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EMERGENCY SURGERY 
 
 S LU SS 
 
THE LEATHER BOUND SERIES 
 
 OF 
 
 MEDICAL MANUALS 
 
 HUGHES. Compend of the Practice of Medicine. Eleventh 
 Edition. By Daniel E. Hughes, M. D., late Chief Resident 
 Physician, Philadelphia Hospital. Revised by R. J. E. Scott, 
 M. A., B. C.L., M.D., New York, Fellow of the New York 
 Academy of Medicine; Fellow of the American Medical Asso- 
 ciation; Formerly Attending Physician to the Demilt Dispen- 
 sary; Formerly Attending Physjcian to the Bellevue Dispensary; 
 Author of "The State Board Examination Series;" Editor of 
 "Witthaus' Essentials of Chemistry and Toxicology", "The 
 Practitioner's Medical Dictionary", Gould and Pyle's "Cyclo- 
 pedia of Medicine and Surgery;" Etc., Etc. With 68 Illustra- 
 tions. xix-f-785 pages. Flexible Leather, Gilt Edges, Round 
 Corners. $3.00 
 
 KYLE. Manual of Diseases of the Ear, Nose and Throat. 
 Second Edition. By John Johnson Kyle, B. S., M. D., Pro- 
 fessor of Otology, Rhinology and Laryngology in the Univer- 
 sity of Southern California; Member of the American Laryn- 
 gological, Rhinological and Otological Society. With 169 Il- 
 lustrations. Flexible Leather, Gilt Edges, Round Corners. 
 
 $3.00 
 
 SLUSS. Emergency Surgery. Fourth Edition. By John W. 
 Sluss, A. M., M. D., Associate Professor of Surgery, Indiana 
 ity School of Medicine; Ex-Superintendent Indianapolis 
 City Hospital; Surgeon to the Indianapolis City Hospital. 
 With 685 Illustrations, xix+848 pages. i2mo. Flexible 
 Leather, (iilt lodges, Round Corners. $4.00 
 
 P. BLAKISTON'S SON & CO. 
 
 ILISHI : : PHILADELPHIA 
 
EMERGENCY SURGERY 
 
 BY 
 
 JOHN W. SLUSS, A.M., M.D., F.A.C.S. 
 
 ASSOCIATE PRO .ERY, INDIANA UNIVLRSIIY SCHOOL 
 
 PERINrKNDKST INDIANAPOLIS CI I Y HOS- 
 PITA m TO TIIK CIIY HOSPITAL 
 
 FOURTH EDITION, REVISED AND ENLARGED 
 
 WITH 685 ILLUSTRATH >NS 
 sOWH OF WHICH ARE PRINTED IN COI 
 
 PHILADELPHIA 
 
 P. BLAKISTON'S SON & CO, 
 
 1012 WALNUT STREET 
 

 Cof>yrk;ht, 191 7, by P. Blakiston's Son & Co. 
 
 MAR 20 1917 
 
 ©CW "9 
 
 1 11 i MAPLI PKBIB r O k K P A 
 
cA 
 
 
 
 DEDICATION 
 
 TO M fPLAR OF 
 
 U-UTI' »\l KB, IN" Nfi MORI NT 
 
 rooi iiii l rras lrtu worm d qbcbib] 
 
PREFACE TO THE FOURTH EDITION 
 
 I\ addition to a correction of minor details, the text pertaii 
 to the Surgery of War has again been carefully revised and 
 brought up to the moment. The treatment of "Wound I? 
 tions n has been completely rewritten it : the la! 
 
 experiences and practice, much of which emanate- from the Euro- 
 pean battlefields. Should our own doc tors be called into the E 
 it is believed they will find herein some in the beginning 
 
 of their work. 
 
 J. \\\ 
 
 VI 1 
 
PREFACE TO THE THIRD EDITION 
 
 The present revision of this volume has adhered to the aim of 
 former editions to present geneva! principles conci id prac- 
 
 tical details amply in short to make a book useful to the general 
 practitioner in the surgical phase of his daily routine. 
 
 < h subject has been carefully re vised. The text oi ires 
 
 has been greatly in< sonant with the new interest to the 
 
 profession generally which this subje uired in recent 
 
 I!'-. 
 
 The chapter on Military Surgery has been entirely rewritten in 
 
 conformity with the surgical experi this latest and greatest 
 
 war. A number of illustrations borrowed from the British Journal 
 Of Surgery and other sources are included. 
 
 The Technique of tin jency interventions will he found 
 
 to coincide with the best practice oi the present time. Finally 
 the hope is expressed that the volume will continue, a- in the 
 past, to find favor with the medical public. 
 
 J. w. s. 
 
 IX 
 
PREFACE TO SECOND EDITION 
 
 THE i'.u t that the first edition of thi sold out within i 
 
 year is particularly gratifying to the author I ttes that 
 
 the results of his effort to ma fill and : I hook have met 
 
 with the approval of the profession. 
 
 In preparing tl d edition of the "Emergenc the 
 
 effort has been to profit by thi - of the 
 
 various revil the first It is hoped, in const- that its 
 
 Usefulness ha 1 and that it will continue I 
 
 with 
 
 A new chapter on thi een 
 
 added; each subject has aid in many in- 
 
 LCes new matter incorporated. Thus, far exam; 
 
 thesia is d< scribed in detail and Subphrenic irdi- 
 
 otomy more fully considered. 
 
 Dr. Helen kna;>e has contributed some new illustrations, and 
 the skiagrams are the work oi Dr. Albert M. ( Indiana]' 
 
 to whom thank- are due. 
 
 J. W. 
 
 XI 
 
PREFACE TO THE FIRS! EDITION 
 
 This is a Surgery for the general practitioner; written not to 
 instruct his leisure hour, bul in the hope some time to serve 
 guide out of uncertainty in a tin. tnd dem< 
 
 should be reckoned from thai point of view alone. I usionally, 
 
 the form of I dogmatic, it merely comport- with the 
 
 constant aim to be practical; certainly that aim has denied any place 
 
 to theoretical dis< USsions and has curtailed e to the var 
 
 view- of recognized authority. An absence of bibliography, it is 
 
 hoped, therefore, will not l ■ to the many 
 
 writers, teachers, and practitioners whose ideas have been - 
 
 appropriated. 
 
 Among the text-books n ntly consulted are Sc 
 
 Practical Surgery, The American Text-book i Walsham's 
 
 Surgery, Treves 1 Operative Surgery, Lejars' Chirurgie d'Urgence, 
 Veau's Chirurgie d'Urgence el Pratique Courante, Von Bergmann's 
 Chirurgie, and Binnie's Operative Surgery. 
 
 The Annals of Surgery, the American Journal of Surgery, the 
 International Journal of Surgery, and the Journal of the American 
 Medical Association have been prolific sources of informati' 
 
 For advice and aid in many ways in the preparation of this book, 
 special thanks are due Drs. John J. Kyle, James H. Ford, A. \Y. 
 Bray ton, and Gust a v Bergener. The original illustrations are the 
 work of Dr. Helen Knabe. 
 
 To the publishers, through whose counsel and patient criticism the 
 book has grown into its present form, a grateful appreciation is to be 
 expressed. 
 
 J. \V. S. 
 
 xiu 
 
CONTENTS 
 
 PART I 
 CHAP1 BR I 
 
 Thi *AL Pkactitionsi I 
 
 hi mi - null I ^ : Bqi iimi wt . . I 
 
 [APTBR II 
 
 um 6 
 
 CHAPTER III 
 Anesthesia, i: 
 
 CHAPTER IV 
 
 Sutukks; Mi Matkki.m - 
 
 CHAPTER V 
 
 I ) R A I \ \ < , 1 ... 
 
 VI 
 Dressings, Bandages, Splints. 35 
 
 CHAPTER VII 
 
 Shock 5 2 
 
 APTBR VIII 
 Hemorrhage 
 
 CHAPTER IX 
 Wounds: General Principles 71 
 
>» n NTS 
 CHAPTER X 
 
 Page 
 
 im i \i Regions 81 
 
 CHAPTER XI 
 
 ■ 1" I HI Tl<l \K HO 
 
 CHAPTER XII 
 
 wi. Othbb Wounds in Military Practice 133 
 
 CHAPTER XIII 
 
 w nds in Civil Practice 186 
 
 CHAPTER XIV 
 
 1 hi: Extremities 200 
 
 CHAPTER XV 
 299 
 
 CHAPTER XVI 
 
 - 01 1 hi ( iwi cle, Scapula, Ribs, Spine, Pelvis 306 
 
 CHAPTER XVII 
 SB Skull and of the Bones of the Face . . . .315 
 
 CHAPTER XVIII 
 
 MS 328 
 
 CHAPTER XIX 
 OR OP 1 363 
 
 CHAPTER XX 
 Repair 01 Nerves 373 
 
 CHAPTER XXI 
 391 
 
 HAPTER XXII 
 Phlegmon; u>ikg Infections 437 
 
CHAP! Ill 
 
 Pace 
 
 Acute 
 
 CHAP1 BR XXIV 
 
 X V 
 CHAP! BR XXVI 
 
 PAKI II 
 
 CHAPTER I 
 
 TbACHBOTOMI 
 
 II 
 
 m Thob m otomi . Rj pair or In : n I.i *> i aik 
 
 01 [NJURYTOI hi Pi ftH \kim M. \k7. 
 
 Pi \. i i ft] 01 i hi Pi ft* UU>I1 m Pi RI4 UU>I 
 
 (II III 
 
 Rmpyi m a I'i kiii\i PLBURIS1 
 
 CHAPTER IV 
 
 mi I H'MV; Tki PHINING 
 
 CHAPTER V 
 
 M tSTOID 
 
 CHAPTER VI 
 
 ( rl m I \i TBCHM h 01 LAPAROTOMY 
 
 CHAPTER VII 
 
 LAPAROTOMI FOB Tk u m \ih\i 
 
 CHAPTER VIII 
 Appendicitis; Appbndiciaj Abscess; Purulent Peritonitis . . . 
 
xv iii \ TENTS 
 
 CHAPTER IX 
 
 Page 
 
 Hem riMA] Obstruction 593 
 
 CHAPTER X 
 Artificial A] hforary, Permanent 605 
 
 CHAPTER XI - 
 
 \iin Hbrnia 614 
 
 CHAPTER XII 
 Ci ki of Lnguinal Hernia 648 
 
 CHAPTER XIII 
 Ci ki: of Femoral Hernia 659 
 
 CHAPTER XIV 
 
 RBCTOMY. [NTESTINAL ANASTOMOSIS . . . . ■ 666 
 
 CHAPTER XV 
 
 tFORATE Anus 678 
 
 CHAPTER XVI 
 
 HON OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS; OF THE 
 
 UfATic Cord; of the Pedicle of the Spleen; of the Omentum. 683 
 CHAPTER XVII 
 Rupti ki am> Hemorrhage of Tubal Pregnancy 691 
 
 CHAPTER XVIII 
 m 698 
 
 CHAPTER XIX 
 of the Urethra 702 
 
 CHAPTER XX 
 
 1 hbtbrization; Suprapubic Puncture; 
 m iii b mion 714 
 
 CHAPTER XXI 
 
 Ligation 79^ 
 
If POTATO 
 
 III 
 
 I ) 1 1 . \ 
 
 . 
 
 CHAP IV 
 
 Phimo i \Pa 
 
 CH KV 
 
 \i! 
 
 CH XXVI 
 
 CH VII 
 
 Skin 823 
 
 I Ml \ 829-848 
 
EMERGENCY SURGERY 
 
 CHAFl I 
 
 THE GENERAL PRACTITIONER AS AN EMERGENCY 
 
 SURGEON: HIS DUTIES AND RESPONSIBILITY. 
 
 EQUIPMENT 
 
 Surgery is no loi nee 
 
 shall be .t to the 
 
 spirit of the times. Modern lif< 
 
 tiling ha form. Whether the 
 
 ■n shall continue to plaj i oblj art in the m 
 
 drama depends upon tl I the 
 
 in him. But thl high 
 
 That pii e bo the medi* 'ess than the 
 
 fulfillmei therapeuti 
 
 opportunity. 'The opportunity is gold with the wonderful 
 
 improvements u al tec lime the field 
 
 that is i the indication for immediate in! i>een 
 
 remarkably broadened and the time finds the public singular! 
 able to that form of relief. 
 
 The " honor of the knife," of all that pertains to surgery, has 
 become a tradition, like the practice which. birth. End 
 
 the public is trained tve emergencies, 
 
 the practitioner will (\o BOmethi rious thi 
 
 quired intervention may be. if it but offers hope, the doctor is expected 
 to act Our predeo ven thos ind willing — often found 
 
 their hands tied under such circun by the ruling polio 
 
 "let alone and let die." It is a part of their glory that they concei 
 planned, and attempted in the face of tremendous obstacles, most of 
 the interventions of urgency which are current to-day. 
 
! i i [ONI K AS W EMERGENCY SURG] 
 
 cal opportunity, then, of the general practitioner is clear, 
 
 di3 (Jut I u p ofessional spirit, the humanities, his 
 
 incumbent upon him to know and act. This 
 
 Irop to the rear in the march of progress, which does 
 
 not halt foi the timid or unwilling, 
 
 led is heavy, the responsibility large; for the gen- 
 ii finds himself isolated, remote from special 
 a compelled to act alone. That he does not always 
 gency and do all that he might do even under 
 &bk drcumst iay often be laid in large part at the door 
 
 of his training. He knows often what he ought to do, yet knows not 
 I lappily the course- of instruction are now generally 
 with this strange antithesis between theory and 
 : a theory, modern, scientific, positive; a practice, as Lejars 
 full of error and based on empiricism age-old. 
 Lt this ni or, now that the indications for operation are 
 
 id and one's duty obvious, vague conception of an opera- 
 far away and desperate, must give way to clear 
 tns of tl ices of surgery, of surgical therapeusis. Every 
 
 doctor must familiarize himself with the technic of interventions 
 which he must undertake at times, if he is not to be inexcusably re- 
 d duty. 
 Surgery in one respect is a handicraft, and as such requires its 
 tin tools of first necessity. If, as has been said, emergency sur- 
 Lomes in the nature of a surprise, then the surprise will at 
 least be less complete if one has an equipment and has it prepared. 
 
 hould have an emergency bag supplied with mate- 
 
 ip, a fountain syringe, hypodermic syringe, 
 
 alcohol, ether, chloroform and carbolic acid, 
 
 bichloride tablet-, a pa< I t crile compresses, sutures, bandages, 
 
 M of ph -, and certain instruments. 
 
 are almost indispensable for emergency sur- 
 t 11 wrapped and should be cleansed 
 *Mi ind sterilized by boiling for one minute before 
 
 using. New br lould be boiled in soda solution for five to 
 
 ten minutes. If bro la< king, one may scrub the hands and 
 
 the : terile gauze. In the hospital where the 
 
i leansing al the time of operation baa been ; I by another 
 
 may be used to the < n of the hand brush* 
 
 untain Syringe or Irrigator. I I full rubber out- 
 
 fit or, what is b< porcelain container and a long ruWxir tube 
 
 with glasfl nozzles. It is absohlfc dtial that the whole be steril- 
 
 ized by boiling, it is aon en done, the 
 
 ( annuls and i ontainer, and negle* I the tube. 1 n nozzles are 
 
 likely to be broken if plunged directly into boilii or if cooled 
 
 too rapidly. If the pon elain l ontainer is used, it may be boiled and 
 t hen singed with burning alcohol It take- up but little room in the 
 
 and the tube and nozzles may be Wrapped Up and in it 
 
 and the whole wrapped and kept than and dry. This outfit is 
 most indispensable, for in many i the only adequate t: 
 
 tnent is by bypodermoclysis or intravenous infusion. 
 
 The Antiseptics. The alcohol must be kept in a well stopped Ba 
 and the carbolu add or lysol, also. The bichloride may be in the 
 form of tabl that th( tfa of a solution may be readily 
 
 calculated. The most commonly emplo the formula contain- 
 
 ing mercury bichloride ; itrii mu\ 3.8 gr. This tablet in 1 
 
 quart of water n 1 to -coo solution, which rongas 1 
 
 be ummI. Instead of the table! may keep a concentrated 
 
 solution of bichloride in alcohol, viz: 7) i bichloride in Ji Aleohol 
 
 oi which solution 7) \ to a pint ^i water makes a i to 2000 
 
 solution. 
 
 Instead o\ the bichloride, the biniodide of mercury. 1 to 4000 may 
 be used. 
 
 Chloraaene tablets Abbott from which Dakins 1 solution may 
 be readily prepared, constitutes an exceedingly convenient and 
 efficient form oi antiseps 
 
 Iodine grows constantly in favor in spite of certain drawbacks. A 
 four ounce vial of the tincture supplies for many sterilizations. It> 
 stain on the hands and linens may be removed by moistening with 
 ammonia or solution of hyposulphite of -odium. 
 
 Anesthetics. — One should keep on hand at least one pint of ether 
 and four to six ounces of chloroform. Cocaine for local anesthesia 
 is best kept in tablet form and the solutions made extemporaneously. 
 
[TIIONEB AS AN EMERGENCY SURGEON 
 
 For cxamp grain tablets of cocaine to i teaspoonful of sterile 
 
 i. solution; 4) 2 -grain tablets of a tea- 
 spoonful er makes a 4 per cent, solution; ioK-grain tablets, 
 !ut ion. This is not exact, of course, but furnishes a 
 good working rule for the emergency. Novocaine is less dangerous 
 e and in M or i per cent, solutions may be used in large 
 1 with excellent effect. Ethyl chloride for local freez- 
 put up in small containers convenient for the emergency 
 bag. 
 
 Too frequently the practitioner commits the error 
 ding upon absorbent cotton for his sponges and compresses. 
 n, as found on the market, is scarcely ever aseptic. 
 [most certain to be contaminated in getting it out 
 ickage. A supply of sterile gauze is one of the best means of 
 i aseptic operation. It should be kept in a hermetically 
 A metal or glass. 
 In lieu of the gauze compresses ready sterilized, one may carry a 
 i ordinary gauze which can be cut into appropriate sizes, and 
 I at the time of operation. It is a good idea to cut two sizes; 
 a small for compresses and wipers, a larger to cover the field of 
 operation. Ail these pieces should be folded once and the borders 
 hemmed. A ball of cotton may be hemmed in between the layers, 
 which makes a still better sponge. The compressed package of 
 gauze as supplied by Borroughs and Welcome is especially appro- 
 priate to the small emergency bag. Once accustomed to its use it 
 seen: i | indispensable. 
 
 L Igotures. — If these materials are not already sterilized 
 
 1 package or container, such as a sealed tube of 
 
 alcohol, catgut must be ruled out, for its preparation takes too 
 
 much til >uld take care to have several sizes of silk, espe- 
 
 ind oo; for these are the sizes required in intestinal 
 
 worm-gut may be sterilized as needed. 
 
 Catheh i liould be kept in a metallic box. Rubber 
 
 1 1 ways readily sterilized by boiling. Rubber 
 
 te rapidly unless properly cared for. They 
 
 may break line ly, the result of an unnoticed change in 
 
 quality, and a piece he left in the bladder. 
 
5 
 Drainc louM be pn in a boi -tic 
 
 \\hi< h may be boiled thoi 
 
 in a tin boi with tight cover and ' 
 
 loose or already rolled A suppl tier band 
 
 OD band, from which the ges may be 
 
 made. 
 
 trumnits. -Any list which might be I 
 
 But ling of 
 
 i ith the i 
 with which I I >n the win 
 
 upon tlif ( ompl< 
 
 imp! should ha •• minimum: dzes 
 
 of amputating kniv< 
 
 artery ton i p the more tl < .a bone 
 
 ( hisel, needle holder and 
 
 tube. The instrumt ently used may be put together 
 
 in a small metal ises, 
 
 or imp rolled up in a blind 
 
 Cleaning instruments and matter 
 
 of no small imp 
 
 apart, scrubbed with ped wil 
 
 saturated with alcohol, and dried thoroug) 
 been delayed, it may be i 
 
 time in a solution of p d final! 
 
 scribed It anj stains still persist tin M be polished with 
 
 chamois skin, 
 1 ormaldehyde, certau line in too d urimity, 
 
 tarnish and spoil instri: 
 
 A dish or two of calcium chloride in th< iment case will 
 
 absorb moisture and tend to prevent rusting. Too often the pr 
 
 tioner m Ids instrument- be* not often U 
 
 and, in the emergency, he finds himself with ki Eld with- 
 
 out an edp rs that will not cut, and f< at ha\« 
 
 map. He will certainly gain time by Spending a little time in carry- 
 ing out these small details in the care ^i hi 
 
CHAPTER II 
 
 EMERGENCY ANTISEPSIS. OPERATION IN A PRIVATE 
 
 HOUSE 
 
 Th at ion for an urgent intervention outside of an operating 
 
 room es itself into a question of asepsis or antisepsis, and 
 
 ind this point gathers a multitude of details. But it is necessary 
 
 only to proceed systematically and intelligently to achieve excellent 
 
 The time was when the idea prevailed that an aseptic operation 
 
 possible outside a hospital. This was a harmful notion 
 
 which restrained many a practitioner from an effort that might have 
 
 itient's life. Every day it is demonstrated that aseptic 
 
 iliar to formal operating rooms. 
 
 Bonnev, ot Philadelphia, writes that he has done many major 
 
 i> in the homes of thepoor in the midst of the most unsurgical 
 
 surroundings theless, the results have been excellent. Most 
 
 were for urgent abdominal, pelvic, or genito- 
 
 urin case, and though such work is often time-consuming 
 
 vs what can be done in the case of necessity. 
 
 Birmingham (Ala.) concludes a useful paper touching 
 
 with the statement that of a thousand cases operated in 
 
 in the patients' homes the mortality rate was zero, 
 
 abdominal gunshot cases three died. (Amer. 
 
 Walker (Month Cyclopedia of Pract. Med., Aug., 1906) 
 
 says that for thirty years he has operated in farm houses through- 
 
 tral New York with as good results as those obtained in the 
 
 a which he was connected for many years. He goes 
 
 further and that, for many reasons, it is desirable that 
 
 there should be a return to more home operating, and that the 
 
 original purpose, the care of the 
 6 
 
i P \M \ i i 
 
 bon k and not invade the home with the 
 
 i.it only within its walls can the sir ase be I 
 
 for. 
 
 But this i From the main point: the practitioner may 
 
 Wed that with ii ewe* under ap- 
 
 par&ntly unfavorable circum tan 
 effective asep 
 \ ! 
 
 and usuall) i with tin e may accompli* 
 
 suffi< ienl sterilization of the instruments, the hands, the field of opera- 
 tion and the dressing. Hut it requires a will to do all the irorl 
 
 eed with method and, above all. quickly, through the mil. 
 oi preparation. One should have a plan in mind and Lejars o: 
 a model whu h, of course, can be modified to suit tl i 
 and the operation. Su] 
 of the preparation to be su] - 
 
 !< p. ll;i\ e a £ II vailable 
 
 tnbled. I ck of lit 
 
 or muslin. Freshly laundered handkerchiefs and napkins (wit! 
 Cringe) furnish material for excellent compn • - for 
 
 the field of operation. Serine one or two large ketti 
 wash-boiler for boiling the water for the operatioi hree 
 
 smaller ret ep meled sto ding 
 
 the in-trument and sutures; anotl the brushes, u 
 
 nozzles and tube, etr.; the third, for the romp id tampons. If 
 
 possible, boil also the dishes or ba I to hold the instrum< 
 
 and the solutions needed during the operation. It i 
 dish or bowl for the instruments, one for the tampons and 
 
 one for the SUtureS, and tWO hand basins for Sterile water and 
 
 bichloride solution. The boiling must be prolonged at half 
 
 hour to be sure of sterilization. It is a good plan to add a teaspoon- 
 ful of salt to the quart of water containing the compi 
 
 to be tied up in a towel to facilitate their removal; and to add a tea- 
 spoonful of washing soda to the water in which the instruments are 
 to boil, since it more readily remo\ >e or blood, makes the 
 
 temperature slightly higher, and prevents rusting. The km 
 should be wrapped in soft gauze to prevent dulling; still better 
 
EMERGENCY ANTISEPSIS 
 
 1 instruments should not be boiled at all but merely immersed 
 
 1 for some time previous to the operation. The instruments 
 
 I be put in until the water is bailing, as otherwise they 
 
 be tarnished. If it is necessary to boil the instruments 
 
 and suture material together, the soda should not be added, since it 
 
 rapidly ruins both silk and silkworm-gut. Even better than boil- 
 
 wilizing instruments is hot oil — olive oil, for example 
 
 oiling-point is a higher than that of water. The vessel 
 
 lining the oil can be set in another of cold water and instruments 
 
 soon be taken from the oil ready for use. This oil may be used 
 
 ■\ many times. Five minutes of actual boiling is sufficient to 
 
 instruments. When once the sterilization is under way 
 
 proceed to the operating room. 
 
 Sec p. Prepare the Operating Room and Table. — If there is 
 
 any choice, select the best lighted and largest room. If it is at 
 
 : range for the illumination. Do not displace the furniture 
 
 pt to make room for the operating table, two small tables, and 
 
 room to "turn about. " An extensive "clearing for action" does 
 
 re harm than good, for by jerking down the curtains, rolling the 
 
 furniture around and sweeping, one stirs up the dust, accumulating 
 
 aps for months. 
 
 It i- preferable -imply to sprinkle the floor or wipe with a wet 
 
 To be sure, if one has several hours in which to prepare, then 
 
 the room may be emptied, the floor covered with moist sheets and 
 
 the walls spr Ouenu suggests, with peroxide, the tables placed 
 
 and the room closed until the time of operating. 
 
 It is never a good idea to use the patient's bed for an operating 
 table, although the first preparation, as the shaving, may be begun 
 ther- dining table can usually be pressed into service, covered 
 
 h a blanket and that with an oilcloth. A table may be im- 
 provised from two wooden trestles with planks laid across and 
 I like the table. Of the two small tables required, the one on 
 the assistant's side will hold the compresses, sutures, etc.; the other 
 le will hold the instruments, 
 patient the preliminary preparation. Shave the 
 parts alway ible, first lathering with soap and hot water. 
 
 The razor is almost indispensable as an agent of disinfection, for it 
 
I be hair and t \\> I 
 
 common fault to be , "" paring with its use. In op the 
 
 skull, the whole BCalp should baving may be < : 
 
 after the patient "zed; bul -ible 
 
 should L« -curtail tin [ftheopei 
 
 be prolonged, wrap I in blai fur hot 
 
 iron- or water bo( til 
 
 Third Sh p. 'Everything bavi rry the 
 
 into 
 its special n bii h of 
 
 It the • 10W 
 
 is the time to Merili with burning alcohol. Into 
 
 ir two or three spoonfuls of alcohol and set it on fire, in the 
 [ting the dish in various dim tions so that the flame is 
 brought in contact with the whelk When thi 
 
 done, lift the compii d instill] it of their 1 .lace 
 
 them in th< r them with an antiseptic 
 
 solution. This protects them from possible contamination until 
 the operation tx compresses till 
 
 led. Remember to rile dipper, if i y to 
 
 dip out the sterile uaM ; U rioiis soluti< 
 
 p. *Direct the . • to begin I and 
 
 now pr< i email. ncc and 
 
 art," the first duty ol the surgeon. They in by a 
 
 desultory rinsing in soapy water, or par with a hot ai 
 
 solution, hut by a patient and systematic scrubbing. Get your 
 BfeeveS rolled up and pinned. Ha\ i basins, 
 
 one with hot and the other with cold sterile water. 
 
 m with SOap and hot water. Lather the arms up to the el' 
 and tllb the soap in until the skin m Then 
 
 begin with the brush; scrub the palms, the dorsum of the hand, be- 
 tween the fingers, all about the nails. One need not rub the skin 
 off, to he sure, hut the disinfection must The w 
 
 should he changed several times, it' possible; next rina erile 
 
 water and then rub vigorously with alcohol to remove all the oils 
 in the skin; finally soak in bichloride solution. The cleansing will 
 probably occupy ten minutes. Tin aics used vary with the 
 
IO l mi RG1 NCi AN riSEPSIS 
 
 it, after all, it is the soap and hot water which is most 
 
 important. At the Indianapolis City Hospital the routine is scrub- 
 
 : with soap and water; rinsing in lysol; rinsing in sterile water; 
 
 finally Bcrubbing thoroughly with gauze saturated with alcohol. 
 
 In an i >ne might feel safe in using the alcohol alone. 
 
 Alcohol as a disinfecting agent has the disadvantage that it fixes 
 the blood of the operation on the skin but this may be removed by 
 a warm solution of sodium carbonate. 
 
 almost universally employed in hospital clinics. 
 trying to the temper where the surgeon must manage 
 them himsdf. One plan is to fill them with the solution used in 
 the operation and which is squeezed out after the hand is in place. 
 rmeister says that just before putting on the gloves, he rubs 
 ils of bolus alba with a little water over his hands 
 Kit they are covered with the thick paste, enabling the glove to 
 be pulled on and off easily, protecting it against tearing and be- 
 has a soothing action on the skin. (Zent. blatt. f. 
 Chi Feb., 1913.) They are probably an extra guar- 
 
 antee ion, but are by no means indispensable. As 
 
 good plan as any, perhaps, is to use them always where infective 
 e likely to be met with; thus the operator is protected; 
 his hands are kept free from septic agents which might 
 
 . — In the meantime the anesthesia has progressed. 
 
 When it is wrll under way, prepare the field of operation, which we 
 
 me has been previously shaved, by scrubbing with soap and 
 
 ohol or ether and bichloride solution. Har- 
 
 iiiiK h employed and consists of 
 
 1 lil"ri<l<\ .8 g. 
 
 60 c.c. 
 
 w ' ' 300 c.c. 
 
 tool, 640 c.c. 
 
 [uite commonly used and for emergency work is prefer- 
 
 In *' shaved dry, scrubbed with ether or 
 
 the plain Tr. of iodine applied and allowed to dry. 
 
 d when it dries the sterilization is 
 
DIMM J. < HON 01 J 111 I I 
 
 In -domen, particularly, the iodine should 
 
 finally n LcohoL batever method may be 
 
 ed, the di m <>f the skin must be, in aery respect , as 
 
 thorough and > i as that 
 
 the proposal li>i< <>i in. j ion in nil <: , for one can never tell 
 
 when- the in< idon may finally enel. A | 
 
 rapidly prepared as a unall one. I i in laparotomies 
 
 the whole abdomen should be included, as well as the lower half of 
 
 the thorax. In hernia operatio as the um- 
 
 bilicus, the groin and th da. In amputat -. the 
 
 thigh should be included in the d< I in amputations of 
 
 the thigh, the whole i Ivis. 
 
 Again wash yOUI hand-. An untrar the 
 
 bowls may spoil the sterilization by getting his fingers or thumbs 
 inside Direct him how to lift and carry a bowl with his palms 
 against the outside. 
 
 Having completed the final i g of the hand-, cover the 
 
 field of operation on th« des with four sterik 
 
 com] d them with sterile safety pins or artery for 
 
 Time gained by relaxing in th i of 
 
 asepsis and antisepsis, is irretrievably lost; it is the operation, i 
 begun, which must pi rapidly. 
 
CHAFFER III 
 ANESTHESIA 
 
 v in most emergency operations, not only 
 
 to obviate pain, but because it is often essential to a good operation. 
 
 Unfortunately, on the other hand, it adds to the doctor's task and 
 
 its some special difficulties. 
 
 In certain grave conditions, as intestinal occlusion, strangulated 
 
 hernia, or abdominal traumatism, it may be the immediate cause of 
 
 \cr carefully administered. 
 
 Not only in emergency work, but in any case, general anesthesia 
 
 should be cautiously induced and narrowly watched; and for this 
 
 especially embarrassing to the doctor compelled to 
 
 entrust it to the untrained in cases of urgency. 
 
 Chloroform has the advantage that it requires no special apparatus 
 
 for its administration; and the smaller bulk is an item of importance, 
 
 I sally in military practice; moreover, it is much more pleasant 
 
 to the patient Unfortunately, it is many times more dangerous 
 
 than ether, even in the hands of the skilled. 
 
 In lieu of a special inhaler, such as Esmarch's, fold a handker- 
 :", napkin, or compress several times to form a square. Begin 
 by pouring on several drops and gently approaching it to the mouth 
 and nose of the patient. The inhaler should be managed with the 
 left hand, leaving the right hand free to raise the eyelid, or feel the 
 pulse, or handle the container. Do not hold it too close to begin 
 ive the patient plenty of air; in other words, give the 
 roform well diluted. Give the patient time to get accustomed 
 Advise him to breathe through the mouth and dis- 
 tract hi ftuch as possible; get his confidence, flatter 
 him, and, in the meant i: ly him and test him. The few min- 
 t in thifl way will soon be regained. 
 Pour < of chloroform at a time; and, as the 
 
 r, hold the inhaler closer, giving the 
 chloroform less diluted with air. Replenish the supply every half 
 
MI! IHI-.SIA 13 
 
 mini nkling it on the Idc of the compress and quickly 
 
 Inverting in over 1 b< 
 
 \ 'I- >mes on, push it more. When the 
 
 ie dosage but increase the frequency 
 val. 
 The drop method i- ideal after thi esia has been attained. 
 
 applied mean the smallest total amount. 
 whi< I) must be the a :t aim (Fig. 1). 
 
 Ili not the 1 can use the largest amount 
 
 of < hloroform without death, hut the one who can hold the pat 
 
 and relfl mount possible. 
 
 ^\ 
 
 ■ 
 
 If the patient coughs or sh< - of nausea, increase the dosage 
 
 ai once. Do not begin the preparation of the field or rt of 
 
 the operation until the anesthesia is cotoplet 
 
 Keep the puht\ the /a/..', tl the thorax under con- 
 
 stant surveillance, for in this way alone may one determine the 
 prognosis, good or had, oi the anesthesia. 
 
 The anestl usually described as occurring in three stag 
 
 the first, sta citement; tl d, loss of consciousness; the 
 
 third, loss of rctlev -urgical I 
 
 fourth, Btage of parol) he automatic centers, but this is a 
 
 Stage which the good anesthetist will never reach. 
 
 The excitement of the initial Stage, in which the patient struggles 
 or talks at random, is followed by loss of consciousness, but the re- 
 flexes are active, the pulse is full and bounding, the pupils respond 
 to light, the eyelid resents the corneal touch, the skin is sensitive, 
 the face is Hushed, and the breathing deep and regular. 
 
M 
 
 ANESTHESIA 
 
 at this time of sudden blanching of the face, of dilated 
 pupils, of weakened pulse, or disturbed breathing. If these symp- 
 toms arise, withdraw the anesthetic and prepare for artificial respira- 
 tion. The patient is not ready for the operation and yet he may die 
 in this 
 
 lor and dilated pupils often precede vomiting, but when the 
 pulse and respiration are good, the nausea is to be quieted by more 
 chloroform. 
 
 When the reflexes are finally abolished, the pulse should be full, 
 though perhaps a little slowed, the respiration quiet and regular, 
 the pupils slightly contracted, and the face moderately pale. Any 
 marked deviation from this standard during the operation is a 
 matter for concern. 
 
 Weak heart action, uncertain respiration, dilated pupils, deep 
 pallor or cyanosis, mean approaching paralysis of the automatic 
 centers governing the circulation and respiration, and the anesthetic 
 must he withdrawn until the symptoms improve under measures 
 employed to stimulate. 
 
 In the case of the average adult, one and one-half to two ounces 
 should be sufficient for the first hour and much less subsequently 
 Children and the debilitated require less. 
 
 Ether has the disadvantages in emergency work that it is danger- 
 ear a light or fire, and that its administration is a little 
 more complicated; but, beyond that, its anesthesia is never at- 
 tended by sudden death in the early stages, as is that of chloroform. 
 It is followed by less shock after abdominal operations or other pro- 
 longed intervention. Bronchial affections are its chief counter- 
 indications. 
 
 Ether may be administered by the drop method using the same 
 
 mask as for chloroform (Fig. 2) and the same general method (Fig. 
 
 Or an inhaler may be fashioned out of a newspaper rolled into 
 
 a co ton or gauze fastened in its apex, on which the ether 
 
 oured. Begin with a drachm; let the patient get accustomed 
 
 luallv to the ether, diluting it well with air by holding the inhaler 
 
 an inch or bo from the face and gradually approaching. In that way, 
 
 the feeling of suffocation is avoided. As the patient approaches 
 
 unconsciousness, hold the mask closely so as to shut out the 
 
II II 
 
 without 
 
 • hi. 
 
 /. 
 
 regulating Mow, unattached, to righ* an. 
 
 1 1 one pit* .ill be hard 
 
 to obtain and mm h mon 
 
 PlG bating flow attached to can. 
 
 ,uv abolished, use small quantities, frequently applied. The i 
 
 dent most to be feared is respiratory parai 
 
ANESTHESIA 
 
 Tb indicating the favorable progress of ether anesthesia 
 
 during the operation are: pulse full and regular; respiration deep and 
 slightly snoring; face Hushed; and pupils slightly dilated. Cyanosis 
 for more oxygen. Any disturbance of the respiration 
 demands immediate attention. Occasionally patients will be 
 found who do not take ether well, but who will take chloroform with- 
 out the least untoward effect. 
 
 TREATMENT OF THE ACCIDENTS OF ANESTHESIA 
 
 ; tain measures are recommended as forestalling the dangers 
 of anesthesia; though they are, as a rule, more appropriate to the 
 general surgery of hospitals. 
 
 A preliminary gastric lavage will save embarrassment in certain 
 cases. In fact, this should be an invariable rule, when compelled 
 to operate on patients who have eaten only a short time previously. 
 A preliminary subcutaneous injection of normal salt solution will 
 sustain the patient in the cases of anemia and grave septic infection. 
 
 Many surgeons precede a chloroform anesthesia by hypodermic 
 injection of morphine or strychnine, or of morphine and atropine, 
 thirty minutes before the anesthesia. This is desirable especially in 
 operations on regions in which the reflexes are more active, for there 
 is scarcely a doubt that some of the circulatory disturbances under 
 chloroform are reflected from the field of operation. This is true of 
 the testicle, the spermatic cord, the anus, and the peritoneum. None 
 of these methods lessens the anesthetist's responsibility and duty to 
 watch every point. 
 
 If the circulation grows weak, the pulse small, rapid, compres- 
 
 i the effect of the anesthetic agent and not to shock or 
 
 hemorrhage, withdraw the agent and lower the head, draw out the 
 
 _ f ue and begin artificial respiration, and the danger is usually 
 
 soon 
 
 Hyp dermic injection of stimulants, such as strychnia or camphor- 
 
 Lo good under these circumstances; but when the 
 
 circulation is paralyzed and syncope has supervened, their use is 
 
 illusory. Do not waste time preparing them, though an assistant 
 
 but proceed to make rhythmic traction on the tongue, 
 
akiii \< i \: 17 
 
 gild art, , both being e.: it methodically. If 
 
 an a oM I hand, I . jltaneo'. 
 
 <>tln or at least get it pulled out 
 
 well. Traction of 1 he tODgUC to do good, must be rhythm. 
 
 « and no force must 
 by the feverish pull> 
 of the ag tor, wh . that the mane 
 
 nal only when rhythmic. 
 
 Ili- rhythm 
 
 the patient 1 • them gently and steadily 
 
 upward until tin above I 
 
 put upon tli i and 1 1 pro- 
 
 din ed A' ili<- unc ' 4). 
 
 i . — SUge of ngue ahould be drawn out with this movement. (SUwtrt.) 
 
 The amis are next brought with a steady ent to the cb 
 
 wall and the diaphragm compresoi ation.) At 
 
 the same time, the tongue is permitted to 
 
 These movements are to 1 a the rate of about twe 
 
 pel minute and should be persisted in without intermission for at 
 least a half hour before giving up hope of resuscitation. 
 
 Direct compression of the heart i> a procedure of real value and it 
 may often be readily managed through the abdominal walls. In the 
 oi abdominal operations, the hand may I J up to the 
 
 diaphragm and the heart seized and kneaded in that manner. 
 
 The Pomiting after anesthesia is often troublesome and is usually 
 
ANESTHESIA 
 
 in lined ratio to the amount of the agent used. Every effort should 
 ,ii its elimination from the blood by keeping the skin 
 and helping the kidneys with saline enemata. 
 emata also diminish thirst. Warm soda water drunk freely 
 helps h out the stomach and thus hastens relief of active vomit- 
 
 I ive to fifteen drops of aromatic spirits of ammonia hypo- 
 well diluted, by mouth, often does good. Both 
 gents probably do good by relieving acidosis which is a large 
 : in producing post-anesthetic troubles. 
 
 piratic 
 
 ted to drop back in mouth. (Stewart.) 
 
 knees of beginning acute gastric dilatation, gastric 
 must be used early. 
 
 1 anesthesia will not often be of service in 
 
 [or obvious reasons, however valuable they may 
 
 It is hardly necessary, therefore, to consider nitrous 
 
 ethyl chloride and their congeners; or general anesthesia by 
 
 i i turn, which promises to be of value in operations on 
 
 the I nd thorax; or hedonal and ether intraven- 
 
 ily which has been the subject of good reports. 
 
 LOCAL ANESTHESIA 
 
 i 1 and without assistants, will many times find 
 
 ttfort in local a: i by hypodermic injection; but 
 
 tob- *.it must be properly induced. A definite technic must 
 
be followed. Either I, the latter 
 
 »rc active, the I Having 
 
 determined the line oi incision, pinch up a fold <>f skin Fig. 6), 
 introdiu e the needL end of the line and push it into the skin, 
 
 but not through tin- skin. Tl * tion is intradern 
 
 I^xral anev' f introducing n< 
 
 An the needle is steadil) advanced, tin I slowly, 
 
 and the line of inje. 1 by the formation of a wheal. 
 
 When the needle ha- entered it- length, it i- rein* 
 
 line and in ;i<1\, 'he previous puncture, hut within the 
 
 already anesthetized. In this : '"t puncture is felt. 
 
 When the line of iru ision ha- been infiltrated in this manner through- 
 
 i-i... 
 
 i; the needle does not penetrate the whole 
 
 thickness of skin; "intra-dermic" in;> rau.) 
 
 out its entire length, it will be completely insensitive after a wait of 
 one to two minutes. The width of the zone of anesthesia will de- 
 pend upon the rate oi movement of the needle through the skin 
 (Figs. 8, 9). It need hardly be said that the needle and solution must 
 always be sterile. It is better to pour the solution out into a sterile 
 
ANESTHESIA 
 
 r 
 
 dish or glass, rather than to aspirate it from the bottle. The air 
 must be forced out before the needle is introduced; care must be 
 
 taken not to throw the injection into a vein. 
 
 When an area, rather than a line, is to be infiltrated, as in case 
 
 LOD is anticipated, Schleich's method is better, in which 
 
 the needle is plunged directly into the tissues and a sufficient quan- 
 
 i 
 
 8. — Local anesthesia; the 
 
 tone of infiltration is narrow 
 
 when the needle is pushed for- 
 
 and emptied rapidly. 
 
 :u.) 
 
 Fig. 9. — Local anesthesia; the 
 zone is broad when the needle is 
 introduced slowly. (Veau.) 
 
 tity of the solution discharged to raise a wheal. The needle is then 
 reintroduced alongside the wheal for another injection. The anes- 
 ia may be renewed from time to time during the operation. 
 Schleich's formula is as follows: 
 
 
 I, STRONG. 
 
 
 in. hydrochlor., 
 
 
 gr. iii. 
 
 Morphin. hydrochlor., 
 
 
 gr. V->. 
 
 Sodii chloridi., 
 
 
 gr. iii. 
 
 Aq. destill 
 
 
 5 iii, 3 iiss 
 
 
 2, NORMAL. 
 
 
 in. hydrochlor., 
 
 
 gr. iss. 
 
 Morphin. hydrochlor.. 
 
 
 gr. %. 
 
 Sn<lii bhloridi., 
 
 
 gr. iii. 
 
 Aq. destill 
 
 
 5 iiiss. 
 

 !• WEAK. 
 
 hydro* bl< 
 Iforphin. hj «lro< hJor., 
 s<>« I i i ( bloridi., 
 
 A«j. di 
 
 ;ii. 
 
 Two or tin Iution of carboli 
 
 1 to p" Iution must be kept cool. ; 
 
 500 of Number 3, 1 | without d 
 
 base. (Veau.) 
 
 -Complete anesthesia of fin- 
 
 •duced by deep injections on each 
 
 The upper and lower needle. 
 
 :u.) 
 
 How- 
 
 lion, though in equal quantities slightly more dangerous. 
 ever, smaller quantiti equired. 
 
 The patient should not be permitted to sit up during the ai 
 thesia it' COCaint 1, for it exposes him to the risk of heart 
 
 failure. It is safer to keep him R eumbent for a half hour or so after 
 the operation. 
 
 if a finger or 1 he amputated, first make an anesthetic 
 
 ring involving the skin only (Fig. 10), and follow this with two deep 
 lateral injeetions to obtund the main nerve trunks (Fig. 11). 
 
\\1 SI HI SI A 
 
 SPINAL ANESTHESIA 
 
 inal anesthesia with stovaine can only very rarely be of use to 
 
 ral practitioner in emergency work, although it is of value 
 
 under certain circumstances. It is of special use in operations in- 
 
 the anal and perineal regions. By this method the heart 
 
 and lungs are not dangerously affected. It is a solace to those pa- 
 
 tien: dread of a general anesthesia is greater than their dread 
 
 «ath. and who will refuse operations of absolute necessity rather 
 
 than take ether or chloroform. The most definite contra-indica- 
 
 tion is uncertainty oi asepsis, since the chief danger of the procedure 
 
 eningitis. It should not be used in the young, in advanced 
 
 s of septicemia, or central nervous disease. 
 
 duration of the analgesia thus produced is one hour. 
 
 i airly uniform; the chief after-effects are headache 
 
 I toe of the author's patients, operated for hernia 
 
 under spinal anesthesia complained for several months of loss of 
 
 sensation in the penis and rectum, though not materially interfering 
 
 with the functions of either. The preparation employed by the 
 
 author i- that of Chaput: stovaine, 10 gr.; sodii chloridi, 10 gr.j 
 
 distilled water, i c.c. This is put up in hermetically sealed am- 
 
 ach containing i c.c. of the solution, which is sufficient for 
 
 an injection. 1 trds cocaine as the most dangerous and 
 
 tropacocaine th< and this latter he employs in doses of % 
 
 in. The syringe employed must be easily sterilized and 
 
 with of at least 2 c.c. A long platinum needle is best. 
 
 with needle for this injection can be readily 
 
 1 hnic. — The patient's back, the instruments, the solution, the 
 
 re duly prepared. The needle is attached to the 
 
 _• and the contents of an ampoule aspirated and the needle 
 
 patient sits bending forward to make the lumbar 
 
 prominent and to enlarge the intervertebral foramen 
 
 which is to 1 by the needle. Locate the iliac crests and 
 
 mark th ion with the finger nails. The line connecting the 
 
 highest points of the iliac crests intersects the fourth lumbar spine 
 
 to be located in the middle line. The tip of 
 
the next spine above the third marked and be 
 
 two points the puncture is made. Hold the left index I n the 
 
 third lumbar -pine. Hold the unattached needle in the right 
 hand, ;tnd enter it* point just below the third lumbar spine a little 
 to the right of the middle line, and push it slightly upward and in- 
 ward at an ufTicient to meet th( the 
 
 middle lint-. Pushing the needle steadily upward an 1. it 
 
 can befell to reach the resisting ligamentumsubflava and, finally 
 pun< iuic of the membra nnounced by th< inal fluid 
 
 from the needle. Hold tin the outlet until the 
 
 (an lied; then let sufficient fluid run in 
 
 Lfl other word-, make a mixture in th« 
 
 equal pa tovaine solution and spinal fluid. 1 pinal 
 
 fluid becomes milky on i: 
 
 '. ly inject the mixture, and when the gyring . ith- 
 
 draw the needle with a rapid m<< d the puncture 
 
 with Collodion. It will require no further attend 
 
 1 lave the patient lie i id now prq 
 
 In ten to fifteen minute- tin 
 complains of a pricking on in th( id numl . the 
 
 A pinch or a pin prik k will he felt hut will n<< - 
 
 the pain become e in the of the o; little 
 
 chloroform or ether can be employed. I does 
 
 not extend high enough, incline the ightly, : 
 
 During the operation the patiei and 
 
 his head will throb. Afterward there i- likely I 
 
 ache \^>v a little while and perhaps some naus 
 
 The site ^i puncture may be numbed with << that the 
 
 spinal injection is painless. If the point of the needle 
 against the vertebra, withdraw slightly and change the direction 
 as the judgment dictates. The most common mi-take is in di- 
 recting the needle too much upward. (Inly very rarely will one fail 
 to reach the spinal canal if the landmarks are well defined. 
 
 Jonnesco has been the great advocate ^i this form of am 
 and reports it^ use in 2500 cases. He believes now more than ever 
 that unlike ether and chloroform there is no contra-indication and 
 that it is the anesthetic of the future. 
 
AM S I 111 MA 
 
 Murphy referring to this and other of the newer forms of anesthesia 
 
 that considering the safety and simplicity of the 
 
 ether drop method the mass of the profession should await larger 
 
 by those who originate and are best fitted to work out 
 
 the destiny of these newei forms. (Practical Medical Series, 
 
 Vol i [, 1014.) 
 
CHAFl ER tV 
 
 SUTURES; METHODS, AND MATERIALS 
 
 Suture plied for the purpose of maintaining the coapta- 
 
 tion of divided structures. This is n< pair 
 
 and function. Suturing serves the additional purpose of 
 
 checking hemon om the smaller There is do part 
 
 of the surgeon's technic that ion than the 
 
 Lection and u It ia of special importance I mer- 
 
 gency Burgeon who bees infection in every direction. His mtui 
 
 however, he may absolutely control and mal and this 
 
 may be the only diffi success and failure. 
 
 Various materials B mmonly, others 
 
 and for a certain puipo -ilk, silkworm-gut, silver * 
 
 kangaroo tendon, and horsehair. The three first named will n 
 
 all the requirements of the em< on. 
 
 No material is available which does not have a certain strength 
 and which cannot be made asepti work, tl 
 
 materials must be already prepared. Th ion of a proper 
 
 suture from the raw material is a matter of time and care. 
 
 The general practitioner will do better to buy his sutures pre- 
 pared in form available for immediate use, being first assured that 
 they come from a reliable source and are put up in a manner to 
 keep them sterile. Much suture material on the market has neither 
 of these qualifications. 
 
 Silk has the advantage of lending itself to emergency steriliza- 
 tion by boiling and immersion in an antiseptic solution, nor is it 
 readily contaminated when once sterile; but it should not be boiled 
 in soda solution, which makes it brittle. It has the disadvantage 
 of not being absorbable. It may be used in buried sutures, but its 
 usefulness in that respect grows more and more limited as the art 
 of sterilization and preservation of catgut improves. It may be 
 
 25 
 
SUTURES, Minions and MATERIALS 
 
 ! in interrupted skill sutures, suture of nerves, of tendon, and of 
 ::n<\ but muscular tissues do not tolerate it. 
 is the ideal material for the buried suture. The chromi- 
 ample strength and is so prepared as to resist absorp- 
 tion in a certain tissue for an approximate time; but it should be re- 
 membered that occasionally chromicized gut becomes practically 
 unabsorbable and, acting as a foreign body, gives rise to persistent 
 >inu- J, With a little attention to this detail, a suture may be 
 which will resist absorption until repair is complete. Plain 
 an be used in those tissues only which rapidly unite. It is 
 J for suturing the peritoneum and for ligating vessels except the 
 ones. It is very easily contaminated. Where there is 
 pus it should never be used as a buried suture. The three qualities 
 which the catgut suture must possess are: sterility, tensile strength, 
 kbility. If a certain brand of catgut produces stitch- 
 istently; if, properly used, it still breaks inopportunely; 
 if it refuses t<> be absorbed, then there is something wrong with its 
 manufacture. The occasional surgeon lacking opportunity to test 
 all the brands, must therefore fall back upon the manufacturer's 
 reputation and guarantee. Absorption of catgut occurs in this 
 manner: at first the fibers untwirl and grow loose and finally become 
 pulpy at which stage the suture has no tensile strength and is a 
 body which is gradually replaced by connective tissue, a 
 ess which i- sometimes exceedingly slow. Even sterile catgut 
 rated into a gelatinous compound becomes a nidus 
 owth, Absorbability is therefore as important as 
 
 W ind certain chemicals as bichloride render cat- 
 
 • s '"' trong, nou clastic, non-absorbable, readily 
 
 d, and is miic h employed where the wound is large and deep 
 
 and the ti ■• nd strongly to spread apart Most surgeons employ 
 
 in and fascia after laparotomy. It should be 
 
 The pa Uuloid linen is in high favor with some sur- 
 
 Bexible than silkworm-gul and absorbs moisture 
 without 
 
■■■■ 
 
 ^^M 
 
 
 ture. 
 
 'I he meth< the 
 
 interrupted utufi and the twi/fj nil y 
 
 employed in general surgery arc the quilled, the quflti 
 the twisted, and the button sutu 
 
 The continuous suture is used in asepti< 
 wound- only. Therefore, a< i idental wounds 
 will only, on rar< em- 
 
 ployment It has the advantage of 1" 
 rapidly applied, but is less sure I 
 the interrupted suture. A little prs 
 
 ntial, for it is not altogether easj 1 1 
 success depends largely upon tl tant. 
 
 This is tin- mode of making the con- 
 tinuous suture: Commence by passing the 
 suture at the upper angle of the wound. 
 
 Make three ive knot r . The 
 
 short thread is caught in I and retained till the sutuit 
 
 which time it is 
 c Lose to tin- knot 1 
 
 The needle tra dy and 
 
 obliquely, firsl the one lip of tl.< 
 
 and then the other; eat h time tl 
 
 ant - the thread at the point 
 
 emergence, and holds it tightly until the 
 
 surgeon make- a new point of en • 
 when the assistant take- a new hold. 
 In this manner, the ten-ion of the suture 
 i- made absolutely uniform. 
 
 Th< wrest of the continu 
 
 suture is important. In making the 
 terminal knot, the suture must not be 
 Fu„ 13.— Method of making a allowed to relax. To accomplish this, 
 ;^ nt j ,nuou i s sut; : the surgeon slips the index anger in the 
 
 holding the suture tight while the 
 
 needle is passed again. (Kmw.) last loop instead 01 pulling the thread all 
 
 the way through. done with all 
 
 the others. Traction with this linger holds the line of suture 
 tight while the terminal thread on the one side is knotted tl 
 times with this loop on the other side (Figs. 14, 15). 
 
14. — Completing the 
 continuous suture; holding 
 the suture tight with finger 
 through loop while getting 
 ready to tie. (Veau.)' 
 
 Fig. 15. — Method of ty- Fig. 16. — Continuous su- 
 ing completed continuous ture interrupted in its course 
 suture. {Veau.) (Hartmann.) 
 
 17. — Method of 
 interrupting the con- 
 tinuous suture in its 
 course. Needle pasted 
 back under last loop. 
 
 Fig. 18.— The 
 needle has 
 passed through the 
 loop which is drawn 
 down tight and the 
 suture proceeds as 
 before. (Veau.) 
 
 Fig. [p. — Method of passing deep inter- 
 rupted sutures. (Veau.) 
 
■mi I i) >\'ii 
 
 the continuous uttu red by crossing 
 
 the threads at the middle of the line of suture 
 suture is thus interrupted at its middle in this manner: the i 
 
 
 '. to se« 
 cure coapt.i 
 
 1 of pawing 
 
 superficial suture*. (V'eau.) 
 
 simply passed bai k under the last loop, taken 
 
 thai the suture does not dip. Tin -ame 
 
 as befoi The suture 
 
 completed, the loose ends are ( ut 
 close to the knot. 
 
 The interrupted suture is generally 
 employed in suturing the skin, and 
 may be of silk, silkworm-gut, >i : 
 
 It must not be absorbable. 
 These sutures may be placed deeply 
 
 or superficially, in the one ease where 
 there is mueh tension, in the other 
 for mere approximation. The deep 
 sutures are placed two or three cen- 
 timeters apart. 
 
 The needle is entered one centimeter from the edge and emerges 
 the same distance from the other side. The thread is eoneealed 
 
 
 Hmi U d* ft 
 
 Brnrmt t*d*it 
 
 22. — Sutures must not be tied 
 too tight. (MouUin.) 
 
SUTURES, Millions AM) MATERIALS 
 
 through most of its extent (Fig. 19). None is tied until all are 
 
 ol. The lips of the wound are brought together as the knots 
 
 o). 
 
 \ few superficial catgut sutures may be necessary if the deep 
 
 sutures do not completely approximate. They are passed through 
 
 the thickness of the skin alone and very close to the edge of the wound 
 
 No knot should be drawn too tight. It may interrupt the circu- 
 lation and defeat repair. The knot should be made to one side of, 
 and not over the wound (Fig. 22). 
 
 If all goes well, the sutures may be removed 
 toward the eighth day. Remaining too long, 
 they favor infection. 
 
 Methods of Removing Sutures. — Seize the loop 
 with a dissecting forceps held in the left hand. 
 With a pointed scissors divide the thread 
 close to the skin, being careful not to cut be- 
 tween the knot and the forceps, else one will 
 be trying to pull the knot through the skin. 
 
 Suppose, in spite of care, infection occurs. 
 The temperature reaches ioo^° on the follow- 
 ing day. On the second day following, it is a 
 little higher. Upon removal of the dressing, 
 the skin around the wound is found to be 
 The subcuticular suture; reddened and swollen. Remove two or three 
 method of passing and f the middle sutures at once. Secure drain- 
 age and use a wet dressing. This will usually 
 k the infective process and pus formation. 
 e subcuticular suture is of great service in aseptic operative 
 inds, wherever it is especially desired to prevent a scar. It is 
 made in thi> manner: 
 
 [ntroduce a small needle threaded with No. 1 catgut, 34 
 inch above the upper angle of the wound, and let it penetrate the 
 -kin and emerge exactly at the upper angle. It next penetrates 
 the face of the skin incision, taking a bite first on one side and then 
 the other exactly opposite (Fig. 23). At the end, the needle 
 traverses the skin at the lower angle of the wound in the same 
 
 
i III 
 
 manner as it entered af the upper angle; the suturi 
 tight mtil tin 
 
 ured from slipping either by knotting or by 
 them <lown with collodion or adhesr U the tl not 
 
 orbed, it ed about the sixth day by clip] 
 
 end in and then gently dra from tin- other 
 
 end. 
 
 tnnaday uses pa( her linen and aft ture 
 
 i bya half bow knot The terminal threa 
 
 m-( ured in the jam< I slipping 
 
CHAPTER V 
 DRAINAGE 
 
 Drainage may justly be regarded as a matter of antisepsis. It 
 prevents sepsis by creating a current which moves away from the 
 wound, and by depriving the bacteria of their chief pabulum — the 
 wound exudates. Drainage facilitates repair by relieving tension. 
 In the same manner it relieves pain. But when these points are 
 made the whole is said, for drainage is by no means an unmixed 
 good. On the contrary, it is a necessary evil and for these reasons: 
 in reality it is a foreign body; it necessitates frequent renewal of 
 gs; it may injure granulations; it keeps the wound open and 
 delay- healing; in the abdominal cavity it sometimes predisposes to 
 fistula, hernia, and intestinal obstruction. Nor is the profession by 
 any means of one mind regarding the indications and contra-in- 
 ktions. It is a matter in which one cannot be dogmatic. The 
 rule of practice must of necessity vary with the patient, the 
 operator, and the environment. 
 
 The emergency surgeon, the general practitioner, will more often 
 <lrain than the hospital surgeon in formal operations. And this 
 leads to the fundamental principles involved. 
 
 ;)tic wounds, as a rule, do not require drainage. 
 Infected wounds or those suspected should always be drained, for 
 infection of any kind demands an outlet. 
 
 \< < idental wounds are presumed to be infected, whereas operative 
 
 umed to be aseptic. 
 
 As an exception to the rule that aseptic wounds do not require 
 
 drainage, note that those in which there is of necessity much post- 
 
 rative oozing do better with temporary drainage. Examples: 
 
 n stumps, and breast amputations. 
 
 wounds are not drained after the third day, if infection 
 
 ' made it- appearance nor seems likely to develop. 
 
 In!' ire drained as long as there are any discharges. 
 
 32 
 
 i 
 
WIC1 
 
 Tk of droit 
 
 :\<\ open iround 
 Rubber tubes t the larger I r in pr< 
 
 draining large cavil 
 ■f drainii They 
 
 ihould I- -I may be improvised from rubber catb I 
 
 Win I close to the sur 
 
 bored by suture or safe: 
 
 Gauze. I'i which drains by c:ij>ill:irit >*, is an 
 
 «tti< >, such as scrum and blood. It 
 
 i be additional advantage that in appropriate ( ascs it may be at 
 
 ame time employed for bo vantage 
 
 that it booo to drain, acquires m la painful t<> 
 
 remo 
 
 Tubal and < apillary dn intageously ( ombined in the 
 
 drain. 91 A wick 91 drain is 
 
 made by splitting a tube of the required and fitting it lo< 
 
 with a strip of gauze. When the tul m of the 
 
 cavity, the projei tii with the o< 
 
 Burfat e, is hem< illy may b< 
 
 turbing the tub i the same principle and 
 
 cnti;ill\ i ick drai within the other. To m 
 
 I (< dgarette drain," take a 10 inch of rubber ti>sue, O 
 
 it with four *>r five L tnd roll the whole into a 
 
 slender cylinder. 
 M Wick " and " v igarette 91 draii s should be removed on the second 
 
 Or third day. If infection i : at that time, a tube should be 
 
 substituted; a tube must be employed if infection develops later. 
 
 Tubes employed in the drainage of pus cavities should be rem*' 
 
 (leaned, and reinserted at cry third day, and arc to be 
 
 shortened pari passu with granular repair. 
 
 As has been said, an open wound i< a means of drainage, and for 
 that reason accidental incised woun is a rule, not completely 
 
 sutured. Lacerated wounds not repairable need no other drainage 
 than that afforded by the gauze dri 
 
 To note briefly some examples of drainage: \ - are alw 
 
 to be drained with tubes. 
 3 
 
DRAINAGE 
 
 V atC spreading infections are to be drained with tubes. 
 
 la Mental incised wounds are to be drained with tubes, or simply 
 by rubber tissue if the wound is small. 
 
 Operative wounds oi the soft parts in emergency practice are often 
 
 drained superficially — all the layers are completely closed ex- 
 
 the skin, A few strands of catgut between the lips of the 
 
 wound will often be all that is necessary for drainage and has the 
 
 advantage oi requiring no change of dressing. 
 
 An empyema or purulent peritonitis must be drained with tubes. 
 
 Manv thoracic and abdominal conditions are to be drained with 
 the wick or cigarette drain. If there is no probability of infection, 
 if there is not much oozing, do not drain at all. 
 
 In compound fractures and compound dislocations drain only the 
 skin wound. If infection develops, deep drainage must be substi- 
 tuted. 
 
 Further details will be given in connection with the various 
 
 rations requiring drainage. 
 
 
CH \l'l ll: \ I 
 DRESSINGS, BANDAGES, SPLINT 
 
 The en 
 If he has tterili c absorb, *, he can efficiently 
 
 meel all the indi< ai i< far u di 
 
 materials furnish in the higl 
 
 \ good dr< 
 te< ii\r. it « ondui i- the I ind and 
 
 prevents the approach <>i' infective irork 
 
 better to buy these mater; pared and n 
 
 instant i the 
 
 most trust worth) produ< I 
 
 tiona the) should b Sized it possibL 
 
 to sterilize is by -team. Still tin the 
 
 high heat in the closed • the kitchen ably 
 
 cpe ted to be germ free, M n useful but not 
 
 itial. nor so much employed as formerly. It may be in. 
 
 dusting the plain steril< with the p r e f e rr ed ai 
 
 powder at the time of dn I or thai matt* 
 
 may be improvised for temporary use bom muslin, linen, or cheese- 
 cloth. Towels or sheets may be prepared by boiling for fift 
 minutes in soda solution, rinsing in g out 
 
 the water, and completing the dryii From 
 
 these material- one may provide not only dl 
 
 and sponges for the operation. 
 
 An aseptic wound requires that the g be dry; whatever slight 
 
 serous oozing there may be is thus rapidly absorbed. 
 
 mds require a dressing moist wit solu- 
 
 tion. Tor one thing, the moist gauze conforms better to the irre- 
 gluarities Of a lacerated wound. Again, the antiseptic agent ex< 
 some slight destructive effect, perhaps, upon the germ already in the 
 
DRESSINGS, BANDAGES, SPLINTS 
 
 ind and is a more effective screen against those trying to get in. 
 ml bichloride gauze are the most commonly used. 
 mt, sterile gauze saturated with peroxide 
 of hydrogen is to be recommended. As an antiseptic dressing New- 
 man particularly recommends gauze saturated with subgallate of 
 bismuth. (Lancet, June 28, 1913.) 
 
 tags must be ample. Too often an aseptic operative 
 wound eventually becomes infected merely because not sufficiently 
 protected. The dressings must not only be thick enough, but they 
 must extend widely beyond the limits of the wound. It is a poor 
 I , if one can lift its edges and inspect the wound. 
 The frequency of redressing is variable. In general, the fewer 
 sings the better. The aseptic operative wound should need 
 but two dressings. The original dressing is removed when the 
 ores are taken out on the eighth to the tenth day. 
 The septic wound may need to be dressed daily. A wound prob- 
 ably infected but not septic, one in which a drainage tube was used, 
 will need to be dressed on the second to the fifth day, when the 
 drainage tube is removed. The frequency of dressing thereafter 
 will depend upon the degree of sepsis. In changing the dressing of a 
 !e wound, every precaution must be taken against infection. 
 v a fine operative result is spoiled by carelessness in changing 
 the dressing. The hands, the solutions, the instruments, must be 
 prepared. 
 It is good practice in the case of any kind of wound to change the 
 \ er soiled, for sterile exudates may become good cul- 
 ture media. One may, however, follow Semi's suggestion, dusting 
 aturated area with boro-salicylic acid or other antiseptic powder 
 and covering with an additional layer of cotton and bandage. 
 
 in or rise of temperature after the first twenty-four hours is 
 
 ition to change the dressing and inspect the wound. 
 
 calls for renewal. The dressing that slips or 
 
 rubs is a very poor one. When the dressings are adherent to the 
 
 urface, they are to be saturated with warm sterile water or 
 
 with n. The latter is excellent when the dressing 
 
 contain^ dried blood. When changing the dressings any undue 
 
 movement of the parts must be avoided. The principles of support 
 
mi. ROLL] 37 
 
 and functional n DOt to be n< i for the short time 
 
 the 'ti. 
 
 BANDAGES 
 
 The gauze roller is porous, absorbent, pn . and therefore 
 
 a part of the dressing. I ith gauze, the gauze 
 is amply covered with al and the whole retainer! by a 
 
 smooth bandage, uniformly coi. Ider 
 
 doctors knew it, is almo Her is accommo- 
 
 Vu;. §5.- D able spies of gr< :h.) 
 
 dating and adhesive pla avenient One may -sing 
 
 the appearance of -lability without its being in reality efficient. The 
 bandage must be so applied that it will not slip and will remain 
 closed at either end. It must extend well beyond the limits of the 
 subjacent dressing, and in the case of the limbs must reach beyond 
 the next joint above. For example: a dn t the foot must 
 
 extend above the ankle; of the leg, above the knee; of the forearm, 
 above the elbow. In the region of the groin a double spica should 
 be employed, extending well up over the abdomen, and down over 
 the thighs (Fig. 
 
DRESSINGS, BANDAGES, SPLIN is 
 
 A of the neck, that it may not slip, must include the head 
 
 I should* 
 
 oi the abdomen and thorax are best held in 
 ride hand- oi flannel firmly applied and secured by 
 pins, and whose edges are held down by suspenders and 
 perineal stri] 
 
 To iifyplv a bandage to a limb, for example: stand in front of the 
 patient. Thai the bandage may unroll more freely, place the free 
 of the bandage in contact with the dressing by its outer surface, 
 and hold the roller to the outside of the limb — in the right hand for 
 the left limb, in the left hand for the right limb. Each turn should 
 rlap about one-half the previous turn. To maintain uniform 
 in spite of the limb's change in contour as the bandage 
 ertain modifications of the ordinary spiral or circular 
 turn> are necessary — the "spiral reverse" and " figure-of-eight" 
 mployed. The "spiral reverse" is used where the cir- 
 cumi rapidly changes, as in approaching the calf of the leg; 
 
 if it i- not made, one edge of the bandage is tight and the other edge 
 To make the reverse, the bandage is slackened when the 
 r side of the limb is reached and a half rotation is made, by a 
 the wrist The beginner is often observed to make a com- 
 plete turn of the bandage instead of a half turn. This tightens the 
 bandage, but does not give uniform compression. In making the 
 turn, the thumb of one hand steadies the lower edge of the bandage, 
 while the other hand makes the half turn mentioned. The reverse 
 M always be made in the same vertical line and should, if 
 - pond to the wound, in order to give it the ad- 
 ra thickn The bandage is then continued 
 
 Otind the leg until the outside is again reached when the 
 eated. The "figure-of-eight," the second means of 
 lack, is most useful in the region of the joints, and 
 ilf. 
 
 'cjor the Foot. (Fig. 26.) Begin near the toes with spiral 
 
 turj kle is neared. Encircle the ankle with the 
 
 turns and continue the spiral turns up the leg. 
 
 H » ! d to cover the heel, the first turn should cross the upper 
 
 part of the heel and over the front of the joint; the second turn 
 
ill. 1 no j 
 
 laps the lower half of the fint; the third turn i the 
 
 Upper half of tl The roller on the third turn reaches the 
 
 PlO. :' Ban lag< I I I H 
 
 vered. 
 
 2th.) 
 
 dorsum of tin toot, ;m<l is carried obliquely acm ird the little 
 
 and the foot ed by spiral turn- whi< b - npwar 
 
 it may be applied as indicated I I the fa 
 
 
 PlO. »8. 
 
 indicated by 1 ? ig, 28. If it is desired to cover the too, hack and forth 
 folds extending from in front of the ankle to a corresponding point 
 
40 
 
 DRESSINGS, BANDAGES, SPLINTS 
 
 Pic. 29. Fig. 30. 
 
 Bandage of leg. (Heath.) 
 
 to Ol "8" of knee. 
 
 Fig. 32. — Bandage of knee. 
 Spiral reverse. (Heath.) 
 
rDAGE I I >r i m LEG AND K N 
 
 on the sole may be run on and held in place by additional <ircular 
 about the I 
 
 Bandage for tk I B /in above the ankle with spiral tUI 
 
 progress upward a: ;>proacl- the re\ 
 
 '. 29); or a " figure -of -eight" ma;. iout 
 
 . 30), but the latter «' 1 well about the calf as the 
 
 forn 
 
 Bandage for ti Thia may be a continuation of the 
 
 include the knee alone; in either ca- /ure- 
 
 ight" runnii la around the outer side of 
 
 PlO. ■ of groin. (Fftath.) 
 
 the knee, aeross and up behind the knee to the inner condyle 
 make circular turns about the thigh. From the inner condyle, 
 cross the knee obliquely downward and outward to the head of the 
 fibula; make a circular turn about the leg below the knee, and, when 
 the patellar line is reached, begin over again the " figure-of-eight," 
 lapping the preceding on< 31, 32). 
 
 Bandage for (lie Groin. — Begin at the inner end of the groin and 
 carry the roller upward and outward to the iliac crest, around to the 
 

 DRESSINGS] BANDAGES, SPUN is 
 
 Fig. 34.— Bandage for breast. {Heath.) 
 
 PlC, 35-— Bandage for both breasts (Heath.) 
 

 oppo the bell; 1 the pubes, around 
 
 the thigh to the starting point. Repeat I urns as often as 
 
 u 1) overlapping the preceding (Fig. 33). 
 
 Pic 
 
 (//,, 
 
 thumb. 
 
 The Double Spica. The right gr ed as described 
 
 above. When the roller, carried about the body, the left 
 
 side of the pelvis, it leaves the original tr.uk, follows the left groin 
 
 ■•••5 
 
 •lnT2 
 
 PlC. r all the ! : . 
 
 downward and thence around the (high; is then carried across the 
 belly and around the body to the right groin again. These band- 
 ages may be applied with the patient standing or with the pelvis 
 
44 DRESSINGS, BANDAGES, SPLINTS 
 
 the Volkman rest. For the perineum and pelvis, one may use 
 the " Si . Andrew's cross," which, after a turn about the body, crosses 
 the left groin, behind the left thigh just below the nates, ob- 
 liquely upward across the perineum, over the right groin toward 
 the right iliac spine. It then passes around the left iliac spine and 
 down the left groin across the perineum. 
 
 r the Urea st. — Begin with two or three turns about the 
 :; carry the roller across the breast to the sound side; next 
 
 Fig. 39- — Bandage for arm. (Heath.) 
 
 ( arry it under the affected breast to the opposite shoulder; across 
 
 the back to the breast again and up over the shoulder; and then 
 
 md the body again (Fig. 34). Both breasts may be bandaged 
 
 Etme time, carrying the turns about first one breast and then 
 
 the 1 
 
 Bandage for the Finger.— Begin with two or three turns about the 
 
 t, and then carry the bandage across the dorsum of the hand 
 
 and er, and run it down to the tip by two or three oblique 
 
 turns; bandage from the tip to the base by regular circular turns. 
 

 mi. siP»n [j 
 
 i arry the band be hand 
 
 and around the pnri ig. 36). 
 
 Bandage for the Thumb. Begin at the aim and 
 
 1 around the wrist toi a turn or 
 
 ry the roller obliquely across the dorsum of the 
 
 hand and toward the radial ride of the thumb, as near the tip as 
 
 1 ure by a ( ireular turn and :rry the roller I 
 
 tnd around, the wri~t again and BO pro. .ard 
 
 the thumb i • all the and 
 
 thumb, .^8. 
 
 {Heath.) 
 
 I . — Bandage for 
 
 42. — Barton's 
 bandage. {Gould's 
 
 IUu 
 
 Bondage for the //,:;/</ (//:(/ Arm. Ih gin with circular turns around 
 
 the wrist and then cam a " figure-of-eight " about the wrist and hand; 
 finish with spiral turns progressing up the arm (Fig. 39). 
 
 Spicafor the Shoulder. — Begin on the arm about the insertion of 
 the deltoid and make two or three circular turns about the arm. 
 Next carry the roller across the shoulder, approaching the sound 
 axilla from behind; across under the axilla and over the breast to 
 the injured shoulder and around the arm again (Fig. 38). 
 
 Bandage far the Xeck. — The shoulder and head must be included 
 in the bandage for the neck if it is to be effective. Begin on the 
 shoulder and carry the roller through the axilla and around the 
 neck once or twice. Take the turn next about the neck and beneath 
 
DREi B WDAC.FS, SPLINTS 
 
 Fig. 43.— Capitellum. {Heath.) 
 
 Pia n -Capitellum completed. {Heath.) 
 

 
 the jaw, behind the ear on t he sound ride, i 
 
 >nt of I "ii the trry the 
 
 roller horizontally around tl and then beneath I once 
 
 more; again vertically around the head; but this time it passe 
 front of the ear on the sound side and behind the car on the 
 
 side. ( any the roll I third til ath the jaw and, finally, 
 
 from the <•< l iput around the the other til] 
 
 mdage for U in many in- 
 
 stances by simple turns about the for od occiput; but 
 
 F i < . 
 
 ■ 
 in the 
 
 ound eye fre« 
 ends of i«c on the sound side. 
 
 bandage may be made to hold firmer if, as it approach rtain 
 
 point, it is raised in one turn and lowered in the next. It has the 
 appearance of a spiral n 
 
 Barton's bandage may be us* d at the top of 
 
 the head, carry the roller beneath the chin, up to the \- 
 and to a point below the occiput From this point, carry it forward 
 to the chin and on to the occiput. Bring it up to the top of the 
 head and again beneath the chin and proceed as in the beginning 
 
 Figs. 43 and 44 represent one method of applying the recurrent 
 or capitellum to the head. 
 
 Morley describe- a useful and practical bandage for the eye 
 (J. A. M. A., Mch. 27, 1909^. Take a piece of muslin, or gauze, 
 
4 S DRESSINGS, BANDAGES, SPLINTS 
 
 long enough to go about the head and wide enough to cover the 
 orbital region. At its center cut a round hole for the ear of the 
 
 Cted Bide and further back an oblong slit for the occiput. Trim 
 the bandage so as to uncover the sound eye. Split the two ends 
 and tie these tails tight enough to prevent slipping (Figs. 45, 46). 
 
 The crossed bandage for both eyes is a figure-of- 
 eight with circular turns about the head (Fig. 47). 
 Bandage for a Stump. Begin with circular 
 spiral turns some distance up the limb. Carry 
 the bandage back and forth over the end of the 
 stump, and finish by more circular turns. 
 
 SPLINTS 
 
 
 Fig. 47.— Bandage for To immobilize, to prevent muscular contraction, 
 or to secure functional rest, splints play a large 
 part in surgical practice. The emergency surgeon must be fami- 
 liar with the principles regulating their employment and with the 
 practical details of their use. A splint must have rigidity; it should 
 be light. A number of materials offer these properties in varying 
 degrees, though none are ideal perhaps, or universally applicable — ■ 
 wood, metal, leather, wire, cardboard, felt, plaster of Paris, silicate 
 of potash — each has its special field of usefulness. More especially 
 employed in emergency practice are wood, metal, and plaster. 
 
 Wooden Splints. — Wood is the material usually most available 
 when temporary splints must be improvised. Often these splints 
 may be used for permanent fixation, though not so much so perhaps 
 as formerly. From soft wood — a thin pine wood — -the appropriate 
 form may be readily whittled; and, when applied, well wrapped 
 so as to conform to the parts, furnishes a fixation at once light and 
 :. The splint must be wider than the limb and long as the part 
 to be immobilized, but not so long as to produce discomfort. The 
 sound limb may be used as a pattern in modeling the splint. Such 
 splints have the disadvantage that they are hard to keep in place. 
 A number of thin wooden strips may be glued to felt, or held to- 
 gether by adhesive plaster, to form effective fixation in certain 
 fractures of the humerus and thigh. On this principle the Dutch 
 
pi • 49 
 
 use in 
 
 •it is made from a pine board tad 6 or 8 in 
 
 wide and 'i inch thick, on to felt and then split in strip 
 
 inch wide. the ordinary wooden splint is applied, it should 
 
 be padded with absorbent cotton a to 4 inches thick and wrap 
 
 with a iler, I be 1 of listributed to i 
 
 id to the irregularities (A the limb. !'• splint is m< 
 
 the limb, and held in place with adhi while the n 
 band ipplied. 
 
 Metal splints as ordinarily employed arc scarcely available in 
 
 emergen< y pnu I u <•. 'I hese del idily 
 
 worked into shape; but, on the other hand, if ready-made, are 
 
 likely not to fit 1 1 splint could be 
 
 (ill from tin Or from wire gauze. Wire gauze, indeed part 
 
 of the OUtfil of the militan D be patterned. 
 
 molded and bandaged to th< hould l>e turned 
 over or 1 overed with cloth. 
 
 Plaster. ! of Paris, on the whole, is the material 1 
 
 adapted to the exigi I dky, 
 
 cheap, easily obtained, and readily pn it is 
 
 not unduly heavy and furni rm support It has the ap< 
 
 advantage that it ran be molded to the part ; tin antage, that 
 it may be difficult to remove when applied as a roller band 
 Plaster is Bpoiled by exposure should buy a good quality and 
 
 keep it dry. Old plaster should 1 » 
 
 may he applied on a roller bandage or on -trips to make a molded 
 splint. The splint form i^ better when the part- must he frequently 
 
 inspected or when mutch swelling is anticipated. The pla* 
 
 roller may he prepared from the ordinary gauze roller or from crino- 
 line. The latter is perhaps the best The rollers should be about 
 4 yards in length; 2, 3, and 5 1 - inches in width. pare the 
 
 plaster bandage^ pour the plaster on a table or in B wide shallow basin. 
 Start the loose end oi the roller through the plaster, rubbing it in 
 thoroughly, and as fast as it is impregnated have the assistant re- 
 roll it (Fig. 48). These bandages will keep indefinitely in an air- 
 tight container. Prepared in this way they are much more satis- 
 

 PK1 BANDAGES, SPLINTS 
 
 than if bought ready-made and certainly much less 
 
 Method of Applying. -When the limb is ready, washed, and 
 
 red with glazed cotton or stockinet, the plaster roller is set in 
 
 I pan of warm water deep enough to cover it. When the bubbles 
 
 rise, it is read\ to apply. Seizing it at each end, wring it 
 
 genth gin by making a few oblique turns at first to secure the 
 
 in, and then cover the limb by systematic circular 
 
 turns, progressing from below upward, each turn overlapping the 
 
 eding one. The "reverse" must not be used. A little loose 
 
 ter may be spread on and moistened to give a smooth and even 
 
 finish. The limb must be supported and the extension maintained 
 
 I ', I 1 1 1 1 v 1 u B^^^l 
 
 Fig. 48. — Method of rolling plaster bandage. 
 
 until the plaster has hardened. A little salt added to the water 
 
 tens the process. If there is danger of swelling, or if the limb 
 
 cannot be frequently inspected, it is better to split the case before 
 
 leaving the patient Sometimes it is quite a task to split a plaster 
 
 after it is thoroughly hardened. The labor may be greatly 
 
 lessened by the use of simple syrup, a groove being first cut with 
 
 Iter knife or saw; if the groove is kept filled with syrup while 
 
 the catting is in s, one will get through the plaster rapidly. 
 
 Plaster splints are made by cutting several thicknesses of crino- 
 line, appropriate to the shape of the limb. It is saturated with 
 Mdl la irately, dipped in warm water until well 
 
 then applied and molded to the limb. Fix it with circular 
 turns of in bandage. The second splint, if needed, is then 
 
 ■Ppl d series of circular turns. The splints 
 
PL \ 
 
 may be fixed by a plaster roller if desired. A ; :'i 
 
 fold the crinoline into the desired number of la; id cut them 
 
 all at once from the pattern determined. Warm water and 
 
 are next provided and plaster is slowly IltO the mtil 
 
 it ceases to bubble; when it 1, until it ha 
 
 kUI. Tlie cloth is then dipped in and saturated. Whi 
 SOaked, the | ut and the Splint 
 
 apply. 
 
 The Bavarian pl<i^t<r -phut i- particularly useful in immobile 
 the leg. Cut two pi< flannel >ugb to extend from the 
 
 upper end of the thigh under the heel to the hall of tin 
 inches wider than the the lit;.' 
 
 pieces together along the middle line for the length of tl 
 
 the splint thus formed under the limb, with the seam e\a- tlv in the 
 
 middle; bring the inner half around, fitting it to the lei:, tin 
 
 and >ole of the foot, like a >tock; a ith 
 
 liquid plaster and, before it sets, turn the outer half over th< 
 
 and mold it and adjust the end pieces to the sole. The splint 
 
 he easily removed, as the -cam along the back 
 hinge. 
 
CHAPTER VII 
 SHOCK 
 
 Shot k is a constitutional state characterized by lowered blood pres- 
 sure vaso-motor paralysis. 
 
 In practice, the term "shock" includes the complex of symptoms 
 
 arising from the vaso-motor paralysis, hemorrhage, mechanical in- 
 
 . ith circulation and respiration, and beginning infection. 
 
 [t may not be possible to analyze the symptoms, determining the 
 
 part played by each of these various conditions in a given case, nor 
 
 is it ry to do so. 
 
 verthdess, the proper understanding of shock as a separate 
 entit sential in emergency surgery next to skill in hemostasis. * 
 
 ripheral impulses reach the automatic centers controlling blood 
 sure and overwhelm them. Such is the commonly accepted 
 view of shock production. 
 
 Lucy Waite, after reviewing the subject from every standpoint, 
 concludes that, according to our present light, we must consider it 
 primarily a disturbance of the great sympathetic nervous system; 
 •ularily, the vascular system, resulting in vaso-motor paresis 
 dilatation of the right side of the heart and the large vessels; 
 in natural sequence derangement of the solar plexus and the auto- 
 matic visceral ganglia follows; finally there is suppression of visceral 
 -of rhythm, absorption, and secretion. (Medical Record, 
 • t. 8, 19c 
 
 This is practically in accord with the results of recent experi- 
 ments of Ja and Ewing. "The loss of vaso-motor control 
 • to OCOpnia or central nervous exhaustion in their 
 but is rather a matter of inhibition. (Annals Surgery, 
 , 1914 ) 
 The sympl iry in degree with its severity and are 
 to the lowered blood pressure: thirst, pallor, subnor- 
 52 
 
1)1 
 
 in.il temperature, hallow breathing, frequ< 
 rapid pulse, rela ied *phin< ters, fail I 
 
 Ull< 0] 
 
 I I I appear in their si ich 
 
 form- as usher in death. A- \\ 
 
 tically identical with the last manif» 
 helming 
 
 Whether Shock will he mild, severe, or fata! : .on the 
 
 state of the individual, the trauma, 
 
 the i >f injury, and the I 
 
 health, and mental 'ion. 
 
 Crushing injurie n it ; 
 nals to the distui furnish conditi rable 
 
 Kailr<<: 
 the k, for fright and violent emoti 
 
 even without injury ma 
 
 I tain ti :han Others. I Jch line 
 
 the body CavitL injury; the 
 
 peritoneum, the pleura, the dura, and tl 
 
 of the ijurge joints. Thu is true whether tl ental 
 
 or operal i\ e. 
 
 The die from hemorrhage and I 
 
 cannot always be made with certainty. A- \\ 
 
 nosia of shock is simply the recognition of the elinieal phenon • 
 
 for we have no chemical or pathological findings to aid US. 
 
 In many instances it may be differentiated from 
 
 history of the case. 
 
 In Collapse the heart action 19 
 
 it is rapid and Feeble. 
 
 In hemorrhage the symptoms may he rapidly proj . but in 
 
 uncomplicated shock the sympton tionary or imp: 
 
 Observe, therefore, the action oi the pulse and tl ment of 
 
 the temperature. In hemorrhage the temperature falls and the 
 pulse rate increases. In shock the.pulse becomes gradually slower; 
 the temperature gradually rfs 
 
 The prognosis in the seven ill be for a little time decidedly 
 
 uncertain. The sufferer from traumatic shock may give the doctor 
 

 SHOCK 
 
 an erroneous notion of the gravity of the case, unless the condition 
 of the pulse is carefully noted; for he may complain of no pain, is 
 cheerful in the face o\ his calamity, discusses the need of operative 
 isures quite coolly and directs the management of his case generally. 
 jeems quite rational, and yet it often happens that after recovery 
 he has no recollection of what he said or did or felt. It is prob- 
 able, in the presence of grave injury that, if the pulse is thready and 
 -till failing, the patient does not know what he is talking about, how- 
 lucid his expression may appear. A little later he may be in 
 active delirium. Any increase, not too long delayed, in the blood 
 sure and the attendant improvement, is a cause for hope. It 
 tnay take many hours before the reaction is complete. 
 . 1 ;/ v aggravation of the symptoms after reaction is once under way 
 > indicates a return of the shock, but points to hemorrhage or 
 infection. 
 
 It is true that, as a rule, when once improvement begins the out- 
 look is favorable, but the prognosis must always be guarded in the 
 e of the elderly. 
 
 An old flagman was brought to the City Hospital with both limbs 
 shed i>\\, having fallen under a passing engine. He was in full 
 k and had lost some blood from a scalp wound. He was almost 
 pulseless and yet his mind seemed clear. His condition precluded 
 at ion. The mangled tissues were trimmed and carefully 
 1 and wrapped in moist antiseptic compress until such time 
 formal amputation might be undertaken. Under the treatment 
 he gradually improved. His circulation and respiration 
 a r, but not sufficiently so as to favor operation. At the 
 end of twenty-four hours he began all at once to grow weaker, fell 
 upor, and in a few hours died. If the amputation had been 
 undertaken, he would have died on the table, and thus another fa- 
 tality would have been charged to active intervention. 
 
 The treatment of shock has been the subject of much discussion in 
 
 The most diverse opinions exist and the most diverse 
 
 - have been proposed, t>ut we have learned from the ex- 
 
 ( !rile and others that it is as important to know what not 
 
 what to do. 
 
 The whole lisl of cardiac and spinal stimulants so commonly in- 
 
MM KM Ul >H 
 
 jected bastiiy, indiscriminately and collect hown to be 
 
 not mil . but distinctly harmful. The patient doubt 
 
 often re not on account erf, but in spit itment 
 
 In ordinal these <lir<<ti<>); 
 
 mind: disturb the patient as little a 
 
 the body warm; attempt do operatr until the sympi 
 arc improved] unless it be to check hemorrhage! or to amputati 
 
 c ertain ( rushing ffijui 
 
 Adrenalin chloride is the most generally useful remedy to n 
 blood pressure in shock pure and simple, and given hypodermically 
 or intravenously, it very seldom compl 3s. 
 
 (Vile w;h enabled by means oi intravenous infusion of adrenalin 
 and salt solution, combined with artificial respiration and thoracic 
 ure, to human heart after it had ( eased I for nine 
 
 minutes, and its a< don was thui sustained for one-half hour. 
 
 It must be given in small doses, frequently rep 
 are powerful, but fleetii 
 
 Hypodermically, give 5 to [5 minim- of the I 1000 adrenalin solu- 
 tion and repeat every Im thirty minut 
 
 [ntravenous infusion is even d tain. 
 
 Give continuous infusion of adrenalin salt solution until then 
 signs of reaction. One teaspoonful of 1 1000 adrenalin added 
 one quart of normal salt solution is of sufficient strength. 
 
 Normal salt solution alone is effective within certain limits, hut 
 
 finds its greatest field of usefulness in shock coexistent with hemor- 
 rhage. In shock uncomplicated by extensh 1 Mood, the -aline 
 
 solution must he used sparingly, perhaps better by enema or hypo- 
 
 dermoclysis; used in large quantities intravenously, it may eventually 
 
 defeat the end for which it is employed by acting as 1 mechanical 
 obstruction to respiration. For it must be remembered that under 
 such circumstances it finds its way into the thoracic and abdominal 
 tissues and interferes with the movements of the diaphragm and 
 ribs by its mere presence. According to Crile, 320 c.c per kilo of 
 body weight led to such accumulation of fluid in the splanchnic area 
 as to embarrass respiration. 
 
 Do not give, then, more than a pint of normal salt solution in- 
 jected slowly, in uncomplicated shock. (For technic of intravenous 
 
SHOCK 
 
 infusion, Bee paj Murphy uses sodium bicarbonate i dram 
 
 1 j pints of hot water as a proctoclysis, repeating the dose every 
 
 three tO live hours. 
 
 Crile's pneumatic suit seems to be entirely trustworthy as a means 
 
 rising blood pressure; but, of course, cannot be used in the 
 
 k occurring in emergency practice. 
 
 lion of shock is always something to be considered in 
 operative work. Morphine, M grain hypodermically, before the 
 is a real aid. " Blocking" the nerves by cocaine in- 
 jections above the site of operation is likewise advantageous and is 
 amended by Cushing and Crile. The nerve may be exposed 
 in its course under local anesthesia and in turn injected. 
 
 In abdominal work the viscera must be handled with care; for, as 
 
 Byron Robinson has shown, shock from this source is directly pro- 
 
 ionate to the amount of manipulation or traction upon the 
 
( II w\ i.k vin 
 HEMORRHAGE 
 
 Definitions, -i. Arterial is due to wound 
 
 and Is chara* terized by spurting and the bright rod < olor. 
 
 2. Venom hemorrhage is due to wounds of the iar- 
 acterized by dark color and steady fl 
 
 3. Capillary hemorrha ized bj 
 and spontan< 
 
 4. Parenchymatous 
 
 and tissues in which the small arteries terminate directly in veins; 
 no < apillaries intervening, as in the erei tile I 
 
 Primary hemorrhage oa ura immediately after the injury. 
 
 6, Intermedial tionary hemorrhage occurs within twenty- 
 tour hours and is due to the release of dots or the slipping of the 
 ligature. 
 
 7. Secondary hetgorrhage occui twenty-four hour-, bef< 
 the cicatrization ^i the wound, and is usually due to sloughing or 
 suppuration or the too rapid absorption of the catgut ligature. 
 
 s. Internal or concealed hemorrhage occurs when the Mood is 
 emptied into one of the large cavities; abdomen, thorai or cranium. 
 
 I 0NST1 11 rlONAJ EFFECTS OF m ICOKSB 
 
 The constitutional effects o\ hemorrhage vary with the amount 
 and the rapidity of the loss of blood. Thus a comparatively small 
 
 amount of blood poured out rapidly will produce more marked 
 symptoms than a much larger amount drained away slowly. 
 
 The constant accompaniments oi "rrhage are pallor, 
 
 dizziness and faint ness, rapid and weak pulse, subnormal tem- 
 perature, rapid and irregular breathing, frequent yawning or sigh- 
 ing, nausea, and vomiting. 
 
 57 
 
HEMORRHAGE 
 
 or one likely to be so, is indicated by livid lips, 
 blue finger nails, dilated nostrils, pallid mucous membranes, dyspnea, 
 ringing in the ears, syncope, collapse and unconsciousness. 
 
 Subsequent to the arrest of a dangerous hemorrhage, occur rapid and 
 irregular pulse, rise of temperature, asthenia, a disturbed mental 
 dition, usually muttering delirium. This is hemorrhagic fever. 
 lie general condition improves, the mind gradually clears up. 
 The lowered vitality following the hemorrhage favors the develop- 
 ment of various inflammatory processes, and one must carefully 
 watch for the onset of these. 
 
 The diagnosis of hemorrhage is not difficult except in the case of 
 internal hemorrhage, or when shock is present. 
 
 In the ease of bleeding into the cranial cavity, various forms of 
 paralysis and nervous disturbances, together with the general 
 symptoms, will form the basis of the diagnosis. 
 
 In the case of bleeding into the thorax and abdomen, the symp- 
 toms, the physical signs, and the history of the case will point to the 
 condition. (See Injuries to Thorax and Abdomen.) 
 
 When shock is also present it may be almost impossible to tell how 
 much of the symptoms are due to the one or the other, for the symp- 
 toms of shock and hemorrhage are practically identical. 
 
 It i> useful to remember that the symptoms produced by shock are 
 usually immediate and tend to improve, except in the fatal cases. 
 On the other hand, the symptoms of unchecked hemorrhage tend 
 
 • 
 
 TREATMENT OF HEMORRHAGE 
 
 Judication is the Arrest of Hemorrhage. Constitutional 
 are then applied with a view to supporting the heart's 
 
 ;i. In moderately severe cases give l A ounce of whiskey or a . 
 hypodermic of strychnine (Ho to Ko grain), or of adrenalin chloride, 
 and i hour until the symptoms have improved. Apply 
 
 ii blankets, hot water bottles, or hot irons well wrapped. Do 
 not burn the patient. Keep him quiet, with head lowered. Attend 
 to the ventilation. As soon as possible give warm drinks and a 
 nutrition^ but easily digested diet. Do not overstimulate, as the 
 
 tion in that case will be unduly severe. 
 
 
r\ i r \\ i 
 In the dan^erou- < a.-es oj hem< >n } i . i lt « ■ , in addition to the-- 
 
 do not fail to employ normal i ither by enema. 
 
 -ill), ulai t( or intra . 
 
 In the grai • ivail, for absorpl 
 
 pra< t i( ally < < ;i>ed. 
 
 Bypoderm I or this purp by: 
 
 It SodiJ 1 MoiidL, 
 
 Sodii l»i< arb., 
 
 Aq. destOl., 3 * N ' 
 
 Th ipptitiiti' n-fullv disinfo ted fountain syringe 
 
 funnel with rubber tubing, a large needl< 
 One half pint or more of the solution is by this n* 
 
 under the -kin over the abdomen ur brc 
 ///.'■■ In tin 
 
 by the sam< may be injected into the circulation. 
 
 Seta t a vein at the elbow, employ tin- stri* j>ose 
 
 the vein by incision. Loosen it from refill 
 
 blunt disse* tion and Blip thr if ligatures under it. Introduce 
 
 the needle. <>r ebe I Ik \ tin may : 1 and a cannula u-ed. The 
 
 cannula or needle is to be held in place by tying the middle ligature 
 Slowly injei t a pint or more of the solution, the temperature of which 
 should be 105 to iiv Withdraw the cannula, remove the middle 
 ligature, and tie the two remaining. Close the wound and di 
 aseptically. Keep the funnel full during the injection, so that no 
 air may be carried into the vein. 
 ('rile recommends direct transfusion from the vein of a well pen 
 
 into that of the patient, hut OJ this method lv available 
 
 in emergencies ^\ general practii 
 
 Parke-Davis & Company market a sterile salt in sterile tu 
 whieh needs only to be emptied into a liter iA sterile water to form a 
 
 solution for instant use. The formula used is as follow 
 
 Calcium chloride. s pn. 
 
 Potassium chloride, 0.1 pm. 
 
 Sodium chloride, 9.0 gm. 
 
 Remember that intravenous infusion is not to he employed until 
 the hemorrhage is arrested. 
 
Oo HEMORRHAGE 
 
 EEMOSTASIS ARKIsr OF HEMORRHAGE; GENERAL PRINCIPLES 
 
 ontaneous arrest of hemorrhage is due to several factors: con- 
 tion and retraction of the injured vessels, diminishing blood 
 -ure due to weakening heart action, formation of a clot, these are 
 the which nature employs. 
 
 Capillary hemorrhage tends to spontaneous arrest, likewise the 
 arterial hemorrhage of lacerated wounds. 
 
 Hemostatic measures locally applied are chemical , thermal, and 
 mechanical. 
 
 \ Chemical remedies, chiefly styptics, are now very rarely em- 
 ployed. Such as are used are expected to favor the formation of 
 a dot without doing violence to the tissues. In a persistent capillary 
 hemorrhage, dioxide of hydrogen or acetanilid is often useful and 
 harmless, but the most useful remedy locally applied is adrenalin 
 chloride. The i-iooo solution is commonly used. 
 
 (B) Thermal hemostasia is that induced by heat. Hot water or 
 hot normal salt solution alone will usually arrest a moderate bleed- 
 
 -e the solution as hot as can be borne by the hand. Hot 
 solutions are especially useful since they serve the double purpose of 
 antisepsis and hemostasis. The actual cautery may be necessary 
 in spongy tissue where the oozing is persistent but ill defined. The 
 iron should not be hotter than a dull red and must be held in contact 
 some moments. Cold may be used but is much more likely to 
 rllular vitality. 
 
 (C) Mi chanical hemostasis includes (i) direct pressure, (2) com- 
 
 . (3) acupressure, (4) forcipressure, (5) torsion, (6) ligation. 
 (1) Direct pressure is of large service especially in "first aid" 
 mint. The finger or thumb is pressed directly into the wound, 
 of the wound. If the pressure is to be prolonged, 
 the ; ill tire and a plug or tamponade of gauze must be sub- 
 
 mit utrd. Gauze wrung out of a sterile solution is packed into the 
 ind. 
 
 1 1 sufficient in the slight hemorrhage of operative 
 
 isistant presses a gauze compress on the bleeding 
 surface, withdraws it by a gliding movement, and the bleeding 
 practically 1 1 
 
HIM 
 
 In general, the larger the ind more prolong 
 
 must be the 
 
 In tem- 
 
 po] i dient. 
 
 Parenchym ked by din 
 
 wound of tl ■ is lined with a layer erf gauze In thi 
 
 cavity, complete the tamponade. This compress should he with- 
 drawn within twenty-four to fort I hour-. It may be painful 
 to pull <>ut . i the adhesions with 
 ride. 
 
 2. ( ■< elude the vessel I tile 
 
 wound. In the ■.< y, a fil 
 
 ( onvenient point along it s i ourse the 
 
 wound. Pre — if i e it' tin 
 
 I imilarly ( ompressed hel wound. 
 
 In tin WOUnds of the c\t remit ICS, the main in- 
 
 cluding both the vein and artery or either alone, ma 
 
 by the tourniquet. The pressure is made fin I by 
 
 laying <>\ er it - i ourse a body bu< h as a -mall roller hair 
 
 the constricting hand i- applied alxn 53, 54). 
 
 The simplest and most convenient tourniquet i- a rubl 1 or 
 
 tube. After being tightened, tl i :ht and held 
 
 in place by an artery forceps. It must always he remembered that 
 the tourniquet i^ likely to cut off all the blood supply to the 
 tremity and if too long applied will prodw Paral 
 
 may follow from pressure on the nerve-. Wrap the arm with a towel 
 and apply the tourniquet over that. 
 
 Capillary oozing i- frequently troublesome after the constriction 
 is removed. Constrictionis objectionable on that account 
 
 3. Acupressure i^ now Bddom used and yet, under certain circum- 
 stances, may render great aid. The artery may he deep and retracted 
 or imbedded in scar tissue or aponeurosis and cannot he seised by the 
 forceps. In such a case a needle passed under the artery and secured 
 with a iigure-of-cight ligature wound around its protruding ends will 
 press the artery between it and the tissues and stop the flow (Fig. 49). 
 
 4. Forcipressure, the control of hemorrhage by seizing the ends 
 of the bleeding vessels with forceps, is the expedient most com- 
 

 Ill MORRHAGE 
 
 nionU employed in operative wounds. In the accidental wounds 
 of large arteries, it affords immediate control of the hemorrhage. 
 For the small vessels such pressure is sufficient, the forceps remain- 
 ittached tor B certain length of time. The end of the vessel 
 should 1 I with as little other tissue as possible. If it is a 
 
 tad it may he cleared by a moment's dissection. 
 
 Hon is added to forcipressure, if that is not sufficient (Fig. 
 50). Before removing the forceps, it is given two or three turns on 
 it- long axis. The inner coats of the artery are ruptured and con- 
 
 producing the same conditions favorable to hemostasis as 
 
 are iound in the artery in lacerated wounds. If the artery is a little 
 
 r. it is drawn for ) £ inch out of its sheath, a second forceps grasps 
 
 Fig. 49. — Acupressure. (Moullin.) 
 
 it higher up and is held stationary, while the lower one twists the 
 intervening segment, the purpose being to avoid injury to the sheath 
 and the vasovasorum. 
 
 In mating tor-ion, do not pull at the same time, for fear of tearing 
 
 the other tissues instead of twisting the artery. Torsion must not be 
 
 I be t issues are loose or cellular. 
 
 Torsion is of advantage especially in plastic surgery, for it leaves 
 
 no ligature behind to interfere with repair; but it is not so certain 
 
 as ligation. 
 
 6. Ligation is finally necessary in bleeding from the larger vessels. 
 
 Employ catgut, chromicized or plain. For the largest vessels silk is 
 
 nally u>« 
 
 Lift the attached >o as to create a pedicle around which 
 
 the thread and tie the first knot (Fig. 51). 
 
 tying 1 1 knot, two things are kept in mind; to tie 
 
Mi III 
 
 thai the thread will hold when the 
 and not to include the tip of the forceps in the ligatur 
 
 on u the first knot fa I that 
 
 one may be ai mred the itil u badly plat ed ix 
 
 the knots. Tin- first kxk ured by I I il -ilk n used, and 
 
 by a third if catgut is used The threads are then cut short, silk 
 i mm. and catgut a or 3 mm. I the pr e f e ra ble ligature 
 
 and a No. a ifl .imply strong for an artery tin the radial. 
 
 \atkm en masse ■ ochymatoufl hemor- 
 
 rhage, capillary oozing, or bleeding from a und. A catgut 
 
 suture b carried around the bleeding area b I curved needle. 
 
 1 •'"• (l Van.) Si. —Showing method of tight- 
 
 ening the ligature. (\'eau.) 
 
 and all the tissues BO included arc tied; or, in the I paren- 
 
 chymatous bleeding from a surface, i catgut suture ma rried 
 
 around the area and subsequently tightened after the manne- 
 
 the purse string. 
 
 BEMOSTASIS i\ 5PECIA] rOEMS 01 BEKOUtHA 
 
 (a) Capillary -pressure, hot water, Irenalin, peroxide, 
 acetanilid, alum, ligation en mass 
 
 (b) Venous — pressure, compression, forcipre<>ure, ligation, re- 
 moval of all obstruction to venous flow above the wound.- 
 
 (c) Arterial pressure, compression, fortipressure, torsion, ligation 
 
64 
 
 HEMORRHAGE 
 
 kymaUus pressure (tamponade), heat, ligation en 
 
 se. 
 (e) Intermediate hemorrhage -reopen the wound, turn out the clots 
 I treat hemorrhage as if it were a primary one. 
 
 hemorrhage — reopen the wound, turn out clots, and 
 apply compresses. H possible catch the ends of the bleeding vessels. 
 It the hemorrhage is alarming and it is impossible to control it by 
 con orcipressure, apply the tourniquet, in the case of an 
 
 entity, and ligate the artery in its continuity above the wound. 
 If this fails and the artery cannot be tied higher up, amputate. 
 
 Fig. 52. 
 
 (g) Operative hemorrhage — In spite of artery forceps, the bleeding 
 remains to the inexperienced one of the bugbears of operative work. 
 In many operations it is the chief drawback to rapid work; more 
 time is lost in catching and tying bleeding points than in doing the 
 actual operation. Oftentimes the field is masked by a general 
 ing, and the procedure must halt until the wound can be packed 
 with hot compr '.Inch will usually be all that is necessary. 
 
 tnd momentary pressure with a gauze compress is usually 
 all that is necessary in capillary bleeding. 
 
 operation- in the various cavities, as the nose, mouth, rectum, 
 
 in the mastoid operation, etc., the hemorrhage, even if not discon- 
 
 ry troublesome and some special measures are 
 
 required. Under the circumstances, Parke Davis' adrenalin gauze, 
 
 li is uit in narrow strips, may be packed in the cavity for a 
 
 I and 00 its removal the operation may proceed (Fig. 52). 
 
EM 
 
 FIRST AID i\ DANG! >RRH IGE' 
 
 Ii i bat the regulated measures for b lied 
 
 hand in a dangl re arc certain temporary 
 
 and makeshift but e x tremely useful procedures which the surgeon 
 should keep in mind, if for no other reason than that he D 
 
 and definite instruction to the layman who may have to 
 play the part of surgeon for the time bei 
 
 Intellig I aid is the chief factor in saving life in most cases 
 
 of dangerous hemorrhage both in militar 
 
 has to meet th< cool. He must 
 
 v to apply three principles of treatment, p< 
 press it' 
 
 i. Position. I the Upp 1: hold the 
 
 arm above the head, [f it is the I tremity: put the patient 
 
 on his back and the limb. If it is the face or scalp: place 
 
 the patient in a sittii ion. 
 
 2. Direct Pressure. -The wound is small, tht >us: 
 plug the wound dire* tly with the thuml r, or press hrml 
 
 each edge of the wound; or, in a tier still, if s 
 
 with a first aid pa< iff the wound tightly with gauze and 
 
 bandage firmly. It should be emphasized that a finger must m 
 thrust into a wound except in and 
 
 where Other means less likely to re not at hand. 
 
 3. Compression. — The bleediiu. I and its COU 
 miliar: compress it with the fingers at some convenient point 
 
 or, in the case of the extremities, by constricting the limb. 
 
 In lieu of the tourniquet, knot a handkerchief, apply the knot 
 over the artery and tie the handkerchief tightly around the limb. 
 If it is not tight enough, a stick may be slipped under the hand- 
 hief and given a few turns, end for end. A suspender, a rope, 
 or a wire may, if necessary, be similarly employed. It must be re- 
 membered that, on the whole, circular constriction is not without its 
 dangers, and it must not be recommended without reserve to the 
 layman. 
 
 1 Sec also "First Aid on Battlefield," page 179. 
 5 
 
IHMOKKll \CK 
 
 incipal arteries near the surface have each certain points 
 where compression is most effective. 
 
 The temporal and occipital furnish most of the dangerous bleed- 
 
 alp wounds. 
 The temporal may he compressed just in front of the upper part 
 be ear. 
 The occipital may be compressed in its course from the tip of the 
 
 upward toward the occipital protuberance. 
 The entire blood supply of the scalp may be shut off temporarily 
 . bandage encircling the head, passing from the forehead, above 
 the car, to the base of the skull and thence upward, just above the 
 Othei the forehead again. 
 
 The facial is compressible as it crosses the body of the jaw just 
 in front of the tnasseter muscle. 
 
 The coronary arteries, supplying the lips, are compressed by seiz- 
 ing the lip between the forefinger and thumb. 
 
 The carotids are controlled by compression of the common carotid 
 over the transverse process of the sixth cervical vertebra. 
 
 Wounds of the vessels of the neck, however, are of such extreme 
 danger, including, as a rule, both arteries and veins, that bleeding 
 should be controlled by direct pressure in the wound. Nothing 
 can I !l trusted here as the ringer. 
 
 The subclavian is compressible against the first rib behind the 
 
 middle of the clavicle. The shoulder is slightly raised to relax the 
 
 Fascia and the finger or a padded stick pushed directly down 
 
 m the artery behind the clavicle. The circulation of the entire 
 
 upp< thus controlled. 
 
 The brachial is compressible against the middle of the humerus 
 
 or the tourniquet may be applied over any part of the artery 
 
 0- 
 
 The radial and ulnar are not compressible except just above the 
 
 therefore, bleeding from them must be controlled by 
 
 dir© ure in the wound, or by the tourniquet, or by com- 
 
 of the brae hial. 
 
 The palmar ar not directly compressible, but hemorrhage 
 
 from the palm is controlled by grasping firmly a round body as a 
 
 billiard ball, an app >ne wrapped with gauze, and bandaging 
 
! v V HE1C0 
 
 the band in this position. If this is oof practical, the tourni< 
 applied to the forearm, or the brai trial com; 
 The digital art lv controlled by constii 
 
 the finger above the m >und. 
 
 The femoral art* -r. lc in the middle of the groin 
 
 the ramus of the pubes, but great pressure u required 
 ontrol it 54). It may lil 
 
 Fi<.. S3. bud. 
 
 I ;. — Compression of femoral. 
 ■life.) 
 
 down against the shaft of the femur. The tourniquet is, in this in- 
 stance, the safer temporary hemostatic, a compn 
 intervening between it and the artery. 
 
 The popliteal is not compressible. Bleeding must be controlled 
 by direct pressure or by compression of the femoral. 
 
 The tibials likewise. They may also be controlled by flexing the 
 knee forcibly upon a pad, holding the pad in place by a cro-s piece 
 pressing forcibly against the popliteal space, and in turn held in 
 place by a bandage around the flexed leg (se<* F ; g. 133, paee 1S3). 
 
68 lirNMRKIl \. 
 
 and plantar arteries ran best be controlled by direct 
 or by compressing the tibials and peroneal as they cross 
 the ankle. 
 
 The arteries of the surface of the trunk most likely to produce 
 
 IS hemorrhage are the internal mammary, the intercostals, 
 
 and the dec' These can be controlled temporarily only 
 
 hby direct pressure,, either with the finger or 
 gauze packing. The method of compressing . 
 |^"^y the intercostal is represented m Fig. 55. 
 
 PI Vi-^ Epistaxis is a form of hemorrhage often 
 
 ^ troublesome and requiring special treatment. 
 
 It may occur in one or both nostrils. The 
 inte F rloU^\r^TT g rit; simpler cases are relieved by the erect posi- 
 a. ar tine. (Wdi- tion, holding the arms above the head, by 
 
 the reflex effects of cold to the back of the 
 -ure over the root or sides of the nose. 
 
 fail, the nostril may be syringed with certain 
 solution-: hot water; antipyrin, 5 to 10 per cent., which is especially 
 recommended in the Am. Text-book of Surgery; adrenalin, 1 to 
 1000. 
 
 The patient must not blow his nose, as this eliminates the clot. 
 In the more severe ry tamponing the anterior nares. If a 
 
 psculum and a good mirror light are available, the anterior 
 nare mat i< ally plugged through the speculum with 
 
 oalin gauze; or, by such means, the bleeding point may be dis- 
 1 with the point of the cautery, with silver ni- 
 trate, or with chromic a< id. 
 
 Tin ;ial Journal of Surgery gives this practical sugges- 
 
 tion: a I ound around a pen holder until the de- 
 
 thickm obtained and then withdrawn. The cotton 
 
 dry, and inserted into the nasal 
 id is now moistened, it will swell up and 
 it compression. 
 arious measures fail, then the posterior nares must be 
 
epi og 
 
 For this purpose, in emerj an ordinary soft nil 
 
 ( at Im mailable, in lieu of the Belle 
 
 threaded and passed dire* tly backward through the inferior 
 until its point en ft palate. I be thread i 
 
 with forceps, drawn out through tin: mouth, and held while the 
 cath( withdrawn. One end of the thread pr rom the 
 
 trfl and the other from the mouth, and a pledget of COtl 
 
 tied to this latter end and traction ma the other, by which 
 
 PlO, r narcs. 
 
 means the tampon, guided by the index finger, is drawn up behind 
 
 the soft palate and into the posterior nan-. When the tamp. 
 tied on it, it od plan to leave the thread still loi . h to 
 
 bang OUt of the mouth, which will greatly facilitate the removal of 
 the plug; otherwise forceps are required or else the tampon will 
 have to be pushed backward into the pharynx. Any plug put into 
 the anterior narcs must be secured by a silk thread, lest, becoming 
 dislodged, it may drop into the larynx. The plugs must not be 
 left in for more than two days, and should be moistened before 
 removal with a mild antiseptic solution. Hertzfeld (J. A. M. A.. 
 March [3, 1909) descril >f serious hemorrhage from the 
 
 nasal cavity treated with perborate of soda. A strip of moist 
 
yo in MokKHAr.i 
 
 tted gauze M inch wide was covered with powdered perborate 
 
 and packed tightly into the anterior nares. The hemorrhage 
 
 ted immediately. The perborate may be insufflated directly 
 
 into the cavity. A grayish-white foam immediately issues, nascent 
 
 gen is liberated, and the bleeding checked. 
 
CHAPTER IX 
 WOUNDS. GENERAL PRINCIPLES 
 
 DEFINITIONS 
 
 A wound is the solution of the continuity of the - ies, due 
 
 to trauma. 
 
 (a) Subcutc mds are traumatic lesions of the deepei 
 
 rithoul any definite break in the -kin. Such 
 more commonly i ailed "< ontusions 
 
 i open wound* are tho mp&nied by a solution <>f < 
 
 tinuity of the integumt i 
 
 i. 1 Hi mds are open wounds produced by Bhai] 
 
 Instruments. 
 2. Stab wounds are those produ< ed by sharp-pointed instrument-. 
 Punctufi I by blunt-pointed in- 
 
 strument-. 
 
 4. Lacerated wounds are those produced by 
 
 5. Gunshot wounds are those produced by projectile 
 cannon balls. 
 
 A penetrating wound is one in which the vulnerating instrument 
 
 reaches a body cavity. 
 
 A perforating wound is one in which the vulnerating body passes 
 through the cavity. 
 
 An aseptic wound is one in which there is an absence of the germs 
 of inflammation. 
 
 A septic or injected wound is one in which the germs of inflammation 
 are present. 
 
 A poisoned wound is one in which some agent destructive to tissue 
 is present. 
 
 An operative wound is one produced by the surgeon's knife, and 
 is presumed to be aseptic. 
 
72 WOUNDS. GENERAL PRINCIPLES 
 
 M1TOMS AND CHARACTERISTICS OF WOUNDS 
 
 All wounds produce more or less pain, hemorrhage, and loss of 
 
 function; in addition, the severer wounds produce constitutional 
 
 disturbanceSj such as shock, although shock may also occur in slight 
 
 wounds. Hemorrhage depends upon the number and size of the 
 
 Is involved; pain, upon the character of the tissue and 
 
 the extent oi nerve injury; loss of function, upon the amount and 
 
 kind of tissue destroyed; shock, upon the mode of injury and the 
 
 ues concerned. 
 
 Subcutaneous wounds vary widely in the amount of tissue di- 
 
 !. There may be any degree, from a mere strain of a few fibers, 
 
 with slight intercellular exudation (bruises), to total division or 
 
 widespread laceration of the various layers of subcutaneous tissue. 
 
 The pain is dull and aching. The hemorrhage is usually slight, 
 
 but occasionally may be dangerous. If the hemorrhage is slight, 
 
 iroduces merely subcutaneous discoloration, most marked in 
 
 lax tissues; if moderate, it produces an ecchymosis; if serious, a 
 
 hematoma. 
 
 Contusion of the nerves may produce paralysis, usually tem- 
 porary; or the nerve may be completely divided in subcutaneous 
 wounds, and the paralysis be permanent. Shock is nearly always 
 tent in some degree. 
 Treatment. — Subcutaneous wounds are nearly always aseptic, and 
 an effort should be made to keep them so. 
 
 The first principle of treatment is functional rest. It may be 
 
 secured in bed, or by the use of splints, slings, or bandages. Mere 
 
 voluntary immobilization is not often sufficient. Apply a cotton 
 
 compress and bandage; a flannel bandage firmly laid on, alone, often 
 
 ! aporating lotions, in the case of superficial 
 
 often do good. Tincture of arnica and witch-hazel are 
 
 •:ion domestic remedies. 
 
 The following solution, freely and immediately applied, will often 
 
 hloridi., gr. v. 
 
 hoi, g i. 
 
I A) WOl 
 
 old, while often ed with caution, since a 
 
 too long applii ation will lower the vitalit 
 with repair, <>r will even precipitate death of the injured 
 
 11- Ett, in the form of a hot water bottle or hot llannel-, i 
 
 If the extravasations of blood an 'hey may be let 
 
 Or if persistent and int. with re; y may I 
 
 In eith< , after the infiamm; 
 
 massage is useful to hasten absorption, promote nutrition, and b 
 
 repair and restoration of function. 
 
 In tho re injury, where 
 
 ubcutaneous hemorrhage is marked 
 and continuous, and where a hematoma 
 
 forms, the skin must be incised without 
 ots turned out, the w<» 
 
 and the wound I 
 
 quently treated as an open 01 
 
 \ workman fell from old Strik- 
 
 ing the gluteal region. H< 
 
 ly bruised. A day or so 
 later it became apparent thai 
 
 hematoma had formed. It v. 
 
 ated and a large quantity of blood re- 
 moved bul the tumor rapidly reformed. 
 It was opened freely and in the torn fibers 
 of the gluteus maximus a lar 1 was 
 
 found still bleeding. The cavity was a 
 long time in healing but no infection occurred. 
 
 Incised wounds are chara by -harp and severe pain, 
 
 bleeding, and a tendency to ga] 
 
 The slight actual destruction of tissue, the comparative cleanli- 
 ness of a cutting instrument, the free bleeding, and the gaping 
 present conditions most favorable for transforming an infected wound 
 into an aseptic one, or at least practically so. At any rate, many 
 presumably infected incised wounds heal with the same readiness 
 and absence of inflammatory symptoms as aseptic operative wounds. 
 
 Treatment. — For the arrest of hemorrhage, ordinarily, a compress 
 wrung out of hot water or normal salt solution is sufficient. If 
 
 57- —Repair 
 
 I wound of thigh. 
 (Kim.) 
 
WOUNDS. GENERAL PRINCIPLES 
 
 this docs not have the desired result, the bleeding vessels are to be 
 ed with artery forceps and ligated. The hemostasis must be 
 complete. 
 
 The wound is next carefully cleansed of clots and foreign bodies, 
 using normal salt solution, sterile water, or very weak antiseptic 
 solutions Under favorable circumstances, that is to say, if there 
 sonable certainty that the wound has been rendered prac- 
 tical! v sterile, it is closed. If sepsis is feared, a small tube or capillary 
 drain must be employed (Fig. 57). 
 
 Fig. 58. — Method of making an incision. (Veau.) 
 
 In the first instance, the wound is as carefully closed by suture 
 as a 1 ive one. In the second case, sutures are employed, but 
 
 ed further apart, leaving the wound free of access for cleans- 
 solutions and for the free escape of the exudates. If drainage 
 yed, it may usually be dispensed with after the third day, if 
 
 [t is safer to regard all large incised wounds as infected. If the 
 
 1 is ( Losed, itmust be carefully watched for signs of infection 
 
 on their appearance, be reopened without delay; or the sutures 
 
 may be placed and left untied until the probabilities of infection 
 
 have been determined. A wound sealed on the surface and infected 
 
 a calamity. 
 
 tec repair of the aseptic incised wound, a dressing of plain sterile 
 
 applied, and over this absorbent cotton and 
 
 I age. 
 
OPJ R \ I I\ I. W« »i 
 
 In certain instano with incised wound- of th> the 
 
 may be disp nth, the tudate being al- 
 
 • -I to dry and form a < rust , whi( h prote* tioi. quale. 
 
 Operative wounds tire incised wounds, and the aim is al 
 make and maintain them aseptic. Aside from preliminary steriliza- 
 tions, tli proper method of mal. which IS 
 lial in keeping them aseptic and promot air. 
 
 SO. — A go 
 
 The aim should be to do ftS little violence as pofl ues 
 
 incised. The cutting instrument must be sharp, and the tissues 
 evenly and smoothly divided. 
 To make a good incision, fii and slightl) 
 
 either side of the proposed Hue • n, with the left thumb and 
 
 index finger. V : r put the -kin on t! h on 01 -nly] 
 
 The first stroke oi the scalpel should divide the skin for the whole 
 length previously determine ^8). D< band, ti. 
 
 PlO. 60. — A bad incision. (\'rau.) 
 
 fore, the probable length of incision required. The inexperienced 
 
 Operator is inclined to make the wound too short aiitl when si; 
 quently it needs to be lengthened it is difficult to keep it straight. 
 When the skin and subcutaneous "connective ire divided, 
 
 identify the deep fascia before biasing it; it is an important land- 
 mark in nearly every part of the body. All the layers must be cut 
 without any gashing or notching. The incision in the deeper la 
 should not be quite so long as in the superficial layer. The good 
 incision gives an equally good view of all parts of the cavity (Fig. 59). 
 
76 WOUNDS. GENERAL PRINCIPLES 
 
 1 tad incision creates irregularities which interfere with inspection, 
 QOt to speak of repair (Fig, 60). 
 
 Stab wounds differ from incised wounds only in their greater 
 
 uncertainties. Their narrowness and depth make it difficult to 
 
 •mine what organs and tissues have been involved. 
 
 In order to make a doubtful diagnosis sure, to repair an injured 
 
 structure, to control, hemorrhage, and, to insure antisepsis, it is 
 
 often necessary to enlarge the wound. In other respects these 
 
 wounds are treated on the same general principles as incised wounds. 
 
 Punctured wounds are peculiarly a source of worry. They are 
 
 most prone to become septic for two reasons; first, infection is very 
 
 likely to be carried into the wound, and, second, it is likely to be 
 
 retained. 
 
 The vulnerating instrument is usually unclean; portions of it may 
 
 roken off and retained; other foreign bodies, such as shreds of 
 
 clothing, sources of infection, may be pushed in and overlooked, 
 
 -much as the narrow tract makes exploration difficult. The 
 
 ies are not divided, but are pushed apart, and tend to close as the 
 
 instrument is withdrawn. The vessels are little wounded, so that 
 
 ding, the best agent for disinfection, for washing out the invading 
 
 microorganisms, is wanting. 
 
 The bottom of these wounds may be shut off from the surface, so 
 
 that the oxygen-hating bacillus of tetanus finds there a congenial 
 
 /ing. 
 
 The treatment for, all these reasons, must be circumspect. In 
 
 doubtful cases, it is better at once to lay open the wound and 
 
 thoroughly disinfect and search for foreign bodies. In any event, 
 
 the wound must be carefully syringed with cleansing solutions. 
 
 Peroxide of hydrogen is particularly indicated if tetanus is antici- 
 
 mic serum is indicated. If suppuration is threat- 
 
 !ily and free incision and drainage are imperative. 
 
 Count. may be required to facilitate the removal of 
 
 es or inflammatory products. 
 
 Lacerated wounds are characterized by the great destruction of 
 
 peaking. "They are peculiarly the product 
 
 The machinery of rapid transit and manu- 
 
 largely responsible. Boiler explosions contribute a 
 
muni i • Gunshot won dly of the face, arc likely to be 
 
 I.k crated wound 
 
 The manner in which the injuries arc produced, the tearing a 
 ( rushing of the I i $uch injure- thefollowingcharacl 
 
 (ij There is Blight primary hemorrhage. 
 
 (2) Tl requentl] ndary hemorrh;. 
 
 (3) Shock is usually present 
 
 (4) Inf. eldom fails to develop. 
 
 (5) Deformity i- likcl It. 
 
 The followi be reaso 
 
 (1) Primary hemorrh ight, out of all proportion to the 
 
 destruction of tissue, be ause the coats of the tor:. curl up and 
 
 contract, tin or coagulation, and the 
 
 blood pi 
 
 (2) Reactionary hemorrhag I the smaller 
 
 losing their plugs of dotted Mood when the blood pn re- 
 
 stored. Secondary hemorrhage occurs ; mppural 
 
 which is the rule rather than the exception, I by 
 
 treatment. 
 
 (3) Shock Is always present in te of the injui 
 
 to the nerve trunk-. In crushing injuries to ' it is 
 
 sometimes difficult to relieve -hock until the mangled nerves are 
 completely divided by amputation. Sometimes under t: 
 
 circumstances, the shock is immediately fatal. 
 
 (4) Infection is coincident with the injury because of the grime 
 which is ground into the tissues. The vitality of the ti-sues ad- 
 joining those which were killed outright and the 
 power to resist microbic invasion lost An invading germ and 
 lowered vitality are the two factor- alwa tial to suppuration. 
 
 Treatment of Lacerated Wounds. — (1) Honostasis, (2) relief of 
 shock, 3) antisepsis, (4) supp 
 
 (1) Hemostasis is usually not difficult It may be necessary to 
 catch up a bleeding vessel with forceps and ligate, but more often 
 pressure with gauze pads wrung out of hot normal salt solution 
 suffices. Unless the hemorrhage is severe, sterilize the adjacent 
 skin with soap and water, bichloride, or alcohol, before beginning 
 exploration. 
 
WOUNDS. GENERAL PRINCIPLES 
 
 Shork is treated on general principles. Maintain the body 
 heat , lower the head, and keep the patient quiet. In severe cases, 
 injections of adrenalin and salt solution are to be employed. (See 
 ck.) 
 
 Antiseptic measures follow the arrest of hemorrhage and shock. 
 tvering the wound with sterile gauze, and then scrub the 
 adjacent skin with soap and sterile water, then with bichloride, 
 1-2000, and finally with alcohol. Next cleanse the wound. By 
 repeatedly flushing with normal salt solution or very weak bichloride 
 or other antiseptics, an effort is made to rid the tissues, as much as 
 able, of dirt and debris. 
 Forter, of Fort Wayne, says with regard to cleansing wounds 
 .American Medicine, September, 1906), that it is an easy matter to 
 overdo in our attempts to render an accidental wound aseptic. By 
 the use of too vigorous scrubbing, too harsh mechanical means, 
 hot water, or too strong antiseptic solutions, more harm than 
 good may be done. The resisting power of the tissues is perhaps the 
 • potent single factor in preventing infection, and it may be 
 diminished by too much antiseptic zeal. We must remember that 
 in -pite of our efforts some germs will be left for nature to take care 
 of, and we must not make it impossible for her to do it. "Person- 
 ally," says Porter, "I find myself using more care, more time, more 
 . more soap, more water, and less vigorous scrubbing, less 
 curettement, and weaker germicides." 
 
 In the author's practice such wounds are freed of grease and 
 grime by pouring on gasoline and then painting very thoroughly 
 with iodine; or in the case of cavities the iodine is poured into the 
 wound. 
 
 It is not always possible to determine to what extent the tissues 
 
 fatally injured. In the case of crushed wounds of the extremi- 
 
 it may be necessary to wait until a line of demarcation appears, 
 
 ihat no useful tissues shall be unnecessarily sacrificed. 
 
 1 drainage is a matter of antisepsis. It is a sine qua non in the case 
 
 Iterated or crushing wounds, but there is usually little trouble 
 
 in this r for the reason that these wounds are not sutured 
 
 and drainage is provided for in the dressing. 
 
 (4) Suture of the skin wound is not possible, as a rule, but certain 
 
\\\ } ( III) 7 
 
 of the d( may demand mm h repair. A divided ru 
 
 trunk, tendon, or nn. 
 
 coaptation of the woundj even though incomplete, will lessen the 
 time require ranulation. 
 
 The dressing must fill two requirements; it m 
 < barge and p out info turn* The most commonly empL 
 
 • hut liberal ( overi >k hloride or 
 
 applied to the wound, and over thi ering of 
 
 absoi >tton held in place by a bandage, which is applied far 
 
 the purp giving equal j and support to the wounded 
 
 The frequent y with which the dr. 
 
 will depend upon th< I ion. 
 
 The author has derived mud m in the treatment of 
 
 this I wounds on the hand- from the use of the ointment 
 
 mentioned on pa with 
 
 iodine, the ointment is applied and the whole with ga 
 
 and bandaged. It tends to relieve tei I pain and proi 
 
 repair. The gauze does not adhere to thl Hind 
 
 and so the i hange i i dn 
 The aim in general is to disturb the I ble, 
 
 and no change 13 DIS I the indication 
 
 Infected wounds may not be 
 but soon the proi i inflammation manifest thi Pain, 
 
 redness and BWelling, accompanied by certain constitut 
 
 such as fever and rapid pub ardinal symptoms. 
 
 The BepSlS may produce no results D* re than tempoi 
 
 disturbances of the character named. On the other hand, it may 
 result in suppuration, which prolongs repair and produces un- 
 welcome cicatrice-; or, even worse, the infection may spread 
 
 rapidly as to invoke extensive area-, rendering thi brawny 
 
 with serous exudates and overwhelming the heart and kidneys with 
 toxins before suppuration has time to appear. It is these un- 
 certainties which make infection BO much to be feared, and mak< 
 prevention the largest element in the treatment of ordinary wounds. 
 When once the sepsis has a definite foothold in a wound, the treat- 
 
WOUNDS. GENERAL PRINCIPLES 
 
 ment has two objects: to destroy the germ and remove and neutralize 
 its toxins; and to support the tissues in their struggle. 
 
 The application of these principles calls for the use of antiseptic 
 solutions, the choice of which will be determined largely by the 
 nature of the chief infective agents, the stage and degree of in- 
 on and the physical characters and topography of the atrium 
 o\ infection: thus bichloride, peroxide, lysol, iodine, etc., have 
 each their special indications, depending on whether the microbe 
 i- an anaerobe, pus producing coccus, or is of fecal origin. 
 
 In the conglomerate infections of the war wounds of the 
 European battlefields, Carrel found hypochlorous acid of peculiar 
 and remarkable efficiency; in special combination and under the 
 name o\ Dakins' solution (see page 161) it has already come 
 into world wide use in civil practice. 
 
 the wound cavity is extensive, it should be opened up in 
 
 such a way that every bit of infected tissue may be reached 
 
 whatever the nature of the solution used. It is sufficient to 
 
 irrigate once daily. In appropriate cases, when, for example, 
 
 there is a large cavity, between irrigations, gauze saturated with 
 
 the solution may be packed around the drainage tubes until such 
 
 time as the infection abates; which should be determined in the 
 
 - by daily bacteriological examinations. Absorbent 
 
 gs of sterile gauze or cotton may be applied over the 
 
 antiseptic wound dressing and changed as soiled without disturb- 
 
 the wound packing. In the case of the extremities ; prolonged 
 
 immersion in warm normal salt solution is of great value. In 
 
 rations, normal salt or Dakins' solution may be 
 
 I by the drip method. The latter measures should promote 
 
 ie regeneration. The value and mode of use of the electric 
 
 light has been indi< and elsewhere (seepage 159, Gun Shot Wounds; 
 
 Conip. Fractures). 
 
 
CHAPTER X 
 WOUNDS OF SPECIAL REGIONS 
 
 WOUNDS OF THE SCALP 
 
 r tain anatomical features determine the q haracter of 
 
 SCalp wound-, and must be kept in mind in pi - and treatment. 
 
 The blood vessels converge toward the vertex; they are the 
 on [pital, posterior auricular, {X)ral, supraorl 
 
 and temporal, a: i whi< h ma -e to troublesome bit 
 
 ing, and all of which are subcut&n< aponeun 
 
 They/ure firmly connected with the dt ie of the scalp and 
 
 for that reason do no! readily contract when di\ ason 
 
 the bleeding from Kalp wound- >U8 and without much tend- 
 
 ency to spontai i l he vessel what difficult to 
 
 catch with artery fon eps. 
 
 The aponeurosis of the occ ipito-fron; he dividing line in 
 
 prognosis: wounds that do not penetrate it are less like \ 
 
 infected, nor do the conditio r spread of infection und 
 
 perforating the aponeurosis is always a matter of concern; for, 
 ing to the loose cellular tissues which conm with 
 
 the pericranium, an infection may spread very rapidly and in every 
 
 direction. 
 All scalp wounds are presumably infected, yet the free bleeding 
 
 minimizes the infection, and the rich blood supply of the tissues 
 favors rapid repair. 
 
 Scalp wounds do not gape unless the aponeurosis is divided, and 
 
 contused wounds often resemble incised wounds. 
 
 Contusions may result in the formation of hematoma beneath the 
 sJW», but they are of little moment. P^vaporating lotions are 
 sufficient to hasten absorption. 
 
 6 Si 
 
WOUNDS OF SPECIAL REGIONS 
 
 A severer injury may cause a hematoma under the aponeurosis. 
 Glancing Mows, other things being equal, are more likely to cause 
 those tumors, rupturing the vessels of the subaponeurotic areolar 
 tissue Such a tumor is likely to be extensive. It may be the 
 source of error in diagnosis, giving the examining finger the sensa- 
 tion of a depressed fracture, being hard around the borders, and soft 
 in the center. If the tumor is of such size as to put the skin greatly 
 on the stretch, it may be punctured. This is preferable to inci- 
 sion, for there is less chance of infecting the exudate. 
 
 Absorption always takes place so that the least interference 
 possible is the best treatment. 
 
 A hematoma may form under the pericranium,, usually in children 
 in whom the bone has a rich vascular supply. Here, also, it is ab- 
 sorbed in time, and intervention is rarely, if ever, necessary. 
 
 Open Wounds. — The treatment of these wounds, of whatever 
 character, may be expressed in certain general formulae. 
 
 The first step consists in cleansing the hair of the blood, which is 
 not always an easy task. Warm water is best to dissolve out the 
 clots, or peroxide of hydrogen. 
 
 The next step consists in removing more or less of the hair, de- 
 pending upon the gravity of the wound. In all serious cases, the 
 whole scalp must be shaved. Begin by cutting the hair with the 
 -ors, and then apply the razor; the " safety razor" facilitates 
 this work. 
 
 vt cleanse the scalp with ether, to dissolve the oil which is al- 
 s present, and follow this with alcohol; otherwise the ether will 
 interfere with the soap and water cleansing which follows, and which 
 i- freely and vigorously applied. 
 
 In the meantime, a light gauze packing prevents the soap and 
 into the wound. Once the scalp is cleansed, the 
 elf is to be cleansed. 
 
 Strong antiseptics are distinctly to be avoided. Sterile water, 
 
 normal salt solution, or peroxide are perhaps the best. An irrigator 
 
 or syriri >1 to be used, but the solution may be squeezed out 
 
 compress into the wound. Be assured that every particle of 
 
 matter is out of the wound before considering repair. 
 
AY 83 
 
 1 rapid b tnd tin* time 
 
 and pal If the 
 
 •iot be lj iture 
 
 ried 00 a needle throug g the 
 
 • I. 'Ill- 
 
 with a hot anti The main thi Ot to 
 
 dis< ouraged or be it hurry. 
 
 The < leansing and hemost pleted, I 
 
 In 1 i ^rounds, the I rimmed. 
 
 The suturing is an important step in fa«ilita* ion. I 
 
 rounds that do not al all tie [ukkly f< >r suturing, silk 
 
 being probably the d. 
 
 In ma] hich are not d< - 
 
 be linn and no drains ired In tl majoriy 
 
 and may be secured by in- 
 
 comp • hit, by .1 I : ; " . or, foU< nan, by stri; 
 
 The dn .ill usually cat 
 
 COtton held in place h\ I le of mi: 
 
 and where 1 ired, it IT the line of 
 
 suture mth sterile vaseline and cover with B< riblc < oUodion. 
 
 It' a l;i Tort 
 
 must be made to readjust and suture it accurately, though the drain- 
 
 age must be ample. Oftentinies with those v. 
 almost completely scalped, the result- i .ellent. 
 
 Flaherty report complete avulsion, occurring in a 
 
 laundry worker. There w< of denuded hone. 
 
 no shock and hut little hemorrhage. The woman who was alone 
 
 at the time o\ the accident remained perfectly 
 
 extracting herself from the machinery, -topped the motor and 
 
 wrapped a towel around her head. 
 
 Hot boric acid compresses were applied without further cleans- 
 ing and after four days Thiersch grafts taken from the thigh were 
 applied to one side of the head and a week later to the other side. 
 The denuded hone was trephined through the outer table that 
 granulations for grafting might form. Pursuing this line of treat- 
 ment the patient was enabled to leave the hospital in two months 
 
84 WOUNDS OF SPECIAL REGIONS 
 
 with head covered with good firm skin. (Annals of Surgery, Feb., 
 
 101. 
 
 WOUNDS OF THE PINNA 
 
 Many form- of injury befall the ear. It may be bruised, cut, or 
 I, and much pr little of it lost. Even a slight loss is a dis- 
 figurement, and any very serious loss of tissue results also in some 
 irbance of hearing. 
 \ laborer came into the City Dispensary with half an ear cut off 
 and hanging by a mere thread of tissue. The sharp edge of a spade 
 wielded by a co-worker had produced the injury. The almost dis- 
 carded member was carefully sutured in place with silk. Some 
 sloughing occurred along the edges of the wound but eventually the 
 repair was complete and almost without a scar. 
 
 These tissues possess great vitality, and the completeness of re- 
 pair after much mutilation is often surprising. Large portions of 
 the ear may be cut off completely, and yet if immediately sutured 
 in careful coaptation, union will occur. There may be some slough- 
 ing along the line of union, but eventually there is but little scar 
 ie left. In every case, then, of incised wound, an effort must be 
 made to suture. The hemostasis must be complete, and if there is 
 much laceration, the edges of the wound must be trimmed. Silk 
 is the best suture material in these cases. 
 
 WOUNDS OF THE FACE 
 
 Accidental wounds of this region, more than any others, approxi- 
 mate aseptic wounds. These wounds do not gape much; the tissues 
 ar, 90 that the conditions are most favorable for re- 
 pair. The chief aim is to avoid scar tissue and the consequent dis- 
 To attain I hat end the suturing must be delicate, the 
 itures must be as small as possible and 
 r> able. 
 The Klh U atiti b may be employed if the wound is ex- 
 
 1 ep. In ordinary incised wounds extensive dressings 
 with, and the line of suture may be covered 
 with collodi is Von Bergman, who dislikes collodion, suggests, 
 
! MI* 
 
 the wound may be amply protected b cab formed b) 
 
 dried exudat 
 
 \VO( \I)> ()] I III. Ml- 
 Woundfl ( »f the lip- arc like! \- to 1)1- -i« i* ral>I\- ? hut the 
 
 licmorrli trolled by <<>ni: lip between the 
 
 thumb and index md then 
 
 the coronary ork rj maj 
 
 ated on each Bide of the wound. 
 
 When the di\ i 
 
 pair by suturing the 
 nun on- membnu with 
 
 it. Suture the skin by 
 tinuous or interrupted Mittu 
 ime silk I it 'I h< 
 
 must be exen ised when the 
 horder of the lip bed; the 
 
 coaptation must be exact or the 
 result will be a disappointing 
 
 A small drain in the -kin 
 
 wound is usually advisable. 
 
 6 i. —Suturing wo 
 
 ;<! nf ; 
 
 WOUNDS 01 I HE T0NG1 E 
 
 Wound- of the tongue, which are not as infrequent as one might 
 
 expect, may give rise to a du ble hemorrhaj 
 
 The tongue is to be drawn out of the mouth and compressed with 
 the fingers above the wound or by a pair of forceps o with 
 
 rubber tubing or with gauze 1 ig 
 
 Suture the bleeding points, employing d^cp sutures of catgut, 
 No. 3« Every quarter hour the mouth should be washed with a 
 solution oi chloral, 2 grains to the ounce, until the oozing and pain 
 have subsided. 
 
 WOUNDS OF TH1 EYELID 
 
 A wound of the eyelid is to be repaired like a wound of the lip, 
 by two lines of suture. First suture the mucous membrane with 
 
WOUNDS OF SPECIAL REGIONS 
 
 nnc catgut Then begin the suture of the skin at the free border, 
 win: dges of the divided tarsal cartilage are to be very ac- 
 
 ipted (Fig. 63). If drainage is used, it must be small 
 ami project from the middle of the wound. 
 
 Fig. 62. — Suturing wound of tongue. A, tongue controlled by tenaculum forceps. B, first 
 suture passed and tied. C, second suture passed, using the Reverdin needle. (Lejars.) 
 
 WOUNDS OF THE NECK 
 
 One has but to consider the multiplicity of the structures in the 
 
 /c that wounds of this region are likely to be complicated. 
 
 Whether the wound he incised or contused, a stab or a gunshot 
 
 md, there- arc dangers that arise from hemorrhage, asphyxia, 
 
 and infection. 
 
 The most common wounds, perhaps, are those which arise from 
 attempts at suicide. That these attempts are often abortive, and 
 the danger done much Less than one might expect, are due to the 
 
 yielding and the vessels recede as the head 
 
 the knife may he directed against the lower jaw or 
 
 a force on the cartilages or hyoid bone; the arm may lose its 
 
WO! 
 
 ton e at the moment the larynx is op >I from failing resolution. 
 
 In these attempts at suit ide, the wound in right-handed people usu- 
 ally beginfl on the left ride high up, and runs obliquely downward to 
 the right, becoming less and Less deep. Not infrequently the wound 
 
 may app the imp or three 
 
 from the folding of the skis before the pressure of the kni 64). 
 
 in the gro usually the first consideration. 
 
 It a carotid is wounded, a geyserof 1 urts out and thepati. 
 
 life Ifl in the hand- of the fir r, for tli< 1 time to call for 
 
 skilled aid. It rnal jugular is wounded, the hemorrha- 
 
 scar- • rous ai 
 
 baps even more difficult definit 
 to control. Air may enter the 
 
 venous 1 in illation and death im- 
 mediately ensue. In cith< 
 anything but intelligent first aid 
 
 will fail. 
 
 The carotid may be ( onto 
 by pressure downward and back- 
 
 1 . j 1 1 f ,1 1 Fig. 6j. — Incised wound of tint* : 
 
 wa r d at the base m the oei k, com- TarsAl ^^ suturcd fir5t p % fau) 
 pressing the v< the 
 
 tran ; i cervical \ may 
 
 be temporarily controlled by direct pressure on the bio 
 in the wound. 
 When the surgeon arrives upon the scene, he finds the wound 
 
 filled with a meat clot, for it cannot be d that the first aid 
 
 will do anything more than partly check the bleeding. EDs first 
 
 effort must he to cleanse out the clots and locate both ends of the 
 bleeding vessels, clamp them, and ligate. Blind clamping of the 
 tissues en masse is absolutely unsurgical. If th< [ the divided 
 
 \ esse] cannot be located, the wound is to be enlarged over the course 
 oi the vessel, using the anterior border of the sternocleidomastoid 
 muscle as a guide. If the character of the wound or the region pre- 
 clude that, then the artery must be exposed below the wound and 
 ligated. It may happen, especially in secondary hemorrhage, that 
 the carotid on the opposite side also may need to be ligated either 
 temporarily or permanently. 
 

 WOUNDS 01 SPECIAL REGIONS 
 
 The internal jugular may be difficult to expose and ligate because 
 
 of its thin and friable walls. Even small openings in the vessel 
 
 may call for circular ligation, for lateral ligation is usually unsatis- 
 
 I hitside of the hospital, suture can scarcely be considered. 
 
 
 io 98765 3 21 
 
 Fig. 6j. — Incised wound of neck involving the larynx. 1, platysma; 2, sterno-mastoid; 
 3. int. jug. vein; 4, vagus nerve; 5, ext. jugular vein; 6, com. carotid art.; 7, upper part of 
 wound in thyroid cartilage opening into larynx; 8, sup. thyr. art.; 9, st. hyoid muscle; 10, 
 sterno-thyroid muse. 
 
 If the trachea, in its upper part, or the larynx is opened, it is better 
 to do a tracheotomy lower down and attempt repair of the wound. 
 In many cases, however, if the wound is not extensive, it is sufficient 
 
mi. i W| 
 
 to close the wound by flexing the neck, omittii and 
 
 leaving nature to repair the - in the air p 
 
 If the esoj >t pharynx fa p< !, repair should be at- 
 
 tempted; but drainage must be employed and the external wound 
 
 left partly open, for, in the B A -allowing, parti od may 
 
 •( ed into the wound I ion. 
 
 If infection or inflammation of the respiratory tra<i arisi 
 to be treated on general prindpl 
 
 Divided nerves should be repaired if p although often the 
 
 difficulties arc too great mount 
 
 A woman, the vi< tim of a murder- brought to the 
 
 City Hospital with a gaping razor cut her tlr 
 
 The hemorrhage had been checked by the ambulance surgeon who 
 had applied three <>r four (lamp 1 with - 
 
 difficulty. It was found that the structures connecting the hyoid 
 bone and the thyroid card the 
 
 pharynx was opened widely and with each ii Sort the 
 
 epiglottis protruded into the wound. 
 
 An effort was made at ananatom* rand with soi 
 
 The mucous membrane was fairly well coapted with interrupted 
 sutures of plain catgut 
 
 Next all the small bleeders were tied and the muscle ends brought 
 
 together with mattress sutures of chromic gut; the fascia next with 
 chromic, and finally the skin was repaired with silkworm-] 
 Rubber tissue drain used on either the middle line 
 
 extending down to the muscle la] 
 
 Following the repair, swallowing v. painful and the 
 
 secretion of mucous excessive Rectal Feeding wa 
 
 three days. 
 
 The subsequent course of the cas remarkable. Her pulse 
 
 and temperature remained normal, there was not the slightest evi- 
 dence of infection and she left the hospital at the end of two w 
 with a light scar as the only evidence of her terrible experience. 
 
 WOUNDS OF THE EYE 
 
 Morrison, of Indianapolis (Indiana Medical Journal, Feb., 1907), 
 has defined the injuries of the eye. whose treatment must most often 
 
^^^^^^^^^^\VOUND^O^STECIAL REGIONS 
 
 be instituted by the general practitioner. From the diagnostic 
 point oi view, he classifies them under two heads: 
 
 (a) Those without superficial lesions of the ball. 
 
 with more or less extensive open wounds. 
 
 The first may lead the practitioner into grievous error in prog- 
 
 s and injudicious lack of treatment. No blow over the eye should 
 
 be considered lightly. While the majority of such cases lead to 
 
 serious consequences, the exceptions are of sufficient frequency 
 
 to be of importance. 
 
 It is possible for the so-called " concussions" to lead to subsequent 
 inflammation or degeneration of the deeper structures of the eye. 
 So, then, though no treatment is to be instituted in the absence of 
 symptoms, yet the case must be kept under observation for some 
 time, the vision tested, irregularities of the pupil noted, and evi- 
 dences of inflammation sought for. 
 
 On the other hand, there may be a hemorrhage into the anterior 
 or posterior chambers, accompanied by pain, protrusion of the eye- 
 hall, and swelling of the lids. Under such circumstances, put the 
 patient to bed at once and apply ice cloths to the eye, this treatment 
 to be kept up until the symptoms begin to subside, when it is 
 probable that the blood has clotted and the hemorrhage ceased. 
 
 In addition to, or instead of hemorrhage, there may be disarrange- 
 ment of the retina, lens or iris, accompanied by disturbance or 
 destruction of vision. 
 
 Put the patient to bed in a darkened room, and drop into the eye 
 
 a solution of atropine, 4 grains to the ounce, followed by the ap- 
 
 plication of cold cloths for at least twenty-four hours. Later a 
 
 dage is to be applied and the patient permitted to go about. 
 
 Any subsequent disturbance calls for an examination by an oculist. 
 
 (b) Deep, penetrating, non-injected wounds of the globe are serious 
 in various degrees, depending upon the region involved, though they 
 usually heal kindly. Injuries of the sclero-corneal junction or ciliary 
 body often lead to sympathetic ophthalmia, and may require early 
 or late enucleation. 
 
 The treatment is simple. Prevent infection by the free use of 
 boric acid solution, followed by one or two drops of the atropine 
 
;v.\ 
 Solution, and the application of a sterile eye dr< 
 
 dicatcd. 
 Every wound of the sclera of any moment requires suture, which 
 i- the best n I preventing infe tion. I mire 
 
 an immediate and <ir< U tment. 
 
 If the vitreous i involved] thi j almost certain to be 
 
 lost. 'Idie pro/ :newhat better if the done i- 
 
 involved. 
 Tli- irrigated with warm, sterile, saturated solution 
 
 of boric add, followed by a few drop- of the a' *ion. the 
 
 whole to be rej' very two or three hours, until the red 
 
 • \ay. In the mcmtii! .Id i> t" -'lied, de- 
 
 ding upon which gives the i pt in the case of 
 
 the eomea, when- licit is always the better application. 
 
 Morrison recommends as the I thicknesses 
 
 sterile gauze held in place by thickness of ba or a 
 
 strip of adhesh e plast requently ch 
 
 To sum up, then, the < hirf ends of l 1 
 
 two; asepsis and conservation. Only tn ly will the 
 
 of enucleation present itself as an 1 1 
 
 ami/nation which should be given every injured eye, should be | 
 
 ceded by .» regulated Prepare the hand-. bital 
 
 and palpebral regions by patient washing with warm sterile v. 
 
 and soap, avoiding all pressure <>r rough handling which ma; 
 vate the ocular lesions. Cleanse the conjunctiva of the gr< 
 
 dirt and immediately instill a few drop- due solution. In a 
 
 few minutes tne cleansing ^i the globe and palpebrae may be com- 
 
 pleted without pain, and a careful examination made and the tr 
 ment instituted. 
 
 If suture is required, use a -mail curved needle held with a forceps, 
 employing catgut No. OO, and above all, a minute care and a light 
 hand. 
 
 The suture should not pas- through the entire thickness of the 
 sclerotic coat, but only through the conjunctiva or the most super- 
 ficial layers of the sclera. The reunion will usually be perfect if 
 the sutures are carefully parsed and slowly tied. See, ah 
 ies.) 
 
Q2 
 
 Woi'NDS OF SPECIAL REGIONS 
 
 WOUNDS OF THE EXTREMITIES 
 
 Wounds of the extremities call for varied application of all the prin- 
 ciples of treatment of wounds, hemostasis, antisepsis, and suturing. 
 
 Only through familiarity with these principles will one acquire 
 address id the management of the individual case, for no two injuries 
 are exactly alike. It will be advantageous to exemplify these prin- 
 ciples with special reference to wounds of the extremities. 
 
 INCISED WOUNDS OF THE WRIST 
 
 Such wounds are frequent and their repair is usually left to the 
 junior surgeon; the task is, however, no light one and the functional 
 
 II.P 
 
 ccJ. 
 
 CJ?2?. 
 
 rfC 
 
 jr.'>f hf %xZr 
 
 PlG. 65. — Cross section showing relations of the various tendons at the wrist-joint. 
 .V. R., radial nerve; L.F.P., long flexor of the thumb; A.R., radial artery; G.P., palmaris 
 longis; N.M., median nerve; L.F., flexors of the fingers; A.C., ulnar artery; N.C., ulnar nerve; 
 C.P., ext. carp, ulnar; C.P.D., ext. min. dig., C.C.D., ext. com. digitorum; L.E.P., ext. long, 
 pollicis; R, extensors carp, rad.; M.P.\ supinator longus extensor brev. pollicis. 
 
 often a source of embarrassment to the operator. To 
 ■te and identify all these tendons and nerves, to get the proper 
 - in contact, to repair them and, above all, to avoid infection 
 
Ill US 
 
 oo end of p and no little skilL The nuu 
 
 these wounds is largi applied anatomy. 
 
 In the more superficial wounds the palmaru longua alone i^ di- 
 vided, a quite -mall tendon in the middle 
 
 line of the wri-1 . 
 
 A little deeper on the radial rid 
 
 the middle line, the flexor < arpi radialis 
 may he invoked; or far out on the ulnar 
 
 side, the flexor carpi ulnaris, in the line 
 
 of the pisiform 1" 
 
 If a -till deeper plane is rea* bed the 
 
 radial artery on the radial border, the 
 
 ulnar artery On the ulnar border mi 
 quire a ligature. The ulnar nerve I 
 the ulnar side of the ulnar art 
 
 little deeper. In the middle line in this 
 
 deeper plane are the tie- 
 
 and the median ner\ I I 
 
 The bleeding in such i ually 
 
 copious. 
 
 Begin the treatment b sting the 
 
 arm and applying circular constriction f or 
 
 temporary heme i ig. 66). 
 
 Next Sterilise the field and then the 
 wound itself. Separate the lips of the 
 wound, loeate and damp the supertieial 
 
 veins (Fig, 67). These are not of much 
 importance yet are large enough to make 
 troublesome bleeding. Search for the 
 artery; both ends must he ligated, the 
 
 companion vein included. 
 
 It may he necessary at this time to 
 enlarge the wound, for the skin may he 
 much less extensively involved than the 
 deeper parts. 
 
 It is of great assistance to mobilize the lips of the skin in order to 
 expose and facilitate the repair of the deeper structures. Remove 
 
 Fig. 66. — Incised wound of 
 t . Tourniquet applied. 
 (Vrau.) 
 

 NDS OF SPECIAL REGIONS 
 
 Fig. 67. — Incised wound of wrist. Bleed- 
 ing vessels clamped. (Veau.) 
 
 Fig. 68. — Incised wound of wrist. 
 Vessels ligated. (Veau.) 
 
 V, -Wound a t bend of elbow. ,. Basilic vein; 2, median eephalic vein; 3. biceps 
 tendon; 4. b.cp.tal fasc.a; 5. brachial artery; 6, brachial vein; 7. median nerve. 
 
\v<»! mm i 95 
 
 the tourniquet, < omplete the In line 
 
 the injuries to tendons and nerves. (For methods of repair 
 
 ;7-) 
 
 WOUND Ai I III. BEND 01 I HE ELBOW 
 The imporl xure of the db 
 
 mdfl in • •::. I 
 
 not infrequent 
 
 Superficially, on the innei the median cephalic vein; on 
 
 the outer the basilic vein; below these the bicipital fascia, an im- 
 portant landmark just beneath which, in the middle line lies the 
 t.iii< trial artery with it- vein to the inner side Th< median m 
 
 JsO to the innei □ the middle li: 
 
 the tendon of the bi< eps. Failure t<» repair an] 
 
 may lead to disability. The bicipital I bould b« 
 
 paired by a separate line oi ig. 69). 
 
 A STAB WO! \i» 01 1 m 1 Hh.il 
 1 70.) 
 
 The femoral ha- I < inded and the hemorr: 
 
 Direct an assistant to make firm digital pressure over th< 
 as it crosses the pubes, nor must this i It his 
 
 fingers tire, a second assistant ma\ upon tfa ra of the 
 
 first (Fig, 71 . Enlarge the ground Eredy in both direction- in the 
 
 COUrse oi the artery. Sponge out the clot-; identify the aponeir 
 and divide it in order to expose the artery; isolate the artery by 
 
 careful blunt dissection and find the two ends, which i- often difficult 
 when the artery is completely divide 
 
 When both ends are found, ligate with catgut Nfo, 3, or silk \ 
 (Fig. 73). Tie the injured vein next both above and below. It is 
 to be tied separately from the artery (Fig. 74). The possibility of 
 including a nerve in the ligature must always be borne in mind and 
 no ligature is to be finally tied until certain that no nerve is to be 
 thus compressed, to become later a source of pain. Remove the 
 
96 
 
 \DS OF SPECIAL REGIONS 
 
 isure and catch any more vessels that might bleed; employ free 
 drainage and suture incompletely. 
 
 Apply sterile gauze dressing, absorbent cotton, and a bandage, 
 making moderate pressure, and maintain the limb in moderate ele- 
 vation. Renew the dressings on the third day, and if there are no 
 
 70.— Stab wound of thigh. 
 (Veau.) 
 
 Fig. 71. — Stab wound of thigh. Com- 
 pressing artery while the wound is en- 
 larged. {Veau.) 
 
 plications, remove the drainage. Remove the sutures about 
 the eighth day. 
 
 triplications may arise. If the ligatures were imperfect, 
 hemorrhage may ensue; the operation has to be repeated and the 
 vessels tied again. If infection occurs, if the temperature reaches 
 
SV01 mi EXTREMIT1 
 
 :ig the wounded vessel. 
 
 I -Isolating and ligating the artery. Fie. 74.— Ligating the vein. (K«M.) 
 
 (YeOU.) 
 
w 
 
 WOUNDS OF SPECIAL REGIONS 
 
 ioi° F., open up the wound and establish better drainage, which is 
 the best means of preventing secondary hemorrhage. Gangrene 
 ollows the ligation of a main artery. Watch the tem- 
 the extremity and look for pulsation in the arteries be- 
 lie ligature. U pulsation is present, be in no haste to amputate. 
 mgrene does not develop before the fourth day, it is not likely 
 to do so. 
 Crushing and lacerating wounds of the extremities, as Lejars 
 e rise to the most perplexing problems of emergency surg- 
 ery. The questions present themselves in this form: To amputate, 
 or not to amputate? and if the latter, when, at what point, and by 
 what method? 
 
 In order not to be vacillating in his treatment, every doctor must 
 have his principle of action settled once for all. 
 
 Lejars states his guiding principle and rule of action in this manner: 
 
 e all, save the patient's life; save the limb wherever possible, 
 
 least limit the mutilation to the minimum. 
 
 Clinically, he places these injuries in two groups: (a) those in 
 
 which a segment of the limb is crushed or otherwise injured without 
 
 peripheral involvement, and (b) injuries extending from the hand or 
 
 foot upward. 
 
 Suppose a case: An arm has been run over by the wheels of a 
 
 vy vehicle. The member is flail-like, although the skin is not 
 
 broken, and there are no particular points of bleeding. Palpation 
 
 through the skin over the injured segment shows that the deeper 
 
 structures have been reduced to a pulp, both muscle and bone. 
 
