Chapter XVIII

.)

Under modern methods more is expected of an amputation stump than in days gone by, and the first demand is that it shall be _useful_, to which end it is necessary that it be both movable and that its end be not too irritable, nor the scar too sensitive to stand at least a certain amount of pressure. It is expected that suitable prosthetic apparatus, _i. e._ artificial limbs, shall take the place of severed lower extremities and of most arms or hands removed. The skill and the mechanical ingenuity of the maker of artificial limbs have now reached a point where most acceptable substitutes are thus provided, but for them suitable stumps should be afforded by the surgeon, and there should be coöperation from each direction. Thus it used to be held that the bone end in every stump should be covered with periosteum, yet it has been recently shown, especially by Hirsch, that such bone ends are as acceptable, and perhaps more so, when stripped of rather than covered with this membrane, the latter being sensitive, and there being no advantage in the presence of such new bone as may be formed by its preservation.

Many a good stump may be molded in various ways, but always provided that the end of the bone be smoothly divided, and have no corners or osteophytic outgrowths to make pressure upon the sensitive scar. For this reason it should be manipulated as early as possible, and should not be allowed to undergo the atrophy noticeable in stumps left after old operations. If primary union be gained, so long as the cicatrix and the nerve ends be kept out of the way, one may expect a stump which is serviceable in every respect. The ideal method is that the skin and the periosteum should retain their normal relationship, an ideal best attained in the supracondyloid operation after Gritti’s method. Various osteoplastic methods have been devised, first by Walther, in 1813, and since him especially by Ollier, Pirogoff, Gritti, and Bier. The latter would cover every bone end not merely with periosteum, but with a bone flap so arranged that its lower surface is one normally covered by periosteum. The introduction of the _x_-rays has permitted a more thorough study of bone ends in stumps which are, on one hand, extremely tender, or, on the other, extremely serviceable, and the osteoplastic methods seem to conduce to the latter condition. Another matter of great importance is to so _place the scar that it shall be neither subject to pressure nor to traction_. If, therefore, the sawed surfaces be covered with a periosteum which shall retain its normal relation to its coverings, a minimum of disturbance in the scar is the result.

The value of early use of the stump and of accustoming it to pressure is considerable, as atrophic stumps are tender, like other disused parts, and there is, therefore, every reason for resorting to prosthetic apparatus as early as possible. As Kocher puts it, the following is the best procedure for the normal operation: “An oblique incision, combined if necessary with a longitudinal one, in the form of a racket or lanceolate incision through skin and fascia. After retracting the elastic skin the muscles are divided obliquely down to the bone. The periosteum is also to be divided obliquely. Periosteum is then separated along with the superficial layer of the cortex of the bone, by means of a sharp raspatory or chisel, or, when possible, a flap of bone having a movable periosteal hinge is made by means of the saw. Lastly, if only a thin shell of the cortex have been raised up along with the periosteum, the end of the bone is simply rounded off, while if a distinct flap of bone, by any osteoplastic method, have been divided, the end of the bone must be sawed in a curved direction so as to fit it. The periosteal or bony flap is sutured over the sawed surface of the bone to its periosteum, and the stumps of the muscles or tendons are sutured to each other, or to the surface of the bone at a distance from the sawed surface. Finally the skin and fascia are sutured; but in case where a periosteal flap or flap of bone and periosteum cannot be obtained in normal relation to other soft parts it is better to remove the periosteum entirely from the end of the stump, to scrape out the medullary cavity, and to round off edges of the bone as dentists do.”

While these methods give better results than those formerly in vogue, they also consume more time; but the days of brilliancy and rapidity in amputation are past, as time should be devoted to careful work, except only in those cases where emergency demands the most rapid and dexterous removal of a limb in the shortest possible time, and where every other consideration is sacrificed to the principal interest of preserving life.[75]

[75] The following is taken from the article of Professor Matas in the third edition of “Surgery by American Authors.” It furnishes a brief but admirable introduction to the general study of amputation methods:

“From Hippocrates to the time of Celsus the surgeon simply followed in the wake of Nature, never venturing to apply the knife for the removal of a limb except within the limits of the mortified tissues; and this seems to have prevailed for at least four hundred years. Celsus, the prince of Roman physicians, who lived shortly after the time of Christ, introduced the first innovation by cutting down to the bone between the living and the dead tissues. It is probable, according to the evidence furnished by his writings, that he was aware of the value of the ligature and that he applied it to control bleeding vessels. Archigenes, following closely after Celsus, was the first to attempt prophylactic hemostasis by applying a cord or band around the limb to control the hemorrhage during the amputation. With the fall of the Roman empire and the advent of the long night of the middle ages the Celsian method was lost in the general darkness and the old Hippocratic doctrines survived, and were maintained by the all-potent influence of Galen and his Arabian commentators. As late as the middle of the seventeenth century the only hemostatic was the actual cautery and boiling oil, though Guy de Chauliac had revived the teaching of Archigenes by constricting the limb, on a level with a joint, with a cord which was allowed to remain in situ, to ensure not only hemostasis, but a certain mortification of the stump. In cutting limbs huge chisels and mallets were used. At this period Botalli invented his guillotine, consisting of a sharp, heavy, axe, which, being allowed to fall from a height upon the limb, severed it instantaneously at a single blow. The revived or independent rediscovery of the ligature by Ambrose Paré in 1579, and the discovery of the circulation of the blood by Harvey, in 1628, led to the invention of Morel’s tourniquet (1674), more commonly known as the Spanish windlass, and to the familiar instrument, Pettit’s tourniquet, which (introduced in 1718) perfected the means of securing prophylactic and direct hemostasis. From this time onward the treatment of the stump began to receive more systematic attention. Instead of merely chopping off a limb, the soft parts were detached from the bone, so that this could be sawed off at a higher level, in order to avoid the conical projection of the stump which invariably resulted when the primitive methods were adopted. All the methods of amputation that followed--and these were numerous--aimed chiefly at celerity, to reduce the pain of the operation to a minimum; hence the rapid, circular section of the soft parts or the rapid transfixion methods which were so much popularized by the brilliant work of Liston, Lisfranc, Desault, Dupuytren, Langenbeck, and others. These finally yielded, in this modern period, to less rapid but more conservative and perfected methods, which aim chiefly at the preservation of useful tissue and at securing the very best functional prosthetic stump for the patient. Such methods could only be perfected after the advent of anesthesia and antisepsis.”

AMPUTATION METHODS.

With a view to simplifying this subject as much as possible the following methods alone will be considered: (1) The _circular_ with its modifications, the _oblique_, the _elliptical_, the _ovoid_, etc.; (2) the _flap method_; (3) the _mixed or skin flap and deep circular_.

Choice of method sometimes leaves much, sometimes nothing, to the tastes or wishes of the operator. It should be based solely on the primary consideration of saving life and the secondary consideration of furnishing the most useful possible stump. To obtain the latter it is necessary that the bone be amply covered, except that its coverings be not adherent, that there be a minimum of disturbance of blood supply, that nerves be drawn down and divided as far from the stump end as possible, in order that they may not be entangled in the scar, and that the scar be so planned for and arranged that it shall be _at one side_, at all events in such position that no pressure shall be made upon it, and, if possible, also no tension by muscle action.

Elasticity of skin and contractility of the muscles vary much in different individuals, and it is not always easy to estimate either of them previous to their division. Consequently it is much better to make cuffs or flaps too long at first rather than too short. The existence of previous disease will always modify these local conditions, but, in general, the rule is laid down that the external flaps should be longer than the bone by from one-third to one-half the diameter of the limb.

1. =Circular Method.=--The simple circular method is the simplest and easiest of all. It may be so performed as to furnish a solid musculotegumentary division, or skin cuffs may be made, which being turned up, permit a further circular division of the muscles and other tissues directly down to the bone. The former is preferable when possible. With an ordinarily long amputating knife the skin, down to and including the superficial fascia, is divided by one clean circular incision, made in one stroke; then by further circular cuts the muscles are divided in sections, the outer group being allowed to retract and expose the deeper layers, which are then divided at a higher plane. In this way the periosteum is reached. If sufficient time be afforded it may be circularly divided at the level of the last incision through the muscles, and then separated with a strong elevator or, as done by Kocher, with a chisel, in order that some portion of the exterior of the bone be raised with it. In this way a cuff of periosteum, or enough of it to cover the bone end, is detached upward, to the level where the bone itself is finally divided. The bone division is done with the ordinary amputating saw, or with the wire or chain saw.

The _skin-cuff_ (Manchette) method differs in that the exterior flap is made wholly of skin, which is dissected as a cuff nearly up to the level of bone section, at which point the muscles are divided directly down to the bone. In this method the skin, fat, and superficial fascia should be raised together, and at no points separated from each other.

Modification of the cuff method, by which it is more easy to evert the circular flap, is made by one or two _vertical incisions_, by which the cuff is split some distance on one or both sides, thus transforming the cuff proper into two nearly square skin flaps. At other times the first method may be similarly modified, in which case we have to deal with two square flaps, including not only the skin, but all the tissues down to the bone.

Neudörfer still further modified the circular method for certain purposes by first making an incision along the outer or least vascular part of the limb, carrying the knife directly down to the bone, retracting the wound edges, and thus exposing the bone, which is then divided with a chain or Gigli saw. After the bone is divided the soft coverings are lifted to a sufficient distance below the saw line to ensure ample covering, then divided as above. The method is a slow one and is especially serviceable for amputation of the thigh, at its middle, for diabetic or senile gangrene, where it is so desirable to protect vascular supply from injury (Fig. 677).

The so-called _elliptical method_ is practically a circular incision carried obliquely around the limb, the upper and lower ends of the ellipse being indicated by previous small incisions at the proper height. The skin and superficial fascia are retracted from the lower portion of the ellipse by turning them up to the level of the highest point, at which level the muscles are divided transversely by a plain circular incision. A modification of this method is the so-called _ovoid_ or _racket_, which is simply an oval division with a pointed end, the margins of the flap being united in the long axis of the bone. This method is frequently applied in amputation of the fingers. (See Fig. 683.)

2. =Flap Methods.=--Flaps are either _cutaneous_ or _musculocutaneous_. In every case the skin surface must be larger than the muscular. They are objectionable in that the skin flap is apt to slough, although least so about joints. The flap method is advantageous in that one flap may usually be made much longer than the other, and the longer one so doubled over at its end as to place the scar out of harm’s way. In certain injuries where the skin is much more injured on one side of the limb than on the other the operator is compelled to resort to flaps, unless he divide the limb much higher than might otherwise be demanded. Double flaps may be _anteroposterior_ or _lateral_. A double flap practically results from a circular incision, carried through to the bone, with lateral division on either side, while a double flap with one long member may be similarly furnished by an oblique circular incision with the lateral prolongations.

[Illustration: FIG. 677

Neudörfer’s method of amputation by primary division of the bone, before shaping the flaps. Neudörfer used the chisel, but one may use the Gigli saw with special advantage in performing this operation. The method is applicable to any portion of the upper or lower extremity, especially in the continuity of the long bones. (Matas.)]

Flaps may be formed by _transfixion_, for which purpose a long, sharp, amputating knife is required. Inasmuch as it makes an oblique and irregular division of the principal vessels, which are in consequence more difficult to secure, and by which nutrition of flaps is endangered, it is not to be commended, save perhaps in certain amputations about the wrist. A better method of making the flap is to divide the skin and fascia with an ordinary stout scalpel, and then, permitting them to retract, to divide the muscles obliquely toward the bone in such a way as to leave a flap wedge-shaped at its base. The anteroposterior amputations of the foot, thigh, and arm are better performed in this way, each flap being in length preferably three-fourths the diameter of the limb. (Matas.) An extension of this method furnishes the possibility for various subperiosteal amputations to be described below.

The _osteoplastic methods_ of today furnish desirable operative procedures. One of the earliest of the good ones was Teale’s method, as applied to the leg, of double quadrangular flaps, the anterior being much the longer. A minor degree of this work includes simply the preservation of a cuff of periosteum, which is supposed to afford protection to the marrow cavity and a smoothly rounded bone end, without adhesions to the overlying soft parts; but much more complete operations are afforded by Pirogoff’s amputation at the heel, and by Wladimiroff and Mikulicz’s amputation of the foot (practically an exsection of the heel), or by Gritti’s and the other methods of supracondyloid knee amputation, with preservation of the patella. Bier and other foreign and domestic surgeons have also devised methods of reflecting or raising bone flaps from the continuity of bone shafts, which, being still connected by periosteal bridges, are so turned and fastened in place as to furnish a complete bone end over the stump (Figs. 678 and 679).

The choice of method must depend, to a large extent, on the character of the case. Some injuries will leave parts so exposed that a portion of a limb can still be utilized if only flaps be cut in an atypical way. One need never hesitate to resort to these, especially about the hand and upper extremity, where it is so desirable to save every inch of tissue. It is not necessary to preserve every possible inch of tissue in the foot and leg, as the makers of artificial limbs can adapt an artificial leg to any kind of a stump. The intent in making these statements is that while it is best to follow conventional methods under ordinary circumstances, there need be no hesitation in departing from them when occasion demands it.

[Illustration: FIG. 678

Bier’s osteoplastic amputation of the leg (procedure advocated by Bier in 1897 and 1899): _F_, long anterior flap reflected on the tibia; _A_, cross-section of tibia; _B_, periosteal flap after excision of intervening section of bone; _C_, osteoperiosteal flap; _D_, projecting border of periosteum to be sutured to tibial periosteum.]

[Illustration: FIG. 679

Bier’s osteoplastic amputation of the leg, with osteoperiosteal flap in position.]

It is essential in caring for every stump, after the actual amputation has been performed, (1) that _bleeding_ be absolutely controlled; (2) that _nerve ends_ be placed out of the way of cicatricial entanglement; (3) that proper _drainage_ be provided; (4) that the soft parts be so brought _together_ as to unite in the promptest and most perfect fashion. The possibility of the latter will depend very much on the occasion for the operation and the condition of the tissues. Operating in the presence of previous disease, as when the parts are inflamed or edematous, or as when one amputates at a point where more or less sloughing and separation of tissues have already occurred, the surgeon cannot look for such primary repair as furnishes an ideal termination, nor should he endeavor to make such close suturing or approximation as he would otherwise attempt. In fact, under these circumstances, it is often desirable to leave the wound widely open, perhaps packing it with yeast, in order to hasten sloughing and secure healthy granulating surfaces, which may be then brought together by secondary suture or by suitable strapping and bandaging. Nothing worse can happen than imprisonment of the debris resulting from the sloughing process.

But an amputation wound made with faultless technique, and in tissues previously healthy, may be closed with a minimum of drainage, or often without any, providing it be so closed as to leave no dead spaces in which blood clot may accumulate. This requires careful _suturing_, by numerous buried sutures, of muscle to muscle, tendon to tendon or to periosteum, and the like, the wound being gradually closed from its depth, and finally so bandaged that equable pressure shall be made, with comfortable support, but without undue pressure at any point. In aseptic cases animal ligatures and sutures (chromic gut) will prove reliable and efficient. In septic cases it would probably be better to trust to (secondary) silk, especially if parts are to be long exposed, so that it can be later removed. For the superficial wound silkworm sutures answer admirably.

For _drainage_ a gauze packing for the worst cases, one or two tubes for ordinary cases, and for those which scarcely need it strands of catgut or of silkworm-gut, or two or three little rolls of oiled silk, will be sufficient.

In this country Link and in Germany Credé have practised the method of bringing parts together merely by equable pressure and bandaging. This has been of late modified by the use of strips of sterile adhesive plaster; and in certain instances, everything else favoring, it has given good results. It might be advantageously adopted in cases where it is feared that it may be necessary to reopen the wound, as it would permit an easy method of so doing.

_Dressings_ should be copious and snugly applied, and the limb involved should be _immobilized_. Thus after a leg amputation it is well to bind the leg and thigh upon a suitably arranged splint, physiological rest, which is so essential to success, being in this way attained. The same is also true of the arm.

AMPUTATIONS OF THE UPPER EXTREMITY.

=Amputations of the Finger and Thumb.=--It is desirable in the upper extremity to save every portion which can be preserved and still made useful. This is particularly true of the fingers, where every half-inch adds to their usefulness. When it is possible the palmar surface should be saved and made to cover the stump end, as it is not only more sensitive but denser and stands wear better. This is equally true of disarticulations or of divisions between the joint ends of the phalanges, which are best exposed by bending the finger, cutting the dorsal flap in this position, then stretching it and cutting the palmar flap (Fig. 680).

The vessels and nerves lying on the lateral aspect should be secured against hemorrhage, and cocaine solution introduced if local anesthesia is being practised. It is important also to remember the arrangement of the common palmar synovial bursa, with the digital prolongations to the thumb and the little finger, and that the three middle fingers are ordinarily shut off from it. Nevertheless if tendons be divided near the hand, and short finger stumps be made, it is easy to infect this common palmar bursa through retraction of the tendon and the consequent opening up of a tunnel directly into that cavity.

[Illustration: FIG. 680

Typical amputation of finger in continuity (through a phalanx); long palmar and short dorsal flaps. (Farabeuf.)]

[Illustration: FIG. 681

Typical or preferred method of disarticulating a finger by long single palmar flap. (Farabeuf.)]

Figs. 680 and 681 illustrate the best methods of amputating fingers through a phalanx or at the joints, while Fig. 682 shows the best method of closing the wound. In this way a serviceable finger-tip is preserved which will stand every irritation to which it will probably be subjected.

When the finger is to be _disarticulated from the hand_ a modified oval flap is preferable, with its long flap on the radial side and the scar on the dorsum rather than in the palm. The _thumb_ is perhaps best separated at an articulation by a single palmar flap, without the preservation of the sesamoids which belong to its short flexor. Fig. 683 illustrates the various flaps and methods preferable at the bases of the different fingers.

When two or more fingers have to be removed the incision should be planned to meet the indications. When the first three fingers have to be removed, with or without that portion of the hand to which they are attached, leaving only the thumb and little finger, I have repeatedly followed to advantage the suggestion of Lauenstein, and through a small incision properly placed have, with cutting forceps, divided the first and fifth metacarpal bones at about their middle, and have then given to each of the remaining digits a quarter of a revolution toward each other, in such a way that when their tips are flexed there was better prehensile power, the hand acting similarly to a more perfect claw. If they are to be maintained in this position during healing they must be suitably held upon the splint to which the entire hand and forearm should be attached.

[Illustration: FIG. 682

Stump resulting from the procedure shown in Fig. 681.]

[Illustration: FIG. 683

Illustrating various finger amputation. (Farabeuf.)]

[Illustration: FIG. 684

Removal of index finger. (Erichsen.)]

[Illustration: FIG. 685

Removal of little finger. (Erichsen.)]

[Illustration: FIG. 686

Results of amputation above metacarpo-phalangeal articulation in middle, index, and ring fingers. (Erichsen.)]

[Illustration: FIG. 687

Hand after removal of metacarpal bones and three fingers, leaving thumb and little finger. (Erichsen.)]

When an entire finger is to be removed it is a question whether the metacarpal belonging thereto should also be sacrificed for cosmetic purposes. In general this is undesirable except in the case of the fifth metacarpal with the little finger. This is easily exposed by lateral incision along the ulnar border of the hand, sufficient to disclose the bone and permit its disarticulation from the carpus. The same is also true, in at least some instances, of the thumb, but it is unwise to expose the carpal joints to the possibility of infection when this can be avoided; moreover, the deep palmar arch crosses just in front of the bases of the second to the fourth metacarpals, where it must be carefully avoided. If, then, the metacarpal is to be sacrificed this should be done rather from the dorsal side, while for cosmetic purposes alone it is usually sufficient to disarticulate the finger at its base and then simply remove the head end of the corresponding metacarpal. Figs. 688 to 692 furnish illustrations of how the incisions may be best planned to effect either of these purposes.

=Hand Amputations and Wrist Disarticulations.=--While it makes but little difference whether the metacarpals be disarticulated from the carpus or the latter from the radial end, it is advisable to adopt whichever line of separation will best meet the indications. For a removal of the _hand at or near the wrist_ two flaps usually afford the most serviceable method, the palmar tissues being preserved, if possible, in order that they may cover the stump. This operation is usually done for injury, and it is more than likely that one will have to plan his flap according to the tissues which still are serviceable.

[Illustration: FIG. 688

Outline of amputation of fingers, with their metacarpals. (Modified by Matas from Mignon.)]

In the lower part of the _forearm_ the flap method furnishes a serviceable stump. As the elbow is approached the circular or elliptical methods are preferable, as illustrated in Fig. 690.

=The Elbow.=--With _elbow disarticulations_ caution should be observed to have flaps of sufficient length. The joint is opened more readily from its radial side. The integument of the back of the elbow region lies closely upon the bone, is thin, and retracts but slightly. Anteriorly there is more muscular covering and consequently a tendency to retraction. Therefore the anterior flap should be made longer than might otherwise seem to be required. Here the ideal scar will be behind the end of the humerus, but it is difficult to obtain because of the tendency to drag it around beneath the end of the bone. An elliptical incision, directed obliquely downward and forward, is the easiest method and furnishes the best stump. The lower end of the posterior part of the flap should be at a distance below the articulation, at least equal to the transverse diameter of the joint itself, _i. e._, in an adult nearly one hand-breadth from the line of the joint to the point of dissection. (Matas.) (Fig. 690.)

=The Arm.=--The _arm_ furnishes that nearly cylindrical outline best adapted for circular amputations. Here, as at the elbow, the greatest retraction is on the flexor side. With the arm should be saved all that is possible even up to its upper extremity.

Remembering the greater tendency of the flexors to contraction the truly circular method should be modified to a somewhat elliptical incision, in order to compensate for this difficulty, while an external liberating incision is often of assistance. Abrupt transverse division of the muscle down to the bone should be made after the oblique incision of the skin.

[Illustration: FIG. 689

Outline of amputation of two fingers simultaneously with their metacarpals; also thumb with its metacarpal. (Modified from Mignon.)]

=Disarticulation at the Shoulder.=--Until accurate methods of blood control were introduced this was an amputation viewed usually with disfavor, in spite of the fact that compression of the axillary artery in theory is easy. The older methods comprised this compression, either above the clavicle, or by exposure of the vessel and its proximal ligation, or by opening and separating the joint and then seizing the vessels within the inner flap, and controlling them by digital pressure until their division. Now with the use of Wyeth’s pins and the elastic bandage, effectual control may be secured without resorting to any of the former expedients. If the removal is to be a high amputation, just below the neck of the humerus, the method shown in Fig. 691, of application of the tourniquet and its control by a constricting strap, may be adopted.

If the surgeon expect to disarticulate he should resort to the pins of Wyeth (_i. e._, to the use of long mattress needles), which are passed through from above downward, or from the axilla upward, one of them being passed anteriorly and the other posteriorly, and brought out at corresponding points on the upper aspect of the shoulder, where, their points being protected by sterilized corks, they serve to prevent sliding of the elastic bandage or tourniquet, which is now placed proximally to them, and is thus held more securely than is possible in any other way.

[Illustration: PLATE LVII

_1. Anterior oval or racquet incision for disarticulation of the shoulder by attacking the joint through the delto-pectoral groove (modified Spence’s operation)._

_2, 3. Circular amputation of lower and middle thirds of arm transformed into double square, antero-posterior flap operation by unilateral or bilateral vertical incisions._

_4, 5, 6, 7. Circular amputation at various levels of forearm, including the disarticulation at elbow. In all of these, one or two lateral liberating incisions, cut down to the bone, may be required, on ulnar or radial side, or both, to permit easy retraction of solid musculo-tegumentary antero posterior flaps._

_8, 9. Circular amputation at lower third of forearm; lateral liberating incision should be added on ulnar side, or radial side, or both, according to tonicity of limb._

_10. Long palmar projection of oval method in disarticulating hand._

Cutaneous Incisions in Amputations of the Upper Extremity (Ventral or Flexor Side).]

[Illustration: PLATE LVIII

_1. Racquet incision (Larrey) intradeltoid for disarticulation at shoulder._

_2. Solid circular with liberating incisions for upper third._

_3. Solid circular with liberating incisions for middle third._

_4. Circular amputation at lower third of humerus; incision slightly favoring the flexor side, to compensate for greater retraction; two lateral liberating incisions, to facilitate retraction of musculo-cutaneous flaps from bone._

_5. Neudörfer’s racquet incision for disarticulation at elbow; preferred in all cases in which a preliminary exploration of the elbow, as in advanced tubercular cases, is attempted before proceeding to disarticulate at elbow._

_6. Elliptical or oval incision with long projection on flexor side to compensate for greater retraction of skin and muscles on flexor (ventral side); the longer end of the oval may be advantageously reversed, the long end on the exterior side, when the tissues on the flexor side are injured. Usually, a slightly elliptical circular, with two lateral liberating incisions, cut squarely to the bone with all the soft parts, including the periosteum, is the preferred method in this region._

_7. Antero-posterior flap incision for amputation at lower third of forearm; tendinous region._

_8. Oval or elliptical incision in typical amputation of the hand (radio-carpal disarticulation)._

Surface Tracings showing Some of the More Useful Lines of Skin Incision in Amputations of the Upper Extremity (Dorsal or Extensor Surface).]

[Illustration: FIG. 690

Lines of amputation in lower third of forearm, of elbow, and lower third of arm. (Modified from Mignon.)]

Circulation being thus controlled, a modified circular operation may be made or a long external and superior flap cut, matching it with another one dissected from the axillary aspect. In the former case the circular incision is made on a level a little below the anatomical axillary border. Then a cuff of skin being raised while the arm is held in adduction, all the soft parts are divided to the bone and separated from it. Now a liberating incision may be made from the anterior border of the acromion to the coracoid process, then over to the deltoid groove, and along it to the first circular incision. Through this all the soft tissues surrounding the glenoid margin are separated, and then the bone is enucleated by opening the capsular ligament, reserving perhaps the detachment of the group of scapular tendons until the last. If one have any fear as to the efficiency of his hemostatic precautions he may secure the axillary vessels so soon as they are divided and then proceed with the disarticulation as above. In some cases it may be preferable to cut a wide flap from the deltoid region, preserving that muscle or not as may be desired, and, after having thus exposed the joint, make the disarticulation, separating the head of the bone sufficiently to allow the passage of an amputating knife behind it and down along the shaft to a distance sufficient to justify turning it abruptly and toward the surface, and then cutting out the axillary flap. The attempt should be to cut all the vessels at right angles rather than obliquely.

