down from one end of the drill. The 
latter consists of two pieces joined in the middle, which, when the union of 
the bones has taken place, can be unscrewed and removed separately in 
opposite directions. Dr. Levis has also devised a modification of Malgaigne’s 
hooks by means of which the traction is rendered more uniform, imagine 
Malgaigne’s instrument divided longitudinally, each half distinct from its 
fellow, and a correct idea will be formed of the modification. The hooks 
are introduced some distance apart. 
Exposing the fracture in recent cases and wiring together the fragments 
has a certain number of advocates. I feel constrained, however, to condemn 
the operation without qualification. Valaguier* has analyzed forty-three 
cases of this procedure, with twenty successes, seven cases resulting in loss 
of motion, seven followed by suppuration, two requiring amputation of the 
thigh, and two deaths, one by pyaemia and one by carbolic acid poisoning. 
Byrd reports a case of death from pyaemia following this operation; 
Fowler, two cases resulting in caries of the bone ; and Lange, two cases of 
anchylosis, one after suppuration of the joint. 
1023 
Fractures of the Bones of the Leg. 
Fractures of the bones of the leg are largely in excess of those of other 
parts of the skeleton. Of the tabulated 8667 fractures treated in the Penn- 
sylvania Hospital, 2315 were fractures of the bones of the leg. Of 1101 cases 
received into the Middlesex Hospital. 289 were fractures of these bones.f Of 
222 cases taken from the records of Guy’s Hospital by Dr. King, 66 were 
situated in the leg. Malgaigne found, from the records of the Hotel-Dieu, 
that there were 652 in a total of 2328. 
Fractures of both bones are more frequent than those of either bone singly. 
By a reference to the table it will be seen that, of 2315 fractures of the leg, 
437 were in the tibia, 437 in the fibula, and 1441 in both bones. The lower 
third of the leg is the most common seat of fracture, and the middle third 
the next. This is true of the bones either separately or conjoined, and is 
doubtless due to their exposed condition from the small amount of soft parts 
in these localities, as well as to the fact that these are the weakest portions 
of the bones. It will also be seen by a reference to the table that of 246 
fractures of the tibia, 120 were in the lower third, 81 in the middle third, 
and 45 in the upper third; that in 252 fractures of the fibula, 210 were in 
the lower and 26 in the middle third; and that in 751 fractures of both 
bones, 399 were in the lower and 282 in the middle third. The largest num- 
ber of fractures of the bones of the leg occur between twenty and thirty 
years of age. 
Sex exercises its influence also, males furnishing by far the greater number 
of such accidents. This disparity, however, diminishes as we advance in life, 
until after seventy-five, when females are in the majority. These injuries may 
be considered under three heads: 1, fractures of both bones; 2, fractures of the 
tibia; 3, fractures of the fibula. 
Fractures of the Tibia and Fibula. 
Causes.—The causes are either direct, such as the passage of a wagon- 
wheel, the kick of a horse, or the falling in of earth, or of massive portions 
of stone; or indirect, as when a person falls from a height, or jumps from a 
carriage or a car which is in swift motion. When determined by indirect or 
transmitted force, Malgaigne thinks the fracture is likely to take place near 
the middle of the lower third. This locality, being at the summit of one of 
the curves of the bone, is necessarily more within the influence of this kind 
* Annual of Univ. Med. Sciences, vol. ii. p. 265. 
| Lonsdale on Fractures, p. 17. 1024 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
of force than would be parts more remote. As far, however, as my own obser- 
vation extends, I have not found any such uniformity as is claimed to exist 
between the seat of fracture and this kind of force, one example of which is 
seen in Fig. 855. When produced by direct force, the lesion 
will generally occur at the seat of violence. For example, 
a young man sitting upon the balustrade at the Philadel- 
phia Academy of Music lost his balance, and would have 
been precipitated headlong some thirty feet, had not one 
foot caught between the rounds of the railing. Ilis entire 
weight was supported by the ankle, and both bones broke 
at the lower part of the lower third. A heavy piece of 
iron fell upon the leg of a moulder, while engaged at his 
employment; the tibia and fibula were both broken at the 
point struck by the metal. I could relate many instances 
where persons have fallen when the foot was wedged in 
between unyielding surfaces, the fracture always taking 
place at the lower portion of the lower third of the leg. 
Occasionally these fractures result from muscular action 
alone; such instances are always found in adults. I have 
seen two cases of intra-uterine fracture of both bones of 
the leg. A colored man was brought into the Pennsyl- 
vania Hospital with a fracture of the tibia and fibula, four 
inches above the ankle, which was caused by the violent 
muscular effort made to recover his equilibrium after slip- 
ping upon an orange-peel. He was thirty years of age, 
of an excellent constitution, and without any evidence 
whatever of pre-existing bone disease. He had never 
before had a fracture. 
The two bones are seldom broken exactly at the same 
level. Usually the fracture of the fibula is higher than 
that of the tibia; and sometimes when the latter bone is 
broken a short distance above the ankle, the former will be found separated 
near its upper extremity. When broken nearly on the same level the force 
has generally been direct, but when the lesions in the two bones are widely 
separated it has usually been indirect, each bone yielding at its weakest 
point; or the rationale may be the one given by Malgaigne, in which both 
direct force and indirect force are in operation. For example, a man is struck 
forcibly by some vulnerating body across the lower part of the leg while 
in the erect position. The tibia gives way at the seat of injury, and, in 
struggling to maintain his footing, the weight of the body is borne by the 
fibula alone, which in turn gives way at the upper third, its most slender 
part. 
Compound and compound comminuted fractures of the bones of the leg 
exceed in frequency those of any other bones of the skeleton. Of 1074 cases 
of such fractures received into the Pennsylvania Hospital, 366 belonged to 
these classes. The superficial position of the tibia and fibula will explain 
these figures. The direction of the fracture is always more or less oblique, 
running downward and inward, and less frequently downward and outward. 
The obliquity is least when near to the upper or lower extremity, and where, 
especially in the tibia, the bone is most voluminous, so that these breaks are 
sometimes spoken of as transverse fractures. It is in the same localities 
that the line of separation is prone to be vertical, splitting the bone and 
extending into the ankle- or knee-joint. 
Symptoms.—The signs of fracture of both bones of the leg are usually well 
pronounced. These are contusion, discoloration, pain, deformity, undue mo- 
bility, and crepitus. Malgaigne attaches much importance to the muscular 
state of the limb as a sign of this fracture,—a condition which is certainly 
very common. The deformity will depend on the degree of displacement. 
In many instances there is little or none, particularly when the bones are 
Fig. 855. 
Fracture at the upper 
extremity of the tibia 
and fibula, caused by 
indirect force. FRACTURES OF THE TIBIA AND FIBULA. 
1025 
broken at different levels, in consequence of which there is often an inter- 
locking of the spiculse which tends to oppose the disarrangement of the 
pieces. When the fracture traverses a voluminous part 
of the bone, as that near to the tubercle, some portion of 
the broken surfaces will remain in contact, and thereby 
lessen the deformity. In other cases the displacement is 
very considerable, and is often determined by the vio- 
lence which causes the injury. That which is sometimes 
witnessed consists in the anterior projection of the upper 
end of the lower fragment; but by far the most common 
displacement is the lateral one, the lower slipping to the 
fibular side of the upper fragment. The gastrocnemius 
and soleus muscles are chiefly concerned in producing 
this deformity, as by drawing the foot back they not only 
carry the lower pieces forward, but likewise produce 
overlapping of the fragments and consequent shorten- 
ing. (Fig. 856.) When the fracture is caused by a force 
applied to the front of the leg, the line of separation 
may be from below upward and from before backward, 
in which case the lower fragment will assume a position 
behind the upper one. The action of the quadriceps 
muscle in tilting forward the upper part of the tibia is 
altogether insignificant, as this movement is counter- 
acted by the posterior and crucial ligaments of the knee- 
joint, 
Lateral angular deformity, when present, is generally 
due to the direction of the fracture—of which I shall 
speak hereafter — and to the weight of the parts, ac- 
companied by an unequal support of the leg, or, when the angle is salient 
internally, to the action of the peroneal muscles drawing the foot outward. 
Another displacement, and not an uncommon one, is that in the longitudinal 
axis of the bones, caused by either external or internal rotation of the foot, 
in most instances the former. In 19 cases of ununited fracture of the bones 
of the leg, Mr. Shaw found the lower fragment rotated outward 16 times. 
Prognosis.—The prognosis will be influenced by several considerations,— 
such as the damage done to the soft parts, the degree of comminution, the 
obliquity of the fracture, and the amount and kind of displacement. When 
the soft parts are lacerated extensively and the bones broken into several 
pieces, or when in connection with this laceration the tibial arteries are torn, 
amputation is the only resort. If. as a consequence of great obliquity, there 
is much overlapping, and this is not corrected, the union will be slow, or 
may fail altogether. Rigidity or anchylosis of the knee or of the ankle is 
occasionally a sequel to delayed union, and, according to my experience, is 
more common in the bones of the leg than in any other part of the skeleton. 
Where, however, none of these complications exist, fractures of the leg heal 
rapidly, so that the cure is usually effected in four or five weeks, and without 
any marked deformity or shortening. 
Treatment.—Yery frequently little is to be done in the way of adjusting 
the fracture,—so trifling is the displacement,—only requiring that the leg 
be placed in some suitable retentive apparatus. At other times the displace- 
ment is very marked, and requires no small amount of patience and judgment 
to correct it. When it is lateral, the foot must be brought into a line with 
the upper part of the leg, which may be all that is required. Should there 
be overlapping, extension from the foot and ankle and counter-extension at 
the thigh must be made until the reposition is complete. To obtain the full 
benefit from these two forces, it will sometimes be necessary to flex the leg 
in order to render powerless the resistance of the gastrocnemius and soleus 
muscles. The semi-flexed position alone will frequently correct the mal- 
position of the fragments when force has proved entirely unavailing. Yarious 
Fig. 856. 
Anterior angular de- 
formity and overlapping 
following fracture of the 
bones of the leg : the dis- 
placing muscles, viz., the 
gastrocnemius and the 
soleus, seen on the poste- 
rior aspect of the cut. 1026 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
little changes of position will occasionally be necessary, which must be learned 
by repeated trials, as they cannot be predicated on any knowledge of muscular 
action, while they differ so much in detail that no one case serves exactly as 
a precedent for another. 
Two positions have been advocated for the treatment of fractures of the 
bones of the leg,—the extended and the flexed. With few exceptions, the ex- 
tended position is the one to be preferred. The dressing necessary for the 
retention of these fractures is very simple, and always accessible. 
Board and pillow or Boyer dressing.—Place across the bed three strips of roller 
one yard long; upon these lay a piece of muslin two feet long and one yard 
wide, and upon this an ordinary feather pillow. Thus arranged, the broken 
limb is laid upon the dressing. Two pieces of light board five inches wide, 
and long enough to extend from the knee to three inches below the foot, are 
next rolled in the splint-cloth or muslin, so that they shall be made to apply 
themselves firmly along the inner and outer aspects of the leg, the pillow 
being interposed, after which 
they are made secure by 
tying together the ends of 
the three strips of muslin. 
To support the foot and 
prevent the toes from fall- 
ing forward too much, pass 
a loop of muslin over the 
metatarso-phalangeal part of 
the foot, and pin its extremi- 
ties to the pillow on either 
side. (Fig- 857.) The band- 
age of Scultetus, used by Boyer, may be omitted. The weight of the bed- 
clothes must be kept from the foot by a rack. Nothing can be more simple, 
and the materials are within the reach of every one. This dressing is suited 
to a case in which there is little displacement and no overlapping, and where 
extension is not demanded. 
Fracture-box.—Next in simplicity is the old fracture-box (Fig. 85S), which 
combines so many advantages that I regard it, notwithstanding all that 
has been said against its use, as an exceed- 
ingly valuable apparatus, answering in a 
large majority of cases every indication 
demanded. It is a box with a foot-board, 
through which are cut two vertical slits, 
and with sides attached by hinges, which 
may be raised or let down at pleasure. It 
should be long enough to extend from the 
knee to the sole of the foot. To apply the ap- 
paratus, place under it two or three strips 
of muslin, let the sides be opened, a pillow 
laid in the box, and upon this place the broken limb, with the sole of the foot 
touching the foot-board, cotton being interposed ; next take a strip of muslin 
or a silk handkerchief, pass it beneath the leg just above the heel, cross it over 
the ankle and instep, then under the sole of* the foot, where a single knot 
should be made, and the ends passed through the slits in the foot-board. The 
next and most important part of the dressing is the careful adjustment of 
the fracture and the proper distribution of the support beneath the leg and 
foot. Let the fingers be passed along the spine of the tibia, in order to 
ascertain if there is any irregularity, and thus determine the accuracy of 
the coaptation. If the upper end of the lower fragment is found above 
the level of its fellow, cotton or oakum must be placed under the tendo 
Achillis and the heel, in order to raise the foot; or if the fragment projects 
backward,—certainly a very uncommon position,—the heel should be lowered. 
Should the upper fragment rise above the level of the lower, it must be 
Fig. 857. 
Boyer’s dressing for fracture of the bones of the leg. 
Fig. 858. 
Fracture-box with hinged sides. FRACTURES OF THE TIBIA AND FIBULA. 
1027 
pressed down and a thick compress laid over the displacement. The toes 
should be turned very slightly outward, so that the ball of the great digit will 
be on a line with the inner edge of the patella, and, in order accurately to 
coaptate the broken ends of the bones, the heel must be raised or lowered 
by pledgets of oakum, according to the requirements of the case. These 
points being attended to, the loose ends of the strip which encircled the ankle 
and were passed through slits in the foot-board should be tied together, and 
the sides of the box brought up to the leg, forcing before them the pillows, 
wThich furnish the lateral pressure ; then keep them in place by tying to- 
gether the ends of the strips which underlie the box. (Fig. 859.) When 
it becomes necessary to make an- 
terior pressure, one of these strips 
should be tied directly over the 
thick compress previously men- 
tioned, or, with a view to distribute 
the pressure over a larger surface, 
a thin book may be interposed be- 
tween the compress and the strip. 
All anterior pressure must be care- 
fully watched, as the soft parts are 
too thin to tolerate any consider- 
able amount, particularly if they 
are stretched by the bone, or in 
the least inflamed, in which event 
pressure will be improper. With the dressing just described, the limb is 
always exposed to view, its condition readily ascertained, and any displace- 
ment immediately detected. 
Among the objections urged against the fracture-box is that it allows the 
foot of the patient, when he attempts to rise or sit up in the bed, to press 
against the foot-board, and thereby to cause overlapping of the fragments. 
In the Pennsylvania Hospital, where the apparatus has long been in use, 
no such effects are observed to occur. If, however, there should be a risk 
of this displacement, or if the patient happens to be intractable or restless, 
the remedy to meet all emergencies is a very simple one, and consists in 
suspending the box to a crane or gallows placed over the bed : indeed, even 
where no such contingencies as those spoken of exist, I find that this arrange- 
ment proves a source of incalculable comfort as well as of safety to persons 
suffering from these fractures. In fitting up this apparatus, all that is 
necessary is to bore two holes near the upper borders of the sides of the 
fracture-box, about fourteen inches apart, and to tie into these two cords, 
which, being brought together, are fastened to a suspension-rope which runs 
over a pulley secured to the gallows-frame. In order to raise and lower the 
box at pleasure, the suspension-rope is connected to and passed through the 
holes in a block of hai*d wood, as represented in the following figure. The 
position of the box can be shifted to one side of the bed or to the other, by 
sliding in the required direction the block into which the pulley is screwed, the 
cross-piece of the frame having a fenestra cut for that purpose. (Fig. 860.) 
Every movement of the patient is imparted to the suspended box, so that, 
whether he rises or inclines to one side or the other, the limb itself cannot 
be disturbed. This dressing is in every way superior to that of Salter, 
which consists of a tin case adjusted to the posterior surface of the leg and 
placed in a sling, which is suspended to two wheels, constructed to run on the 
centre-bar of a cradle placed over the limb. (Fig. 861.) 
Treatment of overlapping.—Cases will be encountered in which there is 
overlapping, and where it becomes necessary to modify the treatment so 
that this may be overcome. To accomplish this there are two methods, 
which are the opposite of each other, namely, extension and flexion. 
Remove the hair from the leg and apply adhesive strips two inches wide 
along its sides, extending upward as high as the upper end of the lower 
Fig. 859. 
Fracture of the leg dressed with the fracture-box. 1028 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
fragments. The longitudinal strips of plaster should be rendered addi- 
tionally secure by circular ones. The leg being now placed upon a pillow 
Fig. 860. 
Fracture of the leg treated by the box and suspension apparatus. Also block with three holes, one end of the 
suspension-rope being tied into the upper hole, and the other passed through the two lower holes. 
in the fracture-box, the ends of the plaster must be conducted through 
vertical slits in the foot-board, and fastened to a piece of board, forming 
Fig. 861. 
a stirrup similar to that used in the extension apparatus for the thigh. 
To this stirrup a cord is to be attached, running over a pulley, and a weight 
fastened to its extremity. (Fig. 862.) If the fracture is near the ankle, the 
adhesive strip may be applied in the form of a spica about the heel and in- 
step. (Fig. 863.) If the weight required to make the necessary extension 
is great, it will be necessary to elevate the foot of the bed, as in fractures 
Salter’s cradle. FRACTURES OF THE TIBIA AND FIBULA 
1029 
of the femur. The lateral support of the leg is supplied by bringing up 
and securing the sides of the box with strips of bandage. 
Fig. 862. 
Fig. 863. 
Fracture of the bones of the leg dressed by extension in tlio 
fracture-box. The upright for the pulley is connected to a 
piece which fits into a mortise formed in the under surface of 
the box and thus can be drawn out or pushed in at pleasure. 
Adhesive plasters applied to the 
heel and instep. 
Neill's apparatus.—Professor John Neill employed a long fracture-box for 
such cases, making extension and counter-extension by adhesive strips at- 
tached to the upper and lower portions of the leg, and connected to cor- 
responding parts of the box, as represented in Fig. 864. 
Fig. 864. 
Professor Neill’s mode of applying extension and counter-extension in frac- 
tures of the leg with overlapping. 
By sawing the sides of the box down at the knee, this apparatus can be 
used with advantage in cases of compound fracture of the leg where it is 
necessary to maintain extension and counter-extension, as the lower sides 
can be let down without in any way affecting those forces. (Fig. 865.) 
Fig. 865. 
Professor Neill’s long fracture-box for the treatment of compound fractures 
of the leg with overlapping. 
When the fracture is so low down that sufficient extent of surface for the 
extending plasters cannot be had to insure their adhesion when the weight 
is attached, or when the surface is so damaged as not to admit of their appli- 
cation, we may, in some cases, resort with great advantage to the plan of 
flexion, or the method of Pott, by which all muscular disturbance is over- 
come. A light piece of board, long enough to extend four inches above the 1030 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
knee and two inches below the foot, is cut so as to conform to the leg and 
a portion of the thigh in the semi-flexed position of the limb. (Fig. 866.) 
This splint is to have an opening for the external malleolus, 
and should be covered with abundance of padding. The leg 
being flexed, and the requisite extension and counter-exten- 
sion made to correct the deformity, its outer surface should 
be laid upon the splint, all inequalities filled up with cotton 
or oakum, and the outside of the foot raised so as to keep it 
in line with the great toe and the inner margin of the patella. 
Along the internal aspect of the limb, from the ankle to the 
knee, a second splint of binders’ board should be applied, pre- 
viously well softened in hot water so as to admit of its being 
moulded to the part, and having an opening for the internal 
malleolus, with padding interposed. These two splints can 
be secured to the leg by strips of adhesive plaster, or, what 
is better, by a roller bandage. The patient can lie upon the 
back or can incline to the injured side, as may best comport 
with his comfort. I consider this simple appliance prefer- 
able to any other device of the kind, in all cases where the 
displacement of fragments in fractures of the bones of the 
leg proves in any degree obstinate. 
When the shortening persists and cannot be corrected by 
the best-appointed efforts, the tendo Achillis may be divided 
subcutaneously (a rare necessity), and the subsequent treat- 
ment carried out either in the position just described or in the extended one, 
in the fracture-box. 
In uncomplicated cases, after the lapse of two or three weeks, or after the 
swelling has subsided, an immovable appareil may be applied, and tbe patient 
be allowed to sit up, or to move about on crutches. For this purpose two 
pieces of light binders’ board should be cut, one for each side of the leg, 
long enough to extend from the knee to the toes, and fashioned so as to cor- 
respond to the figure of the limb and the foot. (Fig. 867.) These should 
be thoroughly softened in hot water, and 
after applying a roller to the leg (observing 
particularly to pad well with cotton about 
the malleoli, tendo Achillis, and spine of 
the tibia) should be moulded neatly to the 
inner and outer aspects of the leg and foot, 
and made fast by two or three spiral re- 
versed rollers, each one receiving a coating 
of liquid glass or of starch. In twenty-four 
hours the dressing will be sufficiently firm, 
and the patient may be relieved from the 
tedium of the bed. This may be worn for 
two or three weeks, when all dressings may 
be discarded and attention given to the 
motions of the ankle- and knee-joints. A 
less cumbersome and equally efficient dress- 
ing can be made with plaster rollers, in the 
use of which it is only necessary to apply 
first a dry roller to protect the skin, and 
over this the plaster bandages, which, as 
soon as the gypsum sets, will form a per- 
fectly secure case for the limb. A patient 
ought not to venture his entire weight upon the limb before seven or eight 
weeks have elapsed. 
Various other forms of apparatus are in use for the treatment of frac- 
tures of the legs. Among these may be mentioned Liston’s modification 
of McIntyre’s splint, which, having a joint at the knee and a screw be- 
E’lG. 866. 
Splint for treating 
fracture of the bones 
of the leg in the Pott 
position. 
Fig. 867. 
Binders’ board splint for fracture of the leg. FRACTURES OF THE TIBIA AND FIBULA. 
1031 
tween the leg- and thigh-pieces, may be used either as a straight splint or as 
a double inclined plane. The pieces for the support of the leg and thigh are 
so made as to admit of being shortened or lengthened and thus answer for 
the limbs of different patients. The splint being well padded, the foot is first 
secured to the foot-piece by the turns of a roller, and afterwards the leg and 
the thigh, leaving, in case of a compound fracture, the wound uncovered. 
Counter-extension is made by the thigh resting against the thigh-piece, the 
apparatus being in the form of the double inclined plane. (Fig. 868.) Splints 
Fig. 868. 
made of wire, as those of Bauer, or of tin (Big. 869), have been recommended. 
In oblique fractures, and when the upper fragment tends to rise above the 
level of its fellowT, Malgaigne 
has devised and used a steel 
segment, with an opening 
at each extremity, through 
which is passed a leather 
strap, having a buckle at one 
end. At the summit of the 
steel arch is fitted a screw 
with a sharp point. The 
limb is laid upon a double 
inclined plane well padded, 
the steel arch is placed across 
the leg a little above the seat 
of fracture, and the point of the screw pushed boldly down to the bone. The 
strap is buckled beneath the splint, and, if necessary, the screw may be turned 
Liston’s McIntyre splint applied 
Fig. 869. 
Perforated tin splint. 
Fig. 870. 
Malgaigne’s apparatus for oblique fracture of the leg applied—From Malgaigne. 
until the fragments are brought into close contact. (Fig. 870.) This appa- 
ratus, like the hooks of the same distinguished surgeon for fracture of the 
patella, is capable of doing much evil by exciting erysipelas, and the case 
which would justify its use must be very exceptional indeed. 1032 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Another plan of overcoming the shortening is to take two pieces of binders’ 
board, moidded to the sides of the leg and foot, similar to the appliance 
shown in Fig. 867. When dry, cut tAvo pieces of adhesrce plaster, which are 
spread on both surfaces, corresponding to the form and size of the splints. 
On the inner side of these the plasters are to be laid down smoothly and 
made to adhere. Let the hair next be cleanly shaAren from the limb, and the 
skin well cleansed and dried ; Avhile extension and counter-extension are being 
made so as to restore the leg to its proper length, warm the plaster surface 
of the two splints, then place one on each side of the leg, and make them fast 
by the turns of a roller extending from the foot to the knee. 
Fractures of the Tibia. 
Fracture of the tibia alone is much less common than fracture of both 
bones of the leg, and about as frequent as fracture of the fibula, these bones 
being each broken 437 times in 8667 cases of fracture received into the Penn- 
sylvania Hospital. That it should occur independently of any similar injury to 
the fibula, a bone so very slender and delicate, is due to its exposed position, 
—a considerable portion being subcutaneous,—and also to its tarsal articula- 
tion, in consequence of which the force of falls upon the foot is transmitted 
directly to the bone. The superficial position of the tibia renders it pecu- 
liarly liable to compound as well as to comminuted fractures. It may be 
broken in any part of the shaft or through the extremities. In 246 cases 
recorded in the table, 45 were in the upper, 81 in the middle, and 120 in the 
lower third. The most common displacement is a lateral one, the fragments 
overlapping, the lower being on the fibular side. (Fig. 871.) The fracture 
occurs with about equal frequency on the two 
sides. A case of separation of the upper epiph- 
ysis in an infant, through the violence of a mid- 
Avife, reported by Madame Lachapelle, I have 
already referred to when treating of fractures 
of the condyles of the femur. This case, so far 
as I know, is unique. Several eases of separa- 
tion of the lower epiphysis have been recorded : 
one by Quain,* in a boy seventeen years old, 
who fell with his foot doubled under him; 
another by Holmes ;f a third by Voss,! in a boy 
of fourteen; and a fourth by R. W. Smith,§ in a 
of sixteen. A lad ten years of age was ad- 
mitted into the Pennsylvania Hospital in 1876 
Avith a compound fracture of the lower epiphysis, 
the epiphyseal fragment projecting some dis- 
tance through the external Avound. 
Fractures which occur near the upper ex- 
tremity of the bone and extend into the knee- 
joint are formidable injuries, and, if they are 
compound, seriously endanger the limb and the 
life of the patient. A fracture may pass through 
the tibia even above its articulation with the 
fibula. When the bone is broken at the lower end Ave may expect to find 
the fibula also fractured. 
Fracture of the inner malleolus is not a very common accident. The 
process may be broken in three ways,—transversely near the tip; on a level 
with the articular surface of the astragalus ; and obliquely, the fracture 
beginning in the shaft above, running dowmvard and outward or inward, 
and detaching the pi'ocess at the angle of union with the articular surface 
Pig. 872. 
Fig. 871. 
Fracture of 
the shaft of 
the tibia. 
Fractured 
malleoli and 
lower end of 
the tibia. 
* Quain’s Medical Journal, August 31, 1867. 
f London Pathological Society’s Transactions, vol. xiii. p. 187. 
J New York Journal of Medicine, November, 1865. 
| Hamilton on Fractures, etc., p. 446. FRACTURES OF THE TIBIA. 
1033 
of the tibia. (Fig. 872.) When the tibia alone is broken, the direction of the 
fracture is—approximately, at least—transverse. 
Causes.—These are, in most instances, such as act directl}-, as a forcible 
blow, the kick of a horse, or the passage of a wheel. Those which operate 
indirectly, as in falls upon the feet, are apt to involve both bones. Proud- 
foot* gives a case of fracture of the tibia within the uterus from, it was 
supposed, severe pressure on the abdomen about the sixth month of preg- 
nancy. The malleolus may be broken by forcible abduction or adduction 
of the foot. 
Symptoms.—As there is often little, if any, displacement, a careful exami- 
nation is necessary to discover the lesion. Persons have been able to walk 
with a broken tibia. There is usually persistent pain, aggravated on press- 
ure, and, after a time, discoloration. Some inequality may be detected by 
carefully running the fingei’s over the spine and the subcutaneous surface 
of the bone; also by grasping the bone above and below the suspected seat 
of injury and forcibly pressing the parts in opposite directions, motion and 
perhaps crepitus may be discovered. When the fracture is near the ankle, 
the lower fragment will obey the motions of the foot, and may, by acting 
upon the latter, be forced backward, forward, outward, or inward, giving 
rise to marked deformity. The same is true in fractures near the upper 
end of the bone: the lower fragment may be carried outward and back- 
ward, from the movable nature of the superior tibio-fibular ai’ticulation. 
The line of fracture is generally from within outward and from below 
upward, a direction exceedingly favorable to lateral displacement of the 
bone. If the fracture is at the upper end of the bone and extends into the 
joint, there will be a large effusion into the articulation. When the malleolus 
is broken, there may be no displacement, the fragments being kept together 
by the strong fibrous investment which is spread over its surface, yet its 
mobility can be detected by pressure. Should the ligamentous expansion be 
completely ruptured, the lower fragment will sink down, and the distance 
between the process and the bone from which it is broken will be increased 
by abducting the foot, in consequence of the traction made on the internal 
lateral ligament. The chief symptom denotive of a separation of the lower 
epiphysis is said by R. Smith to be this,—“ that the internal malleolus 
preserves its natural relations to the foot, but not to the leg or the outer 
ankle.” The accident may also in this way be distinguished from luxation 
anteriorly of the inferior end of the tibia, in which injury the malleoli 
maintain their proper relations to the leg, but not to the foot. Professor 
Quain remarks that it may be distinguished from a fracture at the lower 
end of the bone “ by the absence of a sharp, irregular edge, and by its 
smooth, rugous feel.” 
Prognosis.—In simple fracture of the shaft of the tibia, union occurs with- 
out apparent shortening, and generally with very trifling, if any, deformity. 
If the knee- or ankle-joint is implicated, the danger of anchylosis, more or 
less complete, will be imminent. When the malleolus is detached, its union 
may be ligamentous. 
Treatment.—When the fracture is in the shaft of the bone, the manage- 
ment of the case is very simple indeed. The limb should be placed in the 
fracture-box, after the manner of treating fractures of both bones, either 
with or without suspension ; or it may be embraced on each side with 
binders’ board, soaked in hot water, moulded to the sides of the leg and 
foot, and bound on with a roller. In the course of eight or ten days the 
inflammatory swelling will have subsided : the leg should then be done up 
in some form of the immovable appareil already described, and the patient 
be permitted to leave his couch, on crutches. It is useless to confine him 
to bed under such circumstances until the bone is consolidated. There is a 
form of the immovable dressing often used for these fractures, known as 
the Bavarian. Take two pieces of canton flannel or of blanket, the length 
* Boston Medical and Surgical Journal, vol. xxxv., 1846,—quoted by Hamilton. 1034 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
of the leg, and more than wide enough to envelop its circumference. They 
should be cut so as to correspond to the outline of the leg and a part of the 
foot. Place one of these over the other, and sew them together in the 
middle: the seam answers to the back of the leg. The leg and foot being 
placed upon this, the inner layer of flan- 
nel is brought up and made fast by pins 
in front of the leg and on the dorsum of 
the foot. (Pig- 873.) The limb being 
placed in the proper position, equal parts 
of plaster and water should be mixed 
together, then poured thickly over the 
surface of the flannel next to the limb, 
and distributed properly with a spatula ; 
after which the second piece of flannel 
is brought up about the leg, and the 
whole smoothly modelled to the parts 
by the hand of the surgeon. Before the plaster sets, the pins should be 
removed from the inner flannel, and a few strips of muslin tied about the leg 
to keep the dressing secure. When it is desired either to inspect the limb 
or to remove the dressing entirely, it is only necessary to untie the encircling 
pieces of muslin and draw the edges of the flannel asunder, when the two 
halves will fall apart, the back seam acting as a hinge. Any swelling of 
the limb is also accommodated by the pi’esence of this hinge, and, con- 
sequently, the danger of undue pressure is obviated. The sides can again 
be brought together if desired, and are capable of giving the support with 
as much accuracy as when first applied. Should there be an external 
wound, an opening in the plaster and flannel can be made to correspond 
with it, and the dressing thus rendered applicable to a case of compound 
fracture. 
Professor Gross speaks favorably of a tin case with a foot-piece, as being 
well suited to the treatment of all fractures of the tibia. 
When the fracture involves the upper end of the bone and extends into the 
joint, local depletion and cold applications become necessary in order to pre- 
vent the evil effects of inflammation. Whether the joint is entered or not, 
the extended position is to be preferred, with the knee a little flexed, so that 
in the event of permanent stiffness resulting the leg will be in the best posi- 
tion for future usefulness. The movements of the thigh must also be con- 
trolled, for its condyles will serve to give support to the head of the tibia and 
prevent its displacement. The long fracture-box meets most perfectly the 
indications to be fulfilled in the treatment of this injury. A pillow should 
be laid upon it, with a moderately thick compress of flannel fixed behind the 
knee. Upon this the leg and thigh are to be placed, the foot secured to the 
foot-board, and the sides of the box brought up and tied with strips of muslin. 
If there is displacement by the lateral separation of the tibial tuberosities, 
or by the tilting forward of the upper fragment of the tibia when the lesion 
is below the tubercle, it will be necessary to mould a light piece of felt or of 
binders’ board to the posterior part of the joint, extending four inches above 
and six inches below the fracture, and, after interposing a sufficient amount of 
cotton, to fasten the splint firmly with a roller, and then place the limb in the 
long fracture-box as before. When the internal malleolus is broken, we may 
employ either the short fracture-box or the side-splints of binders’ board, 
taking care to maintain the foot at a little less than a right angle with the 
leg, neither inverted nor everted, and also to defend the surface of the leg 
and foot from pressure by sufficient padding. In five or six weeks all dress- 
ings should be laid aside. As early as the third week it is necessary to make 
gentle movements of the ankle and the knee, so as to establish the func- 
tions of these joints. The employment of massage will serve to lessen the 
swelling of the foot and leg, so common when the patient begins to get 
about. 
Fig. 873. 
Bavarian immovable splint,—the flannel applied 
before the plaster is poured on. FRACTURES OF THE FIBULA. 
1035 
Fractures of the Fibula. 
These fractures are about as frequent as are those of the tibia. They 
may take place at any part of the bone, but are most common at the lower 
third. By a reference to the table it will be seen that in 252 cases, 16 were 
in the upper, 26 in the middle, and 210 in the lower third. Although Dupuy- 
tren found that of the 207 cases which he collected over two-thirds were on 
the right side, yet the observation does not hold good of the 218 cases which 
appear in the table, 113 being on the right side and 105 on the left. The 
same author asserts that the ratio of fractures of the fibula to other frac- 
tures of the leg is as one to three, whilst the table makes it about one to 
three and a half. We further learn from the table that of 315 cases, 273 
were in males and 42 in females. 
The influence of age on the frequency of this fracture will appear from the 
following table : 
Age. 
Under 10 years 
From 10 to 20 years 
“ 20 to 30 “ 
No. of Fractures. 
58 
“ 30 to 40 “ 
107 
“ 40 to 50 “ , 
60 
“ 50 to 60 “ 
37 
“ 60 to 70 “ 
10 
“ 70 to 80 “ 
Total 
Malgaigne, in his collection of 109 cases, saw none below the age of fifteen. 
Causes.—These fractures are produced both by direct and by indirect 
force, but by the former less commonly than by the latter. When pro- 
duced by the first factor, as by a blow, the wheel of a wagon, 
or the kick of a horse, the fracture will usually be found 
at the point where the force is applied; but if by indirect 
force, the bone will give way with singular uniformity within 
the limits of the lower third, and generally within two and 
a half or three inches of the inferior extremity. In two 
hundred instances of this fracture Dupuytren could trace 
only twenty to the etfects of direct violence. The explana- 
tion is probably to be found in the sheltered position of the 
bone, its situation being such that no front or even antero- 
lateral blow upon the leg can reach it without first breaking 
the tibia. 
To understand the manner in which indirect force operates 
as a fracturing cause, we may refer for a moment to the nature 
of the articulation between the foot and the bones of the leg. 
The two malleoli, extending some distance below the articular 
surface of the tibia, form a deep recess, into which is received 
the astragalus as is a tenon into a mortise (Fig- 874), forming 
a hinge-joint, and practically only permitting the movements 
of flexion and extension. When a person falls directly upon 
the bottom of the foot, the latter not being inclined either in- 
ward or outward, the tibia alone must receive the weight of 
the body, and therefore the fibula escapes. When the force 
is applied to the inner or the outer margin of the foot, so as 
to force the latter into extreme adduction or abduction, the 
external malleolus is subjected to powerful pressure,—in the 
first, or that of adduction, by the outer surface of the calca- 
neum, and in the second, or that of abduction, by the outer 
surface of both the astragalus and the os calcis, in which last position the 
internal lateral ligament is frequently ruptured, and the injury followed by 
a partial luxation of the ankle. The fracture, therefore, may take place, as 
Fig. 874. 
Articular surface 
for the astragalus. 1036 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
was first pointed out by Boyer, in these two opposite ways. JDupuytren re- 
quired for the production of the fracture by abduction the precedent lacera- 
tion of the internal lateral ligament or the giving way of the internal mal- 
leolus, believing that until this took place the calcaneum could not press 
sufficiently hard to break the bone, and, further, that after such laceration 
the weight of the body is communicated to the leg in a changed line, that is, 
in the direction of the fibula rather than in that of the tibia. Maisonneuve* 
does not admit this explanation, believing neither in adduction nor in ab- 
duction as a means of producing fracture above the external malleolus, but 
in external rotation of the foot. This rotation of the foot internal as well as 
external doubtless does occur, but it is secondary to that of adduction or ab- 
duction, and follows from the form of the foot. When a person walking over 
an uneven surface loses his balance, and in the struggle to regain it the 
foot is suddenly forced into a state of adduction, the weight of the body 
is received upon its outer margin, the most prominent part of which cor- 
responds to the metatarsal part of the little toe; thus the toes are forced 
inward, and rotation of the foot is produced. So also when in the mis-step 
the foot is abducted, the weight is thrown upon its inner border, the salient 
portion of which is the metatarso-phalangeal projection of the great toe, 
and external rotation of the foot occurs. The fracture then may follow 
violent twists of the foot, the sudden turning in or out of the ankle, or falls 
when the foot is wedged in between unyielding surfaces. It was in the last- 
mentioned way that Sir Astley Cooper broke his fibula. 
Symptoms.—It is not always an easy task to determine the existence of a 
fracture of the fibula, especially if it is situated above the lower third. Pain, 
swelling, discoloration, inability to rest the weight of the body on the foot, 
and mobility, with or without crepitus, when the bone is pressed in opposite 
directions above and below the suspected point of injury, are the signs of the 
injuiy. When the bone is broken within three inches of the ankle, the injury 
is known as Pott's fracture. There is usually no difficulty in recognizing a 
lesion of the fibula at any point in the lower third. Frequently the patient 
will be conscious of a distinct snap or sound produced 
by the yielding of the osseous fibres; some irregu- 
larity in the line of the bone may be discovered by 
the fingers passed over the surface; the foot, having 
lost the resistance of the external malleolus and often 
the check of the internal lateral or deltoid ligament 
in consequence of the laceration of the latter, is often 
found strongly abducted by the action of the peroneus 
longus and peroneus brevis muscles, and the internal 
ankle becomes unduly prominent. As a consequence 
of this position of the foot, the upper end of the lower 
fragment is carried inward towards the tibia (Fig. 
875), producing a decided depression over the seat of 
fracture. The mobility of this fragment may be as- 
certained by alternately adducting and abducting the 
foot. The upper fragment may remain unchanged, 
or, as is more commonly the case, may be carried 
inward towards the tibia. 
A singular difference of opinion exists among 
authors as to the frequency of displacement in these 
fractures. Hamilton found it present in all the cases 
which came under his observation except one ; Dupuy- 
tren declares that it existed in nine-tenths of his patients ; while Malgaignef 
states that in fracture produced by abduction of the foot there is neither 
displacement, swelling, nor deviation of the foot. Ecchymosis is deemed a 
Fig. 875. 
Fiacture at the lower fifth of 
the fibula, with the attendant 
deformity,—Pott’s fracture. 
* Maisonneuve’s Researches into Fractures of the Fibula, Archives Generates de Medecine, 
February and April, 1840. 
f Treatise on Fractures, Packard’s trans., p. 654. FRACTURES OF THE FIBULA. 
1037 
characteristic symptom, Malgaigne having never seen it in a sprain. I have 
seen this fracture occur without, but much oftener with, displacement, by 
whatever agency it may have been produced; and as to the declaration of 
Malgaigne that ecchymosis is not present after sprains of the ankle, I may 
say that 1 have seen it many times after such accidents. 
When the external malleolus is broken, the nature of the 
injury may be determined by grasping the process between 
the thumb and the fingers, when mobility and crepitus will 
be detected. 
Prognosis.—Union of the fragments in fracture of the 
fibula occurs as quickly as in other bones of the skeleton, 
and usually without any noticeable deformity. Occasion- 
ally it happens that the external malleolus fails to unite 
by bone. In eases in which the internal lateral ligament is 
torn, and, as a consequence, eversion of the foot follows, 
there are well-grounded reasons for apprehension. More 
or less stiffness of the joint, together with an undue fulness 
of the internal ankle, is liable to follow. (Fig. 876.) When 
this internal projection of the tibia is great, the weight of 
the body is transmitted to the foot in such a manner as 
tends to increase the prominence, and, in bad cases, the 
skin has become inflamed and ulcerated over the internal 
malleolus. 
Treatment.—The management of a case of fracture of 
the fibula, in any part above the lower fourth, is exceed- 
ingly simple. In a very docile patient simple rest on a 
pillow, without any retentive apparatus, will answer, though, as a rule, it is 
better to apply two pieces of binders’ board, well padded, along the sides 
of the limb, and fasten them with a spiral reversed roller. When the frac- 
ture is in the lower third and there is little displacement, the fracture-box 
will answer every purpose. The plantar surface of the foot should rest 
accurately against the foot-board, having the necessary padding between. 
If there is a tendency to eversion of the foot, as when the fracture is near the 
ankle and the inner ligament has been damaged, we have a special dressing 
which is much resorted to,—that of Dupuy tren,—and which, while it does not 
entirely fulfil all the indications demanded, does so better than any other at 
our command. The mode of preparing and applying it is as follows. Make a 
wedge-shaped pad, by taking a muslin bag nearly five inches wide, and long 
enough to extend from the inner condyle of the femur to the internal malle- 
olus of the tibia; stuff it with cotton or oakum, so distributed that the lower 
end will be two and a half inches thicker than the upper end. Place this 
along the inner side of the leg, the thick end over the malleolus, and upon it 
lay a wooden splint extending from the knee to a short distance below the 
foot. A bandage is next passed round the limb below the knee, making fast 
the upper end of the splint, and a second roller, in the form of the figure-of- 
eight about the ankle, secures its lower end, and at the same time draws the 
Fig. 876. 
Deformity after a 
badly - treated Pott’s 
fracture. 
Fig. 877. 
Dupuytren splint applied. 
foot to the splint (Fig. 877) ; in other words, it brings the foot from a state of 
abduction to one of adduction, which tends to force out, in some degree, the 
upper end of the lower fragment. The disposition of the roller at the ankle 1038 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
should be such as not to rise higher than the external malleolus, otherwise 
it will prevent the lower fragment from turning out. It is 
scarcely necessary to say that the turns of the upper roller 
must not descend too low, as they would tend to force the 
superior fragment towards the tibia. During the use of the 
splint the internal malleolus must be carefully watched, as the 
pressure may induce inflammation and ulceration. Generally 
after six or eight days the dressing can be laid aside and the 
fracture-box substituted. After the lapse of twenty-five or 
thirty days, passive motion must be commenced at the ankle, 
though the patient should not be allowed to rest the weight 
of the body upon the foot for six or seven weeks. Badly- 
treated cases of this kind will be seen where, in consequence 
of the eversion of the foot and the corresponding prominence 
of the internal malleolus, not only is the ankle exceedingly 
weak, but the distortion is also progessive. For such cases 
a shoe, with a splint attached (Fig. 878), will give great sup- 
port and comfort. 
Fig. 878. 
Splint for sup- 
port of the ankle 
after fracture with 
deformity. 
Compound Fractures of the Bones of the Leg. 
These injuries are very common, much more so than compound fractures 
of other bones. By reference to the table it will be seen that of 315 frac- 
tures of the tibia, 49 were compound and compound comminuted; of 315 
fractures of the fibula, 14 were compound and compound comminuted; and 
of 1074 fractures of both bones, 366 were compound and compound commi- 
nuted. Taking the aggregate of all the fractures of the bones of the leg,— 
1704,—no less than 429 were of the above character. 
Causes.—The greater proportion of these injuries which come into our 
hospitals result from the kicks of vicious horses, from railroad accidents, or 
in consequence of the limbs being caught in the machinery of manufactories 
or under falling walls. 
Treatment.—The mode of managing the external wound will depend on 
the manner in which it has been produced. When caused by the sharp point 
of one of the fragments, or by some sharp vulnerating body, it should be 
washed with carbolated water (one to forty) or sublimated water (one to one 
thousand), and the edges drawn together by silver or catgut sutures. The air 
may be excluded by adding a little flour and white of egg to the oozing blood, 
the effect of which will be to form a firm crust or scab. Collodion and silk 
gauze are sometimes used for this purpose: best of all, however, is the collodion 
and iodoform mixture. When the external wound is formed subsequent to 
the fracture, in consequence of the pressure of the displaced fragments from 
within, or from severe contusion of the parts inducing ulceration of the 
skin and subcutaneous tissue, quick union cannot be expected, and conse- 
quently it is only necessary to cover the parts with lint saturated with car- 
bolic acid and olive oil. 
If the ends of the broken bone are found protruding through the external 
wound, their reposition should be attempted, either by flexing the leg so as 
to remove all muscular resistance, and at the same time pressing the pieces 
into place, or by extension and counter-extension. Dilating or stretching 
the external opening by means of retractors will often favor the reduction. 
Should these efforts prove unsuccessful, it may become necessary to enlarge the 
wound, and, in some instances, to remove with the saw the sharp end of one 
or both fragments. During the adjustment the parts must be well douched 
with the bichloride solution (one to one thousand), after which the wound 
is to be closed by sutures and sealed by the air-tight crust mentioned above. 
Still graver cases will be met with, in which the soft parts are extensively 
damaged and the bone or bones comminuted, yet the vessels remain unin- 
jured. These, though serious, are not necessarily hopeless cases, especially COMPOUND FRACTURES OF THE BONES OF THE LEG. 