 Still, below the wound, the radial and ulnar arteries are found to 
 pulsate. This is an absolute indication against amputation. The 
 immediate treatment must be limited to a careful disinfection of the 
 member, the repair of any superficial wounds, a complete envelop- 
 ment in absorbent cotton, and immobilization. 
 
 The immobilization is an essential feature, for by that means 
 any bending and stretching of the vessels is prevented and repair 
 favored. If the skin is broken and the bone crushed or shattered 
 and i i, the injury is a compound fracture and is to be dealt 
 
 with accordingly, but the prognosis always depends upon the blood 
 supply. 
 
1 1 in the case ins! DO pulsation in the 
 
 principal art in that a part of the limb is lost; yet an 
 
 imrri .peratinn is not indicated. There are two reasons for 
 
 this; first, that the shock m ide, and second, that too much 
 
 of the limb may not hich latter an immediate ampu- 
 
 tation nearly always m< 
 
 Proceed to a most rigorous disinfection and await a line of demar- 
 the rule to which there are * one 
 
 apparent, and the other actual. 
 
 It the injury is a crushing one and the member hangs by shreds of 
 ibsolutely no use in wait it the completion of 
 
 the ablation does not require an amputation, it !y what 
 
 rms a " rcgularizatkm." 
 
 im up the ti and n QOUgh bone that a 
 
 lump may be formed, and then patiently cleanse the wound 
 
 with hot sterile water or normal salt solution, followed by alcohol. 
 
 Suture completely and then cover the wound with sterile pauze 
 
 rated with alcohol; finally cover all with a thick layer of cotton 
 firmly banda( 
 Almost always by this me r functional re-ult may 
 
 1 than by a formal amputation quite above the site of 
 
 injury. 
 
 There is an actual be rule of «. -.'ism. The 
 
 and there are all of appr, lion. 
 
 It is not safe to delay and ri>k thfl vhich ml 
 
 under such circumstances, I nmediate amputation. 
 
 (b) Crush or hi :hc hand or foot upward. 
 
 Suppose you are called to treat the Mot and part of the leg, or a 
 hand and part of the forearm, which have been crushed and lacer- 
 ated. The member appears injured beyond remedy. Will you imme- 
 diately proceed to amputate? By no means — or at 
 rule. 
 
 If the case is seen immediately, the first effort should be devoted 
 to combating shock and infection. 
 
 It is not altogether on account of shock that one waits; there are 
 other even more important reasons. The first is that you may not 
 amputate high enough; the second, that you may amputate too high. 
 

 WOTNDS OF SPECIAL REGIONS 
 
 cannot always determine from the first how high the devitalized 
 tissues extend. There may be vascular injuries or muscular lacera- 
 tions which are concealed by a sound integument, and which may 
 later be the source oi gangrene. Out of this grows the necessity of a 
 ularv amputation, which is always a matter of chagrin to the 
 surgeon and an element of danger to the patient. 
 
 On the other hand, tissues which appear devitalized may finally 
 survive and thus preserve a function which might otherwise have 
 been sacrificed. 
 
 It is true that a few inches more or less of the arm or leg, for in- 
 stance, may make no great difference in the usefulness of the stump; 
 quite otherwise when the question is that of amputating im- 
 mediately above or below the 
 elbow or the knee, or through 
 them. Nor do rules of con- 
 servation apply with equal 
 force to the foot and the hand. 
 Injuries of similar degree 
 affecting the upper or lower 
 extremity demand different 
 treatment, because of the much 
 greater freedom of collateral 
 circulation in the former, render- 
 ing gangrene less probable. 
 Where conservatism or ex- 
 n would be proper in the upper extremity, amputation would 
 ailed for in the lower limb. 
 
 tensive comminution and loss of bone of the foot may demand 
 amputation because, if saved, the member may be useless as a means 
 of locomotion, and should give way to a vastly more useful artificial 
 limb. 
 
 eat laceration of the soft parts of the foot, with free comminu- 
 tion of bone and injury to vessels, always demands amputation; 
 for t} LCtionof the skin of the heel and sole will result in a cica- 
 
 trix which can never bear the weight of the body and may never be 
 thing but a source of suffering and discomfort to its possessor. 
 But, aside from these exceptions and others to be noted, the rule 
 
 75. — Bait of gauze for support of fingers. 
 (Marsee.) 
 
WO I 
 
 IOI 
 
 . — Thumb pinched off leaving square- 
 ended stump. 
 
 holds in this < lass of inj id amputation and 
 
 skill to pre n is the 
 
 que Hon; if thi in this H i r ' | half- 
 
 ted, h i to ampul 
 
 at 01 
 
 Immediate omputal .tin, 
 
 I if the wound is 
 
 tei the i 
 dent, and is found soiled and 
 
 dirty and manifestly inf( 
 Under these i onditions, con- 
 in is not the beal 
 for then i many chai 
 
 that the attempt at disinfe* lion 
 will fail; that, in -pit t- of the 
 
 best efforts, sepsis will ai 
 
 Or, if tli> 
 
 the symptoms of d . it i- no longer a 
 
 saving a limb, bu1 of saving a life, and it will be the part of 
 
 the 
 
 With regard to thi 
 tment of th< and 
 
 I injuries of the hands and 
 which n lid be I 
 
 amputate, Reel empha- 
 
 I the value of thorough and patient 
 disinfection of the skin and then of the 
 wound, together with a trimming away 
 of the devitalized fragments of skin and 
 then "embalms" the mem- 
 ber in gauze saturated with an anti- 
 septic pomade, crowded into all the 
 recesses of the wound, and the whole 
 ivd by a thick dressing of absorbent cotton and bandaged. This 
 dressing is left undisturbed until repair is complete, unless the tem- 
 perature should rise or a disagreeable odor develop. 
 
 Fu;. 7 7. — Same 
 plcted. 
 
 Amputation com- 
 
 m.) 
 

 WOUNDS OF SPECIAL REGIONS 
 
 Fig. 78. — Amputation of index finger. Head 
 of metacarpal retained. (Marsee.) 
 
 Joseph Marsee (Ind. Med. Jour., April, 1896) has made some 
 
 \ ations with respect to the treatment of common injuries 
 
 of the hand, which arc well worth repeating and which, as he points 
 
 out, appeal especially to the 
 young man just beginning his 
 life's work, for such will prob- 
 ably constitute the bulk of his 
 surgical practice for some 
 years. There is a natural 
 tendency, in the popular mind, 
 to measure an injury by the 
 size of the member involved, 
 and the man who would insist 
 upon the best advice in other 
 cases, will fly to the nearest 
 doctor's sign when "only a 
 finger" is involved. But Marsee concludes, from his own experi- 
 ence, that the young practitioner is an accomplice in spoiling a 
 good many hands before he [learns to do them justice. On the 
 other side, it is not too much to say that the best human skill is 
 none too good when employed 
 in repairing injuries of the 
 most mechanically perfect 
 human member. 
 
 The majority of these in- 
 juries occur in workers with 
 machinery; the hand, therefore, 
 is always soiled and generally 
 greasy. This grease must first 
 be removed. Nothing is better 
 for this purpose than ordinary 
 gasoline or benzine, which may 
 be poured into the hand 
 directly from the bottle. The 
 fluid will find its way into the • 
 
 smallest recesses of the wound, washing out the grime and preparing 
 the way for the other antiseptics. The benzine is poured on until 
 
 Fig. 79. — Amputation of index finger. 
 Head of metacarpal removed making much 
 more sightly hand. {Marsee.) 
 
1111. I!\M> 
 
 Pic. 80. — Loss of, ring finger. 
 Dorsal view. (Mar see.) 
 
 all tin . and the didn- 
 
 d in the ordinary J 
 
 and 
 
 palms should be treated b 
 
 plint or plaster-of-Paris d 
 < ompletc enough to pre hide all motion. 
 
 This i»roph\ l;r dud as un- 
 
 necessary by those who ha\ 
 marked deformities, th titu- 
 
 tional disturbai 
 
 suit from trifli the hand. 
 
 Eni which leaves nothing to 
 
 chance, to 
 
 dling is alone reliable. Under such tn 
 stent, the rapidity with which alarming 
 symptoms sometimes disap markable. If a plaster 
 
 i tend from 
 
 rist to 
 :" the fingers, the 
 
 thumb ; so enclosed if m 
 
 ry. 
 
 When 
 
 and parallel with the kw . it is 
 
 better not to suture them 
 
 • he swelling will ly he ex- 
 
 tnd the will cut out. 
 
 : the inflammation I sided, 
 
 the I I and ap- 
 
 dmated \ i dm - Mara e ad- 
 immediate splinting in the 
 oi crushing injuries of the fii 
 
 fear that the circulation may be in- 
 terfered with. However, that the 
 crushed member may not be wholly 
 i- u;. 81.— The loss of the ring finger unsupported . a soft ball covered 
 
 lly noticed when the distal half • i ^i . i „.; 4 i 
 
 Of the metacarpal bone is excised. Wlth l0tt0 » "" trapped With gMlM 
 
 (.»'"«.) is applied to the palm so that the 
 
IC4 
 
 WOUNDS OF SPECIAL REGIONS 
 
 fingers may be spread out over it comfortably (Fig. 75), and the 
 whole dressed with absorbent cotton and lightly bandaged. The 
 ball, as Marsee indicates, though unsightly and bulky, has no other 
 fault; it is light, absorbent and wonderfully comfortable, and needs 
 only a trial to be appreciated and adopted. It should be used 
 until the tissues arc beyond danger, though it takes several days. 
 a week or a month. No time is lost, for healing cannot begin until 
 vitality is restored, and this will always be slow in such cases, a 
 
 fact which should be brought 
 
 thoroughly to the p ai t i e n t ' s 
 knowledge from the beginning, 
 that the doctor may not be 
 blamed for the tardy convales- 
 cence. 
 
 With regard to methods of 
 amputating fingers, opinion is 
 divided on the question as to 
 which is the more desirable, a 
 palmar flap, or a slightly longer 
 finger with a dorsal flap cover- 
 ing the stump. 
 
 There can be no douot that 
 a palmar flap is desirable, and 
 Marsee believes in securing it, 
 even at the expense of sacrific- 
 ing more of the finger. If more 
 than half the phalanx is gone, 
 always better, in his opinion, to amputate at the joint line and 
 thus avoid a flexed stump. 
 
 It a portion of the distal phalanx remains, the nail should be re- 
 mover] and the matrix dissected before the flap is adjusted, or some 
 irmed fragment of nail may be left to vex the patient. It is 
 r\ in removing a finger at a joint, to cut off the knobby pro- 
 of the condyles on the palmar surface and to scrape off the 
 1 cartilag 
 If 1 lie finger is pinched off squarely, one must always insist in re- 
 moving enough of the bone to give a good flap, ior if the patient has 
 
 PlG. 82. — The stump of the index finger 
 falls away from thumb when head of middle 
 metacarpal has been removed. (Marsee.) 
 
\\< I] Jill. \ I I . 105 
 
 ui'l the itump hi panulation, the result will be 
 
 ory and the do 'ally, will I r the blame 
 
 li the whole ii mputation, the bead of the dm 
 
 < arpal bone will reqi atioo and tl 1 be 
 
 different with the dififa 
 
 Remove the heads by obli< on in tin and 
 
 little 1 . e the hi 
 
 carpus in tin I therinj ttingback far enough b 
 
 the heads of the adjacent bones fall togethi r I igs. So, 81). 
 
 1 )<> not remove 1 he met* arpal head of the middle finger unless the 
 appi of the hand is I ' ' 
 
 as the reason tor this, thai it tends to Id the 
 from the thumb and thus into 82). 
 
 \\ni NDS 01 I HI VULVA \M» \ tGIN \ 
 
 The chief danger in wound- of these part- is hemon ally 
 
 when the vulva 1- involved and it- venous pi •• 1 
 
 wound- may be contused, lacerated or punctured, and n 
 quently occur from falls astride some ol 1 by that means the 
 
 bulb oi the vagina is crushed against the ramus of the pub 
 
 Porcipressure and ligation may be ineffe* tual to 1 tntrol the bit 
 ing and often the only recourse is tamponade, first disinfecting the 
 wound and the region adjacent, and afterward appl] 
 and bringing the thighs firmly together. 
 
 Perforating wound- of the vagina call for a most careful examina- 
 tion, for not only may the vaginal walls be involved, hut the rectum, 
 bladder, or peritoneum as well, Careful suturing is here the 
 means of controlling hemorrhage. Peritonitis, may result from s 
 
 injuries or more remotely, fistulSB Or astresia of the vagina. 
 
 Any serious hemorrhage following coitus calls for an examination. 
 It may ensue from a tear of the hymen, or oi the posterior wall of 
 the vagina. Cases are on record in which the tear penetrated the 
 rectum. 
 
 Deep suturing serves at the same time to control hemorrhage 
 and to promote repair. 
 
10() WOUNDS OF SPECIAL REGIONS 
 
 WOUNDS OF THE PENIS, SCROTUM AND TESTICLE 
 
 The penis may be fractured nearly always during coitus and in 
 the subjects of a previous gonorrhea which has produced an area 
 of least resistance in some of the peri-urethral structures. Usually 
 the corpus spongiosum is torn. 
 
 Immediately the organ becomes flaccid but within a few minutes 
 again enlarges, this time due to the edema. The extravasated blood 
 produces at once the great discoloration and the acute flexure which 
 is typical. 
 
 Unless the extravasation is very large and progressive, there is 
 nothing to do but to bandage the organ and put the patient at rest. 
 
 Fig. 83. — B, wound of testicle repaired. C, Tunica vaginalis. A, Beginning its repair. 
 
 Otherwise it will be necessary to expose and suture the break in 
 the corpus cavernosum and this Legueu advises as likely to give the 
 functional result. But with such a procedure one may expect 
 hemorrhage. Open wounds of the erectile tissues of the 
 1 orpora cavernosa or corpus spongiosum may be expected to bleed 
 It is usually advisable to pass a sound to determine the 
 _ r rity of the urethra, suturing it first, if involved, and then care- 
 fully coapting the erectile tissues. 
 
 In the case of wounds of the scrotum merely the integuments may 
 Lted, or more deeply the tunica vaginalis or the testicle as 
 
WO! I HI. II 
 
 i r ^7 
 
 well. It mi] red thai any considecabk woundinj 
 
 the tunica of Uk in hernia of th» hyma. 
 
 'I'll- >t be roughly handled in cl< 
 
 must not be too tight, for tl tendem -ma 
 
 and sloughing. I . i i r of these various structun con- 
 
 diK i rately. 
 
 If the tunica vaginalis is opened up and the b herniated 
 
 must urned and the tunica sutured, 
 
 with or without dra Elding upon the probabilities of in- 
 
 on. If the tunica be destnr tains sound 
 
 ration. A. a of the cord and ligature of one-half. 
 
 B. ligature carried around the entire cord. iLejars.) 
 
 it must be preserved, covering it as much ble with such sei 
 
 :overing as remains. Incised wounds of the testicle call for suturing 
 )f the fibrous coat with catgut. 
 
 The tunica vaginalis is next repaired with a continuous suture 
 [Fig. 83), and finally the scrotal wound IS sutured. 
 
 If the testicle is lacerated, or if seen late and manifestly infected, 
 t must be removed without delay. Enlarge the wound, exposing 
 
Io8 WOUNDS OF SPECIAL REGIONS 
 
 the spermatic cord as high up as possible, and at that level ligate the 
 various elements separately and firmly, and resect. Trim away any 
 infected tissues in the scrotum and repair, employing drainage 
 
 i). 
 
 Cotton, of Boston (Amer. Jour. Urol., Nov., 1906), describes a 
 case of injury to the testicle resulting from a blow on the scrotum by 
 a batted base-ball. Shock and excruciating pain ensued, gradu- 
 ally subsiding coincident with the development of a large scrotal 
 hematoma. 
 
 Operation. The superficial tissues were infiltrated with blood. 
 A rent an inch long in the tunica vaginalis. Bleeding from the sper- 
 matic artery. The tunica albuginea was torn in shreds, the paren- 
 chyma destroyed. "The testis had evidently exploded under the 
 swift impact, as a full bladder bursts under a blow." After removal 
 of clots and irrigation, the tissues were sewed up layer by layer 
 with catgut and without drainage, and light pressure applied. Con- 
 valescence uneventful. 
 
 WOUNDS OF THE RECTUM 
 
 ^on- 
 
 Wounds of the rectum are rare. They are usually punctured 
 wounds due to falling upon pointed objects, gunshot wounds, or 
 tears accompanying fractures of the pelvis. The chief dangers are 
 hemorrhage and infection. 
 
 Wounds of this region are usually self-evident, though their extent 
 may be a matter of doubt, so that every such injury demands a care- 
 ful examination. The examination calls for inspection. To depend 
 upon touch alone may lead one into grave error. 
 
 In every serious injury of this character, anesthetize the patient, 
 dilate the anus, and by the use of retractors expose the wound. 
 Douche with hot normal salt solution. If the hemorrhage persists, 
 the bleeding points are to be clamped with long forceps and an at- 
 tempt made to suture en masse, for at that depth it will be hardly 
 ible to ligate the vessels. Sometimes in lacerated wounds, the 
 oozing can be controlled only by tamponing the rectum firmly, 
 pad und a large tube in the center. 
 
 Suturing these wounds is not so desirable as one might at first 
 
W01 P THE RECTUM ic<j 
 
 think, for the Butur< 1 1 
 
 imt suture, thru, unless the ground 
 
 (Iran, it* the suture* are used, ffequenl u - of normal salt 
 
 solution must be employed and tin- bowi 
 da) 
 [f the ound baa penctrc . which I 
 
 develop in i may h ted from 
 
 the tympanites and tenderness of the abdomen, the better plan 
 
 laparotomy. A pa tly had lain for 
 
 months with a Inw grade of sepsis following a punctured woui. 
 the rectum. H< ed promptly affa rotomy exposed and 
 
 repaired a re( tal tear. Opening into t!. . ity. 
 
 The abdomen is to be opened in the middle line, the patient put in 
 the Trendelenbui ion, the pelvis i leai iunds re- 
 
 paired by two I 
 
 li the small intestine should herniated through a rei 
 
 tear, laparotomy n indicated, reducing the hernia by traction 
 
 from above. If the herniated loop protruding from the ann- 
 ul order to avoid infection of the peritoneum the 
 ient should be resected and thi temporarily 
 
 before pro* ceding to the laparotomy. Once the abdomen is opened, 
 the two ends oi the bowel are to be pulled up and ai 
 
CHAPTER XI 
 
 INJURIES TO THE TRUNK 
 
 INJURIES TO THE THORAX 
 
 Certain elementary notions must be clearly comprehended and 
 kept in mind in order to make a definite diagnosis of these injuries. 
 These notions relate to the anatomy, pathology, and symptomatology 
 of the thorax. With respect to the anatomy, one must keep in mind 
 the location of the principal vessels of the chest wall and mediastinum; 
 the relations of the viscera to the ribs; and the normal areas of reson- 
 ance and dullness. In addition, it is necessary to recall the signs and 
 significance of the principal primary complications possible in any 
 form of serious violence to the thorax, viz. : hemoptysis, hemothorax 
 pneumothorax, emphysema, and hemo-pericardium. 
 
 The various points of anatomy and physical diagnosis, elementary 
 though they be, it were perhaps better to enumerate in more detail. 
 
 The principal vessels of the chest wall are the intercostals which, 
 protected from injury, lie in the groove in the lower border the rib; 
 and the internal mammary 1%, inches from the sternal j^order, easily 
 reached by a stab. The intercostal may be compressed in the man- 
 ner indicated on page 68. If a general anesthetic is necessary for 
 another purpose the artery should be exposed and ligated. 
 
 The wounded internal mammary requires ligation and is most 
 easily reached through the second or third intercostal space, lying in 
 close contact with the pleura. 
 
 The relations of the viscera to the chest wall acquire a special 
 significance in connection with traumatism, particularity such per- 
 forating wounds as those produced by pointed instruments and the 
 bullet. 
 
 Imagine the track of the bullet under a variety of circumstances: 
 passing through the right chest antero-posterior, anywhere between 
 its apex and the level of the nipple only the lung will be injured; 
 
 
HI.MOj HOB I I I 
 
 below that level, the diaphragm and liver are likely also to be pcr- 
 tedi ( hll ride the nipple the range may be lower and cape 
 
 the diaphragm since it slopes from the level of the nipple to tl 
 rib in the axillary line. 
 
 In the left ( test, in the area bounded by the second rib, tl 
 Hum, the sixth rib b 1 the nipple line externally, the heart or 
 
 at least the pent ardium is likely to be wounded, and, an] -ark 
 
 ial line, the lung as well. 
 Outside the nipple line and below its It the 
 
 tnacb may complicate the Lung injury. 
 
 Pa ssing I ra I thechei w the nipple 
 
 line wt migl ound to tra dy from the 
 
 right side, the lung, the liver, tl ich, the md the lung 
 
 kin. 
 The principal j > i i 1 1 . iplicati<> 
 
 Hemoptysis, following an injury to the th«»ra\. what nature, 
 
 gnificant oi one thing *thal the Lv 
 
 of injury may be in a manner estimated by the amount of blood 
 
 expectorated. In the dangerous cases, the blood pours from the 
 
 wounded lung tissue into the bronchia and . from the mouth. 
 
 In Other bere is only a di | of blood, leading to the 
 
 belief that the lung has not been seriously torn. It n,\ mi- 
 
 taken for a hematemesis, but the presence of rale- in the branch 
 the affected side (or of both I and the light color of the blood and 
 
 admixture with air, point to the chfl ol the hemo: 
 
 Hemothorax, an accumulation of blood in the pleura, is nearly 
 always the result of injury to the lung; although, of course, the in- 
 ternal mammary artery or the intercostals may occasionally be the 
 source of the extravasation. Gravity determines where the blood 
 will accumulate and therefore the patient's position will modify the 
 physical signs. 
 
 The symptoms and signs are both modified by the quantity of 
 blood and the rapidity with which it is poured into the pleural cavity. 
 In the slighter forms, there is scarcely any disturbance of breathing 
 and only slight dullness over the base of the lung. 
 
 In the graver forms, the lung is collapsed and crowded toward the 
 hilum, so that there are symptoms of asphyxia added to those of in- 
 
llj INJURIES TO THE TRUNK 
 
 tana] hemorrhage. The face is pale, the skin moist and cold, the 
 
 ent is impelled to sit up and gasps for breath, the pulse is rapid 
 
 and thready, and the patient may thus go on to death. Inspection 
 
 i slightly bulging chest wall; percussion, a complete duli- 
 
 . and auscultation, an absence of fremitus and of the vesicular 
 
 murmur. 
 
 ( M ten there is an immediate rise of temperature, due to absorption, 
 and which is to be distinguished from the temperature of infection by 
 earlier appearance. 
 
 No attempt to evacuate the extravasated blood is to be made in 
 the moderately severe cases; in others, of more urgency, an aspiration 
 may give some temporary relief, tiding the patient over a critical 
 point. Finally, in rare cases, the magnitude of the hemothorax will 
 be such as to demand an immediate intervention, with the purpose in 
 view of exposing the lung and repairing the wound in its substance. 
 Subsequently, even if the case is mild, infection may occur and is to 
 be treated as any other empyema. 
 
 Pneumothorax. — Air may enter the pleural cavity from without 
 through an opening in the chest wall, or from within through a 
 rupture in the lung tissue. In the first case it enters during in- 
 spiration, and in the second, during expiration. 
 
 The physical signs and symptoms grow out of the pressure within 
 the pleural cavity and the consequent collapse of the lung. The 
 chest wall on the injured side is distended, the intercostal spaces 
 bulged out, the viscera are displaced, the ribs motionless, the ves- 
 icular murmur absent. If a coin laid on the front of the chest is 
 tapped with another coin, the sound will be heard at the back. The 
 symptoms are principally those of dyspnea. 
 
 If there are no complications, the air is gradually absorbed and 
 the function of the lung restored. 
 
 In i cases, puncture will relieve the intrapleural pressure; 
 
 and in the case of a valvular wound in the chest wall, which per- 
 entrance of the air but not its exit, enlargement of the wound 
 dicated. 
 
 If air and blood accumulate simultaneously — if a hemo-penu- 
 tnoth the physical signs will be altered, but not the 
 
 ptoms. 
 
 _ 
 
JfKRMA OF THE LI 
 
 Emphy m i rhe sub utani hilar tissue m 
 
 char] h air and practically the whole body be involved It 
 
 14 n< ail . due in the marked i the lung 
 
 a broken rib. The air escaping from the lu: . by 
 
 the close contact ot the pleural sun rom entering the pleural 
 
 into the loo the ruptured chest wall. 
 
 In Other rarer ;e inner aspect of the lung is wounded, and 
 
 the air escapes into the I : the mediastinum, and follow- them 
 
 lip into the n 
 
 In ordinary cases no treatment ia indi< ated and th( »on ab- 
 
 sorbed. However, in tbl tih<, the symptom- of asphyxia 
 
 and Cyai y supervene and the: n over the infiltrated 
 
 zone may be requin 
 A man weighing ;oo poui. brought into tb ital 
 
 with a crush of the ( best, frac tin Within a half hour 
 
 after the ;u cident tin- tissuesof his whole ad grad- 
 
 ually the emphysema spread till his -kin from to his 
 
 seemed a- 1 ight .1- s drum. H ditkm was pitiable; b 
 
 Swollen shut, hi- feature- livid, and hi- e breath. 
 
 An eflort was made to strap hi- chest; morphin and atropin in 
 
 small doses were frequently admin: and the the 
 
 chest punctured with num< bars which were left in 
 
 situ. In forty-eight hours his pulse and respiration 1 im- 
 
 prove and in a few days he was entirely out of danger. 
 
 A case of subcutaneous and mediastinal emphysema of extreme 
 gravity was relieved by incising without anesthesia, the skin and 
 fascia above the clavicle and dissecting the : vith finger down 
 
 to the wall oi the trachea. A suction apparatus ttached and 
 
 the air escaped in a continuous stream relieving the symptoms rap- 
 idly; subsequently a valve drainage of the pleura was establish* 
 
 relieve intrathoracic ten-ion and the patient made a smooth n 
 (Amer. Jour. Surg. t Oct., 1913.) 
 
 Hernia of the lung is a rare complication, and may be immediate or 
 secondary. In the first case, the pulmonary tissue is forced through 
 the breach in the chest wall by violent expiratory effort. In some 
 - where the skin is not broken, the hernia may be felt as a crepi- 
 tant tumor beneath the skin. 
 8 
 
114 INJURIES TO THE TRUNK 
 
 In the secondary rases, it forms more slowly, and is often due to 
 the weakening of the thoracic wall by in ilammatory processes. 
 
 IL iirdium. — Blood in the pericardial sac follows injury 
 
 to the pericardium. It develops more rapidly and, of course, the 
 outlook is much more grave if the heart is also wounded. 
 
 The symptoms are those of syncope induced by the compression 
 
 oi the heart by the accumulated fluid; the signs are those of increased 
 
 cardiac dullness. The apex heat is lost, the heart sounds muffled, the 
 
 ordium bulged. It is upon the signs that one must depend for 
 
 the diagnosis, for the symptoms are often complicated by those of 
 
 k and by those which originate in other injuries in the thoracic 
 
 ion. 
 
 To repeat, then, when you reach the patient suffering from some 
 form of chest injury, you will observe the character of his respiration 
 and his pulse; whether his condition is immediately serious or not is 
 to be determined at once by that means. If the circumstances per- 
 mit, you will proceed-to a systematic examination. Learn from the 
 sufferer the location of his pain and the character of his chief distress. 
 the appearance of the sputum, if there is cough. Inspect the 
 chest wall for change in outline and mobility and location of apex 
 Determine by percussion the limits of the lung resonance and 
 heart dullness; and by auscultation, the presence or absence of the 
 dollar murmur or of rales. 
 
 Tl, ay be so grave that exact diagnosis is unnecessary; or, 
 
 in, it may require the most minute examination and judicious 
 
 ghing of the symptoms and signs to make a correct forecast of the 
 
 3, and to formulate a treatment which will leave nothing 
 
 CONTUSIONS OF THE CHEST 
 
 mplc contusions of the thorax, without fracture of a rib or the 
 ium (which are considered elsewhere) and without symptoms 
 g to internal injury, need but brief consideration. A hema- 
 toma is likely to form. The pain and soreness disappear rapidly in 
 young, but are extremely persistent in the aged and the rheu- 
 matic. Strapping and □ with liniment are usually sufficient. 
 
L'KK Ol I HI. 
 
 i the other hand, foil Qtuskm, there may he a de- 
 
 I all proportion to the trauma. 
 
 A man of thirty, apparently in good health, re 
 
 OVCr lli' <t friendly BOlffie. The blow was Blight, and yet it 
 
 <d to touch a vital 5pot and made him <:a>p for breath. It 
 
 with diffi< ulty that i d home and for I ;ned 
 
 upon th( penumonia. A month later he was >till unable 
 
 to work and an ( xarnination at this t i ri - 
 
 Siona of the heart. I ttly dilated and not a 
 
 aed to be performing it- function fully, [nsp 
 ment, his condition gradual) i month- he died 
 
 with a general ai We m ider that the k well 
 
 as other is lial.l- iul that from such inj 
 
 acute endo( arditis may result. 
 
 In 'Mure of 
 
 lung which is ah be feared and which i> usually evidenced by 
 
 a large hemothorax. It must always be remembered that such an 
 injury may occur without fracture ^i the ternum. 
 
 Lejars cites th< i a boy eleven > i 
 
 run over by immediately after the a but 
 
 fell again unconscious, with blood pouring from mouth and nostrils. 
 This hemorrhage did not long persist, but on the fourth day the tem- 
 perature rose and he was taken to the hospital. His condition 
 alarming, the pulse weak with a rate of 104, his sed and 
 
 the dyspnea intense; hi- heart was displaced to the right, and on the 
 
 left side were the signs of marked hemo-pneumothorax. A puncture 
 removing 180 G. of the exudate gave hut temporary relief. The 
 pulse continued to grow weaker and the dyspnea more intense, and 
 an urgent intervention was indicated. The pleura was opened and 
 the lung found retracted toward the hilum. In the upper lobe a tear 
 was found, 7 cm. long, and running upward, and backward from the 
 cardiac incisure. The wound gaped freely. The lung was drawn 
 into the opening in the chest wall, and the pulmonary wound repaired 
 with live sutures of silk which included considerable tissue to prevent 
 their pulling out. The coaptation was perfected by a few superficial 
 sutures. The upper lobe was sutured to the parietes and a tam- 
 ponade with gauze completed the operation. 
 
Il6 INJURIES TO THE TRUNK 
 
 The outcome was unfortunate, for death occurred on the second 
 day, but the autopsy found the lips of the lung wound well aggluti- 
 nated. There was no costal fracture. 
 
 The symptoms of rupture of the lungs are the same whether a rib 
 roken or not: hcmo-pneumothorax, abundant and increasing; a 
 nphysema; symptoms of grave anemia; to all these may 
 lded more or less quickly, the symptoms of pleural infection. 
 
 The treatment, except in the cases of extreme urgency, must be con- 
 itive and expectant. Shock must be combated, the patient 
 kept absolutely quiet, and the dyspnea relieved by the sitting posture, 
 and, if possible, by inhalations of oxygen. 
 
 The anemia can be relieved by injections of small quantities of nor- 
 mal salt solution frequently repeated. 
 
 A puncture will partly empty the pleural cavity, affording great 
 relief; and, eventually, the remaining exudate will be absorbed. 
 
 It may happen that after two or three days the symptoms will 
 improve. 
 
 But in the worst cases, where the dyspnea is progressive and menac- 
 ing, and the heart rapidly growing weaker, the responsibility cannot 
 be shifted. It is indicated to operate at once, to open up the thorax 
 and repair the tear in the lung, to do an urgent thoracotomy (see 
 page 488). 
 
 OPEN WOUNDS OF THE THORAX 
 
 Son-penetrating wounds of the chest wall are of slight significance 
 and are to be treated on general principles. 
 
 Penetrating wounds of the thorax derive their significance from the 
 particular viscera and vessels which may happen to be involved. On 
 the clinical basis, then, these wounds may be divided into three 
 ses: 
 A . Wounds which involve the pleura or lung. 
 B. Wounds which involve the diaphragm. 
 
 Wounds which involve the pericardium and heart. 
 
 A. WOUNDS OF THE PLEURA AND LUNG 
 
 In whatever manner the wound may be inflicted, there are three 
 elements of danger: hemorrhage, asphyxia, and infection. These are 
 
 
OP] 01 THE ( ii: 
 
 the factors which will determine the line of treatment, and without 
 e urgent indication from one of these sources the treatment must 
 be conservative. There are many things which stand in the way of 
 radical procedures such as are employed in the inal 
 
 wounds. In the first place, the operative technic is difficult; there is 
 a marked disturbance of respiration following free access of air to 
 the pleural cavity; the exact location of the lung le>ion cannot often 
 be determined; and, finally, there is always, as Lejars remark-, 
 much guesswork in the prognosis, that we an lined to give the 
 
 nt the benefit of the doubt and leave the case to take its natural 
 course. 
 
 It is best to proceed in this wise: If the case is seen from the first, 
 supervise the transportation. Too much importance cannot be at- 
 tached to the dangers of rough handling. As has ere, 
 
 the nearest shelter is the I ut away the clothing, scrub the skin 
 
 adjacent to the wound, and wash out the wound itself with alcohol or 
 sterile salt solution. If, on opening the lips of the wound, a bleeding 
 point is seen, catch it up and tig 
 
 If there is oozing from the regard it for the 
 
 present. This constitutes the primary intervention for such 
 
 suturing as may be required. 
 
 Apply a dressing of sterile gauze, plain or soaked in collod! 
 Cover this with a layer of absorbent cotton and apply a firm ban* 
 encircling the whole chest. Place the patient on his back with the 
 head and shoulders slightly elevated. Absolutely prohibit cor. 
 sation and movement of any kind; and, in the meantime, keep the 
 patient under close surveillance. 
 
 In general terms, then, the treatment of any ordinary open wound 
 of the chest involving the lung and pleura is to be summed up in two 
 words, immediate occlusion and immobilization. 
 
 But there are conditions which demand immediate intervention. 
 These are acute anemia or asphyxia, which may follow hemorrhage. 
 external or internal; and hernia of the lung. 
 
 External hemorrhage may follow any extensive wound of the chest 
 wall, welling up from its depths or flowing by spurts during expiration. 
 If there is no hemoptysis, it may be inferred that the lung is not 
 wounded; but, in any event, the first treatment must be directed to- 
 
7W 
 
 [NJURIES rO THE TRUNK 
 
 ward the intercostal* and internal mammary. It may be that a tem- 
 
 rv hemostasia will be necessary, and the tamponade described on 
 
 J, will be indicated. 
 
 The definite hemostasis requires a free enlargement of the wound. 
 
 If pressure made against the lower border of the rib by an aseptic 
 
 finger introduced through the enlarged wound causes cessation of 
 
 hemorrhage, it is certain that it is an intercostal artery that is at 
 
 fault. It may be difficult to clamp; it may be necessary to resect a 
 
 rib, or to detach the periosteum, which will carry the artery with it. 
 
 A curved needle threaded with catgut is then carried around the 
 
 artery. The ligature is tied and the hemorrhage thus controlled. 
 
 The internal mammary may require ligation above and below the 
 
 wound. 
 
 Internal hemorrhage is in every way more serious, for to the anemia 
 is added the asphyxia which follows the compression of the lung. 
 
 The patient is pale, anxious, with cold extremities, weak pulse, and 
 sighing respiration, the chest wall bulges; the normal resonance- and 
 vesicular murmur are altered; in short, there are all the signs and 
 nptoms of an increasing hemothorax or hemo-pneumothorax. 
 
 But even in the presence of these grave symptoms, it is by no means 
 always indicated to operate. One must be content to repair the 
 wound, occlude and immobilize, and wait awhile. 
 
 But when the wound is followed by an immediate and complete 
 hemothorax, or when the symptoms and signs point to a rapidly ap- 
 proaching fatality, one must stand by with folded hands and see the 
 end come, or operate; for there is nothing else of any use. An urgent 
 thoracotomy must be done. 
 
 Urmia of the lung is rare. The tumor is of variable size and is at 
 first crepitant, but rapidly darkens and becomes hepatized. 
 
 The indications for treatment depend upon the time which has 
 
 and upon the condition of the tumor. If the wound is recent 
 
 and the lung intact, the hernia must be reduced. Begin by a careful 
 
 disinfection of the wound. Cover the tumor with an aseptic com- 
 
 and tuck its edges under the whole circumference of the wound. 
 
 eady pressure over the central portion of the tumor will expel the 
 
 air little by little; and, by reducing its volume, favor the reduction of 
 
 the tumor. 
 

 OPEN \wm ND& 01 I IN. Mil - I IP; 
 
 The ( ompr< be left until the -kin wound is partially -utured 
 
 by that m< prevent the sudden pneumoth' 
 
 wlii( h sbmetimefl Ed taction. 
 
 If tin- lung has been wounded, it must be repaired by -uture. or by 
 ligation and educed* 
 
 If some lime Ji<: ■/, it is as ui reduce it as to reduce a 
 
 doubtful herniated gut 
 
 jan insists upon resection with the thermocautery. Around the 
 of the tumor pass a ligature threaded on a blunt needle. 
 tying the ligature, a pedicle i- formed which i< to be amputated with 
 .the thermocauter}'. The Stump is carefully disinfected and reduced, 
 the chest wall repaired, and drainage instituted. 
 
 Finally, in the case where the tumor is already ^an^rcnous and 
 sloughing, it is T to limit the treatment : 
 
 the slough to detach itself, and happily a cure may follow such spon- 
 taneous amputation. 
 
 Axtell rep. I open wound of the chest which illu>tr 
 
 what the doctor- patience and nature's etTorts may accomplish in 
 conditions apparently most desperate. ( in Jour. S 
 
 Feb., 1909). 
 
 A shingle sawyer of twenty-eight, robu>t and muscular, fell against 
 a great circular saw revolving many thousand times per minute. 
 Sections of the second, third, fourth, fifth and sixth ribs were cut 
 away, these segments varying in length from 1 inch at the second to 
 3 inches at the fourth and fifth ribs, din- costal pleura was com- 
 pletely destroyed over l 3t injury. The lung and 
 pericardium wei sed. There was one puncture of the lung 
 from which the air bubbled and emphysema followed. All the inter- 
 costal arteries, veins, and nerves in the injured area were severed. 
 The pectoralis major was completely separated from the chest, and a 
 part of the pectoralis minor. The wounded man, thrown from the 
 saw, fell face downward into a dust pile and the whole exposed sur- 
 face oi the wound was filled with sawdust and greas 
 
 He was carried to the hospital and attempt made to repair the 
 damage. "Over 450 spicule of wood fiber were picked out piece by 
 piece from the chest cavity and the surface of the lung. Several 
 large lumps of greasy dust were removed from the depths of the chest 
 
120 INJURIES TO THE TRUNK 
 
 cavity." All the ragged edges of the costal pleura, skin, and muscles 
 were trimmed away. The jagged and uneven ends of the severed 
 ribs were cut off smooth in order to bring the periosteum over them. 
 To take the place of the costal pleura destroyed, a flap was stripped 
 o\\ the pectoralis major from near its attachment to the humerus; 
 left attached near the free end of the divided muscle, it was turned 
 forward toward the sternum and sutured to its margin, to the inter- 
 
 il muscles, and the periosteum of the stumps of the ribs. The 
 
 eJ muscles were drawn together by cable sutures and the skin 
 
 flap drawn into place and incompletely sutured. Ample drainage 
 
 installed. The intervention consumed several hours, something, 
 like 1 80 sutures and ligatures being required. The emphysema was 
 enormous at first, extending from the scalp to the knees, but 
 disappeared after forty-eight hours. At the end of six weeks the 
 patient had practically recovered without adhesions or restriction of 
 the lung. 
 
 B. WOUNDS AT THE BASE OF THE THORAX 
 
 Wounds at the base of the thorax require a separate consideration, 
 for the reason that both the thoracic and abdominal cavities may be 
 involved through wounds of the diaphragm. 
 
 It must be remembered that the diaphragm corresponds to the level 
 of the fifth rib in the right nipple line, and to the level of the sixth rib 
 in the left. 
 
 In stab or gunshot wounds, the lung on the one hand, and the 
 stomach, intestine, spleen, and liver on the other, may be wounded 
 simultaneously; so that, compared with the thoracic wounds just 
 considered, those at the base are much more complicated with respect 
 to prognosis, diagnosis, and treatment. 
 
 These wounds at the base of the thorax involving the diaphragm, 
 will nearly always present an omental hernia. It is often necessary, 
 after enlarging the thoracic wound by resecting a rib or forming a 
 costal flap, to resect the protruding omentum; and, at the moment of 
 reduction of the stump, one may have an unobstructed view of the 
 wound in the diaphragm. If blood oozes from it, there is abundant 
 evidence of a wound of an abdominal viscus. If there is no bleeding, 
 introduce a finger through the opening in the diaphragm and examine 
 
 
\vm i >] i BE THOl 121 
 
 tach and adjacent structures. If no injury is found, and the 
 
 . ith blood, \>: to repair 
 
 the diaphragm. 
 
 A curved needle i and interrupted sutures. If there are 
 
 wounds of the abdominal viscera, they may possibly be repaired 
 through the phrenic wound; and, it \ the 
 
 method of election. By this route one may readily reai h th( 
 surface of the liver on the right r curva- 
 
 ture of stomas h. 
 
 Still, if the exploration is difficult, if the bleeding i< abundant, it is 
 better to lose no time, but to do a median laparotomy ining 
 
 additional room, if necessary >n, following the 
 
 d arch. Subsequently the wound in the diaphragm may be 
 paired through the the 
 
 Ludlow, of Cleveland (Annals of S . June, i is a 
 
 case which illustrate- this Subjei t and exemplifies the treatment in 
 eral. 
 The patient had received t in the left >ide, inflicted 
 
 with a candy maker's knife which had two blade- set in a h< 
 handle. One wound entered at the ninth ii e in the axillary 
 
 line, and through it protruded omentum. The blade had entered the 
 t wall obliquely and the skin acted as a valve; but. when the 
 skin was retracted, the air rushed in and out of the pleural cavity with 
 each respiration. The hemorrhage from the wound was Blight 
 
 The second wound was situated directly below the first in the elev- 
 enth interpsace. ( Omentum protruded from this wound also, and the 
 bleeding was slow, but apparently increasing. 
 
 Operation. Ether anesthe- ireful cleansing of the field. A 
 
 digital examination revealed the fact that the upper wound, tra\ 
 ing the pleural cavity without injury to the lung, had perforated the 
 diaphragm. The finger passed through these wounds, met the finger 
 of the other hand passed through the lower wound, in the abdominal 
 cavity. 
 
 The lower wound was enlarged, revealing an active hemorrhage 
 from the spleen. The cut surface of the spleen was pulled into the 
 wound and a spurting artery clamped. The splenic wound 
 
122 INJURIES TO THE TRUNK 
 
 4 nn. in Length and extended almost through the substance of the 
 
 in. 
 
 The cut surfaces were brought into apposition by mattress sutures 
 of plain catgut No. 2, on a curved round needle. This controlled 
 the hemorrhage. Neither by palpation or inspection could any 
 wound of the stomach or intestines be found. The diaphragm was 
 then repaired with chromic gut No. 3. The operation was accom- 
 plished without the resection of a rib. A small cigarette drain was 
 left in both wounds and the external wounds sutured. The week 
 following the operation there was some discharge of blood and de- 
 
 . but no active hemorrhage. The recovery was uneventful and 
 complete. 
 
 Wounds of the diaphragm of whatever form, perforations, or rup- 
 tures due to crushing injuries to the chest, are likely to be the site of 
 hernia?. 
 
 Especially in the latter class of injuries, must one be on his guard 
 for this injury. Sometimes there are certain signs which point at 
 once to the presence of a diaphragmatic hernia; the displacement of 
 the heart, the bulging of the lower intercostal spaces, and the presence 
 on auscultation of sounds which in no way resemble the vesicular 
 murmur. In these cases, it is best to open up the eighth intercostal 
 space and resect the ninth rib, which will usually give a free access to 
 the site of injury. 
 
 C. WOUNDS OF THE PERICARDIUM AND HEART 
 
 Not every precordial wound will reach the heart. Such a wound 
 may be followed only by a slight emphysema and is to be treated by 
 I > tic occlusion. 
 
 If the wound has actually penetrated to the heart, death is usually 
 SQ rapid that no measure or relief can be considered. If it is a gun- 
 shot wound, death results from shock and hemorrhage; if it is a stab 
 or punctured wound, shock plays a very minor part. It is not very 
 likely that any small size stab wound of the heart interferes at once 
 nisiy with the heart's action, unless it involves the "coordination 
 which, it is claimed, lies in the upper third of the inter-ven- 
 tricular groove. 
 
 If the wound in the pericardium be small or valve-like, the blood is 
 
W( IF THE HEA1 
 
 retained within the cavity and the constantly u 
 
 cardial pressure i r and more yielding of the >tru< * 
 
 within the sac viz., the pulmonary wins and the descendii 
 
 i and the auricles; in this manner, th« the 
 
 auri( if off and the agitated I ■ ■. The 
 
 ion, the i yai tent all hear 
 
 witness to the compression of the auricles In the meantime, the 
 
 puls< erably weak and rapid; the a; 
 
 Bounds are muffled, the lial dull augmented, and the 
 
 thoracic wall bulged. In thifl manner from "heart tarn;. 
 
 deal ensues. If the wound in the pericardium is 1 I the 
 
 pleura opened, the hemorrhage rapidly fill leura produ< 
 
 hempthi ly less di an the hen: rdium. 
 
 If the opening in the thorax u wall is free, the bemori 
 
 ternal; theblood spurt- from the wound or well- up continuously, un- 
 controlled by pr< th ensues from hemor- 
 rhage, simply. 
 
 In spite of all this, however, B wound # of the heart i 
 
 sidered as inevitably fatal and beyon b) skill. The number of 
 
 reported ived by timely intervention tantly ii 
 
 and will increase all the more rapidly as time goes by. Any wound of 
 the heart sufficiently large to produce hemorrhage, whether external 
 
 or internal, is potentially fatal. 
 
 The only i operation. The pericardium is 
 
 \poscd and opened, the heart relieved of >und 
 
 repaired. 
 
 The question ai to how late an operation may be undertaken, 
 
 but this cannot be answered by a general formula; as I acre 
 
 is life, there is hope in skillful intervention. In the :ted, 
 
 the great majority were operated not later than >i\ hours after tra- 
 in jury. 
 
 Regarding the location of the wound in the heart, the right and 
 left sides are injured with equal frequency, but the ventricles are in 
 much greater danger than the auricle in the proportion of seventeen 
 to one (Vaughn). The external wound may be located over any 
 intercostal space, but the great majority will be found in the fourth, 
 fifth, and third in order of frequem 
 
124 INJURIES TO THE TRUNK 
 
 Vaughn, who has carefully studied the statistics of operations for 
 these injuries, and who reports his second successful case of suture of 
 the heart (J. A. M. A., Feb. 6, 1909), offers the following conclusions: 
 that there is no longer any question as to the propriety of the opera- 
 tion, but that its mortality is probably the same as it was twelve 
 years ago when the operation was first introduced. Probably little 
 more can be done to prevent death from hemorrhage, but the pre- 
 vention of the great cause of death following the operation, infection 
 of the pericardium, remains a surgical problem yet to be solved. 
 The principles of asepsis and drainage as applied to the operation, are 
 yet to be more carefully worked out. 
 
 This summary still holds good at this later date except that there 
 is disposition to extend the indications for operation to those cases 
 in which the nature of the wound presupposes heart injury but in 
 which the classical symptoms have not yet developed. For it is 
 certain that heart "tamponnade" with its concomitant clinical pic- 
 ture is often delayed. 
 
 An example is in mind. 
 
 A negro was brought to the City Hospital with a stab wound in the 
 fourth intercostal space about halfway between the sternal border 
 and the nipple line. His condition was good except that he had oc- 
 casional slight attacks of dyspnea; pulse 100, respiration 24. In the 
 course of two or three hours his symptoms had slightly but percepti- 
 bly grown worse. He refused operation. From that time, hour by 
 hour the heart dullness increased, the heart sounds altered, the 
 radial pulse weakened the dyspnea became more distressing and 
 finally after thirty hours he died. 
 
 The autopsy revealed a small wound of the right ventricle. The 
 only hemorrhage was within the pericardial sac. 
 
 An operation at the time of admission or a few hours thereafter 
 would have been performed under very favorable circumstances and 
 almost certainly would have saved the man's life. 
 
 On the other side, Wagner reports a stab case presenting all the 
 
 3 of injury to the heart which an operation proved to be intact, 
 
 although blood had accumulated within and around the pericardium. 
 
 The man would undoubtedly have recovered without operation but 
 

 CONTUSIONS OF THE ABDOM 125 
 
 v 
 
 the < ase would b 
 
 heart under i at 
 
 Arx report in and physical 
 
 injury to the diaphragm and liver, but a laparotomy proved them 
 
 to be intact '1 lie heart was exposed, r- / a hole in the right 
 
 vciil ri< le far under the sternum. When the pericardium 
 nd the clots released the heart improved at once. In this case the 
 
 heart wound A sutured but was (< nth a strip of gauze 
 
 which was brought out through the closely sutured wound. 
 
 pulse kept between So and 88 and tie ature remained normal. 
 
 Arx remarks that thi i mpha-izes the value of proper drainage 
 
 (J. A. M. A., Aug., 1913) 
 
 A number of 1 die punctures of the heart have 1 
 
 reported. About 60 p< die, the result of intra-pericardial 
 
 hemorrhage occurring within ten days of tl nfc 
 
 INJURIES TO THE ABDOMEN 
 
 I. Contusions. II. Wounds. 
 
 I. Contusions n{ the abdomen occur in many they may 
 
 the result of severe blow-, the kick Of a horse, from (alls, or from the 
 
 crush of heavy wheel- of vehicles. The gravity of such an injir 
 proportionate to the amount of visceral injury, but this isoften not 
 apparent from the first 
 
 Whether the viscera arc injured or not, there is always some degree 
 of shock. In the first hours following the injury, in the doubtful 
 cases, the thcrapcusis must be limited to the treatment o; 
 If transportation is necessary, it must be done with t 
 
 Once the patient is placed in bed, his clothing must be remo'. 
 his head lowered, the extremities kept warm, and repeated injections 
 of normal salt solution or adrenalin made, as the character of the 
 shock indicates. 
 
 In the meantime, the case is to be studied and it i< to be decided 
 whether or not there is a rupture of an organ,, or other source of hem- 
 orrhage. 
 
 The responsibility is a heavy one, for an internal injury overlooked 
 or discovered too late, is likely to result in death. The patient may 
 
126 INJURIES TO THE TRUNK 
 
 rapidly recover from the shock, but this by no means proves the 
 
 >ence of a visceral hurt. 
 
 In the typical case of grave injury, the symptoms of shock are only 
 temporarily relieved by the injections; rather, they are shortly re- 
 placed by those of internal hemorrhage. The pulse remains small 
 and frequent, the skin cold, the face anxious and drawn. The abdo- 
 men is distended, and tender to the least pressure, especially in the 
 /one of direet injury. There may be dullness in the flanks. There is 
 no escape of ( u r as from the bowels, or passage of urine. The patient 
 is restless and frequently sighs, and seems to realize his impending 
 fate. 
 
 In such a case, the indications are plain. There can be no excuse 
 for delay, for awaiting the signs that can only be those of beginning 
 peritonitis. Prepare for an immediate laparotomy.* 
 
 But suppose the case is not accompanied by the typical symptoms. 
 How shall we determine in two or three hours whether or not there is 
 a grave lesion? A conclusion must be reached from the study of two 
 factors: (a) the pulse, and (b) abdominal tension. 
 
 (aj The pulse, disturbed at first by the shock, rapidly approaches 
 the normal perhaps, but within a half hour or sooner, it can be deter- 
 mined that it is getting weaker and more rapid. Such a change is 
 particularly indicative of hemorrhage. If there is any discrepancy 
 between the pulse and temperature, Lejars insists that the former is 
 the safer guide, for a subnormal temperature resulting from shock 
 may persist long after the other symptoms have disappeared. 
 
 The abdomen may or may not be swollen, but over the site of 
 i he injury the abdominal muscles soon begin to grow rigid, and resent 
 the least touch, under which they may be felt to contract and stiffen. 
 This rigidity, localized at first, tends to spread and include the entire 
 abdomen. 
 
 Ill i is usually augmented by progressive meteorism, which 
 
 m first localized, but rapidly becomes general. 
 
 Dullness in the flanks is a valuable sign when present, but its 
 nothing. It may be masked by the distended stom- 
 a< h and intestine; again the blood may not collect in the iliac fossa, 
 but may flow dire* tly into the pelvic cavity, especially if the hemor- 
 rhage is on the left side of the mesentery. 
 
 
ii PI i ii 01 I in [NT! 
 
 These modifications of pulse and temperature, of abdominal tender- 
 
 and tension, must \» ifficient indication for urgent in- 
 
 ention; for the p I more upon 
 
 the nature and multiplicity of tin than upon the time 
 
 of intervention, for every hour of delay adds to tin- chai 
 
 tion and elements which the early operation may practically 
 
 eliminate. 
 
 Another eventuality: The until infection has fixed 
 
 Itself upon the peritoneum ; the pulse ami rapid and p 
 
 ively growini mperature i- subnormal, the extremi 
 
 cold; a marked tympanites, with enl vomiting, perhap 
 
 on. 
 
 Then, indeed, it IS late to i dly wlien that mea- 
 
 long and tedious laparotomy. Every d<>. t<>r must for him- 
 
 self the question," I !• \ i 
 
 tar a- possible the limit 3 of intervention in such i last 
 
 in e; and, even though the mortality i- \ t, the occa-ionul 
 
 unexpected recovery Legitimises the operation. 
 
 Who has not had hi- -ad experiences with thi 
 
 example illustrates the subject of inti final rupture. A laborer roll- 
 ing a log oft" a wagon was struck violently in the abdomen by the end 
 oi his Lever caught by tin- |< fell. 
 
 He was unCOnSQOUS for a moment then a mited <»' 
 
 after a little rest to get his breath resumed his labor. 
 
 After an hour or SO, however, he decided he had jo home 
 
 as he began to feel some pain in the right iliac region where the 
 had fallen; six or eight hour- later he vailed his doctor who could 
 find no definite indication of any serious lesion, though the pain had 
 grown very severe. 
 
 The next morning twenty-four hour- later there was some rigidity, 
 some tympanites, an increase in the pulse rate, temperature 101, 
 complete constipation. 
 
 1 saw him some sixty hours after the accident. His aspect was typ- 
 ical of peritonitis. He was vomiting bile with a fecal odor. He was 
 quite conscious and expressed the opinion that he was done for Ul 
 surgery held out some hope. 
 
 He lived far out in the country and it was manifest that he would 
 
128 INJURIES TO THE TRUNK 
 
 not live through the journey to a hospital. His kitchen was hurriedly 
 
 com cited into an operating room and a laparotomy performed. It 
 
 aled two small circular openings in the ileum close to the cecal 
 
 end, a small quantity of the intestinal content free in the cavity and 
 
 general peritonitis. 
 
 The whole operation did not last forty minutes but the poor man 
 died four hours later. 
 
 It was apparent that he had suffered a contusion of the bowel and 
 that subsequently the two small sloughs had occurred and this se- 
 quence accounted for the absence of hemorrhage and the small 
 ape of intestinal fluids. 
 
 Maurice Kahn emphasizes the necessity of early diagnosis of in- 
 testinal rupture and discusses in detail the aids thereto; the part 
 which each symptom and sign should have in this determination: 
 Shock, pain, tenderness, rigidity, vomiting, circulation, respiration, 
 temperature, facial expression, loss of liver dullness. He concludes 
 that if we have the persistence for a few hours of the initial symptoms, 
 especially of rigidity and pain we are justified even in the absence of 
 other symptoms in urging an exploratory operation. (J. A. M. A., 
 March 7, 1914.) 
 
 Rupture of the liver in addition to the indications already discussed 
 may have some special features. 
 
 In the first place whatever shock there may be is early displaced 
 by symptoms of hemorrhage. 
 
 The pulse may be abnormally slow by reason of bile absorption; and 
 the pain is definitely localized in the right hypochondrium. 
 
 Much more frequently the tear involves the right lobe. 
 
 Rupture of the spleen produces neither the shock, the abdominal 
 ion, nor the early peritonitis which follow rupture of the other 
 ra. Hemorrhage is the main feature and the severity of the 
 symptoms are in proportion to the loss of blood and usually this de- 
 ls upon the extent of the laceration. However, even a small cut 
 he hilum might produce early and urgent symptoms. (See 
 also laparotomy for traumatism.) 
 
 H. I VuiinilsoJ the Abdomen. 1 — Clinically, these fall into two groups, 
 (a) those in which there is doubtful perforation of the peritoneum, 
 
 ] For gunshot wounds, see pages 151 and 192. 
 
I) MP ABDOV 129 
 
 and (b) those in which perforation of the peritoneum is quite 
 obvio 
 
 (a) The patient presents himself with a wound of the abdominal 
 parietes, of doubtful depth. It is easy to determine, once for all, 
 whether the peritoneum ha perforated (and upon that the 
 
 1 director. But one 
 should certainly do nothing of the kind. There is a definite mode of 
 examination to whii h one must rigidly adhere. 
 
 Begin by a hurried inquiry into the rircui - of the injury, 
 
 and the I liara< t< r of the M capon. I ttsinfect the hands for an opera- 
 tion. Finally scrub and di- the abdominal walls. Xot until 
 this LS Completed] is the wound ready to be examined. 
 
 Carefully separate the lips of the wound with finger or ret 
 
 and, as you pro, refully wipe each layer I exposed. If 
 
 y !<» l";i< ilitate in-pe< Hon, enlarge the wound; this will often 
 
 be tl bere the vulnerating instrument has ento 
 
 obliquely. 
 
 Dividing the various la ie peritoneum is 1 and found 
 
 intact ; there is no OOZUQg from below the level of the muscular la\ 
 
 and, if this finding accords with the other signs ob» you may 
 
 once thai the wound is non-penetrating. In such a 1 
 fully cleanse the wound and repair each layer separately by con- 
 tinuous suture with catgut; the -kin with silk or silkworm-gut; 
 er with sterile gauze, B thick layer of absorbent cotton, and a 
 firm abdominal binder; and thus have been taken the best St 
 to prevent infection or ventral hernia, which is often the result of 
 these wound-. 
 
 If the wound is penetrating, the mode of procedure depends upon 
 whether it is (a) a narrow, or (b) a large incised wound. 
 
 (a) A stab wound is the type -a thrust from a knife, dagger, or 
 bayonet There may be persistent oozing of blood alone, or blood 
 mixed with bile and urine, or "food products." Such a mixture is 
 pathognomonic of visceral injury, but nothing can be decided from 
 its absence. 
 
 The persistent hemorrhage is strongly suggestive of serious injury 
 to an organ, especially where it coexists with a fading pulse, pallor, 
 tympanites, and rigidity and tenderness of the belly wall; yet the ab- 
 9 
 
130 INJURIES TO THE TRUNK 
 
 sence of all these signs gives no assurance of the absence of a visceral 
 injur\'. 
 
 In any event, then, an explarotory laparotomy is indicated; for only 
 by that means can one assure himself of the conditions. Ordinarily, 
 the wound itself is enlarged for the purpose of exploration, but in the 
 of more than one wound, or when the abdominal walls are very 
 thick, it may be advantageous to resort at once to median laparotomy. 
 \\\ either case, the abdominal opening should be large enough for 
 rapid work. If the laparotomy is done at the site of the injury, it 
 will be wise to disarrange the viscera as little as possible, when spong- 
 ing out the exudates. Carefully inspect whatever parts present, and 
 often the lesion will be revealed by this first search. 
 
 If a median laparotomy is done, as soon as the cavity is opened 
 proceed to the site of the injury; cover the adjacent coils of intestine 
 with compresses, thus preventing their possible infection. 
 
 The lesions are only rarely multiple or difficult of repair in this class 
 of abdominal injuries. 
 
 (b) Extensive Incised Wounds,— These wounds are produced by in- 
 struments with a long cutting edge, or by the ripping cut of small 
 knives. Horned animals occasionally produce them. 
 
 The chief characteristic of these wounds is eventration, always 
 present in some degree. If the case is seen immediately, the mode of 
 procedure is very definite. But only too often the patient's efforts 
 have augmented the hernia, or he or his friends have made untimely 
 attempts to reduce it. 
 
 Having cleansed the hands and the abdominal walls in the usual 
 way, begin next a systematic cleansing of the eventrated mass. 
 Cleanse it with warm sterile water, or normal salt solution, rubbing 
 gently with the fingers, every inch of the projecting bowel or omen- 
 tum. Only in the thoroughness of this step is there any assurance 
 of success. If any visceral wounds are discovered in the cleansing 
 process, they are to be repaired at this time. 
 
 Once the cleansing and repair are complete, proceed to reduce the 
 hernia. The wound may need to be enlarged; if this is necessary, 
 dip a finger under an angle of the wound to serve as a guide, and di- 
 vide the tissues with scissors. The other angle may be treated in the 
 same way. Catch up the peritoneum with forceps along the whole 
 
1 1 iide of the wound. Now lift on tb id in this 
 
 way create a sort of funnel with smooth ver which the b< 
 
 lily glides in redin lion. 
 
 Do not attempt i" reduce by rough pressure, which may conto 
 
 the bowd. If "taxis" fail-, tl I method which will surely 
 
 succeed, 
 
 Spread a large COmpr( .1 under 
 
 the en lire ( in umfer( ie wound; and, with both hand-, make a 
 
 gradual pressure on the g the 
 
 refractor) loops into place with thi d at the same time 
 
 pushing the compress further undei the abdominal walls. 
 
 I ant, in the meantime, liftSUpon the fore cp> a Mac bed to the per- 
 itoneum, raising the abdominal walls as the hernia i 
 
 When the reduction is complete, leave the compress in place, se- 
 cured by forceps until repair of the peritoneum is Dearly com}-' 
 Repair the abdominal wall; begin by suture of the peritoneum with 
 
 small catgut It" the te: t, it may be y to include 
 
 the muscular plane in the sutun N ' repair the muscular la; 
 
 separately by continuous chromic L r ut suture; in th( manner, 
 
 the aponeurosis, and finally the skin, with interrupted silkworm 
 sutun 
 
 A young man was brought to the ( Sty I [ospital followii -age 
 
 at arms with his prospective father-in-law who had given him the 
 
 COUP de grace with a pocket knife. A lai of bis bowel he 
 
 carrying wrapped in his shirt and some towels. 1 1- thetized 
 
 and the examination revealed that the eventrated gut ngu- 
 
 lated, having crowded through a very small peritoneal wound in the 
 lower part of the abdomen; but the external wound was exten 
 and the left rectus muscle was completely divided. 
 
 The strangulated loops were patiently sponged, one by one, with 
 normal salt solution and tlie adjacent skin as well. Xext the wound 
 was enlarged, the strangulation relieved, the bowel reduced and the 
 peritoneum repaired. The wound and adjacent skin were next 
 sponged with alcohol. 
 
 The ends of the severed rectus were widely separated and were 
 with difficulty brought together by mattress sutures. 
 
 The skin and fascia were repaired without drainage. The patient 
 
INJURIES TO THE TRUNK 
 
 recovered with no rise of temperature and without the least sign of 
 
 infection. 
 
 Drainage is a question which always arises, but Lejars assures us 
 that, if the cleansing is carefully carried out, drainage is in no wise 
 necessary. If the ease is seen late, but there exist only a few soft ad- 
 hesions between the bowel and the walls of the wound, the same dis- 
 infection is carried out, the adhesions around the orifice gently 
 broken up, and the mass reduced, as before. Drainage is quite 
 indispensable, if there are already the signs of a beginning peritonitis. 
 
 If the mass has become the site of a purulent peritonitis, the coils 
 agglutinated by false membrane, and gangrenous, there is nothing 
 to do except to keep applied moist antiseptic compresses, which 
 must be frequently renewed. If the patient survives, whatever 
 intervention is needed may be undertaken later. 
 
 
CHAF1 IK XII 
 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 The (arc of the wounded in battle fa din all 
 
 constantly varying problem. Historically speaking, time and ; 
 and the instruments of v the elements of tin spect. 
 
 The chanu ter of a pan i( ular age is dimly reflex ted in the chara 
 
 of it- war wound-, and tin finished products reveal. 
 
 ill things else in Nature, an evolutionary .dual 
 
 change from the rudimentary to the complex. 
 The c&ve mai irliesl progenitor, -allied forth bat 
 
 armed wilh a -hank hone or an unhewn dub of <>ak, his valorous 
 
 purpose to inflict upon hi- enemy some degree of contusion, the 
 
 simplest form (A wound-. The very best hi- effort- might hope f«»r 
 
 were broken hone-. or an occasional broken head, and these, there- 
 fore, were the worst injuries the primeval surgeon had to ma- 
 
 At a later Staj vrilization the warrior had learned how to 
 
 inflict incised, stab, and punctured wound-. Finally, it has 
 
 mained for our own time- to produce the wor-t wounds of all, 
 
 terrible crushes and lacerations, the product ^\ machinery. 
 
 The-Kuropean War ha- proven how far tin - of destruction 
 
 are ahead of those that would SUCCOr and save. Former war- had 
 taught us what the bullet in the field and the bacillus in camp might 
 do, and the sanitary service prepared it-elf to cope with I 
 problems, and prepared itself efficiently. But the unexampled loss 
 o\ life and limb along the Marne, the Y-er and the Vistula, and on a 
 hundred other battlefields, left the Medical Department almost 
 helpless with vet new problems to solve — problems for the most part 
 unsolvable. 
 
 The artillery aided by the aeroplane have made it almost im- 
 possible to give the wounded adequate First Aid and the first aid 
 
 *33 
 
134 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 tini- Henry 
 
 Guedes Lee-Metford Mauser Krag-Jorgensen 
 
 Fig. 86. — The distinguishing feature of the rifle is the spiral grooving which gives the 
 projectile a rotary movement, maintained throughout its flight and which lessens its 
 tendency to depart from the straight line. The various rifles differ with respect to the 
 number of grooves, their depth and the angle they make with the bore. The Martini- 
 Henry represents the first form of the modern Breech loading gun — 0.4s caliber conical leaden 
 bullet weighing 450 grains. The barrel rifled with 7 grooves, with one turn in 22 inches. 
 
 The later rifles have smaller bores, fewer grooves; the trajectory is less, the initial velocity 
 and the range much greater; the steel jacketing diminishing deformation. 
 
 Lee-Metford bullet, caliber 0.303, one turn to 10 inches of rifling. 
 
 The Krag-Jorgensen, caliber 0.315, initial velocity 2034 feet per second and sighted for 
 2078 yards. 
 
 The Mauser, caliber 0.3 n, weight of bullet 154 grains, velocity 2882, range 2187 yards. 
 
 The U. S. Springfield, caliber 0.300, weight 150 grains, velocity 2600 and range 2850 yards. 
 
 The bullet used in the European War is sharply pointed, the center of gravity near the 
 base. The French bullet is not jacketed with steel as the others are, but is composed of a 
 copper compound. 
 

 mi : i i 135 
 
 , whi( h the wounded or his oommde may apph . 
 inadequate for the tremendous lacerations of bur-ting boml 
 
 i;k tor, it would seem, conspired to make wound in! 
 the 1 irgi< al t< • ar. \ n of the 
 
 -<.il in the 1 • battle. The character of the wounds, the 
 
 Aid, the delay in evacuating the 1 and thesl 
 
 tation combined t<> give tl aus, and 
 
 the gafl bacillus a temporary triumph over the- n of 
 
 the highest Hirgu al -kill. I 
 
 the sanitary servio in th< future must be direct 
 
 If the Medical finds it-elf thu- hampered andinad- 
 
 when opposing armies arc rapidly shifting their 
 
 the conditions are quite different when the conflict hassettl* 
 
 to trench wa I ler these 1 m un 
 
 has an opportunity I rk and t ; rtunity ] 
 
 met in keeping with the noblest traditi 
 
 purtenances of the Modern < Operating Room are in-tailed in the Field 
 
 Hospital in comparatively easy reach of the firing line bo that the 
 
 Surgeon is restricted only by hi- own limitation-. It i- likely that 
 
 the armies in Western I died 
 in the World's History in what* it may 
 
 1- of infection, hemorrhage, and t : . have ] 
 
 reduced to the minimum, however horrible that minimum may 
 still I.e. 
 
 Under what may be Called the normal circiu war the 
 
 army bullet wound Mill maintains the charact ibed 
 
 to it for the last twenty years. These wound- vary rity from 
 
 mere contusions through all the grades of injury todestructive lacera- 
 tions, depending upon the range. If the gunshot wounds in military 
 
 practice differ from those seen in civil practice with respec 
 character, progr d treatment it is because the bullets in 
 
 each case differ with respect to hardness, range and initial velocitv 
 and because the wounds are produced in different environmen 
 
 The modern army bullet (Fig. 86) is of small caliber, is jacketed 
 with steel, has a very high initial velocity and, as compared with the 
 older missile, a remarkable range. 
 
 The small, sharp-pointed bullet, used by most of the combatants 
 in the European War, produces some effects differing from tl 
 
GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 produced by the bullets with conical tip. These results are based 
 on its instability of Sight due to the location of its center of gravity 
 near to its base. Its perforating power is immense, yet unless it 
 strikes squarely on the point, it is most easily deflected (Fig. 87). 
 At the moment of oblique impact it acquires a new movement, 
 
 a revolution on an axis transverse to the line of flight. In other 
 words, the bullet moves forward like a wheel. According to Makins, 
 if the velocity at the moment of impact is not great it may make 
 
 ral turns in the tissues. If the velocity is still considerable it 
 may turn end for end merely, or it may remain vertical to its path, 
 making only a half turn. In all these cases it retains to the last the 
 spin on its long axis, imparted by the rifling of the gun. 
 
 Fig. 87. — Gold coins struck by a bullet fired point blank at a Belgian who carried the 
 coins in his belt. He was stunned by the impact and left for dead. The condition of the 
 coins indicates the force of the bullet and its tendency to deflect. (Peacock, Brit. Jour. 
 Surg., Jan., 1015.) 
 
 EFFECTS ON THE TISSUES 
 
 At very close range all these bullets are tremendously destructive 
 to all the tissues alike. 
 
 At long range the conical bullet tends merely to perforate, whereas 
 the pointed bullet, for the reason given above, tends to tear through 
 the tissues in any other position than point first, unless striking 
 squarely. In this manner, even at long range, explosive effects may 
 be produced. On this point Bowlby remarks that in all penetrating 
 wounds by bullets of all kinds and by shell fragments moving v at 
 immense speed, the main injury is done by a force of a divulsive or 
 1 > that the tissues are torn asunder from within 
 
11/ W THE T] 
 
 instead of being crushed -lowly from without. It i> thi- rending 
 inder which is the special d of all typical gunshot 
 
 irounds and ii haa been shown that the injury caused by a bull 
 largely due to the wave of compressed air which the bullet drives 
 
 I in front of it and whi< ds I he I 
 
 In all wounds whi< h ( ompletely traverse the ti- 
 or explo i\ i for( i is pn enl to a gn ter < ent and the 
 
 d produced is heightened by the- resistance 1 to tin 
 
 (plos lilt is that the injury in \g limited 
 
 to the tissues on each rid* n every d 
 
 lion and mounding structures. Ii ir-e. 
 
 well known that in the < ase of the brail 1 in the skull, or the 
 
 liver en< losed in it- i apsule explosr re typical and this is 
 
 attributed t<> the enclosure in a capsul which an 
 
 i omposed of water. But it is not sufficiently appro iated that these 
 same eff< produ< ed in every | be body and in the limbs 
 
 i also; and is proportionate both to the >p- the whirling pro- 
 
 jectile, and to the resi tiered it by the structures which it 
 
 | encounti 
 
 The truth of this may be demonstrated on any limb shattered by 
 a bullet or fragment of a high velocity shell perforating it: for it will 
 be found on examination that the missile has not only shattered the 
 tissues in the line of its flight, but that the divulsive force 
 
 rated the fa>cia from the -kin, and >plit the mus DO eaeh other 
 
 along their intermuscular plane-. T! the injury may 
 
 indeed spread up and down a great part of the length of the limb; 
 and vessels may be bursted and extravasation ^i the blood may be 
 
 found far from the obvious track oi the bullet. On microscopical 
 examination it is found that these eti\ • D more extensive 
 
 than appears to the naked eye. Muscle some distance from the 
 wound, whose sheath is yet intact and appears normal under the 
 microscope, shows fracture oi the muscle bundles, extravasation of 
 blood, and necrotic change in the surrounding libers. Tin 
 may show extensive interstitial hemorrhage and a remarkable cellu- 
 lar disintegration at considerable distances from the track of the 
 missile. When the bones are involved, the effects are even more far- 
 reaching. For example, the brain may be pulped by a bullet | 
 
Gl \MI«M AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 ing through the face; the spinal cord disintegrated without marked 
 destruction of a vertebra; or the bladder or bowel be ruptured with- 
 out a break in the peritoneum, by gunshot fracture of the pelvis. 
 These possible remote effects must always be considered as well as 
 the lowered vitality of the parenchyma cells. 
 
 PlG. 88. — Showing wound df entrance at 
 close range with explosive effect. (Tuffier, 
 Brit. Jour. Surg., Jan., 1015.) 
 
 Fig. 89. — Same, showing wound of exit. 
 Note tremendous laceration. (Tujjier, Brit. 
 Jour. Surg., Jan., 1915.) 
 
 ide from these local conditions which predispose to infection by 
 reason of lowered vitality, there are others of a general nature which 
 
 Iby emphasizes: The time that elapses before assistance 
 arrives, the amount of blood lost, exposure to wet and cold, want of 
 
 and drink, and exhaustion due to want of sleep. There is a 
 great tendency for the wounded brought back from the trenches to 
 fall into an apparenl sleep —but which is, in effect, collapse more or 
 
u 1,1,1 I w< 
 
 profound. Their extremities are cold, their lips pallid, the 
 
 pulse small and rapid or even imperceptible at the wrist With 
 many of these, their best chance of life is to rd their wound> 
 
 for the time being, to keep them warm and quiet, and to give them 
 
 P|G. oo. — Showing small entrance wound at long r • irregular wound of exit. 
 
 (Makins.) 
 
 hot and stimulating drinks. But many of them cannot retain food 
 and even if no food is taken, there may be a retching and vomiting 
 for hours and in such cases saline injections, enemas oi hot water and 
 brandy may tide the patient over. In this class of cases pituitary ex- 
 tract also renders excellent service. (Brit. Jour. Surg., Jan., 1916.) 
 The skin presents a wound of entrance smaller than the bullet 
 and likely to be dirty and discolored. The wound of exit, if present, 
 is larger, more irregular and bleeds more freely (Figs. S8, 89 and 
 
140 G1 NSHOT Wl> OTHER WOUNDS IN MILITARY PRACTICE 
 
 90). The pain in flesh wounds is often moderate, usually a burning 
 sation, and the shock is not severe. 
 The fascia presents a smaller opening than the skin and is likely 
 e slit father than cut in twain and so tends to close the wound, 
 oftentimes materially interfering with drainage. 
 
 The muscles are contused and lacerated, often infiltrated with 
 blood conditions favorable to infection. The manner in which 
 
 the explosive effects of the missile disrupt 
 the minute structure of the muscle remote 
 from the injury has already been mentioned. 
 Late trophic disturbances may develop in- 
 dependent of detectable lesions. 
 
 The tendons are often pushed aside and 
 thus escape serious injury. At other times 
 they are partly or wholly divided — condi- 
 tions to be considered in the course of 
 surgical repair. 
 
 BLOOD VESSELS 
 
 The blood vessels may be pushed aside 
 but ordinarily do not escape if in the 
 bullet's track, so that one of the frequent 
 causes of immediate death is hemorrhage. 
 
 Isolated injuries to the blood vessels in 
 wounds produced by pointed bullets are 
 comparatively rare — even more rare in the 
 
 w SS£SS'vSSS case of she11 wounds - The [n ^y t0 the 
 
 blood vessel may take the form of contusion, 
 
 <>r ol any variety of open wound: a small puncture, a perforation, 
 
 a compl- erance, or any form of laceration. Spontaneous 
 
 hemosta he common result, except in case the artery is 
 
 1 in the Brachial or the Femoral where the artery is 
 
 completely divided, a firm thrombus may form and control the 
 
 ling. Nevertheless the loss of blood is always great and the 
 
 add to the gravity of any necessary second operation. 
 
 eternal hemorrhage, the blood may escape into the tis- 
 
 with resultant hematoma. These hematomata usually re- 
 
141 
 
 elves into take aneurisms. The thrombus, the aneuris- 
 mal varii or the false aneurism may become infi i the 
 
 difficulties and dangers of tin h of the larger arteries 
 
 furnishes its special complications, primary and secondary. Thus 
 
 carotid injury may be accompanied by injuries to the trachea, the 
 esophagus, etc., and be followed by pn ebral 
 
 embolism. 
 
 The subclavian may be divided and followed by spontaneous 
 bemostasis or by hematoma or by a hemothorai which seems likely 
 to occur or by arterio-venous aneurism. 
 
 The axillary artery is in SUCh relation with the brachial plexus 
 
 that the most frequent complications relate to tin- nerve lesions — a 
 more- oi less complete monoplegia is likely to occur. Hematoma, 
 
 false aneurism, and arterio-venous aneurism present their 
 features. Injur}- of the brachial artery is likely to terminate in 
 
 gangrene; and of the radical and ulnar in arterio-venous aneurism. 
 The femor al artery presents certain peculiarities due to the ana- 
 tomical arrangement It will present injury and aneurisms nearly 
 
 as often a- all the other lau kt. • Tl 
 
 tion of the artery in Scarpa's triangle, it- fixity in the lower thin': 
 
 determining factors a- to the frequt m j and character of it- injur 
 Of 36 cases which Makins mentions, primary hemorrh free 
 
 in (j; secondary hemorrhage occurred in <>; gangrene of the limb 
 occurred in 7. Hematoma or false aneurism developed in 
 
 arterio-venous aneurisms in 6, aneurismal varices in S. Femoral 
 
 aneurisms tend as elsewhere to localize, but the hematoma tend to 
 spread out, become superficial and soft and to coagulate late, due to 
 the laxity of the structures in Scarpa's triangle. Injuries to the 
 popliteal vessels are particularly dangerous 90 far as gangreni 
 concerned, since the pressure induced in the popliteal space by the 
 aneurism or hematoma may completely cut off the blood supply. 
 
 Contusion of the blood vessel results in aneurism, the first in- 
 dication of which is the murmur (Fig. 91). The subsequent 
 character depends on whether or not infection occurs. Heyrovsky 
 has specially studied these injuries and points out the dangers, 
 which are secondary hemorrhage, gangrene, and the late hemorrhage 
 following prolonged suppuration. Primary gangrene is most often 
 
HOI AND o rill R WOUNDS IN MILITARY PRACTICE 
 
 BeeD in wounds of the popliteal, and the gangrene sequent to these 
 inju: i the moist variety. 
 
 In the non-infected case, secondary hemorrhage may occur as 
 late as the third week. The vessel in such cases is to be ligated at 
 the site of injury and not at the point of election. The injured 
 exposed and followed up to healthy tissue and no higher 
 and then ligated, the wound to be left open and without tamponade. 
 Following this method not a single case required amputation. Of 
 twenty-one infected cases three died, the result of ascending throm- 
 bosis, and live more were cured only after amputation. 
 
 Fig. 92. — Types of fracture of long bones. (Makins.) (a) Primary lines of stellate 
 fracture; (b) stellate on one side, transverse on the other; (c) complete wedge broken out; (d) 
 incomplete wedge; (e) oblique fracture. 
 
 The mortality of all cases of secondary hemorrhage was 14.2 per 
 . as compared with 81.4 per cent, statistics of Billroth in 1870. 
 (Wiener Klin. Wochenschrift, Feb. n, 1915.) 
 
 The nerves, like the tendons and blood vessels, may be pushed 
 le; but they are more likely to be contused or divided, resulting 
 in paralysis— immediate or remote — or in neuralgia or in trophic dis- 
 turbances, characterized by wasting or contractures of the muscles, 
 ration or inflammation of the skin corresponding to the 
 distribution of the injured nerve. Even though the nerve itself be 
 not directly injured, yet these conditions may later result from its 
 inclusion in scar tissue. In fact, paralysis results more frequently 
 from inclusion in cicatrix than from division of the nerve. It is 
 
BULLET Wni 
 
 M 
 
 often necessary to expose the nerve in order to elear it of exud 
 and debris, or to attempt to suture it. 
 
 Operation on the nerve to he successful must he performed hc- 
 
 the miiM le la atrophied —before 2 or 3 months at least. 
 Bonnet advises the usi raft of cellular tissue from the thi 
 
 I pad for the nerve and to prevent recurrence of the cicatricial 
 inclusion. (Lyon Chirurgical, June, ior 
 
 Fig. 93. — Perforation of the great trochanter, without comminution. Bullet fired at 
 long range lodging in cancellous tissue. Note position of bullet. Bullet was not removed. 
 (Harris, Brit. Jour. Surg., Jan., 1015.) 
 
 Manchet, reporting the results of ioo operations for wounded 
 nerves, says the injury was almost invariably more serious than was 
 anticipated. Cicatricial retraction and inclusion explain the pro- 
 gressive character of the paralysis and other disturbances. Hys- 
 teric phenomena may be superposed on a true paralysis. (Presse 
 Medical, March 27, 1916.) 
 
 Gosset calls particular attention to the musculo-spiral in this 
 connection and emphasizes the value of exposing it throughout its 
 
M4 
 
 ;SIIOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 whole course down the arm. He employs for this purpose an 
 oblique incision extending from the level of the axillary border 
 behind to the front of the external condyle, the arm held vertically 
 
 >4. — Comminuted fracture of the femur. Bullet lodged in soft parts. (Harris, 
 Brit. Jour. Surg., Jan., 1015) 
 
 and the elbow flexed, the hand near the face. Division of the fascia 
 and separation of the muscles readily exposes the nerve, which lies 
 in close contact with the hone throughout its course. The results 
 

 MS 
 
 
 
 ^\ 
 
 L c 
 
 y ^ 
 
 
 
 
 
 
 
 
 Fig. 95- — Lower end of femur, showing tendency of fissures to stop - icular ends. 
 
 (Mai 
 
 Fig. 96. — Small wound of entrance and large wound of exit on left leg. Fragments of 
 bone carried across to right leg producing large laceration, requiring amputation. (Makins.) 
 
,.}<> 
 
 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 have been such as to encourage this procedure in every case of 
 
 injury to the humerus with 
 
 symptoms of nerve involve- 
 ment. (La Presse Medical, 
 Jan. 21, 1915.) 
 
 Bone presents a wide varia- 
 tion in the character of the 
 lesions produced. There may 
 be mere puncture, there may 
 be extensive comminution, or 
 any grade of injury between 
 these two extremes (Figs. 92, 
 
 93). 
 
 The character of the injury 
 will depend upon two factors: 
 (a) the character of the bone 
 and (b) the range of the bullet. 
 
 (a) If the bone is soft and 
 cancellous, the tendency is 
 toward perforation; if it is 
 
 Fig. 97. — Oblique pefroration, implicating 
 both epiphysis and diaphysis, with large frag- 
 ment at exit. (Makins.) 
 
 hard and compact, the 
 tendency is toward com- 
 minution. 
 
 The articular end of the 
 long bones, the short, and 
 the irregular bones are 
 likely to be merely perfor- 
 ated. On the other hand, 
 the shaft of the long bones, 
 the skull, the scapula are 
 much more likely to be 
 -battered. 
 
 (b) At long range, per- 
 foration is rather to be ex- 
 pected; at very close range, 
 
 ,. . ,i 1 Fig. 98. — Transverse section of "gutter" fracture. 
 
 comminution is the rule. (A) No loss of substance . (B) comminution . 
 
 So far as the long bones (.Makins.) 
 
!l< M f !•' \< I 
 
 
 < on< cj aed, if 1 1 
 
 • >i\ of I lie articulatioi I 95). 
 With respect to the bones of the Limb ted that the 
 
 exit wound will be the more rommin ig. 96). Perforating 
 
 fractures without solution of continuity a: difficult of - 
 
 nosi oi the The 
 
 diagnosis ia to be made by n k of the bullet, 
 
 Fig. 99. — Gutter fracture perforating skull in the center of its course. (Makins.) 
 
 by palpation, and from presence of hone dust in the wound of exit, 
 etc. (Fig. 97). 
 
 Comminuted fractures present an excessive mobility, and often 
 crepitus is hard to elicit. Owing to "local shock/' the limb may 
 be quite powerless and yet painless. 
 
 Primary shortening is often absent by reason of the muscular 
 relaxation due to shock. Even though healing takes place un- 
 eventfully, a large amount of callus is likely to be thrown out and, 
 for a long time, the union will not be strong. 
 
I48 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 Acute osteomyelitis may follow infection. On the other hand, 
 necrosis may occur late and after the wound has apparently quite 
 closed. Chronic gas gangrene may occur as late as two or three 
 weeks after the injury and may be fatal. 
 
 In the hones of the skull is frequently seen the so-called " gutter 
 tract uie,'' in which there are usually two apertures in the scalp. 
 connected by a trench ploughed through the outer table and diploe 
 (Figs. 98 and 99). 
 
 The corresponding part of the inner table is comminuted ex- 
 tensively and perhaps depressed. 
 
 PlC. 100. — Superficial perforating fracture; roof lifted at both openings. (Makins.) 
 
 The length of the gutter depends upon the surface curvature, and 
 the antero-posterior are more serious, as a rule, than the transverse 
 g, 100). 
 
 The joints present effects peculiarly variant: the capsule alone 
 may be injured; the articular ends of the bones may be guttered or 
 etrated with or without injury to the capsule; there may be 
 much shattering, fissures radiating in all directions; or the joint may 
 he involved by extension from the wound of the shaft. The bullet 
 may he retained in the joint cavity. Effusion into the joint is a 
 constant symptom following perforation — a mixture of blood and 
 synovial fluid. 
 
BULLE1 WOUNDS 01 B whm 140 
 
 Of the freai own particular 
 
 tnptomatology. 
 
 I lie cranium, according to V( man, presents the follow 
 
 :ull and seal]) are torn to pieces; at 
 160 feet, the scalp is preserved but the skull is shattered; there are 
 two openings with with brain exudate, the wound 
 
 exit always larger than thai of entrai 
 
 
 tew 
 
 Fig. ioi. — Extensively comminuted gunshot fracture, ballet fired at close range. {Senn 
 
 after Von Bergman.} 
 
 At 320 feet, there are two openings, each surrounded by a series 
 of concentric fissures in addition to radiating fissures (Fig. 101). 
 
 At 4000 feet, the radiating fissures still appear. 
 
 At 5600 feet, entrance and exit wounds are clean-cut holes. 
 
 At 8000 feet, there is only the wound of entrance, and the bullet 
 lodges in the brain. The injuries to the dura mater are analogous to 
 those of the skull. 
 
(I NSH01 Wl> OTHER WOUNDS IN MILITARY PRACTICE 
 
 The brain itself, semifluid, is torn to pieces at short range, through 
 hydrodynamic action and here it may be similarly disrupted by a 
 bullet passing through the bones of the face haj> already been 
 indicated. At long range, the bullet merely traverses the brain, 
 producing areas o\ contusion in the neighborhood of its track. 
 There may be a diffuse hemorrhage throughout the brain, the ven- 
 tricles being tilled with blood. 
 
 The symptoms are such as belong to concussion, compression, 
 contusion, or laceration in general. 
 
 Thus following these various degrees of brain injury there occur 
 more or less marked indications of the loss of brain function, both 
 
 ieral and focal. 
 
 Most prominent are motor and sensory paralysis; impairment 
 of the special senses, especially sight and hearing; aphasias and 
 amnesia — all these in various combinations. 
 
 These symptoms usually emanate from the regions adjacent to 
 the track of the bullet, though often it is evident that outlying 
 portions of the brain have suffered as well. 
 
 The amount of damage which the brain may suffer with practical 
 recovery is often astounding. Sometimes it would seem that it is 
 merely a matter of controlling pressure and infection. 
 
 As illustrating this point we may instance some of the case reports 
 of Whitehorne-Cole in service at one of the British evacuation 
 hospitals in France. 
 
 Case i. — Compound comminuted fracture of skull from a shrap- 
 nell bullet. Longitudinal sinus along vertex of the skull, and the 
 brain substance much lacerated. Trephining, debridement, disin- 
 ghth day afterward, mental condition good. Partial 
 motor paralysis. At end of month, paralysis greatly improved, sent 
 home practically well. 
 
 ise 2. — Compound comminuted fracture of skull from rifle 
 bullet through both parietals. Septic. Aphasia, right hemiplegia. 
 iection. Drainage. 
 
 First day after operation: Aphasia, hemiplegia, urinary incon- 
 tinen 
 
 Fourth day: General condition much improved. Hernia of the 
 brain with some oozing of its substance. Alcohol pack applied. 
 
i;i l.I.I l \\<> : PINE 
 
 Sixteenth day: Hernia practically gone. 
 
 One month: Wound healed; aphasi hemiplegia much 
 
 improved; can read and talk and walk; sent home. 
 
 use 3.— Compound comminuted fracture of skull; ritle bullet 
 through left frontal and temporal region. Left facial para! 
 Whole track of bullet laid 
 open. Removal of frag- 
 ments. 
 
 Three weeks after: W r ound 
 healed and paralysis gone. 
 
 Case 4. — Compound com- 
 minuted fracture of right 
 parietal. Hernia of brain; 
 left hemiplegia. 
 
 Three weeks later: Well 
 except for slight paralysis in 
 left arm. 
 
 Case 5. — Compound com- 
 minuted fracture through or- 
 bital region. Left eyeball 
 collapsed. Hernia cerebri. 
 Both wounds septic. 
 
 Did remarkably well after 
 operation until fifth da 
 when pulse and temperature 
 began to rise. Shortly after- 
 ward followed by death. 
 
 There Was an CnomiOUS Fig. 102.— Shrapnel bullet lodged in body of 
 
 amount of bone and brain r ra - s > m P toms of concussion; com- 
 
 plete recovery. {Harris, Brit. Jour. Surg., Jan., 
 
 destruction, and that he IOIS .) 
 
 should have done so well for 
 
 five days is very remarkable. (Lancet, March 13, 1915 
 
 The spine is seriously injured in proportion as the cord suffers 
 (Fig. 102). In some cases the cord lies in the track of the bullet 
 and is partially or completely divided transversely. In other cases 
 the vertebra may be perforated merely without penetration of the 
 canal yet a segment of the cord may be completely destroyed. 
 
NSH01 \NP OTHER WOUNDS IN MILITARY PRACTICE 
 
 Finally there arc those cases in which there is no anatomical lesion 
 of the cord, whatever the injury to the vertebra may be, yet the 
 
 functions of the cord arc markedly depressed. Absence of deep 
 reflexes must not be taken to indicate complete rupture of the cord. 
 This may be due to "concussion" of the cord, which Makins de- 
 scribes in detail. 
 
 The degree of concussion, and therefore the degree of functional 
 depression, depends directly upon the velocity of the ball. 
 
 In slight spinal concussion, the symptoms consist in loss of 
 cutaneous sensibility, motor paralysis, and vesical and rectal in- 
 rsisting for a few hours or even two or three days. 
 Recovery begins with return of sensation, often modified, followed 
 later by return of motor activity. 
 
 "Severe concussion, contusion or medullary laceration, may be 
 idered as lesions of equal degree as to severity, bad prognosis, 
 and unsuitability for active interference; all characterized by the 
 same essential phenomena, viz.: symmetrical abolition of sensation 
 and motility, absence of any sign of irritation in the paralyzed area, 
 and loss of patellar reflex. These severe injuries" are all accompanied 
 by profound shock. The patient lies still, with eyes closed, great 
 {>allor of surface, the sensorium benumbed, the pulse small and 
 irregular, respiration shallow" (Makins). ■ 
 
 In addition to these lesions there are such as arise from com- 
 mon, either from bone or from a lodged bullet. But, as Makins 
 . it may be assumed that a bullet injuring the vertebra suffi- 
 tly to displace bone, has, at the same time, produced grave 
 >ns of the cord. If the pressure is due to the bullet, it argues 
 that it- velocity was low and that there may be no serious lesion of 
 the cord and that the symptoms are those of compression alone, 
 i due to extra-dural hemorrhage can rarely produce 
 symptoms. 
 
 ►me interesting conclusions regarding these injuries 
 which may be used to summarize the subject: 
 
 t. The initial physical signs of concussion and contusion of the 
 spinal cord may be identical but after twenty-four hours a differ- 
 LtlOD may be made. 
 2. ( ion is < haracterized by motor rather than sensory par- 
 
l;i I.I.I. I \\' >] UN. JH'.I- 
 
 alysis; while in the contusion motor and sensory para! 
 
 arc <>i equal degr< es. Con< ussion is attended by numbnc^ and tin- 
 gling in the extremit ( Concussion of the caudal segment 
 
 involving the cauda equina ed with lancinating tab 
 
 pains in the lower extremities. The anatomical 1' era! 
 
 low the physiological, a- will he revealed by a 
 imination. 
 3. Concussion with hematomyeHa frequently results from the 
 impact of the missile against the vertebra: the paralysis will recover 
 rapidly and entirely. Contusion or laceration of the spinal cord 
 by actual contact with the missile does not usually imp d is 
 
 eventually fatal: bed-sores, cystitis, pyelonephritis, occur in 
 
 sequence. Contusion of t 1 ical region usually termins 
 
 fatally before the base hospital i- reached. 'X. Y. Med. Journal, 
 Nov. 25, 191 
 
 The thorax may or may not he- penetrated by the impact of a 
 bullet, though penetration, of course, is the rule, and these wounds 
 constitute a large part of the ( asualties of battle. The non-penetrat- 
 ing wounds present no feat' ial interest The -kin and 
 
 muscle- may be injured in van. pie perfora- 
 
 tion and serious lace-ration. The clavicle and scapula may be 
 fractured; the axillary -pace may be involved, with >eriou< results. 
 
 The penetrating wounds he thorax in every direction, 
 
 transversely, longitudinally, and obliquely. 
 
 Those which traverse the the>rax longitudinally, and are n 
 while firing or advancing in the prone position, are noteworthy in 
 that the abdominal cavity is usually also involved. The abdominal 
 cavity is also likely to be penetrated when the base of the thorax is 
 crossed. 
 
 If a rib is involved, the bone injury is usually limited, and the 
 fractures are considered of importance only when the intercostal 
 artery is wounded. In many of these fractures from the army bullet 
 the ordinary symptoms are absent, either because of the localized 
 character of the injury and absence of contusion of the soft parts, or 
 because the fragmentation in the track of the bullet is so complete 
 as to preclude crepitus. 
 
 The lungs } almost certain to be involved in perforating wounds of 
 
154 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 the chest, escape with remarkably slight damage, owing to their 
 sticity. 
 
 Those bullets which pass near the root of the lungs are very likely 
 to invoke the great vessels, followed by rapid and fatal internal 
 hemorrhage'. 
 
 Certain symptoms manifest themselves in most cases of lung 
 injur\ in some degree. Shock, if it exists at all, is not usually 
 ►US and arises rather from the injury to the chest wall; nor are 
 pain and dyspnea prominent. 
 
 Hemoptysis is fairly constant, but not persistent longer than two 
 or three days. Cough is seldom troublesome and pneumothorax is 
 rare. 
 
 Hemothorax is very frequent, but in the great majority of cases is 
 due to hemorrhage from the chest walls — to the intercostals rather 
 than to the lung injury. 
 Tuffier remarks of these cases as observed in the French field and 
 hospitals that bullet wounds of the chest — such as reach the 
 hospital — are generally remarkably mild and cases of hemothorax 
 requiring intervention are quite exceptional. 
 
 From one of the field hospitals comes this report which is typical: 
 
 -es 4, 5, 6 — perforating bullet wound of the chest. These cases 
 
 of comparatively benign character. Each showed the following 
 
 3 and symptoms: pain, dyspnea, slight hemoptysis, immobility 
 
 ide of the chest and signs of free fluid in the base. They all 
 
 did well during their stay with us. 
 
 Case 7. — Perforating chest wound of more serious character. In 
 this case the right hemothorax showed rapid increase of the fluid 
 with displacement of the heart and urgent dyspnea. We tapped the 
 jl drawing off 3 pints of blood-stained fluid. Two days later 
 there were signs of air in the pleura, but after a second tapping, 
 which drew off air and pus, the patient made a sufficient recovery to 
 be moved" (British Journal of Surgery, Jan., 1915). 
 
 The symptoms of a hemothorax reach their full height on the third 
 
 or fourth day. The pain is severe, the pulse and temperature rise, 
 
 prominent, respiratory movement on the affected side is 
 
 annulled, and there are the physical signs of fluid on the pleura. 
 
 Th of the temperature is a matter of concern, for the fever 
 
BULL1 i WO 
 
 suggests empyema. It. seems always to rise pari passu with the 
 
 increase of blood in the pleural cavity; often declining after the 
 third or fourth day; always falling after a par is and rising 
 
 anew with fresh access of pleural hemorrhage. On the other hand, 
 the fever of infection arises la r -i-ts, or gradually mounts 
 
 higher. A special feature of these pneumonia- is their early resolu- 
 tion and their tendency to relap 
 
 Perforating wounds of the heart in warfare Makin regards 
 certainly fatal, believing that the cause of death is not hemorrhage, 
 but sudden stoppage of the heart action. 
 
 Senn believes that death usually occurs from compression of the 
 heart, due to hemorrhage within the pericardium. In th< 
 where, from the anatomical features, the heart would seem to 
 be involved and yet present mptoms of injury, the inference 
 
 must be that it escaped, owing to change in position and 
 incident to contraction. 
 
 Other observers write that a bullet has been known to pass through 
 the heart without fatal effect Dixon and McKwan report a case in 
 which there was a small bullet wound J^ inch to inner side and ] L > 
 inch above the nipple. The patient did not complain of any pain 
 but of great thirst, temperature 102, pulse 130, respiration 45. 
 The heart sounds were normal and there were evidei blood in 
 
 both pleural cavities. No cough or hemoptysis. The patient lived 
 
 sixty hours. Autopsy showed the track of the bullet through the 
 
 left lung, the right ventricle, and lodging on the right lung. (Brit. 
 Med. Jour., May 27, 10 i 
 
 Penetrating wounds of the abdomen are seldom simple in character, 
 for it only rarely happens that a single viscus is involved. The one 
 symptom which, if it occurs at all, is common to wounds of all 
 abdominal organs, is peritonitis. The sources of hemorrhage are 
 numerous. The degree of injury to every organ decreases with 
 increased range. The small intestine is naturally the structure most 
 frequently wounded and, of course, its perforations are multiple 
 (Fig. 103). 
 
 Pain, collapse, vomiting, and peritonitis are nearly always present, 
 although present also in wounds of the stomach and large intestine. 
 
1 5 o 
 
 GUNSHOT AND OTHEB Wol/NDS IN MILITARY PRACTICE 
 
 The peritonitis is more widespread in the case of the small intestine 
 than in the case of the stomach and large intestine, because of the 
 greater activity and motility of the small intestine. Vomiting of 
 
 blood may be taken to 
 indicate perforation of the 
 stomach. The stomach 
 and intestines escape " ex- 
 plosive' ' effects in propor- 
 tion as they are empty at 
 the time of injury. 
 
 The bladder when 
 wounded may present two 
 openings; both may be 
 extra-peritoneal, both may 
 be intra-peritoneal, or one 
 may be intra- and the 
 other extra-peritoneal. An 
 extra-peritoneal wound 
 bleeds the more profusely; 
 an intra-peritoneal wound 
 permits the escape of urine 
 into the peritoneal cavity, 
 hematuria, or suppressed 
 urination with an empty 
 bladder, points to the 
 character of the injury. 
 
 Gunshot wounds of the 
 Solid Viscera naturally 
 are less grave than those 
 of the digestive tube and 
 uncomplicated by hemor- 
 rhage or infection are of 
 comparatively slight importance. The track of the bullet 
 through the body is usually easily determined from the apertures 
 of entrance and exit, and the range of movement of the organ 
 being limited, a fairly accurate forecast of the course of the bullet 
 through the organ may be made. Retained missiles may be lo- 
 
 PiG. 103. — Perforating wounds of small intestine. 
 (a) Entry; (b) exit. Note slit-like character and 
 eversion of mucous membrane; localized ecchymosis 
 more abundant around exit aperture. (Makins, 
 from St. Thomas Hospital Museum.) 
 
BULLET WOUNDS OF THE LIVER 157 
 
 cated by the #-ray and finally there may be pathognomonic symptoms 
 to aid in the diagnosis of the nature and the extent of the visceral 
 injury. Shell wounds are much more serious than bullet wounds 
 since the laceration is likely to be more extensive, the fragments 
 more likely to be retained, and much more certain to carry in 
 infection. 
 
 Wounds of the Liver may present no evidences other than the track 
 of the bullet, or the symptoms may be overlooked by reason of the 
 more important concurrent damage to the other structures. It may 
 be contused, perforated, or lacerated or even shattered by " explo- 
 sive" effects. By reason of the bulk of the organ, retained missiles 
 are common. The most frequent course of the bullet is transverse. 
 Of 36 cases Makins mentions, in 21 the wound was transverse; 10 
 of these crossed the body completely; 4 had a wound of entrance only. 
 In 7 the course was antero-posterior; and in 5 the missile was re- 
 tained. These ratios would probably persist in any given number of 
 cases. Excoriations or furrows may be the source of more trouble- 
 some hemorrhages than uglier perforations. The shell wounds give 
 rise often to secondary hemorrhages at the base hospital. These 
 wounds after death assume the form of wide gaping cavities or ex- 
 tensive broad tunnels lined with necrotic hepatic tissue, often stained 
 a bright orange tint by bile pigment. Next to the digestive tube 
 the most common concurrent injury is to the pleural cavity and lung. 
 Associated wound of the right kidney is not rare. 
 
 Hemorrhage may lead to a rapidly fatal issue and, even if not of 
 that degree, may be a source of embarrassment in dealing with 
 associated injury to the digestive tract. In the base hospital very 
 rarely is the diagnosis of the liver injury made from the presence of 
 blood in the right loin — the classical sign. 
 
 Secondary hemorrhage, the sequel of septic infection, usually occurs 
 about the tenth day and is accompanied by pain, distention of 
 abdomen, rise of temperature, rapid and weak pulse, restlessness, 
 and increasing weakness. Localized swelling may develop, in- 
 distinguishable from abscess. 
 
 Jaundice is a common sign but variable in degree, most pronounced 
 when developing with septic infection. It is probably hemolytic 
 in character. 
 
GUNSHOT Wl> OTHEB WiUNDS IN MILITARY PRACTICE 
 
 i in the wound is pathognomonic of the injury to the liver or 
 luct It may appear at the external wound, be expectorated 
 through a wounded lung, or collect in the abdominal cavity. The 
 of the biliary fistula depends chiefly upon the size of the 
 wound and the degree of the infection. Makins notes one case in 
 which the fistula opened into the pleura from which 15 pints of 
 bile were removed by repeated aspiration, the internal fistula closing 
 about the fortieth day. The presence of free bile in the peritoneal 
 cavity probably does not of itself excite inflammatory reaction. 
 
 vndary abscess is a grave complication. The subphrenic variety 
 is frequently accompanied by empyema. 
 
 The Spleen is frequently wounded and the effects are comparable 
 with those of the liver. Aside from the intestinal complications, 
 side hemothorax and left kidney injury are most common. 
 Makins is of the opinion that death from hemorrhage in such in- 
 juries is not so common as might be expected. 
 
 The Pancreas is doubtless seldom wounded alone. If the hollow 
 era should escape, there is a likelihood that recovery might 
 occur. 
 
 The Kidney may be simply perforated; or it may be lacerated or 
 shattered: In any case the hemorrhage will depend largely on the 
 extent to which the hilum is involved. The hemorrhage may be 
 peritonea] or peri-renal. 
 
 Hematuria is often absent or so transient as to pass unobserved. 
 [t is rarely profuse or persistent. It may give rise to disturbances of 
 micturition from coagulation of the blood and distention of the 
 bladder by the clot. Extravasation of urine is not a notable fea- 
 ture of kidney injuries, probably due to the fact that the injured 
 kidney does not functionate freely. If the hilum alone is injured, 
 extravasation will be more conspicuous. Secondary hemorrhage 
 following infection, usually from Streptococci or B. coli, develops 
 from the sixth to the twentieth day. It may take the form of a per- 
 mit hematuria or peri-renal hematoma extending into the loin 
 and ilia< 
 
 PROGNOSIS AND TREATMENT 
 / produced by the army bullet and uncomplicated 
 
TREATMENT OF INFECTED WOUNDS 1 59 
 
 by infection tend to heal without difficulty. Whether or not in- 
 fection occurs depends upon the efficiency of the first-aid dressing — 
 that is to say whether it is ample and whether it is applied in due 
 time. 
 
 The aim of the first dressing is to secure aseptic occlusion, but if 
 the wound is exposed to infection from sources other than the bullet 
 before the dressing is employed, the wound may as well be regarded 
 as infected. In trench warfare scarcely a wound, whether from 
 bullet or shell, escapes infection. The reasons for this have already 
 been indicated as arising from the environment and the excessive 
 tissue destruction. 
 
 The impossibility of adequate first aid, the prolonged exposure of 
 the wound to infectivity of the greatest virulence, the lowered resist- 
 ance of the tissues adjacent to those actually destroyed, the explosive 
 effect of the high-velocity missile, the lowered body resistance — are 
 all factors to be considered. 
 
 TREATMENT OF INFECTED WOUNDS 
 
 It has come about that the battlefields of Western Europe have 
 enriched surgery with volumes of new and unique experience in the 
 treatment of Infection. These later experiences have in nowise 
 changed the great principles of treatment — Antisepsis and Drainage 
 — but it has changed in many respects and application of these prin- 
 ciples. The older antiseptic agents have proven themselves woe- 
 fully impotent in the type of wounds under consideration. The 
 surgeons at the front have faced, in this matter, new problems which 
 would appear to be, fundamentally, bacteriological. Armed against 
 the ordinary pus-producing bacteria, they were not prepared in 
 experience or even in theory, to combat a host of strange microbes 
 working their effects in a myriad of bewildering combinations and 
 variations. 
 
 From the reports of various bacteriological studies, it may be 
 assumed that in a given number of infected wounds the various 
 infective agents will be found in these percentages: 
 
5H0T \\P DTIII R WOUNDS IN MILITARY PRACTICE 
 
 I'er Cent. 
 
 Staph} locoed 86 
 
 81 
 
 li. Perfringens 75 
 
 Proteus 47 
 
 B Coli 40 
 
 B. tfalig. Edema 38 
 
 B. Hibler IX 35 
 
 The odor of wounds in which certain bacteria predominate has a 
 tin character. Thus the B. Malignant Edema produces a 
 cadaveric odor: With B. Hibler IX added, the smell is more putrid 
 and penetrating. 
 
 B. Perfringens produces a rancid butyric odor but is not fetid. 
 It furnishes in the majority of cases the background for the odors 
 of the other organisms. B. Hibler IX evolves the most fetid gas, 
 producing an extraordinary and peculiar smell of putrefaction. 
 B. Proteus produces a fecal odor. The nature of the infection 
 determines the other chemical manifestations of the infected 
 wound. 
 
 Suppose the wound is examined on the second to the fourth days 
 
 and is found to be comparatively dry. The edges of the wound are 
 
 kened and surrounded by a reddened margin, though there is little 
 
 Uing; the wound cavity filled with fibrinous exudate beneath 
 
 which is a thin, sanious fluid. Such a wound contains B. Perfringens 
 
 often in pure culture. It may proceed to repair without other 
 
 symptoms. Later other forms of infection may develop, due to 
 
 piococci, B. Proteus or Coli types in addition to the Anaerobes. 
 
 Suppose again the wound be examined on the second to tenth days 
 and is found to be discharging: (a) creamy yellow or bluish-green pus 
 possibly emitting an evil smell — in this case due to the Proteus and 
 Coli type, Staphylo-, Streptococci and Pyocyaneus: (b) Brown, 
 ilored, red-brown or black pus with gas bubbles, fetid 
 odor; patient profoundly anemic and languid and drowsy, Anaerobes 
 present. The color of the discharge is due to the hemolytic action 
 of the B. Perfringens and B. Malignant Edema. It would appear 
 that the infectivity of the Anaerobic bacteria depends largely on the 
 occi; these are always present in the Malignant 
 
 *ma cast 
 
TREATMENT OF WOUND INFECTIONS l6l 
 
 Such are the bacteria and the more common effects they work 
 in the wounds under consideration. To combat these effects the 
 resources of antisepsis have been strained to the utmost. 
 
 Antisepsis, whatever the agent employed, must always be regu- 
 lated by the two cardinal principles: the maximum germicidal 
 efficiency; the minimum injury to the tissue cells. 
 
 Several new agents claiming these properties have been employed; 
 their usefulness is still sab judice. One of the most valuable in these 
 aggravated forms of infection, undoubtedly, is Dakin's solution of 
 hypochlorous acid, and which may be made after the following 
 formula:* 
 
 Bicarbonate of Soda 200 grams 
 
 Chlorinated Lime 140 grams 
 
 Water 10 liters 
 
 Mix and filter through cotton and add 
 
 Boric Acid • • • • 40 grams 
 
 Less affective in its germicidal action, but aiding greatly in rais- 
 ing the vitality and resistance of the fixed tissue cells, is Wright's 
 Solution : 
 
 Sodium Chloride 3 parts 
 
 Sodium Citrate 1 part 
 
 Water 96 parts 
 
 Iodine and alcohol are indispensable in the primary wound treat- 
 ment, but of limited usefulness once infection has fixed itself in the 
 wound. Carbolic acid, the mercury compounds, hydrogen peroxide, 
 boracic acid, salicylic acid, and other germicides, have their special 
 indications. 
 
 The management of these wounds, aside from special complica- 
 tions, may be summarized in this fashion: 
 
 On the firing line the first-aid dressing is applied, bleeding checked 
 as much as possible, and some support extemporized. This may 
 need to be done in the trench, or in the regimental surgeon's dug-out. 
 As soon as circumstances permit — sometimes only after intermin- 
 able delay — the patient is brought to the casualty clearing station 
 
 * The Abbott Alkaloidal Co. have the agent prepared in tablet form from 
 which the solution may be made as needed. 
 11 
 
GUNSHOT WP OTHEB WOUNDS IN MILITARY PRACTICE 
 
 where definite treatment is to be instituted. In many cases support- 
 treatment is essential before the patient can be worked with 
 further. The clothing is removed, the field of operation cleansed 
 with ether or alcohol, and the wound examined. If it is an uncom- 
 plicated flesh wound of recent origin, it is sufficient to trim away all 
 the devitalized tissue, whether that be much or little, cleanse every 
 it with iodine, install ample drainage and dress with gauze. 
 If. on the other hand, the wound is some hours or days old and infec- 
 tion has obviously gained a foothold, a more vigorous treatment is 
 to be applied, the details of which vary somewhat with the sus- 
 ted or obvious character of the chief infective agent. In this 
 case, as before, the wound is to be freely opened and dead tissue cut 
 away. This is in reality the principal part of the treatment, since 
 these tissues are the soil in which the anaerobes grow. 
 
 If the gas bacillus is already at work, as indicated by the odor of 
 the wound, the character of the discharge, and the appearance of 
 the tissues, the procedure will depend on whether (a) it is subcu- 
 taneous; or (b) subfascial, (a) In this case, the infection constitutes 
 a cellulitis; the tissues beneath the skin are edematous, brown and 
 crepitant, while the skin itself is a chocolate brown. The patient's 
 general condition will depend on the area involved. The tempera- 
 ture and pulse rate may not be much disturbed in the mild cases, 
 but both rise when the infection begins to spread along the fascial 
 planes. 
 
 Free Incision is indicated, down to, but not through, the fascia — 
 vertical incisions an inch long at intervals of 2 or 3 inches and 
 implicating the whole area of brown skin. A free discharge of 
 yellowish serum follows. Dressings saturated with peroxide or 
 Wright's solution are applied until the fat assumes a healthy color, 
 when the incisions may be drawn together with one or two stitches, 
 usually about the fourth day. 
 
 The gas bacillus infection is subcutaneous: In this case 
 
 gangrene of the limb occurs; the blood supply is strangled, 
 
 the main vessels thrombosed. There is the characteristic foul- 
 
 wnelling, brown discharge with bubbles of gas; the temperature and 
 
 e are high; vomiting frequently occurs and, perhaps, jaundice 
 
 if the hemolysis is marked; the limb becomes mottled, tightlv swollen, 
 
TREATMENT OF WOUND INFECTIONS 1 63 
 
 and tympanitic, and death may rapidly supervene. Oftentimes the 
 #-ray will reveal the presence of the infection before its usual 
 characteristics are manifest; pale shadows indicate the separation of 
 the muscle bellies along their fascial planes, by which pathways the 
 infection spreads. If the character of the infection is recognized 
 early, while still limited to the region of the wound, free incision 
 through fascias and muscle may be sufficient. If gangrene is immi- 
 nent or present, or if the general intoxication is profound, amputa- 
 tion is alone of any service, while the adjacent body areas, if involved, 
 are freely incised. 
 
 Free incision and free drainage is the best prophylaxis against the 
 Tetanus bacillus, and where this cannot be done to one's satisfac- 
 tion anti-tetanic serum should be employed. 
 
 The strepto- and staphylococcic infections, accompanied or not 
 by coli types of bacteria, are best combated by Dakin's solution. 
 Symonds (British Med. Journal, Nov. 4, 1916) indicates the method 
 of using the solution: In the wound are installed several fenes- 
 trated rubber tubes held in place by gauze lightly packed so as to be 
 in contact with the wound surfaces. The solution is let into the 
 drainage tubes by the drip method and in the severe cases the irriga- 
 tion should be continuous, day and night; but ordinarily intermittent 
 flushing is sufficient. Bacteriological examinations of the secre- 
 tions determine the rate of subsidence of the sepsis, and when the 
 wound after a few days is practically sterile it may be sutured or 
 drawn together with adhesive strips. If the hypochlorous solution 
 is irritating, or after the major infection has been brought under 
 control, Wright's solution may be substituted. 
 
 Crile adds to this form of treatment the use of the electric light. 
 The light is applied through a cluster of bulbs suspended over the 
 wound. Pasteboard cones or metal frames may be used to con- 
 centrate the fight, and the concomitant heat should be measured by 
 the patient's comfort. The light and the irrigation are employed 
 simultaneously until such time as the infection has disappeared, 
 after which the light alone is used until repair is complete. Dress- 
 ings are abolished. Crile believes that this method simulates the 
 effect of the light and heat of the desert, where wound repair proceeds 
 in remarkable measure. (Jour. Surg., Gyn. and Obs., Oct., 1916.) 
 
5H01 ^ N1) OTHEK WOUNDS IN MILATARY PRACTICE 
 
 rbarin (ProgrSs Medical, Paris, June, 1916) describes a method 
 of using Dakin's solution. 
 A gau A agar is fitted into the wound and the projecting 
 
 spread out over the surface, a drainage tube placed in 
 the lowest angle. The agar is now profusely watered with Dakin's 
 solution. It swells, spreads the wound and brings the disinfectant 
 into contact with the tissues. The solution is renewed every two or 
 three hours. He is enthusiastic as to results. 
 
 Davey 1 Lancet, Sept., 1916) does not regard the form of anti- 
 septic as important, provided the drainage is ample; and his plan 
 (A packing the wound with gauze containing salt tablets 
 disinfected in tincture of iodine. The salt tablets are placed at 
 intervals of 1 inch on a strip of four-layer gauze 1% inches wide. 
 This is twisted into a necklace and packed firmly into every crevice 
 ^i the wound. Over this is placed a pad of eight-layer gauze held in 
 place by adhesive strips; over this a covering of cotton wool held in 
 place by firm bandaging. This outer dressing alone should be re- 
 newed until the infection is under control. 
 
 Morrison (Lancet, Aug. 12, 1916) describes his method of treating 
 suppurating war wounds. The wound area is first covered with 
 : 1 united in 1 to 20 carbolic solution. When ready for opera- 
 tion the wound is opened freely and its cavity wiped out with sterile 
 urfaces mopped with methyl alcohol, and the cavity 
 filled with "Bip" — Bis. sub. nit. §i, Iodoform gii, and Liquid 
 Paraffine qs, to make a paste. The wound is covered with gauze 
 and this dressing is not changed for days or weeks. Iodoform 
 poisoning is very rare. Morrison claims excellent results. 
 
 Rilus Eastman of Indianapolis in charge of a base hospital in 
 
 Vienna indicate- the ordinary procedure in the management of the 
 
 mded there; emphasizing the value of sunlight in the treatment of 
 
 purations (Jour. Ind. Stat. Med. Assn., Nov., 1916): 
 
 All clothing is removed from the wounded and taken to the dis- 
 
 I tch man is then blanketed and carried to the 
 
 bath where he is smeared with blue ointment and placed in an 
 
 individual tub. Even those wearing plaster casts go into shallow 
 
 ith their plaster * Limbs held up out of the water by 
 
 After the full baths the patients are carried to the dressing 
 
TREATMENT OE WOUND INFECTIONS 1 65 
 
 rooms where bandages and dressings are removed and minor opera- 
 tive measures carried out. 
 
 Infected wounds are irrigated with hydrogen peroxid solution and 
 douched with normal saline and filled with Peru balsam or coated 
 with Miculicz salve (silver nitrate, boric acid and vaseline). After 
 such simple wound treatment, the wounded are taken to the wards 
 for rest in a clean bed before any painful or depressing manipula- 
 tions or Roentgen examinations are made. 
 
 Cases with enormous suppurating surfaces or extensive decubitus 
 are sent to the Eiselberg clinic and placed in water beds. Other 
 badly infected wounds are treated chiefly by wide incision, continuous 
 drop irrigation with Dakin's solution of sodium hypochlorite or con- 
 tinuous immersion in 4 per cent, acetate of aluminum solution and 
 exposure to sunlight. No single agent seems more inimical to bac- 
 terial growth than the chemical rays of the sun. Superficial staphy- 
 lococcus, B. coli and contaminating infections such as the several 
 forms of proteus steadily attenuate under graduated exposure to the 
 solar rays and even the streptococcus and gas bacillus infections are 
 distinctly benefited by the sun treatment. The large garden in the 
 rear of the Reservespital 8 is utilized to the utmost for direct ex- 
 posure of the infected wounds to the sun's rays. Gauze dressings 
 and bandages are dispensed with wherever possible and foreign 
 body reaction is brought to the irreducible minimum. On bright 
 days 90 per cent, of our patients, bedridden or ambulant, are sun- 
 ning themselves in the garden. Napoleon first expressed a fine 
 appreciation for heliotherapy when he said " disease is in the shadow, 
 its cure is in the sun." 
 
 The reserve hospital is the third station back of the lines. First 
 aid is given immediately back of the trenches in the field, the wounded 
 are then carried to the "Etappen" hospitals where simple and urgent 
 measures such as the application of plaster and starch casts or 
 splints, ligation of bleeding vessels, etc., are carried out. From the 
 " Etappen 7 ' hospitals the patients are sent in transport trains to the 
 reserve hospitals for complete and systematic radical treatment. 
 If radical measures, as surgical operations, orthopedic measures or 
 other energetic treatment are not required, the patients are then 
 sent to the homes for the convalescents. 
 
I NSHOl VND OTHEB WOUNDS IN MILITARY PRACTICE 
 
 In Reserve Hospital 8, as in all other reserve hospitals, the work 
 chiefly in the surgical treatment of nerve and spinal cord and 
 ssel injuries and the removal of bullets, hand grenade frag- 
 ments and shrapnel balls from nearly all parts of the anatomy, 
 including the brain, abdomen, head sinuses, and joints. We re- 
 so a large number of compound and comminuted fractures, 
 rly all of which arc infected. 
 The necessity of energetic treatment of the infected wounds, which 
 complicate nearly all fractures with the exception of those caused by 
 boulder injuries received in the mountains on the Italian front, 
 makes the use of crustacean appliances such as plaster-of -Paris coats 
 of relatively small value. Thus in fractures of the humerus with 
 infected open wounds the traction splint of Thomas, made of heavy 
 wire or wood, provides immobilization and extension and at the 
 same time permits of local wound treatment. In thigh fractures the 
 oman pin passed through the lower end of the femur provides 
 \ tension and allows the free and convenient treatment of 
 open wounds which is so essential. The Hey-Groves cradle splint 
 for thigh fractures supplements the Steinman pin. Plaster of 
 Pari> is, of course, much used even in infected fractures, large 
 defects being left in the cast at the open wounds, these defects 
 being bridged over by metal loops or wire " basket handles." 
 
 Good adhesive plaster being scarce, Buck's extension is secured in 
 appropriate cases by gluing Canton flannel to the skin with "Maste- 
 made of resin, alcohol, benzine and Venice turpentine. 
 
 TREATMENT OF GUNSHOT FRACTURES OF THE LONG 
 
 BONES 
 
 The treatment of gunshot fracture of the long bones varies in 
 
 tiding upon the character of the injury to the bone and 
 
 the soft parts. On this basis, three clinical varieties may be 
 
 r(\: (a) Simple perforating fracture (Fig. 104); (b) ex- 
 
 minution with moderate injury to the soft parts (Fig. 
 
 105); ( c ) extensive comminution with great laceration and de- 
 
 tioD of the soft parts (Fig. 106). 
 
 (a) The treatment of uncomplicated perforating fracture is 
 
 sedingly simple: Aseptic occlusion and immobilization and, 
 
TREATMENT OF GUNSHOT FRACTURES 
 
 167 
 
 provided only that infection is kept out of the wound, the results are 
 uniformly excellent. 
 
 (b) Unfortunately, simple perforation of bone in the present 
 warfare is uncommon. On account of proximity, the missiles 
 strike at high velocity and explosive effects are the rule, both in the 
 bone and the soft parts. So long as the main blood supply is intact 
 
 Fig. 104. — Simple perforating frac- Fig. 105. — Extensive comminution with 
 
 ture of the lower end of the tibia, moderate injury to the soft parts. {Harris, 
 (Makins.) Brit. Jour. Surg., Jan., 1915.) 
 
 an effort must be made to save the limb. Under anesthesia the 
 necessary debridement of the soft parts is performed, the wound 
 cavity thoroughly cleansed with iodine, and the bone fragments 
 adjusted. Nothing but bone divested of its periosteum and living 
 bone in the wound should be removed. Even though a fragment is 
 quite likely later to become a sequestrum, it is better to leave it 
 alone. In case many of the fragments are removed reconstruction 
 
rSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 oi hone docs not occur and a flail limb results, a condition worse 
 than the loss o\ the limb. 
 
 It' the treatment is instituted late, infection in some degree is a 
 certainty, and the main effort is directed toward the wound in the 
 soft parts, assuming of course that the limb is adequately splinted. 
 The treatment of the infected wound in the case of these gunshot 
 fractures is the same as that already indicated in connection with 
 
 1 06. — Extens-ve comminution with great laceration of the soft parts, requiring 
 amputation. (Harris, Brit. Jour. Surg., Jan., 1915.) 
 
 wounds of the soft parts. Each of the long bones presents its par- 
 ticular problem with regard to immobilization and extension. 
 
 (c) In case the bones are shattered, the soft parts reduced to 
 pulp, it is better to proceed to immediate amputation. It is under 
 c circumstances that Fitz Maurice Kelley recommends the 
 -imple circular amputation of the member, dividing all the tissues 
 at the same level, making no effort to fashion a flap. After the 
 dangers of infection are passed, another amputation following the 
 usual lines is to be practised. 
 
TREATMENT OF GUNSHOT FRACTURES 169 
 
 The question of immobilization is complex. On the field shaped 
 splints of zinc or molded wire splints may be employed. Tuffier, 
 however, expresses preference for the wooden splint fashioned and 
 padded in the ordinary way. He praises its simplicity and efficiency. 
 At the field and base hospitals no such simple routine can be followed 
 and each case must be treated according to its character, taking into 
 account the degree of fragmentation, the tendency to displacement, 
 the requirements of frequent change of dressing of the soft parts and 
 the comfort of the patient. 
 
 In the ordinary fracture, with absence of wound infection, the 
 plaster splint remains the dressing of choice. 
 
 In the case of the greatly comminuted fracture with serious sup- 
 purations to be treated, the problem of maintaining coaptation 
 while handling the limb in doing the dressings is one difficult to solve. 
 
 E. W. Hey Groves, in the British Journal of Surgery (April, 1916), 
 has pointed out the value of continuous extension in this class of cases 
 and the manner in which the principle may be applied to the indivi- 
 dual fractures. Two methods he holds in reserve: first, extension 
 splints, modifications of those invented by Borchgevrink; second, 
 transfixion apparatus. 
 
 The splint for the humerus is a Y-shaped wooden piece, the crutch 
 padded for the axilla and the end extending beyond the elbow and 
 fitted with a pulley wheel. A stirrup of adhesive plaster is fixed to 
 the lower part of the arm and a perforated wooden bar fitted into the 
 stirrup. The splint is now adjusted to the axilla and inner aspect 
 of the arm and fixed with adhesive strips. A cord, attached to the 
 wooden stirrup, is passed through the pulley and brought around to 
 the inner surface of the splint where it is fastened with whatever 
 tension may be desired. 
 
 Groves fastens the pulley cord to a solid rubber band arranged as 
 a loop on the inner side of the splint, to perfect the continuous 
 extension. 
 
 When the danger of infection does not contra-indicate, he applies 
 the double transfixion apparatus pictured in connection with the 
 femur (Fig. 113). 
 
 The upper end of the humerus is transfixed at a point in the line 
 between the inner and outer border of the arm, and at the level just 
 
170 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 below the middle of the deltoid, avoiding the cephalic vein and the 
 circumflex nerve. 
 
 The lower pin is passed through the humerus from side to side, 
 
 Fig. 107. — Posterior angular splint for forearm with full supination. Note manner 
 in which the extension cord passes through the pulley and to the rubber bands on back of 
 splint. (Groves, Brit. Jour. Surg., Jan., 1915.) 
 
 1 2 inch above the epicondyles. Before the lower pin is passed, 
 a perforated^iron hoop is adjusted over the elbow and the pin 
 passed through the proper perforations to hold the hoop in position. 
 
 PlC. 108. — Antero-internal splint for forearm, when the elbow and ulna are involved 
 Note the position of the rubber bands on internal surface to which the extension cord is 
 attached. (Groves, Brit. Jour. Surg., Jan., 1915.) 
 
 Extension bars are now fitted to the transfixion pin above and to the 
 hoop below. The screws of the extension bars permit of powerful 
 extension, correction of lateral angulation and rotation, and ready 
 
I 
 
 TREATMENT OF GUNSHOT FRACTURES 
 
 171 
 
 Fig. 109. — Antero-internal splint applied to patient in the 2nd Southern General Hospital, 
 with fracture of the ulna. (Groves, ^Brit. Jour. Surg., Jan., 1915.) 
 
 Fig. no. — Radiogram of elbow shown in Fig. no. Note that the head of the radius is in 
 good position as a result of the extension. (Groves, Brit. Jour. Surg., Jan., 1915.) 
 
GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 access of wounds. Of course the sepsis connected with the trans- 
 fixion pins is the objection to this method to be overcome. 
 
 In the case of the forearm a posterior angular splint is recom- 
 mended, applying the same principle of extension as in the case of 
 the humerus. The extension, in the form of an adhesive plaster 
 stirrup, is attached to the forearm and by means of cord and pulley 
 
 I 1 1. — Antcro-internal splint applied to fractures above and below elbow. The splint 
 with extension reduces both fractures. {Groves, Brit. Jour. Surg., Jan., ioi5-) 
 
 the traction is exerted on the forearm, the arm being fixed to the 
 upright piece of the splint. The cord is attached to an elastic 
 rubber band on the back of the forearm piece (Fig. 107). The 
 rm is thus fixed in complete supination. 
 In case of a wound on the back of the member, it may be neces- 
 sary to employ a metal frame splint with two lateral bars for the 
 forearm, the extension being applied in the same manner. 
 
TREATMENT OF GUNSHOT FRACTURES 
 
 173 
 
 In case the elbow is involved with comminution of the ulna and 
 laceration of the forearm, an antero-internal splint is recommended 
 (Fig. 108), leaving the whole outer and posterior surface accessible 
 for dressings. The same sort of pulley extension is used. This 
 splinting prevents dislocation of the head of the radius. 
 
 Fig. 109 indicates the 
 manner in which the 
 splint is attached. Fig. 
 no is a radiogram of the 
 arm pictured above. This 
 splint is applicable also to 
 fractures involving the 
 lower end of the humerus 
 alone. 
 
 In the case pictured in 
 Fig. in, the patient, a 
 Scotchman, in a Paris hos- 
 pital, had a fracture of the 
 lower end of the humerus 
 and the ulna. Both frac- 
 tures were reduced and 
 held by this splint. 
 
 Fractures of the tibia 
 and fibula present points of 
 special importance because 
 of the probability that the 
 blood supply will be com- 
 promised and all the soft 
 parts implicated; and in 
 the case of the ends of 
 the bones, the joints will 
 be involved (Fig. 112). 
 
 The transfixion apparatus is specially recommended for these 
 conditions. One pin passes transversely through the head of the 
 tibia, the other through the malleoli or os calcis. The same mechan- 
 ism as described for the humerus, consisting of a perforated hoop 
 with lateral extension bars, is adjusted to these transfixion pins. 
 
 Fig. 112. — Comminuted fracture of the tibia and 
 fibula. Part of shell in situ. Belgian soldier in 
 2nd Southern General Hospital. (Brit. Jour. Surg., 
 Jan., 1915.) 
 
174 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 [KlUMl NT OF GUNSHOT FRACTURES OF THE FEMUR 
 
 These compound fractures of the femur present greater difficulties 
 of management than any other class of gunshot injuries. There is 
 always great chance of infection, not to speak of the pain which the pa- 
 tient suffers in transportation and dressing. The treatment naturally 
 falls under two headings: A, at the front and B, at the base hospital. 
 
 A. Once the patient has been rescued from the firing line and 
 brought to the casualty clearing station, it is usually advisable to 
 let him rest quietly for an hour or two, in the meantime combating 
 collapse by hot drinks, etc. In some cases saline solution is 
 necessary. If fortunately the comminution is not great and the 
 flesh wound is not severe, it will be necessary only to apply a clean 
 dressing, splint the limb, and to send the patient on to the base 
 hospital. If the bone is shattered and the soft parts greatly lacer- 
 ated, it is necessary under anesthesia to trim away the ragged 
 flesh and clear away the debris of bone leaving all fragments still 
 attached to the periosteum and to provide for free drainage. 
 
 Amputation is necessary if the femoral or popliteal arteries are 
 torn, if the knee-joint is shattered, of if the muscles are shot away. 
 The time and the method of operating are questions of judgment, 
 each case presenting its individual problem. 
 
 Bowlby says: "I have been much impressed with the need of 
 delaying amputation in most of the cases where it is hopeless to try 
 to save the limb; but there are, of course, many conditions where 
 the shattered remains should be removed and it then becomes a 
 question what sort of operation should be performed. It must be 
 realized that these cases where the limb is hopelessly shattered are 
 the very ones in which collapse is at its worst; for when a leg has been 
 nearly shot away, a great majority of the patients die, and the few 
 who remain long enough alive to allow them to be taken to a clear- 
 ing station are also very near to death. In such as these the only 
 able operation is to sever the remaining tissues and cut away 
 the projecting bone without attempting to do more, for a formal 
 amputation higher up would inevitably be fatal at once. Few of 
 the most of such cases can survive, but as there is every gradation in 
 the amount of shock and the extent of injury, it is possible to save 
 a certain number. In other cases where the soft parts have not 
 
TREATMENT OF GUNSHOT FRACTURES 175 
 
 been so extensively injured, formal amputations may be undertaken 
 but the long skin flaps employed in civil practice are certain to slough." 
 
 The splint to be employed in the transformation to the base is a 
 matter of the utmost importance. In order to prevent further 
 trauma and the spread of infection, to minimize suffering and the 
 tendency to further collapse, it is essential that however much the 
 patient may be handled in transport, the limb remains immobilized 
 and in extension. 
 
 Some modification of the Thomas hip splint is much employed. 
 Groves describes his special wire cradle splint which seems to be 
 efficient and is simple in construction and application as well. 
 "It is made in two shapes, one havng a larger thigh section than 
 the other, for fractures of the upper third of the femur. Otherwise, 
 the one pattern serves for all fractures of the leg above or below the 
 knee. The splint is prepared for use by slinging double strips of 
 flannel or rubber bandage across from side to side. The rubber 
 bandage is employed at any spot adjacent to a profusely discharging 
 wound, or when irrigation is to be used. Ordinary rubber bandage 
 fastened by a safety pin will answer the purpose; but lately I have 
 used old inner tubes of motor tires, which require to be fastened with 
 a special wire clip. This stout rubber is not only much more service- 
 able but it affords a really good elastic extension force when used 
 under the upper part of the calf for fractured femurs, or under the 
 lower end of the thigh for fractured tibias. When the splint has 
 been prepared by the bandage or rubber slings, the leg is lifted off 
 the bed, using traction on the thigh, and laid upon the cradle, the 
 knee being bent over the angle of the splint as the final act in its 
 emplacement. If the patient is delirious, or has to be moved to 
 the operating or #-ray room, a bandage is placed around the lower 
 part of the leg above the ankle. 
 
 This much of the treatment is to be carried out at the earliest 
 possible moment after the case is seen. Apart from the attention 
 to the wound nothing more is required in the early stages, whether 
 on board ship or in hospital, except possibly the provision of counter- 
 extension. The limb once placed in the splint is never removed 
 from it unless after full surgical anesthesia given for the purpose of 
 an operation." 
 
176 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 B. Once in the base hospital a systematic and regulated treat- 
 ment is to be pursued and always the first task is to control sepsis 
 and promote repair in the wound of the soft parts The treatment 
 already indicated for septic wounds is to be pursued: irrigation with 
 
 Dakin's or Wright's solution 
 accompanied or not by Crile's 
 electric light applications. 
 No repair takes place in the 
 bone until the soft parts are 
 well on the way toward heal- 
 ing but in the meantime im- 
 mobilization and extension 
 are to be maintained without 
 cessation. If the fracture is 
 in the upper third of the fe- 
 mur, abduction must be 
 added to the extension. 
 Neither the ordinary treat- 
 ment with metal or plaster 
 Paris splints or the open 
 operation are permissible in 
 this class of cases. 
 
 Buck's Extension is simple 
 in application but reauires a 
 heavy weight and is qvailable 
 only in case the wound requires 
 but little attention. The 
 Thomas hip splint or its modifi- 
 cation is efficient in controlling 
 the extension and permitting 
 the handling of the limb, but 
 the pressure against its upper 
 ring against the pelvis is objectionable under a number of circum- 
 stances, especially if the wound is high up and if the patient is 
 troubled with dysentery or diarrhea. 
 
 Cradle splints with semiflexion of the joints and continuous ex- 
 ion such as the Hodgen (Fig. 192) the Balkan (Fig. 117), the 
 
 PlG. 113- — Double transfixion apparatus ap- 
 plied to the femur. Note the absence of 
 parallelism of the transfixion pins, the manner 
 in which the metal hoop is attached to the 
 lower pin, and the manner in which the screw 
 extension bars connect upper pin with hoop 
 below. (Groves, Brit. Jour. Surg., Jan., IOI5-) 
 
TREATMENT OF GUNSHOT FRACTURES 
 
 177 
 
 wooden trough or wire cradle (Fig. 115) seem best to fit all the 
 indications and of these the best in our opinion is the wire cradle 
 splint described on page 175. 
 
 Fig. 114. — Fractured femur treated by the double transfixion apparatus with little resulting 
 deformity. (Groves, Brit. Jour. Surg., Jan., 1915-) 
 
 Finally in certain cases the method of extension by transfixion 
 is of great value in certain cases where infection can be avoided. 
 The double transfixion (Fig. 113) is not applicable in these cases, 
 
178 GUNSHOT AND 01 111 K WOUNDS IN MILITARY PRACTICE 
 
 Fig. 115- — Wooden trough splint for leg fracture. Note angles of inclination of thigh 
 and leg. Sides are removable, permitting access to the wounds. (Groves, Brit. Jour. 
 Surg., Jan., 1915.) 
 
 . 116. — Cradle splint. Note manner in which weight is attached to the foot-piece. 
 By lifting the foot-piece to which the foot is bandaged, the limb may be handled without 
 disturbing the traction. (Groves, Brit.. Jour. Surg., Jan., 1915.) 
 
i TREATMENT OF GUNSHOT WOUNDS OF JOINTS 179 
 
 but transfixion through head of the tibia or the condyles of the inner 
 femur do not present the same dangers. 
 
 The transfixion pins 6)4 inches long and %q inch thick of 
 plated steel, one end pointed, the other slotted to fit the hand brace 
 is passed through the condyles from within outward. The pro- 
 
 Fig. 117. — The Florschutz method of suspension and extension in the case of fractures 
 of the upper end of the femur is more easily adjusted than the Hodgen splint. The uprights, 
 which support the horizontal bar, can be attached to any bed and the pulley can be attached 
 to any height. In this case, a patient from the 2nd Southern General Hospital, a 12-pound 
 bag of sand is used for extension. {Groves, Brit. Jour. Surg., Jan., 1915.) 
 
 jecting ends are surrounded by gauze dressings and fitted to a horse- 
 shoe-shaped metal to which the extension cord is tied. 
 
 TREATMENT OF GUNSHOT WOUNDS OF JOINTS 
 
 In the cases of simple perforating the skin is sterilized, the wound 
 dressed and the joint immobilized. As soon as the wound is healed, 
 with cautious passive motion is begun and, usually, an excellent 
 
180 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 functional result is obtained. If, on the other hand, suppuration 
 occur-, arthrotomy is indicated and the subsequent treatment to 
 carried out as in civil practice. If there is much com- 
 minution to begin with, the soft parts lacerated, it will often be 
 better to amputate. Unfortunately, the majority of these joint 
 injuries cannot be disposed of so simply; usually the bones and 
 soft part- arc equally traumatized and in a large percentage of these 
 - immediate resection offers the best hope of saving the limb. 
 Infection is attenuated and so permits earlier orthopedic treatment 
 indispensable to restoration of function. 
 
 In the case of the shoulder-joint if the head or surgical neck are 
 shattered resection should invariably be practised. The restoration 
 of function thereafter will depend on the integrity of the deltoid and 
 the circumflex nerve. It is also important to preserve the long 
 tendon of the biceps. 
 
 Such injuries to the hip-joint are extremely grave owing to the 
 concomitant injuries to the pelvic organs. 
 
 The knee-joint is very frequently wounded and the damage 
 is always serious. Hemorrhage into the joint is a constant feature, 
 the hemarthrosis disappearing in about a month in the favorable 
 cases. Under conservative and expectant treatment the results are 
 surprisingly good. If the joint is shattered immediate amputation 
 should be the rule. 
 
 TREATMENT OF GUNSHOT WOUNDS OF SKULL AND 
 
 BRAIN 
 
 Most perforating wounds of the skull prove fatal. The fatalities 
 increase as the range of the bullet shortens and as the impact ap- 
 proaches the base of the skull, death resulting from injury to the 
 automatic centers. The most recoveries follow injury to the 
 s. Blindness may result from injury to the occipital 
 Primary union of the scalp wound is an element in favorable 
 gnosis, since by this means infection is more likely to be eliminated. 
 The Brain is ver ptible to the streptococcus. 
 
 First aid on the battlefield will look to the hemorrhage. The first- 
 aid dressing should include both the wound of entrance and exit. 
 In the case of external hemorrhage, packing the wound is contra- 
 
TREATMENT OF GUNSHOT WOUNDS 
 
 181 
 
 indicated; a few strips of sterile gauze loosely packed in the wound 
 will favor hemostasis and antisepsis. At the field hospital a cra- 
 niectomy should be done. 
 
 All surgeons experienced in recent wars agree on the necessity of 
 exploring every such wound as soon as possible. Where long trans- 
 portation is necessary before a trephining can be done, the mortal- 
 
 Fig. 1 1 8. — Bullet in the tentorium cerebelli. Large clear space above indicates part of skull 
 blown away. Operation; good recovery. {Harris, Brit. Jour. Surg., Jan., 19 15.) 
 
 ity is naturally greatly increased. Enlarging the wound in the 
 scalp, enlarging the wound in the skull sufficiently to remove all frag- 
 ments of bone and debris, controlling the hemorrhage and providing 
 drainage — these represent the chief elements of relief. (See Urgent 
 Craniectomy.) Beril states that hernia of the brain is more likely 
 to occur if the opening is small. Ample trephining favors the grow- 
 
GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 Fig. 119. — Bullet lying in the petrous portion of the temporal bone. Treated by temporal 
 decompression; bullet left in situ; good recovery. {Harris, Brit. Jour. Surg., Jan., 1915-) 
 
 Fig. 120. — Bullet lying in tentorium cerebelli, having entered left parietal region. 
 Marked cerebral compression. Wound of entrance trephined. Bullet removed later, tre- 
 phining the right occipital region. Good recovery. (Harris, Brit. Jour. Surg., Jan., 1915.) 
 
TREATMENT OF GUNSHOT WOUNDS OF THE BRAIN 
 
 183 
 
 ing together of the brain and dura mater. Later the connective 
 tissues are absorbed and the meninges reconstructed. (Lyon Chirur- 
 gical, May, 1916.) If infection occurs the wound is to be opened 
 up. Disturbances of the sensorium, of motion and sensation often 
 improve as by magic following these interventions. A study of 
 the case reports from European hospitals confirms these views 
 
 Fig. 121. — Bullet lodged in the base of the neck, having first perforated the tuberosity 
 of the humerus and the acromion process. Note that the bullet is turned end for end and is 
 pointing at the wound of entrance. (Harris, Brit. Jour. Surg., Jan., 1915.) 
 
 (Figs. 118. 119, 120). Miiller reviewing his experiences advises 
 prompt and extensive operation. Every scrap of projectile or bone 
 should be removed, every focus of softening or suppuration drained. 
 A deep wound of the brain should be drained with rubber tube 
 rather than gauze. Both the wounds of entrance and exit should 
 be trephined. The dura should be opened if a hematoma beneath 
 it is present. (Archiv flir klin. Chirurgie, Berlin, Feb. 19, 1916.) 
 
1 84 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 TREATMENT OF GUNSHOT WOUNDS OF THE FACE 
 
 The chief dangers in these wounds are hemorrhage, infection and 
 interference with respiration. The eye, the fifth and seventh nerves, 
 are most likely to be involved and these injuries are to be treated on 
 general principles. Control of hemorrhage may call for ligation of 
 the facial, temporal or even the external carotid arteries. Careful 
 cleansing and packing with iodoform gauze secure excellent results. 
 
 Fig. 122. — French boy (Hotel Majestic) shot from side to side through the neck, the bullet 
 passing between the trachea and esophagus. Tracheotomy required on account of dyspnea. 
 Leakage of fluids from an esophageal fistula which closed in a few days. Tracheotomy tube 
 still in place. (Thorburn, Brit. Jour. Surg., Jan., 1915.) 
 
 TREATMENT OF GUNSHOT WOUNDS OF THE NECK 
 
 These wounds are always dangerous and yet in no other region 
 does the unexpected more frequently happen in the passage of a 
 bullet. The fact of hairbreadth escape of important structures is 
 explainable only by the small size of the army bullet and the mobility 
 of the structures (Fig. 121). The transverse or oblique track is 
 most common. Such wounds as are not immediately fatal are 
 likely to recover. Sepsis usually has its origin in the air passages 
 or the esophagus. Injuries to the trachea give rise to hemoptysis, 
 emphysema or broncho-pneumonia. Gangrene of the esophagus 
 may occur. Aneurism is not infrequent. Any of the nerves may 
 be injured. 
 
TREATMENT OE GUNSHOT WOUNDS OE THE ABDOMEN 1 85 
 
 No special treatment is called for beyond the hemostasis and 
 antisepsis, unless occasionally a tracheotomy may be indicated 
 (Fig. 122). 
 
 TREATMENT OF GUNSHOT WOUNDS OF THE SPINE 
 
 The treatment of wounds of the spine must be conservative; that 
 is to say, that very rarely will immediate operation be indicated. 
 Absence of the deep reflexes must not be taken to indicate complete 
 rupture of the cord but if motion and sensation do not improve in 
 ten days a laminectomy may be performed. If the laminectomy 
 does not seem to restore the pulsation of the cord the theca must be 
 opened and the clots removed. Recovery does not always take 
 place even though the cord is not lacerated. 
 
 Hull believes that early exploration lightens the prognosis. Ac- 
 curate localization by anterior and posterior #-ray views are essen- 
 tial and the operation may be performed under local anesthesia. 
 He advises the free use of Hexamethylene from the first. (Brit. 
 Med. Jour., April 22, 1916.) 
 
 TREATMENT OF GUNSHOT WOUNDS OF THE ABDOMEN 
 
 Rotter (Berlin. Mediziri. Clinik, Jan. 13, 1915) states as the 
 result of his studies of this class of injuries that the mortality on the 
 field is 90 per cent. ; among those living to reach the field hospital 
 80 per cent, die; of those reaching the clearing hospitals 40 per cent, 
 die, and finally those who reach the base hospitals recover. 
 
 Spontaneous cure is possible only when the perforation is small 
 and single and the bowel empty. If the patient is seen within 
 twelve hours he advises operation and states that the conditions are 
 so good in the German field hospitals that one need not fear sepsis 
 by reason of the operation done there. 
 
 Trench fighting, permitting the installation of were equipped 
 operating rooms reasonably near, and some times at (or under) the 
 firing line, has favored a more radical treatment of these cases, so 
 that early operation has become the vogue. The prognosis varies 
 with the part of the digestive tube involved. The ascending 
 and descending colon and the cecum gives the best prognosis; the 
 
I NSHOT AND o Till R WOUNDS IN MILITARY PRACTICE 
 
 stomach is not quite so favorable, and the perforation of the trans- 
 v colon and small intestine are most likely to result fatally. 
 
 Preceding operative measures, morphine should be given at once 
 to relieve shock, pain and anxiety; salines for shock and thirst. 
 
 The causes of death following gunshot wounds of the abdomen are 
 in their natural sequence: Shock, hemorrhage, peritonitis and 
 septic infection of the retro-peritoneal tissues. In the case of the 
 liver Makins indicates 60 per cent, died of septic infection and 25 
 per cent, from secondary hemorrhage which is itself the result of 
 the infection. In the case of the kidney the most common cause is 
 ►ndary hemorrhage. 
 
 Stevenson and McKenzie operating sJ^ miles in the rear of the 
 French report a mortality of 34 per cent, in their series of cases. 
 The laparotomies were done in some cases five or six hours, in others 
 twelve to twenty -four hours, after the injury. The intestines were 
 repaired by end-to-end anastomosis; the spleen and liver usually 
 packed; the kidney removed when pulped and in case of moderate 
 injury left the abdominal cavity washed out with Saline or Hypoch- 
 lorous acid solutions and mopped dry*; drainage tubes left in the 
 pelvis and flanks if the cavity appears badly infected. (Brit. Med. 
 Jour., November, 1916.) This would seem to represent the ordinary 
 procedure of the present time. 
 
 In the base hospital treatment of. abdominal conditions is 
 directed toward some particular organ and must of necessity be of 
 an expectant character, meeting conditions as they arise. In the 
 case of the liver for example, it may be necessary to enlarge the wound 
 of entrance to reach a retained missile, the source of persistent 
 -uppuration. It is inadvisable to make first incisions for this pur- 
 It may be necessary to operate for subphrenic or hepatic. 
 ess. 
 
 Uncomplicated wounds of the kidney rarely demand treatment 
 aside from rest and morphia. If the hemorrhage is severe as indi- 
 1 by the symptoms and by the hematoma or by the quantity 
 of blood in the peritoneal cavity, it is necessary to expose the kidney 
 and repair; or, in the case of great destruction, perform nephrec- 
 tomy. If a wounded kidney is discovered in the course of a general 
 laparotomy, removal is preferable to extensive suturing or packing. 
 
TREATMENT OF GUNSHOT WOUNDS OF THE THORAX 1 87 
 
 In the case of secondary hemorrhage, nephrectomy is often indi- 
 cated. In the case of blood clot in the bladder, great precautions 
 must be taken against infection and the catheter should not be used 
 except as a last resort. 
 
 If the rectum is involved, a temporary artificial anus may be neces- 
 sary. In the case of the bladder Legueu operates to remove a frag- 
 ment of shell, but bullets he removes by way of the urethra employ- 
 ing a No. 200 lithrotrite. In one of his cases the bullet reached the 
 bladder by way of the shoulder. (Jour. D'Urologie, Oct., 1916.) 
 
 TREATMENT OF WOUNDS OF THE THORAX 
 
 The non-perforating wounds need only an antiseptic dressing. 
 Broken ribs will require adhesive strapping. 
 
 The perforating wounds presenting no special indications of 
 hemorrhage from the chest wall are to be treated by aseptic occlusion. 
 
 The internal mammary or the intercostal arteries may need to be 
 controlled. If the hemorrhage is visceral, opium and compression 
 of the chest wall by firm bandaging seem to be the last resort in time 
 of war. Under no circumstances is the wound to be probed or 
 examined with the finger. Transportation is always to be feared. 
 In every way the patient is to be kept as quiet as possible. He must 
 be made to realize the seriousness of his injury. Paracentesis should 
 not be performed in the case of hemothorax until the bleeding has 
 ceased. If there is effusion, the chest should be explored at the base 
 hospital, and the fluid examined; if sterile it may or may not be 
 aspirated depending upon the symptoms. Removing a part of it 
 hastens the absorption of the remainder. 
 
 If infection develops a rib should be resected and a drainage tube 
 left in the pleura. If the pus cavity is large, a gentle lavage of 
 weak iodine, or Dakin's solution may be employed. If a projectile 
 is to be extracted from the lung to remove a source of infection 
 Centeaud and Billot employ local anesthesia. They claim for this 
 method ease and simplicity; that affords better control of pneumo- 
 thorax; and that it reduces shock. (Bulletin de Pacad. de med., 
 Paris, July 18, 191 6.) 
 
1 88 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 SHELL AND SHRAPNEL WOUNDS 
 
 Shrapnel shells contain from 250 to 400 leaden bullets, varying 
 in size with the shell, usually about M inch in diameter. The 
 shell equipped with a time fuse, is intended to burst over the object 
 aimed at and discharge its leaden hail. The velocity of the bullets 
 is that of the shell at the time of explosion and is never as great as 
 
 Fig. 123. — Fragments of Vickers- Maxim 1 -pound shell. (Makins.) 
 
 the muzzle velocity of the rifle bullet, and their effective range is 
 not long. 
 
 High explosive shells consist of an iron case containing an explosive 
 charge such as trinitro-toluene, and vary in weight from a few pounds 
 to as much as a ton. They are equipped with a detonator and so 
 explode by percussion on impact with the ground or buildings, etc. 
 The jagged fragments into which they burst and the debris of the 
 explosion produce the wounds to be described. 
 
SHELL AND SHRAPNEL WOUNDS 
 
 189 
 
 These wounds constitute a very large percentage of the casualties 
 of battle. Following the usual classification they may be designated 
 as contusions or lacerations, much more frequently the latter. 
 
 These injuries may be arranged in groups: 
 
 1. Large, destructive, mutilating wounds, often resulting in 
 immediate death. A whole limb may be irrevocably damaged; 
 half the skull shot away; the thoracic or abdominal cavities torn 
 open. 
 
 Fig. 124. — Shrapnel bullets normal and deformed. (Makins.) 
 
 2. A multiplicity of small wounds penetrating no deeper than the 
 fascia and containing fragments of the shell or its contents. There 
 may be thirty or forty such wounds scattered over the trunk and 
 limbs. 
 
 3. Surface wounds; the margins irregular; the skin often bruised or 
 burned; no fragments retained. 
 
 4. Penetrating wounds caused by a single fragment of shell, 
 
190 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 passing right through the affected region. The wound exit is always 
 much larger than wound of entrance. Its edges are everted, fat and 
 muscle tissue often protruding. The edges of the entry wound are 
 inverted and often charred. The tissues are widely destroyed, the 
 skin presenting a brawny appearance, due to interstitial hemorrhage. 
 A single penetrating wound, the fragment retained. As in 
 the other cases the amount of deep damage is out of proportion 
 
 to the size of the wound entry. 
 That these projectiles should 
 produce such terrible lacera- 
 tions in many cases is at once 
 apparent from a study of their 
 character (Figs. 123, 124, 125). 
 Isolated injuries to nerves 
 and vessels are unknown. 
 Muscles, vessels, nerves and 
 bones all share together in the 
 destruction caused by these 
 irregularly shaped missiles. 
 The great tendency to infec- 
 tion is not inherent in the 
 wound but in the environment, 
 for according to Pannett it is 
 astonishing how mild the in- 
 fection is in such wounds re- 
 ceived in naval warfare, by 
 reason of the absence of 
 earth dust and, in many cases, 
 by reason of a longer or shorter 
 sea bath (British Journal of 
 Surgery, Jan. 11, 1915). 
 In the limbs all degrees of destruction are met with, from absolute 
 mangling to tearing of the soft parts with compound comminuted 
 fractures of various degrees. Whether immediate amputation shall 
 be practised depends on general principles referable to thQ blood 
 supply. If the circulation of the member is compromised beyond 
 hope, amputation should be performed without delay (Fig. 126). 
 
 Fig. 125. — Fragments of shells (two-thirds 
 natural size) removed from various wounds 
 rceived in naval combat. The shrapnel fired 
 by the Germans consist of irregular metallic 
 fragments — not the round bullets found in 
 English shrapnel pictured above. (Pannett, 
 Brit. Jour. Surg., Jan., 1915.) 
 
SHELL AND SHRAPNEL WOUNDS 
 
 IQI 
 
 In other cases, especially if the wound is produced by the leaden 
 balls of shrapnel, the limb may be treated as in the ordinary case 
 of compound fracture (Fig. 127). 
 
 Fig. 126. — Shrapnel wound. Comminuted fracture of the femur. Frightful mangling of 
 soft parts. Amputation. (Harris, Brit. Jour. Surg., Jan., 1015.) 
 
 Lacerated scalp wounds with compound fracture of the vertex 
 are common. 
 
 In the face, horrible disfigurements result; an eye may be de- 
 
192 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 stroyed; the mouth cavity exposed; the bones of the orbit, face or 
 jaws splintered. 
 
 PlG. 127. — Fracture of lower third of femur. Round shrapnel ball in situ. (Harris, Brit. 
 
 Jour. Surg., Jan., 1915.) 
 
 Chest injuries of this type are usually fatal, either from shock or 
 hemorrhage. 
 Occasionally, however, a fragment of shell may traverse the 
 
SHELL AND SHRAPNEL WOUNDS 
 
 193 
 
 thorax with a result no more serious than a severe hemothorax. 
 Small fragments may be deflected by the ribs without fracture. A 
 fragment may lodge in the thorax and empyema is likely to ensue 
 (Fig. 128). 
 In the abdomen such wounds are almost universally fatal. If 
 
 Pig. 128. — Shell wound of base of thorax. Empyema and subphrenic abscess, com- 
 municating through a hole in diaphragm. (Thorburn, Brit. Jour. Surg., Jan., 1915.) 
 
 the wound is limited to the parietes, however, recovery may follow. 
 In some such cases the contusion of the bowel may result in a fecal 
 fistula (Fig. 129). 
 
 All these wounds are to be treated along the lines already dis- 
 cussed in connection with bullet wounds. In the matter of amputa- 
 tion Fitz Maurice Kelly calls attention to the great advantages of a 
 
 13 
 
104 GUNSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 simple circular section of all tissues at the same level. After infec- 
 tion is passed a second operation is done and flaps formed. 
 
 Fig. 129. — Shell wound perforating abdomen. Arrow shows aperture of entry; the top- 
 most wound the exit; the middle wound marks site of a subsequent fecal fistula leading into 
 the descending colon. (Pannett, Brit. Jour. Surg., Jan., I0I5-) 
 
 BOLO WOUNDS 
 
 According to Foxworthy (Ft. Wayne Medical Journal, June, 1902), 
 every insurgent in the Philippines was armed with a bolo. "This 
 bolo was of iron with a wood or bone handle and varied in shape and 
 size from a sword to a dagger and from a corn knife to a meat ax. 
 
BOLO WOUNDS 195 
 
 It was generally a cruder weapon than the Cuban machete, but 
 very effective in close encounters. As it could be concealed 
 beneath the loose jacket, it was more serviceable than a sword or 
 saber, which was always visible. The kries is a weapon similar to 
 the bolo, but with a wavy edge like a Christy bread-knife. It is 
 often two-edged. The wounds produced by the bolo and kries were 
 often of great length and usually infected. 
 
 " Another class of wounds was caused by spears and tomahawks, 
 used by the Igorrotes and Negrites. The tomahawk, having a 
 concave edge, was not so apt to glance off the skull as an Indian 
 tomahawk. A blow split the skull wide open. 
 
 The spears were often of bamboo, sharpened to a fine point, and 
 their penetrating power was almost equal to that of an iron-tipped 
 spear. The iron-tipped spear had from one to four barbs which 
 made an exceedingly ugly penetrating wound and usually had to be 
 cut out. These wounds were always infected and tetanus fre- 
 quently developed." 
 
 FIRST AID ON THE BATTLEFIELD 
 
 Colonel Nicholas Senn, in his address before the Lisbon Inter- 
 national Medical Congress, 1906, formulated the principles of first 
 aid on the battle field, and his conclusions though needing revision 
 in the light of recent events are nevertheless herewith summarized: 
 
 (1) The fate of the wounded depends largely upon the time 
 and thoroughness with which first aid is rendered. This first aid 
 for many reasons cannot be rendered by the surgeon, but must be 
 given by comrades or by the wounded man to himself. First aid 
 administered in this manner will be effective, owing to the aseptic 
 character of the chief wounds of battle, if previous instructions 
 have been given. It is absolutely essential that the soldier should 
 receive this elementary instruction when he is taught the art of war, 
 and it should not be postponed as has been done only too often in 
 the past until war clouds make their appearance. 
 