Plates LVII and LVIII, prepared by Professor Matas, afford a synoptic view of the more useful lines of skin incision in the principal amputations of the arm and shoulder.

=Interscapularthoracic Amputations. Removal of the Entire Upper Extremity.=--This includes removal not only of the arm, but of the scapula and clavicle as well, or at least its outer portion. It is not often required, and inasmuch as the circumstances which justify it are seldom duplicated, a suitable method for each individual case should be planned, rather than try to make one set of directions cover them all. Much will depend upon whether sufficient skin can be saved in order to cover the large defect thus made. In general, however, an incision should first be made along the clavicle, exposing it and dividing it near its middle. It is convenient to take out the middle portion at this time, and in this way to afford ample room through which a proximal ligation of the subclavian vessels may be made, they being here carefully dissected out, secured by double ligation, and divided. From the outer part of the above incision another is carried downward and outward toward the deltoid groove and then beneath the axilla to its posterior margin. The posterior flap is then furnished by an incision continuous with the last one, which terminates below about opposite the lower angle of the scapula, and is then continued upward along the inner scapular border and over the shoulder until it reaches the outer end of the incision first made. In this manner will be furnished a sufficient covering. The balance of the operation consists in the gradual separation of the entire mass from the outer wall of the thorax. With a preliminary ligation of the subclavian vessels there will be no hemorrhage which cannot be easily checked by pressure and forceps.

The above, however, is only a general description, which may need to be modified in most cases. If the amputation be done for injury all the skin _which is still viable_ should be utilized, no matter how shaped, while if done for disease the incisions may have to be modified materially, taking more skin from one side and less from the other, in order to avoid that involved in the disease process.

In the majority of cases the result is satisfactory, in spite of the mutilation thus afforded.

[Illustration: FIG. 691

Esmarch’s elastic constrictor applied and held in place by a bandage or a strap (Wyeth’s pins may also be used to hold the constrictor in place) in high amputation of the arm. (S. Smith.)]

AMPUTATIONS OF THE LOWER EXTREMITY.

The most important physiological purposes of the foot are those of support and locomotion, not mere tactile sensibility nor prehension. Its purposes being different from those of the upper extremity, the tenets previously held regarding the advantage of conservatism may be changed to some degree, for a tender foot or leg-stump is sometimes extremely annoying, even disabling, and it is in the end far better to so plan an amputation of this extremity as to make the stump most serviceable, without primary reference to its exact length. As in the hand, foot-stumps should be covered with dense plantar (instead of palmar) tissues, and the long flap should, therefore, be made from the sole. When this is impossible it would be wiser to shorten the stump. Moreover, as there will be constant friction upon the resulting cicatrix, this should be placed in the most protected location, on the dorsum of the foot.

The most important indication, then, in all foot amputations is to _furnish a complete plantar flap and to place the scar on top of the foot_.

=The Toes.=--Amputations of the _toes_ are, by virtue of their shortness, nearly always disarticulations. The basal row of phalanges should be preserved when possible, and even here the covering of the stump should be as far as possible fashioned from the sole.

The _big toe_ may be removed by either internal or oval plantar flaps, which should be long enough to cover the metatarsal head, otherwise the latter must be decapitated. These same principles also apply to the _little toe_. When all or most of the toes have to be severed it may as well be done by a single dorsal incision, as seen in Fig. 692, which will permit either their disarticulation or their removal along with that of the ends of the metatarsals. These methods are shown in Figs. 692 and 693.

_Amputation of a toe with its metatarsal_ is best effected by a racket incision. This may extend up to the posterior tarsal joint. Some have recommended to enucleate the metatarsals subperiosteally, through dorsal incisions, all the soft parts being scrupulously left behind. With the first and fifth toes the scar should be so placed as to be removed from the edge of the foot (Fig. 693).

_Partial amputations of the foot_ have been suggested and devised in great numbers, and the subject has been greatly complicated by the number of methods that were taught. Modern ideas of conservative surgery have caused a complete departure from the anatomist’s standard, and it has been shown that with aseptic technique there is no advantage in disarticulating when it leaves irregular lines. As Matas says: “As Agnew taught long ago in this country, and others elsewhere, the skeleton of the foot must be considered a surgical unity, to be treated by the knife and saw just as the femur and humerus would be, at the exact point which will yield the longest and most useful stump to the patient. What is essential in every case is the application of the principle of plantar flaps--preservation and scar protection.”

Concerning the utility of many of these methods and the usefulness of the resulting stumps we may learn more from the makers of artificial limbs than from almost any other source. Thus, Truax, for instance, who has had large experience as a mechanic, has given this advice, as quoted by Matas: “Avoid amputation within three inches of the ankle-joint; do not amputate between the metatarsal bones and the junction of the lower and middle thirds of the tibia. At other points save all you can, and you will in every case have done the best for your patient.” Should one be rationally governed by this advice a large number of amputation methods which cumber most text-books would be discarded.

[Illustration: FIG. 692

1, simultaneous disarticulation of all the toes; 2, amputation of the toes in their continuity. (Mignon.)]

[Illustration: FIG. 693

1, partial amputations of the third and fifth metatarsals; 2, disarticulation of the first and fifth metatarsals. (Mignon and Matas.)]

[Illustration: FIG. 694

Tracings of intratarsal amputations at various levels (outer side): 1, subastragaloid; 2, tibiotarsal; 3, tibiocalcaneal; the different lengths of flaps shown in relation to skeleton.]

[Illustration: FIG. 695

Tracings of incisions in mediotarsal amputations and total amputation of fifth toe. (Mignon and Matas.)]

For my own part I would advise to save all of a foot that can be saved, providing a sufficiently long plantar or heel flap can be retained; but if these are not available, then I would advise amputation, at least three inches above the ankle.

I would advise, moreover, to discard the complicated rules and technique of stilted methods and to use the saw whenever it can be made useful, rather than to go farther back to a row of joints simply because they are joints (Fig. 694).

Figs. 695 and 696 illustrate conservative modern methods, which are perfectly available for most purposes, and from which departure need be made only when peculiar circumstances obtain, which so complicate the case that none of the ordinary rules would apply. A surgeon of judgment and experience is competent to devise a flap for a given case, whether it complies with standard methods or not. It seems to me, therefore, worth while to describe only the so-called _mediotarsal disarticulation of Chopart_, in which but the astragalus and calcis remain of the proper bones of the foot. The joint line extends from just behind the tuberosity of the scaphoid to the outer side of the body of the calcis, where a tubercle can be usually felt. Across this line an incision is carried obliquely over the dorsum of the foot. The plantar flap is the long one, and the line of division is just behind the balls of the toes. Two lateral incisions can be made to facilitate disarticulation if desirable.

[Illustration: FIG. 696

1, disarticulation at the tarsometatarsal joint, showing length of flaps; 2, disarticulation of the big toe in continuity. (Mignon.)]

This operation sometimes leaves the foot in a bad equinus position; accordingly it is wise to make tenotomy of the tendo Achillis, as well as to attach the dorsal or extensor tendons to the stump end. (See Figs. 699 and 700.)

=Amputations of the Foot (Tibiotarsal).=--The former favorite method of amputating the _foot proper_ was that of Syme, illustrated in Fig. 701. This preserved the plantar surface and tip of the heel, thus forming a cutaneous hood, which was made to cover the lower ends of the tibia and fibula, whose malleoli were usually removed close to their terminations. The incision is made directly down to the bone, from the apex of one malleolus across the sole and up to the other. Then the foot is forced into extreme flexion and another incision carried directly across the dorsum, by which the upper ends of the first are joined. This permits opening the ankle-joint in front, after which the lateral ligaments are divided and the astragalus dislocated forward. The heel hood is next carefully separated from the calcis with the knife, and it and all the parts retracted from the ends of the leg bones, which are divided just above the articular surfaces, or the latter may be left and the malleoli alone removed. Now the heel hood is raised, made to cover the end of the leg, and united to the anterior incision, drainage being made by a small opening on the outer side of the tendo Achillis, as the plantar surface of the flap should not be opened (Fig. 703).

[Illustration: FIG. 697

Lisfranc’s tarsometatarsal disarticulation. (Farabeuf.)]

[Illustration: FIG. 698

Stump after same.]

[Illustration: FIG. 699

Classical mediotarsal amputation (Chopart), showing length of plantar flap. (Farabeuf.)]

[Illustration: FIG. 700

Stump after Chopart’s amputation. (Farabeuf.)]

[Illustration: FIG. 701

Syme’s tibiotarsal operation, showing part removed and lines of section, before division of malleoli. (Farabeuf.)]

Fig. 702, the complement of Fig. 701, illustrates the appearance of the stump after the completion of the disarticulation and before the removal of the malleoli.

Pirogoff introduced a serviceable modification by obliquely dividing the os calcis in front of the heel, turning up its sawed surfaces without any dissection of the hood from the heel, and uniting its fresh bone aspect with that made by removal of the articular ends of the leg bones. This would seem to be preferable to Syme’s disarticulation, affording a better walking stump. (See Figs. 704 and 705.)

A reverse of this operation was suggested by Mikulicz and Wladimiroff, independently, and at about the same time, the heel being excised by an incision across the sole and then behind the ankle, the calcis being divided and its posterior end removed, while the articular surfaces of the leg bones are also removed. The foot is then brought down so that these surfaces can be brought in contact, it being expected that after their reunion the individual will walk in the exaggerated equinus position and upon the ends of the metatarsal bones. The operation is, in effect, an exsection rather than an amputation, and is applicable to but a very small number of cases, in which, however, it sometimes gives excellent results. (See Fig. 707).

[Illustration: FIG. 702

Syme’s amputation after disarticulation of the foot at the ankle-joint. The soft parts are being cleared from the malleoli preparatory to sawing the malleoli and lower articular surface of tibia. (Farabeuf.)]

[Illustration: FIG. 703

_S_, line of incision for Syme’s operation; _P_, line of incision for Pirogoff’s operation. (Erichsen.)]

=Amputations Of the Leg.=--Modern prosthetic methods have materially changed the indications in amputating the leg. The pressure in artificial limbs is not borne upon the end of the stump, but is rather circumferential and borne by a conical socket. It is now, therefore, an object to preserve as much of the limb as practicable, in order to have better leverage or control of the artificial member. Consequently the point of election is now the middle of the leg, unless the amputation may be made even below this point. The objection to a short leg stump is the inevitable flexion which the hamstring flexors will produce; in such cases the pressure will be borne upon the knee, while the appearance of the stump is by no means ideal. If, therefore, one is forced to make a high amputation of the leg it would be far preferable to make a good knee disarticulation, or, better still, a supracondyloid amputation, with preservation of the patella, thus furnishing a stump which affords perhaps the only exception to the general rule, _i. e._, that weight cannot be borne upon the stump end.

[Illustration: FIG. 704

Skeleton of stump after Pirogoff’s osteoplastic amputation. The sawed surface of the calcaneum in apposition with divided surface of tibia. (Farabeuf.)]

[Illustration: FIG. 705

Stump after Pirogoff’s operation. The weight of the body must rest upon the thick plantar skin of the heel and never on the thin skin of the retrocalcaneal surface. (Farabeuf.)]

[Illustration: FIG. 706

Sections of bone in Pirogoff’s amputation and its modifications: 1, oblique section of calcaneum to correspond with (1) oblique section of tibia. (Gunther.) 2, curvilinear or concave section of calcaneum to correspond with (2) convex section of tibia. (v. Bruns.) 3″, horizontal section of calcaneum to correspond with (3) similar section of tibia. (Pasquier Le Fort.) 3‴, vertical section of calcaneum to correspond with (3) horizontal section of tibia. (Typical Pirogoff.) (Modified by Matas from Mignon.)]

[Illustration: FIG. 707

Osteoplastic excision of foot. (Mikulicz.)]

Let us, then, consider but one or two amputations of the leg--that low down or near the middle and that at the knee. Whatever the method it is most desirable that the scar be kept off to the side, and especially _away from the front of the shin_. This can be best accomplished by a modified circular (Fig. 708) or a bilateral flap method (Fig. 711), or by the oblique method with lateral incisions, which practically convert it into an anteroposterior operation, while for certain instances the method of Teale may be preferred, _i. e._, that with a long anterior and short posterior flap, or its modification by which the flaps are made more lateral, or the even long flap method of Bell.

[Illustration: FIG. 708

Modified circular amputation of upper third of leg. (Erichsen.)]

Whichever of these be selected, after division of the muscles and exposure of the bone, it is usually helpful to retract the flaps, whatever their shape, by a cloth retractor made of a piece of sterile bandage torn into three strips, the middle of which should be inserted between the bones of the leg, the interosseous membrane being divided for this purpose; by this they are held more perfectly out of the way during the act of dividing the bones. The anterior border of the tibia, which is practically a sharp ridge, should be divided obliquely (bevelled), either by a small oblique section before the transverse division is made, or by effecting this later, in order that there shall not remain a sharp point to project through the skin or be subject to constant irritation. The tibia is usually divided transversely, with the above exception. The fibula may be divided slightly obliquely. It is customary, however, to make the division simultaneously, and to so conduct the sawing process as to divide the fibula completely before the last strokes of the saw cut through the tibia.

There is greater difficulty in the recognition and securing of vessels in leg amputations than in any other, especially if they have been divided obliquely. The principal vessels may be found from their known anatomical location. They nevertheless sometimes tend to retract and they must be followed up in order to properly secure them. The accompanying nerve trunks should also be seized firmly, drawn down, and divided two or three inches above the line of division of the other tissues, in order that they may retract out of harm’s way. Every nerve which can be recognized, even in the skin, should be thus treated. Before closing the wound it is well, unless one is absolutely sure of his work, to release the tourniquet and ascertain if any vessel which would otherwise bleed be not yet secured. Oozing may be checked with hot water, while muscle surfaces which leak too much blood may be lightly enclosed within catgut sutures inserted with a curved needle.

Providing that these stumps have well-nourished flaps, and that no sharp or angular bone ends interfere with subsequent comfort, and that the scars be kept away from their lower surfaces, they serve their purpose admirably.

Supposing, then, that amputation is to be about the middle, the first incision, made with a stout scalpel, is begun at the anterior border of the tibia and carried downward along it until it is turned abruptly backward to the posterior aspect, and then upward until a point is reached opposite that of commencement. The skin is dissected up for perhaps an inch. Then the flap on the other side is cut after the same fashion, after which, with a short or long knife, the muscles are divided transversely or circularly down to the bone. Much will depend now upon whether the desire is to resort to the more modern osteoplastic methods or adhere to the old. In the latter case it is well to separate the flaps for the necessary distance from the bone, with or without the periosteum, dividing the bones after suitable retraction, as above suggested. If preference be for an _osteoplastic flap_ it is planned and made at this time, the bone being divided at the same level as the muscles, and the amputation being thus practically completed, after which the osteoplastic flap is arranged, it being now necessary to carefully preserve the periosteal bridge and to again divide the bone at the base of this periosteal flap, this being the true end of the bone stump. In this case the fibula is divided at a higher level.

It is perhaps less desirable to preserve periosteum in young children than in adults, for if bone be permitted to grow too rapidly conical stumps result, sometimes even with protrusion of bone ends. Ollier and his pupil Mondan have shown that this so-called _atrophic elongation_ of bone is a consequence of abnormally rapid growth from the upper epiphyseal direction, permitted by lack of pressure from below, and that conical stumps will often happen in children in spite of every precaution. Nevertheless it should not be encouraged, and for this reason periosteum should not be preserved.

The _method of Teale_ was to cut a long anterior flap, raising the coverings from the bone with the least possible disturbance, to divide the bone at the high level, then to double the flap upon itself in such a way as to bring the scar at a level one inch or more above the stump end. Heine modified this slightly by raising the periosteum with the rest of the anterior flap. In cases which permit such a long flap to be formed from one aspect of the leg the method gives excellent results (Fig. 709).

[Illustration: FIG. 709

Teale’s method of amputation.]

Bruns devised a method which is begun almost as an exsection, by an oblique circular incision, with liberating lateral incisions, and division of all the tissues over the inner border of the tibia and the outer side of the fibula; after which, without disturbing skin attachments in front, the periosteum is separated from the bones as high as the liberating lateral incisions permit, and then the fibula first and later the tibia divided. It is practically a subperiosteal excision of the leg bones and affords a well-protected stump. In effect it is an anteroposterior flap method.

[Illustration: FIG. 710

Stump after Stephen Smith’s amputation at knee.]

=The Knee.=--It was Brinton who, in 1872, suggested the preservation of the semilunar cartilages in all knee disarticulations, as in this way all the normal relations are preserved and retraction is prevented. But the makers of prosthetic apparatus have urged to abandon all true disarticulations, and to substitute for them the supracondyloid method, which affords ideal stumps. Disarticulations are supposed to produce less shock, less loss of blood, and less danger of sepsis from opening up the bone-marrow, while muscle insertions are less disturbed and the stump covering usually is mobile and not very sensitive. No disarticulation should be thought of unless the joint involved be free from disease and unless about it there be met sufficient healthy integument to furnish a satisfactory flap.

For a true _disarticulation_ Stephen Smith’s bilateral method is now almost universally adopted. Here the incision is begun one inch below the tubercle of the tibia and is carried directly down to the bone, downward and forward around the side of the leg, and then inward and upward toward the middle of the popliteal space, the lateral flaps thus made being nearly duplicates. The flaps thus cut out are completely separated from the bone up to the joint level, where the ligaments are divided, the joint being manipulated as may be necessary to best expose them and facilitate division. In this operation the patella is usually removed, the joint being opened by separating its ligament at its insertion into this bone. One should remember that the internal condyle is lower and longer than the external, and that the internal flap should be perhaps made on this account a little the longer of the two. Fig. 710 illustrates the stump resulting from this operation and shows the cicatrix drawn up out of harm’s way and resting in the fossa between the condyles. Fig. 711 illustrates the simple method by lateral flaps.

[Illustration: FIG. 711

Amputation at knee by lateral flap. (Erichsen.)]

=Amputation of the Thigh.=--Under this head, rather than that of amputation at the knee, should be described the _supracondyloid amputations_ which give decidedly the best results of all, and which are preferable to any others for the middle of the lower extremity. Of these the best is that suggested by Gritti, which consists in not only removing the condyles but sawing off the articular surface of the patella, which is then drawn upward and applied to the end of the femur, the division of the latter being made at a point above the condyles, where the diameter of both bones will nearly correspond, this latter perhaps being a suggestion of Stokes rather than of Gritti, who did not divide the bone quite so high. (See Fig. 712.)

[Illustration: FIG. 712

Gritti’s osteoplastic supracondyloid knee amputation, patella utilized: _a_, shaded parts are those brought in apposition; _b_, appearance of Gritti stump after suture; _c_, correct apposition of patella to femur; _d_, defective apposition. (Farabeuf.)]

Fig. 712 will best illustrate the intent of the method as well as its performance. The incisions are planned much as in the Stephen Smith disarticulation method, only they are placed higher, and the patellar tendon is divided as low down as possible, or even separated from the tibia, in order that it may be made of use in attaching the divided patellar surface to the femoral end. The rest of the operation is performed as by other methods, the attachment of the patella being effected by tendon sutures, or, if necessary, by an ivory peg, or even a metal tack or nail which may be left in place.

The beauty of this method is that the anterior surface of the patella is preserved with its natural weight-bearing facilities and the bursa between it and the skin, while the latter is undisturbed. On the end of this stump as much weight can be steadily borne as when one ordinarily kneels, and to it a most serviceable kind of artificial limb can be attached, with which one may walk as though nothing had ever happened.

Another osteoplastic method, namely, that of Sabanejeff, is illustrated in Figs. 713 and 714. In this instance the bone covering over the end of the femur is taken from the upper end of the tibia, the patella not being disturbed. It permits a lower division of the femur and the formation of a stump which is of practically the same length as the original thigh.

[Illustration: FIG. 713

Sabanejeff’s knee amputation. (Chalot.)]

[Illustration: FIG. 714

Stump made as in Fig. 713. (Chalot.)]

=Amputation of the Thigh above the Knee.=--For _removal of the thigh_ it is well to preserve as much of its length as possible, and yet not at the expense of all other considerations. A thigh stump too short is likely to be pulled awkwardly upward by the psoas muscle, and upon such a stump it is difficult to secure an artificial limb tolerable of control against such action of this muscle. On this account, then, thigh stumps should be long. So far as the method is concerned the circular, or some modification thereof, gives the best results in the majority of instances. It may easily be modified into one of the oblique methods, or liberating incisions may be used whenever they will be of service. If it be absolutely necessary to make the amputation high hemostasis can be secured by the same methods that are used in hip-joint amputations. The dense and strong fascia lata, which lies beneath the superficial fascia, should be divided at the same level with the skin, since it serves admirably, when secured by a separate set of sutures, to make a good covering for the ends of the muscles, after these have been themselves carefully united by buried sutures. The sciatic nerve should be especially sought, thoroughly stretched, and divided high up. The vessels often evince a tendency to retract within Hunter’s canal; it is not, however, difficult to separate the vastus internus from the adductor longus, between which they lie, and in this way gain access to them. Even for high work on the thigh one may, if necessary, do as some have done at the hip, make a preliminary ligation of the femoral artery. This may be especially serviceable as an emergency measure, or in special cases of tumors which have attained large size, are placed high up and call for somewhat atypical methods.

=The Hip-joint.=--Amputation here is essentially a _disarticulation_ and constitutes one of the usually formidable and serious operations of major surgery. Although the joint itself is generally easily reached there are many things to be considered in the performance of this operation, of which the mere arthrotomy is by no means the most important.

Preparations being all made, the first consideration is the _control of hemorrhage_, for which several methods have been suggested, but of which but two or three are in general use. Such procedures as compression of the abdominal aorta, either with the hand or by tourniquet, or of the common aorta through the rectum, with a lever, as suggested by Davey, or with the hand, as suggested by Woodbury, or the exposure of the common iliac, either within the peritoneum as practised by McBurney, or externally, or exposing the common femoral above Poupart’s ligament, are now adopted by very few surgeons. Langenbeck used to be fond of preliminary ligation of the femoral where it is most accessible in the groin, and this is probably the best of all of these methods. But they have been all practically discarded since Wyeth introduced the simple method of transfixing the limb with his pins (_i. e._, long mattress needles or skewers made for the purpose), these serving to hold in place an elastic cord or tourniquet (Fig. 715). This has been found to be a great improvement on the suggestion of Senn, who excised the femoral head and then compressed each half of the limb with a separate elastic band.

[Illustration: FIG. 715

Wyeth’s bloodless method: pins inserted and tube applied.]

The directions for the use of Wyeth’s pins are simple. Here, as in other cases, it may not be practicable to use the elastic bandage from the lower end of the limb, but one may at least elevate the limb and thus coax the blood out of it by gravity or by gentle manipulation. While it is still in this position one of the long pins is introduced just below the anterosuperior spine and a trifle to its inner side, and made to emerge on a level with and about three inches from the point of its entrance. The other needle is inserted just to the inner side of the saphenous opening, and below the level of the crotch, and brought out about one inch below the tuberosity of the ischium. Corks should then be placed upon them so as to protect the needle points. Next a piece of elastic tubing or band is placed around the limb above these pins and tightened, each turn being made a little tighter, so as to absolutely control the circulation. The effect of this is felt upon practically every vessel in that part of the body, and if the method be properly practised it affords absolute security.

The surgeon now has his choice of various methods of disarticulation, either that by anteroposterior flaps or lateral flaps, or by the circular, with the free liberating lateral incision; or he may devise any method of his own which will best meet the indication in a given case. Fig. 715 illustrates the employment of Wyeth’s pins and the first circular incision made as for the circular method. Of these all the latter seems preferable when circumstances permit. It should be combined with a sufficient lateral incision, which should be made to pass well over the great trochanter. The cuff raised through this incision should extend down to the deep fascia and up to the level of the lesser trochanter, at which level the deeper tissues are divided transversely or by a circular cut.

It is well next to lay down the knife and secure the large vessels, after which the deep muscles are separated from the upper end of the shaft and the proximity of the joint, while the entire limb may be still used as a lever in so stretching the joint capsule as to better expose and divide it. So soon as the capsule has been opened, and the entrance of air thus permitted, it will be easy to expose and divide the teres ligament, after which the balance of the disarticulation is easily effected. The large nerve trunks are now sought, retracted, and divided high up, all visible vessels are secured firmly, after which the elastic constriction may be gradually released and any vessels that spurt may still be secured. There will nearly always be troublesome oozing from the cut ends of the large muscles, and here, if hot water prove insufficient to check it, with large curved needles and catgut sutures the muscle ends may be secured by ligature _en masse_, before they are brought together for the purpose of closing the stump.

Whatever the method selected as perfect a closure of the wound as possible should be made, with ample provision for drainage. By careful deep suturing, with tiers of buried sutures, it is possible to avoid leaving dead spaces at any point except perhaps the acetabulum. Through retaining sutures may also be used to advantage. It is most desirable to so plan the incisions and the closure of the wound as to keep them, so far as possible, away from the region of the perineum. Therefore the longer the inner flap or inside of the stump the better. As conditions which necessitate removal of the limb at the hip-joint are always serious, and have each their own peculiarities, any method which will best serve the purpose should be used.

Plates LIX and LX, designed by Prof. Matas, afford the best and briefest epitome of the choicest amputation methods which can be furnished.

THE STUMP.

An amputation having been effected, and the stump closed, there is still occasion to consider how it may best be treated to fit it for its future purposes. When entire chapters, or even small monographs, can be written on the subject of “diseases of stumps” it would appear that the consideration is not one of merely trifling import.