1039 
if the subject is young, or a person possessing a good constitution. All 
loose or detached pieces of bone should be removed, the parts rendered 
thoroughly aseptic, and the wound dressed antiseptic-ally : unless so dressed 
there should be no attempt at sealing up the opening; its closure would only 
serve to prevent the escape of purulent and other discharges, the retention 
of which must necessarily damage both the soft parts and the bone. 
The next step consists in placing the limb upon a pillow in the fracture- 
box, as in the treatment of an ordinary simple fracture. The surgeon should 
never relax his vigilance for one moment. He must see that no abscess 
which is liable to form after such an injury is overlooked, and on the earliest 
evidence of suppuration should open the wound, or, if the pus collects at some 
point more remote, evacuate it at once with the bistoury. Whenever sup- 
puration begins, the pillow should be removed from the box and its place 
supplied by bran, in which article we have not only the best means of im- 
parting an evenly-distributed pressure to the limb, but also a material ad- 
mirably suited to absorb and retain both the discharges and their odors. 
When the suppuration is overpast, the bran may again be exchanged for 
the pillow if desired. 
In still more intense degrees of complicated fractures of the leg, those, for 
example, caused by railroad violence or various kinds of machinery, where 
the bones are ground into pieces, the soft parts bruised, lacerated, and torn 
into shreds, the vessels and nerves destroyed, and the limb cold and pulseless, 
the duty of the surgeon is clear: amputation is the only resort, and should 
be done as soon as the patient has recovered sufficiently from the shock to 
endure the operation. 
Another condition is occasionally -witnessed, in which, in addition to com- 
minution of the bones, there is a purification of all the parts below the skin, 
the latter remaining unbroken or having only the cuticle detached in spots. 
After a shorter or longer time, depending on the degree of injury sustained 
by the blood-vessels, mortification will set in, rendering amputation necessary. 
In a case of this kind which I once saw, the sloughing was delayed for ten 
days, in consequence, I suppose, of the cavities of the vessels becoming slowly 
occluded by emboli. 
Hemorrhage.—In compound fractures we meet with two kinds of bleeding, 
—venous and arterial. The first may continue to ooze or flow for some time, 
even for days, from the external opening. Cold applications to the parts, and 
the elevation of the limb after it is dressed, will generally control it. The 
practice of binding on a compress, especially if the wound is large, is to be 
deprecated, as the blood finds its way among the components of the limb, 
stuffing the muscles and provoking suppuration. Arterial bleeding is of 
more importance. If it comes from one of the tibials and the fracture is at 
the lower third, the vessels should be sought for by incision or enlargement 
of the wound, and tied; if at the upper part of the leg and the flow is per- 
sistent, we have but one resort, and that is amputation. 
Beset as these complicated cases are with the hazards of erysipelas, py- 
aemia, hectic, exhausting suppuration, necrosis, and vicious position of the 
broken portions of bone, their management demands constant and untiring 
attention to details, as well as the exercise of mature judgment in the use 
of surgical dressings. Pressure inducing excoriation and sloughing of the 
heel and other parts must be guarded against; carbolated and other lotions 
thrown into the suppurating cavity ; laudanum and lead-water applied over 
inflamed surfaces; incisions made to evacuate abscesses; pressure shifted 
from place lo place, to prevent accumulation of inflammatory products ; 
dead fragments of bone removed; and a proper diet administered, with tonics to 
sustain the body through an ordeal of exhausting suppuration, and anodynes 
to alleviate pain and to procure rest: all these are matters which will require 
attention. After the union has taken place, there will usually be stiffness 
of the ankle-joint, and perhaps of the knee-joint, with much induration and 1040 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
thickening of the soft parts of the leg. This condition will require for its 
removal, motion, water douches, stimulating frictions, and well-applied press- 
ure by the roller. 
In many cases of these fractures of the leg, deformity will follow,—indeed, 
is unavoidable, even under the most skilful management. 
Fractures of the Bones of the Foot. 
Simple fractures of the bones of the foot are not common. Persons in 
falling from a height not unfrequently alight upon the feet, yet the bones 
of the leg are more likely to sustain the injury than are those of the tarsus or 
of the metatarsus. The explanation of this immunity from injury must be 
sought for in the abundance of cancellated tissue which they possess, in their 
irregularity of form, in their numerous articulations, and in the slight sliding 
movement which they are capable of performing on one another, thus dis- 
tributing and neutralizing the momentum of forces. Compound comminuted 
fractures of these bones are common, and are generally attended by such ex- 
tensive destruction of the soft parts, from the crushing nature of the violence 
wffiich produces them, that the foot is hojDelessly disorganized in its totality 
and will demand removal. 
These fractures are divided into those of the tai'sus, of the metatarsus, and 
of the phalanges. By reference to the table, it will be found that in 8667 frac- 
tures, 172 involved the bones of the foot, and were distributed as follows : 
Fractures of the astragalus, 7, of thecalcaneum, 14, of the other bones of the 
tarsus, 25,—making a total of 46 ; fractures of the bones of the metatarsus, 
26 ; of the phalanges, 9 ; unclassified, 91 : the total being 172. Of this number, 
no less than 77 were compound and compound comminuted fractures. 
The injury is almost peculiar to males. Of the 120 cases classified, 118 
were in males and only 2 in females. The largest number occurred between 
the ages of twenty and thirty, and amputation was performed forty-four 
times,—an evidence of the extensive damage sustained by the structui’es of 
the foot. The mortality following these accidents is shown by the tact that 
23 out of the 172 cases died. 
Fractures of the Astragalus.—This bone, being located between the malle- 
oli, is less exposed than the other pieces of the tarsus, and will often escape 
injury when the latter are extensively broken. Being interposed between 
the os calcis and the tibia, it is placed in the direct line of support of the 
body, so that the forces which reach it injuriously are transmitted through 
the calcaneum, and hence the latter bone is generally broken by falls in which 
the person strikes upon the feet. In nine cases out of ten collected by Dr. 
Monahan,* this was the manner in which the fracture occurred. 
The direction of the fracture may be longitudinal, transverse, or horizontal. 
In the case recorded by M. Tavignotf it was both longitudinal and transverse. 
Lonsdale;}; speaks of having seen a case in which the bone was broken in at 
least two directions. Malgaigne possessed a specimen of a transverse frac- 
ture ;§ and M. Rognetta has seen one of multiple fracture. Sir Astley Cooper|| 
mentions a very singular case, in which the line of separation was horizontal. 
Mr. has seen two cases of this fracture without the implication of 
other bones. 
Symptoms.—If there is no displacement of the fragments, the recognition 
of fracture of the astragalus is a very difficult—often, indeed, an impossible 
—task ; and this is true also of the other pieces of the tarsus. Hence some 
of these fractures have been discovered only by dissections. Bound as these 
* Hamilton’s Treatise on Fractures, etc., 5th ed., p. 502. 
f Bulletin de la Soci6te Anatomique, 1843, p. 170. From Malgaigne. 
j On Fractures, p. 531. 
$ Treatise on Fractures, p. 666, Packard’s trans. 
II Sir Astley Cooper on Dislocations, by Bransby Cooper, p. 290. 
If Surgery, vol. i. p. 388. FRACTURES OF THE BONES OF THE FOOT. 
1041 
bones are by strong and variously-disposed ligaments, and presenting so many 
articular faces, much displacement need not be expected. Moreover, when 
the swelling consequent upon the injury is considered, the difficulties of the 
diagnosis are further increased. Persistent pain, inability to bear pressure 
upon the foot, rapid swelling, and crepitus produced by flexing, extending, 
or abducting and adducting the foot, would constitute ground for predicating 
the existence of this fracture. When, however, displacement is present, the 
diagnosis is in some measure cleared up. 
Mr. Erichsen could distinctly feel the crepitus, and also the line of sepa- 
ration, in one of his cases. The other was a compound fracture, and the 
posterior fragment lay in the wound ; the anterior fragment was commi- 
nuted. 
Treatment.—When the skin is unbroken and there is no displacement, 
the treatment consists in flexing the leg and placing it on its outer side in a 
splint of binders’ board, moulded to receive both the leg and the foot, or 
simply in laying the leg upon a pillow, in the same position. Cold applica- 
tions of lead-water and laudanum should be used to control the inflammation, 
swelling, and pain. After the swelling has subsided, an immovable dressing 
of starch, silicate of soda, or plaster should be applied to the foot and ankle 
and to a portion of the leg, in order to insure quiet. When displacement ex- 
ists without the skin being broken, an attempt should be made to press the 
fragment back into place. Dr. Ashhurst was able to do so in a case which 
he has reported* Norris made a similar attempt, but failed. 
The propriety of reposition, even when no external wound is present, has 
been questioned by Hamilton and others in cases where the displacement 
is great. We are not in possession, however, of sufficient data to speak 
dogmatically upon this subject. In my own judgment, no efforts should be 
spared to restore the fragments to their proper position, and only in the 
event of failure to effect reduction should the excision of the bone be adopted. 
When its removal is decided upon, the entire astragalus should be extracted 
with antiseptic preeaiitions, and not the detached or loose portion, in Dr. 
Norris’s case, to which allusion has been made, only the displaced fragment 
was taken away, the part remaining in position next to the tibia being al- 
lowed to remain; it became carious, and, though it was afterwards ex- 
tracted, the disease had extended to the articular surface of the tibia and 
the fibula and to all the pieces of the tarsus, requiring finally the amputation 
of the foot, from which the patient ultimately died. 
When the fracture is a compound one accompanied by displacement, there 
can be no doubt about the propriety of excision. 
Mr. Erichsen, in his second case, a man thirty years of age, who had 
broken the astragalus by a fall upon the feet, removed, by enlarging the 
external wound, the displaced fragment, which lay posteriorly, between the 
external malleolus and the tendo Achillis. The patient died of pyaemia, and 
the after-examination showed that the anterior fragment had been broken 
into seven pieces ; and yet, notwithstanding this comminution, no crepitus 
could be felt. Mr. Bryantf speaks of two cases of this fracture which came 
under his care, both compound. In one, the anterior portion of the bone 
was broken off and forced entirely out through the external wound; in the 
other, the bone was broken into fragments and extruded below the external 
ankle. In the former, amputation was done ; in the latter, the patient re- 
covered without an operation, though the joint was left permanently stiff. 
Fractures of the Os Calcis.—This bone is particularly exposed to injury 
from falls upon the feet, notwithstanding the thick padding of fat with 
which it is covered. It is liable to be broken by force directly applied to 
its plantar surface, which may rive it into fragments. Malgaigne was the 
first to recognize this variety of fracture, as far back as 1843. It is more 
* American Journal of the Medical Sciences, April, 1862. 
f Surgery, p. 876. 1042 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
especially the subastragaloid part of the bone which suffers. Another vari- 
ety involves the post-astragaloid or, commonly speaking, the heel portion 
(Fig. 879), and has been generally attributed to mus- 
cular action ; oftener, however, in my judgment, it is 
caused by direct force applied to the heel when the 
limb is advanced, in which case the fracturing vio- 
lence would act upon the posterior portion of the bone. 
The two cases, however, related by Sir Astley Cooper* 
would seem to render the fracture explicable on no 
other theory than that of muscular action. The one 
was a lady who, while walking in a field, stumbled, 
and in the violent effort to recover herself broke the 
bone; the other was a lady in whom the fracture was 
produced by the muscular effort made to save herself 
from falling down a flight of stairs. The cases related 
by Petit and Desaultf seem to be of the same kind. In 
these the bone was broken in the act of regaining the 
equilibrium after making a false step. 
Mr. Anningson, of Burnley, England, met with a 
fracture of the os calcis produced in much the same 
manner.! A healthy woman, aged forty-two, in stepping from a store to the 
pavement, which was six inches lower, and forgetting that the two were not 
on the same level, was in the act of falling headlong, which she only pre- 
vented by an unusual muscular struggle, after which the leg wTas found dis- 
abled. On examination, a fragment of bone was found two inches and a half 
above the heel, drawn up by the tendo Achillis, and with the skin tightly 
stretched over it. The piece was about one inch wide, and did not involve 
the entire depth of the calcaneum. 
The exact situation of these fractures we have often no means of deter- 
mining. It seems very improbable that a sound calcaneum—a bone so 
strong and thick—could be severed by muscular power alone, except by the 
detachment of a thin stratum immediately underneath the insertion of the 
tendo Achillis,—a supposition which has not escaped the notice of writers, 
—and I am not aware that the history of any case would disprove this 
statement. 
Symptoms.—These differ according to the portion of the bone involved. If 
the subastragaloid portion is broken, the fracture is usually comminuted, and 
the fragments either settle down together or are driven into one another, in 
which event the vertical diameter or depth of the bone will be diminished, 
while its transverse diameter will be increased. The pain is severe, and 
greatly aggravated by the attempt to rest any weight on the foot. Mal- 
gaigne describes the swelling as being limited to the parts below the front 
of the ankle and the malleoli, and to the sole of the foot, none being present 
over the heel or in the space about the tendo Achillis. 
The limitations of the swelling may be explained by the attachment of the 
lateral, the anterior, and the long calcaneo-cuboid ligaments. These, in a 
great measure, isolate the subastragaloid from the post-astragaloid portion of 
the bone. Too much stress, however, must not be placed on this symptom, 
as the swelling is not invariably confined to these limits. The swelling on the 
two sides differs; that beneath the outer malleolus is soft and unresisting, 
whilst that beneath the internal malleolus has but little depth, and is due 
more to the displaced lesser apophysis of the bone than to the effusion of 
serum. Crepitus may or may not be present, and is most readily produced 
by rotating the foot, by pressing the heel from side to side, or by holding 
the heel and flexing the ankle, as in the cases reported by Mr. Gascoyen§ at 
jPlG 879 
Comminuted fracture of the 
post-astragaloid portion of the 
os calcis. 
* Sir Astley Cooper on Dislocations, by B. Cooper, p. 339. 
f Malgaigne, Treatise on Fractures, Packard’s trans., p. 667. 
j British Medical Journal, January 26, 1878. 
\ Medico-Chirurgical Transactions, vol. xxxix., 1856. FRACTURES OF THE BONES OF THE FOOT. 
1043 
St. Mary’s Hospital. When the post-astragaloid or heel part of the bone 
is broken, there will be pain, swelling about the heel, mobility, and crepitus, 
and if the line of separation is near the insertion of the tendo Achillis, 
more or less displacement backward and upward will follow, caused by the 
action of the gastrocnemius and soleus. This displacement of the posterior 
fragment varies from a quarter of an inch to five inches. In all these cases 
of extreme drawing up of the posterior fragment, the fracture must be near 
the insertion of the tendo Achillis. 
Prognosis.—Unfortunately, I am unable to make any deductions from the 
fractures of this bone recorded in our table, as only the general mortality of 
fractures of the bones of the foot was noticed in the source from which the 
material was drawn ; but after examining those cases in which the results 
have been recorded, and where the fracture was situated in the post-astraga- 
loid part and not comminuted, I find that recovery has generally taken 
place in from six to seven weeks, although the perfect use of the foot and 
ankle was not recovered until after a much later period. When the fracture 
involves the subastragaloid part, the case is far more serious, as being within 
the calcaneo-astragaloid articulation and generally attended with comminu- 
tion. Even in a case reported by M. Voillemier, in which both calcanea were 
broken in this part, the patient recovered. 
The three cases of Mr. Gascoyen, already alluded to, terminated favorably, 
as did also the cases of Beringuier and More, given by Malgaigne. The re- 
covery will be slow, and the patient may expect to suffer for a long time with 
severe pains in the sole of the foot, together with a stiff and swollen ankle. 
Treatment.—When the fracture is in the posterior part of the bone, 
and attended with displacement, the detached fragment being drawn upward 
by the muscles constituting the calf of the leg, the latter should 
be flexed upon the thigh and the foot extended upon the leg. 
Conjointly, these two postures furnish us with the best possible 
position for the limb. The displaced fragment should next be 
drawn down into place and retained by applying above it the 
centre of a strip of adhesive plaster, bringing the ends down 
on each side of the heel to the sole of the foot, where they are 
to be crossed and finally made fast over the instep. 
The limb should now be laid on its outside upon a well- 
padded double angular splint (Fig. 880), having the piece which 
supports the foot cut at such an angle as will conform to the 
extended position. To this the limb should be fixed by a few 
adhesive strips at intervals of four inches, or by a roller carried 
from the foot four or five inches above the knee. Should no 
displacement be present, position alone is all that is required. 
After the swelling subsides, a starch, plaster, or silicate-of-soda 
dressing should be applied. 
Thillaye devised for the treatment of this fracture a slipper 
with a leather strap attached to its heel, and which was to be 
fastened to a circular band surrounding the lower part of the 
thigh. Monro fastened the slipper to a garter laced about the 
calf of the leg. (Fig. 881.) He also placed a splint in front of 
the leg and over the dorsum of the foot, and bound it in place with a roller. 
(Fig. 882.) Professor Gross advises the use of a tin splint, well padded, fitted 
to the form of the limb, and extending from the middle of the anterior sur- 
face of the leg almost to the toes. Against all anterior splints it may be 
stated that extreme extension of the foot becomes very difficult to endure, 
neither is it essential to the adjustment. 
The division of the tendo Achillis would naturally suggest itself in the 
event of other measures proving inadequate to restore the displaced bone to 
its proper position ; but as the fragment depends for its vascular supply 
on its connection with this tendon, such an operation might, as has been 
suggested by Ammington, be followed by the death of the piece. 
Fig. 880. 
Double angular 
or Pott’s splint, 
modified for frac- 
ture of the calca- 
neum. 1044 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
When the fracture is subastragaloid, there is no necessity for splints; the 
leg should be placed in an easy position, and the inflammatory symptoms met 
by the assiduous application of cold lotions of lead-water and laudanum. 
After the danger from this source is past and the swelling disappears, the 
Fig. 881. 
Fig. 882. 
Monro’s modification of Thillaye’s apparatus for fracture of 
the calcaneum 
Monro’s dressing for fracture of the 
os calcis. 
immovable dressing may be applied and the patient allowed to go about 
on crutches. The surgeon must not neglect, at as early a day as possible, 
to make those movements which are required to prevent the probable an- 
chylosis of the ankle-joint. 
Though such an accident has been said to occur, there are, I believe, no 
well-authenticated cases of fracture of the tuberosities of the calcaneum caused 
by muscular action. It is impossible to conceive of one of these strong 
processes being broken away by the action of muscles like the abductor of 
the great toe or the little toe, or by the contraction of the short flexor of 
the digits. 
Fracture of the Sustentaculum Tali.—This injury may occur singly, or it 
may be associated with a comminuted fracture of the subastragaloid portion 
of the calcaneum, and no doubt sometimes exists without being detected. 
Causes.—There are two ways in which the injury may be produced : first, 
by a fall directly upon the heel part of the foot, forcibly driving together the 
os calcis and the astragalus ; secondly, by force applied to the outer side of 
the foot when the latter is strongly adducted. The latter manner of pro- 
ducing this lesion was first pointed out by Dr. Abel.* The external lateral 
ligament may be broken either before the process of bone gives way, or im- 
mediately after the accident: if before, the force transmitted to the susten- 
taculum tali will be immediate and intense. 
Symptoms.—The signs of an uncomplicated fracture of the sustentaculum 
tali are, severe pain experienced on the inner side of the ankle and below the 
internal malleolus, and extreme abduction of the foot as soon as the patient 
* Arch, fur Klin. Chirurg. FRACTURES OF THE METATARSAL BONES. 
1045 
attempts to rest it upon the ground. The heel will also be shortened; while 
crepitus, that most decisive of all signs of fracture, will generally be absent. 
Differential Diagnosis.—This injury may be confounded with commi- 
nution of the calcaneum, with Pott’s fracture of the fibula, and with fracture 
of the internal malleolus.* 
In cases of comminuted fracture of the os calcis, both malleoli sink tielow 
the normal level, the pain is diffused or general, and the heel may be length- 
ened ; whereas in fracture of the sustentaculum tali the depression affects 
chiefly the inner malleolus, the heel is shortened, and the pain is limited for 
the most part to the inner side of the ankle. 
In Pott’s fracture, preternatural mobility and crepitation are prominent 
symptoms of the injury, but not so in fractures of the sustentaculum tali, 
since in the latter the disability of the foot and the severity of the pain are 
unusually great. 
In fractures of the internal malleolus, the inversion and occasional eversion 
of the foot, together with the locality of the pain, simulate a like injury of 
the process under consideration; but on a careful investigation it will be 
found that in the former the pain is higher up, the malleolus Is more promi- 
nent, the mobility is much greater, and the abduction of the foot is greater. 
Treatment.—The treatment consists in bringing the foot from its state 
of abduction to one of moderate adduction, and maintaining it in that position 
by the use of the Dupuytren splint; or, if the inner ankle is too sensitive to 
endure with comfort the pressure of the wedge-shaped pad, this dressing can 
be substituted by the plaster roller, carried over the foot, ankle, and a part of 
the leg, while the foot is kept in the proper position until the gypsum sets. 
The degree of disability following the injury will depend on the amount 
of displacement of the flexor tendons, which pass beneath the sustentaculum 
tali, and also on the degree of crushing to which the calcaneum itself has 
been subjected : except when these are exaggerated, the prognosis is not 
unfavorable. 
Fractures of the Metatarsal Bones. 
These fractures are generally the result of direct and crushing violence. 
They cannot be considered common accidents. Only three or four cases oc- 
curred at the Hotel-Dieu, Paris, during a period of eleven years. Twenty-six 
cases were admitted into the Pennsylvania Hospital during a period of forty- 
four years. As far as the individual pieces broken have been noted, the meta- 
tarsal bone of the great toe was most frequently involved, namely, seven 
times ; and next to this, the fifth or metatarsal bone of the little toe, four 
times. The displacement which follows usually consists in the depression 
of the phalangeal fragment. 
In the simplest form of these fractures—that is, where they are unat- 
tended by laceration and crushing—the prognosis is not unfavorable. Even 
in compound fractures the repair is often very rapid. Hamilton has seen 
the metatarsal bone of the little toe severed with an axe and yet healed in 
thirty days. Delamotte gives a case in which the first four metatarsals were 
divided in a similar manner, which yet recovered in forty days. 
Treatment.—A piece of binders’ board should be moulded to the poste- 
rior part of the leg and to the sole of the foot, the latter being nearly at 
a right angle with the leg. This splint must be well padded, and all the 
inequalities filled with oakum or cotton, so as to maintain the natural form of 
the sole of the foot. Any displacement should be corrected by such manipu- 
lations as ordinary skill would suggest, after which the splint should be 
secured to the foot and leg with a roller. 
Fractures of the Phalanges of the Toes. 
It is very rare to meet with a simple case of fracture of one of these 
phalanges; generally the injury is attended with so much damage to the 
* Dr. B. von Langenbeck, B. xx., 1878. 1046 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
other parts as to necessitate amputation. The great toe is the one commonly 
broken, and, as has been observed by Lonsdale and others, its fracture is 
often attended with unusually severe symptoms, such as swelling of the foot, 
and even of the entire limb, glandular enlargements, multiple abscesses, and 
exhausting hectic symptoms. This is indeed true of other injuries affecting 
this ’part of the foot. Malgaigne states that of forty-three amputations of 
the great toe for injuries, in the different hospitals of Paris, seven proved 
fatal. When the foot is broken, it is usually due to some weight fulling with 
crushing force upon it, and the great toe, being most prominent, receives the 
principal injury. Mobility and crepitus indicate the nature of the case, 
and the simplest plan of treatment is to apply a starch or silicate-of-soda 
dressing; or a piece of light wood, or of binders’ board, well padded, may 
be secured with a roller to the plantar surface of the affected toe, extend- 
ing back under the sole of the foot, so as to give fixation to the metatarso- 
phalangeal joint. 
DISEASES OF THE BONES. 
The osseous* system is liable to morbid processes similar to those which 
affect the soft parts, modified in some degree by the presence of the inorganic 
salts which give solidity and hardness of texture to the skeleton. The 
anatomical construction of a bone, particularly one belonging to the class of 
long bones, furnishes a very natural basis for the division of its inflammatory 
affections. A bone is surrounded externally by a fibro-vascular membrane,— 
the periosteum,—and internally encloses the endosteum or medullary mem- 
brane, prolongations of which extend into the cancellated tissue around the 
medullary canal. 
The inflammatory diseases are the following : 
1. Periostitis, an inflammation of the periosteum or external investing 
membrane. 2. Osteitis, an inflammation of the bone proper. 3. Endosteitis, 
an inflammation of the medullary membrane. 4. Osteomyelitis, an inflam- 
mation of both the medullary membrane and the surrounding bone, particu- 
larly of its cancellated structure. 5. Chondritis, an inflammation of the articu- 
lar cartilage. The four structures, viz., periosteum, bone, endosteum, and 
cartilage, are, in a certain sense, one,—that is, the vital connection or the.con- 
tinuity of structure is so intimate that disease in one part maj’ readily ex- 
tend to the others, thus involving the bone in its entirety. This statement 
does not apply with equal force to all part's of the bone at all periods of 
life; the cartilage which separates the epiphysis from the diaphysis appears 
to render the blood-vessel supply of the one independent of that of the other. 
Thus, in coxalgia, and in the like disease of the knee-joint, the inflammation 
clings to the articular ends of the bone, the shaft remaining unaffected ; and 
in caries located near the end of the shaft, the disease shows little tendency 
to implicate the joint. 
Bone is liable to be attacked by other diseases, which may or may not 
originate in a pre-existing inflammatory condition, and which are the result 
of a constitutional state, as syphilis, tubercle, rheumatism, cancer, osteo- 
malacia, rickets, hypertrophy, and atrophy. 
General Anatomical Considerations.—The bones consist of an external com- 
pact layer and an internal spongy or cancellated tissue; and, in the case of the 
long bones, of a medullary canal in the centre. They are surrounded by a 
laminated periosteum, the fibres of which are closely interwoven. This struc- 
ture is connected to the bone which it invests by filamentous prolongations 
of its own tissue and by blood-vessels, which ramify in the superficial layer 
of the periosteum and afterwards pass through the deeper laminae. Through 
all portions of the bone run canals, called Haversian canals. These open out- 
ward upon its surface, and also inward towards the medullary cavity, and 
are lined by a small amount of connective tissue, which serves to connect 
the vessels to the walls in which they lie. On the inside of the medullary PERIOSTITIS. 
1047 
cavity there is a delicate fibro-vascular membrane,—the endosteum,—which 
supports the medulla, and the divisions of which penetrate into the cells of 
the spongy tissue. The vessels which ramify through the Haversian canals, 
and the connective tissue which lines the latter, are continuous with the 
periosteum and its vessels and with the endosteum and its vessels. The ar- 
ticular ends are tipped with cartilage, belonging, however, to the same group 
of tissue (connective) as the other portions of bone. 
Except as it may be slightly modified by the presence of inorganic salts, 
inflammation of bone does not differ in its phenomena from the same process 
elsewhere. It has the same stages of determination, congestion, and trans- 
udation ; it is attended by like effusions of serum, lymph, leucocytes, blood, 
or pus ; it may be followed by induration (sclerosis), or by softening and atro- 
phy ; and it may result in ulceration (canes'), or in mortification (necrosis). 
Periostitis. 
Inflammation of the periosteum appears under two different forms, the 
chronic and the acute, or the circumscribed and the diffused. 
It is rarely the case that the inflammation is confined strictly to the peri- 
osteum ; it involves also a portion of the compact tissue of the bone with 
which it is connected, giving rise to an osteitis, or, by extension into the 
medulla, may end in osteomyelitis. 
When the disease arises from constitutional conditions, not all the bones of 
the skeleton are alike liable to be attacked. Syphilitic periostitis generally 
elects the tibia, the ulna, the clavicle, and the cranial bones. 
When the subjects of the disease are children with a tuberculous diathesis, 
the tibia, the femur, the radius, and the ulna are attacked in preference to 
other bones. When the disease begins near the articular ends of bones, it 
should be always regarded with anxiety, as the continuity of the periosteum 
with the synovial membrane and with the ligaments of a joint will favor the 
extension of the morbid action to the latter. 
Causes.—Inflammation may be excited by external injury from blows, 
fractures, gunshot and other wounds, and I have no doubt is frequently 
induced by violent contraction of the muscles, the tendons of which are 
implanted upon the membrane. The same influence is active in the produc- 
tion of osteitis. Periostitis may also be excited by a progressive osteitis. 
Among the internal constitutional causes producing periostitis, usually 
chronic, are tubercle, syphilis, gout, and rheumatism. It may arise from 
exposure to the action of certain medicinal substances, as mercury and the 
fumes of phosphorus. Occasionally I have seen periostitis produced by dis- 
ease of the kidneys. 
Symptoms.—Circumscribed periostitis or chronic periostitis is characterized 
by local tenderness, pain, and swelling, without any very marked redness at 
first; the pain is usually increased at night, often attaining great severity 
when the patient becomes warm in bed. The swelling is not abruptly 
defined, but fades off into the adjoining parts, and is round in form. 
In other instances the symptoms pursue a more acute course. The skin is 
discolored, the tenderness becomes exquisite, and the entire limb is disabled, 
accompanied by more or less constitutional disturbance. 
When the periostitis is due to constitutional influences, the local symptoms 
are somewhat modified. If of rheumatic origin, the pain will often change 
or move from place to place, the articulations suffering most; the integument 
becomes white and glossy,—rarely red,—and thickened. There will be also 
signs of defective blood depuration, manifested in the abundance of urates 
which appear in the urine, and in a peculiar sour perspiration which collects 
on the skin. 
Pathology.—The pathological changes in circumscribed periostitis consist 
of an inflammatory transudation into both the superficial and the deeper 
strata of the membrane, forming an enlargement, sometimes termed a node. 1048 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
This transudation, consisting of fibrous lymph and leucocytes, serves to form 
a prominence over the surface of the bone. After this first effect, the in- 
flammatory product will undergo one of three changes: first, it may be 
gradually absorbed, as are similar infiltrations elsewhere; secondly, from 
contact with the bone, it may undergo ossification, much in the same manner 
as in fracture, in which event there remains a corresponding enlargement or 
permanent thickening of the bone, forming hard spines and rugosities or 
miniature exostoses ; thirdly, suppuration may follow, in which case a partial 
death of the underlying bone takes place, leaving a superficial bone-ulcer, 
which is repaired by granulation tissue. 
When the disease is the result of syphilis, the destiny of the node may be 
approximately determined by the period at which it makes its appearance. 
If in the advanced stage of the constitutional vice, the tendency will be to 
suppuration, and as a consequence a portion of the bone will die. 
Treatment.—When the periostitis arises from a traumatic cause, the 
symptoms will be of an acute character, and must be met promptly by ele- 
vation of the part, and the application of leeches, followed by evaporating 
lotions of lead-water and laudanum, and later by a fly-blister, over the affected 
parts. The bowels must be freely acted upon, and the diet restricted to light 
farinaceous articles of food. Pain is best controlled by morphine. 
Should the use of these remedies fail to arrest the disease, and the pain and 
swelling continue to increase, a free subcutaneous division of the periosteum 
should be made, after which the parts may be covered with a flaxseed-meal 
poultice. The effect of this procedure will be to relieve the pain, to allow 
inflammatory products to escape, and to rescue the bone from caries or 
necrosis. 
When the periostitis has a rheumatic or a syphilitic oi’igin, nothing an- 
swers so good a purpose as the iodide of potash, administered in doses 
varying from ten to twenty grains three or four times a day, largely di- 
luted with water. This remedy not only arrests the severe nocturnal 
exacerbations of pain, but also tends to bring about the resolution of the 
inflammatory formations. Until the patient is brought under the influ- 
ence of the remedy, the suffering must be relieved by full doses of opium, 
morphine, or laudanum. 
The induration of the soft parts over the bone, which is due to a periph- 
eral extension of the inflammation from the periosteum, and which some- 
times remains after the original disease has been vanquished, is best managed 
by the application of the tincture of iodine, or by massage, followed by firm 
pressure with a roller. 
Acute or Diffused or Infective Periostitis is often a most formidable dis- 
ease. It is rarely seen after twenty-five years of age, being generally met 
with between the tenth and the fifteenth year of life, and it affects boys 
oftener than girls. Although it is said occasionally to arise from local 
violence in healthy subjects, yet such cases must be very rare. Antecedent 
to such a condition there is either a tuberculous diathesis, or else a de- 
praved state of the general system supervening on some exhausting fever 
from which the patient has suffei’ed. The long bones are in most instances 
the ones attacked, and of these the femur and the tibia most commonly suffer. 
The progress of the disease is often exceedingly rapid. 
Symptoms.—A diffused swelling makes its appearance, which, after a time, 
becomes red, pits on pressure, is painful, and is either preceded or accom- 
panied bv shiverings, fever, a temperature of 103° F. and over, and complete 
loss of appetite. The limb becomes exceedingly sensitive and helpless. The 
swelling may extend over the whole length or only a portion of the limb 
involved, though, as a rule, it does not include the joints. The diffused 
character of the swelling is well calculated to mislead, and often irreparable 
damage is done to the bone before the true nature of the disease is even 
suspected. PERIOSTITIS. 
1049 
Diagnosis.—The real character of the complaint may be deduced from the 
following circumstances: first, the age of the patient, usually under twelve 
years, and its having either the history of a previous injury, received six or 
eight days before the invasion of the attack, or the well-expressed indications 
of a tuberculous state of the system ; secondly, the presence of a diffused swell- 
ing and of pain before any discoloration of the skin is discovered, and the 
limitation of the swelling, the latter rarely extending beyond a joint; thirdly, 
the presence often of an enlargement of the superficial veins of the limb, in 
consequence of the mechanical resistance offered to the circulation through 
the deeper trunks, of which the first are tributaries. 
Pathology.—Diffused periostitis differs from the limited or chronic variety 
mainly in the acute character of the inflammation. There is at first both 
a subperiosteal and a periosteal transudation, consisting of serum, lymph, 
leucocytes, and red blood-corpuscles, which separate the periosteum from 
the bone, finally ending in the formation of pus. The suppuration may be 
limited to only a portion of the bone, or it may detach the membrane up 
and down as far as the cartilage separating the diaphysis from the epiphy- 
sis, beyond which the disease seldom extends, though in some instances it 
has been known to transcend these boundaries and implicate the joints. 
The effect of disturbing the blood-vessel connection between the bone and 
the periosteum is to destroy the firmness of the superficial fibres of the 
former, and finally to cause its complete death. The affection seldom ap- 
pears in the severe form without the coexistence of osteomyelitis. The 
presence of infective organisms as being prominently concerned in the 
causation of the disease cannot well be doubted. In its advanced stage the 
purulent products find their way through openings in the periosteum and 
spread through the surrounding tissues. 
Prognosis.—In cases where the disease is quite limited, after the evacua- 
tion of the abscess, granulations may spring up from the periosteum, or, if a 
superficial portion of the bone dies and becomes detached, from the .Haver- 
sian canals of the osseous tissue, and a sound cicatrix may be established. 
When there is extensive suppuration around the bone, the risk of purulent 
infection is very great; and when a considerable portion or the entire diaph- 
ysis of the bone becomes necrosed, the patient may finally perish from the 
prolonged suppuration, which must continue until the dead shaft or the se- 
questrum can be removed,—the work, it may be, of many months. 
Treatment.—If the disease be recognized early, it is susceptible, in favor- 
able cases, of resolution. For the accomplishment of this end the limb should 
be elevated and free incisions of the periosteum made, followed by the thor- 
ough painting of the parts with the tincture of iodine. This remedy has 
been extolled by Billroth, and certainly is a very efficient agent. It should 
be applied twice in the twelve hours of the day. The bowels should be 
briskly moved by a cathartic, and in thirty-six hours, if the swelling and 
pain do not begin to subside, the parts should be covered with a blister, over 
which may be laid a light flaxseed-meal poultice. The warmth of the latter 
hastens the action of the vesicant, which will most likely be well raised in 
six or seven hours. If in defiance of these measures the disease does not 
yield, and fluctuation can be ascertained, one or several incisions through the 
soft parts down to the bone should be made, so as to give a ready exit to the 
pus, and antiseptic solutions should be frequently thrown into the wound. 
To counteract the exhausting effects of the suppuration, quinine and iron 
must be administered, together with stimulants and the most concentrated 
nourishment. If the bone perishes, its removal should be effected at as early 
a period as possible, unless the patient labors under much febrile disturbance 
of the system, when it is better to delay operative interference until the cir- 
culation becomes more quiet. The reproduction of the bone maybe expected, 
as the osteogenetic property of the periosteum of the contiguous bone is not 
permanently destroyed by the disease. 
If the disease arises from constitutional syphilis or from rheumatism,—a 1050 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
case of which I have never seen, and the existence of ’which I doubt,—full 
doses of the iodide of potash will be indicated. 
Osteitis and Caries. 
Inflammation of bone may be either superficial or deep; that is, it may be 
confined to the external portions of either the long or the short bones, or 
may extend to their deeper, cancellated tissue, including, in the cylindrical 
class, also the medullary structure. The disease is usually chronic in its 
course, and is generally associated with periostitis and endosteitis, either 
primarily or secondarily. 
Causes.—The causes are predisposing and exciting. Among the predis- 
posing causes are tubercle, rheumatism, syphilis, and those blood-changes 
which are engendered by low forms of fever. Age exercises a powerful 
predisposing influence. A very large proportion of the inflammatory dis- 
eases of bones occurs during early life or during the active growing period 
of osseous tissue, and when, of course, the nutritive processes are at high tide 
from the large amount of blood attracted to the epiphyses and the deep 
strata of the periosteum. Under such conditions it is not difficult to under- 
stand how the reckless movements, and the strains and shocks which the 
skeleton receives during irrepressible childhood and adolescence, may convert 
a physiological into an inflammatory state. Among the determining or ex- 
citing causes may be enumerated blows, strains, violent contraction of muscles, 
compound fractures, blood-changes, and exposure to a damp, cold atmosphere. 
Symptoms.—One of the earliest signs of osteitis is pain. This may be 
very slight at first, but becomes more pronounced as the disease advances, 
especially when pressure is made over the affected part. After a time it 
becomes a deep-seated ache, boring or gnawing in its character, and gener- 
ally much aggravated at night, or when the patient becomes warm in bed, 
or when the limb is rudely handled. Accompanying the pain is diffused 
swelling, which is of an oedematous nature, as shown 
by the indentations left in the soft parts when pressed 
upon with a finger. As these symptoms belong to 
periostitis, it is a difficult task to dissociate the two or 
to distinguish the one from the other; and if we could, 
the practical value of such knowledge would be of 
slight importance. It is very certain that neither can 
long exist separately without the other being involved 
in the same trouble. The symptoms wrhich indicate 
that the osseous tissue is implicated are the persistence 
of deep-seated boring pains, and long-continued alter- 
nations of improvement and relapses. When the in- 
flammation is chiefly periosteal, it is usual to have the 
surface of the bone studded over with little masses of 
bone, or osteophytes. The same condition will follow 
osteitis, though not at so early a period in the progress 
of the disease. (Fig. 883.) 
Caries.— If the disease advances to ulceration or 
caries, the thickening around the bone becomes more 
noticeable, the superincumbent planes of tissue become 
infiltrated with inflammatory neoplasia, lymph, and 
leucocytes, giving rise both to induration and to 
structural alteration, the normal structures being re- 
placed by connective and fat tissue. If the inflamma- 
tion is circumscribed in circumference or in depth, or 
in both, the vitality of the portion involved will in all 
probability be destroyed, and it will separate from the bone either in the form 
of a scale (exfoliation) or in small particles. Coincident with these changes, 
Fig. 888. 
Osteophytes springing from 
the tibia and fibula and some 
of the bones of the tarsus, from 
osteitis. OSTEITIS AND CARIES. 
1051 
and as preliminary to one of ejection, the soft parts over the affected portion 
of the bones become inflamed, and an abscess opens upon the surface. If a 
probe is now inserted into this opening, it will be brought into contact with 
either a movable fragment or with a rough and irregular surface of bare 
bone. The sensation imparted to the finger will be peculiar, and can scarcely 
fail to reveal what has occui*red. When the affected part belongs to the 
short or irregular class of bones, instead of scales or crumbling particles 
being detached, the dead portion will often separate in a small shapeless mass. 
After the disengagement and expulsion of the disorganized fragments, a 
cavity remains, the surface of which consists of minute ridges and spiculas 
of bone, presenting a rough, gnawed appearance, and constituting a bone or 
carious ulcer. (Fig. 884.) This ulcer is liable to all the complications which 
befall ulcers of the soft parts; that is, it may heal up spontaneously, it may 
extend in circumference and in depth, it may remain weak and indolent, 
without any tendency to repair, or it may be filled with a rank growth of 
granulation tissue, which will not 
only overtop the depression in the 
bone, but also protrude through the 
sinus in the soft parts. 
Caries often exists, followed by 
complete repair, without any ex- 
ternal opening being formed. This 
is frequently witnessed in Pott’s 
disease of the spine. 
When the inflammation, instead 
of lingering in the superficial layers 
of bones, extends into the deeper or cancellated tissue, it forms internal or 
deep osteitis. The more abundant the eancelli, the greater will be the ten- 
dency of the disease to spread. Accordingly, we find that the bones of the 
carpus, the tarsus, the vertebral column, and the articulating ends of the 
long bones are most commonly affected. 
Pathology.—The changes which take place within the hidden recesses 
of bone in simple inflammation are analogous in most respects to the phe- 
nomena which characterize a similar process in other tissues, and, as I have 
said, the inflammatory process is rarely, if ever, confined to what is generally 
understood as osseous tissue, but involves also the periosteum, the medullary 
membrane, and the intermediate net-work of connective material. The 
vessels lodged in the Haversian canals become over-distended with blood; a 
free transudation of liquid and cell-elements takes place into the scanty con- 
nective tissue between the vessels and their enclosing walls. Part of this 
perivascular connective tissue is converted into a soft jelly-like substance by 
the dissolution of its corpuscles, and possibly some of the latter may pass 
from a stable to an active state. Responsive to the presence of this fresh 
brood of wandering cells and fibrinous transudation, a change occurs in the 
walls of the Haversian canals, the lacunae, and the canaliculi. They begin 
to enlarge, not by virtue of any elastic property, but probably from the 
solvent or eroding action of some constituent belonging to the inflammatory 
neoplasm (it may be the osteoclasts of Yirchow) acting upon the osseous 
salts and thus dissolving their connection with the organic matter of the 
bone. These walls become wider and perforated, the contiguous channels 
opening into one another, until the bone assumes somewhat the appearance 
of the open, porous condition of cancellated tissue. Hew vessels are de- 
veloped and lie embedded in the midst of the transudation, thus forming 
granulations, which grow in all directions into the vacuities left by the 
widened and porous remains of the Haversian canals. The continued pro- 
liferation of these granulations may destroy the bone for some distance 
around the focus of disease. In this work the bone-corpuscles take no part; 
the essence of the process concentrates in the changes which occur in the 
walls of the vessels and in the connective tissue which lies in the Haversian 
Fig. 884. 
Caries or ulcer of the tibia. 1052 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
canals, the result of which is simply one of destruction to the bone without 
any power on the part of the latter to resist. 
In this rapid enlargement of the vascular channels of bone in osteitis we 
have a beautiful illustration of the wonderful adaptation of tissues to meet 
extraordinary conditions. Considering the resistance and the small size of 
these canals, unless the change which has been described did follow, the 
vessels themselves would be so rapidly compressed by the infiltration as to 
destroy the life of the bone, causing extensive necrosis, for it must be remem- 
bered that any sudden swelling of a bone from inflammatory infiltration is 
impossible; especially is this so in the compact portions of bone. The exten- 
sion of caries, like that of ulceration in the soft parts, is limited, in favor- 
able cases, by an inflammatory infiltration into the sound bone immediately 
around the diseased portion. This fills up the cancelli of the osseous tissue, 
and at the same time dissolves the connection between the diseased and 
the sound bone, the former breaking up into small particles, which are either 
discharged through an external opening, when such exists, or, in the absence 
of this opening, undergo interstitial absorption. The discharges resulting 
from caries of bone are composed of the lime salts, mingled with pus, blood, 
globules of oil, and minute particles of osseous tissue. 
In superficial caries, with an external opening, when the disease is arrested 
and the necrosed portions have been detached and. expelled, th e repair is effected 
by an abundant production of granulation tissue, derived from the vessels on 
the walls of the remaining cavity. This is converted into fibrous material, 
which, after the healing of the exteimal opening, becomes continuous with the 
superincumbent tissue, and, as it contracts and finally ossifies, causes the de- 
pressed cicatrix which is so often seen remaining after this form of bone-disease. 
Prognosis.—Inflammation once fully established in a bone rarely termi- 
nates by resolution, though such an event is not impossible. The evil effects 
of the disease may be local in their nature, that is, they may be limited to the 
destruction of a portion of the bone involved, which subsequently undergoes 
reparation ydthout materially impairing the usefulness of the part. When 
the disease implicates a joint, the function of the articulation will most prob- 
ably be destroyed. When to the morbid action in the bone there is added a 
deeply-rooted vice of the constitution, rendering the latter acutely sensitive 
to the presence of the inflammatory products, the danger is greatly enhanced 
by the hectic symptoms which are likely to follow. The social position of 
the patient should also exercise due weight in forming a prognosis, as often 
among the poor and indigent classes an inability to command the proper 
dietetic and hygienic conditions deprives the surgeon of the most potent 
means for controlling the disease. 
The age at which the disease appears constitutes another important con- 
sideration. If in mature or in advanced life, the prospect of recovery is less 
promising than when the patient is young. 
Treatment.—The treatment necessary in osteitis is both local and consti- 
tutional. 
When the disease can be clearly traced to a traumatic cause, independent 
of any marked constitutional predisposition,—a condition certainly very un- 
usual,—benefit will be derived from the local abstraction of blood, and eleva- 
tion of the part when possible, followed by the use of blisters and warm 
emollient poultices medicated with laudanum. In addition to these local appli- 
cations, the bowels should be thoroughly acted upon, after which calomel and 
opium, given in small and repeated doses, will prove to be the most efficient 
remedies at our command. The mercurial may be administered in doses of 
half a grain every four hours, with one-fourth of a grain of opium, and cau- 
tiously continued, always stopping short of the point of producing ptyalism. 
If the pain is not urgent, the opium need not be given oftener than once in 
five or six hours. The diet for the first few days should be restricted, after- 
wards it may be more liberal. Stimulants are contra-indicated. When the 
pain continues severe and persistent, the bone should be freely exposed by OSTEITIS AND CARIES. 