 (2) The first-aid dressing should combine simplicity with safety 
 against post-injury infection. It should be on the person of every 
 combatant and must be simple to be efficient. It must be compact 
 and easy of application. 
 
\>UOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 The dressing consists essentially of two pads of cotton, wrapped 
 in gauze, and fastened together by two stitches and continuous 
 with a gauze roller, which is made use of instead of the triangular 
 bandage for holding the dressing in place and for immobilizing the 
 injured part. The gauze roller should take the 
 place of the triangular bandage in every first-aid 
 dressing as it requires much less space and is more 
 serviceable as a means of fixation and support. 
 
 "The brown iodine spot in the center of the pad 
 on the side to be brought in contact with the 
 wound corresponds with the location of the anti- 
 septic powder incorporated in the absorbent cotton 
 and serves as an infallible guide in applying the 
 pad in the right place.' ' 
 
 (3) The first aid must have in view the treat- 
 ment of shock and hemorrhage, dressing of the 
 wound, and immobilization of the injured part. 
 
 The treatment of shock in the field is very un- 
 satisfactory, but, fortunately, shock is not a char- 
 acteristic of small-caliber bullet wounds. Rest in 
 the recumbent position; hypodermic injection of }/± 
 grain of morphine; spirits internally — these answer 
 the most urgent indications. 
 
 The treatment of hemorrhage at the front must 
 be conducted with the greatest caution. Elastic 
 constriction, if too generally practised, will do 
 vastly more harm than good. It should be applied 
 only in exceptional cases and then by a competent 
 member of the hospital corps or a medical officer, who must make 
 it his duty to send the case to the first dressing station as 
 quickly as possible, where definitive hemostasis can take the place 
 of the constrictor. There are less harmful means of hemostasis 
 which will be efficient in most cases: elevation of the limb (Figs. 
 i 3°j I 3 I )> acute flexion of the joint above the wound (Figs. 132, 
 ^-33)y digital compression over the dressing — these are measures 
 which must be taught. 
 
 Direct treatment of internal hemorrhage of any of the large 
 
 Fig. 130. — Eleva- 
 tion of upper ex- 
 tremity in the treat- 
 ment of hemorrhage. 
 (Senn.) 
 
FIRST AID ON THE BATTLEFIELD 197 
 
 cavities is entirely out of the question at or near the firing line. The 
 cartridge belt, suspenders, or gunstrap can be used to the greatest 
 advantage in limiting respiratory and abdominal movements and 
 thus secure for the vascular bleeding organs a condition of rest, 
 conducive to spontaneous arrest of hemorrhage (Fig. 134). 
 
 Fig. 131. — Gunstack for elevation of the lower extremity. (Senn.) 
 
 Immobilization is an essential part of first-aid treatment, con- 
 ducing to primary repair, relieving pain, and preventing infection 
 by securing the first-aid dressing. 
 
 The ideal fixation splint in such cases would be the plaster-of- 
 Paris splint, but this method of fixation is entirely out of the question 
 on the firing line and must be reserved for the dressing station of 
 field hospital. This first-aid fixation must be extemporized. 
 The sound leg may serve as a splint for the wounded one which is 
 held in place by belt, gunstrap, handkerchief, etc. The rifle, 
 bayonet, and saber are always available as splints (Figs. 135, 
 
 136,137)- 
 A fractured humerus may be splinted to the side of the body. 
 
(I NSHOT AND OTHER WOUNDS IN MILITARY PRACTICE 
 
 A well-padded bayonet will meet the indications in fracture of the 
 forearm. The wire netting cut in the shape corresponding to the 
 fixation of the different fractures of the limbs should be carried, to 
 the front by the sanitary corps in sufficient quantities to meet the 
 expected requirement. Splints made of this material, well-padded, 
 will answer an excellent purpose as first-aid fixation, as they can be 
 
 molded into shape and can be 
 used subsequently to strengthen 
 the plaster bandage at the dressing 
 station. 
 
 (4) The first-dressing station is 
 the most important place for 
 skilled aid. This primary depot 
 of the wounded should be estab- 
 lished in a sheltered place as near 
 as possible to the firing line, pro- 
 tected as much as possible against 
 the fire of the enemy. 
 
 (5) Probing of recent gunshot 
 wounds must be prohibited by the 
 most stringent rules. Under no 
 circumstances should attempts be 
 made to remove bullets until this 
 can be done under strict aseptic 
 precautions in the hospital, and 
 then only in those cases in which 
 such operation is clearly indicated 
 and the exact location of the 
 bullet has been determined by 
 palpation through the intact skin 
 
 or by the use of the "X-ray." 
 
 (6) The surgeon's most important duties at the first-dressing 
 station are: 
 
 (a) Inspection of first-aid dressing. If it is in its proper place, 
 label to this effect that it may not be unnecessarily removed at the 
 hospital. If defective, it must be renewed or more securely 
 fastened. 
 
 132. — Forced flexion of the elbow- 
 joint in arresting hemorrhage from the 
 brachial in that region. (Senn.) 
 
FIRST AID ON THE BATTLEFIELD 
 
 199 
 
 (b) Application of plaster splints to the fractured limbs; the 
 wire-netting splints are cut into strips and incorporated in the 
 plaster-of-Paris dressing. 
 
 Fig. 133. — Forced flexion of the knee in hemorrhage from the popliteal region. (Senn.) 
 
 (c) Emergency operations. The operative treatment of gunshot 
 wounds must be limited to the most urgent 
 cases. The definitive arrest of hemorrhage 
 — of dangerous external or internal hemor- 
 rhage — stands pre-eminent in the list of 
 emergency operations. Iodized catgut is 
 the proper ligature material for field service. 
 
 Intra-cranial and intra-thoracic hemor- 
 rhage should not be interfered with outside 
 of a well-equipped hospital. Dangerous 
 intra-abdominal hemorrhage calls for prompt 
 operative interference. Abdominal section 
 under such circumstances, in a tent, may 
 contribute much in lessening the mortality 
 from hemorrhage by a resort to ligature, 
 suture, or aseptic tamponade. 
 
 By pursuing this aggressive course, some 
 lives may be saved by prompt interference 
 which would be lost by the let-alone treat- 
 ment. Wounds of the larynx and trachea 
 
 J u . F 1 G . 1 3 4 • — Perforating 
 
 which have given rise to respiratory diffi- wound of chest, aseptic tam- 
 culties, either from emphysema or hemor- p° ni f de . a * d immobiiiza- 
 
 x J tion by circular compression. 
 
 rhage, call for an immediate tracheotomy. (Senn.) 
 
JOO GUNSHOT AN1> OTHER WOUNDS IN MILITARY PRACTICE 
 
 Resection, as a primary operation for penetrating gunshot 
 wounds of the joints, is obsolete. 
 
 Amputation must be reserved for cases in which a limb has become 
 
 Fig. 135. — Saber splint for leg and 'thigh." (Senn.) 
 
 mangled by a cannon ball or fragment of shell or in which the 
 fracture is complicated by division of the principal blood-vessels and 
 
 nerves. 
 
 Fig. 136. — Gun splint. {Senn.) 
 
 Laparotomy in the field, for gunshot wounds of the abdomen, 
 with a view of finding and suturing perforations of the gastro- 
 
 Fig. 137. — Stick and blanket splint. (Senn.) 
 
 intestinal canal, has not yielded in practice the anticipated results, 
 and hence must be restricted to exceptional cases. 
 
 Clinical experience has shown that in a fair percentage of 
 
 cases 
 
FIRST AID ON THE BATTLEFIELD 201 
 
 penetrating wounds at and above the level of the umbilicus, inflicted 
 in the antero-posterior direction, do not implicate the gastro- 
 intestinal canal, and in such cases conservative treatment yields 
 better results than operative. On the other hand, in wounds involv- 
 ing the small intestine area, more especially when the bullet takes 
 an oblique or transverse course, we may confidently expect to find 
 from three to fifteen perforations, and it is in this class of cases in 
 which immediate laparotomy offers the only chance of saving life. 
 
 (7) The surgeon's field case should be light, compact, and the 
 instruments wrapped in a canvas roll, so that instruments and 
 envelope can be quickly sterilized in boiling soda solution. 
 
CHAPTER XIII 
 GUNSHOT WOUNDS IN CIVIL PRACTICE 
 
 The projectiles of the ordinary fire-arms of civil life differ from 
 those used in warfare, in that they are composed of soft lead, are 
 easily deformed, are of slight initial velocity, and are usually fired 
 at short range. 
 
 The revolver and pistol, flobert and shot-gun produce the wounds 
 most frequently seen. 
 
 Of the shot-gun it may be said that the wounds which it produces 
 are very likely to be either greatly destructive or comparatively 
 harmless. At close range the charge, acting as a single body, lacer- 
 ates and shreds the tissues; at long range a number of small per- 
 forations are made. 
 
 The dangerous wounds, then, have all the characteristics of lacera- 
 tions and demand the treatment of lacerated wounds in general. 
 It must always be assumed that foreign bodies have been carried 
 into the tissues and that these wounds are therefore infected. 
 
 It is the bullet wound of the revolver, however, which it is most 
 practical to consider. To a limited extent, its pathology is similar 
 to that of the army bullet, and it is unnecessary to state again the 
 effect of a bullet upon the various tissues. It is expedient to con- 
 sider at once, with especial reference to treatment, the bullet 
 wounds of certain localities. 
 
 But let it be emphasized in this connection that the course of the 
 bullet can never be accurately determined. 
 
 Always be on the alert for the unexpected and insist, however 
 simple the wound may appear to be, that the patient be kept under 
 close surveillance. The wound may seem to be a flesh wound of the 
 thigh, for example, and may be dismissed as such; later, and too late 
 perhaps, it may be discovered that the peritoneal cavity wag involved. 
 And this happened to a boy of ten who was brought to the City 
 
BULLET WOUNDS OF THE HEAD 203 
 
 Hospital with not the slightest symptoms to indicate any serious 
 injury. Too late, it was found that the intestine was perforated 
 in many places. 
 
 Again, however well assured we may be that no serious damage 
 has been done we shall nevertheless watch for signs of hemorrhage 
 or beginning infection. 
 
 We must remember, too, that infection may develop late. 
 
 A man of thirty-five was brought in with a 38 bullet wound in the 
 region of the knee. His limb was swelling rapidly and he was im- 
 mediately prepared for operation. 
 
 The bullet had bored through the upper end of the tibia from in 
 front backward and lodged in the popliteal space. A counter open- 
 ing was made from behind, the bullet extracted. The hemorrhage 
 indicated an arterial wound and following the track of the bullet, 
 the anterior tibial was found divided near its point of origin. It was 
 ligated, the posterior opening in the tibia located and a strip of gauze 
 saturated with iodine passed through the hole in the bone. Drain- 
 age left in both anterior and posterior openings. 
 
 For a week the patient did well and was thought to be entirely 
 out of danger. At that time however his temperature rose and very 
 shortly there were signs of suppuration and, in spite of free drainage, 
 gangrene developed and the limb was amputated well above the 
 knee. But the flaps refused to heal and, grave symptoms of general, 
 sepsis supervened. He died three weeks after his injury and the 
 postmortem revealed a septic thrombus along the whole length of 
 the femoral vein. 
 
 WOUNDS OF THE HEAD 
 
 The region of the brain is usually wounded in attempts at suicide, 
 and it is the right temple or forehead which is most frequently se- 
 lected. The vertex, postero-lateral, and occipital regions are seldom 
 wounded and only then as a result of accident or assault. 
 
 As medico-legal questions are often involved in these cases, it is a 
 wise practice to make careful and systematic examinations. Learn 
 as much as possible about the character of the fire-arm, the nature 
 of the projectile, the position of the patient at the time of injury. 
 
204 GUNSHOT WOUNDS IN CIVIL PRACTICE 
 
 Examine the cars and nose for blood, inspect the mouth, examine the 
 head for a wound of exit, or see if the bullet can be located beneath 
 the scalp. 
 
 Next examine the wound itself, but not until the field and wound 
 have been sterilized. Begin the disinfection by shaving the scalp 
 about the wound. Wash with soap and water and then with alcohol 
 or bichloride. 
 
 Enlarge the wound by a cross incision, if necessary, and wipe out 
 with sterile gauze, removing all forms of foreign bodies. 
 
 Finally examine the skull. If you find a mere depression without 
 penetration, it is sufficient to pack the opening with sterile gauze, 
 and bandage. Later the bullet may be located with the "X-ray" 
 and removed, if it becomes troublesome. If the bullet is visible and 
 removable without much difficulty, it is better to take it out 
 at once. 
 
 If the ball has penetrated the entire thickness of the skull and 
 lodged within the cavity, the size of the orifice will be some index as 
 to its probable depth; if the orifice is large, it argues for close range 
 and deep lodgment. If the opening is small, comparatively speak- 
 ing, it is likely that the ball has not penetrated deeply. Note the 
 direction of the fissures. If the base is involved the prognosis is 
 always serious. Note the condition of the dura: it may be lacerated 
 and the brain tissues may exude. If such is the case, the bullet is 
 obviously in the brain, but its exact location must remain a matter 
 of doubt. It is not expedient to explore it; it is not even advisable 
 to attempt to disinfect the cerebral wound. 
 
 It is sufficient to remove all fragments of bone and debris and 
 wipe the wound dry with sterile gauze. On these two points, how- 
 ever, there may be some difference of opinion. The American Text- 
 book of Surgery insists upon the value of disinfection of the entire 
 cerebral track of the bullet and of through-and-through drainage 
 under certain circumstances; also upon the advisability of attempting 
 to locate the bullet by the aluminium gravity probe, and to remove it. 
 Still it may be said that the general practitioner has done his duty 
 and done it well if he has cleansed the skull and dural wounds and 
 controlled the hemorrhage. (For further details of treatments, see 
 Urgent Craniectomy.) 
 
TREPHINING THE SPINAL CANAL 
 
 GUNSHOT WOUNDS OF THE SPINE 
 
 205 
 
 A man was brought into the City Hospital shot in the back with 
 a 38 revolver. Except that he was paralyzed from his hips down 
 and without control of his bladder and bowels, his condition was 
 good. This positive primary paralysis pointed to grave injury to 
 the cord. At the operation it was found that the bullet had smashed 
 into the spinal canal and there lodged, completely obliterating in 
 
 Fig. 138. — Complete division of spinal cord; bullet retained. 
 
 its course a considerable segment of the spinal cord (Fig. 138). 
 Suture of the cord was out of the question, so the poor fellow — a man 
 of great vitality — was condemned to linger in living death for many 
 weeks. 
 
 Happily not all cases of gunshot wound involving the cord are 
 beyond relief. Whenever the symptoms point to severe injury of the 
 cord — whenever there are notable disturbances of sensation and 
 motion — -and improvement fails to take place shortly, it is bad 
 practice to delay. It is indicated to cut down upon the spine, re- 
 move a spinous process, trephine into the canal, and cautiously cut 
 away the arches. It may develop that the symptoms are due 
 
206 GUNSHOT WOUNDS IN CIVIL PRACTICE 
 
 merely to pressure of fragments of bone which are to be removed. 
 If after gunshot wounds of the spine there are no cord symptoms 
 or if they are mild and tend to improve, it is better not to operate. 
 The smaller the projectile the less the likelihood that operation will 
 be required. Without some positive indication in the cord, there- 
 fore, aseptie occlusion is the treatment to pursue. Probing is all the 
 more perilous because infection may be carried directly to the spinal 
 meninges. 
 
 GUNSHOT WOUNDS OF THE FACE 
 
 These may result from shots into the mouth with suicidal intent. 
 Small bullets may remain imbedded in the hard palate or posterior 
 pharyngeal wall. The instinctive tilting of the head backward 
 gives the bullet a characteristic course through the hard palate or 
 the root of the nose, and, owing to the involvement of the base of 
 the brain, such wounds are deadly, except with quite small fire- 
 arms. 
 
 In other cases there are grave comminuted fractures of either jaw. 
 Sometimes there are powder burns and disintegrations suggestive 
 of explosions. 
 
 The chief dangers in cases not immediately fatal are from inter- 
 ference with respiration and from hemorrhage. These wounds are 
 also predisposed to infection, and as a result of sepsis secondary 
 hemorrhage is not infrequent. Paralysis of the facial nerve may 
 occur. The salivary glands or their ducts may be injured and give 
 rise to a troublesome dribbling of saliva. Marked interference with 
 respiration may call for immediate tracheotomy. 
 
 Arteries may need to be ligated and ligation may be difficult owing 
 to their relation to the bones. The oozing, always marked, is to be 
 controlled by pressure. The natural contour is to be restored as 
 much as possible after a thorough cleansing, and the wound cavities 
 packed with iodoform gauze. A young man was brought to the City 
 Hospital with gunshot wound of the face, the range so close the skin 
 was powder burned. He was bleeding profusely from the mouth. 
 It was found that the bullet, a 38, had entered the left upper jaw, 
 passed through it into the nasopharynx, carrying away part of the 
 soft palate and still ranging slightly downward had lodged in the 
 
TREATMENT OF GUNSHOT OF CHEST 207 
 
 middle of the neck of the opposite side. It was located about the 
 depth of the sterno mastoid. An incision under local anesthesia was 
 made and a dissection carried down to the bullet. It was grasped 
 with forceps but slipped away and on further attempts to seize it, 
 was pushed back into the pharynx and coughed out. 
 
 The wound in the jaw was injected with peroxide which escaped 
 through the mouth. 
 
 Finally a slip of sterile gauze was carried through the channel in 
 the jaw, one end of the strip left in contact with the lacerated tissues 
 of the soft palate, the outer end projecting from the wound. Some 
 oozing persisted for twenty-four hours. On the second day the strip 
 was removed and the wound injected with weak peroxide solution. 
 No infection arose and he recovered rapidly, apparently none the 
 worse for the injury. 
 
 GUNSHOT WOUNDS OF THE THORAX 
 
 Gunshot wounds of the thorax do not differ from other wounds in 
 this region except in their graver prognosis. (See page no, Wounds 
 of Thorax, and page 149, Military Practice.) Such as involve the 
 great vessels at the root of the lungs and most of those which involve 
 the heart are not even of interest from a standpoint of treatment 
 because so rapidly fatal as to preclude intervention. 
 
 Such wounds as are not obviously fatal, whether they involve the 
 pleura and lungs or the pericardium and heart, present three sources 
 of danger: hemorrhage, asphyxia, and infection. These are the 
 three conditions which determine the line of treatment, and which 
 have already been discussed under the head of Wounds of the 
 Thorax. 
 
 Aside from these symptoms of urgency, the treatment must be 
 conservative and expectant — quite different from gunshot wounds 
 of the abdomen. 
 
 Begin by covering the wound with an aseptic compress and then 
 carefully disinfect the field. Finally cleanse the w r ound itself and 
 dress antiseptically. Avoid probing or other explorations. 
 
 Transportation must also be avoided, for there can be no doubt 
 that it is often disastrous. In the country, where ambulances are 
 out of the question, the nearest shelter is the best. 
 
GUNSHOT WOUNDS IN CIVIL PRACTICE 
 
 It it is evident, finally, that the hemorrhage is increasing, as indi- 
 cated by the symptoms and physical signs, conservatism is no longer 
 rational and the wounded lung should be exposed and the tear 
 repaired. In the event a tear is found in a pulmonary vein a 
 ligature must be placed on either side of the tear. • Recovery may 
 follow without lung complications. 
 
 Ktitner, of Leipsic, proposes in the future when dealing with these 
 wounds to evacuate the extravasated blood if it is not promptly ab- 
 sorbed, suturing the pleura without drainage. In the case of an 
 already collapsed lung it does not appear that there would be in- 
 creased danger operating without the aid of a Sauerbruch cabinet. 
 
 BULLET WOUNDS OF THE ABDOMEN 
 
 With reference to prognosis and treatment, these wounds fall into 
 three clinical groups: those which are obviously penetrating and ac- 
 companied by grave visceral lesions; those which are doubtful both 
 as to penetration and visceral injury; and those which are probably 
 benign. 
 
 (A) One concludes that a certain wound is grave not from ob- 
 serving the escape of gas and fecal matter, or hemorrhage from the 
 wound, for these are too infrequent to be relied upon, but from the 
 general condition, which alone is of sufficient significance. The 
 pulse is small and rapid; the face is drawn and pale; the belly wall 
 is distended and resistant to the least pressure; dullness of the iliac 
 fossa and flanks develops and there may be vomiting of stomach 
 contents or of blood. 
 
 The persistence of these symptoms for the first two or three hours 
 is sufficient to dispel any illusion of the more sanguine that the case 
 is not dangerous. 
 
 There is but one thing to do, operate as soon as possible. 
 
 This is a principle so definitely established that the citation of a 
 long list of eminent authorities is unnecessary: a rational doctrine 
 that all may accept. 
 
 There are contingencies of time and place, of septic environment 
 which would insure that the operation itself would likely be fatal, 
 but those conditions are very exceptional in civil practice with the 
 
TREATMENT OF GUNSHOT OF ABDOMEN 209 
 
 doctor who has the " savoir-faire." An exceptional condition does 
 not alter the principle, and he who does not act at once, must incur 
 the reproach of having refused the wounded the best resource of 
 safety. 
 
 There is another consideration. One may not be called to see the 
 case until after two or three days have elapsed and may then en- 
 counter one of two eventualities: one almost certain, the other 
 unlikely. 
 
 In the first, there are the signs of general peritonitis. Under these 
 circumstances, again, the rule is to operate, though only as a forlorn 
 hope. 
 
 On the other hand, it may be that despite the apparent gravity 
 of the wounds, the pulse is good, there is no vomiting, the abdomen 
 is not tender, there has been a passage of flatus or a movement of 
 the bowels. Although we know these appearances are often deceitful, 
 that it may be only the lull which precedes the storm, yet we are 
 perfectly justified, under these circumstances, in maintaining an 
 " armed expectancy." Under such circumstances, control peris- 
 talsis with a little morphia, impose an absolute quiet and absence 
 of food, and in the meantime have the patient under vigilant 
 surveillance. 
 
 Fysche reports a case of abdominal gunshot wound, which shows 
 the value of drainage and which might be taken as an indication of 
 the course to pursue in certain desperate cases, where, for example, 
 the circumstances of time or place, the condition of the patient, or 
 the isolation and lack of skill of the operator precluded a more 
 rational and definite procedure. 
 
 A boy of fourteen was shot through the abdomen at close range 
 with a large-caliber revolver. The bullet entered just to the in- 
 side of the right anterior-superior spine. There were all the signs 
 of shock and internal hemorrhage. The abdomen was opened 
 with immediate escape of blood and fecal matter. The first por- 
 tion of the small intestine examined revealed a perforating wound. 
 This and two other wounds were repaired, but the boy's condition 
 called for haste and a hurried examination developed seven more 
 perforations of gut and mesentery along the 6 feet exposed. The 
 abdominal incision was closed with through-and-through sutures 
 14 
 
2IO GUNSHOT BOUNDS IN CIVIL PRACTICE 
 
 with a large deeply placed drainage wick in the lower angle. He 
 was freely stimulated and given large enemas of normal salt solution. 
 The drainage was removed on the second day and from the opening 
 there was a free fecal discharge. On the third day his bowels 
 moved naturally. Thereafter the fistula closed rapidly and in a 
 month he seemed quite well. (Montreal Med. Jour., May, 1909). 
 
 (B) The case is one of doubtful penetration and therefore doubt- 
 ful visceral injury. 
 
 You are called immediately. You find nothing more than a 
 bullet wound in some part of the anterior abdominal wall. The 
 pulse is good, the abdomen is neither rigid nor tender, and there is 
 no other indication worth noting. 
 
 Now, what are you to do? Wait several hours watching for some 
 indication? But this is a dangerous formula, subject to various 
 interpretations, for, as Lejars asks, what shall be regarded as the 
 first " indication" — -the weaker pulse, the tympanites, the altered 
 facies? But these are the signs of beginning peritonitis. 
 
 It is better, as Brown, of St. Louis, and many others have so defi- 
 nitely determined, to answer the question resolutely in these terms: 
 prepare at once to operate; determine whether the wound is a pene- 
 trating one or not, and if so, proceed with the laparotomy — pro- 
 vided, of course, that the situation is such that it can be done with- 
 out very grave danger from the operation itself. It may develop 
 that the operation is not necessary, but it will very much more fre- 
 quently become evident that it is indispensable. 
 
 Admit that these urgent laparotomies are difficult, that they strain 
 every resource of emergency antisepsis and surgical skill, that the 
 perforations are often multiple, that one never knows just what he 
 must meet. Admit that some recover from these wounds without 
 operation, but are we authorized by that to expect in another case 
 so fortunate a denouement? Admit that the patient has several 
 chances of recovery without operation perhaps, but let us remem- 
 ber we have no means of calculating such chances even in the more 
 favorable cases, and certainly the chance of an exceptional proc- 
 ess cannot give more hope than an early, regulated, and aseptic 
 intervention. 
 
TREATMENT OF GUNSHOT OF ABDOMEN 211 
 
 It is prudence which commands operation. As Lejars says, this 
 seems the wisest course: 
 
 Prepare for a laparotomy. Begin by cleansing the field of opera- 
 tion and then the wound, which is enlarged, cutting from above 
 downward, layer by layer. If the peritoneum is found uninjured, 
 repair the incision carefully, first trimming the devitalized tissues 
 away; under these circumstances, one may safely prognosticate a 
 recovery. 
 
 If you find the peritoneum perforated, slightly enlarge that wound 
 also, that you may get some idea as to the conditions: a flow of 
 blood, bile, intestinal contents, or urine may indicate what one may 
 expect. But the fact alone of perforation of the peritoneum is an 
 indication to open the abdomen in the middle line — -to do a median 
 laparotomy. 
 
 The median incision will be above or below the umbilicus, de- 
 pending upon the level of the bullet wound (see Laparotomy for 
 Traumatism). 
 
 (C) There are, finally, as Lejars points out, certain bullet wounds 
 which, even though penetrating, may be regarded as unlikely to 
 have produced serious results. These are such as are produced by 
 pistols in which the bullet is quite small and impelled by an insig- 
 nificant charge of powder, so that its force is practically spent in 
 traversing the abdominal wall. 
 
 And even though the digestive tube should be wounded, the 
 opening is not large enough for the contents to escape, for the mucous 
 membrane acts as a plug and repair quickly takes place. 
 
 In such a case, there being no doubt as to the facts, it is perhaps 
 wiser not to operate, but to treat by aseptic occlusion. Neverthe- 
 less it is the part of prudence, however sanguine of the outcome, to 
 keep the case under close watch for some days. 
 
 GUNSHOT WOUNDS OF THE JOINTS 
 
 The knee, which is the joint most frequently wounded, may serve 
 as a type. Suppose it is wounded by the discharge of a fowling- 
 piece, a not uncommon accident. The character of these wounds 
 
NTSHOT WOUNDS IN CIVIL PRACTICE 
 
 ariable. It may be that only a few shots at long range have 
 penetrated the joint, or it may happen that the whole load has torn 
 iis way into the joint structure. But whatever the condition, no 
 active intervention is called for if the case is seen at once. 
 
 Cover the wound with sterile gauze, provide a temporary splint, 
 and supervise the transportation. Once under shelter, proceed to 
 carry out a methodical cleansing and examination. Cleanse the 
 field first and then the wound itself. 
 
 If the wound was received at long range and probably only a 
 few shots have penetrated the joint cavity, the careful cleansing, 
 antiseptic dressing, and subsequent immobilization will be all that 
 is required to bring about an uninterrupted recovery without loss of 
 function. 
 
 If the wound was received at close range and the joint is freely 
 penetrated by the shot, which have carried in shreds of clothing and 
 other foreign particles, the treatment is quite different. 
 
 Suppose the joint is swollen, dark blood oozes out, and the cavity 
 is exposed through lacerated wounds: in such a case conservatism 
 will not cure. Prepare to operate immediately. Open the joint 
 and with hot normal salt solution freely flush out the shot, frag- 
 ments of bone and cartilage, blood clots and other debris. Do not 
 be sparing of time and patience. Trim away the lacerated tissues. 
 If satisfied with the cleansing, suture the deeper layers over the joint 
 so as to close it completely, and drain only the superficial wound; 
 otherwise, drain the joint cavity as well. Apply an antiseptic 
 dressing and immobilize, and expect a good result. 
 
 The situation is again different if the case has been treated first by 
 the uninstructed. The wound is seen some time after injury and 
 found covered with dirty cloths, or a handkerchief, the worse for 
 usage, is stuffed into the wound. No covering at all is always better 
 than anything less clean than a sterile dressing. 
 
 The treatment is the same as before — -in every way as rigorous 
 and systematic — -but there are not the same certainties by any 
 means that it will head off sepsis. You cleanse, drain, immobilize, 
 and watch. You watch for beginning infection, which for that 
 matter may develop in the simpler cases if the cleansing is not 
 complete. Fever, pain, swelling of the joint, all rapidly increasing, 
 
TREATMENT OF GUNSHOT OF HAND 213 
 
 are the signs of beginning infection and suppuration and call for 
 immediate action. It is indicated to open the joint and drain. 
 (See page 440, Arthrotomy.) 
 
 Bullet wounds produce similar lesions, although usually they are 
 of the milder type. Hemarthrosis indicates injury to bone as well 
 as soft parts. Sometimes these wounds occur with scarcely any 
 injury to the joint structure, the bullet lodging in the epiphysis. 
 In the milder cases, wherever the bullet may be, it is better merely to 
 cleanse and immobilize, and at a later date, if necessary, the ball 
 may be removed. If, however, the hemarthrosis is voluminous, 
 it is better to open the joint at once and clean out the cavity and, 
 by a happy chance, the bullet may be found and extracted. (See 
 also gunshot wounds of joints in military practice, and compound 
 dislocations.) 
 
 GUNSHOT WOUND OF HAND 
 
 A pawnbroker, examining a revolver brought in for a loan and 
 which was supposed not to be loaded, was shot through the hand. 
 The 32 bullet passed between the heads of the third and fourth 
 metacarpals, splintering the fourth in some degree. The tissues 
 were powder-stained along the track of the bullet and the wound 
 bled very freely. 
 
 The wound of entrance in the palm was jagged; the wound of exit 
 smooth. The wounds were cleansed and a slender forceps passed 
 through the hand, a piece of gauze attached and pulled into place 
 for through-and-through drainage by withdrawing the forceps. The 
 bleeding stopped, but later began again, soaking the bandages. 
 Syringing the wound with peroxide and packing with gauze served 
 to check the bleeding for a few hours. This intermittent hemor- 
 rhage persisted for two days. 
 
 The hand was soaked twice daily for a half-hour in hot normal salt 
 solution; the swelling and pain rapidly subsided and after three or 
 four days the wound began to heal without the least evidence of in- 
 fection. The ring finger was stiff and painful for some time, but 
 under massage and passive motion gradually regained its use. 
 
 Injury to the tendons constitutes one of the chief complications 
 of gunshot wounds of the hand. Free trimming away of the 
 
2 14 GUNSHOT WOUNDS IN CIVIL PRACTICE 
 
 shattered tissues, free drainage and free use of hot normal salt solu- 
 tion seem best calculated to promote repair in this class of wounds. 
 
 SUPERFICIAL WOUNDS FROM FOWLING-PIECE 
 
 A farm hand, charged with trespass, was brought to the county 
 jail sorely wounded. Two charges of bird-shot had caught him on 
 the fly and peppered his back, buttocks, and the posterior surfaces 
 of thigh and calves. Evading his pursuers, aided by the darkness, 
 he had reached his cabin exhausted and, without changing his bloody 
 clothes, lay thus unattended for two days, when he was discovered 
 and arrested. By this time infection had set in. His buttocks 
 and calves, particularly, where the shot were thickest, were 
 swollen and inflamed. Many of the shot had carried shreds of 
 clothing into the tissue: each was a focus of suppuration; none had 
 penetrated beyond the skin. The whole injured area was cleansed, 
 first with soap and w r ater, and then rubbed vigorously with peroxide 
 of hydrogen; the more superficial of the shot were picked out, and 
 finally the inflamed surfaces were smeared with Reclus' ointment and 
 covered with sheets of gauze held in place by adhesive strips. The 
 relief from pain was great. In three or four daily seances the shot 
 were all picked out and the inflammation practically gone. 
 
 WOUNDS FROM TOY PISTOLS AND BLANK CARTRIDGES 
 
 Two things are noteworthy in connection with these wounds: 
 first, the surprising power of penetration of cartridges supposed to 
 be harmless; and, second, the great danger of a tetanus infection. 
 The "wad" may be buried out of sight in the tissues, it may entirely 
 perforate the hand, or it may produce a superficial laceration. 
 As a rule, the hemorrhage is insignificant, which may in a measure 
 account for the development of infection, since bleeding is nature's 
 means of disinfection. 
 
 These wounds often present the appearance of punctured wounds, 
 which, more than others, are likely to furnish conditions favorable to 
 the growth of the tetanus bacillus. 
 
 It may be that the disposition of the wad is such that the wound is 
 in a manner stopped up, so that oxygen cannot reach the recesses 
 
PREVENTION OE TETANUS 21 5 
 
 where the bacillus finds its lodgment. It is true that tetanus de- 
 velops in only a small percentage of cases, but one can never foretell 
 positively what such a wound may do. 
 
 It is the duty of every doctor to warn his clientele of the danger of 
 these " Fourth of July' 'injuries. 
 
 Every case is to be treated as if lock-jaw is not merely a remote 
 possibility, but a probability. Free cleansing and douching w T ith 
 peroxide of hydrogen is indicated. 
 
 Luckett says (American Journal of Surgery, July, 1906): " These 
 wounds should be freely incised, particularly if not seen on the first 
 day of the injury, and thoroughly curetted with a small sharp spoon 
 until all the small pieces of wad, the unburned grains of powder, and 
 all the dirt have been removed. If the wad has entered a metacarpal 
 space a counter-incision must be made for through-and-through 
 drainage. Having cleaned the wound as thoroughly as can be done 
 mechanically, we now resort to chemicals and irrigate with some 
 mild antiseptic. After next drying the wound thoroughly, the entire 
 cavity should be sw r abbed out with one of the following, named in 
 order of choice: 
 
 "1. Pure carbolic acid followed by alcohol. 
 
 " 2. Tw r enty per cent, tincture of iodine (made by dissolving iodine 
 crystals, 20 parts, in ether and alcohol, each 50 parts). 
 
 "3. Plain tincture iodine. 
 
 "The wound should now be packed with moist iodoform gauze. 
 A wet dressing is then applied, to be changed daily. Permission 
 should be obtained for a prophylactic injection of antitetanic serum. 
 Ten c.c. are intra-muscularly injected in the buttocks or thigh, under 
 thorough antiseptic precautions." 
 
 Antitetanic powder may be applied to the wound, as advised by 
 Calmette. Experiments conducted by Joseph McFarland, of Phila- 
 delphia, corroborate Calmette's statements as to the prophylactic 
 value of this substance. By its use McFarland was able to protect 
 from infection animals which he had inoculated with the tetanus 
 bacillus. 
 
CHAPTER XIV 
 FRACTURES OF THE EXTREMITIES 
 
 Definitions. — A fracture is a solution of the continuity of bone 
 due to traumatism. 
 
 A simple fracture has a single line of solution and there is no 
 lesion of the soft parts. 
 
 A multiple fracture has more than one line of solution of con- 
 tinuity in the same bone or several bones. 
 
 A comminuted fracture has so many lines of solution running into 
 each other that the bone is in fragments or splinters. 
 
 A complete fracture involves the whole thickness of the bone. It 
 may be transverse, longitudinal, oblique, dentate or comminuted. 
 
 In an incomplete fracture, the line of solution does not involve the 
 whole thickness or extent of the bone. It may be a fissure, "a green 
 stick/' a depression or a separation of an apophysis. 
 
 A subcutaneous fracture has no communication with the surface. 
 
 An open or compound fracture has a communication with the sur- 
 face, has an accompanying solution of continuity of the skin and the 
 subjacent soft parts. 
 
 A spontaneous fracture is produced by an insignificant traumatism 
 and is usually pathological, due to disease of the bone. 
 
 An ununited fracture is one in which bony union has not occurred 
 at the usual time. 
 
 Gunshot fractures are those produced by projectiles (see Gunshot 
 Wounds). 
 
 Fractures of the extremities are emergencies, often of the first- 
 class; their reduction sometimes becomes equivalent to a major 
 operation. But it cannot be said that these cases are always treated 
 well. As Senn says, "Bad results following fractures have been the 
 tombstones that have marked the termination of an otherwise suc- 
 cessful professional career of many an ill-fated, unlucky, disappointed 
 practitioner." 
 
 2lC 
 
DIAGNOSIS OP FRACTURE 217 
 
 Malpractice suits more frequently follow this class of cases, per- 
 haps, than any other, which is an indication that somewhere there is 
 a fault. Doubtless it is the fear of a damage suit that often makes 
 a basis for it and in this way: The doctor, in order that he may have 
 testimony as to his skill, treats the case in the sterotyped, and 
 routine way; he gets a bad result. Had he used his better judg- 
 ment, given his common sense rein and risked the reproach of being 
 an innovator, the result would have been different. 
 
 Every case must be studied and treated on its own merits, with 
 due regard, of course, to certain general principles. To begin with, 
 the prognosis should always be guarded in some degree. As King 
 says (St. Paul Medical Journal, August, 1906): "Optimism as to 
 the final outcome on the part of the physician is a mistake. Take 
 the patient into your confidence, let him anticipate the certainty 
 of some permanent defect, so that in the end an imperfect result will 
 not reflect so much upon your skill and will tend to minimize mal- 
 practice suits. And how very rarely indeed can the result be per- 
 fect. With the very best treatment, there will nearly always re- 
 main as the best outcome some slight weakness, or limitation of 
 motion, or ache, or pain — at least a callus as a 'lasting memorial.' " 
 
 The diagnosis of these fractures is usually easy in the large sense, 
 as King says, but after all difficult as a whole, for no eye can see the 
 injury wrought to the softer tissues. In many cases the position 
 will indicate at once that there is a fracture, but one must endeavor 
 to learn much more — -the possible associated injuries to joints, 
 muscles, blood vessels, and nerves. To be able to do this necessitates 
 a fairly accurate knowledge of anatomy to begin with, aided by 
 systematic examinations, and on this foundation skill grows with 
 experience. 
 
 The diagnosis of fracture in the bones of the extremities is based 
 on several factors: (a) history of the case, (b) deformity, (c) abnormal 
 mobility, (d) pain and loss of function, (e) crepitus, (f) X-ray 
 examination. 
 
 (a) It is essential to know how the accident occurred. Frequently 
 in the absence of definite symptoms, the diagnosis must rest upon 
 the history. For example, in a case of a hip-joint injury in an elderly 
 person presenting loss of function and some pain but no other symp- 
 
FRACTURES OF THE EXTREMITIES 
 
 toms, a diagnosis of impacted fracture should be made if it is learned 
 the patient fell striking the hip. 
 
 (b) Deformity includes changes in the relations or dimensions of 
 the bones and the appearance of the limb. The two limbs must 
 always be compared. It must be determined that there has been 
 no previous injury to cause the deformity. When both ends of a 
 bone are accessible to touch, it may be readily measured and com- 
 pared with its opposite. In the case of the humerus, it is necessary 
 to measure from the acromion; in the case of the femur, from the 
 ilium. The position which the fragments assume may be due to the 
 direction of the force or the action of the muscles. 
 
 (c) Preternatural mobility implies movement in unnatural situa- 
 tions or in unnatural degree or direction. As one of the cardinal 
 signs of fracture, it has hitherto been assigned too much importance. 
 Its presence indicates fracture, but its absence indicates nothing. 
 We all know that in impacted fracture, there is no abnormal mobility. 
 In fractures of the bones of the tarsus and carpus, in epiphyseal 
 fracture, in any fracture where the fragments are small or deeply 
 placed, it may be impossible to discover movement without a manipu- 
 lation which may be distinctly injurious. In the case of fractures 
 near joints, it may be impossible to determine whether the move- 
 ment is in the joint or near it. 
 
 The fact is that in most cases where abnormal mobility is 
 present, the fracture may be readily diagnosed without reference 
 to this sign. 
 
 (d) Crepitus is the almost constant accompaniment of abnormal 
 mobility and is the grating produced by the friction of the two 
 fragments. It is pathognomonic, but must not be sought for too 
 vigorously. It is absent in impacted fracture, and to break up an 
 impacted fracture, testing for crepitus, may be a calamity. Crepitus 
 may sometimes be heard with the phonendoscope and not with the 
 ear. 
 
 (e) Pain and loss of function go together since the pain is usually 
 the cause of the loss of function. Both are present in nearly all 
 fractures, but often occur in as great degree with contusions. 
 
 The amount of pain varies with the location, but is nearly always 
 aggravated by movements or pressure. Taken in connection with 
 
DIAGNOSIS OF FRACTURES 219 
 
 the history of the case, it is a valuable diagnostic aid. The presence 
 of pain may call for anesthesia before the diagnosis can be completed. 
 
 Stimson has recently emphasized the significance of pain in the 
 diagnosis of fracture, and indicated the manner in which it may be 
 interpreted. Crepitus and abnormal mobility are, to his mind, of 
 less importance than pain as a diagnostic aid. 
 
 The search for pain in all doubtful cases should be systematic. 
 Begin first with local pressure over the suspected area with the tip 
 of the finger or with the rubber end of a lead-pencil. There are 
 definite lines of tenderness to be discovered in many of the fractures 
 about joints. For example; in Colles' fracture this line can be plainly 
 traced across the radius just above the wrist; in fracture of the ex- 
 ternal condyle of the humerus, along the external condylar ridge just 
 above the elbow; and in fracture of the surgical neck of the humerus 
 along the front or outer side of the bone. 
 
 Next test the character of pain elicited by cautious movement of 
 the limb. Increased muscular tension thus produced awakens in- 
 creased pain at the site of the fracture, and the patient may be able 
 to indicate the exact location of the lesion. The effort on the part 
 of the patient to produce certain movements is helpful. 
 
 Finally, indirect pressure may be employed: thus, in transverse 
 fracture of the tibia, pressure upward on the foot exaggerates the 
 pain markedly; and in the same manner, pressure upward at the 
 elbow, may assist in locating the fracture in the shaft of the humerus. 
 Stimson notes the important exception, that in the case of fracture 
 of the neck of the femur forcible pressure upward often fails to cause 
 pain. 
 
 In the case of fracture of one of the bones of the forearm or leg, 
 squeezing the two bones together will generally help the patient to 
 locate his trouble. 
 
 (f) The X-ray cannot be ordinarily available in general practice, 
 although of the greatest assistance in cases of doubt. Without its 
 use many fractures in the region of joints will be diagnosed as some- 
 thing else. Bloodgood particularly emphasizes its value (Pro- 
 gressive Medicine, Dec, 1906), believing that the doctor who neglects 
 the aid of the Rontgen picture, when he is able to obtain it, will 
 have much to regret. There is no danger that its employment 
 
220 FRACTURES OF THE EXTREMITIES 
 
 will blunt the diagnostic sense, unless, as is often done in hospitals, 
 it is used to the exclusion of other aids. The X-ray has at least 
 modified our notions as to what constitutes a perfect result in the 
 treatment of a fracture. Wherever the X-ray picture is used to 
 hack up a claim of malpractice by reason of inaccurate apposition 
 of fractured bone, we must insist that restoration of form and func- 
 tion constitutes a perfect result surgically, whatever discrepancies 
 the Rontgen picture may reveal. 
 
 The treatment implies a reposition and an immobilization that 
 the bones may unite in their normal relations. It has that ob- 
 jective, but has also another which is not necessarily a concomitant 
 of the first. The bones must unite without deformity but there 
 also must be restoration of the limb's functions. Union in good 
 position, then, is only one of the means to a larger end. It is better 
 to say that the treatment includes reduction, immobilization, and 
 mobilization. 
 
 In making reduction, violence must be avoided. Gentle but per- 
 sistent effort is always better than rude haste in overcoming the 
 resistance of muscles and ligaments, which is usually the chief 
 obstacle to reposition. The line of traction must be adapted to the 
 muscular action. Traction must usually be accompanied by counter- 
 traction and local manipulation of the broken ends. 
 
 In making traction it should be made directly, if possible, on the 
 bone involved, without the intervention of a joint. For example, in 
 reducing the humerus the traction should be applied above the elbow 
 joint. Often an anesthesia is necessary to relax the muscles, and if 
 anesthesia was necessary to complete the diagnosis, everything 
 should have been prepared previously for the treatment so that 
 only a single anesthesia is necessary for diagnosis, reduction, and 
 dressing. 
 
 In the cases of suspected fracture in the vicinity of a joint, it is 
 not always best to hurry the reduction; often it is better to wait a 
 day or so and try to reduce the swelling, for the swelling aggravates 
 the difficulties which are always great in the differential diagnosis 
 about the joint; and, if flexion is required, as in the case of 
 certain fractures above the elbow, the pressure may shut off the 
 circulation. 
 
TREATMENT OF FRACTURES 221 
 
 So far as the shaft of the long bones are concerned, however, the 
 formula should be immediate reduction and fixation. That the re- 
 duction has been complete is attested by the appearances of the 
 limb, by the absence of any irregularities to the touch, and by the 
 coincidence of its measurements with those of the sound limb. 
 These comparative measurements should be a matter of routine 
 practice. 
 
 Warbasse says (J. A. M. A., March 13, 1909), "the sooner a 
 fracture is reduced and held immovable, the less will be the swelling 
 and the more satisfactory the result. There is a prevalent notion 
 of waiting until the l traumatic reaction has subsided.' This ancient 
 phrase rolls off the tongue sonorously and sounds important, but 
 is to be reverently laid aside. Traumatic reaction is going on all 
 the time as long as the bones are out of place or so long as they are 
 movable. If we can effect immobilization soon enough, the swelling 
 will not come up." This is doubtless true in most cases, yet it is 
 to be remembered that in spite of reduction of the bones, lacerated 
 muscles and ruptured vessels may continue for some time, in some 
 cases, to pour their exudate into the tissues to augment the swelling. 
 This idea, however, pertains more to the mode of dressing and 
 does not refute the doctrine of immediate reduction. 
 
 Immobilization is a phase of treatment raising many questions 
 in dispute. In what manner shall it be applied and for how long? 
 Or, as Championniere insists, may it not in many cases be dispensed 
 with entirely? For he believes that absolute fixation of the frag- 
 ments is not the condition most favorable to the processes of repair. 
 A certain amount of movement is necessary to the vitality of the 
 bone, and therefore movements and massage represent the chief 
 elements of his treatment. That it is the best treatment for frac- 
 tures about joints no one will deny, even though unwilling to dis- 
 pense with fixation in other fractures of the long bones. 
 
 As to the manner in which fixation is to be attained, let it be said 
 briefly that the simplest effective dressing is the best. Its elabo- 
 rateness will depend upon the tendency for the displacement to re- 
 cur, and this tendency must be measured by the degree of obliquity 
 of the fracture and the action of the muscles. Sometimes the tend- 
 ency to recurrence is an indication of imperfect coaptation. In 
 
FRACTURES OF THE EXTREMITIES 
 
 one case, then, only a light retaining splint is necessary and in 
 another it must indeed be firm and strong. 
 
 At the present time there can be no question but that plaster of 
 Paris is the dressing of choice. At any rate, it will render the best 
 service to the general practitioner who must rely on his own re- 
 sources in fashioning splints. Ready-made splints are an abomina- 
 tion. There are other plastic materials that are often useful, and 
 in lieu of all these materials the splint may be cut into forms to 
 suit the case from boards, etc., and applied well padded. (See 
 page 48.) 
 
 Walsham formulates the principles which must regulate the use 
 of splints in any case. 
 
 1 . The splints must be well padded. 
 
 2. Pressure must not be made over the points of bones. 
 
 3. Strapping or bandages must not be put on too tightly. 
 
 4. Circular constriction of the limb must be avoided. 
 
 5. The splints, if possible, should reach beyond the joint above 
 
 and below the fracture. 
 
 6. The patient should be seen within twenty-four hours after 
 
 the splint is applied for the bandage may become too tight. 
 
 7. The splints should not be needlessly disturbed — that is to say, 
 
 if the patient is comfortable and the limb in good condition. 
 
 8. Spasm of the muscles is to be overcome by steady extension. 
 
 9. The part below the fracture should be bandaged, or at least 
 
 raised, to prevent swelling and edema. 
 
 The first immobilization will continue till there is no tendency to 
 spontaneous recurrence of the displacement, which will vary in 
 different cases. After this time a dressing must be used which is 
 easily changed, and daily massage must be instituted. Complete 
 and continuous fixation through a long period is distinctly bad 
 practice and most especially whenever a joint is involved. 
 
 Rossi has shown (Wiener Medical Presse, Jan., 1902) that the 
 amount of new cartilage formation is proportional to the amount of 
 movement permitted and is found in the greatest amount in fractures 
 treated by massage, and is explained by the greater formation of new 
 blood vessels and the consequent more active circulation and ab- 
 sorption of effusion. 
 
TREATMENT OF FRACTURES 223 
 
 You will ordinarily, therefore, proceed in something after this 
 manner: you will carry out a systematic inspection before handling 
 the part, you will observe any deviation of the hand or foot from the 
 normal axis of the member and compare the injured with the un- 
 injured side. In a large number of cases this inspection will be 
 sufficient to diagnose the case. 
 
 Measurements are of great value in many cases and must not be 
 overlooked as a diagnostic aid. In the absence of deformity or 
 shortening you may proceed next to palpate the affected region in 
 order to determine the degree of displacement and other char- 
 acters of the fracture. 
 
 Manipulation may occasionally be required to elicit crepitus and 
 preternatural mobility but certainly should not be considered a 
 routine procedure. In any event handle the injured limb gently, 
 never forgetting that the least haste or carelessness may greatly 
 aggravate the displacement and the traumatism to the soft tissues 
 or change a simple into a compound fracture, not to speak of in- 
 creased shock or suffering to the patient. 
 
 Finally, having determined as nearly as possible the conditions 
 present, you will assemble the dressings suitable to the case. Once 
 these are all prepared, administer the anesthetic. A full relaxa- 
 tion is essential for an easy reduction but as the anesthesia pro- 
 ceeds the injured limb must be watched by an assistant lest in the 
 stage of excitement the patient do himself an added hurt. The 
 anesthesia also favors a more detailed diagnosis and a better deter- 
 mination of the minutiae of treatment. In a few days the part should 
 be skiagraphed and if the position of the fragments is good, the limb 
 well immobilized you may consider that a good union is in sight. 
 
 Finally the question of operative treatment is to be considered. 
 Whatever advantage plating may possess it cannot be the method 
 of choice with the general practitioner. The open treatment, 
 therefore, will be reserved strictly for those cases in which either 
 reduction or fixation cannot be otherwise accomplished. 
 
 First aid to those disabled with fractured limbs is in civil practice 
 more frequently given by others than the doctor. It is desirable, 
 however, whenever possible, that he should direct the transporta- 
 tion and the preliminary treatment. 
 
FRACTURES OF THE EXTREMITIES 
 
 The utmost care must be practised in lifting and handling the 
 broken limb, lest the injuries be augmented and a simple fracture 
 converted into a compound. 
 
 It fracture is merely suspected, it must be assumed to be present. 
 The limb must never be lifted by the foot or hand but must be 
 lifted as a whole, resting upon the palms of the hand. Two at- 
 tendants are always better than one in handling a broken leg. If 
 the deformity is quite obvious even to the unpractised, an effort 
 should be made toward reduction before applying temporary splints, 
 this with a view to preventing further injury to the soft parts. 
 
 The limb is seized by an attendant at each end and gentle and 
 steady traction made in the direction of its axis. If this does not 
 succeed, the attendants must not persist in the effort. It must be 
 left for the surgeon. 
 
 If the fracture is compound, with severe hemorrhage, the clothing 
 must be removed. Otherwise this is not necessary. In removing 
 the trousers or a coat, for example, the sound limb is uncovered first 
 and then, very gently, the injured one. It is better to cut the cloth- 
 ing or rip along a seam. 
 
 A splint is next improvised from whatever may be first at hand, a 
 thin board, laths, an umbrella, or the branch of a tree. The splint 
 is padded, or the limb wrapped with whatever presents itself, 
 blanket or anything to prevent undue pressure, and then is fastenec 
 on the limb by a cord, or belt, or suspenders, etc., and finally the 
 injured leg is bound to the sound leg, the injured arm to the side of 
 the chest or carried in a sling. 
 
 The limb thus temporarily immobilized, the patient is ready to be 
 moved. 
 
 To lift the patient with the greatest safety in the case of a broken 
 for example, one attendant standing on the sound side, places 
 his arms under the body of the patient, who in the meantime locks 
 his arms about the attendant's neck. A second attendant, standing 
 on the same side, places one hand under the body, one under the 
 sound limb, while a third attendant, facing the others, supports 
 the broken limb. At his word of command, all lift. This careful- 
 ness must not be relaxed. 
 
 If a litter is available, or one can be improvised, it is placed parallel 
 
FRACTURES OF THE ARM 225 
 
 with the patient, its feet at his head, so that without any incon- 
 venience the patient may be laid upon it. 
 
 FRACTURES OF THE HUMERUS 
 
 Certain points of anatomy apply to nearly all fractures of the arm, 
 and are useful in diagnosis and reduction. Recall the relations of 
 the humeral head to the acromial and coracoid processes; the loca- 
 tion of the greater tuberosity, the internal and external condyles; 
 the attachments of several muscles, particularly the deltoid, biceps, 
 and triceps; the relations of the musculo-spiral nerve. Remember 
 that in the normal relations a line dropped from the tip of the 
 acromion to the external condyle will touch the greater tuberosity. 
 
 Nor must one forget the location of the great vessels on the inner 
 side of the arm, the proximity of the brachial plexus in the axillary 
 space and the intimate relations of the ulnar nerve to the internal 
 condyle. 
 
 All thSse matters must be present in the imagination as the in- 
 jured arm is inspected. 
 
 The musculo-spiral groove is a line of least resistance and deter- 
 mines many of the spiral fractures of the shaft. 
 
 The age of the patient is of great importance in determining the 
 nature of the fracture at the extremities. The difficulties of reduc- 
 tion and fixation determine largely by muscular action and accord- 
 ingly the musculature must be kept well in mind* 
 
 The symptoms, the deformities, the complications, the treatment 
 all vary, depending on the part of the humerus involved; there- 
 fore the shaft and the two extremities must be studied separately. 
 
 FRACTURE OF THE SHAFT OF THE HUMERUS 
 
 Direct or indirect violence, a fall on the elbow or wrist, a twist, or 
 muscular contraction may produce fracture of the humeral shaft 
 which for the present purpose is considered as extending from the 
 attachments of the deltoid to the upper level of the condyles (Fig. 
 
 139). 
 
 The line of fracture may be transverse, oblique, or spiral, de- 
 pending on the nature of the violence. Thus a blow will more likely 
 15 
 
226 FRACTURES OF THE EXTREMITIES 
 
 produce a transverse; a fall on the elbow, an oblique; a twist of the 
 arm, a spiral fracture of the shaft. 
 
 On inspection the broken arm is usually found to be considerably 
 
 Fig. 139. — Fracture of the shaft of the humerus. 
 
 swollen; the deformity marked, only when the patient lies down; 
 pain, preternatural mobility and crepitation are easily elicited. 
 There is usually shortening as compared with the sound side, meas- 
 
TREATMENT OE ERACTTJRES OE THE ARM 227 
 
 uring from the tip of the acromion to the external condyle and ; 
 normally, this line lies over the greater tuberosity (Fig. 140). 
 
 Fig. 140. — Testing the humerus for shortening. Measuring from the acromion to the 
 
 external condyle. 
 
 The treatment will depend on the degree of displacement. If 
 displacement is absent apply well-padded splints, one internal ex- 
 
228 
 
 FRACTURES OF THE EXTREMITIES 
 
 Fig. 141. 
 
 The patient is seated; bandage the injured member from the wrist to about 3 inches 
 above the elbow; protect the axilla with absorbent cotton; flex the forearm at a right angle 
 and maintain in that position in a sling. Pass a band under the axilla and fasten it to some- 
 thing (a hook in the wall), so that the shoulder is slightly lifted. That is the counter- 
 extension. 
 
 Another band crosses the forearm just below the bend of the elbow and to it is attached 
 a weight, say of 2 K. G., that is the extension. Give the apparatus a little time and it will 
 effect a reduction as the muscles tire. Employ this interval to prepare the fixation dressing. 
 
 Cut out sixteen strips of crinoline, each about 1 yard long, and wide enough to cover the 
 arm at its thickest part. Lay these strips one upon the other, and fasten them together; 
 and from the sheet thus formed, cut a deep scallop out of either end — at the lower end 45 to 
 SO cm. and at the upper end 15 to 20 cm. deep. Of the yokes thus formed, one will fit into 
 the axilla and the other into the bend of the elbow, while the intermediate portion forms an 
 internal splint for the arm. 
 
 Soak the cloth in liquid plaster and apply it in the manner indicated, molding it carefully 
 to the arm. The two upper bands overlap the shoulder and the two lower ones are wound 
 spirally around the arm to the wrist. In this way the shoulder and wrist are immobilized, 
 in the menatime the extension and counter-extension are not disturbed until the plaster split 
 Is fully hardened. The dressing may be further secured by a few turns about the chest. 
 
TREATMENT OF FRACTURES OF THE ARM 229 
 
 tending from the axilla to the bend of the flexed elbow the other ex- 
 ternal from the acromion, below the elbow. These splints are held 
 in place by adhesive strips and the whole firmly bandaged. 
 
 If, on the other hand, the displacement is conspicuous, it may be 
 difficult to reduce, difficult to hold. A number of procedures are 
 available; the patient may be anesthetized, the fracture reduced by 
 strong traction, the patient's shoulder then brought well over the 
 edge of the table, the extremity bandaged with glazed cotton and a 
 plaster roller applied, including the wrist and shoulder. The pa- 
 tient must stay in bed. Instead of the plaster roller, plaster splints 
 may be applied on the same principle as the wooden splints de- 
 scribed above. 
 
 Hennequin's dressing is strongly recommended by Lejars. Its 
 purpose is to reduce the fracture without anesthesia and to maintain 
 the reduction until an internal splint is applied (Fig. 141). 
 
 Union requires from six to eight weeks; failure to unite is usually 
 due to the interposition of the soft parts. The importance of the 
 musculo-spiral nerve in this connection must never be forgotten. 
 Paralysis of this nerve occurs in about 8 per cent, of such fractures; 
 it may be immediate or remote, depending on whether the nerve is 
 itself injured by the traumatism or whether it is caught in the scar 
 tissue. The recognition of this injury is imperative. Inclusion of 
 the soft parts which cannot be remedied calls for an open operation. 
 
 FRACTURE OF THE UPPER END OF THE HUMERUS 
 
 These injuries often offer the very greatest difficulties in diagnosis. 
 Such cases for the most part present themselves with swollen, painful, 
 and contused shoulders, perhaps deformed, and functionless. You 
 ask yourself: is it only a severely bruised joint; is it a dislocation or a 
 fracture of the surgical neck, or perhaps both; or is it an impacted 
 fracture of the anatomical neck; are the soft parts implicated? 
 
 Do .not waste time in vague palpations but proceed at once to a 
 systematic examination, under anesthesia, if necessary. Begin by 
 locating the apex of the acromion; if there is no depression beneath 
 it; if the thumb cannot be pushed into a concavity but comes in 
 contact as it should with the humeral head, you may conclude there 
 is no dislocation. With the thumb still in front, close the fingers on 
 
-3° 
 
 KK.UTURES OF THE EXTREMITIES 
 
 the posterior aspect of the head of the humerus, and with it thus held 
 firmly, attempt rotation of the arm. The humeral head rotates with 
 
 Fig. i p. — Examining the shoulder. Rotating head of humerus. 
 
 The head of the humerus is grasped between fingers and thumb of one hand; the other 
 moves the patient's forearm through an arc. 
 
 In the case of dislocation the rotation is produced with difficulty, if at all. 
 
 In case of fracture of the anatomical neck the joint is much thickened but there may 
 be slight rotation of the head. Fracture of the surgical neck: the arm is freely moved, 
 but the head does not rotate. 
 
 j 
 
TREATMENT OF FRACTURES OF THE ARM 
 
 231 
 
 difficulty in dislocation; it does not rotate at all if there is fracture, 
 and besides, there is crepitation (Figs. 142, 143). 
 
 A source of error: If the lower fragment overrides much, its rota- 
 tion might be felt and mistaken for the humeral head. Abduct the 
 arm; easily done in fracture, with increase of deformity and pain. 
 Pain is also produced by pressure upward at elbow and by local 
 pressure over the front and outer side of humerus. 
 
 Fig. I43«- -Examining the shoulder. Comparing the relations of the coracoid processes. 
 
 Examine the axillary space and all the other aspects of the 
 shoulder, comparing the two sides; and compare the other landmarks 
 of the arm. Do not begin any treatment until the diagnosis is assured. 
 How unfortunate it is to attempt reduction of a supposed dislocation 
 by the ordinary method when it is complicated by fracture; or to 
 treat as a contusion, a fracture with displacement! 
 
 To consider briefly the more common findings of such exami- 
 nations: 
 
232 
 
 FRACTURES OF THE EXTREMITIES 
 
 i. Fracture of the surgical neck without overriding (Fig. 144) needs 
 only the simplest treatment: Brace the arm on the inside with a 
 " V " shaped axillary pad, and with the forearm flexed at a right angle; 
 support the. whole extremity in a sling of the Mayor type. Addi- 
 tional protection may be afforded by a shoulder cap (Fig. 145). 
 Begin massage early. 
 
 ft 
 
 Fig. 144. — Fracture of 
 surgical neck of humerus. 
 (Moullin.) 
 
 Fig. 145. — Fracture of surgical neck. Axillary 
 pad; shoulder cap; forearm supported in sling. 
 (Scudder.) 
 
 2. Oblique Fracture of the Surgical Neck with Much Overriding. — 
 These are difficult to reduce; difficult to maintain; likely to be mis- 
 taken for dislocation (Fig. 146). 
 
 Reduction. — In making traction, draw downward and outward at 
 first and then in the axis of the limb. Do not stop until the arm is 
 the correct length by measurement; until the subcoracoid projection 
 has disappeared; until the acromion, greater tuberosity and the ex- 
 ternal condyle are in the same straight line. Extension must be 
 
TREATMENT OF FRACTURES OF THE ARM 
 
 233 
 
 maintained while the dressing is applied or the displacement will 
 certainly recur. 
 
 The arm must be fixed in abduction and with the elbow slightly 
 forward; only in this position will the lower fragment coapt with 
 the upper which, of course, the fixation apparatus will not affect. 
 Either the patient must be put to bed and extension with weight and 
 pulley applied or else the rather complicated splints of the type used 
 
 Fig. 146. — Fracture of surgical neck with overriding. 
 
 by Heitz-Boyer or Dupuy must be employed to maintain these 
 positions. In either case the fixation must not be prolonged, and 
 massage and passive movement begun early. If the circumstances 
 permit, the open operation gives by far the most satisfactory result. 
 
 FRACTURE OF THE SURGICAL NECK WITH DISLOCATION 
 
 This is a very serious injury; difficult of diagnosis; of bad prog- 
 nosis. Carrying out the systematic examination described, you find 
 the head displaced, but the arm is not fixed in abduction as in the 
 

 FRACTURES OF THE EXTREMITIES 
 
 ordinary dislocation; it drops to the side. Again, the head does 
 not rotate with the arm; there may be crepitation; from these and 
 other confirmatory points the diagnosis is made. 
 
 Reduction.— Anesthesia is necessary. Make a slow, gentle, but 
 
 Fig. 147. — Fracture with dislocation before reduction 
 
 persistent traction on the arm; this combined with manipulation of 
 the head of the humerus in the axillary space may succeed in re- 
 storing the head to the glenoid fossa, for more than likely the 
 head is still attached to the shaft by periosteum and muscular 
 fibers. As the assistant makes the traction apply your thumbs to the 
 
fc 
 
 TREATMENT OF FRACTURES OF THE ARM 
 
 235 
 
 ead in axilla and, with the fingers braced by the shoulder, try to 
 brce the head into place (Figs. 147, 148). 
 Once the dislocated head is reduced, reduce and treat the fracture 
 
 Fig. 148. — Same fracture of surgical neck with dislocation after reduction. 
 
 by the ordinary means. Massage must be begun especially early. 
 If these efforts fail, choice lies between operation and expectant 
 treatment. 
 
FRACTURES OF THE EXTREMITIES 
 
 The expectant treatment may give a surprisingly good result 
 in case the dislocated part includes only the head. With early 
 massage and passive motion a new joint is created, the upper end of 
 the shaft adapting itself to the glenoid cavity. 
 
 In case the dislocated fragment includes the surgical neck a 
 persistently stiff shoulder may be expected and not only that but a 
 large callus may seriously interfere with the brachial plexus, or even 
 the axillary vessels. 
 
 Royster, of Raleigh, N. C. (Journal A. M. A., Aug. 10, 1907), re- 
 views his own experience and the literature dealing with this condi- 
 tion, and concludes very logically that operative treatment in the 
 great majority of cases is alone effective. 
 
 The preferable incision begins at the acromion process, extends 
 vertically downward as far as necessary, and aims to reach the bone 
 by passing between the pectoralis major and the deltoid. The head, 
 thus exposed, is to be reduced by manipulation, although oc- 
 casionally a special hook or bone forceps may be necessary. Wiring 
 will seldom be required except in the cases operated late. The dress- 
 ing should be applied so as to maintain the arm in abduction. 
 Royster believes in immediate operation, regarding such cases as 
 emergencies, as much so as strangulated hernia or appendicitis. 
 "Even in cases of doubt, it is preferable to expose the parts to view 
 rather than to wait in the hope that nature and time will clear it up." 
 Our own experiences seem amply to confirm this view. 
 
 FRACTURE OF THE ANATOMICAL NECK 
 
 This fracture nearly always results from falls upon the point of 
 the shoulder and in consequence is impacted. A fall upon the elbow 
 may produce an impacted fracture of the upper end of the surgical 
 neck but only the X-ray could make the distinction. Great 
 swelling and ecchymosis are prominent characters and loss of func- 
 tion is complete. Palpation and manipulation reveal nothing but 
 the degree of pain. 
 
 The X-ray picture usually shows the head turned either forward 
 or backward and an irregular dentated line of fracture. The treat- 
 ment from the first is massage and passive motion. 
 
 
TREATMENT OF FRACTURES OF THE ARM 237 
 
 The massage of the first two days should be chiefly friction; later 
 kneading will hasten the absorption of the exudates. The passive 
 motion consists of gentle flexion and extension and the treatment 
 must not be such as to aggravate the pain. The daily treatment is 
 followed by fixation in a sling. 
 
 After a couple of weeks the treatment may be carried on more 
 vigorously and as soon as the patient can move the joint actively he 
 must be directed to keep at it many times each day. The first 
 movement to return is the antero-posterior; a little later, rotation; 
 and last of all abduction. Often times in these cases, in spite of sys- 
 tematic treatment the motion is imperfect and the tenderness per- 
 sistent, especially over the acromion, the coracoid, and deltoid 
 tubercle. 
 
 Fracture of the greater tuberosity may occur as the result of either 
 direct or indirect violence, such as fall upon the hand with arm 
 extended. The displacement of the tuberosity may be upward, out- 
 ward, and backward. Early disability and swelling are prominent 
 symptoms; crepitus may be absent. Pain is produced by local 
 pressure. Taylor, of New T York, asserts (Annals of Surgery, Jan., 
 1908) that in uncomplicated cases with moderate displacement 
 recovery may be practically perfect without the use of splints, 
 massage, or special movements, but on the whole the best result will 
 be obtained by immobilization or abduction to a right angle with 
 external rotation. 
 
 FRACTURE OF THE UPPER END OF THE HUMERUS IN CHILDREN 
 
 , With respect to diagnosis and treatment, fractures of the upper 
 
 1 end of the humerus in children present some special features. 
 
 Practically speaking, there are but two types of injury; fracture of the 
 
 . surgical neck and separation of the epiphysis. The head and 
 
 I anatomical neck are immune by reason of their spongy character. 
 If the surgical neck is fractured without displacement of the 
 fragments or with impaction, the pain, loss of function and de- 
 formity are moderate. Usually there is considerable swelling. The 
 i treatment is simple; fixation in a sling for a week and thereafter 
 1 frequent and gentle passive motion without massage and the func- 
 tions of the joint are rapidly restored. 
 
27,8 FRACTURES OF THE EXTREMITIES 
 
 , 
 
 If on the other hand there is much displacement, the deformity is 
 quite constant, the joint is thickened in front and externally and the 
 end of the lower fragment bulges the subcoracoid area. This might 
 be taken for the head of the humerus, but on palpation the head is 
 found to be in the glenoid cavity. The shortening of the shaft of the 
 humerus and the abnormal direction of its axis point to the nature of 
 the injury. 
 
 These same signs and symptoms characterize separation of the 
 epiphysis but this lesion is much the more serious for improper 
 treatment may result in checking linear growth. 
 
 The treatment is the same for the two conditions. Reductio 
 requires a general anesthesia and a definite maneuver. 
 
 Make strong traction on the abducted arm, dircting the assistant 
 to press outward with his thumbs against the broken ends which form 
 with each other an angle pointing toward the coracoid. If the arm is 
 now brought to the side the deformity recurs; on that account there- 
 fore the arm is to be fixed in abduction. This may be accomplished 
 by plaster splints; still better by a plaster dressing including th< 
 thorax. A part of this dressing is applied previous to the anesthesia 
 and reduction. 
 
 The patient is seated and a plaster jacket applied, including the 
 shoulder but not the arm. 
 
 The patient is then anesthetized and the fracture reduced. 
 
 The arm is held in abduction and in a forward position, the 
 forearm flexed to a right angle and semiprone. A plaster roller is 
 now applied, including the shoulder, the arm and forearm. By this 
 means you fix the scapula and relax the abductor group of muscle: 
 which act upon the upper fragment; in this manner the normal axi: 
 of the humerus is maintained. 
 
 After two weeks remove the plaster and for the next two weeks 
 carry the arm in a sling, and function is soon restored. 
 
 FRACTURES OF THE LOWER END OF THE HUMERUS 
 
 Injuries about the elbow are always to be regarded seriously. 
 They occur much more frequently in children and are usually due 
 to falls upon the flexed elbow. Scudder insists that even in the 
 apparently trivial cases the examination should be made under 
 
TREATMENT OF FRACTURES OF THE ARM 
 
 239 
 
 Fig. 149. — Examining the elbow; locating the three cardinal points — the internal condyle, 
 the tip of the olecranon and the external condyle. 
 
 When the elbow is flexed at a right angle the three points stand for the corners of an 
 equilateral triangle; when the elbow is extended the three points are in a straight line. The 
 head of the radius is easily felt on the normal joint one-half to three-quarters of an inch 
 below the external condyle. Gently rotating the forearm helps to locate the capitellum. 
 
 The gutter behind the external condyle is broad and shallow; on the ulnar side deeper, 
 containing the ulnar nerve. 
 
240 FRACTURES OF THE EXTREMITIES 
 
 anesthesia, for only by that means, as a rule, can the injury be 
 exactly diagnosed. 
 
 The diagnosis itself is chiefly a matter of applied anatomy. The 
 landmarks and the normal relations must be clearly in mind. Ob- 
 serve on the sound side the relations of the internal and external 
 condyles, the olecranon, the head of the radius. It is uncertain at 
 first whether it is a contusion, or dislocation, or fracture. Even 
 when sure that the case is a fracture, yet it is to be determined whether 
 it is supracondylar, or condylar, or some combination of the two. 
 
 Scudder formulates a routine mode of procedure in making the 
 diagnosis. 
 
 Observe the character of the swelling — whether general or 
 localized. 
 
 Observe the carrying angle. 
 
 Palpate the external and internal condyles. 
 
 Palpate the olecranon process and head of the ulna. 
 
 Rotate the head of the radius. 
 
 Note the relation of the three bony points in extension and flex- 
 ion (Fig. 149). 
 
 Fig. 150. — Supra-condylar fracture of humerus. Note obliquity. (Moullin.) 
 
 Determine the possible movements of the elbow-joint. Make 
 measurements. Make pressure with the point of the finger to locate 
 a painful line which marks the fracture. If the X-ray ^is used it 
 should show both the lateral and antero-posterior view. 
 
 Certain forms of injury are found most frequently: (1) Supra- 
 condylar fracture, (2) fracture of one of the condyles, (3) multiple 
 fracture involving the joint. 
 
TREATMENT OF FRACTURES OF THE ARM 
 
 241 
 
 Fig. 151. — Extension fracture; slight backward 
 displacement of elbow. 
 
 (1) Supra-condylar Fracture. — This type occurs more frequently 
 
 in children. The joint is not usually involved, the plane of fracture 
 
 extending commonly from 
 above downward #nd for- 
 ward. The displacement of 
 the upper fragment, there- 
 fore, is downward and for- 
 ward, and if union takes 
 place in this position the 
 flexion of the elbow is much 
 abbreviated (Fig. 150). 
 
 This is the so-called " ex- 
 tension" fracture (Fig. 151); 
 whereas in the " flexion" 
 
 fracture the lower fragment is displaced upward and forward (Fig. 
 
 152). It must be definitely determined which form exists. 
 The extension fracture, by the 
 
 far the more frequent, simulates 
 
 backward dislocation but you 
 
 find the condyles, the olecranon 
 
 and the head of the radius in 
 
 their normal relations to each 
 
 other. The condyles may be 
 
 moved independently of the 
 
 shaft and measuring from the 
 
 acromion to ext. condyle you 
 
 will probably find some short- 
 ening and also the normal axis 
 
 is disturbed. 
 
 Compared with the other joint 
 
 there is no change in width which 
 
 excludes intercondylar forms. 
 Along with the ordinary signs 
 
 of fracture the sharp end of the f ig . 
 
 Upper fragment may be felt in placement of elbow. ("Flexion fracture.") 
 
 the flexure of the elbow. 
 
 Imperfect reduction of these fractures leads to some loss of move- 
 16 
 
 3. 152. — Supra-condylar fracture: forward dis- 
 

 FRACTURES OF THE EXTREMITIES 
 
 men! and awkward deformity; and in many instances to nerve 
 complications, the result of a large callus. A "wristdrop" for ex- 
 ample may gradually develop in such a case the result of inter- 
 ference with the musculo-spiral. 
 
 Still more important, if the fracture follows the epiphyseal line 
 the child's arm never attains its normal growth. How greatly 
 necessary then that we recognize not only the type of fracture 
 
 Fig. 153. — Epiphyseal fracture of 
 humerus; backward displacement of 
 elbow. 
 
 Fig. 154. — Fracture and complete dis- 
 location of the epiphysis, lower end of 
 humerus. 
 
 but the variations as well and that we know how to proceed so as 
 to restore form and function to the near-normal. And this is by no 
 means always easy even when the X-ray has exposed the details 
 of the bone disturbance (Figs. 153, 154). 
 
 Three displacements are to be overcome: (a) An antero-posterior 
 which uncorrected leads to interference with flexion and extension; 
 (b) lateral, affecting the carrying angle; and (c) rotation, affecting 
 the supinator function. 
 
 Ordinarily you will proceed in this manner: direct the assistant 
 to make strong traction on the extended forearm, gradually chang- 
 ing the extension to acute flexion and while he does this, you will 
 
TREATMENT OF FRACTURES OF THE ELBOW 
 
 243 
 
 make counter- traction on the humerus grasping it above the line 
 of fracture so as to pull on the shaft and at the same time push against 
 the olecranon with the thumbs . Grinding and tearing, the lower 
 fragment is felt to move forward. Traction and counter-traction 
 must be maintained on the flexed elbow while by manipulation the 
 lateral displacement and rotation are overcome (Fig. 155). Fixa- 
 
 Fig. 155. — Supra-condyloid fracture of the humerus. Method of reduction before ap- 
 plying retentive splint. Counter-traction on upper arm. Traction on condyles of hu- 
 merus with right hand; backward pressure with thumb of left hand. Also illustrative of 
 method of beginning acute flexion. (Scudder.) 
 
 tion in forced flexion may be secured by encircling bands of ad- 
 hesive or still better, we think, by a posterior plaster splint made as 
 follows: 
 
 Twelve to sixteen pieces of crinoline long enough to reach from the 
 deltoid insertion to near the wrist, and wide enough to cover the 
 arm, are quilted together and two oblique notches cut corresponding 
 to the bend of the elbow. This piece of padding is now impreg- 
 nated with liquid plaster and applied to the back of the arm and fore- 
 arm, and well molded (Fig. 156). The two notches permit a ready 
 adjustment at the bend of the elbow. The support of the arm is not 
 
-44 
 
 Ik \CTURES OF THE EXTREMITIES 
 
 relaxed until the plaster has hardened. The gutter thus formed may 
 strengthened by a loosely applied roller which passes from the 
 wrist across to the arm near the axilla, 
 around it and back to the wrist again, 
 and so on. The arm is thus fixed in acute 
 flexion (Fig. 157). Immediate reduction, 
 immediate fixation in forced flexion is the 
 correct formula therefore for this type of 
 injury. But the. case may be seen late and 
 the swelling be of such degree that flexion 
 is out of the question because of interfer- 
 ence with the brachial vessels, something 
 which must be watched whatever the form 
 of treatment. 
 
 PlO. 156. — Fracture of the 
 elbow in the child: pattern for 
 plaster splint. Notched so that 
 when the elbow is flexed splint 
 may be easily molded. 
 
 Fig. 157. — Fracture of elbow in the child: plaster 
 splint molded to the flexed elbow. 
 
 A boy of twelve years was brought in from the country with an 
 injury received the day before by being thrown from a horse. A 
 diagnosis of fracture about the elbow had been made, and with it 
 
TREATMENT OF FRACTURES OF THE ELBOW 245 
 
 the effort to fix the arm in forced flexion. The whole member was 
 greatly swollen, edematous about the elbow with blebs in process of 
 formation. The X-ray confirmed the diagnosis, showing epiphyseal 
 separation with fracture and separation of the internal condyle. 
 The dressing was removed, the arm fixed in extension; daily light 
 massage was instituted to remove the tumefaction, and after 
 four days an effort was made to reduce the fragments and put the 
 arm in forced flexion; but this only resulted in complete obliteration 
 of the radial pulse. The arm was left in semiflexion and pronation, 
 and very light massage was again instituted for a few days; gradually 
 the swelling subsided, and after the end of a week more another 
 effort was made to reduce under general anesthesia, with better 
 results. After a week of fixation in the corrected position the mas- 
 sage was begun again and continued for some weeks. Eventually 
 the restoration of function was almost complete. 
 
 Massage in the case of these elbow injuries in children is likely to 
 do more harm than good and should have for its only object the ab- 
 sorption of the exudates. Too freely used, it overstimulates the 
 new bone formation and produces excessive callus which in this case 
 we wish particularly to avoid lest the olecranon and coronoid fossae 
 be obliterated. Nor need we concern ourselves too much with 
 passive motion. If the joint surfaces are free we may expect the 
 child gradually and unconsciously to increase the amplitude of the 
 movements and in one to five months a practical restoration of 
 function is the rule. Finally there is to be mentioned the occasional 
 case which comes in two or three weeks after the accident with the 
 fragments unreduced and at this time irreducible. Such cases are 
 by no means hopeless for the bone may be exposed, the periosteum 
 turned back, the fragments pried apart, the callus chipped away and 
 the raw bone surfaces adapted; the limb fixed in flexion and there- 
 after treated as a primary fracture. 
 
 FRACTURE OF THE EXTERNAL CONDYLE 
 
 This accident is not infrequent in children, due to fall upon the 
 outstretched hand the force being transmitted through the radius 
 to the condyle. In the adult a direct force is required. 
 
 The diagnosis is easy before much swelling occurs; after that it 
 

 FRACTURES OF THE EXTREMITIES 
 
 can be made with certainty only by the X-ray. The ecchymosis, 
 the pain on pressure, the limited flexion, and painful supination, 
 point to the nature of the injury. 
 
 The fragment may be displaced upward or downward and may 
 be rotated as well. (Fig. 158.) 
 
 Fig. 158. — Fracture of the external 
 condyle in the child. 
 
 Fig. 159. — Fracture of internal 
 condyle. (Moullin.) 
 
 Reduction, sometimes difficult, is accomplished by manipula- 
 tion and the arm is to be put in plaster in either extension or flexion 
 depending upon which holds the fragment in place. The dressing 
 should be removed about the end of the second week and the child 
 encouraged to use his arm. In one or two months the junction will 
 be nearly restored. Massage as mentioned before is not desirable 
 in fractures about the elbow. 
 
 FRACTURE OF THE INTERNAL CONDYLE 
 
 This fracture is not nearly so frequent in children as the supra- 
 form or even fracture of the external condyle because the 
 
TREATMENT OP FRACTURES OF THE ELBOW 
 
 247 
 
 I force of a fall on the hand is much more likely to be transmitted 
 through the radius which abuts on the external condyle (Fig. 159). 
 
 In the adult, however, the internal condylar fracture is the 
 more frequent and is due to direct violence. 
 
 It derives its importance from the loss of joint function, the 
 muscular disability, or the nerve complications which may ensue. 
 
 Fig. 160. — Fracture of the internal condyle with backward dislocation of elbow. 
 
 The movements of the olecranon process are likely to be impaired, 
 the ulnar nerve likely to be compressed by the callus; the flexor group 
 of muscles attached thereto impaired by the shift in their point of 
 attachment. 
 
248 
 
 FRACTURES OF THE EXTREMITIES 
 
 The symptoms and signs of fracture of the external condyle 
 apply with equal force here. Practically the same mechanical 
 principles operate to produce displacement, rotation and tilting of 
 the fragments. 
 
 The diagnosis is to be made from these symptoms and signs, 
 coupled with the physical examination. 
 
 It may be readily mistaken for a backward dislocation, for if the 
 head of the radius is out of place the fragment may move backward 
 
 carrying the ulna with it. In the 
 case of children there may be actual 
 dislocation along with the fracture 
 (Fig. 160). 
 
 The X-ray will confirm these find- 
 ings. The treatment, if no displace- 
 ment exists, is simple; firm bandag- 
 ing and the forearm fixed at a right 
 angle in a sling. 
 
 If the displacement is marked the 
 position of fixation will be that 
 which best maintains the reduction. 
 Usually this will be flexion since 
 thereby the attached muscles are 
 relaxed. 
 
 After a few days gentle passive 
 motion should be practised as the 
 best means of molding the forming 
 callus and keeping the fossae clear. In the course of a few months 
 the joints functions will be normal. If the fracture is complicated 
 by dislocation, this may be easily reduced by traction in extension 
 and subsequently fixing the elbow in forced flexion. 
 
 If flexion is much limited it is certain that the fragment is locked 
 in the joint and an open operation should be practised without delay. 
 (3) The intercondylar and multiple fractures involving the joint, 
 as they do, require a very guarded prognosis (Fig. 161). By referring 
 to the landmarks, the displacements are to be figured out and the 
 fragments are to be manipulated until all the movements of the 
 joint are restored. 
 
 Fig. 161. — Intercondylar fracture 
 of humerus. (Moullin.) 
 
I TREATMENT OF FRACTURES OF THE ELBOW 249 
 
 The forearm is then to be acutely flexed and fixed either by the 
 adhesive strips or plaster splints as before described. If the dis- 
 placements cannot be held by this means the fracture must be 
 treated by extension for a few days and then put up in acute flexion. 
 Massage and passive motion must be very early begun in these cases 
 and persisted in for a long time. 
 
 FRACTURE OF THE OLECRANON 
 
 Following fractures of the lower end of the humerus, fractures of 
 the olecranon should be next considered for the same anatomical 
 features are to be recalled in diagnosis. The diagnosis of this 
 fracture has no particular feature but is to be made by inspection, 
 palpation of the landmarks mentioned and by manipulation. 
 This break is usually due to direct violence, sometimes to muscular 
 action. The amount of separation of the fragments depends upon 
 the amount of the tear in the fibrous attachments of the triceps, and 
 is, of course, most marked in flexion, and is increased by swelling of 
 the joint. A complete fracture opens into the joint. 
 
 As to the treatment it is obvious that no one method is equally 
 applicable to all cases. There can be no doubt that the method of 
 choice, where it is possible, is suturing. 
 
 If this is not advisable, or not permitted, the next best procedure 
 is the treatment by massage begun immediately — and this whether 
 there is much or little separation. No immobilization, only massage. 
 
 If asepsis can be assured or if the fracture is compound, suture is 
 indicated. The operation is not difficult. The bone is exposed by a 
 transverse incision, Qr if there is a wound it may be enlarged. Cleanse 
 the wound of all exudates and trim away the ragged tissues; next 
 expose the fracture, separate the fragments and expose and cleanse 
 the joint. 
 
 There are several methods of suture. If the fracture is transverse, 
 the periosteum on each side is laid back and two holes drilled in each 
 fragment for the passage of two silver wires. When a wire is passed 
 its ends are twisted and the coaptation perfected. The drill holes 
 should not involve the cartilage. The wires are cut short and ham- 
 mered down smooth, and the periosteum and fibrous sheath sutured, 
 and the skin wound repaired without drainage. The arm is im- 
 
2 5° 
 
 FRACTURES OF THE EXTREMITIES 
 
 mobilized in flexion for eight or ten days and then massage is begun. 
 The main object of which is to prevent permanent contraction of 
 the triceps. By this means the fragments are kept as nearly as 
 possible in contact but even in the most favorable cases the union is 
 merely fibrous. 
 
 If the fragments are split, they may be each perforated from 
 without inward and a suture passed and tied on the outer side. By 
 
 Fig. 162. — Suture of the olecranon. The suture in the form of a transverse loop 
 perforates the lower and two upper fragments. (Schwartz.) 
 
 this means the fragments are all drawn into coaptation. If the 
 upper fragment is small the upper transverse perforation may involve 
 only the tendon. 
 
 A carpenter fell from his ladder, striking the point of his elbow 
 upon the sharp edge of a timber. The joint was laid wide open, the 
 olecranon broken across transversely and split as well. At the 
 Deaconess Hospital the joint was cleansed thoroughly with normal 
 salt solution, the mangled tissue trimmed away. The fragments 
 were exposed by free use of the rugine. Two transverse holes were 
 drilled, the upper one including both fragments (Fig. 162). Chromi- 
 
FRACTURE OF THE OLECRANON 
 
 251 
 
 cized catgut was used to draw the fragments together. The single 
 suture was quite sufficient to secure coaptation. A small drainage- 
 tube was left in the joint cavity. The periosteum was repaired 
 (Fig. 163), and the soft parts closed with additional drainage. 
 After the third day, the tube in the joint cavity was removed 
 permanently. There was a little suppuration in the soft parts and 
 
 Fig. 163. — Suture of the olecranon. Repairing the periosteum by a continuous 
 catgut suture. (Schwartz.) 
 
 the superficial drainage was retained for a week. At the end of ten 
 days the soft parts being healed, the position of the elbow was 
 changed from extension to flexion and daily passive motion and mas- 
 sage was begun. The result was perfect use of the joint. 
 
 J. B. Murphy has devised and recommends a method of subcu- 
 taneous suture (Jour. Am. Med. Assn., Jan. 27, 1906). Begin by 
 making a small incision over the external border of the olecranon 
 
252 FRACTURES OF EHE EXTREMITIES 
 
 below the line of fracture. Through this small opening (1% inches) 
 drill the olecranon transversely, and over the point of emergence of 
 the drill on the inner border of the olecranon incise the skin again. 
 An aluminum-bronze wire is passed through the drill-hole from 
 without inward and the inner end is pushed up under the skin along 
 the internal border of the olecranon to the level of the apex of the 
 bone. At this level another incision is made, the end of the wire 
 recovered and pushed through the tendon of the triceps from within 
 outward. A fourth small incision is made over the end of the wire to 
 the outside, and the end of the wire again directed under the skin to 
 the starting point and there tied tightly, in that manner approxi- 
 mating the fragments. Close the skin wounds. 
 
 FRACTURE OF THE HEAD OF THE RADIUS 
 
 Another fracture not infrequent should be considered in con- 
 nection with injuries about the elbow and that is fracture of the head 
 of the radius. It is the result of direct violence,, or indirectly by falls 
 upon the hand. The fracture is usually vertical, much or little of 
 the articular surface being broken off. It derives its importance from 
 the fact that it may interfere with all the functions of the elbow-joint 
 — flexion, extension; rotation, supination. The diagnosis will 
 usually require the X-ray; nevertheless the absence of change in 
 the landmarks along with swelling and tenderness and especially the 
 pain on supination and pronation should point to the character of the 
 break. Sometimes crepitation may be felt by pressing the thumb 
 over the radio-ulnar joint while rotating the forearm. 
 
 The treatment required will most frequently be excision of the 
 fragment followed by two weeks' fixation in semipronation, and after 
 this passive motion. The results are good. 
 
 The neck of the radius may be broken in much the same manner. 
 The lower fragment is drawn upward by the biceps. Flexion of the 
 forearm combined with traction and manipulation will effect a 
 reduction and the forearm which is flexed for two weeks in flexion 
 and semisupination. The point is to keep the biceps from acting 
 on the lower fragment (Fig. 164). 
 
 
FRACTURES OF THE SHAFT OF ULNA AND RADIUS 
 
 253 
 
 FRACTURES OF THE FOREARM 
 
 Fractures of the shaft of the ulna and radius are of the greatest 
 importance because of the possible evil consequences, immediate 
 or remote. The chances of gangrene, of deformity, of anchylosis 
 or paralysis are never slight. This prospect of a crippled or useless 
 
 Fig. 164. — Fracture through neck of radius. Head displaced, requiring excision. 
 
 arm or hand must put us on our guard. There are several anatomical 
 points to be kept in mind as regulating both the diagnosis and treat- 
 ment. The relative position of the two bones in the stages of rota- 
 tion; the attachments of the biceps, the supinator, and the pronators 
 and their pull upon the fragments; the interosseous membrane; the 
 variations in relative size and strength of the two bones at different 
 levels; these are all factors to be taken into account in the study of 
 

 FRACTURES OF THE EXTREMITIES 
 
 the mechanism of these fractures. They are produced by direct or 
 indirect violence; in the latter case, most frequently by falls upon 
 the hands, but it is to be noted that such accidents are more likely to 
 produce, b the adult, a Colles's fracture; in the child, a supracon- 
 dylar fracture of the humerus. The middle third of these bones is 
 most likely to suffer, the radius breaking at a higher level than the 
 
 ulna. The radius loses strength up- 
 ward; the ulna, downward (Figs. 165, 
 166). 
 
 Deformity and displacement may 
 exist in any degree. Thus one bone 
 may be broken completely, a green-stick 
 fracture occur in the other. There may 
 be only a slight angulation, or some 
 lateral displacement or extreme overrid- 
 ing. Naturally, fracture of both bones 
 presents the worst prognosis. The dis- 
 placements of the radius are always the 
 more difficult to manage because of the 
 tendency of the two fragments to rotate 
 in different directions. 
 
 Thus the upper fragment is rotated 
 outward by the biceps; and the lower, 
 inward by the pull of the two pronators. 
 The diagnosis is not difficult. The patient presents himself sup- 
 porting the injured arm which tends to turn inward below, and out- 
 ward above. Pain, deformity, mobility and perhaps crepitation are 
 present. Lateral pressure wherever applied excites pain at the site 
 of fracture. Comparative measurements in the case only one bone is 
 fractured will show but little shortening; or, if there is much shorten- 
 ing it is certain the other bone is dislocated at the elbow. For ex- , 
 ample, isolated fracture of the ulna with overriding is accompanied 
 by forward dislocation of the head of the radius. 
 
 Treatment. — Whether one shaft is broken or both, the principles 
 of treatment are the same. Principally, it is obliteration of the 
 interosseous space which must be guarded against, lest pronation 
 and supination be lost. The contrary rotation of the two fragments 
 
 Fig. 165- — Fracture of both bones 
 of forearm due to crushing injury; 
 in this case the fracture of the radius 
 is at the lower level. 
 
TREATMENT OF FRACTURES OF THE FOREARM 
 
 2 55 
 
 of the radius determines the position in which the forearm must be 
 fixed. 
 
 Complete supination fulfills these two main indications; it separates 
 the shafts most widely; it permits the lower fragment of the radius 
 
 Fig. i 66. — Fracture of the shaft of ulna with separation of the epiphysis; fracture 
 of the shaft of the radius, too high for a Colles' fracture. 
 
 to fall in line with the upper which is fixed by the pull of the biceps. 
 Reduction presents no special difficulties, theoretically, but a perfect 
 coaptation is seldom secured. Nevertheless an excellent functional 
 result is the rule. Under anesthesia, with the forearm supinated and 
 flexed, strong traction and counter-traction aided by manipulation 
 

 FRACTURES OF THE EXTREMITIES 
 
 of the fragments, will bring them into place. Maintaining the trac- 
 tion and supination, the dressing is applied. The simple anterior- 
 
 Fig. 167. — Anterior and posterior splint for forearm. (Heath.) 
 
 posterior splint (Fig. 167) is of little'use, except in isolated fracture of 
 the ulna, because it does not maintain supination. Whatever dress- 
 ing is used, it must have one negative character; it must not compress 
 
 Fig. 168. — Method of supporting arm while applying plaster bandage. 
 
 the forearm laterally lest the bones be forced together and the inter- 
 ims membrane be obliterated. A plaster bandage may be used 
 including the supinated forearm, the wrist and elbow (Figs. 168, 169). 
 
TREATMENT OF FRACTURES OF THE FOREARM 
 
 257 
 
 A molded plaster splint is still better, fashioned in this manner: 
 Twelve to fifteen layers of crinoline are cut in the form of an irregu- 
 lar quadrilateral long enough to reach from the axilla to the palm 
 and wide enough .to encircle the arm are loosely quilted together to 
 form a splint. It is notched where it is to support the elbow and a 
 hole cut near one border for the thumb. The splint is soaked in 
 
 Fig. 169. — Fracture of forearm. Plaster-of-Paris splint 
 applied. Elbow at right angle. (Scudder.) 
 
 liquid plaster and then molded to the posterior surface of the arm 
 and finally fixed with a loosely applied roller. This is the best 
 dressing for children. In the case of adults it may be necessary in 
 some instances to apply extension to prevent overlapping. 
 
 In any event extreme care must be taken to prevent compression 
 of nerves and arteries lest an ischemic paralysis occur. 
 
 FRACTURES OF THE LOWER END OF THE RADIUS 
 
 Certain landmarks about the wrist are useful in diagnosis of in- 
 juries in this region. 
 17 
 

 FRACTURES OF THE EXTREMITIES 
 
 fine 
 
 The styloid processes are easily palpated, the radial styloid lying 
 nearer the joint line. The radio-carpal joint line is indicated on the 
 anterior surface by the higher of three transverse creases. In 
 supination, the styloid of the ulna lies in the plane of the posterior 
 surface while the radial lies nearer the anterior plane. The radial 
 styloid can be best felt in the depression at the base of the thumb, 
 between the long and short extensior tendons. The two wrists 
 
 Fig. 170.— Typical Colles' fracture; 
 impacted fracture of lower end of radius 
 and fracture of styloid process of ulna. 
 
 Fig. 171. — Colles fracture; marked impac- 
 tion, lateral displacement producing widening 
 of the wrist. 
 
 should be compared point for point. In the skiagraph the epiphyseal 
 lines are distinct up to twenty years of age. 
 
 A variety of fractures may occur in the lower end of the radius 
 but by far the most frequent and most important is that produced 
 by falls upon the outstretched palm. The direction of the force is 
 such that the hand is shoved against the end of the radius, carrying 
 it backward at the same time. As a result the lower end of the 
 radius is driven into the shaft, shoved backward and rotated toward 
 the ulna (Figs. 170, 171). 
 
 Colles' fracture is one of the most easily recognized; producing 
 
COLLES ' FRACTURE 
 
 259 
 
 the characteristic hump — the silver fork deformity (Fig. 172). But 
 it is by no means seldom that fracture occurs without deformity. 
 In addition to the injury to the bone, the inter-articular fibrocartilage 
 may be torn loose from both its attachments, the radio-ulnar liga- 
 
 FiG. 172. — Colles' fracture. Silver fork deformity. (Moullin.) 
 
 ments are strained or ruptured, and the head of the ulna carried 
 forward. Sometimes the tendon sheaths are lacerated and blood 
 extravasated into the synovial sac. 
 
 Diagnosis. — -Determine the position of the styloid processes of the 
 
 Fig. 173. — Reduction of Colles' fracture. Note grasp upon forearm and the lower 
 fragment of the radius, traction and counter-traction being made; breaking up the 
 impaction. (Scudder.) 
 
 radius and ulna. If there is a fracture the styloid of the radius is 
 pushed up to a level with that of the ulna, the wrist is broadened. 
 The transverse lines on the flexor surface of the wrist are deepened 
 and the axis of the limb bent toward the radial side. The pain is 
 
260 FRACTURES OF THE EXTREMITIES 
 
 pronounced, mobility and crepitus are absent. Pain is elicited by 
 point pressure across the radius, an inch above the wrist. 
 
 The X-ray is very useful in diagnosis of these fractures. 
 
 Reduction is often difficult, but it is the chief thing and must be 
 complete, otherwise the result will be a disappointment. Anesthesia 
 is usually necessary. Clasp the patient's hand in your own, palm 
 to palm, and with the other hand grasp the wrist at the site of 
 
 Fig. 174. — Plaster splint molded to maintain flexion and adduction, as shown in the two 
 
 views. 
 
 fracture. While the assistant makes counter-traction you make 
 forcible traction on the hand, at the same time inclining it to the 
 ulnar side and making pressure upon the fragments. This combined 
 traction, pressure and ulnar flexion may require force, but it will 
 quickly reduce the fracture (Fig. 173). 
 
 Another method consists in having the assistant support the arm 
 extended and supinated while you grasp the hand in such manner 
 that your two thumbs may make strong pressure on the dorsum of 
 the wrist. 
 
 The fragments grate as the deformity recedes. 
 
 Flexion and adduction are the capital points in this procedure and 
 these positions must be maintained (Fig. 174). The best dressing is 
 indicated in Fig. 175; or a roller plaster dressing may be applied, 
 reviewing the position of the hand before the plaster hardens (Fig. 
 
COLLES' FRACTURE 
 
 261 
 
 176). In some cases when the displacement has been slight simple 
 anterior and posterior splints padded to suit the shape of the hand, 
 may be employed. 
 
 There is very little tendency to recurrence of the deformity if it is 
 properly reduced, and the fixation is a secondary matter. If there 
 was no deformity, or a very slight one easily reduced, it may be 
 1 * M treated altogether by massage. 
 Otherwise a week's fixation in one of 
 the dressings just described is advisa- 
 ble, to be followed by active massage. 
 
 Fig. 175. — Pattern for plaster 
 splint for Colles* fracture. 
 
 Fig. 176. — Fracture of metacarpus. 
 
 Andrews, of Mankato, Minn., emphasizes the necessity, in a 
 reduction of this fracture, of a general anesthesia and a knowledge of 
 the anatomy of the parts, which latter will be of more value to the 
 tyro than any confusing description of the manner of taking hold of 
 the parts. He remarks further that the head of the ulna must be 
 brought back to rest in the sigmoid of the radius. 
 
 Thinking the fracture set when merely the lower fragment of the 
 radius is in position is a mistake that has brought sorrow to many 
 a surgeon after union has taken place. 
 
 The most frequent permanent deformity is the slumping forward of 
 the ulna and the widening of the wrist. Andrews does not believe 
 that early passive motion does a great deal of good and may do harm 
 
FRACT1 VIREMITIES 
 
 by keeping the joint irritated by increasing the amount of callus and 
 by causing useless suffering. Early massage, if gentle, is not only 
 permissible, but to be recommended (Amer. Jour. Surg., July, 1909). 
 
 FRACTURES OF CARPUS AND HAND 
 
 Fractures of the bones of the carpus are not infrequent, and may 
 occur with fractures at the lower end of the radius. The scaphoid 
 is the most frequently involved, either alone or with one of the other 
 bones. The injury results most frequently from a fall upon the hand 
 when it is extended and abducted. 
 
 Fracture will be suspected from the pain and loss of function, and 
 on examination the styloid process of the radius is found too close to 
 the base of the first metacarpal, and the "tabatiere anatomique" — ■ 
 the depression at the base of the thumb between the long and short 
 extensors of the thumb — is occupied by a hard body and pressure 
 there is exceedingly painful. This sign alone is diagnostic of 
 fracture of trie scaphoid. Point pressure in case of fracture elicits 
 much pain. Often the thenar eminence is ecchymosed. The exact 
 character of the lesion can only be determined by the X-ray. Re- 
 duction may be accomplished by putting the hand in the ulnar 
 flexion and making pressure on the fragments through the palm. 
 Excision may be necessary. 
 
 Another type of injury consists of fracture of the scaphoid with 
 dislocation of the semilunar. This is due to a fall upon the hand and 
 is accompanied by pain, swelling and loss of flexion of the wrist, loss 
 of extension of the fingers. The displaced semilunar may be felt 
 in the palmar surface and the fossa at the base of the thumb is 
 filled up. On the back of the wrist the os magnum may be felt. 
 
 These cases untreated are likely to terminate in anchylosis of the 
 wrist. 
 
 The treatment consists in hyperextension of the wrist (under 
 anesthesia) with the purpose of facilitating the pressure into its 
 place of the semilunar. Subsequently the hand is flexed in flexion. 
 
 In neglected cases it may be necessary to resect the semilunar in 
 order to restore function. 
 
 Fracture of the metacarpals is to be diagnosed by swelling, tender- 
 
FRACTURES OF THE FINGERS 
 
 263 
 
 Fig. 177- — Showing "sway-backed" appear- 
 ance after fracture of the first phalanx of mid- 
 dle finger. (Marsee.) 
 
 ness, loss of function, and 
 sometimes by crepitation and 
 mobility (Fig. 176). 
 
 The nature and degree of 
 the displacement is variable 
 and is often quite indetermina- 
 ble without lateral and antero- 
 posterior X-ray views. The 
 deformity is to be overcome by 
 traction on the corresponding 
 finger confined with pressure. 
 The palm is padded with cot- 
 ton and firmly bandaged. 
 
 About three weeks is required for repair. 
 
 Fracture of the metacarpal 
 of the thumb has some special 
 characters and is designated as 
 Bennett's fracture of stave of 
 the thumb. 
 
 It is probably the most com- 
 mon and is the most important 
 of the metacarpal fractures, 
 difficult to reduce and hold. 
 
 After reduction a plaster 
 spica may be applied with the 
 thumb abducted and subse- 
 quently a window may be cut in the plaster over the base of the 
 thumb and padding applied to press the fragments into place. In- 
 stead of plaster three well- 
 padded pencil splints may be 
 used. 
 
 Fracture of the fingers is 
 sometimes compound, requir- 
 ing a careful antisepsis. There 
 is usually a tendency to dis- 
 placement, so that after reduc- 
 
 . . Fig. 179. — Mode of adjusting splint for simple 
 
 tion Splinting IS necessary. fracture of the finger. (Marsee.) 
 
 Fig. 178. — Splint with attachment for correc- 
 tion of lateral deformity. (Marsee.) 
 
204 
 
 FRACTURES OF THE EXTREMITIES 
 
 Fig. i So. — Splint wrapped with gauze ad- 
 usted for fracture of first phalanx, index 
 finger. (Marsee.) 
 
 A well-padded palmar splint is often all that is necessary, retain- 
 ing it by bandages or adhesive 
 strips. 
 
 In many cases, however, the 
 matter is not so simple and it 
 cannot be denied that the 
 splints ordinarily used are 
 often very unsatisfactory, for 
 they are not seldom so fash- 
 ioned as to be inadequate to 
 maintain extension, to immo- 
 bilize perfectly, or to correct 
 deformity. 
 The first or proximal phalanx most frequently suffers and the 
 
 fragments are likely to bulge 
 
 toward the palm, giving the 
 
 finger a "sway-backed" ap- 
 pearance (Fig. 177). As Marsee 
 
 has pointed out, this deformity 
 
 will not yield to the ordinary 
 
 splint, not indeed to any splint 
 
 which is straight or but slightly 
 
 curved. 
 
 The appliance recommended 
 
 for this condition and which may be useful in any fracture of the 
 
 digits consists of a strip of tin, zinc, copper, or galvanized iron, 
 
 14 inches long and 2% inches 
 wide. This is to be folded 
 upon itself lengthwise and 
 hammered flat so as to make 
 a three-ply strip three-fourths 
 of an inch in width. Of what- 
 ever material made, it should 
 be just flexible enough to be 
 bent readily by the unaided 
 fingers. Upon one end of the 
 
 strip, a piece of thin leather or canvas 4 or 5 inches long and 3 
 
 Fig. 181.- 
 
 -Finger splint applied, 
 aspect. (Marsee.) 
 
 Dorsal 
 
 Fir,. 182 — Splint applied. 
 (Marsee.) 
 
 Palmar aspect. 
 
FRACTURES OF THE FINGERS 
 
 26s 
 
 Fig. 183. — Lateral angular deformity 
 of middle finger. Unsightly stump of 
 index. (Marsee.) 
 
 inches wide is to be riveted (Fig. 178) in order to give the strip 
 
 stability when bandaged to the forearm. The strip is then shaped 
 
 to suit the curved outline, in 
 
 which position the ringers should 
 
 be immobilized (Figs. 179, 180). 
 
 The splint is to be adjusted 
 
 snugly to the forearm, so that its 
 
 end projects slightly beyond the 
 
 tip of the finger, and fastened by 
 
 strips of adhesive plaster, by a 
 
 roller bandage, or by a light 
 
 plaster-of-Paris casing. The fin- 
 ger, carefully wrapped in several 
 
 thicknesses of gauze, is then ad- 
 1 justed with painstaking care to 
 l the splint in such a manner that 
 
 the deformity, if any, is thoroughly 
 
 overcome, and longitudinal and 
 
 circular strips of adhesive plaster are applied (Figs. 181, 182). 
 In this manner, almost complete control of the ringer is assured. 
 
 When, however, the lateral 
 angular deformity is pro- 
 nounced (Figs. 183, 184), some 
 modification of the apparatus 
 may be necessary. 
 
 Two or three strips of zinc 
 or copper are cut out 2/4 
 inches long and J4 inch in 
 width. These are bent by one 
 end around the splint, fitting 
 it snugly but yet capable of 
 being slipped backward and 
 forward along the splint. The 
 free end is left wide and is 
 
 bent up to give the finger lateral support. This lateral support 
 
 may be slipped along to the desired point and effectually cor- 
 rects the deformity (Fig. 185). 
 
 Fig. 184. — Crushed hand. Lateral angular 
 deformity of little finger. (Marsee.) 
 

 FRACT1 RES OF THE EXTREMITIES 
 
 Should two or more ringers be broken, several strips may be 
 used side l>y~side, but fastened to the same flange of leather or 
 
 canvas. For two fingers, a 
 splint of double width may be 
 fashioned. 
 
 Should the thumb be 
 broken, the splint may be 
 heated and bent laterally in 
 proper shape, or an arm maj 
 be riveted to the ordinan 
 strip. 
 
 If the fracture or disloca- 
 tion is compound, especiall) 
 if attended with much dis- 
 placement and difficulty in maintaining reduction, the fragment 
 should be exposed and wired, for which one needs only a small 
 
 Fig. 185 
 
 -Splint applied to prevent lateral 
 angularity. (Marsee.) 
 
 Fig. 186. — Suturing bones of finger. 
 Drilling. (Marsee.) 
 
 Fig. 187. — Suturing bones of finger. 
 Drawing suture through with crochet 
 hook. (Marsee.) 
 
 drill or awl, a fine steel crochet-hook and chromicized gut (Figs. 
 186, 187). Such is the method taught by Marsee. / 
 
 The after-treatment is of importance. The splint will be re- 
 quired probably for two weeks or longer, but in order to prevent 
 
DIAGNOSIS OF FRACTURES OF THE THIGH 
 
 267 
 
 stiffness, passive motion should be begun at the end of the first 
 week and repeated every other day at first. The fragments must be 
 held in place during the first seances. Under this treatment, the 
 stiffness and soreness will disappear together. 
 
 FRACTURES OF THE LOWER EXTREMITY 
 
 The first aid in these cases is of special importance, as has already 
 been indicated. Even more than elsewhere the principle applies that 
 there must be absolutely as little mo- 
 tion as possible in order that the pa- 
 tient may be spared pain and aug- 
 mented shock; that the deformity may 
 not be aggravated and the periosteum 
 
 , and other soft parts lacerated; and that 
 a simple fracture may not be converted 
 into a compound one with all the ad- 
 
 , ditional dangers of infection. The 
 
 ( method of lifting a patient so injured 
 
 1 has already been described. 
 
 There are certain anatomical points 
 useful in the diagnosis of injuries of 
 
 ; the lower extremities, certain land- 
 marks that must be kept clearly in 
 mind; the anterior superior iliac spine, 
 
 \ the spine of the pubes, the ischial 
 
 I tuberosity, the great trochanter, the 
 
 1 patella and condyles of the femur, the 
 tuberosities and crest of the tibia, the 
 malleoli 
 
 There are three lines useful in men- 
 suration: Remember that the line pass- 
 ing from the anterior-superior spine to 
 the ischial tuberosity overlies the apex 
 
 of the great trochanter. This is Nelaton's line. Remember that 
 the line dropped from the anterior-superior spine to the internal 
 malleolus touches the inner border of the patella (Fig. 188). 
 
 Fig. 188.— Measurement of 
 lower extremity. Patient lying 
 on the back looked at from above. 
 Position of tape, hands, and limbs 
 to be noted. (Scudder,) 
 

 FRACTURES OF THE KXTREMITIES 
 
 Remember that the line of the tibial crest prolonged reaches the 
 >nd toe. 
 
 A routine method should be practised in diagnosis. Inspection 
 reveals changes in position, deformity swelling. Manipulation de- 
 termines mobility, loss of function and pain; palpation discovers 
 changed relations in bony landmarks and displacement of fragments; 
 mensuration, shortening and deformity. In every case these details 
 oi examination should be carried out. Shortening is determined by 
 two lines of measurement. 
 
 If the injured limb is shorter than the sound, measuring from the 
 anterior-superior spine to the internal malleolus, there is a fracture. 
 Now if the distance from the top of the trochanter to the external 
 malleoli are compared, shortening proves fracture of the anatomical 
 neck. 
 
 Fracture of the neck is indicated also by changes in the relation of 
 the trochanter to Nekton's line. 
 
 FRACTURE OF THE UPPER END OF THE FEMUR 
 
 Fractures of the upper end of the femur have been the subject of 
 much discussion, and various forms of treatment have been recom- 
 mended for imagined clinical and anatomical varieties. At the 
 present time, nearly all surgeons are of the opinion that these le- 
 sions may be grouped under two heads, impacted and non-impacted. 
 Even this division is not important for diagnosis, but only for 
 prognosis, since impaction, provided it is not broken up, offers the 
 conditions most favorable for bony union (Fig. 189). 
 
 Although the differential diagnosis is usually difficult, sometimes 
 impossible, yet the presence of a fracture of some kind is usually 
 determined after a little study. A severe contusion may indeed be 
 mistaken for fracture, but this is not a serious error. On the othei 
 hand, it is a very serious error to mistake and treat a fracture about 
 the hip as a contusion. In case of unresolvable doubt, treat the 
 injury as a fracture. The diagnosis is made from several factors: 
 
 (a) Pain is a symptom upon which one cannot greatly rely. It is 
 more constant in impacted than non-impacted fracture because of 
 the accompanying bruises of the soft parts. The pain is aggra- 
 vated by pressure over the hip. Tenderness and especially a full- 
 
DIAGNOSIS OF FRACTURES OF THE THIGH 
 
 269 
 
 ness in Scarpa's triangle is frequently observed. Pain with thick- 
 ening of the trochanter means impaction. 
 
 (b) Loss of function may also be due to contusion; moreover, the 
 patient may be able to walk with an impacted fracture, so that this 
 
 Fig. 189. — Impacted fracture at the hip. Note lines of fracture in head, neck and 
 
 trochanter. 
 
 symptom is no certain criterion. However, the patient is usually 
 unable even to draw his heel upward. 
 
 (c) Eversion of the foot is nearly always present in some degree, 
 but is more frequently indicative of non-impacted than impacted 
 fracture, and is due to the weight of the limb. 
 
270 FRACTURES OF THE EXTREMITIES 
 
 (d) Shortening is more frequently the accompaniment of im- 
 pacted tract ure. It is definitely determined by comparing with 
 the sound side, measuring from the anterior-superior spine to 
 the internal condyle and internal malleolus; also by determining the 
 relation of the trochanter to Nelaton's line (Fig. 188). 
 
 (e) Crepitation is proof incontestable but rarely available. One 
 should make no effort to elicit this symptom, fearing to break up 
 impaction, which is an accident much to be deplored, according to 
 the usually accepted view. 
 
 Senn (Practical Surgery) says upon this point that it is better to 
 be satisfied with the probable evidence of fracture. If the surgeon 
 in his anxiety to obtain a perfect diagnosis moves the limb freely 
 in all directions, he overcomes impaction, rupturing the cervical 
 ligaments, demonstrating beyond all doubt the existence of the 
 fracture and at the same time effectually destroying all hope of 
 reunion. As Senn suggests, a useless limb is certainly a high price 
 to pay for a perfect diagnosis. * 
 
 Age is an important feature in differential diagnosis. In the el- 
 derly the injury is more likely to be intra-capsular with or with- 
 out impaction: In the middle age extra-capsular, impacted frac- 
 ture is the more likely; and in the child or adolescent, separation of 
 the epiphysis is much the more frequent. 
 
 Oftentimes the X-ray alone can determine the lines of fracture, 
 and again it will often unexpectedly reveal a fracture in the young 
 in whom contusion is the favored diagnosis. 
 
 The treatment resolves itself into two lines of procedure, de- 
 pending upon whether or not the fracture is impacted. In either 
 case the treatment should be modified by the age and constitution of 
 the patient. Confinement on the back may be fatal in the aged, 
 and it is imperative in such cases to give the patient more freedom. 
 This imperfect immobilization may eventually result in an imperfect 
 union, but one must be consoled by the reflection that a fatal attack 
 of hypostatic pneumonia may have been prevented. In the case 
 of the aged, therefore, the main object is to get the patient on his feet 
 as soon as possible. For the first week the limb should be fixed 
 with sand-bags and massaged daily. After that a plaster spica ex- 
 
TREATMENT OF FRACTURES OF THE THIGH 271 
 
 tending halfway to the knee may be applied and the patient per- 
 mitted to get about with crutches. 
 
 In the case of undisturbed impaction in adults, the treatment is 
 of the simplest form. The patient is placed on a smooth mattress, 
 the limb supported by sand-bags or perhaps light extension applied, 
 and systematic massage early instituted. Union may occur with 
 no treatment at all. I recall the case of a man of sixty who fell in 
 the street with what was supposed to be an apoplectic stroke. He 
 was carried to his home to die but it was soon discovered that the 
 conditions were not so serious but it was still supposed that he was 
 paralyzed in one leg. After two months in bed he was able to get 
 about with crutches but he had a very painful hip. A year later 
 he was still on crutches and was brought to the hospital for examina- 
 tion and the X-ray showed that he had suffered an impacted frac- 
 ture of aggravated form. He had marked eversion and shortening 
 but a firm union. Now a year later he still walks lame but without 
 the aid of a cane. 
 
 Union with deformity and large loss of function may be secured 
 by doing little or nothing. 
 
 Restoration of function implies restoration of form and this 
 accomplished by breaking up the impaction, abducting the limb 
 and fixing it with a plaster spica. 
 
 Whitman has formulated a technic : Unless the condition of the 
 patient forbids, he proceeds gently to break up the impaction 
 under anesthesia. The limb is reduced by extension and gradual 
 abduction to an angle of forty-five degrees, in the meantime sup- 
 porting the upper end of the femur and rotating the leg inward. 
 
 In this position, the limb is well covered with cotton batting, all 
 the bony points especially well protected and a flannel bandage 
 smoothly applied. A plaster spica is now applied extending from 
 the lower ribs to, and including, the foot. The plaster fits the pelvis 
 snugly and is molded close to the trochanter and posterior aspect 
 of the joint. It is also molded to the patella and condyles, and to 
 the foot to prevent rotation. This dressing permits the patient 
 to rise up in bed without much discomfort. 
 
 The advantage of abduction is that it makes the capsule tense 
 and thus aligns the displaced fragments; that it directs the surface 
 
172 FRACTURES OF THE EXTREMITIES 
 
 . tV.A 
 
 of the outer fragment toward that of the inner; that it relaxes the 
 muscles that produce distortion by their traction; that it apposes 
 the trochanter to the side of the pelvis and thus checks upward 
 displacement. Repair in these fractures is slow and can hardly be 
 completed within a year; thus prolonged after-treatment is nec- 
 essary to restoration of function (J. A. M. A., Feb. 20, 1909). 
 
 Fk.. ioo. — Xon-impacted fracture of the anatomical neck of the femur; so called 
 intracapsular fracture. 
 
 If the case is one of non-imp action (Fig. 190) with much shortening 
 
 and the condition of the patient will admit Senn advises reduction 
 
 followed by prolonged immobilization in plaster extending from the 
 
 t to the toes and which is fenestrated over the trochanter for the 
 
TREATMENT OF FRACTURES OF THE THIGH 273 
 
 purpose of applying lateral pressure. The lateral pressure he regards 
 as essential to good union. But the plaster cast is difficult to apply. 
 It is necessary that there be some sort of pelvis support and strong 
 traction must be continued until the plaster is hard. 
 
 The limb and trunk are encased in glazed cotton or what is much 
 better drawers of stockinet. Three layers of plaster roller are 
 run on from the thorax to the toes. The plaster splint is then 
 molded to the outer side of the limb, pelvis, and trunk, and fresh 
 layers of the roller applied. The plaster is molded very carefully 
 to the bony points as by this means the dressing secures an effective 
 grip. The plaster splint consists of ten or twelve layers of crino- 
 line, cut in two sections, the first extends from the thorax down to 
 the toes along the outer side and cut to a pattern which covers half 
 the limb, the second section is wide enough to extend from the 
 trochanter to the level of the ensiform and long enough to reach 
 two-thirds about the body. It is fastened to the first section in 
 the manner of a cross. . 
 
 FRACTURE OF THE SHAFT OF THE FEMUR 
 
 In this fracture the lower fragment is nearly always displaced 
 forward and backward. If the fracture has been produced by di- 
 rect force, it may be transverse, but this is the exception. The 
 diagnosis is simple: shortening, eversion, loss of function. 
 
 Manipulation is unnecessary and decidedly to be avoided, not 
 only that the patient may be spared the pain, but also that the 
 trauma may not be aggravated, the periosteum torn, the muscles 
 bruised, the vessels injured. 
 
 Reduction, — This must not be begun till all the dressings are 
 quite ready. General anesthesia. One assistant grasps the thigh 
 with both hands near the pelvis; the other assistant, the foot and 
 lower third of the leg. As they make traction and counter-trac- 
 tion the surgeon manipulates the fragments. The traction must 
 be prolonged as these strong muscles relax only gradually. 
 
 When the fracture is quite oblique and the pointed extremities 
 are caught in the soft parts, a little patience will be required to free 
 the fragments. To effect this, slight rotation and oscillation must 
 be added to extension and abduction. 
 18 
 
J 74 FRACTURES OF THE EXTREMITIES 
 
 How will one know that reduction is complete? 
 
 (i) These points must exactly correspond when the two limbs are 
 placed side by side: the upper border of the two patellae, the lower 
 border of the two internal malleoli, the two soles. 
 
 (2) The limbs must be the same length by measurement from 
 the anterior-superior ilica spine to the inner malleolus. 
 
 (3) The line dropped from the iliac spine to the malleolus must 
 touch the inner border of the patellae. 
 
 Dressing. — Many forms of splints are described; many of them 
 complex; all effective in some degree. Whatever the form employed, 
 the limb must be frequently measured and the patient's general con- 
 dition kept under close watch. Scudder highly recommends a 
 modified Buck's extension. Many are more successful with the 
 plaster cast. 
 
 Lejar recommends, as the simplest in emergency practice, the 
 dressing of Tillaux. From a roll of adhesive plaster are cut eight or 
 nine strips 1^ inches wide, and long enough to extend from the 
 level of fracture down the side of the limb, over the sole of the 
 foot after the manner of a stirrup, and up the opposite side of the 
 leg to the level of the fracture. 
 
 Begin by applying one of the strips in the direction indicated. 
 Next slip a strip transversely under the thigh, another under the calf, 
 and a third under the ankle, and make one circular turn of each. 
 Next apply a second longitudinal strip slightly overlapping the first; 
 follow with another turn of each circular strip, and so on. In this 
 manner the strips are given a firm attachment. 
 
 Every point of contact of the adhesive must be perfectly smooth. 
 Every longitudinal strip must extend the same distance as its fellows 
 below the sole in order that the extension weight shall make uniform 
 traction on all the components of the stirrup. 
 
 A cord is fastened to the stirrup, passed through a pulley at the 
 foot of the bed and a weight of 5 or 10 pounds attached. If a 
 pulley is not obtainable, a hole can be cut in the foot of the bed if it 
 is wooden; or the cord may work over broom handle attached to an 
 iron bedstead. The weight must be increased in the case of the 
 muscular or in the case of a very oblique fracture. 
 
 A case will illustrate the difficulties which may attend reduction in 
 
 
TREATMENT OF FRACTURES OF THE THIGH 
 
 275 
 
 these cases of fracture of middle of the shaft. A young man caught 
 and crushed under a falling load of telegraph poles was brought to the 
 City Hospital in full shock. It scarcely seemed possible for him to 
 survive. It seemed certain that he must have had grave internal 
 injuries though there was no direct evidence to that effect. The 
 shock gradually subsided and no further evidence of visceral compli- 
 
 FiG. 191. — Supracondylar fracture of the femur. 
 
 cation arising, attention was directed to his fractured femur, which 
 was broken about the middle. Efforts at reduction were painless 
 but wholly ineffectual in securing a coaptation. Continuous exten- 
 sion was applied but after two days an X-ray examination showed the 
 fragments still separated and overlapping. 
 
 Later an open operation found the broken ends interlocked with 
 muscular tissue. With some effort they were freed, coapted and 
 plated. Some suppuration delayed repair, but he finally recovered 
 with a good limb. 
 

 FRACTURES OF THE EXTREMITIES 
 
 SUPRACONDYLAR FRACTURES 
 
 These derive their importance from the frequency with which 
 the fragments involve the knee-joint or the structures in the popliteal 
 space, and from the difficulty of maintaining coaptation. Both 
 these eharacteristics depend upon the obliquity of the fracture which 
 usually extends from behind downward and forward (Fig. 191). 
 The complications must be treated on general principles. 
 
 The fixation may be any of the means just described for frac- 
 tures of the shaft. In this case as in any very oblique fracture, 
 flexion of knee and hip seem specially indicated. 
 
 1 f * ant • - ^^f 
 
 Fig. 192. — Hodgen splint for fractured thigh. (Moullin.) 
 
 Hennequin's apparatus secures an efficient extension, combined 
 with flexion of the hip and knee and permits the patient to sit up. 
 Downey, of Gainesville, Ga., has thought out a device which involves 
 the same principles as the Hennequin apparatus but is simpler in 
 application. As Downey remarks (American Jour. Surg., March, 
 1 9 1 5 J the dressing aims to secure at once the position of the Esmarch, 
 Smith, Hodgen (Fig. 192), or Cabot apparatus; the extension of the 
 Buck apparatus; the fixation of plaster of Paris. This is accom- 
 plished by means of a double angular plaster-of-Paris splint. 
 
TREATMENT OF FRACTURES OF THE THIGH 277 
 
 The mode of application (briefly) is this: Secure counter- traction 
 by a padded sheet passed between the legs and brought well up 
 against the perineum; traction, by grasping the leg above the ankle 
 with one hand, under the knee with the other. A plaster cast is 
 applied from the toes to just above the knee, which is well flexed. 
 Now secure coaptation. 
 
 Next apply the second section of the cast, beginning at the upper 
 border of the first and carrying the roller in the ordinary manner 
 up to the ensiform, all the while maintaining the traction with hip 
 well flexed. Strengthen the outer side of the cast at the hip-joint 
 by up-and-down folds of the roller or by metal splints. Split the 
 splint if constriction is feared. 
 
 AFTER-TREATMENT OF FRACTURE OF THE FEMUR 
 
 Whatever the form of treatment, union will scarcely ever occur 
 short of six or seven weeks. Whether union has occurred or not 
 can be determined by manipulation of the fragments^ and if they 
 are well fixed the patient should be encouraged to use his crutches, 
 but he should not be permitted to bear his weight on the injured kg 
 short of three months. And even then only if he can lift his leg 
 without pain, if the callus is rounded, and of moderate volume, and 
 if pressure does not produce pain. 
 
 Attention should be given the selection of the crutches which 
 should just reach to the axilla and the cross piece for the hand should 
 not be too low lest undue pressure fall on the musculo- spiral nerve. 
 The edema, usually moderate, disappears with increased use and 
 likewise the muscular atrophy. 
 
 The knee, nearly always stiffened, gradually regains its move- 
 ments. Shortening in some degree is inevitable but in a general way 
 it may be said that in the course of time the functional cure is 
 complete. 
 
 FRACTURES OF THE FEMUR IN CHILDREN 
 
 Fractures of the shaft present nothing special in the matter of 
 diagnosis. 
 
 The treatment of choice is the plaster spica much more easily 
 applied than in the case of adults. It must be molded carefully and 
 
FRACTURES OF THE EXTREMITIES 
 
 special precautions must be taken to strengthen the cast in the 
 region of the groin. 
 
 The east may be left off after a month. In the case of the new- 
 born the best treatment is by vertical extension. In this portion the 
 infant can be easily kept clean which is the most important part of 
 the treatment. The fracture in the great majority of cases involves 
 the upper third and requires much more force to effect a reduction 
 than might be expected. 
 
 The vertical extension is accomplished by applying adhesive plaster 
 to both limbs in such manner as to make a small stirrup for either 
 foot to which cords are attached and passed through pulleys and 
 fastened to the cross bar over the bed. A weight sufficient to keep 
 the legs straight in the vertical position is applied. 
 
 A very light plaster roller incases the injured limb and which 
 need not be changed till union is fairly firm which will usually be 
 within two weeks (Fig. 193). 
 
 Judet particularly recommends, in these cases, treatment in the 
 horizontal position without extension, using for fixation a gutta- 
 percha splint. The splint is cut out of a sheet of gutta-percha at 
 least 6 mm. thick the upper part wide enough to encircle two-thirds 
 of the trunk from the nates to the lower ribs. 
 
 The lower portion is as long as the limb and so 
 tapered as to cover two-thirds of the circumference 
 of the entire limb forming in other words a posterior 
 splint. 
 
 This gutta-percha splint is next soaked in hot 
 water and when soft is molded to fit the trunk and 
 thigh and leg posteriorly, next dipped in cold water 
 and when hardened is lined with absorbent cotton 
 and, when the fracture is reduced, this splint is ap- 
 plied and held on with a roller bandage. A splint 
 ant's vertical ex- similarly molded to the anterior part of thigh may 
 tension for frac- b e added, This dressing may be removed every day 
 
 ture of femur in . ■ • 7 « * • 
 
 children. when the infant has his bath, taking care to support 
 
 the limb in the interval. 
 Separation of the epiphysis of the lower end of the femur is another 
 injury which must not be forgotten (Fig. 194). 
 
SEPARATION OP THE EPIPHYSIS 
 
 279 
 
 A youth of sixteen was brought to the City Hospital for an ampu- 
 tation of the thigh. He had a greatly swollen and painful knee, of 
 long duration and upon which a great variety of treatment had been 
 applied on various hypotheses. A careful manual and X-ray ex- 
 
 Fig. 194. — Separation of epiphysis of lower end of femur; below is shown the 
 epiphysis of the tibia in its normal relation. 
 
 animation developed the presence of a bony mass projecting into 
 the popliteal space from the inner side of the knee and the patella 
 lay upon the outer aspect of the limb. 
 
 The conditions manifestly insured a permanently useless limb. 
 

 FRACTURES OF III I EXTREMITIES 
 
 There was a history of a fall from a bicycle with injury to the knee, 
 supposed to be a bruise. Nevertheless he had never born his weight 
 on the limb from that time. 
 
 A diagnosis of separation and displacement of the epiphysis 
 was made and operation advised. A semilunar incision below 
 the patella, followed by section of its tendon, exposed the joint and 
 revealed the epiphysis united to the shaft in a distorted position. 
 The spongy tissue was easily divided, the fibrous connections 
 loosened, the raw surfaces of bone trimmed and the condylar end 
 brought back into something like its normal position, and wired. 
 
 The patella was with some difficulty shifted into its proper groove 
 and the tendon reunited. The limb was fixed in plaster and after 
 three weeks passive motion was begun. Now six months after the 
 operation the outlines of the knee are practically normal, there is 
 slight motion and the patient walks easily with only the help of a 
 cane. 
 
 Usually the condyles are displaced forward and laterally and the 
 shaft projects toward the popliteal space. The change in the 
 landmarks, the great swelling about the joint, the deviation in the 
 axis of the limb is sufficient for a diagnosis. The treatment consists 
 in replacement by strong traction with manipulation of the fragments 
 under anesthesia, followed by fixation in plaster. 
 
 Sometimes forced flexion as in the case of the elbow will succeed 
 and after two weeks extension must be begun. 
 
 Finally a few cases will resist reduction and will require immediate 
 operation. 
 
 FRACTURE OF THE PATELLA 
 
 Fractures of the patella are comparable with those of the ole- 
 cranon. They may be transverse, such are usually fractures result- 
 ing from indirect force; or they may be vertical, or oblique, or 
 multiple (Figs. 195, 196). 
 
 There are two obstacles to osseous reunion: the action of the 
 quadriceps extensor and the intervention of the patellar fascias, pre- 
 venting exact coaptation. In spite of these unfavorable circum- 
 stances, there is generally some form of fibrous reunion unless the 
 fragments are very widely separated (Fig. 197). 
 
FRACTURES OF THE PATELLA 
 
 28l 
 
 The treatment of the present time is by one of two methods — mas- 
 sage or suture. If the fracture is transverse, with very little separa- 
 
 
 Fig. 195. — Transverse frac- 
 ture of patella. (Moullin.) 
 
 Fig. 196. — Comminuted frac- 
 ture of patella. (Moullin.) 
 
 r 
 
 tion, and the conditions are not favorable for an aseptic operation, 
 massage may be expected to give a good functional result. If the 
 separation is considerable, massage 
 will still give a better result than 
 any splints. 
 
 In any case suturing is the ideal 
 form, although the ideal cannot 
 always be attained. Again, every 
 compound fracture should be im- 
 mediately sutured. J. H. Ford, 
 whose experience with these frac- 
 tures has been large, describes his 
 method of procedure in ordinary 
 fracture (Ind. Medical Jour., July, 
 1907). 
 
 In the non-operative cases he be- 
 gins by elevating the limb for sev- 
 eral days to relax the quadriceps. 
 If there is effusion he bandages 
 lightly with a flannel roller, or if 
 the hemarthrosis is marked, a firm 
 constriction is practised or ice-bags 
 applied. 
 
 As soon as the acute symptoms 
 have subsided, which is after three to five days, massage is insti- 
 tuted and daily applied. Begin with gentle constriction of _ the 
 
 1 
 
 
 Fig. 197. — Fracture of the patella. 
 Showing separation of fragments and dis- 
 tension of the synovial sac. (Moullin.) 
 

 FRACTURES OF THE EXTREMITIES 
 
 joint with the hands by an upward movement, and ending with 
 more vigorous pressure of the sides of the patella and the joint. In 
 the intervals the limb should be maintained on a posterior splint. 
 After from four to six weeks of this treatment, he immobilizes the 
 joint in a plaster cast, preferably for two weeks more, and subse- 
 quently, he recommends a morning and evening massage and 
 flannel bandaging until the functions are practically restored. 
 
 
 -Suture of patella. Method of drilling and passing sutures. (Labey.) 
 
 The operative treatment is not simple, yet by no means beyond 
 the skill of anyone who knows how to secure asepsis and to apply 
 a bone suture. Begin with a semilunar incision, concave upward, 
 well below the line of fracture and reaching to either border of the 
 Ua. Raise the cutaneous flap and expose the patella. The artic- 
 ulation is carefully wiped out and freed of all fragments and clots. 
 
FRACTURES OF THE PATELLA 
 
 283 
 
 Fixing the upper fragment by appropriate forceps, two slight in- 
 cisions are made in the periosteum at the points where the drill is 
 expected to enter. Two tunnels are now drilled from above, emerg- 
 ing on the face of the fracture well outside the line of the cartilage. 
 The sutures are drawn through these openings and the process is 
 repeated in the lower fragment, but great care must be used in se- 
 curing a correspondence with the first two drill holes or the coapta- 
 tion will be imperfect (Fig. 1 98) . By traction on the sutures the frag- 
 ments are brought together, and great care is necessary to avoid 
 
 Fig. 199. — Suture of patella. Completing repair by suture of periosteum 
 and fibrous coverings. (Labey.) 
 
 including shreds of fascia. The sutures are tied, twisted firmly, and 
 pressed down upon the bone. The periosteum and fibrous coverings 
 are next sutured with catgut (Fig. 199). 
 
 Ford prefers not to wire, but, after approximation, sutures the 
 lateral fascia with No. 3 forty-day chromicized catgut and the 
 aponeurosis in front with No. 1. A No. 1 forty-day suture, 18 inches 
 long, is then threaded on a strong, half-curved needle which is en- 
 tered into the aponeurosis just above and on a line with the outer 
 
IK ifcTURES OF Till-: EXTREMITIES 
 
 edge ol the patella and follows the upper border of the patella to the 
 inner side where it emerges; is re-entered and carried down the inner 
 side; again around the lower fragment, passing through the ligamen- 
 luni patella and emerging at its outer border. This retention suture 
 is now tied tightly at this last point of emergence (Fig. 200). The 
 skin wound is next repaired without drainage. The limb is subse- 
 quently immobilized for two weeks when massage is to be begun. 
 
 Fig. 200. — Fracture of patella. Circular suture. (Labey.) 
 
 >d lays down these rules respecting the treatment of simple 
 transverse fracture: 
 
 (1) Operative treatment should never be undertaken except under 
 the best conditions for maintaining asepsis. 
 
 (2) Even under aseptic conditions not every case should be oper- 
 ated on, but only those in which the separation is at least % 
 inch and the " reserve extension apparatus" is compromised by 
 
 al tears. 
 
 (3) Operative treatment fulfills all the indications in a degree 
 which the non-operative treatment can only partially achieve. 
 
 1 e favors complete restoration of function and 
 
 should be used in all casi 
 
FRACTURES OF TIBIA AND FIBULA 
 
 28 5 
 
 (5) In operative treatment open arthrotomy should be practised. 
 
 (6) Absorbable suture material applied only to the soft parts is 
 sufficient in nearly every case. 
 
 FRACTURES OF THE LEG 
 
 Fractures of the leg present many variations, but the prognosis 
 and the difficulties of treatment depend chiefly upon whether the 
 fracture is transverse or oblique. If transverse there is usually 
 
 IH r J 
 
 \ 
 
 Fig. 201. — Longitudinal fracture of tibia and oblique fracture of fibula. 
 
 slight displacement, easily reduced and easily maintained; if oblique 
 there may be much displacement which is difficult to reduce and hold, 
 and often results in much loss of function. 
 
 Transverse fractures more commonly are due to direct force and 
 the lesion corresponds to the application of force. Oblique fractures 
 

 FRACTURES OF THE EXTREMITIES 
 
 arc more commonly due to indirect force and the two bones give way 
 at their point of least resistance, which in the case of the tibia is at 
 the junction of the middle and lower third; in the case of the fibula 
 in the upper third. In general, displacement is always favored if 
 both bones are fractured (Fig. 201). 
 
 The diagnosis of these injuries usually offers but little difficulty. 
 The deformity, loss of function, pain and crepitus, and preternatural 
 
 Fig. 202. — Fracture of upper end of tibia, involving the joint. 
 
 mobility leave but little doubt except when the injury is at the upper 
 end, and where the joint may be involved (Fig. 202), or when the 
 fibula alone is fractured. A useful test for fracture of the fibula is 
 compression of the two bones some distance from the suspected 
 site; the pain occurs not at the point of pressure but at the point 
 of fracture. 
 
 If there is great displacement of the fragments the deformity is 
 pronounced, the foot turns to the outside, the fragments may be 
 
FRACTURES OF THE TIBIA 
 
 287 
 
 felt projecting under the skin which soon becomes greatly discolored 
 and often covered with blebs. 
 
 Reduction.— -The assistant grasps the leg at the knee, 'the surgeon 
 grasps the foot with one hand and the heel with the other; or two 
 assistants may make the necessary traction while the surgeon man- 
 ipulates the fragments. 
 
 What is the test of good coaptation? The crest of the tibia forms 
 a continuous line without projections or 
 depressions. This line prolonged strikes 
 the first metacarpal space. The internal 
 surface of the tibia is smooth and uniform. 
 With the foot at a right angle, a line 
 dropped from the anterior-superior iliac 
 spine to the inner border of the great toe 
 touches the inner border of the patella. 
 
 I 
 
 Fig. 203. — Cloth cut to fit the limb and notched at the ankle in order to be more easily 
 adjusted to the malleoli when it is soaked with plaster. (Lejars.) 
 
 The reduction is by no means so simple as it seems and even when 
 easily accomplished may be difficult to maintain while the dressing 
 is applied. A maneuver which often succeeds without the use of 
 great force is that which is practiced in the open operation. The 
 limb is flexed at the line of fracture and the two fragments brought 
 into contact along the line of their lower borders. This affords a 
 leverage when traction is applied. Coincident with traction the 
 limb gradually straightens and the lower fragment adapts itself to 
 the upper. 
 

 FRACTURES OF THE EXTREMITIES 
 
 Dressing.- This will vary somewhat, depending upon the situation 
 and tendency to displacement. In the simple case of fracture of the 
 shaft of the tibia, following the counsel of Stimson, it is best to put 
 the patient to bed with the limb in a Volkmann splint for about a 
 week until the swelling has subsided, and then to encase it in plaste 
 erf Paris. Immediate application of the plaster of Paris is objec 
 tionable because it cannot be determined from the first whether th 
 
 .1 
 
 • 
 
 - 
 
 - 
 
 
 
 
 
 •\ ^ • T 
 
 i\ 
 
 
 
 ^mmf' 
 
 s*S&: ^ t 
 
 ^ 
 
 
 
 
 
 
 umMik 
 
 WoT-j^ 
 
 
 Jf 
 
 
 1 
 
 
 m 1 
 
 Fig. 204.- 
 
 -Plaster splint applied and fixed with roller plaster bandage, 
 supporting limb and applying roller. (Lejars.) 
 
 Note manner of 
 
 swelling will increase or diminish. The two dressings may be com- 
 bined by applying a plaster splint from the first, and this we prefer. 
 Lejars describes the construction of such a splint. He measures 
 from the middle of the thigh down to the heel and up the sole to the 
 and this will be the length of the sixteen layers of crinoline from 
 which the splint is to be made. Take the circumference of the thigh, 
 the knee, the middle of the leg, the ankle, and transfer the measures 
 to the crinoline which was cut wide enough in the first place to en- 
 
FRACTURES OF THE TIBIA 
 
 circle the thigh. Connect the ends of these cross measurements with 
 a chalk line and in this manner one forms a rough outline of the limb, 
 and the bandage is cut accordingly. Some prefer to apply the mate- 
 rial to the sound limb and mark it off in that way. 
 
 Opposite the ankle a notch 
 should be cut in the dressing, 
 running toward the heel, that 
 the dressing may be more 
 readily fitted (Fig. 203). This 
 is soaked with liquid plaster 
 and applied while the extension 
 and counterextension are main- 
 tained and the foot fixed at a 
 right angle. This tension must 
 not be relaxed until the plaster 
 has hardened. The dressing is 
 completed by applying a roller 
 bandage (Fig. 204). 
 
 While the plaster is harden- 
 ing it is necessary to test the 
 reduction by the measurements 
 indicated and to readjust the 
 alignment, the assistant must 
 be warned not to carry the foot 
 forward in making traction lest 
 angulation occur. 
 
 The plaster must be well 
 molded about the knee and the 
 ankle in order that shortening 
 may not recur. 
 
 Oblique fractures (Fig. 205), hard to hold, are likely to be near 
 the lower end. The quadriceps extensor pulls the upper fragment 
 forward, and the gastrocnemius pulls the lower fragment backward. 
 The special form of dressing which Scudder recommends for this 
 form of fracture is made by a combination of plaster and adhesive 
 strips. The adhesive strips are applied as indicated (Fig. 206). A 
 thick roll of sheet wadding is applied to the sole of the foot, and a 
 19 
 
 Fig 205. — Typical oblique fracture of the 
 shaft of tibia. 
 
290 
 
 FRACTURES OF THE EXTREMITIES 
 
 plaster bandage applied from the toes to above the knee. A buckle 
 looking upward is incorporated in the plaster just above the level of 
 t he knee. A slit is left in each side at the ankle for the lower exten- 
 sion strips to come through. 
 When the plaster has hardened, 
 the upper extension strips are 
 fastened in the buckles and the 
 lower extension strips pulled out 
 through the slits and drawn tight 
 around the foot piece after the 
 wadding at the sole has been re- 
 moved. The purpose of this 
 arrangement is to maintain ex- 
 tension. 
 
 Whatever form of dressing is 
 used the limb must be watched 
 to see that no displacement oc- 
 curs. While a simple fracture 
 usually firmly unites within six 
 weeks, those which have been hard 
 to keep reduced will remain weak 
 much longer. As soon as there is 
 sufficient union to prevent dis- 
 placement, then massage " should 
 be begun and continued till the 
 limb's functions are restored. 
 
 Whether it is safe to leave off 
 the dressing is to be determined 
 largely by the character of the 
 callus which should be fusiform 
 
 The 
 pain on pressure and movement 
 must be slight and of course there 
 must be no mobility of the fragments. 
 
 Crutches must be used to begin with and light, easily removable 
 splints must be worn. 
 
 irked swelling may always be expected as soon as the patient 
 
 Fig. 206. — Plaster traction splint; a, 
 Application of adhesive-plaster extension 
 strips; b, plaster bandage allowing exit of 
 extension straps. Note space left below 
 the sole to allow for effective traction and anc J f moderate VOlUme. 
 buckles to which the upper extension is 
 attached. (Scudder.) 
 
FRACTURES OF THE TIBIA 
 
 291 
 
 begins to get about on crutches, a condition which may alarm him 
 greatly but this and the pain will gradually subside with increasing 
 muscular and articular activity. 
 
 Fig. 207. — Perfect coaptation secured by plating, but in this case same results would 
 probably have followed non-operative treatment since the fracture was not oblique. If 
 the fracture requires plating at all a longer and stronger plate than is shown should be used. 
 
 The muscular atrophy and joint stiffness are not the least to be 
 considered of the complications of convalesence and it is to be 
 remembered they are aggravated by prolonged immobilization.* 
 
 *For remarks on plating see Fig. 207; fracture of the anterior tuberosity of 
 the tibia, Fig. 208; and page 207. 
 
:o: 
 
 FRACTURES OF THE EXTREMITIES 
 
 Pons FRACTURE. — Fracture of the fibula with eversion and ab- 
 duction of the ankle has a character of its own. As Stimson remarks, 
 the diagnosis can usually be made at a glance (Fig. 210). Three 
 points of tenderness on pressure are constant and characteristic: one 
 
 
 Fig. 208. — Fracture of the tubercle or anterior tuberosity of the tibia, point of insertion 
 of "the patellar tendon is not rare and usually due to striking the knee while strongly flexed. 
 
 There may be considerable displacement and disability and in some cases it may be 
 necessary to wire the fragment. Usually fixation of the extended leg for three weeks is 
 sufficient for a union. 
 
 in the groove between the tibia and external malleolus; another at 
 the base of the internal malleolus; the third over the outer aspect of 
 the fibula, marking the point of fracture. Marked ecchymosis 
 appears beneath the external malleolus and sometimes beneath the 
 internal (Fig. 211). Immediate reduction should be the rule. 
 
FRACTURE OF THE FIBULA 
 
 293 
 
 Reduction. — Grasp the foot in one hand, the heel in the other, and 
 while the leg is steadied by the assistant, draw the foot forward and 
 
 Fig. 209. — Fracture of the fibula in its lower third or near the malleolus may be unsus- 
 pected and the symptoms be attributed to a sprain of the ankle. But swelling and tenderness 
 above the ankle with much pain on walking will give rise to the suspicion of fracture 
 which the X-ray will confirm. 
 
 The patient must keep off his feet for three weeks with the leg lightly splinted with the 
 foot in good position, massage. The nearer the fracture is to the joint the greater the 
 tendency to flat foot. 
 
 inward. If this does not entirely succeed, the fragments may be 
 pressed into place. With the foot at a right angle and the malleoli 
 in their normal relations, the dressing is applied. This dress- 
 

 FRACTURES OF THE EXTREMITIES 
 
 Fig. 210. — Pott's fracture. 
 
 tog, to quote Stimson further, is preferably a posterior and lateral 
 
 plaster splint although the 
 plaster cast may be used. 
 
 The plaster splint may be 
 made from twelve to thir- 
 teen layers, cut from a 
 4-inch plaster roller. The 
 posterior splint should be 
 long enough to extend from 
 the toes along the sole and 
 up the calf nearly to the 
 knee (Fig. 212). The lateral 
 one should begin just in 
 front of the external malle- 
 olus, pass over the dorsum of the foot to the inner side, under the 
 
 whole and up along the, outer side of 
 
 the leg to the same height as the poste- 
 rior ( Fig. 213). They are snugly molded 
 
 and bound to the limb while still wet, 
 
 with a roller bandage. 
 
 In the meantime, till the plaster sets, 
 
 the reduction must be maintained. 
 Dupuytren's splint is often of great 
 
 service in this fracture, especially as a 
 
 temporary dressing. It consists of in- 
 ternal lateral splint, well padded over 
 
 the ankle and which extends from 
 
 above the knee and projects beyond 
 
 the foot. It is held in place by a 
 
 bandage at the knee and above the 
 
 ankle. The foot is then abducted, flexed 
 
 to a right angle to the leg and secured 
 
 to the splint by a third bandage (Fig. 
 214). 
 These fractures are always serious 
 
 from a functional point of view and the 
 
 after treatment is of the utmost importance. 
 
 Fig. 211. — Pott's fracture. Note 
 fracture of internal malleolus. 
 
POTT S FRACTURE 
 
 295 
 
 Fig. 212. — Posterior splint applied. 
 (Stimson.) 
 
 Fig. 213. — Lateral splint 
 applied. (Stimson.) 
 
 Fig. 214. — Dupuytren's splint. Temporary dressing for Pott's fracture. 
 
FRACTURES OF THE EXTREMITIES 
 
 Flat foot is likely to occur from too early use not less than from 
 imperfect reduction. 
 
 Six to twelve weeks is required for a repair sufficient to bear the 
 patient's weight. 
 
 FRACTURE OF THE FOOT 
 
 Fracture of the astragalus may occur independent of injury to 
 the other bones and may occur with or without displacement of 
 
 PlG. 215. — Fracture o os calcis; result of fall, landing upon the feet. 
 
 the fragments. The swelling of the ankle, the pain on pressure 
 on the heel suggest the nature of the injury but only the X-ray 
 can make a definite diagnosis. Fracture of the body usually calls 
 
FRACTURES OF THE FOOT 
 
 297 
 
 for enucleation because of the non-union which is the usual event 
 and is accompanied by a persistent but low grade of arthritis. 
 Fracture of the neck is more favorable under proper treatment 
 which consists in prolonged immobilization in forced extension. Six 
 weeks at least must elapse before any weight is borne. It is essential 
 that this condition be not mistaken for a sprain. 
 
 Fracture with displacement may give rise to various deformities 
 but the most common is lateral dislocation of the foot. Its inner 
 
 Fig. 216. — Fracture of phalanges of the foot. 
 
 border is markedly curved, the outer malleolus projecting and the 
 j dislocated fragment palpated in front or behind the joint. Under 
 
 such circumstances an open operation is indicated with the purpose 
 ; of replacing the fragments or performing a partial or complete 
 I astragalectomy, and in this latter the operation will usually terminate. 
 
 Fracture of the os calcis, due to falls, the patient landing on his 
 feet, produces an impaction which flattens and widens the heel 
 and lowers the malleoli. The pain, swelling and disability are con- 
 
FRACTURES OF THE EXTREMITIES 
 
 - 
 
 stant but an accurate diagnosis can be made only by the X-ra 
 (Fig 215). 
 
 The prognosis depends in some degree upon the line of fracture, 
 but on the whole the outlook is bad. 
 
 Prolonged rest, massage, hot baths, etc., may eventually overcome 
 a large part of the lameness but under certain circumstances an 
 operation with readjustment and suture of the fragments will produce 
 an excellent result. 
 
 Fractures of the bones of the toes require much longer immobiliza- 
 tion than corresponding fractures in the hand (Fig. 216). The de- 
 formity and callus formation may produce points of pressure that 
 become serious impediments. These fractures should therefore be 
 treated with circumspection. 
 
CHAPTER XV 
 
 COMPOUND FRACTURES 
 
 It were perhaps better at once to proscribe the ancient term "Com- 
 pound" as applied to open fractures; but after all it conveys an idea 
 of duplication of traumatisms. And it is only within a recent period 
 that a compound fracture did not mean also an infected one. 
 
 Thanks to antisepsis, most open fractures at this time, progress 
 toward repair as rapidly as the closed. 
 
 But these open fractures require a particular care, and without 
 appropriate treatment, are as prone to give rise to dangerous compli- 
 cations as in former times. The outcome in a given case depends 
 largely on the first treatment. The indications are various, deter- 
 mined by the amount of fragmentation, the degree of destruction of 
 the soft parts, the injury to the blood vessels and, based upon these 
 factors, several clinical groups may be distinguished. 
 
 I. Compound Fracture, Small Skin Wound; no Injury to Blood 
 Vessels. — The first point to be determined is whether the skin lesion 
 communicates with the bone lesion. Often a fragment of bone pro- 
 jects; in other cases an undue amount of bleeding suggests perforation 
 of the soft parts. In any event, the wound must not be probed and if 
 there is doubt the fracture must be regarded as open. The treat- 
 ment is simple and exact. Cover the wound and proceed to paint the 
 field with iodine. Wait five to ten minutes for the solution to pene- 
 trate the skin and then proceed to sterilize the wound itself, injecting 
 it with iodine from a medicine dropper and subsequently, if the size 
 of the opening permits, wipe it out with a gauze swab saturated with 
 iodine. A sterile dressing is applied and from this point the fracture 
 is treated as if it were closed, and appropriate splinting employed. 
 
 II. The Wound is Large, the Bone Exposed and Soiled. — In this 
 case, under general anesthesia, the wound must be freely enlarged 
 and the ends of the bone, as well as the soft parts, painted with 
 iodine. If every angle and corner of the wound and the bone is 
 
 299 , 
 
^OO COMPOUND FRACTURES 
 
 particularly and carefully cleaned with the solution, infection is 
 only remotely probably. The bones are to be adjusted, fixed with a 
 bone clamp if the apposition is difficult to maintain, the muscle and 
 fascia sutured without drainage, and the skin wound with drainage. 
 Some form of splint is applied which will readily permit inspection 
 of the wound, and the bone clamps removed. The dressing must be 
 ample. 
 
 III. Large Wound, much Crushing of the Soft Parts, much Frag- 
 mentation. — The principle of antisepsis is the same as in the 
 previous case, but the disposition of the fragments presents a new 
 problem. It is best, we think, to proceed in this wise: Sterilize 
 the skin and other soft parts with iodine, enlarge the wound, ster- 
 ilize the bone fragments with the iodine and then douche the cavity 
 with hot normal solution until all the clots and debris are removed 
 and all the oozing checked. Next proceed to restore the outline of 
 the bone, replacing the fragments as nearly as possible in their nor- 
 mal relations, suturing them to the main body of bone with chromic 
 gut or securing them by bands of the same material, encircling the 
 shaft. 
 
 These cases are better drained for the first two or three days after 
 which, if there are no signs of infection, the drain should be left off. 
 
 Formerly, it was the practice to discard the fragments of bone. If 
 infection can be avoided or reduced to a minimum the fragments 
 will live and add greatly in restoring form and function. Even if the 
 periosteum is denuded, the fragments, though destined to be ab- 
 sorbed, will serve as scaffolding for the new bone cells, greatly 
 promoting osteogenesis. 
 
 IV. Extensive Fragmentation, Extensive Destruction of the Soft 
 Parts, Obliteration of the Principal Arteries. — In such cases it is the 
 part of wisdom to amputate. Occasionally the limb may be saved 
 but the attempt exposes to an infection that may cost the patient 
 his life. The recovery of a useful limb in these circumstances is 
 so rare as scarcely to justify assuming the septic risk. 
 
 V. Infected Compound Fracture. — If infection occurs by reason of 
 no treatment, or unsuccessful treatment, the temperature rises, 
 the limb swells, the pain augments — in short, the local and consti- 
 tutional signs and symptoms of infection supervene. These must be 
 
GAS BACILLUS INFECTION 3OI 
 
 watched for in every case, and the patient kept under close sur- 
 veillance. 
 
 Once infection manifests itself, the wound must be opened, re- 
 moving the sutures if necessary, and the wound irrigated with per- 
 oxide of hydrogen. Oftentimes it is only the skin wound which is 
 infected and the deeper levels of the wound should not be disturbed 
 until it is certain they have been invaded. 
 
 Even if the bone itself is involved an excellent result may still be 
 obtained, provided the splinting is efficient, the drainage ample, and 
 the general treatment sensible. 
 
 So much cannot be said if the infection is from the gas bacillus. 
 This extremely dangerous form of sepsis develops usually the 
 second or third day and is preceded by pain in the wound, out of all 
 proportion to its apparent seriousness. The wound looks red and 
 angry and exudes a bloody, fetid serum; presently the limb begins to 
 swell, the skin is crepitant, and blebs form. These manifestations 
 extend with the greatest rapidity, accompanied by grave constitu- 
 tional manifestations which end in death in twenty-four to seventy- 
 two hours. The diagnosis must be made at the very beginning of 
 the process if the treatment is to be of any use. Severe pain, an 
 unexpected rise in temperature the first days should put one on his 
 guard and at the first appearance of crepitation in the skin an am- 
 putation well above the infected site must be performed. If the 
 case is untreated or if the treatment is ineffective the progress of 
 the disease is extremely rapid although there is nothing else charac- 
 teristic of this form of toxemia. 
 
 A workman was brought to the City Hospital with a compound 
 fracture of the lower end of the radius. The injury was twenty-four 
 hours old. The wound was cleansed, the fracture splinted; but the 
 patient suffered extremely, out of all proportion to his injury; his 
 temperature began to rise and at the end of the second day it was 
 clear that a gas bacillus infection was under way. He understood 
 no English, but an interpreter explained that he must loose his arm or 
 his life. He chose the latter. At the end of the third day the arm 
 and shoulder were immensely swollen, the skin crepitant and cov- 
 ered with blebs and a few hours later he died in great agony. 
 
 An almost identical injury occurred in a fall from a cherry tree. 
 
: ( 02 
 
 COMPOUND FRACTURES 
 
 The signs of the infection promptly developed, the end of the bone 
 having been covered with soil. The patient, a middle aged woman, 
 consented readily to amputation at the shoulder. The flaps were 
 left open and packed with gauze saturated with peroxide. She made 
 an uninterrupted recovery. 
 
 In the young and healthy patient in the very early stages of the 
 disease a more conservative treatment may succeed. Multiple deep 
 incisions, packing the wounds with peroxide gauze or injecting the 
 
 Fig. 217. — Compound fracture of tibfa. (Moullin.) 
 
 soft parts above the level of infection with the peroxide. Finally the 
 danger of tetanus is to be emphasized and in every case of compound 
 fracture which has not been treated from the first in the manner 
 described, a prophylactic dose of antitetanic serum should be 
 administered. 
 
 COMPOUND FRACTURE OF THE TIBIA 
 
 These are by far the most frequent and require a special attention 
 both that infection may be avoided and that the limb's functions may 
 be preserved. (Fig. 217, 218) The tibia is so near the surface and 
 the line of fracture is so likely to be oblique, producing sharp points 
 of bone, and displacement is so common; these facts explain the 
 frequency of open fractures of the tibia. 
 
 The antisepsis in these cases presents no special feature; the chief 
 problem is in maintaining coaptation. If the fracture is oblique or 
 the bone much splintered, it is best to proceed in this manner; after 
 cleansing both outside and inside the wound with iodine, enlarge 
 
COMPOUND FRACTURE OF THE TIBIA 
 
 303 
 
 the wound freely, clean out all the clots and debris. The amount of 
 injury to the soft parts is often surprising. Expose the bone suf- 
 ficiently to secure an accurate coaptation of all the fragments. Now 
 apply a bone clamp in order to force the bones into intimate contact 
 and to hold them in that position until the dressing is applied. 
 
 Before beginning the operation, have fifteen layers of crinoline cut 
 from a pattern for a posterior splint and saturated with dry plaster of 
 
 Fig. 218. — Compound comminuted fracture of tibia and fibula. 
 
 Paris. The dressing having been applied to the wound in such manner 
 as not to interfere with the removal of the clamp, the posterior splint 
 is soaked and then molded to the leg and fixed with a few layers of 
 roller plaster. In the course of fifteen minutes the plaster is hard- 
 ened and the clamp may be loosened and removed. Interrupted 
 sutures placed but not tied can now be tightened and an additional 
 cover of gauze applied to the wound. 
 
^04 COMPOUND FRACTURES 
 
 
 Usually there is considerable oozing for the first few hours, necessi 
 tating frequent change of dressings, the best form of which is gauze 
 saturated with alcohol, this covered with absorbent cotton and th< 
 whole firmly bandaged. With a properly applied and effective splint 
 the limb can be handled and the dressings changed with but little 
 difficulty. Special care must be taken to prevent soiling of the 
 plaster splint since changing this short of two weeks may result in 
 recurrence of some displacement. Mild infection may occur but is 
 easily managed on general principles. Our results by this method 
 have been excellent. 
 
 COMPOUND FRACTURE ABOUT THE ANKLE AND FOOT 
 
 Fractures of this variety are frequent; always serious; and the 
 prognosis more or less uncertain, depending upon the degree of in- 
 fection and destruction of the soft parts. 
 