A _good stump_ has a regular outline, with a protected scar, and should be firm, yet mobile, and without tender or sensitive surfaces. It should constitute the lower end of a truncated cone, and needs to be of sufficient length to permit leverage within the socket of the artificial limb which will be fitted about it.

A stump failing in these characteristics is a _bad_ stump, the features which especially tend to make it bad being undue conicity (Fig. 716) or sensitiveness of surfaces, ulceration from friction, or, worse yet, occurring without it, and neuralgia from inclusion of nerve ends, or from bone ends which present osteophytic outgrowths and thus distort and displace tissues (Fig. 717). Acute osteomyelitis occurs in stumps, as do slower carious processes which may call for re-amputation, perhaps even at a distance. The stump is for a long time more or less tender and troublesome, and its owner may be a sufferer from hyperesthesia or perverted sensations.

The possibility of the production of a conical stump in children as the result of _atrophic elongation_ was mentioned early in this chapter. While this cannot always be prevented it may sometimes be foreseen, and one should be prepared at any time in such cases to circumcise the bone, forcibly retract the tissues, and then divide the bone ends on a higher level.

[Illustration: PLATE LIX

_1, 2. Circular for middle and upper thirds of thigh._

_3. Circular for lower third of thigh, showing tendency of circle to incline downward on adductor side to compensate for greater retraction._

_4. Incision for Gritti’s or Carden’s amputations at knee (single anterior flap)._

_5, 6. Stephen Smith’s bilateral flaps (posterior racquet)._

_7. Antero-posterior flaps, cut solid to the bone, the soft parts being elevated from the periosteum (Marc See, von Brun’s method). This is the author’s preferred method for leg only, simplified by making a simple circular with two lateral liberating incisions on fibular and tibial sides._

_8, 9, 10. Circular with posterior racquet extension to form bilateral flaps (Stephen Smith)._

_11. Guyon’s supra-malleolar amputation._

_12. Lines of Syme’s amputation._

_13. Inner aspect of Roux’s tibio-tarsal amputation; also subastragaloid._

_14. Medio-tarsal amputation (inner aspect)._

_15. Tarso-metatarsal disarticulation (inner aspect)._

_16. Disarticulation of toe with its metatarsal._

_17. Disarticulation of big toe; in front of this lines for amputating first or terminal phalanx by long plantar flap._

The Right Lower Limb, Internal Lateral View (Surface Incisions).]

[Illustration: PLATE LX

_1. Low circular with external incision (Furneaux Jordan) or at a higher level (gluteo-femoral furrow) applicable to Wyeth’s method of disarticulating hip._

_2. Circular incision with tendency to racquet posteriorly in middle third amputations._

_3. Circular with posterior vertical incision in amputation of lower third of thigh._

_4. Long anterior flap for supra-condyloid amputation of thigh._

_5. Racquet incision with long anterior flap for extreme upper third of leg. Note long posterior tail, which facilitates upward retraction of a solid musculo-cutaneous flap cut down to the periosteum, resembling a bilateral flap operation (Stephen Smith). The same incision cut a little higher is most serviceable in disarticulating at the knee._

_6. Long-hooded anterior flap, with posterior racquet (Stephen Smith and Bier’s osteoplastic)._

_7. Amputation by equal antero-posterior flap (Marc See, von Bruns)._

_8. Amputation by long anterior and short posterior flaps (Teale’s principle)._

_9. Amputation of leg at extreme lower third, practically a circular amputation converted into a solid antero-posterior flap by liberating incisions on fibular and tibial sides._

_10. Guyon’s supra-malleolar amputation of leg._

_11. Medio-tarsal and intra-tarsal amputations (Chopart and its derivatives)._

_12. Tarso-metatarsal amputation (Lisfranc and derivatives)._

Surface Outlines of Amputations Practised in the Lower Extremity.]

An exquisitely neuralgic stump is usually made so by the entanglement of nerve ends and their subsequent enlargement into so-called _amputation stump neuromas_ (which are histologically fibromas), from pressure upon nerve terminals. Under these circumstances their excision through incisions planned for the purpose, or the exsection of a portion of the nerve trunk at a higher level, may be necessitated (Fig. 717).

[Illustration: FIG. 716

Extreme case of conical stump.]

[Illustration: FIG. 717

Neuromatous endings of nerves in a stump.]

[Illustration: FIG. 718

Ideal stump.]

[Illustration: FIG. 719

Bad stump, because posterior flap was cut too short, and there has been great retraction of all soft tissues. (Farabeuf.)]

While patients may prefer disuse of a stump for as long a time as possible the judicious surgeon will prepare it as rapidly as he may for early application of the expected artificial limb. Inasmuch as leg stumps allowed to hang downward become cyanotic and edematous it is well to keep them bandaged, and the makers of artificial limbs prefer to have the bandages kept wet. When the stump is healed, passive motion of the remainder of the limb should be begun, in order that there may be a minimum of stiffening of joints. If, then, such a stump be bathed, massaged, moved, and then bandaged with comfortable snugness with cold, wet bandages, over which oiled silk may be fastened, and if this be done at least once each day, the stump will be prepared for the artificial limb, on the average, in two to three months. One should not wait for this expiration of time if it be thoroughly healed; or, on the other hand, he may have to wait much longer under unfortunate circumstances; but the above general principles of treatment and general statements will be found to prevail. Figs. 718 and 719 illustrate the difference between good and bad stumps, while Plates LIX and LX (reproduced from Matas) furnish the surface outlines for selection of the various amputations of the lower limb.

CINEPLASTIC OR CINEMATIC AMPUTATIONS OF THE UPPER EXTREMITY.

The most pronounced and illustrative of recent methods is perhaps the “cinematic” or “cineplastic” procedure of Vanghetti. This Italian surgeon proposed a prosthetic method, in 1898, which is illustrated in Figs. 720, 721 and 722. He has shown that tendon terminations may be left exposed in stumps, under favorable conditions, and so utilized as to serve remarkably useful purposes--though under exceptional conditions. For a description of these methods the reader is referred to his monograph. (G. Vanghetti, _Plastica e Protesi Cinematiche_, Empoli, 1906.)

[Illustration: FIG. 720

FIG. 721

FIG. 722

Results of Vanghetti’s “cinematic” method, with preservation and utilization of tendons.]

INDEX.

A

ABDOMEN, diseases of, diagnosis of, 768 distention of, in appendicitis, 856 drainage of, 776 general considerations and conditions of, 767 inflation of, 769 inspection of, 768 measurement of, 769 operation on, technique of, 773 palpation of, 768 bimanual, 769 wounds of, gunshot, 214, 232

Abdominal aorta, aneurysm of, 346 ligation of, 356 cavity, irrigation of, 775 diseases, diagnosis of, 768 incisions, closure of, 777 operations, after-treatment of, 777 embolism following, 784 hemorrhage after, 780 peritonitis following, 780 technique of, 773 thrombosis following, 784 viscera, general considerations and conditions of, 767 wall, abscess of, 783

## actinomycosis of, 783

burns of, 783 carcinoma of, 784 contusions of, 781 cysts of, congenital, 783 endothelioma of, 784 epithelioma of, 784 erysipelas of, 783 fibroma of, 784 foreign bodies in, 783 gangrenous cellulitis of, 783 hematoma of, 781 injuries of, 781 lacerations of, 781 osteomyelitis of, 783 phlegmons of, 783 sarcoma of, 784 suppurative spondylitis of, 783 syphilis of, 783 tuberculosis of, 783 tumors of, 783 vascular, 784 wounds of, gunshot, 783 penetrating, 781

Abscess of abdomen, 783 atheromatous, 73, 339 bone, 419, 425 treatment of, 426 of brain, 567 prognosis of, 569 symptoms of, 568 treatment of, 573 of breast, 757 classification of, 58 acute, 58 cold, 58, 112 gravitation, 58 metastatic, 59 subacute, 58 subfacial, 59 subperiosteal, 59 cold, 112 peri-articular, treatment of, 399 collar-button, 319 definition of, 58 frontal, 569 of heart wall, 733 ischiorectal, 879, 1013 of liver, 911 symptoms of, 912 treatment of, 912 lumbar, 114 of lung, 734 of mesentery, 939 metastatic, 59, 91 occipital, 569 of pancreas, 949 parietal, 569 peri-appendicular, 860 perilaryngeal, 704 perineal, 1013 treatment of, 1013 perinephritic, 961 perirectal, 879 treatment of, 879 peritracheal, 704 perityphlitic, 860 of prostate, 994 psoas, 114 of rectum, 879 treatment of, 879 renal, 957 retropharyngeal, 114, 682 signs of, 60 of spleen, 941 subphrenic, 753 treatment of, 754 symptoms of, 60 temporosphenoidal, 569 of tonsils, 662 treatment of, 60

Abstraction of blood, 182

A. C. E. mixture, 198

Accommodation, defects of, 604

Acetabulum, migration of, 453

Acetonemia, 82

Acetonuria, 82

Acheilia, 638

Achondroplasia, 432

Acid intoxication from anesthetics, 203

Acinous carcinoma, 290

Acoustic nerve, neurofibroma of, 584

Acromegaly, 437

Acromial process, fracture of, 494

## Actinomycis, 109

fungi, 55

## Actinomycosis, 109

of abdominal wall, 783 of bone, 432 of breast, 759 definition of, 109 diagnosis of, 110 of face, 640 of intestines, 827 of kidneys, 964 of liver, 914 of lung, 732, 734 of mesentery, 939 of mouth, 657 organism of, 109 prognosis of, 110 pus in, 109 of skin, 308 of thorax, 729 of tongue, 659 treatment of, 110

Adenocarcinoma, 285 of bladder, 992 of pancreas, 953

Adenoids of pharynx, 679 treatment of, 680

Adenoma, 284 of bladder, 992 of breast, 760 of kidney, 969 congenital, 969 of liver, 914 of pancreas, 953 of rectum, 885 sebaceous, 285 cysts, 285 of thyroid, 712

Adenosarcoma, embryonal, 268

Adventitious bursæ, 263

Ainhum, 76

Air embolism, 38 of veins, 363

Aleppo boil, 309

Alimentary canal, infection through, 49

Allantoic cysts, 260

Alveolar sarcoma, 274 suppuration, 664

Alypin, 207

Amastia, 755

Amazia, 755

Amputations, 1023 of arm, 1032 atypical, 1023 control of hemorrhage in, 1024 of elbow, 1031 of finger, 1029 of foot, 1037, 1041 Bruns’ method, 1042

## partial, 1034

Teale’s method, 1042 of forearm, 1031 of hand, 1031 of hip-joint, 1045 Davey’s method, 1045 McBurney’s method, 1045 Woodbury’s method, 1045 Wyeth’s method, 1045 interscapularthoracic, 1033 of knee, 1043 Gritti’s method, 1044 Sabanejeff’s method, 1044 Stephen Smith’s method, 1043 of leg, 1039 Bier’s osteoplastic, 1028 circular, 1041 Pirogoff’s method, 1040 of lower extremity, 1034 mediotarsal of Chopart, 1037 method of, 1026 circular, 1026 flap, 1027 osteoplastic, 1027 of penis, 1010 of shoulder, 1032 stump after, 1046 bad, 1046 good, 1046 neuromas, 1047 supracondyloid, 1043 of thigh, 1043 above knee, 1044 Gritti’s method, 1043 Stokes’ method, 1043 of thumb, 1029 tibiotarsal, 1037 of toes, 1034 typical, 1023 of upper extremity, 1029 cineplastic, 1048 entire, 1033 of wrist, 1031

Anastomosis of arteries, aneurysm by, 344 gastric, 816 of intestines, 842

Anastomotic varix, 364

Anel’s method of treating aneurysm, 347

Anemia, 30 pernicious, 30 primary, 30 secondary, 30 splenic, 31

Anesthesia and anesthetics, 192 A. C. E. mixture, 198 accidents from, 201 arrested respiration, 202 treatment of, 202 cardiac failure, 201 acid intoxication from, 203 administration of, 193 anesthol, 200 chloroform, 195 accidents from, 196

## action of, 196

administration of, 197 death from, 196 choice of, 200 dangers of, 201 discovery of, 192 ether, 193 accidents due to, 194

## action of, 194

narcosis by rectum, 195 petroleum, 199 sequels from administration of, 195 ethyl bromide, 198 chloride, 199 local use of, 199 intraspinal, 207 local, 205 alypin, 207 anesthesin, 207 beta-eucaine, 207 cocaine, 205 liquid air, 205 nervanin, 207 orthoform, 207 stovaine, 207 magnesium salts, 209 management of, 192 methylene bichloride, 198 morphine, 205 nitrous oxide gas, 200 scopolamine, 205 somnoform, 199

Anesthesin, 207

Aneurysmal bruit, 341 varix, 363 of abdominal aorta, 346 arteriovenous, 344 of axillary artery, 345 of carotid artery, 345 external, 345 internal, 345 cirsoid, 278, 339, 344 classification of, 342 diagnosis of, 345 diffuse, 339, 342 dissecting, 339, 342 false, 339, 343 of femoral artery, 346 fusiform, 339, 343 of heart, 732 hernial, 339 of iliac artery, 346 of innominate artery, 345 intracranial, 345 of liver, 914 of neck, 701 of orbit, 592 progress of, 341 pulsation of, 341 racemose, 344 rupture of, 341 sacculated, 339, 342 spontaneous, 339 of subclavian artery, 345 traumatic, 339, 343 treatment of, 346 by extirpation, 348 by introduction of wire, 348 by ligation, 347 Anel’s method, 347 Brasdor’s method, 347 Hunter’s method, 347 Wardrop’s method, 347 by open division, 347 by opening and suture, 348 true, 339 varicose, 339, 342, 363

Angina, Ludwig’s, 658, 703 Vincent’s, 703

Angiocholitis, desquamating, 919

Angioma, 277 arterial, 278 capillary, 277 cavernous, 277 of omentum, 935 of orbit, 592 plexiform, 278 of veins, 366 treatment of, 367

Angiosarcoma, 275

Angiotribe, control of hemorrhage by, 236

Ankle, dislocations of, 544 excision of, 414

Ankyloblepharon, 603

Ankyloglossum, 652

Ankylosis, 403 contractures, 403 of hip, 404 of jaw, 667 of knee, 404 treatment of, 405 true, 403

Annular thrombosis, 35

Anthrax, 106 bacillus of, 54 definition of, 106 incubation in, 107 postmortem appearances in, 107 prognosis of, 107 prophylaxis of, 108 symptoms of, 107 treatment of, 107

Antisepsis, 243

Antiseptic applications, 248 solutions, 248

Antiseptics, toxic, 175

Antitoxin treatment of tetanus, 101

Antrum of Highmore, operations on, 611

Anus, absence of, 873 artificial, 839 congenital defects of, 872 fissures of, 876 imperforate, 873 malformations of, 872

Aorta, abdominal, aneurysm of, 346 ligation of, 356

Aplasia cranii, 547

Aponeurotomy, 327

Apoplectic cysts, 952

Apoplexia neonatorum, 564

Apoplexies, compression, 560

Appendicitis, bacteriology of, 852 causes of, 854 chronic, operation for, 866 complications of, 855 diagnosis of, 857 from acute obstruction of bowel, 858 pancreatitis, 858 from cholecystitis, 857 from colitis, 857 from enterocolitis, 857 from floating kidney, 858 from gastric ulcers, 857 from intestinal ulcers, 857 from lead colic, 858 from mesenteric embolism, 858 thrombosis, 858 from peritonitis, 857 from psoas abscess, 859 from pyosalpinx, 858 from ruptured extra-uterine pregnancy, 858 from strangulated hernias, 858 McBurney’s point in, 855 recurrent, 854 operation for, 866 symptoms of, 859 acute, 855 abdominal distention, 856 bowels, 856 jaundice, 856 muscle spasm, 855 pain, 855 pulse, 856 temperature, 856 tenderness, 855 tumor, 856 vomiting, 856 treatment of, 861 non-operative, 862 operative, 862 indications for, 862 in typhoid fever, 859

Appendicostomy, 850

Appendicular colic, 853

Appendix, vermiform. _See_ Vermiform appendix.

Aprosopia, 638

Arlt’s operation for blepharoplasty, 602

Arm, amputation of, 1032

Arrow poisoning, 173

Arterial angioma, 278

Arteries, abdominal aorta, aneurysm of, 346 ligation of, 356 aneurysm of, 339 by anastomosis, 344 arteriovenous, 344 cirsoid, 339, 344 classification of, 342 diagnosis of, 345 diffuse, 339, 342 dissecting, 339, 342 false, 339, 342 fusiform, 339, 343 hernial, 339 progress of, 341 pulsation of, 341 racemose, 344 rupture of, 341 sacculated, 339, 342 spontaneous, 339 traumatic, 339, 343 treatment of, 346 true, 339 varicose, 339, 344 axillary, aneurysm of, 345 ligation of, 355 brachial, ligation of, 355 calcification of, 339 carotid, aneurysm of, 345 common, ligation of, 351 external, aneurysm of, 345 excision of, 352 ligation of, 352 injuries, 563 internal, aneurysm of, 345 ligation of, 352 circumflex, ligation of, 359 epigastric, ligation of, 359 facial, ligation of, 352 fatty degeneration of, 339 femoral, aneurysm of, 346 ligation of, 359 iliac, aneurysm of, 346 common, ligation of, 356 external, ligation of, 357 internal, ligation of, 357 innominate, aneurysm of, 345 ligation of, 350 ligation of, 350 gangrene from, 73 lingual, ligation of, 352 middle meningeal, injuries of, 563 occipital, ligation of, 352 popliteal, ligation of, 360 radial, ligation of, 356 subclavian, aneurysm of, 345 ligation of, 354 surgical diseases of, 337 temporal, ligation of, 35 thyroid, inferior, ligation of, 353 tibial, anterior, ligation of, 360 posterior, ligation of, 360 ulnar, ligation of, 356 vertebral, ligation of, 353

Arteriorrhaphy in treatment of aneurysm, 348

Arteriosclerosis, 339

Arteriotomy, 183

Arteriovenous aneurysm, 344, 564

Arteritis, 338

Arthrectomy, 400

Arthritis, 382 chronic, 386 treatment of, 386 deformans, 387 treatment of, 389 gonorrheal, 392 postgonorrheal, 152, 392 of jaw, 667 rheumatoid, 387 syphilitic, 385 tuberculous, 393 diagnosis of, 398 pathology of, 394 symptoms of, 397 treatment of, 398

Arthropathic joint disease, 394

Arthrotomy, 400

Artificial respiration, 204 Howard’s method, 204 Marshall Hall’s method, 204 in shock, 180 Sylvester’s method, 204

Ascites, chylous, 368

Ascitic tuberculous peritonitis, 791

Asepsis, 243 sterilization, 243 by boiling water, 244 of dressings, 247 by formalin, 244 fractional, 244 of hands, 245 by heat, 243 of instruments, 246 by mustard flour, 245 of sponges, 247 of suture materials, 247

Aseptic wound fever, 85. _See_ Surgical fever.

Aspergillus fungi, 56

Aspiration, paracentesis by, 184

Asthma, thymic, 163

Astomia, 638

Astragalectomy, 467

Astragalus, dislocation of, 544

Atheroma of arteries, 339

Atheromatous abscess, 73, 339 cysts of neck, 707 of skin, 310 ulcer, 339

Atresia of rectum, 872

Atrophic elongation of bones, 436

Atrophy of bone, 422 of brain, 578 definition of, 26 of muscles, 332 treatment of, 332 pathological, 26 physiological, 26 senile, 26 of skull, 547 of testicle, 1015 trophoneurotic, 27 of veins, 361

Auricle, rodent ulcer of, 606

Auricles, supernumerary, 605, 638

Auto-intoxication, 79 cause of, 79 ferments in, 79 intestinal putrefaction in, 81 osmotic pressure of blood in, 80 potassium salts in, 80 treatment of, general, 83 venesection in, 80 urea in, 80, 81

Axilla, syphilis of, 751 tuberculosis of, 751

Axillary artery, aneurysm of, 345 ligation of, 355

B

BACILLUS aërogenes capsulatus, 55 anthracis, 54 bubonic plague, 54 chancroid, 55 coli communis, 53 diphtheriæ, 54 lepræ, 54 mallei, 54 œdematis maligni, 54 pneumoniæ, 54 proteus, 53 pyocyaneus, 53 of Rauschbrand, 55 of rhinoscleroma, 54, tetani, 54 of tuberculosis, 54 typhi abdominalis, 53

Bacteria of pus formation, 51 facultative pyogenic, 53 bacillus aërogenes capsulatus, 55 anthracis, 54 bubonic plague, 54 chancroid, 55 diphtheriæ, 54 lepræ, 54 mallei, 54 œdematis maligni, 54 proteus, 53 pneumoniæ, 54 of Rauschbrand, 55 of rhinoscleroma, 54 tetani, 54 tuberculosis, 54 typhi abdominalis, 53 obligate pyogenic, 52 bacillus, pyocyaneus, 53 coli communis, 53 colon bacillus, 53 diplococcus pneumoniæ, 53 micrococcus gonorrhœæ, 53 lanceolatus, 53 tetragenus, 53 staphylococcus pyogenes albus, 52 aureus, 52 epidermidis, 52 streptococcus erysipelatus, 52 pyogenes, 52

Bacterial determination of pus as an indication to treatment, 57

Balanitis, 149, 1005

Balanoposthitis, 149, 1005

Bandage, elastic, for control of hemorrhage, 234

Bandaging, 189 kinds of, 189, 190, 191 materials used in, 191

Banti’s disease, 31, 942

Barbadoes leg, 372

Barrel-shaped chest, 719

Barton’s head bandage, 191

Basedow’s disease, 713

Bassini’s operation for hernia, 902

Bastard clap, 148

Bed-sores, a cause of gangrene, 74

Bees, poisoning by, 172

Bell’s palsy, 640

Bellocq’s cannula, 681

Bennett’s fracture, 506

Beta-cocaine, 207

Beta-eucaine, 207

Bichat, fatty ball of, 641

Bier’s osteoplastic amputation of leg, 1028 permanent hyperemia in tuberculosis, 120 treatment of tuberculosis of joints, 399

Biett’s collarette, 131

Bifid penis, 1004 tongue, 652

Biliary calculi, 922 diagnosis of, 925 symptoms of, 924 treatment of, 926 colic, 922 symptoms of, 924 ducts, stricture of, 921 fistulas, 917 intestinal, 917 pathological, 917 postoperative, 917 passages, catarrh of, acute, 918 treatment of, 918 chronic, 918 injuries of, 918 operations on, 927 perforation of, 921 ulceration of, 921 symptoms of, 922 treatment of, 922

Billroth’s chain-stitch suture, 241

Biskra button, 309

Bladder, adenocarcinoma of, 992 adenoma of, 992 calculi of, 986 symptoms of, 986 treatment of, 987 congenital malformations of, 977 dermoid cysts of, 992 ectopia of, 978 treatment of, 978 examination of, 977 exstrophy of, 978 treatment of, 978 fibroma of, 992 foreign bodies in, 982 inflammation of, 984 symptoms of, 984 treatment of, 985 injuries to, 981 treatment of, 981 myxoma of, 992 papilloma of, 992 siphonage of, 1003 tuberculosis of, 118 tumors of, 992 symptoms of, 992 treatment of, 992 wounds of, 233

Blastomycetic dermatitis, 309 lesions of mouth, 658 pus, 56

Blennorrhea, 146. _See_ Gonorrhea.