1053 
an incision and one or two openings made into its cancellated tissue by the 
trephine. In no other way can the pain be so quickly and permanently 
relieved. 
In the great majority of cases, however, the surgeon has to deal with an 
osteitis the local manifestations of which are only expressions of a general 
state which, in spite of all his resources, will run a definite course ; conse- 
quently the treatment must be purely expectant, and local measures are of 
little value. I am, of course, not here speaking of the disease as it affects 
joints. 
The general health takes precedence of everything else. It will be neces- 
sary to dii’ect the use of food rich in all the plastic elements of nutrition, such 
as milk, eggs, and meat, with fruits in their season, and to cause the patient 
to live as much as possible in the open air and to migrate during the heat of 
the summer months to the sea-side or the mountains. If the appetite fails, 
or should emaciation set in, quinine, the iodide of iron, the iodide of potash, 
and cod-liver oil, with preparations of malt, will be found extremely useful. 
When the osteitis terminates in ulceration or caries, it may be recognized, 
if an external opening is present, by the use of a probe. For this purpose 
the ordinary silver instrument of the pocket-case (Fig. 885) will usually 
Fig. 885. 
Silver probe. 
suffice, or, should the sinuses be tortuous, a probe made of a piece of light 
spiral wire may be employed, which, from its flexibility, can be insinuated 
into the winding track. (Fig. 886.) 
Frequently, in caries, whether from syphilitic or other causes, the diseased 
bone will be discharged in minute particles, intermixed with pus, and the 
case will undergo a spontaneous cure,—a fact which should teach the surgeon 
the propriety of not being too forward in resorting to early operation. 
Fig. 886. 
Author’s spiral wire probe. 
When, however, nature proves unequal to the task, much may be done 
towards hastening the cure by removing the diseased osseous tissue. This 
is notably the case where the caries affects the head of the tibia or the os 
calcis. The danger of delay in such cases lies in the involvement of adjoin- 
ing portions of the bone by the proliferation of the granulation tissue, so 
that of late years I am much more disposed to favor early operations than 
formerly. 
The removal may be effected in either of two ways: by destructive acids, 
or by the gouge. The acid employed for this purpose by Mr. Pollock is the 
sulphuric, which is applied, after exposure of the diseased portion of bone, 
first diluted with an equal quantity of water, and afterwards pure, by means 
of cotton, or of a glass brush. 
Chassaignac prefers muriatic acid. The object in view in both applica- 
tions is a chemical one,—to remove the crumbling bone by the action of 
the acid upon the lime salts; but it also excites healthy granulations. 
Fitzpatrick, after destroying the sinuses and exposing the bone by means of 
the Vienna paste, cut into the osseous tissue with the trephine, and applied 
the caustic freely to its surface. Boinet strongly advocated the use of the 
tincture of iodine as an injection, while Notta employed Villatte’s liquor* a 
preparation much used by farriers. The actual cautery has also been used 
for the removal of the diseased bone. 
* Villatte’s liquor consists of sulphate of zinc and sulphate of copper, aa, gr. xv, liquor of the 
subacetate of lead, and dilute acetic acid, f^iiiss. 1054 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
I prefer, however, the use of the gouge or curette, as a more speedy and 
thorough measure for getting rid of the unhealthy structure. The soft parts 
being divided by a curvilinear or a crucial incision, and the bone exposed, the 
gouge (Fig. 887) should be applied to the parts, scooping out the rotten and 
gnawed tissue. For the same purpose a gouge forceps (Fig. 888), or a 
scraper (Figs. 889 and 890), or a burr-head drill (Fig. 891) will be found use- 
Fig. 890 
Fig. 891. 
Fig. 887. 
Fig. 889. 
Fig. 888. 
Gouge for removing 
carious bone. 
Gouge forceps. 
Bone-scraper. 
Bone-scraper. 
Burr-head drill. 
ful. When the healthy structure is reached, it may be determined by its 
florid appearance and texture, characteristics strikingly in contrast with the 
gray or dark color and the brittle nature of carious bone. This is the opera- 
tion of evidement des os of Sedillot. After clearing away the disease, the 
cavity should be lightly packed with oakum or with lint moistened with a 
mixture of carbolic acid and sweet oil. This may be allowed to remain for 
two days, after which it must be removed and the parts washed out daily 
by injections of a solution of permanganate of potash or a weak solution of 
Lugol’s preparation of iodine, renewing the packing until the opening has 
granulated to the surface. 
When the disease involves the articular ends of the bones, without any 
disposition to anchylosis, and where the strength of the patient begins to 
fail under the continued suppuration, excision or amputation will often offer 
the only means of recovery. 
Suppuration.—Another result of osteitis is suppuration. This may be cir- 
cumscribed or diffused. Diffused suppuration in long bones is generally cen- 
tral in its commencement, extending gradually towards the periphery : hence 
it may originate in the medullary membrane. In the short bones this order 
of procedure is not noticed; it may commence as a periostitis and travel in- 
ward. The pus is not found in such cases evenly diffused through the can- 
celli of the bone, but disseminated in numerous small collections through 
its substance, at points where the osseous tissue has become softened and its 
compartments enlarged. SUPPURATION. 
1055 
Circumscribed Suppuration, or Abscess, first described by Mr. Brodie, may 
be regarded as an unusual affection. It generally occurs at the articular ends 
of bones, particularly in the tibia (Fig. 892), and consists in an accumulation 
of ill -conditioned, offensive pus. The amount of the col- 
lection varies very much, ranging from half a drachm to 
three or four drachms. The spaces of the cancelli become 
rarefied for some distance around the collection, or the ex- 
tremity of the bone may become generally expanded. The 
limiting wall of the abscess consists of a rich plexus of 
vessels embedded in lymph and corpuscles. 
Symptoms.—The symptoms indicative of bone abscess 
are in most respects similar to those of non-suppurative 
osteitis. The pain is deep-seated, boring, tearing, or gnaw- 
ing, always very severe at night. The soft tissues over the 
affected part become very sensitive, swollen, and cedema- 
tous, often without any external redness. The strength 
of the patient begins to fail, and with this there is marked 
emaciation. The presence of pus is usually attended with 
rigors, increase of temperature, and profuse perspiration. 
Although there are no symptoms strictly pathognomonic 
of this affection, the presence of a localized enlargement 
sensitive to firm pressure, recurring attacks of deep-seated 
pain and rigors, and a temperature above the normal stand- 
ard, are substantial grounds} for presuming the existence 
of such an abscess, especially when the head of the tibia is 
the seat of disease. 
Treatment.—The treatment of this abscess consists in 
uncovering the bone by a free incision through the soft parts, and excising, 
by means of a trephine or chisel, a portion of its substance sufficiently deep 
to expose and evacuate the purulent collection,—a practice introduced largely 
by Mr. Brodie. As these accumulations are never large, the instrument may 
not reach exactly the spot where the abscess is situated. On this account the 
surgeon should not prematurely abandon his search for the abscess. In case 
of failure it will be proper to extend the limits of the operation beyond the 
boundaries of the first cut, by employing the gouge. Owing to the neglect 
of this precaution, Mr. Brodie once amputated a limb which might otherwise 
have been preserved. 
The operation of laying open bone for the evacuation of pus is a very old 
procedure. It was advised by Celsus* and by Severinus, also by Heynef and by 
Petit. Marchette directed for this purpose an instrument called a “ piercer.” 
In America the operation had been done by Dr. Walker, of Virginia, as 
early as 1757, and later by Professor N. R. Smith. 
Fig. 892. 
Abscess in the head of 
the tibia. 
Multiple Abscess.—When an abscess follows an acute attack of osteitis, such 
as may result from cold or local injury, and the track of communication be- 
tween the surface and the location of the pus is indirect or tortuous, other 
abscesses may form, very much as is seen in cases of perineal cellulitis. 
These abscesses may empty into the primary one, or they may establish for 
themselves an independent opening, perforating the bone at different points. 
The recurring attacks of inflammation, incident to the presence of these 
indirect sinuses, are prone to induce hypertrophic changes in the structure 
of the bone, or to wear the patient out from constitutional irritation. 
Treatment.—As in the burrowing abscesses of other tissues, so in this, the 
bone must be freely exposed and its walls cut away with the chisel, so as 
fully to expose the seat of suppuration and offer a ready escape to all inflam- 
matory products. The wound must be afterwards loosely packed with lint 
moistened with carbolized oil, in order to secure its granulation from the 
bottom ; and at each renewal of the dressing it will be well to wash out the 
* Lib. viii., cap. 2, 3. 
f Lib. de Oss. Morb., p. 68. 1056 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
bone-cavity by injecting a solution of permanganate of potash or of Lugol’s 
preparation of iodine, one-fourth the officinal strength. 
Endosteitis and Osteomyelitis.—Diffused suppuration or osteomyelitis is an 
inflammatory disease, which, commencing in themedullary tissue, afterwards 
extends to all parts of the bone-structure. In many of its aspects the affec- 
tion is not unlike hospital gangrene. The disease, though long known to 
surgeons, has recently been very carefully studied by military surgeons in 
this country, especially by Dr. Lidell and by Dr. Allen. It occurs in two 
forms, acute and chronic. 
Causes.—Osteomyelitis, though it may arise idiopathically, is in almost all 
instances the result of traumatic injury, such as contusions, amputations, and 
gunshot and other fractures. Atmospheric conditions also exert a powerful 
influence in the development of the disease. During our late war it was 
observed by Lidell that in overcrowded hospitals, where the hygienic con- 
ditions were of an unfavorable character, the fatality from this affection 
was greatly increased. It was also noticed that patients who had been the 
subjects of amputation or of gunshot fractures, and were placed in portions 
of the hospital ward where the air was most vitiated, were much more likely 
to be attacked by osteomyelitis than those whose beds were more favorably 
situated. These conditions doubtless furnished the soil suited for the growth 
of the disease-producing germs. 
Pathology.—The disease may be either partial or general; that is, it may 
be confined to a very limited portion of the medullary tissue, or it may im- 
plicate the entire bone. The different stages of the affection are in most 
respects similar to those which are witnessed in the progress of unchecked 
inflammatory disease in other tissues, and are designated by Lidell, carnifica- 
tion, suppuration, and mortification. 
The first stage is one of increased fulness of the vessels of the medulla, 
giving rise to unusual redness in that tissue. This congestion is followed by 
transudation and infiltration, during which large numbers of cell-forms make 
their appearance in the meshes of the medullary membrane, which, together 
with the fibi’ogenous exudate, impart a marked induration to the structure. 
The corpuscular bodies, it is thought by Dr. Woodward, are derived by cell- 
multiplication from the connective-tissue corpuscles of the medullary mem- 
brane, and, when the disease reaches the walls of the bone, also from the 
connective tissue lying around the vessels in the Haversian canals. There 
are, however, two other sources from which doubtless large numbers of cells 
are derived, the first source being the blood-vessels themselves, so that a 
certain proportion—perhaps the largest number—of these forms must be 
credited to emigration ; and the second being the cells of the marrow, which 
under the stimulus of the inflammation are found likewise to increase in 
number. As the turgescence of the vessels increases, the florid color of the 
medullary tissue assumes a bluish hue from venous obstruction, and at many 
points the vessels give way, causing apoplectic extravasation or blood-clots. 
Under favorable circumstances the disease at this stage may undergo resolu- 
tion by the absorption of the inflammatory products, or the granulation tissue 
maybe converted into bone, a result which is constantly seen after fractures, 
and which is also witnessed in the fungoid-looking mass of granulations seen 
to protrude from the end of a bone after amputations, tbe callus filling up the 
medullary cavity and the cancelli at the seat of fracture or at the extremity 
of the bone. 
In the more pronounced varieties of osteomyelitis, so common in mili- 
tary practice, a termination by resolution can scarcely be expected, as the 
severity of the shock sustained by the components of the bone from the 
tremendous momentum of the conical ball, and the peculiar hygienic sur- 
roundings of the patient, are unfavorable to such a result. The inflammation 
in these cases passes on to suppuration ; the infiltration extends into the 
cancellated and from thence into the compact or cortical portions of the OSTEOMYELITIS. 
1057 
bone ; the Haversian canals become tilled with transudation, their walls, by 
the disappearance of the lime salts, become softened and rarefied, and pus 
permeates the bone in all directions. While these changes are in progress, 
the marrow undergoes disorganization, and the fat is forced by the centrifugal 
current of the inflammatory products through the canals of the bone to 
its surface. Nor does the morbid action cease here ; the periosteum par- 
ticipates in the disturbance and becomes inflamed, followed by the rapid 
transformation of the subperiosteal transudation into pus, in consequence of 
w'hich the membrane becomes detached from the bone. After a time the 
aponeurotic layer of the periosteum may give way, and the purulent matter 
passing through the perforations become disseminated among the soft parts 
overlying the bone. Under such structural disorganization, necrosis to a 
greater or less extent must ensue, involving in some instances the loss of 
the entire diaphysis of the bone. Occasionally in osteomyelitis the disease 
extends to the epiphyseal cartilages, when the subjects are persons under 
twenty years of age, or before these cartilages have become ossified. By 
disintegration the diaphysis and the epiphysis are disjoined, and they become 
movable, or even displaced, as in a fracture. If the process just described 
be still more intensified, mortification or necrosis will follow, preliminary to 
w'hich the blood-vessels of the medullary and bone tissues become so firmly 
compressed by the transudation that they are rendered incapable of carrying 
on the circulation. In this event the medullary tissue becomes very dark in 
color; the disease, especially when in one of the long bones, travels preferably 
in the upward direction; all evidences of cell-vitality disappear; shreds of 
disorganized connective tissue, discolored by decomposing blood, may be seen 
here and there in the midst of the diffluent marrow7, and from them an offen- 
sive odor is emitted,—all betokening mortification or the death of the bone 
in its entirety. (Fig. 893.) 
Fig. 89B. 
Death of the entire humerus from osteomyelitis. 
In fatal cases of osteomyelitis the morbid changes observed in the internal 
organs do not differ from those seen in persons who perish from septic or 
pysemic poisoning following other diseases,—namely, emboli, fatty and other- 
wise, with disseminated abscesses. 
Symptoms.—Osteomyelitis is not always easy of recognition. When, howT- 
ever, after an injury in which the bone has been damaged, symptoms of deep- 
seated pain are experienced, attended with great uneasiness in the limb when 
it is moved, and when there is cedematous swelling accompanied with pro- 
longed suppuration, there is reason to apprehend the existence of the disease. 
The diagnosis will be still more conclusive if, in addition to the signs 
already given, there exist separation of the soft parts from the bone, rigors, 
and fever, accompanied by marked loss of strength. Though periostitis and 
endosteitis present analogous symptoms, yet there are certain differences 
which may serve to distinguish these affections from each other. 
In endosteitis the pain is more diffused, and will continue for a long time 
without any external swelling; in periostitis the pain is local, and is accom- 
panied by swelling at the commencement of the disease. In endosteitis firm 
pressure is necessary to cause pain, while the slightest touch in periostitis 
will produce suffering. Again, in the latter, knotty and irregular deposits 
occur on the surface of the affected bone. 1058 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
The constitutional symptoms attending the disease are those belonging to 
septic fever,—rigors, high temperature, sweating, loss of flesh and strength, 
etc. 
Prognosis.—In the aggravated forms of osteomyelitis the danger, not only 
to the bone, but even to the life of the patient, is imminent. The presence of 
an unhealthy suppuration diffused through the cancelli of a bone is always 
attended with risk, and consequently in the severe forms of myelitis many 
persons die from pyaemia. If the constitutional infection is escaped, there 
still remains the probable death of the bone. If the disease is limited to the 
medullary membrane and to the cancellated tissue, the resulting necrosis will 
be central, the external or compact wall of the bone still retaining its vitality. 
If the compact tissue suffers in common with the inner wall, the periosteum 
will participate in the general ruin, and the entire bone will perish. It is not 
improbable, in instances of such extensive destruction, that the disease will 
transcend the limits of the diaphysis and invade the intermediate cartilage, 
the epiphysis of the bone, and the contiguous joint. 
Treatment.—Where the signs of osteomyelitis are well pronounced, the 
bone should be immediately exposed by a free division of the superincumbent 
soft parts. If, on such exposure, the periosteum is found to have receded 
from the bone, the surgeon will have determined the presence of a deep-seated 
suppuration, and may proceed unhesitatingly, if the detachment is not exten- 
sive, on the plan practised by Professor N. E. Smith, to bore one or two open- 
ings with a trephine into the cancellated tissue of the bone, in order to furnish 
a pathway for the escape of the inflammatory products, or he may adopt the 
more radical plan of Perkowski of laying open extensively the medullary 
canal, curetting its contents and dressing with iodoform. The canal might 
with advantage be thoroughly washed out with an antiseptic solution before 
using the iodoform. If, on the contrary, the periosteum is separated from 
the greater part of the bone, there remains only the alternative of excision 
or of amputation. When the latter is determined upon, the operation may 
be done in the continuity of the bone or at the articulation above. If made 
in the continuity of the limb it will not prove radical, as the disease will con- 
tinue to invade the remaining part of the bone and will necessitate a second 
resort to the knife. 
Even in instances where pyaemia has taken place before the surgeon is 
called to the case, it has been advised to operate, a course which has been 
successfully practised by Professor Payer. Such a procedure, however, should 
not be accepted unconditionally. Where the evidence of pyaemic infection is 
conclusive, amputation or excision will only precipitate a fatal result, but in 
cases where the signs are less decisive, and partake more of the character 
of septicaemia, the operation may be performed. In the management of 
these cases constitutional treatment must not be overlooked ; not that it 
can exercise any specific controlling influence over the disease, but because 
the system demands a vigorous support, and hence the necessity for an ample 
supply of nutritious food, together with stimulants, tonics, and anodynes. In 
many instances of osteomyelitis the disease pursues a chronic course, lasting 
for months or even years, one in which an expectant plan of treatment will 
be indicated, and where there is no necessity for haste in resorting to an 
operation. The latter is only required when a sequestrum becomes loosened, 
in which event it should be removed. If the pain is continuous and severe, 
the use of the trephine may be demanded. When, however, the suppuration 
has involved the principal part of the bone, and the strength of the patient 
begins to decline, disarticulation, whether of a long or a short bone, becomes 
imperative, as in the acute form of the disease. 
The value of preventive measures cannot be overestimated; and just in 
proportion as antiseptic measures are enforced on the reception of wounds, 
may we expect to lessen the ravages of this formidable disease. SCLEROSIS, OR INDURATION. 
1059 
Sclerosis, or Induration. 
Another result of osteitis is induration or thickening,—a condition in which 
the bone appears to consist wholly of compact tissue, the cancellated portion 
and the medullary canal being occupied by a dense osseous deposit, which, 
when sawn through, resembles ivory in the closeness of its texture. (Fig. 
894.) The disease is not peculiar to any particular portions of the skeleton, 
Fig. 894. 
Sclerosis of the femur. 
though usually the bones affected are the femur and the tibia, and the com- 
ponents of the pelvis, of the cranium, or of the face. 
The disease generally is not limited to a small portion of the bone attacked, 
but involves the entire structure, which becomes preternaturally heavy and 
dense. It is occasionally associated with great periosteal activity, the sur- 
face of the bone being covered with nodular deposits. (Fig. 895.) This 
form answers to the leontiasis ossium of Virchow. 
Fig. 895. 
Sclerosis of the femur, with irregular periosteal deposits. 
A temporary form of circumscribed sclerosis is seen in the repair of frac- 
tures, in which every portion of the bone at the seat of injury is filled with 
compact callus. Both conditions are the result of inflammation; but in the 
latter, after the union is effected, the central portion of the deposition becomes 
rarefied, as in primary development, while in the former the induration 
remains permanently. 
In sclerosis, the cancelli of the medullary and the Haversian canals being 
in a great measure filled with new osseous material, the vascularity of the 
bone is materially diminished. 
Causes.—Little is known with regard to the causes which determine scle- 
rosis. It may arise in some instances from constitutional conditions, such 
as syphilis, but oftener its causes are of a traumatic nature. In one case I 
was consulted by a gentleman from Tennessee who, fourteen years previous 
to my seeing him, had been struck on the head by a spent fragment of a 
shell, which had produced a scalp wound and an indentation of the external 
table of the right parietal bone, near the sagittal suture. Three years after 
the injury he had an epileptic seizure, the attacks of which became every year 
more aggravated and frequent. I removed two large circles of bone with 
the trephine, expecting to find either a depression of the internal table or an 
exostosis, neither of which, however, wTas present, but instead thereof an 
extensive thickening with sclerosis of the bone, all of the diploic structure 
having disappeared. 
Surgically, sclerosis possesses little interest, as there are no symptoms 
which are pathognomonic of its presence. It is barely possible that the 
growing increase of weight in the limb, when the tibia or the femur is 1060 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
affected, might furnish ground for suspecting the existence of the disease. 
Even if recognized, we have no remedies with which to combat it. 
Actinomycosis.—There is a form of osteitis, described by Bollinger, due to 
the presence of parasitic organisms, frequently found in cattle, and desig- 
nated by the term Actinomyces bovis. The disease, however, is not con- 
fined to cattle, as a number of cases have been observed in Germany. Israel, 
of Berlin, has collected twenty-seven cases. Lahn has succeeded in pro- 
ducing this peculiar osteitis in cows by inoculating with cultures of the 
micro-organism. The portions of the skeleton most commonly attacked 
are the jaws, the vertebrae, and the ribs. There are no characteristic symp- 
toms revealing this form of osteitis. 
The morbid appearances observed consist in the presence of numerous 
yellowish bodies, more or less firm, disseminated through the bone, and 
made up of aggregations of the parasite. 
I believe the disease has not as yet been observed in this country. 
Rarefaction. 
Very different from sclerosis is that osseous change called rarefaction or 
osteoporosis, another result of inflammation, in which the inorganic ele- 
ments of the bone are measurably destroyed, the vascular canals becoming 
larger and larger by the absorption of their partition-walls, until the entire 
bone, enlarged in its bulk but diminished in its weight, resembles in structure 
a sponge. The resistance of the osseous tissue in these cases is so greatly 
diminished that when subjected to pressure or weight it is likely to yield, 
causing deformity, and giving rise to the name osteitis deformans (Paget). 
The disease is sometimes met with in new-born children. In the case of 
a child placed under my cai’e by the late Dr. John Forsyth Meigs, the rare- 
faction had existed from birth, and was limited to two of the phalanges of 
the hand, the bones assuming a fusiform shape. After twelve months the 
enlargement ceased growing; the walls of the phalanges then began to con- 
tract, and eventually they assumed their proper form. There was also in 
this patient a similar swelling of a portion of the spine of one of the 
scapulae. This, however, resulted in suppuration, and on opening the soft 
parts I succeeded in removing a considerable fragment of necrosed bone. A 
second piece was extracted from the same opening several weeks later, after 
which the sinus healed up. The boy is at present ten years old, and ap- 
parently perfectly well. 
Treatment.—The treatment which seems to be indicated in rarefaction is 
a constitutional one, and consists of cod-liver oil and iodide of potash, or 
iodide of iron, and very minute doses of the bichloride of mercury. 
Necrosis. 
The term necrosis is derived from the Greek word vexpow, signifying to de- 
stroy, and was first employed by M. Louis to express mortification of bone. 
This writer restricted its application to the death of the entire bone affected. 
Werdmann used the same term to express the death of small portions of 
the osseous tissue; but the signification of the word has been extended by 
modern pathologists until now it includes the death of any tissue. 
The distinction between necrosis and caries is the same as that between 
mortification and ulceration in the soft parts,—the same really in kind, but 
differing in degree,—the first being death of a structure in considerable 
masses, the second being death by particles. The bones most commonly 
the subjects of necrosis are the tibia, the femur, the inferior maxillary, the 
clavicle, the humerus, the ulna, the radius, and the cranial bones. 
Although the disease exhibits a marked preference for the long or cylin- 
drical and the short bones, yet the flat ones are not entirely exempt. NECROSIS. 
1061 
Though necrosis generally occurs in the compact tissue of a bone, in 
consequence of the pressure to which the vessels are subjected in the minute 
Haversian canals by congestion and transudation, yet it is also found in the 
cancellated tissue. The reverse is the case in regard to caries, the latter 
manifesting a peculiar preference for the spongy portions of bone, as in this 
tissue the space between the blood-vessels and the walls of the cancelli is 
sufficient to accommodate the inflammatory infiltrate without serious com- 
pression of the vascular channels. 
The shafts of the bones are much more frequently the seat of the disease 
than are the epiphyses or their articular extremities. 
All parts of a bone are not equally liable to become involved in the de- 
structive process. Necrosis of the femur is commonly met with in the limits 
of its lower third. When the tibia is attacked, its anterior surface suffers in 
preference to the posterior one, and the upper end of the bone rather than 
the lower. When the humerus is affected, the upper extremity is implicated 
oftener than the lower. 
Causes.—The causes are constitutional and local. While there are some 
who seem disposed to ignore in a great measure the constitutional origin of 
necrosis, yet in my judgment it is the fons et origo of a very large propor- 
tion of all cases of idiopathic mortification of bone. Among children under 
fifteen years of age thus affected will be found in almost every instance 
those unmistakable bodily characteristics which we are wont to term scrofu- 
lous: with such an organization, exposure to a cold damp atmosphere, re- 
pelled perspiration, insufficient food, an attack of measles or of scarlet fever, 
a slight traumatic injury, even the violent contraction of the muscles dis- 
turbing the superficial fibres of the bone, will be sufficient to kindle into 
activity those latent conditions which develop the inflammation that pre- 
cedes the dissolution of the bone. 
While the young are particularly the subjects of necrosis, there is also a 
senile variety of the disease, due to those vascular changes incident to old 
age which serve to embarrass the circulation through the vessels of the hones. 
Constitutional syphilis, especially in its advanced stage, constitutes another 
prolific cause of necrosis, very commonly affecting the palatine plate of the 
upper maxillary, the turbinated pieces of the nose, the tibia, the clavicle, the 
ulna, and the bones of the cranium. 
Low forms of fever not unfrequently are followed by necrosis, arising no 
doubt partly from deterioration in the constitution of the blood, and partly 
from a feeble, tardy circulation, favoring congestion in the vessels of the bone, 
—a condition which is often a fruitful source of inflammation in other tissues. 
Necrosis of a rib or of the humerus is no uncommon sequence of typhoid fever. 
In the same category must be placed those cases of bone-mortification 
which follow scurvy, small-pox, or disease of the kidneys. Rheumatism must 
be also enumerated among the causes of the disease, not so much from the 
retention in the blood of certain products of textural change as from the ex- 
tension of the inflammation, by continuity, from the fibrous to the periosteal 
structure, and from the organic changes induced in the bone itself. 
The injudicious use of mercury not unfrequently causes the most horrid 
destructive inflammation of the bones of the maxilla, accompanied by such 
sloughing of the neighboring soft parts as often, by the vicious cicatrices which 
follow, to render the unfortunate victim deformed and disabled for life. 
Among the local causes of necrosis may be mentioned certain chemical 
virulents, as phosphorus. Persons exposed to the fumes of phosphorus, as 
match-makers, are liable to necrosis of the maxillae. This was first noticed by 
Heyfelder, of Vienna. The lower jaw is usually attacked, but sometimes the 
upper is involved. Phosphorus-necrosis will be treated of under the chapter 
“ Diseases of the Mouth.” 
Among traumatic or local causes may be mentioned gunshot and other 
wounds, bruises, concussions, etc. These act either directly by stripping off 
the periosteum, or indirectly by provoking a suppurative periostitis or by 1062 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
inducing an endosteitis. The extent to which the periosteum can be detached 
without the death of a corresponding portion of the bone it is difficult to 
determine. If there is a constitutional vice predisposing to necrosis, the 
slightest separation will be followed by death ; but in a healthy person with- 
out any such predetermination, considerable detachments may occur without 
the utter loss of vitality in the part. 
It must not be' forgotten that, even though the periosteum be separated, 
there is another source of blood-supply, namely, the vessels of the medullary 
membrane. 
Divisions.—When the disease is limited to the external part of a bone, it 
constitutes peripheral necrosis, the extent of which varies in different cases, 
sometimes affecting only one or two lamellae, at other times extending a 
considerable depth into the compact tissue. When the necrosis is confined 
to the interior of the compact substance, or to the cancellated portion, it is 
termed central; when both the compact substance and the spongy tissue are 
included, it is called total. 
The following varieties of the disease may occur under the central division. 
Multiple Necrosis.—There is a form of necrosis in which several bones of 
the skeleton are attacked either simultaneously or in succession, which may 
be named multiple. This is not an uncommon condition in tertiary syphilis. 
I have seen the same wide-spread necrosis follow an attack of rheumatism, 
and also a convalescence from typhoid fever, where there was no reason what- 
ever for suspecting the existence of a venereal taint. In strumous constitu- 
tions multiple necrosis is by no means uncommon, and is generally limited to 
the outer lamella of the bone. The first form, or peripheral, is likely to 
follow the detachment of the periosteum, from whatever cause; the second, 
or central, is caused by damage to the endosteum; and the third, or total, 
occurs when both the periosteum and the endosteum are damaged. 
Non-Suppurating Necrosis.—In this variety the sequestrum lies in a shell of 
bone covered by a mass of gelatinous granulations and without the presence 
of pus or external abscesses. It is probable that if the examination could 
be made early in the progress of the disease, suppuration would be found to 
exist, the pus in the advanced stage having been absorbed. A parallel case is 
seen in certain indolent ulcers with redundant cedematous granulations from 
which only a thin serum is discharged. The diagnosis must necessarily be 
very perplexing in such cases, and can only be cleared up by an exploratory 
opening. 
Humid Necrosis has its analogy approximately in the moist gangrene of 
the soft parts; by Lidell it is termed mephitic gangrene. The disease, be- 
ginning in the spongy tissue, ultimately involves the entire thickness of the 
bone. The necrosed cancelli becomes soft, presenting a gray or dark-brown 
appearance, the discharges from which are exceedingly fetid. The destruc- 
tion is so general and so deeply affects the vitality of the periosteum that 
any successful attempt to repair the damage need not be expected. 
Pathology.—The succession of changes which in the aggregate embrace 
the dying, the death, and the repair of the necrosed bone, is intensely in- 
teresting to the pathologist. These changes include the phenomena of 
inflammation, the establishment of a line of demarcation, the separation of 
the dead part, and the provisions made for strengthening the diseased bone. 
The inflammatory stage which precedes necrosis may be either acute or 
chronic. The shafts of the long bones, especially those of the femur, tibia, 
and humerus, suffer most from acute necrosis. When the articular ends of 
the cylindrical bones, or the short irregular bones, become the subjects of the 
disease, the inflammation is usually of a chronic nature. 
In whatever way the bone dies, the determining part of the event is the 
absence of circulation. Assuming the bone attacked to be a cylindrical one, NECROSIS. 
1063 
and that from some cause a periostitis is developed, there will follow an in- 
flammatory transudation into the deep layer of the membrane. Not only so, 
but the contiguous vessels of the compact tissue of the bone participate in 
the disease, and a like transudation takes place into the Haversian canals 
If a careful examination be made at this stage of the disease, the periosteum 
will be found at some points thickened by the infiltration, while at others 
suppuration will have been established. The walls of the Haversian canals 
being unyielding, the effect of this sudden infiltration is to compress the 
blood-vessels, so as to arrest the circulation in these channels, and thus de- 
prive the bone of the blood necessary for its nutrition, and consequently 
cause its dissolution. It is thought by some that the destruction of the ves- 
sels is brought about by accumulation of the transudation and suppuration 
between the bone and the periosteum, which by lifting the latter membrane 
destroys the vascular connection between the two,—a theory which is con- 
tradicted by the condition found to exist in the repair of fractures. That 
the spindle-shaped elevation surrounding the seat of a fracture is not formed 
by the raising of the periosteum by the callus I have, by numerous experi- 
ments, determined to my own satisfaction. But to return to the subject 
under consideration, the osseous tissue, being deprived of its blood-vessels, 
dies; it becomes white, gray, or dark colored, is hard, insensible, and blood- 
less when pierced. 
Separation.—The dead bone is now a foreign body, and in order to repair 
the damage its separation and expulsion from the living bone become neces- 
sary. To accomplish this, immediately around the circumference of the dead 
bone a line of increased vascularization is established, which exhibits the com- 
mencement of the process of separation, and forms another illustration of 
the salutary work of inflammation. A free transudation from the vessels 
infiltrates the deeper layers of the periosteum and also the Haversian canals; 
and this, like the induration at the circumference of an abscess, serves to form 
an embankment which not only prevents the intrusion of morbid matters 
into the sound bone, but also serves to dissolve the connection between the 
living and the dead structures. 
The effect of this infiltration is to enlarge the Haversian canals and to 
destroy the union between the inorganic and the organic constituents of the 
bone. The former become disintegrated, and mingling with the inflamma- 
tory products are removed partly through such sinuses as may exist, and 
partly by the absorbent vessels. The presence of lime salts may be detected 
in the discharges by the addition of suitable tests. The animal bases of the 
bone also become softened. The transudation, consisting of fibrin and leuco- 
cytes, is soon penetrated by an outgrowth of capillary vessels, forming a 
granulation tissue, the suppuration from which forms a groove between the 
living and the dead structure, constituting the line of demarcation. As the 
suppuration continues, the necrosed part finally becomes wholly disjoined 
from the sound bone, and either drops out spontaneously or is readily picked 
away with the forceps. The piece thus detached as a scale, when from the 
external surface of the bone, including one or several lamellae, is called an 
exfoliation. All of the changes, therefore, which are concerned in the sepa- 
ration occur in the living bone. The cavity which results from this loss of 
substance is an ulcer, and is repaired by granulation, or by a process similar 
to that which takes place in the healing of an ulcer in the soft parts. The 
resulting cicatrix is depressed, and to it the superincumbent tissues are united. 
When the deeper part of the shaft or the entire diaphysis of a long bone 
dies, the same inflammatory changes occur in the exterior sound portion 
and in the periosteum contiguous to the dead as have been already described 
under peripheral necrosis, and by this process the necrosed piece is disjoined 
from the living. The dead portion thus imprisoned within a sheath or 
involucrum of living bone is called a sequestrum. 
While these changes are going on, if the new bone is tardily formed, a 
fracture may be readily produced on the application of a very trifling force. 1064 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
Epiphyseal Necrosis.—When necrosis implicates the shaft of a bone, it 
will, however extensive, generally not pass beyond the limits of the diaph- 
ysis. When the disease is located in the epiphysis or in the articulating 
extremity of a bone, it is usually followed by the gravest consequences to 
the joint. The necrosis may affect any part of the epiphysis, central or 
peripheral, or, indeed, may destroy the entire extremity. Familiar examples 
of such general destruction are seen in hip-joint disease, in which the head 
of the femur is often totally destroyed. 
Necrosis of Flat Bones.—When a flat bone becomes the subject of necrosis, 
—a very common occurrence,—the dead piece is always detached as an ex- 
foliation, never invaginated or incarcerated in an involucrum of new bone. 
The manner of separation is identical in its pathological history with that of 
the same process in the long bones. 
Necrosis of Irregular Bones.—These bones, of which the best examples are 
those of the tarsus and the carpus, not being laminated, but consisting of a 
reticulation of cancelli, are most prone to ulceration, but are not exempt from 
necrosis, in which case the piece is liable to die in its totality. 
Sequestra.—A sequestrum is readily recognized by its peculiar appear- 
ance, it having a smooth, white, porous or worm-eaten surface, with ragged 
dentated or spiculated edges. When 
such a fragment has been exposed for 
some time to the air, the color often 
changes to a dark gray or brown. 
Sequestra differ much in size, in some 
instances consisting of a small frag- 
ment, in others comprehending the 
entire diaphysis of the bone. In form 
they are sometimes flat, sometimes 
concave, and at other times completely cylindrical. (Figs. 896 and 897.) 
The structure of a sequestrum is very hard, but brittle, and in chemical 
constitution it differs from normal bone in having a very large pi'eponderance 
of earthy over animal matter. This disproportion between the inorganic and 
the organic components is not the same in all sequestra. When the necrosis 
follows an acute course, and the dead piece is quickly detached, this dispro- 
po rtion is very much lessened. 
Fig. 890. 
Cylindrical sequestrum from the femur, following ampu 
tation.—Smith. 
Fig. 897. 
91 inches 
There are two peculiarities possessed by a sequestrum which are worthy 
of notice, namely, its cribriform appearance and the irregular spines which 
project from its margin or extremity. These topographical features are not 
due, as was at one time supposed, to erosion from contact with the pus in 
which the dead bone is bathed. Any influence of this kind, if it operates 
at all, must be very insignificant. We must seek for the true explanation in 
the irregular proliferation of the granulation tissue which separates the dead 
from the living bone. The same condition may be noticed in the irregular 
indentations which are left in the soft parts after the separation of a slough. 
It is this intercalation between the living and the dead osseous tissue, to- 
gether with the penetration of the granulations into the foramina of the 
sequestrum, which often so obstinately resists the traction efforts made by 
the surgeon to remove the necrosed part. 
Cylindrical sequestrum from tbe femur.—American Medical Museum. NECROSIS. 
1065 
The manner in which the spontaneous extrusion of a sequestrum can take 
place has also formed the subject of much speculation. I have seen a con- 
siderable portion of the shaft of the femur protruding to the extent of three 
inches externally, which had become almost black from its long exposure 
to the air. In time, I doubt not, the entire piece would have escaped with- 
out any assistance from the surgeon. Hippocrates thought that the seques- 
trum was pushed forward by a fleshy membrane (granulations) which grew 
underneath ; Swieten referred the movement to the pulsation of the arteries; 
while others, and among them Bell, attributed the change of position to the 
pus and the growing granulations. If to the latter we add the jars to which 
the limb is exposed, we have doubtless the most rational explanation of the 
process. In one instance of spontaneous extrusion of a sequestrum the pop- 
liteal artery was pierced, and a fatal hemorrhage followed. 
In rare instances a sequestrum may become encased or encysted within 
a wall of new or living bone, and remain quiescent for a long time. Broca 
mentions two cases of this kind, in one of which the necrosed piece was 
incarcerated for fifty-three years. 
Provisions for repair.—When a considerable part of a cylindrical bone, or 
the entire bone, becomes the subject of necrosis as a result of periostitis or 
osteomyelitis, the osteogenetic function of the periosteum, and, when the 
death is not total, that of the external lamellae of the bone, and perhaps, in 
some cases, the endosteum, become exceedingly active. A new deposition 
of osseous matter or callus takes place on the outer surface, until the shaft 
may acquire an extraordinary thickness, the remains of the old shaft lying in 
Fig. 898*. 
Pig. 899*. 
Pig. 900*. 
Pig. 901*. 
Sequestrum formed by the 
entire diaphysis of the tibia 
surrounded by new bone.— 
From a specimen in the mu- 
seum of the University of 
Pennsylvania. 
Extra - granular 
deposition of bone 
in necrosis of the 
humerus.—Ameri- 
can Medical Mu- 
seum. 
Nodulated deposition of callus 
in necrosis of the shaft of the 
tibia.—From a specimen in the 
museum of the University of 
Pennsylvania. 
Necrosis 
of the tibia, 
with cloacte. 
—Smith. 
the centre as a sequestrum. (Fig. 898*.) The new bone thus formed is often 
granular (Fig. 899*), or rough and nodulated. (Fig. 900*.) The activity of 
the periosteum in the work of providing a new bone, or strengthening the 
walls of one partially destroyed, cannot now be doubted. In this way the 1066 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
entire shaft of a long bone may be restored. The vacuum remaining after 
the removal of a central sequestrum is tilled up by granulation tissue, which 
subsequently ossifies, the activity of the periosteum is at once sensibly di- 
minished, irregularities over the surface of the bone are rounded away, and 
in time the medullary canal is probably measurably reformed. When the 
epiphysis is attacked with necrosis, as occasionally occurs in young scrof- 
ulous subjects, this power of restoration is lost. 
In order to provide for the discharge of the pus, and also to offer a way 
of escape for the dead parts, another remarkable provision is the formation, at 
points where the periosteum is deficient, of openings through the outer wall of 
the bone, called cloacce. (Figs. 901* and 902*.) These are not always present, 
in which case the products of inflammation can only be removed by absorption. 
A very curious tubular sequestrum sometimes follows 
amputation, the dead bone being situated between two 
tubes of living bone. (Fig. 903*.) I have removed these 
peculiar cylinders when they have extended several inches 
up the shaft of the bone. 1 think that they are most fre- 
quently met with after amputation 
for gunshot injuries of the bone. Oc- 
casionally the end of the bone pos- 
sessing such a sequestrum is large 
and bulbous, the granulations from the 
medullary membrane having spread 
over the extremity and become ossi- 
fied. The rationale of the formation of 
these sequestra is somewhat obscure. 
The portion of bone which dies is the 
inner layer,—the part more especially 
nourished by the endosteum. It would 
seem probable that any cause which 
would destroy the inner lamellae would 
destroy the medullary membrane also, 
in which case no inner cylinder of new 
bone could be constructed. Markoe 
thinks that these sequestra depend 
upon some injury to the nutritious artery, inasmuch as this vessel is destined 
for the supply of the medullary tissue. Such an accident would temporarily 
interrupt the flow of blood to that structure, during which time the inner 
lamellae would perish before the circulation could be sufficiently established 
through the branches of the periosteum. This explanation, in my judgment, 
is the most satisfactory one which has been given. The necrosis often pro- 
gresses so quietly and produces so little local disturbance that it may exist 
for a considerable time without being suspected. 
Ring Sequestra.—Another kind of sequestrum is the ring: this is frequently 
seen at the end of a bone after amputation. 
Fig. 902*. 
Fig. 903*. 
Necrosis of the tibia, with 
a sequestrum protruding 
through a cloaca.—Smith. 
Tubular sequestrum 
(A) of the femur after 
amputation. 
Symptoms.—The symptoms indicative of necrosis are such as belong to 
inflammation. There is local tenderness, followed by deep-seated throbbing 
or gnawing pains, which are characterized by marked evening exacerba- 
tions ; the skin may remain for a long time unaffected, though frequently 
it becomes oedematous, glossy, and of a dark-red color. These phenomena 
may continue for a short time and then subside, leaving only a somewhat 
supersensitive condition of the limb when it is jarred, or when some unusual 
exercise has been taken or the feet have been exposed to cold and dampness. 
This period of quiet is liable at any moment to be interrupted by a recur- 
rence of the inflammatory symptoms. The pain again increases, the skin 
becomes inflamed and swollen, the nights are passed in restlessness, and not 
unfrequently the patient suffers from slight fever. These are the ordinary 
signs of osteitis, and, while they are not invariably followed by necrosis, NECROSIS. 
1067 
they nevertheless point very strongly in that direction, especially if the 
bone is a cylindrical one. If, however, after a preliminary period of such 
suffering, induration and thickening of the parts take place and abscesses 
form in the superincumbent soft parts, ending in sinuses which refuse to 
heal, and through which unhealthy granulations crop out having an um- 
bilicated or a papillary form, all obscurity is removed, particularly if, on 
passing a probe along one of these fistulous tracks, the instrument comes 
in contact with denuded bone. 
In central necrosis, when ulcerated openings or cloacae exist, the probe 
can be conducted through the peripheral portion of the shaft and be brought 
directly against the interior sequestrum. The pus first discharged may be 
healthy in appearance, being the result of an extension of the inflammation 
to the soft tissues, and therefore partaking of the nature of an ordinary ab- 
scess, but subsequently the discharges become sanious and watery, and emit 
an offensive odor, indicating that they originate in the bone and find their 
way out through the cloacse and sinuses to the surface. The inflammation 
which extends to the soft parts covering a necrosed bone soon glues together 
the different planes of tissues, inducing both atrophy and fatty metamorphosis 
of the muscles. When the suppuration is free, or even when only moderate 
and prolonged, the general health begins to fail. There is a marked loss of 
strength and flesh, the appetite fails, the face loses its color and wears an 
anxious expression, and often towards the close of the day the palms of the 
hands and the soles of the feet become hot, followed by a marked acceleration 
of the pulse. 
Prognosis.—Any opinion as to the future termination of a case of necrosis, 
to be valuable, must be based on a variety of considerations. If the patient 
is young and possesses a good constitution, if the disease is confined to a 
single bone, is not too extensive, and is not too deeply situated, a favorable 
result may be reasonably anticipated. The particular bone involved must 
not be overlooked. Necrosis of the femur is much more serious than the 
same disease in the tibia, and necrosis of the bones of the cranium or of the 
pelvis is more dangerous than either. 
When the articulating extremity of a bone is attacked, the risk to life and 
to limb is much increased. Adults and aged persons are less likely to recover 
from the effects of necrosis than the young. Indeed, every case of necrosis 
is environed with so many possibilities of evil that the surgeon cannot feel 
otherwise than anxious about the issue. 
Evil Effects.—The dangers which threaten a patient affected with this dis- 
ease are multiform. If it is situated in the bones of the skull, meningitis or 
intra-cranial abscess is liable to occur. If the disease is in the head of the 
femur, it may involve the ilium and extend into the pelvis, causing destruc- 
tive abscesses in the latter cavity. A dead fragment of bone may lie in or 
may penetrate an epiphysis, and, entering the cavity of a joint, be followed 
by anchylosis or by the loss of the limb. A sequestrum, in its extension by 
natural processes, is liable to come in contact with a great blood-vessel, and, 
bv exciting ulceration in its coats, give rise to fatal hemorrhage. This has 
happened in a number of instances. To the above evil results may be added 
those structural waxy and fatty changes which are provoked in internal 
organs, especially the kidneys and the liver, by long-continued suppuration, 
and the liability to pyaemia, erysipelas, and, if constitutionally disposed, to 
tuberculosis of the lungs. 
Treatment.—There are two general objects which the surgeon must 
keep in view in the treatment of a case of necrosis, namely, first, to moderate 
the intensity of the preliminary osteitis and of the pain, and, secondly, to 
remove the sequestrum. 
The first is accomplished by elevating the limb, by local depletion and 
the use either of anodyne lotions or warm poultices, as may best comport 
with the sensation of the patient, and by the exhibition of opiates to relieve 
pain: a blister applied directly over the diseased part is often followed by 1068 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
the greatest benefit. When the disease has a syphilitic or a rheumatic 
origin, great benefit will be derived from the use of full doses of the iodide 
of potash, and in strumous cases from the administration of cod-liver oil and 
the iodide of iron. A mixture consisting of three parts of the tincture of 
iodine and one part of laudanum, freely applied over the diseased part twice 
a day, will be found to produce a good effect. The bowels must be regulated, 
and the diet consist of nutritious but unirritating articles of food. Whenever 
fluctuation is discovered, or even before, when there are sufficient reasons 
for believing in the presence of deep-seated pus, whether under an aponeu- 
rosis or beneath the periosteum, an opening should be made for its escape. 