 Suppose a fracture of the inner malleolus: the soft parts are widely 
 separated, the joint cavity exposed, the astragalus dislocated. Such 
 an injury must be as conservatively treated as an abdominal wound. 
 Under no circumstances must the wound be explored with unclean 
 fingers or without careful cleansing of the field. Only after all the 
 preparations for definite treatment are made is the wound to be ex- 
 amined. If transportation is necessary, a temporary splint is pro- 
 vided, but at least do not cover the wound with a dirty handkerchief. 
 If there is much hemorrhage, circular constriction of the leg about 
 the knee will temporarily suffice. 
 
 The first dressing will determine the future of the limb, perhaps 
 even the life or death of the wounded. The whole foot and the lower 
 half of the leg are most carefully disinfected and the fracture and 
 joint cavity swabbed with iodine, enlarging the wound if necessary 
 to expose every nook and corner in order to wipe out foreign bodies, 
 splinters of bone and clots of blood. In this case, merely chosen for 
 example, the destruction of tissue is usually slight. After the 
 cleansing, replace the parts, leave one or two drains in the partly 
 sutured wound, bandage amply and place the limb at rest. 
 
 The situation is less simple where there is much destruction of 
 tissue, as in the case where the ankle is crushed. 
 
COMPOUND FRACTURE OF ANKLE 305 
 
 Begin with hot irrigations of normal salt solution. Do not fear to 
 enlarge the wound freely. It is of great importance that one be able 
 to determine definitely the conditions in the wound and to see what 
 he is doing. 
 
 You may find large fragments deformed and overlapping. Try 
 to replace them and often you will be thus enabled to restore the 
 contour of the joint. To retain these fragments, wiring or nailing 
 the fragments will often be an almost indispensable aid. 
 
 Another case: The epiphyses are reduced to fragments of various 
 sizes and forms. In irrigating, they flow away with the solution, so 
 loosened are they. The rest hang by a mere shred. 
 
 Reposition is here useless. The wreck is too great. You must 
 proceed to do an atypical resection. Do your best to spare the mal- 
 leoli or at least two processes which will serve to prevent lateral dis- 
 location when the joint is healed. 
 
 After this operation insert two drainage-tubes, one on either side; 
 and if there is considerable oozing, add an aseptic tamponade. 
 
 The prognosis is worse if infection has developed and there is fever, 
 redness, and swelling in the limb. Amputation will be the measure 
 of last resort and yet do not amputate until free opening has again 
 been tried. Irrigate with peroxide. The removal of dead bone, 
 etc., is followed by deep drainage but this must be done without 
 delay. It is not union, or consolidation, or function of the limb 
 which is the chief concern. It is infection against which all the forces 
 of antisepsis are marshalled. 
 
 Osteomyelitis is the contingency feared. In such a case, do not 
 employ a typical amputation or resection, but an atypical one, re- 
 moving only such tissues as must be removed, and later when the in- 
 fection has disappeared, the necessary operations may be done. For 
 additional remarks on treatment of compound fractures see Gunshot 
 Fractures (page 155). 
 
CHAPTER XVI 
 
 FRACTURE OF THE CLAVICLE, SCAPULA, RIBS, 
 SPINE, PELVIS 
 
 Fractures of the clavicle formerly occurred more frequently than 
 any other, but are not now so frequent. One-half of the cases are 
 in children. The break very much more often occurs in the middle 
 third, occasionally in the outer third, but rarely in the inner third. 
 In the middle third, the inner fragment overrides the outer, the re- 
 
 Fig. 219. — Fracture of clavicle. Inner fragment Fig. 220. — Velpeau's bandage for 
 lifted upward by sterno-mastoid. (Moullin.) fractured clavicle. (Stewart.) 
 
 suit of the action of the sterno-cleido-mastoid and the muscles that 
 pass from the thorax to the humerus, and the weight of the shoulder 
 (Fig. 219). 
 
 The patient leans his head toward the injured side and supports 
 the elbow, the position of greatest comfort. The nature of the 
 accident, the pain, deformity, crepitus, and mobility determine the 
 diagnosis. 
 
 Reduction. — Seat the patient on a low stool; direct the assistant 
 to stand behind and to grasp the patient's shoulders, steadying the 
 sound one with one hand and lifting the injured one upward, back- 
 
 306 
 
FRACTURE OF THE CLAVICLE 
 
 307 
 
 ward, and outward. At the same time the operator stands in front, 
 helping move the shoulder; and, by pressure and manipulation of 
 the clavicle between finger and thumb, molds the broken ends into 
 place. 
 
 The reduction is complete when the injured shoulder is as long 
 as the sound one, measuring each from the sterno-clavicular joint 
 to the tip of the acromion, landmarks which can always be defined. 
 Feel along the injured clavicle Jor any irregularities. Apply the 
 dressing. (1) If the patient is to be kept in bed for other reasons 
 
 Fig. 221. — Sayre's dressing. 
 First stage. (Moullin.) 
 
 Fig. 222. — Sayre's dressing com- 
 pleted. Posterior view. {Moullin.) 
 
 Fig. 223. — Anterior 
 view. {Moullin.) 
 
 than the clavicular fracture, it will be sufficient to keep him on his 
 back with a small pillow between his shoulders and with the hand 
 lifted to the chest. 
 
 (2) Any bandage or dressing which draws the shoulder upward, 
 outward, and backward, and holds it in that position will serve. Of 
 the dressings, a number are especially recommended, among them, 
 the Velpeau type of bandage (Fig. 220). They need to be applied 
 for three or four weeks. 
 
 In ordinary practice, the Sayre's dressing is excellent. The es- 
 sentials are two adhesive strips 3 inches wide and long enough 
 to go once and a half about the body, absorbent cotton, roller band- 
 
FRACTURES OF rill'. CLAVICLE, SCAPULA, RIBS, ETC. 
 
 Begin by fixing the end of one adhesive strip loosely about the 
 injured arm iust below the armpit. The loose end carried around 
 i he body will pass over the lower ends of the scapulae. Before com- 
 plet ing the turn about the body, place layers of cotton wherever the 
 cutaneous surfaces are to be in contact. The turn of the adhesive 
 strip about the body is completed. This holds the shoulder in the 
 backward and outward position (Fig. 224). The hand is drawn 
 across the chest toward the sound shoulder and the second adhesive 
 
 Fig. 224. — Mayor's sling. First stage. (Lejars.) 
 
 strip is applied. Fix one end over the sound shoulder and pass it 
 across the back to the elbow (Fig. 222). It covers the point of the 
 elbow and follows the arm across the chest to the starting-point 
 223). It is designed to lift the shoulder upward. A few turns 
 of roller bandage around the chest lend additional support and com- 
 plete the dressing. 
 
 Romer describes a method of dressing with adhesive strips which 
 does not require the arm to be fixed to the side (Lancet, London, 
 
THE MAYOR SLING 
 
 309 
 
 March 31, 1909). Three strips of Z. O. plaster, each an inch and 
 a half in width, should be applied from a point immediately above 
 the nipple, passing over the clavicle to a point below the angle of the 
 scapula. The middle strip should cover the site of the fracture and 
 should be first applied, the lateral ones overlapping it. The strips 
 should be firmly applied while the fragments are kept in apposition. 
 
 %H 
 
 Fig. 225. — Mayor's sling. Second stage. 
 The bandage is molded snugly to the arm. 
 (Lejars.) 
 
 Fig. 226. — Mayor's sling completed. 
 {Lejars.) 
 
 The scapula may be steadied by a strip crossing its lower angle lat- 
 erally. The arm is to be carried in a sling. 
 
 Mayor's sling serves an excellent purpose here as well as in certain 
 injuries to the arm. It is applied in this manner: 
 
 Take a square of strong, unbleached muslin, or similar material, 
 large enough to reach easily about the body; fold it into a triangle, 
 
3i° 
 
 FRACTURES OF THE CLAVICLE, SCAPULA, RIBS, ETC. 
 
 The elbow having been flexed to an acute angle and the hand carried 
 toward the sound shoulder, the bandage is carried across the flexed 
 arm and around the chest, its upper level being just below the level 
 of the axilla (Fig. 224). The two points are fastened behind with 
 a safety-pin or tied. 
 
 Now turn the third point of the triangle upward between the 
 flexed arm and the body, and carry it up over the shoulder of the 
 injured side (Fig. 225). Mold the bandage well, so that it fits and 
 supports the forearm snugly. The dressing is completed by bands 
 crossing over the shoulders and connecting the anterior and posterior 
 parts of the bandage after the manner of suspenders (Fig. 226). 
 
 FRACTURE OF THE SCAPULA 
 
 These fractures are comparatively rare, about 1 per cent, of all 
 fractures. 
 
 The body, the spine, the acromion process, the coracoid process 
 
 may be involved and the fracture 
 is usually due to direct violence. 
 
 The X-ray will often be neces- 
 sary to locate the lesion definitely 
 although the pain, tenderness, and 
 perhaps crepitation will determine 
 the presence of some kind of frac- 
 ture. In the case of the acromion 
 process the functions of the deltoid 
 are disturbed; in the case of the 
 coracoid, the biceps and pectoralis 
 minor. Respiration may be pain- 
 ful by reason of the pull on the 
 latter muscle. 
 
 The action of these muscles 
 must be considered also in instituting treatment. It is sufficient 
 usually to fit the arm in a sling and immobilize the scapula by adhe- 
 sive strapping. 
 
 Fracture of the neck (Fig. 227) is of importance because it may be 
 mistaken for fracture of the surgical neck of the humerus but in such 
 
 Fig. 227.- 
 
 -Fracture of the neck of the 
 scapula. 
 
FRACTURE OF THE SCAPULA 311 
 
 a case the head can be felt to rotate, which it would not do in disloca- 
 tion. The deformity disappears on lifting the arm forcibly upward 
 with the elbow flexed, which does not happen in a case of fracture of 
 the humerus; the arm hangs vertically at the side and is mobile. 
 There is no notching of the deltoid. 
 
 In the case of fracture of the surgical neck of the humerus with 
 overriding, the arm is shortened. In case of fracture of the scapular 
 neck, the arm is lengthened. 
 
 Generally speaking, the diagnosis of any fracture of the scapula is 
 to be made from crepitus, abnormal mobility, local tenderness, and 
 more or less complete loss of certain functions. Begin the examina- 
 tion by inspection and measurement. Note any loss of contour; 
 any lengthening or shortening of arm. To elicit crepitus, apply one 
 hand to the body of scapula and with the other make traction on the 
 ,' arm. In thin subjects the lower end of the scapula may be readily 
 
 grasped. 
 : Treatment. — The flexed elbow should be well supported by a sling, 
 1 and the arm fixed at the side. Massage will relieve the paip and 
 ( hasten repair. Mayor's sling furnishes an excellent dressing. 
 
 I 
 
 FRACTURE OF THE RIBS 
 
 Fractures of the ribs occur most frequently between the fifth and 
 , ninth, and are usually single and without displacement. If the 
 ! . violence is sufficient to break a number of the ribs simultaneously, 
 it may cave in the chest wall; and, by perforation of the lung, 
 produce emphysema, hemoptysis, pneumothorax. Pain and crepitus 
 point to the presence of fracture. Detect crepitus by laying the 
 palm over the site of the pain or by the stethoscope. 
 
 Slight displacements may be reduced by making pressure over 
 the site of fracture during inspiration, or perhaps by compressing 
 the chest from front to back between the two hands. Apply ad- 
 hesive strips 2 inches wide over the injured side, beginning at the 
 scapula, and following the course of the ribs around to the sternum. 
 
 Three or four strips may be necessary, and they must be applied 
 at the end of expiration. 
 
 The pain will almost always be relieved by such immobilization 
 
 1 
 
SI- 
 
 FRACTURES OF THE CLAVICLE, SCAPULA, RIBS, ETC. 
 
 of the chest wall. Those fractures which involve the viscera are 
 considered with injuries of the thorax. 
 
 FRACTURES OF THE VERTEBRA 
 
 Fractures of the vertebra derive their chief importance from the 
 accompanying injury to the spinal cord and are serious in proportion 
 to the amount of injury to the cord, ligaments, and tendons. 
 
 Aside from local pain and deformity, the symptoms are such as 
 arise from compression or laceration of the cord and vary somewhat, 
 depending on the particular portion of the cord involved. Fractures^ 
 
 of the cervical vertebra are at 
 
 
 
 Fig. 228. — Fracture of vertebra. (Moullin.) 
 
 once the most common and 
 fatal. Fractures in the lumbo- 
 dorsal region occur next in fre- 
 quency. The break which 
 usually involves the body of 
 the vertebra, but may include 
 the lamina or transverse or 
 spinous processes, is generally 
 due to forced flexion. Along 
 with the fracture the ligaments 
 are lacerated, the muscles torn, 
 the vertebra displaced and the 
 blood vessels opened. There 
 may be present paraplegia and 
 disturbances of the functions 
 of bowel and bladder; and in 
 addition to these symptoms 
 common to fractures of the 
 
 there are certain others which are 
 
 vertebra wherever located, such as pain, tenderness to pressure 
 
 and motion. Occasionally one will find deviations and angular 
 
 deformities (Fig. 228). 
 
 r The prognosis in a well-defined case is always bad, although by no 
 
 means always hopeless. 
 
 The emergency treatment is limited generally to transportation and 
 securing the proper bedding. The patient must be handled with the 
 
FRACTURE OF THE SPINE 313 
 
 greatest care. Sometimes the least added pressure on the cord by 
 the movements of the spine may produce immediate death. 
 
 The bed must be uniformly soft and smooth. A water bed is ideal. 
 If the symptoms of compression are urgent, it is necessary at once to 
 make an effort to reduce the fracture by simultaneous traction and 
 pressure. While the assistants pull on the head and feet, the doctor 
 attempts, by pressure, to correct the deformity. There is some 
 danger of a fatal asphyxia where the fracture is high, in making these 
 manipulations, as the patient is turned on his face and the move- 
 ments of the diaphragm may be interfered with. Laminectomy is 
 not to be considered when the indications point to complete crushing 
 of the cord. In other cases where the pressure symptoms are 
 obvious, a laminectomy should be done with delay. (See Wounds of 
 the Spine.) 
 
 FRACTURE OF THE PELVIS 
 
 Fracture of the pelvis may be suspected from the character of the 
 injury, which is usually a fall or a crush. The diagnosis is to be con- 
 firmed by external palpation of the ilium, pubes, and ischium on each 
 side, and by careful rectal and vaginal examination. Disturbance of 
 normal relations, tenderness on pressure, crepitation perhaps, and 
 difficulty in walking indicate fracture (Fig. 229). 
 
 The prominence of the symptoms will depend in some degree upon 
 the amount of displacement. 
 
 The X-ray of course will be used whenever available. 
 
 The treatment in the uncomplicated cases is simple. Usually 
 nothing can be accomplished in correction of the displacement and 
 simple rest in bed with adhesive strapping represent the elements 
 of relief. T ivo recent cases in the City Hospital treated in this 
 manner recovered in six weeks. It is quite different if there are 
 complications. 
 
 If a catheter cannot be passed (and this should always be tried), 
 it will be necessary to do an external urethrotomy for the ruptured 
 urethra. If the catheter finds the bladder empty and ruptured, a 
 laparotomy is imperative. If the exact complications cannot be 
 determined and yet shock, pain, and increasing abdominal tension, 
 
314 
 
 FRACTURES OF THE CLAVICLE, SCAPULA, RIBS, ETC. 
 
 with signs of sepsis, point to a lesion of bladder or rectum, the abdo- 
 men must be opened, and the visceral injury found and repaired. 
 
 A woman was brought into the City Hospital the victim of an 
 automobile collision. She was in full shock and the pelvis was 
 plainly disarranged. The shock improved a little but the pulse re- 
 mained rapid and weak. A catheter brought only a little blood 
 from the bladder. A laparotomy showed the bladder to be greatly 
 
 Fig. 229. — Fracture of the pelvis through the obturator foramen and dislocation 
 at the sacroiliac joints. (Moullin.) 
 
 contused, but not torn and there was much blood in the cellular tis- 
 sues around; a large hematoma had formed under the pelvic perito- 
 neum. Suprapubic drainage was applied but the patient lived only 
 a few hours. Shock, the hemorrhage, and beginning infection were 
 beyond the limits of her resistance. 
 
 Following a variety of traumatisms there is often a condition now 
 well recognized as relaxation of the sacroiliac synchondrosis which 
 simulates fracture and which may become quite chronic. It is re- 
 lieved by adhesive strapping. 
 
CHAPTER XVII 
 FRACTURES OF THE SKULL AND FACE 
 
 Fractures of the skull are important practically only from the 
 point of view of their complications, which number three; infection, 
 hemorrhage, and injury to the brain. 
 
 In a given case, one or all of these complications are possibilities, 
 although for the development of each, certain combinations of 
 circumstances are peculiarly favorable. 
 
 With respect of these variations, fractures of the skull are of two 
 classes: fracture of the base and fracture of the vault. Each has its 
 special symptomatology and prognosis, though the one may merge 
 into the other and the clinical picture be more or less blurred. 
 
 Either may be fissured, fragmented, or compound, with or with- 
 out depression. In either the immediate gravity depends upon the 
 nature and extent of the injury to the brain, and fractures of the base are 
 the more serious, merely because the more important areas of the brain 
 are there. 
 
 With regard to the remoter consequences also, fractures of the 
 base are less favorable; hemorrhage and its resultant complications 
 are more to be feared; and infection is a more certain eventuality 
 owing to the communications opened up between the cranial cavity 
 on the one side and the ear, the nose, or the pharyngeal region on the 
 other. 
 
 The symptoms in either kind of fracture are such as arise from 
 concussion, compression, or laceration of the brain and are general 
 or focal, that is to say, emanating from certain cerebral areas. 
 
 FRACTURES OF THE BASE 
 
 Fractures of the base of the skull are more frequently indirect, the 
 force being transmitted through the spinal column from some part 
 of the vault or the ramus of the jaw; occasionally direct by a thrust 
 
 315 
 
316 FRACTURES OF THE SKULL AND FACE 
 
 through the mouth, a blow on the root of the nose, or upon the 
 mastoid process. 
 
 Any or all of the fossae may be involved. Fracture through the 
 middle fossa is most frequent, and the most serious is fracture through 
 the posterior fossa. These fractures are usually linear because the 
 force is indirect and because there is only one determinable table 
 instead of two, as in the vault. 
 
 These fractures are nearly always compound, which adds to the 
 gravity of the prognosis. The external meatus, the nasal cavities 
 and the naso-pharynx are all prolific sources of meningeal infection. 
 
 The diagnosis is usually by inference, often impossible. There 
 are certain symptoms always suggestive of fracture at the base, 
 but not to be relied upon exclusively. 
 
 Ecchymosis in the tissues about the orbit, or hemorrhage into the 
 sclerotic, appearing first some little time after the injury, and 
 gradually progressive — fracture through the anterior fossa suggests 
 itself. Persistent bleeding from the nose following head injury must 
 be given due consideration. Bleeding from the external meatus, 
 copious and persistent, suggests fracture through the middle fossa. 
 Late ecchymosis over the mastoid or into the tissues of the back of 
 the neck suggests fracture through the posterior fossa. The dis- 
 coloration follows the posterior auricular artery. However, these 
 hemorrhages must not be mistaken for local rupture of mucous 
 membrane or other soft parts and their absence does not necessarily 
 mean absence of fracture. 
 
 The bleeding, if intra-cranial, may come from rupture of the 
 middle meningeal, or the internal carotid, or the sinuses. Instead 
 of the bleeding, or accompanying it, there may be escape of cerebro- 
 spinal fluid. Its presence is pathognomonic of fracture of the skull, 
 and it must be distinguished from ordinary serum and the fluid of 
 the middle ear by these characteristics: the flow begins at once and 
 continues for several hours; the quantity is considerable, sometimes 
 a tablespoonful in fifteen to twenty minutes; the flow is temporarily 
 increased by the increase of intra-cranial pressure, sneezing, cough- 
 ing, and vomiting; alkaline in reaction; contains only a trace of 
 albumin and is rich in sodium chloride. 
 
 Useful in definite diagnosis are the paralyses of the Cranial nerves. 
 
FRACTURES OF THE SKULL 317 
 
 Recall their origin, course, and functions. The facial, optic, and 
 tri-facial nerves are especially likely to be involved. For example, 
 the optic nerve will be involved if there is a fissure of the optic canaL 
 Vision may be lost totally and immediately; even though total at 
 first, the blindness may gradually pass away. It will be impossible 
 for some time to say whether the recovery will be permanent. Added 
 to these nerve symptoms, but not particularly helpful in the diagnosis 
 of fracture, may be those of concussion, compression, or laceration. 
 All these conditions may exist with or without fracture. 
 
 The treatment has two ends in view, the prevention of further irri- 
 tation of the brain and the prevention of infection. 
 
 Keep the patient absolutely quiet in bed with the head elevated, 
 apply ice-bags, and keep the bowels open. 
 
 Whenever fracture of the base is even merely suspected, care- 
 fully wipe out the external meatus and pack lightly with sterile 
 gauze. Do not syringe the meatus or at least only very gently, lest 
 infection be forced through the fissure. 
 
 Remove the gauze as often as it becomes soaked with blood, which 
 may be at frequent intervals for several days. Spray the nose and 
 throat with peroxide of hydrogen or a similar mild antiseptic. These 
 regions cannot be sterilized, but bacterial activity may be mini- 
 mized. Do not pack the nares except for persistent nasal hemor- 
 rhage, as the packing irritates the mucosa and unduly stimulates 
 secretion, and this is undesirable. Again, such packing may excite 
 a sneeze which by its explosive effect may carry infection through 
 the fissure to the meninges. If packing is deemed necessary, pack 
 with sterile gauze saturated with sterile vaseline. In the great 
 majority of cases, active intervention is quite out of the question either 
 for the relief of infection or for hemorrhage. But this is true merely 
 because the technic is not definitely worked out. The principle of 
 drainage for infection and removal of compressing clots applies with 
 as much force here as in fractures of the vault (see Craniectomy). 
 
 FRACTURES OF THE VAULT 
 
 Fractures of the vault of the skull may be fissured, comminuted 
 or compound, any one of which may be complicated by concussion, 
 compression, contusion, or intra-cranial hemorrhage. The symp- 
 
FRACTURES OF THE SKULL AND FACE 
 
 toms belong to the brain complications rather than to the fracture 
 itself. 
 
 Simple, fissured fracture without depression is^practically im- 
 possible of diagnosis. The diagnosis is easier if depression is pres- 
 ent, and yet certain injuries to the scalp simulate fracture with de- 
 pression. A blow crushes the soft tissues and around the crushed 
 area marked swelling ensues. The sensation to the examining finger 
 is that of a depression of the bone. Do not be misled. 
 
 Comminuted fracture of the 
 skull even without depression 
 is generally diagnosed, and yet 
 a hematoma may mask the 
 fragmentation. Be on your 
 guard in that matter. 
 
 The inner table is always 
 more injured than the outer 
 (Figs. 230, 231). 
 
 The prognosis is good and the 
 treatment simple in fissured 
 fracture without depression and 
 without symptoms indicating 
 compression. 
 
 Put the patient to bed, keep 
 the bowels open, limit the diet, 
 and await developments. Un- 
 interrupted recovery usually follows, yet the exceptions to this rule 
 are not infrequent and one must be on his guard for intra-cranial 
 hemorrhage. Or later, there may develop symptoms which are 
 explainable only on the hypothesis of contusion of the brain. 
 
 If at any time symptoms arise indicating the occurrence of hemor- 
 rhage, say from a rupture middle meningeal, immediate interven- 
 tion is indicated. Some surgeons go so far as to recommend tre- 
 phining for every fracture of the skull and exploratory operation 
 in every suspected case, but that seems at the present time too 
 radical, especially for the general practitioner left to his own 
 resource. 
 
 If the fracture is comminuted or even only fissured, with depres- 
 
 Fig. 230. — Fracture of outer table from 
 impact of a hammer. (Moullin.) 
 
COMPOUND FRACTURES OF THE SKULL 
 
 319 
 
 sion, the chances are so great that there is an injury to the brain 
 that even with no symptoms present, immediate operation is indi- 
 cated. (See Urgent Craniectomy.) 
 
 COMPOUND FRACTURES OF THE VAULT 
 
 Much more serious from every point of view are the compound 
 fractures of whatever origin. The constant element of danger is 
 injection. Add to this concussion, contusion, or laceration of the 
 brain, and the outlook is grave 
 indeed. The treatment is not 
 so simple, but its purpose is 
 quite definite, viz.: to prevent 
 infection. 
 
 This is accomplished not by 
 keeping the bacteria out of the 
 wound — they are already in; 
 not by destroying them with 
 strong antiseptics, as these are 
 too injurious to the brain tis- 
 sues, but rather by removing 
 the conditions favorable to 
 bacterial growth. 
 
 To this end operation is im- 
 perative. As in gunshot frac- 
 tures, enlarge the wound, re- 
 move extraneous matter, ele- 
 vate depressed fragments, check the hemorrhage and remove clots, 
 trim away devitalized tissues and provide drainage {See Craniectomy). 
 Careful attention to these details results in the starvation of the 
 germs present, with the result that repair proceeds. 
 
 Skill in diagnosis, prognosis, and treatment in fracture of the skull 
 depends upon a clear understanding of the mode of causation and 
 the symptoms of contusion, compression, and concussion of the brain. 
 
 Although presenting quite a diverse clinical picture, separately 
 considered, these three conditions are nevertheless of the same 
 origin fundamentally. They are each merely a complex of symp- 
 toms expressing, on the one hand, varying degrees of either functional 
 
 Fig. 231. — Same; fracture inner table. 
 Xote greater comminution and depression. 
 (Moullin.) 
 
320 FRACTURES OF THE SKULL AND FACE 
 
 depression or stimulation of the cortex of the brain or, on the other, 
 of the deeper centers of the cerebrum and medulla. The cortex is 
 the seat of consciousness and at the same time the most sensitive 
 part of the brain; therefore it is the first to be affected by conditions 
 disturbing the circulation of the brain. 
 
 The deeper centers, those governing respiration and circulation, 
 are not so readily affected. The result is that loss of consciousness 
 is the first phenomenon following a general disturbance of traumatic 
 origin. This trauma may not be sufficient to reach the cardiac and 
 respiratory centers at first or at all; or it may only stimulate them; 
 or finally it may paralyze them as well as the cortex. It must like- 
 wise be constantly remembered that stimulation of these basal 
 centers means retardation of pulse and respiration; depression of 
 the same centers means acceleration of pulse and respiration, and 
 acceleration is an indication of approaching failure. 
 
 It is only by reference to these first principles that one may ex- 
 plain and reconcile the variations in the derangements of these 
 functions of consciousness, circulation, and respiration in different 
 cases. 
 
 CONCUSSION 
 
 This is in all probability due to a molecular disturbance of the 
 brain substance, and is accompanied by neither microscopic nor 
 macroscopic change. The disturbance may be (a) moderate, (b) 
 severe, or (c) profound. 
 
 (a) The disturbance is moderate. Under these circumstances, 
 the trauma diminishes the function of the cortex, but does not affect 
 the deeper centers of the brain and medulla, so there is therefore only 
 a fleeting loss of consciousness without any change whatever in the 
 pulse and respiration. 
 
 (b) The disturbance is severe. The force depresses the cortex, but 
 only serves to stimulate the deeper centers, and, as before, there is 
 loss of consciousness, but there is this time slowing of pulse and 
 breathing. Very soon the normal rate returns and a little later 
 consciousness is restored. 
 
 (c) The disturbance is profound. The cortex is paralyzed and 
 profoundly depressed as are also the deeper centers. The result 
 
 
CONCUSSION 321 
 
 is loss of consciousness and this time rapid and weak pulse and shal- 
 low breathing which may terminate very shortly in death. In 
 doubtful cases, then, the heart is the chief element in prognosis. 
 The pulse immediately grows either worse or better. 
 
 Therefore the symptoms of concussion are distinctly fugacious. 
 This is its chief criterion. 
 
 If the symptoms once improve and later recede, one may be sure 
 the primary concussion is complicated by compression or contusion. 
 Added to these phenomena of concussion, though not particularly 
 helpful in diagnosis or prognosis, are certain other occasional symp- 
 toms, referable to the reflexes. 
 
 In the severe cases this will usually be the picture: At the moment 
 of injury, unconsciousness occurs, immediate and complete. The 
 patient is more than unconscious, he is anesthetized. The face is 
 pale and sunken and the whole body cool. The pulse is small, 
 rapid, and irregular. The temperature is subnormal. The breath- 
 ing is shallow and sometimes sighing. The urine and feces may be 
 retained or pass involuntarily. Repeated vomiting is quite common, 
 especially as consciousness begins to return. Following the return 
 of consciousness, a stage of excitement occurs. The symptoms of 
 this stage are those of meningeal irritation, and in uncomplicated 
 cases rapidly subside. 
 
 The treatment is quite definite. Disturb the patient as little as 
 possible in getting him into bed. Lower the head at first and try 
 to maintain the body heat with woolen blankets and hot-water 
 bottles. Carefully stimulate the heart. To this end, apply a mus- 
 tard draft over the heart and inject ether hypodermically or a 10 
 per cent, solution of camphorated oil. Repeat these injections fre- 
 quently, being guided by the pulse. Von Bergmann recommends 
 inhalations of ether for the very weak and failing pulse. 
 
 Do not forget artificial respiration. In those severe cases where 
 the respiration is dangerously low, it will sometimes tide the patient 
 over the danger-line. 
 
 In the subsequent stage of congestion, keep the head elevated 
 and apply ice-caps if the dressings will permit. Keep the bowels 
 open. If the excitement and restlessness are pronounced, mor- 
 phin hypodermically is indicated. 
 
322 FRACTURES OF THE SKULL AND FACE 
 
 COMPRESSION 
 
 Any condition, traumatic, inflammatory, or neoplastic, which 
 diminishes brain room, may induce symptoms of compression of the 
 brain. The symptoms and their course will vary according to the 
 manner in which the pressure is produced. 
 
 What is said here applies particularly to the pressure symptoms 
 originating in depressed fracture or traumatic hemorrhage, though 
 much would apply equally well to the pressure of brain abscess or 
 brain tumors, or meningeal exudates and similar conditions. 
 
 Pressure symptoms have fundamentally the same origin as con- 
 cussion symptoms, that is to say, they are an expression of de- 
 pression or of stimulation of the functions of the cortex and the auto- 
 matic centers. In both there may be initial stimulation and terminal 
 paralysis. However, this depression or stimulation is produced 
 differently in the two conditions, concussion and compression. 
 
 In the first case, the disturbance of function is brought about by 
 mechanical injury and in the second by interference with the blood 
 supply. Sudden diminution in the circulation modifies the func- 
 tional activity of the brain centers. 
 
 The cortex, the most sensitive, is first affected, followed by loss of 
 consciousness. The automatic centers are next affected, at first 
 stimulated, though each reacts differently; thus the respiratory center 
 is the first to be stimulated and by the presence of carbon dioxide 
 which was its primal stimulus. The vaso-motor centers are next 
 invaded, and finally the vagal and convulsive centers. * 
 
 In those cases where the circulation becomes gradually slower, 
 the order in which these centers and areas are successively affected 
 is as follows: the cortex, the corona radiata, the gray matter of the 
 spinal cord, the pons, and finally the medulla. Now the symptoms 
 originating in these various areas as a result of pressure are of two 
 kinds: 
 
 (a) General or indirect. 
 
 (b) Focal or direct. 
 
 Each may manifest itself in two stages: 
 
 (i) Stage of stimulation. 
 
 (2) Stage of depression or paralysis. 
 
 
COMPRESSION 323 
 
 It is the knowledge of these facts which enables us to harmonize 
 and reconcile the diverse statements of various observers regarding 
 the character and cause of the symptoms of compression. It is in 
 the hemorrhage arising from the middle meningeal artery that the 
 emergency surgeon is chiefly interested. Traumatic compression 
 sufficiently serious to require immediate operation in nine cases out 
 of ten originates in: 
 
 BLEEDING FROM THE MIDDLE MENINGEAL ARTERY 
 
 This may follow injury to the head with or without fracture. The 
 fracture may or may not be diagnosed. 
 
 In a typical case the concussion symptoms which supervened im- 
 mediately upon the injury disappear after a half -hour. The patient 
 regains consciousness, and the pulse and respiration approximate 
 the normal. 
 
 In the meantime, however, the blood from the torn meningeal is 
 slowly oozing into the space between the dura and the skull, and the 
 "free inter val" is interrupted by headache, irritability, perhaps 
 delirium (stimulation of the cortex). The epidural clot grows 
 larger, the intra-cranial circulation is more impeded and complete 
 loss of consciousness occurs (depression of the cortex). Coincident 
 with this, the pulse grows slower and stronger, the respiration deep 
 and stertorous (stimulation of automatic centers). A little later 
 coma is profound, the respiration begins to fail, and the heart's 
 action grows rapid, weak and irregular (depression of both cortex 
 and automatic centers), and finally all the functions of the entire 
 organ are suppressed and paralyzed, and death ends the scene. 
 
 Along with these general symptoms there frequently occur at 
 various stages certain focal symptoms, monospasms, convulsions; 
 monoplegia or hemiplegia. 
 
 Usually at the time the decision to operate is made, this will be the 
 condition of the patient: He lies inert, unconscious, the pulse full 
 and bounding, the respiration deep and stertorous, the skin hot and 
 perspiring, the pupils irregular, usually dilated on the side of com- 
 pression, partial or complete hemiplegia of the opposite side. 
 
 Treatment, — With a definite diagnosis once made, there is no 
 
324 FRACTURES OF THE SKULL AND FACE 
 
 difference of opinion as to the treatment. It is imperative to operate, 
 and to do so without delay. Every additional hour adds to the 
 certainty of a fatality. The nature of the injury and the focal 
 symptoms point to the site of the clot or the branch of the meningeal 
 most probably involved. 
 
 By trephining, the clot is exposed, and removed, and the bleeding 
 vessel discovered and ligated. (See Craniectomy.) 
 
 The pressure symptoms of hemorrhage from injuries of the sinsues 
 are identical with those from meningeal bleeding except that they 
 develop much more slowly and are likely not to be so typical. 
 Hemiplegia is not always in the side opposite the clot. 
 
 FRACTURE OF THE SUPERIOR MAXILLA 
 
 Fracture of the superior maxilla occurs alone or with fracture 
 the malar or other bones of the face. It may be accompanied by 
 splintering of the bone, caving of the antrum, loosening of the teeth, 
 and disfigurement generally. The alveolar process may be broken 
 off. If this is the case, it may be replaced without great difficulty. 
 
 Oftentimes little can be done to correct the deformity. The lower 
 jaw can be used as a splint and very little force is needed to retain 
 the fragments in position. 
 
 If the fracture is compound, the fragments should be treated con- 
 servatively. It is surprising how perfectly they may sometimes be 
 repaired. The vascularity of both bone and periosteum favors this 
 result. 
 
 With the jaw at rest, a liquid diet should be maintained, frequently 
 cleansing the mouth with alkaline antiseptic fluids. Be on guard for 
 fracture of the base of the skull. 
 
 FRACTURE OF THE MALAR BONE 
 
 Fracture of the malar bone seldom follows the suture lines. The 
 whole bone may be dislocated in a direction corresponding to the 
 force. In this manner, the violence may be transmitted to the supe- 
 rior maxilla, its sinus and infra-orbital canal, to the nose, the orbit, 
 or to the base of the skull. 
 
 
FRACTURE OF THE LOWER JAW 325 
 
 Uncomplicated fractures of the malar bones require little treat- 
 ment. Compound fractures must be treated on general principles. 
 
 It may be possible to replace a depressed fracture of the zygomatic 
 process by pressure through the mouth. 
 
 FRACTURE OF THE NASAL BONE 
 
 Aside from gunshot fractures (see page 190), the bones of the face 
 suffer occasionally from direct violence. 
 
 The nasal bones may be fractured alone or in connection with the 
 ethmoid. Bleeding is profuse and deformity apparent. On account 
 of infection from either the outside or inside of the nasal cavity, 
 inflammation and necrosis may be a sequela. 
 
 An attempt should be made at once to elevate the depressed frag- 
 ments by pressure within the nasal cavity. The reduction may be 
 both difficult and painful. General anesthesia may be necessary. 
 
 Check the hemorrhage by mopping the nasal cavity with a solution 
 of adrenalin chloride, or pack temporarily with sterile gauze. Sub- 
 sequently douche the nasal cavity frequently with glycothymoline or 
 Seiler's solution to prevent infection. 
 
 FRACTURE OF THE INFERIOR MAXILLA 
 
 Fractures of the inferior maxilla occur most frequently just in 
 front of the mental foramen, and are usually compound, opening into 
 the mouth. 
 
 The deformity is determined chiefly by muscular action and the 
 degree of obliquity. 
 
 The diagnosis is rarely difficult. 
 
 Reduction, which is indicated by a correct alignment of the teeth, 
 may be accomplished by bimanual manipulation with the fingers of 
 one hand in the mouth. This is usually easily done, the chief diffi- 
 culty being to retain the fragments in position. The prevention of 
 infection is likewise important (Fig. 232). 
 
 Oliver, of Indianapolis (Ind. Med. Journal, 1906), has described 
 the mode of treatment most applicable in the emergencies of general 
 practice. He recommends, as the result of his experience, that in 
 
326 
 
 FRACTURES OF THE SKULL AND FACE 
 
 the ordinary case, when the patient retains the majority of his teeth, 
 the upper jaw be used as a splint. 
 
 This is his procedure: before attempting reduction and without 
 anesthesia, if possible, he begins by passing a loop of wire (soft iron 
 wire, gauge 26 or 28) around the neck of the most available tooth 
 behind the break in the lower jaw; a similar loop is thrown around the 
 corresponding tooth in the upper jaw. Coming forward of the frac- 
 ture the first solid tooth and its fellow 
 above are both looped in the same 
 manner. 
 
 Next a similar loop is adjusted 
 above and below on the opposite side 
 of the jaw — on the sound side. Alto- 
 gether six separate wires have been 
 used. Each loop is now twisted down 
 tight with a pair of pliers, so that the 
 teeth are firmly encircled and the free 
 ends of the wires left projecting from 
 the mouth (Fig. 233). 
 
 Reduce the fracture as the next step. 
 This is done by pressure and traction 
 with the fingers inside and outside of 
 the mouth. 
 
 Immobilize. — This is accomplished 
 by twisting firmly together by means 
 of the pliers the corresponding upper and lower wires, which brings 
 the lower jaw into intimate contact with the upper. 
 Liquid diet sucked through the teeth. 
 
 Antisepsis. — -Direct the patient to fill his mouth with the antiseptic 
 fluid and to churn it vigorously backward and forth between the 
 teeth. This washing should be done frequently each day, and 
 especially after each feeding. If necessary, as additional support, 
 a plaster-of-Paris or Barton's bandage may be applied. 
 
 The wires are left for three weeks, or longer in the severe cases, 
 and after their removal a bandage should be kept on for another 
 week. The patient should be supplied with a small pair of wire 
 cutters and direct how to use them in an emergency, such as serious 
 vomiting which might result in asphyxia. 
 
 Fig. 232. — Fracture of lower jaw. 
 Temporary bandage. {Moullin.) 
 
 
SUTURING FRACTURE OF THE JAW 
 
 3 2 7 
 
 As Oliver observes, this formula may be varied to suit the indi- 
 vidual case. The many forms of splints need not be here considered. 
 The cases of special difficulty in reducing and retaining, those which 
 are compound and those in jaws practically edentulous, require 
 wiring. This is an operation simple in theory, but more difficult in 
 practice. 
 
 Fig. 233. — Wiring the teeth for fracture of the lower jaw. Note the manner in which 
 the wires encircle the upper and lower teeth before and behind the line of fracture. The 
 upper wire is subsequently twisted with its corresponding wire below, so that the lower jaw 
 is splinted against the upper. 
 
 The main points are to make the incision along the lower border 
 of the jaw, cutting to the bone and letting the middle of the incision 
 fall over the line of fracture. The bone is carefully denuded of 
 periosteum. The sutures are not to come in contact with the buccal 
 surfaces. The bones are drilled; the sutures passed and tied, the 
 periosteum drawn over the sutures, and the soft parts partially 
 repaired. 
 

 CHAPTER XVIII 
 INJURIES TO JOINTS 
 
 Dislocations ; Compound Dislocations ; Open Wounds ; Contusions ; 
 
 Sprains 
 
 DISLOCATIONS 
 
 Shoulder -joint. — Of all the joints, the shoulder is by far the most 
 frequently dislocated. Of these dislocations, there are several forms, 
 and yet only one variety is likely to be met with by the general prac- 
 titioner — the sub-coracoid. A clear conception of the conditions and 
 of the maneuvers necessary to a reduction presupposes a very defi- 
 nite notion of the anatomy of the joint. 
 
 Recall the relation of the acromion and coracoid processes to the 
 glenoid fossa, to the head of the humerus and to the capsular liga- 
 ment; the relation of the long head of the biceps to the joint and the 
 attachments and actions of the various muscles surrounding the 
 joint, particularly the subscapularis, the spinati, the pectoralis 
 major; and the relations of the axillary vessels and nerves. 
 
 However simple a case may appear, do not begin any maneuver 
 until a complete diagnosis has been made. 
 
 Diagnosis. — Begin by inspection. The patient is in evident pain; 
 his head is inclined to the injured side and he supports the injured 
 member with the other hand; the shoulder is flattened, the rounded 
 prominence of the deltoid has disappeared and the acromion projects; 
 the elbow is abducted and the patient is unable to bring it down to 
 the side. 
 
 Palpation reveals the axis of the humerus pointing to the middle of 
 the clavicle; the examining finger can be pushed under the acromion 
 where the humeral head should be. The humeral head itself may be 
 felt below or to the inside of the coracoid, and rotates with slight 
 rotation of the arm. 
 
 328 
 
 
DISLOCATION OF THE SHOULDER 329 
 
 The fingers in the axillary space feel the rounded head of the hu- 
 merus projecting inward more noticeably when the arm is slightly 
 abducted. 
 
 These questions arise: "Is it a case of simple dislocation, or is it 
 complicated by a fracture of the upper end of the humerus, of the 
 great tuberosity, or the rim of the glenoid fossa?" "Have the arter- 
 ies or nerves been injured ?" You must test particularly for lacera- 
 tion of the circumflex nerve. Do this by pin pricks over the deltoid; 
 if the skin is insensitive, forecast paralysis and atrophy of the deltoid, 
 and thus anticipate and disarm censure. 
 
 Whether any of the other complications mentioned are present 
 or not is to be determined by the methods already described in con- 
 nection with fractures of the upper end of the humerus. 
 
 Reduction. — (Lejars.) The method of Kocher seldom fails, if 
 properly applied, and if the various movements are modified to suit 
 the individual case. Its purpose is to put the head of the humerus 
 in the position at which it left the capsule. Through the relaxed 
 tear the head is then to be levered into the socket. 
 
 Seat the patient in a chair facing a little to one side. Let a strong 
 and able assistant, standing behind, seize the patient's shoulder 
 firmly and make pressure downward and backward. Place yourself 
 before the dislocation, and seizing (in the case of the left arm) the 
 forearm at the elbow with the left hand, and the wrist with the right 
 hand, direct the patient to hold the head up and look straight ahead. 
 
 First Stage: Flexion, Adduction. — The elbow is flexed and then 
 gradually adducted until it touches the body, the wrist held firmly 
 meanwhile. The elbow is now pushed backward beyond the axillary 
 line — the first stage is not complete without this. Neglecting this 
 part of the first maneuver is a frequent cause of failure. Do not 
 get in too great a hurry. Remember that the larger part of the re- 
 sistance is due to the muscles and that they yield only gradually. 
 Too sudden and too violent traction on them augments the pain and 
 their resistance. To pause a little now, gives them time to relax 
 (Fig. 234). 
 
 Second Stage: External Rotation. — Hold the elbow fast and flexed 
 at a right angle, and now with your right hand, swing the forearm 
 outward and backward until it lies in the transverse vertical plane 
 
33° 
 
 INJURIES TO JOINTS 
 
 of the body (Fig. 235). Its axis lies directly in front of you. Per- 
 form the maneuver cautiously and smoothly. Again pause until 
 the muscles are relaxed. Do not be alarmed by the snapping dis- 
 tinctly heard in the movement. One may follow the movement 
 
 Fig. 234. — Reduction of shoulder. First stage: Flexion;- adduction; elbow a little 
 posterior to the axillary line. 
 
 of the bulging head of the humerus with the eye. Occasionally 
 reposition occurs at the end of this movement, if it has been carried 
 out methodically. If it has not proceed to the third stage of the 
 maneuver. 
 
 
DISLOCATION OF THE SHOULDER 
 
 331 
 
 Third Stage: Elevation. — Maintaining flexion and external rota- 
 tion, next lift the elbow upward and forward — upward and forward 
 exactly — do not permit the elbow to move outward. Abduction 
 will spoil the maneuver (Fig. 236). Lift upward and forward till 
 
 Fig. 235. — Reduction of shoulder. Second stage: External rotation until fore- 
 arm stands at right angle to body. 
 
 the arm reaches the horizontal — a sudden snap indicates that the 
 head has slipped into the socket. 
 
 Fourth Stage: Internal Rotation. — Proceed now rapidly to swing 
 the forearm inward and across the chest until the hand rests on the 
 
332 
 
 INJURIES TO JOINTS 
 
 opposite shoulder (Fig. 237). The movement is made rapidly but 
 with no great force. This latter holds good with respect to all the 
 movements. It must be observed that the surgeon's hands do not 
 change their hold at any stage of the reduction. 
 
 Fig. 236. — Reduction of shoulder. Third stage: Elevation while maintaining 
 external rotation. 
 
 If these maneuvers fail, repeat them in the same order, using a 
 little more force in the second and third stages and pausing a little 
 longer at the end of a stage. 
 
 In the subclavicular form also this maneuver will succeed, but 
 
DISLOCATION OF THE SHOULDER 
 
 333 
 
 should be modified to this extent: prolong the second stage two or 
 three minutes, using more force to obtain external rotation and the 
 backward position of the elbow. In this wise, the muscles are re- 
 
 FiG. 237. — Reduction of shoulder. Fourth stage. Internal rotation. 
 
 laxed more completely. Without changing the external outward 
 rotation, the elbow is lifted upward and forward as before. 
 
 Not less efficient in certain cases of subcoracoid dislocation is the 
 method of Mothe, or traction in extreme abduction. It is also applicable 
 in all other forms of inward and downward dislocation. 
 
334 
 
 INJURIES TO JOINTS 
 
 In this procedure, counter-extension is indispensable. A long towel 
 will serve. It encircles the injured shoulder, passing under the arm- 
 pit, and the two ends cross the back toward the south side. While 
 the assistant makes forcible counter-extension, the operator manipu- 
 
 
 Fig. 238. — Reduction of shoulder. Traction with high abduction. The axis of the humerus 
 should be in line with the spine of scapula. Assistant steadies the shoulder. 
 
 lates the arm. It is best that he stand on a stool or chair if not tall 
 enough to make good traction upward. Now seize the arm above 
 the elbow and the forearm near the wrist (Fig. 238). Flex the elbow. 
 Next elevate the arm by extreme abduction until it is in line with the 
 spine of the scapula. The arm, you must observe, does not reach the 
 
DISLOCATION OF THE SHOULDER 
 
 335 
 
 horizontal merely, it is elevated beyond that level. This is of the 
 greatest importance. With the arm thus in extreme abduction, next 
 make strong traction in that direction (Fig. 239). Assistance in trac- 
 tion may be necessary; or one may confide the traction to an assistant, 
 
 Fig. 239. — Reduction by high abduction and traction. Note manner in which the assistant 
 steadies the shoulder. (Lejars.) 
 
 while with the thumbs, one pushes against the humeral head in the 
 axillary space. 
 
 If this does not succeed, begin the second stage: 
 
 Depress the arm rapidly and smoothly, letting the point of the 
 elbow pass in front of the chest, all the while maintaining traction. 
 This method occasionally fails for these reasons: 
 
 (1) Traction with high abduction is not long enough continued. 
 
3>3 6 
 
 INJURIES TO JOINTS 
 
 The arm is depressed before the head has been sufficiently elevated by 
 traction. 
 
 (2) The arm is lowered too slowly. 
 
 Fig. 240.- 
 
 -Chipman's method of reducing dislocated shoulder. 
 (International Journal of Surgery.) 
 
 First stage. 
 
 In neglected cases or in the very muscular, general anesthesia may 
 be indispensable whatever the method, but force must then be em- 
 ployed with still greater care, and it must be borne in mind, too, that 
 incomplete anesthesia here is as dangerous as it is useless. The par- 
 ticular danger of this method is laceration of the axillary structures. 
 If general anesthesia is strongly contra-indicated, local anesthesia 
 
DISLOCATION OF THE SHOULDER 
 
 337 
 
 may be employed, injecting the joint and the tendons near their lines 
 of insertion. How long after the injury reduction may be attempted 
 cannot be determined by any rule, but by the conditions in the 
 individual case. 
 
 HVH| 
 
 
 
 
 Fig. 241. — Chipman's method of reducing dislocated shoulder. Second stage. 
 (International Journal of Surgery.) 
 
 Chipman, of New London, Connecticut, suggests a method which 
 must prove of value, especially to the doctor compelled to act without 
 assistance. 
 
 He describes his method thus (Int. Journal of Surgery, November, 
 1906): Stand facing your patient. Gradually raise the dislocated 
 
338 
 
 INJURIES TO JOINTS 
 
 arm to a horizontal position and place it on your shoulder with fore- 
 arm flexed on your back. Direct the patient to pass the well arm 
 under your arm and grasp the wrist of the injured arm with the well 
 hand. Thus the patient's arms encircle your body, the injured one 
 passing over one shoulder, the sound passing under the other (Fig. 
 240). 
 
 Second Stage. — Now direct the patient to sag downward, and the 
 weight of the body drags the head of the humerus outward and up- 
 ward, when you can easily return it to the glenoid cavity with your 
 hands (Fig. 241). The dislocation is so easily and expeditiously re- 
 
 Suh-coracccd 
 
 Fig. 242. — Dislocation of shoulder. (Walsham.) 
 
 duced that even the surgeon himself is surprised. There is the least 
 possible additional injury, the least possible pain; there is no need of 
 an assistant or an anesthetic. 
 
 SUBGLENOID DISLOCATION 
 
 This variety is always the result of forcible abduction of the hu- 
 merus, the tear in the capsule falling below the glenoid cavity, and 
 the head of the humerus remaining fixed there (Fig. 242). 
 
 The diagnosis is to be made from the symptoms already described 
 for the subcoracoid form, the only difference being that the elbow 
 is further from the chest, the flattening of the shoulder more pro- 
 
SUBGLENOID DISLOCATION 
 
 339 
 
 nounced, the head of the humerus more readily felt in the .axilla 
 (Fig. 243). 
 
 The reduction may be affected by Kocher's method, but perhaps 
 the best method is that of extreme abduction with traction, which has 
 
 Fig. 243.— Reduction of a subglenoid dislocation. Second stage, 
 elevation with constant traction. 
 
 Gradual 
 
 already been described. The patient may be seated, but often must 
 recline, for the weight of the pendent limb may be very painful. The 
 injured member is grasped above the elbow with one hand, below the 
 wrist with the other, flexed, slowly raised to form an obtuse angle 
 
34o 
 
 INJURIES TO JOINTS 
 
 with the chest. In this position strong traction and counter-traction 
 arc to be made. Usually this succeeds, though it may help to press 
 the head into place (Fig. 244). If traction and pressure are not suf- 
 
 PlC. 244. — Reduction of subglenoid dislocation. Third stage. Traction with high ab- 
 duction and pressure on the humeral head. 
 
 ficient to effect reduction after the muscles have been thoroughly 
 relaxed, the arm is to be depressed as before described. 
 
 Subspinous Dislocation. — In this case the shoulder is flattened in 
 front and the examining finger finds a marked depression between the 
 tip of the acromion process and the coracoid. The elbow is carried 
 
SUBSPINOUS DISLOCATION 34 1 
 
 slightly forward and the arm rotated inward. The head of the hu- 
 merus can be felt below the spine of the scapula. 
 
 Reduction. — General anesthesia is usually necessary. Grasp the 
 arm above the elbow; slightly abduct the arm; slightly increase the 
 inward rotation (never rotate outw T ard) ; make traction in a direction 
 downward and forward. Pressure forward on the head is helpful. 
 
 AFTER-TREATMENT OF SHOULDER DISLOCATIONS 
 
 The task in any form of dislocation does not end with reduction. 
 There is still the duty to restore usefulness as completely as possible, 
 and to that end the subsequent care must be minutely regulated. 
 The inclination is to immobilize the joint too completely and too 
 long, fearing a recurrence of the dislocation. This enforced rest com- 
 bined with injury is liable to produce atrophy of the muscles, stiffness 
 of the joint, and protracted loss of function. The indications for 
 after-treatment are various, depending upon clinical conditions. 
 
 (A) An uncomplicated, easily reduced dislocation in a healthy 
 strong adult: 
 
 Begin by immobilizing the shoulder, but take care that after three 
 or four days of complete rest massage and passive motion shall be 
 begun. The joint is cautiously put through all its motions, the del- 
 toid, and pectoralis major, and the scapular muscles carefully mas- 
 saged; a daily seance gradually prolonged. 
 
 In the interval the arm is bandaged, but gradually the dressing is 
 relaxed and, after a week, movement left quite free. In two weeks 
 of such treatment the function may be entirely restored. 
 
 (B) The case was complicated with injury to the soft parts, was 
 with difficulty reduced, and only after a number of attempts; it is 
 likely that the capsular ligament was extremely lacerated: 
 
 Under such circumstances not only partial displacement, but 
 actual dislocation is to be feared. Immobilize the joint with a Mayor 
 sling or Velpeau bandage and let it so remain a week. But this will 
 not prevent massage over the shoulder after four or five days. Do 
 not prolong the fixation, remembering that a dislocation accompanied 
 by great violence furnishes the condition most favorable to adhesions 
 and weakness, and against these evils w r e have no remedies but mas- 
 sage and gymnastics, which must be early begun and long continued. 
 
342 
 
 INJURIES TO JOINTS 
 
 A man was brought to the City Hospital with a pronounced sub- 
 coracoid dislocation. The radiograph showed a part of the greater 
 tuberosity scaled off. The injury was a crushing one, a great stack 
 of sacks filled with flour having toppled over and pinned him against 
 the wall. The tendon of the biceps was probably torn from its groove 
 carrying a fragment of bone with it. Under general anesthesia the 
 dislocation was easily reduced by traction with high abduction com- 
 bined with pressure on the head of the humerus. After two weeks' 
 immobilization the tenderness on pressure over the greater tuber- 
 osity was still marked and it was assumed that the fragment was not 
 
 yet reunited. Movement at the 
 elbow also excited pain at the 
 shoulder. After another ten 
 days, massage and passive mo- 
 tion was tried again with better 
 results and at the end of five 
 weeks he had regained the func- 
 tions of the joint in fair degree. 
 
 DISLOCATION OF THE 
 LOWER JAW 
 
 This accident, which may hap- 
 pen at most unexpected times, 
 when yawning or laughing, for 
 instance, might be confused with 
 certain fractures of the inferior 
 maxilla. The opened mouth, the 
 loss of power to close it, are 
 characteristic (Fig. 245). The 
 Both sides, may be reduced simulta- 
 
 Fig. 245. — Dislocation of jaw. (Moullin.) 
 
 reduction is usually easy, 
 neously. Wrap the thumbs; you have to deal with the powerful 
 muscles of mastication, which, when the dislocation is reduced, are 
 likely to close the jaws with much force. 
 
 The thumbs, passed into the mouth, press downward and backward 
 on the molar teeth; at the same time, the fingers hooked under the 
 chin pull upward. In the muscular, considerable force is required. 
 
 The jaws should be moved only slightly for several days. 
 
DIAGNOSIS OF ELBOW DISLOCATION 
 
 DISLOCATION OF THE ELBOW 
 
 343 
 
 Dislocation of the elbow, which occurs with considerable frequency, 
 especially in children, nearly always assumes the form of backward 
 displacement. 
 
 Fig. 246. — Reduction of the elbow-joint. Traction with gradual flexion combined with 
 pressure forward on the olecranon. 
 
 Diagnosis. — The elbow is increased in thickness antero-posteriorly. 
 The flexure of the joint is depressed/ Where the head of the radius 
 should be there is a depression. The olecranon is abnormally promi- 
 
344 INJURIES TO JOINTS 
 
 Dent. Compare the relation of the olecranon to the inner Condylar 
 lines on the two sides. Flexion is quite painful and practically 
 impossible. 
 
 If the diagnosis is doubtful, as it often must be when swelling is 
 great, one thinks of supra-condylar fracture. But in the case 
 of fracture, the relation of the olecranon to the condylar line is 
 unaltered; the humerus is shortened; the deformity disappears with 
 traction. 
 
 Reduction. — (A) Standing on the injured side, seize the arm above 
 the elbow with both hands, and as an assistant makes traction on the 
 forearm, steady the arm and press with both thumbs on the olecranon. 
 The traction is made at first in the direction of the long axis of the 
 forearm, but as the limb yields, the forearm is rapidly flexed — con- 
 tinuing the traction and pressure. By this means reposition is usu- 
 ally quite easy (Fig. 246). 
 
 Traction and counter-traction as before, except that the traction 
 which began in the direction of the long axis of the forearm and pro- 
 duced flexion, now produces hyper-extension. In the meantime, 
 press on the olecranon and the head of the radius. In this way, one 
 will sometimes succeed, but do not forget this method is available 
 only for those who have supple joints. 
 
 (C) Method of Astley Cooper: 
 
 The patient is seated on a chair— you place yourself on the side 
 opposite the injured elbow. If it is the right, for example, stand upon 
 the left side and place a foot upon the chair. Get the bend of the el- 
 bow over the knee. Steadying the humerus with one hand, draw on 
 the flexed forearm with the other, at the same time flexing the elbow 
 over the knee. 
 
 Generally speaking, however, if the first method fails, it is bet- 
 ter to give a general anesthetic, with which the chief difficulties 
 disappear. 
 
 Lateral dislocations are usually replaced without much trouble by 
 pressure combined with extension. 
 
 After-treatment. — This must be begun even earlier than for the 
 shoulder — massage and passive motion — else a stiff joint is very 
 likely to follow. 
 
CLASSES OP THUMB DISLOCATION 345 
 
 DISLOCATION OF THE THUMB 
 
 This accident, apparently simple, presents some peculiarities, 
 which must be borne in mind. ^ ^ 
 
 These displacements at the metacarpo- 
 phalangeal joint, are classified as incom- |- 
 plete, complete, and complicated, de- 
 pending upon the relations which the 
 articular surfaces assume and upon the 
 disposition of the sesamoid bone (Fig. 
 247). Incomplete dislocations leave the g^ 
 articular surfaces in slight contact; com- \ 
 plete dislocations find the articular sur- 
 faces at right angles, the phalanx stand- 
 ing upon the dorsum of the metacarpal 
 (Fig. 248); and, if in addition to this, the 
 torn anterior ligament and sesamoid 
 bone, in attempt at flexion, are wedged Br 
 between the articular surfaces, the dislo- 
 
 cation is said to be complicated, a condi- FlG " ^^^otmT™ 
 tion difficult to manage (Fig. 249). Since 
 this condition is produced by maladroit attempts at reduction of 
 
 %M. 
 
 : in 
 
 m - Lm-i 
 
 
 .■ 
 
 Fig. 248. — Complete dislocation Fig. 249. — Complicated dislo- 
 
 of thumb. (Moullin.) cation of thumb. (Moullin.) 
 
 the complete dislocation, it is especially desirable to understand 
 the maneuvers. 
 
346 INJURIES TO JOINTS 
 
 Whether the dislocation be complete or incomplete, never attempt 
 reduction by flexion. That is the thing to be avoided. Seize the 
 thumb and slightly bend it still further backward, at the same time 
 pushing the base of the phalanx obliquely downward and forward. 
 Directly the phalanx will be felt to slide over the head of the meta- 
 carpal into its place. 
 
 Complicated Dislocation. — (Lejars.) Employ general anesthesia. 
 Only thfc most carefully regulated maneuvers will succeed. Do not 
 attempt the reduction unless the various steps are clearly in mind. 
 
 (i) Make traction on the digit in the direction of its axis until it 
 is as long as normal. 
 
 (2) Seizing the thumb between forefinger and thumb in such man- 
 ner that your thumb presses on the dorsal surface of the dislocated 
 joint, bend it backward until it stands perpendicular to the meta- 
 carpal, or even further. The object is to put the thumb in the posi- 
 tion of uncomplicated dislocation, and thus disengage the sesamoid 
 bone. 
 
 (3) Still holding it at that angle, push the base of the phalanx 
 forward. 
 
 (4) Having pushed the phalanx as far forward as possible in this 
 manner, begin suddenly to flex it, in the meantime keeping the last 
 phalanx extended and do not cease to push forward while flexing. 
 
 If failure attends two or three attempts, do not persist; proceed 
 to operate. 
 
 Dislocations of the fingers should be treated in the same manner — 
 never begin by flexing. 
 
 Reduce by first bending the finger backward and then pushing 
 the base of the phalanx forward. In every case the purpose is to 
 reproduce in reduction the movements of dislocation. 
 
 DISLOCATION OF THE HIP 
 
 These accidents are always serious, and yet are comparatively rare. 
 Of the different forms of luxation of the femoral head, the backward 
 on the dorsum ilii is by far the most frequent (Figs. 250, 251). 
 
 Diagnosis. — The thigh is adducted, rotated inward, and practically 
 immovable. The leg is apparently shortened, the knee slightly 
 
 
DISLOCATION OF THE HIP 
 
 347 
 
 flexed. The trochanter rests above the line drawn from the spine 
 of the ilium to the ischial tuberosity. The femoral head may be 
 felt under the gluteal muscles on the dorsum ilii. 
 
 Reduction. — General anesthesia is usually necessary. Lay the 
 patient on a pallet on the floor. A strong assistant, pressing on the 
 iliac spines, immobilizes the pelvis. 
 
 First Movement: Flexion of Thigh. 
 — Grasp the thigh above the knee 
 with one hand and with the other, 
 the leg,, and gradually flex the hip 
 and knee. Flex the hip to a right 
 angle. 
 
 Second Movement: Traction on 
 the Flexed Femur. — When the hip 
 is flexed at a right angle, begin 
 traction, maintaining that angle. 
 Do not be afraid to use force. 
 This is the most important man- 
 euver. Properly applied, that is to 
 say, with powerful traction on the 
 hip bent at a right angle, the effort 
 will often be rewarded by a sudden 
 snap, which indicates that the 
 femoral head has returned to its 
 socket (Fig. 252). 
 
 Third Movement: External Rota- 
 tion with Abduction. — Persisting in 
 the traction, the resisting muscles 
 are felt to yield. Now carry out the final maneuver, which should 
 guide the head over the rim of the acetabulum into place. Continue 
 traction to some extent, but rotate the thigh outward and at the 
 same time abduct. All the other methods proposed are but modi- 
 fications of this (Fig. 253). 
 
 Fig. 250. — Backward dislocation, dorsum 
 ilii; shortening, inversion. (Moullin.) 
 
 ISCHIATIC DISLOCATION 
 
 Diagnostic points: Adduction, inward rotation, marked flexion 
 of both knee and hip (Fig. 254). 
 
348 INJURIES TO JOINTS 
 
 Reduction. — By the same method as the dorsum ilii. Do not begin 
 the final movement of abduction and external rotation too soon. 
 
 Fig. 251. — Dislocation of the femur upward and backward in a child. 
 The arrow points to the acetabulum. 
 
 SUBPUBIC DISLOCATION 
 
 Diagnostic points: Compared with the ischiatic an opposite con- 
 dition of affairs exists — abduction, external rotation and extension. 
 The great trochanter cannot be located (Fig. 255). 
 
 Reduction. — Flexion is here illusory, and equally so, blind traction. 
 Slightly lifting the extended limb, abduct it as far as possible; while 
 
DISLOCATION OF THE HIP 
 
 349 
 
 abducting continue to lift. The head rolls down toward the ob- 
 turator foramen, and finally the thigh stands vertically. Now 
 adduct and rotate inward. 
 
 Fig. 252. — Reduction of the hip. Flexion of the knee. Gradual, flexion of 
 the hip with traction on thigh. 
 
 OBTURATOR DISLOCATION 
 
 Diagnostic points: The hip is flexed, abducted, and rotated out- 
 ward (Fig. 256). 
 
 Reduction, — -Flexion of hip, traction on flexed thigh, adduction, 
 inward rotation. 
 
v }5° INJURIES TO JOINTS 
 
 DISLOCATION OF THE KNEE 
 
 This accident is infrequent, easy of diagnosis, and comparatively 
 easy to reduce. 
 
 General anesthesia is frequently necessary. Two assistants are 
 needed, one for traction on the leg and one for counter-traction on the 
 thigh, while pressure is applied at the joint. 
 
 
 „J t ._/- 
 
 has* " 
 
 WKr 1 
 
 A 1 Wj^ 
 
 
 m s m 
 
 IHL. 
 
 K 
 
 
 ^""^fr^ta 
 
 jfaBp 
 
 Fig. 253- — Reduction of hip. Third stage. External rotation. 
 Hip strongly flexed. 
 
 One must be concerned here with the condition of the blood 
 vessels. Suppose there is no pulse at the ankle, the popliteal space 
 is evidently filled with blood. Under these circumstances apply a 
 
DISLOCATION OF THE KNEE 
 
 351 
 
 tourniquet, and, under rigid antisepsis, open up the space by a 
 longitudinal incision, turn out the clots, ligate the torn vessels. 
 Remove the tourniquet, complete the hemostasis, and sew up the 
 wound. The limb is bandaged in cotton, elevated, and kept warm. 
 
 Fig. 254. — Dislocation of hip 
 backward into the sciatic notch. 
 Leg shortened, foot inverted. 
 (Moullin.) 
 
 Fig. 255. — Forward dislocation: 
 subpubic; extension, eversion. 
 (Moullin.) 
 
 Time alone can tell whether or not the circulation will be restored 
 and gangrene averted. 
 
 DISLOCATION OF THE SEMILUNAR CARTILAGES 
 
 This is an injury likely to be forgotten in making a diagnosis of 
 disabilities of the knee. 
 
 The internal semilunar cartilage is much more likely to be in- 
 
35 2 
 
 INJURIES TO JOINTS 
 
 : 
 
 volved, the accident usually occurring in this manner: the individual 
 attempts to turn suddenly while the knee is flexed. The cartilage, 
 cither as a whole or, more often, a part, projects to the outside or in- 
 side of the joint circumference. There is a sudden painful locking 
 the of joint. 
 
 The patient himself is often able to relieve the condition by a littl 
 manipulation of the joint, combined with lateral pressure. The 
 
 injury is a serious one, functionally, and 
 demands prolonged rest, in the hope tha 
 union may occur. An elastic silk stockin: 
 for the knee gives support and tends fc 
 jj* \ prevent recurrence of the trouble, bu 
 jS \ violent movements are almost sure t« 
 bring a return. If asepsis is assured, th« 
 joint may be opened and the cartilage 
 sutured to the tibia — an operation to be 
 advised by the general practitioner and 
 yet scarcely ever necessary to be under- 
 taken by him. 
 
 DISLOCATION OF THE PATELLA 
 
 The difficulties in correcting the dis- 
 placement of the patella are various, de- 
 pending not only on the character of the 
 dislocation, but also on the condition of 
 the ligaments and muscles. 
 
 In general, there is one method of treat- 
 ment, viz.: 
 
 Extend the leg completely and, holding 
 
 it in extension, flex the thigh to a right 
 
 angle. By this means the quadriceps extensor, in whose tendon of 
 
 insertion the patella is lodged, is relaxed, permitting the bone to be 
 
 manipulated into place. 
 
 DISLOCATION OF THE ANKLE AND TARSUS 
 
 The diagnosis and correction of these injuries are more especially 
 matters of anatomy. Whoever has clearly in mind the relations of 
 
 Fig. ,256. — Downward disloca- 
 tion. Obturator. (Moullin.) 
 
DISLOCATION OF THE ANKLE 353 
 
 the components of the foot, can determine the character of the disar- 
 rangement with the minimum difficulty. 
 
 If the diagnosis is wrongly made, correct reposition is lacking, 
 and in consequence there persists a degree of deformity and loss of 
 function. 
 
 One must begin his task of diagnosing a serious injury to the foot 
 by recalling the relations of the malleoli and astragalus, the os calcis, 
 and the other tarsal bones, to each other. 
 
 Fig 257. — Backward dislocation of ankle with fracture of the tibia. 
 
 Inspect the foot; the heel, the sole, the borders, the malleoli, the 
 tendo achillis — and compare each of these, point for point, with the 
 sound side. Remember that the line of the tibial crest, prolonged, 
 falls on the second toe. 
 
 A dislocation of the ankle-joint assumes various forms. The other 
 bones may be dislocated from the astragalus, which retains its normal 
 relation to the malleoli. There may be solely a dislocation of the 
 23 
 
354 
 
 INJURIES TO JOINTS 
 
 astragalus, which may take almost any position imaginable. Less 
 often one finds displacement of the metatarsals and phalanges. 
 There may be a fracture of the fibula (Fig. 257). 
 
 It is scarcely possible to indicate an exact method of reducing 
 such luxations. The surgeon's ingenuity must suggest the proper 
 variations of traction combined with pressure. A type may be found 
 
 in backward dislocations of the ankle (Fig. 
 
 258). 
 
 The malleoli are carried forward, the 
 heel is elongated, the foot shortened. 
 There is a transverse fold in front of the 
 ankle, ridged vertically by the stretched 
 extensor tendons. 
 
 Reduction. — -The patient's foot projects 
 over the end of the table, an assistant 
 steadying the flexed knee. Grasp the 
 heel with one hand and the middle of the 
 foot with the other (Fig. 259). Make 
 traction at first to reflex the opposing 
 muscles and then shove the foot forward 
 and at the same time flex it. 
 After-treatment. — -The injured joint, carefully padded, must be 
 
 fixed by a plaster splint. After eight to ten days, passive motion 
 
 and massage must be begun. 
 
 Fig. 258. — Backward disloca- 
 tion of ankle. (Moullin.) 
 
 COMPOUND DISLOCATIONS 
 
 These are accidents always to be dreaded, and yet they yield ex- 
 cellent results under antiseptic methods. 
 
 Before you is a joint wide open, the articular surfaces bare, per- 
 haps protruding, and immediately you think of resection or amputa- 
 tion, and yet you will do neither. You will proceed to do a most 
 careful disinfection and to secure a complete reposition and immo- 
 bilization. The one chief concern is disinfection. 
 
 The same indications for treatment are present as in compound 
 fracture into joints (see page 283) and depend upon the degree of 
 injury to the soft parts and whether the infection is or is not obvious. 
 
COMPOUND DISLOCATIONS 355 
 
 The skin about the wound is prepared as for a surgical operation, 
 the wound is thoroughly flushed out with normal salt solution, foreign 
 bodies are removed, and replacement is effected. The next step will 
 vary, depending upon the degree of confidence in having completely 
 sterilized the joint cavity. If the effort has been exacting in that 
 regard, tightly suture the deep layers over the joint, close the super- 
 ficial layers with interrupted sutures and apply drainage. 
 
 If the articular structures were impregnated with dirt, one will 
 still fear suppuration despite the greatest care in cleansing, and will 
 
 Fig. 259. — Reduction of dislocated ankle. The assistant steadies the 
 flexed knee. (Heath.) 
 
 close the wound less firmly and provide for free drainage. Remov- 
 ing as many bacteria as possible, starving those that remain by re- 
 moving their food supply — -devitalized tissue and blood serum — -are 
 the principles of treatment; cleansing and draining, the means; heal- 
 ing without inflammation or suppuration, the end. 
 
 Dressing and After-care. — Having provided for drainage, cover the 
 wound with sterile gauze, envelop the limb in absorbent cotton and 
 immobilize the joint with a plaster splint. 
 
 As soon as the soft parts are healed and the danger of infection has 
 passed, begin massage of the muscles and slight movement of the 
 parts daily. 
 
 But in spite of careful cleansing, infection may develop. On the 
 third day, perhaps, a chill occurs, the fever mounts rapidly and there 
 are all the local signs of inflammation and sepsis. Do not temporize, 
 
356 INJURIES TO JOINTS 
 
 but immediately open the wound, douche thoroughly with peroxide 
 or iodine water and leave the wound open. Immobilize. If the 
 temperature does not fall and the local conditions do not improve in 
 a few hours, proceed at once to do an arthrotomy (see page 440). 
 
 The thorough drainage by this means obtained will usually control 
 the situation. The drainage is gradually withdrawn, and will not be 
 necessary after about the tenth day. If, even then, the swelling and 
 fever do not subside, there is nothing left to prevent a general in- 
 fection but immediate amputation, and even that may be too late. 
 
 The shoulder-joint rarely suffers a compound dislocation. Such an 
 injury is especially serious for the reason that there are so many com- 
 plications; the shoulder muscles are torn, the axillary vessels and the 
 nerves of the brachial plexus lacerated. 
 
 It must be treated on the general principles enumerated and the 
 result is often surprisingly good. If traumatic aneurism exists, the 
 pectoralis muscles must be divided, the space exposed and the vessels 
 ligated. 
 
 The hip-joint is occasionally the site of a compound dislocation and 
 nearly always the shock is fatal. 
 
 Elbow. — -This is a comparatively frequent accident and is treated 
 on the general principles outlined. If the injuries are severe, a 
 partial excision may be required to perfect drainage and insure a 
 better joint. Amputation will be indicated only in old age, morbid 
 constitutional disability, or extreme local destruction. 
 
 An automobile overturning caught the driver in such way as to 
 produce a compound dislocation of his elbow. He was brought in by 
 the ambulance, with a tourniquet on the arm. 
 
 Under a general anesthesia the wound was explored after cleansing 
 with tr. iodine. 
 
 The end of the humerus protruded through one ugly ragged rent. 
 The brachial artery was torn, the ends widely separated. The 
 brachialis anticus could scarcely be identified and the median nerve 
 stood out prominently, stretched over the projecting bone. 
 
 Reduction was accomplished, the torn vessels ligated, the tourni- 
 quet removed and an effort made to suture the capsule. 
 
 Next the torn brachialis anticus and the group of muscles attached 
 to the internal condyle were repaired in a fashion, with chromic gut; 
 
COMPOUND DISLOCATION 
 
 357 
 
 the bicipital fascia was sutured also with chromic and the skin with 
 silkworm-gut with slight drainage; the joint was fixed in flexion with 
 plaster in the form of a posterior splint. 
 
 On account of the ruptured brachial artery gangrene was feared 
 but at the end of thirty-six hours a slight radial pulse was felt. There 
 was much swelling and great pain, but scarcely any rise of tem- 
 perature. 
 
 
 Jt 
 
 
 
 mmfflflnnfij* 
 
 
 M 1 1 
 
 
 
 ^M ■- 
 
 BBBHWm&PPSt 
 
 
 1 • Wk •"- 
 
 
 
 <9E| 
 
 
 
 
 
 
 mmt 
 
 
 
 Fig. 260. — Fracture and compound dislocation at the wrist. Hand saved. (Scudder* 
 
 Eventually a considerable slough occurred in the wound, but with- 
 out evidence of infection. A month was required for repair of the 
 wound. 
 
 Under an anesthetic the limb was gradually extended and fixed in 
 that position for a while. At the end of the sixth week it was flexed 
 again, this time manipulated quite freely. 
 
 The whole forearm remained very painful and the patient was un- 
 able to move it. He insisted on amputation, but was encouraged to 
 persevere with massage, the electric current and hot baths. Some 
 improvement in the pain was secured and the patient began to work 
 with the joint himself. From that time on the joint gradually re- 
 
358 INJURIES TO JOINTS 
 
 sumed all its functions and at the end of six months he was driving 
 his Ford as swiftly as before. 
 
 The wrist should be treated conservatively. A loose carpal bone 
 may require removal or partial resection. Amputation will be re- 
 quired if healing is obviously out of the question (Fig 260). 
 
 Compound dislocations of the knee-joint are very rare. If con- 
 servatism fails, amputation is the only alternative. 
 
 Ankle and Tarsus. — -These dislocations are frequent and require 
 much attention. Antiseptic foot baths serve an excellent purpose 
 though the primary cleansing must be especially vigorous. The 
 tarsal bones may need to be sutured to be retained in place. Espe- 
 cial care must be taken not to interfere with the circulation (see page 
 288, compound fractures). 
 
 CONTUSIONS OF THE KNEE-JOINT 
 
 These are so frequent as to call for a special word. The aim is to 
 avoid an acute synovitis, which may become suppurative. In milder 
 cases, rest in bed with some mild liniment and light massage will 
 be sufficient, and the pain and stiffness will rapidly subside. 
 
 In the severer cases, indicated by pain and swelling, more active 
 measures must be instituted. 
 
 Wrap the joint in absorbent cotton and apply a plaster bandage for 
 two or three days. The uniform pressure will limit the effusion and 
 hasten its asbsorption. After that you may begin hot sponging and 
 very gentle passive motion with massage, applied at first only to the 
 muscles moving the joint, and afterward, as the tenderness subsides, 
 to the joint itself. 
 
 PUNCTURE AND STAB WOUNDS OF THE KNEE-JOINT 
 
 The treatment will depend largely on the instrument which in- 
 flicted the wound and the appearance of the wound. If the wound 
 is clean-cut, and the instrument presumably non-septic, content 
 yourself with sterilizing the field of the wound, enveloping the knee in 
 an antiseptic compress and putting the joint at rest, preferably in a 
 plaster splint. You will anxiously watch the temperature. If it 
 does not rise within three or four days, one may cease to fear infec- 
 tion, and such swelling as appears is not significant. 
 
 
sprains 359 
 
 It is quite different when the temperature begins to rise and the 
 local symptoms gradually increase, or if the wound is seen after some 
 days of neglect and the symptoms of infection are fully developed. 
 
 Under these circumstances, there must be no delay. Immediate 
 operation is imperative; it is indicated to do an arthrotomy, disinfect 
 and drain (see page 440). 
 
 This treatment, early and properly applied, will save the joint. 
 As infection subsides, the drainage is gradually withdrawn. 
 
 There are cases, however, in which, unfortunately, even these 
 strenuous measures fail. In spite of immediate recognition of the 
 urgency, and immediate action, laying open the joint with the ut- 
 most freedom, followed by repeated irrigations — -in spite of the ut- 
 most endeavor, the symptoms of grave general infection persist and 
 it is necessary to amputate. This may save the patient's life — more 
 often it will not. 
 
 EXTENSIVE INCISED OR LACERATED WOUNDS OF 
 THE KNEE-JOINT 
 
 In these cases, it is never sufficient merely to cleanse the skin and 
 seal the wound with antiseptic dressings. The wound must be en- 
 larged, thoroughly cleansed, and the joint cavity irrigated with 
 sterile water or normal salt solution and wiped dry with sterile gauze. 
 
 After the complete disinfection, the wound in the capsule is sutured 
 and, perhaps, also the skin. More frequently, however, one will 
 feel safer to leave drainage in the skin wound. The joint is immobil- 
 ized, and if everything goes well, the drainage-tube is removed after 
 forty-eight hours. 
 
 SPRAINS 
 
 In general, these conditions are to be treated by firm bandaging for 
 two or three days, to limit the swelling and hasten the absorption of 
 the effusion; and then massage and slight passive motion are begun. 
 It is better to give the joint functional rest until at least the greater 
 part of the pain has subsided. 
 
 The ankle-joint is more frequently sprained than any other, partly 
 on account of its construction and partly on account of its function. 
 The weight of the body falls on the insecurely poised foot and the 
 
360 INJURIES TO JOINTS 
 
 ankle gives way under the load. The ankle usually bends outward 
 and the external lateral ligaments are subjected to great strain. 
 They are undoubtedly often lacerated or the capsular ligament may 
 be torn. The pain in the severe cases is immediate and intense; the 
 patient may faint. If the joint is continued in use, the swelling is 
 aggravated, but in any event swelling rapidly ensues. 
 
 Morphine may be necessary to relieve the pain. If seen at once, 
 the ankle is immobilized in plaster of Paris for a few days, or band- 
 aged tightly with a flannel or rubber bandage, or strapped with adhe- 
 sive plaster, after which massage and passive motion are employed. 
 The patient should walk with crutches at first. The joint will be 
 stronger than if it was used before the pain and swelling had subsided, 
 although excellent authorities advise walking from the first. 
 
 If adhesive strips are used, in order to avoid circular constriction, 
 apply them in this manner: cut the adhesive strips J^ inch wide 
 and in two lengths, 12 and 18 inches. 
 
 (1) Begin with one of the long strips in front of the big toe, carry 
 the strip back around the heel, keeping just above the contour of the 
 sole, and bring the strip back across the dorsum of the foot to the 
 starting-point. Overlap with this a similar strip. Both should be 
 tightly drawn. 
 
 (2) Begin with one of the shorter pieces above the ankle and carry 
 it under the heel to the opposite side. 
 
 The subsequent strips are applied alternately in this fashion, each 
 overlapping the one preceding, until the foot is practically covered. 
 
 The whole is then enclosed in an ordinary roller bandage and the 
 foot kept quiet. After two or three days, the patient may begin to 
 move around a little, but the dressing must be left on till the pain and 
 swelling have subsided. It may be reinforced by additional strips 
 placed over the loose ones. 
 
 The manner of giving massage is also important. In the case of a 
 tender joint, begin by gently stroking the healthy tissues just above 
 the joint in the direction of the blood and lymph currents, and gradu- 
 ally approach the joint. The movements are gradually made more 
 vigorous, using the palmar surface of the hand. After a few minutes 
 of this work, the joint will usually permit a direct manipulation and 
 finally slight passive movement is begun. _ 
 
 
 
RUPTURE OF THE CRUCIAL LIGAMENTS 36 1 
 
 RUPTURE OF THE CRUCIAL LIGAMENT OF THE KNEE 
 
 An injury to the knee-joint often diagnosed as sprain, is rupture of 
 the crucial ligament of the joint. This injury happens when violence 
 is applied to the flexed joint at which time the anterior ligament is 
 very tense. 
 
 Fig. 261. — Rupture of the crucial ligament due to lateral blow on flexed knee. The X-ray 
 usually shows a portion of the tibial spine wrenched off. 
 
 Turning suddenly on the flexed knee may produce the same result. 
 The pain and disability are out of all proportion to the apparent in- 
 jury, but the swelling is not extreme. The X-ray will usually in- 
 dicate the nature of the trouble not because the ligaments cast a 
 

 INJURIES TO JOINTS 
 
 shadow, but because some fragments of the bony attachments are 
 avulsed. In fact in some cases "fracture of the tibial spine" is the 
 better diagnosis (Fig. 261). 
 
 Prolonged fixation in plaster is the proper treatment. Massage, 
 manipulation, or limited use should not begin until repair is prac- 
 tically complete, which will require at least two months; and even 
 after that, a splint permitting restricted motion only may need to 
 be worn. 
 
CHAPTER XIX 
 INJURY AND REPAIR OF TENDONS 
 
 There are three kinds of injuries to tendons which it is practical to 
 consider as emergencies: dislocated tendons, subcutaneous rupture, 
 and divided tendons. 
 
 Dislocation of Tendons. — -Dislocation is not a frequent injury, and 
 yet it occurs and is to be considered as a possibility in making a diag- 
 nosis of disturbances of function after certain joint accidents. Every 
 sprain should be examined with this point in view. 
 
 The tendons most frequently dislocated are those of the peronei 
 muscles, especially the brevis. Following a severe wrench of the 
 ankle, it is torn out of its sheath behind the external malleolus and 
 carried forward onto the malleolus, where it can be felt and moved. 
 
 It is easily replaced, but it is with more difficulty retained. The 
 ankle must be immobilized at a right angle to relax the calcaneo-fibu- 
 lar ligament, and the tendon retained by pressure until the ruptured 
 tendon sheath or lateral ligament is healed, which will require about 
 four weeks. It will sometimes be necessary to expose the tendon and 
 repair the rupture tissues. 
 
 The long tendon of the biceps may be wrenched from its groove in 
 the humerus and the loss of function and prominence of the head of 
 the humerus may suggest dislocation of the humerus. As a rule, the 
 tendon is easily replaced by a little manipulation, but the useful- 
 ness of the arm will be impaired for a long time. 
 
 The other tendons of ankle and wrist occasionally may suffer simi- 
 larly, but not seriously. 
 
 Subcutaneous Rupture. — Subcutaneous rupture is especially likely 
 to occur with the tendon of the quadriceps extensor or triceps cubiti 
 or the tendo achillis. A sudden violent effort is the usual cause. 
 
 The pain, the loss of function, the gap between the ends of the rup- 
 tured tendon, and the history of sudden muscular contraction point 
 to the nature of the injury. 
 
 363 
 
364 
 
 INJURY AND REPAIR OF TENDONS 
 
 There is only one logical treatment, viz. : by an incision to expose 
 the tendon at once and by some of the methods shortly to be de- 
 scribed, reunite the parts by suture. It is the duty of the doctor to 
 insist on nothing less (Fig. 262). But it must be remembered that 
 the synovial sac is peculiarly susceptible to infection and the skin 
 over the patella difficult to sterilize. 
 
 
 Fig. 262. — ;Repair of ruptured tendon of quadriceps extensor femoris. d, tendon; c, 
 basting stitches; b, sutures uniting posterior edges; a, sutures uniting anterior edges of 
 ruptured tendon. (Bryant.) 
 
 If this procedure is not followed, it remains only by position, rest, 
 and massage to favor repair, which, at the best, will be uncertain 
 and slow. 
 
 The position must be such as to relax the muscle, the limb must be 
 immobilized, and after the first few days massage must be begun 
 and carried out systematically. 
 
INJURY OF TENDONS AT THE WRIST 
 
 365 
 
 Fig. 263. — Incised wound of back of wrist. Divided tendons exposed. (Veau.) 
 
 Fig. 264. — "Expression" of retracted end of divided tendon by forced flexion and com- 
 pression of forearm. (Veau.) 
 
3 O0 
 
 INJURY AND REPAIR OF TENDONS 
 
 The history of a case reported by Gage, of Worcester, Mass., is 
 typical. A man, fifty-seven years old, slipped and fell with his left 
 knee doubled under him. He could not lift his leg from the ground. 
 Examination an hour later showed a gap 6 cm. wide between the 
 upper border of the patella and the retracted edge of the quadriceps 
 tendon. 
 
 Fig. 265- 
 
 -Exposure of tendons by enlarging wound in aponeurosis, 
 tendons. (Veau.) 
 
 Suturing 
 
 Operation. — A transverse incision was made across the front of the 
 knee and the ruptured tendon exposed. The rupture was complete 
 except for a few fibers on the outer edge. The joint was exposed, 
 the clots wiped out. The edges of the tendon were then carefully 
 coapted with interrupted catgut sutures. The leg was put up in 
 plaster-of-Paris splint for seven weeks. After that it was massaged 
 daily and the splint definitely removed at the end of twelve weeks. 
 The leg became as strong and flexible as before the accident. 
 
 
SUTURE OF TENDONS 
 
 367 
 
 Divided Tendons. — These are found frequently, especially at the 
 wrist. They must be immediately sutured for then 
 it is relatively easy. Later they retract or acquire 
 adhesions and it is difficult to approximate the two 
 ends, and one must have recourse to special 
 maneuvers. 
 
 Use No. 1 or No. 2 silk or chromicized catgut. 
 A small curved needle or a straight sewing needle 
 will serve. 
 
 Begin by carefully disinfecting the wound and 
 securing complete hemostasis. The lower ends of 
 the divided tendons will usually be found near the 
 lower lip of the wound (Fig. 263). Identify each 
 and count them to be sure none have been over- 
 looked. At the same time, see if a nerve has been 
 divided. Look for the others of the divided ends. 
 If they are not in sight, do not reach blindly for 
 them with forceps, but attempt to bring them into 
 view by "expression," and if this fails, boldly en- 
 large the wound. 
 
 Expression. — Direct the assistant to grasp the 
 member above the wound with both hands and the 
 pressure may force the tendons into view. If the 
 extensor tendons are involved, employ forced flexion 
 with the pressure. These muscular groups are more or less unified 
 
 and the undivided tendons put 
 on the stretch help to drag 
 the divided tendons into view 
 (Fig. 264). 
 
 If this method does not suc- 
 ceed, apply a roller bandage, 
 beginning at the elbow-joint in 
 the case of the upper extrem- 
 ity; at the knee in the case of 
 the leg or foot, and carry it 
 down to within an inch of the 
 wound. If this, too, fails, make a/ra? incision observing this point; 
 
 C.D^-m- 
 
 Fig. 266. — One 
 method of suturing 
 tendon of medium 
 size. (Veau.) 
 
 1IM1S 
 
 Fig. 
 
 267. — Method of introducing suture for 
 divided tendon. (Marsee.) 
 
3&S 
 
 INJURY AND REPAIR OF TENDONS 
 
 Fig. 26S. — Suture of tendons completed. Repair of aponeurosis. The aponeurosis 
 should not be divided directly over the tendons else adhesions may occur. (Veau.) 
 
 Fig. 269. — Suture of a flattened 
 tendon. (Veau.) 
 
 Fig. 270. — Suture of a lacer- 
 ated tendon. (Veau.) 
 
SUTURES OF TENDONS 369 
 
 do not make the incision directly over the tendon for it may later 
 acquire adhesions to the scar tissue, interfering with its free move- 
 ment. Generally with a little patience the tendon is found. It 
 is often practical after incising the skin to make a diagonal incision 
 of the deep fascia or two incisions at a right angle, creating a 
 flap which may be dissected up and the tendon group well exposed 
 (Fig. 265). 
 
 Suture of the Tendon. — (A) The tendon is round, as at the level 
 of the wrist-joint. Seize the tendon with a dissecting forceps, being 
 careful not to bruise it. Pass a suture through the whole thickness 
 34 inch from the end (Fig. 266), entering the superficial surface 
 and emerging on the deep surface of the segment and carrying it 
 then to the other part; entering the deep surface and 
 emerging on the superficial surface. The ends of the 
 divided tendon are then coapted and the suture tied. 
 
 The suture may be passed laterally instead of antero- 
 posteriorly. If the ends of the tendon come together 
 well, a suture may be entered 3^2 i nc h from the divided 
 end and passed obliquely in such a manner that it 
 emerges from the cut surface and then is passed into 
 the cut surface of the opposite end and emerges sym- 
 metrically with the original point of entrance. Marsee 
 advises passing a separate suture three times through 
 the tendon, tying the corresponding ends (Fig. 267). 
 
 Repair the wound in the deep fascia by a continuous 
 suture, being assured once more that no nerve is divided 
 
 ( Fi g- 268 )- . fc27 ,_ 
 
 (B) The tendon is flattened. In this case, the ends Method of 
 must overlap. Make a latero-lateral anastomosis; pass elongating a 
 the suture through the lower end from before backward, 
 beginning near one border. Next pass the suture through the upper 
 end from before backward and again from behind forward. Finally 
 pass the suture from behind forward through the lower end. When 
 the suture is ready to tie, the lower end overlaps the upper (Fig. 269). 
 
 (C) The tendon is shattered or lacerated. In this case before sutur- 
 ing tie a firm ligature around either end, which will prevent the 
 suture from pulling out (Fig. 270). 
 
 24 
 
37* 
 
 INJURY AND REPAIR OF TENDONS 
 
 Fig. 272. — Suture by double anastomosis 
 when the two ends of the divided tendon 
 cannot be brought in contact. (Yean.) 
 
 Fig. 273. — The upper end cannot be 
 found. Suture to adjoining tendon. 
 (Veau.) 
 
 274« — The long extensor of the thumb divided, the upper end lost. The adjoining 
 tendon is split and one segment sutured to long extensor. (Schwartz.) 
 
SUTURE OF TENDONS 
 
 371 
 
 (D) The tendon is voluminous. In this case it is better to vary the 
 method a little. Pass the transverse suture as in Fig. 266. Before 
 tying the suture, the posterior lips are drawn together as neatly as 
 possible. When these sutures are all tied, finally suture the anterior 
 lips together. Over all suture the deep fascia. The transverse 
 suture must be strong, No. 3 silk for example, though the others 
 may be finer. 
 
 (E) The ends cannot be approximated. This will not happen ex- 
 cept in the neglected cases. Two procedures are practical. 
 
 (1) The space may be bridged by sutures, which will favor re- 
 union by scar tissue. Begin by ligating both ends (Fig. 270) and 
 then pass three to six sutures as the one is passed in the figure. 
 
 (2) The space may be bridged by splitting the upper tendon in 
 the manner indicated in Fig. 271. Before the tendon is split, it 
 
 Fig. 275. — Plaster splint applied to maintain flexion. 
 
 must be ligated near its end. In the case of the tendo achillis, it may 
 be lengthened by making several half cross sections at different levels, 
 first one side and then the other. 
 
 (3) The two ends may be sutured to a neighboring tendon (Fig. 
 272). 
 
 (F) The upper portion of the divided tendon cannot be found. In 
 this case, buttonhole a neighboring tendon, selecting one nearest 
 resembling in function the divided one. Into the slit pass the end 
 of the divided tendon and fasten with one or two sutures. The 
 divided tendon should be slightly on the stretch when the suturing 
 is completed (Fig. 273). 
 
372 
 
 INJURY AND REPAIR OF TENDONS 
 
 The healthy tendon may be split and the separated portion sutured 
 to the divided tendon (Fig. 274). 
 
 Drainage. — -Drainage is necessary if the wound was accidental. A 
 small drainage-tube is left beneath the skin. The fascia has been 
 completely closed. Apply a dry antiseptic and absorbent dressing. 
 
 Immobilize the part in a position, flexion or extension, to relax the 
 tendons. If necessary, apply a plaster bandage over the dressing. 
 An excellent splint is made by taking a plaster roller, properly soaked, 
 and folding it back and forth, pressing the folds carefully together 
 until a five- to eight-ply splint of proper width and length is made. 
 This is slightly padded, bandaged in place and held at the necessary 
 degree of flexion till the plaster hardens (Fig. 275). 
 
 
CHAPTER XX 
 
 INJURY AND REPAIR OF NERVES 
 
 THE REPAIR OF DIVIDED NERVES 
 
 It is imperative to suture a divided nerve as soon as the condition 
 is recognized. If the repair is made at once it is more easily done than 
 the suture of tendons, for the ends are not so widely separated; but, 
 on the other hand, it is more delicate work, for the trunks are smaller. 
 
 Do not handle these tissues roughly and, above all, do not cleanse the 
 wound with strong antiseptics, such as bichloride and carbolic acid. 
 
 Remember that the upper part of the 
 nerve retains its sensitiveness and in it are 
 the essentials of repair. The lower seg- 
 ment degenerates if repair is neglected. 
 
 It is usually necessary to freshen the 
 ends, but one must be very sparing of the 
 tissues, removing less than a millimeter 
 from each extremity, using fine sharp 
 scissors. It is better to make the sec- 
 tion oblique (Fig. 276). 
 
 Pass a silk (No. o) suture or a small 
 catgut with a round needle through the 
 whole thickness, as in the case of a round 
 tendon (Fig. 277), draw the ends together 
 and complete the repair by suturing the 
 lips, passing the suture through the 
 nerve sheath only (Fig. 278). Adjust the ends exactly and always 
 where possible make the suture an end-to-end one. 
 
 Repair the various layers of fascia with great care, so that the 
 sutured nerve may be isolated and removed from the sources of 
 infection. Employ drainage in suturing the skin. 
 
 373 
 
 Fig. 276.— Ob- 
 lique section of 
 the nerve ends. 
 
 Fig. 277. — 
 Through and 
 through suture 
 of nerve. 
 
 (Veau.) 
 

 INJURY AND REPAIR OF NERVES 
 
 For the rest, the treatment is the same as for any other wound. 
 
 Secondary Suture. — It may be found necessary 
 to suture a nerve some time after the injury, and 
 this operation will present difficulties. The ends 
 may be separated or they may be imbedded in 
 scar tissue. 
 
 A knob often forms on the proximal stump. 
 In such a case, freshen the ends and pass the 
 suture in the manner pictured (Fig. 279). 
 
 If the two ends are attached by a fibrous cord, 
 split the scar tissue longitudinally (Fig. 280), and 
 transform the longitudinal fissure into a transverse 
 one and suture (Fig. 281). If the ends cannot be 
 approximated or bridged they may be sutured at 
 different levels to a neighboring nerve in the 
 manner described under Repair of Tendons. 
 
 Warn the patient that it may be a long time 
 before function is even partially restored. In the 
 meantime, muscular atrophy must be prevented 
 of nerve through by persistent use of electricity, and massage. 
 
 the sheath. {Heath.) 
 
 
 CONTUSION AND COMPRESSION OF NERVES 
 
 These injuries to nerves are by no 
 means infrequent, following blows, gun- 
 shot wounds, machinery accidents, frac- 
 tures, and dislocations. 
 
 The symptoms vary from slight ting- 
 ling to complete loss of function. The 
 loss of function is often a later de- 
 velopment, due to a neuritis following 
 the contusion, and is accompanied by 
 neuralgia, muscular palsy and trophic 
 alterations corresponding to the distri- 
 bution of the nerve. 
 
 Treatment. —The immediate indica- 
 tions are to restore the parts to their normal condition as much 
 
 Fig. 270. — Seconda 
 Method of coaptation, 
 
INJURY TO THE FACIAL NERVE 
 
 375 
 
 as possible, and to relieve the pain by hypodermic injections of 
 morphine or by phenacetine and codeine. The nerve must be put 
 at rest by immobilizing the limb. Later, alteratives, electricity, 
 and massage are useful. 
 
 INJURIES TO INDIVIDUAL NERVES 
 
 Facial Nerve. — -The facial is more frequently injured than any 
 other cranial nerve: in fracture of the base of the skull; in the mas- 
 toid operation as it passes 
 through the temporal bone; 
 by shots and blows at its 
 exit from the styloid fora- 
 men. Depending upon the 
 distance of the lesion from 
 the central origin of the 
 nerve, there occur paralysis 
 of the muscles of expression, 
 disturbance of salivary secre- 
 tion and the sense of taste, 
 and paralysis of the palatal 
 muscles. Injury to the 
 facial nerve is often accom- 
 panied by injury to the ab- 
 ducens and auditory nerves. 
 
 To Expose the Facial 
 Nerve. — -The incision begins 
 behind the external auditory 
 meatus and extends down- 
 ward and forward to the 
 angle of the lower jaw. 
 
 Divide the integument, superficial fascia and the first layer of the 
 deep fascia. This exposes the parotid gland, the sterno-cleido- 
 mastoid and the mastoid process. The posterior auricular nerves 
 and the vessels are to be avoided. Carefully dissect and draw 
 forward the part of the gland exposed and the posterior belly of 
 
 Fig. 2S0. Fig. 281. 
 
 The two ends of the nerve are connected by a 
 fibrous cord which is split longitudinally and su- 
 tured as indicated. (Veau.) 
 
370 INJURY AND REPAIR OF NERVES 
 
 the digastric appears, just above which the nerve lies upon the 
 styloid process. 
 
 Optic Nerve. — The optic nerves are injured most frequently in con- 
 nection with fracture of the base of the skull involving the anterior 
 fossa, and especially when the fissure involves the optic foramen 
 for there the nerve is firmly attached to the bone. 
 
 As a consequence of such injuries, there may be compression, lacera- 
 tion, or extravasation into the nerve sheath. As a result of these in- 
 juries, there are disturbances of vision of various degrees. In ob- 
 scure trauma of the brain, the ophthalmoscopic examination of the 
 fundus of the retina should never be neglected as a means of diagnosis. 
 
 Motor Oculi Nerve. — -The motor oculi nerve may be injured by 
 wounds penetrating the orbit and by fractures of the base. Its func- 
 tion may be disturbed by pressure following the rupture of the middle 
 meningeal artery and often the only indication of this disturbance is 
 a dilated pupil and drooping of the eyelid. 
 
 Patheticus and Abducens. — These nerves are often injured along 
 with the third, producing loss of rotation and abduction of the eye ball. 
 
 Fifth Nerve. — -The fifth nerve is rarely injured alone, but injury of 
 single branches may occur. 
 
 "The usual consequence of anesthesia of the trigeminals following 
 cranial injury is so-called keratitis neuroparalytica." 
 
 Auditory Nerve. — -The auditory nerve is rarely injured without 
 other serious lesions, and since traumatic disturbances of hearing 
 may be due to injury to the labyrinth or tympanum also, a diagnosis 
 of injury to the nerve trunk must be uncertain. 
 
 The pneumogastric may be divided or contused by bullet or stab 
 wounds in the neck. The injury is not necessarily fatal, but may be 
 followed by difficulty in respiration and deglutition or by pneumonia. 
 When the symptoms point to injury an effort should be made to re- 
 pair it. It is reached by the same operation as that for ligation of the 
 common carotid. 
 
 The phrenic when divided gives rise to disturbances of the func- 
 tions of the diaphragm, cough, difficult respiration. 
 
 The recurrent laryngeal when divided gives rise to hoarseness and 
 aphonia. If injured, an attempt should be made at repair. Laryn- 
 geal spasm may require a tracheotomy. 
 
REPAIR OF MEDIAN NERVE 
 
 377 
 
 Median Nerve. — The median nerve is likely to be divided by stab- 
 or gunshot wounds and may be exposed in any part of its course. 
 
 Injury to the median nerve results in impaired flexion of the hand 
 and fingers and movements of the thumb. 
 
 To Expose the Median Nerve. — (A) In the middle third of the arm 
 (Fig. 282): Place the patient on the back with arms abducted to a 
 right angle, the operator standing to the inner side of the arm. 
 
 With the two hands define the biceps muscle. Along the inner 
 border of the muscle, following the known line of the nerve (from the 
 
 Fig. 282. — Exposure of the median nerve in the middle third of the arm. 
 M. N. Median nerve. B. A. Brachial artery. {Schwartz.) 
 
 B. Biceps. 
 
 middle of the axilla to the middle of the bend of the elbow) make an 
 incision 2 or 3 inches long, dividing the skin and connective 
 tissue. Divide the deep fascia over the biceps and open the sheath 
 of the muscle. Isolate the border of the muscle and with the retrac- 
 tor draw it gently aside. Do not use force or the nerve also will be 
 displaced or the musculo-cutaneous may be exposed instead of the 
 median. 
 
 Now incise the deep layer of the muscle sheath exactly in the line 
 that was occupied by the border of the muscle and the nerve is ex- 
 posed lying a little to the inside of the vessels. 
 
 (B) At bend of elbow (see Brachial Artery). 
 
 (C) In the upper third of the forearm (Fig. 283) : The incision begins 
 
\7* 
 
 INJURY AJNJJ K1M/AIK UJ? JNJ^KVJLt) 
 
 a little below the bend of the elbow, is 2 or 3 inches in length, 
 and follows the line of the nerve, which lies in the middle line from 
 the elbow to the wrist. Divide the skin and ligate the two superficial 
 veins. Under the deep fascia define the external border of the pro- 
 nator radii teres and over this border incise the aponeurosis and re- 
 tract the muscle. 
 
 The nerve is immediately exposed, together with the ulnar artery, 
 which crosses beneath it, running obliquely toward the inner border 
 of the forearm. 
 
 U.art. 
 M.N. 
 
 P.R.T. 
 
 Med.X. 
 
 " > * 5 ^S 
 
 m, lilL ■ "W— ffWf^''*""" 
 
 
 ^^i 
 
 =ni 
 
 0?^ 
 
 
 
 
 
 
 g. 
 
 
 ^ 
 
 Fk,. 283. — Exposure of the median nerve Fig. 284. — Exposure of the median nerve 
 just below the elbow. The pronator radii at the wrist. (Schwartz.) 
 
 teres (p. R. T.) drawn inward exposing the 
 median nerve (m. n.), the ulnar artery (u. 
 art.) being at outer side. (Schwartz.) 
 
 (D) At the wrist (Fig. 284). Make an incision 2 inches in length 
 in the middle line, the middle of the incision corresponding to the 
 crease of the wrist. Divide first the skin and the fascia and then, very 
 carefully, the anterior annular ligament, guarding the synovial sheath 
 of the flexor tendons. Retract the lips of the wound, and the nerve 
 is exposed, easily distinguishable from the adjacent tendons by its 
 fibrillated appearance. 
 
 The Ulnar Nerve. — The ulnar nerve may be divided anywhere 
 along its course, but is more likely to be contused in the ulnar 
 
 
REPAIR OF ULNAR NERVE 
 
 379 
 
 groove. There also it may dislocated by forcible flexion of the 
 forearm. The loss of function of this nerve results in inability to 
 extend the distal phalanges, to adduct the fingers and to flex the little 
 finger. Eventually the "claw hand" appears as a result of atrophy 
 of the muscles. 
 
 To Expose the Ulnar Nerve. — (A) In the arm: Make an incision 
 2 or 3 inches in length along the line of the nerve, which ex- 
 tends from the middle of the axilla to the internal condyle. Divide 
 the skin and superficial and deep fascia. The brachial artery is about 
 a finger's breadth to the outside of the line of incision. Draw the 
 
 M.N 
 
 Fig. 285. — Exposure of the ulnar nerve in the upper third of the arm. M. N. Median 
 nerve. B. A. Brachial artery. U. N. Ulnar nerve. Tr. Triceps muscle. {Schwartz.) 
 
 basilic vein to one side. Carefully divide the subjacent tissue be- 
 neath which is the ulnar and median nerves and the brachial artery; 
 the ulnar nerve is to the. inside and in contact with the long head of 
 the triceps. (Fig. 285). 
 
 (B) At the elbow (Fig. 286) : Place the patient on the back; abduct 
 the arm; flex the forearm at a right angle; stand to the inner side 
 of the arm and locate the inner condyle, the olecranon and the in- 
 tervening gutter. Along the line of the gutter incise the skin and the 
 
3»o 
 
 INJURY AND REPAIR OF NERVES 
 
 Fig. 286. — Exposure of the ulnar nerve at elbow. I. C. Internal condyle. E. C. U. 
 Extensor carpi ulnaris. U. N. Ulnar nerve. Olec. Olecranon process. Trie. Triceps. 
 (Schwartz.) 
 
 feKV-J--/ U.A. 
 
 r u.n. 
 
 Fig. 287. — Exposure of the ulnar nerve at the wrist. U. A. Ulnar artery. U. N. Ulnar 
 
 nerve. (Schwartz.) 
 
 (C) In the lower third of the forearm: Following the line of the nerve, from the internal 
 condyle to the radial side of the pisiform, make an incision 2 inches long to the outside 
 of the flexor carpi ulnaris, dividing the skin and superficial fascia. Retract inward the 
 tendon of this flexor. Carefully incise the deep fascia and the nerve is exposed lying to the 
 ulnar side of the ulnar artery. 
 
fascias for 2 or 3 inches, and the nerve will be exposed, accom- 
 panied by the posterior ulnar recurrent artery. 
 
 (D) In the wrist (see Fig. 287). 
 
 Musculo-spiral. — The musculo-spiral, more than any other nerve 
 of the arm, is subject to injury from stab, contused, or gunshot 
 wounds or to fracture of the humerus. Very characteristic, too, are 
 the symptoms resulting from its loss of function. The wrist and 
 fingers cannot be extended and assume the attitude well known as the 
 
 Sup. Long 
 Mus. Sp. 
 Br. Ant. 
 
 Fig. 288. — Exposure of the musculo-spiral in its lower third. The supinator longus is exposed 
 and the nerve found to its inner side lying upon the brachialis anticus. {Schwartz.) 
 
 " drop wrist." In every fracture of the humerus, the stability of this 
 nerve should be tested. The nerve may be explored in any part of 
 its course, but is most easily reached at the outer side of the arm just 
 above the elbow. 
 
 To Expose the Musculo-spiral. — In the lower third of the arm (Fig. 
 288): The arm is abducted, the forearm extended and the hand 
 supinated. Stand to the outside of the limb. In the line of the 
 nerve, a line drawn along the middle of the external surface, begin- 
 ning half-way between the shoulder and elbow and extending to a 
 point 3^ inch from the center of the bend of the elbow, make an 
 
SU4 ±1>JUJ\.X AINU 1S.IM^\IIV. V.T IN 1^ J\. V Jl, O 
 
 incision 2 or 3 inches in length through the skin and superficial 
 fascia. Retract the cephalic vein. Divide the deep fascia along the 
 border of the supinator longus and expose the muscle fully. Retract 
 it to the outside. At the bottom of the wound is the nerve lying upon 
 the brachialis anticus (see page 139, Gunshot Wounds). 
 
 T. A 
 
 _ Tr 
 
 Fig. 289. — Exposure of the circumflex nerve. D. Deltoid. T. M. Teres minor. Tr. 
 Triceps. T. Maj. Teres major. C. A. Circumflex artery. C. N. Circumflex nerve. 
 (Schwartz.) 
 
 Circumflex. — In addition to such injuries as may be due to stab or 
 gunshot wounds, the circumflex is liable to be lacerated in violent 
 wrenching or in dislocation of the shoulder-joint. 
 
 The immediate result is loss of power to abduct the arm through 
 paralysis of the deltoid. The nerve may be exposed as it winds 
 around the humerus just below its head. 
 
 Operation. — The course of the nerve is in a line drawn from the 
 inner end of the scapular spine to the point of insertion of the deltoid. 
 
m^r-AiJK ui inn, jil jl l lu-l l i.-\.\i,uu3 
 
 6^6 
 
 Place the patient on the sound side, exposing the shoulder well by 
 rotating the arm inward a little and placing it in front of the trunk. 
 
 Along the line indicated make an incision 3 or 4 inches long, 
 corresponding at its outer end to the acromion process, but an inch 
 or two from it. This incision divides the skin and superficial and deep 
 fascia and exposes the posterior border of the deltoid. Bring into 
 view and draw upward this border of the deltoid. 
 
 Next locate the quadrilateral space, bounded above by the teres 
 minor, below by teres major, posteriorly by the long head of the tri- 
 
 Fig. 290. — Exposure of the rausculo-cutaneous nerve in the middle third of arm. The 
 biceps (B) drawn outward exposes the nerve (M. Cut. X.) lying to the outside of the median 
 nerve (Med. X.) and the brachial artery, Br. Art. (Schwartz.) 
 
 ceps, and anteriorly by the shaft of the humerus. By locating the 
 tendons of these muscles define this space in which lie the nerve 
 and the posterior circumflex artery (Fig. 289). 
 
 The musculo-cutaneous is exposed in the same manner as the me- 
 dian in the upper third of the arm (Fig. 290). 
 
 Anterior Crural. — The division of the anterior crural nerve means, 
 among other things, loss of extension of the leg. 
 
 To outline it locate the spine of the pubes and the anterior-superior 
 iliac spine, which points are connected by Poupart's ligament; under 
 
J ui t 
 
 i^jujvi r\.nu js.j^jt^xxss. v^x rNH.j\. v jlo 
 
 this ligament a finger's breadth outside of its middle point the nerve 
 passes (Fig. 291). 
 
 To Expose the Anterior Crural. — Make an incision from this point 
 downward in the axis of the thigh, about 3 inches in length, divid- 
 ing the skin. 
 
 At the upper end of the wound expose the lower border of Poupart's 
 ligament. Immediately below this line, open up the sheath of the 
 
 
 Fig. 291. — Anterior crural and external cutaneous nerves. (Labey.) 
 
 
 psoas magnus, pass a grooved director under the sheath, and divide 
 it to the same extent as the skin incision. Separating the lips of 
 the sheath wound, the nerve is seen lying on the fibers of the muscle 
 and is to be distinguished by its whiteness and its subdivisions. 
 
 The Obturator. — If the obturator is divided, there follows loss of 
 abduction of the thigh. 
 
 To Expose the Obturator. — Abduct the thigh until the border of the 
 adductor longus can be clearly defined, and along this line make an 
 incision 4 or 5 inches long, beginning an inch below the fold of the 
 
INJURY TO THE SCIATIC NERVES 
 
 38S 
 
 groin, a little to the outside of the scrotal base. Divide the skin and 
 superficial fascia, retracting to the outer side the internal saphenous 
 vein, but ligating its cross branches (Fig. 292). Divide the deep 
 fascia in the same line. 
 
 Separate the adductor longus from the pectineus by blunt dissec- 
 tion. A fairly well-defined gutter indicates the line of separation. 
 Retract the two muscles and at the bottom of the upper part of the 
 wound you will see the obturator nerve, consisting of a couple of 
 flattened cords. Now extend the thigh to relax the abductors and 
 
 Fig. 252. — Exposure of the obturator nerve; separating the adductor longus from 
 the pectineus. (Labey.) 
 
 separate more widely the two muscles mentioned and the nerve may 
 be completely exposed, one branch lying upon the adductor brevis 
 and the other passing under it (Fig. 293). 
 
 Ilioinguinal and Genito-crural. — These nerves are frequently 
 wounded in hernia operations, and may give rise to an obstinate 
 neuralgia of the testicle requiring removal of this organ. In such a 
 case an effort should first be made to repair the nerve or resect it. 
 
 The Sciatic Nerve, — -The sciatic nerve may be injured in many 
 
11NJU.KX J\WU ±Ci^Jf/\l«. UJ3 iNJ^KVJk& 
 
 ways and from the functional point of view, these injuries are always 
 serious. It may mean loss of extension of the thigh and complete 
 paralysis of the leg. 
 
 It may be exposed at any part of its course down the back of the 
 thigh. 
 
 Exposure in the Middle of the Thigh. — Place the patient face down- 
 ward or on the sound side. Along the line of the nerve (a straight 
 line extending from a point midway between the ischial tuberosity 
 and the great trochanter to the middle of the popliteal space), make 
 
 Fig. 293. — Obturator exposed. (Labey.) 
 
 
 an incision 3 or 4 inches long, dividing the tissues down to the 
 deep fascia. Determine the interspace between the biceps and the 
 internal hamstring, and over it divide the deep fascia and separate by 
 blunt dissection the muscles of the space. 
 
 Flex the leg so as to relax them. They are then to be retracted 
 widely and in the fatty tissues of the interval the nerve is usually eas- 
 ily found. 
 
 The External Popliteal, or Peroneal. — -This nerve, like others, is 
 liable to injury in fractures and wounds. When it is divided, "foot 
 
REPAIR OF THE PERONEAL 
 
 387 
 
 drop" occurs. The patient cannot walk without stubbing the great 
 toe and to prevent this, the whole leg is raised (steppage gait). 
 This nerve bears an important relation to the knee-joint and to the 
 tendon of the biceps. 
 
 To expose the peroneal behind the head of the fibula place the 
 patient face downward or on the sound side. The line of the nerve 
 corresponds to the tendon of the biceps, which may be palpated 
 along the external border of the popliteal space, or the course of the 
 nerve may be indicated by a line drawn from the tuberosity of 
 the ischium to the head of the fibula. In this line, beginning at the 
 neck of the fibula, make an inci- 
 sion upward 3 inches long, divid- 
 ing the structures down to the 
 deep fascia. Carefully divide the 
 deep fascia over the tendon of 
 the biceps and at once there comes 
 into view the external popliteal, 
 lying to the inner side of the 
 tendon resting upon the external 
 condyle of the femur above, and 
 lower down winding about the 
 neck of the fibula and disappear- 
 ing in the peroneus longus. 
 
 To Expose the Musculocuta- 
 neous. — -Place the patient upon 
 
 his back, the knee flexed and rotated inward, and retained by a 
 cushion placed under the thigh; in this manner exposing the ex- 
 ternal aspect of the leg. 
 
 The line of the nerve is drawn from the anterior border of the pero- 
 neal head to the anterior border of the external malleolus. Along 
 this line, in the middle of the leg, make an incision 3 or 4 inches 
 in length dividing the structures to the deep fascia. 
 
 Incise the aponeurosis of the peronei muscles, isolate the anterior 
 border of the peroneus longus and draw it backward. The muscle 
 may be previously relaxed by rotating the foot outward. The nerve 
 will be seen resting upon the peroneus brevis (Fig. 294). 
 
 The Anterior Tibial Nerve. — The anterior tibial nerve is the 
 
 Fig 294. — Musculocutaneous nerve lying 
 upon the peroneus brevis. (Labey.) 
 
INJURY AND REPAIR OF NERVES 
 
 continuation of the external popliteal nerve. The movements 
 of flexion of the foot and extension of the toes depend upon this 
 nerve. 
 
 To Expose the Anterior Tibial Nerve.— -(A) In the upper third: 
 Put the patient in the same position as for the musculo-cutaneous. 
 
 The line of the nerve is drawn from the front of the peroneal head 
 to the middle of the anklejoint (Fig. 295). 
 
 In the line of the nerve make an incision beginning three fingers' 
 breadth below the articular line of the knee. Divide to the deep 
 fascia; next divide that and then patiently search for the intermus- 
 cular septum separating the wide tibialis anticus from the narrow 
 common extensor. It will aid greatly in the search to seize with a 
 forceps each of the lips of the wound of the sheath and retract. 
 This will help to develop the line of cleavage. 
 
 Fig. 295. — Lines representing the course (c) of the musculo-cutaneous; 
 (ab) Anterior tibial nerves. CLabey.) 
 
 Remember that the tibialis anticus slightly overlaps the common 
 extensor, so that the intermuscular space slopes inward and back- 
 •ward. Retracting the muscles, the nerve will appear as a small 
 rounded white cord lying in front of the vessels. 
 
 (B) In the lower third (see Anterior Tibial Artery). 
 
 Posterior Tibial Nerve. — The posterior tibial nerve supplies the 
 movements of the extension of the foot and flexion of the toes and 
 may be wounded in any part of its course, although in the region 
 of the calf it is deeply situated. Behind the internal malleolus 
 it is superficial and easily exposed. 
 
 (A) To Expose Upper Third. — -To expose the posterior tibial in 
 the region of the calf is difficult (Fig. 296). 
 
 Position. — -Place the patient on his back with the thigh in abduction 
 
 
REPAIR OF THE POSTERIOR TIBIAL 
 
 3»9 
 
 and external rotation, the knee flexed, and the foot lying upon its 
 external border and held in this position by an assistant. Standing 
 to the outside of the limb the operator with this arrangement can 
 see quite well the internal surface of the leg. 
 
 Fig. 296. — Exposure of the post, tibial nerve. Gastrocnemius retracted; 
 soleus exposed. (Labey.) 
 
 Fig. 297. — Fibers of the soleus divided and retracted, exposing deeply- 
 situated, the posterior tibial nerve and artery. (Labey.) 
 
 Locate first the sharp internal border of the tibia, and a finger's 
 breadth behind it make an incision 4 inches long, beginning at the 
 
49° 
 
 IJNJUK'i \:\W KIM'AIK U±< 1NILKV1L& 
 
 level of the tuberosity. Divide the tissues down to the deep fascia, 
 avoiding the internal saphenous vein, which lies close to the tibial 
 border. 
 
 Slightly retract the posterior lip, which will include the gastrocne- 
 mius, and in this manner the soleus is exposed. Division of the 
 soleus is the next step which must be carefully carried out. Divide it 
 longitudinally, but further away from the tibia than the original in- 
 cision. Cutting in this manner through the fibers of the soleus, the 
 yellow aponeurosis covering the nerve and vessels is exposed (Fig. 297). 
 It is important to expose this landmark well. Make an opening in it 
 an inch and a half from the internal border of the tibia, and beneath 
 the opening is the nerve, lying to the outer side of the artery. 
 
 (B) Behind the ankle (see Ligation of Posterior Tibial Artery). 
 
CHAPTER XXI 
 ABSCESS 
 
 An abscess is a circumscribed collection of the liquefied products 
 of infective inflammation. 
 
 There are two kinds of abscesses, differing in their etiology, clinical 
 history, prognosis, and treatment. All these differences arise pri- 
 marily in the nature of the infective agent. The acute abscess is due 
 most generally to the activity of certain of the cocci. The chronic 
 (or cold) abscess is nearly always due to the Bacillus tuberculosis. 
 The chronic abscess may become infected secondarily with the germs 
 of acute inflammation, in which instance it takes on the character 
 of the acute abscess. 
 
 The content of the acute abscess is pus; that of the chronic abscess, 
 though resembling pus, may be merely the liquefied caseated matter 
 of the tubercle without any pus cells whatever. An acute abscess 
 presents all the cardinal symptoms of inflammation: constitutional 
 disturbance, pain, heat, redness, swelling, all in greater or less 
 degree, depending on the locality. A chronic abscess may present 
 none of these symptoms except swelling, and where swelling is not 
 perceptible the abscess is frequently unsuspected. An acute ab- 
 scess is of very rapid development — the chronic of quite slow growth, 
 as a rule. An acute abscess demands immediate evacuation by 
 free incision and drainage. The chronic abscess very often per- 
 mits only of aseptic puncture, followed by the injection of deter- 
 gent remedies, and aseptic occlusion. 
 
 Each occurs by choice in certain locations. The incision, the 
 special dangers and details of treatment depend on the anatomy of 
 the parts, so that the more common abscesses require individual 
 consideration, and in that connection the general principles that 
 underlie the subject may be elaborated. 
 
 The prevention of pus formation should be attempted in all acute 
 
 39* 
 
infectious inflammations by means of the timely application, in 
 favorable localities, of hot antiseptic poultices or prolonged immer- 
 sion in hot antiseptic solutions. Even though the treatment fails 
 to prevent suppuration, it will at least limit it. Such an antiseptic 
 poultice may be made by applying absorbent cotton soaked in hot 
 boric acid solution and covering it with oiled silk or gutta-percha. 
 In this manner heat and moisture are retained. 
 
 The old flaxseed-meal poultice is more often than not the breeder 
 of germs and therefore distinctly non-surgical — a domestic make- 
 shift. Some of the " antiphlogistic'' glycerinated and sterile clay 
 pastes often render an excellent service. 
 
 Treatment. — The evacuation of an abscess is by many regarded 
 as a small procedure in minor surgery. It may be nothing more, 
 and yet, as Lejars says, in certain cases it is a formidable task 
 straining the resources of the most practised. It is an idea too long 
 prevalent that there is a minor and a major surgery. There is only 
 one kind of good surgery, whether the case is of great or little im- 
 portance. It is that which recognizes the indications and meets 
 them promptly, giving the patient relief with the least possible 
 delay. 
 
 Abscesses have too much been regarded as simple conditions which 
 the merest tyro might treat. We all know of patients who have 
 died of these operations; of others who have been disabled by the 
 failure to perform them, or by their being tardily or improperly 
 done. And how often tardily done! 
 
 But what excuse can one make for delay after pus has definitely 
 formed, for any attempt to bring about its absorption is futile. 
 Delay merely means that the collection augments, destroys more 
 tissues, acquires diverticula without end, which may need to be 
 opened up time and time again, or may require months to heal, 
 and eventually give rise to irremediable contractions and adhesions. 
 
 It is one of the most important and least varying rules of surgical 
 practice that every acute abscess, superficial or deep, must as early 
 as possible be incised, emptied, and drained. 
 
 Another point: do not wait for fluctuation, which is so commonly 
 the practice. If the suppuration occurs in the deeper structures, 
 fluctuation may be delayed. But there are ample indications 
 
ACUTE ABSCESS 393 
 
 otherwise; the rapid increase of swelling, the radiating pains, 
 fever, and subcutaneous edema give sufficient evidence that pus is 
 present. 
 
 In certain regions, the thick and brawny skin and fascia is as 
 significant as fluctuation itself. On the scalp, for instance, this 
 brawny edema is a definite symptom of suppuration. 
 
 The edema is superficial; the suppuration, deep. The two 
 processes go together and when the first is present, one may un- 
 hesitatingly diagnosticate the second. 
 
 To repeat, when the skin pits on pressure and is only slightly red- 
 dened even, the diagnosis is no longer doubtful and one may — one 
 should — operate at once. 
 
 The length of the incision is of the greatest importance. Nothing 
 is more unsatisfactory than the mere stab, or puncture, of an acute 
 abscess. The incision, cutting through the middle, parallel with 
 the most important structures, should open up the whole length of 
 the cavity. In this manner no pockets are left behind, and, be- 
 sides, a long, smooth incision will in the end leave the least scar. A 
 counter-incision may be necessary. 
 
 Once the abscess is opened and the pus has ceased to flow, wipe 
 out the cavity with sterile gauze and irrigate with sterile water or 
 some antiseptic. If diverticula are found, they too must be freely 
 opened up and irrigated. 
 
 Insert a drain. If the abscess was small and the incision made 
 early, it is proper to dispense with the drain; but if the suppuration 
 is extensive, the best means of preventing large scar formation is to 
 employ drainage. 
 
 Observe, then, says Lejars, that the whole therapy of abscesses is 
 contained in these two words, " empty" and "drain." 
 
 You do nothing more — there is nothing more to be done — and 
 it is sufficient. To attempt to make an abscess cavity aseptic is 
 wasted effort. An abscess contains infection of limited virulence 
 and when once it is emptied, the living tissues will do the rest, pro- 
 vided they are not embarrassed by new germs introduced by the 
 operation. 
 
 With this notion in view, then, it must be an absolute rule of 
 practice to operate for abscess with clean hands and clean instru- 
 
394 ABSCESS 
 
 ments in a carefully disinfected field. We may put away for all 
 time the old dictum, "If pus is present, antisepsis is useless." 
 
 Disinfect the hands, or what is better, the gloves; boil the instru- 
 ments; cleanse the affected area with soap and alcohol and bichloride 
 or simply paint with Tr. iodine; then, and then only, are you ready 
 to incise the swelling. Wipe out with sterile gauze; use sterile tubes. 
 Do not pack with gauze; there is nothing more illogical than tam- 
 ponade of an abscess cavity. Cover the wound with sterile gauze 
 and absorbent cotton, and bandage firmly so that nothing may enter 
 the wound; so that the dressings will not slip or rub. 
 
 The dressings are to be changed daily at first and the tubes every 
 second or third day, and are to be shortened as the cavity fills up 
 with granulations; are to be dispensed with when pus has ceased 
 to form. 
 
 Treatment of Cold Abscess. — The treatment of a cold abscess 
 differs from that of an acute abscess in that incision is not the method 
 of choice. 
 
 There is always great danger of infection when the abscess cavity 
 is opened up and for that reason incision must be done with circum- 
 spection — with an absolute asepsis. There is not the urgency present 
 in the acute case. 
 
 Puncture is the method of choice. Employ the strictest anti- 
 sepsis. Wash with soap and water, but not too vigorously lest the 
 abscess wall be ruptured; complete the disinfection with alcohol 
 and ether. Employ only such instruments as are carefully sterilized. 
 Use a trocar of sufficient size that the grumous fluid will not occlude 
 it. Do not puncture the summit of the tumor if the skin is quite 
 thin, but select a point where the tissues are sufficiently resistant 
 to close when the trocar is withdrawn. At the end of the evacuation 
 the fluid may need to be aspirated. It may be discolored by some 
 blood from the puncture. 
 
 Injection with some stimulating and antiseptic fluid should follow. 
 Ethereal solution of iodoform has the advantage of distending the 
 cavity by gas formation and reaching all the diverticula; but it has 
 the disadvantage that it is toxic. Inject 5 to 10 c.c. of a 10 per 
 cent, solution; leave the trocar in place, closing its orifice with the 
 finger. When the cavity becomes distended, remove the finger and 
 
CHRONIC ABSCESS 395 
 
 the ether spurts out. Let all the gas escape. If one does not 
 observe this rule there may be a slough. 
 
 A solution of iodoform in glycerine may be employed; inject 3 to 10 
 grams of a 10 per cent, solution, letting the surplus escape. Cam- 
 phorated naphthol may be used in the same way. Bismuth paste in 
 certain localities serves an excellent purpose. After the injection 
 is completed seal the puncture with collodion. Several injections 
 may be necessary for a cure. Constitutional treatment is of the 
 greatest importance. 
 
 ABSCESSES OF THE SCALP 
 
 These are found in three locations : 
 
 1. Superficial — that is, above the aponeurosis of the occipito- 
 frontalis. 
 
 2. Subaponeurotic — that is, between aponeurosis and the perios- 
 teum. 
 
 3. Subperiosteal — between the periosteum and the bone. 
 
 1. Superficial abscess, due to staphylococci, is quite localized, 
 and yet very painful on account of the resistance of the firm tissue. 
 The lymph nodes behind the ear and in the back of the neck are 
 enlarged and tender. The chief danger is in extension to the deeper 
 layers; or the emissary veins may carry infection to the sinuses and 
 produce thrombosis or pyemia. Evacuate immediately by free 
 incision, first shaving the scalp in the immediate vicinity of the 
 abscess. 
 
 Remembering the manner in which the occipital and temporal 
 arteries converge toward the apex, the incision may be managed in 
 such a way as to run parallel to the small vessels distributed to the 
 area. 
 
 The cavity must be kept open by a strip of rubber tissue or a small 
 drainage-tube. A dressing of gauze, absorbent cotton and bandage 
 complete the treatment. Change the dressing every day at first. 
 
 2. Subaponeurotic abscess is likely to follow wound infection. 
 The streptococci follow the areolar tissues that separate the aponeu- 
 rosis from the periosteum, and the spread of pus is limited only by 
 the attachments of the aponeurosis. Septicemia, meningitis, and 
 

 39 6 ABSCESS 
 
 thrombosis are the actual dangers, and on these accounts immediate 
 operation is demanded. 
 
 Make a free incision under antiseptic precautions; that is, after 
 shaving and cleansing the part involved. 
 
 Do not attempt irrigations, above all, in these cases, for the fluid 
 percolating through the loose areolar tissues spreads the infection. 
 Good drainage alone will suffice. The dressings must be changed 
 frequently at first and must be firm enough to prevent movement of 
 the occipito-frontalis muscle. 
 
 If the abscess develops under the temporal fascia, it will not point 
 toward the surface, owing to the extreme density of this fascia, but 
 toward the mouth or neck through the ptergo-maxillary fossa. 
 Even though there be no fluctuation (usually indeed, none can be 
 detected), the diagnosis can, nevertheless, be certainly made from 
 the presence of the edema, redness, and pain. Make a vertical in- 
 cision an inch or so in front of the ear and with the center about the 
 level of the eyebrow. It may be necessary to go through the sub- 
 stance of the muscle to the bone. A few small arteries will be divided 
 and will require ligation. It may be necessary at the first dressing to 
 pack the cavity with gauze to control slight but persistent bleeding. 
 Drainage by means of tubes may be employed subsequently. 
 
 3. Subperiosteal abscesses differ from the others in that they 
 are likely to be the result of bone inflammation, tubercular or 
 syphilitic. The abscesses are limited to the area of one bone as the 
 periosteum along the line of the sutures is continuous with the 
 dura mater. This furnishes an easy means of entrance into the 
 cranial cavity for the infection and in that manner meningitis may 
 result. For this reason, these abscesses, of whatever origin, should 
 be evacuated at once and appropriate constitutional treatment 
 instituted. 
 
 ABSCESS AND FURUNCLE OF THE FACE 
 
 The danger in these conditions is that phlebitis beginning in the 
 facial vein may spread to the cavernous sinus, so free is the com- 
 munication by numerous branches between these venous channels. 
 iallv to be feared are these furuncles beginning on the upper 
 
ABSCESS OF THE FACE 397 
 
 lip or median parts of the face. They may be fatal in a few days. 
 Nearly always the staphylococcus pyogenes is the active causative 
 agent and one need not usually be at a loss to trace the mode of 
 entrance of the infection. 
 
 Early incision is imperative in all such acute septic processes. 
 The best form of local anesthesia in these conditions is by freezing 
 with ethyl chloride spray. Hypodermic injections are best avoided 
 here. The incision must be deep to be effective, and in making it 
 two factors are to be borne in mind, the resulting scar and injury 
 to the branches of the facial nerve. In severe cases even these points 
 must be disregarded. Even more certain than free incision is central 
 puncture with a fine thermo-cautery, followed by the Bier suction 
 treatment. If it is a carbuncle of the diffuse type, accompanied by 
 edema of the face and inflammation of the veins, crucial incision with 
 curettement must be undertaken. The dressing of gauze may be 
 held in place by adhesive strips. 
 
 ABSCESS OF THE NASAL SEPTUM 
 
 Following a blow upon the nose, bleeding ensues and, two or three 
 days later, obstruction. Looking into the child's nasal fossae, they 
 are seen to be filled with a bright red, tender, fluctuating swelling, 
 over the cartilaginous portion of the septum. The whole nose 
 becomes hot, swollen, and painful. 
 
 The treatment is evacuation by a free incision of the mucous 
 membrane over the septum at the point of greatest fluctuation. 
 
 To operate, apply a 4 per cent, solution of cocaine to the mucous 
 membrane, and after waiting a minute or two, make an incision 
 along the septal wall from above downward and forward with a 
 slender, sharp bistoury. Douche the nasal fossa frequently with a 
 mild, alkaline antiseptic. Recovery usually follows within a week, 
 although in the neglected cases, necrosis of the cartilage may occur. 
 
 ABSCESS OF THE EYELIDS 
 
 The loose connective tissues of the eyelids favor exudation and 
 edema. An abscess occurring here is usually due either to trauma- 
 
398 ABSCESS 
 
 tism or to septic infection entering from the face or scalp or to 
 periostitis of the margin of the orbit. Early treatment of con- 
 tusions may prevent not only the unsightly discoloration (" black 
 eye"), but also a later abscess. 
 
 To prevent discolor ations apply cooling or evaporating lotions or 
 wring a gauze compress out of ice-water and apply to the lid, re- 
 newing the compress every two or three minutes. Do not allow the 
 compress to cover the nose, else acute coryza may result. Apply 
 in this manner for an hour and repeat every second or third hour for 
 twenty-four hours. A solution of arnica (2 oz.), in water (1 pt.), 
 may be applied, or 
 
 Ammonii chloride, 1 
 
 Alcohol, 1 
 
 Aquae, 10 
 
 // discolor ation appears, apply flannel cloths wrung out of hot water 
 for an hour at a time, three or four times daily, and follow with gentle 
 massage for five to ten minutes. Before applying the heat it is 
 better to smear the lid with vaseline. Ointment of yellow oxide of 
 mercury is excellent to use with massage. If an abscess appears 
 make an incision parallel with the muscle fibers. Apply antiseptic, 
 absorbent dressings. 
 
 ABSCESS OF THE LACHRYMAL GLAND 
 
 Abscess of the lachrymal gland is rare, yet doubtless is often over- 
 looked. It is seen in infancy, usually traceable to some of the in- 
 fectious diseases. The abscess breaks into the superior cul-de-sac 
 and recovery follows. 
 
 ABSCESS OF THE EXTERNAL AUDITORY MEATUS 
 
 Abscess of the external meatus is extremely painful and alarm- 
 ing, but in fact not particularly dangerous. The meatus is closed 
 by the swelling, but a stab with the point of the knife or, if it is more 
 deeply situated, an incision in the direction of the long axis of the 
 meatus, will cause a speedy disappearance of the symptoms. Gentle 
 
PAROTID ABSCESS 399 
 
 douching with an antiseptic solution, and, after drying, occlusion 
 with absorbent cotton, will soon complete the cure. 
 
 ABSCESS OF THE PAROTID GLAND 
 
 An inflammation begins in the parotid gland, the result of local 
 infection or secondary to an abdominal disease or injury (most fre- 
 quently involving the pancreas, perhaps), and nearly always sup- 
 puration follows. The severe forms are dangerous; happily, how- 
 ever, the pus, even if left to take its own course, works its way to 
 the surface or points at the phraynx. It may burrow down to the 
 anterior mediastinum. The special dangers are meningitis, septic 
 poisoning, and thrombosis. When the swelling is great, pressure 
 interferes with the venous current and, as a result, cerebral con- 
 gestion, headache, and finally delirium ensue. The pus may open 
 into the middle ear and infection by that route reaches the brain. 
 Suppuration of the temporo-maxillary articulation may follow. 
 
 Treatment. — If, when the swelling first appears, a probe be passed 
 into Stenson's duct and the gland be pressed from the outside, a few 
 drops of pus may be squeezed out and this may serve to head off a 
 general suppuration. If the entire gland becomes involved, hot 
 antiseptic poultices should be applied to hasten the localization of 
 the pus. As soon as redness and edema indicate the most probable 
 situation of the pus, an effort must be made to evacuate it. Several 
 important structures are to be avoided; Stenson's duct (a fistula 
 is likely to follow its division), the facial nerve, the carotid arteries, 
 the temporo-maxillary vein and other vessels of lesser importance 
 may be wounded. 
 
 If the anterior part of the gland is involved, the incision is made 
 parallel with and below Stenson's duct. The skin and fascia are 
 divided and retracted and an effort is made to burrow into the depths 
 of the fcland with a probe or grooved director. The pus follows the 
 connective-tissue laminae instead of the lobules of the gland, and it is 
 better, if possible, to avoid dividing the glandular substance. If 
 the posterior and lower part of the gland is involved, the incision should 
 be vertical, with its center a little above and anterior to the angle of 
 the jaw. The temporo-maxillary vein will be seen, running parallel 
 
400 
 
 ABSCESS 
 
 to the incision near the surface of the gland, 
 be left in the deeper abscesses. 
 
 A drainage-tube must 
 
 DENTAL ABSCESS 
 
 These painful affections are not to be neglected, for they may 
 lift up the periosteum and result in necrosis of the jaw. Left to it- 
 self, the abscess may point in the mouth, less frequently on the face. 
 It begins in the alveolar process from infection from a carious 
 tooth. It makes its appearance at the junction of the cheek and 
 the gum. Inspection and palpation make the diagnosis. A cotton 
 
 M.H- 
 
 tyj.M 
 
 Fig. 298. — Dental abscess. 
 (Veau.) 
 
 Fig. 299. — Submaxillary abscess 
 in contact with inner surface of the 
 inferior maxilla. M. H., Mylohyoid 
 muscle. P., Platysma myoides. 
 GLs.M., Submaxillary gland. 
 (Veau.) 
 
 tampon soaked in 2 per cent, cocaine solution is laid on the gum for 
 five or ten minutes, but analgesia will not be complete. Lift the 
 cheek away from the gum as far as possible, and with a sharp- 
 pointed bistoury, wrapped to within a half-inch of the point, make 
 a horizontal incision and cut down to the bone. There is nothing 
 to fear and without getting deep one may fail. The patient may 
 resist further efforts or the field may be obscured by blood (Fig. 298). 
 Order an antiseptic mouth-wash to be used every half-hour at 
 first, and the pain will rapidly disappear. In more extensive sub- 
 periosteal abscess of the jaws, the same principle of procedure should 
 be carried out. 
 
INCISION OF SUBMAXILLARY ABSCESS 
 
 401 
 
 SUBMAXILLARY ABSCESS 
 
 Do not await fluctuation in acute inflammations in this locality. 
 The pain, augmented by pressure, the brawny edema and diffuse 
 redness are sufficient to demonstrate the presence of pus. The 
 pus is not always easy to find, for it is deep, often subperiosteal 
 and in contact with the internal surface of the jaw, and is generally 
 due, in fact, to dental infection (Fig. 299). 
 
 Fig. 300. — Incision of submaxillary abscess. Dotted line represents the 
 facial artery. (Veau.) 
 
 Local anesthesia is often sufficient. Locate the angle of the jaw. 
 This is often difficult on account of the edema. A finger's breadth 
 below, and following the body of the jaw, make a curved nicision 
 (Fig. 300) with slight downward convexity about 3 inches in 
 length. Remember the point at which the facial artery crosses the 
 body of the jaw, just in front of the masseter. Do not cut deeper 
 than the skin, for this is dangerous ground. Now dissect with 
 forceps and grooved director the subjacent tissues, making haste 
 26 
 
402 
 
 ABSCESS 
 
 
 slowly and renewing from time to time the analgesia or injections 
 as the patient complains of pain. 
 
 Carry the dissection upward and inward toward the inner surface 
 of the jaw, and with patience the abscess will be located. As it is 
 approached, the tissues will be found more and more edematous 
 and filled with serum. Having once cut into it, enlarge the opening, 
 always too small, by introducing and opening an artery forceps. 
 Irrigate with normal salt solution, insert one or two small drains, 
 dress with antiseptic gauze and absorbent cotton, and renew daily. 
 
 Fig. 301. — Phlegmon of the floor of the Fig. 302. — Incision for phlegmon of 
 
 mouth. The tongue is pushed to the oppo- 
 site side and the spread downward of the 
 purulent collection opposed by the mylo- 
 hyoid muscle. GSL. % sublingual gland. AL, 
 lingual artery. CW, salivary duct. GGL % 
 genio-hyo-glossus. GY, genio-hyoid. MY, 
 hyo-glossus. D, diagastric. (Veau.) 
 
 floor of mouth. (Veau.) 
 
 The temperature will fall rapidly. After five or six days the drain- 
 age may be diminshed and after ten days entirely removed. 
 
 ABSCESS OF THE FLOOR OF THE MOUTH 
 
 (Ludwig's Angina) 
 
 This is a very grave, usually fatal condition, originating in strepto- 
 coccic infection through the mucous membrane of the floor of the 
 mouth. It more frequently occurs in adults, though childhood is 
 
LUDWIG S ANGINA 403 
 
 not exempt. Its tendency is to extend into the neck, following 
 the cellular planes, and if the patient does not die early from septi- 
 cemia, gangrene may occur. In a very few hours after the infection 
 begins, the floor of the mouth becomes brawny, the tongue is thrust 
 up against the hard palate, and breathing and swallowing markedly 
 interfered with. If anything is to do good, it must be done at once 
 (Fig. 301). 
 
 Try the antistreptococcic serum — if it does no good, it will at 
 least do no harm. In the meantime, operate. Usually a general 
 anesthesia is indispensable. Make an incision a finger's breadth 
 below the body of the jaw about 3 inches long so that it reaches 
 beyond the median line (Fig. 302). If both sides are equally in- 
 
 Fig. 303. — Deep incision for phlegmon in floor of mouth. G.s.M., submaxillary gland 
 M.H., mylo-hyoid muscle. D, digastric muscle. (Veau.) 
 
 volved, make a bilateral incision. One may perhaps recognize the 
 platysma, but the anterior belly of the digastric must be demon- 
 strated and divided. Next expose the mylo-hyoid and divide com- 
 pletely (Fig. 303). Having now reached the sublingual space, you 
 may find merely a serous exudate, characteristic of this form of 
 infective inflammation. Do not stop until the mucous membrane 
 of the mouth has been demonstrated, for otherwise one may mis- 
 take the submaxillary for the sublingual gland and not go deep 
 enough. 
 
 Douche thoroughly with peroxide, place two or three large drain- 
 age-tubes, pack with gauze saturated with peroxide, and apply 
 absorbent cotton. Renew the dressings and flushing three or four 
 times daily and the serum injections as well. Possibly the patient 
 will go on rapidly to death from septicemia. He is almost certain 
 
404 ABSCESS 
 
 to do so without the operation. The drainage may be diminished 
 toward the tenth day. Several weeks will be required for a cure. 
 
 ABSCESSES OF THE TONGUE 
 
 do, 
 
 Abscesses of the tongue do not often occur, but when they 
 may give rise to urgent conditions. They may develop suddenly 
 with much pain, which may be variously reflected — to the ear, for 
 example. 
 
 The tongue may be so swollen as to fill the mouth and severely 
 disturb respiration. The location of the abscess is to be determined 
 by palpation. If it is at the base of the tongue and pointing to- 
 ward the surface, is it to be evacuated by a median longitudinal in- 
 cision 'from behind forward and deep enough to reach the pus. 
 There is no danger of wounding important structures if the incision 
 follows the middle line. Leave a strip of gauze in the wound for 
 drainage. Prescribe frequent antiseptic mouth-washes. If the 
 abscess lies under the tongue and points downward, the incision 
 must be made along the floor of the mouth, if the mouth can be 
 sufficiently opened and fluctuation detected. The ranine artery 
 may be wounded. If the mouth cannot be opened it is best to 
 operate from the outside, making a median vertical incision from 
 the symphysis of the chin down, getting between the two genio- 
 hyo-glossi muscles and following this crevice up to the under surface 
 of the tongue. Drainage-tube, antiseptic absorbent dressing. 
 
 TONSILLAR ABSCESS 
 
 " Quinsy" is an actue suppuration in the tonsil or around the 
 tonsil following acute infection of the gland. 
 
 Often the suppuration occurs only on one side, though both 
 tonsils are inflamed. At any rate the two tonsils do not suppurate 
 simultaneously. 
 
 The temperature is high, the pain extreme, there is difficulty in 
 swallowing and perhaps in breathing. There may be edema of the 
 glottis. Often there is difficulty in opening the jaws. After the 
 -< ess is well formed, the soft palate is edematous and swollen. 
 
 
TONSILLAR ABSCESS 
 
 40S 
 
 Pus begins to form about the third day after the attack. Pre- 
 vious to this an effort should be made to abort the abscess. Give 
 calomel in small frequent doses and follow with a saline purge, 
 and in the meantime administer full doses of sodium salicylate. 
 Phenacetine, 2 or 3 grains frequently, will make the patient 
 more comfortable. Paint the tonsils and pharynx with argyrol 
 once a day and use the peroxide spray (50 per cent, solution) every 
 two or three hours. Apply hot anti- 
 septic fomentations or poultices exter- 
 nally. 
 
 If these measures fail to relieve the 
 symptoms after the third day, it is 
 almost certain that pus has formed, 
 even though fluctuation cannot be** 
 felt, and it is best to make an incision, 
 but this must be free. 
 
 The operation is sometimes difficult. 
 A general anesthesia will be necessary 
 if the jaws are locked. Open the 
 mouth wide. A mouth gag is often 
 necessary. Depress the tongue as 
 much as possible. Swab the tonsil 
 with a 10 per cent, solution of co- 
 caine. With a sharp pointed bistoury 
 (wrapped), make an incision in the 
 
 soft palate just external to, and parallel with, the anterior pillars 
 and extending as low down as possible. If the pus flows freely, some 
 of it may be swallowed, to prevent which bend the head down. 
 Continue the spray and antiseptic mouth-washes for a few 
 days. Whether pus is located or not, free incision gives great 
 relief (Fig. 304). 
 
 RETROPHARYNGEAL ABSCESS 
 
 Fig. 304. — Tonsillar abscess. In- 
 cision should extend as low as possi- 
 ble. (Veau.) 
 
 These conditions are treacherous and dangerous because (most 
 frequent in infants) they may be overlooked and, bursting into the 
 pharynx, may produce suffocation. 
 
 The pharynx is separated from the muscles covering the anterior 
 
406 ABSCESS 
 
 surface of the bodies of the cervical vertebra^ by a loose connective 
 tissue. One or two lymphatic glands lie in front of the bodies of the 
 upper two cervical vertebrae on either side of the middle line. These 
 receive lymph (and infection) from the nasal cavities and their 
 accessory sinuses, the naso-pharynx, the Eustachian tube, the tym- 
 panum, and from the tissues lying on the bodies of the adjacent 
 vertebrae. Septic conditions existing in any of these localities may 
 be the source of the inflammation of these lymph glands, which may 
 end in suppuration. These glands empty by several chains of lymph 
 vessels into the deep cervical glands. 
 
 The suppuration begins on one side usually, but rapidly spreads 
 toward the middle line, where the tissues are loosest. The abscess 
 may be behind the palate; it may be opposite the larynx; in either 
 case almost out of sight. Usually, however, it is seated in the pos- 
 terior wall of the pharynx, opposite the oral cavity. When situated 
 there, it gives rise to fewest symptoms, and for that reason its de- 
 velopment is insidious, and in the infant unsuspected. The con- 
 stitutional disturbance may be slight. 
 
 Obstructed breathing and hoarseness and a feeling of tightness 
 in the throat may first suggest the difficulty. Inspection and 
 palpation, always necessary, are not always easy and, in the case 
 of infants, sometimes dangerous. Still, only by touch, with the 
 finger in the mouth, can the exact condition be determined. To 
 prevent asphyxia or syncope, the main thing is to be rapid in the 
 examination. To facilitate this, the child must be prepared. 
 
 It is seated on the assistant's lap with its face turned to the light, 
 its arms and body encircled by a towel, its legs held firmly between 
 the assistant's knees. Its mouth is forced open by pressing the 
 cheeks between the teeth. The finger is passed to the back of the 
 tongue and rapidly palpates the walls of the pharynx. It is not 
 difficult to determine the point of greatest swelling. 
 
 Operation. — i. Have already prepared a sharp-pointed bistoury 
 wrapped with cotton close up to the point. The index finger in 
 the mouth holds the tongue down and the bistoury is passed along 
 the fmger and plunged into the abscess in the middle line, that no 
 blood vessels may be injured. This puncture is prolonged into an 
 incision from above downward at least an inch; in fact, as low as 
 
RETROPHARYNGEAL ABSCESS 
 
 407 
 
 possible, that chances of a recurrence may be diminished. The 
 patient is immediately inclined forward in order that the pus may 
 pour out of the mouth (Fig. 305). 
 
 If syncope or spasm of the larynx occurs, do not lose your head, 
 but proceed hastily to revive the patient by the ordinary means. 
 Lower the patient's head, pull out the tongue, and employ artificial 
 respiration. 
 
 / 
 
 Fig. 305. — Retropharyngeal abscess. (Veau.) 
 
 As after-treatment, direct frequent irrigations or gargling with 
 sterilized water. A peroxide spray may be used with good effect. 
 Recovery occurs within a few days. 
 
 If the abscess recurs, or in the first place is situated too far down 
 for oral puncture (which may sometimes be done by passing a 
 curved director over the base of the tongue and then downward to 
 the top of the abscess), or the jaws are locked, it will have to be 
 reached from the side of the neck, an operation much more difficult 
 in every way. 
 
 Operation. — 2. Turn the patient slightly to one side, resting the 
 neck upon a cushion to make its lateral aspect prominent; the sterno- 
 
4o8 ABSCESS 
 
 mastoid is the guide. Make an incision about 2 inches in length 
 along the posterior border of the sterno-cleido-mastoid, which is 
 exposed after the skin and fascia are divided. Ligate the veins; 
 avoid the superficial cervical nerves; pull the sterno-cleido-mastoid 
 forward and locate the scalenus anticus. Stick to the scalenus 
 anticus, follow its anterior surface inward, displacing forward by 
 careful dissection with grooved director, the common sheath of the 
 great vessels and pneumogastric. The connective tissues are rather 
 loose; the dissection is not difficult. Be on the watch for the spinal 
 accessory nerve, which lies on the deep surface of the sterno-mastoid. 
 Working inward in this manner reach the outer border of the longus 
 colli which lies in the same plane as the scalenus anticus, and upon 
 which lies the pharynx and the abscess. After opening and empty- 
 ing, a drain must be left. Employ the usual dressings and after- 
 treatment. Sometimes the abscess lies further forward and it will 
 be necessary to go in front of the sterno-cleido-mastoid. After the 
 skin and fascia are divided, the finger in the wound will be able to 
 locate fluctuation and that will be the best guide in the subsequent 
 dissection. It may be necessary to ligate several small veins. Re- 
 tract the anterior border of the sterno-mastoid and with it the 
 sheath of the common carotid, the internal jugular and pneumo- 
 gastric; draw foward the thyroid, the larynx and trachea. The 
 fascias are divided by blunt dissection until the abscess cavity is 
 opened. 
 
 ABSCESS OF THE GLANDS OF THE NECK 
 
 Acute suppuration of the lymph glands of the neck is quite fre- 
 quent and originates in infective disorders of the areas drained by 
 the glands. 
 
 In treating these conditions, the source of the infection must not 
 be overlooked. It is not always advisable to operate immediately, 
 even though suppuration is believed to be present, unless, of course, 
 the infection shows a tendency to become general. 
 
 In the ordinary case, the pus may be very deeply located or out- 
 side the capsule of the gland. It is better under these circumstances 
 to apply hot antiseptic poultices for twenty-four to forty-eight 
 hours. The whole gland then becomes softened, the pus is easily 
 
MAMMARY ABSCESS 409 
 
 evacuated and healing occurs rapidly; whereas a non-suppurating 
 gland cut into may remain enlarged and indurated. Free incision 
 is always out of the question as the many important structures of 
 the neck have to be borne in mind. Use local anesthesia. In mak- 
 ing the incision it is usually best to follow the posterior border of 
 the sterno-mastoid. Make an incision about 2 inches in length. 
 When the muscle is reached, draw it forward with a retractor and 
 with a grooved director search for the pus cavity; drain; use absorbent 
 dressings. 
 
 CHRONIC SUPPURATION OF THE CERVICAL GLANDS 
 
 There are various clinical manifestations of the tubercular proc- 
 esses, each of which demands a somewhat different treatment. It is 
 assumed that the pus, gradually accumulating, has burst through 
 the fascia and has begun to bulge the skin. 
 
 It is best to operate at once. The most careful asepsis should be 
 maintained. The pus is evacuated by free incision and the abscess 
 cavity wiped out with iodoform gauze. A 10 per cent, solution of 
 iodoform emulsion with glycerine is poured into the cavity (2 or 
 3 drams are sufficient) and the wound sutured and treated as 
 an aseptic wound, provided there is no evidence of secondary 
 infection. 
 
 ABSCESS OF THE BREAST 
 
 Abscess of the breast may be either parenchymatous, originating 
 in the substance of the gland; or submammary ', originating in the 
 areolar tissues separating the gland from the pectoralis major. 
 
 In either case infection nearly always begins at the nipple and 
 follows the lymph vessels downward. The first form is usually due 
 to staphylococcic infection, the second to streptococcic. These 
 conditions are preventable in the greater number of cases and for 
 that reason the nipple should be given special care both before 
 confinement and during the first weeks of lactation. 
 
 Even when the breast becomes " caked" and tender and there is a 
 little fever, antisepsis at the nipple and hot antiseptic poultices to 
 the breast may prevent abscess formation. Continued rise in tern- 
 
410 ABSCESS 
 
 perature, slight chills, edema and pain, more or less localized, indi- 
 cate the formation of pus, and immediate operation is necessary. 
 A general anesthesia is best for thoroughness, though the work may 
 be done under local anesthesia. 
 
 Under rigid asepsis, proceed to open up the cavity, and always 
 remember, the earlier the better. An incision an inch or so long 
 should begin near the nipple and radiate from it, as the spoke from 
 the hub of a wheel. In this manner the least possible number of 
 the milk ducts and vessels are divided (Fig. 306). 
 
 1 
 
 Fig. 306. — Abscess of the breast: incision. (Lejars.) 
 
 The first incision goes through the skin and fascia and then the 
 abscess cavity is sought for by blunt dissection with a grooved 
 director. Still there is nothing to fear in cutting boldly down to the 
 abscess. Explore the cavity thoroughly for there may be pockets 
 leading off from the main cavity. Do not neglect this point. If it 
 extends deep, make a counter-opening at the base, being guided by 
 the director introduced through the first opening (Fig. 307). Push- 
 ing a forceps through the channel, it seizes a drainage-tube which is 
 drawn into place as the forceps is withdrawn. Dress with anti- 
 septic gauze, which should be changed twice daily at first, care 
 being taken not to disturb the drainage-tube. 
 
 It the temperature rises again after the second or third day, you, 
 
AXILLARY ABSCESS 411 
 
 will have to re-explore. A new abscess is in process of formation. 
 After five or six days replace the first drainage-tube with a smaller 
 one. The drainage-tube can be entirely dispensed with after ten 
 days or two weeks. 
 
 The submammary abscess develops without edema or redness 
 because it underlies the whole breast. The condition can scarcely 
 be mistaken, for the marked elevation of the whole breast, along with 
 the constitutional symptoms point to the nature of the trouble. 
 Make a curved incision following the base of the breast at its lowest 
 
 Fig. 307. — Abscess of the breast. Manner of making counter-opening. D, grooved di- 
 rector; P, its point; B, bistoury cutting down on to the point of director. (Lejars.) 
 
 part, dividing the skin and fascia. With a grooved director, dissect 
 through the areolar tissues between the gland and the chest wall, 
 working toward the center of the breast. These deep tissues are 
 likely to be infiltrated. In this manner the pus is evacuated and 
 the subsequent treatment will be practically the same as that 
 prescribed for the preceding form. 
 
 AXILLARY ABSCESS 
 
 Three chains of lymphatic glands are found in the axillary space. 
 One lies along the anterior fold of the axilla and drains the anterior 
 
4i- 
 
 ABSCESS 
 
 thoracic region; one lies on the posterior axillary wall and drains the 
 posterior thoracic region; one lies alongside and externally is con- 
 nected with the axillary vessels and drains the upper extremity. 
 Axilla rv abscess usually results from inflammation of one or the other 
 of these chains of glands, the infective agent having been carried 
 to them from a distant point, such as the breast or hand, by the 
 lymph vessels. 
 
 The inflammation spreads from the glands to the adjacent areolar 
 tissue and pus formation follows. Abscess may also form by exten- 
 sion of pus formation from the base of the neck. 
 
 Fig. 308. — Cross section showing relations of axillary abscess. G. F. Pect. major. 
 P.P. Pect. minor. G. D. Latiss, dorsi. S.SC. Subscapularis. G. D. Serratus magnus. 
 (Veau.) 
 
 The most frequent sources of infection, probably, are the breast 
 and the sebaceous glands in the skin of the armpit. Abrasions and 
 small boils in this locality must be treated with circumspection, lest 
 they terminate finally in axillary abscess. The ordinary symptoms 
 of inflammation and pus formation, added to the painful abduction 
 of the arm, indicate the nature of the trouble. 
 
 It is imperative to evacuate the pus promptly for the reason that 
 it may burrow in various directions, usually upward toward the neck. 
 The axillary vessels may be eroded. 
 
 The incision will depend upon the location of the pus — that is to 
 
AXILLARY ABSCESS 
 
 413 
 
 say, whether if lies under the pectoralis major or in the loose areolar 
 tissues of the center of the space. Acute abscess more often lies 
 in the first locality (Fig. 308) ; tubercular abscess in the latter. 
 
 (a) Acute Abscess (Fig. 309). — General anesthesia; place the 
 patient on his back; abduct the arm as much as possible; and locate 
 the border of the pectoralis major. Make an incision 3 inches 
 in length along this line, cutting toward the thorax; expose the 
 muscle border well; dissect along the under surface of the pectoralis 
 major with the grooved director. In this manner you keep in front 
 of the great vessels and nerves and will feel secure. When the pus 
 once flows, enlarge the opening, and insert drainage-tubes. 
 
 Fig. 309. — Incision for acute axillary abscess. The blunt dissection should follow 
 the anterior axillary wall. (Veau.) 
 