Blepharitis, 601 marginalis, 601

Blepharoplasty, 602 Arlt’s method for, 602 Dieffenbach’s method for, 603 Fricke’s method for, 603 Richet’s method for, 603

Blood, abstraction of, 182 by arteriotomy, 183 by cupping, 183 by leeching, 183 by venesection, 182 extravasation of, gangrene from, 73 foreign bodies in, 35 formed elements of, 29 glycogen in, 33 infusion of, 185 intravenous, 186 iodine reaction of, 33 osmotic pressure of, in auto-intoxication, 80 microörganisms in, 35 platelets, 30 surgical pathology of, 28 transfusion of, 185

Bloodvessels, injuries of, 216 suture of, 349 end-to-end, 350 lateral, 349 wounds of, 216

Boils, 304 oriental, 309 treatment of, 304

Bones, abscess of, 419, 425 treatment of, 426 achondroplasia, 432 acromegaly, 437

## actinomycosis of, 432

atrophic elongation of, 436 atrophy of, 422 caries of, 427 cavalryman’s, 331 cavities, filling of, 431 cranial, acromegaly of, 548 injuries of, 552 leontiasis of, 548 osteomyelitis of, 548 periostitis of, 548 dancer’s, 331 diseases of, parasitic, 432 trophoneurotic, 432 epiphysitis of, acute, 421 exostoses of, 441 fencer’s, 331 fibroma of, 438 fragility of, 435 senile, 436 hydatid disease of, 432 treatment of, 432 hyperostoses of, 441 hypertrophy of, 422 injuries of, 218 leontiasis of, 438 myeloma of, 442 myxoma of, 441 necrosis of, 428 pathological, 428 toxic, 428 treatment of, 428 traumatic, 428 osteoarthropathic hypertrophiante pneumique, 436 osteoma of, 441 osteomalacia of, 434 prognosis of, 434 treatment of, 435 osteomyelitis of, acute, 416 complications of, 419 diagnosis of, 419 etiology of, 419 organisms at fault in, 417 pathology of, 416 prognosis of, 418 symptoms of, 418 treatment of, 419 chronic, 421 tuberculous, 423 latent, 421 osteoporosis of, 422 osteopsathyrosis, 435 osteosclerosis of, 422 ostitis deformans, 436 Paget’s disease of, 436 periostitis, acute infectious, 420 causes of, 421 treatment of, 421 albuminosa, 421 rachitis, 433 rider’s, 331 sarcoma of, 441 treatment of, 441 sequestrum formation of, 429 treatment of, 429 of skull, incomplete formation of, 547 syphilis of, 135, 426 transplantation of, 431 tuberculosis of, 116, 422 acute miliary, 423 pathology of, 423 symptoms of, 423 treatment of, 425 tumors of, 438 cartilaginous, 440

Boric acid, toxic effects of, 175

Bow-leg, 465 treatment of, 465

Brachial artery, ligation of, 355 plexus, operations on, 623

Brain, abscess of, 567 symptoms of, 568 prognosis of, 569 treatment of, 573 atrophy of, 578 compression of, 560 symptoms of, 561 prognosis of, 562 treatment of, 562 concussion of, 559 treatment of, 559 contusion of, 559 symptoms of, 560 treatment of, 560 cysts of, congenital, 578 foreign bodies in, 565 hernia of, 566 treatment of, 566 prolapsus of, 566 treatment of, 566 substance, injuries of, 564 lacerations of, 564 prognosis of, 564 symptoms of, 565 syphilis of, 138 tumors of, 582 symptoms of, 583 treatment of, operative, 585

Brasdor’s method of treating aneurysm, 347

Breast, abscess of, 757

## actinomycosis of, 759

adenoma of, 760 anomalies of, 755 cancer of, 761 treatment of, 763 contusions of, 756 cysts of, 760 fibroma of, 760 hemorrhages from, 755 hypertrophy of, 756 inflammation of, 756 injuries of, 756 lipoma of, 760 neuralgia of, 758 treatment of, 758 nipple of, chancres of, 759 eczema of, 316 fissure of, 756 Paget’s disease of, 316, 756 operations on, 764 syphilis of, 759 tuberculosis of, 759 treatment of, 759 tumors of, 760 treatment of, 760

Bronchocele, 712

Brophy’s operation for cleft palate, 654

Bruns’ method of amputation of foot, 1042

Bubo, chancroidal, 144 syphilitic, 128

Bubonic plague, bacillus of, 54

Bubonocele, 893

Bunion, 263, 311 radical cure of, 333 (note) treatment of, 311

Burba, exostosis, 272

Burns, 300 of abdominal wall, 783 of face, 639 of respiratory passages, 675 treatment of, 301

Bursæ, adventitious, 263 prepatellar, 263 surgical diseases of, 332 synovial, 332 syphilis of, 136 tuberculosis of, 116

Bursal cysts of neck, 707

Bursitis, acute, 333 chronic, 333

C

CALCIFICATION of arteries, 339 of thrombus, 36 of veins, 361

Calculi, biliary, 922 diagnosis of, 925 symptoms of, 924 treatment of, 926 of nose, 672 pancreatic, 954 of tonsils, 663

Calculus, renal, 965 diagnosis of, 965 symptoms of, 965 treatment of, 966 of ureter, 973 vesical, 986 symptoms of, 986 treatment of, 987

Canal of Nuck, hydrocele of, 261

Cancer. _See_ Carcinoma. en cuirasse, 289, 784

Cancerous ulcers of intestines, 827

Cancers of branchiogenic origin, 698, 709

Cancrum oris, 75, 658

Capillary angioma, 277

Capsulotomy, 956

Caput succedaneum, 549

Carbolic acid, toxic effects of, 175

Carbuncle, 305 of neck, 704 treatment of, 305

Carcinoma, 289 of abdominal wall, 784 acinous, 290 of breast, 761 treatment of, 763 characteristics of, 289 colloid, 289 corset, 289 diagnosis of, from sarcoma, 293 duct, 290 encephaloid, 289 of esophagus, 744 of gall-bladder, 927 general considerations of, 294 of heart, 336 of intestines, large, 870 small, 828 treatment of, 828 jacket, 289 of jaw, 668 of kidney, 969 of liver, 914 of lung, 732 of lymph nodes, 289, 376 mesentery, 939 miliary, 289 pancreas, 953 prostate, 1002 rectum, 886 treatment of, 887 relation of, to other diseases, 295 scirrhus, 289 of skin, 315 of spine, 462 of spleen, 943 of stomach, 801 symptoms of, 802 treatment of, 803 of testicle, 1017 of thorax, 730 treatment of, 295 liquid air in, 296 radium in, 296 toxins of erysipelas in, 296 ultraviolet light in, 296 _x_-rays in, 297

Cardicentesis of pericardium, 336

Cardiolysis, 337

Cardiospasm, 798 operation for, 808 symptoms of, 798 treatment of, 798

Caries of bone, 427 dental, 657, 664 treatment of, 665 of hip, 452 diagnosis of, 454 prognosis of, 454 symptoms of, 453 treatment of, 454 of spine, 444

Carotid arteries, aneurysm of, 345 common, ligation of, 351 external, excision of, 352 ligation of, 352 injuries of, 563 internal, ligation of, 352 body, diseases of, 709

Carpus, dislocations of, 536

Cartilages, semilunar, dislocation of, 543

Castration, 1022

Cataract, 597

Catarrh of biliary passages, acute, 918 treatment of, 918 chronic, 918

Catarrhal cholecystitis, 919 ulcers of rectum, 876

Catgut, sterilization of, 247

Catheterization, 186 catheters used in, 186 complications of, 187 ureteral, 958

Catheters, care of, 186

Cautery, actual, 184

Cavalryman’s bone, 331

Cavernitis, 1009

Cavernous lymphangioma, 278 tumors, 277

Cecum, cancer of, 870

Celiotomy, 773

Cellulitis, gangrenous, of abdominal wall, 783 of orbit, 592 of scalp, 545

Celluloid thread, sterilization of, 248

Cementoma, 281

Cenencephaloceles, 577

Centipedes, poisoning by, 172

Cephalalgia, treatment of, 582

Cephalhematoma, 263 neonatorum, 549

Cephalocele, 576 treatment of, 578

Cerebellar tumors, treatment of, operative, 585

Cerebral conditions in rickets, 162 palsies, 478 treatment of, 478 sclerosis in rickets, 162

Cervical lymph nodes, affections of, 705 plexus, deep posterior, operations on, 618 sympathetic nerve, operations on, 618

Chalazion, 601

Chancre, diagnosis of, from chancroid, 145 of nipple, 759 of rectum, 876 syphilitic, 126

Chancroid, 144 bacillus of, 55 bubo in, 144 diagnosis of, 144 from chancre, 145 from herpes, 145 extragenital, 145 mixed, 145 phagedenic, 144 prognosis of, 145 treatment of, 145

Chancroidal bubo, 144

Charbon, 106. _See_ Anthrax.

Charcot’s artery of hemorrhage, 564 disease of elbow, 390

Cheek, tumors of, dermoid, 641

Cheiloplastic operations, 648

Chemotaxis, 41, 44 negative, 45 positive, 45

Chest, concussion of, 721 treatment of, 722 contusion of, 721 treatment of, 722 wounds of, 722 treatment of, 723

Chilblains, 299

Chimney-sweeper’s cancer, 287, 316

Chin, galoche, 638 malformation of, 638

Chlorosis, 31

Cholangiostomy, 928

Cholangiotomy, 928

Cholangitis, acute, 918, 920 treatment of, 918 chronic, 918 suppurative, 919 diagnosis of, 920 symptoms of, 919 treatment of, 921

Cholecystectomy, 929

Cholecystendysis, 930

Cholecystenterostomy, 928

Cholecystitis, acute, 919 diagnosis of, 920 from appendicitis, 857 phlegmonous, 920 symptoms of, 919 treatment of, 921 chronic catarrhal, 919 gangrenous, 920 obliterans, 919

Cholecystostomy, 929

Cholecystotomy, 929

Choledochenterostomy, 928

Choledochostomy, 928

Choledochotomy, 928

Cholehepatopexy, 933

Cholelithiasis, 922 diagnosis of, 925 symptoms of, 924 treatment of, 926

Cholelithrotrity, 928

Cholera, secondary infection in, 166

Chondritis, 683

Chondroma, 271 of jaw, 668 of testicle, 1017 of thorax, 730 treatment of, 272

Chondrosarcoma, 274

Chopart, mediotarsal amputation of, 1037

Chordee, 149

Chorion epithelioma, malignant, 292

Choroid, tuberculosis of, 595

Chromicized gut, 247

Chromocystoscopy, 958

Chylocele, 372

Chylothorax, 735

Chylous ascites, 368 fistula, 368 hydrocele, 372 hydrothorax, 368

Chyluria, 373

Cicatrices, horns growing from, 283

Cicatricial keloid, 70

Ciliary body, diseases of, 598

Circumcision, 1010

Circumflex artery, ligation of, 359

Cirrhosis of pancreas, 950

Cirsoid aneurysm, 278, 339, 344

Clap, 146. _See_ Gonorrhea. bastard, 148

Clavi, 311

Clavicle, dislocations of, 529 congenital, 718 treatment of, 529 fractures of, 493 treatment of, 493

Cleft palate, 652 operation for, 654

Clitoris, hypertrophy of, 1007

Clove hitch knot, 241

Club-foot, 465 congenital, 466 treatment of, 466

Coagulation necrosis, 57

Cocaine, 205

Cocainization, intraspinal, 207

Coccidioidal granuloma, 309

Coccodynia, 636

Coccygeal sinus, 635 tumors, 627 congenital, 635

Coccygodynia, 636

Cohnheim’s embryonal hypothesis of cause of tumors, 256

Cold abscess, 112 diagnosis of, 113 lumbar, 114 peri-articular, treatment of, 399 psoas, 114 retropharyngeal, 114 treatment of, 114

Colic, biliary, 922 diagnosis of, 925 symptoms of, 924 treatment of, 926 renal, 964 treatment of, 964

Colitis, diagnosis of, from appendicitis, 857

Collapse, 177

Collar-button abscess, 319

Colles’ fracture, 503 treatment of, 504 law in syphilis, 139

Colloid goitre, 713

Coloboma, 600

Colon bacillus, 53 syphilis of, 869 tuberculosis of, 869

Colopexy, 850

Colostomy, 874, 888

Coma carcinomatosum, 82

Compression apoplexies, 560 of brain, 560 prognosis of, 562 symptoms of, 561 treatment of, 562

Concussion of brain, 559 treatment of, 559 of chest, 721 treatment of, 722 of spine, 628 treatment of, 629

Condyles, fracture of, 498

Condylomas, 282, 312

Congenital abnormalities of testicle, 1014 adenoma of kidney, 969 affections of thyroid, 710 anomalies and defects of kidneys, 955 of intestines, large, 869 small, 822 of neck, 698 of pancreas, 944 of spleen, 940 of ureters, 955 coccygeal tumors, 635 conditions of skull, 547 cysts of abdominal wall, 783 of brain, 578 defects of anus, 872 of diaphragm, 752 of lips, 638 of mouth, 652 of penis, 1004 of rectum, 872 dislocations, 526 of hip, 471 diagnosis of, 473 treatment of, 474 displacements of liver, 910 hernia, 890 diaphragmatic, 897 inguinal, 897 hypertrophy, definition of, 26 lymphangioma of ear, 606 macroglossia, 652 malformations of bladder, 977 of ear, 604 of esophagus, 737 treatment of, 738 of respiratory passages, 671 of stomach, 793 of thorax, 718 occlusion of lymph vessels, 369 rickets, 161 tumors of scalp, 546 varices, 364 venous nevus, 367

Congestion, 19 neuroparalytic, 20 neurotonic, 20 results of, 22 acute swelling, 22 chronic swelling, 22 gangrene, 22 nutritional changes, 23 resolution, 22 treatment of, 23

Conical stump, definition of, 27

Conjunctival sac, diphtheria of, 599 gonorrhea of, 599

Continuous suture, 241

Contractures of muscles, 332 treatment of, 332

Contusions, 211 of abdominal wall, 781 of bloodvessels, 216 of brain, 559 symptoms of, 560 treatment of, 560 of breast, 756 of chest, 721 treatment of, 722 of face, 639 of muscles, 329 of testicle, 1015 treatment of, 212 of viscera, 219

Copremia, 83

Coracoid process, fracture of, 495

Cord, spermatic. _See_ Spermatic cord. spinal. _See_ Spinal cord.

Cornea, diseases of, 598 syphilis of, 137

Corns, 311

Corpora cavernosa, syphilis of, 138

Corpus cavernosum, inflammation of, 1009

Corrosive sublimate, toxic effects of, 175

Counterirritation, 183 by actual cautery, 184 by rubefacients, 183 by seton, 184 by vesicants, 184

Cowperitis, 150

Coxa vara, 475 diagnosis of, 476 symptoms of, 476

Coxitis, 452

Cranial bones, acromegaly of, 548 injuries of, 552 leontiasis of, 548 osteomyelitis of, 548 periostitis of, 548 meningoceles, 263 nerves, injuries of, 612 rickets, 547

Craniectomy, 580

Craniofacial sinuses, accessory, operations on, 608

Craniotabes, 547 rachitica, 162

Craniotomy, 580

Cranium, injuries of soft parts of, 551 operations on, 587 septic affections within, 567 abscess of brain, 567 encephalitis, 513 leptomeningitis, 572 meningitis, 571 pachymeningitis externa, 572 interna, 572 sinus phlebitis, 571 thrombosis, 570 trephining of, 587 wounds of, gunshot, 565 treatment of, 565

Crile’s pneumatic suit in shock, 180

Croupous exudates, 23

Crural nerve, anterior, operations on, 623

Cryptogenetic septicemia, 87

Cryptorchidism, 1014 treatment of, 1014

Cupping, 183

Cutaneous horns, 283, 311 growing from cicatrices, 283 nail, 283 sebaceous, 283 treatment of, 311 warty, 283 myxoma, 276

Cylindroma, 275 of skin, 315

Cystic degeneration, 264 of testicle, 260 kidney, 969

Cysticercus, 310

Cystinuria, 82

Cystitis, 984 gonorrheal, 151 postoperative, 985 symptoms of, 984 treatment of, 985 tuberculous, 985

Cystoma, ovarian, 284

Cystoscope, Nitze’s, 993

Cystoscopic examination, 958, 977

Cysts, 259 of abdominal wall, congenital, 783 apoplectic, 952 of bladder, 992 of brain, congenital, 578 of breasts, 760 degeneration, 264 dermoid, 264 glandular, 261 hydatid, 263 hydroceles, 261 of iris, 594 of liver, hydatid, 913 treatment of, 913 of lung, echinococcus, 732 hydatid, 732 lymph, 278 of mesentery, 940 of neck, 707 atheromatous, 707 bursal, 707 dermoid, 707 sanguineous, 701, 707 thyrohyoid, 707 neural, 263 of omentum, 935 of orbit, dermoid, 593 parasitic, 593 of pancreas, 951 diagnosis of, 952 symptoms of, 952 treatment of, 952 pseudo-, 262 retention, 259 sebaceous, 285 of skin, 310 atheromatous, 310 echinococcus, 310 sebaceous, 310 treatment of, 310 of spine, 627 of spleen, 943 of Stenson’s duct, 641 of testicle, 1016 of tongue, retention, 659 tubulo, 260

D

DACRYO-ADENITIS, acute, 599

Dacryocystitis, 600 treatment of, 600

Dacryopic cysts, 262

Dactylitis, 136

Dancer’s bone, 331

Davey’s method of amputation of hip-joint, 1045

Deciduoma malignum, 292

Degeneration, cystic, 264

Delhi boil, 309

Delirium tremens, 174 treatment of, 174

Dental caries, 657, 664 secondary infection in, 169 treatment of, 665

Dentigerous cysts, 666

Dermatitis, blastomycetic, 309 calorica, 299 treatment of, 299 of radio-active origin, 303

Dermatolysis, 313

Dermoid cyst of bladder, 992 of neck, 707 of omentum, 935 of orbit, 593 of scalp, 546 of testicle, 1016 tumors of cheek, 641 of lung, 732

Dermoids, 264 ovarian, 267 sequestration, 265 tubulo, 266

Desault’s bandage, 190

Desmoids, 271 treatment of, 271

Diabetes a cause of gangrene, 74

Diaphragm, congenital defects of, 752 paralysis of, 753 rupture of, 721, 753 treatment of, 722 tumors of, 753 wounds of, 725, 753 treatment of, 726

Diaphragmatic hernia, 897 acquired, 897 congenital, 897

Dieffenbach’s operation for blepharoplasty, 603

Digital compression for control of hemorrhage, 235

Dilatation of stomach, 793, 795 acute, 795 symptoms of, 796 treatment of, 796 chronic, 796 operation for, 811

Diphtheria, bacillus of, 54 of conjunctival sac, 599 of mouth, 657 secondary infection in, 168

Diphtheritic exudates, 23

Diplococcus pneumoniæ, 53

Disarticulations, 1023

Dislocations, 524 of ankle, 544 of astragalus, 544 of carpus, 536 of clavicle, 529 treatment of, 529 complicated, 524 compound, 524 congenital, 524, 526 diagnosis of, 525 of elbow, 534 treatment of, 536 of fibula, 544 of foot, 544 treatment of, 544 habitual, 524 of hand, 536 of hip, 537 classification of, 537 congenital, 471 diagnosis of, 473 treatment of, 474 signs of, 538 symptoms of, 538 treatment of, 539 unreduced, 542 of jaw, 667 lower, 527 treatment of, 528 of knee, 543 symptoms of, 544 treatment of, 544 of larynx, 528 of lens, 604 metacarpophalangeal, 536 treatment of, 537 of nerves, 624 of patella, 543 treatment of, 543 pathological, 524, 526 of penis, 1008 of radius, 536 recurrent, 524 of ribs, 529 of semilunar cartilages, 543 of shoulder-joint, 530 anterior, 530 diagnosis of, 532 downward, 530 posterior, 530 subclavicular, 531 subcoracoid, 531 subglenoid, 531 subspinous, 532 symptoms of, 532 treatment of, 532 Kocher’s method, 533 upward, 530 of spine, 631 treatment of, 632 of sternum, 528 symptoms of, 525 of tendons, 330 of tibia, 543 traumatic, 524 treatment of, 527 of ulna, 536 of wrist, 536

Dissecting aneurysm, 339, 342

Diverticulitis, 822

Diverticulum, Meckel’s, 262, 822 pharyngeal, 262 vesical, 262

Downes’ electrothermic clamp, 236

Drainage tubes, sterilization of, 248

Dressings, sterilization of, 247

Duct carcinoma, 290 salivary, fistulas of, 649 foreign bodies in, 648 thoracic, injuries to, 725 treatment of, 726

Duodenal ulcers, 825 symptoms of, 825 treatment of, 826

Duodenostomy, 806

Duodenotomy, 928

Dupuytren’s contraction, 319 treatment of, 320

Dysenteric ulcers of intestines, 827

Dysentery, secondary infection in, 166

E

EAR, auricles of, supernumerary, 605 congenital malformations of, 604 epithelioma of, 605 external auditory canal, diseases of, 607 foreign bodies in, 606 keloid of, 605 lymphangioma of, 606 middle, diseases of, 607 neoplasms of, 605 overlapping, 605 papilloma of, 605 rodent ulcer of, 606 syphilis of, 137 tumors of, 605

Ecchondroses, 272

Echinococcus cyst of lung, 732 of skin, 310

Ectasine, 85

Ecthyma, 132

Ectopia of bladder, 978 treatment of, 978

Eczema of nipple, 316

Edema, definition of, 22 gangrene from, 73 of glottis, 699 of larynx, 683 malignant, 75, 108 bacillus of, 54 definition of, 108 postmortem appearances of, 108 prognosis of, 108 symptoms of, 108 treatment of, 108

Edematous ulcers, 67

Effusion, definition of, 22

Elbow, amputation of, 1031 Charcot’s disease of, 390 dislocations of, 534 treatment of, 536 excision of, 410

Electroconductivity of urine, 959

Electrothermic clamp, 236

Elephantiasis, 370 of hand, 370 of leg, 370 of penis, 370 of scrotum, 371 of vulva, 371

Elongation of nerves, 612 of uvula, 682

Embolism, 38 air, 38 fat, 39 prognosis of, 40 symptoms of, 40 treatment of, 40 following abdominal operations, 784 gangrene from, 73 of mesenteric vessels, 938 of veins, 363

Embryonal adenosarcoma, 268 hypothesis of the cause of tumors, 256

Emphysema, gangrenous, 75, 108

Emprosthotonos, 100

Empyema of appendix, 860 definition of, 62 of gall-bladder, 919 of lung, 736

Encephalitis, 573

Encephalocele, 576 of orbit, 593

Encysted hydrocele of testicle, 260, 261

Endarteritis, 338

Endocarditis, secondary infection in, 169 ulcerative, in septicemia, 88

Endoscope, use of, 158

Endothelioma, 274 of abdominal wall, 784 of jaw, 668 of liver, 914 of lung, 732 of orbit, 593 of thyroid, 712

Endotracheal goitre, 713

Enterocele, 892

Enterocolitis, diagnosis of, from appendicitis, 857

Enteroplication, 850

Enteroptosis, 967

Enterosepsis, 83

Enterostomy, 789, 849

Entropion, 601

Enucleation of globe of eye, 596

Eosinophilia, 30

Epicanthis, 600

Epidermoids, 264

Epididymitis, 151, 1016 treatment of, 1017

Epigastric artery, ligation of, 359

Epiglottis, diseases and injuries of, 683

Epilepsy, Jacksonian, 581 treatment of, 581

Epiphysitis, acute, 421

Epiplocele, 892

Epispadias, 1005 balanic, 1005 penile, 1005

Epistaxis, 680 treatment of, 681

Epithelial molluscum, 312 odontomas, 281

Epithelioma, 286 of abdominal wall, 784 diagnosis of, from tuberculosis, 293 of ear, 605 of face, 640 of jaw, 668 of larynx, 687 lymph nodes in, 286 malignant chorion, 292 microscopic appearances of, 285 of orbit, 593 of penis, 1010 seats of, 286 of skin, 315 diagnosis of, 315 treatment of, 315 suprarenal, 292 of tongue, 660 treatment, 660

Epulis, 270, 668

Equinia, 105. _See_ Glanders.

Erectile tumors, 277

Erethistic ulcers, 66

Eruptions in septicemia, 88

Erysipelas, 93 of abdominal wall, 783 definition of, 93, 94 diagnosis of, 95 epidemic form, 93 etiology of, 93 idiopathic, 93, 94 of mouth, 657 organism relation to streptococcus, 93 pathology of, 93 phlegmonous, 75, 93 postmortem appearances of, 95 prognosis of, 95 of scalp, 545 symptoms of, 94 toxin in treatment of carcinoma, 296 traumatic, 93, 94 treatment of, 95 wandering, 94

Erysipelatous laryngitis, 95 pneumonia, 95

Erythroblasts, definition of, 29

Esmarch’s bandage, 234

Esophageal bougies, 743 hemorrhoids, 365 snare, 740

Esophagectomy, 745

Esophagismus, 742

Esophagoscope, 740

Esophagotomy, 745

Esophagus, anatomy of, 737 cancer of, 744 diverticula of, 737 externalization of, 746 foreign bodies in, 739 treatment of, 740 hemorrhage of, 744 malformations of, 737 operations on, 745 perforation of, 742 resection of, transthoracic, 745 rupture of, 741 stricture of, 742 wounds of, 741

Esthiomene, 876

Estländer’s cheiloplastic operation, 648

Ether, 193 accidents from, 194

## action of, 194

administration of, 195 narcosis by rectum, 196 petroleum, 199

Ethmoidal sinus, operations on, 610

Ethyl bromide, 198 chloride, 199 local use of, 199

Eucaine, 207

Excision of ankle, 414 of elbow, 410 of fingers, 412 of foot, 415 of hand, 412 of heel, 414 of hip, 412 of joints, 407 of knee, 413 of shoulder, 409 of wrist, 411

Exophthalmic goitre, 713 treatment of, 714

Exophthalmos, 594 treatment of, 594

Exostoses, 272 of bone, 441

Exstrophy of bladder, 978 treatment of, 978

Extragenital chancre, 127, 145

Extravasation of blood, gangrene from, 73

Exudates, 23 croupous, 23 difference between hyperemic and inflammatory, 23 diphtheritic, 23 fibrinous, 23 interstitial, 23 mixed, 23 mucous, 23 parenchymatous, 23 serous, 23

Eye, accommodation of, defects of, 604 globe of, enucleation of, 596 muscles of, defects of, 604 nerves of, disturbances of, 604 sclerotic of, rupture of, 604 syphilis of, 136, 597

Eyeball, injuries of, 603 treatment of, 604

Eyelids, blepharitis, 601 marginalis, 601 chalazion, 601 coloboma, 600 ectropion, 602 Arlt’s operation for, 602 Dieffenbach’s operation for, 603 Fricke’s operation for, 603 Richet’s operation for, 603 entropion, 601 epicanthis, 600 hordeolum, 600 stye of, 600 trichiasis, 601 xanthelasma, 601

F

FACE, absence of, 638

## actinomycosis of, 640

arteries of, ligation of, 352 burns of, 639 contusions of, 639 epithelioma of, 640 gangrene of, 640 malformations of, acquired, 639 nerves of, injuries of, 640 operations on, 642 syphilis of, 640 tuberculosis of, 640 tumors of, 641 ulcers of, 640 wounds of, 229, 639

Facial artery, ligation of, 352 bones, fractures of, 489 nerve, operations on, 616 neuralgia, 640 palsy, neuro-anastomosis for, 616 paralysis, 640

Facultative pyogenic organisms, 53

Farcy, 105. _See_ Glanders.