The suffering from these confined collections is often intense, and in deli- 
cate or irritable constitutions even dangerous. When the inflammation is 
limited to the external lamellae of the bone, by making an early opening 
we not only alleviate the violent pain, but also limit the spread of the 
disease. These incisions should be made, when carried through the peri- 
osteum, in the longitudinal axis of the bone, in order to furnish a free escape 
for the pus. 
Removal of the Sequestrum.—As long as the dead bone remains, the suppura- 
tion and the sinuses will continue. Its removal, therefore, becomes a matter 
of great importance, and yet, save in one or two exceptional cases, there can 
be no justification for interference, with a view to its extraction, until nature 
has effected its separation from the living bone. If there is any one practice 
whose propriety is more strongly established than that of any other in bone 
surgery, it is the abstinence from all cutting operations antecedent, to this 
separation. The surgeon may have to wait many months, perhaps years; 
but time does not alter the law. The determination of the time for inter- 
ference is not a difficult task. A probe, or, what is better, a director, should 
be carried through one of the sinuses in the bone until the sequestrum is 
reached, when by firmly pressing upon the piece its mobility can be ascer- 
tained, or by tapping it with the in- 
strument the hollow sound which 
indicates its detachment may be 
heard. 
Sequestrotomy.—If the sequestrum 
on the application of these tests is 
found to be loose, its extraction can- 
not be too soon accomplished. When 
free bleeding is anticipated, a tourni- 
quet may be placed upon the limb 
above, or Esmarch’s elastic roller may 
be applied. The incisions through 
the soft parts must be planned so 
as to avoid injuring important ves- 
sels and nerves or dividing muscles, 
and should be ample, in order that 
the bone may be properly exposed. 
In many cases it will be useful 
to insert a director through one of 
the sinuses leading most directly 
into the bone, as a guide for the 
knife. 
Having reached the bone, the next 
step in cases of central necrosis is to 
cut away the involucrum or new wall 
of bone in which the sequestrum is 
encased. This is readily done by the chisel and hammer (Figs. 904*, 905*, 
906*, 907*), or, when two or more cloacae are favorably situated, by di- 
viding the intervening bridges of bone with strong cutting pliers (Figs. 
908*, 909*) and opening them into one another, when the sequestrum being 
Fig. 907*. 
Fig. 905*. 
Fig. 904*. 
Fig. 906*. 
Different forms of bone chisels. 
Hammer. NECROSIS. 
1069 
exposed can be seized with a pair of strong bone forceps (Figs. 910*, 911*, 
912*) and withdrawn. 
Fig. 908*. 
Fig. 909*. 
Bone pliers. 
Sometimes the sequestrum is wedged in between the irregularities of 
the living bone, or is pinned by osseous spines running into the orifices 
or depressions upon its surface, in which event an advantage may be gained 
by slipping a lever or elevator (Fig. 913*) under one of its edges, and prying 
it out of the bed in which it is locked. 
When the opening in the involucrum is too small for the extraction of 
the dead bone, the latter may be cut in twain by the pliers, and each half 
removed separately. 
Fig. 912*. 
Fig 910*. 
Fig 911* 
Fig. 913*. 
Different forms of bone forceps. 
Lever. 
Dr. Garretson, of this city, has introduced into the practice of surgery a 
dental engine, which is not only admirably suited for the performance of 
many operations on the bones, but the applications of which ate almost 
unlimited. 
The engine resembles an ordinary pedal lathe, having a fly-wheel, a driving- 
pulley, and a cord extending between the two in order to communicate a 
revolving velocity to a movable arm, which consists of a flexible shaft of 
wire, enclosed in a pliable sheath, on the free end of which is a mandrel for 
the reception of the instruments to be used. (Fig. 914*.) Into the flexible 
arm can be fitted drills (Fig. 915*) of different sizes, a trephine (Fig. 916*), 
a circular saw (Fig. 917*), a circular knife (Fig. 918*), and burrs for reaming 
out the cavity of a bone (Fig. 919*). 1070 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
There are three forms of the surgical engine. Two of these are by S. S. 
White, one of which can be attached to a table and worked by the hand of 
Fig. 914*. 
Fig. 919*. 
Fig. 915*. 
Drills of different sizes. 
Fig. 916*. 
Trephine. 
One form of the 
burr drill. 
Fig. 917*. 
Two views of the circular saw. 
Fig. 918*. 
White’s surgical engine. 
Two views of the circular knife. 
an assistant, and the other rests on the floor and is driven by the foot. (Fig. 
914*.) The arm in both is a continuous piece, is flexible, and can be worked NECROSIS. 
1071 
in every possible direction. The third engine is one constructed by Dr. 
Bonwill. and is represented in Fig. 920*. The arm is made up of two solid 
rods of metal, and the power is transmitted direct to the tool or instrument. 
All of these engines are 
capable of doing what 
is claimed for them by 
their makers, but which 
of the three can justly 
lay claim to superiority 
I do not undertake to 
decide. There are other 
modifications of the en- 
gine, but the three just 
mentioned appear to be 
the most valuable. The 
rapid revolving power of these engines, 
numbering from fifteen hundred to five 
thousand revolutions per minute, and their 
capacity to carry a drill the size of a cam- 
bric needle or a knife or saw ten and a 
half inches in diameter, enable the sur- 
geon to divide tissues with comparatively 
little pain. Dr. Albert H. Smith, of this 
city, has used the engine with the greatest 
satisfaction for denuding the soft parts in 
operations on the vagina. 
After removing all the dead bone, which 
can be determined by introducing a finger 
into the cavity, when the soft velvety feel 
of the granulation tissue on all sides will 
sufficiently declare the fact, the cavity 
should be thoroughly flushed with the 
usual sublimate solution, and well packed 
with iodoform gauze before removing the 
elastic cord. In order that no obstacle 
may prevent the escape of the discharges 
from the bone, a similar strip of gauze 
must be interposed between the lips of 
the wound in the soft parts, thereby pre- 
venting their quick union. Over the 
whole must be applied the usual antisep- 
tic dressings, consisting of the sublimate, 
carbolized, or iodoform gauze compresses, 
the deep one wet in the sublimate solu- 
tion, the superficial one dry. with a cover- 
ing of absorbent cotton, after which the 
limb must be covered with a carbolized or 
sublimate roller. Barely will it be neces- 
sary to remove the dressing earlier than 
the fourth or fifth day, and when this is 
done the cavity of the bone must be care- 
fully cleansed with the same antiseptic washes as were used in the first 
instance, and the same antiseptic dressings reapplied in detail. It will be 
sufficient, usually, to re-dress at intervals of five days. 
After the removal of the sequestrum, the involucrum soon begins to con- 
tract, the interior granulations undergo ossification, and at length the cavity 
is filled by callus, until, as in the case of repair after fracture, the bone be- 
comes a mass of compact tissue. This new bone subsequently is measurably 
absorbed, and an attempt is made to reform the medullary canal. How per- 
Fig. 920*. 
Bonwill’s surgical engine. 1072 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
fectly this is done we do not yet fully1- know. The wound in the soft parts 
also heals by granulation, and the cure may be considered complete. 
When necrosis affects the bones of the cranium, there is often a per- 
sistent indisposition in the disease to become limited or to establish a line 
of demarcation. It continues assiduously to invade the contiguous portions 
of the osseous tissue. If, after waiting for a reasonable length of time, the 
necrosed piece does not begin to loosen, it will be better to expose the bone, 
and by a careful use of the engine and a fine saw, or by the chisel, to cut 
away the piece beyond the limits of the diseased structure. The danger 
of long-continued delay is the probability of intra-eranial abscess, or of 
meningitis. 
Should a vessel be wounded by the sequestrum in the natural efforts for 
its expulsion, the parts must be laid open freely and the vessel searched for 
and tied. In the event of the principal artery being torn, amputation will 
offer the best prospect of recovery. 
Rachitis. 
Eickets, from the Greek word signifying a spine or a ridge, is the 
name very improperly given to a peculiar disturbance in the nutrition of 
the bones, which consists in an abnormal increase of the cartilaginous and 
transition substance of the osseous tissue, the lime salts at the same time being 
deficient in quantity. This affection belongs to childhood, and was at one 
time called the English disease. Though allusions have been made to this 
morbid change of the bones by Hippocrates, Galen, Celsus, and other ancient 
writers, yet it is to the English that the profession is chiefly indebted for a 
more exact knowledge of the disease. Until the time of Levaeher,* rickets 
and mollities ossium were regarded as the same affection. The distinction 
between the two has been very lucidly established by the labors of Virchow. 
The disease is frequently met with in Great Britain and on the Continent, 
rarely in the United States. In London, according to Jenner, it is very com- 
mon among the children of the poor. At the Hospital for Sick Children in that 
city, 2. 36 percent, of the inmates exhibited signs of rickets,f while among those 
under two years of age it prevailed to the extent of 30.3 per cent. Eitche, 
in his clinical observations on this disease among the children of Manchester, 
gives the same percentage,—that is, 219 rickety out of 728 out-patients. 
This varies very little from the statistics of the general clinic at Prague,J 
which furnish 504 cases of the disease among 1623 children under five years 
of age. The same author states that in Berlin, of 4715 patients under five 
years of age observed, 650 suffered from rickets, or about 13.8 per cent. At 
the Almshouse, Philadelphia, according to Dr. John S. Parry,§ 25 per cent, of 
all the inmates of the children’s department exhibited signs of this disease, 
which is about the same proportion as that given by Knettner for all the 
children of Dresden. I am satisfied, from observations which have been 
recently made, that the estimate of Dr. Parry was entirely too high. Dr. 
Hunter, who has examined carefully the same field, found 6 cases of rickets 
among 99 white children, and 6 cases among 36 colored children, or only 12 
cases of the disease in a total of 135 children,—8.08 per cent. 
Eickets may occur during foetal existence, or at any period between birth 
and the fifth year of life. It is seldom seen as late as puberty. The largest 
number of cases are met with between the first and second years of infancy. 
Of 346 cases of the disease examined by Guerin, 98 occurred during the first 
and 176 during the second year. Only 5 cases were noted after the sixth 
year. Among the whole number, 3 were examples of foetal rickets. The 
statistics of Eitche, comprising 219 cases, furnish 65 instances of the affec- 
tion during the last six months of the first year, and 109 between the first 
and the second year. From the fourth to the fifth year only 4 cases were 
* Traits du Rachitis, 1772. f Gee on Rickets, 
j Solomon, in Ziemssen’s Cyclopaedia, vol. xvi. p. 71. 
§ American Journal of the Medical Sciences, January and April, 1872. RACHITIS. 
1073 
observed, and none at a later period. Yon Rittershain, in 521 children 
affected by the disease, found that 329 were between six and twenty-four 
months old. 
Sex.—On this point there is some discrepancy between different statis- 
ticians. The aggregate summary of the observations made by Guerin, 
Bruenniche, Ritche, and Yon Rittershain would make the sexes nearly 
alike in their liability to this affection; that is, there were 436 males against 
484 females in 920 cases of the disease. 
In striking contrast with this comparison are the results obtained by 
Dufour and Mayolin, in which, according to the first-named writer, the 
number of girls suffering from rickets was found to be fifteen times as great, 
and according to the second, twenty times as great, as that of boys similarly 
affected. 
Causes.—The causes which operate to produce rickets are not certainly 
known. They are probably, in most instances, of a general character, as may 
be inferred from the early appearance of the disease, and from the number of 
bones which are simultaneously affected. The influence of hereditary condi- 
tions transmitted, especially on the maternal side, has been invoked by authors 
in explanation of this affection, especially tuberculosis and syphilis. The mul- 
tiform constitutional defects which are transmitted from parents laboring 
under tubercular disease render it probable that occasionally such a dys- 
crasia may be influential, by vitiating the nutrition of the foetus, in devel- 
oping the disease ; but examples of this kind are so rare that they must be 
deemed exceptional; and as to a syphilitic rachitis, I have never seen any- 
thing which would in the least tend to corroborate the existence of such an 
affection of the osseous tissue, though it is stated by Wagner and others that 
such appearances are sometimes present. 
From some observations which 1 have made, but which as yet are too crude 
to admit of a formal presentation, I am disposed to think that ultimately 
the predetermining vice will be found to originate in the cells of the medulla. 
Food.—Whatever may be the predisposing or underlying conditions of 
rachitis, there can bo no doubt that a powerfully determining influence is to 
be found in the combined operations of imperfect food and of damp, badly- 
lighted, and imperfectly-ventilated dwellings. On this point there is little 
difference of opinion among writers. 
In what this imperfection of food consists has not been definitely ascer- 
tained. It cannot be from the early weaning of infants, or from the use of 
artificial articles of nourishment, as it is well known that the children of 
many German mothers, who nurse at the bi'east for a long lime, supply at 
least as many examples of rickets as are found among those fed in a dif- 
ferent way, and, according to Billroth, the disease occurs with about equal 
frequency in all classes of society. 
The experiments which have been made on lower animals, by confining 
them to an exclusive kind of food, or to a diet in which the lime salts were 
largely absent, have yielded only negative results. As the essence of rachitis 
consists in an inordinate excitation of the normal or bone-forming process, 
the influence of any agents capable of unduly stimulating osteoplastic activity 
would conduce to the morbid condition under consideration. 
If the experiments of Wagner and Heitzmann prove to be l’eliable, we have 
in phosphorus and in lactic acid irritants which cause an extraordinary pro- 
liferation of cartilage-cells and of transition substance ; and if to this be added 
a deficiency of salts concerned in calcification, we have apparently the con- 
ditions requisite for the disease. The power of lactic acid to attack the in- 
organic constituents of bone is unquestionably great, and its abundant pres- 
ence in the intestinal canal of children suffering from disturbed digestion is 
equally clear, but its alleged power of osteoplastic stimulation is against 
many analogies. 
Pathology.—The changes which take place in the skeleton of rachitic 
subjects affect the long, the flat, and the irregular bones. These become 1074 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
enlarged, thickened, softened, and deformed by curvatures. This enlarge- 
ment is particularly noticeable at the epiphyses, which, by their increased size 
and the lateral bulging of the soft redundant cartilages between the diapli- 
ysesand the epiphyses, caused by muscular contraction, give rise to the term 
articuli duplicati, or double-jointed. 
In the early stage of the disease all parts of the bone—periosteal, medul- 
lary, cortical, and cancellated—are found to be greatly congested, deeply 
reddened, and filled with a gelatinous transudation. The changes are more 
distinctly noticed at the epiphyses than in the diaphyses. Instead of the 
regular stages and distinct boundaries observed in the normal development 
of bone, there is a singular disorderly commingling of the exaggerated 
cartilage proliferation and transition substance, with calcification. The carti- 
lage-cells, stimulated to excessive multiplication, are transformed, some into 
bone-corpuscles, some into medullary cells, and others into connective-tissue 
forms. 
The same process is in active operation in the deep periosteal layers, the 
material accumulating to such a degree as to add much to the thickness of 
the shaft. The effect of these changes is to soften and separate the cortical 
lamellae and enlarge the spaces of the cancelli until the bone becomes so 
soft, spongy, and pumice-like that it may be bent, indented, or misshapen in 
various ways by pressure, or by muscular contraction. Rokitansky has also 
shown that the product resulting from boiling rickety bones is unlike the 
chondrin or other animal matter of sound osseous tissue. 
With these alterations there are simultaneous ones affecting the inorganic 
components of the bone. In the normal long bones of children, the earthy 
constituents make from 63 to 67 per cent, of the total bulk, and the animal 
or organic from 33 to 37 per cent. 
In an analysis of a rickety scapula and humerus, given by Rokitansky, 
from Ragsky, the inorganic constituents amounted to only 18.88, and the 
organic to 81.12, a loss in the first, and in the other a gain. In a mean of 
seven analyses made by Friedleben of rickety ribs, the inorganic constituents 
amounted to 37.19, and the organic to 62.91. 
In addition to the morbid changes in the bones, the internal and other 
organs undergo important structural altei’ations. The spleen becomes hyper- 
trophied ; the lungs are attacked by catarrhal, pneumonic, or tubercular dis- 
ease ; the bronchial and the mesenteric glands are enlarged ; the intestinal 
glands are involved, and, as a result of disordered nutrition and the conse- 
quent emaciation, the muscles waste and lose their color; the liver becomes 
somewhat enlarged and fatty ; and, in some instances, the ventricles of the 
brain are found filled with serum, and the brain itself oedematous. 
Symptoms.—The commencement of rickets is usually so devoid of all prom- 
inent or distinctive symptoms that the true nature of the malady may 
remain for some time unobserved. Ordinarily, however, the complaint is 
inaugurated by some disturbance of the digestive organs, indicated bj' flatu- 
lent distention of the intestines, and by a tumid abdomen, diarrhoea, sour 
eructations, and unnatural perspirations. To this last-named symptom 
occurring at night and about the head, Jenner* attached considerable im- 
portance, as being diagnostic of the disease. The child becomes dull and 
spiritless, ceases its accustomed plays, is indisposed to all movement, sleeps 
fitfully, complains when the limbs are pressed, and at length sits with the 
spine bent and with the head sunk down between the shoulders. This position, 
together with the disproportion existing between the size of the head and that 
of the face, gives to the former an unreal magnitude, and confers an expres- 
sion of thoughtfulness and maturity to the latter altogether foreign to the age 
of childhood. With the intestinal disturbances the dentition is retarded or 
arrested, or, if the teeth have already passed through the gums, they often 
begin to decay and loosen ; the bones swell, especially the epiphyseal extremi- 
ties of the long bones, at the wrist, elbow, and knee, which, from their ex- 
* St. Bartholomew’s Hospital Reports, 1868. RACHITIS. 
1075 
posed positions, become markedly prominent. The structural changes having 
advanced sufficiently far to diminish the natural resistance of the bones, the 
latter undergo various distortions, as the result of the weight of the body or 
of muscular action. The lower ex- 
tremities curve outward, and, if 
the child is old enough to walk, 
the gait is waddling and unsteady; 
the upper extremities become bent 
forward; the sides of the chest, 
pressed by the scapular and hu- 
meral muscles, are flattened, and, 
in consequence of the soft, un- 
resisting nature of the cartilages 
at the anterior extremities of the 
ribs, the sternum is forced forward, 
giving an unnatural prominence to 
the breast (pectus gallinaceum, or 
chicken-breasted), the rationale of 
which has been particularly de- 
scribed by Shaw.* This deformed 
condition of the thorax, by which 
the pulmonary chambers are en- 
croached upon, the lungs displaced, 
and the nerves subjected to irrita- 
tion, as in Pott’s disease of the spine, 
has much to do with inducing lung 
complications. 
Deformities of the pelvis may like- 
wise ensue, and will vary in their 
character according to the manner 
in which the pressure is applied to 
the bones, whether by sitting or by 
creeping. If in the former way, the 
mobility of the sacro-iliac junction 
will allow the sacrum to be forced 
forward, thereby diminishing the 
antero posterior diameter of the 
pelvis ; and if in the latter way, by 
a general sinking of the entire sa- 
crum towards the anterior boun- 
daries of the pelvis, and an undue 
projection of the posterior borders 
of the innominate bones. (Fig. 921*.) 
These deformities in the female may 
seriously affect the mechanism of 
labor in after-years. 
The deformities which occur in 
the course of the spinal column, 
depending on the rachitic changes 
in the intervertebral and epiphy- 
seal cartilages, as well as in the 
bodies of the vertebrae, are gener- 
ally expressed by magnifying the 
natural antero-posterior curvatures. 
Lateral and rotary curvatures are 
occasionally witnessed, and are to some extent caused by the child’s habit of 
twisting the body in order to see objects to one side or behind. Green-stick 
fractures of the long bones are often produced as a result of the disease. 
Fig. 921*. 
Rachitic skeleton in the museum of the University of 
Pennsylvania. 
* On Distortions of the Spine and Chest, 1823. 1076 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
In the cranium, the fontanels remain open, and the sutures continue un- 
closed, which, with the continued enlargement of the anterior and posterior 
portions of the head, gives to the skull a fictitious magnitude. Another very- 
remarkable change is noticed in the occipital bone, to which the name of 
craniotabes has been given. The bone at certain points diminishes in thick- 
ness until finally it may at these localities entirely disappear, leaving only 
the pericranium and the membranes of the brain as a covering to the latter. 
This condition Dr. Jacobi refers to the combined effects of the weight of the 
child’s head upon the pillow and that of the brain within acting on the 
softened tissue of the bone and gradually causing its removal. 
There is in rachitis an arrest in the development of the entire skeleton, 
which, as has been shown by Humphrey,* is most apparent in the bones of 
the lower limbs, particularly the femurs. 
To the symptoms already detailed may be added the occasional presence 
of laryngeal spasm. 
There is a mild form of rickets in which neither the constitution at large 
nor the bones are extensively involved. The disease consists mainly in the 
want of general vigor. The child, though slow in walking, is rarely unable 
to stand upon his feet; the bones of the leg are bowed externally, and the 
gait is waddling. The epiphyses of the bones at the knees, 
wrists, and elbows are not enlarged, though the front of 
the chest may be prominent,—“ chicken-breasted." The dis- 
ease is rarely fatal, and is frequently met with among the 
poorer classes of a city population. Hegro children appear 
to suffer most. The curves in the bones often remain per- 
manent through life. (Fig. 922*.) 
Prognosis.—When the disease, commencing about the 
second year or later, is confined to two or three bones, and 
when the nutrition is not too profoundly disturbed and the 
case tends to pursue a chronic course, the prognosis, as 
regards the life of the child, is not altogether unfavorable, 
though few recover altogether from the deformities entailed 
by the disease. The practitioner must not be deceived by 
those remissions which not unfrequently take place in the 
course of rachitis, and during which intervals the general 
health of the child rallies for a time. These are usually 
deceptive calms, which will be followed by a return of the 
former symptoms, and not unfrequently in an intensified 
degree. When an auspicious change does set in and con- 
valescence becomes assured, the gastro-intestinal symptoms 
subside, the abdomen becomes soft and less distended, the 
dentition advances in a natural manner, the emaciation is 
arrested, the swollen epiphyses diminish, the bones grow 
abnormally solid and heavy by a large deposition of the 
lime salts, and finally, after the lapse of years, the patient 
is restored to health. 
In the majority of instances, unfortunately, the disease does not run so 
favorable a course : the little sufferer continues to emaciate; the discharges 
from the bowels become more thin, watery, and offensive; the tympanitis 
increases ; fever is constant; the urine becomes scanty, and the patient per- 
ishes either from sheer exhaustion or from bronchial or intestinal catarrh, 
or sometimes the fatal termination is hastened by the occurrence of some of 
the exanthemata. 
The diagnosis of rachitis is not difficult when once that disease is estab- 
lished. The affection with which it has been confounded is osteomalacia. The 
points of distinction will be noticed under the last-named disease. 
Treatment.—In the management of a case of rickets, attention should be 
given, first, to the hygienic conditions by which the patient is surrounded. 
Fig. 922*. 
Curved tibia and 
fibula. From a speci- 
men in the College 
of Physicians, Phila- 
delphia. 
* Medico-Chirurgical Transactions, 1862. OSTEOMALACIA. 
1077 
The importance of securing a situation free from dampness, with abundance 
of fresh air and sunlight, is so apparent as to require no arguments for its 
enforcement. The character and the quality of the food are next to be care- 
fully examined. Of course, if the child is under one year of age, there can 
be no nourishment so well adapted for its use as the maternal milk; but if 
the mother is feeble and out of health, if she labors under any constitutional 
vice,—tubercular, strumous, or syphilitic,—or if the supply of milk is in- 
sufficient to meet the demands of the infant, a healthy wet-nurse should be 
provided, or, if this is out of the question, the child must be supported on 
properly diluted cow’s milk. Different kinds of artificial nourishment can 
be employed, such as condensed milk, and other forms of infant food. 
When the child is ten or twelve months old and the mother’s supply of 
milk is not abundant, the deficiency may be supplemented by a little animal 
broth. In children still more advanced in years, and in whom the teeth are 
present, considerable license may be allowed in the variety of the aliment: 
fresh beef grated into a pulp, salt ham, farina, a little potato, and fruits, 
such as strawberries, blackberries, and ripe peaches, may often be used with 
decided advantage. 
The medicinal agents must be administered with a view to meet special 
indications. Among the most prominent of these is the disordered state of 
the digestive organs, to meet which, and possibly to supply the calcareous 
defect, lime may be given in some form most readily accepted by the system. 
Lime-water, exhibited in the milk or alone, answers every purpose. To aid 
the stomach in the preparation of the food for absorption, pepsin will be 
found useful, and, when not rejected, cod-liver oil is capable of accomplish- 
ing much good by its alterative and nutrient properties, thus checking the 
rapid waste of the adipose tissue. To restrain the bowels, and to maintain 
the structure of the blood, the tincture of the chloride of iron, or, if a more 
astringent preparation be demanded, the liquor ferri pernitratis, may be 
given; for the same object, minute doses of Dover’s powder may become 
necessary. Other tonics, such as quinine, cinchona, gentian, and quassia, are 
occasionally required. 
As an adjuvant to the treatment, salt bathing, with frictions by means of 
rough towels, will be found to do good. The temperature of the bath must 
be regulated by the vigor of the patient. It is most prudent to commence 
with one moderately warm, and gradually reduce the temperature to the 
point which will not be followed by chilliness, or from which the little one 
will quickly react. When the weather is changeable or cool, the body should 
be carefully protected by flannel and other clothing. 
To prevent curvatures of the bones, particularly in those of the arm or the 
leg, some benefit may be derived from a light plaster dressing applied with 
little pressure to the different sections of the limb, not including the articu- 
lations. When this is not deemed feasible, the child can be laid upon its back 
on a mattress, or on a water- or an air-bed fitted to a little wagon, and in this 
way be drawn about during favorable weather in the open air. As the dis- 
ease improves and the bones become more firm, the curves are frequently 
lessened by the action of the muscles, and, should this not follow, a great 
amount of correction can be effected by properly-constructed instruments, 
and by elastic bands. Suspension by the head for a few minutes twice a 
day will materially straighten any spinal curvatures which have been 
formed, and after a few such suspensions the advantage gained can be pre- 
served by a gypsum roller applied to the trunk over a neatly-fitting flannel 
shirt. (See treatment of Pott’s disease, vol. ii.) 
The cases of bone curvature requiring drilling and fracture are quite ex- 
ceptional. 
Osteomalacia. 
Osteomalacia is the name given to a disease affecting the bones of adults, 
which is characterized by the disappearance of the lime salts or earthy con- 1078 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
stituents, and the subsequent softening and even liquefaction of the organic 
portion of the osseous tissue. This singular affection is also known under 
the names of malacosteon and mollifies ossium. 
By the older writers, osteomalacia and rickets were regarded as identical, 
or, at least, very closely allied, diseases. Their dissimilarity, both in chemical 
and in other structural changes, first indicated by Levacher, has been amply 
confirmed by the observations of Lobstein, and by those of a later date, made 
by a number of English, German, and French writers. 
In osteomalacia the bones are not only soft and flexible, but are also rela- 
tively lighter than normal bones. The disease may be confined to a single 
bone, to one or several points of the same bone, or it may attack the entire 
skeleton. The vertebrae, ribs, and pelvic pieces are the bones most commonly 
attacked, whilst those forming the head and face rarely suffer. The deform- 
ities which follow, though resembling in many respects those of rickets, yet 
possess several material points of dissimilarity. For example, the transverse 
diameters of the pelvis are greatly contracted, and the pubic symphysis ren- 
dered very prominent, by the pressure of the thigh-bones, whereas in rickets it 
is more commonly the antero-posterior dimensions of the pelvis which suffer. 
In the latter affection, when the sternum is displaced, it is, as a rule, pushed 
forward, while in malacosteon it is as likely to be retracted. Charcot has 
noticed* singular changes wrought in the ungual phalanges of the hand 
by osteomalacia, these parts of the fingers becoming very flat, and bending 
unusually far backward, the result, no doubt, of the efforts made by the 
patient to support or to raise the body with the terminal phalanges while in 
the sitting posture. When the skeleton has been generally implicated, the 
most singular distortions and postures have followed, as in the case of the 
Marquis d’Armagnac, recorded by Duverney, or the still more remarkable 
one communicated by Morand, that of Elizabeth Querian, afterwards Madame 
Supiot, who died a victim to the disease in 1752. In this woman the trunk 
of the body was reduced to twenty-three inches in length ; the bones of the 
upper extremities had become greatly misshapen, and those of the lower 
extremities, especially the femora, so softened that the feet could be readily 
placed against the sides of the head. 
Causes.—Osteomalacia is fortunately a very rare disease. It is said that 
the valley of the Rhine furnishes the greatest number of examples of the 
affection. The causes concerned in its production are very imperfectly 
understood. Rickets, struma, syphilis, miasmatic emanations,f rheumatism, 
dampness, and food defective in certain mineral substances, have all been in- 
voked in explanation of the morbid change. In some few instances, as in one 
given by Dr. the disease seems to be hereditary. However little 
may be known on the subject of causation, there are certain conditions of sex, 
of age, and of social life which undoubtedly exercise a determining influence. 
Sex.—The number of females affected by the disease greatly outnumber 
the males. In the 47 cases of Beylard, 36 were women and 11 men. Of 131 
cases recorded by Litzmann, 120 were females and 11 males. Durham found 
132 women and 13 men in an aggregate of 145 cases. That is to sa}r, of the 
above 323 cases of this disease, 288 were females and 35 males. Holmes§ has 
not observed so great a disproportion between the sexes as that furnished by 
the above statistics, though the number on which he bases this statement is 
too small to weigh against the general statement,—namely, 10 cases, in which 
6 were women and 4 men. 
Age.—In Beylard’s cases, the largest number (20) occurred between fifty 
and sixty; next in order of frequency, between thirty and forty (17) ; only 
2 under twenty, and 3 after sixty. Of those given by Durham, the greatest 
number were found between twenty-five and thirty-five years of age. 
* Memoire de l’Academie Royale des Sciences. 1753. 
f Jones, British Medical Journal, September, 1859. 
j New York Medical Record, March, 1869, p. 25. 
| Holmes’s System of Surgery, vol. iii. p. 796. OSTEOMALACIA. 
1079 
Social state.—The influence of child-bearing appears to act as an exciting 
cause, and may explain the predominance of the disease among females. 
In Beylard’s 36 cases, 31 had borne children. In Litzmann’s collection of 
120, 85 had been mothers. Durham found 91 of the 132 women embraced 
in his statistics to have been attacked either during or very shortly after 
pregnancy; and Collineau, who has collected 43 cases of osteomalacia among 
females, states that 29 of this number had given birth to children. 
Food.—The testimony which has been adduced in favor of the causative 
agency of certain kinds of food in the development of malacosteon, especially 
aliment poor in the saline constituents of bone, must be regarded as of a 
negative character, though, independently of experiment, the connection of 
the disease with the parturient state, in which there is an increased demand 
for these salts, gives some plausibility to the theory. The examination of a 
number of bodies of insane persons, made by Dr. Herdner, would seem to 
imply some connection between mental disease and physical changes in the 
bones akin to the one under consideration. 
Pathology.—What part is played by inflammation in producing so re- 
markable a transformation of bone as that present in malacosteon has not 
been determined. Certain it is that one of the earliest phenomena witnessed 
is that of increased vascularity of the medullary tissue. The vessels become 
excessively engorged, and frequently give way, causing apoplectic extrava- 
sation of blood-clots, which are found disseminated through the medulla, 
intermixed with fat and some new cell-elements, the exact import of which 
is unknown, but the presence of a true infiltration, such as commonly char- 
acterizes inflammation, cannot be asserted. This engorgement, at first cen- 
tral in the medullary tissue, and tilling its cells with a gelatinous material, 
moves eentrifugally, extending to the outer portions of the caneelli (the cells 
of which are gradually dilated), and finally passes into the Haversian vessels 
of the compact structure. Coincident with this vascular disturbance com- 
mences the work of decalcification, which, like the first, extends from within 
outward, the products passing off partly by the kidneys, in the form of oxa- 
late of lime, and forming in some instances, according to Solly, renal vesical 
calculi. The saline constituents which impart solidity to the structure are 
gradually removed, rendering the bone soft and flexible, and leaving only a 
frame-work of cartilage, which in turn disintegrates and liquefies. As lactic 
acid has been discovered in the marrow of malacosteon bones, and as this 
agent is known to have a powerful influence over the lime salts, it is not im- 
probable that to it may be ascribed the disjunction of the organic and inor- 
ganic components of the structure. The analysis made by Lehman of four 
malacosteon bones (two femurs and two ribs) exhibits 24.40 parts of earthy 
and 75.60 of animal matter in 100 parts. A number of similar analyses have 
been made by other chemists, the results varying in each case, but all going 
to show the lessened amount of the mineral salts as compared with the 
organic constituents of the bone. 
The appearance presented by the medullary tissue—if such it still be— 
during the progress of these changes will depend much on the particular 
stage of the affection when the examination is made. At the commencement 
it may resemble the marrow of young bones, having a reddish or yellow tint, 
becoming straw-colored, viscid, and gelatinous as the disease advances, or 
exhibiting a cystic degeneration, the liquid of which may fill up the cavities 
of the bone or be enclosed in numerous loculi, until finally the entire bone 
becomes expanded into a mere honey-combed shell. The thin outer lamella 
of the cortex, depending as it does for its life as well as for its renewal chiefly 
on the periosteum, will often resist for a long time the malacosteon aggression, 
though sooner or later this last barrier may yield and the entire structure 
become a sac of flexible matter. 
Changes not unlike those wrought by cancer have been noticed in mala- 
costeon bones, as in the one described by Mr. Hawkins,* which resemblance 
* Medico-Chirurgical Transactions, vol. xxiv. p. 45.—Holmes. 1080 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
has led to a supposition that the two diseases are analogous, if not identical. 
The chemical and other mutations to which the skeleton is thus subjected, 
rendering it powerless to resist the weight of the body or the action of the 
muscles, occasion various curvatures and fractures. The vertebral column 
is among the first to realize distortion, and especially the lumbar portion, 
which from its position is compelled to sustain the greatest pressure; the 
other regions are affected in order from below upward. The curves are 
increased, the individual vertebrae shrink, and the entire column becomes 
shorter. The ribs are bent or broken by the muscular contractions con- 
cerned in respiration, the lesions occurring, as a rule, contiguous to the 
tendinous attachments of the posterior serrati, levatores costarum, and the 
tendons of the erector spinse muscles, or anteriorly in front of the great 
serrati and lesser pectoral muscles. The pelvis participates in these changes, 
undei’going alterations which materially affect the diameters of its cavity, to 
which allusion has already been made. Under the action of the same degen- 
eration the bones of the extremities and the clavicle become curved or broken, 
leaving only those of the head and face comparatively free from the general 
ruin. Notwithstanding the absence, in a great degree, of the mineral salts 
of the bone, the presence of these materials in the blood, and the tendency 
of the latter fluid to return them to the bone, are both very evident from the 
fact that the fractures which occur in the course of the disease sometimes 
undergo repair by the deposition of callus, after the manner adopted by 
nature in similar accidents of an uncomplicated kind, though neither so 
rapid, orderly, nor perfect as in the last. Generally, however, such fractures 
do not unite by callus. 
In addition to the structural alterations of the bones, the muscles early 
undergo certain alterations, characterized by multiplications of the sarcous 
nuclei, albuminoid and fatty degenerations, and other changes which indicate 
a pre-existing inflammatory disturbance. 
Symptoms.—Among the earliest signs of osteomalacia is the presence of 
deep-seated, gnawing pains, resembling those of periostitis and caries. The 
pains are generally located about the pelvis, in the loins, over the chest or 
limbs, situations corresponding to the regions of the skeleton generally first 
affected, and are often intermittent, having nocturnal exacerbations, and 
being increased in severity by dull or damp states of the atmosphere. The 
patient is easily fatigued, is incapable of any prolonged exercise, and finds it 
difficult to make a full inspiration. As the bones begin to yield, the footing 
becomes uncertain and the gait unsteady. From the various deformities or 
curvatures becoming more and more pronounced, and from the frequent oc- 
currence of fracture, the person becomes exceedingly helpless. The progress 
of the disease is usually slow, and prone to pauses or interruptions. This is 
especially so in females, who during gestation experience the greatest suffer- 
ing, and who after parturition, and during the interval betwmen conceptions, 
manage to enjoy a reasonable degree of comfort. The disease does not dis- 
turb the regularity of menstruation at those times when the function is not 
interrupted by pregnancy or nursing. The urine is not diminished in quan- 
tity, but is often increased, and yields an acid reaction. With regard to the 
chemical constitution of the renal and other secretions, we are in possession 
of no observations which are sufficiently numerous or systematic to warrant 
any expression of opinion. While some writers have alleged a great increase 
of the different salts of lime in the urine of malacosteon patients (Solly), 
causing renal calculus, other observers equally competent have been unable 
to discover any change in this particular from its ordinary constitutions. 
The same may be said of the perspiratory and the salivary secretion. Dr. 
Bence Jones,* in a case in which the softening of the bones was not discov- 
ered until after death, noticed in the urine a peculiar albuminoid principle 
(hydrated deutoxide of albumen), which, unlike ordinary albumen, was read- 
* Philosophical Transactions, vol. ixvi. p. 55.—Holmes. FRAGILITAS OSSIUM. 
1081 
ily soluble in boiling water, and the precipitate of which by nitric acid was 
dissolved by heat, reappearing again on the application of cold. 
The duration of the disease varies from two to six years. The shortest 
period in which a fatal termination is known to have taken place was in the 
case mentioned by Schmidt, viz., in three months; and it is not uncommon for 
patients laboring under the affection to linger along for eight or ten years. 
Diagnosis.—In the commencement of malacosteon, when there exist only 
the initial pains and soreness on pressure and movement, it will be veiy dif- 
ficult, if not impossible, to determine the exact nature of the disorder. It 
may very naturally be referred to cold or rheumatism, but when the bones 
begin to yield there need be no uncertainty about the nature of the complaint. 
Though it offers some points of resemblance to rachitis, there are so many 
dissimilar symptoms that when these are revealed no mistake can be possible. 
The following peculiarities of the two affections, when contrasted as below, 
will make this subject clear: 
A disease of adult life. 
Affects chiefly females. 
Softening progressive, rarely becoming arrested. 
Attended with severe pains. 
Depressions in the occipital bone, or eraniotabes. 
Absence of epiphyseal swelling. 
Fontanels closed. 
OSTEOMALACIA. 
A disease peculiar to children. 
Affects males and females indifferently. 
Softening frequently arrested and patients re- 
cover. 
Absence of pain. 
Without any such depressions. 
Epiphyseal swellings. 
Fontanels, and often sutures, open. 
RICKETS. 
Prognosis.—The disease is almost always fatal, death taking place from 
exhaustion, from visceral disturbances consequent on the resulting deformities 
of the surrounding walls of bone, and from those complications which arise 
from a deformed pelvis, rendering the Caesarean operation necessary for the 
delivery of the foetus. In a few instances patients have been carried off by 
pneumonia and other inflammatory affections altogether independent of the 
constitutional disease. 
Treatment.—The treatment in cases of osteomalacia must be regulated 
with a view to sustain the general strength, to alleviate pain, and to guard 
against the effects of pressure. For the first, tonics, such as quinine, cincho- 
nidia, iron, cod-liver oil, and the phosphates, together with a nutritious diet of 
milk, eggs, brown bread, fish and other meats, will answer the best purpose, 
not forgetting at the same time the importance of a dry, healthy location. 
When the pain becomes aggravated and interferes with sleep, anodynes must 
be exhibited ; and, as a defensive measure against bending and fracturing of 
the bones, the recumbent position should be maintained on mattresses, sup- 
plemented by air-cushions, and, when circumstances will allow, by the em- 
ployment of the water-bed. Females who suffer from the disease should, as 
a prophylactic measure, avoid pregnancy. 
Fragilitas Ossium. 
Fragilitas ossium is a very indefinite terra when used to express a specific 
disease. As an effect of several morbid conditions of the osseous tissue it is not 
uncommon. From whatever cause it may arise, it consists in an abnormal 
brittleness of a bone, by which it breaks on the application of the most trifling 
amount of force. Medical and surgical books abound in extraordinary ex- 
amples of this kind. The defect is sometimes local, and occasionally affects 
every bone in the skeleton. In one patient of my own, a female, the fragility 
appeared to be confined to the ribs, a large number of these having been broken 
in the course of her life. In a number of cases, generally females, the patella 
has been in each the seat of several fractures. Professor Gross records the 
case of an aged woman in whom, in consequence of a fall from a considerable 
height, there were produced upwards of eighty fractures. The case given by 
Chaussier, of one hundred and thirteen fractures occurring at different times, 
is another in point among the many mentioned by different writers. The 1082 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
fragility is sometimes so great that the slightest force will cause a bone to give 
way. Thus, the accident may be caused by turning in bed, by tripping over the 
carpet, in the act of gesticulating, and in many other very unexpected ways. 
The bones most commonly affected are the patella, femur, ribs, humerus, 
tibia, and clavicle. Often the brittleness is limited to a portion of a bone, as 
the neck of the femur or the surgical neck of the humerus. 
Causes.—There are various causes which, in consequence of the chemical 
and physical changes induced bj7- their presence, render the bones of the 
skeleton fragile. Among these, aside from inflammatory diseases and from 
rickets and malacosteon, may be mentioned syphilis, gout, rheumatism, cancer, 
hereditary peculiarities of constitution, old age, and atrophy. The children 
of syphilitic parents are more liable to suffer in this way than the parents 
themselves. Bones are often broken even in very gentle attempts to over- 
come rheumatic anchylosis or the adhesions following a luxation. Twice 
have I seen the thigh broken, in persons suffering from mammary cancer, by 
the effort of turning in bed. I attended a child five years of age for a frac- 
ture of the tibia and fibula, caused in the usual gambols of play, whose father 
and grandmother had each been the subject of several similar injuries. A 
like instance is mentioned by Pauli, of Leipsic. 
Fragility of bone is an almost constant attendant on advanced life, in 
consequence of the fatty degeneration and the atrophy which occur in the 
skeleton of old persons. The bones of a paralyzed limb, from defective in- 
nervation and circulation, undergo similar changes, and possess less power of 
resistance than those of the sound member. 
The pathological appearances of fragile bones differ according to the causes 
which are concerned in the production of the disease. It may follow from 
inflammatory infiltration, from decalcification, from fatty degeneration, or 
it may exist from atrophy without any material disturbance in the rela- 
tive properties of the organic and inorganic components of the structure. 
There are no symptoms which declare the commencement of fragilitas os- 
sium, except where the disease has a rachitic or malacosteon origin. The 
first indication of the vice is perhaps given by the occurrence of a fracture 
from a slight cause. The urine has been observed to be loaded with the 
phosphate and carbonate of lime, but, as the presence of these constituents 
in the secretion may be seen in other very dissimilar affections, it cannot be 
regarded in itself as diagnostic. When produced by rheumatic or syphilitic 
causes, severe deep-seated pains may harass the patient. 
Treatment.—When the signs of fragility appear in the young, or when 
there has been a family history of this weakness, much may be done to 
avoid fractures by the use of precautionary measures. As to internal reme- 
dies, they are at best of very doubtful value. Phosphates, cod-liver oil, iron, 
and mineral acids have been recommended, but, except as agents designed 
to improve the general health, there is no evidence that they accomplish 
any good. In the same way a liberal diet and proper hygienic surround- 
ings are important: When the disease is accompanied with severe pain, the 
iodide of potash and opiates will ameliorate the suffering. If the patient be 
young, with the growth and vigor of advancing years improvement is not 
impossible. 
Hypertrophy. 
There are two kinds of bone hypertrophy,—the non-inflamraatory and the 
inflammatory. The first is the effect of an increased normal nutrition incited 
by functional activity. In my possession are two scapulae taken from the 
body of a person who had been the subject of hemiplegia. The helpless 
condition of the diseased side had been supplemented by an increased use of 
the sound arm and shoulder, and the consequence was that the scapula of the 
latter had grown to an unusual size, its ridges and processes being strongly 
developed. The same cause that had necessitated the active exercise of the 
sound limb had been followed by atrophy of the scapula of the paralyzed HYPERTROPHY. 
1083 
one, the bone being undersized, very delicate, and white in appearance. 
The bones of the right arm of the smith, or those of the leg employed by 
the machinist in driving a pedal lathe, will be found of greater magnitude 
than those of the companion limb. The disease is usually confined to the 
bones of the cranium, the femur, and the tibia. Exceptionally it may impli- 
cate the entire skeleton, as in the case recorded by Dr. Mears, of this city.* 
The hypertrophy is frequently one of compensation, the 
most remarkable examples of which may be seen in the 
increased thickening of the bones forming the vault of the 
cranium in cases of brain atrophy from senile and other 
causes. Of this nature also is the specimen represented in 
Fig. 923*, in which the fibula has become greatly enlarged 
from being obliged to supplement a defective tibia, which, 
after a fracture, failed to unite and became atrophied. In 
the inflammatory variety of hypertrophy the increase 
may consist in a centric deposition of callus filling up the 
cancellated tissue, and even the medullary canal, without 
materially increasing the circumference of the bone. This 
follows to some extent the repair of all cases of fracture 
as a temporary condition ; but it exists independently of 
these injuries, as an effect of certain inflammatory affec- 
tions of bones, and is called sclerosis, a process which 
has its analogue in the induration of the soft tissues. The 
inflammation which gives rise to what may be termed 
expansive and elongated hypertrophy—that is, to en- 
largement in the thickness and in the length of bones — 
is rarely of an active type, as may be inferred from 
the subjective nature of the accompanying phenomena, 
and is excited by constitutional influences such as attend 
syphilis, and also in exceptional cases from conditions in 
some way allied to the puerperal state. When the first 
form, the expansive, is observed in the bones of the cranium, it may be 
confined wholly to an increase in the volume of the diploe, the inner and 
outer tables remaining unaltered ( Fig. 924*) ; or it may affect the entire thick- 
ness of the bone, obliterating all distinction of layers, and imparting to the 
piece a grayish-white color and a porous 
appearance, not unlike the open ligneous 
fibre seen on making a transverse section 
of the wood of the grape-vine, or, as Dur- 
ham has designated it, an appearance simi- 
lar to dry mortar,—a form of osteoporosis. 