 To avoid the axillary structures, you must keep these two points 
 in mind: (1) Make the opening large enough to see what you are 
 doing — a blind stab in this region is exceedingly dangerous; (2) 
 stick to the pectoralis major — the pus is in contact with its deep 
 surface. Wash out the cavity and place two drains; use a gauze and 
 absorbent cotton dressing daily for a week, after which remove the 
 tubes, though the external opening must not be allowed to close until 
 the cavity is eliminated. 
 
 (b) Chronic Abscess. — Incision. Begin in the middle of the floor 
 of the, space and follow the middle line away from the arm toward 
 
414 ABSCESS 
 
 
 the chest. In this direction alone is safety. ]n front are the long 
 thoracic vessels; behind are the subscapular vessels; to the outside 
 are the main axillary vessels and branches of the brachial plexus. 
 The skin incision may occasionally divide a small artery, which will 
 at first give some concern. It is best to divide the connective tissues 
 layer by layer in the original line of incision. There is no danger 
 if you keep in this line. Otherwise, the pus may be reached by 
 Hilton's method. After the skin and fascia are divided, a dressing 
 forceps is pushed up into the abscess cavity and the bladeso pened 
 Put in a drainage-tube; use absorbent dressings; maintain a caref 
 asepsis throughout the process of repair. 
 
 is 
 
 PALMAR ABSCESS 
 
 These are always serious conditions, not alone on account of sepsis, 
 but because the hand may be left permanently crippled or useless as 
 a result of the destruction of tissue and inflammatory adhesions. 
 
 Immediate evacuation of pus is imperative. If the pus is limite- 
 to the connective tissues of the palm, has not reached the tendo. 
 sheaths, the incision should be made over, and parallel with, th< 
 interosseous space in the region of the greatest swelling. 
 
 If the tendon sheaths are involved, the incision should be made i 
 the long axis of the metacarpal bone (see Phlegmon, page 424) 
 Whether the condition is a diffuse inflammation (phlegmon) or a: 
 abscess will be determined by the history of the case. 
 
 In the case of abscess, make a longitudinal incision. The palma: 
 arches are chiefly to be considered. Begin the incision just below 
 line drawn across the palm from the web of the thumb. Beginnin) 
 nearer the wrist, the superficial palmar arch or the deep arch as well 
 may be divided. Cut toward the finger, making the incision suffi- 
 ciently deep to go quite through the palmar fascia. Insert a drain- 
 age-tube. Use antiseptic dressings, changing the dressings daily. 
 (See also Phlegmons.) 
 
 POPLITEAL ABSCESS 
 
 Situated in the hollow back of the knee-joint in the superficial 
 fascia are a few lymph glands which may suppurate following an in- 
 
POPLITEAL ABSCESS 415 
 
 fective process in the foot or leg. Situated still deeper beneath the 
 deep fascia are other glands which may similarly suppurate. 
 
 These may be described, then, as superficial abscess and deep 
 abscess of the popliteal space. 
 
 The superficial abscess may be opened simply by a vertical in- 
 cision over the point of greatest swelling. There are no important 
 structures likely to be wounded by a superficial incision. 
 
 It is quite different with a deep abscess. The situation of a number 
 of important structures must be borne in mind. In the center of 
 the lower half of the space lies the short saphenous vein; to the 
 outer side lies the external popliteal nerve, and running vertically 
 through the center of the space, and deeply located, are the popliteal 
 vessels and internal popliteal nerve. The space is roofed over by 
 the dense popliteal fascia which is the chief factor in determining the 
 direction in which the suppuration extends; thus the pus is more 
 likely to point up in the thigh or down in the leg than in the integu- 
 ments of the space. 
 
 A popliteal abscess may likewise be the result of the extension of 
 a suppurative process in the thigh. These abscesses must be opened 
 without delay for the reason that the joint may become involved, the 
 vessels may slough, and there may be destruction of tissue. There 
 may be permanent flexion of the leg due to scar tissue. 
 
 Before opening a popliteal abscess the diagnosis must be con- 
 firmed. It has happened more than once that a popliteal aneurism 
 has been mistaken for an abscess and incised, a mistake serious indeed 
 for both patient and operator. 
 
 Acute inflammation of the bursae must not be mistaken for ab- 
 scess. These bursae are found in the boundaries of the space, 
 separating the tendons from the protuberances of the femur, tibia, 
 and fibula. 
 
 Operation. — Either general or local anesthesia may be used. Make 
 a vertical incision in the center of the space, dividing the skin, the 
 superficial fascia, and the deep fascia successively. With the grooved 
 director separate the fatty tissues filling the space; keep in the line 
 of the original incision. The pus will usually be located before the 
 depth of the vessels has been reached. Enlarge the opening in the 
 connective tissues, irrigate, search for diverticula, insert a drainage- 
 
4 1 (> ABSCESS 
 
 tube and pack lightly around the tube with aseptic gauze. Apply 
 absorbent dressings and extend the leg on a posterior splint. This 
 extension must be maintained until the healing is complete to prevent 
 flexion. 
 
 PLANTAR ABSCESS 
 
 The deep fascia of the sole of the foot is especially developed. It 
 extends as a broad, dense band from one end of the plantar arch to 
 the other, from the os calcis to the base of the metatarsal bones. 
 It is a broad band divided into three portions: outer, middle, and 
 inner. The central portion alone is of much surgical importance. 
 Its anterior extremity is broken up into five slips, and each slip 
 branches and forms an arch for a flexor tendon. 
 
 The result of this arrangement is that here is a closed compartment 
 between the fascia and the bones of the foot which is occupied by 
 the muscles of the middle foot. Following an infection, pus form- 
 ing in this compartment finds great difficulty in escaping. It 
 burrows between the metatarsal bones and makes its appearance 
 on the dorsum of the foot, follows the flexor tendons backward to 
 the inner ankle, or may escape through the small aperture for the 
 arteries into the subcutaneous fascia. 
 
 On account of the denseness of the fascia, the pain in plantar ab- 
 scess is extreme, and for relief of this pain and to prevent destruc- 
 tion of tissue, an early incision is imperative. The incision should 
 be made over the most prominent part of the swelling, its direction 
 corresponding to the long axis of the foot. 
 
 The skin is divided and then the thick fatty tissues, until the white 
 and firm plantar fascia is reached. After the fascia is divided, 
 the dissection is .completed with a grooved director until the pus 
 cavity is located. In this manner no important structures are 
 wounded. Wash out the cavity and insert a small drainage-tube. 
 It is important that the cavity heal from the bottom. 
 
 ISCHIORECTAL ABSCESS 
 
 The ischio-rectal fossa is a wedge-shaped cavity, lying on either 
 side of the rectum, between it and the pelvic wall. Its base is 
 
ISCHIO-RECTAL ABSCESS 417 
 
 covered by the integument and its sharp edge is directed upward 
 and corresponds to a line drawn from the pubes backward to the 
 spine of the ischium — -the line of attachment of the levator ani 
 muscle, the " white line" of the pelvic fascia. The levator ani mus- 
 cle forms its inner boundary. The obturator fascia covering the 
 bony pelvic wall forms its outer boundary. 
 
 The fossa is filled with fatty tissue which seems to form a packing 
 and support for the rectum, but which at the same time forms a 
 site of " lowered resistance" to infective agents. 
 
 These infective agents gain access to the fatty tissues of the fossa 
 through ulcerations or abrasions of the rectal mucous membrane or 
 from similar conditions in the integument around the anal orifice. 
 For the most part the bacteria follow the lymphatics which have 
 their origin in these localities and which follow the branches of the 
 inferior hemorrhoidal vessels through the fossa. The abscess may 
 be secondary to prostatic abscess. 
 
 The symptoms of acute abscess here are the ordinary constitutional 
 symptoms in marked degree, accompanied by intense throbbing 
 pain in the region of the anus. The skin becomes brawny and 
 indurated but no fluctuation appears in many cases. 
 
 The symptoms of chronic abscess differ only in degree, and are 
 often so slight as to be entirely overlooked. Abscess of any kind in 
 this locality, when diagnosed, should be evacuated without delay. 
 If let alone it will eventually open the rectum or through the skin 
 if the patient should survive the general sepsis. But spontaneous 
 evacuation is in every way to be avoided, if possible. A fistula is 
 the inevitable sequel if the case is left to nature. 
 
 This fistula, opening into the bowel whether* the abscess formed 
 near the roof of the fossa or near the floor, is very likely to be just 
 above the external sphincter. There the bowel wall is thinnest, 
 and the fascias of the levator ani act as an inclined plane along which 
 the pus moves toward that part of the bowel. 
 
 The examining finger in the rectum in the case of abscess will 
 nearly always detect the threatened opening there and confirm the 
 diagnosis. 
 
 Operation. — General anesthesia; lithotomy position; antisepsis. 
 
 The incision (Fig. 311), 4 or 5 inches in length, is made from 
 27 
 
4i8 
 
 ABSCESS 
 
 before backward and inclined a little outward midway between the 
 ischial tuberosity and the rectum. Remember that cutting too 
 near the middle line, you may wound the rectum; too near the pelvic 
 wall, you may wound the internal pudic vessels. Some small 
 hemorrhage will follow the skin incision. It may be necessary to 
 cut deeper along the same line and you may wound some of the 
 branches of the inferior hemorrhoidal arteries, but that is not a seri- 
 ous matter. 
 
 With a little patience, in this manner the pus is reached and it 
 pours out, extremely fetid and often mixed with shreds of con- 
 nective tissue. 
 
 
 Fig. 311. — Ischiorectal abscess. Incision. (Veau.) 
 
 Enlarge the wound so that it may be inspected and explore it 
 with the finger. Irrigate vigorously. Being assured that all the 
 minor cavities are opened up, introduce a large drainage-tube and 
 pack around it with gauze. The dressing must be renewed daily 
 at first. The tubes can be gradually withdrawn. 
 
 It is absolutely necessary that the wound heal by granulation from 
 the bottom and this may be a matter of weeks or even months. Of 
 this the patient should always be forewarned. During this time 
 the dressings must be carried out methodically. Often following 
 incision and drainage there is a tendency to relapse because the 
 primary focus of suppuration in the prostate has not been recog- 
 nized and relieved. 
 
 If a small opening is exposed high up in the cavity, through which 
 pus drains, it indicates a peri-rectal abscess above the levator ani, 
 
PERI-ANAL ABSCESS 419 
 
 dangerous because it may become a general pelvic cellulitis or 
 peritonitis. Enlarge the opening by the introduction of a dressing 
 forceps, irrigate and drain. 
 
 These peri-rectal abscesses not involving the ischio-rectal fossa are 
 difficult to diagnosticate, but when once determined they must be 
 opened in the manner already indicated. 
 
 Again, the ischio-rectal abscess may have, unfortunately, already 
 opened through the rectal wall. Make the skin incision as before, 
 and then an additional step is necessary. Push a grooved director 
 up through the abscess cavity and through the rectal opening and 
 then, following along the grooved director, cut through the entire 
 thickness of the rectal and anal walls, holding one finger in the 
 rectum to guide the knife. It will look like a very long wound, and 
 yet it has the excellence of favoring recovery and of preventing a 
 fistula. However, under the most favorable circumstances, it may 
 require several months to heal (Lejars). 
 
 PERI-ANAL ABSCESS 
 
 These are much less serious than those of the ischio-rectal region, 
 both with regard to prognosis and treatment. However, if neg- 
 lected, they are likely to result in fistula; even if not properly in- 
 cised they may so result. The peri-anal abscess is in the glands 
 surrounding the anal margin and lies under the integument or 
 mucous membrane. Local anesthesia is all that is necessary except 
 for those who are timid, and with them general anesthesia is 
 indispensable. 
 
 Puncture the tumor at its apex. The pus is foul smelling. Irri- 
 gate; explore the cavity methodically with a grooved director. 
 There is nearly always an ascending diverticulum on the anal side 
 which communicates with the rectum. Having located the apex 
 of the cavity, push the point of the director through the mucous 
 membrane; in other words, make a fistula if one does not already 
 exist (Fig. 312). Divide all the tissues over the director, in this 
 manner laying open the cavity and anal margin. Carefully wipe 
 out the walls of the abscess and pack with iodoform gauze. As 
 important as the operation is the after-treatment. This the doctor 
 
420 ABSCESS 
 
 must attend to himself. The dressing must be made daily, washing 
 and packing lightly. After each movement of the bowels, the 
 wound must be washed and the packing replaced, if possible. It 
 sential that the cavity granulate from the bottom. Repress 
 excessive granulation with tincture iodine. 
 
 Fig. 312. — Incision for peri-anal abscess. (Veau.) 
 
 PROSTATIC ABSCESS 
 
 The prostate gland, about the size and shape of a chestnut, lies 
 at the base of the bladder, clasping but not quite encircling the first 
 portion of the urethra. The upper surface of the urethra is covered 
 by fibrous tissues which connect the upper surface of the two lateral 
 halves of the prostate, so that the urethra apparently makes a 
 tunnel through the prostate. The ejaculatory ducts empty into 
 this portion of the urethra. 
 
 The prostate is in contact with the second portion of the rectum 
 1^ to 2 inches from the anal orifice. The apex rests against 
 the triangular ligament, which separates it from the bulb of the 
 urethra. 
 
 Suppurative inflammation in the prostate originates from infec- 
 tion caught up by the lymphatics of the prostatic and membranous 
 portions of the urethra. These infective agents are the gonococci, 
 staphylococci, streptococci, bacilli coli communis. 
 
 As might be expected, gonorrhea is the most frequent cause, both 
 directly and indirectly. The passage of sounds, perineal bruises, 
 
PROSTATIC ABSCESS 42 1 
 
 sexual excesses, and high living in one way or another favor the 
 development of an inflammatory process which may result in 
 abscess-formation. 
 
 The abscess may be limited to the gland substance or may develop 
 in the connective tissue surrounding the gland. In this case it 
 may be called a pelvic abscess. It may become an ischio-rectal 
 abscess. 
 
 Chronic prostatic abscess may be overlooked and unrecognized 
 as the direct cause of many conditions: chronic urethral discharge; 
 vesical and rectal irritation; rectal fistula; chronic inflammation of 
 the prostatic adnexa (the ejaculatory ducts and seminal vesicles); 
 suppurating epididymitis and orchitis; nocturnal emissions. 
 
 Any abscess of the prostate may open into the rectum, bladder, 
 urethra, perineum, or suprapubic region. Finally there is, in the 
 case of actue abscess, the imminent danger of the general involve- 
 ment of the pelvic fascia, ending in septicemia. It is manifest that 
 a prostatic abscess is a constant menace. Its evacuation must 
 not be delayed. It cannot be denied that oftentimes spontaneous 
 evacuation is followed by a complete cure, but the outlook is many 
 times more favorable with immediate operation. Sometimes the 
 only cure is in complete removal of the gland. 
 
 Diagnosis. — There is usually a history of gonorrhea, recent or re- 
 mote. Fever and a few chills; violent perineal pain, radiating to the 
 rectum and thighs; painful and difficult urination and defecation 
 point to probable suppuration in the prostatic region. A little 
 later perhaps the perineum is reddened, swollen, and infiltrated. 
 Complete the diagnosis by introducing a well-oiled finger into the 
 rectum, which will excite much pain. On the anterior wall of the 
 rectum will be found a large unsymmetrical swelling, more or less 
 clearly fluctuating, and which loses itself in a doughy tumor extend- 
 ing toward the sides of the rectum and the anus. Now must one 
 operate even though there be some pus discharging through the 
 urethra, having begun spontaneously or following the passage of a 
 catheter. Such drainage is quite insufficient. 
 
 There are two methods of operation: (a) the rectal route when 
 the abscess is about to burst into the rectum; (b) the perineal route, 
 under all other conditions. In either condition general anesthesia is 
 
422 
 
 ABSCESS 
 
 indispensable. The perineum and its vicinity are carefully sterilized 
 and the patient placed in the lithotomy position for the perineal 
 incision. 
 
 Rectal route: Place the patient on the right side, flex the left thigh 
 on the abdomen and let the assistant hold up the left buttock. 
 Dilate the anus and give the rectal mucosa a thorough lavage, wash- 
 ing with soap and water and gauze, followed by an alkaline antiseptic 
 solution. 
 
 Retract the posterior wall of the rectum with a Sims' speculum. 
 The anterior wall will thus be exposed to inspection. Locate by 
 
 Fig. 313. — Prostatic abscess; patient in lithotomy position; incision between bulb 
 and anus extending laterally to the ischial tuberosities. (Veau after Pierre Duval.) 
 
 touch the thinnest part of the abscess wall, for the tumor will not be 
 so conspicuous to sight as it is to the touch. Without hesitation 
 push the point of the knife J^ inch into the tumor. This is 
 to be done by sight and not by touch. When the pus flows, enlarge 
 the opening, cutting toward the anus. Make the opening at least 
 an inch in length. Favor the flow by slight pressure, and finally 
 irrigate. You may be satisfied with that, leaving no drainage, but 
 repeating the rectal flushing several times daily at first. If the 
 cavity is deep and if there is considerable oozing, it is better to 
 
PROSTATIC ABSCESS 
 
 423 
 
 pack very lightly with aseptic gauze, which will be expelled with the 
 first movement of the bowels. 
 
 Perineal route: An incision 1 inch in front of the anus, transverse, 
 slightly curved with convexity forward (Fig. 313). This incision 
 divides the skin and superficial fascia — edematous, it may be. 
 Separate the edges of the wound and identify, if possible, the muscu- 
 lar layers composed of the transversus perinei, the sphincter ani and 
 accelerator urinae, which, coming from the cardinal points, meet at 
 the " central tendinous point of thejperineum," which is to be next 
 
 Fig. 314. — Prostatic abscess. Showing relation of structures concerned in operation; 
 in front the bulb of the urethra, on either side of the erectors of the penis, transversely the 
 transversus perinei which is divided parallel with its fibers. (Veau after Pierre Duval.) 
 
 incised. If these structures are not recognizable, the bulb of the 
 urethra covered by the accelerator urinae can at least be found. It 
 is a prominence which the finger if not the eye will readily detect. 
 Incise transversely through the middle of the transverse perinei 
 (Fig. 314), or at least just behind the bulb. The transversus perinei 
 artery will be divided. Now draw the bulb forward out of the way 
 with a retractor and pull the posterior lip backward with an artery 
 forceps. 
 
 Make the third transverse incision through the layer now well ex- 
 
424 
 
 ABSCESS 
 
 posed, viz.: the superficial layer of the triangular ligament, a dense, 
 fibrous membrane. The abscess is now covered only by the deep 
 layer of the triangular ligament, and this is best opened up with the 
 grooved director, working forward in order to avoid the rectum, 
 which lies immediately behind (Fig. 315). 
 
 As soon as the cavity is located, enlarge the opening with the 
 forceps, irrigate gently, place a drainage-tube and use an absorbent 
 dressing, which is to be removed each morning and evening and after 
 stool. 
 
 Fig. 315. — Prostatic abscess; showing relation to bladder and rectum and the muscular and 
 fibrous layers to be divided. (Veau.) 
 
 Irrigation and Drainage of the Seminal Duct and Vesicle. — -Purulent 
 accumulations in the seminal vesicles demand relief on account of 
 the frequent urination and other symptoms which sometimes may 
 be attributed to the prostate itself. 
 
 Belfield, of Rush Medical College, accomplishes the relief of these 
 conditions by drainage through the vas deferens. 
 
 The vas deferens is caught between the fingers at the base of the 
 §< rot urn and brought up against the skin and held by a half-curved 
 1 eedle passed through the skin under the vas. A half-inch incision 
 under local anesthesia is then made over the vas; it is exposed and 
 
VULVAR ABSCESS 425 
 
 opened by a longitudinal or transverse incision. The blunted needle 
 of a hypodermic syringe is then passed into the canal and the solution 
 injected. The liquid traverses the vas and the ampulla, and distends 
 the seminal vesicles. 
 
 If necessary the vas may be stitched to the skin by a fine silk- 
 worm-gut suture, and a fistula thus established, through which 
 daily injections may be made. By this means, too, the vas is made 
 to serve as a drainage-tube for the ampulla. 
 
 A fine silkworm-gut may be passed into the canal and left until the 
 next injection. Belfield recommends the procedure for chronic 
 gonorrheal infections of the seminal canal; chronic pus infections 
 in the elderly (often mistaken for enlarged prostate) ; for acute gon- 
 orrheal spermato -cystitis; and for the abortion of threatened 
 epididymitis. 
 
 VULVAR ABSCESS 
 
 The labia majoria are composed of areolar and fatty tissues, 
 bounded on one side by skin and on the other by mucous membrane. 
 These integuments have many sebaceous follicles and are exposed 
 to various forms of infection and traumatism. Along these sebaceous 
 follicles and the lymphatics, agents of suppuration may travel to 
 reach the areolar tissues, which are so prone to yield to the 
 attack. 
 
 The traumatisms of accident and brutality and excessive coitus 
 then are the predisposing causes; the streptococci and gonoccoci, 
 the specific agents of inflammation of the vulva, which may end in 
 abscess. The suppuration takes on the diffuse rather than the 
 circumscribed form. The labium majus of the affected side is 
 swollen, doughy, reddened, dry, and there are the other local and 
 constitutional signs of suppuration. The skin, apparently more than 
 the mucous membrane, is involved and the lesser labium, scarcely 
 at all. In order to avoid general infection, or an ugly slough from 
 spontaneous evacuation, the abscess must be incised immediately. 
 The presence of pus can nearly always be determined by fluctuation. 
 After careful antiseptic preparation, a vertical incision in the site 
 of the greatest swelling, usually in the integument, will be sufficient. 
 There are no vessels to fear. Ordinarily, a strip of iodoform gauze 
 

 ABSCESS 
 
 will furnish sufficient drainage. An absorbent dressing and rest 
 will soon bring about a cure. 
 
 VULVO-VAGINAL ABSCESS. (ABSCESS OF BARTHOLIN'S 
 
 GLAND) 
 
 
 Beneath the vaginal mucous membrane, near the junction of the 
 lateral and posterior walls, between the lesser labium in front and 
 the triangular ligament behind, is Bartholin's gland, one on each 
 
 side. The gland is normally 
 about the size of a small almond, 
 and is about i or ij^ inches from 
 the vulvar orifice. Its duct opens 
 into the vulvar canal just exter- 
 nal to the hymen or its remains, 
 the carunculae myrtiformes. Its 
 lymphatics empty into the super- 
 ficial glands. 
 
 Its relation of greatest surgical 
 importance is with the venous 
 plexus (the bulb of the vagina), 
 which covers its upper half and 
 which may be wounded by too 
 free incision. As in the case of 
 vulvar abscess, the cause of sup- 
 puration is an infective agent, 
 most frequently the gonococcus, 
 which reaches the gland by way 
 of the excretory duct. Excessive 
 coitus is a predisposing cause. 
 The symptoms at first are those 
 of acute inflammation of the vulva or vagina; finally the symptoms 
 become localized. 
 
 On examination the vaginal orifice is found to be almost closed 
 on account of the swelling, and the mucous membranes hot and dry. 
 The examining finger detects on the affected side a well-defined 
 body varying in size, perhaps no larger than a chestnut, perhaps as 
 
 Fig. 316. — Vulvo-vaginal abscess. 
 Direction of incision. 
 
PELVIC ABSCESS 427 
 
 large as a hen's egg. It is clearly circumscribed. The labium 
 majus is only slightly edematous ordinarily, the lower part more so. 
 The abscess must be incised as soon as fluctuation is present in the 
 slightest degree. Several serious consequences may attend delay. 
 The inflammation may follow the vaginal areolar tissues into the 
 pelvis; there may develop a phlebitis, or sloughing of the veins, or 
 lymphangitis, or, what is more common, there may result a recto- 
 vaginal fistula. 
 
 Operation. — Cleanse the parts carefully under local or general 
 anesthesia, incise the tumor in the direction of the long axis of the 
 vagina from within outward (Fig. 316). Incise thoroughly, as this 
 is the means of securing the drainage that will prevent a fistula. The 
 incision must not be deep near the vaginal orifice for fear of wound- 
 ing the bulb of the vestibule. A strip of gauze will favor healing 
 from the bottom of the abscess. The region should be frequently 
 douched. 
 
 PELVIC ABSCESS 
 
 Separating the pelvic peritoneum from the organs of this region 
 are loose areolar tissues which are prone to suppurate when attacked 
 by infective agents. 
 
 Pelvic cellulitis usually begins as a lymphangitis, following the 
 absorption of bacteria from some pelvic focus, usually the Fallopian 
 tubes. A salpingitis is the most frequent cause of pelvic abscess. 
 The arrangement of the fascia and organs is such that the inflam- 
 matory exudates gravitate to the cul-de-sac of Douglas. 
 
 Left to its own course, the abscess may open into the vagina, 
 rectum, or bladder; less frequently through the abdominal wall, 
 saphenous opening, pelvic floor, obturator foramen, sacro-sciatic 
 foramen, or into the peritoneal cavity. 
 
 Diagnosis. — The history usually given points to an attack of pelvic 
 cellulitis, following an abortion or complicated confinement, or some 
 pelvic or abdominal traumatism. The temperature remains about 
 ioo° with exacerbations reaching 103 to 104 . There are all the 
 symptoms of septic abortion. 
 
 On pelvic examination you are able to define a mass bulging down 
 into the recto-uterine pouch. This taken with the fever and pain, 
 
4 28 
 
 ABSCESS 
 
 . 
 
 and perhaps some edema of the vulva, points without doubt to the 
 nature of the trouble. A colpotomy should be done as soon as 
 possible. The instruments needed are a speculum, a vulsellum 
 forceps, a long artery forceps or dressing forceps, curved scissors, a 
 scalpel, an irrigator, drainage tube, and iodoform gauze. General 
 anesthesia is usually necessary, though in the simpler cases local 
 anesthesia will suffice. Lithotomy position; the thighs held well 
 apart, the shoulders lowered, the pelvis slightly elevated. 
 
 Fig. 317.- 
 
 -Incision of the vaginal mucous membrane for abscess in the posterior 
 cul-de-sac. (Veau.) 
 
 A careful antisepsis: Shave the vulva and disinfect the inner' 
 surface of the thighs, and the pubic region as well. Disinfect the 
 vagina, rubbing it with soap and water first and being careful to 
 reach every part of the mucous membrane, using the finger wrapped 
 with sterile gauze. Finally irrigate with 1 to 2000 bichloride or 
 other antiseptic solution. Cover the outside parts with sterile towels. 
 Now retract the posterior vaginal wall with a Sims' speculum. With 
 the vulsellum forceps seize the posterior lip of the cervix and pull the 
 cervix forward (Fig, 317). You will now be able to see the site which 
 
PELVIC ABSCESS 
 
 429 
 
 is to be incised. The tumor may be conspicuous, the edema and 
 fluctuation well defined; or nothing but some edema may indicate 
 the presence of the deeper seated inflammation. Do not attempt 
 a mere puncture, however well defined the pus cavity may be. With 
 a curved scissors or scalpel incise the mucous, membrane of the vault 
 of the vagina 1 inch behind the base of the cervix. Make an in- 
 cision from side to side, but do not approach too near the vaginal 
 walls else the arteries there may be wounded. Enlarge the wound 
 by stripping its edges back a little. The abscess wall is exposed and 
 with a little puncture the pus will flow. However, it may be that the 
 
 Fig. 318. — Showing the uterus pulled 
 down, preparatory to opening the 
 abscess in the posterior cul-de-sac. 
 (Veau.) 
 
 Fig. 319. — Showing relations of abscess 
 in the posterior cul-de-sac. Dotted lines 
 represent drainage tube. (Veau.) 
 
 pus is higher up and separated from the mucous membrane by thick 
 and edematous areolar tissues, and this must not be taken, for the 
 abscess. From it will flow a serous fluid which must be accepted as 
 a proof of pus higher-up. 
 
 With the finger or*an*artery forceps follow the posterior wall of 
 the uterus upward. Do not dissect backward. The rectum is there 
 (Fig. 318). Follow the posterior wall of the uterus to avoid danger. 
 There is always some hemorrhage, in nowise dangerous. It may be 
 necessary to dissect upward for an inch; it will seem further than it 
 really is. 
 
 When once the cavity is opened into, enlarge the orifice and with 
 the finger make careful search for a secondary cavity. If you irri- 
 gate, do not employ much pressure. Do not pack the cavity with 
 
43° ABSCESS 
 
 gauze. Introduce a long drainage-tube to the top of the cavity. 
 Its lower end must not protrude at the vulva (Fig. 319). Pack the 
 vagina lightly, changing the packing every day without disturbing 
 the drainage-tube. You may wash out the vagina, but do not use 
 much force. Replace the drainage-tube by a smaller one about the 
 tenth day if the temperature is normal. It is likely that it will 
 be pushed out spontaneously, and if it cannot be reinstated and the 
 temperature is normal, it is certain that it is no longer necessary. 
 
 SUBPHRENIC ABSCESS 
 
 A localized peritonitis is possible only in those localities not 
 occupied by coils of small intestine. The region immediately below 
 the diaphragm is of this character, and it is practically shut off from 
 the general peritoneal cavity by the transverse colon and its meso 
 colon. This space is subdivided by the falciform ligament into a 
 right, occupied by the liver; and a left occupied by the stomach, 
 pancreas, duodenum, and spleen. Guibal describes five sub- 
 divisions of the subphrenic space, in any of which pus may collect 
 (Revue de Chirurgie, April, 1909). 
 
 One is retro-peritoneal; four are peritoneal. The retro-peritoneal 
 space contains the termination of the esophagus, the posterior border 
 of the liver, the pancreas, duodenum, colon, and kidneys. 
 
 Of the peritoneal spaces two lie between the liver and diaphragm 
 and may be the seat of abscesses following lesions of the liver, gall- 
 bladder and ducts, pylorus, stomach, and duodenum. The third or 
 perisplenic space, may be infected through the greater curvature of 
 the stomach, the spleen or splenic flexure of the colon. The fourth 
 space, or the posterior gastro-hepatic, may be infected through the 
 posterior surface of the stomach, the pancreas, or liver. 
 
 In effect, subphrenic abscess is a localized purulent peritonitis, 
 and whatever part the various adjacent organs may play in its pro- 
 duction, yet the most frequent cause of subphrenic suppuration is 
 appendicitis. The pus forming around the appendix, or behind the 
 cecum, follows the ascending and then the transverse colon to reach 
 that region. 
 
 Sometimes it is impossible to determine the original focus of in- 
 
 1 
 
SUBPHRENIC ABSCESS 43 1 
 
 flammation. Usually, however, if the history of the case is suffi- 
 ciently definite, one may arrive at a conclusion. For example, if 
 we find a patient with subphrenic abscess and there has been a 
 history of gastric discomfort, vomiting of blood, etc., one would 
 decide upon perforating gastric or duodenal ulcer. If there has been 
 a history of jaundice and symptoms pointing to the right hypochon- 
 drium, the liver, or its ducts, should be accused; if there has been 
 clear history of previous attacks of appendicitis one need not be in 
 doubt as to the starting-point of the condition with which he has to 
 deal. 
 
 Diagnosis. — You will have, then, usually, a history of some visceral 
 disturbance followed (very quickly in case of perforation of the 
 stomach) by a chill, fever, malaise, pain in the upper abdominal 
 pole. The symptoms, to be brief, are those of peritonitis anywhere. 
 Suspecting from these symptoms an accumulation of pus in the re- 
 gion just below the diaphragm, proceed to a methodical examination 
 by means of inspection, percussion, and palpation. The quantity 
 of pus may be so great, or so near the front, that the bulging of the 
 anterior abdominal wall may settle the matter without further ex- 
 amination. In obscurer cases it will be necessary to recall the normal 
 limits of dullness, or tympany of the various organs, in order to de- 
 termine the nature and degree of their displacement. Remember, 
 too, that in all cases following perforation the abscess cavity will 
 contain gas which will be another source of confusion. But after 
 all, in the typical cases, guided by the history, the symptoms of 
 sepsis and the local signs, one can rarely go astray. Aseptic aspiration 
 may be resorted to in the doubtful cases, and one need not hesitate 
 to aspirate several times. 
 
 But previous to aspiration the patient should be prepared and 
 should be operated upon immediately if pus is found. The X-ray 
 may be helpful in diagnosis, since it shows an abnormal conformation 
 of the diaphragm, and that it is immobile on the affected side. 
 
 The great majority of sufferers from this condition not operated 
 upon die from sepsis. A general peritonitis may supervene. Left 
 to itself, the pus may open into the alimentary tract, which is to be 
 regarded as a complication rather than a cure, for such cases usually 
 terminate fatally from slowly increasing sepsis. In rare instances 
 
432 ABSCESS 
 
 it may open through the abdominal wall. Most often, however, it 
 extends toward the thorax, opening through the diaphragm into the 
 lung to be coughed up. Oftentimes the imminence of rupture into 
 a bronchus may be predicated from increased pain in the shoulder 
 of the affected side, increased cough and muco-purulent or sanguineous 
 expectoration, and heightened temperature. The pleurisy nearly 
 always present may be fibrous, serous or purulent. An empyema, 
 so originating, may even mask the primary condition. But whether 
 the pus opens into a bronchus, or the digestive tube, or through the 
 abdominal wall, the result of nature's drainage is too doubtful. It is 
 imperative to operate as soon as a diagnosis is made, for even a latent 
 case may fire up suddenly and march to rapid death. The prognosis, 
 in fact, does not depend more upon the character and skillfulness of 
 the operation than upon its timeliness. 
 
 Operation. — -The method of operation depends upon the location 
 of the pus; it may be (A) near the anterior abdominal wall, or (B) 
 it may be inaccessible from the front. 
 
 (A) If the epigastric region is bulging, the incision should be over 
 its greatest prominence or where the abscess seems to point. Red- 
 ness and edema of the skin should be taken as an indication that the 
 pus is well walled off and that there is no danger of the incision open- 
 ing into the general peritoneal cavity, which is an accident always to 
 be guarded against. One may cut directly through these tissues 
 whether it be in the linea alba or the line of either border of the 
 rectus. 
 
 Once the cavity is opened and emptied, it is to be carefully wiped 
 out, for there are usually collections in its deeper parts; and before 
 drainage is inserted it should be cautiously irrigated with normal 
 salt solution. Moynihan recommends the " cigarette drain " 
 which may be well saturated with boracic acid. A counter-opening 
 in the loin may be required for efficient drainage. The cavity must 
 fill in by granulation which may require six or eight weeks. 
 
 (B) i. If the abscess is behind the liver on the right side, an inci- 
 sion along the costal margin is perhaps the best. Divide the 
 muscles, or even resect the twelfth rib, and then, by blunt dissec- 
 tion, follow the under surface of the diaphragm until the abscess 
 cavity is reached. If the abscess is retro-peritoneal it may be nee- 
 
 
SUBPHRENIC ABSCESS 
 
 433 
 
 essary to expose the upper pole of the kidney and to draw it down- 
 ward and forward, exposing the renal fossa on the under surface of 
 the liver, and thence work upward between the posterior margin of 
 the liver and the diaphragm. Insert drainage-tubes packed about 
 with iodoform gauze. 
 
 2. More often it is best to employ the transpleural route (Fig. 
 320), which will require resection of a rib or perhaps more than one. 
 The incision exposes the eighth or ninth rib — right side; eighth or 
 seventh — left side. (For technic of resection of rib, see page 506.) 
 The center of the incision lies in the axillary line and about 3^ 
 inches of rib are to be removed. 
 
 Fig. 320. — Subphrenic abscess. Opening in the mid-axillary line. {Bryant.) 
 
 Now determine the condition of the pleura of which the cul-de-sac 
 is exposed. In this region the pleura is easily stripped away from 
 the chest wall, and so room may be made to open the diaphragm 
 without opening the pleural cavity. If this can be done, evacuate 
 and drain the abscess as described above. 
 
 Ordinarily it will be necessary to open the pleural cavity, which is 
 first to be aspirated if it contains serum; or opened and wiped out 
 if it contains pus. If it is not purulent it is likely to become so un- 
 less steps are taken to prevent its infection by suturing the diaphragm 
 to the upper lip of the opening in the chest wall. 
 
 You are now ready to open the diaphragm and the pus cavity. In 
 some cases a perforation will be found in the diaphragm, and this is 
 28 
 
434 ABSCESS 
 
 to be merely enlarged; or, if inconvenient for drainage, may be disre- 
 garded and the incision made lower down. Drain. 
 
 A single case will exemplify some of the characters and progress 
 of the disease. A farmer, thirty years of age, had suffered for several 
 years with a severe affection of the stomach, of which no definite 
 diagnosis had been made. Though debilitated, he was yet able to 
 do his work about the farm. Without warning he was suddenly 
 seized with a violent hematemesis. 
 
 The attack continued for some hours without relief and the total 
 amount of blood vomited was appalling. But gradually the bleed- 
 ing ceased, leaving the patient prostrate. A tardy convalescence 
 followed, interrupted by an intermittent fever diagnosed as malaria, 
 a month elapsed and he was brought to bed with a fresh access of 
 "ague"— chill's, fever, and exhausting sweats. At this time a con- 
 sultation exposed the real character of the process. There was a 
 vast accumulation of pus in the left side involving the abdomen and 
 thorax. A constant irritating cough, a bloody sputum, severe pain 
 in the left shoulder, and increased fever and dyspnea seemed to 
 indicate the nearness of rupture into a bronchus. In fact this occurred 
 within a few hours after our examination. A large amount of pus 
 was coughed up and with temporary relief. An operation was 
 refused. Indeed, it offered but little hope so late in the course of 
 the disease. A week later he died. Had the perforation of the 
 gastric ulcer been recognized, or even later the character of the sepsis 
 been understood, an operation would have saved his life. 
 
 PSOAS ABSCESS 
 
 Psoas abscess is a term sometimes rather loosely applied to puru- 
 lent collections in the iliac region. Properly speaking, it is a 
 tubercular abscess having its origin in caries of the lower cervical, 
 dorsal, or lumbar vertebrae. 
 
 It is necessary to recall the arrangement of certain muscles and 
 fascias. Tne psoas muscle, a rounded fleshy mass, lying alongside 
 the bodies of the lumbar vertebrae, extends across the pelvic brim, 
 and passes in front of the hip-joint to be inserted into the lesser 
 trochanter. The iliacus, its companion muscle, occupies the iliac 
 I 
 
psoas abscess 435 
 
 fossa and converges below in a tendon which merges with that of 
 the psoas. These muscles are covered by the iliac fascia which is so 
 attached as to make the iliac fossa practically a closed compartment. 
 
 The fascia is separated from the muscles by a loose areolar tissue 
 in which suppuration may originate the which constitutes an iliac 
 abscess. This fascia on its other side is separated from the perito- 
 neum by another layer of connective tissue — the subperitoneal 
 areolar tissue, which is liberally supplied with fatty tissue and con- 
 stitutes a site of lowered resistance to germs originating in the pelvic 
 viscera, the cecum, the sigmoid, and the appendix. Suppuration 
 under this layer usually ends as a pelvic abscess. 
 
 It is evident, therefore, that an iliac abscess beginning as such, 
 and abscess in the subperitoneal tissues, are quite distinct from psoas 
 abscess, expect that all have common points of possible opening. 
 The iliac fascia covers the muscles in the iliac fossa, but it also ex- 
 tends upward in such manner as to ensheath the psoas and sepa- 
 rate it from the bodies of the vertebrae. 
 
 In the case of caries, the products of decomposition may burst 
 through the vertebral ligaments and the sheath, and thereafter follow 
 the psoas muscle downward. The muscle itself may be decomposed 
 in whole or part, and the accumulating pus may be directed by the 
 tubular sheath to its point of termination below Poupart's liga- 
 ment to the outer side of the iliac vessels. Or, again, the abscess 
 may burst through the sheath higher up and point in the loin 
 (lumbar abscess); or may point just above Poupart's ligament in 
 the gluteal region, the pelvis, the scrotum, or thigh. 
 
 The diagnosis of psoas abscess rests upon the history of the case, 
 which points to spinal trouble, and upon the presence of fluctuating 
 swelling in the iliac fossa, or below Poupart's ligament. Usually 
 the hip is flexed in some degree, as by that position the tension in 
 the psoas is relieved. 
 
 This flexion and some apparent stiffness in the joint might lead 
 to a mistaken diagnosis of hip-joint disease. The swelling is to 
 be distinguished, also, from a hernial tumor, by the fact that it is 
 fluctuating and lies at the outer side of the iliac vessels. 
 
 Treatment. — As in all cases of tubercular abscess, secondary in- 
 fection and amyloid degeneration are most to be dreaded. For 
 
436 ABSCESS 
 
 that reason, spontaneous rupture and treatment by small incision 
 and prolonged tubal drainage are equally dangerous. 
 
 As early as possible an aseptic evacuation must be practised. 
 This may be accomplished by puncture and the subsequent injec- 
 tion of iodoform emulsion; this seems the advisable procedure, if 
 the abscess is pointing in the region of Poupart's ligament, and it is 
 likely that the destructive process in the vertebra is an abeyance. 
 In general, most authorities recommend the operation of Treves, 
 by the lumbar route. 
 
 Operation. — Begin by locating the last rib, the crest of the ilium, 
 and the outer border of the erector spinae. The incision, 2% inches 
 long, with its center half way between these bony landmarks, 
 follows the outer border of the erector spinae and exposes at first 
 the lumbar fascia. 
 
 Divide the first layer of the lumbar fascia and expose the erector 
 spinae. Develop its outer border the whole length of the wound 
 and retract the muscle inward, exposing the middle layer of the 
 lumbar fascia. Divide this layer which exposes the quadratus 
 lumborum. 
 
 Divide the quadratus lumborum along the line of its attachment 
 to the tips of the transverse processes, which exposes the deep or 
 anterior layer of the lumbar fascia. Divide this layer and finally 
 the psoas magnus is exposed. Divide the attachment of the psoas 
 magnus sufficiently to introduce the finger, which opens up the 
 abscess cavity and determines the condition of the carious vertebra. 
 
 The abscess cavity is to be treated by thorough irrigation with 
 an antiseptic solution, wiped vigorously, or even curetted. The 
 various layers are sutured without drainage and an antiseptic 
 dressing applied. 
 
 Previous to suturing, the cavity may be filled with iodoform emul- 
 sion; or, as Walsham suggests, after the cavity is cleansed it may be 
 packed with strips of iodoform gauze, which are to be changed on the 
 third or fourth day. If at the end of a week no pus has appeared 
 and the cavity is lined with healthy granulations, the wound may 
 ■d by secondary suture. 
 
CHAPTER XXI 
 
 PHLEGMON : ACUTE SPREADING INFECTIONS 
 
 The areolar tissues are less resistant than others. The strepto- 
 cocci in their mode of development tend to spread out so that, under 
 favorable circumstances, the streptococcic infection of the sub- 
 cutaneous connective tissues becomes one of the most dangerous 
 conditions, demanding immediate and radical surgical intervention. 
 The rapid development of toxins makes death from septicemia 
 to be feared; or, short of this, there may be great destruction of 
 tissue and subsequent loss of function. 
 
 Certain regions, owing to the opportunities for infection and the 
 arrangement of the tissues, are more likely to be affected than others; 
 but the general symptoms and the principles of treatment are the 
 same. 
 
 One peculiarity of this inflammation is that pus is often slow to 
 form, so that when the engorged tissues are incised in the earlier 
 stages, merely a serum exudes^ It is innocent-looking, but it is 
 toxic in the extreme. 
 
 The point, then, is this — do not wait for pus formation and 
 fluctuation, before evacuating these products. If pus has formed, 
 immediately is none too soon to operate. 
 
 In the case of superficial phlegmon of moderate severity, it will 
 often be harmless to try to localize the process by the use of hot 
 antiseptic poultices or baths, but the safest thing is free incision for 
 drainage. 
 
 The incision must reach the deepest layer of the affected tissues, 
 as anything less is useless; it may even be harmful by introducing a 
 new infection to tissues which were not previously involved. 
 
 Slight injuries, with subsequent localized accumulations of pus, 
 are often the source of an infection which attacks the connective 
 tissues, reaching them by way of the lymphatics, and then what was 
 
 437 
 
438 
 
 phlegmon: ACUTE spreading infections 
 
 a mere local and harmless infection at first, becomes a very danger- 
 ous diffuse phlegmon. 
 
 These minor conditions, therefore, are emergencies from the point 
 of view of prevention. A few examples will serve to emphasize the 
 principles governing their treatment. 
 
 PANARIS 
 
 This is an infection involving the tissues about the finger-nail. It 
 may be limited to the epidermis, the dermis, the subcutaneous tissues, 
 or the periosteum, the last condition being usually called a felon. 
 
 Fig. 321. — Opening a purulent phlyctena or "run a round." (Veau.) 
 
 Panaris, Subepidermic. — The appearance at first is almost that 
 of a blister, and all of the loosened tegument must be removed. No 
 analgesia is necessary, as the epidermis is non-sensitive. 
 
 Begin by pricking the phlyctena with the point of the bistoury, and 
 then trim around its whole circumference with pointed scissors 
 (Fig. 321). 
 
 Carefully observe the denuded surface, and a small opening may 
 be found, leading to a deeper cavity (button-hole abscess) which will 
 require incision. 
 
 Complete the treatment by a prolonged antiseptic bath and 
 antiseptic dressing. 
 
PHLEGMON OF THE FINGER 
 
 439 
 
 Panaris, Subungual. — In this form the pus accumulates under the 
 nail and loosens it. It will be necessary to remove the part of the 
 nail lying over the pus accumulation. A cure can be obtained only 
 at that price. 
 
 If it is confined to one side only, the skin is removed as described 
 above, the sharp point of the scissors introduced under the nail, 
 and enough of it resected to expose the suppurating surface. If both 
 sides are involved, remove the nail completely. 
 
 Panaris, Subcutaneous {Felon). — Incise as soon as pus is suspected. 
 No harm can be done even if there is no pus, while a day's delay 
 after pus has formed may make a great difference. 
 
 Fig. 322.- 
 
 -Illustrating the situation of the pus in a felon; the dotted lines represent the 
 limits of the incision. (Veau.) 
 
 Under local anesthesia (Figs. 8, 9), make a longitudinal incision 
 in the middle of the palmar surface where the pain is greatest 
 (Fig. 322). 
 
 Do not make a mere puncture, as the whole pus cavity must be 
 exposed. Incise deliberately and let the first stroke cut long and 
 deep enough, after which explore the cavity with a small probe. 
 
 If there is a palmar prolongation, enlarge the opening, and if 
 there is a dorsal prolongation, which is quite rare, make a counter- 
 incision on the dorsum of the finger. 
 
 Immerse the hand in an antiseptic or normal salt solution for an 
 hour. A drainage-tube is unnecessary, if the incision is properly 
 made. 
 
 Dress with moist antiseptic gauze and give the hand a hot bath 
 with each daily renewal of the dressing. 
 
 After two to eight days, or when suppuration has ceased, employ 
 a dry dressing. The dry dressing favors cicatrization, but the 
 moist dressing best relieves pain. 
 
44o 
 
 phlegmon: acute spreading infections 
 
 SUPPURATIVE INFLAMMATION OF TENDON SHEATHS 
 
 Kwrv neglected infection of the fingers or palm may become a 
 
 phlegmon of the tendon sheaths. 
 
 The great danger of these phlegmons is destruction or adhesion 
 
 of the tendons, so that the finger remains permanently flexed or 
 
 extended, unsightly, and more or 
 less useless. 
 
 A threatened suppuration may 
 often be prevented by a prolonged 
 immersion in hot antiseptic or 
 normal salt solution. This should 
 be continued for an hour and used 
 twice daily. 
 
 The Bier treatment is excellent 
 for this purpose. This treatment 
 is to be applied after suppuration 
 occurs, but not until the pus is 
 evacuated. It shortens the in- 
 cision required and the time of 
 repair. 
 
 As soon as pus is suspected, in- 
 cise freely. Recall the anatomy of 
 the parts (Fig. 323). The sheaths 
 of the flexor tendons extend into 
 the palm, whence the necessity of 
 a palmar incision. The tendon 
 sheaths of the thumb and of the 
 little finger communicate with the 
 common tendon sheaths in the 
 palm, whence the additional grav- 
 ity when they are involved. The 
 common sheaths extend from the 
 
 palm under the annular ligament above to the wrist-joint, whence the 
 sity of incision in the forearm. There is in this incision an 
 
 element of danger by reason of the median nerve, which lies on the 
 
 middle of the front of the wrist between the two common sheaths. 
 
 PlG. .1,2$. — Diagram illustrating the 
 arrangement of the synovial sheaths in the 
 hand. Note that the sheath of the tendon 
 of the little finger communicates with the 
 sheath common to all the flexors of the 
 ringers in the wrist and palm. Note also 
 that the sheath of the flexors of the thumb 
 extends into the wrist beyond the annular 
 ligament. The median nerve passes under 
 the annular ligament between these two 
 common sheaths. (Veau.) 
 
PHLEGMON OF TENDON SHEATHS 
 
 441 
 
 The ulnar artery lies on the common sheath on the ulnar side. The 
 incision must pass between the artery and the nerve. 
 
 Phlegmons of the sheaths of the first, second, and third fingers are 
 not likely to extend further than the middle of the palm, while, on 
 the contrary, phlegmons of the sheaths of the thumb and little finger 
 are likely to point above the wrist. 
 
 Fig. 3 24. — Suppuration of digital syno- 
 vial sheath. Incisions. (Veau.) 
 
 Fig. 325. — Opening into the upper part of 
 the ulnar synovial sheath. (Veau.) 
 
 Operation for Phlegmon of the Synovial Sheaths of the Flexor Tendons 
 in the Fingers. — A general anesthesia is usually necessary, for the 
 pain is great. Make an incision about an inch long in the middle of 
 the palmar surface over the point of great swelling. Incise to the 
 bone to be sure of opening the tendon sheath. The wound must be 
 of uniform length in the superficial and deeper tissues (Fig. 324). 
 If necessary, make a similar incision over each of the phalanges and 
 in the palm, but avoid opening into the joints. If the sheath is 
 distended with pus, a drainage-tube is easily passed through from 
 one incision to the other. 
 
44 - 1 
 
 phlegmon: acute spreading infections 
 
 When the pus has been located, immerse the hand in a hot normal 
 sail solution for an hour and repeat twice daily. This greatly favors 
 the evacuation of pus and subsequent repair. 
 Employ moist antiseptic dressings at first. 
 
 Operation for Phlegmon of the Ulnar Synovial Sheath. — Continuous 
 with the synovial sheath of the flexor tendon of the little finger, the 
 
 ulnar synovial sheath is larger than 
 the radial and its suppuration more 
 serious. 
 
 These phlegmons are usually con- 
 secutive to neglected infections of 
 the little finger. 
 
 Complete drainage is indispensa- 
 ble. Begin by making an incision 
 over the radial border of the mini- 
 mal metacarpal (Fig. 325). Avoid 
 wounding the palmar arch, which 
 might require ligation; but, after all, 
 this is not a serious accident and 
 permits a freer incision. 
 
 When the pus is reached, enlarge 
 the incision so that the tendon may 
 be seen the entire length of the wound. 
 Superficially and deep, the incision must be of the same length. 
 
 Next introduce a grooved director into this incision and push it 
 through the synovial cavity until its point, passing under the 
 annular ligament, can be felt beneath the skin of the wrist. Incise 
 carefully over this point until it is exposed, keeping to the inside of 
 the tendon of the palmaris longus to avoid the median nerve. When 
 the point of the grooved director is fully exposed, enlarge the incision 
 to an inch and a half. 
 
 No artery of importance will be wounded. Pass a drainage-tube 
 through from one incision to the other (Fig. 326). 
 
 Operation for Phlegmon of the Synovial Sheath on the Radial Side. — ■ 
 The palmar incision may be made through the muscles of the thumb 
 along the line of the metacarpal, but it is preferable to make it in 
 the commissure between the thumb and index finger. 
 
 Fig. 326. — Drainage of phlegmon of 
 the ulnar synovial sheath. (Veau.) 
 
PHLEGMON OF FOREARM 
 
 443 
 
 Make an incision two fingers' breadth in length. At the depth 
 of i or 2 inches you will find the pus. Pass a grooved director 
 along the sheath as in the preceding case. It emerges beneath the 
 skin above the annular ligament. Locate and expose the point of 
 the director; in incising keep to the outside to avoid the median 
 nerve. The radial artery is in no danger, as it is too far to the 
 outside (Fig. 327). 
 
 Fig. 327. — Drainage of the radial synovial 
 sheath. (Veau,) 
 
 Fig. 328. — Drainage completed. 
 
 In the same manner as before, pass a drainage-tube. Immerse 
 the hand twice daily for an hour in hot normal salt solution, and 
 employ a moist antiseptic dressing. The drainage-tube will probably 
 be unnecessary after the eighth or tenth day (Fig. 328). 
 
 SUBAPONEUROTIC PHLEGMON OF THE FOREARM 
 
 By direct infection, or by extension of infection from the hand, 
 the areolar tissues beneath the fascia of the forearm may become 
 the site of a diffuse suppurative inflammation. 
 
444 
 
 phlegmon: acute spreading infections 
 
 If neglected, it follows the connective tissues into the intermuscular 
 -paces and finally all the soft parts are more or less involved. Free 
 incision must be resorted to without delay. In the earlier stages no 
 pus will be present, but a straw-colored serum pours out along the 
 line of incision. 
 
 Operation. — General Anesthesia. Over the site of the greatest 
 swelling, make a free incision in the long axis of the member. This 
 
 Fig. 329. — Incising the forearm for deep 
 phlegmon. The grooved director search- 
 ing for posterior prolongation, of the pus 
 formation. (Veau.) 
 
 Fig. 330. — Note manner of fixing tubes 
 in drainage for phlegmon of the forearm. 
 (Veau.) 
 
 ion will traverse a thick, infiltrated layer to reach the aponeurosis, 
 which incise carefully, when, in most cases, the pus will pour out. 
 Enlarge the opening sufficiently on the grooved director. 
 
 [rrigate thoroughly with hot normal salt solution and mop out with 
 itixc. With a grooved director explore all the parts of the 
 cavity for a diverticulum (Fig. 329). 
 
PHLEGMON OF THE NECK 445 
 
 If necessary make a counter-opening. Tie such of the larger 
 vessels as are divided and place several large drains (Fig. 330). 
 Change the dressing twice daily, irrigating each time with hot normal 
 salt solution. 
 
 About the eighth day, smaller drains may replace those first em- 
 ployed and these are usually unnecessary after two weeks. Watch 
 the temperature closely. It is rises, there is a retention of pus, the 
 site is not sufficiently drained, or there is a new infection. 
 
 DIFFUSE PHLEGMON OF THE ARM 
 
 All the soft parts are involved and infiltrated with serum. The 
 arm is greatly swollen, edematous, and there are marked symptoms 
 of septicemia. 
 
 General anesthesia is indispensable. The freest kind of incision, 
 even down to the bone from above downward, is essential. Three or 
 four such openings are not too many. 
 
 Irrigate freely with hot normal salt or bichloride solution. Moist 
 antiseptic dressings should be used and at first should be changed 
 several times daily. 
 
 Incision with the Thermo-cautery, Lejars. — With the thermo-cautery 
 make several large incisions in the axis of the member, each at least 
 four fingers' breadth in length and about tw r o fingers' breadth apart 
 (Fig. 331). Under the skin will be found a thick layer, infiltrated 
 with bloody serum. Cutting through this, the aponeurosis appears, 
 which incise and thus expose the muscles. 
 
 On the inner side avoid the vessels. If some of the large sub- 
 cutaneous vessels are opened and bleed too freely, tie them. Irrigate 
 and dress with sterile gauze saturated with peroxide of half strength 
 
 Change the dressing and irrigate two or three times daily. 
 Change to dry dressings when granulation is w T ell under way. Later, 
 skin grafting may be necessary. In the long time necessary for 
 repair, massage and passive motion must be given the muscles. 
 
 PHLEGMON OF THE NECK 
 
 An infection in the floor of the mouth may become diffuse and 
 spread rapidly down the neck. The symptoms of sepsis will be 
 
44< 
 
 PHLEGMON: ACUTE SPREADING INFECTIONS 
 
 aggravated in the extreme and death may rapidly supervene, either 
 from sepsis or asphyxia. The whole neck may be brawny and 
 edematous, and the patient's condition is pitiable indeed. 
 
 Lejars recommends the thermo-cautery as offering the best hope 
 of a cure, though seemingly brutal. 
 
 Fig. 331. — Incising a phlegmon of the arm with the cautery. (Veau.) 
 
 Under general anesthesia several deep vertical incisions are made 
 with the thermo-cautery with numerous punctures between (Fig. 
 332). Do not go too deep over the anterior border of the sterno- 
 mastoid, for the great vessels are there. 
 
 Pack each incision and puncture with gauze saturated with 
 flride of hydrogen, and cover the whole with a similar dressing 
 
PHLEGMON OF THE NECK 
 
 447 
 
 and absorbent cotton. The dressing must be kept saturated with 
 the peroxide. In the meantime use the antistreptococcic serum. 
 
 Watson Cheyne also urges the use of the serum, but does not use 
 the thermo-cautery. His plan is to incise through the deep fascia 
 
 Fig. 332. — Manner of incising phlegmon of neck with the cautery. (Veau.) 
 
 in several places, enlarging the openings by blunt dissection. The 
 wounds are to be freely sponged with undiluted carbolic acid, 
 powdered with iodoform, and packed with strips of iodoform gauze. 
 
CHAPTER XIX 
 ACUTE OSTEOMYELITIS 
 
 This is an acute infection of great gravity, more often due to the 
 staphylococcus or the streptococcus; but, in rare instances, the pneu- 
 mococcus, bacillus coli communis, or tubercle bacillus may be the ex- 
 citing cause. 
 
 Usually the germ reaches the affected site by way of the blood 
 current, originating in a focus quite unsuspected. In every case of 
 bone infection especially where first one bone and then another 
 is involved, the middle ear conditions must be investigated. 
 
 In many of these cases a quiescent mastoid abscess is the focus con- 
 stantly supplying the blood stream with new crops of the infective 
 agent. The patient recovers completely only after the mastoid is 
 drained. In other cases the germ reaches the affected site by way of 
 the lymph channels or by continuity of tissue, the primary focus 
 not having revealed itself. But in all cases the predisposing causes 
 are found in certain constitutional states and slight traumatisms. 
 
 The diagnosis is not always easy in the beginning, as the constitu- 
 tional symptoms may be marked before the local signs are quite 
 definite. 
 
 Acute infectious arthritis, the so-called inflammatory "rheuma- 
 tism," is the wrong diagnosis most often made but this affection 
 does not have the symptoms of sepsis, though, indeed, the fever 
 may be high. The pain is usually in the joint and usually in more 
 than one joint. 
 
 Subacute arthritis likewise involves the joint, although it is to be 
 remembered that an arthritis may be secondary to osteomyelitis 
 and overshadow it clinically, but the history of the case will usually 
 decide between arthritis and osteomyelitis. 
 
 Erysipelas may be thought of when, after a little while, the skin 
 becomes brawny and edematous, but in erysipelas the skin is so in- 
 volved from the first. 
 
 448 
 
 I 
 
ACUTE OSTEOMYELITIS 449 
 
 The symptoms may seem to suggest typhoid fever or other infec- 
 tious fevers, but these may usually be ruled out by the absence of 
 characteristic features. 
 
 The symptoms of meningitis are often present, but by the time they 
 arise, the local conditions point to the nature of the trouble. 
 
 The general symptoms are those of sepsis; high fever beginning 
 with a chill, rapid pulse, foul tongue, and in the severe cases, pro- 
 found prostration, and finally delirium. 
 
 Locally the pain over the affected area is often extreme, and the 
 least pressure tends to aggravate it. Gradually, as the inflamma- 
 tion spreads from the marrow through the bone to the periosteum, 
 the 'skin begins to swell, redden, become edematous, and finally 
 shows fluctuation. 
 
 In the virulent cases not operated upon, the patient dies within 
 the first few days from septic infection. In the milder cases, even, 
 large areas of the bone necrose. 
 
 The treatment, then, must be prompt. It is an emergency. 
 There is only one thing of any use to be done. The suppurating 
 marrow must be evacuated and the medullary canal freely opened 
 and cleaned out. Local applications, poultices, or even incisions 
 through the periosteum are illusory. The bone must be trephined, 
 its cavity opened up at its most accessible part, and all the inflamed 
 tissue scraped away. The whole extent of the canal may need to be 
 opened, irrigated, drained, and treated with vigorous antisepsis. 
 Free incision over the affected area, choosing the easiest and least 
 dangerous approach, if possible reaching the bone through inter- 
 muscular septa; incision and stripping of the periosteum over the 
 proposed site of trephining; opening the bone cavity freely, wiping 
 out the pus, curetting and chiseling away the necrotic bone, swabbing 
 out the cavity with pure carbolic acid followed by alcohol; obliter- 
 ating the larger cavities partially with muscle or fat when possible 
 and employing tubal drainage — -these are the principles of treatment, 
 and aided in this way nature usually effects a cure. 
 
 In the case of long standing where the cavity is surrounded by new 
 bone sclerosed and lacking in osteoblasts it may be necessary to use 
 an artificial filling. 
 
 29 
 
4 5° 
 
 ACUTE OSTEOMYELITIS 
 
 Mosetig-Moorhof's 1 iodoform-plombe is applicable lo such cases 
 as these. It is prepared as follows: 
 
 Equal parts of spermaceti and sesamoil are melted in an evaporat- 
 ing dish, then filtered into a Florentine flask and sterilized in a water- 
 bath; 40 grams of finely powdered 
 iodoform (not crystallized) are put 
 into a sterile flask, and 60 grams of 
 the hot fat mixture are added, under 
 constant agitation. This agitation 
 must be continued without interrup- 
 tion, until the mass solidifies. The 
 flask is closed with a sterile rubber 
 stopper. Before using, the plombe 
 is to be heated in water-bath to a 
 little above 50 C. 
 
 The bone cavity is most carefully 
 prepared for the reception of the 
 filling. Everything must be re- 
 moved down to sound bone. The 
 laws of gravity must, of course, be 
 observed in filling the cavity. If the 
 cavity is large, it is advisable to fill it 
 in several steps, letting the plombe 
 solidify in one portion, before any is 
 poured into another. The cavity 
 must be dry before the mixture is 
 poured in. This may be accomplished 
 by sponging, by the application of 
 adrenalin to oozing points, by hot air, 
 etc. The course of healing after iodo- 
 form filling is aseptic as a rule. Some- 
 times the temperature rises within 
 the first two or three days — so-called aseptic fever — which yields 
 to a cathartic. The disposition of the sprouting granulations toward 
 the solidified plombe varies between complete closure of the wound 
 and healing by primary intention, and incomplete closure. In the 
 
 1 Surgery, Gynecology and Obstetrics, Vol. 3, No. 4. 
 
 Fig. 333.— Exposing the tibial crest, 
 opening into the subperiosteal abscess. 
 (Veau.) 
 
OSTEOMYELITIS OF THE TIBIA 
 
 451 
 
 first cases, absorption of the plombe is effected through the steadily 
 advancing granulations by vital phenomena; in the second, by par- 
 tial displacement and expansion. 
 
 OSTEOMYELITIS OF THE UPPER END OF THE TIBIA 
 
 Here the disease occurs more frequently and here, fortunately, is 
 most easily operated upon. 
 
 General anesthesia; special isntruments: a mallet, a gouge, a 
 periosteal elevator or rugine, and curette. 
 
 Fig. 334- — Trephining of the tibia: 
 making the orifice. (Veau.) 
 
 Fig. 335- — Enlarging the orifice and ex- 
 posing the medullary canal. (Veau.) 
 
 Begin by elevating the limb to empty the blood vessels. About 
 the middle of the thigh apply an Esmarch tube. Do not apply an 
 Esmarch bandage, beginning at the toe and extending upward, for 
 that only spreads infection. 
 
 On the right side, the incision commences at the level of the tuber- 
 osity and extends to the middle of the leg, following the sharp crest 
 of the tibia just to its inner side. However engorged the tissues may 
 be, this first incision reaches to the bone (Fig. 333). 
 
 Often by this first stroke, one opens into a pus cavity. Do not be 
 
45* 
 
 ACUTE OSTEOMYELITIS 
 
 beguiled by this into thinking the operation completed. This collec- 
 tion is to be evacuated and drained, of course, but there is another 
 one in the central canal. Extend the incision to the limit of the 
 loosened periosteum. With the rugine, expose the anterior surface 
 
 of the bone. A fistulous opening 
 leading to the medullary canal may 
 possibly be found. In^any event, 
 proceed to trephine. 
 
 At the upper end of. the* incision 
 make an opening with the gouge 
 down to the canal. The pus will be 
 almost certain to flow, but it is often 
 difficult to distinguish from the 
 marrow. 
 
 At the lower end of the incision, 
 make another opening (Fig. 334). 
 If again pus appears, it is certain that 
 the lowest limit of the suppuration 
 has not been reached and you must 
 lengthen the incision. Continue to 
 expose the canal until the full extent 
 of inflammation has been exposed. 
 It may require the removal of the 
 whole anterior surface of the tibia, 
 but you are engaged in saving life, so 
 that bone is a minor consideration. 
 Chisel away, then, all the anterior 
 wall between the two limits of sup- 
 puration (Fig. 335). Curette vigor- 
 ously the medullary canal down to firm and uninflamed bone, 
 and especially curette the upper part, for there the suppuration is 
 greatest. 
 
 In the case of a child, the epiphyseal cartilage is quickly reached, 
 and this one should try to avoid, since too free removal will end 
 linear growth. 
 
 Mop the cavity with sterile gauze, swab with carbolic acid followed 
 ilcohoJ or Tr. of iodine. If considerable oozing persists it may 
 
 Fig. 336.- 
 pleted. 
 
 -Trephining of the tibia corn- 
 Tubes in place. (Veau.) 
 
OSTEOMYELITIS OF THE HUMERUS 
 
 453 
 
 be necessary to pack with iodoform on sterile gauze, otherwise simple 
 tubal drainage is sufficient. 
 
 The drainage, however, must include the subperiosteal areas as 
 well as the medullary canal in the septic cases (Fig. 336). 
 
 If the operation has been delayed, the muscles of the calf may 
 be infiltrated with pus and will require drainage as in diffuse phlegmon. 
 
 If there is serous effusion into 
 the joint, it will require no 
 especial treatment, for it will 
 gradually be absorbed as the 
 osteomyelitis is cured. 
 
 If the joint is suppurating, it 
 is quite different and another 
 operation is required (see oper- 
 ation for Purulent Arthritis). 
 
 Over the trephined area, ap- 
 ply a moist dressing and change 
 daily. As the exudate becomes 
 less abundant, change to a dry 
 dressing and change the pack- 
 ing in the canal every other 
 day. Smaller drains may be 
 
 inserted about the tenth day, and are removed entirely when the 
 suppuration shall have ceased. 
 
 As Veau says, this intervention is only the first act of a prolonged 
 and tedious process and this the family should understand before- 
 hand. After several months, it may be necessary to remove some 
 necrosed bone; and, long after the cure appears complete, the trouble 
 may recur. 
 
 OSTEOMYELITIS OF THE UPPER END OF THE 
 
 HUMERUS 
 
 Begin the incision a finger's breadth below the clavicle, following- 
 the axis of the humerus. Prolong it downward 5 or 6 inches. 
 The incision will traverse the deltoid near its anterior border. Sepa- 
 rating the lips of the wound, divide the periosteum and proceed to 
 trephine and drain as in the preceding case (Fig. 337). 
 
 Fig. 33 
 
 -Osteomyelitis of the humerus. 
 (Mar see.) 
 
ISA 
 
 ACUTE OSTEOMYELITIS 
 
 OSTEOMYELITIS OF THE LOWER END OF THE 
 
 HUMERUS 
 
 Make an incision 8 to 15 inches in length in the line of, and 
 ending below at, the external condyle. The incision will traverse 
 the thick fibers of the triceps. Trephine and drain. If it is neces- 
 
 Fig. 338. — Cross section showing manner of placing drains after trephining the 
 
 femur. (Veau.) 
 
 sary to make an internal counter-opening for a drain, remember 
 the situation of the ulnar nerve. If the whole bone is affected, the 
 same principles are involved. The prognosis is exceedingly grave. 
 
OSTEOMYELITIS OF FEMUR 455 
 
 OSTEOMYELITIS OF THE LOWER END OF THE 
 
 FEMUR 
 
 Make the incision along the antero-internal border of the thigh, 
 traversing the fleshy vastus internus. 
 
 The femoral vessels are behind this line. The bone is deeply 
 placed and the operation difficult, but trephine thoroughly. Drain 
 the medullary cavity and the periosteal abscess (Fig. 338). 
 
 OSTEOMYELITIS OF THE UPPER EXTREMITY OF THE 
 
 FEMUR 
 
 Make the incision along the outer surface of the thigh over the 
 great trochanter. Divide the aponeurosis of the gluteal muscle, 
 trephine, and drain. 
 
CHAPTER XX 
 SEPTIC ARTHRITIS 
 
 Septic arthritis is acute purulent inflammation of the joints, due 
 to the presence of an infective agent, more frequently the staphylo- 
 coccus or the streptococcus. The infection may reach the joint 
 through a wound, by way of the blood vessels or through the lymph 
 channels. 
 
 This purulent inflammation, therefore either follows direct injury, 
 or is a sequel to various infective diseases, such as typhoid fever, gon- 
 orrhea, scarlet fever, or osteomyelitis; but by no means are all the 
 joint inflammations following these conditions purulent. 
 
 Purulent inflammations are to be distinguished from non-septic 
 inflammation both by the symptoms and the physical signs. The 
 symptoms are those belonging to sepsis, for here it exists in a high 
 degree. The tongue is brown and the temperature is very high, the 
 pulse is weak and rapid, there are the appearances of prostration and 
 finally delirium ensues. The pain is extreme and aggravated by the 
 least touch. With respect to the physical signs, there is marked 
 swelling of the joint and the skin is red and edematous, not only 
 over, but above and below the joint, and fluctuation is usually to 
 be detected. 
 
 Treatment. — This is an emergency of the first rank. It is an inter- 
 vention designed to save the function of the joint; and sometimes 
 even life is threatened. 
 
 There is but one indication, once the diagnosis is made, viz. : to 
 open the joint by free incision and counter-incision, that every part 
 of it may be reached and drained. 
 
 The most careful antisepsis is to be observed. The limb is to be 
 .'irefully cleansed as if no pus was expected. 
 
 Scrub the skin over the joint (the knee, for example), the upper 
 third of the leg, and lower third of the thigh with soap and water and 
 with ether and bichloride. Sterilized instruments are to be used; 
 
 456 
 
ARTHROTOMY OF THE KNEE 
 
 457 
 
 they are simple, a scalpel, a few artery forceps, some rubber drains, 
 and an irrigator. The whole aim is to secure ample drainage and 
 subsequent antisepsis, and nature will take care of the rest. In cer- 
 tain of the joints, however, mere incision may not be sufficient and 
 excision must be added. 
 
 Fig. 339 — Septic arthritis. Incisions for drainage of the knee. (Veau.) 
 
 Arthrotomy of the Knee. — Sepsis affecting the knee-joint causes the 
 knee to become enlarged, globular in outline, painful, reddened, 
 edematous, with constitutional symptoms of sepsis. The operation, 
 under general anesthesia, is very simple and without danger. The 
 important thing is to open freely. Two incisions are to be made, one 
 external and one internal (Fig. 339). 
 
 External Incision. — Locate the lower border of the patella; and, be- 
 
458 
 
 SEPTIC ARTHRITIS 
 
 ginning a little below this line, make an incision parallel with the 
 external border of the patella and ending about two fingers' breadth 
 above its upper border, which will be near the upper limit of the syno- 
 vial sac. This incision traverses the integument and beneath it the 
 firm aponeurosis of the vastus externus. As the joint cavity is 
 reached, very often the pus spurts out with great force. 
 
 Fig. 340. — Drawing the transverse drain into place. (Veau.) 
 
 Internal Incision. — On the inside, make an incision symmetrical 
 with the first, but a little further removed from the internal border of 
 the patella. The aponeurosis is here less firm, but the synovial 
 cavity is deeper; the swelling is usually greater on the inner side. 
 Some of the fleshy fibers of the vastus internus are always divided. 
 The cavity is not so easily reached as on the outer side. 
 
 Drainage. — Place a large transverse drain (Fig. 340). But in some 
 cases this is not sufficient. The lateral diverticula of the synovial 
 sac must be drained separately (Fig. 341). For this two counter- 
 openings are required, one on each side. Into one of the incisions 
 at its lower part, introduce forceps, and push backward and downward 
 through the synovial sac at the level of the interarticular line (Fig. 
 
ARTHROTOMY OF THE KNEE 
 
 459 
 
 Fig. 341. — Cross section of knee-joint showing that the transverse tube drains the upper 
 part; the two lateral tubes the inferior part of the synovial sac. (Veau.) 
 
 Fig. 342. — Manner of making posterior counter-opening for drainage of 
 the knee. (Veau.) 
 
460 
 
 SEPTIC ARTHRITIS 
 
 342). If it is an old arthritis, this is not difficult; but in the case of 
 a recent effusion, the ligaments are tense, and the articular surfaces 
 arc in contact so that the passageway is quite narrow. 
 
 When the forceps, pushed backward in this manner, bulges the 
 skin, open the blades, and, between them, make an incision 1 or 
 2 inches long. Through this opening in the forceps, draw a drain- 
 -tube into place. Repeat the maneuver on the opposite side. 
 
 Fig. 343- — Septic arthritis. Drainage ot the knee complete. (Veau.) 
 
 It is better to make the counter-opening on the external side first, 
 as the ligaments there are less tense. The beginner is seldom success- 
 ful in making the opening internally. He nearly always pushes the 
 Forceps backward at too high a level and the point engages in the 
 tendon of the adductor magnus. It must be directed downward and 
 backward (Fig. 343). When the joint is thus opened, irrigate freely 
 with hot -aline solution, reaching every recess of the joint and wiping 
 with sterile gauze. Aim to clean the whole synovia. If the joint 
 
PUNCTURE OF THE KNEE 
 
 461 
 
 is putrid, finish the irrigation with peroxide. Do not suture the 
 wounds. Employ a moist antiseptic dressing. Immobilize the 
 limb on a posterior plaster splint. 
 
 Subsequent Treatment. — Irrigate and dress twice daily for the first 
 few days. However, if the temperature falls almost to normal and 
 the pain ceases, do not be in a hurry to change the first dressing. 
 
 Fig. 344. — Puncture of the kriee. (Lejars.) 
 Occasionally it is desirable to empty the knee-joint, as in the case of a voluminous 
 hemarthrosis or serous exudation. The same careful asepsis is practised as for arthrot- 
 omy. Locate the upper external angle of the patella. A little above and to the out- 
 side of this point, plunge the trocar directly into the joint. The structures here are quite 
 resistant, but there are no vessels likely to be wounded. As the exudate flows out, gently 
 compress the joint to empty it. Withdraw the trocar with a quick movement, apply a 
 " sterile dressing, and bandage the knee in absorbent cotton. 
 
 If the suppuration diminishes about the end of the first week, put 
 in a smaller drain in the same manner as before, and employ dry 
 dressings. Watch the temperature. A rise indicates a retention of 
 pus and calls for new drainage. Endeavor to avoid permanent 
 flexion of the knee, a matter of the greatest difficulty and of the 
 greatest importance, for such flexion cannot be corrected. 
 
462 
 
 SEPTIC ARTHRITIS 
 
 Alter the second week the lateral drains are removed; and, some 
 days later, the transverse drain. After a month, if the inflammation 
 is all gone, attempt passive motion; but it is almost a certainty that 
 the joint will be stiff; still if it is stiffened in extension, there is no 
 occasion for reproach. 
 
 AM 
 
 Fig. 3,45- — Arthrotomy of the ankle. Trace of the incisions. (Veau.) 
 
 ARTHROTOMY OF THE ANKLE-JOINT 
 
 This operation is not so frequently required as for the knee. Often 
 local anesthesia will suffice. Make the first incision, 2 inches in 
 length, over the anterior border of the external malleolus and reach- 
 ing a little below its tip (Fig. 345). In the upper part of the incision, 
 one may cut freely down to the bone, but in the lower part more care 
 must be used. Some small arteries may be divided if one goes too 
 deep. 
 
 In the middle of the incision, open the joint, enlarge the orifice, 
 and mop out the cavity. 
 
 Introduce an artery forceps and carry it through the joint cavity 
 to the opposite side, and over its point make a counter-opening (Fig. 
 346). This opening should fall over the tip of the inner malleolus. 
 
 
ARTHROTOMY OF THE ELBOW 
 
 463 
 
 As the forceps is withdrawn, it pulls a drainage-tube into place (Fig. 
 
 347)- 
 
 Dressing and subsequent care are the same as in the knee. 
 
 ARTHROTOMY OF THE ELBOW- JOINT 
 
 Make a vertical incision 3 inches in length, with its center over 
 the outer border of the apex of the olecranon, dividing some of the 
 
 Fig. 346. — Septic arthritis. Drainage of ankle-joint. (Veau.) 
 
 fibers of the triceps and, anconeus (Fig. 348). Puncture the synovial 
 cavity at the middle of the incision and enlarge the opening to corre- 
 spond with the incision. Push a forceps transversely through the 
 joint at the upper level of the olecranon. Over its point make the 
 internal vertical incision. Cut carefully, for the ulnar nerve is here 
 in close contact with the posterior surface of the inner condyle. 
 
 Draw a drain into place with the forceps. The dressing and sub- 
 sequent care is the same as that described for the knee. 
 
4<>4 
 
 SEPTIC ARTHRITIS 
 
 ARTHROTOMY OF THE WRIST 
 
 Make an external incision between the long extensors of the thumb 
 and the extensors of the index-finger, lines which may always be 
 determined. Make a second incision on the ulnar side between the 
 tendons of flexor and extensor carpi ulnaris. The two incisions may 
 be connected by pushing a grooved director through. 
 
 Fig. 347. — Septic arthritis of ankle. Drainage placed. (Veau.) 
 
 ARTHROTOMY OF THE SHOULDER 
 
 This joint may be opened by a vertical incision, beginning at the 
 anterior angle of the acromion process and cutting downward in the 
 line of the bicipital groove, or the joint may be opened behind along 
 the posterior border of the deltoid, splitting the tendons of the in- 
 fraspinatus and teres minor. 
 
 ARTHROTOMY OF THE HIP 
 
 The hip-joint, deeply set under a thick muscular mass, may be 
 reached either from in front or behind. The aim of any procedure is 
 
ARTHROTOMY OF THE HIP 
 
 465 
 
 to reach the articulation in such manner as to produce the least de- 
 struction possible in these periarticular muscles; and, therefore, one 
 must seek the intermuscular spaces, or split the various muscles in 
 the direction of their fibers. 
 
 The study of the anatomy of the region demonstrates that several 
 pathways to the joint, complying with the above conditions, can be 
 found. 
 
 In front, the joint is covered by several muscles whose directions 
 correspond to the axis of the thigh — the pectineus, the iliopsoas, the 
 
 Fig. 348. — Septic arthritis of elbow. Incisions for drainage. (Veau.) 
 
 rectus femoris, in direct contact with the capsule; the sartorius and 
 the fascia lata more superficially placed. 
 
 Behind, the joint lies under a group of muscles which are parallel to 
 it when flexed at an angle of 45 . These are arranged in two layers; 
 in the first, the g. maximus; in the second, the g. medius and the ob- 
 turator internus and gemelli; while below and behind is the tendon 
 of the obturator externus. 
 
 anterior arthrotomy. — -If one wishes to reach the joint from in 
 front, he may pass (1) in between the fascia lata and the gluteus 
 medius externally and the rectus and sartorius internally. 
 30 
 
466 SEPTIC ARTHRITIS 
 
 (2) Between the rectus and sartorius externally and psoas in- 
 ternally. 
 
 (3) Through the sheath of the psoas. 
 
 In the first case, the outer end of the neck and the great trochanter 
 is exposed. In the second, the inner end of the neck, and in the third, 
 the head of the femur. 
 
 Position. — On the back with legs extended. Operator stands at 
 outside with assistant opposite, and second assistant moves the leg 
 as directed. 
 
 Incision. — (1) Incision begins above, and finger's breadth inside, of 
 ant. sup. spine, and extends downward and inward parallel to the sar- 
 torius, for 4 inches. Expose the internal border of sartorius, draw it 
 outward. Below it will be exposed the rectus to be drawn outward 
 also. The psoas is exposed and drawn inward to expose the capsule. 
 
 (2) The incision begins directly over the ant. sup. spine, and de- 
 scends nearly vertically, bisecting the angle between the sartorius 
 and tensor fascia lata. The sartorius and rectus are drawn inward 
 and the capsule exposed. 
 
 (3) Finally, the incision, to follow the outer border of the psoas, 
 may begin at the inner third of Poupart's ligament and extend down- 
 ward and slightly inward. The psoas is exposed near its inner border 
 and opened, avoiding the anterior crural nerve. 
 
 Open the Capsule. — Once the capsule is exposed, whatever the 
 route, the muscles are to be relaxed by flexion, abduction, and exter- 
 nal rotation which favors their retraction. The capsule thus freely 
 exposed is incised to any extent necessary. 
 
 Counter-opening in Capsule. — It may be advisable to make an in- 
 ternal incision to secure complete drainage. Make an incision from 
 the external border to the pubes downward and outward, exposing 
 the space between the pectineus and adductor longus. Avoid the 
 obturator nerve. Next introduce a forceps into the opening 
 already made in the capsule and let the point emerge at the second 
 opening; and, on this point as a guide, the counter-opening is made. 
 The forceps is used to draw a large drainage-tube into place. 
 
 
 
CHAPTER XXI 
 FOREIGN BODIES 
 
 THE EYE 
 
 Foreign bodies lodged on the conjunctiva or cornea are painful, and 
 may soon provoke a conjunctivitis, more or less severe. 
 
 The offending particle may be concealed under the lid or be im- 
 bedded in the cornea. The latter is especially likely to be the case 
 with those who have to do with emery wheels. 
 
 The patient's sensation is a very poor guide in locating the object; 
 if it is on the cornea, he is likely to be certain it is under the upper 
 lid. 
 
 Begin by inspecting the eye under a good light and at various angles. 
 Pull down the lower lid, instructing the patient to look upward. 
 Evert the upper lid. This is done by grasping the eye-lashes be- 
 tween the thumb and fore-finger and pulling downward, at the same 
 time making pressure upon the tarsal cartilage of the lid with a pen- 
 cil, stylet, or the opposite thumb. Instruct the patient to look 
 downward. Combined with this pressure, the eyelashes are now 
 pulled upward and in this manner the lid is everted and exposed 
 to inspection. The novice does better, perhaps, to stand behind the 
 patient, but the specialist sits in front of the patient and turns the 
 lid with one hand. 
 
 If the foreign body is free, it is readily picked up with the point of 
 the stylet wrapped with cotton, but if it is imbedded in the cornea, 
 considerable curettement may be required to dislodge it. The in- 
 strument must be sterile, otherwise corneal ulcer may follow the 
 manipulation. In the case of nervous or sensitive individuals or 
 when the conjunctiva is much congested, the manipulation must be 
 preceded by the instillation of a few drops of a 4 per cent, solution of 
 cocaine, which should be fresh and must be sterile. Everything used 
 must be sterile — hands, instruments, cotton, and solutions. 
 
 467 
 
468 FOREIGN BODIES 
 
 Following the extraction, irrigate with normal salt solution and in- 
 still two drops of 2 per cent, collargolum solution or 10 to 25 per cent. 
 argyrol solution and direct the patient to wash the eye frequently 
 with boracic or normal salt solution ; if there is much congestion, band- 
 age the eye for one or two days. 
 
 If the foreign body has penetrated to the anterior chamber, the iris, 
 or the posterior chamber, the immediate treatment must be limited 
 to such measure as will prevent infection — -boracic irrigation and 
 bandage — until the case can be placed in the hands of a specialist or 
 until special text-books can be carefully consulted. 
 
 It may be necessary to employ the X-ray in diagnosis in these 
 cases. The extraction may require a delicate operation or the use of 
 the electro-magnet, and finally the removal of the globe may be 
 necessary. 
 
 Chemical irritants should be removed by free irrigation. For 
 lime in the eye, a solution of sugar in vinegar is recommended, the 
 sugar forming a soluble compound with the lime. A few drops are 
 used, followed by free flushing with water. Afterward atropine, 
 gr. 1 to the ounce is imperatve. 
 
 THE EAR 
 
 The foreign bodies most frequently found in the ear are pebbles, 
 shoe-buttons, peas, beans, pens, pieces of tooth-pick, pieces of cotton, 
 etc., etc. 
 
 Children may place these objects in their ears in play or innocent 
 experimentations or adults may meet with the accident, attempting 
 to relieve an itching in the auditory canal. A tampon may be left 
 in the ear by the doctor. The body usually lodges in the outer part 
 of the canal, and only reaches the tympanic membrane after ill- 
 advised efforts at extraction. 
 
 The pain and discomfort are usually moderate; and, as a rule, there 
 are no very urgent indications for intervention. But if the object 
 rests against the drum, the pain is severe and may even produce 
 mental disturbance. 
 
 The first thing to do, then, is always to confirm the diagnosis. The 
 patient's belief in the matter must, under no circumstances, be ac- 
 
FOREIGN BODIES IN THE EAR 469 
 
 cepted as final. There is only one way to confirm the diagnosis and 
 that is by careful inspection of the whole canal, if the object is not 
 seen in the outer portion. 
 
 Draw the external ear upward and backward, and the tragus for- 
 ward. Under good illumination and with the aid of a head-mirror 
 and otoscope, the drum is readily seen. If no foreign body can be 
 seen, and provided there have been no blind efforts at extraction, it 
 may be definitely concluded that the patient is mistaken. 
 
 If, on the other hand, you locate the object, do not hurriedly intro- 
 duce a forceps into the ear; unless, indeed, the offending body is of 
 such a nature that it may be easily seized, for you will almost always 
 make matters worse, pushing it further into the canal. Remember 
 
 Fig. 349. — Ear forceps. 
 
 that however desirable it may be to empty the ear, there is, as a rule, 
 no great urgency in the matter and you have plenty of time to take 
 counsel with yourself (Fig. 349). 
 
 In some cases, a small hooked instrument may be cautiously 
 pushed past the object and withdrawn, pulling the object out, or a 
 small blunt curette may be similarly employed. Usually a large 
 syringe is the proper instrument. Throw a stream of warm, sterile 
 water into the ear with the purpose of forcing the body out by the 
 "vis a tergo." 
 
 To inject the stream properly, lift the pinna upward and backward 
 as in inspection, and direct the stream along the posterior superior 
 
470 FOREIGN BODIES 
 
 wall. Using moderate force. Use one syringeful after another, until 
 the offending substance is washed away or the patient is tired out. 
 
 If you have failed, instill into the ear a few drops of glycerine or 
 warm oil, lightly tampon, and direct the patient to sleep on the 
 affected side, returning the next day for another trial. The chances 
 are greatly in favor of ultimate success without injury to the ear. 
 
 In the case of a live insect in the ear, fill the ear with oil and sub- 
 sequently the " cadaver " may be removed by irrigation. 
 
 If " instrumentation" seems advisable, there must be no blind 
 grasping for the object — it must be kept clearly in view. It has 
 happened, in violation of this rule, that the middle ear has been in- 
 vaded and the ossicles dragged out.- Death has occurred from such 
 manipulation, though the post-mortem showed that no foreign body 
 had ever been present. 
 
 In the case of children, instrumental extraction will, as a rule, re- 
 quire an anesthetic. If the ear has become much inflamed or the 
 body pushed through the drum, the case is one for the specialist. 
 
 On the whole, the practitioner might adopt the rule, that if left in 
 the ear, untouched, the foreign body is less likely to do harm than 
 rude and maladroit efforts at removal. 
 
 THE NOSE 
 
 The catalogue of bodies, recorded as lodged in the nose, is long. 
 Naturally, children are more frequently the subject of these mishaps 
 although lunatics and hysterical women may intentionally plug the 
 nose. Occasionally, a foreign body previously swallowed, may be 
 coughed up and lodge in the posterior nares. Pledgets of cotton and 
 pieces of gauze, which have been used as tampons, may be over- 
 looked and act as foreign bodies. 
 
 In the case of the irresponsible, the presence of a foreign body may 
 not be suspected, so few are the symptoms, until there develops a 
 profuse sero-mucous discharge. There may be frequent attacks of 
 sneezing; ai)d, if the body remains long, the mucous membranes be- 
 come swollen and perhaps the skin of the affected side also. There 
 may be headache or facial neuralgia. These foreign bodies should be 
 oved as soon as possible, first having determined their nature, 
 size, and situation. 
 
FOREIGN BODIES IN THE PHARYNX 47 1 
 
 Begin by a careful examination of the anterior nares; and, if this 
 is not sufficiently instructive, examine the posterior nares by hooking 
 the finger up behind the soft palate. The examination and removal 
 are often facilitated by the use of cocaine, and in the case of children, 
 a few whiffs of chloroform may be necessary. 
 
 Chloroform is also the effectual remedy for animate foreign bodies, 
 such as insects and maggots. Used for this purpose, it is not inhaled, 
 but is shaken up with an equal amount of water and syringed into the' 
 nose before the two ingredients separate. 
 
 Fig. .350. — Angular forceps for foreign body in the nose. 
 
 A body lying in the anterior nares is usually readily removed by a 
 mouse- toothed forceps; or a curved probe or small curette may be 
 necessary to dislodge it. An angular forceps is sometimes conven- 
 ient (Fig. 350). In other cases, the obstruction may be removed 
 by drawing a tampon through the nasal cavity from behind, as recom- 
 mended by Sajous. 
 
 If the body is lodged in the posterior nares, it is usually pushed 
 backward into the pharynx, care being taken that it does not drop 
 down into the larynx or esophagus. 
 
 "In the case of infants, a small body may be removed by blowing 
 forcibly into the mouth." (John J. Kyle.) 
 
 PHARYNX AND ESOPHAGUS 
 
 Many diverse objects may lodge in these passageways, either 
 through ineffectual efforts at swallowing or by inadvertently slipping 
 

 FOREIGN BODIES 
 
 from the mouth. False teeth are often loosened and carried into the 
 pharynx or esophagus during sleep. 
 
 The point of lodgment, the immediate effect, the dangers, and 
 the difficulty" of removal, depend upon the size and shape of the 
 object. 
 
 The pharyngo-esophageal canal is narrowest behind the larynx, 
 opposite the cricoid cartilage and the sixth cervical vertebra; at this 
 point a large body is likely to lodge. A second constriction lies 
 2% inches further down, behind the left bronchus; and a third 
 where the esophagus passes through the diaphragm. Larger 
 bodies, then, are liable to lodge opposite the larynx. Sharp 
 and pointed objects, such as needles and fishbones, may anchor at 
 any point without reference to the caliber of the conduit. 
 
 The immediate effects of the lodgment of a foreign body vary 
 from instant asphyxia to merely slight difficulty in swallowing. 
 Later there may occur, even in the case of a slight obstruction, the 
 dangerous conditions following infection — -erosion of the walls, 
 perforation of the bronchi or lungs, of the pericardium, the aorta, or 
 carotids — one has but to think of the numerous relations of the 
 esophagus in the neck and thorax to understand how diverse the 
 consequences of such spreading infection might be in various cases. 
 
 Very naturally, the deeper down the object lodges, the greater 
 the difficulty in locating and reaching it. 
 
 Treatment. — Asphyxia, due to occlusion of the lower part of the 
 pharynx involving the larynx, demands immediate action. The 
 patient is livid, gasping, and struggling. Run the finger into the 
 throat over the epiglottis, where the body may be felt and hooked 
 out. If you fail in this, do not waste time in these cases of extreme 
 urgency, trying tentative measures, such as inversion, but do a 
 tracheotomy, or laryngotomy in the adult (see page 477). After the 
 operation, the foreign body may be expelled spontaneously in the 
 efforts of coughing or vomiting. 
 
 In the less urgent cases, the first indication is to confirm the diag- 
 nosis and definitely locate the object. The sensation of the patient 
 is not sufficient index as to the presence and situation of an obstruc- 
 tion in the gullet, for the pain may be due to a wound made by the 
 foreign body in passing. 
 
FOREIGN BODIES IN THE ESOPHAGUS 
 
 473 
 
 Inspect the mouth, the fauces, and the tonsils. Palpate the region 
 of the glottis and behind the soft palate. Palpate externally along 
 the anterior border of the sternomastoid, pressing deeply to reach the 
 esophagus, most superficial on the left side. Even if, as a result of 
 this palpation, the foreign body is believed to be located in the neck, 
 it is better to make certain by passing an esophageal sound. 
 
 In certain instances, the X-ray will be invalu- 
 able, though not always to be relied upon. In 
 the hands of the expert, the esophagoscope has 
 proved to be useful. In the course of time this 
 instrument will probably come to be a part of 
 every doctor's "arsenal." It not only makes 
 exact diagnosis possible, but enables the foreign 
 body to be removed by sight, avoiding thus the 
 injuries to the esophagus which blind efforts 
 often produce. 
 
 The presence and location of the foreign 
 body once established, extraction is indicated. 
 Inversion is illusory and emesis dangerous. 
 
 If the body is in the pharynx, it may be seized 
 with curved forceps, or dislodged with the finger 
 so an improvised hook. To employ the forceps, 
 reat yourself before the patient, whose mouth 
 is propped wide open. When the object is 
 once seized, incline the patient's head forward 
 as the forceps is withdrawn. If you lose your 
 hold, rapidly withdraw the forceps and remove 
 the mouth gag and often the loosened object will be coughed out. 
 
 In the case of an infant, place the patient on its back with the head 
 hanging over the edge of the table, thus preventing the body from 
 dropping into the larynx. (Have everything ready for tracheotomy.) 
 
 In extracting a body from the esophagus, the greatest caution is 
 necessary to prevent laceration. Rough manipulation only aggra- 
 vates the muscular spasm, which is always present in some degree, 
 and which, more than anything else, prevents the body safely reach- 
 ing the stomach; and these esophageal muscles are exceedingly strong. 
 The esophageal forceps is used as in the pharynx. 
 
 Fig. 351- 
 
 hair probang. 
 and closed. 
 
 Horse- 
 Open 
 
474 
 
 FORK1GN BODIES 
 
 The horse-hair probang (Fig. 351), introduced past the object, 
 opened up and then withdrawn, often succeeds in removing an im- 
 planted needle or fish bone. 
 
 # 
 
 Fig. 352. — Coin catchers. 
 
 
 In the case of a coin or similarly shaped object a "coin catcher" 
 may be employed (Fig. 352). Introduce the left indexfinger as a 
 guide and pass the instrument along its posterior wall until the coin 
 is felt, when the catcher is passed on beyond it. Now tilt the handle 
 forward and slowly withdraw the instrument until assured by the 
 
 sense of touch that the coin is engaged. 
 Completely withdraw the instrument 
 by steady, continuous, vertical trac- 
 tion. When the pharyngeal orifice is 
 reached, it is necessary to accelerate 
 the movement to achieve the final ex- 
 traction (Fig. 353). 
 
 If, in the course of the manipulation, 
 the foreign body is dislodged and slips 
 on down into the stomach, do not re- 
 gard it as a calamity, unless the object 
 is very pointed. Indeed, if the object 
 is deeply located, is known to be harm- 
 less in character, and extraction seems 
 impossible, an effort should be made 
 from the first to push it on into the 
 stomach with the esophageal bougie. 
 This should never be done, if the 
 character of the substance is unknown. No effort should be pro- 
 longed and above all else, no violence, is permissible. Finally, if 
 iction fails and propulsion into the stomach is out of the ques- 
 tion, there is only one thing left to be done— aw esophagotorny. 
 
 Fig. 353. — Extracting a coin from 
 the esophagus. (Lejars.) 
 
FOREIGN BODIES IN THE ESOPHAGUS 475 
 
 In certain cases where the body is firmly implanted, or when it is 
 pointed and dangerous to move, resort must be made to the operation 
 at once (see page 484). 
 
 LARYNX AND TRACHEA 1 
 
 The air passage is frequently involved, an accident always of con- 
 cern, often serious, and sometimes fatal. 
 
 The bodies finding their way into the larynx and trachea are of 
 great variety, fluid and solid, animate and inanimate; most often 
 aliments perhaps, and after these, the list may be indefinitely ex- 
 tended. 
 
 Children are more often sufferers, because of their habit of putting 
 objects into their mouths at random. Many times particles of food 
 "go the wrong way," the result of the patient's speaking or laughing 
 during the act of swallowing: the epiglottis is raised inopportunely, 
 and the morsel drops into the larynx. Small bodies are inhaled in 
 ordinary breathing. The accident sometimes happens during sleep, 
 through the dislodgment of false teeth or something held in the 
 mouth; it may follow an attack of vomiting, or it may occur during 
 some operation about the mouth; conditions such as anesthesia, 
 which diminish the reflex irritability or motility of the larynx, favor 
 it. 
 
 The point of lodgment depends chiefly upon the size and shape of 
 the object. Pointed objects, such as pins and fishbones, frequently 
 stick in the supraglottic portion of the larynx; flat bodies, coins and 
 buttons, usually lodge in the ventricles, while small globular, heavy 
 bodies descend into the trachea or bronchus, usually the right. 
 
 The symptoms and sequelae, and therefore the dangers, may be 
 grouped under two heads, obstructive and inflammatory. 
 
 (a) If the body is large and lodged in the larynx, asphyxia may be 
 the immediate result and may be almost immediately fatal. Even 
 small bodies may produce fatal asphyxia through reflex spasm of the 
 glottis, though usually the reflex spasm subsides. Reflexly, also, 
 coughing, sometimes violent, is induced, and this may be the case 
 whether the body lies in the larynx, trachea, or bronchus. Some- 
 
 1 Quotations are from Von Bergman. 
 
47 ( > FOREIGN KODIES 
 
 j. 
 
 times the body may lodge between the vocal cords, thus preventing 
 their closure and allowing some air to pass so that life may be sus- 
 tained for some time. 
 
 If the body is lodged in the ventricles, there may not be so much 
 obstruction, but there is hoarseness or aphonia and cough. 
 
 If the body descends into the trachea, there may be no indication 
 of obstruction, but there is much reflex irritation, evidenced by pain 
 and cough. If the body is light, it may move backward and forward 
 in the trachea, following the current of air. 
 
 If a bronchus is obstructed, a whole or a portion of the lung may 
 collapse, evidenced by altered auscultatory sounds. 
 
 (b) The body may become encysted if not removed, or inflamma- 
 tion may ensue with the most diverse sequences, depending upon the 
 location of the object: edema of the glottis, diphtheritic inflamma- 
 tion, abscess of the larynx, phlegmon of the neck, hemorrhage due to 
 erosion of the large vessels or even of the heart, tracheitis, bronchitis, 
 bronchiectasis, pneumonia, gangrene of the lung, empyema, purulent 
 pericarditis, mediastinitis, or phthisis. 
 
 Treatment. — Asphyxia demands immediate action; there is no time 
 for examination and inquiry. Make a hurried effort to remove the 
 body by passing the finger into the larynx, and if this fails, without 
 further delay do a tracheotomy (see page 481). 
 
 In the less urgent cases, one may be more deliberate, endeavoring 
 to ascertain the character of the object and to locate the point of 
 lodgment. The history of the case, the symptoms and the physical 
 signs derived from auscultation, will furnish valuable information. 
 
 Various procedures are recommended. 
 
 " Inversion and violent shaking of the body do not enjoy their 
 former popularity. Even the conservative Weist considers manipu- 
 lation of this sort dangerous and only justifiable after tracheotomy/ ' 
 
 Still it does not seem likely that it can result in harm if the body 
 is known to be small so that it may readily pass between the vocal 
 cords. 
 
 "The simplest way is to follow the suggestion of Sanders, and let 
 the body hang over the edge of the bed and rest on the hands during 
 the attack of coughing." "Generally speaking, emetics are unre- 
 liable and their use not without danger." 
 
BRONCHOSCOPY 
 
 477 
 
 If there is time, the laryngoscope may be of great aid in diagnosis 
 and extraction, employing cocaine in the adult and chloroform in 
 children. 
 
 In the hands of the skilled, the broncho- J 
 scope often furnishes a happy solution to' 
 the difficulty (Fig. 354). It is to be hoped 
 that the technic of bronchoscopy, now 
 familiar only to the specialists, will soon 
 be popularized with the profession at 
 large. In cases less urgent, the X-ray 
 may be used to locate the substance. 
 
 But after all, tracheotomy or laryngot- 
 omy is the chief reliance of the practitioner 
 left to his own resources, and he must be 
 prepared for immediate operation while 
 other measures are tentatively tried- 
 Lejars urges that an attendant be at hand 
 ready for instant operation as long as the 
 body is known to be free in the bronchus 
 or trachea. 
 
 "It makes no difference what one's 
 views are regarding tracheotomy in gen- 
 eral; the fact remains that no physician 
 will deny the necessity of this step when 
 the danger of suffocation is great." 
 
 "The author has become convinced that 
 the danger of tracheotomy nowadays is 
 insignificant compared with that of a 
 foreign body in the air passages and does 
 not hesitate, even when the body is situ- 
 ated in the larynx, to remove the offending 
 material through an incision should extrac- 
 tion per mas naturalis be impossible. " 
 
 "Tracheotomy is positively indicated 
 when the foreign body is movable in the 
 trachea." 
 
 In any case after the urgent symptoms have subsided, "operative 
 
478 FOREIGN BODIES 
 
 interference is the special form of treatment most rational and the 
 form of operation depends upon the situation." "If the extraction 
 means laceration, it is justifiable to split the larynx itself or a sub- 
 hyoid pharyngotomy may be indicated.' ' 
 
 "The expectant treatment, to which so many patients formerly 
 fell victim, is to be condemned. This method is only justifiable in a 
 small number of cases, in which the body has fallen far down into the 
 bronchus where it cannot be reached. 
 
 " The death rate shown by statistics should not decide the question 
 of operation: the clinical picture of the particular case and the unfor- 
 tunate cases should guide the surgeon. Those that died after the 
 operation did not do so because they were operated upon, but because 
 they were operated upon too late. In an individual case the doctor 
 can never count upon spontaneous expulsion. Every hour the of- 
 fending material remains in situ lessens the chances more and more, 
 while operation furnishes conditions most favorable for its removal. 
 Opening the air passages, then, is the most rational procedure except 
 for the cases in which endolaryngeal methods can be used." 
 
 RECTUM 
 
 The objects which have been removed from the rectum atone time 
 or another, cover a wide range — bottles, pieces of wood, etc., pushed 
 in to stop a diarrhea, to satisfy a perverted sexual impulse, or by the 
 insane. 
 
 It is scarcely necessary to indicate all the instruments and artifices 
 which have been employed in their extraction, but it is helpful, as 
 Lejars points out, to formulate certain general rules of procedure. 
 
 The necessity of these formulae cannot be doubted when one con- 
 siders the difficulties of extraction, often considerable, and the fre- 
 quency with which the rectum is lacerated by misguided effort. 
 
 Often the patient does not admit the nature of his difficulty, con- 
 sulting the doctor on some other pretext, such as constipation or 
 some rectal trouble quite different from the real condition. In the 
 case of obscure trouble in the natural orifices, the doctor should be on 
 guard. If the nature of the complaint is admitted, proceed to a 
 methodical examination and endeavor to get your bearings. 
 
FOREIGN BODIES IN THE RECTUM 
 
 479 
 
 Introduce a finger, which has been well oiled, into the rectum. 
 Sometimes you will find the object just within the orifice, of such 
 size and shape that it can be readily extracted with the finger or with 
 a forceps without further trouble, but you cannot count too much on 
 that. 
 
 If the examination shows it to be lodged high up in the concavity 
 of the sacrum, impacted and perhaps completely filling the rectum, 
 make no effort at extraction, but prepare for a formal operation. 
 
 Fig. 355- — Foreign body in the rectum, b. Bottle; c. Coccyx. (Lejars.) 
 
 Under a general anesthetic, put the patient in the lithotomy posi- 
 tion with the thighs well flexed, the hips elevated, and the anal re- 
 gion in a good light. Dilate the anus with the fingers as completely 
 as possible and then determine the exact "presentation" of the body. 
 Introduce a Sims' speculum, passing it, under the guidance of the 
 finger, beyond the coccyx, and then retract as widely as possible. 
 This is easily done in the young, but may be difficult in the adult. 
 
 When the coccyx is thus sprung back, the body must be seized and 
 traction made in the axis of the outlet if the body is long (a bottle for 
 
4 So FOREIGN BODIES 
 
 example) and firmly fixed (Fig. 355). The fingers or forceps may be 
 used. If you are dealing with glass, the blades of the forceps must 
 be covered with rubber to prevent slipping. If the ends of the for- 
 eign body are pointed, and imbedded in the rectal wall so that traction 
 is dangerous, great care must be exercised. In some cases morcella- 
 tion will be possible. 
 
 If the coccyx cannot be retracted and serves as the direct impedi- 
 ment, it will have to be resected. If the body has found its way up 
 into the left iliac region into the sigmoid, it may possibly be worked 
 down into the rectum by external manipulation. Finally, in such a 
 case, laparotomy and opening the bowel may be the only means of 
 relief. 
 
 Combs, of Indianapolis, reports a case which illustrates the prin- 
 ciples of treatment involved (J. A. M. A., Oct. 23, 1909). 
 
 After a drinking bout and a drunken sleep in the woods, the patient 
 awoke with a pain in his rectum and found it impossible to empty his 
 bowel. He applied to a physician who discovered a beer glass in the 
 rectum, inserted there during the victim's drunken stupor by brutal 
 comrades. An attempt was made to remove the glass without pre- 
 liminary divulsion of the sphincter. During traction with forceps 
 the glass was broken and the attempt failed. 
 
 Some hours later he was seen at the hospital by Combs who found 
 the small end of the glass resting on the promontory, and the large 
 end imbedded in the hollow of the sacrum (Fig. 355), its broken 
 edges buried in the soft tissues. By reason of the edema and swelling, 
 divulsion was insufficient for removal, and consequently the con- 
 tracted muscles were divided in the middle line posteriorly, when the 
 glass, which was four inches long and seven inches in circumference 
 at its large end, was readily removed. On account of the swelling 
 and evident infection, the incision was left to heal by granulation, and 
 on discharge from the hospital. the patient had a perfect control of 
 the sphincter. Combs remarks that the shape, size, and nature of 
 the foreign body, the edema and swelling, and the degree of trauma- 
 tism will be the guiding indications for the course to pursue. It 
 would certainly seem a rare instance in which amputation of the 
 coccyx would be required. Adequate division of the muscles poste- 
 riorly with quick removal is advised in lieu of prolonged efforts at re- 
 
FOREIGN BODIES IN THE URETHRA 
 
 481 
 
 moval by traction, especially of an object with cutting edges from 
 which fatal wounds may result. 
 
 THE URETHRA 
 
 A piece of sound may be broken off in the urethra. Boys or the 
 insane may lose various objects in the urethra, slate pencils, pipe 
 stems, pieces of watch chain, etc. 
 
 As a rule, the accident is not immediately disastrous, for generally 
 the impediment to urination is not complete. The object should 
 be removed as soon as possible and with as little irritation to the 
 urethra as possible. 
 
 Fig. 356. — Urethral forceps of Collin U), Leroy d'Etiolles (b), and Hunter (c). 
 
 It is necessary merely to enumerate some of the methods employed 
 successfully in various cases, and each case must be treated on its 
 own merits. Often the body may be easily reached and extracted 
 with forceps (Fig. 356). In certain instances, it may be gradually 
 worked forward by external pressure; or in urination the meatus may 
 be pinched up and when the urethra is ballooned out by the pressure 
 of the urine, sudden release may result in the body being washed out. 
 
 In case the body is in the deeper part of the urethra, and con- 
 siderable manipulation is necessary, pressure should be applied over 
 the urethra on the bladder side of the foreign body, to prevent its 
 being pushed deeper. A piece of hollow sound or catheter may some- 
 times be removed by passing a smaller sound down into its lumen: 
 31 
 
482 FOREIGN BODIES 
 
 or the urethral speculum or a larger hollow sound may be passed 
 down to, and over the body, which permits its more ready seizure by 
 a forceps passed through the speculum. 
 
 Dayat shaped a lead sheet into the form of a hollow sound and, 
 -nig it beyond the object in the urethra, closed its lower end by 
 pressure over the urethra and in removing the lead catheter the 
 foreign body came out with it. 
 
 Fig. 357. — Extracting a pin from the 
 urethra by "version." Protruding the 
 point through the skin. (Bryant.) 
 
 Fig. 358. — Point grasped with forceps. 
 Its direction reversed and head brought 
 out through the meatus. (Bryant.) 
 
 In another case, a stick forced into the urethra could not be with- 
 drawn on account of a hook on its lower end, but after being split into 
 many pieces, its extraction was accomplished piecemeal. 
 
 In the case of a pin lost in the urethra head downward, its point 
 may be driven through the skin and " version" accomplished and the 
 head brought out through the meatus (Figs. 357, 358). 
 
 In other cases it may be necessary to do an external urethrotomy, 
 and finally the object may have to be pushed into the bladder and 
 removed by suprapubic cystotomy. 
 
FOREIGN BODIES IN THE BLADDER 483 
 
 Hazzard describes a case in which a hat pin was lodged in the ure- 
 thra, its head too high to manipulate. He bent the penis at a right 
 angle to the direction of the pin and thus thrust its point through the 
 skin, which enabled him to practise version (J. A. M. A., May 29, 
 1909). 
 
 Hyde, of Kansas City, reports a shawl pin slipped, head first, down 
 the urethra and into the bladder. The point could be felt at the 
 penoscrotal angle. An incision was made down to the urethra, the 
 point was forced through the urethral wall into the incision, and the 
 pin drawn out till the head reached the urethral floor; it was then re- 
 versed and delivered through the meatus without opening the urethra. 
 The wound was closed by three deeply placed silkworm-gut sutures 
 with prompt repair (J. A. M. A., March 13, 1909). 
 
 Charlton of Indianapolis operated on a case at the City Hospital 
 in which the patient, a man of fifty had lost the bony portion of a 
 dog's penis in his urethra, having inserted it as was his custom to re- 
 lieve an itching. Painful micturition was his chief symptom. The 
 bone was located in the bladder, a cystotomy performed, the foreign 
 body removed, with complete recovery. 
 
CHAPTER XXII 
 BURNS, SCALDS, AND FROSTBITE 
 
 From the point of view of prognosis and treatment, burns are of 
 three degrees: 
 
 (i) Transient application of heat, something below the boiling- 
 points, produces hyperemia. 
 
 (2) A greater degree of heat or a longer application produces a 
 more definite vaso-motor paralysis and there is exudation, particularly 
 into the Malpighian layer, and the epidermis is lifted up in the form 
 of blisters. 
 
 (3) The albumen of the tissues and fluids is coagulated. This 
 necrobiosis may be superficial or it may involve the deep structures 
 as well. 
 
 Symptoms. — -Even in slight burns, pain is always a prominent 
 symptom. In the severer burns, shock is always present in some 
 degree, and as the shock disappears, reaction comes on, with rise of 
 temperature, and the symptoms resolve themselves into some form 
 of internal congestion, or systemic intoxication, characterized by 
 hemoglobinuria or albuminuria, vomiting, or bloody diarrhea. After 
 a few days the symptoms may be those of septic infection. 
 
 The cause of death from burns falls into four groups: 
 
 (a) Shock. This may be rapidly fatal, sometimes as late as twenty- 
 four hours. Death may be due to* cardiac paralysis, the result of 
 over-heating of the blood. 
 
 (b) Toxemia. The tox-albumens resulting from the chemical 
 changes in the tissues find their way into the circulation and over- 
 whelm the heart and kidneys, usually within the first two or three 
 days. It has been demonstrated that these toxic substances are 
 hemolytic and cytotoxic for the parenchyma cells and are eliminated 
 from the body by the kidneys and intestinal tract. 
 
 (c) Internal congestion and inflammation, involving the cerebral, 
 thoracic, or abdominal structures. 
 
 484 
 
TREATMENT OE BURNS 485 
 
 (d) Septic injection or its sequelce. This may be fatal after the first 
 few days or only after a prolonged struggle. 
 Factors Determining the Prognosis, — -(a) Area and depth of burn. 
 
 (b) Age and general condition of patient. 
 
 (c) Region. 
 
 (d) Degree of infection. 
 
 The rules for determining the prognosis can be formulated only in 
 1 general way with reference to these various factors, and yet keep- 
 ing them in mind, a quite definite forecast may often be made in a 
 given case. 
 
 (a) It is the area rather than the depth of the burn which deter- 
 mines the danger. An extensive superficial burn is more dangerous 
 than a limited but deep one. It appears that under the effect of heat 
 muscular tissue generates a poison much less toxic than that from 
 the skin. Mere reddening of two-thirds of the cutaneous surface 
 will almost inevitably result in death, while destruction of one-third 
 of the skin will probably produce the same result, yet most burns of 
 the first and second class commonly met in practice will recover. 
 
 (b) The age and general condition involve the question of the 
 ability to rally from shock and to resist infection. By reason of their 
 lack of resistance to these forces, the young or the aged may succumb 
 to even slight burns of the third degree. 
 
 (c) Burns over the head are dangerous for the reason that menin- 
 gitis may develop, and similarly burns of the thorax and abdomen are 
 likely to result in lesions of their contained viscera. Burns about the 
 face are often accompanied by corresponding injury to the air pas- 
 sages by inhalation of smoke or flames. 
 
 (d) The most important factor, however, in the process of severe 
 burns is infection. Such injuries, in fact, are infected wounds. The 
 coagulated albumens of the destroyed tissues are not favorable soil 
 for the development of the bacteria, but around the circumference of 
 the burn are tissues of lowered vitality which are not only unable to 
 resist the encroaching germ, but, more than that, actually nourish it. 
 
 The serous exudates of superficial burns are likewise culture 
 media, so that in severe burns as well as in other wounds it may be 
 said that the patient's fate lies in the first dressing. 
 
 Treatment. — Slight burns of the first degree require protection, 
 
|.86 BURNS, SCALDS, AND FROSTBITE 
 
 which may be furnished by vaseline; by gauze saturated in boracic 
 acid solution; by carron oil; by dusting powders of various kinds, 
 boracic acid, dermatol, bicarbonate of soda, flour. 
 
 /;/ severe bums the indications are to combat the shock, to relieve 
 the pain, and to prevent infection. In the matter of the local treat- 
 ment of these conditions, the final word has not yet been spoken. 
 The most divergent opinions appear in current literature, and of these 
 various lines of treatment perhaps none are wholly bad, certainly 
 few are altogether good. 
 
 Begin, then, by combating shock and relieving pain. These two 
 conditions are usually relieved at once by frequent but small hypo- 
 dermic doses of morphine, supplemented by subcutaneous or venous 
 injections of sak solutions. If parts beneath the clothing are in- 
 volved, use the greatest care in removing so that the skin will not be 
 removed with it. 
 
 To cut the clothing is safer than to attempt to undress the patient. 
 Always remember that contact with the clothing may be the chief 
 source of infection. 
 
 Now, what will one do to prevent infection? This is the chief 
 problem. 
 
 If the burn is of large extent and depth as well and has been in 
 contact manifestly with sources of infection, there is but one thing 
 to do if the aseptic method is to be employed. Anesthetize the 
 patient after the shock has passed and proceed to sterilize the parts. 
 Scrub the uninjured skin around the wound with soap and water and 
 then alcohol and bichloride. Next proceed to irrigate the burned 
 area with normal salt solution, in the meantime carefully rubbing 
 with sterile gauze, to the end that every bit of foreign matter may 
 be removed. In those parts that are merely blistered, the blebs 
 are to be punctured and the serum washed away. It may be advis- 
 able, even, for the sake of thorough disinfection, to make no effort 
 to spare the cuticle of the blisters in rubbing with the sterile gauze. 
 
 Not hurriedly, but patiently complete this cleansing. It will prob- 
 ably require from one-half to three-quarters of an hour, but it is 
 time well spent. You have now to deal with an aseptic wound. 
 
 Next cover the area with plain sterilized or borated gauze and 
 this apply absorbent cotton and bandage snugly. 
 
OINTMENT OF RECLUS 487 
 
 If much cuticle has been removed, cover with sterile vaseline 
 before applying the sterile gauze. 
 
 The aid of a splint maybe required to prevent deformity. If 
 no fever arises the dressing need not be changed for eight or ten 
 days. 
 
 'It may not be practical to institute the thorough disinfection which 
 anesthesia alone permits, but one can at least cleanse the adjacent 
 area as before described. Prick the blisters and irrigate the burnt 
 area with normal salt solution, but in this case sterilization is not so 
 much a certainty. 
 
 Therefore, you must employ an antiseptic dressing. Whatever 
 dressing you select should have these properties at least; it should be 
 antiseptic, analgesic, and {teratogenic. A number of substances 
 possess these properties in various degrees and are otherwise more 
 or less unobjectionable. 
 
 Picric Acid. — This is employed in solutions of i or 2 per cent. A 
 good solution is made by dissolving 1% drams in 3 ounces of 
 alcohol and adding some of this solution to two parts of water. 
 After cleansing the surface apply strips of sterile gauze, soaked in 
 the solution, cover with absorbent cotton and bandage. Change 
 the dressing in three to four days, soaking it loose with the same 
 solution. Picric acid stains are removed by an alkaline sulphide 
 followed by washing with soap and water or by a paste of manga- 
 nese carbonate and water. 
 
 Turpentine. — This is an excellent domestic remedy, antiseptic and 
 analgesic, but only to be employed in slight burns of the first degree. 
 Cover the area with absorbent cotton and saturate with the turpen- 
 tine, and bandage. 
 
 Aristol. — This, too, renders excellent service. Use as an ointment 
 mixed with sterile vaseline or zinc ointment in the proportion of 8 to 
 10 grains to the ounce and apply spread on sterile gauze. 
 
 The Ointment of Rectus. — This, perhaps better than any other 
 ointment, meets all the indications. It is applied in a thin layer 
 directly to the surface or spread on sterile gauze and the dressing 
 completed with cotton and bandage. Here is the formula of the 
 ointment as modified by the author and prepared by the Pitman, 
 Myers Co., and which should be ready for instant use: 
 
498 BURNS, SCALDS, AND FROSTBITE 
 
 U — Hydra rg. Chlor. Corros., i part. 
 
 Acid Carbol., 30 parts. 
 
 Aristol, 30 " 
 
 Acid Boric, 90 xt 
 
 Salol, ' 90 " 
 
 Antipyrine, 150 " 
 
 Petrolatum, 576 " 
 
 Car ran Oil. — This is an old and useful remedy, but, as ordinarily 
 used, unqualifiedly to be condemned. It favors suppuration because 
 it is in nowise antiseptic and perhaps may — indeed often does — carry 
 infection. If the oil is sterilized and then applied to the surface 
 which has been made as clean as possible, it is an efficient 
 dressing. 
 
 Granger, of Rochester, Minn., uses equal parts of lanolin and zinc 
 ointment spread thickly on gauze, covering the ointment with the 
 waxed paper sold by instrument dealers, and applying the dressing 
 with the paper next to the burned surface. The dressing is next 
 covered with a thin layer of cotton. He claims that it is soothing 
 and easily removed. 
 
 The frequency with which any dressing must be changed will 
 depend on the pain or infection. If the secretions are excessive and, 
 by drying and stiffening the dressing, aggravate the pain, the dress- 
 ings must be frequently changed. 
 
 If there is infection, the rise of temperature will be the index. The 
 same care must be exercised in changing the dressings as in treating 
 any other wound. 
 
 BURNS OF THE MOUTH 
 
 Burns of the mouth and air passages are not infrequent. These 
 may be the result of taking hot substances into the mouth or the 
 inhalation of hot gases in explosions. Pain and difficulty in swallow- 
 ing are the most frequent symptoms. In addition there may be 
 edema of the glottis or finally acute bronchitis may develop. Cold 
 water and bits of ice give the most relief. The edema of the glottis 
 may require tracheotomy. The various forms of inflammation, such 
 as bronchitis or pneumonia, must be treated on general principles. 
 
SYMPTOMS OF ELECTRICAL SHOCKS 489 
 
 ELECTRICAL BURNS AND SHOCKS 
 
 Electrical burns are painful out of all proportion to the size of the 
 lesion and require two or three times as long as the ordinary burn for 
 repair. 
 
 Begin the treatment with hypodermics of morphia and strychnia 
 (1/30). Cleanse the wound by the ordinary surgical methods and 
 dress with sterile gauze, cotton, and bandage. 
 
 The resuscitation of persons shocked by electricity is necessitated 
 much more often than formerly by reason of the widespread use of 
 the electric current. Spitzka has lately outlined the course to pursue 
 in the treatment of such cases. He remarks, in the first place, that 
 one cannot safely predict exactly what will happen in any case of 
 shock by electricity, for many factors modify the action of the cur- 
 rent: its nature, tension, intensity; the resistance and susceptibility 
 of the individual; the duration, location, and area of contact. 
 Broadly stated, the effect is the more severe, the greater the voltage, 
 the greater the amperage, the longer the period of contact, the greater 
 the area of contact, and the longer the path of the current through 
 the body. 
 
 Death by electrical contact would appear to be due to heart paraly- 
 sis or to asphyxia, or a combination of both. In certain cases there 
 is no paralysis of the heart, but only respiratory failure. 
 
 The symptoms of electrical shock in cases which are not immedi- 
 ately fatal, vary greatly in form and degree. 
 
 I. Local signs: 
 
 (a) Burns and superficial necroses. 
 
 (b) Puncture and rupture of tissues. 
 
 (c) Hemorrhages. 
 
 (d) Edema and erythemas. 
 
 II. General effects: 
 
 (a) Loss of consciousness. 
 
 (b) Paralysis and spasms of muscles. 
 
 (c) Disturbances of respiration and circulation. 
 
 (d) High temperature. 
 
4QO BURNS, SCALDS, AND FROSTBITE 
 
 Later there may develop disturbances of the bowels, kidneys, 
 special sense organs, the central and peripheral nervous system. 
 
 The prognosis is good only in cases where there is some heart 
 action and respiration and where treatment can be promptly applied. 
 
 Treatment. — -If the stricken man is not out of the circuit, some cau- 
 tion must be exercised in accomplishing his relief. The rescuer 
 should have on rubber gloves or have his hands wrapped in thick 
 dry, woolen material, to avoid shock from handling the victim. He 
 may be freed by pulling at his clothing or using sticks of wood. If 
 it is necessary to cut a wire, the nippers must have insulated handles 
 and the eyes should be protected from the blinding flash. 
 
 Once freed, the patient should be laid with head elevated and arti- 
 ficial respiration at once begun. This is more effectively done by 
 compressing the chest with the hands applied flat against the sides 
 of the lower part of the thorax. The tongue must be drawn forward 
 so as not to obstruct the larynx. Massage over the heart and 
 faradism help to stimulate its action. Arterial infusion of adrenalin 
 has been proven by Crile and Dolly to have a direct effect. 
 
 Other methods which have been suggested are lumbar puncture, 
 venesection, and the high-tension shock of short duration (Jour. 
 Med. Soc. New Jersey, Jan., 1909). 
 
 FREEZING 
 
 The effects of very low temperature on the tissues are practically 
 the same as those of heat. The ultimate effect is death of the tissues 
 or gangrene. 
 
 The treatment of patients overcome by cold must be circumspect. 
 The main point is to go slow in warming the parts. The patient 
 should never be brought directly from outdoors into a warm room. 
 Sonnenburg advises that a cold bath, the temperature of the cold 
 room, be used, and the temperature gradually raised until in two 
 or three hours it reaches 8o° F. Where life seems extinct, artificial 
 respiration should be practised, and sometimes the circulation may 
 thus be re-established. Subsequently hot rectal enemata of whiskey 
 or coffee may be employed. The limbs and other frozen parts 
 should be covered with moist compresses for the first forty-eight 
 
FREEZING 49I 
 
 hours and then dusted with boracic acid and encased in a thin layer 
 of wool. 
 
 If the trouble is only local — -a frozen ear or foot — -begin by rubbing 
 the part with snow or ice and then with cold water and finally apply 
 cold compresses, gradually raising their temperature until the circu- 
 lation is restored. Subsequently cooling lotions may be employed 
 to allay the inflammation. 
 
 The frostbite of the feet so common in the trench fighting of the 
 European war, resulting often in gangrene is not due so much to 
 the cold as to interference with the circulation, the result of wearing 
 soggy socks and shoes unchanged, perhaps, for days. 
 

PART II 
 
 CHAPTER I 
 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 
 
 Tracheotomy is often performed in general practice as an opera- 
 tion of the greatest urgency, and one should be prepared to do it 
 anywhere, at any time, and, if necessary, with a pen-knife. Yet it is 
 not so simple a procedure as one might infer. To do it properly and 
 quickly, requires coolness, knowledge, and 
 method. It is the measure of relief indicated 
 in every case of laryngeal asphyxia, whether 
 due to spasm of the larynx, edema following 
 burns, injuries, or disease such as diphtheria 
 or cancer; or to the presence of foreign bodies. 
 In the case of diphtheria, intubation is always 
 preferable to tracheotomy, but the necessary 
 appliances may be lacking. The essential 
 equipment for tracheotomy is a sharp pointed 
 scalpel and a tracheotomy tube, and to these fig. 359.— Tracheotomy 
 as mere conveniences, may be added scissors, 
 artery and dissecting forceps, tenacula, mouth-gag, and tongue 
 forceps. • 
 
 The tracheotomy tube (Fig. 359) should be of simple construction, 
 easy to introduce, and as large as the diameter of the trachea will 
 admit. Treves furnishes the following table relative to the age of 
 the patient and the diameter of the tube: 
 
 AGE DIAMETER OF THE TUBE 
 
 Under 18 months, 4 mm. 
 
 1^ to 2 years, 5 mm. 
 
 2 to 4 years, 6 mm. 
 
 4 to 8 years, 8 mm. 
 
 8 to 12 years, 10 mm. 
 
 12 to 15 years, 12 mm. 
 
 Adults, 12 to 15 mm. 
 
 493 
 
40 4 
 
 TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 
 
 Every practitioner should have tubes of various sizes in his "arse- 
 nal;' 1 Senn recommends Trousseau's, while Lejars prefers those of 
 Krishaber, because less likely to become occluded. 
 
 Anesthesia is often unnecessary, owing to the condition of the pa- 
 tient. Otherwise a few whiffs of chloroform should suffice. It need 
 scarcely be said that under these circumstances, free use of the 
 anesthetic will only hasten the fatality. 
 
 The preparation of the field can be hastily but sufficiently done by 
 painting with iodine. 
 
 Fig. 360. — Locating the cricoid cartilage. (Veau.) 
 
 • 
 
 The little patient's arms should be pinioned to its sides with a towel 
 or sheet, it should be placed on its back with a cushion under its 
 shoulders to drop the head backward and bring the trachea into 
 bolder relief. 
 
 Operation. — Stand at the right side of the patient; locate the hyoid 
 bone, the thyroid prominence, the cricoid cartilage, and the sternal 
 notch; and steady the trachea, holding the cricoid between the middle 
 finger and the thumb of the left hand, while the index finger locates 
 the middle line (Fig. 360). 
 
 It is along the middle line that one must incise, and the aim is to 
 divide the upper rings of the trachea and to avoid the thyroid isthmus 
 (Fig. 361). 
 
TRACHEOTOMY 
 
 495 
 
 Make the incision from the index finger downward exactly in the 
 middle line for 2 inches (Fig. 362). Incise rapidly with a single 
 sweep of the knife. The left index finger in the upper angle of the 
 wound hooks up the cricoid and still locates the middle line. Pay 
 no attention to the bleeding, and without hesitation push the point 
 of the bistoury through the upper ring and cut downward through 
 the second and third if necessary. The air hisses through the 
 opening. It is a moment of confusion, but one must keep cool. 
 
 Insert the tube. Without changing its position, 
 the left index finger presses the tracheal wound 
 open and the right hand introduces the tube. 
 It is held horizontally at first, until the point is 
 well in the trachea, and then is carried upward 
 in a curve until its beak corresponds to the 
 lumen of the trachea (Fig. 363). The patient's 
 gasps expel blood and perhaps false membrane, 
 which the attendants must avoid inhaling. The 
 tapes attached to the tube are fastened behind 
 the neck. Apply artificial respiration if the 
 patient's condition is not satisfactory. Let the 
 
 ,, , . ^ ^ M Fig. 361. — Trache- 
 
 air pass through a warm, moist compress until tomy. Dotted lines 
 the temperature of the room can be regulated, represent the thyroid 
 
 As Veau points out, the operation may fail for 
 several reasons, all within the control of the operator. The most 
 frequent cause of failure is faulty introduction of the tube; it does 
 not enter the tracheal canal, but is pushed down between the 
 mucous membrane and the tracheal wall. These structures are 
 loosely connected. The error is to be recognized by the absence 
 of the characteristic sound of escaping air. 
 
 The orifice is to be inspected, and, if too small, enlarged, before 
 trying the second time to introduce the tube. 
 
 Again, too much force in making the incision may result in wound- 
 ing the posterior wall of the trachea. Excited operators have split 
 the trachea its entire length, or wounded the vessels of the neck. 
 There need be but little hemorrhage in the operation, if one but keeps 
 in the middle line; and, as Senn says, that is the secret of success in 
 performing the operation quickly and safely. 
 
496 TRACHEOTOMY, LARYNGOTOMY, ESOPIIAGOTOMY 
 
 Fig. 362. — Tracheotomy. Incision. (Veau.) 
 
 PlC. 363.— Introducing the tracheotomy tube. (Veau.) 
 
TRACHEOTOMY FOR FOREIGN BODIES 497 
 
 The operation may be varied somewhat, depending, of course, 
 upon the conditions. The cricoid may be divided if necessary. In 
 other cases, before cutting downward it may be necessary to draw 
 downward the isthmus of the thyroid gland before enlarging the 
 opening. 
 
 In any case where time does not press, as when the tracheotomy is 
 done preliminary to some other operation, the various steps may be 
 carried out with more detail, the incision made by layers, vessels 
 clamped, and the rings exposed, steadied with hoods and incised. 
 
 The tracheotomy may be done below the isthmus of the thyroid, 
 but the higher operation is much the easier anatomically, although 
 the principle is the same. 
 
 Tracheotomy for foreign bodies differs in some respects from the 
 ordinary technic. Westmoreland, of Atlanta, who has had a large 
 experience with this class of cases has recently emphasized some of 
 these points (Amer. Jour, of Surg., Nov., 1909). 
 
 The incision should vary in length depending upon the size and 
 character of the foreign body. If the opening is sufficiently large 
 the foreign body is easily expelled by the respiratory effort; usually 
 the opening is made too small and the trachea is injured by the forci- 
 ble extraction of the body. In the young the thyroid isthmus is 
 usually in the way and should be divided between forceps and ligated. 
 Even the thymus gland may intrude and is to be depressed with a 
 narrow retractor. A tenaculum should not be employed lest it 
 excite a troublesome bleeding. 
 
 The incision in the trachea itself begins at the first ring. If 
 asphyxia should occur in the course of the operation, the result of 
 fixation of the object in the glottis, the operation should be rapidly 
 finished, a tube or catheter passed into the trachea and the lung in- 
 flated by blowing through the tube — -a great help in artificial respira- 
 tion which soon resuscitates the asphyxiated child. 
 
 Tracheotomy tubes are not to be used. Once the trachea is opened 
 the body may be coughed out which a tube would prevent. The 
 wound may be held open if necessary by silk threads passed through 
 its edges. 
 
 // the foreign body is expelled the trachea is to be sutured at once, 
 employing a mattress suture of silk which is not to pass through the 
 32 
 
40 S TRACHEOTOMY, LARYNGOTOMY, ESOPHAGOTOMY 
 
 mucous membrane. Whether the tracheal wound is made air-tight 
 or not is to be tested by tilling the wound with normal salt solution 
 and obstructing the nose and mouth which will force some bubbles 
 through if not tight. The fascia, muscles and isthmus, and finally 
 the skin are repaired. The dressing is held in place by adhesive 
 strips. 
 
 // inflammation exists, even though the body is expelled, do no 
 suturing; cover the wound loosely with bichloride gauze to keep out 
 cold air and to absorb the discharges. Change the dressing fre- 
 quently. 
 
 // the foreign body is not expelled the protective dressing is to be 
 applied which will not prevent the escape of the object if it should 
 be coughed up later, and under this treatment the inflammation will 
 probably rapidly subside. 
 
 After-treatment. — The success of tracheotomy rests largely on the 
 care with which the after-treatment is conducted. There is no 
 operation, perhaps, in which care and skill are better rewarded and 
 negligence and ignorance more severly punished. If the temperature 
 of the room cannot be kept at close to 65 , the tube should be kept 
 covered with a warm, moist compress. The wound must be kept 
 clean. For the first few days, the inner tube must be removed and 
 cleansed several times daily. This should be done rapidly, and the 
 tube disinfected and oiled before being reintroduced. 
 
 Morse (Post-operative Treatment, page 174) says, unless the 
 cause of obstruction is a permanent one, it is often advisable to 
 remove the tube after twenty- four to forty-eight hours; but the 
 patient should be allowed to try breathing through the mouth before 
 removing the tube, testing his capacity by stopping the cannula. 
 In any event, he should be gradually accustomed to breathing 
 through the mouth by plugging the canula. 
 
 Morse advised that soup, milk, or broth should be given at first, 
 if necessary through a nasal or esophageal tube, although this is not 
 often required. Difficulty in swallowing is likely to occur on the 
 third or fourth day, but encouragement will enable the patient to 
 overcome this. Nutrient enemas are rarely necessary. 
 
 Link, of Indianapolis, relates an experience (Medical Record, 
 March 2, 1907) which illustrates at once the value of the operation, 
 
TRACHEOTOMY FOR LARYNGEAL EDEMA 499 
 
 the improvisation of instruments to meet an emergency, and one of 
 the rarer forms of suffocating edema. 
 
 At midnight he was called to see a patient said to be choking to 
 death and whom he supposed had an attack of asthma. He found 
 the patient, a man weighing 250 pounds, cyanosed and laboring 
 for breath. One hour previously, it seems, his throat had been 
 lanced for the eleventh time in the course of a ten days' attack of 
 tonsillitis. 
 
 A hurried examination found the pharynx too tightly swollen to 
 pass a finger. How much laryngeal edema there might be could 
 only be guessed. Thinking to intubate past the swollen pharynx, 
 Link used the only thing available, the vaginal tip from a hard- 
 rubber syringe, bent at nearly a right angle. The attempt failed. 
 While preparing for a local anesthesia to do a tracheotomy, the 
 patient's neck was surrounded with iced cloths, but this seemed 
 to aggravate the asphyxia; the patient became unconscious and 
 ceased to breathe. 
 
 The anesthesia was no longer necessary. All had fled but one 
 woman, and while she held the patient's head, the doctor did a low 
 tracheotomy. 
 
 He says, kneeling in front of the patient, who was in a sitting pos- 
 ture, he incised the skin and deep fascia in the median line 2 inches 
 above the sternal notch, working with his finger down to the bron- 
 chial rings. With the finger as a guide, the knife was introduced, the 
 trachea stabbed and cut slightly upward. A closed hemostat was 
 then introduced and opened. Very little blood was lost. A female 
 silver catheter from his pocket case was introduced and held in place 
 by the assistant, while the doctor performed artificial respiration. 
 
 The patient soon began to breathe, but his convulsive movements 
 threatened the loss of the small tube in the throat. The hard-rubber 
 vaginal syringe tip was brought into use again, whittled and inserted. 
 The elbow shape fitted perfectly. In half an hour the patient asked 
 to be put to bed, and breathing entirely through the tube, slept the 
 first sleep for several nights. 
 
 The edema declined as fast as it had arisen, and, within a few 
 hours, the patient could breathe through the mouth when the tube 
 was closed, and recovery was uneventful. 
 
TRACHEOTOMY, T ARYNGOTOMY, ESOPHAGOTOMY 
 
 LARYNGOTOMY 
 
 As an emergency operation, this is most frequently done in an adult 
 for cancer, but one need not wait until the patient is asphyxiated for 
 there is nothing gained thereby. Therefore one may operate deliber- 
 ately, for there is not the extreme urgency as with the infant. 
 
 Local anesthesia may be sufficient. Define as before the inferior 
 borcter of the thyroid cartilage and the upper border of the cricoid, 
 between which is the crico-thyroid membrane which is to be incised 
 (Fig. 364). In the middle line over the space, 
 make a vertical incision an inch long. Catch 
 the bleeding points and retract the lips of the 
 wound. Carefully incise the fascia until these 
 cartilages are exposed. Now incise the crico- 
 thyroid membrane transversely and open into 
 the larynx (Fig. "365). 
 
 Introduce the tube as in tracheotomy. Re- 
 move and cleanse the inner tube on the first two 
 days and the large tube on the third day. 
 
 Of course, if the operation is for cancer, it is 
 merely palliative and the patient will continue 
 slowly to die. If the operation is for edema of 
 the larynx, the cause must be treated and the 
 proper time finally to withdraw the tube deter- 
 mined by the conditions. If the operation is for a foreign body, the 
 wound may be sutured at once. 
 
 Fig. 364- — Laryn- 
 gectomy. Incision of 
 crico-thyroid mem- 
 brane. (Veau.) 
 
 ESOPHAGOTOMY (Cervical Region) 
 
 This is an operation only exceptionally of value fort he esopha- 
 goscope will usually enable the foreign body to be removed without 
 operation even after the ordinary maneuvers have failed (see Foreign 
 Bodies). Nevertheless in the case of irregular bodies fixed in the 
 lower cervical region it is preferable to open the esophagus rather 
 than lacerate the mucosa in dragging the object out. A skiagraph 
 will help to locate the body definitely preliminary to operation. 
 
ESOPHAGOTOMY 
 
 50I 
 
 Position, — Place the patient on his back with shoulders elevated 
 and the neck resting on a sand-bag with head turned to the right. 
 
 Incision. — Begin opposite the upper border of the thyroid cartilage 
 and continue downward along the anterior border of the left sterno- 
 mastoid for 3 or 4 inches, incising the skin, superficial fascia, and plat- 
 ysma. Ligate the veins and draw the sterno-mastoid forward and 
 the depressors of the hyoid downward (Fig. 366). The wound is thus 
 enlarged and at the bottom is the layer of cervical fascia connecting 
 
 Fig. 365. — Laryngotomy. Incision of the crico-thyroid membrane. (Veau.) 
 It is better to cut transversely in order to avoid the crico-thyroid artery. 
 
 the thyroid gland and the sheath of the large vessels. Incise it and 
 again enlarge the wound by drawing forward the thyroid gland, 
 trachea, and larynx, and backward, the great vessels in their sheaths. 
 
 At this stage, in the bottom of the wound are the inferior thyroid, 
 which must be ligated, and the recurrent laryngeal nerve, which 
 should be drawn forward. 
 
 TJie esophagus now appears as a red tube. To steady the esoph- 
 agus and define its walls, an esophageal bougie may be inserted. 
 The wall of the esophagus is raised with mouse-tooth forceps (Fig. 
 
rRACHEOTOMY, LARYNGOTOMY, ESOP1IAGOTOMY 
 
 joy) and incised along its lateral wall. A suture is passed through 
 each lip of the incision, that they may be readily retracted while the 
 foreign body is located and removed, not always the easiest part 
 of the task. 
 
 The wound of the esophagus is repaired with sutures of catgut 
 and the rest of the wound lightly packed with gauze until all danger 
 of infection is passed. 
 
 • Slerno-tlit/r. 
 
 ...St.-hyoid. 
 Omp-nyoid 
 Stcrno-mctst. 
 
 Fig. 366. — Esophagotomy: exposing the infrahyoid group of muscles. (Lenormaut.) 
 
 As Bryant says, ordinarily the operation of cervical esophagotomy 
 is not a perplexing procedure, but when the neck is short and fat, 
 the vessels and thyroid gland enlarged, the detection and removal 
 of the foreign body difficult, or the patient exhausted, the operation 
 often taxes the patience and fortitude of the surgeon. 
 
 After-treatment. — The patient must be kept in bed with shoulders 
 
ESOPHAGOTOMY 
 
 503 
 
 raised. Nourishment should be given at first by enemata, and later, 
 if. necessary, by the esophageal tube. 
 
 Nassau reports a case illustrating the subject. A child swallowed 
 a five-cent piece and thereafter could take only liquid foods. "X- 
 ray" examination showed the coin lodged at 
 the level of the suprasternal notch or just 
 above. 
 
 Removal was attempted with forceps but 
 without success, although the coin could be 
 felt. An esophagotomy was done. The opera- 
 tion was completed in fourteen minutes. No 
 vessels require ligation. The esophagus was 
 not sutured and the superficial wound was 
 closed with drainage. There was no leakage 
 and the child made an uneventful recovery. 
 Nassau does not regard esophagotomy as a 
 serious operation, but believes it should not 
 be considered until efforts at extraction have failed. 
 
 Fig. 367. — Esophagot- 
 omy. Final incision. 
 (Bryant.) 
 
CHAPTER II 
 
 URGENT THORACOTOMY. REPAIR OF INJURY TO THE 
 
 LUNGS. REPAIR OF INJURY TO THE PERICARDIUM ; 
 
 OF INJURY TO THE HEART. PUNCTURE OF 
 
 THE PERICARDIUM 
 
 As has been indicated elsewhere (see Injuries of the Thorax), 
 urgent intervention for injuries of the thorax is a form of operative 
 procedure at this present time with but a limited field. Whatever 
 may be the apparent gravity of the case, it is far from being the rule 
 to operate, for such operations require trained assistants, a special 
 equipment, and a superior surgical skill. Of necessity, then, in 
 general practice, the treatment must, generally speaking, be con- 
 servative: that is to say, cleansing of the external wound with en- 
 largement and trimming up if necessary, reunion and aseptic oc- 
 clusion, firm bandaging of the thorax, and an absolute quiet in bed. 
 These measures along with stimulation with caffein and camphor- 
 ated oil and normal salt solution, represent the elements of treat- 
 ment which are within the scope of all. 
 
 But there are cases so manifestly fatal without operation that, as 
 Lejars says, one cannot evade the question, " operate or let die?" 
 
 Grave rupture of the lung indicated by an immediate flooding of 
 the pleural cavity, followed by urgent symptoms of asphyxia and 
 syncope, is the signal for immediate operation. Again, repeated 
 attacks of secondary hemorrhage call for operation. 
 
 URGENT THORACOTOMY 
 
 The technic of this operation can be exactly defined only in a gen- 
 eral way and will need to be modified to suit the individual case. 
 
 Lejars insists that the opening must be large, that anything less 
 will be a disappointment and the operation might as well not be 
 undertaken. 
 
 504 
 
THORACOTOMY - 505 
 
 The operation may proceed in one or two ways: (i) by a permanent 
 resection of the ribs necessary to be removed, or (2) by temporary 
 resection with the formation of a thoracic flap. 
 
 (1) Make a U-shaped incision forming a flap with its base posterior, 
 and of which the two arms run parallel with the ribs and are wide 
 enough apart to include at least three ribs. 
 
 The incision reaches to the ribs. Rapidly dissect up this musculo- 
 cutaneous flap, exposing the ribs and intercostal muscles. With 
 the flap held out of the way, begin the resection of the ribs by incising 
 the periosteum of the lowest rib along its middle line, the full length 
 of the exposed part. Denude the rib with the rugine. Take special 
 care in the denudation along the lower border that the artery and 
 nerve removed with the periosteum are not wounded. Divide the 
 inner and the outer end of the denuded segment. (See Operation 
 for Empyema.) Resect the other ribs exposed in the same manner. 
 
 Raise the musculo-pleural flap. Begin by dividing the upper bor- 
 der; then the lower border; and finally the anterior border, catching 
 each intercostal artery as cut. When this flap is lifted the lung 
 is exposed. 
 
 This procedure has the advantage that it can be rapidly carried 
 out; the disadvantage, that it permanently sacrifices a part of the 
 bony wall of the chest, but that is a small matter in the face of such 
 emergencies. 
 
 (2) A thoracic flap may be formed. Make the same "U"-shaped 
 incision and expose the ribs as in the preceding operation. Each 
 costal' segment is then denuded of periosteum at either end suffi- 
 ciently for the passage of the bone-cutting forceps. In this manner 
 each rib is divided at each end. 
 
 Next carefully divide the intercostal muscle parallel with, and 
 above, the first segment, and lift the anterior end of this rib, and 
 begin the separation of the pleura. 
 
 Work along the front at first, dividing the intercostal muscles and 
 arteries and ligating as necessary. The liberation of the flap along 
 the lower border next follows and, as the musculo-osseous flap is 
 more elevated, the separation of the pleura is more and more 
 facilitated. 
 
 Finally the flap is freed and turned back and the pleura is left 
 
500 URGENT THORACOTOMY 
 
 bared. The pleura is next divided and the wounded lung is now 
 freely exposed. 
 
 Wipe out the clots and search for the bleeding surface. If neces- 
 sary a hand may be slipped under the base of the lung pulling it 
 forward for inspection. 
 
 Repair the lung. The ideal method is by suture, employing a 
 No. i or 2 silk thread and passing it through the parenchyma with 
 a round curved needle. If this is not possible tamponade is the next 
 resort. If a border is lacerated and projecting it may be ligated 
 en masse and resected. 
 
 Whether or not drainage is employed depends upon the amount 
 of oozing and the probabilities of infection. If infection subse- 
 quently develops, the infected area is to be opened and drained as 
 any other empyema. 
 
 REPAIR OF INJURIES TO PERICARDIUM AND HEART 
 
 The general practitioner does not see many injuries to the heart. 
 Gunshot wounds are, of course, usually immediately fatal; so that 
 the form of cardiac injury most likely to present itself for treatment is 
 a stab wound. Occasionally the heart is lacerated by a broken rib. 
 The sudden death from cardiac wounds may occur in several ways. 
 It may occur from syncope arising from the pressure of the blood 
 within the pericardium; or the heart may be unable to contract be- 
 cause of its divided fibers and cerebral anemia follows; or shock or 
 pulmonary edema may be the immediate cause of death. 
 
 Even if death does not immediately occur, hemorrhage and in- 
 fection may later provoke a fatal issue (see Injuries to the Thorax, 
 page no). 
 
 The treatment of traumatisms of the heart and pericardium has 
 three ends in view; to combat shock, to control hemorrhage, and to 
 prevent infection. 
 
 Keep the patient absolutely quiet, lower the head, apply artificial 
 heat, give morphine in small doses (J^ gr.) hypodermically; and, 
 if there is an open wound in the chest, disinfect and dress asepti- 
 caily, but do not operate merely to disinfect. 
 
THORACOTOMY 
 
 507 
 
 If the heart is injured sufficiently to bleed, operate. The sole 
 indication, then, for operative treatment is hemorrhage. 
 
 The patient will probably die even if operated upon, but he will 
 most certainly die without the operation; so that it is our duty to 
 give him the additional chance which intervention offers. 
 
 
 fcfr^,,. 
 
 ^^^ lfMm[ 
 
 
 iw^EBBm 
 
 
 • 
 
 / 
 
 1 
 
 
 
 
 
 * ^^^t 
 *"?! 
 
 1 - Wy&c. 
 
 
 Fig. 368.— Forming the costal flap. The three ribs in the flap are divided near the sternum . 
 and the upper and lower ribs divided at the outer limit of the flap. The middle rib to 
 be fractured by raising the flap. 
 
 If the wound seems likely to have reached the heart; if there is 
 bleeding; if there is pain and precordial oppression; if there are fre- 
 quent attacks of syncope; if there are signs of increase of fluids 
 about the heart; then one is justified in believing that the heart 
 has been wounded sufficiently to produce hemorrhage and must 
 prepare immediately for the operation. There must be no delay. 
 
URGENT THORACOTOMY 
 
 Nevertheless in the haste nothing in the matter of asepsis must be 
 omitted. 
 
 The field may be hurriedly and yet sufficiently prepared by scrub- 
 bing with alcohol followed by iodine. There is little use to stop 
 the bleeding if the patient is to die later from sepsis and that he is 
 certain to do if a faulty technic is followed. 
 
 \ 
 
 
 • 
 
 Fig. 369. — Costal flap reflected. Pleura retracted. Edges of pericardial wound hel 
 in forceps and heart wound exposed. 
 
 General Anesthesia, — Ether should be employed if the patient's 
 condition will permit. 
 
 The operation proposes to make a thoracic flap, to open the 
 pericardium and expose the heart, and to repair the injury. 
 There is no operation that requires more decision, courage, and 
 self-control. 
 
 Incision. — Begin in the third intercostal space just in front of the 
 
EXPOSING THE HEART 
 
 S09 
 
 anterior axillary border and cut inward to the border of the sternum 
 abruptly curving there and following the sternal border downward 
 to the sixth Space; again abruptly curving and following that space 
 outward (Fig. 368). These incisions expose the ribs and intercostal 
 muscles. 
 
 Fig 370. — Heart supported in palm of hand preparatory to suturing. (Ajter Lejars.) 
 
 Formation of the Flap. — Divide the fourth, fifth, and sixth carti- 
 lages near the sternum and also the intercostal muscles, along the 
 line of the original incision. 
 
 At the lower outer angle of the incision, expose the sixth rib by 
 pulling the tissues upward. Incise the periosteum over its external 
 
5i° 
 
 URGENT THORACOTOMY 
 
 surface and with the rugine free the rib of periosteum and divideit 
 At the upper outer angle expose the fourth rib, free it of periosteum 
 and with the costotome or a bone-cutting forceps, divide it in the 
 same way. The flap is now attached only by the fifth rib which is 
 to be fractured. Raise the sternal end of the flap with the left hand 
 and press on the fifth rib with the right hand and with a little force 
 the rib is broken in the line of section of the other two ribs. 
 
 The flap is now gradually raised as its adhesions to the subjacent 
 structures are freed, and the pleura is exposed. 
 
 If there is a wound in the pleura, enlarging it, the pericardium may 
 be reached; otherwise proceed to the liberation and retraction of the 
 
 ; 
 
 &.H- 
 
 Fig. 371. — Suture of wound of heart. Fig. 372. — Suture of heart completed. 
 
 pleura. With a grooved director, liberate the fibrous attachments 
 of the triangularis sterni to the posterior surface of the sternum, 
 which at the same time liberates the pleura. With the fingers, draw 
 outward the free border of the pleura with its covering, the triangu- 
 laris sterni (Fig. 369). In this manner is the pericardium exposed. 
 The assistant holds the pleura with a retractor. 
 
 Incision oj 'the Pericardium. — Enlarge the wound in the pericardium 
 and in that manner expose the heart. Retract the edges of the peri- 
 cardial wounds with forceps. Locate the wound in the heart. Slip 
 the left hand under the apex and pass the first suture, and the heart 
 may be thereafter steadied by traction on the threads of the first suture 
 I r ig. 370). 
 
SUTURING THE HEART 511 
 
 Suture the wound in the heart. Use either interrupted or continuous 
 suture of catgut. There is no particular advantage in passing the 
 suture in diastole. Pass them deeply, but not to the endocardium 
 (Figs. 371, 372). 
 
 Now wipe out the pericardial cavity with sterile compresses and 
 repair the pericardium by continuous catgut suture. Next, wipe out 
 the adjacent portion of the pleural cavity, repair any part of the lung 
 that may be injured and repair the pleura without drainage. Finally, 
 replace the thoracic flaps, and suture. It is generally wise to excise 
 the tissues along the track of the wound. 
 
 No drainage is to be employed except under these circumstances: 
 if the case was operated on late and there is great probability of 
 infection, it is better to leave drainage in the pleural wound, pro- 
 jecting from the thorax at the lower angle of the skin wound; if there 
 is much oozing, it is better to leave a wick of gauze in the pleural 
 wound. 
 
 A case of successful suture by Gibbon, of Jefferson Medical 
 College, illustrates the subject (Jour. American Medical Assn., Feb. 
 10, 1906). Patient, aged thirty-eight, healthy colored man. Stab 
 wound of chest, a few moments after which he fell unconscious. An 
 hour later at the hospital his condition was very grave: unconscious, 
 cyanosed, pupils dilated, skin cold and moist, respiration rapid and 
 shallow. No pulse in the peripheral vessels and the heart sounds 
 were distant, rapid, and irregular. 
 
 Vigorous stimulation was employed with morphine and atropine 
 and his condition slightly improved. Operation about one and one- 
 half hours after the injury. Only a small quantity of ether required. 
 
 The fourth costal cartilage was found and divided and the entire 
 cartilage and a part of the rib was removed. The pericardium 
 was explored and a wound located which would only admit tip of in- 
 dex finger. This pericardial wound was enlarged and the sac emp- 
 tied of clots and liquid blood. It began rapidly to fill again. Two 
 fingers passed under the heart lifted it up into the pericardial open- 
 ing and with rapid sponging, the wound was located. It was 
 situated in the right ventricle near the auriculo-ventricular groove. 
 It bled freely, controlled by pressure; was about % inch in length. 
 The wound in the endocardium was about one-half as long. 
 
512 URGENT THORACOTOMY 
 
 A traction suture of chromicized catgut was passed through both 
 edges and by that means the heart was held in position, while four 
 Other sutures were passed and no effort was made to avoid the en- 
 docardium. A small gauze drainage was applied to the line of 
 sutures and brought out through the pericardial wound which was 
 not sutured. 
 
 During the subsequent twelve hours there was enough oozing 
 to require a change of dressing. His general condition was fairly 
 good. The second day his condition was alarming; respirations 62. 
 The gauze was found to be interfering with drainage and removed. 
 The respirations fell to 38 in a short time. 
 
 Large quantities of salt solution were given by rectum. Liquid 
 food on second day. The dressings were changed every other day. 
 SLx days after the operation the skin wound was sutured almost com- 
 pletely, the wound in the pericardium being practically healed. 
 In six weeks he returned to work completely recovered, with heart's 
 action regular and normal. 
 
 Gibbon does not advise an osteo-plastic flap unless a pleural wound 
 is demonstrated, believing it best to excise as much of the sternum 
 or cartilage or rib as may be necessary to give free access. He em- 
 phasizes the value of the traction suture, and advises the repair of 
 the pericardial wound without drainage, but would always drain the 
 external wound. 
 
 Travers (Lancet, Sept., 1906) operated upon a case in which the 
 patient was impaled upon a spike fence. The right ventricle was 
 torn, the spike penetrating the sternum to reach it. The wound 
 in the heart was closed by twenty sutures. The patient did very well 
 up to the eleventh day, when he died from heart failure, due to the 
 pressure of a slowly forming clot. 
 
 Travers notes that the suturing seemed to stimulate the flagging 
 heart. 
 
 Stewart, among the first in the United States to suture the heart 
 successfully, turned the musculo-cutaneous flap to the left and the 
 thoracic flap to the right, fracturing the cartilages near the base of the 
 sternum. 
 
 The pericardial wound was enlarged in the axis of the heart. The 
 heart wound, produced by a stab with a long, rusty pen-knife, involved 
 
SUTURING THE HEART 513 
 
 the thickness of the left anterior ventricular wall, ran parallel with the 
 axis of the heart, and was about % inch in length, was larger than 
 either the skin, pleural, or pericardial wound. The heart bled freely 
 and continuously, and resembled a mere quivering mass of muscle. 
 
 The wound was closed with a continuous silk suture, the pericardial 
 cavity cleansed and the sac sutured with silk. A gauze drain was 
 left at the lower angle. The pleural cavity was cleansed and irri- 
 gated with salt solution. The thoracic flaps were sutured with silk- 
 worm-gut and a gauze drain left also in the pleural cavity. 
 
 During the operation, which lasted about forty-five minutes, 
 24 ounces of salt solution and adrenalin were injected, and strychnin 
 and atrophin given hypodermically. 
 
 Some infection followed, and by the eighth day, the temperature 
 was 103 , pulse 150, and respiration 50. From^that time, the symp- 
 toms of sepsis gradually declined until at the end of three weeks, these 
 conditions were practically normal; at the end of the fifth week, the 
 patient was out of bed. 
 
 Stewart, discussing the operation (American Journal Med. Sci- 
 ences, Sept., 1904), notes that the size of the heart wound cannot be 
 predicted from the external wound; and concludes that the only safe 
 procedure in doubtful cases is to enlarge the wound and ascertain if it 
 penetrates the chest wall; and if there be symptoms of hemorrhage — ■ 
 of heart tamponade — -operate. 
 
 In all of these cases already mentioned, it was the ventricle which 
 required repair. Peck, of New York, describes a case in which it was 
 necessary to suture the auricle (Annals of Surgery, July, 1909). 
 
 The patient, a colored girl twenty-four years of age, was brought 
 to the hospital suffering from a stab wound over the third costal carti- 
 lage at the left border of the sternum. Her condition was grave: 
 no radial pulse; the heart sounds could not be heard; respiration faint 
 and shallow, and the extremities cold; operation begun about forty- 
 six minutes after the receipt of the injury. 
 
 A quadrangular flap of the soft parts with base external was dis- 
 sected back. The third, fourth, fifth and sixth cartilages were di- 
 vided at the sternal junction, and the third, fourth, and fifth ribs near 
 the costo-chondral junction, and the flap turned out and the internal 
 mammary ligated above and below. The pericardial wound was 
 33 
 
51 4 URGENT THORACOTOMY 
 
 near the border of the sternum, a part of which was resected with 
 rongeur forceps to give a better view. The tense pericardium was 
 incised and the clots emptied out, whereupon the radial pulse could 
 be felt. 
 
 The bleeding seemed to come from the upper part of the cavity but 
 the rapidly beating heart, churning the free blood, made it impossible 
 to locate the wound until a transverse cut in the sac gave a better 
 exposure. 
 
 Lifting the heart forward and slightly rotating it to the left, a 
 wound of the right auricle was brought into view. With each systole 
 a stream of dark blood spouted 2 or 3 inches. Four sutures of 
 chromicized catgut passed on a curved intestinal needle controlled 
 the bleeding. The pericardium was cleansed, close without drainage 
 with continuous chromic catgut suture. The cartilaginous flap was 
 carefully sutured with No. 3 chromicized gut and the soft parts with 
 catgut and silkworm-gut. No drainage was used. The operation 
 lasted sixty-five minutes, during which time 1900 C. of normal salt 
 solution was given intravenously. For the first six or seven days 
 there were signs of mild pleurisy and the temperature ranged from 
 100 to 102.8, pulse 116 to 136; but, at the end of two weeks, these 
 were practically normal, and at the end of another week, she was dis- 
 charged, quite well. 
 
 It will be observed that the incision and flap formation differed 
 with each operation, no one method can be insisted upon to the ex- 
 clusion of all others. 
 