Fasciæ, contraction of, 319 treatment of, 320

Fat embolism, 39 prognosis of, 40 symptoms of, 40 treatment of, 40

Fatty degeneration of arteries, 339 of veins, 361

Fecal fistula, 839 impaction, intestinal obstruction from, 832

Feet, arthritis deformans of, 388

Fehleisen’s coccus, 93

Felon, 328

Femoral artery, aneurysm of, 346 ligation of, 359 hernia, 895 treatment of, 908

Femur, fractures of, 509 diagnosis of, 511 lower end, 513 treatment of, 513 prognosis of, 511 shaft, 513 treatment of, 512

Fencer’s bone, 331

Fetal infection, 48 rickets, 181, 433

Fibrin, 28

Fibrinoplastic tuberculous peritonitis, 791

Fibrinous exudates, 23

Fibro-adenoma, 284

Fibro-epithelioma, 282

Fibrokeratomas, 311

Fibroma, 269 of abdominal wall, 784 of bladder, 992 of bone, 438 of breast, 760 desmoids, 271 epulis, 270 of jaw, 668 keloid, 270 of liver, 914 molluscum, 313 treatment of, 313 of nasopharynx, 679 of nerves, 622 psammoma, 271 of testicle, 1017 of thorax, 729

Fibrous odontomas, 281

Fibula, dislocations of, 544 fractures of, 519 treatment of, 521

Figure-of-8-bandage of leg, 189

Filaria medinensis, 309

Filiform warts, 311

Finger, amputation of, 1029 excision of, 412 trigger, 320 treatment of, 320

Finney’s pyloroplasty, 810

Finsen light in treatment of cancer, 296

Fissured ulcers, 66

Fissures in ano, 876

Fistula, 63 causes of, 63 congenital, 63 foreign bodies, 63 necrosed material, 63 preëxisting abscess, 63 traumatic destruction of tissue, 63 chylous, 368 definition of, 63 fecal, 839 lacrymal, 600 treatment of, 63

Fistulas, biliary, 917 gastric, 801 of lips, 638 perineal, 1013 treatment of, 1013 rectal, 880 treatment of, 880 of salivary ducts, 649

Fistulous ulcers, 66

Flat-foot, 468

Floating liver, 910 symptoms of, 910 treatment of, 911

Follicular odontomas, 281 compound, 281

Folliculitis, 149, 307, 1013

Foot, amputation of, 1037, 1041 Bruns’ method, 1042

## partial, 1034

Teale’s method, 1042 club-, 465 congenital, 466 treatment of, 466 dislocations of, 544 treatment of, 544 excision of, 415 flat-, 468 fractures of, 523 Madura, 110 treatment of, 110 ulcer of, perforating, 66, 310

Forearm, amputation of, 1031 fractures of, 501 treatment of, 501

Foreign bodies in abdomen, 783 in bladder, 982 in blood, 35 in brain, 565 in esophagus, 739 treatment of, 740 in knee-joint, 402 in pharynx, 673 treatment of, 673 in rectum, 874 in respiratory passages, 672 in salivary ducts, 648 in stomach, 794 operations for, 806 symptoms of, 794 treatment of, 794 in tonsils, 663 in urethra, 1009

Formalin gut, 247

Fractures, 479 Bennett’s, 506 of clavicle, 493 treatment of, 493 Colles’, 503 treatment of, 504 comminuted, 479 complete, 479 compound, 480 treatment of, 487 delayed union in, 485 dentated, 479 depressed, 479 diagnosis of, 481 by fluoroscope, 482 by skiagram, 482 extra-articular, 479 of facial bones, 489 of femur, 509 diagnosis of, 511 prognosis of, 511 of fibula, 519 treatment of, 521 fissure, 479 of foot, 523 of forearm, 501 treatment of, 501 green-stick, 479 gunshot, 480 of hand, 507 of humerus, 495 condyles of, 498 external, 499 internal, 499 epicondyles of, 497 intercondyloid, 499 shaft of, 496 supracondyloid, 497 surgical neck of, 496 treatment of, 495 of hyoid, 491 impacted, 479 incomplete, 479 intra-articular, 479, 482 -uterine, 481 of larynx, 491, 676 of leg, 518 treatment of, 521 longitudinal, 479 of malar, 489 of maxilla, inferior, 490 treatment of, 490 superior, 489 multiple, 479 non-union in, 485 of nose, 489 oblique, 479 of olecranon, 501

## partial, 479

of patella, 516 treatment of, 517 pathological, 479 of pelvis, 507 treatment of, 508 of penis, 1008 of radius, 502 lower end of, 503 treatment of, 504 and ulna, 503 repair of, 483 ribs, 491 symptoms of, 492 treatment of, 492 of scapula, 494 acromion process of, 494 coracoid process of, 495 surgical neck of, 495 single, 479 of skull, 549, 552 base of, 556 diagnosis of, 557 prognosis of, 557 treatment of, 558 vertex of, 552 comminuted, 552 diagnosis of, 554 gunshot, 553 splintered, 552 treatment of, 555 of spine, 629 spiral, 479 spontaneous, 434 of sternum, 491 symptoms of, 492 treatment of, 492 of thigh, 509 of tibia, 518 treatment of, 521 transverse, 479 traumatic, 479 treatment of, 486 of ulna, 501 treatment of, 501 of wrist, 507 of zygoma, 489

Frambœsia, 308

Frank’s method of gastrostomy, 807

Fricke’s operation for blepharoplasty, 603

Friedländer, bacillus of, 54

Frontal abscess, 569 sinus, operations on, 609

Frostbite, 302, 639 gangrene from, 73 treatment of, 302

Fungi, 55

## actinomycis, 55

aspergillus, 56 leptothrix, 56 Madura foot, 56

Fungous granulations in tuberculosis, 115 hematodes, 276 ulcers, 66

Funicular hernia, 891 hydrocele, 261

Furuncle, 304 definition of, 60 treatment of, 304

Fusiform aneurysm, 339, 343

G

GALACTOCELE, 760

Gall-bladder, anatomy of, 915 cancer of, 927 empyema of, 919 fistulas of, 917 hour-glass, 916 malformations of, 916 operations on, 927 after management of, 932 anastomotic, 932 tumors of, 927

Gall-ducts, operations on, 928

Gallstones, 922 diagnosis of, 925 intestinal obstruction from, 833 symptoms of, 924 treatment of, 926

Galoche chin, 638

Ganglion, 327

Gangræne oris, 75

Gangrene, 22, 73 angioneurotic, 76 bed-sores a cause of, 74 causes of, 73 constitutional, 74 infectious, 75 local, 73 traumatic, 73 from chemical agents, 74 from edema, 73 from embolism, 73 from frostbite, 73 from extravasation of blood, 73 from ligation of arteries, 73 from thrombosis, 73 from tumors, 74 of face, 640 foudroyante, 75, 108 definition of, 73 diabetic, 74 dry, 76 gazeuse, 108 gross appearances of, 76 hospital, 75 of lung, 734 moist, 76 line of demarcation in, 76 mummification in, 76 noma, 75 phagedenic, 77 senile, 76 signs of, 77 of spleen, 941 spontaneous, 76 symmetrical, 74, 76 symptoms of, 77 of tongue, 659 treatment of, 77 visceral, 76

Gangrenous cellulitis of abdominal wall, 783 cholecystitis, 920 emphysema, 75, 108 pancreatitis, 946 septicemia, 108 stomatitis, 75, 658

Gaspard, putrid fever of, 81

Gasserian ganglion, operations on, 614

Gastrectasis, 796

Gastrectomy, 813

Gastric anastomosis, 816 dilatation, 793, 795 fistulas, 801 intra-abdominal, 801 tetany, 798 ulcer, 799 diagnosis of, from appendicitis, 857 operations for, 811 symptoms of, 800 treatment of, 800

Gastritis, phlegmonous, 804 symptoms of, 804 treatment of, 805

Gastro-enterostomy, 799, 811, 817

Gastrojejunostomy, 816

Gastropexy, 797, 811

Gastroplication, 811

Gastroptosis, 793, 797 Rovsing’s operation for, 813 treatment of, 797

Gastrorrhaphy, 806

Gastrostomy, 806 Frank’s method, 807 Witzel’s method, 807

Gastrotomy, 794, 806

Genitalia, chancroid of, 144 syphilis of, 138

Genito-urinary tract, infection through, 49

Genu valgum, 463 varum, 463

Giant-cell sarcoma, 274

Gigli saw, 588

Gila monster, poisoning by, 172

Gingivitis, interstitial, 657 ulcerative, 664

Glanders, 105, 308 diagnosis of, 106 etiology of, 105 incubation in, 105 organism of, 105 prognosis of, 106 symptoms of, 105 treatment of, 106

Glands, salivary, inflammation of, 649 tumors of, 650

Glandular cysts, 261, 284

Glaucoma, 597 treatment of, 597

Gleet, 155. _See_ Gonorrhea, chronic.

Glioma, 279 of retina, 595

Glossitis, 658

Glottis, edema of, 699

Gluteal hernia, 897

Glycogen in blood, 33

Glycosuria, 945 a cause of gangrene, 74

Goitre, 283, 712 colloid, 713 endotracheal, 713 exophthalmic, 713 treatment of, 714 malignant, 715

Gonococcus myositis, 331 pyemia, 152 septicemia, 152 tendovaginitis, 331

Gonorrhea, 146 chronic, 155 treatment of, 156 classification of, 148 complications of, 149 balanitis, 149 Cowperitis, 150 cystitis, 151 epididymitis, 151 folliculitis, 149 gonorrheal rheumatism, 152 lymphangitis, 151 peri-urethritis, 149 postgonorrheal arthritis, 152 prostatitis, 150 treatment of, 152 of conjunctival sac, 599 course of, 149 diagnosis of, 147 of joints, 392 of lymph nodes, 376 secondary infection in, 169 of seminal vesicles, 1021 of testicles, 151 treatment of, 151 treatment of, 152 in women, 158 treatment of, 159

Gonorrheal proctitis, 875 rheumatism, 152 synovitis, 385

Grafting of nerves, 612 of tendons, 324

Granny knot, 241

Granulation tissue, relation of, to infection, 96

Granuloma, coccidioidal, 309 of thorax, 729

Graves’ disease, 713

Gritti’s method of amputation of knee, 1044

Groin, spica bandage of, 189

Guinea worm, 309

Gumma of penis, 1009 of syphilis, 133

Gummas of tuberculosis, 114

Gummatous syphilide, 134

Gums, retrocession of, 657

Gunshot wounds, 220 of abdomen, 232 of bladder, 233 of chest, 722 diagnosis of, 225 of face, 229 foreign material in, 224 of head, 228, 565 treatment of, 565 of heart, 231 hemorrhage from, 223 of joints, 228 key-hole, 225 of kidney, 233 localizing symptoms, 223 multiple, 224 of neck, 229 pain from, 223 prognosis of, 225 of respiratory passages, 675 shock from, 223 of small intestines, 823 of spinal column, 230 of spleen, 233 of thorax, 230 treatment of, 225

H

HALL’S, MARSHALL, method of artificial respiration, 204

Halstead’s operation for cancer of breast, 766 for hernia, 904

Hammer-toe, 321 treatment of, 321

Hand, amputation of, 1031 arthritis deformans of, 388 dislocations of, 536 elephantiasis of, 370 excision of, 412 fractures of, 407

Hands, sterilization of, 245

Harcourt inhaler, 197

Hare-lip, 638 operation for, 645

Head, arteries of ligation of, 352 injuries of, 545 previous and during birth, 549 caput succedaneum, 549 cephalhematoma neonatorum, 549 depression of skull, 549 fractures, 549 surgical diseases of, 545 wounds of, gunshot, 228, 565 treatment of, 565

Heart, aneurysms of, 732 carcinoma of, 336 malposition of, 334 rupture of, 336, 732 surgical diseases of, 334 tumors of, 336 wall of, abscess of, 733 wounds of, 334, 733 gunshot, 231 suture of, 335 (note), treatment of, 335

Heel, excision of, 414

Hematoma of scalp, 218 of testicle, 1015

Hematorrhachis, 625, 634 treatment of, 634

Hematomyelia, 625, 634 treatment of, 634

Hematuria, 959 treatment of, 959

Hemiglossitis, 659

Hemoglobin, 33

Hemorrhage after abdominal operations, 780 from breast, 755 control of, 234 in amputations, 1024 by angiotribe, 236 by chemical agents, 235 by cold, 235 by destructive methods, 236 by digital compression, 235 by elastic bandage, 234 by electrothermic clamp, 236 by forced flexion, 235 by gelatin, 235 by heat, 235 by ligature, 236 by hemostats, 236 by mechanical means, 236 by pressure, 235 by styptics, 235 by torsion, 236 by tourniquet, 234 of esophagus, 744 from gunshot wounds, 223 intracranial, 563 intra-ocular, 604 intra-orbital, 592 of larynx, 683 secondary, 237 signs of, 237 treatment of, 237 of spinal cord, 625, 634 subdural, 564 traumatic intraventricular, 564

Hemorrhagic pancreatitis, 946 ulcers, 66 treatment of, 72

Hemorrhoidal veins, phlebitis of, 362

Hemorrhoids, 364, 882 esophageal, 365 treatment of, 883

Hemostats, control of hemorrhage by, 236

Hemothorax, 736

Hepatic abscess, 911 symptoms of, 912 treatment of, 912

Hepaticostomy, 928

Hepaticotomy, 928

Hepato-cholango-enterostomy, 932

Hermaphrodism, 1007

Hernia, 890 acquired, 890 causes of, 890 cerebri, 566 prognosis of, 566 treatment of, 566 classification of, 890 congenital, 890 diaphragmatic, 897 acquired, 897 congenital, 897 femoral, 895 treatment of, 908 funiculi umbilicalis, 896 funicular, 891 gluteal, 897 incarceration of, 892 infantile, 891 inflamed, 892 inguinal, 893 congenital, 894 direct, 893 indirect, 893 treatment of, 908 inguinoproperitoneal, 898 interstitial, 898 ischiatic, 897 Littre’s, 898 lumbar, 897 of lung, 725 of muscles, 330 obturator, 897 ovarian, 897 pelvic, 897 perineal, 897 postoperative, 896 treatment of, 909 properitoneal, 891, 897 reducibility of, 892 retroperitoneal, 891, 897 Richter’s, 898 scrotal, 895 signs of, 892 strangulated, diagnosis of, from appendicitis, 858 intestinal obstruction from, 829 strangulation of, 892 symptoms of, 893 taxis in, 899 traumatic, 890 treatment of, 898 Bassini’s operation, 902 Halsted’s operation, 904 Kocher’s operation, 904 McArthur’s operation, 904 Park’s operation, 905 radical cure, 901 umbilical, 896 treatment of, 909 varieties of, 893 ventral, 896 treatment of, 909

Hernial aneurysm, 339

Herpes, diagnosis of, from chancroid, 145 preputialis, 1009 zoster, 728

Heteroplasty, 602

Highmore, antrum of, operations on, 611

Hip, ankylosis of, 404 caries of, 452 diagnosis of, 454 prognosis of, 454 symptoms of, 453 muscle atrophy, 453 spasm, 453 pain, 453 treatment of, 454 dislocations of, 537 classification of, 537 congenital, 471 diagnosis of, 473 treatment of, 474 signs of, 538 symptoms of, 538 treatment of, 539 unreduced, 542 excision of, 412 -joint, amputation of, 1045 Davey’s method, 1045 McBurney’s method, 1045 Woodbury’s method, 1045 Wyeth’s method, 1045 tuberculosis of, 424

Hodgen suspension splint, 515

Hodgkin’s disease, 376 diagnosis of, 377 symptoms of, 377 treatment of, 378

Hordeolum, 600

Hornets, poisoning by, 172

Hour-glass gall-bladder, 916 stomach, 793

Housemaid’s knee, 333

Howard’s method of artificial respiration, 204

Hueter’s incision in excision of elbow, 410

Humerus, fractures of, 495 condyles of, 498 external, 499 internal, 499 epicondyles of, 497 intercondyloid, 499 shafts of, 496 supracondyloid, 497 surgical neck of, 496 treatment of, 495

Hunterian chancre, 127

Hunter’s method of treating aneurysm, 347

Hutchinson’s teeth, 140

Hydatid cysts, 263 of liver, 913 treatment of, 913 of lung, 732 of omentum, 935 of spleen, 943 disease of bone, 432 treatment of, 432

Hydatidiform mole, 292

Hydramnios, 263

Hydrarthrosis, 386

Hydrencephaloceles, 577

Hydroceles, 261, 1018 of canal of Nuck, 261 chylous, 372 of cord, 261 encysted, of spermatic cord, 1019 of testicle, 260 funicular, 261 of neck, 261 ovarian, 261 treatment of, 1018

Hydrocephalus, 263, 578 meningeus or externus, 578 prognosis of, 579 in rickets, 162 treatment of, 579 ventriculorum or internus, 578

Hydrocholecyst, 259

Hydrometra, 259

Hydronephrosis, 971 treatment of, 973

Hydrophobia, 102 diagnosis of, 104 dumb, 103 furious form, 102 incubation in, 103 paralytic type of, 103 postmortem changes in, 104 symptoms of, 103 treatment of, 104 virus of, 102

Hydrops, 333

Hydrothionemia, 82

Hydrothorax, 736 chylous, 368

Hygroma, 333

Hyoid bone, fractures of, 491

Hyperemia, 19

## active, 20

of dilatation, 21 of paralysis, 21 passive, 21 results of, 22 acute swelling, 22 chronic swelling, 22 gangrene, 22 nutritional changes, 23 resolution, 22 treatment of, 23

Hyperinosis, 28

Hypernephroma, 292, 970

Hyperostoses of bone, 441

Hyperplasia, definition of, 22, 25

Hyperthyroidism, 713

Hypertrophy, 25 of bone, 422 of breast, 756 of clitoris, 1007 congenital, 26 of lips, 638 pathological, 26 physiological, 25 of prostate, 995 diagnosis of, 996 symptoms of, 997 treatment of, 998 senile, 26 of skin, 311 of spleen, 941 of thymus, 717, 751 of thyroid, acute idiopathic, 711 intra-uterine, 711 of tonsils, chronic, 662 of veins, 361

Hypinosis, 28

Hypodermoclysis, 186

Hypognathy, 638

Hypopyon, 62, 598

Hypospadias, 1005 balanic, 1005 penile, 1005 penoscrotal, 1005 perineoscrotal, 1005

Hypostatic inflammation, 47 pneumonia, 21

I

IDIOPATHIC erysipelas, 93, 94 hypertrophy of thyroid, 711 pyemia, 91

Ignipuncture, 184

Ileus, 828

Iliac artery, aneurysm of, 346 common, ligation of, 356 external, ligation of, 357 internal, ligation of, 357

Imperforate anus, 873 rectum, 872

Implantation dermoids, 266

Incised wounds, 214 of bloodvessels, 216

Incontinence of urine, 982

Indolent ulcer, 66

Indurated ulcer, 67

Infantile hernia, 891 scorbutus, 161

Infection, auto-, 79 circumstances favoring, 46 association of organisms, 46 fetal infection, 48 habits and environment, 47 hereditary influence, 46 local predisposition, 47 preëxisting disease, 47 virulence of organism, 46 classification of, 50 mixed, 51 primary, 50 pyogenic, 51 secondary, 51 terminal, 51 tertiary, 51 relation of granulation tissue to, 96 of lymph nodes to, 96 sources of, 48 alimentary canal, 49 from flies, 50 from within system, 50 from without, 50 genito-urinary tract, 49 milk in lacteals, 50 mucous membranes, 48 respiratory tract, 49 skin, 48 tonsils, 49

Inflammation, 43 ameboid movement of cells in, 43 as cause of tumor, 256 of bladder, 984 symptoms of, 984 treatment of, 985 of breast, 756 chemotaxis in, 44 of corpus cavernosum, 1009 diapedesis of leukocytes in, 43 hypostatic, 47 of iris, 598 of jaw, 667 of kidney, 956 of larynx, 683 leukocytic increase in, 44 of mediastinum, 728 opsonins in, 44 of pancreas, 946 phenomena of, 43 of prostate, 994 of rectum, 875 of salivary glands, 649 specific irritants in, 45 of spleen, 941 of stomach wall, 804 of thymus, 717 of tongue, 658 of veins, 361

Influenza, secondary infection in, 167

Infra-orbital nerve, operation on, 613

Infusion of blood, 185 intravenous, 186

Ingrowing toe-nail, 318

Inguinal hernia, 893 congenital, 894 direct, 893 indirect, 893 treatment of, 908

Inguinoproperitoneal hernia, 898

Inhaler, Harcourt’s, 197

Innominate artery, aneurysm of, 345 ligation of, 350

Insane, othematoma of, 605

Insanity, traumatic, surgical treatment of, 582

Instruments, sterilization of, 246

Intercondyloid fracture of humerus, 499

Intercostal neuralgia, 728

Interrupted suture, 241

Interscapularthoracic amputations, 1033

Interstitial exudates, 23 gingivitis, 657 hernia, 898 pancreatitis, 950

Intestinal biliary fistulas, 917 diverticula, 262, 822 ulcers, diagnosis of, from appendicitis, 857

Intestine, large, anomalies of, 869 cancer of, 870 obstruction of, 870 from intussusception, 870 from volvulus, 870 stricture of, 870 syphilis of, 869 tuberculosis of, 869 operation on, 840 anastomotic, 842 appendicostomy, 850 colopexy, 850 colostomy, 849 enteroplication, 850 enterostomy, 849 small, 822

## actinomycosis of, 827

cancer of, 828 treatment of, 828 malformations of, acquired, 823 congenital, 822 obstruction of, acute, 828 from bands, 833 fecal impaction, 832 gallstones, 833 intestinal loops, 834 intussusception, 829 causes of, 830 symptoms of, 831 treatment of, 832 invagination, 829 neoplasms, extrinsic, 833 intrinsic, 833 peritonitis, 833 slits and apertures, 834 strangulated hernias, 829 strictures, 832 volvulus, 832 postoperative, 834 symptoms of, 834 treatment of, 836 chronic, 838 symptoms of, 838 treatment of, 839 stricture of, 827 obstruction from, 832 symptoms of, 828 treatment of, 828 syphilis of, 827 tumors of, 828 ulcers of, 825 cancerous, 827 duodenal, 825 symptoms of, 825 treatment of, 826 dysenteric, 827 tuberculous, 827 symptoms of, 827 treatment of, 827 typhoidal, 826 symptoms of, 826 treatment of, 826 wounds of, 823 gunshot, 823 symptoms of, 824 treatment of, 824 suture of, 840 Lembert’s, 841 Murphy button, 844

Intoxications, acid, from anesthetics, 203 acute, 174

Intra-abdominal gastric fistulas, 801

Intracanalicular adenofibroma, 285

Intracranial aneurysm, 345 development, defects of, treatment of, 580 hemorrhage, 563 suppurations, treatment of, 573 tumors, 582 symptoms of, 583 treatment of, operative, 585 vessels and sinuses, injuries of, 563 aneurysms following, 564 sources of, 563 subdural hemorrhage, 564 traumatic intraventricular hemorrhage, 564

Intracystic villous papilloma, 282

Intralaryngeal tumors, 686 symptoms of, 687 treatment of, 687

Intramammary abscess, 757

Intra-ocular hemorrhage, 604 tumors, 594

Intra-orbital hemorrhage, 592

Intraspinal cocainization, 207 hemorrhage, 634 treatment of, 634

Intratracheal tumors, 686

Intra-uterine hypertrophy of thyroid, 711 rickets, 432

Intraventricular hemorrhage, traumatic, 564

Intubation of larynx, 693

Intussusception of intestines, large, 870 small, 829

Invagination, intestinal obstruction from, 829 of rectum, 881 treatment of, 882

Iodine gut, 247 reaction of blood, 33 toxic effects of, 175

Iodoform, toxic effects of, 175

Iris, cysts of, 594 inflammation of, 598

Iritis, 598

Irritation as cause of tumor, 255

Ischiatic hernia, 897

Ischiorectal abscess, 879, 1013

Ivy poisoning, 173

J

JACKSONIAN epilepsy, surgical treatment of, 581

Jarvis’ snare, 678

Jaundice in appendicitis, 856

Jaws, ankylosis of, 667 dislocation of, 667 inflammation of, 667 lower, dislocations of, 527 treatment of, 528 operations on, 668 osteomyelitis of, 667 periostitis of, 667 postgonorrheal arthritis of, 667 synovitis of, acute, 667 tumors of, 668

Jejunum, peptic ulcer of, 816

Joints, ankylosis of, 403 treatment of, 405 arthritis of, 382 chronic, 386 treatment of, 386 gonorrheal, 392 osteo-, 387 treatment of, 389 postgonorrheal, 392 syphilitic, 385 tuberculous, 393 diagnosis of, 398 pathology of, 394 symptoms of, 397 treatment of, 398 diseases of, arthropathic, 394 neuropathic, 389 diagnosis of, 392 treatment of, 392 osteopathic, 394 surgical, 379 excision of, 407 of ankle, 414 of elbow, 410 of fingers, 412 of foot, 415 of hand, 412 of heel, 414 of hip, 412 of knee, 413 of shoulder, 409 of wrist, 411 hysterical, 392 treatment of, 392 inflammation of, 382 injuries to, 380 knee-, foreign bodies in, 402 movable bodies in, 401 diagnosis of, 402 symptoms of, 401 treatment of, 402 pannus of, 395 scrofula of, 393 sprains of, 380 symptoms of, 380 treatment of, 380 synovitis of, 382 acute, 383 treatment of, 383 chronic, 386 treatment of, 386 dry, 383 gonorrheal, 385 purulent, 383 symptoms of, 383 treatment of, 385 treatment of, 385 syphilis of, 135 wounds of, gunshot, 228, 381 amputation in, 381 excision in, 381 penetrating, 381

K

KAHLER’s disease of bone, 442

Kangaroo tendons, sterilization of, 248

Karyokinesis, 44

Keel-shaped chest, 718

Keller’s method of extirpating varicose veins, 366

Keloid, 270, 312 cicatricial, 70 of ear, 605 treatment of, 271, 313

Keratosis of skin, 314 treatment of, 314

Key-hole wounds, 225

Kidney, abscess of, 957 absence of, 955

## actinomycosis of, 964

adenoma of, 969 congenital, 969 anomalies of, 955 calculi of, 965 diagnosis of, 965 symptoms of, 965 treatment of, 966 carcinoma of, 969 cystic, 969 decapsulation of, 960 floating, diagnosis of, from appendicitis, 858 hemorrhage from, 959 treatment of, 959 horseshoe, 955 hydronephrosis of, 971 treatment of, 973 hypernephroma of, 970 infection of, 956 inflammations of, 956 injuries to, 955 movable and floating, 966 symptoms of, 967 treatment of, 967 multicystic, 969 operations on, 974 pain in, 956 polycystic, 969 pus in, 961 treatment of, 961 pyohydronephrosis of, 972 pyonephrosis of, 972 sarcoma of, 969 surgical, 956, 957 symptoms of, 957 treatment of, 957 syphilis of, 138, 964 tuberculosis of, 118, 961 diagnosis of, 962 symptoms of, 961 treatment of, 963 tumors of, 969 wounds of, gunshot, 233