(Fig. 925*.) When the disease becomes lo- 
Fig. 923*. 
Supplemental hyper- 
trophy, from a specimen 
in the museum of the 
College of Physicians, 
Philadelphia. 
Fig. 925* 
Fig. 924*. 
Expansive hypertrophy of the 
occipital bone. 
Hypertrophy including all the layers of 
the skull bones.—From a specimen in the 
museum of the University of Pennsylvania. 
cated in one of the long bones, as in the femur or the tibia, before the 
epiphyseal consolidation is accomplished, the limb of the affected side may, 
* Transactions of the Philadelphia Pathological Society, 1869. 1084 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 
in consequence of becoming longer than its fellow, produce marked lameness. 
When the elongation occurs in the tibia, the fibula remaining unaffected 
and acting like the string of a bow, the diseased bone 
becomes curved anteriorly. (Fig. 926*.) 
Causes.—While in many cases of hypertrophy little is 
known in regard to the nature of the affection, in others 
the connection of the enlargement with certain inflam- 
matory states of the bone has been well established. In 
the case of a gentleman who had been struck on the 
head by a fragment of shell, and whom I trephined in 
consequence of frequent and aggravated epileptic seiz- 
ures, the bone had increased to double the usual thick- 
ness ; and in a second instance of hypertrophy affecting 
the occipital bone which I had an opportunity of ex- 
amining, the disease began after a blow received on the 
back of the head from a slung-shot. Both of these 
could undoubtedly be referred to an inflammatory origin. 
Then it is probable that a few cases beginning in in- 
flammation have subsequently continued by an exagger- 
ated nutrition, which has followed in the wake of the 
first process long after the subsidence of the latter. 
Among these may be placed, I think, the examples of 
hypertrophy given by Paget, in which the femur grew 
too long after recovery from necrosis of that bone. 
When arising in a syphilitic constitution it is no doubt 
due to inflammatory changes within the osseous tissue, 
analogous to those which are concerned in deforming 
the exterior of a bone with nodes. 
Diagnosis.—The only affections with which hyper- 
trophic curvature of the bones can be confounded are 
rickets and osteomalacia. 
From the first it may readily be distinguished by the 
curvatures in hypertrophy being anterior, while in 
rickets they are lateral. In rickets, moreover, the bones 
are shorter than natural. 
Osteomalacia is a disease of adults, and is accom- 
panied by general deformity and an exceedingly brittle 
state of the bones, which will sufficiently distinguish it from hypertroplrp. 
Treatment.—The chief duty of the surgeon consists in providing for the 
inconveniences which result from the disparity in the length of the limbs in 
cases of femoral elongation, which, if neglected, is prone to cause a compen- 
satory curve in the spine, or a pes equinus of the foot, the remedy for which 
is an additional sole placed on the shoe of the normal limb. 
When there is reason to suppose that the affection is due to a syphilitic 
taint, benefit may be derived by exhibiting the iodide of potash either with 
or without mercury. 
Fig. 926.* 
Hypertrophy of the tibia 
with anterior curvature.— 
Paget. 
Atrophy. 
Atrophy, like hypertrophy, has both a non-inflammatory and an inflam- 
matory origin. In the first there is a simple wasting or absorption of the 
organic and inorganic components of the bone, and in the second there are 
infiltration, softening, and rarefaction. 
Among the first or non-inflammatory causes may be enumerated age, 
disease, paralysis, and pressure. 
The wasting which takes place in advanced life is only the counterpart 
of a similar change which, as a rule, reigns throughout the body of old per- 
sons. Two changes are ever in operation during life, namely, supply and 
waste. It is the nicely-adjusted balance of these two processes which confers 
permanency of form and efficiency of function. In old persons, the chief ATROPHY. 
1085 
cause of tissue-decay is diminished functional activity. The enforced rest 
of age is followed by a less active circulation in the bone, the phosphate of 
lime begins to disappear, the cancellated tissue becomes rarefied, accompanied 
by fatty metamorphosis and thinning away of the cortex, the dimensions of 
the bone are materially lessened, and its weight is lightened. In this way do 
we account for those degenerations in the head and neck of the femora of 
old persons, by reason of which fracture is so common. 
After the teeth have dropped out or have been drawn, the office of the 
alveoli being abolished, the process gradually disappears by absorption. A 
limb rendered powerless by a central lesion, as in paralysis, labors under a 
twofold disadvantage,—lack of motion and the withdrawal of nerve-power, 
both of which are inimical to nutrition, and hence the gradual atrophy of the 
bones of an extremity so stricken. 
Pressure not only resists the growth of the skeleton, but is also actively 
concerned in the removal of the bony tissue. Craniotabes is a conspicuous 
example of this kind, though the sound bone is by no means exempt from the 
operation of the same cause. When the pressure is either continuous or in- 
termittent, the absorption begins in that part of the bone which is imme- 
diately in contact with the compressing body. Thus, a tumor of the scalp 
will sometimes hollow out a depression in the bone against which it grows; 
a growth in the antrum, while it expands the walls of that cavity, will at the 
same time thin them out until finally they disappear; and an aneurism of 
the thoi’acic or the abdominal aorta will, by its repeated strokes against the 
vertebrae, form for itself a large cavity, which has gradually deepened from 
without inwards. Such a change results from diminished vascularity, inci- 
dent to mechanical pressure. 
The extent to which the work of absorption may go on is only limited by 
the bone itself. The late Dr. Norris* has recorded an instance in which the 
entire humerus, after being twice broken near its middle, was removed in 
this manner; and in a case of ununited fracture of the same bone which 
was brought to my notice by a medical man, one-half of the bone had dis- 
appeared, and I doubt not, in time, the issue will be the same as that in the 
case given by Dr. Norris. 
Inflammatory atrophy is by no means common. It may occasionally be 
seen after cases of necrosis or caries in which the repair has been imper- 
fectly accomplished, and in cases of the interstitial absorption of the neck of 
the thigh-bone which sometimes follows falls or blows over the trochanter 
major. This last change is an important one from a medico-legal point of 
view. 
No treatment has any power to arrest osseous atrophy, unless the case be 
one arising from disease not occasioned by circumstances attending, or mal- 
adies incident to, advanced life, when, by manipulation and artificial move- 
ments, the waste may in some measure be arrested. 
Tumors of the bones will be considered under their proper head. 
* American Journal of the Medical Sciences, January, 1842. INDEX TO VOLUME I. 
A. 
Abdomen, contusions of, 265, 
430. 
diseases of, 475. 
double T bandage for, 58. 
dropsy of, 476. 
tapping of, 478. 
wounds of, 429, 430, 431, 440. 
protrusion of viscera in, 
432. 
Abdominal aorta, aneurism of, 
718. 
ligation of, 786. 
dropsy, 476. 
muscles, hernia between, 573. 
section, 429. 
tourniquet, 225. 
tumors, diagnosis of, 475. 
varix, 632. 
viscera, contusion of, 265. 
wounds of, 440. 
walls, congenital defects of, 
553. 
rupture of, 433. 
weakness of, 552. 
wounds, 429, 430, 431. 
sequelae of, 460. 
Abdomino-inguinal cravat, 87. 
Abdomino-pelvic wounds, 324. 
Abnormal pulsations in the ab- 
dominal aorta, 720. 
state of the blood, 93. 
Abrasion, 169. 
Abscess, abdominal, diagnosti- 
cated from ascites, 477. 
acute, 157, 161. 
diagnosis of, 157. 
after fevers, 165. 
after hypodermic injection, 
165. 
after scalp wounds, 324. 
bone, 1055. 
multiple, 1055. 
brain, 328. 
search for, 385. 
chronic, 157, 165. 
circumscribed, of bone, 1055. 
coexistent with aneurism, 
658. 
cold, 165. 
complications following, 164. 
congestive, 165. 
constitutional effects of, 167. 
contents of, 166. 
diagnosis of, 157. 
from aneurism, 157, 657, 
658, 697. 
from ascites, 478. 
Abscess, diagnosis of, from en- 
cephaloid, 158. 
from fatty tumor, 158. 
from hernia, 158, 589. 
disseminated, 159, 161. 
following fever, 391. 
hepatic, 451. 
incision of, 163. 
induration of, how removed, 
164. 
intracranial, 328. 
intraparietal, after typhlitis, 
497. 
intraperitoneal, after typh- 
litis, 497. 
ischio-rectal, 535. 
liver, 451. 
lumbar, 156. 
metastatic, 127. 
multiple, 1055. 
of hand, 611. 
of pancreas, 457. 
of spleen, 456. 
palmar, 611. 
pathology of, 161. 
peri-anal, 535. 
peri-nephritic, after abdom- 
inal wounds, 460. 
peri-rectal, 535. 
peri-vascular, 737. 
phlegmonous, 161. 
psoas, 156. 
diagnosis from femoral her- 
nia, 597. 
residual, 166. 
scrofulous, 165. 
treatment of, 162. 
tuberculous, 157, 165. 
varieties of, 161. 
walls of, 167. 
Absorbent cotton, 49. 
Absorption, 171. 
of alveolar process, 1085. 
of bone, 824, 1085. 
of callus, 851. 
of head of humerus, 919. 
of neck of femur, 974. 
of pus, 155. 
ulcerative, 169. 
Accumulation of faeces, 484. 
Acetabulum, fracture of, 968. 
its diagnosis from disloca- 
tion of neck of femur, 
970. 
its diagnosis from fracture 
of neck of femur, 970. 
Acid, carbolic, 46, 212. 
nitric, for hospital mortifica- 
tion, 204. 
Acids in caries, 1053. 
Aconite as a depressant, 138. 
Acromion, fractures of, 913. 
Actinomycosis of bone, 1060. 
Active clot in aneurism, 651. 
Actual cautery for hospital gan- 
grene, 208. 
Acupressure, 228, 231. 
for aneurism, 673, 706. 
for hemorrhage, 228. 
for subclavian aneurism, 706. 
pin, 228. 
Acupuncture, 265. 
for the relief of tympany, 
491. 
needles in aneurism, 678. 
Adams’s saw, 849. 
Adductor canal, 785. 
Adenoma of rectum, 521. 
Adhesion in hernia, 579. 
Adhesive inflammation, 316. 
Adhesive plaster, 244. 
for ulcers, 183. 
for wounds, 244. 
in fractured clavicle, 906. 
olecranon, 954. 
ribs, 894. 
in fractures, 815, 1029. 
in umbilical hernia, 600. 
removal of, 245. 
strips, preparation of, 244. 
Adipose tumor, diagnosis from 
abscess, 158. 
from angeioma, 619. 
from femoral hernia, 597. 
from inguinal hernia, 
589. 
from umbilical hernia, 
600. 
following contusions, 264. 
Aerial fistula, 399. 
iEsthesiometer, 38. 
After-treatment of aneurism, 
666, 668. 
of fractures, 816. 
of hemorrhage, 255. 
Age as influencing inflamma- 
tion, 91. 
in aneurism, 653. 
in fragilitas ossium, 1082. 
in hernia, 553. 
in surgical diagnosis, 27. 
in ulceration, 172. 
its influence on the repair of 
bones, 822. 
Agnew’s anterior angular splint, 
930. 
artery compressor and needle, 
406. 1088 
INDEX TO VOLUME I. 
Agnew’s experiments on repair 
of bone, 804. 
forceps, 233. 
hernia instrument, 559. 
operation, 559. 
internal angular splint, 924. 
operation for salivary fistula, 
391. 
rectal chemise, 549. 
retractor for the peritoneum, 
777. 
spiral wire probe, 1053. 
thoracic trocar and canula, 
420. 
Ahl’s felt splint, 813. 
Air in cold abscess, 168. 
injection of, 490. 
in veins, 395, 626. 
death from, 627. 
symptoms of 626. 
treatment of, 626. 
its exclusion from wounds, 43, 
168. 
organisms in, 44, 45. 
Air-bed, 812. 
Air-passages, wounds of the, 
394. 
Alcohol as a cause of aneurism, 
653. 
of atheroma, 644. 
in inflammation, 142. 
Alcoholic friction after fracture, 
818. 
Alkalies, abscess from the use 
of, 165. 
Allen’s transfusion apparatus, 
240. 
Allingham, on hemorrhoids, 
546, 549. 
Allingham’s rectal plug, 510. 
Allis’s hernia knife, 578. 
sign of intracapsular fracture 
of the femur, 975. 
Alveolar process, absorption of 
the, 1085. 
fracture of the, 879. 
Amaurosis after nasal fracture, 
875. 
Amesbury’s splint, 1002. 
Amputation, analysis of cases, 
309. 
as compared with excision, 
307, 312. 
at elbow-joint for shot wound, 
310. 
at knee-joint for shot wound, 
314. 
at shoulder-joint for shot 
wound, 307. 
at shoulder-joint for subcla- 
vian aneurism, 706. 
for aneurism, 668. 
for gangrene, 196. . 
for penetrating ulcer, 189. 
for senile gangrene, 200. 
gunshot cases demanding, 
306. 
in gunshot wounds, 305. 
in mortification, 196, 200. 
intermediary, 305. 
methods of, 308. 
of arm for shot wound, 308. 
of forearm for shot wound, 
310. 
of thigh for shot wound, 311. 
periods for, 305. 
primary, 305. 
secondary, 305. 
Amussat’s method of colotomy, 
501. 
of torsion, 226, 227. 
Amyloid degeneration, arterial, 
641. 
Anaesthesia in the treatment of 
aneurism by compression, 
672. 
local, by ether spray, 164. 
by iee, 164. 
by rhigolene, 164. 
Anal fissure, 514. 
fistula, 536-540. 
specula, 503. 
Anastomosis between the radial 
and ulnar arteries, 775. 
Anatomical neck of the humerus, 
fracture in, 918. 
tubercle, 271. 
Anatomy of angeiomata, 618, 
619. 
of bones, 1046. 
of scalp, 322. 
of Scarpa’s triangle, 781-784. 
surgical, of anterior tibial 
artery, 791. 
of axillary artery, 767-769. 
of brachial artery, 770. 
of common carotid, 740. 
of dorsalis pedis artery, 792. 
of external carotid, 749. 
of external iliac artery, 
776. 
of femoral artery, 784. 
of femoral hernia, 593, 786. 
of forearm, 773. 
of inguinal hernia, 584. 
of innominate artery, 738. 
of internal iliac artery, 778. 
of peroneal artery, 790. 
of popliteal artery, 787. 
of posterior tibial artery, 
788. 
of primitive iliac artery, 
779. 
of radial artery, 772. 
of scalp, 322. 
of Scarpa’s triangle, 784, 
786. 
of subclavian artery, 756. 
of ulnar artery, 775. 
of vertebral artery, 762. 
Anchylosis after fracture, 821. 
prevention of, 817. 
Aneurism, 647. 
abdominal, 722. 
abscess distinguished from, 
657. 
accidents after ligation, 662- 
669. 
acupressure for, 673. 
acupuncture for, 678. 
age as a factor in, 653. 
amputation for, 668. 
arterio-venous, 647, 684, 713. 
auscultation of, 656, 697, 714. 
Bellingham clamp for, 672. 
Briddon compressor for, 673. 
by anastomosis, 647. 
Carte’s compressors for, 672. 
causes of, 653. 
cervical, 686. 
circumscribed, 683. 
Charriere’s compressor for, 
673. 
cirsoid, 615, 647. 
collateral circulation after li- 
gation for, 664. 
Aneurism, compression for, 662, 
669, 671, 674, 699. 
constitutional treatment of, 
661. 
death from, 660. 
diagnosis of, 656, 657. 
from abnormal pulsations, 
720. 
from abscess, 157. 
diffused, from rupture of an 
aneurismal sac, 681, 717. 
digital compression for, 673, 
699. 
direct, 647, 684. 
dissecting, 639, 647, 680. 
distal ligature for, 700. 
dyspnoea from, 687. 
effects of, by pressure, 651. 
embolism as a cause of, 655. 
ergot for, 700. 
ergotin for, 677. 
exciting causes of, 655. 
external, 647. 
false, 647, 680. 
circumscribed, 683. 
femoro-popliteal, 728, 
flexion for, 675. 
fusiform, 648. 
galvano-puncture for, 676. 
gangrene after ligation of, 
667. 
treatment of, 668. 
hemorrhage after ligation of, 
666. 
hernial, 647. 
Horner’s awl for, 682. 
horse-hair introduced into, 
678. 
how distinguished from cysts, 
660. 
how distinguished from en- 
cephaloid growths, 659. 
how distinguished from erec- 
tile growths, 659. 
how distinguished from solid 
tumors, 659, 660. 
incision and ligation for, 662. 
injections for, 677. 
intermediate, 647. 
internal, 647. 
interparietal, 639. 
intracranial, 707. 
intraorbital, 709. 
causes of, 711. 
diagnosis of, 711. 
galvano-puncture for, 713. 
ligation for, 709, 712. 
strangulation of, 713. 
treatment of, 712, 713. 
kneading for, 700. 
ligation for, 662, 664, 669, 694, 
700. 
on the distal side, 669, 694. 
on the proximal side, 662, 
664. 
local measures for, 662. 
manipulation of, 656, 676, 
700. 
mortification after ligation of, 
667. 
nativity as affecting, 655. 
occupation as a factor in, 655. 
of abdominal aorta, 718. 
compression in, 721, 722. 
diagnosis of, 720. 
spontaneous cure of, 722. 
symptoms of, 719. 
termination of, 720. INDEX TO VOLUME I. 
1089 
Aneurism of abdominal aorta, 
treatment of, 721. 
of aorta, thoracic, 686. 
deglutition in, 687. 
diagnosis of, 688. 
duration of, 688. 
dyspnoea from, 687. 
ligature for, 690. 
physical signs of, 687. 
symptoms of, 686. 
termination of, 688. 
treatment of, 688. 
venous congestion in, 
687. 
of axillary artery, 713. 
cause of, 713. 
death after ligation for, 
715. 
diagnosis of, 714. 
ligation for 715. 
progress of, 715. 
symptoms of, 714. 
treatment of, 714. 
of brachial artery, 717. 
of branches of external ca- 
rotid, 702. 
of carotid, 696. 
compression in, 699. 
diagnosis of, 697. 
from abscess, 697. 
from brachio-cephalic 
and aortic aneurism, 
699. 
from cysts, 698. 
from enlarged lymphatic 
glands, 697. 
from thyroid enlarge- 
ment, 698. 
from tumors, 698. 
from varix of the inter- 
nal jugular, 698. 
digital compression in, 699. 
symptoms of, 697. 
termination of, 699. 
treatment of, 699. 
of dorsalis pedis artery, 733. 
of external carotid, 701. 
of femoral artery, 727. 
deep, 729. 
of iliac, external, 725. 
diagnosis of, 725. 
internal, 723. 
diagnosis of, 724. 
primitive, 723. 
of innominate, 690. 
diagnosis of, 693. 
pressure of, 691. 
prognosis in, 693. 
symptoms of, 691. 
treatment of, 693. 
of internal carotid, 702. 
of internal iliac, 723. 
of intracranial carotid, 707. 
of palmar arch, 718. 
of plantar artery, 733. 
of popliteal artery, 730. 
of primitive iliac, 723. 
of subclavian artery, 703. 
of superficial palmar arch, 
718. 
of superficial volar artery, 
718. 
of tibial artery, 732. 
of transverse cervical artery, 
707. 
of vertebral artery, 707. 
opening of the sac of, 665, 
666. 
Aneurism, popliteal, 651. 
proximal ligature for, 700. 
pulsation of, 656. 
results of ligation for, 700. 
return of, after a cure, 664. 
rupture of, after ligation, 666. 
sac of, 648. 
clot in, 648. 
contents of, 650. 
form of, 649. 
layers of fibrin in, 651. 
rupture of, 650. 
sacciform, 648, 651. 
secondary hemorrhage after 
ligation for, 664. 
sex in, 654. 
Signorini tourniquet in, 671. 
sloughing after ligation of, 
666. 
solid substances introduced 
into, 678. 
spontaneous, 647. 
spontaneous cure of, 660, 689. 
statistics of, 694, 700, 706, 
708, 712, 715, 722, 726. 
suppuration after ligation of, 
665, 666. 
symptoms of, 656, 681, 685, 
686, 697, 703, 709, 710, 
714. 
auscultation, 656. 
bruit, 650, 697. 
dysphagia, 687. 
dyspnoea, 687. 
fremitus, 697, 714. 
manipulation, 656. 
pain, 686. 
pressure-effects, 656. 
pulsation, 657. 
thrill, 697, 714. 
tremor, 697, 714. 
termination of, 660. 
tetanus after ligation for, 
668. 
thoracic, 686. 
tourniquet in, 671. 
traumatic, 647, 681. 
treatment of, 661, 666, 681, 
683. 
after operation, 666, 668. 
by acupressure, 673. 
by acupuncture, 678. 
by Antyllus’s plan, 663. 
by compression, 669. 
by distal ligation, 669. 
by ergotin, 678. 
by flexion, 675. 
by galvano-puncture, 676. 
by incision, 663. 
by introduction of solid sub- 
stance, 678. 
by ligation, 663. 
by manipulation, 656, 676, 
700. 
by opening, 665. 
comparison of the various 
plans, 679. 
constitutional, 661. 
methods compared, 679. 
subcutaneous, 677. 
true, 647, 648. 
varicose, 647, 684. 
venous congestion in, 687. 
Watson’s weight compressor 
for, 672. 
Aneurismal needle, 735. 
sac, 648. 
varix, 647, 684. 
Angeioleucitis, how discrimi- 
nated from phlebitis, 628. 
Angeiomata, 615. 
anatomy of, 618, 619. 
arterial, 615. 
capillary, 617. 
diagnosis of, 616, 618. 
of labium, 624. 
of tongue, 624. 
submucous, 619. 
treatment of, 616, 620. 
by acupressure, 621, 623. 
by excision, 622. 
by galvano-cautery, 620. 
by injection, 620. 
by ligation, 621, 622, 623. 
by strangulation, 621. 
by subcutaneous ligation, 
622. 
venous, 618. 
Angular displacement, 799, 
1025. 
splint, 924, 930, 934. 
union after fracture, 847. 
Animal ligatures, 236. 
poisons, 271. 
attenuated, 272. 
Ankle, amputation of, 314. 
excision for shot wounds, 314. 
splint for use after Pott’s frac- 
ture, 1038. 
sprain of, 1038. 
Annular stricture of the intes- 
tine, 486. 
Anodynes in inflammation, 141. 
Ano-rectal cancer, 528. 
Antecedent history in diagnosis, 
29. 
Anterior angular splint, 930. 
eight (bandage), 72, 73. 
tibial artery, ligation of, 791. 
surgical anatomy of, 791. 
Anthrax, 271. 
bacillus of, 272. 
in man, 272. 
Antimony as a depressant, 138. 
Antisepsis, 43. 
applied to operations, 49. 
germicides in, 46. 
in after-dressings, 250. 
in gunshot wounds, 302. 
in treating inflammation, 137. 
in ununited fracture, 830. 
preparation of materials in, 
46. 
Antyllus, the plan of, for aneu- 
rism, 663. 
Anus, absence of, 505. 
artificial, after hernia, 462, 
464. 
artificial, for divided intestine, 
448. 
condylomata at, 509. 
diseases of, 502. 
fissure of, 512. 
cough with, 513. 
fistula of, 536. 
imperforate, 505. 
inflammation of, 522. 
itching of, 509. 
laceration of, 472. 
loss of co-ordination of mus- 
cles of, 511. 
malformation of, 504. 
faecal fistula in, 505. 
membranous occlusion of, 505. 
narrowing of, 504. 
opening into vagina, 508. 1090 
INDEX TO VOLUME I. 
Anus, papilloma or wart at, 
509. 
position for examination of, 
502. 
prolapsus of, 516 
pruritus of, 509. 
sphincterismus of, 511. 
ulceration of, 522. 
warts of, 509. 
wounds of, 472. 
Aorta, abdominal, aneurism of, 
718. 
compression of, 721, 722. 
ligation of, 783. 
thoracic, aneurism of, 686, 
690. 
wounds of, 422. 
Aphasia following head-injuries, 
374. 
Aphonia after shot wounds of 
neck, 402. 
Aponeurotic canal, ligation of 
the femoral artery in, 786. 
Apoplexy, how distinguishable 
from intoxication, 353. 
Appendicitis, 495. 
suppurative, 496. 
Appendix vermiformis, perfora- 
tion of, 498. 
Apposition in wounds, 260. 
Arachnidans, bites of, 284. 
Arachnoid, blood in cavity of, 
355. 
Aranern, bites of, 284. 
Arch, palmar, superficial, 612. 
zygomatic, fracture of, 877, 
878. 
Arches, vertebral, fracture of, 
864. 
Arm amputated for shot wound, 
308. 
fracture of, 918. 
mortification of, 193, 199. 
sling for, 85. 
wounds of, 610. 
Arms, 291. 
Arrest of hemorrhage, natural, 
215. 
surgical, 219, 255, 259, 264. 
Arrow wounds, 364. 
Arsenic for mortification, 207. 
Arterial obstruction as a cause 
of gangrene, 190. 
varix, 615. 
Arteries, amyloid degeneration 
of, 646. 
aneurism of, 647, 653. 
angeiomata of, 615. 
atheroma of, 642. 
brittleness of, 642. 
calcification of, 643. 
compression of, 221. 
contusions of, 638. 
deligation of, 734, 737. 
dilatation of, 645, 646. 
diseases of, 638. 
hemorrhage from, 214. 
inflammation of, 640. 
injuries of, 638. 
lacerations of, 638. 
ligation of, 232, 734. 
instruments for, 734. 
mortification of, 656. 
obstruction of, 190, 645. 
thrombosis of, 645. 
torsion of, 226. 
ulceration of, 645. 
varix of, 615. 
Arteries, wounds of, 839. 
contused, 638. 
incised, 639. 
lacerated, 638. 
punctured, 640. 
Arterio-venous aneurism of the 
carotid and jugular, 713. 
Arterio-version, 228. 
Arteritis, 640. 
results, symptoms, and treat- 
ment of, 641. 
Artery, anterior tibial, ligation 
of, 791. 
surgical anatomy of, 791. 
axillary, ligation of, 715, 
764. 
for aneurism, 715. 
brachial, aneurism of, 717. 
collateral circulation after 
ligation of, 772. 
ligation of, 770, 772. 
surgical anatomy of, 770. 
carotid, wounds of, 396. 
common carotid, aneurism of, 
696. 
ligation of, 700, 740, 741. 
surgical anatomy of, 740. 
compressor and needle, 406. 
dorsalis pedis, aneurism of, 
733. 
ligation of, 792. 
surgical anatomy of, 792. 
epigastric, ligation of, 778. 
exposure of, before ligation, 
736. 
external carotid, aneurism 
of, 701. 
ligation of, 749. 
external iliac, aneurism of, 
725. 
ligation of, 778. 
surgical anatomy of, 776. 
facial, ligation of, 753. 
femoral, aneurism of, 727. 
collateral circulation of, 
787. 
ligation of, 784. 
peculiarities of its distribu- 
tion, 787. 
surgical anatomy of, 784. 
forceps, 232, 234. 
gluteal, ligation of, 779. 
inferior thyroid, ligation of, 
763. 
innominate, aneurism of, 690. 
ligation of, 738. 
internal carotid, ligation of, 
755. 
iliac, aneurism of, 723. 
ligation of, 778. 
mammary, ligation of, 763. 
ischiatic, ligation of, 779. 
lingual, ligation of, 752. 
occipital, ligation of, 754. 
opening the sheath of, 737. 
peroneal, ligation of, 790. 
surgical anatomy of, 790. 
plantar, aneurism of, 733. 
popliteal, aneurism of, 730. 
surgical anatomy of, 787. 
posterior tibial, ligation of, 
788. 
surgical anatomy of, 788. 
primitive iliac, aneurism of, 
723. 
ligation of, 779. 
surgical anatomy of, 779, 
780. 
Artery, profunda femoris, aneu- 
rism of, 729. 
radial, its anastomosis with 
the ulnar, 775. 
ligation of, 772. 
surgical anatomy of, 772. 
recognition of, 737. 
Spier’s compressor for, 231. 
subclavian, aneurism of, 703. 
ligation of, 756. 
surgical anatomy of, 756. 
wounds of, 396. 
superficial volar, aneurism of, 
718. 
temporal, ligation of, 755. 
tibial, aneurism of, 732. 
torsion of, 226. 
transverse cervical, aneurism 
of, 707. 
ulnar, collateral circulation 
of, 775. 
its anastomosis with the 
radial, 775. 
ligation of, 775. 
surgical anatomy of, 775. 
vertebral, aneurism of, 707. 
ligation of, 762. 
Artery-compressor, 231, 406. 
Articulated angular splint, 934. 
probe, 301. 
Articulations, involvement of, in 
fracture, 820. 
Artificial anus, 464. 
after hernia, 462. 
in divided intestine, 448. 
resection for, 466. 
leech, 134. 
respiration, 626. 
teeth in stomach, 435. 
Ascarides, itching due to, 509. 
Ascites, 476. 
diagnosis of, 477. 
fluctuation in, 477. 
how distinguished from ova- 
rian cyst, 477, 478. 
paracentesis abdominis in, 
478. 
prognosis of, 478. 
symptoms of, 477. 
treatment of, 478. 
Asepsis applied to operations, 
49. 
preparation of materials in, 
46. 
Asphyxia following wounds of 
the neck, 395. 
from vertebral fracture, 867. 
Aspiration of abdominal cavity, 
478. 
of chest, 419. 
of cold abscess, 168. 
of pericardium, 426. 
Aspirator, Dieulafoy’s, 168. 
Potain’s, 168. 
Astragalus, fracture of, 1040. 
its joint with the fibula, 1035. 
Atheroma, alcohol a cause of, 
642, 644. 
anatomical characters of, 642. 
aneurism from, 653. 
arterial, 642. 
calcification in, 643. 
causes of, 643. 
consequences of, 645. 
defined, 642. 
dilatation from, 645, 646. 
gangrene from, 646. 
premature, 642, 644. INDEX TO VOLUME I. 
1091 
Atheroma, senile, 642. 
symptoms of, 645. 
thrombosis from, 645. 
treatment of, 645, 646. 
ulceration from, 645. 
venous, 642. 
Atheromatous ulcer, 642. 
vessels, ligature in, 235. 
Atomizers, 132. 
Atrophy after fracture, 821. 
of bone, 1084. 
of cranial bones, 327. 
of neck of femur, senile, 978. 
of veins, 631. 
Attenuation of animal poisons, 
272. 
Attitude in diagnosis, 31. 
Auriculo-occipital triangle, 80. 
Auscultation of aneurisms, 656. 
Austrian musket-ball, 292. 
Author’s anterior angular splint, 
930. 
artery forceps, 233. 
experiments on the repair of 
bones, 804. 
hernia instruments, 559. 
hernia operation, 559. 
intercostal artery compressor 
and needle, 406. 
internal angular splint, 924. 
operation for salivary fistula, 
391. 
rectal chemise, 549. 
retractor for the peritoneum, 
777. 
spiral wire probe, 1053. 
thoracic trocar and canula, 
420. 
Aveling’s transfusion - appa- 
ratus, 240. 
Awl, Horner’s, 682. 
Awl-shaped drill, 827. 
Axillary artery, aneurism of, 
713. 
ligation of, 765-770. 
surgical relation of, 767-769 
pad for broken clavicle, 906. 
B. 
Bacilli, forms of, 45. 
Bacillus anthracis, 272. 
Bacteria, forms of, 45. 
germicides against, 46. 
Koch’s rules as to disease 
from, 46. 
Bacterium urese, 45. 
Bag for ice, 130. 
rubber, for hot water, 131. 
Bags used in dressing a fracture, 
815. 
Balls, 291. 
change of projected, 295. 
deflection of, 293. 
encysted, 299. 
located by electricity, 364. 
openings made by, 294, 296, 
300. 
probes for, 300. 
removal of, 299, 302. 
retained, causing trouble, 299. 
search too prolonged for, 302. 
slow or spent, 295. 
varieties of, 292. 
windage of, 295. 
Bandage, Barton’s, 74, 883. 
circular roller, 65. 
Bandage, compressor, 76. 
crossed, 75, 884. 
crucial, 56. 
demi-gauntlet, 67. 
double spica, 70. 
Esmarch’s, in aneurism, 674. 
Galen’s, 60. 
Garretson’s, 883. 
Gibson’s, 74. 
Hamilton’s, 883. 
immovable, 813. 
invaginated, 244. 
occipito-facial, 75. 
oblique roller, 65. 
plaster of Paris, 814. 
roller, 62. 
rubber, 674. 
Scultetus’s, 1004. 
spiral roller, 65. 
T, 56. 
unilateral suspensory, 76. 
Velpeau’s, 78. 
Bandages, figure-of-eight, 71. 
for breast, 76. 
for head, 74, 
for lower maxilla, 883. 
machine for rolling, 63. 
plaster, 814. 
machine for rolling, 814. 
recurrent, 76. 
rolling of, 63, 814. 
spica, 69. 
suspensory, 76. 
Bandaging, mortification from 
tight, 193. 
Barker’s hernia operation, 562. 
Barton’s bandage, 74. 
fracture, 943. 
handkerchief, 87. 
Bas-fond of the bladder, 469. 
Basin, in surgery, 47. 
Bat’s wing, inflamed, 106. 
Bavarian rifle ball, 292. 
splint, immovable, 1034. 
Beale’s views as to cells, tissue- 
growth, and inflammation, 
821. 
Bean’s interdental splint, 886. 
Bed, air-, 812. 
in fractures, 810-812. 
of vertebrae, 870. 
Bed-bug bite, 289. 
Bed-sores, 188. 
after fracture, 817. 
Bed, water-, 812. 
in fractures of vertebrae, 870. 
Beer, excessive use of, 554. 
Bee-sting, 289. 
Bellingham’s clamp, 672. 
Bell-probe, De Wilde’s, 364. 
Bell’s double inclined plane, 
1002. 
Bent-stick fractures, 769. 
Bergmann on sepsin, 46. 
Bernard’s experiment showing 
the effect of nerve-influences 
on inflammation, 98, 103. 
Bibron’s antidote, 288. 
Bichloride of mercury in asepsis, 
46. 
Bidet in the treatment of hem- 
orrhoids, 544. 
Bile, retention of, 452. 
Biliary calculus, 452. 
fistula, 461. 
relief of, 454. 
Bill on arrow-poisoning, 364. 
Bill’s wire loop, 366. 
Billings on the trephine in epi- 
lepsy, 372. 
Binders’ board splints, 812, 813, 
1030. 
Birth-marks, 617. 
Bis-axillary cravat, 82. 
Bis-axillo-scapulary cravat, 82. 
Bistoury, Allis’s hernia, 578. 
blunt and sharp-pointed, 160. 
Cooper’s hernia, 577. 
sharp-pointed, 164. 
Bitemporal triangle, 80. 
Bites of animals, 280. 
of arachnids, 284. 
of centipedes, 285. 
of mad dogs, 280. 
of snakes, 286. 
of spiders, 284. 
Bivalve anal speculum, 503. 
Blackadder on hospital mortifi- 
cation, 207. 
Black eye, 386. 
Bladder, bas-fond of, 469. 
bullock’s or swine’s, used in 
tapping the chest, 420. 
foreign bodies in, 469. 
gall, 452. 
hernia of, 608. 
in fractured vertebrae, 871. 
rectum opening into, 508. 
rupture of, 468. 
wounds of, 468. 
catheter in diagnosis of, 470. 
gunshot, 469. 
Blastema, 118. 
Bleeding, 133, 137. 
arrest of, 215, 219. 
natural, 215. 
surgical, 219, 255, 259, 264. 
Bleeding piles, 541. 
Blind fistula, 536. 
piles, 541. 
Blisters, 147. 
Blood, abnormal states of, 93. 
as a poison-carrier, 94. 
coagulation of, in arrest of 
hemorrhage, 215. 
cysts of the arachnoid, 355. 
depots after injuries, 263. 
extravasated, in concussion of 
brain, 346. 
in contusions, 263. 
in fracture, 802. 
from pia mater, 355. 
in cavity of arachnoid, 355. 
intracranial extravasation of, 
351. 
transfusion of, 239. 
transudation of, 150. 
Blood-change as a cause of 
phlebitis, 627. 
in inflammation, 109. 
Blood-clot. See Clot. 
Blood-corpuscles, 107. 
Blood-crasis, 119. 
Blood-letting in inflammation, 
133, 137. 
Blood-swellings after wounds, 
263. 
Blood-tumor, diagnosis from 
fungus cerebri, 371. 
Blood-vessels, closure of, 215, 
219, 255, 259, 264. 
diseases of, 615. 
in inflammation, 104. 
injuries of, 615. 
ligation of, 734. 
torsion of, 226. 1092 
INDEX TO VOLUME I. 
Blue pus, 152. 
Boggie on hospital mortification, 
208. 
Boisnot’s apparatus for the pa- 
tella, 1021. 
Bond’s splint, 950. 
Bone, abscess of, 1055. 
absorption of, 824. 
actinomycosis of, 1060. 
brittleness of, 795, 1081. 
caries of, 1050. 
chisels for, 1054, 1069. 
death of, 1050, 1060. 
development of, from callus, 
804. 
drainage-tube, 242. 
induration of, 1059. 
inflamed, 114, 1050. 
necrosis of, 189, 1060. 
rarefaction of, 1060. 
repair of, 805-809. 
sclerosis of, 1059. 
Bone-drills, 826, 827, 828, 849, 
1070. 
Bone-forceps, 1054. 
Bone-gouges, 1054. 
Bone-pliers, 1069. 
Bone-splinters from shot wounds, 
treatment of, 302. 
Bones, delayed repair of, 822. 
diseases of, 1046. 
fracture of, 899. 
fragility of, 795, 1081. 
gunshot fractures of, 315. 
hypertrophy of, 1083. 
in ununited fracture, 822. 
repair of, in fracture, 801. 
softening of, 1077. 
wounds of pelvic, 467. 
Bonwill’s surgical engine, 1071. 
Boracie ointment, 251. 
Boro-salicylic solution, 47. 
Boston atomizer, 132. 
Bougies, rectal, 526, 529. 
Bowel in fracture of the spinal 
column, 871. 
prolapsus of, 516. 
Box for fractures, 1026. 
Boyer’s dressing for the leg, 
1026. 
splint, 1004. 
Brachial artery, aneurism of, 
717. 
collateral circulation after 
ligation of, 772. 
compression of, 221. 
ligation of, 770-772. 
surgical anatomy of, 770. 
thrombus of, 191. 
plexus, wounds of, 396. 
Bracketed splints, 1012. 
Brain, abscess of, 328, 385. 
compression of, 349, 354. 
in skull-fractures, 342. 
concussion of, 343. 
fissure of Rolando in, 383. 
foreign bodies in, 364. 
fungus of, 369. 
inflammation of, after head- 
injury, 367. 
laceration of, 347. 
lines for localization in, 383. 
motor region of, 380. 
praefrontal lobe of, 379, 382. 
protrusion of, 370. 
rules for operating on, 384. 
sensory region of, 381. 
topography of, 379. 
Brain, trephining in compres- 
sion of, 375. 
Bran-bag, 815. 
Brasdor’s operation, 669. 
Breast, bandage for, 76. 
sling for, 62, 82. 
Breathing, its significance in 
diagnosis, 36. 
Briddon compressor for aneu- 
rism, 673. 
Bridge of callus between bones, 
850. 
Brittleness of arteries, 642. 
of bone, 795, 1081. 
of callus, 852. 
Bromfield’s tenaculum, 234. 
Bromine for hospital gangrene, 
204, 211, 212. 
Broncho-pneumonia after neck- 
wounds, 396. 
Bruises, 261. 
Bruit in aneurism, 650,697, 719. 
Brush for trephine, 377. 
Brush-burn, 257. 
Buck’s method of controlling 
hemorrhage, 231. 
treatment of fractured thigh, 
1008. 
Bufify coat, 110. 
Bullet extractor, 301. 
forceps, 301. 
lever, 302. 
probe, 300. 
Bullets, 291. 
change of form of, during pro- 
jection, 295. 
deflection of, 293. 
encystment of, 299. 
of lint, 53. 
removal of, 299, 302. 
spent, 295. 
Bullock’s bladder used in tap- 
ping the chest, 420. 
peritoneum for ligatures, 237. 
for plasters, 246. 
Burdon-Sanderson on inflam- 
mation, 123. 
Burges’s apparatus for fractured 
patella, 1020. 
Burr-drill, 1054, 1070. 
Bursal enlargement distin- 
guished from popliteal aneu- 
rism, 730. 
Bushe’s compressor, 474. 
Buttermilk for hospital gan- 
grene, 212. 
Buttock, T bandage of, 59. 
Button suture, 249. 
C. 
Cascal hernia, 550. 
Caecum, perforation of, 498. 
Caesarean section, hernia follow- 
ing, 604. 
Calcaneum. See Os Calcis. 
Calcification of arteries, 643. 
Calculus, biliary, 453. 
salivary, 391. 
vesical, 469. 
Callous ulcer, 180. 
Callus, 803. 
absorption of, 851. 
after fracture, 803. 
brittleness of, 852. 
cavity in, 852. 
composition of, 804. 
Callus, definitive, 803, 808. 
ensheathing, 803. 
exuberance of, 851, 852. 
morbid changes in, 851. 
paralysis from, 852. 
provisional, 803, 806, 808. 
redundancy of, 851, 852. 
sensitiveness of, 852. 
transformation of, into bone, 
805. 
Can for hot water, 131. 
Canal, aponeurotic, ligation of 
femora] artery in, 786. 
Hunter’s, 785. 
inguinal, 553, 584. 
of Nuck, 552. 
Canals, Haversian, 1051. 
Cancellated bony tissue, its re- 
formation after fracture, 804. 
Cancer after contusions, 264. 
colectomy for, 498, 501. 
its diagnosis from fungus 
cerebri, 371. 
its effect on the repair of 
bones, 823. 
of dura mater, 371. 
of intestinal canal, 485. 
of pylorus, 485. 
of rectum, 526. 
excision of, 532. 
of umbilicus, 476. 
resection of colon for, 450. 
soot-, 28. 
Cancrum oris, 192. 
Canister-shot, 293. 
Canker, water-, 192. 
Cannon-balls, 292. 
Canquoin’s paste, 637. 
Canula and trocar, 420, 479. 
Cap for the shoulder and arm, 
924. 
of the head, square, 79. 
triangular, 85. 
Capillaries, varicose, 120. 
Capillary drain, 243. 
varix, 617. 
Caput succedaneum, 323. 
Carbolic acid in asepsis, 46. 
Carbolized catgut, preparation 
of, 47. 
gauze, 48. 
silk thread, 48. 
Carbuncle, malignant, 271. 
Carcinoma. See Cancer, En- 
cephaloid, Scirrhus, and 
Epithelioma. 
Caries, 1050. See Osteitis. 
of cranium, 327. 
Carnification in osteomyelitis, 
1056. 
Carotid, arterio-venous aneu- 
rism of, 713. 
common, aneurism of, 696. 
ligation of, 700, 740. 
externa], aneurism of, 701. 
ligation of, 749. 
internal, aneurism of, 702. 
ligation of, 755. 
Carpus, fractures of the, 958. 
Carroll’s knot-tying instrument, 
474. 
Carte’s compressors for aneu- 
rism, 672. 
Cartilages, costal, fracture of, 
895. 
of larynx and trachea, frac- 
ture of, 889. 
repair of, 809. INDEX TO VOLUME I. 
1093 
Case-shot, 292. 
Catarrh following fracture of the 
nasal bones, 875. 
of conjunctiva, 115. 
of rectum, 522. 
Catgut, drainage by, 243. 
ligatures, 236. 
preparation of carbolized, 47. 
Cathartics in inflammation, 139. 
Catheter, double, 871. 
in diagnosis of ruptured blad- 
der, 470. 
in pleural cavity, 421. 
Mercier’s, 871. 
Cat-scratches, 267. 
Cattle, actinomycosis of, 1060. 
foot-and-mouth disease of, 
275. 
murrain, 271. 
Cauliflower epithelioma of rec- 
tum, 527. 
Caustics for piles, 547. 
in ununited fracture, 828. 
Cauterizing-irons, 225, 546. 
Cautery for piles, 516. 
galvano-, 225. 
in prolapsed bowel, 519. 
Cavae, wounds of, 427. 
Cavity in callus, 852. 
Cell-infiltration, 317. 
migration, 108. 
Cells, broods of, 113. 
pus-, 107, 121. 
spindle-shaped, in repair of 
fracture, 803. 
in repair of wounds, 317. 
Centipede, bite of, 285. 
Cephalhydrocele, 338. 
Cerebellar fossa, fractures of, 
339. 
Cerebral abscess, 328. 
difficulties in trephining for, 
329. 
search for, 385. 
concussion, 343. 
fossa, fractures of, 337. 
fungus, 369. 
localization, lines for, 383. 
operations, rules for, 384. 
topography, 379. 
vibration, 344. 
Cerebro-spinal fluid, escape of, 
in skull-fractures, 338. 
Cerebrum, fungus of, 369. 
Cervical cravat, 81. 
region, wounds of, 394. 
vertebrae, fractures of, 867. 
Cervico-brachial sling, 85. 
Cervico-dorsal vertebrae, frac- 
tures of, 867. 
Change of dressings in fracture, 
816. 
Charbon, 271. 
Charpie, 52. 
Charriere’s compressor, 673. 
Chase’s truss, 557. 
Chassaignac’s drainage - tube, 
160. 
Chassepot rifle-ball, 292. 
Cheesy pus, 166. 
Chemico-vital haemostatics, 220. 
Chemise, rectal, 549. 
Chemosis, 97. 
Chest, bandages for, 69, 73. 
fistula of, 422. 
fractures of the bones of, 
891. 
wounds of, 404. 
Chest, wounds of, complications 
in, 413, 
non-penetrating, 404. 
of contents, 408. 
paracentesis after, 419. 
penetrating, 407. 
phthisis after, 411. 
prognosis in, 411. 
treatment of, 412. 
Chicken-breast, 1075, 1076. 
Chimney-sweep’s cancer, 28. 
Chin, sling for, 61. 
Chisel, Holsen’s, 377. 
Chisels for bone, 1068. 