 PUNCTURE OF THE PERICARDIUM 
 
 Puncture of the pericardium — paracentesis pericardii — is indicated 
 in those cases of hemo-pericardium and serous effusion in which 
 the accumulating fluids dangerously interfere with the functions of 
 the heart. The physical signs and the symptoms point to the nature 
 of the difficulty. The symptoms may be overlooked in those which 
 pertain to the primary infection. The patient breathes with diffi- 
 culty and complains of pain and tenderness over the heart, the pain 
 radiating down the left arm or the epigastrium; the temperature is 
 variable; there is leucocytosis. 
 
PUNCTURE OF THE PERICARDIUM 
 
 515 
 
 The physical signs are significant: The pulse is weak and rapid, 
 there is often precordial bulging; the dullness of the heart area is 
 increased the heart sounds are faint; and in some cases the first rib 
 is pushed away from the clavicle (E wart's sign). The exploratory 
 puncture will confirm the diagnosis. It is not more frequently 
 done because of the instinctive fear that one may wound the heart; 
 indeed there are three structures which may be wounded with serious 
 
 Fig. 373. — Puncture of the pericardium and pericardiotomy; vertical lines, represent the 
 anterior border of pleura and lung. The • represents sites of puncture. ■"■, line of 
 incision for, and portion of rib resected in; pericardiotomy. 
 
 consequences; the heart, the pleura, and the internal mammary 
 artery. 
 
 The puncture may be made near the sternum to the inside of the 
 internal mammary; it may be made to the outside of the internal 
 mammary, between it and the line of the lung. The latter is perhaps 
 the better (Fig. 373). 
 
 The point of entrance of the needle is in the fifth left intercostal 
 space, 6 cm. from the sternal border. Use a small trocar or an as- 
 
51 6 URGENT THORACOTOMY 
 
 pirator. Cleanse the field thoroughly. Put the patient in a half 
 reclining position on his bed and mark with the left index finger the 
 site of the puncture. 
 
 Direct the needle obliquely downward and inward and do not 
 penetrate deeper than 2.5 cm., holding the needle so as to regulate 
 its progress. 
 
 As the pericardium empties itself, gradually elevate the trocar so 
 as not to wound the heart. 
 
 PURULENT PERICARDITIS. PERICARDIOTOMY 
 
 If in addition to the physical signs pertaining to effusion, there are 
 edema of the chest wall and the symptoms of sepsis it is almost 
 certain a purulent pericarditis is to be dealt with and if the explora- 
 tory puncture demonstrates the presence of pus, the only rational 
 treatment is drainage, unless the patient is moribund. To incise 
 and empty the pericardium is the only procedure that offers any 
 hope of permanent relief. 
 
 Operation. — Begin by locating the attachment of the fifth costal 
 cartilage and the middle of the sternum. 
 
 Incision. — From the middle of the sternum horizontally outward 
 over the center of the fifth cartilage on the left side, to the costo- 
 chondral junction. Deepen the incision so as to divide all the soft 
 parts down to the cartilage. Strip back the covering of the cartilage 
 with the rugine (Fig. 373). 
 
 Resect the cartilage at its sternal junction and, gently lifting up, 
 gradually detach its coverings behind out to the junction of the rib. 
 Here it may be fractured or permanently resected. Dividing their 
 sternal attachments, retract the intercostal muscles with the arteries 
 in the space opened up and thus expose the pleura. 
 
 Detach the pleura by loosening the sternal attachments of the tri- 
 angularis which allows the pleura to be drawn outward. This 
 should be done with the finger passed under the sternum and hooked 
 around the border of the pleural sac. The pericardial sac is now 
 exposed. 
 
 Incise the pericardium, first catching up a fold between two forceps, 
 
PERICARDIOTOMY 517 
 
 and dividing it with scissors. If possible, the edges of the pericardial 
 wound should be stitched to the margin of the skin wound. 
 
 Insert gauze drainage: A rubber tube is too likely to irritate the 
 heart. This operation is often followed by recovery without any 
 impairment of the heart's action. 
 
CHAPTER III 
 EMPYEMA— PURULENT PLEURISY 
 
 Various bacteria may attack the pleura, most frequently they are 
 the pneumococcus, the streptococcus, the staphylococcus, the 
 bacillus tuberculosis, or the bacillus communi coli. 
 
 The pneumococcus is usually present in the empyema of childhood. 
 Be on your guard for empyema especially in whooping-cough. 
 
 The clinical history and the prognosis vary in different forms of 
 the disease and are directly dependent upon the form of the infection. 
 
 But, whatever the pyogenic agent, when pus has once formed in 
 the pleural cavity, it seeks for an outlet in various directions. It 
 may rupture into a bronchus and escape by the mouth, and, under 
 these circumstances, pneumothorax may ensue; it may perforate 
 the chest wall, manifesting itself as an external abscess of various 
 forms; it may open into 'the pericardium, esophagus, or stomach. 
 
 In every case, the longer relief is delayed, the greater the proba- 
 bility that the lung will be permanently collapsed or bound down 
 by adhesions. Finally, in some degree, there are always the evil 
 results of sepsis. There is every reason, then, when pus is known to 
 exist in the pleural cavity, to drain without delay. 
 
 The diagnosis rests upon the history of the case (remembering that 
 this history will vary with the form of infection), upon the pain, the 
 constitutional symptoms which are those of sepsis generally, and 
 upon the physical signs. These are: distention of the thorax ac- 
 companied perhaps by edema of the chest wall; flatness on percussion 
 and evident displacement of neighboring organs; absence of the 
 vesicular murmur, and the presence of bronchial breathing. 
 
 Taylor, of Springfield (Illinois Med. Jour., 1907), attributes the 
 most frequent source of error in diagnosis to a misconception of the 
 position assumed by the exudate. 
 
 Physicians are observed trying to establish a horizontal line for 
 
 518 
 
EXPLORATORY PUNCTURE 
 
 519 
 
 the exudate with the patient in the sitting posture, under the im- 
 pression that the fluid will follow the influence of gravity. But this 
 is the exception rather than the rule. The dullness is usually higher 
 posteriorly. The "S "-shaped line of Ellis, if present at all, is so 
 variable from day to day as to be of minor importance. Taylor 
 remarks further that the character of the fluid is often a matter of 
 doubt. Chills and variable temperature point to pus, although he 
 
 Fig. 374- — Puncture of the pleura. (Lejars.) 
 
 has seen patients recovering from pneumonia who had none of these 
 symptoms and yet carried around three pints of pus in the pleural 
 cavity. 
 
 Most of the signs and symptoms may occur as well with pleurisy 
 with effusion, and it is only by exploratory puncture that the matter 
 may be definitely determined. 
 
 Exploratory puncture, then, is the court of final resort and must 
 always be employed before deciding upon the form of treatment. 
 
520 
 
 EMPYEMA PURULENT PLEURISY 
 
 PUNCTURE OF THE PLEURA 
 
 Let the patient lie on the sound side with his shoulders elevated 
 and the arm of the affected side extended above the head, the effect 
 of which is to widen the intercostal spaces. Locate, for example, a 
 point in the axillary line and the sixth intercostal space. Freeze the 
 skin with ethyl chloride or inject a little cocaine at the site of punc- 
 ture. Press a finger into the intercostal space and locate the lower 
 border of the rib. With the finger as guide enter the needle so as to 
 avoid the rib and thrust it inward and slightly upward. One can 
 readily determine whether it has reached the pleural cavity by the 
 degree of resistance. Enough fluid, whether pus 
 or serum, will escape through the aspirating needle 
 to make its presence certain; but in order to draw 
 off any quantity an aspirator, of which Potain's 
 (Fig. 374) is the best type, must be attached. A 
 serous pleuritic effusion is relieved by aspiration. 
 Sometimes removal of even a small quantity will 
 start absorption in a case of long standing. If the 
 fluid is pus, the subsequent course of events is 
 quite different. 
 
 As has been said, every purulent pleurisy must 
 be opened as soon as possible, must be opened 
 freely and at its lower point. 
 
 In the case of a child, it suffices usually to in- 
 cise the intercostal space in order to perfect a 
 cure. In the case of the adult, it is necessary to resect a rib for 
 adequate drainage, and even then the patient may shortly die or 
 retain a chronic sinus. These possibilities should always be ex- 
 plained before the operation, necessary but disagreeable, is under- 
 taken. 
 
 Site of the Incision. — The cavity must be opened where it will drain 
 best in the recumbent position. The lowest level of the abscess can 
 be determined only by exploratory puncture; any other method is 
 useless. Having already confirmed the diagnosis by puncture, now 
 at the beginning of the operation, make another exploratory punc- 
 ture in the space next lower. If pus is found there, puncture again 
 
 Fig. 375- — Em- 
 pyema: Relation of 
 the pus cavity to 
 the chest wall and 
 lung. (Veau.) 
 
INCISION OF THE PLEURA 52 1 
 
 in the space below, and so on until no pus is found. The last punc- 
 ture producing pus will be the site of the incision. 
 
 Anatomy (Fig. 375). — The aim will be to incise parallel with the 
 rib. In going through the structures of the intercostal space, re- 
 member that the vessels and nerve lie in or near the groove in the 
 lower border of the rib. Incising any space, therefore, keep close 
 to the lower line of the space, keep near the upper border of the rib 
 forming the lower boundary of the space. If a rib is to be resected, 
 it should be denuded of its periosteum, which is loosely attached and 
 on that account easily stripped off. 
 
 EMPYEMA IN THE CASE OF A CHILD 
 
 In the case of a child, simple incision of the pleura will suffice. 
 Under general anesthesia, if the condition of the patient will permit, 
 make an incision 3 or 4 inches long, parallel with the ribs. 
 The incision traverses the skin, and beneath it a cellular layer, often 
 edematous. Next divide the muscles, letting the rib serve as a resist- 
 
 Fig. 376. — Incision of the pleura without resection of a rib. {Schwartz.) 
 
 ing plane. In front they are thin (pectoralis major) ; behind, thicker 
 (latissimus dorsi and serratus magnus). Divide them at a single 
 stroke and without concern. A small artery may need to be clamped. 
 Having exposed the rib (Fig. 376), retract the upper lip of the 
 wound and locate the upper border of the rib; below, it bounds the 
 space about to be penetrated. Following this border, incise layer 
 by layer, the intercostal muscles. There is never any serious hemor- 
 rhage. As you approach the pleura, be prepared for a sudden spurt 
 of pus, and, when the pus flows, it is evident the pleura is opened. 
 Enlarge the opening, using the left index finger as a guide. Incline 
 the patient so that the cavity may be entirely emptied. Fix the 
 drainage-tube (Fig. 382). 
 
522 EMPYEMA — PURULENT PLEURISY 
 
 EMPYFMA IN THE CASE OF AN ADULT 
 
 In the case of empyema in an adult, it is usually necessary to resect 
 a rib. One needs a bone-cutting forceps or a costotome and a curved 
 periosteal elevator or rugine in addition to the ordinary instruments. 
 
 Fig. 377- — Incision of the costal periosteum. (Veau.) 
 
 Local anesthesia is preferable and with a little patience will be 
 made to serve. Having determined the line of the incision inject 
 with novocain, intradermically. Next infiltrate the subcutaneous 
 
 Fig. 378. — Uncovering the posterior surface of the rib with rugine. (Schwartz.) 
 
 tissues along the same line. Usually after a wait of five minutes the 
 skin and fascias may be divided without pain. 
 
 An injection is next made in the periosteum and the tissues ad- 
 jacent to the site to be sectioned. With the timorous, ether may be 
 necessary but it can never be considered safe in such conditions. 
 
RESECTION OF THE RIB 523 
 
 Having determined, then, the site of incision by exploratory 
 puncture, incise the skin and muscles as in the case of a child. The 
 
 Fig. 379.- — Section of the rib. (Schwartz.) 
 
 length of the incision will equal four fingers' breadth. When the 
 rib is exposed, divide its periosteum in the middle line (Fig. 377). 
 
 The denudation of the rib is an important step. With the rugine 
 or curved periosteal elevator, uncover the upper half of the external 
 surface of the rib first and then the lower half, keeping very close to 
 
 Fig. 380. — Section of the rib. (Schwartz.) 
 
 the rib as you reach the lower border, so as not to wound the inter- 
 costal vessels or nerve, which are closely attached to the periosteum 
 and are removed with it. Finally, uncover the deep surface of the 
 rib.' Carefully slip the elevator upward between the bone and its 
 periosteum, which is loosely attached (Fig. 378). Carry the elevator 
 to one end of the section and then to the other and the part of the 
 rib to be removed is thus entirely freed from its periosteal 
 attachment. 
 
5-4 
 
 EMPYEMA — PURULENT PLEURISY 
 
 Divide the rib.- Introduce one blade of a bone forceps or costotome 
 under one end of the section to be removed and divide it (Fig. 379). 
 
 
 yi 
 
 Fig. 381 — Rib removed, pleura incised. (Veau.) 
 
 Then divide the other end (Fig. 380). The bone removed should be 
 2M to 3 inches long. The stumps should not project beyond the 
 limit of the flesh wound, else necrosis is favored. 
 
 Incise the pleura. With the rib removed, the periosteum remains 
 attached to the pleura and this periosteal layer is incised along its 
 
 Fig. 382. — Drainage of the pleural cavity. {Veau.) 
 
 Be 
 
 middle (Fig. 381), and the pleura is divided at the same time, 
 on your guard, when making the incision, for a spurt of pus. 
 
 Empty and drain the cavity. Incline the patient to one side and 
 instruct him to cough. The pus pours out, often offensively fetid. 
 Take plenty of time. Finally, wipe out the cavity with sterile gauze. 
 Irrigation is usually inadvisable; but, if used, employ only warm, 
 sterile water, salt solution, or a weak solution of peroxide. The 
 stronger antiseptics are dangerous. Do not suture the wound except 
 to cover over the projecting end of the divided rib. The difficulty 
 is to keep the wound open. 
 
DRAINAGE 525 
 
 Drainage must never be neglected. Employ two large and long 
 tubes placed in different directions and anchor with safety-pins (Fig. 
 382) or by a suture, else they may be lost in the abscess cavity. 
 
 Dressing. — This is important. Pack moist sterile or boracic 
 gauze all around the tubes, between the lips of the wound. Apply 
 an ample dressing of absorbent cotton, which covers half the thorax, 
 and hold all in place with a large flannel bandage maintained by 
 suspenders. Let the patient occupy the half-sitting position, in- 
 clined toward the affected side and supported by pillows at the 
 back. 
 
 Subsequent Care. — After a few hours, change the dressing, which is 
 usually saturated, but do not disturb the drains. Change the dress- 
 ing twice daily until the discharge diminishes and about the third 
 day withdraw, cleanse, and replace the tubes in the same place and to 
 the same depth; else look for trouble, if you fail to accomplish this. 
 
 Do not irrigate while making these dressings, unless the discharge 
 has persisted undiminished for a week and continues fetid, when it is 
 best to use a sterile wash of salt solution or dilute peroxide, which 
 is to be injected under very slight pressure. 
 
 The end results vary with the nature of the infection. 
 
 (1) The meta-pneumonic pleurisy of children is usually cured. 
 About the fifteenth day, smaller tubes may be used and are gradually 
 to be shortened as granulation proceeds. In the fortunate case, the 
 opening will close in something like two months. 
 
 (2) In tubercular pleurisy with secondary infection, cure scarcely 
 ever takes place. The patient will probably die in a few months of 
 amyloid degeneration. Even if the patient does not die soon, the 
 suppuration shows little tendency to yield. In these cases with per* 
 sistent sinus, the bismuth paste injection often hastens a cure. 
 
 (3) Streptococcic or staphylococcic pleurisy: The patient may go 
 on to death or else recovers with persistent sinus. Keep the orifice 
 open, for if the pus is allowed to accumulate, it will be necessary to 
 operate again. Keep watch on the functions of the kidney and 
 liver. Remember the frequency of metastatic abscess, as of the 
 brain, for example. 
 
 After two to four months, the case may be referred to a specialist 
 for a plastic operation. 
 
CHAPTER IV 
 URGENT CRANIECTOMY: TREPHINING 
 FRACTURE OF VAULT OF THE SKULL 
 
 
 There are two conditions which may accompany fracture of the 
 skull, singly or together, either of which demands immediate relief. 
 (See Fracture of the Skull.) 
 
 (A) The depressed fragments have contused and lacerated the 
 brain; consciousness was immediately lost and was not regained. 
 Under these circumstances, the fragments must be elevated without 
 delay. 
 
 (B) Hemorrhage has occurred within the cranial cavity and the 
 clot compresses the brain. In this case, there is a "free interval. ,, 
 The patient regains consciousness and, perhaps, for a time — two to 
 twenty-four hours — appears not to be seriously injured, but little by 
 little the signs of "compression" develop, namely: restlessness, dull- 
 ness, stupor, coma; normal pulse at first, but which finally grows slow, 
 full and bounding; and slow and stertorous breathing. Delay is 
 dangerous. The clot must be removed and the hemorrhage checked. 
 
 Nearly always it is the middle meningeal which is at fault. There 
 is in consequence an extradural hematoma. Once in a while, however, 
 the bleeding will be found to proceed from a ruptured sinus or from 
 the pial arteries and there exists at the same time an injury to the 
 brain substance. There is, in this case, an intradural or intracerebral 
 hematoma. 
 
 Whatever the form of compression, one is compelled to operate, 
 but he must first get the anatomy of the middle meningeal artery 
 clearly in mind. 
 
 The middle meningeal, a branch of the internal maxillary, is the size of the 
 radial, entering the cranial cavity at the base of the skull, through the foramen 
 spinosum. It is embedded in the dura and grooves the inner surface of the skull. 
 
 Above the level of the zygoma, the artery divides. The posterior branch 
 
 526 
 
TREPHINING 
 
 527 
 
 the smaller, is directed upward and backward, and the anterior branch (Fig. 
 383), the more important, ascends vertically to the fronto-parietal suture ; 
 which it follows upward, passing a little posterior to it. As it reaches this suture, 
 it gives off constantly a posterior branch. The anterior branch is accompanied 
 by veins which occasionally assume the importance of a sinus. 
 
 The directions for trephining over the middle meningeal are quite definite, 
 but usually unnecessary to regard in emergency surgery, for it is a mistake 
 not to follow the exterior indications and guides furnished by the traumatism. 
 Still one should be able to locate these points readily. 
 
 Two horizontal and two vertical lines are employed to locate the paths of the 
 two branches of the middle meningeal. Draw the first (A) from the inferior 
 border of the orbit along the zygoma to the external meatus. Draw the second 
 (B) from the upper border of the orbit back- 
 ward, and parallel with the first, ending be- 
 yond the line of the mastoid. To locate the 
 path of the anterior branch of the middle 
 meningeal, draw a perpendicular line from A 
 upward from a point corresponding to the 
 middle of zygoma; and where it cuts B is 
 the point most advantageous for exposing 
 the anterior branch. This vertical line is 
 about two inches in length or approximately 
 equal to the length of the last two joints of 
 the index finger. To locate the track of the 
 posterior branch: From the apex of the mas- 
 toid, draw a second vertical line upward; its 
 point of junction with B indicates the path 
 of the posterior branch. These lines may be marked off on the skin by tincture 
 of iodine. 
 
 Fig. 383. — Outline of the middle 
 meningeal artery. (Veau after 
 Cuneo.) 
 
 Operation. — -Provide, besides the ordinary instruments, Rongeur 
 forceps, a mallet and chisel, or a trephine. Carefully shave the half 
 of the head corresponding to the traumatism or, even better, the 
 whole head. Sterilize the field. Scrub with soap and water, fol- 
 lowed by ether, which in turn is followed by bichloride solution. 
 There must be no relaxation in the disinfection, whether exploration 
 is to be extensive or not, for asepsis is the best means of preventing 
 a hernia of the brain. 
 
 General Anesthesia. — -Often the sensibility is so benumbed, the 
 patient so depressed, that anesthesia is both unnecessary and danger- 
 ous. Chloroform is generally best for brain surgery, but ether is 
 safer in these urgent cases with much shock. 
 
5-'S 
 
 URGENT CRANIECTOMY! TREPHINING 
 
 Incision.— The incision will vary with the conditions. We will 
 suppose three circumstances: (a) there is an extensive skin wound; 
 (b) there is a bullet wound; (c) there is no wound of the soft parts. 
 
 (a) If there is an extensive and ragged skin wound, it is better to 
 enlarge it at once by crucial incision. This has the advantage of 
 being rapidly done, but has the disadvantage that it interferes with 
 the blood supply of the flaps (Fig. 384). 
 
 Fig. 384. — Depressed fracture of the skull. Crucial incision. (Veau.) 
 
 (b) If there is a bullet wound, make a "V '"-shaped flap with the 
 bullet wound in the center, and which retains its attachment below, 
 the better to conserve the blood supply. 
 
 (c) If there is no open wound, make the same sort of "U "-shaped 
 flap with its pedicle downward, over the site of the contusion. 
 
 Cut boldly to the bone if it is resistant. If the fragments are 
 mobile under the scalp, proceed cautiously, but do not stop until on 
 the pericranium. The incision will often traverse a zone which is 
 contused and infiltrated, the various layers being indistinguishable. 
 
 If possible, form the flaps first and then catch the bleeding points 
 
TREPHINING 
 
 5 2 9 
 
 along the edges of the flaps. In some cases it may be necessary to 
 clamp a vessel before the incisions are completed. 
 
 As soon as the bone is reached, hurriedly strip back the flaps, in- 
 cluding the periosteum. The site of the fracture is now exposed 
 (Fig. 385). One of two conditions presents: (1) there are depressed 
 fragments which must be removed, or (2) there is & fissure without de- 
 pression, but beneath the bone there is a clot to remove and a hemor- 
 rhage to check. 
 
 (1) The fragments are often superimposed in two layers and those 
 of the internal table are usually the most extensive. In some cases 
 
 Fig. 385. — Stripping back the periosteum to expose the field of fracture. (Veau.) 
 
 the fragments are easily extracted, but in others the bony fragments 
 are so wedged in that it is difficult to induce any instrument to pry 
 them loose. Failing in this, notch the sound bone along the line of 
 fracture with the chisel, and in this manner open up a way to intro- 
 duce the elevator. Be careful not to further bruise the brain in 
 extracting the fragments, employing only horizontal traction. 
 Never wrench or twist the fragments (Fig. 386). 
 
 The deeper fragments are usually adherent to the dura mater and, 
 if so, require to be stripped loose before attempting extraction. 
 
 (2) If there exists merely & fissure, it will be necessary to trephine. 
 
 34 
 
53o 
 
 URGENT CRANIECTOMY: TREPHINING 
 
 At the possible site of the hemorrhage, create an orifice in the skull, 
 either with the trephine or with mallet and chisel. 
 
 Trephine. — (A) The ordinary Gait trephine may be employed. 
 Begin by protruding its sharp point about 1/16 inch and boring it 
 into the skull at the selected site. As soon as the cutting edge of the 
 trephine has grooved the skull, retract the point, and proceed to 
 deepen the groove by rapid half-rotations of the wrist. From time 
 to time, test the groove with the point of a probe to be sure that one 
 
 Fig. 386. — Removal of the fragments. (Veau.) 
 
 side is not cutting faster than the other. If there is any difference, 
 regulate the pressure accordingly. Diminished resistance and 
 increased blood flow indicate penetration of the outer table. 
 
 The inner table is more resistant, and, when it is reached, one must 
 proceed more cautiously. When it is judged that section is com- 
 plete, the trephine may be removed and gentle effort made to elevate 
 the button. If the bone is completely divided, the button is easily 
 removed. 
 
 (B) Doyens' instrument is in less common use, but is simple and 
 efficient. It consists of a brace, a perforator, and burrs of various 
 sizes (Fig. 387). 
 
 Begin by attaching the perforator and drilling a shallow hole, 
 
DOYEN TREPHINE 53 1 
 
 steadying the brace with the left hand. The instrument must always 
 be kept perpendicular to the skull. Next replace the perforator with 
 a burr and rapidly ream out the opening begun by the perforator. As 
 before, one recognizes the approach to the diploe and the inner table. 
 
 Fig. 387. — Doyen trephine. The perforator attached to the brace is used to cut through 
 the outer table; the opening subsequently enlarged by burrs of various sizes, replacing the 
 perforator on the brace. 
 
 The burr pushes the dura before it without injury (Fig. 388). A 
 quadrilateral or circular flap may be outlined by additional openings, 
 and the chisel or rongeur used to complete the section of the flap. 
 (C) The mallet and chisel may be used and, while not so efficient 
 as the trephine, will serve the purpose. Begin 
 by cutting a narrow groove in the skull, deep- 
 ening it gradually until the inner table is 
 reached and divided. The chief point to be 
 emphasized is that the chisel is to be held 
 quite obliquely to avoid concussion and un- Fig 388 _ Doyen tre . 
 
 expected penetration. phine; showing manner in 
 
 Detach the dura mater. Whatever the means ^ the burr a PP roaches 
 
 the dura. 
 
 employed, the dura is now exposed, and if the 
 opening, which should have a diameter of at least 2 inches, needs 
 to be enlarged, the dura should be detached from the edge of 
 bone and the chisel or rongeur employed. Enlarge so as to ex- 
 pose as much as possible of the middle meningeal artery. 
 
 Treat the hemorrhage. Once the cranial cavity is well exposed, the 
 

 URGENT CRANIECTOMY: TREPHINING 
 
 next concern is the hemorrhage, (a) There is a clot to be removed; 
 (b) a bleeding vessel to control. 
 
 (a) The clot may be removed with the finger or with a dull curette. 
 The amount of the accumulated blood may be astonishing, but one 
 must work patiently. The clot must be removed to the last particle, 
 remembering that toward the base there is the greatest abundance. 
 The white and resistant dura mater must be exposed in every direc- 
 tion (Fig. 389). 
 
 (b) Next look for the bleeding vessel. A jet of blood may indicate 
 the proper point at once, and the vessel is caught with forceps and a 
 
 Fig. 389- — Removal of the clot. (Veau.) 
 
 ligature passed with a needle (Fig. 390). If the bleeding point is too 
 deep, the forceps may be left in position for twenty-four hours. 
 More often, perhaps, the source of the hemorrhage cannot be defi- 
 nitely determined and as soon as the compress is removed, the blood 
 wells up from the bottom of the cavity. Depressing the head, the 
 change in the stream's direction may reveal its source which is liable 
 to be the middle meningeal vein; it is to be caught up and ligated 
 like the artery. If the blood comes from a sinus, pack the cavity 
 with sterile gauze. The hemostasis must be complete. If there is 
 only slight, yet persistent oozing, leave a gauze tampon for twenty- 
 
 
AFTER TREATMENT 
 
 533 
 
 four hours. Suture the angles of the wound and apply a dry 
 dressing. 
 
 Another case, more rare: The dura mater is lacerated and the brain, 
 more or less contused, is exposed. Catch the edges of the dural 
 wound with forceps and, raising the membrane, gently wipe out the 
 clots with sterile gauze. 
 
 A mere slit in the dura may be repaired by catgut suture, but if 
 there is loss of tissue, it is useless to attempt suture of this inelastic 
 membrane. The hemorrhage must be cared for in the manner 
 already described. 
 
 Fig. 390. — Ligation of the middle meningeal artery. (Veau.) 
 
 Most trying are those cases presenting a subdural hematoma. Tre- 
 phining is completed and the dura is exposed, but there is no clot. 
 Instead, the dura, tense and darkened, bulges toward the orifice. 
 Make a crucial incision in the dura, or raise a flap with its base above, 
 and wipe out the exudate, usually diffused. Be very careful not to 
 give additional injury to the contused brain tissue. Leave a strip of 
 sterile gauze in the wound for drainage, removing it on the second 
 day. 
 
 After-treatment. — Following the operation, it may be necessary 
 to inject 1 or 2 quarts of salt solution in the first thirty-six 
 hours. No alcoholic stimulants must be used. Keep the patient 
 
534 urgent craniectomy: trephining 
 
 absolutely quiet, the head slightly elevated, and change the dressing 
 as often as soiled. If sepsis occurs, open up the wound. If there is 
 hernia cerebri, Treves advises a gauze pad saturated with alcohol 
 held on under light pressure. 
 
 Results. — -The patient may die without regaining consciousness, 
 owing to the shock of the traumatism, aggra ated perhaps by that 
 of the operation; for this reason, it is absolutely necessary to give 
 as little chloroform and to do the operation as rapidly as possible. 
 
 He may die the next day from persistent hemorrhage. He may 
 die between the third and eighth day from septic meningitis, due to 
 infection from the injury or the operation. Watch the course of the 
 temperature in order to forecast sepsis. 
 
 Finally, he may recover, and even then he may develop a Jack- 
 sonian epilepsy, delayed perhaps as long as ten years. 1 
 
 FRACTURE OF THE BASE OF THE SKULL 
 
 It has already been said it would seem that the only way, as cer- 
 tainly as may be, to forestall infection in fracture of the base is to 
 trephine and drain, leaving a permanent escape for microbes and 
 their toxins. If there is evidence of compression originating at the 
 base, the trephining is even more imperative. 
 
 Cushing recommends drainage through the lower temporal region 
 for the reason that very much more frequently the middle fossa is 
 involved, the middle meningeal artery ruptured, and the tip of the 
 middle cerebral lobe contused. 
 
 Operation. — -Make an incision from the middle of the zygoma di- 
 rectly upward to the temporal ridge. Clamp the divided branches of 
 the artery. Divide the temporal fascia and split the muscle in the 
 same line and cut through to the bone. Strip back the two halves 
 of the temporal by free use of the rugine. If there is a line of fracture, 
 or some indication of pressure, trephine accordingly. Otherwise, aim 
 to make the opening near the junction of the temporal with the great 
 wing of the sphenoid. An extradural hemorrhage may be brought 
 
 1 It occasionally happens that the hemorrhage occurs on the side opposite 
 the traumatism. There is nothing to do but repeat the trephining on the op- 
 posite side, for the matter cannot be determined beforehand. 
 
TREPHINING THE BASE 535 
 
 to light and a ruptured middle meningeal found. In other cases, the 
 effusion will be reached only after the dura is divided. The escape 
 of the bloody cerebrospinal fluid will be favored by passing a curved 
 blunt dissector down under the temporal lobe. If the effusion is 
 merely serous, the wound may be closed; if there is any persistence of 
 oozing, a strip of rubber tissue should be left in the lower angle of the 
 wound, extending into the cranial cavity under the temporal lobe. 
 Vincent (Revue de Chirurgie, Aug., 1909) concludes that this inter- 
 vention will reduce materially the sequelae so common to fracture of 
 the base not treated by operation. But with this conclusion the 
 majority of surgeons do not agree and the tendency is to treat these 
 cases by non-operative methods. Certainly for the general prac- 
 titioner operative procedures will remain a method only to be em- 
 ployed when focal signs of brain pressure are present. 
 
 TREPHINING THE SUBOCCIPITAL REGION 
 
 A case of Ford's illustrates this procedure: A man of fifty years 
 fell from a street-car, striking upon his head. He was only slightly 
 dazed; insisted he was not hurt and walked home. An hour later, 
 his head began to pain severely, and in the course of a couple of hours 
 he began to grow drowsy and so gradually lapsed into unconscious- 
 ness. He developed a divergent strabismus, but his pupils re- 
 mained normal and there were no signs of motor paralysis. There 
 were no marks about his head to indicate injury. 
 
 After twenty-four hours, Ford was called in. He found the pa- 
 tient still unconscious and with the pulse and respiration of com- 
 pression. He was removed to the hospital for operation. After the 
 head was shaved, a flatness was noticed below the occipital protuber- 
 ance, though there was no depression or evidence of contusion. It 
 was decided, however, to trephine over this point. A semilunar 
 incision, convex upward, mapped out a flap with the base downward, 
 and the skull was exposed. A stellated non-depressed fracture was 
 found. A trephine button removed revealed the presence of a large 
 clot. A large area of bone was removed with rongeur forceps and an 
 immense subdural clot cleaned out of the posterior fossa. A strip 
 of iodoform gauze was left for drainage. Uninterrupted recovery. 
 
53*5 urgent craniectomy: trephining 
 
 We might add that in all cases of head injury followed by compres- 
 sion symptoms, but in which there is no evidence of rupture of the 
 middle meningeal artery nor any focal symptom, the suboccipital 
 operation is preferable to the subtemporal. It will give easier and 
 safer access and more efficient drainage. 
 
 TREPHINING THE FRONTAL REGION 
 
 A case reported by Axtell, of Bellingham, Wash. (Northwest 
 Medicine, Nov., 1908), illustrates the procedure: 
 
 A laborer received a violent blow from a cable hook above the left 
 eye. In spite of the severity of the injury, the man walked a mile to 
 camp. Traveling by a logging train, by boat, and by street car, 
 nine hours later he reached the hospital, showing no indication of 
 collapse till he reached his destination. He had a marked depres- 
 sion over the left orbit, a swollen eyelid, and a protruding eyeball. 
 
 A semicircular incision extending from the bridge of the nose to the 
 external angular process exposed the shattered supraorbital ridge. 
 The orbital plate of the frontal bone was broken into fragments and 
 a large blood clot was found filling the upper and back portion of the 
 socket, forcing the eye onto the cheek. 
 
 Three lines of fracture extended from the supra-orbital ridge across 
 the frontal, which was depressed in several places. The fragments 
 of the orbital plate were removed; and, on removing the depressed 
 portions of the frontal, the dura mater and subjacent portion of the 
 brain were found mangled. The brain tissue was trimmed out, the 
 dura adjusted, and the fragment of the supra-orbital ridge that 
 remained attached to the pericranium was so turned and fastened 
 that it covered the supra-orbital ridge that had been destroyed. 
 This was retained in place by sutures passed through the skin flap 
 which was drawn into place. The recovery was uninterrupted, and 
 a year after there was nothing to indicate the injury but a puffiness 
 of the upper lid. 
 
 Trephining or Gunshot Wounds. — Every case of gunshot wound 
 of the skull must be explored; though, of course, no trephining is 
 necessary unless there is perforation of the skull or unless there are 
 evidences of gunshot fracture without perforation. 
 
TREPHINING FOR GUNSHOT 537 
 
 When it has been determined that there is perforation, raise a flap 
 of the scalp with the bullet wound in the center, as has been already 
 described. The flap must be larger than the possible trephine open- 
 ing in the skull. Enlarge the opening in the skull with trephine, 
 chisel and mallet, or with rongeur forceps. Remove all fragments of 
 bone and foreign matter, wipe out the dural and cerebral wounds with 
 sterile gauze. Be patient and persistent in this cleansing. Do not 
 explore the bullet track or attempt to remove the bullet unless, of 
 course, it is within easy reach. A case operated by the author illus- 
 trates the matter. 
 
 A countryman was shot in the top of the head with a 38 revolver 
 by a circus employee, the outcome of a drunken brawl. He was 
 carted home to die but after forty-eight hours he was still alive and 
 surgical aid was called. He had never regained consciousness and 
 he had the pulse and respiration of compression. His kitchen was 
 converted into an operating room and the skull trephined. The 
 bullet ranged from the center of the vault through the brain to the 
 base. Through the ragged hole in the brain the bullet could be felt 
 and was removed only to be followed by serious hemorrhage, con- 
 trolled by packing with a long strip of iodoform gauze which was 
 brought out through the bullet opening in the skin flap in the 
 course of repair. 
 
 In an hour after the operation the patient was conscious, his pulse 
 and respiration much improved. In a few hours, however, he grew 
 restless, and his temperature and pulse rate began to rise and at 
 the end of twenty-four hours he was in active delirium. 
 
 The gauze packing was removed followed almost immediately by 
 improvement. There was only slight oozing from the wound which 
 proceeded to repair without the least sign of infection. 
 
 The man's recovery was rapid and apparently complete, except 
 that for some time he had slight disturbance of sight due possibly 
 to some traumatism of the visual centers in the occipital lobes. 
 
CHAPTER V 
 MASTOID ABSCESS 
 
 The tympanum, and likewise its accessory cavities, are normally 
 sterile, but there are two highways by which infection may reac 
 this site; the Eustachian tube, and the external auditory canal. Th 
 Eustachian canal is the much more common route, the infection first 
 gaining a foothold in the mucous membrane of the naso-pharynx, 
 so that an inflammation of the mucosa of the middle ear is often only 
 a step further in the ordinary pharyngeal catarrhal process. 
 
 Finally, the catarrhal inflammation may become a purulent one, 
 in either case, running an acute or chronic course. Again, the pyo- 
 genic germ may not long limit its operation to the tympanum; but 
 eventually invades the pneumatic spaces adjacent, the antrum and 
 mastoid cells; and then there may develop a mastoid abscess, a con- 
 dition full of potential danger. The thin roof of the middle ear is the 
 dividing line between the posterior and middle cerebral fossae, and 
 through it, infection may reach the cerebellum or the middle lobe 
 of the cerebrum. Meningitis, epidural, cerebral, or cerebellar abscess 
 is the immediate result. 
 
 The mastoid cells are separated from the lateral sinus by a bony 
 partition, so that through the small venous channels or by necrosis 
 of the bony wall, infection may reach the sinus. Finally, general 
 infection and sinus thrombosis may ensue, followed perhaps by 
 metastatic abscess. 
 
 These are the actual dangers of mastoid abscess and one can never 
 tell how fast the pathological process may extend, aided by bone ero- 
 sion or by the escape of the infectious matter through apertures in 
 the bone or by way of the blood vessels and lymphatics. 
 
 Acute purulent mastoiditis , then, is an emergency, and every doctor 
 should feel himself prepared to trephine the mastoid if it beomes his 
 duty, and it is his duty if no one more skilled is at hand. 
 
 How shall one recognize this emergency? 
 
 538 
 
 i 
 
PARACENTESIS 539 
 
 The pain, sleeplessness, prostration, fever, together with the his- 
 tory of the case, point with a great degree of probability to the nature 
 of the trouble. Now, if the examination adds certain other signs to 
 these symptoms, the indications for intervention are definite: 
 
 (1) You find the upper and posterior quadrant of the ear drum 
 (Shrapnell's membrane) bulging and perhaps the superior and poste- 
 rior walls of the canal are swollen. 
 
 (2) You find persistent tenderness over the mastoid process. 
 
 (3) You may observe that a previously free discharge has suddenly 
 diminished and this is an added warning that delay is dangerous. 
 
 To repeat, the cardinal symptoms are pain, redness, swell- 
 ing, bulging of the drum, and fever. The first thing to do is a para- 
 centesis. 
 
 PARACENTESIS 
 
 Douche the auditory canal gently with warm, sterile water; co- 
 cainize the canal with a 10 per cent, solution and wait five or ten 
 minutes. With the otoscope, expose the drum and locate the bulging 
 area. Puncture it with a small pointed bistoury making an incision 
 3 or 4 mm. long, downward and forward. 
 
 There is nothing to fear. Even if the drum has spontaneously 
 ruptured, it is often an advantage to enlarge the opening. Usually 
 a few drops of pus escape. Follow with irrigation. 
 
 If, at the end of twenty-four hours, the symptoms have not sub- 
 sided, proceed without further delay to trephine the mastoid. 
 
 OPERATION FOR MASTOID ABSCESS 
 
 The operation is easy and without much danger if one but knows 
 the anatomy (Fig. 395). The sigmoid sinus is more shallow in chil- 
 dren than adults. Recall the situation of the spine of Henle, the 
 facial nerve, and the lateral sinus. The spine of Henle marks 
 the upper limit of the external meatus; 34 inch above it is the 
 middle cerebral fossa; the mastoid antrum is ^ inch posterior. 
 
 Shave the temporo-parietal region and scrupulously prepare the 
 field. General anesthesia is indispensable. 
 
 Special instruments necessary are a Macewen seeker, a chisel (i 
 
S4o 
 
 MASTOID ABSCESS 
 
 Fig. 391. — Landmarks of the mastoid. The square represents the area to be trephined; 
 the dotted lines, the course of the lateral sinus. (Veau.) 
 
 Fig. 392. — Incision for mastoid operation. {Veau*) 
 
TREPHINING THE MASTOID 
 
 541 
 
 cm. wide), a small gouge, mallet, curette, curved periosteal 
 elevator, and probe. 
 
 Incision (Fig. 392). — Begin at the apex of the mastoid and follow 
 the curve of the external ear to the level of its attachment above. 
 This incision reaches to the bone; and, when operating on children, 
 be careful not to cut through the bone. Catch the bleeding vessels 
 in the gaping wound. Rapidly denude the bone, an undertak- 
 
 Fig. 303. — Denuding the mastoid with the rugine. (Veau.) 
 
 ing somewhat difficult below where the sterno-mastoid is attached 
 
 ( Fi g- 393). 
 
 Introduce a sound into the external auditory canal to determine 
 its direction. Expose the spine of Henle. 
 
 Trephine. Start the chisel vertically 5 mm. behind the 
 meatus; two or three slight blows of the mallet will be sufficient. 
 In a child, a bistoury may be used. Make the second trace with the 
 chisel horizontal and on a level with the spine of Henle. The third 
 is parallel with the second, and finally the fourth, parallel with the 
 first, completes the outline of chip. This fourth line of section is 
 
542 MASTOID ABSCESS 
 
 in the danger area, nearly over the lateral sinus. In making it, hold 
 the chisel obliquely instead of vertically as in the first (Fig. 394). By 
 slight and rapid blows, remove this chip. 
 
 Fig. 394. —Outlining the chip to be removed. (Veau.) 
 
 Fig. 395. — Exposing the lower mastoid cells. (Veau.) 
 
 If this does not expose the cells, deepen the opening carefully with 
 the gouge. Pus will often be found at the first incision into the bony 
 wall. 
 
HNJU.KX jlu ini« j-rAij^jte^i^ aiiNua ^4^ 
 
 Introduce a seeker or blunt probe, which will locate the various 
 cavities and canals leading to the cells of the mastoid and antrum. 
 Their coverings are then chipped off, or they may be merely curetted. 
 
 Chisel below first (Fig. 395), and then, with the guide, locate the 
 posterior limit of the cells and chisel off the bone lying over the point 
 of the guide. A trough may be trephined downward toward the tip. 
 Remember that posteriorly there is the lateral sinus (Fig. 396). Do 
 not stop until all the cells are freely exposed. 
 
 Fig. 396. — Exposing the posterior cells. The lateral sinus must be avoided. (Veau.) 
 
 When the mastoid cells are thus opened up, it remains to expose 
 the antrum (Fig. 397). It lies in the direction upward and forward 
 at what seems a considerable depth, 1 to 3 cm. Locate the 
 cavity with the guide, and enlarge freely. The mastoid cells and 
 the antrum are now a single cavity. Carefully curette the necrosed 
 bone and fungosities, but be very careful when curetting over the 
 posterior wall, for the lateral sinus may be exposed. Throughout 
 the operation, one may be disturbed by the hemorrhage, always con- 
 siderable, and it will be necessary to sponge continually, for it is in- 
 dispensable that one see what he is doing. 
 
 Certain accidents may occur in the course of the operation. 
 
 (1) The lateral sinus may be wounded, immediately recognized 
 by the excessive hemorrhage; but do not be perturbed, for it is easy 
 
J44 
 
 MASTOID ABSCESS 
 
 to arrest the bleeding. Pack the point or apply hot moist applica- 
 tions with sterile gauze and continue the operation. If you find 
 thrombosis, it will be necessary to open the sinus. 
 
 (2) The cranial cavity may be opened, but neither is this particu- 
 larly serious. However, you should avoid, if possible, an injury 
 to the meninges, for there is danger of infection. Chisel discreetly, 
 therefore, at the upper angle of the opening. 
 
 If you do wound the dura, disinfect and tampon, but do not 
 attempt suture. It is scarcely possible at that depth in a cavity so 
 narrow. 
 
 Fig. 397. — The operation completed, the guide is in the antrum. (Veau.) 
 
 The facial nerve may get in the way, and if wounded, that is indeed 
 a serious matter, for you can do nothing to remedy it. It is deeply 
 situated and if you follow the guide, you are scarcely likely to reach it 
 with the gouge. It is almost certain to be injured if the mastoid is 
 fractured in the course of the trephining, and this will happen if the 
 mallet and chisel are recklessly used. Injury to the facial nerve is 
 really the one danger of the operation. Close approach is indicated 
 by twitching of the facial muscles, and for this the anesthetist should 
 be instructed to watch while you are working in the nerve zone. 
 
 Dressing and Subsequent Treatment. — Partially suture the wound 
 and pack with iodoform gauze. The dressings are as important as the 
 operation. If neglected, a fistula may form or the suppuration may 
 
POST-OPERATIVE TREATMENT 545 
 
 recur. Instruct the patient that repair may require six to eight 
 weeks, or longer. 
 
 On the second day after the operation, remove the gauze and irri- 
 gate with warm sterile water, dry carefully and repack methodically 
 so that all the diverticula are filled. They must not be allowed to close 
 over. Granulation from the bottom is indispensable. 
 
 Change the dressing every other day. Repress excessive granula- 
 tion with tincture of iodine or nitrate of silver. 
 
 Keep the patient in bed for one week; keep the bowels open, and 
 regulate the diet. 
 
 3S 
 
CHAPTER VI 
 GENERAL TECHNIC OF LAPAROTOMY 
 
 Since so many urgent conditions require a laparotomy, every doc- 
 tor should be familiar with the general technic of the procedure with- 
 out regard to any particular purpose for which the abdomen may be 
 opened. 
 
 For the purpose of ready review, the various difficulties and their 
 management and the after-treatment are briefly outlined. 
 
 Preparation of the Patient. — Whenever possible, the patient should 
 be under a preliminary treatment for two or three days in order that 
 the bowels may be thoroughly cleansed, the field of operation ster- 
 ilized with certainty, and the functions of the organs noted. In 
 emergency work, these details cannot, of course, be so definitely 
 regulated, but to omit any of them is a handicap. 
 
 To have the bowels emptied by castor oil and enemata is the best 
 prophylaxis against meteorism, which may be a source of embarrass- 
 ment to the operator in the course of the operation, and a source of 
 discomfort and perhaps danger to the patient subsequently. 
 
 However urgent the operation may be, the sterilization of the field 
 must be definite, even though the methods be abbreviated. To 
 scrub with soap and water, shave, wash with alcohol or ether to 
 remove the oils, and finally bathe with bichloride solution and cover 
 with bichloride compresses until ready to make the incision is to 
 realize a practical asepsis so far as the skin is concerned; or the ster- 
 ilization may be even more rapidly accomplished by washing, the 
 skin with alcohol and ether, shaving and drying; and then painting 
 with tincture of iodine. 
 
 To have a definite knowledge of the patient's temperament, of the 
 action of his circulation and respiratory organs and of his kidneys 
 is to forestall many difficulties and dangers. At least, a full stomach 
 should be washed out, and the bladder emptied before the operation is 
 
 546 
 
TECHNIC OF LAPAROTOMY 547 
 
 begun. After the skin is prepared and before the incision is made, 
 the field is covered with sterile towels and the whole body with a 
 sterile sheet, split over the site of the proposed incision. Small 
 towel clamps may be used in fastening the towels to the skin. 
 
 Incision. — -The operator may stand on either side. It is preferable 
 to stand to the patient's right and cut from above toward the pubes, 
 supposing a median laparotomy. 
 
 The skin and subcutaneous fatty tissues are divided first. Clamp 
 the small vessels and gently sponge. In the case of abscess and 
 chronic inflammation, the bleeding is likely to be rather free but 
 never dangerous. 
 
 The aponeurosis, when possible, should be divided in the linea alba, 
 because the bleeding will be less and the access to the peritoneum 
 readier. If made on either side of the middle line, the incision opens 
 into the sheath of the rectus, whose inner border should be displaced 
 to the outer side or its fibers split. The edges of this fascia should be 
 caught with forceps in order to be more readily recognized in the 
 course of repair. 
 
 The peritoneum is now exposed, covered usually by fatty areolar 
 tissue, more or less thick and which may confuse the novice, but it is 
 to be cut through without fear until the peritoneum itself appears. 
 Catch up a fold of it between two forceps and make a small opening 
 with either knife or scissors, using caution not to cut into the bowel 
 or omentum. 
 
 The lips of the peritoneal wound are controlled with forceps which 
 are to be left attached; and now enlarge the opening in either direc- 
 tion, using the finger as a guide and as a protection to the bowel. 
 Approaching the pubes, guard against wounding the bladder, of which 
 there is no danger if it has been previously emptied. In any event, it 
 can be readily located by the sense of touch. 
 
 Protect the Cut Surfaces. — When the peritoneum is opened to the 
 necessary extent, apply two wide compresses of gauze, so as to com- 
 pletely cover the incisions and attached forceps, tucking the edge of 
 each compress under either side of the peritoneum. This is to 
 diminish the chances of infection and to prevent bruising the 
 peritoneum. 
 
 In like manner, and for the same purpose, the parts that are to be 
 
GENERAL TECHNIC OF LAPAROTOMY 
 
 dealt with are packed off from adjacent structures with large com- 
 es which are not only more efficient than small ones, but also are 
 less likely to be lost within the peritoneal cavity. The surgeon or a 
 responsible assistant must always know how many compresses 
 are brought into use, and they must be accounted for before the 
 cavity is closed. It is remarkable how easily a large compress may 
 be lost to sight in the abdominal cavity. It is an added precaution 
 to have a tape sewed to each compress, to which a forceps is applied 
 after the compress is placed. 
 
 The aim is completely to isolate the part operated on, and once this 
 packing is complete the compresses are not to be removed until the 
 operation is finished. If infection is present it is well to have two or 
 three layers of compresses so that the soiled ones may be removed 
 without the bowel being allowed to project into the field. In pelvic 
 operations the Trendelenburg position is of great advantage, per- 
 mitting the bowel the more readily to be displaced and packed off. 
 
 Management of Peritoneal Adhesions. — The novice and even the 
 most practised surgeon may experience the greatest difficulty in sepa- 
 rating adherent organs, their peritoneal surfaces glued together as 
 the result of inflammation. 
 
 In the case of recent adhesions, they are soft and easily broken. 
 In other cases, they consist of bands which need only be divided 
 with scissors; but finally they may bind together large areas of adja- 
 cent structures so as often to render them indistinguishable. 
 
 Even here with a little patience one may often find a plane of 
 cleavage, especially if the parietal peritoneum is involved. If the 
 organ cannot be separated from the parietal peritoneum, a segment 
 of this latter is to be cut out and left attached to the viscus concerned. 
 In the case of the omentum it is to be ligated twice and cut between. 
 In the case of the intestine, the greatest care must be used not to 
 break through its wall. 
 
 In general, intestinal adhesions discovered in the course of opera- 
 tion are not to be broken up except as they interfere with the work in 
 hand or are likely to obstruct the bowel. 
 
 If no plane of cleavage can be found, then the other organ involved 
 must be deprived of its peritoneal coat to protect the gut. If the sur- 
 face of the intestinal loop is left raw after the separation, the Lembert 
 
DRAINAGE AFTER LAPAROTOMY 549 
 
 suture should be employed. If the bowel wall is torn through, it 
 must be repaired by two rows of suture, a through-and-through and 
 a Lembert suture. 
 
 Hemorrhage. — The visceral blood supply is complex; to have its 
 anatomy clearly in mind is a great advantage in the case of hemor- 
 rhage from larger vessels. To locate the vessel at fault, to clamp it 
 and ligate quickly, speeds the operation. Capillary oozing can 
 generally be controlled by a few moments' application of hot com- 
 presses. A compress wet with alcohol will often promptly check free 
 bleeding. If the oozing is persistent at the end of the operation and 
 measures applied have failed to check it, the abdomen must not be 
 closed without drainage. 
 
 To insure against recurrence of hemorrhage as well as to prevent 
 infection and adhesions, all raw surfaces should be covered over with 
 a peritoneal coat. It is never desirable and seldom necessary to 
 leave a denuded area in the peritoneal cavity. Use of the Lembert 
 suture and of the free omentum enables one to obliterate them. 
 Such as must be left should be sprinkled with aristol. 
 
 Drainage. — The old dictum, "When in doubt, drain," does not 
 apply with such force to laparotomy as formerly. In fact, there are 
 those bold enough to say, "When in doubt do not drain." Still it 
 must be admitted that, in spite of drawbacks, drainage is a real 
 safeguard against infection. One should drain, then, when any sep- 
 tic process is present or is likely to develop, as in the case of per- 
 forating wounds of the intestine. 
 
 Drainage must be employed whenever it is impossible to control 
 bleeding from raw surfaces. If there is no infective process present 
 in the peritoneal cavity, if there is no obvious reason for any to 
 develop later, the abdomen is to be closed completely. 
 
 The preferable method of draining the abdominal cavity is by 
 rubber tubes. This is the only method available if pus is present. 
 If the main object is to get rid of blood, then the tube should contain 
 a wick of gauze which should rest upon the oozing surface that it may 
 serve the double purpose of hemostasis and drainage. 
 
 As soon as the oozing has ceased the gauze wick is to be withdrawn 
 and usually it is ineffective after twenty-four hours. The removal 
 of gauze drains is often difficult and the traction must be gentle. 
 
;^o 
 
 GENERAL TECHNIC OF LAPAROTOMY 
 
 The tubal drains are to be removed as soon as the danger of sepsis 
 is passed, which is usually after the third day. If at this time 
 infection has developed the tube is withdrawn, sterilized, and replaced 
 and so on daily thereafter until the suppuration is under control. It 
 is in these cases that Balsam Peru is of service in checking the pus 
 formation. 
 
 Repair of the Abdominal Wall. — -Suppose the operation complete. 
 The final inspection of ligatures and sutures is made, the cavity is 
 
 
 m. 
 
 Fig. 398. — Repair of the abdo- 
 minal wall. Peritoneum sutured. 
 Continuous suture of recti and fas- 
 cia begun. (Guibe.) 
 
 Fig. 399. — Fascia repaired. In- 
 terrupted skin sutures placed, ready 
 to tie. 
 
 wiped out, the compresses are removed and counted, the vessels in 
 the abdominal wall that were clamped are ligated, if necessary, and 
 repair of the abdominal wall is begun. 
 
 The peritoneum, to which the forceps still remain attached, is 
 pulled up into view. If the Trendelenburg position has been used, 
 the table is now brought to the horizontal; the intestines are brought 
 back into place, the omentum spread out over them, and a compress 
 applied to protect the bowel while the peritoneum is repaired with a 
 
POST-OPERATIVE TREATMENT 551 
 
 continuous No. i catgut suture. The compress is withdrawn before 
 the last two or three stitches are passed. 
 
 The aponeurosis and muscles are now repaired with continuous 
 chromic gut suture (Fig. 398). 
 
 The skin, finally, is to be repaired with interrupted silkworm-gut 
 sutures, passing some of them deep enough to include the muscles and 
 aponeurosis so as to obliterate any dead spaces. If coaptation is 
 not perfect, a few superficial catgut sutures may be used as necessary. 
 One may close the skin simply by the continuous catgut or chromic 
 gut suture or, as many prefer, by the subcuticular stitch (Fig. 399). 
 
 Of course, if drainage has been employed, the closure cannot be 
 complete, though the suturing is to be carried close up to the tube. 
 In case great haste is required, the abdomen may be closed by 
 through-and-through sutures of silkworm-gut. 
 
 After-treatment. — -In the uncomplicated case, the after-treatment is 
 simple. The patient is put to bed with hot- water bottles at his feet 
 and provision made for proper ventilation. Fresh air is of the utmost 
 importance. As he recovers from the anesthetic, he is given water 
 cautiously for the first twenty-four hours. After that, liquid nour- 
 ishment should be given in small quantities at frequent intervals. 
 The bowels should be moved on the second day by a light soapsuds 
 enema. 
 
 It is rare, however, that these patients do not have some complica- 
 tion. If there was much shock or much hemorrhage, or if the anes- 
 thesia was prolonged, give normal solution by one of the three 
 methods, hot coffee by the rectum and whatever cardiac stimulant 
 may seem indicated, strychnia, brandy, or camphorated oil. 
 
 If the pain is severe, small doses of morphine hypodermically should 
 be given until the patient is comfortable. 
 
 If there is much nausea, try a glass of warm soda-water which will 
 probably be thrown up, and thus washes out the stomach. If the 
 nausea is quite severe, wash out the stomach and put the patient in a 
 half-sitting position. If the thirst is extreme along with vomiting, 
 enemas of normal salt solution give the most relief. 
 
 Sometimes 5-15 minims of aromatic spirits of ammonia, given 
 hypodermically, tend to relieve the nausea, while acting as a diffusi- 
 ble stimulant. 
 
GENERAL TECHNIC OF LAPAROTOMY 
 
 If there is much flatulence or meteor ism, give minute doses of calo- 
 mel and empty the bowel with soapsuds enema. If this does not 
 give relief, the enema consisting of 2 ounces of Epsom salts and 
 glycerin and 1 ounce of turpentine may be employed. 
 
 a 1 cute J ilatation of the stomach must be watched for. If discovered 
 at once and properly treated it is not a serious complication. Other- 
 wise it may be a large factor in determining a fatality. 
 
 Gastric lavage with alkaline solutions, followed by small doses of 
 calomel, usually speedily controls this complication. 
 
 A special line of treatment is required if post-operative ileus develops 
 (see page 586). 
 
CHAPTER VII 
 LAPAROTOMY FOR TRAUMATISM 
 
 The indications for laparotomy following traumatism are as follows : 
 i. Perforating gunshot wounds. 
 
 2. Perforating stab wounds likely to have wounded a viscus. 
 
 3. Contusions of the abdomen presenting symptoms of dangerous 
 lesions of abdominal viscera or vessels; not always definite, but 
 operate at once if you find these appearances following contusions : 
 
 (a) The abdominal walls are resistant some distance from the in- 
 jury; a progressive meteorism reaching the hepatic region; dullness 
 over the iliac fossae or the flanks, indicating hemorrhage. 
 
 (b) The pulse is weak and rapid, and growing worse. 
 
 (c) The general condition of the patient is alarming, pallor, pain, 
 excitement or delirium, subnormal temperature. 
 
 But whether it be an open wound or a contusion, do not wait for 
 the symptoms of peritonitis, for it will then likely be too late. The 
 operation is delicate and dangerous in the hands of the unskilled, 
 and yet the patient's life depends upon it. There is no time to send 
 for a specialist unless he is right at hand, and, as Veau says, it is 
 better for the patient to be operated on early by an inexperienced 
 surgeon than to be operated on too late by the best surgeon in the 
 land. It is an intervention in which one never knows what he is 
 going to find. 
 
 The steps of the operation are: 
 
 (1) A laparotomy. 
 
 (2) Search for the hemorrhage if there is blood in the abdomen. 
 
 (3) Search for visceral injuries. 
 
 General anesthesia is indispensable, and ether is preferable unless 
 compelled to operate in close quarters by lamp light. Every pre- 
 caution must be taken not to aggravate shock; the limbs should be 
 wrapped and the chest protected. The whole anterior abdominal 
 
 553 
 
554 
 
 LAPAROTOMY FOR TRAUMATISM 
 
 wall must be sterilized. Be prepared for normal salt injections, 
 often necessary throughout the operation. 
 
 (i) Laparotomy. Whatever be the site of the wound or contusion, 
 make an incision in the middle line; below the umbilicus, usually; 
 above, if the injury points to the epigastrium. The incision at first 
 should be about 3 inches long. It will be necessary to extend 
 it if the preliminary examination reveals visceral injuries. Divide 
 the skin and fatty tissues and catch up the bleeding vessels. Look 
 
 for the linea alba, but if not readily 
 found, go through the muscle; it does 
 not greatly matter. Divide the 
 transversalis fascia and expose the 
 subperitoneal fatty tissue. It may 
 be quite thick. 
 
 The peritoneum will probably not 
 be recognized by its appearance, but 
 rather by observing the tissues gone 
 through. It is usually bulging. 
 One may be able to see free blood 
 in the cavity by reason of its trans- 
 parency. 
 
 Catch up the peritoneum with 
 dissecting forceps and incise the cone 
 thus formed, with the cutting-edge 
 of the scalpel turned away from the abdominal cavity, that the 
 bowel may not be wounded (Fig. 400). Enlarge the small open- 
 ing thus created, and direct the assistant to seize the lips of the 
 peritoneal wound with forceps. 
 
 Pay no attention to the blood which may pour out, but proceed 
 rapidly to elongate the peritoneal wound with the scissors, protect- 
 ing the bowel with the left index finger (Fig. 401). Remember the 
 peritoneum envelops the bladder, so do not open the peritoneum 
 down to the pubes, although the skin wound should be carried thus 
 far in order to give the best view (Fig. 402). 
 
 Carefully catch up the lips of the peritoneal wound with forceps 
 which may also serve as retractors; such control of the peritoneum 
 will also facilitate its suturing at the end of the operation. It may 
 
 Fig. 400. — Incising the fold of 
 peritoneum. (GuibeJ) 
 
SOURCES OF HEMORRHAGE 
 
 555 
 
 now be necessary to push the anesthesia a little if there is much 
 resistance. 
 
 (2) Locate and check the hemorrhage. Do not be in a hurry to 
 put a hand in the cavity but observe closely, sponging gently. The 
 character of the fluids may be helpful in diagnosis. The examining 
 
 Fig. 401. — Enlarging the peritoneal opening with the scissors on the index finger 
 to guide. (Guibe,) 
 
 finger may detect lesions, or the injured viscera may push up into 
 the wound. 
 
 The hemorrhage may come from the following: (a) omentum; 
 (b) mesentery; (c) the vascular organs, liver, spleen, kidney; (d) 
 the vessels of the posterior abdominal wall. 
 
 (a) The great omentum should be gently lifted out of the cavity. 
 
556 
 
 7 APAROTOMY FOR TRAUMATISM 
 
 It may contain a hematoma and the divided vessels be hard to find. 
 Tie them with No. 2 catgut. If the omentum is torn and lacerated, 
 t the injured portion (Fig. 410). It may be split; the large 
 sels opened must be tied; the small will be controlled by the con- 
 tinuous suture, which should reunite the edges of the wound. If the 
 
 \ . I 
 
 .<''•.•. 
 
 Fig. 402. — Enlarging the opening toward the pubes, the bladder must not be 
 wounded. (Guibe.) 
 
 omentum is detached from the greater curvature, the stomach should 
 be exposed, and the omentum sutured thereto. 
 
 (b) The hemorrhage from the mesentery may be arrested in the 
 same manner, though one may not find it until in the course of in- 
 specting the gut. Mesenteric wounds often exist without visceral 
 injury. In suturing the tear, the needle must be passed close to the 
 
 
WOUNDS OF THE BOWEL 557 
 
 edges of the wound so that no vessel may be wounded or included in 
 the tie. 
 
 If its attachment to the bowel is disturbed for, say, more than 3 
 inches or if it is necessary to tie a branch as large as the radial, the 
 integrity of the corresponding section of gut is compromised and it 
 will be advisable to resect. If unable to do that, treat it as the 
 doubtful bowel is treated in strangulated hernia (see page 609). 
 
 (c) If the hemorrhage proceeds from a wound of the liver, spleen, 
 or kidney, tampon methodically and firmly with sterile gauze. 
 
 If the liver is ruptured extensively and tamponade has no effect, 
 try deep suturing. If this does not succeed, the wound is probably 
 beyond surgical aid. 
 
 If the spleen is extensively lacerated, remove it (see page 549). 
 
 (d) If the vessels of the posterior abdominal wall are involved or 
 the splenic, mesenteric, or renal, it will often be very difficult to 
 find the starting-point of the hemorrhage, for it is in the midst of a 
 great clot. Begin by applying a large compress to the suspected 
 point and make firm pressure. Following this, rapidly wipe out 
 all the clots and reapply the compress. Raise its edge gradually 
 and as each bleeding point appears, clamp it. It will often be im- 
 possible to ligate at that depth and forceps are left attached. The 
 forceps are to remain twenty-four to thirty-six hours. These must 
 be removed without violence. 
 
 (3) Wounds of the Intestine: Do not forget that intestinal per- 
 forations are often multiple, are usually so after gunshot wounds, so 
 that it is absolutely necessary to inspect the whole intestine that no 
 wound may be overlooked. 
 
 (A) Examination of the Bowel. — The procedure must be methodical. 
 Do not pick up first one segment and then another indiscriminately; 
 in this way one part may be examined several times and another part 
 not at all. 
 
 Begin by picking up with forceps any part of the bowel that may 
 present; these forceps will serve as a starting-point and landmark. 
 It will not hurt the bowel with its pressure, as it includes in its hold 
 only the serous and muscular coats (Fig. 403). 
 
 Begin at this point, then, pulling up to view segment after seg- 
 ment, and as it is inspected, return it to the cavity. The ma- 
 
5S8 
 
 LAPAROTOMY FOR TRAUMATISM 
 
 Deliver may be attended with difficulty especially if one is compelled 
 to operate late, when peritonitis has begun and the partially paralyzed 
 bowel is greatly distended. If several folds of the bowel should 
 
 ipe and there is difficulty in returning them, the procedure as 
 
 cribed on page 131 will be helpful. 
 
 1 
 
 Fig. 403. — Examining the bowel. (Veau.) 
 
 Begin by lifting up the abdominal wall by means of the retractors. 
 Cover the refractory mass with a wide compress and then tuck each 
 border of the compress into the wound, gradually working it into the 
 abdominal cavity. It will carry the bowel along. Then carefully 
 withdraw the compress. 
 
 Examining thus the small intestine, one of its fixed points will 
 finally be reached, either the cecum or the duodenum; return then 
 to the forceps and work in the other direction. 1 
 
 1 In the case of gunshot wounds penetrating the abdomen from behind, the 
 difficulties in locating the injuries may be greatly increased, a fact illustrated by 
 the following case: 
 
 A colored man was brought to the City Hospital with a gunshot wound in the 
 back, the bullet entering the right lumbar region about 2 inches from the 
 middle line. Progressive abdominal distention and tenderness with symptoms 
 morrhage pointed to a visceral injury. He was immediately operated upon; 
 the abdomen was opened below the umbilicus. The pelvis contained consider- 
 able blood, but there was not the quantity expected. A systematic examination 
 of the intestine from the cecum to the duodeno-jejunal juncture revealed no per- 
 
REPAIR OF THE INTESTINE 
 
 559 
 
 Whenever a perforation is found, it must be repaired before look- 
 ing further. 
 
 (B) Repair of the Intestinal Wound. — -When an intestinal wound 
 is located, seize its edges with two forceps, including only the serous 
 and muscular coats, draw the part outside the cavity and isolate it 
 with compresses and then suture. 
 
 (a) Non-perforating wounds are sufficiently repaired by two or 
 three Lembert sutures. 
 
 (b) Small perforating wounds, such as bullet wounds, must be 
 
 Fig. 404. — The inclusive suture passed; tied and Lembert suture passed ;JLembert tied. 
 
 repaired by suture in two layers (Fig. 404). With fine silk, No 1, 
 make a suture which includes all three coats, serous, muscular and 
 mucous (Fig. 405). If the wound is longer than two- thirds of an 
 inch use two such sutures, etc. These sutures are to be covered in 
 and buried by the second layer, which involves only the serous coat 
 (Lembert suture). In introducing them, begin at least % inch 
 
 foration. No opening in the posterior abdominal wall could be found below the 
 level of the umbilicus. The incision was extended and the examining finger 
 located a tear behind the stomach. At this time the patient's condition grew so 
 bad it was necessary to cease the search and before the abdomen could be com- 
 pletely closed, he died. 
 
 The post-mortem revealed a long tear in the transverse portion of the duodenum. 
 The bullet had struck the transverse process of a lumbar vertebra, had deflected 
 to the left, wounding the ascending vena cava and the duodenum, and had lodged 
 in the anterior abdominal wall. The blood escaping from the vena cava had not 
 emptied into the abdomen, but had followed the vein along the spine and had 
 flooded the posterior mediastinum. 
 
qOo 
 
 LAPAROTOMY FOR TRAUMATISM 
 
 back of the first line and use either a continuous or interrupted suture 
 (Fig. 406). 
 
 (c) Large Perforating Wounds. — If the wound is an incised one, 
 
 Fig. 406. — The first layer of sutures 
 include all coats. (Veau.) 
 
 Fig. 407 — Applying sero-serous 
 (Lembert) sutures. (Veau.) 
 
 suture without refreshing the edges, but if it is contused or lacerated 
 4.08) it will be necessary for repair to trim away to the sound 
 
 suture without refreshing the edges, but if it is contused or ' 
 (Fig. 408) it will be necessary for repair to trim away to t 
 tissue; but take care not to diminish the caliber of the gut. 
 
 Fig. 408. — Trimming away the Fig. 409. — Transverse suture to prevent 
 
 bruised tissue. (Veau.) narrowing of the bowel. (Veau.) 
 
 As before, beginning at one angle, introduce the first line of the 
 suture, including all the coats, and using, if possible, a continuous 
 suture (Fig. 409). 
 
POST-OPERATIVE TREATMENT 561 
 
 The second line of (Lembert or sero-serous) sutures must begin 
 and end % inch beyond the limits of the first and the needle must 
 be entered far enough away from the first line that the peritoneal 
 surfaces may be well apposed and the first layer completely covered 
 (Fig. 410). 
 
 (C) Resection of the Gut. — If the wound involves more than two- 
 thirds of the circumference or if there is a contusion of the whole or 
 a large part of the segment, it will be necessary to resect and do a 
 circular enterorrhaphy or some other form of 
 anastomosis. If the operator cannot undertake 
 that, then the gut must be treated as in the 
 gangrene of strangulated hernia, making an 
 artificial anus (see page 651). For resection of 
 gut, see page 609. 
 
 Drain the peritoneal cavity with a Miculicz 
 drain where there is oozing, and with a drain- 
 age-tube if infection is feared (see Chapter V on ~^ 
 Drainage) . FlG - 410.— Applying Lem- 
 
 Close the abdominal wall by three tiers of 
 suture; the peritoneum with a continuous suture of catgut, the 
 muscles with chromicized catgut, and the skin with silkworm-gut. 
 Apply a dry dressing. 
 
 Subsequent Care. — Order complete rest and absence of food for 
 forty-eight hours, not even excepting milk. To quench the thirst, 
 let the patient suck a cloth saturated with water. It will nearly 
 always be expedient to give salt solution either by rectum or sub- 
 cutaneously; in the worst cases by intravenous infusion. 
 
 Change the dressing the following day. It will probably be satu- 
 rated with bloody serum. On the second day remove the tampons 
 and replace with smaller ones. On the fourth day remove the drain- 
 age-tube, if employed, and replace with smaller one, which may be 
 dispensed with after the eighth day. 
 
 Prognosis. — The prognosis will depend upon the extent of the 
 injuries and the skill of the operator. 
 
 Death may occur from hemorrhage or peritonitis shortly after the 
 operation, or about the eighth or tenth day if the suturing has been 
 imperfectly done. 
 36 
 
LAPAROTOMY FOR TRAUMATISM 
 
 Fecal abscess and fecal fistula may result, requiring a later opera- 
 tion, or which may eventually cure themselves. 
 
 Complete recovery happily very often occurs and would be the rule 
 if the doctor had the judgment or authority to operate within the 
 first few hours after the traumatism. 
 
 WOUNDS OF THE STOMACH 
 
 If the injury involves the upper pole of the abdomen, the stomach 
 must be examined carefully. Extensive injuries are often overlooked. 
 An escape of gas and bleeding may point to the situation of the lesion. 
 
 Pick up the stomach with gauze to get a firmer hold, and examine 
 the anterior surface systematically. Repair any wounds, as in the 
 intestine, by two rows of suture; the one including all the coats, the 
 other only the serous and muscular. 
 
 In the case of gunshot wounds, examine the posterior surface. To 
 reach the posterior surface, Auvray insists upon a large incision in 
 the gastro-colic omentum along the lower border of the stomach, 
 for a large incision facilitates examination and does not compromise 
 the vitality of any structure. If even then one cannot gain full 
 access, he advises an exploratory gastrotomy (Revue de Chirurgie, 
 Nov. 10, 1906). 
 
 The posterior surface may be reached another way, by turning 
 up the transverse colon and opening the transverse meso-colon. To 
 prevent the spread of fluids which may escape from the stomach 
 the field must be carefully walled off with compresses as the explora- 
 tion proceeds. If the wound can be felt but is impossible to be seen, 
 then no attempt must be made to suture, but the cavity is to be 
 thoroughly drained. 
 
 If there has been much loss of substance, it may be necessary to do 
 a gastro-enterostomy. 
 
 WOUNDS OF THE LIVER 
 
 If the nature of the abdominal injury leaves no doubt that the 
 liver is wounded, it may be advisable to vary the procedure as al- 
 ready described. A support under the back tilts the abdomen so 
 that the intestine drops down toward the pelvic cavity, and at the 
 same time the liver is bulged forward and made more accessible. 
 
REPAIR OF THE LIVER 
 
 563 
 
 The incision beginning at the ensiform cartilage may follow the 
 costal arch, dividing, if necessary, the right rectus muscle. It may 
 even be necessary, in order to reach the upper surface of the liver, 
 to resect the tenth, ninth, or eighth rib. 
 
 You may find on examination of the viscera that the liver has been 
 
 Fig. 411. — Suture of the liver. (Moynihan.) 
 
 contused, and there is evidently a hematoma formed beneath the cap- 
 sule. It is better not to disturb it unless the conditions seem to 
 indicate continuation of oozing. 
 
 There may be an open wound of any character or extent with great 
 hemorrhage. One should attempt to catch up and ligate the bleeding 
 points, employing a fine clip or artery forceps. The veins, as well 
 as the arteries, will stand the strain of a ligature, but may need to be 
 
564 LAPAROTOMY FOR TRAUMATISM 
 
 1 loose from the liver substance before the ligature can be 
 applied. 
 
 If the patient is not too weak, attempt repair by suture. It is a 
 little difficult, but quite possible and certainly desirable. 
 
 Employs blunt-pointed needleanddo not push it through boldly, 
 but slowly, and as you push, gently oscillate the needle. In this 
 manner, the point may slip by the vessels. Employ a large catgut 
 suture, as a fine suture cuts through the soft tissue (Fig. 411). 
 
 Van Buren Knott (Iowa Med. Journal, Oct., 1907) recommends 
 inserting a strand of catgut parallel with the liver wound, tying the 
 ends of the strand over small skeins of catgut to prevent tearing. 
 Transverse interrupted sutures are then passed so as to include the 
 parallel sutures first passed. 
 
 Failing to suture, there is nothing left but the tamponade, and this, 
 of course, is the only thing available in lacerated wounds. 
 
 Haynes, of New York (Annals of Surgery, July, 1907), describes 
 a case illustrative of some of the difficulties of treatment and the 
 sequelae of liver wounds. 
 
 Patient, a man of twenty years, was brought to the Harlem Hos- 
 pital with gunshot wound just below the tip of the ensiform cartilage. 
 The bullet was found to have traversed the liver from before back- 
 ward, and it was necessary to get at the wound of exit. 
 
 From the median incision, a second incision was made transversely, 
 dividing the right rectus and the seventh and sixth costal cartilages. 
 The falciform ligament was also divided. With strong traction upon 
 the costal arch, the posterior wound could be reached and felt but 
 not seen, readily admitting two fingers. 
 
 By the sense of touch, an iodoform wick was packed into this 
 wound and a smaller one introduced into the anterior wound, and 
 both brought out through the abdominal incision. This did not 
 entirely control the hemorrhage, and so the liver was forced up 
 against the diaphragm and held by a large Miculicz tampon below 
 the liver. 
 
 The rectus was sutured. The peritoneum was repaired with the 
 falciform ligament included; the abdominal walls sutured above and 
 below the gauze wicks. 
 
 On the tenth day the tamponade was removed; and a few days 
 
 
REPAIR OF THE PANCREAS 565 
 
 later, the gauze wicks, for which rubber tubes were substituted, a 
 discharge of bile and pus being present. 
 
 At the end of the third week it became necessary to secure addi- 
 tional drainage, and the ninth rib was resected in the axillary line, 
 where, in the meantime, the bullet had been located; the costal and 
 phrenic pleura were sutured, and the pleural cavity thus shut off. 
 The diaphragm was opened, the pus drained out and a long tube 
 passed from the anterior to the posterior abdominal wounds, and a 
 smaller one left in the posterior wound. 
 
 The progress of repair was slow but sure, five months elapsing 
 before the cure was complete. 
 
 It should be remarked that very rarely after gunshot wounds of 
 the liver is there notable external hemorrhage. One must determine 
 the degree of injury from the signs of internal hemorrhage and the 
 evidences of peritoneal reaction which later develop. 
 
 WOUNDS OF THE PANCREAS 
 
 Do not forget to examine the pancreas in wounds of the upper 
 zone of the abdomen. Reach the pancreas from above the stomach, 
 opening through the gastro-hepatic omentum. 
 
 Carefully mop out the fluids, blood and pancreatic juice. Pack 
 around the site with compresses and try to suture. Sometimes two 
 or three deep sutures will coapt the wound surface and completely 
 check the hemorrhage. If the tail is much crushed, resect it and 
 suture the stump. Use gauze and tubal drainage. If the patient 
 does not die, he may have a subphrenic abscess (Figs. 412, 413). 
 
 WOUNDS OF THE SPLEEN 
 
 Any but the slightest wound of the spleen is universally and rapidly 
 fatal from hemorrhage unless treated. One naturally thinks of 
 suturing. If that and tamponade are not effective to stop the 
 bleeding, it is indicated to try to remove the viscus. This is not 
 difficult if there are no adhesions, though, if there are, failure is 
 almost certain. Under such circumstances, as Moynihan suggests, 
 the only thing left is to pack with gauze, soaked, if necessary, in 
 adrenalin solution. 
 
566 LAPAROTOMY FOR TRAUMATISM 
 
 Xoetzel reviews his experience with six cases in which he removed 
 the spleen for injury and concludes that splenectomy is the only 
 sale way of securing hemostasis. Suturing and tamponing may 
 arrest bleeding for a time, but there is danger that it will return. 
 
 Holliday, of Portsmouth, Virginia, reports a case illustrating the 
 subject (Virginia Medical Semi-monthly Journal, January n, 1907); 
 patient, boy, age 15, was struck in left side by a flying pulley, frac- 
 turing his arm in several places and contusing the abdominal wall. 
 His condition shortly became serious; temperature subnormal, 
 absolute dullness on the left side, and marked rigidity. Immediate 
 
 Figs. 412 and 413. — Method of suture of a wound in the pancreas. Two or three deep 
 sutures of stout catgut or silk are passed, and wound-surfaces drawn together. The wound- 
 edges are then sutured with fine catgut sutures. (Moynihan.) 
 
 operation. The patient was almost eviscerated before the bleeding 
 could be located, but which was finally found to proceed from the 
 lacerated external surface of the spleen; a splenectomy was quickly 
 done, and the abdomen closed without drainage. Convalescence 
 was easy and uneventful. 
 
 Splenectomy. — The operation following rupture generally finds 
 the incision made in the middle line on account of the indications 
 for hemorrhage. 
 
 The spleen is brought up into view and delivered from the abdom- 
 inal cavity and clamped, avoiding any strain upon its pedicle, for the 
 veins have extremely thin walls (Fig. 414). 
 
 Ligate and divide the pedicle. Transfix the pedicle with a double 
 ligature and tie each half separately, and finally tie the whole pedicle 
 in a single ligature. If the ligament is large and thick it may be 
 
SPLENECTOMY 567 
 
 necessary to ligate it "enchaine" (Fig. 415). The pedicle is next 
 divided, the. spleen removed, and its bed examined for any bleeding 
 points. The under surface of the diaphragm is very likely to present 
 some oozing. 
 
 Fiske, of Brooklyn, describes a case which illustrates the varia- 
 tions in the procedure. (Annals of Surgery, Jan., 1908.) 
 
 A man of twenty-five years was brought to the Kings County 
 Hospital with a bullet wound in the left side corresponding to the 
 
 Fig. 414. — Splenectomy: Clamps applied to pedicle preliminary to section along dotted 
 
 line. (Guibe.) 
 
 spleen. The symptoms pointed to visceral injury and intra-abdom- 
 inal hemorrhage. An incision was made over the outer border of the 
 left rectus muscle from the costal arch to a point midway between the 
 umbilicus and symphysis. The stomach and intestine were found to 
 be uninjured. A perforation in the transverse meso-colon was re- 
 paired, but the hemorrhage continued. A transverse incision was 
 made and the spleen examined, revealing a rent which admitted two 
 ringers. The spleen was pulled up into the wound, the pedicle 
 
5 68 
 
 LAPAROTOMY FOR TRAUMATISM 
 
 clamped and ligated en masse. After removing the spleen, the ves- 
 sels were ligated separately, the abdomen was flushed with saline 
 solution, a small gauze drain left in contact with the stump, and the 
 wound closed with through-and-through silkworm-gut sutures. 
 The temperature subsequently did not rise above ioo°. The drain 
 was permanently removed on the fifth day. The patient left the 
 hospital at the end of the third week, entirely recovered. 
 
 Fig. 415. — Pedicle ot spleen ligated "enchaine". (Guibe.) 
 
 WOUNDS OF THE KIDNEY 
 
 If, while examining the viscera in the course of the laparotomy, 
 you find a ruptured renal pelvis or a seriously lacerated kidney bleed- 
 ing into the peritoneal cavity, remove the kidney. Make a longitu- 
 dinal incision in its peritoneal covering, strip the organ out of its bed 
 and, lifting toward the surface, free the pedicle. 
 
REPAIR OF THE KIDNEY 569 
 
 Ligate the ureter first and then, if possible, each of the vessels 
 separately. If the oozing persists, leave a Miculicz drain or a rubber 
 tube. 
 
 Intra-peritoneal rupture without injury to other viscera is very 
 rare. 
 
 Extra-peritoneal wounds of the kidney do not, as a rule, require 
 intervention. 
 
 That the kidney has been involved will be suggested by pain, 
 frequent micturition, and bloody urine. 
 
 Rest in bed, morphine, and limited diet are the special indica- 
 tions. ; An abdominal binder may give relief. 
 
 Eliot (American Journal Surgery, Nov., 1906) has observed twelve 
 cases of subcutaneous rupture of the kidney. In seven cases there 
 was not sufficient extravasation to make a perceptible tumor, and the 
 diagnosis was made by the hematuria and the tenderness over the 
 kidney and persistent rigidity for a number of days. 
 
 In the remaining cases a well-defined tumor appeared in the ilio- 
 costal space, becoming more sharply outlined as the rigidity dis- 
 appeared. In five or six weeks, the tumor disappeared. In no 
 instance was operation necessary. 
 
 In such cases of extra-peritoneal rupture as require operation, the 
 lumbar route should be chosen. Operation is indicated from the first 
 if the violence was known to be great and a large tumor forms im- 
 mediately. An operation is indicated at any time symptoms of sepsis 
 appear, 
 
 Morris Miller rep6rts a case (Annals of Surgery, Feb., 1908) of a 
 man who fell, striking his left side over the lower rib. He felt faint, 
 and almost immediately passed a quart of blood by the urethra and 
 later may clots. Miller saw him at the hospital an hour and a half 
 later. There was no shock, but the side was rigid and tender, and an 
 indistinct dull mass could be felt in the loin. An oblique lumbar 
 incision revealed an extensive rupture of the kidney with much 
 hemorrhage. Wicks of gauze were placed in front and behind the 
 kidney and the ruptured segments pressed together. The patient 
 did well, the hemorrhage gradually ceased, though twice after the 
 fifth day blood appeared in the urine. On the twelfth day the pack- 
 ing was all removed, and the opening finally healed. Gibbon, com- 
 
I UWROTOMY FOR TRAUMATISM 
 
 menting on the case, remarks that hemorrhage severe enough to 
 require operation does not usually mean injury sufficient to require 
 nephrectomy. The question of nephrectomy must be decided when 
 the kidney is exposed. 
 Stewart adds that the two early indications for operation are a 
 jessivelv increasing hematoma and constitutional symptoms of 
 hemorrhage. In several cases of moderate bleeding he had operated, 
 and afterward been sorry he had interfered. 
 
 Fig. 416. — Repair of ruptured bladder. Applying through-and-through sutures. Sub- 
 sequently Lembert suture will be applied and finally the parietal peritoneum will be repaired 
 beginning at point of reflection onto the bladder. Peritoneum retained by forceps. (Lejars.) 
 
 WOUNDS OF THE BLADDER 
 
 Wounds of the bladder, if not previously suspected from the nature 
 of the abdominal injuries, are inferred from the presence of urine in 
 the peritoneal cavity. Sometimes the rent is hard to locate. Inject 
 
REPAIR OF THE BLADDER 
 
 571 
 
 the bladder with normal salt solution and observe its mode of en- 
 trance into the peritoneal cavity. 
 
 The wound is to be repaired by two rows of sutures, the first, of 
 catgut, involving all the coats except the mucosa; the second, of 
 silk, includes the peritoneum alone after the manner of the Lembert 
 suture. The stitches of both rows must be closely placed to seal the 
 wound. The result may be tested by filling the bladder with normal 
 salt solution, and any defect repaired (Fig. 419). 
 
 Fig. 417- — Van 
 Hook's ureteral an- 
 astomosis. (Binnie.) 
 
 Fig. 418. — Van Hook's 
 ureteral anastomosis. 
 (Binnie.) 
 
 Fig. 419. — Anasto- 
 mosis completed. 
 (Binnie.) 
 
 A catheter should be left in the bladder for drainage and the 
 siphonage kept up for two or three days. Subsequently, the bladder 
 should be emptied by aseptic catheterization for a few days longer. 
 The peritoneum should be drained for the first forty-eight hours. 
 
 This mode of treatment applies to the intra-peritoneal wounds of 
 the bladder. The extra-peritoneal wounds should be treated on the 
 same principle, but often, under such circumstances, the operator 
 must be content with suprapubic drainage of the bladder until the 
 wound has healed. 
 
57- LAPAROTOMY FOR TRAUMATISM 
 
 WOUNDS OF THE URETER 
 
 If it is discovered that the ureter is wounded either by the trauma 
 or in the course of the operation, an effort should be made at repair. 
 ral methods are available. If the injury does not amount to 
 complete division, a few perforating sutures followed by Lembert 
 sutures may succeed. Small wounds usually heal readily, but it is 
 safer to use drainage. 
 
 If the separation is complete, both ends of the torn ureter may be 
 ligated, or the kidney may be removed, but naturally it is preferable, 
 if possible, to establish an anastomosis. Under various circum- 
 stances, the proximal end may be anchored in the bladder or in the 
 bowel, or the two ends may be brought together. 
 
 Wan Hook's termino-lateral anastomosis is generally applied. 
 The technic may be briefly described in this wise: 
 
 Ligate the distal portion 1/4 inch from the end and make a longi- 
 tudinal slit in length double the diameter of the tube. Split the 
 proximal end also for 1/4 inch, beginning at the free end. 
 
 Pass the sutures. Employ a long catgut suture threaded on a 
 needle at each end. One-eighth inch from the end of the proximal 
 portion of the ureter, pass the two needles from without inward 
 (Fig. 417). Carry the two needles through the split in the distal 
 portion, into the lumen and let them emerge 1/2 inch below 
 the end of the split (Fig. 418). Tighten the suture, which will have 
 the effect of invaginating the upper segment in the lower (Fig. 419). 
 Around the line of contact run a Lembert suture, and cover with 
 omentum or peritoneum. 
 
CHAPTER VIII 
 
 APPENDICITIS. APPENDICIAL ABSCESS. PURULENT 
 PERITONITIS 1 
 
 Inflammation of the appendix presupposes two factors, lowered 
 resistance and a pathogenic germ. 
 
 The lowered resistance of the appendicial tissue may find its 
 origin in many diverse conditions involving its morphology, anatomy, 
 and physiology. It is generally agreed that it is an organ undergoing 
 a retrograde metamorphosis, or, at any rate, one adapting itself to 
 new functions. 
 
 There is a small facility for compensatory circulation if its main 
 artery is blocked, and, in consequence, it is exposed to vicissitudes of 
 nutrition. 
 
 Owing to its varying position, it is brought into contact and may 
 acquire connections, vascular and lymphatic, with other abdominal 
 and pelvic organs and structures and, by this means, be the recipient 
 of pathogenic bacteria that had not elsewhere found a favorable soil. 
 
 The pathogenic organisms which, under favorable conditions, may 
 here develop and produce various grades of destruction are the bacil- 
 lus communis coli, the streptococci, staphylococci, and others less 
 frequent. 
 
 Whatever part each of these causative agents may play in its de- 
 velopment, the fact remains that appendicitis is one of the frequent 
 and one of the most dangerous and treacherous diseases with which 
 the general practitioner has to deal. 
 
 Diagnosis. — The diagnosis is not difficult in the typical cases, 
 but exceptionally may be extremely difficult, or even impossible, 
 until the progress of the symptoms has been observed. 
 
 A diagnosis should never be made from the mere presence of what 
 
 1 So important is this subject to the general practitioner, that he should be 
 satisfied to have and study no works less complete than the classic volumes of 
 Deaver or Kelly. 
 
 573 
 
574 APPENDICITIS. PURULENT PERITONITIS 
 
 are regarded as the cardinal symptoms; not until each symptom and 
 sign has been weighed and accorded its proper significance, and all 
 other possible conditions excluded, should it be decided definitely 
 that the case is or is not acute appendicitis. 
 
 To discuss briefly the symptoms upon which one must rely: the 
 pain in the milder catarrhal cases is limited usually to the right iliac 
 fossa. In the ulcerative type, with sudden onset, or the perforative 
 type, it is very likely at first to be general over the abdomen, but after 
 a few hours, is rather definitely localized in the right side. In the 
 gangrenous cases, it may be absent in one case or severe in another, 
 depending upon the degree of active peritoneal inflammation. 
 
 Rigidity of the right rectus abdominis and pelvic muscles is an 
 important sign, and its degree is some index to the amount of perit- 
 oneal involvement. 
 
 Gastric disturbance, nausea, and vomiting are fairly constant oc- 
 currences in the first stages of the attack, but last only a short time. 
 T. B. Eastman has very strongly emphasized the frequent connec- 
 tion between the chronic forms of appendicitis and those appearances 
 of gastric indigestion vaguely grouped as " stomach troubles." 
 
 Constipation is almost the rule, and Kelly adds further that it may 
 amount to an actual obstruction. Only rarely does diarrhea appear 
 with the attack, and if it does, may be regarded as indicating a grave 
 form. Most rare of all is it for an attack even of the mildest type, 
 to run its course without some aberration of bowel action. 
 
 Tenderness on pressure is a symptom upon which alone the diag- 
 nosis is too often made. It is scarcely possible for it to be wholly 
 absent, and yet it can by no means be relied upon to indicate the 
 severity of the attack. Rosving states that pressure on the left 
 McBufney point always elicits pain in appendicitis, but not in other 
 cases. 
 
 Robert Morris adds something to this phase of the diagnosis. He 
 claims that tenderness upon pressure over a point opposite the um- 
 bilicus in the line of the anterior superior spine of the ilium has a 
 special significance and is due to involvement of the lumbar ganglia. 
 Thus Morris' point on the right side will be tender in appendicitis. 
 If that point on both sides is tender, the trouble is located in the 
 pelvis. 
 
DIAGNOSIS OF APPENDICITIS 575 
 
 Tumor. — It is folly to wait for this sign to complete the diagnosis, 
 for it means the certainty of a complicated pathology. It means 
 peritoneal involvement with plastic exudates, or a pus formation, or 
 both. 
 
 Disturbance of Pulse and Temperature. — There is no other grave 
 disease, perhaps, in which the pulse and temperature make such 
 limited excursions. The temperature in the most serious cases may 
 not reach 103 . Its elevation is in no wise significant. The pulse 
 in the milder cases holds a certain ratio with the temperature. A 
 temperature of 101 , for example, should be accompanied by a pulse 
 rate of 90 to 100. Any marked disturbance of this ratio is extremely 
 significant; whether it is a low temperature with a rapid pulse or a 
 high temperature with a slow pulse, the outlook is ominous. H. O. 
 Panzter, from extended clinical experience, insists that we must rely 
 largely upon the rectal temperature in making a differential diagnosis, 
 and that the temperature should be invariably taken by both mouth 
 and rectum. The temperature by mouth in such cases may be very 
 deceptive. 
 
 Such, very briefly, are the principal symptoms and signs which, 
 taken collectively, must serve to distinguish the disorder from acute 
 intestinal obstruction, ovarian or tubal inflammation, cholecystitis, 
 typhoid fever, pneumonia, and other acute diseases. 
 
 There is not much danger at the present time, so prominently is the 
 subject before the profession, that an appendicitis will be overlooked. 
 Only too often is an innocent appendix held to be the cause of the 
 illness in hand. Lobar pneumonia, for example, is likely to give rise 
 to appendicial symptoms, and such cases are likely to run an atypical 
 course. 
 
 It is an appendicitis, but what is its character? Is it mild or 
 dangerous? Is it a simple catarrhal trouble which will soon subside, 
 or is it potentially a gangrenous process with general peritonitis 
 ahead? These are the questions which confound the doctor and 
 upon their answer rest the prognosis and treatment. 
 
 Four varieties are described (Fig. 420). 
 
 (1) Catarrhal appendicitis, in which the mucosa alone is involved, 
 the predisposing causes are easily relieved, and the pathogenic agent 
 
576 
 
 APPENDICITIS. PURULENT PERITONITIS 
 
 *0 
 
 /yrfa 
 
 ^ 
 
 Fig. 420. — Types of appendicitis showing pathological changes. 1, Normal append x; 
 R, acute appendicitis; 3, inflamed appendix containing large and small fecolith; 4, 
 ruptured gangrenous appendix containing large fecolith. (Reed and Carnrick.) 
 
DIAGNOSIS OF APPENDICITIS 577 
 
 is of a low order of virility. Neither local nor constitutional symp- 
 toms are severe, and the attack very shortly subsides. 
 
 (2) In the ulcerative type the process extends deeper and involves 
 the muscular and perhaps the serous coat to some extent and there 
 is produced a mild form of peritoneal inflammation. There is usu- 
 ally a diffused swelling of the whole appendix. 
 
 (3) Perforative appendicitis, in which there is local destruction of 
 all the coats and communication with the peritoneal cavity, is due to 
 a sudden and virulent infection or an acute exacerbation of a slum- 
 bering process and begins abruptly with intense pain; and in a short 
 time ends in peritoneal suppuration, local or general. 
 
 (4) Gangrenous Appendicitis, — This form, beginning as such, is 
 the most treacherous, for often the symptoms are in no wise pro- 
 portionate to the seriousness of the case. Death is impending, and 
 yet neither the pain, pulse, nor temperature gives due warning. 
 There is absolutely no way at this present time by which the doctor 
 may recognize this condition de novo. It may be imagined that such 
 a condition arises from sudden interference with the blood current 
 to the organ, while infection plays the lesser part. On the other hand, 
 gangrene which ensues from virulent infection begins at once with the 
 characteristic symptoms of appendicitis added to those of sepsis and 
 peritonitis. 
 
 It is from the point of view of these pathological variations that 
 the most diverse opinions as to treatment have arisen. 
 
 It is evident that nature, unaided, may be able to take care of the 
 milder type. It is a clinical fact that nature by means of her own, 
 may sometimes control and keep the inflammation within bounds, 
 even in the more dangerous cases. By means of plastic exudates, 
 she walls off and limits the suppurating area and later provides a safe 
 means of escape for the products of suppuration. But, unfortu- 
 nately, such a happy issue can never be depended upon. On the 
 contrary, the suppuration is more likely to become diffuse and there 
 presents the picture of purulent peritonitis and the imminent prospect 
 of a fatality. In such a case one loses sight of the local symptoms. 
 
 The abdomen is rigid, tympanitic and everywhere exceedingly 
 tender. The temperature is high; the pulse rapid; the tongue coated, 
 brown and fissured; and as the disease progresses, the 1 symptoms of 
 37 
 
APPENDICITIS. PURULENT PERITONITIS 
 
 circulatory collapse appear. The temperature then becomes sub- 
 normal, the pulse almost uncountable, and the features pinched and 
 anxious, until finally a mild delirium with pleasant hallucinations 
 ushers in the end. 
 
 The infection may be so severe, the toxemia so profound, that the 
 patient may die of septic peritonitis before pus has had time to form. 
 Indeed, death may come from sepsis before the ordinary signs of in- 
 flammation appear. 
 
 Such may be the outcome of what appears to be the mildest case. 
 It is this prospect and the attendant uncertainties which have led 
 many doctors to regard appendicitis as an emergency to be operated 
 upon as soon as the diagnosis is made. As Pfaff, of Indianapolis, 
 puts it, the difference between the mortality of i per cent, in the very 
 early operations, and that of 15 to 30 per cent, in the abscess stage, 
 is so frightful that, in comparison, an occasional unnecessary opera- 
 tion is of no consequence at all. If we are to fulfill our obligations, 
 we must act vigorously and to-day. 
 
 This is undoubtedly a safe rule in the practice of the skilled opera- 
 tor, who has at his command all the facilities of the aseptic operating- 
 room and trained assistants. 
 
 The case is quite different with the general practitioner, remote 
 from these accessories. Moreover, it is known that 80 to 85 per 
 cent, of these cases recover without operation. Even for the relaps- 
 ing from, Treves says that much may be done by medical means,- 
 diet, attention to the bowels, and by placing the patient under con- 
 ditions more favorable to a state of peace within the abdomen. 
 
 Whatever may be proper in hospital practice, it certainly cannot 
 be imposed on the general practitioner that he operate at once. 
 Even in connection with the skilled surgeon, it may be said that his 
 technic has not yet reached such a degree of perfection that an opera- 
 tion is always safer than the milder form of appendicitis unoperated. 
 
 The doctor then will face his responsibility, a heavy one truly, 
 knowing there is much to be accomplished by medical means ancf 
 yet hoping that he will have the judgment to recognize the failure 
 of nature and of his art, and the will to resort not too late to more 
 radical measures. 
 
 Assume that the diagnosis is definitely made; assume that no sur- 
 
TREATMENT OF APPENDICITIS 579 
 
 geon is within beck and call (for appendicitis is strictly a surgical 
 disease), what will you do? It is evident at once that this is a clin- 
 ical hypothesis, and the question is to be resolved on a clinical basis. 
 
 I. You see the case from the first. The attack begins mildly or 
 with only moderate severity; there was perhaps a single attack of 
 vomiting; the pain, abdominal tenderness and rigidity are not 
 marked, and the patient's general condition is good. 
 
 Under these circumstances, as Lejars says, it is perfectly legitimate 
 to institute a medical treatment, in the meantime holding the case 
 under the strictest surveillance. But this formula is null without 
 the last provision. If the march of the disease cannot be watched, it is 
 better to operate at once, and this rule may as well be made to apply 
 to any case in which delay might otherwise be counselled. You 
 decide to try medical treatment, but in what form? Like many 
 others herein involved, the question brings forth a varied response. 
 
 Under these circumstances one may follow the plan of "immobili- 
 zation" which Lejars and others so highly praise. But to be effect- 
 ive, it must be rigorously and consistently applied. 
 
 Keep the patient absolutely quiet in bed. Give no purgatives — ■ 
 and this means give neither calomel nor oil. Give no enemas. Sus- 
 pend nourishment absolutely, relieving thirst by a few drops of water 
 frequently given. 
 
 Ice to the Abdomen. — -Not a handful of ice in a little bag applied 
 over the iliac fossa, but two or three large bags covering the whole 
 abdomen below the umbilicus and refilled as the ice melts. 
 
 Opium, in %-grain doses in pill form every two hours for an adult; 
 but it must not be pushed to the point of annulling all pain and sus- 
 pending the functions of the kidney. 
 
 It is far from being the rule that the practitioner remote from the 
 larger towns can have ice at his command. Likewise, opium in the 
 hands of the inexperienced may be a two-edged tool. He must often, 
 therefore, depend upon other modes of procedure, ' and for these, 
 there is no lack of eminent authority. Under the circumstances in- 
 dicated, begin with a single hypodermic of morphine if the pain is 
 severe and with small doses of calomel (Ko~;Hlo g r «) frequently 
 repeated, until a grain or two is taken; follow at the end of three 
 hours with a large dose of castor oil or larger doses of albolene until 
 
5 So APPENDICITIS. PURULENT PERITONITIS 
 
 the bowels have moved freely. If the bowels are slow to move, 
 supplement the internal remedies with enemas of normal salt solution. 
 Give salol or carbonate of guaiacol every three hours. Apply hot 
 fomentations to the abdomen, flannels wrung out of hot water and 
 sprinkled with turpentine. Cover the hot flannels with several 
 additional thicknesses and apply hot-water bottles filled with boiling 
 water, and cover the whole to retain the heat. As the water cools, 
 withdraw, one by one, the various layers so that the temperature 
 may be maintained at the highest point of comfort. Hot kaolin 
 cataplasms often render service. 
 
 As Oschner commands, food must be withheld absolutely, and if 
 there is much gastric disturbance or pain, the stomach should be 
 washed out. Opium is contraindicated under this form of treat- 
 ment, for it is the purpose to cleanse the bowel. 
 
 McGrath, of New York, probably expresses the prevailing opinion, 
 summing the matter up in this wise (Medical Record, Feb. i, 1908): 
 
 "Only in the catarrhal cases can there be any question as to treat- 
 ment once the diagnosis is made; whether it is better to operate with- 
 out delay or seek to avail oneself of the advantage of an interval 
 operation. If sure of the character of the lesion, we may temporize; 
 it will do no harm watching the patient carefully for any sign of 
 danger. Many of these cases resolve without going on to suppura- 
 tion or gangrene, and therefore escape operation during the acute 
 attack. Nature may be assisted in her efforts at spontaneous cure 
 in these cases by enjoining complete rest, withholding all food and 
 permitting only water to be taken, and by small repeated doses of 
 calomel and sodium bicarbonate. An ice-bag may be applied over 
 the region of the appendix. But if there is any doubt as to the exact 
 pathological condition, operation should be advised unless marked 
 contraindications exist." 
 
 George J. Cook, of Indianapolis, who has had as much experience 
 with this disease as anyone in the Mississippi Valley, does not operate 
 in mild attacks of primary appendicitis. If it is a second attack, he 
 operates without delay. He says that not infrequently a mild catar- 
 rhal appendicitis does not recur. In such cases, he puts the patient 
 at rest. He unloads the bowels with enemas merely. If the attack 
 follows overeating, he employs a mild saline primarily. Nothing but 
 
TREATMENT OF APPENDICITIS 581 
 
 water is permitted. As an intestinal antiseptic, he gives 5 grains 
 of carbonate of guaiacol three or four times in the twenty-four hours. 
 If the patient should complain much, he gives small doses of opium, 
 after the diagnosis is made. He gives it to quiet the pain and not the 
 peristalsis, asserting that the bowel will of itself be quiescent if 
 empty. Ice-bags applied to the abdomen as a routine measure repre- 
 sents to him the chief element in the relief of pain and control of 
 inflammation. 
 
 Note that whatever the form of treatment, the case must be nar- 
 rowly w r atched. If the pulse and temperature remain in harmony; 
 if the abdominal tension and tenderness tend to grow less; if the 
 bowels move and gas escapes per rectum; if the general condition is 
 good; there is ground to expect a satisfactory termination, but no 
 excuse to relax one's vigilance. 
 
 No nourishment should be given by mouth until defervescence is 
 complete, and after that a liquid diet should be maintained for one to 
 two weeks, depending upon the severity of the attack, and rest in 
 bed as well. At the end of a few weeks, the appendix should be 
 removed. 
 
 But the progress of the disease may suddenly change. All the 
 symptoms may become aggravated and the dangerous nature of the 
 case become at once obvious — immediate operation is indicated; 
 or the change may be insidious (unsuspected by the careless observer) 
 and in this instance the chief reliance must be placed upon the pulse. 
 If the pulse is rapid and weak with a falling temperature, or if the 
 pulse falls to 50 or 60 with a rising temperature; in other words, if 
 there is any marked divergence between pulse and temperature, 
 again the indications are to operate at once. To repeat, any marked 
 aggravation of the symptoms after improvement once begins, or the 
 occurrence of any marked disparity between pulse and temperature, 
 however benign the other symptoms may be, are indications for 
 operation without delay. 
 
 II. Another case: You have w r atched the case, but the tempera- 
 ture has persisted, and beyond, say the sixth day, when there should 
 be a marked improvement, you find the temperature rising or 
 fluctuating, the pain increasing, a tumor forming most painful at its 
 center. In this case also the indication is for immediate operation. 
 
APPENDICITIS. PURULENT PERITONITIS 
 
 1 1 T. Suppose you see the case only at the end of several days, dur- 
 ing which time the disease has run a neglected course. May one at 
 this time, with any effect, apply a medical treatment, or should one 
 t at once to an operation? The question can only be answered 
 after a careful consideration of the history of the case, such as the 
 patient or his attendants can give, and a thorough investigation of 
 the present symptoms. Only when the case is obviously benign can 
 one take the responsibility of further delay. For example, if the 
 pulse and temperature are in accord, if the tenderness and tympanites 
 are diminishing, then nothing better can be done than to follow the 
 rules with regard to rest and diet already laid down. Yet one must 
 be ever mindful of the treacherous character of certain forms of 
 septic attack. 
 
 Again, you find the disease progressing and in the active stage of 
 the third, fourth, or fifth day, with no indications of beginning im- 
 provement, but the symptoms are not aggravated, and there is a 
 plastic exudate without softening: again it may be said that under 
 these circumstances it is legitimate to wait. 
 
 Any continuance of the fever beyond the eighth or tenth day, even 
 though the pulse is good and the exudate has not softened, is a matter 
 of grave suspicion, and with the least enlargement of the tumor or 
 disturbance of pulse, operate without delay, and it is more than 
 likely you will find a large abscess. 
 
 IV. In any case, at any stage, if a diagnosis of abscess can be made 
 out — a .palpable fluctuating mass, in the iliac fossa — whatsoever the 
 other symptoms may be, there is but one indication, immediate 
 operation. No practitioner to whom the task falls, whatsoever his 
 ability or training, can do anything else and do his duty. Even 
 though you cannot detect fluctuation, but by vaginal and rectal 
 examination determine that the mass is doughy and painful, operate 
 and you will almost certainly find pus. 
 
 V. Finally, even if the case has progressed to a general peritonitis, 
 it is one's duty to operate unless the patient be practically moribund, 
 and even in these cases, as Lejars puts it, operation has rescued a 
 certain number of patients from the very jaws of death, for without 
 operation they would inevitably have died. 
 
 Even though the diagnosis is not definitely established and one 
 
APPENDECTOMY 
 
 583 
 
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 Fig. 421. — Vertical incision through skin, aponeurosis and sheath of rectus. Outer border 
 of rectus exposed in bottom of wound. 
 
 A. Incision. — Begin 1 inch above or 2 inches below the line con- 
 necting the anterior superior iliac spine with the umbilicus. The 
 incision crosses this line 3^2 mc h to its inner side of its middle point 
 and follows, practically, the outer border of the rectus abdominis. 
 
5«4 
 
 APPENDICITIS. PURULENT PERITONITIS 
 
 Divide first the skin and fat and expose the aponeurosis of the 
 rnal oblique. Divide next the aponeurosis and under one lip is 
 the edge of the rectus, and under the other, the transversalis (Fig. 
 421), Split the sheath of the rectus and retract the edge of the rec- 
 tus exposing the transversalis fascia. 
 
 Fig. 422. — Rectus drawn inward. Posterior layer of sheath and transversalis fascia 
 divided. Peritoneum exposed and cone lifted preparatory to dividing. 
 
 Divide the transversalis fascia, exposing the subperitoneal fat 
 and pick up a fold of the peritoneum, and divide it, turning the cut- 
 ting edge of the knife away from the abdomen (Fig. 422). Usually 
 the great omentum will bulge into the wound after the peritoneal 
 
APPENDECTOMY 
 
 585 
 
 incision is enlarged. Replace the omentum and, if necessary, hold 
 it with a gauze pad. 
 
 Next introduce a finger and feel for the cecum, which will be rec- 
 ognized by its bands, and pull it up into the wound until the base 
 of the appendix can be seen. The appendix may be adherent, and 
 
 Fig. 423. — Appendix and part of cecum delivered and walled off with gauze. 
 
 the adhesions should be broken up very gently. Once the appendix 
 is freed, it is to be brought up out of the wound and the cecum re- 
 turned to the abdominal cavity and walled off with gauze pads 
 (Fig. 423). 
 

 APPENDICITIS. PURULENT PERITONITIS 
 
 Tie o\i the tneso-appendix with catgut, and cut it away from the 
 appendix close to its line of attachment. 
 
 An incision is now carried around the base of the appendix, divid- 
 ing only the serous coat, which is stripped back toward the cecum, 
 forming a peritoneal cuff (Fig. 424). The appendix is now ligated 
 
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 Fig. 424. — Peritoneal cuff turned back; appendix ligated and amputated. 
 
 and cut off, the mucous stump touched with carbolic acid and then 
 with alcohol. The peritoneal cuff is drawn over the stump and su- 
 tured. The stump is now invaginated and buried with a row of 
 Lembert sutures. The gauze pads are removed with the exception of 
 one, which covers the cecum until the last stitches are placed in the 
 
APPENDECTOMY 
 
 587 
 
 peritoneum. Repair by separate lines of suture the peritoneum, 
 transversalis, aponeurosis, and skin. Drainage is unnecessary. 
 
 B. The incision, 4 inches long, is a finger's breadth to the inside 
 of the anterior superior iliac spine, with its middle corresponding to 
 the spine (Fig. 425). 
 
 The first incision traverses the skin and superficial fascia, which 
 are likely to be very vascular in such a case. The external oblique 
 appears, its fibers parallel with the incision. Divide it the whole 
 
 Fig. 425. — Appendiceal incision. (Veau.) Fig. 426. — The external oblique divided; 
 • the internal oblique exposed. (Veau.) 
 
 length of the wound and catch the edges with forceps which will serve 
 as retractors (Fig. 426). 
 
 Next divide the internal oblique and transversalis muscles, whose 
 fibers run transversely. The layer is thick, and several vessels will 
 need to be caught (Fig. 427). 
 
 Retract these layers and the transversalis fascia is exposed. This 
 you divide, bringing into view the peritoneum. 
 
 Catch up a fold with the forceps, and divide its base with the 
 scissors (Fig. 428). From the small orifice thus created, there flows 
 a seropurulent fluid. Enlarge the peritoneal opening and hold back 
 the intestine with compresses. Examine the cavity. It may be 
 that the omentum, thickened and infiltrated, will cover the field, 
 but do not disturb it. 
 

 APPENDICITIS. PURULENT PERITONITIS 
 
 Follow with the index linger the wall of the fossa until the cecum 
 is reached. Wiping out the cavity, you may be able to see the bands 
 of the cecum, which are to be followed downward by sight and touch, 
 for they lead to the appendix. 
 
 Remove the appendix if possible. You may not be able to find it, 
 but do not prolong the search and certainly do not break up adhesions 
 in this search. 
 
 When it is located, gently draw it to the surface. It is exceedingly 
 friable and should not be ruptured. Throw a catgut ligature about 
 its base close up to the cecum and tie moderately tight (Fig. 429). 
 
 
 
 Fig. 427. — The two oblique muscles incised, Fig. 428. — Showing the three muscular 
 the transversalis exposed. (Veau.) layers and the peritoneum incised. (Veau.) 
 
 Amputate the appendix, and if there is no bleeding cut the liga- 
 ture short. Determine now the character of the suppuration, 
 whether circumscribed or diffuse (Fig. 430). 
 
 (a) 77 is Circumscribed. — Wipe out the cavity very carefully with 
 sterile gauze. Do not irrigate. Place a drainage-tube upward 
 toward the diaphragm (Fig. 431). Do not use violence. There a 
 new collection of pus may be found. Pass a second drainage-tube in 
 the same manner down into the pelvic cavity. This is the most 
 important, for the fluids tend to collect there. Leave the third in 
 the iliac fossa and the fourth directed toward the middle of the 
 
APPENDECTOMY 
 
 589 
 
 abdomen. Secure each with a safety-pin. Suture up to the 
 drainage-tubes, so that the opening will be only large enough to ac- 
 commodate the tubes. 
 
 If the patient is a female, after wiping out the cavity carefully, a 
 counter-opening may be made into the vagina in favorable cases, and 
 with efficient drainage secured by that route, the abdomen may be 
 completely closed. 
 
 Fig. 429. — Throwing a ligature around base of sloughing appendix. (Veau.) 
 
 In many cases even without such drainage, the abdomen may be 
 closed after cleansing the cavity, but it cannot be advised in the 
 emergency work of general practice. 
 
 (b) The Suppuration is Diffuse. — Make a second incision from the 
 umbilicus downward for a couple of inches, which is sufficient. 
 When the peritoneum is opened, the fingers can touch through the 
 two openings. 
 
 If the pus seems to have reached into the left side, it may be advis- 
 able to make a third incision over the left iliac fossa. Through these 
 incisions irrigate the abdominal cavity with normal salt solution, 
 using plenty, 3 or 4 quarts, and continue the irrigation until 
 the fluid flows out clear. Unless it be complete, reaching every part 
 of the cavity, irrigation had better be dispensed with. The addi- 
 
SOO 
 
 APPENDICITIS. PURULENT PERITONITIS 
 
 tional incisions may even be unnecessary if the following treatment is 
 pursued: 
 
 The patient is now put in the Fowler position and a continuous rec- 
 tal enema of normal salt solution arranged for. The purpose of this 
 treatment, instituted by Murphy with such signal success, is to secure 
 a constant saline lavage of the peritoneal cavity. In other words, 
 the fluid passes from the bowel into the peritoneal cavity, accom- 
 
 Fig. 430. — Diagram showing directions the pus may extend. A, Sub-hepatic; B, pelvic; 
 
 C, iliac. (Veau.) 
 
 plishes its healing mission, and drains out through the abdominal 
 wound. 
 
 The fluid should be maintained at a temperature of 100 ° F., and 
 should be allowed to flow into the rectum at the rate of 1 pint per 
 hour or thereabout. The patient's sensation should be consulted. 
 If there is a feeling of tightness and distress, the flow should be les- 
 sened. After 2 or 3 quarts have been introduced, the flow 
 
DRAINAGE 
 
 591 
 
 should be shut off for an hour or two. The injections may be con- 
 tinued one to three days. 
 
 Moynihan reviews his experiences with this treatment (Lancet, 
 Aug. 17, 1907) and concludes that it has exceptional value. He 
 insists upon attention to the details of administration and describes 
 the methods found most useful. The largest quantity of the solu- 
 tion taken by any of his patients was 16 pints for the first 
 twenty-four hours, and a total of 29 pints in three days. He 
 
 Fig. 431. — Placing a tube in the sub-hepatic space. (Veau.) 
 
 emphasizes the character of improvement in the appearance of the 
 patient, in his pulse and temperature, and in the action of kidneys 
 and skin. 
 
 The plan pursued by others aims to secure drainage by means of 
 tubes passed in various directions into the intestinal mass and into 
 the pelvic cavity. Under these circumstances, the enemas of nor- 
 mal salt solution should be used at intervals and the dressings 
 changed on the second day. On the fifth day, the tubes should be 
 removed, cleansed and replaced exactly as before. The patient 
 must not strain while this change is being made and children may 
 need to be given a few whiffs of chloroform. Cleanse the drainage- 
 
59a APPENDICITIS. PURULENT PERITONITIS 
 
 tubes every third clay, gradually shortening them as granulation 
 proceeds. 
 
 It a now focus of infection forms, if the temperature reaches beyond 
 ioi° in the evening for two or three evenings, no matter what it was 
 in the morning, one may be sure of suppuration somewhere. It will 
 be necessary to re-operate and re-establish drainage. 
 
 Septic peritonitis, originating elsewhere than the appendix, ought 
 to be similarly treated, but the results are so discouraging that the 
 operation cannot be urged upon the general practitioner, however 
 advisable it may be in hospital practice. 
 
 The principle of treatment is the same. Make a median incision 
 below the umbilicus and search for the cause. It may originate from 
 a ruptured Fallopian tube, it may follow perforation of the stomach 
 or duodenum, and the break must be located and repaired. It may 
 follow the perforation of typhoid fever and for this condition, the 
 operation will be done more and more as time goes by. 
 
 Gerster, of New York, before the 1909 Congress at Budapest, sum- 
 marizes the treatment of diffuse free progessive peritonitis thus: (1) 
 Preliminary lavage of the stomach; (2) anesthesia by nitrous-oxid 
 gas followed by ether; (3) rapid exposure of primary focus of infec- 
 tion; (4) stoppage of visceral leak by suture or tamponade; (5) 
 gentleness and rapidity of procedure, avoidance of friction by wiping, 
 etc.; (6) no irrigation; (7) soft rubber-tube drainage of right iliac 
 fossa and, if necessary, of Douglas' pouch; (8) closure of external 
 wound by three layers of suture; (9) for paralytic ileus repeated 
 gastric lavage, low and high enemata, or systematic rectal lavage, 
 enterotomy by stab done in intractable cases only; (10) rational 
 administration of opiates; (11) withholding of all ingesta while vom- 
 iting is present; (12) Murphy's proctoclysis; (13) Fowler's position; 
 (14) early incision and drainage of secondary abscesses; (15) laxa- 
 tives, calomel and salts, to be given only after cessation of vomiting; 
 (16) tampons used for walling off necrosed areas not to be disturbed 
 without necessity till they become detached of themselves. 
 
CHAPTER IX 
 ACUTE INTESTINAL OBSTRUCTION 
 
 Acute occlusion of the intestinal canal is a condition always to be 
 dreaded, for it begins suddenly and unexpectedly and, unless relieved, 
 hurries to a fatal issue, due either to shock or sepsis. Perhaps, as 
 Bloodgood says, the condition is not a frequent one, yet, none 
 the less, it is an emergency whose character must be thoroughly 
 understood. 
 
 But for that matter its character is variable, depending upon the 
 cause. To simplify the subject, the obstruction due to strangulated 
 hernia is not considered here, for in such cases the cause of the ob- 
 struction is quite obvious; nor need we consider post-operative ileus, 
 for it has a pathology of its own; again the obstruction which may 
 accompany appendicitis is in a class by itself. The acute obstruc- 
 tions to be studied include those changes in the form or direction of 
 the bowel, or those accumulations within its lumen, w T hich completely 
 and suddenly dam the fecal current. Whether it be a kink or twist 
 in the gut; a volvulus or intussusception; an adhesive or constricting 
 band, relict of a former peritonitis (Fig. 432) ; an accumulation of gall- 
 stones or a cancer: whatever the source of the obstruction, the danger 
 arises, as has been said, from two sources — shock and sepsis. By far 
 the lesser of these two evils is shock. In many cases it may be ab- 
 sent, and even when it is the dominant feature early in the attack, it 
 may gradually subside. The sympathetic plexuses seem able to re- 
 gain their balance and adjust themselves to new conditions. For this 
 reason attacks, which begin with collapse, often seem to improve in a 
 short time. But such improvement is deceptive, for sepsis pursues its 
 insidious course, the bowel becomes more distended, its peritoneal 
 coat more permeable, and so the intestinal bacteria find their way 
 into the peritoneal cavity and their toxins into the blood. It is 
 stercoremia, therefore, which is to be dreaded, for there is no way to 
 measure its progress with any certainty. 
 38 593 
 

 ACUTE INTESTINAL OBSTRUCTION 
 
 J. R. Eastman reports a case which illustrates the deceptive char- 
 r of many cases of obstruction. The patient had undergone, 
 some years before, three various abdominal operations. The at- 
 tack came on suddenly, and on the third day the vomiting became 
 stercoraceous. In preparing for the operation, high enemas were 
 given, followed by escape of flatus. The operation was deferred, as 
 the patient continued apparently to improve, the bowels moving, 
 gas escaping freely, and the patient feeling quite comfortable. Two 
 
 Fig. 432. — Intestinal obstruction due to band of adhesions. (Reed and Carnrick.) 
 
 days after, however, the fecal vomiting re-appeared and with it all 
 the ominous signs of obstruction. At the operation, 4 inches of 
 small intestine, adherent in an inflammatory mass, was found to be 
 gangrenous. Resection, anastomosis, recovery. It is to be noted 
 that the bowels had moved though the gut was strangulated and gan- 
 grenous, the gas and fecal matter undoubtedly passing the point of 
 strangulation. (Indianapolis Medical Journal, July 15, 1909.) 
 The group of symptoms constitutes a very definite clinical picture : 
 
DIAGNOSIS OF OBSTRUCTION 595 
 
 (a) pain, (b) tympanites, (c) vomiting, (d) constipation, and (e) 
 collapse. 
 
 (a) The pain develops suddenly and severely, often following 
 some violent exertion, and takes the form of paroxysmal colic. 
 There is localized tenderness. 
 
 (b) Tympanites is marked, the whole abdomen being distended, 
 and often, on this account, the respiration and circulation are im- 
 paired. Peristalsis is exaggerated, and the violent movements of 
 the bowel may often be noted through the abdominal wall. At the 
 site of the greatest tenderness, a tumor may be found. 
 
 (c) There is often at first a rumbling of the bowels and nausea, 
 soon followed by an incessant and distressing vomiting, at first gas- 
 tric and finally fecal. 
 
 (d) Constipation is a constant feature, though at first there may 
 be some movement from the lower bowel. In intussusception there 
 is often all through the attack some discharge of bloody mucus and 
 gas. This may be the case, too, in strangulation near the pylorus, 
 but in such a case, the extreme distention of the stomach and the 
 violence of its movements suggest the nature of the difficulty. 
 
 (e) Collapse is imminent from the first, and is indicated by the 
 weak, thready pulse, the rapid breathing, the pale, pinched features, 
 and the anxious expression. 
 
 These are the symptoms, whatever the form of the acute obstruc- 
 tion, whether it be strangulation, intussusception, or volvulus, and 
 very rarely can the form of the obstruction be definitely determined 
 before the operation or post-mortem. 
 
 Certain factors make one of the conditions the most probable. 
 If it is a child under ten years of age, it is almost certain to be intus- 
 susception; if there have been previous attacks of some form of 
 peritonitis, strangulating bands of adhesions are likely to be present; 
 if the patient is forty or fifty years of age, with a history of constipa- 
 tion, volvulus suggests itself. 
 
 In addition to noting the symptoms and history, a careful 
 search must always be made by palpation for an abdominal tumor, 
 and finally the investigation is terminated by rectal or vaginal 
 examination. 
 
 Treatment. — In the few hours that must elapse before one can 
 
596 ACUTE INTESTINAL OBSTRUCTION 
 
 fully make up his mind that it is a case of acute obstruction, there 
 are certain things to do, but, more especially, certain things not to 
 do. Do not give purgatives. This is an axiom scarcely necessary 
 to repeat. They can do no good and will most certainly do harm. 
 Do not give large and repeated doses of morphine. It will help the 
 patient to die easy, but in such a case, it is "not a remedy for the 
 patient but a refuge for the doctor.' ' It is doubtful even if it should 
 be given at all. It is possible that minute doses may diminish the 
 peristalsis, quiet the vomiting to some extent, relieve the shock a 
 little, and ease the pain measurably without masking the true con- 
 ditions, but under the circumstances, it is an edged tool. Give no 
 nourishment by mouth. The two measures likely to be of the great- 
 est benefit are gastric lavage and rectal injections. 
 
 The gastric lavage may in some measure diminish the vomiting; 
 and, in case an anesthesia is necessary, it may prevent asphyxia 
 from a gush of vomited matter. 
 
 Rectal enemas are sometimes effective in relieving the obstruction, 
 but if used, it must be with the strict proviso that the injection be 
 done carefully. If roughly given, if the fluid is thrown into the 
 bowel with too much force, even if there is no danger of rupturing 
 the bowel, it at least irritates it and defeats its own purpose. It is 
 likely if the condition has existed more than twenty-four hours the 
 enemata will be of no avail. 
 
 There is a definite mode of procedure: put the patient crosswise in 
 bed in the lithotomy position, with the pelvis turned slightly to 
 the right side. Anoint the anal region well with vaseline, and also 
 the rectal tube, which should be of soft rubber, 3 or 4 feet in 
 length. In the case of an infant, a rubber catheter will serve. 
 Guide the catheter with the left index finger, and as it enters the 
 rectum direct it backward at first and then slightly to the left. 
 Keep hold of the tube close up to the rectum, the better to control 
 it. Push the tube a little at a time, and if it meets with the ob- 
 struction, withdraw it slightly, and advance it with a boring move- 
 ment. Any force may result in the tube merely coiling up in the 
 rectum, the doctor in the meantime having the impression that it 
 is ascending high in the bowel. Sometimes it is advantageous to 
 let the injection flow as' soon as the first part of the tube is intro- 
 
TREATMENT OF OBSTRUCTION 597 
 
 duced, as by that means the rectum is dilated and Houston's valves 
 are not so likely to intercept the tube. The tube must be introduced 
 as high as possible without using force. In the great majority of 
 cases it goes no higher than the sigmoid. 
 
 Attach the fountain syringe, holding it low at first and gradually 
 raising it to increase the pressure. It should not be raised much 
 more than 3 feet above the patient's level. The quantity of 
 fluid, either warm salt solution or oil, which may be injected, varies 
 with the age, say 1 pint for the infant and 4 to 6 quarts for the 
 adult. 
 
 When the injection is completed, withdraw the tube rapidly, and 
 lay the patient back in bed. The enema will be expelled sooner or 
 later with severe colicky pains. If ineffective, it returns practically 
 clear. If it has done good, it will be accompanied by flatus, and, 
 at the last, there will be some hard lumps. The final evacuation 
 may not take place for some time, but the escape of gas is a good 
 indication that the obstruction has been at least temporarily 
 relieved. 
 
 If this has not done good, the enema should be repeated with the 
 patient in the knee-chest position. 
 
 Lejars recommends the " electric bath" as efficacious in many 
 cases, but this treatment is scarcely applicable in general practice. 
 
 On the whole, the treatment is surgical; and the doctor must have 
 it on his conscience that if the case is acute obstruction, delay is 
 dangerous or even fatal. The point is to make the diagnosis quickly, 
 and when that is made, there is only one thing to do, operate. 
 
 The practitioner will hesitate between two procedures, median 
 laparotomy and artificial anus. 
 
 Median laparotomy is the ideal operation. It, alone, is curative, 
 for the cause of the obstruction is found and relieved; but it is deli- 
 cate and dangerous. These are the conditions which Veau formu- 
 lates, under which alone the doctor must undertake it: 
 
 (a) The operator must be experienced and resourceful, for it is 
 often difficult to locate the cause and equally difficult to remove it, 
 and the distended bowel is always a source of embarrassment. 
 
 (b) The operation must be conducted where there are the surgical 
 accessories and capable assistants. 
 
59& ACUTE INTESTINAL OBSTRUCTION 
 
 (c) The diagnosis must have been perfected, so that the operator 
 knows about what he will have to do. 
 
 (d) The patient must be vigorous and able to stand a tedious and 
 prolonged operation. 
 
 These conditions are nearly always lacking when the doctor is 
 thrown absolutely upon his own resources, so it may be laid down as 
 a rule that the general practitioner must choose the second pro- 
 cedure. 
 
 An artificial anus will usually save the patient's life and is within 
 the skill of any doctor under almost any 
 circumstances. After the patient has later 
 regained his strength, the operation neces- 
 sary to complete a cure may be under- 
 taken. It will not be an emergency opera- 
 tion, and the time and place maybe chosen. 
 To make a temporary artificial anus will 
 be the proper procedure under the circum- 
 stances indicated. There is a single nota- 
 
 FlG ' 433 (7^rrr Pti ° n ' ble exce P tion: if the Patient is a child with 
 
 an undoubted attack of intussusception, 
 and if the enemas have failed to give relief, it is imperative to 
 do a laparotomy (Fig. 433). 
 
 LAPAROTOMY FOR INTUSSUSCEPTION 
 
 Intestinal invagination or intussusception occurs only in the first 
 years of life for the reason that the mesentery lacks resistance at 
 that age. It occurs at a point where a mobile part of the bowel 
 joins a part more fixed and is most common at the ileocecal junction. 
 
 As a result of colic or spasm the ileocecal valve protrudes into the 
 cecum and is followed by the ileum and its mesentery which alone 
 limits the extent to which the large instestine may swallow the small 
 bowel. 
 
 A thickened band or collar marks the line where the two parts 
 come in contact, and this collar is usually tight; after a little while 
 adhesions may here occur between the invaginating and invaginated 
 parts. 
 
INTUSSUSCEPTION 599 
 
 Here the strangulation occurs and the symptoms are proportional 
 to the degree of strangulation and the rapidity with which it 
 occurs. 
 
 A case reported by Estes (American Journal of Surgery, August, 
 1906) illustrates the subject and emphasizes the danger of expectant 
 treatment. 
 
 A girl of three years in fair health, three days before had been 
 seized with violent abdominal pains with straining and tenesmus. 
 At first the passages were fecal and then mucous, tinged with blood. 
 She had intervals of apparent ease when she would play with her 
 toys and ask for something to eat. After three days' treatment by 
 enemas and light laxatives, she developed signs of complete obstruc- 
 tion. The abdomen was distended, vomiting frequent and at last 
 feculent; there was persistent pain, rapid, weak pulse, and general 
 weakness. At this time Estes was called and found a very pale, 
 emaciated, weak, suffering baby, with pulse 130, and temperature 
 101 . She was vomiting every half -hour. No distinct tumor could 
 be felt, but there was some thickening in the right iliac region. 
 Through that night, while preparing for the operation next morning, 
 she was given some strychnia and morphia and saline enemas, which 
 produced an improvement. 
 
 Operation — median incision. A hand passed into the right iliac 
 fossae located the sausage-shaped tumor of an ileo-cecal intussuscep- 
 tion. Turning the child to get the intestines out of the way, gentle 
 milking motions were made and almost immediately the intussuscep- 
 tion was reduced. Inspection showed a very much thickened and 
 inflamed section of the ileum about 6 inches long. It was decided 
 not to exsect the injured gut. The torn border of the mesentery 
 was sutured, the peritoneal coat bathed with hot saline solution, 
 dried, sprinkled with aristol and replaced, and the abdomen rapidly 
 closed. The child made a rapid and uninterrupted recovery and 
 has been quite well ever since. 
 
 The principal steps in the operation are as follows : 
 
 (1) Median laparotomy. Be careful in opening the peritoneum 
 not to wound the distended bowel. Expect to find trouble in the 
 management of the bowel. A skillful assistant is a great comfort in 
 this matter. 
 
(>oo 
 
 ACUTE INTESTINAL OBSTRUCTION 
 
 Search far the obstruction. The obstruction is usually easily 
 found in intussusception. After the abdomen is opened, proceed 
 directly to the right iliac fossa, having no fear to introduce the whole 
 hand, if gently done. In any case the cecum is first to be examined, 
 for by its condition one can determine whether the obstruction is in 
 the large or small intestine. 
 
 The sausage-shaped tumor (in the case of intussusception) is 
 pulled up into the wound and its topography carefully noted and 
 the integrity of the gut determined. If there are no adhesions, if 
 
 Fig. 434. — Senn's method of performing taxis in reducing an invagination. 
 
 there are no appearances of gangrene; in other words, if the accident 
 is recent, try to reduce the bowel. 
 
 (3) Disinvaginate, following the procedure of Senn, which has 
 for its aim first to reduce the edema. This is to be accomplished by 
 tdy and uninterrupted manual compression of the tumor, 
 soon as the swelling is reduced, grasp the bowel below the tumor 
 and press gently but firmly against the apex of the intussusceptum, 
 at the same time making easy traction at the other end (Fig. 434). 
 Remember it is easy to tear the bowel or mesentery. 
 
INTUSSUSCEPTION 
 
 60 1 
 
 When the bowel is reduced, examine again for gangrene. If 
 there are points of disintegration, cover them in by Lembert sutures. 
 If the whole segment of the bowel is gangrenous, it must be resected; 
 or if doubtful, retained in the wound for further inspection. If the 
 bowel is not impaired, wash and return; and the operation is com- 
 pleted by the repair of the abdominal wall. 
 
 If, as Senn says, repeated attempts at reduction fail, one of two 
 courses must be pursued: the establishment of an intestinal anasto- 
 mosis or resection of the invaginated portion; but the latter, on ac- 
 
 Fig. 435.- 
 
 -Intussusceptum 
 (Guibe.) 
 
 exposed. 
 
 Fig. 436. — Intussusceptum resected. 
 (Guibe.) 
 
 count of the time required, must not be undertaken unless the 
 invaginated parts are gangrenous. 
 
 The anastomosis between the parts of the bowel above and below 
 the invagination may be accomplished by suture or the Murphy 
 button. The technic of resection of the invaginated portion is 
 represented in Figs. 435, 43 6 > 437> and 43 8 - 
 
 The predisposing cause of these attacks of intussusception is often 
 acute indigestion. 
 
 The pain, which is the first symptom, is often merely colicky at 
 first, but later may be persistent. Vomiting is common but not 
 
6oa 
 
 ACUTE INTESTINAL OBSTRUCTION 
 
 nearly so severe as in other forms of obstruction, nor does it appear 
 irlv. The temporary relief following the vomiting is character- 
 istic of intussusception. The nearer the duodenum the invagination 
 is situated, the more severe the vomitus. Rigidity is not an early 
 symptom. Distention is absent until late. Tenderness is also a 
 late symptom; indeed, in the early stages, pressure may give relief. 
 The presence of a tumor is of great diagnostic value; it is usually 
 movable, hard, and resistant. Its size gives no idea of the amount of 
 
 Fig. 437. — Anastomosis after resection. 
 (Guibe.) 
 
 Fig. 438. — Repair of the bowel and appli- 
 cation of Lembert sutures over the site 
 of anastomosis. (Guibe.) 
 
 
 bowel involved. Tenderness is a severe and early symptom; thirst 
 not marked. Early diagnosis and early operation are the life-saving 
 factors in these cases. 
 
 POST-OPERATIVE ILEUS 
 
 The acute obstruction of the bowel which may — which too often 
 does — follow laparotomy is one of the tragic accidents of surgery. 
 An operation of comparative simplicity may terminate uneventfully; 
 the patient rallies from the anesthetic, seems to feel well, and with 
 
 en 
 
POST-OPERATIVE ILEUS 603 
 
 the family is happy at the thought of danger passed. Twenty-four 
 hours pass and it is noticed that the temperature falls to subnormal 
 perhaps, and then begins slowly to rise. The pulse, at first 90 to 
 ioo and of fair volume, slowly increases in rate while decreasing in 
 force. The patient's mind, perfectly clear in the first instance, 
 begins in a little while to be disturbed, and he grows anxious as to 
 the outcome or perhaps calmly forecasts the end. 
 
 In the meantime the tympanites has become marked, but no gas 
 passes per rectum; and there is no sign of movement or peristalsis, 
 in the distended gut. The pain is not severe, the chief distress is 
 want of air; the patient complains that he cannot get a good breath; 
 nausea develops, and finally continuous vomiting. If, now, the 
 ordinary means of relief of gaseous distention fail and the symptoms 
 do not in any respect improve, one may conclude that he has to deal 
 with an intestinal paralysis. In simple tympanites the pain is 
 colicky in its nature, there is little disturbance in pulse and tempera- 
 ture, the vomitus is more nearly normal in character. But in spite 
 of these distinguishing features, it may be impossible to say, during 
 the first few hours, whether the obstruction is serious or not. In 
 any event, certain measures should be employed: If there is much 
 nausea or any evidence of gastric dilatation the stomach should be 
 washed out and %o grain calomel given every half -hour for at least 
 ten doses. At the other end of the alimentary tube, the attempt at 
 relief is begun with an ordinary soapsuds enema. If no flatus passes, 
 a Watkin's enema is next to be tried, or one which consists of 
 
 Magnesia sulphate, 
 Glycerin, aa § ij 
 
 Turpentine, 5 J 
 
 A large tube should be employed, but no effort made to introduce 
 it high. Elevate the hips and inject the fluid slowly, and thus let it 
 find its own way up the bowel. If gastric lavage and the persistent 
 use of enemas fail to give any relief, if the judicious use of hypodermic 
 injections of morphin and atropia, eserine, and pituitrin are with- 
 out effect to awaken the intestine or to sustain the patient's vitality, 
 the only thing left which offers any hope is an enterostomy. This 
 may be done under local anesthesia. The bowel through this open- 
 
(>04 
 
 ACUTE INTESTINAL OBSTRUCTION 
 
 ing is to be kept washed out with normal salt solution. By this 
 means the toxemia may be kept under control until the patient's 
 forces rally. 
 
 Bui p after all, the chief treatment of post-operative intestinal paral- 
 ysis is prophylactic and preventive. By washing out the stomach, 
 by having the bowel well emptied with castor oil, by treating the 
 exposed gut with scrupulous care, one may hope to reduce these 
 accidents to the minimum. Slight traumatisms of the mesentery 
 in the course of the operation, slight infections introduced in the 
 clean cases are at the bottom of these surgical disasters. If they 
 result from infections already fixed upon the peritoneum before 
 operation, the surgeon may have a balm for his conscience but no 
 excuse to relax his precautions. 
 
 In all operations in which there is a diffused peritonitis in order to 
 
 prevent post-operative ileus, Heile injects 50 to 100 c.c. castor oil in a 
 
 oop of the small intestine. The puncture of the gut is closed by a 
 
 small silk suture. He claims excellent results. (Zeitblatt f . Chirurg. 
 
 Leipsic, July 31, 1909.) 
 
 
CHAPTER X 
 ARTIFICIAL ANUS: TEMPORARY; PERMANENT 
 
 TEMPORARY ARTIFICIAL ANUS— ENTEROSTOMY 
 
 An acute obstruction of the bowel may necessitate a temporary 
 drainage through the abdominal wall. This will be the case when 
 circumstances such as environment, lack of experience, assistance, or 
 equipment preclude a laparotomy; or even when a laparotomy is 
 done and it is found impossible at the time to remove the cause. 
 
 Enterostomy is therefore a life-saving operation which every 
 practitioner must know how to perform. 
 
 The operation proposes opening the abdomen, anchoring a loop of 
 intestine in the abdominal wound and opening this loop to secure 
 drainage. The incision will be made ordinarily in the right iliac 
 fossa and the opening in the bowel made above the obstruction. 
 For that matter, one need scarcely fear that he will open into the 
 bowel below the constriction, for it is only the distended portion that 
 will present. It is preferable to open the cecum, but if it is not avail- 
 able, whatever loop presents will do. 
 
 No special instruments are required. It is a good idea to haye 
 several needles already threaded with silk No. o or No. i. Local 
 anesthesia may suffice. 
 
 Incision. — Begin by dividing the skin and fat along a line two 
 fingers' breadth from the anterior superior iliac spine, parallel with 
 the fibers of the external oblique — an incision about 3 inches long, 
 whose central point corresponds to the anterior superior iliac spine 
 (Fig. 439). Catch up the two or three bleeding points. 
 
 This first incision exposes the external oblique (Fig. 426) and the 
 second divides that muscle in the same line. Catch up the edges of 
 the divided muscle. In the same manner, the third incision divides 
 the internal oblique and transversalis, and finally exposes a fibrous 
 layer, the transversalis fascia, which is carefully divided in order to 
 
 605 
 

 ARTIFICIAL ANUS! TEMPORARY; PERMANENT 
 
 reach the peritoneum (Fig. 428). Pick up a fold of that membrane 
 with the dissecting forceps and incise it at its base, remembering 
 that the distended bowel is in close contact (Fig. 422). 
 
 A reddish fluid escapes as soon as the peritoneum is opened; seize 
 each lip with forceps and enlarge the opening, but not to the full ex- 
 tent of the skin wound. Restrain the bulging gut with compresses. 
 Introduce the index finger and examine in various directions for a 
 source of obstruction. Happily it may be found and relieved with- 
 
 Fig. 439. — Trace of incisions for artificial 
 amis: on the right, temporary; on the left, 
 permanent. (Veau.) 
 
 Fig. 
 
 -Locating the cecum, 
 
 out loss of time. Usually, however, it will not be and one must not 
 persist in his search or effort at relief. Attempt next to locate the 
 cecum, passing the index finger down into the iliac fossa, following 
 the external wall (Fig. 440). 
 
 If successful in locating it, pull it up into the wound with index 
 finger and thumb and hold it with two artery forceps. It is easily 
 identified by the appendices epiploicae and by its bands. If the 
 cecum cannot be reached, employ any loop which presents. 
 
 Anchor the bowel. The bowel is sutured to the abdominal wall 
 in this manner: Commence at one angle, passing the needle through 
 
TEMPORARY ARTIFICIAL ANUS 
 
 607 
 
 the parietal peritoneum of one side, through the serous and muscular 
 coats of the bowel, and through the peritoneum of the opposite side. 
 
 Fig. 441. — Attaching the bowel in the angle Fig. 442. — Attaching the bowel laterally. 
 of the wound. (Veau.) (Veau.) 
 
 Fig. 443. — Diagram showing disposition of Fig. 444. — Opening of the bowel with 
 sutures. (Veau.) thermocautery. (Veau.) 
 
 Tie, but do not cut the threads (Fig. 440). Now make on each side 
 three or four "U" sutures % inch apart in this manner: the 
 needle passes through the parietal peritoneum, the mucous and 
 

 ARTIFICIAL ANUS: TEMPORARY; PERMANENT 
 
 muscular coats of the bowel, and out through the parietal peritoneum 
 of the same side. Do the same on the opposite side (Fig. 442). 
 Collect the loose ends of the sutures of the same kind in one forceps. 
 In placing the sutures, do not let the protruding segment of bowel 
 get folded or wrinkled. 
 
 Suture the remaining angle in the same manner as the first and 
 complete the repair of the peritoneal wound. The loop of bowel 
 may not occupy all of it and these peritoneal sutures are cut short at 
 once. (The relative position of the sutures is represented in Fig. 443.) 
 
 Now repair the superficial wound by interrupted sutures in two 
 
 Fig. 445. — Temporary artificial anus. 
 (Veau.) 
 
 Fig. 446. — Incisions for temporary and 
 permanent artificial anus. (Veau.) 
 
 layers, one reuniting the muscles and fascia; the other, the skin. 
 The opening left immediately over the anchored gut is about an 
 inch in length. Cut the threads short. 
 
 Open the bowel. This is reserved for the last, and here the long 
 threads of the lateral bowel suture, left until this time, are used to 
 pull the bowel well into view (Fig. 444). Incise it with the bistoury 
 for about an inch, and there is an immediate escape of gas. 
 
 Cut short all the sutures. The bowel will not immediately empty 
 i t self. It will require possibly twenty-four hours, during which time 
 the dressing should be changed every half-hour, afterward twice 
 daily is sufficient. 
 
PERMANENT ARTIFICIAL ANUS 
 
 609 
 
 Remove the cutaneous sutures on the sixth day, else later they will 
 become septic. Apply ointments to the inflamed skin. 
 
 When the bowel is once emptied, which may require as long as 
 twenty-four hours, seek to locate the site of the obstruction and to de- 
 termine its nature. See if an enema will find exit at the wound or if 
 an injection at the wound will discharge per anum (Fig. 445). A 
 
 FlG. 447. — Opening the peritoneum. (Guibe.) 
 
 month later when the patient has regained his strength, if the bowel 
 has not become normal, send him to a specialist. 
 
 PERMANENT ARTIFICIAL ANUS 
 
 This operation, palliative in the treatment of cancer of the rectum, 
 comes within the scope of every doctor. It may even be regarded as 
 an emergency. There may come a time in the history of the case 
 when the content of the bowel can no longer pass and the pain is un- 
 bearable. Then the operation will give great relief. The patient 
 suffers little pain after the operation, gains in weight, believes that he 
 is going to get well, and so dies happy. 
 
 In this case, the opening is to be in the sigmoid; it may need to be 
 39 
 
OlO 
 
 ARTIFICIAL ANUS! TEMPORARY; PERMANENT 
 
 large. The bowel is completely divided transversely and the two 
 ends anchored separately in the wound. 
 
 Fig. 448. — The sigmoid flexure drawn out through the incision. Note the appendices 
 
 epiploic®. (Vedu.) 
 
 Fig. 448. — A forceps used to make an opening in the mesentery. (Veau.) 
 
 The operation is best done in two stages. In the first, the sigmoid 
 is drawn out and permitted to acquire adhesions. Subsequently the 
 loop is resected. 
 
PERMANENT ARTIFICIAL ANUS 
 
 6ll 
 
 First Stage. — An incision 2 inches in length is made obliquely 
 over the left iliac fossa, a couple of fingers' breadth within the an- 
 terior superior spine. The lower end of the incision reaches to just 
 above the level of the spine (Fig. 446). Dividing the skin and cellu- 
 lar tissue, there will be some small vessels to ligate. The fibers of the 
 
 Fig. 450. — Bowel retained by strip of iodoform gauze. (Veau.) 
 
 external oblique appear, running parallel with the incision. Separa- 
 rate them in the line and length of the skin incision by blunt dissec- 
 tion. Widely separate the two portions of the muscle with retractors. 
 In the bottom of the wound are seen the fibers of the internal 
 oblique and transversalis which lie at right angles to the external 
 oblique. Open through them by blunt dissection in the direction of 
 their fibers and retract (Fig. 447). 
 
 Fig. 451.' — Dividing the loop with the thermocautery. (Veau.) 
 
 Divide the transversalis fascia and expose the peritoneum. This 
 is opened and its lips seized with the forceps. Remove the retractors 
 
 Search for the sigmoid. Introduce the index finger into the iliac 
 fossa, following the posterior wall until arrested by the meso-sigmoid. 
 In this manner locate the sigmoid flexure, and with finger and thumb. 
 
6l2 
 
 ARTIFICIAL ANUS: TEMPORARY; PERMANENT 
 
 draw it to the surface by gentle but persistent traction. It can be 
 felt to yield. Once the loop is exposed, the only difficulty is over- 
 come. The sigmoid is identified by the appendices epiploicae 
 (Fig. 448). 
 
 Spread out the gut and find the least vascular part of the exposed 
 mesentery and this part transfix (Fig. 449) with a closed forceps. 
 Opening the forceps, let it seize a roll of iodoform gauze of the caliber 
 of the index finger and draw it into place. It will hold the bowel in 
 position (Fig. 450). 
 
 Fig. 452. — Upper orifice com- 
 municates with bowel; lower with 
 rectum. (Veau.) 
 
 Fig. 453. — Permanent artificial anus. 
 External opening of bowel with spur 
 leading to rectum. (Veau.) 
 
 If the cutaneous wound is too large and does not fit closely to the 
 projecting loop, it may be diminished by a suture or two. 
 
 Dress with sterile gauze and do not change until ready to resect, 
 unless the dressing becomes loosened or soiled. Keep the patient 
 on a light diet, chiefly milk. 
 
 Second Stage. — Resect the bowel. On the second or third day, when 
 the bowel has acquired adhesions, return with a thermo-cautery and 
 artery forceps; there might be an arteriole to ligate. No anesthesia 
 is necessary, for the gut is quite insensitive. 
 
 The thermo-cautery is heated to a dark red (if at a white heat 
 there may be a little bleeding), and with it the bowel is completel) 
 
PERMANENT ARTIFICIAL ANUS 613 
 
 divided. Do not stop until the roll of iodoform gauze is completely 
 exposed. The few minutes required will necessarily seem a long 
 time, but do not get disturbed (Fig. 451). When the section is 
 complete, the gauze may be readily removed (Veau) . 
 
 Apply a dry dressing. On the second day give a laxative. After 
 a while the patient will be able to regulate his passages to a degree. 
 
 Through the lower orifice the cancer may be douched and the 
 fluids will find their way out per anum (Figs. 452, 453). 
 
 Do not neglect to warn the family that the end must come within 
 from eight to fifteen months. As for the patient, it were better to 
 ease his mind by vague references to the future closure of the wound 
 so repulsive to him. 
 
CHAPTER XI 
 STRANGULATED HERNIA 
 
 What doctor in general practice has not had his experiences with 
 strangulated hernia? And how many have escaped the conviction 
 that it is an emergency deserving its evil fame? 
 
 But, after all, its sinister reputation our predecessors have be- 
 queathed us and, along with it, interminable discussions touching the 
 agent of constriction and the indications for taxis. 
 
 To-day we reverently lay aside those old notions, for we know that 
 no other equally dangerous condition yields better results to appro- 
 priate treatment. By " appropriate treatment " is meant early opera- 
 tion. The indications for operation there is no need to discuss, for 
 operation is always indicated. 
 
 Taxis is an exceptional procedure, permissible only as a tentative 
 measure under certain well-defined restrictions; and even then to be 
 used with fear, for who can certainly tell that he has not reduced 
 gangrenous and perforated gut; and who but the most experiencec 
 may not be misled by certain forms of incomplete reduction? 
 
 The danger from strangulated hernia was formerly supposed tc 
 arise solely from interference with the circulation and the consequent 
 gangrene of the incarcerated loop, and the attention was centered 
 chiefly upon the mechanical element. It was perhaps legitimate 
 upon that hypothesis to treat expectantly or by repeated efforts at 
 taxis an incompletely strangulated hernia. 
 
 But now it is definitely determined that the chief source of danger 
 is septic absorption, and in a given case long before the incarcerated 
 bowel has ceased to be viable, the patient may be overwhelmed by 
 toxins of a virulent type. It is this systemic poisoning that makes 
 strangulated hernia dangerous, and which especially makes the 
 operation dangerous. It is for that reason that procrastination is 
 
 614 
 
DIAGNOSIS OF STRANGULATION 615 
 
 so often fatal. So frequently it happens with these attacks that after 
 hours of waiting, or after repeated efforts at reduction, the patient is 
 finally turned over to the operator; and though the operation be of 
 short duration and simple, yet the patient dies, for the reason that 
 his powers of resistance were paralyzed by sepsis unsuspected. He 
 was a veritable victim of delay. 
 
 The thought to be kept uppermost, then, in treating strangulated 
 hernia is not so much that the bowel is becoming gangrenous as that 
 sepsis is imminent. . 
 
 The diagnosis is not difficult, as a rule. Usually the patient is 
 known to have a hernia; suddenly it becomes painful and irreducible; 
 the bowels refuse to move and become tympanitic; nausea and vom- 
 iting ensue; and there are signs of circulatory depression. The gen- 
 eral symptoms are, in fact, those of intestinal obstruction. The face is 
 drawn and pinched, the lips white and the eyes sunken. There is a 
 clammy sweat. The symptoms may all be mild at first, especially 
 when the obstruction is not complete, or in the aged or debilitated, 
 or if the bowel is surrounded by omentum which at first bears the 
 brunt of the compression. It must be kept in mind that this mild 
 onset may be wholly deceptive. 
 
 It may be necessary to distinguish between an inflamed and ob- 
 structed irreducible hernia on the one hand and strangulated hernia 
 upon the other; in the first, pain and vomiting are not so severe, 
 there is no collapse, and an impulse in coughing can always be 
 detected. If a hernia was not before suspected, a careful examina- 
 tion for one must be made in cases of intestinal obstruction. Small 
 sciatic or obturator herniae are easily overlooked. This is likewise 
 true of small femoral hernia in fat subjects. 
 
 Torsion of the spermatic cord or strangulation of an undescended 
 testicle may simulate strangulated hernia, but the indurated and very 
 painful inguinal tumor, together with the cryptorchism, should 
 suggest the nature of the attack. 
 
 As Senn says, the differential diagnosis between a suppurative 
 lymphadenitis in the groin and a strangulated inguinal hernia may be 
 very difficult. He points out the necessity for caution in using the 
 knife if the inflammatory swelling is single and occupies the site of 
 a femoral hernia. In such a case the supposed gland should be 
 
OK) STRANGULATED HERNIA 
 
 approached by a careful dissection. If it proves to be a hernia no 
 harm is done. 
 
 An accumulation of peritoneal fluid in the imperfectly closed proc- 
 essus vaginalis in the very young may give rise to symptoms of 
 strangulation, but strangulated hernia is rare in infants. In such a 
 case, inversion of the patient for a few minutes will often empty the 
 sac and clear up the diagnosis. 
 
 As has been said the indication for treatment is operation as soon as 
 the diagnosis is made. There are, however, exceptional instances in 
 which judicious efforts at taxis may be applied without greatly 
 prejudicing the prognosis. But it is recommended without enthu- 
 siasm and only out of due respect to those circumstances of time and 
 place which seem to preclude immediate herniotomy. 
 
 Taxis and operation, then, represent the sole measures of relief. 
 Certainly no doctor at the present time would expect anything but 
 harm from the use of drugs. 
 
 As Senn says (Practical Surgery), no modern physician would for 
 a moment consider seriously the therapeutic value of nauseating 
 enemata, or the internal use of relaxing antispasmodic remedies, so 
 much relied upon in facilitating taxis before herniotomy was shorn of 
 its great mortality by the introduction of antiseptic surgery. 
 
 Taxis. — Taxis, or the reduction of a hernia by methodical manipu- 
 lation without instruments, is permissible only under these circum- 
 stances: (a) The case is seen soon after the strangulation began; 
 the hernia is of moderate size; the abdominal symptoms are not 
 severe. 
 
 (b) The patient is an old man debilitated, manifestly a poor sub- 
 ject for an operation; he has had trouble before; it is only a few 
 hours since his hernia became irreducible. 
 
 Under these circumstances use taxis, and it will not be dangerous 
 if properly applied and not repeated. The further proviso must be 
 made that if it fails an immediate operation must be done. In the 
 milder cases Senn advises that taxis may sometimes be facilitated by 
 administering a dose of opium and giving a high enema. A full hot 
 bath in many instances has an excellent effect. 
 
 In the severer cases a general anesthesia is always required. Before 
 beginning the anesthesia prepare the patient for operation so that 
 
REDUCTION BY TAXIS 617 
 
 if taxis fails no time need be lost and a single anesthesia will serve 
 both for the taxis and the operation. Chloroform is usually prefer- 
 able to ether if it is expected that taxis will succeed. It permits 
 a greater relaxation. 
 
 Technic of Taxis: Inguinal Hernia. — Elevate the hips, flex and 
 separate the thighs in order to relax the external ring. Grasp the 
 tumor with the right hand (hernia on right side) so as to compress 
 it uniformly with the tips of the fingers, and thumb. Seize the 
 neck at the external ring between the thumb and forefinger of the 
 left hand. While the right gently compresses the tumor, the left 
 empties the gut by stripping in the direction of the external ring at 
 first, and later along the inguinal canal. The sole aim of this first 
 maneuver is to empty the gut. The manipulations must be 
 made methodically, without interruption and without force. If 
 compression reveals the presence of a doughy mass, it is omentum, 
 and as it probably occupies the lower part of the sac it will be better 
 to compress nearer the neck in order to deal more directly with the 
 intestine. Sometimes, to make traction on the tumor while the 
 fingers at the neck continue the kneading will start the bowel con- 
 tents toward the abdominal cavity. If the tumor under these manipu- 
 lations grows smaller and softer, it is some guarantee of success. 
 When the bowel is sufficiently emptied, it then becomes reducible 
 and its return to the abdominal cavity is announced by a gurgling 
 or a marked sense of yielding. 
 
 When the bowel is reduced, the omentum, if present, should be 
 returned in the same manner. One should not persist if the mass 
 is thick and adherent for there is risk of rupture of an omental vessel, 
 which may be followed by hemorrhage, all the more grave because 
 unperceived. 
 
 After the hernia is reduced the patient must be put to bed and no 
 food by mouth permitted for at least twenty-four hours. Before 
 getting about, a truss must be fitted. 
 
 If after ten or fifteen minutes of gentle effort the hernial tumor 
 remains unchanged in size and hardness, it is a waste of time to 
 prolong the procedure. It cannot be said too often that repeated at- 
 tempts are injurious, becoming with each repetition more and more 
 harmful and illusory. 
 
6i3 
 
 STRANGULATED HERNIA 
 
 It may happen that after the hernia has been apparently reduced 
 the symptoms of obstruction still persist, or even if at first relieved, 
 appear again. The tympanites augments, the nausea and vomiting 
 continue, and the signs of sepsis progress. It is evident that some- 
 thing is amiss. One of several things may have happened, but no 
 time is to be wasted in conjecture, for only the operation which must 
 follow will definitely clear up the doubt. 
 
 It may be that the hernial tumor has been reduced en masse, 
 The hernial sac and its contents have been carried through the ex- 
 ternal ring without having changed their relations and the constric- 
 
 ^ 
 
 \: 
 
 Fig. 454. — Strangulated hernia reduced 
 "en masse" (Moullin.) 
 
 Fig. 455. — Incomplete reduc- 
 tion of strangulated loop. Hernia 
 in a diverticulum. (Moullin.) 
 
 tion persists (Fig. 454). This can occur in recent hernia in which 
 the sac is not adherent and is most common in the direct form of 
 inguinal hernia. 
 
 It may be that instead of entering the peritoneal cavity the herni- 
 ated loop has entered a diverticulum of the sac near the neck and 
 there becomes once more strangulated (Fig. 455). 
 
 It may be that the neck of the sac has torn loose from the rest of 
 the sac and has been reduced with the gut, the strangulation still 
 being maintained (Fig. 456). 
 
 Vgain, a rent may be torn in the sac and the gut escaping there- 
 
HERNIOTOMY 
 
 619 
 
 from pushes up between the peritoneum and the abdominal wall 
 (Fig. 457). 
 
 Finally the reduction may have been complete, but the gut was 
 gangrenous or ruptured and a general peritonitis follows, due to the 
 escape of the intestinal contents; or the peritonitis may even be 
 due to the infection from the sep- 
 tic fluids in the sac. 
 
 Femoral and Umbilical Hernia. 
 — These forms of strangulated 
 hernia require the same modes 
 of procedure as the inguinal but 
 are likely to present more obsta- 
 cles. In the case of femoral her- 
 nia, if complete, the pressure 
 must be made downward toward 
 the saphenous opening at first, 
 and then upward along the fe- 
 moral canal. 
 
 In the case of umbilical hernia 
 the pressure must be made toward 
 the umbilical ring. Often the 
 Trendelenburg position is helpful. 
 The constant effort is first to 
 empty the gut and then reduce it. 
 
 In both these forms of hernia 
 the gut may be enveloped by a 
 mass of omentum which may not 
 be reducible and thus gives rise to 
 some doubt whether the gut has 
 been reduced. 
 
 Operation for Strangulated Hernia : Inguinal Hernia. — To repeat, 
 as soon as a hernia habitually reducible becomes painful and irre- 
 ducible and is accompanied by the signs of beginning prostration, 
 regard it as strangulated, and, aside from the exceptional cases 
 indicated, operate at once. Do not wait for fecal vomiting for that is 
 the last signal of exhausted nature — the precursor of death. 
 
 General anesthesia is usually necessary, although in some cases of 
 
 Fig. 456. — Strangulated hernia reduced 
 11 en masse." A. Upper end of the loop. B. 
 Neck of the sac torn off and reduced with 
 the bowel. C. Reduced loop still strangu- 
 lated. . D. Scrotal portion of sac. (Lejars.) 
 