Knee, amputation of, 1043 Gritti’s method, 1044 Sabanejeff’s method, 1044 Stephen Smith’s method, 1043 ankylosis of, 404 arthritis deformans of, 388 dislocations of, 543 symptoms of, 544 treatment of, 544 excision of, 413 housemaid’s, 333 -joint, foreign bodies in, 402 tuberculous disease of, 456 treatment of, 456

Knock-knee, 463 treatment of, 464

Knots, 242 clove hitch, 241 granny, 241 reef, 241 Staffordshire, 241

Kocher’s operation for hernia, 904 on tongue, 661 treatment of dislocations of shoulder-joint, 533

König’s cheiloplastic operation, 648 incision for excision of ankle, 415

Kyphosis, 444

L

LACERATIONS, 212 of abdominal wall, 781 of bladder, 981 of bloodvessels, 216 of brain substance, 564 prognosis of, 564 symptoms of, 565 of lung, 721 treatment of, 722 of urethra, 1008

Lacrymal fistula, 600 tract, diseases of, 599

Lacteals, milk in, infection through, 50

Laminectomy, 636

Langenbeck’s operation on tongue, 662

Laparotomy, 773 exploratory, 773

Laryngeal phthisis, 684 polypi, 686

Laryngectomy, 689

Laryngismus stridulus, 164 in rickets, 162

Laryngitis, erysipelatous, 95

Laryngoceles, 707

Larynx, chondritis of, 683 dislocations of, 528 edema of, 683 epithelioma of, 687 fracture of, 676 hemorrhage of, 683 inflammation of, 683 intubation of, 693 malformations of, 671 operations on, 688 papilloma of, 686 perichondritis of, 683 sarcoma of, 687 strictures of, 684 symptoms of, 684 treatment of, 684 syphilis of, 138, 686 treatment of, 686 tuberculosis of, 684 treatment of, 685 wounds of, 675 treatment of, 675

Leeching, 183

Leg, amputations of, 1039 Bier’s osteoplastic, 1028 circular, 1041 Pirogoff’s, 1040 elephantiasis of, 370 figure-of-8-bandage of, 189 fractures of, 518 treatment of, 521

Leiomyoma, 277

Lembert’s suture, 841

Lens, dislocation of, 604

Leontiasis, 438

Leprosy, 308 bacillus of, 54

Leptomeningitis, 572 diagnosis of, 573 prognosis of, 573 suppuration, 572 symptoms of, 572 traumatic basilar, 572 treatment of, 753

Leptothrix fungi, 56

Leukemia, 32 lymphatic, 32 pseudo-, 32 splenomedullary, 32

Leukocytes, classification of, 30 count, differential, 32 definition of, 29 diapedesis of, 43 migration of, 43 physical properties of, 40

Leukocytosis in septicemia, 88

Leukoderma, 131

Leukokeratosis, 137

Leukopenia, 30

Leukoplakia, 137, 659 treatment of, 659

Ligation of arteries, 350 abdominal aorta, 356 axillary, 355 brachial, 355 carotid, common, 351 external, 352 internal, 352 circumflex, 359 epigastric, 359 facial, 352 femoral, 359 gangrene from, 73 iliac, common, 356 external, 357 internal, 357 innominate, 350 lingual, 352 occipital, 352 popliteal, 360 radial, 356 temporal, 352 thyroid, inferior, 353 tibial, anterior, 360 posterior, 360 ulnar, 356 vertebral, 353

Ligatures, 236 fate of, 237

Lingua plicata, 652

Lingual artery, ligation of, 352 nerve, operations on, 616

Lipoma, 269 of breast, 760 dolorosa, 269 subcutaneous, 269 subserous, 269 subsynovial, 269 of testicle, 1017 of thorax, 729

Lips, absence of, 638 congenital defects of, 638 fistulas of, 638 hypertrophy of, 638 operations on, 645

Liquid air, 205 in treatment of cancer, 296

Lister’s incisions in excision of wrist, 411

Litholapaxy, 987, 988

Lithotomy, 987, 988 perineal, 990

Lithotrity, 987

Litigation spine, 628

Littre’s hernia, 898

Liver, abscess of, 911 symptoms of, 912 treatment of, 912

## actinomycosis of, 914

adenoma of, 914 aneurysms of, 914 carcinoma of, 914 congenital displacements of, 910 cysts of, hydatid, 913 treatment of, 913 endothelioma of, 914 fibroma of, 914 floating, 910 symptoms of, 910 treatment of, 911 injuries of, 911 sarcoma of, 914 syphilis of, 138, 914 tumors of, 914 wounds of, 911

Lizards, poisoning by, 172

Lock finger, 320 treatment of, 320

Lockjaw, 97. _See_ Tetanus.

Lordosis, 461

Ludwig’s angina, 658, 703

Lumbar abscess, 114 hernia, 897

Lumpy jaw, 109

Lungs abscess of, 734

## actinomycosis of, 732, 734

carcinoma of, 732 decortication of, 750 dermoids of, 732 echinococcus cysts of, 732 empyema of, 736 endothelioma of, 732 gangrene of, 734 hernia of, 735 hydatid cysts of, 732 laceration of, 721 rupture of, 725 sarcoma of, 732 syphilitic gumma of, 732 tumors of, 732 wounds of, 724 treatment of, 726

Lupus vulgaris, 306

Luxation, 524. _See_ Dislocations.

Lymph cysts, 278 nodes, 375 arrangement of, 369 carcinoma of, 376 cervical, affections of, 705 treatment of, 706 syphilis of, 705 tuberculosis of, 705 gonorrhea of, 376 in Hodgkin’s disease, 376 injuries and diseases of, 368 relation of, to infection, 96 syphilis of, 376 tuberculosis of, 376 tumors of, 378 vessels, arrangement of, 369 injuries and diseases of, 368 occlusion of, 369 acquired, 369 congenital, 369

Lymphangiectasis, 370

Lymphangioma, 278 cavernous, 278 circumscriptum, 374 treatment of, 374 of ear, congenital, 606 lymph cysts, 278 lymphatic nevus, 278 of skin, 315 treatment of, 315 treatment of, 279

Lymphangitis, 374 chronic, 375 gonorrheal, 151 treatment of, 375

Lymphatic chlorotic constitution, 163 constitution, 163 leukemia, 32 nevus, 278

Lymphatics, tuberculosis of, 116 tumors of, 378

Lymphatism, 163

Lymphedema, 369

Lymphocytosis, 30

Lymphodermia perniciosa, 164

Lymphoma, 378 malignant, 32

Lymphorrhagia, 372

Lymphosarcoma, 273, 378

Lyssophobia, 104

M

MCARTHUR’s operation for hernia, 904

McBurney’s method of amputation of hip-joint, 1045 point in appendicitis, 855

Macrocheilia, 373, 638

Macroglossia, 373, 660 congenital, 652

Macromelia, 373

Macrostoma, 638

Madura foot, 110, 309 fungi, 56 treatment of, 110

Malar bones, fractures of, 489

Malformations of anus, 872 of bladder, 977 of chin, 638 of ears, congenital, 604 of esophagus, acquired, 737 congenital, 737 treatment of, 738 of face, acquired, 639 of gall-bladder, 916 of intestines, large, 869 small, acquired, 823 congenital, 822 of larynx, 671 of nasal septum, 671 of nose, 676 of nostrils, 671 of pharynx, 671 of rectum, 872 of respiratory passages, acquired, 671 congenital, 671 treatment of, 671 of soft palate, 671 of sternum, 718 of stomach, acquired, 793 congenital, 793 of teeth, 652 of thorax, 718, 719 of tongue, 652

Malgaigne’s operation for hare-lip, 647

Malignant edema, 108. _See_ Edema, malignant. pustule, 106. _See_ Anthrax.

Mania, traumatic, 175

Marasmic thrombosis, 36

Mastitis, 756 chronic, 757 treatment of, 758

Mastodynia, 758

Mastoid disease, 574 operation, 575

Matas’ method of treating aneurysm, 348

Maxilla, inferior, fractures of, 490 treatment of, 490 superior, fractures of, 489

Maxillary sinus, operations on, 611

Measles, secondary infection in, 167

Meatotomy, 155

Meckel’s diverticulum, 822

Median nerve, operations on, 623

Mediastinitis, 728 treatment of, 728

Mediotarsal amputation of Chopart, 1037

Megaloblasts, definition of, 29

Melanoma, 275 of skin, 316 treatment of, 317

Melanosarcoma, 275

Melon-seed bodies, 322

Meningeal artery, middle, injuries of, 563

Meningitis, 571 treatment of, 572

Meningocele, 576 cranial, 263 spinal, 625

Meningomyelocele, 626

Mercurial necrosis of bone, 428

Mercury, toxic effects of, 175

Mesarteritis, 338

Mesenteric phlebitis, 362

Mesentery, absence of, 939

## actinomycosis of, 939

anatomy of, 937 cancer of, 939 cysts of, 940 embolism of, 938 injuries of, 938 syphilis of, 939 thrombosis of, 938 tuberculosis of, 939 treatment of, 939

Metacarpophalangeal dislocations, 536 treatment of, 537

Metastasis, 91

Metastatic abscess, 91 osteomyelitis, 92

Metatarsalgia, 470 treatment of, 470

Methylene bichloride, 198

Microblasts, definition of, 29

Micrococcus gonorrhϾ, 53 lanceolatus, 53 tetragenus, 53

Microörganisms in blood, 35

Microstoma, 638, 652

Mikulicz’s disease, 650

Milk in lacteals, infection through, 50 leg, 362

Milzbrand, 106. _See_ Anthrax.

Molluscum contagiosum, 312

Morphine, 205

Morrison’s operation on omentum, 936

Mortification, 73. _See_ Gangrene.

Morton’s disease, 470 treatment of, 470

Mother’s marks, 367

Mouth, absence of, 638

## actinomycosis of, 657

bacteria of, 657 blastomycetic lesions of, 658 congenital defects of, 652 diphtheria of, 657 erysipelas of, 657 injuries of, 658 syphilis of, 657 tuberculosis of, 657 wounds of, 658

Movable bodies in joints, 401 diagnosis of, 402 symptoms of, 401 treatment of, 402

Mucous membrane, infection through, 48 syphilis of, 132 tuberculosis of, 115 polyp, 283

Mulberry growths, 282

Multicystic kidney, 969

Mumps, secondary infection in, 168

Murphy button, 820, 844

Muscles, atrophies of, 332 treatment of, 332 contractures of, 332 treatment of, 332 contusions of, 329 of eyes, defects of, 604 hernia of, 330 injuries of, 218 myalgia, 330 treatment of, 331 myositis, 331 calcificans, 331 ossificans, 272, 331 syphilitica, 136, 331 tuberculosa, 331 paralytic affections of, 332 treatment of, 332 parasitic affections of, 332 rupture of, 329 treatment of, 330 sprains of, 329 strains of, 329 syphilis of, 136, 331 tuberculosis of, 331 wounds of, 330

Musculospiral nerve, operations on, 623

Myalgia, 330 treatment of, 331

Mycetoma, 309

Mycosis fungoides, 308

Mycotic phlebitis, 90

Myeloid, 274

Myeloma of bone, 442

Myosarcoma, 274

Myositis, 331 calcificans, 331 gonococcus of, 331 ossificans, 272, 331 syphilitica, 136, 331 tuberculosa, 331

Myotomy, 327

Myxoma, 276 of bladder, 992 of bone, 441 cutaneous, 276 neuromyxoma, 276 polypi, 276

N

NAIL horns, 283

Naphthalin, toxic effects of, 175

Nares, anterior, plugging of, 681

Nasal cavities, neoplasms of, 677 symptoms of, 678 treatment of, 678 deformities, 676 polypi, 677 septum, malformations of, 671 submucous resection of, 677

Nasopharynx, fibroma of, 679

Neck, aneurysms of, 701 canal of, hydrocele of, 261 carbuncles of, 704 congenital anomalies of, 698 treatment of, 698 cysts of, 707 atheromatous, 707 bursal, 707 dermoid, 707 sanguineous, 701, 707 thyrohyoid, 707 hydroceles of, 261 injuries of, 698 muscles of, injuries of, 700, 701 nerves of, injuries of, 700, 701 phlegmons of, 700, 703 diagnosis of, 703 treatment of, 703 tumors of, 706 veins of, wounds of, 700 wounds of, 698 air-embolism in, 699 gunshot, 229

Necrosis of bone, 428 pathological, 428 toxic, 428 treatment of, 428 traumatic, 428 coagulation, 57 of skull, 549

Nephritis, chronic, treatment of, operative, 959 indications for, 960 septic, 956 symptoms of, 957 treatment of, 957

Nephrolysis, 960

Nélaton’s incision in excision of elbow, 410 operation for hare-lip, 647

Neoplasms of ear, 605 intestinal obstruction from, 833 of nasal cavities, 677 of spleen, 943

Nephralgia, 956

Nephrectomy, 960, 974

Nephrolithotomy, 966

Nephropexy, 968

Nephroptosis, 967

Nephrotomy, 960

Nervanin, 207

Nerves, acoustic, neurofibroma of, 584 anterior crural, operations on, 623 brachial plexus, operations on, 623 cervical plexus, deep posterior, operations on, 618 sympathetic, operations on, 618 cranial, injuries of, 612 dislocation of, 624 elongation of, 612 of eye, disturbances of, 604 of face, injuries of, 640 operations on, 616 fibroma of, 622 fifth, operations on, 613 Gasserian ganglion, operations on, 614 grafting of, 612 infra-orbital, operations on, 613 injuries of, 217 lingual operations on, 616 median, operations on, 623 musculospiral, operations on, 623 optic, tumors of, 593 peripheral, diseases and injuries of, 622 radial, operations on, 623 resection of, 613 sciatic, great, operations on, 623 seventh, operations on, 616 spinal accessory, operations on, 617 stretching of, 612 supra-orbital, operations on, 613 suture of, 612 tibial, operations on, 623 trunks, upper, injuries to, 725 treatment of, 726 tumors of, 622 ulnar, operations on, 623 wounds of, 612

Nervous system, syphilis of, 138

Nettle, stinging, poisoning by, 173

Neural cysts, 263

Neuralgia of breast, 758 treatment of, 758 facial, 640 intercostal, 728

Neurectomy, 612

Neuro-anastomosis for facial palsy, 616

Neurofibroma of acoustic nerve, 584 of skin, 313

Neuroma, 280 amputation, 1047 malignant, 280 plexiform, 280, 622

Neuromyxoma, 276

Neuroparalytic congestion, 20

Neurorrhaphy, 612

Neurotonic congestion, 20

Nevi of tongue, 659

Nevus, 277 lymphatic, 278 pigmentosus, 314 venous, 367 congenital, 367

Newborn, tetanus of, 97, 99

Nipple, chancre of, 759 eczema of, 316 fissures of, 756 Paget’s disease of, 316, 756

Nitze’s cystoscope, 993

Noma, 75, 658

Normoblasts, definition of, 29

Nose-bleed, 680 calculi of, 672 fractures of, 489 malformations of, 676 operations on, 644

Nostrils, malformations of, 671

O

O’DWYER’s intubation tubes, 693

Obligate pyogenic organisms, 52

Obstruction of intestines, acute, 828 from intussusception, 829 causes of, 830 symptoms of, 830 treatment of, 831 from invagination, 829 from strangulated hernias, 829 from volvulus, 832 large intestines, 870

Obstructive thrombosis, 36

Obturator hernia, 897

Occipital abscess, 569 artery, ligation of, 352 cephalocele, 576

Occlusion of lymph vessels, 369 acquired, 369 congenital, 369

Odontoma, 281 cementoma, 281 composite, 281 epithelial, 281 fibrous, 281 follicular, 281 compound, 281 of jaw, 668 radicular, 281 of teeth, 665

Oïdiomycosis, 310

Oïdium albicans of thrush, 657

Oiled silk, sterilization of, 248

Olecranon, fractures of, 501

Oligocythemia, 29

Ollier’s incision in excision of elbow, 410 of hip, 411 of knee, 413 of shoulder, 410 of wrist, 411

Omentopexy, 936

Omentosplenopexy, 936

Omentum, anatomy of, 934 cysts of, 935 injuries of, 935 operations on, 936 torsion of, 935 tumors of, 935

Onychia maligna, 318

Operations, abdominal, 773 on biliary passages, 927 on breast, 764 for cure of hernia, 901 on esophagus, 745 on face, 642 on gall-bladder, 927 on intestines, 840 on jaws, 668 on kidneys, 974 on larynx, 688 on lips, 645 mastoid, 574 on nose, 644 on omentum, 936 on prostate, 998 on spine, 636 on spleen, 943 on stomach, 805 thoracoplastic, 748 on thorax, 746 on tongue, 661 on trachea, 691 for tumors of brain, 585 on ureters, 976

Ophthalmitis, sympathetic, 595 treatment of, 596

Opisthotonos, 100

Opsonins in inflammation, 44

Optic nerve, tumors of, 593

Orbit, aneurysms of, 592 angioma of, 592 cellulitis of, 592 cysts of, dermoid, 593 parasitic, 593 encephalocele of, 593 endothelioma of, 593 epithelioma of, 593 injuries of, 592 treatment of, 593 sarcoma of, 593 syphilis of, 597 tumors of, 593 cystic, 593 vascular, 593 wounds of, 592

Orchitis, 1017 treatment of, 1017

Oropharynx, syphilis of, 137

Orthoform, 207

Osseous system, surgical diseases of, 416

Osteo-arthritis, 387 treatment of, 389

Osteo-arthropathic hypertrophiante pneumique, 436

Osteogenesis imperfecta, 435

Osteoma, 272 of bone, 441 of jaw, 668 of skull, 548 of thorax, 730

Osteomalacia, 434 prognosis of, 434 treatment of, 435

Osteomyelitis of abdominal wall, 783 acute, 416, 548 complications of, 419 diagnosis of, 419 etiology of, 419 organisms at fault in, 417 pathology of, 416 prognosis of, 418 symptoms of, 418 treatment of, 419 chronic, 421 tuberculous, 423 of jaw, 667 latent, 421 metastatic, 92

Osteopathic joint disease, 394

Osteoporosis, 422, 436 adiposa, 416

Osteopsathyrosis, 435

Osteosarcoma, 274

Osteosclerosis, 422

Ostitis deformans, 436

Othematoma of insane, 605 traumatic, 605

Otis’ dilating urethrotome, 157, 1012 urethrometer, 1012

Ovarian cystoma, 284 glandular, 284 papillary, 284 dermoids, 267 hernia, 897 hydrocele, 261 papilloma, 282

Ovary, tuberculosis of, 118

Overlapping ears, 605

Ozena, 137, 671

P

PACHYDERMATOCELE, 313

Pachymeningitis externa, 572 interna, 572

Paget’s disease of bones, 436 of nipple, 316, 756

Palate, cleft, operation for, 654 soft, diseases and injuries of, 682

Palsy, Bell’s, 640 facial, neuro-anastomosis for, 616

Palsies, cerebral, 478 treatment of, 478

Panarthritis, tuberculous, 395

Pancreas, abscess of, 949 adenocarcinoma of, 953 adenoma of, 953 affections of, acute, 946 chronic, 950 diagnosis of, 951 treatment of, 951 anomalies of, 944 calculi of, 954 cancer of, 953 cirrhosis of, 950 cysts of, 951 diagnosis of, 952 symptoms of, 952 treatment of, 952 injuries to, 947 neoplasms of, 951 non-traumatic surgical diseases of, 946 sarcoma of, 953 tumors of, 953

Pancreatic cysts, 262

Pancreatitis, acute, 946 diagnosis of, 947 from appendicitis, 858 symptoms of, 947 treatment of, 948 chronic, 950 gangrenous, 946 hemorrhagic, 946 interstitial, 950 subacute, 949 diagnosis of, 949 symptoms of, 949 treatment of, 950 suppurative, 946

Pannus of joints, 395

Panophthalmitis, 595 treatment of, 595

Papillary cystoma, 284

Papilloma, 282 of bladder, 992 cutaneous horns, 283 of ear, 605 of larynx, 686 ovarian, 282 of penis, 1009 of tongue, 659 treatment of, 283 villous, 282 intracystic, 282 warts, 282

Paracentesis, 184 by aspiration, 184 by incision, 185 of pericardium, 336, 733 by tapping, 185

Paraffin cancer, 316

Paralysis, diaphragmatic, 753 facial, 640 hyperemia of, 21 of nerve of eye, 604

Paralytic affections of muscles, 332 treatment of, 332

Paraphimosis, 1005

Parasitic affections of muscles, 332 cysts of orbit, 593 diseases of bone, 432

Parathyroids, diseases of, 710

Parenchymatous exudates, 23

Parietal abscess, 569 thrombosis, 35

Park’s club-foot brace, 469 operation for hernia, 905

Paroöphoritic cysts, 260

Parovarian cysts, 260

Patella, dislocations of, 543 treatment of, 543 fractures of, 516 treatment of, 517

Pelvic hernia, 897

Pelvis, fractures of, 507 treatment of, 508 rachitic, deformities of, 162

Penis, absence of, 1004 amputation of, 1010 balanitis of, 1005 balanoposthitis, 1005 congenital defects of, 1004 dislocation of, 1008 double, 1004 elephantiasis of, 370 epithelioma of, 1010 fracture of, 1008 gumma of, 1009 herpes of, 1009 injuries of, 1008 misplacement of, 1004 paraphimosis of, 1005 phimosis of, 1004 posthitis of, 1005 warts of, 1009

Peptic ulcer of jejunum, 816

Perforating ulcer of foot, 310

Perforations of biliary passages, 921 symptoms of, 922 treatment of, 922 of esophagus, 742

Peri-appendicular abscess, 860

Peri-arteritis, 338

Peri-articular cold abscess, treatment of, 399

Pericanalicular adenofibroma, 285

Pericarditis, 733

Pericardium, cardicentesis of, 336 paracentesis of, 336

Perichondritis, 683

Perigastritis, 804

Perilaryngeal abscess, 704

Perilymphangitis, 374

Perineal abscess, 1013 treatment of, 1013 fistulas, 1013 treatment of, 1013 hernia, 897 lithotomy, 990 prostatectomy, 999

Perinephritis, 961 symptoms of, 961 treatment of, 961

Periostitis, acute, 548 infectious, 420 causes of, 421 treatment of, 421 albuminosa, 421 of jaw, 667

Peripheral nerves, diseases and injuries of, 622

Perirectal abscess, 879 treatment of, 879

Peritheliomas, 275

Peritoneum, diseases of, 785 tuberculosis of, 116, 118

Peritonitis, 785 circumscribed, 786 classification of, 786 consecutive, 786 diagnosis of, from appendicitis, 857 diffuse, 786 following abdominal operations, 780 intestinal obstruction from, 833 prevention of, 251 putrid, 786 symptoms of, 786 traumatic, 786 treatment of, 787 tuberculous, 786, 790 ascitic, 791 fibrinoplastic, 791 treatment of, 791 ulcerative, 791

Peritracheal abscess, 704

Perityphlitic abscess, 860

Peri-urethritis, 149

Pes cavus, 471

Petroleum ether, 199

Phagedenic chancroid, 144 ulcers, 66

Phagocytosis, 30, 40

Pharyngeal diverticula, 262

Pharyngotomy, external, 664 subhyoid, 664 transhyoid, 664

Pharynx, adenoids of, 679 treatment of, 680 foreign bodies in, 673 treatment of, 673 malformations of, 671

Phimosis, 1004

Phlebectases, 364

Phlebitis, 361 acute, 361 chronic, 362 symptoms of, 362 treatment of, 363 mycotic, 90 obliterans, 362 sinus, 362, 571

Phleboliths, 36, 362, 364

Phlegmasia alba dolens, 362

Phlegmonous affections of rectum, 879 treatment of, 879 cholecystitis, acute, 920 erysipelas, 75, 93 gastritis, 804 symptoms of, 804 treatment of, 805

Phlegmons of abdominal wall, 783 of axilla, 751 of neck, 700, 703 diagnosis of, 703 treatment of, 703

Phosphorus necrosis of bone, 428

Phthisis, laryngeal, 684

Pigeon-breast, 162, 718

Piles, 364, 882 treatment of, 883

Pilonidal sinus, 635

Pirogoff’s amputation of leg, 1040

Pituitary adenomas, 285

Pleura, rupture of, 724 wounds of, 724 treatment of, 726

Pleurosthotonos, 100

Plexiform angioma, 278 neuroma, 280, 622

Pneumatocele of scalp, 545 treatment of, 546

Pneumocele, 725

Pneumonectomy, 750

Pneumonia, bacillus of, 54 erysipelatous, 95 secondary infection in, 167

Pneumopericardium, 337

Pneumotomy, 750

Poikilocytes, definition of, 29

Poisoning, arrow, 173 by bees, 172 by hornets, 172 ivy, 173 by lizards, 172 by scorpions, 172 by snake-bites, 171 by spiders, 172 by wasps, 172

Poliomyelitis, anterior, 477

Polycystic kidney, 969

Polycythemia, 29

Polyhydronephrosis, 972

Polymastia, 755

Polymazia, 755

Polyp, mucous, 283

Polypi, 276 laryngeal, 686 nasal, 677 rectal, 885

Polypoid degeneration, 678

Popliteal artery, ligation of, 360

Porencephalon, 580 in rickets, 162

Port-wine mark, 277

Posthitis, 1005

Postgonorrheal arthritis, 152, 392 of jaw, 667

Postoperative biliary fistulas, 917 cystitis, 985 hernia, 896 treatment of, 909 mania, 175

Pott’s disease, 444 causes of, 445 complications of, 446 diagnosis of, 448 laminectomy in, 637 prognosis of, 448 sequelæ of, 446 symptoms of, 445 treatment of, 448 by apparatus, 448 by forcible reduction, 450

Powell’s electric saw, 588

Prepatellar bursæ, 263

Procidentia, 881 treatment of, 882

Proctitis, 875 gonorrheal, 159, 875 symptoms of, 875 treatment of, 875

Profeta’s law in syphilis, 139

Prolapse of rectum, 881 treatment of, 882

Prolapsus cerebri, 566 prognosis of, 566 treatment of, 566

Pronated foot, 468

Propagated thrombosis, 36

Properitoneal hernia, 891, 897

Prostate, absence of, 994 cancer of, 1002 hypertrophy of, 995 diagnosis of, 996 symptoms of, 997 treatment of, 998 inflammation of, 994 operations on, 998

Prostatectomy, perineal, 999 suprapubic, 998

Prostatic adenoma, 285

Prostatitis, 150 acute, 994 chronic, 994 treatment of, 995

Prostatorrhea, 994, 1022

Protozoa, 56

Pruritus ani, 878 treatment of, 879

Psammoma, 271

Pseudocysts, 262

Pseudoleukemia, 32

Psoas abscess, 114

Ptosis, 604

Puerperal state, secondary infection in, 169

Punctured wounds, 213

Pus, absorption of, 62 bacterial determination of, as an indication to treatment, 57 blastomycetic, 56 clinical characteristics of, from different agencies, 57 encapsulation of, 62 formation, bacteria of, 51 facultative pyogenic, 53 obligate pyogenic, 52 ichorous, 59 pointing of, 58 sanious, 59 subfacial, collection of, 59 subperiosteal, collection of, 591

Pustular syphilides, 132

Pustulocrustaceous syphilides, 132

Putrid fever of Gaspard, 81

Pyarthrosis, metastatic forms of, 384 treatment of, 399

Pyelectomy, 976

Pyelitis, 956 symptoms of, 957 treatment of, 957

Pyelonephritis, 956 symptoms of, 957 treatment of, 957

Pyemia, 90 chronic, 92 complications of, 91 idiopathic, 91 postmortem appearances of, 92 prognosis of, 92 pyarthrosis of, 92 spontaneous, 91 symptoms of, 91 treatment of, 92 wound, 92

Pylephlebitis, 362, 918

Pylorectomy, 813

Pyloric stenosis, operations for, 808

Pylorodiosis, 808

Pyloroplasty, 808 Finney’s, 810

Pylorus stenosis of, 799 symptoms of, 799 treatment of, 799

Pyogenic organisms, facultative, 53 obligate, 52

Pyonephrosis, 961, 972 treatment of, 961

Pyopericardium, 336

Pyorrhea alveolaris, 664

Pyosalpinx, diagnosis of, from appendicitis, 858

Pyothorax, 736

R

RACEMOSE aneurysm, 344

Rachitis, 161. _See_ Rickets.