Chloride of zinc in asepsis, 47. 
Cholecystectomy, 454. 
Choleeystenterostomy, 454. 
Cholecystotomy, 453. 
Chronic abscess, 165. 
peri-rectal, 535. 
inflammation, 143. 
mortification, 197. 
ulcer, 180. 
Cicatrices, 320. See Cicatrix. 
Cicatricial contraction after con- 
tusions, 263. 
obstruction of the bowel, 486. 
Cicatrix, 175. 
cancer of, 320. 
contraction of, 321. 
hypertrophy of, 320. 
immovable, 321. 
keloid of, 320. 
nodular, 320. 
painful, 320. 
spurious, 320. 
ulceration of, 319. 
Cicatrization, 174, 318. 
in skin-grafting, 187. 
spurious, 320. 
Circular gangrene, 191. 
knife, 1070. 
roller, 65. 
saws, 1070. 
Circulation, collateral, after 
ligation of common ca- 
rotid, 743. 
of brachial artery, 772. 
of common iliac artery, 
780. 
of femoral artery, 787. 
of subclavian artery, 760. 
of ulnar artery, 775. 
in diagnosis, 35. 
Circumclusion, 230. 
Hutchison’s, 231. 
of hernia, 561. 
Circumscribed periostitis, 1047. 
suppuration, 161. 
Cirsoid aneurism, 615. 
Citron comme topique, 208. 
Clamp for piles, 546. 
Bellingham’s, 672. 
Smith’s, 546. 
Clavicle, fracture of, 899. 
axillary pads for, 906. 
causes of, 900. 
comminuted, 902. 
complicated, 902. 
compound, 902. 
Desault’s rollers in, 907, 
908. 
displacement in, 901. 
dressings for, 904-910. 
erect position after, 904. 
figure-of-eight for, 905,910. 
Fox’s appliances for, 908. 
Levis’s apparatus for, 909. 
Clavicle, fracture of, Moore’s 
dressing for, 905. 
non-union after, 840, 903. 
recumbent position after, 
910. 
Sayre’s dressing for, 906. 
seat of, 900. 
sling for, 61. 
symptoms of, 901. 
ununited, 840, 903. 
Velpeau roller for, 904. 
Clinical thermometer, 36. 
Cloacae, necrosial, 1066. 
Closure of blood-vessels, 165, 
215, 219. 
Clot as a cause or an effect of 
phlebitis, 628. See also 
Embolism and Thrombus. 
section of, 110. 
under the dura mater, 352. 
Cloth, mackintosh, 48. 
Clothing after fracture, 812. 
Clysters, 489, 543. 
Coagulum. See Clot, Embolism, 
and Thrombus. 
Coaptation after fracture, 816. 
Cobra-bite, 287. 
Cocaine in inflammation, 137. 
Coccydynia, 964. 
Coccyx, excision of, 964. 
fractures of, 964. 
Cod-liver oil, 146, 169. 
Coeliac axis, aneurism of, 722. 
Cogshill wire-twister, 366. 
Cohnheim’s views on inflamma- 
tion, 122. 
Coins, swallowed, 434. 
Colbach’s suggestions as to anti- 
sepsis, 43. 
Cold abscess, 165. 
as haemostatic, 219. 
in treatment of inflammation, 
128. 
ulcer, 188. 
Colectomy, 501. 
Collateral circulation. See Cir- 
culation. 
Colles’s fracture, 944. 
Collodion for approximating 
wounds, 245. 
Colloid, styptic, 246. 
cancer of rectum, 527. 
Colon, excision of, 501. 
resection of, 450. 
stricture of, 486. 
wounds of, 444. 
Color in diagnosis, 33. 
in inflammation, 96. 
Colotomy, 498. 
after-treatment of, 502. 
anterior or inguinal, 500. 
for imperforate anus and rec- 
tum, 507. 
in infant, 507. 
left lumbar, 499. 
prior to rectectomy, 534. 
right lumbar, 500. 
to identify bowel in, 499. 
Colpeurynter, 962. 
Coma, diagnosis of, 31. 
Comminuted fractures, 293, 797. 
of radius, 945. 
Comminution of internal table 
of skull, 334. 
Common carotid artery, collat- 
eral circulation of, 743. 
ligation of, 740, 741. 
surgical anatomy of, 740. 1094 
INDEX TO VOLUME I. 
Common iliac artery, ligation 
of, 779, 783. See Primitive 
Iliac. 
Complete fractures, 796. 
Complicated fractures, 796. 
Compound bis-axillary cravat, 
83. 
comminuted fracture, 797. 
repair in, 809. 
treatment of, 819. 
fractures, 796. 
necrosis after, 821. 
of hand, 961. 
of joints, 820. 
of leg, 1038. 
repair in, 809. 
treatment of, 818. 
Compresses, 54. 
for approximating wounds, 
243. 
oblong graduated, 222. 
pyramidal, 222. 
Compression, digital, 673, 699, 
702. 
for aneurism, 662, 669, 671, 
674, 696, 705. 
for hemorrhage, 221. 
for hernia, 564. 
in treating inflammation, 
135, 137, 147. 
of brain, 349, 354. 
diagnosis from concussion, 
350. 
in skull-fractures, 342. 
pulse in, 350. 
pupils in, 350. 
trephining in, 375. 
to arrest hemorrhage, 221, 
Compressor, Agnew’s, 406. 
Briddon’s, 673. 
Carte’s, 672. 
Charriere’s, 673. 
Gibbons’s, 673. 
Spier’s, 231. 
Watson’s, 672. 
Compressors, arterial, 231, 406, 
672, 673. 
Concave hot-water can, 131. 
Concealed hemorrhage, intes- 
tinal, 297. 
hernia, 585. 
wounds, 261. 
Concretions in gall-bladder, 453. 
intestinal, 487. 
Concussion of brain, 343. 
blood-extravasation in, 346. 
diagnosis from compres- 
sion, 350. 
lacerated brain in, 347. 
prognosis in, 348. 
transuded sero-sanguino- 
lent fluid in, 345. 
treatment of, 348. 
varieties of, 344. 
Condylar fractures of femur, 
1000. 
Condyle of humerus, fracture 
of external, 931. 
of internal, 931. 
Condylomata, 509. 
Congenital defects causing her- 
nia, 553. 
hernia, 586. 
hydrocele, 588. 
malformation of anus and 
rectum, 504. 
Congestion, 106. 
of bowel in hernia, 580. 
Congestive abscess, 165. 
Conical bougie, 524. 
tent, 160. 
trephine, 376. 
Conjunctiva, purulent catarrh 
of, 115. 
Connective tissue in wounds, 318. 
Constipation causing hemor- 
rhoids, 542. 
forerunning volvulus, 483. 
hemorrhoids from, 542. 
Contagious pus, 151. 
Continued suture, 247. 
Continuous suture, Lembert’s, 
447. 
Contraction of cicatrices, 321. 
of tendons, 266. 
Contre-coup, fracture by, 332. 
Contused and lacerated wounds, 
256. 
wounds, 261. 
Contusions, 261. 
of abdomen, 430. 
of abdominal viscera, 265. 
of arteries, 638. 
of cranial bones, 326. 
gunshot, 358. 
of face, 386. 
of pelvis, 466. 
of scalp, 322. 
of ulnar nerve, 613. 
results of, 263. 
Cooper’s aneurismal needle, 735. 
dressing for fractured olec- 
ranon, 955. 
for fractured patella, 1021. 
hernia bistoury, 577. 
Co-ordination, loss of, in defeca- 
tion, 511. 
Coote on hospital mortification, 
208. 
Coover’s splint, 951. 
Copperhead snake bite, 287. 
Coracoid, fracture of, 915. 
Cork pad for hernia, 601. 
Cornea of a frog, inflammation 
in, 112, 113. 
Coronoid process of ulna, frac- 
ture of, 956. 
Corpuscles of the blood in in- 
flammation, 107. 
connective-tissue, 113. 
pus-, 113. 
red, 109. 
transudation of, 108. 
white, 106. 
Corrosive sublimate in asepsis, 
46. 
gauze, 48. 
Costal cartilages, fracture of, 
895. 
Cotton, absorbent, 49. 
Cough after shot wounds of 
neck, 402. 
in liver abscess, 451. 
in lung-wounds, 410. 
with anal fissure, 513. 
Counter-extension in fractures, 
816. 
Counter-irritants in inflamma- 
tion, 135, 147. 
Court-plaster, 246. 
Coverings of hernia, 551. 
Coxeter’s bullet-extractor, 301. 
Coxo-inguinal cravat, 88. 
Cradle for fractures, 817, 1028. 
Cramps due to atheromatous 
blood-vessels, 646. 
Cranial bones, contusions of, 
gunshot, 358. 
fractures of, gunshot, 358. 
gunshot wounds of, 358. 
inflammation of, 327. 
injuries of, 326. 
epilepsy after, 372. 
sequelae of, 327. 
nerves, injury of, 366. 
Craniotabes, 1085. 
Cranium, abscess within, 328. 
blood-extravasation within, 
351. 
contusions of, 326. 
fractures of, 331. 
injuries of, 322, 326. 
Cravat, 79. 
abdomino-inguinal, 87. 
bis axillary, 82. 
bis-axillo-scapulary, 82. 
cervical, 81. 
coxo-inguinal, 88. 
fronto-oceipito-labialis, 80. 
metatarso-malleolar, 85. 
parieto-axillaris, 82. 
sub-femoral, 88. 
tarso-patellar, 86. 
tibial, 86. 
Crepitus in fracture, 800. 
in thigh-fracture, 977. 
Cribriform compress, 55. 
Cross, Maltese, 55. 
Crossed bandages, 75. 
of the angle of the jaw, 884. 
Crotaline, 287. 
Croupous layer from the fauces, 
115. 
Crucial bandage, 56. 
Cruro-properitoneal hernia, 608. 
Crush of head, 361. 
Crushing of piles, 447. 
Cup for the jaw, 882. 
Cupping apparatus, 133. 
in inflammation, 133. 
Curdy pus, 151. 
Cutaneous occlusion of anus, 505. 
Cuticle, grafting of, 187. 
Cut-throat wounds, 394, 397. 
Cutting-pliers, 249. 
for immovable fracture-dress- 
ings, 815. 
Cylindrical sequestra, 1064. 
trephine, 376. 
Cylindro-conoidal missiles, 292. 
Cyst, diagnosis from abscess, 
157. 
how distinguished from aneu- 
rism, 660. 
of omentum complicating her- 
nia, 582. 
of pancreas, 457. 
of umbilicus, 475. 
Cystocele, 551, 608. 
Czerny - Lembert suture, 449. 
D. 
Dancing for the cure of taran- 
tula-bite, 285. 
Davaine on bacteria, 272. 
Davidson syringe, 490. 
Day’s test for pus, 152. 
Death from air in veins, 626. 
from aneurism, 660, 715. 
of bones, 1057. 
Deep femoral artery, aneurism 
of, 729. INDEX TO VOLUME I. 
1095 
Deer-sinew ligatures, 237. 
Defecation, loss of muscular co- 
ordination in, 511. 
sphincter ani ruptured in, 472. 
Defective innervation as a cause 
of gangrene, 192. 
of ulceration, 188. 
Defects leading to hernia, 553. 
Definitive callus, 803, 808. 
Deflection of balls, 293. 
Deformities after face-injuries, 
394. 
their diagnostic significance, 
32. 
Deformity after fracture, 798, 
846. 
operations for, 849. 
splints for, 848. 
after fractures of the leg, 
1025. 
after fractures of lower end 
of radius, 946. 
after Pott’s fracture, 1037. 
Degeneration, amyloid, of the 
arteries, 646. 
Delayed repair of bones, 822. 
union after fracture. See 
Fractures, XJnunited. 
Deligation of arteries. See Ar- 
teries, Ligation of. 
Delirium tremens in cases of 
fracture, 797, 821. 
Demarcation in gangrene, 194. 
in necrosis, 1063. 
Demi-gauntlet bandage, 67. 
Dental engine, 1069. 
Depots of blood, 263. 
Depressants in inflammation, 
138. 
Depressed fracture of the skull, 
341, 342. 
Depression of the skull, 339, 
340, 341, 342. 
Dermal grafting, 187. 
Desault’s dressings for fractured 
clavicle, 907, 908. 
for fractured patella, 1020. 
splints, 1004, 1005. 
Determination of blood, 106. 
De Wilde’s signal bell, 364. 
Dextrin dressings, 813. 
Diabetes after head-injury, 374. 
mellitus, gangrene during, 
192. 
with cystic pancreas, 457. 
Diagnosis, surgical, 25. See also 
under names of various dis- 
eases and injuries. 
Diagonal suture, 247. 
Diaphoretics in inflammation, 
139. 
Diaphragm, wounds of, 407. 
Diaphragmatic hernia, 606. 
Diarrhoeafollowing wounds, 304. 
with anal fissure, 304. 
with faecal impaction, 515. 
Diastasis of the epiphysis of the 
femur, 1000. 
Diathesis as a predisposing cause 
of fracture, 794. 
Dieffenbach’s drill, 826. 
Diet in inflammation, 142, 145. 
Dieulafoy’s aspirator, 168. 
Diffused abscess, 158. 
aneurism, 681, 717. 
extravasation, 347. 
periostitis, 1048. 
suppuration, 158. 
Digestion in diagnosis, 40. 
Digital branches of palmar arch, 
612. 
compression for aneurism, 
673, 699. 
compression for aneurism of 
external carotid, 702. 
compression for hemorrhage, 
221. 
dilatation of pylorus, 437. 
Dilatation of arteries from ath- 
eroma, 645, 646. 
for piles, 548. 
in anal fissure, 513. 
of pylorus, 437. 
of rectal pouches, 516. 
Diphtheria complicating 
wounds, 252. 
of wounds, 201. 
Diploe, granulations from, 325. 
inflammation of, 326. 
Direct aneurism, 647, 684. 
Direction of fractures, 797. 
Director, grooved, 735. 
notched, for hernia, 577. 
Discharge from ulcers, 181. 
Discoloration as a consequence 
of fracture, 801. 
Disease, foot and mouth, 275. 
Diseased cattle, 271. 
Diseases, abdominal, 475. 
of anus, 502. 
of arteries, 638. 
of blood-vessels, 615. 
of bones, 794, 1046. 
of osseous system, 794, 1046. 
of umbilicus, 475. 
of veins, 624. 
Disinfection. See Antisepsis. 
of instruments, 50. 
Dislocation of hip diagnosti- 
cated from a fracture, 984. 
with fracture, 820. 
Dislocations associated with 
fracture, 797. 
Disordered sensibility after frac- 
ture, 801. 
Displacement in fracture, 798. 
angular, 799. 
longitudinal, 799. 
rotary, 799. 
transverse, 799. 
following fractures of the hu- 
merus in the surgical neck, 
722. 
Dissecting aneurism, 639, 647, 
680. 
Dissection wounds, 268. 
Disseminated abscess, 159, 161. 
Distal ligation for aneurism, 
700. 
for subclavian aneurism, 706. 
Distention of gall-bladder, 452. 
Diuretics in inflammation, 139. 
Diverticula with hernia, 573. 
Diverticular hernia, 608. 
Divulsion of rectal stricture, 530. 
Dog-bite wounds, 267. See also 
Hydrophobia. 
Door-key for pressing the sub- 
clavian, 222. 
Dorsal vertebrae, fractures of, 
866. 
Dorsalis pedis artery, aneurism 
of, 733. 
ligation of, 792. 
surgical anatomy of, 792. 
Dorsey’s splint, 1020. 
Dorso-bis-axillary handker- 
chief, 84. 
Dorso-lumbar region, fractures 
of vertebrae in, 865. 
Double angular splint, 1043. 
catheter, 871. 
inclined plane, 1002. 
roller, 63. 
spica, 70, 71, 88. 
T bandage, 56, 58, 59. 
Dowell’s hernia operation, 561. 
Drain, capillary, 243. 
Drainage, 242. 
Drainage-tube, 160, 242. 
in chest, 421. 
in gunshot wounds, 303. 
removal of, 250. 
Dressing-forceps, 242. 
Dressings, Desault’s, 907, 908. 
dextrin, 813. 
for fracture, 812. 
for wounds, external, 250. 
removal of, 250. 
handkerchief, 78. 
immovable, 813. 
in fracture, change of, 816. 
removal of, 817. 
plaster, 813. 
provisional, 78. 
silicate, 813. 
surgical, 52. 
water-glass, 813. 
Drill, awl-shaped, 827. 
burr-, 1054, 1070. 
for ununited fracture, 826. 
Dropsy, encysted, 480. 
of abdominal cavity, 476. 
of hernial sac, 592. 
of pericardium, 425. 
Dry gangrene, 197. 
Duct of Steno, 391. 
thoracic, 428. 
Dugas on tar-water for hospital 
gangrene, 204. 
Duodenum, operations on, 438, 
439. 
Dupuytren’s enterotome, 465. 
splint, 1037. 
views on callus, 803, 806, 
808. 
Dura mater, blood between bone 
and, 351. 
Duration of symptoms as an 
element in diagnosis, 31. 
Dynamometer, 40. 
Dyscrasia, 188, 189. 
Dysphagia from aneurism, 687. 
in neck-wounds, 395. 
Dyspnoea from aneurism, 687. 
from nerve-injuries, 402. 
from spinal fracture, 866. 
E. 
Ear, hemorrhage from, in skull- 
fractures, 337. 
T bandage of, 56. 
wounds of, 388. 
Eburnation, 824. 
Ecchymoses after wounds, 261, 
262. 
of the eyelids, 386. 
Ecchymosis, lumbar, in chest- 
wounds, 410, 414. 
Echinococci in liver, 451. 
Ecraseur for piles, 547. 1096 
INDEX TO VOLUME I. 
Ectasis as a cause of phlebitis, 
627. 
Eczema attending indolent ul- 
cers, 181, 188. 
from varix, 635. 
Effusions, 148. 
Elaps-bites, 287. 
Elastic bandage for aneurism, 
674. 
loop for detaching ligatures, 
236. 
stocking, 636. 
Elbow, amputation, for shot 
wound, 310. 
compound and comminuted 
fractures of, 936. 
dislocation of, how discrimi- 
nated from supra-condyloid 
fracture, 929. 
excised for shot wound, 309. 
Electric probes, 300, 364. 
Electricity, balls located by, 
364. 
cauterization by, 225. See 
also Galvano-Cautery. 
in aneurism, 676, 706. 
in hemorrhage, 225. 
in inflammation, 148. 
in intestinal obstruction, 491. 
in nsevus, 617, 620. 
in rectal stricture, 532. 
in varix, 638. 
Elevator for depressed bone, 878. 
Elliptic suture, 247. 
Embolism after fracture, 822. 
as a cause of aneurism, 655. 
fat, 822. 
Embolus, 191. 
Emigration of leucocytes, 109. 
Emphysema after fracture of 
the ribs, 896. 
following fracture of the nasal 
bones, 874. 
in chest-wounds, 415. 
in lung-wounds, 409. 
in neck-wounds, 395. 
Empyema after chest-wounds, 
417. 
ribs excised in, 421. 
Encephalitis after head-injury, 
367. 
treatment of, after skull-frac- 
tures, 335. 
Encephalocele, so called, 369. 
Encephaloid cancer of rectum, 
528. 
growths, diagnosis from ab- 
scess, 158. 
how distinguished from 
aneurism, 659. 
Encysted dropsy, 480. 
hernia, 587. 
rectum, 516. 
Endangium, 628. 
Endosteitis, 1056. 
Enemata, 489. 
for hemorrhoids, 543. 
Enfield musket-ball, 292. 
Engine, dental, 1069. 
surgical, 1070, 1071. 
English disease, 1072. 
Ensheathing callus, 803. 
Enterectomy, 449. 
Enteric fever, perforation of in- 
testine in, 444. 
Enterocele, 551. 
Entero-cholecystotomy, 454. 
Entero-epiplocele, 551, 573. 
Enteroliths, 487. 
Enterorrhaphy, 449. 
Enterotome, 465. 
Entrance-wound of ball, 294. 
Epicondyles of humerus, 930, 
932. 
Epidermic grafting, 187. 
Epigastric artery, ligation of, 
778. 
Epigastrium, death from blow 
in, 440. 
Epilepsy after scalp-wounds, 
326. 
after skull-injuries, 372. 
complicating fracture, 821. 
ligation of vertebral arteries 
for, 762. 
trephining in, 375, 377. 
Epiphyseal fracture, 798. 
of humerus, 921. 
necrosis, 1064. 
Epiphysis of great trochanter, 
fracture of, 986. 
Epiplocele, 551. 
Epistaxis in nasal fracture, 873. 
Epithelioma of cicatrix, 320. 
of intestine, 485. 
of rectum, 527. 
Equinia. See Farcy. 
mitis, 278. 
Erectile growths sometimes 
confounded with aneurism, 
659. 
tumor (capillary varix), 617. 
of orbit, 709. 
Ergot for aneurism, 700. 
for angeioma, 624. 
gangrene from, 192, 199. 
in bread causing inflamma- 
tion, 91. 
Ergotin for aneurism, 677. 
Ergotism, 91. 
Erichsen’s double ligature for 
naevus, 622. 
Erigeron, oil of, as a haemo- 
static, 220. 
Erosion of vertebrae due to an- 
eurism, 719. 
Erysipelas after contusions, 263. 
after gunshot wounds, 303. 
after scalp-wounds, 325. 
after shot-wounds of neck, 
403. 
complicating wounds, 252. 
Esmarch’s bandage, 674. 
Ether spray for local anaesthe- 
sia, 164. 
Ethmoid bone, fracture of, 337, 
874. 
Evidement des os, 1054. 
Examination of fracture, 801. 
of surgical cases, 31. 
Excision in continuity, 315. 
in gunshot wounds, 305. 
of ankle-joint for shot 
wound, 314. 
of astragalus, 1041. 
of bone for necrosis, 1068. 
of bone for osteomyelitis, 
1058. 
of coccyx, 964. 
of colon, 501. 
of elbow for shot wound, 309. 
of fibula, 315. 
of fistula in ano, 539. 
of forearm for shot wound, 
310. 
of gall-bladder, 454. 
Excision of head of humerus for 
shot wound, 307. 
of hip-joint for shot wound, 
312. 
of leg-bones for shot wound, 
315. 
of necrosed bone, 1068. 
of nerves, 393. 
of pancreas, 457. 
of piles, 547. 
of prolapsed rectum, 520. 
of radius and ulna, 310. 
of rectum, 532. 
colotomy prior to, 534. 
of shaft of humerus for shot- 
wound, 308. 
of tibia, 315. 
of trifacial nerve, 393. 
of wrist-joint for shot wound, 
310. 
Excoriation, 169. 
Exfoliation of bone, 1063. 
Exit-wound of a ball, 294. 
Exostosis of cranium, 327. 
Expansive hypertrophy of 
bones, 1083. 
Expectant treatment for sub- 
clavian aneurism, 705. 
Experiments on the repair of 
bone, 804. 
Expiration in diagnosis, 37. 
Exploring-needle, 158. 
Expression in diagnosis, 31. 
Extension in fractures, 815,816. 
External carotid, aneurism of, 
701. 
ligation of, 749. 
iliac artery, ligation of, 776. 
surgical anatomy of, 776. 
piles, 540. 
Extra-capsular fractures of hu- 
merus, 924. 
of neck of femur, 980, 984. 
Extravasation of blood in frac- 
ture, 802. 
Extremities, wounds of, 609. 
See also Lower and Upper Ex- 
tremities. 
Exuberance of callus, 851, 852. 
Exudation, 108. 
Eye, aneurism affecting, 709. 
black, 386. 
Eyed probe, 735. 
Eyelids, ecchymosed, 386. 
F. 
Face, anatomical peculiarities 
of, 386. 
bones of, fractured, 872. 
contusions of, 386. 
four-tailed sling for, 61. 
gunshot wounds of, 388, 888. 
injuries of, 386. 
mask for, 61. 
necrosis of, 392. 
sequelae to injuries of, 390. 
wounds of, 387, 888. 
gunshot, 388, 888. 
Facial artery, aneurism of, 702. 
ligation of, 753. 
bones, fractures of, 872. 
neuralgia, 393. 
paralysis, 393. 
Faecal accumulation compli- 
cating hernia, 579. 
obstructive, 484, 514. INDEX TO VOLUME I. 
1097 
Faecal extravasation prevented 
in rectal wounds, 474. 
fistula, 462. 
with anal malformation, 
505. 
Faeces, impacted, 484, 514. 
False aneurism, 647, 680. 
circumscribed, 683. 
joint, 824. 
Fang of a venomous serpent, 
286. 
Faradism for intestinal obstruc- 
tion, 491. 
Farcy, 276. 
buds, 276. 
Fascia, interpectoral, 764. 
lata, 976. 
palmar, 611. 
Fat-embolism, 822. 
Fatty tumors after contusions, 
264. 
how distinguished from ab- 
scess, 158. 
from angeiomata, 619. 
from femoral hernia, 597. 
from inguinal hernia, 589. 
from umbilical hernia, 
600. 
Favre’s electric probe, 364. 
Fayrer on venomous snakes, 286. 
Felt splints, 813, 935. 
Femoral artery, aneurism of, 
727. 
compression for, 728. 
diagnosis of, 728. 
extension of, 728. 
ligation for, 728, 784. 
treatment of, 729. 
collateral circulation of, 
787. 
deep, aneurism of, 729. 
ligation of, 784. 
peculiarities of its distribu- 
tion, 787. 
surgical anatomy of, 784. 
hernia, 584. 
radical cure of, 564. See 
also Hernia. 
ring, 594. 
vein, ligation of, 625. 
Femoro-popliteal aneurism, 728. 
Femur at different ages, 972. 
atrophy of neck of, 1085. 
fracture of, 971. 
by ball, 293, 311. 
compound and comminuted, 
293. 
condylar, 999. 
epiphyseal, 1010. 
extra-capsular, 980. 
gunshot, 293, 311. 
history of its treatment, 
1002. 
impacted, 981. 
in children, 1009. 
in great trochanter, 920. 
in lower third, 991. 
in middle third, 991. 
in shaft of, 987. 
intra-capsular, 972. 
in upper third, 990. 
ligamentous union after, 
979. 
pathology of, 978. 
prognosis in, 844, 977. 
shaft of, 987. 
ununited, 836, 837, 841, 
844, 
Femur, sclerosis of, 1059. 
shot wounds of, 293, 311. 
Fenestrated forceps, 234. 
Fermentation due to micro-or- 
ganisms, 44. 
Ferments, septic, 45. 
Fever, abscess following, 165, 
391. 
as a diagnostic sign, 35, 36. 
inflammatory, 107. 
hay, 94. 
low forms of, as a complica- 
tion with fracture, 797. 
phlebitis following, 627. 
surgical or traumatic, 101. 
Fibrin, 110. 
Fibrinous layers in aneurism, 
648. 
transudation, 149. 
Fibroid polypus of rectum, 
520. 
Fibrous growths of umbilicus, 
475. 
stricture of rectum, 525. 
Fibula, excision of, 315. 
fracture of, 1035. 
Pott’s, 1036. 
Dupuytren’s splint for, 
1037. 
ununited fractures of, 841, 
844, 845. 
Figure-of-eight bandages, 71, 
72, 73, 74. 
for fractured clavicle, 905, 
910. 
suture, 248. 
Finger, spiral reversed of, 66. 
Fingers, anatomical tubercles 
of, 271. 
fractures of, 960. 
pseudo-neuralgia of, 613. 
Fire, Persian, 271. 
Firearms, 291. 
First intention, 316. 
Fissure of anus, 512. 
of Rolando, 383. 
Fistula, aerial, 399. 
after abdominal wounds, 460. 
anal, 536. 
biliary, relief of, 454. 
“ blind,’’ 536. 
faecal, 462. 
in anal anomalies, 505. 
gastric, 436, 441, 461. 
to form, 436. 
horse-shoe, 536, 539. 
in ano, 536. 
division of, 538, 540. 
excision of, 539. 
phthisis with, 537. 
seton for, 539, 
with tuberculosis, 537. 
wounds, 254. 
lachrymal, 393. 
laryngeal, 399. 
of gall-bladder, 401. 
of stomach, 401. 
artificial, 439. 
of thorax, 422. 
parotid, 390. 
perineo-anal, 536. 
perineo-rectal, 536. 
salivary, 390. 
sublingual, 391. 
urinary, 476. 
Fistulas at umbilicus, 476. 
Fistulous tracts, 165. 
Flat bones in necrosis, 1064. 
Flea-bite, 289. 
Flexion for aneurism, 675. 
for hemorrhage, 221. 
Flies as carriers of poison, 272. 
Floating kidney, 458. 
spleen, 456. 
Fluctuation in ascites, 477. 
in suppuration, 156. 
Foetal cord, hernia of, 606. 
Food in intestinal obstruction, 
491. 
in treatment of inflammation, 
142, 145. 
Foot, fracture of, 1040. 
mortification of, 195. 
spica for, 71. 
wounds of, 614. 
Foot and mouth disease, 275. 
Foot-drop due to callus, 852. 
Forceps, 735. 
Agnew’s, 233. 
arterial, 233. 
bone, 1069. 
bullet, 301. 
dressing, 242. 
fenestrated, 234. 
Gross’s, 232. 
Hewson’s, 227. 
Liston’s, 233. 
Rouger, 376. 
spring, 232. 
torsion, 226, 227. 
Forci-pressure, 232. 
Forearm, amputation for shot 
wound, 310. 
excision for shot wound, 310. 
fractures of, 937, 938. 
surgical anatomy of, 773. 
Foreign bodies in bladder as 
nuclei for calculus, 469. 
in brain, 364. 
in rectum, 514. 
in stomach, 434. 
in wounds, 241. 
Form in diagnosis, 32. 
Fountain syringe, 490. 
Four-tailed sling, 60, 61, 62. 
Fox’s appliances for broken 
clavicle, 909. 
Fracture, absorption of bones 
after, 824. 
adhesive plaster in, 815, 894. 
after-treatment of, 816. 
age of patient, 795. 
anchylosis after, 821. 
angular union after, 847. 
atrophy of soft parts after, 
821. 
bags used in dressing, 815. 
Barton’s, 945. 
bed in, 810, 812. 
bent-stick, 796. 
blood extravasated in, 802. 
box for, 1026. 
callus of, 803. 
causes of, 794. 
change of dressings in, 816. 
classification of, 796. 
coaptation in, 816. 
Colies’s, 951. 
comminuted, 797. 
of femur by ball, 293. 
complete, of ribs, 891. 
complicated, 796. 
by dislocations, 797. 
by epilepsy, 821. 
by lacerations, 797. 
compound, 796. 1098 
INDEX TO VOLUME I. 
Fracture, compound, necrosis 
after, 821. 
repair in, 809. 
treatment of, 818. 
compound comminuted, 797. 
repair in, 809. 
of the leg, 1038. 
condylar, of humerus, 930. 
contre-coup in, 332. 
counter-extension in, 816. 
cradle, 817. 
crepitus in, 800. 
defined, 794. 
deformity after, 846. 
deformity in, 798. 
delayed union, 822. 
delirium tremens in, 797, 821. 
depressed, of the skull, 341, 
342. 
direction of, 797. 
discoloration following, 801. 
dislocation with, 797. 
disordered sensibility after, 
801. 
displacement after, 847. 
displacement in, 798. 
angular, 799. 
longitudinal, 799. 
rotatory, 799. 
transverse, 799. 
dressings for, 812. 
due to muscular action, 796. 
embolism after, 821. 
epilepsy with, 821. 
epiphyseal, 798. 
examination of, 801. 
exciting causes of, 796. 
experiments on repair in, 804. 
extension in, 816. 
extra-capsular, of the neck of 
the femur, 980. 
extravasations of blood in, 
802. 
form of bones as favoring, 
794. 
functional causes of, 794. 
functions of joints after, 817. 
green-stick, 796. 
gunshot, 315. 
of pelvis, 467. 
hemorrhage after, 819. 
immovable dressings for, 813. 
impacted, 797. 
incomplete, 796. 
of ribs, 891. 
indirect, of ribs, 891. 
intra-capsular, of the hume- 
rus, 918. 
intra-uterine, 341. . 
laceration of parts as a com- 
plication, 797. 
longitudinal, 798. 
displacement in, 799. 
loss of function as a sign of, 
800. 
low fevers associated with, 
797. 
mania-a-potu with, 797, 821. 
massage after, 818. 
mobility of bones as affecting, 
794. 
morbid callus after, 852. 
multiple, 797. 
muscular action as a cause of, 
796. 
necrosis after, 392, 821. 
nerve-lesions in, 829. 
non-union after, 822. 
Fracture, Norris’s tables of, 829, 
853. 
oblique, 797. 
of acetabulum, 968. 
of acromion, 913. 
of alveolar process, 879. 
of astragalus, 1040. 
of bodies of vertebrae, 864. 
of bones of the forearm, 937, 
938. 
of carpal bones, 958. 
of cartilages of the larynx and 
trachea, 889. 
of cartilages of the ribs, 895. 
of cerebellar fossa, 339. 
of cerebral fossa, 337. 
of cervical vertebrae, 867. 
of cervico-dorsal vertebrae, 
867. 
of chest-bones, 891. 
of clavicle, 899. 
ununited, 841, 903. See 
also Clavicle.. 
of coccyx, 964. 
of coracoid, 915. 
of coronoid process of the 
ulna, 956. 
of costal cartilages, 895. 
of cranium, 331. See Frac- 
ture of Skull. 
of digits, 960, 1045. 
of dorsal vertebrae, 866. 
of dorso-lumbar vertebrae, 
865. 
of epiphysis of great tro- 
chanter, 986. 
of ethmoid bone, 337, 874. 
of external condyle of hu- 
merus, 931. 
of facial bones, 872. 
of femur, 971. See also Fe- 
mur. 
of fibula, 1035. 
of fingers, 960. 
of foot, 1040. 
of forearm, 937. 
of hand, 958, 961. 
of hip, 968. 
of humerus, 918. 
anatomical neck of, 918. 
compound, 936. 
condylar, 930. 
diagnosis of, 918, 919, 920, 
921, 922, 926, 929, 930, 
931, 933. 
epicondylar, 930, 932. 
extra-capsular, 920, 924. 
great tuberosity, 920. 
impacted, 919. 
intra-capsular, 918. 
knee-joint, 313. 
lower extremity of, 928, 
933. 
neck of, 918, 921. 
paralysis from, 928. 
prognosis in, 920, 921, 923, 
926, 930, 931, 932, 933. 
superior epiphysis, 921. 
supra-condylar, 929. 
surgical neck, 921. 
symptoms of, 919, 920, 921, 
922, 926, 929, 930, 931, 
933. 
treatment of, 920, 921, 924, 
927, 929, 933, 936. 
upper part, 918. 
of hyoid bone, 888. 
of ilium, 965. 
Fracture of inferior maxilla, 879. 
of innominate bones, 965. 
of internal condyle of hu- 
merus, 931. 
of internal epicondyle of 
humerus, 932. 
of ischium, 968. 
of jaw, lower, 879. 
upper, 875. 
of joints, compound, 820. 
of knee-cap, 1012. 
of larynx, 889. 
of leg, 1023. 
compound, 1038. 
of lower extremity of hume- 
rus, 928, 933. 
of lower jaw, 879. 
of lumbar vertebrae, 865. 
of malar bone, 877. 
of maxilla, inferior, 879. 
superior, 875. 
of metacarpus, 958. 
of metatarsus, 1045. 
of nose, 873. 
amaurosis after, 875. 
catarrh following, 875. 
causes of, 873. 
comminuted, 874. 
complicated, 873. 
compound, 874. 
emphysema from, 874. 
hemorrhage after, 874. 
necrosis from, 874. 
polypus after, 875. 
symptoms of, 873. 
treatment of, 873. 
of odontoid process, 868, 870. 
of olecranon, 953. 
of os calcis, 1041. 
of ossa innominata, 965. 
of ossa nasi, 873. 
of patella, 1012. 
apparatus for, 1019-1023. 
of pelvis, 962. 
of phalanges of fingers, 960. 
of toes, 1045. 
of pubis, 966. 
of radius, 937, 941. 
at lower end, 943. 
Barton’s, 943. 
below tubercle, 942. 
Colles’s, 944. 
deformity after, 946. 
Moore’s, 947. 
of middle third, 942. 
Smith’s, 944. 
of radius and ulna, 937. 
of ribs, 891. 
adhesive strips in, 894. 
complete, 891. 
complications of, 892. 
emphysema from, 895. 
incomplete, 891. 
indirect, 891. 
prognosis in, 893. 
symptoms of, 892. 
treatment of, 894. 
of sacrum, 962. 
of scapula, 911-917. 
acromion, 913. 
angles, 912. 
body, 912. 
coracoid, 915. 
glenoid, 916. 
neck, 916. 
of shaft of femur, 987. 
of humerus, 925. 
of skull, 331. INDEX TO VOLUME I. 
1099 
Fracture of skull, base of, 336. 
cerebellar fossa, 339. 
comminuted, 342. 
complicated, 336. 
compound, 336. 
treatment of, 342. 
contre-coup in, 332. 
crushed, 361. 
depressed, 339, 341, 360. 
treatment of, 342. 
depression simulating, 341. 
diagnosis of, 341. 
escape of cerebro-spinal 
fluid in, 338. 
external table, 340. 
gunshot, 358. 
splinters in, 302. 
hemorrhage from ear in, 
337. 
internal table, 340. 
intra-uterine, 341. 
meningitis from, 335. 
prognosis in, 334. 
punctured, 343. 
repair of, 334. 
simple, 334, 358. 
treatment of, 335, 342, 361. 
with signs of compression, 
342. 
of spinal column, 862. 
paralysis from, 865, 866, 
867, 868, 871. 
trephine in, 872. 
of spinous processes, 863. 
of sternum, 896. 
causes of, 896. 
complications of, 898. 
direction of, 897. 
displacement in, 897. 
prognosis of, 898. 
seat of, 897. 
symptoms of, 898. 
treatment of, 898. 
of superior maxilla, 875. 
of sustentaculum tali, 1044. 
of tarsal bones, 1040. 
of thorax, 891. 
of tibia, 1032. 
ununited, 836-839, 841. 
of tibia and fibula, 1023. 
compound, 1038. 
ununited, 836-839. 
of toes, 1045. 
of trachea, 889. 
of transverse processes, 864. 
of trochanter major, 985. 
of ulna, 937, 951. 
coronoid process, 956. 
in processes, 953. 
in shaft, 952. 
in styloid process, 957. 
olecranon process, 953. 
of vertebra, 862. 
cervical, 867. 
dorsal, 866. 
lumbar, 865. 
odontoid process, 868, 870. 
spinous processes, 863. 
of vertebral arches, 864. 
bodies, 864. 
of wrist, 958. 
of zygomatic arch, 877, 878. 
pads used in dressing, 815. 
pain after, 800. 
paralysis after, 852, 865-868, 
871, 928. 
Pott’s, 1036. 
predisposing causes of, 794. 
Fracture, preternatural mobility 
in, 799. 
prognosis of. See Tables, 
854-862. 
punctured cranial, 343. 
radiating, of skull, 336. 
removal of clothing after, 812. 
repair of, 801. 
roller of muslin in, 815. 
rotatory displacement after, 
847. 
setting of, 815, 816. 
shock after, 822. 
shortening in, 799, 847. 
signs of, 798. 
simple, 796. 
special, 862. 
splints for, 812. 
statistics of, 829-846, 853- 
862. 
stellated, 797. 
stiff joints following, 817. 
supra-condyloid, of humerus, 
929. 
time for setting, 816. 
transportation of patients 
with, 810. 
transverse, 798. 
treatment of, 809. 
of compound, 818. 
ununited, 822. 
apparatus for, 824. 
caustics in, 828. 
drill in, 826. 
external irritation in, 825. 
friction in, 825. 
gimlet in, 827. 
irritation in, 825, 827. 
of clavicle, 840, 903. 
of femur, 836, 837, 844. 
of fibula, 836, 837, 838, 839, 
841. 
of humerus, 832, 833, 841, 
843. 
of inferior maxilla, 840,842. 
of metacarpus, 841. 
of patella, 836, 837,838, 839, 
841. 
of radius, 832, 833, 834,835, 
841. 
of ribs, 840. 
of scapula, 840. 
of tibia, 836-841. 
of tibia and fibula, 836, 837, 
838, 839, 845. 
of ulna, 832, 833, 834, 835, 
841, 844. 
open wounds in, 827. 
seton in, 826. 
subcutaneous irritation in, 
826. 
treatment of, 824. 
statistics of, 829-846. 
vertebral, 864, 870-872. 
vicious union after, 846. 
violence as a cause of, 796. 
with dislocation, 820. 
with injury of nerves, 829. 
Fragilitas ossium, 1081. 
Fragility of bones, 795, 1081. 
Fremitus in diagnosis, 34. 
French apparatus for fractured 
lower jaw, 884. 
spiral reversed bandage, 68. 
truss, 557. 
Fromotopnoea, 409. 
Function, its loss a sign of frac- 
ture, 800. 
Function, its restoration after 
fracture, 817. 
Fungi, microscopic, in disease, 
95, 154. 
Fungous ulcer, 177. 
Fungus cerebri, 369. 
malignant, 371. 
G. 
Galen’s bandage, 60. 
Gall-bladder, distention of, 452, 
486. 
excision of, 454. 
fistula of, 461. 
rupture of, 452. 
sewed to intestine, 454. 
wounds of, 450, 452. 
Gall-stones, 453. 
obstruction from, 486. 
Galvanism in inflammation, 148. 
in varix, 638. 
Galvano-cautery in hemorrhage, 
225. 
Galvano-puncture for aneurism, 
676. 
for naevus, 617. 
for subclavian aneurism, 706. 
Gangrana contagiosa, 201. 
nosocomialis, 201. 
Gangrene, 189. See Mortifica- 
tion. 
Garretson’s bandage, 883. 
dental engine, 1069. 
operation for salivary fistula, 
391, 392. 
Gastrectomy, partial, 437. 
Gastric fistula, 441, 461. 
artificial, 436. 
Gastrocele, 551. 
Gastro - enteritis, obstructive, 
486. 
Gastro-enterostomy, 438. 
Gastrorrhaphy, 439. 
Gastrostomy, 439. 
Gastrotomy, 435. 
Gauze, carbolized, 48. 
corrosive sublimate, 48. 
Gelatinoid polypus of rectum, 
520. 
Gely’s suture, 448. 
Gemrig’s bullet forceps, 301. 
truss, 555. 
Genito-urinary organs in diag- 
nosis, 42. 
Gerdy’s dressing for fractured 
patella, 1021. 
hernia operation, 558. 
Germicides, 46. 
Germ-tissue, 316. 
Germs of disease, 154. 
Gestation as delaying repair of 
bones, 822. 
Giant-celled myosarcoma, 631. 
Gibbons’s compressor, 673. 
Gibson’s bandage, 74. 
inclined plane, 1008. 
Gimbernat’s ligament, 593. 
Gimlet in ununited fracture, 
827. 
Giraffe-sinews, ligatures of, 237. 
Glanders in man, 276. 
Glands, enlarged, how distin- 
guished from aneurism, 
659. 
from femoral hernia, 596. 
from inguinal hernia, 589. 1100 
INDEX TO VOLUME I. 
Glass drainage-tubes, 242. 
Glenoid cavity, fracture of, 916. 
Glover’s suture, 247. 
Gluteal artery, ligation of the, 
779. 
handkerchief, 87. 
hernia, 606. 
Goddard’s use of collodion in 
surgery, 246. 
Gold-beater’s skin for plasters, 
246. 
Gonorrhoeal inflammation of 
rectum, 522. 
Gouges for bone, 1054. 
Grafts of epidermis, 187. 
of skin, 185. 
Granulation, 319. 
tissue, 173, 176, 316. 
Grape-shot, 293. 
Grease, 278. 
Great trochanter, fracture of, 
985. 
Green-stick fractures, 796. 
Groin, spica of, 70. 
T bandage of, 59. 
Grooved director, 735. 
Gross’s enterotome, 466. 
forceps, 232. 
anal, 466. 
tourniquet, 224. 
Gum-elastic bag for hot water, 
131. 
bandage for ulcers, 184. 
catheter, 871. 
cloth, 48. 
cupping apparatus, 133. 
loop for retained ligature, 236. 
splints, 886. 
suture, 249. 
syringe, 490, 504. 
Gunshot fractures. See Frac- 
tures, Gunshot. 
wounds, 290. 
amputation and excision in, 
305. 
balls removed from, 302. 
erysipelas in, 303. 
expectant treatment in, 307. 
of bladder, 409. 
of cranial bones, 358. 
of face, 388, 888. 
of hand, 310. 
of head, 356. 
of kidney, 458. 
of knee-joint, 313. 
of neck, 400. 
of pelvic bones, 467. 
of rectum, 473. 
of scalp, 325, 357. 
of thigh, 311. 
transfusion for, 239. 
windage in, 295. 
Gut ligatures in asepsis, 47. 
of silk-worm, 47. 
Guthrie’s treatment of hospital 
mortification, 203. 
Gutta-percha splints, 886. 
Gypsum dressings, 814, 1034. 
H. 
Habits in diagnosis, 28. 
influencing inflammation, 91. 
Haematocele distinguished from 
inguinal hernia, 588. 
Haemoptysis in lung-wounds, 
409, 413. 
Haemostatics, 219. 
comparison of, 237. 
Haemothorax, 414. 
Hair drains, 243. 
introduced into aneurisms, 
678. 
Half-Maltese cross, 55. 
Hamilton’s bandage, 883. 
bone drill, 827. 
dressing for fractured olec- 
ranon, 956. 
gutta-percha splints, 886. 
Hand, abscess of, 611. 
fractures of, 958, 961. 
shot wounds of, 310. 
spiral of, 67. 
spray-apparatus, 50. 
T bandage of, 59. 
topography of, 612. 
wounds of, 610. 
Handkerchief, Barton’s, 87. 
dressings, 78. 
for clavicle, 904. 
Hanging, the hyoid bone in, 
888. 
Hard-rubber splints, 886. 
syringe, 504. 
Hare-lip suture, 248. 
Hartshorne’s dressing for frac- 
tured patella, 1021. 
splint, 1006. 
Haversian canals, 1051. 
“ Hay catarrh,” 94. 
Hays’s splint, 950. 
Head, crush of, 361. 
gunshot wounds of, 356. 
injuries of, 322, 326. 
epilepsy after, 372. 
sequels of, 367-375. 