6 jo 
 
 STRANGULATED HERNIA 
 
 profound sepsis local anesthesia with cocaine or stovaine suffices, 
 using Schleich's formula and injecting the various layers just before 
 dividing. No special instruments are necessary. 
 
 trgical Anatomy. — The special points to be remembered are the 
 situation of the abdominal rings, the relations of the external and 
 internal oblique and transversalis muscles to the inguinal canal, and 
 the location of the deep epigastric artery. 
 
 The external ring in -the aponeurosis of the external oblique lies 
 just above the spine of the pubes. The internal ring in the transver- 
 
 salis fascia lies 
 
 inch above the 
 
 Fig. 457. — Imperfect reduction by 
 taxis. Hernia outside the ruptured 
 sac. (MouUin.) 
 
 middle of Poupart's ligament. The 
 deep epigastric artery passing verti- 
 cally between the two rings, lies be- 
 tween the transversalis fascia and the 
 peritoneum. 
 
 The chief condition of operating 
 well is to see and recognize what is to 
 be divided. The coverings enumer- 
 ated with such care by the text- 
 books will not be distinguished, but 
 there is little danger of cutting into 
 the intestine, for before it can be 
 reached the sac must be opened, and 
 that is announced by the escape of a 
 characteristic sero-sanguineous fluid. The greatest injury to the 
 bowel is at the site of constriction, which may be at the external 
 ring, the internal ring, or the neck of the sac. 
 
 The preparation of the field of operation must be painstaking. The 
 pelvis must be shaved and scrubbed; the adjacent abdominal and 
 inguinal regions and the scrotum must be thoroughly disinfected; 
 and the penis after cleansing wrapped in a sterile compress. 
 
 First Step. Incision. Exposure of the Sac. — Begin with a skin in- 
 cision extending from the internal ring down to the spine of the 
 pubes; if it is a scrotal hernia, down to the middle third of the 
 scrotum (Fig. 461). Go directly through the skin and layers of fat 
 to the aponeurosis of the external oblique, dividing the branches of 
 the superficial epigastric artery. 
 
HERNIOTOMY 
 
 621 
 
 Expose the aponeurosis thoroughly and incise it from one ring 
 to the other. It is easily recognized by the oblique direction of its 
 fibers and its shiny look, and will serve during the operation as an 
 important landmark. The lips of this wound should be caught up 
 with forceps, especially at the external ring, to serve later as a guide 
 in beginning repair. 
 
 Once the aponeurosis is opened the sac is exposed and the next 
 effort is to isolate it preparatory to its incision. Separate it from 
 
 Fig. 458. — Strangulated inguinal hernia; primary incision. 
 
 the aponeurosis by careful blunt dissection around its whole circum- 
 ference and divide the remaining coverings layer by layer until the 
 sac is exposed and identified. Strip these coverings by blunt dis- 
 section, isolating the tumor up to the internal ring. 
 
 If these layers are much adherent one may be in doubt as to 
 whether it is the sac or the intestine which he has exposed. The 
 nature of the blood supply will settle the question, for the vessels of 
 the sac stand out distinctly, whereas those of the bowel are not 
 distinguishable in the uniform congestion. 
 

 STRANGULATED HERNIA 
 
 />. Opening flic Sac. — Catch a fold of the sac with dis- 
 secting forceps and cautiously divide the base of this fold with scis- 
 01 scalpel (Fig. 459). It may be one of the connective tissue 
 rings that is opened; divide it the full length of the wound and so 
 proceed until finally the hernial sac itself is opened, which will be 
 announced by a gush of bloody serum. Occasionally this serum will 
 be lacking, the bowel being in intimate contact with the sac, or even 
 adherent to it, but the bowel will be recognized by its uniform color- 
 ing and will be separated as the opening in the sac is enlarged. 
 Cautiously enlarge the opening till a finger can be introduced, and on 
 
 Fig. 459. — Opening the sac of a strangulated hernia. As soon as the sac is opened a sero- 
 sanguineous fluid escapes. (Guibe.) 
 
 it as a guide, split the sac close up to its neck (Fig. 460). When the 
 constricting band is reached slip the finger under it, if possible, and 
 divide it completely. If too tight for the finger, pass a grooved 
 director as a guide. In some cases it may be better to use a herni- 
 otomy knife, but wherever possible avoid cutting blindly. The con- 
 striction must be freely divided so that the intestine can be readily 
 drawn down for inspection. This step is not complete till that is 
 possible. 
 
 It may happen that there is a second constricting band higher up; 
 in such a case the forceps, which should always be attached to the 
 
HERNIOTOMY 
 
 623 
 
 lips of the incision in the sac, are useful in pulling it down so that 
 what is to be divided can be seen. 
 
 Third Step. Examination of the Intestine. — It is of the greatest 
 importance that the site of the constriction be examined, for the chief 
 lesions will be found there. Pull the gut down and observe the line 
 of demarcation between the healthy and injured tissue (Fig. 461). 
 
 Fig. 460. — Dividing the constricting fibers of the strangulated inguinal hernia. The parts 
 should be well exposed. (Guibe.) 
 
 One of the several conditions will be present and the line of procedure 
 will depend upon the one which is found. 
 
 1. The intestine is sound; that is to say, it has a uniform, dark 
 violet color, most marked at the site of the constriction where it 
 is lustrous. There is no erosion of the serous covering. Douching 
 the bowel with warm normal salt solution restores its tonicity, its 
 rounded outline, and after a few minutes it assumes a redder color 
 

 STRANGULATED HERNIA 
 
 and is to be returned to the abdominal cavity. Following this the 
 omentum which usually presents is to be inspected. If there is a 
 considerable mass or if its vitality has been compromised it should 
 be resected, using one or several ligatures as the case may require. 
 Before the stump is dropped back into the peritoneal cavity it must 
 iref ully inspected for bleeding points and should be sponged with 
 salt solution. 
 
 2. The intestine is slightly injured; that is to say, there may be 
 
 Fig. 461.— Examination of the strangulated loop. (Veau.) 
 
 several small zones of erosion exposing the muscular or even the 
 mucous layer. Bury these areas with a few Lembert sutures, repair 
 any injuries to the mesentery, and reduce. If the intestinal loop is 
 long, a methodical procedure may be required to prevent further 
 injury to tissues already compromised. The posterior segment of 
 the loop should be reduced first, as it probably was the last to come 
 down; in the meantime the anterior segment must be carefully sup- 
 ported. The least rudeness may result in a tear. 
 
 
HERNIOTOMY 625 
 
 3. The intestine is doubtful; that is to say, it has a color mottled 
 gray and purple. It does not recover its form under the douching, 
 but stays collapsed and flattened. Under these conditions it may 
 not be possible to say whether it is gangrenous or not, but it should 
 not be reduced. 
 
 Treves, however, advises reduction under these circumstances, 
 remarking (Operative Surgery, p. 534, Vol. II) that whatever theoret- 
 ical objections to this procedure may exist, practice has shown that 
 it may be safely carried out, assuming that this applies to a bowel 
 which is not actually gangrenous, but in a condition which may be 
 termed "doubtful." It is remarkable to what extent these doubtful 
 intestines recover. The idea is that the peritoneal cavity is the 
 most favorable site for recovery. 
 
 If the operator is inexperienced and not certain that he can dis- 
 tinguish between the bowel, possibly gangrenous, and that which has 
 actually lost its viability, he must wait. Wrap the loop in moist 
 gauze, and after twelve hours examine again. It may be gangrenous 
 or it may be viable, lustrous, reddened, rounded, and impels the be- 
 lief that it will become normal. With that belief, reduce it slowly 
 and carefully, breaking up the slight adhesions which have already 
 formed. 
 
 4. The intestine is obviously gangrenous; that it to say, the serous 
 coat has lost its luster, is blistered in spots, and can easily be stripped 
 off with the fingers; its color is ashen or even black, sometimes 
 mottled with white patches; there is a characteristic odor; the tissues 
 are friable; and there may be perforations. 
 
 In this case there is but one of two things to do : either anchor the 
 gut in the wound and make an artificial anus, or resect the bowel. 
 
 There can be no doubt that an enterectomy is the ideal procedure 
 since it eliminates a source of danger and permits the radial cure 
 of the hernia, but it is best not to undertake it unless skilled in intes- 
 tinal suture (which for that matter every doctor should know thor- 
 oughly how to do) for the time required may aggravate the shock 
 and insure a fatality; but the first consideration is to save life. (See 
 Enterectomy.) Allison, of Omaha (Jour. Minn. State Med. Assn., 
 Jan., 1908), takes a different view: " We believe primary end-to-end 
 anastomosis unjustifiable for, though we escape shock and peritonitis, 
 40 
 
626 STRANGULATED HERNIA 
 
 there yet remains the danger of permanent obstruction due to circu- 
 latory and septic changes, or a fatal paralysis due to distention and 
 mia. Artificial anus offers the best way out. The two-stage 
 operation is safer than the primary." 
 
 If an artificial anus is considered safest, pull enough of the gut out 
 to reach sound tissue. Pass a catgut suture through the abdominal 
 wall — that is, through the aponeurosis and the parietal peritoneum — 
 and then through the superficial coats of the bowel, then out through 
 the abdominal wall again to make the letter " U. " Employ four such 
 sutures at the cardinal points. To the gangrenous loop apply a moist 
 antiseptic dressing, changed hourly if the intestine was perforated. 
 If the intestine was not perforated, do not open it at once, but wait 
 a few hours till adhesions form. 
 
 It is then to be opened and the dressings must be frequently 
 changed, for the discharge will be abundant. Later the fistula may 
 gradually close of its own accord, more and more of the bowel con- 
 tents passing by the rectum; or to cure the fistula a difficult operation 
 may be necessary. (See Temporary Artificial Anus.) 
 
 Fourth Step. Ligation and Amputation of the Sac. — In every case 
 where the bowel may be returned to the peritoneal cavity, the treat- 
 ment of the sac is of the greatest importance. After the intestine 
 and omentum have been reduced proceed to disinfect and to dissect 
 the sac, if this has not already been done, remembering that the 
 structures of the cord may be very intimately connected with it and 
 hard to separate. In the strangulated cases the sac is usually 
 thick, but in the congenital cases it may be thin and friable. It is 
 b'est to begin by separating the sac completely from the cord at one 
 point, and then the dissection may proceed first toward the scrotum 
 and then toward the peritoneum. In some cases it is best to make an 
 incision through the whole circumference of the sac being careful 
 not to divide the main vessels of the vas, the two portions being the: 
 dissected separately, carrying one down to the scrotum if necessary; 
 the other, to the internal ring. Dry gauze dissection is the bes 
 method of separating these structures, as a rule. When the sac is 
 completely isolated the neck is to be freed quite into the abdominal 
 cavity, and then a finger is to be passed into the opening that any 
 omental adhesions may be detected or any concealed hemorrhage. 
 
HERNIOTOMY 
 
 627 
 
 Next, the sac is to be twisted and then ligated; or simple ligated as 
 high up as possible, and amputated. 
 
 In freeing the neck at the internal ring the subperitoneal fat is 
 usually seen; at this stage the bladder may be injured, and the point 
 is that any fatty tissues at the inner side of the ring must not be in- 
 cluded in the ligature, for this fat may conceal the bladder. 
 
 In ligating the sac it is best to transfix it rather than use the cir- 
 ular ligature. If the sac has been split so high that the neck cannot 
 
 Fig. 462. — Repair after relief of strangulated inguinal hernia. Suture of conjoined tendon 
 to Poupart's ligament. C, Cord; E, epigastric artery ;J?0, internal oblique. (Guibe.) 
 
 be defined, then the upper end of the peritoneal wound should be re- 
 paired with a few stitches so as to reconstruct the neck which is then 
 to be ligated. 
 
 Fifth Step. — This will depend upon the condition of the patient. 
 If his condition is serious, it is sufficient rapidly to reunite the apon- 
 eurosis and repair the skin incision. If a little more time may be 
 used, proceed to do the radical cure (Fig. 462). Unless this is done 
 
STRANGULATED HERNIA 
 
 recurrence is almost certain, but the operator cannot be held respon- 
 sible for that. In the urgent cases it is sufficient to have saved a life. 
 
 Whether the radical operation is attempted or not, employ drain- 
 The dressing must be carefully applied. 
 
 Subsequent Treatment. — The patient must have no food for twenty* 
 four hours. It may be necessary to employ salt solution freely. A 
 little ice may be given to quench the thirst. At the end of twenty- 
 four hours begin with small quantities of milk. Change the dress- 
 ings the second day, or sooner if much soiled. On the third or fourth 
 day give a laxative. Remove the drain on the fifth. Remove the 
 sutures on the eighth or ninth. Peritonitis may supervene if the 
 gangrenous areas have not been properly treated. 
 
 POSSIBLE COMPLICATIONS IN THE OPERATION 
 
 In the operation just described, the ordinary difficulties are indi 
 cated. But there are others, rarer, which may arise to disconcert th< 
 casual operator not forewarned. The actual operation is alwayi 
 easier if one has in mind all the possibilities. There may be unex 
 pected adhesions; there may be anomalies with resepct to the sac or 
 its contents, or there may be unsuspected conditions produced by 
 attempts at taxis. 
 
 Adhesions must be anticipated when the hernia is large and hai 
 been for a long time irreducible, and under these circumstance: 
 special precautions must be taken not to wound the bowel in openin, 
 the sac. The adhesions if recent and soft may be broken up with th 
 finger or grooved director keeping in close contact with the sac s 
 as to avoid the bowel. 
 
 If the adhesions are old and the union between the bowel or omen 
 turn with the sac firm and fibrous, it will be necessary to divide them 
 with scalpel or scissors, but this is a procedure requiring patienci 
 and a delicate touch. If necessary, long, band-like adhesions may b< 
 divided between forceps and subsequently ligated. 
 
 If, following the decortication, the raw surfaces ooze to any serious 
 extent, apply hot, moist compresses for a moment, and either this 
 will check the bleeding or at least reveal the site of the larger vessels 
 to be caught up with forceps. Usually a few applications of the hot 
 
 n 
 
COMPLICATIONS IN HERNIOTOMY 629 
 
 compresses will entirely suppress the oozing, or at least to such degree 
 as not to contra-indicate reduction; for when the bowel is no longer 
 bent and the circulation no longer interfered with the oozing will 
 spontaneously cease. 
 
 But it is chiefly injury to the bowel which is to be feared, not so 
 much because the rent may be difficult to repair as that some of the 
 septic contents of the bowel may escape. 
 
 If the adhesions cannot be broken up the only thing left is to remove 
 the source of the strangulation and leave the bowel outside. Occa- 
 sionally it will be found that the source of strangulation is in some 
 of the adhesions rather than the rings, or the neck of the sac; or, 
 again, so much scar tissue in the bowel wall leaves it inert and para- 
 lyzed. All these difficulties are more likely to occur in the neglected 
 cases. 
 
 A hernia of the cecum or sigmoid may present difficulties depend- 
 ing upon adhesions. It must be remembered that these two portions 
 of the large intestine are not completely invested by peritoneum; and, 
 in consequence, it may come to pass that when they slide down 
 through the inguinal canal a point is reached where a part of the bowel 
 is outside the hernial sac, and this surface acquires adhesions to the 
 scrotal tissues. In such cases these adhesions cannot be divided for 
 fear of wounding important branches of the mesenteric arteries, so 
 that to effect reduction a special procedure must be employed. 
 
 In the first place, when, on opening the hernial sac, these parts 
 of the large bowel are recognized, the neck of the hernia must be 
 freely incised and the abdominal walls as well. In fact, one does 
 what Lejars calls a hernio-laparotomy. 
 
 Next the hernial sac is separated from the spermatic cord and 
 then an effort is made to reduce the hernia en masse, returning, if 
 possible, the bowel and the peritoneal prolongation at the same time. 
 It will be a slow and tedious process. It is greatly aided by the Tren- 
 delenburg position. If the attempt fails, an artificial anus is the last 
 resort. 
 
 Among the anomalies of the sac which may bother the operator are 
 diverticula and double compartments. One may open into what ap- 
 pears to be the hernial sac and find it empty. In encysted hernia 
 the processus vaginalis may be filled with fluid which surrounds the 
 
030 STRANGULATED HERNIA 
 
 true hernial sac. A little study of the conditions will lead one to go 
 ahead and find and open the true hernial sac. 
 
 The hernial sac may push in between the peritoneum and the 
 muscular layers, bulging toward the iliac fossa or the bladder. This 
 is the pro- peritoneal hernia, and when it becomes strangulated it is not 
 likely a diagnosis will be made. Yet the presence of a tumor in the 
 inguinal region and the signs of intestinal obstruction will demand an 
 operation and again a hernio-laparotomy is indicated. The site of 
 strangulation is located and the bowel treated as in the ordinary 
 form of strangulated hernia. 
 
 In the interstitial form of hernia great difficulties may arise. The 
 incision is likely to be quite different from the ordinary since it fol- 
 lows the long axis of the tumor. Once the hernial sac is exposed it 
 must be freed from its adhesions to the muscles. The neck of the sac 
 corresponds to the internal ring, and if that is the site of constriction 
 it must be divided by cutting outward. The deep epigastric artery 
 lies to the inner side. 
 
 After the bowel is reduced and the sac ligated, the break in the 
 abdominal wall must be sutured, repairing the opening in each layer 
 separately. 
 
 The contents of the hernial sac may be abnormal. At some time 
 or other each of the abdominal organs except the pancreas have been 
 found herniated. It is the bladder which most often gives rise to 
 trouble. 
 
 It may be in the sac and appear as a second "sac" when the hernial 
 sac is opened. It presents as a rounded, reddish tumor, perhaps as 
 large as a hen's egg. Such a tumor should never be opened on sus- 
 picion, but a careful effort must be made to locate its limits by blunt 
 dissection. The fact that it leads down to, and behind, the pubes 
 clears up any doubt. It is to be reduced in the same manner as the 
 intestine. In other instances it is without the sac, lying to the inner 
 side of its neck and is perhaps intimately connected thereto. It may 
 be mistaken for a thickened portion of the sac or an adherent mass of 
 fatty tissue. 
 
 If it is opened into, the escape of urine and the evidence to the ex- 
 amining finger of a large mucous-lined cavity reveals the nature of the 
 accident and imposes immediate repair. 
 
APPENDIX IN HERNIOTOMY 63 1 
 
 A large hernia, easily reducible, or one whose size diminishes, fol- 
 lowing urination or the use of the catheter suggests hernia of the blad- 
 der; but, unfortunately, these signs are not available in strangula- 
 tion. In every herniotomy the danger of wounding the bladder must 
 be kept in mind. 
 
 Another point Lejars makes: One may expose a thin- walled trans- 
 parent cyst at the inner side of the neck of the sac, and unwittingly 
 open it only to find oneself working into the bladder. This trans- 
 parent cyst, in nowise resembling the bladder, is due to a hernia of the 
 mucosa of the bladder between the fibers of the muscularis. 
 
 Following the separation of the bladder from the hernial sac the 
 urine may be bloody for a day or two. This hematuria is of little 
 moment and soon clears up. 
 
 If the bladder is wounded its repair must precede everything else. 
 As soon as the injury is discovered, pack around the site with sterile 
 gauze, catch the edges of the wound with small forceps and suture, 
 uniting the mucosa first with a continuous catgut suture, and the 
 muscular coat with interrupted sutures, accurately applied; a third 
 line connects the superficial tissues. 
 
 The appendix may be found in the hernial sac, either inflamed or 
 normal. If the latter, it is to be removed in the ordinary way unless 
 time presses, in which case one must be satisfied with reducing it. 
 
 If the symptoms of strangulation arise in consequence of an in- 
 flamed and herniated appendix, they may differ somewhat from those 
 ordinarily observed. There will be the same tendency to collapse, the 
 vomiting, the tympanites; but constipation may not be complete, and 
 the hernial tumor, in addition to being swollen and painful, may be 
 reddened and edematous. 
 
 No one should think of taxis under these circumstances: as im- 
 mediate operation is indicated. Regarding these grave cases, Kelly 
 says (Vermiform Appendix and its Disease, page 793) where there is 
 suppuration in the sac it must be drained, and here as well as in the 
 cases where there is gangrene in the appendix, resulting from strangu- 
 lation, the utmost care must be observed in handling the diseased 
 tissues in order to avoid inoculating the peritoneal cavity. If the dis- 
 eased portion is found to extend up into the peritoneal cavity, the 
 
STRANGULATED HERNIA 
 
 operator must at all hazards discover the upper limits of the infection 
 and resect the bowel in its healthy portion. 
 
 Moreover, he must do this with the least possible manipulation 
 and traction upon the parts, preferably by enlarging the abdominal 
 opening in the direction of the inguinal canal while protecting the 
 healthy regions and keeping the disease well isolated by abundant 
 gauze compresses. 
 
 When infection extends still further up into the abdomen an even 
 wider incision must be made, if necessary , in the form of an inverted 
 X in order to provide abundant drainage after removal of the disease. 
 In such cases the cure of the hernia becomes a matter of secondary 
 consideration to be taken up after recovery. 
 
 In a case seen by the author the patient was an old woman, for 
 years affected with an inguinal hernia usually easily reduced. It 
 became strangulated, presenting a hard painful, inflamed lump, 
 the size of a hen's egg. 
 
 She was nauseated, in much pain, slightly febrile, only slightly 
 tympanitic, and enemas were effective in moving the bowel. The 
 operation revealed a strangulated appendix and nothing more. It 
 was well exposed and resected without difficulty and with complete 
 relief. In repairing the abdominal wall the sutures were passed 
 through the lower edge of the external oblique, through Poupart's 
 ligament and out through the upper edge of the aponeurosis, com- 
 pletely obliterating the inguinal canal. This combination is unusual 
 — an old woman, an inguinal hernia and a strangulated appendix. 
 
 McEwen (London Lancet, June 16, 1906) reports a case in which 
 the patient, a man of sixty- two, presented himself for an opera- 
 tion for strangulated hernia. Two weeks previously his hernia (of 
 twelve years' standing) had begun to give him pain, which had gradu- 
 ally increased. 
 
 A large pyriform tumor occupied the right inguinal region and 
 the scrotum, which was much inflamed. The mass was dull on per- 
 cussion, there was no impulse on coughing, and it was irreducible. 
 On opening the sac the hernia was found to consist of the appendix, 
 held in position by a pin protruding through its wall. There was no 
 abscess formation, yet it was not deemed advisable after removal of 
 the appendix to proceed with the radical cure. 
 
FEMORAL HERNIA 633 
 
 Regarding these unusual conditions, Lejars remarks that in be- 
 ginning an operation for strangulated hernia we should expect every- 
 thing and be surprised at nothing; laying aside for the moment all 
 theoretical discussions and applying ourselves to the chief indication, 
 not deeming our work complete until the bowel is properly reduced 
 and lost to view in the abdominal cavity. 
 
 Oliver, of Indianapolis (Ind. Med. Jour., March, 1908), reports a 
 case in which the hernia had grown to remarkable proportions ex- 
 tending as low as the knee. The mass had long been irreducible. 
 The patient was a butcher of about fifty years of age. Following a 
 heavy meal of "pigs' feet" and a lift, his hernia suddenly became 
 painful and he experienced the sensation of something giving way; 
 symptoms of strangulation in mild form gradually developed; taxis 
 being out of the question, immediate operation was practised. On 
 opening the hernial sac it developed that its content was the stomach 
 in its entirety, but no gut was present. With great difficulty it was 
 reduced. The patient's condition did not permit of any further 
 manipulation, and shortly afterward he succumbed. Oliver ex- 
 presses the opinion that the stomach had been forced down into the 
 ; sac by the strain, replacing the gut. 
 
 I 
 
 Strangulated Femoral Hernia 
 
 Operation is even more urgent in the case of strangulated 
 femoral hernia than in strangulated inguinal hernia. Gangrene 
 is likely to develop earlier, and taxis is all the more ineffectual by 
 reason of the anatomical arrangement. Especially must one be 
 1 on his guard in the case of small hernia for the ring is unyielding. 
 It is essential to have the anatomy in mind to understand this and 
 especially in order to operate without embarrassment. 
 
 Surgical Anatomy. — Poupart's ligament stretches across ther front 
 of the pelvic region from the anterior superior spine of the ilium to 
 the spine of the os pubis. The space between this band and the 
 ramus of the pubis is occupied by several structures — from without 
 inward, the iliacus and psoas muscles on their way to the lesser 
 trochanter, the crural nerve, the femoral artery and vein, the femoral 
 canal, and Gimbernat's ligament. 
 
^34 
 
 STRANGULATED HERNIA 
 
 Gimbernat's ligament is a firm triangular fascia with its base 
 directed outward and abutting the femoral canal. 
 
 The femoral sheath, a prolongation of the iliac fascia, encloses the 
 femoral vessels. In the thigh it fits closely about the vessels. 
 
 Fig. 463. — Relations of the neck of a femoral hernia under Poupart's ligament. Beneath 
 Poupart's ligament from without inward; the iliacus, the psoas, the femoral artery, the vein, 
 the hernia, concealing Gimbernat's ligament which is between its neck and the pubes. 
 {Moullin.) 
 
 In the groin the sheath is more capacious so that there is a space 
 left between its inner wall and the femoral vein. This space consti- 
 tutes the femoral canal. The femoral canal is, therefore, conical in 
 shape with its base above and its apex below where the sheath gets 
 in contact with the femoral vein. The circumference of the base 
 
HERNIOTOMY. FEMORAL HERNIA 635 
 
 constitutes the femoral ring which is bounded internally by the base 
 of Gimbernat's ligament; above, by Poupart's ligament; below, by 
 the ramus of the pubes; externally, by the femoral vein. The narrow 
 orifice bounded by these structures is the usual site of strangulation 
 of a hernia descending along this slender channel. 
 
 It is Gimbernat's ligament whose- sharp edge is most likely to 
 shut off the circulation of a loop of intestine bulging past it and which 
 is most likely to cut into or bruise the bowel in efforts at taxis (Fig. 
 
 463). 
 
 In other cases the hernia descending lower finds the direction 
 of least resistance toward the surface and bulges out through the 
 saphenous opening and the cribriform fascia. 
 
 Operation. — If the operation is done early before complications, 
 such as gangrene,, have arisen, the operation for strangulated femoral 
 hernia is simple and without special danger. Begin by disinfecting 
 the whole field; the inner surface of the thigh, the groin, the abdomen, 
 the genitals. 
 
 The incision may be vertical following the axis of the tumor, or 
 oblique, below and parallel to Poupart's ligament; Lejars prefers the 
 latter, claiming that it gives freer access to the femoral ring, facili- 
 tates the dissection of the sac and the procedures in the radical cure. 
 
 The vertical incision is probably better for large and lobulated 
 hernia which extend well below Poupart's ligament. But whatever 
 incision is employed must be of ample length. 
 
 The incision traverses the skin, and then a fatty layer through 
 which ramify a number of veins tributary to the long saphenous. 
 Having divided this layer, the sac is exposed; or, at least, the fatty 
 envelope in which so often it is enclosed — a collection of fat which 
 at times amounts to a veritable lipoma. The hernial sac lies im- 
 mediately beneath this fat — sometimes in thin subjects immediately 
 beneath the skin — and presents itself in divers aspects. Usually 
 it looks like a tense and reddish cyst; often it is lobulated 
 (Fig. 464). 
 
 Second Step. — Isolate the sac. Proceed to separate it from the 
 adjacent tissues by blunt dissection, peeling it out with the fingers, 
 and disengaging it quite up to the neck. It is essential for the later 
 

 STRANGULATED HERNIA 
 
 steps oi the operation that this be thoroughly done and is complete 
 when Poupart's and Gimbernat's ligaments are well in view. 
 
 This dissection of the sac takes less time than one might expect 
 and is greatly facilitated if one is able to find a line of cleavage be- 
 tween the tissues. Sometimes bursae intervene between the sac 
 and adjacent tissues and favor a rapid separation. 
 
 Third Step. — Open the sac; examine the contents. Once the hernial 
 tumor is well exposed up to the constricting ring, cautiously incise 
 the sac. Caution is required because often it is difficult to know 
 when one has penetrated the sac and an adherent intestine may be 
 
 ft 
 
 Fig. 464. — Strangulated femoral hernia: primary incision exposing hernia and Poupart's 
 
 ligament. (Guibe.) 
 
 wounded. In this form of hernia the true sac may be covered by 
 a cyst, which may be filled by bloody serum and thus simulate the 
 appearances of the hernial sac. A moment's examination, however, 
 shows that it is a small closed cavity without communication with 
 the abdomen. The layers are to be cautiously divided one by one 
 until the sac is opened into and the opening enlarged. 
 
 Catch up the lips of the wound of the sac and examine its contents, 
 illy, in this form of strangulated hernia, one will see a small loop 
 of intestine, darkened, tense, and tightly constricted. Occasionally 
 along with the omentum there may be several loops of small intes- 
 tine, or the cecum, or the sigmoid flexure. Irrigate the cavity and 
 
HERNIOTOMY. FEMORAL HERNIA 
 
 637 
 
 its contents with normal salt solution and prepare to relieve the 
 constriction. 
 
 Fourth Step, — Relieve the constriction. The first effort should be to 
 relieve the strangulation by stretching the offending fibers, to this 
 end introducing a finger, if possible, into the ring along the inner side 
 of the hernia. 
 
 Oftentimes the pressure thus exerted will, with a little effort, 
 stretch and enlarge the opening sufficiently to relieve the constriction 
 and to permit the necessary manipulation of the bowel. 
 
 It may not be possible to introduce a finger, and then one must 
 resort to incision. To accomplish this a grooved director may be 
 
 Fig 465.- 
 
 -Strangulated femoral hernia: closing the femoral canal. Note manner in which 
 sutures are passed, avoiding femoral vein at outer border. 
 
 slipped up alongside the bowel and the fibers divided with scissors or 
 bistoury; or if the fibers are in plain view, as they should be, they may 
 be nicked with the point of the bistoury and when room is thus made 
 the finger may be introduced as before. The use of the herniotomy 
 knife should be reserved for exceptional cases, where the subject is 
 fleshy and the obstruction beyond reach and very tight. 
 
 But whatever method may be practised, one must keep to the 
 inside, cutting inward or upward to avoid injury to the bowel or the 
 femoral vein. 
 
STRANGULATED HERNIA 
 
 When the obstruction is removed pull the bowel down and ex- 
 amine it. If it is suspicious or gangrenous, treat it after the manner 
 indicated under Strangulated Inguinal Hernia. 
 
 If it is sound, reduce it; liberate the sac around the femoral ring, 
 ligate and resect it; and close the femoral canal. The after-treatment 
 is the same as for inguinal hernia. 
 
 Fifth Step. — Close the femoral ring. Two circular sutures acting 
 when tied after the manner of a purse string are to be passed; 
 one including the pectineal fascia and the fascia of the external 
 oblique; the second, more deeply placed, including the pectineal 
 fascia, Poupart's ligament and Gimbernat's ligament. 
 
 Avoid wounding the femoral vein, which lies in contact with the 
 outer border of the femoral ring. When these sutures are tied the 
 external oblique is pulled down into close contact with the pec- 
 tineal fascia and the canal obliterated (Fig. 465). 
 
 It remains to be said that in exceptional cases it may be necessary, 
 in order to see what to do, to divide Poupart's ligament; or, in the 
 male where the cord is to be avoided, to make another incision along 
 the inguinal canal, exposing the neck of the hernia; or, following the 
 method of Tuffier, to open directly into the peritoneal cavity through 
 the inguinal canal. 
 
 Strangulated Umbilical Hernia 
 
 A strangulated umbilical hernia is peculiar in two or three respects. 
 It is likely to be deceptive in that the characteristic symptoms of in- 
 testinal obstruction may be wanting. The site of strangulation is 
 more likely to be in the sac than at the umbilical ring. But because 
 the absolute signs of obstruction are absent and because the opening 
 at the umbilicus seems patent, one has no excuse to delay when an old 
 and long irreducible rupture becomes suddenly painful, with vomiting 
 and partial constipation. 
 
 Too often, as Lejars says, we call these attacks with comparatively 
 mild onset, pseudo-strangulation; and so the case drifts along while 
 septic absorption goes on insidiously but surely. From day to day 
 the circulation grows weaker, the abdomen more tympanitic, the 
 vomiting more pronounced, until the vital forces are practically over- 
 
STRANGULATED UMBILICAL HERNIA 
 
 639 
 
 come, at which time, too late, it is decided to operate. The expect- 
 ant treatment and repeated taxis in these cases are merely methods 
 of " losing time." 
 
 Following such practice one can confidently expect a large per- 
 centage of fatalities, though one should not hesitate to operate even 
 in the face of such odds. Operating early, one may give assurance of 
 excellent results. To quote Lejars again, it is not the operation 
 which is to be feared: it is the delay. 
 
 Operation. — Careful disinfection of the whole abdominal wall; a 
 prudent and cautious anesthesia. The incision may follow the 
 
 Fig. 466. — Strangulated umbilical hernia: incision skirting the base of the tumor. 
 The peritoneum opened in the same line exposes the omentum and bowel. Omentum 
 clamped and divided along dotted line. (Guibe.) 
 
 median line extending well beyond the tumor above and below (Fig. 
 466) ; or in the case of a large tumor, may consist of two semilunar 
 incisions on either side of the middle line which enables one to get rid 
 of redundant tissue. 
 
 In either case the incision must not go deep from the first for 
 often the skin is quite thin, often adherent to the sac, and it is easy 
 to go directly into the sac. By reason of this adhesion at the center 
 
640 
 
 STRANGULATED HERNIA 
 
 of the tumor, begin the dissection at the poles of the incision and 
 work toward the center. 
 
 As soon as the skin is detached proceed to isolate the tumor, if 
 able, up to its point of emergence. It may not be practicable 
 if the tumor is large and lobulated to take the time, and in such a 
 case the sac may be opened into at once. 
 
 land Step. — Open the sac. Detach the omentum. Nearly always 
 on first opening the sac only omentum can be seen. It completely 
 envelops the bowel. The fingers are gently insinuated between 
 
 Fig. 467- 
 
 -Strangulated umbilical hernia: the sac laid open to relieve the strangulation 
 and free the bowel. (Guibe.) 
 
 the omentum and the sac, and the adhesions progressively broked 
 down. Wherever a lobule of omentum is found encysted in a diver- 
 ticulum of the sac, it must be dissected out in the s^me manner. 
 Finally the entire omentum will be freed, may be lifted up, and the 
 gut exposed. In other cases divide the omentum as indicated in 
 Fig. 489. 
 
 Irrigate both the bowel and omentum with normal salt solution, 
 wipe with sterile gauze and examine the bowel carefully to see that 
 there is no danger of perforation and of soiling of the peritoneum in 
 the process of reduction. 
 
STRANGULATED UMBILICAL HERNIA 
 
 641 
 
 Third Step. — Relieve the strangulation. Oftentimes the umbilical 
 ring may need only to be stretched a little to permit the free manipu- 
 lation of the bowel; again, it may be necessary to divide the con- 
 stricting fibers. This may be most readily accomplished by pulling 
 down the omentum, slipping a finger between it and the upper part 
 of the ring to the left of the middle line. If this nick does not give 
 sufficient release, repeat on the opposite side. 
 
 Fig. 468. — Strangulated umbilical hernia: completing section of base of the tumor. (Guibe.) 
 
 When the necessary room is obtained, ligate the omentum, resect 
 it, cleanse the stump and reduce it that there may be nothing to 
 interfere with the treatment of the bowel. If the omentum has been 
 resected in the manner indicated, the tumor mass may be laid wide 
 open in order that the strangulated loops may be well exposed and 
 freed (Fig. 467). 
 
 Following this the incision is continued around the base of the 
 tumor, completely removing it and leaving the various layers of 
 the abdominal wall exposed ready for repair (Fig. 468). 
 
 With respect to the bowel, the same principle of treatment holds 
 good as in inguinal hernia. Repair any slight defects or abrasions. 
 41 
 
04- 
 
 STRANGULATED HERNIA 
 
 If its viability is doubtful, keep it under observation for a few hours. 
 If gangrenous, either anchor it in the wound and make an artificial 
 anus or do an enterectomy. 
 
 It may be that in very large umbilical hernia it is better to modify 
 the procedure, following the plan of Mayo and others, in order to 
 gain time. 
 
 A transverse elliptical incision is made around the tumor at such 
 distance from the center that the redundant tissue shall be removed 
 Cut down to the sac. Next cautiously open the sac following the 
 skin incision. Apply several forceps to the edges of the sac so that it 
 
 
 Fig. 469. — Peritoneum closed and first layer of mattress sutures for fascia passed. (Guibe.) 
 
 is constantly under control. Detach the omentum, freeing it com- 
 pletely up to the neck of the sac. Ligate and resect it, and working 
 along its under surface free it from the bowel. Once detached the 
 paquet of omentum carries with it a segment of the skin and of the 
 sac. 
 
 The bowel is next treated and reduced. This may not be as easily 
 done as said, for there are several circumstances under which the 
 
STRANGULATED UMBILICAL HERNIA 
 
 643 
 
 bowel may push out and threaten eventration. But no effort should 
 be made to push back the rebellious loops en masse. 
 
 Proceed at once to enlarge the opening, lift up the edges of the 
 peritoneum by the attached forceps and cover the bowel with a wide 
 compress, tucking its edges under the belly walls on all sides, as de- 
 scribed elsewhere. As little by little the bowel is returned the edges 
 of the compress are slipped farther under. When reduction is com- 
 plete the compress is left in situ until the sutures are placed. 
 
 Fig. 470. — Second layer of mattress sutures completing the overlapping of 
 the fascia. (Guibe.) 
 
 Fourth Step. — The mode of repairing the abdominal wall varies 
 with the circumstances and the operator, and depends upon how 
 much time one may take. When the condition of the patient 
 ( imposes great haste it must suffice to pass interrupted sutures 
 I through the whole thickness of the belly wall and draw the edge of 
 the wound together so that the peritoneal edges point out and the 
 two serous surfaces are thus brought into contact. Before the last 
 suture is tied the compress is removed; and finally a continuous su- 
 ture will complete the reunion. 
 
 If more time is available, the sac is trimmed down to the perito- 
 neum proper and its edges sutured as after a laparotomy. The 
 sheaths of the recti muscles are opened up and the inner border of each 
 muscle exposed. The two sides are then brought in contact and three 
 
644 
 
 STRANGULATED HERNIA 
 
 tiers of sutures applied; one uniting the deep layer of the rectal sheath 
 to its fellow of the opposite side; the second uniting the two muscles; 
 the third uniting the two superficial layers of the sheath overlapping 
 and securing them by mattress sutures (Figs. 469 and 470). 
 
 Fig. 471. — Umbilical hernia: dissection of sac. (Mayo.) 
 
 Finally the excess of subcutaneous fat is trimmed away and the 
 skin sutured. The usual dressing is applied, held in place by a wide 
 binder, and the after-treatment, already indicated, is instituted. 
 
 Figs. 471 and 472 show the manner in which Mayo perfects the 
 radical cure. 
 
 Obturator Hernia. — A strangulated obturator hernia is rare, yet 
 it is to be thought of and ruled out before opening the abdomen for 
 
STRANGULATED OBTURATOR HERNIA 
 
 645 
 
 intestinal obstruction. Several points help to locate the trouble 
 even when no marked tumor is present. The presence of pain over 
 the region of the obturator foramen directs the attention to that 
 point, and pressure made there projects a pain down the inner side 
 
 Fig. 472. — Umbilical hernia: repair of abdominal wall. (Mayo.) 
 
 of the thigh to the knee, along the course of the obturator nerve. In 
 the female, vaginal examination will reveal the tumor. 
 
 In this form of strangulated hernia, taxis is useless and likely to be 
 very harmful, and therefore must never be employed. A herniotomy 
 must be done without delay, though in these cases it is a procedure 
 
o 4 (> 
 
 STRANGULATED HERNIA 
 
 by no means simple. Several anatomical points must be borne in 
 mind. The hernia usually comes out through the upper part of the 
 obturator membrane and is covered over by the pectineus muscle. 
 It may work into the pectineus or it may lie on a lower level, working 
 into the obturator externus. The pectineus is usually the chief 
 guide to the hernia. 
 
 « 
 
 
 Fig. 473- — Obturator hernia. A, Hernial sac-obturator artery; B, pectineus; C, ad- 
 ductor longus. (JLejars.) 
 
 The obturator vessels and nerve are usually found behind and to 
 the outer side of the neck of the hernia. The femoral vessels lie 
 to the outer side. It is the obturator membrane which constitutes 
 the constricting ring. 
 
 The operation , chiefly as described by Treves, is as follows: The 
 pelvis is elevated, the thigh flexed and adducted, the femoral artery 
 located, and about a finger's breadth internal, an incision is made from 
 
STRANGULATED UMBILICAL HERNIA 647 
 
 the spine of the pubes downward for 3 or 4 inches. Incise the 
 skin, the subcutaneous fat and the fascia lata, and expose the adduc- 
 tor longus. Catch up the deep external pudic artery. Retract the 
 adductor brevis and beneath this is the pectineus whose fibers are 
 separated by blunt dissection; or, if necessary, divided in order to 
 expose the sac (Fig. 473). 
 
 When the sac is once in view, free it completely up to the neck. 
 The obturator membrane is now to be nicked, observing first the 
 course of the arteries. It may be better, however, to open the sac 
 at once, cleanse the contents, and endeavor to insinuate the finger 
 alongside the bowel and stretch the strangulating fibers; failing in 
 this, to divide them, keeping in mind the possibility of a hemorrhage. 
 If, in spite of precaution, this occurs, tampon firmly against the 
 obturator membrane, and when the tampons are removed one by one, 
 the bleeding points may be recognized and clamped. Finally the 
 intestine, if sound, is reduced, the sac dissected and ligated high up, 
 and the external wound sutured. 
 
 Lejars remarks that one may find in the sac of a strangulated 
 obturator hernia not only bowel and omentum, but also the tubes 
 and ovaries, the bladder and the appendix; and that it is well to 
 be forewarned of these possibilities, which may greatly complicate 
 an operation at best never simple. 
 
 Of strangulation of other forms of hernia — sciatic, lumbar, perineal, 
 vaginal — it need only be said that they are too rare to be with profit 
 considered here. 
 
CHAPTER XII 
 
 RADICAL CURE OF INGUINAL HERNIA 
 
 <j.O PO T Ft P 
 
 The radical cure of hernia may be attempted at the operation for 
 strangulated hernia under the conditions defined. But aside from 
 those emergency cases there are others in which the family doctor 
 will feel it his duty to recommend and to do 
 the operation. His results will be excellent if 
 he wisely chooses cases not beyond his skill. 
 As Veau says, he should select only such as 
 are small, reducible, congenital. The large 
 hernias are difficult to handle and recurrence 
 will be almost certain. The irreducible hernias 
 may have acquired adhesions that can scarcely 
 be broken up without severe injury to the gut. 
 With respect to age, the ideal case is a young 
 man fifteen to twenty-five years old, who has 
 well-developed abdominal walls, a well-defined 
 external abdominal ring, and a hernia easily con- 
 trolled by a truss. 
 
 Under these favorable conditions, the hernia 
 relation of the hernial ra rely recurs; but almost certainly it will recur 
 
 sac. GO, external ob- . . - . 
 
 Hque; po, internal ob- if suppuration follows the operation, ana there- 
 lique; t, trans versaiis; f ore absolute asepsis is the sine qua non of 
 
 Ft, transversalis fascia; 
 
 P, peritoneum; TC, con- SUCCeSS. 
 
 joined tendon; Crem., Surgical Anatomy. — The hernia, then, which 
 
 cremaster; cd. vas det- . . , 
 
 erens in contact with the general practitioner should undertake to 
 the hernial sac repre- operate on is an external or oblique, which 
 
 sented in black. (Veau.) . . . - . 
 
 escapes from the abdominal cavity through the 
 internal ring to the outside of the deep epigastric artery and follows 
 the inguinal canal down to the external ring (Fig. 474). 
 
 Beneath the skin will be found only a few insignificant vessels. 
 
 648 
 
 Fig. 474. — Transverse 
 vertical section of the 
 inguinal canal showing 
 
SURGICAL ANATOMY 
 
 649 
 
 The aponeurosis of the external oblique is easily distinguished, 
 strong and resistant, and its fibers bounding the external ring are 
 thickened to form the "pillars" of the ring. Behind it lies the cord, 
 which includes the vas deferens and its accompanying vessels and 
 nerves, all surrounded by a common sheath derived from the trans- 
 versaJis fascia, and in this case, it contains also the hernial sac. To 
 reach the sac, the sheath must be divided and the elements of the 
 cord separated from the sac. 
 
 Fig. 475. — The primary incision for hernia. (Veau.) 
 
 In the case of congenital inguinal hernia, the sac is very thin and, 
 in spite of precautions, it is sometimes torn or one even fails to find 
 \ it. The chief difficulty of the operation centers around the recogni- 
 tion and dissection of the sac. The posterior wall of the inguinal 
 canal is formed by the conjoined tendon, the transversaJis fascia, and 
 1 the peritoneum. 
 
 The purpose of the operation is to reconstruct the posterior wall 
 and restore the obliquity of the canal, and the "Bassini" operation 
 is the type the inexperienced operator can best imitate. • 
 Operation. — Prepare the field most scrupulously — abdomen, 
 j thigh, and scrotum. Employ general anesthesia, as a rule, al- 
 though local and spinal anesthesia are available. 
 
050 
 
 RADICAL CURE OF INGUINAL HERNIA 
 
 Begin by locating the external ring, which is to be the first point 
 
 oi attack. 
 
 The incision will extend from this orifice to a point just over the 
 internal ring, which lies ^ inch above the middle of Poupart's 
 ligament. The incision, then, beginning above (on the right), ex- 
 tends downward and forward to the spine of the pubes, where it 
 bends a little to become more vertical and ends in the base of the 
 
 Fig. 476. — The external oblique exposed and the external ring developed. (Veau.) 
 
 scrotum (Fig. 475). However large the hernia may be, one need not 
 extend the incision further, so lax and distensible are the scrotal 
 tissues. 
 
 Having divided the skin and subcutaneous tissues, catch up anc 
 ligate the small vessels. Next divide the fatty tissues layer by 
 layer down to the aponeurosis of the external oblique, which lies 
 deeper than one may expect. 
 
 Now, w r ith the grooved director, completely expose the pillars of 
 the ring. Do not neglect this as it is a most important step in the 
 operation. The inner pillar is easily found, but the outer pillar is 
 covered by the cord and a little patience is required to get it well 
 exposed. Catch up each pillar with forceps; these are not to be 
 
DISSECTING THE SAC 65 1 
 
 loosened until, at the end of the operation, they have served as a 
 guide in the repair of the external ring (Fig. 476). 
 
 Now comes the next step in the operation. Carefully divide the 
 aponeurosis in the line of the pillars and to the full extent of the skin 
 wound. Unless one cuts deeply, there is nothing to fear. You have 
 now laid open the inguinal canal and have left to do the most diffi- 
 cult part of the operation. 
 
 Fig. 477. — The external oblique divided, exposing the cord and hernial sac. (Veau.) 
 
 To Find and to Dissect Out the Sac. — The cord is covered by the 
 cremaster which also covers the hernial sac. You may begin the 
 search for the hernial sac without disturbing the position of the cord, 
 but it is better to raise it up out of its bed. To do this follow along 
 the external pillar and Poupart's ligament and you will find it easily 
 disengaged by blunt dissection (Fig. 477). Slip the left index finger 
 under and support the cord. The sac is enclosed in the fibrous 
 sheath of the cord. 
 
 Very gently incise this sheath, using a sharp bistoury (Fig. 478), 
 and the structures of the cord appear. Rolling them between the 
 finger and thumb, you can recognize the vas deferens by its form and 
 consistency. You can see the distended veins. You will see a 
 I whitish transparent membrane. Catch up a fold of it with the for- 
 ceps and divide its base, and if it is the sac, you will open into a serous 
 cavity (Fig. 479). Enlarge the orifice sufficiently to introduce a 
 finger and, with that as a guide, dissect the sac from its associated 
 
652 
 
 RADICAL CURE OF INGUINAL HERNIA 
 
 Fig. 478. — Dividing the fibrous coverings of the sac. (Veau.) 
 
 Fig. 479. — Incising the hernial sac. (Veau.) 
 
DISSECTING THE SAC 
 
 00 
 
 structures (Fig. 480). It is often a difficult task, for the veins and 
 vas deferens are glued to the sac, especially in the congenital hernia. 
 Sometimes pressing and stripping the tissues back with a gauze 
 compress facilitates the maneuver. Still there need be no great 
 difficulty if only all the coverings are divided with the scalpel or 
 scissors, exposing a plane of cleavage. Pulling and tearing and 
 lacerating the tissues in the effort to liberate the sac, provokes 
 a capillary oozing and predisposes to infection. 
 
 Fig. 480. — The index finger introduced into the sac which is being separated from the other 
 structures of the cord. (Gulbe.) 
 
 It is important that the sac be isolated quite to the internal ring 
 (Fig. 481) ; otherwise when the ligature is applied there will be formed 
 a peritoneal diverticulum, the starting-point later of another hernia. 
 Do not carry the dissection further than the internal ring for fear of 
 wounding the bladder. 
 
 Assure yourself now that the sac is empty by passing a finger up 
 into the abdominal cavity. Now transfix the neck of the sac with a 
 

 54 
 
 RADICAL CURE OF INGUINAL HERNIA 
 
 Fig. 481. — The sac separated from the cord; the cord in the bottom of the wound; on 
 either side are the lips of the external oblique, the forceps still attached to the pillars of the 
 external ring. (Veau.) 
 
 Fig. 482. — Ligation of the neck of the sac. (Veau.) 
 
ABDOMINAL REPAIR 
 
 655 
 
 needle carrying a catgut ligature (Fig. 482) and tie in the manner in- 
 dicated in figure (Fig. 483). If the ligature merely encircles the 
 neck, it is too likely to slip off. Do not cut off the ends of the liga- 
 ture until through dealing with the sack. Amputate the sac within 
 }/2 inch of the ligature and, if everything is all right, cut the 
 threads and the stump disappears in the cavity. Sellenings proposes 
 to dispense with the dissection of the sac. After it is exposed, in- 
 cised, and emptied, he obliterates it by passing a purse string around 
 its neck at the internal ring and suturing the rest of its length (Amer. 
 Jour. Surgery, March, 1909). 
 
 Fig. 483. — Illustrating method of ligating 
 the sac. (Veau.) 
 
 Fig. 484. — The cord drawn to one side 
 while the posterior wall of the canal is 
 restored by suture of the conjoined tendon 
 to the shelving edge of Poupart's ligament. 
 (Veau.) 
 
 Suture of theAbdominal Walls. — This is the next step. Draw the 
 cord down out of the way for the moment and expose the shelving 
 inner edge of Poupart's ligament, which is to be sutured to the free 
 border of the conjoined tendon. In other words, the internal oblique 
 and transversalis are to be sutured jointly to Poupart's ligament. 
 
 Through this shelving edge near the pubis pass a chromic catgut 
 suture on a curved needle and carry it through the corresponding 
 part of the conjoined tendon (Fig. 484), and apply three or four such 
 sutures (Fig. 485). In this manner reconstruct the posterior wall of 
 

 RADICAL CURE OF INGUINAL HERNIA 
 
 Complete the hemostasis. 
 
 the inguinal canal. Place the cord back in position upon this line of 
 sutures. 
 
 Now draw the edges of the divided aponeurosis into position by 
 means of the forceps attached to the pillars at the beginning of the 
 operation. Begin the repair by a chromic catgut suture at the upper 
 end of the wound (Fig. 486) and pass six or eight in this manner. 
 The last will rejoin the pillars and restore the external ring, and 
 when these are all tied the anterior wall of the canal is thus recon- 
 structed. There is some danger of making the external ring too 
 small for the cord (Fig. 487), with the result finally that the testicle 
 atrophies. 
 
 A scrotal hematoma may develop 
 unless one is very particular about 
 the oozing. 
 
 Complete the operation by suture 
 of the skin wound with silk-worm- 
 gut, leaving in it a small drainage- 
 tube if you fear infection or oozing; 
 otherwise this is not necessary; still 
 it does no harm. 
 
 The dressing is of extreme im- 
 portance. Cover the wound with a 
 strip of moist gauze, fix it with collo- 
 dion, and then apply the ordinary 
 A double spica bandage will greatly 
 If drainage was employed, remove 
 the tube in two or three days under strictest asepsis. Otherwise do 
 not disturb the dressing, but watch the temperature. If the tem- 
 perature runs up to 101 on the third day, open up the wound by 
 removing one or two sutures, and if there is any pus, drain. 
 
 Delay in this is likely to result in extensive suppuration, and a 
 recurrence of the hernia is thus assured. If everything goes well, 
 remove the stitches on the eighth day, but keep the patient in bed 
 for three w r eeks. A truss is not necessary. 
 
 Rilus Eastman, of Indianapolis, recommends a modification of the 
 final suturing especially applicable in the case of children. His 
 method aims at the closure of all the layers by a single tier of easily 
 
 Fig. 485.- 
 
 -Posterior wall-repair com- 
 plete. (Veau.) 
 
 gauze and cotton dressing 
 diminish the chance of infection. 
 
ABDOMINAL REPAIR 
 
 657 
 
 removable non-buried sutures. The method described (Annals of 
 Surgery, Jan., 1906) consists in the reduction of the sac by the ordi- 
 nary procedure. A Pagenstecher celloidin linen suture bearing a 
 needle on each end is then first passed through Poupart's ligament 
 
 Fig. 486. — Reconstructing the anterior wall by repair of the external oblique. Forceps 
 still attached indicate the position of the ring. (Veau.) 
 
 from without inward 1 inch from its free margin. It is next 
 passed through the outer border of the obliquus externus and trans- 
 versalis muscles and brought back through Poupart's ligament 
 about 1/3 inch nearer the margin than at its first point of passage. 
 
 Fig. 487. — External oblique repaired. (Veau.) 
 
 The needle now external to, and above Poupart's ligament is made to 
 overlap the free margin of the ligament and the aponeurosis of the 
 external oblique by carrying the thread through in the form of a 
 simple running mattress suture. 
 42 
 
RADICAL CURE OF INGUINAL HERNIA 
 
 The needle is next passed through the superficial fascia, panniculus 
 adiposus, and skin, emerging about 1/8 inch from the skin wound 
 margin upon the side opposite Poupart's ligament. When traction 
 is made upon the two ends of the suture no kinks or curls remain, 
 and the suture is tied up as a simple loop. Five or six such sutures 
 are required to coapt the wound from the internal ring to the pubes. 
 When union is complete they are easily clipped and removed. 
 
 
CHAPTER XIII 
 RADICAL CURE OF FEMORAL HERNIA 
 
 Aside from the cases of strangulated hernia, the general practi- 
 tioner should not undertake the operation for the radical cure of 
 femoral hernia without due consideration and without warning the 
 patient that relapse is possible and even frequent. The operation 
 is not more difficult than that for inguinal hernia, but a cure is much 
 less certain. As with inguinal hernia, he should select only such 
 cases as are small and reducible. 
 
 Surgical Anatomy. — The sac of a femoral hernia is generally thick 
 and imbedded in adipose tissue originating in the extra-peritoneal 
 layer. (See Strangulated Femoral Hernia.) 
 
 The relations at the neck are of the greatest importance. To the 
 outside is the femoral vein in direct contact, easily perforated by a 
 careless needle and producing a hemorrhage that can be arrested 
 only by ligature of the vein. To the inside is Gimbernat's ligament, 
 sharp-edged and tense, the chief structure to be dealt with in strangu- 
 lation. Above is Poupart's ligament, separating the femoral from 
 the inguinal canal, and below is the ramus of the pubes, thinly cov- 
 ered by the pectineus and its fascia. These boundaries are unaccom- 
 modating structures in the matter of repair, and for this reason 
 relapse is frequent. 
 
 Operation. — The anesthesia and preparation are the same as for 
 inguinal hernia. 
 
 The incision, parallel with, and a finger's breadth below Poupart's 
 ligament, begins (on the left side) at the spine of the pubis and is 
 usually about four inches in length (Fig. 488). 
 
 Incise in the same manner the fatty tissues, layer by layer, until 
 the easily distinguishable coverings of the hernia are reached. The 
 line of cleavage between them and the fatty tissues is followed and 
 the neck, lying high and deep, is exposed. Poupart's ligament is 
 
 659 
 
660 RADICAL CURE OF FEMORAL HERNIA 
 
 next freely exposed. Where coverings seem thinnest, catch up a 
 fold with the dissecting forceps and incise the base. It may be that 
 the incision will only open into another fatty layer. Divide the next 
 layer in the same manner, and so proceed until you have opened 
 the sac; secure its edges with forceps and pass an index finger into 
 the cavity. If omentum is found it must be resected (Fig. 489) 
 Be sure there is no adherent bowel. 
 
 Fig. 488. — Incision for femoral hernia. (Veait.) 
 
 Now dissect the sac, proceeding slowly and methodically until the 
 femoral ring is reached. Introduce a finger to be sure the bowel is 
 protected, and transfix and ligate the neck of the sac as in inguinal 
 hernia. Again recall the relations of the femoral ring (Fig. 490). 
 
 Obliteration of the Femoral Ring. — detract the upper angle of the 
 wound so that you can see, divide Gimbernat's ligament freely, 
 cutting horizontally and toward the pubes (Fig. 491). Poupart's 
 ligament can now be approximated to the pectineus. Protect the 
 femoral vein with a retractor and pass the first suture adjoining it, 
 using a strong curved needle and No. 2 or No. 3 catgut. 
 
 The needle enters the pectineal fascia, grazes the bone, comes out 
 a little higher, and then passes up to the posterior surface of the liga- 
 
ABDOMINAL REPAIR 
 
 66l 
 
 ment and forward through it (Fig. 492). Place four sutures in this 
 manner before tying (Fig. 493). Tie them successively from without 
 inward. It is this line of suture alone that will be efficient, but suture 
 the fascia if you wish, and finally the skin. 
 
 The subsequent treatment is the same as in inguinal hernia. 
 
 Such is the method which Veau recommends, and which has the 
 great merit that it is anatomical. But there are many differences 
 of opinion as to the best method of closing the femoral ring, and as 
 to the advisability of even closing it at all. 
 
 Fig. 489. — Resection of the omentum. (Guibe.) 
 
 Ochsner enunciates the principle, applying it to the radical cure 
 of femoral hernia, that circular openings in any part of the body, 
 i will certainly close unless kept open by a mucous or serous lining. 
 Wherever, therefore, the femoral ring is well defined, he is content 
 with high ligation of the sac and dissection of all the fat and simple 
 closure of the wound. With a technic thus reduced to the simplest 
 terms, he obtains excellent results. Unfortunately, the femoral 
 ring cannot always be defined as a circular opening, and especially 
 after the operation for strangulated hernia. 
 
 Coley in the main agrees with Ochsner, but lays somewhat more 
 stress on the closure of the femoral canal. 
 
66a 
 
 RADICAL CURE OF FEMORAL HERNIA 
 
 The cure is the more perfect and certain, we think, if a more partic- 
 ular care is given to the closure of the femoral ring, to obliteration of 
 the femoral canal. Especially in case the hernia is of long standing, 
 the opening large, the structures stretched and weakened. 
 
 Fig. 490.— The neck of the sac ligated and Fig. 491.— Femoral hernia; incision of 
 cut off. Above, Poupart's ligament; below, Gimbernat's ligament. (Veau.) 
 
 the ramus of the pubes; internally, Gimber- 
 nat's ligament. (Veau.) 
 
 Fig. 492. — Suturing Poupart's ligament 
 to pectineal fascia. (Veau.) 
 
 Fig. 493. — Suture of Poupart's ligament 
 and pectineal fascia completed. (Veau.) 
 
 Proceed as described in the case of strangulated hernia, to expose, 
 liberate, and ligate the sac, dividing Gimbernat's ligament to give a 
 good exposure. Ligate the sac high. 
 
 The peritoneum is now freed from contact with the abdominal 
 wall, ^holding it back out of the way with a flat retractor. The vein 
 which is freely exposed is drawn outward. 
 
ABDOMINAL REPAIR 
 
 663 
 
 Poupart's ligament is now lifted up and the free borders of the 
 internal oblique and the transversalis exposed above, and Cooper's 
 ligament below. It is these structures which are to be drawn into 
 contact. The first suture is passed close to the femoral vein. It is 
 the most difficult because the structures from within outward 
 become more deeply placed. 
 
 The remaining two or three sutures appproach the pubes, the last 
 reaching up behind Gimbernat's ligament (Fig. 494). Some diffi- 
 culty may be experienced in passing these sutures, for Cooper's 
 ligament is quite resistant. 
 
 Fig. 494. — Radical cure of femoral hernia. The first plane of sutures approximates th 
 border of the internal oblique and transversalis to Cooper's ligament — the periosteum of the 
 ilio-pectineal line. Gimbernat's ligament divided, the femoral vein drawn outward. (Guibe.) 
 
 The second and superficial plane of sutures approximates Poupart's 
 ligament to the pectineal fascia (Fig. 498). Thus the femoral canal 
 is completely obliterated by two strong fascial planes. The super- 
 ficial fascias are sutured to obliterate any dead spaces and the skin 
 repaired. 
 
 In the case of the male or for that matter in the difficult cases in the 
 
 female the inguinal canal may be opened exactly as in inguinal hernia. 
 
 The cord is drawn down, the transversalis fascia divided, avoiding 
 
 1 the deep epigastric artery, and the neck of the sac exposed. It is 
 
664 
 
 RADICAL CURE OF FEMORAL HERNIA 
 
 Fig. 495. — Radical cure of femoral hernia. The first row of sutures is tied and the second 
 passed, approximating Poupart's ligament and the pectineal fascia. The femoral vein drawn 
 to the outer side must be avoided. (Guibe.) 
 
 Fig. 496. — Radical cure of femoral hernia by the inguinal route. The sac is dissected out, 
 opened, emptied, and ligated. The cord displaced downward, the vein outward. The 
 border of the external oblique drawn upward exposing the internal oblique which will 
 be sutured to Cooper's ligament after the sac is cut off. 
 
ABDOMINAL REPAIR 665 
 
 freed from its pouch in the femoral canal, brought out of the wound, 
 opened, emptied and ligated (Fig. 496). 
 
 The borders of the internal oblique and transversalis are approxi- 
 mated to Cooper's ligament — in other words, the periosteum of the 
 ilio pectineal line, avoiding the femoral vein as described above. 
 Poupart's ligament is next approximated to the pectineal fascia, the 
 cord is replaced and the incision in the external oblique repaired and 
 the operation completed as for inguinal, hernia. 
 
CHAPTER XIV 
 ENTERECTOMY. INTESTINAL ANASTOMOSIS 
 
 Resection of a segment of the small intestine may be a necessary 
 part of several emergency operations. It may be required following 
 gunshot or other lacerating wounds of the intestine; it may be neces- 
 sary in certain wounds of the mesentery and in the gangrene of stran- 
 gulated hernia. 
 
 Large wounds of the gut, those. which carry away more than one- 
 half the circumference, require resection, for any form of repair is 
 likely to result in stricture. In the case of multiple perforations, it is 
 safer to resect than to attempt separate repair of the orifices. A 
 small wound of the omentum near the intestinal border may require 
 an extensive resection, for an inch of mesentery at that level may 
 contain the blood supply of 2 feet of intestine. 
 
 Resection of the bowel implies anastomosis, and this may assume 
 one of three forms: it may be end-to-end — termino-terminal, termino- 
 lateral, or latero-lateral. 
 
 The end-to-end anastomosis is preferable following resection. 
 The method employed may be either by suturing — -circular enteror- 
 rhaphy — -or by the Murphy button or some of the other mechanical 
 devices, such as Robson's bone bobbin or Frank's decalcified bone 
 coupler. With the great majority of surgeons, suturing is the 
 method of choice, although the casual operator may not yet be 
 ready to discard the mechanical device. 
 
 Moynihan, in his great work on abdominal operations, sums the 
 matter up in this wise: "The use of mechanical appliances is no 
 longer necessary; these have played their part — -a most important 
 part, I gratefully admit — -in the development of surgical work, and 
 it is now time that their surgical use should be abandoned. They 
 have been useful, nay, indispensable steps in the march of progress. 
 To Murphy above all other surgeons — for his instrument is one of 
 
 666 
 
TECHNIC OF RESECTION 667 
 
 the most ingenious mechanical contrivances ever invented — we 
 should gratefully acknowledge the debt we owe. The weightiest 
 argument against all mechanical aids to anastomosis is this — -they 
 are unnecessary. By their aid we do not accomplish anything which 
 cannot be accomplished with equal rapidity and greater safety by 
 simple suture. We have nothing to gain from their use and we risk 
 much by leaving something behind which may be and has been the 
 direct cause of danger and of death. The day of mechanical aids is 
 over. The buttons and the bobbins, the elastic ligatures and the 
 forceps of many forms have no more than a historical interest." 
 
 Technic of Resection. — -The first essential of this procedure is 
 that all the impaired gut be removed. Otherwise subsequent slough 
 and perforation are almost a certainty. There is a limit, of course, 
 to the length of the segment which may be safely removed, but in the 
 ordinary operation one need not fear to remove too much. Cases are 
 on record in which as much as 10 feet of the small intestine have 
 been removed with recovery. As Moynihan said, it is not so much 
 a question of how much is removed as how much is left to carry on 
 the intestinal functions. 
 
 A second requisite in resection is that the blood supply of the bowel 
 be left unimpaired. Lack of precaution in this respect may nullify 
 an otherwise careful operation. 
 
 The integrity of a given part of bowel is absolutely dependent 
 upon the condition of the vessels which arise from the last arterial 
 arch to supply it. It must be remembered that the vasa intestini 
 tenuis break up into a number of freely anastomosing arches, but 
 the terminal branches anastomose but little. It is this charac- 
 ter of the circulation which determines the mode of section of the 
 mesentery. 
 
 The third principle constantly to be borne in mind is that the perito- 
 neum is to be completely protected from contamination by the 
 bowel contents. It is true of all the hollow viscera that their con- 
 tents are more or less septic, always sufficiently so to produce perito- 
 nitis. The bowel, then, must always be temporarily constricted 
 beyond the limits of the section. This is ordinarily done by means 
 of intestinal clamps or by elastic ligature or by gauze strips passed 
 through a button-hole in the mesentery. 
 

 ENTERECTOMY. INTESTINAL ANASTOMOSIS 
 
 Not only must the intestinal contents be restrained, but also the 
 field of operation must be shut off from the peritoneal cavity and 
 from contact with the rest of the viscera by means of sterile com- 
 presses. The larger and more deeply placed of these are not to be 
 removed until the end of the operation; the smaller and more super- 
 ficial should be changed from time to time as soiled. 
 
 Fig. 497- — Resection of the bowel; showing lines of incision of bowel and omentum. 
 
 To resect a portion of the intestine, then, begin by getting the 
 injured coil well into view and pack around it with sterile compresses. 
 It may be advisable as a further security now to put the patient in 
 the Trendelenburg position. Strip the portion of bowel to be re- 
 moved, so as to empty it, and apply a clamp well beyond each end 
 of the condemned segment. The clamps are not placed directly 
 across the bowel, but obliquely, so that more of the convex than of 
 the mesenteric border is included. A portion of the mesentery is 
 included in the bite of the forceps. 
 
 The lines of the section are prolonged into the mesentery so that 
 
TECHNIC OF RESECTION 
 
 669 
 
 they meet just short of the nearest arterial arch. It is better to 
 make the base of the mesenteric wedge even narrower than the 
 mesenteric margin of the intestinal segment. There is then scarcely 
 any danger that the circulation will be impaired (Figs. 497, 498). 
 If a lateral, instead of an end-to-end, anastomosis is in- 
 tended, the technic may be varied with great advantage. Under 
 such circumstances proceed in this manner: Determine the 
 
 Fig. 498. — Resection of bowel; showing segment of bowel and omentum removed. 
 
 lines of section; free the mesentery opposite, for a short distance 
 and apply a clamp to the bowel but not including the mesentery; 
 shift the clamp so as to flatten a segment of the bowel an inch long. 
 Ligate both ends of this segment and cut between the sutures, wrap- 
 ping the stump of the healthy portion in sterile compresses. Pass 
 to the other line of section and treat it in the same manner. The 
 portion of bowel to be removed is now freed of its mesentery, dividing 
 it parallel with, and an inch from, the gut, catching the vessels one 
 
070 
 
 ENTERECTOMY. INTESTINAL ANASTOMOSIS 
 
 by one as divided. To each of the remaining stumps a purse-string 
 suture is applied for the purpose of burying the ligated ends; are 
 further closed by a row of Lembert sutures (Fig. 499). Following 
 this step, the lateral anastomosis, to be described further on, can 
 be carried out. 
 
 Technic of End-to-end Anastomosis. — -(a) By suture. Employ two 
 lines of suture. One perforates the bowel wall, brings the cut edges 
 into accurate contact, and is hemostatic; it may be called the " per- 
 forating 1 ' suture. The other passes only through the serous and 
 muscular coats — or even better the submucous — -and after the man- 
 ner of the Lembert suture brings the serous surfaces into contact, 
 buries the perforating sutures and effectually prevents any of the 
 
 Fig. 499. — Resection of the bowel preparatory to lateral anastomosis, showing manner of 
 treating the intestinal stump. 
 
 bowel content from reaching the peritoneal cavity. Most surgeons 
 employ a straight needle and silk. Moynihan likes the curved needle 
 and celluloid thread. 
 
 To introduce the suture begin by placing the clamps side by side, 
 bringing the posterior surfaces of the bowel into contact. Con- 
 nect these two surfaces by a continuous sero-serous suture, extending 
 from the mesenteric border to the convex border (Fig. 500). Leave 
 the thread long where tied at the point of beginning and catch it with 
 forceps. On reaching point "B" leave the needle, still threaded, 
 but wrap it in gauze and lay it aside for the moment. 
 
 Now begin the perforating suture at the mesenteric margin. The 
 two leaves of the mesentery separate here to encircle the bowels, 
 leaving a part of the surface bare. The stitch must be passed so as to 
 bring the mesentery in contact with this bare area. 
 
TECHNIC OF END-TO-END ANASTOMOSIS 
 
 671 
 
 Proceed in this manner: Pass the needle through the bowel wall 
 (beginning with the right side) about % inch from the cut edge, 
 entering the mucus, emerging from the serous coat just where the 
 mesentery reaches the bowel. Carry the needle over and across to 
 the left side, pass it through into the lumen, reversing the first punc- 
 ture. Pass it next from within out, perforating the wall near the 
 mesenteric juncture, and finally perforate the right bowel wall again, 
 passing from without inward. The knot is tied within the lumen 
 of the gut at the original point of entrance. The edges of the mes- 
 
 Fig. 500. — End-to-end anastomosis; the first part of the sero-serous or Lembert suture 
 applied. Beginning the inclusive suture. (Binnie.) 
 
 entery being thus brought together, the suture is carried continuously 
 around the whole circumference of the gut (Fig. 501). The punc- 
 tures are 3<lo to 3^2 i nc h apart and the work is facilitated by keeping 
 the thread taut, which at once tightens it sufficiently and brings 
 into view the site of the next puncture. The end of the suture is 
 knotted, the thread left long at the beginning and thus the perfo- 
 rating suture is completed. Remove the clamps. 
 
 It remains to complete the sero-serous suture which was tempora- 
 rily abandoned. It is carried from the convex border on around to 
 the mesenteric border, and when that point is reached the perforating 
 suture is completely buried. Knot with the thread left long in the 
 beginning and held with forceps, and thus the sero-serous suture is 
 
672 
 
 ENTERECTOMY. INTESTINAL ANASTOMOSIS 
 
 completed (Fig. 502). Finally suture the rent in the mesentery. 
 This must never be neglected, else it may be the site of a strangulated 
 hernia. The line of suture is to be carefully wiped, the compresses 
 removed, and the loop returned to the abdominal cavity. 
 
 (b) By the Murphy button (Fig. 503). The bowel is resected as 
 described above. Begin by passing a purse-string suture around the 
 bowel near its cut edge, involving all the layers. The chief concern 
 
 Fig. 501. — End-to-end anastomosis; the first part of the Lembert suture buried by the in- 
 clusive suture which will be completed before resuming the Lembert A B. (Binnie.) 
 
 is to get control of the mesentery where its layers separate. To do 
 this pass the needle through one layer, on into the lumen of the 
 bowel; out again through the bowel wall and through the other layer 
 of mesentery (Fig. 504). 
 
 When the suture is puckered the intermesenteric space is obliter- 
 ated. Now grasp one-half of the button with forceps and introduce 
 it into the end of the gut so that when the purse-string suture is 
 tightened it will fall into the groove in the button. 
 
 i 
 
ANASTOMOSIS BY THE MURPHY BUTTON 
 
 673 
 
 Adjust the other half of the button in the same manner. The 
 male half is pressed firmly into the female half, noting that all the 
 edges are turned in. Strengthen the union by a few Lembert 
 sutures. Repair the rent in the mesentery and the anastomosis is 
 
 Fig. 502. — End-to-end anastomosis com- 
 pleted. A and B to be knotted. (Binnie.) 
 
 Fig. 503 — Murphy button. 
 
 Fig. 504. — Purse- Fig. 505. — Anastomosis with Murphy button completed. 
 
 string suture (b) run- (Binnie after DaCosta.) 
 
 ning over edge of bowel 
 and closing space be- 
 tween mesentery (c) 
 at (a). (Stewart.) 
 
 complete (Fig. 505). It may be expected that the button will pass 
 about the tenth day. 
 Lateral Anastomosis. — Proceed as before, bringing out of the ab- 
 1 dominal cavity the loops to be anastomosed and pack with sterile 
 
 43 
 
("71 
 
 ENTERECTOMY. INTESTINAL ANASTOMOSIS 
 
 compresses. Each loop is clamped and the two clamps laid side 
 by side so as to bring about 5 inches of the bowel walls in contact 
 (Fig. 507). 
 
 The first line of suture is to be applied nearer the convex than the 
 mesenteric border and should be about 3 inches in length. Unite 
 the opposed surfaces then by a sero-serous suture. The line of 
 
 ; i 
 
 Fig. 507.— Lateral anastomosis facilitated Fig. 508.— Lateral anastomosis; first row 
 by use of clamps. Continuous suture for both of Lembert sutures applied. (Binnie.) 
 
 layers. (Binnie.) 
 
 suture runs toward the operator, and when the line has reached, say 
 3 inches, the needle is left, still threaded, and temporarily laid aside. 
 The next step consists in making the openings which are to afford 
 the means of communication between the two loops. A straight 
 incision about 34 inch from and parallel with this line of suture lays 
 open the bowel down to the mucosa. Section of these superficial 
 
LATERAL ANASTOMOSIS 
 
 675 
 
 coats leave exposed an ellipse of mucous membrane, and this ellipse 
 should be trimmed out with the scissors. The other loop is opened 
 in the same way. 
 
 Fig. 509. — Lateral anastomosis; 
 first part of the through-and- 
 through suture applied (Binnie.) 
 
 Fig. 510. — Lateral anastomosis. Applying 
 last of the Lembert sutures. Interrupted in 
 this case, use the continuous instead. (Binnie.) 
 
 The adjoining edges are now to be coapted by continuous per- 
 forating suture (Fig. 508). As this suture progresses the opposite 
 
6 7 6 
 
 ENTERECTOMY. INTESTINAL ANASTOMOSIS 
 
 angle of the wound is reached, but without interruption it continues 
 to draw together the more widely separated borders (Fig. 509). 
 
 When it has reached the point of beginning, the terminal thread 
 is knotted with the first which was left long, and so the perforating 
 
 Fig. 511. — Cross-section of lateral anastomosis. (Binnie.) 
 
 suture is finished. Remove the clamps, wipe the bowel, and now 
 return to the sero-serous suture and continue with that until the per- 
 
 Fig. 512. — Termino-lateral anastomosis. 
 Clamps and continuous suture employed. 
 (Binnie.) 
 
 Fig. 513 • — Termino-lateral 
 anastomosis completed. 
 (Binnie.) 
 
 forating sutures are completely buried or, in other words, until the 
 sero-serous suture has traveled completely around the bowel and 
 the terminal thread knotted with the primary suture. 
 
TERMINO-LATERAL ANASTOMOSIS 677 
 
 If preferred, this sero-serous suture may be an interrupted instead 
 of a continuous stitch (Fig. 510), but the continuous suture is more 
 rapidly passed and is in every respect as secure. The main thing to 
 be attained, however, is that the serous surfaces be brought into 
 contact through the whole circumference of the bowel. 
 
 Fig. 511 shows the appearance of the bowel on cross section after 
 such an anastomosis. This method may be modified in many ways, 
 but exemplifies really the fundamental principles involved in any 
 anastomosis of the digestive tube. It is purposely stated in its 
 simplest terms and shorn of detail. 
 
 The technic of the termino-lateral form of anastomosis does not 
 differ in any essential detail from that just described for the latero- 
 lateral form (Figs. 512 and 513). 
 
CHAPTER XV 
 IMPERFORATE ANUS 
 
 A correspondent addresses the editor of the Journal of the Ameri- 
 can Medical Association (September 8, 1906) to this effect: 
 
 "Mrs. B., a perfectly healthy woman of twenty-eight years of age, 
 after a normal pregnancy, gave birth to a fine eight-pound boy, well 
 nourished and healthy looking, and perfect in every way except there 
 was no anus nor sign of any. A small amount of meconium was 
 being passed through the urethra. The next morning a local surgeon 
 was called in counsel and an incision was made through the floor of 
 the pelvis and dissected up along the coccyx, but no rectum was 
 found nor trace of a gut until the sigmoid flexure was reached in the 
 free peritoneal cavity. A large opening in the sigmoid was followed 
 by a discharge of feces. No attempt was made to stitch the gut to 
 the wall or the integument. The opening was not closed in any way 
 and no dressing applied, except that the nurse was directed to keep 
 the site of the operation sponged with a saturated solution of boracic 
 acid after each evacuation of the bowels. The child nursed well after 
 the operation and has continued to do so. It sleeps nearly all the 
 time, but has had no elevation of temperature; the passages come 
 free and the urine is passed normally. Can you suggest any means 
 of treatment that will permit the child to grow up with at least a 
 slight control of bowel movement?'' 
 
 That is the question which occurs to every doctor compelled to 
 deal with these cases, which are fortunately rare. The little being's 
 life rests upon the doctor's readiness to act; and if it survives, whether 
 or not it carries a life-long disability depends largely upon his skill. 
 
 It usually happens in the course of such cases that no meconium 
 passes within a reasonable time after the baby's birth. It grows 
 restless, perhaps vomits, and for the first time it is suspected that 
 there is some abnormality about the rectum or anus, which an exam- 
 
 678 
 
OPERATIVE TECHNIC 
 
 679 
 
 ination verifies. It is imperative to relieve the condition at once and 
 if no specialist is within reach, the doctor must undertake it. He 
 may find it quite easy or he may find it impossible. 
 
 In the first instance, the anus and rectum may be both fully devel- 
 oped, but in passing a finger or probe into the orifice, a thin bulging 
 membrane can be felt, apparently almost ready to burst when the 
 infant cries. A sharp-pointed bistoury, wrapped and introduced 
 along the finger or a grooved director, easily punctures the membrane 
 followed by a free passage of meconium; and thereafter the bowel 
 
 Fig. 514. — Incision for imperforate anus. (Veau.) 
 
 readily empties itself. The mother is directed to dilate the opening 
 daily with her little finger, and that, with an occasional stretching 
 with a bougie, is sufficient. 
 
 In another case there may be no depression where the anus should 
 be. The median raphe extends unbroken from the scrotum to the 
 coccyx. The anus is absent and it may be practically impossible 
 to tell how high up in the pelvic cavity the rectal cul-de-sac may be; 
 and yet it is one's dtity to hunt for it through the perineum. 
 
 Operation. — -Put the patient on its back with thighs flexed and 
 pelvis elevated — in short, in the lithotomy position. Employ a light 
 chloroform anesthesia, not that there is any danger if the anesthesia 
 is carefully conducted, unless, indeed, the operation has been too long 
 
68o 
 
 IMPERFORATE ANUS 
 
 delayed, but that a little straining on the patient's part may help to 
 locate the bowel. 
 
 Make a median incision from the base of the scrotum or from near 
 the posterior vaginal wall to the coccyx, which must be exposed 
 (Fig. 514). A number of eventualities may present: 
 
 (1) One may find immediately beneath the skin some of the fibers 
 of the external sphincter, a favorable indication. Split these fibers 
 by blunt dissection. Free incision may spoil their usefulness. Be- 
 neath the muscular layer appears the lobulated fatty tissue peculiar 
 to the new-born, which is to be next divided. Here one must go 
 
 Fig. 515. — Retention suture. (Veau.) 
 
 slowly, keeping in the middle line and all the time working toward 
 the coccyx. The danger is in front. If toward the hollow of the 
 sacrum, a fluctuating pouch is felt or a brownish rounded tumor is 
 seen, one breathes easy, knowing that the imperforate gut is within 
 reach. But do not be in a hurry to open the gut. It is first to be 
 secured by passing a suture on each side of the middle line or by 
 catching the bowel wall with forceps. The suture should not per- 
 forate the bowel. 
 
 Making gentle traction on the bowel, proceed to free it by careful 
 blunt dissection. Do not use knife or scissors to divide what seem 
 to be fibrous bands, for it is possible they contain the blood supply 
 of the bowel; and, if divided, dangerous bleeding may occur or the 
 tissues become gangrenous. 
 
OPERATIVE TECHNIC 
 
 68l 
 
 As the pouch is freed, it is gradually pulled down into the wound; 
 and if they were not passed before, two sutures are now passed with 
 which eventually to fasten the gut to the skin opening (Fig. 515). 
 Now is the time to open the pouch and let the meconium flow out. 
 It may require several minutes for the bowel to empty itself. Evert 
 the mucous membrane, enlarging the bowel wound a little if neces- 
 sary. Suture the mucous membrane directly to the skin; no other 
 tissues should intervene (Fig. 516). 
 
 Irrigate thoroughly and apply a gauze dressing, which is changed 
 as often as soiled. The functional result is often surprisingly good. 
 
 Fig. 516. — Muco-cutaneous suture. (Veau.) 
 
 Broncho-pneumonia may develop when the operation has been too 
 long delayed and septic absorption has begun. 
 
 (2) The pouch cannot be drawn down. In that case when the bowel 
 is opened the discharge will have to flow over the raw surfaces of the 
 flesh wound which will need to be kept open with bougies. Infec- 
 tion is a constant danger, not to speak of lack of control of bowel 
 movement. 
 
 Better than to leave the wound in this condition, the coccyx and a 
 part of the sacrum may be removed and the gut brought out poste- 
 riorly. Still better, open the peritoneal cavity, find and draw down 
 a loop of the sigmoid to fasten in the wound. 
 
 (3) The pouch cannot be found. Obtain more room by resecting 
 the coccyx, follow the sacrum a little higher, open the peritoneal 
 
682 IMPERFORATE ANUS 
 
 cavity and search for the cul-de-sac; if possible, draw it down into 
 the wound and suture. 
 
 If all these measures fail, there is nothing to do but make an arti- 
 ficial anus in the inguinal region. Indeed, there are those who advise 
 this from the first with the idea that later the operation for the con- 
 struction of a normal anal orifice can be better undertaken. 
 
 Tuttle says (Diseases of the Anus, Rectum, and Pelvic Colon) that 
 where there is no evidence that the rectal pouch can be easily reached, 
 and where the child is in an enfeebled condition with distended ab- 
 domen, fecal vomiting, and nausea in progress, one should not hesi- 
 tate to choose the abdominal route, perform an inguinal colotomy 
 at once and thus afford an immediate exit to the intestinal contents, 
 and an escape for the gases which are causing the distention and the 
 constitutional disturbance. 
 
 To this same volume the reader is referred for a full discussion of 
 these problems, and for consideration of those other forms of imper- 
 fect development in which the anus has abnormal openings. Such 
 cases are not strictly emergencies, for usually there is a partial means 
 of escape for the bowel contents. 
 
CHAPTER XVI 
 
 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE 
 TUMORS; OF THE SPERMATIC CORD; OF THE PEDI- 
 CLE OF THE SPLEEN; OF THE OMENTUM 
 
 Torsion of the pedicle of an ovarian or uterine tumor may be either 
 chronic or acute; in the one case developing so slowly as to produce 
 no symptoms or even no effect upon the tumor unless merely to in- 
 hibit its growth, for in the adhesions are new sources of nutrition; 
 in the second case developing suddenly and producing a train of 
 symptoms that demand immediate relief. The acute cases alone, 
 then, are to be regarded as emergencies. 
 
 Cysts of the ovary, especially those which are spherical, non-adher- 
 ent, and connected by a long pedicle, are most liable to this accident. 
 
 Kelly finds two causes for this rotation. The first of these is in 
 the effort of a large cyst to accommodate its convex surface to the 
 concavity of the distended anterior abdominal wall. The second 
 cause is found in contractions of the anterior abdominal wall, which 
 act upon the part of the tumor nearest the middle line. The effect 
 of the force thus applied is to rotate the tumor. In the case of 
 smaller tumors lying in the pelvic cavity it is likely that unusual 
 movement in the intestine or readjustments of the pelvic viscera may 
 1 produce the same effect. Kelly quotes Kiistner to the effect that 
 tumors of the right side, as a rule, rotate from left to right, while 
 left ovarian tumors rotate from right to left. 
 
 The diagnosis of acute torsion is not difficult if an ovarian cyst is 
 known to be present. If such a tumor was previously unsuspected 
 the certain diagnosis may be impossible, especially if the case is 
 seen late and general peritonitis is developing. 
 
 The symptoms, as a rule, arise without warning. There are severe 
 colicky pain, vomiting, marked constipation, and the appearances of 
 collapse. Abdominal rigidity and tension rapidly increase. This is 
 
 683 
 
\ OF 1111 PEDICLE OF OVARIAN OR UTERINE TUMORS 
 
 true of the more urgent cases. In general, the severity of the symp- 
 toms vary with the degree of torsion. 
 
 Appendicitis and acute intestinal obstruction present the greatest 
 difficulties in differential diagnosis which it is desirable to make, not 
 to determine the advisability of operating, but to determine before- 
 hand the kind of operation one is to undertake. Ranzi (Berliner 
 klin. Wochenschrift, Jan. 6, 1908) reports four cases of torsion of 
 ovarian cyst which were not differentiated from appendicitis, except 
 in one case, before the operation, and in this case by the pains in 
 urinating. In three of the cases there had evidently been mild 
 attacks of torsion which had subsided and which had been diagnosed 
 as catarrhal appendicitis. 
 
 The treatment is operative, and, as has been indicated, the operation 
 must often begin as an exploratory laparotomy, for though the symp- 
 toms indicate the seriousness of the case they may not reveal its 
 character. Delay is dangerous in these cases, and seldom will one 
 regret having operated early, for nearly always the lesions found 
 exceed the expectation. 
 
 The appearances once the abdomen is opened will depend upon the 
 size of the tumor, the degree of torsion, and the time of intervention. 
 Usually the tumor will be found enveloped in loops of intestine bound 
 ether by soft adhesions (Fig. 517). 
 
 These adhesions are to be carefully separated, and one must pro- 
 ceed with prudence for the cyst may be filled with pus and its walls 
 may be friable. The intestines, detached, are to be held out of the 
 way with compresses and the tumor thus brought into view. Its 
 nature may be at once apparent in spite of the fact that it is dis- 
 colored, dark red, or even black. If it is a cyst not quite so large, 
 it may resemble a dilated cecum. Its attachments are carefully 
 broken up, and gradually working toward its base the pedicle is 
 finally defined. 
 
 An effort is now made to lift the tumor out of the abdominal 
 
 < ayity, and there need be no hesitancy in enlarging the abdominal 
 
 ion if necessary. Usually it is to be lifted out with the two hands 
 
 applied to its base. Occasionally only after its pedicle is untwisted 
 
 is it possible to deliver it. 
 
 Next the pedicle is tied near its point of implantation, divided, 
 
TORSION, OVARIAN CYST 
 
 685 
 
 and thus the tumor is removed. If there are no evidences of infec- 
 tion the abdomen is to be closed without drainage. 
 
 Tumors springing from the uterus are much less likely to become 
 twisted. Yet, in the case of large non-pedunculated fibroids, the 
 
 
 
 
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 Fig. 517. — Torsion of the pedicle of an ovarian cyst. (Montgomery.) 
 
 uterus itself may be rotated and give rise to symptoms which de- 
 mand relief. In such a case the intervention may be quite complex. 
 In some instances a myomectomy may be sufficient. The uterine 
 wall is incised over the long axis of the tumor, which is exposed and 
 peeled out, and the hemorrhage checked by suture of the uterine 
 
TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS 
 
 wound The uterus may still tend to rotate and may require 
 fixation. 
 
 In still other instances, hysterectomy, either supra- vaginal or 
 complete, may be the procedure necessary for relief. This will be 
 the ease when the condition of the uterine wall after removal of the 
 tumor would preclude repair. 
 
 Harsha reports to the Chicago Medical Society (Annals of Surgery, 
 Nov., 1905) a case of torsion of the pedicle of an ovarian cyst in a 
 woman of thirty-three, who for several years at intervals had had 
 attacks of intestinal obstruction, accompanied by pain and vomiting, 
 lasting for three or four days. 
 
 Her last attack began suddenly with pain, vomiting, constipation, 
 tenesmus, accompanied by the symptoms of shock. At the end of 
 four days the abdomen was opened. A cyst, the size of an orange, 
 with twisted pedicle was removed. There was neither peritonitis 
 nor gangrene. There had been no further indications of obstruction. 
 
 In a second case the cyst was as large as a fetal head and black 
 to within an inch of its implantation. 
 
 Ochsner, commenting on these cases, says that symptoms of ob- 
 struction are not uncommon in such cases and that the history is 
 often that of volvulus. 
 
 He cites a case in which the abdomen had been opened by a prac- 
 titioner who believed he was dealing with intestinal obstruction. 
 Having opened the abdomen, however, he discovered a large black 
 tumor. Disconcerted, he stopped his operation, hurriedly trans- 
 ported the patient to the Augustana Hospital where Ochsner com- 
 pleted the work. 
 
 The doctor performing an emergency laparotomy must not have 
 his mind too definitely fixed on one diagnosis. Expecting one thing, 
 he must still have in view the possibility of having to deal with one 
 or more of a variety of conditions, and so will not be taken completely 
 unaware. 
 
 John Cahill and Sir William Bennett give the history of a case 
 which well exemplifies the difficulties of diagnosis, the occasional 
 complexity of treatment, and the dangers of delay (London Lancet, 
 Dec 8, 1906). 
 
 The patient, aged seventeen, was suddenly seized with abdominal 
 
TORSION OF THE SPERMATIC CORD 687 
 
 pain. There was some tenderness and resistance over the right iliac 
 fossa. The temperature was 98. 8°, the pulse 90. Bowels were 
 emptied by enemata, but the pain continued. On the third day 
 the temperature ran up to 101.8 and the pulse to 120. 
 
 An operation was still refused until at the end of a week the 
 patient's condition had become very grave. An operation for appen- 
 dicitis was then performed and the appendix found adherent and 
 filled with pus, in addition to other evidences of chronic disease. 
 Further examination revealed a dark, firm mass occupying the upper 
 part of pelvic cavity and intimately adherent to the bladder and 
 uterus. Exposed by extending the incision, it proved to be an ovar- 
 ian cyst the size of a cocoanut with a thick pedicle twisted upon 
 itself for three-fourths* of a turn. Its walls were thin and blackish, 
 and its contents mainly decomposed blood. The cyst was removed 
 and the patient recovered. 
 
 Dr. Cahill, commenting on the case, remarked that the situation 
 of the cyst was unusual in that it was wedged between the bladder 
 and uterus, whereas one expects to find such a tumor in Douglas' 
 pouch. 
 
 Sir William Bennett says that although cases not infrequently 
 operated upon for appendicitis prove to be cases of torsion, yet the 
 coexistence of the two conditions must be very rare. He suggests 
 that in this case the appendicitis, by aggravating the intestinal 
 peristalsis, had displaced the tumor with consequent torsion of its 
 pedicle. 
 
 Angus (British Medical Journal, Jan. 27, 1906) reports an attack 
 in a child of six, beginning with pain, vomiting, and abdominal dis- 
 tention. By the rectum a mass was palpable in the cul-de-sac. A 
 diagnosis of appendicitis with abscess formation was made. Opera- 
 tion. The appendix was inflamed at the end where it was attached 
 to a dark cytic swelling in Douglas' pouch. It was the right 
 ovary darkly congested, large as a duck's egg ? and with twisted 
 pedicle. Its contents showed it to be an ovarian dermoid. 
 
 TORSION OF THE SPERMATIC CORD 
 
 Malformations and imperfect descent predispose to rotations of 
 the testicle — an accident rare yet none the less to be borne in mind 
 
TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS 
 
 possibility. The exciting cause is usually to be found in trauma. 
 A heavy lift or strain may produce it. 
 
 It is readily comprehended that an incompletely descended tes- 
 ticle shifting backward and forth through the external ring could be 
 forcibly rotated. The rotation may occur in two ways: either the 
 testicle with its tunica vaginalis may be turned or the testicle alone 
 may rotate. The spermatic vessels, nerve, and vas deferens are 
 all involved in the resulting torsion. 
 
 The symptoms range from moderately severe to grave. Pain, 
 nausea, vomiting, constipation, and tympanites signalize the attack, 
 and soon the signs of local inflammation appear. 
 
 In the more serious cases the pain begins abruptly and persists. 
 It usually radiates from the inguinal region and lower part of the 
 abdomen, and may be intense or even produce shock. The con- 
 stipation is usually relieved by enemata. 
 
 The presence of a painful tumor in the inguinal region together 
 with the symptoms point to strangulated hernia and torsion of the 
 spermatic cord equally, and the differential diagnosis may be a 
 matter of difficulty. The pain is much more intense and sudden in 
 its onset than epididymitis. The cord, in torsion, can be felt tender 
 and swollen; it cannot be felt in strangulated hernia. Of course in 
 strangulated hernia the constipation is absolute. 
 
 Once the diagnosis is assured, an effort to untwist the cord should 
 be made and occasionally it will succeed. It is recorded of patients, 
 who, having had several attacks, learn to give themselves relief. If 
 manipulation fails it is imperative to operate without delay, for there 
 is danger of gangrene of the testicle. 
 
 An incision extending from near the external ring follows the cord 
 down toward the base of the scrotum. Layer by layer the tissues 
 are divided until the tunica vaginalis is reached. The tissues are 
 often edematous, reddened, and swollen. The tunica presents itself 
 as a thin-walled sac. Open it and drain away the serum and the 
 testicle will be found, possibly deformed, perhaps difficult to recog- 
 nize, and above it is the twisted cord. 
 
 Seize the testicle and rotate it from right to left in order to relieve 
 the torsion and restore the circulation. The further procedure will 
 depend upon the integrity of the testicle. If its violet color fades, 
 
68 9 
 
 if the congestion diminishes, it is almost certain the testicle will 
 recover, and it is therefore to be preserved. If it is black or mottled 
 or flaky, remove it by tying the cord above the torsion (see Castra- 
 tion). If its integrity is doubtful, preserve the testicle but provide 
 ample drainage for the tunica vaginalis. 
 
 Lichtenstern, of Vienna, reports a case of torsion of the spermatic 
 cord in a man of forty-six, which began with lifting a heavy load. 
 The scrotum soon became enlarged, and vomiting and constipation 
 ensued. A diagnosis of inguinal hernia had been made, and efforts 
 to reduce had failed. 
 
 At the time of entrance at the hospital his temperature had reached 
 io2° and his pulse was bad. In the scrotum was a large tense tumor 
 and in the inguinal canal another smaller. 
 
 On opening the scrotum an enormously swollen, turgid testicle 
 was found whose spermatic cord was twisted to 360 degrees. Part 
 of the omentum was found at the internal ring. The testicle was 
 untwisted and removed, the cord resected and the inguinal canal 
 closed as in herniotomy. 
 
 TORSION OF THE PEDICLE OF THE SPLEEN 
 
 The pedicle of the spleen may become twisted in cases of wander- 
 ing spleen. As in other varieties of torsion, it may develop slowly, 
 producing no marked symptoms and resulting only in congestion of 
 the organ and increase in size. Developing suddenly it is accom- 
 panied by the symptoms of general peritonitis or intestinal obstruc- 
 tion, and collapse. It may be mistaken for one of these conditions. 
 The tumor may suggest subphrenic abscess. 
 
 As Moynihan says, in the great majority of cases, splenectomy 
 is the better course to pursue, and this is especially true when throm- 
 bosis of the splenic vessels, infarcts in the spleen, gangrene or peri- 
 tonitis upon or around the spleen are present; when also the organ is 
 enlarged, it should be removed, for even though the pedicle be un- 
 twisted, it is useless to try a splenopexy. 
 
 The result of fastening in place a small wandering spleen is doubt- 
 ful. If it is enlarged, failure is certain. Fortunately, as Hartmann 
 has pointed out, a displaced spleen is usually not at all difficult to 
 remove because the lengthened pedicle permits of ready delivery; 
 
 44 
 

 690 TORSION OF THE PEDICLE OF OVARIAN OR UTERINE TUMORS 
 
 and the after effects are not so serious as those which attend removal 
 for organic disease. (Splenectomy, page 550.) 
 
 TORSION OF THE OMENTUM 
 
 Torsion of the omentum must naturally be a rare condition, and 
 yet is to be thought of when symptoms of intestinal obstruction arise 
 in those who have a hernia or are obese. 
 
 Torsion of the omentum as might be expected is very painful. 
 The pain, which is probably due to the plugging of the omental ves- 
 sels, may simulate appendicitis. It is not important that the differ- 
 ential diagnosis is sometimes not made, for the symptoms indicate 
 operation. 
 
 Rinchea and Corner describe a case in the British Medical Journal, 
 Jan. 20, 1906. The patient, a man of forty-eight, had had a hernia 
 for thirty-seven years, and had worn a truss for thirty- three; the 
 hernia had been reducible and painless. He was suddenly seized 
 with pain, and the hernia became irreducible. The pain increased, 
 and the tumor as well, though after two days the bowels moved, a 
 circumstance which ruled out strangulated hernia. The temperature 
 remained 99 , the pulse 102. The skin over the lower part of the 
 abdomen and inguinal region became reddened and the region tender. 
 An incision over the inguinal canal found the tissues inflamed, and 
 on opening the hernial sac a small mass of omentum was found 
 twisted on itself five times, but not constricted at the internal ring. 
 The mass was resected, and the radical operation for hernia 
 performed. 
 
 In another case, the patient, a man of forty-five with recent direct 
 hernia, a mass of omentum was found, pedunculated, the size of a 
 walnut, and containing a hemorrhagic cyst. 
 
 Cullen, of Baltimore (Johns Hopkins Hospital Bulletin, Dec, 
 I 9°5)> reports a case occurring in a very heavy man. The patient, 
 a railway conductor, had found it necessary to eject a recalcitrant 
 passenger and succeeded only after a struggle. In a few hours he 
 had developed the symptoms of appendicitis. 
 
 At the operation a gray, vascular, nodulated mass was found 
 which ended above in a tightly twisted pedicle and which on removal 
 proved to be the omentum. 
 
CHAPTER XVII 
 
 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY 
 
 Rupture of the sac of an ectopic gestation is far from being a rare 
 accident (Fig. 518). When it occurs, it is a major emergency, one in 
 which the doctor, isolated though he may be, must act and without 
 delay. Eighty-five per cent, of these cases operated upon recover; 
 85 per cent, of those treated by expectancy die. These figures 
 are in themselves sufficient argument, but when we add that the 
 
 Fig. 518. — Ruptured tubal pregnancy. Clot protruding from sac. (Montgomery.) 
 
 gravity of the condition grows out of hemorrhage, the reason for im- 
 mediate intervention must be admitted by all. Even in case the 
 hemorrhage tends to cease spontaneously, the urgency is scarcely 
 less pressing to prevent infection. For, from a diseased tube or a 
 stagnant fecal current, bacteria may escape to find a culture medium 
 in the blood free in the peritoneal cavity. 
 
 That the diagnosis of an extra-uterine pregnancy, even when sus- 
 pected, is difficult, no one will deny. After the most careful exam- 
 nation, one may not avoid error. More often, the condition 
 s not even suspected until rupture occurs. 
 
 691 
 
692 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY 
 
 A tubal pregnancy may be unrecognized, but there can be no 
 excuse for overlooking a ruptured tubal pregnancy. It can scarcely be 
 mistaken for anything else. Even if we admit that exact diagnosis 
 may be impossible, yet the indications for intervention are unmis- 
 takable. And that, after all, is the important thing. One does not 
 do grave emergency operations on mere impressions or suspicions 
 or the fear that such and such may be the case. We must have a 
 clear clinical picture in mind. 
 
 The attack comes on suddenly. There are pain, shock from the 
 peritoneal tear, and vomiting, suggestive of acute intestinal obstruc- 
 tion. One might also think of appendicitis or a renal calculus 
 There is often a bloody uterine discharge. Brickner says of the pai 
 that it is usually localized over the site of the lesion. It' has n« 
 definite character; it may be cramp-like over the affected tube; it may 
 simulate labor pains; it may be sharp and sudden. The usual symp- 
 toms of pregnancy may be present, but their absence does not argue 
 against the extra-uterine pregnancy. We have, as yet, no definit< 
 data by which we differentiate between the various forms (Medical 
 Standard). The history of the case and, finally, the signs of progress 
 ive internal hemorrhage point to the nature of the accident. The 
 pulse grows more rapid and feeble, the temperature falls, the features 
 are blanched, dyspnea appears and all the symptoms of collapse 
 Vaginal examination completes the diagnosis. One may find the 
 uterus but little enlarged, but on one side or the other, rising out of 
 the retro-uterine pouch, a boggy mass of variable size is felt. Dixon, 
 of St. Louis (Interstate Medical Journal), says that in fifteen cases, he 
 found the pregnancy on the right side in all but one, and this patient 
 had the peculiar fortune to have one on both sides. The right side 
 ' was relieved by operation, and six months later the left side necessi- 
 tated a second operation. Dixon adds that rigidity of the abdomi- 
 nal walls was present in most of these cases, though the absence of 
 rigidity is often named as a differential diagnostic point. 
 
 There may be an element of confusion. Vineberg, of New York 
 (New York Med. Jour., Feb. 22, 1906), reports two cases out of his 
 fifty-three in which there was a combined intra- and extra-uterine 
 pregnancy. He notes that a persistence of uterine bleeding after an 
 operation for extra-uterine pregnancy should suggest the possibility 
 
 ie 
 
 > 
 
 : 
 
 y 
 
 I 
 
OPERATIVE TECHNIC 693 
 
 of an intra-uterine gestation. He adds, with respect to diagnosis of 
 the condition generally, that amenorrhea, followed later by pain and 
 irregular uterine bleeding, should always put one on his guard. 
 
 From the history, then, and from the physical examination one 
 must diagnose the condition. On the signs of progressive internal 
 hemorrhage the decision to operate immediately is based, and one 
 should scarcely ever deem it too late, for even in the face of the most 
 menacing conditions, we must hold bravely to the last resource in 
 which, even in the desperate cases, there is often safety and life. 
 
 Operation. — AsLejars says, the operation is moving and dramatic, 
 but presents no especial difficulties if one but keeps cool and knows 
 what is to be done. 
 
 Instruments. — The instruments necessary are scalpel, scissors, 
 artery forceps, two long clamp forceps, two retractors, and curved 
 needles. 
 
 General Anesthesia. — -General anesthesia is necessary and must be 
 closely watched, A continual hypodermoclysis is an excellent means 
 of combating the combined effects of shock and anesthesia. It 
 should not be begun, however, until the hemorrhage has been 
 controlled. 
 
 Antisepsis. — -It is scarcely necessary to say that it is of little use to 
 save the patient from hemorrhage to die a few days later from sepsis. 
 The peritoneal cavity, under the conditions assumed, is a dangerous 
 culture medium. 
 
 The Trendelenburg position is almost indispensable, and if neces- 
 sary may be improvised. 
 
 Incision. — A median incision extending from the umbilicus toward 
 the pubes is made. Do not wound the bladder, which may be 
 pushed upward and forward. This, however, is not particularly 
 serious unless the wound should be overlooked. Waste no time. As 
 soon as the peritoneum is opened, catch its edges with artery forceps 
 and enlarge the orifice upward and downward. Do not try to sponge 
 out the cavity. Without regarding the clots, which may mask the 
 viscera, plunge a hand into the pelvic cavity and locate the uterus, 
 which is easily recognized. To one side, a thick, doughy or friable 
 mass will be felt. Slip your fingers under it, break the adhesions, and 
 enucleate it. This will empty the retro-uterine pouch — the cul-de- 
 
RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY 
 
 sac of Douglas. Feel with finger and thumb for the pedicle and, if 
 possible, pull the entire mass up into the wound and clamp. If the 
 mass is not adherent, a single clamp enclosing the broad ligament 
 from the outer side and passing under to include the tube will suffice 
 (Fig. 519). If there is too much adhesion, clamp on either side 
 of the pedicle. When the clamps are placed, the chief end of the 
 operation has been attained. Do not waste time trying to catch the 
 bleeding points, but ligate en masse. 
 
 
 Fig. 519. — Forceps applied to the tubo-ovarian pedicle. Trendelenburg position. (Veau.) 
 
 Ligate the pedicle. With a blunt, curved needle armed with No. 3 
 catgut, transfix the pedicle close to the cornu of the uterus, between it 
 and the forceps (Fig. 520). Ligate and then carry the ligature 
 around the lower segment of the pedicle and tie again, directing the 
 assistant to pull up on the clamp, and finally carry the ligature 
 around the entire mass and tie a third time. Preserve the ends of 
 the ligature. Resect the tumor and lift up the stump by means 
 of the threads to see if there is any bleeding (Fig. 521). This ligature 
 stands between the patient and death. If two clamps have been 
 used, it will be necessary to ligate u en chained 
 
OPERATIVE TECHNIC 
 
 695 
 
 Now clean out the clots, mop out the blood, and lower the pelvis to 
 drain the upper part of the abdominal cavity. The quantity of 
 blood is often enormous. If the patient is very weak, do not prolong 
 the task of cleansing it all out; yet in the long run, it is better to take 
 the time to cleanse out the fossa and wipe the intestine and omentum 
 for then the abdomen mav be closed without drainage. 
 
 Fig. 520. — First ligature applied. (Veau.) 
 
 Drainage. If there is oozing, apply a gauze drain at the site of the 
 tumor, and insert three or four drainage-tubes into different parts of 
 the cavity to carry out the blood left behind. Do not forget to fix 
 the drains, lest they be lost in the abdomen. 
 
 Suture the wound partially, unless able to dispense with drainage, 
 in which case suture completely. Apply a dry dressing of gauze and 
 absorbent cotton. Inject salt solution. After twelve hours, change 
 the dressing, which will probably be saturated; thereafter change 
 daily. About the seventh day the tubes may be shortened, and 
 about the fifteenth day, or often sooner, altogether removed. 
 
 Interstitial tubal pregnancy (Fig. 522) may occasionally be met 
 with and present complications. A case described by O. G. Pfaff , of 
 

 RUPTURE AND HEMORRHAGE OF TUBAL PREGNANCY 
 
 Indianapolis (Western Clinical Recorder, March, 1903) illustrates 
 the subject. On opening the abdomen a large reddish bag presented, 
 which seemed to develop from the right wall of the uterus, involving 
 
 Fig. 521. — Ligation and division of the tubo-ovarian pedicle. (Veau) 
 
 Fig. 522. — Tubo-ovarian pregnancy. (Montgomery.) 
 
 the right tube. In order to minimize the hemorrhage as well as to 
 secure the tumor, the upper portion of the broad ligament was 
 clamped and another clamp placed to the left of the tumor passing 
 
OPERATIVE TECHNIC 697 
 
 obliquely across the fundus and including the uterine artery. The 
 sac was now incised at its summit and the fetus, membranes, and 
 placenta turned out. No ligatures were required. The sac was 
 partially sutured, a drainage-tube fastened in its cavity and brought 
 out through the lower angle of the abdominal wound. The drainage- 
 tube was removed on the fifth day, and recovery was complete. 
 
 In certain of these cases the hemorrhage may be very difficult to 
 control. A " V" shaped section from the uterus in the region of the 
 cornua with firm suturing may succeed. 
 
 Finally in more obdurate cases a hysterectomy may be necessary. 
 
CHAPTER XVIII 
 CESAREAN SECTION 
 
 Cesarean section, designed primarily as an operation to save the 
 babe after the mother's death, is to-day of far broader application. 
 Without considering its exact indications, which for that matter the 
 whole profession is not yet agreed upon, it may be stated broadly 
 that it is the method of choice when the child cannot otherwise be 
 delivered alive. Unfortunately at the present time it is usually what 
 it should not be, viz., an emergency operation. 
 
 The Technic of Operation. First Stage: Laparotomy. — Incise 
 the abdominal wall. The incision extends in the middle line to 
 within 2 inches of the pubes and should be at least 4 inches in length. 
 If the uterus is to be brought out of the abdominal wound it will re- 
 quire to be longer. The peritoneum is to be exposed and opened up 
 in the usual manner. The abdominal walls are often quite thin. 
 As soon as the peritoneum is opened the uterus pushes into view. 
 Correct any lateral deviation. Hurriedly wall off the uterus with 
 sterile compresses, or deliver the uterus, protect with sterile com- 
 presses and suture the upper angle of the peritoneal wound. 
 
 Second Stage: Incision of the Uterus. — Keep exactly in the middle 
 line. Make a small incision in the uterus at the level of the lower 
 end of the abdominal wound that you may not later encroach upon 
 the lower segment of the uterus. 
 
 The peritoneum and superficial muscular layers are divided with 
 the bistoury, the deeper muscular fibers separated with the fingers. 
 Make a small opening in the mucous membrane. Through this 
 wound slip a finger into the uterus and on it as a guide divide the 
 uterine wall with scissors toward the summit; the incision should be 
 6 or 7 inches long. If the placenta is attached over the median line, 
 cut through it also. It makes no difference if the work is done 
 rapidly. 
 
 698 
 
 
OPERATIVE TECHNIC 699 
 
 Third Stage: Deliver the Child. — Slip the hand into the uterus. 
 Grasp the feet, delivering the breech first. Clamp the cord in two 
 places and cut between. 
 
 Fourth Stage: Remove the Membranes. — As soon as the child is 
 delivered the uterus contracts and often the placenta is detached at 
 once. If not it must be peeled off with the fingers. 
 
 Fifth Stage: Suture the Uterus. — Repair the uterine wall with 7 or 8 
 interrupted catgut sutures deeply placed but not reaching the mu- 
 cosa; or suture the mucosa first. Complete the repair by a few 
 superficial sutures. Suture is the best means of hemostasis, but 
 the bleeding is usually inconsiderable, especially if the uterus is 
 brought outside and bent toward the pubes. 
 
 Sixth Stage: Suture the Abdominal Wall. — Repair the peritoneum 
 with continuous suture; the fascias with chromic gut or plain 
 catgut; the skin with silkworm-gut. 
 
 These are the principles involved, bared of details which, of course, 
 vary with the operator and with the environment. Examples are not 
 wanting in current literature. A few will serve to bring out practical 
 points. 
 
 Lanphear, of St. Louis (American Jour. Surgery, Dec, 1906). 
 formulates a technic for country practice. The operator should have 
 a physician for assistant, or a trained nurse. The anesthetic should 
 be given by a physician. 
 
 Instruments. — Vaginal retractor (for cleansing the vagina), knife, 
 scissors, 4 hemostats, needles, chromic catgut No. 2, silkworm-gut, 
 safety-pins. 
 
 The containers for the solutions must be boiled and singed with 
 burning alcohol — -one for bichloride, 1 to 2000. one for alcohol, and one 
 for sterile water, a small dish or two for the instruments. 
 
 Dressings and Sponges. — Boil 15 yards of gauze and 12 towels free 
 from fringes. 
 
 Preparation of Patient. — -Pubes and vulva shaved. Abdomen 
 scrubbed. When the anesthesia is complete scrub the vagina with 
 gauze and soap and water, followed by alcohol. 
 
 Preparation of the Hands. — -They are to be scrubbed for five minutes 
 before disinfecting the patient and for five minutes after, followed 
 by immersion in alcohol and then in the bichloride solution. Again 
 
;oo < I SAREAN SECTION 
 
 sponge the abdomen before covering the field with four sterile towels 
 fastened with sterile safety-pins. 
 
 Abdominal Incision. — -Deliver the uterus and surround with four 
 towels wrung out of very hot water. Protect the edges of the wound 
 with sterile towels packed in around the uterus. 
 
 Incise the uterus; deliver the child; clamp and cut the cord. The 
 anesthetist may now lookafter thechild if there is no one else to do so. 
 Be careful in handling the child that your hands do not come in con- 
 tact with anything not sterile. Deliver the placenta, mop out the 
 uterus; suture. Lanphear advises a final row of Lembert sutures for 
 the peritoneal covering of the uterus. Repair the abdominal wall; 
 dress as usual; pack the vagina lightly and treat subsequently as 
 after any other confinement. Brown, of Manchester, N. H., recom- 
 mends practically the same procedure (American Jour. Surgery, 
 Feb., 1907). He observes that the uterus should be kneaded for a 
 moment to stimulate contraction. He uses in suturing the uterine 
 wall, a row of twenty-day chromicized gut sutures, passing through 
 all the layers a second row of Lembert sutures of silk. 
 
 Paul Martin, of Indianapolis, reports a case (Medical Record, Oct. 
 27, 1906). Operated after twelve hours of labor complicated by 
 eclampsia and a narrow pelvis and in which the bladder was greatly 
 distended and which could not be emptied by catheter. The bladder 
 extended half-way to the umbilicus. The uterus was emptied through 
 a 4-inch incision and the bleeding controlled by the assistant who 
 grasped the cervix. The uterine sutures employed by Martin were a 
 double row of interrupted muscular sutures of chromic gut and a 
 continuous chromic gut for the serous coat. The bladder was 
 not injured and afterward easily emptied. Mother and child both 
 survived. 
 
 S. A. Reynolds (Gaillards Southern Medicine, Feb., 1905) reports 
 an operation which, as he says, illustrates the principle that we should 
 never be afraid to put forth an effort to relieve our patients when 
 absolutely demanded, however hazardous and difficult the inter- 
 vention and however meager the means at our command. Place 
 a Log cabin with one room, lighted by a lamp without chimney. 
 Patient, a colored girl of thirteen with pelvic diameters less than 2 
 inches ; labor for twelve hours with a midwife in attendance. Both he 
 
OPERATIVE TECHNIC 70I 
 
 and Dr. Keen, with whom he consulted, realized the urgency, but 
 neither had ever done a laparotomy. Their equipment consisted of two 
 pocket cases of instruments, carbolic acid, a few ligatures, an earthen 
 pitcher and bowl, with teakettle of hot water. They sterilized their 
 instruments and hands in carbolic solution. Patient was laid across 
 the bed with feet on the floor. The abdomen washed. While Dr. 
 Keen gave the chloroform Reynolds made an incision from the 
 umbilicus down. The sides of the abdomen were pressed against 
 the sides of the uterus to prevent bleeding into the abdominal 
 cavity, and the uterus opened and emptied. 
 
 One suture was put in the uterus. Abdominal wall closed with 
 silk. On the fourth day the temperature was 103. 5 , pulse 150, resp. 
 36, but the symptoms of infection subsided and by the fourth week 
 the patient was well. 
 
CHAPTER XIX 
 RUPTURE OF THE URETHRA 1 
 
 By a fall astride a hard or sharp-margined object, by accidents of 
 saddle or bicycle, by a kick or blow, by a fracture of the pelvis, the 
 urethra may be ruptured. The urethral canal is forced up against 
 the pubic arch or against the sharp edge of the triangular ligament, 
 and is lacerated while the more elastic integument of the perineum 
 escapes. 
 
 Any part of the urethra may suffer, although usually only one part 
 is involved in a given case. The prognosis, and in some degree the 
 treatment, depend upon the portion injured, though the exact loca- 
 tion is not always easily determined. 
 
 Again the prognosis and treatment depend upon whether the 
 
 1 " We consider it unnecessary to speak of the medical treatment which is abso- 
 lutely valueless, and while the mechanical treatment has been in favor even with 
 the surgeon, it must be condemned if it becomes a general procedure. 
 
 The introduction of sounds and catheters into a lacerated urethra will almost 
 invariably be followed by infection at the point of laceration, notwithstanding the 
 aseptic conditions under which the catheterization is performed. The general 
 practitioner has been accused of inefficiency and carelessness in sterilizing his in- 
 struments. While this is true to some extent, it will be seen later, when speaking 
 of the Bacteriology of the Urethra, that a small aseptic instrument may cause 
 infection because the traumatism produced by the passage of a sound increases 
 the virulence of the urethral flora, which normally is in a semi-saprophytic 
 state of life. 
 
 On the other hand, the general practitioner with less ability in the handling of 
 sounds, especially when the urethra is inflamed and edematous, will cause false 
 passages, increase the liability of stricture at the point of laceration and predis- 
 the deep structures to infection and its consequences. It is our object to 
 urge early surgical treatment in these cases and rational treatment of the later 
 equences. The expression, "traumatic stricture," must disappear from the 
 medical vocabulary if the intervention in acute cases be immediate and rational. " 
 — Surgery, Gynecology, Obstetrics, Oct., 1906. Neff and Schrayer, Murphy's 
 Clinu , Chicago. 
 
 702 
 
 
DIAGNOSIS OF RUPTURE 703 
 
 rupture is total or incomplete, for upon the degree of laceration 
 depend the rapidity of extravasation and later the dimensions of 
 the stricture. 
 
 These, then, are the dangers: extravasation of urine, and in its 
 wake suppuration, abscess formation, and general septic infection; 
 on the other hand and later, stricture formation and all its attendant 
 difficulties. 
 
 Rupture of the urethra, therefore, is always a serious injury, and in 
 order that its dangers may be obviated, promptness of recognition 
 and intervention is imperative. 
 
 The symptoms of injury to the urethra are definite though varying 
 in degree and are: retention of urine, hemorrhage from the urethra, 
 and perineal tumor. 
 
 These symptoms, together with the history of the case, readily 
 make the diagnosis, but only by a careful study of each, recalling at 
 the same time the anatomy of the urethra, may one decide upon the 
 location of the injury. 
 
 (a) Retention of urine accompanies in some degree all traumatic 
 ruptures, though one should not make a diagnosis from this symp- 
 tom alone for retention may follow a mere contusion — an interstitial 
 rupture, without any solution of the continuity of the canal and with- 
 out obstruction. It has its origin in "shock," perhaps, with tem- 
 porary paralysis of the bladder musculature. In such a case, there 
 is gradual development of a perineal tumor from the contusion, but, 
 on the other hand, the bladder slowly fills and rises out of the pelvis. 
 
 In a few hours, the urine begins to dribble; a little later micturition 
 becomes voluntary though painful, and gradually the function is re- 
 stored to the normal. In actual rupture, the retention is complete 
 and continuous. 
 
 (b) Hemorrhage from the urethra is indicative of rupture, but its 
 amount in nowise points to the degree of urethral destruction. No 
 inference may be drawn from it as to the severity of the lesion. In 
 fact, the slighter the hemorrhage, the worse the outlook if the other 
 symptoms are aggravated. For instance, if the mucous membrane 
 alone is torn, the hemorrhage is immediate, perhaps voluminous, and 
 yet the lesion is of minor importance. On the other hand, if the 
 rupture is complete, the blood pours out into the lacerated tissues of 
 
;04 RUPTURE OF THE URETHRA 
 
 the perineum, and only a few drops may find their way through the 
 occluded canal. Therefore, one must never conclude that because 
 the hemorrhage from the meatus is slight, the injury is slight. 
 
 (c) Perineal Tumor. — There is always swelling in some degree fol- 
 lowing contusions of the perineum whether the urethra is injured or 
 not. The perineal and scrotal tissues are ecchymosed and the 
 scrotum especially is likely to be engorged with exudates. If the 
 urethra is ruptured the bladder empties itself into the bruised perineal 
 tissues, the ecchymosis rapidly becomes an edema, gradually thicken- 
 ing and expanding. It is at first an ovoid swelling in the middle of 
 the perineum, but gradually spreads until the scrotum, the pelvis, and 
 finally the abdominal walls are infiltrated, thickened or edematous to 
 a marked degree. But do not forget that the absence of a perineal 
 tumor does not always mean that the injury is slight. If the rupture 
 is situated behind the anterior layer of the triangular ligament and if 
 this is not torn, the transudates cannot reach the perineum, for this 
 tendinous band limits the forward movement of the urine; and so, 
 taking the direction of least resistance, it percolates through the cellu- 
 lar tissues of the pelvic cavity .and passes up along the side of the 
 bladder to the abdominal wall. Since, however, the anterior layer of 
 the triangular ligament is nearly always torn to some extent, peri- 
 neal swelling is nearly always present. Slight swelling will give no 
 feeling of security that the injury is slight. It is obviously essential 
 that one must have clearly in mind the anatomy of the urethra. 
 
 THE ANATOMY OF THE URETHRA 
 
 Stretched across the anterior segment of the pelvic outlet, between 
 the rami of the pubes, is the triangular ligament, dense and fibrous, 
 and arranged in two layers, separated by a 3^-inch space. In 
 contact with the deep or pelvic surface of the triangular ligament, is 
 the apex of the prostate gland. In contact with the superficial or peri- 
 neal surface is the bulb of the urethra, the knobbed posterior ex- 
 tremity of the corpus spongiosum. The urethra traverses the pros- 
 tate, perforates and bridges the space between the two layers of the 
 triangular ligament and then tunnels the bulb, runs the length of the 
 corpus spongiosum, and emerges at the glans penis, the anterior 
 
TREATMENT OF CONTUSION 705 
 
 knobbed extremity of the corpus spongiosum. The part of the ure- 
 thra anterior to the triangular ligament consists, then, of two por- 
 tions, the penile and bulbous; the deep urethra of two, the prostatic 
 and membranous, which later is the part which bridges the %- 
 inch space between the two layers of the triangular ligament. The 
 clinical manifestations of rupture depend upon whether the bulb- 
 ous or membranous portion is involved and in a minor degree upon 
 whether the rupture is partial or complete. (See Fig. 546.) 
 
 CONTUSION OF THE BULBOUS PORTION 
 
 Injury to the bulbous portion is by far the more frequent; it is the 
 form which the practitioner will nearly always find. It remains for 
 him to decide whether the injury is a contusion or rupture, for the 
 prognosis and treatment are quite different in the two degrees of 
 injury. If the case is one of contusion, it is likely the hemorrhage 
 was abundant; the patient complains of pain and inability to pass 
 water; there is no perineal tumor though the tissues may be much 
 bruised. After a few hours he begins to pass water after painful 
 effort. The urethral bleeding may persist, but the bladder keeps well 
 emptied. 
 
 Treatment. — -The treatment is very simple. Keep the patient 
 quiet, relieve the pain if necessary with small doses of morphine, and 
 give some urinary antiseptic such as urotropin. 
 
 Do not pass a catheter. Why should you? The bladder empties 
 itself; there is no perineal infiltration; and to do so would only 
 increase the risk of infection. The normal micturition will return in 
 a few days in the cases of mild contusion, and perhaps in a week the 
 patient will be well. If, however, in such a case, after a few days mic- 
 turition should become more painful and finally impossible, due to 
 urethral swelling or spasm, catheterization is indicated. Try a large, 
 soft, aseptic catheter first; try to carry it gently along the upper 
 wall of the urethra. You may fail and be forced to fall back on a 
 catheter of small size, but in no case must violence be used or the 
 attempts prolonged. The catheter may be left in if the introduction 
 was difficult, but it must be kept under constant surveillance, and at 
 the first appearance of a perineal tumor , indicative of infiltration, 
 45 
 
operation is imperative. If a catheter of small size has to be em- 
 ployed, it may not fill the urethra and there may be some dribbling of 
 urine, which favors infection. In such a case the catheter remaining 
 m the bladder may keep it empty by siphonage. 
 
 Contusion, with the formation of a large hematoma in the peri- 
 neum, might simulate rupture, but the presence of a distended blad- 
 der demonstrates that the perineal tumor is not infiltrated urine. 
 In such a case again, an attempt should be made to pass a catheter if 
 the urine does not begin to flow after three or four hours. If suc- 
 cessful, the size of catheter may be increased from day to day. 
 
 It must be borne in mind in making the first attempt that too per- 
 sistent effort may result in rupture of the already contused urethra, 
 or insure infection. 
 
 In case of failure, you may follow the recommendation of Lejars, 
 and proceed to drain the bladder by suprapubic puncture and it may 
 be, after a day or two when the swelling has subsided, a catheter can 
 be passed and drainage secured in that manner as before, but hold 
 yourself ready to operate at the first sign of infiltration. 
 
 This line of treatment can only be recommended to those who are 
 sure they can distinguish between hematoma following contusion and 
 infiltration following rupture. In case of doubt, always treat the 
 case as one of rupture. 
 
 RUPTURE OF THE BULBOUS PORTION 
 
 Urethral hemorrhage, rapidly increasing perineal tumor obviously 
 due to infiltrating urine, and retention of urine following injury point 
 at once to some destruction of the urethral wall. 
 
 There is no use of wasting time attempting to pass a catheter; 
 prepare at once for an external urethrotomy. Even if you succeed 
 in passing a catheter, it will not prevent extravasation in the end, as 
 Reginald Harrison and others have pointed out. Nor is there need 
 to wait for additional symptoms. The indications for operation are 
 unmistakable. Delay merely exposes the patient to all the risks of 
 infection. The end in view is to furnish a free outlet for the urine 
 and if possible to repair the ruptured canal. 
 
OPERATIVE TECHNIC 
 
 707 
 
 Operation for External Urethrotomy. — Provide for the operation 
 soft rubber catheters of various sizes; a grooved staff or steel sound; 
 small, curved needles, silk No. o, and three or four sizes of catgut. 
 
 General anesthesia is indispensable. Place the patient in the 
 lithotomy position with the perineum exposed to a good light. The 
 entire field must be disinfected with extreme care. 
 
 As soon as the patient is anesthetized, an effort may be made to 
 pass a catheter, and, if successful, the operation will be greatly facili- 
 tated. Otherwise pass the guide as deeply as possible without using 
 
 rftftitfi itliii iff III 1 
 
 
 Fig. 523. — Incision exposing the bulb of the urethra. (Duval.) 
 
 force, and let it be held in position by an assistant who also supports 
 the scrotum. 
 
 The median incision extends from the base of the scrotum to within 
 an inch of the anus. Divide the skin and fascia, when you may 
 reach an area filled with clots and lacerated tissues, the site of the 
 bulb and its muscular coverings (Fig. 523). You may not be able 
 to recognize the bulb if the destruction has been great, but after 
 wiping out the clots and debris, a cavity is exposed (Fig. 524). Ex- 
 pose the point of the guide, and you have thus located the opening 
 
;o8 
 
 RUPTURE OF THE URETHRA 
 
 into the distal half of the urethra. Determine the nature of the 
 urethral tear, whether partial or complete. The subsequent pro- 
 cedure will depend largely upon the type of injury present. 
 
 (a) If you find rupture of the lower wall only, the remnant of the 
 upper wall, a mere band perhaps, will be a great help in the next 
 step, which is to locate the orifice of the urethra on the farther side 
 of the tear. The search for this opening must be patient and minute. 
 Let the point of a probe or grooved director follow the remnant of the 
 
 Fig. 524. — The muscular and erectile tissue of the bulb divided, exposing 
 the urethra. {Duval.) 
 
 upper wall backward and it may haply engage in the orifice and pass 
 on into the bladder; if it does not, every bit of the mangled tissue 
 must be examined. 
 
 Another maneuver may be tried: if you have a soft-rubber catheter 
 in the urethra, pull it down into the wound and endeavor to engage 
 its point in the hidden orifice. Once the orifice is found and the 
 catheter carried into the bladder, try to suture the urethral wound 
 over the catheter. Place lateral sutures of fine silk or catgut, begin- 
 ning at the upper wall and suturing toward the lower where the 
 
OPERATIVE TECHNIC 
 
 709 
 
 separation is greatest. If possible, pass the suture through the outer 
 coats only. 
 
 (b) If the rupture is complete and the two ends are widely 
 separated, the difficulties are aggravated. There is no trace of the 
 upper wall left to assist in the slightest degree in locating the orifice , 
 of the proximal segment of the urethra. 
 
 " With the point of the grooved director, every small orifice, every 
 
 Fig. 525. — Soft catheter passed into the bladder after repair ot the upper wall. (Duval.) 
 
 depression, every fringed tubercle must be examined in the hope that 
 it represents the opening." 
 
 If you find something which looks like mucosa and the lumen of 
 the canal, introduce the point of your catheter and if it is in the right 
 track, it will glide into the bladder. 
 
 " A good light, patience, perseverance, and an accurate knowledge 
 of the anatomical relations of the injured parts often lead to success 
 in the most difficult cases." (Senn's Practical Surgery.) 
 
;io 
 
 RUPTURE OF THE URETHRA 
 
 Pressure on the bladder may sometimes help by forcing a drop or 
 t wo of urine through and thus exposing the urethral opening. Some- 
 t hnes bleeding from the ruptured artery of the bulb will serve as a 
 guide to the hidden opening. 
 
 The incision may be extended backward with a view to exposing 
 the canal, but this is often unsatisfactory and care must be taken not 
 to wound the anal sphincter. 
 
 If, by any of these means, the orifice is finally located and the 
 catheter passed into the bladder, it remains to adjust and suture the 
 
 Fig. 526. — Repair of the muscular layers. (Duval.) 
 
 divided ends. The ideal way consists in making an end-to-end 
 anastomosis, passing the sutures through the outer coats only. 
 Occasionally you will be satisfied if, by passing sutures through all 
 the coats, you can approximate, in some degree, the two ends, favor- 
 ing by that much the ultimate restoration of the canal and minimiz- 
 ing the stricture formation (Fig. 525). 
 
 "In twenty-nine reported cases of rupture of the urethra treated 
 by immediate suture, all are announced as successful. These results 
 are astonishing and commend repetition." (Bryant's Operative 
 Surgery.) 
 
SUPRAPUBIC CYSTOTOMY 711 
 
 After suture of the urethral tear, the perineal wound may be short- 
 ened a little by one or two sutures, but ample space must be left for 
 drainage. A wound unnecessarily large is much less dangerous than 
 one too small (Fig. 526). 
 
 Pack the wound with iodoform gauze. The catheter should be 
 left in the bladder for three to four days, when it is removed and a 
 steel sound passed thereafter every two or three days until repair is 
 complete. 
 
 (c) What are you to do in case patient search fails to locate the 
 bladder end of the torn canal and you are unable, therefore, to pass 
 the catheter into the bladder and to suture? Two procedures are 
 recommended: 
 
 (1) Pack the wound with iodoform gauze and empty the bladder 
 as necessary by suprapubic puncture. Perhaps at a later examina- 
 tion the opening may be found, or, as will nearly always happen, the 
 bladder is sufficiently drained after a day or two, through the perineal 
 wound. 
 
 (2) Do a suprapubic cystotomy and "retrograde catheterization." 
 Where the general condition of the patient and other circumstances 
 permit, this procedure is the better, since it assures drainage 
 and facilitates primary repair by definitely locating the bladder 
 end of the torn urethra in the perineal wound. It is necessarily 
 a delicate operation and should not be undertaken by the wholly 
 inexperienced. 
 
 To perform suprapubic cystotomy and retrograde catheterization, 
 begin by carefully disinfecting the abdominal wall. Make an in- 
 cision 2% inches long in the middle line, beginning at the pubes 
 and cutting through the skin and subcutaneous tissues and the 
 fascias. Retract the lips of the wound widely. You may not be 
 able to distinguish the peritoneal covering of the bladder, for it may 
 be above the upper level of the wound. In any event, it must be 
 pushed up out of the way. Next locate the bladder, which is easily 
 felt if it is distended; but if it is not, follow the posterior surface of 
 the pubes. 
 
 Transfix the anterior wall by a suture on each side of the proposed 
 line of incision, and lift the bladder upward to the abdominal wound 
 and open it by a free incision. A small incision is a nuisance, while 
 
712 RUPTURE OF THE URETHRA 
 
 a large incision renders the subsequent steps easier and is easily 
 sutured at the end of the operation. 
 
 With the bladder opened, the next step is to pass the catheter. 
 If possible locate the urethral orifice in the bladder and pass the 
 catheter by sight, but you will usually have to depend upon touch 
 for this procedure. 
 
 Introduce the left index and middle fingers into the bladder and 
 touch the base. Now draw the fingers forward in the middle line 
 and the neck of the bladder will be recognized by its relation to the 
 prostate, and the urethral opening feels like a pimple on the base of 
 the gland. The catheter is now slipped along the finger resting on 
 the orifice. Once engaged, it is pushed on through the urethra until 
 its point emerges in the perineal wound. Couple it onto the soft 
 catheter in the anterior part of the urethra and retract it through 
 the abdominal wound, and by this means the catheter in front is 
 drawn into place and should be left in the bladder after the urethra 
 and perineal wounds are sutured, as before described. 
 
 We must now provide for the drainage of the bladder through 
 the suprapubic wound. Employ a medium-sized catheter and let it 
 reach almost to the bottom of the bladder and anchor it in place 
 with a safety-pin. Suture the bladder wound tightly about the 
 tube. Repair the abdominal wall, leaving enough room for light 
 gauze packing about the tube. 
 
 "Many elaborate methods of suprapubic drainage are described, 
 but this tube connected to a long rubber tube by means of a glass 
 coupler and terminating beneath the bed in a bottle filled one-quarter 
 full of bichloride solution, will meet all the requirements of the case." 
 (Taylor, G. U. and Venereal Disease.) 
 
 The tube may be replaced by a smaller one after two or three days. 
 As soon as possible, the wound is allowed to fill up by granulation 
 and the drain is entirely removed. 
 
 RUPTURE OF THE MEMBRANOUS URETHRA 
 
 This accident is rare except in connection with fractures of the 
 pelvis. Under any circumstances, it is even more dangerous than 
 rupture in front of the triangular ligament, for the extravasated 
 
RUPTURE OF THE PENDULOUS URETHRA 713 
 
 urine may easily spread up into the pelvic cavity and induce cellulitis 
 and general infection. Examination per rectum will often reveal the 
 edema, no signs of which appear in the perineum. 
 
 Nothing but free incision and drainage through the perineum is 
 of any use. 
 
 Finally the pendulous portion of the urethra may be ruptured, 
 sometimes in coitus, and the hemorrhage may be quite alarming to 
 the patient; there may also be retention of urine. Usually catheteri- 
 zation will be sufficient. 
 
CHAPTER XX 
 
 ACUTE RETENTION, CATHETERIZATION, SUPRAPUBIC 
 PUNCTURE, CYSTOTOMY, URINARY INFILTRATION 
 
 Every acute retention of urine demands immediate relief. It 
 must be relieved not only on account of pain and discomfort, but 
 more especially to avoid damage to the bladder or urethra and the 
 evil effects of sepsis. This rule applies equally to the cases due to 
 temporary insufficiency of the bladder musculature and to those due 
 to urethral obstructions. 
 
 Urethral obstruction may assume various forms. In general prac- 
 tice, it will usually originate in one of three ways: spasm of the ure- 
 thra, enlargement of the prostate gland, or stricture. Very many 
 more times than we suspect in those cases regarded as simple reten- 
 tion from spasm, the real and predisposing cause is organic. In every 
 case before instituting measures for relief, it is wise to make minute 
 inquiry into the patient's history with respect to this function. At 
 least one should be suspicious of the presence of stricture and on his 
 guard. 
 
 It is true that, in a particular case, certain circumstances tend to 
 make one or the other of the causes of retention the more probable. 
 Thus, if the patient is in a febrile attack or has suffered some slight 
 trauma of the urethra or has undergone an operation on a region ad- 
 joining the urinary tract, one thinks of retention from urethral spasm. 
 If the patient is known to have a sexual history, has been a votary at 
 the shrine of Bacchus and Venus, the logical inference is organic stric- 
 ture. If the afflicted one is elderly, one thinks of enlarged prostate, 
 though mere age does not rule out other causes of obstruction. One 
 may be past the hey-day of life and yet strictured, paying late the 
 price of pleasures long since fled. 
 
 But after all, whether the predisposing cause is temporary or per- 
 manent, the actual exciting cause is usually congestion. This is a 
 
 7H 
 
ACUTE RETENTION 
 
 715 
 
 practical point constantly to be borne in mind, for it is congestion 
 which makes urethral instrumentation potent to produce trouble, and 
 which makes strict asepsis an absolute necessity. 
 
 CATHETERIZATION 
 
 The first measure of relief to be tried in actual retention, if opium 
 and a prolonged warm bath are not practical, is catheterization. To 
 meet the possible indications every practitioner should be armed. 
 A certain equipment is indispensable. 
 
 A cylindrical metal case capped at one end. is most convenient in 
 which to keep and carry these instruments. The most essential are 
 
 Fig. 527. — Conical. 
 
 Fig. 528. — Olivary. 
 
 Fig. 529. — Cylindrical. 
 {Stewart.) 
 
 tXJEBR'Z.VSQYIS 
 
 Fig. 530. — Elbowed flexible catheter. 
 
 Fig. 531. — Mercier double elbowed flexible catheter. 
 
 soft-rubber catheters of various sizes, flexible bougies with olivary 
 and conical tips, gum catheters with single and double elbows or 
 armed with stylets, filiform bougies (Figs. 527, 528, 529, 530, 531). 
 Sterilization of these instruments may be a problem, except as to 
 
 I the rubber catheters, which may without injury be disinfected by 
 boiling. The other instruments are best sterilized by formaldehyde 
 vapor and should be prepared before leaving the office and carried 
 wrapped in sterile cloths. 
 
 Without the special sterilizer, one must boil these instruments, 
 
 J risking eventual injury. They may be fairly well cleaned by rubbing 
 with an antiseptic ointment or by immersion in a 1-20 carbolic or 
 
; 1 ( ) CATHETERIZATION 
 
 i-iooo bichloride solution. Previous to its introduction, anoint the 
 catheter with sterile vaseline or similar lubricant. 
 
 Position of Patient. — The patient should lie upon a table high 
 enough that the operator does not need to stoop. The pelvis should 
 be elevated and the thighs flexed and abducted. Begin by thor- 
 oughly cleansing the field; cleanse the penis, the foreskin on both sides, 
 i he glans and the meatus, wiping each part with a separate com- 
 press. If possible, irrigate the urethra with boric acid or normal salt 
 solution. 
 
 Whatever condition may be suspected in an unexplored urethra, 
 make the first attempt at relief with a large catheter, seventeen or 
 eighteen French, which, as is well known, excites less resistance than 
 one of smaller size. Standing at the patient's left side, hold the penis 
 between the finger and thumb of the left hand, elongating it, while 
 managing the catheter with the right: Usually it is best to hold the 
 instrument parallel with the groin as its beak enters the meatus, 
 gradually bringing the handle to the middle line of the abdomen as 
 the instrument penetrates. As the catheter progresses it may be 
 helped along by giving it a slightly boring motion. Proceeding thus 
 gently but steadily, always avoiding force, the bladder may be 
 reached. If not, a smaller catheter is to be tried, and so on until one 
 is found that will enter. If all these efforts fail and it becomes 
 evident that a practically impermeable stricture is present, resort must 
 be had to filiform bougies, which may be bent into various shapes, 
 bayonet shape, or corkscrew form, and kept so by a thick collodion 
 coating. 
 
 A filiform bougie is passed until it engages, and then various back 
 and forth, side to side, movements are imparted with the hope of 
 finding a passageway through the scar tissue. The point may en- 
 gage in lucunae or in false passages, and often it is useful to leave the 
 bougie in situ. A half-dozen may be left in the urethra to occupy 
 the false passages, until happily one finally passes into the urethral 
 canal. Once a bougie is introduced into the bladder, it should be 
 fastened and left until the second day, when often it may be replaced 
 by a soft catheter or a larger bougie. In the meantime, the urine 
 trick the stricture drop by drop, until, in a short time, the 
 
 distention is relieved. 
 
CATHETERIZATION 
 
 717 
 
 If the retention is known from the first to be due to stricture, the 
 procedure may vary somewhat. Valentine and Townsend have 
 defined the technic of emergency dilatation of urethral stricture 
 in such a satisfactory manner (American Journal of Surgery, May, 
 1907) that it is transposed for present use practically in its entirety. 
 
 The hyperesthesia of the urethra, often so great an obstacle in 
 
 Fig. 532. — Lubricating the urethra. (American Journal of Surgery.) 
 
 atheterization, is greatly relieved by filling the urethra with a 
 3 per cent, solution of malaleuca sempervirens in sterile oil and 
 olding it for three to five minutes. Local or general anesthesia is 
 I undesirable. 
 
 l . No lubricant is used for filiforms, but the urethra is to be filled 
 
 e jftdth 10 per cent, suspension of iodoform in glycerin, injecting with a 
 
 sterile glass syringe of i-ounce capacity. The penis is held in the 
 
718 
 
 CATHETERIZATION 
 
 left hand, the index finger and thumb pressing the meatus open. 
 The tip of the syringe is inserted and the contents slowly injected 
 until it can be felt that the urethra is full (Fig. 532). When the in- 
 jection is complete the finger and thumb compress the meatus to 
 prevent the escape of any of the fluid to make the fingers or penis 
 slippery. 
 
 The filiform is to be inserted. A straight bougie, 5 French, is in- 
 
 
 Fig. 533. — Inserting a filiform. (American Journal oj Surgery.) 
 
 serted as far as it will go without force (Fig. 533). A smaller one is 
 then passed alongside the first and the procedure continued with 
 smaller straight bougies until a No. 1 has been inserted as far as 
 possible. This is then left in place and from three to six more intro- 
 duced, each one being left at the point of arrest. 
 
 When as many filiforms as will pass the meatus without stretching 
 it are thus inserted, the one first introduced may be urged slightly for- 
 ward. If its point is free but cannot progress, it may be withdrawn 
 
CATHETERIZATION 
 
 719 
 
 and an angular filiform inserted in its place. It should be gently 
 rotated to the right and left as obstruction is met with. If it makes 
 no progress, it may be left in place and another of the straight fili- 
 f orms withdrawn to be replaced by a bayonet filiform. The bayonet 
 filiform is to be pressed forward and then withdrawn slightly and 
 again advanced in a different direction, hoping to find the lumen. If 
 this fails, the corkscrew filiform is to be tried, removing some of the 
 straight filiforms if necessary to have more room. 
 
 Fig. 534. — Kollmann filiform guides. (American Journal of Surgery.) 
 
 When the corkscrew's tip reaches the face of the stricture, it is to 
 be rotated, trying first the right spiral and then the left. If the sec- 
 ond one fails, leave it in place and try each of the straight ones again, 
 pushing it gently forward, and if it fails to enter, withdrawing it. 
 After all the straight ones are tested and removed, try the corkscrew 
 that remains in the urethra and then the one tried first. 
 
 If all these maneuvers have failed, an attempt may be made with 
 
 Fig. 535. — Valentine-Townsend filiform carrier. (American Journal of Surgery.) 
 
 the Kollmann guide (Fig. 534). A straight or curved guide is to be 
 used, depending upon the location of the stricture. It is passed up 
 to, and pressed firmly against the face of the stricture, while a straight 
 filiform is introduced and lightly pushed up against the stricture, 
 changing the position of the guide from time to time. If this attempt 
 
 F'th the Kollmann guide fails, a metal sound as large as will pass to 
 e stricture by its own weight is introduced and held against the 
 

 CATHETERIZATION 
 
 stricture for five minutes or more and quickly withdrawn and the 
 urethra refilled with the iodoform-glycerin solution and all the ma- 
 neuvers with the filiforms repeated, often with the result that the 
 first inserted will traverse the stricture and enter the bladder smoothly. 
 The urethroscope is sometimes useful in locating the orifice, but 
 even then the filiform may be difficult to enter, manifesting the 
 "perversity of things inanimate;" although the shortest urethroscope 
 
 tube be used, the filiform will cling to its 
 sides or will sway to and fro, touching 
 every point of the exposed region except 
 the orifice. Under the circumstances, 
 the Valentine-Townsend filiform carrier 
 (Fig. 535) is to be recommended and its 
 use is thus described: 
 
 After the urethroscopic tube is inserted, 
 the urethral mucosa dried, and the light 
 in place, the carrier, armed with a fili- 
 form, is inserted. The lowermost ring 
 containing the filiform's tip is pressed 
 against the face of the stricture at the 
 point where its lumen is visible. Once 
 fixed by slight pressure, the filiform is 
 very slowly projected into the exposed 
 lumen. If it fails to traverse the stric- 
 ture, an angular and then a corkscrew 
 filiform are tried as before described. 
 
 Whenever a filiform reaches the bladder, 
 the fact is announced by the ease with 
 which the instrument can be moved to 
 and fro, and by the increased desire to urinate when the filiform 
 touches the bladder walls. A few drops of urine trickle by the filiform. 
 The filiform must be fastened in place: No effort must be made at 
 this time to pass a larger instrument. Valentine and Townsend 
 recommend the following method of holding the filiform in place: 
 
 Two -pieces of sterile cord 6 inches long are used, one tied about 
 the bougie in front of the meatus so that the knot corresponds to the 
 dorsum of the penis, and the other tied so that the knot corresponds 
 
 Fig. 536. — Cord attached to 
 instrument in urethra. (A merican 
 Journal of Surgery.) 
 
CATHETERIZATION 
 
 721 
 
 to the insertion of the frenum (Fig. 536). "Take the cords project- 
 ing from one side of the glans and pass them through one of the four 
 holes of a common pearl shirt button, draw the button upon the two 
 joined cords until it rests exactly at the post, coronary sulcus. Tie 
 a knot in each cord at that point to fasten the button in place" (Fig. 
 537). Proceed in the same manner on the opposite side. 
 
 Fig. 537. — Attaching button to cord. (American Journal of Surgery.) 
 
 A cord passing over the penis connects the two buttons; another 
 passing under the penis is threaded onto the two buttons and tied, 
 care being taken not to disturb the position of the two buttons (Fig. 
 538). Finally a cord 12 inches long is fastened into the remain- 
 ing hole of each button, and carried backward to be attached to the 
 pubic hairs after Guyoii's method (Fig. 539). 
 
 Fig. 538. — Uniting cords attached to button, lateral holes. (American Journal of Surgery.) 
 
 "The penis is then to be dressed, covering it with an aseptic gar- 
 ment. 
 
 "Three layers of sterile gauze 10 inches square are folded to form 
 a triangle. This is passed under the penis with the base toward the 
 scrotal angle. The apex is tied to the instrument at its projection 
 46 
 
CATHETERIZATION 
 
 from the meatus. The two angles at the base are carried in front of 
 the penis, one above the other, and their points are attached to the 
 pubic hairs by the extremities of the cords left after tying in the 
 instrument" (Fig, 540). 
 
 A pad oi cotton should cover the genitals, and the whole be covered 
 by a towel, to be changed as often as soiled. 
 
 "While it is better that the patient with a filiform fixed in his 
 
 ■\ r ). — Cords attached to pubic hairs. 
 {American Journal of Surgery.) 
 
 Fig. 540. — Penis dressed. {American 
 Journal of Surgery.) 
 
 bladder remains in bed, there are circumstances in which it is impera- 
 that he be allowed to go about and attend to his occupation. 
 gainst the dangers of retention as above, this is permissi- 
 ble u be engaged at hard labor." 
 
 In the case of retention due to enlarged prostate, the mode of proced- 
 ure i^ quite different if the primary effort at passing a soft catheter 
 fails. 
 
SUPRAPUBIC PUNCTURE 723 
 
 The prostatic catheter with long curve may be tried, passing it as 
 deeply as possible before depressing the handle between the thighs, 
 pulling the penis upward, elongating it to facilitate the movement of 
 the sound. Once the point is in the perineal region, the handle is to 
 be depressed rapidly, at the same time pushing the sound on, hoping 
 in this manner to carry it over the prostatic projection. No force 
 must be employed. Often the Mercier elbowed or double-elbowed 
 catheter will surmount the difficulty (see Figs. 453 and 454). 
 
 Sometimes a large gum elastic catheter armed with a stylet may be 
 useful. The catheter is introduced to the obstruction, the stylet 
 slightly withdrawn, which serves to tilt the end of the catheter and 
 permits it to be pushed on into the bladder. 
 
 In these cases of chronic enlargement of the prostrate, frequent 
 catheterization may be required. As Stewart (Surgery, page 653) 
 says, if it becomes difficult, if there is marked irritability of the 
 bladder, if the residual urine steadily increases in quantity, or if 
 there is stone or persistent cystitis, catheterization must be aban- 
 doned and operation advised. 
 
 PUNCTURE OF THE BLADDER 
 
 When catheterization has failed and relief is imperative, supra- 
 pubic puncture is the next resort. It is in nowise dangerous if aseptic, 
 except possibly in those long strictured or long troubled with enlarged 
 prostate, when the peritoneal covering of the bladder may approach 
 the pubes. 
 
 Begin with a careful disinfection. Shave and scrub the abdomen 
 and pubes. Select for puncture the point immediately above the 
 pubes in the middle line exactly. The instrument, which may be an 
 aspirator or simply a trocar, is to be entered at the point indicated, 
 without fear of going too deep, and pushed backward and slightly 
 downward until resistance ceases. Withdraw the stylet and the 
 urine follows in a steady stream. A rubber tube may be attached 
 to the trocar. The bladder should not be emptied rapidly, but 
 slowly, interrupting the flow from time to time. When the bladder 
 is emptied, the trocar is to be withdrawn with a rapid movement 
 
CYSTOTOMY 
 
 and the opening covered with a sterile compress, or, if quite small, 
 with collodion. 
 
 Aseptic puncture may be practised once or twice a day for a num- 
 ber of days without serious consequences, and at the end of this time 
 the congestion of the urethra may be relieved and the urinary func- 
 tion restored. If, however, at this time the urethral obstruction 
 cannot be overcome, then one must proceed to establish permanent 
 drainage. 
 
 Permanent drainage is indicated from the first if distance precludes 
 two or three daily visits, for there is no use to relieve the patient by 
 puncture and then leave him to the danger and pain of a new re- 
 tention, certain to occur. 
 
 Again, if the urethra has been lacerated by rough attempts at 
 catheterization, and if to the symptoms of retention are added those 
 of sepsis and the signs of beginning infiltration, it is imperative to 
 establish permanent drainage of the bladder. 
 
 Under these circumstances the puncture may be performed with a 
 large trocar, and after the bladder is emptied a catheter can be passed 
 through the cannula into the bladder as far as possible and the can- 
 nula gently withdrawn. 
 
 The catheter must be fixed in position, and this can readily be done 
 by threads attached to the skin with collodion. To the catheter a 
 long rubber tube should be attached, ending below in a vessel con- 
 taining an antiseptic solution. By this means a siphonage is estab- 
 lished and the bladder kept constantly emptied and prevesical in- 
 filtration avoided. 
 
 CYSTOTOMY 
 
 Permanent drainage through the suprapubic puncture is often 
 
 alone available, though by no means ideal. Whenever possible, the 
 
 bladder is to be opened formally and the drainage established by 
 
 that means, nor is the operation beyond the skill of the general 
 
 practitioner. 
 
 No special equipment is necessary: scalpel, scissors, artery forceps, 
 
 i cting forceps, small curved needles. Local anesthesia may be 
 
 employed in case of necessity, though, of course, general anesthesia 
 
 Arable. The region is to be carefully prepared. 
 
CYSTOTOMY 
 
 725 
 
 Operation. — Begin with an incision 3 inches long commencing 
 at the pubes and extending upward in the middle line (Fig. 541). 
 Divide the skin and fat down to the aponeurosis. Divide the aponeu- 
 rosis and expose the prevesical fat (Figs. 542-543). Draw this fatty 
 tissue upward, and with it the vesical peritoneum, exposing the blad- 
 der. The bladder appears dark and globular, marked by large veins. 
 
 Fig. 541. — Cystotomy. Primary incision exposing linea alba. 
 
 In fat subjects it may seem deeply situated in spite of its distention, 
 but one need nor fear to get into something else. 
 
 It is helpful in controlling the bladder and, later on in suturing, 
 next to pass a suture on either side of the proposed line of incision, 
 The sutures should pass through only the superficial tissues and be 
 parallel to the bladder incision. Next proceed to open the bladder 
 

 CYSTOTOMY 
 
 in the middle line, making the puncture at the level of the pubes with 
 the cutting edge of the bistoury turned upward, prolonging the in- 
 cision from a half-inch to an inch. If the sutures have not been 
 jed, catch up the edges of the vesical wound with forceps while 
 the urine flows out. 
 
 PlC. 542. — Partial incision of the deep layer of the sheath of the recti, exposing 
 
 the prevesical fat. 
 
 The bleeding, often considerable at first, is not a matter for con- 
 n and ceases spontaneously as the emptied bladder contracts. 
 When the bladder is emptied, douche it thoroughly with warm 
 
 lie water and explore its cavity for possible calculi. 
 It remains to suture the edges of the bladder wound to those of 
 the skin wound (Fig. 544). If the traction sutures mentioned were 
 passed, they may now be used to draw the bladder up into close con- 
 
 • 
 
OPERATIVE TECHNIC 
 
 727 
 
 tact with the abdominal wall, passing them through the entire thick- 
 ness, and tying them on the outside. 
 
 The mucous membrane is now brought in contact with the skin 
 and sutured with catgut (Fig. 545). It the condition of the vesical 
 walls does not permit the careful coaptation described, then four or 
 five sutures may be employed, passing through all the layers of the 
 
 Fig. 543. — Cystotomy. Recti separated, prevesical fat exposed. 
 
 bladder and abdominal walls, bringing them into contact. In this 
 case a catheter must be introduced and siphonage instituted. In 
 the first case, where the skin and mucosa are exactly coapted, it is 
 not necessary to leave a catheter in the bladder. The skin wound 
 is, of course, sutured above and gauze should be packed around the 
 catheter. The after-history will depend upon the condition present, 
 but the ultimate aim will be to restore the urethral functions. 
 

 INFILTRATION OF URINE 
 
 INFILTRATION OF URINE 
 
 Sometimes it happens that following a retention, partial or com- 
 plete, the urethra gives way and the urine percolates through the 
 adjoining tissues. Under these circumstances, the urine is nearly 
 always septic, the patient debilitated, and the conditions are thus ripe 
 or a rapid fatality. 
 
 Fig. 544- — Cystotomy. Bladder fixed to the abdominal wall, sutures passing through the 
 
 recti; bladder opened. 
 
 Shortly after the rupture of the urethral wall, the perineal tissues 
 become edematous, and the scrotum and penis markedly swollen. 
 The infiltration soon involves the public and hypogastric region. 
 
 The symptoms are those of sepsis: rigors, fever, pulse rapid and 
 weak, tongue dry, anxious facies, profound depression generally, 
 the symptoms depending in degree upon the duration of the accident, 
 
OPERATIVE TECHNIC 
 
 729 
 
 Fig. 545. Cystotomy. Sutures connecting the edges of the bladder wound and the skin. 
 
 Repair of the abdominal wall. 
 

 INFILTRATION OF URINE 
 
 the rapidity of the urine's spread and its septicity. Diffuse phleg- 
 mon and gangrene may rapidly ensue. 
 
 The rupture usually occurs in front of the triangular ligament — 
 the deep perineal fascia — and so the urine moves forward toward 
 the Scrotum and pubes, which is the direction of least resistance 
 ;. 546). 
 
 The treatment has two ends in view: to relieve the burdened tissues 
 
 Fig. 546. — Rupture of the urethra in front of the deep perineal fascia and at point of 
 entrance to the bulb; showing the direction which the infiltrating urine may take into penis 
 and scrotum, perineum, and suprapubic region. (Veau after Harlmann.) 
 
 and to open up a passage to the point of rupture. To relieve the 
 engorged tissues, a series of parallel incisions are to be made, extend- 
 ing beyond the limits of apparent infiltration, for the deeper tissues 
 are always more widely involved than the superficial. The incisions 
 should be deep enough to reach the deep fascia. The bleeding is not 
 likely to be serious, but any bleeding points may be caught up, and if 
 the oozing still persists, the incisions may be packed with iodoform 
 gauze. 
 
OPERATIVE TECHNIC 73 1 
 
 To expose the urethra, put the patient in the lithotomy position 
 and make an incision in the middle line, beginning at the base of the 
 scrotum and terminating in front of the rectum (Fig. 547). There is 
 no guide but the middle line, for the tissues, thickened and infiltrated, 
 are unrecognizable. There is nothing to do but continue to cut, 
 keeping in the middle tine, until rewarded by a spurt of urine. 
 
 All the incisions are to be thoroughly irrigated with hot normal 
 salt solution, the tissues gently squeezed and the dead tissues re~ 
 moved. A compress saturated with peroxide is next applied, this 
 covered with absorbent cotton,' and the whole retained by a T- 
 bandage. 
 
 Fig. 547. — Infiltration of urine: Perineal incision. {Veau.) 
 
 Ordinarily drainage is unnecessary, for the open wounds give free 
 *scape to the fluids. Often one is surprised at the completeness of 
 the repair. 
 
 At first the urine flows out through the breach in the perineum, 
 out after a little while a catheter may be passed and fastened in the 
 oladder and the perineal wound allowed to heal. 
 j Lejars prefers the thermo-cautery to the bistoury, both because the 
 Hemorrhage is less and because it exercises a salutary action upon the 
 dssues about to become gangrenous, but Veau believes the knife to 
 pe better, because it does not seal the mouths of interstitial drains. 
 
 If, in the course of intervention, an abscess cavity extending up 
 

 INFILTRATION OF URINE 
 
 toward the pubes is found, a drainage-tube must be passed as high as 
 possible and fastened in position (Fig. 548). 
 
 Sometimes it happens that the urethral rupture occurs behind the 
 perineal fascia, and again taking the direction of least resistance, the 
 urine may pass up along the side of the bladder to the deep layers of 
 the abdominal wall; or it may pass downward and backward into the 
 
 Fig. 548. — Infiltration of urine; placing drain. (Veau.) 
 
 ischio-rectal fossae. This condition is all the more dangerous for 
 the reason that the external manifestations are often delayed and in 
 consequence the true condition is not suspected until too late. 
 
 But whenever a zone of infiltration is found, wherever it may be, 
 e it and reach the urethra if possible. In the intra-pelvic in- 
 filtrations it may be necessary to open and drain through the bladder. 
 