Radesyge, 308

Radial artery, ligation of, 356 nerve, operations on, 623

Radicular odontomas, 281

Radium in treatment of cancer, 296

Radius and ulna, fractures of, 503 dislocations of, 536 fractures of, 502 treatment of, 504 lower end of, fractures of, 503

Railway spine, 628

Ranula, 261, 660

Rauschbrand, bacillus of, 55

Raynaud’s disease, 74

Rectal fistulas, 880 treatment of, 880

Rectovaginal fistula, 839

Rectum, abscesses around, 879 treatment of, 879 adenoma of, 885 atresia of, 872 cancer of, 886 treatment of, 887 congenital defects of, 872 ether narcosis by, 196 examination of, 871 fistula of, 880 treatment of, 880 foreign bodies in, 874 imperforation of, 872 inflammation of, 875 injuries of, 874 invagination of, 881 treatment of, 882 malformations of, 872 phlegmonous affections of, 879 treatment of, 879 polypi of, 885 prolapse of, 881 treatment of, 882 strictures of, 877 treatment of, 877 syphilis of, 138 tumors of, 885 ulcers of, 876 catarrhal, 876 chancroidal, 876 symptoms of, 877 syphilitic, 876 treatment of, 877 tuberculous, 877 typhoid, 877

Reef-knot, 241

Regnoli-Billroth operation on tongue, 661

Reindeer tendons, sterilization of, 248

Renal abscess, 957

## actinomycosis, 964

calculus, 965 diagnosis of, 965 symptoms of, 965 treatment of, 966 colic, 964 treatment of, 964 syphilis, 964 tuberculosis, 961

Repair, process of, 67 cells in, embryonal, 67 epithelioid, 67 formative, 67 giant, 68 granulation tissue in, 67 karyokinetic activity in, 68 scar formation in, 69 of wounds, 215 by first intention, 215 granulation tissue in, 215 by second intention, 216 by third intention, 216

Resection of esophagus, transthoracic, 745 of nerves, 613

Respiratory passages, burns of, 675 foreign bodies in, 672 fractures of, 675 infection through, 49 injuries of, 675 malformation of, 671 treatment of, 671 wounds of, gunshot, 675

Retention cysts, 259 of urine, 982

Retina, detachment of, 604 glioma of, 595

Retromammary abscess, 757

Retroperitoneal hernia, 891, 897

Retropharyngeal abscess, 114, 682

Rhabdomyoma, 274, 277

Rheumatism, gonorrheal, 152

Rheumatoid arthritis, 387

Rhinoliths, 672

Rhinophyma, 313, 641 treatment of, 314

Rhinoplasty, 644

Rhinoscleroma, 308, 641 bacillus of, 54

Ribs, dislocations of, 529 fractures of, 491 symptoms of, 492 treatment of, 492 malformations of, 718

Rice-grain bodies, 322

Richet’s operation for blepharoplasty, 603

Richter’s hernia, 898

Rickets, 161 causes of, 161 cerebral conditions in, 162 congenital, 161 cranial, 547 deformities of bones in, 162 fetal, 161, 433 hydrocephalus in, 162 laryngismus stridulus in, 162 pathology of, 161 porencephalon in, 162 symptoms of, 162 treatment of, 162

Rider’s bone, 218, 331

Riedel’s lobe, 910

Riggs’ disease, 664

Rodent ulcers, 66, 67, 288 of auricle, 606

Roe’s operation for pug-nose, 645

“Rose, the,” 93. _See_ Erysipelas.

Roseola syphilitica, 131

Rotz, 105. _See_ Glanders.

Round-cell sarcoma, 273

Rovsing’s operation for gastroptosis, 813

Rubber tissue, sterilization of, 248

Rubefacients, 183

Ruptures of bladder, 981 of diaphragm, 721, 753 of esophagus, 741 of heart, 336, 732 of lung, 725 of muscles, 329 of pleura, 724 of stomach, 794 of trachea, 699 of veins, 363

S

SABANEJEFF’s method of amputation of knee, 1044

Sacculated aneurysm, 339, 342

Sacro-iliac disease, 452 treatment of, 452

Saddle-nose, 489, 639, 644

Salivary calculi, 651 ducts, fistulas of, 649 foreign bodies in, 648 glands, inflammation of, 649 tumors of, 650

Saphenous vein, internal, extirpation of, 366

Sapremia, 86 chronic, 87 treatment of, 87 symptoms of, 86 treatment of, 87

Sarcoma, 273 of abdominal wall, 784 alveolar, 274 angiosarcoma, 275 of bone, 441 treatment of, 441 chondrosarcoma, 274 cylindroma, 275 diagnosis of, from carcinoma, 293 endothelioma, 274 general characteristics of, 275 giant-cell, 274 of jaw, 668 of kidney, 969 of larynx, 687 of liver, 914 of lungs, 732 melanosarcoma, 275 myeloid, 274 of omentum, 935 of orbit, 593 osteosarcoma, 274 of pancreas, 953 round-cell, 272 of skin, 316 spindle-cell, 273 of spleen, 943 of thorax, 730 of thyroid, 712

Sardonic grin, 100

Sayre’s incision in excision of hip, 411

Scabbard trachea, 713

Scalds, 300 treatment of, 301

Scalp, cellulitis of, 545 erysipelas of, 545 hematoma of, traumatic, 218 pneumatocele of, 545 treatment of, 546 tumors of, 546 acquired, 546 benign, 546 congenital, 546 gaseous, 545 malignant, 546

Scapula, fractures of, 494 acromion process, 494 coracoid process, 495 surgical neck, 495

Scarlatina, secondary infection in 167

Sciatic nerve, operations on, 623

Scleroderma, 313 pathology of, 313 treatment of, 313

Sclerosis, cerebral, in rickets, 162

Scoliosis, 459 etiology of, 460

Scopolamine, 205

Scorbutus, infantile, 161

Scorpions, poisoning by, 172

Scrofula of joints, 393

Scrofuloderma, 306

Scrotal hernia, 895

Scrotum, elephantiasis of, 371 shortening of, 1021

Scurvy, 160 pathology of, 160 symptoms of, 160 treatment of, 160

Sebaceous adenomas, 285 cysts, 285 of skin, 310 horns, 283

Seborrheic warts, 312

Sédillot’s operation on tongue, 662

Semilunar cartilages, dislocations of, 543

Seminal vesiculitis, 1021

Septicemia, 87 complications of, 88 cryptogenetic, 87 eruptions in, 88 gangrenous, 108 leukocytosis in, 88 postmortem evidences of, 88 spontaneous, 87 symptoms of, 88 treatment of, 89 ulcerative endocarditis in, 88

Septicopyemia, 90

Sequestration dermoids, 265

Sequestrum formation in bone, 429 treatment of, 429

Serous exudates, 23

Seton, counterirritation by, 184

Shingles, 728

Shock, 177 diagnosis of, 179 from gunshot wounds, 223 symptoms of, 179 treatment of, 179 types of, 179

Shoulder, amputation of, 1032 excision of, 409 -joint, dislocations of, 530 anterior, 530 diagnosis of, 532 downward, 530 posterior, 530 subclavicular, 531 subcoracoid, 531 subglenoid, 531 subspinous, 532 symptoms of, 532 treatment of, 532 Kocher’s method, 533 upward, 530 spica bandage of, 190

Sialoadenitis, 649

Sialolithiasis, 651

Sigmoidopexy, 870

Silk, sterilization of, 248

Silkworm gut, sterilization of, 248

Sincipital hydrencephalocele, 577 meningocele, 577

Singer’s nodes, 686

Sinus, 63 accessory craniofacial, operations on, 608 causes of, 63 congenital, 63 foreign bodies, 63 necrosed material, 63 preëxisting abscess, 63 traumatic destruction of tissues, 63 ethmoidal, operations on, 610 frontal, operations on, 609 intracranial, injuries of, 563 maxillary, operations on, 611 phlebitis, 362, 571 symptoms of, 571 pilonidal, 635 sphenoidal, operations on, 610 thrombosis, 570 diagnosis of, 570 prognosis of, 571 symptoms of, 570 treatment of, 573 treatment of, 63

Skin, actinomycosis of, 308 appendages of, 317 carcinoma of, 315 cylindroma of, 315 cysts of, 310 treatment of, 310 epithelioma of, 315 diagnosis of, 315 treatment of, 315 grafting, 187 Thiersch method, 188 hypertrophies of, 311 infection through, 48 infections of, acute, 304 chronic, 306 keratosis of, 314 treatment of, 314 lymphangioma of, 315 treatment of, 315 melanoma of, 316 treatment of, 317 sarcoma of, 316 syphilis of, 130, 308 tertiary, 133 tuberculosis of, 115, 306 tumors of, benign, 311 malignant, 315 vascular growth of, 314 treatment of, 314 xanthoma of, 314

Skull, acute osteomyelitis of, 548 periostitis of, 548 aplasia cranii, 547 atrophy of, 547 senile, 547 bones of, incomplete formation of, 547 congenital conditions of, 547 craniotabes, 547 depression of, 549 diseases of, non-inflammatory, 547 fractures of, 549, 552 of base, 556 diagnosis of, 557 prognosis of, 557 treatment of, 558 of vertex, 552 comminuted, 552 diagnosis of, 554 gunshot, 553 splintered, 552 treatment of, 555 necrosis of, 549 osteoma of, 548 rachitis of, 162 surgical anatomy of, 550 wounds of, incised, 552 penetrating, 552

Sloughing ulcers, 66

Smith, Stephen, method of amputation of knee, 1043

Snake-bites, 171 symptoms of, 171 treatment of, 171

Soft palate, malformations of, 671

Somnoform, 199

Sounds, bulbous, 155

Spasmotoxin, 98

Specific irritants in inflammation, 45

Spermatic cord, encysted hydrocele of, 1019 malignant diseases of, 1019 spermatocele, 1019 syphilis of, 1019 tuberculosis of, 1019 varicocele, 1019 treatment of, 1021

Spermatocele, 1019

Spermatorrhea, 1022

Sphacelus, 73. _See_ Gangrene.

Sphenoidal sinus, operations on, 610

Sphygmomanometer, use of, 177

Spica bandage of groin, 189 of shoulder, 190

Spiders, poisoning by, 172

Spina bifida, 625 occulta, 626 treatment of, 626

Spinal column, diseases and injuries of, 625 sprains of, 628 treatment of, 629 cord, hemorrhages of, 625, 634 injuries of, differential diagnosis of, 635 syphilis of, 138 tumors of, 621 diagnosis of, 622 symptoms of, 621 treatment of, 622 wounds of, gunshot, 230, 624 penetrating, 624 meningocele, 625

Spindle-cell sarcoma, 274

Spine, arthritis deformans of, 388 cancer of, 462 caries of, 444 concussion of, 628 treatment of, 629 curvatures of, forward, 461 rotary, lateral, 459 etiology of, 460 prognosis of, 460 treatment of, 460 cysts of, 627 dislocation of, 631 treatment of, 632 fractures of, 629 diagnosis of, 629 injuries of, 629 differential diagnosis of, 635 kyphosis of, 444 lordosis of, 461 operations on, 636 Pott’s disease of, 444 causes of, 445 complications of, 446 diagnosis of, 448 prognosis of, 448 sequelæ of, 446 symptoms of, 445 treatment of, 448 by apparatus, 448 by forcible contraction, 450 spondylitis of, 444 traumatic, 462 spondylolisthesis, 462 diagnosis of, 463 symptoms of, 462 treatment of, 463 tuberculosis of, 424 typhoid, 462 wounds of, gunshot, 624 penetrating, 624

Spirochæta pallida, 123

Splay-foot, 468

Spleen, abscess of, 941 anomalies of, 940 carcinoma of, 943 cysts of, 943 displacements of, 942 gangrene of, 941 hypertrophies of, 941 injuries of, 941 neoplasms of, 943 operations on, 943 splenectomy, 943 splenopexy, 942 splenotomy, 943 sarcoma of, 943 syphilis of, 138 wounds of, 233

Splenectomy, 943

Splenic anemia, 31 fever, 106. _See_ Anthrax.

Splenitis, suppurative, 941

Splenomedullary leukemia, 32

Splenomegaly, 942

Splenopexy, 942

Splenotomy, 943

Spondylitis, 444 suppurative, of abdominal wall, 783 traumatic, 462

Spondylolisthesis, 462 diagnosis of, 463 symptoms of, 462 treatment of, 463

Sponges, sterilization of, 247

Sprains of joints, 380 symptoms of, 380 treatment of, 380 of muscles, 329 of spinal column, 628 treatment of, 629

Sprengel’s deformity, 458

Staffordshire knot, 241

Staphylococcus pyogenes albus, 52 aureus, 52 epidermidis, 52

Staphyloma, 598

Staphylorrhaphy, 654

Status lymphaticus, 163 diagnosis of, 164 treatment of, 165 thymicus, 163

Steatomas, 310

Stenosis, pyloric, operations for, 808

Stenson’s duct, cysts of, 641

Stercoremia, 83

Sterilization by boiling water, 244 of dressings, 247 by formalin, 244 fractional, 244 of hands, 245 by heat, 243 of instruments, 246 by mustard flour, 245 of sponges, 247 of suture materials, 247

Sternum, dislocations of, 528 fractures of, 491 symptoms of, 492 treatment of, 492 malformations of, 718

Stillicidium, 982

Stokes’ method of amputation of thigh, 1043

Stomach, anastomosis of, 816 cancer of, 801 symptoms of, 802 treatment of, 803 dilatation of, acute, 795 symptoms of, 796 treatment of, 796 chronic, 796 operations for, 811 fistulas of, 801 foreign bodies in, 794 operations for, 806 symptoms of, 794 treatment of, 794 hour-glass, 793 injuries of, 793 leather-bottle, 793 malformations of, acquired, 793 congenital, 793 nerves of, 793 operations on, 805 gastrectomy, 813 gastro-enterostomy, 811, 817 gastrojejunostomy, 816 gastrorrhaphy, 806 gastrostomy, 806 gastrotomy, 806 pylorectomy, 813 pylorus of, stenosis of, 799 symptoms of, 799 treatment of, 799 rupture of, 794 syphilis of, 795 tetany of, 798 tuberculosis of, 795 tumors of, 801 ulcer of, 799 symptoms of, 800 treatment of, 800 wall of, inflammation of, 804 wounds of, 794 penetrating, operations for, 805

Stomatitis, 657 gangrenous, 75, 658 ulcerative, 657

Stovaine, 207

Strains of muscles, 329

Strangulated hernia, diagnosis of, from appendicitis, 858 intestinal obstruction from, 829

Strawberry growths, 367

Streptococcus erysipelatis, 52 pyogenes, 53

Streptothrix maduræ, 100

Stretching of nerves, 612

Stricture of biliary ducts, 921 of esophagus, 742 of intestines, large, 870 obstruction from, 832 symptoms of, 828 treatment of, 828 small, 827 of larynx, 684 symptoms of, 684 treatment of, 684 of rectum, 877 treatment of, 877 of ureter, 973 of urethra, 1011

Struma, 283, 712 fibrosa, 284 parenchymatosa nodosa, 284

Strumitis, 717

Stye, 600

Stypticin, 235

Styptics for control of hemorrhage, 235

Subclavian artery, aneurysm of, 345 ligation of, 354

Subclavicular dislocations, 531

Subcoracoid dislocations, 531

Subcutaneous tubercle, painful, of skin, 313

Subdiaphragmatic abscess, 753 treatment of, 754

Subdural hemorrhages, 564

Subglenoid dislocations, 531

Subhyoid pharyngotomy, 664

Subluxation, 524. _See_ Dislocations.

Submaxillary angina, infectious, 703

Subphrenic abscess, 753 treatment of, 754

Subspinous dislocations, 532

Subungual exostoses, 272

Sunburn, 303

Suppression of urine, 982

Suppuration, 57

Supracondyloid amputations, 1043 fracture of humerus, 497

Supra-orbital nerve operations on, 613

Suprapubic prostatectomy, 998

Suprarenal epithelioma, 292

Surgical diseases, 79 common to man and animals, 97 fever, 85 cause of, 85 diagnosis of, from poisoning by drugs, 85 erysipelas, 93 pyemia, 90 sapremia, 86 chronic, 87 septicemia, 87 cryptogenetic, 87 spontaneous, 87 methods, 177 principles, 177 sequelæ of disease, 166 cholera, 166 dental caries, 169 diphtheria, 168 dysentery, 166 endocarditis, 169 gonorrhea, 169 influenza, 167 measles, 167 mumps, 168 pneumonia, 167 puerperal state, 169 scarlatina, 167 syphilis, 169 typhoid fever, 167 variola, 169

Sutures, 240 Billroth’s chain-stitch, 241 of bloodvessels, 349 end-to-end, 350 lateral, 349 continuous, 241 of heart wounds, 335 (note) interrupted, 241 of intestines, 840 modified plate, 241 quill, 241 of nerves, 612 removal of, 242 of tendons, 324 transfixion, 241

Swelling, acute, 22 chronic, 22

Sylvester’s method of artificial respiration, 204

Symblepharon, 603

Sympathectomy, 714

Sympathetic ophthalmitis, 595 treatment of, 596

Syncheilia, 639

Syncytioma, 292

Synovial cysts, 262

Synovitis, 382 acute, 383 treatment of, 383 chronic, 386 treatment of, 386 dry, 383 gonorrheal, 385 of jaws, acute, 667 purulent, 383 symptoms of, 383 treatment of, 385 treatment of, 385

Syphilides, 130 pustular, 132 ecthyma, 132 rupia, 132 pustulocrustaceous, 132 squamous, 131

Syphilis, 122 of abdominal wall, 783 of axilla, 751 of bones, 135, 426 of brain, 138 of breast, 759 of bursæ, 136 of cervical lymph nodes, 705 chancre, 126 bubo, 128 diagnosis of, from epithelioma, 127 dry papule, 126 extragenital, 127 Hunterian, 127 lymphatic involvement in, 128 mixed, 127 pathology of, 128 superficial erosion, 127 treatment of, 128 in children, 139 Colles’ law, 139 Profeta’s law, 139 of colon, 869 constitutional, 129, 132 of cornea, 137 of corpora cavernosa, 138 of ear, 137 eruptions of, 130 papular, 131 lenticulo, 131 miliary, 131 pustular, 132 pustulocrustaceous, 132 evolution of, 123 of eye, 136, 597 of face, 640 of genitalia, 138 gumma of, 133 Hutchinson’s teeth in, 140 induration of, 126 initial lesion in, 126 of intestines, 827 of joints, 135 of kidneys, 138, 964 of larynx, 138, 686 treatment of, 686 lesions of, 124 of liver, 138, 914 of lymph nodes, 376 manner of contagion of, 123 of mesentery, 939 of mouth, 657 of mucous membranes, 132 of muscles, 136, 331 of nervous system, 138 of orbit, 597 of oropharynx, 137 primary lesion, location of, 125 of rectum, 138, 876 secondary infection in, 169 lesion, 129 secretions of, 124 of skin, 130, 308 of spermatic cord, 1019 of spinal cord, 138 of spleen, 138 of stomach, 795 teeth in, 140 of tendons, 136 tertiary, 132 of skin, 133 of testicle, 138, 1016 of tongue, 659 of tonsils, 662 treatment of, 140 ulcer of, symptoms of, 125 of uvula, 683 of vascular system, 135 virus of, 123

Syphilitic arthritis, 385 bubo, 128 gumma of lung, 732

Syphilodermas, 130

Syringomyelia, 621

Syringomyelocele, 263, 626

T

TABES mesenterica, 939

Tænia solium, 310

Tagliacozzi’s method of rhinoplasty, 644

Talipes, 465 calcaneus, 471 equinovarus, 466 treatment of, 466 equinus, 470 causes of, 470 treatment of, 471 valgus, 468 etiology of, 468 treatment of, 469

Talma’s operation on omentum, 936

Tapping, paracentesis by, 185

Tarantula, poisoning by, 172

Tarsectomy, 467

Tartar on teeth, 657

Tattoo marks, 318, 720

Taxis, 899

T-bandage, 191

Teale’s method of amputation of foot, 1042

Teeth, caries of, 657, 664 treatment of, 665 cysts of, 666 eruption of, faulty, 665 extraction of, 666 accidents from, 666 instruments required, 666 malformations of, 652 odontoma of, 665 re-implantation of, 667 tartar of, 657 tumors of, 665

Telangiectasis, 277

Temporal artery, ligation of, 352

Temporomaxillary joint, ankylosis of, 667 dislocation of, 667 postgonorrheal arthritis of, 667 resection of, 668 synovitis of, acute, 667

Temporosphenoidal abscess, 569

Tendon sheaths, tuberculosis of, 118

Tendons, dislocation of, 330 grafting of, 324 injuries of, 218 ligation of, 326 surgical diseases of, 321 suture of, 324 syphilis of, 136 transplantation of, 324

Tendoplasty, 322

Tendosynovitis, 321 chronic, 322 treatment of, 322 suppurative, 321 treatment of, 321

Tendovaginitis, gonococcus of, 331

Tenorrhaphy, 324

Tenotomy, 327

Teratomas, 268 embryonal adenosarcoma, 268 of thyroid, 712

Tertiary syphilis, 132

Testicle, absence of, 1015 atrophy of, 1015 cancer of, 1017 chondroma of, 1017 congenital abnormalities of, 1014 contusions of, 1015 cystic degeneration of, 260 cysts of, 1016 epididymitis, 1016 treatment of, 1017 fibroma of, 1017 gonorrhea of, 151 hematoma of, 1015 hydrocele of, encysted, 260 injuries to, 1015 lipoma of, 1017 orchitis, 1017 treatment of, 1017 retained, 1014 treatment of, 1014 syphilis of, 138, 1016 tuberculosis of, 118, 1015 treatment of, 1016 tumors of, 1017

Tetanin, 98

Tetanotoxin, 98

Tetanus, 97 cephalicus, 99 chronic, 100 death in, 100 diagnosis of, 101 from hysteria, 101 etiology of, 97 hydrophobicus, 99 of newborn, 97, 99 parasitic nature of, 98 postmortem appearances in, 100 prognosis of, 100 toy-pistol, 97 treatment of, 101

Tetany, bacillus of, 54 gastric, 798

Thecitis, 328

Thiersch method of skin grafting, 188

Thigh, amputation of, 1043 above knee, 1044 fracture of, 509 diagnosis of, 511 prognosis of, 511 treatment of, 512

Thoracentesis, 736, 746

Thoracic duct, injuries to, 725 treatment of, 726 viscera, injuries to, 724 walls, diseases of, 726

Thoracoplastic operations, 748

Thoracotomy, 747 drainage in, 747 irrigation in, 747

Thorax, actinomycosis of, 729 carcinoma of, 730 chondroma of, 730 fibroma of, 729 granuloma of, 729 injuries to, 721 lipoma of, 729 malformations of, 718, 719 operations on, 746 osteoma of, 730 sarcoma of, 730 tumors of, 729 treatment of, 730 wounds of, gunshot, 230