T bandage of, 57. 
Headache after injury, 374. 
Healing by granulation, 319. 
of wounds, 316. 
Heart, feeble, a cause of mortifi- 
cation, 191. 
in diagnosis, 35. 
lesions of, due to atheroma, 
646. 
rupture of, 423. 
wounds of, 422. 
Heat as a haemostatic, 220. 
in suppuration, 156. 
in treatment of inflammation, 
130. 
Hectic fever, 101. 
Hemorrhage, acupressure in, 
228. 
after fractures, 819. 
after gunshot wound of neck, 
401. 
after gunshot wounds, 304. 
after ligation for axillary an- 
eurism, 716. 
after ligation of piles, 549. 
arrest of, by nature, 215. 
by the surgeon, 219. 
from abscess, 165. 
from anal fistula, 539. 
from intercostal artery, 406. 
from leech-bite, 134. 
cauterization in, 224. 
concealed internal, 297. 
during herniotomy, 582. 
from compound fractures, 
1039. 
from ear in skull-fractures, 
337. 
from gunshot wounds, 297. 
Hemorrhage from gunshot 
wounds, arrest of, 299. 
secondary, 297. 
from neck-wound, 395. 
from umbilicus, 475. 
from wounds, 214. 
in chest-wounds, 413. 
in gangrene, 196. 
intracranial, 351. 
ligature for, 232. 
secondary, 253. 
after compound fractures, 
819. 
torsion for, 226. 
transfusion for, 239. 
treatment of, 134, 165, 219, 
224, 226, 239, 406. 
systemic, 238. 
venous, 625. 
Hemorrhoidal truss, 544. 
Hemorrhoids, 540. 
blind, 541. 
chemise for, 549. 
clamp for, 546. 
constipation causing, 542. 
contra-indications for opera- 
tion in, 550. 
6craseur for, 548. 
external, 540. 
incarcerated, 543. 
inflamed, 542. 
injections in, 543. 
internal, 541. 
irrigation for, 544. 
ligation, 545. 
bleeding after, 549. 
open, 541. 
prolapsed, 541. 
treatment of, 542. 
radical, 544. 
Hepatic abscess, 451. 
Heredity in inflammation, 91. 
Hernia, 550. 
adhesions complicating, 579. 
anatomy of, 550. 
artificial anus after, 462, 464. 
author’s operation for, 559. 
Barker’s operation for, 562. 
between abdominal muscles, 
573. 
csecal, 550. 
causes of, 552. 
cerebri, 369. 
circumclusion of, 561. 
compression in, 564. 
concealed, 570, 585. 
congenital, 586. 
congestion of bowel compli- 
cating, 580. 
contents of, 551. 
coverings of, 551. 
crural, 593. 
cruro-properitoneal, 608. 
diagnosis from abscess, 158. 
diaphragmatic, 606. 
diverticular, 593, 608. 
double, 586. 
Dowell’s operation for, 561. 
encysted, 587. 
faeces complicating, 579. 
femoral, 593. 
anatomy of, 593. 
contents of, 594, 595. 
coverings of, 594, 595. 
diagnosis of, 595. 
herniotomy in, 598. 
incomplete, 595. 
radical cure of, 564, INDEX TO VOLUME I. 
1101 
Hernia, femoral, strangulated, 
598. 
symptoms of, 595. 
taxis in, 572, 598. 
treatment of, 597. 
truss for, 598. 
frequency of forms of, 554. 
gas complicating, 579. 
Gerdy’s operation for, 558. 
gluteal, 606. 
herniotomy in, 574. See Her- 
niotomy. 
incarcerated, 565. 
infantile, 557, 586. 
inguinal, 584. 
anatomy of, 584. 
complete oblique, 585. 
concealed, 585. 
congenital, 586. 
coverings of, 584. 
diagnosis of, 585, 587, 589. 
from femoral, 596. 
from varicocele, 587. 
direct, 585. 
double, 586. 
encysted, 587. 
herniotomy in, 592. 
incomplete, 585, 596. 
indirect, 585. 
infantile, -586. 
in females, 587. 
intraparietal, 586. 
irreducible, 587, 590. 
oblique, 585. 
scrotal, 586. 
strangulated, 591. 
taxis in, 572. 
treatment of, 580. 
truss for, 590. 
inguino-properitoneal, 607. 
interstitial, 573. 
intestine congested in, 580. 
intraparietal, 573. 
invagination of, 558. 
irreducible, 565. 
permanently, 566. 
ischiatic, 606. 
knife for, 577. 
labial, 606. 
laparotomy for complications 
of, 574. 
local irritation to cure, 564. 
lumbar, 604. 
Macewen’s operation for, 563. 
manner of occurrence of, 554. 
median ventral, 604. 
mortification of intestine in, 
580. 
obturator, 604. 
of bladder, 608. 
of foetal cord, 606. 
of lung, 415. 
omental, 587. 
omental complications in, 581. 
perineal, 607. 
peristaltic paralysis in, 573. 
properitoneal, 573, 607. 
pudendal, 606. 
radical cure of, 557. 
by invagination, 558. 
by transplantation, 564. 
of femoral, 564. 
of umbilical, 564. 
operations for, 558-565. 
reducible, 552. 
reduction of, 571. 
difficulties in, 579. 
en bloc, 573. 
Hernia, reduction of, en masse, 
573. 
retroclusion of, 562. 
rupture of intestine in, 574. 
sac of, 550. 
appearance of, 575. 
hydrocele of, 551. 
opening the, 575. 
sacro-rectal, 607. 
scrotal, 586. 
sex in, 552. 
Signorini’s operation for, 558. 
sloughing in, 581. 
statistics of, 554, 562, 575. 
strangulated, 567. 
diagnosis of, 570. 
double, 570. 
effects of, 568. 
herniotomy in, 574. 
mortification in, 581. 
prognosis in, 582. 
stricture in, 568. 
symptoms of, 569. 
taxis in, 571. 
too prolonged in, 572, 
583. 
treatment of, 571. 
symptoms of, 554, 569. 
taxis for, 571. 
hiecough contra-indicating, 
572. 
how long to persist in, 572, 
583. 
thyroid, 605. 
time to operate in, 574. 
transplantation operation for, 
564. 
treatment of, 555. 
trusses for, 555, 590, 601. 
application of, 556. 
umbilical, 599. 
acquired, 599. 
congenital, 600. 
cork pad in, 600. 
diagnosis of, 600. 
in adult life, 599. 
infantile, 600. 
irreducible, 602. 
strangulated, 602. 
herniotomy in, 603. 
taxis in, 602. 
treatment of, 602. 
trusses for, 601. 
vaginal, 606. 
varieties of, 550, 584. 
ventral, 604. 
ventro-inguinal, 585. 
vesical, 608. 
vitality of bowel in, 580. 
volvulus in, 580. 
Wood’s operation for, 560. 
Hernias, special, 584. 
Hernial aneurism, 647. 
sac, dropsy of, 592. 
diagnosis of, 592. 
pyriform, 551. 
treatment of, 592. 
Herniotomy, 574. 
after-treatment of, 578. 
hemorrhage during, 582. 
return of contents in, 578 
Hewson’s torsion-forceps, 227. 
Hey’s ligament, 593. 
saw, 377. 
Hiccough contra-indicating 
taxis in hernia, 572. 
Hip-joint excision for shot 
wounds, 312. 
Hip, luxation of, diagnosticated 
from a fracture, 989. 
History of hospital mortifica- 
tion, 205. 
of ligation of common ca- 
rotid, 748. 
of operation of ligating the 
innominate artery, 739. 
Hodge’s splint, 1006. 
Holsen’s chisel, 377. 
Homicidal wounds, 394, 397. 
Hood truss, 555. 
Hooks, Malgaigne’s, 1022. 
Horner’s awl, 682. 
splint dressing, 1007. 
Hornet-sting, 289. 
Horse, diseases transmitted to 
man from, 276. 
Horse-hair, drainage by, 243. 
introduced into aneurisms, 
678. 
Horseshoe fistula, 536, 539. 
tourniquet, 224. 
Hose for irrigating hemor- 
rhoids, 544. 
Hospital mortification, 201. 
Housemaid’s knee, 28. 
Humerus, absorption of, 824. 
amputation of, 307. 
excision in continuity for shot 
wound, 308. 
of head of, for shot injury, 
307. 
fracture across the base of, 
930. 
at lower third, 926. 
of external condyle, 931. 
of internal condyle, 931. 
of lower extremity, 929. 
of shaft, 925. 
treatment of pseudarthrosis 
of, 832, 833, 841, 842. 
ununited fractures of, 832, 
833, 841, 842. 
Humid gangrene, 193. 
necrosis, 1062. 
Hunter’s canal, 785. 
operation for aneurism, 669. 
transfusion-apparatus, 241. 
Hutchison’s • circumclusion 
method for the control of 
hemorrhage, 231. 
Hydatids of liver, 451. 
Hydrocele distinguished from 
inguinal hernia, 588. 
of hernial sac, 551. 
Hydrogen gas test for intestinal 
wounds, 445. 
Hydrophobia, 278. 
forms of, 280. 
in man, 281. 
paralysis in, 282. 
pathology of, 283. 
priapism in, 282. 
prophylaxis against, 284. 
proportion of madness to bit- 
ten in, 279. 
saliva in, 279. 
treatment of, 283. 
by Pasteur’s method, 284. 
water in, 282. 
Hydrops pericardii, 425. 
Hydrostatic injection, 490. 
Hydrothorax after chest- 
wounds, 417. 
Hygiene in treating inflamma- 
tion, 143. 
Hyoid bone, fracture of, 888. 1102 
INDEX TO VOLUME I. 
Hypersesthesia after contusions, 
263. 
Hypertrophy, cardiac, from 
atheroma, 646. 
of bones, 1083. 
of cranial bones, 327. 
of papillas in ulcers, 172. 
of vein-walls, 630. 
Hypodermic injections of pilo- 
carpine in erysipelas, 253. 
syringe, 142. 
in inflammation, 141. 
in treatment of aneurism, 
677. 
in treatment of naevus, 620. 
Hypoglossal nerve, injury of, 
401. 
Hysteria from fissure, 513. 
I. 
Ichor, 171. 
Ichorrhaemia, 258, 266. 
Ichthyocolla plaster, 245. 
Ignis sacer, 271. 
Ileum, rupture of, 443. 
strangulation of, 483. 
Iliac artery, common, aneurism 
of, 723. 
collateral circulation of, 
780. 
ligation of, 776, 779. 
treatment of, 723. 
external, aneurism of, 725. 
ligation of, 726. 
surgical anatomy of, 776. 
internal, aneurism of, 723. 
ligation of, 778. 
Ilium, fractures of, 965. 
shot wounds of, 467. 
Imbecility from head-injury, 
374. 
Immediate compression for an- 
eurism, 670. 
union of wounds, 316. 
Immovable cicatrices, 321. 
dressings, 813. 
Impacted faeces, 514. 
fracture of femur, 797, 974, 
981, 1000. 
of humerus, 919. 
Imperforate anus, 505. 
Impotency from head-injury, 
374. 
Incarcerated hemorrhoids, 543. 
hernia, 565. 
Incised wounds, 254. 
of abdomen, 430. 
of arteries, 640. 
Incision and ligation for aneu- 
rism, 662. 
Incomplete fractures, 796. 
India-rubber appliances. See 
Gum-elastic. 
Indolent ulcer, 180. 
Induration of bone, 1059. 
of old ulcers, 184. 
Infants, lumbar colotomy of, 507. 
Infarctions in malignant pus- 
tule, 271. 
Infectious pus, 151. 
Infective periostitis, 1048. 
Inferior maxilla, fractures of, 
879. 
ununited fracture of, 840, 
842. 
thyroid artery, ligation of, 
763. 
Infiltration in formation of ab- 
scesses, 162. 
in inflammation, 111. 
Inflammation, 89. 
abscess from, 157, 161. 
acute, 96. 
adhesive, 316. 
age in, 91. 
altered secretions in, 93, 100. 
anal, 522. 
anodynes in, 141. 
antiseptics in, 137. 
as a complication in wounds, 
251. 
bleeding for, 133, 137. 
blood in, 92, 110. 
blood-vessels in, 104. 
buffy coat in, 110. 
cathartics in, 139. 
causes of, 90, 144. 
cell-migration in, 108. 
cell-transudation in, 108. 
chronic, 90, 143, 165. 
cicatrization in, 173. 
cocaine in, 137. 
cod-liver oil in, 146. 
cold in, 128. 
color in, 96, 143. 
complicating wounds, 251. 
compression in, 135, 137, 147. 
congestion circle in, 106. 
constitutional symptoms in, 
100, 144, 156. 
counter-irritants in, 135, 147. 
cupping in, 133. 
definition of, 103. 
depressants in, 138. 
determination line in, 106. 
diaphoretics in, 139. 
diet in, 142, 145. 
diuretics in, 139. 
effects of, 148. 
electricity for, 148. 
ergot as a cause, 91. 
erysipelatous, 190. 
exciting causes of, 92. 
extension of, 95. 
exudation in, 108. 
fever in, 101. 
fibrinous, 149. 
fluctuation in, 156. 
food in, 91, 142, 145. 
functional changes in, 100. 
gangrene from, 127. 
habits in, 91. 
healthy, 89. 
heat in, 98, 130, 144. 
hemorrhoidal, 542. 
history of, 115. 
infectious, 95. 
infiltration in, 111. 
internal causes of, 93. 
irrigation in, 129, 148. 
irritative fever from, 101. 
latent, 90. 
leeching in, 134. 
leucocytes in, 107, 127. 
ligation for, 134. 
local symptoms of, 96. 
lymph in, 111. 
mental influence on, 92. 
mercurials in, 140, 146. 
metastasis in, 127. 
microbes in, 95. 
moisture in, 130. 
mortification from, 127. 
moxa in, 147. 
nature of, 103. 
Inflammation, nerve-agency in, 
94, 103, 125. 
nerve-changes in, 102. 
of brain after head-injury, 
367. 
of cranial bones, 327. 
of kidney, after abdominal 
wounds, 460. 
pain in, 98, 144, 155. 
pathology of, 144. 
perivascular tissue-changes in, 
111. 
phenomena of, 103. 
phlegmonous, 161. 
position in treatment of, 
128. 
previous attack as influencing, 
92. 
process of, in fracture, 808. 
pus from, 150. 
rectal, 522. 
redness in, 96, 105, 155. 
resolution of, 127. 
results of, 148. 
scrofulous, 144. 
secretions in, 93, 100, 102. 
serous, 149. 
seton in, 147. 
specific, 90. 
stages of, 103, 107, 108. 
stasis in, 107. 
sthenic, 90. 
suppuration in, 150. 
swelling in, 97, 144, 156. 
symptoms of, 96, 100. 
temperament in, 90. 
temperature in, 92. 
termination of, 127. 
thermometry of, 92. 
tonics in, 142, 146. 
transudation in, 148, 150. 
treatment of, 145. 
anodynes in, 141. 
antiseptics in, 137. 
bleeding in, 133, 137. 
blisters in, 136. 
cathartics in, 139. 
cocaine in, 137. 
cold in, 128. 
constitutional, 100. 
counter-irritants in, 139. 
depressants in, 138. 
diet in, 142, 145. 
diaphoretics in, 139. 
diuretics in, 139. 
irrigation in, 129, 148. 
local, 128, 146. 
mercurials in, 140, 146. 
position in, 128. 
rest in, 128. 
stimulants in, 142. 
tonics in, 142, 146. 
ventilation in, 143. 
vesication in, 136. 
ulceration in, 169. 
varieties of, 89, 149. 
Inflammatory fever, 101. 
infiltrations, 111. 
Inguinal canal, 553, 584. 
glands, enlarged, how distin- 
guished from femoral 
hernia, 596. 
how distinguished from in- 
guinal hernia, 589. 
hernia, 584. See Hernia, In- 
guinal. 
rings, 584. 
truss, 555. INDEX TO VOLUME I. 
1103 
Inguino - properitoneal hernia, 
607. 
Injection-pipe, wounds of rec- 
tum from, 490. 
Injections, hydrostatic, 490. 
hypodermic, 141, 620, 677. 
for angeioma, 620. 
for piles, 546. 
for subclavian aneurism, 707. 
of air, 490. 
of ergot for aneurism, 700. 
rectal, 489. 
Injuries of arteries, 638. 
of blood-vessels, 615. 
of chest, 404. 
of cranial bones, 321. 
of face, 386. 
of head, 322. 
of neck, 394. 
of osseous system, 794. 
of scalp, 322. 
of veins, 624. 
Innervation, defective, mortifi- 
cation from, 192. 
ulcers from, 188. 
Innominate artery, aneurism of, 
690. 
ligation of, 738. 
history of the operation, 
739. 
Mott’s method in, 738. 
surgical anatomy of, 738. 
bones, fractures of, 965. 
vessels, wounds of, 427. 
Inoculation with gangrene, 202, 
204. 
Inosculation of blood-vessels, 
219. 
Insanity after head-injury, 
374. 
due to anal fissure, 512. 
Insect-stings, 289. 
Inspiration, the, in diagnosis, 
37. 
Instruments, disinfection of, 50. 
for ligation, 734. 
Intelligence in diagnosis, 38. 
Intemperance a cause of aneu- 
rism, 644, 653. 
of atheroma, 653. 
Intention, first, second, and 
third, 316. 
Intercostal artery, compressors 
for, 406. 
ligation of, 406. 
needle for, 406. 
Interdental splints, 884—886. 
Intermediary amputation, 305. 
Intermediate aneurism, 684. 
union of wounds, 319. 
Internal angular splint, 924. 
carotid, aneurism of, 702. 
ligation of, 755. 
iliac artery, ligation of, 778. 
surgical anatomy of, 778. 
inguinal ring, 584. 
mammary artery, ligation of, 
763. 
piles, 541. 
saphenous vein, varix of, 635. 
Interparietal aneurism, 639. 
Interpectoral fascia, 765. 
Interrupted suture, 246. 
Interstitial changes in the neck 
of the femur, 974. 
hernia, 573. 
Intertrochanteric fracture, 980. 
Intestinal concretions, 487. 
Intestinal fistula, 462. 
invagination, or intussuscep- 
tion, 481. 
obstruction, 481. 
air-injections for, 490. 
by fibrous bands, 483. 
by inflammatory lymph, 
483. 
chronic, 484. 
cicatricial, 486. 
diagnosis of, 487. 
electricity for, 491. 
faradism for, 491. 
food in, 491. 
from foreign bodies, 484. 
from gall-stones, 486. 
from gastro-enteritis, 486. 
from peritonitis, 484. 
from stricture, 486. 
from twist, 482. 
injections for, 489, 490. 
kneading for, 491. 
laparotomy for, 493. 
massage in, 491. 
mercury in, 491. 
operative treatment, 493. 
slow, 484. 
spontaneous cure of, 491. 
treatment of, 489. 
perforation in enteric fever, 
444. 
strangulation, 463, 483. 
twist, 482. 
Intestine, anomalies of outlet 
of, 504. 
cancer of, 485. 
peristaltic paralysis of, in 
hernia, 573. 
protrusion of, 432. 
resection of, 449. 
rupture of, 442. 
in hernia, 574. 
stricture of, 485. 
sutures removed from, 447. 
wounds of, hydrogen gas test 
in, 445. 
laparotomy in, 445, 448. 
penetrating, 444. 
with protrusion, 446. 
Intoxication diagnosed from 
apoplexy, 353. 
Intra-capsular fractures of the 
femur, diagnosis of, 982, 
984. 
non-union in, 978. 
pathology of, 978. 
Intra-cranial abscess, 328. 
aneurism, 707. 
extravasation of blood, 351. 
of serum, 356. 
Intra-orbital aneurism, 709. 
Intra-parietal abscess after ty- 
phlitis, 497. 
hernia, 573. 
Intra-peritoneal abscess in ty- 
phlitis, 497. 
Intra - thoracic inflammation 
after ligation for axillary 
aneurism, 715. 
Intra - uterine skull - fractures, 
341. 
Intussusception of the bowel, 
481. 
Invagination, intestinal, 481. 
symptoms and treatment of, 
482. 
Inversion of foot in intra-capsu- 
lar fracture of femur, 976. 
Involucrum in necrosed bone, 
1063. 
Iodine in inflammation, 136, 
146. 
Iodoform in asepsis, 49. 
in osteomyelitis, 1058. 
Iron arrow-heads, 365. 
wire in aneurismal sac, 678. 
Irreducible hernia, 565. 
Irregular bones, necrosis of, 
1064. 
Irrigating apparatus, 47, 129, 
544. 
tube, Petitgand’s, 130. 
Irrigation for gunshot wounds, 
303. 
for hemorrhoids, 544. 
in inflammation, 129. 
of the leg, 129. 
Irritable rectum, 516. 
ulcer, 177. 
Irritation, subcutaneous, for un- 
united fracture, 826. 
Irritative fever, 101. 
Ischiatic artery, ligation of, 779. 
hernia, 606. 
Ischio-rectal abscess, 535. 
Ischium, fractures of, 968. 
shot wounds of, 467. 
Isinglass plaster, 245. 
Issues in inflammation, 147. 
Itching at anus, 509. 
J. 
Jaws, fractures of, 840, 842, 875. 
See Fractures. 
Jenks’s fracture-bed, 811. 
Joint, false, 824. 
Joints after fracture, 817. 
compound fractures of, 820. 
Jugular veins, arterio-venous 
aneurism of, 713. 
aspiration of, 627. 
ligation of, 625. 
wounds of, 395, 396. 
Junk-bag in fracture, 1003. 
K. 
Keloid, 320. 
Key as a compressor, 222. 
Kidney, floating, 458. 
inflamed, after abdominal 
wounds, 460. 
wounds of, 458. 
Kingsley’s interdental splint, 
886. 
Kneading for aneurism, 700. 
for intestinal obstruction, 491. 
Knee, housemaid’s, 28. 
Knee-joint amputation for shot 
wounds, 314. 
shot wounds of, 313. 
Knife for abscess, 164. 
for hernia, 577. 
Knots, 235. 
Knot-tying instrument, 474. 
Koch’s rules for relation between 
bacteria and disease, 46. 
L. 
Labial hernia, 606. 
Labium, angeioma of, 624. 
Lacerated wounds, 256. 
of hand, 610. 1104 
INDEX TO VOLUME I. 
Laceration of arteries or nerves 
in fracture, 797. 
Lacerations of arteries, 638. 
Lachrymal disturbances follow- 
ing nasal injury, 874. 
fistula, 393. 
Lactation as delaying the repair 
of bones, 822. 
Laminae in aneurismal sac, 648. 
Laminaria as a compressor, 406. 
Laparotomy, after-treatment of, 
502. 
for intestinal wounds, 445, 
448. 
for ruptured bladder, 471. 
in hernia, 574. 
in perforation of appendix, 
498. 
of caecum, 498. 
in suppurative typhlitis, 497. 
principles to be observed in, 
494. 
rules for, 429. 
statistics of, 493, 494. 
Laryngeal fistula, 399. 
Larynx, fracture of cartilages 
of, 889. 
gunshot wounds of, 400. 
necrosis of, 403. 
suicidal wounds of, 394, 399. 
Lateral displacement in frac- 
ture, 939. 
Lausdale’s apparatus for frac- 
tured patella, 1020, 1021. 
Lead plaster, 244. 
ribbon with collodion as a 
dressing, 246. 
wire ligatures, 237. 
Leech, artificial, 134. 
Leech-bite, arrest of hemor- 
rhage from, 134. 
Leeching, 134. 
Left lumbar colotomy, 499. 
Leg, fracture of, 1023. 
compound, 1038. 
irrigation of inflamed, 129. 
Lembert sutures, 447, 449. 
Lenticular, 377. 
Leontiasis ossium, 1059. 
Leucocytes, 121. 
in inflammation, 107, 121. 
migration of, 317. 
Leucocythasmia, spleen in, 455. 
Lever for bullets in wounds, 302. 
Levis’s apparatus for broken 
clavicle, 909. 
device for fractured patella, 
1022. 
extension apparatus, 995. 
hernia director, 577. 
splint for Colles’s fracture, 
951. 
Lids. See Eyelids. 
Ligament, Hey’s, 593. 
Poupart’s, 593. ’ 
Ligamentous union in fractured 
olecranon, 954. 
after intra-capsular fracture 
of the femur, 979. 
Ligation, 234, 236, 700, 715. 
for aneurism, 662, 664, 669, 
694, 700, 715. 
for axillary aneurism, 715.' 
for hemorrhage, 232. 
for naevus, 622. 
for subclavian aneurism, 705, 
706. 
of abdominal aorta, 783. 
Ligation of anterior tibial ar- 
tery, 791. 
of arteries, 734. 
of axillary artery, 764, 765, 
770. 
of both common carotids, 747. 
of brachial artery, 770-772. 
of common carotid, 703. 
double, 747. 
statistics of, 744, 749. 
of common femoral, 785. 
of common iliac, 726, 779— 
783. 
of dorsalis pedis artery, 792. 
of epigastric artery, 778. 
of external carotid artery, 749. 
of external iliac artery, 776. 
of facial artery, 753. 
of femoral artery, 784. 
at point of election, 785. 
for aneurism, 728. 
in aponeurotic canal, 786. 
in common femoral, 785. 
of gluteal artery, 779. 
of hemorrhoids, 545. 
of inferior thyroid artery, 
762. 
of innominate artery, 738. 
of intercostal artery, 406. 
of internal carotid artery, 755. 
of internal iliac artery, 778. 
of internal mammary artery, 
763. 
of ischiatic artery, 779. 
of jugular vein, 625. 
of leech-bite, 134. 
of lingual artery, 751. 
of naevus, 621. 
of occipital artery, 754. 
of peroneal artery, 790. 
of popliteal artery, 787, 788. 
for aneurism, 731. 
of posterior tibial artery, 788. 
of primitive carotid artery, 
703. 
of primitive iliac artery, 779, 
783. 
for aneurism, 726. 
of radial artery, 772-775. 
of subclavian artery, 756. 
of superior thyroid artery, 
750. 
of temporal artery, 755. 
of ulnar artery, 775. 
of veins, 625. 
of vertebral artery, 762. 
to control inflammation, 134. 
Ligature, animal, 236. 
antiseptic, 236, 237. 
application of, 234. 
to diseased vessels, 235. 
bullock’s peritoneum, 237. 
catgut, 236. 
deer-sinew, 237. 
for hemorrhage, 232. 
for naevus, 622. 
giraffe-sinew, 237. 
Lister’s, 236. 
metallic, 237. 
plaster, 237. 
removal of, 236. 
retained, 236. 
subcutaneous, for naevus, 622. 
time for separation of, 236. 
Line of demarcation in mortifi- 
cation, 194. 
in necrosis, 1063. 
Lingual artery, ligation of, 751. 
Lint, bullets of, 53. 
common or domestic, 52. 
paper, 53. 
patent, 52. 
pellets, 52. 
Lip, angeioma of, 623. 
Lipoma. See Fatty Tumors. 
Lips, wounds of, 388. 
Liquor ammoniae acetatis, 139. 
Villatte’s, 1053. 
Lister’s discoveries in antisep- 
sis, 44. 
ligatures, 236. 
tourniquet, 224. 
treatment of cold abscess, 
167. 
Liston’s forceps, 233. 
splint, 1003, 1031. 
Lithotomy, supra-pubic, blad- 
der ruptured in preparing for, 
468. 
Litter, 811. 
Littrg’s method of colotomy, 498. 
Liver, abscess of, 451. 
hydatids of, 451. 
rupture of, 450. 
wounds of, 450. 
Localization, cerebral, 383. 
Longitudinal displacement in 
fractures, 799. 
fractures, 798. 
Lonsdale’s apparatus for frac- 
tured patella, 1020. 
Loop applied to a retained liga- 
ture, 236. 
Loss of function as a sign of 
fracture, 800. 
Lotz’s enterotome, 466. 
Lower extremity, fracture of, 
971. 
wounds of, 613. 
jaw, fracture of, 879. 
apparatus for, 882-886. 
bandages for, 883. 
complications in, 882. 
delayed union in, 840, 
843, 887. 
Lumbar abscess, 158. 
colotomy, 499. 
for imperforate anus and 
rectum, 507. 
in infant, 507. 
ecchymosis, 410, 414. 
hernia, 604. 
vertebrae, fractures of, 865. 
Lung, hernia of, 415. 
mortification of, 192. 
wounds of, 408. 
Luxation of ankle with Pott’s 
fracture, 1036. 
of elbow distinguished from 
fracture, 929. 
of hip diagnosticated from a 
fracture, 984. 
of shoulder, how distinguished 
from fracture, 917. 
of wrist diagnosticated from 
fracture of lower end of 
radius, 946. 
Lymph, forms of, 111. 
Lymphatic glands, how distin- 
guishable from aneurism, 
659. 
how distinguishable from 
femoral hernia, 596. 
how distinguishable from in- 
guinal hernia, 589. 
Lymphization, 149. INDEX TO VOLUME I. 
1105 
M. 
MacBride yoke, 502, 533. 
Macewen’s hernia operation, 
563. 
MacIntyre splint, 996, 1031. 
Mackintosh cloth in asepsis, 48. 
Macleod's forceps, 186. 
Madness in proportion to bitten 
in hydrophobia, 279. 
Maggots in wounds, 254. 
Magnet in localizing needles, 
267. 
Malaeosteon, 1077. 
Malar bone, fracture of, 877. 
Malarial influences, 30. 
Malformation of abdomen,.553. 
of anus, 505. 
of sternum, 898. 
Malgaigne’s apparatus for ob- 
lique leg-fracture, 1031. 
hooks for fractured patella, 
1022. 
Malignant disease after contu- 
sions, 264. 
diagnosed from fungus cer- 
ebri, 371. 
of dura mater, 371. 
of intestine, 485. 
of rectum, 526. 
of veins, 631. 
pustule, 271. 
Malleolo-phalangeal triangle, 
85. 
Maltese-cross dressing, 55. 
Mamma, sling for, 62. 
Mammary artery, ligation of in- 
ternal, 763. 
triangle, 84. 
Mania a potu after fracture, 
821. See Delirium Tremens. 
Manila-paper splints, 815. 
Manipulation for aneurism, 676, 
700. 
for subclavian aneurism, 706. 
in the diagnosis of aneurism, 
656. 
Martin’s adhesive - plaster 
splints, 928. 
Mask for the face, 62. 
Massage after fracture, 818. 
for intestinal obstructions, 
491. 
Maxillae, fractures of, 840, 842, 
875, 879. 
Mayor’s handkerchief, 904. 
Meconial tumor, 506. 
Median ventral hernia, 604. 
Mediastinum, wounds of, 422. 
Medication for aneurism of 
aorta, 721. 
Medullary canal after fracture, 
804. 
Melanotic cancer of rectum, 527. 
Membranous occlusion of anus, 
505. 
Memory, loss of, after head-in- 
jury, 374. 
Meningitis after head-injury, 
367. 
treatment of, after skull-frac 
tures, 335. 
Menstruation, vicarious, 181. 
Mensuration in diagnosis, 32. 
Mental defects after head-in- 
jury, 374. 
in inflammation, 92. 
states in diagnosis, 29, 38. 
Mereier catheter, 871. 
Mercurials as causing necrosis, 
28, 1061. 
in inflammation, 140, 146. 
Mercury bichloride in asepsis, 
46. 
metallic, for intestinal ob- 
struction, 491. 
Mesentery, elongated, causing 
hernia, 553. 
of frog, 107, 108. 
rupture of, 442. 
Mesh for dressing, 53. 
Metacarpus, fractures of, 958. 
ununited fractures of, 841. 
Metallic ligatures, 237. 
sutures, 247. 
Metastasis in inflammation, 127. 
Metatarsal bones, fracture of, 
1045. 
Metatarso-malleolar cravat, 85. 
Miasmatic influences, 30. 
Micrococci, 154. 
forms of, 45. 
Micro-organisms causing bone- 
diseases, 1060. 
causing fermentation, 44. 
in inflammation, 95. 
in suppuration, 154. 
manner of entering the body, 
45. 
Migration of leucocytes, 109. 
Military surgery, 290. 
Milk, blue, 152. 
Mimicry in pseudo-neuralgia, 
613. 
Mindererus, spirit of, 139. 
Minie ball, 292. 
Mobility after fractures, preter- 
natural, 799. 
of bones as tending to pre- 
vent fractures, 794. 
Moist gangrene, 193. 
necrosis, 1062. 
Moles, 624. 
Molesworth’s dilator for rectal 
stricture, 530. 
Mollities ossium, 1077. 
Monro’s apparatus for fractured 
calcaneum, 1044. 
Monsel’s salt, 220, 390. 
Moore’s figure-of-eight for frac- 
tured clavicle, 905. 
Moral states in diagnosis, 29, 
38. 
Morbid changes in callus, 851. 
Mortality from strangulated 
hernia, 582. 
Mortification, 189. 
acute, 193. 
after ligating for aneurism, 
716. 
amputation for, 196, 200. 
aneurism causing, 190. 
atheroma causing, 646. 
bandages as a cause, 193. 
blood-obstruction causing, 
190. 192. 
causes of, 190. 
changes in blood as causes, 
191. 
chronic, 197, 200. 
circular, 191. 
contagious, 201. 
contusions as a cause, 263. 
defective innervation a cause, 
192. 
demarcation in, 194. 
Mortification, diabetes mellitus 
with, 192. 
diseases causing, 191. 
dry, 197. 
due to atheroma, 646. 
ergot as a cause, 192, 199. 
hemorrhage in, 196. 
hospital, 201. 
endemic, 201. 
history of, 205. 
prognosis in, 200, 203. 
sporadic, 201. 
symptoms of, 202. 
treatment of, 200, 203. 
varieties of, 201. 
in hernia, 380. 
lacerated wounds causing, 
259. 
moist, 193. 
nosocomial, 201. 
of bone, 1060. 
of bowel, 192, 380. 
of feet, 197. 
of intestine, 192, 380. 
of lungs, 192. 
of toes, 197. 
phagedsenic, 201. 
pulpy, 201. 
senile, 197. 
spontaneous, 197. 
treatment of acute, 195. 
of chronic, 200, 203. 
varieties of, 193, 201. 
wounds as causes of, 190. 
complicated by, 252. 
Mosquito-bite, 289. 
Moss-dressing in asepsis, 48. 
Mother’s mark, 617. 
Motility in diagnosis, 33, 34, 39. 
Motion in compression of brain, 
350. 
Motor points in cerebral cortex, 
382. 
region of brain, 380. 
Mouth and foot disease, 275. 
Movement after fracture, 818. 
Movements in diagnosis, 33, 34, 
39. 
Moxa in inflammation, 147. 
Muco-pus, 151. 
Mucous polypus of rectum, 520. 
Multiple abscess, 1055. 
fracture, 797. 
necrosis, 1063. 
Murrain, 271. 
Muscle, reflex paralysis of, 40. 
Muscular action as a cause of 
deformity in fracture, 798. 
as a cause of fracture, 796. 
co-ordination lost in defeca- 
tion, 511. 
movements in diagnosis, 33, 
34, 39. 
spasms after wounds, 254. 
weakness in hernia, 552. 
Musket-balls, 292. 
Muslin rollers used in fracture- 
dressing, 815. 
Mustard-plasters, 135. 
Myosarcoma, 631. 
Myriapods, bites of, 285. 
N. 
Ncfivus. See Angeiomata. 
anatomy of, 618. 
in cranial bone, 617. 1106 
INDEX TO VOLUME I. 
Naevus maternus, 617. 
treatment of, 616, 620, 622. 
Narrowed anus, 504. 
Nasal bones. See Nose. 
catarrh, 873. 
Nativity in hernia, 553. 
in varix, 655. 
Neck, nerves of, injured, 401. 
of femur, absorption of, 974. 
atrophy of, 978. 
intra-capsular fracture of, 
973. 
of humerus, anatomical, frac- 
ture in, 918. 
surgical, fractures in, 921- 
925. 
of scapula, fracture of, 916. 
wounds of, 394. 
gunshot, 400. 
Necrosis, 189, 1060. 
after compound fractures, 821. 
after fracture of the nasal 
bones, 874. 
of the upper maxilla, 877. 
causes of, 1061. 
defined, 189, 1060. 
distinguished from caries, 
1060. 
epiphyseal, 1064. 
from phosphorus, 1061. 
humid, 1062. 
multiple, 1062. 
non-suppurating, 1062. 
of cranium, 327. 
of facial bones, 392. 
of larynx, 403. 
prognosis in, 1067. 
repair in, 1065. 
sequestrum in, 1062, 1063. 
symptoms of, 1066. 
syphilitic, 1061. 
traumatic, 1061. 
treatment of, 1067. 
Needle, acupuncture, in aneu- 
rism, 678. 
Agnew’s, for hernia, 559. 
aneurismal, 735. 
Dowell’s, 561. 
exploring, 158. 
for hemorrhoids, 545. 
for hernia, 559, 561. 
hypodermic, used in acupunc- 
ture, 491. 
surgical, 246. 
Needle-gun, ball from, 292. 
Needles, detection of, 267. 
wandering of, 266. 
Negro, skin of, engrafted on a 
white man, 187. 
Neill’s apparatus for fractures, 
1029. 
Nelaton’s bullet-probe, 300. 
splint for fractured radius, 
949. 
Nerve, agency of, in inflamma- 
tion, 94, 103, 125. 
hypoglossal, pressure of, 401. 
injury of, in fracture, 820. 
paralysis after, 367. 
peroneal, pressure on, 852. 
pneumogastric, injured, 396. 
ulnar, contusion of, 613. 
Nerves, cranial, injury of, 366. 
excision of, 320. 
injury of, in fracture, 820. 
of neck, wounds of, 401. 
puncture of, 613. 
their accidental ligation, 234. 
Nerves, vaso-motor, 103. 
wounds of the, 401, 612. 
Nervous system in diagnosis, 37. 
Neuralgia after contusions, 264. 
after face-injury, 393. 
after scalp-wounds, 326. 
pseudo-, of the fingers, 613. 
Nitric acid for hospital gan- 
grene, 204. 
Nocturnal pruritus ani, 509. 
Nodes in syphilitic periostitis, 
1048. 
Nodular cicatrices, 320. 
Noma, 192. 
Non-suppurating necrosis, 1062. 
Non-union after fracture, 822, 
842. 
See Ununited Fracture. 
Norris on the migration of leu- 
cocytes, 122. 
Norris’s tables of fractures, 853- 
862. 
on the treatment of un- 
united fracture, 829-846. 
Nose, fractures of, 873. 
T bandage of, 57. 
wounds of, 388. 
Nuck, canal of, 552. 
Nuclei of epithelial cells, 124. 
Nussbaum on the vaso-motor 
centre, 104. 
0. 
Oakum for dressing, 53. 
Oblique bandage of jaw, 75. 
fractures, 797, 953, 1000. 
inguinal hernia, 585. 
intra-capsular fracture, 973. 
roller, 65. 
Oblong compress', 54, 222. 
handkerchief, 79. 
Obstruction, intestinal, 481. 
by fibrous bands, 483. 
by inflammatory lymph, 
483. 
chronic, 484. 
diagnosis of, 487. 
from cicatrices, 486. 
from foreign bodies, 484. 
from gall-stones, 486. 
from gastro - enteritis, 
486. 
from peritonitis, 484. 
from stricture, 486. 
slow, 484. 
treatment of, 489. See also 
Intestinal Obstruction. 
Obturator for piles, 544. 
hernia, 605. 
Obtuse felt splint, 935. 
Occipital artery, ligation of, 
754. 
Occipito-facial bandage, 75. 
Occipito - sternal handkerchief, 
81, 398. 
Occlusion of anus, 505. 
Occupation in diagnosis, 28. 
in inflammation, 91. 
in its relation to aneurism, 
655. 
to hernia, 552. 
Odontoid process, fracture of, 
868-870. 
(Edema in suppuration, 156. 
with aneurism, 656. 
(Edematous ulcer, 178. 
(Esophagus, diseased, gastrot- 
omy for, 439. 
wounds of, 394, 398, 428. 
Oil, cod-liver, 146, 169. 
of erigeron as a haemostatic, 
220. 
Oiled silk as dressing, 54. 
Ointment, boracic, 251. 
Old age, its effect on repair of 
bones, 822. 
Olecranon, fracture of, 953. 
Olfactory lobes, concussion of, 
874. 
Olive-shaped rectal bougie, 529. 
Omentum, changes of, in hernia, 
581. 
protrusion of, 432. 
rupture of, 442. 
wounds of, with protrusion, 
446. 
Omo-hyoid muscle in ligation 
of common carotid, 741. 
Open-air treatment in hospital 
mortification, 203. 
Open piles, 541. 
treatment of wounds, 251. 
Opening an abscess, 163. 
an aneurism, 665. 
Openings of a gunshot wound, 
294. 
Opiates for inflammation, 141. 
Orbital pulsating tumors, 710. 
Organisms, pathogenic, 154. 
saprophytic, 194. 
Organization of clot, 216, 217. 
Os calcis, fracture of, 1041. 
Ossa innominata, fracture of, 
965. 
nasi, fractures of, 873. 
Ossification, process of, 805-809. 
Osteitis, 1050. 
causes of, 1050. 
deep, 1050. 
deformans, 1060. 
from microbes, 1060. 
pathology of, 1051. 
prognosis of, 1052. 
treatment of, 1052. 
Osteoclasts, 1051. 
Osteomalacia, 1077. 
age in, 1078. 
causes of, 1078. 
diagnosis from rickets, 1081. 
pathology of, 1079. 
sex in, 1078. 
symptoms of, 1080. 
treatment of, 1081. 
Osteomyelitis, 1056. 
carnification from, 1056. 
prognosis in, 1058. 
symptoms of, 1057. 
treatment of, 1058. 
Osteophytes, 1050. 
Osteoporosis, 1060, 1083. 
Osteotomy, subcutaneous, 849. 
Ovarian dropsy discriminated 
from ascites, 478. 
fistula at umbilicus, 476. 
Overlapping in fracture, 847, 
926, 939, 1027. 
P. 
Pad, axillary, for broken clavi- 
cle, 906. 
Pads for dressing fractures, 814, 
815. INDEX TO VOLUME I. 
1107 
Packard’s bracketed splint, 
1012. 
Paget, Sir James, on inflamma- 
tion, 119. 
Pagliari’s styptic, 220. 
Pain in diagnosis, 39. 
in fracture, 800. 
in lung-wounds, 410. 
in suppuration, 155. 
in wounds, 254. 
varieties of, 172. 
Painful cicatrices, 320. 
Palmar abscess, 611. 
arch, superficial, 612. 
aneurism of, 718. 
fascia, 611. 
triangle, 84. 
Pancreas, cysts of, 457. 
wounds of, 456. 
Pancreatectomy, 457. 
Paper lint, 53. 
splints, 815. 
waxed, 54. 
Papillae, hypertrophied, in ul- 
cers, 172. 
Papillomata at anus, 509. 
of umbilicus, 475. 
Paquelin cautery in hemor- 
rhage, 225. 
Paracentesis abdominis, 478. 
pericardii, 426. 
thoracis, 419. 
Paralysis after nerve-injury, 
367. 
after shot wounds of neck, 
401. 
facial, 393. 
from callus, 852. 
from fracture of humerus, 
928. 
of vertebrae, 865, 866, 867, 
868, 871. 
in diagnosis, 40. 
in hydrophobia, 282. 
its effect on repair of bones, 
823. 
of digital extensors,—wrist- 
drop, 927. 
peristaltic, in hernia, 573. 
reflex, 40. 
ulcer following, 188. 
Paraplegia, 865, 871. 
Paresis in diagnosis, 39. 
Parieto-axillaris cravat, 82. 
Parotid fistula, 392. 
Paste, Canquoin’s, 637. 
Vienna, 637. 
Ward’s, 543. 
Pasteur’s discoveries as to causes 
of fermentation, 44. 
treatment of hydrophobia, 
284. 
Patella, compound fracture of, 
1018. 
fracture of, 1012. 
splint for, 1015-1018. 
ununited fractures of, 841,845. 
Patent lint, 52. 
Patient, transportation of, after 
fracture, 810. 
Peat dressing in asepsis, 48. 
Pectoral fascia, 766. 
Pellets, 52. 
Pelvis, contusions of, 466. 
fractures of, 962. 
wounds of, 466. 
Penetrating wounds of abdo- 
men, 431. 
Penis, spiral reversed of, 67. 
Pennies swallowed, 434. 
Pennsylvania Hospital fracture- 
tables, 829-846, 853-862. 
Perchloride of iron as a styptic, 
220. 
in aneurism, 677. 
in varix, 638. 
Perforated compress, 54. 
T bandage, 59. 
tin splint, 812, 1031. 
Perforating ulcer, 189. 
Perforation of appendix vermi- 
formis, 498. 
of caecum, 498. 
Peri-anal abscess, 535. 
Pericardium, dropsy of, 425. 
paracentesis or tapping of, 
426. 
wounds of, 422. 
Pericranium, contusion of, 326. 
Perineal hernia, 607. 
Perineo-anal fistula, 536. 
Perineo-rectal fistula, 536. 
Perinephritic abscess after ab- 
dominal wounds, 460. 
Perineum, quilled suture for, 
249. 
Periostitis, 1047. 
acute, 1048. 
chronic, 1047. 
circumscribed, 1047. 
diffused, 1048. 
infective, 1048. 
syphilitic, 1048, 1049. 
Peri-rectal abscess, 535. 
Peristaltic paralysis in hernia, 
573. 
Peritoneum, bullock’s, for liga- 
tures, 237. 
for plasters, 246. 
opening the, 776. 
retractor for, 776, 777. 
Peritonitis, acute, 484. 
following strangulated her- 
nia, 511. 
obstruction of bowels from, 
484. 
traumatic, 432. 
tubercular, serous abdominal 
effusion from, 480. 
Perityphlitis, 496. 
Permanently irreducible hernia, 
566. 
Peroneal artery, ligation of, 
790. 
surgical anatomy of, 790. 
nerve, foot-drop from pressure 
on, 852. 
Persian fire, 271. 
Petit’s tourniquet, 223. 
Petitgand irrigating tube, 130, 
Phagedsena complicating 
wounds, 253. 
gangraenosa, 201. 
Phagedasnic wounds, 253. 
Phalanges, fractures of, 960. 
of toes, 1045. 
Pharynx, wounds of, 394, 398. 