CHAPTER XXI 
 SUTURE AND LIGATION OF ARTERIES 
 
 In emergency surgery the suture of a divided vessel is occasionally 
 applicable, but the doctor will usually prefer ligation, which will 
 nearly always suffice. 
 
 To suture a vessel, the blood current must be under temporary con- 
 trol by means of a clamp protected with rubber, that the tunica in- 
 terna may not be injured. 
 
 The vessel wall is seized with a fine forceps. The silk sutures are 
 placed one-sixteenth of an inch apart in a longitudinal wound, and 
 only the outer coats are pierced. 
 
 If an end-to-end anastomosis is required, three sutures are recom- 
 mended by Murphy and the proximal end is invaginated in the distal, 
 the sutures being passed first through the proximal and finally through 
 the distal end from within outward and tied. 
 
 The indications for arterial suture are as follows: 
 
 i. Where ligation might bring about serious nutritional change. 
 
 2. In all wounds of large vessels. 
 
 3. Operative wounds where a part of the vessel must be sacrificed. 
 
 LIGATION OF ARTERIES 
 
 It is a rule almost without exception that a divided artery must be 
 exposed and both ends tied. 
 
 Occasionally, in the case of secondary hemorrhage, it will be im- 
 possible to secure the artery at the site of the hemorrhage and liga- 
 tion at some point in the course of the artery above the lesion will 
 then be imperative. So that though only rarely to be used in emer- 
 gency surgery, yet the technic of special ligations should be kept in 
 mind. 
 
 General rules for all ligations may be formulated: 
 
 1. Put the patient in some position best to expose the artery and its 
 landmarks. 
 
 733 
 

 SUTURE AND LIGATION OF ARTERIES 
 
 2. Outline the course of the vessel, using aniline if necessary. 
 
 3. Tic the vessel, but avoid tying near the origin of a large branch 
 if possible. 
 
 4. Let the middle of the skin incision correspond to the point of 
 ligation and let its length depend upon the depth of the vessel. 
 
 5. Let the first incision include the skin and superficial fascia; the 
 incision in each succeeding layer should be the same length as the 
 first. 
 
 6. Each structure must be identified as exposed. 
 
 Fig. 549. — Ligation of an artery. A, opening the sheath; B, passing the ligature; C, tying 
 
 the ligature. (Moullin.) 
 
 ' 
 
 7. The sheath of the vessel is to be recognized by its position, pul- 
 sation, and feel to the examining finger. 
 
 8. The sheath is pinched up in the form of a cone, the base of 
 which is incised with edge of the scalpel turned away from the vessel. 
 
 9. Through this small opening the vessel is gently detached and 
 the aneurism needle passed, beginning usually on the side in rela- 
 tion with the vein and keeping it in close contact with the artery 
 
 '■ 549). 
 
 10. After the needle is threaded and withdrawn, be assured that 
 no other structures will be included in the ligature. 
 
LIGATION, COMMON CAROTID 
 
 735 
 
 ii. Draw the knot tightly enough to occlude the lumen of the 
 vessel, but not tightly enough to crush the inner coat. 
 
 12. The subsequent treatment is that of an ordinary wound. 
 
 THE COMMON CAROTID (Fig. 550) 
 
 The line of the artery corresponds to the anterior border of the ster- 
 no-mastoid. 
 
 Deseen&ens 
 \icni, nerve 
 
 •Ome-hyeld 
 
 muscte 
 
 Carctid 
 artery 
 
 -Inb l ju<ju,lar 
 yeirt, 
 
 ^ntT border cf JSfitrnC 
 Mastoid Muscle 
 
 Fig. 550. — Ligation of the common carotid and facial arteries. (Moullin.) 
 
 The incision should be 3 inches long in this line, the middl 
 of the incision corresponding to the cricoid cartilage. Divide the 
 skin, fascia, platysma; catch the bleeding veins, and divide the deep 
 fascia along the sterno-mastoid, exposing the sheath upon which lies 
 the de, endlens hypoglossi and the omo-hyoid. Just above the omo- 
 hyoidopcen the sheath from the inner side so as to avoid the internal 
 > jugular Pass the needle from outside, also to avoid the internal 
 ljugular. 
 
736 SUTURE AND LIGATION OF ARTERIES 
 
 EXTERNAL CAROTID 
 
 line. — Continuation of the common carotid. 
 
 Incision. — From the angle of the jaw to the thyroid cartilage, divid- 
 ing the skin, fascia, and platysma. Ligate divided veins. 
 
 I divide the deep fascia, exposing the sterno-mastoid, which is to be 
 ret racted. Locate the posterior belly of the digastric, the hypoglossal 
 nerve, and the tip of the cornu of the hyoid. 
 
 pose the artery opposite the cornu; pass the ligature between the 
 superior thyroid and the lingual arteries, avoiding the decendens hy- 
 poglossi and the superior laryngeal nerve behind. The operation 
 presupposes patience and a thorough knowledge of the anatomy. 
 Through this same incision the superior thyroid, the lingual, the 
 facial, the occipital, and the ascending pharyngeal arteries may be tied 
 at their origin. 
 
 LINGUAL (Beneath the Hyoglossus) 
 
 Position, — Place the patient on his back, turn the head to the oppo- 
 site side and raise the chin (Fig. 551). 
 
 Incision. — -Curved, its center just over the greater cornu of the 
 hyoid, extending from the symphysis of the chin to the angle of the 
 jaw. Divide the skin, superficial fascia, platysma and deep fascia. 
 Ligate the numerous veins which may be divided. Locate the lower 
 border of the submaxillary gland and divide its fascia, thus exposing 
 it, and lift it upward out of the way. 
 
 Develop the mylo-hyoid; also the two bellies of the digastric and 
 draw them down firmly. In the bottom of the wound is the hyo- 
 glossus muscle. Identify the hypoglossal nerve with the lingual vein, 
 which cross the hyoglossus. Incise the hyoglossus below, and paral- 
 lel with, the hypoglossal nerve. Incising carefully, the artery bulges 
 into the wound. Ligate the artery on the proximal side of the dorsalis 
 linguae. 
 
 SUBCLAVIAN (Third Portion) 
 
 
 Position. — -Place the patient on his back with shoulders raised, 
 
 head turned to opposite side, and angle of shoulder depressed 
 
 ' 550. 
 
LIGATION, THE SUBCLAVIAN 
 
 737 
 
 Incision. — From the posterior border of the sterno-mastoid, over 
 the clavicle, to the anterior border of the trapezius, drawing the skin 
 down first to prevent wounding the external jugular. Relax the 
 skin. The incision now lies ^ inch above the clavicle. If more 
 room is needed, partially divide the trapezius and sterno-mastoid. 
 Divide the deep fascia and ligate veins. 
 
 If the transversalis colli or the suprascapular arteries present, 
 draw them to one side. 
 
 frhycidm. 
 
 Fig. S5i. — Ligation of the subclavian and lingual arteries. (Moullin.) 
 
 Now identify the scalenus anticus muscle — -a very important step, 
 as it is the guide to the artery. Follow the external border of the 
 muscle down to the first rib and there the pulsations of the artery 
 will be felt. 
 
 Identify the lowest cord of the brachial plexus, which, as well as 
 the pleura and the subclavian vein, must be avoided in passing the 
 ligature. 
 47 
 

 SUTURE AND LIGATION OF ARTERIES 
 
 THE AXILLARY (Third Portion) 
 
 Position. — Patient supine, shoulders raised, arm at a right angle; 
 operator between arm and body (Fig. 552). 
 
 Incision. — -Along the line of junction of the middle and anterior 
 third of the floor of the space. 
 
 Divide the skin and fascia and expose the inner border of the 
 coraco-brachialis. Draw the coraco-brachialis, the median and mus- 
 culocutaneous nerves outward, the ulnar and internal cutaneous 
 nerves inward. Avoid the basilic and axillary veins. 
 
 Int.. tfuf&neoics nerve- . 
 
 Fig. 552. — Ligation of the axillary artery. (Moullin.) 
 
 BRACHIAL (In the Middle of Arm) 
 (See Operation for Exposure of Median Nerve.) 
 
 BRACHIAL (Bend of Elbow) 
 Position. — Limb extended and abducted, operator outside of arm 
 
 (Fig- 553). 
 
 Incision. — Follow the internal border of the bicipital tendon, the 
 center of the incision corresponding to the bend of the elbow. Divide 
 the skin and superficial fascia. Isolate the median basilic vein and 
 the internal cutaneous nerve, retracting them inward. Next divide 
 t he deep and the bicipital fascia and beneath this latter lies the artery 
 li its venae comites, the median nerve to the inner side. 
 
 Do not neglect to repair the bicipital fascia. 
 
LIGATION, THE RADIAL 
 
 739 
 
 RADIAL (In the Upper Third of Forearm) 
 
 Position, — Hand supine, surgeon to outside cutting downward 
 (on the right) (Fig. 554). 
 
 Incision. — -Along the inner border of the supinator longus for 3 
 inches, dividing the skin and superficial fascia. Divide the deep fas* 
 cia and separate the supinator longus and pronator radii teres. The 
 
 Tendinous Aponeurosis 
 divided 
 
 Fig 553- — Ligation of the brachial at head of the elbow; the median basilic vein and internal 
 cutaneous nerve drawn inward. (Moullin.) 
 
 Supinator lonjus 
 
 Fig. 554- — Ligation of the radial artery. In the floor of the wound is the pronator radi- 
 teres. The nerve lies some distance to the radial side. {Moullin.) 
 
 artery lies under the border of the supinator longus with the nerve to 
 the outer side. 
 
 RADIAL (At Wrist) 
 
 Position. — -The position is the same as before. 
 Incision. — -The incision is along the supinator tendon. Avoid the 
 Iradial vein and the superficialis volae artery. Divide the deep fascia 
 
"40 
 
 SUTURE AND LIGATION OF ARTERIES 
 
 and separate the tendons of the supinator longus and flexor carpii 
 radialis and between them lies the artery and its venae comites. 
 
 ULNAR (At Wrist) 
 (See Exposure of Ulnar Nerve, page 362.) 
 
 Z>ec/i fascia 
 
 SarCeriws 7rvusclei 
 
 Cord 
 
 Fig. 555. — Ligation of external iliac and femoral arteries. (Moullin.) 
 
 SUPERFICIAL FEMORAL (At Apex of Scarpa's Triangle) 
 
 Position.— Thigh slightly flexed, rotated externally, abducted; 
 surgeon to outer side (Fig. 555). 
 
LIGATION, THE FEMORAL 
 
 741 
 
 Incision. — Three inches long, with center over apex of triangle- 
 Divide the skin and superficial fascia. Avoid the long saphenous 
 vein. Divide the deep fascia and draw the sartorius outward; the 
 adductor longus, inward. Avoid the internal cutaneous and the long 
 saphenous nerves. The vein lies to the inner side and a little behind 
 the artery. 
 
 FEMORAL (In Hunter's Canal) 
 
 Position. — -The position is the same as before. 
 
 Incision. — Three inches in the line of the artery in the middle 
 third of the thigh. Divide the skin and superficial fascia. Avoid 
 the internal cutaneous nerve and the long saphenous vein. Divide 
 
 Tibialis anticus 
 
 Extensor lonjjus 
 diqitwum 
 
 Fig. 556. — Ligation of the anterior tibial artery. The nerve lies to the 
 fibular side. (Moullin.) 
 
 the deep fascia, expose the sartorius and draw it inward. Incise the 
 roof of the canal, but do not wound the long saphenous nerve which 
 is just beneath. Draw it inward and expose the sheath of the vessels. 
 
 ANTERIOR TIBIAL (Middle Third) 
 
 Position. — Thighs extended, leg turned inward and the foot ex- 
 tended to indicate the position of the tibialis anticus muscle. 
 
 Incision. — Fo,ur or five inches long in the line drawn from the head 
 of the fibula to the middle of the front of the ankle-joint (Fig. 556). 
 Expose the fascia. Divide it in the same line. By the sense of touch 
 locate the septum between the tibialis anticus and extensor longus 
 digitorum. Flex the foot to permit the separation of these muscles, 
 
74 J SUTURE AND LIGATION OF ARTERIES 
 
 and follow the septum down to the artery. The nerve is to the front 
 and outer side. Pass the ligature from without inward. 
 
 ANTERIOR # TIBIAL (Lower Third) 
 
 Position. — Same as above. 
 
 Incision. — Locate the tendon of the tibialis anticus; along its ex- 
 ternal border divide the skin for 3 inches. Find the septum 
 between the tibialis and the extensor proprius hallucis. In this 
 
 Fig. 55 7. — Ligation of the posterior tibial artery. The gastrocnemius retracted; the 
 
 soleus divided. (Moullin.) 
 
 space lies the artery with the nerve to the front and outer side. Pass 
 the ligature from without inward. 
 
 DORSALIS PEDIS 
 
 Position. — Patient on back with foot extended and resting on heel. 
 
 Incision. — Two inches long beginning at the middle of the lower 
 border of the annular ligament. Expose and separate the tendons of 
 the extensor proprius hallucis and extensor longus digitorum; the 
 artery is seen lying upon the tarsal ligaments. The nerve lies to the 
 fibular side. Pass the ligature from without inward. 
 
 POSTERIOR TIBIAL (Middle Third) 
 
 Position. — Patient on back; leg and thigh flexed; thigh rotated 
 outward so that leg lies on its outer side (Fig. 557). 
 
LIGATION, POSTERIOR TIBIAL 743 
 
 Incision. — -Four inches long, along the line. Y± inch behind the 
 internal border of the tibia. Expose and divide the deep fascia. 
 Expose and develop the inner border of the gastrocnemius; retract 
 and thus expose the soleus attached to the inner border of the 
 tibia. Divide the soleus vertically, and at the bottom of the 
 wound is seen the yellow fibrous aponeurosis which covers the vesssel 
 and deeper layer of muscles. Divide the aponeurosis about i% 
 inches from the internal border of the tibia and expose the artery. 
 Draw the nerve to the outer side and pass the ligature from without 
 inward. 
 
 W 
 
 Fig. 558. — Ligation of the posterior tibial behind the ankle. (Moullin.) 
 
 POSTERIOR TIBIAL (At the Ankle) 
 
 Position. — Turn the foot on its outer surface (Fig. 558). 
 
 Incision. — Curved, 3 inches long, with center midway between 
 malleolus and the inner tuberosity of the os calcis. Divide the fascia 
 and the internal annular ligament cautiously. The artery is just be- 
 neath the ligament. Separate the veins and pass the ligature from 
 without inward. 
 
CHAPTER XXII 
 SOME PRACTICAL AMPUTATIONS 
 
 The primary aim of an amputation is to conserve the life or health 
 of the patient; the secondary aim is to conserve, as much as possible, 
 the function of the member. The first requires that as much as 
 necessary be removed; the second, that no more than necessary be 
 removed. The good syrgeon will always adjust and harmonize 
 these two principles and they will determine the time and technic of 
 the particular operation. 
 
 The time element is of especial concern in traumatism and gan- 
 grene, for if the operation is done too early, too much may be re- 
 moved in one case and too little in the other. In traumatism, tissue 
 that at first sight seemed beyond remedy may survive; in gangrene, 
 tissue that seemed viable may be left, only to necessitate another 
 dangerous operation; so that following traumatism it is better not to 
 operate until the limit of the devitalized tissue has. been definite! 
 determined; and in the case of gangrene, until the line of demarcatio 
 has definitely formed. 
 
 The technic is principally concerned with conservation of function, 
 and looks to the formation of a good stump. " A stump to be service- 
 able, should be sound, unirritable, with good circulation and abun- 
 dant leverage" (Bryant, Operative Surgery). To produce a stump 
 with these qualities requires prevision of the flaps, particularly their 
 shape, length, and vascularity. Upon their shape will depend the 
 position which the cicatrix will take; upon their length, the com- 
 fortable adjustment of skin and bone; upon their vascularity, the 
 prompt repair, proper nutrition, and subsequent freedom from 
 Hi-ease. 
 
 The cicatrix should fall where it will be least subject to pressure 
 and friction wherever that may be done without the sacrifice of useful 
 tissues. In determining the position of the cicatrix, one must then 
 
 744 
 
 O 
 
GENERAL TECHNIC 745 
 
 consider the occupation of the patient and the possibility of an arti- 
 ficial limb being worn. 
 
 In the case of the leg, for example, the greatest tension might fall 
 on the end of the stump, and a scar there be some source of annoy- 
 ance; in the case of an arm, more pressure might fall on the side, from 
 artificial appliances, and an end scar would therefore be more satis- 
 factory. Nerves likely to be pinched up in the cicatrix should always 
 be resected. The ends of severed tendons should likewise be re- 
 sected, but not so high that their empty sheaths may be left to favor 
 the lodgment of infection. 
 
 That the stump may be sound and uniform in its outline, it is neces- 
 sary that the different degrees of contractility of the various groups 
 of divided muscles be known and their division accomplished accord- 
 ingly so that finally their ends may occupy the same level. The 
 bones must also be sawed squarely and care taken that the division 
 is not completed by fracture. The periosteum must not be roughly 
 handled. 
 
 The technic is concerned also with the prevention of hemorrhage. 
 This is best secured by first elevating the limb for several minutes 
 and then applying an Esmarch tube above the site of the operation. 
 
 After the section of the limb is completed and the large vessels se- 
 cured and ligated, the tube must be removed and each bleeding point 
 ligated separately. The tube has the disadvantage that there is 
 nearly always a temporary vaso-motor paralysis due to the pressure, 
 and on that account the oozing is considerable. 
 
 The occasional surgeon will be called upon to do amputations 
 under two entirely different circumstances, and his mode of proced- 
 ure will be quite different in the two cases. In one case, he will 
 attempt the typical amputation of the text-book,** in the other, his 
 sole guide will be the preservation of tissue: he will do an atypical 
 amputation. 
 
 (A) The soft parts are more extensively destroyed than the bone. 
 This is nearly always the case in traumatism and always the case 
 in gangrene. The site of amputation will depend upon the limit of 
 the sound skin; the rule is to remove none of the heal thy. soft parts; 
 the line of incision should follow the line of demarcation, and having 
 fashioned the flap following this indication, divide the bone high 
 
740 SOME PRACTICAL AMPUTATIONS 
 
 enough to accommodate the flaps, and no higher. (See also Injuries 
 to the Extremities.) 
 
 B) In case the bone is more extensively destroyed than the 
 soft parts, as in tuberculosis, sarcoma, etc., one has more option; he 
 can fashion the flaps in any manner desired, for usually much that is 
 healthy will have to be removed. The position of the cicatrix can be 
 determined and such is the typical amputation. 
 
 FINGER AMPUTATIONS 
 
 Practical anatomical points (Jacobson, Operative Surgery) : 
 
 "The three creases in front almost correspond to the joints. The 
 
 lower crease is just above the joint; the middle is opposite the joint; 
 
 the highest, nearly % of an inch distal to the metacarpo-phalangeal 
 
 joint. 
 
 " The prominence of the knuckles is formed by the higher of the twe 
 bones; by the head of the metacarpal bone, the head of the first pha- 
 lanx, the head of the second phalanx for the three joints respectively. 
 
 ' '■??"<<?;?:<<<?<'???. 
 
 
 Fig. 559. — Typical amputation of finger; palmar flap, dorsal scar. (Farabeuf.) 
 
 "The joint in each case is below, or distal to, the prominence; the 
 metacarpo-phalangeal joint is about J^ inch below the knuckle; 
 the second joint, % inch below the knuckle; the terminal joint Jf 2 
 inch beyond the knuckle. 
 
 " In the distal and interphalangeal, the joint is concave from side to 
 side and presents a concavity toward the finger tips. In the meta- 
 carpo-phalangeal joint, the convexity is toward the finger tip. 
 
 "From the readiness with which the tendons conduct infection, 
 care should be taken to keep even so small an amputation as that of a 
 finger strictly sterile, and in amputating through damaged parts the 
 flaps should not be too closely united with sutures." 
 
 It is a rule with but few exceptions to save as much of the finger as 
 possible, and it will almost always happen in removing part of a finger 
 
 
AMPUTATION OF FINGER 
 
 747 
 
 that an atypical amputation will be indicated. Let the scar fall 
 where it will, making a dorsal or a lateral flap if necessary. The 
 palmar flap and dorsal scar is ideal, but rarely attainable (Fig. 562). 
 There are, however, surgeons of large experience who insist that a 
 palmar flap be secured even at the cost of more finger, and that less 
 than half a phalanx should not be saved, but cut back to the joint 
 to avoid flexure. (See Injuries to the Hand.) 
 
 If a distal phalanx is to be removed, begin by pronating the hand, 
 forcibly flex the phalanx and divide the skin 3^ inch distal to 
 
 Fig. 560. — Atypical amputation of a finger, the bone projecting beyond the skin. Dorsal 
 
 incision. (Veau.) 
 
 the knuckle; this incision deepened will open the joint. Divide the 
 lateral ligaments. The edge of the knife is carried under the phalanx 
 and swept downward, grazing the bone and cutting with a steady 
 sawing movement. The result is indicated in Fig. 559. Do not cut 
 the flap too short, a common mistake with the inexperienced. 
 
 AN ATYPICAL AMPUTATION 
 
 Suppose a finger to have been sawed off. The bone projects be- 
 I yond the retracted skin. It is not possible to fashion a flap without 
 I removing some bone. 
 

 SOME PRACTICAL AMPUTATIONS 
 
 Loral anesthesia (Figs, ioandu). Circular constriction at the base 
 will control bleeding and prevent rapid absorption of the solution, 
 i by making a dorsal linear incision an inch long down to the 
 bone (Fig. 560). 
 
 Liberate the whole circumference of the bone }i inch up, 
 cither with a rugine or a bistoury (Fig. 561), and at that level divide 
 the bone with bone forceps (Fig. 562). Employ two or three sutures 
 with drainage if there is much chance of infection (Fig. 563). 
 
 If the dorsal linear incision opens into a joint, the section may be 
 made there — disarticulate. 
 
 Fig. 561. — Liberating the bone. (Veau.) Fig. 562. — Section of the bone. (Veau.) 
 
 Divide first the dorsal ligament, then the lateral ligament to the 
 left, and as the phalanx is twisted toward the left, divide the lateral 
 ligament to the right. Suture as before. It may be necessary to 
 slice off the head of the remaining portion of the digit if it is too 
 prominent. 
 
 TYPICAL AMPUTATION OF THE WHOLE FINGER 
 
 neral anesthesia is usually necessary. The method of procedure 
 is different for the middle and ring fingers, the index and little fingers, 
 
 and the thumb. 
 
AMPUTATION OF FINGER 
 
 749 
 
 (I) The Middle and Ring Fingers. — Locate the articular line by 
 making traction on the finger with one hand and palpating each side 
 of the joint with the index finger and thumb of the other hand. 
 
 Fig. 563. — Atypical amputation: Suture and drainage. (Veau.) 
 
 Fig. 564, — Typical amputation of middle finger: Primary incision directed to 
 the right. (Veau.) 
 
 Begin the incision at the upper level of the joint; carry it obliquely 
 downward and forward between the fingers so that it reaches the 
 palmar surface at the right, a little below the crease (Fig. 564). 
 
75° 
 
 SOME PRACTICAL AMPUTATIONS 
 
 Lift up the hand so that you face the palm and cut transversely to 
 the left (Fig. 565). Now lower the hand and complete the incision, 
 bringing it obliquely upward and backward to the knuckle, the start- 
 ing-point (Fig. 566). 
 
 Having outlined the incision in this manner, repeat the movement, 
 cutting to the bone. Retract the flap, exposing the articulation. 
 
 Fig. 565.- 
 
 -Amputation of the middle finger: Lifting the hand while making the transverse, 
 palmar incision. (Veau.) 
 
 Disarticulate. Pull on the finger to separate the joint surfaces, 
 which helps to locate the joint line. Hold the bistoury vertically, 
 and with its point divide the lateral ligament to the left, then the 
 dorsal ligament (Fig. 567), then the ligaments to the right, at the 
 same time bending the finger to the right. 
 
 Tie the digital arteries, usually one on each side, and suture 
 B- 568). 
 
AMPUTATION OF FINGER 
 
 751 
 
 (II) Index and Little Fingers. — In these two instances, the aim 
 is to carry the scar toward the dorsum and the axis of the hand. In 
 
 Fig. 566. — Amputation of the middle finger. Completing the skin incision. (Veau) 
 
 Fig. 567. Amputation of the middle finger: Traction on the finger while the bistoury cuts 
 
 first the left and then the dorsal ligaments. (Veau.) 
 
 the case of the index, it falls toward the ulnar side; in the case of the 
 little finger, toward the radial side. The scar is, then, in each case, 
 furthest removed from pressure. 
 
 SL 
 
SOME PRACTICAL AMPUTATIONS 
 
 The flap itself, of rounded outline, folds over on an axis passing 
 obliquely through the joint cavity and approximates the adjoining 
 
 linger. 
 
 The removal of the index finger is conducted along the samelines. 
 
 The first semicircular incision is carried around the radial side and 
 completed by a second, following the web of the finger. The appear- 
 ance of the flap is indicated in Fig. 573, and the final result in Fig. 574. 
 
 Fig. 568. — Amputation of the middle finger completed. (Veau.) 
 
 If the patient is a laborer, it is necessary to render the hand as use- 
 ful as possible, nor must the cosmetic effect be neglected. It is neces- 
 to reduce the size of the heads of the metacarpal bones. 
 
 The head of the metacarpal bone of the index is best reduced by an 
 obliq&e section of the radial side; of the little finger, the ulnar side; 
 of the ring finger, by transverse section (Fig. 575). With regard to 
 
AMPUTATION OF LITTLE FINGER 
 
 753 
 
 Fig. 569. — Amputation of the little 
 finger: Flaps completed. (Veau.) 
 
 Fig. 570. — Amputation of the little finger: Disar- 
 ticulation, cutting from left to right. (Veau.) 
 
 In the case of the little finger, begin the incision just below the joint line on the ulnar 
 side of the extensor tendon, and carry it obliquely downward and forward and then across 
 the palmar surface, inscribing a regular semicircle which ends at the free border of the web 
 between the little and ring fingers. Complete the incision by cutting from this point to the 
 starting-point, inscribing a semicircle with its concavity toward the web. Follow this same 
 track again, cutting to the bone. Denude the bone completely (Fig. 569)- 
 
 Disjoint, dividing the left and the dorsal and finally, the right lateral ligament (Fig. 
 (570), and the flap is free (Fig. 57i>. Suture (Fig. 572). 
 
 Fig. 571. — Amputation of the little finger: 
 Flap after disarticulatin. (Veau.) 
 
 48 
 
 Fig. 572. — Amputation of the little finger: 
 flap sutured. The line of union lies toward 
 the axis of the hand on the dorsum. (Veau.) 
 

 SOME PRACTICAL AMPUTATIONS 
 
 the middle finger, the head of its metacarpus should not be removed 
 
 unless shapeliness rather than strength is desired (see page 105). 
 IIP The Thumb. — The thumb must be treated with the utmost 
 nvatism. The smallest part must never be removed unneces- 
 sarily, as it is almost as useful as the rest of the fingers together, 
 
 u i{ i\ 
 
 "73- — Amputation of index; showing Fig. 574- — Amputation of index and little 
 form of flap. (Veau.) fingers completed. (Veau.) 
 
 and nearly always after a traumatism, it is best to do an atypical 
 amputation. (Figs. 582, 583, 584.) 
 
 In the typical amputation, employ a palmar flap.' Begin on the 
 dorsal surface just below the articular line and incise to the right, 
 reaching the edge of the palmar surface just above the interphalan- 
 geal crease. (Fig. 580.) 
 
SECTION OF THE METACARPALS 
 
 755 
 
 In the course of a finger amputation, once the finger is disarticulated at the metacarpo- 
 phalangeal joint (amputation of whole finger), the treatment of the corresponding meta- 
 carpal head is to be considered. 
 
 The mode of procedure varies with the various fingers and is determined by two 
 factors: The future appearance of the hand; and, second, its usefulness. 
 
 Fortunately the best cosmetic effect is consistent for the most part with conservation 
 of function. Formerly we were advised to leave the metacarpal head intact whenever 
 it was desired to maintain the whole strength of the hand. This was based on the 
 notion that destroying the transverse ligaments left the metacarpus unstable and the 
 
 Fig. 575- — Lines of section of the metacarpal heads. (Veou.) 
 
 hand weakened in consequence; but the line of section need not extend so far beyond 
 the articular surface. The line of section differs with the various digits as indicated in 
 Fig. 575. 
 
 Thus the metacarpal head of the index and little fingers is sectioned obliquely to 
 smooth off, in the one case the radial, in the other, the ulnar border of the hand. Com- 
 pare Fig. 574 with figures on page 102. 
 
 The Ring Finger. — Divide the metacarpal head transversely (see page 103}. 
 
 The Middle Finger. — The metacarpal head is best treated by slicing off a part of each 
 lateral surface. If none is removed the separation of the adjacent fingers is too wide 
 Fig. 568^. If too much is removed the index finger falls away from the thumb inter- 
 f erring with apposition (see page 104). 
 

 SOME PRACTICAL AMPUTATIONS 
 
 Fig. 576. — Crush of ring finger. Treatment. 
 
 Every crush of the fingers must be treated with the greatest conservatism. The 
 temptation to get rid of the mangled tissues and to make a sightly stump is always 
 great but the patient's mind dwells more strongly on the loss of tissue. In many cases 
 it is impossible to say what effort the tissues may make toward repair. Trim the skin 
 sparingly therefore. Carefully disinfect and splint in such manner as not to interfere 
 with the circulation and wait for further indications. 
 
 However, a finger crushed in the manner indicated in Fig. 576, it is useless to save, 
 because it will be deformed, unsightly and an actual hindrance. Usually the tissues 
 slough and there is constant danger of infection involving the whole hand. It is best to 
 disarticulate at once at the metacarpophalangeal joint. 
 
 Begin with a dorsal incision extending 1/2 inch above the head of the metacarpal 
 bone, freely exposing the extensor tendon. The incision is now carried around the base 
 of the finger (Fig. 577). 
 
AMPUTATION OF FINGER 
 
 757 
 
 Fig. 577. — Crush of ring finger. Amputation. 
 
 Second step: Raise the finger so that the palmar surface presents and beginning at the 
 dorsal incision cut from left to right along the base of the finger keeping within the limits 
 of sound tissue. Cut down to the bone, dividing the flexor tendons and on either side 
 the digital arteries. Having divided all the soft parts denude the bone with a rugineor 
 periosteal elevator, exposing the head of the metacarpus thoroughly (Fig. 578). 
 
 Third step: Disarticulate by dividing the ligaments, first the dorsal, then the right 
 lateral, and the left. The joint is now widely opened so that the palmar ligaments are 
 exposed and easily divided (Fig. 578). 
 
 Fourth step: Resection of the Metacarpal head. Grasp the exposed bone with a bone- 
 holding forceps and divide it transversely with a saw or bone shears (Fig. 579). Com- 
 plete the hemostasis, ligating the digital arteries. Suture. 
 
758 
 
 SOME PRACTICAL AMPUTATIONS 
 
 Fig. 578. — Crush of ring finger. Third step in amputation. (Lejars.) 
 
 Fig. 579. — Crush of ring finger. Fourth step in amputation. (Lejars.) 
 
AMPUTATION OF FINGER 
 
 759 
 
 FlG. 580. — Line of incision in typical am- Fig. 581. — Lines of incision in removing 
 putation of the thumb. (Farabeufja, a finger with its metacarpus. (Veau.) 
 
 The line of incision in typical amputation of the thumb should mark off, if possible, a 
 palmar flap (Fig. 580). Begin the incision on the dorsal surface below joint line. Cut to 
 the right, reaching the palmar surface at the interphalangeal crease. Continue the in- 
 cision across the palmar surface. Now go back to the starting point and make an incision 
 similar to first on the opposite side, completing outline of flap. While the assistant now 
 steadies thumb, dissect the flap including all the soft parts down to the bone, dividing 
 the flexor tendon and finally exposing the joint. Let the assistant now retract the flap 
 while you pull on the thumb bringing the joint line into relief. Section the ligaments to 
 the left, above and to the right successively. Drain and suture. 
 
 Trace of incision for removing the finger with its metacarpal. Note that incision begins 
 on the back on the line connecting the bases of the metacarpal bones of thumb and little 
 finger; extends along dorsum of metacarpus and branches above level of its head Fig. 581). 
 The head of the metacarpus is cleared and the denudation, sometimes difficult, carried 
 toward the wrist. The point of the knife is inserted in the joint lines to disarticulate. 
 Care must be taken to avoid the deep palmer arch which lies adjacent. 
 
;oo 
 
 SOME PRACTICAL AMPUTATIONS 
 
 
 Fig. 582. — Crush of the Thumb. 
 Atypical amputation. 
 
 Fig. 583. — Crush of Thumb. Atypical 
 amputation. First step. 
 
 A crushed thumb must be treated with the greatest conservatism since even the shortest 
 stump is useful, the metacarpal bone has all the value of a phalanx in the other digits 
 (Fig. 582). 
 
 Do an atypical amputation. Let the primary incision follow the line of viable tissue, 
 cutting down to the bone. Denude the bone with the rugine (Fig. 583). Resect so 
 that the skin flaps will fall into place without undue stretching. 
 
 It must be remembered that the vitality of the flaps is lowered and if they are stretched 
 tightly over the end of the bone are sure to slough. The drainage must be ample (Fig. 
 584). 
 
AMPUTATION OF FOREARM 
 
 761 
 
 ATYPICAL AMPUTATION OF THE HAND (Traumatism 
 of the Metacarpals) (Fig. 585) 
 
 It is often inadvisable to amputate at once, for parts that seem 
 devitalized may survive. Check the hemorrhage and disinfect and 
 await the course of events. The limits of viable tissue can soon 
 be determined. The technique is sufficiently indicated in Figs. 
 585, 586, 587, 588, 589- 
 
 AMPUTATION OF THE FOREARM 
 
 Disarticulation at the wrist is very rarely done in general practice. 
 If a tuberculosis of the wrist calls for intervention, amputate the 
 forearm (Fig. 590). 
 
 wmii 
 
 Fig. 584. — Atypical amputation of the thumb complete; part of metacarpus preserved, 
 
 Drainage. (Lejars.) 
 
 Following traumatism, do an atypical amputation, conserving as 
 much as possible of the member. 
 
762 
 
 SOME PRACTICAL AMPUTATIONS 
 
 Fig. 585. — Crushing injury to hand. Useless to try to save any but the index 
 
 finger. (Veau.) 
 
 Fig. 586. — The metacarpals are denuded upward for an inch; all the soft parts 
 
 saved. (Veau.) 
 
AMPUTATION OF HAND 
 
 763 
 
 Fig. 587.— Section of metacarpals with bone-cutting forceps. (Veau.) 
 
 the case of a crush of the hand involving the metacarpus, no effort is made to do 
 ypical amputation; the whole effort is to save as much useful tissue as possible. 
 As indicated in Fig. 586 denude the bones as high up as the skin flaps, after having 
 been properly trimmed, require. Sometimes it will be advisable to wait for a day or 
 two to see how much of the soft parts will live. Accordingly the hand is carefully dis- 
 infected. A moist antiseptic dressing is applied and kept under close observation until a 
 line of demarcation occurs. 
 
 Once the level of bone section is determined resect with bone forceps, suture loosely 
 with ample drainage, but be sure of the hemostasis. 
 
 If infection develops, remove the sutures and use prolonged immersion in hot normal 
 salt solution. 
 
 
7 ( U 
 
 SOME PRACTICAL AMPUTATIONS 
 
 Typical amputations of the forearm are most easily performed at 
 any level, by a modified circular incision; for Technic, see Figs. 591, 
 3i 594, 595> 59 6 > 597, 598. 
 
 
 Fig. 588. — Amputation completed. (Veau.) 
 
 AMPUTATION AT THE ELBOW-JOINT 
 
 Make a circular incision 3 inches below the joint, involving the 
 skin and fascia. Turn back the cuff to the joint. Divide the mus- 
 cles over the joint line. Divide the lateral ligaments. Open the 
 outer side of the joint first and, directing the assistant to make trac- 
 tion on the arm, separate the ulna and divide the triceps. , Tie the 
 arteries, resect the nerves, and suture. 
 
AMPUTATION AT SHOULDER JOINT 
 
 765 
 
 Fig. 589. — Am- 
 putation of the 
 hand. Thumb 
 saved. (Senn.) 
 
 K 
 
 AMPUTATION OF THE ARM 
 
 Apply an Esmarch tube high up near the axilla, 
 or an assistant may compress the artery in the 
 upper part of the arm or behind the clavicle. 
 
 Stand to the outer side of the arm. Retract the 
 skin with the left hand if operating on the right 
 arm, or direct the assistant to retract the skin if 
 operating on the left arm. The skin section must 
 lie about one diameter below the proposed bone 
 section (Fig. 599). The successive steps of the 
 operation are indicated in Figs. 599, 600, 601, 602, 
 603. . 
 
 AMPUTATION AT THE 
 SHOULDER-JOINT 
 
 Amputation at the shoulder may be per- 
 formed by a variety of methods, each of which 
 has its advantages and disadvantages. The 
 special points to be thought of in making the 
 operation are the control of hemorrhage, good 
 drainage, easy disarticulation and a good stump. 
 No one operation, perhaps, secures all of these 
 principles in equal degree. 
 
 Spence's method is recommended as generally 
 %^f T \r\ serviceable. 
 
 r^\ HJf Recall the principal landmarks of the 
 
 shoulder- joint, the acromion process, the cora- 
 coid, the tuberosities; recall the attachments 
 of the various muscles; and the relations of the 
 blood vessels. 
 
 The patient is placed with his shoulder close 
 to the edge of the table, with shoulder elevated, 
 and face turned to the opposite side. The 
 operator stands to the outer side. 
 
 The operator aims at the exposure of the joint 
 and disarticulation, and finally the formation of 
 an axillary flap. 
 
 a?- 
 
 A/ 
 
 Fig. 590. — Amputa- 
 ion of the forearm, 
 tuberculosis of the 
 prist. (Veau.) 
 
766 
 
 SOME PRACTICAL AMPUTATIONS 
 
 Fig. S9i. — Amputation of the forearm. Beginning the circular incision, which must fall 
 well below proposed line of bone section. 
 
 Fig. 592. — Amputation of the forearm. Completing the circular incision. Not only the 
 skin but the fascia as well must be completely divided. 
 
AMPUTATION OF FOREARM 
 
 767 
 
 Fig. 593-— Lateral incisions extending upward two or three fingers' breadth, favor 
 retraction of skin cuff. 
 
 1 Fig. 594. — Third step. Transfix muscles at upper level of lateral vents, point of knife 
 grazes bones. Hand must be supinated and flexed to relax muscles of forearm. 
 
7 6S 
 
 SOME PRACTICAL AMPUTATIONS 
 
 Fig. 595. — Complete the anterior flap by cutting outward following the transfixion. Re 
 peat the process, passing the transfixing blade posterior to bones and fashion posterior flap 
 in same manner. (Veau.) 
 
 Fig. 596. — The flaps formed, it remains to divide the interosseous membrane and at- 
 tached muscles, and the periosteum. The direction which the point of knife takes is indicated 
 by the arrows. 
 
AMPUTATION OF FOREARM 
 
 769 
 
 Fig. 598. 
 Fig. 600 shows manner in which the periosteum is stripped back after all the soft parts 
 are divided. The bones are completely denuded to level of section previously determined. 
 Use a three-tailed retractor to pull the skin flaps out of the way of the saw, partly divide 
 the ulna, saw through the radius and complete section of the ulna. Ligate all vessels, trim 
 the median and ulnar nerves. Fig. 601 shows the manner of applying drainage which should 
 nearly always be used, and of suturing the skin flaps. 
 49 
 
7 JO SOME PRACTICAL AMPUTATIONS 
 
 Incision. — (i) Begin just in front of the coracoid process and cut 
 vertically downward to the lower level of the tendon of the pectoralis 
 major, keeping in front of the groove between the pectoralis major 
 and deltoid. This incision should reach the bone; the pectoralis 
 major tendon is divided. The bleeding comes from the humeral 
 branches of the acromio-thoracic and from the anterior circumflex. 
 These vessels may be clamped. 
 
 (2) Next carry the incision outward across the arm, making a 
 slight curve, convex downward, and ending at the axillary border 
 behind. All the structures are divided to the bone. The deltoid is 
 divided just above its insertion and the hemorrhage comes from the 
 muscular branches. 
 
 The next step consists in outlining the internal flap by making an 
 oval skin incision, which extends from the termination of the first 
 across the inner surface of the abducted arm to the end of the vertical 
 part of thejirst incision (Fig. 604). 
 
 The third step consists in elevating the external flap which con- 
 tains the deltoid. It is easily dissected and by this means the joint 
 is exposed. The posterior circumflex artery must not be injured 
 and is preserved in the deltoid flap. 
 
 The fourth stage: Disarticulate. Begin by dividing the biceps 
 tendon and the capsule with a transverse cut. Rotate the arm in- 
 ward and divide successively the tendons of the teres minor, the in- 
 fraspinatus, the supraspinatus; rotate the arm outward and divide 
 the tendon of the subscapularis. If the humerus has been broken, 
 rotate the head by means of a bone forceps. 
 
 Dislocate the head, divide the capsule behind and push the head 
 up to the level of the acromion; drawing the head outward, slip the 
 knife behind the head and prepare to complete the section of the 
 soft parts. If the axillary has not been previously ligated, the assist- 
 ant grasps the upper part of the flap about to be divided and his 
 hands follow the knife downward ready to compress the artery as 
 soon as divided. 
 
 The knife follows the bone till opposite the skin incision when it 
 cuts directly through the soft parts that the vessels may not be di- 
 vided obliquely. The arm is now completely removed. 
 
 The next step consists in ligating the vessels and in trimming the 
 
AMPUTATION OF ARM 
 
 771 
 
 Fig. 599. — Amputation of the Arm. Circular flap. (Veau.) 
 Supposing an amputation af the right arm, grasp the arm above the proposed incision, 
 with left hand, pulling the skin tight while the assistant supports the member. First 
 step: Make a semicircular cut from the inside, over the front and to the outside. Repeat, 
 passing from the inside behind the arm. Avoid wounding the artery on the inside. 
 Divide the skin and fascia only. There will be considerable venous hemorrhage which is 
 to be disregarded. There will be about an inch gap when the skin and fascia are com- 
 pletely divided. The next step is liberation and further retraction of the skin flap. 
 
SOME PRACTICAL AMPUTATIONS 
 
 Fig. 600 — Amputation of the arm. Circular flap. (Veau.) 
 
 Second step: Free the skin flap. Divide the fascial attachments with the point of the 
 knife but do not button-hole the skin flap. The fascial attachments are firmest over the 
 line of the artery and a little patience is necessary in freeing them. Loosen the skin until 
 there is a gap of at least 1}$ inches. The flap must be well mobilized. You are ready 
 now to make a circular section of the muscles. 
 
AMPUTATION OF ARM 
 
 773 
 
 Fig. 6oi. — Amputation of the arm. Circular flap. 
 
 Third step: First circular section of the muscles. The soft parts, skin and muscles are 
 to be strongly retracted, either by the operator's left hand or by an assistant. By a circu- 
 lar sweep of the knife divide the muscles at the level of the retracted skin. Divide all 
 the structures down to the bone. But they do not contract evenly; therefore a second 
 circular section is required. 
 
774 
 
 SOME PRACTICAL AMrUTATIONS 
 
 Fig. 602. — Amputation of the arm. Second circular section of the muscles. 
 
 Fig. 603. — Amputation of the arm. Denudation of the periosteum. 
 Fourth step: Second circular section of soft parts at level of retracted skin, forming a 
 stump with a smooth even surface (Fig. 602). The blood vessels are easily identified 
 and should be ligated at this time. Fig. 603 shows the next step which consists in the 
 denudation of the bone, stripping back the periosteum to the level of the proposed bone 
 section when the bone is sawed. Remove the tourniquet and complete the hemostasis. 
 Suture the periosteal flaps over the bone if possible. Mattress suture the muscles and 
 fascia. Drain. Suture the skin. 
 
AMPUTATION AT SHOULDER 
 
 775 
 
 axillary nerves and in suturing the flaps so as to form a vertical scar 
 as nearly as possible. The glenoid fossa may be curetted. 
 
 For the control of hemorrhage, Wyeth's plan of constriction may 
 be followed. An elastic ligature held in place by two pins passed 
 through the soft parts before and behind the shoulder compresses 
 the axillary vessels. 
 
 AMPUTATION ABOVE THE SHOULDER 
 
 This operation, bloody and often fatal, may need to be undertaken 
 for malignant disease in the vicinity of the shoulder-joint or as an 
 emergency in the case of crushing injury to 
 the shoulder or of gunshot wounds. 
 
 The procedure as defined by Berger con- 
 templates the resection of the middle third 
 of the clavicle and ligation of the subclavian; 
 the formation of the anteroinferior and a 
 postero-superior flap; and finally the division 
 of the muscles connecting the scapula with 
 the trunk. 
 
 The operation is thus described: 
 
 Place the patient on his back close to the 
 edge of the table, with the shoulder slightly 
 elevated. Begin the incision over the cla- 
 vicle at the outer border of the sterno-mas- 
 toid, and follow the clavicle outward to the 
 acrominal end, cutting to the bone. Denude 
 the middle third of its periosteum with the 
 
 rugine, and divide the bone at the junction of the inner and middle 
 thirds. Elevate the bone and divide again at the junction of the 
 middle and outer third. Separate by blunt dissection the fascias 
 overlying the subclavian vessels and first ligate the artery at the 
 outer border of the first rib and then the vein. 
 
 Now change the patient's position: the shoulder is brought over the 
 edge of the table, the arm abducted, and the head turned to the 
 opposite side. 
 
 Form the anteroinferior flap. Begin an incision at the middle of 
 
 Fig. 604. — Spence's am- 
 putation. {Moullin.) 
 
Jj6 SOME PRACTICAL AMPUTATIONS 
 
 the first and carry it obliquely downward and outward; just to the 
 outer side of the coracoid process, along the anterior border of the 
 deltoid, to the axillary border and thence across the inner surface of 
 the arm just below the axillary fold and thence down the axillary 
 border of the scapula. Divide the pectorals and the latissimus dorsi 
 close to their insertions. Resect the nerves of brachial plexus. 
 
 From the poster o-superior flap. Begin the incision over and just 
 internal to the acromio-clavicular joint and carry it downward over 
 the spine of the scapula to the lower angle of the scapula, where it 
 joins the preceding incision. Dissect the flap and expose the muscles. 
 Divide first the trapezius and then with heavy scissors divide close 
 to the bone, the muscles attached to the posterior border, the serratus 
 magnus, the rhomboideus major and minor, and the levator anguli 
 scapulae. 
 
 The arm falls away. Complete the hemostasis and drain through 
 button-holes in the flaps in the axilla and scapular region. Bandage 
 firmly so as to obliterate the cavities. 
 
 AMPUTATION OF THE TOES 
 
 These amputations are more frequently consequent upon trauma- 
 tism; occasionally for deformity or other painful conditions. 
 
 In the amputation of fingers, as much as possible is saved; in the 
 amputation of toes, the whole toe is nearly always removed. In 
 consequence these amputations are usually typical, for one does not 
 so much need to concern himself with the conservation of tissue. 
 
 In the case of total ablation of the finger, a part of the metacarpal 
 head must usually be removed to enhance function;. the head of the 
 metatarsals must always be saved, where possible, to preserve the 
 functions of the foot. 
 
 The position of the cicatrix demands more attention in the case of 
 the toes. A special effort must be made to leave the scar farthest 
 from pressure; that is, dorsal and to the inner side with reference to 
 the axis of the foot. 
 
 Local anesthesia is often sufficient, forming an anesthetic ring 
 around the entire toe, involving the skin. The injection may need 
 to be renewed for the deeper tissues; and before disarticulation, 
 inject the joint. 
 
AMPUTATION OF TOE 
 
 777 
 
 AMPUTATION OF THE GREAT TOE 
 
 finger and the scar adjoins the base of the second toe. 
 
 Begin by locating the joint line. The incision commences just 
 below this, and over the tibial border of the extensor tendon, and 
 extends with a slight outward convexity, downward and forward to 
 the interphalangeal crease on the plantar surface and across the pal- 
 mar surface obliquely, ending at the web. 
 
 Begin on the dorsum again at the original starting-point and with a 
 slightly curved incision, join the ends of the first (Fig. 605). 
 
 Fig. 605. — Lines of incision for am- 
 putation of big toe. (Farabeuf.) 
 
 Fig. 606. — Amputation of big 
 toe completed. (Farabeuf.) 
 
 Fig. 607. 
 
 Dissect the flap, keeping close to the bone, so that all the soft parts 
 shall be preserved in the flap. Divide the flexor tendon — sometimes 
 rather difficult. 
 
 Disarticulate. Divide, first, the lateral ligaments to your left, then 
 the dorsal, and finally those at your right. Divide the plantar liga- 
 ments, twisting the toe, as in the case of the finger. Employ drain- 
 age; pull the flap into position and suture. The shape of the flap and 
 the position it assumes are represented in Figs. 606 and 607. 
 
/ 1° 
 
 SOME PRACTICAL AMPUTATIONS 
 
 AMPUTATION OF THE LITTLE TOE 
 
 Incision. — Begin at the inner end of the joint line and cut obliquely 
 downward and outward, meeting the plantar surface at the joint line 
 below, and then backward and inward toward the web (Fig. 608). 
 In this manner a convex flap is formed (Fig. 609). Dissect the flap, 
 preserving in it all the soft parts. Expose the joint line. 
 
 Disarticulate. Making vigorous traction on the toe, divide in 
 regular order the lateral, the dorsal, the lateral (to your right), and 
 plantar ligaments. 
 
 Fig. 608. Fig. 609. Fig. 610. 
 
 Figs. 608 to 610. — Amputation of the little toe. (Farabeuf.) 
 
 Drain from the upper part of the incision and suture. The posi- 
 tion of the cicatrix is represented in Fig. 610. 
 
 AMPUTATION OF ONE OF THE MEDIAN TOES 
 
 Incision. — The line of the joint having been determined, begin just 
 above it on the dorsum, incising forward and downward to just be- 
 low the web, crossing the palmar surface and back to the starting- 
 point, completing the racket (Fig. 611). Remember that themeta- 
 tarso-phalangeal joint is considerably above the line of the web. 
 Denude and divide the flexor tendon. 
 
 Disarticulate in the manner already described for the other toes. 
 Drain from the upper end of the incision and suture (Fig. 612). 
 
AMPUTATION OF TOE 
 
 779 
 
 FiG. 611.— Line of incision for amputation Fig. 612. — Suture and drainage after 
 of toe. (Veau.) amputation. (Veau.) 
 
 Fig. 613.— Lines of incision for removal of toes with head of corresponding 
 metatarsals. (Veau.) 
 
7 So SOME PRACTICAL AMPUTATIONS 
 
 AMPUTATION OF A TOE WITH PART OF ITS 
 METATARSUS 
 
 This amputation presents some difficulties in dissecting the flaps, 
 because of the palmar projection of the head of the metatarsal. 
 
 The incision is racket-shaped, as in amputation of the toe, but it 
 begins higher up, above the level of the diseased bone, and runs down 
 to the web, across the palmar surface and back to the starting-point, 
 as represented in Fig. 613. To dissect the flaps for the middle toes, 
 denude the dorsum of the metatarsus and divide it with the bone for- 
 
 Fig. 614. — Amputation of big toe with head of metatarsal. (Farabeuf.) 
 
 ceps, and lifting upon the divided end, dissect forward along the 
 mar surface. 
 
 The metatarsus of the little and great toes may be sawed. In 
 forming the flap for the great toe and its metatarsus (Fig. 614) do not 
 forget to remove the sesamoid. Drain as in amputation of the toe: 
 and suture. 
 
 AMPUTATION OF A PART OF THE FOOT 
 
 * 
 
 As in the case of the hand, the rule is to conserve as much as pos- 
 sible of the foot with this proviso, that a painful mass of scar tissue 
 does not form in the stump and the action of the flexors of the foot is 
 retained. 
 
 In the case of traumatism or gangrene, where the soft parts are 
 more involved than the bone, the line of section follows the healthy 
 skin and the bone section will be made to accommodate itself to the 
 skin flaps. 
 
 Atypical Amputation. — If the case is one of tuberculosis, the bone is 
 
AMPUTATION OF FOOT 
 
 7 8l 
 
 more involved than the skin, and one may determine the upper limit 
 of the diseased bone and divide it there. In such a case, one may 
 fashion a palmar flap, and make a dorsal scar — the typical amputa- 
 tion. But, as Veau says, do not concern yourself with the formal 
 operations, such as a Lisfranc or a Chopart — excellent exercises on 
 
 Fig. 615. — Following the line of demarca- 
 tion. Atypical amputation. {Veau.) 
 
 Fig. 616. — Dividing the bones. (Veau.) 
 
 the cadaver — but saw the bones where you must, to remove all the 
 disease. 
 
 In the case of gangrene or traumatism, then, divide the tissues to 
 the bone, along the line of demarcation. 
 
 The borders of the palmar and dorsal flaps must correspond to 
 the borders of the foot (Fig. 615). Once the soft parts are divided, 
 

 SOME PRACTICAL AMPUTATIONS 
 
 they should be retracted by dividing their attachments close to the 
 bone, and the bones are divided high enough for the flaps to come 
 together (Fig. 616). 
 
 In the case of tuberculosis make a transverse incision dorsally and 
 
 mi i 
 
 \m 
 
 mi / 
 
 1 1 
 
 i 
 
 Fig. 617. — Suturing extensor tendons 
 to skin flap. (Veau.) 
 
 Fig. 618. — Suture and drainage. (Veau.) 
 
 shape the long palmar flap by transfixion and cutting outward, or by 
 cutting from without inward (Fig. 617). 
 
 Suture the tendons to the periosteum or fibrous tissues, for if the 
 tendo-achilles is left unopposed the result will be a useless stump. 
 Resect the nerves and suture, using drainage (Fig. 618). 
 
AMPUTATION OF FOOT 783 
 
 TOTAL AMPUTATION OF THE FOOT 
 
 In total amputation of the foot, the exact procedure will depend 
 chiefly upon the condition of the os calcis. If it is sound, Pirogoff's 
 osteoplastic amputation is indicated. If the os calcis is diseased, 
 Symes' amputation is indicated — -a disarticulation at the ankle-joint, 
 with erasion of the malleoli. But one cannot always determine be- 
 forehand the state of the os calcis, and therefore an incision should be 
 made which will permit either procedure after the os calcis has 
 been examined. 
 
 First Incision. — -The first incision extends across the sole with one 
 end at the tip of the external malleolus and the other a finger's 
 
 Fig. 619. — Line of incision for complete amputation of foot. (Veau.) 
 
 breadth below the tip of the internal malleolus. (The internal mal- 
 leolus does not extend quite so low as the external) (Fig. 619). 
 
 An assistant elevates the limb; you seize the foot with the left hand 
 and make this plantar incision from left to right; that is to say, in the 
 case of the right foot begin the incision at the end of the outer malleo- 
 ! lus and terminate it a finger's breadth below the internal. In the 
 case of the left foot, begin at the internal and end at the external 
 malleolus. 
 
 Repeat the movement several times, for there is always consider- 
 able difficulty in accomplishing complete section of the tendons, some 
 of which are oblique to the line of incision and others deep and im- 
 bedded in grooves. 
 
 Second Incision. — -Connect the extremities of the first incision by a 
 

 SOME PRACTICAL AMPUTATIONS 
 
 dorsal incision, which should be slightly convex forward toward the 
 toes. This line crosses over the head of the astragalus. The foot 
 should be lowered and the cut made from left to right. Extension 
 of the foot will facilitate the division of the anterior tendons and 
 ligaments. 
 
 Now distinguish the head of the astralagus, and between it and the 
 articular surface of the malleolus pass the point of the knife and cut 
 
 Fig. 620. — Section of the lateral ligaments. 
 (Veau.) 
 
 Fig. 621. — Clearing the upper and internal 
 surfaces of the os calcis. (Veau.) 
 
 downward (Fig. 620). By this means, the lateral ligaments are 
 divided. 
 
 The posterior ligaments are divided by cutting along the upper 
 surface of the os calcis (Fig. 621). The joint is now freely exposed 
 and the os calcis may be brought into view and examined. In exam- 
 ining the outer side, dissect back the soft parts for an inch, but not 
 quite so far on the inner side. To be sure of the condition of the bone, 
 its substance must be inspected. 
 
AMPUTATION OF FOOT 785 
 
 (A) Suppose the Os Calcis is Sound. — Grasp the foot firmly with 
 the left hand, depress it and pull upon it at the same time, while the 
 assistant retracts the flaps, which have been loosed from the sides of 
 the bone. 
 
 The flaps are held back by retractors on each side, which are 
 slipped down with the progress of the saw, the assistant bracing his 
 thumbs against the heel. 
 
 The saw is started in the upper face of the os calcis, a finger's 
 breadth behind the astragalus in a manner to take off a slice from 
 above downward and forward (Fig. 622). With the completion of 
 
 Fig. 622. — Section of the os calcis. The saw directed downward and forward. The re- 
 tractors slipped downward as the saw progresses. (Farabeuf.) 
 
 this section, the foot is removed, and the posterior part of the divided 
 os calcis is left in the heel flap. 
 
 The next step is to saw of the malleoli. Begin by completely de- 
 nuding these processes of their covering, skin, fascia and tendons. 
 Carry the denudation upward, a distance of two fingers' breadth be- 
 hind; just above the level of the articular surface of the tibia, in front. 
 The posterior tendons especially are sometimes difficult to dislodge 
 from their groove.. 
 
 The line of section being thus cleared, the heel flap is held well up 
 toward the calf, out of the way, by the assistant, who also supports 
 the leg in the horizontal position. 
 
 It is well for the operator to steady the limb by seizing one of the 
 malleoli with a bone-holding forceps. The saw enters just above the 
 articular line in front, and emerges a full finger's breadth above that 
 level (Fig. 623). If the section is not carefully made, the coapta- 
 
JVQ 
 
 SOME PRACTICAL AMPUTATIONS 
 
 tion of the sawed surface of the os calcis to that of the tibia may 
 he imperfect. 
 
 Complete the hemostasis, bring the two bone surfaces together, and 
 suture the anterior tendons to the fibrous covering of the under sur- 
 face of the os calcis, the better to fix this stump in position. If it is 
 feared the bone will slip, one or two bone sutures may be employed. 
 Suture the skin, usually employing drainage. 
 
 (B) Suppose the Os Calcis is Diseased. — -In case the os calcis is dis- 
 eased, it must be entirely removed, instead of sawed. 
 
 Fig. 623. — Parts removed in PirogofTs amputation represented in dark. (Veau.) 
 
 The left hand strongly flexes the foot, until the posterior end of the 
 os calcis points upward (Fig. 624), and as the point of the knife dis- 
 sects the tissues off the left side, the foot is rotated to the right, and 
 when working on the right side, rotated to the left; in this manner the 
 os calcis is finally enucleated, being careful to follow the bone closely 
 and not to "button-hole" the flap. 
 
 Remember the principal vessels are to the inner side and are to be 
 lifted up with the flap. 
 
 pecial care is required when the attachment of the tendo-achilles 
 is divided; the bone must be shaved, for it is here practically sub 
 
 : 
 
AMPUTATION OF FOOT 
 
 787 
 
 Fig. 624. — Denudation of the posterior surface of the os calcis. (Farabeuf.) 
 
 Fig. 625. — Syme's amputation of the foot. (Farabeuf.) 
 

 SOME PRACTICAL AMPUTATIONS 
 
 cutaneous, and it is easy to puncture the flap. You may expect 
 this stage to be tedious. 
 
 Finally the foot will be removed (Fig. 625). 
 
 Now denude the lower end of the bones of the leg, observing that 
 the tendons in front are held down by their fibrous sheaths. In 
 order to facilitate this dissection, sweep the point of the knife around 
 the bone, keeping it in close contact with the bone. This dissection 
 
 Fig. 626. — Suture and drainage. (Veau.) 
 
 must be carried upward for an inch and the malleoli will be com- 
 pletely exposed. 
 
 Steady the leg with a bone-holding forceps, and saw the bones at 
 the level of the cartilage. Begin by notching the tibia, then com- 
 plete the section of the external malleolus and terminate with the 
 section of the tibia. If some cartilage remains, it may be scraped off. 
 
 Resect the nerves, suture and drain (Fig. 626). 
 
 AMPUTATION OF THE LEG 
 
 The leg may be amputated at any level. Formerly, when sup- 
 puration was the rule, and the cicatrix was large, adherent, and pain- 
 
AMPUTATION OF LEG 
 
 789 
 
 ful, prohibiting the use of artificial limbs, the " point of election" 
 was high up. The knee was flexed and the patient made use of a 
 "peg-leg," the weight falling on the patella (Fig. 627). 
 
 With present methods the scar is a matter of less concern and the 
 aim should be to amputate as low down as possible, to the end that 
 
 Fig. 627. — Knee flexed for 
 "peg-leg." (Veau.) 
 
 Fig. 628. — Artificial limb Fig. 629. — Amputation of 
 applied. (Veau.) leg. Lines of section of soft 
 
 parts and bone. (Veau.) 
 
 the muscles may be preserved to render efficient an artificial limb 
 (Fig. 628). 
 
 This principle is true only within certain limits. Amputations 
 just above the ankle never furnish a good stump for an artificial limb. 
 It is better to amputate at the junction of the middle and lower thirds. 
 

 SOME PRACTICAL AMPUTATIONS 
 
 In the case of traumatism and gangrene, then, do an atypical 
 amputation, preserving carefully the sound tissue and dividing the 
 \)onc to accommodate the skin flap. 
 
 If the bone is involved to a greater extent than the skin, as in 
 tuberculosis, a typical amputation may be done. If the stump be- 
 low the knee is 4 inches long it can manage an artificial limb. 
 
 Fig. 633. — Loosening the attachments of 
 the flap to the tibia. (Veau.) 
 
 Fig. 634. — Dissecting up the muscles 
 with the artery. (Veau.) 
 
 There are numerous methods of amputating the leg, some appro- 
 priate to one level and some to another, but for the sake of simplicity 
 but one need be described — one which may be used with fair success 
 in any part of the leg. In any case avoid redundancy of flap if an 
 artificial leg is to be worn. 
 
 Incision. — Begin with a circular incision of the skin about 2}4 
 inches below the level of the proposed bone section (Fig. 629). This 
 incision will divide the skin and aponeurosis. If front, carefully 
 
AMPUTATION OF LEG 
 
 791 
 
 separate the skin from the tibial crest (Fig. 630). Next divide the 
 muscles at the level of the retracted skin. Divide the muscles 
 completely, but make the incision oblique to the axis of the limb, so 
 that the incision reaches the bone at a higher level than at the sur- 
 face (Fig. 631). 
 
 To be certain that all the muscles are divided, one may re-pass the 
 bistoury, as in the forearm (Fig. 596). Next denude the bones with 
 the rugine, reaching above the level at which the bones are to be 
 sawed. This denudation is most difficult and 
 tedious behind, on account of the fibrous at- 
 tachments of various muscles. 
 
 The interosseous membrane is to be detached 
 by a few vigorous strokes with the rugine from 
 below upward. Divide it at the level of the 
 proposed bone section. 
 
 Retract the flaps with three gauze compresses, 
 one passed between the bones, one applied in 
 front and one behind; all to be held firmly by 
 the assistant. 
 
 Begin the sawing by notching the tibia, then 
 completely divide the fibula and end with the 
 section of the tibia. Plane off the projecting 
 angle of the anterior border of the tibia, resect the nerves and ligate 
 the bleeding points. Be sure the fibula is not left longer than the 
 tibia to interfere with an artificial limb. Drain, suture the anterior 
 muscular flap to the posterior, and suture the skin (Fig. 632). 
 
 Fig. 635. — Amputa- 
 tion complete. Trans- 
 verse drainage. (Veau.) 
 
 AMPUTATION THROUGH THE KNEE-JOINT 
 
 This operation should be done in preference to an amputation of 
 the thigh. 
 
 "The femoral artery having been controlled, the limb supported 
 over the edge of the table and slightly flexed, the surgeon standing on 
 the right side of either limb, marks out two broad lateral flaps as 
 follows: his left thumb and index finger being placed, the former over 
 the center of the head of the tibia, the latter at the corresponding 
 point behind, opposite the center of the joint, he marks out (in the 
 
SOME PRACTICAL AMPUTATIONS 
 
 case of the right limb) an inner flap by an incision which commences 
 behind at the index finger and runs down the back of the leg for 3^ 
 inches, and then curves up to the thumb. A similar flap is shaped 
 on the outer side. 
 
 "The inner flap must be slightly larger, in view of the large side of 
 the inner condyles. 
 
 44 The flaps consist of skin and fascia. When they have been raised 
 to the level of the articulation, the ligamentum patellae is severed, 
 
 h 
 
 1 1 
 
 Fig. 633. — Amputation of thigh. Circular incision of the skin. 
 
 allowing the patella to go upward. The soft parts around the joint 
 are then cut through with a circular sweep and the leg removed. In 
 doing this, the limb being flexed to relax the parts and facilitate 
 opening the joint, the semicircular cartilages will very likely be found 
 encircling the condyles of the femur and are to be left in situ by 
 dividing the coronary ligaments which tie them to the tibia. The 
 condyles should always be saved if possible for they favor the useful- 
 ness of an artificial limb. Resect the nerves, ligate the vessels, 
 drain and suture," (Jacobson's Operative Surgery.) 
 
AMPUTATION OF THIGH 793 
 
 AMPUTATION OF THE THIGH 
 
 Determine the level of the bone section. About the distance of one 
 diameter of the limb below this level, describe a circular incision, 
 dividing the skin and fascia, which may descend a little further be- 
 hind than in front, if desired. 
 
 The patient's legs are drawn out well over the edge of the table, the 
 sound limb flexed and the injured one held by an assistant. The 
 
 jfl$0«*t** 
 
 Fig. 634. — Amputation of thigh. Loosening the flap after a circular skin section. 
 
 : operator stands to the outside. Another assistant encircles the thigh 
 above the level of the incision, with his hands. If the conventional 
 amputating knife is used, begin (on the right thigh) by passing the 
 
 I knife under the limb and with its heel resting upon the upper surface, 
 bring it in a circular sweep back around the thigh, dividing succes- 
 
 ! sively the integument of the internal, inferior and external surfaces. 
 The position of the hand may be slightly changed and the incision 
 continued up over the anterior surface; or that may be divided by a 
 second movement (Fig. 633). 
 
 In the meantime, the left hand has steadied the skin; the assistant 
 now retracts it while its fibrous attachments are loosened (Fig. 634) 
 until there is a separation of at least three fingers' breadth. At the 
 
7<)4 
 
 SOME PRACTICAL AMPUTATIONS 
 
 level of the retracted skin, divide the muscles as the skin was divided, 
 aiming to reach the bone. But the divided muscles do not equally 
 retract, and a second circular incision oj the muscles at the level of the 
 retracted skin is necessary to insure a uniform stump (Fig. 638). 
 
 Denude the femur beyond the level of the proposed bone section. 
 Direct the assistant to retract the flap with two lateral compresses or 
 retractors. 
 
 Fig. 635. — Amputation of thigh. Circular section of the muscles after retraction of skin. 
 
 Saw the femur, ligate all vessels likely to bleed, suture the muscles 
 over the end of the femur, drain, and suture the skin. 
 
 AMPUTATION OF THE HIP- JOINT 
 
 " Primary amputation of the hip comes under consideration in any 
 extensive crush of the thigh or gunshot injury, but offers hardly any 
 chance while the primary shock exists. 
 
 "The better plan is to try and check the hemorrhage, clean the 
 wound as much as possible, pack with gauze and wait. The patient 
 having rallied from the shock, and gangrene, sloughing and necrosis 
 
AMPUTATION HIP-JOINT 795 
 
 being imminent, amputation is indicated with a fair prospect of sav- 
 ing life.* * * The first step is to control hemorrhage. * * * But there 
 is one method safe and applicable to all cases and especially when the 
 surgeon is unaccustomed to the operation, and that is to divide the 
 common femoral vein and artery, each between two ligatures. There 
 is then no further bleeding, except from the region of the crucial 
 anastomosis behind, the vessels forming which are easily picked up 
 and divided." 
 
 Formation of the Flaps. — "From the lower end of the longitudinal 
 | incision for tying the vessels, a circular incision is continued around 
 the thigh, the skin flaps retracted and the soft parts divided as ampu- 
 tation of the thigh." (Walsham's Surgery.) 
 
 Senn's Bloodless Amputation at the Hip-joint. — First incision: with 
 the pelvis resting on the lower edge of the table, make a straight in- 
 cision (beginning about 3 inches above the great trochanter) about 
 8 inches in length, directly over the center of the great trochanter, 
 and parallel to the long axis of the limb. When the knife reaches the 
 great trochanter, its point should be kept in contact with the bone 
 the whole length of the remaining part of the incision. 
 
 The margins of the wound are now retracted and any spurting ves- 
 sels secured. 
 
 The trochanteric muscular attachments are now severed close to 
 the bone with a stout scalpel. The cleaning of the digital fossa and 
 the division of the obturator externus tendon, require special care. 
 The thigh is now flexed, strongly abducted, rotated inward, when 
 the capsular ligament is divided transversely at its upper and poste- 
 rior aspect. The remaining portion of the capsular ligament is sev- 
 ered, while the thigh is brought back to a position of slight flexion, 
 after which it is rotated outward and, if possible, the ligamentum teres 
 is cut. If this cannot be done, the head of the bone is forcibly dis- 
 located upon the dorsum of the ilium by flexion, adduction and rota- 
 tion of the thigh. 
 
 The trochanter minor and upper part of the shaft of the femur are 
 cleared by using a scalpel and periosteal elevator alternately. At 
 the completion of this part of the operation, the femur is in a position 
 of extreme adduction and the upper portion projects some distance 
 from the wound. 
 
SOME PRACTICAL AMPUTATIONS 
 
 If the surgeon has kept in close contact with the bone and has used 
 the knife sparingly and the periosteal elevator freely, the hemorrhage 
 has been slight. 
 
 Elastic constriction is now applied. Bring the limb down in a 
 straight line with the body. A long straight hemostatic forceps is 
 inserted into the wound behind the femur and on a level with the 
 trochanter minor when in a normal position. The instrument is 
 then pushed inward and downward 2 inches below the ramus of the 
 ischium and just behind the adductor muscles. As soon as the point 
 
 Fig. 636. — Amputation at hip- joint. Elastic constriction completed by constricting the 
 posterior segment of the thigh. Flaps formed, including all the tissues down to the muscles. 
 (Senn.) 
 
 can be felt under the skin in this location, 2-inch incision is made 
 through the skin, through which the instrument is made to emerge. 
 
 After enlarging the tunnel made in the soft tissues by dilating the 
 branches of the forceps, a piece of aseptic rubber tubing, 3 or 
 4 feet in length, is grasped in the middle with the forceps and 
 drawn along the tunnel as the forceps are withdrawn, whereupon the 
 rubber tube is cut in two where it was held by the forceps. 
 
 With one-half of the tube, the anterior segment of the thigh is 
 constricted sufficiently firmly to intercept both the arterial and ven- 
 ous circulation completely. 
 
AMPUTATION OF HIP-JOINT 
 
 797 
 
 Before the constrictor is tied, the limb should be held in the vertical 
 position long enough to render it practically bloodless. The elastic 
 constrictor is either tied or, still better, held with a forceps at the 
 point of crossing. 
 
 Fig. 637. — Senn's method of performing bloodless amputation at the hip-joint. Dislo- 
 cation of head of femur and upper portion of shaft through straight external incision. 
 Elastic constrictors in place; the anterior one tied. 
 
 The posterior segment of the thigh is constricted by the remaining 
 half of the tube, which is drawn sufficiently tight behind; the ends of 
 the tube are made to cross each other and are brought forward and 
 made to include the anterior segment, when they are again firmly 
 drawn and tied, or otherwise fastened above the first constrictor, 
 
SOME PRACTICAL AMPUTATIONS 
 
 furnishing an additional security against hemorrhage from the larger 
 els in the anterior flap, when cut during the amputation 
 (Fig. 636). 
 
 After the principal blood vessels have been tied, the posterior con- 
 st rictor is removed and additional bleeding points are secured before 
 the anterior constrictor is removed (Fig. 637). 
 
 Surface compression with a compress wrung out of hot, normal 
 salt solution, is a valuable aid in minimizing the hemorrhage, after 
 the removal of the constrictors. 
 
 "As this method of controlling hemorrhage does not require the 
 presence of a skilled assistant, it will prove of especial value in emer- 
 gency cases. The operation can be performed with the instruments 
 contained in every pocket case. Should an elastic tube not be at 
 hand, the constriction can be made in a satisfactory manner by sub- 
 stituting a cord made of sterile gauze, tightened with a lever of some 
 kind, as is done in applying the ordinary Spanish windlass." (Senn, 
 Practical Surgery.) 
 
 The amputation is completed by cutting antero-posterior flaps as 
 shown in Fig. 636. 
 
CHAPTER XXIII 
 
 DILATATION OF THE SPHINCTER ANI; OPERATION FOR 
 PILES; OPERATION FOR FISTULA 
 
 DILATATION 
 
 temporary paralysis of the anal sphincter is the preliminary step 
 to most of the interventions on the rectum, and is of itself usually 
 sufficient for the cure of fissures. 
 
 The patient should be purged the day preceding the operation 
 
 Fig. 638. — Dilatation of the rectum. (Veau.) 
 
 and the rectum should be washed out with soap and water, prelim- 
 inary to the actual operation. 
 
 General anesthesia is almost indispensable and it needs to be pro- 
 found, for the anal reflex is one of the last to yield. Spinal anes- 
 thesia is often useful in anal operations. 
 
 799 
 
8oo 
 
 DILATATION OF THE SPHINCTER ANI 
 
 In the absence of a special dilator, begin by inserting the two 
 thumbs back to back, and bracing the fingers against the outer sur- 
 face of the hips, stretching the sphincter by rhythmic movements of 
 the thumbs, gradually increasing the force. There is no danger of 
 overdilatation, so continue until the thumbs are in contact with the 
 ischial tuberosities (Fig. 638). Drainage is indicated in simple 
 dilatation for fissure. 
 
 Fig. 639. — Drainage after dilatation. (Veau.) 
 
 Employ either one large or two or three small tubes well wrapped 
 with iodoform gauze soaked in cocainized vaseline (vaseline thirty 
 parts, cocaine one part), in order that the subsequent pain may not 
 be so severe (Fig. 639). The tubes may be removed on the second 
 day and the bowels moved on the third. 
 
 OPERATION FOR HEMORRHOIDS 
 
 Most cases of piles are curable by local and constitutional treat- 
 ment; however, those that are very large, bleeding and inflamed, 
 require an operation for their removal and radical cure. 
 
 There are several methods of procedure, many of which are 
 
OPERATION FOR PILES 
 
 80 1 
 
 successful, none dangerous and quite within the scope of every 
 practitioner. 
 
 The following may be recommended in those cases in which the 
 marginal tumors are well defined but not pedunculated: 
 
 Begin by a careful cleansing of the bowel by purgation and lavage. 
 Three days before the operation, give a free purge and prescribe a 
 liquid diet. Prescribe an enema each morning and evening for the 
 next two days. On the day preceding the operation, it is a good idea 
 to check peristalsis with a small dose of opium. 
 
 Pig. 640. — Making the first incision. (Veau.) Fig. 641. — Passing the first suture. (Veau.) 
 
 Employ general anesthesia. Carefully cleanse the peri-anal region 
 and scrub the rectum with soap and water. Dilate the anus, as pre- 
 viously described; and when the dilatation is complete the anal orifice 
 will be everted more or less, presenting a ring of pile tumors. Fasten 
 the pile tumor with a forceps, and at its lower end, make a short 
 curved incision (Fig. 640). The incision involves only the skin, 
 which is to be loosened from the underlying structures by a little 
 blunt dissection. Suture this part of the skin before proceeding 
 further, using a small curved needle armed with a No. 2 catgut. 
 Tie the suture moderately tight and leave the threads long for a 
 
802 
 
 DILATATION OF THE SPHINCTER ANI 
 
 landmark, which will be appreciated later on. Pass two or three 
 sutures in this manner, depending upon the length of the incision 
 
 (Fig. 641). 
 
 \M 
 
 Fig. 642. — Freeing the veins by blunt Fig. 643. — Ligation of the first vascular 
 ' dissection. (Veau.) pedicle. (Veau.) 
 
 *-,. 
 
 Fig. 644. — Burying the pedicle by Fig. 645. — Ligation of the last vascular 
 
 suture. (Veau.) pedicle. (Veau.) 
 
 Again prolong the incision on either side a little way and detach, 
 by blunt dissection, the lips of the wound from the veins beneath, by 
 which means a sort of pedicle is formed (Fig. 642). This pedicle 
 consists of a part of the veins which are to be ligated and^excised. 
 
OPERATION FOR PILES 
 
 803 
 
 Pass a ligature around a part of the veins (Fig. 643) and tie. Di- 
 vide the ligated veins to the outer side and cut the ligatures short. 
 
 Now pass a suture so as to enclose and cover in the stump 
 (Fig. 644). 
 
 Again prolong the original incision on each side of the base of the 
 tumor and expose more of the pedicle; ligate, excise and suture as be- 
 fore, until finally the upper pole of the tumor is reached, and the last 
 of the pedicle tied off (Fig. 645). 
 
 The terminal sutures enclose the last stump of the pedicle and com- 
 plete the repair of the incision at the same time (Fig. 649). 
 
 Fig. 646. — Applying the last suture. (Veau.) 
 
 Fig. 647. — Treatment of ulcerated 
 piles by cautery. (Veau.) 
 
 It is better to proceed thus from below upward in order that the 
 blood, always considerable, will flow downward and mask only the 
 field already sutured. 
 
 The line of incision must follow closely the base of the tumor, for 
 if the edges of the wound are too widely separated, the strain may 
 cause the sutures to tear out. 
 
 If the whole of the anal circumference is involved, it is necessary to 
 treat in the manner described the two sides only. 
 
 Do not disturb the anterior and posterior poles of the anal border, 
 although, if necessary, those points may be touched up with the 
 thermo-cautery. 
 
 ^ Place drainage-tubes wrapped with iodoform gauze saturated in 
 vaseline, as described under the head of Dilatation of the Sphincter. 
 
So4 
 
 DILATATION OF THE SPHINCTER ANI 
 
 The subsequent pain is always severe and will require a hypoder- 
 mic injection of morphine. Retention of urine is often present. 
 The external dressings should be changed daily and liquid diet main- 
 tained for five or six days and the bowels kept under restraint. Do 
 not be concerned with the swelling. 
 
 On the sixth day, remove the drainage-tube; on the seventh, open 
 the bowels with castor oil or compound licorice powder, one heaping 
 
 Fig. 648. — Laying open the track of fistula on the grooved director. (Veau.) 
 
 teaspoonful every four hours till the bowels move, and instruct the 
 patient to cleanse carefully the anal region after each movement. 
 
 The sutures will be absorbed and if none give way too soon, the 
 healing will be complete in about two weeks; otherwise there may be 
 a raw surface which will need to be dressed a little longer. 
 
 In certain cases there is no well-defined tumor, but the surface is 
 ulcerated, infected and exceedingly painful, and is unaffected by pa- 
 tient local treatment. 
 
 In such a case, the thermo-cautery will probably give the best re- 
 sults. For one or two days the patient is kept in bed and a moist 
 dressing applied which will diminish the swelling. 
 
 Employ general anesthesia, cleanse and dilate the anus. The 
 
OPERATION FOR PILES 805 
 
 thermo-cautery is heated to a dull red. Pressed into the tumor, it 
 loses its glow (Fig. 647). Reheat it and reapply a short'distance 
 from the point of application, and in this manner proceed until the 
 pile has been well punctured. It is not necessary to puncture deeply. 
 Apply drainage and a moist dressing. The subsequent pain is al- 
 ways severe and must be controlled by a hypodermic of morphine. 
 There may be retention of urine requiring relief by catheterization. 
 
 Fig. 649. — Cauterization of the diverticula of the fistula. (Veau.) 
 
 The dressing must be renewed twice daily. The eschar will drop off 
 between the fourth and eighth day, and the bowels should be moved 
 about the eighth day. The cure will be complete in about a month. 
 
 OPERATION FOR ANAL FISTULA 
 
 A grooved director is passed through the fistulous tract and emerg- 
 ing in the rectum, its point is caught by the finger in the rectum and 
 brought outside the anus. The whole length of the tract is laid open 
 (Fig. 648). 
 
 The diseased tissues are then curetted or touched with the cautery 
 (Fig. 649). Pack with gauze until repair by granulation is complete. 
 
CHAPTER XXIV 
 
 PHIMOSIS; PARAPHIMOSIS; CIRCUMCISION; 
 HYDROCELE; CASTRATION 
 
 PHIMOSIS 
 
 Phimosis may be congenital or acquired, though itns much more 
 frequently the former. There is usually present one or both of two 
 conditions: a redundant prepuce with contracted orifice; or a frenum 
 so short as not to permit retraction without marked bowing of the 
 organ. 
 
 The disturbances produced by congenital phimosis are due either 
 to mechanical interference or reflex irritability, although, of course, 
 many cases of phimosis seem to give rise to the symptoms. The 
 mechanical interference may lead to infection, balanitis, or even ure- 
 thritis, or to straining which may be the origin of an inguinal or 
 umbilical hernia; the straining may also produce prolapsus ani or 
 hydrocele by pressure on the spermatic vessels. 
 
 The reflex symptoms, often due perhaps to the adhesions of the 
 prepuce to the glans, are numerous and varied, the most common be- 
 ing disturbances of micturition, erethrism, and functional nervous 
 derangements. 
 
 Every case of phimosis, therefore, should receive attention in in- 
 fancy, and in general the only treatment worth while is circumcision. 
 
 The acquired phimosis of adult life, most often due to acute in- 
 fective inflammations, is usually to be relieved by antiseptic washes 
 and treatment addressed to the septic cause. 
 
 PARAPHIMOSIS 
 
 Paraphimosis has its origin in certain malformations, traumatism, 
 or inflammations, and appears in many degrees of severity. In some 
 causes it is easily reduced; in others, irreducible without an operation. 
 There is always the danger, in severe and neglected cases, of ulcera- 
 
 806 
 
PARAPHIMOSIS 807 
 
 tion, sloughing, or gangrene. The appearances are more or less con- 
 stant: the exposed glans is swollen and reddened; behind it is a collar 
 of congested mucous membrane; behind this a deep furrow in which 
 lies the constricting band; and behind this, another band of swollen 
 integument. 
 
 An effort must be made at once to reduce the foreskin. The re- 
 duction is always painful. Begin by thoroughly cleansing and cocain- 
 izing the parts. Apply a compress saturated with a 20 per cent, 
 solution of cocaine and then wait ten mi»utes. 
 
 Smear a little vaseline on the balano-preputial furrow, but not over 
 the glans generally, else the manipulating fingers will slip. 
 
 Fig. 650. — Reducing a paraphimosis. (Stewart.) 
 
 The purpose is to apply a slow, firm, and progressive pressure to the 
 engorged tissues, at the same time making traction forward on the 
 foreskin and pressure backward on the glans. 
 
 There are several ways of doing this, of which the following is an 
 excellent method: grasp the penis behind the glans, between the first 
 and second fingers of each hand, and while these make compression 
 and traction, the two thumbs are braced against the apex of the glans 
 (Fig. 650). 
 
 After reduction is accomplished, measures must be employed to 
 subdue the inflammation and the patient advised of the necessity for 
 a circumcision later to insure against a recurrence. 
 
 If reduction cannot be accomplished by these measures, an opera- 
 tion must be done without delay. The purpose is to divide the re- 
 stricting band, which lies in the groove between the two ridges. 
 
8o8 
 
 CIRCUMCISION 
 
 Inject a little cocaine along the line of incision which is usually in 
 the middle line of the dorsum and just behind the corona (Fig. 571). 
 
 Use the point of the knife, making short, firm, shallow cuts, until 
 the constricting band is felt to yield. A too bold incision may result 
 in seriously wounding the corpora cavernosa. 
 
 Fig. 651. — Dividing the constricting band in paraphimosis. (Veau.) 
 
 The bleeding in any event will usually be free but ceases spontane- 
 ously. The wound which at first was vertical, becomes transverse 
 when reduction is completed, and is sutured in that direction. 
 
 Apply a moist dressing and if there is no ulceration or gangrene, the 
 swelling will soon subside. But in this case also the patient must be 
 advised of the danger of recurrence unless a circumcision is done for 
 the relief of the narrowed prepuce or the short frenum after the in- 
 flammation has subsided. 
 
 CIRCUMCISION 
 
 This is an excellent operation probably not often enough done in 
 infancy, when it is simple and without danger, and may prevent the 
 disturbances of adolescence, consequent upon phimosis. 
 
CIRCUMCISION 
 
 809 
 
 In adult life it is often the primary step toward the relief of acute 
 disorders and sexual irregularities. 
 
 The Operation. — General anesthesia is nearly always indicated in 
 children; local, in adults. To secure local anesthesia, begin by lightly 
 tamponing the preputial orifice with a pledget of cotton saturated 
 with a 10 per cent, solution of cocaine, and left in position for at least 
 five minutes. Next inject the foreskin in the line of the proposed 
 incision, using a 4 per cent, solution of cocaine or Schleich's solu- 
 tion. The too rapid absorption of cocaine may be prevented by 
 constriction of the base of the penis. 
 
 Fig. 652. — Resection of the prepuce. (Veau.) 
 
 When the anesthesia is established, break up the preputial ad- 
 hesions with a grooved director or probe, usually not difficult in an 
 infant but sometimes difficult in the adult, following balanitis. 
 
 There are various methods of making the incision, any of which, 
 properly employed, will give good results. Suppose the prepuce is 
 long and slender: begin by holding the penis vertically and without 
 making traction on the foreskin, apply a forceps so that its blades lie 
 parallel with the oblique line of the corona (Fig. 652). Use care, of 
 course, not to pinch the glans. Divide the foreskin with the bis- 
 toury, allowing the blade to hug the upper side of the forceps, that no 
 bruised tissues may be left behind. The skin retracts, leaving the 
 
8io 
 
 CIRCUMCISION 
 
 mucosa covering the glans. Divide this mucous covering along the 
 middle line to within J£ inch of the coronal border (Fig. 653). 
 The glans will now be completely exposed. 
 
 Trim off the two mucous flaps so that a narrow cuff is left. It is 
 better to begin near the f renum and trim toward the terminal point of 
 the dorsal incision (Fig. 654). If the f renum is too short, divide it 
 transversely with the scissors (Fig. 655), catching up the little artery 
 which will be divided. This completes the necessary incisions. 
 
 Fig. 653. — Splitting the mucous membrane. (Veau.) 
 
 Hemostasis must be assured. It may be necessary to tie two or 
 three small vessels and nearly always the artery of the frenum re- 
 quires ligation, using catgut No. 1. 
 
 A brief application of adrenalin solution on a compress will check 
 the oozing if it should persist. 
 
 Suture, The mucous and cutaneous borders are brought into 
 exact contact and united by several small, interrupted sutures of 
 catgut (Fig. 656). The transverse incision of the frenum is made a 
 vertical one by extending the glans, and is sutured in that direction 
 (Fig. 657). 
 
 In the case of children*, it may be sufficient, instead of suturing, to 
 use small clips, by which means, it is claimed, swelling is avoided. 
 
 Dressing, — -Wrap the penis in a sterile compress, leaving the glans 
 
CIRCUMCISION 
 
 8ll 
 
 Fig. 654. — Resection of the mucous mem- Fig. 655. — Section of the frenum. (Veau.) 
 brane. (Veau.) 
 
 Fig. 656.— Maintaining coaptation by means Fig. 657.— After section of the frenum the 
 of a small clip. {Veau.) raw edges are coapted. (Veau.) 
 
Si 2 HYDROCELE 
 
 exposed. Enclose the whole in a second compress perforated over 
 the meatus, and secure with adhesive strips. 
 
 Adults require bromides to prevent painful erections. The dress- 
 ings are not to be changed unless soiled. Remove the sutures and 
 re-dress the fifth day. It will probably require ten to twelve days 
 for repair to be complete. 
 
 Children usually need a daily change of dressing. If clips are 
 used instead of sutures, they are to be removed at the end of twenty- 
 four hours, and if the adjustment was perfect, the reunion by that 
 time will often be practically complete. 
 
 HYDROCELE 
 
 The chief test of a hydrocele is its "translucency." The first 
 treatment usually tried is tapping and the injection of an alterative. 
 If the hydrocele recurs, then a radical operation should be done. 
 Often this should be resorted to from the first without preliminary 
 tapping, especially in the long-standing cases, where the „ tunica 
 vaginalis is thickened and it is almost obvious that the trouble will 
 recur. 
 
 Occasionally the patient will prefer repeated simple puncture and 
 evacuation without subsequent injection, rather than the more 
 radical procedures which will lay him up for some days. 
 
 Tapping. — Anesthesia is not necessary. Prepare the field as for 
 a surgical operation. Seize the tumor behind with the left hand so as 
 to make it tense in front. The trocar, held in the right hand with 
 index finger an inch from the point to limit its penetration, is entered 
 with a sharp thrust into the middle and lower part of the anterior 
 surface of the tumor (previously assure yourself that the testicle is 
 not inverted). Withdraw the plunger, being careful that the tube is 
 not displaced. When the fluid is evacuated, attach a syringe to the 
 trocar and inject a drachm of a 3^2 P er cent, solution of cocaine; 
 gently massage the scrotum so as to bring the solution in contact 
 with the whole testicle, wait ten minutes and then let the solution 
 flow out. 
 
 In the meantime charge the syringe with a drachm of pure tincture 
 
HYDROCELE " 813 
 
 of iodine and inject. Hold it for five minutes and then let it escape. 
 Withdraw the trocar and seal the puncture with collodion. 
 
 The next day the scrotal wall is painful, reddened and swollen. 
 The scrotum must be well supported, and moist compresses may give 
 some relief. The patient should be kept in bed for ten days and 
 warned that several weeks may be required for absorption of the 
 exudates. 
 
 Fig. 658. — Incision for hydrocele. (Veau.) 
 
 RADICAL OPERATION 
 
 Sterilize the penis, scrotum, and perineum. Wrap the penis in a 
 sterile compress and have it held out of the way. 
 
 Local anesthesia may be employed, but a general anesthesia is 
 better. 
 
 iMake an incision 2 inches long over the middle of the tumor, 
 dividing first the several layers over the tunica (Fig. 658). Then 
 open the tunica the whole length of the wound and evert the testicle. 
 The tunica is stitched to the cord above and its free borders, brought 
 together behind the epididymis, are to be sutured to each other 
 
8i 4 
 
 CASTRATION 
 
 (Fig. 659). Or, the membrane may be resected completely, follow- 
 ing close to the epididymis, and if the cut edges bleed, they are to be 
 sewed with a continuous suture (Fig. 660). 
 
 Restore the testicle, insert a small drain, and suture the scrotum. 
 The drain should be removed on the second day and the sutures on 
 the sixth, and in a day or two longer, the patient may get up. 
 
 Fig. 659. — Everting the tunica vaginalis. (Veau.) 
 
 CASTRATION 
 
 The removal of the testicle is more frequently indicated as the 
 result of cancer or tuberculosis, and may be done under either local 
 or general anesthesia. 
 
 The incision begins just below the external ring (on the right) 
 and follows the direction of the cord for from ij^ to 2 inches 
 (Fig. 661). 
 
 Expose and isolate the cord up to the inguinal canal which, if in- 
 volved, should be opened, as in the operation for hernia. Separate 
 the different elements of the cord, so as to require two or three sepa- 
 rate ligatures. Do not include the cremaster in the ligatures 
 (Fig. 662). Just below the catgut ligatures, resect the cord and enu- 
 cleate the testicle from above downward (Fig. 663). 
 
CASTRATION 
 
 815 
 
 Fig. 660. — Hydrocele. Resection of the Fig. 661. — Incision for castration. (Veau.) 
 tunica vaginalis. (Veau.) 
 
 Fig. 662. — Ligation of the spermatic cord. (Veau.) 
 
Si6 
 
 CASTRATION 
 
 This step is usually tedious in the tubercular cases on account of 
 the adhesions which may have to be divided with the bistoury, and 
 the bleeding points tied. 
 
 Again inspect the cord (you have left the ligatures long till now) 
 to be sure there is no bleeding; and it is recommended to cauterize 
 the end of the vas in tuberculosis. 
 
 
 Fig. 663. — Separating the testicle from the scrotal tissues. (Veau.) 
 
 Repair first the inguinal canal, if it was opened. Insert a drain- 
 age-tube reaching to the bottom of the scrotum and projecting from 
 the upper angle of the wound which is the point least likely to get 
 infected after the dressings are applied. The tubercular cases espe- 
 cially require drainage. Suture and apply a dry dressing. Remove 
 the tube on the third and the sutures on the sixth or seventh. 
 
CHAPTER XXV 
 INGROWING TOE-NAIL 
 
 The particular point in this operation is to obliterate the matrix 
 corresponding to the part of the nail removed. It is insufficient to re- 
 move only that part of the nail gouging the flesh. Usually one side 
 only is involved, the outer side, and the removal of half the nail will 
 effect a cure. 
 
 ~T^<tt- 
 
 Fig. 664. — Local anesthesia. . (Veau.) 
 
 Employ local anesthesia. Constrict the base and make a circular 
 injection of cocaine or stovaine (Fig. 664). 
 
 Remove the Nail. Introduce the sharp point of the scissors under 
 the nail and divide its entire length (Fig. 665). Next seize the dis- 
 eased portion with a forceps and tear it out (Fig. 666). 
 
 Extirpate the Matrix. Incise the integument of the matrix to be 
 eliminated, with a sharp-pointed bistoury, holding the cutting point 
 
 52 
 
 817 
 
Ji8. 
 
 INGROWING TOE-NAIL 
 
 Fig. 665. — Splitting the nail. (Veau.) Fig. 666. — Wrenching the nail out. (Veau.) 
 
 Fig. 667. — Incision over the matrix. {Veau.) Fig. 668. — Extirpation of matrix. (Veau.) 
 
INGROWING TOE-NAIL 
 
 8lQ 
 
 obliquely, so that it gets a larger bite deeply than superficially (Fig. 
 
 567). The soft parts are thus removed down to the bone (Fig. 668). 
 
 deep cavity is left in the bottom, of which the bone may be seen 
 
 r ig. 669). This cavity should be packed with sterile gauze and 
 
 Fig. 669. — The matrix removed. (Veau.) 
 
 Fig. 670. — Wound sutured. (Veau.) 
 
 allowed to heal by granulation, which will require two or three weeks. 
 It is advisable to diminish the size of the cavity by a suture, including 
 on one side the skin, and on the other, the subungual tissues (Fig. 
 670). It will probably give way finally, yet it facilitates repair. 
 
 * 
 
CHAPTER XXVI 
 REMOVAL OF SMALL TUMORS 
 
 The technic for the removal of small tumors on or under the skin 
 should be kept in mind. As in more difficult operations, a definite 
 procedure should be followed. A lack of system may make a minor 
 matter one of difficulty. 
 
 Local anesthesia will usually suffice. It should be complete. To 
 secure a complete local anesthesia, begin by determining the lines of 
 incision, ai>d along these lines inject a 2 per cent, solution of co- 
 
 1 
 
 
 Fig. 671. — Anesthesia of the skin. 
 (Veau.) 
 
 Fig. 672. — Anesthesia of the deeper layers. 
 (Veau.) 
 
 caine; intradermic, not subcutaneous. If the tumor is large or if the 
 skin is loose, redundancy may be avoided by making two semicircu- 
 lar incisions, thus removing an ellipse of the skin (Fig. 671). 
 
 Next loosen the edges of the skin and partially expose the tumor 
 and make a new injection along its sides. Later inject the base of the 
 tumor as the dissection proceeds (Fig. 672). 
 
 In the case of sebaceous cysts, the main point is to remove the sac in 
 its entirety ; anything else insures a return of the trouble. If possible, 
 
 820 
 
REMOVAL OF SMALL TUMORS 
 
 821 
 
 dissect the sac out without emptying its contents. The dissection 
 will be done with ease only in case all the layers are incised down to 
 the true capsule. If the cyst walls are particularly thick, the contents 
 may be emptied out from the first. 
 
 Once the cyst is exposed retract one lip of the skin wound and 
 
 Fig. 673. — Detaching the capsule. (Veau.) 
 
 Fig. 674. — Dissecting a loose capsule with the bistoury. (Veau.) 
 
 loosen the attachments by blunt dissection (Fig. 673). Or if the 
 fibrous attachments are loose and tough, divide them with scissors or 
 scalpel (Fig. 674). 
 
 There will be some slight hemorrhage from the cavity following 
 the removal of the cyst, but it will be easily controlled by pressure or 
 by a hot compress. In case the cyst was emptied in the course of the 
 
S2 2 REMOVAL OF SMALL TUMORS 
 
 operation, be assured that all the cyst wall is removed, or the growth 
 will recur. 
 
 The procedure is the same in the case of a fatty tumor unless it is 
 pedunculated; if so, make a curved incision on each side of its base. 
 Usually a small blood vessel at the base of the tumor will require 
 ligation. 
 
 Synovial cysts require special attention to asepsis or the cavity with 
 which they are connected, and from which they originate, may .be- 
 come infected; thus an arthritis or teno-synovitis might develop. 
 The pedicle requires careful ligation. 
 
 Branchial cysts are often intimately connected with the vessels in 
 the neck and their dissection may be extremely difficult. The pedicle 
 of such cysts usually terminates in the thyro-glossal duct. 
 
 Angiomas are likely to give rise to dangerous hemorrhage. Only 
 such as are small and well defined should be undertaken by the prac- 
 titioner. No effect should be made to enucleate; instead elliptical 
 incisions should be made quite beyond the borders of the tumor and 
 the whole removed "en masse" Usually a well-defined vascular 
 pedicle will require careful ligation. 
 
CHAPTER XXVII 
 SKIN GRAFTING 
 
 Skin grafting is a measure deserving to be more generally employed 
 by the practitioner. Very often it would save time and trouble in the 
 treatment of those conditions in which epidermitization is long de- 
 layed, for this it hastens and also it tends to prevent the formation of 
 scar tissue. Thus chronic ulcers, burns, and lacerated wounds fol- 
 lowed by extensive sloughs may require grafting. 
 
 The operation is simple in theory yet attended by many failures 
 through lack of attention to detail. 
 
 Three factors require the minutest supervision: (i) the field must 
 be properly prepared; (2) the grafts must be cut correctly; (3) the 
 after-treatment must be appropriate. 
 
 (1) The area to be grafted must be sterile and must be free of any 
 oozing. If an ulcer is to be treated, the granulations must previously 
 be made as healthy as possible: if sluggish, by currettement ; if exuber- 
 ant, by touching up with nitrate of silver. A few days afterward it 
 will be ready to receive the graft. A dry sterile dressing should be 
 applied a day previous to the operation; before the graft is applied, 
 the surface should be thoroughly douched with normal salt solution. 
 
 (2) The skin which is to furnish the graft should be shaved and 
 thoroughly scrubbed with soap and water. Antiseptics had better 
 be avoided for they may compromise the vitality of the cellular ele- 
 ments. A sufficient anesthesia may be obtained by injection of 
 Schleich's solution No. 3. 
 
 Two methods of cutting the grafts are currently employed, Rever- 
 din's and Thiersch's. 
 
 (I) Reverdin's Method. — A small fold of the skin is picked up with 
 fine tissue or mouse-toothed forceps and cut off at its base with small 
 pointed scissors (Fig. 675). This section includes practically all the 
 layers of the skin (Fig. 676). The graft is applied and gently pressed 
 
 823 
 
824 
 
 SKIN GRAFTING 
 
 out. Fifteen or twenty points are thus placed about 15 mm. or 
 say 1 i inch apart. If the surface is large enough to require more, the 
 center should be left bare and treated by a second operation (Fig. 
 677). 
 
 _- ^ 
 
 Fig. 675. — Manner of cutting the 
 Reverdin graft. (Veau.) 
 
 Fig. 676. — The graft 
 removed. (Veau.) 
 
 (II) Thiersch's Method. — This method is the better when it suc- 
 ceeds, but the conditions of success are more exacting. Granulation 
 tissue usually needs to be removed by curettement, exposing the 
 
 Fig. 677. — Placing Reverdin grafts. Ulcer of leg. (Veau.) 
 
 fibrous layer. The edges of the ulcer must be scraped (Fig. 678). 
 The oozing which follows must be completely checked. A firm com- 
 press applied for ten or fifteen minutes will usually suffice. If oozing 
 persists, the operation will fail. 
 
SKIN GRAFTING 
 
 82 i 
 
 The grafts in this case consist of thin slices of the epidermis, as long 
 as necessary and as wide as convenient. They are usually taken 
 
 Fig. 678. — Thiersch's method. Preparing the wound for the graft. (Veau.) 
 
 from the anterior surface of the thigh. A sharp, thin-bladed razor 
 is used in cutting the slice (Fig. 679). 
 
 Fig. 679. — Cutting the Thiersch graft. (Veau.) 
 
 The skin must be put on the stretch. Special retractors are occa- 
 sionally employed. The two hands of the assistant and the left hand 
 

 SKIN GRAFTING 
 
 of the operator can make it sufficiently tense (Fig. 680). The razor 
 is held nearly horizontally and cuts by a rapid, short, sawing motion. 
 As the razor progresses, the thin and pliable tissue piles up on the 
 blade. 
 
 The graft is now applied to the raw surface and the free end fixed 
 by a pointed instrument and slowly worked of the blade, and then 
 teased out flat (Fig. 681). 
 
 Fig. 680. — Cutting the Thiersch graft. (Veau.) 
 
 So proceed until the whole surface is covered. Small angles may 
 be filled in with Reverdin grafts (Fig. 682). The area denuded need 
 only to be covered with a sterile dressing and repair will soon be 
 complete. 
 
 (3) The grafted area must be carefully covered with strips of 
 rubber tissue or gutta-percha, placed in various directions so as to 
 hold the grafts in place and at the same time give exit to any exudates. 
 A layer of gauze saturated with salt solution is next applied, which in 
 
SKIN GRAFTING 
 
 827 
 
 turn is covered by absorbent cotton, and the whole held in place by a 
 moderately firm bandage. 
 
 Fig. 681. — Method of applying the 
 graft. (Veau.) 
 
 Fig. 682. — Wound covered by 
 grafts. (Veau.) 
 
 The part should be immobilized, employing plaster splints if 
 necessary. Change all the dressings except the rubber tissue every 
 day or two and douche gently with normal salt solution. At the 
 end of a week or ten days, change the tissue. 
 

INDEX 
 
 Abdomen, contusions, 125 
 
 gunshot wounds, 153, 185, 235 
 
 incised wounds, 130 
 
 injuries, 125 
 
 laparotomy, 131 
 
 non-penetrating wounds, 127 
 
 penetrating wounds, 129 
 
 punctured wounds, 129 
 
 stab wounds, 129 
 Abdominal drainage, 131 
 
 hemorrhage, 549 
 
 section, 549 
 Abducens nerve, 412 
 Abscess, acute, 391 
 
 alveolar, 400 
 
 anal, 419 
 
 antrum, mastoid, 543 
 
 appendicial, 587 
 
 axillary, 411 
 
 Bartholin's gland, 426 
 
 breast, 409 
 
 cervical glands, 409 
 
 chronic, 394 
 
 definitions, 391 
 
 dental, 400 
 
 drainage, 393 
 
 external auditory meatus, 398 
 
 eyelids, 397 
 
 face, 396 
 
 floor of the mouth, 402 
 
 iliac, 432 
 
 ischio-retcal, 416 
 
 kidney, 568 
 
 labium, 426 
 
 lachrymla, 398 
 
 liver, 430 
 
 Abscess, lung, 518 
 
 mammary, 409 
 
 mastoid, 538 
 
 nasal septum, 397 
 
 palmar, 414 
 
 parotid, 398 
 
 pelvic, 427 
 
 peri-anal, 419 
 
 perineal, 420 
 
 plantar, 416 
 
 popliteal, 414 
 
 prostatic, 420 
 
 psoas, 434 
 
 rectal, 419 
 
 retropharyngeal, 405 
 
 scalp, subaponeurotic, 395 
 subperiosteal, 396 
 superficial, 395 
 
 seminal ducts, 424 
 
 submammary, 411 
 
 submaxillary, 401 
 
 subphrenic, 430 
 
 symptoms of, 391 
 
 tongue, 404 
 
 tonsillar, 404 
 
 treatment, acute, 392 
 chronic, 394 
 
 urinary, 728 
 
 vulvar, 425 
 
 vulvo -vaginal, 426 
 Accidents, anesthesia, 16 
 Actual cautery, phlegmon, 446 
 Acupressure, 61 
 Acute intestinal obstruction, 593 
 
 retention of urine, 714 
 Adrenalin chloride, anesthesia, 16 
 
 829 
 
8 3 o 
 
 Adrenalin chloride, epistaxis, 68 
 
 gauze tape, 64 
 
 shock, 55 
 Air passages, foreign bodies, 475 
 
 burns, 488 
 Alcohol, antisepsis, 3 
 Allison, strangulated hernia, 625 
 Alveolar abscess, 400 
 Ammonia after anesthesia, 18 
 Amputations, arm, 765 
 
 Chopart, 781 
 
 elbow, 764 
 
 finger, 746 
 
 foot, 783 
 
 forearm, 761 
 
 general technic, 744 
 
 great toe, 787 
 
 hand, 761 
 
 hip-joint, 794 
 
 index finger, atypical, 751 
 
 knee-joint, 791 
 
 leg, 788 
 
 little finger, 751 
 toe, 778 
 
 metacarpal, 755 
 
 metatarsal, 780 
 
 middle finger, 749 
 toes, 778 
 
 PirogofFs, 785 
 
 principles, 744 
 
 Syme's, 786 
 
 thigh, 793 
 
 thumb, atypical, 760 
 typical, 754 
 
 toes, 776 
 
 scapulo-humeral, 775 
 
 shoulder, 765 
 Anal abscess, 419 
 
 dilatation, 799 
 
 fistula, 795 
 Anastomosis, intestinal, 666 
 Andrews, Colles' fracture, 261 
 Anesthesia, 12 
 
 accidents, 16 
 
 ammonia, 18 
 
 INDEX 
 
 Anesthesia, chloroform, 12 
 
 cocaine, 18 
 
 ether, 14 
 
 ethyl chloride, 1 8 
 
 local, 18 
 
 spinal, 22 
 
 stovaine, 19 
 
 vomiting, 17 
 Anesthetics, 3 
 Aneurism, gunshot, 141 
 Aneurismal varix, 141 
 Angina, Ludwig's, 402 
 Angiomas, 822 
 Angus, torsion, 6S7 
 Ankle amputation, 785 
 
 arthrotomy, 462 
 
 dislocation, 352 
 
 fracture, 292 
 
 sprain, 359 
 Anterior crural nerve, exposure, 383 
 
 injury, 382 
 Anterior tibial artery, ligation, 741 
 
 nerve, injury, 387 
 Antipyrine, epistaxis, 68 
 Antisepsis, emergency, 6 
 Antiseptics, 3 
 Antitetanic serum, 215 
 Antistreptococcic serum, phlegmon, 
 
 447 
 Antrum, mastoid, 538 
 Anus, abscess, 419 
 
 artificial, permanent, 609 
 temporary, 605 
 
 dilatation, 699 
 
 fistula, 815 
 
 imperforate, 679 
 
 piles, 800 
 Appendectomy, 579 
 Appendicial abscess, 587 
 Appendicitis, 573 
 
 after-treatment, 590 
 
 catarrhal, 575 
 
 diagnosis, 573 
 
 gangrenous, 578 
 
 operation, 583 
 
INDEX 
 
 831 
 
 Appendicitis, perforating, 577 
 treatment, 579 
 ulceration, 577 
 varieties, 576 
 Appendix in hernia, 631 
 Arm, amputation, 765 
 bandages, 45 
 fractures, 225 
 phlegmons, 445 
 Army bullet, 135 
 Aristol in burns, 487 
 Arrest of hemorrhage, 60 
 Arterial hemorrhage, 57 
 Arteries, ligations, rules, 733 
 suture, 733 
 torsion, 62 
 
 wounds, gunshot, 140 
 Artery forceps, 4 
 
 ligation, anterior tibial, 741 
 axillary, 738 
 brachial, 738 
 common carotid, 735 
 compression, 66 
 dorsalis pedis, 742 
 external carotid, 736 
 femoral, 740 
 lingual, 736 
 obturator, 384 
 posterior tibial, 740 
 radial, 739 
 subclavian, 736 
 ulnar, 740 
 Artificial anus, permanent, 609 
 temporary, 605 
 limbs, 788 
 respiration, 17 
 Arthritis, septic, 456 
 Arthrotomy, 457 
 ankle, 462 
 elbow, 463 
 hip, 464 
 knee, 457 
 shoulder, 464 
 wrist, 464 
 Arx, heart injuries, 125 
 
 Asphyxia, anesthesia, 16 
 
 foreign bodies, 472 
 
 retropharyngeal abscess, 405 
 Aspiration, bladder, 723 
 
 pericardium, 504 
 
 pleura, 520 
 Astragalus, dislocation, 352 
 
 fracture, 296 
 Auditory nerve, injuries, 375 
 Automatic centers, paralysis, 13 
 Axillary artery, ligation, 738 
 
 abscess, acute, 411 
 chronic, 411 
 Axtell, wound of chest, 119 
 
 trephining, 536 
 
 Bandage, arm, 45 
 
 Barton's, 47 
 
 breast, 44 
 
 eye, 47 
 
 finger, 44 
 
 foot, 38 
 
 groin, 41 
 
 hand, 45 
 
 head, 47 
 
 knee, 41 
 
 leg, 41 
 
 neck, 45 
 
 shoulder, 45 
 
 St. Andrew's cross, 44 
 
 stump, 48 
 
 thumb, 45 
 Bandages, 37 
 
 method of applying, 38 
 
 plaster, 49 
 Barbarin, wound infections, 164 , 
 Bartholin's gland, abscess, 426 
 Barton's bandage, 47 
 Base of thorax, wounds, 120 
 Bassini, operation for hernia, 648 
 Bavarian splints, 51 
 Belfield, drainage of seminal ducts, 
 
 424 
 Bellocq's cannula, 69 
 Bennett, Sir W., torsions, 676 
 

 INDEX 
 
 Bennett's fracture, 263 
 
 Beril, hernia of the brain, 181 
 
 Biceps tendon dislocation, 363 
 
 Bi-COUde catheter, 715 
 
 Bier treatment, 440 
 
 "Black eye," 398 
 
 Bladder, aspiration in retention, 723 
 
 Bladder, cystotomy, 724 
 
 foreign bodies, 483 
 
 hernia operation, 630 
 
 gunshot wounds, 153 
 
 puncture, 723 
 
 rupture, 569 
 
 suture, 571 
 
 wounds, 570 
 Blank cartridges, 214 
 Bleeding (see Hemorrhage) 
 Bloodgood, intestinal obstruction, 
 
 583 
 
 fractures, 219 
 Blood vessels, injuries, 92, 95 
 Bolo wounds, 189 
 Bone plating, 283 
 
 wiring, 250 
 Bonnet, repair of nerves, 143 
 Bonney, emergency operations, 6 
 Bowel, acute obstruction, 593 
 Bowlby, gunshot wounds, 136 
 Bowls, sterilization, 9 
 Brachial artery, compression, 66 
 
 ligation, 738 
 Brain, abscess, 182 
 
 compression, 322 
 
 concussion, 320 
 
 contusion, 322 
 
 gunshot wounds, 150, 180 
 
 hemorrhage, 526 
 
 injuries, 315 
 
 topography, 526 
 Branchial cysts, 822 
 
 5t abscesses, 409 
 
 bandage, 44 
 Brickner, tubal pregnancy, 692 
 Bronchi, foreign bodies, 475 
 Bronchoscopy, Killian, 477 
 
 Brown, Cesarean section, 700 
 Bruises (see Contused wounds) 
 Brushes, hand, 2 
 Bryant, esophagotomy, 502 
 
 vertical extension, 278 
 Bullet wounds, civil, 202 
 
 military, 133 
 Bullets, types, 135 
 Burmeister, preparation of the 
 
 hands, 10 
 Burns and scalds, 484 
 Burns, air passages, 488 
 Burns, electrical, 489 
 Burns, mouth, 488 
 
 Cahill, torsions, 686 
 
 Calmette's antitetanic powder, 215 
 
 Cannaday, subcuticular suture, 31 
 
 Capitellum, 46 
 
 Carbuncle, 397 
 
 Carotid artery compression, 66 
 
 ligation, 735 
 Carpus, dislocation, 358 
 
 fracture, 262 
 Carrel, wound infections, 161 
 Carron oil, 488 
 Castration, 814 
 
 emergency, 107 
 Catgut, 26 
 
 chromicized, 26 
 Catheterization, equipment, 715 
 
 retrograde, 711 
 Catheters, acute retention, 715 
 
 box for, 4 
 
 sterilization, 715 
 Cecum in hernia, 629 
 Cerebro-spinal fluid, characters, 316 
 Cervical glands, suppuration, 408 
 Cesarean section, 698 
 Championniere, fractures, 221 
 Charlton, foreign body in bladder, 
 
 483 
 Chest contusions, 114 
 
 wounds, no 
 Cheyne, phlegmon of neck, 447 
 
INDEX- 
 
 833 
 
 Chipman, reduction of shoulder, 337 
 Chloral, wounds of tongue, 85 
 Chlorazene tablets, 3 
 Chloroform anesthesia, 12 
 
 face in, 13 
 
 pulse in, 13 
 
 pupil in, 13 
 container, 13 
 Chopart's amputation, 781 
 Cigarette drain, 33 
 Circular enterorrhaphy, 670 
 Circumcision, 808 
 Circumflex nerve, exposure, 382 
 
 injury, 382 
 Clavicle, fracture, 306 
 Cocaine, 4 
 
 anesthesia, 18 
 Coley, femoral hernia, 585 
 Collapse, 53 
 , Colles' fracture, 258 
 Colon bacillus, 573 
 Colostomy, 609 
 Colpotomy, 364, 427 
 1 Combs, foreign body in rectum, 480 
 \ Comminuted fractures, 216 
 Compound dislocations, 354 
 
 elbow, 356 
 
 hip, 356 
 
 knee, 358 
 
 shoulder, 356 
 
 wrist, 358 
 fractures, 299 
 
 ankle and foot, 304 
 
 tibia, 302 
 1 Compression of arteries, brachial, 66 
 
 carotids, 66 
 
 coronary, 66 
 
 facial, 66 
 
 femoral, 67 
 
 intercostals, 68 
 
 occipital, 66 
 
 plantar, 68 
 
 popliteal, 67 
 
 subclavian, 66 
 
 temporal, 66 
 
 53 
 
 Compression of arteries, tibial, 67 
 ulnar, 66 
 
 of brain, 320 
 Concussion of brain, 320 
 Condyles of humerus, fracture, 246 
 Congenital hernia, 648 
 Coin catchers, 473 
 Conjunctiva, foreign bodies, 467 
 
 wounds, 91 
 Continuous suture, 27 
 Contusions, 72 
 
 abdomen, 125 
 
 brain, 322 
 
 chest wall, 114 
 
 eye, 89 
 
 eyelid, 86 
 
 knee-joint, 358 
 
 lung, 114 
 
 nerves, 374 
 
 scalp, 81 
 
 urethra, 705 
 Cook, appendicitis, 580 
 Cooper, reduction of elbow, 344 
 Coracoid process, examination, 231 
 Corner, torsions, 690 
 Coronary artery, compression, 66 
 Cotton, injuries to testicle, 108 
 Cradle splint, 170 
 Craig, gunshot of spine, 152 
 Cranial nerves, injuries, 375 
 Craniectomy, emergency, 526 
 Crepitus, 217 
 Crile, direct transfusion, 55 
 
 shock, 55 
 
 infections, 163 
 Crucial ligaments, rupture, 361 
 Crushing injuries to the extremities, 
 
 97 
 
 Cullen, torsions, 690 
 Cushing, shock, 56 
 Cut throat, 86 
 
 wrist, 91 
 Cystotomy operation, 691, 724 
 
 Davy, wound infections, 164 
 
$34 
 
 INDEX 
 
 Dalrin's solution, 161 
 Dayat, foreign bodies, 482 
 Deep epigastric artery, 68 
 Dental abscess, 400 
 Depressed fracture, skull, 318 
 Diaphragm, wounds, 122 
 Digital arteries, compression, 67 
 Dilatation of the anus, 799 
 
 urethral stricture, 717 
 Direct pressure in hemorrhage, 60 
 Dislocations, 328 
 
 ankle, 352 
 
 compound, 354 
 
 elbow, 343 
 
 finger, 346 
 
 hip, 346 
 
 jaw, 342 
 
 knee, 350 
 
 patella, 352 
 
 shoulder, 328 
 
 after-treatment, 341 
 subclavicular, 331 
 subcoracoid, 328 
 subglenoid, 338 
 subspinous, 340 
 
 semilunar cartilages, 351 
 
 thumb, 345 
 
 wrist, 356 
 Dixon, tubal pregnancy, 692 
 Dorsalis pedis artery ligation, 742 
 Dorsum ilii, dislocation, 346 
 Double spica, 37 
 Downey, fracture of femur, 282 
 Doyen's trephine, 530 
 Drainage, 32 
 
 abdominal, 131 
 
 abscess, 393 
 
 accidental wounds, 32 
 
 amputations, 744 
 
 appendicitis, 587 
 
 arthrotomy, 458 
 
 aseptic wounds, 32 
 
 cigarette, 33 
 
 compound fractures, 34 
 
 empyema, 524 
 
 Drainage, gauze wick, 33 
 Drainage, heart wounds, 511 
 
 operative wounds, 34 
 
 tubes, 33 
 
 urinary infiltration, 732 
 Dressings, 35 
 
 first aid, 161 
 
 frequency, 36 
 Dupuytren's splint, 295 
 Dura mater, wounds, 533 
 Dutch cane splints, 48 
 Dyspnea, heart wounds, 123 
 
 Ear drum, paracentesis, 539 
 
 forceps,- 469 
 
 foreign bodies, 468 
 Eastman, J. R., hernia, 656 
 
 intestinal obstruction, 594 
 
 military hospital service, 164 
 Eastman, T. B., appendicitis, 574 
 Ectopic gestation, 691 
 Edema of glottis, 499 
 Elbow, amputation, 704 
 
 arthrotomy, 463 
 
 dislocation, 343 
 
 fracture, 246 
 
 gunshot wounds, 173 
 
 wound, 95 
 Electrical burns, 489 
 
 shock, 489 
 Elliott, wounds of kidney, 569 
 Emergency antisepsis, 6 
 
 operations, preparation, 7 
 
 surgery, equipment, 2 
 military, 201 
 Emphysema, chest injuries, 113 
 Empyema of thorax, 518 
 
 adult, 522 
 
 after-treatment, 225 
 
 child, 521 
 
 diagnosis, 518 
 
 puncture for, 520 
 Enemas, technic, 596 
 Enterectomy, 666 
 Enterorrhaphy, 669 
 
 
INDEX 
 
 §35 
 
 Enterostomy, 605 
 
 Epis taxis, 68 
 
 Equipment, emergencies, 2 
 
 Esophagotomy, 500 
 
 Esophagus, foreign bodies, 471 
 
 wounds, 89 
 Estes, intussusception, 599 
 Ether anesthesia, 14 
 
 adrenalin chloride in, 15 
 External auditory meatus abscess, 398 
 
 carotid artery ligation, 736 
 
 urethrotomy, 707 
 Extravasation of urine, 728 
 Extremities, crushing injuries, 97 
 
 fractures, 216 
 
 wounds, 92 
 Eye bandage, 47 
 
 foreign bodies, 467 
 
 injuries, 89 
 ' Eyelid, abscess, 397 
 
 contusion, 86 
 
 wounds, 86 
 
 Face, abscesses, 396 
 fractures, 315 
 furuncle, 396 
 gunshot wounds, 184, 206 
 wounds, 84 
 Facial artery, compression, 66 
 ligation, 736 
 nerve injuries, 374 
 
 mastoid operation, 544 
 Felon, 439 
 
 I Femoral artery, compression, 67 
 ligation, 740 
 stab wound, 95 
 hernia, anatomy, 633 
 radical cure, 659 
 strangulated, 633 
 operation, 635 
 taxis, 619 
 Femur, amputations, 793 
 fractures, 268 
 
 after-treatment, 276 
 children, 279 
 
 Femur, epiphyseal, 279 
 
 gunshot fractures, 174 
 
 fractures, shaft, 273 
 supracondylar, 276 
 
 osteomyelitis, 454 
 Fibula, fractures, 282 
 Field of operation, sterilization, 10 
 Figure-of-eight bandage, 38 
 Fingers, amputations, 747 
 
 bandages, 44 
 
 dislocations, 346 
 
 fractures, 253 
 
 infections, 438 
 First aid, dressing, 161 
 
 fractures, 214, 247 
 
 hemorrhage, 65 
 
 splints, 169, 186 
 Fiske, wounds of spleen, 567 
 Fistula, anal, 805 
 
 urinary, 728 
 Fitzmaurice-Kelley, amputation for 
 
 shell wounds, 168 
 Floor of mouth, abscess, 402 
 Florschutz suspension, 179 
 Foot, amputations, 783 
 
 bandages, 38 
 
 fractures, 296 
 Forceps, artery, 5 
 
 aural, 469 
 
 nasal, 471 . 
 
 urethral, 481 
 Forcipressure, 61 
 Ford, ether anesthesia, 16 
 
 fracture of patella, 281 
 skull, 435 
 Forearm, amputation, 761 
 
 gunshot fracture, 172 
 
 phlegmon, 443 
 Foreign bodies, air passages, 475 
 
 bladder, 483 
 
 ear, 468 
 
 esophagus, 471 
 
 eye, 467 
 
 larynx, 475 
 
 nose, 470 
 
836 
 
 INDEX 
 
 Foreign bodies, pharynx, 471 
 
 rectum, 478 
 
 trachea, 475 
 
 urethra, 481 . 
 Fountain syringe, 3 
 Fowling piece, gunshot wound, 214 
 Fox worthy, bolo wounds, 189 
 Fractures, 216 
 
 ankle, 292 
 
 anterior tuberosity of tibia, 289 
 
 arm, 225 
 
 astragalus, 296 
 
 carpus, 262 
 
 clavicle, 306 
 
 Colles', 258 
 
 compound, 299 
 
 condylar, 246 
 
 crepitus,^ 18 
 
 definitions, 216 
 
 diagnosis, 217 
 
 elbow, 246 
 
 extremities, 216 
 
 face, 315 
 
 femur, 268 
 gunshot, 174 
 
 fibula, 292 
 
 fingers, 263 
 
 first aid, 224 
 
 foot, 296 
 
 forearm, 253 
 
 gunshot, 166 
 
 hand, 262 
 
 head, 317 
 
 humerus, 225 
 
 immobilization, 221 
 
 intercondylar, 248 
 
 jaw, lower, 324 
 upper, 323 
 
 leg, 286 
 
 lower extremities, 277 
 
 malar, 324 
 
 maxillae, 180, 324 
 
 metacarpus, 262 
 
 nasal bone, 325 
 
 olecranon process, 249 
 
 Fractures, os calcis, 297 
 
 pain, 218 
 
 patella, 280 
 
 pelvis, 313 
 
 Pott's, 292 
 
 prognosis, 217 
 
 radius, 252 
 head, 252 
 lower end, 257 
 
 reduction, 220 
 
 ribs, 311 
 
 scapula, 310 
 
 skull, 315 
 
 compound, 319 
 
 spine, 312 
 
 splints, 223 
 
 supracondylar, 241 
 
 tarsus, 296 
 
 thumb, 263 
 
 tibia, 285 
 
 toes, 298 
 
 treatment, 220 
 
 ulna, 253 
 
 vertebra, 312 
 
 wrist, 262 
 Freezing, 490 
 Frost bite, 491 
 Furuncle of face, 396 
 Fysche, gunshot wound, 209 
 
 Gage, rupture quadriceps extensor, 
 
 466 
 Gangrene, amputation, 744 
 Garrison, emergency operations, 
 Gas bacillus infection, 162 
 Gastric lavage, 14, 16, 596 
 Gastro-enterostomy, 494 
 Gauze, 4 
 
 drainage, 33 
 
 dressings, 35 
 General practitioner as emergency 
 
 surgeon, 1 
 Genito-crural nerve injury, 375 
 Gerster, treatment of peritonitis, 595 
 Gibbon, suture of heart, 511 
 
INDEX 
 
 837 
 
 Gloves, rubber, 10 
 
 Gooch's splint, 48 
 
 Gosset, wounds of nerves, 143 
 
 Granger, burns, 488 
 
 Great toe, amputation, 777 
 
 Groin, bandage, 41 
 
 Groves, gunshot fractures, 169 
 
 Guibal, subphrenic abscess, 430 
 
 Gunshot fractures, 166 
 
 wound of abdomen, 155, 171, 192 
 
 bladder, 156 
 
 blood vessels, 140 
 
 bone, 146 
 
 brain, 150, 166 
 
 cranium, 149, 166 
 
 face, 206 
 
 fascia, 140 
 
 hand, 213 
 
 head, 203 
 
 heart, 155 
 
 intestine, 155 
 
 joints, 148, 179, 211 
 
 kidney, 158 
 
 knee, 180, 211 
 
 liver, 157 
 
 lungs, 153 
 
 muscles, 140 
 
 neck, 184 
 
 nerves, 142 
 
 pancreas, 158 
 
 rectum, 187 
 
 skin, 139 
 
 skull, 148, 180 
 
 solid viscera, 156 
 
 spine, 151, 183, 205 
 
 spleen, 158 
 
 stomach, 156 
 
 tendons, 140 
 
 thorax, 153, 187, 212 
 
 trachea, 185 
 wounds, civil, 202 
 
 effects on tissues, 136 
 
 hemorrhage, 136 
 
 military, 133 
 
 prognosis, 158 
 
 Gunshot wounds, shock, 137 
 
 suicidal, 204 
 
 treatment, 158 
 Gun-splint, 200 
 Guyon, catheterization, 721 
 
 Hand, abscess, 440 
 
 amputations, 761 
 
 bandages, 45 
 
 brushes, 2 
 
 fractures, 262 
 
 gunshot wound, 213 
 
 infections, 440 
 
 injuries, 100 
 
 sterilization, 9 
 Harrington's solution, 10 
 Harsha, torsions, 686 
 Hartmann, splenectomy, 689 
 Haynes, wounds of liver, 564 
 Head wounds, 81 
 
 bandages, 47 
 Heart, gunshot wounds, 154 
 
 massage, 17 
 
 repair, 506 
 
 suture, 511 
 
 wounds, 122 
 Heile, treatment of ileus, 603 
 Hemarthrosis, 148, 179, 213 
 Hematoma, 72 
 Hematuria, 568 
 Hemopericardium, 114 
 Hemopneumothorax, 112 
 Hemoptysis, in 
 Hemorrhage, 57 
 
 acupressure, 61 
 
 adrenalin chloride, 58 
 
 arrest, 60 
 
 arterial, 57 
 
 capillary, 57 
 
 chemicals in, 60 
 
 constitutional effects, 57 
 
 definitions, 57 
 
 diagnosis, 58 
 
 ectopic gestation, rupture, 691 
 
 fatal, 58 
 
8 3 8 
 
 INDEX 
 
 Hemorrhage, first aid, 65 
 
 forcipressure, 62 
 Hemorrhage, heat, 60 
 
 hypodermoclysis, 59 
 
 infusion, intravenous, 59 
 
 intermediary, 57 
 
 internal, 57 
 
 kidney, 557 
 
 laparotomy, 548 
 
 liver, 557 
 
 meningeal, 317 
 
 mesentery, 557 
 
 normal salt solution, 59 
 
 operative, 60 
 
 parenchymatous, 57 
 
 primary, 57 
 
 secondary, 57 
 
 spleen, 557 
 
 spontaneous arrest, 60 
 
 symptoms, 57 
 
 torsion, 62 
 
 tourniquets, 61 
 
 treatment, 58 
 
 tubal pregnancy, 691 
 
 venous, 57 
 Hemorrhoids, operations, 800 
 Hemostasis, 60 
 Hemothorax, in 
 Hennequin's dressing, 227 
 Hernia, appendix, 631 
 
 bladder, 630 
 
 cecum, 629 
 
 encysted, 629 
 
 femoral, 659 
 ' gangrenous, 625 
 
 inguinal, 648 
 
 interstitial, 630 
 
 lumbar, 647 
 
 lung, 113 
 
 obturator, 644 
 
 ovaries, 647 
 
 perineal, 647 
 
 properitoneal, 630 
 
 radical cure, femoral, 659 
 inguinal, 648 
 
 Hernia, radical cure, umbilical, 642 
 vaginal, 647 
 
 sciatic, 647 
 
 septic absorption, 614 
 
 sigmoid, 629 
 
 stomach, 633 
 
 strangulated, 614 
 
 umbilical, 638 
 Hernial sac, anomalies, 629 
 Hernio-laparotomy, 629 
 Hertzfeld, epistaxis, 69 
 Heyvrosky, bullet wound of blood 
 
 vessels, 141 
 Hilton, abscess, 412 
 Hip-joint, arthrotomy, 464 
 
 amputations, 794 
 
 dislocations, 346 
 
 gunshot wounds, 180 
 Hodgen's splint, 278 
 Holliday, splenectomy, 566 
 Humerus, fractures, 225 
 
 anatomical neck, 236 
 
 external condyle, 245 
 
 greater tuberosity, 237 
 
 gunshot, 169 
 
 internal condyle, 246 
 
 lower end, 238 
 
 osteomyelitis, 453 
 
 shaft, 225 
 
 supracondylar, 241 
 
 surgical neck, 232 
 
 upper end, 229 
 in children, 237 
 Hunt, tubal pregnancy, 697 
 Hyde, foreign body in urethra, 483 
 Hydrocele, 812 
 
 radical operation, 813 
 
 tapping, 812 
 Hypodermoclysis, 59 
 Hysterectomy, 697 
 
 Ice, appendicitis, 579 
 Ileus, post-operative, 602 
 Iliac abscess, 434 
 Ilio-inguinal nerve injury, 385 
 
INDEX 
 
 839 
 
 Imperforate anus, 688 
 Incised wounds, 73 
 
 of elbow, 95 
 
 of neck, 88 
 
 of wrist, 92 
 Index finger, amputation, 751 
 Infected wounds, 79 
 Infections, acute, 437 
 Inferior maxilla fracture, 325 
 Infiltration of urine, 738 
 Ingrowing toe-nail, 817 
 Inguinal hernia, anatomy, 648 
 
 radical cure, 648 
 
 strangulated, 614, 619 
 Injuries, abdomen, 125 
 
 hand, 107 
 
 joints, 328 
 
 nerves, 373 
 
 thorax, no 
 Instruments, emergency, 5 
 
 cleansing, 5 
 
 preparation, 7 
 Intercondylar fractures, 248 
 Intercostal artery, hemorrhage, 68 
 Internal mammary artery, 68 
 Interrupted sutures, 29 
 Interstitial hernia, 630 
 
 tubal pregnancy, 695 
 Intestinal anastomosis, 666 
 end to end, 670 
 lateral, 673 
 Murphy button, 672 
 termino-lateral, 676 
 
 obstruction, acute, 593 
 gastric lavage, 596 
 laparotomy, 597 
 rectal enema, 596 ' 
 symptoms, 594 
 treatment, 595 
 
 resection, 667 
 
 rupture, 127 
 Intestines, suture, 559 
 
 wounds, 557 
 Intracranial hemorrhage, 526 
 Intravenous infusion, hemorrhage, 59 
 
 Intravenous infusion, shock, 55 
 
 technic, 59 
 Intussusception, 598 
 
 operation for, 601 
 Iodine, sterilization of the skin, 10 
 Irrigator, 3 
 
 Ischiatic dislocation, 347 
 Ischio-rectal abscess, 416 
 
 Jaw, dislocation, 342 
 
 fracture, 324 
 gunshot, 184 
 Joints, contusions, 358 
 
 dislocations, 328 
 compound, 354 
 
 gunshot wounds, 147, 178 
 
 hemorrhage into, 148, 179 
 
 incised wounds, 359 
 
 injuries, 328 
 
 punctured wounds, 358 
 
 sprains, 298, 359 
 
 stab wounds, 358 
 
 suppurations, 456 
 Jonnesco, spinal anesthesia, 23 
 
 Keen, Cesarean section, 700 
 Kelley, torsions, 683 
 Kidney, abscess, 568 
 
 hemorrhage, 557 
 
 injuries, 568 
 
 removal, 568 
 
 rupture, 568 
 
 wounds, 568 
 Killian, bronchoscopy, 477 
 King, fracture of extremities, 217 
 Knott, suture of liver, 564 
 Kocher, shoulder dislocation, 329 
 Kollman, filiform guide, 719 
 Konig, preparation of the skin, 10 
 Knee, amputation, 791 
 
 arthrotomy, 460 
 
 bandage, 41 
 
 contusions, 348 
 
 crucial ligaments. 361 
 
 dislocations, 350 
 
840 
 
 INDEX 
 
 Knee, gunshot wounds, 148, 179 
 
 puncture, 459 
 
 sprains, 359 
 
 stab wounds, 358 
 
 wounds, 358 
 Kiitner, wounds of lung, 208 
 Kyle, foreign body in nose, 471 
 
 Labium, abscess, 425 
 Lacerated wounds, 77 
 Laceration of brain, 315 
 Lachrymal abscess, 398 
 Lanphear, Cesarean section, 699 
 Laparotomy for Cesarean section, 698 
 
 general technic, 546 
 
 gunshot wounds, civil, 202 
 military, 133 
 
 intestinal obstruction, 695 
 
 for traumatism, 553 
 Laplace, peritonitis, 592 
 Laryngotomy, 500 
 Larynx, foreign bodies, 465 
 
 wounds, 88 
 Lateral anastomosis, intestine, 673 
 
 sinus thrombosis, 539 
 Lavage, gastric, 151, 596 
 Leg, amputations, 788 
 
 bandage, 41 
 
 fractures, 275 
 
 osteomyelitis, 451 
 Legueu, gunshot of bladder, 187 
 Lejars, appendicitis, 579 
 
 preparations for operation, 7 
 
 reduction of shoulder, 329 
 thumb, 345 
 
 rupture of the lung, 115 
 
 splint for leg, 288 
 Lembert suture, 560 
 Lichtenstern, torsion, 689 
 Ligation, 62 
 Ligation en masse, 63 
 Ligations, anterior tibial, 741 
 
 arterial, principles, 733 
 
 axillary, 738 
 
 brachial, 738 
 
 Ligations, common carotid, 735 
 
 dorsalis pedis, 742 
 
 external carotid, 736 
 
 facial, 736 
 
 femoral, 740 
 
 lingual, 736 
 
 occipital, 736 
 
 posterior tibial, 742 
 
 radial, 739 
 
 subclavian, 736 
 
 superior- thyroid, 736 
 
 ulnar, 740 
 Lingual artery, ligation, 736 
 Link, tracheotomy, 498 
 Lipomas, removal, 817 
 Lips, wounds, 85 
 Little-finger amputation, 751 
 Little toe amputations, 778 
 Liver, hemorrhage, 557 
 
 injuries, 562 
 
 suture, 563 
 Local anesthesia, 18 
 Lower extremity, fractures, 267 
 Lower jaw, dislocation, 352 
 Lowery, compound fracture, 301 
 Luckett, Fourth-of-July injuries, 21 = 
 Ludlow, wounds, diaphragm, 121 
 Ludvvig's angina, 402 
 Lung, abscess, 518 
 
 gunshot wounds, 153 
 
 hernia, 113, 118 
 
 rupture, 116 
 
 stab wounds, 116 
 
 suture, 506 
 
 Malaleuca sempervirens, 717 
 Malar bone fracture, 324 
 Mammary gland abscess, 309 
 Manchet, repair of nerves, 143 
 Marsee, fracture of fingers, 24 
 
 injuries to hand, 102 
 
 suture of tendons, 371 
 Martin, Cesarean section, 200 
 Mastoiditis, 538 
 Mastoid operation, 539 
 
INDEX 
 
 841 
 
 Materials for sutures, 25 
 Maxilla, fractures, 324 
 Mayo, umbilical hernia, 646 
 Mayor's sling, 309 
 Meatus, foreign bodies, 468 
 Median nerve exposure, 378 
 
 injury, 377 
 Meningeal hemorrhage, 323 
 Mesentery, hemorrhage, 566 
 
 repair, 557 
 Metacarpals, amputations, 759 
 
 fracture 262 
 Metal splints, 50 
 
 McEwen, strangulated hernia, 633 
 McFarland, antitetanic powder, 215 
 McGrath, appendicitis, 586 
 Middle-finger amputation, 749 * 
 Middle meningeal artery, hemor- 
 rhage, 323 
 Miller, kidney, injury, 569 
 Miller, pelvic abscess, 430 
 Mitchell, peritonitis, 590 
 Morley, bandage for eye, 47 
 Morris, appendicitis, 574 
 Morrison, wounds of eye, 89 
 Morrison, wound infections, 164 
 Mosetig-Moorhof bone wax, 450 
 Mothe, dislocation of shoulder, 333 
 Motor-oculi nerve injury, 376 
 Mouth burns, 488 
 
 Moynihan, intestinal anastomosis, 
 666 
 
 purulent peritonitis, 689 
 Miiller, gunshot of brain, 183 
 Murphy, anesthesia, 24 
 Murphy button, 672 
 
 purulent peritonitis, 690 
 
 suture of arteries, 733 
 olecranon, 251 
 Musculo-cutaneous nerve, 387 
 Musculo-spiral nerve exposure, 387 
 
 injury, 386 
 
 Nares, plugging, 68 
 Nasal bone, fracture, 325 
 
 Nasal septum, abscess, 397 
 Nassau, esophagotomy, 503 
 Nausea, anesthesia, 17 
 'Neck, bandage, 45 
 Neck wounds, 86 
 
 gunshot, 184 
 Nefl, rupture of urethra, 704 
 Nelaton's line, 267 
 Nephrectomy, 579 
 Nerve, compression, 374 
 
 contusion, 374 
 
 grafting, 375 
 
 suturing, 373 
 
 wounds, 374 
 gunshot, 142 
 Nerves, individual, 375 
 
 abducens, 376 
 
 anterior crural, 383 
 
 auditory, 376 
 
 circumflex, 382 
 
 facial, 375 
 
 fifth, 376 
 
 genito-crural, 385 
 
 ilio -inguinal, 385 
 
 laryngeal, 376 
 
 median, 377 
 
 motor-oculi, 376 
 
 musculo-cutaneous, 387 
 
 musculo-spiral, 381 
 
 obturator, 384 
 
 optic, 376 
 
 peroneal, 386 
 
 phrenic, 376 
 
 pneumogastric, 376 
 
 popliteal, 386 
 
 radial, 381 
 
 recurrent laryngeal, 376 
 
 sciatic, 385 
 
 tibial anterior, 387 
 posterior, 388 
 
 trifacial, 377 
 
 ulnar, 378 
 Noetzel, wounds of spleen, 567 
 Nose, foreign bodies, 470 
 
 hemorrhage, 68 
 
842 
 
 INDEX 
 
 ruction of bowel, 593 
 Obturator artery ligation, 38 4 
 
 dislocation, 349 
 Obturator hernia, strangulated, 644 
 
 nerve, 374 
 Occipital artery ligation, 736 
 (Edema of the glottis, 499 
 (Esophagotomy, 500 
 
 /hagus, foreign bodies, 471 
 
 injuries, 87 
 Ointment of Reclus, 487 
 Olecranon, fracture, 249 
 Oliver, strangulated hernia, 633 
 
 jaw fracture, 326 
 Omentum, hemorrhage, 555 
 
 resection, 661 
 
 torsion, 690 
 Open wounds of thorax, 115 
 Operation in private houses, 6 
 Operative hemorrhage, 64 
 
 wounds, 75 
 Opium, appendicitis, 579 
 Optic nerve injury, 376 
 Os calcis, PirogofFs amputation, 785 
 
 fracture, 297 
 Oschner, appendicitis, 680 
 
 femoral hernia, 661 
 
 torsion, 686 
 Osteomyelitis, acute, 448 
 
 femur, 455 
 
 humerus, 453 
 
 tibia, 451 
 Ovarian cysts, torsion of pedicle, 683 
 
 Pagenstecher, linen, 25 
 Palmar abscess, 414 
 
 arches, 66 
 Panaris, 438 
 Pancreas, gunshot wounds, 158 
 
 injuries, 565 
 
 suture, 565 
 Pannett, shell wounds, 19O 
 Pantzer, appendicitis, 575 
 Paracentesis, ear-drum, 539 
 
 pericardium, 514 
 
 Paracentesis, pleura, 520 
 Paraphimosis, 806 
 Parotid gland abscess, 398 
 Patella, dislocation, 352 
 
 fracture, 280 
 
 wiring, 282 
 Peck, wounds of heart, 513 
 Pedicles, ligation, 683 
 Pelvic abscess, 427 
 Pelvis, fractures, 313 
 Penis, injuries, 106 
 Perborate of soda, epistaxis, 70 
 Peri-anal abscess, 419 
 Pericardiotomy, 516 
 Pericardium, paracentesis, 514 
 
 puncture, 514 
 
 suture, 506 
 
 wounds, 122 
 Perineal abscess, 420 
 
 bruises, 730 
 
 section, 731 
 Peritonitis, purulent, 792 
 
 treatment, 593 
 
 typhoid, 592 
 
 septic, 592 
 Peroneal nerve, 386 
 
 tendons, dislocation, 363 
 PfafT, appendicitis, 578 
 
 tubal pregnancy, 695 
 Phalanges, fractures, 263 
 Pharynx, foreign bodies, 471 
 Phimosis, wounds, 89 
 Phlegmon, 437 
 
 arm, 445 
 
 fingers, 440 
 
 forearm, 443 
 
 neck, 445 
 
 perineum, 730 
 
 tendon sheaths, 440 
 Phrenic nerve, 376 
 Picric acid, burns, 487 
 Piles operation, 800 
 Pinna, wounds, 84 
 Pirogoff 's amputation, 785 
 Plantar abscess, 416 
 
INDEX 
 
 843 
 
 Plaster-of- Paris bandages, 49 
 
 Bavarian, 51 
 
 preservation, 4 
 Plaster-of-Paris splints, 50 
 Pleura, empyema, 525 
 
 incision, 525 
 
 puncture, 520 
 
 wounds, 116 
 Pneumogastric nerve, 376 
 Pneumothorax, 112 
 Poisoned wounds, 71 
 Popliteal abscess, 414 
 
 artery compression, 67 
 Porter, treatment of wounds, 78 
 Posterior nares, plugging, 69 
 
 tibial artery, 741 
 nerve, 388 
 Post-operative ileus, 602 
 Potain's aspirator, 520 
 Pott's fracture, 292 
 Precordial wounds, 122 
 Pregnancy, extra-uterine, 690 
 Preparation, emergency opera- 
 tions, 8 
 
 hands, 9 
 
 skin, 8 
 Primary hemorrhage, 57 
 Probang, foreign bodies, 474 
 Preperitoneal hernia, 630 
 Prostatic abscess, 620 
 Psoas abscess, 624 
 Pulse, abdominal injury, 126 
 
 appendicitis, 575 
 
 chloroform anesthesia, 13 
 
 ether anesthesia, 15 
 
 hemorrhage, 58 
 
 shock, 53 
 Puncture, bladder, 723 
 
 knee-joint, 461 
 
 pericardium, 514 
 
 pleura, 520 
 
 scrotum, 712 
 Punctured wounds, 76 
 Purulent pericarditis, 516 
 
 pleurisy, 518 
 
 Quadriceps extensor tendon, rup- 
 ture, 354 
 Quenu, preparation of room, 8 
 Quinsy, 404 
 
 Radial artery, compression, 67 
 ligation, 739 
 
 synovial sheath drainage, 440 
 Radius, fractures, 253 
 
 gunshot, 160 
 • head, 252 
 
 lower end, 257 
 
 neck, 252 
 
 shaft, 254 
 Ranzi, torsions, 684 
 Reclus, lacerated wounds, 100 
 
 ointment, 487 
 Rectal injections, 597 
 Rectum, abscess, 419 
 
 dilatation, 799 
 
 foreign bodies, 478 
 
 hemorrhoids, 800 
 
 wounds, 108 
 Recurrent laryngeal nerve, 376 
 Reduction "en masse," 618 
 
 dislocations, 329 
 
 fractures, 220 
 
 hernia, 617 
 Removal of small tumors, 820 
 Resection of bowel, 667 
 Respiratory paralysis, 14, 15 
 Responsibility of general practi- 
 tioner, 2 
 Retention of urine, 714 
 Retropharyngeal abscess, 405 
 Reverdin, skin grafting, 823 
 Reynolds, Cesarean section, 700 
 Ribs, fracture, 211 
 
 resection, 520 
 Rinchea, torsions, 790 
 Ring-ringer amputation, 749 
 Robinson, shock, 56 
 Romer, fracture, clavicle, 308 
 Rongeur forceps, 527 
 Rossi, fractures, 221 
 
8 4 4 
 
 INDEX 
 
 Rosving, appendicitis, 574 
 Rotter, gunshot of abdomen, 185 
 Royster, fracture of humerus, 245 
 Rubber gloves, 10 
 Rugine, 522 
 
 Rupture, tubal pregnancy, 691 
 urethra, 702 
 
 Saber splint, 184 
 
 Sacro-iliac synchondrosis, 314 
 
 Saline solution in hemorrhage, 55 
 
 sepsis, 590 
 Sayres' dressing, 307 
 Scalds, 484 
 Scalp, abscesses, 395 
 
 arteries, 66 
 
 contusion, 81 
 
 hematoma, 319 
 
 wounds, 81 
 Scapula, amputations, 765 
 
 fracture, 310 
 Schaute, Cesarean section, 701 
 Schleich's formulae, 20 
 Sciatic nerve injury, 385 
 Sclerotic wounds. 90 
 Scrotum, injuries, 106 
 Scudder, fracture of leg, 288 
 Sebaceous cysts, removal, 820 
 Secondary hemorrhage, 57 
 Semilunar cartilages, dislocation, 
 
 351 
 Seminal ducts, abscess, 424 
 Senn, first aid on battlefield, 185 
 
 fracture of femur, 270 
 
 hip-joint amputation, 795 
 
 intussusception, 600 
 Septic arthritis, 456 
 Septum nasi abscess, 397 
 Shaving skin, 8 
 Shell wounds, 188 
 Shock, 52 
 
 diagnosis, 53 
 
 treatment, 54 
 Shoulder amputation, 765 
 
 arthrotomy, 464 
 
 Shoulder bandage, 45 
 
 dislocations, 338 
 
 fractures, 229 
 shells, 188 
 Shrapnel wounds, 188 
 Silk sutures, 25 
 Silkworm sutures, 26 
 Simons, crushing wounds, 99 
 Skin grafting, 823 
 
 preparation, 10 
 Skull, bullet wounds, 149, 180 
 
 fracture, base, 315 
 compound, 319 
 vault, 307 
 
 trephining, 526 
 Spence, shoulder amputation, 770 
 Spermatic cord, ligation, 816 
 
 torsion, 687 
 
 vasectomy, 424 
 Spica for breast, 44 
 
 foot, 39 
 
 groin, 41 
 
 shoulder, 45 
 Spinal anesthesia, 22 
 
 cord injuries, 3 
 Spine, fractures, 212 
 
 gunshot wounds, 151, 185 
 
 wounds, 104 
 Spleen, hemorrhage, 565 
 
 injuries, 565 
 
 removal, 566 
 
 rupture, 566 
 
 torsion, 631 
 Splenectomy, 566 
 Splint, Bavarian, 51 
 
 Dupuytren's, 293 
 
 first aid, 196 
 
 Hodgen's, 278 
 Splints, 48 
 . cradle, 170 
 
 Dutch cane, 48 
 
 Gooch's, 48 
 
 metal, 49 
 
 plaster-of-Paris, 50 
 
 silicate of potash, 48 
 
INDEX 
 
 845 
 
 Splints, trough, 170 
 
 wire gauze, 49 
 
 wooden, 48 
 Sprains, 359 
 St. Andrew's cross, 44 
 Stab wounds, 76 
 
 abdomen, 129 
 
 heart, 441 
 
 knee, 358 
 
 thigh, 95 
 
 thorax, no 
 Sterilization, dressing, 7 
 
 hands, 9 
 
 instruments, 8 
 
 skin, 10 
 Stevenson, gunshot of abdomen, 186 
 Stimson, pain in fracture, 218 
 Stomach, hemorrhage, 152 
 
 hernia, 633 
 
 suture, 562 
 
 wounds, -562 
 Stewart, suture of heart, 512 
 Stovaine, spinal anesthesia, 22 
 Strangulated hernia, 614 
 
 complications, 628 
 
 diagnosis, 615 
 
 femoral, 633 
 
 inguinal, 619 
 
 obturator, 644 
 
 operation, 619 
 
 taxis, 616 
 
 umbilical, 638 
 Stricture of urethra, 710 
 Stump bandage, 48 
 Subclavian artery, compression, 66 
 
 ligation, 736 
 Subclavicular dislocation, 332 
 Subcoracoid dislocation, 328 
 Subcutaneous wounds, 72 
 Subcuticular suture, 30 
 Subglenoid dislocation, 338 
 Submammary abscess, 411 
 Submaxillary abscess, 411 
 Subphrenic abscess, 430 
 Subpubic dislocation, 348 
 
 Subspinous dislocation, 340 
 Suicide, attempts, 202 
 Superior maxilla fracture, 324 
 
 thyroid artery ligation, 736 
 Suprapubic cystotomy, 711 
 
 puncture, 713 
 Surgical dressings, 35 
 Suture of arteries, 733 
 
 bladder, 571 
 
 heart, 511 
 
 intestine, 559 
 
 liver, 563 
 
 lung, 506 
 
 nerves, 373 
 
 pancreas, 565 
 
 tendons, 369 
 
 ureter, 573 
 
 wounds, 25 
 Sutures, catgut, 26 
 
 continuous, 27 
 
 horsehair, 25 
 
 interrupted, 29 
 
 Lembert, 560 
 
 linen, 25 
 
 methods and materials, 25 
 
 Pagenstecher linen, 26 
 
 quilted, 25 
 
 sero-serous, 559 
 
 silk, 25 
 
 silkworm-gut, 26 
 
 subcuticular, 30 
 Syme's amputation, 786 
 Symonds, infections, 163 
 Syncope, 58 
 Synovial sheath suppurations, 440 
 
 cysts, 822 
 
 Tampon for intercostal hemor- 
 rhage, 68 
 Tapping, hydrocele, 812 
 Tarso-metatarsal, amputation, 783 
 Tarsus, dislocations, 352 
 
 fracture, 296 
 Taxis, indications, 616 
 
 technic femoral hernia, 619 
 
8 4 6 
 
 INDEX 
 
 Taxis, technic, inguinal hernia, 617 
 
 umbilical, 549, 619 
 Taylor, empyema, 518 
 
 fracture of humerus, 237 
 Temporal artery compression, 66 
 Temporo-maxillary joint disloca- 
 tion, 342 
 Tendon, dislocations, 363 
 
 divided, 367 
 
 rupture, 363 
 
 suture, 369 
 
 wounds, 363 
 Testis, removal, 814 
 
 suture, 107 
 
 wounds, 107 
 Tetanus, bolo wounds, 190 
 
 Fourth-of-July injuries, 215 
 
 prophylaxis, 215 
 
 punctured wounds, 76 
 Thiersch, skin grafting, 824 
 Thigh, amputations, 793 
 
 wounds, 95 
 Thoracotomy, indications, 504 
 
 technic, 504 
 
 gunshot wounds, 187 
 Thorax, injuries, no 
 
 open wounds, 116 
 Throat, cut, 86 
 Thrombosis, lateral sinus, 539 
 Thumb, amputations, 754 
 
 bandage, 45 
 
 dislocations, 345 
 
 fracture, 263 
 Tibia, fractures, 286 
 
 osteomyelitis, 451 
 
 trephining, 455 
 Tibial arteries, ligation, 741 
 
 compression, 67 
 Tillaux's dressing, 274 
 Toe-nail, ingrowing, 817 
 Toes, amputation, 777 
 Tongue, abscess, 304 
 
 suture, 85 
 
 wounds, 85 
 Tongue-traction, asphyxia, 16 
 
 Tonsil, abscess, 304 
 Torsion, arteries, 62 
 
 diagnosis, 683 
 
 omentum, 690 
 
 pedicle ovarian cysts, 683 
 spleen, 689 
 
 spermatic cord, 687 
 
 uterus, 685 
 Townsend, catheterization, 715 
 Toy-pistol wound, 214 
 Trachea, foreign bodies, 475 
 
 gunshot wounds, 185 
 
 incised wounds, 88 
 Tracheotomy, after-treatment, 495 
 
 foreign bodies, 497 
 
 indications, 493 
 
 operations, 493 
 
 tubes, 493 
 Transfixion apparatus, 170 
 Travers, suture of the heart, 512 
 Trephine, Doyen, 530 
 
 Gait, 530 
 Trephining, femur, 454 
 
 fracture of skull, 526 
 
 gunshot wounds, 536 
 
 humerus, 453 
 
 tibia, 451 
 Treves, stangulated hernia, 624 
 Trunk injuries, no 
 Tubal pregnancy, diagnosis, 691 
 
 operation, 693 
 
 rupture, 691 
 Tubercular abscess, 395 
 Tuffier, chest wounds, 154 
 Tumors, superficial, 820 
 Tunica vaginalis, resection, 813 
 Turpentine burns, 487 
 Tuttle, imperforate anus, 682 
 Typhoid perforation, 593 
 
 Ulna, fractures, 253 
 Ulnar artery, ligation, 740 
 nerve exposure, 378 
 
 injury, 378 
 
 synovial sheath, 440 
 
INDEX 
 
 847 
 
 Umbilical hernia, strangulated, 638 
 
 radical cure, 566, 643 
 Ureter, repair, 573 
 
 wounds, 573 
 Urethra, anatomy, 704 
 catheterization, 711 
 contusions, 705 
 Urethra, foreign bodies, 481 
 
 rupture bulbous portion, 706 
 diagnosis, 703 
 membranous portion, 712 
 pendulous portion, 713 
 symptoms, 704 
 treatment, 706 
 Urethral forceps, 481 
 Urethrotomy, 707 
 Urgent craniectomy, 526 
 
 thoracotomy, 504 
 Urinary abscess, 728 
 Urine, extravasation, 728 
 
 retention, 714 
 Uterus, torsions, 685 
 
 Vagina, abscess, 426 
 injuries, 105 
 
 Vagus nerve, 376 
 
 Valentine, emergency catheteriza- 
 tion, 715 
 
 Van der Walker, emergency sur- 
 gery, 6 
 
 Van Hook's anastomosis, 572 
 
 Vasectomy, 424 
 
 Vaughn, wounds of heart, 124 
 
 Vault of skull fracture, 317 
 compound, 319 
 
 Veins of liver, ligation, 563 
 
 Velpeau's bandage, 306 
 
 Venous hemorrhage, 57 
 
 Vincent, trephining, 534 
 
 Vineberg, tubal pregnancy, 692 
 j Vertebrae, fractures, 312 
 I Viscera, abdominal, rupture, 126 
 ' Volvulus, 595 
 
 j Von Bergman, gunshot wounds, 149 
 1 Vulva, wounds, 105 
 
 Vulvar abscess, 425 
 Vulvo-vaginal abscess, 426 
 injuries, 105 
 
 Wagner, heart injuries, 124 
 Waite, shock, 52 
 Walker, fractures of femur, 271 
 Warbasse, treatment of fracture, 
 
 221 
 Wathen, wounds of liver, 563 
 Westmoreland, tracheotomy, 494 
 Whitehorne-Cole, gunshot wounds of 
 
 brain, 150 - 
 
 Whitman, fracture of femur, 271 
 Wick drains, 33 
 Wire gauze splints, 49 
 Wiring fractured fingers, 265 
 
 olecranon, 249 
 
 patella, 282 
 Wooden splints, 48 
 
 trough splint, 170 
 Wounds, abdomen, 128 
 
 aseptic, 74 
 
 base of thorax, 119 
 
 bend of elbow, 95 
 
 bladder, 570 
 
 blank cartridge, 215 
 
 bolo, 173 
 
 chest, no 
 
 cleansing, 79 
 
 contused, 72 
 
 definitions, 71 
 
 diaphragm, 122 
 
 drainage, 93 
 
 dressings, 78 
 
 elbow, 94 
 
 esophagus, 89 
 
 extremities, 92 
 
 eye, 89 
 
 eyelids, 85 
 
 face, 84 
 
 femoral artery, 95 
 
 fingers, 101 
 
 general principles, 71 
 
 gunshot, civil, 200 
 
848 
 
 INDEX 
 
 Wounds, gunshot, military, 133 
 hand, 102 
 head, 81 
 heart, 122 
 hemorrhage, 73 
 incised, 73 
 infected, 79 
 intestine, 559 
 kidney, 568 
 lacerated, 76 
 larynx, 88 
 lips, 84 
 liver, 562 
 lung, 116 
 neck, 86 
 open, 71 
 operative, 75 
 pancreas, 565 
 penis, 106 
 pericardium, 122 
 pharynx, 89 
 pinna, 84 
 pleura, 116 
 precordial, 122 
 punctured, 76 
 rectum, 108 
 scalp, 81 
 scrotum, 106 
 shell, 188 
 
 Wounds, special regions, 81 
 
 spine, 104 
 
 spleen, 565 
 
 stab, 76 
 
 stomach, 662 
 
 subcutaneous, 72 
 
 suture, 26 
 
 symptoms, 72 
 
 testicle, 107 
 
 thigh, 95 
 
 thorax, no 
 
 tongue, 85 
 
 toy pistols, 215 
 
 trachea, 88 
 
 treatment, 70 
 
 trunk, no 
 
 ureter, 572 
 
 vagina, 105 
 
 vulva, 105 
 
 wrist, 92 
 Wrist, arthrotomy, 464 
 
 dislocation, 356 
 
 fractures, 262 
 
 wounds, 92 
 
 X-ray, foreign bodies, 473 
 fractures, 219 
 
 Zone of anesthesia, 19 
 
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