Thrombo-arteritis, 91

Thrombophlebitis, 37, 90

Thrombosis, 34 annular, 35 causes of, 35 following abdominal operations, 784 gangrene from, 73 infective, 36, 570 marasmic, 36, 570 mechanical, 36 of mesenteric vessels, 938 obstructive, 36 parietal, 35 primary, 35 propagated, 36 sinus, 570 diagnosis of, 571 prognosis of, 571 symptoms of, 570 treatment of, 573 traumatic, 36 valvular, 35

Thrombus, calcification of, 36 decolorization of, 36 organization of, 36 softening of, 37

Thrush, oïdium albicans of, 657

Thumb, amputation of, 1029

Thymic asthma, 163

Thymus, hypertrophy of, 717, 751 inflammation of, 717

Thyroglossal duct, 710

Thyrohyoid cysts of neck, 707

Thyroid arteries, inferior, ligation of, 353 body, adenoma of, 712 bronchocele, 712 congenital affections of, 710 endothelioma of, 712 goitre of, 712 hypertrophy of, acute idiopathic, 711 intra-uterine, 711 sarcoma of, 712 struma of, 712 teratomas of, 712 tumors of, 711 dermoids, 267

Thyroidectomy, 715

Thyroidism, 82

Thyroiditis, 711

Thyroids, accessory, 710

Thyrotomy, 674, 688

Tibia, dislocations of, 543 fractures of, 518 treatment of, 521

Tibial arteries, ligation of, 360 nerve, operations on, 623

Tibiotarsal amputations, 1037

Tic douloureux, 640

Toe-nail, ingrowing, 318

Toes, amputation of, 1034 hammer, 321 treatment of, 321

Tongue, absence of, 652

## actinomycosis of, 659

bifid, 652 cysts of, retention, 659 epithelioma of, 660 treatment of, 660 gangrene of, 659 inflammation of, 658 leukoplakia of, 659 treatment of, 659 macroglossia of, 660 malformations of, 652 nevi of, 659 operations on, 661 Kocher’s, 661 Langenbeck’s, 662 Regnoli-Billroth’s, 661 Sédillot’s, 662 Whitehead’s, 661 papilloma of, 659 ranula of, 660 syphilis of, 659 -tie, 652 tuberculosis of, 659 tumors of, 659

Tonometer, use of, 177

Tonsillotomy, 663

Tonsils, absence of, 662 calculi of, 663 enlarged, 662 foreign bodies in, 663 hypertrophy, 662 infection through, 49 syphilis of, 662 tuberculosis of, 662 tumors of, 664

Torsion, control of hemorrhage by, 236 of omentum, 935

Torticollis, 457 diagnosis of, 458 pathology of, 457 treatment of, 458

Tourniquet for control of hemorrhage, 234

Toxic antiseptics, 175

Toy-pistol tetanus, 97

Trachea, operations on, 691 rupture of, 699 scabbard, 713 tumors of, 687 wounds of, 699

Tracheal tugging, 345

Tracheocele, 707

Tracheotomy, 691

Trachoma, 599

Transfixion suture, 241

Transfusion of blood, 185

Transhyoid pharyngotomy, 664

Transplantation of bone, 431 of tendons, 324

Transudates, 23

Trauma as cause of tumor, 255

Traumapnea, 724

Traumatic abscess of brain, 567 erysipelas, 93, 94 fever, 85. _See_ Surgical fever. hematoma of scalp, 218 hernia, 890 insanity, surgical treatment of, 582 intraventricular hemorrhage, 564 mania, 175 neuroma, 280 othematoma, 605 peritonitis, 786 spondylitis, 462 thrombosis, 36

Treatment of abscess, 60 of bone, 426 of brain, 573 of liver, 912 of rectum, 879 of actinomycosis, 110 of acute catarrh of biliary passages, 918 cholecystitis, 921 pancreatitis, 948 after abdominal operations, 777 of adenoids of pharynx, 680 of aneurysm of abdominal aorta, 346 of angioma of veins, 367 of ankylosis, 405 of anthrax, 107 of arthritis, chronic, 386 deformans, 389 tuberculous, 398 of atrophy of muscles, 332 of biliary calculi, 926 of boils, 304 of bow-leg, 465 of bunions, 311 of burns, 301 _x_-ray, 304 of carbuncle, 305 of carcinoma, 295 of breast, 763 of intestines, 828 of rectum, 887 of stomach, 803 of cardiospasm, 798 of caries of hip, 454 of cerebral palsies, 478 of cervical lymph-node affections, 706 of chancre, 128 of chancroid, 145 of cholelithiasis, 926 of chondroma, 272 of chronic affections of pancreas, 951 pancreatitis, 950 prostatitis, 995 sapremia, 87 tendosynovitis, 322 of cold abscess, 114 peri-articular, 399 of compression of brain, 562 of concussion of brain, 559 of chest, 722 of spine, 629 of congenital anomalies of neck, 698 club-foot, 466 dislocation of hip, 474 of congestion, 23 of contraction of fasciæ, 320 of muscles, 332 of contusions, 212 of brain, 560 of chest, 722 of cryptorchidism, 1014 of curvature of spine, 460 of cutaneous horns, 311 of cystitis, 985 of cysts of pancreas, 952 of skin, 310 of dacryocystitis, 600 of delirium tremens, 174 of dental caries, 665 of dermatitis calorica, 299 of desmoids, 271 of dilatation of stomach, 796 of dislocations, 527 of clavicle, 529 of elbow, 536 of foot, 544 of hip, 539 of jaw, 528 of knee, 544 metacarpophalangeal, 537 of patella, 543 of shoulder, 532 of spine, 632 of duodenal ulcers, 826 of Dupuytren’s contraction, 320 of ectopia of bladder, 978 of epididymitis, 1017 of epistaxis, 681 of epithelioma of skin, 315 of tongue, 660 of erysipelas, 95 of exophthalmic goitre, 714 of exophthalmos, 594 of exstrophy of bladder, 978 of fat embolism, 40 of fibroma molluscum, 313 of fistula, 63 of rectum, 880 of floating liver, 911 of foreign bodies in esophagus, 740 in pharynx, 673 in stomach, 794 of fractures, 486 of clavicle, 493 Colles’, 504 of femur, 513 of fibula, 521 of forearm, 501 of humerus, 495 of inferior maxilla, 490 of leg, 521 of patella, 517 of pelvis, 508 of radius, 504 of ribs, 492 of skull, base, 558 vertex, 555 of sternum, 492 of thigh, 512 of tibia, 521 of ulna, 501 of frostbite, 302 of furuncle, 304 of gallstones, 926 of gangrene, 77 of gastric ulcer, 800 of gastroptosis, 797 of glanders, 106 of glaucoma, 597 of gonorrhea, 152 complications, 152 of testicles, 151 in women, 159 of hammer-toe, 321 of hematomyelia, 634 of hematorrhachis, 634 of hematuria, 959 of hemorrhage, 234 secondary, 237 of hemorrhoids, 883 of hernia, 898 of brain, 566 femoral, 908 inguinal, 908 postoperative, 909 umbilical, 909 ventral, 909 of Hodgkin’s disease, 378 of hydatid cysts of liver, 913 disease, 432 of hydrocele, 1018 of hydrocephalus, 579 of hydronephrosis, 973 of hydrophobia, 104 of hypertrophy of prostate, 998 of hysterical joints, 392 of injuries of eyeball, 604 of orbit, 593 to thoracic duct, 726 to upper nerve trunks, 726 of intestinal obstruction, acute, 836 chronic, 839 of intraspinal hemorrhage, 634 of intussusception, 832 of invagination of rectum, 882 of keloid, 271, 313 of keratosis of skin, 314 of knock-knee, 464 of laceration of lung, 722 of leptomeningitis, 573 of leukoplakia, 659 of lock finger, 320 of lymphangioma, 279 circumscriptum, 374 of skin, 315 of lymphangitis, 375 of Madura foot, 110 of malformation of esophagus, 738 of respiratory passages, 671 of malignant edema, 108 of mastitis, 758 of mastodynia, 758 of mediastinitis, 728 of melanoma of skin, 317 of meningitis, 572 of metatarsalgia, 470 of Morton’s disease, 471 of movable and floating kidney, 967 bodies in joints, 402 of myalgia, 331 of necrosis of bone, 428 of neoplasm of nasal cavities, 678 of neuralgia of breast, 758 of neuropathic disease of joints, 392 of orchitis, 1017 of osteo-arthritis, 389 of osteomalacia, 435 of osteomyelitis, 419 of panophthalmitis, 595 of papilloma, 283 of paralytic affections of muscles, 332 of perforations of biliary passages, 922 of perineal abscess, 1013 fistulas, 1013 of perinephritis, 961 of periostitis, 421 of perirectal abscess, 879 of peritonitis, 787 of phlegmonous affections of rectum, 879 of phlegmons of neck, 703 of piles, 883 of pneumatocele of scalp, 546 of Pott’s disease, 448 of procidentia, 882 of proctitis, 875 of prolapse of brain, 566 of rectum, 882 of pruritus ani, 879 of pyelitis, 957 of pyelonephritis, 957 of pyemia, 92 of pyonephrosis, 961 of renal calculus, 966 colic, 964 of retained testicle, 1014 of rhinophyma, 314 of rickets, 162 of rupture of diaphragm, 722 of muscles, 330 of sacro-iliac disease, 452 of sapremia, 87 of sarcoma of bone, 441 of scalds, 301 of scleroderma, 313 of scoliosis, 460 of scurvy, 160 of septic nephritis, 957 of septicemia, 89 of sequestrum formation, 429 of shock, 179 of sinus, 63 thrombosis, 573 of snake-bites, 171 of spina bifida, 626 of spondylolisthesis, 463 of sprains, 380 of spinal column, 629 of status lymphaticus, 165 of stenosis of pylorus, 799 of strictures of intestines, 828 of larynx, 684 of rectum, 877 of subphrenic abscess, 754 of suppurative tendosynovitis, 321 of surgical kidney, 957 of sympathetic ophthalmitis, 596 of synovitis, 385 acute, 383 chronic, 386 purulent, 385 of syphilis, 140 of talipes equinovarus, 466 equinus, 471 valgus, 469 of tetanus, 101 of torticollis, 458 of traumatic insanity, 582 of trigger finger, 320 of tuberculosis, 120 of bone, 425 of breast, 759 of joints, 398 of knee, 456 of kidneys, 963 of larynx, 685 of mesentery, 939 of peritoneum, 791 of skin, 307 of testicle, 1016 of tuberculous hydrops, 399 ulcers of intestines, 827 of tumors, 258 of bladder, 992 of brain, 585 of breast, 760 of larynx, 687 of spinal cord, 622 of thorax, 730 of typhoid ulcers of intestines, 826 of ulcerations of biliary passages, 922 of varices, 365 of varicocele, 1021 of varicose veins, 365 of vascular growths of skin, 314 of vesical calculus, 987 of warts, 312 venereal, 312 of wounds, 238 of chest, 723 contused, 212 of diaphragm, 726 gunshot, 225 of head, 565 of heart, 335 of intestines, 824 of larynx, 676 of lung, 726 open, 239 of pleura, 726 punctured, 214 of wryneck, 458 of xanthoma of skin, 314

Trephining of cranium, 587

Trichiasis, 601

Trigger finger, 320 treatment of, 320

Trismus, 97. _See_ Tetanus.

Tropacocaine, 207

Trophoneuroses, 310

Trophoneurotic atrophy, 27 diseases of bone, 432

Tuberculides, 307

Tuberculin in tuberculosis, 121 dose of, 121 manner of preparation, 121

Tuberculosis, 111 of abdominal wall, 783 of axilla, 751 bacillus of, 54 of bladder, 118 of bone, 116, 422 acute miliary, 423 chronic tuberculous osteomyelitis, 423 pathology of, 423 symptoms of, 423 treatment of, 425 of breast, 759 treatment of, 759 of bursæ, 118 of choroid, 595 cold abscess in, 112 diagnosis of, 113 lumbar, 114 psoas, 114 retropharyngeal, 114 treatment of, 114 colon, 869 degenerative changes in, 111 diagnosis of, 120 from epithelioma, 293 of face, 640 fungous granulation in, 115 giant cells in, 111 gummas in, 114 of joints, 393 diagnosis of, 398 pathology of, 394 symptoms of, 397 treatment of, 398 of kidney, 118, 961 diagnosis of, 962 symptoms of, 961 treatment of, 963 of knee-joint, 456 treatment of, 456 of larynx, 684 treatment of, 685 lupus, 115 of lymph nodes, 376 cervical, 705 of lymphatic structures, 116 of mesentery, 939 treatment of, 939 method of healing, 112 absorption, 112 calcification, 112 caseation, 112 encapsulation, 112 suppuration, 112 miliary tubercles in, 111 of mouth, 657 of mucous membrane, 115 of muscles, 331 of ovary, 118 paths of infection, 119 of peritoneum, 116, 118 of rectum, 876 of seminal vesicles, 1021 of skin, 115, 306 folliculitis, 307 lupus vulgaris, 306 painful subcutaneous, 313 scrofuloderm, 306 treatment of, 307 verruca necrogenica, 306 verrucose, 306 of spermatic cord, 1019 of stomach, 795 of tendon sheaths, 118 of testicle, 118, 1015 treatment of, 1016 of tongue, 659 of tonsils, 662 treatment of, 120 constitutional, 120 tuberculin in, 121 local, 120 amputation in, 121 Bier’s permanent hyperemia, 120 excision in, 121 ignipuncture in, 121 iodoform injections in, 120

Tuberculous cystitis, 985 hydrops, treatment of, 399 panarthritis, 395 peritonitis, 786, 790 ascitic, 791 fibrinoplastic, 791 treatment of, 791 ulcerative, 791 ulcers of intestines, 827 symptoms of, 827 treatment of, 827

Tubulo cysts, 260 allantoic, 260 of vitello-intestinal duct, 260 of Wolffian body, 260 dermoids, 266

Tumid ulcer, 67

Tumors, 255 of abdominal wall, 783 vascular, 784 albus, 393, 456 of bladder, 992 symptoms of, 992 treatment of, 992 of bone, 438 cartilaginous, 440 of brain, 582 symptoms of, 583 treatment of, 585 of breast, 760 treatment of, 760 of cheek, 641 classification of, 259 connective tissue, 269 cysts, 259 dermoids, 264 epithelium, 281 of nerve elements, 279 teratomas, 268 clinical observations of, 257 coccygeal, 627 congenital, 635 comparative pathology of, 256 connective tissue, 269 angioma, 277 chondroma, 271 exostoses, 272 fibroma, 269 lipoma, 269 lymphangioma, 278 myoma, 277 myxoma, 276 osteoma, 272 sarcoma, 272 cysts, 259 glandular, 261 hydrocele, 261 pseudo-, 262 retention, 259 tubulo, 260 derived from epithelium, 281 adenoma, 284 carcinoma, 289 epithelioma, 286 malignant chorion, 292 suprarenal, 292 fibro-adenoma, 284 fibro-epithelioma, 282 goitre, 283 hydronephroma, 292 mucous polyp, 283 odontoma, 281 ovarian cystoma, 284 papilloma, 282 struma, 283 dermoids, 264 ovarian, 267 sequestration, 265 tubulo, 266 of diaphragm, 753 of ear, 605 embryonal hypothesis of Cohnheim, 256 of face, 641 of gall-bladder, 927 gangrene from, 74 of heart, 336 heredity of, 256 inflammation as cause of, 256 inoculation experiments on, 257 of intestines, 828 intralaryngeal, 686 intra-ocular, 594 intratracheal, 686 irritation as cause of, 255 of jaw, 668 of kidney, 969 of larynx, 686 of liver, 914 local infectivity of, 257 of lung, 732 of lymphatics, 378 metastasis of, 257 microscopic appearances of, 257 of neck, 706 of nerve elements, 279 glioma, 279 neuroma, 280 of nerves, 622 nomenclature of, 258 of omentum, 935 of optic nerve, 593 of orbit, 593 cystic, 593 vascular, 593 of pancreas, 953 parasitic theory of, 256 of rectum, 885 of salivary glands, 650 of scalp, 546 acquired, 546 congenital, 546 gaseous, 545 of skin, benign, 311 malignant, 315 of spinal cord, 621 diagnosis of, 622 symptoms of, 621 treatment of, 622 of stomach, 801 of teeth, 665 teratomas, 268 of testicle, 1017 of thorax, 729 treatment of, 730 of thyroid, 711 of tongue, 659 of tonsils, 664 of trachea, 687 trauma as cause of, 255 treatment of, 258 of operable, 259

Typhoid fever, secondary infection in, 167 spine, 462 ulcer of intestines, 826 symptoms of, 826 treatment of, 826 of rectum, 876

U

ULCER, 65 atheromatous, 339 of auricle, rodent, 606 of biliary passages, 921 symptoms of, 922 treatment of, 922 callous, 67 causes of, 65 constitutional, 66 local, 65 traumatic, 65 duodenal, 825 symptoms of, 825 treatment of, 826 edematous, 67 erethistic, 66 of face, 640 fissured, 66 fistulous, 66 of foot, perforating, 310 fungous, 66 gastric, 799 diagnosis of, from appendicitis, 857 operations for, 811 symptoms of, 800 treatment of, 800 healthy, 66, 67 hemorrhagic, 66 indolent, 66 indurated, 67 inflamed, 67 of intestines, 825 cancerous, 827 diagnosis of, from appendicitis, 857 duodenal, 825 treatment of, 826 dysenteric, 827 tuberculous, 827 treatment of, 827 typhoidal, 826 symptoms of, 826 treatment of, 826 irregular, 66 irritable, 66 livid, 67 peptic, of jejunum, 816 phagedenic, 66 process of repair in, 67 of rectum, 876 catarrhal, 876 chancroidal, 876 symptoms of, 877 syphilitic, 876 treatment of, 877 tuberculous, 876 typhoid, 876 regular, 66 rodent, 66, 67, 288 sloughing, 66 treatment of, 70 tumid, 67 undermined, 67 of urethra, 1011 venereal, 144. _See_ Chancroid.

Ulceration, 65. _See_ Ulcers.

Ulcerative endocarditis in septicemia, 88 gingivitis, 664 stomatitis, 657 tuberculous peritonitis, 791

Ulna, dislocations of, 536 fractures of, 501 treatment of, 501

Ulnar artery, ligation of, 356 nerve, operations on, 623

Umbilical hernia, 896 treatment of, 909 vein, phlebitis of, 362

Upper extremity, amputations of, 1029 entire, 1033

Uranoplasty, 654

Urea in auto-intoxication, 80

Ureteral catheterization, 958

Ureters, anomalies of, 955 calculus of, 973 operations on, 976 stricture of, 973

Urethra, congenital defects of, 1004 epispadias, 1005 foreign bodies in, 1009 hypospadias, 1005 injuries of, 1008 lacerations of, 1008 strictures of, 1011 ulcers of, 1011

Urethritis, 147 gonorrheal, in women, 159

Urethrometer, 155 Otis’, 1012

Urethrotome, Otis’ dilating, 157, 1012

Urine, electroconductivity of, 959 incontinence of, 982 retention of, 982 suppression of, 982

Uveitis, 596, 598

Uvula, elongation of, 682 syphilis of, 683

V

VALVULAR thrombosis, 35

Vanghetti’s cinematic method of amputation, 1048

Varices, 364 congenital, 364 symptoms of, 365 treatment of, 365

Varicocele, 364, 1019 treatment of, 1021

Varicose aneurysm, 339, 342 veins, 363 extirpation of, 366 symptoms of, 365 treatment of, 365

Variola, secondary infection in, 169

Varix, anastomotic, 364 aneurysmal, 363 compound, 367

Vascular growth of skin, 314 treatment of, 314 system, surgical diseases of, 334 syphilis of, 135

Veins, air embolism of, 363 angioma of, 366 treatment of, 367 atrophy of, 361 calcification of, 361 fatty degenerations of, 361 hemorrhoidal, phlebitis of, 362 hypertrophy of, 361 inflammation of, 361 injuries of, 217, 363 treatment of, 364 mesenteric, phlebitis of, 362 rupture of, 363 umbilical, phlebitis of, 362 varicose, 363

Velpeau’s bandage, 189

Venereal ulcer, 144. _See_ Chancroid. warts, treatment of, 312

Venesection, 182

Venous nevus, 367 congenital, 367

Ventral hernia, 896 treatment of, 909

Vermiform appendix, actinomycosis of, 852 anatomy of, 851 cysts of, 852 diseases of, 851 empyema of, 860 foreign bodies in, 852 inflammation of, 851 tuberculosis of, 852 tumors of, 852

Verruca necrogenica, 306

Verrucæ, 311

Vertebral artery, ligation of, 353

Vesical calculus, 986 symptoms of, 986 treatment of, 987 diverticula, 262

Vesicants, counterirritation by, 184

Vesicovaginal fistula, 839

Villous papillomas, 282 intracystic, 282

Vincent’s angina, 703

Viscera, wounds of, 219

Vitello-intestinal duct, cysts of, 260

Volvulus, 832, 870

von Langenbeck’s incision in excision of elbow, 410 of wrist, 411

von Mosetig-Moorhof’s incision in excision of elbow, 410

Vulva, elephantiasis of, 371 gonorrhea of, 158

W

WAGNER’s osteoplastic resection of cranium, 590

Wandering erysipelas, 94 liver, 910 symptoms of, 910 treatment of, 911

Wardrop’s method of treating aneurysms, 347

Warts, 282, 311 filiform, 311 seborrheic, 312 treatment of, 312 venereal, treatment of, 312

Warty horns, 283

Wasps, poisoning by, 172

Weir’s operation for saddle-nose, 644

Wens, 285

White swelling, 393

Whitehead’s operation for hemorrhoids, 884 on tongue, 661

Whitlow, 328

Witzel’s method of gastrostomy, 807

Wolffian body, cysts of, 260

Woodbury’s method of amputation of hip-joint, 1045

Woolsorters’ disease, 106. _See_ Anthrax.

Wounds of abdominal wall, gunshot, 783 penetrating, 781 of bladder, 981 of chest, 722 treatment of, 723 contused, 211 of bloodvessels, 216 of tendons, 218 treatment of, 212 of viscera, 219 of diaphragm, 725, 753 treatment of, 726 of esophagus, 741 of face, 639 fever, aseptic, 85. _See_ Surgical fever. gunshot, 220 of abdomen, 232 of bladder, 233 diagnosis of, 225 of face, 229, 639 foreign material in, 224 of head, 228, 565 of heart, 231 hemorrhage from, 223 of intestines, 823 of joints, 228, 381 key-hole, 225 of kidney, 233 localizing symptoms of, 233 multiple, 224 of neck, 229 pain from, 223 prognosis of, 225 of respiratory passages, 675 shock from, 223 of small intestines, 823 of spinal cord, 624 of spine, 230, 624 of spleen, 233 of thorax, 230 treatment of, 225 of heart, 334, 733 suture of, 335 (note) treatment of, 335 incised, 214 of bloodvessels, 216 of skull, 552 of intestines, 823 lacerated, 212 of bloodvessels, 216 of muscles, 218 of larynx, 675 treatment of, 675 of liver, 911 of lung, 724 treatment of, 726 of mouth, 658 of muscles, 330 of neck, 698 of nerves, 612 open, treatment of, 239 of pancreas, 945 penetrating, of joints, 381 of chest, 722 of orbit, 592 of skull, 552 of spinal cord, 624 of spine, 624 of stomach, 805 of pleura, 724 treatment of, 726 punctured, 213

Wounds, punctured, of abdomen, 214 treatment of, 213 repair of, 215 of respiratory passages, 675 of stomach, 794 of trachea, 699 treatment of, 238 drainage in, 239

Wrist, amputation of, 1031 dislocations of, 536 excision of, 411 fractures of, 507

Wryneck, 457 diagnosis of, 458 pathology of, 457 treatment of, 458

Wyeth’s exsector in excision of joints, 409 method of amputation of hip-joint, 1045

X

XANTHELASMA, 601

Xanthoma of skin, 314 planum, 314 treatment of, 314 tuberosum, 314

X-ray burns, 303 treatment of, 304 in treatment of cancer, 207

Y

YAWS, 308

Yeasts, 55

Z

ZYGOMA, fractures of, 489

Transcriber’s Notes

Inconsistent and archaic spelling, hyphenation and capitalisation have been retained, also in anatomical and medical terminology and in proper names, except as mentioned under Changes made below.

Depending on the hard- and software used to read this text, not all elements may display as intended.

Page 195, ... that 5 per cent. is more than adequate ...: appears to be contradicted by the remainder of the sentence; possibly 5 per cent. is an error for .5 per cent.

Page 275, Fig. 80: There is no line in the source document to indicate item a.

Page 411, ... two lateral incisions, with through drainage ...: possibly an error for ... thorough drainage.

Page 425, ... absorbents are eared or closed ...: as printed in the source document; possibly erroneously.

Page 534, ... the section on fractures of the elbow-joint ...: there is no such section in the book; these fractures are discussed under fractures of the arm and the forearm.

Page 1037, Fig. 696: reference numbers 1 and 2 are not present in the illustration.

Changes made

Some obvious minor typographical, lay-out and punctuation errors and inconsistencies have been corrected silently.

Footnotes, tables and illustrations have been moved out of text paragraphs; some of the wider tables have been split or otherwise re-arranged to fit the available width.

Plate I: the heading PLATE I has been inserted as in other plates.

Page 25: ... their lumen marrowed ... changed to ... their lumen narrowed ....

Page 229: (See Chapter XXXV .) changed to (See Chapter XXXVI .)

Page 234: (See Chapter LVI .) changed to (See Chapter LVII .)

Page 266, 267: Numbers 2 and 3 inserted before subsection headings Tubulodermoids and Ovarian Dermoids and Teratomas.

Page 278: (See Aneurysm, Chapter XXVIII .) changed to (See Aneurysm,

## Chapter XXIX .)

Page 293: ... will be found in Chapter IX . changed to ... will be found in Chapter X .

Page 332, caption Plate XXX: Chapter XXVII changed to