Philadelphia atomizer, 132, 
Phlebectasis, 631. 
Phlebitis, 627. 
acute, 628. 
causes of, 627. 
chronic, 630. 
diagnosis, 628. 
diffuse, 629. 
following low fevers, 627. 
Phlebitis from ligation of veins, 
627. 
from thrombus, 628. 
idiopathic, 627. 
pathology of, 628. 
septic, 627. 
symptoms of, 628. 
traumatic, 627. 
treatment of, 629, 630. 
Phleboliths, 631. 
Phlebotomy, 133, 137. 
Phlegmatic temperament, 30. 
Phlegmonous abscess, 101. 
Phosphorus as a cause of ne- 
crosis, 28, 1061. 
Phrenic nerve, wounds of, 
396. 
Phthisis, fistula in ano with, 
537, 540. 
pulmonalis after chest- 
wounds, 411. 
Physick’s splint, 1005. 
treatment for ununited frac- 
ture of humerus, 826. 
Pia mater, blood-extravasation 
from, 355. 
Piles, 540. See also Hemor- 
rhoids. 
blind, 541. 
clamp for, 546. 
inflamed, 542. 
ligature for, 548. 
obturator for, 544. 
Pill, Tanjore, 288. 
Pin suture, 248. 
Pins for nsevus, 621. 
wandering of, 266. 
Pistol balls, 292. 
Pitting in dropsy, 477. 
Plantar artery, aneurism of, 
733. 
Plaster, adhesive, in fractures, 
815. 
court, 246. 
ichthyocolla, 246. 
in approximating wounds, 
244. 
mustard, 135. 
skin, 246. 
Plaster-of-Paris dressings, 814. 
Pledget, 53. 
Pleura, catheter in, 421. 
wounds of, 416. 
Pleurisy after chest-wounds, 
416. 
Plications of neck of hernial 
sac, 568. 
Pliers, bone, 1069. 
for cutting immovable frac- 
ture-dressings, 815. 
Plug, rectal, 510. 
Pneumatic aspiration, 251. 
Pneumocele, 415. 
Pneumogastric nerve, wounds 
of, 396. 
Pneumonia after chest-wounds, 
416. 
Pneumothorax in chest-wounds, 
409, 415. 
Pointing of pus, 156. 
Poison-apparatus of bee, 289. 
of serpent, 286. 
of spider, 284. 
Poisoned wounds, 267. 
from insects, 289. 
from reptiles, 284. 
Poisoning, septic, in mortifica- 
tion, 194. 1108 
INDEX TO VOLUME I. 
Polypus following fracture of 
nasal bones, 875. 
of rectum, 520. 
Popliteal artery, aneurism of, 
651, 730. 
acupressure for, 731. 
compression of, 730. 
diagnosis of, 730. 
double, 732. 
ligation for, 731, 787, 
788. 
mortification in, 732. 
surgical anatomy of, 787. 
Porte-moxa, 148. 
Position in approximating 
wounds, 243. 
in treating inflammation, 
128. 
Posterior eight for fractured 
clavicle, 910. 
Posterior tibial artery, ligation 
of, 788. 
surgical anatomy of, 788. 
Post-mortem wounds, 268. 
Potain’s aspirator, 168. 
Pott’s fracture, 1036. 
splint, 1043. 
Poupart’s ligament, 584, 593. 
Pourriture d’hopital, 201. 
Prsefrontal lobe of brain, 379, 
382. 
Pregnancy, diagnosis from as- 
cites, 477. 
Premature atheroma, 642, 653. 
Pressure for retaining hemor- 
rhage, 222. 
in treating aneurism. See 
Compression. 
Preternatural mobility after 
fracture, 799. 
Priapism in hydrophobia, 282. 
Primary adhesion, 316. 
amputation, 305, 312. 
cellular tissue, 316. 
Primitive carotid. See Carotid, 
Common. 
iliac. See Iliac, Common. 
Prismatic compress, 54. 
Probe, 300. 
Agnew’s spiral, 1053. 
eyed, 735. 
silver, 1053. 
spiral wire, 1053. 
wire, 1053. 
Process of ossification, 805-809. 
Processes of ulna, 951. 
of vertebras, 864. 
Procidentia ani et recti, 516. 
Profunda femoris, aneurism of, 
729. 
Projectiles, 291. 
Prolapsed hemorrhoids, 541. 
Prolapsus ani et recti, 516. 
excision of, 520. 
Properitoneal hernia, 573, 607. 
Prostate body, wounds of, 471. 
Prostration accompanying gan- 
grene, 194. 
Protective, 54. 
in asepsis, 48. 
Protoplasm of a fibre-sheath, 
114. 
Protrusion of bowel, 516. 
Provisional callus, 803, 806, 808. 
dressings, 78. 
Proximal ligation for aneurism, 
700. 
Pruritus ani, 509. 
Pseudarthrosis, 822. 
femoris, danger from using 
the seton in, 826. 
tabular statements regarding 
its treatment, 829-846. See 
Ununited Fracture. 
Pseudo-neuralgia of fingers, 613. 
Psoas abscess, diagnosis from 
femoral hernia, 597. 
from hernia, 158. 
Ptomaines, 46. 
Pubis, fracture of the, 966. 
Pudendal hernia, 606. 
Puffy tumor, 330. 
Pulley in fracture, 993. 
Pulmonary apoplexy, 409. 
artery, atheroma of, 644. 
Pulpy gangrene, 201. 
Pulsating encephaloid distin- 
guished from aneurism, 659. 
orbital tumors, 710. 
Pulsation of the aorta, abnor- 
mal, 719. 
Pulse in compression of brain, 
350. 
in diagnosis, 35. 
Pump-apparatus for cupping, 
133. 
Puncture of hernia, 579. 
of nerves, 613. 
Punctured fractures of skull, 343. 
wounds, 265. 
of abdomen, 430. 
Pupils in compression of brain, 
350. 
Purulent catarrh of the conjunc- 
tiva, 115. 
Pus, 150. 
absorption of, 155. 
blue, 152. 
cells, 107, 121. 
cheesy, 166. 
contagious, 151. 
corpuscles of, 151. 
diagnosis of, 152 
from ulcers, 176. 
gummy, 151. 
in blood, 94. 
laudable, 151. 
microscopy of, 150. 
origin of, 152. 
sanious, 151. 
scrofulous, 151. 
tests for, 151. 
varieties of. 152. 
Pustule, malignant, 271. 
Putrefaction, chemical process 
of, 194. 
Putrid ulcer, 201. 
Pyaemia after head-injury, 374. 
after osteomyelitis, 1058. 
after shot wounds of neck, 403. 
Pylorectomy, 437. 
Pylorus, digital dilatation of, 
437. 
stenosis of, 436. 
Pyocyanine, 152. 
Pyogenic membrane, 153. 
Pyothorax, 411. 
Pyramidal compress, 54, 222. 
Pyriform hernial sac, 551. 
Q. 
Quiet, its therapeutic value, 128. 
Quilled suture, 249. 
Quinine in inflammation, 142. 
R. 
Rachitis, 1073. 
age in, 1073. 
bones in, 1075. 
causes of, 1074. 
diagnosis from osteomalacia, 
1081. 
food in, 1073. 
pathology of, 1073. 
prognosis in, 1076. 
sex in, 1073. 
skeleton in, 1075. 
symptoms of, 1074. 
treatment of, 1076. 
Radial artery, its anastomosis 
with the ulna, 775. 
ligation of, 772. 
surgical anatomy of, 772. 
Radiating fracture of the skull, 
336. 
Radius and ulna. See Forearm. 
fractures of, 937, 941. 
treatment of ununited frac- 
ture of, 832, 833, 841, 843. 
un uni ted fractures of, 841, 
843. 
Rami of the innominate bone, 
fracture of, 996, 997. 
Rarefaction of bone, 1060. 
Ratchet splint, 928. 
Rattlesnake-bite, 286. 
Rectal accumulations, 514. 
bougie, 529. 
chemise, 549. 
hemorrhage, 473. 
obturator, 544. 
plug, 510. 
pouches, dilatation of, 516. 
specula, 503. 
splint, 964. 
Rectangular splint, 935. 
Rectum, abnormal termination 
of, 505. 
absence of, 505. 
Allingbam’s plug for, 510. 
bleeding from, 473. 
carcinoma of, 526. 
colotomy for, 498. 
encephaloid, 528. 
epithelial, 527. 
melanotic, 527. 
scirrhous, 527. 
treatment of, 532. 
catarrh of, 522. 
“encysted,” 516. 
epithelioma of, 527. 
excision of, 532. 
colotomy prior to, 534. 
of prolapsed, 520. 
foreign bodies in, 514. 
gunshot wounds of, 473. 
impacted fames in, 514. 
inflammation of, 522. 
gonorrhoeal, 522. 
irritable, 516. 
malformation of, 504. 
obturator for, 544. 
opening into bladder, 508. 
into urethra, 508. 
into vagina, 506, 508. 
polypus of. 520. 
position for examination of, 
502. 
prolapsus of, 516. 
sarcoma of, 527. 
scirrhus of, 527. 
stricture of, 524. INDEX TO VOLUME I. 
1109 
Rectum, stricture of, division of, 
531. 
electricity for, 532. 
malignant, 526. 
spasmodic, 524. 
syphilitic, 531. 
treatment, 528. 
of malignant, 532. 
ulceration of, 522. 
wounds of, 472. 
gunshot, 473. 
Recumbent treatment of broken 
olavicle, 910. 
Recurrent bandage of head, 
76. 
for amputations, 76. 
Redness in inflammation, 96, 
105. 
in suppuration, 155. 
Redundancy of callus, 851, 852. 
Reef-knot, 235. 
Reflex paralysis, 40. 
Refracture of bones, 849, 850. 
Relaxation suture, 249. 
Removal of clothing after frac- 
ture, 812. 
Renal aneurism, 722. 
cyst, 499. 
fistula, 476. 
wounds, 458. 
Repair in compound commi- 
nuted fractures, 809, 
in compound fractures, 809. 
of bone, 805-809. 
of bones, delayed, 822. 
of cartilage, 809. 
of fractured bones, 801. 
of wounds, 317. 
Reptiles, bites of, 284, 286. 
Resection. See Excision. 
of colon, 501. 
of intestines, 449. 
Residence in diagnosis, 30. 
Residual abscess, 166. 
Resolution of inflammation, 127. 
Respiration in compression of 
brain, 350. 
in diagnosis, 36. 
Rest in treating inflammation, 
128. 
Restoration of function after 
fracture, 817. 
Retained ligature, 236. 
Retentive dressings in fracture, 
812. 
Retraction of wounds, 254. 
Retractor, 735. 
for peritoneum, 776, 777. 
Retractors with tails, 55. 
Retroclusion, 230. 
of hernia, 562. 
Rheumatism, its effect on the 
repair of bones, 823. 
Rhus toxicodendron, poison 
from, 94. 
Ribs excised for empyema, 421. 
fractures of, 891. 
ununited fractures of, 840. 
Richardson’s styptic colloid, 
246. 
Rickets. See Rachitis. 
Rifle-ball, 292. 
Right lumbar eolotomy, 500. 
Rigidity of joints after fracture, 
817. 
Ring, femoral, 594. 
inguinal, 560, 568, 584. 
Ring sequestra, 1066. 
Rokitansky on inflammation, 
119. 
Roll for dressing, 53. 
Roller bandage, 62. 
in asepsis, 49. 
directions for applying, 64. 
for approximating wounds, 
243. 
spiral reversed, 66. 
French, 68. 
varieties of, 64. 
Velpeau’s, for fractured clavi- 
cle, 904. 
Rollers of muslin used in dress- 
ing fractures, 815. 
special, 65. 
Ropy pus, 151. 
Rotatory displacement after 
fracture, 847. 
Rouger forceps, 376. 
Rubber bougies, 528. 
cloth, 54. 
as dressing, 54. 
drainage-tubes, 242. 
plaster, 245. 
splints, 885. 
suture, 249. 
syringes, 504. 
trusses, 556, 590. 
Rupture of abdominal walls, 
433. 
of axillary aneurism, 717. 
of bladder, 468. 
of gall-bladder, 452. 
of heart, 423. 
of intestine, 442. 
in hernia, 574. 
of liver, 450. 
of mesentery, 442. 
of omentum, 442. 
of pancreas, 457. 
of spleen, 455. 
of stomach, 440. 
Ryneck on inflammation, 122. 
S. 
Sabre wounds, 315, 358. 
Sac, aneurismal, 648. 
hernial, 551, 563, 568. 
Sacculated aneurism, 648, 651. 
Saeer ignis, 271. 
Sacro-rectal hernia, 607. 
Sacrum, fractures of, 962. 
shot wounds of, 467. 
Salicylic acid in asepsis, 260. 
Salicylized cotton in asepsis, 49. 
Salivary calculus, 391. 
fistula, 390. 
after face-injury, 390. 
Salter’s cradle, 1028. 
Sand-bags, 815. 
Saphena interna, varix of, 635. 
magna, varix of, 632. 
Saprophytic protophytes in mor- 
tified tissues, 194. 
Sarcocele distinguished from in- 
guinal hernia, 589. 
Sarcoma of rectum, 527. 
Saw, Adams’s, 849. 
circular, 1070. 
subcutaneous, 849. 
Sawdust dressing in asepsis, 
48. 
Sayre’s dressing for broken clav- 
icle, 906. 
Scabbing, 319. 
Scalp, anatomy of, 322. 
aneurismal varix of, 615. 
caput suceedaneum of, 323. 
contusions of, 322. 
depressions of, 341. 
everted during labor, 324. 
evulsion of, 324. 
gunshot wounds of, 325, 357. 
surgical anatomy of, 322. 
varix of, aneurismal, 615. 
wounds, 323. 
abscess after, 324. 
epilepsy after, 326. 
erysipelas after, 325. 
neuralgia after, 326. 
suppuration after, 324. 
Scalpel, 735. 
Scapula, fractures of, 911-917. 
acromial, 913. 
complete, 912. 
coracoid, 915. 
glenoid cavity of, 916. 
incomplete, 912. 
neck of, 916. 
prognosis of, 913, 914, 916. 
symptoms of, 912, 914, 915, 
917. 
transverse, 912. 
treatment of, 913, 914, 916, 
917. 
varieties of, 912. 
Scar-tissue, diseases of, 320. 
Scarification, 133. 
Scarpa’s triangle, anatomy of, 
784, 785. 
in femoral aneurism, 728, 
729. 
Scirrhus of rectum, 527. 
Sclerosis of bone, 1059. 
Scolopendra wounds, 286. 
Scorbutic disease as delaying the 
repair of bones, 822. 
Scorpion, bite of, 285. 
Screw, Stromeyer’s, 934. 
Screw-elevator for depressed 
bone, 878. 
Scrofulous abscess, 165. 
pus, 151. 
Scrotal hernia, 586. 
Scroto-lumbar suspensory tri- 
angle, 88. 
Scurvy, causes of, 94. 
Sea-tangle as a compressor, 406. 
Second intention, 316, 319. 
Secondary amputation, 305, 312. 
hemorrhage, 253. 
in gunshot wounds, 297, 
304. 
Sections of ligated arteries, 216- 
219. 
Semi-cuneiform compress, 55. 
Senile atheroma, 642. 
atrophy, neck of the femur, 
978. 
gangrene, 197. 
Senn’s hydrogen gas test for in- 
testinal wounds, 445. 
Sensations in diagnosis, 38. 
Sensibility, disorders of, after 
fracture, 801. 
in compression of brain, 350. 
Sensitive callus, 852. 
Sensory region of brain, 381. 
Separation of an epiphysis, 
921. 
Sepsin, 46. 
Septic matters a cause of phle- 
bitis, 627. 1110 
INDEX TO VOLUME I. 
Septicaemia accompanying gan- 
grene, 194. 
Sequels of abdominal wounds, 
460. See also names of va- 
rious diseases and injuries. 
Sequestrum, 189, 1063, 1064. 
cylindrical, 1064. 
expulsion of, 1065. 
removal of, 1068. 
ring, 1066. 
tubular, 1066. 
Serous transudation, 149. 
Serpent-bites, 286. 
Serrated process, 234. 
Serres-fines, 232. 
Serum, intracranial extravasa- 
tion of, 356. 
Seton for fistula in ano, 539. 
for parotid fistula, 392. 
in inflammation, 147. 
in pseudarthrosis, 826, 838, 
839. 
needle, 147. 
Settee used as a litter, 810. 
Setting of fractures, 816. 
Sex in hernia, 552. 
in inflammation, 91. 
in surgical diagnosis, 27. 
Shaft of the humerus, fractures 
of, 925. 
Sharp-pointed bistoury, 164. 
Sheepskin and slat splints, 813. 
Shells, 292. 
Shell wound of knee, 313. 
Shock after wounds, 262, 306. 
as delaying repair of bones, 
822. 
in gunshot wounds, 297. 
Shortening in and after frac- 
tures, 799, 847. 
Shot compressor, 247. 
suture, 247. 
united by heat, 291. 
varieties of, 292. 
Shoulder, cap for, 85, 924. 
spica of, 70. 
triangular cap for, 85. 
Shoulder-joint, amputation for 
shot wounds, 307. 
excision for shot wound in, 
307. 
plans of treating shot wounds 
in, compared, 307. 
Shrapnel, 292. 
Signal-bell, De Wilde’s, 300. 
Signorini’sherniaoperation,558. 
tourniquet, 224, 671. 
Signs of fracture, 798. 
Silicate dressings, 814. 
Silkworm-gut in asepsis, 47. 
Silver probe, 300, 1053. 
sutures, 246. 
wire ligatures, 237. 
Silver-fork deformity after frac- 
ture of lower end of radius, 
946. 
Simple fractures, 796. 
Simpson’s acupressure methods, 
229. 
Sims’s speculum, 504. 
Sinapisms, 135. 
Single roller, 63. 
T bandage, 56, 58. 
Sinuses in wounds, 254. 
wounds of cranial, 356. 
Six-tailed sling, 61. 
Skey’s abdominal tourniquet, 
224. 
Skin-grafting, 185. 
plaster, 246. 
Skull, crush of, 361. 
depressed fractures of, 339, 
341. 
diagnosis of, 341. 
depressed, treatment of, 342. 
depression without fracture 
of, 341. 
fractures of, 331. 
comminuted, 342. 
compound, treatment of, 
342. 
depressed, 360. 
gunshot, 358. 
of base, 336. 
of external table, 340. 
of internal table, 340. 
punctured, 343. 
simple, 358. 
treatment of, 335, 342. 
trephining in, 375. 
injuries, epilepsy after, 372. 
sequels of, 367-375. 
treatment of, 375. 
penetrating shot wound of, 
360. 
separation of sutures of, 343. 
Slat and sheepskin splints, 
813. 
Slings, 60. 
for clavicle, 904, 905, 906, 
908. 
for humerus, 925, 928. 
four-tailed, 60, 62. 
six-tailed, 61. 
Slough, 189. 
Sloughing after wounds, 259, 
261. 
ulcer, 178. 
Slow ball, 295. 
Smell in diagnosis, 35. 
loss of, after nasal fracture, 
874. 
Smith’s apparatus for ununited 
fracture, 825. 
clamp for piles, 546. 
wire splints, 997. 
Snake-bites, 286. 
Snider bullet, 292. 
Social condition in diagnosis, 
30. 
Softening of bones, 1077. 
Soluble glass dressings, 813. 
Spanish windlass, 223. 
Spasmodic cough after shot 
wounds of neck, 402. 
rectal stricture, 524. 
Spasms of muscles after wounds, 
254. 
Special fractures, 862. 
Speculum for anus, 503. 
Spent ball, 295. 
Spermatic artery and cord 
wounded, 431. 
Sphacelus, 189. 
Spherical case shot, 292. 
Sphincter ani ruptured in defe- 
cation, 472. 
Sphincterismus of anus, 511. 
Spica bandages, 69. 
bandage of foot, 71. 
of groin, 70. 
with cravat, 87. 
of shoulder, 69. 
of thumb, 72. 
Spider-bites, 284. 
Spier’s artery-compressor, 231. 
Spinal column, fractures of, 862. 
Spindle-shaped material in re- 
pair of fractures, 803. 
in repair of wounds, 317. 
Spine. See Vertebral Column. 
Spinous processes, fractures of, 
863. 
Spiral reversed rollers, 65 
bandage of arm, 66. 
of fingers, 67. 
of hand, 67. 
of leg, 68. 
of penis, 67. 
Spirilla, forms of, 45. 
Spleen, abscess of, 456. 
floating, 456. 
hypertrophied, in leucocythaj- 
mia, 455. 
removal of, 456. 
rupture of, 455. 
wounds of, 455. 
Splenectomy, 456. 
Splint, Agnew’s, 930. 
Ahl’s, 813. 
Amesbury’s, 1002. 
angular, 924, 927. 
anterior angular, 930, 934. 
wire, 997. 
Bavarian, 1034. 
Bean’s interdental, 886. 
Bell’s, 1002. 
binders’ board, 812, 813,1030. 
Bond’s, 950. 
Boyer’s, 1004. 
bracketed, 1012. 
Buck’s, 1008. 
concave, 927. 
Coover’s, 951. 
Desault’s, 1004, 1005. 
double angular, 1043. 
Dupuytren’s, 1037. 
extension, 1012. 
felt, 813, 935. 
for carpus and metacarpus, 
960. 
for deformity after fracture, 
848. 
for fracture, 812, 813. 
of lower extremity of hu- 
merus, 934. 
of shaft of humerus, 927. 
for lower jaw, 882, 885, 886. 
for phalanges, 961. 
Gibson’s, 1008. 
Gunning’s, 885. 
Hartshorne’s, 1006. 
Hays’s, 950. 
Hodge’s, 1006. 
Horner’s, 1007. 
Hutchinson’s, 1005. 
immovable, 1034. 
interdental, 885. 
James’s, 1002. 
Kingsley’s interdental, 885. 
Levis’s, 951. 
Liston’s, 1003, 1031. 
MacIntyre’s, 1031. 
N baton’s, 949. 
Packard’s, 1012. 
perforated, 812. 
Physick’s, 1005. 
Pott’s, 1043. 
rectal, 964. 
rectangular, 935. 
rubber, 885. 
slat and sheepskin, 813. 
Smith’s anterior wire, 997. 
tin, 812. INDEX TO VOLUME I. 
Splint, trough-shaped, 935. 
wire, 813, 997. 
wooden slat, 813. 
zinc, 812. 
Sponges, aseptic, 47. 
Spontaneous aneurism, 647. 
cure of aneurism, 660. 
Spray, apparatus for, 49. 
in asepsis, 49. 
Spreading gangrene, 201. 
Spring forceps, 232. 
Springfield rifle-ball, 292. 
Spurious cicatrization, 320. 
Square cap, 79. 
handkerchief, 79. 
Stagnation of blood, 107. 
Stanchion in fracture of thigh, 
999. 
Starch dressings, 813. 
Stasis in inflammation, 107. 
Statistics of carotid aneurism, 
700. 
of compression of abdominal 
aorta for aneurism, 722. 
of fractures, 853-862. 
of ligation in aneurism of 
femoral, 728. 
of axillary for aneurism, 
715, 716. 
of common carotid, 744- 
749. 
of primitive iliac for aneu- 
rism, 726. 
of subclavian artery, 759, 
760, 761. 
of popliteal aneurism, 730, 
731. 
of ununited fracture, 830-842. 
Steam atomizer, 132. 
Stellated fracture, 797. 
of glenoid cavity of scapula, 
917. 
Steno’s duct, 390. 
Stenosis of pylorus, 436. 
Stercoraceous fistula at umbi- 
licus, 476. 
vomiting, 482. 
Sterilized water in asepsis, 47. 
Sternum, fracture of, 896. 
Stethoscope in aneurism, 656, 
697, 714. 
Stiffness of joints after fracture, 
817. 
Stimulants in inflammation, 
142. 
Stings of insects, 289. 
Stocking, elastic, 636. 
Stomach, closure of openings in, 
439. 
fistula of, 461. 
made into, 439. 
foreign bodies in, 434. 
pyloric stenosis of, 436. 
rupture of, 440. 
sutured to intestine, 438. 
wounds of, 440. 
Stomata between cells, 125. 
Stone in bladder, 469. 
Stones in gall-bladder, 453. 
Strangulated hernia, 567. 
taxis too prolonged in, 583. 
Strangulation, intestinal, 483. 
Strapping of ulcers, 183. 
Strieker on inflammation, 122. 
Stricture, hernial, 568, 575. 
of intestine, 485. 
of rectum, 524. 
divulsion of, 530. 
Stricture of rectum, fibrous, 525. 
malignant, 526. 
syphilitic, 531. 
seat of, in strangulated her- 
nia, 568. 
Stromeyer screw, 934. 
Stump in mortification, 195. 
Stumps, bandages for, 77. 
Styloid process of ulna, fracture 
of, 957. 
Styptic collodion, 246. 
Monsel’s, 220, 390. 
Styptics, 220. 
Subclavian aneurism, 703. 
artery, ligation of, 756. 
surgical anatomy of, 756. 
wounds of, 396, 427. 
Subcutaneous irritation for un- 
united fracture, 826. 
ligation of naevus, 222. 
section of bone, 849. 
wounds, 256. 
Subfemoral handkerchief, 88. 
Sublimate, corrosive, in asepsis, 
46. 
gauze, 48. 
Submucous venous angeioma, 
619. 
Subsulphate of iron, 220. 
Sugar in urine after injury, 374. 
Suicidal throat wounds, 394, 
397. 
Superficial palmar arch, 612. 
aneurism of, 718. 
volar artery, aneurism of, 
718. 
Superior epiphysis of humerus, 
fracture or separation of, 
921. 
maxilla, fractures of, 875. 
thyroid artery, ligation of, 
750. 
Suppuration, 150. 
after scalp wounds, 324. 
bone-, 1054. 
causes of, 153. 
circumscribed, 101, 1054. 
complicating wounds, 252. 
constitutional signs of, 156. 
diagnosis of, 157. 
diffused, 158, 1054. 
divisions of, 158. 
fluctuation in, 156. 
micro-organisms in, 154. 
persistent, 252. 
pointing in, 156. 
signs of, 155, 156. 
superficial, 158. 
symptoms of, 159. 
theories of, 152. 
tissues furnishing, 154. 
treatment of, 159. 
value of, 155. 
Suppurative appendicitis, 496. 
typhlitis, 496. 
Supra-eondylar fractures of hu- 
merus, 929. 
Supra-pubic lithotomy, rupture 
of bladder in preparing for, 
468. 
Supra-renal capsule, wounds of, 
458. 
Surface expression in diagnosis, 
31. 
Surgeon’s knot, 235. 
Surgical anatomy. See Anat- 
omy, Suryical. 
diagnosis, 25. 
Surgical dressings, 52. 
engine, 1070. 
fever, 101. 
neck of humerus, fracture 
through, 921-925. 
needles, 246. 
Suspensory dressing for the 
breast, 77. 
triangle, scroto-lumbar, 88. 
Sustentaculum tali, fracture of, 
1044. 
Suture, 246. 
button, 249. 
catgut, 246. 
continued, 247. 
cranial, 348. 
Czerny-Lembert, 449. 
diagonal, 247. 
frontal, fracture through, 343. 
glover’s, 247. 
interrupted, 246. 
intestinal, 441. 
Lembert’s, 447, 449. 
metallic, 247. 
of skull, separation of, 343. 
pin, 248. 
quilled, 249. 
relaxation of, 249. 
removal of, 247, 248. 
rubber, 249. 
shot, 247. 
thread, 248. 
twisted, 248. 
wire, 247. 
Swelling in suppuration, 156. 
Sword wounds, 315, 358. 
Syphilis as a cause of aneurism, 
653. 
its effect on repair of bones, 
823. 
Syphilitic necrosis, 1061. 
stricture of rectum, 531. 
Syringe, Davidson’s, 490. 
fountain, 490. 
hard-rubber, 504. 
hydrostatic, 490. 
hypodermic, 142. 
in aneurism, 677. 
T. 
Table of ligations of primitive 
iliac, 781-783. 
Tables showing the results of 
treatment in ununited frac- 
ture, 829-841. 
Tampon, rectal, 510. 
Tanjore pill, 288. 
Tapping after chest wounds, 419. 
for ascites, 478, 479. 
of pericardium, 426. 
Tarantula, bite of, 285. 
Tardy union, 822. 
Tarsal bones, fracture of, 1040. 
Tarso-patellar cravat, 86. 
Taxis for hernia, 571, 591, 598, 
602. 
how long to persist in, 583. 
T bandages, 56. 
of abdomen, 58. 
of buttock, 59. 
of ear, 56. 
of groin, 59. 
of hand, 59. 
of head, 57. 
of nose, 57. 
of thorax, 58. 1112 
INDEX TO VOLUME I. 
Teeth, wiring of, in fracture, 
884. 
Telangiectasis, 617. 
Temperament in diagnosis, 30. 
in inflammation, 90. 
Temperature in diagnosis, 34, 
36. 
in inflammation, 98. 
Temporal artery, ligation of, 
755. 
Tenaculum, 234, 610. 
Tendo Achillis, 1042. 
Tenotomy, 1042. 
Tents, 52. 
Testicle, undescended, distin- 
guished from inguinal hernia, 
589. 
Tetanus after gunshot wounds, 
298. 
after head-injury, 375. 
after lacerated wounds, 259. 
after ligation for aneurism, 
668. 
Thanatophidia, 286. 
Thecal suppuration, 259. 
Thermo - cautery, Paquelin’s, 
226. 
Thermometer, clinical, 36. 
Thermometry, 36. 
in inflammation, 101. 
Thigh. See Femur. 
Thillaye’s apparatus for the cal- 
caneum, 1044. 
Third intention, 316. 
Thomassin’s bullet-forceps, 301. 
Thoracentesis, 419. 
Thoracic duct, wounds of, 428. 
Thorax, fistula of, 422. 
fractures of bones of, 891. 
T bandage of, 58. 
wounds of, 404. 
penetrating, 407. 
vessels of, 426. 
Three-tailed retractor, 56. 
Thrill in aneurism, 697, 714. 
Thrombosis, 190. 
as a cause and an effect of 
phlebitis, 628. 
from atheroma, 645. 
Thrombus in arresting hemor- 
rhage, 215. 
Thumb, evulsion of, 257. 
Thyroid artery, inferior, liga- 
tion of, 763. 
superior, ligation of, 750. 
cartilage, wounds of, 889. 
enlargement, diagnosis from 
aneurism, 698. 
hernia, 605. 
Tibia, fractures of, 1032. 
and fibula, fractures of, 1023. 
compound, 1038. 
epiphyseal, 1032. 
ununited fracture of, 836,837, 
838, 839, 841, 844, 845. 
Tibial arteries, aneurism of, 732. 
artery, anterior, ligation of, 
791. 
surgical anatomy of, 791. 
artery, posterior, ligation of, 
surgical anatomy of, 788. 
788. 
Tibio-cervical handkerchief, 86. 
Time for setting fractures, 816. 
Tin irrigating vessel, 129. 
splints, 813, 1031. 
Tissue, destruction of, in ulcer- 
ation, 171. 
Toes, fracture of, 1045. 
Tongue in diagnosis, 40. 
Tonics in inflammation, 142,146 
Topography of brain, 379. 
of hand, 612. 
Torsion in hemorrhage, 226. 
Torsion-forceps,. 226. 
Torsoclusion, 230. 
Torticollis after shot wounds, 
403. 
Touch in diagnosis, 34, 38. 
Tourniquet, 735. 
abdominal, 224. 
Bellingham’s, 672. 
Briddon’s, 673. 
Carte’s, 672. 
Charriere’s, 673. 
Gibbons’s, 673. 
Gross’s, 224. 
in aneurism, 671. 
Lister’s, 224. 
Petit’s, 223. 
Signorini’s, 224, 671. 
Skey’s, 224. 
Watson’s, 672. 
Towels, aseptic, 47. 
Trachea, fracture of cartilage 
of, 889. 
gunshot wounds of, 394. 
wounds of, 394. 
Tracheotomy in aneurism, 690. 
in hydrophobia, 284. 
Transfusion, 239. 
immediate, 239. 
mediate, 240. 
Translucency in diagnosis, 33. 
Transplantation operation for 
hernia, 564. 
Transportation of a patient with 
a fracture, 810. 
Transudation of cells, 108. 
Transverse cervical artery, aneu- 
rism of, 707. 
fractures, 798. 
of scapula, 912. 
processes, fracture of, 864. 
Trap-door flap, 339. 
Traumatic aneurism, 683. 
diabetes after head-injury, 
374. 
fever, 101. 
necrosis, 1061. 
peritonitis, 432. 
pleurisy, 416. 
Traumatism as a cause of phle- 
bitis, 627. 
Trephine-brush, 377. 
Trephines, 376, 1070. 
Trephining, 375. 
button of bone replaced in, 
379. 
cases demanding, 375. 
contra-indications for, 375. 
for osteomyelitis, 1058. 
for skull-fractures, 361. 
in cerebral abscess, 329. 
in epilepsy, 372, 375, 377. 
in fractured spine, 872. 
Triangle handkerchief, 79. 
Scarpa’s, 784. 
Triangular cap, 85. 
compress, 55. 
Trivalve anal speculum, 503. 
Trocar and canula, 479. 
Trochanter major, fracture of, 
985. 
fracture of epiphysis of, 986. 
Trough-shaped splints, 935. 
Truss, Chase’s, 557. 
femora], 598. 
for hemorrhoids, 544. 
for hernia, 555. 
French, 557. 
Gemrig’s, 555. 
hard-rubber, 556. 
Hood’s, 555. 
inguinal, 555, 556, 590. 
ring, 556. 
umbilical, 556, 601. 
Trusses, 544, 555, 590, 591, 
598, 601, 602. 
Tubercle, anatomical, 271. 
Tuberculosis after chest wounds, 
411. 
fistula in ano with, 537, 540. 
Tuberculous abscess, 165. 
Tumor, blood-, 371. 
meconial, 506. 
Tumors after contusions, 264. 
diagnosis from abscess, 158. 
fatty, diagnosis from abscess, 
158. 
from angeioma, 619. 
from femoral hernia, 597. 
from inguinal hernia, 
589. 
from umbilical hernia, 
600. 
following contusions, 264. 
orbital pulsating, 710. 
puffy, 330. 
solid, how distinguished from 
aneurism, 659. 
Turpentine as a haemostatic, 
220. 
Twist, intestinal, 482. 
Twisted suture, 248. 
Two-tailed retractor, 56. 
Tying of nsevi, 621. 
Typhlitis, 495. 
suppurative, 496. 
Typhoid fever, perforation of 
intestine in, 444. 
U. 
Ulceration, 169. 
concealed, 169. 
granulations in, 173, 176. 
of anus, 522. 
with fissure, 512. 
of cicatrices, 319. 
of rectum, 522. 
of umbilicus, 475. 
open, 169. 
pathology of, 170. 
repair in, 172. 
Ulcers, 175. 
bone, 1050. 
callous, 180. 
chronic, 180. 
cicatrization of, 174. 
classification of, 175. 
cold, 188. 
common, 175. 
complicated, 177. 
concealed, 169. 
constitutional, 188. 
dissection - wound causing, 
269. 
fungous, 177. 
indolent, 180. 
irritable, 177. 
local, 175. 
cedematous, 178. INDEX TO VOLUME I. 
1113 
Ulcers of tibia, 1051. 
perforating, 189. 
putrid, 201. 
simple, 175. 
skin-grafting in, 175. 
sloughing, 178. 
varicose, 182, 635. 
vicarious, 181. 
Ulna, fractures of, 937, 951. 
ununited fracture of, 832, 833, 
834, 835, 841, 843, 844. 
Ulnar artery, collateral circula- 
tion of, 775. 
its anastomosis with the 
radial, 775. 
ligation of, 775. 
surgical anatomy of, 775. 
nerve, contusion of, 613. 
Umbilical hernia, 599. 
radical cure of, 564. 
truss, 556, 601. 
Umbilicus, carcinoma of, 476. 
cysts of, 475. 
fistulae at, 476. 
hemorrhage from, 475. 
papilloma of, 475. 
ulceration of, 475. 
Undescended testicle, 589. 
Union, first, second, and third 
intention in. 316. 
of wounds, 316. 
tardy, of bones, 822. 
under a scab, 319. 
vicious, after fracture, 846. 
Ununited fractures. See Frac- 
ture, Unuuited. 
Upper extremity, fracture of 
bones of, 899. 
wounds of, 609. 
jaw, fractures of, 875. 
Ureter, wounds of, 459. 
Urethra, rectum opening into, 
508. 
Urinary bladder, wounds of, 468. 
calculus, foreign bodies as 
nuclei of, 469. 
fistula, artificial, 460. 
fistula at umbilicus, 476. 
Urine, bacterium in, 45. 
Urinous cysts, 459. 
infiltration, 470. 
Uterus, gravid, mistaken for 
ascites, 478. 
V. 
Vagina, anus opening into, 508. 
rectum opening into, 508. 
Vaginal hernia, 606. 
Varicocele distinguished from 
inguinal hernia, 587. 
Varicose aneurism, 615,647,684. 
ulcer, 182, 635. 
veins, 631. 
age as a factor in, 633. 
causes of, 632. 
caustics in, 637. 
coagula as a cause of, 633. 
effects of, 635. 
elastic stocking, 636. 
form of, 633. 
heart-diseases as causing, 
632. 
operations for, 636. 
pathology of, 633. 
portal obstruction as a 
cause, 632. 
Varicose veins, pressure as a 
cause, 632. 
sex in, 633. 
symptoms of, 635. 
treatment of, 635. 
ulceration of, 635. 
Varicosity, capillary, in inflam- 
mation, 120. 
Varix, 631. 
aneurismal, 615, 647, 684. 
arterial, 615. 
capillary, 617. 
of neck, 713. 
of saphena magna, its diag- 
nosis from femoral hernia, 
597. 
venous, 631. 
Vaso-motor nerves, 103. 
V bandage of face, 75. 
Vegetations at anus, 509. 
Veins, air in, 395, 626. 
atrophy of, 631. 
diseases of, 624. 
healing in, 626. 
hemorrhage from, 625. 
hypertrophy of, 630. 
inflammation of (phlebitis), 
627. 
injuries of, 624. 
ligation of, 625. 
malignant disease of, 631. 
varicose, 631. 
wounds of, 624. 
Vein-walls, hypertrophy of, 634. 
Velpeau’s bandage, 78. 
roller for fractured clavicle, 
904. 
Venae eavae, wounds of, 427 
Venereal warts at anus, 509. 
Venesection, 133, 137. 
Venetian soap styptic, 220. 
Venomous snakes, 286. 
Venous angeioma, 619, 623. 
atrophy, 631. 
hemorrhage, 675. 
hypertrophy, 630. 
Ventilation in treating inflam- 
mation, 143. 
Ventral hernia, 604. 
Verruca microgenica, 271. 
Vertebrae, fractures of, 862. 
Vertebral arches, fracture of, 
864. 
artery, aneurism of, 707. 
ligation of, 762. 
Vertigo after head-injury, 374. 
Vesical calculi, 469. 
hernia, 608. 
wounds, 468. 
Vesicants in inflammation, 136, 
147. 
Vibration of brain, 344. 
Vicarious function of ulcers, 
181. 
Vicious union after fracture, 846. 
Vienna paste, 637. 
Villatte’s liquor, 1053. 
Villous polypus of rectum, 520. 
Viper wounds, 286. 
Virchow's cellular pathology, 
120. 
Viscera, protrusion of abdom- 
inal, 432. 
wounds of abdominal, 440. 
Vital haemostatics, 219. 
Volar artery, aneurism of, 718. 
Volvulus, 482. 
complicating hernia, 580. 
Von Bruns’s cutting-pliers, 815. 
Von Recklinghausen on leuco- 
cytes, 121. 
Vulcanized rubber splints, 490, 
504, 886. 
W. 
Wads, wounds from, 291. 
Wandering cells, 108. 
needles, 266. 
Ward’s paste, 543. 
Warmth in treatment of inflam- 
mation, 131. 
Warts at anus, 509. 
microgenic, 271. 
Wasp-sting, 289. 
Water bed in fracture, 812. 
in fractured spine, 870. 
canker, 192. 
glass dressings, 814. 
treatment for inflammation, 
129. 
Watson’s weight-compressor for 
aneurism, 672. 
Waxed paper, 54. 
Weber’s arterio-verter, 228. 
Wedge-shaped pad, 908. 
Weight-compression for aneu- 
rism, 672. 
White’s surgical engine, 1070. 
Wilde’s signal-bell, 364. 
Windage of balls, 295. 
Windlass, Spanish, 223. 
Wire ligatures, 237. 
loop for hemorrhage, 229. 
probe, 1053. 
splints, 813. 
Wiring of teeth in fracture, 884. 
Wooden-slat splints, 813. 
Wood’s hernia operation, 560. 
Woodward on stomata in blood- 
vessels, 124. 
Wool-sorter’s malady, 272. 
Wounds, 214. 
abdominal, 430, 444. 
sequelae of, 460. 
after-treatment of, 251. 
antiseptic treatment of, 250. 
approximation in, 243. 
by collodion, 245. 
by plasters, 244. 
by sutures, 246. 
arrow, 364. 
arterial, 638. 
blood-swellings from, 263. 
classification of, 214. 
complications after, 251. 
concealed, 261. 
constitutional treatment of, 
251. 
contused, 259, 261, 263, 386. 
cut-throat, 394, 397. 
diphtheria of, 201, 252. 
dissection, 268. 
drainage of, 242, 303. 
dressing of, 43, 250. 
dressings of, renewed, 250. 
ecchymoses after, 261, 262. 
erysipelas after, 252. 
fistula after, 254. 
foreign bodies in, 241. 
from wads, 291. 
gangrene in, 190, 252. 
gunshot, 290. 
amputation-in, 305. 
aneurism from, 647, 681. 
balls removed from, 302. 1114 
INDEX TO VOLUME I. 
Wounds, gunshot, bone-splinters 
in, 302. 
character of, 296. 
drainage of, 303. 
erysipelas after, 303. 
excision in, 305. 
expectant treatment in, 
307. 
frequency of, 296. 
healing of, 304. 
hemorrhage from, 297. 
muscular spasms after, 254. 
of bladder, 409. 
of cranial bones, 358. 
of face, 888. 
of hand, 310. 
of head, 356. 
of innominate vessels, 427. 
of kidneys, 458. 
of knee, 313. 
of neck, 400. 
of pelvis, 467. 
of rectum, 473. 
of scalp, 325, 357. 
of thigh, 310, 311. 
openings in, 294, 296, 300. 
parts involved in, 296. 
prognosis in, 297. 
shock in, 297. 
tetanus after, 298. 
treatment of, 298. 
windage in, 295. 
healing of, 304, 316. 
hemorrhage from, 214, 253. 
arrest of, 215, 219, 238. 
transfusion for, 239. 
homicidal, 394, 397. 
incised, 254. 
inflammation of, 251. 
intestinal penetrating, 444- 
448. 
lacerated, 259, 611. 
laparotomy after, 445, 448. 
maggots in, 254. 
mortification of, 190, 252. 
muscular spasm after, 254. 
occlusion of, 43. 
of abdomen, 430, 444. 
of anus, 472. 
of aorta, 422. 
of arm, 610. 
of arteries, 638. 
of bladder, 468. 
of brachial plexus, 396. 
of brain, 347. 
of brain-sinuses, 356. 
of carotids, 396. 
Wounds of cavae, 427. 
of chest, 404, 426. 
of colon, 442. 
of diaphragm, 407. 
of ear, 388. 
of extremities, 609. 
of face, 386, 387, 888. 
of foot, 614. 
of gall-bladder, 450, 452. 
of hand, 310, 610, 611. 
of head, 356. 
of heart, 422. 
of innominate vessels, 427. 
of intestines, 446. 
of jaws, 387. 
of kidneys, 458. 
of knee-joint, 313. 
of larynx, 394, 399. 
of lips, 388. 
of liver, 450. 
of lower extremity, 613. 
of lung, 408. 
of mediastinum, 422. 
of neck, 394. 
of nerves, 612. 
of nose, 388. 
of oesophagus, 394, 398, 428. 
of omentum, 446. 
of palmar arch, 310, 610. 
of pancreas, 456. 
of pelvis, 466, 467. 
of pericardium, 422. 
of pharynx, 394, 398. 
of phrenic nerve, 396. 
of pleura, 404, 426. 
of pneumogastric nerve, 396, 
of prostate, 471. 
of rectum, 472. 
of sacrum, 466, 467. 
of scalp, 323. 
of skull, 360. 
of spine, 862. 
of spleen, 455. 
of stomach, 440. 
of subclavian, 396, 427. 
of supra-renal capsules, 458. 
of thigh, 614. 
of thoracic duct, 428. 
vessels, 426. 
of thorax, 404, 426. 
of throat, 394, 397. 
of tongue, 388. 
of trachea, 394. 
of ulnar nerve, 613. 
of upper extremity, 609. 
of ureter, 457. 
of veins, 624. 
Wounds of venae cavae, 427. 
of vessels of thorax, 426. 
open treatment of, 251. 
pain in, 254. 
penetrating, 431. 
phagedaena of, 253. 
pneumatic aspiration of, 251. 
poisoned, 267. 
post-mortem, 208. 
punctured, 265. 
repair of, 316. 
retraction after, 254. 
sabre, 315. 
scalp, 325*357. 
secondary hemorrhage of, 253. 
serpent, 286. 
shock after, 262. 
sinuses in, 254. 
sloughing in, 259. 
subcutaneous, 256. 
suicidal, 394, 397. 
suppurating, 251. 
sutures for, 246. 
sword, 315. 
tetanus after, 259, 298. 
treatment of, 43, 219, 238, 
251, 259. 
union in, 316. 
Wrist, fractures of, 958. 
Wrist-drop due to callus, 852. 
from fracture of humerus, 
928. 
Wrist-joint, excision for shot 
wound, 310. 
Wry-neck after shot wounds, 
403. 
Wutzer’s hernia operation, 558. 
Y. 
Yellow-jacket sting, 289. 
Yeo on atheroma of pulmonary 
artery, 644. 
Youatt on hydrophobia, 279, 
283. 
Young skull, its impressibility, 
341. 
Z. 
Zinc chloride in asepsis, 47. 
splints, 813. 
Zooglcea, 45. 
Zygomatic arch, fractures of, 
877, 878. 
END OF VOL I.